THE DIFFERENTIAL DIAGNOSIS BETWEEN DIPHTHERIA AND OTHER DIPHTHEROID (PSEUDO-MEMBRANOUS) INFLAMMA- TIONS OF THE UPPER AIR-PASSAGES CAN ONLY BE POSITIVELY ESTABLISHED IN DOUBTFUL CASES, BY THE PRESENCE OF THE KLEBS- • * LOEFFLER BACILLUS. By A. W. de ROALDES, M. D„ Surgeon-in-Chief of the Eve, Ear, Nose and Throat Hospital, and in charge of the Ear, Nose and Throat Department; Professor of Otology, Rhinology and Laryngology in the New Orleans Polyclinic ; Fellow of the American Laryngological Association; Corr. Member of the “Societe Francaise d’ Otologie, de Rhinologie et de Laryn- gologie”; Pres, of the Orleans Parish Medical Society. NEW ORLEANS: L. Graham & Son, Ltd., 44 and 46 Baronne Street. 1894. The Differential Diagnosis Between Diphtheria and other Diph- theroid (Pseudo-membranous) Inflammations of the Upper Air Passages can only be Positively Established, in Doubtful Cases, by the Presence of the Klebs-Loefler Bacillus. One of the Propositions Presented for Discussion before the Orleans Parish Medical Society at the December Meeting- Medical ideas entertained formerly on the subject of sore throat in general, and especially of the membranous forms, have become so modified in the last few years, and errors of diagnosis, when made in the early stage of these diseases, have been so numerous, that physicians of the greatest experi- ence and repute are rapidly giving up as worthless for differ- ential diagnosis most of the clinical signs and symptoms laid down in our text books as characteristics of these different morbid entities. The fact is that modern investigations have clearly demonstrated that for the early differential diagnosis of the different forms of white anginas stress must be laid on the bacteriological examination in preference to the clinical appear- ances. As for myself, I will say in the language of Dr. Raven, “ The more I see ot diphtheria, the more fully I recognize the difficulty of speaking positively, in the early stage at least, as to the exact nature of a sore throat.” That the uvula be or not wrapped up in a membrane, that the pillars and pharynx be or not invaded, that the membran- ous formation be white, grayish or yellowish; that it be slightly adherent or deeply imbedded in the mucous membrane, that the ganglia be engorged or uninvolved, is no longer of very great importance to the modern clinician when he is called upon to pronounce on the contagious or non-contagious nature of the sore throat, or of the rhinitis. The pseudo-membranous forms are no longer limited as formally to two or three varieties. Their classification has become much more complex, thanks to modern histological and bacteriological studies. Every variety of membranous sore throat corresponds to a different pathological microbe, or to a microbic association. The angina is white because the membrane is the product of inflammatory reaction of the parts in consequence of a micro- bic infection; the objective appearances of the membrane, its disposition, its localization, can not of themselves inform us as to the real cause of the sore throat. Alongside of herpetic pharyngitis, of follicular tonsillitis, etc., are to be placed the sore throats caused by the Klebs- 2 Loefler bacillus (true diphtheria), by the streptococcus (erysipe- las, scarlatina, croupous angina, etc.), by the staphylococcus albus or aureus, by Eberth’s bacillus (typhoid fever) and probably by other microbic entities actually unrecognized. A bacteriological investigation is therefore the only certain differential diagnostic means in those numerous forms of mem- branous formations. With such views regarding the unreliability of an early diagnosis based solely on the clinical appearances of a pseudo- membranous affection of the upper air passages, you will par- don me if I avoid the finesses, not to say the fallacies, of the numerously enumerated text-book appearances, and I limit myself to a classification of these different morbid entities, with an enumeration of the broad differential characters which may allow the modern clinician to prejudge, to some extent, the nature of the affection in anticipation solely of a bacteriological culture. The nose may be the seat of membranous formations under three different conditions: (1) When invaded secondarily from the throat by the Klebs-Loefler bacillus, or when itself the primary seat of diphtheria; (2) when affected by what has been termed croupous or fibrinous rhinitis; (3) when a fibrin- ous exudation is produced as a result of a galvano-cautery or chromic acid, etc., application. Outside of the fact that in this last class of cases there is a history of an operative interference, and that in fibrinous rhinitis the throat is never invaded, all other clinical signs are so uncertain that, in most cases, a bacteriological culture is absolutely necessary for an early differential diagnosis. Sore throats may be conveniently divided into two classes, viz. : the membranous anginae, and those which are non-mem- branous but may be accompanied by a white or pultaceous ex- udate underlined by an unaffected or by an ulcerated mucous membrane. Pseudo-Membranous Rhinitis. class no. 1. Pseudo-Membranous Angina. This class can be conveniently subdivided into two groups : Group No. 1: Primitive Pseudo-Membranous Angina. 1. Diphtheritic sore throat. 2. Angina due to the presence of streptococci. 3. Angina due to the presence of staphylococci. 4. Angina due to the presence of pneumococci. 5. Angina due to the presence of other cocci. Pseudo- diphtheritic anginas. 3 To this group belong, outside of true diphtheria, the in- flammations which reproduce so closely the symptomatic tableau of diphtheria that they have been lately classified under the name of false diphtheria. They include such affec- tions known formerly as pseudo-membranous angina, croupous tonsillitis, etc., and are due to the presence of streptococci, of stophylococci, of pneumococci and other cocci. The physical and histological appearances of the false membrane bear such a resemblance to the membranous productions of true diphtheria and the microbic associations are so numerous and the clinical history of this group (diphtheriaexcepted) is yet so incomplete as to force upon us the necessity of a bacteriological culture in order to differentiate positively these sore throats from the one of true diphtheria. These are the anginas so often mistaken for diphtheria. Their causative micro-organisms, their different systemic infection and their low mortality mark the broad lines of demarcation. The brusque onset of these anginse, the rapid elevation of temperature, the violence of the sore throat, and the peculiar red and inflamed condition of the throat are the few points to be remembered as worth anything for the clinical differentia- tion of these forms from true diphtheria. Group No. 2: Secondary Pseudo-Membranous Angina. i. Scarlatinous Agince.—The early pseudo-membranous sore throat which accompanies an eruption of scarlet fever must be considered most ordinarily as pseudo-diphtheritic, no matter if it invades the larynx or nasal fossas. If it precedes the eruption, the diagnosis must be reserved or made bacterio- logically. It will generally reveal the presence of the staphyl- ococcus pyogenes. The insidiousness of the attack, the greater implication of the general health, paler complexion, depression of strength, lower temperature in diphtheria, with an absence of the appear- ance of the tongue and of the redness of the soft palate pecul- iar to scarlet fever, will furnish a few clinical data for the differential diagnosis. Let us, however, remember that mild cases of diphtheria will be met with where the general health is almost unaffected, and that septic forms of scarlet fever will produce very grave symptoms. As to the pseudo-membranous formations which appear in the advanced stage of an attack of scarlatina, they must be con- sidered very generally as being truly diphtheritic, for in most such cases a culture develops the characteristic Klebs-Loefler bacillus. 4 2. Syphilitic Angince.—The pseudo-membranous anginas of syphilis may at times be difficult to distinguish from true diphtheria. For the diagnosis of the chancre, when covered by a fibrinous exudate, the marked induration of the tonsil, the unilateral location, and the closer adherence of the membrane, which unlike other pseudo-membranous productions has no ten- dency to spread, the characteristic bubo and absence of fever are clinical signs of great value. The mistake, however, has oftener been made in the pseudo-membranous anginas of secondary syphilis, which re- semble more closely diphtheria. The localization of the psetido-membrane on the tonsils, on the pillars, uvula, and even on the posterior pharyngeal wall, the color and the adherence are somewhat alike. In some cases of secondary syphilitic laryngitis the vocal and respiratory disturbances might impress one with the idea of a concomitant croup. Still the usual absence of fever and the preservation of the general health are in marked contrast with the extent of the pseudo-membranes; the absence of albumi- nuria, the presence of a specific roseola or of mucous patches, the study of the anamnestics, with the use of the laryngo- scope, will allow a careful clinician to formulate a positive diagnosis. 3. Traumatic Pseudo-Membranous Angince.—Pseudo-mem- branous formations will at times develop on the section of a tonsil or in the nose as a result of cauterization with the gal- vano-cautery or with certain acids, as chromic acid, etc. The knowledge of this fact will suffice to prevent any error of diag- nosis. CLASS NO. 2. Non-Membranous, Pliliaceous and Ulcerated Angince. These forms of sore throat, while less liable to be mistaken for diphtheria, will still at times present difficulties of early diagnosis, especially in cases of confluent herpes of the throat or in acute lacunar tonsillitis. i. Herpes of the Pharynx, Herpetic Angina or Confluent Herpes of the Throat.—The phlyclenularor vesicular appearance of this sore throat at its onset will prevent any mistake; but when the vesicles have disappeared and are replaced by minute ulcerations, which have coalesced and are covered by a white and adherent exudate, the differentiation of herpes from diph- theria may be difficult. The suddenness of the attack, the violent initial chill, in- tense cephalalgia, gastric disturbance, marked elevation of temperature, accompanied often by great general malaise and a concomitant labial herpes will justify the probable diagnosis of herpetic angina, especially if the patch is polycyclical and underlined by an ulcerated surface. Albuminuria and ganglionic enlargement are very uncom- mon symptoms in this disease, but may also be absent in light cases of diphtheria. Herpes of the throat is rarely met with in children. 2. Lacunar, Follicular or Cryptic Tonsillitis.— The lim- itation of the exudation to the tonsils, the short duration of the attack, the severity or the mildness of the accompanying febrile excitement, the infectious or non-infectious character of the disease, the presence or the absence of albuminuria or of adenitis, should be of less weight in making a differential diag- nosis than the two following points, which in my experience are most important. The white spots or membraniform patches of lacunar tonsillitis occupy a direct relation to the crypts, and are consequently located on the more central portion of the con- vexity of the tonsil. In diphtheria limited to the tonsil while the pseudo-membrane may be seen on that portion of the ton- sil, it will develop also on the lateral or marginal portion of this organ. Pressure or a bent probe introduced in the lacunae will force out the cheesy contents of the crypts. In cases of struggling children I have found the advice of Jacobi, who, in doubtful cases of follicular tonsillitis, syringes the throat with warm salt water, and thus cleanses it of much deceptive material, a most serviceable diagnostic sign. If this cheesy exudate is not thoroughly removed under a forced stream of water, and there remain spots of membraniform appearance, adherent to the mouths of the crypts, the diag- nosis should be reserved and a culture made at once. I must confess, however, to have met several instances which were to all clinical appearances typical cases of follicular ton- sillitis, and still turned out to be cases of true diphtheria, one of which ended fatally in diphtheritic laryngo-tracheitis; two others, in which a Klebs-Loefler culture was made, ended fav- orably without having ever developed a true pseudo-membran- ous formation. 3- Acute Tonsillitis.—In such cases thin, translucent, milky patches will be met with covering a red mucous mem- brane and a swollen organ ; also at times the soft palate, the uvula, but more rarely the pharynx. This epithelial exudate, resembling the saburrhal condition of high and prolonged fevers, is easily detached and easily dissolved in water, and can not, except through gross carelessness, be mistaken for a pseudo-membrane. 6 4. Pultaceous Angina.—In this form, which is encountered in low or debilitated states of the system, as in the cachexias or in the course of typhoid, also of scarlet fever, the exudate is friable and soft, easely brushed off without injury or bleeding of the mucous membrane, and can not be mistaken. 5. Confluent Muguet.—When this cryptogamic disease in- vades the tonsil or throat, which is rather rare, it will be dif- ferentiated easily from diphtheria by its characteristic appear- ance, which is grumous and resembles dots of curdled milk, which are easily swabbed off. In case of any doubt, the mi- croscope will readily demonstrate the presence of the mycelium and spores of the oidium albicans. 6. Ulcero-membranous Angina.—The fact that it is an extension of an ulcero-membranous stomatitis, generally uni- lateral, characterized by a necrobiotic process, an abundant salivation, devoid of constitutional symptoms and unaccom- panied by fever or glandular swelling will readily distinguish this disease from diphtheria. 7. Gangrenous Angina or Sore Throat.—This angina is ordinarily secondary to a general disease or to an eruptive fever; at times it will be met with as an idiopathic affection, characterized from the beginning by the blackish color, the fetid odor, the sloughing tendency of gangrene, leaving be- hind it, upon the elimination of the eschar, etc., sometimes very deep ulceration. It is very seldom accompanied by en- largement of the lymphatic glands. 9. Pharyngo-Mycosis.—These last two affections are mentioned fro forma, as confusion with diphtheria is scarcely possible. The coexistence of aphthas in the mouth or on the tongue, with their peculiar small transparent vesicles, gen- erally isolated, ending in a shallow, round ulceration covered with a thin film of dirty yellow slough, will clear all doubt as to the nature of the angina, which is, anyhow, a very rare affec- tion of the throat. As to the pharyngo-mycosis the deposit is elevated on the surface of the tonsil, pharynx or base of tongue, composed of white or yellowish, somewhat indurated projections hard to remove, and unaccompanied by local or general inflammatory reaction. If doubt was possible as to the nature of the affection, the microscope would always reveal the presence of the characteristic leptothrix buccalis. In conclusion I will say that if there are a great many forms of sore throat where an early diagnosis, based on the clinical appearances, will acquire a high degree of probability, there are also many cases in which a culture affords the only means of avoiding very fatal mistakes, especially if we re- 8. Afhthous Angina. 7 member that bacteriology has confirmed the existence of cases, rare it is true, of “diphtheria sine diphthera,” that is of sore throat without pseudo-membranous formation, stimulat- ing simple angina, but in which a culture develops numerous colonies of virulent Klebs-Loefler bacilli. * * * * A. W. De ROALDES,’M. D., 136 Grcivier St. (Citizen’s Bank Building), New Orleans, La.