ACUTE INFECTIOUS DISEASES. 



into the skin ; a pemphigus bleb may resemble a blister induced by 

 a circumscribed burn, but no one would assert that these scarcely-dis- 

 tinguishable disturbances of nutrition were due to the same disease. 

 The previously-described parenchymatous degeneration of the kidneys 

 is found in about half of the cases. The spleen is usually enlarged 

 and soft. The anatomical changes of the nerve centres, or peripheral 

 nerves, on which diphtheritic paralyses depend, have not yet been dis- 

 covered. We know as little about the anomalies of the blood in diph- 

 theritis as in other infectious diseases. 



SYMPTOMS AND COURSE. The disease almost always begins with 

 apparently insignificant and harmless symptoms. In some cases the 

 general health is disturbed a few days before the disease breaks out ; 

 the appetite is less ; the patients complain of dulness, depression, and 

 chilliness. More rarely the disease begins with a severe chill, ac- 

 companied by nausea and vomiting. At the same time the patient 

 complains of difficulty of swallowing; but in most cases this is no 

 greater than it usually is, in simple catarrhal angina. If the fauces be 

 not yet covered with false membrane, but only somewhat reddened 

 and swollen, at this stage we can only suspect or recognize the disease, 

 when we know that diphtheritis is epidemic, or that persons about the 

 patient have or have had the disease. A very suspicious, and usually 

 a very early, symptom is a hard swelling of the lymphatic glands lying 

 at the bifurcation of the carotid artery, which, as I/uschka especially 

 insists on, are directly connected with the lymphatic vessels of the soft 

 palate. Not un frequently the persons about the patient have their 

 attention first called to the disease by swelling of these glands, the 

 complaints of slight difficulty of swallowing having passed unnoticed. 

 It is far more common for us to find more or less extensive grayish- 

 white patches in the fauces at our first examination, than to have the 

 opportunity of examining the throat at the commencement of diphthe- 

 ritis, before the formation of false membranes has begun. And then 

 we can have no doubt about the dangerous and malicious foe with which 

 we have to deal. Even in cases where the disease has begun without a 

 chill, where the fever is slight, or entirely absent, where the general 

 health is excellent, so that the patient can hardly be kept in bed, even 

 where the difficulty of swallowing is very insignificant, and where the 

 deposits are very slight, are thrown off without putrescence, and leave 

 a scarcely-perceptible loss of substance, we are not at all sure that 

 the disease will run a favorable course, that the dangerous accidents, 

 of which we shall hereafter speak, will not occur, and that there will 

 be no paralysis during convalescence. The fact, which I have fre- 

 quently observed, that albuminuria occurs during the above cases, 

 which run their course without fever, shows that the parenchvmatous 





