evidence of the sore throat. The fauces are red and swollen, sometimes very much so, but the redness is not vivid, and there is not in general that difficulty in opening the mouth which is experienced in scarlet fever when the sore throat is at all severe. The false membrane appears almost simultaneously on both tonsils; and soon after on the soft palate and uvula, and the latter is generally much swollen, and contributes a good deal to obstruct the channel of the fauces. Accompanying this state of the throat, there is often a discharge from the nares, resembling the coryza of scarlet fever, and as has already been mentioned false membrane is occasionally deposited there, whence it may travel to the posterior nares, and so to the throat and air-passages. When the deposit is considerable the appearance of the tongue is peculiar. It is usually red at the tip, but thickly coated with white fur, which on the dorsum and towards the root of the tongue is almost membraniform. It is not usual for the inside of the mouth to be affected, but now and then the gums are red, soft, and spongy, and covered here and there, as well as the inside of the cheek, with patches of false membrane, beneath which the tissue appears red and shining. When the mouth is thus affected the secretion of saliva is considerably increased; but I have never seen that profuse dribbling of it which takes place in stomatitis, nor have I observed that complication of stomatitis with diphtheria of which M. Bretonneau speaks, and which led him to regard the two diseases as closely related to each other. It is after the false membrane has been formed somewhat abundantly for two or three days that it undergoes those changes which impart to the breath its peculiarly offensive odour, and give to the fauces that appearance of being the seat of a sloughing ulceration, whence arose the old names of angina maligna, angina gangrænosa. Even when the affection of the throat is most considerable, deglutition can still almost always be performed, not easily indeed, but yet in general without that extreme difficulty which one often observes in the sore throat of scarlet fever, and of common quinsy. The voice is often hoarse and indistinct, independently of actual affection of the larynx, and a short spasmodic, slightly ringing cough, is frequently heard, due to the irritation of the larynx by the mischief in its vicinity. But, though these symptoms do not necessarily imply that the air-passages are actually involved in the disease, they should keep us most anxiously on the watch, since very few tokens indicate this event, and they are often of a kind to escape the notice of the unobservant. 410 VARIOUS MODES IN WHICH In proportion to the severity of the case is usually the shortness of the premonitory fever, which sometimes does not exceed twelve hours in its duration, and at other times scarcely occurs at all, the child being struck down at once by the disease; false membrane being deposited extensively on the fauces in the course of a few hours, and the coryza, which usually does not appear before the third day, showing itself almost from the first. The mode in which such cases tend to a fatal issue is very various. As a general rule it may, I think, be said that the laryngeal affection, which is so grave a source of peril, does not so frequently occur in cases where the constitutional symptoms of diphtheria are most severe, as in those in which they wear a milder form. At the same time, however, no guarantee is furnished against its supervention by the gravity of the disease in other respects, while, when the larynx becomes involved in severe diphtheria, the case must be regarded as at once utterly hopeless.* The subjoined Tables represent the conditions in which 34 cases of diphtheria proved fatal. In 18 cases the affection of the air-passages was the chief, if not the only, cause of death; in the remaining 16 the larynx was unaffected. Table of cases in which death took place from diphtheria independent of affection of the larynx. DIPHTHERIA PROVES FATAL. 411 Setting aside these cases, we find that the evidence of general constitutional disorder becomes more marked day by day, and this F. 2 0 Diabetic patient; Exhaustion; urine albumi 23rd day of came on on the nous. Exhaustion; state of urine Exhaustion; state of urine Date of Death 28th day from commencement of pleuropneumonia;19th of diphtheria. 50th day of diphtheria; 27th of measles; clot choking both common iliac, right external iliac, femoral and popliteal arteries; veins healthy. In the following, death was due mainly to the laryngeal affection: 412 VARIOUS MODES IN WHICH even without an invariable aggravation of the local malady. Of these evidences one of the most important is furnished by the presence of albumen in the urine. I believe that albumen is rarely absent in cases of other than the very mildest diphtheria; though the amount is strangely fluctuating, varying even on successive days; and these fluctuations are by no means constantly associated with any corresponding modifications in the other symptoms of the disease. When the albumen, however, is very abundant, the urine is invariably scanty,* and there is perhaps no single symptom of worse omen than the extremely scanty secretion of urine. In cases of average severity the albumen seldom makes its appearance * I am glad to be able, from further experience, to correct an error which I fell into in my former edition; in which I stated that no relation existed between the amount of albumen in the urine and the scantiness of the secretion. My friend and colleague Dr. Hillier, has pointed out this mistake in his very valuable article on Diphtheria, in the British Medical Journal for September 24, 1864. DIPHTHERIA PROVES FATAL. 413 within the first four or five days; and then, according to the subsequent progress, it either goes on increasing, or lessens with the gradual improvement in the patient's condition. The complete suppression of urine is an almost invariably fatal symptom, and I do not know of any instance in which the patient has recovered after the urinary secretion has been suspended for twenty-four hours. In these circumstances, and even in cases where the urinary secretion, though not absolutely suspended, is unusually scanty, uræmic convulsions are likely to occur and suddenly to carry off the patient. But even where the urinary secretion continues in tolerable quantity, and the albumen is not excessive, the symptoms that attend the progress of the disease are invariably those of depression, and of depression which, like that attendant on the worst forms of puerperal fever, is by no means constantly proportionate to the apparent local mischief. The child, feeble yesterday, becomes still feebler to-day, and often, without any actual increase of deposit, sometimes even in spite of its diminution, and of the absence of any apparent cause for difficult deglutition, the repugnance to take food goes on increasing, until at length he positively refuses all nourishment. This refusal of food, whether in childhood or in adult age, is a very unfavourable occurrence. It is sometimes associated with vomiting, and may then be dependent on the presence of false membrane in the stomach, though this is by no means always the case; but whether it be so or not it tends to reduce the patient's strength very much, and if persistent for any considerable time almost invariably occasions fatal depression. It is not always easy to realise the degree of peril, for the intellect is generally clear, and the muscular powers are not inconsiderable, while at the same time the extremities are cold, and the pulse is either extremely frequent or else very feeble or irregular in its beat. For two or three days together, this condition may continue, the pulse growing feebler, the signs of failing power more manifest, and this in spite of stimulants being administered lavishly, and taken readily, until at length either the signs of the last stage of croup suddenly appear, showing that the local mischief has been extending silently and unperceived, or else an attack of syncope follows on some sudden and violent action of the bowels, or causeless convulsions come on, and in the subsequent coma the patient dies. This depression too, as already mentioned, is by no means constantly proportionate to the extent of the false membrane, nor is the danger of it passed even when the local mischief, as far at |