In the malignant form of the disease the constitutional symptoms are very severe, and may be quite out of proportion to the amount of local lesion. Vomiting is usually frequent. There is often diarrhoea. The child is pale and haggard-looking, and seems stupid and drowsy. His skin is spotted with petechi. His pulse is rapid, small, and feeble. His feet and hands are cool and clammy, and even the internal temperature of the body seldom reaches a high elevation. Sometimes, indeed, it is normal or even subnormal. Thus a little boy, aged two years and a half, was ad mitted into the East London Children's Hospital with wash-leather-like exudation on the fauces, great swelling of the cervical glands, and marked prostration. In this boy the temperature never rose above 98.2°, and a few hours before death was only 97° in the rectum. The child died two days after admission in a convulsive fit.
The false membrane is generally of a dirty-brown colour. Extension of the inflammation takes place rapidly into the nose ; epistaxis often occurs, or there is a flow of thin blood-stained fluid from the nostrils. Sometimes the lachrymal ducts become obstructed ; the eyes then look watery, and false membrane may even appear on the conjunctivm. The mucous mem brane of the fauces may become ulcerated or gangrenous, and the smell from the mouth is very offensive. may occur from the gums and throat. The urine is often smoky and almost always albuminous. Delirium comes on followed by stupor, and the child dies exhausted.
Secondary Diphtheria.—Sometimes diphtheria occurs secondarily to some acute disease. Thus it may arise as a complication of typhoid fever, pymia, erysipelas, measles, scarlatina, whooping-cough, or other form of acute illness. In these cases the amount of false membrane is usually limited in extent, but the inflammatory process is apt to run on into ul ceration or even gangrene. The ulcers are rounded or sinuous, and may penetrate deeply into the tissues. Gangrene is not common. It usually occurs in the tonsils and pillars of the fauces. These parts become gray and exhale a most offensive odour. The sloughs separate after a time and leave grayish, unhealthy-looking pits which in favourable cases may heal, with considerable contraction of tissue in the affected parts.
Complications.—The ordinary course of diphtheria may be interfered with by various complications which delay recovery or unfavourably in fluence the issue of the illness. The occurrence of albuminuria cannot be looked upon as a complication. This symptom is found in mild as well as in severe cases, and is far more often present than absent. It ap
pears to be the consequence of elimination of the poison by the kidneys, and has probably little influence on the prognosis. The complications which will be considered consist of the formation of false membrane in unusual situations ; the occurrence of inflammation of special organs, such as the lungs, the heart, and the pericardium_; the formation of a thrombus in the heart or large vessels ; and the appearance of paralysis.
Nasal diphtheria has been already referred to as constituting a symp tom of the malignant type of the disease. A diphtheritic coryza is, how ever, sometimes seen as a complication of milder attacks. In these cases a thin discharge flows from the nostril, usually at first on one side only. It produces some excoriation of the margin of the nasal opening as well as of the upper lip, for these parts are often red and raw-looking. No doubt the presence of false membrane in the nasal passages is a sign of the ut most gravity ; but I have known coryza with excoriation of the nostril to occur in cases of a comparatively mild nature without producing an unfa vourable influence upon the course of the illness.
Sometimes in epidemics of diphtheria more unusual manifestations of the disease are met with. The false membrane may form upon the con junctivm, the external auditory meatus, the outlets of the vagina and rec tum, upon the glans penis, and upon any wounds or abraided surfaces present on the skin. Often after tracheotomy the edges of the wound quickly become covered by the diphtheritic exudation. These exceptional seats of the false membrane may be the only local signs of the disease to lie discovered, or may be accompanied by the usual affection of the throat. When a wound or abraided surface becomes attacked by the diphtheritic process, its borders become purple-red and swollen, and the surface pours out a profuse, watery, fetid discharge. Soon a pellicle forms on the sore, and from this point the disease may spread over the skin. Thus the discharge irritates the neighbouring cutaneous surface ; little vesicles form, break, and become themselves converted into diphthe ritic sores covered by the characteristic false membrane. In this way, ac cording to Trousseau, the diphtheritic process may spread over a large ex tent of surface ; and the layers of membrane, constantly moistened by the discharge, undergo rapid decomposition, and give out a most offensive gangrenous stench. The general symptoms in such cases are very severe, and the patient usually sinks rapidly from exhaustion.