The presence of the Loeffler bacillus is a sure sign that the accompanying pseudomembranous inflammation is diph theritic; the bacillus of diphtheria, may be present without causing symptoms of thc disease; the bacillus may disappear when the symptoms cease, or may con tinue in a virulent state for months upon the fauces of the infected person. Loeffler (Lancet, Sept. S, '94).
With such appearances in the throat I there is usually a distinct swelling and 1 tenderness of the submaxillary and cer vical lymph-nodes.
The extent of membrane in the mild cases is usually limited, and there seems little tendency toward spreading; but, on the other hand, we may see 'cases in which tonsils, fauces, and pharynx are covered with membrane and yet the con stitutional depression is slight.
After the onset in a mild case the membrane may extend somewhat, so as to involve the fauces or pharynx; but may remain limited to the tonsils. The throat continues sore, the temperature shows some elevation, and the children feel moderately sick. In the course of three to five days the membrane begins to separate, either gradually or in masses, the throat clears up, the temperature falls, the glandular swelling subsides, and in a week or so the patient is well again. I A mild diphtheria, may be accom panied by albuminuria, and may be fol lowed by nephritis or paralysis, but, as a rule, the cause is benign and the out come satisfactory. We must, however, be prepared at any time to see an appar ently- mild case of diphtheria change character and become a virulent infec tion. From a mild tonsillar, or pharyn geal, diphtheria a severe diphtheritic laryngitis may be developed.
The most troublesome features of these mild cases of diphtheria is the difficulty of maintaining proper quaran tine. If adults, the patients do not re gard themselves sick after the first day , or two, and can hardly be made to under stand that even when well they may be the source of grave danger to others.
If the patients are children, the par ents find it difficult to take a serious view of an apparently trifling sore throat and are often unwilling to take the necessary precautions to prevent the spread of the disease. It cannot be too emphatically laid down in such cases that the clinical phenomena are no test of the virulence of the bacteria present. From an appar ently mild case Para obtained the most virulent bacillus he has yet met with, and employed its toxins in the produc tion of antitoxin of nnusual strength.
It has likewise long been well known that an apparently mild case of diph theria may communicate a malignant in fection to others.
The mild cases should be quarantined just as faithfully as the most severe, and should be allowed freedom only when the specific bacteria have disappeared from the throat.
(C) The Severe these the manner of onset may be sudden, with chill, vomiting, fever, and severe sore throat, the temperature rising to 103° 104°, and the prostration being marked, or the affection may begin as a mild case and gradually develop the severe symp toms, the invasion being very insidious. If seen at the beginning, there may be little membrane visible in the throat, only a small patch or two upon the ton sils, exactly similar to that described in the mild cases; the throat will, how ever, be more reddened and the swelling more marked. The submaxillary and cervical lymph-nodes will be swelled and tender. The child looks and acts sick. The elevation of temperature may not be in keeping with the degree of consti tutional depression, oftentimes being only 101° to 102°. As the disease de velops, the membrane rapidly extends, until the tonsils, pharynx, uvula, and fauces are covered with a thick gray, green, or even black layer of necrotic material. If any effort be made to re move it the nnderlying tissues bleed freely. The membrane fills the rhino pharynx, involves the nasal cavities, and may even appear in the nares. With the involvement of the nose there is seen a thin, acrid, often bloody and foul-smell ing discharge from the nostrils. The membrane may also invade the mouth and appear upon the lips. In one case seen at the Foundling Hospital, the ex tent of gray membrane upon the lips, cheeks, and tongue was so marked as to suggest the possibility that the child had been drinking carbolic acid. Mechan ical removal of the membrane in such cases does no good whatever; it seems only to open up a fresh surface to the attack- of the virulent bacilli, and the membrane is reproduced with almost marvelous rapidity. At any time the inflammatory process may involve the larynx, giving rise to laryngeal diph theria, or it may involve the middle ear through the Eustachian tubes; in rare cases by extension through the lacrymal duct or by accidental inoculation the conjunctiva is involved.