transparent, and gives to the surface it covers the aspect of being painted over with varnish or thin glue; at others, it is opaque and white, but filmy, the mucous surface being covered with an extremely fine pellicle. The transparent glazing is most frequently seen on the posterior wall of the pharynx, where it is very apparent from its refractive property. The filmy pellicle is seen both on the tonsils, the posterior fauces, the inside of the cheeks, and the gums. The swelling of the tonsils is generally either absent or slight in these cases, and the redness of the inflamed mucous membrane is not intense. There is usually slight depression of strength, and more or less general malaise, but the constitutional symptoms are mild, and such cases rarely or never terminate seriously, or are followed by troublesome results.

"This form of diphtheritic sore throat, for the most part, yields readily to treatment, but it is very liable to relapse, and sometimes becomes chronic, causing uneasiness of the throat of many weeks' duration.1

DANGEROUS CASES OF DIPHTHERIA.

Dr. Greenhow. "The class of cases to which attention must be directed, is of a much more serious kind than any of those hitherto described. The exudation may, as in the former varieties, commence in the form of a thin, translucent pellicle, or in detached patches, but it rapidly becomes thicker, and, the separate patches coalescing, soon cover the inflamed sur

This form of diphtheria was very prevalent in Philadelphia during the last eighteen months. It is still prevalent (May, 1866) to some extent. I may truly say, that I have attended several hundreds of such cases during this time. The disease particularly attacked the tonsils, pharynx, and also roof of the mouth and tongue. If there was any tendency to bronchitis, pneumonia, or chronic catarrh, it was sure to complicate itself with these diseases, as well as with affections of the stomach and intestines. The throat affection was frequently accompanied with enlargement of the tonsils, a thin veil-like pellicle covering them, as well as the surrounding mucous membrane. It was frequently accompanied by a very hard, obstinate cough, aggravated by the reclining position at night in bed.

face, which often continues to widen in extent, until the disease has crept into the nose, the oesophagus, or the larynx. This variety of diphtheria is, in truth, one of the most formidable of diseases, and very often, indeed, baffles the bestdirected efforts of the practitioner. The exudation may appear as a granular deposit, possessing little cohesion, and of various degrees of dryness or humidity, or as a more or less dense, elastic, and coherent false membrane. Doubtless, the two forms pass by insensible gradations into each other, and coexist on different mucous surfaces of the same subject.

"The most usual appearance of diphtheritic exudation is that of a false membrane, possessing more or less cohesion, and frequently very firm and elastic. Doubtless liquid, when first effused, it speedily coagulates, and, as it grows in thickness, becomes, denser, firmer, and tougher. It usually makes its appearance in the form of detached spots, very frequently upon one or both tonsils; these spots becoming thicker by successive additions from below, at the same time extend in circumference, and coalesce, so as to form a single plate of deposit. When first seen, they are usually white or ash-colored, and when these have united so as to form a uniform layer, they very closely resemble wet parchment, thus agreeing very accurately with the description given by Villa Real of the false membrane observed by him in the Spanish epidemics of the sixteenth and seventeenth centuries. By and by they become discolored from the effects of decomposition or exposure, or stained of a blackish hue, probably in consequence of a slight hemorrhage. In other cases, the membrane assumes a buff or brownish color, very much resembling damp wash-leather, and then usually adheres very firmly to the subjacent surface. In either case, the breath is apt to smell offensively, partly, no doubt, from the decomposition of the exudation; but likewise, and especially as the smell sometimes exists at a very early stage of the disease, from the depraved secretion of the tonsils. Whichever of these appearances the exudation may present, the disease is very apt, as has already been said, to spread along continuous

mucous surfaces. It will thus invade the nares, and sometimes, but rarely, the eye. It extends to the lower part of the pharynx, larynx, trachea, more rarely to the oesophagus, and sometimes on to the cheeks and gums.1

"The invasion of the nares by diphtheritic inflammation is generally manifested by redness of the margin of the nostrils, and a discharge of sanious ichor, resembling that common in scarlet fever and also like it, sometimes excoriating the upper lip. Epistaxis is not an unfrequent consequence of nasal diphtheria.

"Hemorrhage from the throat also occurs in pharyngeal diphtheria, but, unless in connection with purpura, less frequently, I think, than that from the nose. In either case, the loss of blood, by exhausting the already enfeebled powers of life, has sometimes appeared to determine a fatal result, and must always be regarded as an unfavorable symptom."

DIPHTHERITIC OPHTHALMIA.

Dr. Greenhow. "This variety of diphtheria is so rare that, according to Mr. Dixon, of the Royal Ophthalmic Hospital of London, there was only one genuine case out of thousands of cases of ophthalmia in that institution. The membrane was situated on every part of the conjunctiva of one eye, palpebral as well as ocular, and was concealed from sight by a thick layer of coherent lymph."

Professor Von Græfe, the celebrated oculist, has published an excellent monograph on Diphtheritic Conjunctivitis. We avail ourselves of the labors of Dr. Liebold, contained in the North American Journal of Homœopathy, November, 1866. Quoting Von Græfe, he says: "While in blennorrhoeic inflammation the tissue of the mucous membrane is loose, succulent and saturated with infiltrated fluid exudation, in diphtheritis we find it resistant, stiff with consistent exudation all through it.

'The spreading of the disease into the nares, larynx, and trachea, was most common in our epidemic, and generally in the most dangerous In the eye, I have never seen it.

cases.

A lid attacked with blennorrhoea is consequently, in general, soft, puffy, easily to be turned; a diphtheritic one, hard, and without elasticity and mobility.

"In blennorrhoea, the mucous membrane presents a dark-red, puckered appearance, as if covered with small red grains, which look, in the higher grades, like so many papillary excrescences or intensely inflamed little warts. The histological examination shows the net-work of vessels under the epithelium very much enlarged in every direction; they expand most when the least resistance is offered, and therefore preserve externally those erectile loops, filled to overflowing with fluid blood. An incision, therefore, induces profuse bleeding, showing that in blennorrhoea the circulation is so far free, that at least the majority of vessels contain coagulated blood. A partial collapse follows the incision.

Quite a different picture the mucous membrane presents in diphtheritis; instead of the dark-red color of blennorrhœa, the appearance is pale, of a yellowish-red, or white, or whitishred; the surface is perfectly even and smooth. The smal red spots of ecchymosis never unite in large suffusions; they give a speckled appearance to the pale-yellowish conjunctiva, but are visible on the conjunctiva bulbi, when the layer is thinner and the underlying white sclerotica heightens the contrast.

An incision into the diphtheritic mucous membrane neither evacuates blood nor exudation; there is no collapse and the cut gapes.

The swelling of the mucous membrane is much greater in diphtheritis than in blennorrhoea.

The production of heat and pain is very much greater in diphtheritic than in blennorrhoeic and catarrhal inflammation. Many an eye is destroyed by gonorrhoeal ophthalmia with re. markably little pain; but in diphtheritis Von Græfe had often to give chloroform when simply inspecting the lids, so excruciating is the suffering.

The secretion also presents essential differences; in blennorrhoea the discharge is of thick yellow pus, which gradually, as the disease subsides, becomes of a lighter color and more mu

cous like; in diphtheritis it is a thin, serous, dirty-grayish fluid, in which shreds of pseudo-membrane of a yellow color are floating; it is very corroding, making the adjacent parts very

sore."

Regarding the nature and causes of this diphtheritic inflammation, Professor Von Græfe observes: "Blennorrhoea has no necessary connection with any other disease; the perfectly healthy is just as liable to contract it as one suffering from other causes. Very different in diphtheria." Among forty children so affected he observed three times death by croup; several times by pneumonia and hydrocephalus acutus; frequently, too, affections of the skin, diphtheritic patches on the genital organs, angles of mouth, blister sores and other wounds. During dentition he saw frequently the occurrence of diphtheritis, even relapses or returns of the disease, simultaneous with the cutting of single teeth. Altogether diphtheritis is more common in diseased and weak individuals than in healthy ones.

Diphtheritis appears mostly as an epidemic. The first cases, as in other epidemics, were always found to be the most acute and serious. Affections of the cornea were then often produced in a few hours, leading to rapid destruction of the eye, while later in the epidemic the cornea was affected in latter stages of the disease, or escaped entirely, a circumstance of the greatest importance with regard to prognosis. Other diphtheritic affections were at those times also prevalent, and almost every other acute inflammation of the conjunctiva showed a certain tendency to diphtheritic infiltration; tumefaction was harder, the exudation contained more solid ingredients, and the elimination of artificially produced eschars took more time.

DIPHTHERITIC CROUP.

Dr. Greenhow. "The extension of diphtheria to the larynx and trachea is a common occurrence in some epidemics, and in particular localities, but rare in others. It was very common in at least the earlier epidemics seen by Bretonneau, and in some of the older epidemics, which, on this account, obtained for the disease the name of morbus strangulatorius, or