is commenced at once, the reduction of the mortality is considerable. The Report of the American Pediatric Society gives results which are superior to those obtained by any other observers. Thus, while the Metropolitan Asylums Board found that the percentage of mortality between the ages of two and five was 33.5 per cent., for the same ages the American Society found a mortality of 14-7 per cent. Under two years of age their mortality was 23-3 per cent., as compared with 51.1 per cent. of the Metropolitan Asylums Board. These statistics are drawn from the private practice of 615 different physicians in widely separated localities, hence the possible influence of local conditions can be excluded, and the personal bias of individual members of the profession can also be eliminated. In comparing the results obtained in private practice with those from hospital treatment, it must be remembered that the former undoubtedly include many milder cases, and that the children are generally better able to face the dangers of the later stages of the disease by being in a better state of nourishment and development. The class of cases in which the improvement effected by antitoxin appears to be the most noteworthy are those in which the diphtheria affects the larynx. I have previously referred to the improvement in the results obtained from intubation since the introduction of antitoxin, and it is satisfactory to find that the American observers agree in stating that antitoxin checks the rapid spreading of the membrane downward in the respiratory tract, hence in the cases in which they have performed intubation they have obtained a mortality of 25.9 per cent. as against a previous mortality of 51.6 per cent. before the use of antitoxin. They have also found that over a half of the laryngeal cases do not require any operation at all, and this must undoubtedly be laid to the credit of antitoxin in checking the spread of the disease and favouring the detachment of membrane. A similar improvement in cases of laryngeal stenosis has been noted by Zuppinger in his report upon 160 cases treated with antitoxin at the Crown Prince Rudolf Children's Hospital in Vienna. In twelve out of fifty-one cases the laryngeal stenosis improved, and operative interference was averted; while in the previous year forty-five out of fortysix laryngeal cases required operation. It is somewhat doubtful whether the occurrence of various forms of diphtheritic paralysis is in any way influenced by the employment of antitoxin. The cases which have come under my observation since the employment of this treatment have been remarkably free from paralytic affections. Recently I have seen some paralysis of the soft palate and slight loss of power in the forearms in a nurse who had been treated with antitoxin; but, so far as children in the hospital are concerned, paralytic sequelæ have been absent from the records. We were able at one time to collect nearly all the cases which had been treated with antitoxin at the Evelina, some six months after they had left the hospital, and none of the children exhibited any paralytic affections at the time when they were examined, and, so far as the parents' accounts can be trusted, they had been free from any trouble since leaving the hospital. Still, the returns of the Metropolitan Asylums Board indicate that while 403 cases. (13.2 per cent.) of diphtheritic paralysis occurred in 1894, 732 (20-7 per cent.) occurred during 1895, when antitoxin was being employed. The Report of the American Society states that trustworthy data could only be obtained in 3,384 cases, and of this number there were paralytic sequelæ in 328 cases, or 9.7 per cent. Of the 2,934 cases which recovered, paralysis was present in 276, or 9.4 per cent.; of the 450 cases which died, paralysis was noted in 52, or 11.4 per cent. It must be remembered that statistics are frequently fallacious, and that in attempting to estimate the value of antitoxin, before satisfactory comparison can be made, we require to have some measure of the strength of the antitoxin employed. The different forms of serum supplied by different makers seem to vary considerably in efficacy, and when we consider that many practitioners have hesitated to use the dose recommended for adults, it will at once be seen that the statistical method is not satisfactory. Even the strength of the serum supplied from the same source has in many cases been altered; thus the serum supplied by Behring at the present time is considerably stronger than that which was originally introduced. Mode of administration. The serum can be injected in any place where the subcutaneous tissue is loose. Some have recommended that it should be injected into the buttock, others into the flank, but my own practice has been to inject sometimes into the subcutaneous tissues over the thigh, sometimes over the abdominal wall. The syringes employed must be of somewhat large size, and it is advisable that they should be able to be readily detached so that every portion may be disinfected by boiling. The syringe usually employed holds about 25 c.c., and the washer of the plunger is made of asbestos so that it can be tightened up when within the tube by means of a screw at the end of the piston rod. A piece of indiarubber tubing is sometimes employed to connect the needle with the nozzle of the barrel, and this has the advantage of permitting slight movement of the patient without additional pain. If the operation is performed with care, the use of this indiarubber tubing is not necessary. It is only when the serum is rapidly injected that patients experience any pain beyond that produced by the prick of the needle. Before using the serum it is advisable to wash the skin thoroughly, first with soap and water, and then with a solution of carbolic over the site of the puncture, and this, if the serum exudes, Dosage. It is most important to remember that the date of the disease when the patient first comes under observation. In hospital practice doubtless the tendency has been to employ relatively large doses owing to the delay which commonly occurs before the children are brought to the hospital. In broad terms it may be said that it is always better to begin with a fairly large dose, and to employ a smaller dose later if necessary. As above indicated, the amount given must also vary with the potency of the serum employed. Much disappointment has arisen from attempts to compare results obtained with different preparations which vary in strength, and much of the doubt which has been expressed as to the value of the treatment has probably arisen from an attempt to regulate the dose according to the age of the patient. It is also probable that disappointing results have followed from the disinclination to use the seemingly large bulk of fluid recommended in the earlier days of the introduction of antitoxin. There is no doubt a prejudice in favour of the smaller doses by the hypodermic method of administration. Practitioners have been so much in the habit of employing hypodermic doses of from one to five minims, that the dose of 10 or even 20 c.c. is regarded with feelings akin to dismay. These doses are no longer necessary, though they were frequently employed when the serum was first introduced. With improved methods of preparation it has been found possible to produce serum of greater potency, and it has also been found possible to express the degree of potency in terms of immunising power without reference to the absolute volume of serum; that is to say, that the strength of the serum is expressed in terms of its protective value upon guinea-pigs injected with such a dose of toxin as to be fatal in twenty-four or thirty-six hours to a control animal. The Report to the American Pediatric Society recommends that for a child over two years old the dose |