4ii REVIEW — TROPICAL MEDICINE, ETC. 



Diphtheria— MaoCombie' deals with the grave clinical significance of skin haEmorrhages in diphtheria. 



cantiiiwd In pre-antitoxin days patients hardly ever survived more than two days after their 

 appearance, and while they are now, thanks to antitoxin, rare, they almost invariably herald 

 death within 4 or 5 days, though sometimes life is prolonged for a week or a fortnight. The 

 fatal issue is due to toxaemia and cardiac failure, and persistent vomiting is often a marked 

 symptom. 



Ashby,- in a very well-illustrated paper, records an outbreak of milk-borne diphtheria 

 associated with an ulcerated condition of the udders of cows. Like all such epidemics it 

 was less severe and less fatal than the usual form. 



Davies'' has a very useful and practical paper with diagrams of highly magnified bacilli 

 classified according to the types described by Westbrook, i.e. the granular, the barred and 

 the solid types, each of which are sub-divided into varieties. He points out that school 

 examination of contacts in infected classes is a much more rational procedure in urban 

 communities than mere school exclusion without such examination, provided the possibility 

 of home contacts is not forgotten. As regards " Carrier Cases," he quotes the conclusions of 

 the Committee of Massachusetts Association of Boards of Health, which are as follows : — 



1. It is impracticable to isolate well persons infected with diphtheria bacilli, if such persons have not, 

 so far as known, been recently exposed to the disease. 



2. It is not advisable, as a matter of routine, to isolate from the public all the well persons in infected 

 families, schools and institutions. 



The exceptions have to be made as a matter of expediency, in regard to wage-earners, business and 

 professional men. 



It is, however, advisable to keep the children in infected families away from day school, Sunday school 

 and all public places. 



Wage-earners may usually be allowed to continue their work, but teachers, nurses and others who are 

 brought into close contact with children, and also milkmen, should not be allowed to do so. 



In schools and institutions all infected persons, sick or well, should, if the infection is not too wide-spread, 

 be separated from the others. 



When diphtheria appears in a community which has for some time been free from it, it is advisable to 

 isolate all persons who have been brought into contact with the patient until it shall have been shown that 

 they are free from diphtheria bacilli. 



Davies also suggests that the modified phenomena of the late stages of epidemic 

 invasion may be due to an acquired immunity resulting from the prevalence of atypical 

 forms of the diphtheria organism, especially Hoffmann's bacillus. 



Eothe^ describes a cultural method of distinguishing between true and pseudo-diphtheria 

 bacilli. He uses a medium composed of a mixture of one part of neutral broth free from 

 sugar and four parts beef serum. To this he adds ten parts of litmus, and dextrose or 

 laevulose in a proportion of 10 per cent, of the whole. He finds that true diphtheria bacilli 

 always attack the dextrose or lasvulose and colour the litmus red, while, so far as is known, 

 no pseudo-diphtheria bacillus has this combined action. 



Graham-Smith"' has a paper somewhat on the same lines. He found that most 

 diphtheria-like organisms tested produce less acid than the diphtheria bacillus. Hoffmann's 

 bacillus and diphtheria-like bacilli from the normal ear can be easily differentiated, since 

 they form no acid. Any bacillus which acts on mannite or saccharose could also be easily 

 differentiated. 



Lewis" has a very useful paper on the bacteriological diagnosis of diphtheria. He 

 notes that fallacies may arise, owing to fault on the part of (1) the clinician, or (2) the 

 bacteriologist. As regards (1), the throat may have been treated with antiseptics prior to 

 the application of the swab ; the swab used may have been of wool impregnated with an 

 antiseptic ; the wrong locality of the throat may have been swabbed, this being a frequent 



' MacCombie, J. (December 22nd, 1906), "Exanthem of Scarlet Fever and some of its Counterfeits, and the 

 Chemical Significance of Skin Hemorrhages in Diphtheria." British Medical Journal, p. 1757, Vol. II. 



^ Ashby, A. (December, 1906), " A Milk Epidemic of Diphtheria associated with an Udder Disease of Cows." 

 Public Ucaltli, p. 145, Vol. XIX. 



3 Davies, D. S. (March, 1907), " Diphtheria and Small- Pox : An Epidemiological Contrast." Public Health. 



* Rothe (August 31st, 1907), " Beitrag fiir DifEerenzierung der Diphtheriebacillen." Cent. f. Bakt. I., Oria., 

 t. XLIV. 



= Graham-Smith, G. S. (July, 1906), "The Action of Diphtheria and Diphtheria-like Bacilli on various 

 Sugars and Carbohydrates." Journal of Htjijicnc, p. 286, Vol. VI. 



» Lewis, C. J. (August, 1907), "The Bacteriological Diagnosis of Diphtheria." Birmingham Medical Mevieia. 



