USE OF ANTITOXIN. 245 



The most thorough antisepsis should obtain when the 

 serum is injected. Many of the unsatisfactory results follow- 

 ing injection can be ascribed to a careless injection. Abscesses 

 may develop at the site of the injection and death may follow 

 from septicaemia or even pysemia. These are the cases that 

 are " made worse " by the injection. A hypodermic injection 

 should always be looked upon as a surgical procedure, and 

 the strictest asepsis carried out. 



The injection can be made into the buttock or the loose 

 tissues of the abdomen, but the best place is the subcutaneous 

 tissue of the back between the shoulder-blades. The patient 

 should be held absolutely quiet during the injection. The 

 child can be wrapped in a sheet or cloth, and held by the 

 assistant in such a manner that only the back of the patient 

 is exposed. The instruments, hands of the operator, and the 

 site of inoculation are rendered sterile. The smallest quan- 

 tity of antitoxin, consistent with the dose it is desired to 

 inject, should be used. The injection should be made slowly 

 and the needle withdrawn gradually, the skin at the punct- 

 ure being held firmly between the first finger and thumb 

 of the left hand. By gently manipulating the tissues absorp- 

 tion of the antitoxin will be facilitated considerably. The 

 wound is sealed with collodion and covered with a protective 

 dressing. It is useless to give the antitoxin by mouth, 

 because it is digested in the alimentary canal without exhibit- 

 ing any action. 



No matter what the age of the patient, the initial dose 

 should be from 1500 to 2000 units. In very severe cases at 

 least 3000 units should be used. If the reaction does not 

 occur within twenty-four hours after the injection is made, 

 another 1000 units should be injected. This may be repeated, 

 if necessary, on the following day. It is a matter of record 

 that since the advent of the antitoxin treatment of diphtheria 

 the mortality from this disease has been reduced at least one- 

 half; and in the hands of some clinicians the percentage of 

 fatalities is even less. The necessity for intubation or trache- 

 otomy has been correspondingly diminished ; and in cases in 

 which these procedures have been performed the mortality is 

 less now than what it was wheiv the antitoxin was not used. 



