2. PHARYNGEAL, OR TONSILLAR, DIPHTHERIA.—(A) Mild Cases Without Membrane, or Catarrhal Diphtheria.— During the prevalence of an epidemic of diphtheria, especially in institutions, a certain number of cases may be ob served in which, without the appearance of pseudomembrane, the pharynx and tonsils become reddened and somewhat swelled, the children complain of slight soreness of the throat and have a rise in temperature, but do not appear or feel very ill; yet cultures made from such throats show the presence of the diphtheria bacillus. Such cases we have learned to class as true diphtheria. The mildness of the affection is attributed either to the small number of bacilli present, to a diminution in the viru lence of the bacilli, or to an increased resistance on the part of the patient. In many of these cases the nose is involved as well as the pharynx and tonsils, and there is consequently a thin, watery, irri tating discharge from the nostrils. In the course of a few days all symptoms subside, and the bacilli disappear, or they may persist for weeks without fur ther symptoms.
Series of 20 children in which the ba cillus was found in 6 on admission, while in the other 14 cases it was discovered at times varying from a few days to several weeks after admission. The infants in whom the bacilli were present in the mouth presented no symptoms, either general or local. These bacilli often re mained for several weeks, and even months (in one case two and a half months), in an indolent condition, al though in several cases they declared themselves in a virulent manner. Of the fl children who arrived at the hos pital with diphtheria bacilli already in the mouth, only I came from a, family in which there bad been a ease of diph theria five weeks previously; 2 came from a house infected by measles, and the remaining 3 had not been in con tact with any cases of infectious disease. In 12 cases the bacteriological examina tion was supplemented by inoculation of animals. The bacilli found in 6 eases were so virulent as to cause the death of the animals in from twenty-four to forty-eight hours, while in the other 6 eases the virulence was only of medium intensity. Heubner (Jahrb. f. Kinderh., B. 43, S. 54).
Diphtheria bacilli may exist in the throat for months after an attack, and they may occur in the healthy pharynx. Cases of chronic exudate are, however, much less common. The following illus trates the latter: A 19-year-old servant girl became ill with general symptoms and an ulcer on the right half of the soft palate, in the secretion of which virulent Loeffler bacilli were found.
During the next five months there con tinued to be an exudate in the pharynx in which virulent diphtheria bacilli could always be demonstrated. The ba cilli were characteristically influenced by the l3ebring serum, while it had no effect on the exudate. The blood-serum of the patient protected twenty times more than normal serum against injec tions of Loeffler's bacilli. F. Jensen (Centrelb. f. innere Medicin, No. 19, '97).
The bacilli derived from cultures from such cases may prove to be fully virulent, and any such case may readily be the means of communicating a severe or viru lent type of the disease to others.
The patients themselves may show al buminuria during the course of their mild attack, or they may later develop the paralyses belonging to the severer types of diphtheria. The latter out- , come is, fortunately, rare.
From the catarrhal process in the throat and nose there may arise by ex tension a diphtheritic laryngitis either catarrhal or pseudomembranous in char acter, which may be followed by stenosis or other grave symptoms.
(B) Mild Cases, with Membrane, of Pharyngeal, or Tonsillar, Diphtheria.— These cases are characterized by the de velopment of more or less pseudomem brane upon the tonsils, fauces, or pharynx, and a moderate toxternia. The onset of the trouble is marked by sore throat; a moderate fever, 100° or 102'; and a slight prostration. -Upon examin ing the throat we usually find one or both tonsils reddened, swelled, and pre senting upon their surfaces one or more patches of pseudomembrane. These patches may be small and difficult to distinguish from the yellow plugs seen in follicular tonsillitis. The membrane is usually firmly adherent to the under lying tissue, and, if removed, leaves a bleeding surface. The area covered by membrane may sometimes be marked off from the surrounding tissues by a zone of congestion. The membrane is usually white-gray, or grayish-green in color, sometimes yellow, and the patches are of irregular form. It is sometimes thick and heavy, sometimes so thin as to be translucent. Over against this descrip tion of diphtheritic membrane we might set the characters of pseudomembrane not diphtheritic, but the more painstak ing the description, the more evident would it become that it is perfectly im possible to distinguish one from the other by simple inspection. Nothing short of a bacteriological examination will enable us to make the distinction with certainty.