izr - 
 
 LIBRARY OF CONGRESS: 
 
 (SMITHSONIAN DEPOSIT.) 
 
 Chap. "KC \^* 
 
 UNITED STATES OF AMERICA, 
 
ORIGINAL INVESTIGATIONS 
 
 IN 
 
 DIPHTHERIA AND SCARLET 
 
 FEVER, 
 
 SHOWING THEIR KINSHIP AND CAUSE TO BE THE 
 
 MUCOR -MALIGNANS, 
 
 (A Fungus in the Exudations, Blood, Urine and Sputa,) 
 
 CURED BY QUININE TOPICALLY ADMINISTERED IN POWDER ON THE TONGUE, 
 
 AND B Y INHALA TION 
 
 BY 
 
 JAMES H. SALISBURY, B. N. S., A.M., M. D., 
 
 MkMBER PHILOSOPHICAL SOCIETY OF GREAT BRITAIN, OF AMERICAN ANTIQUARIAN SOCIETY, AMERICAN ASSOCIATION FOR THE 
 
 ADVANC MFNT OF SCIENCE, VICE-PRESIDENT WESTERN RESERVE HISTORICAL SOCIETY, AUTHOR PRIZE ESSAY ON 
 
 MALARIA, 1882, AND OF PUBLISHED AND UNPUBLISHED WORKS AND PAPERS. 
 
 / V ' 
 
 >F PUBLISHED AND UNP 
 
 NOV 7 1882 ) 
 
 All rights reserved. Reprint Gai/lard's Medical Journal, May, 1882. 
 
 NEW YORK : 
 
 E. S. GAILLARD, 
 
 1882. 
 
 

 
 
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DlPHTHEEIA AND SCARLET FEYER. 
 
 {Reprinted from " Gaillard's Medical Journal") 
 
 DlPHTHEEIA AND SCAELET FEVEE, BY 
 
 James H/ Salisbury, B. N. S., A. 
 M., M. D., New York : 1882. {All 
 rights reserved.) 
 
 Microscopical investigations con- 
 nected with the exudation and expec- 
 toration of angina membranacea, an- 
 gina maligna or gangrenosa, and scarla- 
 tina anginosa; resulting in the discov- 
 ery of the source of and the patholo- 
 gical process by which the exudations 
 are produced, and the further discov- 
 ery of a peculiar species of Mucor 
 developing in the diphtheritic mem- 
 branes of angina maligna and which 
 appears to be the true cause of the 
 disease ; with some remarks on 
 
 treatment. 
 
 Also some general conclusions on 
 the setiology of fevers; the peculiar 
 functions of the epithelial systemic 
 cell envelope; and the probable way 
 
 in which the system receives a more plow their soilj for put ting in the winter 
 or less permanent protective immu- wheat. The grasses of pastures and mead, 
 nity, by one attack of certain conta- ws were parched, dry, and mostly dead; 
 gious diseases against a second inva- and the herbaceous plants of the fields and 
 
 that there is a tendency also for the lining 
 membranes of the genital organs, intestines 
 and bladder, and in short the epithelial cells 
 of the entire mucous surface to take on the 
 diphtheritic action. This renders it evi- 
 dent that this disease, like scarlatina angi- 
 nosa, (which it will be shown to resemble) 
 is systemic,with a marked tendency to local- 
 ization in the respiratory tract. 
 
 Angina maligna, in its worst form, ac- 
 companied by angina membranacea,became 
 epidemic during the months of October, 
 November and December of the year 1862, 
 and January and February, 1863, over a 
 tract of country, about five miles long from 
 north-west to south-east, and three miles 
 wide, situated from two and a half to five 
 miles south-west and west of the city of 
 Lancaster, Ohio. 
 
 It first appeared immediately after a snow 
 storm (the first of the season in October). 
 The snow fell about two inches deep, upon 
 a remarkably dry, parched soil, and was the 
 beginning of the fall wet weather, after a 
 long period of drought, which was so severe 
 that it was impossible for the farmers to 
 
 sion of the same. 
 
 M.Bretonneau gave to angina membranacea 
 the name of diphtheritis, on account of the 
 pellicle-like exudations. The ordinary sites 
 of these exudations, as is well known, are 
 the fauces and pharynx; often however they 
 extend past the pharyngeal and laryngeal 
 regions far down the oesophagus, and into 
 the trachea and bronchial tubes, and even 
 upward into the nasal fossae. 
 
 Microscopic examinations show, further, 
 
 forests were in the same condition. The 
 disease first made its appearance at the 
 south-east end of the section before describ- 
 ed, among the dry sandy hills, and gradu- 
 ally progressed to the north-west. ' It ex- 
 hibited, often in the same family, all grades 
 of severity from a mild type of angina mem- 
 branacea to the most severe form of angina 
 maligna-, where the extremities would be- 
 come gangrenous, in some cases, several 
 days before death. The malignant form 
 
 401 
 
402 
 
 DIPHTHERIA AND SCARLET REFER. 
 
 was unusually fatal and rapid in its pro- 
 gress; often from two to five persons dying 
 in a single family, within a few days of each 
 other. The young became the victims; 
 while those above twenty-five usually es- 
 caped. 
 
 The section over which this malignant 
 disease prevailed, composed of hills and 
 high table lands, is abundantly supplied 
 with fine springs of cold, free stone water, 
 and is regarded as a particularly' healthy 
 region. It is inhabited mostly by sober, 
 industrious German farmers. 
 
 An excellent opportunity was here of- 
 fered for studying the disease. Through 
 the kindness of Doctors Effinger, Boerstler 
 and Lewis I was able to obtain the best of 
 material for examination. 
 
 From its progress in this region, from 
 family to family, and from other circum- 
 stances,hereafter mentioned,there appeared 
 to be no doubt of its contagious character. 
 The period of incubation ranged,in different 
 cases, from three to six and eight days; un- 
 less, accidentally, the air passages became 
 directly inoculated with the virus or vege- 
 tation, in which case, the disease would 
 begin to show itself immediately. 
 
 The cases could be nearly all traced to 
 exposure to the contagion of the disease. 
 When it once made its appearance in a 
 family, any of the younger members seldom 
 escaped. 
 
 Before entering upon a description of the 
 following cases, and the microscopic exam- 
 inations of the exudations, etc., I will 
 briefly narrate the characters of angina 
 membranacea and angina maligna, set 
 forth by Dr. Tweedie; as his remarks upon 
 these diseases, in several important partic- 
 ulars, point in the direction of the results 
 of these investigations. 
 
 In speaking of angina membranacea, he 
 says: "The patches are of various extent; 
 in mild cases, white and ashy, separate, and 
 presenting the appearance of superficial 
 sloughs, for which they have often been 
 mistaken; in others, dark colored, coales- 
 cent, and forming one uniform crust. 
 TJle exudations may extend far down tho 
 
 oesophagus, or into the larynx, trachea and 
 bronchise, and upward into the nasal fossae. 
 The membrane beneath and between the 
 pellicles is in some cases of a bright red 
 and in others purplish or livid. The exu- 
 dations vary in density, from that of coag- 
 ulable lymph, to that of soft pultaceous 
 matter." 
 
 " The local sensations are similar to those 
 of angina diffusa, with the addition of that 
 produced by irritation and obstruction of 
 the air passages, when the disease has ex- 
 tended in that direction. It is common 
 also for the sub-maxillary and cervical 
 glands to become inflamed and tumefied. 
 
 " The general symptoms are those of fever, 
 and vary with the type of the latter and 
 the degree of the inflammation. Where the 
 patches are but few and circumscribed, the 
 disease is often called ulcerated sore 
 throat, such as may be seen in scarla- 
 tina anginosa, but there are no ulcers in 
 these cases, for on removing the pellicles or 
 sloughs, as they are called, we find the 
 membrane beneath quite free from any 
 other disorganization than the loss of its epi- 
 thelium. In the worst cases, the pellicles are 
 discolored by the admixture of bloody exu- 
 dation and vitiated secretions of the throat, 
 so as to create an impression that the parts 
 are in a state of sphacelus. 
 
 "These casts correspond to the angina 
 maligfia of others; but we have the united 
 testimony of Bretonneau, Guersent, and 
 Deslandes, formed on extensive micro- 
 scopic observations, that there are no true 
 eschars in these cases. The idea of gan- 
 grene existing has been further kept up by 
 the discharge of serous and fetid matter 
 from the nostrils, and by the putrid char- 
 acter of the fever. Instances of this des- 
 cription are very rarely met with, excepting 
 when the disease prevails as an epidemic. 
 
 "From the above, it appears that angina 
 membranacea occurs in two forms. J In 
 one the local affection bears the marks of 
 active inflammation, in the bright hue of 
 the mucous membrane, and in the white, 
 circumscribed exudations, unmixed with 
 blood or sanies. 
 
DIPHTHERIA AND SCARLET FEVER. 
 
 403 
 
 " The constitutional symptoms in this form 
 arc likewise sthenic, the pulse being full and 
 firm, the skin warm, and the nervous sys- 
 tem — though disturbed — not exhibiting the 
 prostration so common in typhoid forms. 
 The other variety may well be called an- 
 gin maligna. 
 
 "Its approach is often insidious,being at- 
 tended with little pain or disturbance in the 
 throat till the false membrane is already 
 extensively formed, then the dysphagia be- 
 comes extreme ; liquids are forced back 
 through the nostrils, and symptoms soon 
 occur denoting that the air passages are ob- 
 structed ; such as a croupy cough, hoarse- 
 ness, and stridulous breathing. 
 
 " The feeling of suffocation accompanying 
 these symptoms, is in part owing to the 
 swelling of the lymphatic glands. On in- 
 spection of the throat, we see a thick pel- 
 licle, sometimes dense, not unfrequently 
 pultaceous, variously colored, according to 
 the degree of its decomposition, or to the 
 accompanying secretions, and either con- 
 tinuous or interrupted by fissures which 
 exhibit the livid hue of the membrane 
 beneath. The pulse is extremely rapid 
 and feeble, delirium sets in early, and is 
 soon followed by coma ; and the collapsed 
 face and sunken eyes indicate extreme ex- 
 haustion. Death often takes place sudden- 
 ly from the laryngeal complication. 
 
 " Bretonneau was led by the results of his 
 dissections, to attribute the death, in all the 
 fatal cases, to the changes in the air pass- 
 ages. 
 
 "As might be expected, a priori, the vic- 
 tims of malignant angina, are persons living 
 in humid districts, where the disease is oc- 
 casionally epidemic ; among the inhabitants 
 of crowded buildings, and the poor ill-fed 
 classes of the community. 
 
 " Persons, however, not under these de- 
 pressing agencies, may be attacked by a 
 severe form of the disease. Children are 
 ?nore liable to it than adults. Whether it is 
 propagated by contagion is not absolutely 
 determined, but there are strong presump- 
 tions in favor of this view. When the af- 
 fection is epidemic, the difficulty of dis- 
 
 tinguishing the operation of some generally 
 diffused cause from that of contagion, 
 meets us in this disease with the same force 
 as in other epidemic maladies. The most 
 unexceptionable instances of contagion are 
 those in which the sporadic form has been 
 transmitted from one person to another. 
 Guersent relates the case of a nun who 
 caught the disease from a little girl whom 
 she had nursed in the Hopital des Enfans, 
 and he remarks that practitioners are fre- 
 quently attacked after inspecting the throats 
 of their patients. That the inflammation 
 of the mucous membrane takes place in 
 angina membranacea cannot be denied, 
 but why it should cause the secretion of 
 coagulable lymph, rather than of serum and 
 mucus, which are the ordinary products of 
 mucous inflammation, cannot easily be ex- 
 plained. It is probable, however, that the 
 peculiarity does not depend upon the local 
 action merely, but upon the state of the 
 constitution previously modified by epidemic 
 influence. 
 
 "In this disease there is frequently ob- 
 served an erythematous or papular eruption 
 on different parts of the body, and there 
 can be little difficulty in arriving at the 
 conclusion that it is a variety of scarlatina 
 maligna" 
 
 Dr. Tweedie further says: "We are in- 
 clined to affirm that scarlatina simplex, 
 scarlatina anginosa and the scarlati?ia or 
 angina maligna, and the sore throat, with- 
 out efflorescence on the skin, are merely 
 varieties of one and the same disease." 
 
 REPORT OF CASES. 
 
 The following communication contains a 
 report of several well-marked cases of an- 
 gina maligna which were attended and re- 
 ported by Dr Effinger: 
 
 Dear Doctor: At your request, I have 
 kept a careful record of the following well- 
 marked cases of angi?ia maligna, from 
 which I have sent you, from time to time, 
 as the disease progressed, samples of blood, 
 urine, exudations and sloughs. 
 
 Case I. — Amos Bear, a strong, healthy 
 young man, aged seventeen, was taken 
 down December 4th, 1862. 
 
404 
 
 DIPHTHERIA AND SCARLET EEVER. 
 
 Thursday morning, December 4th, he 
 felt so badly that he remained in bed and 
 ate no breakfast or dinner. Towards even- 
 ing he vomited, felt pain in throat, neck 
 swelling rapidly, externally. Sent for me 
 about dark; could not see him that evening; 
 prescribed a cathartic and foot bath, and 
 flannel cloths wrung out of hot vinegar and 
 sprinkled with salt, to be applied about the 
 neck. 
 
 Friday, 10 A. M., Dec. 5 th, made my 
 first visit; found him in bed, face anxious 
 and look depressed; pulse 92; not much 
 fever or heat of skin; back and side of neck 
 much swollen; more cedematous than gland- 
 ular. 
 
 On examination of throat, discovered a 
 large diphtheritic patch, one inch in diam- 
 eter and oval in shape, on left tonsil. It 
 had a dark, ashy appearance, was of soft 
 consistence and easily penetrated, with 
 well-defined edges; breath offensive, with a 
 sickly meatish smell. The right side of the 
 throat was deeply infected, engorged to a 
 purplish hue, with a slight bloody exuda- 
 tion from a small surface posterior to the 
 tonsil. Continued external applications, 
 and left chlorate of potash to be taken in- 
 ternally every four hours and used as a 
 gargle. 
 
 Saturday, 12 M., Dec. 6th. — Pulse 92. 
 General symptoms same as yesterday; no 
 change in slough on left side; some lumps 
 of putrid matter, separated with difficulty by 
 a spoon-handle; fetor of breath more de- 
 cidedly putrid than before. On the right 
 tonsil, a well-defined diphtheritic exudation 
 had made its appearance, three-fourths of 
 an inch in diameter, closely adherent, but 
 the edges could be slightly raised. The 
 purplish engorgement not quite so distinct 
 as yesterday. Continued treatment, with 
 addition of mur. tinct. iron, and a more 
 liberal diet. 
 
 Sunday, 1 P. M., Dec. 7th. — Patient not 
 so well; had a bad night; forehead hot, 
 pulse 92; more lassitude than before. Fetor 
 of breath intolerable, decidedly putrid. 
 Slough on left side about the same; dark 
 fetid shreds removed, showing considerable 
 
 depth of slough. On the right side, the 
 diphtheritic patch was much increased in 
 size, oblong in shape, extending below the 
 tonsil as far as could be seen. It is much 
 thicker than yesterday, of a whitish yellow 
 color and more adherent. The mucous 
 membrane on its edge still of a dark, livid 
 color; obtained a sample of his morning 
 urine, and the hawking expectoration pro- 
 duced by my examination, which I sent you. 
 Applied wash of nitric acid, diluted two- 
 thirds, freely, to both sides; general treat- 
 ment continued, with iron omitted. 
 
 Monday, 4 P. M., Dec. 8th. — Had a very 
 comfortable night; feels better; pulse &6; 
 no heat of skin; fetor of breath not so of- 
 fensive; slough on left side evidently ar- 
 rested; dead lumps easily detached. On 
 the right side, the tripe-looking membrane 
 has extended over the dark, livid border of 
 yesterday. 
 
 It now has an oval shape, and is larger 
 than the slough opposite; its lower edge 
 well defined a short space below tonsil. 
 Edges closely adherent; cannot yet be de- 
 tached by gentle force. Took from arm 
 \ x /z ounces of blood for examination, which 
 I sent you, with some sloughs from fauces 
 and a sample of his morning urine. Applied 
 freely the nitric acid, and commenced the 
 iron again. 
 
 Tuesday noon, Dec. 9th. — Amos not so 
 well to-day; pulse 100; forehead too warm; 
 neck still much swollen in front, as well as 
 on sides; pulse rapid, feeble, and not of 
 much force; poison evidently telling on the 
 general system; throat same as yesterday, 
 except on the right side, where, under the 
 diphtheritic exudation, there is apparently 
 a large slough; tried to separate it, but the 
 least touch made the exposed surface bleed, 
 and I discontinued my efforts. After a 
 slight laxative, bowels being constipated, 
 ordered quinine and iron, with nourishing 
 food. I used no topical applications, except 
 chlorinated soda and potash. 
 
 Wednesday, 12 M., Dec. 10. — Amos lias 
 less fever; pulse 92 and feeble; face hag- 
 gard, and I do not like the expression of 
 his eyes; continued the quinine and mur. 
 
DIPHTHERIA AND SCARIET FEVER. 
 
 405 
 
 tinct. iron, with liberal diet. The slough 
 on left side is clearing somewhat, but still 
 looks badly. The left side is perfectly foul 
 and ragged. I detached a portion that 
 was loose, which I sent you in the bottle, I 
 believe, on Saturday. I detached a few 
 shreds from this side, and sent them to you 
 between glass slides. You can readily dis- 
 tinguish them by their dirty-white appear- 
 ance and tripe - like consistence, being 
 tougher than the porous soft lumps from 
 the left side. In the bottle you will also 
 find some soft matter that I scooped with a 
 spoon-handle from immediately under the 
 exudated membrane. 
 
 Thursday, 3 P. M., Dec. nth. — Amos 
 has had a bad night. The diphtheritic ex- 
 udation has appeared on uvula and palatine 
 arch, on the right side. They are much 
 swollen, and render deglutition very diffi- 
 cult. He drinks with great difficulty even 
 water; most of it comes back through his 
 nose. 
 
 It is evidently spreading upward, and is 
 in the nasal fossae. No difficulty yet in 
 breathing. I obtained his morning urine 
 and some expectoration, and matter from 
 throat, which I sent you. I also sent you 
 a large bottle of water from the Bear Spring. 
 Pulse 96 and feeble. 
 
 Friday noon, Dec. 12th. — Amos is worse, 
 prostration more apparent ; difficulty of 
 swallowing increased ; the respiration more 
 labored, and I fear the diphtheritic exuda- 
 tion has reached the bronchi ; pulse 100, 
 and feeble. The diphtheritic membrane is 
 covering the velum palati and the arches 
 to-day, for the first time. 
 
 I penciled the edge with nitrate of silver, 
 hoping to arrest the spreading. Neck, back 
 of ears, and half way down very much 
 swollen, and just above the sternum very 
 cedematous. 
 
 Saturday 10 A. M., Dec. 13th. — The 
 diphtheritic exudation has traveled beyond 
 the penciled caustic mark. 
 
 The specimen I send you to-day speaks 
 for itself. You see the dark line ; all be- 
 yond has spread since yesterday noon. 
 This specimen was taken from the uvula. 
 
 Amos is sinking ; respiration still more 
 labored, and deglutition impossible. You 
 can hear his laborious breathing all through 
 the house. Under the separated exudation 
 from the uvula, there is no slough, simply 
 a raw bleeding surface. The swelling of 
 the neck noticed yesterday has to-day al- 
 most entirely disappeared 
 
 Sunday 10 A. M., Dec. 14th. — Amos is 
 still living, respiration becoming more and 
 more difficult. Asphyxia is creeping on 
 slowly but surely. Obtained a sample of 
 morning urine which I sent you. 
 
 Monday, Dec. 15th. — Amos died at 1 P.M. 
 Death painful. Died of suffocation. Exu- 
 dation extends into bronchi, and probably 
 into pulmonary air cells. 
 
 Case II. — Nancy Bear, sister of Amos, 
 aged 21. For some months prior to her 
 brother's illness, Nancy was absent from 
 home, visiting relatives, some twenty 
 miles distant. On Saturday, Dec. 13th, 
 the family sent for her, and she came 
 home on horseback, the evening of the 
 same day. Though much fatigued, she 
 hung over her gasping brother that 
 whole night. She was constantly about 
 him till he died, giving way very 
 much to her feelings. She became com- 
 pletely prostrated on Monday ; fainted at 
 the church on Tuesday morning at the fu- 
 neral, and had to be carried home. I was 
 sent for Tuesday afternoon. 
 
 Nancy is a heavy, thick-set girl of leuco- 
 lymphatic temperament ; general health 
 good. I saw her about dusk. Found her 
 nervous and prostrated, but with no tangible 
 disease, except a severe coryza affecting 
 nasal cavities and frontal sinus. I advised 
 salt water pediluvium, and a cathartic at 
 bed time. 
 
 Wednesday, Dec. 17th. — Was called 
 again to see her. Complained of soreness 
 about the neck and throat. Both nostrils 
 were completely stuffed up with ropy mu- 
 cus, and the throat so filled as to interfere 
 with the examination of parts, but being re- 
 moved, no sign was seen of diphtheritic 
 exudation ; but the next day, Dec. 18, after 
 a careful swabbing out of the throat, I de- 
 
406 
 
 DIPHTHERIA AND SCARLET EEVER. 
 
 tected a slight pearly exudation on the left 
 tonsil. 
 
 Friday, Dec. 19th. — The symptoms about 
 the same as yesterday. 
 
 Saturday, Dec. 20th. — Was much im- 
 proved, the nasal catarrh being the promi- 
 nent symptom, and the white adherent ex- 
 udation not increasing. Nancy was sitting 
 up, was cheerful, and said she was much 
 better. 
 
 Her beau called to see her as usual, Sat- 
 urday night, and she imprudently remained 
 up with him most of the night. 
 
 Sunday, Dec. 21st. — Was sent for. Found 
 her much worse, the tonsils and velum were 
 swollen and red, swallowing difficult, the 
 voice hoarse and the breathing labored and 
 painful. Auscultation of left lung gave the 
 sibillant rhonchus. Clearly was it evident 
 that the catarrh of the nasal passages had 
 crept down into the trachea and lungs, and 
 that the whole mucous membrane of the air 
 passages was now involved. Still there 
 was no increase of exudation in the throat 
 beyond the slight patch on the left tonsil. 
 
 Monday, Dec. 22nd. — Had a restless night. 
 On raising the velum, evidence of diphthe- 
 ritic patches were seen on the fauces, high 
 up. The nostrils were filled with mem- 
 brane, but not easily detached. 
 
 Tuesday, Dec. 23rd. — With my polypus 
 forceps, I detached specimens, from both 
 nostrils, one-eighth of an inch thick, which 
 I sent you. In the throat it was only too 
 apparent, both in fauces and on tonsils ; in 
 appearance, white, glossy, thin and closely 
 adherent, but in patches. It never became 
 continuous though she lived for a week 
 longer. 
 
 Wednesday. — Disease gradually progress- 
 ing. 
 
 Thursday, Dec. 25th. — Obtained some 
 blood from Nancy's arm ; the blood flowed 
 directly into the smaller bottle. The blood, 
 in larger bottle flowed into a saucer, and 
 after standing for a short time, was poured 
 into the bottle. Obtained also some mem- 
 brane from throat and nose,with some freshly 
 expectorated mucus, which was sent to you. 
 
 Friday, Dec. 26th. — Nancy is about the 
 same as yesterday. 
 
 Saturday, Dec. 27th. — Nancy appears 
 to be improving and there is some hope 
 that she may recover. 
 
 Sunday, Dec. 28th. — Worse than yester- 
 day ; very weak ; breathing labored, and 
 pulse rapid and feeble. The exudations 
 have extended into the tracheal and bron- 
 chial passages. From this time, the breath- 
 ing grew more and more labored, until she 
 died asphyxiated, like her brother Amos, 
 on the night of January 1st, 1863. 
 
 Case III. — Jesse Bear, brother of 
 Nancy, a fine healthy boy, aged 8 years 
 was taken down Dec. 22nd, '62. 
 
 Dec. 25th. — Jesse very sick, has a large 
 diphtheritic exudation on each tonsil. 
 
 Dec. 27th. — Large and extensive exuda- 
 tions, but very little constitutional disturb- 
 ance. Obtained his morning urine and 
 some of his expectoration, which I sent 
 you. Jesse continued to fail and the exu- 
 dation to pass lower and lower into the 
 trachea and bronchi, till, on January 6th, he 
 expired as did his brother Amos. 
 
 Case IV. — Peter Bear, brother of Jesse, 
 a strong healthy boy of 12 years, was 
 taken down with the disease, Dec. 25. 
 
 Dec. 27. — Fever very high; exudation on 
 right tonsil; vomited while I was penciling 
 his throat; a sample of vomited matter I 
 sent you; Peter's case was one of sim- 
 ple angina membranacea and did not ter- 
 minate fatally. There were three other 
 cases in this family. Mrs. Bear, who had a 
 slight attack; Susan, a young daughter, and 
 a little grand-daughter, all of whom recov- 
 ered. The only persons escaping were Mr. 
 Bear, and his eldest son aged about 23. 
 
 Yours, truly, 
 
 M. Effinger. 
 Dr. J. H. Salisbury. 
 
 From Dr. Efnnger's report it will be seen 
 that out of seven cases in the Bear family, 
 three died and four recovered. In almost 
 every instance, when malignant diphtheria 
 {angina maligna) appeared in a family, it 
 was equally, if not more fatal. In support 
 
DIPHTHERIA AND SCARLET REFER. 
 
 407 
 
 of this fact, we will mention briefly the fol- 
 lowing instances: 
 
 Mr. Bailor had six children, and one 
 grandchild, all of whom had diphtheria. Four 
 died, and three recovered. Of the four 
 that died, three were female, and one male; 
 they were respectively three weeks, seven, 
 eleven and twenty years of • age. Of 
 those that recovered, one was the married 
 daughter who had but a mild attack of an- 
 gina membranacea.The ages of the two others 
 were respectively thirteen and fifteen years. 
 Of the daughter aged eleven, who died, one 
 leg became gangrenous to the knee several 
 days before death. One foot of the boy 
 aged 7 was very much swollen and also final- 
 ly became gangrenous before death. 
 
 Dr. Lewis attended this family. In the 
 Sandris family the mother and all the chil- 
 dren, six in number, had the disease. 
 The mother and four of the children died, 
 so that out of seven cases in this family, 
 only two recovered. 
 
 In Mr. Karn's family out of tour chil- 
 dren that -had the disease three died. Their 
 ages were respectively five, eleven and four- 
 teen. A grown daughter, aged about twen- 
 ty-one, and a nursing infant escaped with- 
 out taking the disease. Dr. Lewis attended 
 this family. In two of these cases, the feet 
 and legs up to the knees became pulseless 
 and cold twenty-four hours before death, 
 and there was a disposition to gangrene. 
 
 In the Brooks family, all of his children, 
 three in number, had the disease, two re- 
 covered and one died. In Warren Stripes' 
 family, two grown daughters, the only chil- 
 dren at home, had the disease. One recov- 
 ered and one died. The first one taken 
 down, four or five days previous to the at- 
 tack, visited Mr. Bailor's family, and help- 
 ed to "lay out" one of his children that 
 had died of the disease. In Mr. Himes's 
 family the mother and one child only had the 
 disease. The former recovered and the 
 latter died. 
 
 In Mr. McCabe's family, all the children, 
 six in number, had the disease, and all re- 
 covered. 
 From the foregoing statements! it will be 
 
 seen that out of thirty-eight cases, there 
 were eighteen deaths, and twenty recoveries 
 Many of those that recovered, had merely 
 the membranous type of the disease. This 
 however will represent about a fair average 
 proportion of the recoveries and deaths in 
 those attacked with the disease, in the dis- 
 trict previously mentioned, where malignant 
 diphtheria prevailed. But few families in 
 the district were exempt from the invasion, 
 Since writing the foregoing, I have re- 
 ceived the following letter from Dr. Lewis, 
 in which are reported two interesting cases 
 of angina maligna or gangrenosa. 
 
 Lancaster, O., April 3d, 1863. 
 
 Dr. Salisbury — Dear Sir: Your let- 
 ter asking for a report of cases of diphtheria 
 has been received. In referring to my notes 
 of cases, I find that the epidemic which 
 ravaged the south-west part of our coun- 
 ty, made its advent on the 19th day of 
 October, 1862. Two children were attack- 
 ed simultaneously in the same family, one 
 aged nine and the other eleven years, one 
 male and the other female. These cases had 
 progressed for four days, before I was 
 called to see them. I cannot, from person- 
 al observation, state the mode of the attac'.;, 
 but at my first visit I found the eldest (a 
 girl), with a quick, feeble pulse, cold ex- 
 tremities; shrunken, pale and agonized 
 countenance; unable to articulate; the par- 
 otid and submaxillary glands enlarged; the 
 tonsils enlarged; the uvula elongated and of 
 an ashy appearance; the tonsils on the right 
 side covered with a dark fetid slough, sur- 
 rounding which was an areola of an ashy ap- 
 pearance, beyond which the parts presented 
 a dark cherry color, gradually disappearing. 
 The case terminated fatally in about six 
 hours after I saw her. 
 
 The boy was in about the same condi- 
 tion, but had a less aggravated form of the 
 disease. He recovered. These two cases ap- 
 peared to be the nucleus from which the dis- 
 ease spread; mostly in a north-west direction, 
 choosing the slopes of the hills and high table 
 lands, rather than the summits and valleys. 
 
 This disease in its progress presented 
 
408 
 
 DIPHTHERIA AND SCARLET EEVER. 
 
 two distinct forms; the first, and most usual, 
 was what I have termed the malignant or 
 typhoid. This form was ushered in by a 
 low, quick pulse, a dry harsh condition of 
 the skin, a feeling of fulness and uneasi- 
 ness in the head (not amounting to head- 
 ache) dry tongue, great thirst, the parotids 
 and glands of the neck on about the second 
 day becoming sore to the touch, the mus- 
 cles of the neck at the same time becoming 
 stiff, the tonsils, pharynx and uvula assum- 
 ing a dark cherry or purple hue. In from 
 six to twelve hours, a small yellowish-gray 
 spot would make its appearance upon one 
 cr both tonsils, about the size of a grain of 
 wheat. This spot had the appearance of an 
 erysipelatous blister, which would spread 
 rapidly and burrow deeply, assuming a dark- 
 brown or black hue, and forming in a few 
 hours a fetid slough, which would, in the 
 course of from thirty-six to forty-eight 
 hours, begin to break down. > 
 
 The condition of the skin remaining the 
 same, the pulse becoming weaker,the strength 
 failing rapidly, the pupil of the eye enlarged 
 and vision partially lost, so that small objects 
 could not be seen, and the disease often 
 terminating fatally in from four to seven 
 days. 
 
 The other form I have taken the liberty 
 of calling the inflammatory, to distinguish 
 it from the typhoid form; its mode of attack 
 being entirely different. Coming on with 
 full, hard, bounding pulse, congested state 
 of the capillaries, high fever, headache, 
 nausea, sometimes vomiting, the tongue 
 coated with dark-brown fur, the throat 
 assuming a clean bright scarlet hue, the 
 exudation making its appearance about the 
 second day, and having the appearance of 
 milk curd of a clear white cheesy character, 
 easily broken down. This form was readily 
 amenable to the ordinary treatment. No 
 death occurred from such attacks, in my 
 practice, which during the winter was ex 
 tensive, fur I treated over one hundred 
 cases from October, 1862, to February, 1863. 
 A more detailed account of the following 
 cases may be of interest : 
 
 Case i. — Aged 11. Attacked Nov. 6th, 
 
 and, from all I could learn, it appeared to 
 be at first a mild form of the malignant type 
 of the disease. I did not see the case till 
 some four weeks after the attack. This 
 with the succeeding case (2), was of much 
 interest. The child was laboring under a 
 low grade of fever, dry, husky skin, loss of 
 appetite, partial vision, tenderness of abdo- 
 men, periods of intense suffering occurring 
 every two, three or four hours, which he 
 attributed to a sore on his foot from which 
 the skin had been rubbed by the shoe. Upon 
 examining the sore, I found the extremity 
 cold, the ulcer about the size of a dime, with 
 a shrivelled bluish elevated border, the cen- 
 tre of a dark fetid slough, without any ap- 
 pearance of granulations, having much the 
 appearance of a chancre. The ulcer con- 
 tinued to increase in size, the foot assuming 
 a mottled appearance. Soon the toes began 
 to shrivel about the nails, dry gangrene 
 made its appearance, soon invading the 
 whole foot ; the brain became implicated, 
 and the patient rapidly sank. 
 
 Case 2. — Aged 13, sister of case 1 ; at- 
 tacked about the same time, and, from what 
 I could learn, in the same manner. I was 
 unfortunate in not seeing this case until the 
 lapse of about four weeks. When I did see 
 the patient, found her in about the same 
 condition as Case 1 at my first visit. After 
 treating the case for some days, the ulcers 
 in the throat gradually healed, but the pow- 
 ers of life were far spent. Like her brother, 
 she had upon her foot a sore caused by the 
 chafing of the shoe. This sore was an ordi- 
 nary one, showing considerable indisposition 
 to heal, but an ordinary abrasion, till after 
 the throat healed, when to my amazement a 
 regular diphtheritic deposit made its ap- 
 pearance upon the sore, which rapidly 
 passed into an ulcer with the same appear- 
 ance that was presented in Case 1 ; refus- 
 ing to granulate, and absolutely maintain- 
 ing that cold, flatly malignant appearance of 
 the chancre. This ulcer spread by a grad- 
 ual death of the tissue, not rapid but sure 
 and persistent. In the course of ten or 
 twelve days, gangrene showed itself upon 
 the toes, gradually advancing until the tpei 
 
DIPHTHERIA AND SCARLET REFER. 
 
 409 
 
 were entirely involved. Mortification now 
 made its appearance in the foot around the 
 abrasion caused by the shoe, which spread 
 slowly until it reached a point about three 
 inches above the ankle joint, where a partial 
 line of demarcation was formed, and gradu- 
 ally became more distinct for four days, but 
 finally claimed more, and gangrene slowly 
 continued up the leg until the whole mem- 
 ber was involved, and the little patient was 
 relieved from her sufferings. 
 Very respectfully, 
 
 J. W. Lewis. 
 
 The two cases reported by Dr. Lewis, 
 where gangrene attacked the extremities 
 several days previous to death, are highly 
 interesting. It appears that these two cases 
 had lingered under the influence of the dis- 
 ease some four weeks previous to the first 
 visit of the Doctor, and that gangrene did 
 not set in till several days after. The 
 diphtheritic exudation on the surface of 
 the abrasion on the foot of each of these 
 patients shows that the morbific cause had 
 pervaded the entire system, and that it is 
 capable of producing a gangrene in the ex- 
 tremities, similar to that which it causes in 
 the original region. 
 
 MICROSCOPIC EXAMINATIONS OF EXPECTOR- 
 ATIONS, EXUDATIONS AND SLOUGHS 
 IN DIPHTHERIA. 
 
 The exudations and sloughs herein exam- 
 ined were taken from the throat and fauces 
 of Amos Bear, December ioth, the sixth 
 day of the disease, and sent to me on the 
 same day by Dr. Effinger. The membranes 
 had the usual appearance of diphtheritic ex- 
 udations. With them was considerable 
 expectoration or mucous secretion of the an- 
 ginal region. £ 
 The cells of this mucous secretion had a 
 peculiar and interesting appearance. The 
 minute cell contents appeared more distinct 
 than in health, and in many instances were 
 in active and independent motion, moving 
 rapidly among each other and around the 
 large central nuclei. By carefully watch- 
 ing the mucous cells it was also discovered 
 that they too exhibit independent vitality, 
 
 and had a slow progressive movement most- 
 ly in right lines, either singly or in whole 
 columns or in masses. This motion was 
 very slow, but by watching, in many in- 
 stances, a single cell for hours together, its 
 movements and general metamorphosis were 
 fully and satisfactorily determined. The 
 mucous cells of the spittle and expectora- 
 tion, as is well known, are the products of 
 the parent epithelial cells, lining the air pas- 
 sages, and those forming the secreting and 
 organizing surfaces of the salivary system. 
 These cells, in a normal or healthy condi- 
 tion, immediately after being formed, have 
 the appearance as seen at a, s and t, Fig. 
 i, PL I. 
 
 In the diphtheritic exudations and ex- 
 pectoration, these cells have taken on an 
 increased tendency to be metamorphosed 
 into filaments, each being provided with a 
 minute hair-like appendage and possessing 
 the power of independent motion. These 
 diphtheritic mucous cells are seen at b, c and 
 h, Fig. i. PI. I. Their minute cell con- 
 tents could be readily seen moving inde- 
 pendently about among each other and 
 around the central nuclei. As the vitalized 
 mucous cells (b and h) gradually progressed, 
 it was found that the hair-like appendage 
 gradually became larger and longer, till it 
 could be seen to be a tube, into which a 
 portion of the minute cell contents of the 
 mucous cell passed, (c) This metamor- 
 phosis or filament development from cells 
 gradually progressed till, after many hours, 
 the cell entirely disappeared, having been 
 spun into a filament like that seen at f. 
 Fig. i, PL I Sometimes from two to 
 many cells would be seen united in a mon- 
 iliform line, the cells of which would begin 
 to separate, remaining connected by a fila- 
 ment as seen at d, e and m, Fig. i, PI. I., 
 and this separation would become greater 
 and greater, until the entire string of cells 
 would be metamorphosed into a long tubu- 
 lar filament containing in it a portion of the 
 minute cell contents of the mucous cells. 
 
410 
 
 DIPHTHERIA AND SCARLET EEVER. 
 
 The only portions not metamorphosed 
 into filaments were the large central nuclei. 
 This operation of cell metamorphosis was 
 watched day after day for several weeks, till 
 I became fully satisfied that this general ac- 
 tive filamentous development of the mucous 
 cells was abnormal, and that from it result- 
 ed the membranous exudations of diph- 
 theria. It was satisfactorily determined that 
 the diphtheritic membranes are formed by 
 the rapid metamorphosis of the mucous 
 cells into filaments, which process begins 
 in this disease befoie they are fairly liber- 
 ated from the mucous follicles, and even 
 from the parent epithelial tissue. 
 
 As the filaments are developed they be- 
 come interwoven and thus form a more or 
 less thick and compact adherent membrane, 
 according to the activity of the secretion 
 and the cell metamorphosis. The external 
 surfaces of the exuded membranes have the 
 appearance seen at r and q, Fig. i, PI. I. 
 
 The filaments are so transparent, and 
 their plastic walls become so blended with 
 each other, that it is with difficulty they are 
 distinguished after the membrane is fully 
 formed. In its early stages, however, it can 
 be readily resolved into its ultimate fila- 
 ments, u. Fig. i, PI. I, represents the 
 two kinds of minute cells, highly magnified, 
 that have independent motion in the mu- 
 cous cells, b. c and i, Fig. i, PI. I. p rep- 
 resents the minute cells, highly magnified, 
 seen on the surface of the fragments of ex- 
 udation q and r. g are masses of sporidia 
 of the sphaerotheca pyra — the species that 
 produces blight in the apple, pear and 
 quince trees and decay in their fruit, h, i, 
 k, m, n and o, Fig. i, PI. I, represent the 
 mucous cells in the expectoration and exu- 
 dations of Nancy Bear, in their various 
 stages of metamorphosis. Many other 
 cases have been examined, all of which go 
 to confirm the views here advanced. 
 
 SLOUGHS OF ANGINA MALIGNA. 
 
 The sloughs from the throat of Amos 
 Bear were subjected to a careful microscopic 
 examination. The bodies represented under 
 Fig. 2, PI. II, were in the sloughs. 
 
 Examinations of like sloughs from Mr. 
 
 Karn's son and several others, revealed the 
 same bodies with the single exception of 
 the genus anguillila seen at a, Plate VI., Fig. 
 6, which was only found in the sloughs of 
 Amos Bear, and which probably came from 
 some vinegar gargle he may have used. The 
 minute forms represented at a, Fig. 1 1, PI. II 
 are peculiar active bodies, which are really 
 the spores of embryonic filaments of minute 
 species of algae or fungi. The parent gland 
 cells of animals have the power of taking 
 in and transmitting freely the spores of this 
 vegetation. All organic bodies are filled 
 with these spores, which seem to be quies- 
 cent during the physiological states, but as 
 soon as pathological conditions arise they 
 develop and multiply with incredible 
 rapidity. They become very abundant 
 during the fermentation and incipient de- 
 cay of all organic matter, and especially so 
 in nitrogenized animal tissues. At b, c, d 
 Fig. 2, PI. II, are represented the mature 
 algoid filaments, which are found in multi- 
 tudes running in all directions through the 
 exudations and sloughs, e, f, g and h Fig. 2, 
 PI. II, are cells that have the appearance of 
 being the spores and sporangia of the mucor 
 maligiians described further on; g and h 
 are more highly magnified than e and f ; i 
 appears to be an ascus highly transparent 
 and colorless, k and p. sporidia of the 
 apple blight fungus, (sphaerotheca pyra), m. 
 n and o sporidia, single and in mass of the 
 sphaerotheca pyra, vegetating with myce- 
 lial filaments. These occur abundantly in 
 the sloughs. They are present in large 
 quantities in apple fruit this season and may 
 be carried into the system through the 
 apples eaten. This species of fungus ap- 
 pears to be poisonous to some vegetable 
 tissues, and the sporidia excite irritation of 
 the fauces, trachea and bronchi when inhaled. 
 Another species Spersica (erysiphe graminis) 
 produces the disease known as the " curl 
 and blister" in peach leaves, and which 
 proves so deleterious and destructive to 
 peach orchards. Its known deleterious 
 effects upon vegetation, together with its 
 tendency to irritate the pulmonary mem- 
 branes when inhaled, renders it probable 
 
DIPHTHERIA AND SCARLET EEVER. 
 
 411 
 
 that it may have some influence in exciting 
 disease in the human subject. At b and x, 
 Fig. 6, PI. VI, are represented two species of 
 fungous filaments. These are found in the 
 expectoration of diphtheritic patients this 
 season. That represented at x occurs in 
 vast numbers in ripe persimmons this year, 
 in central Ohio, q Fig. 6, PI. VI. represents a 
 sample of numerous knots of mycelial fila- 
 ments, that are highly transparent, scattered 
 over the surface of the sloughs, and 
 patches of exudation. 
 
 u, v and w Fig. 2, PI. II, large mucous cells. 
 
 Besides the bodies represented under Fig. 
 2, PI. II, there were numerous highly trans- 
 parent large and loosely formed filaments, 
 single and in bundles, that had the appear- 
 ance of the mycelium, ce.Fig.3, PI. Ill, of the 
 mucor malignans. There were, however, 
 no fertile threads. Strongly suspecting 
 that these filaments were fungoid, after cut- 
 ting off a portion of the slough for further 
 microscopic examination, I placed the bal- 
 ance in a tightly corked two-ounce wide- 
 mouthed bottle, and set it aside in a room 
 where there was no fire. The temperature 
 in this room ranged from 60 to 65 ° F. In 
 a few days after being set aside, a white 
 mould or fertile thread began to appear on 
 the surface of the slough. This mould 
 gradually increased till on December 28th, it 
 enveloped the entire surface with a mass of 
 white fertile threads that resembled fine 
 cotton. On examining this under the mi- 
 croscope, I found the surface fertile threads 
 to emanate from the same mycelium as was 
 noticed running all through the slough and 
 exudation on Dec. ioth, when freshly sep- 
 arated. 
 
 At that time, however, there were no 
 signs of fertile threads, and the mycelium 
 was very much more transparent and less 
 firm than on Dec. 28th. On placing this 
 mycelium and fertile threads under the 
 microscope, a most beautiful fungus in full 
 fruit was exhibited, samples of which are 
 seen at a, b, c, d, e and u, Fig. 3; PI. III. d re- 
 presents the threads of the mycelium pack- 
 ed together and filled with minute cells 
 and granules, and covered often as at e 
 
 with minute cells. Mingled with the threads 
 were numerous highly transparent spore-like 
 bodies, that had no connection with them. 
 This fungus appears to belong to the genus 
 mucor. Not having met anywhere with a 
 description of this species, I have named it 
 the malignanS) as at this stage of the inves- 
 tigation it seems to have something to do 
 as the cause of malignant diphtheria, as will 
 more fully appear further on. 
 
 a represents a fertile filament bearing tnree 
 grape-likeclusters of sporangia. These bodies 
 resemble mucous cells, and appear like the 
 cells of diphtheritic exudation and expector- 
 ation. The mycelium and minute cells are 
 matted together in the exudation and sloughs 
 of diphtheria, and covered with clusters of 
 large cells, somewhat as seen at u, Fig. 3, PI. 
 III. Often however, the large cells are most- 
 ly absent. 
 
 b, Fig. 3, PL III, represents a iertile fila- 
 ment, covered with fruit or sporangias in 
 an early stage of developement. m repre- 
 sents the minute cells highly magnified, 
 that fill the large cells. 
 
 g, n, s and t Fig.3 PI. Ill, represent numer- 
 ous active bodies moving about among the 
 filaments, and which are seen at a,Fig.2,Pl.II. 
 
 v,Fig.3,Pl. Ill, represents the mature fruit 
 after it has separated from the fertile 
 threads. These cells are what I have found 
 frequently in diphtheritic exudation. They 
 so much resemble mucous cells that they 
 would readily be mistaken for them. I 
 had supposed them to be mucous cells until 
 I obtained the mature plants producing 
 fruit. 
 
 The minute bodies at w, Fig. 3, PI. Ill, are 
 what appear to be the spores of the mucor 
 malignans. 
 
 Diphtheria Produced oy Inhaling the Spores 
 of the Mucor Malignans. — On the 28th of 
 December, before opening the bottle con- 
 taining the diphtheritic slough and exuda- 
 tion, covered with white mould, I locked 
 nvyself in my room and opened the windows 
 to prevent exposing the rest of the family 
 to the disease. All the food I took for the 
 next three days was hastily passed to me by 
 my wife through the door slightly opened. 
 
412 
 
 DIPHTHERIA AND SCARLET FEVER. 
 
 I was determined to make careful micro- 
 scopic examinations and drawings of the 
 fungus, with full description of all the cir- 
 cumstances and conditions, no matter what 
 might be the result to me. 
 
 In removing the cork from tne bottle, the 
 slight jar sent the light spores out of the 
 mouth of the bottle,appearing like the spores 
 flying from a compressed " puff ball." 
 These I freely inhaled. 
 
 In a few minutes I had the vegetation 
 under the microscope, and was making my 
 drawings of the plant which are represented 
 in Plate III., Fig. 3. 
 
 My throat and fauces began to get dry, 
 hot and feverish almost immediately after 
 inhaling the spores. In less than thirty 
 minutes, the same symptoms excited in the 
 throat and fauces had extended down the 
 trachea and bronchi, and seemingly into the 
 air cells. With the dry, congested, hot 
 feeling, was a heavy, persistent, dull pain, 
 as if the parts affected were partially hepa- 
 tized and useless. There was a feeling of 
 oppression about the whole chest, and the 
 breathing unsatisfactory and labored. These 
 feelings became more and more intensified, 
 so that in a few hours I was almost inca- 
 pacitated from going on with the micro- 
 scopic work and drawings. The spores had 
 passed so freely and deeply into the air pas- 
 sages, and the oppression and irritation of 
 the parts was so intensified, that I began to 
 fear that I should not be able to pursue the 
 investigation further, unless I could get re- 
 lief. 
 
 Believing the cause of my suffering to be 
 the spores inhaled, I immediately began 
 taking one grain of quinia sulph. every 
 thirty minutes; and also to inhale and snuff 
 an equal amount at the same time. In ad- 
 dition to this, I gargled a strong solution of 
 tine, ferri chloridi every time my throat 
 became dry and sticky. In a short time 
 the troublesome irritation in the throat, 
 fauces and air passages began to be relieved, 
 so that I was comparatively comfortable 
 
 and able to go on with the microscopic work 
 and drawings. 
 
 I am fully satisfied from what occurred 
 during the attack and from my subsequent 
 experience with the disease, that I should 
 probably not have recovered if I had not 
 treated myself heroically, as I did; for the 
 mucous membranes of the entire air pas- 
 sages were inoculated with the cause of the 
 most malignant type of diphtheria I have 
 ever met with. 
 
 The quinine, taken internally and inhaled 
 every half hour, kept the system and sur- 
 faces so saturated with it that the vegetation 
 
 could make but little headway, and conse- 
 quently the disease was comparatively 
 
 light and soon overcome. The disease was 
 accompanied by a ropy, adhesive exudation, 
 which excited hawking and spitting fre- 
 quently. The same state extended down 
 the oesophagus, and into the stomach and 
 intestines. 
 
 Bowels (which were before regular and in 
 fine, healthy condition) became constipated, 
 and faeces hard and plastic. During the night 
 there was considerable burning, heavy pain 
 in the stomach and bowels, aggravated by 
 lying on the abdomen, and eased by lying 
 on the back. There was scarcely any ten- 
 derness on pressure. Counter irritation 
 produced no relief. 
 
 On the following morning, the first mucus 
 that was coughed up contained many of the 
 bodies v and the spores w, Fig. 3, Plate III. 
 Hawking to dislodge the adhesive mucus 
 would excite hiccoughing, while but little 
 matter would be raised. Coughing aggra- 
 vated the pain. 
 
 Dec. 30th and 31st. — All the symptoms 
 were aggravated. On the 30th there was 
 considerable fever, with a dry, hot, heavy, 
 congested feeling of the whole mucous lining 
 of the air passages and oesophagus, stomach 
 and intestines. Urine became scanty and 
 high-colored, and deposited a large sedi- 
 ment. There was a dry, pricking, con- 
 stricting feeling in the throat and fauces, 
 with a sticking together of the part. The 
 mucous secretions from the air passages 
 and mouth were ropy and filamentous, and 
 
DIPHTHERIA AND SCARLET FEVER, 
 
 413 
 
 the mucous cells had the appearance seen 
 at Fig. i, Plate I. 
 
 There was also pain in the sides of the 
 neck, in the thyroid cartilage, and in the 
 parotid and sub-maxillary glands. During 
 the night, slept well. 
 
 Dec. 31st. The back part of the throat 
 and fauces were covered with diphtheritic 
 exudations. The mucous membrane of the 
 air passages and digestive canal felt less 
 congested and hot, and the secretions of 
 the bronchi and fauces were less ropy, and 
 had less tendency to pass into filamentous 
 metamorphosis. Bowels less constipated. 
 Urine still scanty and high colored, with a 
 large sediment. 
 
 1863. January 1st. — Still better. The ex- 
 udation patches in the throat are disappear- 
 ing, and the secretions of the air passages 
 less ropy, and bowels quite regular, appe- 
 tite good. Continue the quinine sulph. 
 every half hour. 
 
 January 4th. — Have been constantly im- 
 proving since the first. The diphtheritic 
 patches have entirely disappeared, and feel 
 quite well except a heavy, aching pain in 
 the laryngeal and pharyngeal region, with 
 a slight difficulty in perfect articulation. 
 
 This latter result is of frequent occur- 
 rence after recovery from severe attacks. 
 Often this partial paralysis of the anginal 
 region lasts for some days after recovery 
 from the disease. 
 
 A good illustration of the contagiousness 
 of the disease occurred in this instance. 
 Notwithstanding the precautions taken, 
 about eight days after the appearance of 
 the first symptoms in my case, my wife was 
 taken down with the disease. The only 
 exposure she had was in passing the food 
 to me through the slightly opened door, 
 and this only for a moment, three times a 
 day. Her attack was sudden and severe, 
 and required energetic treatment to prevent 
 the exudation from extending into the 
 bronchi. Two days after her attack, her 
 sister was taken down, and on the follow- 
 ing day her brother. All recovered. 
 
 Blood in Diphtheria. — The blood cor- 
 puscles of malignant diphtheria are plastic 
 
 and sticky, and have a peculiar tendency to 
 adhere together, and to filamentous meta- 
 morphosis, showing that the disease is not 
 local but systemic, probably influencing 
 and modifying the organizing functions of 
 the parent cells of the lacteal and lymphatic 
 systems and spleen — in short, the entire 
 parent gland cell tissue. 
 
 At Fig. 4, Plate IV., are seen the various 
 abnormal conditions and bodies of the 
 blood of angina maligna. At a and b are 
 seen masses of cells, resembling diphtheritic 
 anginal cells. They are, however, colorless 
 corpuscles formed by the spleen and the 
 lacteal and lymphatic glands, and contain 
 the micrococcus spores of the diphtheritic 
 fungus. 
 
 This peculiar tendency to stick together 
 and become aggregated in irregular masses 
 is abnormal. 
 
 At c c, Fig. 4, PI. IV, are thin, pliable 
 sacks, constantly changing in shape, filled 
 with minute, vitalized granules constantly in 
 motion — protoplasmic. 
 
 The sacks have an amceba-like motion, 
 and communicate with the cavities of the 
 cells b, and their contents are the minute 
 cell contents of these cells, d represents 
 these minute, independently moving gran- 
 ules, more highly magnified, e a cell like 
 those at i and b, Fig. 1, PI. I, having a 
 hair-like appendage, it having taken on and 
 commenced the process of filamentous met- 
 amorphosis, f rhomboid epithelial cells, 
 that are removed from their attachment and 
 are floating in the blood, g a large cell 
 passing into a filament. At h and k are 
 represented algoid filaments that occur 
 in little groups and skeins in the blood. 
 
 Attached to the filaments k are many 
 spores of the vegetation, m and n are 
 masses of fibrin, through and in 
 which are seen algoid filaments. i 
 filaments resembling filamentous neu- 
 rine. This kind of filament was frequently 
 met with in the blood of Amos Bear. All 
 these bodies occur abundantly in the blood, 
 showing a formulative condition, and a dis- 
 position in its cells to become metamor- 
 phosed into filaments, and a tendency in 
 
414 
 
 DIPHTHERIA AND SCARLET FEVER. 
 
 these filaments to become aggregated in 
 masses, forming clots. This explains why- 
 there is a disposition to gangrene — from a 
 kind of embolism in this malignant form of 
 the disease, the algoid spores and filaments 
 and spores, and the blood aggregating, 
 forming masses, clots and emboli choking 
 up the capillary vessels, so as to impede and 
 in some cases entirely stop the circulation. 
 
 Uri7ie in Diphtheria. — The lining mem- 
 brane of the urinary organs also takes on 
 diphtheritic functional derangements. In 
 all cases of diphtheria, there is the same pe- 
 culiar, flocculent, pinkish-white deposit, 
 made up of minute granules of urates, like 
 those at Fig. 5, PL IV. With these are many 
 crystals of lithic acid, often very large, and 
 having the appearance of those seen at a, 
 b, c, d and f, Fig. 5, Plate IV. 
 
 With these are frequently found cystine 
 and the peculiar crystalline forms seen at e, 
 d, and k, Fig. 5, Plate IV. 
 
 Also epithelial cells and their products, 
 undergoing the filamentous metamorphosis, 
 with many algoid filaments. 
 
 At i are represented crystals of the lith- 
 ates of soda and ammonia, which frequently 
 occur in diphtheritic urine, w and v 1 , Fig. 
 7, Plate VI, represent peculiar mucous cells, 
 ruptured by their minute cell contents es- 
 caping, q and q 1 , Fig. 6, PI. V, spherical 
 algoid cells uniting into moniliform fila- 
 ments, g fungoid filaments, h and 1 the so 
 called vibriones, which are united into em- 
 bryonic algoid or fungoid filaments, m and 
 m 1 , Fig. 6, Plate V, algoid or fungoid 
 filaments already formed, in which no 
 structure can be made out. t, u, v and w, 
 Fig. 6, Plate V, various stages in the 
 formation of algoid filaments, from the 
 so-called vibrio, r and s are highly mag- 
 nified. 
 
 The bodies here represented in diphthe- 
 ritic urine, under Fig. 5, PI. IV, are the result 
 of careful microscopic examinations of the 
 urine of twenty-three cases of well marked 
 diphtheria. In one case that has come un- 
 der my observation, through Dr. Effinger, 
 the attending physician, the diphtheritic 
 derangements were wholly confined to the 
 
 bladder, it never producing any abnormal 
 anginal conditions that were noticed by the 
 patient. The patient was a married lady, 
 this attack occurring while she was attend- 
 ing on her husband, who lay sick with or- 
 dinary diphtheria (angina membranacea). 
 
 Treatment. — During the twenty years 
 that have elapsed since making these inves- 
 tigations and preparing this paper, I have 
 treated several hundred cases of diphtheria 
 with quinine sulphate and tinct. ferri chlor- 
 idi, and I can only call to mind the loss of 
 a single case, and that was a German boy, 
 who would not take the medicine with any 
 regularity. The quinia sulphate should be 
 given by the mouth, in powder, every half 
 hour, keeping the mouth, fauces and throat 
 constantly covered and saturated with it — 
 also snuff and inhale it at the same time, so 
 as to keep the surfaces of the entire air pas- 
 sages covered and saturated with it. 
 
 In addition to this I have used the fol- 
 lowing as a gargle: — 
 
 Ijt Tinct. ferri chloridi 3 j 
 
 Aqua 3 viij 
 
 S. Gargle every hour. 
 
 3 Carbolic acid (cryst. white) . . 3 j 
 
 Salicylic Acid 3 ss 
 
 Water 3 xii 
 
 Pure glycerine 3 iv 
 
 01. menth. pip gtt. xv 
 
 S. Gargle every half hour before taking 
 the quinia sulphate. 
 
 The quinia sulphate is the remedy to be 
 depended upon for checking the develop- 
 ment of the case. 
 
 There are many little things to be done 
 to relieve and make more comfortable, such 
 as hop poultices around the neck, so cov- 
 ered in as to bring the steam from the hops 
 up around the mouth, where it is inhaled. 
 This often soothes and relieves the suffo- 
 cating and croupy condition in children. 
 The swallowing of small bits of ice often aids 
 in loosening up the particles of exudation. 
 
 Penciling the throat with alcohol also re- 
 lieves the sufferings of the patient. 
 
 If quinine cannot be obtained, any anti- 
 septic remedy, or any medicine that will 
 
DIPHTHERIA AND SCARIET FEVER. 
 
 415 
 
 check or control the fermentation in a yeast- 
 pot, or preserve meat from spoiling, will be 
 useful in aiding the cure. Among these 
 may be mentioned permanganate of potash, 
 sulphites, all the mineral acids, salt, borax, 
 benzoate of soda, potassium chlorate, sal- 
 icylic'acid, carbolic acid, tinct. ferri chloridi, 
 bromine, iodine, sulphur, &c , &c. * 
 
 In certain conditions where the cough is 
 croupy, and the membranes tough, and ex- 
 pectoration adhesive and ropy, with a strong 
 tendency for the disease to invade the tra- 
 chea and bronchi, small doses of mercurial, 
 often administered, check or control this 
 dangerous tendency, so that the exudations 
 become softer, membranes less adhesive, 
 croupy cough ceases, and the patient 
 begins to improve. 
 
 Scarlatina, the Symptoms and Derange- 
 ments of; Similar to those of Diphtheria. — 
 The mucous cells of the anginal exudation 
 of scarlatina, with the bodies found in the 
 blood and urine, present marked similarities 
 to those of diphtheria. 
 
 In both diseases there is a strong tenden- 
 cy for the cell products of parent epithelial 
 cells to undergo filamentous metamor- 
 phosis. 
 
 The disease in both cases appears to em- 
 anate from functional derangements in the 
 organizing processes of the ultimate epithe- 
 lial cells,and in part appears to result in a too 
 rapid development of cells into filaments. 
 The primary cause of both diseases, how- 
 ever, must consist in some morbific agent, 
 which operates upon these cells, poisoning 
 the nutrient products which they originate, 
 so that after a certain limited period, which 
 is the period of incubation, the whole sys- 
 tem begins to sympathize, and take on a 
 series of abnormal actions, which are sim- 
 ply systemic efforts to eliminate from the or- 
 ganism the morbific poison, and which ac- 
 tions constitute the symptoms or peculiar- 
 ities of the disease. In this light the func- 
 tional derangements in toe organic pro- 
 cesses of epithelial cells, become simply a 
 resultant action excited by the primary 
 cause of the disease, and is one of the ef- 
 forts of nature to eradicate morbific matter, 
 
 by accelerating normal changes in organic 
 processes. 
 
 It should therefore be the constant care 
 of the physician, not to run counter to na- 
 ture in her efforts to cure the disease, but 
 simply to so equalize, aid and modify her 
 actions, as to alleviate suffering and guard 
 against dangerous results. 
 
 With these few preliminary remarks we 
 proceed to the microscopic examination of 
 the expectoration, exudation, blood, urine 
 and the desquamated cuticle of scarlatina. 
 
 Expectoratio7i and Exudation. — The pecu- 
 liar abnormal and similar tendency to the 
 filamentous development of the mucous 
 cells of the expectorated and exuded pro- 
 ducts of scarlatina and diphtheria, renders 
 it evident that the anginal epithelial func- 
 tional derangements in both diseases are re- 
 markably similar. This similarity is found 
 also to extend to the abnormal products of 
 the blood and urine. This makes it conclu- 
 sive that the same systemic, epithelial, func- 
 tional derangements are common to both 
 diseases. The results here obtained are 
 confirmatory of Dr. Tweedie's supposition 
 previously given. 
 
 Fig. 7, Plate VI, represents the appearance 
 of the mucous cells of the expectoration 
 and exudation of scarlatina angina. By 
 comparing the filamentous metamorphosis 
 going on in these cells with that exhibited at 
 Fig. i, PI. I, a remarkable similarity will be 
 noticed. 
 
 a. Fig. 7, PI. VI, represents the normal mu- 
 cous cell immediately after being formed and 
 before it takes on the active condition, or 
 begins to manifest independent activity, b, 
 c and h are mucous cells in scarlatina, in 
 the active stage. , The most of the cells in 
 this stage have a single fine caudal filament, 
 resembling an extremely fine hair, tapering 
 from the cell, and projecting from its pos- 
 terior side, or from the side opposite to the 
 direction in which it moves. Sometimes 
 there are two or even three hair-like pro- 
 cesses visible. The length of these hair 
 like processes in the early stages is usually 
 from two to three times the diameter of 
 the cell. 
 
416 
 
 DIPHTHERIA AND SCARLET FEVER. 
 
 The motion of these cells is a very slow, 
 uniform, progressive one, often so slow that 
 even an experienced eye would fail to de- 
 tect it, unless the attention was called par- 
 ticularly to it, and the observations con- 
 tinued on the same cell often for hours. 
 By selecting,however, a single cell standing 
 alone, and keeping the eye on it for some 
 time, a perceptible movement is plainly 
 manifest. 
 
 In this stage of development or metamor- 
 phosis, the cells are usually more or less 
 elongated, though they often appear spher- 
 ical. They have the power of changing 
 their shape, sometimes appearing very 
 much elongated,at other times slightly oval, 
 and then spherical. 
 
 All of these forms are noticed frequently 
 within a brief space of time, in the same 
 cell, while watching its motions. 
 
 The elongation is always in the direction 
 in which the cell moves. Before the cell 
 becomes active the hair-like appendage 
 (cilium) cannot be seen, and in many in- 
 stances after motion has commenced these 
 processes are so line that it is impossible to 
 detect them,even by the best glasses. These 
 cells contain a large central single or com- 
 pound nucleus, around which are numerous 
 minute spherical and oval granules or cells, 
 many of which are in active motion. 
 
 Those in active motion are probably 
 sperm cells to these organisms, and the 
 others germ cells. 
 
 Following the stage of independent ac- 
 tivity comes that of filamentous metamor- 
 phosis. During this period the activity is 
 slight,being confined to very slow, almost im- 
 perceptible, forward motion,which takes place 
 at short intervals, or appears to be some- 
 what periodic. The hair-like projection 
 becomes elongated and enlarged in calibre, 
 and soon is seen to be a membranous tube. 
 As tli is tube enlarges and elongates, the 
 contents of the mucous cells (consisting of 
 fluid and minute granules) pass into it, and 
 the minute cells usually become arranged 
 in a single moniliform row along its cavity, 
 as seen at z Fig. I, Plate 1, d, e, 1, m and i, Fig. 
 7, Plate VI. As the contents of the mucous 
 
 cell pass into the tubular filament, it (the 
 cell) grows smaller, and smaller till finally it 
 entirely disappears, leaving simply the re- 
 sultant filament.* 
 
 Often two or more cells are united by 
 one or more tubular filaments, i, m, Fig. 7, 
 PL VI, z, Fig. 1, PL I. 
 
 Sometimes two or more filaments proceed 
 from the same cell, as seen at 1, Fig. 7, 
 PL VI. The number of filaments is 
 determined by the number of hair-like 
 processes, and these are increased as 
 the tendency to filamentous metamor- 
 phosis is increased beyond the normal 
 standard. At m two mucous cells have 
 entirely emptied their minute cell contents 
 into the connecting filaments. After the 
 cells have disappeared, we have simple fila- 
 ments, as seen at p and q, Fig. 7, Plate VI. 
 Often the mucous cells arrange themselves 
 in moniliform rows, as at n and o, Fig. 7, 
 Plate VI. 
 
 r are the minute cells and moniliform 
 short filaments that make up the contents 
 of the mucous cells. These are highly 
 magnified. At the extremity of the forming 
 filaments at g, Fig. 7, Plate VI, short, active, 
 moniliform lines of minute cells and single 
 cells are escaping. This has only been no- 
 ticed in a few instances. 
 
 u spores of the saccharomycetes cerevis- 
 ise, which occur through the mucus sin- 
 gly and in short, branching, moniliform 
 rows. 
 
 s and t highly refractive, oblate spheroid- 
 al cells of a pearly appearance, containing 
 bodies resembling spores, t is an edge 
 view and s a side view. In the right hand 
 
 * Here is described briefly an interesting organic 
 process, one from which, when physiologically, or 
 slowly and healthfully performed, emanate all the fil- 
 aments of the muscular, fibrous and nerve tissues of 
 the animal body, but which, when the metamorphosis 
 is too hasty or rapid, becomes an abnormal action, 
 resulting in a preponderance of solids, and, in con- 
 sequence, congestions and exudations, the damming 
 up of the capillary blood streams, checking and 
 even stopping circulation locally, which may pro- 
 duce the pathological states of inflammation and gan- 
 grene. This subject will be more fully treated in 
 another paper. 
 
DIPHTHERIA AND SCARLET FEVER. 
 
 417 
 
 cell at s are short filaments with the spores. 
 The spores are of a reddish transparent 
 orange color. 
 
 Many of these cells are entirely empty. 
 When mature they fracture from the cir- 
 cumference towards the center at numerous 
 points, allowing the spore contents to es- 
 cape. They are quite numerous in the ex- 
 udations, and are the same as b and c, Fig. 
 8, Plate VII, in the urine. 
 
 The expectoration and exudation in scar- 
 latina contain numerous confervoid fila- 
 ments, like those at h, f, Fig. 6, Plate V. 
 e, n, i, Fig. 8, Plate VII., of the urine of 
 the same disease. 
 
 Blood of Scarlatina. — The appearance of 
 the abnormal bodies in the blood of scarla- 
 tina anginosa is so nearly identical with 
 those seen under diphtheria, Fig. 4, Plate 
 IV., that they will not require repetition 
 here. 
 
 Desquamated Cuticle of Scarlatina. — 
 Dec. 19th. Placed about four grains of des- 
 quamated cuticle from a scarlatina patient 
 in a watch glass, with a little pure water, 
 tightly covered and set aside at a tempera- 
 ture of 65 ° Fahr. The dry cuticle was made 
 ud of flat, scale-like epithelial cells, each 
 containing a large central nucleus, sur- 
 rounded by minute cells or granules. 
 
 Twenty-four hours after the large central 
 nuclei, s and s 1 , Fig. 9, Plate VII, of the 
 epithelial cells n and q had taken an inde- 
 pendent motion, and were moving about in 
 the epithelial cells and escaping. 
 
 After having escaped from the epithelial 
 cells, the minute, hair-like appendages could 
 be quite distinctly seen, as at a and b, 
 Fig. 9, Plate VII. 
 
 The movements were very much more 
 active than I had previously noticed in the 
 epithelial cell products of mucous surfaces. 
 c represents the cells a and b after the hair- 
 like processes have begun to enlarge into a 
 tubular filament. 
 
 d represents the spores of a minute algoid 
 vegetation, that have escaped from the flat- 
 tened epithelial cells. These spores move 
 independently in all directions. 
 
 e, f and k represent these spores united 
 into moniliform filaments. 
 
 m represents a blunt, tubular filament 
 (algoid) with cells united in twos. 
 
 g and h represent short, algoid filaments 
 with cells united in twos and threes, and 
 the lines of demarcation between the indi- 
 vidual cells obliterated. 
 
 r represents a long, algoid or fungoid fil- 
 ament, with no appearance of cross lines or 
 cells. The inside cells have united into a 
 uniform inside tube. 
 
 All of these filaments have the power of 
 independent motion. 
 
 The motions are slow, and consist of the 
 waving or vibrating of their extremities — 
 leptothrix ? 1 is a diatom from the water 
 drank, u probably the urate of soda, x 
 crystal, probably phosphate of lime. 
 
 Urine of Scarlet Fever. — Fig. 8, Plate 
 VII, represents the various abnormal bodies 
 found in the urine of scarlatina, when the 
 disease is at its height, a, b and e rep- 
 resent a peculiar kind of flattened, oblate 
 spheroidal cells, containing orange-colored 
 sporoid bodies, a and b represent side 
 views, and an edge view. They belong to 
 the same class of bodies as s and t, v and 
 w, Fig. 7, Plate VI. They occur frequently 
 in the urine. 
 
 d represents cells from the parent epithe- 
 lial cells of the bladder. They are single, 
 and also aggregated in masses, and many of 
 them manifest a disposition to filamentous 
 metamorphosis, e, Fig. 8, Plate V., and f 
 and g, Fig. 6, Plate V., algoid filaments, 
 made up of an outside tube enclosing a 
 moniliform line of minute spheroidal or oval 
 cells, bearing a close resemblance to ana- 
 baina mollis. 
 
 h r, Fig. 6, Plate V., represent a species 
 of leptothrix. Attached to the filament h 
 are a number of short ones, belonging to 
 the genus anabaina. These short monili- 
 form filaments are the prevailing ones in 
 scarlatina urine, a single drop often con* 
 taining many hundred, i, k and 1, Fig. 8, 
 Plate VII., a species of hypheothrix which 
 is quite frequently met with. o large 
 
 3 
 
418 
 
 DIPHTHERIA AND SCARLET FEVER. 
 
 rhomboid crystals of lithic acid. These are 
 quite abundant. 
 
 w, Fig. i, Plate I., a large, partially 
 collapsed, membranous sack, resembling 
 those found in the tomato or apple, and is 
 probably accidentally present. Fig. 8, Plate 
 VII., r r r crystals of creatine. The crys- 
 talline forms s, t and u are also sometimes 
 met with. 
 
 Some General Remarks connected with the 
 Pathology of Fever 's, and the Tissues upon 
 which Fever Poisons Primarily Act. — The 
 first layer of cell organisms, through which 
 food, medicinal agents and poisons have to 
 pass in entering the animal body, is the 
 epithelial. 
 
 It is very evident that medicinal agents 
 and poisons must act upon these cells, mod- 
 ifying their organizing and nutritive func- 
 tions, and the derangement produced must 
 first exist in these cells, and secondarily the 
 more highly animalized elements and tissues 
 beyond become affected, through the poi- 
 soned and medicated products furnished 
 them by the epithelial tissue. 
 
 There is hence evidence for believing 
 that all febrile diseases, eruptive and other- 
 wise, are intimately connected with func- 
 tional and structural derangements of the 
 cells of epithelial tissue. So intimate is the 
 relation that these functional and struct- 
 ural derangements appear to constitute the 
 disease. The different functional and 
 structural disturbances of the various por- 
 tions of the epithelial structure would seem 
 to give rise to the various types of fevers. 
 The primary causes of these functional and 
 structural derangements in most fevers are 
 varied, numerous and obscure, while in 
 others which are contagious they are more 
 defined, each being excited only by a par- 
 ticular, specific cause. 
 
 Before entering upon a few general re- 
 marks on the aetiology, &c, of fevers, indi- 
 cated by microscopic investigations of the 
 epithelial system in pyrexial states, I will 
 briefly refer to some generally received 
 views on these diseases. 
 
 In primary fevers there is a general py- 
 rexial state, without any evident patholog- 
 
 ical lesion, there being, to the unaided eye, 
 no observable localized disease. 
 
 As all organs and tissues appear to par- 
 ticipate in the febrile action, when it is once 
 established, its seat appears, and is supposed 
 to be, no more in one tissue than in another. 
 It has however been noticed that the first 
 symptoms of the manifest invasion present 
 themselves through the nervous system. 
 
 It has therefore been supposed probable 
 that the " fever poison " first invades the 
 animal system through the channel of the 
 nerves. These nerve symptoms, however, 
 will be shown further on to be probably 
 but secondary results in the invasion. 
 
 Cullen's definition of fever, modified by 
 Christison, is as follows : " After a prelim- 
 inary stage of languor, weakness and defec- 
 tive appetite, acceleration of the pulse, in- 
 creased heat, great debility of the limbs and 
 disturbance of most of the functions with- 
 out primary local disease." 
 
 The great French anatomic schools, com- 
 posed of able investigators, advanced a 
 theory, which was generally entertained 
 throughout Europe. 
 
 This theory regarded fever as the " con- 
 stitutional result, and its symptoms as the 
 general expression throughout the system, 
 of the effects of a localized process of dis- 
 ease, having for its constant seat a part of 
 the intestinal canal. 
 
 In fevers there is an increase of tempera- 
 ture above the natural standard of about 
 4° Fahr. ; even during the algid stage of the 
 disease, the elevation of temperature is 
 present. 
 
 This has been noticed to be a constant 
 morbid condition of fevers. It is now gen- 
 erally admitted that the chief source of the 
 increased temperature in fevers, arises from 
 increased activity of the causes which oper- 
 ate in the production of the healthy tem- 
 perature. 
 
 The source of healthy animal heat is 
 held to be developed by the nutrient 
 changes perpetually going on in the tis- 
 sues. 
 
 An able enquirer — Virchovv — assumes 
 that the nutrient metamorphosis of the 
 
'DIPHTHERIA AND SCARLET FEVER. 
 
 419 
 
 tissues is increased in fever, and as a natural 
 and necessary consequence, this gives rise 
 to increase of temperature. This nutrient 
 metamorphosis consists of those organizing 
 changes going on both in nutrient materials 
 supplied to the system, and those interstitial 
 changes by which the constituents of the 
 body themselves are metamorphosed and 
 removed. Virchow supposed that this in- 
 creased metamorphosis was the consequence 
 of some internal, excitant cause, the real 
 nature of which is unknown. 
 
 Lyon, in his work on fevers, p. 33, says : 
 " Some facts determined by recent investi- 
 gations and experiments would appear to 
 show that the first steps in the establish- 
 ment of febrile conditions are not to be 
 sought for in the blood itself, or in any part 
 of the circulating apparatus, but to indicate 
 certain deranged conditions of the nervous 
 system as more likely to furnish us with an 
 explanation at once natural and proper on 
 this point." Virchow believed that the ele- 
 vation of animal temperature in fevers arose 
 from a kind of paralytic condition of the 
 nervous system. This is supposed to have 
 been well established by numerous experi- 
 ments. Becquerel, Brescher and Helm- 
 boltz,in experiments on that kind of nervous 
 irritation which excites muscular contrac- 
 tion, found that it increased animal tem- 
 perature. In opposition to this, Bernard 
 has proved that section of the sympathetic 
 nerve in the neck is followed by rapid in- 
 crease of temperature in the corresponding 
 half of the head. Brown Sequard's experi- 
 ments are to the same effect. Weber has 
 shown that the heart's action is arrested by 
 the irritation of the vagi nerves. It has 
 long been known that section of these 
 nerves causes acceleration of the pulse. 
 
 Ludwig and Hoffa have shown that in 
 moderate irritation of the vagi, the lateral 
 pressure of blood in the arteries is lessened : 
 while Volkman andTowelin have determined 
 that it increased after section of the nerves. 
 Fraube has found that digitalis acts as an 
 irritating stimulant upon the regulating 
 nerves of the heart, and that a diminished 
 temperature is produced by it, which he at- 
 
 tributes to the diminished velocity of the 
 I blood stream. 
 
 From these experiments it has been in- 
 ferred by authors " that the causes that reg- 
 ulate the velocity, tension and other physical 
 conditions of the blood stream and the 
 vessels which carry it, seem unquestionably 
 to reside in the nervous system, which ex- 
 ercises a sort of regulator or moderator 
 function over the circulation, and through 
 the circulation over the animal tempera- 
 ture." 
 
 Cullen held that " the first link in the chain 
 of fever actions, was a depressed brain and 
 nervous system." The spasm (or tonic 
 contraction) of the capillaries, he considered 
 as resulting from the depression of the 
 brain and nervous centers, and that the re- 
 action of the circulation was an effort to 
 overcome this state of spasm of the extreme 
 vessels. After the tissues have become 
 once deranged by being nourished with ab- 
 normal food, organized by epithelial cells 
 deranged in their functions, we might well 
 expect to find them in a diseased, irritated 
 condition, which would manifest itself by a 
 train of abnormal symptoms, which would 
 continue until the exciting cause was re- 
 moved. 
 
 With regard to the elevation of animal 
 heat, we would state in this connection 
 some few facts which go to show that ani- 
 mal heat may to a considerable extent be 
 developed by the organizing processes of 
 epithelial cells. After animal life has 
 ceased, we have known the temperature of 
 the body of a horse twelve hours after 
 death (temperature of atmosphere 4o°Fah.) 
 to stand at 160 Fah. This high tempera- 
 ture arose mostly from the rapid organic 
 changes going on in epithelial tissue, and 
 from interstitial tissue dissolution. We have 
 known the body of a dog, poisoned with 
 veratrine, twelve hours after death to stand 
 at 90° Fah. In the development of yeast 
 cells in fermentation, the temperature of the 
 fermenting mass often rises (where large 
 masses of matter are fermenting), to from 
 120 to 150? Fah. 
 
 In the decay of nitrogenized tissues the 
 
420 
 
 JDIPHTUER1A AND SCARLET FEVER. 
 
 temperature sometimes rises even above 
 150 Fah. 
 
 In the rapid interstitial changes going on 
 in fevers, we might well expect to find an 
 elevated temperature of the animal 
 body. 
 
 After the phenomena noticed in the mi- 
 croscopic examinations of the epithelial cells 
 in various parts of the epithelial structure, 
 in health, during the period of febrile incu- 
 bation, and after the manifest invasion of 
 the disease, there appears to be evidence 
 for believing that the nervous system is not 
 the department of the organism first en- 
 croached upon, or the avenue through 
 Which the exciting cause of fever first pass- 
 es, in invading the animal system. 
 
 There is a cell structure making up a 
 considerable portion of the organism, which 
 possesses a life independent of the animal 
 body, the cells of which vegetate and de- 
 velop after animal vitality ceases, as has 
 been fully shown in the preceding pages. 
 
 This tissue is composed of cells, the func- 
 tion of which is to assimilate and organize 
 the nutrient matters of the food into the va- 
 rious products which are designed to be ap- 
 propriated in building up and nourishing the 
 various tissues of the animal body. It is 
 known by the name of epithelial tissue, and 
 makes up the organizing portion of all 
 glandular masses and surfaces. The cells 
 of this tissue are extra-vascular, and so far 
 as known, not supplied with nerves. All 
 the external surfaces of, and avenues of ap- 
 proach to, the more highly animalizcd parts 
 of the system are covered and guarded in 
 all and every part by these epithelial cells. 
 Nothing can enter the system without first 
 passing through the cells of this assimilat- 
 ing and organizing epithelial envelope. This 
 epithelial envelope is the ultimate basis of 
 the entire organic structure. Its individ- 
 ual cells are the avenues and apparatus 
 through which all the nutrient materials of 
 the food have to pass, and be assimilat- 
 ed and organized, ere they are fitted to 
 nourish and sustain the various tissues. 
 
 The tissues themselves, outside of epithe- 
 lial or glandular cells, have no power within 
 
 themselves of organizing matter from food 
 for their support. The epithelial cells are 
 the avenues through which alimentary, med- 
 icinal and morbific agents reach the syste- 
 mic tissues, and are the ultimate bases of 
 many important physiological and patholog- 
 ical processes. 
 
 All febrile excitants must consequently 
 act primarily upon the ceils of this tissue, 
 deranging their organizing functions so as to 
 impart abnormal properties to the matters 
 organized. 
 
 The period from the commencement of 
 the action of the deranging influences upon 
 these cells to the time when the abnormal 
 organized products begin to produce per- 
 ceptible derangements in the nerve and 
 other tissues which these organized matters 
 nourish, is the period of incubation. Of 
 the different types of morbific agents which 
 produce the different types of disease, each 
 acts in its own peculiar way upon these cells 
 of extravascular life, producing in them 
 specific changes in their organizing func- 
 tions, which in each case results in a partic- 
 ular type of disease. 
 
 This matter will be more fully set forth 
 in a paper in progress on the " Ultimate 
 structure and functions of epithelial (gland- 
 ular) tissue, and how influenced in function 
 by morbific agents." 
 
 It is through the cells of this tissue that 
 most of our medicinal agents and poi- 
 sons produce their beneficial or baneful re* 
 suits. 
 
 The study of the specific action of the 
 various agents of the materia medica, &c, 
 upon the gland cells, opens up a new and 
 rich field for careful investigation, which 
 will yet result in the discovery of ultimate 
 organic actions and cardinal truths that will 
 tend to reduce the healing art more to an 
 exact science, and establish ( unvarying 
 guides in many instances foi the practition- 
 er. It is in studying the functions of this 
 primordial structure in health and disease, 
 and under the influence of medicinal agents, 
 that we may expect to find much that is 
 new and true respecting those obscure ulti- 
 mate physiological and pathological changes 
 
DIPHTHERIA AND SCARLET EEVER. 
 
 421 
 
 and medicinal effects which lie at the very 
 foundation of medical science, and which 
 are so important to understand in order to 
 free the practice of medicine from an empir- 
 icism which has ever clung to it in defiance 
 of past research. 
 
 In fevers the organizing cells (epithelial) 
 become dry, parched, and are so poisoned 
 by morbific agents that their normal func- 
 tions of organizing cells are much deranged, 
 and to a great extent cease. 
 
 Nutrient materials introduced into the 
 stomach not being, save to a limited extent, 
 assimilated and organized, act as foreign 
 bodies, producing irritation of the intes- 
 tinal canal and system generally. On the 
 other hand interstitial death and decay be- 
 come rapid, producing debility, emaciation, 
 &c. This state of things necessarily results 
 in the long train of symptoms attendant 
 upon fevers. 
 
 The rapid interstitial changes are efforts 
 on the part of nature to purge the system 
 of morbific materials which have already 
 been organized and become incorporated in 
 the tissues during the period of incubation. 
 This morbific matter must be disposed of 
 or eliminated before recovery can take 
 place. 
 
 The symptoms in any given case of fever 
 are but the expressions of the extent to 
 which the morbific poisoning has invaded 
 the tissues, and of the efforts on the part of 
 nature to rid the system of the poisoned 
 epithelial products already appropriated, 
 and the tendency to check the further or- 
 ganization of products for nutrient purposes, 
 until the system becomes purged of the 
 fever poison. This explains the reason why 
 it is so useless to attempt to " break up" well 
 established fevers, except by removing or 
 rendering inert the morbific cause. In pure 
 fevers there are no perceptible organic le- 
 sions. The disease is one of function in- 
 stead of structure. The primary seat of 
 the derangement is in the ultimate epithelial 
 cells, the very basement structure of the 
 organism. In eruptive fevers the cutaneous 
 surface becomes involved, and there is also 
 a tendency for the mucous and serous sur- 
 
 faces to take on like pathological condi- 
 tions. These fevers are distinguished from 
 each other by the character of the surface 
 lesions. In scarlatina and measles there is 
 a peculiar tendency for the mucous mem- 
 branes to become involved. The former is 
 commonly attended with a peculiar and 
 characteristic form of sore throat (diphthe- 
 ritic), while the latter is usually accompanied 
 by a watery exudation from the eyes and 
 nose (coryza;, and a bronchial affection 
 varying in extent and importance. 
 
 In s?nall-j)ox there is a tendency to lesion 
 of the serous surfaces (the pleura especially) 
 and occasionally the mucous coats of the 
 intestines arc involved (pustules on the mu- 
 cous intestinal surfaces). 
 
 In eruptive fevers and typhus, one at- 
 tack gives a peculiar protective immunity 
 against its recurrence in the same individual. 
 The cause of this protective immunity may 
 possibly be arrived at by carefully studying 
 the changes impressed upon the ultimate 
 epithelial cells by the specific causes of 
 these diseases.* 
 
 The spores of many algae and fungi and 
 perhaps other cryptogams produce a febrile 
 condition of the mucous lining of the air 
 passages when inhaled. This febrile con- 
 dition is local, and confined to the delicate 
 parent epithelial cell surfaces with which 
 the spores come in immediate contact. It 
 often lasts from one to several hours after 
 removal from exposure to the morbific cause. 
 In walking over, disturbing, or pitching old, 
 mouldy straw or hay, the throat, mouth and 
 fauces become dry, hot and parched, and 
 there is a constant desire to swallow, hawk 
 and spit, with an almost entire suppression 
 of the normal secretions of these surfaces. 
 
 Very soon this dry, congested sensation 
 extends into and throughout the air passages 
 of the lungs, and is there accompanied by a 
 heavy, congested feeling. 
 
 * The length of time that this impress of immunity 
 lasts in any given case is determined by the length 
 of the life and existence of the epithelial cells re- 
 ceiving the impress. Our epithelial cell envelope is 
 
 constantly dying, disintegrating and disappearing 
 and new cells are formed to take their place, so that 
 the integrity of the envelope is constantly preserved. 
 
122 
 
 DIPHTHERIA AND SCARLET FEVER. 
 
 In walking over " peaty ague bogs," 
 where the surface is broken, exposing the 
 fresh soil covered with ague vegetation, 
 during the months of July, August and 
 September, or in passing through the heavy 
 night air and vapors in malarial districts, 
 the same or similar febrile sensations to 
 those from mouldy straw and hay are ex- 
 perienced.* 
 
 These sensations often last for hours, 
 and sometimes during an entire day, after 
 removal from the morbific cause. On ex- 
 amining the expectorated mucus, it is found 
 filled with fungoid and algoid spores, and 
 fragments of fungoid filaments. We have 
 them here an exciting cause of local febrile 
 excitement^ which any one may be fully sat- 
 isfied of by exposing himself to the con- 
 dition just described. That the morbific 
 poison in these cases is cryptogamic, there 
 is no possible doubt, as in hundreds of in- 
 stances in our observations, where > this 
 febrile condition of the air passages has 
 been excited, the expectorated mucus has 
 been found to contain uniformly fungoid 
 and algoid bodies in great numbers : and 
 further, these bodies were the only foreign 
 substances in the mucus that was constant- 
 ly present in such cases. 
 
 Vllie atmosphere in certain localities, 
 especially the heavy, damp, night atmos- 
 phere, is often found loaded, during the 
 season of active cryptogamic development, 
 with the invisible spores of numerous mi- 
 croscopic cryptogams, that multiply and 
 develop with great prolificness, some upon 
 living, some upon diseased, and others upon 
 dead and decaying organic tissues. 
 
 This established, we may go one step 
 further and reasonably conclude that bodies 
 which are capable of exciting local fever i?i 
 the epithelial surfaces with which they come 
 in contact, by a few minutes exposure to them, 
 may, by frequent ana 7 long exposure of the 
 system to the same cause, become so diffused 
 
 * That this local febrile excitement acts primarily 
 upon the epithelial cells is evident from the fact 
 that the first abnormal indication noticed is the sup- 
 pression of the epithelial cell secretion; the throat, 
 fauces, bronchi and pulmonary membranes becom- 
 ing dry, parched, &c. 
 
 throughout the organism by being inhaled and 
 taken into it with the food and drink, as to 
 communicate their mo?'bific properties to the 
 entire epithelial surfaces of the intestinal 
 canal, and the lacteal, lymphatic, gla?idular 
 and vascular epithelial surfaces, and so de- 
 range the functions of the organizing cells as 
 to render the products organized by them, for 
 the nourishment of the nervous and all ether 
 tissues of the body, poisonous. As soon as 
 these poisoned nutrient products become appro- 
 priated by the tissues, to a certain extent, the 
 system gives way to those powerful efforts of 
 nature, which are designed, ?wt only to pre- 
 vent as far as possible the further introduc- 
 tion of the fever poison, but by rapid inter- 
 stitial changes eliminate from the organism 
 the poisoned organized matters that have 
 already been appropriated by the tissues during 
 the period of incubation. 
 
 The sum of these manifestations of nature 
 constitutes the disease known as fever. w 
 
 These remarks apply to all fevers, and 
 especially to those which are not regarded 
 as contagious. In those that are contagious 
 there are generally surface lesions in the 
 shape of eruptions. In this class, called 
 eruptive, the morbific cause is no doubt 
 of a similar character to that of other fevers, 
 but seems to possess in addition the pecu- 
 liar property of those organisms known as 
 " yeast plants," capable of multiplying 
 almost infinitely in the animal system from 
 a small beginning. The animal system to 
 this vegetation seems to be a prolific u hot 
 bed," in which they develop and multiply 
 and extend without limit. They also pos- 
 sess the peculiar property of impressing upon 
 the epithelial cell system the power of resisting 
 to a remarkable extent subsequent invasions of 
 the same disease. 
 
 It has been, however, observed, that as 
 the period lengthens from the time of the 
 first invasion of the disease to subsequent 
 exposures, the tendency becomes greater 
 and greater, or the epithelial cell system 
 has less and less power to resist a second 
 
 invasion. 
 
 This is an interesting field for inquiry. 
 I will here suggest what appears to point 
 
DIPHTHERIA AND SCAR.IET FEVER. 
 
 423 
 
 in this direction, and which may be found 
 on careful and extended research to be the 
 true cause of this susceptibility to a second 
 invasion. 
 
 The parent epithelial cells are to a consid- 
 erable degree permafient and independent or- 
 ganisms. Each has its attachment, and car- 
 ries on its own organic processes, more or less 
 independent of its neighbor. These parent 
 cells are the bodies through which fever poi- 
 sons gain access to the system. They are the 
 bodies that are deranged in their organizing 
 functions by fever poisons, and the organisms 
 that 7?iust receive the more or less permanent 
 prophylactic or resisting impress. This im- 
 press, upon any given epithelial cell, is no 
 doubt permanent. It has been observed, and 
 I have 710 doubt of its truth, that these parent 
 epithelial organisms from time to time, and 
 from a variety of causes, die, disintegrate and 
 disappear, while new parent cells develop to 
 take their place. 
 
 In process of time, varying greatly in dif- 
 ferent persons, a great share of ihe original 
 epithelial cell structures that had at some pre- 
 vious period received from an invasion of one 
 of this class of diseases a protective impress, 
 may have passed away, and a new system of 
 epithelial cells taken their place. This new 
 system of epithelial cells, having never been 
 invaded, are, of course, like the first, suscep- 
 tible of invasion, and in such case there- would 
 be a second attack of the disease in the same 
 individual. This attack would vary in inten- 
 sity with the proportion of new epithelial cells 
 in the glandular surf ace (each epithelial cell 
 may be regarded to all intents and purposes a 
 glana). If there are but few, the tende?icy 
 to the second attack would be very slight — so 
 slight that it would not be attended with any 
 eruption, and with but slight febrile symptoms. 
 
 This is what every physician has often 
 noticed in his own case, when attending 
 upon contagious fevers. 
 
 I trust the investigations and few re- 
 marks here offered will interest the serious 
 consideration of medical observers in this 
 interesting field of inquiry. 
 
 I am satisfied that careful observation of 
 the epithelial cell organisms, the study in 
 detail of their ultimate and all-important 
 functions, will not only be highly interest- 
 ing to the observer, but will inspire him 
 with that confidence he has seldom before 
 felt, that his researches are now in the way 
 of ultimate and important physiological and 
 pathological truths, the solution of which 
 has resisted past research, and which are 
 destined to remove many remnants of em- 
 piricism from the healing art, and reduce it 
 more to a science of unvarying principles. 
 
 It is only by the study in detail of this 
 organizing cell system that we may expect 
 to discover those primary and ultimate 
 physiological and pathological actions and 
 medicinal effects which lie at the very 
 foundation of all healthy, diseased and cura- 
 tive processes. 
 
 Resume. — The following* is a brief sum- 
 mary of the facts and inferences which ap- 
 pear to be indicated by the foregoing in- 
 vestigations. 
 
 i st. — That the disease occurring near 
 Lancaster, Ohio, here described, and which 
 proved so fatal, is Angina Maligna. 
 
 2nd. — That Angina Maligna is a conta- 
 gious disease. 
 
 3rd. — That Angina Maligna is closely al- 
 lied to Scarlatina Anginosa and that diph- 
 theritic diseases generally are allied to those 
 of the scarlatina type. 
 
 4th. — That the primary seat of the dis- 
 ease in both scarlatina and diphtheria is 
 the epithelial cells. That these are so de- 
 ranged in their functions by the morbific 
 cause of the disease, that the nutrient pro- 
 ducts which they organize become so 
 poisoned that they poison the tissues they 
 are designed to nourish. This poisoning 
 takes place during the period of incubation. 
 
 5th. — That morbific poisons cannot enter 
 the system without first passing through and 
 primarily deranging the epithelial cells and 
 their products; as these cells envelop the 
 entire organism, and guard all the ap- 
 proaches to it. That they affect the tissues 
 by poisoning the organized matters which 
 go to their support. 
 
 6th. — That the epithelial cells of mucous 
 and serous surfaces assimilate and organize 
 all the nutrient matters which go to build 
 up and support the tissues. 
 
 7th. — That the perceptible symptoms of 
 these diseases are but expressions of the ef- 
 forts of nature to eliminate from the system 
 the morbific poison. 
 
 8th.— That the exudations of the mucous 
 surfaces in diphtheria are produced by the 
 too rapid metamorphosis of mucous cells in- 
 to filaments, which filaments become woven 
 together, forming a felt-like membrane, be- 
 fore they are fully liberated from the follicles. 
 
 9th. — That the tendency to filament me- 
 tamorphosis in diphtheria is general 
 throughout the epithelial system, showing 
 that it is a systemic disease. 
 
 1 oth. — That the Mucor Malignans appears 
 to be the primary cause of Angina Maligna, 
 and of Angina Membranacea. That the 
 diseases are specifically the same, the dif- 
 ference being caused by the state of the 
 system in the person attacked. 
 
424 
 
 DIPHTHERIA AND SCARLET FEVER. 
 
 nth. That as the tendency is for the 
 cells to become developed into filaments 
 and resultant membranes before they are 
 fairly out of the follicles, the object of any 
 treatment should be to retard this filamen- 
 tous development and promote the secre- 
 tions, so that the cells may escape before 
 they become filaments, also to check the de- 
 velopment and to destroy the fungoid cause. 
 
 1 2th. — When the filaments are strong and 
 membranes tough and adhesive, mercurials 
 should be resorted to, to soften the threads 
 and render exudation less adhesive. 
 
 13th.'— That these diseases are but the ef- 
 forts of nature to eradicate from the system 
 morbific matters, that it should be the con- 
 stant care of the physician not to run coun- 
 ter to nature in the efforts to cure the vi- 
 tiated condition of the organism, but sim- 
 ply to endeavor to destroy the cause, and 
 so to equalize, aid and modify her actions 
 as to alleviate suffering, facilitate her pro- 
 cesses, and guard against dangerous re- 
 sults. 
 
 14th. — That it is a normal action for the 
 cell products of epithelial cells to become 
 gradually metamorphosed into filaments. 
 
 15 th. — That if by any cause the metamor- 
 phosis prematurely commences and the 
 process is accelerated, it becomes a patho- 
 logical action, which tends to result in grave 
 abnormal conditions. In epithelial tissue 
 there result membranes, exudations, and 
 clots; in connective tissue, the various can- 
 cerous and fibrous growths. 
 
 1 6th. — That the epithelial cells have a life 
 independent of the animal, all the external 
 and internal surfaces of which they envel- 
 ope and protect. 
 
 17 th. — That they appear to be the primary 
 seat of the functional derangements in all 
 true fevers. 
 
 1 8th. — That they are the probable organ- 
 isms which receive the protective immunity 
 by one attack of certain contagious dis- 
 eases that tends to guard the system against 
 a second invasion of the same. 
 
 19th. — That in health it would seem that 
 neither nutrient, medicinal nor morbific 
 agents can enter the system so as to nourish, 
 medicate or vitiate the tissues of the organ- 
 ism, without first passing through the cells, 
 and imparting a primary influence to them 
 and the products they organize. 
 
 20th. — That it is probable that morbific 
 matters poison the tissues of the body 
 through the nutrient products organized for 
 their support by the epithelial cells. 
 
 2 1 st. — That local fever of the mucous 
 surfaces may be excited at will by exposing 
 them for a few minutes to contact with the 
 32 West 26th St., June, 1882, 
 
 spores of certain algae and fungi that devel- 
 ope upon ague bogs, old straw, &c. 
 
 22nd. — That it is probable that by con- 
 tinued exposure to these and similar causes 
 (the taking of spores into the system through 
 the food eaten and the air inhaled), that 
 febrile action over the entire epithelial sur- 
 faces, including those of the lacteal and 
 lymphatic systems, would be excited, in 
 which case general fever would result. 
 
 23d. — That the altion of the " fever poi- 
 son " upon the nervous system is through 
 the nutrient nerve products organized by 
 the vitiated and functionally deranged epi- 
 thelial cells, and hence is a secondary pro- 
 cess or manifest symptom of the primary 
 functional derangements of these epithelial 
 cell organisms, or of the ultimate disease. 
 
 24th. — That the treatment should be 
 prompt and direct, aimed not only at the 
 destruction of the cause, but at the removal 
 of all the pathological conditions and states 
 which this cause has excited. 
 
 The Mucor Malignans should be checked 
 in its development and destroyed, and at the 
 same time the toughness and adhesiveness of 
 the exudations should be softened, the chok- 
 ing and suffocation should be relieved, and 
 the throat, fauces and air passages be kept in 
 as comfortable a state as possible. To de- 
 stroy the cause, quinia sulphate — all things 
 considered — is the best and most reliable 
 remedy, as it braces up the enfeebled sys- 
 tem while it is destroying the fungus. 
 
 It is not enough to give it every two hours 
 or every hour, but it should be administered 
 every half hour, and in some instances per- 
 haps even oftener. It should be given in 
 powder, so as to keep the throat and fauces .? 
 constantly covered with it, and if necessary 
 it should be snuffed and inhaled into the air 
 passages. To destroy the toughness of 
 the filaments and the adhesiveness of the 
 membranes, small doses of mercurial often 
 repeated are useful. To relieve the chok- 
 ing and suffocation, the simple hop poul- 
 tice, applied as hot as it can be borne 
 around the neck, and so covered as to allow 
 the steam from it to be inhaled, is a very 
 effectual relief. Also small doses of sul- 
 phuric ether in coffee, or the inhaling of a 
 few drops of nitrate of amyl, may prevent 
 sudden suffocation incases where the phy- 
 sician is called in the last stages, and 
 through these precious time may be gained 
 for using vigorously the quinine. 
 
 In conclusion, I take pleasure in express- 
 ing my obligations to Drs. Boestler, Effinger 
 and Lewis, who have felt interest in my la- 
 bors, and to whom I am indebted for much 
 excellent material in these examinations. 
 
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DESCRIPTION OF PLATES. 
 
 Amplification 2500 diameters and over. 
 
 Plate ist. Forms found in the expec- 
 toration and exudations of diphtheria. 
 A-S-T — Healthy buccal mucous cor- 
 puscles—page 409. B-C-H-I — Mucous 
 corpuscles from Amos Bear's mouth, show- 
 ing the spinning of filaments in diphtheria. 
 D-E-M — Mucous cells connected with fila- 
 ments. E — A row of mucous cells. F— mu- 
 cous cells spun into a long branched fila' 
 ment. G. — Sporangia of sphaerotheca py- 
 rus — found also in pear blight. H-I-K-M- 
 N-0 — Mucous cells from Nancy Bear. 
 U— Automobile microspores — the bacteria 
 and micrococci of authors. P-Microspores 
 found in Q and R. Q-R — Membrane in diph- 
 theria. W-Membranous vegetable sac found 
 in urine of scarlet fever, placed here for con- 
 venience. Z — Three cells in active filamen- 
 tation. 
 
 Plate 2D. Fig. 2. Bodies found in the 
 sloughs of Amos Bear. Diphtheria. A — Em- 
 bryonal form of vegetation — the bacteria 
 and micrococci of writers — page 410. B-C-D 
 — Mature mycelial filaments, running in all 
 directions through the sloughs. E-F-G-H — 
 Spores and microspores of the mucor ma- 
 lignans. I — Ascus. K-P — Spores of apple 
 blight — sphaerotheca pyrus. M-N-0 — 
 Spores with mycelial filaments do. U-V-W 
 — Large mucous cells with entophytic fungi. 
 
 Plate 3. Fig. 3. — The mature plant of 
 diphtheria developed by culture. — page 411. 
 
 Mucor Malignans. — A-Fertile plant of 
 Mucor Malignans with three clusters of 
 sporangia. B — Plant with erect filament and 
 undeveloped fruit. C-D-E — Stroma or mem- 
 branous net work of mycelial filaments 
 dotted over with microspores. W — Micro- 
 spores that fill the sporangia at A. G-M- 
 N-S-T — Automobile spores, some arranged 
 into filaments. U — Collection of mature 
 sporangia and filaments matted together as 
 in the membrane. V — Separate mature spor- 
 angia. 
 
 Plate 4. Fig. 4. — Abnormal morpholog- 
 ical elements found in the blood of diph- 
 theria and scarlet fever. A-B — Masses of 
 colorless corpuscles filled with embryonal 
 forms (spores) of the mucor malignans. C- 
 C — Amoeboid projections of protoplasm do 
 do. D — Automobile microspores more 
 highly magnified. E — Caudate cells like I 
 and B, Fig. 1, PI. 1. F— Endothelia of 
 blood vessel with entophytal vegetation es- 
 caping. G — Colorless corpuscles forming 
 into a filament. H and K — Skeins of my- 
 celial filaments in the blood. M-N — Fibrin 
 masses enclosing mycelial filaments. I — 
 Filament resembling neurine — page 413. 
 
 Fig. 5. — Crystalline bodies found in the 
 blood of scarlet fever and diphtheria. A- 
 B-C-D — Uric acid. E-K — Peculiar forms 
 do. I — Urates of soda and ammonium. 
 
 Fig. 6. Plate 5.— Forms found in urine 
 and sputa of scarlet fever and diphtheria. 
 B — Mycelial filaments found in sputa of 
 diphtheria. F-G — Filaments from urine of 
 scarlet fever. H - R — Leptothrix with 
 anabaina. M& M 1 — Structureless mycelial 
 filaments — urine of diphtheria. A — Anguil- 
 lila aceti from vinegar gargle of Amos 
 Bear. Q-Q 1 — Cells uniting to form fila- 
 ments. C — A knot of mycelial filaments 
 such as are found scattered over the mem- 
 branes of angina malignans. L-S-T-U-V- 
 W — Embryonal spores and filaments more 
 highly magnified. — The bacteria and mi- 
 crococci of authors. X — Mycelial filaments 
 such as also occurred in vast numbers in 
 ripe persimmons in Ohio, 1862. 
 
 Plate 6. Fig. 7. — Bodies found in the 
 excretions of scarlet fever. A — Normal 
 mucous cell. B-C-H — Mucous cells (scar- 
 let fever), in an active state. D-E-L-M-I — 
 Do. Do. in active filamentation. See also 
 Z, Fig. 1. Plate 1. G — Mucous cell with 
 micrococcus spores escaping at end of fila- 
 ment. N-O-near A — Do. Do. arranging 
 themselves into rows to form filaments. 
 P-Q — Mycelial filaments of mucor malig- 
 nans. R — Moniliform filaments formed and 
 forming. S & T— Highly refractive spheroi- 
 dal cells of reddish orange colored fila- 
 ments in cell on right. U — Alcholic yeast. 
 V-Vi-W— Cells shedding contents. V-X-Y- 
 Z-N near Z — Contents more highly magni- 
 fied. 
 
 Plate 7, Fig. 8. — Bodies found in urine 
 of scarlet fever. A, B, C, sporangia of mu- 
 cor malignans. D, parent epithelial cells 
 from bladder. E, mycelial filament, I, K, 
 L, N, near B, species of hypheothrix. O r 
 uric acid. R, R, R, creatine. S, T, U, 
 (N should be U) other forms of uric acid. 
 
 Fig. 9. — Scarlet fever. A, B, C, dermal 
 epithelia cultivated. D, micrococcus spores 
 from epithelium. E, F, K, ditto, united in 
 moniliform filaments. G, H, ditto, united 
 by twos and threes. L, diatom from drink- 
 ing water. M, filament of spores united 
 by twos. N, Q, Epithelial cells of skin 
 of scarlet fever. O, P, abnormal spor- 
 angia of mucor malignans, both broken. 
 R, long tubular mycelial filament. All 
 these were automobile like oscillatori- 
 acae. S, S, central nuclei of N and Q. T, 
 patch of membrane with mycelial filaments 
 of mucor malignans curiously twisted to- 
 gether and curled. U, urate of soda. W, 
 barb of feather. X, phosphate of lime. 
 Y patch of membrane. 
 
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