Antitoxin Treatment of Diphtheria: 1895-96. PREFATORY NOTE AND TABLES BY THE ASSISTANT COMMISSIONER. DURING the winter of 1894-95 the first attempt of the DEPARTMENT toward the production of diphtheria antitoxin was made by the City Bacteriologist, Dr. GEHRMANN. Proper facilities, however, were wanting, and although some antitoxic serum was obtained it was not of sufficient strength to be useful, and the difficulties met with during the attempt demonstrated that an outlay far beyond the resources of the DEPARTMENT would be necessary for the production of a safe and potent serum. In August, 1895, the increasing deaths from diphtheria led the COMMISSIONER-who had been much impressed with the results of antitoxin treatment shown by the New York Health Department-to establish a number of antitoxin stations for the convenience of physicians who desired to use the serum and to secure bacterial diagnosis of their cases. By arrangement with the New York Department supplies of antitoxin from its own laboratory were made available at reduced prices and for charity cases without charge. By September 18, some 60 of these stations had been established and their locations and other information concerning them were repeatedly published in the daily press. It was not, however, until October 5 that the first vial of the serum was called for from a station and, meanwhile, the diphtheria deaths continued to increase rapidly, the disease assuming epidemic proportions and threatening to cause the closing of some of the public schools. Every available medical officer of the DEPARTMENT was assigned to duty as an antitoxin administrator, and before the close of October the demand for antitoxin for a short time exceeded the supply. The products of Behring, Roux and Mulford were bought in open market to supplement the New York supply, and a successful appeal was made to the City Council for an emergency appropriation and authority to employ an additional staff of experts in intubation and antitoxin administration the antitoxin stations at the same time being nearly doubled in number. The work of this staff is set forth in detail in the report of Dr. E. P. MURDOCK, one of the regular Medical Inspectors of the DEPARTMENT, who was early assigned exclusively to the treatment of diphtheria and charge of the Antitoxin Corps. By the close of March, 1896, the epidemic was substantially at an end and the following summary and statistics were compiled by the ASSISTANT COMMISSIONER. SUMMARY OF ANTITOXIN REPORTS. Total number reported cases of diphtheria visited Oct. 5, 1895, to Percentage of recoveries in 1468 cases of true diphtheria treated with antitoxin, 93. In addition to the foregoing there were 1423 individuals— children and other members of the families exposed, nurses and other attendants, inmates of orphan asylums and kindergartens in which the disease had appeared-treated with the immunizing dose of antitoxin. Nine of these were subsequently attacked with diphtheria, but all recovered. The first tabulation of the individual reports of the antitoxin administrators was made for the period between October 5, 1895, and January 10, 1896, and is here reproduced in detail in order to afford a comparison between the earlier and later forms of report blanks. The forms adopted at the beginning of the diphtheria season of 1896-October 1furnish the data from which are compiled the interesting tables on a subsequent page, showing the results of the antitoxin treatment with reference to ages as well as by day of treatment. REPORTED CASES OF DIPHTHERIA VISITED, DIAGNOSED AND TREATED; WITH GENERAL RESULTS. Total number of reported cases of diphtheria visited: October 5, 1895-January 10, 1896.... .1221 Total number recovered under antitoxin treatment. 961 86 1047 Death rate under antitoxin treatment 8.21 per cent. Total number in which antitoxin was not used...... of these known to have died. Death rate where antitoxin was not used, 52.46 per cent. NOTE:-"Not used"-either because the case was hopeless when first seen, or because the administrator feared the result of its use-as, for example, in a late stage of the disease-or because the family or the attending physician changed attitude after calling on the DEPARTMENT and refused its use. .61 .32 Total cases treated with antitoxin. .1047 Total cases proved (bacterially) true diphtheria.. not proved (bacterially) true diphtheria 805 242 1047 Total cases proved (bacterially) true diphtheria. 805 753 died. 52 805 Death rate, 6.46 per cent. Total cases not proved (bacterially) true diphtheria.. 242 NOTE: The excess of this death rate over that of the "bacterially" proved may be attributed to the fact that in the majority of these cases the DEPARTMENT was called on in the late stages of the disease, and when the clinical symptoms were conclusive. The great majority of these cases were seen and antitoxin administered later than the third day of the disease. RESULTS OF ANTITOXIN TREATMENT IN 805 CASES OF TRUE DIPHTHERIA (BACTERIALLY VERIFIED): NOTE: The "day of disease" when antitoxin treatment was begun is only approximately correct, as above stated. In many cases definite information could not be obtained and "day of disease" was reported by the administrator on his best judgment. There were 2 deaths within 6 hours and 3 within 12 hours after first injections of antitoxin made on second day of disease. Total 5. There were 2 deaths within 12 hours and 3 within 24 hours after first injections of antitoxin made on third day of the disease. Total 5. There were 5 deaths within 6 hours, 2 within 12 hours and 12 within 24 hours after first injections made on fourth day of disease. Total 19. There were 8 deaths within 6 hours, 8 within 12 hours, 9 within 24 hours and 2 within 36 hours after first injections made later than fourth day of disease. Total 27. Total all such deaths 56. Total number of children and others exposed to the disease and treated with the protective dose of antitoxin......... Total number of these who subsequently contracted diphtheria... 810 4 The accompanying diagram, prepared by Dr. C. ST. CLAIR DRAKE, Assistant to the Registrar of Vital Statistics, shows the results of the antitoxin treatment between October, 1895, and April, 1896, contrasted with the corresponding period immediately before antitoxin was made available. 9 APR. MAY JUNE JULY AUG. SEPT. OCT. NOV. DEC. JAN. FEB. MAR. -9 The diagram shows that the daily average of deaths was greater for every month of the period beginning April, 1895, than for the contrasted period beginning April, 1894, and so continued until antitoxin administration was generally adopted in November, 1895. Thenceforward the figures were.reversed, and for the remaining months of November and December, 1894, and January, February and March, 1895, the total deaths were 774 as against 613 for the corresponding months ended March, 1896-a reduction of more than 20 per cent. It further shows that the maximum mortality in 1895 was reached in October, during which month the deaths averaged 8.1 per day. In November they were 6.9; in December 5.5; and in January, 1896, they were 3.9 per day. For the |