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responding period in 1894. A very marked diminu- 250 gm. against ten times a fatal dose of diphtion in the death percentage from diphtheria is appar- theria toxin, while one of our immunized horses furent. That the diminution is not greater, is probably nishes a serum which, according to the last test made due to the fact that most of the serum available in of it, was sufficient in a quantity of gevo c.c. to imJanuary and during a part of February was weak and munize a guinea-pig against ten times the fatal dose of was not generally used. The mortality for March thus diphtheria antitoxin. Expressed in antitoxin units this far is much lower.

statement would be as follows: In connection with the subject I would like to call

Antitoxin normal attention to a new antitoxin syringe made by Tiemann & Co., after my design, and illustrated by the ac- 20 c.c. Behring's No. 3 contains...

2,600 to 3,200

20 c.c. Board of Health's strongest serum contains companying cut, which does not, I think, have any of

4,400 the objectionable features of the ordinary syringe. The

The full antitoxin strength that the serum of the difficulty of cleansing the ordinary syringe is very great,

horse can be made to develop varies in different aniand is due to the packing of the piston, which is gen

mals. The animal which produced the serum to which erally of leather, and to the leather washers used to

I have alluded has developed an extraordinary degree make the end of the barrel air-tight. Koch's syringe of immunity. is really the only thoroughly good syringe from the

The number of immunized animals at present in the stand-point of cleanliness, i.e., ease of sterilization, but

Health Department Laboratory stables is thirty. The the instrument is difficult to handle and is liable to in

amount of antitoxin capable of being produced by ject air with the serum. My syringe consists simply of

them is about forty thousand c.c. per month. a glass barrel (A) graduated in c.c., containing 10 c.c.,

I desire to place on record here my appreciation of open at one end and ground to a fitting at the other.

the services of Dr. Hermann M. Biggs, of the Health The ground end fits a needle (D) Department, especially in connection with the produchaving a hard-rubber shoulder.

tion of antitoxin in this country. By Dr. Biggs's reThe piston (B) is in one piece, quest the Board of Health detailed him, in May, 1894, the plunger extremity being a lit

to study the subject in the laboratories abroad. Shortly tle smaller than the diameter of

after his arrival in Berlin he wrote letters fully describthe barrel of the syringe. A disk of

ing the new remedy and its great promise. He also rubber (C) or tightly woven cloth

wrote directions to his assistant, Dr. William H. Park, of suitable thickness is placed over

to prepare the necessary toxin, so as to be ready to be. the open end of the syringe and

gin at once, on his arrival, to administer it to animals. the plunger inserted. The rubber,

To Dr. Biggs more than to any other man is due the
which may be cut from an ordi-

early introduction of antitoxin into the United States.
nary 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 or- MODERN TREATMENT OF LARYNGEAL AND
dinary hypodermic syringe. Be-

fore using the syringe the rubber

and the entire syringe should be

sterilized by means of hot water.
I have also had Messrs. Tieman In presenting some of my observations in the treat-
apply this principle to the ordi- ment of pulmonary tuberculosis I may say that, in my

nary hypodermic syringe, and the experience, the general management of the patient has C.C.

result is extremely satisfactory. proven itself of such importance that, without its cor

A metallic case or box is pro- rect application, there is little, if any, prospect for sucvided to hold the syringe and

cess. No matter what measures we may otherwise emdisks. The ordinary velvet-lined syringe case is an ploy, the faulty conduct of the patient, his unhygienic abomination, and should never be used in connection environment, or his dietetic errors cause him to relapse with any hypodermic syringe, still less with any syringe so frequently from any benefit our therapeutic measused for the administration of antitoxin. The case for

ures may have brought about, that the course of the the syringe should be as easily disinfected as the syringe disease is, as a rule, a downward one, in spite of all the itself. The wooden cases now generally provided for remedies which we employ. antitoxin syringes cannot be sterilized by means of heat,

The general management must therefore be considwhich in this connection is the only perfect disinfectant. ered the foundation for the superstructure of sympto

An instructive paper might be written on the subject matic and direct treatment, and the fundamental prinof the introduction of antitoxin in the United States. ciple which in its application should govern us at all

. Such a paper would illustrate forcibly the great inter- times and under all circumstances is, ** To secure and est taken by the laity in medical matters, and their ap- maintain the highest possible degree of general and preciation of the valuable discovery in question. It

local nutrition." In order to secure it in all directions was this interest and appreciation that made it possible

we must not only have enough of good, well-cooked for the Board of Health to obtain the necessary appro- food, but we need also good digestion, assimilation, priations to extend the facilities of its bacteriological oxidation, and .excretion, which to obtain and to mainlaboratory so as to produce the serum, and that caused tain we must look into our patient's whole mode of the New York Herald to give the project such effec- life, and control it wherever necessary ; we must learn tive aid by its support and the large sum of money it his good and bad habits, and his tendencies to errors ; collected through popular subscription. The outcome examine into the healthfulness and function of all the has been the rapid production of antitoxin, so that at

rest of his organs and correct everything that is posthe present writing the Board of Health can easily sup- sible toward getting the greatest amount of vitality and ply the State of New York from its surplus of serum, physical vigor, by which we increase the inherent forces with sufficient to treat all the cases of diphtheria that of the organism for successful resistance to the disease. occur during the ordinary prevalence of the disease. Much of this serum is equal to the excellent prepara

To this end we should not only understand the patholtion known as “ Behring's No. 3,” and some of it is general and special pathology and physiology in their

ogy and course of pulmonary tuberculosis, but also even stronger and better. As I have stated in another relation and effects to health and disease. part of this paper, Behring's preparation No. 3 requires isoy to toto c.c. to immunize a guinea-pig weighing

* Read by invitation before the County Medical Association of New York, March 18, 1895.


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The physician who can bring the greatest amount of partial or complete exposure to sudden variations of such special and general knowledge to his case, must temperature, or to draughts and the like, are all imporof necessity be the most successful (providing he also tant matters for watchfulness and proper advice; and makes painstaking application of the same). Failure instead of relaxing our vigilance when the patient is is practically certain for him who does not appreciate improving we need to double it, for then he is willing the great influences exerted by the individual physical to take more chances than he would have taken at a condition of the patient, especially through the organs time when his symptoms made him aware of his danof circulation, digestion, assimilation, and excretion, ger. All this means, however, that the patient must be upon disease in general, and upon the course of pul- under continuous observation, and a single misstep or monary tuberculosis in particular,

deviation from the proper course can be followed by In considering these influences it would be next to relapse which it may take weeks, and months, to overimpossible to anticipate every abnormal condition an come, or which, indeed, may prove itself an irretrievindividual patient may present, but the more impor- able loss. tant and most frequent indications I will endeavor to Near relatives are seldom reliable enough to so take outline by a short review of my own practice.

charge of a patient, especially if the case is a severe Excepting cases in the earliest stages, when I take one; they are only too apt to regard the patient's desires charge of a patient I order rest in bed, stopping all and entreaties in a more or less hazardous direction, previous medication, and observe the course of the dis- and it is difficult for them to say “no” in matters the ease for a day or two, during which I make such importance of which they, as well as the patient, are changes in diet and the patient's mode of life as seem apt to underestimate. Thus the ideal management is to be indicated. I also look after the condition of the extremely difficult in private practice, and by no means skin ; begin with baths or cold rubbing, examine the an easy task in a special institution. urine, the sputum, the blood-obtain a record of the By the time a patient has learned from bitter expetemperature, pulse, and respiration ; and, with a full rience all that may prove injurious, he is, as a rule, in physical examination after having taken the previous an advanced stage, and it takes character, will-power, history, I am now ready to consider the evidence before and self-control of a high degree for a patient to make me and to form an opinion as to what my patient's a smooth and uninterrupted recovery, even when he condition really is. The future management depends comes in an early stage. The physician who, however, entirely upon what I have found. If the patient is can have personal control, who can see and observe his practically free from fever, or if fever is absent for the patient at all times, whose directions are rigidly comgreater part of the day, constant confinement in bed plied with by his assistants, and who can so circumwould not only be unnecessary, but would otherwise stance his patient that harmful influences are practiinterfere with the patient's best interests. According cally excluded, has a great advantage, and he gains to his strength, he is allowed to be up during the hours much valuable experience. Under such care arrest, when the temperature is not elevated, and must be out more or less permanent, of pulmonary tuberculosis may of doors, either at rest there, or taking such exercise as occur without resort to any other treatment, especially his physical condition would warrant to risk, without in the early and uncomplicated stage of the disease. incurring any sense of fatigue or shortness of breath. In the symptomatic treatment of pulmonary tubercuThe amount of the exercise is controlled by its effect losis almost any therapeutic agent may find rational upon the circulation and upon the fever, and an in- employment at one time or another during its course crease is only allowed cautiously and gradually. Un- of months and years. The limits of this paper forbid less the digestiv organs are deranged the patient is

their consideration in detail, but so far as we may emallowed a liberal mixed diet, which is supplemented by ploy drug remedies, it means often that we are to milk between the meals, if necessary. If the tempera- choose between two evils, and we must, therefore, have ture record at any time shows elevation above 100° F. good reason to believe that the benefits which expethe patient must go to bed and remain there until the rience justifies us in expecting will result, without incitemperature has declined, and he must anticipate the dental drug effects, which would prove in the end that probable rise on the following day by retiring at least our interference has done more harm than good. one hour earlier. During fever hours the diet is light, Upon such consideration rests the symptomatic treatthe feeding more frequent. Hearty meals of meats, ment of all disease, and tuberculosis is no exception. eggs, and coarser vegetables, if given shortly before, or Under the head of general management I should during fever, are very apt to increase it or invite its also speak of climatic treatment, which, of all our means, recurrence. The patient receives a cold rub every day is one of the most important for the arrestment of phthibefore rising ; but subnormal temperatures require cau

sis. There is, however, nothing specific in climate any tion in this respect, and it is best to wait with the bath more than there is in water or food. Climate is everyuntil a normal temperature is reached, the patient re- where, and the difference in the purity of the air or in maining in bed until then.

its density, in dryness of the soil, or in temperature, are If the case is of an acute character, or if complica- relative matters, between one locality and another. tions occur, with continuous fever, every attempt to

Clinical benefits result altogether from its influence treat such a case without absolute rest in bed interferes upon nutrition ; and in so far as elevation is also a with the arrestment of acute symptoms, and, as a rule, factor, from its influence upon the circulation, the imdefeats the chances for improvement or recovery. In provement of which is again a matter of better nutrisuch cases we apply massage or electricity, or both, and tive processes, both local and general. substitute therewith the desirable exercise, while in The employment of climate means that we seek pure suitable weather we bring the bed near the windows air, as free as may be from micro-organisms, from dust for the direct exposure of the patient to sunlight and

and from deleterious emanations of decomposing orout-of-door air. Absolute rest in bed is also impera- ganic matter ; air which is sufficiently dry so that the tive during complications like pneumonia, pleurisy, or functions of the skin are under most favorable condihemorrhage, and they must have entirely subsided be- tions, in a locality which, by its elevation, improves the fore the patient is allowed to be up and take exercise. circulation, and at which the conditions of temperature

In all other ways the general management is con- favor an out-of-door life with the resultant better apstantly endeavoring to keep the patient from all harm- petite and oxygenation, while with the increased solar ful influences on the one hand, while taking advantage

effect at elevated places, under a clear sky, we hope to of everything, little as it may appear, toward keeping influence the usually deteriorated blood state for the him in the best possible condition, on the other. Ex- better. ercise, amusements, or light occupation, reading, men- That all of these conditions are highly desirable for tal states, clothing, position in sitting or reclining, the phthisical patient I need not dwell upon, nor is it

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necessary to seek for mysterious specific effects when from tuberculin or from the culture-fluid of the tuber: the explanation of its benefit through nutritive influ- cle bacillus. With this substance Professor Klebs has ence is so apparent. Climatic treatment is thus justi- made numerous experiments upon animals, and its fied in every respect, but it is a serious error to believe apparent safety and the success claimed by him and that when the best is not within our reach that we are others in its clinical use upon the human subject also, justified in ignoring its rational use in less favorable caused me, over a year ago, to make use of it, first in a localities.

few of my causes in which tuberculin was not tolerated If I were treating my patients in New York City, in- even in minute doses. stead of Asheville, N.C., I should still make the climatic Professor Klebs found that the use of this remedy is treatment a most important part in their general man- also followed by involution of the tubercular tissue and agement, and it would here, as there, begin with proper by the disappearance of the specific germ in tubercuand judicious ventilation of house and room. I would


lar guinea-pigs, the same as he had previously observed take advantage of the best air I could get, and of every it to occur under the use of the crude tuberculin from hour of sunshine nature would vouchsafe, while I like doses; he also found that guinea-pigs can bear would protect my patients against unfavorable influ- much larger doses of the remedy than of tuberculin, ences from changes of weather, etc.

In the open

one-half cubic centimetre of the latter killing such an country still better results would follow, and its good animal, as a rule, within twenty-four hours, while influence through the purer air and the greater out-of- several cubic centimetres of the purified substance door life has been a matter of common observation in cause no material disturbance in its health. The toxic places that in nowise can pretend to compare with the substances which he separated from tuberculin proclimatic conditions of celebrated health resorts. In duced the poisonous effect of the latter, and seemed to the choice of the latter for phthisical patients I can exert no curative influence when given in doses under add little to what has already been stated by Dr. Gleits- which tuberculin caused the recovery of the pig. mann, and only call your attention to the fact that as I am at this time repeating these experiments, and far as elevation is concerned a golden mean offers as far as I have gone, I find the claims of Professor every advantage and none of the disadvantages of sea- Klebs to be borne out by my results. This would prove level and the high-altitude localities. In the latter that when this substance, now called "antiphthisin" is the effect of the greatly diminished air-pressure upon separated from tuberculin, the latter loses its curative the circulation of patients at all beyond the earliest influence upon guinea-pigs, and acts as a poison only, stages has often caused serious disaster, and the ex- and also, that antiphthisin represents the curative tremes of temperature which increase with the eleva- properties of tuberculin, since under its use guineation, as well as the excessive dryness, are often serious pigs show involution of the tuberculin tissue, outlive hindrances, rather than benefits for the patient's best the control animals for many months, increase in welfare. But whatever the climate may be, it cannot weight, and recover entirely when the treatment is sufprotect the patient from errors in his general conduct, ficiently active and applied for a sufficient length of and an ideal general management must ever con- time. It further shows that antiphthisin is non-poisontinue to be the most potent factor in the final results ous in doses much larger than required of tuberculin obtained.

to cause the death of an animal in twenty-four hours, From these considerations it naturally follows that all of which is certainly an excellent showing for the comparatively few patients are treated under ideal remedy so far as we deal with guinea-pigs, small aniconditions for their recovery. The insufficiency is mals in which death occurs at an early period from attested by the enormous mortality which we witness pure non-complicated tubercular disease. in pulmonary tuberculosis, and the benefit of such care In the treatment of human tuberculosis, while the is shown by the good results obtained in special animal experiment is of great value, it is not justifiable closed institutions, particularly in such as have the to assume that the same result would necessarily foladvantages of a favorable climate also. At the very low ; first, because human tuberculosis follows, as a best, however, the arrestment of the disease is often rule, a much slower course, the tubercular disease havonly temporary, the cures are few, and take a long time ing existed perhaps for months, or even years, before to accomplish. In no case can we be sure for years to distinct symptoms of its presence make their appearcome that the disease is really eradicated, and the ance; and we cannot hope to apply the remedy a short possession of a specific germicidal remedy is the desire definite time after infection. It is only exceptionally of all who have to treat tubercular patients.

that we have opportunity to treat our patients before Hoping so much from the use of tuberculin after caseation, fibroid changes, and other effects have been observing the involution and disappearance of the produced. tubercular tissue and of the specific germs in the ani- To get at all analogous conditions for comparison we mal experiment, the despair which took possession of must expect to find them in cases of acute miliary us when we realized that, owing to the toxic properties tuberculosis, but even there it is probable that the gen. of the remedy, a specific for human tuberculosis was eral infection had its source in some degenerate gland yet a matter of the future, is still keenly felt by all of or local focus from which the germs became liberated.

Most physicians failed on that account to take If antiphthisin is a true specific germicide, we can advantage of what good there was in the remedy from only hope to influence the specific germ by its use, but its use in well-selected cases, in minute, safe doses, and we cannot expect to reach it except in living tubercuthey are now more sceptical than ever as to the possi- lar tissue, and its effect under the same dose must be bility of obtaining a safe and true specific germicide. in proportion to the vascularity of the part. In recent Such a pessimistic position is certainly unjustifiable. tubercular eruption in the lúng the remedy should On the contrary, the successful animal experiments, as therefore give us the best results, while a cheesy dewell as the good effects of tuberculin in a great num- generated mass, or a fibroid nodule, would remain enber of well-observed cases of pulmonary tuberculosis tirely uninfluenced. Dead or necrosed tissue represtill justify the greatest hope for the future.

sents a foreign body, which, as well as fibroid changes I 'am not at all prepared to state to you to-night or formed cavities, are results of tuberculosis, and canthat this hope has been entirely realized, but I am very not be made to disappear from the use of a germicidal certain that an important step forward has been taken. remedy which can only remove the cause. Indeed, so far as I have been able to observe from The coagulation of the protoplasm in the still living clinical evidence and animal experiment, it appears cells of tubercular tissue is caused by the specific germ that the germicidal part of tuberculin is now success- or by its products; under the removal of the cause fully separated in a substance resembling in its chemi- such cells again return to their normal condition, and cal reaction a deuter-pepton, which can be obtained Professor Klebs has shown this to occur under the use

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both of tuberculin and of antiphthisin. This is all we tive changes. The local and general improvement in can hope from the most perfect germicide.

such cases was, as a rule, less evident, although some The destruction of the bacillus of tuberculosis upon portions of the consolidation present cleared up in alopen surfaces, therefore upon the surface of cavities most every case treated. In quite a number of such and localities where necrosis has already occurred, is advanced cases the improvement became more maninecessarily more difficult, because under such condi- fest as the treatment was continued and led to satisfactions the blood cannot exert its germicidal properties, tory restoration of the general health and apparent arand at most but feebly upon the slightly vascular base, restment of the local disease justifying their discharge. while the growth of the germ upon surfaces to which With this clinical evidence in my own cases, and the air has free access is more rapid and luxuriant. with corroborating statements by all other practitioners

I cannot here follow the possibilities and limitations who have used the remedy for a sufficient length of
of a germicide for the bacillus of tuberculosis act- time, I believe that I can conscientiously recommend
ing through the blood, the serum of which probably its trial to the profession, especially since I have seen
further enhances its effect. Any thoughtful student not the slightest indication of any harmful incidental
can do this and find why, for instance, the remedy effect.
would be less potent in effect upon the dense, firm, In conclusion, I would once more call attention to
tubercular infiltration in the larynx, and most effective the necessary limitations of the remedy which suggest
upon recent young tubercular tissue in the lung. themselves from a full consideration of the pathology

While the animal experiment and theoretical consid- of tuberculosis, especially of the advanced stages, and
erations in the light of the histological and pathological which my experience has shown to exist. If we bear
changes in the disease under consideration are neces- these in mind we shall not expect to accomplish the
sary as a basis for all new therapeutical procedures, the impossible nor shall we be likely to suffer disappoint-
clinical results, as we observe them in our patients, must ment.
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 MODERN TREATMENT OF LARYNGEAL
which I have treated nearly a hundred patients with AND PULMONARY TUBERCULOSIS.
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 convic-

The subject submitted to your consideration this evention as to its clinical value has steadily grown stronger,

ing is of such importance and magnitude that I felt and that I have uniformly observed favorable changes

some embarrassment as to how to present it to you in the tubercular processes, often to their entire disap

without too great a tax on your time and patience. In pearance, in the lungs of my patients, with return to

order to keep the paper within the necessary limits it normal conditions, where percussion and auscultation

was found advisable to eliminate all details, and to had given every evidence of a pathological state before merely touch upon the salient features of some points its application.

which otherwise would deserve a lengthy consideration. I have further seen the rapid involution of the tuber

By the courtesy of our esteemed President, permission cle bacilli in the sputum, and their entire disappearance

has been granted me to turn over the larger part of the from it while the sputum was still purulent, in early pulmonary therapeutics to my friend, Dr. von Ruck, stage cases; I have not observed their return in such

who, on account of his large experience, enjoys special sputum upon subsequent examinations when continued

facilities to do the subject justice. until no more expectoration was available. On the other

Historical Sketch.—The treatment of laryngeal and hand, I have seen the persistence of consolidation, or

pulmonary tuberculosis has undergone such a radical only partial clearing up of the percussion note, or noted change in the last half of our century, that the advance no apparent change at all, especially in old lesions and

science has made and the advantages patients have over cavities, and I have explained this by the fibroid gained will be better appreciated if you will permit me changes which were evidently present.

In cases with

to devote a few remarks to the development of our cavity the tubercle bacilli have been much more per

present therapeutics of the disease. As long as it was sistent, and degenerative forms did not appear as early

considered doubtful that consumption could be cured, in globular or cavernous sputum. It is similar with palliative measures were en vogue ; equable, warm clithe fever, but most encouraging as to the specific effect

mates were recommended, among which the Isle of of the remedy has been its success in acute cases, of

Madeira enjoyed the special favor of our English conwhich I have had four among my patients.

frères ; the whole treatment was a more passive one, In one case acute and general dissemination had oc

and consisted largely of guarding against injurious incurred from an older circumscribed focus, in the other

fluences. About the beginning of the last half of the three cases only diffused acute processes were present

present century, publications of climatologists appeared in both lungs, and all four had continuous tempera

in quick succession, stating the decrease of phthisis at tures between 102° and 105° F. All the patients dated

high altitudes. Their statements were soon followed the beginning of their illness from within two months,

and confirmed by those of medical writers, who oband severe anæmia, exhaustion, and rapid emaciation

served the beneficial effect of a prolonged sojourn in were well-marked symptoms. In every one of these

these regions. Among the former I will mention cases the fever began to decline within the first two

Fuchs, Jourdanet, Hirsch,' and Archibald Smith ; 5 weeks ; it soon became intermittent, and after a month

among the latter, Herman Weber," Charles R. Drysor six weeks it was so far controlled that it rarely dale, Lombard, and Biermann." In 1854, Brehmer reached 100° F., while the local and general improve

Read before the Medical Association of the County of New York,

March 18, 1895. ment of the patient was satisfactory in the highest degree. 2 Fuchs': Medizinische Geographie, Berlin, 1853. One patient is discharged apparently cured, the three 3 Jourdanet : Les Altitudes de l'Amérique tropicale, Paris, 1861. others are still under treatment and are steadily im

= + Hirsch: Handbuch der historisch geographischen Pathologie, vol. ii., Erlangen, 1862.

5 Smith, A. : Climate of the Swiss Alps and the Peruvian Andes In the early stages of the chronic form I have with- compared, Dublin Journal, 1864 and 1866. out exception seen the same favorable course. On the

6 Weber, H.: On the Treatment of Phthisis by Prolonged Resi

dence in Elevated Regions ; Transactions Medical and Chirurgical Soother hand, I found the temperature less influenced in ciety, London, 1869. cases which had suppurating cavities, or which pre

? Drysdale : Alpine Heights and Change of Climate in the Prevensented evidence of cheesy pneumonic processes, with

tion and Treatment of Pulmonary Consumption, London, 1869.

* Lombard: Les Climats des montagnes, Genève, 1873. or without apparent softening and progressive destruc- • Biermann : Hochgebirge und Lungenschwindsucht, Leipzig, 1874







1 1





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founded his sanitarium for consumptives at Goerbers- For the introduction of the acid, special instruments dorf, Silesia, and although starting from the wrong

have been devised, but an ordinary good laryngeal premise, that an abnormal smallness of the heart was cotton-carrier will answer the purpose. The acid must the principal cause of consumption,' he obtained ex- be rubbed into the ulcer with a moderate degree of cellent results by his method of treatment. Of nine force, and the strength of the solution employed should hundred and fifty-eight consumptives treated by him be gradually increased from twenty to seventy-five or during the first fifteen years, twenty per cent. were per- eighty per cent., or even the full percentage. As a manently cured. His method was based on the prin- rule, an eschar is formed, which, when exfoliated, ciple of tonic and roborant treatment, and consisted of leaves a clean ulcer, showing a tendency to cicatriza. the freest possible use of pure mountain air, proper tion. Contra-indications are a high degree of hectic, diet, methodic exercise, and hydro-therapeutics, with far-advanced destruction of lung tissue, or extensive such constant supervision of the patient as is only pos- ulcerations of the lower larynx and trachea. sible in an institution. His success stimulated the The connecting link between local applications and foundation of other institutions on similar principles, surgical treatment are sub-mucous injections. As to which I also committed myself (1874) and adhere to lactic acid is only efficacious in the treatment of ulcerto the present day.2.3 About the effects of and the ations, and does not act on parts covered by intact results obtained with tuberculin, tuberculocidin, etc., mucous membrane, infiltrations must be treated in a you will hear in a later part of the paper.

different manner, and they can be reduced by sub-muProgress in the treatment of laryngeal tuberculosis cous injections. Quite recently, such injections with was much slower. The words of Tobold, 1866,4 that an oily solution of creosote, two drachms to the ounce, "in the majority of cases the prognosis is very unfa- have been highly lauded by Dr. Chappell, and if furvorable," were repeated by Mackenzie, 1880,5 who ther experiments confirm his results we shall have in says : The prognosis of laryngeal phthisis is always creosote a fair rival of lactic acid for this purpose. extremely unfavorable, and it is not certain that any There is a difference of opinion as to the length of cases ever recover."

time which should be allowed to intervene between The treatment was symptomatic and remained un- each injection, as well as to the strength of the solusatisfactory, although some remedies recommended at tion. In my cases I had the best results from injecthis period are still in use at the present time, with tions of five to eight drops of a fifty per cent solution varying success. A great advance was made when of lactic acid, which were not repeated until the Krause announced his results obtained by applications usually large eschar had sloughed away; this it genof lactic acid. The first series of observations from erally does in from six to ten days. Although ingenthe lactic-acid treatment in this country was published iously constructed syringes for this purpose are in the by the author, in the New York Medical Record, market, an ordinary good syringe, with a properly 1886. Krause was followed by Heryng, who intro- curved laryngeal attachment and a good point, accomduced the surgical treatment as it is now practised. plishes everything that is desired. I have found in

Laryngeal Tuberculosis : Local Applícations.-Al- jections most useful and beneficial in large, clubthough careful attention to the general condition of a shaped thickenings of the arytenoids, giving rise to patient suffering from laryngeal tuberculosis is indis- distressing dysphagia, and in such cases, I prefer them pensable, I shall not touch on this part of the treat- as a rule to either curettage or excision, as the latter ment, but shall speak of the local treatment only. are much more trying and painful to the usually weak Disinfecting and anodyne sprays and insufflations are and emaciated patients. extensively used up to the present day. Intra-laryngeal Surgical Treatment.—We now come to the surgical injections of twenty per cent, menthol in an oily solu- treatment, which is threefold, consisting of either intion were first practised by Rosenberg,' and lately an cision, curettage, or excision. The idea of surgical addition of two per cent. of guaiacol to the menthol treatment in laryngeal tuberculosis emanated from the solution is well spoken of by English authors. In the reports of the good results obtained by surgeons in the opinion of the writer, the best results in laryngeal ul- treatment of tubercular affections in more accessible ceration-aside from curettage-are obtained by the regions of the body. Incisions into the infiltrated parts, proper and judicious application of lactic acid. In especially in the region of the epiglottis and the ary. making this statement we must not lose sight of the epiglottic folds, were first practised by Moritz Schmitt, fact that in laryngeal tuberculosis we have to deal with who observed lessening of the infiltration and subsea most intractable disease, and which until lately was quent relief in a number of cases. Curettage and exgenerally regarded incurable. As isolated cases of a cision, by far more frequently employed, especially on spontaneous cure are known to occur, and as relief

the continent, were first practised by Heryng, who, in can be afforded and even an apparent cure effected conjunction with Krause, worked indefatigably to imby different remedies, a long period of observation of

prove this method. Curettage is indicated in ulcerathe patient and an extended trial with the remedy tions, while excision is better adapted for infiltrations. mentioned is necessary in order to become convinced By the former the ulcerations are scraped until the disof its efficacy. Very appropriately the late Gottstein eased tissues are entirely removed, and then lactic acid says in the last edition of his book on diseases of or iodoform is applied. By excision the infiltrated parts the larynx : “ The physician who discards lactic acid

are cut away until healthy tissue is reached. after a few unsuccessful trials will not be able to The three sets of instruments I present to you

for form an unbiassed judgment; only one who uses the inspection plainly show the vast improvements that method systematically for a longer time will achieve have recently been made in this direction. For operabetter results with it than with any other method of tions in the sub-glottic space, Scheinmann's forceps treatment.”

is an excellent instrument. The contra-indications to 1 Brehmer: Die chronische Lungenschwindsucht, Berlin, 1869, p.

surgical treatment, as enumerated by Heryng, are,

advanced pulmonary disease, diffuse miliary tuber65.

Gleitsmann: On the Nature and Curability of Pulmonary Phthi- culosis of the larynx, severe stenosis of the larynx, sis, Richmond and Louisville Journal, July, 1874.

when tracheotomy is indicated, and lastly irritable, Same: Contribution to the Treatinent of Pulmonary Phthisis, New Orleans Medical and Surgical Journal, July, 1877.

distrustful patients, who lack the necessary fortitude * Tobold: Die chronischen Kehlkopfskrankheiten, Berlin, 1866. and perseverance. Mackenzie: Diseases of the Throat and Nose, vol. i., London,

It would carry us too far to speak of the technique 1880. • Krause: Berl. kl. Wochensch., No. 29, 1885.

of operating, or to enter into the literature and contro* Gleitsmann: New York MEDICAL RECORD, January 16, 1886. versies which this treatment has elicited among dif• Heryng: Die Heilbarkeit der Larynxphthise, Stuttgart, 1887. Rosenberg : Menthol gegen Tuberculose, Therapeutische Monat.,

ferent writers. Sufficient to say that Heryng, who unNo. 3, 1887.

Schmitt, M, : Deutsches Archiv fur klin. Med., 1880, vol. xxvi.

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