In all civilized countries the manufacture of diphtheria antitoxin is under government control. In the United States this is one of the functions of the United States Public health Service. No one can manufacture diph theria antitoxin without a pertnit from this service and such permits are not granted until personal inspection has convinced the service ot the reliability and scientific intellige-ice of the manufacturer. Besides this, every batch of diphtheria antitoxin prepared is tested not only by the manufacturer but in the Hygienic Laboratory at Washington. It is highly essen tial that the preparation and standardization of so valuable an agent as this should be under government control.
Tetanus, or lockjaw, is one of the most strikingly distressing and fatal diseases kmown. Therefore it is not strange that it is men tioned in some of the earliest medical writ ings. It was known to the writers of clas sical times that tetanus was in sotne way con nected with wounds and that it was much more common in military than in civil life. Furthermore, it has long been known that the frequency of the development of tetanus does not run parallel with the extent or gravity of the wound. Indeed it is more likely to result from a trivial penetrating wound than from a large open one. The infectious nature of this disease was first demonstrated by French phy sicians, especially Verneuil. However the ex perimental transfer of tetanus was first made by two Italian physicians, Carle and Rattone, in 1884. They inoculated 12 rabbits with matter taken from a pustule on a man who had tetanus. Within a few days 11 of these animals developed the disease, and from these it was transferred to other rabbits. Soon thereafter Nicolaier induced tetanus in rabbits, guinea pigs and mice, by inserting bits of earth under the skin. This investigator also discovered the specific bacillus, but failed to separate it from associated bacteria. This was done by a Japanese bacteriologist, Kitasato. The tetanus bacillus develops spores which are highly re sistant to heat and other adverse agents and may retain their vitality quite indefinitely. In some localities 100 per cent of rabbits inoculated with the soil develop this disease. As a rule, the spores are most abundant in filthy soil, espe cially that richly impregnated with horse ma nure. Before the days of aseptic surgery tetanus was especially prone to follow operative procedures, as was noted by Larrey, Napoleon's great surgeon, and many other operators both in the field and in hospitals. Among certain primitive dirty people tetanus of the newly born is frequent on account of the methods of cutting and dressing the cord. On certain islands, as Reunion and Cayenne, the infantile death rate from this cause has in some years been as high as 50 per cent. In other localities tetanus works havoc among women in the puerperal state. Some savage tribes smear
their arrowheads with mud rich in tetanus spores. The marked mortality from Fourth of July celebrations in this country a few years ago was due to tetanus infection. Fortunately the barbaric rites with which we were ac customed to celebrate the birthday of our na tion have been beneficially modified, largely through the knowledge spread by the Journal of the American Medical Association. The parts of our country most abundantly infected with this virus seem to be the Atlantic States, especially Long Island and the Valley of the Hudson. Commercial gelatin and catgut used by surgeons have been the bearers of this in fection, and most thorough sterilization is neces sary in order to destroy the spores. Formerly we spoke of idiopathic and traumatic tetanus. Now, we are quite sure that the former does not exist. The wound may be so trivial that it is healed before symptoms of the disease develop. In other cases the wound may not be on the skin, but on a mucous membrane, as in the mouth, nose or throat. The writer saw a case in which the virus had entered through the gum from which a tooth had been extracted. It has been claimed that tetanus is more preva lent in black and mixed races than among whites, and some have endeavored to show the existence of racial susceptibility. The truth is that filthiness is the predisposing agent rather than a racial difference. The simple custom of drying the wash by spreading the clothes on the ground has been found to play a part in the prevalence of this disease. The distribution of the tetanus virus seems to be world-wide. It has been found in every land, in the temperate and torrid zones at least, and in many waters such as those of Lake Geneva and the Dead Sea. It may be present in bilge water and men on ships have been infected from this source. Many years ago on an English ship after a naval battle 16 of the wounded died of tetanus. It may be carried into wounds with bits of infected clothing or with the dirt on the skin, and it has been found on nearly every article worn by the soldier, from his shoes to his collar. Virgin forest soil has gen erally been found free from this virus, but the sweepings from the streets, stables, houses, boats and cars frequently produce tetanus when introduced under the skin of animals. Of our domestic animals, the horse is the most sus ceptible and is a frequent victim. The ox comes next, followed closely by sheep and goats. Dogs and cats are not easily infected, but do succumb to inoculation. When swallowed, the tetanus bacillus has no effect unless there be some break in the mucous membrane and it is eliminated with the fasces unchanged. In this way the fecal matter of men and animals pollutes the soil.