complicated with oedema, but sometimes it is but a symptom of a local
or general nephritis, and then hyaline, epithelial, and fibrin casts
and granular cells are found in the urine. Nephritis then assumes as
serious a character as it possesses in scarlatina. Cases of nephritis,
fortunately rare in a very early period of diphtheria, are liable to
run a rapid and often fatal course.
The heart and blood are affected in various ways by the diphtheritic
process. Where the disease runs a slow course, accompanied by high
fever, a granular degeneration occurs, similar to that appearing in
other acute infectious disorders--typhoid, for example. In diphtheria,
however, it would seem that this condition may arise even without
marked elevation of temperature. The pathological changes in the heart
produced by diphtheria are not always the same. Ecchymoses, cellular
hypertrophy, and granular degeneration have frequently been noticed
after death where the symptoms had been severe. The result, of course,
is considerable weakness of its muscular tissue, evidenced by the
formation of local (Beverly Robinson) thrombi, general sluggishness of
the circulation, dyspnoea, muffled heart-sounds, a cool and pale skin,
and sudden death, preceded by a very feeble and frequent, sometimes,
however, by a very slow, pulse. Aside from this, there is actual
endocarditis during the course of diphtheria or convalescence
therefrom. It affects especially the valves, and among them
particularly the mitral. It is characterized by high fever, precordial
pain, attacks of syncope, and a systolic murmur.
The rapid decrease of red blood-cells and a moderate increase of
leucocytes were demonstrated by Bouchut and Dubrisay, but the
disproportion was not such as to necessitate the diagnosis of
leucocythæmia. Wunderlich reports two cases of Hodgkin's disease, the
pseudo-leukæmia developing during diphtheria. And the slowness of
final recovery in many cases, even of but short duration and not
complicated with nervous disorders, appears to point to a serious
disintegration of the elements of the blood. The dark color and
defective coagulation of the blood in autopsies of diphtheria cases
have often been remarked.
The direct and rapid introduction into the blood of a foreign
substance has amongst its earliest symptoms fever. This reaction of a
nervous system depends both on the quantity and quality of the
substance or poison introduced, and on the susceptibility of the
patient. High temperatures are, however, not the only, nor are they
the most dangerous, nervous symptoms. To the latter belong the
different shades of paralysis met with during or subsequent to
diphtheria.
Sudden and unexpected collapse is sometimes observed, not infrequently
in the earlier part of the disease. The changes found in autopsies,
such as a dark color of the blood, deficient coagulability,
extravasations into and friability and granular degenerations of the
tissues, accumulations of degenerated cells, and granules between the
fibres, degeneration mainly of the heart-muscle, the presence of
heart-clots, thrombi in remote veins,--they all show to what extent
the disease can destroy life in the shortest time possible. In the
heart either the pneumogastric or the ganglionic {676} nerves may be
affected, and the symptoms will vary accordingly. Paralysis of the
former will accelerate the pulse, degeneration of the sympathetic will
diminish its frequency, yet death may ensue in either.
The usual form of diphtheritic paralysis makes its appearance during
the period of convalescence, at a time when all danger seems to have
passed by. As a rule, the soft palate and the muscles of deglutition
are the first to be attacked, while the condition of these organs is
apparently normal (and no longer oedematous, and thereby inactive, as
in the first period of the disease). While they are recovering, or
before, the accommodation muscles of the eyes become paralyzed.
Sometimes, however, these are the first to be affected. This paralysis
does not, as a rule, follow severe cases; on the contrary, it is not
uncommon to observe it after apparently mild attacks of the disease.
In consequence of the former paralysis, deglutition becomes difficult;
fluids are expelled through the nose or enter the larynx and bronchi,
thereby giving rise to pneumonia; in the latter there is strabismus.
The upper and lower extremities become paralyzed afterward. As a rule,
a number of muscles are affected at the same time, and improvement
will take place in about the same order in which the individual
muscles became affected. After paralysis has become affected,
circulation begins to suffer. The extremities now and then become
bluish, cool, emaciated; rarely atrophy and fatty degeneration have
been observed. The muscles of the neck also become paralyzed; the head
cannot be carried, or with difficulty only. The fingers are but seldom
affected. The same holds good of the bladder and intestines. The
respiratory muscles are not frequently attacked. Their paralysis is
very ominous, and may prove fatal in a short time from apnoea.
Not only motory but sensory paralyses may occur. Anaesthesia,
amaurosis, deafness have been observed; a number of cases of locomotor
ataxia are on record, and but lately Hadthagen[12] publishes a case
which he claims as disseminated sclerosis.
[Footnote 12: _Arch. f. Kinderheilk._, vol. v., 1883.]
Sometimes the nervous affection in diphtheria is localized in a
peculiar manner; it seems as if there is a predisposition on the part
of a certain nerve to become diseased. The case of a boy, active and
healthy, in the practice of H. Guleke, is very interesting. In the
course of three years he had three attacks of diphtheria. In the very
beginning of the disease he always became soporous with an almost
normal temperature and a slow but regular pulse. Probably the heart's
ganglia are the first to submit to the influence of the poison and
exhibit symptoms of flagging function. In most of the cases of
diphtheritic paralysis the prognosis is good; the large majority will
run a favorable course in from six to ten weeks.
INVASION.--Is diphtheria, primarily, a local or a constitutional
disease? Mercado's well-known case of diphtheria, engendered by the
biting of a finger, has been alluded to. I know of one case in which
the vagina became first affected, and later the pharynx. Bayles saw
denuded portions of skin assume a membranous character, and general
diphtheria develop afterward. Fresh wounds become diphtheritic, and
the general disease arises from this source. Even paralysis will
follow. I had a death from diphtheria when a long incision into a
phlegmon of the thigh had become diphtheritic. A little girl, who had
a considerable amount {677} of discharge from a catarrhal vagina, and
sore thighs in consequence, exhibited first, during the epidemic of
1877, membranes on the denuded cutis, and afterward general
diphtheria. Brehm reports the case of a woman on whom he performed
colotomy. The wound became thoroughly diphtheritic and gangrenous, but
the pharynx and respiratory organs remained intact. A few days after,
her daughter, who attended her in her sickness, was infected. In her
the pharynx was the seat of disorder. Besides, the tonsils are very
frequently coated with a membrane without any general symptoms in the
beginning, fever and general illness occurring only later on. Now, all
of these facts tend to show that there are cases in which the origin
of the disease is purely local.
It must, however, not be forgotten that during the prevalence of an
epidemic every one is more or less under its influence, and but little
is wanting to call forth the disease. Some years ago a well-known
physician, with whom I was intimately acquainted, died from facial
erysipelas and meningitis which had originated in a slight abrasion of
the upper lip. During an epidemic of typhoid we daily see persons with
fever, headache, and lassitude. Diarrhoeas are frequent during an
epidemic of cholera. An epidemic of diphtheria is accompanied by a
great number of cases of pharyngitis. When, in the year 1860,[13] I
reported two hundred cases of bonâ fide diphtheria, I at the same time
observed one hundred and eighty-five cases of non-membranous
inflammations of the throat. Such occurrences may be considered as
possible or incipient cases of pharyngeal diphtheria. Therefore,
contrary to the view of a local origin of diphtheria, it may be
claimed that the individual taking the disease was already saturated
with the poison, and the local membrane represented perhaps nothing
but a symptom, or at the utmost the causa proxima. Accordingly, then,
there are undoubtedly cases in which the pharyngeal membrane is the
first cause and symptom of the final affection, and others in which
the poisoning of the blood through inhalation is the first step in the
development of the disease, amongst the symptoms of which the
pharyngeal or nasal membrane counts as one.
[Footnote 13: _Amer. Med. Times._, Aug.]
In these cases the first complaints of the patients relate to their
general condition. Sometimes they are ignorant of any local trouble
when they consult a physician. When it is perceptible, however, it is
usually found on the visible pharyngeal and respiratory mucous
membranes. This would seem to indicate that the infectious elements
while being inhaled are there deposited. Thus there is a possibility
of simultaneous affections of both the throat and the blood in the
lungs, in either equal or variable proportions. We are easily led to
defend at least a partial admission of the poison by the respiratory
act, when we reflect that the membranes which are swallowed are
rendered innocuous by the action of the gastric fluids, and,
therefore, the alimentary canal, from the oesophagus downward, cannot
be made responsible for the admission of the poison into the system.
Thus it is that the general symptoms--as fever, lassitude,
etc.--precede the local phenomena in very many cases, while there are
exceptional cases in which the membrane appears first and the fever
later. This is especially the case when the tonsils are very large and
occupy a prominent position in the throat.
Those cases which begin with high fever and moderate or no local {678}
symptoms must be looked upon as constitutional diseases. If a person,
in the course of several hours or a day, be taken with high fever and
a moderate membrane-formation, these symptoms subsiding in one or two
days, leaving the patient weak and exhausted, but fully restored to
health at the end of a week, we would be justified in assuming
(cæteris paribus) that there was a rapid absorption of a large amount
of poison, and an equally rapid elimination thereof. They are,
moreover, the same cases in which the second or third day of the
disease furnishes albuminuria, with rapid elimination and speedy
recovery. When, however, the process is slow in developing,
accompanied by moderate fever, and the course is indolent, we have
reason to infer that moderate amounts of the poison are being
continually taken into the system and making their influence felt to a
moderate degree, but for a longer period. Such are the cases which,
without any violent symptoms, are accompanied by frequent local
relapses, or run, when the absorption is constant as well as copious,
a septic course, or terminate in paralysis.
Thus there are cases in which a local infection of the skin or of a
wound may be one of the causes, or the only cause, of the disease, and
there are cases in which the poison, in passing through and caught in
the pharynx, gives rise to local phenomena before the system at large
gives evidence of infection. But, as a general thing, diphtheria must
be looked upon as a constitutional disease, giving rise to local
phenomena, in the same way as scarlatina does on the skin, on the
mucous membrane of the alimentary canal, and in the uriniferous
tubules; measles on the skin and respiratory mucous membrane; or
typhoid in the lymph-follicles and on the mucous membrane of the
intestine; or, in other words, the diphtheritic poison may enter the
system locally through a defective, or sore, or wounded integument or
through the lungs.
Is diphtheria contagious? Undoubtedly it is. The contagious element is
liable to be directly communicated by the patient; it also clings to
solid and semi-solid bodies, and in this way is transmitted even after
a long time. There is hardly any disease which can cling so
tenaciously to dwellings and furniture; it can be transported by the
air, though probably not to a great distance, and hence in houses
artificially heated, while the windows and doors are mostly closed,
rises from the lower to the upper stories; and it is for this reason
advisable to keep the sick on the top floor. It is certainly
transmitted by spoons, glasses, handkerchiefs, and towels used by the
patient. The contagious character increases directly in proportion to
the neglect of proper ventilation. That it is spread by the feces is
not clearly established in my mind. I can give personally no examples
of its being carried by visitors or by the attending physician; this
is said to have occurred, however. The character of the disease
communicated, and the local manifestation, do not depend on that of
the original sufferer; thus mild cases may produce severe ones, and
vice versâ, and convalescents can convey the disease in its full
force. Naturally, the softer character of the tissues in children
renders them more susceptible to infection, and the activity of their
lymphatic system more liable to severe forms of the disease.
Many tragic cases are recorded in literature of infection by direct
contact from pharynx to pharynx, or from the opening in the trachea to
the mouth of the surgeon; and one of the saddest cases, perhaps, is
that of {679} the much-lamented Carl Otto Weber. Myself and others
have contracted diphtheria from sucking tracheotomy wounds.
In regard to the length of the incubation periods, there can be no
better authenticated facts than those contained in a report of Elisha
Harris to the National Board of Health, an abstract of which is found
in No. 1, _National Board of Health Bulletin_, June 28, 1879. The
report says that in the fourth school district of the township of
Newark (Northern Vermont), amidst the steep hills where reside a quiet
people in comfortable dwellings, the summer term of school opened on
the 12th of May. Among the twenty-two little children who assembled in
the school-room in the glen were two who had suffered from a mild
attack of diphtheria in April, and one of them was, at the time school
opened, suffering badly from what appeared to have been a relapse in
the form of diphtheritic ophthalmia. Besides, it is proved that these
recently sick pupils had not been well cleansed, one of them having on
an unwashed garment that she had worn in all her sickness three weeks
previously. At the end of the third day of school several of the
children were complaining of sore throat, headache, and dizziness, and
on the fourth day and evening so many were sick in the same way that
the teacher and officers announced the school temporarily closed. By
the end of the sixth day from school opening, sixteen of the
twenty-two previously healthy children became seriously sick with
symptoms of malignant diphtheria, and some were already dying. The
teacher and six of the pupils were not attacked, nor have they since
suffered from the disease.
A case[14] is reported of a surgeon who, while attending a
diphtheritic child, had some secretion thrown into his face. Twelve
hours after his right eye was inflamed and painful. The affection
proved diphtheritic, and recovery was completed after several weeks
only. In a case seen by me, with Dr. L. Bopp, a child removed from a
house infected with diphtheria was attacked after fourteen days and
eight hours.
[Footnote 14: _Würt. Med. Corresp. Bl._, 1878, No. 2.]
It would then appear that, in the direct communication of the disease
to healthy or nearly healthy mucous membranes--as healthy as the
prevailing epidemic will allow--the period of incubation is from one
or two to fourteen days. In only a small number of cases the disease
has an even shorter period of incubation than this, as when
tonsillotomy or a similar operation is undertaken during the
prevalence of an epidemic. One may rest assured that any operation on
the tonsils while an epidemic of diphtheria is at its height will be
followed within twenty-four hours by diphtheritic deposits on the
wounded part. To what extent we are justified in considering this a
bonâ-fide incubation of the disease in a previously healthy body is,
of course, another question. It seems to me that these cases
positively prove that the operation is only the causâ proxima of a
diphtheritic affection, and that we may take it for granted that
during an epidemic every individual is more or less under its
influence and affected by it, so that it needs but a wound or an
accidental abrasion of the surface of the mucous membrane to call the
disease into action. In a similar way, fresh wounds or morbid
conditions of the mouth may call forth the disease. The ruptured
vesicles of a follicular stomatitis are liable to serve as
resting-places for diphtheritic membranes, and thus I have seen the
complication of a follicular stomatitis with oral diphtheria; and any
{680} lacerations of the vagina during labor may become diphtheritic
within twenty-four hours. If now, on the one hand, incubation depends
on the condition of the affected surface, it is probable, on the other
hand, that the intensity of the poison at the time plays an important
part in determining the period that is to elapse between infection and
the invasion of the disease.
ETIOLOGY.--Diphtheria is pre-eminently a disease of early life; in
this respect it is said to differ from the genuine fibrinous
bronchitis, which by some is held an absolutely different disease, and
stated to occur but rarely in children. But even this statement is
probably incorrect. In the spring of 1879 I met with four cases of
fibrinous bronchitis in children under three years of age. The number
of cases of diphtheria in adult life is not very large, while in old
age it is very small. Of 501 deaths in Vienna in 1868, only 1 had
reached the age of sixty-two; of more than 300 cases in which I
performed tracheotomy but 2 were over thirteen years old.
I do not know that sex exerts any predisposing influence over
diphtheria, yet of the six hundred cases or thereabouts of laryngeal
diphtheria in which I either personally performed tracheotomy or
observed the progress of the disease in the practice of others, I
found the majority in males, and the recoveries in inverse proportion
to the number thereof, the mortality being greater among boys. As far
as age is concerned, nearly all the zymotic diseases are seen most
frequently in children. They exhibit a greater disposition to submit
to diphtheria than adults, if we except those under ten months. Where,
however, the disease has occurred previous to the seventh or eighth
month, the greater number of cases has been found under three months.
Tigri reports the disease in a child of fourteen days. A child of
fifteen days was seen with diphtheritic laryngitis and oesophagitis by
Bretonneau, one of seventeen days by Bednar, one of eight by Bouchut,
one of seven days by Weikert; Parrot mentions several cases, and
Sirédey[15] reports eighteen cases of diphtheria in the newly-born.
They occurred in the Hospital Lariboisière in the spring of 1877, and
were probably infected by the nurses of a neighboring children's
asylum. Membranes were found on the soft palate, tonsils, or larynx,
and also on both pharynx and larynx. One case occurred where the
posterior nares alone were affected. I have met with four cases of
diphtheria of the pharynx and larynx in the newly-born myself. One of
these became sick on the ninth day after birth, and died on the
thirteenth day; the other died on the sixteenth day after birth; the
third was taken when seven days old, and died on the ninth day. The
predisposition to diphtheria during childhood[16] seems to be
explainable by several circumstances. The mucous membrane of the mouth
and pharynx in the child is more succulent and softer, and frequently
the seat of a congestive and inflammatory process. The nasal cavities
are small and frequently affected by catarrhs, the buccal cavity often
the seat of catarrh and of stomatitis, and insufficient cleanliness
leads here to irritation of the mucous membrane. Any abnormal state of
the mucous membrane, with {681} the exception of an atrophic condition
and cicatricial changes, affords an excellent abode for diphtheria.
The tonsils are proportionally large; in fact, we rarely see the
tonsils in children completely sheltered by the arches of the palate.
On the other hand, the pharynx is anything but spacious, and while the
protuberant condition of the tonsils affords a resting-place for the
invading disease, the remaining space is so small that it becomes a
source of uneasiness to the well in many instances, and very much more
than that to the child during diphtheritic tumefaction. Furthermore,
we must take into consideration the large number and size of the
lymphatics, which can be more easily injected in the child than in the
adult, according to Sappey, and the fact of greater intercommunication
amongst the lymphatics and between them and the system; for S. L.
Schenck has found that the network of lymphatics in the skin of the
newly-born, at least, are endowed with stomata, loopholes through
which the lymph-ducts can communicate with the neighborhood, and vice
versâ.[17] These circumstances, although they may have no influence in
calling the disease into existence, yet assist in its development and
in adding to the severity of the symptoms.
[Footnote 15: Thèse, Paris, 1877.]
[Footnote 16: W. N. Thursfield (_London Lancet_, Aug. 3d, 10th, 17th,
1878) collects 10,000 cases of diphtheria in England between the years
1855 and 1877. Of these 90 per 1000 were under a year, 450 per 1000
from 1-5 years, 260 from 6-10, 90 from 11-15, 50 from 16-25, 35 from
26-45; 25 per 1000 were 45 years and over.]
[Footnote 17: _Mittheil. aus d. Embryol. Instit._, i., 1877.]
On the other hand, while the above reasons go to prove that diphtheria
attacks children by preference, there is again an anatomical and
physiological condition--to wit, the free slightly acid secretion of
the mouth, beginning with the third month--that acts as a hindrance to
the frequent occurrence of diphtheria after the third month. A poison
or poisonous product of whatever nature can less readily find a
hiding-place so long as it can be readily--we might always say must
surely be--washed away. During these months of eruptive secretion from
the mouth diphtheria, therefore, is not very frequent; thus teething,
in the case of diphtheria, cannot be held responsible by mothers fond
of diagnosticating dental diseases. In this connection the remark of
Krieger ought not to be overlooked, who explains the relative scarcity
of the disease in the first year of life by the fact that cumulative
influences will produce a great number of cases, and cumulation
requires time. Undoubtedly, however, an important etiological
consideration is the fact of having had the disease previously. We can
cite a host of zymotic diseases the occurrence of which once serves as
a protection against future attacks. Not only can no such security be
expected after one attack of diphtheria, but, cæteris paribus, the
disease shows a preference for those who have survived a previous
attack. The statement that only the mild cases, with but slight
elevation of temperature and freedom from severe constitutional
symptoms, are likely to suffer a relapse is founded on error. True, I
have more frequently seen relapses after mild cases--which,
fortunately, are in the majority--but the disease has also recurred
where originally high fever and an extensive lymphadenitis proved it
to be a severe case. Besides, second attacks of membranous croup are
also recorded (Guersant, N. F. Gill, Quincke).