With the increase in the local process the lymph-nodes of the neck become more swelled and tender, until it seems that they will surely suppurate, but they rarely do so. The constitutional depres sion becomes more and more marked. The pulse becomes more rapid and feeble; the strength fails steadily.
Eight hundred consecutive cases of diphtheria observed. Less than half of the cases in which the pulse-rate ex ceeds 100 recover. The pulse-rate and the mortality appear to be very much in a direct ratio to each other, and recov ery is improbable v-hen the pulse gets above 150. Extreme slowness of the pulse is less significant; but in children bradycardia does at times presage evil. Variations of rhythm and volume occur in some 10 per cent. of all cases, and are a useful premonition of cardiac com plications. A systolic murmur at the apex of the heart is heard in about one case in ten; its significance depends en tirely upon its cause. This is far more commonly rnitral insufficiency, due either to weakness and inadequate contraction of the cardiac muscle, or to dilatation of the left ventricle, but in rare instances to an endoearditis of diphtherial origin. Hibbard (Boston Med. and Surg. Jour., Jan. 27, Feb. 3, '98).
The temperature may not at any time be very high, 101° or 102°, or it may reach 103° or 105°. The swelling and tenderness of the throat render swallow ing painful and sometimes almost im possible. The tonsils may almost meet in the median line, the nostrils may be plugged and even respiration seriously interfered with. At times in the early days of the disease we may see fluids regurgitate through the nose, when any attempt to drink is made, and it may be difficult to determine whether the regur gitation is due to the obstruction of the throat by the swelled tonsils or to an early paralysis of the pharyngeal muscles.
As the diphtheria advances, the urine becomes scanty and high colored, and contains albumin in some quantity; at times an acute exudative nephritis is de veloped, with large quantities of albu min, casts, and even blood. The onset of the complication may bring, in its train, all the symptoms of an acute ne phritis.
Examinations made for albuminuria in 279 cases of diphtheria, it being found in 131; rate of mortality, 50.37 per cent. .No evidence of albuminuria could be discovered in 148 cases,—the rate of mor tality here being 14.2 per cent. Cases free from albuminuria thus afford a more favorable prognosis. Baginsky
(Archiv f. Einderli., B. 16, H. 3-6, '93).
Besults of examination of 1000 urines in diphtheria by both Fellling's test and the phenylhydrazin test. In 230 cases examined reaction was noted in 25 per cent. of all cases; in those that recovered it was obtained in 19 per cent.; and in the fatal eases in 77 per cent. In cases without false membrane no reaction was obtained.
In a second series of 96 cases a positive reaction was obtained in 33 cases by both tests.
The glycosuria was often associated with albuminuria. A certain number of cases were examined before and after the injection of antitoxin, and it wa-s found that for a few days after the injection a slight glycosuria sometimes occurred. Hibbard and Morrissey (Jour. of Exper. Med., Jan., '99).
Diphtheritic albuminuria has no other relation to diphtheritic paralysis than that both complications are more prone to occur when the diphtheritic intoxica tion is most intense. E. F. Trevelyan (Lancet, Nov. 24, 1900).
The mind may remain clear through out; but, as a rule, with the deepening of the toxmmia the patients become dull and listless. In the severest cases stu por or delirium may be developed. Coma is rarely seen. Convulsions may occur either early or late in the disease, from the toxmmia of the diphtheria or from urwmia.
In some cases the patients die from the diphtheria toxwmia alone; but in most of the fatal cases one or the other of the complications is the direct cause of death. Most important of these is the pneumonia. Although most often seen in laryngeal cases, pneumonia is a common sequel of diphtheria, either nasal or pharyngeal. The onset of the broncho-pneumonia is usually marked by a decided rise in the temperature, a quickened respiration, and some cough. Not till the pneumonia has advanced to the consolidation of large areas do definite physical signs attest its presence. Usually we hear more or less numerous fine crackling Ales over one or both chests posteriorly. Later there may be scattered areas of dullness, with chial voice and breathing. For evidence of the onset we must depend upon the rational rather than the physical signs. The development of pneumonia is al ways a grave and often a fatal complica tion. In but few fatal cases do we fail to find a more or less extensive involve ment of the lungs, and in the greater number it plays an important part in the unhappy outcome.