DIPHTHERIA; ITS BACTERIAL DIAGNOSIS AND 
TREATMENT WITH THE ANTITOXIN. 
BY 
HENRY W. BETTMANN, M.D., 
OF CINCINNATI, OHIO; 
CURATOR AND MICROSCOPIST, CINCINNATI GENERAL HOSPITAL. 
FROM 
THE MEDICAL NEWS, 
July 6, 1895. [Reprinted from The Medical News, July 6, 1895.] 
DIPHTHERIA; ITS B ACT ER I AL DIAGNOSIS AND 
TREATMENT WITH THE ANTITOXIN ? 
By HENRY W. BETTMANN, M.D., 
OF CINCINNATI, OHIO 
CURATOR AND MICROSCOPIST, CINCINNATI GENERAL HOSPITAL. 
In 1884 Loeffler announced the cause of diph- 
theria, but the medical world was little interested. 
Five years later Roux declared that the bacterial 
diagnosis of suspected cases was of the greatest im- 
portance, and Baginsky added further proof, and 
still the medical world heeded little. In 1894 
Roux and Behring announced independently that 
they had discovered a cure for diphtheria, and in 
six months the medical world is aflame. 
The scientific structure is complete : the etiology 
first, the bacterial diagnosis second, the prophylaxis 
and cure the capping-stones. The task before the 
medical profession is to see if the structure can 
stand. If it stands, it is the highest achievement of 
the new medical era, and a glorious and memorable 
tribute to scientific medicine. 
I shall say nothing about the etiologic relation 
between the Loeffler bacillus and diphtheria. In 
the minds of all except the ultra-skeptical, the cause 
of the vast majority of cases of Bretonneau's diph- 
theria is the Loeffler bacillus; this fact was incon- 
1 A paper read before the Cincinnati Academy of Medicine, 
June 3,1895. 2 
trovertibly demonstrated years ago, and need no 
longer form the basis of discussion. The questions 
that concern us to-night are far more practical and 
more important to us as physicians. They may be 
enumerated as follows: 
1. What clinical significance has the bacterial 
investigation of throat-exudates? 
2. Can diphtheria be cured by the antitoxin ? 
3. Can diphtheria be prevented by the antitoxin ? 
4. Is the antitoxin a specific remedy for diph- 
theria in the sense advocated by Behring, Aronson, 
and Roux? 
1. The Clinical Significance of Bacterial Investi- 
gation of Throat-exudates. My conclusions are 
based on the bacterial investigations of 122 throat- 
cases. These studies were made in the laboratory 
of the Cincinnati Hospital by Dr. A. H. Freiberg 
and myself, with the generous assistance of Dr. 
Charles H. Castle. We are also indebted to the 
assistance of Superintendent Hendley, who first 
suggested the investigation. Our methods were 
copied from those of the New York City Board of 
Health, and our way of distributing, collecting, and 
examining tubes was modelled after that of New 
York. Altogether we examined about 160 inocu- 
lated tubes. A majority of the local profession did 
not avail themselves of the opportunity for diag- 
nosis that was offered. On the other hand, a large 
number realized the value of the bacterial examina- 
tion and lent us their support and their interest. 
The vast majority of the tubes examined were sent to 
us in January, February, and March of this year. 
In all cases we used Loeffler's serum for diagnos- 
tic purposes. This is by far the best medium with 3 
which to demonstrate the presence of the Loeffler 
bacillus. Investigators who use glycerin-agar, 
peptone-agar, or even plain blood-serum cannot 
expect reliable results.1 As a rule, we were able to 
make a diagnosis after the tubes had remained in 
the incubator from twelve to sixteen hours; and 
if the inoculation was at all successful, twenty-four 
hours sufficed in all cases. With some experience 
it is possible to distinguish diphtheria-colonies from 
cocci-colonies macroscopically, diphtheria-colonies 
of sixteen hours' duration looking gray and small as 
compared with the larger and whiter cocci-colonies ; 
of course, it is best in all cases to resort to micro- 
scopic examination with alkaline methylene-blue. 
Early in January we were puzzled occasionally by 
the appearance in the cultures of short, thick bacilli, 
and very long, slender, evenly staining ones. We 
soon found out, however, that these colonies devel- 
oped in imperfectly sterilized tubes, and later ruled 
out all doubt by sterilizing the serum more perfectly. 
After this we were never seriously puzzled to know 
whether a tube contained Loeffler bacilli or not. 
After the statistical report of the New York Board of 
Health, covering 5611 cases, it might seem super- 
fluous for us to report our series of 122. Yet even 
so small a series is full of interest and instruction. 
The Loeffler bacillus was present in forty-seven 
cases; of these, eight, or 17 per cent., died. The bacil- 
lus was absent from seventy-five cases; of these, three 
1 C. Fraenkel: Die Aetiologische Bedeutung des Loeffler'sche 
Bacillus (Deutschemed. Woch., 1895, No. ri). AlsoSilberschmid: 
Miinchener med. Woch., Feb. 26,1895. Compare also the defec- 
tive results obtained by Vierordt (Deutsche med. Woch., 1895, 
No. 11, p. 169), by use of plate-cultures of glycerin-agar. 4 
(4 per cent.) died. In one of these fatal cases the ex- 
amination was made after the disease had existed two 
weeks, and proved negative; in another, on the 
eighth day, two days before death, and it was also 
negative. Everyone familiar with the subject knows, 
and the New York report has sufficiently emphasized 
the fact, that examinations made quite late in the 
disease are not reliable, and we may properly ex- 
clude these two last-mentioned cases from our 
consideration. Thus, out of seventy-three cases in 
which no Loeffler bacilli were found under proper 
conditions of examination, only one proved fatal, 
or nearly per cent., while 17 per cent, of those 
died in whom the Loeffler bacillus was found. This 
teaches one important lesson, viz., the presence of 
the Loeffler bacillus in the throat adds very seri- 
ously to the gravity of our prognosis. 
But mortality is not the only test of severity. A 
few weeks ago I sent postal cards to the physicians 
who had had cases examined, asking for clinical 
data, laying special stress upon the duration of the 
disease, the presence of alarming symptoms, the oc- 
currence of sequelae and complications, and the con- 
dition of the heart. I received complete data con- 
cerning forty-one cases, in which the Loeffler bacil- 
lus had been found ; in eighteen of these (just 40 
per cent.) the physicians reported the patients as 
dangerously sick, in many cases from weakness of 
the heart; of the non-diphtheric cases, aside from 
the three that died, only one patient was reported as 
having been in danger, and that one from laryngitis ; 
i. e., seventy-one out of seventy-five cases from which 
the Loeffler bacillus was absent ran a mild course 
without arousing any alarm. 5 
Can anything be more convincing than that the 
bacillary sore-throat is a very different disease from 
the non-bacillary sore-throat ? So much for gross 
figures. I think, however, that examination into 
the details of several series of cases will prove still 
more striking and show still more forcibly the value 
of bacterial diagnosis. 
On January 5th a tube was sent with the diagnosis 
of tonsillitis. The physician in charge said that there 
was no suspicion of diphtheria, and the patient was 
not isolated. Two days later the child's brother 
contracted an angina. Bacterial examination of the 
first case revealed the presence of many cocci and 
few Loeffler bacilli; the second throat contained 
almost a pure culture of Loeffler bacilli. Both 
children were markedly prostrated, out of all pro- 
portion to the apparent throat-lesion ; the first child 
was weak for a month after recovery; the second 
child was in great danger from heart-failure for a 
week, and suffered later from paralysis of the 
pharyngeal and ocular muscles. 
On February 14th a tube was sent with the diag- 
nosis of severe tonsillitis. Examination revealed 
almost a pure culture of Loeffler bacilli. The case 
ran a very mild and favorable course for four days; 
on the fifth the patient, sixteen years old, died very 
suddenly from heart-failure. 
In January a tube was sent with the diagnosis of 
non-diphtheric croup. No membranes were visible 
in the throat, and the temperature was normal. 
Intubation was performed. Bacterial examination 
revealed the Loeffler bacillus; stenosis returned, 
tracheotomy was performed, large tough mem- 
branes were found occluding the trachea, and the 
child died on the ninth day, after extension of the 
membrane to the lungs. 
In March a tube was sent, and Loeffler bacilli 6 
were found in abundance. The first physician in 
attendance had diagnosticated catarrhal laryngitis, 
and had let the case run on from bad to worse for 
several days. He was then discharged. The second 
physician immediately had the case examined 
microscopically, and intubation was performed, but 
death followed after sixteen hours. 
In all of these cases early bacterial examination 
would have thrown much light on the diagnosis 
and prognosis, and lives might have been saved. 
Other similar cases might be cited, but those de- 
tailed are sufficiently striking to show the great 
value to the clinician of bacterial investigation. 
A few words in regard to the fatal cases in which 
no Loeffler bacilli were found. One was in a child, 
fourteen months old, that suffered from purulent 
coryza for two weeks, laryngeal stenosis and pro- 
found sepsis being present on its admission to the 
hospital. Only cocci were found after a minute 
examination. The antitoxin was used, and the 
child revived considerably. Cultures were made 
at intervals of two days, and no Loeffler bacilli were 
ever found. The child died seven days after ad- 
mission to the hospital. 
Case No. II occurred in a family in which several 
members suffered from true Loeffler diphtheria. All 
the cases were malignant, and this one fatal, 
although no Loeffler bacilli were found. Only one 
culture was made, and lam inclined to believe that 
I must have made an imperfect examination, as 
Loeffler bacilli were found in other members of the 
same family. 
Case No. Ill was the one referred to. A six- 
months-old baby suffered with large extensive mem- 7 
branes in the throat; no culture was made until the 
eighth day, two days before the fatal issue. I am 
not informed as to whether the cause of death was 
croup or sepsis. There is no doubt that some cases 
of diphtheria occur in which Loeffler bacilli play no 
role. Fischer1 reports a case of septic diphtheria 
in which cultures made daily for seven consecutive 
days failed to discover the Loeffler bacillus, and even 
a post-mortem culture revealed nothing but cocci. 
Fraenkel2 admits also that there is such a thing as 
coccus-diphtheria, although its occurrence is quite 
rare. For the present we must simply shrug our 
shoulders at these rare and unfortunate cases, and 
leave their explanation to further investigation. 
I approach with some diffidence the subject of 
the therapeutic effects of the antitoxin. Veterans 
in medicine have tried it in a large series of cases, 
and have been reticent as regards the scientific value 
of their results. Rapidly, however, a large litera- 
ture on the subject is accumulating, and it behooves 
us at least to keep in touch with the advanced 
thought. No one, I think, can follow what has been 
written on the subject during the past six months 
and regard it with indifference. Certainly no one 
can read the calm judicial testimony of medical 
experts in all parts of the world that classes of cases 
that formerly died do now recover, that a smaller 
percentage of cases die than formerly, and that 
severe cases now recover without need of operative 
interference, without wishing in his heart that such 
testimony is true. When men of world-wide repu- 
tation range themselves one after the other on the 
1 N.Y. Med. Rec., April 6, 1895, p. 420. 
2 Loc. cit. 8 
side of the new remedy we are compelled, with all 
our natural skepticism, to be encouraged. The 
names of Virchow, Escherich, Ganghofner, Ranke, 
Vierordt, all on one side, are strong testimony of 
themselves. In February of this year Foster1 col- 
lected statistics of 2740 cases treated with antitoxin ; 
of these 18.5 per cent, died ; also of 4445 cases 
treated without antitoxin ; of these 45 per cent. died. 
I shall not load down your minds with bald statis- 
tics. Nothing is more tiresome or unprofitable. 
Since January of this year I have had occasion to 
observe closely seventeen cases of diphtheria. Dur- 
ing February and March Dr. Forchheimer very 
generously placed his diphtheric patients at the 
City Hospital under my charge, and I am greatly 
indebted to him for the cases treated in that insti- 
tution. 
In January two brothers were admitted to the hos- 
pital suffering from a very severe form of diphtheria. 
The younger brother, four years old, had been sick 
eight days and had a very intense nephritis, with 
weak heart and complete anorexia. Many Loeffler 
bacilli were present; two days later they were absent 
from the throat. No antitoxin was used, owing to the 
condition of the kidneys and the advanced stage of 
the disease.2 The nephritis grew worse daily, notwith- 
standing active treatment, and the child died twelve 
days after admission. The older brother, aged eight 
years, had contracted the disease three days before 
admission. At first he presented indications of only 
a moderately severe pharyngeal diphtheria and re- 
ceived tonic treatment. Soon, however, he de- 
1 Foster : The Medical News, Philadelphia, Feb. 2, 1895. 
2 Neither of these conditions, however, is a contraindication 
against the use of antitoxin. 9 
veloped a marked nephritis, like his brother, and 
five days after admission had severe symptoms of 
laryngeal stenosis; his temperature rose to 103.8°, 
and his condition became very critical. Ten c.cm. 
of the Roux antitoxin were injected in the inter- 
scapular space. During the next twenty-four hours 
the temperature fell steadily, the pulse-rate and 
frequency of respiration remained about the same, 
and the dyspnea was markedly moderated, recurring 
only for short intervals. The further course was 
favorable, the albuminuria lasted two weeks, Loeffler 
bacilli persisted only two days after the injection, 
and the boy made a slow but complete recovery. 
This, my first case, made a very favorable impression 
on me. 
A week later a child aged fourteen months was 
brought to the hospital in an apparently moribund 
condition; the pulse was scarcely palpable; opis- 
thotonos was marked, and the fetid odor from the 
throat scarcely endurable. The mother at first 
refused treatment, saying she did not wish the 
child uselessly tormented, and death seemed a ques- 
tion of only a few hours. We injected, however, 
5 c.cm. of Behring's antitoxin, No. 2, and were 
much astonished to see in the course of twelve 
hours a remarkable change in the child's condition. 
It now sat up in bed and took nourishment greedily, 
but during the course of the day relapsed into its 
former condition. Injections of the antitoxin were 
repeated twice, both times causing a very marked 
and unmistakable change for the better. On the 
fourth day we were inclined to make a favorable 
prognosis; the heart, however, became very weak, 
the respirations rapid, fetid diarrhea set in, and the 
child died with high fever on the seventh day. 
Repeated examinations in this case failed to reveal 
Loeffler bacilli. Here was a case ending fatally, 
which, nevertheless, afforded to the few of us who 10 
witnessed it the greatest encouragement regarding 
the value of the antitoxin. 
A few days later five children were placed under 
my charge at once. Two sisters, Mary and Gertrude 
E., aged respectively six and nine years, had exten- 
sive exudations with almost pure cultures of Loeffler 
bacilli, and yet the local and constitutional symp- 
toms were so slight that no treatment was instituted, 
except rest in bed and light diet. Both cases 
developed albuminuria of moderate degree, which 
persisted sixteen days. 
Three other sisters, aged respectively four months, 
four years, and six years, all had extensive exuda- 
tions in which the Loeffler bacillus was demon- 
strated. One case ran so favorable a course that 
no antitoxin was used; on the second day the 
infant's temperature rose to 103 8° and the mem- 
branes extended. Five c.cm. of Behring's No. 2 
were injected at 10 p.M.,and the change for the 
better began in a few hours, and after that the tem- 
perature remained below ioo° F., and no threaten- 
ing symptoms recurred. The oldest sister received 
two injections of the antitoxin, each 5 c.cm., which 
seemed to affect the course of the disease very 
favorably. These children also had albuminuria 
lasting two weeks, the one in which no antitoxin 
had been used no less than the others. 
I shall not detail all the cases treated. One child, 
aged ten years, received 10 c.cm. of the antitoxin 
for laryngeal obstruction present on admission, and 
died four hours afterward from sudden increase of 
stenosis. All the other cases recovered, some with 
and some without the antitoxin. Altogether, nine 
cases received the antitoxin; two of these died, as 
already recited. Of the seventeen cases observed, 
three died, representing a mortality of 17.6 per cent. 
The mortality in the city during January, Febru- 11 
ary, and March was 26 per cent. I do not lay any 
stress on the results obtained by us in the hospital. 
The number of cases is too small to be convincing. 
All who saw the cases treated with the antitoxin felt 
sure that we had in our possession a wonderful 
remedy. This subjective feeling of trust in the 
value of the antitoxin is almost universal among 
those who have tried it in any number of cases, and 
speaks more in favor of the remedy than the published 
figures. I shall reserve for another occasion a 
critical estimate of the antitoxin-literature thus far 
published. 
Of some things I am convinced : 
1. That the antitoxin does undoubtedly affect 
favorably a large number of diphtheria-cases. 
2. That it is the duty of physicians to use the anti- 
toxin early in every case of severe diphtheria 
occurring in children. 
3. That the mortality from diphtheria is destined 
to be largely diminished by prompt use of the 
antitoxin. 
I cannot urge upon physicians too strongly to use 
the antitoxin early in their cases of diphtheria. 
The testimony is universal that the earlier the remedy 
is used the more certain is its curative effect. In 
Foster's table, of the 44 cases injected on the first 
day none died; of 106 cases injected on the second 
day 3 died. Later the mortality ranged from 10 
per cent, to 40 per cent. In Ganghofner's table,1 
of 68 cases treated during the first three days 5 
died ; of 42 cases treated after the third day 10 
died. In Kossel's well-known table, of 82 cases 
treated during the first four days only 2 died ; of 35 
1 Ganghofner: Prag. med. Woch., 1895, Nos. 1, 2, 3. 12 
cases treated after the fourth day n died. To wait 
for sepsis or laryngeal stenosis before using the anti- 
toxin is folly. The chances of success are greater 
the sooner the remedy is used. All observers agree 
that when the antitoxin is used in pharyngeal 
diphtheria the larynx is not thereafter affected. 
Bad effects from the antitoxin we did not see, 
although about twenty injections were made. I 
prefer the fleshy part of the thigh as the seat of 
injection. Pain was remarkably slight or wholly 
absent, and absorption took place in a very few min- 
utes. One child had a slight erythema after the 
fifth day. 
Can we prevent diphtheria with the antitoxin ? 
The published reports of prophylactic injections 
are not very encouraging. As the antitoxin does 
not prevent the growth of the bacillus, it is hard to 
understand how it can prevent diphtheria. It has 
been noted that relapses after cure by the antitoxin are 
not infrequent; this itself is a strong argument 
against belief in any prophylactic virtue of the new 
medicine. As a matter of fact, diphtheria is not a 
highly contagious disease. Henoch says that in 
seventeen consecutive years only one attendant 
caught diphtheria in his diphtheria-pavilion. It 
is, therefore, a very difficult question to decide, 
especially as diphtheria occurs not infrequently in 
those prophylactically injected. Brewer1 injected 
two children for the purpose of prophylaxis. One 
of them developed a membrane the next day, the 
other in six days after inoculation. Richter2 made 
72 preventive injections, and 7 of the persons were 
1 Brewer: The Medical News, Philadelphia, Jan. 19, 1895. 
2 Richter: Deutsche med. Woch., 1895, No. 7. 13 
nevertheless affected. Sonnenburg1 made 16 in- 
jections ; diphtheria occurred in 2 of the cases. 
Hager2 immunized 35 children and 3 took sick. 
Brunstein3 immunized 28 cases and 1 took sick. 
Pear? immunized 67 persons between the ages of 
four months and fifteen years; 13 contracted diph- 
theria and 2 died. 
Summing up these reports we find that of 220 
persons injected, 28 (12.7 per cent.) were never- 
theless affected. This is certainly not a good show- 
ing. If one out of eight people had smallpox, 
Jenner's name would not be celebrated as it is to- 
day, and smallpox is far more contagious than 
diphtheria. On the whole, we are compelled to say 
that evidence of the value of prophylactic injec- 
tions of the antitoxin is still wanting. 
Is the antitoxin a specific against diphtheria in the 
sense advocated by Behring and Roux ? By the 
question we mean, does the antitoxin neutralize the 
effects of the disease in the system and thereby in- 
sure recovery ? In one thing all authors agree, i.e., 
that the antitoxin does not kill the Loeffler bacillus 
or prevent its further development. In several of 
our hospital-cases the bacilli persisted in the throat 
for days and even weeks, notwithstanding the use 
of the antitoxin. Other observers have demon- 
strated that the bacilli not only persist in the throat 
but also retain their virulence for guinea-pigs.5 
Therefore the antitoxin cannot be called a specific 
1 Sonnenburg: Deutsche med. Woch., 1894, No. 50. 
2 Hager: Therap. Monatsh., February, 1895, p. 91. 
3 Brunstein: Wiener klin. Woch., 1895, No. 3. 
4 Pearl: Ibid. 
5 Virulence for guinea-pigs should by no means be made the 
test for human beings, as it is in no sense conclusive. Each species 
of animal is a law only unto itself. 14 
for diphtheria in the sense that quinin is a specific 
for malaria. It certainly does not destroy the cause 
of the disease. 
Mercury is called a specific for syphilis without 
presumably destroying the cause of syphilis; in 
some way it neutralizes for the time being the syph- 
ilitic virus. It is difficult to say just to what extent 
this is true of the antitoxin of diphtheria. The 
children seem certainly to improve under its use, as 
every eye-witness can testify. And yet there is 
much evidence to show that the poison is not neu- 
tralized. Diphtheric nephritis and post-diphtheric 
paralysis are commonly assumed to be the result of 
the action of the diphtheric virus on the kidneysand 
nervous system respectively. Certainly the poison 
that leads to nephritis and paralysis is not neutral- 
ized by the antitoxin ; so in the sense of mercury 
for syphilis, we can scarcely speak of the antitoxin 
as a specific for diphtheria. In a word, all our the- 
orizing about the antitoxin is as yet without avail. 
The clinical fact is plain that a larger percentage of 
cases recover with it than ever did under any other 
form of treatment. This is the one practical fact, 
testified to almost universally, that makes the use of 
the antitoxin a matter of duty in cases of diphtheria 
in children. 
And now a few words regarding the relations of 
the city to the question of the bacterial diagnosis of 
diphtheria. Modern custom has relegated to the 
city officials all over the world the task of dealing 
with the health-questions of the respective cities. 
The more advanced cities in Europe and America 
have already established disinfecting bureaux and 
stations for the destruction or disinfection of con- 
tagious material. Cincinnati has done little that is 15 
efficient in that regard. New York was the first city- 
in the world to make adequate arrangements for the 
control of diphtheria and tuberculosis by means of 
bacteriologic examinations. The fact has been made 
perfectly plain that only by repeated bacterial ex- 
aminations of the throat can we test whether a case 
of diphtheria has became free from infecting power 
or not. It is known that Loeffler bacilli remain in 
the throats of diphtheria-convalescents for many 
days and even weeks. One series of examinations 
at the City Hospital revealed the presence of the 
germ up to the fortieth day of convalescence; and 
repeatedly have we found the germ at the end of the 
third week. Nothing is more evident than that our 
present mode of placarding houses is not only un- 
just to the occupants, but also inadequate for public 
safety; many a family is seriously discommoded, its 
children kept from the schools-because the physi- 
cian assumed a simple angina to be diphtheric. It 
has been my fortune more than once during the 
past five months to see cases which other physicians 
had called diphtheria, and which proved to be non- 
diphtheric. Patients have a right to demand bac- 
teriologic examination before submitting to weeks 
of isolation, often with considerable detriment to 
business and always to convenience and comfort. 
The ipse dixit of the attending physician is by no 
means sufficient, be he who he may. On the other 
hand, placards are removed from houses four days 
after the physician signs a certificate that the patient 
is well, no matter whether the patient still be a 
source of public danger or not. The only possible 
control is the bacterial control-and it is now a 
matter of public necessity that every municipal 
health-department should be under the management 16 
of a professional and expert bacteriologist, with as- 
sistants and clerks who should devote all their time 
to the work in hand. 
Cincinnati has recently applied salve to its own 
conscience by providing for the expenditure of 
$500 to pay for apparatus, office-work, and the 
salary of the city bacteriologist; while everyone 
knows that that sum is ridiculously inadequate to 
supply what is needed. Other cities have out- 
stripped us. Brooklyn has adopted the same sys- 
tem as New York. In Boston the work has been 
done for the past seven months. In November and 
December of 1894 1002 cultures were examined by 
the city bacteriologist, who was relieved of all 
other work; in January, 1895, 842 cultures were 
examined. Boston has also provided for the manufac- 
ture of antitoxin, and has seven horses under treat- 
ment. The Philadelphia Board of Health has ap- 
propriated $15,000 to establish a bacteriologic 
bureau. In St. Louis the City Board of Health 
has for some months been examining for tubercle- 
bacilli and Loeffler bacilli, having established 
eighteen stations in the city for the receiving of 
specimens. New Orleans has for more than a year 
had a fully equipped and active bacteriologic bureau. 
Cleveland is supplied with antitoxin from the 
Western Reserve University. Buffalo has two pro- 
fessional bacteriologists who devote all their time to 
the work. Tubes for diphtheria-diagnosis are dis- 
tributed to the thirteen police-stations of the city, 
and examinations are also made for tuberculosis. 
The tap-water and reservoir-water are examined 
daily; the mik and ice at proper intervals. Detroit 
has begun the work of bacterial diagnosis, and In- 
dianapolis will fall into line this autumn. The Medical News. 
Established in 1843. 
A WEEKLY MEDICAL NEWSPAPER. 
Subscription, $4.00 per Annum. 
The American Journal 
OF THE 
Medical Sciences. 
Established in 1820. 
A MONTH! YMEDICAL MAGAZINE. 
Subscription, $4.00per Annum. 
COMMUTA TION RA TE, $7 50 PER ANNUM 
LEA BROTHERS CO. 
PHILADELPHIA.