Treatment.-Far better than even to treat tetanus well is to prevent it. Careful antisepsis will banish it as thoroughly as it has banished septicemia. Every wound must be disinfected with the most scrupulous care. Every punctured wound is to be incised to its depth and thoroughly cleaned and drained. Puerperal tetanus is prevented by antiseptic midwifery, and tetanus neonatorum is obviated by the antiseptic treatment of the stump of the cord. When tetanus exists, always look for a wound, and if one is found, open it, cut away sloughs, wash with peroxid of hydrogen and corrosive sublimate, swab it out with bromin, and secure drainage by packing it with iodoform gauze.

Isolate the patient, as the disease is infective; keep him in a darkened, well-ventilated, and quiet apartment, so as to exclude as far as possible peripheral irritation. Watch for retention of urine, and use the catheter if it occurs. Secure movements of the bowels by salines, castor oil, croton oil, or enemas. Give plenty of concentrated liquid food, and stimulate freely with alcohol. If swallowing causes convulsions, give an inhalation of nitrite of amyl before an attempt is made to swallow. If this treatment fails, partially anesthetize the patient and feed him by means of a pharyngeal tube passed through the nose. Large doses of the bromid of potassium, or of this drug with chloral, give the best results. If bromid is used, give about 3j every four to six hours. Other drugs that have been used with some success are gelsemium, morphin, curare, injections and fomentations of tobacco, physostigmin, anesthetics, cocain, and cannabis indica. An ice-bag to the spine somewhat relieves the girdle-pain. Hot baths have been advised.

Yandell says, in summing up Cowling's report on tetanus :1 "Recoveries from traumatic tetanus have been usually in cases in which the disease occurs subsequent to nine days after the injury. When the symptoms last fourteen days, recovery is the rule, apparently independent of treatment. The true test of a remedy is its influence on the history of the disease. Does it cure cases in which the disease has set in previous to the ninth day? Does it fail in cases whose duration exceeds fourteen days? No agent tried by these tests has yet established its claims as a true remedy for tetanus."

2

It is now claimed by some observers that we have a remedy which fulfils the requirements of Yandell in the tetanus

1 American Practitioner, Sept., 1870.

2

Quoted by Hammond, in his Diseases of the Nervous System.

antitoxin of Tizzoni and Cattani. To prepare this antitoxin a horse is rendered immune to tetanus by inoculations with mitigated cultivations of the microbe; stronger and stronger cultures are given; the blood is drawn, and the serum is separated and treated with alcohol and dried in a vacuum. The antitoxin is dissolved in glycerin, and is used hypodermatically in doses of from 15 to 25 centigrammes. Some physicians have injected the serum itself. Cures seem to have followed its use, and if it can be obtained it is our duty to try it in acute tetanus. Kitasato has shown that injections of iodoform render animals immune, and Sonnani has maintained that this drug in a wound prevents the disease. If antitoxin is not obtainable, give hypodermatic injections of iodoform 3 to 5 grs. t. i. d.

XIII. TUBERCULOSIS.

A

Tuberculosis is an infective disease due to the deposition. and multiplication of the bacilli of tubercle in the tissues of the body. It is characterized either by the formation of tubercles or by a widespread infiltration, both of these conditions tending to caseation, sclerosis, or ulceration. tubercular lesion may undergo calcification. A tubercle is an infective granuloma, appearing to the unaided vision as a semitransparent gray mass the size of a mustard-seed. The microscope shows that a gray tubercle consists of a number of cell-clusters, each cluster constituting a primitive tubercle. A typical primitive tubercle shows a center consisting of one or of several polynucleated giant-cells surrounded by a zone of epithelioid cells which are surrounded by an area of leukocytes. When the bacillus obtains a lodgement the fixed connective-tissue cells multiply by karyokinesis, forming a mass of nucleated polygonal or round cells, called epithelioid" from their resemblance to epithelial cells, and at the same time the blood-supply of the growth is limited by occlusion of surrounding vessels through multiplication of their endothelial coats. Some of these epithelioid cells

proliferate, and others attempt to, but fail for want of bloodsupply. Those that fail succeed only in dividing their nuclei and enormously increasing their bulk (giant-cells). Giant-cells, which also form by a coalescence of epithelioid cells, are not always present. The presence of irritant bacterial products induces surrounding inflammation and exudation of white blood-cells (Fig. 37).

The bacillus, when found, exists in the epithelioid cells, and sometimes in the giant-cells; it may not be found, having once existed, but having been subsequently destroyed. It is often overlooked. In an active tubercular lesion, even if the bacillus be not found, injection of the matter into a guinea-pig will produce lesions in which it can be demonstrated. A tubercle may caseate-a process that is destructive and dangerous to the organism. Caseation is due to a coagulationnecrosis arising from direct microbic action upon a cellular area which contains no blood-vessels, the nutrition of the area being cut off by obliteration of surrounding vessels. This process starts at the center, and the entire tubercle becomes converted into a soft yellowish-gray mass. Caseation forms cheesy masses, which may soften into tubercular pus, may calcify, and may become encapsuled by fibroid

tissue.

A tubercle may undergo sclerosis, which is an attempt on the part of Nature to heal and repair. Coagulation-necrosis occurs in the centre of the tubercle; "hyaline transformation proceeds, together with a great increase in the fibroid elements, so that the tubercle is converted into a firm, hard structure" (Osler). Infiltrated tubercle is due to the running together of many minute infective foci, or to widespread infiltration without any formation of foci. Infiltrated tubercle tends strongly to caseate.

The bacillus of tubercle, discovered by Koch, is a little rod with a length equal to about half the diameter of a red blood-corpuscle. It can be stained with anilin, and this stain is not removable by acids (it being the only bacillus except leprosy which acts in this way). In its growth the tubercle bacillus causes the formation of toxins, and the absorption of toxins induces constitutional symptoms. These bacilli exist in all active lesions: the more active the process the greater is their number. They may be widely distributed, and are occasionally though rarely identified in the blood. They exist in enormous numbers in phthisical sputum, but are not found in the breath of consumptives. Their great medium of distribution is dried sputum mixed with dust.

They are found in the milk of tubercular cows, and sometimes in the meat of diseased animals.

Infection may be due to hereditary transmission. Congenital tuberculosis is occasionally, though rarely, seen. Tuberculosis is apt to appear in young children. Some think this is due to infection from without upon tissues whose resistance is lowered by hereditary predisposition; others think it is due to a tardy development of the germs transmitted by heredity. That the disease may be present in a latent form is shown by the experiment in which the viscera of the fetus of a consumptive mother showed no tubercles, but produced the disease in guinea-pigs when inoculated. Tuberculosis may arise by inoculation, inoculation-tuberculosis being seen in leather-workers and in those who dissect tubercular bodies (butchers and doctors are liable to anatomical tubercle). Osler mentions as other causes of inoculation the bite of a tubercular patient, the washing of infected garments, and circumcision in which suction is employed by an individual with phthisis. Granulation-tissue, chronic abscess, and areas of dermatitis may be infected from without (G. R. Fowler). Infection through the air is very common. The bacteria of the dried sputum adhere to particles of dust and are carried into the lungs. Infection by meat, milk, and other foods may arise by this dust settling upon them in quantity. Commonly, however, it is due to disease of the animals. Milk is a common vehicle of contagion, and it can be infected even when an ulcerated udder does not exist.

Infection is favored by hereditary predisposition—that is to say, by hereditary tissue-weakness, which, by maintaining a lowered momentum of nutritive processes, lessens the normal resistance to infection. Hutley studied 432 cases of tuberculosis. In 23.8 per cent. one or both parents had the disease (the father alone in 11.5 per cent., the mother alone in 9.9. per cent., and both in 2.4 per cent.). Two types of these predisposed persons are mentioned: (1) the sanguine type, or those with oval faces, clear skin, large blue eyes, long lashes, a nervous manner, precocious minds, but little fat, and with long, slender bones, these children being often graceful and beautiful; and (2) those with stolid countenances, thick lips and noses, thick, muddy skin, dark, coarse hair, swollen necks, heavy bones, clumsy gait, and ungainly figure. The latter type is the phlegmatic form-the classical scrofula.

1 Quoted by Osler from Birch-Hirschfeld.