of the disease. In a majority of diphtheria cases, the diagnosis is readily made from the clinical symptoms by a skilled physician. There are, nevertheless, quite a large number of cases of diphtheria that look so much like follicular tonsillitis as to defy the highest skill of the physician to make a differential diagnosis. Here the microscope and culture-tube are of great assistance and should never be neglected. For it is these mild, unrecognized cases that spread the disease widely, especially if the patient attends school. And further, because a case of the disease is mild in one person it is no evidence whatever that the diphtheria bacillus is not highly virulent. This point was illustrated forcibly in the case of a culture-tube sent to the New York City Bacteriological Laboratory from a patient supposed to be suffer ing with an attack of follicular tonsillitis. The diphtheria bacillus was found in the culture-tube, and so reported to the attending physician. He disagreed with the department, and Dr. Wm. H. Park of the laboratory separated out the bacillus in

pure culture and found it highly virulent for guinea-pigs in very small doses. This bacillus is known as Park No. 8, and is now used in every bacteriological laboratory of prominence in the world for the production of diphtheria toxins for the preparation of antitoxin, as it produces the most poisonous toxins of any bacillus found in a human throat.

DR. LOVE: I would like to hear from Dr. Ravold in regard to the toxic effects of antitoxin.

DR. RAVOLD: There have been several fatal cases reported in this and foreign countries of death following an injection of antitoxin.

He

A few weeks ago a physician applied at the health department laboratory here for antitoxin and was given a curative dose for his case. hurried away and we heard nothing more of him. until when asked for a history of the case in which he had used it. He replied that when he reached the house of the patient and was preparing to give the antitoxin the patient suddenly died. Now, if he had arrived an hour earlier and given the antitoxin, another case of death following antitoxin would have been recorded.

In regard to Dr. Nifong's case of death following an immunizing dose of antitoxin, a complete history of the case, with the discussion, can be found in the MEDICAL REVIEW.

believe we should use the remedy in every suspicious case of sore throat; but we should not give the antitoxin credit for curing diphtheria if we are not sure the disease exists. Human nature is very much the same the world over, and bacteriologists do not differ from the rest of us. We know, furthermore, that the specialist in every department, that the man in every position in life who gets into the habit of looking for a given thing can very easily find that particular thing. The man who looks for grievances generally gets them; the man who looks for disagreeable things, the man who trains his nose to seek out disagreeable odors generally discovers them; he who is always looking for trouble generally obtains it. Now, this is why I do not believe the bacteriologist is different from the rest of mankind; and I think that a vivid imagination, referred to by my friend Dr. Ravold, is apt to make up a part of the brilliant bacteriologist. In cases of sore throat, I wonder if our bacteriologists look for the la grippe bacillus or the various other bacilli that may be found. I wonder if they could find the as yet undiscovered scarlet fever bacillus, whether or not they would make a diagnosis of scarlet fever or of any other particular disease represented by the particular bacillus. For instance, suppose we should find in the throat some stray bacilli of tuberculosis, we should not make, from that fact alone (in the absence of fever, cough and other clinical evidences of infection), a diagnosis of tuberculosis; we would wait until we had other evidences of the disease; in other words, the bacteriological evidences of disease are simply confirming evidences; but in spite of this evidence, unless we have a clinical picture of the disease, we are not warranted in making the diagnosis. An individual may have a sore throat; he may be possessed of the native, inherent antitoxin in his system which resists the disease, and in that case he certainly has no diphtheria. But as I remarked in my paper, for more than fifteen years-twenty years I have treated every case of sore throat as a possible diphtheria, locally and constitutionally. I have educated the mothers of the children under my care into the thought that every case of sore throat, every case of irritation of the nose is a possible diphtheria and should be treated as such. I should be afraid to say in these fifteen or more years how few of my cases of diphtheria had died. For

DR. RAVOLD: So far as my experience goes, it seems to have no untoward effect whatever.

DR. LOVE: I advocated the early use of antitoxin, but I suggested that we should report our cases carefully, and when we use the remedy as a prophylactic a careful report should be made.

fully: then suddenly I would be called down by the loss of a patient who was near and dear to me, and I would feel almost like quitting, deserting my profession, and taking to the woods. I now feel differently about it; I believe that I am strengthend definitely and distinctly with antitoxin; and I believe I put it conservatively in my paper

although it may seem pretty strong. But there is still one thought running in my mind, and the remark of the chair called it up. I recollect the case of the child out here at the Christian Orphan Asylum, in the hands of Dr. Nifong, which died from an immunizing dose of antitoxin. I do not remember to have seen many other cases of death recorded. Are there many more, Dr. Ravold? DR. RAVOLD: Oh, yes.

DR LOVE: I do not remember the cases, but I think they are few; and I am disposed to think there may have been some incidental cause not related to the antitoxin. It is certain that unless there is some such danger we should certainly give the child the benefit of antitoxin if it has a suspicious case of sore throat. The point made by Dr. Meisenbach was well taken. Of course, in hospitals and public institutions where the records are carefully kept and cases carefully diagnosticated, the statistics are most reliable. But I think, oftentimes, outside as well as inside of these institutions there is a disposition to make a diagnosis too readily, and sometimes the gentlemen draw largely on a vivid imagination.

case.

DR. R. H. FUNKHOUSER reported a case which showed the necessity for constantly and repeatedly making examination of throat exudates. The case appeared to be one of ordinary sore throat, the right tonsil being somewhat more implicated than the other. The usual local applications were administered and the parents were informed that the patient would speedily recover. In the meantime a specimen was sent to the city bacteriologist. The authorities immediately placarded the house. He was very much surprised at the second visit to find the child's throat well, no exudate being present. Of course, this may have been an exceedingly mild About ten days ago he was called to see that same child: after making an examination of the throat, a specimen was again sent to the city bacterologist. This second attack looked very much like diphtheria. However, the health department reported that it was not diphtheria. The child got well in three or four days; in fact, by the end of the third day the exudate on the tonsils had disappeared. The speaker emphasized the point, that in all cases a bacteriological examination should be made, even though the inflammation may be of a mild type. For if there is any truth in what the bacteriologists have spread throughout the country, that the very mildest cases, if carried through several individuals, may develop into the most malignant kind, then, in these apparently mild cases, there is grave danger. If the first attack of this child was in fact diphtheria, then if other children had been permitted to associate with her, there was danger of spreading the disease, whereas by placarding the house this was prevented.

DR. LOVE: I desire to call Dr. Miller's attention to the fact that the benzoate of soda, to which he refers as a remedy in this disease, was, I think, first suggested or recommended by Salkowski in 1876. I, however, had not noticed it; and the suggestion came to me to use benzoate of soda as a remedy in diphtheria because it stimulates the secretion, it is an eliminating agent, and therefore it is valuable in diphtheria and scarlet fever. As to this, I put myself on record in a paper written in the early eighties. I can readily understand how Dr. Miller and many other active workers and therapeutists who knew the action of the remedy and its indications should have incidentally selected it and applied it. It is the history of all remedies, and it is simply an additional tribute to the remedy. I recall in particular a large, robust, healthy man suffering from laryngeal diphtheria, with an intense dryness of the mouth and pharynx. The administration of calomel and enormous rectal doses of benzoate of soda was followed in six hours by moistening of all the surfaces, increasing each hour. There was free secretion from the kidneys. I gave water liberally in the rectum along with benzoate of soda, and within twenty-four hours he had coughed up a cast of the trachea going down two inches below the bifurcation. However, he died within forty-eight hours from blood poisoning. This is an illustration of how we may have diphtheria present and not discover it locally, though an enormous amount of evidence justifies the diag nosis of diphtheria and its early heroic treatment.

DR. J. J. MILLER: I would like to make an explanation. My attention was called to the use of benzoate of soda by an article written by Dr. J. Solis Cohen, of Philadelphia, in which he stated that the remedy had been recommended by German physicians for the treatment of diphtheria and had been highly successful, but that, so far as he knew, it had not been used in this country. I had been using it, and wrote Dr. Cohen, mentioning the fact that I had used it successfully in two cases. I do not wish to make any claim as to priority in its use, but to emphasize the statement made by Dr. Love, that it is one of the best remedies we have in this disease. There is another point that you can take for what it is worth. It has been my custom in differentiating between diphtheria and tonsilitis, that if the exudate does not extend to the velum and posterior wall of the pharynx within twenty-four or, at most, forty-eight hours to consider it not diphtheria.

THE following is the program for the meeting of the St. Louis Medical Society of Missouri, Saturday evening, May 13, 1899: "Unguentum Crede and its Use in a Case of Septicemia Post-Abortum," by DR. HUGO SUMMA.

GURRENT MEDICAL LITERATURE

*

The Thermal Death Point of Tubercle Bacilli in Milk and Some Other Fluids.-THEOBALD SMITH, in contradiction to other observers, shows that tubercle bacilli are no more resistant to heat than many other bacilli not producing spores, and that at sixty degrees destruction is complete in fifteen to twenty minutes. Even after exposure lasting ten minutes the bacilli were dead in most instances. After five minutes' exposure the inoculation disease produced in guinea-pigs was generally retarded, even though three times the control dose was injected. When, however, milk is used as the suspending fluid, the formation of a surface pellicle into which bacilli are carried by fat globules, shields them from the effect of the heat, so that they may survive an exposure of sixty-five minutes. The importance of a clear understanding of this phenomenon in the pasteurization of milk is obvious, and it remains to be seen how far bottled milk may be freed from tubercle bacilli without resorting to the higher temperature of sixty-eight degress C. now generally employed. Probably a complete immersion, or else a complete filling of the receptacle may furnish the conditions desired. It is likely that the resistance of other pathogenic bacteria in milk is increased in an analogous way.

Clinical and Scientific Contributions upon the Value of the Widal Reaction, Based upon the Study of Two Hundred and Thirty Cases.-ANDERS and MCFARLAND† make the following claims:

1. The disease is not to be excluded on account of the absence of a positive Widal reaction, since genuine cases have been met in which a negative result had been obtained throughout. 2. All cases that react positively are to be regarded as typhoid fever, until a thorough bacteriologic examination fails to reveal typhoid bacilli anywhere in the body, as cases occur in which the usual enteric lesions are entirely wanting. 3. Taken singly, the sero-reaction is the most trustworthy indication of typhoid fever. 4. Although not an early diagnostic symptom, it nevertheless serves to complete the diagnosis in the great majority of cases at the earliest date possible. 5. Since the sero-reaction may be long delayed, and very exceptionally absent throughout, it cannot be solely relied upon for therapeutic purposes. 6. Previous attacks of typhoid fever, within one or two to three years, render the test valueless. 7. In order to secure accurate results, the technic is to be carried forward by a trained bacteriologist.

*Journal of Experimental Medicine, March, 1899. †Philadelphia Medical Journal, April 15, 1899.

The Effect of Streptococci and of Their Toxins on the Liver.-BJOERKSTEIN* investigated streptococcal infections of the liver and saw that after injection into the ductus choledochus, liver infection without general infection could be produced. In earlier cases the streptococci were found in the bile ducts; around the latter round cell infiltration and parenchymatous degeneration are observed. If, however, the toxin alone was injected, in addition to the general phenomena of toxin-marasm, degeneration and decay of the adjoining liver cells with interstitial infiltration and connective tissue proliferation were found. The changes are most pronounced at the place of entrance of the toxins; i. e., near the hilus. If the toxin is injected directly into the liver tissue, degenerative processes mainly ensue. When injected subcutaneously, intravenously, or into the nerves, smaller degenerative or necrotic foci in the liver may arise.

Extensive Bowel Resection.-DREESMANN+ reports a case of resection of the ileum, in which 2.15 meters of the intestine was removed.

The patient, a woman of 37 years, had an inguinal hernia for ten years, which always disappeared when she went to bed. On the evening of peared when she went to bed. May 6, 1898, the hernia did not go back. There was pain and vomiting. Under an anesthetic an attempt to reduce the hernia was made, but without success. A herniotomy was then performed, and the bowel was found extensively gangrenous, caused by a torsion. The bowel was resected until healthy tissue was found; 2.15 meters were removed. The patient made an uninterrupted recovery, and three months later showed no bad effects from the extensive removal of the intestine. The author quotes from several experimental papers in regard to the question of how much bowel it is safe to remove. Senn holds that more than one-third of the small intestine cannot be removed with safety to the subsequent good health of the patient. Trzebicky, from experiments on animals, says that, taking the whole length of the small intestine as 560 c.m., a resection of 280 c. m. can be made. Senn's figures are regarded by the author as the more convincing. From an analysis of twenty-six cases, the author arrives at the following conclusions: First, resection of more than two meters can be borne with safety only by comparatively young and vigorous patients. Second, resection of less than two meters causes no digestive disturbances. Third, resection of more than two meters is followed, as a rule, by digestive disturbances, diarrhea, etc. It was found that a compensatory hypertrophy of the bowel remaining follows in some *Ziegler's Beitrage, XXV, No. 1.

+ Ber. klin. Woch., April 17, 1899.

cases. In young and vigorous individuals this hypertrophy could be counted upon; therefore a resection of two meters or a little more than one-third of the bowel might be done. In cases of old or enfeeb'ed people, as no such compensatory hypertrophy can be expected, an extended resection should not be attempted.

A Study of the Spinal Cord by Nissl's Method in Typhoid Fever and in Experimental Infection With the Typhoid Bacillus. As the result of very careful research, J. L. NICHOLS* comes to the following conclusions: 1. The motor cells of the spinal cord and the nerve cells of the dorsal root ganglia undergo pathologic changes during

typhoid infection. 2. The alterations in the motor cells are more constant, and of a severer grade than are those in the cells of the sensory ganglia. The more characteristic changes consist of disintegration, solution and destruction of the chromatic substance of the cell, starting from the axone hillock and proceeding towards the nucleus. Coincidently the nuclei of the affected cells seek the periphery. Alterations are also suffered by the nucleus and nucleolus. 3. While this central form of chromatolysis is the prevailing type, disintegration of the Nissl bodies, situated in the periphery of the cells and in the dendrites, is also observed. 4. In experimental infection, similar changes are found. The peripheral nerves arising from the lumbar section of the cord show well-marked parenchymatous degeneration. 5. It is probable that lesions of the peripheral nerves in typhoid fever patients are common, and that the post-typhoid hyperesthesia and paralysis are due to this cause. As restoration of the chromatic granules may take place in the affected nerve cells, the new formation beginning about the nucleus and extending through the protoplasm.

Treatment of Colle's Fracture.-BARNES describest a new dressing for the treatment of this fracture. He has found that the usual pistol shaped splint has given most unsatisfactory results, which has led him to use a simple strip of adhesive plaster about the broken wrist. This, as far as it goes, is all right, as the dressing proposed by him gives considerably more freedom than the more fixed dressings. There is accumulating evidence to the effect that all retentive appliances in the treatment of this fracture are worse than useless. Results have been reached by massage, both in the prevention of deformity and in the adhesion of tendons, which have not been approached by any of the dressings so far used. The immobilization of fractures has been so long before the profession that it seems almost like flying in the face of the *Journal of Experimental Medicine, March, 1899. +Medical Record.

best established traditions to recommend other than the usual fixed dressings. It is evident that so radical a departure as the treatment of this fracture without splints will only be reached by degrees, one step in this direction being the proposed modification of Barnes'. The dangers of immobilization, after fractures of the lower end of the radius, are adhesions of the tendons and a partial ankylosis of the wrist. This may be avoided if early massage and passive movements are employed. They are much more serious than the slight deformity which usually occurs after this fracture. The amount of deformity in cases in greater, indeed if it is so marked, as when which no retentive appliances are used, is not thorough immobilization is secured.

The Introduction of Foreign Serum Into the Circulation.-FRIEDENTHAL and LEWANDOWSKY* claim that if a proteid preparation is to be introduced for alimentary purposes with the avoidance of the intestinal tract, it must be easily assimilable, non-poisonous and germ free. The authors found that the serum of animals possessed these three qualities as soon as its toxicity is done away with, by heating the serum for about two hours to fifty-five or sixty degrees. It loses in this way its globulicidal and toxic qualities, and can be injected in large quantities, without producing detrimental effects. The authors believe that human blood withdrawn during venesection, supposed that it is not taken from febrile and infected patients, could be utilized for artificial nutrition, especially since it can easily be obtained sterile.

A Case of Tabes Dorsalis with Bulbar Paralybination. The patient is fifty-five years old and is sis.-M. BLOCH† reports a case of this rare coma teacher. No hereditary history, no excesses of alcohol or tobacco, no syphilitic infection. No special trauma, nor does his profession demand any excessive physical exertion. P. is married and has two healthy children; two have died at an early age. His wife has had one abortion.

His sickness began eight years ago with lightning pains in the legs, weakness, girdle sensation, paresthesia in the hands. In 1893 paralysis of the muscles of the right eye, with double vision; since 1896 progressive decline in the sharpness of his sight. Atactic condition marked in the upper extremities. One year ago P. complained of a feeling of numbness in the right half of the tongue and of the right side of the face. Saliva flowed from the corners of the mouth. The patient could not swallow normally, and fluids often came through the nose.

Physical Examination.-Lungs and abdomen are negative. The heart is enlarged in all directions. *Ber. klin. Woch., 1899, No. 12.

+Neuroglishe Centralblatt, April 15, 1899.

Ophthalmoscopical Examination gives the typical white degeneration of the optic nerve. Anesthetic areas in the region of the fifth nerve. The speech is a typically bulbar-nasal, hoarse, monotonous. Marked paresis of the facial on both sides. Lips are thin. The mouth is held half open and the saliva drips continuously from the corners of the mouth. The tongue moves to the right on protru sion. The muscle is thin, flaccid, and shows febrillary twitching.

Laryngological Examination.—Sensibility of the pharynx somewhat diminished. The right vocal

cord shorter and smaller than the left and less

tense. Glottis smaller than normal. Adduction follows almost to the middle line, with the exception of a small oval space of the right cord. Abduction of the right vocal cord entirely lost, while

the abduction of the left is normal.

Diagnosis.-Right posticus paralysis with conservation of the superior laryngeal. Hypalgesic in the region of the right ulnaris. The gait is atactic. Right patellar reflex can be obtained by reinforcement. The electrical examination of the tongue and lip muscles give slight change of quantitative reaction; no qualitative change.

The interesting points brought forward by Bloch in this case are: the coincidence of aortic disease with tabes and the bulbar symptoms. He considers the laryngeal condition as a part of the tabes and not to be taken in connection with the bulbar paralysis.

The Action of Streptococci and of Their Toxins on Peripheral Nerves, Spinal Ganglia and the Spinal Cord.-HOMEN and LAITINEN* find that virulent cultures of streptococci injected into the peripheral nerves extend in a distal as well as in a proximal direction by means of the lymph channels of the nerve fasciculi. They get into the cord mainly by the way of the posterior roots and proliferate here within the intermeningeal spaces, mostly in the neighborhood of the roots; but they penetrate, too, by means of the septa and of the pial vascular sheaths into the interior of the cord. In a week after the injection no more streptococci are fonnd in the cord. They are, however, still found, although in a degenerated *Ziegler's Beitrage, XXV, No. 1.

nerves.

condition, at the site of injection in the peripheral From the intermeningeal spaces of the cord propagation takes place towards the brain. The pathologic changes are generally in the beginning more of a degenerative character, and later on inflammatory and sclerotic. Sometimes even partly destructive processes take place; sometimes the changes are merely exudative. Microbes and pathologic changes are more generally found in the posterior than in the anterior roots. On injection of bacteria (not of the toxins) the changes are seen first around the cocci. These investigations are to a degree a support for the opinion that several cord affections, just as well such of degenerative as of inflammatory character, are of infectious or toxic origin. In particular they form a basis for the theory of ascending nephritis.

The Visor-Plastic Operation for Replacing the Lower Lip.-ALFRED STIEDE* describes the operative procedure for cancer of the lower lip as practiced in the clinic of Prof. v. Eislesberg, in Königsberg. A curved incision from one angle of the mouth to the other, extending far into the healthy tissues, removes the entire lower lip. A second incision parallel to the former and somewhat longer, is made about midway between the joint of the chin and the hyoid bone. The tissue bridge this left must, when drawn up to form a new lip, be large enough still to cover the inferior maxilla. The skin flap is now loosened from deeper structures, beginning below and going as far as the jaw-bone. The knife is now thrust through the remaining tissues adhering to the bone and the same cut loose to both sides. After the tissues

covering the chin have in this way been made sufficiently movable they are drawn upward like the "visor of a helmet" till the upper edge of the defects stands higher than the lower lip did. A nail driven into the middle line of the maxilla holds all in place. The defect beneath the chin can be left to granulate or be treated with transplantation.

Since April, 1896, v. Eiselsberg has operated on twenty such cases and is fully satisfied with results obtained as regards covering the teeth and preventing the escape of saliva. In no case did gangrene of the "visor" occur.

Remote Consequences of Gastro-Enterostomy. -HARTMAN and SANPOULT.+

1. General Results.- No matter what the cause

for operation, the subjective symptoms disappear in most cases, and with them the infective process accompanying stagnation.

The weight increases markedly in non-malignant disease; of course less in malignant. Most surgeons agree that seven months is the average *Deutsche medicinische Wochenschrift, 1899, No. 13. + Revue de Chirurgie. March 2, 1899.