3. CASES OF MIXED INFECTION, OR SEPTIC DIPHTHERIA.—rncier this head are grouped those cases in which bac teriological investigation shows the pres ence of the diphtheria bacillus, together with other pathogenic bacteria, usually streptococci, in some cases pneumococci, and in which these additional organisms seem to exert a definite influence upon the course of the disease. Most of these cases are fatal and in post-mortem ex aminations systemic infection with strep tococci or pneumococei is said to be found. The appearance of the mem brane in these cases does not differ essentially from that seen in the severer forms of infection with the diphtheria bacillus alone. It may be white, yellow, gray, or olive colored, or, where hmmor rhages accompany the inflammatory process, more or less black. The mem brane is usually extensive, covering the tonsils, pharynx, fauces, and uvula. The swelling of the affected parts is usually very marked, the cedema being pro nounced, the tonsils often so filling the throat as to preclude examination of the pharynx and giving rise to dyspha gia and dyspncea. There is the same muco-purulent or bloody discharge from the nose and mouth; the nares are ob structed and the patients often breathe only through the mouth. A peculiar sickening, sweetish fcetor is character istic. The lymphatic nodes and cellular tissues of the neck are most commonly swelled and indurated, the process in many cases leading on to suppuration and occasionally to gangrene. The press ure upon the veins of the neck may produce congestion of the head and swelling of the face. The swelled, dusky features, with the sanious discharge from nose and mouth, is characteristic and im pressive.
The constitutional symptoms are those of a profound septicmmia. The tem perature often runs as high as 104° or 106°, but may not be remarkable. The pulse is rapid, feeble, and compressible. With the feebleness of the pulse, the extremities may be cold and pale, in marked contrast to the dusky face. Vomiting and diarrhcea are common, and may be persistent. The urine con
tains considerable albumin and casts, and in some cases blood. The quantity may be diminished; suppression may occur and cause death from urmmia. (Edema of feet or hands may be seen. The liver and spleen may both be en larged. The cerebral symptoms are marked. The patients are usually dull and stupid, indifferent to their condi tion or surroundings, but at times they are delirious and extremely restless, tossing continually from side to side or crying out as though in pain. Broncho pneumonia is very common and usually hastens death. At any time during the course of the disease the larynx may be involved by extension. The cases, as a rule, terminate fatally within a week, sometimes within forty-eight hours. Rapid failure in the strength of the heart marks the fatal progress of the disease, and the end may be brought about by sudden and unexpected syn cope. If they survive the first violence of the infection, these cases are espe cially liable to complications attributed to the pathogenic action of the strepto cocci, such as suppuration of the cervical lymph-nodes and cellular tissues, bron cho-pneumonia, and nephritis.
Results of the examination of 234 cases of membranous angina bacterio logically:— 1. Loeffler's bacillus was absent in 26 cases, there being present staphylococci, streptococci, pneumococci, and bacillus coli communis. Two died,-1 of menin gitis. Excluding this 1, the mortality was 3.84 per cent.
2. Loeffler's bacillus occurred alone in 102 cases; mortality 28,-27.45 per cent.
3. Loeffler's bacillus found in associa tion with the staphylococcus pyogenes in 76 cases; mortality 25,-32.89 per cent.
4. Loeffler's bacillus found with strep tococcus pyogenes in 20 cases; mortality 6,-30 per cent.
5. Loeffler's bacillus with streptococ cus and pneumococcus (Friinkel's) in 7 cases; mortality 3,-43 per cent.
6. Loeffler's bacillus with bacillus coli communis found in 3 cases, all of which ended fatally. De Blasi and Russo Trarali (Riforma INIed., Nos. 179, 180, '96).