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Diphtheria and Croup

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These two diseases will be considered together, since they are the same disease—called diph theria when it principally attacks the tonsils and parts in their neighbourhood, and called croup when it principally attacks the top of the wiudpipe—the larynx (p. 354).

Diphtheria is a contagious disease, the result of the introduction into the body of a parti cular organism (p. 502). The poison may be harboured on clothes, and so carried about and spread. In some places it is more or less con stantly present, probably because of some bad sanitary conditidn. It occurs in every climate and season. It may attack persons of any age, but is most common between the ages of two and ten years. It seems to have some relation ship to scarlet fever, for in many cases diph theria occurs after scarlet fever.

Symptoms.—The disease begins to show it self within a few days after the poison has been received into the body. But the symptoms may be so ill-defined and vague that the disease is far advanced before the patient really appears seriously ill. The symptoms at the commence ment are chills and feverishness, loss of appetite, general weakness and dulness, and marked paleness of skin. Sometimes in the child the first thing that attracts attention is a complaint of soreness of throat.' The exact nature of the ailment may be made certain by microscopic detection of the organism in the phlegm or membrane removed from the throat. When the throat is examined, already there may be seen the presence of white patches that too surely indicate the nature of the disease. These are patches of false membrane, of a dull white or gray colour, like pieces of wash- leather. They are placed on the tonsils and neighbouring parts of the back of the throat. The patches are small to begin with, but they tend to spread, so that in severe cases the whole back of the throat, including tonsils and uvula (p. 195), is covered with the membi:ane. If the membrane be scraped it separates in shreds, but grows on again. The throat is also con , siderably swollen ; indeed, even though only one side is attacked, the swelling may be so great as almost quite to block the passage. The glands at the side of the jaw are also swollen. As a result of the swelling there is difficulty of swallowing, though the attempt to swallow does not produce the intense pain common in a severe attack of quinsy (p. 216). , In many

cases swallowing can be performed all through the illness. The swelling and loss of appetite combined render the patient not inclined to take food, and in children this is a cause of much trouble. For a marked feature of the disease is the excessive prostration it produces. It is to combat this that remedies are, from the first, directed ; and so where disinclination to swallow exists, there is great difficulty in getting sufficient food taken to maintain the strength. The disease may not go beyond the stage described, and in ten days or a fortnight recovery begins, the membrane separating in pieces, and being spat out, or, in young children, swallowed. The breath is frequently very foal, because of the decomposition of the false mem brane. Even after the throat is quite clear and clean, the patient remains extremely feeble, and in some cases the voice is altered, perhaps lost for a time, owing to paralysis.

But the membrane may extend up into the back of the nostrils, and be evidenced by stop ping of the nostrils and discharge of matter and blood ; and it may pass down the gullet towards the stomach. Thus the disease may be so prolonged that the patient dies of ex haustion.

A most frequent and the most fatal form of the disease is that in which the formation of the false membrane proceeds downwards into the windpipe. The symptoms of this occurrence are those of croup. The voice is hoarse and there is a short dry cough of a peculiar charac ter. It is hoarse and muffled, "like the distant barking of a puppy." Sometimes it is a brassy sound. Accompanying the progress of the dis ease down the windpipe there is increasing difficulty of breathing. These signs are of the most serious nature, especially so in children, in whom the passage of the windpipe is narrow and easily blocked. As the membrane thickens the voice is lost, and the cough becomes muffled and almost noiseless. Suffocative fits come on, partly due to spasm, partly to the membrane blocking the air-passage, and the patient strug gles for breath, the face becoming blue and the eyes staring. One fit lasses off, and the patient becomes easier, but speedily another conies ' on, the person at last sinks into a state of ex haustion and stupor, and death occurs. Usually the end happens before the fourth or fifth day after the symptoms began.

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