Chapter 13 - Diseases of the General System and Miscellaneous Diseases
Introduction to Diseases of the General System and Miscellaneous Diseases
Blood Aneamia
Typhoid Fever
Prevention of Typhoid
Bilious Remittent Fever
Congestive Fever
Fever and Ague
Yellow Fever
Purple Disease
Bubonic Plague

13.19 Diphtheria


DIPHTHERIA is an acute, contagious and infectious disease, whose characteristic feature is the formation of a pseudo membrane upon a mucous surface. It is a comparatively recent disease in this country, and only lately well understood as to its origin and pathology. The excessive mortality of this disease within the last fifty years has been so great as to justly frighten all parents at its approach, and lead them to regard it as the most terrible of all modern scourges. In New York city alone, over fifty thousand deaths have occurred in twenty five years. It is one of the most fatal, as well as one of the commonest of children's diseases. It is impossible to say at the outset whether the type will prove to be a mild or severe one. A case commencing with sudden, severe constitutional symptoms and high fever may go on to recovery; while one with slow, gradual development, and little systemic disturbance, may progress gradually and end in death. Nor is the amount of membrane present in any case a guide as to the final outcome of the case. Many very mild cases may not at first be recognized as diphtheria until later, when some post diphtheritic paralysis or other complication ensues. These mild cases are equally contagious, and often the origin of a severe and most malignant epidemic.

Cause. True diphtheria is caused by a germ known as the Klebs Loffler bacillus, either alone or in company with other germs; it is originally a local disease, becoming general as the poisons emanating from these germs are absorbed into the system.
This bacillus is always present in diphtheria, and found only at the site of the local infection, and when injected into animals produces all the characteristic symptoms of the disease.
In doubtful cases, recourse is now had to the finding of these germs by cultures made from little particles taken from the suspected membrane.
There is, besides the true diphtheria, a pseudo membranous inflammation which runs a mild course, but which cannot be distinguished clinically from the real disease, except by making these cultures in the laboratory; in the latter disease, the Klebs Loeffler bacillus is always absent. On the other hand, there are often seen cases of true diphtheria so mild in character, and showing so little membrane, as to pass unnoticed, but which on bacteriological examination prove to be the dreaded disease ; hence in all doubtful cases arises the necessity, in these modern times of refinement in diagnosis and treatment of disease, of having an examination made that the exact disease may be properly diagnosed, and the appropriate treatment be speedily instituted. The development of bacteriological science within the last few years renders this a very practical and sure test of the presence of the disease. Accepting the proven origin of the disease to be microbic, still there are many circumstances influencing the development or arrest of the germs when once introduced into the throat, since it is one of the most variable and uncertain of the contagious diseases. It is said that a normal throat will not be attacked by the bacillus, while one with some slight abrasion, inflammation, or other lesion, certainly offers a fertile field for its development. It is essentially a disease of childhood, although it occurs at all ages. Cold and dampness, and all unsanitary conditions, are known to favor the germ development.
It occurs mostly in cold weather, as at this time catarrhal conditions are present, favoring the rooting of the germ.

Propagation. The germs are introduced for the most part by the air, although food may contain these bacilli. Domestic animals have been known to frequently convey the poison. All articles of furniture, clothing, the hands of attendants, etc., are common carriers of the diphtheritic germ, which is very tenacious of life, unless previously disinfected, hence the absolute necessity of the greatest care in thoroughly cleansing everything which has come in contact with a diphtheritic patient. The writer once had the disease. The mattress on which he slept was put away, after a simple cleaning, in the attic for two years, and when later on it was brought down to accommodate his two little brothers on one occasion, the disease was communicated to them and they both died.

Incubation Period. This is quite uncertain in the ordinary case of air inoculation, depending on the condition of the throat, but probably it varies from one to twenty days. In the case of inoculation of the bacillus into the tissues of animals the period is only from one to three days.

Location of Disease. The tonsils, uvula, pharynx, nasal pas. sages and the larynx are the ordinary locations where the membrane is formed, but it may be found less commonly on the conjunctivae, border of the anus, vagina, and respiratory tract.
All the internal organs may eventually become involved through the absorption of the germ poisons, and at the autopsy show marked hemorrhages, inflammations, congestions or fatty degeneration of their tissues.

Symptoms and Diagnosis. The characteristic feature is the membrane, which is apt to be of a dull gray color, firmly adherent to the tonsil or throat, spreading gradually and becoming thicker. To distinguish it from simple follicular tonsillitis, which is so common, is often difficult and frequently impossible without a bacteriological examination. The membrane of simple tonsillitis is white, beginning as little white specks like the curd of milk, and is usually easily removed without bleeding. The membrane of diphtheria spreads and attacks the uvula back of the throat, the adjacent tissues become swollen, the neck increases in size, breathing becomes more difficult, the pulse more rapid and smaller, and prostration with drowsiness, as a rule, more and more marked.
In simple cases, there is usually not much fever, but in severe cases the temperature may run high, with great prostration and languor; delirium and restlessness accompany the severe cases of great absorption of poison. The heart usually is rapid, with feeble pulse, but many severe cases have a very slow pulse, which ordinarily is a bad symptom. The heart in diphtheria is always the uncertain element, many cases dying suddenly and unexpectedly from heart paralysis. Albumen often appears in the urine, and is usually an evidence of the involvement of the kidneys; this nephritis may become chronic and persist long after the convalescence from the original disease, and may even prove fatal. When the membrane is deposited in the nares, the breathing is more labored, and bloody mucus may be seen in the nostrils, which hardens, forming crusts, or may run down on to the lip and cause sore places. As the tonsils grow larger and the nose becomes plugged, sleep is more and more disturbed by snoring and inability to properly inspire the air, so that the child tosses from one side of the bed to the other every few minutes. Add to this an encroachment by the membrane on the vocal chords or the larynx, and one sees a truly terrible malady, distressing in the extreme. The encroachment into the larynx is suspected when the voice becomes husky and hoarse; it finally may be reduced to a whisper. The membrane may be limited to the larynx alone, as in the so called membranous croup, which is no more or less than diphtheria of this region. The symptoms of this affection are at first local, and as the disease progresses, become more and more marked and distressing till death ensues from suffocation. The face becomes blue, the chest heaves with the deep, labored respirations, the nostrils dilate, and the little spaces below the collar bones more and more depressed and drawn in.
The severity of the case depends much on the amount of absorption from the throat, nose, or pharynx, of the toxins produced by the growth of the germs on the one hand, and the ability of nature ok the other hand to resist the invasion.
The odor of the breath in diphtheria is characteristic, and when once experienced is never forgotten.

Sequelae. Besides the chronic catarrh which is left at the original site of the membrane, and the anemia (or paleness consequent on the impoverished blood), the most frequent, and the most characteristic sequel of diphtheria is paralysis, which comes on in from one to five weeks after convalescence. This paralysis lasts from two to six weeks, though it may last for months, and even for a lifetime. It is in no wise, apparently, proportionate to the severity of the disease. It is seen in all parts of the body, particularly the throat and nose, causing a nasal twang to the voice, and the regurgitation of food through the nose. It may affect the muscles of deglutition and speech, may attack the legs, arms, diaphragm, and the sphincter muscles of the bladder and rectum.

Prognosis. The prognosis varies according to the age and health of the patient, the severity of the symptoms, place of attack, and the character of the epidemic prevailing; nasal and laryngeal complications, as well as the large area of mucous membrane involved, increase the risks of the patient. The mildest cases may terminate fatally from relapse. The heart may give out at any time, and death may be close at hand when apparently all is going well. Unfavorable symptoms are pallor, prostration, vomiting, and inability to take much nourishment, weakness of pulse with great rapidity or slowness, hemorrhages into the skin, restlessness and delirium.

Prophylaxis. The complete isolation of the patient in a room of the top story, supplied with as little furniture as possible, is requisite. All utensils and dishes should be thoroughly disinfected before taken out of the room. All discharges received into a vessel containing corrosive sublimate. All clothing should be boiled when possible.
During the disease, some volatile oil, like eucalyptus, turpentine, carbolic acid, etc., should be vaporized through the room. The nurse in charge should not be in communication with other members of the household, nor children of the family allowed to play with others in the neighborhood, although they should be kept out of doors liberally, but carefully fed and in every way protected from catarrhal disorders. The patient after convalescence should be thoroughly bathed with soap and water, and finally with corrosive sublimate solution, including the hair. As much as possible of the furniture and other equipments that cannot be thoroughly cleansed by boiling water, steam or corrosive sublimate, should be destroyed; finally the room and its contents should be fumigated with sulphur fumes by burning three pounds of sulphur to every thousand cubic feet of air space.
Members of the family should be kept from school and church and other public places, and their mouths and nostrils daily washed with some disinfectant like carbolic acid gargle. Only thin, washable clothing should be worn in the sick room.

Treatment. From the first the treatment should be supportive, tonic, and stimulating. The temperature of the room should be kept at about seventy degrees, and plenty of fresh air and sunlight admitted. The clothing and bedding should be changed frequently, and the recumbent position without exertion be insisted on. The diet should be liquid, and given every two to four hours, in definite quantity, not exceeding what the child can easily digest. Beef tea, milk and lime water, egg and milk, Bovox or Bovinine in milk or water, are samples of the class of foods to be administered. Alcohol in the form of brandy, whiskey, champagne, etc., should be given freely; there is more danger of giving too little than too much. The more septic or poisoned the patient, the more the alcohol will be tolerated and required. Very large amounts are taken in this disease, as well as in all severely septic diseases. A five year old child will easily take from two to fifteen ounces of whiskey a day. Other valuable stimulants are strychnine, digitalis, ammonia, camphor, etc.
Fever when high should be allayed by cold sponging or the cool bath. All hemorrhages, diarrhea, or other exhausting complications must be stopped. Of internal treatment, perhaps none has stood the test of time better than that recommended years ago by Dr. Jacobi of New 'York, of which the following is an illustration:
Corrosive sublimate, one half grain; wine of pepsin, four ounces. Teaspoonful every two hours, for a child five years old. This is an antiseptic to the intestinal tract, and helps disinfect the system. Locally, the throat is to be sprayed with a solution of peroxide of hydrogen. If this smarts or excoriates the mouth, it may be diluted even to equal parts with lime water. This solution may be injected through the nose. It must be used freely and often.
To destroy the bacilli, a one part to one thousand solution of corrosive sublimate in the form of spray may be used after the cleansing with the peroxide of oxygen solution, or what has recently been introduced as the Loeffler diphtheria spray, which consists of several antiseptics.
The use of papoid, papayotin and other solvents of membranes, is frequently very beneficial: they may be sprayed or swabbed on to the throat. The sequelae are to be treated on general tonic principles; the catarrh is to be treated by the application of mild nitrate of silver solutions, and the paralysis by strychnia, massage, electricity, and general tonics.
These measures constitute the main essential points in treatment in those cases which for any reason do not receive the modern antitoxin treatment.
Since the better understanding of the Klebs Loeffler bacillus, attempts have constantly been made to produce an antidote to the diphtheria poison, and it would now seem as if bacteriology had at last revolutionized the entire treatment of diphtheria, for of late a remedy called antitoxin has been found and successfully tested. The death rate of diphtheria has been reduced nearly one half ; apparently, one of the greatest boons ever sent to humanity has been realized in antitoxin.
For some time it has been known that the serum of animals immune from diphtheria, when injected into susceptible animals, would prevent the infection of cultures made from the Klebs Loeffler bacillus; and at last the essential elements, or the antitoxin, has been isolated.
Not only has it been found that the injection of a given amount of antitoxin into the human subject would kill out the diphtheria, but also that, when injected into children not yet taken down with the disease, but who have been subjected to it, this antitoxin would actually prevent the occurrence of the disease iii them, or, technically speaking, render them immune.
For a long time now this ' modern blessing has been enjoyed by thousands of people all over the world. Reports are everywhere published by public institutions and private practitioners, speaking in figures more convincing than any statement could be, of the greatest advance in medicine that the last half century has witnessed, It is to diphtheria what Listerism was to surgery.
The essential features of this treatment consist in the injection into some convenient part of the body, like the back, loins, or thigh, of a certain amount of this liquid proportionate to the age of the patient, the severity of the disease, and the time elapsed since the outset of the symptoms.
The dosage varies with all these conditions, and the particular variety of antitoxin employed. The repetition of the dose depends on the amount of improvement in the membrane. At first a reddening about the diphtheritic patch is seen, then a thinning out of the membrane and a general amelioration of the symptoms. To prevent the occurrence of the disease, only quite a small amount is required, and it needs to be, injected but once. The great advantage of this treatment, outside of its favorable statistics, is the comfort derived by the patient in not being so frequently disturbed by other auxiliary treatment, as nothing else is required to be done when the case is seen early. As a matter of fact, cases are often seen so late, and the poison has so successfully invaded the system as to render the antitoxin treatment less potent, that medical men employ local measures to help out the antitoxin. The earlier the treatment is begun, the less antitoxin will be required, and the surer the successful issue.
Like all great advances in medicine and surgery, this method is not without its enemies, who will tell of the ill effects to the blood experienced later in life. The only ill effects are certain rashes resembling hives, or urticaria, situated generally near the site of the punctures and clue to local irritation. These all pass off in a few days, and axe only annoying at the very worst. Should abscesses occur they may be put down as the result of an unclean Syringe, or ascribed to the neglect of proper aseptic precautions on the part of the Physician.
This antitoxin serum, taken from horses after repeated inoculation, may now be obtained from local boards of health, and other similar authorities, thus enabling the poor to be able to procure free of cost this antidote against the most ravenous of diseases.

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