out full and well; from the first there were abundant sonorous and mucous ronchi audible over the whole chest. On the 3rd of January, that is, the fourth day of the eruption, there was much discharge from the nose, and a little ulceration of the orifice of the nares. His appetite was good, there was no difficulty in swallowing; the skin was very hot.

By ten o'clock the same night a marked change had taken place in the child, and the following notes of its state were made by Mr. Sydney Ringer, the very able Medical Registrar to the Hospital:

"Child prostrate; pulse 160, weak; respirations hurried but not laborious; no lividity of the face or body. Abundant dirty muco-purulent discharge from the right nostril. Fauces, uvula, and tonsils red, and very much swollen, and covered with thick tenacious mucus. No exudation can be seen, but then the thick mucus in the pharynx prevents a perfect inspection of the parts." At nine A.M. the fifth day of eruption, the child was weaker, but could still swallow solids and fluids, and apparently without difficulty. The eruption was well out.

About one P.M. the nurse raised the child's

head, in order to give it some food-it fell back and died without a struggle.

The body was examined the next day. The lungs were the seat of extensive acute emphyema, and of a little collapse. The lymphatic glands along the trachea were not enlarged; those behind the angles of the lower jaw were only just perceptible to touch before the integuments over them were divided. The whole substance of the velum pendulum palati and uvula was considerably thickened and toughened. The cavity of the pharynx was smaller than natural, the mucous and sub-mucous tissues thickened; the mucous membrane was bright red, and elevated into rugæ. Here and there, on the surface of the mucous membrane at the upper part of the pharynx in the vicinity of the posterior nares was a little lymph, granular in form, very soft, and easily removed by scraping with the knife, nowhere forming a continuous layer. The aryteno-epiglottidean folds were greatly thickened, the epiglottis also decidedly but less thickened. The mucous membrane of the larynx was less smooth and polished, and at the same time redder than it should be, and the chorda vocales were more spongy looking than natural. The

abnormities of the larynx were all insignificant in degree-perhaps such as are often present in measles. The lesions of the upper part of the pharynx were decided, although still trifling; they were the result of nasal diphtheria complicating the measles. The child probably died at so early a period of the diphtheria, in consequence of the weakness resulting from the severe attack of measles under which it was suffering at the time the diphtheria supervened, and its natural delicacy of constitution (it was not only ricketty but also tubercular). The cause of death was asthenia.

As if to prove to us the nature of this case, the child in the next bed sickened with well-marked diphtheria within twelve hours of William W.'s death. In twenty-four hours from the first symptoms of illness, its trachea was opened by Mr. Berkley Hill, death by suffocation being imminent. I shall describe this case at some length in my next lecture when speaking of the value of tracheotomy.

FIFTH VARIETY.-The primary laryngeal form of diphtheria.—I have seen three cases in which the exudation seemed without doubt to occur first in the larynx, the pharynx being subsequently affected. We may call this-primary laryngeal

diphtheria. In one of these cases the patient was a medical man, about forty-five years of age. The disease began with pain in deglutition, and redness and swelling of the mucous membrane of the pharynx, arches of the palate, uvula, and soft palate. Laryngeal symptoms rapidly supervened; then a little lymph was seen on the arches of the palate, the exudation being more abundant at the base of the arch than above, and equal on the two sides; it looked as if it had spread upwards from the larynx. The patient would have died from apnoea had not the larynx been opened on the third day of illness. During the second week of illness, he almost died from asthenia.

Another case was that of the child whose pharynx, larynx, trachea, &c., are on the table (Specimen 3). I described the parts to you early in the lecture.

In all the varieties of diphtheria I have described, the disease when fatal proved so in consequence of exudative inflammation affecting the larynx. The patient dies in such case from the impediment to the entrance of the air into the lungs. In the variety of which I am now about to speak the patient, when the disease proves fatal, dies from the general disease.

SIXTH VARIETY.-The asthenic form of diph

theria. In this form the disease begins sometimes with general and local symptoms of moderate severity. Soon, however, the pulse is rapid and feeble; the sense of weakness and of illness extreme; the skin is not very hot, but there is a peculiar feverish pungency in its heat as appreciated by the touch; the complexion has that dirtylooking, pallid, and opaque aspect which we see in so many general diseases. In some cases, from an early period of the disease, the brown tongue, the sordes on the teeth, &c., and the muttering delirium which are characteristic of the so-called typhoid condition, are present. On examining the throat, more or less lymph is seen on the pharyngeal mucous membrane. The lymph in these cases has always, in my experience, been of the granular, pulpy, or softer form. The patient may swallow with perfect facility and the throat symptoms be trivial in degree, and this even when the pharyngeal mucous membrane is covered with lymph. In other cases the pain in deglutition is extreme. The extension of the exudative inflammation to the larynx, when it occurs, is shown by a little huskiness and want of power in the voice, and imperfectly marked laryngeal breathing. The patient usually dies in about ten