responding period in 1894. A very marked diminution in the death percentage from diphtheria is apparent. That the diminution is not greater, is probably due to the fact that most of the serum available in January and during a part of February was weak and was not generally used. The mortality for March thus far is much lower. In connection with the subject I would like to call attention to a new antitoxin syringe made by Tiemann & Co., after my design, and illustrated by the accompanying cut, which does not, I think, have any of the objectionable features of the ordinary syringe. The difficulty of cleansing the ordinary syringe is very great, and is due to the packing of the piston, which is generally of leather, and to the leather washers used to make the end of the barrel air-tight. Koch's syringe is really the only thoroughly good syringe from the stand-point of cleanliness, i.e., ease of sterilization, but the instrument is difficult to handle and is liable to inject air with the serum. My syringe consists simply of a glass barrel (A) graduated in c.c., containing 10 c.C., open at one end and ground to a fitting at the other. The ground end fits a needle (D) having a hard-rubber shoulder. The piston (B) is in one piece, the plunger extremity being a little smaller than the diameter of the barrel of the syringe. A disk of rubber (C) or tightly woven cloth of suitable thickness is placed over the open end of the syringe and the plunger inserted. The rubber, which may be cut from an ordinary rubber bandage, engages the end of the piston so as to form when wet a water-tight cushion which is operated just as is an ordinary hypodermic syringe. Before using the syringe the rubber and the entire syringe should be sterilized by means of hot water. I have also had Messrs. Tieman apply this principle to the ordinary hypodermic syringe, and the result is extremely satisfactory. ค 4 10 6 8 9 10 C.C. A metallic case or box is provided to hold the syringe and disks. The ordinary velvet-lined syringe case is an abomination, and should never be used in connection with any hypodermic syringe, still less with any syringe. used for the administration of antitoxin. The case for the syringe should be as easily disinfected as the syringe itself. The wooden cases now generally provided for antitoxin syringes cannot be sterilized by means of heat, which in this connection is the only perfect disinfectant. An instructive paper might be written on the subject of the introduction of antitoxin in the United States. Such a paper would illustrate forcibly the great interest taken by the laity in medical matters, and their appreciation of the valuable discovery in question. It was this interest and appreciation that made it possible for the Board of Health to obtain the necessary appropriations to extend the facilities of its bacteriological laboratory so as to produce the serum, and that caused the New York Herald to give the project such effective aid by its support and the large sum of money it collected through popular subscription. The outcome has been the rapid production of antitoxin, so that at the present writing the Board of Health can easily supply the State of New York from its surplus of serum, with sufficient to treat all the cases of diphtheria that occur during the ordinary prevalence of the disease. Much of this serum is equal to the excellent preparation known as "Behring's No. 3," and some of it is even stronger and better. As I have stated in another part of this paper, Behring's preparation No. 3 requires 1300 to 100 c.c. to immunize a guinea-pig weighing The full antitoxin strength that the serum of the horse can be made to develop varies in different animals. The animal which produced the serum to which I have alluded has developed an extraordinary degree of immunity. The number of immunized animals at present in the Health Department Laboratory stables is thirty. The amount of antitoxin capable of being produced by them is about forty thousand c.c. per month. I desire to place on record here my appreciation of the services of Dr. Hermann M. Biggs, of the Health Department, especially in connection with the production of antitoxin in this country. By Dr. Biggs's request the Board of Health detailed him, in May, 1894, to study the subject in the laboratories abroad. Shortly after his arrival in Berlin he wrote letters fully describing the new remedy and its great promise. He also wrote directions to his assistant, Dr. William H. Park, to prepare the necessary toxin, so as to be ready to begin at once, on his arrival, to administer it to animals. To Dr. Biggs more than to any other man is due the early introduction of antitoxin into the United States. MODERN TREATMENT OF LARYNGEAL AND ASHEVILLE, N. C. IN presenting some of my observations in the treatment of pulmonary tuberculosis I may say that, in my experience, the general management of the patient has proven itself of such importance that, without its correct application, there is little, if any, prospect for success. No matter what measures we may otherwise employ, the faulty conduct of the patient, his unhygienic environment, or his dietetic errors cause him to relapse so frequently from any benefit our therapeutic measures may have brought about, that the course of the disease is, as a rule, a downward one, in spite of all the remedies which we employ. The general management must therefore be considered the foundation for the superstructure of symptomatic and direct treatment, and the fundamental principle which in its application should govern us at all times and under all circumstances is, "To secure and maintain the highest possible degree of general and local nutrition." In order to secure it in all directions we must not only have enough of good, well-cooked food, but we need also good digestion, assimilation, oxidation, and excretion, which to obtain and to maintain we must look into our patient's whole mode of life, and control it wherever necessary; we must learn his good and bad habits, and his tendencies to errors; examine into the healthfulness and function of all the rest of his organs and correct everything that is possible toward getting the greatest amount of vitality and physical vigor, by which we increase the inherent forces of the organism for successful resistance to the disease. To this end we should not only understand the pathology and course of pulmonary tuberculosis, but also general and special pathology and physiology in their relation and effects to health and disease. 1 Read by invitation before the County Medical Association of New York, March 18, 1895. The physician who can bring the greatest amount of such special and general knowledge to his case, must of necessity be the most successful (providing he also makes painstaking application of the same). Failure is practically certain for him who does not appreciate the great influences exerted by the individual physical condition of the patient, especially through the organs of circulation, digestion, assimilation, and excretion, upon disease in general, and upon the course of pulmonary tuberculosis in particular. In considering these influences it would be next to impossible to anticipate every abnormal condition an individual patient may present, but the more important and most frequent indications I will endeavor to outline by a short review of my own practice. Excepting cases in the earliest stages, when I take charge of a patient I order rest in bed, stopping all previous medication, and observe the course of the disease for a day or two, during which I make such changes in diet and the patient's mode of life as seem to be indicated. I also look after the condition of the skin; begin with baths or cold rubbing, examine the urine, the sputum, the blood-obtain a record of the temperature, pulse, and respiration; and, with a full physical examination after having taken the previous history, I am now ready to consider the evidence before me and to form an opinion as to what my patient's condition really is. The future management depends entirely upon what I have found. If the patient is practically free from fever, or if fever is absent for the greater part of the day, constant confinement in bed would not only be unnecessary, but would otherwise interfere with the patient's best interests. According According to his strength, he is allowed to be up during the hours when the temperature is not elevated, and must be out of doors, either at rest there, or taking such exercise as his physical condition would warrant to risk, without incurring any sense of fatigue or shortness of breath. The amount of the exercise is controlled by its effect upon the circulation and upon the fever, and an increase is only allowed cautiously and gradually. Unless the digestive organs are deranged the patient is allowed a liberal mixed diet, which is supplemented by milk between the meals, if necessary. If the temperature record at any time shows elevation above 100° F. the patient must go to bed and remain there until the temperature has declined, and he must anticipate the probable rise on the following day by retiring at least one hour earlier. During fever hours the diet is light, the feeding more frequent. Hearty meals of meats, eggs, and coarser vegetables, if given shortly before, or during fever, are very apt to increase it or invite its recurrence. The patient receives a cold rub every day before rising; but subnormal temperatures require caution in this respect, and it is best to wait with the bath until a normal temperature is reached, the patient remaining in bed until then. If the case is of an acute character, or if complications occur, with continuous fever, every attempt to treat such a case without absolute rest in bed interferes with the arrestment of acute symptoms, and, as a rule, defeats the chances for improvement or recovery. In such cases we apply massage or electricity, or both, and substitute therewith the desirable exercise, while in suitable weather we bring the bed near the windows for the direct exposure of the patient to sunlight and out-of-door air. Absolute rest in bed is also imperative during complications like pneumonia, pleurisy, or hemorrhage, and they must have entirely subsided before the patient is allowed to be up and take exercise. In all other ways the general management is constantly endeavoring to keep the patient from all harmful influences on the one hand, while taking advantage of everything, little as it may appear, toward keeping him in the best possible condition, on the other. Exercise, amusements, or light occupation, reading, mental states, clothing, position in sitting or reclining, partial or complete exposure to sudden variations of temperature, or to draughts and the like, are all important matters for watchfulness and proper advice; and instead of relaxing our vigilance when the patient is improving we need to double it, for then he is willing to take more chances than he would have taken at a time when his symptoms made him aware of his danger. All this means, however, that the patient must be under continuous observation, and a single misstep or deviation from the proper course can be followed by relapse which it may take weeks, and months, to overcome, or which, indeed, may prove itself an irretrievable loss. Near relatives are seldom reliable enough to so take charge of a patient, especially if the case is a severe one; they are only too apt to regard the patient's desires. and entreaties in a more or less hazardous direction, and it is difficult for them to say "no" in matters the importance of which they, as well as the patient, are apt to underestimate. Thus the ideal management is extremely difficult in private practice, and by no means an easy task in a special institution. By the time a patient has learned from bitter experience all that may prove injurious, he is, as a rule, in an advanced stage, and it takes character, will-power, and self-control of a high degree for a patient to make a smooth and uninterrupted recovery, even when he comes in an early stage. The physician who, however, can have personal control, who can see and observe his patient at all times, whose directions are rigidly complied with by his assistants, and who can so circumstance his patient that harmful influences are practically excluded, has a great advantage, and he gains much valuable experience. Under such care arrest, more or less permanent, of pulmonary tuberculosis may occur without resort to any other treatment, especially in the early and uncomplicated stage of the disease. In the symptomatic treatment of pulmonary tuberculosis almost any therapeutic agent may find rational employment at one time or another during its course of months and years. The limits of this paper forbid their consideration in detail, but so far as we may employ drug remedies, it means often that we are to choose between two evils, and we must, therefore, have good reason to believe that the benefits which experience justifies us in expecting will result, without incidental drug effects, which would prove in the end that our interference has done more harm than good. Upon such consideration rests the symptomatic treatment of all disease, and tuberculosis is no exception. Under the head of general management I should also speak of climatic treatment, which, of all our means, is one of the most important for the arrestment of phthisis. There is, however, nothing specific in climate any more than there is in water or food. Climate is everywhere, and the difference in the purity of the air or in its density, in dryness of the soil, or in temperature, are relative matters, between one locality and another. Clinical benefits result altogether from its influence upon nutrition; and in so far as elevation is also a factor, from its influence upon the circulation, the improvement of which is again a matter of better nutritive processes, both local and general. The employment of climate means that we seek pure air, as free as may be from micro-organisms, from dust and from deleterious emanations of decomposing organic matter; air which is sufficiently dry so that the functions of the skin are under most favorable conditions, in a locality which, by its elevation, improves the circulation, and at which the conditions of temperature. favor an out-of-door life with the resultant better appetite and oxygenation, while with the increased solar effect at elevated places, under a clear sky, we hope to influence the usually deteriorated blood state for the better. That all of these conditions are highly desirable for the phthisical patient I need not dwell upon, nor is it necessary to seek for mysterious specific effects when the explanation of its benefit through nutritive influence is so apparent. Climatic treatment is thus justified in every respect, but it is a serious error to believe that when the best is not within our reach that we are justified in ignoring its rational use in less favorable localities. In If I were treating my patients in New York City, instead of Asheville, N.C., I should still make the climatic treatment a most important part in their general management, and it would here, as there, begin with proper and judicious ventilation of house and room. I would take advantage of the best air I could get, and of every hour of sunshine nature would vouchsafe, while I would protect my patients against unfavorable influences from changes of weather, etc. In the open country still better results would follow, and its good influence through the purer air and the greater out-ofdoor life has been a matter of common observation in places that in nowise can pretend to compare with the climatic conditions of celebrated health resorts. the choice of the latter for phthisical patients I can add little to what has already been stated by Dr. Gleitsmann, and only call your attention to the fact that as far as elevation is concerned a golden mean offers every advantage and none of the disadvantages of sealevel and the high-altitude localities. In the latter the effect of the greatly diminished air-pressure upon the circulation of patients at all beyond the earliest stages has often caused serious disaster, and the extremes of temperature which increase with the elevation, as well as the excessive dryness, are often serious hindrances, rather than benefits for the patient's best welfare. But whatever the climate may be, it cannot protect the patient from errors in his general conduct, and an ideal general management must ever tinue to be the most potent factor in the final results obtained. con From these considerations it naturally follows that comparatively few patients are treated under ideal conditions for their recovery. The insufficiency is attested by the enormous mortality which we witness in pulmonary tuberculosis, and the benefit of such care is shown by the good results obtained in special closed institutions, particularly in such as have the advantages of a favorable climate also. At the very best, however, the arrestment of the disease is often only temporary, the cures are few, and take a long time to accomplish. In no case can we be sure for years to come that the disease is really eradicated, and the possession of a specific germicidal remedy is the desire of all who have to treat tubercular patients. Hoping so much from the use of tuberculin after observing the involution and disappearance of the tubercular tissue and of the specific germs in the animal experiment, the despair which took possession of us when we realized that, owing to the toxic properties of the remedy, a specific for human tuberculosis was yet a matter of the future, is still keenly felt by all of us. Most physicians failed on that account to take advantage of what good there was in the remedy from its use in well-selected cases, in minute, safe doses, and they are now more sceptical than ever as to the possibility of obtaining a safe and true specific germicide. Such a pessimistic position is certainly unjustifiable. On the contrary, the successful animal experiments, as well as the good effects of tuberculin in a great number of well-observed cases of pulmonary tuberculosis still justify the greatest hope for the future. I am not at all prepared to state to you to-night that this hope has been entirely realized, but I am very certain that an important step forward has been taken. Indeed, so far as I have been able to observe from clinical evidence and animal experiment, it appears that the germicidal part of tuberculin is now successfully separated in a substance resembling in its chemical reaction a deuter-pepton, which can be obtained from tuberculin or from the culture-fluid of the tubercle bacillus. With this substance Professor Klebs has made numerous experiments upon animals, and its apparent safety and the success claimed by him and others in its clinical use upon the human subject also, caused me, over a year ago, to make use of it, first in a few of my causes in which tuberculin was not tolerated even in minute doses. Professor Klebs found that the use of this remedy is also followed by involution of the tubercular tissue and by the disappearance of the specific germ in tubercu lar guinea-pigs, the same as he had previously observed it to occur under the use of the crude tuberculin from like doses; he also found that guinea-pigs can bear much larger doses of the remedy than of tuberculin, one-half cubic centimetre of the latter killing such an animal, as a rule, within twenty-four hours, while several cubic centimetres of the purified substance cause no material disturbance in its health. The toxic substances which he separated from tuberculin produced the poisonous effect of the latter, and seemed to exert no curative influence when given in doses under which tuberculin caused the recovery of the pig. I am at this time repeating these experiments, and as far as I have gone, I find the claims of Professor Klebs to be borne out by my results. This would prove that when this substance, now called "antiphthisin" is separated from tuberculin, the latter loses its curative influence upon guinea-pigs, and acts as a poison only, and also, that antiphthisin represents the curative properties of tuberculin, since under its use guineapigs show involution of the tuberculin tissue, outlive the control animals for many months, increase in weight, and recover entirely when the treatment is sufficiently active and applied for a sufficient length of time. It further shows that antiphthisin is non-poisonous in doses much larger than required of tuberculin to cause the death of an animal in twenty-four hours, all of which is certainly an excellent showing for the remedy so far as we deal with guinea-pigs, small animals in which death occurs at an early period from pure non-complicated tubercular disease. In the treatment of human tuberculosis, while the animal experiment is of great value, it is not justifiable to assume that the same result would necessarily follow; first, because human tuberculosis follows, as a rule, a much slower course, the tubercular disease having existed perhaps for months, or even years, before distinct symptoms of its presence make their appearance; and we cannot hope to apply the remedy a short definite time after infection. It is only exceptionally that we have opportunity to treat our patients before caseation, fibroid changes, and other effects have been produced. To get at all analogous conditions for comparison we must expect to find them in cases of acute miliary tuberculosis, but even there it is probable that the general infection had its source in some degenerate gland or local focus from which the germs became liberated. If antiphthisin is a true specific germicide, we can only hope to influence the specific germ by its use, but we cannot expect to reach it except in living tubercular tissue, and its effect under the same dose must be in proportion to the vascularity of the part. In recent tubercular eruption in the lung the remedy should therefore give us the best results, while a cheesy degenerated mass, or a fibroid nodule, would remain entirely uninfluenced. Dead or necrosed tissue represents a foreign body, which, as well as fibroid changes or formed cavities, are results of tuberculosis, and cannot be made to disappear from the use of a germicidal remedy which can only remove the cause. The coagulation of the protoplasm in the still living cells of tubercular tissue is caused by the specific germ or by its products; under the removal of the cause such cells again return to their normal condition, and Professor Klebs has shown this to occur under the use both of tuberculin and of antiphthisin. This is all we can hope from the most perfect germicide. The destruction of the bacillus of tuberculosis upon open surfaces, therefore upon the surface of cavities and localities where necrosis has already occurred, is necessarily more difficult, because under such conditions the blood cannot exert its germicidal properties, and at most but feebly upon the slightly vascular base, while the growth of the germ upon surfaces to which the air has free access is more rapid and luxuriant. I cannot here follow the possibilities and limitations of a germicide for the bacillus of tuberculosis acting through the blood, the serum of which probably further enhances its effect. Any thoughtful student can do this and find why, for instance, the remedy would be less potent in effect upon the dense, firm, tubercular infiltration in the larynx, and most effective upon recent young tubercular tissue in the lung. While the animal experiment and theoretical considerations in the light of the histological and pathological changes in the disease under consideration are necessary as a basis for all new therapeutical procedures, the clinical results, as we observe them in our patients, must still remain our chief guide for the estimation of the value of a remedy, whatever it may be. Having now a year of such clinical experience behind me, during which I have treated nearly a hundred patients with antipthisin, and having had as good opportunity as a special institution under most careful observation of the patients in the light of a considerable previous experience can afford, I can only say that my conviction as to its clinical value has steadily grown stronger, and that I have uniformly observed favorable changes in the tubercular processes, often to their entire disappearance, in the lungs of my patients, with return to normal conditions, where percussion and auscultation had given every evidence of a pathological state before its application. I have further seen the rapid involution of the tubercle bacilli in the sputum, and their entire disappearance from it while the sputum was still purulent, in early stage cases; I have not observed their return in such sputum upon subsequent examinations when continued until no more expectoration was available. On the other hand, I have seen the persistence of consolidation, or only partial clearing up of the percussion note, or noted no apparent change at all, especially in old lesions and over cavities, and I have explained this by the fibroid changes which were evidently present. In cases with cavity the tubercle bacilli have been much more persistent, and degenerative forms did not appear as early in globular or cavernous sputum. It is similar with the fever, but most encouraging as to the specific effect of the remedy has been its success in acute cases, of which I have had four among my patients. In one case acute and general dissemination had occurred from an older circumscribed focus, in the other three cases only diffused acute processes were present in both lungs, and all four had continuous temperatures between 102° and 105° F. All the patients dated the beginning of their illness from within two months, and severe anæmia, exhaustion, and rapid emaciation were well-marked symptoms. In every one of these cases the fever began to decline within the first two weeks; it soon became intermittent, and after a month or six weeks it was so far controlled that it rarely reached 100° F., while the local and general improvement of the patient was satisfactory in the highest degree. One patient is discharged apparently cured, the three others are still under treatment and are steadily improving. In the early stages of the chronic form I have without exception seen the same favorable course. On the other hand, I found the temperature less influenced in cases which had suppurating cavities, or which presented evidence of cheesy pneumonic processes, with or without apparent softening and progressive destruc = tive changes. The local and general improvement in such cases was, as a rule, less evident, although some portions of the consolidation present cleared up in almost every case treated. In quite a number of such advanced cases the improvement became more manifest as the treatment was continued and led to satisfactory restoration of the general health and apparent arrestment of the local disease justifying their discharge. With this clinical evidence in my own cases, and with corroborating statements by all other practitioners who have used the remedy for a sufficient length of time, I believe that I can conscientiously recommend its trial to the profession, especially since I have seen not the slightest indication of any harmful incidental. effect. In conclusion, I would once more call attention to the necessary limitations of the remedy which suggest themselves from a full consideration of the pathology of tuberculosis, especially of the advanced stages, and which my experience has shown to exist. If we bear these in mind we shall not expect to accomplish the impossible nor shall we be likely to suffer disappoint THE subject submitted to your consideration this evening is of such importance and magnitude that I felt some embarrassment as to how to present it to you without too great a tax on your time and patience. In order to keep the paper within the necessary limits it was found advisable to eliminate all details, and to merely touch upon the salient features of some points which otherwise would deserve a lengthy consideration. By the courtesy of our esteemed President, permission has been granted me to turn over the larger part of the pulmonary therapeutics to my friend, Dr. von Ruck, who, on account of his large experience, enjoys special facilities to do the subject justice. Historical Sketch.-The treatment of laryngeal and pulmonary tuberculosis has undergone such a radical change in the last half of our century, that the advance science has made and the advantages patients have. gained will be better appreciated if you will permit me to devote a few remarks to the development of our present therapeutics of the disease. As long as it was considered doubtful that consumption could be cured, palliative measures were en vogue; equable, warm climates were recommended, among which the Isle of Madeira enjoyed the special favor of our English confrères; the whole treatment was a more passive one, and consisted largely of guarding against injurious influences. About the beginning of the last half of the present century, publications of climatologists appeared in quick succession, stating the decrease of phthisis at high altitudes. Their statements were soon followed and confirmed by those of medical writers, who observed the beneficial effect of a prolonged sojourn in these regions. Among the former I will mention Fuchs, Jourdanet, Hirsch, and Archibald Smith; 5 among the latter, Herman Weber, Charles R. Drysdale, Lombard, and Biermann." In 1854, Brehmer 8 4 1 Read before the Medical Association of the County of New York, March 18, 1895. 2 Fuchs: Medizinische Geographie, Berlin, 1853. 3 Jourdanet: Les Altitudes de l'Amérique tropicale, Paris, 1861. 4 Hirsch Handbuch der historisch geographischen Pathologie, vol. ii., Erlangen, 1862. Smith, A. Climate of the Swiss Alps and the Peruvian Andes compared, Dublin Journal, 1864 and 1866. 6 Weber, H. On the Treatment of Phthisis by Prolonged Residence in Elevated Regions; Transactions Medical and Chirurgical Society, London, 1869. Drysdale: Alpine Heights and Change of Climate in the Prevention and Treatment of Pulmonary Consumption, London, 1869. Lombard: Les Climats des montagnes, Genève, 1873. ⚫ Biermann: Hochgebirge und Lungenschwindsucht, Leipzig, 1874 founded his sanitarium for consumptives at Goerbersdorf, Silesia, and although starting from the wrong premise, that an abnormal smallness of the heart was the principal cause of consumption,1 he obtained excellent results by his method of treatment. Of nine hundred and fifty-eight consumptives treated by him during the first fifteen years, twenty per cent. were permanently cured. His method was based on the principle of tonic and roborant treatment, and consisted of the freest possible use of pure mountain air, proper diet, methodic exercise, and hydro-therapeutics, with such constant supervision of the patient as is only possible in an institution. His success stimulated the foundation of other institutions on similar principles, to which I also committed myself (1874) and adhere to to the present day. 3 About the effects of and the results obtained with tuberculin, tuberculocidin, etc., you will hear in a later part of the paper. Progress in the treatment of laryngeal tuberculosis. was much slower. The words of Tobold, 1866, that "in the majority of cases the prognosis is very unfavorable," were repeated by Mackenzie, 1880,5 who The prognosis of laryngeal phthisis is always extremely unfavorable, and it is not certain that any cases ever recover." The treatment was symptomatic and remained unsatisfactory, although some remedies recommended at this period are still in use at the present time, with varying success. A great advance was made when Krause announced his results obtained by applications of lactic acid. The first series of observations from the lactic-acid treatment in this country was published by the author, in the New York MEDICAL RECORD, 1886. Krause was followed by Heryng, who introduced the surgical treatment as it is now practised. 8 Laryngeal Tuberculosis: Local Applications.-Although careful attention to the general condition of a patient suffering from laryngeal tuberculosis is indispensable, I shall not touch on this part of the treatment, but shall speak of the local treatment only. Disinfecting and anodyne sprays and insufflations are extensively used up to the present day. Intra-laryngeal injections of twenty per cent. menthol in an oily solution were first practised by Rosenberg," and lately an addition of two per cent. of guaiacol to the menthol solution is well spoken of by English authors. In the opinion of the writer, the best results in laryngeal ulceration-aside from curettage-are obtained by the proper and judicious application of lactic acid. In making this statement we must not lose sight of the fact that in laryngeal tuberculosis we have to deal with a most intractable disease, and which until lately was generally regarded incurable. As isolated cases of a spontaneous cure are known to occur, and as relief can be afforded and even an apparent cure effected by different remedies, a long period of observation of the patient and an extended trial with the remedy mentioned is necessary in order to become convinced of its efficacy. Very appropriately the late Gottstein. says in the last edition of his book on diseases of the larynx: "The physician who discards lactic acid after a few unsuccessful trials will not be able to form an unbiassed judgment; only one who uses the method systematically for a longer time will achieve better results with it than with any other method of treatment." 1 Brehmer: Die chronische Lungenschwindsucht, Berlin, 1869, p. 65. Gleitsmann: On the Nature and Curability of Pulmonary Phthisis, Richmond and Louisville Journal, July, 1874. Same: Contribution to the Treatment of Pulmonary Phthisis, New Orleans Medical and Surgical Journal, July, 1877. Tobold: Die chronischen Kehlkopfskrankheiten, Berlin, 1866. > Mackenzie: Diseases of the Throat and Nose, vol. i, London, 1880. Krause: Berl. kl. Wochensch., No. 29, 1885. 7 Gleitsmann: New York MEDICAL RECORD, January 16, 1886. Heryng: Die Heilbarkeit der Larynxphthise, Stuttgart. 1887. Rosenberg: Menthol gegen Tuberculose, Therapeutische Monat., No. 3, 1887. For the introduction of the acid, special instruments have been devised, but an ordinary good laryngeal cotton-carrier will answer the purpose. The acid must be rubbed into the ulcer with a moderate degree of force, and the strength of the solution employed should be gradually increased from twenty to seventy-five or eighty per cent., or even the full percentage. As a rule, an eschar is formed, which, when exfoliated, leaves a clean ulcer, showing a tendency to cicatrization. Contra-indications are a high degree of hectic, far-advanced destruction of lung tissue, or extensive ulcerations of the lower larynx and trachea. The connecting link between local applications and surgical treatment are sub-mucous injections. As lactic acid is only efficacious in the treatment of ulcerations, and does not act on parts covered by intact mucous membrane, infiltrations must be treated in a different manner, and they can be reduced by sub-mucous injections. Quite recently, such injections with. an oily solution of creosote, two drachms to the ounce, have been highly lauded by Dr. Chappell, and if further experiments confirm his results we shall have in creosote a fair rival of lactic acid for this purpose. There is a difference of opinion as to the length of time which should be allowed to intervene between each injection, as well as to the strength of the solution. In my cases I had the best results from injections of five to eight drops of a fifty per cent. solution of lactic acid, which were not repeated until the usually large eschar had sloughed away; this it generally does in from six to ten days. Although ingeniously constructed syringes for this purpose are in the market, an ordinary good syringe, with a properly curved laryngeal attachment and a good point, accomplishes everything that is desired. I have found injections most useful and beneficial in large, clubshaped thickenings of the arytenoids, giving rise to distressing dysphagia, and in such cases, I prefer them as a rule to either curettage or excision, as the latter are much more trying and painful to the usually weak and emaciated patients. Surgical Treatment. We now come to the surgical treatment, which is threefold, consisting of either incision, curettage, or excision. The idea of surgical treatment in laryngeal tuberculosis emanated from the reports of the good results obtained by surgeons in the treatment of tubercular affections in more accessible regions of the body. Incisions into the infiltrated parts, especially in the region of the epiglottis and the aryepiglottic folds, were first practised by Moritz Schmitt,' who observed lessening of the infiltration and subsequent relief in a number of cases. Curettage and excision, by far more frequently employed, especially on the continent, were first practised by Heryng, who, in conjunction with Krause, worked indefatigably to improve this method. Curettage is indicated in ulcerations, while excision is better adapted for infiltrations. By the former the ulcerations are scraped until the diseased tissues are entirely removed, and then lactic acid or iodoform is applied. By excision the infiltrated parts are cut away until healthy tissue is reached. The three sets of instruments I present to you for inspection plainly show the vast improvements that have recently been made in this direction. For operations in the sub-glottic space, Scheinmann's forceps is an excellent instrument. The contra-indications to surgical treatment, as enumerated by Heryng, are, advanced pulmonary disease, diffuse miliary tuberculosis of the larynx, severe stenosis of the larynx, when tracheotomy is indicated, and lastly irritable, distrustful patients, who lack the necessary fortitude and perseverance. It would carry us too far to speak of the technique of operating, or to enter into the literature and controversies which this treatment has elicited among different writers. Sufficient to say that Heryng, who un1 Schmitt, M.: Deutsches Archiv fur klin. Med., 1880, vol. xxvi. |