The constant use of a hot flaxseed poultice (as large as the whole hand and an inch thick, spread between thin layers of cotton and applied as hot as can be borne, and changed every half hour) gives more relief than anything else, and may possibly lead to disappearance of the trouble if employed early enough. The use of the poultices is to be kept up until recovery, although they need not be applied so frequently as at first. A surgeon's services are especially desirable in this disorder, as early puncture of the peritonsillar tissue may save days of suffering in affording exit for pus as soon as it forms.

DIPHTHERIA.-The consideration of diphtheria will be limited to emphasizing the importance of calling in expert medical advice at the earliest possible moment in suspicious cases of throat trouble. For, as we noted under tonsilitis, it is impossible in some cases to decide, from the appearance of the throat, whether the disease is diphtheria or tonsilitis. A specimen of secretion removed from the throat for microscopical examination by a bacteriologist as to the presence of diphtheria germs alone will determine the point. When such an examination is impossible, it is always best to isolate the patient, especially if a child, and treat the case as if it were diphtheria. Diphtheria may invade the nose and be discoverable in the nostrils. A chronic membranous rhinitis should be treated as a case of walking diphtheria.

Antitoxin is the treatment above all other reme

dies. It has so altered the outlook in diphtheria that, formerly regarded by physicians with alarm and dismay, it is now rendered comparatively harmless. The death rate has been reduced from an average of about forty per cent, before the introduction of antitoxin, to only ten per cent since its use, and, when it is used at the onset of the disease, the results are much more favorable still. This latter fact is the reason for obtaining medical advice at the earliest opportunity in all doubtful cases of throat ailments; and, we might add, that the diagnosis of any case of sore throat is doubtful, particularly in children, whenever there is seen a whitis't, yellowish-white, or gray deposit on the throat. Antitoxin is an absolutely safe remedy, its ill effects Jeing sometimes the production of a nettlerash or some mild form of joint pains. In small doses, it will prevent the occurrence of diphtheria in those exposed, or liable to exposure, to the disease. The proper dose and method of employing antitoxin it is impossible to impart in a book of this kind. Paralysis of throat, of vocal cords, or of arms or legs-partial or entire is a frequent sequel of diphtheria. It is not caused by antitoxin.

The points which it is desirable for everyone to know are, that any sore throat-with only a single white spot on the tonsil-may be diphtheria, but that when the white spot or deposit not only covers the tensil or tonsils (see Tonsilitis) but creeps up on to the surrounding parts, as the palate (the soft cur

tain which shuts off the back of the roof of mouth from the throat), the uvula (the little body hanging from the middle of the palate in the back of the mouth), and the bands on either side of the back of the mouth at its junction with the throat, then the case is probably one of diphtheria. But it is often a day or two before the white deposit forms, the throat at first being simply reddened. The fever in diphtheria is usually not high (often not over 100° to 102° F.), and the headache, backache, and pains in the limbs..? not so marked as in tonsilitis.

cori

creks.

MEMBRANOUS CROUP.-Membranous cres is diphtheria of the lower part of the throat (larynx), in the region of the Adam's apple. If in a case of what appears to be ordinary croup (p. 97) the symptoms are not soon relieved by treatment, or if any membrane is coughed up, or if, on inspection of the throat, it is possible to see any evidence of white spots or membrane, then a physician's services are imperative.

It is not very uncommon for patients with mild forms of diphtheria to walk about and attend to their usual duties and, if children, to go to school, and in that inviting field to spread the disease. These cases may present a white spot on one tonsil, or in other cases have what looks to be an ordinary sore throat with a simple redness of the mucous membrane. Sore throats in persons who have been in any way exposed to diphtheria, and especially sore throats in children

under such circumstances, should always be subjected to microscopical examination in the way we have alluded to before, for the safety of both the patient and the public.

There is still another point perhaps not generally known and that is the fact that the germs of diphtheria may remain in the throat of a patient for weeks, and even months, after all signs in the throat have disappeared and the patient seems well. In such cases, however, the disease can still be communicated in its widt t severe form to others. Therefore, in all cases of

part

phtheria, examination of the secretion in the throat must show the absence of diphtheria germs before the patient can rightfully mix with other people.

Gargling and swabbing the throat with the (poisonous) solution of bichloride of mercury, I part to 10,000 parts of water (none of which must be swallowed), should be employed every three or four hours each day till the germs are no longer found in the mucus of the tonsils.

HOARSENESS (Acute Laryngitis).—This is an acute inflammation of the mucous membrane of the larynx. The larynx is that part of the throat, in the region of the Adam's apple, which incloses the vocal cords and other structures used in speaking. Hoarseness is commonly due to extension of catarrh from the nose in cold in the head and grippe. It also follows overuse of the voice in public speakers and singers, and is seen after exposure to dust, tobacco, or

other smoke, and very commonly in those addicted to alcohol.

Symptoms. - Hoarseness is the first symptom noticed, and perhaps slight chilliness, together with a prickling or tickling sensation in the throat. There is a hacking cough and expectoration of a small amount of thick secretion. There may be slight difficulty in breathing and some pain in swallowing. The patient feels generally pretty well, and is troubled chiefly by impairment of the voice, which is either husky, reduced to a mere whisper, or entirely lost. This condition lasts for some days or, rarely, even weeks. There may be a mild degree of fever at the outset (100° to 101° F.). Very uncommonly the breathing becomes hurried and embarrassed, and swallowing painful, owing to excessive swelling and inflammation of the throat, so much so that a surgeon's services become imperative to intube the throat or to open the windpipe, in order to avoid suffocation. This serious form of laryngitis may follow colds, but more often is brought about by swallowing very hot or irritating liquids, or through exposure to fire or steam. In children, after slight hoarseness for a day or two, if the breathing becomes difficult and is accompanied by a crowing or whistling sound, with blueness of the lips and signs of impending suffocation, the condition is very suggestive of membranous croup (a form of diphtheria), which certainly is the case if any white, membranous deposit can be either seen in the throat or is