ITALIAN EPIDEMIC.

Cortesius. "Redness and inflammation of the surface of the palate and mouth, the tonsils remaining unaffected; more frequently, these glands were swollen, and sometimes so much so that they touched each other, thereby interfering with deglutition and respiration. In the beginning, there was usually swelling, heat and redness; afterwards, pain, and difficulty of swallowing. When there was only inflammation of the parts about the throat, the sick easily recovered; but sometimes a certain pituitous substance, (exudation,) descending from the head, so speedily and unexpectedly followed the inflammation, that the patient was suddenly suffocated. Very often a white substance, which soon became liquid and afterwards black, unaccompanied by pain, appeared on the inflamed surface. This material could be readily torn away from the subjacent parts, either by the finger or an instrument; but, although the operation caused no pain, the patient invariably died a short time afterwards, as happened, among others, to the son-in-law and the grandchild of Cortesius. Sometimes mortification, accompanied by fetor, quickly invaded some part of the throat; and when this occurred, whether fetor were present or not, remedies proved unavailing, and the patient died about the fourth day, or even earlier, rarely so late as the seventh day."

Cortesius notices the frequent occurrence of several fatal attacks in the same family. There was reason for supposing the disease to be contagious, and a case reported by Cortesius strengthens the opinion. A monk being attacked by the disease, constantly complained that he observed a foul odor proceeding, as he supposed, from his mouth; so to assure himself of the truth, requested a friend to verify the fact by smelling. Not many hours after doing so, in the presence of Cortesius and others, the friend was laid up with inflammation of the fauces and tonsils, and, remedies proving useless, died on the fourth day of his illness.

1 Joannis Baptista Cortesii, Miscellaneorum medicinalium. Decades Denæ Messanæ, 1625.

SECTION II.-DIPHTHERIA IN THE EIGHTEENTH CENTURY.

Dr. Fothergill

ENGLAND.

"Children and young people were more liable to the disease than adults, girls more than boys, women more than men, the delicate more than the robust. The illness usually began with giddiness, chilliness or shivering, followed by fever, acute pain in the head, stiffness of the neck, soreness of the throat, and sometimes vomiting and diarrhoea. The pain, heat and restlessness increased towards night, and were often mitigated by the breaking out of a sweat towards morning.

"If the mouth and throat be examined soon after the first attack, the uvula and tonsils appear swelled, and these parts, together with the velum pendulum palati, the cheeks on each side near the entrance into the fauces, and as much of them and the pharynx behind as can be seen, appear of a florid red color. This color is commonly most observable on the posterior edge of the palate, in the angles above the tonsils, and upon the tonsils themselves. Instead of this redness, a broad spot or patch of an irregular figure, and of a pale white color, is sometimes to be seen, surrounded with a florid red; the whiteness commonly appears like that of the gums immediately after having been pressed with the finger, or as if matter ready to be discharged was contained underneath.

Generally on the second day of the disease, the face, neck breast, and hands to the fingers, are become of a deep, erysipelatous color, with a sensible tumefaction; the fingers are frequently tinged in so remarkable a manner, that from seeing them only it has not been difficult to guess at the disease. A great number of small pimples, of a color distinguishably more intense than that which surrounds them, appear on the arms and other parts. They are larger and more prominent

1 An Account of the Putrid Sore Throat, by John Fothergill, M. D. 5th edition, London, 1769.

in those subjects, and in those parts of the same subject, where the redness is least intense, which is generally on the arms, the breast, and lower extremities.

"These white places presently became more of an ash color, when it was discernible that what at first might have been taken for the superficial covering of a suppurated tumor, was really a slough, concealing an ulcer of the same dimensions. All parts of the fauces were liable to be affected, but the disease generally first appeared in the angles above the tonsils, or on the tonsils themselves, on one of the arches formed by the uvula and tonsils, on the posterior wall of the pharnyx, on the inside of the cheeks, or on the base of the tongue.

"In the milder forms of the disease, an irregular, superficial ulcer, scarcely to be distinguished from the sound parts but by the roughness of the surface it occasioned, appeared on one or more of the above-mentioned parts. A thin, pale, white slough seems to accompany the next degree;1 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. The 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 a greater or less depth, as the sloughs were superficial or penetrating.

"In one case these sloughs were separated by a surgeon's probe without much difficulty, but the same parts were cov ered the following day with thick, dark, ash-colored sloughs, penetrating deep into the substance. The eruption was not always present, and especially in the winter of 1754, it either did not appear at all, or its appearance was retarded. There was commonly much swelling of the parotid glands and neighboring parts, and the tonsils and uvula were sometimes

1 During the winter of 1862-63, diphtheria in Philadelphia was characterized by this appearance. The same white membrane was observed in the ulcers, sores, and even whitlows of diphtheritic patients. It seemed to mingle with all kinds of diseases and modify them.

so much swelled as to leave but a narrow entrance to the gullet, which was also frequently surrounded with ulcers and sloughs. Yet, although food was sometimes forced back through the nose, patients often swallowed with little difficulty or pain. An offensive putrid discharge, and a corrosive, sanious discharge from the nostrils often accompanied the complaint; it was also sometimes attended by an excessive faintness, the greater or less urgency of which seemed to indicate the degree of danger. There was less thirst than usual in other acute diseases, and the tongue was moist and seldom furred. Hemorrhage from the nose and mouth sometimes suddenly carried off the patient."

Dr. Fothergill distinguished the disease from scarlet fever, for which one of his cases was mistaken by the persons about the patient, but several of the symptoms he describes, particularly the appearance of a red rash on the second day, are rather those of scarlet fever than of diphtheria. It seems probable, as has happened in more recent epidemics, that scarlet fever and diphtheria were intermingled; that the cases of scarlet fever had a diphtheritic character, and that, while in all probability Dr. Fothergill saw some cases of uncomplicated diphtheria, especially of that kind in which the exudation remains until the subjacent surface sloughs, he nevertheless confounded the two diseases. Indeed, we have other evidence, both that scarlet fever sometimes presented unusual features, and that diphtheria, complicated with scarlet fever, prevailed in England about the time when Dr. Fothergill observed the particular form of sore throat described in his book.1

Dr. Nathaniel Cotton, St. Albans, 1748,2 describes the same peculiar form of scarlet fever. "Upon looking into the

1 During the recent epidemic in Philadelphia, I have observed this intermingling of scarlet fever and diphtheria in twenty cases. In fact I am more convinced every day, that the two diseases are the product of the same miasma in the blood.

2 Observations on a particular kind of scarlet fever, that lately prevailed in or about St. Albans, in a letter to Dr. Mead, by Nathan. Cotton, M. D.

mouth, there were frequently seen, especially after the disease was a little advanced, ulcers scattered up and down the fauces, pretty broad upon and about the tonsils, superficial, and covered with a whitish slough. The scarlet efflorescence differed as to extent and time of appearance; there was high fever, intense thirst, a moist and but slightly-furred tongue, frequent cough, sudden loss of strength, and great dejection of spirits, especially towards evening, which continued for some time after the patient was convalescent."

Dr. Starr, Cornwall, 1748 or 1749.1 "Swelling of the tonsils, parotid and submaxillary glands; gangrenous sloughs (which were evidently false membranes) often formed in the mouth at an early stage of the illness. Others again complained of a slight pain on swallowing, succeeded by fever; a short, low, barking, hoarse cough, which sooner or later was productive of a difficult, noisy, and strangulated respiration (croupy form). After an illness of a day or two, the voice usually became so hoarse that it was difficult to understand. The expectoration was never a well-digested or concocted phlegm, or mucus; on the contrary, the greater part of it was of a jelly-like nature, glairy and somewhat transparent, mixed with a white, opaque, thready matter, sometimes more and sometimes less resembling a rotten membranous body or slough.

"Such a slough I have seen generated on the neck and arm, where blisters had been applied. The blister had been dressed with colewort leaves, and ran but little; but contiguous to its place, small red pustules, not exceedingly fiery, arose, and, sweating plentifully, in a few hours became quite white. These, hourly enlarging their bases, united and covered a large surface,-fresh pustules arising in the adjacent parts. This white surface had the aspect of an oversoaked membrane that had become absolutely rotten." "I scratched the slough," says Dr. Starr, "with my nail; it separated with ease, and without being felt by the child."

1 Philosophical Transactions, vol. xlvi.

This is a most accurate account of the origin and progress of the