toxemia of this patient, whom your essayist saw in consultation with Dr. Chamberlain, of Tiffin. You will see in this first mount a few neutrophile myelocytes, eosinophile cells, a lymphocyte, and evident decrease in the erythrocytes, a few pale degenerated cells, which are seen as the faintly stained discs.

This patient of five years had pharyngeal diphtheria, as the bacteriologic and cultural method of diagnosis demonstrated, followed on the fourth day by laryngeal diphtheria; the subsequent bacteriologic examination revealed a mixed infection, the streptococcus being demonstrated as existing with the Klebs-Loeffler bacillus.

The second mount exhibits the effect of the antitoxin within the second day after the initial dose was given of 5,000 units, and the great decrease in the poly-morphonuclear leucocytes; the change in the erythrocytes is well marked on contrast with the first mount.

The first and well-indicated method of diagnosis of pharyngeal and laryngeal diphtheria is the bacteriologic and verified by the cultural investigation of the inflammatory exudates, as the same condition may be caused by the streptococcus before the Klebs Loeffler bacillus invades the seat of inflammation or abrasion. Streptococcic anginas or anginas from other bacteria, lack the Klebs-Loeffler bacillus, run a mild course, but in the beginning may be confusing for a satisfactory diagnosis, unless differentiated by a bacteriologic investiga

tion.

The scope of this paper will permit of but a brief mention of the method of securing a specimen of a suspected exudate. Specimens for bacteriologic or cultural examination are taken with swabs, such as are shown you, constructed, sterilized for this special purpose, can be made extemporaneously, or can be purchased of instrument dealers, but best obtained direct from any of the biologic laboratories. In either case, whether made on the spur of the moment or purchased, it should be sterilized most thoroughly just before using, which can be done by a half-hour in the common stove oven, until the cotton plug turns brown.

The patient should not have received an antiseptic gargle or wash for at least. two and a half hours previous to the swabbing, placed in a good light; if a child,

held in the nurse's lap, or held by some member of the family, who is not easily excited or too indulgent, as such a person cannot render the service needed in examining or treating children.

Holding the tongue depressor with the left hand, obtain a clear view of the inflamed area; in taking the swab from the tube great care should be taken that the swab does not touch the mouth or adjacent parts; press and roll the swab between the fingers against the exudation firmly, secure a portion of the exudate upon the swab if possible, and without touching the adjacent surfaces replace the swab in the tube; singe the cotton plug before replacing it in the tube. The swab is now ready to make immediate mounting, or to forward to the nearest laboratory for diagnosis.

If the physician has a good microscope, with a 1-12 oil immersion objective, film or slides can be prepared at once from the swab, one stained with Loeffler's methylene blue, another film or slide stained after Neisser's differential method, which has proven of great practical value, and can be relied upon with great confidence. If the cultural method is to be used, the swab is passed, rolled over the surface of the culture media that the Klebs-Loeffler bacillus will thrive on, and at the same time prove antagonistic to the development of other bacteria. Such a media is the coagulated blood serum of Koch or Loeffler, prepared for ready use by the biologic laboratories, as is here shown you in these tubes.

Care must be taken not to break or roughen up the surface of this media when inoculating with the swab, then placed in the incubator at 37° C. for at least ten hours, then is ready for examination.

Colonies of the Klebs-Loeffler bacillus, if present, will be seen as small and larger round elevated spots, opaque, whitish, discrete, not confluent, having a moist appearance at first, which becomes dried after four days. A pure culture from colonies is here shown, which has been replanted from time to time, from a case examined some months ago, and herein mentioned. A mount of this case, made from the first colonies, is the mount now placed under the microscope, which exhibits the Klebs-Loeffler bacillus in a characteristic morphology and arrangement of the bacilli.

Cultural methods are best carried on in the laboratory, for general reasons, but for "a home talent" cultural method, the following procedure will be found useful, if all the necessary care and detail are used, as is demonstrated by this bottle and egg. Take a wide-mouth bottle, boil in an antiseptic solution, sterilize thoroughly in oven for a half hour. While the bottle is being sterilized, take a fresh egg, boil for ten minutes, allow it to cool until it can be handled; with a knife sterilized by passing it through an alcohol flame cut off the top of the broad end of the egg, care being taken not to penetrate the yolk. The swab is quickly removed from the tube, rolled and rubbed gently over the cut surface of the egg, then placed cut end down in the sterilized bottle, care taken not to allow the egg to slip in too far and slide to the bottom. Press the egg in the neck of the bottle firmly, place it in a warm corner or situation for eighteen hours, then examine for colonies as on other media.

The presence of the Klebs-Loeffler bacillus in the bacteriologic and cultural methods of investigation prove four facts. 1. That the patient has diphtheria. 2. That the patient has had diphtheria, may be convalescent, but still infectious as regards others.

3. The patient may have the true bacillus in the throat for weeks or months, and is liable to an invasion, if any abrasion in the pharynx or larynx occur, or any sore throat occur from other causes, associated with a sudden depression of the physical powers.

4. It is proof that the patient may communicate diphtheria to any one in a susceptible condition. While the real pathology of the Hoffman bacillus may be obscure at the present time, yet any throat containing these bacilli is to be considered dangerous for infection.

If the Klebs-Loeffler bacillus is not found in the first mounts, or in the cultural investigation, it may be considered:

1. That the patient does not have diphtheria.

2. That the swab did not come in contact with the exudate, or the method of using the swab was faulty, and, of course, excluding the "mistakes of Moses" in the laboratory, or the faulty technique.

3. Should a sterile culture result, then it indicates that an antiseptic gargle was used shortly before the swabbing, or that

the exudate was not touched, and the whole procedure should be repeated with most careful precautious and technique.

TREATMENT.

The treatment of pharyngeal and laryngeal diphtheria is local, systemic and specific. Of the numerous local applications, none is better than the sub-sulphate of iron applied full strength on an applicator to the site of the exudation, from two to four times daily. This produces but little coughing and expectoration, which, resulting, greatly aids the loosening of the membrane. Hot steam inhalations from a steam atomizer afford great] relief. If the patient is old enough, gargles of potassium chlorate, one-half teaspoonful in a half-teacup of hot water every half hour, gives decided relief. In some cases the hot pack, in others the cold pack, or ice about the neck, gives great comfort to the patient. Antiseptic gargles are always indicated, none better than Loeffler's, or sodium salicylate in hot water. Any or all of these gargles should be used as hot as can be borne.

Internal.-Alcohol as indicated in good quantities; digitalis in form of infusion made from English leaves every two to three hours as indicated; quinia, strychnia, nitroglycerine and ammonia as the physical powers decline.

In condition of collapse, hypodermic injections of alcohol, aromatic spirits of ammonia, strychnia, adding the normal salt solution to any of the remedies injected. The paralysis appearing, strychnia in good dosage, the faradic current.

The diet of nutritive fluids, as milk hot or cold, beef juice freshly prepared. eggs, eggnogs, "Thomas and Jeremiahs" (the saloon formula), frequently administered, animal broths ad libitum. When deglutition becomes too painful or impossible, then rectal nutritive enemata if the patient is a child; if an adult, use the stomachtube for gavage if possible.

Specific.-The modern treatment of diphtheria is but one, that of serum or antitoxin; added to this, whatever of the local and internal medication is indicated.

Guinea-pigs were first immunized with the specific toxin against diphtheria by Fraenkel, but it was left to Behring to place the fact in our possession that the blood of an immunized animal can be used not only in small doses for protection, but

in larger doses for a curative action against the absorption of the toxalbumin. To Behring belongs the honor of one of the greatest research discoveries of modern medicine. This has led to the use of other serums for the prevention and treatment of diseases produced by different bacteria. The mortality before the serum was used was as high as 59 per cent. in some localities, with the best results from other treatment; since the serum treatment the rate has fallen to 9 per cent. in some cities. As time passes and more cases are treated with the serum, better results will be obtained; the technique improved, there will be no valid position for its non-use by any practitioner, as the progressive physician to-day relies on the serum as a real specific.

Diphtheria toxin forms in the body tissues as it does in the culture tubes, and is found in the tissues, blood and urine. The toxins and anti-toxins of diphtheria neutralize each other in the body in the same manner and process of chemic reagents; the stronger the solutions the more rapid the neutralization.

The power of an antitoxin serum is tested by the amount of bacterial toxin of a known or given strength, which is capable of neutralizing it, and the quantity reduced to units, so that the uniform power of one unit of antitoxin will neutralize one hundred units of toxin in the tissues.

It is impossible to foretell the amount of toxin a given exudate may develop in a case, or be produced by a membrane, hence the key to the successful treatment of diph-. theria by antitoxin lies in the large dosage, given as early as possible, the initial dose repeated every six to ten hours, until improvement takes place, continued at longer intervals until the patient is in a safe condition. Children take enormous doses with no ill-effect, and the most brilliant results in extreme cases have been achieved from apparently extreme dosage, yet harmless.

The serum is put up in packages containing from 500 to 3,000 units, of either the ordinary or special concentration, of which experience has taught the concentrated strength is best to administer. To a child one year old the initial dose should be from 500 to 2,000 units, repeated every six hours until symptoms improve, then repeated at intervals of twelve hours until membrane separates and sloughs off. To

a child two years old the initial dose is from 2,000 to 5,000 units, repeated every eight hours until improvement is decided, and repeated at intervals of ten to fifteen hours until patient is in a safe condition. In extreme cases, in child or adult, the initial dose must be large, 5,000 to 10,000 units given every twelve to twenty hours until convalescence is established, the exudate is removed, and parts resume a safe condition.

The serum does not kill the Klebs-Loeffler bacillus, but neutralizes the toxin of the developed and developing bacilli at the seat of inoculation; hence, full doses must be repeated until the toxin is neutralized and the patient convalescent, regardless of age or dosage, as the Klebs-Loeffler bacillus may remain in the throat for weeks, even months.

The urticaria, soreness at the points of injection, or now and then the swelling of the joints, are transitory effects, and will soon abate without any reminders. Abscess is rare, may be said never occurs when faultless antisepsis and technique are used in the administration of the

serum.

The containers for the serum put up by the different biologic laboratories are here displayed, one of antiseptic bulb ready to use; another of glass, recently placed before the profession, which is an already to use antiseptic, sterilized in a glass syringe, which in some respects is an improvement over the already clever devices for the administrations on the market.

If the ordinary antitoxin syringe like this one exhibited is to be used, it should be boiled in an antiseptic solution, sterilized before use.

Rubber plungers are more easily rendered atiseptic than leather, which are more difficult of sterilization without damaging the leather, which will render the syringe unsatisfactory when least expected, and more than once has caused the attending physician to think "mad-dog backward," if not audibly, to have an ill-working syringe, a screaming child, serum half injected, with excited parents to contend with.

Such devices as are presented are a friend in need, to escape the complications that may arise at any moment with the antitoxin syringe; not least, the antisepsis of the treatment added to the convenience and safety.

Great care must be taken to render the skin at the point of intended injection antiseptic, which can best be accomplished by hot water and green soap, followed by alcohol. The point of injection should be touched with a drop of carbolic acid on an applicator or end of a match, which not only renders the point of needle entrance aseptic, but acts as a local anesthetic for the needle puncture.

The patient, if a child, should be firmly held by a cool-headed member of the family, and that is a very scarce article in most households; the injection made about the hips, or at the interscapular space, where the patient cannot see the procedure; the injection made very slowly, without any massage of the fluid after injection. The assistant must be cautioned to hold the child very firmly, as the cries of fear and motion will interfere with the continuous and safe administration of the serum; to hold the child by force, if necessary.

The serum should be administered at body temperature in whatever container is used; if the antitoxin syringe is used, a portion of the normal salt solution should be given with the serum when injected.

The serum treatment applies to any form of diphtheria in suitable doses, as indicated by the symptoms; if a mixed infection supervenes, then a mixed serum treatment should be given, the antistreptococcic given in addition to the diphtheritic, but not at the same hour.

The

In a case of pharyngeal diphtheria in a patient of six years, seen in consultation with Dr. Stitt, of Rising Sun, bacteriologic investigation revealed a mixed infection; the streptococcus was demonstrated with the Klebs - Loeffler bacillus. serum treatment was used for both infections; 5,000 units of the antidiphtheritic serum was given every eight hours, to which was added 20 c.c. of the antistreptococcic serum every ten hours until the patient was in a safe condition, then repeated every fifteen hours until membrane sloughed.

At a meeting of the Toledo Academy of Medicine, January 16, diphtheria was up for discussion. Your essayist, being present, reported the case just mentioned, the results of the mixed serum treatment given for a mixed infection, which was discussed favorably by Dr. Van Pelt and others.

A child can be rendered immune by a

dosage of from 500 to 1,000 units, an adult from 1,000 to 3,000 units given every other day for three days, then once a week, according to the indications, ceased after six to eight doses have been administered.

An attack of diptheria gives immunity for a time, but another infection will occur, when the soil and other conditions favor an invasion of the virulent Klebs-Loeffler bacillus. In some cases, milder, perhaps, the Klebs - Loeffler bacillus disappears about the same time as the sloughing of the membrane, but most frequently the bacilli remain for a much longer time apparently non-virulent, yet in other cases appear to retain all their virulency as regards infection, remain active in the nasal tract, prolonging a free and sanious discharge from the nares.

That the serum does directly antagonize the toxin in the blood is proven by the condition of the blood following the serum injection. The erythrocytes show little or no change from the initial injection, but are protected from further and continued destruction; but the large number of polymorphonuclears are diminished to a marked degree in forty-five minutes after the initial injection, that condition lasting for twenty to thirty hours; then, if no further injections are given, the leucocytes will gradually increase, but will not reach the first high number before the serum was injected.

Favorable cases show a steady decrease of leucoycytes and myelocytes; the pale cells take a firmer stain; but in fatal cases the reduction of the leucocytes are controlled and remain stationary after the fourth day.

If uticaria follow the antitoxin injection, the leucocytes, especially the large mononuclears, will increase during the acute stage, and diminish as the case becomes subacute. In extreme cases, when suffocation seems at hand, it may be necessary to incubate, or make a tracheotomy in absence of intubation-tubes or operator, but the serum should be pushed to the highest doses during such a crisis, 10,000 units or more given every three hours until improvement appears, then continue the same doses at longer intervals until the patient is safe.

Even when the intubation or tracheotomy tube becomes occluded by the membrane, 10,000 to 30,000 units have saved the patient, and when such results are seen

can be attributed to no other agents. No one, even the most sceptical, can question the specific action and reaction of the

serum.

If this paper will cause the older and younger members of this society to "lock horns on the treatment, and a general exchange of ideas and experiences result thereby, which is always very profitable, the object of your essayist and the paper has been accomplished.

We are indebted to Parke, Davis & Co., Frederick Stearns & Co., and the Mulford Company for the different serums and containers here exhibited; to the Mulford Company for the personal loan of this. beautiful wax model of the disease discussed, which model is prepared for the World's Fair at St. Louis, loaned to me as a personal favor to bring to this meeting to present to you.

Midwives and Antisepsis.

According to law the midwife's outfit has become so extensive in order to guard against infection that the possibility of lightening her burden has been brought before the medical profession. It is pointed out that about forty sections are devoted to drugs and apparatus which the midwife is expected to carry about with her on every occasion, and to use at the proper time. A clear distinction is made between the use of instruments during pregnancy and those after labor. After defining the nature of the case to hold the instruments, the names of the various articles are stated, from soap, lanoline, vaseline, spirits of wine, tincture of cinnamon, permanganate of potash, irrigators, uterine tubes, rectal appliances with brushes for cleaning the tubes, catheters, nail scissors, nail brushes, a given quantity of lysol with measuring glasses, bath and body thermometers, bandages, towels, etc., and even comprise a text-book, the whole requiring a small ambulance van to convey a midwife to a confinement.

A medical genius has attempted to solve the difficulty of complying with the law by a case that will not exceed 4,750 grammes, or about six pounds, in weight. Such a trousseau is likely to meet with favor at the hands of the present overloaded midwife.- Vienna Cor. Med. Press and Circular.

INEBRIETY IN ANCIENT EGYPT AND CHALDEA.

BY T. D. CROTHERS, M.D.,

HARTFORD, CONN.,

SUPERINTENDENT WALNUT LODGE HOSPITAL, ETC.

There is something startling in the revelations from the tombs and papyri of ancient Egypt, disclosing the history, social life and thought of a people who lived five thousand years ago. The religion of that ancient civilization taught that the body must be preserved and cared for after death, so that the soul in long ages could come back and take possession of the tabernacle which it vacated at death. The magnificent monuments, tombs, and the temples where the dead were buried, covering hundreds of miles of country, were made the receptacle of inscriptions, carvings, pictures and papyrus rolls containing a history of events in the lives of the dead and the political and religious thought of the day. The climate, with its dry air, the hot sun and drifting sand has preserved these records of that ancient civilization down to the present with but little change. Miles upon miles of these houses of the dead have been buried deep in the sand of long millenniums and are yet uncovered. Only a few excavations have been made, but these bring to light remarkable descriptions of habits and social life in that faroff time. Many of the papyri are autobiographical histories of the kings and other mummies, and seem to be written by themselves, and, like biographies of that class, relate to the good deeds and events of the actor, with no reference to his mistakes or errors. The inscriptions and references which are here grouped extend back one thousand years before the reign of the Pharoahs, in which Moses and Joseph were prominent. Egypt was then at its zenith, and its civilization was at its highest point. A thousand years after, when the Ramases were so prominent, the nation was in a period of decadence.

Egypt is particularly a dry and very thirsty land, where both barley and grapes grew very luxuriantly in ancient times; hence beer and wine were largely made and used. Life five thousand years ago

*Read at the annual meeting of the American Association for the Study of Inebriety, at Bos ton, Mass., December, 1902.