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Klebs-Loeffler bacilli, and even seventeen days after I necessary for me to cite other cases, having gone into discharged the child as cured there still could be found detail with the last few, but I would rather speak of the Klebs-Loeffler bacilli by a bacteriological examination. indications necessary for the treatment of diphtheria In all five cultures were made, which proved the pres- with this new remedy. ence of Klebs-Loeffler bacilli.

This, therefore, is a If we consider that antitoxin is a product of the toxvery important point, proving the necessity of the ex- ins of diphtheria injected into the horse, and that we tremest care in the sick and the isolation of the healthy use the blood-serum after an immunity has been prochildren, and especially the useless disinfection as duced in the horse, then we see that these toxins propractised to-day too early. It has been proved by a duce antitoxin and are only capable of healing diphgreat many observers that a child should not be dis- theria and really nothing but diphtheria. In one of charged as cured until really two distinct cultures his last reports Behring mentions the fact that he was were made on two different days, and both proved neg- prompted to produce antitoxin by watching the course ative. The one should be made, if possible, by an of pneumonia. He noticed that nature will in a good, officer of the Health Department, and the second healthy individual, suffering with pneumonia, permit should be made by the attending physician.

the same to have a temperature as high as 105° F. on one Dr. Ladinski was called, on November 9th, to a child day, say at the crisis, and without any medication. about two years of age, and diagnosed tonsillar diph- Without any reason the temperature will suddenly drop theria. He sent a culture to the Health Department, to normal, proving what ? Proving that nature has which reported the presence of Klebs-Loeffler bacilli generated in the body certain antitoxins, which have and diagnosed diphtheria. Dr. Ladinski gave the certainly neutralized all the septic poisons generated usual antipyretic and antiseptic treatment, using corro- by the toxins in the course of a pneumonia, and hence, sive sublimate internally, until the child appeared to the septic material being neutralized, the temperature get worse.

He next resorted to calomel fumigation, as returns to normal and the febrile process is at an end. recommended by Dr. Dillon Brown in this city. The It is easier, however, to write this on paper than to temperature rose in four hours from 102.2° to 103.6° prove it on the living, and I will caution you, therefore, F., and the child appeared very weakened. So I was not to believe that antitoxin is a cure-all, but rather, sent for, in consultation, to use antitoxin. I injected 10 that it is a remedy which has served me well and which C.C. of antitoxin in the interscapular region on the has served the most prominent clinicians in Europe, midnight of November 21st. The temperature fell and besides, has reduced the mortality in a great many to 100.6° F. at 2.30 A.m., and was 101.5° F. at 4.30 instances from forty per cent. and fifty per cent. to fifA.M., and then fell slowly until eight o'clock the follow- teen per cent., and even lower. Considering also the ing evening, when the temperature registered 102.2° fact that epidemics of diphtheria vary in different seaF. At eleven o'clock on the night of November sons, it is a very welcome remark to read Professor 22d, the temperature was 99.6° F; therefore the tem- Baginsky's paper in the MEDICAL RECORD, October 6, perature fell in this case in twenty-three hours from 1894, and note that he expresses himself in the follow103.6° to 99.6° F., without using any medication in- ing terms :

ing terms: “That given our worst form of epidemic ternally besides the injection of antitoxin. On Friday, and our mildest form of epidemic, and the ordinary the 23d, at four o'clock, in the afternoon, the tempera- form of treatment as practised heretofore, the morture was normal and remained normal. The membranes tality was about thirty per cent., whereas since the which were visible previous to the injection had disap- introduction of the antitoxin the mortality sank as peared with the sinking of the temperature, and in the low as eleven per cent." This latter speaks volumes. same way the glands at the angle of the jaw reduced in In the application of the remedy we must consider, their size and slowly disappeared. The local treat- therefore : 1. To apply the remedy as soon or as early ment in this case was carefully followed out by Dr.

in the disease as possible. 2. To inject a sufficient Ladinski's orders, using a 1,000 to 2,000 sublimated so- quantity. 3. Remember that the remedy given to us lution on cotton swabs or by spray.

is absolutely harmless. 4. That the same can be used In this case, as in all other cases, we were indebted for prophylactic purposes by injecting the one-tenth to the careful comments of the trained nurses in part necessary for healing an acute case of diphtheria. charge. The child remained well and had neither 5. It is well to remark that although we use antitoxin a complication of nephritis nor paralysis. The cases the patient still requires local treatment of the infected just cited have all of them been under five years places with a sublimated solution or other antiseptics; of age. They were all cases in which we had recog- that the question of stimulants and hygienic and dietetic nized a severe diphtheria, and in which the prognosis rules must be strictly carried out, and that, in a word, was not only extremely grave, but in most of them the we must not expect healing wonders from this new prognosis was fatal. The fact that the children were remedy. extremely weak, and had had different forms of treat- In thirty-six or forty-eight hours, at times, we should ment previously, did not seem to affect the action only look for the neutralization of the septic poisons of the antitoxin, nor did it influence it in any way ; it absorbed in the body, and that therefore we can promdid not seem to exert any influence in the complica- ise a great deal more in the commencement of the tions following the injection of the antitoxin whether diphtheria by injecting a sufficient quantity, without treatment was or was not used before the injection of further internal medical treatment. Emphasize, howthe serum. Besides the cases above cited, I have seen ever, the extremest caution for hygienic and dietetic other severe and complicated cases in consultation rules—if so, we must and will cure our case. with Dr. Romm, Dr. Waechter, Dr. Samuel M. Lands- In order, however, to be sure that we are dealing man, Dr. David Goldstein, Dr. Lazear, Dr. A. C. Car- with a case of diphtheria, which appears clinically so, penter, Dr. Stieglitz, Dr. Landes and so on, in all 225 it is necessary to prove the diagnosis by making a bac

In 45 of these cases it was necessary to intu- teriological culture of the same. We can, however, bate; in 3 of these cases tracheotomy was performed. always safely treat a case as diphtheria that shows a One case, in consultation with Dr. Goldstein, died membranous deposit on the pharynx, larynx, or tonsils through the carelessness of the nurse, and it is hoped or uvula, swollen glands, high temperature, or even low that Dr. Goldstein will publish his own report of the temperature, somnolence, and then wait for the result same. In none of these cases was intubation or trache- of a bacteriological culture to prove the diagnosis. otomy performed unless it was found absolutely nec- In Berlin a child is put into an observation pavilion

In some cases an emetic was first tried to and a culture for Klebs-Loeffler bacilli made immedidislodge membranes and possibly relieve stenosis. In ately upon admission, and if the case looks clinically others ice-poultices, in the form of ice-bags on the neck, like diphtheria it receives at once its injection of anwere used, and other palliative remedies. It is hardly titoxin. If, however, the culture does not prove Klebs

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Loeffler bacilli the child is isolated and the treatment toxin injected, the more liable are we to have eruptions, continued symptomatically and cultures again made; especially of purpura.

especially of purpura. In one typical case in which for how often has it happened, especially in the ex- we had purpura hæmorrhagica spots, there also apamination of newly formed pseudo-membranes, that no peared spots in the throat, and the gums looked like a bacilli could be found, and how often can bacilli be typical case of scorbutus. Whether these eruptions are found in older portions of the pseudo-membranes in due to impurities of the antitoxin, or whether they are almost a pure culture, so that we must also not forget due to a previous disease of the horse and some imputhat a technical error might be made in making cult- rity of its circulation, I do not know. It is, however, a ures, and not be satisfied with one or two negative ex- positive fact that I have seen twenty-five cases of diphaminations. I saw a child with a severe form of septic theria injected with one kind of antitoxin, in which I did diphtheria in which seven cultures on seven different not have any exanthema whatsoever, and again, in andays showed the absence of Klebs-Loeffler bacilli. other twenty-five vials of antitoxin injected, I seemed to This child died, and the post-mortem culture, two hours have an eruption in almost every case, one eruption after death, was negative, and still no membranes involv- milder and others severer. These eruptions would aping larynx and trachea were present, as still no bacilli pear and disappear and reappear when the first, second, could be found. This shows that isolated cases may and third injection of antitoxin were given, so that there give us some trouble in verifying our clinical diagnosis. could be no question that the coincidence of the erupIt is, therefore, perfectly proper to rely on the clinical tion and the antitoxin injection was positive and that diagnosis, as in the last case cited by me.

one was due to the other. I was called to a child, about seven years of

age, Finally, permit me to state that the choice of the seat which had a severe pharyngeal, nasal, and tonsillar of injection is entirely secondary to me, because I had diphtheria, enormous infiltration on the throat and injected the arm, I had injected the leg, I had injected glands, not a very high temperature, extreme somno- the abdomen, but chose the interscapular region, belence, fetor of the breath. The case was attended by cause children do not see the needle, and I always could Dr. Gengenbacher. In consultation, on November

In consultation, on November eventually lay a child on the knees of the nurse, face 29th, and after a careful examination, we decided that down. It appears to me to be the same as the choice of we were dealing with rather a severe form of septicæ- vaccination of the arm or leg, as practised to-day with mia, and believing that antitoxin would do good in this

cow virus. case, I injected 10 c.c., exitus lethalis, after twenty I had brought over a small syringe containing 20 hours. Had I known then what I know to-day of the C.C., which was recommended to me by the kindness of value of antitoxin, I should not have injected that case, Dr. Aronson in Berlin, and which was used by Profesbut would have warned the physician rather to use sor Baginsky in the Children's Hospital in Berlin. I other remedies and not depend on antitoxin. To have had this syringe constructed through the courtesy prove that, I was called in consultation, on December of Mr. George Ermold, instrument-maker of this city. I 3d, by Dr. N. S. Roberts to a severe form of septic am informed, however, that the firm of Schering & diphtheria. I found the case to be the same as the Glatz has imported the original syringe from its maker clinical picture which I have given in the case of Dr. in Berlin. I should like to emphasize what has already Gengenbacher. I decided not to inject this case, after been reported and published by me last October and consultation with Dr. Roberts, as it was really mor- November, that 52.c. of Aronson's healing serum will ibund and in the last stages of septic poisoning. serve me, and has served me, as well as 10 c.c. of BehrThe child was suffering from a mixture of scarlet fever ing's No. 2, and sometimes as well as Behring's No. 3. and diphtheria. Another child, however, in the same No. 1 solution of Behring is so weak for healing purposes family, which was two years of age, and which Dr. that it should only be used, if at all, for immunity purposes. Roberts told me had been exposed to this infection, When we think of the small quantity that can be inwas injected by me in presence of the attending phy- jected by using a concentrated solution, as sold in this sician, with 2 c.c. of antitoxin for immunity purposes. city, of Aronson's serum, it is wise in my opinion to Dr. Roberts wrote me that this child remained well use rather 5 c.c. than to be forced to inject 20 c.c., and did not suffer any infection, proving the value as the pressure of a larger quantity of fluid has in most of the immunity injection.

of my cases made the children cry with pain for several Contra-indications for the usage of antitoxin are: 1. days. Older children and adults described the pain as Cases of mixed infection; cases of scarlet fever compli- of a neuralgic character. cating diphtheria ; cases of measles complicating diph- I have seen in all 225 cases in New York, in Brooklyn, theria ; cases of chicken-pox complicating diphtheria, and in Jersey City in consultation and private practice. and so on. 2. Cases that are moribund.

3. Cases that I have reported in the American Journal of the Medical appear to be true septicæmia, where we have rather a Sciences, January, 1895, 34 cases. In a great many

of result of the diphtheria than a real diphtheria to con- my cases I have injected two and three in one family; tend with.

4. I found that it was very important to seven children for prophylaxis, besides injecting at make a careful urinary examination microscopically, times one, two, and three sick children for the curing of and cases that showed a distinct evidence of casts and diphtheria. Several of my cases had been injected in large quantities of albumin should not be injected with the Children's Department of the German Poliklinik, antitoxin.

One hundred and sixty-five cases were children under I find, furthermore, that in a great many cases where five years of age. I have also injected six adults. The casts appear in the urine, and large quantities of albu- other children were all over six years

Of these min, before injecting the antitoxin, that we frequently I have discharged as cured 191 cases in my own prachad quite some hæmaturia, bloody urine, as also severer tice, and through the reports of the attending physisymptoms, like swollen joints, swollen extremities, etc. cians in the various other cases, my mortality has been

The eruptions which most commonly appear to fol- 34 cases, besides one accidental death, due to the carelow the antitoxin have been varied. Some look like lessness of a trained nurse in a case in which tracheotscarlet fever, some appear like measles, most of them omy was performed. Of these cases 68 showed dislook like erythema ; seven cases looked like urticaria ; tinct symptoms of nephritis, which could be proven nine cases showed purpura hæmorrhagica ; where, how- microscopically. The importance, therefore, of a careever, these last purpura spots appeared it was found ful microscopic examination of the urine cannot be that coincident with these there was blood in the urine. overdrawn. Besides the cases just cited of nephritis, I found these purpura spots chiefly surrounding the 141 cases showed albumin in the urine ; in these cases, joints, on the face, and never did I find one in a case however, we could not find any casts. In 64 cases that received less than 10 c.c. of antitoxin, so that I was hæmaturia appeared about thirty-six hours, in some ready to believe that the greater the quantity of anti- forty-eight hours, following the injection of antitoxin,

of age.

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and in which, I believe, we can ascribe the existence of which completely prevents the entrance of septic mathe same to the injection of the antitoxin. It is, how- terial. The injected spot can also be sealed by dropever, of the extremest importance to wait some time, ping collodion over it. until we can definitely prove whether this is a fact or The absorption of the antitoxin takes usually from not. In a given case, a strong boy, three

years

of

age, one-half to one hour. At times I have seen a swelling with albumin in the urine 5 pro mille, according to produced by the injection of 5 or sometimes io c.c. of Eschbach, the quantity of albumin increased to 9 pro antitoxin remain for fifteen and even eighteen hours in mille twenty hours after the injection of 5 c.c. Aron- one case. This is, however, rare. In other cases I can son's antitoxin. In this case there were distinct symp- remember that the swelling disappeared within twenty toms of hæmaturia present. The symptoms, however, minutes. disappeared in two days after the injection, as also I have previously mentioned the fact that I refused every symptom of blood. This was verified by a mi- to inject a case after consultation with Dr. Roberts. croscopical examination. Three days later I gave an- The same was true, later on, in consultation with Dr. other injection of antitoxin, and again the albuminuria Shulman, in which case the child was so moribund that was increased and also the hematuria. Then a distinct we believed it useless. Both children died very soon eruption of purpura hæmorrhagica was visible. The

The afterward, and I have therefore reduced my mortality eruption disappeared in five days. A strange obser- somewhat by not injecting these hopeless cases of septivation was the fact that the eruption appeared much cæmia. Finally, I desire to state that my mortality has heavier and much thicker in the evening until mid- been 35 in 225 cases treated ; 22 cases were under five night and disappeared toward morning. These symp- years of age ; 16 of the latter were under three years. toms were found in one distinct consignment of anti- My mortality has, therefore, been equivalent to 15t per toxin, consisting of twenty-five bottles. Strange to say, cent., although my percentage of cures in the first 34 the next consignment of twenty-five bottles, which cases reported was 5 per cent. The high death-rate arrived from Berlin three weeks later, did not give me given by me is far above what has been given in any exanthemæ, resembling measles, urticaria, or scarlet Berlin, the Children's Hospital, and in several other fever, so much so that I was greatly impressed with the hospitals abroad. This can easily be explained by the idea that possibly the eruptions in my previous case fact that in the majority of cases in which I was called were due to some specific impurity traceable to the in consultation to use antitoxin, it was used as a last rehorse's blood or his system, and possibly the other con- sort only, and therefore the majority of cases were looked signment of antitoxin, which did not yield eruptions, upon as hopeless. I took chances of injecting a great may have been drawn of a healthier horse.

many cases in which we considered a grave prognosis, tity to be injected is of very great importance. So I and therefore have attained the results specified above. find that 5 c.c. of Aronson's antitoxin yielded just the In conclusion, I desire to state that antitoxin should same results as 10 and 12 c.c. of Behring's No. 2. be used early, and believe that if the rules given This concentration of Aronson's antitoxin I regard as above be carefully carried out, it is a safe remedy of very great value. This has been repeatedly pointed and can cure every case of diphtheria seen early ; and out by me in the MEDICAL RECORD-October 6, 1894, even the most malignant cases should be injected, beand later on, November 17, 1894, same journal.

cause I have seen moribund cases that were considered Post-diphtheritic paralysis has been frequently ob. absolutely beyond medical control get well. I again served by me during the course of antitoxin treat- state, however, that I do not believe it a cure-all, but ment. I have in all had twenty-one cases of facialis believe it to be the best known remedy for the treatparalysis, and also paralysis of motion ; paresis of ment of diphtheria in use to-day. the upper and lower extremities has also been ob- 187 SECOND Avenue. served by me. In all these forms of paralysis, however, there appeared some symptoms, and some are still to-day under treatment, although it is three months

ANTITOXIN IN DIPHTHERIA. since the injection of antitoxin was given. I do not, therefore, believe that we can modify the course or

BY CYRUS EDSON, M.D., the form of the paralysis occurring during diphtheria by injections of antitoxin. I do think, however, and I have seen cases that were injected early, that did have I HAVE recently had an unusually good opportunity very mild forms of paralysis, so much so that it is pos- to observe the use of antitoxin in the treatment of diphsible that the antitoxin neutralizing the poison of the theria, in two cases, occurring in my own family. diphtheria absorbed in the system prevents, and prob- CASE I.-On Sunday, March 3d, a boy, aged seven, ably modifies, the amount of septic matter absorbed, so was attacked with vomiting; there was slight elevation that the toxins in the system do not affect the muscles of temperature, and his throat was slightly congested, and nerves as if they were not neutralized so early. but in no respect was there anything characteristic of The technique of the injection consists of–1. A careful diphtheria. On Monday morning a thin, grayish memsterilization of the skin of the patient to be injected at brane covered the soft palate, the tonsils, and the the seat of injection, the interscapular space, or the pharynx. A culture was at once taken, and without pectoralis region. Sterilization consists of washing of waiting for the result of its examination, 6 c.c. of the the skin with soap and warm water, then sponging the antitoxin serum was administered at 3 P.M. of that day. skin with a 1,000 to 2,000 sublimate solution.

This, it will be seen, was within thirty-six hours of the hands of the physician must be carefully and properly attack. The serum used was prepared in the laboracleaned and rendered aseptic. 3. The syringe should tory of the New York Health Department, and was be completely sterilized by boiling fifteen minutes in a unusually strong ; zooo c.c. of it having prevented soda solution. The needle should be dipped in alco- the death of a guineu-pig weighing 250 gm., which hol, followed by a two per cent. solution of carbolic had received an amount equivalent to ten fatal doses acid. 4. It is necessary to inject slowly ; at the same of diphtheria toxin. It will be remembered the prepatime to have the proper quantity of serum drawn into ration known as Behring's No. 3 (the strongest of Behrthe barrel of the syringe, so that no time is lost. The ing's antitoxins) is considerably weaker than this serum needle should be pushed into the deep cellular tissue, used, since it requires a dose of 1367 to To'to C.C. to at least two inches in a semi-horizontal position. 5. neutralize“ ten times a fatal dose to a 250 gm. pig. Massage of the fluid injected with the skin should not The temperature on Monday at 8 P.M. was 104° F. ; be practised ; finally, I should apply a very small the membrane appeared thick, white, and of a leathery pledget of absorbent cotton over the injected space, and

consistency, almost completely covering the pharynx; the oozing of a small quantity of serum makes a film breathing was rapid and difficult. In a very large ex

COMMISSIONER OF HEALTH FOR THE STATE AND CITY OF NEW YORK.

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perience with the disease I have never seen a more slight point where the needle entered the skin nothing profuse exudation nor one of more malignant aspect. is visible to show the site of any of the injections. This view, as taken by me, was not due to the natural To a girl of twelve years, a sister of the children anxiety of a father, for Dr. H. M. Biggs, to whom the treated, 2/2 c.c. of the same serum was administered for medical direction of the case was entrusted, concurred preventive purposes. Notwithstanding the fact that with me in the opinion.

she was closely exposed, has a sensitive throat, with On Tuesday morning the result of a culture showed hypertrophy of the tonsils, and is extremely subject to Loeffler bacilli ; temperature at 8 A.M., 1031° F.; cer- tonsillitis, she escaped infection, but on the seventh day vical glands much enlarged and inflamed. The cir- developed urticaria, which at first was localized over cumference of the neck was very much increased, and the site of the injection. The eruption covered an over the enlarged glands the skin was red. Eleven oval spot three by four inches, but did not extend or cubic centimetres of the same serum was injected at 9 appear elsewhere until the ninth day, when a number A.M. On Tuesday night, 8 P.M., temperature, 102° F.; of shotty papules, very closely resembling chicken-pox, the membrane was detached along its free margin and but not proceeding to vesiculation, covered the dorsal a considerable portion of it was cast off. On Wednes- aspect of the arms and hands, the chest, abdomen, and day, 8 A.M., temperature, 100° F.; the membrane was lower extremities. partly cast off, though a large, loose mass was still to The rash was most profuse over the arms and legs, be seen in the pharynx ; the respiration was not much and the itching caused by it was a very distressing impeded, nor was it so rapid. The throat was sprayed symptom. The papules lost their shotty feel after for the first time with Dobell's solution, and this was twenty-four hours and spread by increasing their diamcontinued during the waking hours at intervals of every eter until they coalesced and covered the extremities two hours. This, with the exception of four grains of almost uniformly, leaving little streaks of white skin gray powder, given on Wednesday and Friday nights, visible in places. On the third day after the appearwas the only treatment in addition to the serum. On ance of the rash it began to fade, and by the evening of Thursday, 8 A.M., temperature, 984° F.; the membrane the fourth day it had totally disappeared. The temwas nearly all gone, small granular spots of it only ap- perature just preceding the appearance of the rash was pearing over the tonsils (which were congenitally large) considerably elevated. and over the posterior walls of the pharynx ; the appe- During the outbreak the temperatures were as foltite on Thursday returned, for prior to this time during

lows : the course of the disease it had been difficult to in

Degrees, Degrees, Day.

Degrees, Degrees, duce the child to take milk, which was the only nourishment. On Friday, temperature, 8 A.M., 998° F. ; 8

1013

3.

99 99 P.M., 1001° F.; appetite good, membrane entirely dis

99

4.

Normal. Normal. appeared. On Saturday, 8 A.M., temperature, 991° F.;

On the eighth day after the injection the younger girl 8 P.M., 100° F.; throat normal, glands almost so; no

suffered from a profuse general urticaria. The erupredness of skin. On Sunday, temperature, 8 A.M., 9840

tion was intense and confluent, closely resembling the F.; the afternoon temperature was not taken, but it ap

eruption of measles and involving the conjunctiva and peared to be normal ; the appetite was ravenous and

mucous membrane of the mouth and palate. The the child could with difficulty be kept in bed, as he itching and discomfort were so great that bromide and asserted he was well and had been for some time. He

camphorated tincture of opium had to be given. The did not seem to have lost flesh, nor to have been much

rash was preceded by a rise in temperature and perweakened by his illness. He is an unusually robust

sisted for five days. After the second day the eruption child. CASE II.— A girl, aged nine, also remarkably robust, isolated spots, but reappearing after eating breakfast the

was much better at night, disappearing except in a few but with extremely large tonsils and a very nervous

following morning. During the middle of the day it temperament, was taken sick with sore throat on Tues

appeared to be at its height. The temperatures taken day morning, before the report from the culture taken

night and morning were as follows: from the boy's throat showed positively his disease was

Degrees, Degrees, diphtheria. Within three hours, however, subsequent to the visible commencement of the attack she received

Ist day of eruption..

1031

103 6 c.c. of the same serum that had been administered

2d day of eruption

102 102] to the boy. Temperature, Tuesday night, 104° F. ;

3d day of eruption

.101 throat much congested but no membrane, and the

4th day of eruption

102) culture taken showed the presence of suspicious bacilli, 5th day of eruption

99% 1003 the report from this culture being received Wednesday 6th day (eruption disappeared)..

1003 103

7th day, normal.... morning. On Wednesday, 8 A.M., temperature, 10242°

99 Not taken. F. ; patches of grayish exudate appeared over both ton- Vaseline containing four per cent. carbolic acid apsils

, but this was not sufficient to entirely cover them; peared, in the case of the younger girl, to best allay the pharynx and uvula much inflamed. Six cubic centi- itching. In the case of the older girl, however, a solumetres of the serum were again administered at 9 A.M. tion of one ounce sodium benzoate in a pint of glyceThe child was much terrified by the method of adminis- rine was made, and this being mixed with hot water in tration and had to be forcibly held. Temperature, 6 equal parts and used as a wash, seemed to give the P.M., 104%° F. This high temperature was accompanied most relief. The boy, who received the largest dose of by a slight delirium, and was attributed to the effect on

the serum, and had the most profuse diphtheria exuthe nervous system of the struggle and fright incident to

date, did not, however, develop any urticaria until the giving the antitoxin. By the advice of Dr. Biggs a sin- seventeenth day after receiving the serum. Just pre: gle dose of ten grains of sodium bromide was given, and ceding the appearance of the rash he seemed languid two drachms of whiskey administered every three hours. and complained of feeling tired. His temperature

. Within two hours and a half after the administration of taken showed a rise to 1024° F. During the course of the sodium bromide the temperature dropped to 100° the day a number of wheals appeared on his arms, legs, F. On Friday, temperature, 8 A.M., 99% F. ; 8 P.M., and face. The diameter of these blotches was from 991° F. Saturday, temperature, 8 A.M., 99° F. ; 8 P.M., one inch to two inches. The patches were isolated and 991° F. The child appeared well and extremely anx- gave rise to intense itching, which was relieved by a ious to get up. During the course of the disease this

four per cent. carbolated vaseline. The temperature child's throat was frequently sprayed with Dobell's

at night had fallen to 101° F., and the following morn. solution. The injections of the serum in both cases ing was normal, The rash disappeared within six were made in the abdominal region. Beyond the

hours of its appearance, and did not again appear.

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The two girls did not have at any time during the of time to do its work. This period varies from ten to
course of the disease, or afterward, any albuminuria, twenty-four hours, and makes it essential that the
though the urine was frequently examined. The urine remedy should be given early in the attack to effect its
of the boy, however, on the third day after the attack object.
was found to contain a trace of albumin, which disap- The theories advanced, when antitoxin was first used,
peared about the sixth day.

and which seemed to be the most tenable from a bacA study of this eruption is very interesting. The teriological stand-point, were: the immune serum sufficases treated by antitoxin at Willard Parker Hospital ciently

reinforced the natural resistance to the disease to have developed it in comparatively few instances. Dr. turn the balance in favor of a cure, and that the blood Somerset, the resident physician, has reported the fol- of the immunized horse contained a sufficiency of lowing facts concerning it :

something that neutralized the poison of diphtheria as Of 117 cases treated with antitoxin in the Willard an alkali neutralizes an acid. These theories do not Parker Hospital, 12 had an eruption which appeared appear to be correct, for if they were, the action would between the eighth and twelfth days. Of these 12, the follow the administration more promptly. It seems to character of 4 was erythematous, somewhat resembling me more probable that serum acts through the changes measles in appearance, distributed principally on the it effects in the blood itself, and that it requires time to extremities, and exclusively so in 2 cases.

These 4

bring about these changes. Whether it is that these cases were differentiated from measles by the irregular changes are chemical and are due directly to the effect distribution of the eruption, the absence of coryza, con

of the serum on the blood itself, or that they are junctivitis, and the characteristic measles temperature. brought about through cell stimulation, or that they Of the remaining 8, 5 were urticarial. The distribution are due to the development in the blood of some new of the eruption was irregular, the wheals varying in size, substance, is not in the least apparent. but seeming to be larger in the vicinity of the site of the It is interesting to study the mortality among cases injection, where they first appeared in 3 of the 5 cases. of diphtheria treated with antitoxin at Willard Parker Most of the wheals had extensive peripheral erythema. Hospital, since January i to March 10, 1895. The The other 3 cases presented a distinct blush, irregu- total number of cases treated was 117 ; the total numlarly distributed in areas of varying size. These areas ber of deaths 27; the per cent. of mortality, twentywere scarlatinal in appearance, but the distribution, three ; per cent of mortality for corresponding period tongue, and temperature were in nowise characteristic of 1894, thirty-three. During January the antitoxin of scarlet fever. None of these rashes lasted longer used was very weak, requiring about ito c.c. to prothan thirty-six hours, but in the urticarial forms they tect a guinea - pig weighing 250 gm. against an would disappear and again reappear, the alternations amount of toxin equivalent to ten fatal doses. This is occurring perhaps three or four times in a single case. about the strength of the solutions used for immunizThe eruptions seemed to occasion no inconvenience ing purposes. Of the 117 cases above named, 46 oCnor discomfort, and received no treatment other than curred during the month of January and the number occasional washing with some simple lotion, The of deaths was 13. The per cent. of mortality, theretemperatures were very irregular, and were usually fore, for January was twenty-eight plus. January 31st highest before the rash appeared, but were in some to March 1oth the number of cases treated was 71, cases highest during the eruption or immediately after the number of deaths 14, and the per cent. of mortality its disappearance. Four of the five urticarial rashes nineteen. The serum used during this period was conoccurred in cases receiving antitoxin from one particu- siderably stronger, the immunizing dose for guinealar horse, whose serum would thus seem to be more pigs being from io to sobo C.C. likely to cause an eruption than that from the other The number of cases of croup since February ist at animals.

Willard Parker Hospital was 30, the number of deaths It will be seen there is a very distinct period of in- since February ist 10; per cent. of mortality 33} ; cubation after the administration of the serum and and the croup mortality for 1894 was fifty per cent. before the appearance of the urticaria. This period The number of operative cases of croup since may be put at from five to seventeen days, and it shows, January ist was 22 ; the per cent. of mortality among in my opinion, the eruption is not due primarily and these cases forty-five ; per cent. of mortality for 1894, directly to anything contained in the serum, but rather eighty. The average number of days that the diphto the action of the serum on the system of the patient ; or theria cases were sick before admision and administraperhaps to the development in the blood of the patient of tion of antitoxin was, in the fatal cases, 510 days. some pathogenic substance through this action. To effect this action, or, rather, to effect this change in the system of the patient, requires the time which elapses during the

Percentage

Week endingperiod of incubation. It is evident that not every per

Piph

Diph

Croup. son is susceptible to this effect of diphtheria antitoxin, or that the toxin of diphtheria is an antidote to the urticarial effect of the antitoxin. Time and a careful

January 6, 1894....

January 13, 1894. study of a great number of cases will alone demon- January 20, 1894.

January 27, 1894. strate which, if either, of these two hypotheses is cor

4350/100 rect. The normal horse serum may have the property

February 3, 1894. of causing the eruption in susceptible persons.

February 10, 1894...

February 17, 1894...
Experiments are at present being conducted in the

February 24, 1894...
Health Department Laboratory, with a view of ascer-

3943/100 taining the truth or falsity of this theory. It may be, January 5, 1895. however, I think, safely assumed that the eruption is a January 12, 1895

January 19, 1895 local lesion of a general disease, of which the serum is January 26, 1895

2577/100 the cause. This seems to be proved by the distinct period of incubation and the rise in temperature, whichi, February 2, 1895...

February 9, 1895. I think, will be found more or less characteristic in the

February 16, 1895 majority of cases where the temperatures are carefully February 23, 1895... recorded.

Concerning the therapeutic action of antitoxin there is much conjecture. The agent does not act at The above table shows the cases of, and deaths once like drugs administered hypodermically, but re- from, diphtheria, occurring in New York City from quires a very distinct and somewhat prolonged period January 5, 1895, to February 23, 1895, and for a cor

Cases.

Deaths.

Total.

Total.

deaths to cases.

theria.

theria. Croup.

210

175

9 13 16 8

59 63 68 69

16 12 18 12

195 106

732

317

58

171 173 122

15 TO 13 20

59 47

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76

58

700

276

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