THE 
PATHOLOGY AND TREATMENT 
OF 
TETANUS: 
Including a Series of Investigations in regard to the 
Micro-Organism of the Disease and the Influence 
of Disinfectant Substances on the same. 
A STUDY FROM THE PATHOLOGICAL LABORATORY OF THE 
JEFFERSON MEDICAL COLLEGE. 
BY 
D. BRADEN KYLE, M.D., 
Assistant Demonstrator of Pathology in the Jefferson Medical College. 
REPRINTED FROM THE THERAPEUTIC GAZETTE, FEBRUARY 15, 
MARCH is, AND APRIL is, 1892. 
DETROIT, MICH. : 
GEORGE S. DAVIS, PUBLISHER. 
1892. Bacillus of Tetanus. Beck homogeneous immersion, camera lucida. Drawn by Dr. Bevan. THE PATHOLOGY AND TREATMENT 
OF 
TETANUS, 
INCLUDING 
A SERIES OF INVESTIGATIONS IN REGARD 
TO THE MICRO-ORGANISM OF THE DIS- 
EASE AND THE INFLUENCE OF DIS- 
INFECTANT SUBSTANCES ON 
THE SAME. 
A STUDY FROM THE PATHOLOGICAL LABO- 
RATORY OF THE JEFFERSON 
MEDICAL COLLEGE.* 
TETANUS is an acute infectious disease 
which follows traumatisms, and is due 
to a special micro-organism, the bacillus 
tetani. The disease is characterized by per- 
sistent rigidity of the muscles of the jaw 
(trismus), and frequently of the greater part 
of the voluntary muscular system, with par- 
oxysms of tonic spasms, irregular tempera- 
ture and pulse, the intelligence being pre- 
served. 
The disease has been classed as traumatic 
and idiopathic. From the present knowledge 
of the origin of the disease, possibly a better 
classification would be traumatic and simu- 
lated, as it is generally conceded that there 
* My thanks are due to Dr. Coplin for the directions 
given me in this research. 2 
must be some traumatism, no matter how trivial 
or how produced. Under the simulated class 
would be placed all cases now known as 
nervous, emotional, or psychical; in fact, all 
cases which do not follow traumatism. 
As to the duration of tetanus, it is classed 
as acute and chronic. The acute lasting from 
a few minutes to several days ; the chronic 
lasting from eight days to seven weeks ; in 
which case a more favorable prognosis may 
be given. 
As far as the writer is aware, no case of 
traumatic tetanus, accompanied by bacterio- 
logical research, has been reported in this 
country. Senn has reported the production 
of tetanus in an animal from a case of chronic 
tetanus, but does not state that any attempt 
at isolation of the bacillus was made. 
Several investigators on the continent 
(Nicolaiev, Rosenbach, Flugge, Bonomi, 
Beumer, Eiselsberg, Giordano, Ohlmuller, 
Kitasato, Belfanti, Pescarolo, and others) 
have made more or less complete studies of 
cases, but the present status of the bacillus 
of Nicolaiev has been reached by the com- 
bined work of at least one dozen investi- 
gators. 
In this country no reports other than the 
one cited have been published. The writer 
is aware that a most complete investigation 
was made at the Johns Hopkins Hospital by 
Welch, Abbott, and others, as to the exogen- 
ous origin of the disease, but there has been 
no published report. The report of Professor 
Park, of Buffalo, which he read at the Col- 
lege of Physicians in Philadelphia, showed 
the bacillus of tetanus, with which he was able to produce the disease in animals, but 
did not state that a pure culture was again 
obtained from the animal. 
The attempts made at isolation and pure 
cultivation have been almost entirely futile, 
and the inoculation experiments made have 
been with impure cultures, contaminated with 
cocci and a smaller bacillus ; a greater num- 
ber of the experiments were made by inocu- 
lations from different kinds of earth and a 
very few were made from traumatic cases. 
In the laboratory reports made by Park, of 
Buffalo, and Charcot and Belfanti, of Paris, 
they claimed to have procured pure cultures 
of the bacillus of tetanus. 
In August, of last year, the writer began 
these investigations, and at that time our 
knowledge of the disease was fragmentary, 
made up of the combined investigations of 
Continental observers, to be referred to later 
on. These observations were, many of them, 
contradictory and confusing, and the scien- 
tific world recognized the chaotic condition 
of the study of this most fatal disease. 
Although the date of the investigations made 
by Belfanti and Pescarolo in Charcot's lab- 
oratory is not given, it is to be assumed that 
they began much earlier than the writer, but 
his work had been nearly completed at the 
time of their published report, in December. 
The writer has attempted to make clear 
points not hitherto understood, and, long 
before the reports above referred to, had 
arrived at conclusions essentially the same, 
on many points at wide variance with pre- 
existing knowledge on the subject. Had he 
known that others were also reaching con- 
3 4 
elusions which he had reached, and invariably 
arrived at the same result,-viz., that the 
bacillus was not an obligate anaerobe,-many 
repeated experiments could have been avoided 
and further research added. 
Tetanus is by no means a new disease ; it 
is described by Hippocrates and Galen. In 
1859, Betoli related the case of a bull that 
died of tetanus after castration. Several 
slaves ate of the flesh of the dead animal, and 
of these, three were affected with tetanus, two 
of whom died. In 1870, Anger reported a case 
of spontaneous tetanus in a horse, after which 
three puppies, in the same stable, were also 
affected. Kelly, in 1873, had three cases in 
the same week, all arising in a civil hospital, 
and a few days later there was a fourth case 
in a neighboring hospital. Larger, in 1853, 
reports a case in which the patient received 
a slight injury while working in a barn-yard, 
and in four weeks developed tetanus; on 
investigation, it was found that a horse af- 
fected with the disease had been in the 
stable opening into the yard in which the 
accident occurred. The same writer reports 
five cases in one village in eighteen months 
and under different climatic conditions. 
Senn, who refers to Bonomi's observations, 
states that out of seventy persons injured by 
the falling of a church tower during an earth- 
quake, seven were attacked by tetanus. 
Gower reports two cases following alcoholic 
intoxication; at least, there was no other 
assignable cause. As to puerperal tetanus, 
which occurs chiefly in tropical climates, it is 
supposed to be due, in at least a majority of 
cases, to retained placenta. The same writer reports that in Bombay, in three years, two 
hundred and thirty-two women died of the 
disease. 
As to the time of incubation, it may last 
for varying periods after the infliction of a 
wound. The case reported by Dr. Robinson, 
where the patient cut or rather scratched his 
finger with a broken piece of porcelain, died 
of tetanus in fifteen minutes ; although this 
occurred in a hot climate, and is reported as a 
case of tetanus, the diagnosis is to be ques- 
tioned. Larrey, who had great experience 
with the disease during Napoleon's cam- 
paigns in Egypt, found that it occurred from 
the fifth to the fifteenth day. The reports of 
surgeons during the Peninsula war showed 
that the disease manifested itself after the 
twenty-second day; it may occur as late as 
one month, as in the case reported by Sir G. 
B. Lane. The wound may have undergone 
complete cicatrization before any symptoms 
appear. 
Even racial peculiarity seems to effect the 
disease, as the dark-skinned are more likely 
to take it than the white, even when exposed 
to the same climatic influences. In trau- 
matic tetanus the proportion between the 
sexes is six male to one female. The order 
of frequency with which the several parts 
have been the seat of the wound that caused 
tetanus is (i) hand; (2) leg; (3) foot; (4) 
head and neck ; (5) arm ; (6) trunk (Gow- 
ers). The disease is most common in North- 
ern Italy, its maximum being in Lombardy. 
Hospital reports show a mortality of fifty per 
cent. ; in private practice it is somewhat 
higher. 
5 6 
Stewart, of England, reports a case of 
tetanus in an infant fourteen days old. The 
cord was ligated in the usual way. On the 
fifth day the cord dropped off, and nine days 
after tetanus developed, and in five days 
more the child died. When tetanus devel- 
oped the cord was perfectly healed {British 
Medical Journal, February 21, 1891, p. 405). 
Cold climate and altitude is detrimental to 
the development of the disease, while a tropi- 
cal climate tends to enhance its development. 
During the campaign of Caucasus, the weather 
being persistently cold, Pirogoff saw hardly 
any cases among the Russian wounded ; 
while after battles during the warmer 
weather the mortality from tetanus had been 
great. 
Of three hundred and sixty-three cases re- 
ported during the late civil war, three hun- 
dred and thirty-six died. 
The disease sometimes seems to occur in 
epidemics ; thus, in 1782, one out of every 
six infants born in the Rotunda at Dublin 
died within the fortnight after birth from the 
disease. 
In St. Mark's Hospital, 1858, there were 
five cases of tetanus following operations for 
hemorrhoids. 
Prior to 1884 various hypotheses were set 
forth as to the cause of tetanus. It was said 
to be a disease consisting essentially in an 
excited state of the spinal cord and of the 
medulla oblongata, in fact, of the whole spinal 
system, giving rise to painful and continued 
spasms of the voluntary muscles and the dia- 
phragm, following a peripheral nerve irrita- 
tion, causing an ascending neuritis (Erich- 7 
sen). It was claimed by the same writer to 
be due to the irritation of the nervous sys- 
tem, from the presence of worms in the in- 
testinal canal, and also by uterine irritation ; 
it seems sometimes attributable to exposure 
or cold, and in this apparent causation it is 
called by some writers tetanus a frigore. It 
has been conjectured that the disease is some- 
times a manifestation of rheumatism. Bill- 
roth states that " all symptoms indicate an 
irritation of the spinal cord," or of the portio- 
minor of the fifth pair. 
In 1875, Professor Wm. S. Forbes, in a 
paper read before the College of Physicians 
of Philadelphia, in which he reported a case 
of traumatic tetanus, in speaking of the cause, 
stated it to be his belief " that it is a self-gen- 
erated agent, akin to rabies and strychnine, 
exciting the nerve peripheries, which, by re- 
flex action cause the augmented disintegra- 
tion of muscular tissue, the product of disin- 
tegration further excitingthe nerve peripheries 
until there is established the condition known 
as tetanus. 
Rokitansky claimed to have seen the devel- 
opment of young connective tissue in the 
spinal medulla, which would make it appear 
that there was an inflammatory affection of 
this nerve-centre. Goll, of Zurich, and Mey- 
nert, of Vienna, confirm this, but as to its 
cause there was a difference of opinion. Some 
writers do not believe that the nervous sys- 
tem is primarily affected, but think that the 
blood first becomes diseased and acts secon- 
darily on the nervous system. 
The morbid anatomy of the disease re- 
vealed nothing but what has been found in 8 
other diseases. Rose claimed that tetanus 
and hydrophobia were both primary blood- 
diseases, and it is a well-known fact that the 
two diseases are very much alike. It has 
been stated by some experimenters that by in- 
oculating animals with the blood or secretions 
from a case of tetanus, hydrophobia was in- 
duced. Leyden produced tetanus in a dog 
by passing a strong current of electricity 
through the whole spinal medulla ; the symp- 
toms were accompanied by marked elevation 
of temperature. Frick claimed that a sur- 
plus of heat was formed in the muscles and 
thence distributed to the blood. Some wri- 
ters (Erichsen and others) believed that de- 
pressing emotion predisposes to the disease ; 
this form might be properly called psychical 
tetanus. 
Theorizing as to how particular varieties of 
injuries to nerves produce tetanus is useless. 
It is rare that a simple division of the nerve 
produces the disease, but crushing and par- 
tial division have been attributed as frequent 
causes. The disease has followed simple 
wounds of the skin, and arisen from granu- 
lating surfaces, even after cicatrization ; 
a blister, or the sting of an insect may pro- 
duce it. All kinds of wounds cause it ; such 
as incised, punctured, contused, lacerated, and 
surgical-operation wounds, as well as burns. 
In rare instances it has followed injuries 
which involved no breach of surface, as flog- 
ging or a fall on the back and spine. It has 
long been known that troops are peculiarly 
susceptible to it; also persons injured by fire- 
arms and toy pistols; persons engaged in 
taking care of horses are frequently affected, hence the " equine origin horse-dung seems 
especially open to suspicion, and it is found 
that ordinary dust, garden-earth, and surface- 
soil play an important part in the causation 
of tetanus. That tetanus is especially apt to 
occur in the feeble and debilitated has also 
been noted ; hence any condition that lowers 
the tone of the nervous system is likely to 
cause the disease. 
It is most likely to follow injuries of the 
extremities; in the present light of investiga- 
tion this is to be explained on the ground 
that these injuries are more likely to be in- 
fective. A tropical climate seems to favor 
the disease, and altitude seems to lessen the 
liability to its development. It may occur 
at any age ; the young, the middle-aged, and 
the old alike suffer, yet all cases follow trau- 
matism, even the "tetanus neonatorum," 
which may follow the ligation of the umbilical 
cord. Although the disease was known to be in- 
fectious, it was only in 1884 that the microbian 
cause was discovered, almost simultaneously 
by Nicolaiev and Rosenbach. Nicolaiev 
showed the exogenous origin of the disease 
by finding the bacillus of tetanus in earth. 
Rosenbach found a similar bacillus in the 
pus from a case of traumatic tetanus. The 
identity of the bacillus of tetanus with Nico- 
laiev's bacillus of earth tetanus was demon- 
strated in Koch's laboratory, April 10, 1887. 
The discovery made by Nicolaiev and Rosen- 
bach has been confirmed by many noted 
bacteriologists, such as Koch, Carle, Ratione, 
Beumer, Giordano, Ferrari, Hacksinger, 
Shakespeare, Bonomi, Brigger, Kitasato, 
Park, Abbott, Welch, and many others. 
9 The ptomaines of tetanus have been iso- 
lated, but the writer was unable to make any 
investigation on this subject. The four pto- 
maines isolated are (i) tetanine ; (2) tetano- 
toxine ; (3) not named ; (4) spasmotoxine. 
It is generally conceded that the cause of 
death in the disease is due not to the bacillus, 
but its products,-the ptomaines. 
The history of the case which I studied, 
which extends over a period of thirty-five 
days, is as follows : 
M. J. McL., male, aged 20, residing in 
Philadelphia, is by occupation a stone-cutter. 
On August 5, while at work, he stepped on 
a board containing three sharp-pointed scaf- 
folding nails, the nails being driven through 
the board so that they pointed together ; the 
sole of his shoe being thin, the nails penetrated 
into the foot, inflicting a punctured wound 
three-quarters of an inch in depth, extending 
obliquely inward at a point one inch behind 
the last metatarso-phalangeal articulation; 
the injury caused him so much pain that he 
was obliged to quit work immediately. He 
applied at a drug-store for something with 
which to relieve his pain, and was given a 
bottle containing equal parts of tinctura opii 
and liquor plumbi subacetatis dilutus. The 
wound was not opened, and nothing was 
done to cleanse it or in any way to render 
it antiseptic. The solution was applied 
to the injured part by means of cotton and 
lint. 
At 8 p.m. the wound was very painful, 
slightly swollen, with great discoloration of 
surrounding parts. A poultice of bread and 
10 11 
milk was applied, being placed over the lint 
and cotton ; this was left on until 8 a.m., 
when the poultice and lint were removed, 
and a few drops of bloody serum and pus 
showed on the cotton which was next to the 
wound. The patient had passed a quiet 
night. The wound was then washed in water 
in which wood ashes had been soaked for 
three hours ; this was on the morning of Au- 
gust 6 ; after washing the wound in this 
solution a large piece of fat bacon was ap- 
plied. This treatment was continued until 
August 9, the patient suffering very little 
pain. The wound closed on the third day ; 
no discharge on the dressings, except the first 
two, and then only a few drops of pus and 
blood. The foot was slightly swollen, but at 
no time very painful. On Saturday, August 9, 
the fat pork was followed by flaxseed poultices, 
and this treatment continued until August 16, 
when all treatment was stopped. The wound 
was never washed out, and remained closed 
after the third day. On the 13th the swell- 
ing entirely left the foot, but on the next day, 
when dressing it, the patient noticed some 
discoloration on top of the foot, extending out 
to the toes ; this had all disappeared by the 
16th. 
On Friday, August 15, he felt a stinging 
sensation, seeming to originate in the temporo- 
maxillary articulation. On moving the jaw 
slight rigidity was found to exist; also slight 
rigidity of the muscles of the neck. These 
symptoms continued until Monday, the pa- 
tient saying nothing as to his condition at 
the time. 
On Monday, August 18, the patient re- sumed work, but on account of increased 
rigidity of muscles and general indisposition 
he was unable to work longer than 12 m., 
when, on attempting to eat his dinner, his 
jaws were more rigid, deglutition difficult; he 
suffered from pain in his back, occipital head- 
ache, weakness in the lower extremities, and 
slight muscular inco-ordination. 
During the afternoon he called at Dr. 
Smith's office ; this was the first medical ad- 
vice sought. After examining the patient 
Dr. Smith pronounced it a case of tetanus, 
and gave him a plaster for his back and pre- 
scribed for him ; what was prescribed the 
writer was unable to learn. Two doses of 
the medicine were administered, and that 
evening, August 18, the patient sought medi- 
cal advice at Dr. J. W. Hearn's office. Dr. 
Hearn being out of the city, he was exam- 
ined by Dr. Coplin. 
On examination the condition of the patient 
was found as follows : 
Temperature 990 F., pulse 90, muscles of 
the jaw rigid, the patient not being able to 
open them more than one-half inch ; there was 
inability to protrude the tongue, rigidity of the 
muscles of the neck, flushed face, and quick, 
jerky articulation ; on tapping the muscles 
of the face great pain was produced ; he 
also complained that the jostling and jolting 
of the car increased his pain ; the expression 
of his face showed mental anxiety ; his bowels 
were constipated. The patient could not 
take solid pabulum, but could imbibe fluids, 
showing marked difficulty of deglutition. He 
complained of temporo-frontal headache. 
From the symptoms given and history, the case 
12 13 
was diagnosticated one of traumatic tetanus ; 
he was ordered a saline purgative and a mix- 
ture containing bromide of sodium, x drachm 
to each dose, to be given every two hours, 
and the importance of feeding the patient 
at intervals of every two hours was urged 
upon the parents, the diet to consist of liquids, 
especially milk, to be administered frequently, 
so that not less than thirty-two ounces of milk 
be given in twenty-four hours ; also broths 
and beef-tea to the same amount. He was or- 
dered to bed in a dark room, and to be kept 
absolutely quiet. 
On August 19, at 2 p.m., Dr. Coplin paid 
the first visit to the house. The patient had 
then taken one ounce of the bromide of so- 
dium ; the trismus was still marked ; the 
rigidity of the muscles of the neck was in- 
creased, with marked arching forward of the 
lumbar region (opisthotonos). He complained 
of twitching and jerking of the muscles in the 
injured limb, affecting more particularly the 
calf muscles and gluteal muscles. The opis- 
thotonos was more marked during the pains, 
the facial expression distorted (risus sar- 
donicus), lips cyanotic, finger-nails blue, re- 
spiratory movements quickened, and short 
clonic and tonic spasms were induced by any 
movements which involved the muscles of 
the neck, back, or inferior extremities ; also 
by attempts at laughter,-less marked by 
talking ; mental condition showed no change, 
except he was lapsing into a condition of in- 
difference as to the termination of his case. The 
foot was carefully inspected, and no evidence 
of inflammatory process, either upon dorsum 
or plantar surface, could be observed ; except at the point where the nail had entered, it 
would have been impossible to have told 
which foot was the seat of the disease ; cica- 
trization was complete. At the point of the 
wound there was a small indurated area, 
about one-half inch long and one-quarter of 
an inch wide, somewhat tender, which pro- 
duced convulsive movements of the limb and 
increased the opisthotonos when pressed 
upon. It was not surrounded by an area of 
redness, and showed no evidence of an in- 
flammatory process other than that offered by 
the tenderness. 
The advisability of opening the wound was 
discussed at the time, but the full consent of 
the patient and family could not be obtained. 
Treatment was ordered continued, and on 
account of the large number of friends who 
had visited the patient, the family were again 
made fully aware of the necessity of absolute 
quiet; the patient was ordered to a larger 
room, put in a large, roomy bed, and the 
feather-bed was removed. 
On the 20th the trismus was marked, and 
general tetanic condition was certainly unim- 
proved, if not more marked. The necessity 
for opening the wound was urged upon the 
family, and conditional consent was obtained, 
providing he was no better on the following 
day. The patient's sleep had been inter- 
rupted, restless, irregular, rather a condition 
of somnolence than sleep, from which he was 
aroused by the slightest noise; even the 
striking of a parlor match in the room an- 
noyed him ; symptoms of mental aberration 
began to evince themselves ; while apparently 
perfectly conscious he made remarks which 
14 had no connection with his surroundings ; he 
was laboring under the impression that he 
was not at home, and expressed a desire 
continually to be taken home. 
On the 20th the patient had a slight nasal 
hemorrhage, the blood being collected on a 
linen handkerchief, and kept for inspection. 
(See laboratory notes.) The amount of urine 
passed was about forty ounces per day, and 
it was dark colored. (For report see labo- 
ratory notes.) He recognized all his friends 
and acquaintances who were permitted to 
see him, but inquired for no one. 
On the evening of the 20th, Dr. Coplin 
called on Professor Bartholow, and gave him 
a brief outline of the case and details of treat- 
ment, which met with his full approbation, 
except that he urged the necessity for opening 
the wound. 
On the 21st the trismus was improved ; the 
tongue could be slightly projected ; it was 
coated with a brownish, furry coat ; the sur- 
face was fissured longitudinally, and slightly 
swollen ; the secretion of saliva was appar- 
ently diminished, although respiration was 
carried on through the nostrils ; the lips and 
whole mucous surface of the mouth were dry 
and parched ; the lips were slightly blue ; 
the patient was indifferent as to his condition, 
and seemed to have lost all interest in the 
ultimate result of his case ; he had hallucina- 
tions, imagining work was going on in his 
room,-working at his occupation ; although 
he recognized all his friendsand answered all 
questions rationally, the general tetanic con- 
dition was worse and tonic contraction of the 
muscles was most marked ; when the nurse 
15 16 
laid one of the patient's feet across the other 
he could not move it on account of extreme 
rigidity of the muscles. 
The consent of the family having been ob- 
tained, it was decided to open the wound. 
The foot was thoroughly antisepticized, first 
scrubbed with soap and water, and then with 
a solution, as follows : 
R Hydrarg. chlor, corros., ; 
Ammonii chloridi, gi; 
Alcohol, q.s. ad 
Sig.-One drachm of this solution to one pint of water. 
The instruments were rendered thoroughly 
aseptic by means of heat and carbolic solu- 
tion. An incision one inch in length was 
made through the seat of induration. From 
the wound blood was drawn by means of 
vacuum-tubes, assisted by a fillet around the 
limb to prevent the venous return ; about 
two ounces of blood were withdrawn from the 
wound. In the bottom of the wound was a 
sinus, which contained sero-sanguineous fluid, 
but no pus ; in the blood that escaped, min- 
ute particles of rust and other foreign sub- 
stances were found, both macroscopically and 
microscopically. The blood was all collected 
in tubes for examination. (See laboratory 
notes.) The wound was then washed out 
with an aseptic solution, as first used ; after 
thoroughly washing and drying the wound, 
it was mopped out with pure bromine and 
packed with iodoform gauze *, a dressing 
of bichloride gauze was applied with a turn 
of the roller. The bromides were increased 
to 45 grains of the sodium salt and 15 grains 
of the ammonium salt every two hours. At 9 p.m. the patient was resting easier, was evi- 
dently affected by the bromides, and upon 
rousing him to take his medicine would im- 
mediately be attacked with . paroxysms of 
pain, the muscles become rigid, and he would 
assume the position of opisthotonos ; at times 
he would lapse into a restless sleep, or rather 
somnolence, from which he would be dis- 
turbed by pain, the body assuming the charac- 
teristic position and the face being distorted. 
He was aroused every two hours, and the 
medicine given regularly. 
Friday, August 22, at 9 a.m., on rousing 
the patient, exacerbations of spasms took 
place, during which the muscles became very 
hard ; these paroxysms lasted from one-quar- 
ter to one-half minute, and were accompanied 
by excruciating pain in the suboccipital and 
lumbar region ; the tetanic symptoms were 
more marked than on the previous day ; the 
trismus remained the same, the jaws being in 
a semiclosed condition, which condition they 
had been in from the beginning of the dis- 
ease, as the patient, finding his jaws gradually 
becoming set, pushed between them some 
of the bedclothes, thus preventing their en- 
tire closure ; the angles of the mouth were 
slightly drawn upward and backward, giving 
him the peculiar expression called risus sar- 
donicus. 
At nine in the evening, the thermometer 
marked an increase of two degrees, the other 
symptoms continuing about the same, except 
the tetanic wave, which was increased ; each 
paroxysm showed increasing intensity, the 
patient assuming the positions of opisthot- 
onos, emprosthotonos, and pleurothotonos, 
2 
17 18 
alternating from one to the other during the 
spasm. The patient, since the morning of 
the 19th, had taken one drachm of bromides 
every two hours, making one and one-half 
ounces in the twenty-four hours, and in all, 
up to the morning of the 22d, four and one- 
half ounces. The symptoms were increased 
in intensity from six o'clock until eleven in 
the evening ; the paroxysms could be excited 
by mental emotion and by peripheral impres- 
sions. During the paroxysm the tetanic 
fixation of the respiratory muscles threatened 
a fatal termination by asphyxia ; this condi- 
tion led to the most marked irregularity of 
the cardiac movements, both in number and 
in rhythm ; attempt was made to use the 
sphygmograph and cardiograph, but the jerk- 
ing tendons, and rapid alternation between 
posterior and lateral arching of the trunk, 
precluded their use either at the wrist in the 
one case, or at the apex in the other. The 
bowels being constipated, an enema of hot 
water was ordered ; this failing, it was re- 
peated in the morning ; the stool consisted 
of hard masses of fsecal matter. The patient 
was ordered, in connection with the bromides, 
15 grains of chloral, to be taken every 
two hours, making in all three drachms of 
chloral and twelve drachms of bromides in 
twenty-four hours. The patient's intellect 
was unaffected. 
August 23.-Same treatment continued ; 
the trismus was still well marked ; the other 
symptoms were increased ; the spasm often 
commenced in the injured limb. This fact is 
of much interest, as many writers, of which 
Gower is the most prominent, assert that the spasm rarely, if ever, begins in the injured 
limb. It is also stated by some writers 
(Flint and others) that the paroxysms occur 
more during the day ; if there was any dif- 
ference in this case, they were more frequent 
at night. During the intervals between par- 
oxysms the patient assumed the characteristic 
position of the disease ; his condition was 
that of stupor or somnolence rather than 
natural sleep; occasionally he would lapse 
into a sleep from which he would be aroused 
by paroxysms of pain. 
The nourishment taken by the patient con- 
sisted of thirty-two ounces of milk and twenty- 
four ounces of the beef-tea in twenty-four 
hours. The temperature showed the usual 
morning remission and evening exacerbation. 
The paroxysms, although brief, were repeated 
frequently,-every ten to twenty minutes, 
lasting from a few seconds (five) to one-quar- 
ter of a minute ; the clonic paroxysm was ac- 
companied by tonic spasm, affecting different 
groups of muscles ; the patella tendon re- 
flexes were exaggerated ; the ankle clonus 
could not be tested satisfactorily, but we 
failed to elicit it at any time. 
August 24.-The patient showed no change 
in symptoms from the previous day, but the 
effects of the combined use of the bromides 
and chloral were manifesting themselves ; the 
medicine seemed to hold the spasm in abey- 
ance for a time after administering, but as 
the effects of the medicine gradually passed 
off, the spasms recurred, seemingly in in- 
creased proportion to the length of the time 
they had been held in abeyance, the longer 
the period of rest the more intense the sue- 
19 20 
ceeding tetanic paroxysm. The wound was 
dressed with antiseptic gauze and the nurse 
ordered to keep the dressings damp with a 
bichloride solution (strength i to 1000). 
The amount of nourishment was increased 
to six ounces of liquid diet every two 
hours, and the necessity of nourishing the 
patient was urged. The nurse was also 
directed to administer the medicine and ali- 
ment regularly,-every two hours,-unless the 
patient was asleep, in which case the interval 
was not to exceed four hours. Treatment 
was continued as before ; the patient's bowels 
still being constipated, he was ordered one 
ounce of the liquor tnagnesii citratis of the 
shops, to be repeated every two hours; 
this was also supplemented by a soapsuds 
enema night and morning ; the constipation 
was obstinate, but was overcome on the fol- 
lowing morning. 
The tonic rigidity of the abdominal mus- 
cles was most marked ; by palpation the 
feeling was that of passing the hand over 
marble. During the paroxysms of pain, the 
muscles of respiration being interfered with, 
the respiratory movements were limited in 
depth and increased in number ; the respira- 
tions increasing to as high as thirty-two per 
minute, their character jerky, irregular, and 
shallow ; during the paroxysms of pain the 
body was bathed in perspiration. It is a 
matter of interest to note at this point the 
remarkable connection between the spastic 
conditions and increased sudorific activity. 
Post-mortem sweating has been noted in cases 
of well-marked and rapidly-developed rigor 
mortis, and explained on the hypothesis that the contraction has squeezed out the already 
secreted fluid in the gland. This same hy- 
pothesis is here applicable and well taken, as 
it seems hardly possible that in fifteen to 
thirty seconds the large drops of perspiration 
could have been secreted. The urine was 
scanty and highly colored, with specific grav- 
ity 1024, due to the exaggerated cutaneous 
activity. 
August 25.-No change in the symptoms 
from the day previous, except a decline in 
temperature of one degree ; the patient mani- 
fested no concern as to his condition and 
took no interest in his surroundings, but on 
being aroused, answered all questions intelli- 
gently. During the tetanic spasm the pupils 
always showed pin-point contraction, re- 
suming the normal condition during the in- 
termission. On the evening of the 25th slight 
symptoms of bromism were manifested ; the 
patient's sensation was slightly impaired, and 
there was fetid, bromine breath, with cold 
extremities. The food consisted of thirty- 
two ounces of milk, animal broths thirty-two 
ounces, and two soft-boiled eggs during 
twenty-four hours. 
August 26.-The symptoms of bromism 
were more marked ; the trismus was much 
diminished, while the tetanic symptoms 
showed no diminution, except, while held in 
abeyance by the combined action of the bro- 
mides and chloral. On examining the patient 
the peculiar acne of bromism showed plainly 
on his face, shoulders, and upper extremities. 
There was marked pallor, and the heart was 
quick but strong, and there was a general sub- 
jective sense of coldness, the muscular move- 
21 ments being tremulous and uncertain. The 
patient was unable to put his hand to his 
mouth or to cross his leg ; there was, in fact, 
well-marked muscular inco-ordination. 
The altered character of the voluntary 
muscular movements presented so many 
points of interest as to merit the closest 
study. The modified motor and sensory con- 
ditions were due, of course, to the presence of 
the two conflicting elements,-viz., the tetanus 
and bromism; these producing subjective 
and objective phenomena complex and not 
constant in any two consecutive observations. 
This may be illustrated by the fact that the 
patient could not put his hand twice in the 
same place ; if a hand was held out to him 
for hand-shaking, he would see it, recognize 
what the object was, and make futile attempts 
to grasp it, rarely succeeding; his grasp 
when obtained was firm, even exaggerated, 
and he was little conscious of the force which 
he exerted, many times causing pain in the 
hand grasped, so firm was his grip. There 
was no loss of muscular power. Lying in 
his bed he could not cross his legs, although 
he was able to move them, even when at- 
tempts to restrain such movements were 
made. There was marked perversion of the 
so-called muscular sense. As already noted 
above, he was little cognizant of the force 
used in hand-shaking ; in conveying a glass 
to his mouth, he was likely to bring it abruptly 
against his face at almost any point; his feet 
would press firmly against anything without 
his being conscious of the resistance. With 
this condition there was perversion of cutane- 
ous sensibility ; heat and cold could be dif- 
22 ferentiated unless intense,-eg., ice could be 
told from water at 130° F., but between 450 
F. and no° F. he could recognize no differ- 
ence upon prolonged contact. The aesthe- 
siometer elicited some very interesting facts ; 
one point could be recognized, but he could 
neither tell where he was being touched nor 
could he put his hand on the painful point; 
he could only recognize two points when they 
were forcibly applied and under the most 
favorable conditions, at least four inches 
apart, if on the lower extremities, and but 
slightly, if any better, upon the upper ; the 
anaesthesia was well marked over the abdomen 
and the muscles of mastication ; two points 
could not be detected if applied to one finger, 
but if applied to two fingers, he could not tell 
which finger. After a few experiments the 
sensation became so perverted that he would 
declare you were touching him when no one 
was near him ; this could only be disproved 
by his seeing. The sensation conveyed to 
the sensorium through the sense of sight and 
hearing were never perverted, and only at 
brief intervals did he show the least tendency 
to temporary mental aberration, and this only 
when in the broken, restless, soporific condi- 
tion, which we might term sleep. His men- 
tal condition was one of hallucinations and 
delusions, he imagining work was being 
carried on in his room ; sometimes his ideas 
were based on false objects, and then again 
based on a true object with a false idea, but at 
all times could he be reasoned out of his belief, 
and never was his condition one of insane 
hallucination or insane delusion. He would 
often talk in a rambling manner and often 
23 24 
indulged in meaningless and uncontrollable 
laughter. The mucous membrane of the 
mouth showed the same perversion of sensi- 
bility as already noted of the skin ; taste was 
perverted ; everything tasted sour; coffee 
could not be sufficiently sweetened, and even 
the bromide mixture, made with syrup, had a 
taste of acidity. The patient's temperature 
had now declined to normal, 98.6° F. The 
nourishment taken was diminished from the 
day previous, consisting wholly of liquids, to 
the amount of twenty-four ounces in twenty- 
four hours, being allowed all the water he 
wanted to drink. 
August 27.-The symptoms of bromism 
more marked ; the temperature declined to 
subnormal,-98.5° F.; the trismus much di- 
minished, the tetanic spasms occurring at 
greater intervals and with less severity. In 
the evening the bromides were stopped ; the 
patient up to this time having taken thirteen 
and one-half ounces of the bromide and one 
ounce and seven drachms of chloral in eight 
days ; the patient was ordered to continue 
the chloral in 15-grain doses every two hours 
for three doses, beginning at 9 a.m. ; no more 
to be taken unless symptoms demanded. 
August 28.-Patient rested well during the 
night, the paroxysms of spasms being less 
frequent and lighter. The tonic rigidity of 
the muscles of the neck and jaw showed les- 
sening in degree, while the abdominal mus- 
cles were in a state of marked tonic rigidity ; 
the patient's bowels were kept open by means 
of enemata and magnesium sulphate in drachm 
doses ; nourishment consisted of forty ounces 
of milk and sixteen ounces of chicken- 25 
broth; chloral administered at i, 3, 5, and 
7 P.M. 
August 29.-Temperature had risen to one- 
half a degree above normal; slight diminu- 
tion in all the tetanic symptoms, except 
marked rigidity of abdominal muscles ; chlo- 
ral administered at 8.30 and 10.30 p.m. ; the 
nourishment same as the day previous. 
August 30.-Chloral at 1, 3, 8, and 10 a.m. ; 
trismus less marked, patient being able to 
open his mouth and partly protrude the 
tongue, but the muscles of the jaw were still 
stiff, as well as the muscles of the neck. 
August yt.-The symptoms continued the 
same, the tetanic spasm being slightly more 
marked but at longer intervals. Chloral was 
given at 4, 6, and 8 a.m. and 7, 9, and 11 p.m. ; 
the circulation showed no signs of weakening. 
The medicine was now changed, and he was 
ordered the following prescription : 
1£ Chloralis, 
Sodii bromidi, aa gr. xv; 
Extract, hyoscyami, 
Extract, cannabis indicse, aa gr. *4. 
Sig.-To be taken every two hours as indicated. 
The amount of chloral taken up to this 
time was two ounces, three drachms, and 
forty-five grains. 
September i.-The tonic rigidity of the ab- 
dominal muscles was still marked, the patient 
resting well during the night, with occasional 
paroxysms of spasm ; these paroxysms never 
occurred during sleep. Pulse was regular, 
although always increased in frequency 
during the spasm, which was probably due 
to a general vaso-motor spasm, due to ex- cessive muscular contraction. The tempera- 
ture in the morning was normal, with an 
evening rise of one degree. Patient's nour- 
ishment for the day consisted of thirty ounces 
of milk and eighteen ounces of broth. The 
medicine was given at 8 and io a.m. and 4.30, 
8.30, and 10.30 p.m., and the patient was also 
ordered one-half ounce of beef peptonoids, to 
be given four times a day regularly. 
September 2 to 8.-Symptoms continued 
about the same, the tetanic symptoms grad- 
ually becoming lighter and less frequent; 
the incision at point of wound had entirely 
healed. Some stiffness of the muscles of the 
jaw and extremities was noticed, more espe- 
cially the extensors. The patient had now 
fully recovered from the effects of the bromide. 
The medicine was administered on September 
3 at 9 and 11 a.m. and 1 and 3 p.m. ; on Sep- 
tember 4, at 11 a.m. and 3, 5, 7, and 9 p.m. ; on 
Septembers, at 2, 5, and 8 p.m. ; on Septem- 
ber 6, at 11 a.m. and 6 and 9 p.m. ; on Septem- 
ber 7, at 10 a.m. and 4 and 9 p.m. The bowels 
during this time were constantly constipated 
unless relieved by purgatives or enemata. 
September 8.-The patient was able to take 
solid food for the first time, the muscles of 
his jaw being considerably relaxed ; he was 
able to use the muscles of mastication, al- 
though they were somewhat limited in their 
action, and he still complained of dull aching 
pains in his extremities, especially in the in- 
jured limb. The medicine was used at 4, 8, 
and 11 p.m. 
September 9, 10, 11, and 12.-Symptoms 
continued the same, the tonic rigidity of the 
muscles gradually lessening in inverse order 
26 from their appearance, disappearing first in 
the parts affected last. 
On the evening of the 12th the patient 
complained of severe pains shooting all 
through his body; the abdominal muscles 
were still very rigid, and temperature slightly 
elevated (ioo° F.). There was slight increase 
in the tetanic symptoms. The medicine was 
administered September 9 at 4 and 6 p.m. ; 
September 10, at 5, 8, and n p.m. ; Septem- 
ber 11, at 9 a.m., 1 and 5 p.m. ; September 12, 
at 10 a.m., and 2, 4, 6, 8, and 10 p.m. Food, 
consisting of milk, toast, soft-boiled eggs, and 
coffee, in fact, any easily-digested food, was 
given. The patient complained of great 
pain on moving. 
On morning of September 13 the patient 
complained of pain on top (dorsum) of foot, 
at a point opposite the original wound. 
Upon examination, all the local signs of an 
abscess were present,-pain, swelling, heat, 
discoloration. The medicine was adminis- 
tered on 13th at 5 and 7 a.m. and 9 and 11 
p.m. The foot was dressed antiseptically, 
and on the following day, the 14th of Sep- 
tember, upon examination by Dr. Coplin, it 
was decided to open the abscess, which was 
done immediately, under the strictest aseptic 
and antiseptic precautions. When opened, 
it discharged two drachms of blood and 
pus; the wound was thoroughly irrigated 
with a 1 to 1000 solution of corrosive sub- 
limate ; a free incision was made, and 
drained by means of rubber tube and liga- 
tures ; then dressed with antiseptic gauze 
held in position by turns of a roller. During 
the operation the patient showed no signs of 
27 tetanic spasm, only of pain such as would 
usually attend the opening of an abscess ; no 
anaesthetic was given ; medicine was adminis- 
tered at 7, 9, and 11 a.m. and 3, 5, and 7 p.m. ; 
on the night of the 14th the patient rested 
well, being disturbed by occasional paroxysms 
of pain. 
September 15.-On redressing the foot and 
removing the tube, very little discharge on 
the dressings was found. Patient complained 
of dull, grinding pain in his body, extending 
down his left leg ; the wound showed very 
little signs of inflammation ; it was dressed 
antiseptically, and the nurse ordered to keep 
the dressings damp with the antiseptic solu- 
tion. Abdominal muscles still rigid ; no tris- 
mus ; the patient was still unable to protrude 
the tongue normally ; was cheerful and talked 
rationally. The medicine was administered 
at 9 and n a.m. and 1, 3, and 5 p.m. The 
nourishment consisted of soup, rice-pudding, 
and some solid food. 
September 16.-Patient was resting com- 
fortably, having slept six hours during the 
preceding night; the tetanic symptoms les- 
sened, with long interval between spasms, 
but still complained of the dull pains extend- 
ing all over his body ; temperature normal ; 
respiration 18; pulse 74; on dressing the 
foot, dressing showed no discharge except a 
little bloody serum ; the wound was thor- 
oughly washed out and redressed as before ; 
medicine administered at 9 and 11 a.m. and 
2 and 6 p.m. 
September 17.-The patient was able to sit 
propped up in bed ; no paroxysms or spasm ; 
lessened rigidity of abdominal muscles, but 
28 GRAPHIC CLINICAL CHART. 
DAY OF MONTH. 
kg.18 19 20 21 22 I 23 24 25 26 27 28 29 30 31 I Sept.1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 
1 2 3 4 5 6 7 8 9 10 11 12 ~13~ 141 15 ~ll6~ 17 18 ~19~"2~0 ~25 ~26~ 27 28 ~29~~30~nTH2 
8 
<n 
<u 
aJ 
So 
<3 
DAY OF DISEASE. 
TIME 
OF 
DAY. 
A. M. 
9 n 9 11 11 11 10 9 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 I9 11 11 
9 10 i 3 3 3 3 4 3 3 3 3 3 3 3 3 ~3 3 3 3~*3_H 2 3 2~~3~ 3~ 
P. M. 
43 
PUL8BIU8PIT1MP. 
470 
460 
450 
-440 
430- 
429 
440- 
460; 
HE 
-80- 
-70 
-60- 
HE 
HE 
-42 
-44- 
--4G 
"-68 
-97- 
-35 
~35~ 
-34- 
Z?± 
-32- 
-34- 
-30- 
_29- 
-23- 
27 
-26- 
-25- 
-24 
-22- 
-24- 
-20- 
zzt±z 
-48- 
-47- 
z±E 
-45 
-44- 
-49-- 
-42- 
-tee- 
-IG7- 
-496 
466 
-404- 
:4O9- 
-482d 
-404 
-400- 
HE 
Horinal 
Lins. 
-98- 
42 
■41 
40 
39 
-38 
-37 
-36 
Os. 
32 32 34 36 28 23 18 16 14 13 15 17 19 22 22 28 28 26 27 24 24 27 31 30 26 30 32 36 36 40 140 43 
URINE 
Contains 
Sp. Gr. 
Normal, except increased amount of Urea. 
Pulse Respiration Temperature Trismus - Tetanus "" 
Note.-There cannot be, of course, any true method of measuring degree or intensity of trismus or tetanus, and the graphic presentation is traced upon the chart merely with 
the idea of conveying to the eye the relation between the true graphic record of pulse, temperature, and respiration, and the general symptoms of the disease; also to emphasize the 
well-known fact that trismus is not essentially an index of the severity of the disease. still complaining of the pains, especially in 
the limbs. Temperature, pulse, and respira- 
tion normal; medicine administered 9 and 
11 a.m. and 5 and 7 p.m. 
Saw the patient again on the 19th of Sep- 
tember, and found his condition much im- 
proved ; pains diminished and wound almost 
entirely healed ; the patient, on attempting 
muscular movements, showed great muscular 
inco-ordination; all medicine was ordered 
discontinued ; and the patient's bowels being 
constipated, he was ordered a saline purga- 
tive, and relieved on the following day by 
rectal enema. 
Patient was seen again on the 22d ; he was 
able to walk about the room by the aid of a 
cane, still complaining of pains in his limbs 
and soreness of muscles, and also of a condi- 
tion of malaise. He was ordered easily- 
digested food, moderate amount of exercise, 
and, as no further attention was necessary, 
the visits were discontinued. 
One remarkable fact in the patient's favor 
was the large amount of nourishment taken, 
also that the bowels were kept constantly 
open, never, under any circumstances, being 
over forty-eight hours without being moved. 
The total amount of the bromides admin- 
istered was fourteen and one-half ounces; 
chloral, three ounces, three drachms, and 
forty-five grains. 
CULTIVATION EXPERIMENTS. 
The experiments made from the case 
of traumatic tetanus described were from 
(1) blood collected on a handkerchief (not 
sterile) from a slight bleeding at the nose 
3 
29 30 
(epistaxis), from which the patient suffered 
on the second day of the disease. The part 
containing the blood-stains was cut out and 
placed in sterilized water. After soaking for 
six hours, six tubes were inoculated with the 
fluid. In twenty-four hours, at a tempera- 
ture of 8o° F., the tubes showed slight 
growth, varying in color and form, showing 
the cultures to be contaminated. From each 
of the six tubes, tube-plates were made, 
which, in thirty-six hours, at a temperature 
of 8o° F., showed numerous localized colo- 
nies of different growth. After development 
of each, stains were made, and the micro- 
scope revealed the pure cultures of cocci, 
the staphylococcus pyogenes aureus and 
albus, but the remaining slides showed mixed 
cultures of bacilli and cocci of different sizes 
and forms. From the tubes showing con- 
tamination, tube-plates were made, three 
from each tube, and, after development, five 
removals were made from each colony. 
These were cultivated from tube to tube 
until the eighth generation of each tube was 
reached, stains being made from each tube as 
it developed. By this method two more pure 
cultures were obtained,-i.e., staphylococcus 
pyogenes citreus and proteus. The other 
tubes showed bacilli of different dimensions ; 
tube-plates were made of these, and by re- 
movals, by scratch- and stab-cultures, two 
pure cultures were obtained, one of which 
grew both aerobic and anaerobic. From 
the odor of one, and by microscopic appear- 
ance, it proved to be the bacillus pyogenes 
foetidus ; and, after a series of removals and 
cultivation, both aerobic and anaerobic, by 31 
stab-culture and by pure hydrogen growths, 
the other proved to be the bacillus of tetanus, 
as described by Nicolaiev. Stains were made 
from each culture, which, at the same age, 
from different tubes, showed the same micro- 
scopic appearance. These experiments were 
confirmed by Dr. David Bevan. 
Two rabbits were inoculated with a solu- 
tion from a pure culture of bacillus, both of 
which proved negative, neither manifesting 
any symptoms of the disease, although 
watched for eight weeks. 
2. From blood obtained on opening the 
wound, which was done under strict aseptic 
precautions. The same process was gone 
through as previously described, and, after 
carrying to tenth generation, the same micro- 
organisms were isolated, with the exception 
of proteus vulgaris. From each pure culture 
tube-plates were again made, which showed 
no new growths. By macroscopical com- 
parison, they showed the same appearance 
as the ones previously isolated. The staphy- 
lococcus pyogenes aureus and albus after- 
wards proved their presence by the forma- 
tion of an abscess, which has been described. 
Two rabbits were inoculated with the blood, 
but in both the writer failed to produce 
tetanus. 
From the pure cultures of the bacillus, two 
rabbits and two guinea-pigs were inoculated. 
After three days, one guinea-pig manifested 
tetanic symptoms ; there was slight abduc- 
tion and stretching of the hinder extremity 
nearest the seat of the inoculation, the limb 
becoming completely stiff ; there was muscu- 
lar inco-ordination, the animal suffering from clonic convulsions, which grew more frequent 
as the case progressed. The trismus was 
only slight, the animal taking food between 
the paroxysms. The animal could be thrown 
into violent spasm by a wave of air or by any 
sudden movement; these symptoms con- 
tinued to increase, and on the third day the 
animal died. Blood and serum, and also 
portions of tissue from the point of inocula- 
tion were immediately inoculated into tubes, 
and another guinea-pig inoculated with a por- 
tion of the spinal cord (cervical region) of the 
animal dead of tetanus. From the tubes the 
bacillus of tetanus was isolated, but the ex- 
periment on the guinea-pig proved negative, 
the animal manifesting no symptoms of the 
disease. The other guinea-pig showed no 
symptoms of the disease. The guinea-pig 
which was not affected had been inoculated 
with pure hydrogen culture. According to 
Belfanti and Pescarolo, the virulence is di- 
minished when cultivated in an atmosphere 
of hydrogen. 
Of the rabbits, after eighteen days, one 
showed signs of muscular inco-ordination, 
first affecting the muscles nearest the point 
of inoculation ; the convulsions were se- 
vere and frequent, marked trismus, and on 
third day of disease, and twenty-one days 
after inoculation, the animal died. From 
the cord and tissue the original bacillus of 
tetanus was isolated. On the twenty-second 
day after inoculation the other rabbit showed 
symptoms of the disease, and four days after- 
wards, twenty-six days after inoculation, the 
animal died. From this case the writer 
failed to isolate the bacillus of tetanus. 
32 3. From the pus obtained from the abscess 
which formed on the patient's foot, by tube- 
plating and by removals, I obtained the 
micro-organisms of suppuration, and also the 
bacillus pyogenes fcetidus, and a bacillus which 
resembled the bacillus of tetanus ; but the 
writer failed to produce tetanus in animals, 
either by inoculation of pus or of pure cul- 
tures obtained from the pus, although one 
guinea-pig showed symptoms of malignant 
oedema ; in fact, it was well marked in the 
limb which was the seat of inoculation. It is a 
well-known fact that the bacillus isolated from 
pus obtained from a tetanic patient resembles 
the bacillus of malignant oedema, the same 
bacillus sometimes causing tetanus, and at 
others malignant oedema. 
4. In the blood, after the patient had fully 
recovered from the disease, by careful tube- 
plating and removals, no bacillus of tetanus 
was found. 
5. From a case of so-called idiopathic tet- 
anus, which was in the wards of St. Mary's 
Hospital, the writer obtained a few drops of 
the patient's blood, but by careful cultivation 
no bacillus of tetanus was obtained. 
6. From a case of traumatic tetanus, which 
died at the Episcopal Hospital. From the 
post-mortem the writer obtained some of the 
serum from the body ; also portions of the 
cervical region of the spinal cord and me- 
dulla. Cultivations on agar-agar were made, 
from which the bacillus of tetanus was iso- 
lated. No inoculation of the pure culture 
obtained was made ; but a small portion of 
the medulla, being emulsified in bouillon, was 
injected into a rabbit, which caused a series 
33 of rapid convulsions, and in one minute the 
rabbit was dead. Post-mortem revealed 
nothing, except that it died a pulmonary 
death; the true cause was most likely 
ptomaine-poisoning or pulmonary thrombo- 
sis. All the experiments from the body of 
the animal proved negative. The experiment 
was repeated in two other rabbits with nega- 
tive results, although these were inoculated 
with a portion of the cord two days after its 
removal from the body. 
Experiments were also made with earth 
obtained from around the building where the 
patient was working when the foot was in- 
jured. From this the bacillus of tetanus was 
isolated, as well as numerous other micro- 
organisms,-viz., staphylococcus pyogenes 
aureus and albus, staphylococcus pyogenes 
citreus, bacillus pyogenes foetidus, and pro- 
teus vulgaris. No inoculation of animals 
was made from the bacillus obtained from 
the earth, but macroscopically and micro- 
scopically it corresponded in every way with 
the bacillus of tetanus. 
The period of incubation of the guinea-pigs 
was from three to five days ; of the rabbits, 
much longer,-eighteen to twenty-two days, 
-with the one exception. In several of the 
rabbits, in from four to six days after the in- 
oculation, they showed slight symptoms of 
the disease,-muscular inco-ordination, rigid- 
ity of limb nearest seat of inoculation ; but in 
one to two days all these symptoms passed 
off, with no further manifestation. On post- 
mortem examination of the case previously 
mentioned no important pathological change 
was found ; nothing, at least, but what would 
34 35 
occur in other diseases, the cord and brain 
being slightly congested. In the post-mor- 
tem examination of the animals no important 
or constant pathological alteration was notice- 
able in any organ or in the cord. Micro- 
scopical examination of the blood and inter- 
nal organs was almost entirely negative ; at 
least, nothing definite was learned. Upon 
examining the patient's urine, both by chem- 
ical tests and microscopically, it proved to be 
normal, except for a large increase in the 
amount of urea, it being double the usual 
amount. The urine was examined several 
times while the patient was in the height 
of the disease, with almost the same result. 
From the animals inoculated, and before 
any symptoms appeared, blood was taken 
from the veins to the amount of one-half 
drachm ; but cultivations from this failed to 
demonstrate the presence of the bacillus of 
tetanus. In the guinea-pigs the blood was 
taken in from twenty-four hours to three 
days ; in the rabbits, at varying intervals, 
from twenty-four hours to sixteen days after 
inoculation. From the animals suffering 
from tetanus, blood was taken in varying 
amount, never exceeding one-half drachm. 
By cultivation from this, the bacillus of tet- 
anus was found in only two cases,-one rab- 
bit and one guinea-pig ; all the others proved 
negative. But at the point of inoculation the 
bacillus was found, except in two cases ; while 
the experiments with the blood, as before re- 
lated, was not so constant. 
Experiments with the blood, before inocu- 
lation was made, as well as those from the 
blood of the animal in which no symptoms 36 
had developed, were negative. It has been 
asserted by Nicolaiev and Kitasato that the 
bacillus of tetanus is localized at the point of 
inoculation, and while Shakespear, Hock- 
singer, Deor, and others demonstrated the 
existence of the bacillus in the blood and 
internal organs ; yet, out of twenty cases, in 
only three were they able to find the bacillus 
in the blood. From the writer's research in 
this case we must admit that it does exist in 
the blood as well as in the wound. Belfanti 
and Pescarolo failed in fifteen different cases 
to produce tetanus from the spinal cord of 
the animals that died of the disease. They 
also failed in some instances to find the ba- 
cillus at the point of inoculation. These 
same experimenters found that if the blood 
was taken immediately after death, the re- 
sults were negative, but if they were to wait 
for six to twelve hours, they could also find 
the bacillus in the blood and internal organs. 
Their theory for this is that during life there 
was enough of oxygen in the blood to pre- 
vent the growth of the bacillus, and only at 
the time of death, in death's agony, it enters 
the blood, and, as the body is anaerobic after 
death, it then exists in all parts,-in the cord, 
blood, internal organs, and other tissues. Bel- 
fanti endeavored to prove that the bacillus 
does enter the blood, by inoculating several 
rats at the tip of their tails, and after from 
one hour to twenty hours cauterizing the 
root of the tail, but the animals died of tet- 
anus, which, it is said, was due to the action 
of the bacillus of tetanus, while others claim 
that it was due to the action of the ptomaines 
in the blood. Rosenbach found the bacillus 37 
of tetanus in the spinal cord of rabbits killed 
with tetanus. Nicolaiev, out of many obser- 
vations, only once found the bacillus in the 
nerve (sciatic) near the point of inoculation, 
and only twice in the spinal cord. 
As to the resistance of the spores, it was 
found that old cultures-three to four months 
old-retained their virulence, and from them 
new cultures could easily be obtained. Kita- 
sato has also found this to be true where the 
spores were dried on silk. The bacillus has 
been obtained from the decomposed body of 
a person who died of tetanus even after a 
lapse of more than a year. 
The bacillus of tetanus resists the action 
of other micro-organisms ; even in tube-cul- 
tivation, where the growth is contaminated, 
the bacillus loses none of its virulency. 
Souchez-Toled showed that in blood kept in 
aseptic tubes the bacillus was found, and that 
it retained all its virulency. The writer was 
able to confirm this by the blood taken from 
the wound, from which, after five months, the 
bacillus was isolated. That the bacillus is 
present in the cadaver and in putrefying 
bodies was proven by the same experimenter 
and confirmed by the writer. 
That, in order to induce tetanus, you must 
have an abrasion, has been definitely settled. 
Lorrani, Belfanti, and others found that the 
bacillus and spores may be drawn into the 
respiratory passages by inhalation, and even 
injected into the bronchial tubes, without 
producing tetanus. The pure cultures have 
been fed to animals without any result what- 
ever ; yet Betoli cites the case where slaves 
fed on the bull died of tetanus, and yet three 38 
of their number suffered from the disease, and 
two died. 
Thermal Tests.-The great resistance which 
the bacillus of tetanus has to heat has been 
well established. The writer exposed stab- 
cultures to a temperature of 200° F. for five 
minutes, and from this removals were made ; 
out of ten tubes inoculated, nine showed 
growth in thirty-six hours. Again, a tube 
was exposed to 2120 F. for five minutes, and 
removals made ; out of ten, eight showed 
growth, and when exposed to 2120 F. for ten 
minutes, out of ten removals, five showed 
marked growth. These experiments were 
verified by using cultures of different ages,- 
from eight days to three months. Those con- 
taining few spores were destroyed at 180° F. 
by exposure for twenty minutes, but those con- 
taining a larger number of spores were more 
resisting. 
It was found that, in order to destroy the 
bacillus and its spores, a continuous ex- 
posure to a temperature of 2120 F. for not 
less than thirty minutes was necessary. This 
only confirms the statements of Belfanti and 
Pescarolo, who found that an exposure of 
one hour to a temperature of 8o° C. did not 
destroy the bacillus or spores. Kitasato ex- 
posed a pure culture to a temperature of 
90° C. for one hour, and yet was able to 
make cultures from the tube ; but, by ex- 
posing to a temperature of ioo° C. from ten 
to twenty minutes, he claimed to have de- 
stroyed both bacillus and spores. Kitasato 
used the following method to obtain a pure 
culture of the bacillus. He exposed a mixed 
culture to a temperature of 180° F., at which temperature the other micro-organisms were 
destroyed ; but the bacillus of tetanus being 
more resisting to heat, pure cultures were 
obtained. While this method is suitable for 
obtaining pure cultures of the bacillus of tet- 
anus, it is entirely useless for obtaining any 
other organism which might be found with it, 
and is thus robbed of its scientific value. 
Effects of Drugs.-Ten tubes of the pure 
culture of the bacillus on agar-agar were ex- 
posed to a solution of corrosive sublimate, 
i to 1000, for five, ten, fifteen, and twenty 
minutes, and three removals made from each 
tube, at each exposure, and without exception, 
in from twenty-four to thirty-six hours, every 
cultivation showed marked growth. Five 
tubes were then exposed to a solution of the 
same strength, for intervals ranging from one 
hour up to ten, and from these three removals 
were made from each tube at each exposure, 
and it was found that when exposed for ten 
hours or over no growth could be obtained. 
It was found that the spores even resisted its 
action longer. The experiments were re- 
peated, bouillon being used. Seven tubes, 
each containing twenty-five cubic centimetres 
of the culture medium, were then inoculated 
with the bacillus of tetanus. After forty-eight 
hours the tubes showed marked growth ; each 
tube was subjected to solutions of corrosive 
sublimate, the first tube being exposed to a 
solution of i to 1000 ; the second, i to 2000 ; 
and so on up to 1 to 7000. After three hours, 
three removals were made from each tube. 
From the tube which was exposed to 1 to 
1000 solution, no growths were obtained, and 
from the three removals from the tube ex- 
39 40 
posed to i to 2000, two showed no growths ; 
the other removals all showed marked growths. 
These experiments showed the effect to be the 
same in liquid or solid media, and these results 
agree with those of Belfanti and Pescarolo. 
2. The effect of carbolic acid was next 
tried ; five tubes of the pure culture of the 
bacillus were exposed to varying solutions of 
carbolic acid, one, two, three, four, and five 
per cent, strength. After three hours, three 
removals were made from each tube, and 
after from twenty-four to forty-eight hours, 
all developed growths. After exposure for 
six hours, three removals were again made 
from each tube, and those exposed to the 
weaker solutions, one to three per cent.; all 
developed growths, but from those which 
were exposed to the four and five per cent, 
no growths were obtained. The experiments 
were repeated on bouillon with similar re- 
sults, and the acid seemed to affect the 
bacilli and spores alike. 
3. The hydrochlorate of cocaine was then 
used. Four different tubes were exposed to 
different strengths of a solution of the drug,- 
one, two, three, and four per cent.; after five 
minutes, three removals were made from each 
tube. After thirty-six hours, two tubes, which 
had been exposed to the one per cent, solu- 
tion, showed slight growth, and one tube 
from the two per cent, solution. From the 
three and four per cent, solutions no growths 
were obtained. Two tubes were then ex- 
posed to a one and two per cent, solution for 
ten minutes ; from each three removals were 
made, from which no growths developed. 
Five tubes were then inoculated from a cul- 41 
ture, which had not been exposed to the 
action of the drug. These tubes were imme- 
diately subjected to a one per cent, solution 
of the drug. In twenty minutes the solution 
was removed, but the tubes failed to develop 
any growth ; confirmatory experiments were 
made on bouillon. 
4. The peroxide of hydrogen was next used. 
Ten tubes were exposed to the drug for 
twenty-four hours; three removals were 
made from each tube, all of which developed 
growths. Ten tubes were then exposed to 
the drug for forty-eight hours, and three re- 
movals made from each, and, without excep- 
tion, all developed growths. The only effect 
noticeable was, that it liquefied the growth 
almost immediately on contact, a gas being 
evolved. These experiments were repeated 
on bouillon with the same results. 
Five tubes were exposed to the fumes of 
bromine for twenty seconds ; three removals 
were then made from each tube. Out of all 
the removals, four developed growths. The 
tubes were then exposed to the fumes for 
forty seconds, and three removals were made 
from each tube, all of which failed to develop 
any growths. 
SUMMARY. 
Although these experiments are largely 
confirmatory, at least, in many points, of 
what has been done by others, yet some im- 
portant observations have been added ; and, 
from the research made, it has been proven 
that Belfanti and Pescarolo were correct in 
their statement that the bacillus of tetanus 
was not an obligate anaerobe. 
While the bacillus does not proliferate 
4 more rapidly in an atmosphere of pure hydro- 
gen, yet it lessens its virulency when deprived 
of oxygen, and from pure hydrogen cultures 
inoculation experiments are almost always 
negative. In this the writer confirms the 
observations made by Widal, Chantenesse, 
Tizoni, Babes, Pescarolo, and Belfanti. 
From the laboratory experiments, it was 
found that from stab cultures the growth 
would extend out over the top of the medium 
in from five to ten days after inoculation. 
By removal from this, as aerobic growths, the 
development was uninterrupted ; but if the 
removals were made from portions of the 
growths beneath the surface, the removal 
showed no growth until after the sixth to as 
late as the fourteenth day ; yet the same ba- 
cillus could be cultivated, either aerobic or 
anaerobic. It is the belief of the writer that 
no micro-organism is purely anaerobic,-Z.<?., 
acting as such in the body. One can scarcely 
conceive where, in the human economy, such 
an organism could find a suitable nidus for 
its existence and proliferation. This view is 
further substantiated by many continental 
observers. The bacillus grows best at a 
temperature of 98° F., but \yill grow rapidly 
at 510 to 710 F. 
Of the eleven animals inoculated, five died 
of the disease. From these the writer failed 
to produce tetanus in other animals; in 
one case he failed to isolate the bacillus of 
tetanus from the dead animal. From the 
blood of the animals, while suffering from 
the disease, the bacillus was found in only 
two cases,-from one rabbit and from one 
guinea pig ; also from the traumatic case re- 
42 ported. From the point of inoculation, the 
bacillus was found except in two cases. Ex- 
periments from point of inoculation and from 
the blood after inoculation, and before any 
symptom of the disease,-?>., during the 
period cf incubation,-gave negative results 
Neither could the bacillus be demonstrated 
in the blood of the animals inoculated but 
not taking the disease at all. 
That the bacillus is polymorphous is clearly 
proven by macroscopic appearance of growths 
at different ages, and by microscopic appear- 
ance of stained cover-glass films. Its marked 
resistance to the action of heat is clearly 
proven, requiring a continuous temperature 
of 2i2° F. for not less than thirty minutes to 
destroy it. Its resistance to the action of the 
corrosive sublimate and carbolic acid is def- 
initely established, the experiments with these 
drugs being confirmed by many experiment- 
ers, among the most noted of whom are Bel- 
fanti and Pescarolo. 
Peroxide of hydrogen showed no marked 
effect on the bacillus, except it seemed to re- 
tard its growth ; but, without exception, the 
tubes on which the experiments were con- 
ducted developed growths. As to the use of 
the hydrochlorate of cocaine, its action was 
almost one of a specific, as all the cultures 
subjected to the drug for five to ten minutes 
failed to develop any growth. 
Growths exposed to the fumes of bromine 
for twenty seconds, with few exceptions, 
showed no growths, and when exposed for 
forty seconds no growths were obtained. 
It would be necessary, in order to arrive at 
anv definite conclusion as to the effect of 
43 44 
these drugs, to administer the drug to the 
animal suffering from the disease, and note 
its effect. As yet this has not been done, 
except that bromine was used locally in mop- 
ping out the wound in the case reported. 
Treatment.-The disease being an infec- 
tious one, isolation of the patient is of 
great importance. As the wound is the seat 
of inoculation, thorough antiseptic meas- 
ures must be employed. As a prophylactic 
precaution, all irritating substances must be 
removed. If the wound be closed, it should 
be freely incised, disinfected, and free drain- 
age established. In the case reported, pure 
bromine was applied, with undoubted bene- 
ficial results. Too much importance cannot 
be attached to the nourishment of the patient, 
whose diet should be entirely of a liquid na- 
ture. If this be impossible by the mouth, 
then nutrient rectal enemata must be em 
ployed. The bowels must be kept open, 
under no conditions allowing thirty six hours 
to pass without an evacuation. 
The patient should be kept quiet in a dark- 
ened room, preferably by himself, and no one 
allowed in the room except the attendant. 
The room should be well ventilated, but no 
current of air should be allowed to strike on 
the patient, as even slight draught will suffice 
to produce a paroxysm. 
The remedies which have been most suc- 
cessful are those which lessen the reflex func- 
tion of the spinal cord, the most successful of 
these being the bromides and chloral, both 
given in decided doses, until their full physi- 
ological effect is produced. Thirty grains of 
chloral should be used, with sixty grains of the bromide of potassium or sodium, and in 
two hours, if necessary, thirty grains more of 
the bromide may be administered. If the 
drugs are vomited, they should be given by 
the rectum, and, if necessary, the patient may 
be chloroformed until they are absorbed. Dif- 
ferent remedies have been used with varied 
success, such as conium, atropine, nicotine, 
wine of tobacco, physostigmine, eserine, chlo- 
roform, alkaline baths, and hypodermic injec- 
tions of carbolic acid. 
Chloral and the bromides have undoubt- 
edly the most marked influence upon the 
severity of the spasms. For the relief of the 
paroxysms, much can be done by application 
of cold to the spine. 
Professor H. A. Hare, in his essay on " The 
Physiological and Pathological Effects of the 
Use of Tobacco," cites nineteen cases treated 
with tobacco, of which nine recovered. The 
drug was used in the form of fomentations, 
injections, and cataplasms, or given inter- 
nally, nicotina, in doses of from T'T to | drop, 
or nicotine, in doses from | to 3 drops every 
few hours. 
Miller recommends cannabis indica pushed 
to narcotism. 
Elliston highly recommends some prepara- 
tion of iron, preferably the carbonate, in 
chronic cases. 
Topez reports a case successfully treated 
with injections of morphine and cocaine, each 
five per cent, solution. Billroth strongly re- 
commends narcotics, especially morphine and 
chloroform, also warm potassium baths, strong 
irritants to spine, large blisters, and the hot 
iron. 
45 Treves recommends the use of chloral, in 
15- to 20-grain doses, at onset of the disease, 
followed by bromide of potassium. He also 
suggests the use of cocaine to control reflex 
action. Brunauer's case of rheumatismal (?) 
tetanus, which he reports cured by pilocar- 
pine, was also given chloral hydrate. 
Moullin recommends, above all other rem- 
edies, chloral and potassium bromide. He 
also urges the necessity of keeping up nutri- 
tion and of keeping the bowels open. 
Potter, in his article on " Special Thera- 
peutics," in which he enumerates some twenty 
different remedies, shows the best results from 
chloral, combined with the bromides. Shaw 
and Tordeus each report a case cured by com- 
bined doses of chloral and potassium bromide. 
In both cases this was continued one month 
before a cure was effected. 
Ore, of Bordeaux, cites one case where in- 
travenous injections of chloral, after one or 
two repetitions, entirely relieved the par- 
oxysms. Chopard, in his thesis on tetanus, 
enumerates one hundred and thirty-two cases 
treated with chloral hydrate, with sixty-nine 
cures. Tabbi, in 1871, thirty-two cases, with1 
fourteen cured. Beck, one year later, recorded 
thirty-six cases, with twenty-one cured. 
Knechl, in 1878, one hundred and thirty- 
four cases, with seventy-nine cured. 
Professor W. S. Forbes reports a case of 
traumatic tetanus cured by the continued 
use of amyl nitrite. 
Hansen reports two cases successfully 
treated by morphine and amyl nitrite. Rich 
ardson, three successfully treated by amyl 
nitrite alone. 
46 47 
Coste, of Marseilles, successfully treated 
one case with sulphate of quinine. 
Bright cites one case in which quinine 
afforded permanent relief. 
Navarro, in 1869, reported seventeen cases 
treated with eserine, with success in twelve 
cases. 
Of cases successfully treated by curare, 
Chassaignac, in 1854, reports one case; 
Wells, two, with one cure ; Demme, twenty- 
two cases, with eight recoveries; Busch, 
eleven cases, with five recoveries. 
Capozzi, Morra, and Gherini each report 
one case cured by curare. 
Eilert, Halhouse, Wilkis, Wood, and Wat- 
son report one case each in which calabar 
bean effected permanent relief; while Ash- 
down, Spencer, and Dickerson had no suc- 
cess from the use of the drug. 
Hunter was successful in two cases by 
using chloral and cannabis indica. 
Delsae saved three out of four cases 
by opium and chloral ; Wood, nine out of 
eighteen by chloral alone; Birkett, one 
case ; Page and Morgan report one cured 
case each, treated by aconite. Franzolini 
reports one case cured after twenty-nine 
days' treatment, during which time four 
ounces of chloral and twenty-two grains 
of hydrochlorate of morphine were admin- 
istered. 
Johnston, of Baltimore, successfully treated 
several cases by means of hypodermic injec- 
tions of conine. 
Mattingly's traumatic case, following a 
crush of the finger, was relieved by amputa- 
tion. Frederick, in 1837, reported two hun- 48 
dred cases in which amputation was resorted 
to, with twenty-four recoveries. Curling, in 
1835, reported seven recoveries out of eleven 
amputations ; Paland, two cases, with one re- 
covery ; Yandell, seventeen cases, with ten 
recoveries; Early, in 1871, one case, with 
recovery. 
Bartholow recommends excision of the 
cicatrix. 
Buck reports one case in which dissect- 
ing out the scar afforded almost immediate 
relief. 
Farrey, in two cases, divided the tissues 
forming the floor of wounds, followed by 
rapid disappearance of the tetanic symp- 
toms. 
Samuel Wood, in a case following com- 
pound fracture of the femur, divided the 
saphenous nerve, and the operation was fol- 
lowed by recovery. 
Watson reports sixteen cases in which 
neurotomy was performed, ten of which 
recovered. Farrey and Murray's cases were 
entirely relieved by division of the injured 
nerve. 
Base and Marinelli divided the musculo- 
cutaneous nerve for tetanus, following a 
gunshot wound of arm, and the patient 
recovered. 
Edwards records an instance of recovery 
following the division of the short saphenous 
nerve, the original injury being a lacerated 
wound of heel, followed by sloughing. 
Fayer's case, following a lacerated wound 
of the hand, was relieved by division of the 
median nerve. 
The treatment of traumatic tetanus by 49 
means of injections of the tetanus antitoxin of 
Tizzoni and Cattani by Dr. Rudolf Schwarz, 
assistant in the surgical clinic of Padua, is 
discussed in the British Medical Journal of 
January 2, 1892. 
Tizzoni and Cattani claim to have suc- 
ceeded in producing immunity against tet- 
anus, even in animals susceptible in a high 
degree, and have shown that the blood 
serum exerts an antitoxic action, and is 
capable of producing immunity. The tet- 
anus antitoxin is obtained in a solid state by 
the addition of alcohol to the serum, and by 
drying the precipitate in vacuo. 
The antitoxin was used hypodermically, in 
doses of 15 to 25 centigrammes. Thus far 
four cases have been reported as treated with 
the antitoxin,-one by Gagliardi, of Moli- 
nella ; one case by Dr. Pacini, in the hos- 
pital at Colle di Vai d'Elsa, Tuscany; one 
by Professor Nicoladoni, in the surgical 
clinic of Innsbruck; and the fourth by 
Dr. Schwarz. The latter case was also 
treated by chloral, warm baths, injections 
of carbolic acid, and by division of the 
nerve. 
The general treatment may be summed up 
as follows : 
1. Disinfection of the nidus of develop- 
ment of the bacilli. 
2. The elimination of the poisonous prod- 
ucts of the bacilli from the system. 
3. Drugs which are sedatives to the nervous 
system. 
4. Excision of the cicatrix. 
5