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CONCENTRATED ANTITOXIN.
292 of an increasing amount to the Middlesex to pass something of the nature of a Hospitals (PayHospital. In 1919 and 1920 an additional 1000 ment for Treatment) Bill, to provide that where a guineas was given. In 1921 and subsequent years plaintiff recovers damages for personal injuries due the subscription was 100 guineas ; in 1926 the company to negligence, such damages may include sums added a subscription of 4000 guineas. The extra reasonably paid or promised to a hospital for treatsums in 1919 and 1920 were made because it was ment in respect of such injuries. The companies felt that there was an accumulated liability to the which insure motorists against third party risks might hospital on account of the frequent use made of it object that the Hill would impose a burden on them ; by the firm’s employees during the war. The firm but at present their policy-holders are trading on the took a very proper view of its responsibilities for its charity of the hospitals. employees and had an understanding (though not, of course, a binding agreement) with the hospital that none of its employees would be refused admission. CONCENTRATED ANTITOXIN. From the firm’s point of view, therefore, the subSOON after the introduction of diphtheria antiscriptions were a quid pro quo, a proper business toxin 30 years ago, medical men began to inquire admissible deduction and an as expense being (under the Income Tax Act Rules) money wholly and whether it would not be possible to obtain antitoxic exclusively laid out or expended for the purposes of serum of higher potency so that a large dose of sums
its trade. The claim was for deduction of the sums subscribed in 1919 and 1920, and it appeared that the Commissioners of Inland Revenue had actually allowed a subscription of 50 guineas as a business expense. The Inland Revenue, however, argued that * this was a concession, not a legal right ; alternatively, so ran the argument, the large sums subscribed in 1919 and 1920 were not wholly and exclusively laid out for the purposes of trade in relation to those particular years, because the subscriptions were intended to make up deficiencies for previous years. The Special Commissioners held that there was no legal right to make the deduction, and Mr. Justice RowLATT agreed with them. He remarked, however, that if the Special Commissioners had taken the opposite view of the question of fact he would not have dreamt of disturbing their decision. On a question of fact the Commissioners’ decisions are hard to shake. Counsel for the firm essayed to treat the matter as one of law not of fact, by submitting that the Commissioners had misdirected themselves in law by deciding that a hospital subscription could never be an allowable deduction. This view the judge was unable to accept ; the upshot is that, to the extent of the taxation upon the amount subscribed, a hospital subscriber has been penalised. Whether the firm merely decided to show gratitude for hospital services rendered or whether the arrangement could be vieived as a simple, though informal, working agreement, the result is the same. The second case in which the gift of money to a hospital was unfortunately discouraged by the law occurred at the Liverpool Assizes on Jan. 31st. In awarding some £3000 to a man injured by a motorist’s negligence, the jury recommended that, if possible, there should be a further sum of £50 paid to the Stanley Hospital where the plaintiff had had 13weeks’ treatment. Mr. Justice WRIGHT pointed out that he had no power to award damages to anyone but the plainti:H. Counsel suggested that the jury might have awarded the sum to the plaintiff to be paid to the hospital for operations performed, but the judge replied that no such condition could be imposed. Hospitals, lie said, have extraordinary hardships in having to deal with injuries, often serious, sustained by members of the public after being run into by motor-cars. " There ought to be some means by which they could be reimbursed ; as a rule, the costs of the hospital are not included in damages at all, and the hospital has no claim." Hospitals might, he added, send in a bill to the unfortunate sufferer, and he might include that bill in his claim for damages. " It is certainly a matter which ought to be considered by the proper authorities." The learned judge presumably meant that Parliament should be asked
antitoxin could be administered in small volume, and that at the same time the incidence of " serum sicknesswith its troublesome train of urticaria, malaise, and arthralgia might be lowered. Dried serum appeared to promise stability, and search was made for a reliable preparation of dry material which might be dissolved in a small volume of water when required for injection. Dried serum, however, was apt to become partly insoluble and the solution or suspension in water was not always limpid. This method of providing antitoxin has now fallen almost entirely into disuse except for isolated communities. But when E. P. PICK and his co-workers showed in 1902 that most of the antitoxin was attached to a certain easily separable fraction of the total protein in serum, the possibility of concentrating serum by discarding the useless protein arose and was welcomed by serologists. When ammonium sulphate is added to serum to about one-third the saturation point, a precipitate is formed which is insoluble in water free of salts. This " euglobulin," when redissolved in saline solution, contains practically no antitoxin ; nor does albumin, which is precipitated by between half and full saturation with ammonium sulphate. The middle fraction, however, termed " pseudoglobulin," precipitated by ammonium sulphate between one-third and half saturation, and soluble in water or in saturated solution of sodium chloride, contains almost the whole of the antitoxin. The " processes of concentration or purification, arising largely from the work of R, B. GIBSON and E. J. BANZHAF, are based on the application of these characteristic solubilities. The euglobulin and albumin, containing no antitoxin, are removed by fractional salt precipitation or by methods of electrodialysis, and the pseudo-globulin, rich in antitoxin, is retained. By these processes concentrated antitoxin is produced which, for each unit of protein present, contains from two to three times as much antitoxin as the original serum. The concentration per cubic centimetre obviously depends on the protein percentage in the final fluid provided. It is found that with a protein percentage higher than 20-the limit under various official regulations-the fluid is undesirably viscous. In America, for many years past, and, more recently in England, concentrated diphtheria and tetanus antitoxins have been in routine Concentrated or purified serum has now made use. its appearance in other European countries, though we understand that in Germany none of the antitoxins subject to control may be issued as serum concentrated with ammonium sulphate. Various objections to the adoption of concentrated serum have been brought forward. During concentration, it has been said, certain curative bodies
modern
293 of unknown composition are lost, and, therefore, we believe, economically applicable to the commercial unconcentrated serum has a more rapid and thorough production of antitoxin. All proteins known may sensitise animals and proinfluence in diphtheria than does concentrated serum containing the same number of units ; moreover, duce some form of liability to anaphylactic phenodoubt has been thrown on the rapidity of absorption mena ; if, therefore, antitoxins could be prepared of concentrated serum compared with natural serum. free of protein, presumably serum reactions and serum HETSCH and BIELING,1 working with serum con- sickness would disappear. But unluckily this hope centrated by evaporation, concluded that this serum has not yet been realised. The promising pneumococcal antibody prepared by HUNTOON was not was absorbed less readily than natural antitoxic serum, but the careful experiments of W. H. PARK entirely free of the property of causing reactions. and colleagues appear to supply strong evidence RAMON has stated3 that his purified serum does not that this is not true of ordinary concentrated serum. cause reactions ; we cannot trace the publication Clinical experience in England does not confirm the of the details of the process of preparation and objections ; medical superintendents of isolation comment must therefore be reserved. It is of hospitals, who have had ample opportunities of interest to note that the antibody to pneumonia comparing natural and concentrated antitoxin, have, prepared by FELTON,4 which has also been successduring the past ten years, gradually transferred their ful in other hands (see THE LANCET, 1928, ii., 766), is favour to concentrated serum, and this is now used obtained by a variation of these methods of concenalmost universally. The change is the more impressive tration which are based on solubilities of the various in that concentrated serum formerly cost hospitals protein fractions. New processes are likely to considerably more for a given number of units, and develop on similar lines. The keen interest of the it yields far less profit to the manufacturer. The academic biochemist in the real constitution of patient’s interests have, however, triumphed over antitoxin, as well as the wholesome rivalry between these objections, and the incidence of serum sickness members of the scientific staffs alike in State and has, by the use of concentrated antitoxin, been in commercial serum institutes, leads to ever active reduced to a fraction of what it was when uncon- attempts to improve the potency of the sera used centrated serum was used. An objection of another by the practitioner in his daily work, while State kind has also been raised. TH. MADSEN, R. control ensures their safety. and have KRAUS,2 others, questioned whether the classical Ehrlich method of titrating antitoxin units measures the real value of an antitoxic serum, and suggest that two antitoxins of equal unit value may vary widely in therapeutic potency because one may have a greater " avidity," and may therefore seize more speedily and more firmly any toxin molecules Ne quid nimis. it encounters. This problem is at present the subject of inquiry by a committee of the Medical Section of THE KING’S HEALTH, the League of Nations. The methods of concentration hitherto described THE removal of the KING to Bognor marks a definite applv to antitoxins designed for use in the stage in his illness, but we protest again that it is treatment of diphtheria, tetanus, scarlet fever, premature to speak of convalescence. There has dysentery (Shiga), and diseases caused by the gas- been throughout the pastweek a slow but definite gangrene bacilli. An entirely different method of increase in strength, and we learn that a slight concentration consists in adding the specific antigen improvement has even been observed in the weight. to an antiserum and obtaining an antigen-antibody On two occasions the KING has been allowed to sit complex which is separated by the centrifuge and up for a brief period when the relief to monotony then split into its two components. Thus, red bloodwas beneficial, and was appreciated by the patient. cells added to antiserum absorb the hæmolysin and The latest official calls attention to these hæmagglutinin, and may be then separated by facts while it refersbulletin to the further employment of sedimentation or spinning. By warming in approThe here is that in the choice therapy. position priate alkaline or sugar solution the hæmolysin may ray of the clinical condition of the and rays apparatus be freed from the red cells and obtained in a solution has been the controlling anxiety. a minimal of patient throughout amount HUNTOON protein. containing in 1920 (Trans. Philadelphia Path. Soc., 1920, xxii., When treatment was begun the exposure could only 75) added pneumococci to antiserum and thus be made for short periods and on portions of the body linked the specific antibody to the cocci ; he then in order to reduce the degree of disturbance to a centrifuged the preparation and, by treating the cocci minimum. The need at that time was the stimulation in weak alkali, was able to detach a highly potent of parathyroid activity, the adjustment of calcium antibody which contained but a minute amount of metabolism, the rectification of the leucocyte count, nitrogen-so small that 5 c.cm. of the solution would and the raising of the bactericidal power of the blood. not sensitise a guinea-pig. This achievement was The mercury-vapour lamp was judged, at this serious acclaimed in certain quarters as a proof that antibody stage of the illness, to be the method of choice in was not necessarily protein in constitution, but biofurthering these ends, and we understand that there chemists to-day do not unreservedly accept this view. is reason to think that the progress which occurred In the Ramon flocculation method, the toxin added the period of the application of rays from this during to antitoxic serum forms a union with the specific source was in part due to their influence. Local antitoxin. The floccules can be separated by spintreatment of the wound by ultra-violet light has a ning, portion of the antitoxin detached from the The improvement now toxin by warmth and acid, and a purified antitoxin never been employed. attained renders treatment by the carbon possible obtained. At present this process is not apparently,
Annotations. "
arc, with its
more
penetrating
"
luminous rays.
1
Arbeiten aus dem Staatsinstitut für Exper. Therap., Frankfurt a.M. 1928, xxi., 230. 2 Zeit. fur Immunitatsf., 1928, lviii., 399.
3
La Presse Médicale, 1926, xxxiv., 323. 4 Jour. Inf. Dis., 1928, xliii., 531.
its trade. The claim was for deduction of the sums subscribed in 1919 and 1920, and it appeared that the Commissioners of Inland Revenue had actually allowed a subscription of 50 guineas as a business expense. The Inland Revenue, however, argued that * this was a concession, not a legal right ; alternatively, so ran the argument, the large sums subscribed in 1919 and 1920 were not wholly and exclusively laid out for the purposes of trade in relation to those particular years, because the subscriptions were intended to make up deficiencies for previous years. The Special Commissioners held that there was no legal right to make the deduction, and Mr. Justice RowLATT agreed with them. He remarked, however, that if the Special Commissioners had taken the opposite view of the question of fact he would not have dreamt of disturbing their decision. On a question of fact the Commissioners’ decisions are hard to shake. Counsel for the firm essayed to treat the matter as one of law not of fact, by submitting that the Commissioners had misdirected themselves in law by deciding that a hospital subscription could never be an allowable deduction. This view the judge was unable to accept ; the upshot is that, to the extent of the taxation upon the amount subscribed, a hospital subscriber has been penalised. Whether the firm merely decided to show gratitude for hospital services rendered or whether the arrangement could be vieived as a simple, though informal, working agreement, the result is the same. The second case in which the gift of money to a hospital was unfortunately discouraged by the law occurred at the Liverpool Assizes on Jan. 31st. In awarding some £3000 to a man injured by a motorist’s negligence, the jury recommended that, if possible, there should be a further sum of £50 paid to the Stanley Hospital where the plaintiff had had 13weeks’ treatment. Mr. Justice WRIGHT pointed out that he had no power to award damages to anyone but the plainti:H. Counsel suggested that the jury might have awarded the sum to the plaintiff to be paid to the hospital for operations performed, but the judge replied that no such condition could be imposed. Hospitals, lie said, have extraordinary hardships in having to deal with injuries, often serious, sustained by members of the public after being run into by motor-cars. " There ought to be some means by which they could be reimbursed ; as a rule, the costs of the hospital are not included in damages at all, and the hospital has no claim." Hospitals might, he added, send in a bill to the unfortunate sufferer, and he might include that bill in his claim for damages. " It is certainly a matter which ought to be considered by the proper authorities." The learned judge presumably meant that Parliament should be asked
antitoxin could be administered in small volume, and that at the same time the incidence of " serum sicknesswith its troublesome train of urticaria, malaise, and arthralgia might be lowered. Dried serum appeared to promise stability, and search was made for a reliable preparation of dry material which might be dissolved in a small volume of water when required for injection. Dried serum, however, was apt to become partly insoluble and the solution or suspension in water was not always limpid. This method of providing antitoxin has now fallen almost entirely into disuse except for isolated communities. But when E. P. PICK and his co-workers showed in 1902 that most of the antitoxin was attached to a certain easily separable fraction of the total protein in serum, the possibility of concentrating serum by discarding the useless protein arose and was welcomed by serologists. When ammonium sulphate is added to serum to about one-third the saturation point, a precipitate is formed which is insoluble in water free of salts. This " euglobulin," when redissolved in saline solution, contains practically no antitoxin ; nor does albumin, which is precipitated by between half and full saturation with ammonium sulphate. The middle fraction, however, termed " pseudoglobulin," precipitated by ammonium sulphate between one-third and half saturation, and soluble in water or in saturated solution of sodium chloride, contains almost the whole of the antitoxin. The " processes of concentration or purification, arising largely from the work of R, B. GIBSON and E. J. BANZHAF, are based on the application of these characteristic solubilities. The euglobulin and albumin, containing no antitoxin, are removed by fractional salt precipitation or by methods of electrodialysis, and the pseudo-globulin, rich in antitoxin, is retained. By these processes concentrated antitoxin is produced which, for each unit of protein present, contains from two to three times as much antitoxin as the original serum. The concentration per cubic centimetre obviously depends on the protein percentage in the final fluid provided. It is found that with a protein percentage higher than 20-the limit under various official regulations-the fluid is undesirably viscous. In America, for many years past, and, more recently in England, concentrated diphtheria and tetanus antitoxins have been in routine Concentrated or purified serum has now made use. its appearance in other European countries, though we understand that in Germany none of the antitoxins subject to control may be issued as serum concentrated with ammonium sulphate. Various objections to the adoption of concentrated serum have been brought forward. During concentration, it has been said, certain curative bodies
modern
293 of unknown composition are lost, and, therefore, we believe, economically applicable to the commercial unconcentrated serum has a more rapid and thorough production of antitoxin. All proteins known may sensitise animals and proinfluence in diphtheria than does concentrated serum containing the same number of units ; moreover, duce some form of liability to anaphylactic phenodoubt has been thrown on the rapidity of absorption mena ; if, therefore, antitoxins could be prepared of concentrated serum compared with natural serum. free of protein, presumably serum reactions and serum HETSCH and BIELING,1 working with serum con- sickness would disappear. But unluckily this hope centrated by evaporation, concluded that this serum has not yet been realised. The promising pneumococcal antibody prepared by HUNTOON was not was absorbed less readily than natural antitoxic serum, but the careful experiments of W. H. PARK entirely free of the property of causing reactions. and colleagues appear to supply strong evidence RAMON has stated3 that his purified serum does not that this is not true of ordinary concentrated serum. cause reactions ; we cannot trace the publication Clinical experience in England does not confirm the of the details of the process of preparation and objections ; medical superintendents of isolation comment must therefore be reserved. It is of hospitals, who have had ample opportunities of interest to note that the antibody to pneumonia comparing natural and concentrated antitoxin, have, prepared by FELTON,4 which has also been successduring the past ten years, gradually transferred their ful in other hands (see THE LANCET, 1928, ii., 766), is favour to concentrated serum, and this is now used obtained by a variation of these methods of concenalmost universally. The change is the more impressive tration which are based on solubilities of the various in that concentrated serum formerly cost hospitals protein fractions. New processes are likely to considerably more for a given number of units, and develop on similar lines. The keen interest of the it yields far less profit to the manufacturer. The academic biochemist in the real constitution of patient’s interests have, however, triumphed over antitoxin, as well as the wholesome rivalry between these objections, and the incidence of serum sickness members of the scientific staffs alike in State and has, by the use of concentrated antitoxin, been in commercial serum institutes, leads to ever active reduced to a fraction of what it was when uncon- attempts to improve the potency of the sera used centrated serum was used. An objection of another by the practitioner in his daily work, while State kind has also been raised. TH. MADSEN, R. control ensures their safety. and have KRAUS,2 others, questioned whether the classical Ehrlich method of titrating antitoxin units measures the real value of an antitoxic serum, and suggest that two antitoxins of equal unit value may vary widely in therapeutic potency because one may have a greater " avidity," and may therefore seize more speedily and more firmly any toxin molecules Ne quid nimis. it encounters. This problem is at present the subject of inquiry by a committee of the Medical Section of THE KING’S HEALTH, the League of Nations. The methods of concentration hitherto described THE removal of the KING to Bognor marks a definite applv to antitoxins designed for use in the stage in his illness, but we protest again that it is treatment of diphtheria, tetanus, scarlet fever, premature to speak of convalescence. There has dysentery (Shiga), and diseases caused by the gas- been throughout the pastweek a slow but definite gangrene bacilli. An entirely different method of increase in strength, and we learn that a slight concentration consists in adding the specific antigen improvement has even been observed in the weight. to an antiserum and obtaining an antigen-antibody On two occasions the KING has been allowed to sit complex which is separated by the centrifuge and up for a brief period when the relief to monotony then split into its two components. Thus, red bloodwas beneficial, and was appreciated by the patient. cells added to antiserum absorb the hæmolysin and The latest official calls attention to these hæmagglutinin, and may be then separated by facts while it refersbulletin to the further employment of sedimentation or spinning. By warming in approThe here is that in the choice therapy. position priate alkaline or sugar solution the hæmolysin may ray of the clinical condition of the and rays apparatus be freed from the red cells and obtained in a solution has been the controlling anxiety. a minimal of patient throughout amount HUNTOON protein. containing in 1920 (Trans. Philadelphia Path. Soc., 1920, xxii., When treatment was begun the exposure could only 75) added pneumococci to antiserum and thus be made for short periods and on portions of the body linked the specific antibody to the cocci ; he then in order to reduce the degree of disturbance to a centrifuged the preparation and, by treating the cocci minimum. The need at that time was the stimulation in weak alkali, was able to detach a highly potent of parathyroid activity, the adjustment of calcium antibody which contained but a minute amount of metabolism, the rectification of the leucocyte count, nitrogen-so small that 5 c.cm. of the solution would and the raising of the bactericidal power of the blood. not sensitise a guinea-pig. This achievement was The mercury-vapour lamp was judged, at this serious acclaimed in certain quarters as a proof that antibody stage of the illness, to be the method of choice in was not necessarily protein in constitution, but biofurthering these ends, and we understand that there chemists to-day do not unreservedly accept this view. is reason to think that the progress which occurred In the Ramon flocculation method, the toxin added the period of the application of rays from this during to antitoxic serum forms a union with the specific source was in part due to their influence. Local antitoxin. The floccules can be separated by spintreatment of the wound by ultra-violet light has a ning, portion of the antitoxin detached from the The improvement now toxin by warmth and acid, and a purified antitoxin never been employed. attained renders treatment by the carbon possible obtained. At present this process is not apparently,
Annotations. "
arc, with its
more
penetrating
"
luminous rays.
1
Arbeiten aus dem Staatsinstitut für Exper. Therap., Frankfurt a.M. 1928, xxi., 230. 2 Zeit. fur Immunitatsf., 1928, lviii., 399.
3
La Presse Médicale, 1926, xxxiv., 323. 4 Jour. Inf. Dis., 1928, xliii., 531.