TETANUS COMPLICATING VACCINIA. BY S. W. S. TOMS, Ph.G., M.D., OF BELLPORT, L. I. J LATE HOUSE SURGEON, BUFFALO GENERAL HOSPITAL. FROM THE MEDICAL NEWS, February 24, 1894. [Reprinted from The Medical News, February 24, 1894.] TETANUS COMPLICATING VACCINIA. By S. W. S. TOMS, Ph.G, M.D., OF BELLPORT, L. I. J LATE HOUSE SURGEON, BUFFALO GENERAL HOSPITAL. On November 6, 1893, I was requested to vaccinate M. D. W., a female white child, five years and five months of age, of American birth and parentage, and apparently healthy. The father is living, and healthy. The mother has two children, and has had one five months' miscarriage. She is of a strumous diathesis, and has had suppurative cervical adenitis. A second sister, aged about sixteen years, is living and in good health. The mother had scarcely made a tedious recovery from a five months' spontaneous abortion, when she again became pregnant. She was in a poor state of health throughout the entire period of gestation, having been subject to some severe trials and afflictions and emotional shocks. The child consequently started life handicapped, developed a neurotic temperament, and was the subject of a strumous diathesis, weak vitality, and poor nutritive functions, slight ailments always pro- foundly affecting her. Two years ago she had measles, followed by mumps, and although both attacks were light she had a strumous keratitis developed upon a preexisting conjunctivitis. She suffered from exacerbations of chronic nasal catarrh and dyspeptic attacks. She was much pampered by her parents, who over-dressed her and in- dulged her in every whim. When in good health she was bright and vivacious, although a delicate child. On November 6, 1893, I vaccinated the child with a fresh 2 ivory-point of bovine virus, using alcohol and a clean towel in preparation of the field of inoculation. The tenotome, with which I scarified the skin of the left arm at the insertion of the deltoid muscle, fifty millimeters square, was sterilized. The slightest scarification spos- sible were made, and the point, moistened with water, from a driven well, was gently rubbed in, covered by a small piece of Lister's green protective and bandaged. This very slight operation produced great pallor, and the child almost fainted. I mention these minute details for reasons obvious that will appear. I directed the mother not to disturb the bandage for several days ; to use a simple dressing of vaselin, and to keep the ulcer free from accumulating pus by weak carbo- lized washings ; and should there be any severe cellulitis, to bathe the inflamed area with aqua hamamelis. I cautioned against allowing the vaselin used to be em- ployed for any other domestic purpose, and to use nothing but clean linen or muslin rags; and should anything require my professional attention to advise me accord- ingly. I was informed on my second visit, November 24th, just eighteen days from the date of vaccination (when I was requested to call because the sore was not doing well), that my directions had been carried out. The vaselin had been taken from a partly used bottle into which those who had made use of it dipped their fingers. A quantity for this special purpose had been set aside on an individual butter-dish, uncovered, on a shelf in a cupboard. I found the child slightly indisposed, with a temperature of about 100.5°, with the tongue slightly coated; she was not inclined to eat, and had sluggish bowels. The arm was not swollen or discolored to any ex- tent. The ulcer was about the size of a silver fifty-cent piece, deep, and containing a quantity of sanious pus of a very fetid odor. I examined the axilla, but no nodes were perceptible, nor did the child complain of tenderness at 3 this point or around the sore. I inquired into the history since vaccination, and was informed that four days after I inoculated the arm it was inspected. Slight redness existed at the site of scarification, and there was a vesicle in process of formation. The surrounding parts were bathed and rubbed with witch-hazel water, and the pro- tective and bandage were reapplied. During the latter part of the second week the slough was complete. At no time had there been much dis- turbance ; the cellulitis was insignificant, and the child was out playing every day. For a few days previous to my second visit there appeared an offensive odor, and the pus was more abundant, although the child did not give evidence of any aggravation of the local trouble. The ulcer was full of pus ; it had not been dressed since the evening before, awaiting my visit. There was nothing in its appearance to arouse suspicion. The ulcer was deep and the granulations were unhealthy, because of the indolent character they presented, and induration existed around the edges for a distance of about i cm. It had been cleansed by using a sponge and 4 c.c. of carbolic acid to 500 c.c. of warm water. The' vaselin was said to have irritated the part where it had been applied to the edges to prevent the dressings adhering, and had been discontinued for a week or more. The witch-hazel water was used for bathing the parts, and the wound was dressed twice daily. I prescribed calomel in 0.015 doses every hour, until a stool should take place, to be followed by oleum ricini or Rochelle salts; to employ 4 c.c. of carbolic acid to 250 c.c. of boiled water instead of 500 c.c., as had been used; to discard the use of the sponge and employ a syringe or irrigator, and to moisten the dressings in the same solution, and to use balsam of Peru after the ulcer had been thoroughly cleansed. The vaselin was not used further. I was informed that under this treatment immediate improvement was perceptible- The odor and the pus 4 did not reappear. The dressing only required changing once daily. The bowels responded, appetite returned, and the child felt reasonably well. The size of the ulcer diminished, and what little induration existed around the margin disappeared entirely, and the granulations im- mediately assumed a healthy character. On November 30th, the father took the child out for a walk, and when near the bay, a stiff breeze blowing at the time, she complained of a sharp pain in her throat on the right side, just posterior to the angle of the jaw. When she returned home the mouth was examined, and a number of small aphthous ulcerations on the margins of the tongue and lips were noticed. I was requested to call and see her. I found the child with a slight stomatitis and the aphthous patches mentioned. The tongue had a dark-gray coating. The pulse was 96, and the tempera- ture 100.50. The bowels were constipated, an d the appetite fair up to that day. I wished to examine the throat, and on depressing the base of the tongue with the handle of a spoon (the child could not separate the jaws more than 75 mm.), she would close her mouth and bite on the handle, holding it for a few seconds quite firmly. I made three attempts with a like result, and abandoned further efforts, as the child was peevish. This trismus was characteristic; but as it often happens in such ex- aminations with children, I attached no importance to the occurrence. I prescribed a simple antiseptic astringent mouth-wash, also advising the extraction of a number of ragged de- cayed teeth, as there was occasionally some pain in the throat radiating from the angles of the jaws, and the left cheek and upper lip were slightly swollen. Providing she had fever, she was to be sponged with tepid water and alcohol until remission occurred. This was done once or twice, free diaphoresis following. On my visit next morning I found the patient about the same, with possibly more trouble in the throat, of which complaint 5 was made on swallowing. The girl had not been taken to a dentist. There had been periods of depression and restlessness, and the child had taken only liquid nourishment and wished to drink frequently, which was allowed as much to cleanse the mouth as on general principles, as it was almost impossible for the parents to get her to use the mouth-wash to any effect. She talked freely, and most of the time seemed bright, but was apprehensive and wanted to be held in the lap. Occa- sionally, after sleeping, she would have slight strangling attacks from the accumulated mucus in the throat, which seemed to excite trismus, for she had difficulty in ex- pelling it. Biniodid of mercury, 0.00065, was given every hour for "sore-throat" ; also a mixture containing sodii bromidum and chloral, 0.24 of each to a dose. I saw her again early on December 2d, still finding the symptoms about as before, together with some rigidity in the muscles of neck, and pains complained of in the back. The latter I attributed to her position, as she was almost constantly held in the lap. Although the child's general condition did not improve, she was less restless. The bowels were constipated, and calomel in 0.015 doses hourly was ordered until a stool was induced. She also had retention or suppression of urine, only urinating twice in twenty-four hours and indiminished quantity. The arm was examined each day and appeared healthy, not sore or inflamed ; the temperature and pulse were normal. In the evening I was hurriedly summoned, as the child " had spit some blood " in one of her strangling or cough- ing attempts to expel the accumulated mucus from the throat. This was no doubt due to an injury to the tongue from trismus. The aphthae seemed to be getting worse, and all attempts at using the mouth-wash with a swab excited trismus. In fact, the muscles of the jaws seemed to be in slight tonic spasm, as the girl was unable to sepa- rate her jaws more than from 60 mm. to 70 mm.; yet she conversed freely and drank her broth and milk up * 6 to this time quite readily. At midnight I was again called and informed that she had had a convulsion- "became stiff, did not breathe, and bent backward.'' This lasted "about a half-minute.'' When I arrived at the house she was resting quietly. She had not had any of the antispasmodic mixture since the previous after- noon. Although she sat up in bed, drank some broth and talked, and afterward relapsed into a quiet sleep, she could not be induced to take the medicine or use the mouth-wash. I remained until 2.30 a.m., leaving a bottle of chloroform to be used in case of further con- vulsions. What I had been apprehending for thirty-six hours I now became convinced was true, and I deter- mined in the morning to suggest counsel, which I did; when I was called at 8.30 a.m., with the intelligence that she had had three more convulsions, but of slighter character-the anesthetic being promptly brought into use. At noon of December 4th I met in consultation Dr. A. H. Terry, of Patchogue. During our examination the child had a typical paroxysm with opisthotonos, and deep anesthesia failed to separate her jaws. The grave prognosis I gave early in the day was confirmed by my confrere. The plan of treatment agreed upon was bromid and chloral per rectum, nutritive enemata, ice-bags to the spine, and chloroform when necessary to control the spasms. The paroxysms were clonic. The girl lapsed into coma from the time the anesthetic was administered; at the time of which she also received a nutritive enema with the antispasmodic mixture, com- bined with tr. opii deod., gtt. x, and every three hours sub- sequently. While under the influence of these she was perfectly free from convulsions, even her jaw relaxing to its full extent, allowing the nurse to swab out the buccal cavity, which was not possible before. In the morning I had detected cooing and mucous rales at the left base posteriorly. This unfavorable sign 7 rapidly advanced and soon appeared as well in the right lung, and although she subsequently had only six more very slight convulsions she died from edema of the lungs on the next morning, December 5th, at 10.45. She had eleven distinct and characteristic convulsions, four of which were moderately severe, but lasting less than thirty seconds. Although the course of the disease was short, its essen- tial characteristics answered perfectly to the description given by Watson: "During the fits of exacerbation the aspect of the sufferer is often frightful. The forehead is corrugated and the brow is knit, the orbicularis muscle of the eye rigid, the eyeball motionless and staring, the nostril spread, the corners of the mouth drawn back, the set teeth exposed, and all the features fixed in a ghastly grin-the true risus sardonicus. The tongue is apt to get between the teeth and be severely bitten. All the contractions are attended with intense pain.''1 At the time of death the ulcer on the arm was not larger than a silver quarter of a dollar, was superficial, without tenderness or discoloration of the surrounding skin, or induration. Pus was slight, granulations were healthy ; there was no cellulitis in the arm, nor were the axillary glands enlarged. Several hours before death the face became " bloated," the eyelids and lips much swollen, the jaw relaxing and the mouth open, while the purulent discharge drained along the dependent track of the buccal cavity and angle of the mouth quite profusely. The face soon after death rapidly assumed the natural features ; the emphysema (?) entirely disappeared. Cuta- neous discoloration from blood-stasis in the superficial circulation was marked in the dependent portions of the body, and rigor mortis was well advanced in less than one hour after death. 1 Prac. of Phys., Leet, xxxii. 8 From the fact that this fatal case of tetanus has created a grave suspicion in the minds of a large number of people generally 1 and a deep prejudice in the locality against vaccination, I undertook to collect statistics from various sources. I wrote to the managers of the vaccine farm-one of the largest, most reputable, and scientific- ally conducted establishments in the world; and one in which thousands of the best physicians have unqualified confidence, besides being, perhaps, the largest producer of vaccine on the continent-and was informed that they had never had a case reported to them from the millions of points they had sold, nor had they heard of a case of tetanus from vaccination. I also wrote to Dr. Cyrus Edson, Health Commissioner of the city of New York, and Surgeon-General George M. Sternberg, U. S. A. Replies from these gentlemen and from Dr. J. S. Billings, of the Army Medical Library, are reproduced. Besides these I have to state that I am greatly indebted to the courtesy of Dr. Judson C. Smith, of the Pathological Laboratory of the New York Post- Graduate Medical School and Hospital, who endeavored to make cultures from some of the pus and part of the tissue taken at time of death from the vaccination ulcer on the arm, with negative results. Efforts were made to obtain cultures from the point used for inoculation, and this also without success.-2 1 Several distorted articles appeared in the New York City papers, particularly in the New York Sun of December 9, 1893- only another evidence of the utter inability of the lay mind to correctly state facts or describe a scientific subject devoid of sen- sationalism. Also, an article appearing in the Suffolk Co. (N. Y.) Argus of January 6, 1894, emanating from a homeopathic phy- sician of a neighboring town, stating that death was "lockjaw caused by vaccination," and denouncing in unmeasured terms vaccination and the statute that makes it compulsory. 2 Dr. Cyrus Edson, of New York, wrote: " During my services in this department I have supervised the performance of over one The fact that the child had an aphthous sore mouth, with a purulent discharge from the buccal cavity or 9 million vaccinations; among all these cases not a single instance of tetanus has occurred. I believe that the disease is endemic in the eastern part of Long Island, and possibly as near us as Bell- port. I should consider an abrasion of any kind in the locality I have named a dangerous thing. For this reason it is very unjust to blame vaccination for the circumstance.'' Dr. George M Sternberg, Surgeon-General, wrote as follows: " I do not know of any case of tetanus having occurred as a com- plication of vaccination, but I will refer to Dr. Billings, who has charge of the Army Medical Library, requesting him to have the literature of the subject looked up. As your case occurred four weeks after the vaccination, I agree with you in believing that it was a secondary infection, for which you were in no way re- sponsible." Dr. J. S. Billings, Surgeon U. S. A., wrote as follows: " I en- close herewith a memorandum of six cases of tetanus following vaccination, which are all I find recorded under that heading. You will see that they were all secondary infections : " CASE I.-Dr. W. T. C. Bates, Transactions of South Caro- lina Medical Association, 1882, page 105. Mulatto boy, aged five years; vaccinated February 9, 1882, with humanized virus. Tetanic symptoms supervened March 8th. No other cause than vaccination found. Boy lived fifteen days. " Case IL-Dr. R. Carcia Rijo, Cronica Medico- Quirurgica de la Habana, 1886, vol. ii, page 388. White child, two years old; vaccinated in April, 1886; characteristic tetanus appeared in latter part of May. No lesion beyond vaccination found. Death fol- lowed on fourth day. "Case III.-Dr. George Ross, The Southern Clinic, 1878-79, vol. i, page 468. Boy, three and one-half years old; vaccinated, tetanus supervening three weeks afterward, with death on the third day. No other lesion beyond vaccination. " CASE IV.-Dr. Theodore Dimon, St. Louis Courier of Medi- cine, 1882, vol. vii, page 310. Boy, nine years old, vaccinated January 6,1882; bovine virus. Tetanus set in January 27th; no cause discovered except from vaccination, which was followed by an irregular-shaped ulcer. Boy died on tenth day. "CASE V.-Dr. Joseph B. Cottman, New Orleans Medical and Surgical Journal, 1854-55, vol. ii, page 783. Negress af- 10 throat, together with the open wound on the arm, leaves open a question of just how secondary infection may have occurred. True it is the sore mouth was coincident and coexistent with the first symptoms of the disease. Watson1 cites cases of tetanus from salivation. More- over, beside this case stand the hosts of so-called idio- pathic cases. Although no attempt is made to believe this case might have been such in view of the presence of an open wound on the arm and eroded mucous mem- branes of the mouth and throat, yet the possibility of such being a coincidence might not be altogether dis- regarded. From the period of time elapsing from the date of vaccination to the developing of the tetanus, it is certain fected with tetanus following vaccination; period of time not stated. Recovery in two weeks by the use of large doses of opium. " Case VI.-Dr. H. J. Berkeley, Maryland Medical Journal, 1882, vol. ix, page 244. Healthy man, forty years old, vaccinated in middle of January, 1882. February 7th, tetanus set in; death followed February 13th. No lesion was discovered except at the point of vaccination ; on the latter there was a deep ulcer, which had an inflamed and indurated border.'' Dr. George M. Oxford, of Ridgewood, N. J., wrote me: " I have had under treatment, since November 29th, a case of idio- pathic tetanus; it came on suddenly, without any vaccination or injury as far as can be learned. The symptoms were very severe at first, with marked trismus. Now there is more remission and better sleep, but renewal of lighter attacks from reflex irritation, such as noises, etc. I write you this to show that other causes than vaccination may account for your case. My patient is twelve years old." [Dr. Oxford evidently had seen one of the New York papers with the account of my case, and voluntarily wrote me the fore- going letter. I am not personally acquainted with him. The Doctor writes me under date of January 22, 1894, that his patient is still under treatment, and that his condition is almost un- changed.] 1 Watson's Prac. of Physic, Leet, xxxiii. 11 that this does not correspond to the accepted view of the period of incubation.1 In conclusion, the possible source of infection of the ulcer might have been from (i) vaselin (which might have been infected from previous use); (2) sponge (which might have been dirty); (3) unsterilized dressings ; also from the solution of continuity of the mucous mem- branes of the mouth and throat. Against the theory that it was due to vaccination is 1. The existence of "sore mouth," which is possible as offering a nidus for infection. 2. The date of onset not corresponding to the gene- rally accepted period of incubation; and absence of bacilli of tetanus in the pus and tissue from the wound. 3. The fact that the disease manifested such a mild course, and that the fatal issue was depending upon an intercurrent complication. Had not this unfortunate circumstance occurred, and had the child possessed ordinary vitality, it is but reasonable to assume that she would have recovered. A point that is a matter of regret to the writer is that there was no attempt made to obtain cultures from the purulent discharge from the mouth. 1 " Within two weeks " (Osler, page 162). " Most frequently makes its appearance at end of first week" (Amer. Text-book of Surgery, page 67). Although Senn (Principles of Surgery, page 392) says: " The period of incubation appears to be extremely variable." The Medical News. Established in 1843. A WEEKLY MEDICAL NEWSPAPER. Stibscription, 00 per Annum. The American Journal OF THE Medical Sciences. Established in 1820 A MONTHL YMEDICAL MAGAZINE. Subscription, $4.00 per Annum. COMMUTATION RATE,$7.50 PER ANNUM. LEA BROTHERS & CO PHILADELPHIA.