THE EPIDEMIC OF 1857-60.

IN ENGLAND.

MILD FORM.

Dr. Greenhow, 1860.1 Diphtheria generally begins with very slight and almost imperceptible premonitory indisposition. Sometimes there is a slight malaise for a few days before the throat becomes sore; sometimes drowsiness or chilliness, occasionally amounting even to shivering, followed by febrile reaction. Sometimes aching of the limbs and loins, or headache, and less frequently nausea and vomiting are forerunners of the local affection. More commonly the earliest complaint is of slight stiffness of the neck or of soreness, or a sense of pricking in the fauces. On examination, the glands at the angles of the lower jaw are almost always found to be slightly swollen and tender. Internally, one or both tonsils are for the most part swollen, and usually reddened and inflamed, but occasionally much enlarged without much redness. The redness, when present, is of a rose color in young children, and of a crimson or deep claret color in older children and adults, the hue varying with the intensity of the disease. The arches of the palate, the velum, uvula, and sometimes the posterior wall of the pharynx, generally participate more or less in the inflammatory action. The tonsils are sometimes so much swollen that they touch one another and impede deglutition and speech, especially when, as is common in severe cases, the uvula is also much enlarged. Deglutition is sometimes painful, but is often easy, even to the termination of the worst cases; and is rarely, if ever, so difficult as in the angina of scarlet fever, or in ordinary tonsillitis. Indeed, the pain and difficulty of swallowing afford no index of the intensity of the disease, being sometimes very

1 Dr. Greenhow on Diphtheria, 1860.

slight in the most serious cases, and severe in the slightest. Some of my patients have spoken of the uneasiness in the throat as being rather a sensation of fulness or of a "lump" in the throat, than of pain.

"The pulse is usually accelerated, but not very high at this period of the disease, and the temperature of the skin slightly, but not much, above the standard of health. There is never, so far as I have observed, the pungent heat or dryness of skin which accompanies scarlet fever and most other acute febrile diseases.

"The general malaise, drowsiness, discomfort and soreness of the throat bear no direct proportion to the severity of the suc ceeding attack, being frequently more marked in cases which do not present symptoms of a severe character than in others. of the worst description. Indeed, in the severest forms of diphtheria, these premonitory symptoms are sometimes so slight as to escape observation altogether, and the illness is not noticed until it has assumed a serious aspect. It has frequently happened, especially with children, that patients have continued to go about without complaining until the disease has reached an almost hopeless stage. Thus far, there is little, if any, difference between true diphtheria and the cases of mild sore throat, that so often prevail simultaneously with it, and which, as I have already said, probably differ from it only in degree. The essential character of both is inflammation of the throat and fauces, but little prone to terminate in suppuration or ulceration; and, although the milder kind differs greatly from fully developed diphtheria, the two forms pass insensibly into each other, so that cases of intermediate degree of severity may often be observed in the same epidemic.

A MORE SEVERE FORM.

Dr. Greenhow. "If it be conceded that the kind of mild sore throat unattended by diphtheritic exudation, which prevails so commonly during epidemics of diphtheria, differs only in degree from the latter, then does the early stage above described sometimes comprise the whole of the disease. In

other cases it is but the prelude to the exudation of fibrinous material upon the inflamed mucous surface, the tendency to which constitutes the essential local character of diphtheria. In such cases the inflammation, instead of terminating in suppuration of the tonsils, or in ulceration of the inflamed membrane, as in the commoner inflammatory affections of these parts, is followed by an effusion of plastic fibrinous material upon the free surface of the mucous membrane, when it coagulates, forming a false membrane, or more rarely a pasty or friable deposit.1 This exudation, which has frequently been mistaken for sloughs, takes place when the preliminary symptoms have lasted with more or less intensity for a time which in some cases extends to a few days, and in others terminates in the course of a few hours. It usually appears first on one of the tonsils or the soft palate; sometimes simultaneously upon both, or upon the posterior wall of the pharynx, more rarely—at least, during the recent epidemic—upon the buccal mucous membrane of the gums.

"The exudation generally shows itself at first in the form of detached specks, which, enlarging at their edges, coalesce, forming plates of deposit, investing the inflamed surface, and bordered by a margin of inflamed membrane, the more or less deep hue of which presents a striking contrast to the white, gray or ash-colored concretion. In some cases both tonsils, the soft palate, and the posterior fauces are coated with exuda tion, which, if it coagulates firmly, forms an exact cast of the parts it envelopes. The disease often likewise creeps upwards into the nares, or begins there simultaneously with its appearance in the throat, or it extends downwards into the œsophagus, or through the glottis, into the larynx and trachea. Besides growing in extent with the wider spread or increased intensity of the inflammation, the deposit increases in depth by successive additions from below, until it occasionally attains a thickness of more than a line. In other cases the dis

This appearance the membrane assumes, according to my experience, in the latter stages of the disease.

eased action is more limited, the deposit manifesting but little tendency to extend either in depth or breadth, and appearing only upon the tonsils or posterior wall of the pharynx, when it may consist of a rough patch, or of several distinct patches, or of a mere filin, covering the parts at first affected. The intensity and danger of a case, though mostly, are by no means always in exact proportion to the extent of the exudation. Sometimes cases attended by excessive exudation make a favorable recovery; at others, the exudation is of small extent, when the case is in other respects of severe character.

"The exudation is sometimes firmly attached to the subjacent mucous membrane, from which it is with difficulty removed; at others, it is so loosely adherent as to be easily rubbed off or removed with a forceps. In either case the subjacent membrane is generally more or less deeply reddened, and if there should have been difficulty in removing the false membrane, it exhibits spots of blood. With this exception, the mucous surface is in general free from abrasion or ulceration. In some cases, the inflamed membrane surrounding the exudation is much congested, very tender, and so lacerable that the slightest touch with any instrument used for depressing the tongue, or removing the false membrane, causes hemorrhage.

"When the exudation has been artificially removed, it commonly reappears within a few hours, and several successive false membranes may thus be formed on the surface of the throat. Sometimes, even when the exudation has come away spontaneously, it is followed by a second, or by several others in succession, but when this happens, the later membranes are, for the most part, less and less dense, more and more filmy, and whiter than the preceding, until the diseased. part recovers its normal condition. Frequently, when the false membrane has exfoliated naturally, it leaves the subjacent surface unbroken, paler than in health, and either ragged, or sensibly diminished in size. The uvula, for example, if it has been affected, appears shrunken, the tonsils more or less excavated, the flat mucous surface depressed; the depression being often abruptly bounded, as if its margin corresponded

with that of the space lately covered by the false membrane. This depression of the surface, which has been covered by false membrane, is sometimes very marked after death; and is perhaps, in some measure, attributable to the loss of fluids by the part, consequent upon the exudation; but probably still more to the pressure of the false membrane, which, in coagulating, contracts, and will thus, when only moderately adherent, exert considerable pressure upon the subjacent surface. In other cases, the false membrane, instead of exfoliating entire, or in large slips, wastes insensibly, day by day, until it disappears; lessening from the circumference towards. the centre, but probably, also, at the same time becoming attenuated.1

"The exudation varies much in texture in different cases, being sometimes dense, firm, coherent, and elastic; at others, soft, gelatinous, almost liquid, or dry and friable. In color it varies from white to gray or ash-colored, brown, and blackish. Although these varieties do not proceed from any essential difference in the nature of the disease, they indicate different degrees of its intensity, and their careful observation affords valuable aid to prognosis.

"In the several epidemics which I have had the opportu nity of studying in different places, but more particularly in this metropolis, (London,) many cases of diphtheritic sore throat, the course and symptoms of which, save for the presence of exudation, have scarcely differed from those of simple tonsillitis, have been intermingled with the severest form of the disease. The most common, and, as regards danger or suffering to the patient, the least important of these, have been cases of inflamed sore throat, attended by a thin exudation, glazing the posterior wall of the pharynx or the tonsils, and manifesting little or no tendency to increase in breadth or thickness. Sometimes the exudation is almost

1 This description is remarkably accurate, and I have seen the same lessening of the membrane from the circumference to the centre, in nu merous instances.