1915 Journal of the American Medical Association  
Within the past two years, new evidence as to the efficacy of antitetanic serum in developed tetanus has been obtained from animal experiment by Permin and by Park, and from carefully gathered hospital statistics. From this evidence it seemed likely that if antitoxin were given so as best to meet the pathogenesis of the disease (that is, by intraspinal and intravenous routes in massive doses at the earliest possible moment), the course of developed tetanus could be favorably modified, and the
more » ... modified, and the mortality materially reduced. The probability that, within a few months, statistics of large numbers of cases in the war zone will be available, makes one hesitate to attempt generalizations on data insignificantly small in comparison. The encouraging results obtained in Cook County Hospital in 1914 are of interest, however, in showing what can be accomplished on the rather unfavorable material of a metropolitan hospital. In May, 1914, in a report to the staff, the results of the use of antitetanic serum for the years 1908 to 1913, inclusive, were summarized. The combined mortality of all (fifty-three) cases was 81.4 per cent.; the mortality of serum treated cases, 75.6 per cent. In fifteen cases receiving antitoxin in adequate dosage, but often relatively late in the disease, the mortality was 53 per cent. ; thirty cases received small doses, with a mortality of 87 per cent., approximately the same as that of eight cases treated without antitoxin, in one of which, with an incubation period of six weeks, the patient recovered (87 per cent, mortality). The high mortality of tetanus in Cook County Hos¬ pital, either with or without serum, has been attributed by some to the late institution of treatment and the unfavorable condition of many of the patients who apply for treatment at the hospital, and by others to assumed inadequacy of antitetanic serum to modify developed tetanus. In 1914, fourteen cases of tetanus were treated with antitoxin by combined intraspinal and intravenous methods, with a mortality of 57.1 per cent. This mortality is about 20 per cent, lower than that of the previous six years, 75.6 per cent., in the same unfavor¬ able class of patients. By reference to the table, it will be seen that, as a rule, patients reached the hos¬ pital and received treatment only after the lapse of two or more days from the appearance of symptoms of tetanus. Two patients were moribund on admission and died less than twelve hours later. If we omit these cases in which treatment was delayed till death was impending, the mortality of the remaining twelve cases is 50 per cent. The latter figure, however, does not represent the percentage of cases in which the dis¬ ease was modified, for in two other cases, to be referred to later, death was attributable, in part at least, to complications after the symptoms of tetanus had subsided. Conclusions based on this relatively small number of cases are necessarily open to question ; but the fact that a previous mortality of 81.4 per cent, in all cases, and of 75.6 per cent, in serum treated cases, has been From the Medical Department of Cook County Hospital. reduced in the same class of patients to slightly over 50 per cent, when serum was used with due regard to the pathology of the disease, must be given some weight in estimating the value of antitetanic serum as a curative agent. Clinical observations of the course of individual cases has a limited but definite value, particularly when numbers of cases are studied. The patients of this series who recovered suffered from severe tetanus, and in two, convulsions occurred while first treatment was being given. The longest incubation period was fourteen days, the shortest four days, the average ten days, and this group included two cases of head tetanus with incubation periods of four and seven days, respectively. The total antitoxin given was from 17,000 to 35,000 units, with an average of 23,500 per case. This relatively small amount was given in such a way as to get the maximum effect at the earliest possible moment, that is, by intraspinal and intra¬ venous injection. INFLUENCE OF PYOGENIC INFECTION· ON MORTALITY IN TETANUS The effect of sepsis developing in lacerated wounds coincident with tetanus deserves more consideration than it has thus far received in estimating the suc¬ cesses and failures of antitetanic serum. In compound fracture and extensively lacerated wounds, streptococcal infection alone may be sufficient to kill the patient, even though he had no tetanus; thus, in one of the fatal cases with compound fracture of both bones of the leg, there was an extensive lymphangitis extending to the hip, with the symptoms of severe sepsis and delirium, a picture not seen at the onset of the uncomplicated tetanus. Yet this death must be charged against the method. LATE DEATH IN TETANUS Two instances in which death occurred after patients were apparently convalescing from tetanus deserve mention, because they recall the late deaths from tetanus described in preantitoxin days, and sug¬ gest an analogy with diphtheria, in which the intro¬ duction of antidiphtheric serum caused an apparent increase in postdiphtheric paralysis because more severe cases lived to develop them. Case 1.-An obese woman, aged 60, who developed tetanus following a stab wound of the arm, was admitted and received intraspinal and intravenous antitoxin on the fourth day of symptoms. On two occasions, severe reactions followed the giving of serum. On the eighth day after admission, and the twelfth day from the onset of the tetanus, the jaw was relaxed, other muscular rigidity had disappeared, the tempera¬ ture was normal, and the patient appeared to be convalescent. The respirations then became more rapid, with fever, rapid pulse, and dulness and rales over the base of both lungs, with death four days later. At the necropsy, pneumonia was found. In this case, while the tetanus no doubt was a contributory cause of death, the outcome cannot be justly charged as a failure of antitoxin to modify symptoms of tetanus. The age (60), the obesity, the injury to the heart muscle during the course of tetanus, and the secondary infection with localiza¬ tion in the lung, probably all had a part in determining the fatal result. Case 2.-A man, aged 65, received first antitetanic serum on the third day of tetanus, which developed nine days after a contused wound of the chin, sustained by a fall and blow on the head. On the sixth day after the first treatment, and the ninth day of tetanus, when the muscular rigidity was decreasing, he died in a sudden convulsion. At the necropsy, Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 06/17/2015
doi:10.1001/jama.1915.02570450014004 fatcat:376la547kvgo7pf5ccxtndbw6y