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If at any time cases of this disease are required to be registered or are kept under observation by authorized inedical inspectors, this laboratory will be in a position to render nearly as valuable services to all concerned as it now does by its diphtheria diagnosis work .

The Production of Diphtheria Antitoxin.

The method used in this work is the same as is used by all those producing a reliable remedy.

Diphtheria toxin is prepared by growing, for 6 or 7 days in incubators kept at the body temperature, special virulent diphtheria bacilli, in boullion, specially made from decomposed meat, and after the addition of two per cent. of peptone, bringing the reaction to the neutral point, with litmus paper as the indicator, and then adding 7 c.c. of a normal soda solution to every litre of the bouillon.

At the end of the specified time the bouillon cultures are filtered through several layers of filter paper, and one

, half of one per cent. of carbolic acid is added to the clear filtrate to preserve it.

Such toxin is injected subcutaneously or deeply into the muscles of young healthy horses in progressively increasing doses. The period of time occupied by such treatment, before the blood serum of the horse is considered of value for treatment of cases of diphtheria, varies with each horse. Indeed, many horses may be given such treatment without the production of antitoxic properties in their blood serum, sufficiently strong to be of any value. . Moreover it is at present impossible to tell beforehand whether a horse will give strong antitoxic serum or not.

With the hope of finding method or means of foretelling the result of the injection of horses with toxin, experimental work was carried on in this laboratory under the direction of Dr. B. Meade Bolton, Director of the Laboratory, until November 1, 1896. (Journal of Experimental Medicine, Vol. 1.) It was thought that possibly some horses might have antitoxin normally present in their blood, which would influence the result of the treatment. It was found that certain horses did possess antitoxic properties in their blood, but subsequent observation failed to show that such normal antitoxin affected the result of our work on those horses. Equally good and quite as poor

. results were obtained from both horses with, and horses without, such normal antitoxin.

January 1, 1896, there were nine horses under treatment. In May two died suddenly, from overdoses of toxin. The serum of one of these two was of sufficient antitoxic strength to be of value. The other horse's serum was of no value so far as antitoxin was concerned. Two horses were discarded, in December, after eighteen months fruitless treatment.

Of the remaining five, three have produced serum containing 100 to 150 units of antitoxin to each cubic centimeter or slightly superior to the ordinary standard antitoxin. The serums produced by the other two horses contain between 60 and 80 units per cubic centimeter, and has not been used on cases of diphtheria. Three horses have been received during the year, but none of them produced a strong antitoxic serum.

In March, the laboratory began to regularly supply the Municipal Hospital with diphtheria antitoxin of standard strength. Shortly afterward the medical profession and

. the general public were notified that diphtheria antitoxin could be obtained on application at the laboratory, provided the physician obtaining it would signify that it was to be used on a patient unable to pay for it, and also that he would report the result to the laboratory.

Physicians applying for antitoxin are requested to fill out and sign the proper application :

APPLICATION FOR ANTITOXIN.

Date....

Physician using the Antitoxin........
Residence........
Patient's name.......
Residence ......

(over)

Is the antitoxin to be used for treatment or protection ?..........

This is to certify that the antitoxin is to be used on a patient who is unable to purchase Antitoxin, and the result will be reported on the proper blank form to the Laboratory.

Signed......

........

.........

TO BE FILLED OUT AT THE LABORATORY.
Description of the Antitoxin supplied.........
Lab. No. of the Antitoxin...........
Quantity and strength........

He is then given the amount he has applied for, each bottle of which is labelled, with the amount of serum it contains and its antitoxic value.

PHILADELPHIA BOARD OF HEALTH.
No.......... Date..........
This bottle contains.................C.C.

antitoxin units.

Every bottle is enclosed in a neat, round paste-board box, which also contains a blank form for reporting the result of the use of the remedy.

RESULTS OF THE INOCULATION OF ANTITOXIN.

Date....
Name of the physician using the Antitoxin.......
Residence ........
Patient's name.
liesidence...

(over)

Lab. No. of the Antitoxin.......... Dose employed in c. C............
Day and hour of inoculation.......... Day of the disease.
Was 'Tracheotomy or Intubation employed ?............

State on the following pages the general condition of the patient 24 hours after the inoculation; the effect, if any, on the temperature, pulse, respiration and membrane.

Please notify the laboratory when the patient recovers or dies.

From March to December 31, 730 bottles, each containing 10 c.c. of serum, having a strength of 1,000 antitoxic units or over, have been supplied to the Municipal Hospital.

To physicians applying for the antitoxin or requesting that it be injected, 170 bottles, containing the same quantity and of the same strength as that mentioned above, have been supplied. Results of the Use of Diphtheria Antitorin Supplied to

Physicians.

Of the 170 bottles thus sent out, 137 were for use in cases of disease; whereas 33 were for persons who had been in contact with cases of disease and where its use was simply as a protection.

We received reports of the results of the use of antitoxin from only 76 cases out of the 137 in which it was used. The reports show that 57 cases recovered and 19 died, giving a death rate of 25 per cent.

By means of weekly reports of deaths from diphtheria, obtained from the Registration Division of the Bureau of Health, we were able to ascertain the termination in 47 more cases. However, while applications were made for antitoxin to be used in these cases, we have no other evidence that it was actually used. Including these latter cases in the total we find the mortality to be 27.6 per cent.

It has been universally conceded by the supporters of the antitoxin treatment of diphtheria, that in order to obtain the best results it should be first used before the fifth day of the disease. When the antitoxin is injected on or after the fifth day the results are no better than where it is not used at all.

The average day of disease, on which the injection was given, in the 76 cases reported to us, was 3.8 day. Of these 56 were injected before the fifth day, and the death rate was 16.6 per cent. Among the remaining 20 cases injected after the fourth day the death rate was 50 per cent.

It could hardly be expected of antitoxin that it restore a dying patient. Of the 19 fatal cases out of 76, from which reports were received, 6 died from 3 to 24 hours of the first injection.

It is reasonable to expect it to be necessary in some cases to give a second or third dose in case the first did not produce the desired results. Therefore, while unknown factors prevent a positive statement, it is not improbable that the results would have been more favorable, if six cases receiving one dose of antitoxin and dying from 5 to 11 days later, had received several more injections.

If from the 19 fatal cases we deduct the cases where antitoxin was not used until the fifth, or a later day, of the disease or where the patient was moribund at the time of injection, or where the patient was allowed to linger for over 5 days after the first dose without any further use of the remedy, we find but four (4) cases where the antitoxin was apparently given a fair trial and failed, or a mortality of only 5.2 per cent.

Thirty-three healthy persons received injections of our antitoxin on account of having been in contact with cases of diphtheria. We received reports from 10 of these cases, none of whom contracted the disease.

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