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among the best arterial and nerve sedatives, and at the same time they favor the absorption of other medicines, and the elimination of bloodpoison.

The bromides, chloral, and morphia are to be used freely. The quinine should be used hypodermically in not less than 5-grain doses, and at not longer intervals than one hour; the bisulphate is the best for this purpose and can readily be dissolved in warm water. There are a few cases which cannot be controlled in every epidemic of any disease, but they all have their prodroma, and if the medicines are given in time many cases can be prevented from reaching the grave type. This is eminently true of cerebrospinal meningitis. It is as a prophylactic that quinine is to be the greatest boon. When it is threatening to be epidemic the physician should warn his patients that the first shooting pain and the earliest uneasy aching, the slightest headache or slightest arthralgia, must be met with quinine. It is here that the inflammatory theory has done its greatest harm by withholding the hand in the fear of exciting it.

Let it be remembered that malaria is killing the patient, and not inflammation. If the patient survives the deadly touch of the blood-poison then there will be plenty of time to treat the inflammation, which is one of the sequalæ of the perverted blood vessels caused by an influence exerted through the nervous system.

THE ETIOLOGY OF DIPHTHERIA.

BY J. LEWIS SMITH, M.D.,

OF NEW YORK CITY.

No other infectious disease of childhood has been so much investigated in recent years as diphtheria. It has been the subject of full and accurate study by the most distinguished clinical instructors in both hemispheres, and numerous microscopic examinations and experiments with cultures of its specific principle have thrown light on its nature. Nevertheless, it has continued to extend and destroy its victims. It has encircled the globe, occurring with a heavy mortality in every country reached by commerce or travel. We read in medical journals of its prevalence, with the usual death rate, in Brazil, Algiers, and in distant Australia. It has occurred for ages Eastern Asia, where it probably originated, and the complex prescriptions of the Chinese doctors, which have descended as an inheritance with little variation from their ancestors, and which are frequently employed by European residents of China, have lately been added to the literature of this disease.

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Notwithstanding the many discussions of the

treatment of diphtheria in medical societies, the many remedies which have been employed, and the additional light thrown upon its nature by the discovery of its cause, the percentage of deaths from this disease continues large. A recent French writer on diphtheria states that the deaths in France are in numerical excess of the births, . and largely on account of the prevalence of this disease. In London the mortality from diphtheria has been steadily increasing. Within the metropolitan registration area it caused 952 deaths in 1887, 1,311 deaths in 1888, and 1,588 deaths in 1889. These numbers would be greatly increased if the deaths reported from croup, which, wherever diphtheria is prevailing, is known to be, with few exceptions, a manifestation of this disease, were added to them. (London Lancet, May 17, 1890.) In New York City the deaths from diphtheria were 1,914, and from croup 639, aggregate 2,553 in 1888; from diphtheria 1,686, and from croup 605, aggregate 2,291 in 1889. In Brooklyn the deaths from diphtheria were 984, and from croup 391 in 1889; from diphtheria 1,101, and from croup 366 in 1890. These are probably the average statistics of the mortality from diphtheria in the cities where it prevails.

The presence of a great evil always leads to strenuous efforts to determine the exact nature and the most effectual mode of combatting it. It is now known that diphtheria is produced by a linear or rod-shape microorganism, having

about the length of the one which causes tuberculosis, but considerably thicker. A rod-shape microbe is termed a bacillus, and that which causes diphtheria, is designated the KlebsLoeffler bacillus in honor of Klebs, who announced his discovery of it in 1883, and of Loeffler, who subsequently more thoroughly investigated its nature. Loeffler cultivated it in appropriate media, and after a succession of cultivations, which removed it several generations from its source in the child, inoculated pigeons, rabbits and guinea pigs, with the last culture, and produced in them typical diphtheritic inflammation. Many others have repeated and varied these experiments with results similar to those obtained by Loeffler, so that the theory that diphtheria is caused by the Klebs-Loeffler bacillus is accepted. This bacillus presents aspects which to the experienced eye are characteristic. It often has a granular appearance and is stained in two minutes by the violet of methyle; it often exhibits a more intense coloration of its extremities than of its central parts, and its extremities are sometimes swollen so as to present a dumb bell appearance, or only one extremity is swollen, so that it has the shape of a pear or gourd; occasionally it is curved like an arc. (Le Bulletin Med., June 15, 1890.)

The Klebs-Loeffler bacillus alighting upon the faucial or other mucous surface, or the skin denuded of its epidermis, obtains a nidus favorable for its development and propagation, but it does

not enter the interior of the system; it is not taken up by the lymph ducts or blood vessels and conveyed to the internal organs; it remains localized upon the surface and produces there the characteristic inflammation; acting solely upon superficial parts, it cannot in itself produce systemic infection, or blood-poisoning, but like as the venomous reptile or the bee secretes its poison, which it communicates by its fang or its sting, it produces a chemical poison, which is readily taken up by the vessels and conveyed to the internal and vital organs.

This substance, which is the poisonous agent in diphtheria, and which produces systemic infection and death of the multitudes who perish from diphtheritic blood-poisoning, has been carefully examined and experimented with by L. Brieger and K. Fraenkel (Berliner KlinischeWochen., March 17th and 24th, 1890). They say that it may be evaporated at 122°, but is destroyed by a heat above 140°. It is soluble in water, but is insoluble in alcohol. It is not precipitated by ebullition, nor by the following medicinal agents: sulphate of sodium, sulphate of magnesium, chloride of sodium, nitric acid and acetate of lead. On the other hand, it is precipitated by concentrated carbonic acid, the ferro-cyanide of potassium, acetic acid, carbolic acid and nitrate. of silver. It has, say Brieger and Fraenkel, the following composition: Carbon, 45.35; hydrogen, 7.13; azote, 16.33; sulphur, 1.39; oxygen, 29.80.

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