PART II.

REVIEWS AND BIBLIOGRAPHICAL NOTICES.

Diphtheria its Natural History and Prevention.

Being the

Milroy Lectures delivered before the Royal College of Physicians of London, 1891. By R. THORNE THORNE, M.B. Lond., F.R.C.P., F.R.S.; Assistant Medical Officer to her Majesty's Local Government Board, &c. London: Macmillan & Co. 1891. Pp. 266.

It is with much pleasure that we welcome this edition of Dr. Thorne's valuable Milroy Lectures. The work is well worthy of its author's reputation, high though it be already, and the subject is one of the most important that could be chosen. Diphtheria, as Dr. Thorne shows, is steadily, if not rapidly, extending its ravages among us, and, as yet, we seem unable to cope with it successfully. Sanitary works, cleanliness, and other hygienic measures, have considerably diminished the mortality from the so-called "zymotic" diseases, whereas none of our modern improvements have checked the spread of diphtheria. Under these circumstances, although it may not yet be possible to clear up all the mysteries connected with this disease, the first step towards improvement is to ascertain clearly the present state of our knowledge, and on this subject Dr. Thorne's lectures will be found to be the standard authority.

Dr. Thorne calls attention to the change in the distribution of diphtheria which is taking place. Formerly the disease used to be far more rife in sparsely-peopled districts than in towns and crowded localities. For some time past, however, a speciallymarked increase of its incidence is in progress in large cities and towns. The disease is becoming, in fact, one more and more affecting urban populations.

With regard to the influence of soil, site, and locality on diphtheria, we read-"Soil, and especially surface soil, when considered in connection with relative altitude, slope, aspect, and prevailing rainfall, has, I believe, concern in the maintenance and diffusion

of diphtheria, and has very possibly some relation with its beginnings. Speaking generally, I think that the experience of careful investigations extending over a number of years is to the effect that when a surface soil is, by reason of its physical condition and topographical relations, such as to facilitate the retention of moisture and of organic refuse, and where a site of this character is in addition exposed to the influence of cold wet winds, there you have conditions which do tend to the fostering and fatality of diphtheria, and which also go to determine the specific quality of local sore-throat."

There are several tables illustrating the importance of age and season; the greatest number of cases, both actually and relatively both fatal and non-fatal, occurring between the ages of three and twelve years, and the disease being most prevalent during Octobe and November, then subsiding slowly, and being least frequentl met with from May to July. All this statistical material worked up with the greatest care, and will repay study.

In the second lecture Dr. Thorne calls attention to the grea difficulty which is met with in attempting accurately to define th disease" diphtheria." Before and at the commencement of mos epidemics of this disease many cases of ill-defined throat-diseas are met with, and many such occur also during and after the regular epidemic. "Are affections of this ill-defined and appa rently trivial kind capable of passing, by a process of development from an innocent to a specific form of throat-disease? or is it tha the local mischief they occasion provides a soil favourable to th reception and multiplication of the contagium of diphtheria? Dr. Thorne seems to hold both of these views. He believes tha there may be a progressive increase in virulence-"a progressiv development of the property of infectiveness "-until the epidemi culminates in true diphtheria; and also that there is such a important relationship between diphtheria and a morbid conditio of the mucous membrane of the fauces as to intimate some doul whether the contagium of diphtheria ever finds in a throat, th mucous surface of which remains unabraided and unaltered b reason of local disease or otherwise, the soil necessary either to i progressive maturation or to the production of those speci changes which follow on its reception and multiplication. We not see any reason why both of these views should not be tru On the one hand we know by experimental research that the san micro-organism can vary enormously in virulence, and that

infectiveness can be artificially increased or diminished-for example, the same organism which often produces boils or simple subcutaneous abscesses can produce affections of every degree of gravity, until, in its highest virulence, it produces, when introduced into a living body, the most rapidly fatal blood-poisoning.* On the other, many instances are known in which one organism, so to speak, opens the door by which a second organism obtains entrance into the tissues and organs.

In connection with the last-mentioned subject is the question of the identity or otherwise of scarlatina and diphtheria. The opinions and observations of several authorities-Bond, Parsons, Ballard, and others are quoted. Dr. Thorne thus sums up:

"One thing at once strikes the reader, and that is the marked sequence of the events narrated. It is the scarlatina that almost always takes the precedence of the diphtheria. The few instances in which the reverse takes place may easily be accounted for by the well-known circumstance that two different infectious fevers may run their course synchronously in the same person, the characteristic features of both undergoing some modifications. And I would submit that just as is the case with regard to the non-specific forms of sore throat to which I have referred, so also in the case of scarlet fever does the morbid condition of the fauces supply the soil favourable to the reception of the diphtheria contagium, the scarlatinal throat thus acting as a predisposing cause to diphtheria."

With regard to the relation between faulty sanitary circumstances and occurrences of diphtheria, Dr. Thorne's views are important, and are at variance with those generally held. He says:-"I would at once say that no trustworthy evidence is forthcoming to show that polluted water supplies have ever caused diphtheria; whereas, on the other hand, there is abundance of negative evidence in the opposite direction." With regard to sewage-polluted air, he regards it as operating in much the same way as the scarlatina poison-viz., by causing non-specific sorethroat, or in some other way preparing the human system for the reception of the specific infection of diphtheria.

The third lecture chiefly treats of the relation of diphtheria to the gathering together of children in schools. Among these

children diphtheria seems to prevail more than among any other class, and that for several reasons. These children are at the most susceptible period of life; they are closely arranged side by side; ventilation is often imperfect; faulty sanitary surroundings

Levy. Archiv f. Exper. Pathol. u. Pharmakol. 1891.

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often cause non-specific sore-throats; children, especially girls, kiss one another, and are apt to transfer sweets from mouth to mouth. Dr. Thorne suggests that the recent increase of diphtheria may have a connection with the increase in the number of children who attend school regularly.

The practices of kissing patients suffering from an infectious disease and of carrying them in the arms are alluded to. Many cases of diphtheria have been caused in this way. "In one hospital there is a rigid rule that no diphtheria patient shall be lifted or carried about, and in that institution no nurse has for a long series of years contracted the disease. In another, regulations of like stringency are not observed, and nurses tending the sick not infrequently endeavour to alleviate the distress of their little patients by fondling them and carrying them about, and in this institution diphtheria among nurses has all but amounted to an epidemic prevalence."

In the fourth lecture a careful account is given of several epidemics in which it was ascertained that milk was the vehicle by which the virus was conveyed. Dr. Thorne comes to the conclusion that the milk derived its infectiveness directly from the cows; that milk derived from cows suffering from an apparently trifling disease, a condition called "chapped nipples," may produce diphtheria in human beings and other susceptible animals—e.g., cats. A long account is given of Dr. Klein's researches on this point.

In the last lecture some useful hints are given on the prevention of the disease—e.g., isolation, the closing of schools, the systematic examination of the throats of the children, disinfection, boiling milk before using it, &c. The last point-boiling milk-Dr. Thorne lays much stress on. There are three appendices containing Local Government Board directions as to closing infected schools, and on the general methods to be adopted in places attacked or threatened by an epidemic.

The whole book is very well written, and extremely interesting, and contains the best account we have as yet obtained of the natural history of diphtheria. There is only one matter in which we could wish Dr. Thorne had seen his way to compile his book differently. It is written too much from the standpoint of the Medical Officer of the Local Government Board. Local Govern ment Board Reports are the source of most of the quotations and Government inspectors are the authorities most largely

quoted. We regret this narrow standpoint. If the author could have taken a wider view of the disease, if he had alluded more fully to the foreign experimental work which has been done in connection with this subject, if he could have paid rather more attention to the rest of the world outside England and Wales, we believe this book would have been even more valuable than it is.

RECENT WORKS ON TREATMENT.

1. La Pratique journalière des Hôpitaux de Paris. Par le PROFESSEUR PAUL LE FORT. Paris: J. B. Baillière et fils. 1891. Pp. 356.

2. The Treatment of Typhoid Fever, especially by "Antiseptic Remedies. By J. BURNEY YEO, M.D., F.R.C.P.; Professor of Clinical Therapeutics in King's College, London, and Physician to the Hospital. London: Cassell & Co. 1891. Pp. 70. 3. Prescribing and Treatment in the Diseases of Infants and Children. By PHILIP E. MUSKETT, late Surgeon to the Sydney Hospital; formerly Senior Resident Medical Officer, Sydney Hospital. Edinburgh and London: Young J. Pentland. 1891. Pp. 293. 4. Prescriber's Companion. By THOMAS SAVILL, M.D. Lond., M.R.C.P.; Medical Superintendent of the Paddington Infirmary. Second Edition, revised by the author, assisted by T. E. HILLIER, M.B., M.A., Cantab. 1891. London: John Bale & Sons. Pp. 48.

1. PROFESSOR LE FORT has earned a debt of gratitude at the hands of all practical physicians by focussing in his little work the views on treatment entertained by the most brilliant living representatives of the French school of medicine and surgery.

His work, described on the title-page as an "aide-mémoire" and a formulary of applied therapeutics, embraces 518 opinions on the most novel and varied cases by no fewer than 135 practitioners. Among them we find such names as Ch. Bouchard, Charcot, Debove, Dieulafoy, Dujardin-Beaumetz, Alf. Fournier, Grancher, Félix Guyon, Hallopeau, Hayem, Jaccoud, Landouzy, Lannelongue, Ledentu, Peter, Pinard, Potain, Germain Sée, Paul Segond, Tarnier, Terrier, Tillaux, Verneuil, &c.-truly a goodly list.

The plan of the book is this-a disease is named in alphabetical