in our prognosis. I have met with several instances of this kind. In one case, where I was consulted, that of a little boy `living in West Philadelphia, all the dangerous symptoms, the swelling of the cervical and submaxillary glands, and cellular membrane, the stupor, etc., had disappeared, and the patient was apparently getting better, when he suddenly died, as it were, from mere exhaustion. In another case, the disease had disappeared from the throat, and the patient was walking about, when he fell down suddenly and died. Quite lately, (May, 1865,) in another case of a little boy, aged four, in West Philadelphia, where I was called into consultation towards the close of the disease, the patient died very suddenly, with symptoms of anæmia and congestion in the spine and left lung. An hour before his death his symptoms were by no means alarming; he appeared much better. In three or four cases of the croupoid form in which I was consulted, the patients died very unexpectedly, without any apparent cause. A post-mortem was not permitted in most of these. One has been detailed under another head.

cases.

Dr. Greenhow remarks: "Sudden death in patients, the aspect of whose case is not alarming, or who appear out of danger, is a peculiar characteristic of diphtheria; and this circumstance has added greatly to the fear with which this disease has been regarded by the relatives of the sick and the public at large.

"Mr. West has sent me the history of a young woman, aged twenty, who presented herself as an out-patient of the Queen's Hospital at Birmingham, suffering from diphtheria. She declined to enter the hospital, but continued to attend, among the out-patients, for three successive days, on each of which she walked a distance of a mile from her home for

this purpose. The throat improved in appearance daily; but, notwithstanding this amendment, she became weaker, and, returning home tired on the third day, she took some food and went to bed. She appeared very drowsy during the remainder of the day, was disinclined to exertion, refused nourishment, and continued in a dozing condition till the

following morning, when she asked for breakfast. Whilst being lifted to receive it, she fell back fainting, and died before assistance could be obtained."

Mr. Carr, of Blackheath, also mentions extreme suddenness of death as one of the most-marked characteristics of true diphtheria, and adds, that it occurs in an instant, when the patient has the power of sitting up in bed, of speaking and of swallowing. Mr. Ritchie, of Leek, had such a case, in which he had discontinued his attendance; the throat being well and the sick person apparently convalescent. The patient suddenly became worse; there was vomiting, the surface of the body was cold, and there was depression without hemorrhage or other ostensible cause. When visited, the patient sat up in bed and answered questions; but then, having laid himself back and stretched out his arms, he diedbefore the medical attendant left the room. Sometimes sudden death has occurred after patients were able to resume active habits, and may, perhaps, have been induced by overexertion whilst in the very depressed, anæmiated condition produced by the disease.

A boy, aged ten years, who had been suffering from diphtheria for five days, although well enough on the previous evening to hold the surgeon's horn, died on the sixth day of his illness. A carpenter's apprentice, convalescent from diphtheria, went home to visit his parents, who lived at a distance of three miles from his master's house. On his arrival he took a basin of bread and milk, went to bed, and died suddenly three hours afterwards. A man-servant, aged sixteen years, who had been ten or twelve days under treatment for diphtheria, seeming to be convalescent, obtained leave to go home and see his friends before returning to his occupation, and there died suddenly.

Dr. Bellyn mentions a case of this kind, that of a boy aged ten years, who, having been ill nearly three weeks, had so far recovered as to be able to go out, and on the day of his death walked to a farm-house at a considerable distance from his home. About ten o'clock the same evening, Dr. Bellyn, on

being summoned to see his patient, who had suddenly been seized with violent pain in the bowels, about an hour before, found him sinking from exhaustion. Although relieved by fomentations and other remedies, he died very soon after the visit. A post-mortem examination was refused. Convalescents from diphtheria cannot be considered out of danger until some time after the throat is well, and the very marked anæmia produced by the disease has disappeared. It is true that death, whether sudden or otherwise, usually occurs within a few days; but, according to Greenhow, sometimes as late as the sixteenth and seventeenth day of the illness. Such was also the case with the little boy from West Philadelphia, mentioned above.

N-Sequelæ.

In the first place, it must be mentioned that, under a true Homoeopathic treatment, there are no sequelae of any consequence. In the great majority of the most malignant cases that I attended, the recovery was often slow, but no serious disease supervened. In a few of the more violent cases which recovered, a long-continued very fetid running from the nose and ear was observed. Patients liable to lung disease were afflicted with a cough which was difficult to cure. Chronic laryngitis and bronchitis were aggravated by the poison of diphtheria.

Among the other sequelæ are mentioned anæmia, impaired voice or power of deglutition, though rarely is there complete aphonia. I have observed several cases of anæmia, but none of aphonia, except for a short period of time. A husky, nasal voice is also very striking, according to Greenhow. I observed it only in one case. Paraplegia, hemiplegia, impaired vision and deafness are also mentioned among the sequelae of diphtheria. One little boy, who was treated by a very good Homoeopathic physician in the country, with strong doses of the Biniodide of Mercury, returned to the city with complete paralysis of the lower extremities, accompanied

with violent pain. A few doses of Rhus. tox. 3 restored him in two days.

Dr. J. B. Reynolds published in the May number of the American Journal of Medical Sciences, 1859, seventy-seven cases of diphtheritic paralysis.

Four children, who got very well over a violent attack of diphtheria, could not read black letters for a whole month. There was a complete obscuration of sight. These symptoms gradually disappeared without any remedies.

The most striking phenomenon after diphtheria is, according to my experience, an excessive prostration of strength. The convalescence is always lingering. The poison of the diphtheria has affected the whole nervous system.

O.- Contagion.

The special character of diphthérite according to Bretonneau, is the exudation, whence the name he has applied to the disease. No inflammation unattended by exudation is diphthérite. The virus of the membranous exudations, according to him, forms the distinctive pathological feature of the disease.

Bretonneau further asserts it to have been proved by numerous facts, that persons who attend cannot contract diphtheria unless the diphtheritic secretion, in the liquid and pulverulent state, be placed in contact with a soft or softened mucous membrane, or with the skin on a point denuded of epidermis, and this application must be immediate. In a word, a true inoculation is the only mode of transmission of the disease. On the other hand, he states that facts supplied by the epidemics of diphtheria which have broken out in the department of Indre et Loire, or which have extended to the surrounding departments, prove in the most evident manner, that the atmosphere cannot transmit the contagion of diphtheria.

Trousseau steeped a lancet in a false membrane which he had just extracted from a diphtheritic wound, and made a puncture on his left arm, and five or six on the tonsils and

velum palati. He found on his arm, on the seat of the puncture, that a vesicle was developed very similar to that of vaccination, but there was no result upon the mucous membrane.

Some physicians in England have experimentally inoculated dogs with the poison, without any very decided effect.

The opinion of the able Bretonneau, that the disease can only be propagated by actual contact, has received no support from subsequent observers. In no one instance have I seen the disease transmitted in this way.

During the five years that the disease has been prevalent in Philadelphia, it seemed almost to disappear during the summer months, but reappeared during the first damp, cold and rainy days of the autumn, attacking, according to constitutional idosyncrasies, more or less severely the younger members of families. It is of an epidemic miasmatic origin, but becomes, in time, endemic in certain localities favoring its growth. It becomes less violent and fatal in the course of time, but still occasionally will assert its ancient virulence. Like all contagious diseases, it is most easily communicated when concentrated in a family.

P.-Statistics.

From the accompanying table it will be seen that the wards on the outskirts of the city, with low grounds and marshes of stagnant water, near the Delaware as well as the Schuylkill, have the greatest mortality from diphtheria. Highest on the list stands the First Ward, with 137 deaths in a population of 30,886; next to that, the Twentieth Ward, with 132 deaths in a population of 29,963; and third, the Fifteenth Ward, with 119 deaths in a population of 32,091; all these during the last five years. On the other hand, the Second Ward, with a population of 29,123, has only 85 deaths; and the Seventh, with a population of 31,276, 92 deaths; the Eighth Ward, with a population of 27,770, 52 deaths during the last five years. The superior cleanliness of the Eighth Ward,

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