der government supervision and has /10 per cent trikre Paris in 1891, 1,531, against 440 in 1895. As reported sol added to preserve it. Dr. Aronson recommends and in Berlin 1,078 in 1891, and 996 in 1895. The absolute uses trikresol exclusively because: first, it possesses at death rate from diphtheria and deaths to 100,000 in all least twice the antiesptic power of carbolic acid; second, the German cities over 15,000 population has been in the strength in which it is employed it has no injuri- reduced from an average of 106 in 1889-1894 to 53 in oas effect on the antitoxin; third, it is only half as poi. | 1895." sonous as carbolic acid. I understood Dr. Aronson to say that Roux uses cam phor, and the Hochst Farbwerke carbolic acid as a pre servative. Am unable to say which of the above are used, if any, or any other, by the manufacturers in this country. At times an antitoxin is found of very high immuniz ing power and this is mixed with a serum of lower power to equalize them. All antitoxin bottled in Germany is sealed with leaden seal with double imperial eagle. Antitoxin preserved as above stated will keep six months to a year and probably longer. The horses remain immune for quite a while and their serum is used, some a longer, others a shorter length of of time, very large quantities of antitoxic serum having been obtained from some of the animals, the best results in this respect being obtained from an almost thorough bred horse, so says Dr. Aronson. After a horse ceases to be immune it may be re-inoculated, but there is a limit to this and the animal ceases to be of any further use in this line. It seems as though its stock or supply has given out or the organism is no longer able to pro duce the antitoxin. Quite as a matter of course the quality of the serum is repeatedly tested by control experiments on guinea pigs. Though Behring announced his discovery but three years ago this month, antitoxin is used throughout the civilized world, reducing the at times frightful mortality of 50 and 60, yes even 63 per cent to as low as 13 per cent, and some even claim 8 per cent, and hope that even this will be lowered as the use of antitoxin becomes more general and is used early in the case, with first appearance of symptoms. That this low mortality is not due (as has been claimed) to a milder form of diphtheria is shown by the following: "At the Kaiser & Kaiserin Friedrich Hospital in Berlin the supply of antitoxin became exhausted in the fall or early winter of 1894, and the mortality rose again to about 35 per cent, which it had been before antitoxin was used; again, at the time that Roux's mortality fell to 24.33 it remained 63.20 per cent at the Hospital Trousseau in Paris where the serum treatment was not used."-(British Medical Journal). Dr. Herman M. Briggs' comparative statistics in the New York Medical Journal as well as the New York Medical News, are very interesting and highly instructive: "Diphtheria and croup cases reported in New York in 1891, 5,364, number of deaths, 1,970, or 36.7 per cent; in 1895, 10,353, number of deaths, 1,976, or 19.1 per cent; in 1896 (nine months up to November 1), 8,286, number of deaths, 1,392, or only 16.8 per cent. Total number of deaths due to diphtheria and croup in These statistics would seem to prove conclusively that the ahsolute mortality from diphtheria has been reduced at the same time that the number of cases have increased, and they prove, moreover, that the epidemic of diphtheria, in Germany at least, instead of being on the decrease, has been steadily on the increase for the last six years up to 1894 and 1895, when there was a sudden marked decline in the death rate, corresponding to the use of antitoxin. That would indeed have been a strange coincidence of natural causes which reduced the mortality of diphtheria for the benefit of antitoxin, instead of the reduction of mortality being due to the effects of antitoxin. "The most remarkable results have been obtained in cases of laryngeal diphtheria with stenosis. In a total of 15,148 cases treated taken from 72 reports there were 2,626 deaths, or a mortality of 16.6 per cent of these in 12,066 the patients were not operated on (80 per cent) and 1,491 died, giving a mortality of 13.5 per cent; 3,082 were operated on by intubation or tracheotomy (20 per cent) and 1,135 died, or 36.07 per cent. "Previous to the antitoxin treatment 40 per cent of all cases were reported as having required operative interference. In the 3,082 operative cases 1,355 were tracheotomized, with 569 deaths, or a mortality of 42 per cent; 1,173 were intubated with 361 deaths, or a mortality of 30.8 per cent; 52 were intubated and required secondary tracheotomy and 37 died, or 71 per cent; 502 required tracheotomy or intubation (does not state which) with a mortality of 32.2 per cent. "According to Monti and Hirsch the mortality in tracheotomy previously was 68.5 to 73.3 per cent and the lowest estimated mortality for intubation is 51.6 per cent; taking these results we see that in operative cases there is a reduction of mortality also of some 50 per cent, while at the same time the number of cases requiring operative interference has been reduced onehalf as the result of antitoxin."-(New York Medical Jaurnal). "Antitoxin modifies the cell activity so that the or ganism becomes tolerant to the diphtheritic poison."(Welsh, "Vital Theory.") Quite a number of syringes have been devised for the administration of antitoxin and I presume most of them are good. Dr. Aronson recommends a large hypoder mic syringe of metal with asbestos piston, as it is kept aseptic easier than any of the other ones; most any large hypodermic syringe is good if thoroughly cleansed before use. I have been using a 2.0 cc.m. Lewin syringe and inject between shoulder blades, but I see some phy. sicians recommend to inject into skin of abdomen, others prefer the thigh; I inject deep into the cellular tissue, withdrawing the needle as the serum is forced out of the syringe. Immediately after the injection considered worthless, when used too late in the case. iodoform collodion and cotton is applied, sealing the We can not expect it to step in and repair the damage wound. Before puncture the selected spot is scrubbed already done to heart, kidney, brain and nervous syswith soap and water, at times a bichloride solution, and tem, nor can we expect it to overcome sepsis, but, as afterwards scrubbed with ether, not only cleaning the stated before, to modify cell activity so that the organskin but also causing local anesthesia. I usually inject ism becomes tolerant to the diphtheritic poison. Statisin several places; the pain is almost nil, whereas, if we tics prove that if injected early enough it always acts as inject a large amount of fluid in the subcutaneous tissue a specific. at once, in the same puncture, the pain is said to be considerable. As a matter of course I give other local as well as constitutional treatment, iron, quinia, strychnia, and if larynx is affected, also calomel and mercurial inunction. Locally I use peroxide of hydrogen spray, at times KClO, or salicylic acid gargle. Like every great discovery antitoxin has a good many opponents; foremost Dr. Lenox Brown, London, and Dr. Joe Winters, New York. The editor of some monthly medical journal even calls it a foreign un-American fad; quite patriotic, I am sure. But I believe like a great many other opponents, they will overcome their preju dice and see the true value of the treatment Dr. Love, of St. Louis, says very appropriately: "Prejudice and self-interest of all should not enter into this discussion. The interests of humanity, the lives of many loved ones are at stake. After all, the way to decide the question, as of all others of a like nature in volved in a doctor's life, is to ask ourselves, Were my child attacked with diphtheria would I feel right if I permitted him to die without using the serum treatment?'" Admitting that the injection of antitoxin has caused death, we must remember that in ante-serum days pa tients suffering from diphtheria have died upon turning over in bed, or upon rising to drink, or on being taken into the nurse's arms. Why should not piercing the skin with a needle cause death? Why should not the shock thus caused be the factor and not the innocent serum? Before using the serum I consider it a good plan to thoroughly examine the patient's condition, heart, amount of intoxication, nervous system, etc.; a good full dose of strychnia seems to act as a safeguard against accidents. Rarely and unavoidably the patient has an urticaria following the injection. I think my friend Dr. Hall had this occur in one of his cases. It seems that the serum of certain horses only causes this trouble, but just what peculiar condition in the ani mal is necessary for this, investigators have been unable to find. Antitoxin also acts as an immunizing agent, isolation being unnecessary. This immunity, however, lasts only several weeks and if the epidemic continues the patients ought to be re immunized. For this purpose it is ad ministered in reduced doses. Up to two years 0.5 cc.m. (8 m.); two to ten years 1. cc.m. (16 m.); over ten years and adults 2 cc.m (32 m.). My experience with antitoxin, though limited, has been the most gratifying in the world, not having had a death by diphtheria in 1896 as compared with three deaths in the first two weeks of 1895 alone. In preparing this article I have used and am indebted to the various late medical journals and text-books. In conclusion I will give the histories of a few of my own cases treated by antitoxin. Bacteriological examinations were not made in any of the cases, all of them presenting the typical clinical picture of diphtheria. CASE I.-Daisy M., aged 9; had been ill several days and had been given some "croup tea." Temperature, 101°; pulse, 130; membrane on both tonsils, aphonea and marked stenosis; gave unfavorable prognosis on account of time wasted. I injected 400 units and was surprised to find patient breathing quite naturally next morning, when I injected 600 units more. Voice began to return 24 hours after last injection and patient made an uneventful recovery. CASES II-VI.-Brother and sisters of Case I, aged 24 to 13. Gave immunizing injection of 1.0 cc.m. each. There was no reaction and all escaped excepting CASE VI-Maude M., aged 13, who developed disease about ten days after recovery of Case I. She was not very ill; membrane on left tonsil and uvula, larynx not involved. In injected 600 units and re-immunized the rest of the family. Maude made prompt recovery, membrane disappearing in twelve hours. None of the others took the disease. CASE VII.-C. Jones, aged 4. Both tonsils, posterior pharynx and larynx involved; aphonea and stenosis very pronounced. Parents are ignorent Poles, thinking nothing much being the matter with the child, brought him to my office one evening. Not having any antitoxin on hand, deferred injection till next morning when I injected 500 units; symptoms not improving, repeated the dose in 24 hours. Must state that parents did not give medicines as directed; could not even get them to slack lime in the room. Notwithstanding all this and the first injection given almost three days after onset of the disease, recovery took place with slight vocal paralysis lasting a few weeks. It is hardly necessary to say anything about "crooked eyes" or "loss of speech" following the use of antitoxin. Nevertheless this was used as an argument against the use of the agent by some one in Kewanee, and strange to say, the child died for the want of 500 antitoxin units, after "catching more cold and develoring mem branous croup." Post diphtheria paralyses have been known ever since the disease has been recognized, and yet the innocent serum causes "crooked eyes." Often CASE VIII-George C, aged 8. Sick three days beantitoxin is blamed for the death of the patient or is fore giving injection of 600 units; repeated the dose next day. Both tonsils and larynx covered with mem brane, aphonea and marked stenosis; had to give 1/40 gr. of strychnia every three hours for two days when com plete recovery set in. CASE IX.-Rose C., aged 6, sister of above. Tonsilar only; injected 400 units on first day, membrane disap. pearing in 24 hours; recovery uneventful. CASE X-George W., aged 16. Tonsils, uvula and posterior pharynx involved; injected 800 units 18 hours after onset. Patient fainted sitting in chair, just as I got through injecting the serum; also vomited. Mem. brane disappeared in 48 hours, and recovery was com plete. Remember patient's brother became sick at stomach when vaccinated. CASE XI.-Mrs. M. F., aged 24. Uvula, both tonsils and naso-pharynx involved. Ill one week before injec tion of 600 units. Membrane disappeared 36 hours after injection and patient rapidly recovered. The pa tient had been objecting to the use of antitoxin in some other family, therefore I did not offer to inject, till almost too late MEDICAL REVIEW. L. T. RIESMEYER, M.D., EDITOR. DEPARTMENT EDITORS: DR. F. J. LUTZ, General Surgery. PUBLISHED UNDER THE AUSPICES OF THE BY O. H. DREYER. YEARLY SUBSCRIPTION, $3.50. SINGLE COPIES, 10 Cents. TO CONTRIBUTORS AND CORRESPONDENTS. All letters whether intended for publication or not must contain the writer's name and address, not necessarily for publication. No attention will be paid to anonymous com munications. Secretaries of medical societies will confer a favor by keep tive societies, and of officers elected. Members of the profession who send us information of matters of general interest to our readers will be considered as doing them and us a favor, and we shall take pleasure in inserting the substance of such communications. Communications, Medical Books for review, and all letters containing business communications or referring to the publication, subscription, or advertising department of the REVIEW, must be addressed to O. H. DREYER, Publisher 112 N. 4th Street, St. Louis. Entered at the St. Louis Postoffice as Second-Class Matter. EDITORIALS Aural and Nasal Hemorrhage in Bright's ing us informed of the dates of the meetings of their respecDisease.-Haug (Deut. Med. Woch.), after referring to the literature of the subject, says the British Medical Journal, relates a case occurring in an alcoholic, aged 39. During the previous eighteen months he had suffered from cardiac weakness and arrhythmia. Threequarters of a year ago he had a profuse epistaxis. The urine was then free from albumen. Quite recently he had a still more severe nasal hemorrhage, which could be stopped only by plugging the nares from the front. The plugs had to be continued for a week. The urine now contained both albumen and casts. There now oc curred very severe pain in both ears, together with tinnitus and some deafness. Hemorrhage was found to have taken place in the tympanic cavities and mem branæ tympani. An albuminuric retinitis with hemorrhages was also noted. In three weeks' time the blood in the ears was absorbed without the hemorrhagic otitis having become purulent. In this case epitaxis along with cardiac symptoms were among the earliest indica tions of Bright's disease. These hemorrhagic manifes tations were all more pronounced on the left than on the right side. They must have been brought about by vascular disease. The prognosis of these local manifes tations in themselves is not so unfavorable, but when such hemorrhages occur they usually indicate an early unfavorable termination of the kidney disease. The occurrence of such hemorrhages should at once draw at tention to the possibility of Bright's disease. The author thinks that these hemorrhages are the result of diapedesis rather than the outcome of rupture of vessels. It is thus correct to speak of an albuminuric tympanitis or myringitis. The apparent rarity of this affection is to be explained by insufficient examination of the pa tient's ears; often the patient does not complain about these aural symptoms, so that it is easy to overlook their real cause. Medical Charity. As virtue carried to excess may become a vice, so may misdirected and unreasonable charity become a curse instead of a blessing to the common weal. The establish ment of free hospitals and free clinics is a most laudable undertaking, whether it be for the sake of charity alone or with an eye upon scientific research, furnishing phy. sicians with interesting or rare cases and colleges with typical cases for the instruction of students. Nearly all physicians are charitably inclined and willing to do more than their share in well directed charity. It 18 only when free medical treatment, or its equivalent, is extended to individuals who are able to pay a moderate fee, that a great wrong is done to the recipients of such free treatment as well as to the members of the medical profession and that the thoughtful and well meaning begin to plan how such an abuse may be successfully squelched. The indications are that the question of who is a fit subjeot for free treatment will be settled in this country by the medical profession sooner or later. Complaints are numerous, particularly on the part of general practitioners, with regard to the extension of Nevertheless the mushroom growth of new free hospi free treatment to individuals that are able to pay and often in much better circumstances than the practitioner whom they desert in order to be treated at a free clinic or a free hospital because it is cheaper. ute his share and take care of those patients that live in his district and unable to pay a fee. This fact is almost superfluous to mention before an audience of physicians. tals and free clinics and their latest twin-creation, the treatment on the insurance plan, characterizes the eagerness of competition for hospital positions and im. presses one with the deplorable fact that the medical profession has become overcrowded to an extent that the tumbling all over each other of candidates for free hospital and free clinic, etc., positions, has taken on such proportions as to make it appear that the struggle of physicians for charity practice-so-called, has be come a matter of sauve qui peut-après nous le déluge! ** What is true, in this respect, of free clinics and hospitals is also true of that but too natural result of an overcrowded profession-the fifty cents per month treatment on the insurance plan. By misdirected char ity its recipients are educated into dependent pauperism. Such a course on the part of free hospitals, free clinics, etc., is inconsistent with the best in terests of the community. It has the tendency of That the practical and just American mind, which is creating greater and greater numbers of dependents. as quick and keen in perceiving an advantage as a disBut not only are dependents thereby made more advantage, will not allow such a state of affairs to go on dependent and helpless, but the field of usefulness indefinitely, but that, sooner or later, it will place an of the general practitioner who does not work for effectual damper upon misdirected charity, need not any corporation and is not connected with any free here be pointed out The recommendations adopted by clinic or free hospital, is thereby greatly curtailed and the Medical Association of the District of Columbia, often unpardonably encroached upon. The general February 16, 1897, are a true reflection of the views of practitioner or family physician is, above all, the person the entire profession. They deserve a thorough discuswho is best enabled to judge whether people are so sion at the various meetings of State societies with a poor that they deserve free treatment. The necessity view of adopting similar means to place the free treatof some control in this respect is recognized by the ment of patients under proper control in order to premedical profession and it is encouraging to learn that vent an artificial increase of the dependent classes as efforts are being made to correct the free hospital and well as the pauperization of the medical profession. In free clinic abuse. Charity should be based upon previ- fine, the recommendations adopted by the Medical ous investigation. Free medical treatment, like the Association of the District of Columbia, which appear giving of alms, is a crime unless it be extended to the in another place in this issue, should be printed in gold real needy only. Self-help, where it is possible, is a letters and placed in a prominent place of all hospitals healthful gymnastic, morally elevating the individual, and clinics. while indiscriminate charity has a paralyzing effect upon the moral principles of its recipients. The moral strength for self-help should be stimulated instead of The Dry Form of Diphtheria Antitoxin. paralyzed. The philosophers say that all human action, when anal. yzed as to its ultimate motives, is based upon selfishness, and the hatred that sometimes is said to exist between rival philanthropists would speak in favor of this philosophical analysis of human motives. However this may be, there can not be any question as to the usefulnes and necessity of properly directed charity and philanthropy under present social conditions. The State control of all charitable work, by taking care of its dependants as a duty, not as a privilege of charitably inclined individuals, sects and philanthropic societies, seems to be desirable and would do away with the objectionable features of misdirected charity. In the same degree as the social conditions of the present civilization are responsible for the dependent and criminal classes should it be made the duty of the State to properly care for and educate these unfortunates by teaching them selfhelp. Every member of the medical profession knows, of course, that as far as charity pure and simple is con cerned, every medical practitioner is willing to contrib Some time ago the MEDICAL REVIEW called attention to the fact that Prof. Behring, the discoverer of diph. theria antitoxin, has succeeded in preparing a dried form of diphtheria antitoxin. In this consistency the antitoxin is free from all albuminous substances to which Behring describes any possible noxious effects of antitoxin in the form of serum. The improved form is free from carbolic acid contains no preservative, and is protected from micro-organisms by sealing in a closed vessel; one gramme of the dried preparation is equivalent to 5,000 normal units. The living cells of the body have been found by Behring to be entirely uninfluenced by the pure antitoxin; while serum affects the cells whether it be in the form of diphtheria antitoxin serum or the serum of a healthy animal that has not been subjected to the process of immunization against diphtheria. Before Behring discovered a method of preparing a dried antitoxin free from any possible noxious substances found in every serum, he tried to reduce the relative quality of serum in diphtheria antitoxin serum by obtaining a very concentrated antitoxin. He ob served, however, that such concentrated solutions soou lose their strength by keeping. Behring has also pub lished in Fortschritte der Medicin of January, 1897, some researches on the absorption and excretion of diphtheria antitoxin according to which it does not form any chemical combination in the living tissues, but circulates in the fluids of the body unaltered in its chemical composition. In trying to prolong the time of immunity conferred by diphtheria antitoxin Behring states that it is better to repeat the dose than to increase its strength, for an increased dose of antitoxin produces a disproportionate increase of secretion of the kidneys and mammary glands. Behring makes the positive assertion, moreover, that the antitoxin as such, without any admixture of serum, is absolutely harmless, and can never under any circumstances in the healthy or unhealthy organism of man or animals produce any toxic effects. The antitoxin, he says, is the only ingredient in the diphtheria antitoxin serum that has any therapeutic value. bidden for any member of this Association to accept a position on the staff of said hospital or dispensary. 8. That whenever one or more members of the medical staff of a hospital or dispensary are dismissed, and when after due investigation, this Association finds that such dismissal was without just and sufficient cause, it shall be forbidden for any member of this Association to fill the vacancy created thereby. 9. That complaints made under Rules 7 and 8 shall be made in writing to the standing committee, which after due consideration shall report its findings to the Association. W. P. CARR, M.D., President. J. R. WELLINGTON, M.D., Secretary. TRANSLATIONS. BY EDGAR THOMPSON, M.D. Recommendations Adopted by the Medical Association of the District of Columbia, February 16, 1897. 1. That every institution for medical charity shall require from every applicant for relief in a hospital or dispensary, a written certificate to be obtained as hereinafter provided. Emergency cases are to be excepted from the operation of this rule. 2. That such certificate be obtained from physicians to the poor, the board of associated charities and any registered physician. 3. That cases of sick and injured persons found up on the streets, in the stations or elsewhere, who require immediate treatment shall be carried to the emergency hospital, or the nearest hospital having an emergency service, or to their homes, if so directed by the patient or his friends. 4. That emergency patients shall not be detained longer in such institutions than the necessity of the case imperatively demands, but shall be discharged from the service and sent to their homes or to some public hospi tal as the patient may elect. 5. That members of this Association shall be enti tled to the privilege of attending private patients occu pying private rooms in any of the public hospitals of this city. 6. That in future the members of the medical staff of hospitals when attending medical or surgical cases in private pay-rooms shall insist upon proper payment for their services except in the case of such patients who are clearly unable to pay for same. 7. That whenever the medical staff or a majority thereof of a hospital or dispensary resigns, and, when after due hearing, this Association finds that the resig nations were for just and sufficient cause, it shall be for Treatment of Influenza. According to Ver. non (La Rev. Med.), there are two main etiological principles to be considered in a study of la grippe. The first is the microbic contagion; the second being the depressing action of cold on the mucous membrane of the respiratory tract. The first is, of course, the most important factor. The disease would have no entity without a specific infection. But the action of cold has an important part. The cold diminishes the natural resistance against microbic infection; it modifies the intrinsic immunity; diminishing phagocytosis. Treatment must be of such a nature as to combat these two causative agents. In the first place if one can artificially re establish the resistance which was depressed by the cold, a normal equilibrium will be resumed and the danger of infection will be safely passed. This can be best effected by stimulating the mucous membrane to a profuse secretion. The mucus is an antiseptic agent capable to attenuate and destroy pathogenic germs. The train of symptoms is almost the same in all cases. After a primary chill, or chilly sensations, headache, swelling of the nasal mucous membrane, and cough fol. low. Fever comes on soon and a general depression is pronounced. The cough is spasmodic and it fatigues the patient by its frequency. The cough is very dry and it is several days before a mucous or muco purulent expectoration is expelled. If thorough treatment is instituted early in the stage of invasion much can be accomplished. Abundant hot drinks with small amounts of alcohol, with large doses of Dover's powders and quinine will bring on a reac tion. The ipecac and opium and quinine exercise a general tonic action; they also have an antipyretic ac tion against the fever; analgesic effect against the mus. cular pains; and cephalalgia. If the cough is distressing it can be calmed by hot mucilaginous drinks and with |