tonsils, with success. The pressure is to be repeated three or four. times a day, and as soon as the gland becomes softer and absorption commences, gargles may be used. Dr. Churchill (Diseases of Children) suggests that a fair trial should be given to an application of the caustic tincture of iodine to the enlarged tonsils, with the external use, also, of the iodine ointment. This he has seen very successful in several cases. He very properly opposes strongly any attempt to remove by the knife the hypertrophied tonsils during childhood. The operation is by no means generally successful, and may be productive of consequences more troublesome than the disease.

3.-Pseudo-membranous, or Diphtheritic Inflammation of the Throat. Diphtheria.

This is one of the most common forms of inflammation of the throat in children, and is that which most generally accompanies scarlatina, when the latter prevails as an epidemic. Its most conspicuous character is the early excretion, especially in the throat, of a thin, pseudo-membranous pellicle, either continuous or in patches, and closely adherent to the surface of the inflamed mucous membrane, upon which it is produced.

Pseudo-membranous inflammation of the throat commences often with symptoms of so mild a character, as to attract scarcely any attention until the local disease has made considerable progress. The deglutition is but little or not all-impeded; only a trifling soreness, or rather a sense of roughness in the fauces is experienced, while no febrile excitement is present. The child often continues to indulge in its ordinary sports, with, perhaps, a little more fretfulness and dejection than usual, and becoming, apparently, more quickly tired.

In other cases there is, from the commencement of the attack, a sense of languor and general discomfort; a feeling of chilliness, alternating with flushes of heat; increased thirst; pain of the head; a sense of heat or burning in the throat; while the act of swallowing, and the slightest motion of the neck, cause more or less pain. The skin is hot and dry; the eyes are often red and watery; and the countenance flushed. Frequently, however, the countenance is tumid, pale, and expressive of sadness or dejection. When there exists any decided febrile excitement, an exacerbation generally occurs night and morning. There is, in many cases, considerable nausea, and tenderness of the epigastrium. At first, there is usually a constipated state of the bowels: diarrhoea, however, occasionally supervenes in the course of the disease, and in severe and protracted cases is often copious.

From the very commencement of the attack, the mucous membrane of the fauces and tonsils is of a deep red color, and becomes speedily covered with a layer of tenacious transparent mucus. The mucous membrane, particularly of the pharynx and soft palate, is in some cases infiltrated with blood, in the form of small disseminated

points, having a linear arrangement, or of small, oblong ecchymoses, of a dark red color. Occasionally, the mucous membrane presents a few dry, oblong, grayish spots, as though it had been, at these points, cauterized with an acid.

As the disease advances, the exudation becomes more abundant, and forms a firm pellicle, of a dirty yellow or grayish color. It is usually disposed, at first, in patches, more or less circumscribed, often slightly elevated in the centre, but thin and flocculent at the circumference. These patches increase in extent, more or less rapidly; sometimes in the course of a few hours the whole of the posterior fauces becomes covered with them. They are at first thin, but become increased in thickness, by successive depositions, and acquire, often, so much firmness, as to permit them to be detached entire from the mucous membrane, to which they adhere by numerous minute filaments that appear to penetrate the orifices of the mucous follicles. Their detachment is generally followed by more or less oozing of blood from the denuded membrane, which exhibits but little intumescence, and is of a dark red color, often variegated with points or striae of a deeper hue.

Between the pseudo-membranous patches, the submucous cellular tissue assumes, occasionally, an oedematous appearance. In consequence of this, the corresponding portion of the membrane is elevated, and causes the portions that are occupied by the pseudomembrane to assume somewhat the appearance of ulcers, covered with a tenacious exudation. The patches, very generally, become soon continuous; so that, in many cases, the whole of the soft palate, the pharynx, and the inner surface of the cheeks, are lined uniformly by a pseudo-membranous exudation, often of considerable consistence, which is rapidly renewed, as often as it is detached.

In the commencement of the disease, the tongue is pointed, red at the edges, and covered on its surface with a thin layer of white mucus, through which the enlarged and florid papillæ protrude. There is an increased secretion of saliva, which soon becomes darkcolored, from the admixture of blood discharged from the mucous membrane as portions of the pseudo-membranous deposit are detached, and of an offensive odor, from the vitiated state of the secretions of the throat and mouth.

In the course of the disease, the color of the pseudo-membranous excretion changes to an ash-brown, and, finally, black color, the mucous membrane beneath becoming of a dusky red hue. The tongue and mouth are often dry and dark-colored, and the teeth more or less thickly covered with a dirty white, or blackish incrus

tation.

If the affection of the throat is of any extent, and the inflammation. is not early arrested, the submaxillary glands become enlarged and painful, and the surrounding cellular tissue infiltrated with serum, causing often a considerable intumescence of the neck. More or less tumefaction of the tonsils and soft palate, and occasionally of the tongue, takes place; frequently to such an extent as to interfere with the freedom of respiration; ulcers form along the edges of the

tongue, the palate, and upon the inner surface of the cheeks; and there is a constant oozing of blood from the mucous membrane of the mouth and fauces, which is increased upon the slightest irritation.

The febrile excitement sometimes continues with but little abatement, until toward the close of the disease. The heat of the surface, however, in general abates-the skin assuming a dusky appearance, and doughy feel. Profuse diarrhoea often occurs. The secretions, generally, become vitiated, and either increased or diminished in quantity. There is very generally albuminous urine; in many cases attended with tubular casts. The prostration of strength aug. ments; and a state of torpor, or even decided coma, is not unfrequent.

When the inflammation and pseudo-membranous deposit extend into the pharynx and commencement of the oesophagus, there is a sense of soreness and heat in these parts, accompanied with increased difficulty of swallowing every attempt at which is productive of severe pain. When the disease extends, through the posterior nares, to the mucous membrane of the nose, the patient is unable to respire through the nostrils; from which there takes place a discharge of a serous, yellowish, and flocculent or bloody sanies, often of a very fetid odor, and which produces more or less inflammation and excoriation of the external openings. When the disease extends to the Eustachian tube, pain is experienced in the ear, with more or less defect of hearing, often complete deafness, which, in consequence of the obliteration of the tube, is, occasionally, permanent.

The pseudo-membranous inflammation is particularly liable to extend into the larynx and trachea. When this extension of the disease takes place, it may be almost immediately upon the first appearance of the patches in the fauces. In other instances the res piratory organs are not affected until about the second or third day, or even later. At whatever period the respiratory tube becomes implicated, the symptoms of croup-hoarseness, shrill cough, great difficulty of respiration, and more or less aphonia, are immediately developed, and, in the greater number of cases, the patient is rapidly destroyed. It is supposed by many pathologists, that croup is in every instance produced by an extension of the pseudo-membranous inflammation from the throat to the larynx and trachea. Although we cannot admit that such is invariably the case, still we have reason to believe that croup is more frequently preceded by pseudo-membranous inflammation of the throat, than is generally supposed.

Pseudo-membranous inflammation is said by Guersent to be productive, also, in certain cases, of a species of pneumonia, extremely insidious in its commencement, and marked, in part, by the symptoms which are referable to the disease of the throat. The cough, in this affection, is different from that of croup, and is unattended with aphonia. The mucous expectoration is often streaked with blood, while auscultation and percussion give all the indications of more or less extensive engorgement of the lungs.

Pseudo-membranous inflammation, likewise, often occurs upon remote parts of the body, particularly in situations covered by a

mucous membrane, or from which the cuticle has been accidentally removed by a blister, or by ulceration. Thus, it is often observed upon the lips, the alæ nasi, the concha and external meatus of the ear; upon the parts behind the external ear, upon the nipples, in the folds of the groin, around the contour of the anus, within the vulva, upon the surface of blisters, leech-bites, &c.

In favorable cases, as the membranous exudation becomes detached its place is quickly supplied by a new formation, and after each separation, it becomes, in general, whiter, and much thinner. In other cases, the exudation, instead of being separated in fragments, becomes, in part, softened to a pulpy consistence, and is discharged from the mouth, mixed with bloody mucus. This separation and renewal of the pseudo-membranous deposit continue, in most cases, for the space of eight or ten days. When, finally, it ceases to appear, it leaves, most generally, the mucous tissue to which it had been attached perfectly sound throughout its whole extent; of a light red, uniform color, and covered, usually, with a thick yellow mucus, more or less resembling pus.

With the disappearance of the disease in the throat, the glands of the neck, if not in a state of suppuration, which is very rarely the case, diminish in volume, and are no longer painful or tender to the touch. The difficulty in deglutition disappears. The tongue loses its pointed appearance, and becomes clean and moist; the skin soft, moist, and of a more natural appearance; the countenance more animated and cheerful; the stomach and bowels gradually resume the regular performance of their functions, and the general strength and vigor of the patient become slowly reinstated.

In severe and unfavorable cases, the disease is often more prolonged. The whole of the symptoms become aggravated; the mouth, tongue, and throat become dry, and of a deep black color; the diarrhoea becomes profuse, and the strength of the patient more and more exhausted; general colliquation ensues, and death takes place, frequently preceded by deep coma, or, in children somewhat advanced in age, by violent delirium.

When the disease is confined to the soft palate, isthmus of the fauces and pharynx, it is seldom attended with much danger, and generally yields readily to an appropriate treatment. When the inflammation is of little extent, it may even disappear spontaneously in a few days. When, however, the disease extends to the larynx, it is very frequently fatal. Convalescence in the majority of cases is slow and protracted. The duration of the disease is variable. The disease may last from one to fourteen days. Within the first week, when death occurs it is usually from the extension of the local disease into the larynx. When death takes place at a more remote period of the disease, it is usually the result of asthenia. A favorable termination may happen at the end of the first week, or it may not take place until the termination of the second week.

The causes, nature, and treatment of pseudo-membranous inflammation will be noticed after we have described gangrene of the throat.

4.-Gangrene of the Throat.

Actual gangrene of the throat is far less frequent than it was generally supposed to be by the old writers, or is believed to be by many physicians of the present day. That form of anginose disease, to which the term putrid, malignant, or gangrenous, has been most commonly applied is, strictly speaking, unattended with either gangrene or sloughing of the throat. It is, in fact, a highly aggravated or malignant form of pseudo-membranous inflammation. Sloughing of the throat, or a species of gangrenous ulceration of this part may, however, occur in certain cases of epidemic pseudo-membranous angina, and particularly in the angina accompanying epidemics of scarlatina of a very malignant character.

Malignant angina, in its commencement, differs but little from ordinary pseudo-membranous inflammation. The fauces present the same membraniform exudation; it is more generally confined, however, to the mucous membrane anterior to the larynx, over which it is more uniformly spread; it also assumes, at an earlier period, a dull ashcolor, quickly changing to dark brown or black. The disease sel dom, if ever, extends to the trachea. The pain and tumefaction of the submaxillary glands are much more considerable than in the preceding form of the disease; and they are, also, more liable to run into suppuration. The mucous membrane of the fauces is almost uniformly injected with blood of a violet color, and more or less swollen, but without the ecchymosed appearance noticed in the preceding variety; the tonsils, also, are more swollen, softer, and infiltrated with mucus and pus. The face exhibits a bloated, bronzed aspect; the eyes are heavy, dull, and watery.

There is often extreme difficulty of deglutition; the voice is entirely guttural, and the power of articulation is occasionally sus pended. In some instances, the respiration is rendered difficult from the excessive tumefaction of the tonsils and soft palate.

In the commencement of the attack there is generally intense febrile excitement, with a dry, hot, burning skin, parched mouth, urgent thirst, and often considerable delirium. The fever is attended with an exacerbation towards evening. Nausea, vomiting, with tenderness and oppression at the epigastrium, and diarrhoea, accompa nied with thin, acrid, and intolerably offensive discharges, are often present from the commencement of the attack, or occur at an early period.

A fetid, sanious discharge from the nostrils occurs often from the very commencement, and the patient discharges from the throat at first, a thin, bloody mucus, which becomes, subsequently, puriform, and mixed with shreds of a membranous appearance. In some cases, the discharge is dark colored, almost putrid, and highly offensive.

In the milder cases of the disease, upon the separation of the pseudo-membranous exudation, the mucous surface beneath presents a moist, red appearance, without ulceration or loss of substance; the discharges from the mouth become of a less offensive character, and