was received and the postmark shows when mailed, hence any considerable delay in transit can be detected.

Special cases, for the examination of Blood or Pus, Diphtheria, Sputum, Typhoid, Urine and Water, may be had at the various agents free of charge. Bottles for the analyses of town supplies will be forwarded on request.

The several mailing packages are properly labeled and addressed, but in case others are sent, all specimens and communications should be addressed "State Board of Health Laboratory, Newark, Del."

TUBERCULOSIS.

Import. It is quite unfortunate for the patient, the community and the physician when the diagnosis of tuberculosis is based on the pronounced clinical symptoms. For the patientbecause tuberculosis is curable only in its incipient stage and in proportion to the incipiency; for the community-because an unrecognized case of tuberculosis is a constant source of infection; for the physician-because his reputation suffers and he may be justly held responsible for the neglect of a disease which at one. stage might have been cured. Therefore, in all cases in which there is the least suspicion that tuberculosis may exist, samples of sputum should be sent to Laboratory for examination. Repeated examinations of the expectoration are frequently necessary to demonstrate the presence of tubercle bacilli in incipient cases; for this reason physicians should not hesitate to make free use of the Laboratory for frequent examinations.

Outfit for sending specimens. A round pasteboard box with a pink label. The box contains a tin box, enclosing a 4 drachm vial, filled with I drachm of 5 per cent. carbolic acid solution. This case answers the requirements of the postoffice and must be used in place of bottles, jars, etc., in mailing tubercular material to Laboratory.

Method of preparing specimen.

I. Collect the sputum which is coughed up preferably in the morning on rising, avoiding the more superficial naso-pharyngeal secretion.

2. Have the patient rinse his or her mouth thoroughly before expectorating.

4

3. Pour the expectorated sputum into a vial and shake vigorously until a fairly uniform emulsion is obtained.

4. Place the vial in the tin case.

5. Fill out the accompanying blank.

6. Enclose in the case and forward to the Laboratory.

To obtain sputum from infants proceed as follows: The index finger of the left hand moistened with a 3 per cent. solution of boracic acid is introduced into the mouth of a child along the base of the tongue until it reaches the larynx. The finger is held to one side, so as not to obstruct breathing. With the right hand a piece of cotton on a tampon holder is introduced, using the left index finger as a guide. As soon as the cotton touches the vocal cords, a reflex cough is caused, and the expectoration is caught by the cotton. This method requires only a few seconds and offers the advantage that the sputum can be collected at any time.

To obtain urine for examination for tubercle bacilli proceed as follows: Wash the external gentials with soap and warm water and withdraw the urine by means of a sterile catheter. If tuberculosis of the kidneys is suspected and cystitis is present, the bladder should be first irrigated with a sterile saturated solution of boric acid. To secure the urine from each kidney separately, use Harris' instrument. Place the urine obtained as above outlined in our 4 oz. bottle designated for urine and forward to the Laboratory.

Should it be found necessary to resort to animal experimentation to establish the presence of tubercle bacilli, a especially prepared bottle will be sent to the physician and instructions given as to the modus operandi of obtaining the specimen of urine. EXAMINATION OF FECES FOR TUBERCLE BACILLI.

The detection of tubercle bacilli in the feces is not always possible even in cases of primary intestinal tuberculosis. Nevertheless, such examination should be invariably made, and made repeatedly in suspected cases.

Method of preparing specimens. Give the patient an opiate until the bowels are well constipated. Examine the evacuations and collect any white particles or mucus adhering to the surface

of the well formed feces. Place them in the vial accompanying the outfit for Tuberculosis.

Examination of Milk, Butter and other substances of Tubercle Bacilli: The detection of tubercle bacilli in these instances is extremely difficult and not always successful. The more reliable method is to inoculate a guinea pig with the suspected material and await the results of the inoculation. All such substances should be sent in clean preferably sterilized bottles or ointment jars, avoiding the addition of any antiseptic.

Don't send Saliva for Sputum.

Don't forget to mark the specimen so it can be identified.

Don't send a specimen poorly corked.

Don't send specimens with transit charges collect.

PNEUMONIA.

Import. The majority of cases of pneumonia are caused by a diplococcus observed independently by Sternberg and Frankel, the so-called Frankel's pneumococcus. In cases of suspected pneumonia, where corroborative bacteriological evidence is wanted, the sputum should be examined for the presence of pneumococci.

Outfit: The same as for Tuberculosis.

Directions for preparing specimen: The same as for Tuberculosis.

DIPHTHERIA.

Import. Diphtheria is an acute infectious and contagious disease produced by the Klebs-Loeffler bacillis. According to this modern definition, all cases of sore throat, even with the formation of a pseudo-membrane, but in which after careful and repeated search no diphtheria bacilli are found, are not cases of true diphtheria. On the other hand this definition includes those cases of angina in which no membrane is formed but the KlebsLoeffler bacilli are present, the presence or absence of the bacilli being the determining factor of the existence or non-existence of diphtheria.

As for the presence or absence of diphtheria bacilli cannot be determined in a large number of cases from the clinical symptoms alone, a bacteriological examination is by far the most important aid in diagnosis, and should be resorted to in every suspicious

case.

Outfit. A square screw-top wooden block or paper fibre case, contaning a tin can in which is enclosed a small glass tube holding a swab made of copper wire with a piece of non-absorbent cotton rolled around one end. Label marked "Diphtheria."

Method of preparing specimen. Don't use any local antiseptic within two hours.

I. Straighten the wire without touching the cotton swab. 2. Rub the swab against the exudate, rigorously avoiding contact with any parts other than the inflamed surface.

3. In the absence of membrane, rub the swab against inflamed surface.

4. Bend wire to original position and place in tube.

5. Pack tube in cotton.

Interpretation of results. The presence of diphtheria bacilli in the secretions of the mucous membrane of the upper respiratory passages of persons suffering from some form of inflammation in these regions establishes the diagnosis of diphtheria.

A negative result of the examination, on the other hand, may be' due:

I. To the case not being one of Diphtheria.

2. To the use of antiseptic washes, sprays or gargles shortly before the swab is made.

3. To the improper preparation of the swab.

4. To the absence of the bacilli from the surface of the mucous membrane, while present within the deeper layers.

5. To the bacilli not being reached by the swab, as in the case of laryngeal or exclusively nasal diphtheria.

Therefore, in all cases in which negative results have been

obtained in the presence of suspicious symptoms, repeated examinations should be made.

Release Cultures. Diphtheria bacilli persist in the throat for varying periods, after the disappearance of the clinical symptoms and so long as they persist, the person who harbors them is a constant source of infection. It is therefore an injustice to the community to release a patient convalescent from diphtheria from quarantine without having obtained evidence of the absence of diphtheria bacilli. No quarantine should be lifted without a bacteriological examination, showing the absence of the bacilli. For this purpose one or more swabs should be submitted to the laboratory during convalescence.

TYPHOID FEVER.

Import. The investigations of Pfeiffer, Gruber and Widal have shown that the blood serum of persons ill with typhoid fever exercises a peculiar agglutinating action over the typhoid bacilli. This special action appears as a rule about the fifth or seventh day of the disease, and persists during convalescence and may persist for as long as seven years after recovery. The cessation of motillity and the aggregation of the bacilli in clumps can be observed under the microscope when the blood serum and a bouillon culture containing motile typhoid bacilli are mixed in proper dilution.

Numerous investigations by competent observers have shown that the so-called Widal reaction is by far the most pathognomonic evidence of typhoid fever, occurring as it does in about 95 per cent. of the cases, which cannot be said of any of the other clinical symptoms.

Outfit. Small self-addressed envelope containing several strips of all white filter paper. Typhoid outfits supplied immediately by mail to all physicians, therefore enabling him to have a supply on hand at all times.

delay.

Malaria outfits may be used or white filter paper to avoid

Send at least one drop of blood on the filter paper.

Interpretation of results: A positive reaction, providing the proper dilution was used and a previous attack of typhoid fever can be excluded is positive evidence of typhoid fever.