ACUTE NONDIPHTHERITIC AFFECTIONS In all doubtful cases the indications of diphtheria are: (1) the con temporaneous development of a unilateral, decided coryza with a sero sanguinolent discharge; (2) the contemporaneous development of laryn gitis; (3) great swelling and hardness of the adjacent lymph-nodes; (4) the appearance of typical diphtheria in the family, in the neighborhood or in the school attended by the child.
Angina without which do not show deposits. by the second day at the latest, are hardly to be suspected of being diphtheria, even if diphtheria bacilli are found on the mucous membrane. Since diphtheria bacilli are found in the throats of healthy people, a. mucous membrane ought not to be considered as the seat of diphtheria if it is not altered in the typical way by the bacilli, showing epithelial necrosis and fibrinous exudate. The occasional finding of large masses of diphtheria bacilli ip a starting angina makes it possible that a non specific secondary infection precedes the diphtheria, which will follow in a short time; or that the bacilli conic from a neighboring part, inaccessi ble to examination (the posterior, under surface of the tonsils, the naso pharynx), but affected with the diphtheritic process.
Failure to make the diagnosis at the first examination is also ren dered possible by the scanty development at the outset of the charac teristic changes in the mucosa, which may be only a delicate, cloudy or frost-like deposit. Further diagnostic difficulties arise when different.
parts of the same region react differently to the diphtheritic virus, the diphtheritic exudate penetrating deeply in places, but not spreading equally on the surface and so causing changes in the mucosa which are seen in other nondiphtheritic pseudomembranous affections of the pharynx.
Nondiphtheritic Pharyngeal Affections with are principally anginas or stomatitis with circumscribed or diffuse catarrhal purulent or pseudomembranous deposits. In all of these a secondary infection with diphtheria bacilli is possible and must always be borne in mind.
Follicular swollen and suppurating follicles of the tonsils project as small yellow dots above the level of the red mucous membrane. Fever at the onset is high, with moderate swelling of the
regional lymph-nodes, but there is no fetor to the breath. Usually there is no more than a family epidemic. In punctate diphtheria the islands of membrane are irregularly formed, not glistening, and the mucous membrane is frequently only a little or not at all reddened, especially in the beginning of the disease; the temperature is only moderately elevated.
Lacunar Angina.—By a deposition of catarrhal secretion in the lacuna' there appear on both inflamed tonsils small spots of unequal size, as in diphtheritic lacunar angina. The nondiphtheritic angina is rec ognized: (1) by the color of the deposit, pure white, glistening, changing later to a decided yellow; (2) by the limitation of the deposits to the ton sils, while in diphtheria by the second or third day the palate is attacked and through confluence the palate may be covered; (3) by the consis tency of the deposit, which can easily be rubbed off and pressed out, while the fibrinous diphtheritic deposits are firmly knit and hard to detach.
Phlegmonous Tonsillitis (angina parenchymatosa). The swelling of a tonsil is associated with chills, high fever and general discomfort. On its bluish red mucosa there appears a membrane-like, oval white spot, sharply limited and made up of tenacious mucus and cast-off epithelium. Secondary (edema and excessive secretion of mucus interfere with breathing, while spasm of the masseters hinders chewing. The termina tion is in abscess-formation, or rarely in resolution. Transition to diphtheria is possible, but in diphtheria there is never so great a degree of inflammation limited to one tonsil, with cramp of the muscles of mastication.
Aphthous is very rare to a primary localization of aphthous stomatitis on the isthmus of the fauces. The appearance is that of small, yellowish ulcers, round or oval, with slightly elevated and very red walls. If these become confluent there is a resemblance to diphtheria, but the distinction is made by the presence of the narrow but pronounced inflammatory edge, the depression of the plaque, and the appearance of disseminated aphthfe in other parts of the mouth.