MALIGNANT PHARYNGEAL DIPHTHERIA, DIPHTHERIA GRAVISSMA The underlying cause of this most severe form of diphtheria, is either an extraordinary virulence of the bacilli (with the combined action of allied streptococci or putrefactive bacteria) or a high degree of individual susceptibility.
It rarely appears in children under four years of age, and its fre quency varies greatly according to the type of the epidemic, the average being from ten to eleven per cent. of all cases. It is characterized by widespread and deep-seated lesions of the mucous membrane often with putrefactive processes, localized in many places (pharynx, nose, mouth), and with very severe toxic symptoms. It may be secondary to a localized or progressive diphtheria, or it may be primary from the start.
In the former instance its onset is more insidious, the temperature is hardly raised, while the threatened danger makes itself manifest first in a rapid and profound anemia and decided lymph-node enlargement.
The primary form sets in with incredible swiftness and violence. So sudden is it that in a brief space of time all resistance is battered down. The first symptoms are fever and vomiting with tenderness on pressure in the epigastrium. The patients are greatly excited, sleepless, occa sionally slightly delirious, and they soon become prostrated and apa thetic. Small red spots appear on the cool. dusky skin. The features are bloated orvery sharply drawn and the eyes arc dull. From the open mouth or the red and swollen nostrils flows blood or blood-stained serum containing particles of foul-smelling membrane, which excoriate the naves and lips. The air of the room is laden with a sweetish, lime-like, cadaveric fetor from the breath of the child.
The neck is tremendously swollen by an enlargement of the lymph nodes and cedema of the periglanclular connective tissue, which makes the lateral contour of the neck stand out prominently.
Even at the first inspection of the pharynx the soft parts are found excessively swollen and the tonsils at times so greatly enlarged as to push the elongated uvula backwards or forwards. Tonsils, uvula, pillars palate, posterior pharyngeal wall and not rarely the soft palate are covered with a slimy, grayish yellow or blackish membrane dotted with points of Memorrhage. The swollen mucosa in its uncovered parts shows
intense redness and isolated areas of bleeding. The tongue is coated heavily with a brown or blackish slimy deposit. The secretion of mucus is greatly increased. Removal of the membrane in the pharynx causes bleeding and loss of tissue; it is usually of mushy consistency and poor in fibrin, but in a few cases it is tough and gristly from a great amount of fibrin. It contains many cellular elements, diphtheria bacilli and in almost. all cases streptococci, more rarely staphylococci or colon bacilli (Bernheim).
The temperature may remain persistently high or only slightly ele vated, but as a rule it falls by the second day to or below normal. In other respects the severity of the picture re mains unchanged. The patients remain apa thetic and motionless and scarcely pay atten tion to the most urgent demands. Food and liquids are pushed aside, from dread of the pain of swallowing. Even in willing and rational children feeding is accomplished with difficulty because of the excessive swelling of the soft parts of the pharynx, and the early development of paralysis. The speech is unintelligible.
The swelling in the neck is often so great that the head is held stiffly backward—Angina Ludovici. The pulse is very rapid, small and compressible.
Albumin is almost always present in the scanty urine, but the amount does not accord with the severity of the case. As a rule the albumin content is marked but only reaches or exceeds two per milk in the severest forms (Marfan).
In the majority of cases the pharynx becomes clear—with the use of antitoxin—in about eight days. Most cases show more or less deep. ulcers which heal slowly with scar formation. The lymph-nodes subside and the patient enters on a long and tedious convalescence. Alarked weakness, anamia, slowing of the pulse, arrhythmia and albuininuria may persist for a long time. Postdiphtheritic paralysis occurs in almost every ease.