up mal and remained so. This delay would have been unpardonable, but I consider the diagnosis doubtful, and the patient was a robust adult with no bad symptoms. The membrane spread very slowly, and as soon as it began climbing up from the tonsils to the pillars of the fauces, I injected antitoxin. I kept the strychnin and whiskey from the start. The membrane disappeared completely in twenty-four hours after the injection. Now, when I was about to dismiss this patient, they told me that three weeks before there had been a child visiting in the house from New York, and that during its visit it had a sore throat, but recovered in three or four days without a physician, that since its return home, three other children in the New York family had had diphtheria. This visiting child's sore throat was evidently mild diphtheria with spontaneous cure, but capable of conveying the disease to others in virulent form. About two weeks after dismissing Case V, I was in the same neighborhood again, and saw a diphtheria sign on a house only a few doors from where Cases IV and V had been. I did not see the patient. On August 15th, a lady who lives across the street from the patients reported as IV and V, and opposite the diphtheria sign mentioned, brought her 3-year old girl to my office for examination. I found what appeared to be a simple catarrhal vulvo-vaginitis, with no evidence of traumatism. There was a rather profuse, greyish mucous discharge, no pus. I considered it a catarrhal vulvo-vaginitis, and prescribed a simple lotion. October 6th, seven weeks later, I was called to see an 8-year old sister of this child, and found her with diphtheria of twenty-four hours standing. The mother told me that this little girl had the same vaginal discharge as the 3-year old sister, and that another 5 years old and one 10 years old had the same discharge. It was late in the evening when I was called, so I injected the child with the faucial diphtheria with 3000 units of antitoxin (P. D. & Co.'s), at the same time taking a swab from her throat and vagina and a vaginal swab from the 3, 5 and 10-year olds. The specimens were examined at the City Board of Health laboratory, and all gave almost pure culture of Klebs-Loeffler bacilli. The family consisted of father and mother, nine daughters ranging in ages from 3 to 25 years, and a boy child 11 months old. I returned the next morning after finding the case of faucial diphtheria, prepared to give immunizing doses of antitoxin to all the children of 13 and under. On arrival I found the 10, 5 and 3-year old girls with well developed faucial diphtheria. The 11-months old boy had a slight temperature and a white speck on one tonsil. The 13-year old girl was given 1500 units Mulford's antitoxin for immunization, and escaped until October 21st, two weeks later, when she was taken violently. A girl 16 and one 18 were also attacked, when I injected the next one, 23 years old. I report them all briefly as follows: Case VI. Frances N., white, female, aged 8. Attacked with chill on morning of October 5th. When seen thirty hours later temperature was 101°F., and pulse 164 and weak. Membrane covering both tonsils, filling posterior nares and partly covering post-pharyngeal wall. Given 3000 units antitoxin (P. D. & Co.'s), and whiskey and strychnin. Eighteen hours later temperature was 99°F., pulse 140, membrane crimping around edges. Twenty-four hours later, forty-two hours after injection, throat was clean, temperature 99°F., pulse 128. Temperature remained 99 until the 11th, five days after the injection, when it was normal and pulse 88. Recovery uneventful. Cases VII, VIII, IX and X were three sisters and a brother of Case VI. Ages 3, 5 and 10 years, females, and a male of 11 months, and were identical. All the females had the vaginal discharge antedating the faucial diphtheria for seven weeks, beginning about three weeks after the neighborhood became infected. All were attacked during the night of October 6th, or about thirty-six hours later than Case VI. All had moderate temperature with weak fast pulse, and ugly gray membrane on the tonsils and post-pharyngeal wall. The treatment was routine, 3000 units Mulford's antitoxin for the elder three, and 2000 units for the youngest, each within twelve hours of the beginning of the faucial symptoms, and whiskey and strychnin were given liberally. The whiskey and strychnin were continued until the pulse became nearly normal, which required from a week to ten days. The recovery was satisfactory in every case. Case XI. Clara N., white, aged 18, of the family just reported. Disease appeared on October 8th, a typical text-book diphtheria. Injected with 3000 units Mulford's antitoxin, when the disease was twenty-four hours old, and was given the regulation whiskey and strychnin. Reaction and recovery the same as in the cases above reported, and detailed in Case VI. Case XII. Mary N., white, female, aged 16, above family. A nervous girl, inclined to be chlorotic. Menstruation slightly irregular and painful. A mitral regurgitation with hypertrophied ventricles, also a neurotic pulmonary murmur. Diphtheria appeared on the morning of October 9th. Thirty hours later, temperature 102°F., pulse 120. Given 3000 units Mulford's antitoxin. Twelve hours after injection, temperature 102, pulse 142. Membrane spreading. The injection of 3000 units Mulford's antitoxin repeated twenty-four hours after the first dose. Out of a total of sixteen cases reported, this is the second one in which the injection had to be repeated, and the only one in which there was no reaction from the first dose. Twenty-four hours after the second injection, temperature 99.4°F., pulse 128, throat cleaning off. For three weeks pulse ranged about 120, running up to 160 on slight exertion. I kept the patient in bed for ten days after the throat was clean, on account of the bad pulse. She now seems perfectly well. Case XIII. Theresa N., white, female, aged 13. Belongs to family of cases just mentioned. On October 7th was given 1500 units Mulford's antitoxin to immunize. October 20th developed diphtheria with a chill and temperature 103.2°F., pulse 140. Within twenty-four hours was given 3000 units of P. D. & Co.'s antitoxin. Recovery uneventful. On investigating the literature of diphtheria, I find a number of instances of the disease attacking the genitals in both sexes, but usually following circumcision in male children and parturition in females, and always with the characteristic membrane formation. I have been unable to find any such vaginal cases as the four reported above. Their clinical features are: First: That the four developed almost simultaneously in one family and in a neighborhood known to be infected with diphtheria, and during the time the other cases were in progress; that there was a lapse of seven weeks between the last previous case and the appearance of the faucial disease in this family, and that during this time these little girls were suffering from this vaginal discharge; that at the end of the sever weeks of the vaginal discharge they were all attacked simultaneously with the faucial disease of a virulent type; that the other children in the family, a boy 11 months old, and girls 13, 16 and 18 years old, were not attacked until later; all of which seems to indicate that these vaginal diseases were the sources of the infection for the fauces, and that they really were cases of auto-inoculation. It seems probable that the vaginal infection was gotten from contact with the other children in the neighborhood who had the disease, and that these vaginæ harbored the germs for the seven weeks, at the end of which time the throats of the same children became infected. Second: The pathological condition, which was a mild catarrhal inflammation, and a rather profuse grayish mucous discharge with no pus in it, specimens of which gave diphtheritic culture, and which condition was cured by the use of antitoxin. In conclusion I wish to make a few remarks on the use of diphtheritic antitoxin. As to the propriety of using it, there is no room for argument; it is a specific; but I wish to urge upon you the necessity for prompt action in its use and for the use of a large initial dose. In suspected cases inject the antitoxin and get a specimen from the throat at the same visit. Its early use will prevent the nerve degenerations which were so frequent and so dangerous before its introduction. These degenerations are caused by the direct action of the toxin generated by the diphtheritic germs upon nerve tissue. Antitoxin has the double effect of neutralizing this toxin and of increasing tissue resistance to it, thus preventing the secondary degenerations, not only of nerve tissue, but of all body tissues. In all cases where the disease is developed the initial dose should be 3000 units with all patients 2 years old or more. The amount of the toxin already absorbed as evidenced by depression, as well as the age and weight of the patient, should be considered in determining the dosage of antitoxin. The more of the toxin absorbed the larger the dosage of antitoxin required. In from 1 to 2-year olds I use 2000 units, 1 year old and under, 1500 units. In one of the cases just reported I gave a child of 11 months 2000 units in the incipiency of the disease, with no ill effects. Among the seventeen cases reported in my two papers, I have had two with secondary paralyses; one of these had been sick three days before I saw it, and the other was its mother, who was injected about twenty-four hours after the beginning of the attack. In neither case was the paralysis serious. Among a large number injected for cure or prevention, I have had two cases of secondary eruption with joint pains, one a child of 5 years injected with 2000 units of antitoxin for immunization, and one an adult with 3000 units of antitoxin for cure. In each case these symptoms lasted about forty-eight hours and disappeared without treatment. In only two cases in seventeen has it been necessary to give a second dose of antitoxin, and in only one of these was the repetition clearly indicated. It is very important, however, to watch the effect of the first injection and repeat it if the reaction is not satisfactory. Antitoxin is innocuous. Do not be afraid of using it. All children of 15 years and under who are exposed to the disease should be injected with immunizing doses of antitoxin. The train of contagion related in this paper shows that older children and adults should be observed carefully after continued exposure. I injected myself with 1000 units while attending these patients. 299 Main Street. GUNSHOT WOUNDS, WITH REPORTS OF CASES.* BY H. S. WOLFF, M.D. MEMPHIS. Late Resident Surgeon, Memphis City Hospital THE following cases came into the surgical wards of the Memphis City Hospital during my service as resident surgeon from May 1, 1899, to November 1, 1899. I have classified them as follows: Wounds of the head, 5 (3 of these being of the jaw); chest, 6; abdomen, 5; arm, 7; forearm, 9; hand, 4; thigh, 8; leg, 12; foot, 7-61 in all. In this classification, which is as near correct as I could make it, there were several cases which had more than one wound. The wound of most importance is recognized in this plan. In one case there were twenty-nine small shot wounds and three from a pistol. In this case I removed seventeen small shot from the side and back of the chest, most of these being merely buried under the skin. This patient remarked, as I was removing his extra weight, "I had an altercation with a colored gentleman, and I believe he surely tried to hurt me." * Read before Memphis and Shelby County Medical Society, Jan. 20, 1903. |