In order to determine the relation be tween forms of the Klebs-Loeffier bacil lus and the severity of the disease, twenty-seven cases studied. The follow ing conclusions submitted: 1. The short Klebs-Loeffler apparently produces a toxin of greater virulence than the longer forms, although local manifestations may not be so extensive. 2. The long Klebs-Loeffler bacillus and the strepto cocci when found alone (together) give rise to a mild type of the disease. 3. The streptococcus is found associated with the short bacillus in the most se vere cases; possibly by causing a more intense inflammatory reaction it opens avenues by which the toxins of both are more readily absorbed. 4. The beneficial a.ction of antitoxin in cases in which the Klebs-Loeffler bacillus is not present may be due to the fact that, although the local effect of different microbes varies, there are many features of similarity in the constitutional sytnptoms produced by them. 11T. J. Class (Jour. Amer. Med. Assoc., Apr. 30, '93).
The streptococcus and the diphtheria bacillus enhance each other's virulence, and diphtheria antitoxin has no effect after septicmmia has developed. Hence the necessity of beginning antitoxin treatment at the first indication of diph theria infection, before the streptococcus has had time to get in its work and increase the virulence of the diphtheria bacillus and to be reciprocally affected. P. Hilbert (Deut. med. Woch., Apr. 14, '98).
The method. of administration of the antitoxin and its mode of action are such that it in no way interferes with the use of any other form of treatment that may be regarded beneficial. Being given hypodermically, it does not disturb the stomach or interfere with feeding or medication. Fish, of St. Louis, has re cently reported experiments going to prove that antitoxin given by mouth is effective. Similar experiments made by Park gave negative results. It is doubt ful whether any advantage would be gained if it were possible to introduce the antitoxin in this way.
Antidiphtheria serum given by the mouth bas proved eminently satisfactory in nine cases. The effect was quite as good as if the serum had been given hypodermically, and no evil results fol lowed,—no gastric disturbance, no skin eruption, and no joint or renal affection. Before deciding a.s to the dose required, however, further experience is desirable. In the first five cases the dose given was the same as would have been given hypodermically. De Minicis (Gaz. degli Osped., July 19, '96).
For curative purposes the administra tion by the mouth should be restricted to exceptional eases; but for prophy lactic purposes this method should re ceive the preference. J. Zahorsky (N. Y.
Med. Jour., Mar. 19, '9S).
Laryngeal stenosis may call for further treatment. The general testimony is that antitoxin exerts a marked, in some cases a marvelous, influence upon diph theritic stenosis. It is also agreed that since the general use of antitoxin a greater percentage of laryngeal cases have escaped operative interference than were before, and of those finally operated upon a greater number had recovered.
The triumph of antitoxin has been that of intubation as well. (See INTIMATION.) Tracheotomy has practically passed out of use in diphtheritic stenosis of the larynx.
Many forms of treatment were for merly combined with the use of antitoxin, but, as the power of the antitoxin has been more fully demonstrated, the tend ency to rely upon it has become stronger. At the present time, apart from the general treatment—diet, rest, etc.—after giving antitoxin we confine our efforts to the careful cleansing of the nose and throat and the use of stimu lants.
Advantages of intubation in diph theria.. It is rapid and requires no anms thetic; there is no operation; the res piration takes place through the nat ural openings. In these days of anti toxin, if there is skilled assistance to refy on during the absence of the opera tor, it has enormous advantages over tracheotomy, but these quickly disappear when skilled assistance is absent, and it must not be forgotten that tracheotomy tubes can now be removed after a much shorter period than formerly. Hughes (Scottish 3Ied. and Surg. Jour., June, '97).
There is still some doubt as to the method of taking out the tube after intubation. There are disadvantages at tending the thread method, and espe cially becaus.e the fixing of the tubes thus produced does not allow of its free play, and hence causes erosion of the parts. The extractor, on the other hand, is hardly possible in private practice, as a sudden stoppage of the tube by mem brane may cause suffocation unless the tubc can be withdrawn without delay; it also requires considerable skill, espe cially where a small tube sinks deeply into the larynx. Where attempts at extraction cause a small tube to sink farther down, pressure with the thumb on the trachea, just below the cricoid ca.rtilage, where the end of the tube can be felt; the cough thus produced forces the tube out. This method of expression never fails. The pressure may be made with both thumbs, tbe finger finding support on the neck; it should be di rected inward and directly upward. If more powerful pressure is exerted, the tube may be forced, not only into the mouth, but even completely out of it. No disadvantages attend this method. Trumpp (Munch. med. Woch., Jan., '98).