at whom the Commercial Appeal takes its fling, has performed. Since vaccination became virtually optional in England, it is stated that smallpox has been very much on the increase. Glasgow, Scotland, was one of the most fertile fields in which the antivaccinationist has delved, and as a result of the campaign waged by these people, vaccination was several years ago brought to a practical standstill in that city. The result was a terrible epidemic of smallpox, and even now Glasgow is reported to be afflicted with another visitation of this horrible. disease in epidemic form. And yet Glasgow is a remarkably clean city. Where then is the sanitation argument of the antivaccinationists? Similar instances without number could be mentioned.

If those who doubt the efficacy of vaccination could witness the results attained by its use, in some of the negro-populated counties of Mississippi for instance, where the virtues of the Jenner method are made apparent by not merely rendering smallpox mild in its effects, but also in actually preventing the disease, they would have a valuable object lesson. The United States government has practically eradicated smallpox from the island of Porto Rico by enforcing compulsory vaccination throughout the island. In Cuba a similar result is being obtained. This cannot be attributed to a better sanitary condition, for the decrease in prevalence and mortality of this disease is in too great a ratio to the small amount of cleaning up that has been done. Indeed, in many portions of these islands where the death rate has fallen off in marked degree there has been virtually no change in the condition of affairs so far as sanitation is concerned.

It is too much that we should be asked to doubt the teachings obtained from the history of that wonderful machine, the German army, in which, by the use of universal vaccination, the mortality from smallpox has decreased in a few decades from thousands of deaths annually to literally nothing. Many people are only too ready to grasp at anything that will tend to disparage the efforts of the medical profession, and from the very inception of our guild we have had to fight popular superstitions and beliefs with the resources at our command; and when one reads of the remarkable and amply

demonstrated successes attained in medicine and surgery by our profession during the past hundred years, and as is portrayed even in the Commercial Appeal in a recent issue of that paper, then indeed is realized what wonderful attainments have been those of the medical scientist, and under the most adverse conditions. But it is merely a repetition of history that those who are the most self-sacrificing are often the recipients of the most derogation.

THE MOSQUITO AND MALARIA.

IF ANY One theory in medicine may be assumed to be a definitely settled fact, it is that of the mosquito transmission of malaria. But even here there are some features arising from time to time in reported instances of malarial outbreaks that give rise to a question as to whether mosquitoes were veritably the transmitters of the disease. Still, this method of germ transmission is now so generally accepted, that it has been claimed, and, we might say, conclusively demonstrated, that yellow fever may also in a like manner be carried from individual to individual.

There are nevertheless some phases of the mosquito-malaria theory that remain to be settled. Chief among these is the question as to whether the malarial organism is harbored within the mosquito during the winter months, or whether it is merely taken afresh from the blood of an individual with latent malaria remaining in his system by the insect in feeding and thence conveyed to a non-infected person whom the insect attacks. The latter view is the more popular one.

While the etiology of malaria is now sufficiently well established, nothing has been added to the therapy of the disease, nor is it necessary, since we have in quinin practically an absolute specific. Of course there are now, and always will be, varying opinions as to whether quinin should be administered in the hemoglobinuric form of malaria, and the average practitioner who has had any experience at all in the treatment of this condition very quickly determines whether his mode of treatment shall be with quinin or hyposulphite of soda. It is then useless to endeavor to convince him that his treat

ment is incorrect, and, no matter what argument may be adduced as to indications for therapy in keeping with the pathology of the condition, he relies wholly upon a knowledge born of experience. Two physicians living and practicing within a few miles of each other in the Mississippi delta may use entirely different treatment for malarial hemoglobinuria, and yet each swears by his results. So let it remain; for the longest-winded and most profitless arguments that take place on the floors of the various medical societies of this section of the country are those devoted to discussion of the treatment of malarial hemoglobinuria.

With the etiology and therapy of malaria settled on a working basis, the most important question that now presents itself is that of prophylaxis. To obtain this we are told that destruction of the mosquito in the larval form is the most successful method. Various ways in which to destroy the larvæ as they float upon the surfaces of ponds and of stagnant waters have been suggested, but the cheapest and most effectual means by which to attain this end is by pouring crude petroleum upon the water. This is an efficient procedure, but will require universal and careful execution to thoroughly eliminate this etiologic agent. Other prophylactic methods that have successfully been practiced are those of living in thoroughly screened houses, and the wearing of mosquito netting in the daytime. We fear that the majority of human beings are too indifferent to conditions that are not absolutely imperative to ever secure the general adoption of these latter precautions. The very best preventive measure would, it occurs to us, be the thorough destruction of the host.

SEROTHERAPY IN DIPHTHERIA.

OPPOSITION to the antitoxin treatment of diphtheria, except in a few isolated instances, seems to be a thing of the past. This is due no doubt to the overwhelming mass of testimony in the shape of statistics gathered from the most reliable sources-observations made by the leaders in medical opinion throughout the civilized world, likewise from the experience of numberless practitioners in the rural and urban districts of all countries.

In the February issue of the MONTHLY was published an article from the pen of Dr. T. J. Happel, of Trenton, Tenn., in which he gives his experience in the treatment of membranous croup (which, by most physicians and health boards, is regarded as identical in etiology with diphtheria), with diphtheria antitoxin. To Dr. Happel's experience may be added that of a correspondent in this issue of the MONTHLY, Dr. G. W. Penn, of Humboldt, Tenn., who states that he has been using antitoxin in the treatment of diphtheria ever since 1897, in all of his cases where a diagnosis of diphtheria was reasonably certain.

The antitoxin treatment of diphtheria was first considerably exploited by Behring in the winter of 1894-5, and at that time the writer of this editorial was working in Heubner's diphtheria wards at the Charité Hospital in Berlin. Antitoxin was even at that early date used as the almost exclusive treatment for diphtheria, and, while we doubt if later years have shown the same remarkable decrease in mortality as was heralded as brought about by the use of antitoxin in those years, still this agent has since continued in use at that hospital and almost every children's hospital in the world as practically the sole treatment for diphtheria.

Accepting the antitoxin treatment of diphtheria as the single therapeutic offering that we now have for combating this disease, even though it be not the absolute specific that was at first claimed for it, and as still maintained by some, the question of most importance to us appears to be that of the handling of those cases of diphtheria -sometimes classed under the heading of membranous croup-which have their severest or chief manifestations in the larynx. With the frightful mortality that characterized this disease prior to the introduction of antitoxin, which then ranged from 85 to 90%, anything that promised the slightest hope for reduction of this mortality in any degree was looked upon as a godsend.

Although O'Dwyer's method of intubating the larynx for the relief of the stenosis in laryngeal diphtheria had been advocated several years prior to the discovery of antitoxin, and had been used with a varying degree of success by some, it had not received the great vogue that was accorded it after the use VOL. XXI-12

of antitoxin became general. Since 1894 great masses of statistics of the results obtained with intubation have been published. Some of these statistics have been devoted to intubation without the concurrent injection of antitoxin, while the greater number of observations have been made in cases in which both measures had been invoked. Results of treatment have seemed to be somewhat more favorable in the latter, and it is now common practice to inject with antitoxin, no matter how advanced the symptoms of stenosis may be, before using intubation. Statistical study permits us now to assert that the mortality in laryngeal diphtheria has, by the use of the antitoxin-intubation treatment, been reduced to perhaps 60%. That this percentage will be lessened even more in the future there can be no doubt when the necessity for early intervention becomes more apparent. Intubation should not be deferred until the child is veritably moribund, but where interference with respiration is developing to such extent that this function is in any degree labored the tube should be inserted. The question of the relative value of intubation as compared with tracheotomy naturally, even at this date, continues to present itself, and the latter operation has, of course, its advocates among surgeons. In this connection the author of this article desires to state that while he has many times witnessed the beneficent and life-saving results obtained from intubation, he has never, although his field of observation has not been narrow, seen a single case of tracheotomy for the relief of laryngeal stenosis in diphtheria, in private practice,

recover.

EDITOR'S NOTES.

A PHYSICIAN'S ORPHAN HOME is to be established in Bristol, Tenn. An organization has been effected, officers elected, and plans are on foot for the raising of the necessary amount to purchase a handsome property in the neighborhood of Bristol. The plan is to establish and maintain a home by endowment and subscription from the profession, and it will be under the management and control of the regular medical profession.