TETANUS 235 



Von Behring's fluid antitoxin is marketed in 100 unit (10 c.c.) 

 and 20 unit (2 c.c.) doses; in addition to this a solid antitoxin, of 

 which 20 units represent a dose, is also available. 



Dosage and Uses. For prophylactic purposes, 20 units (2 c.c.) 

 should be injected about the site of injury, and if large nerve trunks 

 have been exposed, in part into their substance: the idea being to 

 bind the toxin which is formed about the point of infection, before 

 it leaves this district, which takes place along the lymphatics and 

 the nerve fibers. At the same time, it is recommended to give 

 a subcutaneous injection of 100 additional units (10 c.c.) at an 

 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 which 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 



