be forgotten that these delayed and hence selected cases represent a series of more than average severity, and hence ordinarily of more than average mortality. For otherwise there would be no need of beginning the injections at this late time. Deaths occurring within twelve hours after the injection simply show that the treatment was begun too late and had not had time to exert its effect.

202. There are no contraindications against the use of antitoxin. In about 10 per cent. of cases the injection gives rise to disagreeable, but not serious, consequences. Within one or a few days it may be followed by a rash. resembling either measles or scarlet fever, but lasting only a day or two, with moderate fever, occasionally nettle-rash, and in rare instances inflammatory swelling around some joints, which subsides within a few days. The few deaths which have occurred shortly after injections were due partly to the severity of the disease, partly to other sometimes unaccountable influences, like habitus lymphaticus. It is well known that any trivial operation may sometimes be followed by immediate unaccountable death. Very few minor operations have been practised on so enormous a scale as antitoxin injections.

203. It is very questionable whether we possess any means of treatment to influence diphtheria except antitoxic serum. A comparison of the enormous array of drugs recommended formerly by every writer, with strong individual preferences not shared by any other writer, leaves but little doubt that the treatment was more suggested by humane intentions than by positive knowledge. None of the means of local applications have ever been tested statistically according to the day of their employment. They are all being gradually discarded. Löffler, the discoverer of the diphtheria bacillus, tested the ability of antiseptics to kill the bacillus immediately and to penetrate at the same time through thick layers of a culture. His most satisfactory results were obtained with a fluid known as the Löffler mixture-viz.:

This has been tried on a limited scale for the local treatment of diphtheria, and while moderately praised, has not found universal recognition. It undoubtedly does penetrate deeply, killing both the diphtheria bacillus as well as other germs present as far as it reaches. But, after all, those in the depth of the false membranes escape largely. Yet, judged by clinical evidence in individual cases, its use, when brushed upon the affected spots once in four to eight hours, is not without some benefit. It certainly has a very decided and lasting effect upon the foulness of the breath. The offensiveness of the breath is also controlled to some extent by mouth-washes and gargles of the less irritating antiseptics and aromatics, as, for instance

of which one teaspoonful is dissolved in a glass of water (8 oz.).

The constitutional treatment of diphtheria and the methods of quarantine and disinfection can be found in all text-books on general medicine. The indications and surgery of intubation and tracheotomy are likewise outside of the scope of the present work.

204. Individuals exposed to the disease are protected against it almost infallibly by a prophylactic injection of at least 150 units of antitoxin, if given within twentyfour hours after exposure. Two or three days after exposure a larger dose (600 units) is required, and even this may not protect absolutely, but infallibly reduces the disease to a very mild type. The passive immunity pro

duced by antitoxin injection lasts a number of weeks, not exceeding about six.

205. A singular and exceptional form of chronic disease apparently due to the diphtheria bacillus has recently been reported (Neisser and Kahnert). Five instances were observed, all in young women. For years they had complained of dryness in the throat, discomfort, even some pain, and viscid secretion, but practically only during the cold season, with apparent intermission during summer. Purulent crusts without fetor were found in the nose and entire pharynx down to the larynx. The mucous membrane appeared atrophic, somewhat vulnerable, partially congested. The symptoms resembled those of non-fetid atrophic rhinitis, but with extension through the pharynx. The only micro-organism found absolutely constant was the typical genuine diphtheria bacillus, but devoid of pathogenic property in some of the cases. In one instance only the disease dated from a former attack of diphtheria. The serum of several patients had antitoxic efficiency. Injections of antitoxin did not influence the disease.

CHAPTER XXV.

SYPHILIS OF THE NOSE AND PHARYNX.-TUBER

CULOSIS.

SCROFULA.-LEPROSY.

RHINOSCLEROMA.

SYPHILIS OF THE UPPER AIR-PASSAGES.

206. In the course of syphilis the pharynx is involved, as a rule, during the early period of secondary manifestations. But this form of lesion is not often seen by the rhinologist. Yet syphilitic manifestations in general are so common in the nose and throat that they constitute at least 2 per cent. of average practice in this field.

The primary sore, very exceptionally found in the nasal vestibule or near the front end of the septum, is not so rare in the mouth and pharynx. In statistics of over 10,000 cases of extragenital chancres compiled by Bulkley, and continued by Münchheimer, 5 per cent. were observed in the tonsils and nearly 3 per cent. in other parts of the pharynx. The infection was conveyed partly by lascivious modes of kissing and sexual aberration, partly by utensils and tools-for instance, the blowpipe of glass-workers. More than 50 pharyngeal chancres have been reported from the use of infected Eustachian catheters. Infants acquire the disease by nursing. The sore appears as a sharply cut ulcer with unclean surface, surrounded by an edematous and reddened areola, of indolent course, lasting weeks, even up to two months. Usually but not always the base becomes indurated. Adjacent lymph-glands become inflamed and palpable. The diagnosis cannot be made absolute unless the history of exposure is certain, or until secondary symptoms appear. Yet the only ulcers for which it might be mistakenafter an existence of two weeks or more-are secondary

syphilitic ulceration, tubercular ulcers, and ulcerating carcinoma.

Until the diagnosis is beyond the possibility of doubt it is not to the interest of the patient to use specific medication. If a sore disappears under specific treatment before its nature is certain, the diagnosis of syphilis may be left in uncertainty for months and years. The ulcer heals in the end without treatment, but its cure can be hastened by nitrate of silver, tincture of iodin, or Löffler's solution, and its discomfort lessened by orthoform insufflations.

207. During the early secondary stage the throat, as a rule, is affected by syphilis. But as these lesions are relatively mild and their cause is usually known to the patient, they are but seldom seen in special rhinologic practice. Syphilitic erythema, common on the palate, less so on the posterior pharyngeal wall, appears in the form of red, well-circumscribed spots, often symmetric. It causes slight soreness and is transient. It may persist, however, as a deeper type of inflammation in the form of a tonsillitis, presenting sometimes the typical appearance of follicular tonsillitis. Whenever this lasts more than about a week, with steady but moderate soreness and without acute onset, it can be safely referred to syphilis.

Mucous patches are among the most frequent and persistent of the early syphilitic manifestations, with distressing liability to recurrence. They occur anywhere in the mouth-on the tongue, or at its base, along the pillars, on the tonsils, or less commonly the posterior wall of the pharynx. At first resembling spots produced by cauterization with nitrate of silver, they are oval or irregular, slightly raised, grayish-white patches of variable size, surrounded by a slightly reddened areola, the color of which is most saturated (by contrast) at the edge of the gray patch. In mild or well-treated instances. they may disappear in the course of one to two weeks. But, as a rule, they undergo further changes. The epithelium becomes macerated and gradually detached, and