A ntitoxine in Diphtheria in Berlin, New 
York, Municipal Hospital 
of Philadelphia. 
BY 
LOUIS FISCHER, M.D., 
INSTRUCTOR IN DISEASES OF CHILDREN AT NEW YORK POST-GRADUATE SCHOOL AND 
HOSPITAL; PHYSICIAN OF THE MESSIAH HOME FOR CHILDREN; ATTENDING 
PHYSICIAN TO THE GERMAN POL1KLINIK (CHILDREN’S DEPARTMENT). 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
January, 1895. Reprinted from The American Journal of the Medical Sciences, January, 1895. 
ANTITOXINE IN DIPHTHERIA IN BERLIN, NEW YORK, AND 
IN THE MUNICIPAL HOSPITAL OF PHILADELPHIA. 
By Louis Fischer, M.D., 
INSTRUCTOR IN DISEASES OF CHILDREN AT NEW YORK POST-GRADUATE SCHOOL AND HOSPITAL ; 
PHYSICIAN OF THE MESSIAH HOME FOR CHILDREN; ATTENDING PHYSICIAN TO THE 
GERMAN POLIKLINIK (CHILDREN’S DEPARTMENT). 
The new therapeutic agent antitoxine has been before us since 1890, 
when, at the hygienic institute at Berlin, Behring told us of its effects 
in rendering animals immune in diphtheria. He described the method 
of injecting small quantities of virulent cultures into the abdominal 
cavity of guinea-pigs. 
It is a well-known fact that guinea-pigs are more sensitive to the 
action of diphtheritic poison than are other animals, and for this reason 
they serve the purpose of experimental work better than other animals. 
Behring modified the action of this virulent diphtheritic bouillon, by 
previously injecting his animals with iodine trichloride, and found that 
guinea-pigs could endure larger doses by this method than otherwise. 
Behring read a paper in the summer of 1891, at London, before the 
International Congress of Hygiene and Demography, in which he 
detailed his methods and results. 
Commencing with guinea-pigs, Wernecke then secured immunity 
in sheep, and Aronson in dogs; then oxen were tried, but yielding very 
unsatisfactory results were finally abandoned. In order to secure large 
quantities of serum it was tried on horses, and finding that immunity 
could be transferred they are at present utilized. 
In speaking of serum or antitoxine I invariably refer to that derived 
from the blood serum of the jugular vein of the horse. 
Theory of Immunity. Behring and Ehrlich found that by injecting 
small quantities of virulent poisons and allowing the animal to recover 
we could arrive at a certain point which could be called tolerance of 
their specific poison, and this tolerance is called immunity. It was further 
found that this immunity could be conveyed to other animals by inject- 
ing certain quantities of serum derived from the blood of immune 
animals, and this immunity would not only last for some time but would 
protect the animal against disease from this one toxic agent if injected. 
Behring found that this immunity applied to tetanus and diphtheria. 
Ehrlich used vegetable poisons, ricin'and abrin, and produced immu- 
nity. This being, then, the foundation of serotherapy, it was found that 2 
FISCHER: ANTITOXINE IN DIPHTHERIA. 
certain quantities of serum, 0.1 c.c. would protect a guinea-pig weigh- 
ing 400 gm., or 1 c.c. would protect a guinea-pig weighing 4000 gm. 
Thus the weight was transferred to human beings and the approximate 
quantity necessary to render a child immune was thus determined. At 
present two men are prominent in this work, Behring and Aronson. 
Both have prepared so-called “ Heilserum.” Another kind of serum 
prepared is called “ Immunisirungs-Losung.” The former is healing 
serum, powerful, and is to be applied where diphtheria has already 
manifested itself. The latter serum is to be used as a prophylactic. 
While in Berlin last summer I was permitted to see cases of diph- 
theria in the Institut fur Infektions-Krankheiten, through courtesy of 
Dr. Wasserman—five malignant cases, all of which recovered. 
It is proper to state that the so-called Koch’s Institute for Infectious 
Diseases was erected at the time of the tuberculin era, and is still used for 
this purpose. In this institute Behring’s serum only is used. The 
largest Children’s Hospital for Infectious Diseases is under the director- 
ship of Prof. Baginsky—known as the Kaiser und Kaiserin Friedrich 
Kinderkrankenhaus, where Aronson’s serum only has been used. 
Extended courtesies by Prof. Baginsky and Dr. Hans Aronson gave 
me opportunity of acquainting myself with the method and details of 
antitoxine. I need only refer to statistics given to me by Prof. Baginsky, 
who stated that, averaging all mild and malignant cases, the mortality 
was in three years from 1890-93 out of 1081 cases of diphtheria treated 
421 deaths, or 38.9 per cent, mortality. 
From January 1 to March 14, 1894, there were 86 cases, with 38 
deaths, a mortality equal to 41.8 per cent. On March 14th Aronson’s 
antitoxine was first used, and until June 20th there were 128 cases treated 
with the same remedy—of these 128 cases, 17 died, or a mortality of 
13.2 per cent. 
Baginsky’s statement is well worth repeating, that “We have never 
had such a low mortality with our mildest epidemics and our best form 
of treatment.” 
The following cases treated by me will serve to illustrate how antitoxine 
was used, and the results : 
Case I.—Dora T., aged eleven years, a healthy, well-nourished girl, 
had been ill about one day. In an adjoining room, a boy, aged fifteen 
years, was sick with diphtheria. My patient was exposed, and her mother 
examined her throat and discovered patches. When I first saw her I 
found the temperature in the axilla 102|° F. There was intense thirst, 
general pains in the body, marked malaise, dysphagia, and a headache. 
Pseudo-membranes covered both right and left tonsils and the posterior 
pharyngeal wall. I ordered a placebo. 
I first made a culture from the throat, the report proved Klebs-Loefiler 
bacilli, verifying the clinical diagnosis. I then injected 5 c.c. of serum, 
in the presence of Dr. Gerlach, of the New York Post-Graduate Hospital, 
with a small hypodermatic syringe, at which injection some serum was FISCHER: ANTITOXINE IN DIPHTHERIA. 
3 
wasted. I then took a better syringe, and injected 5 c.c. of Aronson’s 
serum in the back by pinching a fold of skin between the shoulder- 
blades. No reaction followed. The next day my patient was greatly 
improved. Greenish-yellow pseudo-membranes remained about two 
days following the injection, and on the third day no traces of membranes 
were visible, although the pharynx and tonsils were still inflamed. On 
the fourth day no sign of the disease remained, and the little girl was up 
and hungry. The general malaise seemed to pass off about one day 
after the injection. 
This patient was attacked much more severely than the first child 
that infected her. A careful examination of the urine was made. 
Albumin sparingly and an excess of phosphates were present. The 
trace of albumin also disappeared. No reaction followed the injection 
of antitoxine. 
Case II.—H. F., aged two years and two months; had never been 
sick until October 16th ; examination by Dr. Berger showed lungs 
normal; temperature 102° F.; severe inflammation of pharynx and 
tonsils on both sides. The following day a slight grayish-white pseudo- 
membrane was visible; the temperature remained 102° F.; the child 
was apparently very sick. 
On the following day the child showed signs of dyspnoea ; this con- 
tinued until October 18th, when the temperature rose to 103° F.; cough 
appeared; pseudo-membrane extended to both tonsils, pharynx, and 
uvula; evening temperature rose to 104° F.; severe laryngeal stenosis;, 
pulse 140 ; left lung behind showed sign of dulness. October 19th, 
child very restless; urgent dyspnoea, which necessitated intubation. The 
latter was done by Dr. Isaac M. Ilottenberg, who pronounced it a septic 
case and gave a grave prognosis. It was also agreed by Dr. Goldberger 
that no chance of recovery existed. At 2 p.m., on October 19th, 20 c.c. 
of Aronson’s antitoxine was injected by me in the intra-scapular region 
in the presence of Dr. Berger. The child seemed to breathe easier after 
intubation, but passed a restless night. Injection of antitoxine showed 
no local reaction. October 20th, temperature 103° F., pulse 120; 
slight dulness on percussion ; pseudo-membranes appear the same. On 
the night of October 20th the child appeared easier; breathing less 
difficult; temperature 102° F. ; pulse 110. On the following day, about 
forty eight hours after injection of antitoxine, it was decided to extubate, 
as all grave symptoms seemed to have subsided. The respiration im- 
proved hourly, and the membrane commenced to melt away. Tem- 
perature (evening) was 101° F., pulse normal. On October 21st there 
was noticed a few small pinpoint disseminated plaques on pharynx, 
looking like tonsillitis follicularis in contrast to one huge mass of grayish- 
white membrane completely hiding the pharynx and tonsils and uvula. 
On October 22d, temperature and pulse normal, no macroscopic evidence 
of local disease, and child apparently well and discharged as cured. 
This is the most striking case of all, and astounded the attending phy- 
sicians, as this case was considered hopeless and beyond medical control. 
Case III.—Child; he was seen in consultation with Dr. S. Cohn. 
Diagnosis, laryngeal croup (diphtheritic). The usual harsh, ringing, 
croupy cough was distinctly noticeable, and it appeared that unless in- 
tubation was rapidly performed asphyxia might result. At midnight 
10 c.c. of Aronson’s serum was injected by me into the intra-scapular 4 
FISCHER: ANTITOXIN E IN DIPHTHERIA. 
region. This was not followed by any local reaction. Child improved 
gradually, and although no further medication was used, was reported 
well on the second day. This was one of the worst cases, for the laryn- 
geal symptoms were well marked, besides the elevated temperature. 
Case IV.—F. V., aged six-and-a-half yeai’s, predisposed to catari'hal 
tonsillitis; taken sick November 11th. Mother discovered white deposit 
on tonsils. Sent for Dr. Valentine on November 12th. Examination 
showed that right tonsil was completely covei'ed with a thick membranous 
deposit, and also a long narrow deposit on the mucous membrane cover- 
ing palato-pharyngeus muscle behind left tonsil, which moved up and 
down with it. The postnasal cavities were plugged. Axillai’y tempera- 
ture, 101.4° F., pulse 120. 
November 13th. Both tonsils more swollen ; left one also well covered 
with membranous deposit. Discharge from nose thick, tenacious, and 
profuse. Pain in right ear, back of neck, and back of head. Child 
drowsy. A. M. temperature 101.4° ; pulse 120, p. m. 101.6°; pulse 120. 
1 Qth. Attempted to pull membrane off with forceps, which latter 
slipped, and bleeding resulted. Extension on anterior fauces in front 
of left tonsil, and in front of uvula. Nares absolutely occluded. 
I saw the case about 6 p. m. and injected 20 c.c. of antitoxine of the 
strength of 1000 antitoxine normal units, in the presence of the nurse 
and Dr. Valentine. The injection was thrown deeply into the connec- 
tive tissue of the inter-scapular region to the left of the spine. Tem- 
perature at time of injection, 102° ; pulse, 120, at 6 p. m. At 9 p. m. FISCHER : ANTITOXINE IN DIPHTHERIA. 
5 
of same evening, three hours later, temperature fell to 100.4° ; pulse, 
114. Extension of membrane to roof of mouth upward from left tonsil 
about an inch long and three-quarters of an inch broad. The cervical 
glands swollen on left side. Bloody mucus from left nostril. All 
former medication stopped and nurse directed to swab the throat hourly 
with a 1:2000 bichloride of mercury solution. The new membrane 
discovered in the morning looked shrunken, and there was no fresh 
deposit. Right tonsil less swollen. 5 A. m. Temperture, 99° ; pulse, 
100. No new membrane in throat, but continual shrinkage in size and 
thickness. Pulse weak and irregular. Stimulants hourly. The mem- 
brane melting, and the tonsils assuming normal shape and size; the 
swelling of cervical glands lessened. Patient feeling well. Nourishment 
every two hours, succeeded by teaspoonful of bovinine. Stimulants 
hourly, from ’Thursday morning until Saturday morning. Nasal irriga- 
tion was done every three hours, with lukewarm normal saline solution. 
Two immense plugs of membrane were discharged from nose. The nasal 
passages remained clear. Treatment was continued by Dr. Valentine. 
The diagnosis in all cases was confirmed by a bacteriological culture 
made by removing a small particle of membrane from portion which 
appeared oldest, and stroking over agar-agar or blood-serum, and 
placing in the thermostat. In some instances I submitted inocula- 
tions to other bacteriologists and sent cultures to New York Health 
Department.1 
Case V.—A. H., aged nine years, first complained of being unwell 
Saturday, October 6th ; general malaise, feverish and debilitated, loss of 
appetite, disposed to keep the recumbent posture. Was first seen Sun- 
day morning October 7th. Debility extreme. Skin hot and dry. 
Temperature 102°. Pulse 120. Coated tongue, foul breath, and ex- 
amination showed a mass of exudation Avhich completely filled the 
fauces ; nasal breathing obstructed. Diphtheria of a low type diagnos- 
ticated. Put upon the bichloride and tine, f'erri chi. npv, every 
three hours, and throat sprayed hourly with weak solution of chloride, 
and for nourishment whiskey punch freely. Made culture and for- 
warded to Board of Health. Secured five grammes of antitoxine and gave 
the whole amount in one injection between shoulder-blades. This was 
accomplished at 7 p.m. Sunday, when the disease had been present at least 
forty-eight hours, possibly seventy-two hours, in view of the extent of sur- 
face involved by the exudate, although no attention was called to the throat 
until the morning of the day that the antitoxine was used. No reaction 
followed the injection. Patient passed a feverish, restless night, and was 
found no better Monday morning. Report on culture from Board of 
Health, “ true diphtheria.” Cadaveric odor from throat almost intoler- 
able. Heart action weak and debility even more pronounced than oh 
previous day. Temperature 100.5° to 102°. Pulse feeble, 120. Posi- 
tively refuses to take stimulant in any form by mouth. Condition of 
throat makes deglutition difficult. Appearance of exudate about the 
same as at the time of the injection the night before. Directed continu- 
ance of bichloride treatment and was hourly rubbed and bathed in hot 
1 To-Miss Philipps, the nurse in charge of this case, I am greatly indebted tor the accurate 
report, and for temperature, pulse and respiration charts. 6 
FISCHER: ANTITOXINE IN DIPHTHERIA. 
brandy, keeping hot brandied cloths to bowels continuously. Monday 
evening no progress noted and the case assuming a grave aspect. 
Prognosis unfavorable. New remedy considered inert. 
Tuesday morning (thirty-six hours after the use of antitoxine) evident 
change for the better. Temperature steadily falling. Pulse stronger. 
Tongue cleaner. Exudate loosening at edges, and surrounding parts 
look bright and healthy. Improvement continued through the day. 
Free flow of saliva and mucus from throat, but no membrane exfoliated. 
It appears thinner and is evidently melting. More comfortable night 
and evidences of gain in every way. 
Wednesday morning. Temperature nearly normal. Pulse 86. Odor 
from throat nearly gone and membrane rapidly disappearing. Can see 
underlying surface, and whole appearance is fresh and healthy. No 
masses or flakes of membrane were loosened or coughed up. It all 
appears to be melting away. 
Thursday. Temperature touched normal. Pulse 86. Throat nearly 
clear. Nasal passages much freer. Patient declares himself well, and 
his general tone is excellent. Hungry and calling for solids. Urine 
examined and found free from albumin. 
Friday. All visible throat free from exudate. Tongue slightly 
coated, but moist on edges. Breath entirely free from odor. Tempera- 
ture 97.5° to 99°. Report on culture taken on Thursday, Loeffler’s 
bacilli still present. 
Saturday. Child to all appearances well. Throat normal. Nasal 
passages open. No evidence of the disease about him. Temperature 
averaging normal. 
Sunday. One week from the use of the antitoxine. Would declare 
the child quite well, but find report on culture reads, bacilli still pres- 
ent. Kept child quarantined and in bed for ensuing week, and on 
eleventh day sent culture to the laboratories of both New York and 
Brooklyn Boards of Health to secure comparative tests. Reports from 
both read, bacilli present. Persistent nutrition kept up and throat 
sprayed with Seiler’s solution and the bichloride alternately. 
Seventeenth day. Sent another culture, and same report is returned. 
Have not detected any evidence of the disease since Saturday, October 
13th, six days after hypodermatic was given, but culture made on 23d 
inst. still shows characteristic bacilli, and this return was made on 
every culture until the twenty-first day, when the Board of Health 
declared them absent. No albumin found save on eighth day, and then 
only a trace. 
(The last case is published by permission of Dr. Catlin, of Brooklyn.) 
GEO. EE)MOLD, /V. V. 
The syringe used consists of an ordinary glass barrel like any. ordi- 
nary aspirating syringe, but the fittings are made with asbestos and FISCHER: ANTITOXINE IN DIPHTHERIA. 
7 
linoleum. I have tried to do away with the linoleum, and have had 
Mr. Ermold construct the syringe of asbestos only. It can easily be 
sterilized by boiling. The syringe holds about 10 c.cm. or enough for 
one hypodermatic injection of antitoxine. The calibre of the needles is 
very large owing to the thick consistence of the serum. 
In looking over my list of cases I find that the most instructive were 
Case V., in consultation with Dr. Catlin, of Brooklyn, Case II., in con- 
sultation with Dr. Berger, of New York, and Case IV., in consultation 
with Dr. Valentine, of Brooklyn, 
The most rapid result was achieved in Case III., in consultation with 
Dr. S. Cohn of this city; laryngeal symptoms subsided in about 
twelve hours. The following cases were treated in the Municipal 
Hospital of Philadelphia, through the courtesy of Dr. Welch, physician 
in chief, and Dr. Bemis, house physician: 
Case I.—F. N., two and-a half years old, white, female, of Russian 
descent, had been ill a little longer than forty-eight hours when admitted 
to the hospital, October 2d. On admission the tonsils were large, in- 
flamed, and covered with an extensive exudate, dark-gray in color, and 
the breath was fetid. There was also involvement of both nares. The 
glands of the neck were somewhat enlarged, and the color of the face 
was pale and sallow. The temperature was 100.2°; pulse, 124; the 
respirations, 24. Ten cubic centimetres of the antitoxine were injected 
at 6 p.m. (the day of admission). During the following twenty-four 
hours the temperature was recorded hourly, and varied between 99° and 
101.4°; the pulse between 100 and 138 beats per minute; the respira- 
tions were from 16 to 28 The exudate in the fauces continued un- 
changed ; there was free discharge from both nares; the greater part of 
the time this discharge consisted largely of blood. There was also 
oozing of blood from the mouth; the breath was fetid; the pallor was 
increasing and of a leaden hue. On November 4th the exudate in the 
fauces was unchanged ; there was considerable epistaxis ; the glands in 
the neck were enlarging; the temperature ranged from 98° to 100° ; the 
pulse was 120 ; the respirations about 36. On November 5th the exu- 
date in the fauces was not diminished; there was continued epistaxis; 
the breath was still fetid; the glands in the neck were even larger; there 
were some purpuric spots on the face ; the color was very pale; prostra- 
tion was great; the temperature ranged from 100.6° to 102.6°; the pulse 
was 140; the respirations, 28. At 1 p.m. of this day a dose of the 
stronger preparation of Aronson’s antitoxine was injected by me. At 7 
p.m. of the same day the condition of the patient was unchanged. For 
twenty-four hours after the first injection no other treatment was em- 
ployed except the liberal use of milk and stimulants. Subsequently 
tincture of ferric chloride and mercuric chloride were given every two 
hours, and hydrogen dioxide applied locally every hour to the nares and 
fauces; strychnine sulphate, gr. y-J-y, was also given every six hours, 
continuing, of course, the free use of milk and whiskey. 
On November 6th the exudate in the fauces was thinner, though still 
dark in color; blood was slowly dropping from the nose; the glands in 
the neck were somewhat diminished in size ; the temperature, pulse, and 
respiration were unchanged. The pulse had considerable volume. Ex- 8 
FISCHER; ANTITOXINE IN DIPHTHERIA. 
haustion had not increased, and the child took nourishment freely. On 
November 7th the exudate in the fauces had increased since the previous 
day, and a few small purpuric spots remained on the face. Epistaxis 
had ceased, though the nose was somewhat moist from blood. A large 
ecchymosis on the thigh appeared where the first dose of antitoxine 
was injected; the temperature was about the same, and the pulse was 
very weak indeed, just barely perceptible at the wrist, and could not be 
counted. The extremities were cold, the face pale and livid, and there 
was great drowsiness. The child was disinclined to take nourishment; 
there had been no bowel movement for twenty-four hours. Tinct. ferri 
chloridi and hydrarg. chlor. corrosiv. were continued every two hours, 
and hydrogen dioxide was applied to the throat. Strych. sulph., gr. 
To"ir> every four hours, and whiskey and milk were ordered at short in- 
tervals. At 12 midnight, gr. strychnine sulph. was given hypoder- 
matically. 
On November 8th the exudate in the fauces had very much increased, 
covering not only the tonsils, uvula, and the anterior half-arches, but 
extending forward in front of the uvula. The exudate in the nares was 
also increasing; the glands in the neck were sensitive but not swollen. 
The temperature ranged between 97.6° and 99.8°; the pulse was just 
barely perceptible at the wrist; the heart’s action was feeble, and the 
extremities were cold. In spite of this condition the child appeared 
bright and took milk fairly well. Strychnine sulph., gr. jfa, was or- 
dered every three hours until two or three doses should be given. 
At 5.20 a.m., 10 c.c. of Behring’s antitoxine were injected. At 6.10 
p.m., sulphuric ether npxv, was given hypodermatically, also at mid- 
night gr. strychnine sulph. hypodermatically. On November 9th 
the exudate in the fauces was very much diminished; the heart’s action 
was very weak, the pulse just perceptible at the wrist, but could not be 
counted. The temperature was about the same. The expression of the 
child was bright, but it took nourishment less willingly. There had 
been no bleeding from the nose for three days. Injections of strych- 
nine were continued, gr. every four hours, and artificial heat was 
applied to extremities. At 2 p.m., 10 c.c. of Behring’s antitoxine were 
again injected. 
On November 10th there was still considerable exudate in the fauces 
and also in the nares; the heart’s action was feeble, and the pulse at 
the wrist was still almost imperceptible; the extremities were cold, and 
the child took nourishment and stimulants somewhat reluctantly. Three 
hypodermatic injections of strychnine sulph. of a grain, were made in 
the last twenty four hours. The child’s expression, when awake, was 
quite bright. The heart-sounds were growing less and less audible, and 
death occurred at 10 p.m. from asthenia. 
Case II.—E. G. T., aged two years and eight months, white, female, 
born in Philadelphia, was admitted to the hospital October 2d, having a 
well-marked exudate on both tonsils and in one of the nasal cavities, of 
less than forty-eight hours’ standing. At 6.10 p.m. on the day of admis- 
sion 10 c.c. of Behring’s antitoxine were injected. During the follow- 
ing twenty-four hours the temperature varied between 99° and 100.8°, 
being about the same as before the injection was administered; the pulse- 
rate was between 120 and 135; the respirations were from 20 to 30. 
The exudate on the tonsils seemed unchanged, as did that in the nose, 
except that the discharge from the nares was slightly less. On Novem- FISCHER: ANTITOXINE IN DIPHTHERIA. 
9 
ber 4th the exudate in the fauces and nares had neither extended nor 
diminished; the temperature was unchanged; the pulse-rate and res- 
pirations were about the same. On November 5th the exudate in the 
fauces and nares was unchanged, except that both nares were now in- 
volved ; the glands in the neck were only very slightly swollen; the 
general condition of the child remained about the same as when the 
injection was given, with slight improvement. The child received the 
same internal and local treatment as the previous case, and took nour- 
ishment freely. 
On November 6th there was but little change in the exudate in the 
fauces; the temperature had risen to 101.6°, and the rash of scarlatina 
had appeared. A sister of this child had developed scarlet fever two 
days previously. On November 7th the exudate was diminishing both 
in the fauces and nares; the temperature ranged between 100.8° and 
101.8°; the pulse was 120. On November 8th the exudate in the 
fauces had disappeared; in the nose it was dry and much less distinct; 
the temperature was 101°. On November 9th there was no exudate in 
the fauces, and very little in the nose. The rash of scarlet fever was 
just barely characteristic. The child’s 'general condition was much im- 
proved, and she had quite recovered from the diphtheria. The attack of 
scarlatina was very mild. 
On November 12th gradual improvement was noted, and there was no 
exudate in the fauces, but there was still a very little in one nasal cavity. 
The temperature was about normal, and, from the time the scarlet 
fever began, it had not been higher than 101.8°. The pulse was 120. 
Desquamation commenced on this date. The child took nourishment 
well. 
Case III.—A. J., thirteen years of age, colored, was admitted No- 
vember 3d, having been ill four days. The exudate in the fauces covered 
the tonsils, the anterior half-arches, and the uvula completely. The 
temperature was 101.6°, the pulse 100, the respiration 28. There was 
only one very slight enlargement of the glands of the neck. There was no 
nasal involvement. Tinct. ferri chloridi and hydrarg. chlor. corros. were 
given internally every two hours, and hydrogen dioxide was applied 
locally every two hours. On November 4th the condition of the fauces 
remained unchanged; the temperature was 99.2°, the pulse 86, the 
respiration 25. A 1 per cent, solution of formalin was applied to the 
throat every two hours alternately with the hydrogen dioxide. On 
November 5th the exudate in the fauces remained the same; there was 
no increase of swelling of the glands of the neck ; the temperature 
was 99°, the pulse 88, the respiration 20. There was very little exhaus- 
tion, and the child took nourishment well. At 1.10 p.m. I injected 10 
c.c. of Behring’s antitoxine (a bacteriologic examination was made by Dr. 
Kyle, and typical bacilli were found). Following this the temperature 
ranged between 100° and 106°. On November 6th the exudate in the 
fauces continued much the same, though somewhat thinner on the uvula. 
The temperature ranged from 98.4° and 98.8° to 100.8° ; the pulse was 
about 90, the respiration about 20. The same internal and local treat- 
ment was continued ; the child took nourishment and stimulants freely. 
On November 7th the exudate in the fauces had greatly diminished; the 
temperature was 99.4°, the pulse ranged from 80 to 90, the respiration 
was 18; nourishment was taken as usual, and the patient slept well. On 
November 8th the exudate was diminishing rapidly, the swelling of the 10 
FISCHER: ANTITOXINE IN DIPHTHERIA. 
uvula was much less, and exhaustion was not great. On November 9th 
the exudate was much thinner and had disappeared in part, though con- 
siderable still remained. The same local and internal treatment was 
continued. The patient was now doing very well, and was placed on the 
regular house-diet. 
On November 10th the general condition continued favorable; the 
fauces were quite free from exudate, but a little still remained on the 
uvula. Albumin continued in the urine in the same proportion. 
On November 11th there was no exudate in the fauces except a little 
on the uvula; the temperature and pulse were about normal; the child 
took nourishment well, and strength was increasing. On November 12th 
there was a mere trace of exudation on the uvula; the temperature 
ranged between 98° and 100° ; the pulse and respiration were about 
normal. The child was anxious to sit up. 
Case IY.—B. M., white, male, aged five years, was admitted October 
18th, on the third day of the disease. The exudate in the fauces was 
very great, covering the tonsils, the uvula, the anterior half-arches, and 
extending on the roof of the mouth in front of the uvula; there was 
also nasal involvement. The glands of the neck were enlarged. On 
October 19th the child was bleeding from the nose and mouth. On No- 
vember 20th the exudate was unchanged, and there were croupy symp- 
toms. On October 23d the general condition was about the same; the 
albumin on this date was about 60 per cent, of the bulk of the urine. 
The temperature had been running from 101° to 102°, the pulse from 
100 to 118, the respiration from 22 to 26. On October 25th the exudate 
had diminished and epistaxis has ceased. The temperature was about 
99°, the pulse 100, and the albumin was only 10 per cent, by bulk. On 
October 30th the fauces were almost free from exudate; no albumin was 
found in the urine; the temperature was about normal, sometimes sub- 
normal ; the pulse ranged from 96 to 100. There were marked evidences 
of toxemia; there was great pallor and weak heart-action. On No- 
vember 5th the temperature had been ranging from 100° to 102.6°; 
there was no albumin in the urine; the pulse was from 98 to 112. There 
was a mere trace of exudate in the fauces, and still some nasal involve- 
ment ; the pallor and prostration continued; there was a feeble pulse, 
and the cervical glands were still enlarged. There was an herpetic erup- 
tion on the lips. At 1.30 p.m. I injected 10 c.c. of Behring’s antitoxine, 
the Klebs-Loeffler bacteria having been found to be present by Dr. 
Kyle. On November 9th the patient was gradually improving; the 
temperature was from 98.6° to 100° ; the pulse from 90 to 120; no exu- 
date existed in the fauces, and that in the nares was gradually growing 
less ; the color was also improving, and the child took nourishment well. 
The general condition was much improved. 
On November 12th the fauces were entirely free from exudate, and 
only a very little remained in the nares; the temperature was 98.6°. 
No albumin had been found in the urine for several days past. The 
child was constantly improving. 
On November 15th no exudate could be seen in the fauces, but the 
nares had not quite assumed their normal appearance. The tempera- 
ture and pulse were normal, and the appetite was good. The urine 
continued free from albumin. On November 19th the patient sat up 
a short while for the first time; the improvement continued, although 
the circulation was feeble and the pallor extreme. The fauces, with FISCHER: ANTITOXINE IN DIPHTHERIA. 
11 
the exception of marked redness, seemed healthy, but the nares were 
still somewhat abnormal. The appetite continued good, and the patient 
had apparently gained in weight. Jn this, as well as in the preced- 
ing cases, tincture of ferric chloride was continued three times daily, 
together with a nutritious diet. 
On November 20th the child was somewhat indisposed, and the 
temperature was found to be 101°. During the two preceding days the 
patient had been sitting up. 
On November 21st a rubelloid rash covering the trunk and extrem- 
ities appeared. The temperature fell to normal, or nearly so, and the 
appetite was as usual. There were no catarrhal symptoms. 
On November 23d the temperature continued normal, and the rash 
had entirely disappeared, without leaving the mottled condition of the 
skin peculiar to measles; hence the diagnosis of that disease must be 
excluded. There was no albumin in the urine, but there was slight 
evidence of paralysis. 
Case V.—A w'hite male, eight years of age, was admitted November 
9th, having been ill seven days. The exudate in the fauces covered the 
tonsils, the anterior half-arches, and the uvula, and extended a short 
distance on the roof of the mouth in front of the uvula ; both nares were 
also involved. The breath was offensive; the glands on both sides of 
the neck were considerably enlarged, and the skin over the swollen 
glands was red. The temperature was 102.8°, the pulse 136, the respira- 
tion 36. Ten c.c. of Behring’s antitoxine were injected under the skin 
on the back at 12 o’clock m. by me. The patient was at this time 
taking internally about 6 minims tinct. ferri chlorid. and gr. of mer- 
curic chloride every two hours; locally, hydrogen dioxide undiluted, 
alternately with a one per cent, solution of formalin, was applied every 
hour, whiskey every two hours, and milk ad libitum. On November 
10th the temperature was 100°, the pulse 120, the respiration 32. The 
exudate in the fauces remained about the same, except that it presented 
the appearance of peeling off in some places; in the nares the exudate 
was unchanged ; the glandular swelling also remained about the same. 
The child at times was drowsy, and at other times restless. 
On November 11th the exudate in the fauces and nares remained 
about the same; it was still dark in color and the breath was offensive. 
The glandular swelling had not increased. The temperature was about 
100°, the pulse 128, the respiration 32. Albumin was found in the 
urine in the proportion of about one-tenth part of the bulk of the urine. 
The child took nourishment well. 
On November 12th there was very little, if any, change in the exudate 
in the fauces and nares ; at times there was slight epistaxis. The tem- 
perature was 99.8°, the pulse 116, the respiration 26. There was no 
increase of the glandular enlargement; exhaustion was not great; and 
the child continued to take nourishment and to rest well. 
On November 13th the exudate in the fauces was somewhat thinner, 
and that in the nares also seemed to be slightly diminished. The 
temperature ranged between 98.4° and 99.6° F.; the pulse was more 
feeble, but the respirations were unchanged. Nourishment was taken, 
though somewhat reluctantly, and vomiting occurred once or twice. 
The heart’s action was weak and the extremities were growing cold. 
Strychnine sulphate was ordered in doses of gr. every four hours, 
and the whiskey was increased. On November 14th the exudate in 12 
FISCHER : ANTITOXINE IN DIPHTHERIA. 
the fauces had diminished still further; the pulse ranged from 96 to 
104, and was almost imperceptible at the wrist; the respirations ranged 
from 20 to 30; the temperature ranged from 98° to 98.4°. Albumin 
was found to be present in the urine (about 2 per cent, by bulk). 
The extremities were constantly growing colder; vomiting was occur- 
ring occasionally; the child took nourishment and medicines more 
reluctantly; the pallor of the face was increasing, and the patient 
was rapidly losing strength. Spiritus ammonii aromaticus in fgss doses 
was ordered every half hour, and strychnine sulphate, gr. hypo- 
dermatically, every four hours. The exhaustion progressively increased, 
and death occurred from toxemia at 10 o’clock p.m. 
In conclusion I desire to say that many of my cases not reported are 
from private families who begged me not to publish them ; from several 
other cases my detailed reports are lacking—these will be published later. 
To sum up: I have injected in all 34 cases; of these 29 were malig- 
nant cases, in which a grave prognosis was given by the attending physi- 
cian or by myself in consultation ; 4 were mild cases in the commencement 
of the disease, and one case was moribund. 
By malignant I mean cases that had either distinct evidence of sepsis, 
showing low temperatures or very high temperatures, and where marked 
somnolence was evident, where cervical glands were considerably en- 
larged, and where at times the skin showed, in addition to cold, clammy 
perspiration, a decided icteric appearance; where there was also a foul 
mouth, a distinct cadaveric breath, and where only a grave prognosis was 
given. Such cases not only showed pharynx, tonsils, and uvula involved, 
but also symptoms of stenosis of the larynx and occlusion of the nares. 
By mild I mean such cases as were seen on the first few days of illness, 
where the membranes were limited to either small areas of the pharynx, 
tonsils, or uvula, and where no complications of larynx and nares were 
observed. Mild cases were also those in which small quantities of albu- 
min in the urine were noticed, and where no pulmonary or distinct 
nephritic complications could be diagnosticated. 
The moribund case referred to was the one seen in consultation with 
Dr. Welch at the Municipal Hospital of Philadelphia, and the child 
not only was pulseless, but had cold extremities and showed marked 
evidence of general septicaemia. Still it lingered a number of days, 
showing the influence of the strong Aronson serum in neutralizing the 
toxic elements. 
I have had 34 cases—30 malignant and 4 mild—32 of which recov- 
ered. I have 32 cures and 2 deaths—in all 34 cases treated, or a mor- 
tality of 5.8 per cent. 
These cases were not selected, for some were poorly nourished, some 
in excellent vitality, with careful nursing, good hygiene. The main 
point was to apply the antitoxine as early as possible, and counteract 
the septic matter absorbed, and thereby avoid complications, besides FISCHER: ANTITOXINE IN DIPHTHERIA. 
13 
using the local treatment of swabbing the throat with a 1: 2000 bichlo- 
ride of mercury solution, using a fresh swab for each application, and 
burning the same immediately after using it. 
The technique of injection is simple. Having properly sterilized the 
syringe by boiling and using 0.5 per cent, tricresol, I commence by 
injecting 10 c.c. in mild cases, and 20 c.c. in malignant cases, by pinch- 
ing a fold of the skin in the intra-scapular region, and allowing the 
serum to be slowly injected. I believe it proper, however, to have a 
syringe of suitable size and inject the required amount, rather than 
inject several places. The calibre of the latter must necessarily be 
quite large, owing to the thickness of the serum, which is at times rather 
mucilaginous. It is proper to note all differences and effects on the 
false membrane and the swelling of the glands, the behavior of the 
temperature, the condition of the urine, the effect on the heart, and 
especially the pulse. 
There should be no hesitation in injecting on the second day, and, if 
no effect is seen, repeating the injection on the third day, as there is 
absolutely no risk from the injection. It is a perfectly safe remedy, and 
shows no immediate reaction. It differs from tuberculin and vaccine in 
that it causes no reaction. A case of antitoxine treatment will show no 
symptoms directly attributable to the remedy, unless it be in some cases 
urticaria. The temperature does not fall by crisis, but by lysis, with 
antitoxine treatment. Massage of the serum after the injection should 
not be practised, according to Heubner, Aronson, Baginsky, and others. 
Let us not lose sight of the fact that in the use of this new agent we 
are treating diphtheria, and that all discharges, be they from the nose, 
throat, or mouth, and possibly feces and other excrements, should be 
subjected to a rigid disinfection. This, if possible, before leaving the 
body. For this purpose local swabbing of all visible membranes with 
a 1: 2000 bichloride of mercury solution, using glass rods with absor- 
bent cotton—the latter to be burned immediately after swabbing ; the 
glass rod to be put into bichloride solution. We still require most 
thorough naso-pharyngeal antisepsis for this purpose, lukewarm (105° 
to 110° F.) normal table-salt solution, injecting either nostril until the 
stream flows out of the other side, using considerable force at times. 
Great attention must be paid to the recumbent posture, which has been 
so strongly advocated in Berlin, especially so where the patient’s heart 
is weak from diphtheritic poison, and the child is douched while flat on 
its back, with a rubber sheet around its arms and neck to prevent useless 
struggling, so well known in the former method of syringing in the 
sitting posture. One nostril only need be irrigated until the saline 
solution flows out of the other side. 
Stimulation should be cautiously followed out. It should be used 
where there is weakness of pulse and where the heart’s action is slowed 14 
FISCHER: ANTITOXINS IN DIPHTHERIA. 
—then, however, it should be freely administered ; good Tokay, and 
Baginsky advises Greek wines (Mavrodaphne), and other kinds. These 
latter wines, being sweet, are very greedily taken by children. Neither 
the ice-collar nor any other form of external local application was used 
in my experience abroad or in this country with the serotherapy. 
187 Second Avenue, New York.  Jotirijal 
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