The serum-treatment of diphtheria rests upon the foundation of the following principles established by Behring and Kitasato, and published in 1890: "1. The blood of an animal immunized against diphtheria is able to destroy the poison of the disease. 2. This property can be demonstrated in the blood taken from the vessels and also in the serum which comes from it freed from all corpuscles. 3. This property is so durable that it persists even after transfusion into other animals, and can thus be used in the treatment of the affection. 4. This property is wanting in the blood of non-refractory animals, and the poison can be discovered after their death in the blood and other fluids."

The objections to the use of antitoxin are, the natural repulsion which patients have in submitting to an inoculation of an animal-lymph, and with children we have the fright and resistance to overcome. In any case where it is absolutely impossible to give the remedy hypodermically, it is better to give it by the mouth or rectal injection than not at all; for we have learned recently by the researches and experiments of Escherich and Fisch that the serum is absorbed and renders the blood antitoxic within twenty-four to thirty-six hours. It is true that its use is followed in some cases by a slight shock, rise of temperature, and later by urticaria, which makes its appearance usually after the fifth day. There is a rise of temperature accompanying the urticarial eruption in about twenty per cent. of the cases, which lasts from one to four days; occasionally there is a tenderness of the joints with swelling and redness. These cases usually recover in a few days, but some are more protracted. That antitoxin increases the danger of nephritis and paralysis, no one who has had much experience in its use will admit. Given a clean skin, a sterilized syringe, and carefully prepared antitoxin serum, and

there is comparatively no danger from local abscess or sepsis. To avoid the local irritation caused by injecting a large quantity of serum, a high grade or concentrated preparation is advised. The amount to be given should be graduated according to the size of the patient and the severity of the disease. In mild cases occurring in children, one thousand to one thousand five hundred units; for laryngeal or nasal diphtheria two thousand to two thousand five hundred units, followed in eighteen hours by a similar injection; for an adult the quantity should be from one-half as much more to double the amount.

We have learned from experiments that with each hour after the onset of the disease, so rapid is the septic absorp tion, that the beneficial effect of antitoxin becomes less marked, hence the great importance of giving the treatment early. We are tempted to wait until after a culture has been made, or until the case becomes desperate before using the serum. Is it not better to use it at once in a case of marked symptoms instead of waiting for a culture test, or in a mild case immediately after we have found the Klebs-Loeffler bacilli?

RECOMMENDATIONS.

In order that antitoxin may be obtained without dangerous delay, a supply should be kept at some accessible place where it can be obtained at any hour, on any day, in every town of the Commonwealth. Furthermore, it should be supplied free of cost to those unable to pay for it, as is now the case in New York city. What greater charity can be imagined, what alms-giving could be more far-reaching in its results? I also believe the healthboards should be empowered to use it for immunizing whenever and wherever there is an outbreak of the dis

ease.

The fact that in ninety per cent. to one hundred per cent. of children exposed to diphtheria the disease can be

averted by immunizing injections, and the fact as reported by the members of our Society that while, prior to the use of antitoxin from eighty per cent. to ninety per cent. of the laryngeal cases of diphtheria died, and that now the percentage of recovery is reversed, brings us to realize that this agent is in the highest degree a life-saving factor. Few of us have witnessed any recoveries under five years of age, with operation or without, in cases of the laryngeal type; now recovery is the rule, and death the exception. Who among us cannot recall case after case of the little sufferer struggling for breath, the voice becoming fainter and fainter, until the whispered appeal for air can no longer be heard? Who among us has not felt heart-sick at his helplessness to relieve the agonies of the suffocating child, and the untold anguish of the distracted parents? And what a prodigious relief to awaken to the realization that we can now hold out hope in every case, and that we have at our command a remedy which is the truest specific of any therapeutic agent which has been given to us since the days of Esculapius.

Let us felicitate ourselves that in the closing decade of the nineteenth century, a century of scientific triumphs, this, one of the greatest of achievements when measured by its saving of human lives, has been given to the world by the medical profession.

INTUBATION OF THE LARYNX.-REPORT OF

FIFTY CASES.

FRANK W. WRIGHT, M.D.,

NEW HAVEN,

The perfection of intubation of the larynx, by the late Dr. Joseph O'Dwyer, after years of patient labor and unceasing care, marks a bright epoch in the treatment of laryngeal stenosis that can never be eclipsed by any future invention. He states in an article entitled, “The Evolution of Intubation," which was read before the American Pediatric Association at the Montreal meeting in 1896, and published in the June number of the Archives of Pediatrics for the same year, that "complete failure with tracheotomy in the New York Foundling Hospital extending over a period of several years was the real incentive to the work."

Too much honor cannot be given to the man who has done so much to diminish the sufferings of infancy and childhood, who labored so many years on lines entirely original as far as he knew, and who, when he learned that another had attempted to relieve obstruction of the larynx by a tube, refused to look up the literature of the subject for fear he might be discouraged by the failure of his predecessor. His great work in conjunction with the more recent diphtheritic antitoxin serum treatment has now robbed diphtheritic laryngitis of its terrors and so revolutionized the results of treatment that instead of a mortality of at least ninety per cent., we now under favorable conditions expect as high a percentage of recoveries. Indeed, intubation is now done to the almost entire exclusion of tracheotomy. This latter operation is not now performed in any of the public institutions.

or in private practice except when an intubationist is not at hand or except when intubation has failed to give relief on account of the membrane having extended beyond the reach of the tube.

The advantages of intubation over tracheotomy are that the former is more quickly done, there is no cutting and it consequently is more readily consented to, does not require trained assistants or trained nurses, can be done without special preparation, and there is no wound offering a point for fresh infection, which requires careful attention long after the original trouble has disappeared. As I have said, a trained nurse is not necessary. Any intelligent person who is used to the sick, who will minutely follow instructions, and can put herself in touch with the little ones will do, but when it is practicable a trained nurse is to be preferred.

It must be borne in mind that notwithstanding intubation has given very gratifying results it is a serious surgical operation and should be practiced only after due consideration and the certainty that dyspnea is so great as to threaten life. On the other hand, it should not be delayed until the little patient is exhausted. The better the physical condition, the more favorable the prognosis.

The technique of the operation is as follows: The tube is selected according to the age and size of the patient and a piece of braided silk is passed through the eye in its head. This should be long enough to extend several inches beyond the mouth after the tube is in the larynx. The object of this is to withdraw the tube should it be necessary either from its being plugged by membrane, or having failed to have entered the larynx. Two assistants are necessary, a physician and a nurse if practicable, yet any intelligent person will do who will follow instructions and not get excited. The patient is then wrapped in a sheet, carefully pinned so that the arms cannot be raised. If this is neglected the child is almost sure to