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lieves the danger past when the febrile stage and eruption are gone. The majority measure the time of isolation by the process of epidermal exfoliation.
SCARLATINA.-In scarlatina, also, we have opposing opinions, ranging from that which considers it as a pythogenic disease, slightly, if at all, contagious from the person, to that which holds the infection to be communicable by the pulmonary exhalations, the blood, the naso-pharyngeal secretions, even the urine, as well as by the epithelial scales. One of my correspondents thinks the infection remains so long attached to the person that quarantine should endure for eight weeks; another cites an example of transmission after six weeks of isolation, followed by a change of clothing; the rest concur in releasing the patient after desquamation has ceased and the surface been thoroughly cleansed. Most of us, I dare say, have adopted this "rule of thumb." In my own practice, for some years, I had the patient frequently anointed with carbolized or thymolized vaseline, endeavored to maintain complete isolation until all desquamation was at an end, and then prescribed two or three thorough baths, including a careful washing of the hair and scalp. But on several occasions I found that the quarantine which I had ordained was considerably abbreviated by the parents or the patients themselves, and that children still furfuraceously desquamating after scarlatina or measles had indulged in social intercourse, or had even returned to school, without conveying infection to their companions; and it occurred to me to wonder whether-granting that the exfoliated epithelial scales are the principal carriers of the contagion-all the successive crops of cast-off scales were acting as chariots for infective micro-organisms, or whether the later-arrived cells, as they rose from the deeper layer to become cornified in their turn and ejected, might not be quite free from taint. The same idea has evidently struck one of my most esteemed correspondents, who, speaking of quarantine during desquamation, adds that "forty days are sufficient," and that if, as sometimes happens, the scaling process seems to last much longer, it is "no longer scarlatinal in character, but the result of dermatitis in general in a skin which has
not regained its original health, without its being the seat of an infectious or contagious process."
I am quite aware that I ought to apologize for even this brief intrusion on your patience, when, instead of bringing any addition to your stock of knowledge, I come only to subtract from it, so to speak. But, forasmuch as "the promotion of public health" stands second on the list of objects of this Association, I trust that I shall be pardoned for simply pointing out the uncertainty which exists in relation to one of the most needful means to promote public health, and for invoking your collective aid in elucidating the problem.
THE THERAPEUTICS OF DIPHTHERIA.
By J. W. MOORE, M. D., of Albany County.
THE specific character of diphtheria, its contagiousness, either as an epidemic or endemic, I shall not discuss.
That it is characterized by a peculiar lymph-exudation, manifesting itself on mucous surfaces, such as the uvula, tonsils, palate, nares, larynx, and trachea; that this exudation is cacoplastic, which, with the epithelial cells, forms a thick, tenacious membrane, depositing itself, sometimes with great rapidity, upon the organs named; and that the local manifestations are accompanied or preceded by various constitutional symptoms, we all know, and I shall not attempt to describe these characters.
In the "Medical Record," a few months ago, accounts of the treatment of diphtheria by five different authors of note are given. All agree so far as hygienic laws are concerned, but they differ considerably as regards the therapeutics of the disease. Four advocate the use of iron in various forms; one attaches no value to it whatever as a faucial remedy; one lays considerable stress on iodine, while the rest do not mention it. Quinine is advocated by three, and disapproved by two; chlorate of potassa has friends in three out of five; topical remedies are recommended by three, and not mentioned by two; and so on, showing the differences of opinion of five celebrated practitioners, each of whom has given extensive study to this disease. For instance, Dr. Stillé recommends ice in the mouth, muriatic acid applied with a brush, with potassium chlorate, tincture of iron, lactic acid, and potassium permanganate. He mentions emetics as sometimes advantageous in the carly stages, alcohol
and stimulants of quinine and iron, fluid beef and milk. He says tracheotomy is fatal in about three fourths of the cases.
J. Solis-Cohen maintains that keeping up the supply of nourishment and stimulants and providing for the detachment and discharge of the morbid accumulations are the two main indications. Besides his hygienic directions, he regards the chlorine compounds as of more efficacy than all the other remedies; the principal of these being the tinctura ferri chloridi, in thirty-drop doses, every half hour or every second hour, given with glycerin or sirup of lemon. He also recommends hydrochlorate of quinine, strong wine or brandy in decided doses, and, at moments of sinking, carbonate of ammonia and ice in the mouth at intervals; but ice compresses are not approved. He suggests applications of the tinctura ferri to the pseudomembrane, but does not advise the forcible removal of the deposit. Upon invasion of the larynx, or if respiration be impeded, he recommends inhalation of the vapor from slaked lime, and emetics to provoke expectoration in children but not necessarily in adults. In threatened asphyxia, tracheotomy is to be employed to avert death.
Bartholow believes in two indications: first, to shorten the duration of the disease; second, to obviate the tendency to death. He disapproves of caustics and acid applications, as inviting the disease to the adjacent portions of the mucous membrane by destroying the epithelium. He approves of the application of sulphur, in form of powder, by insufflation, and of the vapor from slaked lime, and a weak solution of lactic acid applied to the throat by a large mop. He attaches no value to potassium chlorate or tinctura ferri as faucial remedies. In gangrenous sloughing, he recommends a one-per-cent solution of carbolic acid, applied either to the throat or nares. Under the second head, with the earliest appearance of an exudation, he gives from two to ten grains of the bromide of ammonium every three hours, in the belief that its diffusion tends to detach the exudation. To prevent septic decomposition, he advises a drop or two of Lugol's solution of iodine in water every hour or two, giving alcohol and quinine steadily when the exudation is fully
developed. Fearing the injurious action of potassium chlorate upon the kidneys, he does not believe in its power as a curative agent. He gives as food, milk, eggnog, and beef tea, freely every three hours.
Dr. A. Jacobi believes alcohol to be a very important remedy, given in large doses, from two to twelve ounces daily; also, chlorate of potassa not to exceed a scruple daily, inhalations of vapor, particularly in fibrinous tracheo-bronchitis, and the drinking of large quantities of water, with a view of macerating the membrane. He believes that the internal and external use of ice and the use of lime-water and lactic acid have been greatly overestimated. He uses glycerin simply as an adjuvant. Chloride of iron is valuable, as is carbolic acid, in a one-per-cent solution, both by local and internal administration.
Dr. C. E. Billington recommends an iron-mixture with glycerin and water, and also a mixture of potassium chlorate, alternating with glycerin and lime-water. He uses a spray of car-. bolic acid and lime-water, never applying a brush or swab to the throat. He does not give quinine or any other unpleasant medicine to children, or employ alcoholic stimulants, unless when a child will not take other nourishment except eggnog. He depends for nourishment on cold milk with a little lime
Assuming the asthenic character of the disease, with the remarkable tendency to produce anæmia, some form of iron seems to be indicated.
It seems to me the main object in treatment is to induce the solution of the membrane and to prevent its re-formation when once removed. I do not believe in gargles, but sprays and topical applications are of great service. As regards antiseptics, Mackenzie lays considerable stress upon potassium chlorate, giving as much as from ten to twenty grains every two or three hours, and does not mention the nephritic danger so much dreaded by many physicians; and I may say that, while recognizing the possible deleterious effects of the chlorate upon the kidneys, and while I give it in nearly every case coming under my care, I have yet to see the first case of nephritic trouble