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The tetanus bacillus is widely distributed in the soil, and in certain regions there seems to exist more or less of a local soil infection, regions in which tetanus occurs very frequently, as in parts of Long Island and New Jersey. The soil probably becomes infected from the feces of animals, since the tetanus bacillus is known to thrive in the gastro-intestinal tract of various animals. It does not, however, appear to be capable of setting up an infection from the gastro-intestinal

tract.

All cases of tetanus are essentially of a traumatic nature, whether one speaks of cerebral tetanus, rheumatic tetanus, puerperal tetanus or tetanus neonatorum. A trauma always forms the portal of entry of the bacillus.

At autopsy, the tetanus bacillus is found only at the original site of infection, or occasionally in the regionary lymphatic glands. Not infrequently it is impossible to grow the bacilli from the original site of infection, due to the fact that they have died out.

At the portal of entry of the tetanus infection, are produced the toxines which find their way into the general circulation and give rise to the clinical signs and symptoms of

tetanus.

From cultures of the tetanus bacillus, Brieger has isolated four toxines to which he has given the names of tetanin, tetanotoxin, spasmotoxin, and acid toxin. All of these toxines possess the power of reproducing the clinical symptoms of tetanus in a more or less marked degree.

The first successful attempts to render animals immune to tetanus were made by Kitasato and Behring. The immunity in the case of tetanus is not one against the bacilli but against the toxines produced by the bacilli, since they are the elements which gain access to the general circulation. The method practiced to produce immunity in animals is to treat the filtrate of tetanus cultures with the trichloride of iodine, or with Lugol's solution, which greatly reduce the toxicity. Animals are inoculated with this weakened filtrate and after the reaction has occurred, a stronger filtrate is inoculated, and so on until the animal has acquired an immunity to large quantities of pure, living cultures of the tetanus bacillus. is the blood serum of these immunized animals which con

It

tains the tetanus antitoxin, and which is so extensively used to-day in the treatment of tetanus.

If a sufficient quantity of the antitoxin be injected into an animal at the same time that the animal is inoculated with the tetanus bacillus, tetanus will not develop. If, however, more or less of an interval elapses between the inoculation with the tetanus bacillus and the injection of the antitoxin the prognosis is unfavorable.

Behring in Germany, Roux in France, and Tizzoni in Italy have been the leaders in establishing the antitoxin treatment of tetanus.

Since the tetanus antitoxin was put upon the market several years ago, there have been a large number of cases of tetanus reported in which the serum therapy has been practiced. From a careful study of this literature some interesting and practical conclusions can be drawn. The important question seems to be whether the tetanus antitoxin is of therapeutic value after the symptoms of tetanus have developed, or whether it is of value only as a prophylactic measure.

Three methods of administration of the tetanus antitoxin have been practiced-subcutaneous, intravenous and intracerebral. The intracerebral method was proposed by Roux and Borrel and has been practiced chiefly by French surgeons. This method of administration of the antitoxin is based upon the idea that the nerve cells do not have the same affinity for the antitoxin that they possess for the toxin, and thus the antitoxin injected beneath the skin or into the vein, while it may neutralize the toxines in the blood, will not neutralize those in the nerve cells. The method is to trephine the skull and plunge a fine needle into the brain substance from 4 to 6 c. m., and to slowly inject from 1 to 6 c. c. m. of the antitoxin. This is also accompanied by subcutaneous injections of the antitoxin. Autopsies have shown that this method may, in some instances, produce areas of softening and degeneration of the cerebral tissue.

There are only relatively few cases in the literature in which strikingly good results have followed the use of tetanus antitoxin, and in most of these cases the antitoxin was used after the disease had existed a week, 1. e., when the most dangerous period was past. Many observers maintain that

the antitoxin has absolutely no effect on the disease, while some even go so far as to claim that it is injurious.

Holsti has collected from the literature 171 cases of tetanus which were treated with antitoxin, and of these 43.2 per cent. died. From the statistics of various observers he concludes that the mortality in cases of tetanus not treated with antitoxin is from 40 to 50 per cent.

Behring says that the results of antitoxin treatment depend upon how soon it is used after the first symptoms of tetanus appear. In answer to this claim that the antitoxin must be used very early in the disease, may be cited the 49 cases collected by Holsti in which it was used within the first two days and yet 69.4 per cent. of these cases died. The lowest mortality rate is in the cases treated late in the disease, when, naturally, the prognosis is more favorable.

The results of the antitoxin treatment of tetanus in all European countries, except Italy, practically agree. The Italian physicians and surgeons claim to have much better results with Tizzoni's serum, than have been published in any other country, but in the hands of English or German surgeons, Tizzoni's serum does not appear to give better results than that made by Roux or Behring.

In connection with puerperal tetanus some interesting facts have been recently brought out. Cases of puerperal tetanus are almost uniformly fatal. This seems to be due to the fact that the uterine cavity or vagina seem to afford a most favorable place for the growth of the bacilli and the development of the toxines. The opportunities for the absorption of the toxines in large quantities are also most favorable.

In Rosthorn's clinic at Prag, there occurred a severe epidemic of puerperal tetanus. The wards were closed and thoroughly cleaned and disinfected. A short time after they were reopened another epidemic broke out and again the wards were closed and disinfected. For some time past they have used protective inoculations with the tetanus antitoxine in all of their operative puerperal cases and have had no cases of puerperal tetanus in those thus treated.

The German veterinarians have long experienced much difficulty in their operations upon horses because of the great

number of horses that develop tetanus after the operation. To obviate this difficulty, they now give the horses protective inoculations of the tetanus antitoxin before operation with the result that they practically never have a case of postoperative tetanus in animals thus treated.

In an epidemic of tetanus among animals, Nocard treated 375 of the animals with protective antitoxin inoculations and none died, while 55 other animals not treated thus succumbed to tetanus.

The chief reason for the lack of success in the antitoxin treatment of tetanus lies in the fact that when the symptoms develop, a large amount of the toxines have been produced and absorbed, and there is already a marked involvement of the nerve centers. We cannot expect the antitoxin to restore the nerve cell to its normal condition, and thus the administration of the antitoxin is followed by little or no improvement of the symptoms. The general consensus of opinion seems to be that the tetanus antitoxin possesses mainly an immunizing power, but does not possess very marked curative properties.

Tetanus antitoxin can restrain the extension of the process if it is used early enough and the process is not too toxic. It cannot, however, relieve the symptoms already present. It seems to have the power of preventing, in many cases, the involvement of nerve centers not already affected and of neutralizing the toxin present in the blood, which makes it evident that it is of value in some cases at least.

In tetanus antitoxin, then, we appear to have a drug that is of distinct prophylactic value and in uncomplicated cases of traumatic tetanus its administration may improve the prognosis and lessen the death rate.

It would appear especially advisable to use the tetanus antitoxin as a prophylactic measure when there is a possibility of the development of tetanus and especially when it is prevailing in more or less of an epidemic form. If the case of tetanus is seen early the immediate administration of antitoxin would appear in general to render the prognosis slightly more favorable.

ARTHUR W. ELTING.

In Memoriam

CHARLES E. JONES, M. D.

Dr. Charles Edmund Jones died at the Albany City Hospital, Dec. 1st, 1899, of cancer of the colon. He was the only son of Dr. E. Darwin Jones and was born at Albany, N. Y., February 15th, 1849. Dr. Jones was graduated from the Boy's Academy in 1866, and entering Hope College, at Holland City, Michigan, graduated with honor, receiving the degree of Master of Arts, in 1873. He began the study of medicine under the supervision of his father, and graduated from the Albany Medical College in December, 1873. Being filled with that high ambition, energy and determination to do in a thorough manner whatever he undertook, which ever characterized his life, he entered the New York Homœopathic College, and after a course of post-graduate study in that institution, spent the year 1875 in Europe, the major part of the time at the Vienna General Hospital. Returning to Albany, he entered his father's office and began at once the duties of his chosen profession.

He brought to his life work a well-trained mind and a great heart, that beat in sympathy with distress and suffering wherever found. With an energy that never tired, with a love for humanity that never faltered, and with a willingness to serve his fellow man found in few, he began a life work which crowned him at the age of fifty years with most of the honors the medical profession can bestow. His untimely death is a shock and sorrow to the community and a loss to the medical profession.

Dr. Jones was a prominent member in State and National Medical Societies, being elected president of the New York Homœopathic Medical Society in 1897, and while identified with the Homoeopathic School of Medicine he was a broad, liberal-minded physician, whose skill and attainments in his profession, gained for him the high esteem of medical men regardless of school.

As a recognition of his valued services, the New York State Homœopathic Medical Society conferred upon him, in

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