February 28, 1895J 



NATURE 



427 



The following table (VII.), given by Kossel, brings out the 

 great importance of this element in keeping down the case 

 mortali'y. In ihe first column is given the day of the illness 

 on which antitoxic serum was first injected : — 



117 13 ... Ill 



I'"or statistical purposes, too, only those cases which have 

 been bacteriologically examined and found to be due to the 

 action of LocfHer's diphtheria bacillus should be accepted as 

 being cases of true diphtheria. As most of the cases in which 

 ihe diphtheria bacilli are absent run a much milder course, and 

 .ire much more amenable to general treatment, and as many of 

 these have been included under diphtheria in the old statistics, 

 such elimination will necessarily make the record X'W rather 

 against the antitoxic serum treatment than in its favour. 



I'rom a somewhat extended experience (although condensed 

 into a very short period of time) I am satisfied that this question 

 of the Loeffler bacillus is most important, and that every case 

 in which the serum is used should be bacteriologically 

 examined. 



It has been said, however, and said very truly, that statistics 

 may be made to prove anything, and I have heard it said that 

 the observation of a few cases of diphtheria under the antitoxic 

 treatment is worth all the statistics that could be brought 

 together for convincing a man of the value of the antitoxic 

 serum treatment. 



A distinguished physician, who has had charge of diphtheria 

 wards for some time, informs me that the patients he sees now 

 wear an entirely different aspect from those he saw before the 

 serum treatment was adopted. Instead of being struck by the 

 stupor,tbe pain, the difficulty of breathing, and the other distress- 

 ing symptoms that so frequently manifest themselves during the 

 lourse of this treacherous di-ease, he observes children with 

 patches of membrane in the throat sitting up and playing with 

 their toys. There is little of that distress of breathing, very 

 little of the anxious look, and the wards altogether present a 

 much more pleasant and genial appearance than he has ever 

 litfore noticed. The other day I received a short note from 

 another colleague, whohasbeengoingover the German hospitals 

 !n study this question, in view of taking out with liim to the 

 colonies a supply of antitoxic serum ; he al-o stales that this 

 difference in the appearance of the diphtheria wards has im- 

 pressed him far more than any statistics he has yet come across. 



The alleged Ill-effects of the Use of the Serum. 



It has been said that most unfavourable symptoms have 

 followed the exhibition of this serum. Theiccan be nodoubt of 

 the fact ; but alter a careful study of the cases repotted, I am 

 thoroughly convinced that a very large proportioniof them, at any 

 rate, are merely post hoc ^ and xiQi propter hoc. There can be no 

 doubt that a kind of nettle-rash makes its appearance during the 

 course of treatment, and that this may be accompanied by pains 

 in the joints. Both these conditions, however, are usually quite 

 transient, and seldom give rise to permanent ill effects. 

 Albuminuria has also been ascrilied to this treatment; but any 

 one who has had to deal with children not only suffering from 

 diphtheria, but from any form of disease, and even from none at 

 all, will bear witness that albuminuria in children is of compara- 

 lively frequent occurrence. It is not striking, therefore, that 

 1 hose who have hitherto paid little attention to this subject should, 

 v.hen they come to make a careful examination of children af- 

 fected with diphtheria, find a considerable number of cases in 

 which transient albuminuria is a prominent symptom. More 

 than this, however, it has been my duty to examine a large num- 

 ber of cases in which diphtheria has proved fatal, and in these 

 cases there were certain lesions in the kidney, so distinct and so 



NO. 1322, VOlv. 51] 



frequently present, that in describing Ihem I used to note simply 

 "diphtheritic condition," and then describe in detail only 

 those features in which the appearances differed from the type 

 that I had in my mind. This will indicate to you that altera- 

 tions in the internal organs, especially in the kidneys, such as 

 would lead to marked interference with the performance of their 

 proper functions, were present, and had been noted long before 

 the antitoxic serum method of treatment came into use. I may 

 give an example of what, under ceriain circumstances, might have 

 been used as a powerful argument against the use of aniitoxic 

 serum. In the Deiiliche Medizinischer Wochemchrift for 

 December 20 of last year is reported a case of acute haemorrhagic 

 nephritis coming on after the use of Bchring's curative serum. 

 The patient recovered. But a similar case of acute hasmorrhagic 

 nephritis in diphiheria, in which, however, the curative serum 

 was not used, is reported in the same number of the same journal. 

 The author of the second paper quotes some interesting statistics 

 to show that albuminuria is of frequent occurrence in cases of 

 diphtheria not treated with aniitoxic serum. One observer found 

 it in 131 out of 279 cases ; anoiher in i6 out of 53 ; another in 60 

 per cent, of all his cases ; anoiher in 227 out of 470. Sup- 

 pression of urine has also been ascribed to the action of this 

 agent ; but here again, if a careful search be made of the records 

 of diphtheria cases treated under the old method, it will be 

 found that just as in scarlatina and acute specific infective dis- 

 eases generally, but especially in those associated with rapidly 

 supervening toxic symptoms, suppression of the urine is of 

 common occurrence; and until we have statistics on these 

 several points, which can be compared with those above men- 

 tioned, it will be impossible and unjust to ascribe conditions to 

 the therapeutic agent which, so far as those best able to judge 

 can see, are to be ascribed to the disease itself. 



It has been held t>y some that the paralysis which is 

 so common a sequel of diphtheria should disappear entirely 

 under the use of what they are pleased to call a specific cure for 

 the disease. It should be remembered that the antitoxic serum 

 cannot make good any organic damage that has been caused by 

 the action of the toxic products of the diphthuria bacillus. It 

 may stop their action on the tissues, and it may stimulate the 

 tissues to react against the poison, but to the tissues themselves 

 must be left the process of repair ; the rvi mcdicatrix natiira: is 

 alone responsible for the making good of damage already done. 

 This damage may be done at a very early stage of the disease, 

 and if the nerves or the muscles are attacked before the anti- 

 to.xine is injected, then we must expect to find degenerations and 

 evidence of these degenerations in the various forms of post- 

 diphtheritic paralysis ; but of this we may be sure, the sooner 

 the poison is antagonised ihe less will be the risk of permanent 

 damage to the tissues. It is for this reason, I believe, that the 

 antitoxic serum treatment of diphtheria has been so much more 

 successful than the antitoxic serum treatment of tetanus. 



Conclusion. 



The hope of success in diphtheria depends upon the early 

 application of the remedy. One word of warning. It .should 

 not be accepted that this agent can reduce the cure of diphtheria 

 to a mere process of injection. Everything must be done to 

 improve the conditions under which the patients are treated, to 

 maintain their strength, to give them fresh air, cleanly 

 surroundings and good general hygienic conditions. It 

 will be found withal that a certain number of deaths from 

 rapid poisoning will take place, while a number of others will 

 succumb in the later stages of the disease. This scrum can no 

 more act as a specific in every case than can quinine cure every 

 case of malaria; but if properly used, we believe it will reduce 

 the mortality in a very marked degree, and if at the same time 

 those practical sanitary reforms and improvements for which 

 our country is so justly renowned are carried out, «e may expect 

 that diphtheria as a scourge may gradually die out from our midst. 

 .•\s Dr. Seaton pointed out at Buda-Pcsth, we have done more 

 in this country to improve the conditions associated with most 

 specific infective diseases than any other nation in the world. 

 If, now, we can graft on to our system what is best in Behring's 

 treatment, I am convinced that we shall soon have diphiheria 

 statistics which will compare very favourably » iih any that have 

 yet been presented. The antitoxic serum treatment is only 

 one of our lines of defence against this disease ; but so much 

 progress htis already been made along this line, that within a. 

 few years, or even months, We may fairly anticipate the an- 

 nouncement of still greater advances and successes. 



