deducted from the lenses found to correct the error of refraction. A hypermetropic eye with its accommodation paralyzed requiring at five meters + 1.25 S. for the best vision will be overcorrected for the infinity to the extent of +0.20 S.* A myopic eye under the same conditions will be undercorrected to the extent of a quarter of a dioptre, hence with accommodation paralyzed it becomes necessary to deduct a quarter of a dioptre from the lens required to correct the error of refraction in hypermetropic eyes and to add a quarter of a dioptre to the correcting lens of a myopic eye. With me this rule is not applied to myopic eyes, as I desire just this amount of under correction. This rule may seem a little confusing when applied to cases of simple hypermetropic astigmatism. For example, an eye with its accommodation paralyzed requires + 1.00 Cyl. ax. 90° for the most distinct vision of five meters. This eye is one-quarter dioptre myopic or it woudl not accept such a lens hence, it becomes necessary to prescribe - 0.25 S.+1.00 Cyl. ax. 90°. Again, suppose the above eye accepted +0.25 Cyl. ax. 90°, the same rule would apply and we would prescribe 0.25 Cyl. ax. 180°. The above rule does not apply to eyes not under the influence of a cycloplegic. When the accommodation is active there is no danger of over-correcting in hyperopia and too much danger of doing so in myopia.

*The actual correction is + 0.20 D, but since a lense of this strength is not commonly in use, we will therefore speak of the overcorrection as + 0.25 D., i. e., that a quarter dioptrie plus lens is the strength of the lens required to render parallel the rays of light coming from a test card five meters distant.

(ABSTRACT.)

THE RELATION OF STATE AND LOCAL BOARDS OF HEALTH TO OUTBREAKS OF DIPHTHERIA.*

By G. E. TYLER, M.D.,

Secretary Colorado State Board of Health,

Denver, Colorado.

It is the writer's purpose to attempt to set forth the methods to be used by health officials in their battle with disease.

There should, at all times and in all places, be offered competent bacteriologic facilities free of charge to every citizen. The absolute uncertainty of clinical phenomena for mild or atypical cases has been repeatedly proven. The throat may present but the faintest hyperæmia, yet the culture may be positive. In well marked cases the clinical appearances are sufficiently distinct to

* Read before the Colorado State Medical Society, June, 1900.

warrant a positive diagnosis, without the aid of a bacteriologist, but it cannot be too strongly emphasized that the greatest skill in clinical work is not sufficient to detect mild cases of genuine diphtheria. Because of this fact no obstacle should be placed in the way of obtaining a prompt bacteriological diagnosis. On the contrary, every facility should be offered the interested persons, whether he be a physian or an anxious parent. Culture outfits in convenient form should be placed at accessible supply depots, each outfit being accompanied by plain printed instructions as to the method of use. In cities, messengers should be provided to collect the outfits as soon as the cultures had been taken. Whenever requested, an officer of the local board of health should be sent to take the culture. In small communities it is quite out of the question to maintain a bacteriological laboratory. It then becomes the duty of the State Board of Health to supplement the work of the local board furnishing the necessary facilities. To accomplish this, the State Board of Health must have a competent bacteriologist, not appointed for political reasons. It must also provide all incorporate towns which have no local laboratory with culture outfits, and there must be prompt communi cation between the supply depots and the laboratory. The culture outfits should be as complete as possible, in order that the cost of sending them may be reduced to the minimum. The former regulations of the Postoffice Department required a clumsy ontfit, which was poorly adapted to the work. and which required twelve cents postage every time it was mailed. Through the efforts of the Colorado State Board of Health, assisted by others interested, the regulations were so modified as to permit the use of much smaller outfits. It was formerly the custom to treat these specimens as fourth class mail, but the new order directs that they be treated as letter mail. This may mean a difference of twelve hours in the receipt of the specimen. Every State Board of Health should be granted sufficient funds to establish these supply depots. The State Board of Health of Colorado will have such depots established in every county on or before September 1, 1900. The service of the laboratory is free of charge to every citizen, and reports are emade as promptly as possible. In every positive case, immediate report will be made by telegraph. A like prompt report will be made in negative cases when requested. In sending specimens the name of the patient should be given, as well as that of the person sending the specimen.

Physicians should take cultures in every case which looks at all suspicious. Much tact is required to secure the active participation of some in this movement, but the wise health officer will so protect the interests of the profession that all, except the

few who are by habit opposed to everything, will see the advan tage to be gained by frequent use of the laboratory.

Free antitoxin should be provided for all infected individuals who cannot afford to buy it.

Every case of diphtheria should be reported to the health authorities and a record of it made by them. Physicians outside the large cities of Colorado do not seem to know that the law requires immediate report of all cases of contagious disease, but they have usually been willing to make such reports when informed of the law. The State Board of Health furnishes blanks free of charge and is seeking to make complete and accurate record of all cases. The record made by the health authorities should show the exact location of the patient, the number and names of the rest of the family and all others known to have been exposed. The local boards should make note of the milk, water and ice supply, and, if there are children in the family, the school and Sunday school should be recorded. The officers of such schools should have early notifications of the existence of the disease, the public librarian should be notified in order to see whether any books are in the family, and care should be exercised to prevent the spread to other families by the milk supply. For the protec tion of the public, every house in which diphtheria is present should be distinctly placarded. Some have questioned the neces sity of the placard, but every person visiting a house has a right to know before he enters whether he will encounter diphtheria by entering. If every infected house is placarded, without favor to rich or poor, the community will appreciate the value and justice of the regulation. The regular notification of public school and Sunday school officers does much to educate public sentiment. Furthermore, the record of such data often enables the intelligent health officer to trace the different cases to a common source.

The question of quarantine is important. Who shall be quarantined and for how long? The patient must be quarantined until his throat is free form bacilli. This seldom occurs under three weeks, and because people grow restive under repeated positive reports, it is wise to fix the minimum period of quarantine at three weeks, and to take no secondary cultures during this time. The Colorado State Board of Health has adopted the following rule:

"In all cases where the bacteriologist reports the diphtheria bacilli present, the patient should be absolutely quarantined. A second culture should be taken twenty-one days after the first and forwarded for examination. Quarantine must be maintained until the bacteriologist reports the throat free from diphtheria bacilli. No children from the family should be allowed to attend

school until two weeks after the throat is free from diphtheria bacilli,"

The bread winners need not be kept from their work, unless they be school teachers, or others who mingle much with children, but they should be cautioned to be little in the sick room, or else to be careful to change their clothing and bathe with antiseptics before leaving the house. Before a nurse employed in a diphtheria case goes to another patient a culture from her throat should be examined and her clothing should be disinfected. In fatal cases of diphtheria the funeral should be private and under the supervision of a health officer.

Those exposed should be given immunizing doses of antitoxin and this should be repeated in two weeks, if exposure continues. With the present state of public opinion, it is not wise for health officers to insist upon immunization of the exposed, but they should do all in their power to encourage it. Some day the custom of immunization after exposure to diphtheria will be as common as vaccination after exposure to small pox.

The state or local board of health should have circulars for public distribution, and one of these should be placed in the hands of the head of the family where the disease appears. The following is from a circular on this subject issued by the Colorado State Board of Health, it being identical with the one previously issued by the Denver Bureau of Health:

"Diphtheria is a disease which manifests itself especially in the throat. It is so dangerous, and so difficult of identification, that every sore throat should be regarded as suspicious, and the the person suffering from it kept out of school until the throat has been examined by a competent person and the nature of the sickness determined. The State Board of Health determines absolutely the existence or non-existence of diphtheria by a bacteri ologic examination of the secretion from the throat, and this examination is made at the request of any citizen without charge. Children from houses in which diphtheria has occurred should not be allowed to resume school attendance until two weeks after a bacteriological examination has shown the throat of the sick person to be free from diphtheria germs, as certified by the health authorities."

Toys with which the sick child has played should be destroyed or soaked in a strong antiseptic. Books should be burned and all articles which will stand it should be separately boiled. The necessity for thorough fumigation is apparent. For disinfection of the room, the Colorado State Board of Health recommends five pounds of sulphur to each 1,000 cubic feet of space with exposure for twelve hours; or formaldehyde sprinkling, using five ounces

of the forty per cent. solution for each 1,000 cubic feet of space. The objection of the former is its very corrosive action and to the latter its poor penetration.

SYMPTOMS, PROGNOSIS AND TREATMENT OF GASTRIC ULCER.*

By W. T. LITTLE, M.D.,
Canon City, Colorado.

The order of frequency of gastric ulcer he places as follows: Pain, vomiting, hemorrhage, tenderness, pallor, constipation, thirst. The pain, while nearly always felt in the epigastrium, frequently radiates to the back, down into the abdomen, into the chest, up the esophagus and even to the back of the neck. Pain may be absent. The time of vomiting is not a factor in diagnosis, for it may occur on an empty stomach, although oftenest following eating. Vomiting does not always relieve the pain.

Hemorrhage occurs in fifty per cent. of the cases. The mortality is greater in males and women recover more quickly. Death of females under thirty is rare. In suspected bleeding, the stools should be examined for haemin crystals. As to prognosis, forty per cent. are cured permanently and forty per cent. relieved. Treatment: Rest in bed for not less than four weeks. Rectal feeding for one week in hemorrhagic and irritable cases. For the next two weeks the food by the mouth should consist of peptonized milk, somatose, albumen water, stock, soups with toasted cracker, puree, ice cream, etc. Later, scraped beef, minced breast. of fowl, soft egg, toast and light desserts. A teaspoonful of Carlsbad salts in hot water is given every morning and repeated if there is hyperacidity.

Medicine, in his experience, has but little value, and time should not be wasted with it. After the dietetic and rest treatment have been faithfully tried and the ulcer continues, surgery is recommended.

*Abstract of Paper read before Colorado State Medical Society, June, 1900.