446 Diphtheria 



£ul comparisons of the pre-antitoxin period with the present anti- 

 toxin period, by Park and Bolduan is found in "The Bacteriology of 

 Diphtheria" edited by G. H. Nuttall and G. S. Graham-Smith, 

 London, 1908. The paper is ill adapted to the purpose of quotation 

 and should be read by those interested in the subject. The chart 

 shows the diminishing death-rate in 19 large cities between the years 

 1878 and 1905. 



Nothing should so impress the clinician as the necessity of begin- 

 ning the antitoxin treatment early in the disease. Welch's statistics 

 show that 1115 cases of diphtheria treated in the first three days of 

 the disease yielded a fatality of 8.5 per cent., whereas 546 cases in 

 which the antitoxin was first injected after the third day of the dis- 

 ease yielded a fatality of 27.8 per cent. 



On the other hand, it can scarcely be said that any time is too late 

 to begin the serum treatment, for the experiences of Burroughs and 

 McCollum in the Boston City Hospital show that by immediate 

 and repeated administration of very large doses of the serum, ap- 

 parently hopeless cases far advanced in the disease, may often be 

 saved. 



After the toxin has occasioned destructive organic lesions of the 

 nervous system and in the various organs and tissues of the body, 

 no amount of neutralization can restore the integrity of the parts, and 

 in such cases antitoxin must fail. 



One disadvantage under which the diphtheria antitoxic serum is 

 administered both for purposes of prophylaxis and treatment, is 

 the inability of the operator to find out what may be the aheady 

 existing antitoxin content of the patient's blood. Though it is cer- 

 tain that existing diphtheria is proof that the patient needs the 

 remedy, it is by no means certain that all normal persons exposed 

 \o diphtheria in institutions, etc., require it for prophylactic purposes. 

 Some may already possess enough to defend them and the promiscu- 

 ous administration of the serum to every child in an asylum, may re- 

 sult in sensitizing some to the allergizing effect of the horse-serum 

 without just reason. A means by which some knowledge of the nor- 

 mal diphtheria-toxin neutralizing quality of the blood of a healthy 

 individual can be arrived at, has been devised by Schick,* and is now 

 known as Schick 's reaction. It consists in the intracutaneous ad- 

 ministration of a minute dose of diphtheria toxin. If the patient's 

 blood contains the neutralizing substance, no reaction takes place; 

 if it contain none, a reddened and tumefied circumscribed area ap- 

 pears, persists for from seven to ten days and then disappears with 

 desquamation. W. H. Park uses one-fiftieth of theL-|- dose of diph- 

 theria toxin, injecting it into the skin with a very fine hypodermic 

 needle. Kolmer prefers to use one-fortieth of theL-j- dose.f The 



* "Miinchener. med. Wochenschrift," 1913, p. 2605. 



t The L.+ dose is the least quantity of diphtheria-toxin that will kill a 250- 

 gram guinea-pig on the fourth day. Fibr the method of computing it, see 

 Antitoxins." 



