24G TIII'IITIIKUIA IN THl'; TROPICS 



(Films made from the swab showed no cocci. At first nothing was found except 

 tlie large spore-bearing organism to be described, but prolonged and careful search 

 revealed the presence of a few but quite typical li. diphtheriie. They were very 

 nearly overlooked. The cultures on LtElHer's blood serum yielded only the former 

 organism which grew rapidly, and completely obscured any colonies of B. dipJdherise 

 which may have been present.) 

 November 29, 1909. No improvement. Follicular tonsillitis still present on the right side. 

 No change in patch on left tonsil. An ulcer with a bright red margin has appeared 

 on the hard palate and another under the tongue. The bases of these ulcers are 

 covered with a dirty greyish-yellow slough. 



The report on the previous days' examination having been received, 2000 units of 

 diphtheria antitoxin were given subcutaueously about 7 p.m. The ulcers were 

 swabbed and so was the throat. 



(Film from the ulcer swabs showed the large rods only, those from the throat 

 swabs showed a double infection but, as before, B. diphtherite was present in very small 

 numbers. In cultures from the swabs B. diphtheriie was lost owing to the profuse and 

 rapid growth of the larger organism. Plate cultures failed to separate out the two 

 bacilli.) 

 November 30, 1909. Patient feels very much worse. Voice very weak and husky. 

 Considerable pain at seat of injection probably owing to the antitoxin being rather old. 

 Throat slightly better. The question of preparing a vaccine from the spore-bearing 

 organism was discussed, but it was decided that it would not be safe to administer any 

 such vaccine, and it was recognised that the great depression was due, in the main, to 

 the diphtheritic poison. Enquiries elicited the fact that some days previously patient 

 had been in the comijany of an oflBcer who had recently suffered from diphtheria 

 and may have been a carrier case. In the evening there was a distinct improvement. 

 The patch on the left tonsil was smaller. A fresh ulcer was found to have appeared on 

 the lower gum of the right side. 



Another 2000 units of antitoxin given. 

 December 1, 1909. Patient distinctly better. Pulse very slow but of good tension. Several 

 fresh angry-looking ulcers have appeared on the buccal mucous membrane of the left 

 side. The other ulcers are improving. 

 December 2, 1909. General improvement maintained. A biniodide of mercury mixture 

 ordered. Swabs taken. 



(No Klebs-Loeffler bacilli found. Other organism still present.) 

 December 3, 1909. Patient nmch better. One of the ulcers was touched with silver nitrate. 

 December 4, 1909. Progress very satisfactory. Ulcers on the gum and under the tongue 

 healed, others in a healthy state. Fresh swabs taken. (Only the spore-former 

 present.) 



A tonic was now ordered in addition to the mouth-wash. 



From this date onwards a gradual improvement took place, the mouth and fauces 

 beinf clear and free from all bacillary infection by December 9. Patient went to his 

 ofi&ce on the 11th, but felt so weak that he was unfit for work. Accordingly he left 

 Khartoum for a change and sea-trip which had the desired effect of establishing 

 complete convalescence. 



Comments. — The diphtheritic infection need not detain us. There was nothing special 

 about it. Bacteriologically, the infection was slight and yet the rather severe constitutional 

 symptoms, evidenced chiefly by extreme weakness and a tendency to heart failure, umst be 



