PHILADELPHIA LETTER [SPECIAL CORRESPONDENCE OF THE MEDICAL FORTNIGHTLY.] Golden Anniversary of the A. M. A.-History Repeating Itself—New Medical PHILADELPHIA, PA., March 12, 1897. Extensive preparations are being made for the annual meeting of the American Medical Association to be held in this city. Dr. Hobart A. Hare, Professor of Therapeutics in Jefferson Medical College, is chairman of the Committee of Arrangements, and he has an able staff of co-workers. Every effort will be made to make this meeting a gala one, and the medical colleges will vie with each other in showing courtesies to the visitors. Philadelphia, with its many hotels, will have no trouble to comfortably accommodate the large crowd of doctors expected. Its brotherly arms will be thrown wide open to welcome the disciples of Esculapius, many of whom, probably the majority, possessing a diploma from one of its schools. How many "Saw-bones" will look for their old boarding-houses; will hunt up the friends of their student days; will, perhaps, seat themselves in the same old amphitheatre, where they once heard the elder Gross or Pancoast, Agnew or Goodell expound the elements of medical art. Some things are changed. Hospitals and colleges have enlarged, have put on new The university has taken itself across the river, and built up for itself a town of its own, but outside of this the older part of the city will still be recognized by the visitor of thirty years ago. The boarding-houses that sheltered "medicoes" at that time are still in the business, at the old stand. The landladies and housekeepers have changed, but the furniture hasn't, and, possibly, the meals are also the same. You, busy practitioner, commence to get your affairs in order, for you cannot afford to miss this year's meeting. We have a new medical society in town. It is called the Pediatric Society. Its purpose is, as its name implies, to associate those who are interested in disease in children. Dr. J. P. Crozier Griffith is the President. Its meetings have been very interesting and well attended, and it promises to be a valuable addition to our society life. An interesting paper read recently before the County Medical Society was one by Dr. Edward Jackson on "The Dispensary Evil." This problem is growing in proportions. It has been estimated that in 1895, 39 per cent of the population of New York City received free medical aid. Dr. Jackson, like all other thinkers who approach this question, sees that the hospital system is bound to spread more and more, and more and more bound to encroach upon the domain of the individual or private practitioner. He urges that the profession should so organize itself as to obtain control of the management of hospitals. The profession must find some new relation to hospitals. In our humble opinion, hospitals, like department stores, are going to become larger and more embracing. They will send their visiting physicians to the homes for a certain amount per annum, just as now many of them guarantee hospital care when needed for so much per month. Large corporations will insure their employes, or erect hospitals of their own to make up for a portion of the wages they withhold from their employés. The young physician will find times harder each year. No cross-roads but what has its two or three men. He belongs to the rapidly dying out middle class, and he must soon find himself in the ranks of the wage-earner working for a salary, or the capitalist owner of a hospital, the doctor's factory. "La grippe," or something very much like it, has been in our midst for the past two months, producing all sorts of complications. Everything nowadays is traceable to the grippe, and so we have a multitude of nervous diseases coming from this disorder. A very interesting discussion occurred at the last meeting of the neurological section over a case of supposed hysteria in a male. It was a battle of experts. One side taking the ground that the ankle clonus could not be obtained in anything else but a grave lesion of the central nervous system, and the other side taking the opposite view. The question at issue was, if the patient under examination had suffered from a hemiplegia of cerebral origin after having undergone a severe mental and physical strain; or were the hemiplegic symptoms somewhat in the nature of a railway spine and functional in character. The problem, after considerable discussion, was left in as undecided a condition, as it was before its consideration. Dr. Abbott, author of Abbott's Bacteriology and lecturer at the Laboratory of Hygiene, has been made chief of the municipal bacteriologic laboratory. The force of assistants has been increased, and every effort will be made to give good service to the physicians. It is unfortunate that the institutions under the management of the city are continually hampered by lack of funds, notably the municipal hospital for contagious diseases. Its accommodations have been taxed to the utmost, and should a case of smallpox occur tomorrow it would be at least twenty-four hours before the case could be taken care of. Children who should accidentally be suffering from measles and diphtheria, or pertussis and diphtheria, cannot be taken at all, as there is no possibility of isolating the children. Private institutions, through their lobbying, can obtain large sums from the public treasury, beside the private bequest and gifts they manage to catch, but the city hospital must beg and beg for a mere living, and every improvement demanded is only obtained, if obtained at all, after the most strenuous efforts. PAPERS for the Original department should be in hand one month in advance, and contributed to THE MEDICAL FORTNIGHTLY exclusively. A liberal number of extra copies will be furnished authors, and reprints may be obtained at reasonable rates, it request accompanies the manuscript. Engravings from photographs furnished free. Signature of contributor, for reproduction, should be sent with every article, on a separate slip; use heavy ink, and allow autograph to dry without applying blotter. Contributions, books and exchanges should be sent to the Managing Editor, Union Trust Building, St. Louis The Antitoxin Treatment of Diphtheria. A Symposium. DITOR MEDICAL FORTNIGHTLY: Dear Doctor:--I have much express my good opinion of the FORTNIGHTLY, and partly to express my approval of your course in relation to antitoxtin treatment. My own personal experience with this treatment has not been so large as that of some of my colleagues in Philadelphia, notably Dr. Edwin Rosenthal, as the cases of diphtheria which I see are principally in consultation. From this experience, however, from the cases which I have treated personally, with and without antitoxin, and from my study of the subject, I believe that the remedy should be used in every case of diphtheria which promises to be at all serious. To be effective it should be used promptly and in sufficient dosage. When a case is seen for the first time late in the disease, the dosage of antitoxin must be largely increased. If 1500 immunity units represent the dose of the second day of the disease, 3000 should represent the dose on the fourth day, if the remedy has not been earlier used. I am in complete accordance with the conclusions formulated by the Committee on Collective Investigation of the American Pediatric Society, and these, I presume, are so well known that it would be superfluous to repeat them. It is true that many desiderata are still to be noted concerning the commercial supply of antitoxin. Certain makes do not keep well, becoming turbid with age; others, as the analyses of the Medical News have shown, are stronger or weaker than the manufacturers state upon the labels; some seeming never to have had the strength claimed, others seeming to have lost it, and others seeming to have been made excessively strong to "make sure." It is, therefore, highly important that the preparation of antitoxin used should be known to be good, and should be as recent as possible. The solid antitoxin prepared by Behring may prove to have solved this question. As yet, experience is lacking. Furthermore, it is to be remembered that diphtheria antitoxin does not protect against streptococcus infection or intoxication. If streptococcus toxemia exists, and is not controllable by the administration of tincture of ferric chloride, I am inclined to believe that trial should be made of anti-streptococcus serum, as well as of subcutaneous infusion of normal saline solution (hypodermoclysis). The toilet of the throat must be as scrupulous when antitoxin is used as under any other circumstances. For this purpose, spray of hydrogen dioxid solution at proper intervals may be conjoined with the topical application once or twice daily of Loeffler's solution of toluene, etc., or the solution I have recommended in the Philadelphia Polyclinic, February 16, 1895, which consists of guaiacol 50 per cent, menthol 10 per cent, and sterilized olive oil 1 50 per cent. And by-the-bye, let me again call attention to the decided and proved usefulness of this solution as a prophylactic application to the throats of healthy children in the infected houses. For this purpose it should be used once daily. It stings for a few moments, but the pain soon passes off, and is followed by a sense of comfort. Strychnia sulphate, internally or hypodermically, may also have to be given for the purpose (to use Jacobi's words) of "treating heart failure before it happens." It is essential not to disturb the child too often for local applications, or for food, and yet to feed and to make the local applications with sufficient frequency. This becomes a matter of good judgment in the individual case. In laryngeal cases timely intubation must be made. The conclusion to which I desire to point is this: that neither antitoxin nor any other treatment should be used blindly or unintelligently; but that the antitoxin treatment, intelligently used as the main dependence, and supplemented by such other treatment as may be necessary in the individual case, has greatly reduced the mortality of diphtheria all over the world, and may be confidently expected to show still better results, as physicians become more familiar with its use and its limitations, resorting to it more promptly, and as manufacturers become better able to furnish efficient preparations of standard strength. Very truly yours, PHILADELPHIA, February 10, 97. Solomon Solis Chen DR. FREDERICK C. WINSLOW, of Jacksonville, Ill., has been appointed superintendent of the Illinois Central Hospital for the Insane, to succeed Dr. Walter Watson. This is a most excellent appointment, for Dr. Winslow is by education and experience thoroughly qualified to discharge the duties of this position. He is a graduate of both the literary and medical departments of the North-Western University of Chicago, and served for eighteen months as interne in Cook County Hospital, Drs. Roswell Park, of Buffalo, N. Y., and D. A. K. Steele, of Chicago, being fellow internes at the same time. In 1876, he became assistant physician on the medical staff of the Illinois Central Hospital for the Insane, where he served until 1893, excepting the time spent in Europe in post-graduate study and the few years he was engaged in general practice in Freeport, Ill. Dr. Winslow ranks high in Masonic circles in Illinois, being Grand High Priest of the Grand Lodge of Royal Arch Masons of Illinois, and also one of the Grand Lodge officers of the Knights Templar. The MEDICAL FORTNIGHTLY extends its best wishes to Dr. Winslow, and predicts a successful and eminently professional service in his new position. The Antitoxin Treatment of Diphtheria. BY FLOYD M. CRANDALL, M. D., NEW YORK, N. Y. Adjunct Professor of Pediatrics, New York Polyclinic; Visiting Physician, Children's and Infants' Hospitals. THE HE antitoxin treatment of diphtheria is well past the stage of probation. It is true that it still meets with vigorous opposition, which arises in some quarters, from very competent and experienced practitioners. Until all men, however, join one church and one political party, and agree upon the tariff and silver questions, we must expect differences of opinion upon medical questions, and particularly upon treatment. When schools of medicine disappear, and all physicians practice alike, adopt the same course of treatment, and approve the same drugs, we may expect unanimity regarding vaccination and antitoxin. Evidence regarding the efficacy of the serum treatment has attained such proportions, that it cannot be lightly dismissed with the statement that men have been mistaken in their observations, or that the results are due to carbolic acid or other antiseptic. This evidence comes from thousands of observers in Europe, America, and Australia, and covers a period of almost three years. It cannot, therefore, be attributed either to personal prejudice, local conditions, or mildness of type of the prevailing disease. The evidence was at first based chiefly upon hospital experience. Notwithstanding its favorable character, it was regarded as not wholly satisfactory, for the hospital test is, for various reasons, not the most reliable in a disease like diphtheria. During the past year results of treatment in private practice. have been reported in large numbers. The most notable of these is the report of the American Pediatric Society, which has received very wide reading. This report has very properly been considered of great scientific value, compiled as it was from most carefully sifted data by men like Holt, O'Dwyer, Northrup, and Adams, whose integrity and honesty of purpose cannot be doubted, and whose ability to handle statistics cannot be questioned. While some of the evidence presented during the past two years has been conflicting, and some has been unfavorable, the conclusion cannot be avoided, that, taken as a whole, it overwhelmingly proves that we have in antitoxin a most potent remedy against diphtheria. One of the most positive proofs of its value is the almost universal approbation it receives from the men who have had the largest experience with it in private practice. It should be judged by the experience of men who have used it early in adequate doses in a large number of cases, and not by the experience of those who have used a dilute serum timidly in a few cases. The evidence now at hand as to the great potency and practical value of the serum treatment is so complete that it certainly seems that it were better in the future to devote less time to debating this question, and to devote more time to the study of its applications and dosage. A few suggestions in this direction may, therefore, be appropriate. |