m superadded infection. There is pain on
swallowing, and often earache; and the patient speaks with a nasal
accent. He becomes weak and anaemic, and loses his appetite. There is
often albuminuria. Leucocytosis is usually well marked before the
injection of antitoxin; after the injection there is usually a
diminution in the number of leucocytes. The false membrane may separate
and be cast off, after which the patient gradually recovers. Death may
take place from gradual failure of the heart's action or from syncope
during some slight exertion.

_Laryngeal Diphtheria._--The disease may arise in the larynx, although,
as a rule, it spreads thence from the pharynx. It first manifests itself
by a short, dry, croupy cough, and hoarseness of the voice. The first
difficulty in breathing usually takes place during the night, and once
it begins, it rapidly gets worse. Inspiration becomes noisy, sometimes
stridulous or metallic or sibilant, and there is marked indrawing of the
epigastrium and lower intercostal spaces. The hoarseness becomes more
marked, the cough more severe, and the patient restless. The difficulty
of breathing occurs in paroxysms, which gradually increase in frequency
and severity, until at length the patient becomes asphyxiated. The
duration of the disease varies from a few hours to four or five days.

After the acute symptoms have passed off, various localised
paralyses may develop, affecting particularly the nerves of the palatal
and orbital muscles, less frequently the lower limbs.

#Diagnosis.#--The finding of the Klebs-Loffler bacillus is the only
conclusive evidence of the disease. The bacillus may be obtained by
swabbing the throat with a piece of aseptic--not antiseptic--cotton wool
or clean linen rag held in a pair of forceps, and rotated so as to
entangle portions of the false membrane or exudate. The swab thus
obtained is placed in a test-tube, previously sterilised by having had
some water boiled in it, and sent to a laboratory for investigation. To
identify the bacillus a piece of the membrane from the swab is rubbed on
a cover glass, dried, and stained with methylene blue or other basic
stain; or cultures may be made on agar or other suitable medium. When a
bacteriological examination is impossible, or when the clinical features
do not coincide with the results obtained, the patient should always be
treated on the assumption that he suffers from diphtheria. So much doubt
exists as to the real nat