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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 are not so marked as in tonsilitis.
MEMBRANOUS CROUP.-Membranous croup 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. 83) 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 most severe form to others. Therefore, in all cases of diphtheria, 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
coughed up. Whenever there is difficulty of breathing and continuous hoarseness, in children or adults, the services of a competent physician are urgently demanded.
Treatment. The use of cold is of advantage. Cracked ice may be held in the mouth, ice cream can be employed as part of the diet, and an ice bag may be applied to the outside of the throat. The application of a linen or flannel cloth to the throat wrung out of cold water and covered with oil silk or water-proof material, is also beneficial, and often more convenient than an ice bag. The patient must absolutely stop talking and smoking. If the attack is at all severe, he should remain in bed. If not so, he must stay indoors. At the beginning of the disorder a teaspoonful of paregoric and twenty grains of sodium bromide are to be taken in water every three hours, by an adult, until three doses are swallowed.
Inhalation of steam from a pitcher containing boiling water is to be recommended. Fifteen drops of compound tincture of benzoin poured on the surface of a cup of boiling water increases the efficacy of the steam inhalation. The head is held above the pitcher, a towel covering both the head and pitcher to retain the vapor.
The employment, every two hours, of a spray containing menthol and camphor (of each, ten grains) dissolved in alboline (two ounces) should be continued throughout the disease. If the hoarseness persists and
tends to become chronic, it is most advisable for the patient to consult a physician skilled in such diseases for local examination and special treatment.
CROUP.-Croup is an acute laryngitis of childhood, usually occurring between the ages of two and six years. The nervous element is more marked than in adults, so that the symptoms appear more alarming. The trouble frequently arises as part of a cold, or as a forerunner of a cold, and often is heralded by some hoarseness during the day, increasing toward night. The child may then be slightly feverish (temperature not over 102° F., usually). The child goes to bed and to sleep, but awakens, generally between 9 and 12 P.M., with a hard, harsh, barking cough (croupy cough) and difficulty in breathing. The breathing is noisy, and when the air is drawn into the chest there is often a crowing or whistling sound produced from obstruction in the throat, due to spasm of the muscles and to dried mucus coating the lining membrane, or to swelling in the larynx. It is impossible to separate these causes. The child is frightened, as well as his parents, and cries and struggles, which only aggravates the trouble. The worst part of the attack is, commonly, soon over, so that as a rule the doctor arrives after it is past. While it does last, however, the household is more alarmed than, perhaps, by any other common ailment.
Death from an attack of croup, pure and simple, has probably never occurred. The condition described