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Related post: culture ; their growth was probably inhibited by the pres- ence of corrosive sublimate. On the sixteenth day, the throat was clear. The heart was noticeably weak in its action, and tincture of digitalis was given. After six weeks, the patient left the hospital for the Convalescent Home. There had been nothing seen in the throat for twenty-six days, and she had been about the ward. She passed three weeks in the Convalescent Home, and then on account of hoarseness returned to the hospital. My service was then at an end, but the records, which I have the privilege of inserting here, state that there was "a piece of membrane adherent to one vocal chord. After eleven weeks, the tonsils were large and covered with a whitish film or membrane which could be wiped off with difficulty ; breath foul. Dr. Coun- cilman found Klebs-LoefBer bacilli abundant." The last record of membrane which was on the tonsils was almost twelve weeks after the onset of the disease. The patient was discharged on the one hundredth day of the disease. This case illustrates the futility of the 1 : 10,000 solution of corrosive sublimate in preventing the spread of the mem- brane, and the persistence of the bacilli in spite of its use. It would be desirable to have bacteriological examinations made of every throat before the patient is allowed to leave the contagious ward, care being: taken not to have corrosive sublimate used at the time the swab is rubbed over the throat, as a very small amount of it will inhibit the growth of the bacilli in the culture tubes. 1 In the two following cases the attempt was made to get 1 Since this paper was read a man has come to the hospital with naso- pharyngeal paralysis. No membrane was seen in the throat by two phy- sicians who examined him, but Klebs-Loeffler bacilli were found in the cultures. The history of the case showed that the attack of diphtheria had begun about eight weeks previously. This case shows the importance of bacteriological examination before isolation is ended, as well as in the beginning of the disease. 240 DIPHTHERIA AND OTHER MEMBRANOUS a cleansing action from a weak (7.5-volume 1 ) solution of hydrogen peroxide to assist the action of the 1 : 10,000 cor- rosive sublimate. In the first of these the patient, a woman 22 years old, had paralysis on the 15th day of the disease, and the throat was not clear until the 17th day of the disease. In the second case, M. McP., a woman 28. years old, en- tered the hospital on the third day of the disease. Thick membrane on both sides of uvula and on left tonsil. Klebs- Loeffler bacilli found in culture. The local treatment was a spray of 7.5-volume solution of hydrogen peroxide every two hours, followed by a spray of corrosive sublimate 1 : 10,000. On the seventh day of the disease the patient was hoarse, and the membrane had evidently spread to the larynx. Prostration. Reduplication of heart sounds. After ten days a spray of corrosive sublimate 1 to 20,000 was used every four hours. Three days later this was omitted, as the patient was salivated. Seventeenth day ; paralysis ; thirty-fourth day the throat was clear. The patient was discharged on the Buy Clofazimine forty-first day of the disease. These cases show that the membrane may not be removed, but may continue to spread under a local treatment of corrosive sublimate 1 to 10,000 (as illustrated by J. B.) 5 and also when this is used in connection with a 7.5-volume solution of hydrogen peroxide, as illustrated by the last two cases. 1 In the United States a 20-volume solution of hydrogen peroxide has been and still is one which will yield twenty times its volume of oxygen if decomposed by permanganate of potassium ; but one-half of this oxygen is contributed by the permanganate as it is likewise decomposed. The hydrogen peroxide (or dioxide) water described in the U. S,' Pharmacopoeia for 1890, which will be official on January 1st, 1894, is a 10- volume solution, and one in which the number of the volumes named denotes the amount of its own available oxygen. This 10- volume solution is, therefore, equivalent to the 20-volume solution described above. I have adopted in this article the pharmacopceial manner of indicating the strength of the hydrogen peroxide solutions, and therefore the 50-volume solution of my paper of 1892 becomes here a 25- volume solution. AFFECTIONS OF THE THROAT. 241 It would take too long even to enumerate the various kinds of local treatment that have been used in diphtheria, but there are certain conditions to be fulfilled that will serve as a guide in our selection. We need an agent that will kill the bacilli quickly, and will not injure the patient by its harmful or poisonous attributes. The first step in an investigation of this kind is to ascertain what will kill the organism in the laboratory, although it does not follow that the same result will be obtained in the throat. In the experiments made for me in the Biological Laboratory of the Massa- chusetts Institute of Technology with various germicides on .the bacillus of diphtheria, I chose the short period of ten seconds during which they were allowed to exert their ac- tion, as the contact of the germicide with the membrane in the throat must necessarily be short. The results of a few of the experiments were as follows : A saturated solution of carbolic acid did not kill the bacilli in ten seconds. A solution of hydrogen peroxide, of between 12 and 25 volumes, containing J to J per cent, of acid respectively, killed the bacilli in ten seconds, but it took over a 50-volume nearly neutral solution of hydrogen peroxide to do the same work. The ordinary hydrogen peroxide solutions offered for sale have a strength of 7.5 or 10 volumes, or much less some of these are neutral, others acid. 1 These weak solutions, whether neutral or acid, are not active germicides, judged
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