Pathogenesis 429 



are found only in the membranous exudation, 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 in severe cases it is not rare. 



The disease pursues a course of variable length, in favor- 

 able cases the patient recovering gradually, the pseudo- 

 membrane first disappearing, leaving an inflamed mucous 

 membrane behind it, upon which virulent diphtheria bacilli 

 persist, always for weeks and sometimes for months. Smith * 

 describes the bacteriologic condition of the throat in diph- 

 theria as follows: "The microscope informs us that during 

 the earliest local manifestations the usual scant miscel- 

 laneous bacterial flora of the mucosa is quite suddenly 

 replaced by a rich vegetation of the easily distinguishable 

 diphtheria bacillus. Frequently no other bacteria are found 

 in the culture-tube. This vegetation continues for a few 

 days, then gradually gives way to another flora of cocci and 

 bacilli, and finally the normal condition is reestablished." 



Diphtheria bacilli were first found in the heart's blood, 

 liver, spleen, and kidney, by Frosch.f Kolisko and Pal- 

 tauf t had already found them in the spleen, and other 

 observers in various lesions of the deeper tissues and occa- 

 sionally in the organs. In the blood and organs it is com- 

 monly associated with Streptococcus pyogenes and some- 

 times with other bacteria. While present in nearly all of 

 the inflammatory sequelae of diphtheria, the Klebs-Loffler 

 bacillus probably has very little influence in producing them, 

 the conditions being almost invariably associated with the 

 pyogenic cocci, either the streptococci or staphylococci. 



Howard studied a case of ulcerative endocarditis caused 

 by the diphtheria bacillus, and Pearce || has observed 

 it in i case of malignant endocarditis, 19 out of 24 cases of 

 broncho-pneumonia, i case of empyema, 16 cases of middle- 

 ear disease, 8 cases of inflammation of the antrum of High- 

 more, i case of inflammation of the sphenoidal sinuses, i 

 case of thrombosis of the lateral sinuses, 2 cases of abscesses 

 of the cervical glands, and in esophagitis, gastritis, vulvo- 



* " Boston Med. and Surg. Jour.," 1898, i, p. 157. 



f " Zeitschrift fur Hygiene," etc., 1893, xm, Heft 1. 



J "Wiener klin. Wochenschrift," 1889. 



"Amer. Jour. Med. Sci.," Dec., 1894. 



|| "Jour. Boston Soc. of Med. Sci.," March, 1898. 



