708 PASSIVE IMMUNIZATION SERUM THERAPY 



be fatal to wait for the result of a culture, except perhaps in the case of the 

 mildest of infections. In fact, the necessity for early administration of 

 antitoxin cannot be overestimated. When once suspicion is aroused, anti- 

 toxin should be given at once and the diagnosis may follow. A few hours 

 may make an enormous difference in the prognosis of any case, and while 

 a dose of 2000 units of antitoxin may prove of the utmost value in 

 checking diphtheria, it will do no harm whatever in case the disease is 

 not present. 



It is true that a physician will naturally hesitate to administer anti- 

 toxin unnecessarily; nevertheless, diphtheria is frequently a difficult 

 disease to diagnose clinically, and is quite likely to be mistaken for tonsil- 

 litis. For this reason many physicians prefer to wait for the result of a 

 culture, and this is proper, provided that the patient, especially in the 

 case of a child, is given the benefit of the doubt by receiving 2000 units 

 of antitoxin. It is to be emphasized that a single negative culture does not 

 exclude diphtheria. As ordinarily made, about 20 per cent, of primary 

 cultures from genuine cases of diphtheria fail to show the presence of 

 bacilli, whereas subsequent cultures will show them to be present in 

 large numbers. A primary negative culture is most likely to be obtained 

 from a patient having a heavy exudate, as the physician may rub lightly 

 over the membrane, culturing the microorganisms of secondary infection 

 and overlooking the diphtheria bacilli in the depths of the membrane 

 adjacent to the diseased mucous membrane. To wait another twenty- 

 four hours for a second culture still further reduces the patient's chances 

 for recovery. In the vast majority of instances, therefore, antitoxin should 

 be given at once and repeated as often as is necessary until the correct diag- 

 nosis is established, and not one but at least two successive negative cultures 

 should be obtained before diphtheria is to be excluded with any reasonable 

 degree of safety. 



The following table, compiled from the annual reports of the Phila- 

 delphia Hospital for Contagious Diseases, shows the decided influence 

 of early treatment upon the mortality of diphtheria. This table com- 

 prises cases of diphtheria alone, and does not include cases complicated 

 by other diseases, such as scarlet fever and measles. It is worthy of 

 special notice that of IJ+l cases treated with antitoxin on the first day of the 

 disease, not one died. Ker, 1 in an exceptionally rich experience, has 

 never seen a fatal result occur in a case that developed in a hospital and 

 in which antitoxin was administered on the first day of the disease. 

 1 Infectious Diseases, 1909, Oxford Med. Press. 



