Malignant Diphtheria sometimes commences thus:-A child is noticed to be more still than usual, to have some pallor of the face, loss of appetite, and restlessness.

Close inquiry elicits no history of sore throat, but the tonsils have fragments of deposit upon them, and the submaxillary glands are slightly swollen; very soon the pulse becomes excessively rapid, the local conditions of the throat suddenly change for the worse, and the child sinks into a hopeless state of exhaustion.

Again the malignant form may supervene on symptoms which have been for several days of the ordinary simple kind; or, lastly, it may be well marked from the very first, and manifest very serious conditions without any premonitory illness.

The duration of inflammatory or feverish symptoms is very short. The local exudation is produced with great rapidity, less firm, less closely attached to the subjacent textures than in the simple form, and under the microscope presents corpuscular appearances. Local, and even severe, hæmorrhages may occur, staining the coriaceous material deposited on the mucous membrane of the fauces, and adding materially to the weakness and discomfort of the patient. Not unfrequently ulceration of the exposed mucous membrane may be noted, and the destructive process, so commencing, may run on into actual sloughing of the deeper tissues. Hence much of the fœtor which attends on the later stages, and also certain stages of the general system, which are probably due to absorption of the putrilage from the decomposing surface. When these are noticed, analagous somewhat in their characters to surgical pyæmia, there is practically no hope left for the sufferer.

Published opinions vary much on the value which should be attributed to the coincident appearance of engagement and infiltration of the glands below the jaw. I confess that I have been led to look on early and marked swelling of these structures as a symptom of impending malignancy of type; and in this view I have rarely been deceived. A certain amount of enlargement may in the most simple cases be met with, and is in them of little practical moment; but when the glands become considerably swollen, and with great rapidity, I think the prognosis should, from this fact alone, be a very guarded one.

The supervention of laryngeal implication on this sceptic form of diphtheria is, I believe, very rare; the breathing may be oppressed, and more or less cough and dyspnoea be present, but the fatal termination is due to asthenia, not to apnœa.

On the other hand, the invasion of the nasal mucous membrane should be looked on as a variety of the malignant type.

The first warning of the extension is the appearance of mucous discharge from the nostrils, which reddens and excoriates the nasal orifices and the upper lip; then swelling, and the characteristic exudation, followed very speedily by oozing of blood from the much injected mucous membrane. Remedial agencies have appeared of very little service, probably in part from the extreme difficulty of dealing with the affected surfaces. The great majority of such cases that I have seen have terminated fatally, two of them by profuse and frequently recurring loss of blood.

The foregoing pages take little cognizance of any thing other than the tangible characters of diphtheric affections, yet one symptom, on which much stress has at times been laid, demands a passing remark. I refer to the occurrence of albuminous urine. Some nine years ago, in a number of consecutive cases, I examined the urine day by day; in the majority there was evidence of the presence of albumen, but I was not able then or since to link its appearance with any special tendencies or peculiar virulence of the attack. In several of the worst cases it was not to be found, while in some less severe the urine contained albumen continuously and for some time. I have rather looked upon its existence as a comparative accident, often but of short duration, and not of material import; owing its being, too, far more to the vitiated condition of the blood than to any implication of the structure of the kidney.

The natural history of the class of diphtheric affections does not end with the outbreak and its subsidence, for certain well marked sequelæ are commonly met with. After an interval of apparent progress to convalescence, these consequences usually declare themselves and are to be referred to disordered innervation-varying from defective controlling power over some one or more sets of muscles, to a more or less completely defined paralysis. Nerves of motion and sensation appear almost equally susceptible of the benumbing influence of the poison of diphtheria, though the former have seemed sometimes most affected.

The whole spinal system may be implicated, and the extremities lose for a time much of their power, or the condition may be that of almost complete paraplegia, the arms remaining unaffected.

Special nerves suffer-notably those nearest to the original seat of the local manifestations-thus, very commonly, the voice becomes husky, swallowing is not accomplished without difficulty, and fluids are apt to return through the nose. The velum palati hangs loose and flaccid, has lost much of its sensibility, and fulfills none of its purposes as a muscular curtain. So, too, I have twice seen the portio dura affected,

and in one case the external rectus of the eyeball was paralyzed. Vision may be defective, the eyes easily wearied, and objects after a short time are blurred and indistinct a state of things due to defective innervation, relieved by the use of convex glasses, and ultimately disappearing as physical health is restored.

Another fairly well marked class of cases must be referred to loss of power about the "vagus," as evidenced by slowness and feebleness of heart beat, slow and infrequent respiration, and failure of digestive power.

Recovery is often tedious, yet has commonly happened. Those cases where the spinal cord is involved are of most grave future.

[Conclusion in next number.]

Boils and Carbuncles. BY TILBURY FOX, M. D., London, Physician to St. John's Hospital for Skin Diseases.

The points involved in Mr. Startin's letter are of so much pathological interest, that I hope I may be allowed space for a few comments. Mr. Startin's therapeutical experience is entitled to the profoundest respect; but the explanation which he has given of the cause of boils and carbuncles is scarcely that which modern pathological observations would seem to indicate. Unfortunately empiricism of the rankest and most tyrannical kind has held its sway for many a long day over cutaneous medicine; and no one (since Carswell's day) specially conversant with the facts of general pathology has thought it worth while to study the subject; yet, unquestionably, the philosophical study of skin diseases is pregnant with results of great general significance, and the case of carbuncle is fully illustrative of this fact.

Mr. Startin views boils and carbuncles as having "frequently or constantly a parasitic origin ;" and he bases his belief upon the facts (1): that they are sometimes contagious; and (2), the success and efficiency of the practice in the cure of these ailments, rather than on microscopic verification in other words, on the occurrence of occasional contagion, and the beneficial action of acid nitrate of mercury. One word will suffice in reference to the second argument. Acid nitrate of mercury, in virtue of its caustic properties, removes a host of ills, lupus, acne, warts. cancerous masses, and other diseased structures the most dissimilar. Are they then parasitic? Mr. Startin's chief ground for his belief in the parasitic nature of boils and carbuncles is the occurrence of contagion. This, however, is only occasional; and considering the absence of all relative proportion between the amount and kind of the local

diseased action and that observed in parasitic maladies; the absence of parasitic growths in the vast majority of cases; the fact that fungi will but very scantily develope in purulent fluids; the absence of any aperture by which the fungus germs could enter from without into the cellular tissue; the non-access of air, and the want of relation between the amount of tissue change and that of the fungus when present-the unlikeliness of its parasitic nature is evident. And, if we seek among the parasitic diseases of animals, of human beings, or of plants, we shall not findany analogical grounds (nay, just the contrary) upon which to rest such a belief. Again, the constitutional conditions anteceding, accompanying and following the local changes, in relative proportion to the extent and character of the latter, are not seen in any parasitic disease. The occasional presence of vegetable parasites is common to all diseases. Parasites are essentially ubiquitous, and they may be found in almost all skin diseases; it is only when they luxuriate, that they give rise to special mischief. It is, unfortunately, fashionable to ascribe too many diseases to the influence of parasites.

How, then, explain the contagion of boils? for they seem to be occasionally contagious. What mean we by contagion? The labors of all pathologists seem to show that it is essentially connected with the growth of living particles of matter, detached from living bodies and carried to others, of course, under favoring circumstances. Occurrences of the kind are universal in the vegetable kingdom, and there seems no reason why animal cells should not be transplanted and grow as well when isolated as in masses; and they do so. The cells in the secretion from a leprous sore, from Egyptian ophthalmia or the mucous surface of a rinderpest cow, cancer cells, the pus cells of syphilis and of small-pox, and, from recent observation it seems likely, tuberculous cell matter, all possess this faculty; and, to take another example, in the case of molluscum, the cells found in the little "varioliform" tumors are the means by which, being transplanted from person to person, the occasional contagion of molluscum is to be explained. One feature that is necessary in all these cases is the presence of free proliferation on the part of the cell growth, and an adapted state of nutritive fluid (blood). In the active and early stage of boils, the cells of the enlargement may, no doubt, be removed from one body to another, and, growing under favorable circumstances, reproduce the original disease? Why not? What law would this contradict? Dr. Laycock's cases of contagious furunculoid are explicable upon the same ground.

Contagion is scarcely a distinctive feature of any one disease: the VOL. II.-No. 1.-3.

degree of contagion no doubt is. If it were possible to transplant an alphos scale, and it were to grow and produce alphos on a second subject, there would be no great mystery in it; it would harmonize (though an unusal occurrence) with true pathological facts, and be contagion in one sense of the word. There is nothing improbable, but probable, to say the least, in the supposition that the cell-growth in a boil may be the means by which the disease is rendered "contagious." In carbuncle, there is a good deal of superadded inflammation, and a tendency to gangrenous change, which, implying a tendency to the death of the cell tissues, is accompanied by a very much less likelihood of contagion.

But what is the pathology of boils and carbuncles? We may assume that in kind it is the same; the difference between the two diseases is dependent upon (1) variations in the vigor of the constitution, (2) the state of the nutritive fluid (the blood), and (3) the activity of the local tissues. In the central part of boils and carbuncles are one or more pieces of dead tissue, sloughs, or cores. How is the tissue killed?-by arrest of the circulation, or failure of nutrition? What has been noted about the blood? Three very important sets of facts: 1, bacteridia oftentimes in great amount; 2, excess of urea in the urine, and uric acid in the blood; 3, diabetes. Bacteridia, however, seems to be developed only secondarily, and to be unable per se to produce furuncle. The excess of urea and uric acid can scarcely be said to be the cause of carbuncle and boils; and we come to the third condition, noticed by Cheselden, Prout, Latham, Landouzy, Marchal de Calvi, and othersviz., a tendency to, or actual diabetes. Dr. Wagner has given details. of fifty-two cases of gangrenous inflammation, including carbuncles and furuncles, in which a diabetic condition existed; and M. de Calvi has confirmed Wagner's observations. My own observations on this point are small; but I am convinced that, if we would clearly understand the true pathology of carbuncle, we must carefully investigate the matter in connection with the production of sugar in the system. The existence of a diabetic habit explains satisfactorily the fatality of carbuncular disease, and the serious constitutional disturbance. Nothing is more common than for carbuncles to arise in the course of diabetes; and it will be remembered that Cardinal Wiseman suffered for no less than four years before his death with carbuncles. More recently, Dr. Fonseca, of Pernambuco, has investigated the subject; and he tells us that in Pernambuco, anthrax is very common, and that one of its forms is regarded as diagnostic of diabetes. Küchenmeister, Menestrel, and Jordão, of Lisbon, have also given similar evidence.