of the fact that there is a time in the history of this affection when the use of this drug has been passed. In the secondary manifestations of this disease, the drug alone plays much good. The dose required to reach this termination is usually from onetwentieth to one-fourth of a grain three times daily, for such time as is required to produce a result. I do not believe this drug has any influence in the so-called tertiary varieties of this affection. Hereditary syphilis is favorably impressed with it, and the manner of application may be by baths, using in each bath about ten grains, and giving the person about one-half hour sittings every day, or every other day, according to the effect produced. I do not think it necessary to lengthen this paper any on this point, because it would unnecessarily carry it beyond its limit.

This list contains most of the affections in which this drug may be found beneficial, but some few other affections may often be treated with it with advantage, but as they arise mostly through complications, I will not include them here.

315 South Eighteenth Street.

ANTITOXIN IN DIPHTHERIA. BY H. HERTEL, M. S., M. D., FREEBURG, ILL.

President St. Clair Co. Medical Society. Read before the St. Clair Co. Medical Society, Sept. 2, 1897.

MY

Y APOLOGY for reading this paper before the St. Clair Co. Medical Society, is the youth of the patient, the extreme gravity of the case when first seen, the great mortality in children afflicted with diphtheria, and the speedy and permanent cure attained.

Case: Minnie Donaldson, aged 12 years, average size and of fair previous health, was first seen by me at 10 a. m., March 7, 1897.

The child had been sick for some days, but as the parents thought it had just taken a cold and was teething, it was given some patent medicine. However, as it grew progressively worse in the following twenty-four to thirty-six hours, I was sent for. Upon entering the room

and approaching the child, distinct fetor could be detected. Respiration was loud, harsh and interrupted— could be distinctly heard on the farther (distal) side of the next room.

The child was lying on its back, eyes closed, mouth open and breathing through it, and with head far thrown back, evidently in an instinctive effort to give the larynx freer play and to throw the mouth into a more direct line with the trachea, thus materially facilitating the obstructed respiration.

Both tonsils were enormously enlarged, the right side of neck bulging far beyond the cheek. The lymphatics of neck were hard and very much enlarged.

Upon making an ocular inspection, the whole pharynx (so far as could be seen on account of swelling) was found to be much inflamed, the tonsils being thickly covered with the typical pseudo-membrane of diph. theria, which membrane extended up towards the posterior nares.

The nasal passages were totally occluded and the respiration indicat ed beyond doubt that the trachea also was involved. Not only this, both eyes were affected, the right eye being firmly closed from œdema of lids and the left one nearly so.

The temperature in axilla was 1031° F. and the pulse 181 and feeble. All in all, the symptoms were of so grave a nature and the general appearance of the child so very bad, that I feared the outcome of the case would be of but one kind-a speedy dissolution of child.

I thought of antitoxin at once, but feared that it was too late to do any good, even if its merits should be equal to those claimed for it by its most ardent advocates in the medical profession.

Treatment: Quinine mixture for fever every three hours and:

B Acid. carbol., gtt. viij.

Aq. calcis, 3 viij. M. This spray evidently gave the child very much relief as she would open her mouth wide to receive it after it had been used for a day or two.

The eyes were constantly kept moist with a solution of:

Ꭱ Acid. borac., gr. x.
Aq., 3 j.

At 8 p. m., patient the same. March 8th, 7.30 a. m. Temperature in axilla 102° F., but otherwise patient is about the same; had a rest. less night. I now told the father that I wanted to give antitoxin a trial, but he wavered, saying that Dr. L. P. Stookey, of Belleville, their former physician, did not believe much in it, etc. I told him that at first many physicians did not believe in it, but that the accumulated evidence now in its favor was overwhelming. Still he did not give his consent, but I sent to the city that morning and received the antitoxin before night.

After my return home, I was called some eight miles into the country and did not return till late in the afternoon.

In the meantime, Mr. D. studied. about what I had said and concluded to telephone to Dr. S., telling him what I had proposed to do.

The Dr. came out, also bringing antitoxin with him, he having become favorably impressed by late reports concerning its use.

At 7 p. m. (March 8th), we found the child about the same as before, but temperature 1032° F.

We decided to use antitoxin at once. The site selected was above the left groin, and I injected 5 c. c., 500 immunizing units of the antitoxin. We also gave her gr. 14 phenacetine, to be repeated in two hours if necessary, watching its effects and ordering brandy in case of depression. One powder was sufficient. This was also used on the following night, but not later. Other treatment continued.

March 9th, 9 a. m. (could not get to patient sooner on account of high water). Temperature 1021⁄2° F., pulse 168. The child is restless and passed a restless night. Respiration harsh and interrupted. Both eyes are completely closed, both lids being

very oedematous, those of right eye so much so that even by everting them fully the globe cannot be seen. By oversight of nurse, the acid boracic lotion was not used on eyes since my last visit, hence the result. Instilled several drops of argenti nitras solution (gr. 1⁄2 to 3 j) into both eyes and ordered constant application of boracic acid lotion to eyes. Other treatment continued; gave second injection of antitoxin.

At 6.45 p. m., conditions were about the same, temperature being 103° F. and pulse 156. Respiration bad, but swelling of neck has somewhat decreased and cervical glands are smaller. Treatment continued and gave third injection of antitoxin. Gave more brandy.

March 10th, 8 a. m., temperature 102° F. Otherwise the condition of child is about the same, though it appears weaker. Injected fourth and last dose of antitoxin. At 6 p. m., temperature was 103° F., and pulse 168. Child restless, breathing harsh and interrupted, but membrane seems loosening. As child seems weaker, brandy was increased in quantity and frequency. (Now watch.)

March 11th, 8 a. m., temperature 10034° F., pulse 150 to 156 in sleep. (Child has heretofore not slept much). Membranes are loosening and being cast off. Again, for the first time since sick, the child breathes through its nose, but not freely. Rests better, eyes are much better, has had two good evacuations (had about one. daily before, some after enema). Child is generally better. Continued. swab of hydrogen peroxide (1⁄2 strength) solution. This has been used with acid boracic and listerine solution since second day. Stopped hydrarg. bichloride solution and gave Acid. borac., gr. xvj. Listerine, 3 iv. Glycerine, 3 iij.

R

Elix. lactopept., 3 ix. Teaspoonful every four hours, in

stead.

At 6 p. m., temperature is 100% F., pulse 144; looks better, rests better and breathes much better. It opened the left eye for the first time in three days; right eye much better, but still closed; breathes freely through nose. General condition is much more

A

BY FRANK S. MILBURY, M. D.,

BROOKLYN, N. Y.

Laryngologist, Otologist and Ophthalmologist to the Bedford Dispensary and Hospital, and North Brooklyn Eye, Ear and Throat Hospital, Brooklyn, N. Y.

ON

N MAY 25, 1897, Mrs. G. brought her sister, Mrs. J., aged 33, to my office, bearing a letter from Dr. James J. Bowen, requesting me to look over the case and render my opinion; at the same time stating that he believed a mastoid operation was indicated. As I could get no intelligent satisfaction from the patient, I interrogated the sister, who stated that there had been more or less continuous discharge from left ear since infancy, following scarlet fever. At this time it was extremely offensive. By the touch of a sound, dead bone was easily perceived in tympanum and posterior wall of meatus, which was swollen and bulged forward. Mastoid odematous was very red. The entire side of the head was acutely sensitive to the most gentle pressure. Violent, uncontrollable headaches, had continued several weeks. Slight paralysis of left side of face, and right arm and leg existed. Her past life seemed wrapped in complete oblivion, and it was almost impossible for her to put what thoughts she had into words-showing amnesic-aphasia.

Temperature, 100; pulse 115. Excessive vomiting on the least movement of the head, and nearly as much so when lying down and the head perfectly quiet. The ophthalmoscope showed optic neuritis in the left eye, and, more than that, the condition of the patient precluded any further examination of the eyes, by the perimeter or other wise. In all probability there may have been present hemianopsia. It was evident that mastoid necrosis and suppuration existed, with possible cerebral abscess and meningitis, and the sooner an operation was performed the better. Accordingly she

* Read before the last session of the N. Y. State Medical Association.

The next day, May 26th, at 11 o'clock, A. M., with the assistance of Drs. Bowen and Rickard, she was anæsthetized, head shaved, and under the most careful antiseptic precautions we incised the soft tissues, detached the lining membrane of the meatus, laying the ear forward, and retracted the posterior integument, giving a clear view of an extended field. The cortex in places were soft, but no fistulæ or pus was visible on the surface of the bone. By cautious chiselling, the antrum was entered. With a probe I explored, and found in every direction carious bone, which was easily removed by a sharp spoon, and nearly the entire mastoid was found to be involved. The antrum and large cell at tip of mastoid and smaller cells were filled with the foulest pus imaginable. The lateral sinus came into view, but looked blue, healthy and pulsating. A large sequestra was removed from the posterior wall of the meatus, making a broad connection between the tympanic cavity and antrum. Also the posterior-superior wall, which was soft, was removed, and the moment the brain cavity was entered, pus welled out in large quantities. I enlarged the wound in the skull with a rongeur, and with a sound measured the depth and extent of the pus cavity. Greatly to my astonishment, the instrument passed in about 41⁄2 inches, and I should think the sinus had a diameter of fully an inch, and involved a portion of the temporosphenoidal lobe. Dr. Arthur C. Brush, a well-known neurologist of Brooklyn who was called in consultation, is of the opin ion that the abscess was, in this case, formed by local purulent meningitis, the walls of which were formed by adhesion between the dura and the arachnoid. In other words it was an intra-dural abscess. He does not think it involved the brain tissue proper to any extent, on account of the rapid and complete disappearance of the symptoms after the pressure was relieved by the evacuation of the pus, which would preclude any destruction of brain tissue.

The position of the lateral sinus would indicate that it was situated