Bacteriological Study of Four Cases of 
Diphtheria Treated with Antitoxine by 
Dr. Louis Fischer at the Municipal 
Hospital\ Philadelphia. 
BY 
D. BRADEN KYLE, M.D., 
CHIEF LARYNGOLOGIST, ST. AGNES’ HOSPITAL; BACTERIOLOGIST, ORTHOPEDIC 
HOSPITAL AND INFIRMARY FOR NERVOUS DISEASES; AND ASSISTANT 
DEMONSTRATOR OF 1’ATHOLOC.Y, JEFFERSON MEDICAL COLLEGE. 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
January, 1895. Extracted from The American Journal of the Medical Sciences, January, 1895. 
BACTERIOLOGICAL STUDY OF FOUR CASES OF DIPHTHERIA 
TREATED WITH ANTITOXINE BY DR. LOUIS FISCHER 
AT THE MUNICIPAL HOSPITAL, PHILADELPHIA. 
By D. Braden Kyle, M.D., 
CHIEF LARYNGOLOGIST, ST. AGNES’ HOSPITAL ; BACTERIOLOGIST, ORTHOPEDIC HOSPITAL AND 
INFIRMARY FOR NERVOUS DISEASES ; AND ASSISTANT DEMONSTRATOR OF PATHOLOGY, 
JEFFERSON MEDICAL COLLEGE. 
While much has been written on laboratory technique in the study 
of the bacillus of diphtheria, yet the subject is of sufficient interest and 
importance to necessitate the publication of the methods employed in the 
study of these cases. 
The bacillus of diphtheria grows best on blood-serum prepared after 
the method of Loeffler. The following was the mode of procedure in 
this laboratory study: 
A wide-mouthed jar, with a ground-glass stopper, which has been 
thoroughly sterilized, is taken to the slaughter-house and filled with 
freshly-shed blood of the ox or sheep, young animals being preferable. 
The skin of the neck of the animal to be killed is shaved, washed with 
soap-water and a brush, then with alcohol or ether, or a 1:1000 solu- 
tion of bichloride of mercury may be used if the skin is again washed 
thoroughly with boiled water. One of the great vessels of the neck, 
preferably an artery, is then opened, and the blood is allowed to spurt 
directly into the prepared receptacle. The edge of the jar is then 
cleansed and the jar is sealed by means of the ground-glass stopper, and 
set aside until the blood has firmly clotted. The jar is then removed to 
the laboratory, and placed in an ice-chest for twenty-four hours. It 
should be examined every few hours, and if the clot tends to adhere to 
the sides of the jar it should be loosened by means of a sterilized glass 
rod. There should be placed in the ice-chest at the same time the beef 
from which the nutrient broth is to be made. Take one pound of finely- 
chopped lean beef, to which is added one litre of water; this is allowed 
to stand for twelve hours. The meat and water are then placed in a 
cheese-cloth or towel and the fluid pressed out. The fluid thus obtained 
should be heated and again filtered through a towel, and the amount 
brought up to one litre by the addition of distilled water; to this is 
added 1 per cent, of peptone, 1 per cent, of glucose, and 0.5 per cent, 
of common salt. If the fluid has an acid reaction a few drops of sat- 
urated solution of bicarbonate of sodium may be added. The mixture is 
then boiled for half an hour and filtered through absorbent cotton into 
sterilized flasks; then sterilized for half an hour. While the serum is 
collecting test-tubes may be cleansed and sterilized. Two sizes of tubes 
are needed. A tube four inches long and two-thirds of an inch in 
diameter may be used for the serum, while a tube six inches long and 2 
KYLE: DIPHTHERIA TREATED WITH ANTITOXINS. 
three-quarters of an inch in diameter is used for the cotton swab. The 
tubes are carefully washed and dried, then plugged with cotton so 
wrapped that its surface will be smooth, and when withdrawn from the 
test-tube will not spread out, but remain firm. 
The tubes to be used for the swabs are prepared as follows: A stiff 
steel rod (an ordinary knitting-needle may be used) is passed through a 
plug of smaller diameter than the tube. The plug is wrapped so as to 
firmly hold the steel rod, which is passed through layers of cotton until 
the plug will tightly fit the calibre of the tube. The end of the rod 
which is placed in the tube is then wrapped with a small piece of cotton, 
which should be loose and fluffy at the end, but tightly adherent further 
up the rod. This arrangement can be effected by frilling the cotton and 
extending the fine fibres well up on the rod and wrapping firmly toward 
the end. The swab is now introduced into the tube, which is placed in 
an incubator and exposed to dry heat at a temperature of 150° C. for at 
least one hour. This should be repeated two hours before using the 
tube. The blood-serum is now siphoned off through a sterilized glass 
tube and mixed with the nutrient beef-broth in the proportion of 3 to 1. 
The serum is poured into the sterilized test-tubes by means of a sterilized 
pipet, which should be inserted to the bottom of the test-tube so as to 
avoid the formation of air-bubbles and to secure a perfectly even surface. 
Two c.c. of the serum are sufficient for each tube. The tubes are now 
placed in an incubator and kept at a temperature just below the boiling- 
point, care being taken to have them inclined in order to obtain a wide 
surface for the growth of the inoculated germs. Great care must be 
taken that the serum does not boil. 
If kept for several hours at a temperature just below the boiling- 
point, and if the process is repeated two or three times after intervals of 
twelve hours, the serum will remain sterile. The serum thus prepared 
is opaque, yet firm. The tubes can be placed in glass jars, sealed by 
means of a clamp-top, and kept for months. The method given by Ball 
is much shorter and equally as good. 
The swab for obtaining the membrane for inoculating the tubes is 
preferable to the inoculating needle, as the infected areas can be quickly 
passed over, and the secretions are readily gathered in the meshes of the 
cotton. Besides, the operator is not exposed so long in front of the 
patient. 
The serum-tube may be brought to the bedside and inoculated at once 
after the swabbing of the throat, or the swab can be returned to the 
sterile tube and taken to the laboratory and the inoculation made there, 
and the serum-tube placed at once in the incubator. 
A few words as to the method of obtaining the infective material 
from the throat and inoculating the tubes may not be amiss. With the 
patient in a strong light, the operator puts one hand on the patient’s 
head, grasping the head firmly so as to control the movements of the 
patient should he cough, while with the other he holds the tube contain- 
ing the serum. An assistant depresses the tongue, and with the other 
hand holds the tube containing the swab. The operator removes the 
swab and rubs it firmly but gently against any visible membrane, either KYLE: DIPHTHERIA TREATED WITH ANTITOXINE. 
3 
on the tonsils, pharynx, or uvula. It is advisable to make two tube 
inoculations, one from the well-formed membrane, the other from the 
ulcerated or oozing surface. The swab can now either be placed back 
in its tube, and the extending cotton singed and the whole be taken to 
the laboratory, or the serum-tube can be inoculated at once. After the 
swab has been used and the inoculation made, the cotton should be 
burned, while the steel rod can be again sterilized and used. Should 
no false membrane be visible the swab should be passed over the red- 
dened mucous membrane. Should false membrane be present in the 
nose, inoculations should be made from it also. Inoculations should not 
be made for at least four hours after the application of disinfectants to 
the throat. 
After the inoculation has been made, the serum-tubes are placed in 
the incubator and kept at a temperature of 37° C., the optimum tem- 
perature of the Klebs-Loeffler bacillus, for from ten to sixteen hours. 
After incubating the inoculated tube for ten or twelve hours the surface 
should be inspected, and as soon as the surface shows minute colonies, 
which spring up as almost pin point elevations, a spread should be made. 
Great care must be taken not to spread the material too thickly on the 
cover-glass. This can be avoided by first placing a tiny drop of steril- 
ized water on the cover-glass. The platinum needle is then introduced 
into the tube and swept over the colonies, and the bacteria adherent to 
the needle are washed off in the drop of water previously placed on the 
cover-glass, and evenly distributed over the entire surface. 
The spread is then allowed to dry in the air, and before being 
placed in the stain is fixed by being passed quickly through the flame 
of an alcohol lamp. The spreads should then be stained with Loeffler’s 
alkaline methylene-blue. The cover-glass is left in this stain without 
heating for from ten to fifteen minutes; it is then rinsed with distilled 
water, dried, and mounted in Canada balsam. 
This brings us to the actual study of the individual inoculations. 
The cases are taken up separately. The report is mostly that of daily 
work in the laboratory, which was largely routine, being the examina- 
tion of the inoculations made from day to day. As to proving in each 
case that the germ found was Klebs-Loeffler’s germ, and virulent, 
inoculation of guinea-pigs would have been necessary. To do this with 
each daily inoculation would have been scarcely possible, at least not 
necessary, the standard germ being one which had been demonstrated 
beyond doubt to be Klebs-Loefller’s by producing the disease in animals. 
This was not necessary in two of the cases under observation, as they 
died of the disease. Tubes containing blood-serum prepared after the 
manner described by Loeffler were used in each inoculation. 
In the four cases studied stains were made from each tube inoculated 
as soon as the growth appeared, also second stains were made after a 4 
KYLE: DIPHTHERIA TREATED WITH ANTITOXINE. 
few hours which show more markedly the growth of other germs. The 
stain used was Loeffler’s alkaline methylene-blue. The slides were all 
examined by Leitz oil immersion No. v. eye-piece. 
Case I.—F. N. (8668.) This case was examined by Dr. W. M. L. 
Coplin before injection with serum, and the Klebs-Loeffler bacillus was 
found in great numbers. The case was injected with serum, November 
5th. Forty hours alter injection a tube inoculation was made, which 
was incubated as described above, and after twelve hours a characteristic 
growth appeared. Stains from this showed many large Klebs-Loeffler 
bacilli, some showing the pole granules or retractile bodies, others 
showing small bacilli, rather pointed ; a few streptococci were present, 
the Klebs-Loeffler presenting the same appearance. Stains made 
November 8th showed the Klebs-Loeffler bacillus more irregular and 
present in greater numbers, with increase in the number of streptococci, 
while the staphylococci remained about the same. Slides made November 
10th showed an increase in the number of Klebs-Loeffler germs in the 
field as compared with other germs present on second stain ; yet the 
first stain made from the tube showed nothing different from stains 
made November 8th. On November 10th the patient died. Total 
tube inoculations, six. Total stains made, thirty-six. 
Case II.—A. J. (8678 ) Tube inoculations were made before in- 
jection with serum, November 5th. After incubating for sixteen hours, 
stains were made which showed the characteristic Klebs-Loeffler 
bacillus with few staphylococci. Later stains showed many cocci as 
well as the Klebs-Loeffler bacillus in large numbers, but somewhat 
irregular. Inoculations were made from this case as follows : November 
7th, 8th, 10th, 11th, 12th, 13th, 15th, 16th, 17th, 18th, 19th, 21st, 23d, 
24th, and 25th. It is not necessary to burden the reader with a de- 
scription of each tube and slide ; a statement of the general characteristics 
of the slides as the case progressed will suffice. On November 7th 
the slides showed very little difference from those made November 
5th, except slight irregularity in the Klebs-Loeffler; on November 8th 
stains showed the beginning irregularity of the Klebs-Loeffler bacillus, 
many large and small, yet each showing some form of the germ. The 
cocci showed nothing different. No streptococci present. 
November 10th, 11th, 12th, 13th were much the same, the Klebs- 
Loeffler bacilli being fewer in number, less irregular than in the earlier 
slides or in the other cases, and the cocci present in increased numbers, 
that is, by comparison. Bv some the irregular forms of the Klebs- 
Loeffler bacillus would possibly be described as another germ, but by 
closely watching the growth, and by isolation from the first growth 
appearing, the pure culture obtained showed the same characteristics. 
November 15th, 16th, 17th, and 18th showed practically the same, dif- 
fering from the earlier tubes in that the Klebs-Loeffler was larger in 
size, showed the peculiar dumb-bell shape, some showing the retractile 
bodies, the germ being very irregular as to size and shape. A few 
bacilli somewhat resembling the Loeffler bacillus were present, but 
they did not present the characteristics. Stains from tubes inoculated 
November 19th, 21st, and 23d showed many cocci present, but fewer 
characteristic Klebs-Loeffler bacilli, also short rod-like bacilli which 
presented no characteristic appearance of being Klebs-Loeffler, either 
in appearance or by stain. The Klebs-Loeffler bacilli were markedly 
irregular and difficult to stain. Stains made November 24th and 25th CASE A. 
Fig. 2. 
Fig. 3. 
Fig. 1 
CASE B. 
Fig. 1. 
Fig. 2 
Fig. 3 
CASE C 
Fig. 1. 
Fig. 2. 
Fig. 3. KYLE: DIPHTHERIA TREATED WITH ANTITOIINE. 
5 
showed few Klebs-Loeffler bacilli, which were not so characteristic, and 
only an occasional one found present in the field. Many other non- 
characteristic bacilli were present as well as numerous cocci. Total 
number of tubes inoculated, seventeen. Total number of slides stained 
and examined, one hundred and ten. 
Case III.—B. M. (8612.) Tube inoculations were made on 
November 5th, before the patient was injected with serum. After in- 
cubating for twelve hours spreads were made and stained. The field 
showed both strepto- and staphylococci, a short plump bacillus which 
tended to arrange itself in parallel rows, also the characteristic Klebs- 
Loeffler bacillus with its rounded ends, some swollen at one end, some at 
both, and some swollen in the middle, others presenting the refrac ile 
bodies. Stains made forty hours after the injection with serum showed 
on first and second stain the following: The number of cocci were in- 
creased as well as the number of short, thick, and deeply stained bacilli, 
while the Klebs-Loeffler bacilli were diminished in number and most 
markedly irregular as to size and shape; also more difficult to stain. 
Test-tube inoculations were made in this case as follows : November 
7th, 8th, 10th, 11th, 12th, 13th, 15th, 16th, 17th, 18th, 19th, 21st, 23d, 
24th. Stains made from tubes inoculated on the 8th and 10th showed 
considerable alteration in appearance from those made from tubes 
inoculated on the 7th, the slight alteration being on the 10th ; the Klebs- 
Loeffler were slightly increased in number and more uniform; the 
cocci and short bacilli about the same. Stains made from inoculations 
made on the 11th, 12th, 13th, and 15th, showed nothing markedly dif- 
ferent from those made on the 10th, except the presence of what I 
believe to be the monilia Candida and a more irregular formation of the 
Klebs-Loeffler bacilli, yet they still presented their characteristic fea- 
tures. Stains made from the tubes inoculated on the 16th, 17th, 18th, 
and 19th showed gradual diminution in the Klebs-Loeffler bacilli. 
The germ showed irregular forms, many with swollen ends and many 
showing pole granules. The small thick bacilli increased in number 
from the 18th to the 21st, few streptococci, but many large and small 
staphylococci, many monilia Candida present. Stains from tube inocu- 
lation made on the 21st, 23d, and 24th showed practically the same, 
except the gradual diminution of the Klebs-Loeffler bacilli with the 
irregular forms, yet there still could be found in every microscopic field 
some characteristic germs. Total tube inoculations made, sixteen. 
Total stains made, ninety-six. 
Case IV.—J. H. (8689). This patient was injected with serum on 
November 9th. Stains from tube inoculation which was made before 
the injection showed as follows: From the first growth appearing the 
field was filled with characteristic Klebs-Loeffler bacilli, regular in size 
and shape, and few strepto- and staphylococci. Stains made a few hours 
later showed no diminution of the Klebs-Loeffler germ, but increase in 
the cocci, especially the streptococci, with a few non-characteristic bacilli. 
Stains made on the 10th showed increase in the non-characteristic bacilli, 
the cocci presented the same appearance, while the Klebs-Loeffler bacilli 
showed marked alteration in form, but no diminution as to number. 
Stains made on the 11th and 12th showed the same, while those made 
on the 13th and 15th showed an increase in the number of Klebs- 
Loeffler bacilli, although they were somewhat irregular. On the 15th 
the child died. Total tube inoculations, 6 ; total number of stains, 6 
KYLE: DIPHTHERIA TREATED WITH ANTITOXINE. 
36 ; total tube inoculations from four cases, 45; total stains made and 
examined, 278. 
From each tube, after from six to ten days, second stains were made 
which in each case showed a diminution of the Klebs-Loeffler bacilli, 
with marked alteration, which alteration in form rendered the recogni- 
tion of the germ almost impossible, with an increase in the non-charac- 
teristic bacilli and also of the cocci. This diminution and alteration in 
the Klebs-Loeffler bacilli was most marked in the tubes which con- 
tained no streptococci. Two cases were studied in which no serum 
was used. The tube inoculations were made at intervals to correspond 
with those made from the cases in which the serum was used. One case 
died after four inoculations, while the other improved, and the experi- 
ments were carried on at a length of time to correspond to the serum 
cases. These showed the characteristic germ present, yet from day to day 
they did not present such marked alteration in appearance as those from 
the serum cases, the Klebs-Loeffler bacilli remaining more uniform in 
appearance until after the disappearance of the membrane, when the 
non-characteristic germs were more numerous, cocci increased, and the 
Klebs-Loeffler diminished and more irregular. Stains made from the 
tubes of mixed growth of six days showed much the same as in the 
serum cases. 
Conclusions.—The recognition of the bacillus of true diphtheria is 
somewhat difficult, owing to its resemblance to the germ described by 
Hofmann, yet I believe with others that with a careful examination of 
the bacterial growth in a blood-serum tube, which tube has been care- 
fully inoculated according to the rules given above, then kept at first 
at a temperature slightly below the optimum, and yet not the minimum, 
for a few hours, then gradually brought up to the optimum and 
retained at that point for six or eight hours, then gradually lowered 
to about 32° C., the microscopic examination can be without doubt 
relied upon. 
Roux and Yersin have shown that now and then bacilli from cases 
which clinically are diphtheria, and which show the Klebs-Loeffler 
germ, may possess little or no virulence ; moreover, they also say, as 
quoted by Sternberg, “ it is then possible by commencing with a virulent 
bacillus of diphtheria to obtain artificially a bacillus without virulence, 
quite similar to the attenuated bacilli which may be obtained from a 
benign diphtheritic angina, or even from the mouth of certain persons 
in good health. This microbe, obtained artificially, resembles com- 
pletely the pseudo-diphtheritic bacillus ; like it, it grows more abun- 
dantly at a low temperature ; it renders bouillon more rapidly alkaline ; 
it grows with difficulty in the absence of oxygen.” 
As to the significance of whether it is the Hofmann germ or Klebs- 
Loeffler much has been written, and authors differ widely in their views. KYLE: DIPHTHERIA TREATED WITH ANTITOXINE. 
7 
Personally I believe that the degree of resistance on the part of the 
patient has much to do with the variance in the germ. If in one case 
the Klebs-Loeffler germ fails to produce the disease when inoculated 
into animals, or the Hofmann’s germ in one case causes the disease, 
it matters little in the care of the case whether it be the true or 
false germ—if there is a difference. Loeffler himself found the Klebs- 
Loeffler germ present in the case of a perfectly healthy child. Was the 
germ found virulent? Was it the germ of true or false diphtheria, or 
was it the resistance on the part of the patient, the healthy secretions of 
the mucous membranes, which lessened the virulence of the germ. In 
a certain number of cases which clinically are diphtheria the first inocu- 
lations may fail to show any Loeffler bacilli, yet a second inoculation 
made in a few hours will show many characteristic germs. It must be 
remembered that in each lot of test-tubes of culture media there are 
always some tubes in which no growth of any germ will develop. This 
is not the fault of the bacteriologist, but is due to the action of a mate- 
rial which forms within the tube, due to changes produced by excessive 
heating. What this material is has not been demonstrated, yet that it 
renders the culture media inert there is no question. Barring this 
one source of error, I think when the germ is not found in cases which 
are clinically diphtheria that the fault is on the part of the bacteri- 
ologist. It will be seen in the report of the cases in which the serum 
was used, that forty-eight hours after the injection of the serum the 
character of the germ was altered, yet it is not claimed that the 
antitoxine serum has any action directly on the germ ; but by coun- 
teracting the poison in the system, produced by the product of the 
germ, the resistance on the part of the patient manifested at the nidus 
of infection indirectly affected the germ’s nutrition, thereby altering its 
character. This is true, providing the previous products have not caused 
pathological alteration in tissue structure ; in such cases it is not possible 
for the serum to effect such alterations. At one time it was thought 
by some observers that the size of the germ had to do with its viru- 
lence. It is now conceded by most observers that the size and length 
of the germ have nothing to do with its virulence. Certainly in these 
cases studied, which clinically were most severe in character, no 
definite conclusion could be made from the appearance of the germs. 
They were irregular in size in each case. Strepto- and staphylococci 
live long in the throats of healthy individuals without causing any 
disturbance so long as the mucous membranes are healthy; but under 
certain conditions, as when the mucous membrane’s resistance has 
been lessened by exposure to cold or other deleterious influences, or by 
the poison of scarlet fever or other infectious diseases, the streptococci 
alone or associated with other germs attack the mucous membranes and 
cause inflammation ; it has been shown that when there are cases of 8 
KYLE: DIPHTHERIA treated with antitoxine. 
scarlet fever in the same institution, the Klebs-Loeffler bacilli may be 
found in the pseudo-membrane forming in such cases. 
It is a well-known fact that environments alter the characteristic 
features of all germs; that in the description of a germ, temperature, 
light, culture medium, and absence or presence of other bacteria must be 
taken into consideration. Also that laboratory germs which depend on 
artificial nutrition differ somewhat from those found in the body ; this 
is especially true of the bacillus of diphtheria, which is demonstrated 
by the difference in description given by various authors; the alteration 
of the Klebs-Loeffler bacillus, as due to the age and conditions under 
which the germ was found and grown, may be shown in the following 
plates, the legend explaining the growth. The germs were subjected as 
nearly as possible to the same conditions, all being grown on Loeffler’s 
blood-serum, except Case C, Fig. 1. 
Case A, Fig. 1. Tube inoculated before serum injection. The diph- 
theria bacilli are seen as irregular staves, dumb-bell shape, with refrac- 
tile bodies at the poles, and unevenly stained staves, the poles staining 
intensely while the central portion is pale. (Eye-piece iv., Beck objec- 
tive ol. im. Leitz.) 
Case A, Fig. 2. Tube inoculated forty hours after serum injection. 
The diphtheria bacilli have lost some of their irregular form ; though 
still markedly irregular, some are now seen as short staves which stain 
intensely at the poles. 
Case A, Fig. 3. Tube inoculated five days after tube 1. The bacilli 
are larger and more irregular than in tube 2, though they show other- 
wise the same characteristics. 
Case B, Fig. 1. Tube inoculated upon the admission of patient. No 
serum was used. The diphtheria bacilli are slightly irregular in form, 
though the larger number are small staves staining intensely at the 
poles. 
Case B, Fig. 2. Tube inoculated forty hours after admission. The 
diphtheria bacilli are smaller and more regular in form than the pre- 
ceding. They stain intensely at the poles. 
Case B, Fig. 3. Tube inoculated five days after admission. The 
diphtheria bacilli are slightly larger than in tube 2, otherwise they 
appear the same. 
Case C, Fig. 1. From agar-agar tube of Klebs-Loeffler bacillus six 
months old. The bacilli are shown as irregular staves, staining unevenly. 
The staining is quite intense at the poles. In some few of the bacilli 
one end is greatly enlarged. There are present, also, a large number 
of ovoidal bodies which stain only at the periphery. 
Case C, Fig. 2. Tube 2, inoculated from tube 1, growth forty-eight 
hours old. Irregular staves, staining for the most part very unevenly. KYLE: DIPHTHERIA TREATED WITH ANTITOIINE. 
9 
The bacilli seem to tend to the formation of short chains. Few ovoidal 
bodies are present. 
Case C, Fig. 3. Tube 3, inoculated five days later from tube 2. The 
bacilli closely resemble those in tube 1, though the ovoidal bodies are 
not so numerous. 
It will be seen that the most marked change occurred in the bacilli 
from the serum case and from the old culture. In many slides present- 
ing the irregular involution forms it would be difficult to distinguish 
many of the germs from the germ described by Hofmann. 
If, when the germ is grown on different nutrient media its form is so 
markedly altered, certainly we must grant that in different individuals 
the germ would be placed under equally as great variations in nutrition, 
besides the resistance on the part of the patient. 
From the drawings made from the stains which were made from 
growths subjected as nearly as possible to the same conditions, it is 
quite clear why it is so difficult to distinguish the true from the pseudo- 
diphtheritic bacillus. It is impossible to differentiate microscopically. 
That the Klebs-Loeffler bacillus exists in the throats of healthy indi 
viduals who have been exposed to diphtheria has been demonstrated by 
many observers. It may be interesting to note that in tube inoculations 
made from the throats of individuals exposed to diphtheria while exam- 
ining the cases in the hospital ward, the characteristic Klebs-Loeffler 
bacilli were found ; the virulence was not tested. 
All bacilli found in cases which are clinically diphtheria, which bacilli 
are identical with the Klebs-Loeffler bacillus, should be classed with the 
diphtheria bacillus, even if their virulence has not been tested on guinea- 
pigs, or even if tested and little or no virulence is shown. 
In three cases streptococci were found. Two of these cases proved 
fatal; one in which a few were found recovered. One thing noticeable 
was the absence of other germs besides those mentioned, which was 
practically the case when the Klebs-Loeffler bacilli were present in large 
numbers. 
I am indebted to my laboratory assistants for their help in these 
investigations.  Jotirojal 
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and Year-Book, $8.50. Thumb-letter index for Visiting List, 25 cents extra. 
LEA BROTHERS & CO., PUBLISHERS, PHILADELPHIA, 706, 708 & 710 SANSOM STREET.