AND MEMBRANOUS RHINITIS The most frequent site for primary diphtheria, next to the pharynx, is in the nasal cavities. The fibrinous exudate may remain limited to the nose or it may spread through the posterior nares to the pharynx and mouth, or passing over the pharynx it leap to the air-passages; in rare eases it may extend up through the lachrymal canals to the conjunctiva.
It is likely in this, as in pharyngeal diphtheria, that the lymphatic ring of the pharynx is the portal of infection for the diphtheria bacillus, and that for some special reasons not the faucial but the pharyngeal ton sil is the starting point of the process. This seems to be the ease espe cially with nurslings in whom the acid reaction of the oral cavity acts to inhibit the growth of the diphtheria bacilli. (The fundamental cause for the extremely rare cases of pharyngeal diphtheria in the newborn may be traumatism of the oral and pharyngeal mucosa and artificial inoculation by the infected finger of the accoucheur.—Christeanu and Bruckner).
Primary nasal diphtheria begins with the symptoms of a marked coryza with fever, a feeling of heat and fulness in the head, and of dry ness in the throat, with obstruction of the nostrils, earache and swelling of the lymph-nodes in the floor of the mouth.
The pharynx is dry and reddened in spots. The nasal mucosa is reddened and greatly swollen, discharging an abundant, watery, sero mucus, which is sometimes bloody.
After a day or two, with an increase of fever, the fibrinous exudate appears, first as small, isolated, grayish spots which soon coalesce to form a thick, yellow or greenish deposit, which may become brown from extravasation of blood. The first deposits are found especially on the choante and the mouths of the Eustachian tubes (W. Anton). Dur ing the whole course the membrane may remain limited to the naso pharynx, but cases are seen in which the brunt of the attack is borne mainly or wholly by the anterior part of the nasal passages. In other respects the development and course are like those of secondary nasal diphtheria, with the exception that secondary complications are more frequent in this form.
Mention should be made of an appearance of pseudo-erysipelas as described by Monti and Escherich, starting at the anterior Dares and spreading along the bridge of the nose up to the forehead.
If there is not transition to the chronic form, recovery occurs in eight or ten days in those cases which are not progressive or which do not develop complications. The exudate becomes limited and is sepa rated from the basal membrane by an increased secretion of mucus which becomes admixed with the purulent discharge. According to the extent of the necrosis, recovery occurs with or without scarring.
Some peculiarities arc seen in primary nasal diphtheria in the new born and in infants. At the start there are only symptoms of a decided coryza : a brief elevation of temperature with a profuse, watery dis charge from the nostrils; a high degree of swelling of the nasal mucoste, making breathing difficult with a gurgling sound, while it is hard for the infant to nurse, owing to the obstructed respiration; apathy and stupor follow as a result of the lessened aeration in the lungs, with the attendant carbon dioxide poisoning: In a few days there is increased fever with rapidly developing antemia, great prostration and speedy enlargement of the regional lymph-nodes. Nourishment. is refused and
a state of somnolence supervenes, interrupted by periods of excitement. The nose is completely occluded but there is a bloody, ichorous dis charge. As a result. of the nasal plugging, cyanosis comes on whenever the infant tries to suckle. Sometimes the membrane is visible in the nostrils. The extension of the fibrinous exudate to the pharynx or more rarely to the oral cavity may occur in two or three days with increase in the fever and in the general intoxication. Symptoms of malignant gangrenous diphtheria may arise, with death from the seventh to the ninth day, frequently in an attack of asphyxiation (Monti).
Only about forty per cent. of the cases recover. A favorable turn may come after the first or sometimes after the second elevation of temperature, and it is accompanied by a profuse purulent discharge containing particles of membrane. It is noteworthy that the first stage may be very mild and may continue for several weeks. There is an ordinary coryza which is suspicious only through being wholly or mainly unilateral. Then with a sudden onset of severe general symptoms, that side presents the first appearance of pseudomembrane, usually on the septum.
Microscopic examination shows the same typical appearance as in pharyngeal diphtheria. In looking through many preparations only a few bacilli are found, the evidence for diphtheria being the fibrin-content with the paucity of bacteria. On the other hand, that the presence of the diphtheria bacillus is alone not sufficient to make the diagnosis of diphtheria has been shown by the researches of Trumpp, Bailin and Schaps, who found them frequently present in the nasal passages of infants who were healthy or had only simple catarrhal processes.
On the same grounds many authors hesitate to regard a peculiar kind of croupous disease of the nose, the membranous or pseudomem branous rkinitis, as a specific disease or to rank it as diphtheria.. There is moderate fever, with slight redness and swelling of the nasal nnicosa and a superficial fibrinous exudate. This sits lightly on the mucosa and can easily be removed, or it may fall off spontaneously, only to be fol lowed soon by a new formation, but not causing any loss of substance or scarring. There is no tendency to involve the neighboring parts, nor are there any symptoms of general toxfemia either during or after its formation, and the only sequels are local ones (Hartmann). The only thing pointing to diphtheria is the presence—not without exception— of diphtheria bacilli.