nomena observed are purely nervous, they soon subside, and their progress is altogether peculiar. They appear suddenly, and in a very high degree of intensity, in subjects who are otherwise in good health or slightly affected with cold. They manifest themselves in the middle of the night. The paroxysm lasts about two hours, and is reproduced on the following two or three nights in succession, but it becomes gradually more feeble, and at last it disappears. Diphtheritic croup presents nothing like this, for the symptoms increase gradually, and suffocation presents itself only at the end of several days. The fits appear by day as well as by night, and they are reproduced as long as the false membranes in the larynx are not thrown up. Far from diminishing gradually, they become, on the contrary, more alarming every moment, and they terminate by carrying off the patient.

K.-Diagnosis between Diphtheria and Aphthæ. (By Empis.)

DIPHTHERIA.

In diphtheria there is great force of cohesion in the membrane. True membranes are formed. The adhesion of the tissues is such that we are rarely able to detach them without causing the raw part covered by them to bleed in some measure.

АРНТНЕ.

Aphthæ present themselves in the form of a multitude of small white points, at first distinctly separate from each other, but which, in proportion as they become more numerous, touch one another, and are accumulated together so as to form a continuous whitish layer, which invests all the inflamed mucous membrane, and thus constitutes a pseudo-membrane. If we endeavor to detach this false membrane with a pair of forceps, we find it difficult to obtain strips of it, because each of the points adheres too slightly to the others; but if, with a fine compress, we lightly wipe the part, we easily remove all the whitish layer,' and we uncover the mucous

'I have often observed this in patients dying of consumption, when, the aphtha were thus easily detached, although they reappeared next morning.

The diphtheritic product has the greatest tendency to propagate it self over the mucous membrane of the air-passages, where its presence constitutes croup.

The appearance of diphtheritis is preceded by a very circumscribed irritation of the parts of the mucous membrane, which are completely covered by the pellicle.

Diphtheritis is preceded by a serous exudation, is never developed "above the epidermis, and always adheres to raw parts.

membrane, which is red and inflamed, but by no means raw. As the adhesion to the mucous membrane is inconsiderable, there is no bleeding.

Aphtha especially affect the buccal mucous membrane, and never extend to the larynx and trachea; there has been hitherto no example of aphthæ extending to the respiratory organs and producing croup, but they often extend to the pharynx and digestive canals.

Aphthæ are always preceded by a general inflammation of the mucous membrane of the mouth, characterized by a general redness and a very acute sensibility, which, in young children at the breast, presents an obstacle to sucking.

Aphtha are never preceded by a serous exudation, but it appears in the mucous membrane when still covered with its epithelium.

L.-Pathological Anatomy.

I have made only two post-mortem examinations of the disease.

I. A professional friend called me in consultation in a case of a child, æt. 2, afflicted with the croupoid form of diphtheria. On examining the throat, the tonsils were found to be partially free from the exudation, but it had extended farther down the throat. His respiration was short and hurried, accompanied, every now and then, with a strangling croupy cough. His face was pale and swollen, as were also the submaxillary glands; and there was sopor. The case was evidently hopeless, and terminated fatally three or four hours after I saw it. This case was not very severe at the begin ning; the violent symptoms appeared only during the last two days.

A

A post-mortem examination showed the membrane as having penetrated the larynx, trachea, and the smallest ramifications of the bronchia, for in all of them it could easily be detached in the softened state in which it was found. specimen, a small piece of this lung, is still in my possession. One lobe of the lung was also hepatized, and there was a high state of inflammation visible along the whole course of the bronchia. All the other organs of the body were perfectly healthy.

II. In a case where the disease was apparently cured in the throat, it reappeared by sickness of the stomach, and complete poisoning of the whole systern. The patient, a boy, æt. 12, died. A post-mortem examination showed the corruga of the stomach in a highly congested state, and covered with a softened diphtheritic membrane, extending, as far as I could perceive, through the whole alimentary canal. The liver was very much enlarged and also highly congested; the kidneys in the same state; the peritoneum not inflamed; the anterior part of the cerebrum softer than natural after death; the larger venous trunks engorged with blood, diffused through the parenchyma of the brain. Back part of the cerebrum more natural; cerebellum in a normal condition.

A resumé of the post-mortem examinations of Bard, M. Louis, Ramsey, Greenhow, and Keller, gives the following data:

The epiglottis and larynx generally were thickened; the respiratory mucous membrane reddened, the larynx, trachea and bronchia were lined with a tube of false membrane, which began in the pharynx and extended into the smallest traceable ramifications of the air-tubes. The exudation varies in consistency, from an almost liquid form to a more or less elastic membrane. It varies from a quarter of a line to a line in thickness (Greenhow). In one instance, Greenhow saw it two lines in thickness. In some cases it is so tough that it is difficult to tear it (Bard). There is generally more or less inflammatory effusion into the structures of the tonsils. The lungs were oedematous, not very crepitant, but floated in

water. The left pleura presented very extensive adhesions at its lower part; the right, only a few. The right lung was more congested than the left.

Professor Helmuth, of St. Louis, to whom we are indebted for three or four autopsies, speaks of a fluid gushing out from the trachea as soon as the knife penetrated the cartilaginous rings. "This transudation was sanious and frothy in character, and floating in it small particles of membrane were noticeable." The quantity was over a pint.

M.-Prognosis.

All writers on the subject agree that diphtheria is a very serious disease, and will often prove fatal in spite of all the remedies applied.

The croupoid form, where the disease attacks the trachea and bronchia, is considered particularly dangerous.

Bouchut remarks that when the false membrane, developed in the mouth, exists only on the epiglottis and at the superior opening of the larynx, the disease may be cured by suitable treatment. But if the products are extended to the trachea and bronchia, it is almost inevitably fatal.

Dr. Lea Williamson, of Mississippi, even maintains that all died when the disease invaded the larynx and trachea.

Drs. Greenhow and Empis agree with the above statements about the danger of the disease attacking the trachea and bronchia.

Empis relates a case of a child where the diphtheritis began on the point of the tongue, ran through its stages on that part, and disappeared on the thirteenth day, after a complete cicatrization of the affected part; then, on the fourteenth day, and when, by the disappearance of this local lesion, it might have been supposed that the child was henceforward out of danger, the mucous membrane of the larynx became the seat of a reappearance of the membranous exudation, and the patient was carried off by croup.

In a similar case occurring in my own practice, mentioned

under the head of Post-mortem Examinations, the disease was entirely cured in the throat, but a week later it returned, this time attacking the stomach and whole alimentary canal, and terminating fatally. Many such cases might be detailed in this place from various authors, both Allopathic and Homoeopathic, showing the absurdity and uselessness, if not positive injury, of a mere local treatment in this disease of the blood. Nevertheless, I have cured about fourteen cases of the croupoid form of diphtheria, where the symptoms were not too

severe.

As unfavorable symptoms, Greenhow also mentions, "complications with pneumonia, a brown or blackish appearance of the false membrane, hemorrhage from the nose, throat, and bronchial tubes or intestines, purpura, copious discharge from the nostrils, intense albuminuria, great swelling of the cervical glands, sickness of stomach or diarrhoea, especially at an advanced period of illness." All these symptoms denote, no doubt, the great severity of the disease, but if there is sufficient power of reaction they are not necessarily fatal.

With Empis, the paleness of the face, the feebleness of the pulse, and, particularly, the great prostration of strength, were signs of danger. He also remarks, that diphtheria is always serious when persons are already victims of an inveterate disease, and it may be followed by a fatal termination. Thus he has seen a child, affected with constitutional syphilis, sink rapidly under the influence of diphtheria.

The most fatal signs with me, during the Philadelphia epidemic, were complete want of appetite, or even aversion to food, with disposition to constant drowsiness and stupor. When these symptoms appear, the patient is not absolutely lost, but the physician who neglects to use the most active measures to restore the patient, e. g., exhibiting the proper specific every ten minutes, with milk-punch, wine whey, and other stimulants, will surely lose his case.

Sudden death in patients, whose symptoms apparently present nothing alarming, is one of the most remarkable features of this disease, and will caution us not to be over-sanguine