SERUM TREATMENT OF TETANUS 727 



in places best suited to secure the maximum neutralizing action of the 

 serum. 



Surgical Treatment. 1. The site of the wound should be located, 

 and if possible incised under ether or chloroform anesthesia and thor- 

 oughly cleansed of foreign material and necrotic tissue. It should then 

 be swabbed with the 3 per cent, alcoholic solution of iodin, washed with 

 hydrogen dioxid solution, and packed loosely with gauze soaked in the 

 iodin solution. 



2. Cauterization with pure phenol, followed by alcohol, may be em- 

 ployed, but, as a rule, the weaker germicide is preferable in order not to 

 produce necrosis of the tissues, which furnishes pabulum for bacterial 

 growth. The wound should be dressed daily. 



Serum Treatment. A maximum amount of antitoxin should be 

 given the patient as soon as possible, and the greater the delay in giving 

 the antitoxin, the greater is the amount required. Since absorption 

 after subcutaneous injection is very slow, valuable time may be lost, 

 and since enormous amounts must be given, at great expense, this route 

 possesses much less value than the intravenous and intraspinal methods. 



1. Administer intravenously from 10,000 to 20,000 units of antitoxin 

 at once, and repeat the dose if no effect is apparent or if the good effect 

 wears off in about from eighteen to twenty-four hours (the technic is 

 described on p. 690). After one or two intravenous injections the good 

 effect may be maintained by direct intramuscular injections of from 5000 

 to 10,000 units for one or two doses. 



2. From 3000 to 5000 units should be given intraspinally by means 

 of lumbar puncture. This dose should be repeated every twenty-four 

 hours unless the symptoms have markedly ameliorated. The technic 

 of this injection is described on p. 694. A quantity of cerebrospinal 

 fluid should be removed before the serum is injected. After the first 

 injection the fluid may be found to have become cloudy, with a large 

 increase of cells, especially of the polynuclear variety, although bac- 

 teriologically it may be sterile. This outpouring of leukocytes is prob- 

 ably a reaction to the irritant effect of the serum, and especially of the 

 preservative it contains. 



3. If a surgeon is at hand, from 500 to 1000 units of antitoxin should 

 be injected slowly intravenously into the sheaths of the nerve-trunks 

 leading from the infected region. These injections are directed to be 

 made as near the trunk as possible, and to distend the nerve so as partly 

 to neutralize and partly mechanically to interrupt the passage of toxin 

 to the cord or brain. 



