PROGRESSIVE PHARYNGEAL DIPHTHERIA The onset of this form may, like the preceding, be insidious and run a rather mild course with moderately severe symptoms of general tox annia, as long as the affection of the larynx is not so great as to offer considerable obstruction to the entrance of air. In the majority of cases, however, the disease sets in abruptly and with severe symptoms, even with convulsions in very young children. The children suddenly feel very sick, sometimes they arc chilly, there is severe headache with gen eral pains in the body, the appetite is gone, they may feel nauseated and they sit around listless and dull with flushed, swollen features. When put to bed they lie rather apathetic with a temperature of 39°-40° C. (102°-104° F.), and the pulse is proportionately accelerated to 140 to 160. The submaxillary lymph-nodes are tender and swollen to the size of a hazel-nut while those at the angle of the jaw are as large as a walnut and sometimes the surrounding region is prominent with a boggy swelling due to oedema of the subcutaneous connective tissue. The tongue is moist and slightly coated and there is a profuse secretion of tenacious glistening mucus in the mouth and pharynx. The mucous membrane of the mouth is bright red while that of the isthmus and of the posterior pharyngeal wall is dark or streaked with red. The faucial pillars, the tonsils, the uvula and the lateral roots of the posterior pharyngeal wall are swollen, usually more on one side. On one or both tonsils there is a uniform, mucous exudate, firmly seated, rarely ap pealing only as isolated yellowish fibrinous streaks or spots. By the end of the first or the beginning of the second day of the disease the children complain of burning and choking in the throat and of sharp pains on swallowing, especially when the mouth is empty. Both tonsils and ultimately the uvula and parts of the posterior pharyngeal wall are now seen to be covered with a grayish white membrane, often mottled and either smooth or lumpy in appearance. In the course of the next two or three days the membrane spreads, finally covering the whole pharynx, the anterior and posterior pillars of the fauces and advancing up into the posterior flares. The fever and the severe disturbances of the general system continue or even increase in force. The odor from the mouth becomes unpleasant, sweetish, even fetid. The sense of fulness in the throat causes dyspncea. The voice becomes thick and, through fixation of the faucial pillars and occlusion of the nasopharyngeal space, decidedly nasal. Secretion is so greatly increased in the nasal passages
as to occlude them, so that the child breathes with the mouth open. Otitis is not a rare complication.
The kidneys are affected in almost every case. After about the third clay an abundant sediment is found consisting of many small epi thelial cells, cylindroids and epithelial casts; from the first to the third weeks of the disease there is albuminuria, varying in amount but never being very great (Ileubner).
As a rule the bowels are sluggish even far into convalescence. Examination of the blood shows a very decided leucocytosis (L. G. Simon). In cases tending to recovery the proportion of the lympho cytes is increased; in severe cases inyeloeytes are found (Engel). When antitoxin is injected, the advance of the process is checked in the great majority of cases. The fever falls rapidly and the temperature becomes normal or even subnormal, often within a day. At the same time the pulse-rate falls to its normal, or frequently below, the pulse becoming small and not rarely arrhythmical. The local lesions disappear. The general strength is increased; but the convalescence is nevertheless pro longed by anemia and general weakness. Not rarely postdiphtheritic paralyses appear, with secondary infections, especially bronchitis and pneumonia, and in many cases there is the threatening danger of an acute cardiac failure, which may also appear very unexpectedly in the acute stage.
If the antitoxin is not given or if its use is delayed until late, the local process may spread by continuity or it may leap to different spots, advancing to the anterior nares, to the larynx and trachea, while in rarer cases the mouth-cavity may show the false membrane. Following these severe local changes, which may sometimes directly threaten life, symptoms of general intoxica tion set- in : rapidly developing general weak ness, lowering of force of the heart-beat, evi denced by an ominous pallor of the skin and cyanosis of the mucous membranes; coolness of the extremities due to the poor quality of the blood-stream; right sided or general dilatation of the heart with an impure first sound at the mitral orifice; a small, arrhythmic pulse, becoming, slower, finally thread-like and imperceptible. Death occurs toward the end of the second week with collapse, or later than this with urfemia or dropsy.