infiltration are found at the same time, and where both history and
evidence indicate that these two phenomena are the result of one and
the same process. When the uvula takes part in the process the
swelling is, as a rule, more marked than when the remaining parts of
the fauces only are implicated. Its circumference is very
considerable, and amounts sometimes to the treble or quadruple of the
normal, in consequence of the oedematous condition of the entire
tissue.
We have to deal, then, with three different manifestations of the
diphtheritic process: first, with a membrane lying on the mucous
membrane, and removable without causing much injury to the epithelium
or any to the basement membrane; such membranes were given by some the
name of croupous deposits; secondly, with a membrane implicating the
epithelium and upper layers of the mucous membrane; to this the title
of diphtheritic membrane has been given by preference; thirdly, with a
whitish or grayish infiltration of the surface and the deeper tissue,
which, if abundant, may give rise to a necrotic destruction of the
tissue.
The severity of the disease does not always depend on the predominance
of one of these three forms, for any of them may accompany a mild or a
severe attack. By a severe attack we understand one attended with
chills, temperatures as high as 105° and 107° F., and marked nervous
symptoms, such as vomiting and convulsions. It is characteristic of
such cases that when the membrane is accidentally or forcibly removed
it is speedily reproduced; the lymphatic system, in addition, takes an
active part in the process. The neighboring glands become swollen; the
periglandular tissue does likewise, so that the circumference of the
neck becomes enormous, and the space between the lower jaw and the
clavicle appears one immense tumefaction. These are the cases in
which, as a rule, loss of strength and general debility speedily
ensue, and death occurs from exhaustion. The membrane in cases of this
description frequently undergoes changes in appearance; under the
influence of the atmosphere and of foreign substances, and by
admixture of blood, its color becomes yellowish or brownish. The odor
of the membrane and surrounding parts becomes sweetish and musty, and
occasionally so fetid that it contaminates the atmosphere of the room,
and the air in its transit through the nose and over the pharynx
becomes by inhalation dangerous to the patient. His throat becomes
more swollen, his respiration loud; he keeps his mouth open
constantly, has an indifferent expression; the saliva dribbles
continually, the color of the skin is sallow and livid, the {669}
appetite very poor, and pulse both frequent and small. When the
symptoms are of long duration, and a deep infiltration of the affected
parts occurs, hemorrhages not infrequently make their appearance.
These may be slight although frequent; occasionally, however, larger
blood-vessels are encroached upon in the process of destruction, and
dangerous, nay even fatal, hemorrhages may be the result. The septic
forms which I have here described are more dangerous than the mild
ones previously mentioned. Still, even in the latter bad results may
ensue from a direct absorption into the blood of putrid substances and
by the penetration of fetid gases to the lungs.
Occasionally, where the infiltration has been extensive, we meet with
a condition that can only be considered as gangrene. In such cases we
see collections of a grayish pulpy mass, which on falling off leaves a
considerable loss of tissue, the further course of the disease being
either favorable, or dangerous through absorption of septic material,
or accompanied by local hemorrhages. When, after a time, health is
completely restored, marked cicatrices are left behind. Such loss of
tissue is generally seen in the tonsils only, but it may also be
encountered in the soft palate. Its cicatrices on the soft palate are
always a source of inconvenience, partly in swallowing, partly in
speaking. Actual local perforation of the soft palate I have seen but
five times in twenty-five years, sloughing without perforation very
often.
The diphtheritic membrane not infrequently spreads from the pharynx to
the neighboring organs. From the posterior aspect of the soft palate
or pharynx the disease gradually ascends to the nasal cavities; this
is particularly apt to occur when the uvula is the seat of extensive
deposits, and by forced inspiration and deglutition its posterior
surface becomes affected. In such cases the membrane which extends
thence to the nasal cavities is very dense, and capable of narrowing
the capacity of the nasal cavities anteriorly, and occasionally even
to close them entirely; as a rule, however, several days elapse before
the membrane assumes such a condition. Usually, when this form of
nasal diphtheria is in its incipient stage, it is impossible to
diagnosticate it; the most important sign thereof, besides a more
nasal articulation and sometimes greater difficulty in deglutition,
and the result of close ocular examination while the uvula is turned
sideways or drawn forward, is a swelling of the deep facial glands at
the angle of the lower jaw; when these swell rapidly it can be
asserted positively that the nasal cavities have been invaded. There
is little or no discharge from the nostrils under these circumstances.
The picture is a very different one, however, when the nose becomes
primarily affected. This usually occurs only where an acute catarrh
with but little secretion, not so often where a chronic catarrh, has
preceded infection. When the secretion is thin and serous, the
diphtheritic infection renders it no thicker, but makes it slightly
flocculent, and it may become very profuse. This form is frequently
attended with a disagreeable odor, equally unpleasant to the patient
and to those around him. During the prevalence of an epidemic one must
always be prepared to see an acute nasal catarrh or an influenza, or
even a chronic nasal catarrh, become complicated with diphtheria or
pass into it. Schuller reports the case of a five-weeks-old male child
who, having had a nasal catarrh since birth, became affected with
diphtheria of the nose. The glandular {670} swelling of which I spoke
above is a very important diagnostic, and likewise a decidedly
unpleasant symptom, which becomes very marked inside of twenty-four
hours; frequently a partial swelling remains long after the
disappearance of the diphtheritic membrane. Such glands rarely
suppurate or undergo a necrotic degeneration; sometimes they become
permanently indurated. This induration and a chronic pharyngeal and
nasal catarrh are very serious matters in many instances. Both of
these conditions are starting-points for a number of acute or subacute
attacks of diphtheria in the same person. It is they which constitute
the liability of persons once affected to be taken sick again. Not
only are they liable to be affected themselves, but they are a
constant danger to all around them. Diphtheria, in a large family of
children living in one of the best houses of the city, after having
returned half a dozen times in the course of a year, disappeared
instantaneously, not to return, when a seamstress living in an
infected neighborhood and suffering from occasional sore throats was
relieved of her daily work in the house. Oedematous swelling of the
mucous membrane and submucous tissue is often observed for a long
period to come; elongated uvulæ, enlarged tonsils, often date back to
such an acute attack. Thus it is with the upper portion of the larynx
about the posterior insertion of the vocal cords (see below); its
large amount of loose submucous tissue is liable to swell considerably
in acute attacks. Frequent spells of croupy cough and a certain degree
of dyspnoea are often observed for years afterward. Though the cases
of genuine cicatrization between the arytenoid cartilages, as
described by Michael,[10] be rare, with their result of permanent
paresis of the thyroarytenoid interni muscles, when they do occur they
are either obstinate or altogether incurable.
[Footnote 10: _Deutsch. Arch. f. klin. Med._, 1879, xxiv. p. 618.]
Diphtheritic conjunctivitis occurs either primarily or as a
complication of pharyngeal or nasal diphtheria. Fortunately, it is not
of frequent occurrence; the cornea may become destroyed either by
pressure through the considerable swelling of the eyelid or by
diphtheritic keratitis. Usually the upper eyelid is the first to
suffer; it is red, rigid, swollen. In the beginning the conjunctiva
palpebræ is smooth, dry and pale, while that of the eye is chemosed;
afterward diphtheritic deposits take place either in floccules or in
solid masses. Knapp distinguishes between croup and diphtheria of the
eyelid according to the facility or impossibility of removing the
deposit. In favorable cases the membranes begin to macerate and the
eyelids to soften after a few days. In those less favorable
perforation of the cornea, prolapse of the iris, or total destruction
of the eye take place.
The ear is but rarely the primary seat of diphtheria. A girl of three
years died of laryngeal diphtheria on Sept. 6, 1882, after an illness
of four days. A girl of seven years was removed from the house on
Sept. 6th and returned on Sept. 8th. On the afternoon of the 10th an
earring taken from the corpse was attached to the left ear of the
sister, after having been washed with soap and water only. About noon
on the 11th the lobe of the left ear reddened, on the 12th it
exhibited a membrane and became swollen, and some glands enlarged in
the neighborhood. On the right mastoid process the skin was not quite
healthy, a vesicatory having been applied three weeks previously. This
surface became {671} diphtheritic on the 12th, without consecutive
glandular swelling. On the 13th the membranes grew thicker; on the
14th the pharynx was also affected, and the physician called in.
Most diphtheritic affections of the ear, however, are secondary. In
pharyngeal and nasal diphtheria the narrow orifice of the Eustachian
tube is easily obstructed by either catarrhal swelling or diphtheritic
deposit. The disease may invade the middle ear and the drum membrane
with perforation, caries, and deafness following.
The descent of the diphtheritic process into the respiratory organs
may give rise to various conditions. The membrane is not always found
to pass uninterruptedly from the mucous membrane of the fauces into
the larynx; not infrequently isolated diphtheritic spots are found in
the pouches on either side of the attached extremity of the
epiglottis, or on the epiglottis, or in the larynx. At such times the
epiglottis is moderately swollen, its margins hard and reddened.
Occasionally the redness is interrupted by small diphtheritic
deposits, which may remain isolated for a considerable time, but
generally coalesce so as to coat the edges of the epiglottis with a
continuous membrane. As a rule, the upper surface of the epiglottis is
not completely covered by membrane, while only now and then
diphtheritic deposits are found on its under surface.
The subjective symptoms accompanying the affection of the epiglottis
are not always in direct proportion to the extent of the membranes.
Dyspnoea and hoarseness occasionally occur where the only abnormal
condition is a marked oedema at the entrance of the larynx,
particularly of the posterior wall near the arytenoid cartilages and
the attachment of the vocal cords. The oedematous condition causes a
functional paralysis of the vocal cords, together with marked dyspnoea
on inspiration. The difficulty of breathing may become so excessive
that the clinical diagnosis of croup is unquestionable, and
tracheotomy resorted to, while expiration is comparatively free and
the voice not markedly affected. Furthermore, cases occur in which
there is no marked oedema, but merely a general catarrh of the
epiglottis and larynx; here, too, the subjective symptoms of
hoarseness and dyspnoea may become severe and necessitate the
performance of tracheotomy. Still, bearing this in mind, I have on
several occasions refrained from performing this operation where I
judged that, aside from the diphtheria of the pharynx, I had to deal
with a moderate oedema of the glottis or a laryngeal catarrh.
Frequently, however, membranes form in the larynx in the same way as
in the pharynx or nose; then inspiration and expiration are equally
interfered with, and hoarseness is a more constant symptom than in the
above-mentioned cases. Fever and pain are not necessarily prominent
symptoms; in fact, they are frequently unimportant, but in proportion
as the degree of narrowing of the larynx increases the respiration
becomes more difficult, long-drawn, and loud.
It may happen that the trachea and bronchi may become affected,
although diphtheria of the fauces does not exist. This does not occur
as rarely as Henoch and Oertel seem to believe. They think that
diphtheritic tracheo-bronchitis is mistaken for the primary condition,
because the throat is not examined early enough.
Oertel is of the opinion that the membrane in the fauces is {672}
overlooked in such cases. Steiner,[11] too, asserts that "the tendency
of the times is to question, nay, rather to deny, the existence of
croup extending from below upward." Now, on the contrary, repeated
experience enables me to assert with positiveness that diphtheritic
tracheo-bronchitis may occur without an affection of the pharynx at
the same time. I do not deny that it may last for days without giving
rise to dangerous symptoms. I know it does. But when the process
reaches the larynx, the symptoms of suffocation become so urgent that
tracheotomy may be absolutely required at once, and, in spite of the
operation, death soon after occurs.
[Footnote 11: _Ziemssen's Handb._, iv., 1, 126.]
Of course these cases are exceptions; as a rule, laryngeal and
tracheal diphtheria result from a descent of the disease from the
fauces. More or less uncomplicated cases of primary laryngeal
diphtheria, or so-called sporadic membranous croup, were, however,
observed before the end of the sixth decade of this century. They were
then almost the only cases of diphtheria, and linked former epidemics
and the present one together.
Inflammatory affections of the lungs may occur at various times and in
various forms during an attack of diphtheria. That which appears after
tracheotomy is usually a broncho-pneumonia, and results from
rarefaction of the air in the respiratory passages during the period
of impeded respiration, with consequent collapse of pulmonary tissue
and dilatation of the blood-vessels, and hence a disturbance of the
circulation. It may not fully develop until after tracheotomy, and is
a frequent cause of death on the second or third day after the
operation. Now and then a case of lobular pneumonia will result from
the aspiration of pieces of membranes into the smallest bronchi. It
can be easily recognized when the trachea is opened, but previous to
the operation the auscultatory signs are of little or no value, being
masked by the laryngeal râles. Percussion is equally useless, for a
dulness may just as well indicate collapse of the lung as
infiltration. The second form of pneumonia associated with diphtheria
is from the beginning fibrinous in character. Here, too, auscultation
and percussion are of little assistance in establishing a diagnosis
when there is a laryngeal diphtheria at the same time, for the above
reasons. Where, however, the dulness on percussion is accompanied by
high fever, and the long-drawn inspiration is replaced by rapid
respiratory movements, the diagnosis of pneumonic complication is
justified.
Diphtheria of the mouth, as a primary affection, is not of very
frequent occurrence; not rarely, however, is it associated with
diphtheria of the fauces and nose, mainly when they have assumed a
septic or gangrenous character; it appears on cheeks, tongue, angles
of the mouth and gums, and, after the fetid discharges have excoriated
the skin, on the lips also. In all of these localities it appears less
in the form of an extensive, thick membrane than an infiltration of
the tissues. It is most apt to occur where, from the start, the mucous
membrane of the mouth was eroded or ulcerated. The ulcerated base of a
follicular stomatitis is very frequently the starting-point of a
general diphtheria of the mouth. It is always a disagreeable symptom,
points to a long duration of the whole process, and threatens septic
absorption.
The oesophagus and the cardiac portion of the stomach are the seat
{673} sometimes of very massive and extensive, mostly fibrinous
exudations, in typhoid fever, dysentery, cholera, measles, and
scarlatina, or after injuries following contact with mineral acids,
alkalies, corrosive sublimate, or antimony. When the normal tissue was
not injured I never saw any that were not superjacent and could not
easily be peeled off (croupous). In cases of extensive pharyngeal and
laryngeal diphtheria the upper part of the oesophagus is often covered
to a distance of half an inch or an inch with membrane, the lower part
of which is thinning out into a mere film. A case of local
diphtheritic deposit near the cardiac portions of the oesophagus, upon
the seat of a stricture, I have described in my _Treatise_, p. 83.
Actual diphtheria of the stomach is rare. So is that of the intestine,
which is much more liable to be affected in animals than in man. In
the cow intestinal diphtheria is frequent (Bollinger). In the
gall-bladder, resulting from the irritation produced by calculus, it
was seen by Weisserfels. The diphtheritic form of inflammation of the
human colon and rectum--dysentery--is frequent enough, but will be the
subject of discussion in another place. But, besides this, in the
lower portion of the small intestines and in the colon long, tough,
coherent membranes are sometimes found in the male and female (not in
the hysterical female only). As a rule they are not diphtheritic, but
consist mostly of nothing but mucus hardened and flattened down by
protracted compression. The few cases of intestinal diphtheria I have
met with gave rise to the usual symptoms of enteritis, and were
diagnosticated as such.
Wounds of all kinds are easily and rapidly infected by diphtheria; for
instance, vaginal abrasions and erosions of the external ear, tongue,
and corners of the mouth. Scarification or removal of part of the
tonsils is followed in half a day or a day by a deposit of
diphtheritic membrane on the wound. The wound caused by tracheotomy
becomes liable to be infected with diphtheria within twenty-four
hours. Leech-bites, skin denuded by vesicatories, removal of the
cuticle by scratching during cutaneous eruptions, all furnish a
resting-place for diphtheria in a short time. What Billroth has
described under the name of muco-salivary diphtheritis, as it occurs
after the extirpation of a large portion of the tongue and resection
of the lower jaw, belongs to this class.
At times immediately at the beginning of an invasion of diphtheria, at
other times only on the second or third day, an erythematous eruption,
more or less general, appears on the skin. Now and then it appears on
the chest, shoulders, and back; at other times it covers the body, and
has not infrequently led to its being confounded with scarlatina. It
is not always accompanied by much fever, and cannot therefore be
mistaken for that form of erythema which frequently appears in
children with delicate skins during high fever from any source. I
cannot say that I have found this complication to give a more
malignant character to the disease, but true erysipelas does. I am not
prepared to prove that the two processes, erysipelas and diphtheria,
are identical under some circumstances, but the complication of the
two, and the ferocity with which they combine, renders a close
relationship probable. I have seen an infant dying from an erysipelas
added to a post-auricular diphtheria, this being due to a slight
abrasion of the surface. Erysipelas originating in the tracheotomy
wound, though ever so carefully disinfected and secured, is {674}
frequently observed after two or three days, and is a very ominous
symptom. Erysipelatous surfaces, denuded of their epidermis by
spontaneous vesication or injured by ever so slight a trauma, are very
liable to be covered with diphtheritic membranes.
An eruption resembling urticaria in the beginning is as innocent as
erythema, but purpura in the latter stage is a symptom of mostly
ominous nature.
On the vulva and vagina of little girls diphtheria is sometimes met
with; probably in every case it is due, under the epidemic influence,
to a local catarrh or erosion. In but few cases, comparatively, the
inguinal glands are swollen. There are not many cases of vaginal
diphtheria which are followed by the pharyngeal affection. Diphtheria
of the vagina in puerperal women is liable to become the cause of
general sepsis, and is a dangerous disease; it is seldom complicated,
but uterus, Fallopian tubes, and peritoneum may become the seat of
inflammatory and septic disturbances. In the bladder it may occur when
the urine is alkaline, in chronic cystitis, after lithotomy,
urethotomy, the operation for vesico-vaginal fistula, and in ectopia
vesicæ. This form has a marked tendency toward localization, but by
extension of the phlegmon, when of putrid character, to the
retro-peritoneal cellular tissue, peritonitis may ensue and terminate
fatally. Sepsis from absorption is also frequent. Vesical diphtheria
is sometimes quite unsuspected. A man of sixty had urinary trouble a
long time; his urine was frequently very offensive, containing blood
and pus. About five days before his death he suddenly collapsed. I
found the bladder well filled, and introduced a catheter, but
succeeded in removing but a few drops of fetid liquid. Assuming the
presence of a malignant tumor at the neck of the bladder, I attempted
to draw off the urine by puncturing above the symphisis pubis; again
without success. At the post-mortem examination a thick membranous
lining of the bladder was found detached in the form of a sac
containing about a quart of urine. During life the beak of the
catheter evidently passed into the space between the bladder and the
membranous sac, which accounts for the unsuccessful attempts at
catheterization.
Diphtheria of the placenta was observed by Schüller. The membrane was
between uterus and placenta, and attached to the latter. It resulted
from puerperal sepsis. Balano-posthitis is liable to result in local
and general diphtheria; so are circumcision wounds. They are apt to
become affected either primarily, without apparent cause, or when
other members of the family are suffering from the disease.
The kidneys may become affected in various ways. Albuminuria is not
always of significance, as it occurs in severe and mild cases alike,
both before and after tracheotomy, and therefore is not connected
always either with the height of the fever or the degree of dyspnoea;
at times it disappears in a few days, in other cases it is of longer
duration. It is not invariably complicated with changes in the kidney,
neither do we always discover casts or degenerated epithelial cells in
the urine. In other respects also it does not behave like albuminuria
in scarlatina. In the latter it appears seldom before the second week
of the process, and frequently later, while in diphtheria it is often
seen early. It sometimes lasts but a few days, particularly in many
cases which set in with a high fever, which rapidly diminishes, and
terminates in speedy recovery. In {675} these occurrences the presence
of albumen appears to attend the rapid elimination of the poison.