the alae and the dark red flush in one cheek. In meningitis the tache cerebralis is nearly always present; strabismus; rigidity of the neck, and Kernig's symptom are quite commonly present, and it is not likely that a cough will be present. Some assistance may be derived from an estimation of the chlorides in the urine, since in no other acute disease will the chlorides be found so low as in pneumonia.

Other diseases may somewhat closely simulate pneumonia, but probably none so important as those mentioned.

If the physician is not in constant attendance upon children with the infectious diseases of childhood, he should warn those in attendance to be alert and observant of any symptom, no matter how slight, and to report to him at once, so that the invasion of broncho-pneumonia may be met promptly. And, further, before making a diagnosis of appendicitis or meningitis, the physician should give the chest and head the very best examinations of which he is capable.

THE UNCERTAINTIES OF EARLY DIAGNOSIS AND THE NECESSITY OF EARLY AND VIGOROUS TREATMENT OF DIPHTHERIA.*

By T. F. MCMAHON, M.D.,

OF ONTARIO.

The death rate from diphtheria in Ontario, as elsewhere, is altogether too high. In 1902, 2696 cases were reported, with a mortality of 15 per cent. In Toronto, 893 cases were reported with 115 deaths-a mortality of 13 per cent. Hamilton had 22 per cent. of deaths, Brantford 16 per cent., and Ottawa 12 per cent. In Ontario the people are as a rule well fed and well housed, and the results ought to be much better than in the crowded, poverty-stricken centers of the older countries. In the pre-antitoxin days our percentage of mortality was much lower than in New York and the large cities of Europe, where the mortality averaged from 30 to 40 per cent. If their percentage mortality has been lowered from the above rate to 16 per cent. or less, surely ours in Ottawa ought to show a corresponding decrease. But the report of the Ontario Board of Health shows that in 1902 it was 15 per cent.

I have questioned a large number of practitioners who use antitoxin faithfully and intelligently and they tell me that they now rarely lose a case of diphtheria, whereas in the pre-antitoxin days a very large percentage of their cases succumbed.

I am not going to enter into any argument to prove the efficiency of antitoxin. I take it that you will agree with me that nearly every intelligent practitioner is as firmly convinced of the efficacy of antitoxin in diphtheria as that of quinine in malaria or mercury in syphilis. I shall assume then that we are all believers. The object of my paper is to point out that many lives. are lost that ought to be saved, and that as a result of faulty or tardy diagnosis and late and half-hearted treatment the death rate is double or treble what it ought to be. Let us examine our consciences and find wherein we have been remiss.

For many deaths we are not responsible. Those in charge of sick children often do not call in the physician until fatal poison

*Read at meeting of Ontario Medical Association, 1904.

ing has occurred. But there remain a large number of cases in which the physician is called and yet the undertaker follows in his wake. Let us examine the causes of his failure.

I. His attention is not specially directed to the throat and he fails to look at it, and diagnoses something else. By the time he recognizes his error the case is hopeless. The golden rule is, "Always examine the throat of a sick child no matter what the symptoms are." The physician who fails to diagnose diphtheria because he did not look at the throat ought to be prosecuted for malpractice.

2. He examines the throat and thinks he has a case of tonsillitis or coryza or croup to deal with; or that, even if it is diphtheria, it is so mild that the old-fashioned remedies are sufficient for its cure.

3. He fails to follow up a suspicious case and finds too late that the patient is in a desperate condition.

4. He treats one amongst many children and fails to protect others exposed to contagion by a preventive injection.

5. He uses antitoxin, but is half-hearted and does not use enough.

6. In a case of laryngeal diphtheria he uses antitoxin-perhaps in large doses-but fails to make an early resort to accessory remedies such as calomel fumigation and intubation.

7. He makes an early diagnosis but puts off the injection of antitoxin until to-morrow or the day after.

For myself I must confess I have made all these blunders, and have had occasion more than once to bitterly regret them. But it is now some five or six years since I have had a death from diphtheria in my practice. I well remember the last two I lost. In one I was called in to see a sick child; it had a discharge from the nose, but on carefully examining the throat I found no membrane. The parents told me they would let me know if the child was not doing well. Three days later I was called in and found the child dying from laryngeal and nasal diphtheria. In the other case I diagnosed herpetic tonsillitis, because the spots were confined to the tonsils-small, white and discrete. Some four or five days later I was called in to find the child-who in the interim had been playing on the street, and doubtless spreading the disease among the neighbors-dying of laryngeal stenosis.

I had a couple of similar experiences in which the result was not so deplorable, but my culpability was as great.

Catastrophies like these caused me to ask myself "Can they not be avoided?" "Is it possible to always diagnose diphtheria at the first visit?" "Can I afford to wait from one to three days for a bacteriological report?" "And can such report always be depended upon?" The conclusions I have arrived at are that such catastrophies almost always can be avoided; that it is often not possible to diagnose diphtheria at the first or any other visit without bacteriological examination, and I believe firmly that a bacteriological report is not always to be depended upon.

The Toronto Board of Health has an exceedingly efficient and painstaking bacteriologist-so has the Ontario Board of Health. And yet both will, I think, admit that they have made many negative reports where the subsequent course of events proved beyond any reasonable possibility of doubt that the swabs were taken from a case of diphtheria. I could quote some examples from my own practice, but the following three cases will serve to illustrate the difficulties:

Dr. Dwyer reports the case of a Toronto physician, swabs from whom were repeatedly examined by both Prof. Amyot and Prof. Shuttleworth, without any diphtheria bacilli being found. And yet severe-indeed almost fatal-paralysis, involving the arms, legs, throat, larynx and heart, supervened, and two others in the family developed the disease.

2. Dr. Nevitt reports the case of a young woman who had a violent sore throat-clinically, diphtheria. To prevent the spread of infection to the children in the house he sent her to the Isolation Hospital. Repeated examination failed to reveal the presence of diphtheria bacilli, and yet she developed well-marked paralysis.

3. Dr. Uren reports the case of a girl aged twenty sent by him to the Isolation Hospital as a case of diphtheria. In four days she was sent home, as no diphtheria germs were found. But three weeks later extensive and serious paralysis supervened.

I need not multiply examples, for it is admitted that for some mysterious reason we may fail to get diphtheria germs from swabs taken from undoubted cases of diphtheria.

Having arrived at the above conclusions, I asked myself,, "What are you going to do about it?" And the answer was

evident-take no chances. In every case in which there is even a suspicion of diphtheria give antitoxin at once, and give it freely. Get a report in every doubtful case, but do not wait for the report but inject at once. As soon as bacteriological examination shows the presence of diphtheria bacillus give an injection to all the children of the household to prevent the spread of infection. Of course isolation and other methods of preventing the spread of infection must not be neglected, but neither must the preventive injection. Doubtless, if this practice is carried out, many unnecessary injections will be given. I have often injected antitoxin and found as a result of bacteriological examination that the case was not one of diphtheria. But what harm has been done? I have never seen any bad results from the injection. In fact, it has been my experience that the cases of membranous tonsilitis thus treated seemed to clear up more rapidly than those treated otherwise, and many physicians have expressed to me the same opinion.

There is but one serious objection-that of expense. But in my opinion prevention is cheaper as well as better than cure, and it would be cheaper for the municipality to supply physicians with preventive injections for the poor than to have the diphtheria hospitals crowded with patients kept for an average period of five weeks at an average expense of well on to a dollar a day.

There is nothing like a local examination to illustrate a truth, and this is supplied in the experience of the Victoria Hospital for Sick Children with preventive injection, as related by Dr. Rudolf in a recent article in the British Medical Journal.

In 1901 about one hundred cases of diphtheria developed in the hospital, nearly all of which were treated with antitoxin. Of these only three died, and one of these was complicated with scarlet fever. Between January 1 and July 7, 1902, forty-two cases (all showing Klebs-Loeffler bacillus) developed. All, except a few of the mildest, were treated with antitoxin. Forty-one recovered, and the last one that died developed uremia due to kidney disease that predated her admissioon to the hospital. For five years there had never been two successive weeks in which diphtheria had been completely absent from the hospital. Early in July, 1902, a determined effort was made to stamp out the disease by the injection of immunizing doses into all the patients. The result was most gratifying. For the five months reported not