Pathogenesis 419 



seat of inoculation and only rarely invade the blood. Death and 

 illness result from toxemia, not from bacteremia. 



When examined post-mortem, the liver is found enlarged and 

 sometimes shows minute whitish points, which upon microscopic 

 examination prove to be necrotic areas in which the cells are com- 

 pletely degenerated, and the chromatin of their nuclei scattered 

 about in granular form. Similar necrotic foci, to which attention 

 was first called by Oertel, are present in nearly all the organs in 

 cases of death from diphtheria intoxication. No bacilli are present 

 in these lesions. Welch and Flexner* have shown these foci to 

 be common to numerous intoxications, and riot peculiar to diphtheria. 



The lymphatic glands are usually enlarged, and the adrenals 

 enlarged and hemorrhagic. The kidneys show parenchymatous 

 degeneration. 



Roux and Yersin found that when the bacilli were introduced 

 into the trachea of animals, a typical pseudo-membrane was 

 formed, and that diphtheritic palsy sometimes followed. 



Diphtheria in man is characterized by a pseudo-membranous in- 

 flammation of the mucous membranes, particularly of the fauces, 

 though it may occur in the nose, in the mouth, upon the genital 

 organs, or upon wounds. Williams! has reported a case of diph- 

 theria of the vulva, and Nisot and Bumm have reported cases of 

 puerperal diphtheria from which the bacilli were cultivated. It is 

 in nearly all cases a purely local infection, depending upon the pres- 

 ence and development of the bacilli upon the diseased mucous mem- 

 brane, but is accompanied by a serious intoxication resulting from 

 the absorption from the local lesions of a poisonous metabolic product 

 of the bacilli. The bacilli are found only in the membranous exuda- 

 tion, and are most plentiful in its older portions. 



The entrance of the diphtheria bacillus into the internal organs 

 can scarcely be regarded as a frequent occurrence, though metastatic 

 occurrence of the organism with and without associated staphylococci 

 and streptococci, and with and without purulent inflammations have 

 from time to time been reported. Diphtheria bacilli were first 

 found in the heart's blood, liver, spleen, and kidney, by Frosch.J 

 Kolisko and Paltauf|| had already found them in the spleen, and 

 other observers in various lesions of the deeper tissues and oc- 

 casionally in the organs. In the blood and organs it is commonly 

 associated with Streptococcus pyogenes and sometimes with other 

 bacteria. While present in nearly all of the inflammatory sequelae 

 of diphtheria, the Klebs-Loffler bacillus probably has very little in- 

 fluence in producing them, the conditions being almost invariably 

 associated with the pyogenic cocci, either the streptococci or 



' "Bull, of the Johns Hopkins Hospital," Aug., 1901. 



t "Amer. Jour, of Obstet. and Dis. of Women and Children," Aug., 1898. 

 j "Zeitschrift fur Hygiene," etc., 1893, xm, Heft i. 

 I! "Wiener klin. Wochenschrift," 1880. 



