States have furnished scientists whose names will remain associated with the most important means of advancing scientific medicine in the nineteenth century. Prominent among these are the original discoveries and the additions thereto which have been made by the different contributions of such observers and scientists as Schwann (1839), Ehrenberg (1840), Dujardin (1841), Robin (1853), Schröder and Van Dusch (1854) and Devaine (1859); and by the later advanced work of Pasteur, Cohn, Hoffman, Tyndall, Koch, Polender, Eberth, Klebs, Löffler, Schultz and others. In this country the works of Surgeon-General Sternberg, Abbott, of Philadelphia, and others are important. A mention here of the specific work of any of these contributors may not be attempted. A partial list of recent publications in this department, and a few references to the journal literature of the same, will be given.

Present Outlook.

In this, as it ever is in matters where change, whether for better or worse, is involved, different opinions obtain in the professional world. There are those who, from want of knowledge and the consequent ability to observe and judge rightly, are active in unintelligent opposition. Well informed, scientific workers, not unmindful of the magnitude and difficulties of their work, are too busy to regard unworthy objections, and are patient in their efforts to discover and utilize what is valuable. In our present study and outlook the following appears: New terms and new material have found a place in our materia medica, some of which seem to have acquired a permanence. "Inmmunity and Serum Therapy" is the title of a practical work by Sternberg. The terms are properly applied; the first, to a feature or condition in pathology and physiology now understood; the second, to effective modern therapeutic means for the relief and prevention of disease The question of what constitutes immunity of the body from disease infection, and how it is induced, has long been a subject of study The knowledge of bacteria, of what may occur in connection with their pathogenic action, their agency and behavior in the different forms of tissue pathology, now seem to promise a satisfactory solution.

It is found, that immunity may be natural to the body, may be produced by an attack of the infectious disease, or secured by artificial means. The first is seen, for instance, in localities subject to yellow fever, where a certain percentage. of the native inhabitants are found to be incapable of contracting the disease. It is not uncommon during the prevalence of diphtheria among children to find in the throats of attending adults, who have never suffered from the disease, the diphtheria bacillus, which does not

produce infection. Immunity of the second kind is well known as resulting from attacks of ordinary contagious diseases, and varies in completeness and permanence in different diseases and persons. The immunity obtained by artificial means is what especially concerns our present observation. The following is given as a brief explanation: Pathogenic bacteria affect the animal organism in two principal ways: first by depriving the cells of different animal tissues of oxygen and nitrogen, appropriating the same to themselves in their multiplication and growth; and second, by infecting the solids and fluids of the body by certain toxic substances which they secrete. These toxic substances, which in full strength are in a greater or less degree injurious to the tissues and may cause death, may so affect the body as to prevent after infection by the same or a similar germ. These germs may be isolated and reduced by cultures outside the body. Attenuated cultures may still contain toxins whose virulence has been reduced. antitoxin is a substance elaborated by the animal tissues in reaction to a toxin. The methods of obtaining from the tissues and of preparing the various antitoxins for therapeutic use are various, and require skillful manipulation by expert hands. The antitoxins, when prepared, are used by inoculation. Thus, in the warfare of disease the army of defense is strengthened, successful opposition favored, and the resulting condition of the country, immunity, is the guarantee of future protection.

An

Credit for the discovery that animals may be rendered immune to specific infections by the injection of the products of disease germs is given to Pasteur, who, in 1880, experimented with fowls in the disease known as chicken cholera.

The different antitoxin serums have become numerous, but as yet are found to vary to some extent in their effectiveness in securing the desired result. We have serum antidiphtheria, antipneumonia, antibubonic, antirabic, antisyphilitic, antitubercle, antityphoid, antitetanic, antistreptococcic, antivenomous, etc.

Great and continuous efforts on the part of many able scientists have been required to advance the standard of serum therapy to what appears at the present time, but more time will be required before the desired results can be secured in the treatment and prevention of im

portant diseases now under experimental study. It is generally admitted that the antitoxin treatment of diphtheria has afforded better results than has been realized in that of any other disease. A recent estimate is given as follows: "From the most trustworthy statistics that are now available, it appears that the actual mortality from diphtheria including membraneous croup) has been reduced at least one-half by the general adoption of the serum treatment."* In this connection comes the thought that greater results may be expected when physicians generally become more prompt in the application, and are always in possession of a high grade of antitoxin serum. As prophylaxis is better than cure, greater advantage may be made possible by securing immunity in the bodies of those exposed to the contagion.

In tetanus and rabies, and now in pneumonia, good results are claimed from the use of the serum treatment. Cases of trismus nascentium are reported as successfully treated by the tetanus antitoxin.

In the matter of the tuberculin treatment of tuberculosis, greater difficulties have been experienced than, perhaps, in that attempted in any other disease. Great credit is due to Koch for his continued efforts and valuable discoveries in this important study which point to a future success. The character of the disease and the varieties and complications found in its various forms are the chief elements of difficulty. Many scientists are still at work in this investigation. An American physician has recently reported concerning his success as follows: "The scientific gain of my investigation is the preparation of a really antitoxic and bactericidal antiphthisic serum, with a probability next to a certainly we may expect this serum to become an important factor in the preventive and curative treatment of human tuberculosis." The use of mallein in the diagnosis of glanders, and the Widal test, or the serum diagnosis, of typhoid fever, are established procedures of great value in the study and management of these diseases. Because of the extent and importance of typhoid fever, great interest has attended the studies in bacteriology pertaining to its etiology, pathology, prevention and treatment. An exhaustive account of laboratory investigations of the bacteriology of this disease, as shown in the serum diagnosis, appears in the Journal of the American Public Health Association for April, 1898. *

These diseases and their treatment by serum therapy are mentioned as illustrative rather than as an approach to a summary of the scope of

* Jacob Friedman, Jour. Am. Med. Assn., Oct. 9, 1897.

+ Carl Fisch, M. D., St. Louis, Mo., Jour. Am. Med. Assn., Oct. 30, 1897.

this treatment. It must be borne in mind, however, that other valuable means and methods may not be supplanted by what is contained in this. Discoveries in bacteriological pathology have not only extended the field of therapeutic measures, but have increased our knowledge of the value and the reasons therefor of means and methods long since in use. For instance, in tuberculosis, correct climatic influence and supporting treatment, cod liver oil and hypophosphites may tend to secure a degree of immunity by improving organic action and vitality in the tissues. Disinfecting the alimentary canal and judicious elimination in typhoid fever are in opposition to the life and activity of bacteria. Rational practice in medicine will endeaver to accept what has merit in the new, and to hold fast to what is valuable in the old.

In this brief mention of what appears in the present general outlook concerning medical bacteriology in its relation to the medicine and surgery of the present time, no full account has been attempted. What is given may in a measure be illustrative and suggestive as to the present direction of a study in science which has already afforded much of value, and now promises still more important and beneficent results and victories in the great arena of practical medicine.

Bibliography.

Some of the recent publications on bacteriology are shown in the following list of works by English, German, French and American authors:

Works in English:

Sternberg; Manual of Bacteriology; New York, Wm. Wood & Co., 1895.

Sternberg; Immunity and Serum Therapy; New York, Wm. Wood & Co., 1895.

Muir & Ritchie; Manual of Bacteriology; London, Pentland, 1897.

Abbott; Principals of Bacteriology; Philadelphia, Lea Bros., 1897.

Schenk; Elements of Bacteriology; London and New York, Longmans, Greene & Co., 1893. Crookshank; Text Book of Bacteriology; Philadelphia, W. B. Saunders, 1897.

McFarland; Text Book Upon the Pathogenic Bacteria; Philadelphia, W. B. Saunders, 1890.

Klein; Microorganisms and Disease; London, Macmillan & Co., 1896.

Kanthack; Course of Elementary Practical Bacteriology; London and New York, Macmillan & Co., 1895.

Woodhead; Bacteria and Their Products: New York, Scribner & Welford, 1891.

Hueppe; Methods of Bacteriological Investigation; New York, Appleton, 1897.

Senn; Surgical Bacteriology; Philadelphia, Lea Bros. & Co., 1891.

Salmonsen; Bacteriological Technique (English Translation).

De Bary; Lectures on Bacteria; Oxford, Clarendon Press, 1887.

Frankland; Microorganisms in Water; London, Longmans, Green & Co., 1894.

Novy; Ptomains and Leucomains; Philadelphia, Lea Bros., 1898.

Eisenberg; Bacteriological Diagnosis; Philadelphia, F. A. Davis, 1892.

Miller; Microorganisms of the Human Mouth; Philadelphia, S. S. White Dental Mfg. Co., 1890.

Works in French:

Corneil & Babes; Les Bacteries; Paris, Felix Alcan, 1886.

Desflocq; Lecons sur les Bacteries Pathogenes; Paris, Masson et Cie, 1897.

Nocard & Leclainche; Les Maladies Microbiennes des Animaux; Paris, Masson et Cie, 1896.

Charrin; Poisons de l'Organism; Paris, Masson et Cie, 1896.

Macé; Traité Practique de Bacteriologie.
Works in German:

Flugge; Die Mikroorganismen; Theil I, II. Leipsig, Vogel, 1896.

Migula; System der Bacterien; Erster Band, Jena, G. Fisher, 1897.

Frankel & Pfeiffer; Microphotographischer Atlas der Bacterienkunde; Berlin, Hirschwald, 1896.

Fischer; Verlesungen uber Bacterien; Jena, Gustav Fischer, 1897.

Stubenrath; Das Genus Sarcina; Munchen, Lehman, 1897.

Levy & Wolf; Bacteriologisches Notiz und Nachschlagebuch; Strassburg, Friedrich Bull,

1897.

Busse; Heen als Krankheitserreger; Berlin, Hirschwald, 1885.

Brieger; Uben Ptomaine; Berlin, Hirschwald, 1885.

Gunther; Einfuhring in das Studium der Bacteriologie.

Brieger; Weitere Untersuchungen uber Ptomaine; Berlin, Hirschwald, 1885.

The following are the principal periodicals devoted especially to bacteriology and allied sciences now published.

Journal of Pathology and Bacteriology; London. Pentland.

Journal of Exeprimental Medicine; N. Y. Appleton.

Baumgarten; Jahresbericht uber Pathogene Mikroorganismen; Braunschweig. Harold

Bruhn.

Centralbatt fur Bacteriologie; Jena. Gustav

Fischer.

Zeitschrift für Hygiene, &c.; Leipsig. Von Voit & Co.

Archiv für Hygiene; Munschen. Oldenbourg.

Annales de l'Institute Pasteur; Paris Masson et Cie.

In addition to what appears in the foregoing bibliography of bacteriology, an important part of the literature belonging to this department, and much of practical value to the physician, has appeared of late in the leading medical journals of this and other countries.

are

as 1

LEUCOCYTHEMIA.*

By Charles O. Wright, M. D.,
Kasson, Minn.

Leukæmia, one of the many forms of anæmia, is an affection characterized by the increase of white blood corpuscles associated with enlargement of the spleen and lymphatic glands or changes in the bone marrow, either of which may be alone or they may be associated together. Of the etiology of leukæmia we know but little, as the causes are somewhat obscure. Males more prone to this disease than females, suppose they are more exposed to its predisposing causes, which are thought to be malaria, syphilis, bad hygiene, frequent hemorrhages, hard labor with exposure to cold, rheumatism, etc. As to heredity, Camerion describes a case of a woman passing through three each occasion nonpregnancies, bearing on leukæmic children. Sanger claims that intrauterine transmission of leukæmia from mother to child does not exist, as leuycotes cannot pass through the placenta from mother to child, which was proved by examining the blood of the placenta and cord. The blood of the former was leukæmic, while that of the latter was normal. Yet there may be an hereditary predisposition transmitted, which may cause the subsequent development of the disease.

SYMPTOMS.

The beginning of the leukæmia is so gradual that the first symptoms usually pass unnoticed, especially in the splenic form.

In lymphatic leukæmia we may first notice enlargement of the glands. Palpitation of the heart, shortness of breath, pallor and gastro-intestinal symptoms sometimes precede the onset. Cases are reported of fatal hemorrhage before pro

*Read before the Southern Minnesota Medical Society, August 4, 1898.

nounced symptoms were manifested. On examining the blood we shall find a large increase in the white cells. The ratio of white to red may be I to 10 or more. Sometimes the white cells exceed the number of the red. The pulse is rapid and compressible. There are seldom cardiac symptoms, except palpitation. Where there is much enlargement of the spleen, the heart may be lifted upwards and otherwise displaced. Edema of the feet and legs usually occurs early where there is much enlargement of the spleen. In the late stages of the disease we may have

CUT NO. I.

general anasarca and dropsy, caused by pressure of the tumor on the large vessels. Epistaxis is the most common of nemorrhages that occur in this disease. We may have severe pain in the tumor, which is very sensitive to pressure; ringing in the ears is common and very annoying to the patient. The nervous system is not usually involved.

TREATMENT.

Many drugs have been recommended for the treatment of this disease, but those thought to

be of most value by our best authorities are arsenic and iron, internally, and the local applications of mercury.

Dr. Page, of New York city, recommends and uses in the early stages mercurial plaster over the spleen and arsenic internally.

HISTORY OF THE CASE.

Mrs. C., a widow, American, age 45 years, was taken sick during the summer of 1893. Complained of being tired and weak, loss of appetite, etc. In February, 1894, the patient ap plied at St. Mary's Hospital, Rochester, for operation on hemorrhoids. It was at this time that enlargement of the spleen was made out by Dr. W. J. Mayo, and on examining the blood the diagnosis of leukæmia was made. After the patient was discharged from the hospital she got along without much suffering until September of the same year, when I was called to see her, and found her suffering with severe pains in the tumor and stomach, which lasted the greater part of September and October, and could only be relieved by the use of morphine. At this time the spleen was very much enlarged and firm, extending very near the medium line on a level with the umbilicus. Her temperature at this time was 98° to 100° (F.) and the pulse 100; this continued about the same throughout her sickness. After this attack she got along very well, with the exception of occasional pains in the spleen, until April, 1895, when she was again taken with pain in the tumor and diarrhoea, which lasted about one week.

From this time until April, 1897, I was only called to see her a few times. On April 21 I drew off a large pail of fluid, which gave her considerable relief for some time, when it recurred, and I did not feel safe in repeating the operation, owing to the difficulty and danger attending it, as it could only be accomplished by lifting the spleen upwards and forward and passing the trochar in behind it.

At this time the spleen extended about three inches to the right of the median line and down to the pubes, very hard and smooth. In September, 1897, she was advised by friends to visit the "Divine Healer" at Chicago, but after three weeks of treatment his "divine" power failed to reduce the size of the tumor, and she returned home.

Cut No. I shows two large carbuncles which I corrected by incision, causing a slough of six inches square.

Cut No. 2 is a side view, showing the marked degree of emaciation and the size of the abdomen, which measured 28 inches from the ensiform cartilage to the pubes and 56 inches in circumference. The tumor was estimated to weigh between 50 and 60 pounds. Soon after

these pictures were taken, anasarca and dropsy developed and the patient died on Feb. 6, 1898, after an illness extending over five years. I was unable to get the consent of the family to have an autopsy, but after drawing off the fluid I could make out a very large liver and the spleen diminished in size about one-third.

CUT NO. 2.

There are several points of interest in this

case:

The duration of the sickness.

The size of the spleen.

The enlargement of the lymphatic glands.
No hemorrhages, except late, and then slight.
The marked degree of emaciation.

A study of sixty-one cases of locomotorataxia in the Colorado Sanitarium, by Dr. W. H. Riley, showed the knee-jerk absent in 55, severe paroxysms of pain present in 54, atoxia in locomotion (with eyes closed) in 54, various paræsthesia, numbness, pricking, etc., in 53, and the girdle sensation in 39.

HOSPITAL AND CLINICAL MEMORANDA.

A CASE OF MYXCEDEMA.*

This case came under my observation at the City Dispensary. She does not present all the symptoms described in a typical case of myxœdema. She complains of pain on the right side; she is tired; does not feel like makng physical effort; is nervous and apprehensive, and has bad dreams. She says she is always cold and does not perspire. Most of the typical cases do not perspire at all. She has frequent urination and is unable to control it; appetite is fair and bowels fairly regular.

Examination will reveal a large deposit all over her body; it shows in her face, her lips are thick and you will also notice her hands are tremendously enlarged. The ankles are very large but there is no pitting upon pressure. The urine shows no albumen at all, no casts, and the specific gravity is normal. Her eyes are expressionless, sheepy, looking as if she were sleepy all the time. Her skin is thickened as you can demonstrate for yourselves by pinching a portion of it between the thumb and finger; her hair has fallen out which is also typical. The temperature is normal, and although I have taken it several times I have not been able to find it subnormal. In most of the reported cases the temperature has been subnormal.

The ears are thoroughly characteristic and feel like cartiliges.

I have refrained from putting her on full treatment, but during the past three weeks she has been taking three five grain tablets daily of P. D. & Co's. thyroid extract, but up to the present time there has been no appreciable improveW. R. Ramsey, M. D.

ment

The Albion, St. Paul.

Koplik describes as a pathognomic sign of measles an eruption which appears from seventytwo to twenty-four hours before the outbreak of the exanthem of the skin, and consists of minute bluish-white specks, surrounded by a reddish area upon the mucous membrane of the cheek and lips. These minute specks are but slightly attached to the mucous membrane, and may be rubbed off if the mouth has been washed.

*Read in the Section of Practice of Medicine of the Minnesota State Medical Society, June 15, 1898.