to take place, and recovery is also slow when the tissue has finally
submitted. Pavement epithelium yields the easiest foothold to
diphtheritic membrane. Thus it is that the tonsils, not from their
prominent situation alone, favor the reception and development of the
infection. But the elastic and connective fibres when once affected
are apt to harbor the disease a long time. Still, there is another
reason why the diphtheritic process should favor the tonsils. For Th.
Höhr has demonstrated that their epithelium exhibits interruptions in
its continuity. Through them round cells may emigrate. Wherever the
epithelial covering of the integuments (skin or mucous membrane) is
intact and unbroken, diphtheria takes hold with difficulty. But where
a defect is established, large or small, diphtheritic formations will
be apt to take place according to the size of the abrasion. This is
one of the modes of the formation of small diphtheritic deposits on
the tonsils, which it has been the tendency of many, both
practitioners and authors, to honor with special names.
Ciliated epithelium is not so liable to be affected. It occupies a
higher rank in the scale of animal formations, has a more complex
function and a greater power of resistance. The presence of a large
number of mucous glands impedes, as a rule, by the presence of the
normal secretion, an extensive destructive action upon the tissues.
The secreted mucus assists in removing epithelial masses, and even
fibrinous exudations, from the surface. Thus it is that the deposits
in the respiratory portion of the nasal cavities are frequently cast
off through the nostrils, and in a similar manner the membranes that
have formed in the trachea are ejected in a semi-solid condition
through the opening made by tracheotomy. The large number of mucous
glands in the larynx and trachea is unquestionably the reason why the
lymphatic vessels of the mucous membrane are not influenced by the
overlying loosened masses, and will not absorb; hence laryngeal and
tracheal diphtheria, when not complicated, have decidedly a local
character, and are usually devoid of constitutional symptoms. For the
{689} same reason the usual form of tonsillar diphtheria is a mild
disease. On the other hand, the large number and size of the lymphatic
ducts of the Schneiderian mucous membrane, as well as their direct
communication with the lymphatic glands of the neck, accounts for the
dangerous character of nasal diphtheria.
Diphtheria of the intestinal canal is characterized by fibrinous
deposits on the surface and in the tissues of the intestine, with
subsequent granular degeneration. It is mostly preceded by a catarrhal
process. The same condition is found in the urinary organs.
There are but few autopsies of cases which have died of, or during,
diphtheritic paralysis. In some instances there was considerable
thickening of the spinal nerves at the junction of the posterior and
anterior roots, with hemorrhages. The superficial connective tissue in
these places exhibited a diphtheritic exudation (Buhl). There was in
the sheath of the nerves of the cerebral and spinal meninges and in
the gray substance of the cord voluminous nuclear infiltration; in one
case there were extensive hemorrhages in the spinal meninges, with
nuclear proliferation in the gray substance of the cord (Oertel).
Disseminated meningitis with perineuritis of the neighboring roots,
characterized by infiltration of nuclei between the nerve-fibrillæ was
found by Pierret; and degeneration of the palatine nerves and fatty
degeneration of the palatine muscles by Charcot and Vulpian. Dejerine,
in five autopsies, records an atrophy of the anterior roots secondary
to a myelitic degeneration of the ganglia of the anterior horns. E.
Gaucher found the same in the case of a boy who died with paralysis of
the muscles of deglutition, of the extremities, and of the trunk. In a
child of two years with paralysis of the palate and extremities the
autopsy was negative. In two cases Dejerine reports finding changes in
the intramuscular nerves, such as liquefaction of myelin and loss of
axis cylinders.
Thus, Buhl, Charcot, Vulpian, and Dejerine are unanimous about an
affection of the peripheric nerves and muscles. Oertel, Dejerine, and
Gaucher believe in a disease of the spinal cord. It is true that a
disease of the gray substance would fully explain the symptoms of the
bad cases, but what we know of poliomyelitis anterior, with which this
affection would be identical, precludes the idea of the rapid and
almost certain complete recovery. Therefore, in most cases,
diphtheritic paralysis consists of a trophic affection of the motor
system, almost always seated peripherally in the nerves and muscles,
seldom, if ever, in the centres. This affection must be compared, in
most of its relations, with the degenerative processes taking place in
the muscular tissue after typhoid fever, or in the renal epithelium
after infectious diseases, both of which give rise to serious results,
with usually a favorable termination.
DIAGNOSIS.--The characteristic sign of diphtheria is either the
membrane or the gray infiltration, with more or less injection of the
surrounding parts. In regard to this greater or less injection, I will
say that pharyngeal congestion, when it is uniform, may or may not
point to imminent diphtheria. When it is local, confined to one side
mainly, it is either traumatic or diphtheritic. White spots which are
easily washed away, or which can be removed with a brush, or squeezed
out of the follicles of the tonsils, into which a probe can be
introduced sometimes to the depth of one-half inch, soon announce
their true character--viz. either a {690} simple catarrhal secretion
or suppuration. Even though the superficial deposit contain oidium or
leptothrix in considerable numbers, it can easily be removed; I have
only known the totally inexperienced to mistake muguet (thrush) for
diphtheria. In the larynx muguet is, moreover, very rare indeed, and
always circumscribed. It is sometimes seen on the true vocal cords.
The gray discoloration of superficial follicular ulcerations, as
observed in the ordinary form of stomatitis follicularis, can hardly
fail to be recognized. Such patches are very numerous in the fauces
and on the lips and cheeks--never on the gums, except in ulcerous
stomatitis (which is not follicular). They are accompanied, too, by
vesicles containing more or less serum which have not yet ruptured. It
must be remembered, however, that the mucous membrane, when deprived
of its superficial covering, is liable during an epidemic of
diphtheria to become infected, like every other wound. I have seen
cases in which stomatitis and diphtheria existed side by side, the
latter having invaded the surfaces exposed by the former. The
examination of the entire throat is not always easy. Very young
children vomit frequently and persistently before the whole surface is
exposed to view, and not infrequently repeated examination with the
spatula is absolutely necessary. In general, however, the slight
attempts at vomiting suffice to cause a great part of the swollen
posterior portion of the tonsils to become visible. I have heard that
the pale surface of old hyperplastic tonsils has been mistaken for
diphtheria; I merely mention the fact. When a discoloration happens to
be the result of a deposited flake of mucus, a drink of water will
remove it.
Fever is not always a prominent symptom; as a rule, simple diphtheria
of the tonsils is accompanied by very little fever. Still, there are
plenty of exceptions. But the differences of temperature are not more
striking than in most other infectious diseases, whose either mild or
severe invasion may offer an obstacle to immediate diagnosis. As the
height of the fever does not absolutely determine, or even indicate,
the character of the subsequent course of the disease, but little
importance is to be attached to the temperature unless there be a very
marked elevation. A sudden rise frequently occurs with lymphadenitis.
High fever in the beginning may render the diagnosis difficult or may
postpone it.
The absence of glandular swelling does not exclude the diagnosis of
diphtheria, for when the tonsils are affected by the disease there is
usually little or no swelling of the neighboring glands. Swelling of
the glands enables us to locate the affection in a mucous membrane
richly endowed with lymphatic vessels. It is very marked when the nose
is affected. A few hours' duration of nasal diphtheria suffices for
the development of a severe lymphadenitis, especially at the angles of
the jaw. When the latter condition is found to exist, the throat
should be examined with the idea of finding a membrane extending
upward; nasal diphtheria is very liable to complicate an affection of
the uvula and arches of the palate. The membrane cannot well be seen
by looking through the nostrils; highly serviceable for this purpose
is a very short, broad rhinoscope reaching upward to the bony
structure of the nose. However, nasal diphtheria may frequently be
diagnosticated some days before the membrane becomes visible, by the
rapid development of lymphadenitis; this may be done even where the
sweetish, musty odor of certain forms {691} of diphtheria is absent.
Still, nasal diphtheria may occur without much lymphadenitis; as, for
instance, when the blood-vessels are very numerous and superficial,
and thereby give rise to slight hemorrhages at the very beginning of
the sickness. In such cases the lymphatic vessels are little, if at
all, required to transmit the poison, the open blood-vessels replacing
them in the function of absorbing. Naturally, there are cases in which
an ocular examination cannot be satisfactorily made. In the journals
we read of brilliant results of rhinoscopic and laryngoscopic
examination; in practice we see but few. This holds good especially
for the cases of dyspnoea accompanying laryngeal diphtheria, where the
diagnosis may be doubtful when no membrane can be detected in the
fauces; even if membrane be observed there, symptoms of suffocation
may still arise from a laryngeal stenosis independent of membranous
deposits in the larynx. If aphonia and difficulty of both inspiration
and expiration be present at the same time, there is certainly
membranous occlusion. If aphonia appear late, or even toward the very
last, and only inspiration be impeded while expiration is
comparatively free, there is an oedematous saturation of the
ary-epiglottidean folds and of their copious submucous tissue, and
consequently of the posterior attachment of the vocal cords. Although
a general oedema glottidis in connection with diphtheria is of
exceedingly rare occurrence, the above condition is not at all
uncommon, and has forced me to tracheotomize many times; but, again, a
comprehension of the true condition, where it occurred in not very
severe cases, has on several occasions enabled me to avoid an
operation. This local oedema may sometimes be detected by palpation in
the region of the swollen posterior wall of the pharynx.
One of the diagnostic symptoms of membranous laryngitis, believed in
and referred to by Krönlein, does not exist--viz. the swelling of the
lymphatic glands, which in his opinion is pathognomonic. Not only is
that not the case, but the absence or scarcity of lymphatics on the
vocal cords and in their neighborhood renders the absence of glandular
swellings a necessity, provided the latter do not depend on
complicating diphtheria in other localities. In uncomplicated
diphtheritic laryngitis I expect no lymphadenitis. The character of
the laryngeal pseudo-membrane does not depend at all on the condition
of the pharynx. The latter may have membranes of any description or
consistency without permitting the diagnosis of the condition of the
larynx. I lay stress on this fact because no less a writer than
Krönlein believes that where there is but little or no membrane in the
pharynx, that in the larynx is rather loose and movable.
One of the diagnostic symptoms of diphtheritic laryngitis, or
membranous croup, is the relative absence of fever. Catarrhal
laryngitis, or pseudo-croup, is a feverish disease. A sudden attack of
croup with high temperature, provided there is no pharyngeal or other
diphtheria present, yields a good prognosis; without much fever, a
very doubtful one.
The diagnosis of diphtheritic paralysis offers very little difficulty
in most cases. Its occurrence after an attack of diphtheria, its
beginning in the fauces or in the muscles controlled by the ciliary
nerves, the immunity of the sphincters, the gradual development, the
irregularity of its progress, are good diagnostic points. Examination
by the interrupted or continuous current is not conclusive. Very
frequently in the {692} beginning the response to the interrupted
current is normal, sometimes deficient; to the continuous current,
exaggerated. After some time the power of both to excite contraction
is diminished. When we reflect on the numerous causes which may
underlie diphtheritic paralysis, and that we have not to deal with one
and the same anatomical change in all cases, it becomes apparent that
no reliable conclusions can be based upon electrical examination.
PROGNOSIS.--In general, the prognosis in diphtheria is favorable when
the affected surface is of small extent and where such parts are the
seat of disease as have little communication with the lymphatic
system. To the latter class belongs simple diphtheria of the tonsils.
Marked glandular swelling, particularly if arising suddenly, is always
an unfavorable sign, and calls for the utmost caution in prognosis,
especially if the region of the angles of the jaw be speedily and
markedly infiltrated. This, as we have seen, is particularly apt to
occur with nasal diphtheria, whether developed primarily, (and then
accompanied by a thin fetid discharge), or, as is more commonly the
case, secondarily from an affection of the pharynx and palate which
ascends into the posterior nares. With the appropriate local
disinfection this form of the disease is neither so alarmingly
dangerous as Oertel depicts it, nor so assuredly fatal as Roger but a
few years ago taught in his clinique, or as Kohts appears to
believe,[38] yet it is ever grave. With energetic treatment many cases
will, however, get well. Diphtheria of wounds, complicating diphtheria
of the pharynx, is always an unfavorable sign; that of the mouth and
angles of the mouth, associating itself with a previously existing
diphtheria, having an indolent course, and producing more frequently a
deep impregnation of the tissues than a thick deposit, causes a
painful and serious condition. Diphtheria of the larynx, whether it be
of primary origin or the result of extension from the fauces, is
nearly always fatal. In severe epidemics the mortality is 95 per cent.
Tracheotomy, too, saves but few of those who take the disease at such
a time. In fifty consecutive tracheotomies from 1872 to 1874 I did not
see one recovery. In the last few years I have seen few good results.
In average epidemics tracheotomy will save 20 per cent. A pulse of 140
to 160, and high fever immediately after the operation, render the
prognosis bad; so does absence of complete relief after the operation.
An almost normal temperature the day after the operation is an
agreeable symptom, but does not exclude a downward extension of the
diphtheritic process, and hence cannot be looked upon as assuring a
favorable prognosis. A marked elevation of temperature is apt to
indicate a renewed attack of diphtheria or a rapidly-appearing
pneumonia, and is an unfavorable symptom. A dry character of the
respiratory murmur some time after tracheotomy indicates the approach
of death within from twelve to twenty-four hours from descent of the
membrane; so does cyanosis, whatever be its degree of intensity.
Diphtheria of the trachea, which ascends to the larynx, is positively
fatal. It has a rapid course, and tracheotomy only postpones the end
for a little while, if at all. The general health and strength of the
little sufferer have no influence whatever.
[Footnote 38: Gerhardt, _Handb. d. Kinderkr._, iii., 2, p. 20, 1878.]
Thick, solid deposits need not of themselves render the prognosis so
unfavorable as do septic and gangrenous forms. Even in the nose they
{693} are not of as serious import as the thin, putrid discharge. I
have seen recovery ensue in cases where I was obliged to bore through
the occluded nasal cavities with probes and scoops. Fetid, putrid
discharges are unfavorable, but in no wise fatal; conscientious
disinfection accomplishes a great deal. Slight epistaxis indicates the
possibility of rapid absorption through the blood-vessels; but here,
too, the final result depends on whether the disinfection be equally
rapid and thorough. The same holds true for the sweetish, fetid odor
of the breath, whether of the nose or mouth, which, on the one hand,
demonstrates the significance of the disease, while, on the other
hand, it indicates the possibility of infection by inhalation.
The height of the fever is not in proportion to the danger in any
individual case; some have a favorable, some an unfavorable
termination, without fever of any account. Simple catarrh of the
pharynx and larynx frequently begins with a sudden and marked rise of
temperature; diphtheria in the same parts but rarely. There are cases,
however, in which the height of the fever and the deposited membranes
are in inverse proportion to each other. In these cases the fever may
subside rapidly, owing to a speedy elimination of the poison. Young
children only are in danger of death from convulsions or a rapid
tissue-degeneration due to hyperpyrexia. If the temperature rise
suddenly after some days of sickness, either a complication or a fatal
termination is to be apprehended. Yet, there are as many deaths in
cases with comparatively low as with very high temperatures. Whether
collapse has resulted rapidly or slowly, the patient dies often with
low temperature. Thus, a rapid elevation is hardly a more unfavorable
sign than a rapid fall. The pulse, too, may be very variable. True, a
small, rapid, and irregular pulse is always unfavorable, because it
indicates a weakening of the cardiac function; yet as long as it
retains an approximately normal relation to the frequency of
respiration a rapid pulse gives no cause for alarm. Moreover, the
pulse is not always rapid when the strength gives way. It occasionally
becomes slower, and sometimes very slow, and may then become a
dangerous symptom.
Every complication adds to the danger. Bronchitis and pneumonia are
not infrequent, yet I have seen cases of laryngeal diphtheria recover
in which I had suspected pneumonia before performing tracheotomy, and
was enabled to diagnosticate it after operating. Albuminuria in the
early part of a diphtheritic attack with high fever is of little
significance; nephritis, later in the course of the disease, partakes
of the character of scarlatinous nephritis; cases of acute diffuse
renal disease are fortunately infrequent, and the remainder are very
submissive to treatment. The cases of diphtheria complicated with
endocarditis in my practice have ended fatally. An early affection of
the sensorium, not dependent on pressure upon the jugulars by greatly
swollen glands, is an unfavorable symptom. Purpura, with profuse
hemorrhages and a livid hue of the skin, is ominous; icteric
discoloration, together with marked glandular and periglandular
tumefaction, is absolutely fatal.
Most cases of diphtheria of the pharynx and of the tonsils have a
favorable termination, yet a positive prognosis can in no case be
given with certainty. Still, even in malignant epidemics the mortality
is not very great, for even though there be a large number of severe
cases in {694} any one epidemic, yet it is greatly overbalanced by the
number of moderately severe and mild ones. True, not a few cases end
fatally in several days, owing to the high fever, or to septic
absorption, or nephritis, or croup, but the majority of cases end in
recovery in one or two weeks. Yet diphtheria does not always take so
regular a course; not infrequently, after the pulse has become
stronger, the appetite improved, and the pharynx cleared, and the
patient is apparently on the high road to recovery, another attack
occurs accompanied by fever, as before, and a rapid formation of
membrane. Occasionally two or three such relapses may occur in the
course of three, four, or five weeks; not to speak of the fact that
those who have once suffered from diphtheria are more susceptible to
the action of the poison than those who never suffered before.
TREATMENT.--Every case should be treated on general principles; thus,
it is not possible to lay down a routine treatment for every
individual case. High fever should be reduced by sponging and bathing,
quinia, and sodium salicylate; collapse speedily treated, and severe
reflex symptoms, as vomiting, etc., checked at once. Whether to employ
for this purpose ether, wine, cognac, champagne, or coffee must be
decided by the physician in individual cases. The administration of
the remedy, whether by mouth, by injection into the bowels, or
subcutaneously, as I have employed cognac, ether, alcohol, and camphor
dissolved in ether or alcohol, in some cases with decided and rapid
success, must depend on the condition of the organs and on the urgency
of the case. However, all the above remedies are frequently of no
service, because administered too late and in too small doses. If I
have ever had cause to feel contented with the results of treatment in
diphtheria, it is owing to the fact that I lost no time. No medicines,
however, must be resorted to which are apt to derange the digestion of
the patient; alcoholic stimulants must be given in fair dilution only,
for that reason. The nourishment of the patient is a matter of very
great importance. On general principles it is true that care must be
taken in regard to food administered to febrile patients, but we must
bear in mind that, when the lymphatic vessels are kept empty and no
new and proper material is introduced into them, the absorption of
locally-existing poisonous substances is proportionately increased.
Hungry lymph-vessels are the organism's fiercest enemies.
I dwell particularly on the foregoing remarks for the reason that in
diphtheria, unlike certain diseases having a typical course and those
of a simple inflammatory character, expectant treatment should not be
indulged in. Oertel's advice, that when neither high fever nor
complications are present we should quietly wait, and "act only when
new and most alarming symptoms present themselves," is decidedly
perilous. A mild invasion does not assure a mild course. Never has a
"possibly superfluous" tonic or stimulant done harm in diphtheria, but
many a case has a sad termination because of a sudden change in the
character of the disease, putting the bright hopes of the physician to
shame. Only the philosopher may be a passive spectator; the physician
must be a guardian. When I again read, in the work of the same
meritorious author, "that when in exceptional cases, in children and
young people, death is imminent, not from suffocating symptoms in the
larynx and trachea, but from septic disease and blood-poisoning, it is
necessary to resort to {695} powerful stimulants," it strikes me that
he is frequently too dilatory with his remedies, and, furthermore,
that his experience concerning the terrible septic form of diphtheria
which is so frequently met with in some epidemics must have been very
limited at the time he was writing. In New York, during the past
twenty-five years, for every death from diphtheritic laryngeal
stenosis (membranous croup) there have been three from diphtheritic
sepsis or from exhaustion.[39]