That evidence has been so fully pre sented in the articles by Welch, Biggs and Guerard, and the Report of the American Pediatric Society, already re ferred to, and is so complete, that no attempt is made to introduce it here.
There are certain definite limitations of the efficiency of the diphtheria anti toxin. It has already been pointed out that not all the lesions of diphtheria are produced by the action of the diphtheria bacillus or its toxins.
Certain of them, especially the bron cho-pnenmonia and nephritis, are be lieved to be due to the action of strepto cocci.
Diphtheria associated with streptococci is the gravest form met with; in chil dren it is the most frequent determining factor of broncho-pneumonia. E. Roux (Universal Med. Journal, p. 289, '94).
In the severe and most highly infec tious forms of diphtheria accompanied by marked hypermmia and swelling of the faucial and adjacent surfaces, strepto cocci occur not only in the superficial, inflamed parts, but in the deeper, con tiguous tissues, as the submaxillary and perilaryngeal glands and the a,djacent connective tissue. In some cases these adventitious germs, by penetrating deeply, cause not only a, cellulitis which may end in suppuration, but set up a broncho-pneumonia. Barbier (Gaz. Med. de Paris, Sept. 30, '94).
Organisms present in 32 fatal cases: Loeffler's bacillus only, 37.5 per cent.; with streptococci, 25.0; with staphylo cocci, 13.7; with streptococci and staphy lococci, 18.7. In all cases staphylococci pyogenes aurei found. No fatal results took place when only cocci were present. Shuttleworth (Lancet, Sept. 14, '93).
By mixing cultures of the strepto coccus with those of the Klebs-Loeffler bacillus, a, considerable increase in the virulence of the latter is observed. The dose necessary to kill a guinea-pig was much less than that required for ft cult ure of the diphtheria germ. If the dose was decreased to the point of permitting life for two or three weeks, there was observed, besides etuaciation, a diminu tion of the secretion of urine, which be came sanguinolent. The autopsy showed especially-profound alterations in the kidneys, visible to the naked eye. The
glomerules were swelled, and projected above the cut surface. The microscope showed the shedding of epithelium from the urinary tubules and the presence in their lumen of numerous altered red globules. These lesions cannot be ob tained with pure cultures of the strep tococcus, but only by adding to the diphtheria cultures the toxins of strepto cocci obtained from cultures four weeks old. Bonhoff (Hygienisehe Rundscha,u, No. 3, S. 97, '96).
In cases of mixed infection the symp toms of ptomaine poisoning due to the Klebs-Loeffler bacillus may be preceded by those due to staphylococci and strep tococci, which latter may even subsist before the onset of the graver symptoms. If the Klebs-Loeffler bacillus is the "prin cipal invading germ," then "antitoxin will bring the crisis of the disease within twenty-four hours. If it is the strep tococcus, there will be a long, hard fight." Streptococcic angina is marked by pain, and is not benefited by anti toxin. Jaques (Lancet, Jan. 15, '93).
Upon these processes the antitoxin can have no direct effect. By lessening the depression produced by the diph theria, antitoxin may enable the patient to resist the further attack of the strepto cocci or other pathogenic organisms; it cannot be expected to do more. It has also been urged against the antitoxin that diphtheritic paralysis is quite as fre quent after its use as it was without anti toxin.
To this two reasonable replies have been made: One, that the nervous sys tem is most susceptible to the action of the diphtheria toxins and therefore most difficult to protect; so that, while anti toxin can save the life of the patient, it cannot protect him from the particular effect of his disease. The other is the in genious suggestion that by saving the lives of many who, suffering from severe diphtheritic infection, would, in all prob ability, have died under any previous form of treatment, antitoxin increases the number of those in whom we should rea sonably expect to see diphtheritic paraly sis develop.