SERUM TREATMENT OF DIPHTHERIA 763 



absorption of toxin by the nasal mucosa a small patch in the nose may be 

 accompanied by severe general toxemia and frequently requires ener- 

 getic treatment. 



In diphtheria of the eye, vulva, or of wounds relatively large doses 

 should be given at least from 10,000 to 20,000 units. 



All these doses must be regarded merely as suggestions for the initial 

 dose in cases seen on about the second day of the disease. Physicians 

 with extensive hospital experience, for example, Woody and McCullom, 

 generally favor large doses, and while in private practice the question 

 of expense and economy may be a factor, the physician will be wise to 

 err on the side of safety and give a little too much serum rather than too 

 little, especially in the first dose, when so much depends upon how soon 

 antitoxin is introduced into the body-fluids. 



2. The general condition of the patient, or the effect which the tox- 

 emia will have on the patient, is highly important in estimating the 

 dosage of antitoxin. A patient who is pale, drowsy, prostrated, and 

 has a weak and irregular pulse; who has large masses of glands around 

 the neck, or who has marked albuminuria, will require a much larger 

 dose than one who presents none of these signs. Two persons of about 

 the same age and suffering from the same lesions may show very differ- 

 ent degrees of toxemia. In the severe cases we must administer the 

 maximum dose and repeat it at suitable intervals until an effect is pro- 

 duced. 



3. The day of illness on which the patient comes under observation 

 is important in deciding the initial dose of antitoxin. For corresponding 

 tonsillar lesions a dose of 2000 units on the first day may do more good 

 than 5000 units given on the fourth day. Ker gives second-day cases 

 of purely tonsillar diphtheria 3000 units, and adds an additional 1000 on 

 the following day. 



4. If the age of the patient exerts any influence at all on dosage, it in- 

 dicates that more antitoxin should be 'given to children than to adults 

 with corresponding lesions, as the disease is more fatal in children. So 

 far as infants are concerned, Ker seldom gives more than 4000 units at a 

 single dose, which should be an adequate amount when we consider the 

 small size of the patient. Children over one year of age may be given 

 from 5000 to 10,000 or more units, depending upon the location of the 

 lesion and the degree of toxemia. 



Repeating the Dose. Whether or not subsequent doses of antitoxin 

 will be required is dependent upon the circumstances of the individual 

 case. In ordinary cases if on the day after treatment is commenced 



