ties for consumptives. He quotes the statement of Ringer that turpentine employed as a medicine enters the blood, and may be detected in the breath, the perspiration and in an altered form in the urine of the patient. The presence of the vapor of turpentine in the pine forests, Dr. Loomis remarks, cannot be doubted, and its "local and constitutional effects" he adds, "are those of a powerful germicide as well as stimulant." Dr. Loomis quotes the opinion of Mr. Kingsett that turpentine, during its oxidation, evolves the peroxide of hydrogen, and therefore by the "oxidation of the terebinthinates, there is produced in extensive pine forests an almost illimitable amount of peroxide of hydrogen, which renders the atmospheres of such forests antiseptic." He believes that the peroxide of hydrogen, so abundantly produced in pine forests "successfully arrests putrefactive processes and septic poisoning," and therefore he recommends residence in the pine forests as one of the most efficient means of relieving the symptoms of tuberculosis and retarding the progress of this fatal malady. At high altitudes, the coniferous or evergreen trees usually predominate, and if the views of Professor Loomis be substantiated by future investigations, it may be that the benefit believed to be obtained by consumptives at high elevations is partly due to the exhalations from these trees.*

THE INFECTIOUSNESS OF DIPHTHERIA.

Diphtheria is undoubtedly more frequently spread by direct contact than by indirect methods, yet that it is transportable upon the clothing of persons who have not had the disease there should be no doubt. The following few cases will serve to illustrate the ways in which the contagion is spread. Similar instances in our own experience will be found in the reports of the local boards of health and in former numbers of the Annual Report of this Board.

In a paper of the past year Dr. Jacobi† refers to a case in which a simple inflammation of the tonsils appeared to have had the diphtheritic inflammation engrafted upon it by the infection preserved two years in an old swab.

The case was at first tonsillitis, the result of exposure to cold. An abcess formed in one tonsil, and, after its rupture and discharge, the child had temporary relief. Up to this time there had been no particular systematic disturbance other than the tonsillar trouble would account for, nor were the voice and breathing affected any different from what would be expected in this disease. A day or so before the abcess broke, his mother thought swabbing the throat with alum water might give him relief, and she proceeded to do this, using a sponge swab that she had used in swabbing the throat in a case of

Medical News, LVI., 164, 1890.

Archives of Pediatrics VI., 131, 1889.

diphtheria in her family in Chicago two years ago. Two days after using this swab laryngeal stenosis began to show itself, together with a profound systematic disturbance characteristic of diphtheria, and death resulted in three or four days from septic absorption and obstruction to breathing.

Dr. Downes* narrates the following history of indirect contagion: Diphtheria had been brought from Halstead to a family at Goldhanger, in the neighborhood of which village no throat illness was then known. Two children were attacked at Goldhanger, of whom one died. On October 19th, their mother took some needle-work to an isolated farmhouse some two miles distant. On October 22d, two boys at the farmhouse sickened with diphtheria. One of them had been in the kitchen at the time of the needle-woman's visit, but had not spoken to her; the other was away at a day-school, a mile distant, in another direction. The needle-work was sent straight to the wash-tub, and the boys never touched it; but the brown paper in which it was wrapped was given, it was believed, to the two boys on the evening of the 19th, and was cut up by them into patterns for their amusement.

De Cresantignes states that in 1884 he was externe to l'Hopital des Enfants Malades in the service of Jules Simon. It was his duty to take notes, examine diphtheritic patients, and watch the cannula of tracheotomized cases. When he left the service each day he thoroughly washed his hands, and did not remember having ever soiled his clothes with the blood, mucus, or particles of pseudomembrane, and at no time did he have symptoms of diphtheria. After the day's work he returned to the rooms occupied by his mother. The mother, without any other exposure, so far as could be ascertained, contracted diphtheria, of which she died. That the disease was conveyed by the garments worn and infected during the hours of service in the pavilion could not be doubted. An interne of l'Hopital de la Pitiè visited the child of one of the employès of the establishment, whom he found with diphtheria, for which he prescribed. He then returned to his father's house, a long distance, on foot, and embraced his parents and sister. On the following day the sister, who had not been exposed to any patient, complained of her throat, and the next day her tonsils were covered with the characteristic pseudo-membrane, and the cervical glands were slightly tumefied. The brother, who had not changed his clothes after visiting the patient, was apparently the the medium of communication, although he himself was not affected with the disease.†

A study was made at Ouillins by Prof. Bard of Lyons, in the latter part of 1888, for the purpose of learning in what ways the infectious germ of diphtheria is transported from person to person.

There were under observation twenty-nine cases, between the eighteenth of September and the end of November. The first case

*Trans. Epidemiological Society of London, VII., 209. fAn. Univ. Med. Sciences, Vol. I., J-18. 1889.

could not be traced to anything in the local surroundings of the village, and the conclusion was forced upon the investigator that it was to direct or mediate contagion which was imported into the place. Such conclusions coincide with the known resisting power of the diphtheritic germ, and the possibility of its prolonged preservation and transportation. Roux and Yersin have shown that the bacillus of Loeffler preserved its virulence after five or six months of culture, and clinical facts have shown that its virulence continued as long as four years. In twenty-six of the twenty-nine cases which were studied, the author was enabled to ascertain the subject who had been the bearer of the contagion, and in most cases could trace the day upon which the contagion was borne. In twenty-five cases there was direct contact between the bearer and the sufferer of contagion; in one the contagion was mediate. Of the twenty-five direct communications, ten were from brother to brother, three were among neighbors, and twelve at school. The remission of the epidemic followed the closing of the school. In only two of the secondary cases was the dangerous contact suspected, but not demonstrated. The first case developed six secondary ones; five of the latter were sterile, but the sixth developed another case, and the latter still another. The productive power of other cases has been carefully traced out, and the general conclusion may be drawn that in the development of epidemics of diphtheria, the disease is usually propagated from the persons of the sick to those of the well, usually by direct contagion.*

Lancry† tells us of an outbreak of diphtheria in a school which was undoubtedly started by a single diphtheritic pupil. Of seven pupils who came into pretty close contact with this child all took the disease, while of twelve who associated with her but little if any, all escaped. And yet the space in the school-room which separated the infectious child from the twelve that escaped, was only seven or eight feet, but her position was in a chair of her own near the fireplace and not on the benches common to the other scholars. On the strength of this Lancry argues that the infection of diphtheria does not have much power to diffuse itself through the air, a fact which, if determined to be true, will have a practical significance in the isolation of diphtheria patients. Many authorities believe that the diphtheritic virus has a high degree of power of adhering to articles and thus of becoming transported, but many would agree with Lancry that, if we can be assured against the carrying of the infection by the medium of persons and things, a separation with only a limited intervening space of air, not too confined and stagnant, would be sufficient to give a considerable degree of certainty against the spread

*Arch. of Pediatrics, VII, 318. 1890.

†De la Contagion de la Diphtherie, p. 81.

of the infection. Dumez* has also given a history, somewhat like that of Lanery's, of an outbreak of diphtheria in a school in which the boys and girls upon the same floor were separated by an open space only a few yards wide. Diphtheria prevailed among the girls, but did not affect the boys.

AS TO THE IDENTITY OF CROUP AND DIPHTHERIA.

The relation of croup and diphtheria was investigated by Lennandert by carefully finding out, whenever a case of croup came to his notice, whether cases of diphtheria had also occurred, either previously or subsequently, in the same house or in the neighborhood. In this way he was repeatedly able to connect a case of croup with a case of diphtheria. In all cases in which he tracheotomized for croup, and in which there was no deposit upon the pharynx, he was either able to demonstrate with positiveness a relation to diphtheria, or to show that it was highly probable. In the greater number of cases it was believed that secondary croup also depended upon diphtheria.

QUESTIONABLE CASES.

Dr. Downes in "Notes on Diphtheria," makes the following remarks on the confusion which exists in England in regard to the nosology (classification) of diphtheria, and what he says is as applicable to this side of the water as it is to the other:

The Registrar-General repeatedly notes and exemplifies the confusion which renders the diphtheria returns "very untrustworthy," save on the broadest scale and with the greatest care. Unfortunately, this chaos involves a very considerable amount of danger to the public health, as some examples taken quite at random from my journals may suffice to show.

Kate B- a servant, sickened with diphtheria, then locally prevalent in a part of my district, was sent to her home, and died in a village fifteen miles away, also in my district. No diphtheria was then known for many miles around. Within a week, her child, at the same house-an inn-sickened and died also. The mother's death certificate was "diphtheritic croup," the child's "cynanche trachealis." I was aware of the whole matter at the onset, and warned the school authorities of the village. In reply the rector "As to the disease, we are not very clear. Kate's was said first of all to be diphtheria, then croup, now diphtheritic croup. You evidently consider it infectious. The medical attend

wrote:

*An. Univ. Med. Sciences, Vol. I., J. 14, 1889.

Arch. of Pediatrics, V., 694. 1888.

Trans. Epidemiological Society of London, VII., 195.

* *

ant told the mother that the ch ld's complaint is not infectious, that she was not to be afraid. * I hope language is not used in any technical sense calculated to mislead the public mind."

Now, we had no more "diphtheria" in this village, but I will tell you what we did have-some "sore-throats"; and in the autumn came a fatal outbreak in the next village, followed early in next year, in the parish beyond, by the following succession of cases, the record of which I take from the Medical Relief and Death-Returns:

Yet I was assured on medical authority that, with the exception of Emily W., there had been no diphtheria in this parish.

Again, one of the most fatal outbreaks I have ever witnessed was initiated by the school attendance of two diphtheric children. They had recently lost a little brother, but "only of croup," and their own swelled necks were merely "mumps," though mumps of a kind that left behind it nasal voice and impaired vision. And let me say by the way that very often indeed do I find diphtheria masquerading in this guise.

My able predecessor in office drew a distinction between diphtheria and what he described as "spreading-quinsy," but the medical attendant of cases regarded by Dr. Fox as spreading-quinsy tells me that paralysis subsequently followed in some of them. Again, the term "diphtheritic sore-throat" is becoming to the public as comfortable a euphemism as was, and to a great extent still is, scarlatina a convenient excuse for shutting one's eyes to unpleasant responsibilities. Finally, a new candidate for popular favor has sprung up with an attractive title, which should become both popular and fashionable. I refer to the so-called "Sandringham sore-throat." Now, I wish to emphasize my belief that, if we are to understand diphtheria aright, and to cope successfully with its spread, we must, in the first instance, bring ourselves to recognize, or at least to admit, its insidious and often trivial forms, and seek not to split up, but to unify our classification of its varieties.

So trustworthy an authority as Dr. J. Lewis Smith tells us :

Diphtheria will continue to spread and largely increase the aggregate of deaths until stringent measures be employed to prevent its propagation by mild walking cases. Children mildly affected with diphtheria, with little or no complaint of sore throat, are allowed to go abroad. They enter public conveyances, sit among other children in the schools or churches, are allowed to promenade the streets, and call upon their friends. I have in a number of instances seen children with diphtheria sitting among other children in the