PHARYNGEAL DIPHTHERIA Onset.—At the start subjective symptoms of discomfort arc so slight that it is usually difficult to fix a definite onset for the disease. The children feel somewhat tired, they are disinclined to eat and to play, they are sleepy, the voice is rather hoarse and slightly nasal from mod erate occlusion of the nostrils. The child breathes through the mouth and the respirations are visibly accelerated. Occasionally the onset is very sudden, with chill, high fever and headache. An unpleasant odor to the breath and elevation of temperature are usually the first symptoms that bring the child to the physician and although the child has not seemed sick enough to be put to bed it looks pale and tired. The cer vical lymph-nodes, especially those at the angle of the jaw and sometimes also the submaxillary nodes, are swollen on one or both sides, being hard and somewhat movable. An irritating discharge flows from the nostrils. The pulse and respiration are accelerated, and the first sound of the heart is often rather impure. The temperature is usually between 3S° and 39° C. (100.4° to 102.5° F.) and is rarely higher. Pain in the neck and discomfort on swallowing arc sometimes present early. On inspec tion of the mouth and pharynx only slight evidences of inflammation are seen. The tongue is dry and moderately coated, the pharyngeal mucous membrane is a little reddened and glistening with increased secretion, the pillars and tonsils of one side, rarely both, are prominent. On the tonsil, less frequently on a swelling to one side of the posterior pharyngeal wall is seen a small, slimy-looking deposit which, after wip ing away the mucus, is found to be a pseudomembrane adherent to the mucosa and without sharply defined edges (Plate 21). In a still earlier stage the appearance is that of a web-like etching on the mucous membrane. It can usually be loosened without injuring the underlying structures and if it is rubbed between two cover-slips, the firmness of its structure can be appreciated. On staining the preparation, fibrin is found with Lofrler bacilli aggregated in clumps, in company with the saprophytes of the oral cavity. The further course of the case depends on whether or not the specific treatment is adopted.
If the antitoxin is injected immediately, the spread of the mem brane ceases, or during the next. twenty-four hours it extends over only the immediate surroundings; new deposits of fibrin, ordinarily only small ones, may appear during this time on various parts of the pharyn geal or oral mucosa as a result of the action of the germs before the administration of the antitoxin. With a rapid fall of the temperature and pulse to the normal, the pseudomembranes undergo liquefaction, they become sharply circumscribed and are either thrown off in flakes or melt away more slowly, disappearing entirely by the end of the third day.
Eight clays after the onset of the first symptoms the children feel so completely recovered that it is almost impossible to keep them in bed.
Without the gracious help of the antitoxin the course of the disease is usually very much more protracted. The membrane appears on sym metrical parts or spreads by continuity until it may finally cover like a velvet skin both sides of the faeces, the uvula and even small spots on the posterior pharyngeal wall. It then remains station ary for five or six days (Plates 21 and 22). Sometimes the nasal passages are also affected but here the diphtheria is seldom so intense as to lead to the for mation of false membrane. There are ca tarrhal changes with a profuse discharge, sometimes thin, sometimes mucopurulent or of pure pus, and the voice has a decided nasal character. One nostril is more ob structed, as a rule, than the other. With the spread of the local condition the general condition becomes worse (but to this there are exceptions) with pain on swallowing, tenderness on palpation of the lymph-nodes, with increased depression and total anorexia. The pulse is accelerated in proportion to the fever winch falls more slowly than when the antitoxin is used. Moderate. albumi Duni a is found in sonic cases. The entire course rarely lasts longer than a week, but convalescence is protracted. The prognosis without. anti toxin is always doubtful, for even in apparently mild cases the local condition may suddenly spread to the larynx, or severe toxcemia or secondary infections may occur. Postdiphtheritic paralysis is also met with at times, even when the case has not been one of great severity.
In addition to this which is the ordinary form of localized diph theria, rudimentary forms are seen from time to time presenting such slight symptoms clinically that the diagnosis is suggested by the simul taneous occurrence of typical diphtheria in other members of the house hold and the suspicions become confirmed by bacteriological study.
In some of these cases there is a slight pharyngeal catarrh with a mot tled clouding of the tonsillar epithelium, the merest suspicion of a mem brane. There is very moderate fever and complete recovery in a few days. In other cases the exudate re mains limited to the crypts of the tonsils and the appearance and course of the dis ease show great simi larity to ordinary fol licular tonsillitis. A further discussion of these and other forms resembling tonsillitis and stomatitis will be found in the section on differential diagnosis.