brane in the larynx; his parotid glands were greatly swollen. In this instance Dr. Kossel conjectured that the disease was of longer duration than was known. All three recovered.

At a recent meeting of the Medical Society of Hamburg, Rumpf (Münchener medicin. Wochenschr., 1894, No. 47, p. 938,) reported the results obtained in the New General Hospital from the employment of Behring's antitoxine in the treatment of diphtheria. Twenty-six cases were thus treated, the clinical diagnosis being confirmed by the results of bacteriologic examination in all of the cases but one. Eighteen of the cases came under observation on the second day of the disease, 3 on the third day, and 5 later. All were in children between the ages of ten months and twelve years. Among the whole number there were 2 deaths (8 per cent), I among the group of 18 cases, the other among the group of 5. Four of the cases were mild, 8 moderately severe, and 13 severe. Tracheotomy was performed in 7 cases; among this number were 2 fatal cases. The injections were made into the abdominal wall. In not a single instance was there any local reaction. In II cases the temperature appeared to be influenced by the injections; in 3 it rose, while in 8 it declined. In several cases the false membrane continued to spread. Albuminuria was found in 8 cases, in one of which it had not been present before the injection. The complete statistics for several months showed that there had been 91 cases of diphtheria in the hospital, with 11 deaths (12 per cent). On bacteriologic examination of the kidneys and spleen from all fatal cases of diphtheria for a given period it was possible to isolate streptococci in 27 of 42 cases.

No. 45 Deutsche medicin. Wochenschrift, November 8, 1894, has the following:

Dr. Lublinski reports a case of diphtheria in a girl eight years old, who, after the use of serum, made a very good recovery in twelve days.

Later some inflammatory conditions about the point of injection developed an extensive erythema, such as is occasionally seen after ordinary vaccination. The case was attended with high fever, but at no time was there any danger of the patient's life, and the complication progressed through full recovery uninterruptedly. The doctor states that, though he has seen similar cases before in vaccination, he regarded it as his duty to report this as a possible complication of the use of the serum.

Dr. Cnyrin reports cases of two of his assistants with severe urticaria following the injection of the serum. The doctor states that the possibility of an accidental infection can not come into consideration, and further states that the illness of both was so severe that, had it taken place in a child or weakly person, it would have been a very serious matter. The cases are reported in full in No. 48 of the Deutsche medicin. Wochenschrift, November 29, 1894.

In No. 48 of the Berliner medicin. Wochenschrift Dr. F. Mendel reports a case of a four-year-old boy who had the characteristic deposit on the tonsils and pharynx and beginning stridor at the time he came under treatment. On the second day he received one vial of No. 2 Behring serum, and on the third day, despite the fact that there was considerable improvement in the local and general condition, he gave an injection of one vial of the No. I serum. On the fourth day the deposit had practically disappeared and the cough vastly improved and no stridor present. The temperature and pulse normal. On the seventh day there was a sudden hemorrhagic exanthem appeared over the whole body, with pain in the bones and retrogression of the general condition. This condition gradually improved during the next five days, so that after one week he was regarded as cured.

The following from American Journals:

American Journal, July, 1894. Antidiphtherin of Klebs applied in 19 cases, the percentage of deaths was 52.6 per cent. Omitting one case of a rare accident, late secondary hemorrhage after tracheotomy, the rate fell to 50 per cent.

The following figures, compiled from a lengthy article by Dr. E. Roux in a recent issue of Les Nouveaux Remèdes, form the numerical basis on which rest the claims of sero-therapy in diphtheria (the bracketed figures being the Journal corrections of a few minor errors of computation in the original article, which do not, however, vitiate the the general results): Serum treatment was begun in the Hospital for Sick Children in Paris, February 1, 1894, and continued to July 24th; all sick children found in the diphtheria pavilion from day to day were treated with the serum without regard to their condition and without other change in the treatment usually employed, so that the gross results of the months of serum treatment may be compared with those of similar preceding periods; the statistics of the diphtheria service for previous years were furnished by the superintendent and the director of the hospital, and supply all the elements necessary for comparison; in addition, the statistics of the Trousseau Hospital for Children, which also has a diphtheria pavilion, and in which the serum was not used, furnish another term of comparisons. During the years 1890-1893 inclusive, 3,971 children were admitted to the diphtheria pavilion of the Paris Hospital for Sick Children, and of these 2,029 died; the yearly percentages of mortality were: 1890, 55.88; 1891, 52.45; 1892, 47.64; 1893, 48.47—a mean of [51.11] per centum. During the period of serum treatment 448 children were admitted, and of these 109 died, or [24.33] per cent. All the conditions being the same, except the addition of the serum to the usual treatment, the difference between these percentages measures the benefits of the antitoxine treatment. During precisely the same period in 1894 there were 520 children admitted to the diphtheria pavilion of the Trousseau, and of these 316 died-a mortality of [60.7] per cent. Obviously the disease was not of a benign type during this period. Differentiating between the anginas and the tracheotomized croups, the anginas gave a mortality of 33.94 per cent in 1890, 1891, 1892, and 1893; during the serum treatment period of 1894 the mortality was 12 per cent, but in the Trousseau, where the serum was not used, the mortality was 32 per cent during the same period. The tracheotomized croups gave a mean mortality of 73.19 per cent in 1892-93; during the serum period the mortality was 49 per cent, but during the same period in the Trousseau the mortality was 86 per cent. Dealing only with the cases bacteriologically demonstrated to be true diphtheria-300 in number, with 78 deathsthe mortality was 26 per cent, as against the 50 per cent mortality of the ante-serum period demonstrated by the researches of MM. Roux and Yersin and MM. Martin and Chaillou.

The most important German statistics with which to compare the foregoing are those of Ehrlich, Kossel, and Wassermann, who report 220 cases, 168 recoveries, 52 deaths-mortality [30.9] per cent; among these were 67 tracheotomies with 30 deathsmortality [44-7] per cent; in another article Ehrlich and Kossel report 55 new cases— 26 tracheotomized with only 8 deaths; they do not state, however, that a bacteriologic examination was made in all cases.

January, 1895. Louis Fisher reports that while in Berlin, through the courtesy of Dr. Wassermann, he saw five malignant cases treated with the serum, all of which recovered. He also says that Dr. Baginsky's statement is well worth repeating: "That we have never had such a low mortality with our mildest epidemics and our best form of treatment." He further reports four of his own cases and one of Dr. Cattlin, of Brooklyn, that were cured by the serum treatment. Again he says, “I have had 34 cases, 30 malignant and 4 mild, 32 of which recovered, or a mortality of 5.8 per

cent.

Moeller (Centralblatt für Innere Medicin, 1894, No. 48, p. 1130,) reports the results obtained from the employment of the antitoxine in the treatment of diphtheria at the Magdeburg-Alstadt Hospital between August and November, 1894. Mild and moribund cases were excluded from this mode of treatment. From April 1st until November 8th there came under observation 388 cases, of which 162 required tracheotomy. Of the whole number 76 were treated with the antitoxine; 48 of these required tracheotomy, with 19 deaths and 22 recoveries, while 7 were yet under observation. Of the 28 not requiring tracheotomy 8 died, 15 recovered, and 5 were yet under observation. Of the 312 cases not treated with the antitoxine, 114 required tracheotomy; of these 57 died, 45 recovered, while 12 were yet under observation. Of those not requiring tracheotomy, 34 died, 136 recovered, and 28 were yet under observation. From April 1, 1888, to March 31, 1889, the mortality of cases in which tracheotomy was required was 59 per cent; from 1889 to 1890, 57 per cent; from 1890 to 1891, 51.43 per cent; from 1891 to 1892, 48.6 per cent; from 1892 to 1893, 63.4 per cent; from 1893 to 1894, 64.2 per cent; from April 1st to November 8, 1894, 55.6 per cent among cases not treated with the antitoxine, and 39.6 per cent among cases treated with the antitoxine.

At Buda-Pesth Professor Bokai has reported the results of the treatment of 35 cases of diphtheria with Behring's serum. The number of children who died was 5, giving a mortality-rate of 14.28 per cent. Of the 30 children who recovered, intubation was done in 12. Drs Gottstein and Schleich, of Berlin, have attacked both the theory of the antitoxine treatment and the hospital statistics which have been quoted in its support.

A recent number of the New York Medical Record, December 22, 1894, contains the following:

At a recent meeting of the Medical Society of Munich, which was attended by more than three hundred practitioners, the serum treatment formed the subject of a prolonged discussion. Professors Buchner, von Ranke, and C. Seitz presented a report on the subject, and resolutions were passed to the effect that the time was not yet ripe for a definite judgment as to the value of the method, and the trials of the remedy on an extensive scale would be necessary to settle the question. It was considered important that this view should be impressed not only on the profession but on the public. A committee, consisting of Professors Buchner, von Ranke, Bollinger, Oertel, C. Seitz, von Kerschensteiner, and Wertheimer, was appointed to study the whole question thoroughly.

In France the War Department has ordered the antitoxine treatment in the army; the cities of Lille and Havre have voted money for undertaking the new treatment.

A recent number of the American Journal of Medical Science has the following:

M. Martin, after giving briefly the method of preparing the antitoxine and the technique of its injections, presents certain facts in regard to its employment. It probably does not act injuriously upon the kidneys, but, on the other hand, it appears to protect them against the diphtheria poison; while in two thirds of the cases of benign diphtheritic angina albumen was found; in the same anginas treated by antitoxine it did not occur in more than one half of the cases. As for local treatment, it is not necessary to employ it when the antitoxine is used. Inasmuch as corrosive mercuric chloride destroys the diphtheritic poison, it may, perchance, destroy the antitoxine, and thus the bad results with local treatment may be accounted for. Roux has used equal parts of menthol and powdered camphor, which

liquefy on mixing, and so are easily prepared for application. However, no local applications are excluded save those which interfere with the action of the antitoxine, of which corrosive mercuric chloride is mentioned above, and phenol is the second.-Le Progrès Médical, 1894, No. 42, p. 249.

In the American Journal of Medical Science Reynold W. Wilcox, M. A., M. D., LL. D., says:

Mr. Hunter Urquhart Walker reports a single case. He made use of the Behring solution, which contains 2 to 2.5 per cent of egg albumen and 0.4 per cent of tricresol for preservative purposes. For the immunization of adults and older children fifteen drops of the solution is injected subcutaneously by means of a Pravaz syringe, which has been previously sterilized by alcohol, and 3 per cent of a carbolic acid or 1 per cent of a tricresol solution. For young children up to two years the dose should be one half of the quantity. To persons who are threatened by diphtheria at least ten times as much is required to render them immune. The patient was a girl of eight years of age, who had been ill for a day or two before being seen. After three days' treatment with iron and potassium chlorate internally, and the constant use of lime-water spray, the membrane was well formed, even extending well over the soft palate and hanging down into the mouth. Eleven minims of antitoxine was injected into the forearm, with strict antiseptic precautions. The temperature at that time was 103° F., and the pulse 140. In four hours there was no fever, and the pulse was quite quiet; it was necessary to rouse the patient to receive nourishment, which throughout consisted of beef tea, chicken soup, brandy and milk, and wine whey. On the following day the same improvement continued, although the membrane was still present; it was apparently loosening on the right side. During the day much of the membrane came away. On the next day the membrane had entirely disappeaped, the temperature was normal, and the pulse good; there was no pain. The injection was entirely innocuous, being followed by neither local nor general disturbance. -The Lancet, 1894, No. 3710, p. 791.

Mr. Athel T. Saw reports six cases upon which the operation of tracheotomy was performed, which upon admission to St. Mary's Hospital were apparently cases of ordinary severity. No antiseptics were applied to the pharynx, but the wound was sprayed with a 1 to 1000 solution of corrosive mercuric chloride. The ages were eleven, seventeen months, five, five and one half, six, and seven years; the first was fatal. After the fourth or fifth day the membrane, which previously had come up abundantly through the wound, ceased, and the wound was allowed to close. In none of the cases did the wound become unhealthy, neither was there any cellulitis of the neck, although on two occasions the neck showed signs of swelling on the morning after the operation. By the third or fourth day after the operation the patients' general condition had completely changed; they were bright, took interest in their surroundings, and played with their toys. The fatal case was moribund when admitted, the operation was performed without an anesthetic, the patient not stirring, and death occurred on the following morning. On necropsy it was found that the membrane extended into the secondary divisions of the bronchi. The previous twelve months' mortality in tracheotomy for laryngeal diphtheria was 30 per cent. In twelve years no child under two years of age had been saved. Aronson's antitoxine in ten minim doses was injected, with antiseptic precautions, subcutaneously at twelve-hour intervals for three days. In no case was there inflammation at the seat of the injection.-The Lancet, 1894, No. 3711, p. 851.

Mr. Ernest Hart states that there is a fairly complete record of 36 English cases within the past three months, with 2 deaths. It is impossible to run over this record without being strongly impressed with the fact that we have in diphtheria antitoxine a substance which has a marked influence on a most serious and fatal disease. What is now wanted is a standard preparation. So far it would appear that the exact dose is not a matter of extreme nicety; but it is difficult to believe that a substance capable of so modifying the susceptibility of the body to the diphtheria toxine will not have also considerable effect in other ways. Both for the sake of economy and safety no more should be used than is necessary, and a standard preparation ought to be available. The British Medical Journal, 1894, No. 1764, p. 889.

To summarize, then, what is now known of the treatment of diphtheria by antitoxine: The earlier the treatment the better the result. Larger doses, I think, will still give better results. That all symptoms usually improve within ten or twelve hours after an injection made early in the disease, say the first three days. That immunizing injections are of much service; of 10,000 individuals receiving the preventive injections of 60 units each, only 10 developed the disease. That some mild skin affections and a few cases in which, some days after the injections were made, there were developed pains in joints and limbs and some swelling, with considerable fever, have been reported.

That the effect of the injections upon laryngeal complications is very favorable, some cases being aborted, and in those having to be intubated or tracheotomized the percentage of recoveries is much increased, and the tubes have had to be worn for a shorter time. It is said, by serum therapy tracheotomy can be entirely replaced by intubation. That the complications of diphtheria, such as sepsis, involvement of heart and kidneys, and after-paralyses are much less frequent, have been demonstrated.

That antitoxine is an incorrect name is, according to most authorities, considered true; that it does not destroy the toxines, but renders the living cells less susceptible is probably correct. That it does not correct sepsis is true, thus limiting its success very greatly. I myself am not yet an enthusiast on this new treatment of diphtheria. My experience with the Koch tuberculin makes me skeptical, yet one must. see from the first a marked difference as to the two substances, and as to the two diseases they are to combat. I have though this much faith as to its curative powers and as to its toxicity: Should a member of my family have this dreadful disease, diphtheria, I would not hesitate one moment to use Behring's antitoxine, so-called.

LOUISVILLE.