(e) Succus entericus seems capable of destroying them.

(f) Intestinal bacteria and epithelium also act destructively. III. Parallel to antitoxin may be quoted the oral exhibition of glandular and other organic products such as thyroid and supra-renal, which are given freely and with the best results, and yet there cannot be the slightest doubt that while the glandular portion is digested in the process, the active principle, on which depends the characteristic therapeutic effects of the gland, escapes digestion and goes on unaltered to do its own work in its own way. IV. The skin eruptions produced by the hypodermic use of diphtheria antitoxin, have been proved to be caused by the serum and have nothing to do with the antitoxin. That even this part of the serum is absorbed so unchanged that it produces in suitable cases its characteristic eruption when given orally is proved by cases occurring here and there in my own practice and in that of others using antitoxin orally. And if this part of the serum is absorbed in such a form as to be capable of producing its characteristic symptoms, how much more probable is it that antitoxin is absorbed in an active form. V. Carrier finds that gastric secretion has little effect on antitoxins. With diphtheria antitoxin my experience shows that the change is made as follows:Diphtheria antitoxin hypodermically is specific for the Klebs-Loeffler bacillus, and weak for the septic organisms; orally it is specific for the staphylococcus and streptococcus and weak for the Klebs-Loeffler. The writer has had to give it hypodermically after trying to cure diphtheria with it given orally, and is of opinion that those cases recently reported as diphtheria cured by its oral exhibition were probably largely septic and mildly diphtheritic. VI. Need one add their own experience of three and a half years' hard work, the use of 9,000,000 units of diphtheria antitoxin, the grateful thanks of patients and their united testimony all agreeing with my own observation to prove the worth and value of the remedy in its own peculiar sphere. In that sphere are included erysipelas, peritonitis, appendicitis, acute rheumatic

polyarthritis, puerperal infection, secondary infection in phthisis, traumatisms, bronchopneumonia, abscess suppuration-et hoc genus omne-wherever the staphylococcus and streptococcus are to be found.

The form in which it is now being used in my own practice is to add carmine 8 grs. per zi. to the B.P. solution of tragacanth as a colouring and suspending agent. ing and suspending agent. The formula would then run:

R. Diphtheria Antitoxin, 3000 units.
Trage carmine q.s.
Aq. ad. zii.

=

M. Siq.-Dose 3ss. 750 units-varies from night and morning to every four hours, but the latter is only used in exceptionally severe cases, and it is better to give too much than too little. For erysipelas 3ss. 8tis. horis is usually effective. For acute peritonitis and appendicitis 3ss. at once, 3ss. in two hours, 3ss. four hours later, and afterwards 6tis. to 8tis. now usually does all that is required. For children the full doses may be given, as the antitoxin is harmless, but usually for small children half the dose is quite effectual. In about 1 per cent of the cases either a little kidney irritation or skin eruption may be seen, but they are of the most superficial and fleeting character.

The best way to begin the treatment is to use it in some septic or simple inflammation visible to the eye, as in erysipelas, carbuncle, or traumatism, to reduce inflammation, remove pain, and bring the process to a surprisingly quick end. When the principle has been established in what may be seen it can then be trusted to do its work in what is unseen. The skilful use of it comes only with experience, but the principle can be depended upon and where the diagnosis is correct, and the case within the limits of the treatment the results are more certain than in any other, as no idiosyncrasy of the patient hinders its action, except such as prevents its inception and absorption. It really does not treat the patient, but his unwelcome guests.

Any other suitable treatment may be added as required, but as time goes on and confidence in antitoxin is gained, many of the ordinary adjuncts are discarded, and antitoxin is trusted to do the whole of the work.

Abscess is the great difficulty, and has usually to be incised as in ordinary cases, although by the use of antitoxin its maturation is usually hastened, and many of the constitutional symptoms are abated. If the inflammation be got in time the process can be readily aborted. In this as in all serum treatment the earlier

the case is taken in hand the less antitoxin will be required. Its action orally in septic conditions is exactly parallel with its action hypodermically in diphtheria. Given at the first onset of the disease the infection is promptly met by a comparatively small amount, but if neglected the amount required for cure increases rapidly for each day in which the process is unchecked. There is an exception to this, and that is in a person in which the septic process has run its course to a large extent, and has been met by a natural antitoxin formed more freely in some than in others. In such cases the virulence of the infection has been greatly modified, and nature requires only a small reinforcement to effectually expel the enemy. Such conditions arise only in those cases in which the virulence of the infection and the antitoxin-forming reaction in the patient, are of such a nature as to allow the patient a chance to fight the disease. As this exception only happens after a long and serious struggle with the disease, common sense should lead us to prevent or promptly treat all such cases in their earliest stages. The remarkable results obtained by Wernicke and Behring on this point emphasise what has been said. Using diphtheria virus they found that given an amount of antitoxin necessary to antidote a lethal dose of diphtheria virus if given at the same time, eight hours afterwards 10 times the amount of antitoxin, and 24 hours afterwards 50 times would be required to antidote the dose. Although the staphylococcus and streptococcus are not usually so rapid in their growth as the Klebs-Loeffler, yet they increase rapidly enough, and in very virulent cases, unless promptly treated, they act so quickly that the patient dies completely overwhelmed by the infection. It stands to reason that a local peritonitis will require less than the same attack when it has become general and the principle holds good all through.

The question is not is it ridiculous? is it revolutionary is it unheard of? but is it true? Nothing but actual test is of any value in settling the question, for no such use of antitoxin is on record for such diseases. It is no use quoting accepted opinions on the subject; they are only theory, and do not touch the matter in hand. Actual trial will soon settle the question, and the writer is prepared to stand or fall by the results. The statements made are based on actual facts, and if they contradict theories so much the worse for the theories if the facts are right. To test the matter let any one take a case of erysipelas, acute peritonitis (local or general), acute or chronic appendicitis,

or carbuncle, use diphtheria antitoxin alone as directed, only feed the patient and attend to his secretions-no poulticing or anything of the kind-and let the results settle the question. Of course where there are collections of pus they will require incision, and it will affect no other infection than the staphylococcus or streptococcus. If such others are present, then the treatment will eliminate the septic and leave the others behind.

The question is of such tremendous importance that anything claiming even to influence the septic infection demands the immediate and careful attention of the profession in all lands.

Many men ask me how does diphtheria antitoxin do what is claimed for it, and seem to think that until that question is answered the treatment is outside the range of practical therapeutics. Nothing could be more ridiculous than such an idea. Frankly, I do not know, and we certainly know practically nothing about how the different sera act; we only know that they do so, and, as in hypodermic use of the serum for diphtheria, give it, get the results, and wait patiently for the explanation as to how it is done. True, Ehrlich has a theory which, if true, and it has to be proved, would explain fairly well the action of all such antitoxins; but it has yet to be proved, and the writer for one is in no great hurry for the explanation, so long as he can get the practical results in the treatment of disease. Like Jenner, who had been in his grave for close on a century before any feasible explanation of his work could be given, he is quite content to leave to his grandson or great-grandson the task of solving the problem, satisfied to know that he can in the meantime reap the benefits of the discovery.

Suppose such a theory was applied to medicine in general, viz., that we use no treatment until we know precisely and scientifically how it did the work peculiar to it, how much would we have left? The practical man who is really desirous of helping his patients uses all means which have been proved to do the work required, without waiting for science to explain the why. He is just as pleased as any other when the explanation comes, but takes the present benefit whenever he can get it.

The writer will be glad to answer any questions of a practical nature which may trouble any practitioner giving antitoxin a trial in his own practice, that is, as far as his experience with the remedy will enable him to do so.

The difficulty is not with the prescription, but with the choice of cases suitable for the treatment, etc. Rules for this will gradually be

found, but the writer is of opinion that it will be at least ten years before the profession have thoroughly mastered what is nothing less than a revolution in therapeutics. The serum used in all the work has been Burroughs, Wellcome and Co.'s Liquid Antitoxin, and can be had for 2s. 6d. per 2,000 units. The experiences of the last three years and a half, with plenty of clinical illustrations, are now being collated, and will be published as early as the exigencies of a busy practice will allow.

THREE CASES OF SYPHILIS.

bone, but beyond that were of no assistance to the diagnosis. The teeth were carious, the eyes clear, and the fauces clean.

A thorough life history of the case was necessary, and this I presently got from the mother. The patient was born in India, and was the second child-the first being a premature which lived three months. She was breast fed by the mother for two or three weeks, when, the mother getting "fever," she was wet-nursed by a native woman for three months. From her birth," she apparently had difficulty in breathing fully through her nose when sucking, for she used to let go the breast

parton, Victoria.

THE recorder of cases of a common disorder should be able to claim that something may be learnt from them. The cases here recorded cannot claim to teach us much about that common disorder of which we think we know so much but of which we really know so little, syphilis. They may be worthy of record as showing some of its vagaries, and also as a reiteration of the need of care in diagnosis. But I claim the apology that syphilis is not a common disorder -in a country practice it is rare. My average is hardly more than a case per annum, and it will be noticed that the three cases here recorded were really imported cases.

The first case was that of a young lady at. 19, who came to me about a lump on her arm which had been swelling steadily for two or three weeks. This lump, which was on her right ulna, just above the wrist, was an ugly, purplish, highly-inflamed swelling about the size of a flattened bantam's egg, involving the bone, and apparently about to break down, and yet not painful, and hardly tender-in fact, a typical gumma. The mere idea of such seemed absurd on the face of it in such a person of such a family. She was a big, strong girl, the eldest of five strapping, well-built children of a rather strikingly handsome couple, socially of the first water of the district. However, in the course of the examination, I noticed her breath was ozanatous, and her skin very muddy, and I learnt that during the previous five years, many similar lumps had arisen in different parts of her limbs, burst, and discharged as running sores; that she had been eight times under chloroform for operations upon these various sores, and that on one of these occasions amputation of a leg had been advised by two of the doctors present, but had not been agreed to by the third. The scars of these old sores and wounds showed that they had all affected the

It

He

her mouth open." When four months old, she had " blood-poisoning" with sores round the mouth and between the fingers." After this cleared up, all went well till she was thirteen years old, when abscesses occurred from time to time on her legs, arms or hands. For one of these, "a periosteal abscess of tibia," she was operated upon in Madras. She then came to Australia and the trouble continued as already stated. Such a case forced its own diagnosis. But there was still a doubt whether it might not have been acquired from the wetnurse. This was a delicate point, as the parents had apparently no idea of the nature of the trouble beyond it being "bone disease." To clear this point I broached my diagnosis to the father, and asked for enlightenment. was a great shock to him. But he manfully told me he had contracted a venereal sore with buboes, which suppurated and healed under treatment, ten years before his marriage. was assured he was cured, and had had no further signs of any sort since. But before he married, to make sure, he consulted two doctors, who again assured him there was no danger. So much for the history. The diagnosis was confirmed by the healing of the gumma under medical treatment. And the last I heard of the patient was that she was well in every way except for the ozæna, and that it was very difficult to induce her to continue her treatment. The second case was a simple matter of physical diagnosis. A young farmer, æt. 36, consulted me about a lump on his liver. had been a bit of a globe-trotter, and frankly told me that he had had syphilis eight years before, for which he had been treated in London and pronounced cured. No after effects or reminders had come, but for the last 12 months or so he had been very bilious and "livery," and had to be very careful about his diet and drink, and he had just found out this lump on his liver. On examination the lump

He

was found just below the rib margin, was smoothly rounded, and apparently fluctuating. The liver was enlarged, and its margin was felt below the tumour. There was no pain or tenderness. Beyond the drawn, "livery," appearance of the face, no other sign of disease could be found. The further history was that for the last five years he had been knocking about Australia-mining, droving, jackarooing, and farming-in fact, getting what is known as "colonial experience." The question was-Is the tumour syphilitic or hydatid? I could not say. But as there was no urgency, and the patient was about to take a trip to England, I advised a course of anti-syphilitic treatment, and heard later that the tumour completely disappeared.

The third case was that of a big, strong, young man who had just returned from West Australia. He consulted me about a swelling of his right knee. While examining this, which was much swollen with fluid in the sac, and "boggy" round about, I noticed some suspicious looking spots on his leg, and on making a further examination I found the other knee in a similar but less marked state, and a fairly typical maculo-squamous rash all over his body. There was a soft ulcerating chancre on the corona, enlarged glands in each groin, and oedema of each leg. Temperature normal, but pulse 96, and respiration 24. And on examining the lungs, the base of the right lung gave all the signs of congestion.

Course. During the next few days, the œdema increased to a general anasarca, both knee joints became tensely distended, the skin pitted readily on pressure all over the body, and the swelling became so great in the neck and lower part of the face that at one time breathing became very difficult. The temperature ranged between 100° F. and 102°, the pulse never above 96. No fluid could be found in abdominal or thoracic cavities, but the pneumonic signs increased in the lung. The urine solidified on heating.

Treatment. The excretions were all forced, and patient was mercurialized to salivationunintentionally-and on the 11th day, the dropsy had all gone, the lungs were clear, temperature normal, and the trouble was over, but patient was extremely pulled down, and it took him three weeks to convalesce. A course of treatment was then advised.

The Premier of Victoria has endorsed the recommendation of the Board of Public Health that two sites be set apart at different parts of the State as sanatoria for comsumptives, and has asked the Board to report on suitable localities.

A CASE OF CESAREAN SECTION. By James T. Mitchell, M.D., Ballarat.

CESAREAN section is still so comparatively rare an operation as to make every case worth recording. Wide divergence of opinion continues to exist among medical practitioners as to the advisability of the operation and nothing but the most extreme necessity will bring men to feel that the risk is justifiable. For this, of course, statistics are responsible. The rate of mortality has, undoubtedly, in the past been very high, as we would naturally expect it to be in an operation tried often as a last resort, and most frequently after hours of exhausting labour with or without manipulative assistance. Not only has the operation been performed upon women in this exhausted condition, but it has been undertaken by men who had not previously performed or even witnessed the operation. And further, the whole thing has frequently been hurriedly prepared for and undertaken at inconvenient hours with but imperfect aseptic precautions. The mortality of these unfavourable cases has naturally pulled down the average of successful results from those performed under more suitable conditions, and hence the public, as well as the the medical profession, has looked askance at Cæsarean section. And yet, under suitable conditions, the death rate ought to be but very little higher than that in an ordinary laparotomy, unless Porro's operation be performed, which adds greatly to the risk of simple delivery. Zinke, in a late number of the American Gynecologic and Obstetric Journal, gives some figures which indicate that Cæsarean section ranks high as a means of saving life, provided that the time, place, and method be as carefully selected as they would for any other important operation. On collecting statistics from a large number of European and American authors he finds that the average mortality for the mother is 4 per cent. and for the child 13 per cent. When Porro's operation is undertaken, the mortality rises to 38 per cent. for the mother, and 22 per cent. for the child.

L.W., single, aged 34 years, primipara, an unhealthy cripple was admitted to the lying in ward of the Ballarat Benevolent Asylum on November 11th, 1901, expecting to be confined in a week or ten days. She had, in the previous June, been an in-patient at the Ballarat Hospital under treatment for hip-joint disease, and had been examined under chloroform by Drs. Pinnock and Scott, who found her pregnant, and the pelvis so contracted as to

cause them to inform her that she could never be delivered of a full term child. On examination in the lying-in ward the pelvis was found very considerably contracted generally, the outlet being especially restricted, as the pubic arch was of the male type. The left hip joint had very limited movement, and a sinus was open on the front of the thigh, communicating with the joint. The left leg was three inches shorter than the right. Drs. Holthouse and Jordan agreed with me that the case was one in which section was advisable, and offered the best chance for the mother as well as the child. On November 17th, at 7 a.m., I sterilized the vagina, and inserted a bougie into the uterus. At 2.30 p.m. the os was dilated to two fingers' breadth. I therefore ruptured the membranes and drew off the liquor amnii. Dr. Richards then administered chloroform, and Dr. H. A. Bennett assisted me in the operation. The abdominal incision was to the right of the mid line, and extended from beside the umbilicus to two inches above the pubes. The abdomen was packed with large flat sponges, above and each side of the uterus. The womb was opened longitudinally on its anterior surface, and in the middle third of its length. This was done rapidly without any attempt to check the rather sharp hæmorrhage. As soon as this incision was complete, Dr. Bennett dragged the wound open by a finger hooked into each end. This effectually controlled all bleeding. There was not much difficulty in picking up the legs and delivering the child by the breech. The placenta did not quickly separate, so it was peeled off, and the uterus immediately douched with hot saline fluid, which was allowed to flow away by the vagina. By this means there was no escape of fluid into the abdomen, either liquor amnii or uterine hæmorrhage. bleeding having ceased and the organ being well contracted, eleven silk sutures were inserted deeply almost through to the mucous membrane. Ten shallow silk sutures were then placed between these, and the whole twentyone were buried by a fine, continuous chromic gut suture in the peritoneum, which was dragged over from each side, thus making the peritoneal envelope complete. On withdrawing the three flat sponges, they were found to be dry and clean. The abdominal parietes were then completely approximated in three layers with chromic gut and silkworm gut. The temperature rose slightly for three or four days, but there was never any trouble with the lochia, constipation, distention, or other drawback, except two stitch abscesses in the skin layer, which remained open for nearly three weeks.

All

The child, which was a healthy, well-formed female, was nursed by the mother, assisted by one of the other inmates of the institution, and she made good progress. On the twenty-first day a well-fitting abdominal belt was applied, and the patient was permitted to get out of bed, being finally discharged to her home two weeks later.

On reviewing the case I feel perfectly satisfied that the right course was adopted in stopping short of Porro's operation, but I regret that I did not ligature the tubes and remove portions of them so as to cause a permanent occlusion. Further reading at leisure has convinced me that, in patients without uterine disease where the pelvic contraction is the only reason for section, this simple device is all that is necessary. Being free from danger, and occupying but a few minutes, this addition to the risk is practically nil.

THE VALUE OF THE DIAGNOSTIC SIGNS OF SUPPURATION IN THE MAXILLARY ANTRUM.

By H. Russell Nolan, M.B.,

Clinical Assistant to the Throat Department at Prince Alfred Hospital, Sydney; late Clinical Assistant at the Golden Square Hospital for Diseases of the Throat, London.

A CONSIDERABLE number of signs and symptoms, indicative of this condition, have accumulated, which may, according to St. Clair Thomson1, be classed as Presumptive, Probable, and Certain. These may be briefly stated, as follows:

1. Presumptive.-The presence of pus in the maxillary antrum may be presumed if there bea. Unilateral nasal discharge.

b. Intermittence in discharge.

c. Pain-infra-orbital, supra-orbital, dental, or
more distant.

d. Subjective cacosmia-intermittent.
e. Carious teeth.

f. Pus in the middle meatus (canary-yellow in
colour-Tilley)

g. Polypi in the middle meatus.

h. Hypertrophy in the middle meatus (swelling of the mucous membrane covering the Uncinate process).

2. Probable. This presumption may be turned into probability if there are any, or all, of the following signs:

a.

Re-appearance of pus on cleansing the middle meatus and bending the head down (Fraenkel). b. Trans-illumination, showing opacity of the pupil (Heryng).

e. Trans-illumination, showing obscurity of the pupil (Davidsohn)

d. Trans-illumination, showing absence of subjective sensation of light (Burger).

1. Lecture at London Polyclinic on the Accessory Nasal Cavities