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ease that has a stage of incubation from two to eight days, or even longer, should be considered a constitutional disease."

This pathological law seems to be well marked in all contagious diseases. Facts speak even in favor of a shorter stage of incubation. Although considered by many physicians first a local disease, which becomes, later on, a general one, it has never yielded to any local treatment.

We are not always so fortunate as to see every case of diphtheria at an early date, nor does the disease follow a strict rule, as for instance the fever, which may come on first, before the local trouble shows itself; or the local affection of the throat may present itself to our view first, and the fever appear later on.

The great tendency in our days of many investigators of the causes and nature of contagious diseases, is almost too one-sided.

Each investigator lays particular claims to his own investigation as being supreme.

This freedom and arbitrary researches and investigations in medicine are a great misfortune, and never more prominent and dangerous than in contagious diseases.

Beautiful theories based on brilliant hypotheses, although the latter may contain many grains of truth-perhaps a single midnight investigation in the laboratory by means of chemicals or the microscope revealed to us some facts, notwithstanding we are still standing on the lower steps of empirical science observing phenomena and conditions without a clear understanding of their true causes.

A great American (J. Russell Lowell) said: "But through the perversity of human affairs, it not unfrequently happens that men are possessed by a single idea, and that a small and rickety one; some seven months' child of thought, that maintains a querulous struggle for life." Or a microcephalic head that is not able to create broad and rational ideas for the welfare and good of the human race; even a microcephalic one extends his ideas too far and his imagination becomes too vivid and expanded beyond all reason—a single discovery-which is sent forth with eclat through the public press "another great and wonderful discovery!"

The etiological millennium is dawning. brightly, the sky is blue, and a superb all things radiant awaits all medical men.

The sun begins to shine spring day that makes Epidemics of contagious

diseases will be easily conquered. The new doctrine of immunity of

Behring, Agato, Brieger, Kitosato and Wassermann will perhaps in future be useful. In all the new treatments of late with "toxine," we recognize the genius of Hahmemann, and the law of similia. similibus will be triumphant.

The discovery of a new bacillus stirs up the scientists in medicine as much as the discovery of the new comet a few years ago. Astronomers were hard at work in all parts of the world. Little comets, in fact, every celestial phenomenon is of importance and brings them face to face with the immensities of space and time.

A comprehension of the causes and nature of contagious diseases and their prevention is of vital importance to every individual in as much as great, almost criminal carelessness, prevails amongst the uneducated in regard to diphtheria, even assisting in its spreading.

The argument of those who claim that it is a local disease, affecting an individual several times, finds but few adherents. They also claim that its course is mostly irregular, that it begins with local symptoms: its absence of toxæmic symptoms in certain cases, the localization of the disease in the throats of those, who are subject to angina; the non-serious effect of local diphtheria.

I have seen but two cases of local affection: "Diphtheria gingivalis" of Trousseau, and I may add another one, ulcus diphthericus of the leg. I am tempted to say that diphtheria is a local disease, while I have seen hundreds of cases that will disprove it and speak in favor of the following:

Diphtheria is a systemic disease. Its epidemic character and its clinical features speak decidedly in favor of it. It is, as Trousseau remarked, "exquisitely contagious and infectious." I have seen nurses that became infected the first twenty-four hours. The frequency of the disease during childhood, and the subsequent diseases as nephritis, multiple paralysis, fatty degeneration of the heart and other serious complications, as pneumonia, anæmia, its slow convalesence, etc.

It differs from catarrhal angina or follicular tonsillitis, not in quantity but in quality. These facts have even been known to older authorities, as Barthez and Rilliet and the great observer, Trousseau, and of late by Professors Oertel, Jacoby and J. Lewis Smith.

Epidemics of diphtheria are sometimes mild, other times more grave; sometimes we notice the tonsil-pharyngeal and nasal form,

Its

other times, the laryngeal or the septic form. A single mild case of diphtheria can produce in another person, the malignant form. course is irregular; not all cases take the typical form.

The disposition of the young organism is easily accounted for, if we take into consideration the anatomical and physiological peculiarities, and their incompleteness, which differ materially from that of adults.

The mucous membranes and other tissues of the mouth and pharynx are more delicate-the mucous membranes more succulent, its epithelium oftentimes the seat of congestion or inflammation; the nasal passages are more prone to catarrhal troubles, the tonsils relatively large and more exposed, in short, the whole respiratory apparatus more vulnerable. The larger and greater supply of lymphatic vessels and active glands.

Hecker, of Germany, and Radcliff, of England, think the disease is autochthonous, that is, of spontaneous origin.

In Van Diemen's Land in Australia, diphtheria appeared in different places, which had no communication with each other. Those who share this opinion are but few. Johannesson, of Sweden, who has paid particular attention to this point, says: "The germ is carried from the infected district to remote parts, following the road of travel."

Epidemics of diphtheria can appear at any season, yet medical observers abroad assert that the disease is more common during cold and wet weather. At least the statistics show the greatest mortality during winter and spring.

In our city, the disease has been more common during spring, summer and fall (our dry season), rarely during our wet season, when our sewers are thoroughly flushed.

Is there not a possibility of a spontaneous development of diphtheria when special and potent factors are at play, as filthy localities, stagnant water, polluted drinking water, poor food, etc.

It takes only one case to produce an epidemic. It is not always necessary to import the germ from India, Russia, Mecca or Egypt. We find plenty of culture beds in every large city amongst the poor and destitute.

It is likely that the disease was brought here in 1857 by the great influx of people at that time. However, we have no direct evidences. The disease was introduced into this country, North

America, by emigrants; so says Prof. J. Lewis Smith. In our State it appeared first in a small town, Sonoma, about fifty miles northwest from here; then it appeared in the city of Oakland, ten miles due north. My first clinical introduction to this terrible scourge of the present century, I had in a friend at Roxbury, Mass., in the year 1847. It was called "putrid sore throat." Its pathology I learned from the works of Barthez and Rilliet, published in 1853; later on from the works of Trousseau and Canstatt and Eisen

mann.

Since 1857 we have had a number of epidemics, and it is now a common disease. I admit the superiority of our treatment, still, we are in need of a more uniform and positive treatment in the septic form of diphtheria. I do not believe in any direct treatment of the bacillus, and so far, no specific against the toxine is known.

The experiments made on animals with anti-diphtheritine to destroy the Klebs-Loeffler bacillus is a very venturesome affair, like the tuberculinum in tuberculosis. The remedy worse than the disease (Aegerecit medento).

It will take many years before the serum treatment will be adopted. Epidemic diseases change in virulence and extent. Do they increase or decrease?

We can confidently say that variola epidemics have decreased, the mortality much less; even scarlatina is less virulent and less frequent. Epidemics are much milder in this State. On the other hand, diphtheria has increased ever since Brettenneau described the fearful epidemic of Tours.

It is said that the city of New York has lost in the last twentyfive years, 50,000 children. In the district of Khartoff, Russia, between the years 1878-1880, 30,000 persons perished.

During the year 1893, 90 children died of diphtheria in this city, whilst during the year previous, 1892, 315 children died. Defective sewers was the prominent ætiological factor.

If we take in consideration the nature of diphtheria, its malignancy, its transmissibility, its epidemilogical character, its great mortality, it is the duty of every physician to use the strictest measures known to prevent its spreading. In all contagious diseases I have always made it a rule, even in the mildest form, to use the surest prophylacticum-isolation of the patient.

Not many years ago an autocratic doctor said to a mother in my

presence that there was no danger for those who are well to be in company with the sick.

Whilst the health officer places a conspicuous notice on the front door, as a warning to outsiders, virtually quarantining the house, I quarantine the patient and the nurse, forbidding them to come in contact with those who are well, eating their meals in an adjoining

room.

The room of the sick should be a large one, with good ventilation, following the maxims of Miss Nightingale, "keep the windows open and the doors closed."

Platts' chlorides are placed in the corners of the room, the pillows and bed are charged with Chloralum, sometimes with Bichlor. of mercury. Amongst the poor I vaporize vinegar, which is always on hand, or I use a 4 per cent. Acetic acid solution and sometimes Bichlor. of mercury 1-6000. Amongst the better class I have the bed-clothes changed twice daily. All excretions should be disinfected.

In the halls I make use of carbolic acid, or chloride of lime. To the latter I add a few drops of vinegar.

When the room of the sick is unoccupied, I make use of carbolic acid as a disinfectant of the air. As a rule our health officer does the disinfecting of the room, furniture and bedding as soon as the patient is well. I am informed he uses large quantities of sulphur. The burning of sulphur for this purpose offers certain difficulties and danger. It may occasion serious chances of fire; besides it has bleaching qualities on any textile fabrics. The thorough carbolizing of the air is preferable. In the room of the sick I make no use of carbolic acid; its smell is objectionable and causing often headaches. Permanganate of potash I rarely use. It is a deodorizer, and a most powerful oxidizing agent. It gives up its oxygen to every organic body with which it comes in contact. Deodorants are not necessarily disinfectants. For laryngeal diphtheria I prefer Iodium, or Eucalyptol (Merck's) vapors. For rinsing the mouth, salt and water, or Zymocide, instead of Listerine. On leaving the house of the patient, I wash my hands with brown soap or bichloride of mercury soap, disinfect my hair and clothes, and see that my finger nails are clean and change my outer garments; antiseptic clothing would be better. Before visiting my patient, I inspect the throats of every member in the house, and as a precaution, I order every

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