TOXINS AND ANTITOXINS 59 



follows the introduction of the bacilli or their spores into wounds in 

 such a fashion that anaerobic growth is permitted. The incubation 

 period is usually considered to be eight days, but there are many 

 variations from this standard period, including cases that have an 

 incubation period of over sixty days. The mortality from the dis- 

 ease is extremely high, the average ranging between 78 and 90 per 

 cent. Its incidence in civil life is not very great, but in time of war 

 it is likely to occur with considerable frequency because of the con- 

 tamination of war wounds by soil containing the organism or its 

 spores. In the American Civil War the disease occurred in 2.5 per 

 cent, of the wounded; in the Franco-Prussian War in 3.5 per cent.; 

 and in the World War 6.5 per cent. In the earlier wars the mortality 

 ranged between 80 and 90 per cent., but in the World War, owing 

 in all probability to prophylaxis and treatment, the mortality was 

 50 per cent. In carefully studied statistics it is found that the longer 

 the incubation period the lower is the rate of mortality. This general 

 statement held true before the use of anti-tetanic serum was instituted 

 and still holds true. The difference between the mortality rate of 

 80 to 90 per cent, in the earlier wars and 50 per cent, in the World 

 War gives an excellent illustration of the decrease in mortality that 

 has followed the introduction of serum prophylaxis and treatment 

 as well as rational surgery. Knowing that the organism is anaerobic 

 in growth, surgery demands that contaminated wounds be kept open 

 for the access of air. 



Prophylactic Use of Serum. The use of tetanus antitoxin is 

 directed toward prophylaxis and toward cure. As can readily be 

 understood from the experiments outlined above, the toxin of this 

 disease is very firmly bound to nerve tissues ; therefore, treatment 

 established after the disease has appeared is not likely to be so 

 effective as in the use of some other antitoxins. Nevertheless, not- 

 able success has been attained in some cases where the disease has 

 become well advanced before serum treatment has been instituted. 

 Prophylactic treatment with serum is given as early after the 

 wound as possible, and in both military and civil life all wounds 

 contaminated with soil should receive protective doses of tetanus 

 antitoxin. This is given subcutaneously in doses of 500 to 1000 

 units. Wolff reported that in the German army prior to December, 

 1914, prophylactic injections were not regularly given and the inci- 

 dence of tetanus amounted to 1.4 per cent, of the wounded. During 

 the following seven months prophylactic injections were given in 

 the field to all those wounded. by grenades and shrapnel, but not 

 those wounded by rifle bullets, and the incidence of the disease was 

 reduced to 0.16 per cent. Protection was equally as successful in 

 the Allied armies, and instructions were given to administer serum 

 as soon after injury as possible, either in the first-aid station or in 

 the field hospitals. Experiences in the British army demonstrated 

 that cases might develop a considerable time after the wound was 

 inflicted, and for this reason subsequent orders directed the use of 



