TETANUS 227 



indifferent point, and to repeat the dose within six to eight weeks, 

 as the immunity which is afforded only lasts for that length of time. 



When symptoms of tetanus already exist, very little is to be 

 expected from the use of the antitoxin for the reason that these 

 symptoms indicate that a union with sensitive receptors (in the 

 central nervous system) has already occurred, and that the anti- 

 toxin cannot penetrate to those points from intact bloodvessels. 

 Neither the subcutaneous nor the intravenous route hence offers 

 much hope of a satisfactory result. The attempt has accordingly 

 been made to bring the material into immediate contact with the 

 central nervous structures, by intraneural injections, through intra- 

 cerebral injections and by its introduction into the subarachnoid 

 space. The intracerebral method is to be deprecated altogether, 

 as the death rate following its use has been exceedingly high. More 

 appropriate is the intraneural route, to w r hich end the larger nerve 

 trunks along which absorption has likely taken place, must be 

 exposed and injected at different points in their course. Unfortu- 

 nately, not much serum can be introduced in this manner, and it is 

 natural that the patient should subsequently suffer a good deal from 

 the resulting neuritis. By the subdural route, on the other hand, it 

 is easy to introduce large quantities of serum, and as Stintzing and 

 Kiister have already demonstrated that the cerebrospinal fluid 

 usually contains a considerable amount of toxin in human tetanus, 

 this method of treatment seems rational and likely to do good so 

 long as recovery is at all possible, i. e., so long as the union between 

 toxin and the sensitive receptors is still capable of being broken. 

 It is recommended to tap the subarachnoid space in the usual manner, 

 to allow as much of the meningeal fluid to escape as possible, care 

 being taken, however, not to let the pressure fall too low, and then to 

 slowly inject an equivalent volume of serum (10 to 20 c.c.) at a rate 

 of about 2 c.c. per minute. According to the requirements of the 

 case, this may be repeated several times within the same twenty- 

 four hours, and continued on the following days. 



As antitoxin treatment in tetanus can be expected to do good 

 only so long as the toxin has not combined with the sensitive recep- 

 tors of the central nervous system (barring those exceptional cases 

 where this union can still be broken), and so long as it can be readily 

 reached by the antitoxin, i. e., before it has begun its travel along 

 the axis cylinders of the affected nerves, it follows that its use must be 



