Diseases of the lungs are particularly apt to be complicated with diphtheria, as already mentioned under slight cases, B. Hectic fever was a common symptom in tubercular patients, some of whom recovered with difficulty. Dr. Greenhow mentions that cases of ulcerated sore throat have sometimes been intermixed in the same epidemic. Cases from Drs. Sanderson, Becquerel, etc., are adduced to illustrate this statement.

Dr. Galli1 mentions having seen in a child suppuration of the inguinal glands simultaneously with slight diphtheria of the fauces.

Albuminuria is a frequent but not a constant attendant upon diphtheria. Its occurrence was first observed by Dr. Wade, of Birmingham, who, when examining the body of a person who had died of diphtheria, found such changes in the kidney as induced him to examine the state of the urine during life more carefully than he had previously done. He thus discovered that albumen is frequently present in the urine of patients suffering from diphtheria, a fact which has been confirmed by subsequent observers both abroad and at home. When albuminuria occurs in diphtheria it usually does so at an early period of the illness, generally within a few hours after its commencement. In this respect diphtheria differs essentially from scarlet fever, in which albuminuria is rarely found in the urine till a much later period of the illness.

I myself have discovered the presence of albuminuria, particularly in those cases connected with pneumonia.

Dr. R. Ludlam mentions a case of a friend of his, Dr. Lord, where two sets of symptoms succeeded each other with such distinctness as to attract the attention of the nurse and friends of the patient. The urine in each interval becoming clear, non-albuminous, and deficient in the chlorides, while a little of the sputa in the field of the microscope afforded a beautiful specimen of the crystals of chloride of sodium. He gives

1 Second Report of the Medical Officer of the Privy Council, page 301. 2 Midland Quarterly Journal of the Medical Sciences, vol. ii., p. 318.

two drawings of the experiments, and concludes as follows: "It is an interesting query for pathologists, to determine whether the presence of the chloride of sodium in the sputa and its absence in the urine-hitherto thought to be pathog nomonic of hepatization of the lung-may frequently occur in case of functional disorder of the kidneys, as in diphtheritic albuminuria.

"From the foregoing observations, the following conclusions are plainly deducible:

"1st. That albuminuria may be produced by causes acting exclusively through the nerve-centres.

"2d. That disordered innervation of the kidneys may result in such a congestion or stasis of the blood, in their capillary vessels, as interferes with the function of excretion, thus permitting the escape of albumen along with the urine.

"3d. That albuminuria, from this cause, is usually transient. When, however, the cause is persistently applied, the symptom continues, and a structural lesion may finally result.

"4th. That the diphtheritic virus has a specific determination to the nerve-centres, but more commonly affects the renal nervous system, and may produce albuminuria as a concomitant of diphtheria, without structural changes in the kidneys themselves.

"5th. That the time when albumen generally appears, the freedom of the urine from epithelial casts in many well-marked examples of diphtheritic albuminuria, the possible alternation of this symptom with another, which involves a remote organ, as well as the fact that it may disappear at the end of a few hours or days, a reason why it is frequently unnoticed,— and the complete absence of renal sequelæ in a majority of cases, all serve to establish the position we have assumed.

"6th. That this view of the origin of the diphtheritic albuminuria has a therapeutical bearing of which the intelligent physician may avail himself."

Besides hemorrhage from the nose and throat, there is also frequently purpura on the gums, mouth, etc. Claret-colored blotches of purpurous nature are not uncommon. Other

eruptions besides purpura sometimes accompany or follow diphtheria. An irregular, measly mottling of the skin is not infrequent at an early stage of the disease.

Dr. Greenhow has, in several instances, seen an eruption very closely resembling the rose-rash of typhoid fever. Similar eruptions were observed by other physicians.

I have seen, in six cases, an eruption resembling varicella, either preceding or following the disease.

Dr. Nicholson, of Reddish, observes that erysipelas of severe and unmanageable character commenced, increased, and declined simultaneously with diphtheria. An unusual prevalence of erysipelas has also been observed by practitioners of Birmingham, Brentwood, Maldon, Wirksworth, Derby, Dudley, Wolverhampton, and Leek. Puerperal and typhoid fevers were unusually frequent, as was also roseola.

In October, 1863, I was attending two children of the ages of five and three years respectively, who had diphtheritic angina, with erysipelas of the face. At first there were symptoms of swelling of the submaxillary glands and face, with diphtheritic membrane visible in the throat. Three days afterwards, the erysipelas appeared on both cheeks, accompanied by delirium at night. In one child, the erysipelas made its appearance, with convulsions lasting ten minutes. In November, 1864, I attended a child which had at first diphtheria, and afterwards very severe erysipelas of the face. Two cases of chancre I saw complicated with diphtheria. The diphtheritic membrane was clearly visible, surrounding the chancre, on the penis.

In one case of secondary syphilis, where there were syphilitic ulcers in the throat, diphtheritic deposits could be seen mingled with them.

In another case, there appeared a white membrane over four very malignant chancres on the glans penis. Both chancre and diphtheria were cured by the alternate use of Merc. precipt. rubr., one-tenth, and the solution of Chlor. of Lime. The Mercury, which was at first used alone, did not cure the diphtheria.

According to Bouchut, diphtheria has been observed in combination with hooping cough, phthisis, and eruptive fever. In the case of an elderly lady, occurring in my own practice, the phthisical symptoms were excited to such a degree that she was brought to the brink of the grave. Her life was saved with great difficulty.

In many cases of malignant typhoid fevers, which have been very common of late years, false membranes have been observed on the tongue and throat.

CHAPTER V.

NATURE OF DIPHTHERIA.

WHEN it is asked what is the interior nature of the disease which makes its appearance with such formidable symptoms, devastating a whole continent, and gathering its victims in every part of the world, we can only answer that we have made approaches towards unfolding the secret source of this scourge, but have not, as yet, succeeded in unravelling its complete mystery. We shall state here all the facts which have been discovered, and the speculations which have been entertained concerning its nature.

A.-Cause Miasmatic.

All authorities and writers on the subject agree that the main essence of diphtheria consists of a poison in the blood derived from miasmatic causes. Like all poisons of an epidemic nature, as that of cholera, small-pox, etc., it is most violent in its manifestations at the beginning of the epidemic, but is gradually diminished in power as it becomes more diffused, although occasionally it will show its ancient violence. Professor A. E. Small, in a letter to the author, observes "that the disease arises from a poisonous miasma, that first prostrates the vital

forces and predisposes to chilliness and fever; that particularly affects the mucous surfaces of the air-passages, causing an exudation upon them of a plastic substance, which soon assumes a pseudo-membranous character;" and subsequently he again avers, "that there is a specific poison or miasma that causes the disease, I firmly believe." The cause of diphtheritic false membranes consists, according to Empis, in a special morbid property, manifested by an inflammation on which it impresses its special characters. Empis also confirms the fact, indicated by Roberts, that wounds, before being invested with the diphtheritic pellicle, change their aspect, become more painful, and furnish a less abundant and thinner suppuration.

Dariot truly says, that pharyngeal diphtheria must derive its origin from some agent which is occult in its nature, but which always determines pellicular inflammation, and is similar in its effects to certain chemical substances, as Mercurius, Chlorine, Ammonium, the Caustic Alkalies, the Ethereal Tincture of Cantharides, etc., etc., which induce the same pathological state. Might not reagents, which demonstrate the presence of these different bodies, assist in discovering in the atmosphere the nature of the epidemic agent?

Dariot agrees with Bretonneau, that epidemic pharyngeal diphtheritis is a specific inflammation. The existence of the false membrane which constitutes its essential symptom, is due rather to the special character of the disease than to its intensity. Afterwards, Dariot comes on rational Homoeopathic ground in saying: "The pellicular exudation is not the only distinguishing feature which exists between simple angina

1 Must not the true specific be found among these similar agents? Of all these we have found the Liquor Calcis Chlorinate as the most powerful and trustworthy. It was not, however, selected owing to the above remark, but from the similarity of the symptoms both of Chlor. and Calc. carb. to this disease. More than the Iodide of Mercury, Ammon. causticum, and Caustic Potash, it seemed to arrest the progress of the disease in the blood. Next to it, and in some cases of decided benefit, were Argentum Nitricum, Nitric Acid, Bichromate of Potash, and also Lachesis and Crotalus.