PTOMAINES OF THE BACILLUS TETANI. 153 



in others weeks may lapse between the time of inoculation and the 

 first manifestations of the disease. This may depend on one of 

 three things: 1. The number of bacilli introduced may be so small 

 that a much longer time is necessary before active symptoms are 

 produced than if a larger quantity had been introduced, as Watson 

 Cheyne has shown that in animals the injection of a limited num- 

 ber of the bacilli of tetanus produced no symptoms. 2. The loca- 

 tion of the infection-atrium and anatomical characteristics of the 

 tissues surrounding it may influence the time which is necessary to 

 develop the disease. 3. Brieger's investigations have shown that 

 tetanic convulsions in animals are produced by injections of tetauin, 

 one of the toxic ptomaines derived from cultivations of the bacillus 

 of tetanus, and it is more than probable that the active symptoms 

 of tetanus in man are due not to the presence in the tissues of the 

 bacillus, but to the toxic action of the ptomaines on the spinal cord, 

 so that the length of the stage of incubation is further modified by 

 the capacity of the infected tissues to yield the different ptomaines. 

 The degree of virulence of the bacillus of tetanus must certainly 

 play an important part not only in determining the length of the 

 incubation stage, but also the intensity of symptoms. There can 

 be no doubt that both the acute and chronic forms of tetanus are 

 caused by the same microbe, and that the clinical difference depends 

 upon the degree of virulence of the primary cause. Whether culti- 

 vations from chronic cases of tetanus can produce an acute and 

 rapidly fatal attack in animals remains to be determined. In this 

 direction I have recently made an observation which, if not con- 

 vincing, is, at least, very suggestive. A boy, fifteen years of age, 

 previously in good health, was attacked with acute osteomye- 

 litis in the lower extremity of the femur. The surgeon in attend- 

 ance trephined the bone over its outer and lower aspect during 

 the first few days and before an abscess had formed in the soft 

 parts. A few days after the operation trismus set in, followed by 

 typical chronic tetanus. Six weeks later, the patient entered the 

 Milwaukee Hospital, and was placed under my charge. At this 

 time the patient had become emaciated to a skeleton. Trismus and 

 opisthotonus were well marked, and the lower extremities were 

 rigid and fixed in the extended position. The slightest touch, or a 

 draught of air in the room, would bring on intense convulsive 

 attacks lasting for several minutes, attended by excruciating pain. 

 Profuse fetid discharge at the site of operation; pulse 140, tempera- 

 ture from 99 to 101 F. (37.3 to 38.3 C.). Believing that the 

 primary infection had taken place through the operation wound, 

 and that osteomyelitic products served the purpose of a nutrient 

 medium for the bacillus tetani, I determined to operate in spite of 

 the grave symptoms. As the spinal cord at this stage of the dis- 



