ACTIVE IMMUNIZATION IN DIPHTHERIA AND TREATMENT BY TOXINANTITOXIN
WILLIAM H. PARK
1914
Journal of the American Medical Association
blade should be beaten from the shank. The belly of the blade should be acutely sharp so that each portion will come in contact with the incision. If not acutely sharp you will lose vitreous. Each knife should be tested out on a drum to see that the cutting edge of the blade is sharp clear up to the point. On account of lack of this some accidents have occurred. Tiemann makes the best knife. Dr. Risley takes up the point of preliminary capsulotomy as a routine measure in acute cataracts. It is
more »
... niversally adopted in England. In my paper the matter of the immediate extraction of mor¬ gagnian cataract is taken up, and I do not allow the six-hour interval because there is no cortex to deal with. If there is loss" of aqueous at the time of the capsulotomy there is no trouble following, because the anterior chamber can be refilled by an irrigator with normal salt solution and you can go on with the extraction immediately without further waiting. In all the cases reported, 180, there were no infec¬ tions whatever, so that matter is a negligible factor; But high tension is another matter. In a number of cases there will be high tension, and the longer the interval between the preliminary capsulotomy and the extraction proper the greater the risks of high tension. The high tension cases require some variation in the technic. A speculum should not be used, but fixation. If the anterior chamber is shallow, then you have three operative courses : The incision can be begun by and continued with the scissors curved on the flat. If the anterior chamber is almost completely obliterated, the section can be made from the outside with a broad-bladed scalpel through the sclerocorneal junction. I have seen that done at Moorfields repeatedly. The scissors may be applied in that case also. all high tension cases the section can be made full size in the ordinary way, but should be com¬ pleted with the utmost gentleness on account of the risk to the vitreous. I said in my paper that secondary opera¬ tions are rare; I did not say they are never required. There is a small percentage of cases in which it does not work. has long been known. One. of us (W. H. P.) published a series of successful results in 1903. Smith suggested the attempt to immunize children, but no one undertook it until 1912, when von Behring made the attempt. In May, 1913, Behring published the results obtained in human beings. The combined substances were either neutral or slightly toxic to the guinea-pig. Individuals were injected with small doses (from 1/20 to 1/10 c.c.) which were repeated in from seven to ten days. The first injections were made subcutaneously or intramuscularly, while later the intracutaneous administration was favored, since the more distinct local reaction was believed to induce a greater efficiency of vaccination. The results as reported from different observers have not been uniform and as a rule are not distinctly stated. Hahn reports antitoxin production in thi rty\x=req-\ six out of forty treated; as we shall see later, the fact that twenty-five of the forty patients had natural anti¬ toxin already present modifies greatly the favorable nature of this result. Failure to respond was at first attributed to a lowered general condition but now we realize that it was because the susceptibility to the immunizing response to vaccine varies. It seems greatest in young adults. Zangmeister reports the interesting fact that the new-born are nearly a hun¬ dred times less susceptible to vaccine than adults. Kleinschmidt and Viereck report the active immuniza¬ tion of twenty-seven cases, but give no definite data. They advise combined active and passive immuniza¬ tion in persons exposed to diphtheria and also suggest the use of the Schick reaction in determining antitoxin content of persons after vaccination. Kissling reports results at Hamburg-Eppendorf in the immunization of 310 patients who were exposed to infection. In the 111 who were injected twice, no diphtheria devel¬ oped. In the 109 cases injected once, 8 patients devel¬ oped clinical diphtheria. During an epidemic of diph¬ theria, Hahn and Sommer vaccinated part of the inhab¬ itants of several villages : of 633 patients considered fully immunized only two developed mild diphtheria, but 10 of the group developed it during the first ten days. The disease continued to spread to some extent among those not vaccinated. Bauer finds that the persistence of the bacilli in carriers is not shortened by active immunization. He believes that not only all patients with antitoxin, but also those without natural antitoxin can be immunized, if sufficient doses and amounts of vaccine are injected. The interval between the injections of vaccine and development of antitoxin varies in different cases. According to Hahn it is usually not less than three weeks. Kleinschinidt and Viereck found it shortereven eight days. Patients with natural antitoxin usually show early and considerable antitoxin produc¬ tion. They also generally show a somewhat greater local susceptibility to vaccines. This according to von Behring is due to sensitization from previous infections with the Klebs-Loeffler bacillus. According to von Behring, the higher temperature of fever will destroy antitoxin at an increased rate so that an amount of antitoxin, which generally protects, fails to do so in measles and scarlet fever. Schick and Karasawa find, however, that no change in anti¬ toxin content is caused by measles. Von Behring con¬ siders that 0.01 unit per cubic centimeter is sufficient to protect healthy persons. Much less than this prob¬ ably suffices except under unusual conditions, as in scarlet fever. PERSONAL EXPERIENCE During the past twelve months the attempt has been made to immunize actively against diphtheria the patients in the scarlet fever wards of the Willard Par¬ ker Hospital. Owing to the large number of diph¬ theria-carriers admitted, the conditions in this hospital during the winter were such that on the average about one-quarter of the inmates were diphtheria-carriers. For this purpose mixtures of diphtheria toxin and antitoxin were prepared, either slightly antitoxic, neutral or slightly toxic to the guinea-pig. A strong diphtheria toxin was used, where the minimum lethal dose was 0.0023 c.c. and L-f-dose 0.27 c.c. The mix¬ tures represented 50 per cent., A 66 per cent., G 66 per cent., F 80 per cent, and E 90 per cent. L-(-toxin to each unit of antitoxin. The L-f-dose of toxin is
doi:10.1001/jama.1914.02570100045012
fatcat:vzupe74jxfcw3h6w4lloyfy2ma