the large number of cases that come under treatment outside the hospitals and without antitoxic serum, keep the general rate to the high figure (25 per cent. of all cases) already quoted. It must be recollected, also, that many cases that have been reported to the local Boards of Health as due to membranous croup, to heart failure, and to nephritis in children, are really due to diphtheria, the initial lesion.

The consensus of opinion seems to be that when antitoxin is given in time to prevent degenerative changes from taking place in the nerves, muscles, kidneys, and liver, most of the patients, recover. But, when the patient is allowed to go beyond the third or fourth day of the disease, the mortality is still high. Yet even in these the death-rate is lower than in cases which are treated with the old methods. This apparently demonstrates that even in this type of cases antitoxin enables some of the cases to tide over the acute period and to recover, altho the treatment be begun late, but that the best results can be expected only when the treatment is begun early.

In cases of the laryngeal type, not only is the percentage of cases requiring intubation largely diminisht, but even in those cases in which intubation or tracheotomy becomes necessary, the percentage-mortality has been reduced from 70 to 41 per cent., or, in some instances, even less.

Drawbacks of the Antitoxin Treatment. Perhaps the most obvious of the drawbacks of the serum-treatment is the formation of abscesses at the seat of the injection, but with a more perfected technic the danger of this is becoming lessened. It has also been found by experimentation that smaller doses of the more potent serum, rather than the large injections of the weaker as formerly so generally advocated, will practically obviate the rash, the pains in the joints and the secondary pyrexia, such being comparatively trivial when they do occur. The abscesses are due to the septic element that is always

present in this disease, at least in every severe attack, and, taking this into account, the number occurring is not excessive.

Albuminuria is certainly due to the use of the serum, but this does not usually occur in an uncontrollable form. The occasional lethal effects of the antitoxin that have been reported are attributed to the idiosyncrasy of the patient and not to any toxic property of the serum. Hematuria has been reported, bnt the connection between the injection of the serum and the occurrence of the complication is not very clear.

The most common ill-effect of the remedy is the occurrence of an exanthematous rash, which, as to type, may be divided into Serum urticaria; diffuse serum exanthems; scarlatina-like rashes; macula exanthems (measles, etc.); polymorphous serous exanthems. This trouble may occur in about 30 per cent of the cases in which antitoxin is used, and usually lasts about nine or ten days. The urticarial form is the most common, and the scarlatinal probably the most unusual.

Unfortunately it must be admitted that not all the serums on the market are what they profess to be, nor are all samples of the same brand of the same strength. Some of these variations have been as follows: One preparation claiming a strength of 1,500 normal units possessed 3,465; another claiming 1,000 possessed only 647.5; a third claiming 1,200 had only 834 normal units.

A so-called normal unit of antitoxin is ten times the amount necessary to neutralize a given quantity of toxin (ten times a lethal dose), within 48 hours in a guinea-pig of from 250 to 300 grams bodyweight, approximately eight ounces. From this it will be obvious that the more concentrated the serum the less the bulk of the fluid injected. It has been proposed to get a more potent serum by estimating the relative proportion of normal units in the blood of each horse that was injected, after a stated time, and casting out those

whose antitoxin-forming powers were not up to a given standard, since this power may vary from 1,000 to 50 normal units per cc.

The dose of antitoxin should be larger for patients with laryngeal stenosis than for others. For a child two years old suffering from this form of diphtheria it should be 1,500 to 2,000 normal units as an initial dose. For an average case the dose for a child two years old should be about 1,000 normal units, this varying with the constitution of the child and the severity of the attack. Hence it will be seen quite readily that the standardizing of any serum is a matter of considerable consequence in order that neither too little or an overdose be given. Some authors claim to have had their best results with a dosage of 4,000 to 8,000 units, altho it is possible that they may have been using serum not quite up to the percentage of normal units claimed.

As Regards Intubation.

If the dyspnea connected with the laryngeal form of diphtheria becomes progressive it is well to try the inhalation of calomel-vapor or calomel-fumigation, but when this does not succeed in controlling the condition, operative interference is indicated. This used to be done entirely by tracheotomy, in itself a measure not without grave dangers, and now practically superseded by intubation.

Intubation should be used in all cases when, despite previous treatment, the difficulty of breathing increases unremittingly, and interferes with the inflation of any considerable part of the back of the lungs, and when sensible exhaustion is produced by the effort of breathing. Nothing but harm can result from this condition, and the use of the tube can produce nothing worse than can be anticipated without it. If air cannot be aspirated into the lungs, blood will be, and the clogged condition of the lungs will surely result fatally.

Intubation has become so well known

even in outlying districts, that it is generally possible to get someone to operate if the attending practitioner does not possess the facilities. Yet there are exceptional localities and instances when the method is not practicable, and in these there is no recourse save to the method of tracheotomy.

The time when to remove the tube depends on the age of the child. The older the child is the sooner the tube can be dispensed with. The duration of the disease before intubation was resorted to is also a factor of consequence. Estimating the maximum of the disease to be seven days, five days' wearing of the tube should be, on an average, considered sufficient.

The chief objections to the use of the tube are the possibility of the formation of pressure-ulcers; the inability to cough up the loosened membrane; the possibility of the air being infected by passing over diseased surfaces; the difficulty of the operation; the possibility that membrane may be pusht down into the trachea by the tube; the extreme care necessary in nursing.

In reply to these objections it has been urged that with regard to ulceration, the larger the tube, within reasonable limits, the less the liability to ulceration, as the tube has less opportunity to move. Again, it is claimed that the ulceration and consequent stenosis, which has so frequently been reported, is more a consequence of the disease than of the treatment, since in many specific fevers ulcers of the larynx occur and stenosis of the trachea follows when no tube has been introduced. Such cases have been reported as occurring in typhoid fever as well as in other dis

eases.

The fact that feeding is difficult in intubation is considered greatly to its disadvantage, altho parents will consent more readily to intubation than to tracheotomy, since the operation is bloodless. There is no cutting, no anesthetic, and this means much to the friends of the patient. It is

performed quickly and needs no trained assistants or trained attendants, (training being necessary only in the operator). The feeding is difficult because the larynx is sore, sometimes because of the inexperience of the operator. The less the larynx is bruised in the act of intubation, the less the child will dread the contraction of the pharyngeal muscles in the act of swallowing.

Yet, even under the most favorable circumstances, the fact remains that there is more or less difficulty is swallowing, both from pain and cough. The coughing arises from the entrance of the fluids into the trachea, tho this is in some degree a matter of training of the patient, some children learning to swallow very well. It is well in feeding to incline the head of the child downward, so that it may be said to swallow "uphill," any fluid that may chance to get into the trachea thus gravitating directly out again. Medication may be continued as well after tubation as before.

Some children show the utmost opposition to the entrance of the tube, but others soon reason from analogy that there is more comfort with it in, and, when old enuf, will even ask for it. A notable case of this kind was treated at the Philadelphia Municipal Hospital a few years ago. The child, at the first intubation, showed every sign of extreme terror, and struggled to a dangerous degree of exhaustion. The tube was removed at the expiration of the usual 114 hours, and a sudden recurrence of dyspnea took place within an hour. The child in much fright gasped, "Put it back! Put it back!" and held perfectly motionless until the tube was reinserted. This occurred three times, before it was deemed safe to allow the tube to remain out permanently.

Drugs and Local Applications in Diphtheria.

Quite a number, not only of the most conservative of the profession, but also others who are generally ranked as among the most progressive, advocate the use of drugs and local applications, either alone.

or in connection with the use of antitoxin. Among those drugs which have been most highly vaunted by the profession are calomel, mercuric chlorid, mercuric cyanid, and protoiodid of mercury. Citric acid, sodium hyposulfite, tincture of myrrh, guaiacol, resorcin, sodium chlorid, and papayotin solution, all have their enthusiastic advocates. astic advocates. A favorite local application with the entire profession is hydrogen dioxid, either full strength or diluted, applied as a spray or allowed to flow gently over and wash the affected parts. Its solvent action on septic processes is well known, and its use seems founded on a rational therapeusis.

Alcoholic stimulation, either in the form of whisky or brandy, is of inestimable value in this disease. Small doses should be given at first and the effect watcht. the pulse improves and the mental condition becomes clearer and the temperature lower, the stimulant should be considered as meeting all conditions, and the dose should be gradually increast until the limit of its beneficial action is reacht. But if the condition becomes duller and the pulse feebler, strychnin sulfate in small doses should be given and will better meet the indications. The drug may be given quite freely up to the point of increasing the deep reflexes.

Every effort should be made to secure abundant nourishment for the child, giving all that can be digested of milk, beefjuice, scraped beef and other highly nutritious and easily absorbed foods. If these are refused, it is better to give whatever the child may fancy, sooner than let nutrition suffer. The chief question after all is one of nourishing and sustaining the failing energies, and all medication that will possibly interfere with this end should be avoided. Food should preferably be given at regular intervals of two or three hours, but in severe cases all regulations must yield to the whims of the patient, no matter how obstinate and intractable it may be.

In cases of threatened syncope aromatic

aromaty anima Cafferratral

spirits of ammonia in doses of from 20 to 30 drops may be given every hour for a time, or a grain of caffein citrate may be given, repeating the dose in four hours, if necessary.

Tincture of ferric chlorid in doses of from 3 to 5 drops or more may be given in water every three hours, for its general sustaining power and to counteract the tendency to anemia. It also has an astringent effect upon the pharyngeal mucous membranes, and is thus much extolled; but in some cases it deranges the stomach, and then should not be given.

Potassium chlorate has been largely used in the past, but many cases of nephritis consequent upon diphtheria have been attributed to it, and it has of late fallen into disuse.

The bowels should be kept free by the use of gentle salines and also aseptic so far as possible, the sulfocarbolates and small doses of mercury meeting this indication. But should diarrhea appear in the disease, salol or the sulfocarbolates in varying dosage are indicated.

There is no difference in the treatment of the possible complications from the way in which they would be treated if occurring independently.

Some advocate the use of weak solutions of silver nitrate as a spray or wash and nascent chlorin liberated by the union of potassium chlorate and strong muriatic acid, adding tincture of ferric chlorid and water. For the hemorrhagic form that sometimes is seen, a solution of five grains of chromic acid to the ounce of water, used to syringe the nostrils and fauces, has been highly recommended.

It may be well to render the atmosphere of the room moist by slaking lime, by evaporating water on the stove or over a spirit lamp, or by means of a steam atomizer. The addition of turpentine or oil of eucalyptus is often recommended.

Listerine, Dobell's solution, and the Löffler solution are all of use in keeping clean the nasopharynx. The last named is as follows:

Menthol Toluol. Solve et adde

M.

Alcohol abs.

Liquor ferri chloridi

With all these measures isolation and absolute rest must be enjoined, and free ventilation without drafts should be provided for. The nursing is a factor of greatest importance and should be carefully guarded.

Treatment of Scarlet-Fever.

Isolation and absolute rest are the first important injunctions in the treatment of scarlet-fever. The diet should be liquid and sustaining, and it would be well to anoint the body two or three times a day with carbolized vaselin, camphorated oil, or some other mild unctuous preparation.

Certain German authorities advocate the use of full baths in scarlatina, given twice a day at a temperature of at least 95°. In 110 cases thus treated, nephritis did not occur and desquamation was mild; at least the baths removed the exfoliating epithelium, and, it is also believed, the poison excreted by the skin.

The patient should be encouraged to drink freely of water or lemonade, or any other cooling and demulcent drink. The bowels should be kept open by the use of epsom salt or rochelle salts, and small doses of jaborandi should be given in order to encourage sweating, unless contraindicated by the action of the heart. If there is no special irritation of the stomach the tincture of ferric chlorid in conjuction with small doses of dilute hydrochloric acid is productive of excellent results.

The same treatment for the local conditions of the throat as are advocated in diphtheria may often be used with advantage, such as spraying with hydrogen peroxid and Dobell's solution, or dilute listerine.

Yet the remedy above all others that seems to be indicated in almost all noted conditions is the intestinal antiseptic, cal