washing all the cans as well as distributing milk to the customers. The first case in Portsmouth did not occur until after the man had been taken sick and the disease has continued to develop slowly up to the present time. There have been in all sixteen or seventeen cases, nearly all of which had partaken of the milk in question, but, as a rule, had held no communication with the man who delivered it. There has been but one death in this city thus far, and the majority of the cases have been of mild type. One child continued to drink freely of the infected milk during its entire illness. The latter was of a rather severe type, but the patient is now convalescent. Among several of Mr. Leavitt's customers there have been instances of severe sore throat without any diphtheritic exudation whatever. Instructions were given regarding the disinfection of the premises, the bedding, and the milk cans, and the delivery of the milk was prohibited until the board raises the quarantine upon the farm.

Yours truly,

JOHN J. BERRY.

An inspection of the farm of John H. Leavitt of Newington, made June 17, 1893, by this board, establishes the following facts:

"The sanitary condition of the house and farm buildings was fairly satisfactory.

"The water supply was pure and abundant, and with the exception of a few minor defects in plumbing, the drainage was fully up to the average.

"The live-stock was examined by a veterinary surgeon and pronounced absolutely free from disease.

"In the opinion of the board, the infection of the milk resulted from a case of diphtheria which occurred at the farm a few days prior to the epidemic, and which terminated fatally on the twelfth of the present month.

"The proper sanitary measures recommended by us having been carried out by Mr. Leavitt, the milk furnished by him

is, in our judgment, no longer infectious, but may be safely used by his customers.

"JOHN J. BERRY, M. D.,

"Member of State Board of Health, Portsmouth, N. H., June 21, 1893."

The distribution of diphtheria by infected milk is a matter of record in more than one locality during the present year.

Dr. Hunt, medical inspector of the New Jersey State Board of Health, has reported' upon the outbreak of diphtheria occurring at Hightstown in that state. He found that eighteen out of the twenty cases investigated, were in families supplied by the same milkman, in whose employ was a lad suffering from diphtheria, but at work in the dairy. The general sanitary condition of the town was good, and had no part in the epidemic.

1 B. M. and S. Journal, August 10, 1893.

DIPHTHERIA AND MEMBRANOUS CROUP.

Under date given below, the following circular was issued to the local boards and physicians of New Hampshire:

STATE OF NEW HAMPSHIRE.

STATE BOARD OF HEALTH.

MEMBRANOUS CROUP.

Membranous croup will hereafter, in New Hampshire, be included in the list of quarantinable diseases. It will be the lawful duty of physicians to report every case of membranous croup to the local board of health, in accordance with the rules and regulations established by the State Board of Health, under the law entitled "An act to prevent the introduction of epidemic diseases into the state." Local boards of health, upon receiving notice of a case of membranous croup (or diphtheritic croup), will at once proceed to take official charge of the case, in the same manner and under the same rules and regulations as in cases of diphtheria.

Many observers now believe in the pathological identity of membranous croup and diphtheria. At all events it is much the safer course to regard all throat and laryngial conditions accompanied by membranous deposits as diphtheria, and to exercise the same sanitary precautions that are required in the management of the latter disease. The frequent appearance of diphtheria and membranous croup simultaneously, in the same family or community, is one evidence of the identity of the two conditions. The death returns in New Hampshire for the past eight years, show that upon the average, "croup" causes one half as many deaths as diphtheria, appearing simultaneously with the latter and under the same local conditions and circumstances. The infectious character of membranous croup (laryngial diphtheria) has been witnessed by many observers. It therefore becomes the duty of physicians and health

officers to take the same sanitary precautions in a case of membranous croup that they are instructed to observe in a case of diphtheria.

Local boards of health must quarantine every case of membranous croup reported, placard the premises, prohibit public funerals in cases of deaths from this disease, see that at the proper time disinfection is carried out-all in accordance with the instructions embraced in a circular issued by the State Board of Health, on the "Prevention and Restriction of Diphtheria."

Concord, N. H., June 1, 1893.

IRVING A. WATSON,
Secretary.

The following is a copy of the placard authorized, and which will be furnished local boards of health upon application. A copy has already been forwarded to every board in the state:

MEMBRANOUS CROUP.

All persons are strictly forbidden to enter or leave these premises without special permit from the Board of Health.

All persons are strictly forbidden to remove this card without orders from the Board of Health.

Any violation of these regulations will be punished to the fullest extent of the law.

BOARD OF HEALTH.

So far as preventive measures are concerned, there should be no distinction beween diphtheria and croup. Indeed, it is the writer's opinion that there is no difference whatever between the two, except in local symptomatic manifestations that pathologically the so called membranous croup is true diphtheria. Dr. C. R. Early, of Pennsylvania, in a paper presented to the American Medical Association upon Croup, says,

Dr. William Cullen calls this disease "Cynanche Trachealis."

"This name has been given to an inflammation of the glottis, larynx, or upper part of the trachea, whether it

affect the membranes of these parts, or the muscles adjoining. It may arise first in these parts, and continue to subsist in them alone; or it may come to affect these parts, from the cynanche tonsillaris or maligna spreading into them. In either way it has been a rare occurrence, and few instances of it have been marked and recorded by physicians. It is to be known by a peculiar ringing sound of the voice, by difficult respiration, with a sense of straitening about the larynx, and by a pyrexia attending it."

We will now refer to the writings of Bartholomew Parr, M. D.1

66

ANGINA TRACHEALIS.

In compliance with Doctor Johnson and consonantly with our observations in a former article, we mention this species as a separate one, and distinct from that sometimes comprehended under this title by other authors.

"The croup we shall consider under the appellation of angina stridula, and confine the present term to the malignant angina, extending to the trachea, or to that species of the disease in which the larynx and trachea are originally attacked. To this complaint authors have not, perhaps, paid due attention; it is indeed seldom an original disease; yet, within our observation, it has appeared to be so. It is truely an erysipelatous inflammation in contradistinction to the phelgmonic; nor does it materially differ in its treatment from putrid pneumonia, or angina maligna. We need not in such instances dread the power of the bark in inducing dyspnoea, but employ it freely with cordials. The only question is, whether blisters are more admissible or more effectual? From our own experience we cannot encourage their application; but they certainly do no harm.”

ANGINA STRIDULA.

"This is the cynanche trachealis of Cullen; a disease that, for its singularity and fatality, has fixed the attention.

1 Parr's Medical Directory, D. D. 1808. Vol. 1, pp. 119-120.