the patient begins to move about, the eye should be protected from injury by some sort of a shield or mask. Fuchs uses the wirewoven protector pictured in Fig. 11, and in FIG. II. troduced as long ago as 1883. There are many modifications of this mask in the market, one of the best of which has been suggested by Würdemann. (See Fig. 4.) Certain operators who make use of the roller bandage gain protection by starching the dressing. When this has dried, the eye will receive a considerable blow without injury. Snellen has lately used a turtle-shaped aluminium shield (Fig. 9), about ten centimeters long and five wide, placed over the eye and held in position with strips of adhesive plaster; it forms an admirable protector. One of the best shields I am acquainted with is the papier maché half-mask (Fig. 10), which when carefully adjusted to the nose and surrounding parts makes a light, comfortable and effective protector. A small proportion of patients object to wearing any sort of mask, claiming that it prevents them from sleeping and makes them nervous. In such cases I find that one may very well get along with a large, stiff and very concave eye-shade placed over the dressing and held in place with a piece of rubber plaster (Fig. 8). I am in favor of always removing the bandage and looking at the eye twenty-four hours after the extraction. The corneal wound is now either altogether healed over, especially if a conjunctival flap has been made, or if not the danger of prolapse of the iris has generally passed. That is to say, if no iridic hernia has occurred at the end of twenty-four hours, it is not likely to occur at all from any cause, except from violent sneezing, coughing, direct traumatism, etc. In cases of uncomplicated cataract-removal the lids at the end of twentyfour hours are not discolored or edematous. From a glance at them, one can generally predict the condition of the eye beneath. The discharge on the bandage should be watery only (or contain little mucus) and ought not to be copious. The main object, however, of the inspection is to determine the position of the iris. If prolapse has occurred, now is the best time to deal with it. The eye should be gently bathed with boric acid solution, and any mucus, vaselin or ointment washed off the lids and cilia. This should be daily repeated. Solutions instilled into the eye must be neutral or slightly alkaline to test-paper, and always warmed. When the corneal wound is healed and the anterior chamber re-established, the ordinary bandage may be dispensed with. I am in the habit of substituting for it a concave monocular eye-shade which, while touching the brow, cheek, and nose, is clear of the eyelashes. This is worn loosely over the eye during the day, and at night is kept in place by a small strip of adhesive plaster, as in Fig. 8. In a week or ten days one may usually dispense with any dressing or protection whatever, particularly where the patient remains indoors. On what day should the patient be allowed out of bed? In all ordinary cases twentyfour hours is long enough for him to maintain absolute rest. Still avoiding sudden movements he may then be allowed to sit up in an arm-chair and even to move about in the room, and so gradually regain his wonted liberty. After forty-eight hours the bowels should be moved by an enema, and more solid food is to be added to the diet list. Common sense will dictate when and under what circumstances the subject of cataractextraction should be allowed to venture out of doors. If exercise be taken in a close carriage, he may, with the eye wearing an ordinary shade, be allowed out, even in severe weather, as early as the end of the second week; when the day is comfortably warm and there is no wind blowing, walks may be taken with impunity. There should be absolutely no use of the eyes for a month, when glasses should be allowed for distance; when the patient is accustomed to these, lenses for near work may be prescribed. ANTI-DIPHTHERITIC SERUM AND LOEFFLER'S SOLUTION, WITH A REPORT OF TWENTY-SIX CASES. BY BURT RUSSELL SHURLY, B.S., M.D., It is a well recognized fact that diphtheria is the most fatal and treacherous of the contagious diseases. Within the past nine months 675 cases have been reported in this city, with a mortality of 175, or 25.9 per cent. During the same space of time sixty-one of these cases have been under treatment at Harper Hospital, with a death-rate of eight, or 13.1 per cent. Diphtheria has a hospital mortality throughout the world of twenty to seventy-five per cent., being twenty per cent. greater than the death-rate from smallpox among the unprotected. In view of these facts, corroborated by general statistics, we are able to show a reduction in the percentage of mortality over previous hospital records, and we report in detail our methods of treatment from the time the patient is admitted until he is discharged. We shall lay aside all pathological and theoretical considerations and endeavor to demonstrate the results of clinical study and observation. Before patients are received in the contagious wards at Harper Hospital the ambulance surgeon takes a detailed history of the symptoms. In some cases the facts cannot be elicited, through lack of sufficient observation on the part of friends or relatives, but when possible we thus obtain a continuous record of the case. On admission the patient is isolated at once, the pulse and temperature recorded, blood-serum cultures from the exudate taken, and a thorough examination of the throat made. The clinical symptoms of the case are now noted in detail. Special observations are made and recorded on the character of the exudate, and the various socalled tests applied. The culture tubes are removed to the incubator in our own laboratory, and a culture sent to the bacteriological department of Parke, Davis & Co. for supplemental verification. The patient is now taken in charge by the head nurse; the clothes removed to the disinfecting-room; the patient wrapped in heavy blankets, and a sponge bath immediately given. Meanwhile the regular hospital treatment is ordered, together with any additional medication the symptoms may indicate. This consists in the first place in a careful systematic dietary, for the most part of milk, together with liquid beef peptonoids, Mosquera's beef-jelly, broths, soups, gruels, eggnoggs, etc. These are alternated every two hours, according to the taste of the patient, and additions are made as may be necessary. Along the line of therapy we have endeavored to follow the most modern methods of treatment and to combat the progressive character of the disease from the local and systemic standpoints. After eight years of careful investigation and experimental study by the hospital staff in the therapy of these cases, during which time we have run the gamut of pharmacopoeial preparations, the combined hospital treatment is generally accepted by the local physicians as highly satisfactory in its results, and I cannot too strongly express my confidence in its efficacy and favorable influence. The anti-diphtheritic serum has demonstrated remarkable results, especially in cases of laryngeal stenosis requiring intubation and tracheotomy. Medication. In the use of anti-diphtheritic serum the neglect of local disinfectants is not justifiable, as our first indication in treatment is to prevent or limit the growth of bacteria in the throat. The regular hospital treatment includes first the application of Loeffler's Solution, manufactured by Parke, Davis & Co., according to the formula of the celebrated Dr. Loeffler. It contains: Menthol, 10 grammes; Toluene, q. s. ad 36 Cc.; Then add: Creolin, 2 Cc.; Solution chloride of iron, 4 Cc.; A small piece of absorbent cotton is neatly wrapped around a long wire applicator and saturated with the solution. The pledget is then firmly pressed against the exudate for ten to twenty seconds. This procedure is repeated at intervals of three or four hours, night and day. Each application is followed in twenty minutes by irrigation of the throat and nose with our mixture, containing: Peroxide of hydrogen, I part; Dobell's Solution, or aqua calcis, 3 to 5 parts. The thorough irrigation of the mucous membrane in this manner is of the greatest importance, affording a practical method of antiseptic treatment which limits the local development of the bacteria and secondarily the absorption of the toxalbumins, with the concomitant constitutional effects. This we have made of the first importance in connection with the treatment of this disease, and in seventy-three consecutive cases (mild epidemic) treated by these local antiseptics we had four deaths only, one case being moribund at the time of admission. We next direct our therapy toward combating and neutralizing the absorption products of the toxalbumins. Where the disease is attended by swelling and edema of the lymphatic glands of the neck we endeavor to control the inflammation by the use of an ice-bag or ice-collar. Strychnine, quinine and spiritus frumenti are administered in large doses to meet the indications of constitutional disturbance. On admission to the hospital all well marked or moderately severe cases are given an hypodermic injection containing 10 Cc. anti-diphtheritic serum No. 1 (1500 or 1000 immunizing units, Behring's standard), prepared in the bacteriological laboratory of Parke, Davis & Co. It is with the greatest confidence that we administer this remedy in the early stages of the disease. The skin and the hypodermic syringe being first made aseptic by the use of a five-per-cent. carbolicacid solution, followed by sterilized water, the antitoxin is slowly injected into the subcutaneous tissue of the buttocks, back, or abdomen. Observations are made hourly on the temperature, pulse, respiration, and the character of the exudate. Cases not showing marked improvement, and those of a laryngeal type, are given a second dose of 10 Cc. six to twelve hours later. Observations are now recorded as before, and the same dose of 1000 units repeated, followed by a fourth in twelve hours, according to the indications. Every case should be treated as early as possible. We never postpone the treatment for bacteriological verification, as we believe the most valuable time is often lost in this way. The great value of the remedy seems to be manifested by using it in sufficient quantity. Our results show no deleterious effects when pushing the antitoxin to three or four, or even five inoculations, but on the other hand we find a positive limitation in the progressive character of the exudate, as well as marked decrease in the amount of systemic infection. With this general outline of treatment as carried out in Harper Hospital, I present a report of twenty-six cases there treated, showing results and conclusions which I trust will aid in the demonstration of the power and specific influence of serum treatment in cases of diphtheria: CASE I.-L. L., female, age seventeen years; admitted to Harper Hospital at 5 P.M. March 29; temperature 101.2°, pulse 92. Had been complaining of malaise, headache, fever, dysphagia, and anorexia, for twenty-four hours. On examination, tonsils, pillars of the fauces, uvula, and posterior wall of the pharynx, were found covered with a thick, grayish exudate, only a small passage remaining between the right tonsil and uvula; neck swollen; cervical glands greatly enlarged, especially on the left side; fetid odor to breath: Klebs-Loeffler bacillus present. Irrigations of hydrogen peroxide and Euthymol, equal parts, followed by topical treatment with Loeffler's Solution; one-half hour later the throat was irrigated with Seiler's Solution. This was repeated every two hours. Ice-collar ordered to neck, and milk diet every two hours. One hour after admission, and forty-eight hours after the disease had developed, temperature being 101.2° and pulse 90, 12 Cc. of anti-diphtheritic serum (1000 immunizing units) were injected hypodermically in the dorsal region of the back. Two hours later, temperature was 101.2°; at 12 midnight, 100.2°; at 4 A.M., 100°; at 8 A.M., 99.2°—a fall of two degrees in fourteen hours. At 2 P.M., temperature being 99.4°, a second injection of 12 Cc. serum was made in the back, with the following temperature reaction: Two hours later, 99.6°; four hours, 100.4°; eight hours, 100°; twelve hours, 100.2°. Ninety-two hours after exudate was first discovered and twenty-four hours after second injection, temperature being 100°, 2.5 Cc. of serum were given hypodermically, between the shoulders; two hours later, 4 P.M., temperature was 100°; at 8 P.M., 101°; at 12 midnight, 99.8°. During the first thirty-six hours, patient showed marked constitutional effects from the rapid absorption of the toxalbumins; vomiting, marked prostration, languor, restlessness and mild delirium developed. It was necessary to give nourishment through a catheter passed back into the lower pharynx. Twenty hours after first injection of serum a large piece of membrane was detached, when deglutition became less difficult. Thirty hours after first injection and ten hours after the second, hyperemia was considerably subdued; six ounces of milk taken without the tube. March 31, thirty-six hours after first injection, bright red rash observed on buttocks and calves of legs, continuing for twelve days. Swelling much reduced, deglutition much less painful; large patches of membrane detached during the morning. Third injection, of 70 minims, given at 2 P.M.; at 8 P.M. more difficulty in swallowing was noticed; slept well. During the next four days, patient improved rapidly; patch of membrane reduced in size; April 3, had paralysis of the palate, slight regurgitation. On the tenth day the pulse dropped from 72 to 54; felt weak, with pain CASE II.-C. M., age three years; admitted at 5 P. M. April 28; axillary temperature 100°, pulse 118; objective and subjective symptoms well marked; Loeffler bacillus present; exudate covering both tonsils, steadily progressing to pharynx and naso-pharynx. Had been developing about forty-eight hours; pulse very irregular and weak, showing rapid absorption. Spray of Dobell's Solution three parts, hydrogen peroxide one part, water two parts. Loeffler's Solution applied every three hours. With temperature 100°, pulse 130, about twenty-four hours after admission, 10 Cc. of anti-diphtheritic serum were administered, with the following effect on the temperature: One hour later, 100.6°, pulse 136; two hours, 100.8°, pulse 128; three hours, 101°, pulse 128; four hours, 100.8°, pulse 120; five hours, 100.6°, pulse 116; seven hours, 99°, pulse 120; eleven hours, 99.6°, pulse 116; fifteen hours, 98.8°, pulse 104. The condition of the throat continued to improve daily; the progressive character of the exudate was lost after two days' treatment; exudate disappeared ten days after admission; no albumin, paralysis, or rash developed. Recovery uneventful. CASE III.-C. W., girl, age nine years; admitted 3.30 P.M. May 26; temperature 101.2°, pulse 108. pulse 108. Had been subject to frequent attacks of tonsillitis, which the onset of this attack simulated in every clinical feature during the first two days. The persistent and progressive character of the exudate on the second day made diagnosis doubtful, and a bacteriological examination revealed the presence of Loeffler bacilli and streptococci. On admission, two and a half days after onset, case was marked by abundance of membraneformation over tonsils, uvula, posterior pillars, and pharyngeal wall; subjective symptoms were severe vomiting, restlessness, prostration, delirium, enlarged cervical glands, fetid breath. Quinine sulph., 3 grains every three hours, ordered, with the regular hospital treatment; spiritus frumenti; strychnine sulph. On the fourth day of the disease 10 Cc. anti-diphtheritic serum (1500 units) were injected, temperature being 100.6°, pulse 84; four hours later, temperature 100°, pulse 84; eight hours, temperature 99.2°, pulse 72; twelve hours, temperature 99.6°, pulse 72; temperature 98.8°, pulse 72. off in pieces, and progressive character lost; throat clear eight days after admission; recovery uneventful; no albumin or paralysis. Discharged eleven days after admission. sixteen hours, Exudate came CASE IV.-S. K., age ten years; admitted at 2 P.M. June 6, first day of the disease; temperature 100°, pulse 96. Examination on admission showed a grayish exudate on both tonsils; uvula swollen; throat hyperemic; Klebs-Loeffler bacillus present. Regular hospital treatment was adopted. Twenty-four hours after, patient complaining of sore throat, with a temperature of 98.6°, pulse 88, 10 Cc. (1500 units) of antidiphtheritic serum were administered, with the following effect on temperature: Three hours after, 99.4°, pulse 98; seven hours, 99.8°, pulse 84; eleven hours, 98.6°; fifteen hours, 100°, pulse 100; nineteen hours, 99.6°, pulse 94. Sixteen hours later temperature reached normal, where it remained during convalescence. Membrane improved gradually every day, a few shreds remaining on the fourth day; throat clear on the seventh day. Slight epistaxis during convalescence. Albuminuria developed five days after admission; no paralysis. CASE V.-G. A., girl, age three years; admitted July 30; temperature 98.6°, pulse 108. Usual symptoms of invasion began about thirty-six hours prior to admission. Exami |