was as persuaded of the curative effect of his remedy gists. About one-third of the article is devoted to the

TWENTIETH CENTURY PRACTICE. An International
Encyclopædia of Modern Medical Science by Lead-
ing Authorities of Europe and America. Edited by
Thomas L. Stedman, M.D., New York City. In
Twenty Volumes. Volume II., Nutritive Disorders.
New York: William Wood & Company. 1895.
WE have received the second volume of this most ambi-
tious work, and we must admit that the expectations
that were raised by the first volume are more than ful-
filled by the contents of the one before us. This vol-
ume differs from the one that preceded it in that the
subjects treated of are wholly medical in their nature,
relating for the most part to the results of disturbances
in the nutritional processes. The first article is a short
but instructive exposition of diseases of the supra-re-
nal capsules by Sir Dyce Duckworth, of London. The
subject is still one that calls for much study and inves-
tigation, but this article goes quite a way toward the
solution of some of the problems connected with dis-
ease of the adrenals. This is especially the case in re-
gard to degenerations of these bodies, the results of a
number of original researches by Kanthack and oth-
ers, hitherto unpublished, being here presented for the
first time. The greater part of the article is naturally
devoted to Addison's disease, which the author seems

Society Reports.

NEW YORK ACADEMY OF MEDICINE.

Stated Meeting, April 4, 1895.

JOSEPH D. BRYANT, M.D., PRESIDENT,

CHAIR.

IN THE

Portrait of the Late Dr. Valentine Mott.-An oil portrait of the late Dr. Valentine Mott, copied from an original painting made in 1865, the gift of his daughter, Mrs. Isaac Bell, was presented, in a few appropriate words, by DR. ELY, at whose suggestion Mrs. Bell had had the copy made.

THE PRESIDENT, in some remarks accepting the generous and highly prized gift, said one could not express more forcibly the debt of the profession to Dr. Mott than to quote the words of Sir Astley Cooper, that Dr. Mott had probably performed more and greater operations than any living man.

The Late Dr. Loomis.-DR. POLK, of the Special Committee, read some resolutions on the death of the late Dr. Alfred L. Loomis, which will be found on another page. The meeting set apart for the memorial exercises will be held on the first Thursday in May, not the first Thursday in June, as announced previously.

Department of Charities and Correction.-DR. ANDREW H. SMITH, of the Special Committee appointed. to consider the Advisability of separating the Department of Charities and Correction, read a report setting forth at some length reasons why there should be a division into two entirely distinct departments of the city's dependents and its criminals. The arguments were based upon such well-known facts as that the combined department had become unwieldly; the original act had contemplated their separation; there was no natural law of association of the dependents (including the poor, the sick, the blind, the insane, etc.) with the criminals; no official board could become expert in both branches, and indeed the very qualifications which fitted an officer for dealing with criminals unfitted him for dealing with dependents. To be sent to the "Island" cast a stigma upon the innocent dependent the same as upon the criminal; appropriations were refused the one class because associated with the other. The report concluded with the following resolution, which was adopted without opposition: "Resolved, That the New York Academy of Medicine respectfully urge upon the Legislature now in session the passage of an act by which the existing Departments of Charities and Correction in the city of New York shall be abolished, and two separate and distinct departments be created, one of Charities and one of Correction."

66

Diphtheria Antitoxin.-The following papers, to be found on pages 481 et seq., were then read: 1, Some experiences in the Production and Use of Diphtheria Antitoxin," by Dr. H. M. Biggs; 2, "The Technique of the Production of Diphtheria Antitoxin," by Dr. W. H. Park; 3, "Experiences in Diphtheria Antitoxin for Immunization," by Dr. G. H. Peck; 4. "The Autopsies on Persons Dying after Treatment with Diphtheria Antitoxin," by Dr. George P. Biggs.

Opposed to Antitoxin.-DR. JOSEPH E. WINTERS, in opening the discussion, said:

MR. PRESIDENT: Some months ago I shared with my colleagues the hope that a specific against the toxins of the diphtheria bacillus had been discovered, but three months of daily observation in the Willard Parker Hospital has been a sad-an extremely sad disappointment to me, and I regret to say that, as a result of that experience, I am here to-night to speak in opposition to the antitoxin treatment of diphtheria. My remarks will be

based entirely on three months of daily clinical observation of the effects of the antitoxin in one hundred and fifty-four cases of diphtheria treated in the Willard Parker Hospital. In the paper of the evening reference has been made to the effects of the antitoxin on the pseudo-membrane of diphtheria. What I have to say with reference to this may be best illustrated by referring to four cases which were recently admitted into the Willard Parker Hospital in the course. of one day.

Case I. had a few patches of pseudo-membrane in various portions of the throat, showing that the exudate had already exfoliated, only small portions of it remaining.

Case II. had pseudo-membrane on both tonsils, which was thick at the edges, and exfoliation had already begun, in some places being detached from the mucous membrane one-eighth of an inch.

Case III. was in the early stage of the disease process. The pseudo-membrane was thin at the edges, involving the tonsils and slightly the pillars of the fauces. At one point there was inflammation at the edge of the pseudo-membrane.

Case IV., a septic case, with an abundance of membrane on the tonsils and pillars of fauces and some on posterior wall of pharynx.

In Case I., where detachment of membrane was nearly complete before patient was brought to hospital, the throat cleared rapidly. In Case II. the exfoliation, which had begun at the time of admission of the patient, continued, but some membrane remained on pillars of fauces and on tonsils ten days after admission. Case III. was free from membrane for first time on tenth day after admission. Case IV., the septic case, lived three days. During this time, though thoroughly under the influence of antitoxin treatment, the antitoxin never made the slightest impression on the symptoms of toxæmia. These four cases may be taken as a sample of what I have seen repeatedly at the Willard Parker Hospital during the three months of antitoxin treatment of diphtheria. In not a single case has there been the least evidence that the formation of the pseudo-membrane was checked, that the exfoliation. of the pseudo-membrane was hastened, or that the throat was free from membrane earlier than in cases which have not been treated by antitoxin. In not a single septic case has the antitoxin made the least impression on the symptoms. The toxæmia has not in one instance been relieved or lessened. There has been no indication in the character or frequency of the pulse, or in the general condition of the patient, that a specific for the toxæmia had been administered.

Reference was next made in the paper of the evening to the laryngeal cases of diphtheria, and I should like to ask the author of the paper and those who are supporters of the antitoxin treatment, why it is that antitoxin should be administered for the relief of the laryngeal stenosis due to a diphtheritic pseudo-membrane? While the diphtheritic process remains confined to the laryngeal mucous membrane there is no toxæmia. There is, therefore, no indication for the exhibition of an antitoxin. It has been stated in the paper that the death-rate in the laryngeal cases under the antitoxin treatment has been lower than under the methods of treatment in vogue before the use of antitoxin, but in so doing he compares results one year ago. with the results during the past three months. author has neglected to state to the Academy that at the Willard Parker Hospital, in the month of December last, we had eight consecutive recoveries after intubation in cases of laryngeal diphtheria without antitoxin. During the same month at the Foundling Asylum in this city, out of fourteen cases of intubation for laryngeal diphtheria there were twelve recoveries without antitoxin. At the Willard Parker Hospital in the month of December, 1894, the recoveries from laryngeal diphtheria without antitoxin were about seventy-five per

The

ness.

fraud. At the trial Dr. Long, medical officer at the Berlin law courts, was asked by the defendant's counsel if it was not possible to cure "consumption." Dr. Long answered that it would be as easy to fetch a star from the sky as to find a universal remedy for this illThe defendant's counsel asserted that his client was as persuaded of the curative effect of his remedy as Professor Koch was of tuberculin, and could, therefore, not be made responsible because it was a failure. Dr. Long answered that in his opinion they were, both Dr. Koch and the defendant, guilty of the same crime, and he did not understand the public attorney only prosecuting the little and not also the great thieves. This allusion caused the utmost sensation in the court. The judge said he was sorry he must blame Dr. Long for comparing a scientific authority like Professor Koch with a quack. The defendant was condemned to three months' imprisonment.-Lancet.

Suicide in Chicago.-According to Coroner McHale, Chicago suicides have averaged one a day for the past three months. The average but equals that of the World's Fair year.

Intravenous Saline Infusions. At a recent meeting of the New York Surgical Society, reported in the Annals of Surgery, Dr. Dawbarn stated his opinion that the amount of fluid usually recommended for intravenous infusion in hemorrhage was ridiculously small. A smaller amount than a quart will seldom be of much use, and in bad cases this should be repeated several hours later, as indicated. It is a bad rule to replace the blood lost at an operation only by an equal amount of salt water. The inward bleeding from shock, especially into the patient's own veins should not be forgotten. The chief advantage of infusion is the effect. of the bulk of the fluid, which makes possible effective action of the heart.

Reviews and Notices.

TWENTIETH CENTURY PRACTICE. An International
Encyclopædia of Modern Medical Science by Lead-
ing Authorities of Europe and America. Edited by
Edited by
Thomas L. Stedman, M.D., New York City. In
Twenty Volumes. Volume II., Nutritive Disorders.
New York: William Wood & Company. 1895.
WE have received the second volume of this most ambi-
tious work, and we must admit that the expectations
that were raised by the first volume are more than ful-
filled by the contents of the one before us. This vol-
ume differs from the one that preceded it in that the
subjects treated of are wholly medical in their nature,
relating for the most part to the results of disturbances
in the nutritional processes. The first article is a short
but instructive exposition of diseases of the supra-re-
nal capsules by Sir Dyce Duckworth, of London. The
subject is still one that calls for much study and inves-
tigation, but this article goes quite a way toward the
solution of some of the problems connected with dis-
ease of the adrenals. This is especially the case in re-
gard to degenerations of these bodies, the results of a
number of original researches by Kanthack and oth-
ers, hitherto unpublished, being here presented for the
first time. The greater part of the article is naturally
devoted to Addison's disease, which the author seems

inclined to regard as anatomically, in many cases at least, a tuberculosis of the adrenals.

Diabetes Vellitus "is the title of the second article, which is contributed by Von Noorden, of Frankfort-onthe-Main. We have been agreeably disappointed in this article because of its exceedingly practical character a quality which we are not accustomed to look for in the writings of German physiologists and pathologists. About one-third of the article is devoted to the subject of treatment, the question of diet coming in for an extended discussion. Not the least interesting portion of the treatise is that relating to the nature and causes of diabetic coma.

The third article is on rheumatism and is very appropriately handled by the originator of the specific treatment of the disease, Dr. Maclagan, of London. Whether the reader agrees or not with the author as to the miasmatic nature of rheumatism he cannot read without interest the exposition of the theory here made, since it was upon it that Dr. Maclagan based his salicyl treatment, than which few therapeutic discoveries of recent years have been more efficacious in relieving suffering and saving life.

Following this is a very long yet readable article on gout, by the only American contributor to the volume, Dr. Henry M. Lyman, of Chicago. The section on pathology is interesting, and that on treatment seems to be thoroughly practical and detailed. The writer accepts in great part Garrod's theory as extended and elaborated by Haig concerning uric-acid formation and excretion.

Dr. Archibald E. Garrod supplies the article on arthritis deformans. He writes well, and the paper contains a presentation of the latest views on the subject, yet it is valuable chiefly, it seems to us, in showing how little is really known as yet concerning the true nature of this disease.

Following this is a treatise on diseases of the muscles by the late Dr. Dujardin-Beaumetz, of Paris. It does not include tumors or other surgical diseases of the muscles, but is confined to a description of the various forms of myositis and of the trophic myopathies. Only the essential muscular paralysis, so-called, are considered here, the reader being referred to the volumes on nervous diseases for a description of those which are due to some obvious nerve-lesion. As Dr. Dujardin-Beaumetz died in February last, this must have been one of the last works written by him, but it betrays no sign of weakness, being written in the same lucid, and what we might call reiterative, style which characterizes the many works of this most prolific writer.

Professor Oertel, of Munich, contributes the article 66 Oeron "Obesity," with which the volume closes. tel's" is known as one of the most successful methods of treating obesity, and we are glad to find here a description of the method in the inventor's own words. In this article, as in that on diabetes, the section on treatment is recognized as the most important, and is the one to which the greatest space and the most detailed description are devoted.

We have been at some pains to test the index of this volume, and have found it very satisfactory. In a work of reference, or in any other for that matter, a good index is of such vital importance, that it seems but proper to note its presence or absence, as also its degree of excellence or the reverse. This volume will doubtless be welcomed by the general practitioner, for whom most of the subjects here treated are of absorbing interest, relating, as they do, to affections which are of common occurrence, yet of more or less obscure patholIt is an encouraging sign to find so much space devoted to the therapeutic management of these diseases, for it is an evidence that the authors do not regard their treatment as hopeless. The work of translating the foreign articles has been well done, for they read as smoothly as though written originally in Eng

ogy.

lish.

cent. This has never been equalled with the antitoxin treatment with or without intubation.

The paper of the evening deals largely with statistics. I wonder if the members of the Academy have noticed that the author treats the matter of statistics largely by elimination and exclusion. In comparing the results of antitoxin treatment with the former methods of treatment, in the antitoxin cases he excludes numerous deaths for one or another reason, while in speaking of the results before antitoxin treatment no deaths are eliminated. The facts are that during the first three months of 1894 the death-rate at the Willard Parker Hospital without antitoxin was thirty-two per cent. During the first three months of 1895 with antitoxin treatment the death-rate was twenty-eight per cent. But in order to make it clear to you that this mortality rate does not represent the exact state of things as it should, I will ask you to consider for a few moments the class of cases which have been brought into the Willard Parker Hospital for antitoxin treatment during the past three months. In many of these cases there has been no clinical evidence of diphtheria. They were cases of diphtheria from the bacteriological stand-point only. Examination of the nose and throat, examination of the constitutional condition of the patient, revealed no evidence of diphtheria. They had in the throat the KlebsLoeffler bacillus, but the presence in the throat or in the nose of this bacillus, in the absence of any lesion, is not evidence of the existence of diphtheria. I should like to know why antitoxin is used in cases where the presence of the Klebs-Loeffler bacillus is the only evidence of diphtheria, when it is a well-established fact that the antitoxin treatment has no influence on the bacillus-it persists as long in cases treated with antitoxin as it does in cases treated without it.

During the first three months of 1894 no case of diphtheria was seen in the Willard Parker Hospital that did not have abundant clinical, as well as bacteriological, evidence of diphtheria. These cases of socalled "diphtheria" without any of the clinical manifestations of the disease, should be eliminated from the statistical report, and there have been a score or more of such cases during the past three months, and were these cases eliminated from the list, the death-rate under antitoxin treatment during January, February, and March would be much higher than it was during the corresponding months of 1894; and this, too, at a time when diphtheria is far milder than it was one year ago. Some of the cases brought to the hospital in February and many of those admitted in March are still very ill and will surely die. Were these included, the mortality during the antitoxin treatment would be startlingly high.

The author of the paper, like all others who have written about the antitoxin treatment of diphtheria, has insisted upon early treatment as a sine qua non for the best results, but the record from which Dr. Biggs has prepared his paper will show that the first two cases on the list which recovered had their first injection of antitoxin on the eighth and sixth days respectively.

In the next seven cases on the list the first injection was given on the fourth day in two cases, on the fifth day in two cases, on the third day in two cases, on the sixth day in one case, and all died. Case XXIV. on the list had first injection on the ninth day and recovered. One case, injection on second day, died. One case, injection on tenth day, got well, and one injected on the third day died; and so on throughout the list. It is not the date of first injection which determines the result, but it is the individual character of the case and the nature of the disease.

At the Willard Parker Hospital any case which, at the time of admission, has given evidence that the disease was progressive in its course, that course has not been stayed or changed in any particular by the antitoxin treatment.

It has also been stated that the serum used in the

early part of the antitoxin treatment at the Willard Parker Hospital was so weak that little could be expected from it. A careful study of the record will show that the cases which were treated with the weaker serum did better than those which were treated with the stronger serum. Again, a study of the records will show that those who had the smaller dose of serum did better than those who had a larger dose. In fact, a careful study of the individual cases of diphtheria treated with antitoxin in the Willard Parker Hospital will show that there has been no relation between the antitoxin treatment and the recoveries. As to the early treatment of diphtheria with antitoxin, it may be definitely and confidently stated that diphtheria at the present time, almost invariably recovers under any method of treatment if brought under proper hygienic surroundings and surveillance on the first day of the disease. Diphtheria is scarcely ever fatal if the patient is put to bed and properly cared for on the first day of the illness. It is the insidiousness of diphtheria which constitutes its greatest danger.

Now as to some of the untoward or unfavorable effects of the antitoxin treatment. The rashes have been spoken of in the paper, and some of the minor features attributable to antitoxin, but the more serious effects of the antitoxin treatment have not been alluded to.

I will ask you to go with me for the time being to the Willard Parker Hospital and see some of the effects of antitoxin which I have witnessed there. Babies have been brought to that hospital with slight clinical evidence of diphtheria, babies, with the exception of a slight exudate in the throat, and perhaps a slight croupy cough, that were apparently healthy and with rosy color. They remained in good condition for perhaps ten days or two weeks after receiving antitoxin, when one day as you enter the ward you hear a moan, and approaching the crib you find the baby lying on its side with its head retracted, its arms and legs flexed, and moaning piteously. I can best make it clear to you what this baby's condition is by relating to you a case about which I was consulted. A physician came to my office to advise with me regarding his wife. Two weeks previously this lady had had a slight sore throat, and a medical friend had immediately injected her with antitoxin. The following day it was decided that she had no diphtheria, but a slight tonsillitis, and the throat was all but well. Fifteen days after the injection of antitoxin her temperature was 105° F., pulse 160, and she was suffering severe pain in all her joints. Sleep and rest were absolutely impossible except as obtained by large doses of morphine administered hypodermically. This was a case of antitoxin infection. In her case the antitoxin eliminated itself and the patient recovered. This is the condition in which I have seen many of the little babies in the Willard Parker Hospital. The temperature chart shows a record of 105° to 106.8° F., and a note of the night nurse tells that the patient has scarcely slept at all. This antitoxin infection pursues one of two courses, either the symptoms may gradually subside, leaving the baby emaciated and extremely anæmic, or there may be a fluctuating temperature, ranging from 99° to 106.8° F. and existing for days together. What is this condition? It is due to the action of the antitoxin on the blood. Horse serum dissolves human blood corpuscles, and thereby produces new elements of decomposition. The condition of the babies just spoken of was one of antitoxin septicemia, and brought about by the influence of the antitoxin on the blood. A further evidence of septicæmia was in occasional suppurations, as seen in one case in the neck and ear, in another in small points of suppuration in various portions of the body. In these cases we have a temperature range such as has not been seen in the hospitals of this city since the introduction of aseptic surgery. This is a temperature