112 ELEVENTH REPORT. 



UNDETECTED CASES OF NASAL DIPHTHERIA. 



P. M. HiCKEY, M. D. 



From the attempt which the profession is making to stamp out diphtheria 

 by the isolation of patients afflicted with that disease and by the hberal use 

 of antitoxine both as a curative and prophylactic, we find that a marked 

 diminution of cases has resulted. 



However, in spite of the recognition of typical clinical cases and their 

 proper treatment, we find cases occurring in individuals and in families 

 where the history of contagion is difficult to trace. In the pharynx and 

 larynx where the adjacent lymphoid tissue makes the absorption of the 

 toxic products very evident, the general condition of the patient is usually 

 sufficient to call attention to a systemic disease, even where the local symp- 

 toms may be such as not to be very prominent. 



One of the ways by which diphtheria is spread, in the writer's opinion, is 

 that nasal diphtheria is very frec|uently um-ecognized, and owing to the 

 mildness of the disease may run a long course, giving rise to the infection 

 of many with whom the case comes in contact. The nose may be infected 

 and the culture made from the nasal secretion may show a pure growth of 

 the Klebs-Loeffler bacillus, and yet the constitutional symptoms may be 

 so slight that the clinical picture is often interpreted as that of a simple 

 coryza. The following cases may illustrate the point which the writer 

 would strive to make prominent. 



Case I. In September, 1907, the writer was asked to see a case in con- 

 sultation, with reference to the removal of adenoids for difficult breathing. 

 The patient was a child of four years of age, and upon talking with the mother 

 it was found that the breathing up to three weeks previous had been c{uite 

 free, with no symptoms of nasal obstruction. At that time the child was 

 supposed to have contracted a cold, since which time the respiration had 

 been principally oral, with attacks of choking at night. 



Examination of the case showed a thick discharge, principally from the 

 left nostril. This was evidently of an acrid, irritating nature, as the skin 

 of the upper lip and the edge of nose w^ere all inflamed. Inspection of the 

 throat showed no membrane upon the larynx or tonsils, and there was no 

 hoarseness to indicate any pharyngeal involvement. 



Owing to the acuteness of the condition, its short clinical history, and 

 the fact that the discharge was principally unilaterally, it was decided to 

 make a culture from the nose. This was done, and the report from the 

 Board of Health showed pure growth of Klebs-Loeffler bacillus. The child 

 was given antitoxine and the other children of the family were given suitable 

 immunizing doses, and the trouble was ended. 



Case II. A little girl, age 7, child of a physician on the east side, was 

 brought to the office by her father for an acute cold. She gave no history 

 of a severe illness, having manifested only a slight indisposition for about 

 two weeks. This had been accompanied by a slight rise of temperature. 

 The discharge from the nose was seen to be principally from the left nostril 

 and of a very thick nature with a slight tendency to bleeding. 



Examination of the pharynx and larynx was negative. As the child 

 was old enough to exclude the introduction of a foreign body into the nose, 



