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ferential diagnosis between viagra wholesale uk those cases of broncho- pneumonia which have been caused by an extension of the diphtheritic process through the trachea and bronchi into the lungs and those cases in which the lungs have become inflamed in greater or less areas without the respiratory mucous membrane intervening between the seat of disease in the throat and that in the lungs being affected by diphtheria. Fortunately it is generally easy to follow the course of disease in those cases of laryngeal diphtheria in which the process spreads downward through the trachea and bronchi into the lungs. There will be the coarse bronchial rales in disease of the bronchi, then fine sibilant rales showing its progress into the capillary bron- chioles and almost at the same time crepitant and subcrepitant rales indicating the involvement of the lungs. If a considerable area of lung tissue has be- come involved, the prognosis in these cases is ex- where to buy viagra manila tremely fatal. Indeed, even when at first but a small portion of lung tissue is involved the process is apt to extend very rapidly. Some portions of lung tissue which do not become inflamed are apt, through the closing of their terminal bronchioles and consequent imperfect inflation, to be the seat of atelectasis. Fur- thermore, vesicular emphysema is apt to incapacitate portions of lung tissue that have remained healthy so far as the inflammation was concerned, so that in these cases the prognosis is almost certainly fatal. Isolated patches of broncho-pneumonia, even when of considerable size, provided the larger bronchia are not the seat of diphtheria, as a rule give a much bet- ter prognosis than broncho-pneumonia the result of extension of the primary disease as above described. Lobar pneumonia, although its occurrence as a complication of diphtheria is much rarer than viagra wholesale uk lobular pneumonia, has a comparatively good prognosis, more favorable than that of broncho-pneumonia even of the latter variety. It resolves by crisis and, as a rule, where to buy viagra manila in much shorter time than broncho-pneumonia. Septic or gangrenous pneumonia, it is unnecessary to say, is absolutely fatal. Furthermore, the prognosis depends upon the sever- ity of the diphtheritic viagra wholesale uk process, the stage of the disease in which the pneumonia has occurred, the surround- ings and strength of the patient, and finally as to whether the case has been operated upon or not. Pneu- monia complicating tracheotomy is, as a rule, almost certainly fatal, but viagra wholesale uk in pneumonia complicating cases that have been intubated, while the prognosis is ve grave, still it is better than in similar cases that have been tracheotomized. While we can only accentuate the gravity of pneu- monia complicating diphtheria, it is but proper to remember that, taken all in all, a great many cases re- cover from where to buy viagra manila even this serious condition. Treatment, Prophylactic or Preventive This being a disease due primarily to bacterial infection, it necessarily follows that cases of broncho-pneumonia complicating diphtheria should be isolated from other where to buy viagra manila children having diphtheria. Indeed it would be per- fectly proper to go further, were that the object of this paper, and lay down the general rule that where to buy viagra manila all cases of pneumonia should be isolated from persons in health in order to prevent infection. The fact that broncho- pneumonia is so much more prevalent in diphtheria hospitals than in private houses where single cases of diphtheria occur is probably due, first, to this conta- gious element in broncho-pneumonia; second, to the fact that the air of the hospital ward in which many cases of diphtheria lie becomes surcharged with bac- teria, especially with streptococci. Hence it follows that cases of broncho-pneumonia occurring in diph- theria hospitals should not only be isolated, but that even cases of diphtheria uncomplicated by broncho- pneumonia should have allowed a much larger air space for each patient than is given in viagra wholesale uk general hospitals to each bed. The ventilation should be perfect, the air of the ward being frequently changed without the pro- duction of a draught. The temperature of the ward should be kept at 70 F. in order to avoid viagra wholesale uk weakening the patients by too warm an atmosphere. The latter precautions as to ventilation and temperature should be followed in private houses also, wherever a case of diphtheria is being treated. Cases tljat have been intubated and above all viagra wholesale uk those that have been tracheotomized should be carefully- guarded from contact with cases of broncho-pneumo- nia, for, as I have already said, micro-organism are generally active in viagra wholesale uk the production of this complication when the mucous membrane of the respiratory tract has undergone a lesion ; this viagra wholesale uk is apt to be the case in intubation and it certainly occurs in tracheotomy. In intubated cases it is further necessary that great care be taken in feeding, that liquid particles of food do J/ o MEDICAL RECORD. [March 14, 1896 not regurgitate into the larynx and thus produce " Schluckpneumonie." This can be, to a great ex- tent, where to buy viagra manila prevented by feeding the child in the supine po- sition, with the head thrown well back over the edge of the couch or the lap of the nurse. Curative Treatment. We can do nothing locally to treat the seat of disease. I say this in order to discourage the treatment of broncho-pneumonia by inhalations of antiseptic vapors. I do not think that