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 CITIZENSHIP
WHAT EVERYONE NEEDS TO KNOW®
 CITIZENSHIP
WHAT EVERYONE NEEDS TO KNOW®

PETER J. SPIRO

1
 3
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 To the memory of
my father, Herbert J. Spiro,
and grandfather, Howard C. Petersen.
Citizens both.
 CONTENTS

Introduction 1

1 Citizenship Through Birth 6

Why do states give anyone citizenship at birth? 6

Does being born in a country’s territory entitle one to citizenship in
that country? 7
What are the origins of territorial birthright citizenship? 8
How does territorial birth citizenship relate to the Dred Scott decision? 9
Do all persons born in US territory enjoy US citizenship under the
Fourteenth Amendment? 10
What are the arguments for and against birthright citizenship for
unauthorized immigrants? 11
Does the history of the Fourteenth Amendment support the
extension of citizenship to the children of unauthorized immigrants? 13
Do people born in US territories have citizenship at birth? 14
What are “anchor babies”? 15
What is “birth tourism”? 16
Does a child born abroad get the parent’s citizenship? 17
Do children born abroad have to “sign up” for citizenship? 19
What are “accidental Americans”? 20
When only one parent is a citizen, does it matter whether it is the
mother or the father? 21
viii Contents

When born on an airplane or a ship, what citizenship does one

have at birth? 22
Do noncitizen children adopted by citizen parents automatically get
citizenship? 22
How easy is it to demonstrate entitlement to birth citizenship? 23

2 Naturalization 25

Why do countries grant anyone citizenship after birth? 25

What is the history of naturalization? 26
Have racial and religious criteria been applied to naturalization
eligibility? 27
Do all countries require legal residency as a condition
of naturalization? 29
Why is a period of residency usually required for naturalization? 30
Do some naturalization applicants get preferential treatment? 31
What is Israel’s Law of Return? 32
What is the so-​called citizenship test for US naturalization? 33
Do other countries have citizenship tests? 35
Are naturalization exams justifiable? 36
Is naturalization contingent on language facility? 37
Do would-​be citizens have to show they are good people? 39
What is the citizenship oath? 41
If unauthorized immigrants are legalized in the United States,
should they get a “path to citizenship”? 43
Can one buy citizenship? 44
Do states sometimes extend citizenship to individuals with
special talents? 48
Does military service result in citizenship? 49
Can countries naturalize whomever they want? 50
What was the Nottebohm Case? 52
Do all eligible immigrants naturalize? 53
Who administers naturalization? 54
When can individuals secure citizenship on the basis of ancestry? 56
 Contents ix

Is citizenship ever granted on the basis of past persecution? 56

How is citizenship allocated when states break apart? 58
What is honorary citizenship? 59

3 Rights and Obligations of Citizenship 61

What were the rights and obligations of citizenship in the ancient

world? 61
Do noncitizens enjoy civil rights today? 62
In economic matters, have noncitizens been discriminated against
as a matter of law? 63
What were “declarant aliens,” and how was the status advantageous? 64
Are noncitizen permanent residents discriminated against for
economic purposes today? 65
Are noncitizens eligible for public benefits such as welfare? 67
Can citizens be deported? 68
What other immigration-​related benefits attach to citizenship? 70
Are noncitizens required to serve in the military? 71
Do noncitizens have to pay taxes? 72
What are the distinctive obligations of citizenship? 72
Can noncitizens vote? 73
Can noncitizens engage in other forms of political activity? 75
Do naturalized citizens have the same rights as birthright citizens? 76
Do governments help citizens abroad? 77
Do citizens abroad carry constitutional rights with them? 79
Do citizens in US territories have the same rights as those in the fifty
states of the United States? 81
Can only citizens commit treason? 82
Do citizens abroad have to pay taxes? 83
Do citizens abroad get to vote? 84
x Contents

4 Dual Citizenship 87

Why did states once abhor dual nationality? 87

How did states formerly police against dual citizenship? 88
How does one get dual citizenship at birth? 91
How does one get dual citizenship after birth? 92
Is the US renunciation oath enforced? 93
Why do people want dual citizenship? 94
How many people have dual citizenship? 96
How can one be loyal to more than one country? 97
What if two countries in which a person holds citizenship get into a
war with each other? 99
Can dual citizens serve in government positions? 100
Does dual citizenship undermine the value of citizenship? 102
Why have many “sending states” embraced dual citizenship? 103
Are there regional variations in the acceptance of dual citizenship? 105
Why should states allow dual citizenship? 108
Does dual citizenship result in inequality? 109
Can one have more than two citizenships? 110

5 Citizenship Deprivation and Statelessness 112

What terms are used to describe loss of citizenship? 112

Why did people want a “right” to expatriate in the nineteenth century? 112
Did women at one time lose nationality if they married foreign men? 115
What was a Nansen passport? 117
Can termination of citizenship be used as a penalty for
criminal activity? 118
Are there constitutional constraints on the government’s power to
terminate citizenship under US law? 119
Are individuals deprived of their citizenship against their will under
current US practice? 121
Should countries “citizenship strip” terrorists? 121
 Contents xi

Is the United States likely to adopt a terrorist expatriation law? 123

How is passport revocation similar to citizenship stripping? 125
What is denaturalization? 126
Are individuals free to renounce their citizenship today? 127
What are the causes of statelessness? 129
What are the more notable cases of group statelessness not
involving migration? 130
How have states worked to combat statelessness? 132
Are refugee status and statelessness the same? 134

6 Interrogating Citizenship and Its Alternatives 136

Is citizenship inclusive or exclusive? 136

What is the “birthright lottery”? 137
To what extent does citizenship reflect social solidarities? 138
Will the presidency of Donald Trump and the rise of nationalistic
political parties revive citizenship as an institution? 140
Is citizenship being gamed? 142
How is local citizenship determined? 145
To what extent does local citizenship represent an alternative to
national citizenship? 145
In the United States, can states discriminate against citizens of other
states? 146
Can local and national citizenship be decoupled? 147
Can one have “dual” local citizenship? 148
What is the significance of European Union citizenship? 149
How does citizenship relate to “good citizenship”? 151
Can citizenship translate to other forms of community? 151
Is “global citizenship” a meaningful aspiration? 153

BIBLIOGRAPHIC NOTE 155

INDEX 163
 CITIZENSHIP
WHAT EVERYONE NEEDS TO KNOW®
 INTRODUCTION

Citizenship is a like the air we breathe; it’s all around us but

often goes unnoticed. That is not a historically ordinary sit-
uation. Citizenship was once an exceptional status, a kind of
aristocracy of the ancient world in which freedom and polit-
ical voice were not taken for granted. Even as the nation-​state
emerged as the primary form of human association, citizen-
ship remained an anomalous status, reserved for the few who
were privileged as such in republican democracies. More re-
cently, it has been the individual marker of membership in all
national communities. It is generic; almost everyone has it,
hence the ubiquity that has made it sometimes unseen. Most
people never change the citizenship that they are unthinkingly
born into; they have no cause to consider it any more critically
than their choice of parents. Insofar as citizenship during the
twentieth century came to be aligned with national commu-
nity on the ground and in the public imagination, there was
even less reason to look at it searchingly.
To the extent that it took residence in the public conscious-
ness, “citizenship” came to represent an anodyne synonym
for virtuousness in society and in individuals. It became the
form of political address, a way of describing any public
audience. Citizenship is something that everyone could
agree on. It has consensus status across political divides.
Citizenship telegraphs the shared equality among individuals

Citizenship. Peter J. Spiro, Oxford University Press (2020). © Oxford University Press.
10.1093/actrade/9780190917302.001.0001
2 Introduction

in contemporary society, a status that anchors rights and indi-

vidual dignity, something that frames the individual’s place in
the community. In the public imagination, citizenship has been
considered an unalloyed good.
But citizenship is ripe for closer examination. Globalization,
increased mobility, and growing anti-​ immigration politics
highlight the fact that although most people in the world have
citizenship someplace, there are vastly unequal entitlements
attached to citizenship in particular countries. The universal-
ized sense in which the word is used in political discourse in
the United States masks the obvious fact that not everyone
has US citizenship and that most of the world is excluded
from it. To the extent an implication of equality holds fast
within the citizenry, it clearly does not apply to those outside
the fold. In more sedentary, state-​oriented times, it was easy
to blinder out those who were excluded from the citizenry
because their citizenship was held in other, distinct commu-
nities largely out of view. Those communities were different
enough that one could keep them at arm’s length, a part of
the natural order of things. The result has been a global kind
of separate but equal.
That mindset is more difficult to sustain as national iden-
tities blur and distances are eclipsed. Citizenship still has
its virtues. But as it more obviously marks the boundary of
human community, citizenship is a tool of exclusion as well
as inclusion. Citizenship has been a badge of equality. It may
be turning into a badge of privilege. As citizenship is in-
creasingly situated in a global context in which some have
a “good” one and some do not, it is important to explore its
meanings and mechanics.
This book addresses citizenship not as an institution to be
venerated but as one that is contingent and constructed as a
marker of membership in a state-​based association. The book
lays out the status fundamentals of citizenship: how one gets
it, at birth and afterward through naturalization; how one
loses it; what it gets you and what it demands of you by way of
 Introduction 3

rights and obligations; how the once-​reviled status of dual cit-

izenship became broadly accepted; and how local and global
citizenships along with nonstate memberships may comple-
ment or even displace national citizenship. This material is not
offered as a practical guide, but rather as a lens on the past
and future of citizenship and ultimately on the state itself. For
example, territorial birthright citizenship is contested in the
United States in the context of undocumented immigration,
but the debate rarely stops to ask why location at moment of
birth should determine one’s citizenship and what that says
about the demarcation of the national community. How can
we justify making equality contingent on passing a test, as
we do with naturalization applicants? What does the fact that
some countries sell citizenship say about it as an institution?
How has citizenship become cheap in the sense of requiring
no distinctive obligations? How does dual citizenship under-
mine citizenship solidarities? In what circumstances should
states be able to strip individuals of citizenship against their
will? What are the implications of citizenries that no longer
reflect social solidarities on the ground? These are the kinds
of questions that start with the legal parameters of citizenship
and lead to explorations of citizenship’s broader significance
in global society.
Citizenship has been a central organizing principle of
modern global society and a primary dimension of individual
identity. It may stay that way, but its ascendancy is being tested.
As with any new challenge to an established institution, it is
important to have some understanding of the backstory and
how that backstory has shaped the current landscape. I hope
this book will help orient critical thinking on a subject by those
(most of us) who have not really thought about it at all.
A word on terminology and coverage: Today, “citizenship”
and “nationality” are almost entirely synonymous. As a uni-
versal descriptor, however, “citizenship” is relatively new,
accompanying the rise of constitutional democracy. Although
not all countries are democratic, all countries now denominate
4 Introduction

their members as citizens. In the past, however, citizenship

was a distinctive feature of democracy. Individuals belonging
to other sovereignties were often called “subjects” for domestic
purposes. As a matter of international law, “nationality” has
historically been the term of art. For purposes of this book,
then, historical discussions use “nationality,” especially when
describing developments beyond the United States (where
“citizen” has been used from its founding).
The book also uses immigration-​related terms that are nec-
essarily incidental to citizenship status. “Permanent residence”
indicates the status under which individuals are admitted to a
country with no temporal limitations, a status available in al-
most all countries but which is extended under various labels.
(In the United States, it is colloquially known as “green card”
status after the color of the card that once evidenced the status.)
“Non-​immigrants” are those who are legally admitted but with
limitations on activity (employment for instance), and usually
also time. I use “unauthorized immigrant” to describe those
who are present in the territory of a state in violation of immi-
gration controls. Citizenship implicates full membership in a
national community; it is distinct from immigration, which is
about the regulation of entry into territory. But because access
to territory comes with citizenship, and because immigration
is often a predicate to citizenship, the two are inevitably cou-
pled in some respects.
This book is about citizenship as a global institution and
includes material from all global regions. It is more focused on
citizenship practices in the Global North, to the extent that cit-
izenship is largely an artifact of the West. That is certainly true
as a historical matter. Nationality was once a matter deeply
contested between European sovereigns and the United States
in particular, and so the historical background, important to
understanding citizenship’s trajectory, is the history of na-
tionality in those countries. Today, citizenship in developed
economies remains more highly prized, precisely because of
 Introduction 5

global inequalities, which translates into a focus on citizenship

practices in those countries. There have nonetheless been inter-
esting and consequential developments in citizenship practices
among states of the Global South, which are also recounted in
the pages that follow.
 1
CITIZENSHIP THROUGH BIRTH

Why do states give anyone citizenship at birth?

As in all forms of human association, states are composed of
individual members. In theory, states could delay the con-
ferral of citizenship until individuals reach adulthood and the
fully formed identity that comes with it. In practice, all states
provide for citizenship at birth, and that is how the vast ma-
jority of the world’s inhabitants acquire citizenship. From the
state’s perspective, birth citizenship is a practical necessity
and an easy mechanism for replicating membership on an
intergenerational basis.
There are two primary forms of birth citizenship: on the basis
of place of birth and on the basis of parentage. Historically,
these two forms of birth citizenship have been known as jus
soli, which translates from Latin as “right of the soil,” and jus
sanguinis, or “right of the blood.” The first is based on terri-
torial location at time of birth, the second on parentage and
ancestry. In some contexts, as discussed later in this chapter,
they act in combination. Both imply a logic under which birth
parameters predict a life trajectory. Birth citizenship is best jus-
tified on the grounds that circumstances surrounding birth—​
location, parentage, or both—​point to subsequent membership
in the national community.

Citizenship. Peter J. Spiro, Oxford University Press (2020). © Oxford University Press.
10.1093/actrade/9780190917302.001.0001
 Citizenship Through Birth 7

Does being born in a country’s territory entitle

one to citizenship in that country?
In many countries, birth within national boundaries can lead
to a grant of citizenship. In some, birth in a country’s territory
will automatically result in citizenship. The United States most
famously practices this near-​absolute form of birth citizenship.
With the minor exception of the children born to diplomats,
all persons born on US territory are US citizens at birth. This
approach is common among Western Hemisphere states, in-
cluding Canada, Mexico, and most Latin American countries.
Other countries have adopted modified jus soli birth citi-
zenship mechanisms. Some states make automatic territorial
birth citizenship contingent on parental immigration status.
Children born on national territory to parents who are citi-
zens will always have citizenship in that country. The United
Kingdom, for example, extends citizenship to those born on
UK soil to a permanent resident parent. Germany grants citi-
zenship to individuals born on German territory if their non-
citizen immigrant parents have resided in Germany for at least
eight years prior to the birth of the child. Some European states,
for example, Belgium, France, the Netherlands, and Portugal,
restrict territorial birth citizenship to the children of parents
who themselves were born on state territory. This is known as
“double jus soli.”
Some states will in certain cases require a combination of
birth and subsequent residence on the part of the individual
claiming citizenship. In the United Kingdom, a child born to
temporary or unauthorized immigrant parents will not have
automatic citizenship at birth. However, if that child remains
habitually resident in the United Kingdom from birth until
her tenth birthday, she is entitled to citizenship at that time. In
Germany, eight years of noncitizen parental residence is a nec-
essary but not sufficient condition for jus soli; on top of this the
child must reside in Germany for eight years before she turns
twenty-​one, failing which birth citizenship will expire.
8 Citizenship: What Everyone Needs to Know

The global trend is to allow birth citizenship based on place

of birth in at least some circumstances. Most states, for in-
stance, extend citizenship at birth to those born on state terri-
tory of unknown parentage (so-​called foundlings), to reduce
the incidence of statelessness. More important, an increasing
number of countries now recognize at least double jus soli birth
citizenship; in other words, more states now confer citizenship
on intergenerational immigrants than was historically the case.
But many countries continue to reject jus soli citizenship in
all cases except when statelessness would result, including
Austria, Finland, Indonesia, Egypt, Botswana, Kenya, and
most Middle Eastern states. Some even fail to extend citizen-
ship when statelessness will be the consequence, as is the case
in India, Thailand, Nigeria, and Zambia. In these countries it
is possible to have noncitizenship status persist on an indef-
inite, intergenerational basis. For example, a person born in
one of these countries to parents and grandparents who were
also born in that country but lack citizenship will not have
citizenship at birth. Even when it doesn’t increase the risk of
statelessness, this older model poses human rights concerns,
to the extent that lack of citizenship results in status inequality.
For example, without territorial birth citizenship a fourth-​
generation legal resident would still lack full political rights.

What are the origins of territorial birthright citizenship?

Absolute territorial birthright citizenship has its roots in the
feudal era. Under medieval conceptions of natural order,
individuals were born into the protection of sovereigns, to
whom they owed perpetual allegiance in return. Automatically
and for life, they were subjects of the sovereign in whose ter-
ritory they were born. The principle was notably articulated
in the 1608 decision by the English Court of the King’s Bench
in Calvin’s Case, which considered whether a person born in
Scotland after James I’s ascension to the English crown quali-
fied as an English subject. As recounted by Sir Edward Coke,
 Citizenship Through Birth 9

one of fourteen judges sitting on the case, “Every one born

within the dominions of the King of England . . . is subject to
all the duties and entitled to all the rights and liberties of an
Englishman.” It was by virtue of this common law interpre-
tation (there was no statute governing the issue) that persons
born in the American colonies were considered British subjects.

How does territorial birth citizenship relate

to the Dred Scott decision?
The US Supreme Court’s 1857 decision in the Dred Scott case
addressed the question of whether free blacks were capable of
holding US citizenship. At the time of its adoption in 1789, the
US Constitution failed to address birth citizenship. Through
the common law practice inherited from the United Kingdom,
white persons born on US territory were assumed to have US
citizenship at birth. In Dred Scott, the Supreme Court ruled that
persons of African descent could not hold national citizenship
even if they were free. (The heart of the dispute was whether
a slave owner’s move to a non-​slave territory had resulted in
Scott’s emancipation, but the Court had to consider the citi-
zenship issue since only citizens could invoke the Court’s
jurisdiction.)
The Court turgidly and illogically argued that various
disabilities suffered by blacks evidenced that the Constitution’s
drafters could not have contemplated African American cit-
izenship. The decision was better explained by the constitu-
tional mechanics of citizenship, under which each state would
have to respect the “privileges and immunities” of US citizens
present in other states. If free blacks could hold citizenship,
they would be entitled to travel freely in slaveholding states,
a prospect in which slaveholding interests saw an intolerable
threat. That explains why the question of black citizenship had
been left open in the Constitution itself; abolitionist interests
would have rejected a bar on blacks holding citizenship, while
the slaveholding states would never have accepted black
10 Citizenship: What Everyone Needs to Know

citizenship. Dred Scott forced the question and accelerated the

road to civil war.
In 1868 the Constitution was amended to resolve the issue
of black citizenship definitively. The Fourteenth Amendment
provides that “all persons born in the United States, and sub-
ject to the jurisdiction thereof, are citizens of the United States
and of the State wherein they reside.”

Do all persons born in US territory enjoy US

citizenship under the Fourteenth Amendment?
While the Fourteenth Amendment extended birth citizenship
to blacks born in US states, its application to other groups
was unclear. In its 1884 decision in Elk v. Wilkins, the Supreme
Court found that Native Americans born into tribal member-
ship were not “subject to the jurisdiction” of the United States
and thus ineligible for citizenship at birth. Native Americans
were extended birth citizenship by statute under the Indian
Citizenship Act of 1924, which remains in effect today.
The Fourteenth Amendment’s coverage was also contested
with respect to the children of noncitizens born in the United
States. In its 1898 decision in Wong Kim Ark, the Supreme Court
considered the citizenship of a person born in San Francisco
to legal immigrants from China. The immigrant parents were
themselves barred from citizenship under then-​ applicable
laws disqualifying Asians from naturalization. Nonetheless,
the Court found the children of such immigrants entitled to
birth citizenship under the Fourteenth Amendment. The
Court concluded that the Fourteenth Amendment codified the
jus soli birth citizenship rule inherited from British rule and
the common law. The Court did not act out of any concern
for the children of Chinese immigrants. Rather, the Court un-
derstood that birthright citizenship was key to the American
experience. “To hold that the Fourteenth Amendment of the
Constitution excludes from citizenship the children, born in
the United States, of citizens or subjects of other countries,” the
Another random document with
no related content on Scribd:
Franklinic or Static Electricity.—This form of electricity is now being
much used, especially abroad, in the treatment of nervous affections,
but does not appear to have been employed in the different
copodyscinesiæ, as but few reports of such treatment have found
their way into current literature. Romain Vigouroux111 states that he
has cured one case by statical electricity. Another case is reported
by Arthuis112 as rapidly cured by this treatment after many other
means, carried on during a period of five years, had failed; but his
brochure contains too many reports of cures of hitherto incurable
diseases to be relied upon.
111 Le Progrès médical, Jan. 21, 1882.

112 A. Arthuis, Traitement des Maladies nerveuses, etc., Paris, 1880, 3me ed.

Gymnastics and Massage.—As those suffering from copodyscinesia

are generally compelled by their vocation to be more or less
sedentary, exercise in the open air is indicated, inasmuch as it tends
to counteract the evil effects of their mode of life; but the use of
dumb-bells or Indian clubs, riding, rowing, and similar exercises do
not ward off the neuroses in question or diminish them when they
are present.

Such is not the case when rhythmical exercises and systematic

massage of all the affected muscles are employed, as marked
benefit has followed this method of treatment. The method employed
by J. Wolff, a teacher of penmanship at Frankfort-on-the-Main, which
consists of a peculiar combination of exercise and massage,
appears to have been wonderfully successful, judging from his own
statements and editorial testimonials of such eminent men as
Bamberger, Bardenleben, Benedikt, Billroth, Charcot, Erb, Esmarch,
Hertz, Stein, Stellwag, Vigouroux, Von Nussbaum, Wagner, and De
Watteville. The method is described by Romain Vigouroux113 and Th.
Schott,114 the latter claiming priority for himself and his brother, who
employed this method as early as 1878 or 1879. Wolff,115 however,
states that he had successfully treated this disease by his method as
early as 1875. Theodor Stein,116 having had personal experience in
Wolff's treatment, also describes and extols it: 277 cases of
muscular spasms of the upper extremities were treated; of these,
157 were cured, 22 improved, while 98 remained unimproved; these
comprised cases of writers', pianists', telegraphers', and knitters'
cramp.
113 Le Progrès médical, 1882, No. 13.

114 “Zur Behandlung des Schreibe- und Klavierkrampfes,” Deutsche Medizinal

Zeitung, 2 März, 1882, No. 9, Berlin; also “Du Traitement de la Crampe des Écrivains,
reclamation de Priorité, Details de Procedes, par le Dr. Th. Schott,” Le Progrès
médical, 1re Avril, 1882.

115 “Treatment of Writers' Cramp and Allied Muscular Affections by Massage and
Gymnastics,” N. Y. Med. Record, Feb. 23, 1884, pp. 204, 205.

116 “Die Behandlung des Schreibekrampfes,” Berliner klinische Wochenschrift, No.

34, 1882, pp. 527-529.

It must be borne in mind that Wolff, not being a physician, can refuse
to treat a case if he thinks it incurable; and in fact he does so, as he
has personally stated to the writer, so that his statistics probably
show a larger percentage of cures than otherwise would be the case.

His method may be described as follows: It consists of a combined

employment of gymnastics and massage; the gymnastics are of two
kinds: 1st, active, in which the patient moves the fingers, hands,
forearms, and arms in all the directions possible, each muscle being
made to contract from six to twelve times with considerable force,
and with a pause after each movement, the whole exercise not
exceeding thirty minutes and repeated two or three times daily; 2d,
passive, in which the same movements are made as in the former,
except that each one is arrested by another person in a steady and
regular manner; this may be repeated as often as the active
exercise. Massage is practised daily for about twenty minutes,
beginning at the periphery; percussion of the muscles is considered
an essential part of the massage. Combined with this are peculiar
lessons in pen-prehension and writing.
The rationale of this treatment is not easy, but any method which
even relieves these neuroses should be hailed with pleasure, as they
heretofore have been considered almost incurable.

The method employed by Poore, as mentioned under Electricity, of

rhythmical exercise of the muscles during the application of the
galvanic current, is worthy of further trial, as it combines the two
forms of treatment hitherto found most successful.

Internal and External Medication.—Generally speaking, drugs are of

comparatively little value in the treatment of these affections. This
statement does not apply to those cases where the symptoms are
produced by some constitutional disorder, or where there is some
other well-recognized affection present which does not stand in
relation to these neuroses as cause and effect.

In any case where an accompanying disorder can be discovered

which is sufficient in itself to depress the health, the treatment
applicable to that affection should be instituted, in the hope, however
unlikely it is to be fulfilled, that with returning health there will be a
decrease of the copodyscinesia. In the majority of cases no
constitutional disease can be detected, and it is in these that internal
medication has particularly failed.

The following are some of the remedies that have been employed:
Cod-liver oil, iron, quinine, strychnia, arsenic, ergot, iodoform, iodide
and bromide of potassium, nitrate of silver, phosphorus,
physostigma, gelsemium, conium, and some others.

Hypodermic Medication.—Atropia hypodermically, as first suggested

by Mitchell, Morehouse, and Keen117 in the treatment of spasmodic
affections following nerve-injury, has been used with good effect in
those cases where there is a tendency to tonic contraction; it should
be thrown into the body of the muscle. Vance118 speaks very
favorably of one-sixtieth of a grain of atropia used in this manner
three times a week. Morphia, duboisia, and arsenic in the form of
Fowler's solution have been used hypodermically with but little effect.
Rossander119 reports a cure in one month of a case of two years'
duration by the hypodermic use of strychnia. Onimus and Legros120
used curare in one case without effect.
117 Gunshot Wounds and Other Injuries to Nerves, Philada., 1864.

118 Reuben A. Vance, M.D., “Writers' Cramp or Scriveners' Palsy,” Brit. Med. and
Surg. Journal, vol. lxxxvii. pp. 261-285.

119 J. C. Rossander, Irish Hosp. Gazette, Oct. 1, 1873.

120 Loc. cit.

Local Applications.—The apparent benefit following the local

application of lotions, etc. to the arms in some cases appears to be
as much due to the generous kneading and frictions that accompany
them as to the lotions themselves. Onimus and Legros, believing the
lesion to be an excitability of the sensitive nerves at the periphery,
employed opiated embrocations, but report amelioration in one case
only.

When there are symptoms of congestion of the nerves or of neuritis,

then the proper treatment will be the application of flying blisters, or
the actual cautery very superficially applied to the points of
tenderness from time to time, so as to keep up a continual counter-
irritation. This treatment may be alternated with the application of the
galvanic current (descending, stabile, as previously mentioned) or
combined with it. As these conditions are often found in nervous
women, care should be taken lest this treatment be too vigorously
carried out.

Considerable relief has been reported from the use of alternate hot
and cold douches to the affected part—a procedure which is well
known to do good in some cases of undoubted spinal disease; the
application peripherally applied altering in some way, by the
impression conveyed to the centres, the nutrition of the spinal cord.

Tenotomy.—Tenotomy has been but little practised for the cure of

these affections. Stromeyer121 cut the short flexors of the thumb in a
case of writers' cramp without any benefit, but in a second case,
where he cut the long flexor of the thumb, the result was a cure.
Langenbeck122 quotes Dieffenbach as having performed the
operation twice without success, and states that there has been but
one observation of complete success, and that was the one of
Stromeyer. Aug. Tuppert123 has also performed this operation, and
Haupt124 advises it as a last resource.
121 “Crampe des Écrivains,” Arch. gén. de Méd., t. xiii., 1842, 3d Series, p. 97.

122 Ibid., t. xiv., 1842, 3d Series.

123 Quoted by Poore, loc. cit.

124 “Der Schreibekrampf,” rev. in Schmidt's Jahrbuch, Bd. cxv., p. 136, 1862.

Very few would be willing to repeat the experiment in a true case of

copodyscinesia after the failures above enumerated, for the
temporary rest given the muscle does not prove of any more service
than rest without tenotomy, which has failed in all the more advanced
cases, which are the only ones where tenotomy would be thought of.

Nerve-Stretching.—It is curious that no cases have been reported (at

least I have not been able to discover them) of nerve-stretching for
aggravated cases of copodyscinesia, as the operation has been
performed in several cases of local spasm of the upper extremity
following injuries to the nerves.

Von Nussbaum125 alone mentions the operation, and states that it

has been of no avail, but gives no references; he previously126
stretched the ulnar nerve at the elbow and the whole of the brachial
plexus for spasm of the left pectoral region and of the whole arm,
following a blow upon the nape of the neck; the patient made a good
recovery.
125 Aerztliches Intelligenzblatt, Munich, Sept. 26, 1882, No. 39, p. 35.

126 London Lancet, vol. ii., 1872, p. 783.

This operation, according to an editorial in the American Journal of
Neurology,127 has been performed seven times for spastic affections
of the arm with the following results: 2 cures (1 doubtful), 3 great
improvement, and 2 slight relief.
127 Am. Journ. of Neurology and Psychiatry, 1882.

This procedure would seem to be indicated in those cases of

copodyscinesia where spasms are present which have a tendency to
become tonic in their character, where other means of treatment
have failed. One such case has fallen under the writer's notice,
which, on account of its singularity and the rarity of the operation,
seems worthy of record. The patient is a physician in large practice,
and his account, fortunately, is more exact than it otherwise would
be:

—— ——, æt. 36. Paternal uncle had a somewhat similar trouble in

right arm, father died of paralysis agitans, and one brother has
writers' cramp. From nine to twelve years of age he was considered
an expert penman, and was employed almost constantly, during
school-hours, writing copies for the scholars. At the age of eleven he
began to feel a sense of tire in right forearm and hand when writing;
soon after this the flexors of right wrist and hand began to contract
involuntarily and become rigid only when writing. He remembers
being able to play marbles well for two years after the onset of the
first symptoms. The trouble gradually increased until every motion of
the forearm became involved. At the age of nineteen he became a
bookkeeper, using his left hand, but at the end of one year this
became affected also. Since then both arms have been growing
gradually worse, and at one time exhaustion would bring on pain at
the third dorsal vertebra. At the age of thirty a period of
sleeplessness and involuntary contractions of all the muscles of the
body came on, accompanied by difficulty in articulation from
muscular inco-ordination. After persistent use of the cold douche to
spine these symptoms ameliorated, but the general muscular
twitching sometimes occurs yet, and overwork brings on spasm of
the extensors of the feet. The condition of his arms in December,
1882, was as follows: At rest the right forearm is pronated, the wrist
completely flexed and bent toward the ulnar side, the thumb is
slightly adducted, and the fingers, although slightly flexed, are
comparatively free, enabling him to use the scalpel with dexterity.
This contraction can be overcome by forcibly extending the fingers
and wrist and supinating forearm, but if the arm be now placed in
supination the following curious series of contractions occur,
occupying from one to two minutes from their commencement to
their completion: gradually the little finger partially flexes, then the
ring, middle, and fore finger follow in succession; the wrist then
slowly begins to flex and to turn toward the ulnar side, and finally the
arm pronates, in which position it will remain unless disturbed. The
contraction is accompanied by a tense feeling in the muscles, but is
painless. The left arm behaves in a somewhat similar manner, and if
this is placed in supination a gradual pronation of the arm begins;
then follows the flexion of the fingers, commencing with the little
finger and ending with the thumb; the wrist also flexes, but not as
much as the right, although the flexion of the fingers is more marked.
There is no pain on pressure over muscles or nerves. The extensor
muscles of both arms, although weaker than normal, are not
paralyzed, those of the right responding more readily to both faradic
and galvanic currents than do the left. There is no reaction of
degeneration. The flexors respond too readily, the right showing the
greatest quantitative increase.

In 1879, while abroad, his condition being essentially as above

described, he consulted Spence of Edinburgh, who as an experiment
stretched the left ulnar nerve at the elbow; immediately after the
operation the muscles were paralyzed and the arm remained quiet;
in twenty-four hours the nerve became intensely painful, and
remained so, day and night, for three weeks; this gradually subsided,
and ceased with the healing of the wound two weeks later. Forty-
eight hours after the operation the spasm of the muscles returned,
and in a short time became as bad as ever, proving the operation to
have been a failure.
An interesting point to decide in this case is whether the symptoms
point to an abnormal condition of the nerve-centres, first manifesting
itself in difficulty of writing, or whether the constant writing induced a
superexcitability (for want of a better term) of the spinal cord in a
patient markedly predisposed to nervous troubles. This last
hypothesis I believe to be the correct one.

It might be considered at first sight that the symptoms presented by

this patient were due to a paralytic condition of the extensors, and
not a spasm of the flexors, or at least that the latter was secondary
to the former. While the extensors are somewhat weaker than
normal from want of use, a careful study of the mode of onset of this
affection and the symptoms presented later prove this idea to be
erroneous.

In regard to the operation and its results, it seems that a fairer test of
the efficacy of nerve-stretching in this case would have been made if
the median and not the ulnar nerve had been stretched, as the latter
only supplies in the forearm the flexor carpi ulnaris and the inner part
of the flexor profundus digitorum, while the former supplies the two
pronators and the remainder of the flexor muscles.

Of the mode of action of this operation we are still much in the dark,
but it would seem to be indicated in any case where the contractions
are very marked and tonic in their nature—not, however, until other
means have failed to relieve.

In the ordinary forms of copodyscinesia, it is needless to say, the

operation would be unjustifiable.

Mechanical Appliances.—Most of the prothetic appliances have

been devised for the relief of writers' cramp, the other forms of
copodyscinesia having received little if any attention in this direction.
The relief obtained by their use is usually but temporary, especially if
the patient attempts to perform his usual amount of work, which is
generally the case.
These instruments are of undoubted benefit when used judiciously in
conjunction with other treatment, as by them temporary rest may be
obtained, or in some cases the weakened antagonists of cramped
muscles may be exercised and strengthened. They all, without
exception, operate by throwing the work upon another set of
muscles, and failure is almost sure to follow their use if they alone
are trusted in, as the new set of muscles sooner or later becomes
implicated in the same way that the left hand is apt to do if the whole
amount of work is thrown upon it.

To accurately describe these instruments is out of place in this

article: those wishing to study this branch of the subject more fully
are referred to the article by Debout,128 where drawings and
descriptions of the most important appliances are given.
128 “Sur les Appareils prothetiques, etc.,” Bull. de Thérap., 1860, pp. 327-377.

Their mode of action may be considered under the following heads:

I. Advantage is taken of muscles as yet unaffected, which are made

to act as splints (so to speak) to those affected, greater stability
being thus given and cramp controlled when present.

Under this head may be mentioned the simple plan of placing a

rubber band around the wrist, wearing a tight-fitting glove, or
applying Esmarch's rubber bandage with moderate firmness to the
forearm. Large cork pen-holders, by distributing the points of
resistance over a larger surface, are thus much easier to hold than
small, hard pen-holders.

Two of the instruments devised by Cazenave—one, consisting of two

rings joined together in the same plane (to which the pen-holder is
attached), and through which the index and middle fingers are thrust
as far as the distal joints; and another consisting of two rings of hard
rubber, one above the other, sufficiently large to receive the thumb,
fore and middle fingers, which are thus held rigidly in the writing
position—act in this manner, and are used when the cramp affects
the thumb or fore finger.
II. The cramp of one set of muscles is made use of to hold the
instrument, the patient writing entirely with the arm movement.

The simple plan of grasping the pen-holder in the closed hand, as

previously described, or of thrusting a short pen-holder into a small
apple or potato, which is grasped in the closed hand, occasionally
affords relief and acts in this way. The instruments of Mathieu,
Velpeau, Charrière, and one by Cazenave are based upon this
principle. The first consists of two rings rigidly joined together about
one inch apart, one above the other, through which the fore finger is
thrust, and of a semicircle against which the tip of the thumb is
pressed; the pen-holder is attached to a bar adjoining the semicircle
and rings. Velpeau's apparatus consists of an oval ball of hard
rubber carrying at one extremity the pen-holder at an angle of 45°;
the ball is grasped in the closed hand, and the pen-holder allowed to
pass between the fore and middle fingers. Charrière's instrument is a
modification of the last, having in addition to the ball a number of
rings and rests for the fixation of the fingers. The latter has also
devised an instrument consisting of a large oval ball of hard rubber;
this is grasped in the outstretched palm, which it fills, and is allowed
to glide over the paper; the pen-holder is attached to one side.
Cazenave's instrument is simply a large pen-holder with rest and
rings to fix the fingers.

III. The instrument prevents the spasm of the muscles used in

poising the hand from interfering with those used in forming the
letters.

One of the instruments devised by Cazenave acts in this way: it

consists of a small board, moving upon rollers, upon which the hand
is placed; lateral pads prevent the oscillations of the arm due to
spasmodic action of the supinators. The pen-holder is held in the
ordinary manner.

IV. The antagonistic muscles to those affected by cramp are made to

hold the instrument, while the cramped muscles are left entirely free.
But one instrument acts in this manner—viz. the bracelet invented by
Von Nussbaum,129 which consists of an oval band of hard rubber to
which the pen-holder is attached. The bracelet is held by placing the
thumb and the first three fingers within it and strongly extending
them.
129 Aerztliches Intelligenzblatt, Munich, 1883, No. 39.

The inventor claims great success by its use alone, as the weakened
muscles are exercised and strengthened and the cramped muscles
given absolute rest.

Résumé of Treatment.—In the complicated cases of copodyscinesia

rest of the affected parts, as far as the disabling occupation is
concerned, must be insisted upon: this should be conjoined with the
use of the galvanic descending stabile current, combined with
rhythmical exercise of the affected muscles and of their antagonists,
and massage. Where there is evidence of a peripheral local
congestion or inflammation, this must be attended to; for instance, if
there is congestion of the nerves, or neuritis, flying blisters or the
actual cautery should be applied over the painful spots, followed by
the galvanic current. Where there is paralysis of one or more
muscles, with evidence of interference of nerve-supply, the faradic
current may be used with advantage.

Evidences of constitutional disease should lead to the employment

of the treatment suitable for those affections.
 RÉSUMÉ OF 43 CASES OF TELEGRAPHERS' CRAMP.

Age at time of onset:

Under 20 years 7
Between 20 and 30 25
Between 30 and 40 7
Doubtful 4—43

Average age 23.94 years.

Average age of males 24.22 years.
Average age of females 20.66 years.

Average length of time before the disease appeared after the

commencement of telegraphing was—
In males 7.27 years.
In females 4 years.
The shortest period being 6 months.
The longest period being 20 years.

Left arm implicated in 21

(Not counting case with amputation of right arm) 1
Never used left arm 8
Left arm not affected, although used 12
Doubtful 1—43

Percentage with left arm implicated 63.63

No. of cases with difficulty in telegraphing only 9

No. of cases with difficulty in writing only 0
No. of cases with difficulty in telegraphing most 22
No. of cases with difficulty in writing most 11
No. of cases with difficulty in both alike 1—43
Use of tobacco or alcohol:
No effect in 14
Bad effect in 16
Good effect (in moderation) in 3
Don't use either 10—43

Flushings in arm or face during work in 22

Brittleness of nails in 5
Emotional factor present in 29
Sympathetic movements in other parts in 9
Pain in back during work in 18
Trouble in performance of other acts in 19
Pain on pressure over nerve or muscle in 13

Cramp of flexor group of muscles:

In writing only 0
In writing most 3
In telegraphing only 1
In telegraphing most 5— 9
Cramp of extensor group of muscles:
In writing only 0
In writing most 0
In telegraphing only 4
In telegraphing most 7—11
Doubtful as to character of cramp 11
No cramp 12—43

Manner of telegraphing:
Arm resting on table 22
Arm raised from table 12
Alternating one with the other 7
Doubtful 2—43

Manner of writing:
 Arm movement 13
Finger movement 6
Combination of the two 24—43

TETANUS.

BY P. S. CONNER, M.D.

Tetanus (τεινω, to stretch) is a morbid condition characterized by

tonic contraction of the voluntary muscles, local or general, with
clonic exacerbations, occurring usually in connection with a wound.
Cases of it may be classified according to cause (traumatic or
idiopathic); to age (of the new-born and of those older); to severity
(grave and mild); or to course (acute and chronic), this latter
classification being the one of greatest value.

Though known from the earliest times, it is in the civil practice of

temperate regions of comparatively rare occurrence, and even in
military surgery has in recent periods only exceptionally attacked any
considerable proportion of the wounded.
Occurring in individuals of all ages, the great majority of the subjects
of it are children and young adults. Women seem to be decidedly
less liable to it than men. That this is due to sexual peculiarity may
well be doubted, since the traumatic cases are by far the most
numerous, and females are much less often wounded than males.
The traumatisms of childbed are occasionally followed by it
(puerperal tetanus).

That race has a predisposing influence would appear to be well

established; the darker the color, the greater the proportion of
tetanics. Negroes are especially likely to be attacked with either the
traumatic or idiopathic form.

Atmospheric and climatic conditions, beyond question, act powerfully

in, if not producing at least favoring, the development of tetanus.
Places and seasons in which there is great difference between the
midday and the midnight temperature, the winds are strong, and the
air is moist, are those in which the disease is most prevalent; and it
is because of these conditions that the late spring and early autumn
are the periods of the year when cases are most often seen.1
1 In his account of the Austrian campaign of 1809, Larrey wrote: “The wounded who
were most exposed to the cold, damp air of the chilly spring nights, after having been
subjected to the quite considerable heat of the day, were almost all attacked with
tetanus, which prevailed only at the time when the Reaumur thermometer varied
almost constantly between the day and the night by the half of its rise and fall; so that
we would have it in the day at 19°, 20°, 21°, and 23° above zero (75°–84° F.), while
the mercury would fall to 13°, 12°, 10°, 9°, and 8° during the night (50°–61° F.). I had
noticed the same thing in Egypt.”

Cold has, from the time of Hippocrates, been regarded as a great

predisposing if not exciting cause, and the non-traumatic cases have
been classed together as those a frigore. It is not, however, the
exposure to simply a low temperature that is followed by the disease,
but to cold combined with dampness, and quickly succeeding to a
temperature decidedly higher, as in the cool nights coming on after
hot days in tropical regions, or in the spring and fall seasons of
temperate latitudes, or in the cold air blowing over or cold water
dashed upon a wound or the heated skin. That such cold, thus
operating, does most usually precede the attack of tetanus is
unquestionable; and it has by many been held that without it no
traumatism will be followed by the disease. Observers generally are
agreed, with Sir Thomas Watson, that “there is good reason for
thinking that in many instances one of these causes (wound and
cold) alone would fail to produce it, while both together call it forth.”

In the low lands of hot countries (as the East and West Indies) the
disease is very frequently met with, at times prevailing almost
epidemically; and, on the other hand, it is rare in dry elevated
regions and in high northern latitudes, as in Russia, where during a
long military and civil experience Pirogoff met with but eight cases.
Trismus nascentium would seem to be an exception to the general
rule of the non-prevalence of tetanus in places far north, since, e.g.,
it has been at different periods very common in the Hebrides and the
small islands off the southern coast of Iceland. But these localities,
from their peculiar position, are not extremely cold, and their climate
is damp and variable; so that, even if the lockjaw of infants be
accepted as a variety of true tetanus, the geographical exception
indicated is but an apparent one.

Traumatic cases are greatly more numerous than idiopathic, and no

class of wounds is free from the possibility of the supervention of
tetanus. Incised wounds are much less likely to be thus complicated
than either of the other varieties, though operation-wounds of all
sorts, minor and major, have been followed by this affection. So
frequently has it been associated with comparatively trivial injuries
that it has become a common belief that the slighter the traumatism
the greater the danger of tetanus. That this is not true the records of
military surgery abundantly show. Wounds of the lower extremity are
much graver in this respect than those of the upper. Injuries of the
hand and feet, especially roughly punctured wounds of the palmar
and plantar fasciæ (as, e.g., those made by rusty nails), have long
been regarded as peculiarly liable to develop the disease, and
accidents of this nature always give rise to the fear of lockjaw.
Though there can be no question but that more than one-half of the
cases of tetanus in civil life are associated with wounds of these
localities, yet the number of such injuries is so much greater than of
those of other parts of the body that the special liability of the
subjects of them to become tetanic may well be questioned. In this
connection it is a significant fact that during our late war of perhaps
12,000 or 13,000 wounds of the hand, only 37 were followed by
tetanus, and of 16,000 of the foot, but 57. A few years ago numerous
cases of tetanus were observed in our larger cities complicating
hand-wounds produced by the toy pistol—injuries that were often
associated with considerable laceration of the soft parts, and
generally with lodgment of the wad.

Not even the complete cicatrization of a wound altogether protects

against the occurrence of the disease, the exciting cause of which,
under such circumstances, is probably to be found in retained
foreign bodies or pent-up fluids.

ETIOLOGY.—Almost universally regarded as an affection of the central

nervous system, inducing a heightened state of the reflex irritability,
though some have maintained that the reflex excitability of the
medulla and the cord is actually lessened, how such affection is
produced is unknown; and it is an unsettled question whether it is
through the medium of the nerves or the vessels, whether by
ascending inflammation, by reflected irritation, or by the presence of
a septic element or a special micro-organism in the blood.

That the disease is due to ascending neuritis finds support in the

congested and inflamed state of the nerves leading up from the
place of injury (affecting them in whole or in part, it may be in but a
few of their fibres), and in the inflammatory changes discoverable in
the cord and its vessels. But time and again thorough and careful
investigation by experienced observers has altogether failed to
detect any alterations in the nerves or pathological changes in the
cord, other than those that might properly be attributed to the
spasms, the temperature, or the drugs administered. The symptoms
of acute neuritis and myelitis (pain, paralyses, and later trophic
changes) are not those which are present in cases of tetanus. The
evidences of inflammation of the cord are most apparent, not in that
portion of it into which the nerves from the wounded part enter, but,
as shown by Michaud, so far as the cellular changes in the gray
matter are concerned, always in the lumbar region, no matter where
the wound may be located.

The much more generally accepted theory of reflex neurosis is

based upon the association of the disease with “all forms of nerve-
irritation, mechanical, thermal, chemical, and pathological;” upon the
direct relation existing between the likelihood of its occurrence and
the degree of sensibility of the wounded nerve;2 in the, at times, very
short interval between the receipt of the injury and the
commencement of the tetanic symptoms; in the local spasms
unquestionably developed by nerve-pressure and injury; in the
primary affection of muscles at a distance from the damaged part; in
the already-referred-to absence of the structural lesions of
inflammation; and in the relief at times afforded by the removal of
irritating foreign bodies, the temporary cutting off of the nerve-
connection with the central organs, or the amputation of the injured
limb. But that something more than irritation of peripheral nerves is
necessary to the production of tetanus would seem to be proved by
the frequency of such irritation and the rarity of the disease; by the
not infrequent prolonged yet harmless lodgment of foreign bodies,
even sharp and angular ones, against or in nerves of high
sensibility;3 by the primary affection of the muscles about the jaws,
and not those in the neighborhood of the wound; by the almost
universal failure to produce the affection experimentally, either by
mechanical injuries or by electrical excitations; by certain well-
attested instances of its repeated outbreak in connection with a
definite locality, a single ship of a squadron, a particular ward in a
hospital, or even bed in a ward; by the usual absence of that pain
which is the ordinary effect of nerve-irritation; and by the small
measure of success which has attended operations, even when
early performed, permitting the taking away of foreign bodies
pressing upon or resting in a nerve, interrupting the connection with
the cord, or altogether removing the wound and its surroundings.
Even in the idiopathic cases—many of which, it would at first sight
appear, can be due only to reflected irritation—another explanation
of the mode of their production may, as we will see, be offered.
2 According to Gubler, the danger is greatest in wounds of parts containing numerous
Pacinian corpuscles.

3 Heller has reported a case in which a piece of lead was lodged in the sheath of the
sciatic nerve. Though chronic neuritis resulted, the wound healed perfectly. Two years
later, after exposure while drilling, the man was seized with tetanus and died of it.

The so-called humoral theory would find the exciting cause of the
disease in a special morbific agent developed in the secretions of the
unbroken skin or the damaged tissues of the wound, or introduced
from without and carried by the blood-stream to the medulla and the
cord, there to produce such cell-changes as give rise to the tetanic
movements. It finds support in the unsatisfactory character of the
neural theories; in the strong analogy in many respects of the
symptoms of the disease to the increased irritability and muscular
contractions of hydrophobia and strychnia-poisoning, or those
produced by experimental injections of certain vegetable alkaloids; in
the recent discoveries in physiological fluids, as urine and saliva, of
chemical compounds,4 and in decomposing organic matter of
ptomaïnes capable of tetanizing animals when injected into them; in
the rapidly-enlarging number of diseases known to be, or with good
reason believed to be, consequent upon the presence of peculiar
microbes; in the more easy explanation by it than upon other
theories of the ordinary irregularity and infrequency of its occurrence,
its occasional restriction within narrow limits, and its almost endemic
prevalence in certain buildings and even beds; in the extreme gravity
of acute cases and the protracted convalescence of those who
recover from the subacute and chronic forms; in the very frequent
failure of all varieties of operative treatment; and in the success of
therapeutic measures just in proportion to their power to quiet and
sustain the patient during the period of apparent elimination of a
poison or development and death of an organism.
4 Paschkie in some recent experiments found that the sulphocyanide of sodium
applied in small quantities caused a tetanic state more lasting than that caused by
 strychnia.

This theory is as yet unsupported by any positive facts. Neither

septic element nor peculiar microbe has been discovered.5 Failure
has attended all efforts to produce the disease in animals by
injecting into them the blood of tetanics. There is no testimony
worthy of acceptance of the direct transmission of the disease to
those, either healthy or wounded, coming in contact with the tetanic
patient; nor can much weight be attached to such reports as that of
Betoli of individuals being attacked with it who had eaten the flesh of
an animal dead of it.
5 Curtiss of Chicago thought that he had found a special organism, but further
investigation showed that it was present in the blood of healthy members of the family
and in the water of a neighboring pond.

The ordinary absence of fever has been thought to prove the

incorrectness of this theory, but increased body-heat is not a
symptom of rabies or strychnia-poisoning, of the tetanic state
following the injection of ptomaïnes, or of cholera—a disease very
probably dependent upon the presence and action of a bacillus.
Martin de Pedro, regarding the affection as rheumatic in character,
located it in the muscles themselves, there being produced, through
poisoning of the venous blood, a muscular asphyxia.

MORBID ANATOMY.—The pathological conditions observed upon

autopsy in the wound, the nerves, the central organs, and the
muscles, have been so various and inconstant that post-mortem
examinations have afforded little or no definite information respecting
the morbid anatomy of the disease. Many of the reported lesions
have unquestionably been dependent upon cadaveric changes or
defective preparation for microscopic study. The wound itself has
been found on the one hand healthy and in due course of
cicatrization,6 on the other showing complete arrest of the reparative
process (“the sores are dry in tetanus,” wrote Aretæus),7 or even
gangrenous, with pus-collections, larger or smaller, in its immediate
vicinity, usually in connection with retained foreign bodies.