Diphtheria

Diphtheria (Greek diphthera, a membrane or pellicle), an acute specific disease characterised by general constitutional disturbance, associated with a peculiar inflammatory condition involving the tonsils and surrounding parts, or the larynx. In rare instances a skin-wound or the conjunctiva of the eye may be affected by an inflammation of a diphtheritic character; the local mischief is, however, usually manifested in the throat. In a typical case of diphtheritic sore-throat the tonsils are red and swollen, and present certain patches which are at first difficult to distinguish from particles of secretion exuding from the tonsillar follicles such as may occur in cases of simple sore-throat, follicular tonsillitis, a disease quite distinct from true diphtheria. These patches, however, if the inflammation be really diphtheritic, usually extend, assume a greyish white or dirty yellow colour, and form distinct pellicles on the surface of the mucous membrane. On attempting to strip off such a pellicle ("false membrane," as it is called), the subjacent mucous membrane bleeds readily. If the case be a severe one, extensive sloughing occurs, the breath becomes exceedingly foul, the glands of the neck undergo considerable enlargement, and the constitutional disturbance is great. The mischief is apt, too, to extend to the larynx, producing hoarseness and difficulty of breathing, which latter may assume very grave proportions, and terminate, if unrelieved by operation, in actual suffocation from blocking of the air-passages with false membrane. Diphtheria was first recognised as a distinct form of disease early in the present century by a French physician, Bretonneau. In Scotland cases similar to those described by Bretonneau were designated croup (q.v.), and there has resulted a great deal of discussion as to whether croup and diphtheria should be regarded as co-extensive terms. Pathologists have adopted the expressions croupous and diphtheritic inflammations, and have attempted to distinguish between the two by the microscopical appearances of the mucous membranes affected. [Croup.] Practically, it is nowadays considered advisable to look upon all forms of sore-throat in which false membrane is detected, whether in the pharynx or the larynx, as contagious.

The symptoms of diphtheria are general and local. The first general symptom is sometimes a rigor or an attack of vomiting. More often the commencement of the disease is very insidious. There is usually, when the disease is established, some fever present, but the temperature does not as a rule attain any considerable degree of elevation. Indeed, prostration and collapse are marked features of the most severe cases. The pulse is small and feeble, the tongue dry and brown, the skin cold, and death, if it do not originate from local complications, usually occurs by syncope. The urine is generally found to contain albumen, sometimes in considerable amount.

The local symptoms are those of sore-throat, or, when the larynx is involved, of laryngitis, rapidly culminating in marked dyspnoea. The larynx is particularly apt to be involved in young children; the disease in them may apparently involve the larynx from the first. A "croupy cough" is rapidly succeeded by difficulty of breathing, with marked inspiratory recession of the chest-wall. If this condition is allowed to continue, cyanosis supervenes, and death occurs from suffocation. In such instances the only measure which will produce relief is tracheotomy. Unfortunately, in many cases, however, the benefit following upon the operation is only temporary, as the disease extends downwards, involving the lungs. Still, in not a few instances the temporary benefit gains a respite for the patient, in which the force of the malady spends itself, and recovery supervenes.

Certain sequelae of a troublesome nature sometimes appear after an attack of diphtheria. The most common is a group of symptoms known as diphtheritic paralysis. There is some loss of movement in the muscles of the soft palate, with consequent difficulty in swallowing, and regurgitation of fluids through the nose. There may, too, be paralysis of the limbs, affection of the ocular muscles, loss of sensation, and loss of "knee jerk."

Diphtheria is said to affect damp situations. It has been attributed to insanitary surroundings, and the poison is said to be communicated by milk. The discharges from the inflamed surfaces are eminently contagious, and careful disinfection should be insisted upon. The attendants upon the patient should be careful, too, to avoid inhaling his breath.