LITERARY NOTES.

THE American Journal of Surgery and Gynecology, formerly published at Saint Louis, has been sold to Dr. J. Macdonald, Jr., well known to the medical world as a successful journalist, who will publish it in New York under the name of the American Journal of Surgery. It will be edited by Dr. Walter M. Brickner, and the publication office is located at 92 William street.

J. B. LIPPINCOTT COMPANY, Philadelphia, announce that they will publish during the present year a translation by Dr. Albion Walter Hewlett of the third German edition of the Principles of clinical pathology, by Dr. Ludolf Krehl, with an introduction by Dr. William Osler, of John Hopkins University. The work is well known in this country and in Europe as an authority upon the subjects treated, and has been copyrighted in the United States under the interim copyright act.

ITEMS.

THE New York Pharmacal Association, Yonkers, has issued recently a panel chart in colors, to illustrate Hæckel's theory of evolution. It will be found of especial value to the student, by means of which he will be enabled to fix in his mind the epochs of the several geological eras, the flora and fanna belonging to each, and the descent of man through each by an ingenious ancestral tree. The chart will be sent to any physician who may not have received it, if a request be made to the New York Pharmacal Association.

THE Denver Chemical Company, New York, proprietors of antiphlogistine, has published an artistic booklet dealing with substitutions and the substitutor in an original fashion. The cover page bears a life-like portrait of the original substitutor, clothed in his official robes. Anyone who may not have seen it should apply to the publishers for a copy.

BATTLE & COMPANY, Saint Louis, have sent out the fifth of their series of twelve illustrations of intestinal parasites. The entire group will be sent free to physicians on application to the publisher.

BUFFALO MEDICAL JOURNAL.

VOL. XLIV.-Lx.

MAY, 1905.

No. 10

T

ORIGINAL COMMUNICATIONS.

Traumatic Tetanus.'

BY CHARLES BENTZ, M. D., Buffalo, N. Y.,
Lecturer in Bacteriology, University of Buffalo.

ETANUS was recognised and described before the Christian era. In 1884, Nicolaier discovered the bacillus tetani. In 1889, Kitasato obtained it in pure culture. It is now recognised as the cause of tetanus. It is a common saphrophytic organism found in garden earth, street sweepings, putrefying organic material and in the intestinal discharge of herbivorous animals. According to Woodhead, certain savage tribes of Africa and the East Indies use soil that is capable of producing tetanus for an arrow poison.

Tetanus may be defined as "an infectious disease caused by a specific organism, which is localised at the point of inoculation. It is characterised by painful spasmodic contraction of the muscles, referable to the nervous system and with the absence of obvious tissue changes." It is the result of a specific wound infection. All mammalia, including man, are susceptible. The human species is especially so.

MORPHOLOGY OF THE TETANUS BACILLUS.-In its vegetative form it is a slim, straight bacillus, with rounded ends, which may form threads. It is slightly motile. In the spore-bearing form, the spores are located at one end which is swollen, giving the bacillus the characteristic drumstick or pin shape. The spores are very resistant. It is stated that they are killed by moist heat at 100° C. in 5 minutes; by bichloride of mercury 1-1000, in 3 hours; by 5 per cent. carbolic acid in 15 hours. The tetanus bacillus stains readily with solutions of the ordinary anilin dyes, also by Gram's method. It is a strict anäerobe. It may be cultivated

1. Paper read at the January meeting of the Roswell Park Medical Club.

at the room temperature, but better in the incubator. It grows upon ordinary culture media, preferably those containing dextrose, and gives off a characteristic odor. Upon gelatin a colony presents characteristic radiating filaments and looks like a thistle.

Mixed infections are favorable to the development of tetanus. Other organisms require oxygen for their growth; hence, by using up the oxygen renders conditions suitable for the development of this germ. The organisms multiply locally at the seat of inoculation and never enter the blood or deeper tissues. The disease is always contracted through wounds which may be of a trifling character. Clinically, persons having the disease suffer from spasms which start from the point of inoculation and finally become general. The period of incubation varies from one day to several weeks. The shorter this period of incubation in the human subject, the more serious is the disease.

Tetanus belongs to that class of diseases which exhibits the element of poisoning by bacterial products in an extremely marked manner. The symptoms are produced by the poison elaborated, which is probably small in amount, but extremely powerful and rapidly produced. Kitasato found that excision and cauterisation of the point of inoculation in mice failed to save the animal unless practised within an hour after inoculation.

It has been estimated that 1-280 of a grain of pure tetanus toxin would be the fatal dose for a man weighing 155 pounds. This poison has a specific affinity for the ganglion cells of the anterior horns of the spinal cord.

Meyer and Ransom explain the delayed effect of the poison thus: the toxin does not reach the spinal cord through the bloodstream, but travels up the axis-cylinders of the motor cells, from their terminations. The myelin sheath acts as an impervious membrane, and the toxin enters at the end of the neuron, where it is not provided with the sheath. Sensory nerves do not transport toxin. Part of the toxin enters the nerves in the region of the wound, the rest is carried by the blood and lymph to be later taken up by the motor nerves in other parts of the body. Experimentally, if tetanus toxin is injected into the spinal canal, the symptoms appear at once. The toxin produces degenerative changes of the Nissel granules and protoplasm of the motor cells.

CASE I.-J. S., male; age, 38; previous history, good. In June, 1902, sustained a compound comminuted fracture of the right leg. A considerable quantity of dirt was found in the wounds. The patient was advised to have his leg amputated. Operation was declined. Microscopic examination was made of the pus from the wounds. A few short bacilli and cocci were

found. About the eleventh day after the injury the patient complained of severe headache and stiffness in the muscle of mastication. Another examination of the pus from the wounds was made, a few drumstick bacilli and many cocci were found. Tetanus antitoxin was injected in 20 c.c. amount in the groin every two hours. The other symptoms developed rapidly, trismus became pronounced. The physiognomy of the patient was distinctive. It was immobile, features were fixed, the forehead wrinkled and the corners of the mouth retracted producing the sardonic grin. There was an increased flow of saliva, which escaped from the corners of the mouth. Next there was rigidity of the muscles of the body and then the spine was bowed anteriorly (opisthotonos). The position of the body was constantly rigid. Convulsive seizures of variable duration occurred, causing patient to groan frightfully. The skin was covered with profuse perspiration. The intellect remained clear until death, which occurred two days after the appearance of the first symptoms. Autopsy was not permitted.

CASE II.-P. M., male; age, 42. In October, 1903, sustained a crushing injury of the right foot necessitating amputation of four toes. Street dirt was ground into the wound. About eleven days after injury the patient complained of stiffness of the muscles of mastication. A microscopic examination of pus from the wound was made, a few pin shaped bacilli and cocci were found. The patient suddenly died in convulsions. From these findings and the few symptoms present tetanus was suspected.

Autopsy was permitted. The findings were as follows: body was that of a middle aged man, not remarkable in external appearance, except that rigor mortis was marked and there were bandages on the right foot and around the neck, the latter bloody. On removing the bandage from the foot, the first four toes were found amputated at various joints, covered with dressing, the stump of the second toe black, and some purulent discharge present. Smears and cultures were made from the discharge from the toes and the deeper parts of the wounds. On removing the bandage from the neck a sinus was found on the right side, evidently of long standing, a little below the mastoid process. Cultures and smears were made from this sinus.

The brain and upper part of the spinal cord were removed and examined in all parts, but presented no remarkable features. There were no changes in the cranium. There was a roughening of the upper bones of the spine, of an extent which was impossible to determine. It was most marked in the odontoid process of the axis. There was softening and loosening of the ligaments in the vicinity of the atlas and axis. The odontoid process projected abnormally behind and must have compressed the medulla. This was decided to have been the immediate cause of death. A probe inserted into the sinus in the neck went in the direction of the diseased area, about four inches. The sinus evidently led

to this point. Cultures and smears were made from the region. Examination of the internal organs were negative, except an area of tuberculosis of the apex of the right lung.

Subsequent study of the smears and cultures was made. Those from the sinus in the neck and from the diseased vertebræ showed ordinary pus cocci. The process was, however, probably tuberculous in the beginning and was very likely connected with the tuberculous area in the lung. The smears made from the foot showed numerous pus cocci, and bacilli having the characteristic form of tetanus bacilli, with a few bacilli of other forms. Subsequent study of the suspicious organisms in culture showed that they presented the characteristics of tetanus bacilli. Among other points their spores still grew well after being at a temperature of 80° c. for 45 minutes. Minute portions of the cultures killed each of three guinea pigs in about 48 hours, producing muscular spasms. The bacilli grew in the absence of

Oxygen.

It is my opinion that the man suffered from tetanus; that he had a weakening of the ligaments about the upper part of the spine and the lower part of the skull owing to previous tuberculous disease, and that tetanic convulsions led to a partial dislocation of the axis; the odontoid process compressed the medulla and produced death, probably very quickly.

CASE III.-Name, F. D.; year, October 31, 1904. Diagnosis, traumatic tetanus. Nature of injury, stepped on rusty nail which penetrated the foot between fourth and fifth metatarsal bones. Period of incubation, 6 days. Method of administration of antitoxin, subcutaneous and into nerve trunk of affected side. Amount, 100 c.c. Other treatment, bromides, chloral, morphine, and chloroform. Result, death.

CASE IV.-Name, L. B.; year, August 17, 1904. Diagnosis, traumatic tetanus. Nature of injury, compound fracture of left wrist. Period of incubation, 6 days. Method of administration of antitoxin, subcutaneous. Amount, 200 c.c. Result, death.

CASE V.-Name, A. L.; year, July 21, 1904. Diagnosis, traumatic tetanus. Nature of injury, stepped on rusty nail, which penetrated the foot between second and third metatarsal bones. Period of incubation, 5 days. Method of administration of antitoxin, subcutaneous. Amount, 200 c.c. Other treatment, bromides, chloral, morphine, chloroform. Result, death.

CASE VI.-Name, E. S.; year, 1904. Diagnosis, traumatic tetanus. Nature of injury, laceration of foot. Period of incubation, 12 days. Method of administration of antitoxin, subcutaneAmount, 330 c.c. Result, death.

ous.