At any time an unfavorable turn may come in the course of the dis ease. Anemia advances to an intense degree, with great general weak ness. The pulse becomes thready, extremely rapid and arrhythmic. The developing heart-weakness causes signs of stasis in enlargement of the liver and spleen, with dilatation of the right heart and at times of the left also. The apex-beat is diffuse and almost imperceptible, and the sounds are weak, especially the first which may be impure. The pulse finally can scarcely be felt. The weakness of the patient is so great that dissolution seems imminent. Towards the end of the first week or the beginning of the second, with an elevation of temperature, vomiting sets in, a certain precursor of death. The pulse falls to sixty or forty beats per minute, and the end conies about the tenth (lay, sometimes earlier, sometimes later, being immediately preceded by suddenly de veloping dyspncea of high degree, cyanosis and an expression of great anxiety.
If the disease runs a less violent course, the cervical lymph-nodes may suppurate and the middle ear may become involved by extension of inflammation to the Eustachian tube.
The larynx and trachea are not affected in black diphtheria, as a rule, or, if so, marked stenosis rarely occurs. In such cases the mucous membrane is deeply reddened with isolated hemorrhages and dotted with small patches of false membrane.
In some epidemics, however, a considerable exception is found to this rule, amounting to twenty per cent. of the cases of malignant diph theria (Madan). In these cases the local process advances in full inten sity to the larynx, trachea and even the bronchi, with such rapidity that even in spite of early treatment by antitoxin and operation, the majority of cases succumb in from one to three days with obstruction and intoxication.
Not less dangerous but running a somewhat longer course is the luemorrhogic form of malignant diphtheria, which is seen in about twenty per cent. (Marian). Profuse hemorrhages occur front the nose, mouth and pharynx which can with difficulty be controlled. There are also
bleedings in the stomach, intestines and urinary tract. In the dusky skin there appear numerous spontaneous, bluish red, green or black ecchymoses, or, on very slight trauma, larger hemorrhages. On the ex tensor surfaces of the knees and elbows many cases show an eruption like that of scarlet fever (Malian). Vomiting and malodorous diarrhoea contribute to a state of great discomfort. With a profound antrinia, a progressive weakness of the heart which nothing can check, a falling temperature and a failing pulse, death occurs after a few hours or days, in coma or convulsions, or with the signs of myocarditis with or without cardiac thrombosis. In more protracted cases pneumonia or nephritis or a general septic state may develop.
In addition to these types there may be more fulminating or more protracted forms of malignant diphtheria.
In the very rare hypertoxic form, as in cholera sicca, the general intoxication gains the upper hand so quickly that death occurs in twenty-four hours, before typical local changes have time to develop. The general symptoms, which appear suddenly, are heart failure, cyanosis and unconsciousness. The tonsils are seen to be moderately swollen, glistening, red and as if covered with a delicate hoar-frost (Escherich).
In the milder forms the local process is found less extensive, or only on one side, with less of a tendency to necrosis. The accompanying phenomena are correspondingly mild. Because the course is more protracted, there is time for the development of the sequels of the diphtheritic toxiBmia and also for the appearance of the so-called scrum disease. Secondary infections with pyogenic cocci also occur in the majority of cases; purulent inflammation of the middle ear, the glands, the joints, the bones and the serous membranes are possibilities.
The majority of these cases are saved by the timely administration of antitoxin.