The methods of its propagation are now known to be by means of the discharges from the nose, naso-pharynx, pharynx, and larynx, and the tenacity of life in the Löffler bacilli is said to be very great. One observer found that in the dried state it was active for twenty weeks. The care with which all discharges are destroyed or disinfected, and all clothing, furniture, and surroundings of a given case are burned, boiled, or thoroughly cleansed, will to a great extent decide the further development of the contagion. All forms of local treatment have their limitations and are controlled largely by the surroundings and the docility of the patient. A well-disciplined child that will submit to active and judicious treatment from the inception of the disease will rarely have much trouble, but a spoiled, fighting child is often injured by unwise and badly carried out efforts.

The methods resorted to in applying local measures are often unscientific and ill-advised. If resorted to early in the course of the disease they so frighten the child that its efforts to resist lead to serious loss of vital force, so much needed later in the disease. Sitting the child up and forcibly spraying the nose and throat, swabbing the naso-pharynx with painful and disagreeable agents, or blowing in bitter powders not only disturb the stomach, but by producing such bad tastes in the mouth destroy the desire for food and nourishment, of so much value when the septic stage is reached. In selecting the local agent in a given case we must be controlled to a great extent by the situation of the false membrane, its extent, and the stage of the disease. Löffler believes that if the disease is attacked early and properly, there will be no extension and no systemic infection. If the membrane is confined to the tonsils, pharynx, naso-pharynx or nose, of first importance is a thorough cleansing of the surface by some mild non-irritating agent that can be used in sufficient volume to wash away all loosened secretions and all accumulated mucus. This can be done in any child by washing the nose and naso-pharynx with a warmed alkaline solution; the ones I have most often used are bicarbonate of soda and chloride of sodium. At one time I used for these applications a nasal atomizer or a syringe; recently I have used exclusively a fountain douche and found that some member of the family can use this often, and that by placing the child on its side close to the edge of the bed it will generally submit to the douching without resistance, especially after it has found out that the solution is warm and not painful. These washings may be repeated often and undoubtedly bring away large quantities of bacilli and their

toxic products. Farther application to the membrane I have attempted in most cases, trying to destroy all possible portions of the membrane. The agent consists of the well-known and universally recognized germ destroyer, bichloride of mercury.

For several years I have used a formula as follows:

M. S: Use in atomizer every three hours after washing parts well with douche.

If this solution is irritating, a small quantity of salt or bread soda will lessen the irritating effects. The formula contains enough bichloride to act as a germicide, and the peroxide is sufficiently active in strength to loosen up the membrane and allow bichloride to come more thoroughly in contact with the organisms contained in the superficial parts of the membrane. If the child is easily managed, locally the preparation of iron certainly has a wonderful effect in destroying or shrinking and disintegrating the false membrane. In children over seven years of age I believe gentle swabbing, not roughly tearing or rubbing, the following well-known mixture over the tonsils, pharynx, and naso-pharynx materially hastens a disappearance of the local lesion. Carbolic acid, . . Liq. ferri persulph., Glycerine,

. gtts. vi;
3j;
. 3j.

M.

I tried at one time trypsin, recommended as a solvent of the membrane, but saw no material benefit follow. Other agents recommended by well-known authorities consist in such things as papoid, sulphocalcium, resorcin, Monsell's solution, Seibert's submucous injections of chlorine water, aniline dyes, etc., and lastly the now much-vaunted Löffler solution of toluol, consisting of liq. ferri sesquichlor. 4 parts, menthol 20 parts, toluol 36 parts, alcohol 60 parts. I have used this recently in follicular tonsillitis, but not enough to be able to speak personally of its value.

Many of the most powerful antiseptics are illy suited because of either their local or general poisonous action. Those of us who confine our practice to throat diseases are most often called into a case only when the evidences of laryngeal invasion are well defined and the urgency of the case points to immediate relief of the impending obstruction to respiration. The treatment of the laryngeal form, or so-called.

membranous croup, is first and foremost a surgical one. If, however, the case be seen sufficiently early much relief can be obtained and surgical treatment materially postponed or averted. As soon as evidence of laryngeal invasion is apparent the treatment by sprays and douches. becomes of no avail.

The form in which local remedies can be applied to these parts differs from that used higher up. In the nature of things they must be in the form of vapors or fumes. Inhalation of steam exciting activity in the mucous gland produces a lessening of the swelling in the mucous membrane and an improvement in the dyspnea. Many agents have been advised for use in this manner. I have found compound tincture of benzoin to be exceedingly pleasant, and often to give decided temporary relief. Again I have used the formula of J. Lewis Smith:

M. Sig: Teaspoonful in a quart of boiling water and inhale steam. So long as laryngeal symptoms are apparent the child should be left in a room containing moisture and of an equable temperature of about 70°. Tenting the child by surrounding the crib with sheets or spreading a sheet over an opened umbrella and filling the space with the vapor just mentioned must be kept up day and night. Recently I have had some experience with the so-called Brooklyn treatment by calomel fumigations, and believe that next to intubation it is the best treatment that can be established in laryngeal cases, and the only one suitable after intubation. Dr. Dillon Brown has proven by statistics that this treatment possesses merit. In 358 intubations his percentage of recoveries was 28.2, while in 218 cases intubed, and then calomel fumigation instituted, his recoveries were 39.9. The calomel is burned under a tent containing the child, and the fumes of the burning calomel fill the tent and are inhaled. From twenty to forty grains can be used every few hours, depending on the severity of the case. Little or no bad effects have been known to follow its use.

Dr. Brown advises the following precautions be taken: The nurses and attendants should be warned against inhaling the fumes.

The child's skin should be covered so that the full effect of the fumes are confined as much as possible to the local deposit on the mucous membrane.

Before each sublimation the child should be given a small dose of whisky.

After each sublimation the mouth, gums, and teeth should be cleansed with a weak solution of potassium chlorate.

If the prostration and anemia seem to be greater than the local manifestations would account for, the amount and frequency of the calomel should be diminished and stimulants increased.

If the nasal cavities are not affected, it may be wise to cut off fumes by loose plugs of cotton in each nostril.

Use pure calomel that is free of irritation.

In conclusion I may summarize the local treatment of this disease as follows:

1. Modern research having proven that diphtheria is primarily a local disease, local treatment must be immediately instituted on assuming charge of a case and making the diagnosis, and should be carried out day and night.

2. This treatment must aim at removal of all secretions and debris that may possibly contain the Löffler bacillus, and destruction as far possible of all bacilli contained in the pseudo-membrane.

3. The best local applications are bichloride of mercury and the preparation of iron, with possibly papoid and peroxide of hydrogen as adjuvants.

4. When the larynx shows signs of invasion, the use of steam and vapors increase mucous secretion, lessen swelling, and hasten loosening of the membrane.

5. Before and after resort to surgical methods mercurial sublimations exert a beneficial influence on the false membrane and by their disinfecting powers lessen the further complications that so often arise.

LOUISVILLE.

CARBOLIC ACID IN THE TREATMENT OF ACUTE PHLEGMONS.

BY W. C. DUGAN, M. D.

A few days since, in looking over the Daily Lancet Medical, I noticed that interstitial injection of carbolic acid was highly recommended. About three years ago I read a paper advocating this same treatment before the Louisville Clinical Society, and it was published in the New Albany Medical Journal (?). I am very glad to find the treatment so satisfactory in other hands. It appears that both he and myself found it especially beneficial in those "boils" coming on the back of the neck.

About one month ago a patient called to see me with a large one on his neck; it had been developing about one week. The induration was very extensive, but at one point it was thought that slight softening was detected, so it was decided best to incise it. A few drops of a four-per-cent solution of cocaine was injected, and then an incision made down through its center. The tissue cut like leather, and had a peculiar ashy-gray color, but we found no pus.

I treated this case as I do all such, by taking a probe with cotton on the end, which is saturated with the liquid carbolic acid. Then the wound is thoroughly mopped out with it, renewing the cotton and acid often, till much of this gray tissue is destroyed. Some force should be used to press the end of the probe as thoroughly out into the tissue as is advisable, so that the acid is thoroughly diffused.

It might be thought that the operation is painful, but such is not true. Rarely do they complain. Then the wound is dressed by first packing it thoroughly with cotton saturated with the acid, and then over this apply the regulation dressing of gauze and cotton.

As a rule all the acute symptoms subside in a few hours, and the patient feeling generally much improved. The man referred to above was asked to come in on the following day, but he was feeling so well he waited till the second day, when he came to ascertain if he could put on his collar and go on with his work. The dressing was removed, and the change that had taken place was really beyond expectation. In fact it was rapidly healing without suppuration, and in only a few days it was entirely so; and this case was one of the ordinary. I could report many others, but it would be but a repetition, for it is an exception for them to do otherwise than described. So, in such cases as