In the prosecution of the work of collecting the data relative to the treatment of diphtheria in children, with its antitoxin, in private practice, in the District of Columbia, cases cases of diphtheria in which the serum was not used formed such a large proportion of the whole number that they have been incorporated in this paper for purposes of comparison. It must be understood that information asked for in the circular was not sought in the latter class of cases. All cases (311) of diphtheria, except ten, officially recorded, occurring in the District of Columbia from January 1, 1895. to April 15, 1896, are included in this paper. The exclusion of seven of the exceptional cases was because the bacilli diphtheria were present without the membrane and the injection being used for immunization, and in the other three it was impossible to obtain any information from the two reporters which would enable classification. While the physicians themselves have furnished the details in the cases treated with serum, the official records of the Health Department have been relied upon in the other

cases.

During the period named 83 physicians treated 176 cases of diphtheria with antitoxin. Of these, 71 reported 160 cases in full, while 12, who had treated the remaining 16 cases, did not respond. The latter, however, are covered in this report, as sufficient information was gleaned from other sources to warrant proper classification. During the same time 80 physicians treated 135 cases of diphtheria without using its antitoxin. A third class, of 22 physicians,

used the antitoxin in 56 cases, but did not use it in 38.

Ages. As the investigation was confined to children the sixteenth year represents the maximum age. The youngest child receiving the antitoxin was aged 10 months, and the eldest 16 years, the average age being 6.51 years.

Table showing ages of those receiving antitoxin: 6 months to 1 year, 1; 1' to 2 years, 6; 2-3, 15; 3-4, 16; 4-5, 21; 5-6, 17; 6-7, 16; 7–8, 20; 8–9, 18; 9-10, 20; 10-II, 9; II-12, 4; 12-13, 3; 13-14, 3; 14-15, 3; 15-16, 4; total, 176.

The youngest child treated without antitoxin was four months old and the eldest 15 years, the average age being 5.96 years.

Table showing the ages of those not receiving antitoxin: Under 6 months, 1; 6 months to 1 year, 1; 1 to 2 years, 7; 2-3, 12; 3-4, 23; 4-5, 14; 5-6, 14; 6-7, 12; 7-8, 10; 8-9, 6; 9-10, 10; 10 -II, 10; 11-12, 3, 12-13, 6; 13-14, 5; 14 -15, 2; total 135.

Sex and color. Of those receiving antitoxin, there were white, male 78, female 85; colored, male 3, female, 10; total, 176.

Of those treated without antitoxin there were white, male 52, female 56; colored, male 11, female 16; total, 135.

While girls seem to be more susceptible to diphtheria in the proportion of 167 to 144 boys, the infrequency of the disease in the negro is most astonishing. The negroes affected represent but 12.54 per cent of the whole number of cases, while the proportion of negro population to white in the District of Columbia is 90,000 to 195,000.

Physical condition. The following table is supposed to show the physical condition of the patient at the time the antitoxin was injected. Although the exact condition given by the reporter was recorded in every case, it cannot be accepted as being correct, owing to discrepancies in other statements. For instance, some reported "good" and further on "sepsis" and "death" within twenty-four hours; others as "fair" when the comments showed the patient cyanosed, requiring immediate intubation; and still others wrote "bad" although the injection was given a "few hours" after the appearance of the membrane. Thus the purport of the question referring to the physical condition of the patient at the time of injecting the antitoxin was undoubtedly misunderstood by many. Good 73, fair 41, bad 52, not stated 10; total 176.

The fol

Time of injecting antitoxin. lowing table shows the time elapsing between the first appearance of the membrane and the injection of the antitoxin. A vast majority answered this question correctly, but a few understood it to apply to the time between the diagnosis. and the injection. The importance of being accurate in this observation will be appreciated in studying the results of this treatment.

Table showing the duration of the membrane when antitoxin was injected: 6 hours, 2; 12 hours, 3; 24 hours, 26; 36 hours, 12; 2 days, 31; 3 days, 29; 4 days, 21; 5 days, 9; 6 days, 8; 7 days, 11; 8 days, 1; 9 days, 1, 10 days. 1; 11 days, 1; not stated, 20; total, 176.

Thus 103 cases received the injection on or before the third day of the disease. Diagnosis. The diagnosis was confirmed by a bacteriological examination in 159 cases and was made without it in seventeen.

Number of Injections given in each case. One injection was administered in 119 cases; two in thirty-four cases; three in five cases; seven in one case; and the number of injections was not stated in

seventeen cases.

Intubation was performed twelve times and tracheotomy once, the latter having been performed after the expulsion of the intubation tube, which had been in place seven hours.

Operations. The three fatal cases in which intubation was performed require some comment. In one, aged three years, the alarming symptoms were relieved, but the patient, unfortunately died from strangulation before any idea of the action of the antitoxin could be formed.

In another, aged four years, the injection was administered, and intubation and tracheotomy were performed on the fifth day after the recognition of the disease. The physician pronounced this case hopeless upon his first visit, but must be commended for his efforts to relieve the child's suffering by the second operation.

In the third, aged four years, the child's condition and surroundings were such that death was imminent when the physician first saw him, but nevertheless, intubation was performed and the antitoxin administered.

The other cases of diphtheria, which recovered after intubation were unusually severe; seventy-five per cent recoveries of intubation in children between two and seven years is more than creditable and must be greatly due to the beneficial effects of the antitoxin.

Location and extent of the membrane. The location of the membrane has been accurately recorded. Tonsils, 46; larynx, 3; tonsils and pharynx, 34; nose, pharynx and larynx, 2; tonsils and nose, 8; pharynx, 3; tonsils and larynx, 11;

pharynx and larynx, 3; nose and larynx, I; nose and pharynx, 2; tonsils, pharynx and larynx, 11; tonsils, nose and larynx, 1; tonsils, nose, pharynx and larynx, 15; nose, 1; tonsils, nose and pharynx, 19; not stated, 16; total, 176.

Complications. The following are the complications in the order of their frequency: Nephritis in 13; paralysis in 13; sepsis in 12; nephritis and paralysis in 5; broncho-pneumonia in 3; sepsis and paralysis in 3; nephritis and sepsis in 2; nephritis, sepsis and paralysis in 2; broncho-pneumonia, sepsis and paraly

sis, I.

Only three cases of erythema are reported. Scarlatinal infection complicated two cases, one being fatal.

Results. That which concerns us most in a discussion of this kind is the therapeutic value of the antitoxin of diphtheria. One reporter may assert that it acts as if by magic; another that he could see nothing astonishing in its action, but has no objection to using it; while a third, the defender of the timehonored compound of the ferric chloride and potassium chlorate, decries its use. altogether. The members of each class are entreated to ponder over the following data before passing final judgment.

During the year ending June 30, 1894, before the introduction of antitoxin, 432 cases of diphtheria were reported in this District, the average age of those attacked being 8.7 years. Fifty-eight were white males, fifty-four white females, twenty-six colored males, and thirty-four colored females. There were 172 deaths, the percentage of deaths to cases being 39.8.

age of deaths to all cases being 23.44.

During this same period 135 cases were treated without antitoxin, the average being 5.96 years. There were forty-seven deaths, the percentage of deaths to all such cases being 34.81, a death-rate of only 4.99 per cent less than that when antitoxin was unknown, the average age of the decedents being 4.25 years.

During the fifteen and a half months. ending April 15, 1896, after the introduction of antitoxin, 311 cases of diphtheria were reported, the average age of those attacked being 6.23 years. There were seventy-three deaths, the percent

During this period also 176 cases were treated by the injection of antitoxin, the average age being 6.51 years. There were twenty-six deaths, the percentage of deaths to all cases receiving the antitoxin being 14.77, the average age of the decedents being 4.66 years. There were twenty-two physicians who used antitoxin in fifty-six cases, but did not use it in thirty-eight cases during the same period. In the former group there were fourteen deaths, the percentage deaths to such cases being twenty-five; in the latter group there were eleven deaths, the death-rate being 28.94 per

cent.

of

The reporters notes on the fatal cases in which antitoxin was used may be summarized as follows: 2 years, 2; 22 years, 2; 3 years, 4; 31⁄2 years, 2; 4 years, 6; 5 years, 2; 6 years, 3; 7 years, 2; 8 years, 1; 9 years, 1. The youngest child was two years old, and the eldest nine years, the average age being 4.66 years.

The ages of the decedents that did not receive antitoxin are given below: 5 months, 1; 9 months, 1; I year, 3 months, 2; 1 year, 5 months, 1; 1 year, 6 months, 2; 1 year, 8 months, 1; 2 years, 5; 2 years, 6 months, 2; 2 years, 9 months, 1; 3 years, 5; 3 years, 6 months, 1; 3 years, 10 months, 1; 4 years, 4; 4 years, 11 months, 1; 5 years, 3; 5 years, 2 months, 1; 6 years, 4; 6 years, 3 months, 1; 7 years, 2; 7 years, 3 months,

youngest being six months old and the eldest twelve years, the average age being 4.25 years.

Fifteen white males, nine white females and two colored females, that had received antitoxin died. While of those treated without antitoxin, twenty white males, sixteen white females, five colored males and six colored females died. The physical condition at the time of the injection was stated to be good in three, fair in two, bad in nineteen and was not given in 2. The time from the first appearance of the disease to the first injection was 6 hours, 1; 12 hours, 1; 36 hours, 2; 21⁄2 days, 1; 3 days, 1; 4 days, 1; 5 days, 2; 6 days, 4; 7 days, 4; 8 days, 1; 10 days, 1; 11 days, 1; a few hours before death; 2; not stated, 4.

It will be seen that twenty of the fatal cases did not receive the injection until after the third day. It is very generally admitted that the value of antitoxin rapidly declines after the third day of the disease.

The diagnosis was confirmed by cultures in twenty of the fatal cases, but not in six. The number of injections given in the fatal cases were as follows: I in 17; 2 in 7; 3 in 1; 7 in 1.

The extent of the membrane is as follows: Tonsils in 1; tonsils and larynx in I; tonsils and pharynx in 2; tonsils, nose and pharynx, 3; tonsils, pharynx and larynx, 4; tonsils, nose, pharynx and larynx, 7; nose and pharynx, 1; pharynx and larynx in 2; larynx in 1; not stated in 4. Intubation was performed in three and tracheotomy also in one of them.

The complications noted in the fatal. cases were: Sepsis in 8; nephritis in 3; paralysis in 2; sepsis and scarlatina in 1; sepsis and nephritis in 1; sepsis, nephritis and paralysis in 1; broncho-pneumonia in 1; strangulation in feeding in 1; not stated in 8.

Kind of serum which was used in

fatal cases:

U. S. M. H. S. in 8; Behring's in 7; Mulford's in 2; Roux's in 1, Fraser's in 1; not stated in 7.

The reporters commented upon their fatal cases as follows: One called his case malignant; two said theirs were hopeless when the injection was given; one said no effect was noted; five that the serum was used too late; two that the membrane rapidly disappeared; one that the case was of marked severity; five that the patient's were moribund; one that temporary improvement followed the injection; and one that the patient was strangulated with milk; while seven offered no comments.

Treatment. General In almost all, the diet was restricted to liquids, the preference being given to milk. The drugs used in the order of frequency were: Ferric chloride in 51; stimulants in 37; strychnia in 16; mercuric chloride in 15; quinia in 14; mercurous chloride in 4; digitalis in 2. In a vast majority of cases internal medication was stopped as soon as the serum was injected, with the exception of stimulants, strychnia and digitalis.

Local-The local treatment appears not to have been neglected, as the following table shows: Hydrogen peroxide in 51; potassium chlorate in II; antiseptic sprays in 7; trikresol in 6; borolyptol in 5; listerine in 1; creolin in 1; vapor of quicklime in 1.

Antitoxin used. The kind of antitoxin used in each case is as follows: U. S. Marine Hospical service in 66; Behring's in 64; Roux's in 4; Mulford's in 5; Parke, Davis & Co's in 4; Aronson's in 2; Fraser's in 2; not stated in 30; total, 177. One patient received Behring's at one time, Roux's the next, which accounts for the extra one.

DISCUSSION.

Dr. J. J. Kinyoun being asked to open the discussion, said: I have very little

we separate the years into periods there occurred from 1891-94 inclusive 130,000 cases with a mortality of 51,500, making a percentage of about 39. In the last year, 1895, there were 45,000 cases reported with a mortality of 11,000, a dropping from thirty-nine per cent to 24.4 per cent. Notwithstanding, there has been during the last year an epidemic of diphtheria not noted in the table as a whole. In St. Louis, Chicago, New York and Boston there have been a greater number of cases than in previous years. It is claimed by those holding an opposite view, that we regard a great many more cases as diphtheria now than formerly, because we rely upon the microscope for diagnosis. We are willing to admit that cases are reported now to the Health Officer-mild cases which formerly would not have been classed as diphtheria, but the reports show that only seventy per cent of the cases previously reported were really diphtheria, consequently instead of having thirty-nine per cent of deaths they would have fifty-five per cent. There has not been an increase of thirty per cent more cases reported in the last year -1895-so that the figures can be equalized, and we must ascribe the low death rate to some other cause. In the cities of Massachusetts, several of those in New York, Chicago, St. Louis, New Orleans and Washington the death rate has been materially lowered-not in actual numbers only, but in percentage of mortality. To arrive at an accurate conclusion as to whether antitoxin has value or not, the larger the number of cases considered the better. I believe that 3,000 cases, or 5,000 or 10,000 cases reported just as they are reported to the Health

Officer should have just as much weight this year as we were prone to give them in former years. I have collected re

the

ports of 5,125 cases of diphtheria and croup treated with antitoxin with 552 deaths, a mortality of 10.7 per cent, and 2,396 cases of diphtheria and croup not treated with antitoxin with 1,110 deaths, a mortality of forty-two per cent. I have also to show the value of antitoxin for its immunizing effects, and its harmlessness. Reports have been received of 2,400 cases of children under ten years of age who have been immunized, with the result of only nineteen mild cases of diphtheria, majority occurring on the second or third day after inoculation, while others appeared after the eighteenth day. The classic paper of Prof. Welch, bears out the prophesy, that was made, that the better we become acquainted with the remedy the better would be the results obtained. He reports over 7,000 cases treated with antitoxin with a saving of seventy-eight per cent of cases, a majority of them being hospital cases of the worst kind; 2,500 cases were treated without antitoxin with a mortality of forty-two per cent. If we combine these two reports we have a total of over 12,000 cases treated with antitoxin, with a mortality of fourteen per cent, against 4,500 cases treated, synchronously, without antitoxin with a mortality of fortytwo per cent. The reports received from every part of the world bear out the above figures. From London we have a report from the superintendent of the Metropolitan Asylum Board that for 1894 the mortality was forty-two to fifty per cent, and in 1895 has been diminished seven per cent. The authorities are unanimously of the opinion that this result cannot be attributed to any other cause than the effects of the antitoxic remedies.

All agree that the remedy should be given early, as after the fifth day it does no good. I would urge on the profession to give it in every case of diphtheria, for it is the greatest remedy for the disease which has been discovered.

Dr. C. H. Alden, U. S. A., said: It has occurred to me that a report of some of the results obtained in the army from