diphtheria, but merely to emphasize a few salient points of diagnosis, prophylaxis and treatment as they present themselves to my mind.

Diphtheria, as it is superfluous to mention, is an infectious and contagious disease with an incubation period of from two to seven days, caused by a special germ, the Klebs-Loeffler bacillus, with the lesion or site of lesion in the throat and larynx, usually accompanied by the deposit of a membrane, varying in color from a white to pearly gray or ashy gray, on tonsils, uvula, palate, pharynx, sometimes extending into the larynx, tough and usually incapable of being mopped off without hemorrhage, and leaving a raw surface. In a simple case of diphtheria the clinical history is usually as follows: Child complains of slight soreness in throat, headache, anorexia, slight fever; temperature increasing each day. On examination, the throat is found slightly inflamed, small white or grayish deposits are seen on the tonsil, which gradually spreads on to the fauces, pharynx, uvula, and finally the larynx and other tonsil, the temperature gradually rising with the spread of the membrane, cervical glands enlarged slightly without swelling of adnexa or cellular tissue. There may be an inflamed catarrhal diphtheria without any deposit. In follicular tonsillitis in contradistinction to diphtheria, we have both tonsils usually involved at once. Mucopus is seen in the follicles or crypts, which can be early swabbed off. Beginning with a chill, the temperature is highest the first day, and continues so from three to five days, when it declines. In the "mixed infection," or when we have both the Klebs-Loeffler and the streptococcus pyogenes, we have a severer beginning or initiative, and the local symptoms are severer. The disease

may be ushered in by a chill, high fever, vomiting, violent inflammation, mucopurlent discharge, deep structures more swollen and involved, lymphatics and cellular tissue much more involved, more toxemia and more complications generally. The pathologic lesion in diphtheria is in the cells throughout the body; the bacilli throw off their toxin or toxalbumin in and under the membrane from which it is absorbed and carried into the general circulation. The streptococci are more often thrown into the circulation and carried to

the more remote organs, hence nephritis, myocarditis, abscesses and the more violent toxemia, hemorrhages, etc.

I fear that we, as country physicians, with the health and lives of the community entrusted to our care, are inclined to be rather lax or careless about prophylaxis. I refer to isolation, disinfection and quarantine. Very often as soon as the membrane has disappeared from the throat, these patients are turned loose to return to school or mingle with their associates, when it is a known fact that the germ remains in the air passages sometimes for weeks. I think we should at least keep them isolated for two weeks, using an antiseptic gargle. Those that have already been exposed should have an injection of the immunizing fluid.

In my opinion we have for the treatment of diphtheria, whether laryngeal or pharyngeal primarily, a remedy as true and efficacious as quinin is for malaria. I refer to antitoxin. I don't mean to say that it will cure every case-not that, but it has materially reduced, and will continue to reduce, the rate of mortality. Antitoxin, like all remedies, has had its enemies, and notwithstanding this fact it has continually gained ground, and is now recognized as the treatment par excellence by all leading authorities. I think where it has failed so often is due to the fact that it is given too late after the patient is toxic beyond repair, or toxemic beyond hope, when antitoxin thrown into the circulation only adds fuel to the fire. I do not think antitoxin can be given indiscriminately, neither do I think that any man can definitely state a fixed time or number of days that have elapsed when it would be unsafe to give the remedy. I do not think that it should be given in a case of profound toxemia, neither do I think it should be withheld because a certain number of days have elapsed, but I think we should take into consideration the physical condition of the patient, and use this as a criterion. I should say in passing that we often fail to get the result we expect because we have a case of mixed infection. All manner of objections are offered to the serum. I, in my limited experience, extending over a period of five years, have never seen an untoward effect. Some bad effects which are claimed for antitoxin are: local abscesses, urticaria, diffuse erythema, joint pains and albuminuria. I

do not think the cause of the untoward symptoms is due to the remedy, but the method of giving and the quantity and quality of the article used. I think the more concentrated the serum, and the smaller the volume to the unit of potentiality, the less trouble we will have from it. The larger the volume, the more the distension of cellular tissue, and the greater the liability to abscess; the larger the volume, the more carbolic acid thrown into circulation, and the more liability to albuminuria; the larger the volume, the more serum to produce urticaria, etc. Antitoxin, according to the statistics of fiftythree New York hospitals, shows that after its use, 9893 cases showed a mortality of 18.3%, whereas the same hospitals had a previous mortality of 44.3%. In 1893, when the remedy was being used in the Kaiser and Kaiserin Friederich Hospital in Berlin, the supply of antitoxin was exhausted, and in two months the mortality jumped again to three times what it was under the use of the serum, being again reduced on resuming the antitoxin.

The same statistics come from all the large cities of the whole country-a reduction of the mortality by one-half. And no doubt were the cases carefully selected, the mortality rate in simple diphtheria would be almost nothing.

My own experience with antitoxin dates from about five years ago, and illustrates the point that in some cases it may be administered late in the disease with good effect.

My first case was one of pharyngeal diphtheria, in a young lady 18 years of age, who had been treated by me for fourteen days with sprays, irrigation and mops locally, mercury, stimulants, etc., internally. The membrane covered the uvula, fauces and most of the pharynx, and on its spreading to the larynx on the fourteenth day, I used Behring's antitoxin, 3000 units; no improvement in twelve hours, and I used 2000 units. After twenty-four hours half the membrane was gone; in twenty-four hours more I used 1500 units, after which the membrane entirely disappeared, and temperature became normal. The pulse and temperature in this case had never been over 96 and 101°F., respectively. She made an uninterrupted recovery, save that she had post-diphtheritic paralysis of the constrictor and palati muscles which lasted two or three months.

I have never lost a case of diphtheria treated with antitoxin, whether laryngeal or pharyngeal, which was not, in my judg

ment, too toxic for the remedy. It no doubt often relieves the surgeon of the operation of tracheotomy or intubation, as I have recently witnessed in two cases where it seemed that an operation was inevitable if the child survived. Holt says of antitoxin : "At the present time, after the serum has been in use two years, no evidence has been adduced as to its dangerons or injurious effects which should deter anyone from its use." I am truly glad that we at last have a remedy of which it may not be said, as once Jacobi said to a noted confrére of the use of mercury in diphtheria, that he gave it because he knew of no better remedy. Antitoxin is said to exert its effect in one of two ways: First, by chemically neutralizing the toxin from the Klebs-Loeffler bacillus; second, by increasing vitality of the cells, rendering them tolerant of toxin in the arrest of bacilli growth and membrane formation. I would not disparage the use of other remedies. I think it essential to irrigate, spray or mop when feasible, and it is also of paramount importance to have an eye to judicious supportive measures, such as nourishment, stimulants, etc.

The necessity for watching closely the heart's action in diphtheria, and even in convalescence, was vividly impressed on me not long since by seeing a bright little girl die either from heart clot, or cardiac thrombosis, toxic myocarditis or neuritis after she had begun to convalesce; membrane all gone, temperature normal, but heart's action feeble and irregular. No strychnin, whisky, etc., had been given, so when she exerted herself by raising in upright position, she had heart failure and death. These conditions need strychnin, whisky, and above all, quietude and recumbent position.

AFTER-RESULTS IN FORTY CONSECUTIVE CASES OF VAGINAL HYSTERECTOMY PERFORMED FOR CANCER OF THE UTERUS.-Lewers (Lancet, Jan. 5, 1901) says: (1) That in a certain proportion of cases, patients suffering from cancer of the uterus may be relieved by operation for periods of many years-in some cases for so long a time, seven years and upward, that there seems some probability that the relief may be permanent; (2) that the proportion of cases in which this result can be expected must remain very small so long as patients generally only seek advice at a late stage of the disease; and (3) that consequently the great desideratum is early diagnosis.

THE TREATMENT OF PNEUMONIA,

PAST AND PRESENT.*

BY J. C. YOUNG, M.D.

MARTIN, TENN.

WE CAN send our patients who have chronic malaria to the mountains and our tuberculous cases to the proper altitudes of North Carolina and other places, and wisely too; but where shall we send the man or woman that they may be free from the dangers of pneumonia? In infancy, childhood and middle age it claims its victims here and there. In old age about 90% die who have pneumonia. In some of the higher altitudes and dryer atmospheres the disease is more fatal than in some localities of this country, excluding the very malarial districts.

Our forefathers in medicine mention three methods of treating pneumonia- the antiphlogistic, the stimulant, and the expectant- all of which have been practiced, and to some extent are used even to this day. Blood-letting in early times was the favorite remedy, not only with the physicians, but also with any person who "happened to be around;" and such persons could be found at almost every cross-roads in the community, their lancets always ready, seeking whom they might relieve or rather devour; and we have no doubt that many persons were hastened on to eternity by the reckless use of the lancet not only in pneumonia, but in other diseases. Yet I would not in this article attempt to detract from or cover up in any way the great benefit of blood-letting in the proper subject at the proper stage of the disease, but prefer rather to be conservative than too radical. That our predecessors bled too much and too often, but few or none will deny, and the pendulum has swung so far the other way and the prejudice against blood-letting grown so great, that many of the physicians of the present day would scarcely know how to open a vein if necessary.

Dr. Flint says in his work on Theory and Practice of Medicine, published about 1866, that in most of the cases in which * Read before West Tenn. Med. & Surg. Assn., Martin, Dec. 6 and 7, 1900.