use for immunity is open to more question, in our opinion, than its value in the disease. The best results have, with a fair degree of uniformity, been obtained when the serum was used early in the affection, and when there might be a question as to the diagnosis; but it must be remembered that the statistics embrace a great many hundreds of cases in which, if bacteriological examinations are to be depended upon, true diphtheria was already an assured fact. Unquestionably, the personal equation will enter largely into its use, unless the public arrive at a condition where a failure to use it will be regarded as criminal negligence. With this, as with many other new remedies, its fate for each man is often determined by the results in a single case, without reference either to the quality of the material used, or the character, stage and condition of the case upon which it is employed. Those who have been unfortunate enough to have a paralysis, sudden death or a severe nephritis co-incident with, or sequent to the use of antitoxin, will readily join in the crusade against it. Those who have seen cases in which a material and rapid improvement seemed to follow its use-cases like those which, in their experience, have previously proved fatal with the ordinary means of treatment— will doubtless be eager to rush to its defense. The present status of the question undoubtedly justifies the early use in moderate quantities of a good preparation of antitoxin. We are not prepared to say that the failure to use it under such conditions would be as easy to explain or to justify."

*

Is it an impossibility (or extremely unlikely) for even an 'experienced hypodermist to have injected air into a vein, with shock or death resulting?

No doubt there's a lion in the land. Whether he can be tamed and be made a safe burden-bearer, able, capable, reliable to such a degree that an overwhelming tendency for good be conceded by all, with rare exceptions, is the question for time to prove. Electricity has been "subdued" for our purposes, but with liabilities to accidents.

There's a growing evidence in favor of antitoxin treatment, which is a little short of being established beyond questioning. At present too much may be claimed for it by its friends; too little (for good) admitted by its foes. The compromise, or place of meeting will probably be somewhere between the extremes, or antithesis of the rod, but even now is nearer the affirmative than negative end. The strongest tide is in favor of antitoxin's use. The spirit manifested by its advocates is fully as conservative and consistent as the opponents, and as for many, fully as disinterested, personally. That general excels who can gain vantage ground with the least loss of life, though he may lose his child in battle. From somewhere and at some time I learned this formula: The least

of that which is the greater is greater than the greatest of that which is least.

Now, here is the application: Failures, and even some accidents, with the remedy, when used for good purposes and conscientiously, are better than the "hands off" of those who, though may not take any risks, fail in probably a greater number of cures than if they had practised serum-therapy.

MY CONCLUSIONS.

A digest, or synopsis, of my study, reading, reflection, thought: 1. Antitoxin is a therapeutical measure of importance.

2. It is powerful for good in the great majority of cases, especially if used in the incipiency of the case.

3. "Delay is dangerous," for in proportion as the system is saturated with the disease germs, in same rate are chances of victory for antitoxin lessened. The great need in the proposition is this: Permeate the tissues and blood with antitoxin early enough to assist the recuperative powers of nature.

4. Wiser to use a moderate dose as curative and minimum as preventive. But dosage not positively agreed upon. One party favors large doses-even larger for a child-to destroy the powerful germs (or antagonize); other smaller doses, so as not to endanger disorganization of blood globules. The requirement is proper dosage, but most evident that minimum is preferable to maximum as already intimated, for this reason: Intact red blood globules are more important (admitting their liability to injury by serum) to the economy, than deficiency of antitoxin, especially when used early. Besides, antitoxin can be repeated, upon this principle, viz.: Powerful remedies can be borne better in small, repeated doses, than in one large one. This in accordance with established principles of therapeusis generally.

5. Recent antitoxin safer.

6. There never was a drug of power that has not shown some untoward results, for some reasons; or that, at times, has not utterly failed.

7. It is agreed that the hypodermatic method is the plan. Antitoxin inert (or without effect) per rectum, unless through a broken surface.

8. Doubt about the diagnosis of diphtheria, or bacteriological results not imperative (at least need not delay treatment), and need not forbid the use of antitoxin. Proof: It is used to immunize those liable to be attacked, and, if so, why not to counteract supposed poison already existing?

9. I conclude this question as yet unsettled, namely, whether it is an individual practitioner's "bounden duty" to practice sero-therapeusis. I believe the moral code at present, while there is questioning among ad

mitted competent judges, must decide for him from an individual standpoint:

"The lesser doubt must yield to the greater."

An experience: Last year I had a case of empyema, with pent-up pus, fever and diarrhoea when I saw him. I irrigated with reduction of fever. The treatment was corroborated by one of our best surgeons, in letter of reply to me: "He would have been dead ere this time if you had not drained him and washed out the cavity." One day in irrigating to bring out the pus he was attacked (during the process) with tetanic convulsions, and for several days was near dying. Afterwards, in this same case, it seemed best to two of us, with the consent of the family to irrigate again, which was done, and repeatedly afterwards, being careful, however, to let the fluid flow out after nearly every ounce introduced. This same surgeon kindly replied to another letter of inquiry thus: "DEAR DR. : Yours of Tuesday received. The tetanic convulsions may have resulted from the washing out, a certain number of such instances are reported, and it would be therefore unwise to continue the irrigation. It would seem to be more safe if the tube were retained still, and the flow from the cavity allowed to take place freely. If you have had the tube out some days and no evil has followed, you will, of course, defer re-introducing it until circumstances justify.

With kind regards, yours truly,

I mention this, and it is applicable to my above conclusion: If in these days of sepsis in surgery, a measure of antisepsis be questionable, much more open to question is a method as yet not unanimously received by the profession, and one man may have clear conscience in using, and another in not using serum-therapy.

THE BRAND METHOD FOR TYPHOID FEVER IN PRIVATE PRACTICE. By CHRISTIAN SIHLER, M.D., Cleveland, O.

The communications of Osler and of Wilson on the hydriatic treatment of typhoid fever in hospitals induce me to add a few words on this mode of treatment in private practice.

That Osler and Wilson will save the lives of hundreds upon hundreds of typhoid fever patients and bring comfort and relief to thousands, I, for one, feel certain. They will accomplish this principally by instructing the coming generation of physicians in the use of the bath-tub and making the American people acquainted with the Brand method. They can do this to a less degree by lowering the mortality from typhoid fever in the hospitals, in which they can make their influence felt.

While I am of the opinion that the Brand method ought to be the regular form of treatment, I would not think of reproaching any one

for not using this method systematically in general hospitals. The baths act in some sense like the antiseptic method in surgery: They do good by preventing the harm the disease would otherwise do, but they cannot undo the harm brought about by the disease in one or two weeks. The amount of good which can be accomplished, where advanced cases are subjected to the bath treatment, is rather meager, when the amount of labor is taken into consideration, that has to be spent on them. Necessarily in a number of such cases labor must be wasted. Nor should we judge of the value of this method by results obtained on cases ill one to two weeks, any more than of the value of antiseptic surgery by its effect on wounds of two or three days' standing. On the other hand, I do not see why hospitals should exclude late or even moribund cases from their statistics as long as they practice medicinal treatment, because the treatment which these cases received at home was essentially the same as that which they would have received in the hospitals.

Some years ago I published in the Medical News a paper on the hydriatic treatment of typhoid fever in private practice, and expressed myself in favor of the method.

Nothing, I think, will interfere so much with the introduction of a new method as the suspicion in the minds of the profession that the friends of the new method may be uncritical enthusiasts who are given to report the favorable results only of the new line of treatment they are advocating. As I still wish to be regarded as an advocate of the Brand method, I would state that during the years of 1893 and '94, out of a small number of patients I lost not less than three persons from typhoid fever and its sequelæ. The immediate cause of death in all three cases was pneumonia.

I expect to hear now the outcry: Was it not predicted that the cool baths would bring on pneumonia?

I can, however, in a measure, quiet the apprehensions of these objectors.

In the first case the patient had been improving a number of days, perspiring freely, and the baths had been omitted, when one morning instead of a normal temperature I found a high fever; delirium and a typical croupous pneumonia spreading over one whole lung and carrying off my patient on the seventh day. While being bathed neither bronchitis nor cough had been present. In the second case, also, pneumonia set in after we had omitted the baths, partly on account of a hæmorrhage, partly on account of improvement in the general condition. In the third case alone pneumonia set in while the baths were being used. That pneumonia is a so-called complication of typhoid fever has been known long before baths were used. In fact, since using the baths I was called to treat cases of typhoid fever where pneumonia had been

developed, without the patient having been bathed, and one of my colleagues here, Dr. L., informed me lately that he had apparently saved the life of a grave case of typhoid complicated with pneumonia, and about given up by the physician who treated without water, by the use of the baths.

Looking upon pneumonia as an infectious disease, I do not see why cold should produce it any more than typhoid fever, and as in my experience the cool baths act more like a tonic than any therapeutic procedure or medicine I am acquainted with, I have no reasons to think that the pneumonias in the cases mentioned had anything to do with the baths. Having never been of the opinion that one could save every case of typhoid by the baths, this experience has not made any change in my opinion on the value of the baths.

To illustrate the potency of the baths I will relate a case, which, in a glaring way, demonstrated the valuable properties of the water treatment. The patient was a young lady, a teacher in the public schools, ill over a week. I found her in a delirium of the most intense kind, with all the muscles of the trunk in a semi-pasueodic condition, so that the body was almost rigid. With one arm she was carrying out convulsive movement. Asked to show her tongue, she stared at me with a stupid expression, and clenched her teeth. In fact her teeth were set so firmly all the time that the nurse was unable to get her to take fluids; urine and fæces were discharged involuntarily, and there was a bed-sore of the size of a dollar, although the disease had not lasted much over a week. Her temperature was 103, her pulse from 130 to 140. She had not slept for a week, and had been in the condition I found her for three days. The fact alone that fluids could not be given made the case a grave one in my opinion.

Now, as to the treatment. I do not consider it wise to begin with the regular formula in a case like this one was, even if serious organic changes are absent. (Thus, in a case with many unfavorable features, which I saw in consultation lately, baths of 84° produced at first very marked depressions of temperature, from 105 to 102. This, in my opinion, was a bad sign. After a few days bathing the temperature was more stubborn, and we then lowered the temperature of the baths.) In such cases I think it is well to use the luke-warm half-bath with cold affusions, a bath principally stimulating, which at the same time allows one to form an opinion as to the cooling which the patient will bear.

My directions in this case then were to give a bath of 90° and ten minutes' duration, and to use three pails of water from the hydrant for affusion to the head. The baths were to be repeated every two hours, excepting the patient should be sleeping, when three hours should be the interval. Of course the hair was cut short. One of my nurses and a