During the year 1396 there were ex amined at the laboratories 7332 cases that had been certified "diphtheria." Of these cases, 5063 had diphtheria bacilli in the throat and 1362 suffered from pa ralysis of a more or less marked kind. Of these cases, 1096 had been treated with antitoxin, and there were 273 deaths among them; 266 received no antitoxin (that is, they were most of them inild eases in all probability), and there were 49 deaths. In 1764 of the cases examined in which no diphtheria bacilli were found, there were 177 cases of paralysis with 59 deaths; 89 of these eases were treated with antitoxin-31 deaths. There were, moreover, 88 not treated with antitoxin, 2S of these suc cumbing. G. Sims Woodhead (Brit. Med. Jour., Sept. 3, '98).
Coupling the danger of delay with the harmless nature of the antitoxin, it is quite plain that antitoxin should be given in every ease where the diagnosis of diphtheria is probable. Only in mild cases may we wait for the bacteriological diag,nosis. Especially in all laryngeal cases should the immediate use of anti toxin be advised.
No harm is done if the case is not diphtheria, an.d, if it is, a great ad.van tage is gained.
We may safely assume that the use of antitoxin is harmless, for if all the re ported cases of sudden death or aggrava tion of cardiac or renal disease or other unfavorable influence were accepted as proved, they could not, for a moment, be weighed against the accumulated evi dence of the curative effect of antitoxin in diphtheria.
Effect on the kidneys of sinall pre ventive doses (2 to 3 centimetres) of diphtheria antitoxin studied in 73 eases, and shows no deleterious influence. No traces of albumin were discovered in the urine. Also report of a case of severe scarlet fever and nephritis in which diphtheria supervened, and larger doses of the antitoxin (10 centimetres) were administered. The diphtheria was arrested at once, and the nephritis also seemed to be favorably affected and re trogressed, although more slowly. Ro janski (Botkine's Gazette, No. 36, '96).
Since the introduction of the antitoxin treatment the incidence of paralysis following diphtheria has certainly in creased. The reason of this is believed to be that patients IIOW recover, or, at any rate, live long enough to show symp toms of paralysis, who without antitoxin would have died at an earlier period, Though the number of cases of paralysis, relatively as well as absolutely, has in creased, the number of fatal eases has diminished. If the serum-treatment were
commenced early enough, the number of cases of paralysis would be lower instead of higher than before. E. IV. Goodall (Brit. Med. Jour., Sept. 3, '98).
Antitoxin has been given in large doses in guinea-pigs and rabbits, but a case has never been seen in which by itself it bad produced any paralytic symptoms. The heart fails earliest and most fre quently because it is the organ which really gets least rest. This condition of overwork and ill nutrition is the great factor even in those paralyses that ap pear later. The poison does its work, but it is only when muscle and nerve are called into functional activity that the damage is unmasked and the tissues give way under a strain which in health they would readily stand.
Cases of paralysis are now not so fre quent as formerly; and those which do occur are less severe. The antitoxin should be used before degenerative changes have been set up, and enough antitoxin should be given to neutralize not only the lethal action of the diph theria toxin, but also its local and pa ralysis-producing action. Sims Wood head (Brit. Med. Jour., Sept. 3, '98).
Influence of antitoxin on diphtheritic paralysis summarized as follows: Up to the present the pereentage of paralysis has increased, on the whole. There is some evidence that large doses—i.e., not less than 4000 units—of antitoxin are more effective than small ones, both in preventing paralysis and diminishing the mortality due to it. The earlier anti toxin is given in diphtheria, the less likely is paralysis to follow. Should it occur after early injection, it will prob ably be mild and of comparatively short duration. The type of paralysis has be come less dangerous to life, Finally, diphtheritic paralysis has become more prone to attack the young. The full value of antitoxin is only obtained by using it early and in efficient doses.
Woollacott (Lancet, Aug. 26, '99).
Conclusions regarding action of diph theria toxin on the nervous system are: the essential lesion is parenchymatous degeneration of the peripheral nerves, the slight changes in the anterior-horn cells are held to be secondary or of ea chectic origin, while the vascular altera tions play but a subordinate role in the pathogeny of post-diphtherial palsy. Bielschowsky and Nartowski (Neurol. Centralb., July 1, 1900).