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Related post: various forms of cocci, may also be found in the throat without the bacillus, but associated with such appearances that they often cannot be distinguished from those accom- panying the bacillus, except by the aid of the microscope. It has been agreed to call the most fatal of these membra- nous inflammations of the throat, the disease identified ´┐Żby the Klebs-LoefHer bacillus, diphtheria ; certain other forms of membranous throats are often designated as pseudo- diphtheria. Let me recall to your minds some of the characteristics of this bacillus disease, diphtheria. In the beginnincy it is local ; the bacilli grow on or in a mucous membrane or wound, at which point a false membrane is formed ; they do not, as a rule, enter the system, although Frosch 1 has found them in various organs of the body at ten out of fifteen autopsies after diphtheria, but their baneful effects are exerted chiefly through a very poisonous substance, diphtherotoxin, which they secrete and which is soluble and readily absorbed. This substance, which is a tox-albumen, has been isolated, and when freed from all bacilli and injected into animals, causes many of the symp- toms of dipththeria, such as paralysis, heart failure and local necrosis, but it does not give rise to a false membrane. The early recognition of a disease so dangerous to the individual and to those near him as diphtheria is of the first importance, and yet by the ordinary methods an early diag- nosis is not infrequently impossible. It may even in the very early stage be confounded with follicular tonsillitis. Fortunately, we have now in our hands a means of diagnosis 1 Zeitschrift fur Hygiene und Infectionskrankheiten, 1893, Band xiii., Heft 1. AFFECTIONS OF THE THROAT. 229 which is excellent precisely in the early stage of the disease. It consists in the examination of cultures made from the suspicious throat and subsequent inoculation of animals ; this requires special training and appliances, and it Buy Stavudine Online is necessary to wait about 20 hours to learn the result of the cultures, and longer to learn that of the inoculations. The Boston City Hospital is now erecting much larger buildings for contagious diseases ; at present there are two buildings, each containing two wards besides separate rooms, devoted to the contagious service, one for diphthe- ria and the other for scarlet fever. In the diphtheria wards patients when needing tracheotomy or intubation go to the suroical service, the others to the medical service. Beginning with 1891 I have had during medical services in these wards 442 patients, 211 of these had membranous inflammation of the throat; 231 scarlet fever, complicated in 58 cases with severe membranous inflammation of the throat, making in all 269 patients with membranous throats. The diagnosis by cultures, which I initiated at the Hospital, was made in 93 of the cases of membranous throats that were under my care during about three" months of 1892 and 1893. In 3 of the cases cover-glass preparations only were made. These 96 cases are classed as follows : TABLE I. Cases. Bee. Died. Diphtheria, 40 20 20 Diphtheria and scarlet fever, 12 6 6 Diphtheria and measles, - -1 1 Diphtheria and typhoid fever, 1 1 Pseudo-diphtheria, - - 19 17 2 Pseudo-diphtheria and scarlet fever, 23 18 5 96 230 DIPHTHERIA AND OTHER MEMBRANOUS These examinations showed that a considerable number of the cases with false membranes that were admitted to the diphtheria ward were not diphtheria, thus demonstrating the necessity for bacteriological examinations. Furthermore, in four of those that were diphtheria, there was no membrane in sight. This likewise shows the importance of a bacterio- logical examination where there is the least suspicion of diphtheria. Let me now direct your attention to these 96 cases in which the diagnosis was made by means of the micro- scope. My plan was to have a sterilized cotton swab rubbed over the throats of all patients coming to the medical side of the diphtheria ward, except those too weak to be disturbed, and over the throats of all those in the scarlet fever ward who might at any time have a deposit in the throat, and cultures were then made, except in a few in- stances, where cover-glass preparations only were made. These 96 cases consist of two series: the first series of 23 cases in 1892, from which the cultures, followed in some cases by inoculation of guinea-pigs, were made for me by Mr. A. P. Mathews, assistant in biology at the Massa- chusetts Institute of Technology, to whom I am much in- debted, and a second series of 73 cases in 1893, for which I enlisted the interest and cooperation of Professor Councilman, under whose direction the cultures were made, and of Dr. E. M. Holden, who gave freely the large amount of time which work of this character requires and on which its success so much depends. In 49 of the 96 cases, Table II., I made a preliminary cover-glass examination, when I first saw the patient, from the material adhering to a sterilized cotton swab directly after it had been rubbed over the suspected throat this examination can be made in a few minutes in the ward or at the patient's house and on the following day learned the result of the examination made from
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