and the quotations of statistics by textbook compilers were given in refutation. In making this statement I was quite cognizant of the fact that numerous series of statistics placed the mortality at from 35 to 50 per cent., or even lower, but such data was largely compiled from hospital practice, where the facilities for early and maintained intervention were readily available. In private practice, especially in the rural districts, the practitioner is handicaped by inability frequently to avail himself of the services of a skilled intubationist, and many times intubation is not even thought of until the child is in a state of exitus; therefore we must reckon with a considerably larger mortality in general practice than is shown by Eastern and European hospital statistics. Even 60 per cent. mortality is, however, a decided improvement over the previous fearful death rate of from 90 to 95 per cent. in this condition. If every case demanding it could be early intubated, I believe that the mortality would be less than 10 per cent. That antitoxin is the potent agent in laryngeal diphtheria, that it is faucial diphtheria, I am unwilling to admit, for the course of pseudo-membranous croup is so exceedingly rapid that it is but rarely that the antitoxin is administered in time for it to have an opportunity to exercise its curative powers. Indeed I am for this reason inclined to doubt its value at all in the majority of these cases, especially where there is mixed infection. But I should not fail to advise the administration of the remedy in any case to which I was called, for I am not sufficiently convinced of its lack of utility in even these late cases to discard a remedy so popularly and universally accepted, therefore I would not feel that I had done my whole duty were I to fail to urge the prompt and thorough use of antitoxin. This brings up a much discussed question of the dosage of serum to be employed, and while such a topic is not strictly in keeping with the title of my paper, I cannot refrain from adding in this place my plea for large and frequent doses of this agent. In cases presenting the severe and urgent symptoms that we find in laryngeal diphtheria, the dose of antitoxin should never be less than 2000 units, and should no favorable results be noted within six hours thereafter, this dose should be repeated or even increased to 3000 units; at times it may be advisable

to run the dose even higher. Favorable symptoms after the administration of one dose of antitoxin should not be taken as indication that further injections of the serum are unnecessary, for it is characteristic of this disease that there may be remissions, with apparent betterment of the condition, followed by symptoms of increased severity. Therefore a second or third dose of antitoxin should be administered, notwithstanding a seeming improvement in the symptoms of stenosis.

Frequently I am asked as to the time necessary to leave the tube in the larynx, but it is readily understood that this is governed largely by existing conditions. From personal observation I should judge that the average duration of intubation is about three days. The majority of the cases of membranous croup that I have seen have passed the crisis within that time, but it has not been a rare experience with me to intubate cases that have worn the tube much longer. One case in particular that I have in mind occurred during the time that I was in Heubner's diphtheria wards in Charité Hospital in Berlin, in the spring of 1895. This patient was a little girl six years of age, and she wore the tube off and on for three weeks. While this is an unusual length of time for intubation to be continued, still cases have been reported where the tube was worn from five to six thousand hours. In cases in which it is necessary to prolong the intubation, we must ever bear in mind the possibility of the production of a terminal pressure neuritis with paralysis of the vocal cords as a result. Also we must endeavor to avoid ulceration of the vocal cords which sometimes is a complication in these protracted cases. Frequent extubations and attention to the general regimen are the best preventive measures.

Since the death of O'Dwyer there have been various modifications of his apparatus placed upon the market, but I have not found any instrument that could supersede in my favor O'Dwyer's improved intubation set. It is claimed for the hardrubber tubes that they are less susceptible to the corroding process that is sometimes complained of than are the goldplated ones, but this matter of corrosion has not troubled me in my experience, and I find that the only element of superiority possessed by the hard-rubber tubes is that they are of a

lighter weight than the metal ones, and this no doubt is more an apparent than real value.

Among the few complications that are mentioned as possibly occurring in the introduction of an intubation tube is the danger of making a false passage through one of the ventricles of the larynx, or of otherwise lacerating the tissues of this organ. It would seem to me that such a result as either of these should be ascribed to great carelessness or roughness in the introduction of the tube, for I cannot conceive of a blunt-pointed intubation tube being pushed through the mucous membrane and tissues that it must encounter in penetrating a ventricle or other portion of the larynx. A case such as this has never come under my observation, but I have seen several reported in the literature.

The apparent ease with which the skillful operator passes a tube into the larynx is quite likely to impress on-lookers with the idea that this is an operation requiring little skill, but if there is any operation connected with the throat that demands technical knowledge and skill derived from continued practice it is that of intubation. The finger must be educated to the recognition of the structures with which it comes in contact, for the operator, as it were, is groping in the dark, and the introduction of the tube is guided by the sense of touch, and considerable manual dexterity is essential.

The most successful intubations are done in patients above two years of age, in fact most of my intubated cases have occurred in children from two to six years old, but this perhaps is explained from the fact that the incidence of the disease is greatest during this period.

At times the intubationist is discouraged by his unsuccessful attempts to induce the tube to remain in situ, but it should be borne in mind that it is not unusual for the little patient to eject the tube by retching a number of times before it will be retained. It has not been a rare experience with me to be compelled to reintroduce the tube as many as a half dozen times within a half hour ere the reflexes would be sufficiently quieted to avoid expulsion of the tube.

While some operators make a practice of removing the thread from the tube after it is once securely placed in the larynx, I

cannot recommend that this be done unless the child is very restless and likely to displace the tube by tugging at the string, and on older patients, over whom we have more control, it is but rarely necessary. The disadvantages of leaving the string attached to the tube are that the child may remove the tube while it is not being watched, and that the string may act as an irritant in the throat and excite coughing, with resultant expulsion of the tube. The advantage is that in the event the tube becomes occluded, a not infrequent occurrence, it may readily be extracted by any one in the room, thus removing impending danger of suffocation. I would also add, if the string is removed from the tube and the child dies there is a probability of your losing your tube, for one naturally feels reluctant to perform extubation on the body of a child in a house of mourning. This occurred to me in one instance last winter.

As a parting injunction I would endeavor to impress upon my hearers the importance of continuing to observe these patients for several days and even weeks after the tube is removed, for it is a most disagreeable thing indeed after a successful intubation to one day be informed that our patient, perhaps while out in the yard playing, has suddenly dropped over dead, due to cardiac paralysis.

Lyceum Building.

OBSERVATIONS ON THE USE OF HYPNOTICS.

BY H. P. COILE, M.D.

KNOXVILLE, TENN.

FOR the last few years the spirit of commercialism has played such an important part in the matter of production and introduction of new remedies that it requires careful observation to select from the innumerable preparations on the market the occasional product of real merit. In this country we have a large number of manufacturers of recognized character, besides thousands of drug stores and pharmacies striving to obtain recognition of their remedies. These products are carried by representatives into physicians' offices with an urgent request for a trial. Some of them are of

known chemical properties, while many others are simply crude mixtures of medicines of uncertain and varying physiologic action. In many cases manufacturers or proprietors extol with astounding assurance the virtues of these so-called remedies, and it is also my experience that among all those offered the profession in no instance was an endorsement by "leading physicians" wanting.

To such an extent has the spirit of commercialism invaded the realm of chemistry and pharmacy that it behooves the careful and conscientious physician to carefully weigh the claims made for any new remedy offered the profession. It is far from the object of the writer to minimize the value of the work of our great and responsible manufacturers. The profession is grateful for the many useful products given it by them. Some of what are called new remedies have stood the test of exhaustive clinical experiments, and have been weighed in the balance and not found wanting. Some have had their day, and flourished and withered as the grass, while others have scarcely had recognition.

There are old established remedies whose uses have been in some degree modified or restricted by the newer ones. Opium and its preparations formerly constituted our main supply of hypnotics; afterward chloral hydrate was added, and in many cases was preferred to opium. It had advantages over opium in certain conditions and cases. Its hypnotic properties were constant; it produced sleep when opium failed, and it did not lock up the bowels. However, chloral possesses a very unpalatable taste, and in full doses it is not free from danger, especially in cases of weak heart. It is, however, a valuable acquisition to our list of hypnotics. Bromides are so weak in hypnotic action as to merely deserve passing notice. A more valuable addition to the hypnotic class is sulfonal, whose action is reasonably certain and after-effects insignificant. Perhaps the greatest objection to its use is the length of time required to produce sleep after the medicine has been taken.

The most important remedy of this class which has in recent years been brought to the attention of the medical profession is trional. My attention was first called to it about six years