27

the respiratory tract. Rachitis seems to furnish a protection from severe lung complications, a statement we think very questionable. Tyler lately read an interesting paper on measles before the Washington Obstetrical and Gynecological Society. He thinks that Ellis is in error in giving the average mortality of the disease as one in fifteen, and that it is really much lower. Among the negroes of the District of Columbia, who constitute about one-third of the population, the mortality is both relatively and actually greater than among the whites. This, he thinks, plainly demonstrates the potency of insanitary environment, for the negroes generally live in the utmost squalor.

Aug.

Treatment.-Montefusco 11 does not consider medicinal treatment necessary in cases which run the regular course. He thinks it irrational to seek to subdue the fever. This does not signify that high temperature should be disregarded if it reach such an elevation as to produce granulo-fatty degeneration of the tissues, or diminish the resisting power of the patient, and produce functional trouble of the heart and brain which may lead to paralysis.

Children

Alimentation is the treatment for such conditions, and the writer regards the suggestion of Semmola and Dujardin-Beaumetz, to substitute glycerine for alcohol, as a very good one. who were treated with glycerine by the author retained their strength, showed diminished temperature, and excreted less urea. An ounce (31 grammes) of glycerine may be given daily, combined with about eight ounces (249 grammes) of water and half a drachm (1.9 grammes) of citric or tartaric acid.

The broncho-pulmonary complications should be treated with a combination of infusion of ipecacuanha, tincture of aconite, and syrup. Iodide of sodium diminishes expectoration and rapid breathing. When the cough is particularly rebellious good results are obtained by giving iodide in combination with bromide of sodium. Tyler says the cough of measles does not yield to ordinary palliatives. Cool water and ice pellets give some relief. A mixture of bromides, chloral, and deodorized tincture of opium in a syrupy vehicle gives good results.

June

Huchard 18 uses in heart and lung complications dry cups twice a day, fifteen centigrammes (2 3 gr.) each of Dover's powder and powdered squill thrice daily, alcohol in tonic doses, sinapisms to the lower extremities, and hypodermic injections of caffeine.

108

Mar.1

Bayle employs the following treatment in the paralysis following measles: Should paralysis depend upon simple congestion of the marrow it is to be treated with ergot, strychnia, and the galvanic current to the spine, followed by a cold douche, the faradic current being employed at the same time to stimulate the paralyzed muscles. This should be followed by dry friction, sulphur- and seabaths. If the symptoms do not subside chronic inflammation may be feared and iodide of potassium should be given in small doses. Heat may be applied to the spine or an eschar made with the thermocautery. Calomel in small doses is of service and laxatives are indicated. Should respiration become difficult or the heart fail, artificial respiration and injections of ether must be used. If congestion is evident, a wet cup should be applied to the nape of the neck. In case of retention of urine a catheter must be passed two or three times a day.

Dec.24,87

RÖTHELN.

Osborn. 82 De States that there is one pathognomonic feature eminently distinctive of rötheln, one, indeed, so constant in its occurrence that when observed there can be no longer a doubt, an enlargement of the small glands just at the edge of the hair on the postero-lateral sides of the neck. This feature has never been absent in any case coming under the author's observation.

Complications.-C. W. Smith, saw, in an epidemic, two cases complicated by rheumatism—one a child, the other a young girl, neither of whom had ever been affected with rheumatism. There was great pain in the right ankle, the wrists, and the first and second metatarso-phalangeal joints, attended with swelling and tenderness, which lasted, however, but a day or two. The attacks occurred on the second and third days of the eruption respectively. Blepharitis marginalis resulted in one case, a young, healthy girl. Greenlee says that out of sixty cases of rötheln distributed between both sexes, and ranging in age from two to twenty years, thirty were followed by severe catarrhal pneumonia, and thirty by scarlet fever. Dulles reports a case in which rötheln was followed by undoubted evidences of pus formation in various parts of the body, including the brain.

51

19

Feb.

199

Aug.

Treatment.-Mayers treated thirty cases of rötheln without one death by first using saline purgatives and diuretics, followed by salicylic acid and pyrophosphate of iron.

DIPHTHERIA, PERTUSSIS, AND PAROTITIS.

BY J. LEWIS SMITH, M.D.,

ASSISTED BY

FREDERICK M. WARNER, M.D.,

NEW YORK.

DIPHTHERIA.

NOTWITHSTANDING the many preventive and remedial measures which have been recommended and applied, and strenuous efforts of health boards to limit and control it, diphtheria continues to extend, and every year largely increases the mortality in both hemispheres. The following table exhibits the mortality from diphtheria and croup, which is but a form of diphtheria, and, for the purpose of comparison, the mortality also from scarlet fever in New York City since 1880:

In six consecutive months in 1888 the deaths from diphtheria

in ten of the principal cities of Europe were as follow:

Etiology. During the last year many experiments and microscopic examinations have been made, in order to discover the cause and throw light upon the nature of diphtheria. These have strengthened the belief that the cause is microbic, but it is still doubtful which microbe is the causal agent, or whether there may not be more than one species of bacteria which, by action upon and in the tissues, cause diphtheria.

Jan.23

D'Espine obtained the Löffler bacillus from the laryngeal pseudomembrane in a case of croup occurring without angina

and without complications of any kind, except such as occurred from the mechanical obstruction. The child had been tracheotomized in l'Hôpital Canton, and rapidly recovered. Pure cultures of this bacillus even to the twenty-fifth generation always preserved the same pathogenic characters in inoculations of the rabbit and guinea-pig. The fifteenth generation was sent to Löffler, who stated that the bacillus was identical in form and pathogenic properties with the bacillus discovered by him. In twenty-four cases of non-diphtheritic angina (the herpetic, etc.) Löffler's bacillus was not present in the scraping from the fauces, while in fourteen of the scraping in diphtheritic angina or croup with clear diagnosis the bacillus was uniformly present. Therefore, D'Espine believes that the presence or absence of this bacillus in cases of faucial inflammation of doubtful nature aids in diagnosis. Löffler's bacillus is thicker and better nourished in the pseudomembrane than in cultures. It has, says D'Espine, nearly the length of the tubercle bacillus and at least twice its thickness. But serious and fatal objections were soon found to the theory that the Klebs-Löffler bacillus is the causal agent in diphtheria. Löffler himself ascertained that it is not always present in undoubted diphtheria, and this stubborn fact, which militated against his theory, he sought to explain by the supposition that the bacillus, after producing the mischief, had died and been eliminated before the patient's death. This is certainly a very improbable explanation. But recent and more thorough microscopic examinations have demonstrated the fact that the bacillus of Klebs and Löffler occurs in non-diphtheritic cases, and even in healthy persons, as well as in diphtheria. Thus, von Hofmann-Wellenhof, detected this bacillus in twenty-six of forty-five cases of various conditions of the buccal and faucial surfaces. He discovered it in seven cases of diphtheria, three of measles, in six of nineteen cases of scarlet fever, and in four of eleven normal cases. In cultures and experiments these bacilli from different sources seemed to be identical. Therefore, in the light of recent investigations, the Klebs-Löffler bacillus has no more significance as a cause of diphtheria than the micrococcus of Oertel.

Emmerich, of Munich, examined seven cases of diphtheria immediately after death, and in five of them found a short bacillus always accompanied by the streptococcus or staphylococcus pyo

genes aureus. This short bacillus, not that of Löffler, was found not only in the mucous membrane of the larynx, trachea, and bronchi, but also in pneumonic infiltrations whenever they were present. A few times they were also found in the blood taken from the heart, but never in large numbers. On examining the pseudomembrane, Löffler's bacillus and other bacteria were found, among which was the short bacillus. In the superficial parts of the mucous membrane underlying the pseudomembrane the short bacillus was found with the staphylococcus and streptococcus, and in the deeper portions of the mucous membrane a larger number of the short bacillus occurred with a smaller number of other species. The laryngeal surface of cats and dogs was inoculated with the short bacillus, and an unmistakable pseudomembrane produced.

5 1889

25

Mar.31

T. M. Prudden, of New York, has recently made cultures and experiments which will direct attention to another microbe, the streptococcus, as perhaps the causal agent in diphtheria. The well-known ability of Dr. Prudden as a microscopist and the unusual pains which he takes to avoid sources of error will render his paper, now in process of publication, the most important of the recent contributions to the etiology of diphtheria. Even Oertel, who twenty years ago was a strenuous advocate of the theory that the micrococcus is the causal agent of diphtheria, now states that, though many bacteria occur in the diphtheritic pseudomembrane, there are only two which are to be considered in studying the etiology of diphtheria, to wit, the streptococcus or chain-forming coccus, and the bacillus or rod-shape bacterium with rounded extremities. Oertel has recently endeavored to elucidate the etiology of diphtheria by a minute examination of the structural changes which occur in the various organs of the body under the influence of diphtheria, but, although his investigations throw light on the pathology of this disease, they seem to have effected little toward determining the causal agent. The identification of the specific microbe and of the ptomaines which it produces will be the work of the future.

B. K. Rachford, Feb.2, in commenting on our present knowledge relating to the causation of diphtheria, states that the most experienced bacteriologists do not find in the blood or tissues any microbes which can sustain a causal relation to diphtheria. Every pseudomem