held by numerous pedicles, or, if it fell, left a second crust, hidden under the first. There was ichorous discharge, and often bleeding from the nostrils, and the smell became putrid and insupportable. The trachea was eroded by ulceration, the respiration became laborious and sibilous, and the lung ulcerated. Death took place sometimes on the fifth, more frequently on the seventh or ninth day. The sick emaciated from day to day, had a difficulty in articulating, and spoke with a nasal tone. Sometimes there were large swellings of the glands of the neck, which did not suppurate. Convalescence was much retarded; patients remaining long feeble and delicate.

"The illness was neither preceded by shiverings like acute and inflammatory diseases, nor was there headache, delirium, nor the other symptoms of malignant fever. The digestion was unimpaired. The patients were free from heat and thirst, and when pressed to drink were able to do so, and even to eat without pain. The disease especially attacked children, whom, when they lived together, it seized either all at once or one after the other, and but rarely affected persons above the age of fifteen or sixteen years."

SWEDEN, FROM 1755-1762.

Wilcke, Upsala, 1764.1 "In many houses it carried off the children, proving fatal sometimes as early as the second, but more commonly on the fourth or fifth day of the illness. It appeared to be contagious; children from other houses, who visited the sick, being frequently seized by the disease shortly afterwards. The disease, as has so frequently occurred in other places, appeared under two forms. In one, the tonsils, uvula, and the pharynx were found, on inspection, to be the seat of the characteristic membranous exudation. In the other, the symptoms were almost exclusively referable to the larynx and trachea, which were found after death to be covered with false

1 Dissertatio Medica de Angina Infantum in patria recentioribus.

membrane." On account of their difference of situation and character, the two varieties were regarded as distinct diseases by some of the Swedish physicians, the former variety being classed as malignant sore throat, the latter as croup. The description of the first form of the disease, given by Wilcke, does not differ materially from that of the physicians of other countries about the same time.

UNITED STATES OF AMERICA.

Dr. Samuel Bard, 1789.1 "In general, this disease was confined to children under ten years of age, though some few grown persons, particularly women, (while it prevailed,) had symptoms very similar to it. Most of those who had it, were observed to droop for several days before they were confined. The first symptoms, in almost every case, were a slightly in: flamed and watery eye, a bloated and livid countenance, with a few red eruptions here and there upon the face, and in one case a small ulcer in the nose, whence issued an ichor so sharp as to inflame and erode the upper lip. At the same time, or very soon after, such as could speak, complained of an uneasy sensation in the throat, but without any great soreness and pain. Upon examination, the tonsils appeared swelled and slightly inflamed, with a few white specks upon them, which in some increased so as to cover them all over with one general slough; but this, although a frequent symptom, did not invariably attend the disease, and some had all the other symptoms without it. The breath was either noways offensive, or had only that kind of smell which is occasioned by worms, and the swallowing was very little, if at all, impeded.

"These symptoms, with a slight fever at night, continued in some for five or six days without alarming their friends in others, a difficulty of breathing came on in twenty-four hours, especially in the time of sleep, and was often suddenly in

1 Researches on the Nature, Causes, and Treatment of Suffocative Angina, etc. By Samuel Bard, M. D. New York, 1771.

creased to so great a degree as to threaten immediate suffocation. In general, however, it came on later, increased more gradually, and was not constant; but the patient would now and then enjoy an interval of an hour or two in which he breathed with ease, and then again a laborious breathing would ensue, during which he seemed incapable of filling his lungs, as if the air was drawn through too narrow a passage.

"This stage of the disease was attended with a very great and sudden prostration of strength; a very remarkable, hollow, dry cough, and a peculiar change in the tone of the voice, not easily described, but so singular, that a person who had once heard it could almost certainly know the disease again by hearing the patient cough or speak. In some, the voice was almost entirely lost, and would continue very weak and low for several weeks after recovery. A constant fever attended this disease, but it was much more remarkable in the night than in the daytime, and in some there was a decided remission towards morning. The pulse at the wrist was in general quick, soft and fluttering, though not very low, and it was remarkable, that at the same time the pulsations of the heart were rather strong and smart, than feeble. The heat was not very great, and the skin was commonly moist.

"These symptoms continued for one, two or three days. By that time it was usual for them to be greatly increased in such as died, and the patients, though commonly somewhat comatose from the beginning, now became much more so; yet even when the disorder was at the worst, they retained their senses, and would give distinct answers when spoken to, although, on being left to themselves, they lay, for the most part, in a lethargic condition, only raising up now and then to re. ceive their drink. Great restlessness and jactation came on towards the end of the disease the sick perpetually tossing from one side of the bed to the other; but they were still so far comatose as to appear to be asleep immediately upon changing their situation or posture. A universal languor and dejection were observed in their countenances; the swelling of the face subsided; a profuse sweat broke out about the

head, neck and breast, particularly when asleep; purging in several came on; the difficulty in breathing increased so as to be frequently almost entirely obstructed, and the patient died apparently from the suffocation. This commonly happened before the end of the fourth or fifth day; in several, within thirty-six hours from the time the difficulty of breathing came on first. One child, however, lived under these circumstances to the eighth day, and the day before he died his breath, and what he expectorated, were somewhat offensive; but this was the only instance in which I could discover any thing like a disagreeable smell, either from the breath or expectoration.

"Out of sixteen cases attended with this remarkable suffocation in breathing, seven died; five of them before the fifth day, the other two about the eighth. Of those who recovered, the disease was carried off in one by a plentiful salivation, which began on the sixth day, in most of the others by an expectoration of a viscid mucus.

"Some cases during the epidemic began with a few red pimples behind the ears, itching violently and discharging profusely. These ulcers would sometimes continue for several weeks, and appeared in some cases to be covered with sloughs, resembling those on the tonsils."

SECTION III.-DIPHTHERIA IN THE NINETEENTH CENTURY.

FRANCE.

M. Bretonneau, 1821-1826.1 "At the beginning of the disease a circumscribed redness is perceived, covered with a coagulated semi-transparent mucus. The first layer, which is slight, supple and porous, may be still further raised up by

1 Des Inflammations Spéciales du Tissu Muqueux et en particulier, de la Diphthérite, ou Inflammation Pelliculaire, connue sous le Nom de Croup, D'Angine maligne, D'Angine gangréneuse, etc. Par P. Bretonneau, Médecin en Chef de l'Hopital de Tours. Paris, 1826. Also, in Memoirs on Diphtheria, selected and translated by Dr. Semple for the New Sydenham Society, pp. 176–7.

some portions of unaltered mucus, in such a manner as to form vesicles. Often in a few hours the red spots extend perceptibly from one to another, by continuity or by contact, like a liquid which is effused on a flat surface, or which flows by streaks in a tube. The concretion becomes opaque, white and thick, and assumes a membranous consistence. At this period it is easily detached, and does not adhere to the mucous membrane, except by some very slender prolongations, of concrete matter, which penetrate into the muciparous follicles. The surface which it covers is generally of a slight red tint, with points of a deeper red, this tint being more vivid at the periphery of the spots.

If the false membrane, in detaching itself, leaves the surface of the mucous membrane uncovered, the redness which was obscured by the exudation returns, and the points of a deeper red allow blood to transude. The concrete coating is renewed, and becomes more and more adherent upon the points which have been first attacked; it often acquires a thickness of several lines, and passes from a yellowish-white color to brown, gray or black. At the same time, the transudation of blood becomes still more free, and is the source of those stillicidia which have been so generally remarked by authors.

At this time the alteration of the organic surface is more apparent than at the beginning; portions of concrete matter are often effused into the substance itself of the mucous tissue; a slight erosion and a few ecchymoses are observed in the spots, which, by their situation, are exposed to some friction," or from which the avulsion of the false eschars has been attempted. It is, above all, towards this period that the pellicles, which are being decomposed, exhale a foul odor. If they are circumscribed, the oedematous swelling of the surrounding cellular tissue makes them appear depressed, and by this appearance alone we might be tempted to believe that we have under our eyes a foul ulcer, with a considerable loss of substance. If, on the contrary, they are extended over large surfaces, they are partly detached, they hang in more or less