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brane by increasing and liquefying the secretions. Steam generated in a tea-kettle by boiling water over a grate when the temperature will permit and carried out into the room or to a tent on the bed, if desired, by a piece of hose or tin conductor is practicable and most effective. Oil of eucalyptus, carbolic acid and turpentine may be added with benefit. Increased secretions from the membranes is also secured by partaking freely of water, liquid foods and spirits. This outward flow of fluids not only macerates and floats the false membrane but retards the absorption of toxins. The slaking of lime in the room by which application of steam and lime is secured is as effective as it is old. The methods of application have been dwelt upon. What is the best remedy for local use? Peroxid of hydrogen. Why? To accomplish the greatest good a local remedy must combine the greatest efficiency and ease of application. This is just what peroxid of hydrogen does. It is necessary to be able to apply the local remedy without resistance from the patient. In the asthenic stage the child cannot withstand the evil effects of fright and struggling. It is necessary in the early stage to have the patient's cooperation in order that the development of dangerous conditions may be avoided by thorough treatment. With a medicine practically without odor, taste and color and leaving the patient more comfortable after its use, its administration is always easy. It may, and usually should be used in full strength, consisting of a 10 to 15 volume solution. It can be used by spray, gargle or swab, and if swallowed accidentally or intentionally, good, and not harm will result.

GENERAL TREATMENT

The diet should be chiefly liquid and soft food, but it should be highly nutritive. Milk, eggs and broths are important articles. The patient should be encouraged to drink water freely. One or two grains of calomel in broken doses in the very early stage renders good service by relieving

nausea and stimulating and invigorating the digestive organs and creating appetite. The tincture of the chlorid of iron administered with glycerin, or in the form of many of the excellent pharmaceutic preparations, is a time-honored remedy, capable of great good by its local as well as by its general effect, and it is seldom contraindicated. When constitutional symptoms are severe, stimulants should be given freely. Weak and irregular heart-beats call for cardiac and general stimulants, such as strophanthus and strychnin and absolute rest. Paralysis requires rest, strychnin, massage, electricity and the best nutrition. The management of complications and sequelæ in general is hardly in place in this paper.

ANTITOXIN TREATMENT

In a recent issue of the British Medical Journal an English surgeon of note in a communication entitled "Notes on a Visit to Some American Hospitals," states that in a Philadelphia hospital he was told that anyone who would withhold serum in diphtheria might expect an early summons before a magistrate. This indicates the consensus of opinion. in favor of antitoxin in this country. Nevertheless the fact remains that there is much skepticism. This skepticism is In a found where inexperience and prejudice abound. report of a recent meeting of a medical society, not of the orthodox faith, I am pleased to say, I read that after a thorough discussion of antitoxin, the society arrived at the conclusion that it was still in the experimental stage and further development would be awaited, before pinning their faith to the new remedy. The developments were occurring with great frequency in the community at the time, in the form of deaths from diphtheria treated without antitoxin. Those who have read or heard of any of the literature on the subject, or have observed the results of physicians who use it intelligently and still hesitate to use it, must still entertain a lingering doubt of the value of quinin in malaria and wonder if Jenner's discovery after all is not a myth.

Dosage: The quantity to be administered is a matter which has to be determined in each case. We cannot tell how much toxin is generated in any case. Our only guide is to administer the antitoxin until the good local and constitutional effects are evident. The local effects consist of the limitation and shrivelling of the membrane, diminution of discharges, improvement in the odor, subsidence of the swelling in the throat and involved lymph-bodies. The characteristic general effects are a decline in temperature, slowing and improvement in the pulse, subsidence of gastric disturbance, restoration of the nervous equilibrium, and a general sense of relief. In a series of 61 consecutive cases with as many complete recoveries occurring in the past nine months, during which period the disease was epidemic for several months, I administered the serum in doses varying from 1,000 to 20,000 units. All of these cases received antitoxin except three. My observation has been that persons suffering from tuberculosis of the throat require very large quantities. One who has had considerable experience only needs to recall a few cases in which in the early stage he suspected a mild infection and withheld serum and later in the cases found his patients in a gallop to the grave and then witness the unmistakable good effects of the serum to convince him that in antitoxin there is life. It is scarcely necessary in this audience to add that reliable statistics show that in all classes of the disease treated with antitoxin, the mortality has dropped from about 30% to 10 or 12%. In laryngeal cases the mortality and recovery percents have been reversed by antitoxin and intubation. Referring to our English cousin again, I recall an article in the British Medical Journal in which it was claimed that a large number of cases in which carbolic acid had been injected to determine whether or not after all it was not the carbolic acid which possessed the curative power the results were equal to the antitoxin treatment. However that may be, it is certain that the antitoxin results are good if the practice is extravagant. While the injection may be made in any region where there is an abundance of loose areolar tissue, by

far the preferable regions (from every view point) are the lateral abdominal walls. The asepsis practiced in its administration has much to do with the development of skin complications.

Untoward Effects: Of these the most common are urticaria and erythemias. They have no more serious effects than to occasionally retard convalescence. In a report of a series of over 500 cases reported in the British Medical Journal resultant skin eruptions appeared in 115. In my own cases I observed urticaria once and a local erythemia once. This includes in addition to the 61 cases of diphtheria something over 30 cases in which it was used for immunizing purposes. It is worthy of note that diphtheria did not develop in a single one of these immunized cases. The immunized patients varied in age from 8 weeks to 40 years. The immunizing doses from 500 to 2,000 units. In the management of laryngeal cases emesis produced by ipecac or zinc sulphate will very frequently dislodge the membrane and relieve embarrassed breathing. Especially is this true when serum therapy is practiced. The emesis may have to be repeated one or more times and can safely be done in sthenic cases. Where this fails or cannot be judiciously practiced intubation as per the paper on operative treatment is required.

A FEW SUGGESTIVE REMARKS IN CONCLUSION

The disease is primarily local, hence the value of efficient local treatment.

Antitoxin should be the initial and not the last remedy.
Antitoxin is specific in its action on the diphtheritic

toxins.

Antitoxin if relied on to the exclusion of other remedies will frequently disappoint.

It will not meet all the requirements in mixed infections. A good rule is to immunize all children under three years of age in a family in which the disease is present.

Don't believe that very young infants will not contract

the disease. In our epidemic, a few at least, one, only a few days old, died of the disease.

Don't delay from night till morning or morning till night making a call to a case of suspected diphtheria.

Always assume that every case may be severe, unless vigorously and thoroughly treated.

The Surgical Treatment of Laryngeal Diphtheria By C. L. PATTERSON, M. D., Dayton

Since the discovery and general use of antitoxin, operative interference is not required as often as formerly in cases of laryngeal diphtheria, or membranous croup. Dyspnea is not so marked a symptom, nor does it continue so long as was the case before the use of antitoxin, but an operation is required in a certain percentage of cases, and is one of the most important operations with which the surgeon has to do. No other operation in all surgery is so urgent when required; no other operation is followed by such marked and gratifying immediate results. No sight more distressing is ever witnessed by the physician than the struggle of a child for the breath of life. The look of pain and suffering on the face of a child that is exerting all of its fast-failing strength and directing all of its efforts and attention to the securing of a sufficient quantity of air to keep alive the spark of life, is one that, once seen, will never be forgotten.

The prominent symptom calling for surgical treatment in this disease is obstructive dyspnea, characterized by suppression of the voice, great difficulty in inspiration, retraction of the abdomen, great restlessness, lividity of the lips and inability to breathe in the recumbent posture. All these symptoms, together with a high temperature, call imperatively for operative interference.

When such a condition prevails the operator has a choice of two methods of procedure-first intubation, and second tracheotomy. The first, which consists in introducing a tube

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