The submaxillary glands are enlarged and tender ; and there is much swelling of the neck. Sometimes haemorrhages occur from the nose, throat, and gums. The face is pale with a tendency to lividity ; the pulse is rapid and feeble ; appetite is completely lost ; the bowels are generally relaxed with thin offensive stools ; and there is great prostration. Some times in these cases the false membrane is loose in consistence and may even be pultaceous. It may assume a dirty gray or brownish hue, and is sometimes almost black from admixture with blood.
When the end is favourable this form lasts for ten days or a fortnight. After a time, if no serious complication occurs, the false membrane sepa rates and is not renewed ; the swelling subsides ; the pulse becomes stronger ; the appetite begins to return ; and the child enters into con valescence, although for some time he remains anmmic and feeble. Often, however, the patient dies at the end of the week either from exhaustion, from extension of the inflammation to the larynx, or from one of the com plications to be afterwards described. The mind is usually clear through out, although in the worst cases—those in which the disease approaches most nearly to the malignant type—death may be preceded by delirious wanderings or stupor. In such cases a real septicaemia may occur, the blood being poisoned by the absorption of foul putrescent matters in con tact with the tissues of the pharynx. The child often shivers, and his temperature rises to 103°or 104°, often sinking again in rapid daily varia tions. The pulse is small and feeble ; the eyes sunken and dull-looking ; the complexion of a dirty yellow tint. There is often epistaxis ; the cer vical glands swell to a large size ; and the loose areolar tissue of the neck is infiltrated with serum. The prostration is extreme ; apathy is complete ; delirium comes on ; and the child quickly dies.
In severe diphtheria the amount of fever varies. Even in very bad cases it need not be high. Sometimes the temperature is 103° or 104° at the beginning of the illness, and sinks to the normal level or even below it when the more serious symptoms declare themselves. Sometimes after falling it may again become elevated and reach 106° or higher before death. Some inflammatory complication is then probably present.
Albuminuria is a frequent symptom. It occurs in about two-thirds of the cases, but does not necessarily imply gravity in the prognosis. Its
amount is usually in proportion to the extent of surface involved. The albuminuria appears to be the consequence of a rapid elimination through the kidneys of poison absorbed from the affected mucous membrane. In severe cases it may be found as early as twenty-hours from the beginning of the illness. This is, however, exceptional. Usually it appears on the third or fourth day, but it may be sometimes delayed as late as the ninth or tenth. Sometimes the urine is smoky. It contains an excess of urea, and hyaline and granular casts may be detected in the deposit. The kid neys are in a state of mild parenchymatous nephritis, but this passes off as convalescence becomes established, and rarely leaves ill consequences be hind. It is very rare for urkemic symptoms or dropsy to occur.
When the disease attacks the larynx (laryngeal diphtheria ; membranous croup) the child is at once in serious danger. In the majority of cases the laryngeal disease is due to extension of inflammation from the fauces. Less commonly the inflammation begins in the trachea and spreads thence upwards and downwards. Cases where the disease develops originally in the glottis (the so-called true membranous croup) are very rare. Still rarer are the cases where the false membrane remains limited to the glot tis. In my own experience I cannot call to mind a single case of mem branous laryngitis in which some evidence of false membrane in other parts was not to be obtained. In most cases there was also exudation in the fauces. In a few the membrane had spread down the trachea and the fauces were free ; but even in these cases patches of exudation were usu ally found on examination after death at the back of the naves.
The extension to the air-passages often takes place quite suddenly and unexpectedly. The preceding symptoms had been slight, attracting little attention, when suddenly the breathing is noticed to be stridulous. The symptoms of membranous croup then develope themselves with startling rapidity. Usually the sore throat and signs of catarrh continue for sev eral days before any more alarming symptoms are observed. The child is not thought to be ill. He seldom refuses his food ; and although a little languid and unusually anxious for drink, does not appear to be dis tressed.