DIPHTHERIA OF THE SKIN AND OF WOUNDS In diphtheria of the nose, conjunctiva, or ear it sometimes happens that the irritating discharge excoriates the neighboring skin with the formation of true diphtheritic membrane. This is also found exception ally on the sides of a tracheotomy wound. In a similar way the virus may be carried to more remote parts if, for any reason, they become denuded of their epithelium by scratches, vaccination, impetigo, eczema, erythema multiforme or other skin diseases. The affected parts of the skin show a doughy swelling and are covered usually with a thin, firmly seated membrane which may, however, change by extensive inflamma tion and necrosis of the skin to a thick deposit of a dirty grayish yellow or green color. From the affected parts a turbid serosanguinolent dis charge issues, often of foul odor.
Primary cutaneous diphtheria and diphtheria of the unbroken skin are very rare. In the latter case there appear on the skin red spots, rather painful, of round or irregular outline and of varying sizes. In the
centre of the spot. a whitish yellow blister appears which soon becomes aggravated. Immediately after this an ulcer forms which is covered with diphtheritic membrane (Seitz). In ninny epidemics diphtheria has been observed on the toes and fingers (Colimani, quoted by Filatow).
As bacterial toxins may be absorbed by the skin, primary cutaneous diphtheria may therefore be accompanied and followed by symptoms of toxemia; indeed, Malian makes the noteworthy observation that postdiphtheritic paralyses occur more frequently after the cutaneous than after other localizations of diphtheria, always appearing first in that part of the body on which the diphtheria was seated. Even with antitoxin fatal results may occur (E. Adler), being usually caused by a secondary infection with the development of sepsis.