762 PASSIVE IMMUNIZATION SERUM THERAPY 



continuous enteroclysis of normal salt solution during the early periods 

 of severe infections; this appears to dilute the toxins and aid in their 

 destruction and excretion. 



In administering antitoxin the physician must be guided by the 

 clinical condition of the patient, as we have as yet no practical labora- 

 tory method for estimating the degree of the toxemia. Treatment may 

 be regarded as satisfactory when 



1. The local patch of exudate has ceased to spread and shows indica- 

 tions of disappearing. 



2. The general condition of the patient is improved, i.e., the toxemia 

 is decreased, the pulse grows stronger and more regular, and the patient 

 feels more comfortable. 



The temperature is not a reliable guide, for not infrequently in 

 severe infections it may be normal or subnormal throughout. 



So long as the exudate shows no signs of loosening and disappearing, 

 but tends to spread, and so long as the general condition remains unim- 

 proved or grows worse, large amounts of antitoxin should be given. 

 No case should be regarded as hopeless until death supervenes. 



Every case of diphtheria is to be treated individually, rather than by 

 any set rule. The amount of antitoxin given in the initial dose, and in 

 subsequent doses as well, is dependent on the following factors : 



1. The situation and extent of the lesion. 



2. The general condition of the patient. 



3. The day of the disease. 



4. The age of the patient. 



1. The Situation and Extent of the Lesion. In ordinary tonsillar 

 diphtheria in which there is a small patch on one tonsil and which is first 

 seen on the second day of the disease, the initial dose should be at least 

 5000 units. When the exudate involves the pillars of the fauces, the 

 uvula, the posterior pharyngeal wall, or is well forward on the palate, 

 this dose should be doubled, and 10,000 units be given. 



Cases that present laryngeal symptoms in addition to faucial lesions 

 should never receive less than 12,000 units. In well-marked laryngeal 

 diphtheria with dyspnea and partial suffocation at least 20,000 units 

 should be given, preferably by intramuscular or intravenous injection. 



In nasal diphtheria a distinction must be made between those cases 

 that exhibit merely a dirty, chronic discharge containing bacilli, in which 

 2000 units may suffice, and those that present an actual membrane ac- 

 companied by well-marked toxic symptoms, when a large amount of 

 serum at least 10,000 units should be given. Owing to the ready 



