cases of a somewhat similar character. There is no question as to the accuracy of these observations. I do not admit, however, that such cases necessarily prove any antagonism between the streptococci of erysipelas and the germ of syphilis or its products. Erysipelas cures a simple ulcer, and the hard, callous ulcers of the leg, quite as readily as the syphilitic processes. described by the authors mentioned. Not that I deny the possible antagonism of germs of various kinds, but I believe that in our microbic enthusiasm we are forgetting the relations of such processes as erysipelas and syphilis to tissue nutrition.

As is well known, it is not the poison of syphilis per se that prevents healing of syphilitic ulcers, but it is the local choking up of tissues with the syphilized cells. Erysipelas is for the time being attended by greatly exaggerated activity of the nutritive processes and a rapid breaking down and removal of the syphilitic neoplasm. Inasmuch as the syphilis has probably no directly corrosive action upon the tissues, and no effect at the sight of the neoplasm other than that incidental to a heaping up of rapidly proliferated material, the erysipelas runs essentially the same course as under ordinary circumstances. I am of the opinion I am of the opinion that the cessation of active anti-syphilitic treatment and the substitution of the tonic and stimulant regimen so essential in erysipelas, has much to do with the beneficial effects of erysipelas in such cases as those described by Horwitz and Neumann. It is to be remembered that malignant syphilis is probably so not because of a high degree of toxicity of infection, but because of a high degree of constitutional susceptibility and lack of tissue resistance. The effects of a germ of any variety depend on the condition of the soil in which it is implanted. To say that erysipelas is beneficial to the local process in patients suffering from syphilitic ulceration because the streptococcus of the one antagonizes the bacillus of the other-admitting for the sake of argument that syph ilis has a bacillus--is the argument of post hoc propter hoc with a vengeance! If, however, we admit the clinical facts, and explain them by a modification of the soil, we are at least within the bounds of logic.

As to this point, although irrelevant to the immediate question in hand, it is worthy of note that in spite of all that has been said regarding the relation of the bacillus tuberculosis to consumption, and the action of the latest scientific phantasm, tuberculin, upon the disease, we are still brought face to face with the discouraging fact that we have no method of treatment to offer that is more reliable than that of our medical forefathers, who achieved their best results from measures that modified the soil in which the bacillus flourishes. There are few clinicians that, however enthusiastic they may be regarding the lymph treatment, would not give more for measures of hypernutrition and superoxygenation than for all the lymph ever manufactured. I would not pose as an iconoclast, but I think that we had better realize that there is much in the heritage of philosophy that the fathers in medicine have left us. Our hero-worship and our dalliance with strange gods are fast leading us away from the philosophical relations of medicine into the realms of medical sensationalism and fadism.

Vaccination of subjects recently syphilitic is apt to be followed by unpleasant results. In this connection I recall a case in which I vaccinated a gentleman who

for about three months had been under treatment for syphilis. For a short time the vaccine vesicles ran their ordinary course; they finally dried, but pus formed beneath them, and ulceration progressed until a perfectly typical syphilitic ecthymatous ulcer resulted, This extended to the size of a half dollar and did not yield until I substituted the mixed treatment for the mercury that the patient was then taking. Aside from his syphilis this patient was healthy, and as he was taking mercury in small doses, there is no question in my mind as to the relation of the syphilis to the ulceration. In this connection the question arises whether such instances do not explain many cases in which the accusation of having used impure virus is made against the physician. In children with hereditary syphilis, such a case might lead to results very embarrassing to the physician. I have in mind the case of a practitioner that narrowly escaped a malpractice suit at the hands of the parents of a child that, it was claimed, lost its eyesight as a result of a syphilitic keratitis following vaccination with impure virus. Knowing the gentleman who had vaccinated the child; and being assured by him that he had used bovine virus obtained from a reliable firm, and furthermore, being rather skeptical as to the possibility of the existence of the syphilized heifer, I took some pains to inquire into the case. I found that the vaccinia had run its usual course for about two weeks, when transformation into an ulcer occurred, and it was less than two weeks after this that the trouble with the eyes developed. This alone was enough to exculpate the physician, and if it were not, the cachectic aspect of the child, the peculiar appearance of its teeth, and the absence of axillary bubo certainly proved his innocence. It required very little argument upon my part to convince the father of the child that it was best not to take his case into court.

Chancroids occurring upon syphilitic subjects are likely to become phagadenic, and gangrene is likely to occur in patients broken down in the period of sequelæ from overtreatment and the disease in combination. I am inclined to think that overactive treatment has more to do with the constitutional condition and tissue depravity than the syphilis.

I have had a rather limited experience in fractures occurring in syphilitic subjects, but I have not noticed any difference between the rapidity and thorough. ness in repair of otherwise healthy subjects with secondary syphilis and the rapidity and thoroughness of repair in absolutely healthy patients. I have in several instances observed bad results in cachectic and intemperate syphilitic subjects. Such cases seem to be especially prone to necrosis and nonunion.

I have seen one case of necrosis of the humerus, following a fracture in a syphilitic subject, in a man who absolutely disregarded my advice and kept himself comfortably intoxicated for some weeks following the injury. This case finally went out of my hands, and I know nothing of its subsequent history. In another instance I observed nonunion of a Pott's fracture in an intemperate syphilitic subject, but in both of these cases I attributed the unfavorable result to constitutional depravity induced by dissipation rather than to the syphilis per se. In the period of sequelæ or the so-called tertiary stage of syphilis, operation wounds and surgical lesions are liable to pursue an unfavorable course as a consequence of one or all of three conditions:

2. The abuse of mercury.

3. The condition that often prevails-alcoholism. Operations about the mouth, naso-pharynx, and fauces during the active period of syphilis have, in my experience, been attended with some disagreeable results. Clean incised wounds are rarely made in operating in these localities, and it is well nigh impossible to keep wounds of these parts in a perfectly aseptic condition, or free from irritation. Rest is also difficult to secure. In the case of the mouth and pharynx, the contact of the food and the movements of chewing and swallowing are sufficient not only to aggravate mucous patches and ulcers, but even in perfectly healthy individuals often serve to develop ulceration in wounds of these parts. In syphilitic patients, typically specific ulceration is apt to follow surgical lesions. Excision of the tonsils in syphilitic subjects has, in my experience, several times resulted in obstinate ulceration. An illustration of this has recently come under my observation. A gentleman who had been under my care for syphilis for nearly two years, but in whom no lesions had been observed for eighteen months, came to see me in regard to several ulcers on the inner surface of the lower lip. These had the appearance of typical gummatous ulcers, one of them being quite deep and ugly looking. On inquiry I found that these ulcers followed a blow upon the mouth that caused laceration of the mucous membrane by the teeth at the site of the ulcers.

I have seen several cases in which laceration of the gums by the dental forceps, in the careless extraction of a tooth during the active period of syphilis, had caused ulceration of a typical specific character. In one instance I noted extensive ulceration of the palate, apparently precipitated by laceration of the gums in the removal of tartar. Crushing injuries are apt in syphilitics to be followed by ulceration of a typical character. I have seen several cases of onychia syphilitica, with loss of the nail resulting from crushing of the end of the finger.

Operations upon the cartilaginous and bony structures of the nose in syphilitic subjects are apt to be followed by slow healing, and perhaps ulceration of the operation wounds. Lack of rest and the contact of irritating secretions in all such cases afford sufficient explanation. Bruising of the periosteum and bone is likely to be the determining factor in the production of a node. Ulceration and caries or necrosis are, of course, thus more likely to result than in syphilitic nodes and osseous inflammations occurring independently of traumatism.

In broken down syphilitic cases suffering from operation wounds and injuries, my experience has led me to exercise great caution in the exhibition of antisyphilitic remedies, and I have come to regard the general condition of the patient, independently of his syphilis, as much more importance than the old constitutional affection; in other words, I find much better results from treating the patient than from treating his syphilis.

The question of the influence of the syphilitic dyscrasia upon the repair of operation wounds was brought to my mind not long ago by the protest of a physician against my operating upon a case of syphilitic necrosis of the tibia. The physician thought that an operation was unwarrantable, and that repair of the bone and of the operation wound would not be

likely to occur until the patient had had a thorough course of mercury and iodide of potash. The patient has not yet made up his mind upon the question of operation, but most practical surgeons will bear me out in the assertion that an operation will be the surest method of treatment for the patient's general condition.

A case in point is one in which I operated for central syphilitic necrosis of the tibia involving the entire shaft of the bone for about four inches. The question arose in council as to the propriety of operation until after vigorous antisyphilitic treatment for a few weeks. I advised immediate operation, which was finally consented to. After removal of the necrotic bone I applied a fenestrated plaster bandage, put the patient upon cod-liver oil, and allowed him to go out on crutches. Repair was quite rapid, and at the end of three months the patient was able to get about without artificial support and had gained about twenty pounds in weight.

Infant Feeding.*

BY S. C. STREMMEL, M. D., MACOMB, ILL.

Owing to a variety of circumstances and many individual idiosyncrasies infant feeding is a most difficult problem.

The clinical experience of different writers has given rise to a wide diversity of opinions, well suited to keep one tossing upon the wide sea of unsettled knowledge.

Every practitioner has seen infants thrive heartily under miserable hygienic conditions, and by the use of foods that would, in the average case prove fatal within a fortnight. These cases are the exception, and should not influence us in the management of infants as a class.

The chief barrier to our success in infant feeding is our comparative ignorance of the physiology of infancy and a sufficiently thorough knowledge of the minute chemistry of foods. The efforts of the past remind us of the alchemist of the dark ages who filled his crucible with mysterious compounds and sat by patiently waiting for the evolution of some grand discovery only to meet with dire disappointment.

We however know that the digestive apparatus of the newly born infant is in a state of incomplete development. The secretions of the salivary, peptic and intestinal glands are scanty, and the diastatic action of the ferments is scarcely perceptible. The bile

is deficient in inorganic salts, cholesterin, lecithine and bile acids; but emulcine is present in sufficient quantity to dispose of a fair amount of fat.

For the nutrition of this delicate organism nature has provided a food which is simple in composition and universally acknowledged as the food par excellence for infants. Nevertheless we frequently see the nursing infant suffering from every form of indigestion. and showing unmistakable signs of malnutrition.

These disturbances are caused by temporary or permanent changes in the composition of the mother's milk or to irregularity in nursing. I will not discuss here the many conditions which influence these changes further than to say that an improper diet or anything which interferes with the general health and peace of mind of the mother may cause them.

* Read before the Military Tract Medical Association at Peoria, Ill., Oct. 20 and 21, 1891.

Unfortunately many of these little sufferers are recklessly weaned to take their chances as bottle fed babies, when by proper attention to the mother or perhaps by taking it from the breast for a few days or weeks as the case may be it would go on to natural improvement.

I wish to state here emphatically that the nursing infant should never be weaned under age unless it is absolutely necessary, and that it is seldom necessary except in the presence of serious and wasting diseases. Sometimes the mother does not have sufficient nourishment for her infant. In that case it should by no means be weaned but should be fed and nursed alternately. The popular and fallacious belief in the incompatibility of nursing and feeding disappears before the brilliant results of experience. My own experience coincides with that of others and has been most satisfactory.

Irregular and too frequent nursing is often responsible for a fretful and despeptic baby, and sometimes seems even to afford a pretext for weaning. I recall to mind now a little patient whose mother, a hearty robust woman, gave me the following history: "Six weeks ago when the baby was three weeks old it began to be restless, vomited frequently and wanted to nurse every few minutes. The doctor told me that my milk was poison to it and that I must wean it. I did so and fed it boiled milk, but that didn't help it. It vomited more, cried nearly all the time and four weeks ago began to have a diarrhoea. The medicine would check the bowels for a day or two then they would be as bad as ever again. It was getting worse all the time and losing flesh rapidly." I told her to put the baby back to the breast. She said she hadn't nursed it for six weeks and didn't see how she could. I encouraged her and advised her to use the breast pump, then in two hours nurse it, then in two hours use the breast pump again and to continue alternating in this way. She did so and in two weeks succeeded in restoring the normal secretion of milk, and her baby made a rapid recovery.

The unnatural habit of putting the infant to the breast whenever it cries as though nursing was a panacea for all its ills and wants as well as to appease its hunger should be strictly discouraged. Under six months of age it should not be allowed to nurse more than once in two hours, and above that age not more than once in three hours. If the mother cannot nurse her infant the next best thing is to get a wet nurse. In the country this is very difficult and sometimes impossible.

When from any cause whatever it becomes necessary to resort to artificial feeding our skill and genius are taxed to the utmost. The tendency of the age is to herald every new theory with enthusiasm to the exclusion of everything else. For some time the quality of food alone engaged the attention of the medical profession. Then sterilization was declared the secret of success. We know now that these are but factors in the solution of the problem, and not until all the different elements of the subject are known and appreciated can we hope for a fair state of perfection.

I have tried to emphasize the importance of mothers nursing their infants, because it is eminently the most successful method of bringing them up. If this be true it behooves us to imitate nature by the selection of a food whose physical and chemical characteristics resemble as nearly as possible the natural food.

This, of course, is subject to variation. In the albuminoids are included casein and an albumin rather obscure in its composition. Cow's milk, though not the nearest approach to human milk, is accessible to every one in the civilized world, and when properly prepared is the best food to use. This, however, presents differences which seem slight but are sufficient to cause failure frequently when used as a substitute for the natural food of infants. The following analysis shows us the composition of cow's milk:

We see that it is acid in reaction, contains more fat, much more of the albuminoids, a large percentage of which is casein, and less sugar. To give a baby this food in its original state as it was intended by nature for the calf, whose digestive power is superior and whose organism and growth differ in many respects, is unscientific and a grave injustice to the human infant. We can, however, modify cow's milk in such a way as to make it resemble fairly well human milk, by first adding lime water to change the reaction, then add water sufficient to bring the albuminoids down to one or two per cent. By so doing we diminish the fat and sugar too much. We must now add cream and sugar of milk enough to bring them up to four and seven per cent. I know of no better formula than that suggested by Dr. T. M. Rotch, of Boston. It has been more satisfactory in my hands than any other food I have ever used. It is as follows: Take of milk two ounces, cream three ounces, water ten ounces, sugar of milk six and three-quarter drams, and lime water one ounce. The milk, cream, water and sugar of milk are mixed and steamed in sterilizer for one hour, then add lime water. Of course this as it is will not suit every case. I diminish or increase the solids as each individual case requires. I make little or no variation in the quality of a food for the different periods of infancy. There are few if any changes in the mother's milk. It is important, however, to increase the quantity from time to time.

If

Having selected the above food the next step is to sterilize it. By so doing we again imitate nature. human or cow's milk is put into a carefully sterilized test tube without exposure to the air and sealed, it will remain sterile for months, while if exposed to the air as cow's milk is during the process of milking, straining, etc., it will swarm with bacteria and germs in the course of twenty-four hours. We thus see that the nursing infant gets sterile milk, and we know that the greater bulk of adult food is sterilized by

cooking. By what mode of reasoning then can we impose upon the helpless infant a food which we know contains a variety of bacteria, ptomaine poisons and often diseased germs.

The modern researches in bacteriology demonstrate beyond a doubt the transmissibility of various disease germs through milk. The most virulent and deadly of which are the bacilli tuberculosis. These bacilli have been found in the milk of cows whose general condition was such as not to lead to a suspicion of tuberculosis. As a safeguard to these germs alone, if for no other cause, milk should be strictly sterilized. I cannot lay too much stress upon the importance of sterilizing milk. It is scientific and right.

I have used a number of Siebert's sterilizers, which are cheap and good. I prefer Arnold's steam sterilizer and think it is the best apparatus I have seen. If a sterilizer can't be gotten, use ordinary four, six or eight-ounce bottles, as the case may be, put them in a kettle of water or common steamer and boil for one hour, then close the bottles with a plug of absorbent cotton and it will keep for weeks.

My experience with patent foods has been such that I cannot recommend them. We need but notice their composition to see that they are very different from human milk. Nestle's food contains three per cent starch, very little fat and but three and one-half per cent of sugar. Melin's food and the Imperial granum are acid and contain starch, little sugar and fat. Carnrick's food, when ready for use, consists of 97.22 per cent of water, 2 per cent dextrin and only .78 per cent other ingredients. The formula which I have given is a much nearer approach to human milk and the clinical experience with it is far superior.

It seems strange to me that so many general practitioners pay little or no attention to infant feeding, yet more human lives may be saved by the judicious administration of foods than in any other department of medicine. I do not exaggerate when I say that thousands of infants die every year who could be saved by proper feeding. This is a frightful statement, but it is true.

Frequently, when giving directions for feeding, the mother will say, and sometimes the physician too, that they have seen a number of cases get along all right without any such mode of procedure. Such statements are as sensible as to say that a number of our soldiers came from the late war without a scratch, therefore there is no danger in facing a storm of shot and shell. They fail to appreciate the cause of the symptoms of bad feeding and are ever ready to attribute them to teething and worms. These cases often present every symptom of indigestion, mycotic diarrhoea and enterocolitis, and unless treated by proper feeding, as a rule prove fatal.

The following patient which I saw some time ago in the last stage of entrocolitis illustrates this unfortunate class of cases. The mother and nurse gave me the following history: When the baby was six months old the mother had a suppurating mastitis. By the advice of her physician she weaned it and fed it cows milk. She used a common nursing bottle with long rubber tubing; the most pernicious apparatus ever made for infants. It did very well for a few weeks when it began to have colic, was restless at night and the passages from its bowels contained thick curds. In a few days a diarrhoea developed, the discharges of which were green, egg colored and

very offensive. Then came a system of treatment which is more conspicuous for its common employment than for a judicious and scientific medication. Bismuth, opiates and astringents were used freely. The acid cow's milk rich in casein bacteria and ptomaines was continued, It was like dashing a cup of water into a fire to extinguish the flames then persistently applying the torch. Of course it went from bad to worse. The food instead of digesting fermented and decomposed. This soon brought about pathological changes of a serious nature. First there was a general catarrhal condition of the bowels then there was hyperplasia of the lymph nodules followed by follicular ulceration. by follicular ulceration. The characteristic remissions of pain and restlessness raised the suspicion of malaria then quinine and Fowler's solution were added to its woes.

The little patient was now extremely emaciated. Its little body and limbs were little more than skin and bone. The skin was flabby, the eyes sunken and the sickly pale features were bathed in a cold, clammy perspiration. The respiration was shallow and the feeble pulse beat one hundred and eighty times per minute. I was the third physician called and told the mother that it had but a short time to live. In a few days it was driven to the cemetery another victim to bad feeding.

Diphtheria.*

BY W. S. MCCLANAHAN, M. D., WOODHULL, ILL.

It is not the purpose of this paper to enter the realms of science to discuss the bacterian theory and its relation to diphtheria, whether the disease be primarily in the pseudo, membranous formation and followed by constitutional affects. Nor whether the active poison be first in the blood and tissues as a cause and favoring the development of the diphtheritic membrane; nor will any attempt be made to change the minds of any one regarding the endemic, epidemic, infectuous and contagous character of malignant diphtheria, but will simply relate a few facts. gathered during an epidemic of this disease which occurred prior to and during the month of May this year in the town of Nekoma and vicinity. To make this history more complete it will be necessary for me to record several cases that were not in my own practice. The latter part of December, 1890, two children of Mr. H, living in N-, died of malignant diphtheria in the course of three or four days from date of attack in each case. In both cases the membrane extended to larynx, also to schneiderian membrane. In a few days the mother developed the same disease, but as the membrane was confined to tonsils and pillars of fauces she recovered in the course of ten days or two weeks. In May, 1891, a four year old son of another Mr. H. died of diphtheria and measles combined, was sick but a few days, membrane extended to larynx. I saw none of these cases but it was in this same house that I afterward treated five cases and lost one.

May 5th, was called in consultation with Dr. W. to see the first case of malignant diphtheria I had ever seen. Mack L., aged fourteen, had been sick about one week. Tonsils, uvula, and pharynx had been. covered with pseudo membrane and partially cleared

*Read before The Military Tract Medical Association, Peoria, Ill., Oct. 20 and 21, 1891.

off, but at this time the membrane was extending over the same territory again. Membrane had also invaded the larynx. We had tubular breathing and a barking, whistling cough. Temperature, 102°; pulse, 80. Patient restless. It might be well to add that this patient had been exposed to measles shortly before he was taken sick and at this time the characteristic measle eruption showed on face, neck and chest. An unfavorable prognosis was given. The unfavorable symptom being the croupous character of the diphtheria.

The treatment had been a spray of dilute solution of hydrogen peroxide used occasionally for the throat and gelsemiun and bryonia. (I don't know what dilution) to allay fever. I ordered in addition 20 gr. hydrarg. bichloride every two hours The case was seen again that evening, with no change in the symptoms. Patient could get out of bed without help. The same treatment kept up till he died, which event took place about two o'clock the next morning. Dr. W. remained with him during the night, and said about two the patient remarked that he must use the chamber, which he did, getting out of bed and back again without help, and in less than ten minutes was dead. The cause supposed to be heart failure.

May 8th, was called to see Ethel H- and Guy B— saw them both at the commencement of the throat trouble. As these two cases were the first cases I treated, being the same age, nine years, and seen the same day and in many respects running a similar course, I will describe them together. At first visit found them vomiting, temperature 10234, pulse 120 and 135 respectfully. Glands of neck slightly enlarged. On examining throat, the tonsils were enlarged and red. Small patches of membrane on both but more on the left than right in each case, but in less than the twenty-four hours from date of first visit the tonsils, fauces, uvula and schneiderian membrane were all covered with a thick chamois skin membrane, completely obstructing the nostrils and. causing a constant discharge from the nose. The respiration was guttural. This symptom was more prominent during sleep. The fauces were swollen and of a deep red hue as seen around the edge of the pseudo membrane. When any of the membrane was removed by the action of remedies it rapidly reformed. The worst symptoms lasted three days with Ethel and five with Guy, during which time both were threatened with heart failure, which at times would become extremely weak and irregular. Ethel had slight bleeding from the nose the third day, and from the third to fifth day Guy had several violent attacks of epistaxis, so much so at one time that the tampon was resorted to in order to arrest the bleeding; this was done by saturating some cotton with tr. ferri chlor. and placing it in the anterior nares, this stopped the external outlet.

The posterior one was already closed with membrane. It was ten days before all traces of the membrane left Guy's throat, his tonsils were still swollen and evidences of the violent disease we had been fighting could still be seen. The uvula was at least one-half destroyed. There were ragged edged fissures and holes in the tonsils that looked like they had been torn and at least one-fourth of an inch in depth, but from this time on he gradually improved for nearly one month when paralysis began to show itself, principally in the lower limbs; he also had double vision for about three weeks, but with the aid of tinct. nux

vom. and electricity these have all disappeared and now five months after he is walking one and one-half miles to school every school day.

Ethel's nose and throat were clear in five days and from that time on made a rapid recovery. The fourth day of her sickness her sister aged twelve, and brothers aged ten and fourteen all had characteristic patches on their tonsils. Membrane spread rapidly in all. With the fever, prostration, and other symptoms of a severe disease. The ten year old boy grew rapidly worse without one favorable symptom and died the morning of the fourth day. In this case the whole throat, tonsil fauces, pharynx and uvula and as far forward in the mouth as the first molar tooth were all covered with membrane. The nose was also full of membrane, which in this case was fully one-fourth of an inch in depth or thickness. The night before he died I attempted to remove some of it by grasping the anterior edge on the roof of the mouth with a pair of dressing forceps. It bled so freely and was attached so firmly to the mucous membrane that all efforts in that line were abandoned. The disease in the other two ran a similar course to the first two cases described and fully recovered. The worst symptom not lasting more than eight days in either case. weeks after Guy B. was taken sick, his sister aged sixteen came down with the disease. I saw her about three o'clock in the morning. Was well the evening before. On examination throat was very red, tonsils swollen, and on the right one could be seen two little chamois colored spots not larger than twice the size of a pin's head. I tried to wipe them off but failed. Still I informed the parents that owing to her age and strong constitution she would likely not have the disease very hard, which I admit now was a great mistake on my part, for when she was seen about thirty hours after, somebody was actually frightened, for in looking into that throat nothing could be seen but that terrible membrane that I for one was getting tired of seeing. Her throat was so similar to the ten year old boy's that died, that I felt sure this case would end in the same way, but we worked faithfully for four days and nights when the membrane began to loosen around the edge on the roof of her mouth.

Two

The fifth day I removed one piece from the roof of the mouth and one from each buccal surface. The three pieces together measuring two and one-half inches square and one fourth inch thick and each succeeding day for several days great pieces of membrane would be removed from some part of her throat, leaving usually a bleeding surface. It would reappear but not so thick as at first. In two weeks time all was gone, yet it was two months before she could be understood when talking and several weeks before she could take any but liquid nourishment and that only by holding her nose and throwing her head back to allow the liquid to run down her throat. She could neither talk, swallow, cough nor (spit). She is now

perfectly well. The family of Mr. L. had lost a four year old girl after a six days sickness and the father was now down and very sick with diphtheria, both under the care of another physician, but I was called to attend the only remaining child, a little twenty-one months old girl. The disease in this case assumed the usual type. The membrane was confined to tonsils, fauces and schneiderian membrane; her throat was free from diphtheritic membrane by the sixth day, but being so young none of it was expelled but passed into the stomach, she gradually became