HEALTH DEPARTMENT, 
CRIMINAL COURT BUILDING, 
NEW YORK CITY. 
A Study of Tetanus and its Treatment. 
BY 
ALEXANDER LAMBERT, M.D., 
VISITING PHYSICIAN TO BELLEVUE HOSPITAL; 
ASSISTANT BACTERIOLOGIST TO THE NEW YORK HEALTH DEPARTMENT. 
FROM 
THE NEW YORK MEDICAL JOURNAL, 
June 5, 1897. • A STUDY OF TETANUS AND 
ITS TREATMENT 
BY 
ALEXANDER LAMBERT, M. D. 
VISITING PHYSICIAN TO BELLEVUE HOSPITAL J 
ASSISTANT BACTERIOLOGIST TO THE NEW YORK HEALTH DEPARTMENT. 
REPRINTED FROM 
THE NEW YORK MEDICAL JOURNAL 
JUNE 5, 1897 
NEW YORK 
D. APPLETON AND COMPANY 
1897 Copyright, 1897, 
By D. APPLETON AND COMPANY. A STUDY OF 
TETANUS AND ITS TREATMENT/ 
Statistics.-Since the advent of antiseptic surgery 
tetanus has become less common than before, and is now 
usually considered a rare disease. That it is, however, of 
more frequent occurrence in New York city than is gen- 
erally supposed is shown by the following table of deaths 
from tetanus, taken from the records of the Bureau of 
Vital Statistics for New York city. 
Record of the Deaths from Tetanus in New York City from 1868-96. 
TETANUS NEONATORUM. 
IDIOPATHIC TETANUS. 
Male. 
Fe- 
male. 
Total. 
Aver- 
age. 
Male. 
Fe- 
male. 
Total. 
Aver- 
age. 
1868- 77 
278 
193 
471 
47'1 
52 
24 
76 
7-6 
1878-'87 
305 
202 
507 
50'7 
16 
9 
25 
2-5 
1888-'96 
219 
144 
363 
403 
31 
21 
52 
5-7 
The foregoing statistics of tetanus neonatorum may be 
considered as accurately representing the death-rate from 
that form of tetanus; while the statistics of idiopathic 
tetanus show a less number of deaths than actually oc- 
curred from traumatic tetanus. This is because in all 
cases of traumatism in which death occurred from tetanus 
the record of death was placed under the accident which 
caused the trauma. These figures, therefore, represent 
only the number of deaths from the so-called idiopathic 
* Read before the Society of Alumni of Bellevue Hospital, April, 
1897. LAMBERT: TETANUS AND ITS TREATMENT. 
4 
and rheumatic tetanus-that is, those cases in which the 
lesion giving rise to the infection was either overlooked 
or had healed and could not he found. The death-rate 
in tetanus neonatorum is usually estimated as from ninety 
to ninety-five per cent. (1); therefore, the number of cases 
from this disease in children in the last twenty-nine 
years has amounted to about fourteen hundred and fifty, 
or fifty a year. Counting the traumatic cases, it seems 
a safe estimate to say that in this city there have aver- 
aged about sixty cases of tetanus a year for the past twen- 
ty-nine years. 
The Tetanus Bacillus.-The tetanus bacillus is 
now accepted as being the cause of all the various so-called 
forms of tetanus, such as puerperal tetanus, tetanus 
neonatorum, idiopathic, rheumatic, and traumatic tet- 
anus. To produce the disease there must always be some 
wound in which the bacillus finds lodgment. The ba- 
cillus itself is a slender, round-ended rod, usually occur- 
ring singly, but in cultures often growing in long 
threads. In its resistant stage it contains a round spore 
at one end. It will not grow at temperatures below 14° 
C., but grows at ordinary temperatures of 20 to 22° C., 
and best at body temperature of 37° C. It will not grow 
in the presence of oxygen, but is a strict anaerobe. Its 
growth in the animal organism is comparatively scanty, 
and is usually in association with other germs. It remains 
at the seat of infection, and does not spread through the 
body. The disease is a true toxaemia. The spores are very 
resistant to external influences. Henri jean (2), by means 
of a splinter of wood which had once caused tetanus, was 
able after eleven years to again cause the disease by in- 
oculating an animal with the same splinter. 
The Occurrence of Tetanus Bacilli in Nature.- 
Since Nicolaier, in 1884, discovered and identified the 
tetanus bacillus as the cause of tetanus, the bacilli have 
been found not only to be exceedingly common inhabit- 
ants of the soil, but when present even being as abun- 
dant at the depth of six or seven feet as in the superficial 
layers (3). They have also been found in many different 
substances and places-in hay dust (4), in horse and cow LAMBERT: TETANUS AND ITS TREATMENT. 
5 
manure (5), in the mortar of old masonry (6), in the 
dust from horses' hair (7), in the dust in rooms of houses, 
barracks, and hospitals (8), in the air (9), in spider webs 
(10), in the water of the Dead Sea (11). Ledantec (12) 
has proved that the arrow poison of certain savages in the 
New Hebrides is made by smearing the arrowhead with 
dirt from crab holes in the swamps, and thus infecting 
the head with the spores of malignant oedema and 
tetanus. 
It is well known that certain localities in the vicinity 
of New York are notorious for the number of cases of 
tetanus which develop from slight wounds-for example, 
some parts of Long Island and New Jersey. The writer 
has obtained tetanus bacilli from the dirt from various 
parts of Long Island and New Jersey as well as from the 
dirt of New York streets. Dr. Williams, of the New 
York Health Department, has twice obtained them from 
air in this city. 
Factors favoring Tetanus Infection.-Considering the 
wide distribution of the germs, why does not tetanus 
occur more frequently? The work of Vaillard, Vincent 
(13), and Rouget (14), corroborated in the main by 
Klipstein (15), throws some light on the subject. These 
authors found that pure cultures of tetanus, after the 
germs had sporulated and the toxines had been destroyed 
by heat, could be injected into animals without producing 
tetanus. Even one or two millions of spores, if deprived 
of the toxines, proved harmless to guinea-pigs, and from 
fifteen to thirty cubic centimetres of broth cultures were 
harmless to rabbits. But if a culture of a non-pathogenic 
organism, such as the Bacillus prodigiosus, was injected 
simultaneously with the spores, or if there was an effusion 
of blood at the point of injection, or if there was a previous 
bruising of the tissues, the animals surely died of tet- 
anus. 
Even irritating foreign bodies were introduced simul- 
taneously with the spores deprived of their toxine and 
tetanus did not develop. But if the wounds containing 
the foreign bodies became infected with extraneous germs, 
tetanus developed and the animals died; or if the spores 6 
LAMBERT: TETANUS AND ITS TREATMENT. 
were protected by filter paper, or even by such a soft sub- 
stance as agar jelly, the animals invariably died. Because, 
as was assumed, the phagocytes were prevented from at- 
tacking them, they thus had time to germinate, and the 
bacilli formed from them were able to produce their tox- 
ines. The pus from several cases of human tetanus was 
injected into animals, and both the tetanus bacillus and 
each separate species of germs were cultivated out in pure 
cultures. A pure culture of each germ was mixed with 
the non-toxic spores and injected into animals. The 
majority of the animals did not have tetanus; only 
certain species of germs favored the development of the 
spores and produced tetanus. In some cases the species 
was found to be a bacillus, in others a coccus; in one case 
none of the bacilli or cocci alone favored the develop- 
ment of the tetanus spores, but it was necessary to inject 
a mixture of one of the bacilli and one of the cocci with 
the spores before tetanus could be produced. From these 
experiments it seems that a mixed infection is necessary 
to the development of tetanus when the infection is 
produced by spores. 
As a matter of fact, in human tetanus the infection 
may be considered as probably universally produced by 
the germs in their spore state. If in any given case, the 
tissue being healthy, the ordinary saprophytic germs are 
killed by proper disinfection, a mixed infection does not 
take place, and tetanus will not develop. Or, if the germs 
happening to be present, even if not killed by disinfection, 
do not favor the development of the spores, either by 
interfering with the integrity of the tissues or in some 
other way, tetanus will not develop. If, however, the 
tissues infected be badly bruised or lacerated, the spores 
may develop, as in the experiment on animals with pre- 
viously bruised tissues. This conception of the impor- 
tance of concurrent infection is still further supported by 
experimental data. It has long been noticed that direct 
infection from animal to animal with pus from wounds 
causing tetanus could not be carried beyond the third or 
fourth generation. The third or fourth animal would 
not become tetanic or would acquire only local and pass- LAMBERT: TETANUS AND ITS TREATMENT. 
7 
ing tetanus. Vaillard and Rouget (16) infected animals 
with earth known to contain tetanus spores, and counted 
the number of colonies developing in a given amount of 
the pus in each successive animal. In the animal infected 
with earth some thousands or hundreds of colonies were 
obtained, in the next animal scarcely a hundred colonies, 
and the pus from the third animal failed to produce 
tetanus. For example: 
Guinea-pig 1, inoculated with earth, died of tetanus 
in five days; pus gave 32,570 colonies. 
Guinea-pig 2, inoculated with pus from No. 1, died in 
thirty-six hours; pus gave 120 colonies. 
Guinea-pig 3, inoculated with pus from No. 2, died 
in forty hours; pus gave 7 colonies. 
Guinea-pig 4, inoculated with pus from No. 3, did 
not have tetanus. 
The writer, as well as many other workers, has sev- 
eral times repeated these experiments with similar results. 
The micro-organisms which enhance the infective capa- 
city of the tetanus bacilli, being usually saprophytic, can 
not be indefinitely transmitted from one animal to an- 
other, but soon die out, leaving the tetanus germs without 
favoring assistance, and these are thus unable to prolifer- 
ate and produce their death-dealing toxines. Thus, in 
spite of the wide distribution of the tetanus germs, they 
seem to require some favoring condition of the wound or 
some favoring concurrent infection to enable them to 
grow in the animal organism. 
Localization of Tetanus Bacilli in the Body.-Another 
factor in the case is that the tetanus bacillus does not 
belong to the septicaemia class of organisms which 
spread through the body and by their growth and enor- 
mous increase produce their effects, but, on the contrary, 
remains localized at the original point of infection. While 
there are a few cases on record in which the bacilli have 
been found in the tissues of the animal body other than 
at the point of infection, it does not militate against the 
fact that in the vast majority of cases the tetanus bacillus 
remains localized. This will be seen later to have an im- 
portant bearing on the treatment of the disease. Niko- LAMBERT: TETANUS AND ITS TREATMENT. 
8 
lai er (17), in many experiments, found, tetanus bacilli 
only twice in the spinal cord and once in the sciatic nerve. 
Bosenbach (18) found only occasional individual bacilli 
in two rabbits. Tizzoni and Cattani (19) also obtained 
positive results in their search for the bacilli. Monastyrski 
(20) in one out of four cases in human beings found the 
bacilli. Vaillard and Vincent (21), using a whole brain of 
a guinea-pig, once obtained a culture of the bacilli. 
Schnitzler (22) found them in the lymphatic glands in 
the groin of a patient who died from tetanus following 
an extensive gangrene from frostbite of the leg and foot. 
Dor (23) found the bacilli in an effusion of blood in the 
gray matter of the brain in a patient who died from 
tetanus from a compound fracture of the skull, and in the 
cerebro-spinal fluid from this patient. While this case is 
usually classed as one in which the tetanus bacilli 
were found away from the point of infection, it cer- 
tainly would be more conclusive if the primary infection 
had not probably occurred within the skull. Biidinger's 
(24) experiments with the lymph nodes of tetanic animals, 
also cited as proving the presence of bacilli in the nodes 
distant from the seat of infection, do not sufficiently 
prove what the author alleges for them. The writer 
endeavored in two cases of human tetanus to repeat the 
findings of Schnitzler, but without success. The cultures 
remained sterile, and the animal experiments absolutely 
negative. 
Nature of the Tetanus Poison.-What is the nature of 
this poison, and what is the mechanism of its action on 
the organism? 
Richardson (25) in 1859 expressed his belief that the 
production of tetanus in traumatic cases was due to the 
fact that the wound in the process of healing secretes a 
special albuminous product which has the property of a 
ferment. This substance absorbed into the body excites 
new chemical changes, and as a product of these there 
is developed an alkaline or alkaloid substance having 
properties analogous to strychnine. Of course it was un- 
known to this observer that this " ferment " was of mi- 
crobic origin, but after many years of research this the- LAMBERT: TETANUS AND ITS TREATMENT. 
9 
ory has again been brought forward by several observers 
as the true solution of the character and action of the 
tetanus poison. These views are strenuously defended by 
Courmont and Doyon (26) and Uschinsky (27), this last 
observer having succeeded in obtaining albuminous sub- 
stances from tetanus cultures grown in non-albuminous 
media, and considered the substances obtained to be the 
tetanus poison, more or less pure, and classifies it as a 
ferment, but the isolation of the pure poison was unsuc- 
cessful. As the result of their earlier experiments,. 
Kund, Faber (28), Vaillard and Vincent (29), Tizzoni 
and Cattani (30), all believed that the tetanus poison was 
a ferment or enzyme. Fermi and Pernossi (31), in a long 
series of experiments, seem to have proved conclusively 
that the poison is not a ferment, and can not be classed 
with the enzymes. Brieger (32) has worked on another 
theory, and at first thought the poison a ptomaine, as he 
succeeded in separating four ptomaines from impure cul- 
tures of tetanus; these he named tetanin, tetano-toxine, 
spasmo-toxine, and the fourth was an unnamed base. 
But these substances did not on injection give the typical 
clinical picture of tetanus, though they caused the death 
of the animals by convulsions, etc. Brieger and Frankel 
(33) shortly after this obtained from pure cultures of 
tetanus a substance which they called the toxalbumin of 
tetanus, which, on injection into animals, induced the 
symptoms of tetanic infection. 
Recently Brieger and Cohn (34) and Boer (35) have 
succeeded in isolating the tetanus toxine in seemingly a 
nearly pure state, and show that the purer the poison the 
more it lacks the reactions characteristic of the albu- 
minous bodies. Blumenthal's (36) researches seem to 
confirm the non-albuminous nature of the poison. 
What the true composition and constitution of the 
tetanus poison are, thus remain as yet unknown, but the 
vigor of its action stands out with terrible distinctness. 
Brieger and Cohn found that their purified poison was 
surely fatal to a fifteen-gramme mouse in a dose of 
0.00000005 gramme. Reckoning according to the body 
weight for a man of seventy kilogrammes or a hundred 10 
LAMBERT: TETANUS AND ITS TREATMENT. 
and seventy-five pounds, it would require but 0.00023 
gramme, or 0.23 milligramme, to prove fatal. Comparing 
it with the snake poisons, Calmette (37) has found that the 
dried cobra venom requires 0.25 milligramme to kill a 
rabbit of four-kilogramme weight, and according to body 
weight it would require 4.375 milligrammes to kill a man 
of seventy kilogrammes, or a hundred and seventy-five 
pounds. As the fatal dose of atropine for an adult is 
a hundred and thirty milligrammes, of strychnine from 
thirty to a hundred milligrammes, and of anhydrous 
prussic acid fifty-four (38) milligrammes, the appalling 
strength of the tetanus poison can readily be appreciated. 
Without doubt, this poison is the most deadly yet dis- 
covered. 
The Action of the Tetanus Poison in the Body.-Al- 
though the exact mechanism of the action of the tetanus 
poison on the animal organism is still a subject of con- 
troversy, especially concerning some matters of detail, 
the main points of its action may be considered as fairly 
proved. After the poison is once formed or injected in 
the body its absorption is rapid, as the following experi- 
ment shows, lloux and Vaillard (39) injected a fatal dose 
of toxine into the middle part of the tail in several rats; 
after varying lengths of time the tails were cut off at the 
base. All animals in which this operation was delayed 
for forty minutes or more died with the same rapidity as 
the controls. 
The blood usually contains the poison, as has again 
and again been proved. Nissen (40) first proved that the 
blood of a tetanic patient was capable of inducing tetanus 
in animals when injected subcutaneously. Kitasato (41) 
also found the serous exudates of the pleural and peri- 
cardial cavities, as well as the blood, of tetanic animals 
would cause tetanus when transferred to other animals. 
Kallmeyer (42), Bruschettini (43), and others have ob- 
tained similar results. The blood, after absorption, soon 
carries the poison over the whole body, the rapidity of 
the development of the symptoms depending on the 
amount and virulence of the poison. In experimental 
tetanus, and in about one third of the cases in human LAMBERT: TETANUS AND ITS TREATMENT. 
11 
beings, the first symptoms appear in the muscles adjacent 
to the point of inoculation or infection. In mild cases, 
or when a dose too small to be fatal has been received, the 
tetanic spasm may remain confined to these same mus- 
cles. But this peculiar localization of the earliest symp- 
toms can not be explained by the diffusion of the poison 
through the body by means of the blood, because after 
absorption the poison must be evenly diffused wherever 
the blood circulates. Brunner (44) brought forward the 
theory that the nerve fibres themselves were the diiect 
carriers of some of the poison from the point of entrance, 
and that the cells in the cord from which the nerves 
originated were thus the first to receive the poison, and, 
receiving it in more concentrated doses, first succumbed 
to its destructive action. Bruschettini's (45) experiments 
support this view. He found that the part of the spinal 
cord adjacent to the point of inoculation, either above 
or below, was always toxic, while other parts were non- 
toxic. Key and Retzius (46) injected solutions of Rich- 
ardson's blue in the subdural space with low pressure, and 
found that the color made its way into the nerve trunk, 
often through the ganglia, and far out into the nerve 
branches. When injected into the ganglia or into the 
nerves the injection mass permeated the perineurium in all 
directions, and into the endoneurium, and isolated the 
individual fibres from each other. Injections into the 
cord showed a spreading of the fluid in all directions, up 
and down, and transversely. Hence, a fluid can easily 
go from the periphery to the centre. It is probable that 
such is the action of the tetanus poison. After the poi- 
son reached the central nervous system we had no clew, 
until lately, as to its further action. There was no 
appreciable characteristic pathological lesion which could 
be discovered macroscopically or microscopically. Beck 
(47), however, has described a peculiar degeneration in 
the motor cells of the cord in animals killed by tetanus. 
This degeneration does not seem to attack the entire cells, 
but only a peripheral part, and seems to be confined 
chiefly to the body of the cell, usually leaving the nucleus 
intact. Only very late do the nucleus and the nucleolus 12 
LAMBERT: TETANUS AND ITS TREATMENT. 
take part in the changes. The changes consist in a swell- 
ing of the cell and a homogeneous or finely granular 
degeneration with a swelling, and finally coarse lumping 
together of the chromatin. This is especially evident at 
the tiny eminence from which the axis cylinder arises 
and in the axis cylinder itself. Beck considers this as 
proving that the poison travels along the axis cylinder, 
and that, as the nucleus is the last portion affected, the 
change is not a necrosis, but only a modification of cell 
function. 
Nissl (48) and Sailer (49) have also found undoubted 
changes in the ganglion cells in animals, and Nerlich 
(50) has found, in a case of human " head tetanus," a 
vacuole formation and progressing degeneration in the 
cells of the nuclei of the motor portion of the trigeminus, 
and in the nuclei of the facial and hypoglossal nerves. 
The experiments of Gumprecht and Brunner prove that 
the lesion is undoubtedly confined to the central nervous 
system, the muscles and motor nerves of the inoculated 
portion of the body having nothing to do with the origin 
of the tonic spasm nor of the convulsions. The sensory 
nerves may convey irritant stimuli to the cord, and in this 
way cause convulsions, but are not otherwise directly the 
cause of the convulsions. After section of the sensory 
nerves the convulsions occur in the completely anaes- 
thetic limb. 
Goldscheider (51) also believes that the action of 
the tetanus poison is on the central nerve cells, in conse- 
quence of which they assume an increased and ever-in- 
creasing excitability, the change taking place gradually, 
but going on continuously as long as there is absorption 
of poison from the wound. He maintains that the poison 
is conveyed to the nerve centres by the nerve trunks, 
and that it there acts on the ganglion cells gradually, 
covering a larger and larger area and increasing their 
excitability. But he believes, in addition, that there is 
a diffusion of the poison by means of the blood and lymph, 
to which the general spasms are to be attributed. It 
seems, therefore, without doubt that the tetanus poison 
causes an increased reflex excitability of the motor gan- LAMBERT: TETANUS AND ITS TREATMENT. 
13 
glion cells of the cord and medulla, and is thus analogous 
in action to strychnine. This theory of the action of the 
tetanus poison seems to the writer far more probable than 
the theory of Courmont and Doyon (52). According to 
these observers the so-called toxine elaborated by the 
tetanus bacillus is not the true poison, but is a ferment, 
which forms the poison in the body at the expense of the 
organism, and is found in the blood, sometimes in the 
urine, and in especial abundance in tetanized muscles. 
After this poison is formed it can be extracted from the 
muscles by boiling, and when injected into other animals 
causes immediate tetanic symptoms without any period of 
incubation. The contractures are the results of an irrita- 
tion of the peripheral sensory nerves, and not due to any 
direct action on the medullary nerve centres. The char- 
acteristic incubation period is the time necessary for the 
fermentation to take place, and after the minimal fatal 
dose has been given any larger dose will not shorten the 
incubation period. 
The results of Brieger, Cohn and Boer, and Fermi 
and Pernossi seem to prove that the poison is not albu- 
minous and is not a ferment. Uschinski and Brunner 
(53), repeating the experiments of obtaining an imme- 
diately tetanizing substance from the muscles, have failed 
to confirm Courmont and Doyon's results. The incuba- 
tion period can be as well explained by the dilution of 
the poison in the blood. From the experiments of Kita- 
sato, and from his own experiments, the writer is con- 
vinced that the amount of toxine injected influences the 
duration of the incubation period. Gumprecht and 
Brunner have shown that the tetanic spasm and convul- 
sions occur after section of the sensory nerve, and are 
not dependent on it for a causation of the spasm or con- 
vulsions. The injection of blood from tetanic animals 
causes tetanus in other animals, but always with the char- 
acteristic incubation period. 
These are the reasons, briefly stated, why Courmont 
and Doyon's theory does not seem tenable. 
All experiments fail to show why in the majority of 
cases in human beings, and in some of the higher animals, 14 
LAMBERT: TETANUS AND ITS TREATMENT. 
as the horse and ass, trismus and spasm of the pharynx 
are the first symptoms, regardless of the point in the 
body at which the infection has taken place. We must 
here suppose an elective action of the poison in some 
animals for the motor cells in the medulla, or, as the 
poison is slowly formed and acts slowly, an accumulation 
is necessary, and the muscles in which the inhibitory 
mechanism is least developed will be the first attacked 
(54). 
When the poison is circulating in the body, do the 
excretory organs endeavor to discharge it? There is no 
doubt that this takes place in man and animals, as both 
the urine (55) and saliva (56) have been found to pro- 
duce symptoms of tetanus when injected into animals. 
Treatment of Tetanus.-The successful treatment 
of any infectious disease depends largely on our thorough 
knowledge of its mode of infection, and the mechanism 
of its action in the body after the infection has taken 
place. It is for this reason that in this paper the patho- 
logical physiology of tetanus has been dealt with in so 
much detail, for the best treatment of the disease is based 
upon the logical deductions drawn from our knowledge 
gained by scientific research. 
From the foregoing it is readily seen that the indi- 
cations for treatment in tetanus are both local and gen- 
eral. 
Local Treatment.-First, what are the local indica- 
tions and how are they best fulfilled? As has been shown, 
the infection as it occurs in practice can be considered 
in the majority of cases as an infection with tetanus 
spores. These spores require favoring circumstances to 
develop. If we remove these favoring elements we render 
the germs harmless. Thus, in regions where tetanus is 
prevalent, thorough cleansing of all wounds, however in- 
significant, becomes of more than the usual importance. 
Tetanus may and often does arise from wounds so insig- 
nificant that they are healed and forgotten before even 
the first symptoms of tetanus develop. 
For this reason there still remain ideas of idiopathic 
and rheumatic tetanus. But these forms of tetanus are LAMBERT: TETANUS AND ITS TREATMENT. 
15 
nothing more than cases of true traumatic tetanus, in 
which the point of infection can not be found or is over- 
looked from its supposed insignificance. A case re- 
ported by Sahli (57) well illustrates this point. In a 
boy suffering from tetanus the only lesions found were 
some insignificant scabs on the knee and one on the 
dorsum of the foot. This last was pulled off, and showed 
underneath healthy granulations nearly healed and no 
pus. This scab was put in culture and under the skin 
of a mouse which died of typical tetanus. The cultures 
showed no tetanus bacilli. The scab, therefore, was sim- 
ply a source from which fresh toxine might be absorbed. 
The blood of the child at this time was non-toxic. Not 
only, therefore, should we carefully attend to slight fresh 
wounds, but the most strict and careful search should 
be made in cases in which tetanus has developed for all 
lesions of the skin, and all scabs should be pulled off 
and the surface beneath thoroughly treated by the cau- 
tery or by some disinfectant. 
Disinfection.-Our ordinary disinfectants or antisep- 
tics must here be considered from a different standpoint 
than is the case in ordinary surgery. Such disinfectants 
must be used as are not only antiseptic, but also antitoxic- 
that is, not only destructive to the micro-organisms them- 
selves, but also destructive to their toxic products-for, 
as we have already seen, the toxines in the tetanic wound 
are almost as great a source of danger as the tetanus ba- 
cilli themselves. 
Against our ordinary antiseptics tetanus spores are 
quite resistant, as five-per-cent, carbolic acid requires fif- 
teen hours' contact to destroy them, and solutions of 
bichloride of mercury (1 to 1,000) require three hours 
(58). If, however, a half per cent, of hydrochloric acid is 
added to either of the above-mentioned solutions the ac- 
tion is greatly accelerated. Five-per-cent, carbolic and a 
half-per-cent, hydrochloric acid kills them in two hours, 
and 1 to 1,000 bichloride and a half-per-cent, hydrochloric 
acid kills them in thirty minutes. If the solution contains 
1 to 1,000 bichloride with five-per-cent, carbolic and a 
half-per-cent, hydrochloric acid the spores are killed in 16 
LAMBERT: TETANUS AND ITS TREATMENT. 
ten minutes (59). Silver-nitrate solutions destroy the 
spores in one minute in one-per-cent, solution, and in five 
minutes in l-to-1,000 solution (60). Bichloride alone, still 
further, does not fulfill the requirements in a tetanus 
wound, as it is absolutely inactive against the tetanus 
poison (61). The most active antitoxic agents we have 
are the iodine preparations-e. g., iodine trichloride, 
Gram's solution, and Lugol's solution. These, besides be- 
ing antiseptic, destroy the toxine already formed; iodine 
trichloride, in a half-per-cent. (61) solution, destroying it 
in less than an hour, and it is with Gram's or with Lugol's 
solution that the French experimenters weakened their 
toxine in their first immunity experiments. Kresol, in 
one-per-cent. (61) solution, is also markedly destructive 
to the toxine, destroying it within an hour; (61) carbolic 
acid, one-and-a-half-per-cent. solution, is equally anti- 
toxic, while formalin, one-to-two-per-cent. solutions, ex- 
erts a decidedly destructive action in twenty-four hours' 
contact, as shown by the writer's experiments. Iodo- 
form, chromic acid up to two per cent., and pyrogallol 
have no effect on the poison, while lysol (62) and potas- 
sium manganate, ten-per-cent, solution, require twenty- 
four to forty-eight hours to be effective. A tetanus wound 
should not, therefore, be casually cleaned with bichloride 
or carbolic alone, but should be treated with a stronger 
mixture, to kill whatever germs are present; but above 
all should the treatment further consist in a thorough 
application of the iodine solutions. In sloughing wounds 
these solutions should be deeply injected in the neigh- 
borhood around the wound. When the iodine solutions 
are not immediately available, and perhaps the hydro- 
chloric acid, carbolic, or bichloride solutions are at hand, 
rather than rely too much on the hydrochloric acid, which, 
though antitoxic in a half-per-cent, solution, would be 
quickly neutralized in the alkaline tissues, it would be 
advisable to use caustic soda or potash (63) in solutions 
of 0.3 per cent, or 0.4 per cent., as they are as active as the 
0.5 per cent, hydrochloric acid, and would not be subject 
to the same disadvantage, and would thus act more effect- 
ively. LAMBERT: TETANUS AND ITS TREATMENT. 
17 
Amputation.-The question of amputation, when the 
wounds are on the fingers or toes, or when the tetanus 
follows serious contusions of the limbs, is a question 
to be carefully weighed and acted upon promptly. It is 
better for a patient to live minus a finger, toe, or limb 
than to risk in an acute attack of tetanus the absorption 
of more poison from a wound whose lacerated and dirty 
condition prevents a thorough cleansing. In severe 
wounds of the head and body this question, of course, 
does not arise, and disinfectants must be relied on to pre- 
vent further absorption. 
General Treatment.-In the general treatment of 
tetanus we have, as in all cases of poisoning, three indi- 
cations to follow: 1. The speedy elimination of the 
poison. 2. The administration of physiological anti- 
dotes to counteract the action of the poison on the 
body cells. 3. Chemical antidotes which change the poi- 
son by destroying it or by rendering it inert, and thus 
prevent, retard, or arrest its action. 
Means to further the Elimination of the Tetanus Poi- 
son.-To fulfill the first indication we have but to assist 
the action of the kidneys and endeavor, by their in- 
creased action, to eliminate the poison circulating in the 
blood. Probably the best means for this purpose is an 
excessive addition of fluids in the body. There is usually 
no trouble in persuading tetanic patients, if they can 
swallow, to drink an abundance of milk or water, as 
their thirst is usually excessive. Sahli (64) reports that 
in one of his cases he used with advantage subcutaneous 
and intravenous injections of salt solution. The intra- 
venous injections seem preferable, as the subcutaneous 
irritation of the sensory nerves would distinctly tend to 
increase the convulsive seizures. Diuretin may be rec- 
ommended to aid the diuresis, as it increases both watery 
and solid constituents of the urine. Whether the toxines 
are eliminated by the sweat is unknown; therefore it is 
hard to say whether an increase in the usual excessive 
sweating of tetanus would be an advantage. On the 
grounds that as the urine and sweat vary in inverse ratio 
to each other, and we are sure of elimination by the kid- 18 
LAMBERT: TETANUS AND ITS TREATMENT. 
neys, it does not seem that it would be of advantage to 
increase the already excessive sweating. The toxine is 
also eliminated by the saliva, but whether this be dis- 
charged or swallowed can be disregarded so far as reab- 
sorption is concerned, for in both herbivora and carniv- 
ora the living intestinal mucous membrane quickly de- 
stroys the tetanus toxines (65). 
Physiological Antidotes.-Secondly, in choosing our 
physiological antidotes we must look for those that will 
counteract the damage already done by the tetanus poi- 
son. We are dealing with an enormously increased re- 
flex excitability of the central nervous system, especially 
of the motor cells of the cord and medulla. Now, if we are 
able to hold in check the dreaded tetanic spasms and 
convulsive seizures of the glottis and respiratory muscles 
until the organism can recuperate, or if we can prevent 
the complete exhaustion by the incessant spasms of the 
cells governing the respiratory and circulatory functions, 
we may hope for success in our treatment. Fortunately, 
we possess several excellent remedies which can control 
this reflex excitability. 
The best remedy of all is chloral, while the use of 
morphine, bromides, physostigmine, and antimony is 
often indispensable. All narcotics act more or less to 
diminish the reflex excitability, but chloral is the most 
reliable and effective. Bromides exert their action more 
on the cortical centres, and are thus less powerful in a 
disease like tetanus when the cerebrum is not involved. 
Physostigmine has been highly praised by many writers 
for its action in tetanus, seeming especially to control the 
convulsions. Its action is on the gray matter of the cord, 
acting first on the posterior horns and then on the ante- 
rior. It may in this way diminish the ability of the sen- 
sory nerve fibres to conduct external stimuli to the already 
overexcited motor centres, and thus diminish the reflex 
convulsions. Later, its paralyzing effect on the anterior 
horns would in itself prevent the spasms. Antimony was 
suggested to the writer as a remedy in tetanus by Dr. W. 
R. Bross, of New York city, who used it in Costa Rica in 
five cases of acute tetanus with short incubation periods, LAMBERT: TETANUS AND ITS TREATMENT. 
19 
and succeeded in saving all five patients. He recom- 
mends that it be given in an eighth to a sixth of a grain 
doses with an equal amount of morphine every two hours. 
When given in this way it does not cause vomiting, and 
certainly seems to control the spasms, as was evident in 
a case of tetanus recently under the writer's care. Ac- 
cording to Nothnagel and Rossbach (66), antimony causes 
complete disappearance of reflex activity, which on physio- 
logical grounds places it among the desirable remedies. 
Morphine has an especially advantageous action of its 
own. Only in large doses is it usually considered to dimin- 
ish the reflex excitability of warm-blooded animals; still it 
causes a cessation of the pain and produces sleep. As the 
tonic spasm in tetanus relaxes during sleep, morphine 
indirectly secures the end in view. Sleep in itself to the 
exhausted patient is a necessity, so that morphine fulfills 
two indispensable indications. The bromides are also 
useful in this connection, as they tend to diminish the 
overwrought condition of the brain and aid in producing 
sleep. The anaesthetics are not to be recommended for 
more than short periods, and their repetition is not with- 
out danger. Sahli (67) rightly emphasizes two factors in 
dosage: one is the individual factor in each case, the other 
the changing and alternating the remedies, for the purpose 
of preventing a tolerance to the drugs. As this author 
points out, if from the beginning one should reckon in a 
given case of tetanus the dose of the narcotics to be 
administered for several days, one is apt to give either 
too much or too little, since it is quite impossible to esti- 
mate the sensitiveness of the patient, as it is so greatly 
modified by the disease itself. Even in a single day the 
doses may have to be modified. It is wisest to begin 
with doses which in a healthy individual would produce 
a decided effect-e. g., thirty grains of chloral hydrate, 
forty-five grains of bromide of sodium or potassium, and 
a sixth of a grain of morphine. The convulsions are the 
best criterion for judging whether narcotics should be in- 
creased or diminished. The toxic spasm is not so danger- 
ous as the sudden convulsive seizures, and usually begins 
to relax simultaneously with the cessation in frequency of 20 
LAMBERT: TETANUS AND ITS TREATMENT. 
the convulsions, when improvement begins. As Sahli 
expresses it: "In the choice of the remedy the principle 
of alternation is the chief factor. If one always gives the 
same preparations, or always all the remedies in combina- 
tion, one will generally have the experience that the 
effect is soon lost by tolerance. It is in one's power to 
prevent this by alternating the remedies. Of course, in 
giving the remedies of the chloral group a careful super- 
vision of the pulse is necessary, while with bromides and 
morphine this effect is much less to be feared." 
Chemical Antidotes.-Thirdly, have we any true 
chemical antidotes which circulating in the blood are 
able to destroy or render inert the tetanus poison? The 
substances which Kitasato, and later Fermi and Pernossi, 
have shown to be antitoxic are, as a rule, not available for 
therapeutic purposes. The most effective antitoxic sub- 
stances, as we have seen, are carbolic acid, kresol, and the 
iodine solutions. While these substances are so effective 
outside the body, is it possible to obtain a sufficient con- 
centration within the body to destroy the toxine? Our 
experience with internal antiseptics in general infectious 
does not give us much hope in this direction. Too great 
a concentration of the antidote is necessary for us to hope 
for any effect on the tetanus poison. Bacelli (68), it is 
true, recommends subcutaneous injections of one-per-cent, 
solutions of carbolic acid, and several cures are reported 
following this plan of treatment. Though this was rec- 
ommended empirically at first, carbolic acid is antitoxic 
and it may perhaps have some action; but as a half-per- 
cent. carbolic acid is used to preserve the toxine in the 
laboratories, it is more than doubtful if sufficient concen- 
tration could be obtained in the blood to make it effective, 
and besides, its poisonous effect on the organism is cer- 
tainly to be feared. 
Antitoxine.-We have therefore to turn to anti- 
toxic serum, which, as we know by absolute proof, in some 
way renders inert the toxine circulating in the blood. 
Preparation of the Antitoxic Serum.-The tetanus 
antitoxine is prepared in the same manner as the diph- 
theria antitoxine, by inoculating the tetanus toxine in in- LAMBERT: TETANUS AND ITS TREATMENT. 
21 
creasing doses into horses. The toxine is grown in bou- 
illon under hydrogen, and after ten or fifteen days filtered 
through porcelain, and the germ-free filtrate is used for 
the inoculations. The horses receive half a cubic centi- 
metre as the initial dose of toxine, and this dose is in- 
creased as rapidly as the horses can stand it, until they 
support seven to eight hundred cubic centimetres or more 
at a single dose. After some months of this treatment 
the blood of the horse contains the antitoxine in suffi- 
cient amount for therapeutic use. When the animals' tem- 
peratures are normal and they have recovered from the 
dose of toxine last given, they are bled into sterile flasks 
and the serum collected. The serum contains the antitox- 
ine and is tested on white mice or guinea-pigs. 
The Antitoxic Serum of the New York Health Depart- 
ment.-The New York health department has at pres- 
ent two horses well immunized against tetanus, and fur- 
nishes serum of the strength of one to four hundred million 
-that is, one cubic centimetre will protect four hundred 
million grammes of white mice against a three-to-four-day 
fatal dose of tetanus toxine. Reckoning in antitoxic units, 
twenty cubic centimetres of serum will contain eight 
thousand antitoxine units, an antitoxine unit in tetanus 
being the amount of serum necessary to protect one mil- 
lion grammes of test animal. 
The serum is supplied in twenty-cubic-centimetre bot- 
tles, and should be injected in ten-to-twenty-cubic-centi- 
metre doses. In severe cases the patient should receive 
fifty cubic centimetres in the first twenty-four or thirty- 
six hours, and these ten-to-twenty-cubic-centimetre doses 
repeated once or twice each day during the following 
four or five days or longer, according to the course of the 
disease. The circular accompanying the bottles explains 
more fully the proper method of procedure. 
The Action of the Antitoxic Serum in the Body.- 
As has been shown by Roux (69) and Calmette (70), the 
antitoxic serum has no direct destructive action on the 
toxine itself, but through some unknown action on the 
body cells the serum prevents the toxine from exerting its 
destructive action. Behring's first idea that there was 22 
LAMBERT: TETANUS AND ITS TREATMENT. 
a direct destructive action between the antitoxine and 
toxine or some neutralizing effect, such as occurs between 
an acid and an alkali, has been shown to be incorrect. 
As Buchner (71) also shows, there is no destructive ac- 
tion of the antitoxic serum on the toxine either out- 
side or within the body, the action seeming to be one 
which, by producing certain changes within the cells, 
renders the action of the toxine inert. Tizzoni (72) con- 
cludes that the blood serum of vaccinated animals does 
not act as a remedy which neutralizes in the organism 
a certain active principle of disease and directly counter- 
acts certain functional changes [as our physiological anti- 
dotes do], but it acts, in all probability, in curing tetanus 
by immunizing the parts of the body not already teta- 
nized, and so limits the tetanus to a local form. 
Comparison of Statistics.-In estimating the value 
of any new remedy we must have certain undeniable facts 
on which to base our comparisons of old and new, such as 
a known death-rate, and we must criticise minutely our 
statistics rather than simply compare the death-rate. Un- 
fortunately, the death-rate in tetanus has been so vari- 
ously stated by different authors that it is difficult to say 
what is the true average mortality. In acute cases it 
is given as being from seventy-eight to 96.6 per cent.; 
in chronic cases, as being from 17.8 to fifty-five per 
cent.; the average for all cases varying from twenty-one 
to 87.5 per cent. The largest number of cases collected 
are 1,222 (73) war cases, with a mortality of 88.6 per 
cent., and 280 (74) cases occurring in time of peace, 
with seventy-six per cent, mortality, making 1,502 cases, 
with 87.7 per cent, mortality. 
The fairest estimate seems to be eighty per cent, 
for acute cases, and about forty per cent, for the milder 
or chronic cases, and sixty per cent, mortality for all 
cases. In estimating the value of the antitoxine treat- 
ment we must consider in each case the duration of the 
incubation period of the disease (75), the rapidity of the 
onset, with the frequency and intensity of the convul- 
sions, and finally the promptness with which any kind 
of rational or radical treatment can be or has been ap- LAMBERT: TETANUS AND ITS TREATMENT. 
23 
plied. The prognosis in cases not treated with antitoxine 
is relatively favorable if the incubation period is long, 
ten days or more, the onset slow, and the spasms are 
not severe; it is bad if the incubation period is less than 
ten days, the onset rapid, and the spasms severe (76). 
The following cases of tetanus comprise published and 
unpublished cases treated with antitoxine. 
Resume of Cases Treated with Antitoxine.-We have 
a total of a hundred and fourteen cases with a mortality 
of forty-six, or 40.35 per cent. All those with an incu- 
bation period of eight days or less and with a rapid onset 
of the symptoms, or those with a longer period of incuba- 
tion, but with an intensely rapid onset, have been classed 
as acute cases. All those with incubation period of nine 
days or more, or those with a shorter incubation where 
the onset was slow, have been classed as chronic. Six 
cases from lack of sufficient data are not classed; five 
of these patients recovered, one died with a complication 
of pneumonia. There remain forty-seven acute cases, 
with twelve recoveries, thirty-five deaths, and a mortality 
of 74.46 per cent. Of the chronic type, sixty-one cases, 
fifty-one cures, and ten deaths-a mortality of 16.39 per 
cent. Following Kanthack's system of criticism, we must 
exclude all cases which have died with intercurrent dis- 
eases, and all cases of those who died twenty-four hours 
after treatment was begun, as these really prove nothing 
as far as a fair estimate of any treatment is concerned; 
but we must also exclude all mild cases of recovery which 
did not receive treatment till the tenth to fifteenth days 
of disease, as such cases usually get well under any treat- 
ment. We must therefore exclude sixteen deaths in the 
acute cases, leaving thirty-one cases, with twelve recov- 
eries and nineteen deaths-i. e., 61.29 per cent, mortal- 
ity. We must also exclude in the chronic cases thirteen 
cures and eight deaths, leaving forty cases, with thirty- 
eight recoveries and two deaths, or five per cent, mortal- 
ity. This is certainly an improvement on the usual death- 
rate, being a total mortality of only 29.57 per cent. Of 
course, a final judgment of any treatment must be based 
on a larger total than seventy-one cases. But such a num- 24 
LAMBERT: TETANUS AND ITS TREATMENT. 
ber is sufficient to show that some new beneficial factor has 
been present in the new treatment which was absent in 
the old methods. Yandell, in 1870 (77), in speaking of 
the prognosis of tetanus, declared that " recoveries from 
traumatic tetanus have been usually in cases in which 
the disease occurred 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 nine days? Does it fail in cases whose duration 
exceeds fourteen days? No agent tried by these tests has 
yet established its claim as a true remedy for tetanus." 
Does antitoxine by these criteria establish a claim as a 
true remedy for tetanus? In acute cases, developing 
eight days or less after the injury, in thirty-one cases 
the recoveries have amounted to 38.71 per cent., deaths 
61.29 per cent., as against treatment without it of twenty 
per cent, of recoveries and eighty per cent, of deaths. In 
one hundred and one cases in which the duration of the 
disease is given, all those which passed the fourteenth 
day recovered. Antitoxine, therefore, by Yandell's cri- 
teria, fairly establishes itself as a true remedy for tet- 
anus. 
There are some cases of tetanus of such short incuba- 
tion and such intense rapidity of onset that in spite of all 
treatment they die within from twenty-four to thirty-six 
hours after the first symptoms appear. These cases at 
present seem hopeless. 
Limitations of the Treatment with Antitoxic Serum.- 
From the nature of the antitoxic serum and its peculiar 
action in the body it is necessarily limited in its action. 
We have shown that it does not directly act on the tetanus 
poison and destroy it, and that it can not undo the injury 
already done; it can only prevent further damage. It is 
possible, as certain cases of Roux's (78) show, that the 
disease may go on to a fatal termination, even after the 
blood of the patient has become markedly antitoxic. 
This emphasizes very strongly the necessity of the early 
use of the antitoxine; besides, as Behring (79) has shown, LAMBERT: TETANUS AND ITS TREATMENT. 
25 
the amount of serum necessary to protect an animal, 
when introduced simultaneously with the toxine, must 
be increased a thousand times if we wait till the first 
symptoms appear, and ten or a hundred thousand times 
if we delay a few hours longer. The serum will render 
inert the toxine circulating in the blood and any more 
toxine which may be generated in the wound; it is there- 
fore necessary to inject the serum as soon as possible, and 
in sufficient abundance. Compared with the results of 
serum in diphtheria, the results in tetanus must always 
fall far short in their success. In diphtheria the position 
and character of the lesion give early warning before 
the body is hopelessly poisoned, but the tetanus poison 
has insidiously gained control and often irreparably dam- 
aged the organism before its symptoms show themselves. 
The rapidity of recovery in the cases treated with anti- 
toxine does not seem to depend on the amount of antitox- 
ine injected nor as much as one would expect on the day 
of injection. This seems in direct opposition to what has 
just been said above, but is the logical consequence of the 
mechanism of the action of both toxine and antitoxine. 
Recovery depends entirely upon the degree of damage 
which the toxine has done before the antitoxine has been 
injected. As the virulence and the amount of poison and 
the extent of damage already existing in any given case 
are always unknown, and must remain unknowable, it is 
but another warning, stronger than anything else can be, 
that we must use the antitoxine at the earliest possible 
moment. 
The general treatment of a tetanus patient, such as 
nourishment and absolute quiet and rest, stuffing the ears 
with cotton to keep out sounds, etc., has not been touched 
upon, as it is self-evident. 
Preventive Inoculations.-By means of the antitoxine 
treatment, combined with other rational methods, the 
prognosis, even in acute cases, has been improved; but it 
still remains exceedingly grave, so much so that the pre- 
ventive inoculation of serum in all cases where dirt has 
been ground into serious contusions deserves a much 
more extensive consideration than has yet been given it. 26 
LAMBERT: TETANUS AND ITS TREATMENT. 
In France, Dr. Bazy (80), after having four fatal cases 
of tetanus in one year, has made it a practice to inject ten 
cubic centimetres of serum into all patients who have 
come under his care with wounds which caused him to fear 
a possibility of tetanus. He has not seen a single case of 
tetanus since, though his practice has been in a region 
where the soil is notoriously contaminated with tetanus 
bacilli. Nocard (81), in veterinary practice, first followed 
this plan of treatment, and reports that of three hundred 
and seventy-five animals treated with immunizing doses of 
serum not a single animal has acquired tetanus, while in 
the same locality he has seen fifty-five cases of tetanus in 
animals not so treated. These are certainly striking re- 
sults, and it seems wise in a neighborhood like New York, 
where tetanus is not uncommon, to treat patients with 
immunizing doses of serum when the lacerated and dirty 
condition of their wounds may indicate the possibility of 
a tetanus infection. They will not have tetanus, and 
we may never know whether they otherwise might have 
had the disease, but we certainly shall prevent the patient 
from running the risk of an acute attack of tetanus, which 
is the main point. 
An attempt has been made in this paper to explain 
the pathological physiology of tetanus, and to build on 
established scientific data the rational line of treatment 
which promises the greatest success. There is no line 
of treatment which will give as brilliant results as one 
would wish for, but, as Roux has said, one can not choose 
in practice either the case or the time of intervention. 
We must, therefore, use that which gives us most prom- 
ise-local disinfection, physiological antidotes to hold the 
disturbed functions of the cord in check, and the anti- 
toxic serum to annul all further action by the toxine. By 
these means the recovery of the patient seems best as- 
sured. 
1. Holt. Diseases oj Children, 1896. 
2. Henrijean. Baumgarten's Jahresbericht, 1892, 
and Flugge. Microorganismen, 1896, and Bibliography. 
3. Marchesi. Baumgarten's Jahresbericht. 1893. 
4. Peyraud. Semaine medicale, 1890, p. 372. LAMBERT: TETANUS AND ITS TREATMENT. 
27 
5. Sormani. Centralblatt fur Bakteriologie, 1890.- 
Sanchez-Toledo and Veilion. Semaine medicale, 1890, 
p. 381. 
6. Bonome. Baumgarten's Jahresbericht, 1887, p. 238. 
7. Turco. Baumgarten's Jahresbericht, 1891, p. 217. 
8. Turco. Ibid. 
9. Schwarz. Centralblatt fur Bakteriologie, 1892, 
vol. ix, p. 697. 
10. Turco. Loc. cit. 
11. Lortet. Baumgarten's Jahresbericht, 1891, p. 219. 
12. Ledantec. Annates de VInstitut Pasteur, 1890. 
p. 716. 
13. Vaillard and Vincent. Ibid., 1891. 
14. Vaillard and Rouget. Ibid., 1892. 
15. Klipstein. Hygienische Rundschau, 1893, p. 1. 
16. Vaillard and Rouget. Annates de VInstitut 
Pasteur, 1892, p. 386. 
17. Cited from Gumprecht. Pfliiger's Archiv, vol. 
lix, pp. 105-152 and Bibliography. 
18. Gumprecht. Ibid. 
19. Gumprecht. Ibid. 
20. Brunner. Experimentelle und klinische Studien 
uber Tetanus, 1894, and Bibliography. 
21. Annates de VInstitut Pasteur, 1891, p. 1. 
22. Schnitzler. Centralblatt fur Bakteriologie, vol. 
xiii, p. 679. 
23. Dor. Semaine medicate, 1890, p. 184. 
24. Biidinger. Wien. klin. Wochenschrift, 1893, p. 
287. 
25. Richardson. Medical Times and Gazette, vol. ii, 
1859, p. 538. 
26. Courmont and Doyon. Revue de medecine, 1894. 
27. Uschinsky. Centralblatt fur Bakteriologie, vol. 
xiv, p. 316. 
28. Kund Faber. Berlin, klin. Woch., 1890, p. 717. 
29. Vaillard and Vincent. Loc. cit. 
30. Tizzoni and Cattani. Centralblatt fur Bakterio- 
logie, vol. viii, p. 69. 
31. Fermi and Pernossi. Zeitschrift fur Hygiene, 
vol. xvi, p. 385. 
32. Brieger. Deutsche med. Woch., 1887. 
33. Brieger and Frankel. Berlin, klin. Woch., 1890, 
p. 241. 
34. Brieger and Cohn. Zeitschrift fur Hygiene, vol. 
15, p. 1. 
35. Brieger and Boer. Ibid., vol. xxi, p. 259. 
36. Blumenthal. Zeitschrift fur klin. Med., 1896, 
vol. xxx, p. 538. 
37. Calmette. Annates de VInstitut Pasteur, 1894, 
p. 276. 28 
LAMBERT: TETANUS AND ITS TREATMENT. 
38. Wormley. Microchemistry of Poisons, second 
edition. 
39. Roux and Vaillard. Annates de VInstitut Pas- 
teur, 1893, p. 65. 
40. Nissen. Deutsche med. Woch., 1891, p. 775. 
41. Kitasato. Zeitschrift fur Hygiene, vol. x. 
42. Kallmeyer. Deutsche med. Woch., 1892, p. 72. 
43. Bruschettini. Centralblatt rilr Bakteriotogie, 
1891, p. 15. 
44. Brunner. Loc. cit. 
45. Bruschettini. Loc. cit. 
46. After Gumprecht. Loc. cit. 
47. Beck. Ungar. Archiv fur Medicin, 1893, p. 344. 
48. Nissl. Neurolog. Centralblatt, 1895, p. 108. 
49. Sailer. Univ. Med. Mag., Philadelphia, 1896, p. 
203. 
50. Nerlich. Archiv fur Psychiat., vol. xxiii, p. 672. 
51. Goldscheider. Deutsche med. Woch., 1895, p. 735. 
52. Courmont and Doyon. Revue de medecine, 1894, 
p. 76. 
53. Brunner. Loc. cit. 
54. Allbutfs System of Medicine, 1896, vol. i. 
55. Bruschettini. Deutsche med. Woch., 1892, p. 349. 
56. Brunner. Loc. cit. 
57. Sahli. Annates suisses de science medicate, 1895, 
and Bibliography. 
58. Kitasato. Zeitschrift fur Hygiene, vol. vii, p. 225. 
59. Tizzoni and Cattani. Centralblatt filr Bakterio- 
logie, vol. viii, p. 562. 
60. Ibid. 
61. Kitasato. Zeitschrift filr Hygiene, vol. x. 
62. Fermi and Pernossi. Ibid., vol. xvi. 
63. Kitasato. Zeitschrift filr Hygiene, vol. x. 
64. Sahli. Loc. cit., p. 388. 
65. Fermi and Pernossi. Loc. cit. 
66. Nothnagel and Rossbach. Nouveaux elements de 
mat. med. et therapeutique. 
67. Sahli. Loc. cit., p. 393. 
68. Bacelli. Baumgarten's Jahresbericht, 1890, p. 
205. 
69. Roux. Annates de VInstitut Pasteur, 1894, p. 
722. 
70. Calmette. Ibid., 1895, p. 251. 
71. Buchner. Berlin, klin. Woch., 1894, p. 73. 
72. Tizzoni. Cited by Buchner. Ibid. 
73. Schmidt's Jahresbericht, vol. cciv, p. 141.-Rot- 
ter. Berlin, klin. Woch., 1893. 
74. Wallace. Indian Medical Record, 1891, p. 482. 
75. Kanthack. Med. Chron., Manchester, 1896; N. 
S., vol. iii, p. 92. LAMBERT: TETANUS AND ITS TREATMENT. 
29 
76. Worthington. St. Bartholomew's Hospital Re- 
ports, 1895, p. 137. 
77. Yandell. Cited by Hartley, Lancet, London, 
1895, vol. ii, p. 424. 
78. Roux. Annales de VInstitut Pasteur, 1893. 
79. Behring. Die Blutserumtherapie, Part II, p. 21. 
80. Bazy. Bull, de la Soc. de chir., 1896, vol. xii, p. 
454. 
81. Nocard. Bull, de VAcademic de medecine, vol. 
xxxiv, 1895, p. 407. THE 
New York Medical Journal. 
A WEEKLY REVIEW OF MEDICINE. 
EDITED BY 
FRANK P. FOSTER, M.D. 
THE PHYSICIAN who would keep abreast with the advances in 
medical science must read a live weekly medical journal, in which 
scientific facts are presented in a clear manner ; one for which the 
articles are written by men of learning, and by those who are good and 
accurate observers ; a journal that is stripped of every feature irrelevant 
to medical science, and gives evidence of being carefully and conscien- 
tiously edited; one that bears upon every page the stamp of desire to 
elevate the standard of the profession of medicine. Such a journal ful- 
fills its mission-that of educator-to the highest degree, for not only 
does it inform its readers of all that is new in theory and practice, but, 
by means of its correct editing, instructs them in the very important yet 
much-neglected art of expressing their thoughts and ideas in a clear and 
correct manner. Too much stress can not be laid upon this feature, so 
utterly ignored by the " average " medical periodical. 
Without making invidious comparisons, it can be truthfully stated 
that no medical journal in this country occupies the place, in these par- 
ticulars, that is held by The New York Medical Journal. No 
other journal is edited with the care that is bestowed on this ; none 
contains articles of such high scientific value, coming as they do from 
the pens of the brightest and most learned medical men of America. A 
glance at the list of contributors to any volume, or an examination of 
any issue of the Journal, will attest the truth of these statements. It 
is a journal for the masses of the profession, for the country as well as 
for the city practitioner ; it covers the entire range of medicine and sur- 
gery. A very important feature of the Journal is the number and char- 
acter of its illustrations, which are unequaled by those of any other journal 
in the world. They appear in frequent issues, whenever called for by the 
article which they accompany, and no expense is spared to make them of 
superior excellence. 
Subscription price, $5.00 per annum. Volumes begin in 
January and July. 
PUBLISHED BY 
D. APPLETON & CO., 72 Fifth Avenue, 
NEW YORK,