BY J. C. RAYMOND, M. D., UTICA, N. Y.

This disease has prevailed at times in various parts of Europe since the year 1557, and in North America since the year 1635. The following description, given by J. A. Symonds, M. D., Physician to the British General Hospital, in England, several years ago, corresponds closely to the symptoms which we observe at the present time. “This species of Angina is characterized by the formation of albuminous pellicles on the surface of the inflamed membrane, whence it was named by M. Bretonneau of Tours, “Diphtheritis.” The patches are of various extent, in mild cases white or ashy, separate and presenting the appearance of separate sloughs, for which they have often been mistaken: in others, dark colored, coalescent, and forming one uniform crust. The exudations may extend far down the aesophagus, or into the larynx, trachea, and bronchi, and upwards into the nasal fossae. The membrane beneath and between the pellicles is in some cases of a bright red, in others purplish or livid. The exudations vary in density from that of coagulable lymph to that of a soft pultaceous matter.

The local symptoms are similar to those of Angina diffusa, with the addition of those produced by irritation and obstruction of the air passages when the disease has extended in that direction. It is common also for the submaxillary and cervical glands to become inflamed and tumefied. The general symptoms are those of fever, and vary with the type of the latter, and the degree of the inflammation. When the patches are few and circumscribed, the disease is often called ulcerated sore throat, such as may be seen in Scarlatina anginosa; but there are no ulcers in these cases, for on removing the pellicles or sloughs as they are called, we find the membrane beneath quite free from any other disorganization than the loss of its epithelium. In the worst cases the pellicles are discolored by admixture of bloody exudation, and vitiated secretions from the throat, so as to create an impression that the parts are in a state of sphacelus. These cases correspond to the Angina maligna of many authors, and to the gangrenous angina of others; but we have the united testimony of Bretonneau, Guernsent, and Deslandes, formed on extensive microscopic observations, that there are no true escars in these cases. The idea of gangrene existing, has been further kept up by the discharge of serous fetid matter from the nostrils, and by the putrid character of the fever.

From the above remarks it may be inferred that diphtheria appears in two forms. In one, the local affection bears the marks of active inflammation, in the bright hue of the mucous membrane, and in the white circumscribed exudations, unmixed with blood or sanies. The constitutional symptoms in this form are likewise sthenic, the pulse being full and firm, the skin warm, and the nervous system tho' disturbed, not exhibiting the signs of prostration so common in typhoid fever. The other form may well be called Angina maligna. Its approach is often insidious, being attended with but little pain or distress in the throat until the false membrane is already extensively formed. Then the dysphagia becomes extreme, liquids are forced back through the nostrils, and symptoms soon occur denoting that the air-passages are obstructed; such are a croupy cough, hoarseness and stridulous breathing.

The feeling of suffocation accompanying these symptoms is in part owing to the swelling of the lymphatic glands. On inspection of the throat we see a thick pellicle, sometimes dense, not unfrequently pultaceous, variously colored according to the degree of its decomposition, or to the accompanying secretions, and either continuous or interrupted by fissures which exhibit the livid hue of the membrane beneath. The pulse is extremely rapid and feeble, delirium sets in early and is soon followed by coma; and the collapsed face and sunken eyes indicate extreme exhaustion. Death often takes place suddenly from the laryngeal complication. Bretonneau was led by the results of his dissections to attribute the death in all the fatal cases to the changes in the air-passages.

Causes. — A humid atmosphere, decomposing fecal and vegetable matter, crowded dwellings, a deficiency of proper nourishing food and clothing, are considered to be the most prominent in inducing the disease. By nearly all observers the decease is admitted to be contagious.

Diagnosis. — 1st. The fibrinous exudations in this disease, with the obstruction of the air passages, has caused it to be confounded with croup, yet the diseases are very different. In the latter the inflammation is confined to the tracheal and bronchial membrane; while in diphtheria the inflammation is seated in the fauces and pharynx, and only in severe cases extends to the larynx and trachea.

(I should state from my observations, that Angina membranea, true croup, commenced with inflammation of the laryngeal, tracheal, and bronchial membranes and extended to the throat and fauces; for in almost every case fully developed, the arches of the palate, uvula, tonsils and pharynx will be found to be inflamed, and the tonsils dotted with small patches of false membrane.

In diphtheria the inflammation is seen first, on the curtains of the palate and tonsils, and from thence spreads over other portions, or the entire throat, pharynx, and in most severe cases to the air passages.) True croup is rarely if ever attended with the low typhoid fever so common in diphtheria, the symptoms of exhaustion in the advanced stage being clearly referable to the impeded respiration.

2d. “Diphtheria is with difficulty discriminated from angina gangrenosa, the affection described by Fothergill as putrid sore throat, the cynanche maligna of Cullen. The general and local symptoms are very similar, but in the latter disease the difficulty of breathing is attributable rather to the general tumefaction than to any laryngeal complication, and these are true gangrenous sloughs, which, on separating, leave corresponding concavities in the tissue. On this point Fothergill speaks very distinctly, and where the disease is of the mildest kind a superficial ulceration only is observable, which may easily escape the notice of a person unacquainted with it. A thin white slough seems to accompany the next degree; a thick opaque or ash-colored one is a further advance, and if the parts have a livid or black aspect, the case is still worse. These sloughs are not formed of any foreign matter spread upon the parts affected, as a crust or coat, but are real mortifications of the substance; since, whenever they come off, or are separated from the parts they cover, they leave an ulcer of greater or less depth, as the sloughs were superficial or penetrating. In this disease moreover, there is frequently observed an erythematous or papular eruption on different parts of the body; and there can be little difficulty in arriving at the conclusion that it is a variety of scarlatina maligna. Dr. Tweedie observes, “we are inclined to affirm that the scarlatina simplex, scarlatina anginosa, and the scarlatina or angina maligna, and the sore throat without efflorescence on the skin, are merely varieties of one and the same disease.”

Treatment. — The remedies which have been found the most efficacious to arrest, and effect a radical cure of this disease when fully developed, are the alternate Use of Kali bichromicum, and Mercurius iodatus; when the prostration is extreme, Arsenicum and Ammonium carb. In the milder varieties of the disease Aconite, Belladoma, Capsicum, Jodine, Lachesis and Nitric acid have induced cures. The diet should be very liberal, the patient urged to take all the beef-tea and similar nourishments that he can get down. In case of great difficulty in swallowing injections of rich meat soups are advisable.

Remarks. — From November 1858 to May 1859 we had in this city an epidemic of Scarlatina miliaris which proved very fatal, more than one hundred deaths having occurred from this cause during the time specified. Death resulted from three causes, paralysis of the brain, paralysis of the lungs, and the exhaustion produced by the malignant character of the throat disease; complete disorganizations of the tissues involved, being induced by ulceration, and gangrene; with low typhoid symptoms; attended in some cases with profuse hemorrhage from the throat, nose and ears. In no case which I saw was there any appearance of diphtheritic formation.

Affections of the throat were also very prevalent. In cases of simple inflammation the attack usually commenced with chills, followed by the usual Symptoms of fever. When the throat was examined the palate, fauces and tonsils would be found inflamed with a bright red appearance, with little or no tumefaction, and yielding promptly to a few doses of Aconite and Belladonna. In another form more severe than the first, the inflammation was more strongly marked, the tonsils, one on both, very much enlarged, and in some cases suppuration would ensue. These cases required Aconite, Belladonna, Mercurial preparations, Baryta carb, Capsicum and Lachesis according to their indications.

Another form more severe was ushered in by chills and in many cases by nausea and vomiting. The fever would be very intense, the difficulty in swallowing great, and at night with children more or less delirium would be present; in these cases the tonsils would be swollen and ulcerated. Three remedies would control these cases, Aconite, which I only used when the fever was very violent, and Belladonna and Mercurius iodatus. The remaining form was Diphtheria of which a description has already been given.