sion ought to feel grateful to the Legislature of Kentucky for the wise manner in which it disposed of this bill. It would have rendered Kentucky a nuisance not only to the profession but to the general public. The profession will certainly not forget those members of the legisla ture who took an active part in defeating this bill; they deserve more than ordinary consideration, as they have been really and truthfully public benefactors, and when they ask favors at the hands of the public we most earnestly ask our professional brothers not to forget that one good turn deserves another.

DR. J. R. TIMBERLAKE died in this city on the 15th of March, 1902, from a paralytic stroke. He was sixty-seven years old, and was a native of Ohio, but moved to Kentucky with his parents in 1847. He graduated from the Kentucky School of Medicine in 1857 and began the practice of medicine in this city, and a few years later became editor of the Louisville Medical Journal. At the beginning of the war between the States he sold his journal, and in 1864 moved to Beard's

Station, in Oldham County, and remained there until about fourteen years ago, when he returned to Louisville, and almost immediately he was in full practice, and at the time of his death but few practitioners in this city had a better clientele than he. He was a quiet, unassuming man, and was one of nature's noblemen, honest in every particular, and idolized by his patrons and friends. He leaves a wife and five daughters.

Certainly it is excellent discipline for an author to feel that he must say all he has to say in the fewest possible words, or his reader is sure to skip them; and in the plainest possible words, or his reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain way; and we want downright facts at present more than any thing else.-RUSKIN.

Original Articles.

DIPHTHERIA.*

BY M. K. ALLEN, M. D.

Diphtheria was first definitely described by Bretenneau, who presented his celebrated treatise on the subject to the French Academy of Medicine in 1821. The recognition of the disease clinically as a specific contagious disease was first determined by Trosseau; the anatomic investigation of the membrane and its mode of formation is credited to Virchow, Wagner, Weigert, Cohnheim, and others; the remote lesions to Oertel, Babes, and others; the discovery of the bacillus and its relation to the disease to Klebs, Loeffler, Yersin, and others; the clinical evidence of the value of antitoxin to such men as Welch, McCollon, and others.

While it is now possibly one of the best known of any of the infectious diseases, yet it was not until 1884 that Loeffler fully succeeded in demonstrating that a certain germ, known as the Klebs-Loeffler bacillus, was the cause of diphtheria, and was to be found in the inflamed patches in the throats of persons suffering from this disease. It was also known at this time that if a portion of the diphtheritic membrane. was rubbed over the surface of solidified blood-serum the diphtheria germs present in the membrane would multiply and produce a visible growth, an examination of the latter showing the presence of large numbers of characteristic germs, which the skilled bacteriologist could readily and at once recognize. Thus it becomes possible to make an accurate and positive diagnosis of diphtheria, and to distinguish true Read before the Louisville Clinical Society, March 11, 1902. For discussion see p. 303.

diphtheria from other forms of inflammation. Prior to 1895, when diphtheria antitoxin was first used to any great extent, the mortality from this disease was very great, both in this country and in Europe.

It is my purpose to give you some statistics as to the mortality from diphtheria as occurring both in this country and abroad, comprising both the pre-antitoxin period and since. It it well to bear in mind the fact that it is extremely difficult to obtain or determine the exact deathrate occurring from diphtheria, because of errors in diagnosis. Follicular tonsillitis and other throat troubles are sometimes no doubt diagnosed true diphtheria, and especially is this error liable to occur during the prevalence of an epidemic of this disease. It may also happen that diphtheria is sometimes not recognized, and the little patient is treated for some other affection. Still again, the children of poor parents may have the disease who never come under the notice of a skilled physician. The most reliable statistics must, therefore, be gotten from hospitals and boards of health.

There is an additional difficulty in obtaining the death-rate from diphtheria for any given period. It sometimes occurs that visitations of this disease are extremely mild and again very virulent. In 1854, for instance, England experienced an epidemic of diphtheria with a mortality rate of 95 per cent in cases with nasal involvement. In 1881 Dr. Bulowsky, a Russian physician, reported an epidemic of diphtheria in a town called Samara, on the Volga River, in which of those affected under the age of five years 86 per cent died, and between that age and ten years 80 per cent died. In Germany, from 1885 to 1894, there were 119,038 deaths from diphtheria, the average number thus being 11,904 per annum. In the city of New York, in 1894, 2,359 persons died of diphtheria. In Boston there were more deaths from diphtheria in 1895 than for any other year in the previous eighteen, excepting the year 1881. In 1895 Philadelphia had a death-rate from this disease away above its average. Brooklyn, Chicago, Cincinnati, and St. Louis had more deaths from diphtheria in 1895 than for ten or fifteen years previous. In the city of Baltimore, for a number of years past, the health authorities and practicing physicians have had to contend with a very virulent type of the disease, which resulted in an unusually high mortality, the death-rate in 1894 reaching 74.15 per cent; in 1895, 71.42 per cent; in 1896, 51.78 per cent; and in 1897 they experienced a greater mortality than in any previous year. In that city it became necessary for the health

authorities to take very active steps in order to control the spread of the disease; they enforced isolation and thorough disinfection. They also required reports from the bacteriological department, based upon cultures obtained by a special competent medical officer, showing the throats of patients or other inmates of infected houses to be free from the Klebs-Loeffler bacillus before being released from quarantine. In addition to these practical precautionary methods, antitoxin was distributed gratuitously to the amount of 1,300,000 units. Notwithstanding the means thus employed, the disease still prevailed in epidemic form in the years 1898 and 1899, during the last year of which the health department distributed 2,238,900 units of antoxin. During the last-named year they experienced a reduction in mortality to 17.49 per cent.

In contradistinction to the high mortality rates just mentioned, when an exceptionally virulent type of the disease prevailed, I will refer to periods when a much milder type must have been experienced. In 1876 Bernheim published a series of cases of diphtheria, four hundred and fourteen in number, showing a gradual fall in the mortality from this disease covering a period of twenty years. In one group of fiftyseven cases, from 1876 to 1880, in his private practice, there was a death-rate of 26.3 per cent; in two hundred and twenty-two cases, from 1881 to 1886, 20.05 per cent; and in seventy-three cases, from 1887 to 1896, the percentage fell to 13.7. He accounted for the lessened mortality by a diminution in the intensity of the disease. In the German Empire, according to a collective investigation of a summary of 4,479 cases of diphtheria in which no claim seems to have been made for special treatment-extending over a period from October 1, 1894, to April 1, 1895-there was experienced the low mortality of 14.7 per cent.

It is obvious that a death-rate so light as this, based upon such an immense group of cases covering a wide area, can only be accounted for by assuming that during that particular period there was a diminished virulence in the character of the disease prevailing. Such statistics show conclusively that an unexpectedly large number of recoveries from diphtheria may take place in a given series of cases, even though these cases in their clinical manifestations may appear to be of a degree of severity upon which we would ordinarily predicate an average deathrate. For instance, Piliere reports ninety-eight cases, in six of which tracheotomy was performed, with ninety-four recoveries. Flahaut forty cases, no deaths. Ritter published a report of sixty-two cases, with no

deaths. Piedallu, in 1894, without giving the number of cases, claimed to have no deaths since 1891, yet many were of the laryngeal variety. Loeffler, in 1894, reported seventy-one cases and no deaths. Gibbes, New Zealand, reported one hundred and forty-five cases treated with eucalyptus, and but one died, that one being an infant eight months old.

These and similar reports concerning diphtheria often come from sources of the highest repute, and go to prove how otherwise reliable observers may be misled by the vagaries of this disease, and the question of its mortality hopelessly confused. A study of the line of variation in diphtheria is important in guarding the physician against an over-confidence in measures that for a while only are apparently successful, and an incentive also to persistent effort, looking to the better control of this malady when the disease reappears in its more dangerous and malignant form. The best obtainable statistical information at the present time indicates a wonderful reduction in the mortality from diphtheria by the use of antitoxin, as I will proceed to show, giving results prior to and since the antitoxin period:

The average of a group of nine other sets of statistics of pre-antitoxin mortality, in this country and abroad, shows a mortality of 41.8 per cent. In October, 1895, the Chicago health department took over the treatment of diphtheria among the poor and destitute of that city. During the five years previous to that time there had been an aggregate of 7,411 deaths from diphtheria, or an annual average of 1,482 deaths. Between October 5, 1895, and December 31, 1900, the health department treated 5,727 cases of bacterially verified diphtheria, with the following results: Treated on first day, 476; second day, 1,426; third day, 2,034; fourth day, 1,037; later, 754. Mortality per cent of those treated on first day, 0.42; second day, 1.54; third day, 3.59; fourth day, 11.38; later, 23.1. Total deaths, 389; cases intubated,