DIPHTHERIA 237 



toxin with the receptors of sensitive cells will be the firmer the 

 longer this has lasted. It follows that large doses will be required, 

 if the patient first comes under observation after the disease has 

 already existed for a number of days, and that in the presence of 

 toxic symptoms, indicating that toxin has already been anchored 

 by sensitive cells, very large doses only can be expected to be helpful. 

 It is accordingly recommended that the physician should not delay 

 the use of antitoxin until a bacteriological examination has been 

 made, but to resort to it whenever diphtheria is suspected. This 

 rule is indeed the only natural one to follow. 



As to the size of the initial dose, the last word has probably not 

 yet been spoken. In the earlier days of antitoxin treatment 100 to 

 200 units were recommended, but since then there has been a ten- 

 dency to ever-increasing amounts, and in the United States 3000 

 units may now be regarded as an average dose in cases of moderate 

 severity. If a longer interval than twenty-four hours has elapsed 

 before the patient is first seen, the dose should be still larger, and if 

 threatening symptoms of any kind exist the physician should not 

 hesitate to inject 10,000 units or more at the time of his first visit. 

 Some writers, indeed, have used much larger amounts (up to 50,000 

 to 100,000 units) and have reported favorable results in the most 

 desperate cases. 



Following the first injection the antitoxin is continued at intervals 

 of twelve to twenty-four hours, until the disease is evidently under 

 control, and I would emphasize once more that much time may be 

 saved if the injections are given intravenously, or even intramus- 

 cularly. In severe cases the subcutaneous administration should 

 unquestionably be abandoned, since the absorption owing to the 

 lowered blood-pressure must then be still slower than in a healthy 

 individual, where the maximal blood content in antitoxin is scarcely 

 reached before the third day. 



Total Quantity that may be Administered. As to the quantity 

 of antitoxin which may be administered in the course of the malady 

 there is apparently no limit. Bankier thus reports the case of a 

 child in which 72,000 units were given, and in which recovery 

 occurred in spite of the most ominous symptoms (profuse nose-bleed, 

 extensive hemorrhagic ecchymoses of the skin, paresis of the pharyn- 

 geal muscles of the palate, of the larynx and some of the skeletal 

 muscles, nephritis with edema, etc.). Gabriel, at Neisser's clinic, 



