Although diphtheria (or putrid fever, a more appropriate name, and comprehensive of all the phases of the disease) is eminently a constitutional affection, it is liable to spe cial local manifestations, the latter sometimes apparently predominating. Now-, why does it so often have predominating local characteristics? The following is probably the explanation. The attack is usually brought on by a "cold," and if the system be only slightly contaminated at the time, the symptoms are not likely to be alarming, and will readily yield to prompt treatment, hut it should always be borne in mind that the disease is exceedingly stealthy and treacherous, and to be watched like a wolf. Again, the system may be considerably loaded with the germs of the disease, although not to the culminating point. Here, also, causes which produce a "cold" will, besides bring ing on the general attack, also give rise to violent local symptoms. But when no excit ing causes occur to hasten the attack, and the septic poison is being constantly received, there comes at last a time when a fully developed case of putrid fever will make its appearance. a disease of the gravest character, but which may be recovered from.
One of the conclusions which have been arrived at by the medical profession is that those who live in badly ventilated or drained houses are, with perhaps some exceptions depending on the effects of temperature which are not yet well understood, constantly in a condition which renders them liable to a diphtheritic attack of varying importance. It is true that there are physicians who do not like to pronounce certain cases of sore throat as diphtheritic, unless they have more or less of an alarming character, or appear during an undoubted epidemic, but diphtheria is so treacherous a disease that it is not well to strive to balance arguments at the risk of life, especially when observation has almost surely decided the question on the safe side. It is well known that persons are not as likely to take a "cold" on our Pacific coast or in some of our western territories, as in the Mississippi valley, or between it and the Atlantic ocean. It is therefore probable that organic matter has much to do with the development of "colds;" undoubtedly it has with that of influenza. If we call this organic matter zymotic, then we may assume that with the aid of the vitality of the system it works itself out, or recovery takes place without recourse to medicine. Now, in regard to the septic germs of diphtheria, it is known that they are generally present in the effluvia of cesspools, sewers, and filthy habitations, perhaps more especially developed or active in the temperate and moist weather of spring and autumn, and mild winters. Therefore, it is reasonable to believe that persons inhabiting badly drained localities, where putrescent effluvia more or less pollutes the air, never have inflammatory affections of the mucous membrane of the mouth or fauees, without having it more or less modified by this circumstance. All persons, therefore, who live in houses where the dridn-pipes are not properly trapped, and where there is more or less intrusion of sewer gas through the wash-basins, bath tubs, etc., will have reason to suspect that when they have febrile symptoms, alternat ing with chills, but unlike those of fever and ague, and a feeling of weariness, whether accompanied with pain in the throat, or not, there may be diphtheritic complications. Tho above symptoms are those of milder cases. The attack, when acute, frequently commences with a decided chill, followed by a high fever. The chill and the fever are characteristic, and generally easy to be recognized by the experienced physician. The pulse, however, affords a still stronger indication, and when taken in connection with the chill and the following fever, and the condition of the throat, together with the sur rounding sanitary conditions, is quite diagnostic. It is variable, and soft and weak;
sometimes quite full, but easily compressible; sometimes not more frequent than in health, but generally ranging from 100 to 140 beats per minute; sometimes reaching 160, and in children going still higher. The cheeks are often of a bright red color, one cheek often much redder than the other, the latter sometimes being quite pale. There is a fluctuation in the circulation, and also, apparently, a fluctuation in the nervous force of the system, It must not be supposed that the throat affection, even when serious, will be indicated by pain, for there is often found considerable mischief, upon inspec tion. where the patient suspected nothing of the kind. There may be pain only on swallowing; while on the other hand there may be diminution of sensitiveness, espe cially in grave cases, when also the muscles of deglutition may be so paralyzed as to interfere with swallowing, and in extreme cases there maybe paralysis of different parts of the body, generally affecting one side more than the other; but this condition, caused by the great development and accumulation of poisonous matter, may be relieved by the prompt administration of proper remedies. The disease is, indeed, singular in some respects. Although sometimes perfectly unmanageable, and causing death in a few hours. it is at times, even when violent, easily overcome. if attacked with resolution and courage. The paralysis which sometimes occurs at the commencement of the disease must not be confounded with that which often comes on during convalescence atter serious attacks. The breath is always more or less fetid, and in severe cases is very offen sive. Sometimes the membranous exudation is extensive, spreading over a considerable portion of the fauccs. often causing sloughing, especially when efficient remedies are not employed. The exudation may not he confined to the throat or any part of the air pas sages, but may form on the mucous membrane of the intestines, and has been recognized in the evacuations of the rectum. It niny also form on the mucous membrane of the larynx or wind-pipe, or even pass into the bronchial tubes, and when diphtheritic sputa has been thrown upon the mucous membrane of the eyelids, exudations have developed there. Observation has shown that the range of temperature in the axilla is lower than in other acute diseases. There is usually loss of appetite, with vomiting, and often diarrhea; the latter are unfavorable symptoms. There is more or less delirium in all severe cases, and unless good treatment is speedily adopted the throat is liable to become gangrenous. There is great variableness, no doubt, in the virulence of the poison during different epidemics, and sometimes three fourths of the members of a family will die. The urine, in a majority of cases, at some time during the attack contains albumen, and the symptom is regarded as unfavorable, yet a majority of such cases recover. The neck is often considerably swollen, with considerable inability to move the jaws or to swallow. The tongue and throat arc covered with a thickened mucus; the tonsils are generally considerably swollen when the first examination is made, and may have patches of a grayish or yellowish membrane upon them. The membrane, however, is sometimes not seen, either upon the tonsils or other parts of the mouth or throat, till the second day. The tonsils generally increase in size, and sometimes close the entrance to the wind-pipe, and render swallowing very difficult. The color of the parts is also peculiar; indeed, many of the symptoms of D. are peculiarly characteristic, usually making the diagnosis, especially when the history of the person is taken into consideration, easy.