In light of their patient’s adequate immunisation record, Shimoni et al presume that he ought to have mounted a protective titre of neutralising antibody. With this I agree. But against what, in distinct, does this titre confer protection– clinical infection or fatal infection The understanding of “protection” was derived from animal studies that correlated serum concentrations of tetanus antibody with symptoms of tetanus.two The threshold of 0.01 IU/ml was established due to the fact guinea pigs with titres above this level were protected from fatal tetanus, not from clinical tetanus; six of 45 animals with protective levels developed non-fatal tetanus.three Similarly, in humans, non-fatal tetanus has been described in 10 out of 64 consecutive individuals with antitetanus titres higher than 0.01 IU/ml.four Much more recent situations have borne this out.five Quite a few uncommon and exceptional situations of tetanus happen in spite of adequate immunisation and protective levels of neutralising antibodies. Considering the fact that tetanus is likely to become fatal if not recognised and treated correctly, the caveat from Shimoni et al1 merits repeating: physicians must entertain the diagnosis of tetanus inside the correct clinical setting, irrespective of the patient’s immunisation record.David R Vinson staff doctor Division of Emergency Medicine, Kaiser Permanente Health-related Center, Sacramento, CA 95825, USA [email protected] Shimoni Z, Dobrousin A, Cohen J, Pitlik S. Tetanus in an immunised patient. BMJ 1999;319:1049. (16 October.) two McComb JA. The prophylactic dose of homologous tetanus antitoxin. N Engl J Med 1964;270:175-8. 3 Sneath PAT, Kerslake EG, WZ4003 biological activity Scruby F. Tetanus immunity: the resistance of guinea pigs to lethal spore doses induced by active and passive immunization. Am J Hygiene 1937;25:464-76. four Goulon M, Girard O, Grosbuis S, Desormeau JP, Capponi MF. Les anticorps antit aniques: titrage avant s oanatoxinoth apie chez 64 t aniques. Nouv Presse Med 1972;1:3049-50. five Crone NE, Reder AT. Extreme tetanus in immunized sufferers with high anti-tetanus titers. Neurology 1992;42:761-4.Not such distant mirrorsWarm tap water by the bucketful might be valuable in flushing physique cavities and wounds Editor–An excerpt from A single hundred years ago describes the flushing on the peritoneum introduced by Lawson Tait as being “greatly to the patient’s benefit.”1 Within the closing years in the very first globe war my mother was ward and theatre sister towards the celebrated gynaecologist Russell Howard at the London Hospital. She employed to inform me how he would empty a bucketful of warm tap water in to the abdomen at the end of an operation just before sewing up, pelvic peritonitis becoming then prevalent in Whitechapel. I identified this a great way of cleaning up nasty compound fractures ahead of routine debridement.J W Dickson retired orthopaedic surgeon Suffolk IP6 9AJ1 1 hundred years ago: Generalisation of salt infusions.The overall health status of people today of a nation is reflected by their morbidity and mortality patterns. The data is essential for arranging and implementing healthcare techniques and for monitoring healthcare services with the nation (1-3). In a lot of building countries, accurate population-based morbidity information are largely deficient or absent (four).