putrefied shreds, and they put on the appearance of the last stage of sphacelus."

M. Louis, 1824. "The commencement of the disease was marked by more or less severe pain in the throat, which, nevertheless, was sometimes preceded by the formation of false membrane in the nasal cavities, and by coryza. This pain was accompanied by a more or less vivid redness of the pharynx, tonsils, and soft palate, by slight swelling, tightness, pricking, and especially by difficulty in swallowing. The difficulty in swallowing, commonly inconsiderable at first, sometimes became so great that the patients returned a portion of their drink by the nose; or deglutition even became impossible, and the separation of the jaws impracticable. Sooner or later after the commencement of the pain in the throat, a false membrane was observed, which successively or simultaneously covered the pharynx, soft palate, uvula and tonsils. Once only, throughout the whole course of the disease, were any of these parts left uncovered by the membrane. The neck became more or less swollen. A slight pain in the larynx and trachea was observed sometimes before, sometimes simultaneously with the appearance of the false membrane, but always after the commencement of pain in the throat. This pain, the character of which was, in general, difficult to describe, manifested itself in certain subjects under the form of a burning heat, which they endeavored to mitigate by the application of cold. Soon after its appearance, the voice, which until then had exhibited only a change similar to that which occurs in simple sore throat, assumed a character more or less perfectly analogous to what is called croupal voice. Respiration became more or less difficult, but was rarely sibilous; and out. of the five patients, whose cases have been related, it was only observed to be so in one, a few hours before death. Throwing back the head appeared in certain cases to lessen the dyspnoea. The cough was sometimes distressing, but generally so slight that it only inconvenienced the patient by exasperating the pain in the throat. Paroxysms of suffocation were very rare. Some of the patients exhibited great

uneasiness and anxiety; others, though very uneasy about their condition, did not lose the kind of quietness in which we saw them, till a few hours before death."

Dr. Mackenzie, 1825.1 His views of the pathology of the disease coincide very exactly with those of Bretonneau, a circumstance, he says, in a subsequent paper, which, as it arose without any knowledge of each other's labors, tends to confirm the observations of both. In 1821, two cases of the disease proved fatal under Dr. Mackenzie's care. In both, the fetor of the breath and the sloughy appearance of the effused lymph were remarkable. "In the first case," he adds, “I was surprised, on dissection, to find the tonsils and uvula entire and coated over only with an effusion, for I had laid my account to find a gangrenous loss of substance in these parts." He now announced to several of his medical brethren, that what had been considered as ulcers and sloughs in this disease, were nothing else than effused lymph, the progress of which over the velum and uvula, and towards the alimentary and respiratory passages, he had distinctly observed.

The following description of the disease by Dariot very much corresponds to our Philadelphia epidemic:

Dr. Dariot, 1845.2 I. "In the first stage, the pathological conditions were sometimes limited to a slight sense of uneasiness in the throat, accompanied by scarcely any difficulty in deglutition. There was, most commonly, in addition to these symptoms, a more acute pain in the pharynx, while the movements of the neck were constrained, and there was in some degree torticollis. The cervical and submaxillary glands soon became engorged, the face was congested and puffy, with injection and lachrymation of the eyes. On examining the lower part of the buccal cavity, all or nearly all the parts constituting the guttural fossa were seen to present a deep rose-red color

1 Edinburgh Medical and Surgical Journal, vol. xxiii., p. 296.

2 Relation Historique d'une Epidémie de Diphthéropathie observée dans le Département de Saone et Loire, et de la Nièvre, pendant les années 1841, 1842, 1843 et 1844. Par D. J. Dariot. Autun, 1845.

in children, and a more deep brown one in adults. There was also swelling of one of the tonsils, more rarely of both; the uvula was almost always tumefied and relaxed; there was almost habitually coryza. At these periods the disease, when suitably treated, lasted, in certain cases, for several days, but was terminated in other cases at the end of a few hours.

II. "When the disease passed to a more advanced stage, commencing often on the very day of invasion, and sometimes a few hours afterwards, this transition was inaugurated by a very remarkable state. The parts which were about to become the seat of a pseudo-membranous exudation, presented an oedematous appearance, similar in tint to a piece of meat bleached by the action of boiling water. Soon afterwards, there were observed upon the tonsils, the uvula, the velum palati, the posterior surface of the pharynx, etc., etc., either solitarily, simultaneously, or progressively, small vesicular points, formed by partial elevation of the epithelium, of a shining and whitish appearance, and which, though at first separated, in general soon became united and confused together, and then were transformed into patches of lardaceous, smooth, whitish, yellowish, or brownish appearance, irregu larly circumscribed, more prominent in the centre, and becoming thin at their edges. Sometimes the primitive patches remained isolated, and appeared to rest on a depressed surface." (This latter I have seen very often in the Philadelphia epidemic.)

"With the appearance of false membranes, the glandular engorgements increased considerably, especially on the side where the tonsil was more swollen, and the pellicles were more numerous and thicker. Deglutition was more difficult. It was never painful in proportion to the inconvenience which must have existed, a character which establishes a wellmarked line of demarcation between pharyngeal diphthérite and simple angina. The voice was altered and became nasal; cough was infrequent; there was stoppage of the nose, and a flux of a serous liquid by the nostrils; the patient was abundantly salivated, and voided a semi-transparent fluid, inter

spersed with large bubbles, pouring out like white of egg and manifestly albuminous. Liquids were often thrown up and ejected by the nasal fossæ; the mouth exhaled an odor sui generis, compared to that of carious teeth. With the local pathognomonic symptoms were united some general symptoms, such as more considerable swelling, but less deep coloration of the face; more or less intense febrile reaction; the pulse was generally frequent, nearly always small and compressed; cephalalgia more or less marked; tongue swollen, covered with a thick and yellowish mucous coat; rather frequently nausea and vomiting. We often also remarked, on different parts of the body, diphtheritic patches, especially on the lips, around the alæ nasæ, behind the ears, around the circumference of the anus. of the vulva, of the nipples, on the penis and the hands, and on the blisters which had been applied to the patients.

"When the disease was about to terminate favorably, the extension of the false membranes ceased; the latter were then circumscribed by a red areola, were swelled up, and began to separate, and being detached in strips, allowed the oozing of a few drops of blood, and were then thrown up by the patients, together with a frothy saliva. These pellicles would be frequently reproduced in a short space of time, and we were often astonished at the prodigious quantity of decomposed matter which was expelled in certain cases. Those of the second and third formation were more white, thinner, and more transparent than those of the first; at least they ceased to be reproduced after their detachment.

"In proportion as the resolution of the disease took place in the pharynx, the lymphatic glands diminished in volume and ceased to be painful; there was a diminution, and then a complete cessation of all the general phenomena. Convalescence was established, but slowly and with difficulty, and was remarkable for a state of languor, which remained for a long time, and a peculiar paleness of face, etc.

III. "Lastly, the disease was aggravated-the tonsils became enormously enlarged, so as to touch one another, and to

form with the uvula, which was very large itself, a mechanical obstacle to the introduction of liquids, as well as to the passage of air. The membranous patches began to thicken, were very adherent, of a dull yellow-grayish or brownish color, and invaded the whole guttural cavity, the nasal fossæ, and very often the palatine arch; there was considerable enlargement of the cervical and submaxillary glands, extending sometimes as far as the clavicular regions, more marked especially at the base of the lower jaw, a circumstance which gave to the patients a peculiar expression; laborious respiration, accompanied by more or less noisy guttural rattle; not much cough; voice generally feeble; discharge by the nostrils of a sanious and fetid fluid; frequent epistaxis, sometimes so abundant as to require hæmostatic measures; mouth always open, and exhaling a gangrenous odor; spitting of a viscid purulent matter, mixed with membranous flakes, often blackish, and then presenting altogether the color and aspect of gangrene; lips bleeding and covered with brownish crusts; greater puffiness of the face; remarkable lividity of the complexion; continued cephalalgia; an expression of weakness and languor, but never great alteration of features; constipation, either persistent or replaced by a fetid diarrhoea, and fever, with irregular paroxysms. The pulse soon became thready, and lost regularity, the extremities were cold and covered with a viscid sweat, there was drowsiness in children, and agitation in subjects of more advanced age. Lastly, the patients, after having presented the paleness of the face which Laennec calls a semi-cadaverous phenomenon, expired, having exhibited all the symptoms of true asphyxia. If combined with pneumonia, it was uniformly fatal."1

1 Several cases combined with pneumonia, in my practice, have been cured.