pear, but, whenever the disease advanced to a more malignant stage, this smell would return. This would occur several times in the course of the treatment.

In many malignant cases the membrane in the throat at first looked white, afterwards became yellow, and finally turned entirely black, together with the tongue, which was swelled. The appetite now began to fail, and the food had almost to be forced down the throat, but the thirst for water and ice was very great in all cases. The patients would drink to the last. The urine was high colored and fetid. The discharge from the bowels had, generally, a natural appearance. A constant drowsiness and sleep, with difficulty of breathing, is among the early symptoms of the malignant type. There is also considerable heat in the forehead. The skin remains dry. The pulse is moderately frequent, and often, even in unfavorable cases, quite strong to the last. Finally, if the hands and feet get cold and the pulse sinks, all hope is over.

Of this malignant type, as above described, I have attended about one hundred cases during the last six years, of which I lost five by death,—all during the first year.

B.-Combined with Croup.

The disease always commenced with the ordinary diphtheritic symptoms of the malignant type. As the disease advanced, symptoms of croup would gradually manifest themselves. This form was very dangerous. I lost, however, only one of the twenty cases which I attended. The details will be given under the head of treatment. I was called in consultation in four cases of this kind, all of which terminated fatally. Two of these I saw only two hours before death.

The breathing, in such cases, is short and accompanied by wheezing, with frequent attacks of croupy cough and suffocation. It is sufficient to say that the symptoms of croup would not in themselves constitute an element of danger if the system was not overpowered by the diphtheritic poison in the blood.

C-Extension of the Throat Disease to the Stomach and
Alimentary Canal.

These were cases where the disease, after being apparently cured in the throat, reappeared, with symptoms of vomiting and pain in the stomach, and great tenderness on touching the abdomen. There was generally great prostration of strength, deadly paleness of countenance, and sinking of the vital power. Fortunately, I had to attend a few only of these dangerous cases. In one case, of which, a post-mortem examination was made, the true nature of the disease was discovered. The stomach and whole alimentary canal were lined by a membrane of an albuminous nature. The symptoms will be detailed in another place.

Dr. Greenhow also mentions a similar case. The following symptoms detailed by him clearly indicate the nature of the disease:

"Complained that swallowing gave him pain in the ears and head, and of being sick. Beef-tea and wine have returned several times; brandy was therefore substituted for wine. Sixteenth day: passed an uncomfortable night; there was difficulty in getting him to take any thing; was thirsty and craved for water, which very generally returned immediately after it was taken, as did food, brandy and the medicines, prescribed with the hope of allaying the irritable (?) stomach; pulse sixty, no fever, no pain. Seventeenth day: every thing is rejected by the stomach immediately, and alarming attacks of vertigo or swimming of the head were complained of, accompanied by temporary loss of consciousness; pulse, forty. By the eighteenth day, the action of the heart. had declined to thirty-two beats in the minute; on the morning of the nineteenth day, it had fallen to twenty-four, but, on being disturbed to taste food, would suddenly rise to seventy or eighty per minute. He would lose consciousness in a minute. In the afternoon he died."

In the Philadelphia Medical Examiner, a similar case, that of a lady, is mentioned. She also died. The post-mortem revealed the nature of the case.

1

II. SLIGHT CASES, UNDER THE FOLLOWING FORMS:

A.-A slight Deposit of the Membrane is visible on the Schneiderian Membrane of the Nose, on the Tongue, Pharynx, Tonsils, etc. The Glands of the Neck are only slightly swollen.

These cases occur in adults as well as children. Numbers of these merely called at the office to be prescribed for, and recovered in a few days. I counted over three hundred of such cases. The glands of the neck were in many cases swollen only on one side; and on the same side a speck of the membrane was always visible on examining the throat. The appearance of the membrane was generally preceded by a violent chill and followed by very great prostration of strength, but no further evil consequences.

B.-Diphtheritic Cough, with or without Croup.

This variety occurred in adults as well as children. One case occurred in a man eighty-eight years of age. Patches of the membrane could be distinctly seen in all cases on the tonsils, extending down the throat. The disease was also characterized by a hard, dry cough, causing choking and often of a croupy nature. On auscultating the chest, there was discovered more or less wheezing and whistling, with oppression of breathing at night. Doubting at first the diphtheritic origin of these cases, the usual remedies for obstinate and croupy cough, Belladonna, Phosphorus, Laurocerasus, Hepar sul. and Spongia mar. tost., were exhibited, but without the slightest benefit. There was no difficulty, however, in curing this cough with what I may call the diphtheritic remedies, as meeting not merely the symptoms, but also the pathological condition of the throat and ramifications of the bronchia. Such remedies were Liquor Calc. chlorin., Kali bichrom., Lachesis, and Crotalus.

During the autumns and winters of the years 1861 and '62, as well as '63 and '64, a great number of persons suffered with a sore throat, characterized by dryness, soreness, and

slight swelling of the tonsils. More than a hundred of such cases came under my observation. On examining these very carefully, the tonsils, palate, and pharynx, as far as could be seen, were covered by a veil-like membrane lining the throat, sometimes, also, hanging loosely in detached pieces. It was not mucus, but a skin. The disease was not at all dangerous, and was generally cured by a few doses of Caustic. 1 and 2, or Calc. chlor. .

Where, however, the patients were liable to bronchitis or chronic lung disease, the diphtheria always complicated itself with these diseases, and was on this account more difficult to eradicate. The cough was particularly severe at night in the reclining position. In addition to the specific remedies for diphtheria, Kali hydriodicum, Calc. phosphor., Antim. sulph. aur., etc., had to be administered.

The typhoid fevers so extensively prevailing during the winters of 1862, '63, were more or less complicated with this disease. Although often determined not to see it, the evidence of its presence in many chronic and acute diseases was too convincing to be cast aside.

Where the attack commenced with croup, without any violent symptoms of the throat or severe general derangement, the cases in variably recovered, often, however, with great difficulty. Their number was about thirty. In this variety may be included a kind of diphtheritic fever, exacerbating in the evening and remitting in the morning, with want of appetite, great thirst and many other symptoms, according to the individuality of the case. That this fever was of diphtheritic origin, was evident from the mouth and pharynx being covered by a slight membrane.

C.-Characterized by a Mucous Diarrhea and Dysentery.

When the disease was on the decline, many persons were affected by a peculiar diarrhoea, preceded by a pain in the stomach, particularly at night. The discharges consisted of large flakes of mucus, and were accompanied by a soreness in the hypogastric region. Ordinary remedies remained pow

erless against this diarrhoea. The best remedies against the diphtheria were also the best against this diarrhoea.

Toward the close of 1864 and the beginning of 1865, the diphtheritic miasma again showed itself in the form of mucous dysentery, with straining of the bowels, white membranous and mucous discharges, thickly white-coated tongue, and sometimes, also, slight cough, with thin pellicular deposit on the pharynx, as far as could be seen. There was sometimes considerable fever, nausea and vomiting, and complete loss of appetite. That the disease was of the same origin was manifest, for the same remedies as were given in diphtheria were the best, with the addition of Gummi Gutta. I must have attended, on a close calculation, something like fifty or sixty of such cases. They were generally very obstinate, lasting from two and three days to two weeks; and two cases connected with scrofulous constitutions were even of longer duration. Although children from two to seven years of age were the most frequent objects of these attacks, they were not confined to them. A considerable number of adults also came to consult me. These were mostly but slightly affected. Latterly, some of the most obstinate cases of this mucous diarrhoea were cured by Ac. muriat. dil., 1st and 2d dil.

D.-Diphtheria Complicated with other Diseases.

Although some of these forms are dangerous, I still have classed them among the slight cases, because I have not lost any of them.

The English writers mention such combinations as taking place with scarlet fever, pneumonia, hectic fever with tuberculosis, small-pox, rheumatism, and pericarditis. Excepting smallpox, I have seen all these combinations. Of the complication with scarlet fever, there came twelve cases under my treatment, generally slight, and all terminating in recovery.

The most dangerous combination is that with cerebral affections, and is very apt to occur in children liable to brain disease. I observed the disease also in one case of parturition and one of erysipelas.