place of inoculation which reached its maximum at the end of a week and then gradually became smaller and firmer. The animals had a raised temperature and left off feeding on the second or third day, then to all appearances recovered; but on the eighth or tenth day, they were attacked by a slight cough which gradually increased; both became emaciated; one died on the fifteenth day, the other was killed (being very ill) on the twenty-fifth day. During the illness both animals had an eruption on the teats and skin of the udder. From one of the cows on the fifth day milk was drawn from the healthy teat, the outside of the teat and the milker's hand having been first thoroughly disinfected from this milk cultivations were made, and it was found that thirty-two colonies. of diphtheria bacillus without any contamination were obtained from a single cubic centimetre. Contrary therefore to what happens in the guinea-pig and in the cat; the diphtheria bacillus passes from the seat of inoculation into the system of the cow and makes its appearance in the milk. The presence of the bacillus in the eruption on the udder was also demonstrated both by microscopic examination and experiment. Two calves were inoculated with matter from this eruption and both developed a similar eruption, besides becoming affected with severe broncho-pneumonia and fatty degeneration of the kidney. It therefore appears that a definite disease can be produced in the cow by the diphtheria bacillus and the contamination of the milk shows that the bacillus contaminates the general system.

At the beginning of the month of April, two cats died at the Brown Institute after having been ill for several days with symptoms like those of natural cat diphtheria between the beginning of April and the beginning of May; fourteen cats became similarly affected, some more severely than others, and some died with the characteristic morbid changes. This epidemic, as it may be called, commenced with the illness of the first two cats about the end of March; and the question arises as to how the disease originated in these two animals; no cats had been ill in their shed and the two affected ones were healthy when received at their institution some weeks later. But during the latter half of March there were in the stables of the institution two milch cows ill with diphtheria induced by inoculation with the human diphtheria bacillus-in fact the two cows already referred to. The diphtheria bacillus

was found in the milk of one of these animals on the fifth day after inoculation, and orders were given to the attendant that the milk of both cows was to be thrown away. This order was not obeyed, for part of the milk was given to the two cats above mentioned, and they sickened as described within a day or two afterwards. It ought to be mentioned that the man in attendance on the cows had also charge of the cats, but in view of the fact that he himself was free from the disease the possibility of his having conveyed it to the cats may be dismissed.

(332) The Prevention of Diphtheria.

A common source of infection is actual contact with persons suffering from diphtheria. It is not unfrequently produced from the unnecessary and very dangerous plan of sucking a tracheotomy tube in order to clear it. There are epidemics on record distinctly connected with milk. Nevertheless a large proportion of the cases are obscure in origin. It is noteworthy that in Loeffler's investigation into the organisms of the healthy mouth and throat he found in one case Klebs's bacillus, so that it may be presumed it. gets access to persons' throats without necessarily causing illness. Persons with large tonsils and relaxed throats are probably more liable to be attacked than those whose mucous membranes are in a healthy state, for the micro-organism has then opportunities to attach itself to the interior of a follicle, and unless destroyed by other saprophytic bacteria, or by the secretions of the mucous membrane, to divide and multiply, and get access ultimately to the deeper layers of the tissue. One important factor in prevention of diphtheria is, therefore, when diphtheria is epidemic for persons with weak throats to apply local applications under advice so as to get the mucous membrane into a healthy and therefore resistant condition.

If the view is correct that a large proportion of the cases are septic, such are likely to be caused by bad drainage, and foulness

It is obvious that a wash-bottle arrangement containing at the bottom of the flask a solution of corrosive sublimate or else strong carbolic acid, and from the glass tube which dips beneath the liquid a rubber tube carrying a little nozzle fitting in the silver canula, would make a most effective apparatus to clear the tracheotomy tube, and the operator could not be directly infected, for the sucked out matter would pass into the disinfectant. By drawing air through the shorter tube a very considerable vacuum will be produced.

of all kinds. The possibility of infection from cats in the light of Klein's recent research must also be remembered. Diphtheria actually present in a house, the patient should be isolated, and those in attendance should spray the throat with a half or one per cent. solution of carbolic acid two or three times a day. The writer has known families which have taken this precaution and escaped, although for days in hourly contact with bad cases of diphtheria. So far as is known, the diphtheritic poison is easily destroyed, and therefore the disinfecting measures described at page 358 should be successful.

PUERPERAL FEVER-SEPTICEMIA-PYEMIA-BLOOD-POISONING.

(333) Influence of Season on Septic Diseases.

The above names are given to diseases which have so much in common that, in a public health sense, they may be considered almost identical save in relation to sex, and as to whether they arise from external wound or otherwise.

Puerperal fever and septic diseases generally are also closely allied to erysipelas, for when erysipelas is frequent, puerperal fever and the other septic class are also frequent in their incidence; whereas when erysipelas is not frequent, there are also fewer cases of the septic class than usual. For example, take the twenty-five years ending 1888: the maximum number of puerperal fever deaths occurred in 1874 (3,108), in the same year the maximum number of deaths from erysipelas (3,358) were registered; in 1867 occurred the minimum number of puerperal deaths (1,066), in the same year the minimum number of deaths from erysipelas (1,446). The two curves also given by Buchan and Mitchell, showing graphically the seasonal mortality variations for each week of the year, based upon the mortality records for thirty years ending 1874, show the same general fluctuations for erysipelas and for puerperal fever. The minimum of each falls in the latter end of August, the mortality rising gradually, to attain the maximum in the last week of November, to decline somewhat throughout December, but to be still above the average, to rise again in January, and then to gradually decline through the succeeding months to the lowest point in August.

(334) Statistics of Puerperal Mortality.

The actual number of deaths from puerperal fever in the twentyfive years ending in 1888 was 46,162, the number of births (living) was 19,746,768, which would give a rate per birth of 23 per 1000. The rate is not quite so high as this, because the number of births (living) is less than the number of confinements. The mean yearly number of puerperal deaths is 1,846; the maximum, as before stated, fell in 1874 (3,018), the minimum in 1867 (1,066). These maxima and minima do not coincide with the maximum or minimum of birth: the greatest number of births took place in 1884 (906,750), the least number in 1864 (740,275).

During the three years ending 1888 (the full returns have been published for the last three) there has been an increase of death from puerperal fever in relation to the number of births, the rate per thousand births being for those three years 2-6 per thousand. This increase occurs in confinements treated at the woman's own home by medical practitioners, midwives, &c., and not in the lyingin hospitals.

The use of disinfectants has caused a complete and happy change in the mortality of lying-in institutions. In the largest childbed institution of the world, viz. the Vienna Lying-in Hospital the mortality previous to 1862 was 28 per 1,000; then by hygienic reforms it was reduced by 1880 to 16 per 1,000; lastly, during the period since 1880 it has fallen to 7 per 1,000. At Dresden the mortality has been reduced from 50 per 1,000 to 10 per 1,000. The mortality at the Maternité in Paris has been reduced by the same agencies from nearly 10 per cent. to 11 per 1,000. In our own institutions, such as Queen Charlotte's Hospital, and the General Lying-in Hospital, York Road, puerperal fever is almost unknown. It is therefore evident that midwives and a large proportion of the profession can either not use antiseptics, or are not able to enforce their use in the subsequent nursing. As Dr. Cullingworth has already stated, in pleading for the more general use of antiseptics in obstetric practice :-"The lying-in hospitals have very properly led the way, and it now rests with those engaged in private practice to take the matter up. It was obvious that the 2,078 deaths certified as having occurred in England and

1 Public Health, vol. i., p. 210.

Wales from puerperal fever in 1886 could not have all taken place in hospitals. Indeed, two-thirds of them occurred in counties where not a single lying-in hospital existed. It was not, therefore, a disease of hospitals alone. The only way to avoid this terrible mortality, and to avoid also the enormous amount of puerperal disease which, because it was not fatal, remained unrecorded, was for every practitioner to recognize his responsibility in the matter. The use of antiseptic precautions in midwifery practice in Germany was made compulsory by the State. The tendency of public opinion in this country was not in the direction of compulsory legislation in such matters. The use of antiseptics in Great Britain was, and was likely to remain, a question of individual responsibility, not of penal enactment. Surely it ought not on that account to be considered the less binding."

(335) Bacteriology of the Septic Diseases.

In the septic diseases generally, there have been various microorganisms, such as bacilli and cocci, found, which, when isolated by cultivation, and the cultures injected subcutaneously, cause abscess, or purulent foci, or gangrene, or erysipelatous inflammations in the lower animals. It is pretty certain that in puerperal fever and septicemia one or more pathogenic micro-organisms cause the illness. In the puerperal state, the raw surface of the uterine mucous membrane, and any laceration of the peritoneum or other parts, afford an excellent soil for pathogenic microbes; in other cases a wound or abrasion of the skin is the portal through which the mischief enters; in others again there is a direct infection or inoculation, such, for example, as the pyæmia which so often ensues after wounds occurring in dissection. There is another class of cases, which seem to depend upon bad drainage or foul emanations; this class of blood-poisoning, which often runs its course similar to traumatic pyæmia, is obscure, and requires farther investigation.

(336) The Duty of the Health Officer in relation to Puerperal

Fever.

Under the Notification Act, cases of puerperal fever must be certified by the medical man, notified by the householder. It