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Synonyms:—Malignant sore throat (angina maligna); diphtheritis.

Definition:—An acute infectious disorder, characterized by great prostration, a serious throat inflammation with an exudation and the formation of a false membrane.

Etiology:—The immediate exciting cause is the Klebs-Loeffler bacillus, which is deposited in the mucous membrane of the fauces and in the follicular structure of the tonsils. The bacilli do not become absorbed, but develop upon the membranes, inducing a specific inflammation, which results in the formation of a croupous or fibrinous membrane, which covers the structures, penetrating all the layers of the mucous membrane, causing the membrane to pass through a process of disintegration, or necrosis. In the processes of the growth and nutrition of this specific organism a toxin is produced which being immediately absorbed, produces the constitutional effects which are the serious factors of this disease.

This infective principle of the disease is transferred from one patient to another in many ways. There is direct infection from the breath of the patient, or from coughing, the germ being thus thrown through the atmosphere. Anything that is brought into immediate contact with the patient will carry the germ also. The bacilli are very tenacious of life, as they have been found to be virile months after the patient has recovered.

It has been determined that cats, dogs and birds, as well as rats and mice, will contract the disease, and from them it is conveyed to children, an entire family having been so inoculated.

That form of diphtheria which presents the essential characteristics of the disease, but in which the Klebs-Loeffler bacillus is not found, is known as pseudo-diphtheria. In this form the streptococcus is usually found present.

Children from two to seven years old are the most susceptible. At twelve years of age the liability of infection is at its maximum. From puberty to adult age the liability decreases, until after twenty-five years of age immediate direct infection is necessary for the conveyance of the disease, and even then, one exposed may escape. An individual worn down with exhaustion, or with previous disease, or surrounded with an unhygienic environment, is especially liable to infection. Exposure to cold and damp is especially provocative, the disease being much more frequent in cold weather and in cold climates. It is seldom seen in the tropics. Epidemic outbreaks are found to depend upon the presence of organic matter in the drinking water and upon the decomposition of organic matter with defective drainage and markedly unhygienic conditions.

Symptomatology:—The period of incubation, depending somewhat upon the degree of infection, is from two to eight days. During the last two days of this period the prodromal symptoms—malaise, indisposition, aching and some chilliness—are apt to appear, although the onset in some cases is rather abrupt. The throat is at once complained of, with the chill. The fever rises quite rapidly, soon reaching 103° F. It has not the sudden high rise of some of the other infectious diseases, as the infection is progressive in its development. There is a wide difference in different cases: some are most violent at the onset, developing the entire train of classic symptoms within six hours, while in others mild symptoms may prevail for two or three days, the child playing around the house, before the real character of the disease is discovered. It is common for parents to pay but little attention to a mild sore throat while the child is able to be about, and because of this neglect the disease develops fully before the physician is called. A single small patch first appears, usually upon one tonsil. It is shaped like a grain of wheat and is grayish and sunken, with a narrow bright red areola of inflamed tissue. It sometimes forms on the posterior surface of an enlarged tonsil, or between the tonsil and the fauces. This patch rapidly increases in size, and the characteristic fetor of the breath appears. It assumes more of a dirty gray color and quickly spreads, involving both tonsils and the fauces. The edges are ragged and the approximate tissues are intensely red and angry in appearance.

In cases where no attention has been paid to the complaint of a sore throat, the entire throat may be covered with the exudate, when first examined, and it may have advanced to the anterior surface of the anterior faucial pillars and hard palate, or it may have filled the nasal passages. In other cases it develops on the post nasal membrane, and occludes the nasal passages before its real character is discovered.

An excoriating discharge from these passages may appear before it is known that the disease is present, and such a discharge should always be looked upon with suspicion. When the post-nasal passages are involved the constitutional symptoms are usually very severe and unmistakable.

With development of the membrane on the tonsils or upon the pharyngeal walls, the glands in the neck at the angle of the jaw become enlarged and often tender. This is not common in tonsilitis, nor in the non-specific forms of sore throat.

The symptoms of constitutional involvement increase as the toxins are elaborated and absorbed. This occurs more or less rapidly, according to the severity of the infection. The temperature increases, the pulse becomes rapid, and perhaps irregular, and prostration occurs and increases rapidly. While the patient is usually dull, with perhaps a mild delirium, restlessness is almost invariably present, with signs of distress and general discomfort, the patient appearing severely ill. Convulsions seldom appear.

Laryngeal Diphtheria:—When the diphtheritic exudate is formed first in the larynx, the throat appearances may not be suggestive until difficult breathing, with hoarse metallic croupal cough, appears. I had an experience in my early practice, in 1876, with an epidemic of diphtheria of a severely malignant type, in which obstruction of the respiration was the first apparent symptom in all cases. There was no cough, but labored breathing, with intensely fetid breath and feeble, irregular and very rapid pulse. Within twelve hours the exudate would cover the throat, and if death did not soon occur, would extend to the post nasal membranes. This was the history of perhaps two hundred and fifty cases. The mortality was very great. Post-mortem examination in several cases showed a uniform rapid spread of the membrane downward, into the ramifications of the bronchial tubes, apparently completely obstructing the minute tubes, as well as the larger ones.

With the increase of difficulty in breathing in laryngeal diphtheria, the restlessness of the child increases. It tosses and cries out in sharp, distressed cries, and grasps the throat or appeals for help. Soon the face becomes pale and livid, and covered with a cold sweat, and ultimately cyanosis appears. The characteristic harsh, ringing, metallic cough is more frequent and distressing at first than after the disease has progressed some hours. The constitutional symptoms are not so severe nor so characteristic, when the larynx alone is invaded, as the absorption of the toxins takes place more slowly, the child dying from respiratory obstruction often before they appear, but the local symptoms are very alarming and demand instant relief, as suffocation seems imminent.

Albuminuria is so constantly present in diphtheria that it should be given as one of the symptoms of the disease rather than as a complication. If the infection is sudden and rapid, albumen will be found present on the second day, and the quantity is apt to increase in proportion to the increase in. the severity or malignancy of the disease. The urine will decrease in quantity, although dropsy is not common, and tube casts, both hyaline and granular, will ultimately prove the presence of a true nephritis.

A rash is sometimes present in diphtheria, so closely resembling that of scarlet fever as to render a symptomatic diagnosis difficult. I have seen this rash exfoliate similarly to that of scarlet fever. Purpura and cyanosis appear in malignant cases.

Nasal hemorrhage, persistent and intractable, is a common complication, and this of course increases the anemia by reducing the quantity of the blood.

In cases that terminate favorably, there is an improvement in the symptoms about the fifth day. The membrane shrinks and separates at the edges and becomes thin and dark in hue. It leaves a red, raw, irritable surface, which is very sore and tender and bleeds readily. As the active symptoms abate, the patient exhibits extreme weakness, and anemia is apt to appear. As convalescence advances these two symptoms will be most apparent. Difficulty of swallowing—dysphagia—is apt to occur early, as a result of local paralysis, during the active stage of the disease. Because of this, as sufficient food cannot be swallowed, the nutrition of the patient, which is of the greatest importance, becomes a serious problem.

Heart complications are common, whether from paralysis or from direct failure from extreme exhaustion. Sudden death has occurred in many cases, after diphtheria, when convalescence was thought to be advancing favorably. A sudden exertion, or rising quickly to a sitting posture, has been followed by death. There is doubtless disturbance of the nervous mechanism of the heart, as of the vagus, due to the severity of the disorder.

Nervous disturbance is shown in various ways. Multiple neuritis or paralysis of the ocular muscles, or of the ciliary muscles, are not uncommon. General paralysis, or locomotor ataxia, has resulted.

The patient usually recovers readily from these nervous complications under positive tonic and restorative treatment, and with the use of electricity. The restoration of the red blood corpuscles—the overcoming of the anemia—must be accomplished conjointly with the treatment of the nervous condition. Otitis media from extension of the disease through the eustachian tube, and deafness from paralysis are occasional sequelae. Capillary bronchitis, pneumonia or bronchopneumonia follow laryngeal diphtheria in occasional cases.

Diagnosis:—An experienced physician will observe in the first stages of diphtheria certain conditions which underlie all the symptoms, which are difficult to describe, and yet which occur to him intuitively as evidences of this disease. An immediate diagnosis is of great importance, at the same time an absolutely correct diagnosis is essentially difficult, and in no disease are errors of diagnosis more common, when made independently of the microscopical evidences.

It was the author's invariable plan, before this method was adopted, to treat every questionable case of throat disease, from the first, as if it were a severe case of diphtheria.

A bacteriological examination of a smear preparation of the exudate will show the presence of the Klebs-Loeffler bacillus, in all cases of true diphtheria. It should be made when the membrane is forming and where no antiseptic has been used. In failure to find the bacillus upon the first examination, repeated examination should be made.

In follicular tonsilitis, a differential diagnosis is extremely difficult from appearances alone. Usually the exudate is very white, thin, and uniformly distributed over a considerable area of the tonsils, and is quite readily removed. The severity of the constitutional symptoms of tonsilitis is nearly as great at the onset as are those of diphtheria. In other ulcerative conditions of the throat the exudate is whiter and soft and does not adhere so tenaciously to the mucous membrane.

Prognosis:—Without specific treatment, the mortality of this disease is very high. The use of antitoxin by the municipal authorities of the large cities has so greatly reduced the mortality that the disease is no longer dreaded. Those cases that involve the post-nasal membranes, or the larynx, as has been stated, are much more severe in their manifestations, and are more difficult to cure, even with the most approved methods.

Treatment:—The use of antitoxin in the treatment of diphtheria has become so universal and is so satisfactory to the profession at large, that all other measures are neglected. In the text books of the regular school almost no medicinal treatment is given. This, in our opinion, is a positive retrograde movement in therapeutics. The work of the past half century has certainly not been without results in the advancement of our knowledge of the treatment of this disease, and this knowledge must not be lost. A rational method of treatment is certainly one which is conducted in line with the physiological and therapeutic action of reliable remedies, administered in the line of the rational treatment of other diseases, and our own observations, and the experience of ten thousand of our physicians have proven that from ninety to ninety-five per cent of the patients can be saved by the proper medication, except in malignant or laryngeal cases, where the mortality is higher.

It is the universal opinion of our observers that aconite and phytolacca have a positive influence in combating the progress of this disease, and in inhibiting the advancement of the inflammatory process, and the absorption of the toxins, as well as in exercising a positive control over the temperature. These two remedies should be given from the first, but the use of a powerful internal antiseptic must accompany them. Five drops of echinacea should be given with each dose.

From the first a remedy must be used for its contact influence upon the developing membrane. In the writer's opinion, the most effectual remedy for this purpose is sulphurous acid. This acid, officially dilute, in properly adjusted dosage is comparatively non-toxic, and can be prescribed in a form that is palatable, and which will be readily taken by any child. The following is a favorite prescription with me: Sulphurous acid dilute, two drams; flowers of sulphur, one dram; syrup of acacia and simple syrup, of each one ounce. Mix; give from one-half to one teaspoonful of this every half hour, or hour, for the first twenty-four hours to a child above five years of age. To a younger child it is well to give the smaller dosage frequently for perhaps three or four hours, and then discontinue for two hours to begin again, examining the throat once in from four to six hours to observe the progress of the development of the membrane. This prescription should be taken without being diluted, and no water should be drunk immediately afterward. It is surprising how rapidly the exudate will disappear under the action of this remedy.

With older children it has been my plan to apply with a camel's hair pencil, at the very start, a few drops of the tincture of the chlorid of iron to the beginning exudate. With infants, the use of a spray of the peroxide of hydrogen is of much importance in keeping the parts cleansed. It should be thoroughly sprayed into the nasal passages as well.

A course of treatment based upon the use of a solution of the chlorate of potassium, to which is added the tincture of the chlorid of iron, was very popular among the older physicians. A solution which contained about two grains of the chlorate with six or eight minims of the chlorid of iron to each dram, was given in dram doses every two hours.

In a very severe case of nasal diphtheria, some twenty-five or more years ago, I conceived the idea of clearing the passages of the exudate by the use of the oils of eucalyptus and turpentine, suspended in hot water in a steam vaporizer. The results were so highly satisfactory in every case used, that I wrote a description of the method and published it. Since that time this course has had quite general acceptance. It is a good plan also to keep an open vessel containing water, to which a few drops of these oils, combined in equal parts, are added, simmering over a fire in the room. For laryngeal diphtheria the patient should be made to breathe a strong vapor of water in which fresh lime is slaking, confined by a proper hood; this should be continued from fifteen to thirty minutes, about once in three or four hours. With some practitioners the use of iodized calcium (calcidin) is becoming a popular method in membranous croup. The membrane is loosened and separated rapidly and the strength of the patient is conserved, and yet its efficacy in true diphtheritic laryngitis has not been conclusively proven. A mixture of equal parts of specific jaborandi and specific echinacea, administered in doses of from five to eight drops, will do much toward loosening and assisting in the exfoliation of the exudate.

An internal remedy of much importance, when specifically indicated, is rhus toxicodendron. The indications are those usually described—a very red, narrow, thin and pointed tongue, reddened mucous membranes, with a tendency toward those appearances which resemble a typhoid condition. Baptisia tinctoria is indicated where there is dusky discoloration of the tongue and mucous membrane, with dull or purplish discoloration of the face. Belladonna antagonizes local congestion, and if given in minute doses, during the early part of the treatment, it will greatly enhance the influence of the other remedies. Capsicum is of excellent service in the restorative process, after the exudate has disappeared, and where the pharyngeal membranes are of a dark red or purplish color. Echinacea antagonizes the influence of the toxins, and prevents their development within the system. It preserves the integrity of the blood and stimulates the processes of absorption and the appropriation of nutrition. Hamamelis is indicated where there is great relaxation of mucous membranes with an inclination to hemorrhage. Hydrastis should be used as soon as any tonic treatment can be introduced. Its general tonic influence upon the nerve centers, upon the heart and stomach, and intestinal canal, is of great importance. Phytolacca, in addition to the influences described, acts in harmony with echinacea, but specifically antagonizes the development of inflammation of the glands. In the treatment of threatened heart weakness, and anticipated failure, we have no remedy equal to cactus; it should be given through the entire period of convalescence, and may be introduced early in the disease, if indicated. It certainly operates directly upon the nutrition of the heart, it strengthens the muscular and nervous structure of that organ, and antagonizes the depressing influence of the toxines, and if given in conjunction with avena, or later with strychnin or with the arsenate of strychnin, it will prevent paralysis or correct existing paralysis.

Antiseptic measures are of primary importance in this disease. Among those which we have named, salicylic acid, mercuric chlorid, formaldehyd and potassium permanganate have been used with good results.

The use of antitoxin, the anti-diphtheritic serum, has reduced the mortality of diphtheria in all cases reported from fifty to perhaps sixty-five per cent. Taking into consideration the very large number of cases treated in the past ten years, the agent has produced serious results in comparatively few. The facility of its administration, its undoubted prophylactic influence when given early, and its influence in malignant cases which are apt to run a course too rapid to be influenced by the action of internal medicines all argue strongly in favor of its adoption in cases that are at all severe in character, if true diphtheria. The milder cases of diphtheria and all severe cases of sore throat, in which the Klebs-Loeffler bacillus is not found, should be treated with the specific measures here advised. Antitoxin is especially applicable, and I believe should be used without hesitation in those cases that have developed the severe and dangerous symptoms of the disease, when the physician is called and which have had no preliminary treatment. It should also be used where marked and dangerous laryngeal symptoms appear, whether there has been preliminary treatment or not.

Where employed alone, the best results have been obtained when it was used early in the attack. It is advised that a few full doses be given at the onset, as they are considered of more value than repeated small doses. The full initial dose of this remedy is two thousand units. This should be repeated in about six hours. In the markedly severe cases from twenty-five hundred to three thousand units should be used.

When convalescence is established, forced feeding with concentrated highly nutritious food must receive first attention. For the first week the patient should be kept in a recumbent position most of the time, and but little physical exercise should be allowed. Later, as the strength and general health improves, the amount of physical exercise may be increased. The condition of the heart and nervous system should be taken into consideration in determining the amount of physical exercise. As anemia is nearly always present, measures which will most rapidly restore the reel blood corpuscles must be correctly adapted to each individual case. Attention must be paid to the action of the kidneys. Any irritation of these organs must be relieved and congestion carefully overcome. The application of dry heat for an hour or two, two or three times each day, will be of much benefit in restoring the normal functional action of these organs.

The Eclectic Practice of Medicine with especial reference to the Treatment of Disease, 1910, was written by Finley Ellingwood, M.D.

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