A Plea for the more Extensive Use of 
Antitoxine in Diphtheria. 
Resume of One Year's Experience. 
Indications and Contraindications for 
its Use, with Some Practical Points 
in the Application of the Same. 
BY 
LOUIS FISCHER, M.D., 
Instructor in Diseases of Children at the New York Post- 
graduate Medical School and Hospital; Visiting 
Physician to the Messiah Horae for Children ; 
Attending Physician to the Children's 
Department of the German 
Polyklinik. 
REPRINTED FROM THE 
Neto York fHelncal 
for Nov. 30 and Dec. 5, 1895. Reprinted from the New York Medical Journal 
for November 30, and December 5, 1895. 
A PLEA FOR TIIE MORE EXTENSIVE USE OF 
ANTITOXINS IN DIPHTHERIA. 
RESUME OF ONE YEAR'S EXPERIENCE. 
INDICATIONS AND CONTRAINDICATIONS FOR ITS USE, 
WITH SOME PRACTICAL POINTS 
IN THE APPLICATION OF THE SAME. 
By LOUIS FISCHER, M. D., 
INSTRUCTOR IN DISEASES OF CHILDREN 
AT THE NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL ; 
VISITING PHYSICIAN TO THE MESSIAH HOME FOR CHILDREN ; 
ATTENDING PHYSICIAN TO 
THE CHILDREN'S DEPARTMENT OF THE GERMAN POLYKLINIK. 
When, in September of last year, I had the honor of 
being invited by Professor Roosa to read a paper on anti- 
toxine before the New York Post graduate Clinical Society 
little was known of the therapeutic value of this drug on 
this side of the ocean. My experience at the time was lim- 
ited to only a few cases in this city, but by far the most 
was learned in Europe from such authorities as had been 
using the remedy in the laboratory as well as at the bed- 
side. 
The history of the manufacture of this wonderful agent 
has been so often described in detail by myself and by 
others that I do not think it wise to again rehearse it, but 
would rather speak of the practical value gained by the use 
of this remedy. 
COPYBIGHT, 1895, BY D. APPLETON AND COMPANY. 2 
ANTITOXINE IN DIPHTHERIA. 
Several papers have appeared by me from time to 
time, notably, however, the paper published in the Medical 
Record, October 6, 1894, in conjunction with a paper by 
Professor Baginski, from whom I learned the clinical value 
of this new therapeutic agent. Later, a series of papers 
appeared, with more experiences, in the Medical Record, 
November 17, 1895; also in the December issue of the 
Post graduate; a very elaborate paper in the American 
Journal of the Medical Sciences for January, 1895; then a 
very complete article, embracing in all two hundred and 
twenty-five cases, appeared in the Medical Record of April 
6, 1895. This paper was read before the German Medical 
Society of this city on March 4, 1894. 
In our country so much has been said in favor of this 
valuable remedy that what has been said against it would 
be as infinitesimal as an ordinary mortal trying to swim 
against the great tide of success! At the Munich Medical 
Congress, last April, it was the unanimous opinion that no 
remedy had up to the present time been used in diphtheria 
that, from a scientific standpoint, exerted a healing effect. 
In looking over the materia medica and studying what rem- 
edies can be used with success in diphtheria, there is not a 
single drug with which we can positively say we can cure 
diphtheria. Modern science has taught us that the local 
manifestation of the disease can be determined by making a 
culture from the pseudo-membrane, and in these cultures 
we find at times a streptococcus, at other times the strep- 
tococcus in combination with the Klebs-Loeffler bacillus, 
and again at other times we find the pure Klebs-Loeffler ba- 
cillus ; so that there are various clinical and bacteriological 
manifestations which, although appearing differently under 
the microscope, prove to the clinician that they are probably 
various forms or modified forms of the same disease, and are 
virtually combined under that one term, diphtheria. We ANTITOXINE IN DIPHTHERIA. 
3 
are, however, dealing not only with the local manifestations 
of the disease, but with the complications, and it is rare to 
find a patient with a simple, ordinary, membranous diph- 
theria-proper care being taken-to die, unless some special 
reason exists for it. Let me illustrate: If I were called to 
a robust child, in good hygienic surroundings, that had a 
slight elevation of temperature, and found a small diphthe- 
ritic patch of membrane on one or both tonsils and the 
glands of the neck swollen, if there was a good, strong, 
regular pulse, and I had a good, common-sense mother or 
nurse looking after it, I should certainly expect a recovery 
if the ordinary rules of antisepsis (antisepsis, practically 
speaking, meaning only cleanliness) were carried out; 
whether the ordinary salt solution or boric acid or perman- 
ganate of potassium were preferred would be immaterial, 
for the latter merely tend to destroy the germs on the sur- 
face and do not by any means destroy the germs in the 
deeper structures. 
In a case like the one above described I should invaria- 
bly give a good prognosis, and have found that by injecting 
five cubic centimetres of a good standard preparation of 
antitoxine I could accomplish all that was desired without 
subjecting the body to the poisonous influences of the in- 
ternal administration of bichloride of mercury. I am con- 
fident that every clinical observer can go into the wards of 
a diphtheria hospital and pick out the patients that had 
been subjected to the administration of bichloride of mer- 
cury, for there is an extreme pallor of the skin, a so-called 
anaemic appearance, which is usually recognized by the 
skilled clinician, so much so that he can recognize at once 
those cases that have received a bichloride treatment and 
those that have not. The same holds good of those cases 
treated with calomel, whether by fumigation or by its in- 
ternal administration. So much can be said for bichloride ANTITOXINE IN DIPHTHERIA. 
4 
of mercury, that enough bichloride of mercury can never 
be introduced into the body to render the blood thoroughly 
aseptic. If this could be accomplished, then we should not 
only kill the germs, but at the same time kill our patient. 
Some very interesting cases were reported by me at the 
Section in Diseases of Children of the American Medical 
Association held at Baltimore on May 8th. It was highly 
interesting to hear some very eminent gentlemen in our 
profession extol antitoxine, and to hear the almost unani- 
mous verdict in favor of this new agent during the course 
of the discussion. Let me repeat again what I wished to 
impress in my paper read at Baltimore, that antitoxine and 
blood serum are two distinct remedies, or rather, that they 
are not synonymous terms. While we may have blood 
serum manufactured and sold and labeled as antitoxine, a 
great many failures that are reported are due to the fact 
that these specimens are blood serum pure and simple, and 
do not contain any antitoxine, and hence are worthless for 
therapeutic purposes. It is therefore of the utmost impor- 
tance to have an absolutely reliable remedy before promis- 
ing any success; and how disappointed do we feel if a pa- 
tient, let me say, receives a dose of morphine to produce 
healthy refreshing sleep, and tells us the following day that 
he was awake all night, due at times to either the smallness 
of the dose or the unreliability of the drug used. If it is 
proper for practitioners all over the world to specify a cer- 
tain chemical or a certain drug and ask for it, or if it is 
proper to specify a certain brand of wine when we desire 
to get it, then I do not see why we can not specify a cer- 
tain brand of antitoxine in order to test the real merit of 
an article so valuable in the treatment of this disease. It 
is not my intention in the course of this paper to belittle 
the preparations of antitoxine manufactured and sold in 
our country; but I have had the greatest success with the ANTITOXINE IN DIPHTHERIA. 
5 
antitoxine manufactured at Berlin and tested by the Ger- 
man Government, and the results have been so satisfactory 
that I could not but continue in the present path of success. 
On April 13th I was called in consultation by Dr. New- 
field, of 111 East One Hundred and Sixteenth Street, to see 
a case with severe laryngeal, pharyngeal, tonsillar diphtheria. 
The case was seen between three and four in the afternoon 
of Saturday, and at the time that we saw it, it was evident 
that nothing but the gravest prognosis could be given. The 
child had been very ill, and although I injected five cubic cen- 
timetres of Aronson's concentrated antitoxine in the inter- 
scapular region, I told the attending physician that in my 
opinion it would be wise to hold ourselves in readiness to 
intubate the child within five or six hours if the symptoms 
of dyspnoea and laryngeal stenosis did not disappear. The 
doctor promised to meet me the following morning at eleven 
o'clock, provided I was not called on the Saturday evening 
in question, to intubate. For some reason the attending phy- 
sician was very considerate, and, not wishing to trouble me, 
as the patient was several miles from my house, called in a 
laryngologist, Dr. Emil Mayer, to perform the intubatior 
When I saw the case on Sunday morning I had the pleasure 
of meeting, besides the attending physician, Dr. Newfield, 
Dr. Emil Mayer, and Dr. N. S. Roberts. This was about 
eighteen to twenty hours after my injection of antitoxine 
had been given. Although by midnight the child had been 
intubated by Dr. Mayer, the violent coughing had forced the 
tube out, and when we saw it on Sunday morning there was 
marked depression at the scrobiculus cordis and at the jugu- 
lum on inspiration, which are such prominent symptoms of 
laryngeal stenosis wherein we almost always require either to 
intubate or to perforin tracheotomy. Through the courtesy 
of the three physicians mentioned, I was permitted to intro- 
duce a suitable tube as rapidly as possible. There was an 
immediate relief of the stenosis following the introduction 
of the tube, so much so that two days later 1 had the pleasure 
of a visit from Dr. Newfield, who told me that the child was 6 
ANTITOXINE IN DIPHTHERIA. 
absolutely well, so far as he could see; that not only had the 
stenosis of the larynx remained away since the introduction 
of the tube, but that the pseudo-membranes, which had been 
so very visible on Saturday and also on Sunday, had gradually 
melted away and disappeared. This was in all about two days 
following the injection of this one bottle of Aronson's con- 
centrated antitoxine containing five cubic centimetres. 
In all my cases my experience with intubation lias been 
uniformly good where the treatment has been combined with 
the use of antitoxine. I have thought it, however, safer 
generally to allow the tube to remain in situ three or four 
days, so that I asked the doctor to please allow the tube to 
remain in the child's throat until Thursday, which was in 
all less than four days. I removed the tube on Thursday, 
and the child has been well and remained well since that 
time. No emaciation, albuminuria, or other symptom or 
complication has arisen since then, and I believe that this 
is one of my most successful cases, or at least one of the 
usual successful class that I have been reporting from time 
to time. 
In most cases, especially where we are not dealing with 
a very intelligent class of people, I have found that the at- 
tending physician is usually bothered to administer some 
medicine, so that we have almost always been forced to 
administer a placebo in most of our cases. If a placebo is 
given we can give anything that will do neither good nor 
harm in order to quiet the minds of the parents. 
An equally instructive case is the following: W. S., three 
years old, was seen by me on the 23d of May. Previous his- 
tory: Had had measles in March, with a sequela of otitis 
media of the left ear. In the same month a case of diph- 
theria occurred in the house. The child was well until Sun- 
day, May 19th, when the first symptoms appeared. Lan- 
guor, general malaise, vomiting on Sunday and again on 
Tuesday; epistaxis every night as well as during the day on ANTITOXINE IN DIPHTHERIA. 
7 
exertion and excitement. When seen on Wednesday, the 23d 
of May, tlie child was in the following condition : Tempera- 
ture, 99'9°per rectum; pulse, 134; respiration, 22. Skin ac- 
tive and normal, bowels regular, appetite good, tongue clean; 
child very heavy-looking, peevish; swelling of the anterior 
mastoid and submaxillary glands. The throat contained a 
heavy, yellowish-gray membrane, covering the tonsils more 
on the left than on the right, the uvula, and the posterior 
pharyngeal wall. The nasal passages were involved, shown by 
a considerable expectoration and a dirty ichorous discharge 
from the nose. A bacteriological examination of the mem- 
brane showed the presence of the Klebs-Loeffler bacillus. In 
the same family two other children were found, the one with 
a severe form of acute pharyngitis and very mild septicaemia, 
but no visible membranes could be located by inspection. 
Another child showed slight patches on the pharynx and ton- 
sils, but did not have any symptoms of malaise, or a tempera- 
ture elevation, or anything which showed the presence of diph- 
theria. This child was running about in apparently good 
health, so that in this family we had the first case, which was 
very malignant; the second one, which was mild; and the third, 
which was really in the period of incubation. I injected five 
cubic centimetres of Aronson's antitoxine in the interscapu 
lar region, using the ordinary antiseptic precautions with the 
syringe as well as local disinfection of the parts to be used for 
injection, and covering the injected place with a small film of 
collodion, and irrigated the nose and as much of the throat as 
possible with the ordinary normal saline solution. The tem- 
perature rose in the evening to 101° F., which was a slight 
reaction from the injection. The child was very bright, hav- 
ing slept the whole of this afternoon. After that the im- 
provement was steady. The only point of importance was 
that the throat was practically clean four days following the 
injection. An interesting point was the condition of the 
child's temperature, which is well illustrated in the accom- 
panying temperature chart. ANTITOXINE IN DIPHTHERIA. 
9 
For the careful report in this case, as also for the sub- 
sequent taking of temperature, T am greatly indebted to Dr. 
A. Levinson. This child was given the injection in the 
presence of Dr. Nelson, Dr. Howard B. Gates, Dr. Tinley, 
Dr. Selling, and Dr. Levinson. There was also a slight 
laryngeal stenosis with a croupous cough, so that a diag- 
nosis of nasal, tonsillar, pharyngeal, uvular, and laryngeal 
diphtheria was made. This case showed such rapid im- 
provement that nothing but the antitoxine and the warm 
salt water locally was used. 
Such cases I could record by the dozen. An impor- 
tant point in conjunction with this case is the fact that a 
child which lived two flights above this one with diphtheria, 
in the same house, was attacked with a severe fever and 
convulsions. When I saw the child, which was a few days 
after I had given the injection in this case of diphtheria, 
it was practically moribund, and I pronounced the case a 
hopeless one of diphtheria. The child died before I left 
the house. I am confident that in the case in which I used 
the injection, which was of the extremest type of diph- 
theria that we have seen during this winter, the patient 
would have practically succumbed to the septic influence of 
diphtheria, for I believe that we all recognize that where 
pharyngeal, tonsillar, and uvular diphtheria exists, we can 
in a good, healthy child under good hygienic conditions 
give a fair prognosis; but that where the elements of lar- 
yngeal complication, with stenosis and croupous cough, 
exist, marked dyspnoea, with a tendency to cyanosis, with 
distinct evidence of carbonic-acid poisoning, we are justified 
in calling such cases very grave ones. The same is also 
true where we have nasal complications, for in m.y experi- 
ence nasal diphtheria has been one of the worst to com- 
bat in all the cases that I have had. 
Another equally instructive case is one which I saw 10 
ANTITOXINE'TN DIPHTHERIA. 
in consultation with Dr. S. H. Smyth, of No. 112 East 
Tenth Street, some time ago. I prefer to report the case 
from the pen of Dr. Smyth. lie writes: 
" I was sent for to see B. B., female, aged ten years, on 
May 13th. On the previous evening the child had a chill, fol- 
lowed by fever and vomiting. As she complained of sore 
throat, I made an examination and found both tonsils cov- 
ered with a dirty gray membrane. The temperature was 103°, 
pulse 120. Diagnosticated diphtheria. 
" May HtJi.-Temperature, 101°; pulse, 100. Membrane 
had extended, covering the uvula as well as the tonsils. 
There was an excoriating discharge from the nose, together 
with a croupy cough. 
" 15th.-Symptoms much the same. Breath very foetid. 
" 16th.-Dr. Fischer saw the child with me, and, concur- 
ring in the diagnosis, at my request he injected antitoxine. 
This was at 4.30 p. m. 
" 17th.-No particular change noticeable, except that the 
discharge from the nose had stopped. Temperature and pulse 
both seemed normal. 
" 18th.-Membrane began disappearing from left tonsil. 
No cough ; temperature and pulse same. 
" 19th.-Membrane disappeared entirely from tonsils, leav- 
ing the parts very red and inflamed. 
" 20th.-Membrane entirely disappeared. The child did 
well, except that the throat was somewhat painful until the 
26th, when there was a slight patch on either side of the 
uvula which disappeared entirely by the next day. After this 
the child made a steady recovery. There is no paralysis. 
There was no albumin in the urine at any time. I might say 
that a report from the health department verified the diag- 
nosis." 
In Dr. Smyth's case judicious treatment, consisting of 
hygiene, diet, and supporting treatment generally, was all 
that was necessary to complete the cure in that case. Dr. 
Smyth was very careful to use the proper local antiseptics ANTITOXINE IN DIPHTHERIA. 
11 
previously, and did not resort to antitoxine until he believed 
that the disease would extend either upward or downward, 
or until he saw that there was a nasal involvement. The 
patient, besides, was an extremely restless and nervous girl. 
In these cases so much more patience is required to apply 
the old forms of treatment, consisting of spraying or swab- 
bing the throat generally. In such cases as these the rule 
has been to administer one injection of antitoxine and await 
the effect of the same in the following thirty-six to forty- 
eight hours, and, if no marked improvement existed, then 
I have resorted to a second injection of the same dose as 
the first. 
A similar case to the one just reported I had in con- 
sultation with Dr. Bullard, which I have previously reported 
in a large series of cases in the Medical Record, April 6, 
1895. Tn Dr. Bullard's case the child struggled against 
pharyngeal irrigation, and besides absolutely refused to 
take a mixture that the attending physician prescribed, 
consisting of iron and glycerin, and finally was so obstinate 
that it refused food, and Dr. Bullard told me he believed 
that nothing would be of any service as long as the child 
remained so obstinate. The surprising benefit following 
the injection of antitoxine made by me was so marked that 
all symptoms disappeared within a few days. We gave the 
antitoxine a careful trial in Dr. Bullard's case, for we dis- 
continued all other forms of medication. 
One of the worst cases that I have attended this year 
was sent to me through the courtesy of Professor H. J. 
Boldt, and I reported it at the meeting of the Paediatric 
Section in Baltimore, May 8th: 
This child (Dr. Boldt wrote to me asking me to intubate 
the child R. on Sunday, April 7th) I saw at noon and found it 
in a condition of extreme dyspnoea, cold extremities, cold 
perspiration, sunken eyes, contracted fontanelle, gasping for 12 
ANTITOXINE IN DIPHTHERIA. 
breath. The examination showed a very weak heart sound, 
pulse feeble, little or no appetite; the bowels very loose; 
the child in extreme agony, panting for breath. The well- 
known croupous cough was occasionally heard, besides the 
familiar inspiratory crowing that we are used to hear in 
laryngeal stenosis. An inspection of the throat showed 
nothing abnormal. The tonsils, pharynx, and uvula were 
apparently clean, and but for the presence of a slight redden- 
ing I should not have pronounced it a case of diphtheria. A 
culture made and sent to the health department showed, 
however, the presence of Klebs-Loeffler bacilli. I very rapid- 
ly intubated with a No. 2 tube. The child was immediately 
relieved. The stenosis that existed seemed to gradually disap- 
pear after the reaction from the intubation subsided. Besides 
ordering a mustard bath, I gave nothing. In the evening the 
mother reported favorable progress. The child improved fair- 
ly well, slept all night, and, although we had quite some diffi- 
culty to encounter with feeding, the child was gaining strength. 
The following day I ordered rectal feeding, using the yolk of 
an egg beaten up with starch water and occasionally an emul- 
sion containing beef tea and other nutrient eneraata, and 
allowed the tube to remain undisturbed. I had found that 
after a few days the child suffered neither thirst nor hunger 
and got along very well with feeding per rectum, so that I ad- 
vised the mother to allow the mouth to remain absolutely 
dry, and when the child had very severe thirst I told her to 
place a piece of ice, surrounded by a piece of clean linen, 
in the child's mouth in order to cool it. 
In several of my cases I have been extremely successful in 
avoiding the usually fatal complication of pneumonia in the 
course of intubation cases by not feeding by the mouth, and I 
believe if more children were fed by the rectum the mortality 
in intubation cases would be greatly lessened. In this case, 
after three days, the child had improved very much, so that I 
removed the tube. The mother called on me an hour later, 
saying that the symptoms of harsh breathing and croupy cough 
(just as I had found them three days previous) had reappeared, 
and begged of me to reinsert the tube. The moment I put the ANTITOXINE IN DIPHTHERIA. 
13 
tube in situ the child's breathing was again apparently nor- 
mal, and but for the slight shock following the introduction 
of the tube there was nothing unpleasant from the reaction 
of the second intubation. I again cautioned the mother re- 
garding the feeding and allowed the child to progress in the 
natural way. Solid stools were passed once a day and some- 
times even but once in two days, and it was necessary once 
during the course of the treatment to give an enema, clean- 
ing the child's bowels, showing that a carefully administered 
enema will not only be retained but be absorbed by the rec- 
tum, and, being guided by the condition of the child's pulse 
and the heart's action, I am persuaded that this child received 
ample nourishment to give it strength. 
A very bad case was reported by me in the American 
Journal of the Medical Sciences for January, 1895, which 
was seen by me in consultation with Dr. li. K. Valentine, of 
Brooklyn. Under ordinary conditions a most fatal prog- 
nosis would have been given, and it was only judicious at- 
tendance and careful attention to details of supporting diet 
that enabled Dr. Valentine to keep his patient for three or 
four days, in a hopeless case of septic diphtheria, in a 
tolerably fair condition. The case was reported in extenso 
in the North American Journal of Homoeopathy for Febru- 
ary, 1895, to which I should like to refer for the details of 
this instructive case. The child received one injection of 
antitoxine subcutaneously in the interscapular region in the 
evening, and the following day it was so improved that the 
benefiting influence of the antitoxine was visible. Two or 
three days following the injection the doctor agreed with 
me that what had been a malignant and septic case of diph- 
theria was changed into a mild form of diphtheria-the 
pulse, heart's action, and general appearance of the child, 
previous nose-bleeding, all changed, and the child was rap- 
idly improving. The patient was discharged cured within 
a week after the injection of the antitoxine. 14 
ANTITOXINE IN DIPHTHERIA 
A very instructive case was one which I saw on July 
17, 1895, in the children's department of the German Poli- 
klinik: 
The child had been ill two days and had been attended by 
a physician who had diagnosticated fever (?). A careful exam- 
ination of the throat made by me showed the presence of 
large patches of dirty membrane covering the pharynx, the 
tonsils, the uvula, and as much of the throat above and below 
as could be seen with the naked eye. A croupy, barking, 
hoarse cough indicated the involvement of the larynx, and a 
further examination of the chest wall showed extensive dysp- 
noea; besides the general appearance of the child indicated a 
rapid carbonic-acid poisoning. There were blueness of the 
finger nails, cyanosis, and the generally livid expression of the 
child indicated that it was fast succumbing to the septic in- 
fluences of diphtheritic poison. The main thing when I first 
saw the child was to relieve the stenosis and allow a proper 
influx of oxygen into the lungs. I therefore rapidly intubated 
with the assistance of Dr. Joel. This was at 9 p. m. The 
stenosis was at once relieved and the child allowed to go to 
sleep to overcome the exhaustion following the intubation. 
After giving the usual precautions as to feeding by the mouth, 
I ordered an ice bag on the top of its head and cold spong- 
ings to the body at intervals of fifteen minutes to check the 
perspiration and to freshen the child up generally. The fol- 
lowing morning the child's breathing was much easier and 
the stenosis entirely relieved; but, as the temperature, which 
had been at the time of intubation 101°, had gone up the fol- 
lowing morning to 102°, and the pulse, which at the time of 
intubation had been 130, had gone up to 142, I decided that 
the inflammatory condition and the diphtheria generally had 
not been improved. I then injected five cubic centimetres of 
Aronson's diphtheria antitoxine in the interscapular region. 
On the evening following the injection of antitoxine the tem- 
perature still remained as in the morning, 102°, pulse was 
still 140, and there was no visible sign of improvement. The 
stenosis had been entirely relieved, judging by the quiet ANTITOXINE IN DIPHTHERIA. 
15 
breathing. The child, when I saw it, was asleep and appeared 
to rest very easily. The difficulty of feeding was manifest, and 
I gave instructions not to feed at all by the mouth, but to rely 
in this case solely on nutrient enemata. I ordered the yolk of 
an egg beaten up with starch water, alternating with starch 
water and beef tea and starch water with veal tea, made in 
the same manner as beef tea, giving an injection every two 
hours. Before administering the nutrient enema I instructed 
the mother of the child to wash the lower bowel (rectum), 
using a teacupful of ordinary Castile-soap water to cleanse 
away any faeces that might possibly be there. As in the case 
previously reported above, not only was the injection very 
easily retained, but it was necessary to inject a pint of water 
containing some glycerin in order to cause a free movement 
of the bowel on the second day following the commencement 
of the nutrient enemata. Large masses of solid faeces of a 
brownish-yellow color were passed with the enema, showing 
not only that the nourishment was well absorbed, but that it 
was easily retained until the injection was given. The pulse, 
which had before been weak, was on the second day following 
the injection of antitoxine, combined with this treatment, 
strong, full, and regular. The child appeared very bright and 
seemed to be gaining strength. This treatment had been 
continued in all for five days, when the membranes, which 
had previously completely covered the throat, as mentioned 
above, had entirely melted away. No signs of stenosis exist- 
ing, I decided to remove the tube, which was done with no 
unpleasant symptoms following. There exists to-day, about 
nine days after treatment, a slight cough and also a slight 
hoarseness, which are possibly the effects or the results of 
pressure by the intubation. The temperature is normal, the 
pulse is between 95 and 100, the appetite is ravenous, the 
bowels are regular, the urine, which had been examined sev- 
eral times, has shown only slight traces of albumin, but 
enormous quantities of phosphates or urates and casts micro- 
scopically. There has been no eruption in this case following 
the injection of the antitoxine, or any unpleasant symptom 
which could be directly or indirectly attributed to the action 16 
ANTITOXINE IN DIPHTHERIA. 
of the antitoxine. The specimen used was of the latest im- 
portation, which, as is well known, is tested at present by a 
special officer detailed from the German Government for this 
purpose. 
Cases such as have been cited I could cite by the 
score, but they would only reiterate what I have already 
carefully detailed as the effects and proper results attended 
by the use of a good and reliable antitoxine. 
A word about the syringe to be used. While there 
are at present dozens of syringes in the market, made of 
tin, zinc, and all sorts of metal, hard rubber, black and 
of other colors, I have found that the best syringe that could 
be used for the purpose is the one which has been made by 
Codman <fc Shurtleif, of Boston, of which the accompany- 
ing cut is an amply good illustration. In the administra- 
tion of antitoxine everything depends on (1) the absolute 
Codman & Shurtleff, 
Boston. 
purity of the substance used; (2) the reliability of the 
same ; (3) the administration of the proper quantity, after 
having been assured of the quality used; (4) the absolute 
sterility of all substances coming into contact with the 
antitoxine, and, first of all naturally, the syringe and its 
attachment; (5) the absolute sterility of the skin of the 
patient prior to the injection of the same ; (6) and last, 
but not least, the strictest antisepsis or asepsis of the 
operator or physician giving the injection. The syringe, 
therefore, should be boiled and properly sterilized. I pre- AXTITOXINE IX DIPHTHERIA. 
17 
fer to use a 0*5-per-cent. solution of trikresol, or, if that 
is not handy, carbolic acid of 0-5-per-cent. solution will do 
equally well. The syringe which has been constructed by 
Codman & Shurtleff consists entirely of glass and has a 
glass piston with an asbestus packing. A small, flexible 
rubber-tube attachment allows of an easier method of in- 
jection, and is well appreciated by those who have any ex- 
perience in the handling of children, and know how rest- 
lessly they will toss about, and how difficult it is at times 
to administer an injection without doing some damage to 
either the patient or to the needle. The rubber attachment, 
therefore, on this syringe is of some value, as is the small 
rubber attachments on our large aspirators, which are so 
well known in diagnosticating the presence of pus in 
suspected empyema cases. Another great advantage of 
this syringe is that the rubber can be thrown away and a 
fresh piece used with each injection, and that the glass 
syringe can be boiled in any antiseptic solution. I need 
not refer to the fact that all metal syringes, be they. of 
silver or other metal, corrode in the presence of bichloride 
of mercury, and, as the bichloride is one of the most 
favored antiseptics among physicians to-day, it is well to 
remember that this syringe, being of glass and glass only, 
can be put into bichloride as well as into any other anti- 
septic solution and stand the boiling. A disadvantage, if 
I may call it such, is that it must be handled with care, as 
we would any other instrument made of glass, on account 
of its being brittle. I have been in the habit of using a 
glass tongue spatula for examining the throat, so that the 
absolute sterility of the instrument coming in contact with 
the patient can be assured by proper disinfection after 
using it. z 
Among the most recent publications pertaining to serum 
therapy, I should like to refer to that most admirable book 18 
ANTITOXINE IN DIPHTHERIA. 
by Professor Adolph Baginsky, which details all his most 
recent experiences to date in the Kaiser and Kaiserin 
Friedrich Children's Hospital. In our country a most ex- 
cellent book has recently appeared by Dr. George M. Stern- 
berg, Surgeon General of the United States Army, entitled 
Immunity, Protective Inoculations in Infectious Diseases, 
and Serum Therapy. I have the honor of being quoted by 
Dr. Sternberg on pages 166 and 167. As recent experi- 
ences have altered some of the technical details there, I 
will first reprint from his work and then give the altera- 
tion in question. In his book he says : 
"Fischer (January, 1895) reports thirty-four cases-thirty 
malignant and four mild-treated with a mortality of two 
= 5'8 per cent. He says: 
" These cases were not selected, for some were poorly 
nourished, some in excellent vitality, with careful nursing 
and good hygiene. The main point was to apply the anti- 
toxine as early as possible, and counteract the septic matter 
absorbed, and thereby avoid complications, besides using the 
local treatment of swabbing the throat with a l-to-2,000 
bichloride-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. tri- 
kresol, I commence by injecting ten cubic centimetres in 
mild cases and twenty cubic centimetres in malignant cases, 
by pinching a fold of the skin in the interscapular 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 in several places. The 
calibre of the latter must necessarily be quite large, owing to 
the thickness of the serum, which is at times rather mucilagi- 
nous. It is proper to note all differences and effect 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. ANTITOXINE IN DIPHTHERIA. 
19 
"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 reac- 
tion. 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 of 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, accord- 
ing to Heubner, Aronson, Baginsky, and others." 
As the more recent specimens of antitoxine appeared, 
it was noted that the healing dose, or rather the dose con- 
tained in one of the small brown, glass-stoppered bottles, 
was five cubic centimetres according to the label. I have 
repeatedly measured the exact amount, and have invariably 
found that it was between five and six cubic centimetres. 
This whole quantity should be injected where the skin 
hangs very loosely, the most convenient place being the 
one in vogue in Berlin at the Kaiser and Kaiserin Fried- 
rich Children's Hospital, the interscapular region. I also 
give preference to this point for the injection because the 
child, lying face downward, does not see the needle and 
is not so quickly demoralized, and can be easily held by 
the assistants holding the shoulders and the legs of the pa- 
tient respectively. I therefore do not, as I am quoted by 
Sternberg, commence with an injection of ten cubic centi- 
metres, but rather commence with one of five cubic centi- 
metres of Aronson's concentrated antitoxine, and if then 
there is no immediate relief following, say within twenty- 
four to forty-eight hours, I repeat the same dose, giving 
the injection in the immediate neighborhood of the first 
one. I have never seen any ill effects following the injec- 
tion done under proper aseptic or antiseptic precautions. 
Professor Baginsky, of Berlin, reports but one case of ab- 20 
ANTITOXINE IN DIPHTHERIA. 
scess following the puncture. I have frequently seen pa- 
tients in private practice that had suffered an abscess fol- 
lowing the puncture of an ordinary hypodermic needle 
after receiving an injection of morphine, so that I believe 
that every careless puncture of the skin, which can by rea- 
son of septic matter on the needle carry into the body be- 
neath the skin various micro-organisms, may in this way 
form the focus for an abscess, and that the accidental in- 
jection of morphine or an'itoxine has absolutely nothing to 
do with the infected matter carried in by a dirty or some- 
times rusty needle. I invariably seal the point of punc- 
ture with a drop of flexible collodion, which I always carry 
in a small bottle having a cork with a small camel's-hair 
brush fitted in its centre, so that it is constantly moist 
with collodion and therefore does not harden. The technics 
then of the injection is so simple than any one can use it. 
The complications arising during the course of the 
antitoxine treatment of diphtheria are mainly due, as ex- 
perience has taught me, to the same causes that were for- 
merly so prevalent before antitoxine was used, so that an 
albuminuria or nephritis or paralysis in the various forms, 
resulting or coming on as a sequela to the diphtheria, 
should not be attributed offhand to the antitoxine. A 
careful study of the complications and sequelae of the sev- 
eral hundred cases which I have had has convinced me 
that, although I have seen a certain batch of cases in which 
all forms of complications ensued, another batch of cases 
would have no complications and a smooth termination 
ending in recovery and no loss of flesh, perhaps a slight 
anaemia due to the exhaustion caused by this infection 
within the body. In a previous paper in the Medical 
Record, April 6th, I have distinctly stated that albuminuria 
was sometimes seen so soon after an injection of antitoxine 
and sometimes could be made to disappear when the anti- ANTITOXINE IN DIPHTHERIA. 
21 
toxine was discontinued, and again to reappear when the anti- 
toxine was again injected, so much so that I looked upon one 
and the other as a matter of cause and effect. I should 
like to correct myself, for in a larger number of cases, with 
an equally careful observation by myself as well as my col- 
leagues, I am convinced that, although there may be im- 
purities in the antitoxine which may at times cause an irri- 
tation of the kidneys, by far my greater number of cases 
not only did not show any unpleasant effects after the in- 
jection, but even the kidneys behaved much better, and 
kidney complications, such as albuminuria, nephritis, etc., 
were, on the whole, greatly lessened and improved by this 
mode of treatment. 
I am willing to again correct myself in regard to the 
use of antitoxine in those cases of diphtheria in which a 
complicating scarlet fever arises, for I have seen a very 
good result in a child recently in which the scarlet fever 
predominated and in which the latter was a complica- 
tion to the diphtheria, which had commenced ten days 
prior to the first symptom of vomiting and twelve days 
prior to the first appearance of an eruption. The same 
holds good in a complication of measles during the course 
of a diphtheria. While I will not say that all cases of 
diphtheria with measles, as well as all cases complicated by 
diphtheria in conjunction with scarlet fever, must and do 
end well, I am willing to be placed on record as having 
seen in all from twenty to thirty cases of the so-called 
mixed infections-i. e., scarlet fever complicating diphthe- 
ria, measles complicating diphtheria, and chicken pox com- 
plicating diphtheria-in which I am confident that the worst 
symptoms were at times modified if not benefited by an 
injection of antitoxine. It all depended upon the dose 
used and also the kind of antitoxine injected. Naturally, 
an important point in the treatment of this most fatal dis- 22 
ANTITOXINE IN DIPHTHERIA. 
ease is the so-called symptomatic treatment; by that I 
mean that a sudden high fever should be looked to at 
once, and the cause of the same looked into, if possible. 
So, for example, I could cite the case of a child, which was 
under treatment for diphtheria of a malignant type, in which 
laryngeal stenosis supervened, where it was necessary to 
intubate, and in which, after the final removal of the tube, 
the child was really convalescent. On the eleventh day 
from the commencement of the treatment a sudden eleva- 
tion of temperature gave all indications of some existing 
trouble. A careful examination of both tonsils and the 
uvula showed a slight amount of dry and moist mucous 
rales ; no dullness could be made out on auscultation ; a 
slight cough existed, which later I attributed to the irrita- 
tion caused by the tube used for the intubation. Nothing else 
was found. The child, being two years old, was not ex- 
pected to expectorate as older children would, consequently 
the question of pneumonia was rather doubtful and a fur- 
ther careful examination was necessary. It was then found 
that the child had eaten oranges and cheese and drank 
some beer; in other words, a mixed and faulty diet ex- 
isted, resulting in an acute catarrhal gastric fever. Hav- 
ing corrected the gastritis, I watched the lungs for the pos- 
sible appearance of pneumonia. I determined that we 
were dealing with one of those acute septic forms of gas- 
tritis and corrected it at once. The child remained well 
after two days of treatment. It required but one careful 
irrigation of the stomach with a quart of normal saline so- 
lution to free it as much as possible from the offending 
septic material, and thus it is that these grave symptoms 
may sometimes cause death if all possible precaution is 
not used, as it had been used in the course of this serious 
trouble. 
Another equally interesting case is one which had been ANTITOXINE IN DIPHTHERIA. 
23 
seen and treated by three physicians prior to my see- 
ing it: 
I saw the case in consultation and treated it with Dr. S. 
Cohn, of this city. Prior to this the child had been intubated 
by several physicians, among them Dr. Goodman and Dr. L. 
Kohn, and had been seen by Dr. Weissberger. This child 
when I saw it had a tube within the larynx which was en- 
tirely too large, so that a great deal of trouble with dyspnoea 
arose directly from the tube. The first indication was to re- 
lieve the stenosis by removing the larger tube and placing a 
smaller one. Besides, a temperature of 105° appeared every 
evening, followed by a fall to 101° in the morning. This 
kept on for three consecutive weeks, although at the end of 
eight or nine days the temperature remained normal for three 
or four days. A careful examination of the lungs revealed a 
pneumonia, first on one side, and, after a resolution had set 
in, it was followed by the same condition of affairs on the 
other side. The pneumonia was evidently the result of 
" which is so often caused by swallow- 
ing fluids which enter the trachea and lungs through the 
tube instead of going to the oesophagus and stomach. In 
order to guard against a repetition of this in this case, and 
besides to give the child the very best opportunity to recover, 
we resorted to rectal feeding and did not give anything by 
the mouth for a number of days. The child's strength re- 
mained well; it did not lose flesh, and seemed, but for the 
anaemic condition following the diphtheria, to get well, and is 
well to-day, which is about three months since the com- 
mencement of the treatment. The urine in this case did not 
show any casts, but contained varying quantities of albumin, 
sometimes slight traces, at other times almost fifty per cent, 
of the volume, so that, although a distinct nephritis existed, 
it passed off without further treatment. A peculiar condi- 
tion of affairs was noticed the second week of the treatment 
of this case. The temperature, which had remained normal 
for two days, suddenly rose to 105°. The stomach was in 
good condition; there was no other reason for a febrile con- 24 
ANTITOXINE IN DIPHTHERIA. 
dition, excepting the possibility of a pulmonary complication. 
The question of an exanthematous eruption came up, but was 
dismissed, so that I decided to reinject the case with five cubic 
centimetres of Aronson's antitoxine. Within twelve hours 
after this injection, without any further treatment, the tem- 
perature went down to 101°, and the following day, thirty 
hours after the injection, the temperature was normal, so 
much so that Dr. Cohn and myself were led to believe that 
we were dealing with an extensive diphtheritic, membranous 
laryngo-tracheitis, for about thirty hours after this injection 
a large cast was coughed out which was about four inches 
long, which showed a complete extension of the disease from 
the larynx to the trachea and finally the bronchial tubes inot 
the smaller bronchi. 
Where a febrile condition has existed for more than a 
week following the injection of antitoxine in a given case of 
diphtheria, where the urine is quite free from albumin, where 
there is no history of an exposure to an exanthematous erup- 
tion, if all further factors, such as gastritis and other dis- 
eases, are wanting, and there is no really assignable cause 
for the existence of the fever, it has been my rule to suspect 
an extension of this pseudo-membranous condition down- 
ward, especially so where the larynx had been involved pri- 
marily, and the more so when we hear on auscultation some 
moist rales or dry rales and other signs pointing to the ex- 
istence of a bronchitis without distinct manifestations of 
the disease. In such cases I have given the most benefit 
by resorting to a second injection of antitoxine in the same 
dose as I commenced-namely, five cubic centimetres. In 
order to illustrate the fact that antitoxine can be used to 
advantage in all forms of diphtheritic processes, I desire 
to record the following case : 
A child was taken down with a severe form of diphtheritic 
croup; was attended by a physician without antitoxine and 
died. In the same house another child came down with ANTITOXINE IN DIPHTHERIA. 
25 
diphtheria about a week later. I was called on the second 
day of the disease, and but for a slight drowsy condition and 
also a small membranous deposit on the pharynx I should 
have called this a mild case of diphtheritic pharyngitis. The 
temperature did not go beyond 100° and the other factors in 
this case were so mild as merely to mark it as an ordinary case 
of mild diphtheria. The child was well as far as we could de- 
termine in about a week after the commencement of the treat- 
ment, which I have heretofore detailed. It was then that the 
trouble in this family, commenced. The mother of this child 
had been in puerperium since the second day after the com- 
mencement of her child's diphtheria. From that time it was 
noticeable that she had had fever. Her midwife used all neces- 
sary precautions, such as antiseptic irrigations and all modern 
dressings, but the temperature persisted, and the question of 
retention of placenta or other debris post partum came up. 
She finally sent for me to examine this woman. I was sur- 
prised to find a large, yellowish-white, croupous deposit cov- 
ering the external genitals as far as I could see, probably in 
all covering three or four inches of mucous membrane. The 
temperature of the woman was 105°, she was constantly 
drowsy, complained of a burning pain in and around the 
genitals, of excessive thirst, and otherwise had no further 
symptoms. On questioning her, I found that her child, four 
years of age, which had suffered with diphtheria, had slept 
on her bed every night during his illness, as sh^thought she 
could be of some service in nursing him. It was easy, there- 
fore, to associate her infected condition with that of her dis- 
eased child. The midwife had given her several doses of 
quinine on the day previous, and but for a buzzing noise in 
her ears it did not seem to relieve her condition. I ordered 
an enema of soap and warm water to clear her bowel; I used 
locally a hot solution of l-to-5,000 bichloride of mercury by 
soaking weak iodoform gauze in this solution and changed 
this antiseptic every few hours, and gave her an injection of 
ten cubic centimetres of Aronson's antitoxine. What had 
been one large, solid mass on the day of injection appeared 
to be a shriveled, loose mass of suppurating tissue on the 26 
ANTITOXINE IN DIPHTHERIA. 
following day. The temperature, which at the time of the 
injection had been 105°, came down the following morning to 
102-4°, and two days after the injection it came down to 
100-2°. Instead of the croupous deposit, there was a large 
amount of pus flowing constantly from the external genitals, 
so that it appeared as though an abscess involving the whole 
of the external and internal genital tract had been opened. 
From this time forward nothing of any importance appeared; 
the patient made a complete recovery in about two weeks 
although her temperature came down to normal on the fifth 
day after the injection. The further treatment of this case 
consisted of local antiseptic dressings of iodoform gauze, and, 
as I found a large ulceration involving the perinseum, I sent 
the case to the Post-graduate Hospital for operation. The 
patient was operated on and is entirely well. 
The second case of this kind occurred in a patient of Dr. 
S. Cohn of this city. According to the doctor, he changed 
his clothes, bathed, and used all necessary antiseptic precau- 
tions in going from one patient's house to the other. Still, 
for some unexplained reason, the patient in puerperium con- 
tracted fever, and, as he was exceedingly careful of the 
condition, he suspected at once the possibility of an infec- 
tion from an outside source. When I was called in consul- 
tation I found the patient suffering from very high fever, 
constant headaches, some pain in the abdomen, but no 
distinct evidence of any croupous or diphtheritic deposits. 
That it was a case of septic peritonitis we easily agreed, and 
it was determined to try the efficacy of antitoxine in this 
case. I therefore injected five cubic centimetres into the 
right abdominal region and gave the patient a placebo. The 
attending physician had previously used all necessary intra- 
uterine irrigations and used all careful details in the treat- 
ment of this puerperal stage, so that there could have been 
nothing but possibly an infection through some unexplained 
reason. On the following day the temperature had gone 
down two degrees, so that we were so much encouraged by 
this that the doctor asked me to give a second injection of 
antitoxine. Following this second injection the temperature ANTITOXINE IN DIPHTHERIA. 
27 
went down to 100°, and but for slight therapeutic measures 
nothing required looking after. Dr. Cohn attended to all the 
other details of her treatment and, besides giving pills con- 
taining inspissated Warburg's tincture, employed nothing but 
careful dieting. 
It was primarily a case in which the septic elements 
were destroyed by the introduction of antitoxine into the 
system, and if, as the two previous cases just cited show, 
any step toward the amelioration of the septic condition in 
the puerperal stage-and I think it is well worth consider- 
ing-I believe that I am justified in saying that these two 
patients were saved directly by the introduction of this new 
therapeutic measure ; and although I am not willing to say 
that all patients with puerperal fever can and will get well 
by the treatment just detailed, I am confident that possibly 
some of the patients that are left to the ordinary means of 
to-day, to die of septic diseases, can be cured if this treat- 
ment is tried. I repeat, however, that my experience in 
septic puerperal diseases is limited to two cases, both of 
which were successfully treated. 
An equally instructive case was one similar to one that 
I reported last September at the meeting of the Post gradu- 
ate Clinical Society : 
A child, ten days old, had had extensive sloughing of the 
umbilical cord. A child in the same family was sick with 
diphtheria for a number of days. The physician in attend- 
ance was rather puzzled at the peculiar state of affairs of 
the navel. It was in a highly inflamed condition, the tissues 
surrounding the umbilical cord were covered with large 
membranous deposits for several inches. When I saw the 
child in consultation, I at once associated this factor with 
the child that was sick with diphtheria, and told the attend- 
ing physician that I believed it to be a case of diphtheritic 
omphalitis. When I saw the case the child was seventeen 
days old. Iodol was sprinkled over the external surface, also 28 
ANTITOXINE IN DIPHTHERIA. 
the ordinary lotio nigra had been used with little or no effect. 
The temperature of the child was 102°, and all in all the child 
appeared to be dying. It refused the breast, and was constant- 
ly crying; had had several movements of the bowels lately; 
peevish; had his legs flexed on his abdomen. We decided that 
as the child had probably been infected, an injection of anti- 
toxine might do some good. I injected in this case three 
cubic centimetres of Aronson's antitoxine in the interscapu- 
lar region and applied lead water locally. Whether the anti- 
toxine or the lead water did the most good I am not prepared 
to say, but the very fact that calomel and limewater had 
been used for several days prior to the commencement of this 
treatment without any avail points to the fact that the anti- 
toxine must have had some direct specific effect, for two days 
following the injection large deposits, which consisted of 
pseudo-membranes, sloughed away, and a culture made from 
a piece of this pseudo-membrane showed the presence of 
Klebs-Loeffler bacilli. It was then more than ever that I be- 
lieved that I was dealing with this true form of diphtheritic 
omphalitis. In this same child, following the disappearance 
of the omphalitis, which lasted in all eleven days after the 
commencement of the injection, a severe diphtheritic con- 
junctivitis was set up, owing most likely to the carelessness 
with which the nurse handled the baby and the probability 
of the carrying of some of the infected material of the in- 
flamed navel to the eyes. In fact, the nurse admitted having 
used the same towel to wash the eyes and the eyelids that 
she used to dry the umbilicus, so that we had here again the 
direct transmission from the umbilicus to the conjunctival 
mucous membrane. 
I could continue to report other interesting cases, but 
desire to confine myself to the fact that not only neces- 
sarily must a diphtheria be located in the nose, in the 
throat, on the tonsils, on the larynx, or even in the trachea, 
but that all diphtheritic processes involving, as in the case 
reported above, cutaneous diphtheria, conjunctival diphthe- 
ria, omphalitis, diphtheria of the external genitals-in fact ANTITOXINE IN DIPHTHERIA. 
29 
in all processes in which I have suspected a croupous or 
diphtheritic foundation, I have used antitoxine with most 
positive results, and I believe that some of our patients with 
septicaemia that died from external cutaneous diphtheria 
could have been saved by the timely injection of a sufficient 
quantity of proper antitoxine. 
One word more as to the strength of the antitoxine. 
Strength of Antitoxine.-Heretofore antitoxine has been 
prepared and put up in bottles of various sizes, the one 
being known as antitoxine to confer immunity, and really a 
prophylactic antitoxine, which was a very weak therapeutic 
agent in comparison with the antitoxine that was put up in 
larger bottles for healing purposes only. A very wise plan 
has, however, been adopted abroad of putting up the anti- 
toxine in phials containing five cubic centimetres only. This 
quantity is sufficient for an ordinary healing dose in a mild 
as well as in a malignant case of diphtheria; but if a case 
shows no alleviation of its most urgent symptoms within 
the first twenty-four to thirty-six hours following this in- 
jection, then a wise plan is to inject the same quantity on 
the day following the first injection. The most important 
change that has transpired within the last few months in 
the manufacture of the antitoxine is that the German Gov- 
ernment will not permit this therapeutic agent to appear in 
the market without giving it its official seal, after having 
tested its strength and the quantity of normal antitoxine 
units. It is therefore very pleasant to know that the firm 
of Schering & Glatz have only one kind of antitoxine, which 
should be used in the dose above mentioned. In order 
that I may be properly understood, I should liki to state 
that a child two years old can be infected and have as 
much septic matter in its system as an adult from a given 
patch of diphtheria. In fact, the child, being more prone 
to the action of this diphtheritic poison, shows more mani- 30 
ANTITOXINE IN DIPHTHERIA. 
festations of the disease than an adult, and hence it is that 
the same dose of five cubic centimetres can be injected 
with impunity into an infant as we would inject into an 
adult within the same time and in the same locality. I 
should like to emphasize this point, owing to the large 
number of questions that have been put to me by various 
correspondents since the publication of various papers on 
antitoxine by me. 
The Effects of Frost and Heat.-A series of very inter- 
esting experiments have been conducted by Dr. Ilans 
Aronson, of Berlin, to determine the efficacy of antitoxine 
after having been subjected to a freezing temperature, 
owing to numerous inquiries following a severe spell of 
cold weather during last winter. Fortunately, according to 
Aronson, the antitoxine does not lose any of its therapeutic 
value by being subjected to low temperatures far below the 
freezing point. This is very important for us to know, es- 
pecially in the smaller towns, where a supply of antitoxine 
is not so near at hand, and where physicians have usually 
taken some antitoxine and kept it as a precautionary 
measure. While speaking of the effect of cold, a word 
about the action of very warm temperature is also not 
amiss. Antitoxine can stand very high temperature with- 
out being decomposed; this has also been conclusively 
proved by experiments, so that we have neither to fear 
from either the extremes of heat or cold as endangering 
the value of this drug. 
According to the statement of Dr. Hans Aronson, the 
antitoxine sent to this country by the Schering Chemical 
Works, of Berlin, manufactured in their bacteriological 
laboratory under his supervision, will keep at least a year, 
and specimens of longer time than this have been tested and 
found efficacious; but I believe that an antitoxine that will 
retain its active power for a year is all that we can desire. ANTITOXINE IN DIPHTHERIA. 
31 
It is my earnest hope that the good results attained by 
me in the management of some of the most malignant 
cases of diphtheria that I have known since I have been in 
practice shall be also repeated by those colleagues who 
have hitherto been skeptical in the use of this valuable 
remedy, and I believe that the large number of consultations 
that I have hitherto reported have been only due to the 
fact that most physicians still believe the antitoxine treat- 
ment to be in its experimental stage. A careful review, 
however, of this paper will prove the fact that my cases 
have not been selected, but that I have usually been called 
especially in those cases which have been kindly referred 
to me by physicians in this and the neighboring cities, and 
have been cases in which antitoxine was only called for as 
a last resort and where most frequently all the customary 
treatments of diphtheria hitherto in vogue had been unsuc- 
cessfully applied, so that I may candidly say that the com- 
plications arising in the course of some of my cases have 
been rather due to a long-continued disease which has 
really undermined the whole organism of the patient and 
saturated it with the septic elements of the diphtheria and 
its products, and that while we were really called to a so- 
called case of diphtheria it was in most cases a long-con- 
tinued diphtheritic septicaemia that required skillful man- 
agement. Such brilliant results as I have observed from 
combining antitoxine with intubation and antitoxine with 
tracheotomy have never hitherto been attained by me in 
the mildest form of epidemic and with the strongest patient 
before me. 
187 Second Avenue. The New York Medical Journal. 
A WEEKLY REVIEW OF MEDICINE. 
EDITED BY 
FRANK P. FOSTER, M.D. 
THE PHYSICIAN who would keep abreast with the advances in 
medical science must read a live weekly medical journal, in which 
scientific facts are presented in a clear manner; one for which the 
articles are written by men of learning, and by those who are good and 
accurate observers ; a journal that is stripped of every feature irrelevant 
to medical science, and gives evidence of being carefully and conscien- 
tiously edited ; one that bears upon every page the stamp of desire to 
elevate the standard of the profession of medicine. Such a journal 
fulfills its mission-that of educator-to the highest degree, for not 
only does it inform its readers of all that is new in theory and practice, 
but, by means of its correct editing, instructs them in the very important 
yet much-neglected art of expressing their thoughts and ideas in a clear 
and correct manner. T00 much stress can not be laid upon this feature, 
so utterly ignored by the " average " medical periodical. 
Without making invidious comparisons, it can be truthfully stated 
that no medical journal in this country occupies the place, in these par- 
ticulars, that is held by The New York Medical Journal. No 
other journal is edited with the care that is bestowed on this; none 
contains articles of such high scientific value, coming as they do from 
tbe pens of the brightest and most learned medical men of America. A 
glance at the list of contributors to any volume, or an examination of 
any issue of the Journal, will attest the truth of these statements. It 
is a journal for the masses of the profession, for the country as well as 
for the city practitioner; it covers the entire range of medicine and 
surgery. A very important feature of the Journal is the number and 
character of its illustrations, which are unequaled by those of any other 
journal in the world. They appear in frequent issues, whenever called 
for by the article which they accompany, and no expense is spared to 
make them of superior excellence. 
Subscription price, $5.00 per annum. Volumes begin in 
January and July. 
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