62 THE PRINCIPLES OF IMMUNOLOGY 



on Tetanus published by the British War Office gives a plan for 

 combined injections in a case of acute tetanus; 



Day Subcutaneous Intramuscular Intrathecal 



First 8,000 units 16,000 units 



Second 8,000 units 16,000 units 



Third 4,000 units 8,000 units 



Fourth 4,000 units 8,000 units 



Fifth 2,000 units 



Seventh 2,000 units 



Ninth 2,000 units 



This outline is offered as a suggestion for treatment and has 

 been applied successfully. The doses are arranged in multiples of 

 8000 because that was the size phial issued in the British army. 

 Doses may be varied, but it is strongly advised to administer a 

 total of 75,000 to 100,000 units. In those cases with long incuba- 

 tion period the dose may be smaller, and if the case is one of spasm 

 in one extremity, without evidence of involvement of higher centers, 

 such as spasm of jaw muscles (trismus), the serum may be given 

 by intramuscular and subcutaneous routes in amounts of 3000 to 

 6000 units. The patient should be placed so that he lies with the 

 feet considerably higher than the head, so as to allow drainage to- 

 ward the head. It has also been suggested that the antitoxin be 

 applied near or in the wound. Calmette recommended that pow- 

 dered antitoxic serum be applied locally. Suter recommended rub- 

 bing the fluid serum into the wound. Bockenheimer recommended 

 that it be introduced in the form of ointment, and Robertson satur- 

 ated pads of cotton with antitoxin, dried these for twenty-four hours 

 at 40 to 45 C, and applied them locally. As will be seen, these 

 latter measures are probably more in the nature of prophylaxis than 

 treatment, and no definite information has accrued as to their value. 

 The disadvantages of serum treatment are essentially the same as 

 those in the use of diphtheria antitoxin, but in addition we have to 

 deal with the factor of introduction of foreign serum into the spinal 

 canal. This frequently leads to the development of a sterile menin- 

 gitis with a formation of purulent fluid. As far as can be learned, 

 this inflammation does no damage. A few reports of nerve and 

 cord lesions following the use of antitetanus serum intrathecally 

 have been reported, but they are extremely small in number com- 

 pared to the number of cases treated, and it would appear that the 

 high percentage of mortality in this disease justifies the intrathecal 

 treatment in spite of the minor element of danger. 



Dysentery Toxin and Antitoxin. Dysentery toxin may be pro- 

 duced in broth by the growth of the Shiga bacillus. It is probable 

 that the Flexner and Hiss-Russell types produce only an endotoxin. 

 This is consistent with the greater clinical and pathological severity 

 of the Shiga type of dysentery. The broth must be definitely alka- 

 line, the optimum stated by Doerr being reached where 0.3 per cent. 

 soda is added to a broth neutral to litmus. Rabbits are very sus- 

 ceptible and the intravenous injection of a filtered toxin broth in 



