Crescent. Several children of the family had just suffered, and recovered without treatment, from sore throat. They had been, in the parents' estimation, worse than was our little patient (æt. 6), when her croupy breathing excited their alarm. The friends declined to allow tracheotomy to be performed, and the child died within forty-eight hours from the supervention of the first laryngeal symptoms.

A child, aged about six years, had suffered for two or three days from sore throat. The surgeon who saw the child before the father left home in the morning assured him that the disease was trifling. On the father's return, late at night, the croupy breathing excited his alarm. I saw the child, with the surgeon, about midnight. There was then rapid pulse, husky whispering voice, shrill respiration, and great dyspnoea. Before seven o'clock in the morning the child was dead.

The infant child, aged eleven months, of a surgeon, had for a day or two slight symptoms of sore throat. The father's fears, although he is an anxious parent and a most intelligent and experienced practitioner, were not excited till between ten and eleven at night when he noticed for the first time laryngeal breathing. The extreme

recession of the softer parts of the chest walls during inspiration proved the impediment to the passage of the air through the larynx. There was a little lymph on the pharyngeal mucous membrane when I saw the child about eleven P.M. Before morning it was dead. These cases will impress on you the importance of examining carefully the pharynx in every case, even the most trifling, of sore throat.

FOURTH VARIETY.-The nasal form of diphtheria. -Another set of cases constitute what has been termed the nasal form of diphtheria. After some febrile disturbance of low type, a sanious discharge from the nose attracts attention; then the glands about the angles of the jaw swell; the arches of the palate and the tonsils are found to be red and swollen; muco-purulent fluid bubbles in quantity from the narrow isthmus faucium, and prevents you obtaining a clear view of the pharyngeal mucous membrane. After a few days the disease subsides, and you remain in doubt as to its nature; or it spreads to the larynx, and the diagnosis becomes easy, and death enables you to verify it; or some other member of the family or an attendant sickens with unmistakeable symptoms of diphtheria. Or the disease begins with trifling sanious

discharge from the nares; the lymphatic glands are scarcely at all affected, and the nature of the disease is not even suspected till death is imminent from suffocation; or again, when the exudation reaches the pharynx, the pharyngeal symptoms may be most distressing, and lead to inspection of the part and the detection of the disease.

In November, 1859, I saw, with Dr. Carlill of Berners Street, a very interesting case of nasal diphtheria, remarkable especially for the difficulty of the diagnosis, even at a time when serious symptoms were present. The patient was a girl aged two years. The parents first observed that the child had a little sanious discharge from the nose, and was very decidedly out of health. The discharge from the nose had ceased when I saw the child. There was no enlargement of the lymphatic glands of the neck. The great feature in the case at that time was frequent vomiting. Almost every attempt to swallow was followed by efforts of vomiting, and the forcible ejection of fluids through mouth and nose. As the vomiting seemed sometimes to come on before the fluids could have reached the stomach, the throat was inspected by both Dr. Carlill and myself; nothing wrong in it could, however, be detected. Although

the nature of the case was obscure, the whole group of symptoms present led us to the opinion that they were the consequence of disordered innervation from cerebral disturbance, rather than the result of any throat affection. "Two days," Dr. Carlill wrote me, "after you visited her, I saw a thin pellicle partly covering the velum pendulum palati, and partly detached and hanging down into the mouth. She died the next day, never having been able to swallow more than a small part of what was given her for about six days." The immediate cause of death was the extension of the exudation to the larynx; the child died from suffocation, as in primary croup.

The following case of nasal diphtheria possesses special interest from the chief evidence in favour of the diagnosis being the communication of the disease to another-just the kind of evidence which we consider conclusive in regard of the nature of some obscure cases of scarlet fever.

Master P., aged about two years, suffered some febrile disturbance of low type, and profuse mucopurulent discharge from the nares, and redness and swelling of the velum pendulum palati, uvula, arches of the palate, and tonsils; the posterior wall of the pharynx was not very clearly to be

seen, in consequence of the large quantity of muco-purulent fluid that bubbled in the pharynx. Dr. Carlill, whose patients this little one and his brother, less severely but similarly affected, were, thought the cases were true diphtheria. I had considerable doubt on the point. At any rate, as we could see no lymph, and the larynx was not affected, I hesitated to admit it. Dr. Carlill was in attendance from the 15th to the 28th of March, 1860, and a lotion was injected into the nares and throat by Dr. Carlill daily, from the 15th to the 25th. On two occasions Dr. Carlill remembered distinctly that the child coughed some sputa into his face. On April 2nd, Dr. Carlill was himself attacked by diphtheria.

Had the child whose case I am now about to relate recovered, and had not the child in the next bed suffered within a few days from unquestionable diphtheria, doubts as to the nature of the disease under which it suffered might have been felt.

William W., aged two years and three months, a delicate child, the subject of rickets, was admitted into the Hospital for Sick Children on the 31st of December, 1860, the rash of measles having appeared on that day. The rash came