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AMERICAN

MEDICO-SURGICAL BULLETIN

A WEEKLY JOURNAL OF PRACTICE

AND SCIENCE

ISSUED EVERY SATURDAY

CHIEF EDITOR

WILLIAM HENRY PORTER, M.D.

ASSOCIATE EDITOR

EGBERT H. GRANDIN, M.D.

NINTH YEAR, VOL. IX

1896

THE BULLETIN PUBLISHING COMPANY

CORNER UNIVERSITY AND CLINTON PLACES, NEW YORK

Copyright, 1896, by The BULLETIN PưBLISHING COMPANY

E. H. B.

<IBRARY

CONTRIBUTORS

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Amidon, R. W.
Armour, J. P.
Barclay, Robert.
Bates, W. H...
Benedict, A. L.
Bishop, Louis Faugeres.
Brewer, George Emerson
Brown, Dillon ...
Cantrell, J. Abbott..
Clark, L. Pierce..
Coit, Henry L...
Collyer, Herman L..
Coudert, Frank E...
Currier, Andrew F.
Cutler, Colman W.
Dudley, A. Palmer.....
Dunham, H. B..
Dunham, Theodore
Eliot, Chas. W...
Ferguson, R.....
Ferris, Albert Warren..
Fischer, G. Theo....
Fisher, Edward D...
Fowler, George B.
Frank, Louis
Freeman, Rowland G..
Goelet, Augustin H....
Goodwillie, D. H..
Gordon, Bernard..
Gottheil, Wm. S....
Grandin, Egbert H...
Guiteras, Ramon..
Harrington, F. M.
Hobbs, Alfred T..
Hodge, G...
Hubbard, A. E.
Hubbard, Le Roy W.
Ingraham, Charles W..
Jarman, George W.....
Kane, Evan O'Neill.
Kelsey, Charles B..
Lederle, Ernest J...
Lengfeld, A. L. ...
Maisch, Charles 0..
Martin, Edward W...
Marx, S....
Massey, G. Betton

652 Mathews, J. M
378 Mays, Thomas J.
872 Mellish, E. J....
284 Menger, Rudolph..

64 Metzerott, John H.
183 Meyer, Willy
246 Michaelis, L. M...
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Monell, S. H.....
619 Moore, Wm. Oliver
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Morris, Robert T.. 418

Muir, Joseph...

Mulford, Henry J..
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Myers, T. Halsted
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591 Noble, George H...
106 Nottage, H. P.
519 Noyes, Wm. B.
838 Oertel, T. E...
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Peterson, Frederick...
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Pope, Curran... 132

Porter, Wm. H 447, 768

Robinson, Byron. 15, 419

Reynolds, Edward 419

Richer, A. J.. 279

Sachs, B... 99

Satterthwaite, Thomas E. 282, 487

Scheppegrell, W..... 104

Schwarzschild, H. Davison. 62

Sheffield, Herman B. 583

Sherman, Harry M. 875

Shoemaker, John V 6

Sprague, Homer B. 216

Stinson, J. Coplin. 4

Suiter, A. Walter.... 349

Swinburne, George Knowles. 412

Tansley, J. Oscroft ..... 724

Taylor, Henry Ling. 654

Taylor, Robert C.

Trowbridge, John... 18

Van Peyma, P. W.... 415

Vineberg, Hiram N 381 Von Engel, Dr... 690

Walker, Agnes...

Wallian, Samuel S.
878 Watkins, Robert L.
725 Welch, H. E...

White, David.
311 Winter, Henry Lyle.
876 Woolsey, George.

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mucous

was

As a further step in its onward march this journal NTIL quite recently a diagnosis of diphtheria has transformed into a weekly, appearing hereafter

was accepted only when a necrosis of a membrane

demonstrable. every Saturday. This is only in line with the many progressive Many affections of the fauces which are now looked

upon as diphtheria were previously classed as insigfeatures recorded by this enterprise during the past

nificant affections, disappearing after the simplest eight years. There has been a constant develop- form of treatment. This change of classification was ment and improvement in all departments from the brought about by the almost universal acceptance of very day of its conception. At no time was there a the bacillus of diphtheria as the chief etiological facself-contented standstill; and in view of the high

tor. While a full acceptation of the Löffler bacillus

as the distinguishing feature of true diphtheria aims guiding and urging us in this journalistic work

greatly simplifies the etiology of pseudo-membranwe may safely promise that there will be made also

ous affections, such acceptation utterly invalidates in the future such further extensions and improve

our old standard of comparison, so far as statistics ments as the evolution of science and practice may

are concerned. It is quite well known that a nesuggest.

crosis of the mucous membrane exists without the Aside from the change of issue just stated, there slightest trace of the Löffler bacillus; e.g., in the will be noted an enlargement of size, which we

fauces, colon, rectum, bladder, uterus, etc. On the trust will meet with hearty approval.

other hand, this organism may be present without

the coexistence of any pathological lesion. As in the past, so in the future the editorial office

The Löffler bacillus is very peculiarly situated. of this publication will have absolute control of its

It appears to have a prototype which differs from it pages and will be independent of all outside influences, in one respect only, namely, in virulence. Acand especially will it be above all business interests.

cording to Abbott, however, virulence may be The various departments will, during the current

generated even in this prototype. In fact, the

virulence of the true diphtheria bacillus varies year, be further built out. Our complete reports of

greatly. When cultivated in nutrient bouillon, the meetings of the New York Academy of Medi

and subsequently injected into the tissues of lower cine, during the last year, have met with such uni- animals, death may result at any time from 24 hours versal recognition that we have determined to con- to 7 days after injection, provided the culture has been

grown under favorable conditions, and was virulent

at the outset. The subscription price of The Bulletin for the

But if the growth has taken place at fifty-two issues has been placed at $4.

40° C., it loses itsvirulence entirely. This makes

it clear that more than 24 hours are necessary to THE PUBLISHERS. make a diagnosis from cultures alone.

tinue the same.

Thus changing the diagnosis of diphtheria, it is said to be almost indifferent in its action upon the plain that the percentage of mortality will be very healthy organism. Now, let us consider this statemuch decreased; but it will not change the actual ment: mortality caused by the disease.

As a general rule, the blood-serum of some The bacilli are most frequently found at the site of mammals dissolves the blood-corpuscles of other necrosis; seldom in the internal organs. Furthermore mammals (Landois).

mammals (Landois). Before the corpuscles are it is rare that the Klebs-Löffler bacillus is not accom- dissolved they run together and form sticky masses, panied by other organisms. Examination of the which are apt to occlude the capillaries. After a blood and viscera reveals a streptococcus more often while they give up their hemoglobin, leaving the than the diphtheria bacillus. Consequently, a pure stroma, which yields a sticky, fibrin-like mass that infection is a rarity; but when it does occur, the may occlude the vessels. As a result there are tendency is to recovery.

The literature upon

anti- often signs of the circulation being impeded in varitoxin shows that a number of clinicians have ous organs. In man, after transfusion of blood, the classified diphtheria cases received at the hospitals skin is bluish-red (bloody urine has been observed as "mild," “moderate," and “malignant" (and in man after the injection of 100 gme. of lamb's treated them accordingly), thus immediately prog- blood), in consequence of the stagnation of the nosticating the course of the disease. According blood in the cutaneous vessels. Difficulty of to Baginsky (Berl, klin. Woch., Nov. 4, 1894, p. breathing occurs from obstruction in the capillaries 1025), it is impossibbe to foretell the results of this of the lungs; while there may be rupture of small disease, for the advent may be extremely mild, and, bronchial vessels, causing sanguineous expectorain a very short time, present a most malignant tion. Degeneration of the parenchyma of the kidcharacter, or vice versa.

ney occurs as a result of the occlusion of some of As to the changes produced in the viscera by the renal vessels. The uriniferous tubules bediphtheria, we are wholly dependent upon malignant come plugged with coagulated albumin (Poncases;

for
very

mild cases rarely have a fatal issue, fick). Other symptoms, referable to the nervous consequently do not reach the autopsy table. Those system, sense organs, and heart, are all due to the cases, however, which are subjected to pathologico- interference with the circulation through them. An anatomical examination usually reveal what is found important symptom is the occurrence of considerin nearly all instances where infection was the cause able amount of fever half an hour or so after the of death. Excluding the changes observed in the transfusion of heterogeneous blood." (Landois and fauces before death, the heart muscle may be found Stirling: “Human Physiology," 3d ed., 1888.) a trifle cloudy, and, when endocarditis or pericarditis From this it is seen that transfusion of heterois noted, it is generally ulcerative in character. geneous serum is liable to cause very nearly the Slight hemorrhages into the lungs are sometimes same changes in the organism as an infection with seen; slight swelling of the spleen, cloudy swelling diphtheria; therefore, transfusion of a heterogeneof the liver and kidneys, are almost invariably ous serum would be contra-indicated. The proof present. It is plain, therefore, that the immediate that subcutaneous administration of antitoxin does causes of death may be legion.

not produce the same effect is still lacking; while, At times a certain remedy has been successfully on the other hand, the ill effects of its use, which employed in combating every case occurring in one have so often been reported from the very beginvillage, whereas, in an adjoining village, the same ning of its administration, indicate that the condiremedy employed by the same physician (A. Bagin- tions above noted after transfusion of blood and sky) was almost devoid of therapeutic action. Even serum were not exaggerated by the observers. up to the present time, the mortality varies within Several cases have been noted in which a fatal extremely wide limits, depending not so much upon issue followed the administration of small the remedy used as upon the character of the epi- dose of antitoxin, to immunize apparantly healthy demic. Consequently, a period of one or two years children who had been exposed to the contagiori. is not sufficient in which to judge the efficacy of a (Huebner, in Deutsche med. Woch., 42, 1895.) In new remedy, especially one derived from the animal these cases diphtheria did not appear, but this does kingdom, and the nature of which is so little known not preclude the possibility that death may have as is antitoxin. In the latter we have the serum of been due to infection. a horse, which has been rendered immune to the From what is known of the effects of serum toxic action of the Löffler bacillus. This serum is transfusion, it is not altogether improbable that ery

a

thema, hemorrhages in the skin, pain in the joints sitory in character. According to the most san(with or without swelling), albuminuria, hematuria, guine, the immunity lasts from about two to four rise of temperature, heart-weakness, and arhythmic weeks. Now, if, as we are taught, the serum has no pulse, which have so often been noticed after the effect upon the Klebs-Löffler bacillus, and this administration of antitoxin, were induced by the organism may live in the fauces for as long a period injection of a heterogeneous serum. However, as two months, a single dose of antitoxin is utterly these conditions are sometimes seen in diphtheria useless; for, if this organism causes the disease, without the use of antitoxin. As to paralyses, we what is to prevent an attack after the immunizing remember none proved to be due to transfusion of effect has passed away? Experiments on animals serum; but Huebner (loc. cit.) states that 7# per show that antitoxin lowers vitality, and if several cent. of paralysis followed the administration of 1110 doses are administered the vitality is correspondingly immunizing units, and 12 per cent, followed the lowered, the patient being thus rendered less able administration of 1700 units.

From this it appears to combat infection. This increased liability to inthat, if the dose is increased, the paralysis following fection is indicated, though not absolutely proved, its use in diphtheria increases in a greater ratio. by several reports. For example: Aaser (Deutsche

The experiments of Vissman (Med. Rec., Sept. med. Woch., No. 22, 1895) found that 20 per 14, 1895), undertaken for the purpose of determin- cent. of the children in his hospital had diphtheria ing the effects of antitoxin upon animals in which bacilli in their fauces. The remainder (24) were infection with diphtheria could be excluded, show transferred to another ward, where antitoxin was that subcutaneous injection with this remedy may administered for purposes of inmunization. Three produce swelling of the spleen, cloudy swelling of of the latter group were attacked by diphtheria, the liver, acute parenchymatous nephritis, and, if while those having Löffler bacilli in their throats large doses be given, even a hemorrhagic nephritis. suffered no ill effects from their presence. These experiments have been corroborated by So far as we know, no instance in which a single Chapin (N. Y. Acad. of Medicine, Nov. 7, 1895). or several doses of antitoxin have caused the death They would seem to indicate that subcutaneous of animals has been reported; but several cases have injections of antitoxin probably produce the same been recorded in which death soon followed after its effect upon the organism as transfusion of hetero

administration to children, and that, too, without geneous serum or blood.

there being positive evidence that lethal exitus was Now, if this so-called remedy possesses im- due to another cause-for example, Alfoeldi's case munizing and healing properties, as claimed, it (Pesth. med.-chir. Presse, No. 10, 1895). deserves to be classed with Jenner's discovery, Finally, while the percentage of mortality in diphwhich not only reduced the number of cases of theria, as compared with the total number of cases smallpox, but also reduced the percentage of the reported, has been appreciably diminished, it is still community who succumbed to the disease. Thus doubtful whether the percentage of the community far such satisfactory results have not been attained, succumbing to this malady has been reduced or and, judging from the experiments of Vissman, increased. Chapin, and Landois (1874), it is questionable whether this cherished hope will ever be realized. Money Value of a Limb.-In the case of James The number of cases of diphtheria reported has Roberts, a brakeman, against the New York, New certainly not been reduced, and it is very doubtful Haven and Hartford Railroad Company, before whether the health reports of a single city will show Judge Lacombe in the United States Court, the jury that there were not more cases in 1894 and 1895 returned a verdict for the plaintiff for $5,000. Rothan in any two years previous to 1894. It is quite berts sued to recover $50,000 damages for the loss probable that every health report will show that, in of his right leg through being struck by a low certain years since 1890, there was a smaller mor- bridge. tality from the disease than in 1894 or 1895. The In the case of Rouss vs. the New York Biscuit Comcause of the increased number of cases is due to the pany, before Judge Wallace in the United States change in the methods of diagnosis, as above stated; Circuit Court, the jury recently returned a verdict other reasons for the very great increase reported for $10,000 for the plaintiff. Rouss lost his right can scarcely be adduced.

hand through an accident while at work in the deAs for the immunizing properties of antitoxin, fendant's factory. He sued to recover $20,000. they are, to say the least, doubtful and very tran- Journal of Amer. Med. Assn.

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