Primary Nasal Diphtheria. 
BY 
CHARLES W. TOWNSEND, M. D. 
Reprinted from the Bosto7i Medical and Surgical Journal 
of May 24, 1844. 
BOSTON: 
DAMRELL & UPHAM, Publishers, 
283 Washington Street. 
1894. S. J. PARKHILL & CO., PRINTERS 
BOSTON PRIMARY NASAL DIPHTHERIA.1 
BY CHARLES W. TOWNSEND, M.D. 
That nasal diphtheria is a severe and often fatal 
disease, and that it is almost always secondary to diph- 
theria in the throat, is the generally received idea both 
from practice and text-books. 
Thus Dillon Brown, in Starr’s “ Text-Book of 
Children’s Diseases,” just published, says: “ In the 
nares diphtheria is very serious, on account of the 
abundant lymph and blood-supplv,” etc. 
W. Gilman Thompson, in Pepper’s “ American 
Text-Book of the Theory and Practice of Medicine,” 
also just published, says: “ Cases of nasal diphtheria 
are apt to end fatally unless vigorously treated.” 
And J. Lewis Smith says, in Keating’s “Cyclo- 
paedia of Children’s Diseases”: “Nasal diphtheria in- 
volves great danger, from the fact that it is likely to 
give rise to systemic infection of a grave type.” Lower 
down he says: “Although commonly diphtheritic in- 
flammation of the nasal surfaces is secondary to that 
of the fauces, it is sometimes the primary inflamma- 
tion. It may exist for some days before the fauces 
become affected, and under such circumstances the 
diagnosis is frequently not made until the disease is in 
an advanced stage and profound blood-poisoning has 
occurred.” 
That mild primary cases sometimes occur, the mild- 
ness of whose symptoms may permit them to go un- 
recognized, is a point I wish to emphasize, and particu- 
larly the fact that these cases are of great danger to 
the public health. 
Dr. A. L. Mason2 refers to these cases when he 
says: “ Primary nasal diphtheria is probably more 
1 Bead before the Boston Society for Medical Improvement, March 
12, 1894. 
2 Burnett: System of Diseases of the Ear, Nose and Throat, vol. 
i, p. 270. 2 
common than is supposed, and a not infrequent source 
of unsuspected danger.” Jacobi also alludes to them; 
and Major8 reports five cases very similar to those I 
am about to relate. The latter says of nasal diph- 
theria : “ When of a primary nature, it is very likely 
to be overlooked altogether.” It seems probable that 
some cases formerly supposed to be membranous rhini- 
tis were in reality nasal diphtheria. 
During the months of November, December and 
January of this winter fourteen cases of diphtheria oc- 
curred among the patients of the Children’s Hospital, 
all but two of which came under my charge in the iso- 
lating wards. 
The bacteriological examinations were made for the 
hospital by Dr. J. H. McCollom at the Harvard Medi- 
cal School, and, it is unnecessary to say, were of the 
greatest value.4 
There were seven cases where the nose was affected ; 
in six cases the disease was limited to the pharynx; 
and in one case an old tracheotomy wound was 
attacked, the disease spreading to the bronchi and 
rapidly proving fatal. 
The six pharyngeal cases I will pass over briefly. 
They illustrate the well-known difficulty and ofttimes 
the impossibility of making a diagnosis of diphtheria 
from gross appearances or symptoms. They were all 
mild cases; all recovered. One of the earlier cases 
began with coryza, and had a nose-bleed on the day 
preceding the beginning of the throat affection; and 
although there is no positive proof of nasal diphtheria 
from the absence of cultures from the nose in this 
8 Diphtheria and Scarlet Fever at the Boston City Hospital. Bul- 
letin 4, Harvard Medical School Association. 
4 “The various cultures from the Children’s Hospital were interest 
ing from the fact that in a large number of cases guinea-pigs were 
inoculated, and in the majority of instances the pigs died in from 24 
to 48 hours, showing clearly that we were dealing with a virulent 
form of the Kleb-Loffler bacillus.” [Remarks by Dr. McCollum at 
the meeting.] 3 
case, it is extremely probable, in view of the other 
cases, that this one was originally nasal diphtheria, 
and as such was overlooked. 
Of the seven nasal cases of diphtheria, in five the 
disease was primarily nasal, being confined to the nares 
alone in four, in one extending later to the pharynx 
and larynx, while in the remaining two cases the dis- 
ease was at first pharyngeal, and later involved the 
nose. These last two cases represent the secondary 
nasal forms more commonly seen, partly from the fact 
that the diagnosis of the trouble in the throat having 
been made, it is natural to suspect an extension to the 
nose in case there is a nasal discharge, and to look for 
membrane there, and partly because secondary nasal 
diphtheria is usually a very severe disease. 
The primary nasal cases are easily overlooked; the 
diagnosis frequently cannot be made without a bac- 
teriological examination, and they are particularly 
dangerous as sources of infection from these causes, 
and from the fact that the bacilli may be retained for 
a long time on the voluminous mucous membrane of 
the nose after the patient has apparently recovered, 
and may even at times elude the search of the bac- 
teriologist, as some of my cases show. 
Case I. A boy, four years old, began to have a 
nasal discharge on January 3d. This increased on 
the following day, but there was no rise of tempera- 
ture, and the pulse showed no weakness. The nasal 
discharge was watery and at times muco-purulent, and 
was not offensive. On the third day of the coryza 
careful examination showed some gray membrane in 
each nostril, and a bacteriological examination demon- 
strated the Klebs-Loffler bacillus. There were nose- 
bleeds from time to time. The temperature, as will 
be seen by the chart, remained between 99° and 100° 
until the twelfth day of the disease, going once to 4 
101°, the child feeling meanwhile well enough to be 
up. Examinations by cultures taken from the nose 
by the platinum wire were made from time to time, 
and the Klebs-Loffler bacilli were still found on the 
thirteenth day, or three days after the temperature 
had dropped. On the fifteenth day, the day’ following 
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Case I. 
the cessation of nasal discharge, a culture was taken 
and no bacilli found. 
The child was not allowed to go home until six 
days later, or a week after the cessation of the nasal 
discharge, but the sequel shows he still retained some 
of the Klebs-Loffler bacilli in his nose. Shortly after 
returning home, a servant, who had not been away for 
over three weeks, came down with diphtheria. That 
the child’s nose was the probable source of infection 
was proved by the fact that the specific bacilli were 5 
discovered there when he presented himself at the 
clinic four weeks after his discharge from the hospital, 
and over five weeks since his apparent recovery. At 
this late date, however, a nasal discharge was present, 
having started up after leaving the hospital. 
Case II. A boy, four years old, was the mildest 
case of all. He was kept isolated in the main hospi- 
tal, not coming under my charge; and I am indebted 
to the courtesy of Dr. Bradford for permission to in- 
clude it with the others. The child began with coryza 
and nose-bleed and a temperature of 101.3° A cult- 
ure was at once taken from his nose, and the Klebs- 
Lbffler bacilli were found. On the following day a 
little membrane was visible, and there was a watery 
discharge from the nose. On the third day there was 
apparently nothing the matter with him but a bad 
coryza. No more membrane was seen, and the tem- 
perature came to normal on the fifth day. On this 
day the Klebs-Lbfiler bacilli could not be found. No 
subsequent cultures were taken, but it is probable 
that the bacilli would have been found for some time 
in his nose. 
Case III. A girl, seven years old, again illustrates 
the purely nasal forms. During the first week a 
thick, glistening, gray membrane was plainly visible 
in the nose, and the patient suffered from nose-bleed 
twice. The Klebs-Loffler bacilli were found until 
the fourteenth day of the disease, on which day the 
membrane disappeared from sight. As will be seen 
by the chart, the temperature continued between 99° 
and 100° for twelve days after the disappearance of 
the membrane. She was not discharged from the hos- 
pital until all signs of nasal disease had disappeared 
and the last bacteriological examination was negative. 
Two or three days after her return home her brother 
was taken sick with diphtheria, recovered, but died 6 
suddenly a week later with, as far as could be learned, 
suppression of urine. 
Case IV. Girl, two and a half years old, began 
with a cold in the nose, and at the same time some 
white circumscribed pin-head spots appeared on the 
tonsils, but entirely disappeared within forty-eight 
hours. The diphtheritic bacilli were found in these 
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Case IV. 
apparently follicular spots, as well as in the nose. 
Membrane then appeared in the nose, and there was 
some sanguino-purulent discharge for a day or two. 
After this the discharge was slight and muco-purulent 
or watery, coming and going like an ordinary coryza. 
At no time after the first three days could one have 
made from the gross appearances any other diagnosis 
than a coryza, as there was no membrane to be seen. 
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Case V. 7 
were, however, found at every examination, which 
was on alternate days, until the twenty-sixth day of 
the disease, and there was some muco-purulent dis- 
charge at intervals until the twenty-third day. The 
temperature, as will be seen by the chart, started off 
at first as if in correspondence with the apparent folli- 
cular tonsillitis, and then ranged from the third to the 
fourteenth day between 99° and 100°, remaining nor- 
mal after the fifteenth day. 
The pulse showed but little evidence of weakness, 
except of an occasional slight nasal obstruction, the 
child appeared perfectly well after the first four days, 
and at home would have been, if the diphtheria were 
unrecognized, an active spreader of the disease. 
For the sceptical, as to the value of the bacteriologi- 
cal method of diagnosis, the following case is of inter- 
est, for its later violent course confirmed very fully 
the early bacteriological diagnosis. This was the only 
primary nasal case in which there occurred an exten- 
sion of the membrane from the nose. 
Case V. A boy, six years old, said his nose was 
sore on January 12th. There was a slight discharge 
at this time, which dried up in a day or two, and noth- 
ing was thought of it. Seven days later he had a 
nose-bleed, and on the following day glistening white 
membrane was discovered in one nostril, and a nasal 
discharge began. An examination on this day showed 
the Klebs-Loffler bacilli. Two days after the mem- 
brane appeared it spread to both nostrils, and again two 
days later both tonsils and the posterior wall of the 
pharynx were rapidly covered with the membrane. 
Again, two days later, evidence of laryngeal infection 
was shown by the croupy cough; and although intuba- 
tion was performed by Dr. Goldthwait, the patient 
died on the following day. 
An examination of his temperature chart is inter 8 
eating. The child was in the hospital for a stiff knee, 
and there was no active process going on there to 
cause an elevation of temperature. It will be seen 
that for a week -before the first temporary nasal dis- 
charge occurred the temperature was elevated about 
100°. This is certainly suggestive of a beginning of 
the nasal diphtheria at this time. Another interesting 
point is the normal and subnormal temperature for 
three days following the appearance of the membrane 
in the nose and the discovery of the specific bacilli. 
The continued slight elevation of temperature be- 
tween 99° and 100° seen in several cases when the 
disease is confined to the nose is interesting. In the 
following case this continued for a month after the 
membrane had disappeared from the portion of the nos- 
trils easily visible. With this temperature in bed, the 
patients seemed to feel perfectly well. If they had 
been about, they would very likely have shown evi- 
dences of debility by feeling tired and irritable. The 
early history of this case is very suggestive as regards 
the “ follicular tonsillitis.” 
Case VI. Boy, six years old, had an attack of 
what appeared to be follicular tonsillitis on October 
15th, lasting five days. No bacilli could be found. 
On November 2d he again complained of sore throat; 
his tonsils were swollen and covered with white spots. 
Again no bacilli could be found. A failure to carry 
the wire to the bottom of the crypts may have ac- 
counted for this, and it is possible that these were in 
reality mild attacks of diphtheria. On November 
20th began a third attack, apparently similar to the 
others, but the Klebs-Lofller bacilli were found. This 
time the spots coalesced, spread to the uvula, and pre- 
sented the clinical appearance of diphtheria. A week 
later the membrane was seen in the nose; but it dis- 
appeared from there on December 7th, and from the 9 
throat on December 16th. A slight nasal discharge 
continued at intervals, and the bacilli continued to be 
found in the nose for a month after the membrane 
ceased to be visible. The temperature ranged from 
100° to 102° for the first three weeks of the disease, 
and from 99° to 100° during the last three weeks, 
during which time no membrane was visible. 
The child was discharged from the hospital appar- 
ently well over a mouth after membrane had disap- 
peared from sight, and nearly a week after a bacterio- 
logical examination failed to find the Klebs-Loffler 
bacilli. The terrible bacilli were still concealed in his 
nose, however, and would undoubtedly have been dis- 
covered if he had been retained longer in the hospital 
and more examinations had been made. The lapse of 
a month since the disappearance of the membrane, his 
apparently complete recovery, as well as the fact that 
the last bacteriological culture was negative, served to 
justify his discharge. He was given an antiseptic 
bath and a complete change of clothing. 
Eight days after his return home to a neighboring 
town the child’s sister developed a violent case of 
diphtheria, the membrane spreading to the nose, roof 
of the mouth, pharynx and larynx, and proving fatal on 
the tenth day. The mother and older sister also con- 
tracted diphtheria and recovered. There had been no 
cases of diphtheria reported in the town for two months 
before this, and but one since. The parents had not 
visited the diphtheria wards at the hospital for five 
weeks before the little girl’s sickness. 
It would seem as if the boy from whom these cases 
spread had acquired an immunity from the effects of 
the disease by the length of time in which he harbored 
the bacilli. That the virus had not become attenuated 
by its long stay in this individual was proved by the 
virulence of its action in the fatal case. 10 
Case VII was of the usual type of secondary nasal 
diphtheria. The patient was already very sick with 
surgical sepsis, which obscured the symptoms of diph- 
theria. The case proved fatal.6 
All but one of the nasal cases had nose-bleed, slight 
or severe, at some time in the course of the disease, 
often when no membrane was visible. Only two of 
the others had nose-bleed, and in one of them, as I 
have already remarked, nasal diphtheria is strongiy to 
be suspected. A swelling of the cervical glands in 
these cases was not noticed. 
The source of these cases of diphtheria it is not diffi- 
cult to trace, as there had been free intercourse between 
the patients at different times. The habit of picking 
the nose, so common among children, must furnish an 
easy method of infection. 
By way of summary, the following points seem to 
me to be of interest: 
(1) The fact that primary nasal diphtheria may 
occur of a very mild type. 
(2) The dangerous character of these cases, as they 
are likely to go unrecognized for the following reasons : 
(a) The resemblance of these cases to ordinary 
coryzas, a membrane not being noticed in some cases 
except by careful scrutiny. 
(b) The normal or only slightly elevated tempera- 
ture often present, with but little constitutional dis- 
turbance. 
(c) The intermittent character of the nasal dis- 
charge, absent for several days, and then starting up 
again. 
(d) The apparent recovery, even with cessation of 
nasal discharge, while Klebs-Loffler bacilli are still 
present. 
6 Since going off duty on February 1st five cases of diphtheria 
have occurred at the hospital, four being of the mild nasal type. 11 
(e) The fact that these bacilli have not lost their 
virulence; or, in other words, the fact that the patient 
having the bacilli in his nose, although apparently 
well, may transmit the disease in a fatal form to others. 
(f) The difficulty of always finding the bacilli in the 
nose, even when they are present. 
(3) The importance of bacteriological examinations 
in all suspicious cases of nasal discharge. 
(4) The importance of prolonged isolation, together 
with a refusal to consider a case cured until several 
consecutive negative cultures have been obtained. H H R *i O rf P c-t- .j 
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