A clinical study of 2093 cases shows that the recovery of the patient depends almost entirely on whether or not anti toxin is administered early enough and in sufficient quantity. The amount of diphtheritic membrane alone is an im perfect guide; it is often necessary to continue giving antitoxin af ter this has disappeared, for evidences of toxminia sometimes outlast the false membrane. Clinical experience teaches that the effects of antitoxin are only salutary, a.nd that there is no danger in giving too much. It also teaches that the sooner the total amount of antitoxin required can be given, the better. In the eases mentioned, therefore, 4000 unit doses were given and repeated every four hours as long as was neces sary. In some exceptionally severe and late cases 4000 units were given every two hours, and in some cases 8000 units every four hours. Some patients thus received large quantities of antitoxin, and some moribund and apparently hopeless cases were saved from dea.th. Indeed, some of the recoveries that have adtended this mode of treatment were so wonderful that only those who saw them could appreciate them. F. G. Bur rows (Amer. Jour. Med. Sci., Feb., 1901).
The injections of antitoxin may be made upon almost any part of the body, now that the quantity of serum used is comparatively small; the abdomen, thighs, or back may be preferred. An hypodermic syringe capable of holding 5 cubic centimetres is most convenient, but the ordinary hypodermic may be used in emergency. Some slight pain, red ness, and oedema may be seen at the site of the injection, but nothing more, if proper care be taken in making the in jection.
Reduction of post-injection accidents by heating the senun. In 1895-96, out of 1365 patients treated with unheated serum, 208, or 15.2 per cent., suffered from post-injection accidents. In 1897, however, of 251 patients injected with the warmed serum, accidents were mani fested in only 12, or in 4.7 per cent. The method of preparing the serum is as follows: It is collected under condi tions of as perfect asepsis as possible, and without the addition of any anti septic, and is put into small flasks. of the capacity of ten cubic centimetres, closed with a cork and a capsule of caoutchouc. These flasks are kept for twenty minutes at a temperature of be tween 138° F. and 139° F. The heated serum is no way inferior to that not so treated. Spronck (Gaz. Hebd. de Med. et de Chin, Apr. 21, '98).
G eneral eruptions may be seen in a large percentage of the cases in which antitoxin is used, if watch be kept for them. The eruption is in the form of an urticaria, as a rule, and develops about the tenth day after the injection. It may
be transient and give no trouble or may continue for several days and be very annoying.
Temporary albuminuria has been re peatedly noted after immunizing doses of antitoxin, but this disturbance of the kidneys has always passed off without symptoms or sequelm.
Swelling of the joints has also been reported in some cases, but must be very rare. These sequelm of the use of anti toxin seem to be dependent upon the quantity of serum employed in the injec tion, and have certainly been much less frequent since the concentration of the antitoxin has allowed the use of smaller quantities of the serum.
The effects of the antitoxin upon the diphtheritic process may be almost im mediate, and should be evident within twenty-four hours in all cases. Although it has no bactericidal power whatever, it affects both the local and the general condition. In the throat an advancing process stops or at once begins its retro gression. The amount of discharge les sens, the swelling diminishes, the mem brane ceases to spread, begins to soften, and becomes looser. The favorable in fluence is quite as marked in the larynx as upon other parts. The stenosis is re lieved, as a rule, and the membrane is more rapidly thrown off. The general testimony is that, of the laryngeal cases, a much smaller proportion requires operative treatment for the relief of the stenosis since antitoxin has been used.
If intubation is resorted to, the tube is ruore often coughed out, or can be removed earlier than under any other form of treatment.
In 1892 the mortality of 5546 cases of intubation was 69.5 per cent.; 30.5 per cent. recoveries. In the cases treated with antitoxin and operated upon, the mortality was 27.24 per cent. The mor tality of laryngeal diphtheria at present rests at 21.12 per cent.; GO per cent. approximately have not required intu bation; and the inortality of operated eases is at present 27.24 per cent. Mc Naughton and Maddren (Med. News, May 15, '97).
In Boston the mortality in the iutuba tion-cases has fallen since 1895 from 83 per cent. to as low as 23 per cent. in those CMOS intubated this year. There have been 15 cases of diphtheria of the eye. In only one case there was de struction of the eye, and this organ was not in normal condition at the beginning of the attack; it is believed that there would have been a number of CaSCS of blindness had it not been for the anti toxin. Large doses should be given early in the disease. J. H. McCollum (Boston Med. and Surg. Jour., Aug., '98).