garrotillo. Of fifty-two post-mortem examinations made by Bretonneau in two years, the larynx or trachea was only free from exudation in one instance, that of a child, who appeared to die from exhaustion, on the fifteenth day of the disease. The recent epidemics in the north of France, and the English epidemics of the last four years, have less uniformly manifested that character. In a few places the disease is said to have manifested no disposition to attack the larynx or trachea; in others, most of the cases ending fatally have terminated in croup, consequent upon the extension of the disease through the glottis. But in a large proportion of the districts where the disease has prevailed, its character has, in this respect, been mixed, many cases ending in recovery or death without affection of the larynx; others being complicated with the symptoms of croup. Dr. Heslop, of Birmingham, informs me that he does not think the disease has reached the larynx in more than five per cent. of the cases he has seen in that neighborhood. Of thirteen fatal cases in the practice of Mr. Schofield, of Highgate, near Birmingham, with the particulars of which he favored me, only three were accompanied by symptoms of croup. Diphtheria had been the sequel of scarlet fever in all three. Of nine fatal cases seen by Dr. Capron, of Guilford, only three died with laryngeal symptoms. Of twenty-six fatal cases reported by correspondents of the British Medical Journal, only nine, including one from bronchitis, appear to have proved fatal from laryngeal complication. Mr. Thompson, in an account of the disease in the neighborhood of Launceston, says, that of four hundred and eightyfive cases that came under his observation, the air-passages were involved in fifteen, eleven of which died, generally within a few hours after the commencement of croupy breathing."

1 Diphtheritic croup has been observed by me as only fatal when the diphtheritic poison in the blood has been in such quantities as to overpower the vitality of the system. The mere symptom of a croupy cough did not constitute a symptom of danger. Numerous cases of this kind were cured without any difficulty.

DIPHTHERIA OF THE ESOPHAGUS AND STOMACH.

Dr. Greenhow. "Mr. Stiles, of Pinchbeck, informs me that he has met with cases in which there was difficulty of swallowing, without any evident throat affection. He attributed this to the existence of diphtheritic exudation in the lower part of the pharynx, or in the œsophagus, beyond the reach of vision. In one instance, a patient thought, from a sensation of choking, that some substance was sticking in his throat, and, on passing a probang, shreds of false membrane were brought up on the sponge. Diphtheria existed in the patient's house at the time. Probably oesophageal diphtheria is most frequently caused by the extension of the disease from its usual seat in the fauces, and thus sometimes occurs after the disease would seem to have disappeared. It is attended by extreme difficulty of deglutition, often followed within a day or two by pain, either during the passage of food through the oesophagus, or after it has arrived in the stomach. Indeed, severe gastrodynia is not of infrequent occurrence during convalescence from diphtheria; but has not, under my observation, led to any worse result than delaying recovery by preventing the patient from eating. In one instance, in the practice of Mr. Balls, of Spaulding, diphtheria was followed, after apparent recovery, by intense pain at the epigas-` trium, vomiting, and collapse, which proved fatal in thirty hours. The patient had been imprudent in diet the day previous to the attack of pain, but this would scarcely have determined so serious an affection. Unfortunately, as no postmortem examination was made, it is impossible to decide whether the cause of death was, as supposed, perforation of the stomach, or not. Mr. Coleman, of Wolverhampton, also had a case of diphtheria, that of a female, aged twenty-two years, in which severe pain of the cardiac extremity of the stomach, much aggravated by taking food or wine, came on after the exudation had disappeared from the throat, and the

patient was supposed to be going on favorably. The case proved fatal.1

Monsieur Espagne, of Montpellier, relates a case of œsophageal diphtheria in a patient, aged ten and a half years, suffering from typhoid fever. The diphtheria came on about the twenty-third day of the illness, and, after death, the arch of the palate, the uvula, and tonsils were covered with shreds of firm, gray-colored false membrane. The entire posterior wall of the pharynx was coated with a thick false membrane, which extended, without breach of continuity, down to the cardiac orifice of the stomach. This false membrane was exactly moulded upon the oesophagus, and about the thickness of a line almost throughout its entire length. It became notably thinner towards the stomach, ceasing abruptly at the lesser curvature, but ending by some very thin portions, prolonged in the direction of the greater curvature. The diphtheritic concretion formed a complete tube, flattened from before backwards, and plaited longitudinally. It was easily detached from the oesophagus, the mucous membrane below it being injected and of a violet color, without any trace of ulceration. The larynx and trachea presented no appearance of false membrane.

DIPHTHERIA OF THE MOUTH.

Dr. Greenhow. "The extension of diphtheria forwards into the mouth has been less common in this country (England) than it would appear from the French writers to have been in France. The exudation has occasionally appeared on the gums, has sometimes extended on to the buccal mucous membrane, and has more rarely formed a complete covering to the

1 A similar case observed by me will be detailed in its proper place. The post-mortem examination showed the membrane not only in the stomach, but along the whole course of the alimentary canal. In one case, which recovered, the membrane was seen in the rectum and verge of the anus. Dr. Guernsant1 also mentions a case where the membrane was discovered in the stomach; he showed it to Dr. Albers, of Bremen.

1 Dr. Guernsant, on Croup, Dictionnaire de Médecine, 1833. New Sydenham Society, 1859, page 221.

palate and inside of the cheeks, and from the fauces to the teeth. One such case proved fatal in the practice of Mr. Rush, of Southminster, and in a second, the patient nearly died of starvation, from inability to swallow after the membrane had come away. The first case seen by me was one of pellicular diphtheria of the inside of the cheeks and gums; and I have observed exudation in the same locality in several other instances, but the danger in such cases has always arisen from the condition of the fauces, and not from that of the mouth.

DIPHTHERIA OF THE PUDENDA.

Dr. Greenhow. "The pudenda and vaginal mucous membrane are perhaps, after the throat, the most common situation of diphtheritic deposit." According to Dr. Greenhow, pudendal diphtheria is generally an accompaniment of diphtheritic disease of the throat, but sometimes it occurs without the latter. "The late Mr. Edwards, of Wolverhampton, saw two cases of vaginal diphtheria, both of which proved fatal from exhaustion. The disease accompanied diphtheria of the fauces, and both children were inmates of the same cottage, where there had already been two fatal cases. Mr. Cooper, of Cromer, had in one instance seen the pudenda of a little girl covered with exudation, unattended by diphtheria of the throat. Dr. Nicholson, of Redditch, also writes me word that he has met with one case of pudendal diphtheria in a patient, whose throat remained unaffected, and several practitioners in *the fenny parts of Lincolnshire, Cambridgeshire and Norfolk, inform me that they have, from time to time, met with cases of pudendal diphtheria, unaccompanied by throat affections, anterior to the present outbreak. In Dr. Nicholson's patients, the parts were abraded by an acrid discharge; there was great depression, requiring the free use of stimulants, and recovery was very tardy."1

1 In one or two cases I have met with this pudendal diphtheria, but the mothers of the children thus afflicted would with difficulty be persuaded of the existence of such a disease.

DIPHTHERIA ON WOUNDS.

Dr. Greenhow. "Wounds and abrasions of the skin often become covered with diphtheritic deposit, analogous to that on the throat. Dr. Nicholson mentions the occurrence of diphtheria on wounds without throat affections. One of these, a man aged thirty-two years, had been operated upon for fistula in ano. On the fifth day, diphtheritic exudation appeared on the wound, which eventually sloughed under the use of caustics. The patient died. The other case was that of a female, aged fifty-three years, who was suffering from caries of the metacarpal bones of the second and third fingers. On the third day after an abscess connected with the diseased bones had been opened, the wound became covered with diphtheritic exudation. The parts were subsequently amputated, but diphtheria reappeared on the new wound, hemorrhage from the bowels supervened, and the patient sank fourteen days after the operation.

More frequently diphtheritic exudation has appeared on wounds simultaneously with the occurrence of diphtheria in the fauces."1

DIPHTHERIA ON BLISTERED SURFACES AND ON ABRASIONS OF THE SKIN.

Dr. Greenhow. “M. Becquerel mentions the occurrence of eighteen cases of gangrene of blistered surfaces, during an epidemic diphtheria, at a hospital for sick children at Paris, in 1841. The gangrene was always preceded by the development of membrane upon the raw surface. This false membrane did not separate, but became confounded with the slough, which frequently spread so as to occupy a gradually widening surface. The affection sometimes occurred simulta

1 I have in numerous instances observed a deposit of diphtheritic membrane, in the ulcers of children, as well as in some grown persons; also, in panaritio and in the Schneiderian membrane of persons subject to the annual cold.