THE BULLETIN A WEEKLY

As a further step in its onward march this journal has transformed into a weekly, appearing hereafter every Saturday.

This is only in line with the many progressive features recorded by this enterprise during the past eight years. There has been a constant development and improvement in all departments from the very day of its conception. At no time was there a self-contented standstill; and in view of the high aims guiding and urging us in this journalistic work we may safely promise that there will be made also in the future such further extensions and improvements as the evolution of science and practice may suggest.

Aside from the change of issue just stated, there will be noted an enlargement of size, which we trust will meet with hearty approval.

As in the past, so in the future the editorial office of this publication will have absolute control of its pages and will be independent of all outside influences, and especially will it be above all business interests. The various departments will, during the current year, be further built out. Our complete reports of the meetings of the New York Academy of Medicine, during the last year, have met with such universal recognition that we have determined to continue the same.

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THE PUBLISHERS,

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upon as diphtheria were previously classed as insignificant affections, disappearing after the simplest form of treatment. This change of classification was brought about by the almost universal acceptance of the bacillus of diphtheria as the chief etiological facWhile a full acceptation of the Löffler bacillus as the distinguishing feature of true diphtheria greatly simplifies the etiology of pseudo-membranous affections, such acceptation utterly invalidates our old standard of comparison, so far as statistics are concerned. It is quite well known that a necrosis of the mucous membrane exists without the slightest trace of the Löffler bacillus; e.g., in the fauces, colon, rectum, bladder, uterus, etc. On the other hand, this organism may be present without the coexistence of any pathological lesion.

The Löffler bacillus is very peculiarly situated. It appears to have a prototype which differs from it in one respect only, namely, in virulence. According to Abbott, however, virulence may be generated even in this prototype. In fact, the virulence of the true diphtheria bacillus varies greatly. When cultivated in nutrient bouillon, and subsequently injected into the tissues of lower animals, death may result at any time from 24 hours to 7 days after injection, provided the culture has been grown under favorable conditions, and was virulent at the outset. But if the growth has taken place at 40° C., it loses itsvirulence entirely. This makes it clear that more than 24 hours are necessary to

make a diagnosis from cultures alone.

Thus changing the diagnosis of diphtheria, it is plain that the percentage of mortality will be very much decreased; but it will not change the actual mortality caused by the disease.

The bacilli are most frequently found at the site of necrosis; seldom in the internal organs. Furthermore it is rare that the Klebs-Löffler bacillus is not accompanied by other organisms. Examination of the blood and viscera reveals a streptococcus more often than the diphtheria bacillus. Consequently, a pure infection is a rarity; but when it does occur, the tendency is to recovery. The literature upon antitoxin shows that a number of clinicians have classified diphtheria cases received at the hospitals as "mild," "moderate," and "malignant" (and treated them accordingly), thus immediately prognosticating the course of the disease. According to Baginsky (Berl. klin. Woch., Nov. 4, 1894, p. 1025), it is impossible to foretell the results of this disease, for the advent may be extremely mild, and, in a very short time, present a most malignant character, or vice versa.

As to the changes produced in the viscera by diphtheria, we are wholly dependent upon malignant cases; for very mild cases rarely have a fatal issue, consequently do not reach the autopsy table. Those cases, however, which are subjected to pathologicoanatomical examination usually reveal what is found in nearly all instances where infection was the cause of death. Excluding the changes observed in the fauces before death, the heart muscle may be found a trifle cloudy, and, when endocarditis or pericarditis is noted, it is generally ulcerative in character. Slight hemorrhages into the lungs are sometimes seen; slight swelling of the spleen, cloudy swelling of the liver and kidneys, are almost invariably present. It is plain, therefore, that the immediate causes of death may be legion.

At times a certain remedy has been successfully employed in combating every case occurring in one village, whereas, in an adjoining village, the same remedy employed by the same physician (A. Baginsky) was almost devoid of therapeutic action. Even up to the present time, the mortality varies within extremely wide limits, depending not so much upon the remedy used as upon the character of the epidemic. Consequently, a period of one or two years is not sufficient in which to judge the efficacy of a new remedy, especially one derived from the animal kingdom, and the nature of which is so little known as is antitoxin. In the latter we have the serum of a horse, which has been rendered immune to the toxic action of the Löffler bacillus. This serum is

said to be almost indifferent in its action upon the healthy organism. Now, let us consider this statement:

"As a general rule, the blood-serum of some mammals dissolves the blood-corpuscles of other mammals (Landois). Before Before the corpuscles are dissolved they run together and form sticky masses, which are apt to occlude the capillaries. After a while they give up their hemoglobin, leaving the stroma, which yields a sticky, fibrin-like mass that may occlude the vessels. As a result there are often signs of the circulation being impeded in various organs. In man, after transfusion of blood, the skin is bluish-red (bloody urine has been observed in man after the injection of 100 gme. of lamb's blood), in consequence of the stagnation of the blood in the cutaneous vessels. Difficulty of breathing occurs from obstruction in the capillaries of the lungs; while there may be rupture of small bronchial vessels, causing sanguineous expectoration. Degeneration of the parenchyma of the kidney occurs as a result of the occlusion of some of the renal vessels. The uriniferous tubules become plugged with coagulated albumin (Ponfick). fick). Other symptoms, referable to the nervous system, sense organs, and heart, are all due to the interference with the circulation through them. An important symptom is the occurrence of considerable amount of fever half an hour or so after the transfusion of heterogeneous blood." (Landois and Stirling: "Human Physiology," 3d ed., 1888.)

Stirling:

From this it is seen that transfusion of heterogeneous serum is liable to cause very nearly the same changes in the organism as an infection with diphtheria; therefore, transfusion of a heterogeneous serum would be contra-indicated. The proof that subcutaneous administration of antitoxin does not produce the same effect is still lacking; while, on the other hand, the ill effects of its use, which have so often been reported from the very beginning of its administration, indicate that the conditions above noted after transfusion of blood and serum were not exaggerated by the observers.

Several cases have been noted in which a fatal issue

followed the administration of a small dose of antitoxin, to immunize apparantly healthy children who had been exposed to the contagion. (Huebner, in Deutsche med. Woch., 42, 1895.) In these cases diphtheria did not appear, but this does not preclude the possibility that death may have been due to infection.

From what is known of the effects of serum transfusion, it is not altogether improbable that ery

thema, hemorrhages in the skin, pain in the joints (with or without swelling), albuminuria, hematuria, rise of temperature, heart-weakness, and arhythmic pulse, which have so often been noticed after the administration of antitoxin, were induced by the injection of a heterogeneous serum. However, these conditions are sometimes seen in diphtheria without the use of antitoxin. As to paralyses, we remember none proved to be due to transfusion of serum; but Huebner ('oc. cit.) states that 7 per cent. of paralysis followed the administration of 1110 immunizing units, and 12 per cent. followed the administration of 1700 units. From this it appears that, if the dose is increased, the paralysis following its use in diphtheria increases in a greater ratio.

The experiments of Vissman (Med. Rec., Sept. 14, 1895), undertaken for the purpose of determining the effects of antitoxin upon animals in which infection with diphtheria could be excluded, show that subcutaneous injection with this remedy may produce swelling of the spleen, cloudy swelling of the liver, acute parenchymatous nephritis, and, if large doses be given, even a hemorrhagic nephritis. These experiments have been corroborated by Chapin (N. Y. Acad. of Medicine, Nov. 7, 1895). They would seem to indicate that subcutaneous injections of antitoxin probably produce the same effect upon the organism as transfusion of heterogeneous serum or blood.

Now, if this so-called remedy possesses im-. munizing and healing properties, as claimed, it deserves to be classed with Jenner's discovery, which not only reduced the number of cases of smallpox, but also reduced the percentage of the community who succumbed to the disease. Thus far such satisfactory results have not been attained, and, judging from the experiments of Vissman, Chapin, and Landois (1874), it is questionable whether this cherished hope will ever be realized. The number of cases of diphtheria reported has certainly not been reduced, and it is very doubtful whether the health reports of a single city will show that there were not more cases in 1894 and 1895 than in any two years previous to 1894. It is quite probable that every health report will show that, in certain years since 1890, there was a smaller mortality from the disease than in 1894 or 1895. The cause of the increased number of cases is due to the change in the methods of diagnosis, as above stated; other reasons for the very great increase reported can scarcely be adduced.

As for the immunizing properties of antitoxin, they are, to say the least, doubtful and very tran

sitory in character. According to the most sanguine, the immunity lasts from about two to four weeks. Now, if, as we are taught, the serum has no effect upon the Klebs-Löffler bacillus, and this organism may live in the fauces for as long a period as two months, a single dose of antitoxin is utterly useless; for, if this organism causes the disease, what is to prevent an attack after the immunizing effect has passed away? Experiments on animals show that antitoxin lowers vitality, and if several doses are administered the vitality is correspondingly lowered, the patient being thus rendered less able to combat infection. This increased liability to infection is indicated, though not absolutely proved, by several reports. For example: Aaser (Deutsche med. Woch., No. 22, 1895) found that 20 per cent. of the children in his hospital had diphtheria bacilli in their fauces. The remainder (24) were transferred to another ward, where antitoxin was administered for purposes of inmunization. Three of the latter group were attacked by diphtheria, while those having Löffler bacilli in their throats suffered no ill effects from their presence.

So far as we know, no instance in which a single or several doses of antitoxin have caused the death of animals has been reported; but several cases have been recorded in which death soon followed after its administration to children, and that, too, without there being positive evidence that lethal exitus was due to another cause-for example, Alfoeldi's case (Pesth. med.-chir. Presse, No. 10, 1895).

Finally, while the percentage of mortality in diphtheria, as compared with the total number of cases reported, has been appreciably diminished, it is still doubtful whether the percentage of the community succumbing to this malady has been reduced or increased.

Money Value of a Limb. In the case of James Roberts, a brakeman, against the New York, New Haven and Hartford Railroad Company, before Judge Lacombe in the United States Court, the jury returned a verdict for the plaintiff for $5,000. Roberts sued to recover $50,000 damages for the loss of his right leg through being struck by a low bridge.

In the case of Rouss vs. the New York Biscuit Company, before Judge Wallace in the United States Circuit Court, the jury recently returned a verdict for $10,000 for the plaintiff. Rouss lost his right hand through an accident while at work in the defendant's factory. He sued to recover $20,000. — Journal of Amer. Med. Assn.