SERUM TREATMENT OF DIPHTHERIA 759 



ministered by subcutaneous injection into the tissues of the back, ab- 

 domen, or buttocks. Experimental studies have tended to show that 

 complete absorption does not occur until forty-eight hours after, al- 

 though it is common clinical experience to observe improvement take 

 place during the first twenty-four hours after injection. 



As will be emphasized later, it is highly desirable and necessary "to get 

 antitoxin into the circulation as soon as possible after infection has occurred. 

 Usually this is best accomplished by giving antitoxin to every patient 

 even suspected of being diphtheric, and making the diagnosis afterward; 

 the next best method is to administer the antitoxin in such manner as to 

 favor quick absorption. For this reason intramuscular and intravenous 

 injection should be resorted to in all severe cases. As pointed out in 

 Chapter XXXI, the Schick reaction in diphtheria has indicated that 

 diphtheria toxin may be dissociated from tissue-cells by large doses of 

 antitoxin. Park and his associates have shown experimentally by this 

 reaction that 20,000 units of antitoxin given subcutaneously were neces- 

 sary to yield an effect equal to 1000 units given intravenously. 



Intramuscular injections into the muscles of the buttocks are just as 

 readily given as subcutaneous injections, and are probably no more pain- 

 ful to the average patient. It insures quicker absorption, and may, 

 indeed, be adopted as a routine practice. 



Intravenous injections are far more difficult, especially in children 

 with fat arms and feeble circulations. An anesthetic or ten minutes 1 

 struggling may do the patient harm, and unless the injection can be 

 given with little disturbance and danger, the serum should be given by 

 intramuscular injection. Not infrequently, however, an intravenous 

 injection yields splendid results in severe and apparently hopeless cases, 

 and in older children and adults this route of administration should be 

 considered. 



The syringe method is well adapted for the intravenous injection of 

 antitoxin, as the bulk method of serum is usually small, especially if a 

 concentrated antitoxin is being used. 



The technic of these injections has previously been described. 



Antitoxin has also been given by the mouth and even by rectal in- 

 jection. The presence of a preservative, usually phenol, renders the 

 oral administration objectionable. While a therapeutic effect may be 

 secured after large doses have been swallowed, there are very few oc- 

 casions when this should be the method of choice. 



Importance of Early Treatment. The most important point to be ob- 

 served in the treatment of diphtheria is to give antitoxin at once. It may 



