Diphtheria and Other Membranous 
Affections of the Throat. 
BY 
FRANCIS H. WILLIAMS, M.D., 
OF BOSTON. 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
November, 1893. Reprinted from The American Journal of the Medical Sciences, November, 1893. 
DIPHTHERIA AND OTHER MEMBRANOUS AFFECTIONS OF 
THE THROAT.1 
Francis H. Williams, M.D., 
OF BOSTON. 
In discussing this subject there are three principal points to which I 
shall have the pleasure of calling attention. First, the diagnosis of 
diphtheria by means of the microscope. Second, the coincidence of 
diphtheria and other diseases. Third, the treatment of diphtheria. 
The Report of the State Board of Health for 1891 gives valuable 
tables prepared with great care by Dr. S. W. Abbott, which show the 
mortality of various diseases in Massachusetts, from 1871 to 1890 inclu- 
sive. From them it may be seen that during these twenty years there 
were 56,474 deaths from pneumonia; 36,553 deaths from diphtheria and 
croup; 19,421 deaths from typhoid fever; and 14,639 deaths from scarlet 
fever. I shall show later, that even this large figure of 36,553 deaths 
from diphtheria and croup probably does not represent all the fatal 
cases of membranous throats during the twenty years. Osier states that 
while other contagious diseases have diminished within the past decade, 
diphtheria, particularly in cities, has increased. Moreover, the mortality 
in this disease is very high, from 40 per cent, to 60 per cent, of the 
patients dying. 
Precise discrimination between different kinds of membranous throats 
was formerly impossible, but within the last ten years, beginning with 
the careful observations of Klebs and Loeffler, it has been shown that 
among membranous affections of the throat there is one of supreme 
importance Avhich is characterized by the presence of an organism 
known as the Klebs-Loeffler bacillus. There are often other organisms 
present with this bacillus, but they are not of sucb serious import. 
These other organisms, chiefly 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 accompanying the 
bacillus, except by the aid of the microscope. It has been agreed to 
call the most fatal of these membranous inflammations of the throat, 
the disease identified by the Klebs-Loeffler 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 beginning it is local; the bacilli 
1 Read at the annual meeting of the Massachusetts Medical Society, June 14,1893. 2 
WILLIAMS: MEMBRANOUS THROAT AFFECTIONS, 
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 
Frosch1 has found them in various organs of the body in 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 toxalbumin, has been isolated, and when freed from all bacilli and 
injected into animals, causes many of the symptoms of diphtheria, 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 diagnosis is nearly always impossible. 
It may even in the very early stage be confounded with follicular ton- 
sillitis. Fortunately, we have now in our hands a means of diagnosis 
which is excellent precisely in the early stage of the disease. It con- 
sists in the examination of cultures made from the suspicious throat, and 
subsequent inoculation of animals; this requires special training and 
appliances, and it is necessary to wait about twenty 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 diphtheria and the other for scarlet fever. In the diphtheria wards 
patients when needing tracheotomy or intubation go to the surgical ser- 
vice, 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, compli- 
cated 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 3of the cases cover-glass preparations only were 
made. These 96 cases are classed as follows: 
Table I. 
Diphtheria ...... 
Cases. 
. 40 
Recovered. 
20 
Died. 
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 
1 Zeitschrift fur Hygiene und Infectionskrankheiten, 1893, Bd. xiii. Heft 1 WILLIAMS: MEMBRANOUS THROAT AFFECTIONS. 
3 
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 bac- 
teriological examination where there is the least suspicion of diphtheria. 
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 instances, where cover- 
glass preparations only were made. 
Let me now direct attention to these 96 cases in which the diagnosis 
was made by means of the microscope, which 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 Massachusetts Institute of Tech- 
nology, to whom I am much indebted, and a second series of 73 cases in 
1893, for which I enlisted the interest and co-operation of Professor Coun- 
cilman, 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 (Table II.) of the 93 cases 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 sus- 
pected 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 cultures. If either examination 
shows the characteristic bacilli every precaution should be taken. 
Table II.—Diagnosis of Diphtheria based on Cultures. 
(Both cultures and cover-glass examinations made.) 
Diphtheria 
. 20 
Diphtheria and scarlet fever 
. 3 
Pseudo-diphtheria .... 
. 8 
Pseudo-diphtheria and scarlet fever 
. 10 
Tonsillitis ...... 
. 6 
47 
In 38 of these 47 cases (cases 48 and 49 will be referred to later) 
the cultures and cover-glass examinations agreed, in 7 disagreed, and 
in 2 cases the result of the cover-glass examination was doubtful. Two 
of the 7 cases where the two methods disagreed are classed in the table 
as pseudo-cliphtheria, the bacillus not being found in the cultures, 
although thought to be present in the cover-glass examinations. These 4 
Williams; membranous throat affections. 
two patients died. The third case is classed in the table as pseudo- 
diphtheria and scarlet fever, as the bacilli were not found in the cultures, 
although thought to be present in the cover-glass examination. The 
brother of the patient had diphtheria and scarlet fever. In the fourth 
case, where the two methods disagreed, I probably mistook some other 
organism for the bacillus on the fourteenth day of the disease. In the 
three remaining cases I failed to find the bacilli in the cover-glass ex- 
amination, but they were found in the cultures. In the forty-eighth 
case, not noted in Table 11., the bacilli were found neither in the cul- 
ture nor in the cover-glass examination, but the patient did not enter the 
hospital until the thirty-fifth day of the disease ; she had post-diphtheritic 
paralysis on the thirty-third day of the disease. 
The preliminary examination is of service when the cover-glass shows 
abundant and characteristic bacilli; it seems to be more satisfactory in 
the early than in the later stages of the disease. In the later stages the 
bacillus is more apt to be obscured by slower-growing organisms ; failure 
to find the bacilli does not establish their absence, and the cover-glass 
examinations should of course be followed by cultures. 
The cultures are not infallible; for some reason, such as the presence 
of a small quantity of corrosive sublimate, the bacilli may not grow 
when planted, and therefore may not be found in the cultures. With 
all the sources of error, however, we now have at our disposal a method of 
diagnosis far better than anything we have had heretofore, which enables 
us to recognize early the most dangerous among the acute diseases 
of the throat which are characterized by a membrane. It is a great 
relief to the family and friends, as well as to the physician, to have 
such assurance as this means of diagnosis gives us, that certain ap- 
parently most serious cases are not cases of diphtheria. It likewise 
points out to us mild cases of diphtheria that clinically might be classed 
as pseudo-diphtheria, but the contagion from which might give rise to 
a serious illness in another individual. By its aid also we may learn 
in the future to recognize better the symptoms that distinguish diphtheria 
from other membranous affections of the throat. Further, it shortens 
the stay of the patient in the hospital and diminishes the period of con- 
valescence for those who have had only pseudo-diphtheria, as unless we 
can distinguish between them we are compelled to be over-careful of 
cases in which the after-effects are not so much to be dreaded. As a 
rule patients in whose throats the bacillus is not found may get up and 
go about early, while in the cases of diphtheria one should make haste 
slowly, as even lifting a child out of its crib to feed it may bring on 
heart failure some time after the acute symptoms have disappeared. 
Likewise it may sometimes be of great importance to summon the family 
or friends from a distance if we are assured early that the disease is a 
very dangerous one. WILLIAMS: MEMBRANOUS THROAT AFFECTIONS. 
5 
Diphtheria usually begins on the tonsils, so far as ray experience 
goes. It is sometimes stated that when the false membrane is limited to 
the tonsils the disease is not diphtheria, but that if the membrane covers 
also other parts of the throat the disease probably is diphtheria. Let us 
consider for a moment what bearing, if any, the distribution of the false 
membrane has upon the diagnosis. In the 23 cases of scarlet fever 
complicated with pseudo-diphtheria (Table III.), the membrane was 
limited to the tonsils in 5 only, and in 3 it had evidently extended to 
the larynx. In 2 cases of pseudo diphtheria (Table I.) the membrane 
had also extended to the larynx.1 These 5 laryngeal cases were children, 
the eldest of whom was five years old. In 4of the 40 diphtheria cases 
(Table I.) there was no membrane in sight; in 5 the membrane when 
first seen was on the tonsils only, but it spread later to other parts. In 
one-half of the pseudo-diphtheria cases (Table I.) the membrane was 
on the tonsils and other parts. These facts show that in making a diag- 
nosis it is not advisable to place reliance upon the distribution of the 
membrane, although it seems usually to be more widely distributed in 
diphtheria than in pseudo-diphtheria. 
Extreme youth, the presence of membrane in the larynx or even 
lower, and a weak heart all influence the prognosis most unfavorably. 
We now come to the second point, the coincidence of diphtheria and 
other diseases. Let us consider first the coincidence of diphtheria and 
scarlet fever, the occurrence of which has been questioned and much 
discussed. In the series of cases of both 1892 and 1893, already alluded 
to, such association occurred. In 97 of the cases of scarlet fever the 
diagnosis was made by cultures in all those that had membranous throats. 
The result was as follows: 
Cases. 
Died. 
Scarlet fever ...... 
. 62 
8 
Scarlet fever and pseudo-diphtheria 
. 23 
5 
Scarlet fever and diphtheria . 
. 12 
6 
97 
Table 111. 
In one of the 12 cases of diphtheria complicated with scarlet fever 
diphtheria was followed by scarlet fever, in one preceded by scarlet fever, 
and in ten cases diphtheria and scarlet fever occurred simultaneously. 
This class of cases seems to be rapidly increasing in Boston. 
A noteworthy point in this table is the fact that there were more 
deaths among the 35 cases of scarlet fever complicated with membranous 
throats than in the 62 cases of scarlet fever only : as we should expect, 
in scarlet fever complicated with diphtheria, it is the Klebs-Loeffler 
bacillus which is the dangerous factor and which threatens the life of 
1 Intubation or tracheotomy may be required in pseudo-diphtheria. 6 
WILLIAMS: MEMBRANOUS THROAT AFFECTIONS. 
the patient much more than the scarlet fever. In the light of this ex- 
perience, a former series of my scarlet-fever cases is interesting. There 
were 86 in this series, 19 of which were complicated with membranous 
throats, and 67 were uncomplicated. Of the 67 cases of scarlet fever, 
3 died, or 41 per cent.; of the 19 cases of scarlet fever complicated 
with membranous throats, 9 died, or 47 per cent., showing in this series 
also the high mortality of scarlet fever when complicated with mem- 
branous throats as compared with scarlet fever only. These cases came 
under my charge before a diagnosis by cultures was made in this com- 
munity. 
The source of some of the cases noted in Tables I. and 111. deserves 
a word in passing; 35 of them came from two Homes for Children, 
The first home sent 19 patients to the hospital between February 14th 
and March 20th, inclusive. The epidemic began with scarlet fever, of 
which there were 13 cases, and continued with cases of scarlet fever 
complicated with pseudo diphtheria, and scarlet fever complicated with 
diphtheria, and ended with one case of diphtheria alone; this patient was 
an adult. The second Home for Children sent 16 cases to the hospital, 
which included the same variety of diseases as the first. 
The coincidence of this bacillus with other diseases than scarlet fever 
is also interesting. In three of the cases diphtheria and measles prob- 
ably occurred together. Two of these died. The third and only one 
in which a swab was taken from the throat (Case 49, already alluded 
to), has a special interest in that the bacilli were detected readily on a 
cover-glass by both Dr. Councilman and myself, but they failed for some 
unknown reason to grow in the culture media, although two trials were 
made. There was abundant opportunity in this case to get some of the 
membrane, as the child coughed up large pieces of it. 
Another case of interest is one in which diphtheria and typhoid fever 
occurred simultaneously: 
L. J., a girl aged seventeen years, well developed and nourished, was 
ill with cellulitis of the leg, with possible caries of the femur, for some 
weeks before she came into my service. Five days before entrance she 
complained of sore-throat, and two days later a membrane was seen in 
the throat, in which Dr. Councilman found the Klebs-Loeffler bacillus 
The membrane was seen for the last time on the eighth day after 
entrance. On the day of entrance the temperature was 104° to 105°, 
and the pulse 130 to 140, but on the following day the temperature 
reached 105° and the pulse 150; one rose spot was found on the abdomen ; 
the number of spots increased daily for seven days, and were unusually 
numerous and chai’acteristic. The spleen was enlarged, and its lower 
edge could be felt at the margin of the ribs. Haemoglobin was 90 per 
cent., and the number of leucocytes normal, 7500. On the third day 
the stools were typhoidal and the patient dull. The pulse was 110 to 
120, the temperature remained about 104° for a week, and then fell by 
lysis to normal. Recovery. WILLIAMS: MEMBRANOUS THROAT AFFECTIONS, 
7 
These cases suggest a connection between the bacillus of diphtheria 
aud certain of the paralyses which sometimes occur after scarlet fever, 
measles, and typhoid fever. Furthermore, the mortality from diphtheria 
in our State should include some of the cases classed under scarlet fever, 
measles, and typhoid fever, as already suggested. 
We now come to the third point, namely, the treatment of diphtheria, 
and this subject divides itself naturally into two parts, general and local 
treatment. The former may be outlined in a few words. The food of 
the patient deserves special attention. Alcohol is, in some cases, of 
service. Iron is frequently given for ansemia. 
In 19 cases— 
Diphtheria 9 
Diphtheria and scarlet fever .... ... 8 
Pseudo-diphtheria 4 
Pseudo-diphtheria and scarlet fever . . ... 3 
19 
—most of which appeared anaemic, I determined the haemoglobin by 
Fieischl’s haemoraeter, and this instrument did not in the majority of 
cases confirm the apparent anaemia. Sixteen of these 19 cases, children 
and adults, had about, and in some cases more than, 100 per cent, of 
haemoglobin. The 3 remaining cases were all children. In the first of 
these, a child five years old, ill with diphtheria, the haemoglobin was 
75 per cent. In the other two, children of a year old, one ill with 
diphtheria, the other with pseudo-diphtheria, the haemoglobin was about 
50 per cent. Mercury in small doses has been recommended, but it did 
not seem to me of service in the few cases in which I have used it or 
seen it used. The cases of Behring treated with the blood-serum of 
immune animals encourage us to hope that a feasible internal remedy 
may be found. 
At present local remedies are our best means for the treatment of 
this disease, and obviously they are best adapted to those cases that are 
seen early, before much of the poison has been absorbed, and further, to 
cases in which the membrane is accessible. 
Given a patient in whose throat is a patch of membrane filled with 
bacilli that reproduce themselves in a very short period and which 
generate a soluble and most virulent poison; a membrane that may be 
thick and tough, and over the surface of which there constantly passes 
a stream of saliva that will quickly carry away the remedies applied to 
it; situated in a region to which applications can be made for short 
intervals only, and even then is not easy of access: what should we 
do? It is worse than useless to tear off the membrane; this causes 
bleeding; the membrane rapidly returns, and over a larger area. The 
bacillus seems, above all things, to delight in the blood-serum, and the 8 
WILLIAMS; MEMBRANOUS THROAT AFFECTIONS. 
spread of the membrane follows the course of the bleeding as eagerly 
as a hungry horse will follow oats. Bacteriologists, in searching for a 
medium in which to tempt the bacillus to grow outside of the body, have 
found nothing better adapted to the organism than blood-serum. 
Chlorate of potash does not seem to me of service and in excessive doses 
may do serious harm. Nitrate of silver is a caustic that does not penetrate 
deeply. Chromic acid is one of the most relentless of all caustics. lodine 
is irritating when inhaled, as are the vapors from saturated solutions of 
chlorine. Solutions of carbolic acid are poisonous and inefficient as 
germicides. I have not succeeded with digestives. Sesq id-chloride of 
iron, often used in the form of a tincture, has been, and with some still 
is, a favorite application. Knowing that these iron preparations con- 
tained free acid, I thought it probable that the acid rather than the iron 
would prove to be the active agent. To test this, Mr. A. P. Mathews 
compared for me a solution of chloride of iron with a solution contain- 
ing no iron, but having the same quantity of acid as in the iron solu- 
tion. The iron solution was found to be no better as a germicide against 
the bacillus of diphtheria than the acid water, thus showing the acid to 
be the essential agent in the iron solution. The tincture of the chloride 
of iron contains 2.5 per cent, to 3.4 per cent, of free hydrochloric acid; 
the solution of chloride of iron contains from 5.4 per cent, to 7.4 per 
cent, of free hydrochloric acid. These iron solutions are an excessively 
unpleasant treatment. Corrosive sublimate has much reputation as a 
germicide, but its action seems to be inhibitory rather than germicidal. 
I insert here three cases of diphtheria, the diagnosis of which was based 
on cultures, in which corrosive sublimate was used locally, as better treat- 
ment was not at the time practicable, and they show how the membrane 
may persist under its use; 
J. 8., aged twelve years, entered the hospital on the third day of the 
disease. Membrane was seen on both tonsils, both sides of pharynx, 
and a small spot one-eighth of an inch in diameter on posterior pharynx. 
Klebs-Loeffler bacilli found in culture. The local treatment for 
thirteen days was corrosive sublimate 1:10,000 in spray every four 
hours, but in spite of this the membrane continued to cover more area 
and to become thicker until the eighth day of the disease, when the 
throat began to clear. Septic odor. On the tenth day, no bacilli were 
found in culture; their growth was probably inhibited by the presence 
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 Conval- 
escent 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 mem- 
brane adherent to one vocal cord. After eleven weeks, the tonsils were 
large and covered with a whitish film or membrane which could be WILLIAMS: MEMBRANOUS THROAT AFFECTIONS. 
9 
wiped off with difficulty ; breath foul. Dr. Councilman found Klebs- 
Loeffler 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 membrane, and the persistence 
of the bacilli in spite of its use It would be desirable to have bacterio- 
logical 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 a cleansing 
action from a weak (7.5-volume2) solution of hydrogen peroxide to assist 
the action of the 1:10,000 corrosive sublimate. 
In the first of these the patient, a woman aged twenty-two years, had 
paralysis on the fifteenth day of the disease, and the throat was not 
clear until the seventeenth day of the disease. In the second case, M. 
McP., a woman aged twenty-eight years, entered the hospital on the 
third day of the disease. Thick membrane on both sides of the uvula 
and on the left tonsil. Klebs-Loeffler bacilli found in culture. The 
local treatment was a spray of 7.5-volume solution of hydrogen per- 
oxide 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 evidently the membrane had spread to the larynx. Prostration. 
Reduplication of heart sounds. After ten days a spray of corrosive 
sublimate 1: 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 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 
1:10,000, as illustrated in J. 8., and also when this is used in connec- 
i Since this paper was read a man has come to the hospital with naso-pharyngeal paralysis. 
No membrane was seen in the throat by the physicians who examined him, but Klebs-Loefller 
bacilli were found in the cultures. The history of the case showed that the attack of diph- 
theria had begun about eight weeks previously. This case also shows the importance of 
bacteriological examination before isolation is ended. 
2 In the United States a 20-volume solution of hydrogen peroxide has been and still is one 
which will yield 20 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 United States Pharmacopoeia for 
1890, which will be official on January 1,1894, 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 Pharmacopoeial 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. 10 
WILLIAMS: MEMBRANOUS THROAT AFFECTIONS. 
tion with a dilute solution of hydrogen peroxide, as illustrated by the 
last two cases. 
It would take too long even to enumerate the various kinds of local 
treatment that have been used in diphtheria, but there are certain con- 
ditions 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 Massachusetts Institute of Technology with 
various germicides on the bacillus of diphtheria, I chose the short period 
of ten seconds for the limit of time during which they were allowed to 
exert their action, 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 
\ to 2 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 by their effect upon the bacillus of diphtheria, 
an organism which is not so difficult to kill as the staphylococcus for 
instance, but the neutral solutions have far less germicidal power than 
the acid ones. I pointed out by some observations published last year,2 
the distinction that should be drawn between the nearly neutral and the 
acid solutions, but it is evident that this point needs further emphasis, 
particularly as the solutions of hydrogen peroxide are coming more into 
use, and neutral ones are made which are excellent for certain purposes, 
but which being nearly free from acids, have little germicidal value 
against the bacillus of diphtheria, except in unusual strength. 
The strong hydrogen peroxide acid solutions, by which I mean strengths 
of 25 to 50 volumes or more, as already shown, are efficient germicides 
in the laboratory, and they have besides the special quality of breaking 
up and disintegrating certain portions of the diphtheritic membrane 
without injury to the healthy tissues, thus rendering the bacilli more 
accessible. 
1 It is interesting to note the importance of the mineral acids, especially hydrochloric acid ; 
they are of value in the hydrogen peroxide solutions, and are good germicides when used alone; 
hydrochloric acid is, as we have seen, the active agent in the iron solutions, and is also a 
valuable germicide in the gastric juice. 
2 Boston Medical and Surgical Journal, September 29,1892. WILLIAMS: MEMBRANOUS THROAT AFFECTIONS. 
11 
Having found a substance that has no poisonous properties, namely, 
a strong solution of hydrogen peroxide, that is shown to be an effi- 
cient germicide in the laboratory, let us see what it will do clinically. 
I was so situated that in most of the cases in which the diagnosis 
was carefully made by cultures, the strong hydrogen peroxide solu- 
tions were not used, and in most of the cases in which the peroxide 
treatment was used the cultures were not made. I have made some 
use, chiefly in 1892, of strong peroxide solutions, in seventy-four cases 
in all; sixteen of these died and fifty-eight recovered; but as, in most 
of these, the diagnosis was not based on cultures, it is impossible to 
state exactly how many were diphtheria and how many pseudo-diph- 
theria. In the sixteen cases that died the patients entered the hospital 
after they had been ill an average of five days, so far as I could learn. 
Eight of these died within one to three days after entrance. There 
was not much opportunity for treatment, and the hydrogen peroxide 
was omitted when the patients seemed too weak. Two entered the 
hospital on the last day of my service, and the strong solutions of 
hydrogen peroxide were employed on that day only. These patients died 
about two and four weeks later, respectively. In four cases the mem- 
brane was in or extended to inaccessible parts of the throat, and in but 
one of these was there temporary improvement. In the fifteenth case the 
patient had diphtheria (as shown by subsequent paralysis) and scarlet 
fever simultaneously. There was local improvement, but the child died 
about the fifteenth day of the disease. In the sixteenth case scarlet 
fever developed on the twelfth day of the disease, when the throat was 
nearly clear. The patient did well until the fifteenth day, then had 
suppurating glands and died on the nineteenth day of the disease. 
In the four following cases, the diagnosis of which was based on cul- 
tures, the strong hydrogen peroxide acid solutions were used. The first 
two are cases of,pseudo-diphtheria. 
E. F., aged twenty years, entered the hospital on the second day of 
the disease. Thin, gray membrane on left tonsil and all along the arch 
of soft palate. Mr. Mathews found streptococci on cover-glass and in 
culture, but no bacilli. The membrane was cleared off completely with 
50-volume solution of hydrogen peroxide applied with a swab, and 
this was followed by an application of chlorinated soda. Spray of 
25-volume hydrogen peroxide solution every four hours. On the fifth 
day of the disease, but the third after treatment, the throat was clear. 
Recovery. 
C. D., aged twenty-three years, consulted me on account of some 
slight difficulty, and, as a matter of routine, I looked in her throat, 
which was then clear. On the following day, I was much surprised to 
be sent for in some haste, and then found on both anterior pillars, tonsils 
and uvula, patches of membrane, which were one-sixteenth of an inch 
thick and could be removed with some difficulty with the edge of a tea- 
spoon, but this caused bleeding. I removed most of the membrane with 12 
WILLIAMS : MEMBRANOUS THROAT AFFECTIONS. 
a 25-volume hydrogen peroxide solution, but left the base of one patch 
on the soft palate, about one-fourth of an inch in diameter, fearing that 
further attempts to remove it might set up bleeding, as here the mucous 
membrane looked as if the surface had been etched off. As this patch 
was at a point readily accessible to a gargle, I left the patient at 1 p.m. 
with directions to use a dilute acid solution of hydrogen peroxide every 
half-hour and to follow this by a gargle of diluted solution of chlorin- 
ated soda. At my second visit, three and one-half hours later, I was 
much gratified to find the throat entirely clear of membrane. I saw the 
patient daily for some days, during which mild antiseptic sprays and 
gargles were used, but there was no return of the membrane. This 
was seen only at my first visit. No Klebs-Loeffler bacilli were found in 
cover-glass examination. Cultures showed streptococci and staphylococci. 
We may look for better results in private practice than at the hospital, 
as in the former case patients are generally seen earlier. 
In the two following cases of diphtheria, the diagnosis of which was 
based on cultures, there was partial use only of strong solutions of 
hydrogen peroxide, but even by this, good results were accomplished. 
A. 8., aged twenty-four years, entered the hospital on the second day 
of the disease. 4 p.m., membrane on right tonsil, thick in places, car- 
tilaginous in character. Membrane also on left tonsil and left wall of 
pharynx. Klebs-Loeffler bacilli found on cover-glass and in culture. 
Strong hydrogen peroxide acid 25-volume solution was applied in 
spray, and 50-volume by syringe and swab, and the membrane re- 
moved except in points around anterior edge of left tonsil which were 
cartilaginous in character. The patient said there was less pain in 
swallowing a few minutes after the application of the peroxide than 
before, and after this application he ate his evening meal of eggs on 
toast, etc. At 9 p.m. the membrane had returned to some extent over 
its area of 4 p.m., but was not so thick and had not spread. Strong 
hydrogen peroxide was again applied. Spray of corrosive sublimate 
1:10,000 given every two hours through the night. Large dose of 
bromide at night to prevent serious loss of sleep from frequent waking. 
The patient slept ten hours. No hydrogen peroxide solution was applied 
during the night, and the next morning the membrane was found to 
have spread rapidly over both sides and on to the back of pharynx in 
spite of the 1:10,000 corrosive sublimate that had been applied every 
two hours. There seeemed to be some membrane in naso-pharynx. Strong 
hydrogen peroxide acid solution 25 and 50 volumes was-then applied to 
the throat on swab. A solution of chlorinated soda, 1: 6, was applied 
every two hours in spray. At 8 p.m., large dose of bromide. On fourth 
day of disease, membrane over same area as on the third day; 25- and 
50-volume hydrogen peroxide applied morning and afternoon, followed 
by chlorinated soda. The membrane seemed to be kept from spread- 
ing or becoming thick if the applications of hydrogen peroxide were 
made every four hours, but otherwise it gained in thickness and some- 
what in extent. Fifth day of The disease, general condition excellent. 
Membrane much less in extent and thinner. Hydrogen peroxide only 
twice during the day. Membrane seemed under control. Sixth day ; 
the patient had eaten well before, but now had appetite. General 
condition excellent. Throat clearing. Two applications of hydrogen WILLIAMS: MEMBRANOUS THROAT AFFECTIONS. 
peroxide, although this seemed hardly necessary, but it was done to pre- 
vent the possibility of relapse. Two per cent, spray of cocaine applied to 
throat prevented pain from the application of the peroxide. On the 
seventh day of the disease, and the fifth after entrance, a final applica- 
tion of peroxide was made. The patient left the contagious ward six days 
later. There was no cardiac weakness, no depression, and no paralysis. 
M. L., aged eighteen years, entered the hospital February 25th, on 
the second day of the disease. His throat had the appearance of a 
follicular tonsillitis. On my first visit I found Klebs-Loeffler bacilli, 
micrococci and streptococci in a cover-glass examination. The next 
day Dr. Councilman obtained an almost pure culture of Klebs-Loeffler 
bacilli. At 1 p.m., there were two small patches of membrane on the 
right tonsil, the one an eighth by a quarter of an inch and the other an 
eighth of an inch in diameter. These were removed with six minims 
of a 25-volume hydrogen peroxide solution in syringe, and this was 
followed by an application of chlorinated soda. At 5 p.m., the throat 
was again cleared carefully with 25-volume hydrogen peroxide solution 
by swab and syringe, followed by an application of strong chlorinated 
soda on swab. At 9.30 p.m., the membrane was not visible except a 
thin, yellowish, translucent deposit over original area, namely, on right 
and left tonsil. This was cleared off with the hydrogen peroxide solu- 
tion, and was followed by chlorinated soda solution. No hydrogen 
peroxide was used through the night, but a solution of chlorinated soda 
was applied every two hours. In spite of this, on the following morn- 
ing the membrane had spread over the larger part of the right tonsil, 
and there was also a strip of membrane three-fourths by one-eighth of 
an inch on each side of the pharyngeal wall. This was cleared off 
again with 25-volume hydrogen peroxide solution on swab at 10.30 a.m. 
and again at 5.10 p.m. On the fourth day of the disease, only two appli- 
cations of the peroxide were made, as the membrane was readily con- 
trolled, and on the fifth day one final application of the peroxide was 
made. On the sixth day of the disease, and fourth after entrance, the 
throat was clear. Patient felt well and asked if he might get up. Dis- 
charged after being kept under observation ten days longer. There 
was no cardiac weakness, no depression, and no paralysis. 
In these two cases the strong solution of hydrogen peroxide was used 
only two or three times in the twenty-four hours, and the membrane 
returned during the long intervals of several hours when it was not 
applied, in spite of the use of corrosive sublimate or chlorinated soda 
every two hours. These cases had only a partial peroxide treatment. 
In both instances, the condition of the patient was excellent throughout 
the illness. These two cases suggest that by early local treatment with 
peroxide we may diminish the generation and absorption of poison from 
the bacilli. 
I have found nothing that will remove the membrane so well as the 
strong solutions of hydrogen peroxide. 
The drawbacks of the strong solutions of hydrogen peroxide 1 consist, 
1 I give some details concerning tlie strong hydrogen peroxide solutions, as they are a 
novelty. Physicians and chemists told me that even 25-volume solutions were impracticable 14 
WILLIAMS: MEMBRANOUS THROAT AFFECTIONS. 
first, in the fact that the acid solutions, which are stronger germicides, 
cause pain, due to the acid, which lasts about one minute. Some 
patients object to this very much ; others, including children, will per- 
mit the use of a 50-volume solution with little fuss. In private practice, 
I recall a young lady who applied the 50-volume solution to her own 
throat on a swab and used it more frequently than I had directed. On 
another occasion I suggested in consultation that cocaine be first applied 
to the throat, but the physician in attendance said it was unnecessary, 
as the patient, a child three and one-half years old, did not mind the 
50-volume solution, which he had been using in spray. The discom- 
fort is due to the acids rather than the hydrogen peroxide; if the 
solutions are neutralized the discomfort is largely obviated. We may 
disguise the acid by adding sugar, as in lemonade, showing that it is the 
acid taste that is disagreeable rather more than the so-called irritation. 
Instead of adding sugar we may apply cocaine to the throat before we 
use the hydrogen peroxide solution. The amount of acid in the 25-vol- 
urae solution which I used was i per cent., in the 50-volume 1 per 
cent. This is far less than the amount of acid in the chloride of iron 
solutions, for, as already stated, the tincture contains from 2.5 per cent, 
to 3.4 per cent, of hydrochloric acid, and the solution of the chloride of 
iron from 5.4 per cent to 7.4 per cent, of hydrochloric acid. 
Second. Strong solutions of hydrogen peroxide1 have not been easily 
procured, nor do they bear transportation well, but these inconveniences 
may be readily surmounted. The apothecary or physician has merely 
to evaporate a 10-volume solution in a shallow, open dish, over a 
water-bath, or on a range or stove, to obtain a solution of either about 
25 or 50 volumes.2 The initial solution should not be too acid, the dish 
should not be of metal and should be free from organic matter. 
or impossible, but as the caution came after I had had a 100-volume solution I was not dis- 
mayed. 
Unlike chlorine and chlorinated soda, corrosive sublimate, if desired, may be mixed with 
hydrogen peroxide; citric or tartaric acid should be added to prevent the precipitation of 
albuminate of mercury in the throat. 
It gives me pleasure to again express my indebtedness to Professor H. P. Talbot, of the 
Massachusetts Institute of Technology, for his assistance in the study of hydrogen peroxide. 
1 The stability of the strong solutions and the precautions to be used for keeping them I 
have already described in a former article. As soon as the properties of strong solutions are 
more widely known and it is appreciated that they may be obtained without much difficulty, 
they will, I believe, find other uses than that of a local application in diphtheria. They should 
not, of course, be employed in closed cavities, as the oxygen liberated might cause pressure. 
2 To be more precise, a 25 or 50-volume solution may be obtained by evaporating a 10-volume 
solution to y?, or %of its bulk respectively. The loss of the hydrogen peroxide is usually less 
than 10 per cent, in the former ease, and about 20 per cent, in the latter. The temperature 
being the same, the loss seems to be less when the hydrogen peroxide is evaporated quickly 
than when the process is carried out more slowly. One teaspoonful of a 50-volume solution 
is ample with which to begin the treatment. The strong solutions should be kept in a cool 
place. 
By evaporating 200 c.c. of a 11.5-volume solution I have obtained a 275-volume solution. 
A drop of this applied to my tongue caused momentary smarting. 
A 10-volume solution of hydrogen peroxide may be tested in the following way : One drachm WILLIAMS: MEMBRANOUS THROAT AFFECTIONS. 
15 
Third. Hydrogen peroxide is a bleaching agent and should not be 
brought into contact with the hair or with colored fabrics, but it does not 
injure white cotton or linen. One should avoid getting it on the fingers, 
as it may, after a few minutes, whiten a thickened epidermis and cause 
a sensation of pricking. 
The advantages of the strong hydrogen peroxide solutions are that 
they are good germicides and are not poisonous nor harmful to the 
mucous membrane; they cleanse a foul throat and break up and dis- 
integrate certain portions of the diphtheritic membrane, thus rendering 
the bacilli more accessible. They likewise assist in diagnosis, for when 
the hydrogen peroxide, even in weak solution, is applied to the throat 
where there is any trace of membrane, it causes it to asume a white color 
from the presence of fine foam which is made by the liberation of the 
oxygen gas. It thus becomes a useful agent in detecting spots of mem- 
brane earlier than they would be apparent in any other way, and thus 
indicates the areas to which the treatment should be directed. With 
this end in view, the throat may be sprayed or the mucous membrane 
may be swabbed with dilute hydrogen peroxide. It is known that cor- 
rosive sublimate to a considerable extent is inhibitory rather than germi- 
cidal in its action, but it would be difficult to conceive of a merely 
inhibitory action on the part of hydrogen peroxide, as this substance is 
so readily decomposed. 
No rule can be given for applying these solutions that will cover all 
cases. In a general way it may be said that the strong solutions of 
hydrogen peroxide containing about i per cent, of acid, made up 
chiefly of hydrochloric or sulphuric acid, should be gently but thor- 
oughly applied every four hours during the night and more frequently 
during the day for the first few days. The 25-volume solution may be 
used in spray; the 50-volume may be applied, a drop or two at a time, 
on a swab until the membrane is removed or much diminished, or in 
certain cases the 50-volume solution may be applied with the syringe. 
Even a stronger solution than 50 volumes may be used for resistant 
membranes. It is well to use cocaine before applying the peroxide. 
By the help of bromide at night, the patient loses very little sleep in 
being aroused for the local treatment. Every precaution should be 
taken to spare the patient’s strength, and it is not necessary that the 
head should be raised from the pillow while the applications are being 
made. 
As the bacilli are not limited to the diphtheritic membrane, antisep- 
tics should be brought into contact with other portions of the throat 
of it diluted with about an ounce of water and acidified with about three drachms of dilute 
sulphuric acid will dissolve and decompose three grains of permanganate or potassium (in 
crystals) and leave a colorless solution. If the strength is less than 10 volumes the solution 
will finally be of a bright-red color. 16 WILLIAMS : MEMBRANOUS THROAT AFFECTIONS. 
Pig. 2. 
and nose than those covered with membrane, by such means 
as sprays and gargles, as a prophylactic measure. 
The accompanying cuts show the instruments which I have 
designed for making applications to the throat; but any good 
atomizer, not of metal, that will reach the desired spot conve- 
niently, or a swab made by twisting a small piece of absorbent 
cotton about the end of a small stick, may be used. 
Fig. 1. 
Fig. 3. 
Fig. 1.—A, rubber tubing to hand-bulb. The cut is one-half size except the 
section of the tube at B, which is full size. The bulb in the drawing should have 
more the shape of a top, and when of such shape it can be placed on its side 
without losing any of its contents if it is not more than half full. If the tubing, 
A, which joins the rubber hand-bulb to the atomizer is only about one inch long, 
the atomizer can be worked with one hand. It will be noticed that the straight 
tube of the atomizer is unusually long—more than four inches from the rubber 
tubing to the tip. 
Fig. 2.—The syringe is of glass one inch longer than the drawing, otherwise 
this is the full size. The walls of the syringe beyond the piston are thick, and 
the tip is smooth, having been rounded in a flame. The form is such that it can 
reach any part of the throat within sight. The corks are now replaced by glass 
projections. The packing may be of cotton or asbestos. The cost of the syringe 
is trifling. 
Fig. 3.—The swab is eight inches long, but otherwise the drawing is full size.l 
1 These are made by P. J. McElroy, East Cambridge, Mass., U. S. A. WILLIAMS: MEMBRANOUS THROAT AFFECTIONS. 
By means of this atomizer (Fig. 1) the spray may be sent in three 
directions, up and right and left, in the throat without taking it out of 
the mouth, but merely turning it in the hand. 
The syringe (Fig. 2) may be pushed through the false membrane and 
a drop or two of solution pressed out, the oxygen then generated under- 
neath a thick membrane will lift off large pieces of it. In this way large 
numbers of bacilli are removed, the poison from which might otherwise 
be swallowed and absorbed. 
The swab (Fig. 3) used to apply the solution consists of a small glass 
tube drawn out at one end into a smaller rod, about which sufficient 
absorbent cotton has been twisted to hold two or three drops of liquid. 
The end of the rod has been rounded in a flame and made slightly 
bulbous, as shown by the dotted line; by this device the cotton is held 
firmly. 
The sterilized swab and its holder, seven inches long, which I used for 
taking specimens from the throat are shown in the woodcut (Fig. 4), which 
is about one-half size. After the swab has been rubbed over 
the throat it is replaced in the tube of thick glass, which 
is stopped with sterilized cotton. A small piece of this 
having been previously torn off is moistened with a few 
drops of water and placed above the stopper to prevent the 
specimen from drying. The tube is then closed with a 
cork to prevent evaporation. There should be no delay in 
taking a swab from the throat, and the treatment should 
then be applied without waiting for the result of the 
cultures. 
I have found it difficult to obtain some common germi- 
cides—not only hydrogen peroxide—of the strength which 
they purport to be. This leads me to emphasize the need 
of caution concerning the quality of the remedies we em- 
ploy. Physicians may well take a lesson in therapeutics 
from the surgeons, for in antiseptic surgery, which is largely 
therapeutics, they set us an example of painstaking care in 
the use of remedies that we should do well to follow. If 
in surgery, where the conditions are comparatively simple, 
so much pains must be takenfhow much more careful 
should we be when the problem is more complex. When 
in the selection and application of our remedies we approach the standard 
antiseptic surgery has set for us, we shall hear less about the inefficacy 
of drugs. 
Fig. 4. 
Diphtheria usually begins on the tonsils, and, to avoid serious con- 
sequences—for instance, those resulting from the spread of the mem- 
brane to the neighboring air-passages—no moments should be lost before 
beginning treatment. Until we have found something that will find 18 
WILLIAMS : MEMBRANOUS THROAT AFFECTIONS. 
and kill all the bacilli at a single blow, any local treatment must be 
frequently applied to be efficient, as the bacilli reproduce themselves in 
a very short period. From these frequent applications during the early 
days of the disease I see, at present, no appeal. The use of the strong 
hydrogen peroxide solutions reduces the number of applications to a 
minimum, as the more thoroughly the membrane is disintegrated and 
removed the less frequent is the necessity for treatment and the shorter 
its duration. 
In those cases that are first seen several days after the onset of the 
disease, and when the patient has become weakened by the poison gen- 
erated by the bacilli, we must weigh carefully the loss of strength result- 
ing from frequent applications, especially in very young children, against 
the gain to be derived from the removal or destruction of the bacilli. 
Further, if the patients have been ill some days when first seen, the 
chances of recovery are much diminished, and in some cases no treat- 
ment as yet at our command is of avail; just when the physician shall 
renounce all hope of aid from local treatment each one must, of course, 
decide for himself in the individual case. The usefulness of good local 
treatment is in direct ratio to the stage of the disease, the accessibility 
of the membrane, the age and strength of the patient, and the ability 
of the practitioner to apply it with the least tax on the patient’s strength 
combined with the greatest destruction of the bacilli. 
I beg you not to go away from here with the impression that diph- 
theria can always be cured by strong hydrogen peroxide solutions. I 
maintain only that when properly used they are more efficient and less 
harmful than any other treatment I know of. Under their use all of the 
few cases that I have thus far seen early in the disease, recovered. 
As already stated in the opening of this paper, there were 36,553 
deaths from diphtheria and croup in Massachusetts from 1871 to 1890, 
inclusive. Rather more than one-half of these, 19,310, occurred within 
a very limited area, that is, within the area of the twelve cities, or those 
fractions of them represented by the nine1 black spots on the accom- 
panying map. During these twenty years about 43 per cent, of the 
population was to be found in these cities, and 53 per cent, of the deaths 
from diphtheria and croup during this time occurred in them. Further, 
it is of interest to note that the greater part of these deaths occurred 
during four months of the year, na*nely, from October to January, 
inclusive. These are suggestive facts when considered from the stand- 
point of prevention. It is highly important for each city and large 
town to have a suitable hospital for contagious diseases, and also to 
offer facilities for bacteriological examinations in those diseases in which 
false membranes develop. In smaller communities it would seem de- 
sirable to extemporize a hospital during an epidemic. 
i Pour cities—Boston, Cambridge, Chelsea, and Somerville—are contiguous. WILLIAMS: MEMBRANOUS THROAT AFFECTIONS. 
19 
Diphtheria seems to me to be chiefly a hand-to-mouth or mouth- 
to-mouth disease; its cause is tenacious of life, especially in damp 
places, and is not killed by cold, but is killed by sunlight. The 20 
WILLIAMS: MEMBRANOUS THROAT AFFECTIONS. 
period of incubation after the bacilli have reached the mucous mem- 
brane is probably in some cases not days but hours only. With the 
improved means of diagnosis at our command, by early isolation, and 
the co-operation of intelligent citizens with the Boards of Health, it 
may become one of the most preventable of diseases, and I hope that 
before many years have elapsed we shall see diphtheria considerably 
diminished in our State as well as elsewhere. The members of this 
Society can do much to further this end. The best defence against this 
disease is educated public opinion. 
1. The necessity of cultures as a means of early diagnosis. 
Summary. 
2. The coincidence of diphtheria and other diseases. 
3. The bacteriological examination of all patients ill with scarlet fever, 
typhoid fever, measles, or other disease, who have membranous throats. 
4. The bacteriological examination of specimens from the throats of 
all diphtheria patients before isolation is ended. 
5. Seven and one-half- [known at present in the United States as fif- 
teen-] volume solutions of hydrogen peroxide are weak germicides. 
6. The advantages of strong hydrogen peroxide solutions, locally, in 
diphtheria. The substitution of harmless and more efficient for harmful 
or inefficient local treatment. 
7. The importance of frequent, early local applications. 
Note.—Dr. John F. Young, of Newburyport, Mass., was present when 
this paper was read, and ten days later had a case of diphtheria, in 
which he used the strong hydrogen peroxide solutions. I heard of it 
by chance some weeks afterwards, as the patient was the child of an 
acquaintance. In reply to my inquiries, Dr. Young kindly wrote me 
about the case. With his permission I quote his letter almost in full: 
“My patient was a bright and sensible girl aged ten years. On the 
morning of the 24th of June she complained of headache and sore- 
throat ; I saw her for the first time about four o’clock that afternoon. 
There was some stiffness of the neck and some swelling on each side at 
the angle of the jaw. The tonsils and arches of the palate were red and 
swollen. There was considerable fever and also a good deal of dizziness 
when the patient sat up in bed. Small dose of calomel, as bowels were 
somewhat confined, and boric acid gargle. 
“ Saw her next morning, 25th, about ten o’clock, when tonsils and 
arches of palate nearly up to uvula were covered with a thick, grayish 
exudation, the cervical glands were more swollen, and more constitu- 
tional disturbance was present than on first visit. Treatment with per- 
oxide of hydrogen was now begun after evaporating the solution to 
one-quarter its original bulk; and, as the patient complained of no very WILLIAMS: MEMBRANOUS THROAT AFFECTIONS. 
21 
disagreeable sensation from its use, it was ordered to be applied in the 
form of a spray every hour. Saw the patient again about 7 p.m. There 
had been no extension of exudation, no other change noticed, except 
that the exudation looked thicker and more swollen. Directed that 
spray be used every two to three hours through the night. 
“ On the morning of the 26th, no considerable change in appearance 
of throat, no extension, but patient had decidedly less trouble (dizziness) 
on sitting up, and expressed herself as feeling better. Evening about 
the same. 
“ 2.7 th, a. m. Patches on tonsils and palatine arches appeared to be more 
loosely attached and also thicker than before. A patch of exudation 
(rather thin) about the size of a finger-nail, was seen opposite the last 
inferior molar on right side, and another on the front of soft palate near 
roof of mouth on left side. The peroxide was now applied by means of 
a swab and repeated again toward evening by myself, the spray being 
used as before by the nurse. During the evening on swabbing the 
exudation in the mouth it seemed to melt away, leaving raw and bleed- 
ing surfaces, and the original patches to diminish in size considerably, 
and on the m orning of the 28th it came off almost at the first touch of the 
swab. The surfaces left bare were raw and bleeding, and a spray of 
carbolic acid and lime-water was now substituted for the peroxide and 
used every hour. No reappearance of patches at the evening visit. 
“ 29th, a. m. White patches again covered tonsils and arches of palate, 
not so thick, however, as before, and were removed entirely by two 
swabbings with peroxide on same day, and did not again return. Spray 
of carbolic acid and lime-water was continued for the next two days, 
when one of boric acid was substituted for it. 
“By the 4th of July the throat was looking almost well. At this time 
a slight nasal intonation was noticed, and after this there was some 
tendency to regurgitation of liquids through the nose. (This became 
more marked later.) 
“ It seemed to me that the peroxide had a decidedly beneficial effect, 
the constitutional symptoms growing less and less every hour from the 
very start. The general treatment of the patient consisted in the admin- 
istration of iron, brandy and milk every three hours, and meat juice 
midway between feedings of milk and brandy.” 
The noteworthy points in this case are, first, the effect of the local 
treatment by strong hydrogen peroxide solutions on the patient’s general 
condition ; second, the disappearance of the membrane under the use of 
this application; its reappearance when carbolic acid and lime-water 
were substituted, and its final disappearance when the strong hydrogen 
peroxide was resumed. 
I wish to express my appreciation of the courtesy and kindness that 
have been extended to me in the chemical and biological laboratories 
of the Massachusetts Institute of Technology, by Professor T, M. Drown 
and Professor William T. Sedgwick, while I was carrying on some of 
the investigations connected with this paper. Tl?0 America Johrrjal 
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