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THE MEDICAL WORLD.

the large number of cases that come under present in this disease, at least in every treatment outside the hospitals and with- severe attack, and, taking this into ac. out antitoxic serum, keep the general rate count, the number occurring is not excesto the high figure (25 per cent. of all cases) sive. already quoted. It must be recollected, Albuminuria is certainly due to the use also, that many cases that have been re- of the serum, but this does not usually ocported to the local Boards of Health as cur in an uncontrollable form. The occadue to membranous croup, to heart failure, sional lethal effects of the antitoxin that and to nephritis in children, are really due have been reported are attributed to the to diphtheria, the initial lesion.

idiosyncrasy of the patient and not to any The consensus of opinion seems to be toxic property of the serum. Hematuria that when antitoxin is given in time to has been reported, but the connection beprevent degenerative changes from taking tween the injection of the serum and the place in the nerves, muscles, kidneys, and occurrence of the complication is not very liver, most of the patients, recover. But, clear. when the patient is allowed to go beyond The most common ill-effect of the remthe third or fourth day of the disease, the edy is the occurrence of an exanthematous mortality is still high. Yet even in these rash, which, as to type, may be divided the death-rate is lower than in cases which into : Serum urticaria ; diffuse serum ex. are treated with the old methods. This ap- anthems; scarlatina-like rashes; macula parently demonstrates that even in this exanthems (measles, etc.); polymorphous type of cases antitoxin enables some of the serous exanthems. This trouble may occases to tide over the acute period and to cur in about 30 per cent of the cases in recover, altho the treatment be begun which antitoxin is used, and usually lasts late, but that the best results can be ex- about nine or ten days. The urticarial pected only when the treatment is begun form is the most common, and the scarlaearly.

tinal probably the most unusual. In cases of the laryngeal type, not only Unfortunately it must be admitted that is the percentage of cases requiring intu- not all the serums on the market are what bation largely diminisht, but even in those they profess to be, nor are all samples of cases in which intubation or tracheotomy the same brand of the same strength. becomes necessary, the percentage-mortal. Some of these variations have been as ity has been reduced from 70 to 41 per follows: One preparation claiming a cent., or, in some instances, even less. strength of 1,500 normal units possessed

3,465; another claiming 1,000 possessed Drawbacks of the Antitoxin Treatment.

only 647.5 ; a third claiming 1,200 had Perhaps the most obvious of the draw- only 834 normal units. backs of the serum-treatment is the forma- A so-called normal unit of antitoxin is tion of abscesses at the seat of the injec- ten times the amount necessary to neution, but with a more perfected technic the tralize a given quantity of toxin (ten danger of this is becoming lessened. It times a lethal dose), within 48 hours in a has also been found by experimentation guinea-pig of from 250 to 300 grams bodythat smaller doses of the more potent weight, approximately eight ounces. From serum, rather than the large injections of this it will be obvious that the more con the weaker as formerly so generally advo- centrated the serum the less the bulk of cated, will practically obviate the rash, the fluid injected. It has been proposed the pains in the joints and the second- to get a more potent serum by estimating ary pyrexia, such being comparatively the relative proportion of normal units in trivial when they do occur. The abscesses the blood of each horse that was injected, are due to the septic element that is always after a stated time, and casting out those

whose antitoxin-forming powers were not even in outlying districts, that it is generup to a given standard, since this power ally possible to get someone to operate if may vary from 1,000 to 50 normal units the attending practitioner does not posper cc.

sess the facilities. Yet there are excepThe dose of antitoxin should be larger tional localities and instances when the for patients with laryngeal stenosis than method is not practicable, and in these for others. For a child two years old there is no recourse save to the method of suffering from this form of diphtheria it tracheotomy. should be 1,500 to 2,000 normal units as The time when to remove the tube an initial dose. For an average case the depends on the age of the child. The dose for a child two years old should be older the child is the sooner the tube can about 1,000 normal units, this varying be dispensed with. The duration of the with the constitution of the child and the disease before intubation was resorted to severity of the attack. Hence it will be is also a factor of consequence. Estimatseen quite readily that the standardizing ing the maximum of the disease to be of any serum is a matter of considerable seven days, five days' wearing of the tube consequence in order that neither too little should be, on an average, considered sufor an overdose be given. Some authors ficient. daim to have had their best results with The chief objections to the use of the a dosage of 4,000 to 8,000 units, altho it tube are the possibility of the formation is possible that they may have been using of pressure-ulcers; the inability to cough serum not quite up to the percentage of up the loosened membrane; the possibility normal units claimed.

of the air being infected by passing over

diseased surfaces; the difficulty of the As Regards Intubation.

operation; the possibility that membrane If the dyspnea connected with the lar- may be pusht down into the trachea by yngeal form of diphtheria becomes pro- the tube; the extreme care necessary in gressive it is well to try the inhalation of nursing. calomel-vapor or calomel-fumigation, but In reply to these objections it has been when this does not succeed in controlling urged that with regard to ulceration, the the condition, operative interference is larger the tube, within reasonable limits, indicated. This used to be done entirely the less the liability to ulceration, as the by tracheotomy, in itself a measure not tube has less opportunity to move. Again, without grave dangers, and now practically it is claimed that the ulceration and consuperseded by intubation.

sequent stenosis, which has so frequently Intubation should be used in all cases been reported, is more a consequence of when, despite previous treatment, the dif- the disease than of the treatment, since in ficulty of breathing increases unremit- many specific fevers ulcers of the larynx tingly, and interferes with the inflation occur and stenosis of the trachea follows of any considerable part of the back of when no tube has been introduced. Such the lungs, and when sensible exhaustion is cases have been reported as occurring in produced by the effort of breathing. typhoid fever as well as in other disNothing but harm can result from this eases. condition, and the use of the tube can The fact that feeding is difficult in produce nothing worse than can be antici: intubation is considered greatly to its dispated without it. If air cannot be aspir- advantage, altho parents will consent more ated into the lungs, blood will be, and the readily to intubation than to tracheotomy, clogged condition of the lungs will surely since the operation is bloodless. There is result fatally.

no cutting, no anesthetic, and this means Intubation has become so well known much to the friends of the patient. It is performed quickly and needs no trained or in connection with the use of antitoxin. assistants or trained attendants, (training Among those drugs which have been most being necessary only in the operator). highly vaunted by the profession are caloThe feeding is difficult because the larynx mel, mercuric chlorid, mercuric cyanid, is sore, sometimes because of the inexperi- and protoiodid of mercury. Citric acid, ence of the operator. The less the larynx sodium hyposulfite, tincture of myrrh, is bruised in the act of intubation, the less guaiacol, resorcin, sodium chlorid, and the child will dread the contraction of the papayotin solution, all have their enthusipharyngeal muscles in the act of swallow- astic advocates. A favorite local applicaing. Yet, even under the most favorable tion with the entire profession is hydrogen circumstances, the fact remains that there dioxid, either full strength or diluted, apis more or less difficulty is swallowing, plied as a spray or allowed to flow gently both from pain and cough. The coughing over and wash the affected parts. Its arises from the entrance of the fluids into solvent action on septic processes is well the trachea, tho this is in some degree a known, and its use seems founded on a matter of training of the patient, some rational therapeusis. children learning to swallow very well. Alcoholic stimulation, either in the form It is well in feeding to incline the head of of whisky or brandy, is of inestimable the child downward, so that it may be value in this disease. Small doses should said to swallow "uphill," any fluid that be given at first and the effect watcht. If may chance to get into the trachea thus the pulse improves and the mental condi. gravitating directly out again. Medication tion becomes clearer and the temperature may be continued as well after tubation as lower, the stimulant should be considered before.

as meeting all conditions, and the dose Some children show the utmost opposi- should be gradually increast until the limit tion to the entrance of the tube, but others of its beneficial action is reacht. But if soon reason from analogy that there is the condition becomes duller and the pulse more comfort with it in, and, when old feebler, strychnin sulfate in small doses enuf, will even ask for it. A notable case should be given and will better meet the of this kind was treated at the Philadel- indications. The drug may be given quite phia Municipal Hospital a few years ago. freely up to the point of increasing the The child, at the first intubation, showed deep reflexes. every sign of extreme terror, and strug- Every effort should be made to secure gled to a dangerous degree of exhaustion. abundant nourishment for the child, givThe tube was removed at the expiration of ing all that can be digested of milk, beefthe usual 114 hours, and a sudden recur- juice, scraped beef and other highly nutrirence of dyspnea took place within an tious and easily absorbed foods. If these hour. The child in much fright gasped, are refused, it is better to give whatever 6. Put it back! Put it back !” and held the child may fancy, sooner than let nutriperfectly motionless until the tube was re- tion suffer. The chief question after all is inserted. This occurred three times, be- one of nourishing and sustaining the failfore it was deemed safe to allow the tube ing energies, and all medication that will to remain out permanently.

possibly interfere with this end should be

avoided. Food should preferably be given Drugs and Local Applications in Diphtheria.

at regular intervals of two or three hours, Quite a number, not only of the most but in severe cases all regulations must conservative of the profession, but also yield to the whims of the patient, no others who are generally ranked as among matter how obstinate and intractable it the most progressive, advocate the use of may be. drugs and local applications, either alone In cases of threatened syncope aromatic

Annem MADICAL WORLD.

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THE MEDICAL WORLD,

97

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Liquor ferri chloridi Tincture of ferric chlorid in doses of M. from 3 to 5 drops or more may be given With all these measures isolation and in water every three hours, for its general absolute rest must be enjoined, and free sustaining power and to counteract the ventilation without drafts should be protendency to anemia. It also has an astrin. vided for. The nursing is a factor of gent effect upon the pharyngeal mucous

greatest importance and should be caremembranes, and is thus much extolled ; fully guarded. but in some cases it deranges the stomach, and then should not be given.

Treatment of Scarlet-Fever. Potassium chlorate has been largely used Isolation and absolute rest are the first in the past, but many cases of nephritis important injunctions in the treatment of consequent upon diphtheria have been at- scarlet-fever. The diet should be liquid tributed to it, and it has of late fallen into and sustaining, and it would be well to disuse.

anoint the body two or three times a day The bowels should be kept free by the with carbolized vaselin, camphorated oil, use of gentle salines and also aseptic so far or some other mild unctuous preparation. as possible, the sulfocarbolates and small Certain German authorities advocate doses of mercury meeting this indication. the use of full baths in scarlatina, given But should diarrhea appear in the disease, twice a day at a temperature of at least salol or the sulfocarbolates in varying dos- 95°. In 110 cases thus treated, nephritis age are indicated.

did not occur and desquamation was mild; There is no difference in the treatment at least the baths removed the exfoliating of the possible complications from the way epithelium, and, it is also believed, the in which tbey would be treated if occurring poison excreted by the skin. independently.

The patient should be encouraged to Some advocate the use of weak solutions drink freely of water or lemonade, or any of silver nitrate as a spray or wash and other cooling and demulcent drink. The nascent chlorin liberated by the union of bowels should be kept open by the use of potassium chlorate and strong muriatic epsom salt or rochelle salts, and small acid, adding tincture of ferric chlorid and doses of jaborandi should be given in order water. For the hemorrhagic form that to encourage sweating, unless contraindi. sometimes is seen, a solution of five grains cated by the action of the heart. If there of chromic acid to the ounce of water, is no special irritation of the stomach the used to syringe the nostrils and fauces, has tincture of ferric chlorid in conjuction been highly recommended.

with small doses of dilute hydrochloric It may be well to render the atmosphere acid is productive of excellent results. of the room moist by slaking lime, by The same treatment for the local conevaporating water on the stove or over a ditions of the throat as are advocated in spirit lamp, or by means of a steam ato- diphtheria may often be used with advanmizer. The addition of turpentine or oil tage, such as spraying with hydrogen of eucalyptus is often recommended. peroxid and Dobell's solution, or dilute

Listerine, Dobell's solution, and the listerine. Löffler solution are all of use in keeping Yet the remedy above all others that clean the nasopharynx. The last named seems to be indicated in almost all noted is as follows:

conditions is the intestinal antiseptic, cal

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cium sulfocarbolate usually yielding the much importance. Basham's mixture and best results. From five to thirty grains Blaud's pills are useful. To induce the may be given daily according to the age of return of appetite bitter tonics such as the patient and the fetidity of the stools. nux vomica, gentian, elixir of calisaya, It is best given in solution and in the or tincture of calumba are of much service. drinks of the patients.

The use of nuclein is indicated from the Should vomiting occur it must be al- necessary point of the production of inlayed, and if excessive diarrhea results creast leukocytosis to repel the infective from treatment or during the progress of processes. the disease, it should be treated in the usual way with bismuth or opium.

Justice is a jewel that we Americans The use of antipyretic drugs is to be de- should insist upon having. Remember precated except in very exceptional cases the following:

Per ounce in order to produce a temporary effect, and

in Canada. in U. S. Phenacetin

. 18c. $.95 in this event phenacetin in doses of one

Sulfonal

38c. 1,25 half grain is the best. When the rash is Trional

78c. 1.40 well defined all over the skin and on the

These are quotations in twenty-fivemucous membrane and with symptoms of

ounce lots. A duty of 25 per cent. is to marked general depression, antipyretic be calculated, but that will not account for drugs only increase existing danger and

the exorbitant excess charged to Amerishould positively not be given.

can consumers above the prices charged When there is sleeplessness and delirium

the consumers of other countries. This which cannot be relieved by the use of injustice is made possible by our patent the icebag or the bath, the bromids should

laws. If foreign manufacturers persist in be given in full doses, about 30 grains taking advantage of our laws to overbeing given in one dose at night. This is

charge us, we should change our patent conceded to be better than the giving of laws, and make them similar to the patent repeated small doses. Sulfonal in full

laws of Germany. It is right to protect doses, dissolved in boiling water and drank

an inventor against infringement, but he when sufficiently cool may be also given.

should not be protected in such monstrous In the tonsillar forms of the angina overcharging as is illustrated above, which current with the disease the injection of

are some of the most extreme cases of such carbolic acid into the affected tissue yields overcharging. excellent results. But excellent effects can be obtained by the use of hydrogen Don't send subscriptions on a postal card. Save your

card and save us trouble. When you want THE MEDIdioxid, a 25-volume solution as a spray or CAL WORLD badly enough to pay for it, send the price a 50-volume solution as a wash or gargle, and your order will be promptly filled. There is only

one right way to subscribe-do it in the right way. being preferable.

The postal card fraternity have been increasing of late, Close watch must be kept over the urine and they are a nuisance in an office conducted in a business

The humanitarian question is a different thing. for the appearance of nephritis, and this

way.

If you can't pay full price, send what you can and write should be treated, when developt, in a in full, and you will not be overlookt. manner no different from that indicated

WORLD for four years for $3. when occurring under other circumstances.

What have you learned about the treatment of phthisis ! As a measure of prophylaxis, a partic

Read THE WORLD's special articles on seasonable diseases ularly bland and unirritating diet may be and you will surely subscribe. One year, $1 ; four years, $3. enjoined, and the room kept moist and “I take eight or nine journals and periodicals, and I think

that I always get from THE WORLD more practical points warm, tho well ventilated.

than from any other journal."--F. C. MORGAN, M. D., Felch

ville, Vt. During convalescence it is imperative to THE WORLD is

The editorials are

worth many times the price of the journal and it also conadminister some form of iron, altho the

taids articles that are like clear-toned bugle blasts above form in which it is given does not seem of

the din of the mediocre.-J. H. CALLBREATH, M. D., Waterbury, Ct.

Let us have it for the benefit of others.

great value to me.

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