In the epidemic of diphtheria at Col chester during 1901 one of the most marked features was the fall in ease mortality at the isolation hospital after the routine use of antitoxin. Previous to July 16th antitoxin seems to have been employed only in the bad cases, and the mean ease-mortality during this period was 25.9 per cent., while during the same titne the mean case-mortality among patients treated at home was only 10.8 per cent. Prom July 1Gth onward antitoxin was administered as a routine measure. There was immedi ately a remarkable diminution in the case-mortality, and for all the cases up to the end of December the mean case mortality became 5.8 per cent. It is notable that the case-mortality among the cases treated at home (luring the same period not only did not diminish, but was rather higher than before,— viz.: a mean of 14.5 per cent. The diminution in the number of deaths, therefore, at the isolation hospital was not due to a diminution in the severity of the disease, but must be ascribed to the use of antitoxin; it was, moreover, abrupt, and coincided exactly with the administration of antitoxin.
Bacteriological examination of the throats of the school-children proved of considerable value in controlling the epi demic. All children coming' from houses in which a case of diphtheria ha,d oc curred were examined, and were not admitted to the various schools until notified as being free from diphtheria bacilli. As regards the Hofmann bacil lus, the opinion is expressed that it has no relation with the true diphtheria bacillus. Diphtheria bacilli were found to persist for a long period in the throat: in healthy children who had not been attacked up to ninety-four days; among those who had suffered from an attack up to eighty-seven days. Graham-Smith (Jour. of Hygiene; Treat ment, May, 1902).
The constitutional effect of the injec tion is as marked as the local. 'Usually the temperature falls within twenty-four hours, the pulse improves, the mind is clearer, and the patient is evidently bet ter in every way.
High tempera.ture with corresponding rapidity of pulse, varying according to age and form of disease, fell following day and was normal third day when no complications present. Distinct dispar ity between temperature and pulse fre quently present. Disturbances of the circulatory system, among 154 cases, caused no deaths and did not in any noticeable way hinder recovery. Variot (La Semaine Med., Mar. 6, '95).
Rise of temperature always an im portant one; return to normal then very gradual, but temperature often remains very- high; repetition of injection caused renewal of the elTect produced. Kurt
111filler (Berliner klin. Woch., No. 37, Prompt fall of temperature accom panied by remarkably improved sub jective sensations, typically altered course of fever. IIeubner (Weber die Erfolge der Heilserum-behandlung bei Diplitherie, '95).
Temperature of 106.6° F. twenty hours after injection in a child and later on the disparity noted by Variot between tem perature and pulse. Legendre (Annual, Rise in temperature after injection not only with antidiphtheritic serum, but also with artificial serum of Hayem and with the serum of non-immunized animals. Hutinel, Debove, and Sevestre (Annual, '96).
The cases apparently severe or fatal are transformed into mild ones. Bag insky tells us that, in recording the ef fects of antitoxin upon the various types of diphtheria, he found it necessary to require his assistants to write their judg ment of the severity of the cases upon the admission card, when each case was first seen, since the antitoxin in most cases completely changed the picture.
The time of the injection has a most vital relation both to the immediate ef fect and to the ultimate outcome of the case. In experimental work an animal can usually be saved from a fatal dose of diphtheria toxin, if antitoxin is given within forty-eight hours, but not later. Clinically good results can. usually be had if antitoxin is given within three days of the onset of the diphtheria, but later than that its influence is greatly lessened. In the "Antitoxin Report of the Ameri can Pediatric Society" the mortality of first-day injections was 4.7 per cent.; of second day, 7.4 per cent.; of third day, 8.8 per cent.; of fourth day, 20.7 per cent., and of fifth day, 35.3 per cent.
Report of the American Pediatric So ciety's collective investigation into the use of antitoxin in the treatment of diphtheria in private practice.
Result as influenced by the time of in jection: 5794 cases with 713 deaths,— a, mortality of 12.3 per cent., including every case returned; excluding 218 cases moribund at the time of injection, or dying within twenty-four hours of the first injection, the mortality was only S.S per cent.
Of the 4120 cases injected during the first three days there were 303 deaths,— a mortality- of 7.3 per cent., including every case returned. If, again, the mori bund cases are excluded, there were 4013 cases with a mortality of 4.5 per cent. After three days the mortality rises rapidly, and does not materially differ from ordinary diphtheria statis tics.