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 As the lungs fill with the first crop of infected emboli, and the first
series of metastatic abscesses form there, there is more or less
dyspnea and sense of oppression; there may be also pulmonary
complications—pleurisy, bronchitis, etc., even pulmonary edema.
Frequently there is expectoration of frothy and discolored sputum;
occasionally there is blood in the sputum. A peculiar sweetish odor
of the breath has been noted by many observers in this disease, and
is supposed to be idiopathic and characteristic. (See acetonemia in
previous chapter.) With the dispersion of the second crop of emboli
from the lungs there is apt to be icterus, with evidence of metastatic
abscess in the liver, and collection of pus as the result of
coalescence of small abscesses. The sensorium is not so affected in
pyemia as in septicemia, and in the former disease patients are
more likely to be alert and active in mind. General hyperesthesia and
restlessness are common. Colliquative sweats are also a feature of
pyemia. There is the same liability to eruptions, etc., which may
mislead or complicate the diagnosis. A dermatitis is seen sometimes
in pyemia, the lesions assuming a papular or pustular form, due to
local infections of the skin. Purpuric spots are also seen, and
vesication is not infrequent. Within the mouth sordes collect upon the
teeth or gums; the tongue becomes dry and brown and heavily
coated. Diarrhea is less common in pyemia. The urine is usually
scanty and high colored, containing solids in excess; albumin is
sometimes found therein, as well as peptone. The presence of
peptone in the urine is probably an indication of the breaking down of
pus corpuscles in various parts of the tissues.
A significant objective evidence of pyemia is met with in the
metastatic collections of pus within the joints, which occur relatively
early, and which, if multiple, may lead to a correct diagnosis. One of
the earliest joints to be involved is the sternoclavicular, although
none of the joints are free from the possibility of invasion. The
articular serous membranes seem to have the property of carrying
and holding the infective thrombi better than any other tissue in the
body. The pyarthrosis of pyemia is for the most part painless, yet
implies loss of function of the affected joints. The distention of these
is usually evident to the eye, the fluctuation pronounced, tenderness
not extreme, but the swollen part merges into tissues which are
edematous and reddened. When pain in the limb is extreme, it is
usually because of metastatic abscess within the bone-marrow
cavity. In other words, we now have a metastatic osteomyelitis.
In all cases of pyemia prostration is marked, yet the pulse is
seldom weak, at least until toward the close of life. As cases
progress from bad to worse subsultus tendinum is often noted.
The appearance of the wound or site of operation does not differ
essentially from that already described under Septicemia. There is
usually, however, less discharge, granulations are smoother and
dryer, and if tissues are gangrenous they are not as wet and
nauseous as in the other case. Evidences of thrombophlebitis and
lymphangitis will proceed from the wound toward the body, as in
other instances of septic infection.
Prognosis.—Prognosis is usually bad. While recovery may follow
where metastatic infiltration has not been too general,
the ordinary case of pyemia will die within twelve to fourteen days
after diagnosis. Sometimes the entire process is much slower, and
isolated cases occur which can be designated as so-called chronic
pyemia, which differs but little from the acute form. A case of pyemia
should not fail of recognition because there is no evidence of
infection from without. A fatal case of pyemia has been known to
occur from a suppurating soft corn which was not discovered during
life; also from peridental abscess, etc., which had been overlooked.
Death is the result of tissue destruction and septic intoxication.
Postmortem Appearances.—In the vessels these consist
essentially of thrombosis, examples
of which may be seen, for instance, in the cranial sinuses and in the
large veins. Aside from these, with the enlargement and softening of
the spleen, the liver, and lymphatic structures, already described
under Septicemia, the principal objective evidences consist in the
discovery of metastatic abscesses in many or all parts of the body.
As stated above, there is no tissue or organ in which they may not
be found. The mechanism of their production has been already
described. Infarcts may also be met with, in the kidneys especially,
the liver and spleen as well, and indicate areas already cut off from
blood supply by thrombo-arteritis, in which abscess formation would
have occurred had time been given. In the liver large abscesses may
be found; joint cavities may be filled with pus; the lungs are usually
the site of innumerable small abscesses. The other postmortem
changes commonly noted are not difficult of explanation, but are not
so characteristic or pathognomonic as to call for further mention. In a
joint which has become filled with pus there usually has been
loosening of the cartilage and more or less disorganization of all the
joint structures, which appear to have undergone rapid ulcerative
destruction and putrefaction.
Treatment.—Treatment of pyemia is in large degree
unsatisfactory. That which used to be the terror of
surgeons in the pre-antiseptic era is now, thanks to Lister and others,
almost abolished. Pyemia is a rare disease in modern surgical
practice. Its possibility should be borne constantly in mind, however,
and the necessity for careful antiseptic or for a rigid aseptic
technique is in large degree based upon fear of pyemic
consequences.
When once established, the disease is to be treated on lines
nearly similar to those laid down for septicemia, including resort to
the ichthyol or silver ointments, and to intravenous infusion of silver
solution. (See p. 89.) Amputation or extirpation of the part from which
infection has first proceeded may be of avail. Among the most
successful measures for surgical treatment of this disease is to
expose the infected area, open the involved veins, and either excise
them or scrape them out and disinfect them. This treatment has
been successful in cases of cranial infection following middle-ear
disease, etc. (See chapter on Cranial Surgery.)
Disinfection of the infected area and immersion in hot water should
be practised. Metastatic abscesses should be opened and drained,
and every accessible collection of pus evacuated, either by the knife
or aspirator needle—e. g., in the liver.
The medicinal treatment is practically the same as in septicemia,
while the surgeon’s mainstays are alcohol and strychnine. These,
with cathartics and intestinal antiseptics, will practically sum up the
drug treatment, the surgeon meantime not neglecting the matter of
nutrition, crowding it in every assimilable form.

ERYSIPELAS.
 Erysipelas is an acute infectious disease characterized by its
tendency to involve the skin and cellular structures, to extend along
the lymphatic vessels, to involve wounds and injuries under certain
conditions, accompanied by more or less fever of septic type,
leading frequently to septic disturbances of profoundest character,
yet tending in the majority of instances to spontaneous recovery. It
has been observed probably from prehistoric times, but has not
found a proper description nor appreciation until perhaps within the
past century. It occurs in so-called traumatic and idiopathic form—
which latter means that the site of infection is not discovered—and
also in a virulent and contagious type, which leads to the
appearance of a number of cases over a large territory; it often
appears in the epidemic form. On account of the reddening of the
skin it goes by the name of the rose among the German laity. It may
assume the type of an infectious dermatitis, subsiding without
suppuration, or a similar lesion of exposed mucous membrane may
be noted, or, occasionally, its virulence seeming greater, its lesions
are met with in more deeply seated parts, accompanied by
suppuration or even gangrene, and it is then called phlegmonous. In
a small proportion of cases the infectious organism appears to be
transported from one part of the body to another, and thus we have
metastatic expressions of this disease. The most common examples
of this are seen in erysipelatous meningitis after erysipelas of the
face or scalp, and erysipelatous peritonitis after the disease has
manifested itself on the truncal surface. It is of a type which makes
itself almost interchangeable with puerperal fever; and when
epidemics of erysipelas have involved certain states or areas, it has
been noted also that nearly every obstetrical case developed
puerperal septicemia.
Etiology.—There is more than passing interest connected with
this last statement. It is now definitely established that
the infectious organism is a streptococcus which is allied to, if not
identical with, the streptococcus pyogenes, the ordinary pyogenic
organism of this form. This specific organism has been separated,
studied, and its role assigned by Fehleisen, and the organism is
frequently called Fehleisen’s coccus. Preserving always its
morphological characteristics, it acts, as do many other pathogenic
organisms, within wide limits in virulence. Cultivated from some
cases, it scarcely seems infectious, while from others it is fatal.
Pathology.—The disease manifests a tendency to travel via
lymphatic routes. As long as it is confined to the skin
and superficial tissues it has the appearance of an acute dermatitis.
When it migrates deeper it generally leads to suppuration, another
reason for believing that the streptococci of erysipelas and of pus
production are the same. In the affected and infected area the
minute lymphatics will be found crowded with the cocci, which are
seen much less often in the small bloodvessels; also in the tissues
beyond the apparently infected area they may be found dispersed
less freely. The bacterial activity seems most active along the
advancing border of the superficial lesion. Here the phenomena of
hyperemia and phagocytosis are most active. Even in the vesicles
that are characteristic of the disease the organisms may be found.
The discharges from this region are infectious, and caution should
be observed in dressing such cases. A finger pricked by a pin from a
dressing may subject the individual to loss of life. The dressings
containing the discharges should be burned immediately.
The path of infection is usually through a wound, and as soon as
discovered a case of erysipelas should be separated from all
surgical cases, or if the erysipelatous patient cannot be isolated, he
should be removed from proximity of other wounded individuals.
Erysipelas which follows injury, however slight, is termed
traumatic. The terms “idiopathic” or “spontaneous” should be
restricted to those cases in which the path of infection is not
discovered.
Symptoms.—With the exception of the local appearances, they
are essentially the same in both of the above-
mentioned forms. The characteristic feature of the disease is a
dermatitis with its peculiar roseate hue, which it is impossible to
describe in words. In tint it differs slightly from that noted in certain
cases of erythema. It is, however, accompanied by an infiltration of
the structures of the skin, so that the area which is reddened is at the
same time elevated above the surrounding surface. Its edges are
often irregular. As exudate takes the place of blood in the tissues,
the red tint merges into a yellow. At this time there is more induration
of the skin and tendency to pit on pressure. Vesication of this
involved area is now frequent, the vesicles often coalescing and
forming large blebs and bullæ, which fill with serum that may
become discolored or purulent. When exposed to the air, unless the
tissues become gangrenous, this serum usually evaporates and
forms scabs. This disturbance of the skin is always followed after a
number of days by desquamation. This infectious dermatitis shows a
constant tendency to spread in all directions. Its most characteristic
appearances are limited to the margin of the enlarging zone, while in
its centre there may be evidences of recession of the disease. If it
commences in the vicinity of a wound it will probably spread in all
directions from it. Beginning in the face, it usually spreads upward; in
the trunk, in all directions; if on the extremities it tends to migrate
toward the trunk. Wandering erysipelas is a term often applied to
these phenomena. The metastatic expressions of the disease have
been described.
When this affection attacks a recent wound the local appearances
are not essentially distinct from those mentioned under Septicemia.
The wound margins separate to a greater or less extent, the
surfaces slough, and a characteristic seropurulent discharge occurs.
Granulating surfaces usually become glazed—often covered with a
membrane resembling that of diphtheria; deep sloughs may occur,
undermining of wound edges, even hemorrhages from destruction of
vessel walls. In rare instances, however, under the influence of the
microbic stimulation granulations proceed faster than normal.
Whether the disease proceeds from an injury or not, the
constitutional symptoms vary but little. There is usually a period of
malaise with nausea, followed by alimentary disturbance, coating of
the tongue, elevation of temperature, sometimes with occurrence of
chill. Complaint of pain or unpleasant sensation will lead to
examination of the area involved, when the above symptoms will be
noted, with evidences of lymphangitis and enlargement of lymph
nodes. When chill occurs it is followed by pyrexia. Temperature
fluctuates, with a tendency to assume the remittent type. When the
disease subsides spontaneously it is by a gradual process of
betterment and subsidence of temperature. In other instances the
constitutional symptoms assume more or less of the septicemic or
typhoid type, and it is seen that the patient’s condition is practically
one of mild septicemia, which often proves fatal.
When the disease assumes the phlegmonous type the
constitutional symptoms become more and more typhoidal and the
septicemia becomes most pronounced. Locally exudation goes on to
the point of threatening, even of actual, gangrene, unless tension is
relieved by incisions. Pain is usually intense, partly because of
confined exudates beneath resisting structures. More or less rapidly
the local and constitutional signs of pus formation are noted, and
unless these are observed and acted upon early there will not only
be suppuration, but more or less actual gangrene, so that not only
pus, but sloughs of tissue will be discharged through the incision, or
will, when this is delayed, make their escape by death of overlying
textures.
In all phlegmonous cases there is practically coincidence of
septicemia, already described, and of the local appearances above
noted. In proportion to the extent of the lesion in these phlegmonous
cases, and failure to afford relief, will be the opportunity for septic
intoxication.
The mucous membrane does not always escape, and even in the
nose, the pharynx, the vagina, and the rectum a distinctive
erysipelatous lesion may be found. The disease may travel from the
pharynx through the nose and involve the face, or through the
Eustachian tube to the ear and thence to the scalp, or vice versa.
Erysipelatous laryngitis is to be feared on account of edema of the
glottis, which would soon be fatal unless overcome by intubation or
tracheotomy. An infectious exudation into the lungs is also known to
follow erysipelas, and has been considered an erysipelatous
pneumonia. The cellular tissue of the orbits may also be involved,
when abscesses will occur, which should be opened early; the
parotid and other salivary glands may become involved, usually in
suppuration.
Many cases are accompanied by much gastric irritation, which it is
difficult to explain. Ulcers are sometimes found in the intestines, as
after burns. These usually give rise to bloody diarrhea. The cerebral
symptoms may be simply those of delirium from irritation or of
meningitis from infection. Strange phenomena have followed the
disease in certain instances—cessation of neuralgic and of vague,
unexplainable pain, improvement in deranged mental condition,
spontaneous disappearance of tumors, etc. Advantage has been
taken of this last in the treatment of these cases. (See Cancer.)
It is quite likely that some of the worst forms of phlegmonous
erysipelas are due to mixed infection. To inject the bacillus
prodigiosus together with the streptococcus of erysipelas will greatly
enhance the virulence of the latter, so that reaction may proceed
even to gangrene.
Postmortem Appearances.—These are not distinctive, but are a
combination of local evidences of
suppuration and gangrene, with the deterioration of the blood, the
softening of the spleen, etc., which are characteristic of septic
poisoning. Only in the skin, and then under microscopic examination,
can any pathognomonic appearance be discovered. This will consist
in the crowding of the lymphatic vessels and connective-tissue
spaces with cocci, in the evidences of rapid cell proliferation, in the
quantity of exudate, in vesication, sloughs, etc.
Diagnosis.—Diagnosis of erysipelas should be made mainly from
various forms of erythema, from certain drug eruptions,
and from other forms of septic infection which do not assume the
clinical type of erysipelas. The gastric symptoms of this disease are
sometimes produced by certain poisonous foods or the distress
which is produced by medicines, such as quinine, antipyrine, etc.
Prognosis.—The majority of instances of idiopathic erysipelas run
a certain limited course, although the eruption may
spread to almost any distance upon the body. When the disease
attacks surgical cases, and especially when it involves wound areas,
the prognosis is not so good. When the disease assumes an
epidemic type and involves cases of all kinds, it will be found to have
a virulence that may make it a most serious affair. In proportion to
the extent to which it assumes the phlegmonous type it will be found
locally, if not generally, destructive. The ordinary case of facial
erysipelas will recover with almost any treatment. Nevertheless
meningitis may develop, and even a mild case is to be treated with
care and caution.
Treatment.
—Danger comes from two sources—septic intoxication and local
phlegmons or gangrenous destruction. Each is therefore to be
combated. Treatment should consist of isolation. There is no specific
internal treatment for this disease. Tincture of iron, which was long
vaunted as such, has proved unsatisfactory, and is of benefit only as
a supporting measure in a limited class of cases. Constitutional
measures should be employed: First, for the purpose of maintaining
free excretion by bowels and kidneys; second, for the purpose of
supporting and maintaining strength; third, for tonic and stimulant
measures in prostrated and debilitated patients; and, fourth, for the
purpose of combating intestinal sepsis or intoxication from any other
source. The robust patients with this disease need no particular
tonic. The aged, the enfeebled, the dissipated, the prostrated
individuals, and the confirmed alcoholics are those who need
vigorous stimulation, partly by alcohol and quinine, and partly by
strychnine, preferably given hypodermically, and by the other
diffusible stimulants by which they may be kept alive. Pilocarpine,
given subcutaneously and pushed to the physiological limit, has
been praised by some. If along with prostration there occur
restlessness and delirium, then anodynes and hypnotics are
serviceable, and should be administered to meet the indication—
morphine hypodermically and any of the agents which produce sleep
are now most beneficial. Finally, if there is any drug which can be
administered in doses sufficient to saturate the system with an
antiseptic which shall at the same time not prove fatal because of
toxicity, this is the ideal medicament for constitutional use only. Such
a drug is not known, but it will be well to give some near approach to
it internally, as by administering corrosive sublimate, salol,
naphthalin, or something else of this character in doses as large as
can be tolerated.
Should patients become violent it may be necessary to resort to
mechanical restraint—a strait-jacket, a restraining sheet, a camisole,
etc.
Nourishment must be kept up by the administration of the easily
assimilable and predigested foods.
Locally the number of remedies that have been resorted to is
legion. In a mild case of spontaneous erysipelas—i. e., where no
infection can be traced—it will sometimes be sufficient to put on a
soothing application, like a lead-and-opium wash. It often gives relief
to have the part protected from air contact, which may be done by a
soothing ointment or by dusting the part with a powder, such as
bismuth oleate or subnitrate, zinc oxide, etc., these being rubbed up
with powdered starch; or by a film of rubber tissue or of oiled silk.
Brewers’ yeast applied on compresses and covered with oiled silk is
efficacious.
Even before the bacterial origin of the disease was accepted it had
been suggested to use antiseptic applications, either in watery
solution or combined with oil or some unguent; this is now the ideal
method of local treatment, the difficulty being only to find that which
shall be efficacious as an antiseptic, yet not injurious in other ways.
Compresses wrung in solutions of various antiseptics are often
serviceable. The following preparation has given satisfaction:
Resorcin (or naphthalin) 5, ichthyol 5, mercurial ointment 40, lanolin
50. The proportions of these ingredients may be varied, and the
amount of ichthyol sometimes increased, especially when the skin is
not too tender. The affected parts are anointed with this, and then
covered with oiled silk or other impermeable material, simply to
prevent its absorption by the dressings; the parts are then enveloped
in a light dressing and bandaged. Credé’s silver ointment has also
proved useful. As the disease becomes mitigated the ointment may
be reduced with simple lard, and discontinued when local signs have
disappeared. Absorption of any of these preparations may be
hastened by scratches over the affected area with the sharp point of
a knife.
Treatment of threatening phlegmon, or phlegmonous erysipelas,
must be more radical, and consists of free incision down to the depth
of the deepest tissues involved. In treating dissecting and other
septic wounds of the fingers incision should be made to the tendon
sheaths, even to the bone. It is only by such radical measures that
worse disaster may be avoided. Some aggravated local cases are
treated by a series of deep incisions with the use of the curette, the
surface after careful clearing being kept buried under an antiseptic
solution (silver lactate 1 to 500) or ointment.
RELATION OF LYMPH NODES AND GRANULATION TISSUE TO
INFECTION.
In connection with erysipelas and the role of the lymphatics, it is
advisable to consider the relation and behavior of the lymph nodes
and granulation tissue to infecting agents. Depending on the
virulence of the infectious material, the site of infection, and the
variety of the microbe will be its arrival in these protective filters.
Then follows a series of cycles of maximum and minimum activity in
the nodes, during the former the bacteria almost disappearing. The
more pathogenic the microörganism the more certain the destruction
of the lymph node, or perhaps of the individual. The well-known
enlargement of the nodes is due almost solely to an increase in their
lymphoid elements. Halban, who demonstrated these cyclic
variations in the contents of the lymph nodes, is inclined to insist on
an intimate relation between them and the temperature variations
noted in cases of septic infection.
When granulations are present the lymph sacs are closed, as by a
sanitary cordon. Unless this tissue is broken they are proof against
ordinary infection. It is well known that erysipelas will appear about
an old wound or sinus that has been rudely probed. Even virulent
organisms spread upon healthy granulating surfaces fail to infect.
Strong carbolic and other toxic agents can be used in and about
such granulating cavities with an exemption from poisoning that
otherwise would produce dangerous effects.
 CHAPTER VIII.
SURGICAL DISEASES COMMON TO MAN AND
DOMESTIC ANIMALS.

TETANUS.
Synonyms: Trismus, Lockjaw.
Tetanus is an acute infectious disease, of relatively infrequent
occurrence, invariably of microbic origin, characterized by more or
less tonic muscle spasm with clonic exacerbations, which, for the
most part, occurs first in the muscles of the jaw and neck, involving
progressively, in fatal cases, nearly the entire musculature of the
body. Certain races of people seem predisposed, and in certain
climates and geographical areas the disease is exceedingly
prevalent. Negroes, Hindoos, and many of the South Sea Islanders
show a peculiar racial predisposition, and, in a general way,
inhabitants of warm countries are less resistant. This is shown partly
by the fact that in various European wars the Italians and French
have suffered more than the soldiers of more northern climes.
Tetanus is by no means confined to adult life, since infants are far
from exempt, and in the tropics the trismus of the newborn is the
cause of a high mortality rate. In Jamaica one-fourth of the newborn
negroes succumb within eight days after birth, and in various other
hot countries the proportion is at times equally great. One plantation
owner states that fully three-fourths of the colored children born upon
his plantation succumbed to the disease. The peculiar reason for this
infection will appear later when speaking of tetanus neonatorum.
Men seem more commonly affected than women, probably because
of their occupations, by which they are more exposed. Military
surgeons have had to contend with the disease in its most virulent
form, and it has been noted that soldiers when worn out by fatigue or
suffering from the disaster of defeat seemed more liable to the
disease. In 1813 the English soldiers in Spain suffered from tetanus
in the proportion of 1 case to 80 wounded men. In the East Indies, in
1782, this proportion was doubled. Quick variations of heat and cold,
such as warm days and cold nights, coupled with the other
exposures incidental to military life, seem to exert a great effect.
Curiously enough, the wounded in many campaigns who have been
cared for in churches have suffered more from the disease than
those cared for in any other way. Tetanus, however, is by no means
necessarily confined to any one clime or race, but may be met with
anywhere, at any time, providing only that infection has occurred. A
celebrated Belgian surgeon lost by tetanus ten cases of major
operations before he discovered that the source of the infection was
his hemostatic forceps. As soon as these were thoroughly sterilized
by heat he had no further undesirable complications. If the disease
can be conveyed by the instruments of a careful surgeon, how much
more so by the dirty scissors of a careless midwife, etc.
It is true, also, that the popular notions of the laity concerning the
liability to tetanus after certain forms of injury are not ill-founded.
Small, ragged wounds of the hands and feet are those which
ordinarily receive little or no attention, and are among those most
likely to be followed by this disease. The toy pistol, which, a few
years ago, was such a prevalent and widely sold children’s toy, was
the cause of many a small laceration of the hand, due to careless
handling and the peculiar injury produced by the explosion of a small
charge of fulminating powder in a paper or other cap. It was not the
character of the laceration or injury thereby produced, but the fact
that such injuries occurred in the dirty hands of dirty children, which
were most likely to become infected, that has caused the so-called
toy-pistol tetanus to be raised almost to the dignity of a special form
of this disease. During the month of July, 1881, in Chicago alone,
there were over 60 deaths from tetanus among children who had
been injured in this way by these little toys. This led to their sale
being suppressed by law.
Etiology.—Two theories have had strong advocates, one being
that which would account for the disease by irritation of
nerves; while the second, the humoral, would explain the disease by
alterations in the blood. Each has had its most ardent defenders, but
both have now completely yielded to the investigations of a few
observers, among whom Kitasato and Nicolaier are the most
prominent. These ardent workers were, in 1885, able to clearly
establish the parasitic nature of this disease, and to isolate and
investigate the organisms by which it is produced.
Fig. 17
The bacillus of
tetanus is a
somewhat slender,
rod-shaped organism,
with a peculiar
tendency to spore
formation at one end,
which gives it a
drumstick
appearance. It is
essentially an
anaërobic organism,
and can never be
cultivated in contact
with the air. In
laboratory
experiments it is
grown in the depths
of a solid culture
medium or else in
Tetanus bacilli, showing spore formation. (Kitasato.) fluids and on surfaces
in an atmosphere of
hydrogen gas. It is one of the apparent contradictions of bacteriology
that this organism, which can only be grown as an anaërobe,
nevertheless abounds in earth, particularly the rich, black loam which
best supports luxuriant vegetable life, and that it practically inhabits
the upper layers of the soil, which accounts for the fact that so many
contaminations and infections have occurred from stepping upon
planks or boards with nails projecting, or from introduction of
splinters, or from lacerations of the hands and feet which are so
often followed by contact with such materials. There is nothing about
a rusty nail wound which, by itself, predisposes to tetanus, but the
rusty nail upon which a person steps is either itself infected or leaves
a rent or wound which may become infected within the next few
moments, and which is not likely to receive the careful attention
which it should. Verneuil has of late laid stress upon the fact that in
localities where horses are kept tetanus is more prevalent, and that
the infectious organism abounds in and upon stable floors, about
barn-yards, and wherever the excretions of a horse may be found.
Bacteriologists are aware that in the intestines of herbivorous
animals the bacilli (anaërobic) of tetanus and malignant edema are
often found. Verneuil has further shown that almost the only
instances of tetanus which occur on shipboard are upon those ships
which are used for transportation of horses and cattle. His
statements are at least interesting, if not absolutely well-founded. At
all events, tetanus is certainly of telluric origin.
A French veterinary surgeon of twenty-five years’ experience had
not seen a single case of tetanus until 1884, when he “removed a
tumefied testicle from a horse, with the ecraseur, and it died of
tetanus; in the following six months he castrated five, and all died;
another castrated fifteen in one day, and all died but one; another in
ten days castrated six bulls and operated on three fillies for umbilical
hernia, when five of the bulls and one of the fillies died.” This will
illustrate how the infectious agent may be conveyed by instruments,
etc.
The tetanus bacillus manifests other peculiar properties, for some
of which it is most difficult to account. Upon susceptible animals it is
violently infectious, but is rarely found at any distance from the
tissues in which it has first lodged. In laboratory investigations the
period of incubation is seldom longer than forty-eight hours. Another
peculiarity of the organism is that it generates certain poisons of
active properties which may be separated from pure cultures, by
whose injection the peculiar spasms of the disease itself may be
reproduced. These have been isolated, especially by Brieger, who
has given to them the names of tetanin, tetanotoxin, spasmotoxin,
etc. It has been estimated that about ¹⁄₃₀₀ Gm. of the pure toxin of
tetanus would be a fatal dose for a man. This toxin seems to have a
specific affinity for the ganglion cells of the anterior horn of the spinal
cord, with which it unites with great force. Herein lies the secret of its
disturbing power.
 It is peculiar that some time may elapse after its injection before
the appearance of the first symptoms. Diphtheria toxins appear to be
prompt in their action, and thus display quite opposite
characteristics. Experiment would seem to show, moreover, that the
tetanus toxins do not reach the cord through the blood stream, but
appear to slowly pass along the axis cylinders. Sensory nerves do
not transport the toxins to the cord. The toxin enters the nerve
termination, first of all, at the site of the infection, where it is most
concentrated, which will explain why the spasms most frequently
begin in the vicinity of the infection, or are the most marked there.
Most of the toxin is taken up by the blood and lymph and distributed
all over the body, and then passing along the motor fibers it enters
the cord and leads to general convulsion. When the toxin is injected
directly into the cord the symptoms begin at once. Therefore, for
protective purposes, much may be expected from the administration
of the antitoxin in cases of suspicious injury or those where
experiment has shown there is reason to fear the development of
tetanus. There does not appear to be on record a single instance in
which a person who had been given antitoxin soon after receiving
such a wound has developed tetanus, nor does the antitoxin by itself
seem to have done any harm. Obviously, then, the earlier antitoxin is
used in the case the better. It may be recalled that there are no
diagnostic symptoms of tetanus until the first spasm develops,
usually after the expiration of from five to twelve days. By this time
the nerve cells are thoroughly saturated with the poison and
considerable time may elapse before the antitoxin can reach these
cells by a more indirect route.
Tetanus Neonatorum.—Tetanus neonatorum, or tetanus of the
newborn, a condition already alluded to, is
a remarkably fatal affection, very prevalent among the negro race,
especially in hot climates. It nowise differs from traumatic tetanus,
but is such in effect, since the infection in these instances always
follows the division of the umbilical cord, which is usually effected
with dirty scissors in the hands of a dirty midwife, while the thread
with which the cord is tied is itself a possible source of infection, as
well as the rags which are used to cover the umbilicus in the first
dressing. It is generally fatal, because of the weakness and lack of
resistance of these little patients. It occurs usually within a week after
birth, if at all.
Tetanus Cephalicus.—Tetanus cephalicus, called also tetanus
hydrophobicus and head tetanus, is only a
peculiar manifestation of this same affection, confined mainly to the
head and usually following injuries to this region. The muscle
spasms are mostly confined to the facial, pharyngeal, and cervical
muscles, sometimes extending to the abdominal. These
manifestations may be reproduced in animals by inoculating them on
the head rather than upon the extremities. It is the least fatal form of
the disease.
Symptoms.—There is always a period of incubation, usually three
or four days, occasionally a week in length, but rarely
longer.
It is generally held that the longer the period of incubation the
more hopeful the prognosis. While for the great part the disease
assumes an acute type, a chronic tetanus is described and
occasionally seen. The first warning of the disease usually comes as
more or less stiffness of the cervical and maxillary muscles, which is
likely to be referred to by the patient as a “sore throat,” because of
the consequent difficulty in deglutition. A complaint to this effect
should be regarded as a warning, especially if on inspection no
visible reason for it can be detected in the pharynx. This complaint is
usually made in the morning after an ordinary night’s rest. This
muscle stiffness will be followed by increasing tonic spasm in the
muscles of the jaw, making it difficult to open the mouth, while the
head and neck gradually become stiffened and fixed by spasm of the
cervical muscles. These muscles may now be felt more or less
rigidly contracted, as if by voluntary effort, and the condition, which is
at first not painful, becomes after some hours a source of discomfort,
perhaps of actual pain, to the patient. If the disease pursues the
usual course, the other muscles of the body become gradually
affected, usually in the order of their proximity, but not necessarily
so. The abdominal muscles are firm and board-like, and the dorsal
muscles more or less contracted, sometimes to an extent which
causes arching of the spine. Should the original wound or port of
entry for infectious germs have been in the hand or foot, the muscles
of this limb become contracted, more or less rigidly, holding it in a
position which is not easily changed, even by efforts of the attendant.
Sensation is also often more or less perverted. In this condition of
tonic rigidity the muscles remain, to relax usually only with death.
The most characteristic features of the disease, however, are the
peculiar clonic exacerbations, which convert spastic rigidity into
violent and convulsive muscle activity, so that the limbs and even the
frame of the patient are more or less contorted, the muscle exertion
being sometimes painful to witness. Notable effects are thus
produced; the mouth is peculiarly puckered, and its corners drawn
upward and backward by the risorius muscles, giving to the face that
peculiar expression known as the “sardonic grin.” When the
abdominal and flexor muscles of the thighs are involved, and the
body is more or less curved forward, this condition is known as
emprosthotonos; when the muscles of the back especially are
involved, with the extensor muscles of the thighs, as opisthotonos;
and when the body is bent to one side or to the other it is called
pleurosthotonos. It is said that opisthotonic convulsions occur to
such an extent in some instances that the heels touch the head. At
all events, the patient’s body is frequently raised from the bed, so
that he rests upon the head and feet.
Another characteristic feature of the disease is the reflex irritability,
or hyperesthesia, by which these convulsive attacks apparently are
produced. Into this condition the patient falls more or less rapidly
within the first day after the inception of the disease, and to such a
height may it be augmented that the slightest movement in the room,
jarring of the bed, or displacement of clothing, even noise or a flash
of light, may immediately bring on a convulsion. Rupture of muscles
has been reported during some of these violent convulsions.
 Fig. 18

Characteristic tetanic spasm in a rabbit twenty-six hours after inoculation with pure
culture of tetanus bacilli. (Tizzoni and Cattani.)

During the course of this disease the jaws are so fixed that
patients speak with extreme difficulty and the tongue cannot be
protruded. The mind is clear until the end. The pain is rather the
acute soreness due to intense muscle strain. There is spasm of the
sphincters, by which urine and feces are often retained. There is
nothing characteristic about the temperature, which is seldom much
augmented. Attempts to swallow give pain, and are resisted because
of the renewed muscle spasm which is likely to follow the irritation
inseparable from the act itself. As the result of spasm of the glottis
peculiar respiratory sounds may be noted.
Until the last only the voluntary muscles are involved. Finally,
however, there are spasms of the accessory respiratory muscles and
of the diaphragm. Death is usually produced by involvement of these
muscles analogous to those of the others, and results usually from
apnea or suffocation. During the last hour or two perspiration may be
copious and the temperature may rise.
Chronic tetanus is characterized throughout by a milder and much
more prolonged series of symptoms. The period of incubation is
much longer, and, while the general program of the acute form is
adhered to, it is of less severe degree and is spread over a longer
time; in fact, cases covering two months or more are reported. In
chronic tetanus the prognosis is much more hopeful than in the
acute form.
 The wound is but slightly, if at all, affected. In some cases it will be
found to have healed before the onset of the disease. If suppurating
or open, its evidences of repair will be found unsatisfactory and
some indications of septic infection may be noted. Pricking or needle
sensations may be subjective phenomena.
Prognosis.—Prognosis is almost invariably bad; if patients live
more than five or six days it is thereby improved.
Postmortem Appearances.—These are rarely distinctive. In most
instances there are evidences at least
of hyperemia, if not of more active changes, in the upper portions of
the cord. Less often slight changes have been noted in the brain,
consisting, in some measure, of disintegration and softening.
Evidences of ascending neuritis in the nerve trunks leading to the
injured area have been claimed in some instances. Few if any
distinctive postmortem changes can be described as due to this
disease.
Diagnosis.—The diagnosis should be made as between
strychnine poisoning, hysteria, hydrophobia, tetany,
and, in the beginning, from pharyngitis, tonsillitis, etc. When the
disease is fully developed it is not likely to be mistaken for anything
else.
Tetanus may be simulated by hysteria, but in this event the
phenomena will be so uncertain, and the evidences of organic
disease so essentially lacking, that it is not likely that mistake can
occur.
Treatment.—If any case can be imagined in which efficient
treatment is most urgently demanded it is one of
tetanus. In scarcely any disease, however, is drug treatment so
unsatisfactory. In the rare instances in which patients have
recovered it is questionable whether it is not due to individual
resistance rather than to medication. Treatment may be subdivided
into local, constitutional, and specific. If there is still an open
suppurating or discharging wound, it is, of course, essential to
cleanse this out, basing this advice in some measure upon general
principles—largely upon the fact, already stated, that ordinarily only
the immediate surroundings of such a wound are found infected by
the bacilli themselves. Consequently thorough scraping, excising,