under my father's care, a number of cases of the most virulent forms before antitoxin was known, where whole families were wiped out, and I have seen in comparison other families affected with the disease upon whom antitoxin was used, and the families have not been wiped out. No one who has seen the effects of quinin in malaria can doubt its specific action and there is a strong parallelism between this specific action of quinin and the specific action of antitoxin in diphtheria.

Finally, I wish to urge not only the use of antitoxin for the patient affected with diphtheria, but wish also to urge its use as a prophylactic for those who have the care of the patient, and also in those cases where the diagnosis is uncertain. Those of us who have seen the fulminating form of appendicitis realize with what astonishing rapidity the disease may develop, and the same is equally true of the fulminating forms of diphtheria. It was only recently that I took cultures from the throat of a patient, and before I could make a diagnosis from the cultures which were placed in the ·laboratory, the disease itself had advanced so far as to make the diagnosis unmistakable. In this case the prostration of the patient was great, and it was one of the cases whose course was calculated to convince me, and two others who saw it, as to the value of sometimes giving antitoxin before the tube cultures clinch the diagnosis of diphtheria.

I am strongly in favor of urging the use of antitoxin. exactly contrary to the spirit, or to the effect of the paper, whatever the spirit was.

Dr Chas. S. Judy, Miamisburg: There was one thing in the paper by Dr Myers in reference to the treatment of diphtheria that I could not endorse, and that was the use of the swab. I think if the treatment for this disease is properly carried out it will not be necessary to use a swab. In this matter it seems to me the treatment is behind the times.

In reference to the use of antitoxin I think this ought to be used as soon as the diagnosis is made.

Dr Freeman D. Case, Ashtabula: There is one point about which I wish to speak, and that is in reference to the detachability of the diphtheritic membrane. This point was touched upon by the essayist. My experience has been that at the beginning of the disease it is readily detachable, but after 48 hours it is not. Seven years ago I had the pleasure

of presenting to this Society a paper on an epidemic of diphtheria which occurred in our city, which had two peculiarities, one of which was that the disease was caused by infected milk, and the other that it was the first instance in this country in which antitoxin was used in an epidemic of diphtheria. In 1894 there were 111 cases of diphtheria with 23 deaths. Of this number 100 cases occurred within four weeks in families taking milk from one milk wagon, and 21 of the deaths occurred out of this 100 cases. Out of all the cases in which antitoxin was administered (amounting to 54), there were only four deaths, and in those four cases of death the antitoxin was administered something like five or six days after the patients were taken ill. There was not a death occurred where the antitoxin was administered within the first four days. The story is told that at one time a history of Ireland was written in which one chapter was devoted to the subject of snakes and read about as follows: "There are no snakes in Ireland." So far as the medicinal treatment of diphtheria is concerned, where the case is seen before sepsis is present, there is practically no medicinal treatment save the use of antitoxin; and when I say this I am speaking not only from my own experience but from the experience of every physician in Ashtabula who went through the epidemic of which I have just spoken.

There is one other point about which I would like to say a few words, and that is in reference to the use of the concentrated antitoxin. It has been my experience, and also that of my friends in my home city, that the use of the concentrated antitoxin is not attended with the skin trouble that the more dilute preparations which we first used produced. In those cases in which skin trouble manifested itself it was in the form of a severe erythema, or urticaria, and sometimes symptoms analogous to rheumatism were present, but when the more concentrated solutions were used these symptoms rarely appeared.

It is my practice to give antitoxin if I have any reason to suspect the case may prove to be diphtheria. I give the patient the benefit of the doubt. I do not wait until I hav

made a culture, but as soon as I suspect that it may be a case of diphtheria I give antitoxin, and give it in large doses. I never give less than 3,000 units to a child five years old and not less than 2,000 units to a child of any age younger than five years. The dose should be repeated in 12 hours if the

symptoms have not improved in that time. Frequent spraying of the throat is indicated as a matter of cleanliness and adds greatly to the comfort of the patient.

Dr J. C. Crossland, Zanesville: I am aware that there is a feeling on the part of some physicians that the advocates of antitoxin are careless in their differential diagnosis, and are disposed to use antitoxin in all cases of throat trouble. On the other hand, I think I do not believe that this is true. the reverse is true, that physicians who use antitoxin are more careful in making differential diagnoses, and more painstaking than those who do not use it. Recently, within 48 hours following two double funerals of children dead of diphtheria, I saw in my visiting practice just one dozen children suffering from throat trouble, all of whom were sick enough to justify calling a physician to the home, and all of whom were suspected of having diphtheria. There was not a single case of diphtheria in the entire number. They were cases of follicular tonsilitis, simple tonsilitis, pharyngitis, and one case of suppurated tonsilitis. I saw, the latter part of last week, two children in one family suffering from tonsilar disease, in which the conditions showed clearly that the exudate was primarily follicular. There was a cobweb-like exudate over the tonsils, and the parents suspected diphtheria. They wanted antitoxin administered, but I did not use it, believing the condition not to be diphtheritic. It is not my practice to use antitoxin until the exudate develops. I desire to express my pleasure at the endorsement of my views on the treatment of this disease by such celebrities as Drs Tyson, Ochsner, and others.

Dr A. V. Paterson, Mansfield: I only wish to add my endorsement as to the efficacy of antitoxin. I began to use it under compulsion, as I did not want to use it. One day another physician asked me to visit a case of his and give it a dose of antitoxin and see what it would do. I did it with a great deal of reluctance. After I had given the injection I went to see the case through and watched it very carefully, kept a temperature chart, etc., and was so gratified with the result that I have been using antitoxin in every case since. In nine years' practice I have not lost a case of diphtheria, probably due more to special providence than a special I myself have had a personal experimethod of treatment. ence with antitoxin. Monday I contracted diphtheria from

a case of membranous croup. I went to bed and in the evening of the same day I had antitoxin used on me the next morning, and on Friday I was in the office at work. That is evidence enough to me of the efficiency of antitoxin. It is not what one man says—it is what the men of the country say after having had experience in a great number of cases concerning the merits of any drug. Now in the use of antitoxin it seems to me that the great reduction in the death rate should lead us to form a correct opinion as to the merits of antitoxin. I know that there are different opinions as to its use some men of prominence use it in every case; others do not, but the same objections which are advanced against antitoxin could be advanced against vaccination. We have deaths occurring from vaccination, more deaths than from the use of antitoxin, but no one doubts or discontinues the use of vaccination on that account. I cannot believe that any of the deaths attributed to antitoxin were caused directly by antitoxin. Some of the patients whose death has been attributed to antitoxin have been reported to have died within a few minutes after its introduction into the system. If it were such a powerful poison it would cause the death of many more cases. I think possibly the deaths might be due to the introduction of a half a syringeful of air when the antitoxin is injected.

Dr Park L. Myers, Toledo, closing: Mr President, When, in reply to your request for a paper, I suggested an antitoxin article, it was hinted by you and other friends that if I should read such an article before this Society, I might expect to "get it" where diphtheria usually locates. Hence I was prepared for antagonism. Yet, i want to thank the gentlemen for their fair and kindly criticism. One gentleman (Dr Sawyer) has suggested that my article was one written in a spirit of ridicule that my experience must have been limited, or very peculiar, to make such an article possible. I protest, however, that my spirit was not that of thoughtless or malignant ridicule. True, I try to keep myself alive to the ridiculous-the ridiculous in myself, I hope, as well as that of my fellow-man,—my fellowparasite. It is a great corrective, none better. I thank Dr Tyson for calling my paper a study in the psychology of disease recognition and treatment. Such it was intended to be: diphtheria being taken only as an instance.

I have had some experience; may be it has been peculiar,

Yet I have no right to think my experience exceptional, however peculiar my interpretation. My friend, Dr Hubbard, dislikes my "insinuation of danger in the use of antitoxin.' I thought I touched this phase very carefully. I emphasized the harmlessness of it, even calling it homeopathic. I spoke of but three cases, the two mentioned by Dr Anders, and one which was reported from Chicago. I could have given others had I deemed it necessary. I might have given two very curious cases which came under my own observation. But I am enough in accord with my fellow practicians to believe these cases accidents. Honestly though, inter nos, isn't it good that the Lord (or accident) always stands ready to lift the burden of our failures, while our science or skill so easily carries the successes?

Dr Crossland gives statistics of 30 cases in which injections for immunizing were given, in no one of which did diphtheria follow. I can recall a number of cases of diphtheria in 22 years' practice. I have had three deaths in my own practice. I think I can safely estimate that in these 22 years I have known of at least 200 children exposed to diphtheria contagion, in not one of whom was an immunizing injection used. And yet (and maybe this is my peculiar experience) I have never had two consecutive cases in any family. Above all, I insist that in this inquiry I have had not other motive than the advancement of truth. And if I have failed, it is only because that I, in common with my fellow mortals, am subject to the great axiom of Hippocrates, viz., "Experience is fallacious."

Practical Deductions from Experiences in a Hospital for Pulmonary Tuberculosis

By B. F. LYLE, M. D., Cincinnati

I wish to express to our honored President my thanks for suggesting a title for my paper when the order came to appear before you today.

His desire for deductions rather than statistics shows the profession is already aware that males as a rule have the