A system of practical medicine. By American authors. Vol. 1

by Unknown

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 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 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 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.

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 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.