k;iHH» V Surgeon General's Office N ^O.^QgaQOQTAuQ.OQiOOG '' :. y^JQC' I c! $ I I i : vl* •is ON DIPHTHERIA. BY EDWARD HEADLAM GREpHOW, M.D. FELLOW OP THE KOTAL COLLEGE OP PHYSICIANS, PHYSICIAN TO TnE WE8TEEN GENEBAL BISPENSAKT, AND LECTUEEB ON PUBLIC HEALTH AT ST. THOMAS'S HOSPITAL. t.00 ^nl'Si% NEW YOEK: BAILLIERE BROTHERS, 440 BROADWAY LONDON: II. BAILLIERE, 219 Regent St. MELBOURNE: F. BAILLIERE. PARI8: J. B. BAILLIERE ET FIL8, Rue Hatttefeuille. MADRID: B. BAILLT-BAILLIERE, Calle del Pbincipe. m 1861. wcc PUBLISHERS' NOTICE The prevalence of Diphtheria in this country, and the daily demand for a recent and practical treatise on this disease, have induced the publishers to issue the treatise of Dr. Edward Headlam Greenhow, immediately after its appearance from the English press. The author is recognised as one of the ablest writers on epidemic diseases. In the belief that this work will meet the necessities of practitioners^ it is submitted to the medical public. PREFACE. The following treatise is founded partly upon the study of diphtheria in public and private practice, partly upon information obtained in the course of an inquiry into the causes, symptoms, and treatment of the disease, made for the Privy Council, in the spring of 1859.* In the progress of this investigation I visited several districts in which diphtheria then prevailed, both for the purpose of observing the disease and also of ascertaining the result of the experience of those provincial practitioners who had been most extensively engaged in its treatment. From these gentlemen I received the most efficient aid in the prosecution of my inquiry, and I gladly take this opportunity to express my sense of their kindness, and of the great value of the information with which they supplied me. The materials then collected having been published in an official form, I have felt myself at liberty to make use of them for my present purpose. Being desirous that my book should contain as complete an account as possible of the present state of professional knowledge on the subject of diphtheria, I have not scrupled, especially in the chapters devoted to the history of the disease, to quote freely from other authors whatever facts were suitable for my purpose, in every instance stating my authority for information not resulting from my own experience. * The minute containing the heads of this inquiry, and the report of its results, have been printed in the Second Report of the Medical Officer of the Privy Council, pp. 167-237. London, 1860. viii preface. The facts recorded in the following pages, in my opinion, clearly prove that the recent epidemic of diphtheria has been occasioned by some wide-spreading influence, deriving intensity of action from local conditions either of population or of place. It is only on such a supposition that we can account for the wide extension of the epidemic; its mildness in some districts, its excessively malignant character in others; its occasional limita- tion witbin very narrow bounds; and its tendency to linger in particular districts, or to return again and again to the same spot. These conditions being as yet undiscovered, and our acquaintance with the disease being of so recent a date as to ren- der it doubtful whether we have as yet witnessed all its phases, I have for the most part confined myself to the statement of facts, and in a great measure avoided the expression of theoretical opinions which could at best be founded on but imperfect data. I am well aware that the work which I now venture to submit to the judgment of my professional brethren cannot claim to be regarded as containing a perfect elucidation of its subject. Perhaps the time has not yet arrived when such a work could possibly be written. My object will, however, have been attained, if my inquiries should be found to have supplied information which may lead to a more enlarged and perfect acquaintance with so formidable a disease. London, November 1, 1860. CONTENTS. CHAPTER I. Preliminary Observations—Definition of the Disease . CHAPTER II. Diphtheria in the Sixteenth, Seventeenth, and Eighteenth Centuries . l( CHAPTER III. Diphtheria in the Nineteenth Century ... 4c CHAPTER IV. Diphtheria as a Sporadic and Endemic Disease ... 58 CHAPTER V. Non-identity of Diphtheria and Scarlet Fever . . . . 68 CHAPTER VI. Human and Brutal Diseases coincident with Diphtheria—Relation of Place, Age, Sex, and Social Position to the Epidemic . . . .75 CHAPTER VIL Communicability of Diphtheria . 86 CHAPTER VIII. Symptoms—Description of the several Grades and Varieties of Diphtheria . 93 PAGE 11 CONTENTS. PAGE CHAPTER IX. Symptoms—Diphtheria on the Cutaneous Surface and Wounds—Occasional Concomitants of the Disease—Manner of Death . . . .114 . CHAPTER X. Symptoms—Sequela? of Diphtheria ... . 132 CHAPTER XI. Morbid Anatomy of Diphtheria .... 140 CHAPTER XII. Suggestions for Treatment . . . , , * 154 ON DIPHTHERIA. CHAPTER I. PRELIMINARY OBSERVATIONS--DEFINITION OF THE DISEASE. The history of epidemic diseases forms at once one of the most interest- ing and important subjects of medical inquiry. For the most part, pre- vailing simultaneously over a wide extent of country, and attacking large numbers of the inhabitants, these diseases are yet sometimes remarkable for the singular immunity enjoyed by particular places or persons at times when all around are subject to their influence. Thus the disease which forms the subject of this memoir has been repeatedly observed, whilst very prevalent in certain districts, to pass over others in their immediate vicinity, of precisely the same character with respect to soil, climate, aspect, and inhabitants. A remarkable illustration of this fact came under my own observation in the summer of 1859. Diphtheria had prevailed for many months, and had proved most fatal in a certain district of the Union of Christchurch, in Hampshire; the remaining portion of the Union having been almost, if not entirely, exempt from the epidemic. The. two districts are divided by the lliver Stour, and the disease prevailed in all the hamlets on the western side of the river, while scarcely any cases occurred on the eastern, although both are similar in character, and appeared to be exposed to the same influences. The sweating sickness of the fifteenth and sixteenth centuries is said, by Caius, to have attacked almost exclusively the upper and wealthier classes of the community, and in some of jts visitations the English race so exclusively, that no alien was affected by it in this country, and none but the English suffered from it abroad. Diphtheria is said to have exhibited a manifest preference for the English at Boulogne during its late severe visitation of that town. The medical history of the present century is remarkable for the reap- pearance in this country of two very definite forms of epidemic disease 2 12 ON DIPHTHERIA. described by the physicians of former centuries, but unknown to our immediate predecessors. I have elsewhere shown that the disease which, in our day, is called Asiatic or epidemic cholera, is identical with a dis- ease named Bysenteria incruenta by Willis, and Diarrhoea colliquativa by Morton, which prevailed during many years of the middle and latter part of the seventeenth century* The kind of epidemic sore-throat, now called diphtheria, which has prevailed so extensively during the last four years, tliough unknown to the last two or three generations of physicians, was familiar to the medical practitioners of this country about the middle of the eighteenth century, under the names of malig- nant sore-throat, epidemic croup, and morbus strangulators. Both cholera and diphtheria have, it is true, been observed from time to time in a sporadic form; and small outbreaks of each of these diseases have sometimes occurred : but in an epidemic form they had been long unknown when they reappeared in our own time. The terms cholera and diphtheria are, generally speaking, and perhaps properly, only applied to the malignant forms of these epidemic diseases, to the exclusion of the milder and commonly more numerous cases of illness induced by the epidemic influence. These milder cases, although characterized by an affection of the same mucous surfaces, lack the more striking features usually understood to be associated with the terms cho- lera and diphtheria. The mucous membrane of the alimentary canal is alike the seat of the principal phenomena, both in cholera and the diar- rhoea which commonly prevails so extensively during a visitation of cho- lera. The mucous membrane of the throat, especially of the tonsils and immediately adjacent parts, is not only the seat of the simpler form of sore-throat which has prevailed so extensively during the last three or four years, but is likewise, almost invariably, the situation in which the first symptoms of the more severe cases, properly termed diphtheria, manifest themselves. The diarrhoea of cholera times does not present the excessive prostration, the blue, cold, clammy surface, the pulseless extremities, or the whispering voice of fully developed cholera; the simpler sore-throats which have usually prevailed simultaneously with diphtheria have been often unattended by the characteristic exu- dation of false membrane, or by the prostration of strength, and have rarelv, if ever, been followed by the raucous nasal voice, the paralysis of the muscles of deglutition or of locomotion, and the impaired vision which so frequently follow in the train of diphtheria; but the diarrhoea * Willis's Pharmaceutice Rationalis. Translated by S. Bordage. Part I., pp. 51-6. London: fol. 1684. Pyretologia seu Exercitationes de Morbis U/iiversalibus Acutis. Londini: 1692, pp. 420-1. On the Study of Epidemic Disease, as illus- trated by the Pestilences of London. By E. Headlam Greenhow, M.D., 8vo. Also, The British and Foreign Medico-Chirurgical Revieio, vol. xvii. pp. 292. DESCRIPTION OF DIPHTHERIA. 13 and sore-throat are respectively congeners of cholera and diphtheria, from which their difference is less one of character than of degree. I will not pause to inquire whether the term diphtheria should be applied to sore-throat epidemics, of which cases, characterized by diph- theritic exudation, sometimes form but a small section. It would, per- haps, have been better to have retained the English name, ' epidemic sore-throat,' or the older term ' angina,' as the generic name of such epidemics; but as the word diphtheria is now in ordinary use for one form of the disease, I shall employ it as the generic term for the entire epidemic. The following description will, I trust, be found sufficiently comprehensive to include every variety of the disease, from that of mild epidemic sore-throat to the severest form of malignant diphtheria. Diphtheria, comparatively rare as a sporadic disease, more frequently prevails as an epidemic, in which form it often exists contemporaneously over considerable tracts of country, or it may occur in smaller groups, limited to particular hamlets, or even to particular houses. Sometimes it has prevailed so extensively, that distant countries, including, portions both of the Old and New World, have been simultaneously or successively visited by it. Diphtheria is sometimes preceded, and usually accompanied, by fever, which, in certain epidemics and in severe cases, is only transient, speedily giving place to depression. There is often a stiffness of the neck at the commencement of an attack, and usually more or less swell- ing and tenderness of the glands at the angles of the lower jaw. The tonsils are commonly swollen, and, together with the immediately con- tiguous parts of the mucous surface, more or less inflamed. Sometimes the swelling and inflammation subside without further local mischief; at others, the inflamed surface presents, from an early stage of the disease, whitish specks, or patches, or a continuous covering of a membraniform aspect, which may appear as a mere thin, almost transparent pellicle, but usually soon becomes opaque, and in some cases assumes the appear- ance of wet parchment or chamois leather. This membranous concre- tion varies in colour from being slightly opaque to white, ash-colour, buff, or brownish, and in rarer instances, to a blackish tint. This false membrane is a true exudation which has coagulated upon the mucous surface, from which it may often be readily separated, leaving the subjacent membrane mostly unbroken or merely excoriated, usually reddened, vascular, tender, and dotted with small bloody specks or points, but sometimes superficially ulcerated, and more rarely in a sloughing condition. When the false membrane has been artificially removed, it is apt to be renewed ; and when not meddled with, to become thicker by continued exudation from the mucous surface. The severity of the disease is commonly in proportion to the continuity and density of the exudation; but cases sometimes occur in which the membranous exuda- 14 ON DIPHTHERIA. tion is inconsiderable, and yet the general symptoms arc of a very alarm- ing kind. If the patches are small and remain distinct, the case ordi- narily runs a favourable course; if they rapidly spread and coalesce, if the membrane becomes thick, and especially if it assumes a brownish or blackish colour, danger is imminent. In proportion as the membrane increases in thickness and density, does its attachment to the subjacent surface generally become firmer. The surface of the mucous membrane around the exudation is red and vascular, and so tender that in severe cases it bleeds on the slightest touch. The throat is in general the primary seat of the disease; but the inflammation is apt to spread along continuous mucous surfaces, and thus to extend upwards into the nares and to the conjunctiva; down the pharynx into the oesophagus; through the glottis into the larynx, trachea, and downwards into the bronchial tubes; or forwards on to the buccal mucous membrane, the gums, and lips. Wounds and excoriations of the skin, and the mucous membrane of the nymphae and vagina when tender or irritated, especially in persons already suffering from diphtheria of the throat, are during an epidemic liable to undergo the same process of exudation, which, coagulating, forms a false membrane analogous to that on the tonsils and throat Albuminuria, commencing early in the disease, usually within a few hours, and gradually disappearing with the local affection, sometimes, but by no means invariably, accompanies diphtheria. If the urine be much loaded with albumen, the complication is a serious one; but cases have done well in which a considerable cloud of albumen was deposited from the urine by the proper tests, and very severe and even fatal cases of diphtheria have been unattended by albuminuria. After a time the false membrane is thrown off, either entire, so as to represent a mould of the parts it covered, or, which is more usual, comes away in shreds or flakes intermingled with mucus. Sometimes it under- goes decomposition prior to separation, giving rise to a very offensive smell. When the membranfform exudation has come away spontane- ously, it is sometimes repeatedly renewed, each successive false membrane becoming less and less dense, having le6s and less of the character of exudation, and more and more that of mucous secretion, until at length the affected surface is merely covered with a thick mucue, which gra- dually disappears as the mueous membrane recovers its healthy condition. In other cases the exudation is not renewed when it has once been thrown off, but the subjacent membrane is observed to be either redder or paler than natural, has a rough, ragged appearance, or is depressed below the adjacent surface on the parts where dense false membrane has existed. Occasionally sloughing takes place beneath the exudation, or even more deeply, as in the centre of a tonsil, and may implicate the tonsils, uvula, and soft palate. More rarely the tonsils suppurate. DESCRIPTION OF DIPHTHERIA. 15 Haemorrhage from the nose and throat, independently of the co-existence of purpura, often occurs in the course of diphtheria, and is sometimes very profuse. The local affection may pass into a chronic form, in which relapses or exacerbations are readily produced by vicissitudes of weather or by exposure to damp or cold. Even perfect recovery from an attack affords no immunity from the disease in future. A peculiar character of the voice, resembling that produced by affections of the throat in secondary syphilis, is a common result of diphtheria, and often continues for many weeks after recovery. The power of swallowing is sometimes so impaired that there has been diffi- culty in sustaining life during convalescence; and liquids especially are apt, even after a comparatively slight attack of the disease, to be regur- gitated through the nostrils. Extreme anremia, impairment of vision, a peculiar form of paraplegia, weakness of the hands and arms, numbness, tenderness of the limbs, tingling, wandering pains, and more rarely, nervous sequelae of a hemiplegic character, are, in the order here written, ulterior consequences of diphtheria. Gastrodynia, and sometimes dysen- teric diarrhoea, occasionally follow diphtheria. Pain of the ear, deafness, and abscess, are occasional but rare results of the disease. CHAPTER II. DIPHTHERIA IN THE SIXTEENTH, SEVENTEENTH, AND EIGHTEENTH CENTURIES. Although diphtheria as an epidemic disease is new to the present generation of medical practitioners, it was well known, and has been very accurately described, under other names, by several of the older physicians. Like cholera and influenza, it has prevailed in so many countries and in so great a variety of climates, as may well entitle it to be called pandemic. It prevailed in Spain, Italy, Sicily, and other European countries in the sixteenth and seventeenth centuries. It visited England, France, Italy, Sweden, Holland, Germany, and North America about the middle of the last century, and, then disappearing, seems to have remained almost unnoticed till towards the close of the first quarter of the present century. Within the last three or four years it has prevailed in an epidemic form on the Continent, in this country, in North America, and in Australia. It would occupy more space than is compatible with my present pur- pose were I to endeavour to trace fully either the local or the literary history of diphtheria; but it seems desirable to adduce such evidence as may suffice to show the disease is not of recent origin, its tendency to prevail epidemically at uncertain periods, and its very wide distribution at such times as regards region and climate. The following extracts from his description of ulcerations about the tonsils, quoted from the English version of his works published by the first Sydenham Society, evidently show that Aretaeus was well acquainted with diphtheria.* ' Ulcers occur on the tonsils; some, indeed, of an ordinary nature, mild, and innocuous; but others of an unusual kind, pestilential and fatal. Such as are clean, small, superficial, without inflammation and without pain, are mild; but such as are broad, hollow, foul, and covered with a white, livid, or black concretion, are pestilential. If the concretion has depth, it is an eschar, and is so called; but around the eschar there is formed a great redness, inflammation, and pain of the veins, as in car- * The extant works of Aretceus the Cappadocian. Book i. chap. ix. pp. 253-255. London, 1856. DESCRIPTION OF DIPHTHERIA BY ARETAEUS. 17 buncle ;* and small pustules form, at first few in number, but others coming out, they coalesce and a broad ulcer is produced.' Aretaeus then goes on to describe the extension of the disease to the tongue and gums, and sometimes to the windpipe, when it rapidly proves fatal by suffocation. Children under the age of puberty are, he says, espe- cially subject to the disease. Egypt, Syria, and more particularly Coelo- Syria, engender the complaint, which has hence derived the name of Egyptian and Syrian ulcers. In describing the mode of death, Aretaeus speaks of the foetor as so loathsome that even the patients themselves cannot endure it (a fact which has also come under my own observation), of the regurgitation of liquids through the nostrils, and of hoarseness and loss of speech. Three Spanish physicians, Villa Real,f Fontecha,J and Herrera,§ who wrote early in the seventeenth century, have described with great accuracy the garrotillo, or morbus suffocans, then prevailing in Spain, which was evidently identical with the diphtheria of our own time. Fontecha, whose work was published in 1611, says he had seen the dis- ease as far back as 1581, and adds that it prevailed in an epidemic form in 1599 and 1600. Villa Real mentions its appearance in Andalusia and other parts of Spain in 1590 and 1591. Dr. de Fontecha|| says garrotillo sometimes began with little, at others * ' Quod si concreta ilia sordes altius descenderit, affectus ille eschar est, atque ita Graece vocatur, Latine crusta; crustam vero circumveniunt rubor excellens et inflammatio, et exiguae rarseque pustular orientes, hisque alia? supervenientes in unum coalescunt, atque inde latum ulcus efficitur.'—Aretozus, quoted by Bretonneau. \ Joannis de Villa Real, de Signis, Causis, Essentid, Prognostico, et Curatione Morbi Suffocantis. Compluti, 1611. \ JDisputaliones Medicai super ea qua Hippocrates, Gahnus, Avicenas, necnon et alii Grmci, Ardbes, et Latini, de Anginarum naturis, speciebus, causis et curationibus scripsere diversis in locis; et circa affectionem hisce temporibus vocatam Garuotillo. Opus Doctoris Johannis Alphonsi de Fontecha, &c. Compluti, 1611. § De Essentid, Causis, Notis, Prcesagio, Curatione, et Prcecautione Faucium et Guituris Anginosorum Ulcerum Morbi Suffocantis, Garrotillo Hispane appellati, &c. Authore Doctore Christophero Perez de Herrera, &c. Matriti, 1615. || 'Aliquando incipit cum parvo dolore, aliquando cum magno, aliquando cum parvo tumore super ligulam, aat ad latera, aliquando altiori, quandoque vero cum ampula, aliquando minime, quandoque cum vescicula, multoties vero deficit. Saepe • tumor magnus ostenditur ad partes externas ita, ut descendat usque ad os juguli, redendo vero quasi planum spacium, quod interest inter mandibulam et jugulum; millies vero non videtur, nunc per initia majora ulcera apparent albicantia, et fere scamosa ; nunc vero solus quidam color albicans, aut inter libidum, et passeum. Per initia et vidimus scarum nigricantem, aut in livorem, ceu colorem cliloron tendentem ; aliquando hsec omnia ab oculis effugiunt; febris coticomitata frequenter hanc affectio- nem : saepe vero anno isto 1597, vidi ipsam deficere, veluti etiam contingit in epide- mical ilia affectione anni 1599 et 1600 in hoc regno. Sit ergo certum, quotiescumque apparet quidam color veluti farinaceus in gutture aut faucibus (etiam si non reperia- tur magnus dolor) cum aliquali deglutiendi difficultate: [et febris, pulsusque parvus, 18 ON DIPHTHERIA. with much pain. There was always more or less swelling of the throat, both external and internal. At one time large whitish scabby ulcers appeared, at other times, only a white colour. He had also seen at the beginning, a blackish crust, inclining to a blueish or greenish hue. Sometimes these signs were not discoverable. Fever often accompanied the disease, but was also frequently absent, particularly in certain epide- mics. He adds that the disease was unquestionably present when, although there was little pain, a colour like flour appeared in the throat and fauces, accompanied by some difficulty in swallowing, by fever, and a small, weak, irregular pulse. And these signs denoted not only the presence of this throat affection, but likewise, its intensity. In describing the diagnostic signs of morbus suffocans, Villa Real says the disease did not always begin in the same manner; for the mouth being opened and the tongue held down, at one time he saw the apex altogether white; at another, a certain membranous crust, not perfectly white, but of a blueish colour, covering the fauces, throat, and gullet. The tongue, from the root upwards, was also either wholly or partially white, a symptom, which, taken in conjunction with difficulty iu swallowing during the prevalence of an epidemic, was a sure proof of the commencement of this disease even before the white false membrane became apparent to the eye. For although whiteness of the tongue is not uncommon in other acute diseases, yet if the morbus suffocans be prevailing at the time, and there be diffi- culty in swallowing, it certainly indicates the existence of the white crust in the unseen adjacent parts, and also that it will presently appear in the oesophagus and throat. The certainty is much in- creased if tumefaction be observed in the neck behind and below the ears, such swelling being always present in this disease, but especially in cases where the crust tends to a livid hue, and resembles a membrane.* Although the diseased parts in morbus suffocans were swollen, the debilis, et inaequalis; adest et anginosa lues dicta; reliqua enim uti ulcera supra dicta, et reliqua signa jam non solum affectionem hanc conotant, verum, et illam jam valde confirmatam saevitiem causarum, et illarum extensionem, et intensionem. Ita ut nullus fere fuit visus ex his, qui habent ilium tumorem, non remittenti febre, qui non fuerit et mortuus.'—Fontecha, loc. cit., p. 28. * ' Circa signa propria, qua} in hoc morbo conspiciuntur, non semper eodem modo apparent; nam ore adaperto, et depressa lingua, modo conspiciebam apicem omnino album, exeuntem ab imo gulee, et impedientem deglutitionem, modo quan- dam crustam, veluti membranam, cingentem fauces, guttur, et gulam, non per- fects albam, sed declinantem ad lividam; quae diversitas nascitur ex causae diver- sitate; et simul cum hoc apparebat lingua alba, a radice ejus usque ad medie- tatem, aut fere totam, per quod signum simul cum difQcultate deglutiendi et grassante tali epydemia, potest cognosci morbus hie incipiens, anteaquam appareat frustrum illud album; albedo enim lingua? indicat esse iu parte subjects, et infe- riori, crustam albam, quae jam jam per cesophagum, aut guttur, se roanifestat: nam licet possit reperiri lingua alba, iu febre alia acuta, aut secus, et sic non sit SPANISH EPIDEMIC OF THE SEVENTEENTH CENTURY. 19 material which caused the swelling was not effused into the pores, but external to the part, as if it had flowed over the surface, which it covered like a solid membrane. The false membrane is said by Villa Real to have been so consistent and elastic that it could be handled and stretched like moist leather or wet parchment, without injury to its texture and shape,* These statements, he says, were founded upon experience, for he had often observed the excretion of white or blueish fragments of membrane, flexible as wet leather, in patients who recovered ; and in the post-mortem examination of those who had died, had found the fauces covered with a similar membrane, which he could raise with an instrument, leaving the subjacent parts apparently sound.f As has been sometimes observed in this country during the recent epidemic, the white false membrane often existed in the throat at the very commence- ment of the illness, without any previous indisposition.^ Haemorrhage from the nose or mouth, always a serious symptom in diphtheria, was, according to the experience of Villa Real, invariably fatal.§ proprium et pathonomonicum hujus morbi; tamen sensata simul dimcultate deglu- tiendi, et grassante tali epj'demia, sis certus morbum esse suffocantem. Auget certi- tudinem, si in collo, et retro aures declivius, tumores conspicias; nam tales tumores in omnibus reperiuntur, et magis in illis, quorum crusta ad lividum declinat, et est velut membrana, hie enim tumores simul cum aliis signis, syndromen constituunt signorum morbi suffocantis, nondum apparente crusta; aut si jam appareat," sit tamen puer renitens oris apertioni: in gradioribus enim crusta jam manifesta, ore adaperto, et depressS. lingua, evidenter cognoscitur.'—Villa Real, loc. cit., pp. 90, 91. * ' Tamen nullus scripsit vidisse in faucibus, gula, et gutture, quasdam velut membranas (como pergamino) cingentes fauces, &c, et tali constantes modo substan- tias, ut si propriis manibus tendas, videas ejus partes cedere, quas si desinas, videas refluere, propriumque adquirere locum: non secus ac si corium madidum aut mem- branam madidam tendas et sinas. Haec experientia didici, turn in viventibus excreta causa, per os, turn in morientibus facta anatomia.'—Villa Real, loc. cit., pp. 34, 35. f' Partes vero, quae in hoc morbo apparent affici, tument supra naturam, non tamen vero tumore: nam materia morbi suffocantis non est in partis poris, eandem in tumorem attollens, sed per modum irrigationis partis superficiem afflcit, et velut membrana quasdam solida cingit fauces, guttur, et gulam; neque enim propter maxi- mam ejus crassitiem, et soliditatem, potest recipi in poris. Quae ratio desumitur ab experimento: nam saepe vidi, in his qui fuerunt liberati, excerni frustra quaedam alba, aut ad livorem declinantia, membranosa quidem, et velut corium madidum flexibilia, et in his qui interierunt, facta anatome, inveni dictam membranam cin- gentem partes dictas, quam instrumento ferreo levavi, parte subjecta integra appa- rente ; est ergo causa hujus morbi per modum adliaerentis, et irrigantis corporis, non per modum tumoris praeter naturam.'—Villa Real, loc. cit., pp. 102-3. \ ' Ego vero, qui millies vidi hos aegrotantes, statim in primo insulto morbi, con- spexi jam adesse frustrum album in faucibus, gula, aut gutture, nulla prius (dicente aegro), sensata laesione.'—Villa Real, loc. cit., p. 34. § ' Observavi saepissime, sanguinis narium aut oris fluxum, in hoc morbo esse lethalem; nullum enim vidi liberatum ex his. qui sanguinem e naribus, aut ore rejecerunt.'— Villa Real, loc. cit., p. 136. 20 ON DIPHTHERIA. Hen-era describes eight varieties or stages of this destructive disease, which tally very nearly with what has been observed in this country during our own time. Indeed, it is evident that these Spanish physi- cians studied the complaint very carefully, and described what they saw with great fidelity ; their descriptions, as far as they extend, being quite applicable to the disease which, after an interval of two centuries, has so lately appeared among ourselves. The first two varieties closely resembled common sore-throat, and were characterized by inflammation of the throat and surrounding parts, unaccompanied either by exudation or ulceration, and, whilst differing from each other in intensity, were very mild in comparison with the others. Although perhaps less properly called morbus suffocans, yet Herrera places them in the same category, seeing that they may pass into it; a circumstance which, as will hereafter be seen, has also been observed during the recent epidemic. Indeed, there can be no doubt that Herrera was perfectly justified in considering these milder kinds of sore-throat as caused by the same epidemic influence, and identical with the more malignant disease, from which they differed only in intensity, as is acknowledged to be the case with simple and malignant scarlet fever, discrete and confluent small-pox, or choleraic diarrhcea and cho- lera. The third variety had advanced a stage farther ; there was excoria- tion, attended by slight soreness. In the fourth, there was ulceration, with purulent'secretion and severer pain. In the fifth, a spreading sani- ons ulcer, with still intenser pain and an offensive smell, but without the crust. In the sixth variety, the characteristic crust, from which the disease derives its modern name, diphtheria, was plainly observable upon the ulcer. In this variety, which was more dangerous than any of the preceding, the crust was of a white colour. In the seventh variety the crust was livid ; and in the eighth, which is the worst variety of all, the crust was black.* Herrera mentions the peculiar character of the voice in this disease, * ' Cujus perniciosi morbi octo sunt species seu gradus. Primus, quando capacitas ipsius gutturis et ambitus, et partes vicinae, ut aspera arteria, epiglottis, larynx, aut oesophagus, musculi interni et externi, fauces et aliae rubescere incipiunt. Secundus, quando partes praedicta? insigniter rubescunt, et inflammantur, discratiaque afficiun- tur, et jam quodammodo dolorem aliquem sentiunt: qui gradus reapectu reliquorum benigni nuncupari possunt. Et hae duae species primse absque ulcere non ita propria hujus morbi suffocantis species sunt; sed communis cum angina, qui gradus, etsi verae anginae sint ex permutatione ejusdem anginae in morbum suffocantem quando- que transeunt: et quousque excoriari, aut exulcerari partes illae incipiant, nonien suf- focantis affectus non meretur, cum hi duo gradus ad alterutrum, anginam scilicet, et morbum suffocantem viae existant. Et quoniam hujus morbi principia sunt, ad majc- rem intelligentiam et ad indicationem curativam principii hujus morbi merito inter species retulimus. Tertius gradus est, quando ulcera, apparent, et est saevior. Quo- rum ulcerum tres etiam sunt species, seu differentiae. Prima scilicet, quando sola excoriatio cum aliquo dolore ulceroso perspicitur, quae tertia est in ordine graduum. Secunda, quando ulcus cum suo pure, majorique cum dolore adparet, et est quarta. SICILIAN EPIDEMICS OP THE SEVENTEENTH CENTURY. 21 resembling that of persons suffering from secondary syphilis. This, he says, disappeared altogether in the course of time, after the patient had recovered ; a circumstance which scarcely happens in the venereal dis- ease. It is hardly necessary to observe that this symptom affords addi- tional confirmation of the identity of the morbus suffocans of the seven- teenth with the diphtheria of the nineteenth century; or that it shows partial paralysis of the muscles of the throat to have been a common sequel of the disease when Herrera practised as well as now. Lastly, he mentions the occurrence of diarrhoea as an unfavourable sign, at what- ever stage of the illness it appeared.* Some years after its appearance in Spain, but yet early in the seven- teenth century, the morbus suffocans showed itself in the kingdom of Naples, and afterwards in Sicily, where it raged with much severity, proving very fatal among children, and overspread the whole island. I have not had an opportunity of consulting the writings of the Neapoli- tan physicians who described the epidemic in Italy, but I have read the account of the disease in Sicily written by Alaymus and Cortesius. The latter, in his introductory observations, asserts that the several Neapo- litan physicians held very different and often quite opposite opinions respecting the nature of the disease, which they called by various names, in accordance with the diversity of their views.f In Sicily it was called simply the throat disease—' gulce morbus.'' As in the present day, the disease differed greatly in malignity, in the Tertia, cum cancrosum instar carbunculi et cum sanie percipitur, pessimique odoris et figurae; attamen sine .crusta, cum dolore tamen vehementiori, qui usque ad octa- vum et ultimum gradum .incrementum accipit, quae quinta in gradu existit. Sextus est gradus, cum crusta supra ulcus jam clare conspicitur, et serpit, corrodendo, et putrefaciendo partem; et tunc vere et proprie crustosum ulcus, et carbunculosum, cancrosumque appellari potest; et est omnibus pra?dictis gradibus periculosior. In triplici etiam differentia tale ulcus versatur, album scilicet, quod in sexto etiam est gradu; lividum in septimo, et nigrum in octavo, et omnium graduum pessimo.'— Herrera, loc. cit., pp. 6, 7. * ' Depressa lingua, in imo gulce nota quaedam alba solet conspici, quae in causa est, ut 83gri non bene loquantur, ut accidit in his, qui morbo Gallico corripiuntur . . . . et aegroti ad sanitatem redacti decursu temporis eque ut antea loquuntur; quod in morbo Gallico secus accidit' .... Herrera, loc cit., p. 19. ' Ex alvi fluxu symptomatico, continuo et immoderato, sine ope et auxilio medi- camenti purgantis, malum etiam potest desumi praesagium, sive in principio, sive post accidat.'—Herrera, loc. cit., p. 20. f 'Morbus hie, cujus naturam scire optas, respirationem, sed maxime deglutitionem laedit, nullumque aliud nomen in hae Urbe adeptus est, nisi gulae morbum, eo quod appareat partes spectantes ad gulam ita hesas esse, ut etiam deglutiendi actio plane laedatur. De eo varie quidem multi authores Parthenopaei hactenus scripserunt, sed inter se parum constantes sunt, sive nomen, sive essentiam consideremus; alii enim affectum strangulatorium, alii phlegmonem anginosam, alii pestilentem faucium affectum, nonnulli epidemiam gutturis luem, et aliqui tandem variis nominibus pro varia ipsorum opinione designarunt; et haec quo ad nomen. 22 ON DIPHTHERIA, extent of the local affection, in its tendency to spread over the adjoining parts, and in depth; being sometimes wholly superficial, at others- attended by much swelling find inflammation, both of tbe external and. internal parts of the neck.* Sometimes there were redness and inflam- mation of the surface of the palate and uvula, the tonsils remaining unaf- fected ; but at others, and more frequently, these glands were swollen, and sometimes so much so, that they touched each other,, thereby inter- fering with deglutition and respiration. In the beginning there were usually swelling, heat, and redness^ afterwards, pain and difficulty of swallowing. When there vas only inflammation of the parts about the throat, the sick easily recovered ; but sometimes a certain pituitous sub- stance (exudation), descending from the head, so speedily and unexpect- edly followed the inflammation, that the patient was suddenly suffocated. Very often a white substance, which presently became livid, and after- wards black, unaccompanied by pain, appeared on the inflamed surface. This material could be readily torn away from the subjacent parts, either by the finger or an instrument; but, although the operation caused no pain, the patient invariably died a short time afterwards, as happened, amongst others, to the son-in-law and grandchild of Cortesius. Some- times mortification, accompanied by fcetor, quickly invaded some part of the throat; and when this occurred, whether foetor were present or not, remedies proved unavailing, and the patient died abont the fourth day, or even earlier; rarely so late as the seventh day.f ' Quod spectat ad essentiam, alii scribunt eum esse aphtas malignasr alS arbitrati sunt reponendum esse in genere carbunculornm, alii intrepide pronuatiarunt esse anginam, qui inter se tamen divisi sunt; nam horura aliqui existimarunt esse angi- nam proprie dictam, alii e contra anginam lato modo, et improprie acceptam, alii determinarunt esse erysipelas, seu ignem sacrum fauciuni, alii denique putarunt esse inflammationem proprie dictam, quam phlegmonem Grseci appellant.'—Joannis Bap- tists Cortesii, Miscellaneorum Medicinalium Decades Denoz, p. 696. Messanse, 1625. * ' Et propterea ulcerum alia sunt maligniora, alia minus maligna, alia magis, alia minus serpentia, alia profundiora, alia minus descendentia, alia sordidiora, alia minus, alia escharam profundiorem, alia superficialem habent, alia gangrenosa, et alia sphacelata, alia crustam, et sorditiem albam, alia nigram admittunt, alia maxima cum infiammatione, et tumore, turn internarum, turn externarum gulae partium con- junguntur, alia ver6 minus, alia, et ut plurimum, in tonsillis, alia in columella, alia iu faucibus, alia aliquando in laringe, et in musculis gutturis, alia, et rard in palato, alia in naribus nascuntur.'—Marci Antonii Alaymi, Consvltatio, pro Ukeris Syriaci nunc Vaganlis Curatione, p. 54. Panhormi, 1632. f ' Haec affectio laedit pharynga. . . . Modus erat diversus; nam aliquando pars extima palati rubicunda, et inflammata simul cum ipsa uvea apparebat intactis glandulis, nonnunquam et saepiiis glandulae praedictie intumescebant, cum calore, et rubore primum, deinceps cum dolore, et magna deglutiendi difficultate, nonnunquam adeo tumidae erant, ut ad invicem se contingerent, viam ad deglutiendum, et respi- randum intercludentes, igitur omnes istse partes aliquando sola infiammatione, non- nunquam solo erysipelate, interdum omnes simul corripiebantur uno, vel altero affectu. Yertim si ad hunc remansissent modum, hoc est vel infiammatione vel SICILIAN EPIDEMICS OP THE SEVENTEENTH CENTURY. 23 Cortesius notices the frequent occurrence of several fatal attacks in the same family; a circumstance which has also added largely to the distress and alarm which diphtheria has lately caused in England. According to Alaymus, the disease generally commenced in the tonsils, the uvula, or the fauces; sometimes in the larynx* at others, but rarely, in the palate, and occasionally in the nostrils* There was reason for supposing the disease to be contagious, and a case reported by Cortesius strengthens the opinion. A monk being attacked by the disease, con- stantly complained that he observed a foul odour proceeding, as he supposed, from his mouth ; and, to assure himsejf of the truth, requested a friend to verify the fact by smelting. Not many hours after doing so, in the presence of Cortesius and others, the friend was laid up with inflammation of the fauces and tonsils, and, remedies proving useless, died on the fourth day of his illness.f erysipelate affectse, facile sagrotantes liberati fuissent, sed ad pradictarum partium inflammationem subsequebatur interdum materia quaedam pituitosa a capite tarn repente, et inopinato descendens, ut miseri segrotantes subito suffocarentur. Xon raro apparebat materia quaedam alba in superfieie, quae paulo post ad iivorem, deinde ad nigredmem absque dolore mutabatur, quod gangraease signum est manifes- tissimum, verum in sola superfieie esse sensus judieabat, et quod magis est, videbatur a subjectis partibus facile divelli posse. ' Si quis tamen vel digitis, vel aliquo instrumento levi ipsara auferro jentasset, quamvis operatio Usee fieret absque dolore, ea tamen ablata brevissimo tempore peribant ajgrotautes, quod prae cseteris in Petro Soprano genero meo observatum est, cui cum hujusmodi mortificatio apparuisset in suprema superfieie dietarum glandularum faucium, et palati, ita ut videretur esse maximo respirationi, et degluti- tioni impedimento, Chirurgus existimans posse faeillimo negotio a subjectis partibus earn separari solis digitis, levissime quidem earn abstulit, qua ablata tantum abest ut juverit deglutitionem, aut respirationen, ut potius utraque actio laesa magis fuerit, unde brevissimo tempore miser meo cum maximo dolore mortem oppetiit, id quod etiam in aliis quamplurimis, pueris stepiiis observavi, et praesertim in ejusdem Petri filiolo nepoti ex filia quinque annorum mihi carissimo, qui post paucos dies eodem modo, quo pater vitam cum morte mutavit. ' Aliquando, ut dixi, harum partium unam tantum, vel duas, vel etiam omnes simul hujusmodi mortificatio eeleriter invadebat cum fo3tore, et ubi tale symptoma apparebat, sive cum fcetore, sive sine ftetore casus omnino erat deploratus; omnia enim med'icamenta tam intus, quam extra frustra admovebantur, quia segrotantes eeleriter moriebantur, nonnunquam in quarta die, et eitiiis etiam, raro septimam diem attingentes, et quod miserabile admodum erat, observabatur in una, et eadem domo plures periclitari et absque auxilio interire.'— Cortesius, loc. cit., p 697. * Loc. cit, p. 54. f ' An modo contagiosa fuerit hujusmodi morbus, non vaeat suspicione; nam multi medici observantes tot interire, et prsesertim in unaet eadem domo, et tam fre- quenter cogitabant omnino morbum esse eontagiosum..... Anno praeterito conti- git res digna auditu. Divi Francisei Cusios vir doctrina et moribus insignis hae lue obsessus,°tonsillas solummodo, et gargareonem infiammatione laesa habebat, et con- tinue qu'erebatur se percipere in ore foetorem quendam, et ut hae de re certior red- deretur, ad se vocavit Baccalaureum quendam sibi amieissimum, qui maximo affectu assisteb'at, rogavitque, ul vellet olfacere, pereipereque naribus, an verum esset talcm 24 ON DIPHTHERIA. Although the description of the disease given by these Sicilian phy- sicians is in some respects less minute and graphic than that of the Spanish authors already quoted, it is impossible to study their writings carefully without coming to the conviction that the disease recorded by them was identical with the garrotillo of the Spanish authors, and also with the disease termed diphtheria described by Bretonneau and other writers of the present century. The several varieties of the disease men- tioned by Cortesius and Alaymus closely correspond with those described by Herrera, and also with those recorded by later observers. The sim- ple inflamed sore-throat, yielding readily to remedies ; the sloughing of the tonsils and adjacent parts of the pharynx ; the foul foetor of the throat, in certain cases; the exudation of a white, livid, or blackish crust on the inflamed surface, from which it was often readily removed without pain; the rapid and sometimes unexpected death from suffocation ; the peculiar nasal voice; the probable commnnicability of the disease, and its dire ravages in households attacked by it, are umuistakeable features identi- fying the fatal Sicilian disease with the recent epidemic of diphtheria. Thus, then, undoubtedly diphtheria, although under other and various names, prevailed for many years as an epidemic in the south of Europe about the close of the sixteeuth and commencement of the seventeenth centuries. Whether it then disappeared altogether as an epidemic or not I have been unable to discover ; but it certainly prevailed again epidemically in many parts of the continent of Europe, in Great Britain, and in North America, about the middle of the following century. The earliest notice of the disease in this country is that contained in Dr. Fothergill's Account of the Sore Throat attended with Ulcers, pub- lished in 1148. A disease, supposed to be the morbus strctngulatorius, had been observed in London or the neighbourhood in the year 1739, and cases were now and then met with by most medical men in exten- sive practice, especially in the City, during the subsequent years, until 174(5, when it broke out in a more alarming manner at Bromley in Mid- dlesex, -and at Greenwich. It afterwards appeared more generally in the metropolis and the surrounding villages. Children and young people were more liable to it than adults, girls than boys, women than men, the delicate than the robust. The illness usually began with giddiness, dull- ness or shivering followed by fever, acute pain in the. head, stiffness of the neck, soreness of the throat, and sometimes vomiting and diarrhoea. foetorem emitters, an ab imagination ejus prodiret: olfecit Baccalaureus me prae- seute, et multis aliis, at statim non multis elapsis horis decubuit sola faucium, et glandularum infiammatione vexatus absque aliqua nianifesta corruptione partium, omnibusque praesidiis ex arte frustra faetis quarto die suffocatus periit, et tamen Cus- todem non tetigerat, sed solo olfactu aerem ab ore prodounte naribus traxerat, quare ab hujusmodi exemplo veni in sententiam hunc morbum non esse absque aliqua cantagione.'—Cortesius, loc. cit., p. 698. ENGLISH EPIDEMICS OF THE EIGHTEENTH CENTURY. 25 The pain, heat, and restlessness increased towards night, and were often mitigated by the breaking out of a sweat towards morning. ' If the mouth and throat,' says Dr. Fothergill, ' be examined soon after the first attack, the uvula and tonsils appear swelled; and these parts, together with the velum pendulum palati, the cheeks on each side near the entrance into the fauces, and as much of them and the pharynx behind as can be seen, appear of a florid red colour. This colour is commonly most observable on the posterior edge of the palate, in the angles above the tonsils, and upon the tonsils themselves. Instead of this redness, a broad spot or patch of an irregular figure, and of a pale white colour, is sometimes to be seen, surrounded with a florid red, which whiteness commonly appears, like that of the gums, immediately after having been pressed with the finger, or as if matter ready to be discharged was contained underneath. ' Generally on the second day of the disease, the face, neck, breast, and hands to the fingers' ends, are become of a deep erysipelatous colour, with a sensible tumefaction; the fingers are frequently tinged in so remarkable a manner, that from seeing them only, it is not difficnlt to guess at the disease. ' A great number of small pimples, of a colour distinguishably more intense than that which surrounds them, appear on the arms and other parts. They are larger, and more prominent in those subjects, and in those parts of the same subject, where the redness is least intense, which is generally on the arms, the breast, and the lower extremities.' * These white places presently became more of an ash colour, ' when it was discernible that what at first might have been taken for the superficial covering of a suppurated tumour, was really a slough con- cealing an ulcer of the same dimensions.' All parts of the fauces were liable to be affected; but the disease in general first appeared in the angles above the tonsils, or on the tonsils themselves, on one of the arches formed by the uvula and tonsils, on the posterior wall of the pharvnx, on the inside of the cheeks, or on the base of the tongue. In the milder form of the disease, an irregular superficial ulcer, scarcely to be distinguished from the sound parts but by the roughness of surface it occasioned, appeared on one or more of the above-mentioned parts. ' A thin, pale, white slough seems to accompany the next degree; a thick, opaque, or ash-coloured one is a further advance; and if the parts have a Hvid or black aspect, the case is still worse. These sloughs are not formed of any foreign matter spread upon the parts affected, as a crust or coat, but are real mortifications of the substance ; since, when- ever they come off, or are separated from the parts they cover, they * An Account of the Putrid Sore Throat, by John Fotheegill, M.D., pp. 32-34. Fifth edition. London, 1769. 26 ON DIPHTHERIA. leave an ulcer of a greater or less depth, as the sloughs were superficial or penetrating.' * In one case these sloughs were separated by a surgeon's probe without much difficulty ; but the same parts were covered the following day with thick, dark, ash-coloured sloughs penetrating deep into the substance.f The eruption was not always present, and especially in the winter of 1754, it either did not appear at all, or its appearance was retarded- There was commonly much swelling of the parotid glands and neigh- bouring parts, and the tonsils and nvula were sometimes so much swelled as to leave but a narrow entrance to the gullet, which was also frequent- ly surrounded with ulcers and sloughs. Yet, although food was some times forced back through the nose, patients often swallowed with little difficulty or pain. An offensive putrid smell and a corrosive sanious discharge from the nostrils often accompanied the complaint ;| which was also sometimes attended by an excessive faintness, the greater or less urgency of which seemed to indicate the degree of danger.§ There was less thirst than is usual in other acute diseases, and the tongue was moist and seldom furred. Haemorrhage from the nose and mouth sometimes suddenly carried off the patient.|| Dr. Fothergill distinguished the disease from scarlet feverT for which one of his cases was mistaken by the persons about the patient ;^[ but several of the symptoms he describes, particularly the appearance of a red rash on the second day, are rather those of scarlet fever than of diph- theria. It seems probable, as has sometimes happened in more recent epidemics, that scarlet fever and diphtheria were intermingled ; that the cases of scarlet fever had a diphtheritic character; and that whilst, in all probability, Dr. Fothergill saw some cases of uncomplicated diph- theria, especially of that kind in which the exudation remains until the subjacent surface sloughs, he yet confounded the two diseases. Indeed, we have other evidence, both that scarlet fever sometimes presented unusual features, and that diphtheria, uncomplicated by scarlet fever,pre- vailed in this country about the time when Dr. Fothergill observed the particular form of sore-throat described in his book. Dr. Nathaniel Cotton, in a letter addressed to Dr. Mead, describes a peculiar form of scarlet fever which had -broken out in St. Albans towards the end of September, 1748. The early symptoms were sickness, vomiting, and purging, accompanied or speedily followed by sore-throat and swelling of the tonsils, parotids, and maxillary glands. Sometimes the tonsils only were inflamed and swollen, at others there was likewise considerable tumefaction of the external glands. 'Upon looking into the mouth, there were frequently seen, especially after the disease was a little advanced, ulcuscula scattered up and down the fauces, which were * Loc. cit, p. 61. ■)• Loc. cit, p. 62. \ Loc. cit, p. 38. § Loc. cit, p. 58. \ Loc. cit, p. 4(L •[ Loc. cit^ p. 53. ENGLISH EPIDEMICS OF THE EIGHTEENTH CENTURY. 27 pretty broad upon and about the tonsils, superficial (at least all that I saw were superficial), and covered with a whitish slough. The eyes appeared watery, and the countenance, particularly the eyelids, was puffed up as in the measles. In many, the neck, arms, and hands were puffed up and swelled likewise.'* The scarlet efflorescence differed as to extent and time of appearance; there was high fever, intense thirst, a moist and but slightly furred tongue, often cough,f sudden loss of strength, and great dejection of spirits, especially towards evening, which continued for some time after the patient was convalescent.! An epidemic sore-throat which prevailed in Cornwall about the same period, and was admirably described by Dr. Starr, was evidently identi- cal with diphtheria, which has also again recently prevailed in the same neighbourhood. The disease first appeared in Cornwall about 1748 or 1749. Dr. Huxham, who also wrote an account of it, as seen at Ply- mouth, says it had prevailed in that neighbourhood from the latter part of the year 1751 to 1753 ; but adds that it had raged with great fatality in and about Lostwithiel, St. Austel, Fowe, and Liskeard a year or two earlier.§ Dr. Starr says the disorder did not always begin with the same train of symptoms; but, ' on the contrary, a vast difference was observable.' It often commenced with swellings of the tonsils, parotid, and submaxil- lary glands. What he terms gangrenous sloughs, but which clearly were false membranes, often formed in the mouth at an early stage of the illness; sometimes so early that the disorder was scarcely complained of until the slough appeared. Others, again, only complained of a slight pain in swallowing, succeeded by fever; a short, low, ' hacking,' hoarse cough, which sooner or later was productive of a difficult, noisy, and strangulated respiration.|| After an illness of a day or two, the voice usually became so hoarse that it was difficult to understand. The expectoration was never'a well-digested or concocted phlegm or mucus; on the contrary, the greatest part was of a jelly-like nature, glairy, and somewhat transparent, mixed with a white, opaque, thready matter, sometimes more, sometimes less resembling a rotten membranous body or slough.'^" The prevalence of simple sore-throat during the epidemic is mentioned by Dr. Starr, and also by Dr. Huxham, who likewise records the frequent occurrence of sore-throat as an attendant of other diseases, especially * Observations on a particular Kind of Scarlet Fever that lately prevailed in and about St Albans, in a Letter to Dr. Mead, by Nath. Cotton, M.D., p. 4. f Loc. cit, p. 4. % Loc. cit, p. 13. § A Dissertation on the Malignant Ulcerous Sore Throat, by John Huxham, M.D., &c, p. 3. London, 1759. || Phil. Trans., vol. xlvi., pp. 437, 438. ^[ Loc. cit, p. 440. 3 28 ON DIPHTHERIA. small-pox, during the epidemic* Thus the epidemic diphtheria of that day, like that of our own time, was apt, so to speak, to impress its character upon other diseases, and included simple sore-throats unaccom- panied by exudation, as well as those of a more malignant nature. Membranes, or, as Dr. Starr calls them, sloughs, analogous to those seen on the fauces, also formed on the raw surfaces of blisters and other parts of the skin denuded of cuticle. ' Such a slough I have seen generated on the neck and arm where blisters had been before applied. The blisters had been dressed with colewort leaves, and ran but little ; but, contiguous to them, small red pustules, not exceedingly fiery, arose, which, sweating plentifully, in a few hours became quite white. These, hourly enlarging their bases, united and covered a large surface, fresh pustules arising in the adjacent parts. This white surface had the aspect of an oversoaked membrane which was becoming absolutely rotten. . . . . I scratched the slough,' says Dr. Starr, of one of these cases,. ' with my nail; it separated with ease, and without being felt by the child. What my nail took off afforded the same appearance with the matter of the spittle before mentioned.'! The same disease, observed by Dr. Huxham, of Plymouth, began in various ways, bnt commonly ' with chills and heats, load and pain of the head, soreness of throat and hoarseness, some cough, sickness at stomach, frequent vomiting and purging, in children especially, which were some- times very severe, though a contrary state was more common to the adult. There was in all a very great dejection of spirits, very sudden weakness, great heaviness on the breast, and faintness, from the very beginning. The pulse in general was quick, small, and fluttering, though sometimes heavy and undose. The urine, commonly pale, thin, and crude, was however, in many grown persons, in small quantities, and high-coloured, or like turbid whey. The eyes were heavy, reddish, and as it were weeping; the countenance very often full,flushed, and bloated, tliough sometimes pale and sunk. 'How slight soever the disorder might appear in the day-time, at night the symptoms became greatly aggravated, and the feverish habit very much increased, nay, sometimes a delirium came on the very first night; and this exacerbation constantly returned in the evening through the whole course of the disease. Indeed, when it was considerably on the decline, I have been often pretty much surprised to find my patient had passed the whole night in a phrenzy, whom I had left tolerably cool and sedate in the day. ' Some few hours after the seizure, and sometimes cotemporary with it, a swelling and soreness of the throat were perceived, and the tonsils became very tumid and inflamed, and many times the parotid and * Huxham, loc. cit., pp. 11-14. f Phil. Trans., voL xlvi., p. 440. ENGLISH EPIDEMICS OP THE EIGHTEENTH CENTURY. 29 maxillary glands swelled very much, and very suddenly, even at the very beginning; sometimes so much as even to threaten strangulation. The fauces also very soon appeared of a high florid red, or rather of a bright crimson colour, very shining and glossy ; and most commonly on the uvula, tonsils, velum palatinum, and back part of the pharynx several whitish or ash-coloured spots appeared scattered up and down, which oftentimes increased very fast, and soon covered one or both the tonsils, uvula,