MONOGRAPHS OF 
 
 THE ROCKEFELLER INSTITUTE 
 
 FOR MEDICAL RESEARCH 
 
 No. 8 
 
 July 31, 1918 
 
 BOTULISM 
 
 A ClinicaS'and Experimental Stxidy 
 
 By 
 
 ERNEST C. DICKSON, M.D. 
 
 
 NEW YORK 
 
 The RocKcFtLLER Institute for Medical Research 
 
 1918 
 
Cornell University Library 
 RA 1260.D55 
 
 Botulism; a clinical and experimental stu 
 
 3 1924 000 296 339 
 
 LIBRARY 
 
 NEW YORK STATE VETERINARY COLLEGE 
 
 ITHACA, N. Y. 
 
MONOGRAPH No. 8 
 
 BOTULISM 
 
 A CLINICAL AND EXPERIMENTAL STUDY 
 
 BY 
 
 ERNEST C. DICKSON, M.D. 
 
 NEW YORK 
 The Rockefeller institute for Medical Research 
 
 1918 
 
 

MONOGRAPH OF THE ROCKEFELLER INSTITUTE FOR MEDICAL RESEARCH, 
 
 NO. 8, July 31, 1918. 
 
 BOTULISM. 
 A Clinical and Experimental Study. 
 
 By ER2OTST C. DICKSON, M.D. 
 
 (From the Division of Medicine of Stanford University Medical School, San 
 
 Francisco.) 
 
 Plates 1 to 10. 
 
 (Received for publication-, September 5, 1917.) 
 
 Introduction 2 
 
 Historical review 4 
 
 European literature , 4 
 
 Incidence and geographical distribution 4 
 
 Types of foodstuffs infected ; 5 
 
 Theories as to etiology 8 
 
 Mortality 13 
 
 American literature 13 
 
 Report of new cases 24 
 
 Symptomatology and course 38 
 
 Diagnosis 49 
 
 Mortality of American cases 51 
 
 Treatment 52 
 
 Bacillus botulinus and its toxin 54 
 
 Pathology 67 
 
 Record of experiments 81 
 
 Critical review 93 
 
 Conclusions 106 
 
 Bibliography 107 
 
 Explanation of plates 115 
 
INTRODUCTION. 
 
 The term BotuUsmus (botulus, a sausage) was coined by the physi- 
 cians of Southern Germany in the beginning of the XlXth century, to 
 apply to a peculiar type of food-poisoning which was caused by the. 
 ingestion of spoiled sausages. Synon5mious terms which are in use 
 in the literature are allantiasis and Wurstvergiftung. When the term 
 was first appHed, its use was restricted to cases of sausage-poisoning, 
 but gradually it became known that the symptom complex which is 
 produced by sausage-poisoning may also be produced by poisoning 
 from preserved, usually smoked, meat and fish, and that it may be 
 closely simulated by poisoning from cheese. For many years its 
 application was often inaccurate as there was much confusion con- 
 cerning the different types of illness which were known to follow the 
 ingestion of spoiled foods; but in 1895 van Ermengem succeeded in 
 isolating a bacterium from ham which had caused the illness of twenty- 
 three persons, in all of whom the symptoms were those of true botulism, 
 and was able to prove that in botulism the poisoning is due to a toxin 
 which is produced when the bacillus is grown upon suitable culture 
 medium. The present day significance of the term botulism is there- 
 fore restricted to poisoning by the toxin of Bacillus botulinus, and 
 includes poisoning from any foodstuff in which the bacillus has grown 
 and has produced its toxin. 
 
 The investigation which is recorded in this report was commenced 
 in December, 1913, at which time twelve persons were poisoned at a 
 banquet in a student's club-house at the Leland Stanford Junior 
 University. The clinical picture and the course of the illness were in 
 all respects identical with those of botulism. The outbreak was of 
 peculiar interest in that the only article of food of which all the patients 
 had partaken was not meat or fish, but was salad prepared from string 
 beans which had been canned at the home of one of the members of the 
 club. A further point of interest was revealed when histologic exami- 
 nation was made of the tissues of the one patient who died as a result 
 of the poisoning. Professor Ophiils, of the Stanford University Med- 
 
 2 
 
ERNEST C. DICKSON -3 
 
 ical School, observed a peculiar t3^e of thrombosis in the blood 
 vessels of the meninges and of the brain tissue, a lesion which had not 
 previously been described in victims of poisoning from botulism. 
 Proof that the illness was due to the ingestion of the toxin of Bacillus 
 botulinus was lacking, as there were no remnants of the salad which 
 could be examined, and Bacillus botulinus was not recovered from the 
 organs of the patient who died. 
 
 My experimental work was undertaken to determine whether it is 
 possible that the toxin of Bacillus botulinus may be formed in canned 
 string beans in which there is no addition of protein of animal origin, 
 and whether the thrombosis is a lesion which is characteristic of 
 poisoning by the toxin. Subsequently, the investigation was extended 
 to include other vegetables and fruits, and the importance of deter- 
 mining whether the toxin may be formed in foodstuffs which are not 
 of animal origin was emphasized by the fact that there were several 
 more outbreaks of a similar type in various portions of the States of 
 Cahfornia and Oregon, all of them following the ingestion of home- 
 canned vegetables or fruits. 
 
 It has been thought that botulism is exceedingly rare in this country. 
 It is only in the larger Systems of Medicine that the symptomatology 
 is discussed in detail, and there are very few reported cases in the 
 American literature :n which the diagnosis has been made. It has 
 been generally understood that the intoxication is one of the group of 
 poisonings from contaminated meat, and the importance of vegetables 
 and fruits as a possible source of poisoning has not been recognized. 
 
 Because of the fact that there is no complete review of the history 
 of botulism in the English language, and because of the importance 
 which this type of food-poisoning has assumed in the United States, 
 particularly upon the Pacific Coast, the subject is discussed in much 
 greater detail than would otherwise be justifiable. 
 
HISTORICAL REVIEW, 
 
 EUROPEAN LITERATURE. 
 
 Incidence and Geographical Distribution. 
 
 Botulism has been recognized by German physicians since the latter part of 
 the XVIIIth century. The first recorded Case occurred in 1735 (1), and others 
 were described in 1755 (2) and 1789 (3); but the outbreak which seems to have 
 attracted the attention of the medical profession occurred in 1793 (4), in Wildbad 
 in Wiirtemberg, where thirteen persons became ill and six died after eating 
 " Schweinsmagen" or "Blunzen," sausage which was packed in the stomach of a 
 hog, and which contained a great deal of blood. The number of cases rapidly 
 increased after this time and became so numerous that in 1802 Jaeger (5) pub- 
 lished an official warning from Stuttgart, in which he detailed the symptoms of 
 the condition, drew attention to the danger of eating spoiled sausages, and gave 
 instructions concerning the proppr method of preparing and curing sausages. 
 
 In spite of this warning the number of cases of sausage-poisoning in Wiirtem- 
 berg steadily increased. In 1815 voft Autenrieth (6) published a report of a series 
 of four cases which had been observed by two of his students, Kerner and Stein- 
 bach. In 1820 Kerner (7) published a monograph in which he recorded seventy- 
 six cases of sausage-poisoning, of which thirty-seven had been fatal; and in 1822 
 he published a second monograph (8) in which he recorded eighty-four new cases 
 of which forty-seven were fatal. In 1824 Weiss (9) reported twenty-nine new 
 cases, of which three were fatal, and in 1828 Dann (10) recorded that, between 
 the years 1793 and 1827, there had been 234 cases of sausage-poisoning in Wiir- 
 temberg, of which 110 were fatal. 
 
 The rapid increase in the number of recorded cases was largely due to the 
 efforts of Kerner, who had been instrumental in having laws enacted which re- 
 quired the registration of all cases of sausage-poisoning within the Kingdom of 
 Wiirtemberg. He was so impressed with the importance of this type of food- 
 poisoning in Wiirtemberg that he wrote: "Es ist moglich, dass in einem gleich 
 grossen Landstriche der tropischen Lander nicht viel mehr Menschen durch 
 Schlangengift, als wie bei uns durch diess unselige ^Wurstgift siech und getodtet 
 werden" (7). 
 
 The earlier cases were confined to Wiirtemberg and to the adjoining portions 
 of Baden and Bavaria, but gradually isolated cases were recorded in other por- 
 tions of Germany. In 1821 Kahleis (11) reported the first case in Anhalt, in 
 Grobzig, and, later, cases were also described in Dessau. In the interval between 
 1820 and 1830 several outbreaks were described in Westphalia, and in 1822 and 
 
EEJSTEST C. DICKSON 5 
 
 in 1828 official warnings were published by the authorities at Arnsberg (12). 
 The majority of cases, however, continued to occur in Wiirtemberg, and in 1852 
 Schlossberger (13) recorded that between 1800 and 1850 there had been about 
 400 cases of sausage-poisoning in Wiirtemberg, of which 150 had been fatal, 
 while in 1862 von Faber (14) reported that between 1832 and 1862 there had 
 been at least 82 cases, of which 19 had died. Subsequent to 1860 the occurrence 
 in Wiirtemberg has been less frequent, but cases in other portions of Europe 
 have been more frequent. Senckpiehl (15) in 1887 collected 412 cases, 165 fatal, 
 which had occurred during the period between 1789 and 1886, and in 1909 Wos- 
 nitza (16) added 59 additional cases, of which only four died. Several outbreaks 
 have been described since 1909. In 1913 Biirger (17) recorded twelve cases of 
 whjch five died, and Schumacher (18) described six cases of which one died. 
 In 1915 Paulus (19) reported four cases of which two died, and Hoeg (20) recorded 
 one in Denmark which recovered. The most recent report which I have found 
 is that of Schede (21), 1916, who described five cases of which two died. 
 
 The collection of cases by Senckpiehl (15), Kaatzer (22), Wosnitza (16), and 
 Paulus (19) includes many which occurred in various portions of Germany and a 
 few from other countries. Cases are recorded which occurred in Wiirtemberg, 
 Baden, Bavaria, Prussia, Pomerania, Hessen, Westphalia, Saxony, Anhalt, Han- 
 over, Posen, and Silesia. Several reports occur from Russia, Austria, Hungary, 
 and Denmark. One outbreak was described in England in 1860 (23), and one in 
 France in 1875 (24), in which it was stated that the poisonous sausages had been 
 prepared in England. Two other outbreaks were described in France, one in 
 Holland, and two, including the one in which van Ermengem established the 
 etiology of the poisoning, occurred in Belgium. 
 
 A review of the medical literature indicates that outbreaks of botulism have 
 been considerably less frequent in Germany during the pa^t 50 years, but in an 
 elaborate discussion of food-poisoning in which the data were obtained from 
 official records, Mayer (25), in 1913, showed that it is still comparatively fre- 
 quent. The following table is summarized from one in his report:' 
 From 1793-1820, 76 cases, 37 fatal. 
 " 1820-1822, 98 " 34 " 
 " 1822-1886, 238 " 94 " 
 Since 1886, about 800 " about 200 fatal. 
 
 Types of Foodstuffs Infected. 
 
 The symptoms of botulism have developed after the ingestion of various kinds 
 of foods. In the report by Jaeger (5) in 1802 only blood sausages, " Blutwurste," 
 were mentioned, but in 1815 von Autenrieth (6) reported an outbreak in which 
 liver sausages, " LeberwUrste,'' were the cause of the poisoning. Weiss (9) in 1827 
 described a case which developed after the ingestion of a sausage prepared from 
 
 1 Mayer (25), p. 57. 
 
BOTULISM 
 
 goat blood and sheep plucks, and in 1830 Horn (26) referred to cases due to 
 " Schlackwurst," prepared from pork to which is added veal and calf blood, 
 and "Fresskopf" prepared from livers or tongues and meat from the heads of 
 hogs. In practically all the subsequent outbreaks in which sausages have been 
 responsible, the sausages were of the varieties which were recognized so early. 
 
 Kerner (7) noted that meat sausages were less frequently infected than blood 
 or liver sausages, and he believed that this was due to the fact that they were 
 not cooked before they were smoked. Schlossberger (13) agreed that meat 
 sausages were rarely affected, but he noted that they were usually packed in 
 small casings, and that, as they were more expensive, and were used chiefly by 
 the wealthier classes, they were more likely to be prepared by skDlful butchers 
 under cleanly conditions. All the authors agreed that sausages which were 
 packed in large casings, such as the stomach and large intestine, were more apt 
 to be poisonous than those which were packed in small casings, and as early as 
 1824 Kerner (27) advised against the use of large casings. 
 
 Outbreaks due to the eating of smoked ham were described as early as 1822 
 (IS), the one which was resjxinsible for the official warning in Arnsberg being 
 the first recorded. Hauff (28) in 1829 described a case in. which the patient had 
 eaten smoked pork, and numerous other authors have recorded cases in which 
 ham was responsible for the poisoning. Geiseler (29) in 1824, Thorer (30) in 
 1834, Ulrich (31) in 1882, Roth (32) in 1883, Groenouw (33) in 1890, van Ermen- 
 gem (34) in 1897 and in 1906 (87), Romer (35) in 1900, Blattmann (36) in 1909, 
 Burger (17) in 1913, Schumacher (18) in 1913, and Schede (21) in 1916, have 
 all placed the responsibility for the poisoning of their patients upon smoked 
 and pickled ham, and Roth also recorded one series of cases in which smoked 
 bacon was responsible. In Paulus' series (19) the poisoning was traced to poorly 
 salted pork 
 
 Autenrieth in 1833 and 1835 (37) referred to the similarity of the symptoms 
 of the sausage-poisoning of Wiirtemberg and those of the smoked fish-poisoning 
 ■of certain parts of Russia. In 1850 Jaechnichen (38) described a series of cases of 
 fish-poisoning in Russia and noted the close resemblance to botulism. Schreiber 
 (39) in Prussia in 1884, and Hirschfeld (40) in Pomerania in 1885, reported cases 
 in which the poisoning had been produced by herrings which had been cooked 
 and then preserved in vinegar. Von Anrep (41) in 1886, Schmidt (42) in 1890, and 
 Arustamoff (43) in 1891 reported outbreaks in Russia in which the poisoning 
 was caused by smoked sturgeon, and Tschel-nyschew (44) in 1889 in Russia, 
 and David (45) in 1899 in Germany, reported cases which followed the eating 
 of smoked herring. Arustamoff also recorded a series of cases which were poi- 
 soned by eating preserved salmon, and Fischer (46) in 1897 described an out- 
 break which followed the ingestion of crabs. 
 
 In all these cases of " Fischvergiftung" the symptoms were apparently identical 
 with those which occur in true botulism, and many authors, including Mayer, 
 identify this type of fish-poisoning with botulism. However, there has been 
 •considerable discussion as to whether this should be done. Schlossberger (13), 
 
ERNEST C. DICKSON 7 
 
 1852, believed that fish-poisoning and sausage-poisoning were similar but not 
 identical. Bohm (47), 1876, agreed with him. Erben (48) stated that the two 
 conditions ar§ apparently identical, but Esmein (49) does not think there is suffi- 
 cient proof to estabKsh identity. The question has apparently been settled by 
 Madsen (50) in Denmark, who isolated a bacillus from poisonous fish which was 
 identical with B. botulinus, thereby establishing that a certain type of fish-poi- 
 soning and botulism are identical. 
 
 Various other foodstuffs have been held responsible for poisoning of this type, 
 but it is doubtful whether in all, especially in the earlier cases, the condition 
 was really botulism. Kerner (27), 1824, and Siedler (51), 1827, recorded cases 
 in which the poisoning was caused by the eating of old goose fat, and Kerner re- 
 ferred to another case in which smoked fat beef was responsible. Krugelstein (52) , 
 1839, believed that butter, cheese, lard, smoked goose, flounders, and eels could 
 produce the poisoning. Romans (53), 1871, referred to cases which had been 
 produced by eating partridges, and Cohn (54) described one which followed the 
 eating of rabbit paste which had been preserved under fat. Senckpiehl (15), 
 1887, and Wosnitza (16), 1909, described cases in which the liver of venison was 
 at fault, and the latter author noted that persons who ate the heart of the same 
 animal were not affected. Senckpiehl also recorded a case in which the symptoms 
 followed the ingestion of stuffed goose, and Quincke (55), 1885, described one 
 in which home-canned duck was responsible. 
 
 The most interesting outbreak, in view of the findings recorded in this report, 
 occurred in Darmstadt in 1904 (56, 57), in which it was shown that the poisoning 
 was caused by a salad which had been prepared from home-canned white beans. 
 This is the only record in the European literature of the production of true bot- 
 ulism by a foodstuff of other than animal origin, and it was suggested by Land- 
 mann (58) that some pork must have been cooked with the beans, as otherwise 
 the toxin of botulism could not have been formed. 
 
 Observations which are of interest in view of the present day knowledge of 
 botulism were noted by many of the earlier investigators of this condition. Ker- 
 ner (7), 1820, emphasized the fact that sausages in which the casings were incom- 
 pletely filled did not become poisonous, and he concluded that exclusion of the 
 air was necessary for the formation of the poison. He also noted that sausages 
 which were packed in large casings, in which thorough smoking was difficult, 
 were more apt to become poisonous than those which were packed in small cas- 
 ings. Schlossberger (13), 1852, also referred to this fact and noted that the 
 poison was most often found in the center of the large sausages "wo der Abschluss 
 der ausseren Luft am ausgesprochensten ist." Kerner also noted that the 
 odor of the poisonous sausages was not putrid as in ordinary putrefaction, and 
 Schlossberger recorded that it had a peculiar cheese-like odor. Kerner, Weiss 
 (9), and others noted that the poison might be confined to certain portions of 
 the sausage and that there were peculiar cheese-like, crumbly areas which they 
 believed to be the poisonous portions. The taste was variously described as 
 sour, bitter, and burning. Kerner suggested that it was possible that cooking 
 
8 BOTULISM 
 
 the sausage might inhibit the action of the poison, and Jaechnichen (38), 1850, 
 recorded a series of cases in Russia in which those who ate the smoked fish with- 
 out cooking became ill, whereas those who cooked the fish remained well. 
 
 Theories as to Etiology. 
 
 Numerous theories as to the origin of this poison in sausages and meats have 
 been advanced by different authors. Perhaps the most fantastic theory was 
 that of Wunderlich (59) who recalled that in mythology it is recorded that when 
 slaves were tortured to death in the arena, their saliva became poisonous by the 
 formation of ogwa toffana, a substance which developed during the period of 
 fear and suffering which preceded death. Wunderlich stated that the method 
 of killing hogs in Wurtemberg was exceedingly cruel and slow, and he suggested 
 that there might be some poisonous substance produced in the saliva which was 
 analogous to aq^ia toffana, and that in some way the flesh of the animal might 
 become contaminated with this substance. It was believed at first that the 
 poison might be due to contamination from lead and copper vessels in which 
 the sausages had been cooked (60), but in 1793, when thirteen persons became 
 ill and six died after eating " Schweinsmagen" or "Blunzen" at Wildbad, the 
 attending physician was so impressed with the resemblance to belladonna-poison- 
 ing that he wrote : 
 
 ' 'Dass die an und fvir sich schadliche Blunze einen krankmachenden Einfluss auf die 
 gesunden Personen aufgeiibt habe, der todliche Ausgang aber durch ^ne betrachtliche 
 Gabe Belladonna (man habe sie nun im Aufguss in die Wurst oder in die Briihe aus Un- 
 vorsichtigkeit oder Bosheit gethan) verursacht worden sei" (4). 
 
 In 1799 another outbreak occurred in Hofe Mosburg in which five persons 
 became ill and two died, and, as a result of an investigation, the son of the family 
 was accused of having poisoned the sausage with henbane seeds. (61). In 1802 
 Jaeger (5), in the official warning which was published at Stuttgart, stated that 
 chemical examination of the poisonous sausages had faUed to show any evidence 
 of the presence of mineral poisons, and he suggested that the toxic action of the 
 sausages must have been due to the presence of some vegetable poison, probably 
 to some poisonous seeds which had been mistaken for spices. 
 
 The first comprehensive discussion of the subject was published by Kerner in 
 his two monographs which appeared in 1820 (7) and 1822 (8) respectively. The 
 rapid increase in the number of reported cases had demonstrated that the poison- 
 ing was not due to any accidental or deliberate contamination with mineral or 
 vegetable poisons, but that it depended upon the formation of some poison within 
 the sausage itself. The chief interest of Kerner's work lies in the fact that he 
 was the first to apply systematic, experimental investigation to the solution of 
 the problem. After it had become evident that the poison was formed within 
 the sausage, various theories were advanced, among which were two which seemed 
 to be the more generally accepted; viz., that prussic acid and pjnroligneous acid 
 had been formed within the sausage. 
 
ERNEST C. DICKSON 9 
 
 Emmert (62) had shown that prussic acid could be demonstrated in putrefy- 
 ing blood which was taken from cadavers, and he suggested that the blue-black 
 color of the blood in the bodies of persons who had died from sausage-poisoning 
 might be taken as evidence that the poisoning had been produced by prussic 
 acid. Kiihn (63) also held this opinion, for he wrote: 
 
 "Da die Blausaure aus Blutlauge erhalten werden kann, so war die Vermuthung, das 
 der in den verdorbenen Wiirsten sich so schadlich aussernde Giftstoflf nichts anderes als 
 Blausaure sei, sehr naturlich." 
 
 However, chemical examination of poisonous sausages and of the blood and 
 tissues of victims of sausage-poisoning failed to show any evidence of prussic 
 acid (Kerner, Weiss, and others), and Ruble (64) wrote: 
 
 ' 'Vorstehende Analyse beweist, dass diese Wiirste weder Blausaure, noch Metallgifte 
 enthalten, ob aber der der Gesundheit nachtheilige Stoff in der in diesen Wiirsten augen- 
 scheinlich enthaltenen Saure liege und ob dieselbe von einer eigenthumlichen Beschaffen- 
 heit sei, das ware noch durch weitere chemische und medicinische Versuche zu bestimmen." 
 
 Kerner undertook experimental investigation to determine this point, and he 
 showed that the s)rmptoms and signs of prussic acid-poisoning are quite unlike 
 those of sausage-poisoning, especially in the length of time which elapses before 
 the beginning of the symptoms, the long course, and the absence of odor in the 
 cadaver. He mentioned, however, that the sjnnptoms of sausage-poisoning niore 
 closely resemble those of prussic acid-poisoning than those of such plant-poison- 
 ing as is produced by belladonna in that there is a complet,e absence of mental 
 S3rmptoms. 
 
 The theory that sausage-poisoning was due to the presence of pyroligneous 
 acid was based upon the experiments of Cormack and Corneliani (65) who found 
 that it was present in the smoke of certain kinds of wood. It was thought that 
 during the process of smoking there was an accumulation of the acid in the sau- 
 sages, and the theory was apparently substantiated to a certain extent by the 
 fact that analysis of the poisonous sausages had always shown the presence of 
 some acid. 
 
 Kerner (7) recorded that a colleague had pickled meat by immersing it in 
 crude acetic acid and had then smoked it. One person who had eaten some of 
 the meat had suffered from vomiting and diarrhea, but had recovered, and another 
 had shown no symptoms. However, a cat had also eaten a portion of the meat, 
 and it died within a few hours. He also recorded experiments on rabbits and 
 cats in which he noted the symptoms and pathological findings after poisoning 
 with crude acetic acid. He foimd that herbivorous animals withstood much 
 larger doses than carnivorous animals, and he concluded that poisoning with 
 crude acetic acid produces symptoms and pathological conditions which are 
 somewhat similar to those produced by sausage-poisoning, although they are 
 not identical. 
 
10 BOTULISM 
 
 Kerner noted that the majority of cases of sausage-poisoning occurred in the 
 spring months, especially in April, at a time after there had been alternate spells 
 of freezing and thawing, and that sausages which had been prepared in the fall, 
 and had been subjected to alternate freezing and thawing, were especially liable 
 to undergo putrefaction, even though they had been boiled during the process of 
 preparation. He conducted an elaborate series of chemical investigations of 
 these sausages by various methods of distillation, and succeeded in isolating a 
 fatty acid substance which was extremely toxic for animals, and which produced 
 dysphagia, aphonia, and paralysis, symptoms which were analogous to those 
 of sausage-poisoning. He was also able to produce the same fatty acid sub- 
 stance, which he called " Leichensdure," from rancid fat aiid from the blood of 
 cadavers. 
 
 At first Kerner (8) believed that this "Leichensdure" was the toxic agent of 
 sausage-poisoning, but in 1823 Jaeger (66) expressed the opinion that the fatty 
 acid was not the toxic agent in the sausage, but that there was some nitrogen- 
 containing substance, such as picric acid or "Welther's Bitter," which was the 
 poisonous substance. Kerner (27) then modified his view to the extent of con- 
 sidering the fatty acid element an essential constituent which was closely related 
 to some nitrogen-containing substance, probably an alkaloid analogous to 
 Welther's Bitter. To substantiate this theory he pointed out that in such plants 
 as Veratrum the active principle consists of an alkaloidal substance which is 
 closely associated with certain fatty acids. 
 
 Kerner emphasized the point that the change which led to the formation of 
 this fatty acid compleix in sausages was not identical with ordinary pUtrefaction. 
 He noted that it was never found in sausages in which the casing was incom- 
 pletely filled, or in those which had not been boiled, and he assumed that for 
 its formation it was necessary that the fats should be cooked, possibly incom- 
 pletely, and that they should be excluded from the action of the air. He also 
 stated that if putrefaction subsequently occurred, the presence of the sulfur 
 dioxide gas would lead to a further reduction of the fatty acid complex into its 
 simpler, non-toxic constituents. 
 
 In 1824 Weiss (9), one of Kerner's students, reported a series of cases in which 
 he had made the observation that in the vomitus of the patients, and in the 
 contents of the stomachs and intestines of the cadavers, there was a peculiar 
 yellow substance which had a bitter taste, and which was not bile. In an extract 
 of the poisonous sausage, prepared by placing it in boiling water and allowing 
 it to stand for several days, a scum of a similar yellow substance collected on 
 the surface. Weiss believed that this substance was adipocere which had been 
 formed in the sausage, but Kerner, in a foot-note, stated that it was probable 
 that had chemical analysis been made, it would have shown that the yellow sub- 
 stance was a combination of Welther's Bitter and fatty acid. Weiss agreed with 
 Kerner that the toxic agent was probably a fatty acid with a closely associated 
 alkaloid, but he behaved that the action of the gastric juice was necessary before 
 it was rendered poisonous. 
 
ERNEST C. DICKSON 11 
 
 Various investigators attempted to confirm the observations of Kerner, but 
 without success. Buchner (67) conducted a series of investigations with a poi- 
 sonous sausage and with fresh lard, but failed to obtain any toxic product of 
 distillation. He succeeded in isolating a combination of acetic acid and an 
 ethereal oil to which he gave the name " Pyrofetiather," but Kerner had also 
 obtained a similar substance which he called "Fettsaures-Fett," and which was 
 different from his " Leichensdure." Kastner (68) also made chemical analysis 
 of sausage and concluded that " Wurstsaure" may be an intimate combination 
 of acetic acid or lactic acid with some of the products of putrefactive fermenta- 
 tion of animal material, which are themselves poisonous in small doses. Horn 
 (26), 1828, reported a series of experiments which he had made in collaboration 
 with Schrader, a chemist, in which they had attempted to produce an acid sub- 
 stance from lard, but without success. He concluded his discussion of the sub- 
 ject by saying "that he cannot concur in any of the opinions put forth as to the 
 nature of this poison; and that it appears to him to be some matter developed 
 by spontaneous putrefaction, and that this spontaneous putrefaction arises 
 perhaps in improperly made farcimina."^ 
 
 Various other authors advanced theories from time to time. Dann (10), 
 1828, believed that the poisonous material did not necessarily reside in an acid, 
 but was probably due to an " Empyreumatisches Oel," acrolein, or acrol, which 
 was not toxic in the pure state, but became poisonous when combined with various 
 fatty acids. Bodenmiiller (69), 1834, noted that there had never been any poi- 
 soning from " Leberwurst" which had not been smoked, and which had been pre- 
 pared during the winter months, and he concluded that the formation of the 
 poison must depend upon the method of smoking and heating the sausages. Kru- 
 gelstein (52), 1839, agreed with him. Tritschler (70) believed that the active 
 principle of the poisonous sausage was not a pure chemical compound. Lussana 
 (71), 1845, ascribed the poisoning to the presence of creosote which was formed 
 during the process of smoking the meat, by its combination with the crude acetic 
 acid in the smoke. Liebig (72), 1843, believed that the toxic action was due to 
 the action of a ferment, but Schlossberger (13), 1852, argued that this could not 
 be true, and suggested that it was due to the presence of an organic base belong- 
 ing to the group of alkaloids. 
 
 Heller (73), 1853, was the first to suggest that the poisonous material might 
 be due to the growth of a microscopic vegetable organism within the sausage, 
 and he described a phosphorescent, fatty growth or mould which he believed 
 to be responsible for the formation of the poison. Van den Corput (74), 1855, 
 believed that it was due to a low form of plant life, a mould or alga, which he 
 called "Sarcina botulina.'' Wittig (75), 1856, and Kasper (76), 1858, also believed 
 that a mould was at fault. 
 
 Subsequent to Zenker's discovery (77) in 1860 that Trichina spiralis is respon- 
 sible for a characteristic symptom complex in man, various authors advanced 
 
 2 Arrowsmith (26), p. 39. 
 
12 BOTULISM 
 
 the theory that sausage-poisoning is but a typie of trichinosis. However, Virchow 
 (78), 1864, and Husemann (79), 1866, showed that the two conditions are etio- 
 logically distinct; and Rupprecht (80), 1864, and Miiller (81), 1870, published 
 elaborate tables of differential diagnosis. 
 
 No new theory of importance was advanced until 1886 when von Anrep (41) 
 reported the isolation of a fixed base from the flesh of a sturgeon, to which he gave 
 the name " Ptomato-Atropin." He found that the base could be separated by 
 precipitation, and that it was extremely toxic for rabbits. He believed that this 
 was the toxic substance of poisonous sausages. In the same year Ehrenberg (82) 
 had isolated choline, neuridine, dimethylamine, and trimethylamine from a poison- 
 ous sausage, and he believed that the choline and neuridine were responsible for 
 the poisoning, although he was unable to reproduce the characteristic symptoms 
 in rabbits with either. Nauwerck (83), 1886, announced that putrefaction of a 
 type which could produce the substances which Ehrenberg had described, must be 
 of bacterial origin, and he reported the isolation of three forms of bacteria which 
 he had isolated from the same sausage. One of these was a bacillus which 
 liquefied gelatin and caused rapid putrefaction of sterile blood. An apparently 
 identical bacillus was isolated from the intestinal contents of a hog by Redner 
 (84), and Nauwerck beUeved that it was the true cause of the poisoning. He 
 explained the late appearance of the symptoms by assuming that the bacUli were 
 introduced into the intestinal tract with the sausage, and that they produced 
 putrefactive changes in the intestine, which, in turn, led to an autointoxication. 
 
 The actual cause of botulism was demonstrated by van Ermengem (34, 85, 
 86, 87) who studied a series of cases which occurred at EUezelles, in Belgium, 
 in 1894. In the EUezelles outbreak twenty-three persons became ill, and three 
 died, after eating ham which had been preserved in brine. From portions of 
 the ham and from the spleen and intestinal contents of one of the victims, van 
 Ermengem succeeded in isolating a Gram-positive, spore-bearing, anaerobic 
 bacillus to which he gave the name Bacillus botulinus. He found that infusions 
 of the macerated ham, and bouillon cultures of Bacillus botulinus, produced 
 the typical symptoms of botulism in guinea pigs, rabbits, cats, pigeons, and 
 monkeys. The bacillus itself is a saprophyte, and the poisoning is due to a toxin 
 which is formed when it is grown under anaerobic conditions. 
 
 Van Ermengem's observations have been confirmed by various authors. In 
 1900 Romer (35) isolated a similar bacillus from ham which had caused the ill- 
 ness of four persons. In 1901 Madsen (50) recorded the recovery of a bacillus 
 from fish which had caused the illness of three persons, and he stated that the 
 toxin of his strain was neutralized by the antitoxin of van Ermengem's strain. 
 In 1904 Landmann (58) demonstrated Bacillus botulinus in the beans which had 
 caused the poisoning in the Darmstadt outbreak, and in 1906 van Ermengem 
 recovered another strain from ham which had poisoned eight persons in West 
 Flanders. In 1913 Ornstein (88) reported that he had recovered the bacillus 
 from ham which had caused the death of two persons, and from the spleen of 
 
ERNEST C. DICKSON 13 
 
 one of the victims; and in 1913 Schumacher (18) reported that he had recovered 
 the bacillus from ham which had caused the illness of six. 
 
 Mortality. 
 
 The mortality of botulism has varied greatly in different outbreaks. In in- 
 dividual instances it has been extremely high, in some 100 per cent, but in others 
 it has been correspondingly low. Wosnitza (16) recorded a series of fifty-nine 
 cases of which only four died. In Kerner's (7, 8) series of 159 cases there were 
 84 deaths, a mortality of 52.8 per cent, and in Schlossberger's series (13) 
 of 400 cases there were 150 deaths, a mortality of 37.5 per cent. The most 
 complete collection of cases is that of Mayer (25) in 1913, in which he reports 
 812 cases of which 365 were fatal. The mortality of Mayer's series was 44.9 
 per cent. 
 
 AMERICAN LITERATURE. 
 
 A review of the American literature reveals the fact that very few 
 cases of botulism have been recognized in this country, but in a survey 
 of the available reported cases of food-poisoning during the past 25 
 years it was found that there have been a number of cases in which the 
 symptoms are more or less indicative of this condition. 
 
 In 1894 Seelye (89) reported an outbreak of food-poisoning in which fifteen 
 persons were affected after eating turkey at Thanksgiving dinner. The chief 
 symptoms were dizziness and disturbance of vision, and it is noted that the 
 pupils of all the patients were widely dilated. He believed that the poisoning 
 was due to belladonna, stramonium, or hyoscyamus which had been eaten by 
 the turkey, but Herzog (90) drew attention to the fact that all the symptoms 
 could be explained on the basis of ptomaine poisoning, and that this was a more 
 probable explanation of the poisoning. The rapidity of the onset of symptoms, 
 about three-quarters of an hour, and the rapid recovery practically exclude a 
 diagnosis of botulism, although the initial symptoms were somewhat suggestive. 
 
 In 1898 SpUler (91) reported a case of "neuritis from the ingestion of putrefy- 
 ing pork." The initial symptoms in this case were soon followed by dizziness 
 so severe that the patient was unable to stand. Symptoms of a polyneuritis 
 Boon developed and persisted for over 2 months. 
 
 The clinical course of this case does not suggest botulism, but the author refers 
 to the ganglion cell lesions of botulism as indicative of the changes that may be 
 produced in the central nervous system by food-poisoning, and he suggests that 
 similar lesions in the ganglion cells of the spinal cord could explain the symptoms 
 of his case. / 
 
 In 1899 Lewis (92) (Southern California) reported a case of poisoning after 
 
14 BOTULISM . 
 
 eating a beef tamale. Several hours after the meal the patient became ill, had 
 a severe headache, and soon developed vomiting and purging which persisted 
 for more than 24 hours. Ptosis, photophobia, deafness, and dysphagia followed, 
 and there was a diminution of "all the secretions." There was extreme pros- 
 tration and a tedious convalescence, and for a time there was paralysis of the 
 rectum and bladder. 
 
 A number of unusual symptoms were noted in this case, such as a persistent 
 high fever for several weeks, a hypereriiic blush of the skin of the trunk, swelling 
 of the joints, and a coarse scaly rash on the body. During the 4th week of the 
 illness there was coma and opisthotonos for several days. The author states 
 that typhoid fever was excluded by the type of fever and the laboratory tests. 
 
 There is some doubt as to whether this case was one of botulism complicated 
 by an intercurrent infection, a combination of events which is not unknown, 
 but the type of onset and the early course of the disease are strongly indicative 
 that this was the case. 
 
 In 1902 Jellinek (93) (San Francisco, California) reported seven cases of botu- 
 lism after eating "tainted" boiled beef. Three of the patients died. The symp- 
 toms of one fatal case were outlined in some detail as follows: The patient became 
 ill on December 3, 6 days after the meal, and complained of lack of appetite, 
 dryness and scratching in the throat, and great prostration. On the following 
 day there was dryness of the mouth and throat, extreme thirst, ptosis, diplopia, 
 inability to swallow, choking whenever attemp'ts were made to swallow, retarded 
 movements of the tongue, slow, hoarse, nasal voice sounds, and inability to raise 
 the head. At this time there was a fever of 102°F., a pulse rate of 120 to 140, 
 and evidence of consolidation in the lungs. Sensation was undisturbed through- 
 out. There was obstinate constipation and a small amount of albumin in the 
 urine. Death occurred 10 days after the meal. 
 
 Necropsy was performed by Dr. Ophiils who recorded marked rigor mortis, 
 hyperemia and edema of the meninges with much dark blood in the basilar 
 sinuses, hyperemia and edema of the cerebellum, hyperemia of the plexuses and 
 basal ganglia, bilateral hydrothorax, injection of the pericardium, petechiae in 
 the pleura, hyperemia, edema, and bronchopneumonjc patches in the lungs, 
 enlargement of the spleen, passive congestion of the liver, kidneys, and mucous 
 membrane of the stomach, and hyperemia of the mesenteric and retroperitoneal 
 lymph glands. Complete record of the histologic examination is not given, 
 although it is noted that there was engorgement of the capillaries of the medulla, 
 pons, and cerebellum. 
 
 In 1904 Anderson (94) described a case in which nausea, dizziness, and incoordi- 
 nation of muscular movement persisted for 6 weeks. The suspected meal con- 
 sisted of soup, beefsteak, sweet potatoes, and dessert. The clinical picture in 
 this case is not typical of botulism, although there are some points in which it 
 is suggestive. 
 
 In 1905 Bryant (95) attempted to explain the onset of deaf-mutism in two 
 children by assuming that it was due to food-poisoning. The record of the clini- 
 
ERNEST C. DICKSON 15 
 
 cal findings is incomplete and does not suggest botulism, but the author believed 
 that the deafness was due to an involvement of the nuclei of the auditory nerves 
 which was produced by the food-poisoning in a manner similar to that which 
 had been described by Marinesco, Kempner, and others in cases of experimentally 
 produced botulism. 
 
 In 1907 Sheppard (96) (Ontario, California) recorded an outbreak of food- 
 poisoning in which three persons became ill, and two died after eating canned 
 pork and beans. The onset of symptoms occurred in from 36 hours to 4^ days 
 after the first meal of the suspected food. Twelve chickens became ill, and 
 nine died after eating the remains of the food. 
 
 The symptoms were practically identical in all the cases. There was an 
 absence of pain, fever, gastrointestinal, and sensory disturbances. The first 
 complaint was dimness of vision; the party was on a shooting trip and one of the 
 men noted that he could not shoot straight, and another that he could not hit a 
 stick of wood which he was attempting to chop. There was early ptosis, diplopia, 
 and difficulty in swallowing. Later there was progressive muscular weakness 
 "with gradually developing motor paralysis," inability to swallow, inability to 
 raise thick mucus from the throat, and marked constipation. The urine secre- 
 tion was normal, the iJulse showed little change except irritability when move- 
 ments were attempted, there was no fever, and the mentality was clear. Inco- 
 ordination of movement was so great that the writing was illegible. There is 
 no record of necropsy findings. 
 
 In 1910 Peck (97) (Sawtelle, California) described an outbreak in which twelve 
 persons were ill and eleven died after eating home-canned pears which "were not 
 exactly sour but tasted sharp and bit or tingled the tongue and throat." The 
 only person who recovered had merely tasted the fruit and had swallowed a very 
 small amoimt. 
 
 The S5Tnptoms were alike in all the cases, including the one which recovered. 
 There was marked incoordination of movement and muscular weakness. The 
 tongue was thickly coated and could be moved with difficulty. There was dim- 
 ness of vision, dUatation of the pupils, and disturbance of the prnpUlary reflexes. 
 The pulse was rapid in the only case in which it was recorded, the temperature 
 was subnormal, speech was difficult, and there were choking spells when the 
 patients attempted to swallow. There was initial nausea and vomiting, and 
 constipation was persistent. Mentahty was clear throughout. 
 
 The average length of time which elapsed between the taking of the food and 
 death was 40 hours, the shortest time being 25 hours, and the longest 63 hours. 
 There is no record of necropsy findings. 
 
 There was some difference of opinion as to the real cause of the poisoning in 
 this outbreak, as some of the victims had also eaten tamales, but it was definitely 
 established that the only article of food of which they all had partaken and which 
 was at all open to suspicion was the spoiled fruit. 
 
 In 1913 Stiles (98) (Boston, Massachusetts) recorded his own illness which 
 followed a meal in which the suspected food was minced chicken. About 2 
 
16 
 
 BOTULISM 
 
 hours after the meal he "became consdous of growing inertia" and "of a curious 
 hyperesthesia|of the pharynx." He was faint and unable to stand. About 4 
 hours after the meal he became nauseated and vomited portions of chicken which 
 tasted "rough,|^rancid, or acid." Nausea, vertigo, and nystagmus occurred 
 
 Text-Fig. 1. Temperature, pulse, and respiration curves of Miss F. G., one 
 of^the patients of the Stanford University series. The patient was taken to the 
 hospital on the 6th day after she had eaten the string bean salad. She was very 
 Ul for the first few days, sat up for the first time on the 19th day, and was allowed 
 to go home on the 23rd day. 
 
 whenever he raised his head. On the foUowing day there was extreme vertigo 
 if he moved his head, vomiting of undigested chicken, nystagmus, and cardiac 
 irregularity. Evacuation of the bowels was obtained with an enema and there 
 was resumption of urine secretion. For a few days there was a gradual return 
 
ERNEST C. DICKSON 17 
 
 of strength and the patient walked half a mile on the 6th day after the meal, 
 and visited his laboratory on the 7th, but during the night of the 7th day he 
 awakened to find that the prostration and vertigo had returned and that he 
 could scarcely speak. On the following day there was difficulty in talking and 
 swallowing, and food was regurgitated through the nose. Thick mucus collected 
 in the pharynx and was removed with difficulty. The attacks of nystagmus 
 became less frequent but diplopia developed, and there was great prostration. 
 
 Recovery was extremely slow and tedious. The persistent symptoms were 
 constiJ)ation, burning in the throat, ataxia, and disturbances of vision. The 
 left pupiil was smaller than the right and there was some failure of accommodation. 
 
 In 1914 Wilbur and Ophiils (99) (Stanford University, California) reported a 
 series of twelve cases which developed after eating salad which was prepared 
 from home-canned string beans. The symptoms of all were typical of botulism 
 but varied greatly in degree of severity. One of the patients died. 
 
 The following record of the clinical and autopsy findings of the fatal case is 
 quoted from their report. 
 
 "Young healthy woman, aged 23, on the second morning following the ingestion of the 
 meal at which time beans were taken, complained that objects were often seen double. 
 There was no headache or vomiting; urination apparently as usual. A laxative had been 
 taken because of constipation and the bowels had acted. On the fourth morning the 
 patient was unable to eat because of the inability to swallow. There was no pain. Later 
 on in the day she swallowed with difficulty. On the sixth morning her mouth was dry, 
 there was considerable thirst, no abdominal colic, no appetite, marked asthenia, with the 
 muscular power in the left arm less than normal. Voice was slightly nasal with inability 
 to articulate distinctly. Temperature was 97.8° to 99° F., pulse 104. There was ptosis of 
 both upper lids; both pupils were dilated but reacted to light, with normal fundi. The 
 breath was foul, tongue coated, and it and the pharynx covered with sticky, whitish, viscid 
 mucus. There was considerable edema of the uvula. 
 
 "The condition did not change very much in the next few days except that the patient 
 felt very weak, was unable to raise the head without help, at times would swallow well, at 
 other times was unable to take the simplest food, and the pulse became more rapid and 
 dicrotic. Blood pressure was normal. At one time she became quite talkative and com- 
 plained that her jaws did not open naturally and she could not see well, but for the most 
 part she was quiet and slightly depressed. 
 
 "On the tenth day she brought up with very much difficulty some mucus which had been 
 interfering greatly with her throat and had a period in the afternoon when she was unable 
 to swallow, had difficulty in breathing, and cold extremities. Later on she was able to take 
 an egg-nog, but complained of a spontaneous choking sensation. In the night to the dis- 
 tress of these attacks was added an inability to breathe through the nose. 
 
 "On the twelfth day involuntary movements of the bowels occurred. Some relief from 
 the choking, breathless sensation was gained by swabbing the throat. The patient vom- 
 ited some dark green fluid after a large soft involuntary stool and began to feel very warm 
 and excited, axillary temperature going up to 100.4°. After a period of chills, great rest- 
 lessness, choking sensation, increasing temperature, and higher pulse rate, together with 
 the signs of hypostatic pneumonia, the patient had a coUapse from which she recovered on 
 the administration by Dr. Williams of an intravenous transfusion of normal salt solution. 
 
18 BOTULISM 
 
 • 
 
 She vomited later a considerable amount of blood and although her breathing became more 
 superficial, her weakness more evident, the sensorium remained perfectly intact" (Text- 
 fig. 2) . 
 
 "On the thirteenth day she died following a respiratory disturbance apparently due to 
 sudden paralysis of the diaphragm, since the heart continued to beat for some time. Vari- 
 ous forms of stimulant and other treatment were administered without avail. The nec- 
 ropsy, performed by Dr. William Ophiils, was practically negative except for areas of col- 
 lapse and bronchopneumonia in the posterior parts of the lungs, and certain lesions of the 
 central nervous system, which will be described later." 
 
 Necropsy. — "The brain in our case was obtained within twenty-four hours in a very 
 good state of preservation. • 
 
 ' 'The gross findings at necropsy were entirely negative except for a moderate hyperemia 
 of the cerebral vessels, which was especially pronounced at the base of the brain and in the 
 region of the fourth ventricle, where there also was found some edema. No hemorrhages 
 could be made out with the naked eye on several sections through the brain stem. The 
 internal organs were markedly hyperemic, which was especially noticeable in liver, kidneys , 
 and intestines. This general hyperemia has been a constant finding in all cases of human 
 botulism and is also found in the experimental disease in animals. The dilatation of all 
 the blood vessels was also very evident in sections from all organs examined. Tj^ical 
 bronchopneumonic lesions were found in the lungs, which condition probably accelerated 
 the death of the patient. 
 
 "The following is a short description of the microscopical findings in the brain: 
 
 "The brain stem was sectioned.transversely at diflferent levels at the time of the autopsy 
 and carefully hardened in frequently changed absolute alcohol. Numerous sections were 
 made from all levels and special attention paid to the r^ons of the more important nuclei. 
 Sections were obtained from all motor and some of the sensory nuclei on both sides. The 
 nuclei studied were those of the oculomotorius (third), trochlearis (fourth), trigeminus 
 (fifth), abducens (sixth), facialis (seventh), acusticus (eighth), glossopharyngeus (ninth), 
 vagus (tenth), and hypoglossus (twelfth) nerves. The following lesions were found: 
 
 "Thrombosis of the right arteria vertebraHs at lower end of the meduUa and extending 
 into the arteria basilaris some distance. The middle part of the arteria basilaris is free. 
 The anterior portion of it again is filled with thrombus. There are thrombi in a few of the 
 pial branches of the basilar artery. Many pial veins at the base of the medulla and pons 
 are filled with thrombi, more especially on the right side, and there are several thrombi in 
 the veins of the tela choripidea above the corpora quadrigemina and the posterior part of 
 the third ventricle. All blood vessels in the brain tissue are much distended and full of 
 blood. Both in the ventral and in the dorsal parts of the brain stem one finds quite a few 
 thrombosed blood vessels, some of which are situated near important nuclei; for instance, 
 one was found near the right vagus nucleus, several in the nuclei of the olives, several in the 
 substantia ferruginea, several in the right nucleus trochlearis, several near the right nucleus 
 of the oculomotorius, and similarly several near the left nucleus oculomotorius, but some- 
 what further away from it. Several perivascular hemorrhages were encountered quite 
 commonly about thrombosed veins and others. The thrombi in all places were very rich 
 in polymorphonuclear leukocytes, but no bacteria could be demonstrated in spite of the use 
 of various staining methods, including Weigert's modification of Gram's method. All 
 thrombi were very rich in fibrin and contained comparatively few masses of conglutinated 
 blood platelets" (Fig. 2). 
 
 "The Nissl granules stain unusually well in all sections especially in the large motor 
 
ERNEST C. DICKSON 19 
 
 ganglion cells. They are quite normal in size and arrangement. Nothing unusual could 
 be detected in spite of especially careful study of them. The nuclei of the ganglion cells 
 are perfectly normal. 
 
 '"Sections were also taken from various parts of the cortex of the cerebellum. There 
 was no difference in the appearance of the ganglion cells from these other regions. Few 
 thrombi were seen in the pial veins. The blood vessels in the cortex are dilated and full 
 of blood, but none show thrombosis or perivascular hemorrhages. 
 
 No thrombi were found in any other organs in spite of the study of many sections 
 except one in a vein in the submucosa of the intestine and the very beginning of the 
 thrombotic process in few of the dilated vessels in the ovarian cortex. 
 
 "Anaerobic cultures were made from the intestinal content both of the small and large 
 intestines, from the cerebrospinal fluid, from the heart blood, and from the spleen. The 
 cerebrospinal fluid and the heart blood were sterile and the Bacillus botidinus was not 
 found in any of the other cultures." 
 
 Dr. T. M. Williams (100) (Palo Alto, California) treated seven of the patients 
 of the Stanford University series, and reported his observations at the annual 
 meeting of the California State Medical Society in 1914. It is unfortunate that 
 his report has not been published. The following brief description is abstracted 
 from his manuscript. 
 
 The initial symptoms developed in from 1 to 4 ddys after the poisonous food 
 was eaten. Two of the patients were not seriously ill; one had attacks of vomit- 
 ing, and the other diarrhea, biit showed no other symptoms. They did not 
 consult a physician. In Williams' series, disturbance of vision was the initial 
 symptom in four, difficulty in swallowing in one, rapidly progressing weakness 
 in one, and nausea, vomiting, and abdominal pain in the other. One died on the 
 14th day after eating the poisonous food, two were discharged from the hospital 
 on the 21st day, three were discharged on the 23rd day (Text-fig. 1), and one was 
 unable to leave until the 40th day. All the surviving cases were apparently well 
 in from 4 to 8 weeks, and had returned to their University work within 2 months. 
 It is noted that IS months later none showed any ill effects from the poisoning. 
 
 The symptoms and course of the Ulness were practically the same in all the 
 cases, varying only in severity. There was blepharoptosis, mydriasis, diplopia, 
 strabismus, and nystagmus. The dilated pupils reacted sluggishly to light 
 stimulation, and accommodation was impaired. Some of the patients com- 
 plained of dimness of vision but there were no demonstrable lesions in the retinas. 
 In only one of the cases were disturbances of vision absent. There was a peculiar 
 expressionless appearance of the face, and the jaws could not be' opened more 
 than one-half to three-quarters of an inch. The breath was fetid, the tongue 
 heavily coated, and the walls of the pharynx covered with tenacious, glairy 
 mucus. In one case there was marked edema of the glottis. The voice was 
 nasal in character and articulation was indistinct. There was difficulty in swal- 
 lowing, and in the more severe cases there was regurgitation of food through 
 the nose. The pharyngeal muscles and the soft palate were partially or com- 
 pletely paralyzed in all the cases. The patients experienced great difficulty in 
 
20 BOTULISM 
 
 clearing the mucus from the pharynx. There was a continuous sensation of 
 fullness in the throat and of choking, and the patients complained bitterly of the 
 difficulty in breathing. One patient was so fearful that respiration would cease 
 unless he maintained voluntary respiratory efforts, that he dared not go to sleep, 
 and all the more severe cases were conscious of impending suffocation. 
 
 A striking feature of all the cases was the progressive muscular weakness. 
 This was especially marked in the muscles of the head and neck. Several of the 
 patients complained that they were unable to masticate their food. 
 
 ' 'There was extreme flaccidity of the muscles of the neck, allowing the chin to rest upon 
 the chest, or the head to fall backward if not supported when the patient was elevated. 
 It was a common occurrence to see a patient move her head with her hands, and one girl 
 who had long braids used them, with the head of the iron bed as a pulley, to swing her 
 head into position when she wished to move. The head could be rotated and held from 
 falling to either side, but the anterior and posterior supports were lacking." 
 
 There was a general muscular relaxation and an appearance of fatigue that 
 was most distressing. The reflexes in the extremities were normal. 
 
 Mentality was unimpaired in all the cases. The pulse varied from normal to 
 over 130 per minute, and the blood pressure was normal or slightly lower than 
 normal. The temperature tended to be subnormal, except in the last stage of 
 the illness. The excretion of urine was unimpaired, except in one case, and the 
 blood picture was unchanged. Obstinate constipation was noted in all the cases. 
 
 Williams noted that there was a most striking variation in the intensity of the 
 symptoms within short periods of time. It was not unusual to find a patient, 
 who a few hours jJreviously had seemed extremely ill, complaining of great respira- 
 tory distress and unable to raise the eyehds, able to swallow and talk without 
 difficulty, and to breathe comfortably. He added: "Had I other cases to treat, 
 I should be guarded as to my prognosis, and I should not be too much elated or 
 discouraged by sudden variations." 
 
 In 1915, Frost (101) (Los Angeles, CaUfornia) recorded three fatal cases of 
 botulism. In two it was probable that the poisoning was due to the ingestion 
 of old "Wienerwurst," but in the other the cause was not estabhshed. There 
 was initial weakness, dizziness, and disturbance of vision. In one there was 
 vomiting. There was difficulty in swallowing and in enunciation, and the tongue 
 was swollen and heavily coated. Marked weakness, diplopia, and stranghng 
 followed. In two cases death occurred from "inanition," and in the other during 
 an attack of stranghng. The temperature was subnormal in aU, and the pulse 
 was rapid and weak. In one case there was evidence of a terminal- broncho- 
 pneumonia. 
 
 In 1916 Lancaster (102) (Boston, Massachusetts) reported a case in which 
 the source of poisoning was not determined. The initial symptom was diplopia, 
 but was soon followed by vertigo, ptosis, complete ophthalmoplegia, and fixed 
 eyeballs. There was no dilatation of the pupils but reaction to light was sluggish. 
 
ERNEST C. DICKSON 21 
 
 The appearance of the fundi was normal. Nausea and vertigo were made worse 
 by movement, but were less severe in the dark. There was moderate dysphagia, 
 di£5culty of speech because of impaired movement of the tongue, tremor of the 
 hands, and marked weakness. There was no disturbance of secretions. Facial 
 paralysis developed and persisted for 6 weeks. Mentality was clear although 
 there was persistent somnolence. Recovery was slow and tedious, disturbance 
 of vision, incoordination of muscular movement, and vertigo being the persisting 
 symptoms. 
 
 There were several unusual syinptoms in this case, a fever which reached 102° 
 and which subsided by lysis, and persistent diarrhea being the most important. 
 Nausea persisted for weeks. The leukocyte count was 7,000, the systolic blood 
 pressure was 120 mm., and the urine was normal. 
 
 The most recent report in the American literature appeared in February of 
 this year, when Curfman (103) recorded seven cases, five of them fatal, which 
 had occurred in Colorado several years ago. The poisoning was apparently 
 caused by canned string beans or canned spinach, and the outbreak is of consider- 
 able interest in that it is the first recorded instance in which the poisonous vege- 
 tables were prepared in a regularly equipped canning factory. It is also of inter- 
 est that the vegetables were canned in Kansas, as proof is thereby established 
 that B. botulinus is to be found in the middle western states. 
 
 The onset of symptoms in Curfman's cases varied from a few hours to 4 days 
 after the poisonous food was eaten. Three of the patients complained of initial 
 gastrointestinal disturbances, nausea, vomiting, and abdominal distress, but in 
 the four remaining cases the symptoms of central nervous system involvement 
 were the first noted. In one case the nausea and vomiting occurred 3 days after 
 the appearance of dizziness and visual disturbance. The symptoms were very 
 similar in all the cases. There was dizziness, some headache, diplopia, ptosis, 
 dilatation of the pupils, diminution of reaction to light, paralysis of accommoda- 
 tion, difficulty in swallowing, difficulty in talking, and eventually complete 
 aphonia in the more severe cases, marked general weakness, and constipation. 
 The patients complained of the accumulation of glairy mucus in the throat and 
 of dryness in the mouth. They strangled when they attempted to swallow. Men- 
 tality was clear throughout and there is no record of any sensory disturbances. 
 It was noted in two cases that the temperature was subnormal, and, in one of 
 these, that the pulse rate was above 100 per minute. Two of the patients died 
 within 48 hours, one on the 3rd day, one on the 6th day, and one 2 weeks after 
 the poisoning. Death occurred from respiratory failure. 
 
 Of the two patients which recovered, one was apparently a very rruld case 
 but the other was more seriously ill. The latter patient recovered very slowly; 
 she was unable to comb her hair for 4 weeks, or to walk without assistance for 
 6 weeks. She suffered much from dyspnea on exertion, and "the heart action 
 was weak and rapid." 3 months after the poisoning it was noted that the patient 
 was "unable to read or do any close work," that she had frontal headache, was 
 dyspneic on exertion, and was very constipated. The pulse was 96 per minute. 
 
22 BOTULISM 
 
 regular, and of fair quality. Muscular strength was gradually returning. The 
 pharyngeal reflex was still sluggish but the knee-jerks were overactive. 
 
 An interesting feature of Curfman's report is the statement that fi.ve burros 
 died after eating the garbage which contained the remnants of the meal. It is 
 noted that they had "symptoms similar to those observed in the human cases." 
 
REPORT OF NEW CASES. 
 Outbreak 1. Five Cases. 
 
 On Sunday, Mar. 7, 1915, five persons in Fallbrook, California, ate together 
 at supper, which consisted of bacon, potatoes, cooked dried beans, bread, butter, 
 and home-canned apricots which had been canned without sugar. The food was 
 all a^'arently of good quality except the apHcots which were moulded on the 
 surface and discolored for about one-half the depth of the jar. The upper por- 
 tion of the fruit was discarded, but the lower portion was served and was found 
 to be somewhat bitter, though not unpleasantly so. On the following Tuesday 
 three of the party were very tired, and some were dizzy and had transient double 
 vision and headache. On Wednesday the three adults attempted to work but 
 became exhausted and went to bed. Each took a large dose of sodium phosphate. 
 On Thursday morning all were much worse and Dr. Charles Pratt of Fallbrook 
 and Dr. Reid and Dr. Nichols of Oceanside were called, to whom I am indebted for 
 the record of the cases. I have also made use of the Coroner's report which was' 
 published in The San Diego Union of Mar. 22, 1915. 
 
 When first seen, two of the three adults were almost in collapse, and the third 
 was confined to her bed. All showed the same symptoms; viz., ptosis, double 
 vision, extreme dilatation of the pupils, dryness of the mouth and throat, accu- 
 mulation of thick, viscid mucus in the throat, difficulty in swallowing, difficulty 
 in talking, and extreme muscular weakness. There was no nausea or vomiting, 
 no pain, and no sensory disturbance. Purgatives and enemata were given, and 
 strychnine and atropine were administered hypodermically. Two of the patients 
 died the same evening, the immediate cause of death being "paralysis of the 
 respiratory tract." Consciousness was maintained to the last, and the heart 
 continued to beat for several minutes after respiration ceased. There was marked 
 terminal cyanosis. 
 
 On Friday it was noted that the mother was considerably better and that there 
 was less disturbance of vision and swallowing, but on Saturday she exhibited 
 the same symptoms as in the two previous cases, and died in the afternoon. 
 
 On Thursday morning the youngest grandchild, aged 5 years, was apparently 
 in perfect health, although on the previous day he had become very tired while 
 walking to his home, a distance of about a mile. During the afternoon of Thurs- 
 day, however, he developed ptosis, double vision, and difficulty in swallowing, 
 talking, and breathing. He died the following day. The elder grandchild, aged 
 9, showed the initial symptoms on Friday afternoon, and she died the following 
 Thursday. The course in this case was much more prolonged, but the terminal 
 symptoms were identical with those of the other patients (Text-fig. 3). 
 
 23 
 
24 BOTULISM 
 
 The symptoms were practically identical in all the cases, and were of the type 
 seen in bulbar paralysis. There was no fever, no gastrointestinal disturbance 
 and no mental or sensory disturbance. The pulse was rapid and of poor quality. 
 
 Necropfey was performed on the body of the elder grandchild, but "no infor- 
 mation was obtained which throws any light upon the subject, as to the origin 
 of the trouble." 
 
 A dog which ate part of the discarded apricots became paralyzed in 
 the hind legs for a few days, but ultimately recovered. Several 
 chickens, which also ate some of the apricots, became ill with limber-neck, 
 and seven of them died. "Bacteriologic examination of the viscera 
 and of the blood of one of the chickens revealed nothing of a patho- 
 logical significance."' 
 
 There was some difference of opinion as to the cause of this outbreak, 
 although all agreed that it was clinically botulism. Some of the inves- 
 tigators believed that the bacon was responsible for the poisoning, 
 although they admitted that there was no evidence of spoihng in the 
 portion that remained. Moreover, other persons had eaten portions 
 of the same bacon without injury, and it is known that the chickens 
 and the dog did not eat any of the bacon, although they did eat the 
 portion of the apricots which was discarded. 
 
 Outbreak 2. One Case' 
 
 On Sunday, Oct. 17, 1915, Mrs. X., a housewife aged 35, opened several jars 
 of corn which she had canned a few months previously. The contents of the 
 first two jars were evidently spoiled and were thrown out. The corn in the third 
 jar appeared to be good, but after she had tasted about two teaspoonfuls Mrs. 
 X. decided that it was also spoiled. About 4 or 5 hours later she noticed a pain 
 in the abdomen for which she took some laxative pills, and obtained an evacua- 
 tion of the bowels on Monday morning. Later in the day she began to have 
 difficulty in swallowing, and called in Dr. I. E. Barrett of Hillsboro, Oregon, to 
 whom I am indebted for the following record. 
 
 The patient when first seen was very restless, almost hysterical, and com- 
 plained of inability to get her breath, inability to swallow, and pressure about 
 the throat. There was no history of nausea or vomiting, and no diarrhea. The 
 mouth was dry. There was much severe cough without sputum, and the patient 
 complained of difficulty in raising thick mucus from the pharynx. Swallowing 
 
 ' The portions of the text which are in quotation marks are quoted from the 
 County Coroner's report. 
 
ERNEST C. DICKSON 25 
 
 was at first difficult and later impossible. Articulation was poor, and, toward 
 the end, the patient mumbled unintelligibly. There was no disturbance of 
 mentality except the hysterical condition at the onset, and coma for a short time 
 before death. The pulse was thready, from 100 to 120 per minute. There was 
 no fever and the temperature on the last day was subnormal. The excretion 
 of urine was normal. Respiration was extremely labored toward the end, and 
 death occurred from respiratory failure. 
 
 Necropsy was done by Dr. Barrett. No cause of death could be found. 
 
 Several hogs and chickens ate the discarded corn. The hogs 
 showed no ill effects, but fifty chickens became paralyzed and died. 
 Through the courtesy of Dr. Leon W. Hyde of Hillsboro, the carcass of 
 one of the chickens was sent to me. Putrefaction had progressed to 
 such an extent that it was impossible to make histologic examination 
 of any of the tissues, but from the contents of the gizzard an anaerobic 
 bacillus was isolated, which is morphologically like Bacillus botulinus, 
 and which produces an extremely virulent toxin when grown on suit- 
 able media. 
 
 Outbreak 3. One Case. 
 
 On Nov. 18, 1915, Mrs. H. opened some home-canned asparagus and noted that 
 the contents of the jar "were a little sour," but, as was her habit, she drank the 
 juice from the jar, and placed the stalks on the stove to cook. While the aspara- 
 gus was cooking the odor was not good, and her son, after tasting a piece, threw 
 it all out. About 6 hours after drinking the asparagus juice Mrs. H. became 
 nauseated and vomited repeatedly. She was attended by Dr. F. P. Gundrum 
 of Sacramento, California, who sent me the record of the case. 
 
 Dr. Gundrum first saw the patient on the 4th day of the illness, a short time 
 before she died. There was dimness of vision, bilateral ptosis, strabismus, dip- 
 lopia, and loss of pupillary reflex to light. The tongue was coated, speech was 
 impaired, and there was difficulty in swallowing, decrease in the flow of saliva, 
 accumulation of thick, tenacious mucus in the throat, and dryness of t.he skin 
 and bjiccal mucous membrane. There was persistent constipation and almost 
 complete suppression of the urine. There was marked general weakness and 
 incoordination, especially of the muscles of the arms. The pulse was 108, of 
 poor quality, and the temperature was 102°F. Death occurred from respiratory 
 failure, 3| days after the appearance of the first symptoms. 
 
 Necropsy was not permitted. 
 
 Outbreak 4. One Case. 
 
 Mrs. R., aged 35, was first seen on Jan. 16, 1916, by Dr. E. J. Holbrook of 
 San Jose, CaUfornia, from whom I obtained the following clinical record. 
 
26 BOTULISM 
 
 On Friday, Jan. 14, when Mrs. R. opened a jar of home-canned string beans, 
 she noted that the odor was unpleasant. She tasted one of the pods and decided 
 that it was good, but as the beans became heated the odor became much more 
 unpleasant, and, after "nibbling" a pod upon which she had put some salt, she 
 decided that they were not good, and threw them out. 
 
 On the following day she did not feel well ; there was some dizziness and head- 
 ache, and she "felt weak." On Sunday she was nauseated and so weak that 
 she was unable to get up; and during the day the weakness became more marked. 
 There was a full movement of the bowels after a course of calomel and magnesixjm 
 sulfate. During the day a neighbor told her that the chickens which had eaten 
 the beans were all sick, whereupon the patient became alarmed and called Dr. 
 Holbrook. 
 
 On examination it was noted that there was bilateral ptosis, double vision, 
 slight difficulty in swallowing, and difficulty in pronouncing certain words. On 
 the following day the ptosis was more marked, speech was more difficult, and 
 the patient was unable to swallow any solid food. On Tuesday she seemed to 
 be somewhat better, but on Wednesday morning there was an attack of extreme 
 respiratory distress which was apparently due to paralysis of the respiratory' 
 muscles. Artificial respiration with oxygen was carried on about 2 hours, but 
 the patient failed to rally. Death was due to respiratory failure. 
 
 The patient was entirely conscious throughout the illness. There was no pain 
 at any time and no sensory disturbance except a feeling of numbness of the lips. 
 The temperature was never above 99°F., and for a time before death was sub- 
 normal. Muscular weakness was extreme, and for the last 24 hours there was 
 apparently paresis of the arms. The urine was normal. On the last day of 
 illness the leukocytes numbered 17,600, of which 86 per cent were pol3rmorpho- 
 nuclear neutrophils. 
 
 Necropsy was performed by me 5 days after death, but, as the body had been 
 embalmed a few hours after death, the tissues were still well preserved. There 
 was very marked congestion of the vessels of the meninges of the brain and lower 
 cord, but no hemorrhage was seen. The tissues of the abdominal and thoracic 
 organs were so discolored by the embalming fluid that it was impossible to deter- 
 mine how much they were congested, but one definite hemorrhage was found 
 in the left adrenal, and one in the wall of the small intestine. 
 
 Microscopic examination of the tissues of the brain showed much congestion 
 in the vessels of the meninges on the surface and in the sulci. In some of the 
 veins of the meninges there were thrombi containing bunched leukocytes, of 
 the type which was described by Ophiils, and in several small veins in the tissue 
 of cerebellum and cerebrum there were thrombi in which were fewer leukocytes 
 (Fig. 3). Careful examination of the ganglion cells of the stem, especially in the 
 region of the various motor nuclei, failed to reveal any definite disintegration of 
 the Nissl granules or of the cell protoplasm. Sections of the cord showed nothing 
 abnormal.^ 
 
 Sections of the lungs showed moderate hyperemia and edema, and several 
 
EI^ST C. DICKSON 27 
 
 large areas in which the air spaces were filled with blood. The bronchi were 
 filled with plirulent material and there were small areas of bronchopneumonia. 
 Several arteries and veins contained thrombus in which were masses of conglu- 
 tinated blood platelets and many leukocytes (Fig. 4). 
 
 The kidneys showed moderate p,arenchymatous degeneration, exudate in the 
 glomerular capsules, and thrombi containing leukocytes in some of the arteries 
 and veins. Sections of the liver showed little degeneration of the epitheUal 
 cells. 
 
 Eight chickens which ate the discarded beans became paralyzed and 
 died within 3 days. Necropsy was performed by me on six. Exami- 
 nation of the brain showed marked congestion of the meninges, especi- 
 ally aroimd the base of the brain and upper part of the cord. There 
 were also large hemorrhages at the base. The tissues were all soft 
 and discolored, but showed evidence of general congestion. Micro- 
 scopic examination showed much degeneration which was probably 
 postmortem, and thrombi containing conglutinated blood platelets in 
 the vessels of the brain, lungs, liver, and kidneys. 
 
 From the contents of the crop or gizzard of three of the chickens an 
 anaerobic, Gram-positive bacillus was recovered, which is morpho- 
 logically and culturally identical with Bacillus botulinus, and which 
 produces a virulent toxin when grown in suitable media. 
 
 Outbreak 5. One Case. 
 
 On Tuesday, May 23, 1916, Dr. C. Bigelow of San Francisco was called in to 
 see Mr. J. C, who complained that he was "going blind." When first seen the 
 patient was l}dng on a couch from which he arose with difficulty. There was 
 ptosis of the left eyelid, apparent paralysis of the left sixth cranial nerve and 
 diplopia. He stated that he had felt badly on Saturday and Sunday and was 
 much worse on Monday, and compJlained of soreness in the back and shoulders 
 which he attributed to the fact that he had slipped while cranking his automobile. 
 The eye symptoms developed rather suddenly on Tuesday. 
 
 On the following day the sjrmptoms became more severe. Respiration became 
 difficult, the throat kept filling with thick mucus which he was unable to expec- 
 torate, the movements of the tongue became impaired, and articulation was 
 difficult. On Friday, May 26, it was noted that "all the tissues in the throat 
 and pharynx were densely swollen, but there was no deposit on the tonsils" 
 (Dr. F. B. Carpenter). Later in the day the edema had disappeared! Culture 
 in Loeffler's serum showed no Klebs-Loeffler bacilli. 
 
 On Saturday, May 27, Dr. Tracy Russell made the following notes: 
 
28 BOTULISM , 
 
 "The patient was sitting on the edge of the bed and a nurse was attempting to remove 
 glairy mucus from the pharynx. After a few minutes he said, ' I am so tired,' and threw 
 himself back on the bed. He was lethargic but would answer questions. He did not 
 complain of photophobia. There was ptosis of both eyelids, double vision, trismus, con- 
 traction of the pharyngeal muscles which prevented him from swallowing, tache c^r^brale, 
 generalized small petechiae, and marked Cheyne-Stokes respiration, the last three deep 
 inspirations being assisted by the patient grasping the head of the bed and using the acces- 
 sory muscles of respiration.'' 
 
 Examination of the eyes was made by Dr. E. W. Alexander, whose report 
 states: 
 
 "Subjectively the patient complained of photophobia and double vision. The fields 
 of vision were normal (the perimeter was not used), the central color vision was normal, 
 and there was no tenderness on pressing the eye back into the orbit or pain on rotation 
 (no retrobulbar neuritis). He could see a small test-color object clearly enough to dis- 
 tinguish its color (1 mm. in diameter at 18 inches), hence the intraocular muscles were 
 normal. The pupils were normal in size, shape, and reaction. There was some paresis of 
 the horizontal external muscles, and ptosis of the upper eyelids. The corneal reflex was 
 hyposensitive and the fundi were normal except for slight venous retinal enlargement, 
 which was not more than might occur physiologically." 
 
 There was no gastrointestinal disturbance, no headache, no pain except in 
 the back and shoulder, and no disturbance of mentality. There was some dizzi- 
 ness and slight ataxia, and the knee-jerks were somewhat overactive, especially 
 on the left side. The diplopia was transitory. The pulse varied from 80- to 
 100 per minute, and the respirations from 20 to 30. The urine was clear until 
 the last 2 days when there was a heavy cloud of albumin and the sediment con- 
 tained a few hyaline and epithelial casts and some red blood corpuscles. The 
 leukocytes varied from 10,000 to 14,000. The Wassermann reaction and the 
 tuberculin test were negative. Examination of the cerebrospinal fluid showed 
 80 cells per c.mm. 
 
 Death occurred on Saturday evening, 4 days after the onset of the eye symp- 
 toms. The cause of the poisoning was not determined. 
 
 Partial necropsy was permitted; the brain was removed, but the abdominal 
 and thoracic cavities were not opened. Examination of the brain was made by 
 Dr. W. Ophiils whose report is as follows: 
 
 ' 'The pia mater and the substance of the entire brain were intensely congested. Fairly 
 large groups of Pacchionian granulations were on the convexity of the brain. Frontal 
 sections were made throughout the cerebrum, pons, and medulla, and, except for general 
 intense congestion, no gross lesions were made out. 
 
 "Sections of the brain from various places show very marked dilatation and hyperemia 
 of all blood vessels. There are quite a few microscopical hemorrhages in the pia mater. 
 Several blood vessels (small arteries and veins) in the pia mater as well as in the brain 
 substance are either partly or completely filled with thrombi consisting of hyaline masses 
 (probably conglutinated blood platelets), some fibrin, and many leukocytes. The latter 
 
ERNEST C. DICKSON 29 
 
 are mostly polymorphonuclears. Few small similar accumulations of leukocytes occur in 
 the pia. 
 
 "An especially careful microscopical study was made of the region of the pons and 
 medulla oblongata. The tissues are not well enough preserved to show the finer details 
 of the ganglion cells, but otherwise the nuclei of the cranial nerves appear normal, except 
 for the congestion and occasional microscopic hemorrhages." 
 
 Outbreak 6. One Case. 
 
 On July 1, 1916, Mrs. W. of San Pasquale, near Escondido, California, noticed 
 that one of a number of jars of string beans, which she had canned 2 weeks before, 
 was leaking. She tasted one of the pods and noted that it was "slightly sharp," 
 and when she began to "heat them over" she noticed that there was a "strong, 
 disagreeable odor." The contents of the jar were then thrown out. 
 
 On the morning of the following day some of the chickens which had eaten 
 the beans were sick and could not lift their heads. Later in the day several 
 more chickens became affected, and by the next day all the chickens which had 
 eaten the beans were ill. A neighbor who raised large numbers of chickens told 
 Mrs. W. that the chickens had limber-neck. About twenty-five of them died 
 within 3 or 4 days after they had eaten the beans. 
 
 On the 3rd day after she had tasted the beans Mrs. W. noticed that she "felt 
 queer," was weak and tired, had double vision, and could not open her eyes. 
 Her mouth and throat were dry, the tongue felt too large for her mouth, and she 
 had difficulty in pronouncing words, and in swallowing. She noted that she was 
 very "unsteady" on her feet, "as if on ship-board," and that when she tried 
 to walk she raised her feet high as if going upstairs. She had great difficulty in 
 combing her hair and in pricking up small objects. There was no nausea or 
 vomiting. 
 
 The symptoms became more severe for several days, but the patient did not 
 remain in bed, although she was unable to do her work and lay down frequently 
 during the day. At times there was severe pain in the back of the head and neck. 
 She thinks her mentality was below normal and that her memory was poor. She 
 was restless but slept well. She noticed that there was an accumulation of 
 mucus in the throat, but there was never any strangling or disturbance of respira- 
 tion. She summed up her symptoms in the words, "Everything that I tried 
 to do was a great effort." An optician who examined her eyes told me that there 
 was paralysis of the third nerve on both sides, and that there was no retinal 
 involvement. 
 
 About 3 weeks after the onset of the symptoms, Mrs. W. commenced a course 
 of osteopathic treatments and physical culture exercises, and in 2 months was 
 practically well. At the present time (7 months after the beginning of the illness) 
 she states that there is a tendency to basilar headaches and that she becomes 
 hoarse after talking for some time; otherwise there is no apparent ill effect of 
 the poisoning. 
 
30 BOTULISM 
 
 Outbreak 7. Seven Cases. 
 
 On Monday, January 15, 1917, fifteen persons had dinner in a hotel 
 at Escondido, California. Eight partook of salad which had been 
 prepared from home-canned string beans, and, of the eight, seven 
 developed symptoms which were in evety way typical of botuHsm. 
 Four of the patients died, one was seriously ill, and two were ambula- 
 tory cases. I had an opportunity of making a personal investigation 
 of this outbreak and of examiriing three of the patients. I am much 
 indebted to Dr. B. L. Crise of Escondido, Dr. Edward Fly of National 
 City, and Dr. Robert Smart of Coronado, who placed the records of 
 their cases at my disposal, and who permitted me to examine their 
 patients. Coroner Otto Marsh of San' Diego County and Dr. George 
 B . Worthington, autopsy surgeon, also assisted me in every way, and 
 provided me with portions of the organs of one case in which necropsy 
 was performed. 
 
 There can be no doubt that the bean salad was responsible for the 
 poisoning, as only one of those who ate salad escaped illness, whereas 
 none who did not eat it showed any symptoms. That the poisonous 
 food was served at the evening meal was proved by the fact that one of 
 the victims was a guest at the hotel for that night only. His com- 
 panion, who also remained over night, did not eat any of the salad, and 
 escaped iUness. Two cans of home-canned string beans were used in 
 the preparation of the salad. As the cook is dead it is impossible to 
 obtain definite information as to whether she noted that the beans 
 were spoiled, but one waitress, who assisted in preparing the salad, 
 said that the contents of one of the cans did not taste quite right; and 
 another waitress noticed that the cook had tasted the beans several 
 times while preparing the salad, although she did not hear her say that 
 anything was wrong with them. The beans were served with mayon- 
 naise on lettuce. They were not cooked after they were removed 
 from the cans. 
 
 It is probable that only one of the cans of beans was contaminated, 
 since the severity of the illness of the victims varied so greatly. It 
 seems reasonable to presume that the person who failed to develop 
 symptoms after eating the salad received only beans from the unspoiled 
 can, that those who showed mild symptoms received but little from the 
 
ERNEST C. DICKSON 31 
 
 spoiled can, and that those who were seriously ill had eaten larger 
 portions of the beans from the contaminated can. 
 
 The cKnical picture in all the cases was practically identical, except 
 in severity, and can best be illustrated by a description of two fatal 
 cases in which necropsy was performed, and of one ambulatory case 
 which recovered. 
 
 Case 1. — Miss N., waitress, aged 27, consulted Dr. B. L. Crise, Escondido, 
 California, at his office on Wednesday, Jan. 17, 2 days after the meal. She com- 
 plained of great muscular weakness and said she was "all in." Examination 
 showed no apparent cause for her condition. On Thursday morning Dr. Crise 
 was called to the hotel and found the patient in bed, complaining of headache, 
 pain in "the pit of her stomach," nausea and vomiting, double vision, and diffi- 
 culty in swallowing and in pronouncing certain words. She was extremely pros- 
 trated, orientation was slow, the pulse was 120 and rather weak, and the tempera- 
 ture was 96°F. The piipils were dilated but reacted to light, the tongue was 
 heavily coated although the edge and tip were clean, and the skin was moist. 
 Examination of the heart and lungs showed nothing abnormal, except the heart 
 rate, but the abdomen was somewhat distended and tympanitic. There was no 
 paralysis of the skeletal muscles but there was marked weakness. The i)atient 
 staggered when she attempted to walk and was unable to pick up small objects, 
 although she could feel them without difficulty. There was marked vertigo 
 whenever she moved her head. 
 
 Active purgation was instituted and it was noted that an excessive amount of 
 purgative was necessary before evacuation of the bowels was obtained. 
 
 On Friday practically all the symptoms had increased in severity. The pa- 
 tient was anxious and restless although she had slept well. She complained of 
 dryness in the mouth and throat, greater difficulty in talking and swallowing, 
 strangUng when she attempted to swallow, and inability to clear the throat of 
 mucus. She was extremely weak. Examination showed a marked pallor of the 
 skin, pulse 120, and temperature about 96°F. There was paralysis of accommo- 
 dation and double and cloudy vision, although vision with either eye was fairly 
 good. The bowels moved after the administration of Glauber's salts. The 
 superficial reflexes were intact. 
 
 On Saturday and Sunday the symptoms were stUl more severe, prostration 
 was extreme, and the patient was unable to raise the arms and legs. There was 
 greater difficulty in swallowing and talking, and the strangling spells were more 
 frequent. The breath was fetid and there was a peculiar ammoniacal odor from 
 the skin. The pulse was stUl rapid, and on Sunday the temperature rose to 
 97.5°F. 
 
 On Monday there was complete paralysis of the muscles of deglutition, and 
 speech was almost unintelligible. There was bilateral ptosis of the eyelids and 
 the pupils were widely dilated and reacted sluggishly to light. There was still 
 
32 BOTULISM 
 
 complete loss of accommodation. Strangling was most distressing and there 
 was much difficulty in removing the thick mucus from the pharynx. Attempts 
 to swallow were followed by strangling and regurgitation through the nose. The 
 pharyngeal reflex was apparently lost as there was no gagging when the mucus 
 was forcibly wiped out with cotton attached to a hemostat. The knee-jerks 
 were sluggish and sensation was unimpaired. There was incontinence of urine. 
 
 On Tuesday the general condition was still worse. The pulse was weaker 
 and more rapid, 140 per minute. Death occurred from respiratory failure, the 
 heart beat persisting for some time after respiration had ceased. 
 
 The secretion of urine did not seem to be diminished at any time; it showed 
 a heavy cloud of albumin. Blood pressure was taken several times and was 
 always about 120 mm. of mercury (systolic). There was no terminal rise in 
 temperature which would indicate an insufHation pneumonia. 
 
 Necropsy was performed by the Coroner's autopsy surgeon after the body had 
 been embalmed. There was marked congestion of the brain and meninges and 
 of the abdominal and thoracic organs. The spleen was large and apparently 
 had been soft. There was no macroscopic evidence of bronchopneumonia. The 
 tissues were not placed in fixing fluid for several days after death. 
 
 Microscopic examination showed marked postmortem change in all the tissues. 
 Sections of the brain showed marked congestion in the meninges and in the tis- 
 sue, but no thrombi or hemorrhages were seen. The ganglion cells of the basal 
 nuclei showed evidence of degeneration, but there was nothing that was not 
 typical of cells which are undergoing postmortem degeneration. 
 
 Sections of the kidneys, liver, spleen, and lungs showed marked congestion. 
 There was marked degeneration of the parenchyma of the liver and kidneys 
 which was at least partially due to postmortem change. The spleen contained 
 several small hemorrhages. No typical thrombi were found in any of the tissues. 
 
 Case 2. — Mrs. M. P., aged 48, first complained of symptoms on Tuesday, 
 Jan. 16. She noted a "peculiar sensation about the eyes," and a cloudiness of 
 vision which became progressively worse during the day. On Wednesday she 
 had difficulty in walking, "was walking upstairs all the time,'' and was very tired. 
 Toward evening she began to have double vision. On Thursday she was very 
 weak and had difficulty in talking and swallowing; she said, "my tongue felt as 
 if it was too large for my mouth and there was a sort of constriction in my throat." 
 On Friday she complained of extreme muscular weakness, frontal headache, 
 diplopia, and photophobia. She was unable to swallow and she talked with the 
 greatest difficulty. On Saturday the symptoms were more severe. She was then 
 seen by Dr. Smart, who gave me the following case record. 
 
 The patient was extremely weak and had great difficulty in talking. Her 
 speech was almost unintelligible. There was bilateral ptosis, the pupils were 
 widely dilated and reacted very sluggishly to light, and there was a slight con- 
 junctivitis. The jaws could not be opened widely, the lips and tongue were 
 parched, and the tongue was heavily coated. There was thick, tenacious mucus 
 in the pharynx which the patient was unable to raise. Examination of the chest 
 
ERNEST C. DICKSON 33 
 
 revealed nothing abnormal in the lungs. The rate of the heart beat was rapid 
 and the sounds were weak, but there were no cardiac murmurs. Nothing 
 abnormal was found in the abdomen. The knee-jerks and plantar reflexes were 
 normal, mentality was unclouded, and taste, smell, hearing, and the cutaneous 
 and deep sensations were unimpaired. There was no disturbance of respiration 
 and the temperature was subnormal. 
 
 On Sunday the patient was much weaker. She complained of difficulty in 
 breathing, and, toward evening, the respiration was of the Cheyne-Stokes type. 
 The pulse was very weak at times but responded temporarily to stimulation. 
 There was an offensive, almost uremic, odor to the breath. The urine was 
 diminished in amount and contained a large amount of albumin. The bowels 
 responded freely to magnesium sulfate enemata. 
 
 On Monday morning there was little change in the general condition of the 
 patient, but about 4 o'clock in the afternoon she began to fail rapidly. About 
 3 hours later there was a sudden attack of cardiac failure from which she did not 
 rally. Mentality was unclouded to within a few minutes before death. A 
 striking feature of the whole clinical picture was the combination of subnormal 
 temperature with a rapid, weak pvdse, a combination which persisted to the end 
 (Text-fig. 4). 
 
 Necropsy was performed by Dr. George B. Worthington, who reported marked 
 congestion of the brain and meninges, and of the abdominal and thoracic viscera. 
 The spleen was small and contained several small hemorrhages. There was no 
 bronchopneumonia . 
 
 Microscop^ic examination of sections of the brain showed marked hyperemia 
 in the meninges and in the brain tissue, and a few small hemorrhages in the region 
 of the basal ganglia. Many of the vessels of the meninges and of the brain con- 
 tained masses of thrombus in which were a few leukocytes (Fig. 5) . The gan- 
 glion cells of the basal nuclei were apparently normal, except for the fact that they 
 were shrunken. There was no evidence of any protoplasmic degeneration or of 
 vacuolization. 
 
 Sections of the liver showed moderate congestion. There was very little 
 evidence of parenchymatous degeneration, and none of proliferation of the inter- 
 stitial tissue. 
 
 Sections of the kidneys showed moderate congestion and extreme parenchy- 
 matous degeneration. Practically all the cells in the convoluted tubules were 
 degenerated, and many of them were necrotic and desquamated. The epithelium 
 of the straight tubules was also severely damaged, and many of the tubules 
 were filled with necrotic debris. The glomerular tufts were filled with blopd but 
 were apparently intact. There was no exudate in the glomerular clefts. There 
 were a few scattered areas of chronic interstitial change. Many of the blood 
 vessels contained masses of thrombus in which were numbers of leukocytes, and 
 some of the medium sized arteries were completely plugged. No hemorrhages 
 were seen. 
 
 Sections of the lungs showed moderate congestion. Many of the blood vessels 
 
34 BOTULISM 
 
 contained masses of loose fibrin but there were no typical cellular thrombi. There 
 was no evidence of bronchopneumonia. 
 
 Sections of the spleen showed very little congestion. Many of the vessels 
 in the trabeculae and in the pulp were filled with dense masses of fibrin in which 
 were moderate numbers of leukocytes (Fig. 6). There were no hemorrhages. 
 
 Case 3. — Mr. C. A. B., of San Diego, a travelling salesman, had taken dinner 
 on Monday night and breakfast on Tuesday morning at the hotel in Escondido. 
 He had eaten heartily of the bean salad and had not noticed any unusual taste 
 or odor. He had been suffering from a severe "cold" for several days and was 
 taking daily doses of magnesium sulfate. He did not notice any symptoms 
 except what he attributed to the " cold" until Wednesday, when he found difficulty 
 in driving his automobile because "things seemed to move in front of me." On 
 Thursday and Friday he had still more difficulty in driving his car, and on Friday 
 he was dizzy at times. About this time his wife observed that "the eye clefts 
 were narrow," presumably ptosis, and that the eyelids were swollen. There had 
 been no special weakness and no gastrointestinal disturbances. He had con- 
 tinued taking magnesium sulfate and the bowels had moved daily. 
 
 A "peculiar tight sensation in the throat" and transient attacks of diplopia 
 were noted on Saturday. The tongue "seemed thick and moved slowly" on 
 Sunday, and the patient, who is a member of a church choir, had great difficulty 
 in singing at the Sunday services. He described his difficulty in the words "it 
 felt as though my throat was paralyzed and as though I could not get my breath 
 quickly enough." He was extremely tired Sunday night. On Monday the 
 symptoms were more severe and he was unable to drive his car. On Tuesday 
 he had a "faint spell" when at breakfast, and also during the forenoon. He 
 was unable to cover his regular territory during the week but did a certain amount 
 of work each day. 
 
 When seen by me the following Sunday he said that he could not remember 
 any marked change from day to day, although he believed that he was not im- 
 proving, and that he was weaker and more easily fatigued than earlier in the 
 week. His vision had been impaired, there had been frequent, transient attacks 
 of diplopia, and the ptosis and dilatation of the pupils had persisted. He had 
 suffered from attacks of faintness whenever he overexerted himself, and had 
 noticed that he "stepped higher" than normally and it was an effort for him to 
 talk. He soon became hoarse when he attempted conversation. He had been 
 unable to eat as rapidly as usual because of difficulty in swallowing; it was fre- 
 quently necessary to take a drink of water before he could swallow solid food. 
 The mouth had been very dry but he had not experienced great thirst. There 
 had been no nausea, vomiting, or constipation, and no abdominal pain. Several 
 times at night he had suffered from choking spells, but they had not troubled 
 him during the day, even when he attempted to swallow. There had been no 
 cough. He had complained a great deal of being cold, even when in a warm 
 room. There had been no disturbance of urination. 
 
 Physical Examination. — The patient was well developed and well nourished. 
 
ERNEST C. DICKSON 35 
 
 The skin was pale and rather dry. There was no cyanosis. After the exertion 
 of undressing there was considerable dyspnea. The pulse varied from 96 to 
 120 per minute during the examination. There was moderate bilateral ptosis, 
 the left lid being lower than the right. The pupils were dilated, slightly irregular 
 in outline, and reacted somewhat sluggishly to light (direct and indirect). Ac- 
 commodation was very slow. There was no nystagmus. The tongue was 
 protruded rather deliberately and was heavily coated. The mouths, lips, and 
 pharynx were dry. The chest movements were equal, and there was no im- 
 pairment of the lungs. The area of cardiac dullness was not increased, the car- 
 diac impulse was not felt, and the heart sounds were feeble and indistinct, but 
 there were no murmurs. The abdomen was slightly distended and soft but there 
 was no tendefness. The liver, spleen, and kidneys were not felt, but the colon 
 was palpable. There was no edema of the ankles or legs. The pharyngeal, 
 jaw, biceps, triceps, abdominal, cremasteric, patellar, knee, ankle, and plantar 
 reflexes were normal. The Romberg test was negative. There was no definite 
 local muscular weakness and sensation was unimpaired. When dressing, the 
 patient had considerable difficulty in buttoning his clothes. 
 
 The systolic blood pressure was 136 mm. of mercury and the diastolic 90 mm. 
 (Mercer). 
 
 The red blood cells numbered 5,300,000, and the leukocytes numbered 7,000. 
 The differential count showed polymorphonuclear neutrophils, 49.5 per cent, 
 lymphocytes, 35.5 per cent; large mononuclear cells, 3.5 per cent; eosinophils, 
 4.5 per cent; basophils, 0.5 per cent; and transitional ceUs, 6.5 per cent. 
 
 The urine contained a moderate amount of albumin. 
 
 In addition to the three which have been described, there were four other cases 
 in this outbreak, two of whom died. The cook became ill Tuesday night, com- 
 plained of severe pains in the head and of difficulty in talking and swallowing, 
 and died Wednesday morning. It was thought at the time that death was due 
 to apoplexy, but, in view of the fact that she had eaten a considerable quantity 
 of the beans, it is probable that she died of a very acute poisoning with the botu- 
 linus toxin. 
 
 The wife of the proprietor of the hotel first noticed symptoms on the Ffiday 
 following the poisonous meal. She went on a business trip to Los Angeles and 
 had great difficulty in going around the streets because of double vision. WhUe 
 in Los Angeles she consulted an optician who prescribed glasses. When she 
 returned home that evening she was very weak and tired, and immediately went 
 to bed. Her illness was severe and prolonged, and the symptoms were identical 
 with those that have been described. She died on Feb. 10, 26 days after she 
 had eaten the poisonous food. Necropsy was not permitted. 
 
 On Jan. 27, the red blood corpuscles numbered 5,200,000, and the leukocytes 
 12,500. The differential count showed polymorphonuclear neutrophils, 77.5 
 per cent; lymphocytes, 19.5 per cent; large mononuclears, 2 per cent; eosino- 
 phils, 0.5 per cent; and transitionals, 0.5 per cent. 
 
 The daughter of the proprietor was able to do the work in the kitchen on Thurs- 
 
36 
 
 BOTULISM 
 
 day and Friday, although she had some disturbance of vision on Thursday and 
 some difficulty in walking on Friday. On Saturday morning she was able to 
 dress herself and to wait on her mother, but by evening was so weak that she 
 was forced to go to bed. She told me that on Saturday she had had the greatest 
 difficulty in balancing her head when she walked, and that it was often necessary 
 to "steady" her head by supporting her chin with her hand. She was extremely 
 ill for several weeks, her symptoms during the first 11 days being almost as severe 
 as those of her mother. The first sign of improvement appeared on the 12th 
 day when she was free from strangling spells for nearly 24 hours. Recovery was 
 very gradual. 21 days after the poisoning she was able to be propped up in bed, 
 and about 2 weeks later was allowed to sit up in a chair. On Mar. 1, 6 weeks 
 after the poisoning, she was able to walk a few steps. She was able to swallow 
 solid food after the 15th day of her illness. 
 
 On Jan. 27, there were 5,400,000 red blood corpuscles and 13,000 leukocytes. 
 The differential count showed 78.5 per cent polymorphonuclear neutrophils, 
 14.5 per cent lymphocytes, 3.5 per cent large mononuclears, and 3.5 per cent 
 transitional cells. 
 
 The seventh patient left for Colorado on Tuesday, the day following that on 
 which the beans were served, and the first symptoms developed while he was 
 en route. They consisted of swelling in the throat, difficulty in swallowing, 
 double and cloudy vision, and disturbance of accommodation. He complained 
 of grea:t muscular weakness, which came on suddenly. There was especially 
 marked weakness of the muscles of the neck which he described in the words 
 "when putting on my shoes I found it very difficult to get my head and neck 
 back to normal position, and in many cases it was necessary for me to push my 
 head up with my hands." He found that the double vision was relieved when 
 he wore amber-colored glasses, but that it returned as soon as he removed them. 
 He was troubled with shortness of breath and rapid heart beat, and had no appe- 
 tite. There were no other gastrointestinal symptoms. His symptoms all dis- 
 appeared in a few days, with the exception of the "swelling in the throat" and 
 the muscular weakness. On Mar. 1 he wrote me that he had almost completely 
 recovered, although he had not yet regained his former strength. 
 
 The duration of the illness of the fatal cases varied greatly. One 
 patient died within 40 hours from the time she tasted the beans, one 
 died on the 7th day, and another on the 8th day after the poisonous 
 meal. The longest course was that of the wife of the proprietor, who 
 became ill on the 4th day after she had eaten the beans, and died on 
 the 26th day. The immediate cause of death in all the cases was 
 respiratory failure. 
 
 An interesting development of the investigation in Escondido was 
 the disclosure of the fact that within the past few years there have been 
 
ERNEST C. DICKSON 37 
 
 two instances in which numbers of domestic fowl died of hmber-neck 
 after eating spoiled home-canned beans. In one of these instances 
 seventeen chickens, and in the other over fifty chickens and several 
 turkeys died. When considered in connection with the frequent 
 occurrence of limber-neck in the outbreaks of botuhsm which have 
 been recorded in this report, it seems justifiable to suppose that the 
 beans had been infected with Bacillus botulinus. Fortunately no 
 persons had tasted or eaten the beans in these two cases. 
 
SYMPTOMATOLOGY AND COURSE. 
 
 The best review of the symptomatology of the earlier cases of botulism is 
 contained in the report of Miiller (81), 1869, in which the records of 263 cases 
 are carefully analyzed. The earliest observers had noted that the onset of the 
 paralytic symptoms was frequently preceded by acute gastrointestinal distur- 
 bances, and Dann (10), 1828, had suggested a division of the symptoms into two 
 groups, (a), the primary "irritative" group, and (6) the later "paralytic" group. 
 This division was not generally accepted, however, for, as was pointed out by 
 Schlossberger (13) and Miiller (81), the primary irritative group of symptoms 
 was frequently absent. 
 
 Van Ermengem (34), 1897, reviewed the previous records of the sjrmptoma- 
 tology and summarized his conclusions as follows: 
 
 "Le syndrome botulinique consiste essentiellement en un ensemble de ph6nomenes 
 neuroparalytiques: troubles secr6toires des premieres voies et paralysies motrices syme- 
 triques, totales ou partielles, dependant tres probablement de lesions de la moelle-allongee, 
 du bulbe, principalement des noyaux d'origine de divers nerfs c^rebraux, et des comes 
 antSrieures de la moelle epiniere. 
 
 II se caracterise: 
 
 1. par un arret de secretion ou une hyper-secretion de la salive et des mucosites bucco- 
 pharyngees; 
 
 2. par une ophthalmoplegic externe et interne plus ou moins complete (blepharoptose, 
 mydriase, paralysie de I'accommodation, diplopie, strabisme interne) ; 
 
 3. par de la dysphagie, de I'aphonie, de la constipation rebelle, de la retention des urines; 
 
 4. par un a£Eaiblissement general de la contractilite de tous les muscles volontaires; 
 
 5. par I'absence d'un Stat febrile, de troubles de la sensibilite g6nerale et derintelligfence. 
 
 6. A cet ensemble phenomenal s'ajoutent souvent des troubles de la respiration et de la 
 circulation, qui peuvent aboutir a une mort plus ou moins rapide par paralysie bulbaire; 
 
 7. Enfin, les manifestations caracteristiques ne surviennent, au plus t6t, que douze 4 
 vingt-quatre heures apres I'ingestion des aliments. EUes sont souvent prec6d6s de troubles 
 gastro-intestinaux passagers, apparaissent gradueUement et persistent pendant des 
 semaines." 
 
 The first S3Tnptoms usually develop in from 18 to 24 hours after 
 the ingestion of the poisonous food, but rarely they may occur earKer, 
 and not infrequently they may be delayed for 2 or 3 days or even 
 longer. Miiller (81) records one case in which the initial symptoms 
 appeared 9 days after the poisonous food was eaten, but he notes that 
 he was unable to confirm the report of Lebert (104) in which it was 
 stated that they might appear as late as 14 days or even several weeks 
 
 38 
 
ERNEST C. DICKSON 39 
 
 after the ingestion of the poisonous food. The earhest appearance of 
 symptoms which has been noted in the American Hterature is recorded 
 by Stiles (98) who noticed weakness and irritation in the throat within 
 2 hours, and suffered from nausea and vomiting about 4 hours after 
 the meal. In the series described in this report the usual length of 
 time which elapsed before the appearance of symptoms was from 36 
 hours to 4 days, although in two instances the patients became ill in 
 from 4 to 6 hours, and in one there were no symptoms until the 6th 
 day. In general it may be said that when symptoms appear very 
 early, they are usually of a gastrointestinal t3^e; viz., gastric distress, 
 nausea, and diarrhea. 
 
 Botulism differs from the majority of types of food-poisoning in that 
 there are usually no acute gastrointestinal disturbances. Occasionally 
 there may be burning and distress in the stomach, early nausea and 
 vomiting, which may persist for several hours or even a day or two, 
 and diarrhea. The vomitus is frequently yellow and extremely bitter 
 and irritating. There is apparently an early inhibition of the motor 
 function of the stomach; Biirger (17) reported that he had washed 
 from the stomach particles of food which had been eaten 5 days pre- 
 viously, and cases are recorded where portions of the poisonous meal 
 have been found in the stomach at autopsy, several days after the food 
 had been eaten. Constipation is an almost constant manifestation of 
 the condition, and may resist all efforts to induce evacuation of the 
 bowels. It may be present from the outset or may develop after 
 several hours of violent purging. Frequently there is moderate dis- 
 tention of the bowels with gas, but there is rarely any abdominal 
 tenderness or rigidity. Occasionally the patients complain of cohc. 
 When evacuation is induced, the stool is frequently scybalous in char- 
 acter. Kerner (7) recorded that the stool was often clay-colored as in 
 biliary obstruction, but this does not seem to be the rule. 
 
 Perhaps the earliest symptom of botulism in the majority of cases 
 is a peculiar, indefinite indisposition associated with a feeling of fatigue, 
 sometimes with headache or dizziness, and with definite muscular 
 weakness. Not infrequently the acute gastrointestinal symptoms are 
 lacking and the patient associates his condition with the accompanying 
 constipation, and attempts to relieve his symptoms with laxatives. 
 
 Disturbances of vision occur very early, in many cases being the first 
 
40 BOTULISM 
 
 definite signs of serious illness which are noted by the patient, and it 
 is noteworthy that a fairly large number of cases of botulism are first 
 seen by ophthalmologists and opticians. There may be initial scin- 
 tillations and dimness; of vision, but changes in the retina are rarely 
 found. Kerner (27). referred to a case in which the dimness of vision 
 progressed to complete blindness; Miiller (81) quoted from von Faber 
 (1854) that there were eleven cases in the literature in which ambly- 
 opia had progressed to blindness; and Ruge (105) reported one case in 
 which he made a diagnosis of papilloretinitis, but these are the only 
 instances in the available literature in which actual damage of the first 
 cranial nerve is recorded. Practically all the authors agree that the 
 disturbances of vision are entirely dependent upon impairment of the 
 extrinsic and intrinsic muscles of the eye.^ 
 
 There is early involvement of the third cranial nerve in all its func- 
 tions, and blepharoptosis, mydriasis, loss of reflex to light stimulation, 
 and diplopia are practically constant. Occasionally the pupils are of 
 unequal size, and the contour of one or both may be irregular. There 
 is early loss of ability to accommodate for near vision, and complete 
 loss of accommodation soon follows. It is apparently the impairment 
 of accommodation which is responsible for the cloudy vision, as vision 
 with either eye is usually unimpaired for distant objects. Paralysis 
 of the external rectus muscle occurs earlier and more frequently than 
 paralysis of the superior oblique muscle, but occasionally there is com- 
 plete fixation of the eyeball in the socket, due to paralysis of all the 
 extrinsic muscles. Nystagmus and vertigo, especially on movement, 
 are not uncommon. Photophobia has been recorded in a few cases, 
 and some authors have noted that the vertigo was less marked when 
 bright light was excluded. 
 
 Coincidently with, or closely following the onset of disturbances of 
 ■ vision, the patients usually complain of difi&culty in swallowing and 
 talkng, and frequently there is a peculiar sensation of constriction of 
 the throat. The tongue appears to be larger than normal and is slug- 
 gish in its movements. Cases are recorded in which the patient was 
 
 * I have consulted with Dr. Hans Barkan and Dr. A. B. McKee of the Ophthal- 
 mological Department of the Stanford University Medical School, and they agree 
 that the signs which Ruge has described are evidence of retrobulbar neuritis 
 rather than of papilloretinitis. 
 
ERNEST C. DICKSON 41 
 
 unable to lift the tongue over the lower teeth, but usually it can be 
 protruded without deviation, although the movements are slow and 
 are performed with evident effort. The tongue is usually heavily 
 coated on the surface although the edges may be clean. There may be 
 complete paralysis of the pharyngeal muscles and frequently there is 
 loss of the pharyngeal reflex. The mucous membranes of the mouth 
 and pharynx as well as of the nasal passages are dry and may be hyper- 
 emic and swollen. Ulcerations and aphthous patches on the pharyn- 
 geal mucous membrane have been described, and Niedner (106) re- 
 ported cases in which there was a typical diphtheritic exudate on the 
 tonsils. It is probable that Niedner's cases were complicated with 
 true diphtheria,, as a similar angina developed in one of the attendants 
 who had not eaten any of the poisonous sausage. It is not probable 
 that he had to do with a postdiphtheritic paralysis, as the s}Tiiptoms 
 of angina and the formation of the exudate occurred comparatively 
 late in the course of an illness which was otherwise typically botuhsm, 
 and, moreover, did not develop in all of his patients. 
 
 The difficulty in pronouncing words is apparently chiefly due to the 
 impaired motihty of the tongue, although paralysis of the laryngeal 
 muscles is also an important factor. The voice is low and without nor- 
 mal tone, and later in the course of the illness there may be complete 
 aphonia. At first the speech is slow and there is difficulty in pro- 
 nouncing certain words, but ultimately the difficulty becomes greatly 
 increased, and attempts at speech produce only an unintelhgible 
 mumble. Even in the milder cases the onset of fatigue is extremely 
 evident, and speech becomes slower and more difficult and the voice 
 becomes husky after a comparatively short attempt at conversation. 
 Occasionally there is a distressing croupy cough which is unproductive. 
 
 The difficulty in swallowing is largely due to paralysis of the pharyn- 
 geal muscles. The patients complain that they cannot force the food 
 from the pharynx into the esophagus, but they say that if they can get 
 it started there is no further difficulty. It is probable that the dryness 
 of the mouth is also an important factor, since in the milder cases the 
 patients note that they are able to swallow solid food if they take a 
 drink of water. Attacks of strangling often occur when the patient 
 attempts to swallow or to free the thick, tenacious mucus from the 
 pharynx. As a rule, strangling occurs only in the more severe cases 
 
42 BOTULISM 
 
 and may persist until the patient is extremely exhausted, and not in- 
 frequently the attacks are accompanied by a return of the food or fluid 
 through the nose, and by insufflation into the trachea and bronchial 
 tree. 
 
 A striking feature of this type of food-poisoning is the extreme pro- 
 gressive muscular weakness. Not infrequently the patient's first 
 complaint is of weakness in the arms and legs, and later it may become 
 so marked that he is unable to raise the arms or legs from the bed. It 
 is especially noticeable that there is difficulty in supporting the weight 
 of the head. One of the patients at Escondido told me that even 
 before she was forced to remain in bed it was necessary for her to 
 ' 'steady'' her head by supporting the chin with her hand whenever she 
 attempted to walk, and another said that after he had leaned over to 
 lace his shoes it was necessary to push his head back into position with 
 his hand. Many of the patients complain of inability to masticate, 
 and it has been noted that there is a pecuKar dull facial expression 
 which is dependent upon weakness of the facial muscles. Some of the 
 earlier authors noted that their patients were able to sit up in a chair, 
 and even preferred to do so when they were quite unable to walk, and 
 they assumed that the muscles of the back were not involved, but 
 later authors do not confirm this observation. The general muscular 
 weakness is rapidly progressive and in the end may lead to a condition 
 of relaxation of the muscles which closely simulates paralysis. 
 
 It is seldom, however, that true paralysis of the skeletal muscles is 
 found. There is almost always paralysis of some or all of the muscles 
 of the eye and those of the pharynx and larynx. Wertheim (107) 
 described a case in which there was complete paralysis of the soft 
 palate, and various authors have noted unilateral or bilateral facial 
 paralysis. In general it appears to be true that there may be true 
 paralysis in muscles which receive their motor nerve supply from the 
 cranial motor nerves, and the loss of reflexes in the eyes and pharynx 
 indicates that it is of the lower neurone t3q3e. There is usually a more 
 or less marked incoordination of muscular movement in the arms and 
 legs, so that the patients have difficulty in picking up small objects, 
 and walk with an ataxic gait, but, although a few cases are recorded in 
 which there was an absence of the knee-jerks and the Achilles reflexes, 
 in the great majority of cases the superficial reflexes are aU intact, 
 although response to stimulation may be considerably diminished. 
 
ERNEST C. DICKSON 43 
 
 In view of the many evidences of involvement of the cranial motor 
 nerves, it is surprising that botulism is characterized by an almost com- 
 plete absence of sensory disturbances. There may be an initial head- 
 ache, which occasionally persists, and at times there is early distress 
 or even pain in the region of the stomach, but otherwise it is unusual 
 for the patient to suffer any pain. He usually is apathetic and 
 may be somnolent or apparently semicomatose, though not infre- 
 quently there is considerable restlessness and sometimes insomnia, 
 and he may become quite irritable because of the difficulty in express- 
 ing himself and of clearing the pharynx of mucus. Occasionally there 
 is some loss of memory and orientation may be slow, but it has been 
 recorded from the earliest times that an outstanding feature of the 
 condition is that mentahty remains unimpaired throughout the illness. 
 
 Reference has already been made to the fact that in a very few cases 
 there has been impairment of the optic nerve with blindness. It has 
 also been noted that a few patients complained of tinnitis and partial 
 deafness, but, with these exceptions, there is practically no reference 
 in the hterature to any disturbance of the sensory nerves. A few cases 
 were described by the early authors in which the patients complained 
 of loss of sensation in the tips of the fingers and of formication, but 
 Husemann (79) concluded that these were cases in which it was prob- 
 able that the patients were suffering from trichinosis and not from 
 botulism. Collatz (56) noted that in one of the more chronic cases of 
 his series there were ' 'neuralgic pains " in the neck, and that, associated 
 with paresis of the arms, there was slight disturbance of sensation in 
 the arm and hand. The majority of authors, however, report that 
 their patients were entirely free from sensory disturbances, and this 
 observation has been so frequently confirmed that absence of disturb- 
 ance of sensation is considered to be one of the characteristic features 
 of the poisoning. 
 
 Inhibition of many of the secretions is also an almost constant mani- 
 festation of botuhsm, and the patients usually complain of extreme 
 dryness of the mouth, pharynx, and the nasal passages. Occasionally 
 there is an increase in the amount of sahva, but usually the serous 
 secretions of the mouth are greatly diminished and- the mucus is 
 secreted in a thick, tenacious form which is removed with extreme 
 difficulty. It is probable that the absence of serous secretion in the 
 
44 BOTULISM 
 
 mouth is largely responsible for the occasional impairment of the sense 
 of taste, although the glossopharyngeal and chorda tympani nerves 
 may also be impaired. A similar inhibition of the serous secretions is 
 found in the gastrointestinal tract and is probably partly responsible 
 for the persistent constipation. Usually there is an inhibition of the 
 sweat secretion and the skin becomes dry and hard. According to 
 Kerner (7), this is especially noticeable on the palms of the hands and 
 soles of the feet where the skin becomes extremely thick and dry and 
 may be desquamated in large patches. Various authors have referred 
 to an absence of tear secretion, and Senckpiehl (15) states that in one 
 case in the literature it was accompanied by severe conjunctivitis. 
 Weiss (9) recorded one case in which the secretion of milk was not 
 diminished and the nursing infant was unaffected, and another in 
 which the patient passed through a normal menstrual period during 
 the course of her illness. There is considerable variation in the reports 
 concerning the secretion of urine. Apparently there is normal secre- 
 tion in the majority of cases, but instances are recorded in which there 
 was polyuria, oliguria, or even anuria. It is not surprising that the 
 flow of urine should be diminished in the more severe cases, as the 
 patients are unable to swallow any large amount of fluid, although this 
 would be partly counteracted by the inhibition of sweat secretion. 
 It has been variously recorded that the urine is entirely normal and 
 that it contains varying amounts of albumin. Records of renal func- 
 tion tests have not been reported. 
 
 The earher authors emphasized the fact that the pulse rate was 
 extremely slow, and compared it with that which is found in digitalis- 
 poisoning. Senckpiehl (15) noted that at the outset the pulse is fre- 
 quently 50 to 60 per minute, but that later in the course of the illness 
 it may become as frequent as 100 per minute. A survey of the more 
 recent cases shows that a rapid pulse is extremely common, one of Col- 
 latz' (56) cases having a rate as high as 150 per minute. The action of 
 the heart muscle is impaired and an absence of visible cardiac impulse 
 and distant and weak heart sounds are very common. 
 
 The temperature is usually subnormal. In the majority of cases it 
 ranges between 96° and 98°F., and in uncomplicated cases it remains 
 subnormal until death. Not infrequently fever develops in the later 
 stages of the illness, but this is usually a sign of the development of 
 
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 Text-Fig. 2. Temperature, pulse, and respiration curves of Miss R. L., the 
 fatal case of the Stanford University series. The patient was not so ill as some 
 of the other patients during the first part of her illness, but developed broncho- 
 pneumonia and died on the 13th day. Note the rise in temperature which is 
 coincident with the onset of bronchopneumonia. 
 
 Text-Fig. 3. Temperature, pulse, and respiration curves of Miss F. M., the 
 elder grandchild in my series No. 1. The patient was taken to the hospital on 
 the 6th day after she had eaten the apricots, and died S days later. Note the ex- 
 tremely high pulse and the low temperature. 
 
 Text-Fig. 4. Temperature, pulse, and respiration curves of Mrs. M. P. 
 Case 2 of Outbreak 7, of my series. Note the rapid pulse rate and the subnormal 
 temperature. The patient was taken to the hospital on the Sth day after she 
 had eaten the bean salad, and died 2 days later. 
 
 45 
 
46 . BOTULISM 
 
 bronchopneumonia. Eichenberg (108) has stated that fever is never 
 found except in cases which are compHcated by pneumonia or some 
 other acute infection. 
 
 Respiration is frequently unimpaired in the earHer stages of the 
 ilkiess although it may become accelerated on slight exertion, and may 
 be somewhat irregular. Later in the course of the illness, however, 
 disturbances of respiration become very severe. There may be ex- 
 treme dyspnea, often irregular breathing, and all the sensory muscles of 
 respiration may be brought into play. Still later there may be partial 
 or complete asphyxia and the most frequent immediate cause of death 
 is respiratory failure. Not only are the accessory muscles of respira- 
 tion apparently paralyzed, but Fischer (109) records a case in which 
 incision was made to allow of kneading the heart to induce its further 
 action, and the diaphragm was found to be completely paralyzed. 
 
 The general appearance of the patient is most distressing. The 
 extreme muscular weakness, the anxiety and the utter helplessness, 
 the difficulty in swallowing, the attacks of strangling, the struggle for 
 breath, and the unsuccessful attempts to articulate constitute a clinical 
 picture which, when once observed, can never be forgotten. The face 
 is usually pale, but in the early stages may be congested. There may 
 be normal appetite and excessive thirst, but the patient is afraid to try 
 to swallow. At times the stranghng spells are so severe that there is 
 incontinence of urine, and the accumulation of thick, tenacious mucus 
 in the pharynx is a constant source of annoyance. The fact that the 
 patient remains in full possession of his mental powers and can reahze 
 the seriousness of his condition only adds to the distressing character 
 of the situation. . 
 
 Records of laboratory examinations are very incomplete. In none 
 of the reports in the literature is there any, mention of the condition 
 of the blood except that there is a progressive anemia in the more 
 chronic cases. Blood counts were made in five of the cases of my 
 series. In one the leukocytes numbered 7,000 and showed nothing 
 abnormal in the differential count. In two they numbered 12,500 
 and 13,000, the differential count showing respectively 77.5 and 78.5 
 per cent polymorphonuclear neutrophils. In one it was noted that 
 the leukocytes varied from 10,000 to 14,000, and in the other that, on 
 the last day of the illness, there were 17,600 leukocytes of which 86 per 
 
ERNEST C. DICKSON 47 
 
 cent were polymorphonuclear neutrophils. Subsequent histologic 
 examination showed that in the last case there was a well advanced 
 bronchopneumonia . 
 
 A cell count of the cerebrospinal fluid was made in one case and 
 showed 80 cells, but, unfortunately, there is no record of further 
 investigation. The Wassermann reaction in the blood of the same 
 patient was negative. Examination of the urine in several cases 
 showed var3dng amounts of albumin, but was incomplete in all. 
 Estimation of blood pressure was made in three cases, two of which 
 were very ill, and one which was an ambulatory case, and showed no 
 appreciable variation from normal. 
 
 Little can be deduced from the blood counts in these cases as, in 
 all but one, a single examination was made. In the case where two 
 blood counts were recorded there was no opportunity of determining 
 whether the increase of 4,000 cells was dependent upon the beginning 
 of a pneumonic process. In the two cases where there were 12,500 
 and 13,000 leukocytes respectively, the patients were extremely ill, 
 one subsequently died, but showed no clinical evidence of inter- 
 current infection. In the case in which the leukocytes numbered 
 7,000, the patient was an ambulatory case in which the symptoms were 
 comparatively mild. 
 
 The duration of the illness varies greatly. Occasionally death may 
 occur within 48 hours after the poisonous food is eaten, but as a rule it 
 occurs considerably later. Miiller (81) recorded that of 150 fatal 
 cases, the majority died in from 4 to 8 days after the poisoning, and he 
 added that few persons die who have survived for more than 10 days. 
 In the series of cases which is recorded in this report, one died within 
 48 hours, one on the 3rd day, seven in from 4 to 6 days, one on the 8th 
 day, one on the 11th day, and one on the 26th day after eating the 
 poisonous food. 
 
 Death usually occurs from cardiac or respiratory failure. Fre- 
 quently it has been recorded that the heart continues to beat for 
 several minutes after respiration has ceased and cases are described in 
 which artificial respiration, especially with oxygen, has kept the 
 patient alive for several hours. Usually there is a terminal asphyxia 
 with its accompan5dng cyanosis. Not infrequently the patients be- 
 come comatose some time before death, and in a few cases convulsions 
 
48 BOTULISM 
 
 have been noted. Very often they die during an attack of strangKng 
 which has been induced by an attempt to swallow food or drink. 
 Occasionally there is apparent improvement in all the symptoms for a 
 few hours or even a day before the sudden failure of respiration or the 
 development of bronchopneumonia precipitates dissolution. 
 
 When recovery occurs the convalescence is extremely slow and 
 tedious. The severity of the illness usually reaches its maximum 
 within 10 days and improvement follows slowly. The strangKng 
 spells and the difficulty in swallowing and in talking are frequently 
 the first symptoms to diminish in severity. The muscular weakness 
 disappears more slowly. Many cases are recorded in which the 
 patients were comparatively well within 2 or 3 months, but the weak- 
 ness, vertigo, and emaciation may persist for a much longer time. 
 The disturbances of vision are apparently the last to clear up and may 
 persist for months. The patient frequently retains a tendency to 
 constipation. In so far as can be gathered from the hterature there 
 seems to be no permanent disabiHty, although it is frequently several 
 months before the patients regain their former condition of health. 
 
DIAGNOSIS. 
 
 There may be difficulty in diagnosis if one has to do with a single 
 case of botulism, especially if there is no available history of the 
 patient's having eaten spoiled food. But when, as occurred in several 
 cases in my series, the iUness closely follows the ingestion of food which 
 was known to be spoiled, especially when domestic fowl have shown 
 symptoms of poisoning after eating the discarded food, or when all 
 the members of a family or a number of the guests at a hotel have de- 
 veloped the symptoms within a short time after a meal of which they 
 had all partaken, there is Httle difficulty in concluding that the illness 
 is due to food-poisoning, and, as a rule, in determining the article of 
 food which is at fault. When one has decided that he is deahng with 
 cases of food-poisoning, the disturbances of vision, the difficulty in 
 swallowing and talking, the absence of sensory disturbances, the 
 marked muscular weakness, and the subnormal temperature at once 
 suggest botuhsm. Bacteriologic examination of the remnants of the 
 food may reveal the presence of Bacillus botulinus, and in the absence 
 of any remnants of food, the recovery of the bacillus from the spleen 
 or intestinal contents of a fatal case, or the demonstration of the typical 
 thrombosis in the blood vessels will establish the diagnosis. 
 
 The most common diseases with which botulism may be confused 
 are acute poliomyelitis and cerebrospinal syphilis, but one must also 
 exclude bulbar paralysis, various toxic ophthalmoplegias, and poison- 
 ing from belladonna, gelsemium, hyoscyamus, and methyl alcohol. 
 
 Lochte (110) and Niedner (106) reported cases in which it was 
 thought that the patients were suffering from hysteria, and it is inter- 
 esting that in two of the cases of my series the attending physicians at 
 ffirst considered hysteria as a probable diagnosis. 
 
 Poisoning from fish roe and from partly decomposed fish which has 
 been salted may produce symptoms that resemble botulism. Novy 
 (ill) referred to the so called fugu-poisoning of Japan which is pro- 
 duced by certain fish in which the ovaries and testicles contain a 
 curare-Kke substance. Certain other fish are poisonous only during 
 
 49 
 
50 BOTULISM 
 
 the spawning season, and fish roe-poisoning is not uncommon in 
 Russia. There may be dilatation of the pupils, disturbances of 
 salivary secretion and difficulty in swallowing, but the symptoms are 
 essentially those of a severe gastroenteritis. Konstansoff (112) has 
 shown that the initial products of decomposition of fish are extremely 
 toxic, and that they produce symptoms which resemble those of 
 botulism. The toxin is not destroyed by salting, although the putrefy- 
 ing bacteria are killed, and will produce severe poisoning if the salted 
 fish is not cooked before it is eaten. The poisoning from mussels and 
 oysters may also be of this type, and may closely simulate botulism. 
 Senckpiehl (15) stated that the s)anptoms of fish-poisoning are usually 
 more acute, are more of a gastrointestinal type, and may be accom- 
 panied by a generalized erythema. 
 
MORTALITY OF AMERICAN CASES. 
 
 The mortality of the cases which have occurred in this country has 
 been extremely high, but this is probably due to the fact that botulism 
 has not been generally recognized, and that only the fatal cases of food- 
 poisoning have been recorded. Excluding the reported cases in which 
 the diagnosis is not reasonably certain, there have been, during the 
 past 25 years, sixty-four cases of botulism, of which forty-one died, 
 and it is an interesting fact that of the sixty-four cases, fifty-four 
 have occurred in California. 
 
 The percentage of fatal cases in the various outbreaks has varied 
 greatly. In Outbreak 1 of this report and in Sheppard's and 
 Frost's series the mortality was 100 per cent, and in Peck's series of 
 twelve cases it was 91.6 per cent. In Wilbur and Ophiils' series of 
 twelve cases, on the other hand, the mortality was only 8.3 per cent, 
 but in the collected cases which have occurred in the United States, 
 the mortality has been slightly more than 64 per cent. 
 
 51 
 
TREATMENT. 
 
 The extremely high mortality of botulism is an indication of the 
 unsatisfactory results that are obtained by therapy. The percentage 
 of fatal cases is as great today as it was 50 years ago, and we know very 
 little more concerning treatment than did the physicians of that time. 
 It was hoped that the antitoxic serum would be of value, but there are 
 no available records of its use, except in laboratory experiments. Like 
 the tetanus antitoxin, the botulinus antitoxin must be given very early 
 if it is to be. effective, and it is probable that, as in tetanus, it is already 
 too late when the symptoms of the poisoning are well established. 
 The fact that Kob (127) demonstrated the toxin in the blood 9 days 
 after the poisoning, indicates, however, that the antitoxin should be 
 given even though the symptoms have been present for some time. 
 
 The gratifying results of the prophylactic use of diphtheria and 
 tetanus antitoxins suggest that a similar use of botulinus antitoxin may 
 be of value if it is possible to recognize an indication for its adminis- 
 tration. The occurrence of limber-neck in domestic fowl, if it devel- 
 ops after they have eaten refuse from the kitchen, should be sufficient 
 reason for administering botulinus antitoxin to all persons who have 
 eaten any of the suspected food. Chickens usually develop the symp- 
 toms of limber-neck within a few hours, and die within 24 to 36 hours 
 after they have eaten the poisonous food, whereas it is not uncommon 
 to find that human beings are free from symptoms for from 24 to 36 
 hours after the meal. It is possible that the antitoxin may mitigate 
 the severity of the illness if it is administered before or even shortly 
 after the appearance of symptoms due to disturbances of the central 
 nervous system, and it should be given a trial. Leuchs (114) has 
 shown that polyvalent sera should be used. 
 
 Miiller (81) outlined the course of treatment which is the basis for 
 all that have since been advocated. Emesis should be induced or 
 lavage performed even when the symptoms have been present for some 
 time, or when the patient has been vomiting, as it is not uncommon to 
 find that portions of the poisonous food are retained in the stomach, 
 
 52 
 
ERNEST C. DICKSON 53 
 
 sometimes for several days. Active purgation should be obtained if 
 possible, preferably with magnesiimi sulfate or castor oil, and the 
 colon should be thoroughly irrigated. The patient should be kept in 
 bed, and as free from excitement as possible. Simple, nourishing food 
 and water should be given in sufficient quantities, but the danger of 
 aspiration pneumonia should be remembered, and it is better to give 
 the water by rectum or by hypodermoclysis when the patient has 
 difficulty in swallowing. 
 
 Strychnine seems to be of value in improving the action of the dam- 
 aged central nervous system and may be given freely. Pilocarpin 
 has been used to counteract the diminished secretions, especially to 
 relieve the distress caused by the accumulation of tenacious mucus in 
 the pharynx, and has given temporary relief in many cases. Pelzl 
 (121) stated that twenty drops of a 1 per cent solution may be given 
 daily without producing toxic symptoms, but Schede (21) reported 
 that in one of his cases, 0.01 gm. of pilocarpin produced a very severe 
 pulmonary edema which almost caused the death of his patient, as he 
 was unable to cough up the fluid. Cardiac and other stimulants 
 should be used as indicated. 
 
 Since the illness is due to the action of a poison which is not elabo- 
 rated within the body, the chances for recovery are good if the patient 
 can be carried over the period in which the toxin is acting. Death 
 is usually due to respiratory failure, and the heart action may be 
 good when the respiratory mechanism is faiUng. Artificial respiration 
 is therefore indicated, and should be continued, and combined with the 
 administration of oxygen, for hours if the heart continues to beat. 
 
BACILLUS BOTULimJS AND ITS TOXIN. 
 
 Van Ermengem (34, 86, 87) was the first to demonstrate the real cause of the 
 poisoning in botulism. From remnants of the poisonous ham, and from the 
 spleen and intestinal contents of a victim in the Ellezelles outbreak, he isolated 
 an anaerobic, spore-bearing bacOlus, which produces a virulent toxin when grown 
 under suitable conditions; and he showed that it is the toxin of the bacillus, to 
 which he gave the name Bacillus hotuUnus, which is responsible for the poisoning. 
 In 1906 he obtained another strain from ham which had caused the illness of 
 eight persons in Iseghem in Flanders (87), and his observations have been con- 
 firmed by several authors in Europe. In 1900 Romer (35) recovered a strain of 
 B. hotulinus from ham which had poisoned four persons in Giessen, and in 1901 
 Madsen (50), in Denmark, obtained a culture from poisonous fish. In 1913 
 Ornstein (88) found the bacillus in the ham which had caused the illness of two 
 persons, and in the spleen of one of the victims. He recorded that, including 
 his own, four strains of B. hotulinus had been isolated from poisonous ham, but 
 in 1913 Schumacher (18) recovered another strain from ham which had caused 
 the illness of six persons. There is one record of the isolation of the bacillus from 
 food material which is not of animal origin, that of the Darmstadt outbreak in 
 1904, in which the bacillus was recovered from home-canned beans which had 
 been served as salad. This strain, which was isolated by Landmann (58), was 
 very similar to that recovered from ham by van Ermengem, although there were 
 certain differences, and various investigators, including Landmann, Gaffky (113), 
 and Leuchs (114), concluded that both were strains of the same organism. 
 
 The only record of the isolation of B. hotulinus from nature is that of Kempner 
 and Pollack (115) who recovered a strain from the intestinal contents of a normal 
 hog. Many materials have been suspected of harboring the bacUlus, and van 
 Ermengem (34) made repeated cultures from garden soil, dirt from the streets, 
 mud from ponds and rivers, manure from stables, cow manure, horse manure, 
 duck excreta, and the intestinal contents of several varieties of fish, but in none 
 was he able to demonstrate the presence of B. hotulinus. 
 
 In the course of my investigations of the various outbreaks of botu- 
 Hsm on the Pacific Coast, I have succeeded in isolating three strains of 
 Bacillus hotulinus. The first strain, No. Ill of my series, was obtained 
 from the crops or gizzards of three chickens which had died after eating 
 the string beans which had caused the poisoning in Outbreak 4; the 
 second strain, No. IV, was found in the gizzard of a chicken which 
 died after eating the discarded corn in Outbreak 2; and the third 
 
 54 
 
ERNEST C. DICKSON 55 
 
 strain, No. V, was obtained from a can of string beans which was pre- 
 pared with that which caused the poisoning in Outbreak 7. 
 
 In a review of the available Hterature I have been unable to find any 
 record that Bacillus hotulinus has been previously isolated in this 
 country, but I have been informed by Dr. G. L. Hoffmann of the 
 Mulford Biological Laboratories that, several years ago, a strain was 
 recovered from cheese in one of the New England States. Recently 
 a bacillus, which may be Bacillus botulinus, was recovered by Dr. Ivan 
 C. Hall, of the University of California, from home-canned corn which 
 had poisoned a number of chickens in Hanford, California, but the 
 identification of this strain is not yet established. Morphologically 
 and culturally it appears to correspond to Bacillus botulinus, but, up 
 to this time, I have been unable to demonstrate a toxin production 
 in any of the favorable media. ^ 
 
 The method which was adopted in the isolation of the bacilli from 
 the crops and gizzards of the chickens is as follows: The contents of the 
 crop or gizzard were washed into a sterile flask with sterile water, and 
 thoroughly shaken. The flasks were then placed in a water bath at 
 60°C. and heated for an hour. Films from the contents of the flasks 
 showed a mixture of many kinds of bacteria, including some large, 
 spore-bearing bacilli which had the morphology of Bacillus suUilis, 
 and others which were club- or spindle-shaped, also with spores, which 
 resembled Bacillus hotulinus. 
 
 Transplants were made to deep glucose agar cultures which were 
 incubated at 28°C. for several days. All tubes which failed to show 
 gas formation were discarded, but from the others transplants were 
 made to tubes of glucose pork or beef infusion, 0.2 per cent alkaline 
 to phenolphthalein, which were covered with albolene and incubated 
 at 28°C. for about 4 weeks. Films from the agar cultures and from 
 
 * Since this report was written, Graham, Brueckner, and Pontius have re- 
 corded the isolation of two strains of B. hotulinus from oat hay and ensilage, 
 respectively, which had been responsible for outbreaks of forage-poisoning in 
 horses and mules (Graham, R., Brueckner, A. L., and Pontius, R. L., Studies 
 on forage-poisoning. V. Preliminary report on an anaerobic bacillus of etio- 
 logical significance, Kentucky Agric. Exp. Station, Bull. 207, 1917, 51; Studies 
 on forage-poisoning. VI. An anaerobic organism isolated from ensilage of etio- 
 logical significance, Kentucky Agric. Exp. Station, Bull. 208, 117.) 
 
56 BOTULISM 
 
 the infusion cultures showed a mixture of bacteria, among which were 
 spore-bearing bacilli which were morphologically like Bacillus botu- 
 linus. The odor of the cultures was characteristic. Portions of the 
 unfiltered and also of the filtered infusion produced the typical s)mip- 
 toms and thrombosis in animals. . 
 
 There was considerable difficulty in obtaining the club-shaped 
 bacilh in pure culture. Repeated attempts at plating were unsuccess- 
 ful as Bacillus subtilis grew so much more rapidly that it overgrew 
 the plates. Strain III was ultimately recovered from the spleen of a 
 rabbit which had received an intravenous injection of the mixture of 
 the bacilli, but Strain IV was only obtained in pure culture after a 
 large series of progressive dilutions had been made in deep glucose agar. 
 In both instances the organism proved to be a virulent strain of 
 Bacillus botulinus. Strain V was not contaminated but was obtained 
 in pure culture from the can of beans. 
 
 The recorded descriptions of the morphology and the cultural char- 
 acteristics of Bacillus botulinus are based upon a study of the Ellezelles 
 strain (van Ermengem, 34, 86) and of the Darmstadt strain (Land- 
 mann, 58). A comparative study of these two strains was recorded 
 by Leuchs (114), and an investigation of these and one other strain 
 was made by von Hibler (116). 
 
 The baciUi are large, 4 to 6 by 0.9 to 1.2 microns, have slightly 
 rounded ends, and may arrange themselves in pairs, end to end, or, 
 in unfavorable environment, in long chains. When grown under 
 favorable conditions they form oval spores which are usually situated 
 in the ends of the bacilli, giving them a club-shaped appearance, but 
 they may be placed in the center, producing spindles (Fig. 1) . The 
 bacilli are slightly motile and have from four to eight flagella arranged 
 around the periphery. They stain by the Gram method but are apt 
 to be decolorized if left too long in the alcohol. 
 
 The organism is a strict anaerobe, although it may grow under 
 imperfect anaerobic conditions if in symbiosis with certain aerobic 
 bacteria, with the white Sarcina (van Ermengem, 87) or with Bacillus 
 subtilis (Romer, 35) ; and, according toHarrass (117) andTarozzi (118), 
 will grow in freshly prepared bouillon under aerobic conditions if a 
 piece of sterile flesh or potato is placed in the bottom of the culture 
 tube. The addition of glucose to the culture medium greatly increases 
 its activity in growth and in toxin formation. 
 
ERNEST C. DICKSOIN 57 
 
 In glucose gelatin plates, in an oxygen-free atmosphere, the young 
 colonies appear as transparent, pale yellow spherules which are sur- 
 rounded by a zone of liquefaction. As they grow older the transpar- 
 ency is lost, the colonies become opaque, darker in color, and are 
 nodular in appearance. Gelatin is quickly and completely liquefied 
 and the bacteria collect in flakes at the bottom of the tube, leaving the 
 supernatant fluid clear. In glucose bouillon the medium is at first 
 cloudy but soon becomes clear as the bacteria settle in the bottom. 
 In all media in which there is glucose the bacteria grow more readily 
 than when glucose is lacking, and there is marked and continuous gas 
 formation. According to van Ermengem (34, 86), the bacilli fail to 
 develop normally, and produce involution forms and but Httle toxin 
 in media which are in every way suitable except for the presence of 
 glucose. He believes that the amount of gas formation is an indication 
 of the activity of the organism, especially in toxin production. The 
 gas contains among others, H2, CO2, and CH4. 
 
 In milk, according to van Ermengem (34, 86), there is practically no 
 change in the appearance of the medium, and there is no coagulation, 
 but, according to von Hibler (116), there is precipitation of the casein 
 and peptonization of coagulated protein. The bacilli grow luxuriously 
 in bouillon to which lactose and saccharose have been added, but there 
 is no formation of gas. 
 
 The reaction of the medium is of great importance to the growth of 
 the bacillus, especially in so far as the formation of toxin is concerned. 
 Van Ermengem (34, 86) found that the Ellezelles strain would not 
 form toxin in an acid medium, but Leuchs (114) obtained a fairly 
 virulent toxin from the same strain in medium of neutral reaction. 
 The latter author once succeeded in producing a toxin of low virulence 
 by the growth of the Darmstadt strain in acid medium, but, on the 
 whole, the Darmstadt strain required a more alkaline medium for its 
 optimum development than did the Ellezelles strain, and both strains 
 produced much stronger toxin when grown in medium of slightly 
 alkaline reaction. 
 
 A small amount of sodium chloride, 0.5 per cent, is necessary for the 
 growth of the bacillus, but too much salt will inhibit its development. 
 Van Ermengem (34, 86) found that 2 per cent sodium chloride was 
 deleterious to the growth of the bacillus in bouillon, but Forssman 
 (119) found that from 0.6 to 1 per cent sodium chloride was 
 
58 BOTULISM 
 
 harmful. The growth of the bacillus is completely inhibited in the 
 presence of 6 per cent sodium chloride, a fact that is of considerable 
 economic importance, as meats which are pickled in brine which con- 
 tains more than 6 per cent sodium chloride will not become con- 
 taminated with the toxin. 
 
 Van Ermengem (87) obtained the strongest toxin when he grew B. botu- 
 linus in a medium consisting of beef infusion to which he added 1 per cent sodium 
 chloride, 1 per cent peptone, and 2 per cent glucose, but Leuchs (114) preferred a 
 medium prepared from infusion of pork (500 gm. per liter) to which was added 
 0.5 per cent sodium chloride, 1 per cent glucose, and 1 per cent peptone. He 
 added calcium carbonate to each container. Van Ermengem (87) recorded that 
 the organism will not grow on peptone-free glucose media such as were used by 
 various authors for studying the fermentation of the Klebs-Loeffler and tubercle 
 bacilli, and Landmann (58) stated that it is impossible to produce the toxin 
 unless animal protein is present. 
 
 The optimum temperature for the growth of the bacillus and for 
 the development of the toxin lies between 20° and 30°C. Van Er- 
 mengem (34) found that the Ellezelles strain grew very slowly below 
 16°C., but that its growth was fairly profuse between 18° and 20°C. 
 At from 37° to40°C. the colonies appeared early, but there was little 
 gas formation, and after about 48 hours the development ceased. At 
 this high temperature there was never any spore formation, the bacilli 
 grew in long chains, and soon developed involution forms. There was 
 never any toxin. Landmann (58) found that the optimum tempera- 
 ture for the Darmstadt strain was about 24°C., but he observed 
 spore formation at 36°C. and obtained a toxin of low virulence at 
 37.5°C. 
 
 Spore formation occurs early, within 48 hours, when the organism 
 is grown upon suitable medium at the optimum temperature, but is 
 delayed or even prevented if the medium or the temperature is unfavor- 
 able. According to Van Ermengem (87), the spores are considerably 
 less resistant than are those of the other pathogenic anaerobic bacilli; 
 they are destroyed by heating at 80°C. for | hour, at 85°C. for 15 
 minutes, or by boiling for 5 minutes. They remain viable for a long 
 time, for months or even a year, if protected from the action of light 
 and air, even though the medium in which they are immersed is of 
 acid reaction. 
 
ERNEST C. DICKSON 59 
 
 The bacilli are apt to die unless they are transplanted from time to 
 time. Van Ermengem (34) found that if subcultures were made 
 every 4 to 6 weeks, the virulence was maintained, but Forssman (119) 
 found it necessary to return the bacilli frequently to the glucose pork 
 infusion medium. In laboratory cultures there is a tendency for the 
 bacilli to lose their power of spHtting glucose with the formation of 
 gas, and of producing toxin, and, in so far as I have been able to learn, 
 there is no rehable method of restoring these properties when once they 
 have been lost. 
 
 According to van Ermengem (34), B. hotulinus is strictly saprophytic 
 and will not reproduce or produce its toxin in the animal body. When washed 
 bacilli are injected subcutaneously into animals, no symptoms of botulism develop 
 and the bacilli rapidly disappear from the site of injection. After intravenous 
 injection of bacilli, cultures of the spleen and liver may show that they are present 
 in these tissues, but they are so few in number that they cannot be demonstrated 
 in microscopic sections. Guinea pigs and rabbits can take large numbers of 
 bacilli by mouth without showing any signs of poisoning, and large numbers of 
 spores may be fed or injected without producing symptoms. Van Ermengem 
 (34) inoculated glucose agar blocks with spores of the virulent strains, and placed 
 them in the peritoneal cavity of a guinea pig, and he also duplicated Vaillard and 
 Rouget's method (120) of intensifying tetanus intoxication by injecting the 
 washed spores under the skin with lactose and sodium carbonate, or with other 
 forms of bacteria such as B. prodigiosus, without obtaining any evidence of pois- 
 oning. He concluded that the organism could not form its toxin in the bodies 
 of warm blooded animals, probably on account of the high body temperature. 
 
 The cultural characteristics of the strains which I have isolated corn 
 respond in most respects with those that have been detailed. Strains 
 III and IV produce a highly virulent toxin when grown on glucose beef 
 or glucose pork infusions, prepared according to the formulae of van 
 Ermengem (86) andLeuchs (114) respectively; 0.0001 cc. of the toxin 
 of Strain III and 0.0002 cc. of the toxin of Strain IV will kill a guinea 
 pig within 24 hours. Sufficient toxin is formed within 4 days (Strain 
 III) to cause the death of a guinea pig 24 hours after 1 cc. is injected 
 subcutaneously. 
 
 Cultures were made in several of the sugars and showed similar 
 results with Strains I, II, III, and IV. Strain V has not been tested. 
 When grown in Dunham's solution containing the sugars, there was 
 acid and gas formation with glucose, maltose, levulose, and galactose. 
 
60 BOTULISM 
 
 In the dextrin-Dunham solution there was acid formation but no gas, 
 and with lactose, mannite, inulin, and saccharose there was neither acid 
 nor gas. A series was grown in the Hiss serum water containing 
 sugars, but in these the reactions were very irregular. The medium 
 was acidified, coagulated, and ultimately peptonized in practically all 
 the tubes, and there were varying amounts of gas in all, but in view of 
 the results with Dunham's solution it is probable that the gas forma- 
 tion depended upon the splitting of the proteins. 
 
 The reactions of all four strains upon litmus milk are interesting in 
 view of the fact that the earlier authors had found no change. In all 
 the tubes there was precipitation of a finely divided coagulum, 
 without the formation of acid, and, eventually, complete peptoniza- 
 tion. The precipitation began in Strain III on the 2nd day, but in the 
 others was first noticed in from 4 to 6 days. Peptonization began 
 shortly after the precipitation, and was not complete for from 10 to 12 
 days. The reaction is probably the same as was described by von 
 Hibler (116), and is of especial interest in that the two virulent strains 
 produced the same reactions as the two which are of low virulence. 
 Van Ermengem (87) believed that von Hibler's results had been due 
 to the fact that his strains had deteriorated, as their virulence was very 
 low, but Strain III, the most virulent of my series, produced the reac- 
 tions more quickly than did either of the old and relatively non- 
 virulent strains, I and II. The peptonization of the coagulated pro- 
 tein corresponds to observations of von Hibler, but he did not record 
 that the bacilli will also coagulate the protein. 
 
 The toxin of Bacillus botulinus is formed when the organism is 
 grown upon suitable media under strictly anaerobic conditions. It 
 may develop in small quantities at temperatures below 20°C. and 
 above 30°C., but at the ordinary body temperature of warm blooded 
 animals it is rarely produced. It is analogous in many respects to the 
 toxins of the Klebs-Loeffler and the tetanus bacilli, but differs in that 
 it is not destroyed by the action of the gastric secretions. 
 
 Van Ermengem (34) showed that it is an albuminous substance which is pre- 
 cipitated by alcohol, tannin, and neutral salts, and Brieger and Kempner (122) 
 obtained it in a dried form by precipitation with zinc chloride. Their method 
 was as follows: One part of the filtered bouillon culture was heated with two parts 
 of 3 per cent zinc chloride after traces of ammonium hydrate had been added if 
 
ERNEST C. DICKSON 61 
 
 the medium was acid. The precipitate was separated and washed, and the solu- 
 tion was made slightly alkaline with 1 per cent ammonium carbonate. The 
 zinc was precipitated with ammonium phosphate, and filtered off. The toxin 
 was then separated from the albumoses by the addition of ammonium sulfate. 
 At this stage the toxin was practically full strength, but if further purification 
 ,was attempted, it rapidly lost from 40 to 50 per cent of its virulence. The 
 authors found that the dried toxin was resistent to the action of reducing 
 substances but that it was highly susceptible to alcohol, ether, and oxidizing 
 reagents. If protected from light and air it would retain its full virulence for 
 several weeks, and a diminished virulence for more than a year. 
 
 The toxin in solution is quickly destroyed by exposure to the action 
 of light and air, but will maintain its virulence for 6 months or more if 
 kept in the dark, and sealed. According to van Ermengem (34), the 
 toxicity is diminished by heating at 56°C. for 3 hours, and is destroyed 
 by heating at 80°C. for half an hour or by boiling. The toxin dialyzes 
 slowly, and is not affected by drying. It is insoluble in alcohol, ether, 
 and chloroform. The addition of 20 per cent by volume, of normal 
 soda solution destroys it in a short time, but an equal amount of nor- 
 mal hydrochloric acid does not reduce its virulence in 24 hours. Pu- 
 trefaction has no effect on the virulence of the toxin if the access of 
 air is prevented, and the growth of other saprophytic bacteria in the 
 medium does not injure it. 
 
 The virulence of the toxin varies greatly, depending upon the strain 
 with which the culture mediiun is inoculated, the medium upon which 
 it is grown, and the conditions of anaerobiosis, temperature, etc., in 
 which it has developed. In laboratory experiments it has been pos- 
 sible to obtain a toxin of which 0.000001 cc. would kill a 250 gm. 
 guinea pig in from 3 to 4 days (Brieger and Kempner, 122). In the 
 Ellezelles outbreak (van Ermengem, 34) about 200 gm. of the poison- 
 ous ham were sufficient to cause the death of one of the patients; in 
 the Darmstadt outbreak (Fischer, 57) two spoonfuls of salad were 
 fatal, and in Quincke's series, a piece of preserved duck, the size of a 
 walnut, was sufficient to cause an illness which lasted for 8 weeks. In 
 my series of cases, one patient died after tasting a small spoonful of the 
 spoiled corn, one died after "nibbling" a portion of a pod of the 
 spoiled string beans, and a third was ill after ' 'tasting" a pod of beans 
 which she did not swallow. 
 
 The culture medium which has been used by almost all investi- 
 
62 BOTULISM 
 
 gators in preparing toxin has been made from beef, pork, or mutton, 
 but Leuchs (114) reported that Gaffky had told him that he had suc- 
 ceeded in producing the toxin in a medium prepared from white beans. 
 In my series of experiments the strongest toxin was produced in pork 
 and beef infusion, but virulent toxins were also produced in media 
 prepared from string beans, green peas, and green corn, respectively; 
 and much less virulent toxins were obtained in media prepared 
 from asparagus, artichokes, peaches, apricots, and crushed apricot 
 stones. 
 
 The method in which the toxin acts upon the tissues is unknown. 
 There is comparatively little local reaction at the site of subcutaneous 
 injections in animals, and there are no characteristic local lesions in 
 the stomach when the toxin is administered by mouth. Kempner 
 and Schepilewsky (123) showed that there is an especial affinity for the 
 tissues of the central nervous system as in tetanus. They found that 1 
 cc. of an emulsion of the brain or cord of a guinea pig will neutralize 
 from three to four times the lethal dose of the botulinus toxin and that 
 there is a partial protection if the toxin and the emulsion are simul- 
 taneously injected on opposite sides of the body of a white mouse. 
 They also found that there is a delay in the onset of the symptoms if 
 the tissue emulsion is injected 6 hours before the toxin is admin- 
 istered, and that the animals live for about 1 day longer than the 
 controls; but when the emulsion is injected 12 hours before the toxin, 
 the animals die as soon as the controls. They were unable to increase 
 the protection to more than four times the lethal dose by mixing 
 with larger amounts of the emulsion. Cholesterol and lecithin pro- 
 tect as well as the brain tissue emulsion, and butter and emulsified 
 oil neutralize about twice the lethal dose. Tyrosine and antipyrine 
 also protect to a certain extent. Emulsions of other tissues have no 
 effect. 
 
 Van Ermengem (34, 86) investigated the effect of the toxin when administered 
 by mouth, subcutaneously, intraperitoneally, intravenously, and intraocularly. 
 He found that the symptoms appear earliest after intravenous injection, and that 
 they appear somewhat later, but at about the same time, after subcutaneous and 
 intraperitoneal injections. Guinea pigs and monkeys are susceptible to poison- 
 ing when the toxin is administered by mouth, although a larger amount of toxin 
 is required; but rabbits and cats are much more resistent to the administration 
 by mouth, although they are susceptible to subcutaneous, intraperitoneal, and 
 
ERNEST C. DICKSON 63 
 
 intravenous injections. Rabbits are not affected when the toxin is dropped into 
 the eyes, but when it is injected into the anterior chamber of one eye, symptoms 
 of involvement of the third nerve appear simultaneously in both" eyes. 
 
 Lippmann (124) estimated the difference in the amount of toxin necessary to 
 poison a white mouse when it is administered by mouth, and subcutaneously, 
 and found that of a toxin in which the lethal dose by subcutaneous injection was 
 0.000025 cc, the amount necessary to give by mouth was 0.04 cc. Forssman 
 (125) found that if the toxin is placed in the large intestine there are no symp- 
 toms of poisoning, even though from 1,000 to 2,000 times the lethal subcutaneous 
 dose is injected; and in test-tube experiments he showed that 10 gm. of the cecal 
 contents of a rabbit will precipitate 1,000 times the lethal dose of toxin, although 
 the precipitation does not destroy the virulence of the toxin. The contents of the 
 small intestine are less active than those of the cecum, 10 gm. of the contents of 
 the small intestine wiU precipitate about 90 times the lethal dose of toxin. Forss- 
 man concluded that the larger dose which is required to produce poisoning from 
 the gastrointestinal tract is dependent upon this precipitation of the toxin. 
 
 Forssman (125) also investigated the effect of direct administration of the 
 toxin into the brain by using the methods of Roux and Borrel (126) with which 
 they demonstrated that there is a peculiar virulent type of "cerebral" tetanus. 
 He found that there is no "cerebral" botulism which differs from that produced 
 by other methods of injection, a fact which is somewhat surprising in view of the 
 neutralizing effect of the tissue of the central nervous system which was demon- 
 strated by Kempner and Schepilewsky (123). 
 
 The only evidence that there may be some local effect of the toxin of B. boiu- 
 linus is given by Forssman (125) and Leuchs (114). Forssman found that if the 
 toxin is injected into the peritoneal or pleural spaces, the respiratory symptoms 
 appear much earlier than when it is administered by other routes, and he believed 
 that this is due to the fact that there is a local effect upon the diaphragm which 
 causes it to become paralyzed earlier. Leuchs injected the toxin into one of 
 the extremities and observed a condition analogous to local tetanus, in which 
 the symptoms appear first in the extremity into which the toxin has been in- 
 jected. Neither author suggested an explanation for the phenomenon. 
 
 The fate of the toxin after it enters the blood stream is also unknown. Kemp- 
 ner and Schepilewsky (123) found that the brain of a guinea pig which had died 
 from botulism was non-toxic, and other authors have recorded that the tissues 
 of animals which had died after injection showed no trace of the toxin. The 
 only record of the identification of the toxin after it has entered the blood stream 
 is reported by Kob (127), who found that blood serum taken from a patient 9 
 days after she had eaten the poisonous food, and 3 days after the appearance of 
 the paralytic symptoms, produced the typical symptoms when injected into white 
 mice. 
 
 Van Ermengem (34, 86, 87) investigated the effect of the hotulinus toxin on 
 various kinds of animals. He found that white mice, guinea pigs, rabbits, cats, 
 pigeons, and monkeys are susceptible to subcutaneous, intraperitoneal, and intra- 
 
64 BOTULISM 
 
 venous injection, and that white rats, dogs, chickens, frogs, and fish are highly 
 resistent. In his feeding experiments he found that mice, guinea pigs, and mon- 
 keys are especially susceptible, that rabbits are less susceptible and that cats 
 must be given enormous quantities of the toxin before they show any symptoms. 
 He found that dogs, rats, and chickens are practically unaffected, the only result 
 of very large doses being vomiting, diarrhea, and emaciation. 
 
 It is surprising that van Ermengem obtained no positive results 
 in his experiments with dogs and chickens, especially with chickens, 
 as in the series of outbreaks of botuhsm which I have investigated 
 it has been the rule to find that varying numbers of chickens have 
 died from limber-neck, a disease in which the clinical picture is en- 
 tirely analogous to that which occurs in botulism in susceptible 
 animals; and in one case a dog, which had eaten the discarded food, 
 became paralyzed in the hind legs. In one instance, a number of 
 turkeys were also ill with limber-neck, and in one it was proved that 
 the limber-neck was caused by the discarded food, as all the chickens 
 in the pen into which the food was thrown became ill and died, 
 whereas none in the adjoining cages was affected. In my laboratory 
 experiments I have found that chickens are highly susceptible to 
 subcutaneous injection and to feeding, and that dogs are also sus- 
 ceptible to subcutaneous injection. In one of my experiments a 14 
 pound dog died within 3 days after a subcutaneous injection of 1 
 cc. of a pork infusion culture; the amount of toxin per kilo being 
 about 600 times that necessary to kill a guinea pig in the same time. 
 In a series of five experiments with dogs, four died and one recovered, 
 and the symptoms were practically identical with those that are 
 observed in cats. Similar results were obtained with toxin prepared 
 from Strains III and IV of Bacillus botulinus. 
 
 The symptoms which are produced in the different animals are 
 similar to those which are observed in himian beings, although they 
 vary somewhat in the different species. There are disturbances of 
 vision, the pupils are dilated, reaction to light is impaired, in monkeys 
 there is ptosis, and in rabbits, guinea pigs, and chickens there 
 is sluggish movement of the nictitating membrane. There may be 
 prolapse of the tongue, an increase or a decrease in sahvary secretion, 
 and marked constipation. The animals are weak, and there may be 
 local or general paresis of the skeletal muscles. A characteristic 
 
ERNEST C. DICKSON 65 
 
 attitude is that the animal lies on its belly on the floor with the head 
 resting on one side and the legs sprawled out on either side. Respi- 
 ration may be rapid but is sometimes labored and slow, and death 
 may be preceded by convulsions. In cats there is thick mucus in 
 the phar3aix, and the animal has a persistent toneless cough. 
 
 When a sublethal dose of the toxin is given, the animals may be 
 very ill for a time and then gradually recover. Often, however, they 
 become emaciated and cachectic and may die from exhaustion after 
 several weeks. 
 
 The pathological anatomy is discussed in another section of this 
 report. 
 
 Kempner (128) was the first investigator to study the immunology of botulism. 
 In his first experiments he was unable to demonstrate any antitoxin formation 
 in small animals, as he was unable to keep them alive after the initial inoculation. 
 In 1897, however, he recorded the successful immunization of goats, in which he 
 obtained a serum of such potency that it would neutralize ten times the lethal 
 test dose for a guinea pig. He found that the antitoxin would protect an animal 
 against an injection of toxin given 30 hours after the antitoxin, and that if the 
 antitoxin was given 24 hours after a 48 hour fatal dose of the toxin it would save 
 the life of the animal in many cases. 
 
 Forssman and Lundstrom (129), 1902, succeeded in immunizing smaller ani- 
 mals by attenuating the initial dose by heat, and were able to obtain a high degree 
 of immunization in goats in a much shorter time than Kempner (128). They 
 confirmed Kempner's observations regarding the prophylactic powers of the 
 antitoxin, but were unable to demonstrate any protection when the antitoxin 
 was given more than 12 hours after the toxin. Forssman and Lundstrom agreed 
 with Kempner that if the antitoxin is to be of any value as a therapeutic agent, 
 it must be given very early. 
 
 In a later report Forssman (130), 1905, stated that it is impossible to deter- 
 mine any relation between the amount of antitoxin that is formed, and the 
 amount of toxin injected. He found that after subcutaneous injection of the 
 toxin there is much more antitoxin formed than after an equal amount injected 
 intravenously, and that the maximum of antitoxin formation is reached in 15 
 days in the former, whereas it required only 10 days in the latter. 
 
 Leuchs (114), 1910, performed a series of comparative investigations with the 
 antitoxins of the EUezelles and the Darmstadt strains, which he obtained by 
 immunizing horses, and found that each antitoxin was specific for the homologous 
 toxin, but had no protective action against the other. He concluded that for 
 therapeutic purposes it is necessary to have a polyvalent antitoxin. Leuchs also 
 showed that an animal could be protected against subcutaneous injection of 
 toxin if the antitoxin is given by mouth, but noted that if the toxin-antitoxin 
 
66 BOTULISM 
 
 mixture is given by mouth, an excess of antitoxin is required, as a unit of anti- 
 toxin given by mouth will not counteract a corresponding amount of toxin in 
 the stomach. He referred to some experiments which showed that the virulence 
 of the toxin is increased if it is mixed with horse serum, and that the alcohol- 
 soluble portion of the serum, as well as an emulsion of lecithin, will increase 
 the virulence if added in equal volume to the toxin. 
 
 Tchitchkine (131), 1905, attempted to immunize rabbits by giving the toxin 
 by mouth, but was only partially successful, and Lippmann (124) in 1910 showed 
 that while the feeding of toxin by mouth did not produce immunity to subcu- 
 taneous injections, it produced a local immunity to the extent that the animal 
 would survive ten times the fatal dose of toxin by mouth. 
 
 Serological investigations have not shown very definite results. Herman 
 (132), 1900, reported that he had found that the serum of animals with botulism 
 would agglutinate the bacilli in dilutions of 1:400, and Leuchs (133) recorded 
 that there is weak agglutinating power. The latter author also stated that there 
 is a faint complement fixation reaction, but added that as the experiments were 
 performed with unfiltered bouillon, there is some doubt as to the accuracy of the 
 results. 
 
PATHOLOGY. 
 
 The earlier descriptions of the pathologicat anatomy of botulism need only be 
 mentioned. Kerner (7) noted that there was marked congestion of all organs, 
 and emphasized the fact that there was very early and persistent rigor mortis, 
 and that putrefaction occurred very late. Various other authors agreed as to 
 the general hyperemia but differed greatly in their descriptions of the other 
 changes. Hasselt (134) wrote: "Die angegebenen Leichenerscheinmigen sind 
 uberhaupt nicht constant, wie man auch von einigen Autoren mehr Entziindungs- 
 erscheinungen, von Anderen mehr septische hervorgehoben findet." Miiller 
 (81), 1869, collected all the available necropsy findings and carefully analyzed 
 them to determine what pathological changes were most constant. He concluded 
 that the great differences in interpretation among the earher authors were due 
 to the fact that they did not recognize the difference between true inflammation 
 and hypostasis; and that many of the lesions which had been described were 
 merely manifestations of postmortem change. His analysis showed that there 
 was no inflammatory process, and that the only characteristic feature was a 
 general hyperemia. He did not find any conclusive evidence of the rapid devel- 
 opment of rigor mortis, or of delayed putrefaction. 
 
 The first important investigation of recent times was recorded by van Ermen- 
 gem (34, 86, 87), whose repwrt dealt with the changes which were found in animals 
 in which botulism had been experimentally produced. He noted that the macro- 
 scopic appearance of the tissues in animals was the same as in those of the per- 
 sons who died in the EUezeUes outbreak, but he was unable to compare the micro- 
 scopic pathology as the examination of the EUezelles cases was incomplete. He 
 described the general appearance of the tissues in botulism in the words: "EUes 
 (les lesions macroscopiques) consistent surtout. . . . en un etat hyperemique 
 plus ou moins prononce de tous les organes s'accompagnant souvent de ruptures 
 vasculaires, d'extravasations sanguines" (34). At the site of subcutaneous injec- 
 tion there was slight injection and local edema in the more susceptible animals, 
 and marked local reaction, sometimes with pus formation, in the more resistant ; 
 namely, cats and dogs. JL.ocal necrosis was never found. When the toxin was 
 administered by mouth there were various changes in the mucosa of the stomach 
 which van Ermengem believed to be due to the local action of the toxin. The 
 author ascribed especial importance to the enlargement and parenchymatous 
 degeneration of the liver, although he noted that the kidneys were similarly 
 involved. In a number of cases in animals as well as in the victims of the EUe- 
 zeUes outbreak, he found areas of bronchopneumonia in the lungs. The brains 
 and cords were soft, more so than he believed could be due to postmortem change, 
 and contained numerous small hemorrhages. 
 
 67 
 
 ^^ ,v,s. 
 
68 BOTULISM 
 
 Microscopic examination of the tissues of the animals was made under the 
 direction of van der Stricht (135), and a special study of the central nervous 
 system was conducted by Marinesco (136). The tissues were fixed by various 
 methods, and special tissue and bacterial staining methods were used. 
 
 Van der Stricht (135) recorded changes in the stomach, small intestine, liver, 
 kidneys, spleen, heart muscle, lungs, bone marrow, and submaxillary glands. In 
 the stomach there was hyperemia, usually associated with hemorrhages in the 
 mucosa and ulcerations. There was desquamation of cells in the region of the 
 orifices of the glands, and fatty degeneration of the cells of the glands. In the 
 small intestine there were more or less marked evidences of enteritis in addition 
 to the hyperemia and hemorrhages. The liver was markedly congested and 
 contained small hemorrhages. There were evidences of inflammation of the 
 interstitial connective tissue as well as marked parenchymatous degeneration 
 of the epithelial cells and fatty degeneration of the endothelial cells of the 
 capillaries. The kidneys were markedly congested and there were parenchy- 
 matous degeneration and desquamation of the epithehal cells. Degeneration 
 of the endothelial cells of the glomerular tufts was not noted. In the region of 
 the papillae there were areas of interstitial proliferation. The spleen was some- 
 times smaller, but more often larger than normal; when larger, the increase in 
 size was apparently due to engorgement of the splenic pulp. There were many 
 large phagocytic cells in the vessels of the pulp. The lungs were congested and 
 sDmetimes showed areas of peribronchial pneumonia. Hemorrhages were also 
 described. There was proliferation of many of the cells in the bone marrow. 
 The submaxillary glands showed fatty degeneration of the mucous cells. The 
 muscle fibers of the heart muscle and of skeletal muscles showed fatty 
 degeneration. 
 
 The changes which were found in the central nervous system are of especial 
 interest in that they seemed to give an anatomical explanation for the peculiar 
 combination of symptoms in botulism. The following description of these 
 changes is quoted from van Ermengem (86) : 
 
 "Beim Centralnervensystem sind die Lasionen in dem Grosshirn fast Null; sie fehlen 
 in den Nervenfasern und sind sehr ausgesprochen im Riickenmark, weniger in der Medulla 
 oblongata, Protuberanz und Gehirnschenkel. Im Riickenmark und Pons sind die fast 
 ausschlieslich in dem Vorderhorner und Hinterhorner (motorische Kerne der Glieder und 
 Bulbarkerne) vorhanden. Im ersten Stadium findet man nur in den Nervenzellen eine 
 von der Peripherie ausgehende Verminderung der chromatophilen Elemente, spiiter sind 
 die Nissl'schen Korperchen in feine pulverartige Granula umgewandelt. Noch spater 
 entstehen Vacuolen durch Auflosung der achromatischen Substanz. Diese chromatoly t- 
 ischen Degenerationsercheinungen sind im Kern der N.hypoglossus,im Nucleus ambiguus, 
 im Nucleus dorsalis des N. vagus, in den Purkinje'schen Zellen des Kleinhirns und im 
 Mittelkern des Oculo-motorius beobachtet worden. Neben diesen regressiven Lasionen 
 der Nervenzellen bestehen stets progressive Veranderungen des Gliagewebes. Die Glia- 
 zellen sind an mehreren Stellen vermehrt und spielen die Rolle von Neurophagen, indem 
 sie die krankhaften Elemente wegschaffen. Endlich, seitens der Blutcapillaren treten 
 
ERNEST C. DICKSON 69 
 
 auch constant hamorrhagische Herde, mehr oder minder diffus, interstitiell in der grauen 
 Substanz der Hinterhorner, hauptsachlich der Bulbar und der Oculomotoriuskerne auf ." 
 
 The observations of Marinesco (136) have been confirmed by several authors. 
 Kempner and Pollack (115) agreed with Marinesco in as far as the distribution 
 and type of lesions in the nerve cells are concerned, but found an earlier stage 
 of protoplasmic degeneration which they described a.s a. " klumpige Schwellung" 
 of the cell granules. They did not find any evidence of proliferation of the 
 neuroglia cells. They noted that in cases in which a full lethal dose was given 
 (an amount sufficient to kill the animal in 48 hours) a^ji followed by antitoxin 
 within 24 hours, the life of the animal would be saved; but the lesions in the nerve 
 cells were still present 2 weeks later, and apparently disappeared very slowly. 
 They stated that the cells were evidently damaged for a long time after the dis- 
 appearance of the clinical symptoms, and that they could not find any corre- 
 spondence between the severity of the lesions and that of the clinical symptoms. 
 
 OssipofE (137) made a study of the changes produced in guinea pigs, cats, and 
 monkeys, and also found the lesions which had been described by Marinesco. 
 He noted that they were most severe in the cord, especially in the portions which 
 supply the nerves for the extremities, and that they were less numerous in the 
 bulb, but he also described changes in the Purkinje cells of the whole brain, 
 whereas Marinesco has stated that none were to be found in the cells of the brain. 
 An interesting feature of Ossipoff's report is his observation concerning the blood 
 vessels. He wrote: "Dans les vaisseaux hyperemies ainsi qu'en dehors d'eux 
 on rencontrait aussi beaucoup de globules blancs. Dans les Vjaisseaux il y avait 
 parfois ime agglomeration de ces globules." He concluded his report by stating 
 that he had not found sufficient reason to assume that the changes which are 
 produced in the nerve cells are specific of botulism, and different from changes 
 produced by all other toxins such as tetanus or diphtheria, but he believed 
 that it is probable that the cell changes in botulism are more intense and more 
 extensive. 
 
 Romer and Stein (138) made a careful investigation of the region of the nuclei 
 of the third cranial nerve in monkeys which had been poisoned with botulinus 
 toxin. They observed extensive changes which were especially marked in the 
 cells of the unpaired median nucleus. The cells shpwed tigrolysis and pyknosis, 
 and the Nissl granules were gathered into clumps. In the more advanced cases 
 there was complete disintegration of the cell structure, and the position of the 
 former cell was occupied by a structureless mass. Vacuoles were not observed. 
 The authors noted that in the upper and lower portions of the nuclei of the ocu- 
 lomotor nerve, the appearance of the nerve cells was practically normal. They 
 concluded that there was sufficient histologic change in the nerve Cells to account 
 for the disturbances of function which had been observed in the muscles of the 
 eye. 
 
 Previous to 1915 all the descriptions of the lesions which are produced in 
 botulism were based upon examinations of the tissues of animals in which the 
 
70 BOTULISM 
 
 poisoning had been experimentally produced. In that year, however, Paulus 
 (19) reported a series of cases in which careful histologic examination was made 
 of the brain and cord of one of the victims. The history of the illness was of 
 some interest in that there had been transient symptoms of diplopia 3 weeks 
 before the onset of the difficulty in swallowing, and death did not occur for 3 
 weeks after the latter symptom was first noted. Because of the fact that it is the 
 first comprehensive report of the changes in the human brain, the report is given 
 in some detail. 
 
 The brain was large and somewhat soft, and the meninges and brain were 
 markedly congested. There was no evidence of meningitis or of hydrocephalus. 
 On section, numerous hemorrhages up to the size of the head of a pin were seen 
 in the substance of the brain, especially in the gray matter in the region of the 
 ventricles, in the basilar nuclei, and in the floor of the fourth ventricle. In places 
 in the stem the hemorrhages were confluent. The vessels of the ependyma were 
 engorged. The spinal cord was hyperemic, and, in the cervical portion, con- 
 tained a cystic cavity in the region of the central canal. There was no macro- 
 scopic evidence of destruction of any of the columns. 
 
 Microscopic examination showed marked congestion of all the vessels. In 
 many places the hemorrhages occurred around the vessels, although the wall did 
 not seem to be destroyed. The hemorrhages were most numerous in the region 
 of the medulla and basal nuclei, and were most severe in the floor of the fourth 
 ventricle. There was no evidence of inflammatory change, no round cell 
 infiltration, and no destruction of tissue structure except where there was 
 hemorrhage. 
 
 There were varying degrees of nerve cell changes in different portions of the 
 brain, but the severity of the lesions did not seem to bear any relation to the 
 number of hemorrhages which were adjacent. On the whole, they were most 
 marked in the regions of the fourth ventricle and the aqueduct, where there were 
 also numerous hemorrhages, but in places the most severe nerve cell changes 
 occurred where there were no adjacent hemorrhages. Paulus' description of 
 the changes in the ganglion cells is as follows: 
 
 ' 'Die Ganglienzellen zeigen verschiedene Grade der akuten, teilweise auch der schweren 
 Zellveranderung im Sinne Nissls: einfache triibe Schwellung, kornigen Zerfall der Tigroid- 
 schallen, Kernblahung, Auflosung der Kernmembran, Randstandigkeit und ZerfaU des 
 Kerns, Auflosung des Zelleibs bis zum volligen Zellschwund. Vielfach liegen zwischen 
 stark veranderten Zellgruppen vereinzelte, ganz normale Elemente." 
 
 The changes in the ganglion cells were especially marked in the region of the 
 nucleus of the fourth nerve, and slightly less so in the nucleus of the third. In 
 these areas a peculiar pigmentation was seen, in some places the pigment coexist- 
 ing with the nucleus, and in other places completely replacing it. The nuclei 
 of the vagoaccessorius group were also involved. The ganglion cells of the cord, 
 especially in the cervical region, were markedly damaged, but the hemorrhages 
 in the cord were more numerous in the posterior horns than in the anterior. In 
 
ERNEST C. DICKSON 71 
 
 neither the brain nor the cord were there any evidences of inflammatory processes, 
 or of proliferation of the neuroglia cells. The columns of the cord were un- 
 impaired. 
 
 Paulus described the lesion as a polioencephalitis superior and inferior, with 
 acute degenerative hemorrhagic myeUtis, or, in other words, as a polioencephalo- 
 myelitis hemorrhagica. He believed that the distribution of the lesions in the 
 various nuclei was sufficient to explain the symptoms which were present during 
 life. 
 
 Komotzki (139) investigated the changes which occur in the viscera in rabbits 
 and guinea pigs in which botulism had b,een p^erimentally produced. He found 
 marked congestion of all the organs, and an increase of leukocytes in the dilated 
 vessels. In the liver there was marked dilatation of all the vessels, but especially 
 of the veins and capillaries, and in many cases there was secondary atrophy of 
 the adjacent liver cells. In about one-third of the cases there was fatty degen- 
 eration of the liver cells in the central portion of the liver lobules, and in a very 
 few cases the fatty degeneration was diffuse and marked. It was never found 
 exclusively at the periphery of the liver lobules. He noted that the toxin was 
 extremely toxic for the liver cells ; in the majority of cases there were miliary or 
 larger necroses scattered irregularly throughout the liver tissue. In most of the 
 necrotic areas there was complete destruction of the liver cells, including the 
 nuclei, and in all there was infiltration with polymorphonuclear leukocytes. In 
 some of the cases which survived for a longer time, from 11 to 49 days, there 
 was evidence of regenerative processes around the necrotic areas, and in one the 
 granulation tissue had invaded them. He did not find any evidence of specific 
 toxin action on the cells of any other organs. 
 
 Bogomolez (140) investigated the changes in the adrenals of cats in which 
 botulism had been produced. He found that there was an increase in secretory 
 power of the medullary cells and believed that it was a compensating phenomenon 
 to counteract the diminution of the cardiac muscle power. He also found an 
 increase in the amount of lipoidal substance from the cortical cells of the adrenal, 
 and he believed that this was of especial importance in view of the fact that 
 Kempner and SchepUewsky (123) had observed that lipoids have an inhibiting 
 action on the toxin of B. bolulinus. Bogomolez advanced the hypothesis that 
 the duration of life in botulinus-poisoning may depend upon the amount of 
 lipoidal substance which is produced by the adrenals. 
 
 An important observation was made by Ophiils (99) in his study of the fatal 
 case of the Stanford University series in California, the detaUs of which have 
 been previously recorded in this report. Ophiils found the usual hyperemia of 
 the internal organs of the body, as well as bronchopneumonia and areas of col- 
 lapse in the lungs. There were no macroscopic hemorrhages. Microscopic 
 examination of sections from various portions of the brain showed marked con- 
 gestion, and widespread thrombosis in the blood vessels, arteries, and veins of 
 the meninges and of the brain. The thrombi were especially numerous in the 
 stem and consisted of dense masses of fibrin in which many polymorphonuclear 
 
72 BOTULISM 
 
 leukocytes were enmeshed; there were very few conglutinated blood platelets. 
 Perivascvdar hemorrhages were quite frequent in the meninges and in the brain 
 tissue. There was no evidence of destruction of the ganglion cells of the various 
 motor nuclei; the arrangement of the Nissl granules and the appearance of the 
 nuclei were entirely normal. Examination of sections from the various internal 
 organs showed one small thrombus in a vein of the submucosa of the small intes- 
 tine and one in the ovarian plexus, but otherwise none was found. 
 
 /. 
 
 The following description of the pathology of botulism is based upon 
 a study of the tissues of 30 guinea pigs, 37 rabbits, 30 cats, 4 dogs, and 
 3 chickens, in which the poisoning was produced experimentally; of 
 6 chickens which died after eating the discarded string beans in Out- 
 break 4; and of 4 human cases in which I had the opportunity of mak- 
 ing histologic examination. 
 
 The toxins which were used in the experimental work were derived 
 from four strains of Bacillus botulinus which are described as Strains 
 I, II, III, and IV. The animals were injected with toxins prepared 
 by the growth of the bacilli in commercially prepared cans of string 
 beans, and in infusions prepared from beef, pork, canned string 
 beans, canned green peas, canned corn, canned asparagus, fresh arti- 
 chokes, fresh peaches, fresh apricots, and crushed apricot stones. The 
 virulence of the toxins varied greatly, that of Strains I and II being 
 comparatively low, and that of Strains III and IV being very 
 high. The symptoms of the animals and the type of the lesions 
 which were produced differed only in degree, depending upon the 
 amount of the toxin which was injected and the length of time which 
 elapsed before the animals died. 
 
 The human cases from which the material was obtained consisted 
 of one in which the brain was removed by the attending physician and 
 was sent to Dr. Ophiils for examination; one in which the necropsy 
 was performed by me ; and two in which necropsy was performed by 
 Dr. George B. Worthington, of San Diego, who sent me portions of 
 the organs for examination. Two of the bodies had been embalmed 
 before necropsy was performed. 
 
 The only constant finding on macroscopic examination of the bodies 
 of victims of botulinus-poisoning is the marked congestion of the cen- 
 tral nervous system and of the abdominal and thoracic viscera. In the 
 central nervous system the meninges at the base of the brain, especially 
 
ERNEST C. DICKSON 73 
 
 around the pons and the medulla, are usually more markedly con- 
 gested than at the cortex, and the basilar sinuses are usually engorged 
 with blood. Not infrequently there are multiple hemorrhages around 
 the base of the brain and the upper part of the cord. The tissues of 
 the brain are also congested, and may be edematous and contain 
 macroscopic hemorrhages (Fig. 7). The lungs are usually extremely 
 hyperemic and may also show areas of collapse and of bronchopneu- 
 monia. The heart muscle may be opaque and flabby but shows nothing 
 that is characteristic. There may be hemorrhages in the lungs (Fig. 
 8), and ecchymoses in the pleura, pericardium, and endocardium. 
 The spleen is frequently enlarged, due to engorgement, and, when 
 large, is apt to be soft. It may contain multiple hemorrhages. The 
 liver and kidneys are usually cloudy and hyperemic; a considerable 
 amount of blood escapes when the liver is sectioned. The vessels of 
 the mesentery are engorged a&d the intestines are congested. Hem- 
 orrhages may be found in any of the abdominal organs but are 
 especially frequent in the intestines. There is rarely any excess fluid 
 in the pleural or peritoneal cavities. 
 
 At the site of subcutaneous injection in animals there may be local 
 edema and hemorrhagic infiltration of the surrounding tissues, but 
 there is never necrosis. The local reaction appears to depend rather 
 upon whether filtered or unfiltered toxin has been injected, than upon 
 the susceptibility of the animal, as it is more often found when the 
 bacilli are injected with the toxin. The extreme, purulent reaction 
 which van Ermengem (34, 86) described was never seen in my series. 
 
 The frequency with which hemorrhages occur varies considerably 
 in the different kinds of animals. They may occur in the larger ani- 
 mals and in human beings, but are much more constant in guinea pigs 
 and in chickens. In the smaller animals and in chickens there are 
 practically always large hemorrhages around the base of the brain and 
 upper part of the cord, whereas in the larger animals they are more 
 rarely found, and, if present, are smaller. There were no macro- 
 scopic, meningeal hemorrhages in any of the himian cases. 
 
 Microscopic examination of all the tissues shows that the congestion 
 is even more marked than would appear from macroscopic examina- 
 tion. The veins are practically all engorged with blood, the capil- 
 laries are usually distended, and the arteries may remain filled. In 
 
74 BOTULISM 
 
 the spleen the greatest engorgement occurs in the medullary venous 
 sinuses, and in the liver it is greatest in the intralobular veins and the 
 adjoining capillaries. In the meninges and in the brain there are 
 numerous minute hemorrhages around the distended veins, often 
 without apparent break in the contour of the vessel wall; and in the 
 brain, as in the other organs, there are often larger hemorrhages which 
 are not confined to the immediate vicinity of the vessels. In some 
 cases there is an excessive number of leukocytes in the blood in some 
 of the vessels. 
 
 Thrombosis, of the t)^e which was observed by Ophtils (Fig. 2) , is ex- 
 tremely common; in fact the thrombi are so uniformly present and are 
 so characteristic in appearance that they may be considered pathogno- 
 monic of botulism. Their appearance differs slightly in different 
 animals, but in cats and dogs they are apparently identical with those 
 found in human beings. The thrombi consist of dense masses of fibrin 
 (Fig. 9) which is arranged in thick bands, and have many polymor- 
 phonuclear leukocytes enmeshed between the strands. They are 
 frequently adherent to the sides of the blood vessels, but in a given 
 section may be free from any connection with the vessel wall. In 
 many cases there are no visible conglutinated blood platelets, but in 
 some there are hyaline masses which are probably composed of plate- 
 lets (Fig. 10). At times the red blood corpuscles have disappeared 
 from the lumen of the vessel, as seen in cross-section, but in many 
 cases they are intimately mixed with the leukocytes between the 
 strands of fibrin. 
 
 The appearance of the earlier stages of the thrombus formation is 
 . not so characteristic. The blood vessels may contain a hyaline ma- 
 terial, which may be conglutinated blood platelets, or there may be 
 bunches of loose fibrin, frequently whorled, in which leukocytes and 
 red blood corpuscles are enmeshed (Fig. U). Not infrequently the 
 hyaline material and the fibrin may coexist in one blood vessel, and 
 the two may even be intimately mixed together. It is uncommon to 
 find any leukocytes at this stage, but occasionally there may be large 
 or small bunches of leukoctyes embedded in the hyaUne material. It 
 is probable that it was this stage of thrombus formation which was 
 observed by Ossipoff (137). 
 
 There can be little doubt that this is an early stage of the thrombus 
 
ERNEST C. DICKSON 
 
 75 
 
 fonnation in the blood vessels; it is entirely different from anything 
 that is seen in postmortem clotting, and may be found in tissues which 
 are placed in fixing fluid within 1 or 2 minutes after the animal is killed. 
 Moreover, it is not uncommon to find that in animals where numerous 
 
 TABLE I. 
 
 Frequency of the Occurrence of Thrombosis. 
 
 Material. 
 
 Guinea pigs. 
 
 Thrombus 
 
 Prethrombus stage 
 No thrombus 
 
 Rabbits. 
 
 Thrombus 
 
 Prethrombus stage 
 No thrombus 
 
 Cats. 
 
 Thrombus 
 
 Prethrombus stage 
 No thrombus ..... 
 
 Dogs. 
 
 Thrombus 
 
 Prethrombus stage 
 No thrombus 
 
 Human beings. 
 
 Thrombus 
 
 No thrombus 
 
 Total 
 
 Animals lived. 
 
 1 day. 
 
 21 
 
 2 days. 
 
 11 
 
 3-7 
 days. 
 
 30 
 
 Over 
 1 wk. 
 
 S 
 1 
 3 
 
 11 
 
 5 
 
 14 
 2 
 
 43 
 
 Total. 
 
 12 
 8 
 
 10 30 
 
 21 
 9 
 7 37 
 
 26 
 1 
 3 30 
 
 3 
 
 1 4 
 
 105 
 
 Classification under "prethrombus stage" indicates that there was evidence 
 of beginning thrombosis, as shown either by masses of loose fibrin within the 
 blood vessels or by the presence of hyaline masses which are probably conglu- 
 tinated blood platelets. There were no typical thrombi. 
 
 fully formed thrombi are present, there are some vessels which contain 
 this incomplete stage of thrombus formation, and in some cases it has 
 been observed that on one side of a vessel lumen there may be a fully 
 formed thrombus, while on the other there is the incomplete form, the 
 
76 BOTULISM 
 
 two merging at the point of contact. For want of a better name I have 
 called this early stage of the thrombus formation the "prethrombus 
 stage" of the thrombosis. 
 
 The thrombi and the prethrombus structures are found in arteries 
 and veins, though considerably more often in the latter. They may 
 occur in the larger vessels which lie inside the organs, but are more 
 frequent in the smaller branches which ramify within the tissues. 
 They have never been observed in the blood which has escaped into 
 the tissues, but it is common to find that there is a thrombosed vein in 
 the vicinity of a hemorrhagic area. 
 
 There is some doubt as to the time which elapses before the thrombi 
 are formed. Of eleven guinea pigs and ten rabbits which died within 
 24 hours after the administration of the toxin, one guinea pig and two 
 rabbits showed fully developed thrombi in the vessels, and six guinea 
 pigs and seven rabbits showed the earlier prethrombus formation. 
 Of four rabbits, five cats, and two dogs which died on the 2nd day after 
 inoculation, one rabbit, four cats, and both dogs showed the typical, 
 fully formed thrombi, and none showed any of the prethrombus 
 formation; and of sixty-nine guinea pigs, rabbits, cats, and dogs 
 which survived for longer than 2 days, there were only thirteen which 
 did not show fully formed thrombus or definite evidence of the earlier 
 hyaline and loose fibrin formation. It would appear, therefore, that 
 the formation of the thrombus begins during the first 24 or 48 hours of 
 the intoxication, and that it reaches its full development very soon 
 after that time. The relative frequency of the occurrence of thrombo- 
 sis in the different animals is shown in Table I. 
 
 The difference between the thrombus which is usually found in the 
 smaller animals, guinea pigs and rabbits, and that which occurs in the 
 larger animals and in human beings, consists in the fact that the leuko- 
 cytes are less numerous or even absent in the former. The difference 
 is only relative, however, for in rabbits, especially, there may be accu- 
 mulations of leukocytes in the thrombi, and in a few of the larger 
 animals and in one of the human cases, the thrombi contained rela- 
 tively few leukocytes. It is an interesting fact that, whereas the 
 occurrence of thrombosis is relatively less frequent in guinea pigs and 
 rabbits, that of large hemorrhages, especially in the meninges and 
 brain, is relatively more frequent than in the larger animals. 
 
ERNEST C. DICKSON 77 
 
 The reason for the formation of the thrombus has not been deter- 
 mined. It was noted by the earlier authors, Kerner (7), Weiss (9), 
 Schlossberger (13), and others, that the blood of victims of botuKsm 
 remained fluid for a longer time than normally, but of this there is no 
 recent proof. Van Ermengem (34, 86) recorded that the endothehal 
 cells of capillaries were frequently degenerated, and, if this is true, it is 
 reasonable to conclude that the thrombi, and also the hemorrhages, 
 are secondary to the endothelial damage. However, in a short series 
 of experiments in which the vital staining methods were used, I was 
 unable to demonstrate any endothelial damage in the vessels in which 
 thrombosis was present. The reason for the accumulation of leuko- 
 cytes is also unexplained, and it is interesting that in none of the human 
 cases in which blood counts were made, was there any marked actual 
 or relative increase in the polymorphonuclear elements. 
 
 In a preliminary report (141) I recorded that thrombosis was fre- 
 quently found in the blood vessels of the central nervous system. 
 Subsequent investigation has shown that the thrombi are not confined 
 to the central nervous system but that they are also found in other 
 portions of the body. In general it may be said that thrombosis has 
 been demonstrated in every organ where a systematic search has been 
 made. Thrombi have been found in the meninges and tissues of the 
 central nervous system, in the lungs (Fig. 4), heart muscle, liver 
 (Fig. 12), kidneys, spleen (Fig. 6), adrenals, pancreas, and bone mar- 
 row. In a given case they may not be present in all the organs; 
 they are most frequent in the vessels of the meninges, especially in 
 the sulci, and in those of the lungs. In the kidneys, liver, and spleen 
 they are comparatively common, and in the other organs they have 
 been seen occasionally. They are perhaps more frequently found in 
 the smaller veins, but are not uncommon in the large veins and 
 arteries. 
 
 A careful examination was made of the nerve cells of the cranial 
 motor nuclei and of the anterior horns of the spinal cord. In a few 
 cases the tissues were placed in fixing fluid, absolute alcohol, within a 
 few minutes after the animal was killed, and many sections were made 
 from different portions of the brain and cord. The tissues of most of 
 the other animals were placed in Orth's fluid within a few hours after 
 death, and very few showed any appreciable amount of postmortem 
 
78 BOTULISM 
 
 degeneration. A few animals were treated with vital staining methods 
 according to the procedures described by Kiyono (142) and Goldmann 
 (143), in which carmine and trypan blue were used respectively. The 
 tissues were fixed in situ by injecting 20 per cent formalin through 
 the aorta, and were examined in frozen sections and paraffin prepara- 
 tions. Of the four human cases, necropsy was performed in two 
 within 24 hours after death, and in two after the bodies had been 
 embalmed. One of the latter cases had undergone so much post- 
 mortem degeneration that practically all the nerve cells showed more 
 or less disintegration. 
 
 In a few of the animals, especially in cats, there was some evidence 
 of change in the nerve cells of the motor nuclei. The cells were • 
 shrunken, the contour was irregular, the protoplasm was opaque and 
 sometimes vacuolated, and the nuclei stained poorly. Occasionally 
 there were cells in which the normal structure was entirely lost, and 
 there remained only an opaque, hyaline mass in the position which the 
 cell had occupied. There was never any evidence of invasion by 
 leukocytes or large phagocyte cells, or of proliferation of the neurogha 
 cells, as were described by van Ermengem (34, 86) . In the majority 
 of the animals, however, and in the three human cases in which the 
 tissues were well preserved, there was no evidence of any change in the 
 nerve cells which could be compared to those described by van Ermen- 
 gem (34, 86), Marinesco (136), Ossipoff (137), Romer and Stein (138), 
 and Paulus (19). The cells were of normal appearance, the nuclei 
 were well stained and contained a nucleolus, and the granules of the 
 protoplasm were arranged in the usual way. 
 
 There is some doubt as to how much of the damage in the nerve 
 cells was due to artifact. The changes were very inconstant, were not 
 locaHzed to particular cell groups, and were not seen in those cases 
 where the tissues were preserved immediately after death. Moreover, 
 there was no evidence of pigment granules in the nerve cells of any of 
 the animals which had been vitally stained, a point which is of con- 
 siderable- importance, since MacCurdy and Evans (144) have shown 
 that when nerve cells are damaged before death, they may be easily 
 recognized by the deposit of the pigment granules in their protoplasm. 
 
 The usual appearance of the brain and of the cord corresponds to 
 that which was described by Ophiils in the fatal case of the Stanford 
 
ERNEST C. DICKSON 79 
 
 University series. There is marked hyperemia of the meninges and 
 tissues, the veins being especially congested. Numerous small hemor- 
 rhages are seen in the region of the small veins in the meninges and the 
 tissues, and not infrequently are situated in the immediate vicinity 
 of a small vein, often surrounding it. The smaller hemorrhages are 
 much more frequent in the brain than in the cord, and are scattered 
 irregularly throughout the tissues of the cerebrum, stem, and cere- 
 bellum. The larger hemorrhages are more frequent in the stem. 
 
 Thrombi may be present in large numbers or may be difficult to find. 
 They are most frequent in the vessels of the meninges, but are also 
 present in those of the tissues. They are perhaps more common in the 
 region of the stem, but are often found in the vessels of the pia mater in 
 the sulci of the cerebrum and cerebellum, more frequently in the former 
 than in the latter. An especially frequent situation for thrombosis, 
 as well as for hemorrhage, is the space between the upper surface of the 
 pons and the lower surface of the posterior portion of the cerebral 
 hemispheres. The hemorrhages are often adjacent to veins which are 
 filled with thrombus. 
 
 Reference has already been made to the frequency and distribution 
 of the thrombi in the abdominal and thoracic viscera. The appear- 
 ance of the lungs, heart muscle, adrenals, and gastrointestinal tract 
 corresponds closely to that which was described by van Ermengem 
 (34, 86, 87). The liver is congested, and shows varying amounts of 
 parenchymatous and fatty degeneration of the liver cells, but the 
 frequency of focal necrosis is much less, in my series, than was ob- 
 served by Komotzki (139). The kidneys show marked parenchy- 
 matous degeneration of the cells of the convoluted tubules, which may 
 be completely necrotic and desquamated. The cells of the straight 
 tubules are less severely damaged, but the lumina contain casts of 
 debris from the convoluted tubules. The congestion is chiefly con- 
 fined to the veins and capillaries, but sometimes the glomerular tufts 
 are engorged with blood. In a few of the animals and in one human 
 case there were accumulations of exudate in the glomerular clefts (Fig. 
 13), and in some of them th^re were also red blood corpuscles. There 
 was no demonstrable change in the epithelial cells of Bowman's 
 capsule. In none of the organs were there any evidences of prolifer- 
 ation of the interstitial tissue or of infiltration with lymphocytes, 
 
80 BOTULISM 
 
 except in cases where it was evident that the proliferation of the in- 
 terstitial connective tissue had preceded the intoxication. Some of 
 the rabbits showed coccidial infections of the liver with proliferation 
 of the interstitial connective tissue, and some showed some sponta- 
 neous chronic nephritis, but otherwise there was no evidence of in- 
 terstitial tissue proliferation. 
 
 An interesting feature of a few cases was the occurrence of masses of 
 cells in the lumina of the veins, especially in the liver. The cells were 
 rhomboidal in shape, and had large, clear, vesicular nuclei. They 
 were grouped in bunches of from 4 or 5 to 8 or 10, and were evidently 
 desquamated endothelial cells. 
 
RECORD OF EXPERIMENTS. 
 
 The experimental study of Bacillus botulinus was undertaken pri- 
 marily to determine two points: (1) whether the organism is able to 
 grow and to produce a virulent toxin in vegetable mediimi in which 
 there is no protein of animal origin; and (2) whether the thrombosis 
 which was observed by Ophiils (99) is a characteristic manifestation 
 of poisoning with the botulinus toxin. A number of other problems 
 have presented themselves during the course of the investigation, 
 problems which deal with the method in which the toxin acts upon the 
 tissues, but these have not been solved, and will not be discussed in 
 detail. 
 
 Four strains of Bacillus botulinus were used in the investigation. 
 Strain I was obtained from the American Museum of Natural History, 
 New York; Strain II was suppHed by Professor Hans Zinsser of Co- 
 lumbia University, New York; Strain III was isolated from the crop of 
 a chicken which died after eating the beans in Outbreak 4; and Strain 
 IV was recovered from the gizzard of a chicken which died after eating 
 the spoiled corn in Outbreak 2. Another strain. No. V, was recently 
 obtained from a can of string beans, one of the lot which caused the 
 poisoning in Outbreak 7, but it has been studied only sufficiently to 
 prove that it is Bacillus botulinus. 
 
 Experiments with Media Prepared from Vegetables and Fruits. 
 Canned String Beans {Table II). 
 
 Twelve cans of commercially prepared string beans were opened by punching 
 a nail-hole in one end. A small amount of fluid was removed for culture and for 
 the injection of control animals, and about 1 cc. of a suspension of B. botulinus 
 (Strain I) in normal salt solution was inserted. The nail-holes were closed with 
 solder and the cans were kept at room temperature for from 2 to 12 months. 
 The control cultures were all negative, but four of the control animals died within 
 a few days, and although no bacterial cause of death could be established, the 
 four suspected cans were discarded. 
 
 When the cans were reopened, aerobic slant agar, and deep glucose agar 
 culture tubes were inoculated with the beans, the reaction of the fluid to phenol- 
 
 81 
 
82 
 
 BOTULISM 
 
 phthalein was determined, and guinea pigs, rabbits, and cats were injected with 
 varying amounts of the fluid. In the majority of cases the fluid was injected 
 subcutaneously, but in some it was injected into the peritoneal cavity. 
 
 TABLE II. 
 Results with Canned String Beans, Strain I. 
 
 Can 
 No. 
 
 Date 
 inocu- 
 lated. 
 
 Date 
 opened. 
 
 Odor. 
 
 Re- 
 action. 
 
 Culture. 
 
 Guinea 
 pig No. 
 
 Rabbit 
 No. 
 
 Cat 
 
 No. 
 
 Died. 
 
 2 rt 
 
 Throm- 
 bus. 
 
 
 1914 
 
 1914 
 
 
 
 
 
 
 
 
 
 
 8 
 
 Mar. 31 
 
 May 22 
 
 Good. 
 
 
 
 1 
 
 2* 
 
 1 
 
 2 
 
 1* 
 
 ? 
 
 3 wks. 
 2 " 
 
 + 
 
 + 
 + 
 
 + 
 + 
 
 6 
 
 " 31 
 
 June 29 
 
 a 
 
 +3.2 
 
 + 
 
 3* 
 4* 
 
 3* 
 
 4* 
 
 2* 
 3 
 
 ? 
 
 
 . + 
 
 7 
 
 " 31 
 
 " 29 
 
 u 
 
 +2,5 
 
 
 
 5* 
 6* 
 
 5* 
 6* 
 
 4* 
 
 5* 
 
 
 
 
 4 
 
 " 31 
 
 Nov. 10 
 
 a 
 
 +2.1 
 
 + 
 
 7* 
 8* 
 
 7* 
 8* 
 
 6* 
 
 
 
 
 11 
 
 " 31 
 
 " 10 
 
 1915 
 
 it 
 
 + 1.7 
 
 + 
 
 9* 
 10* 
 
 9* 
 10 
 
 7* 
 
 2 days. 
 
 - 
 
 - 
 
 1 
 
 " 31 
 
 Mar. 23 
 
 it 
 
 +2 
 
 + 
 
 11 
 
 11 
 12 
 
 8t 
 9 
 
 6 wks. 
 
 10 daj-s. 
 
 2 wks. 
 
 1 n>o. 
 
 + 
 + 
 
 + 
 
 + 
 
 + 
 + 
 + 
 
 10 
 
 " 31 
 
 " 23 
 
 i( 
 
 +2.2 
 
 + 
 
 12 
 13* 
 
 13 
 14* 
 
 10* 
 11 
 
 6 wks. 
 1 wk. 
 
 6 wks. 
 
 . + 
 + 
 
 + 
 
 + 
 
 + 
 
 + 
 
 12 
 
 " 31 
 
 " 23 
 
 n 
 
 +2 
 
 + 
 
 14 
 15* 
 
 IS 
 16* 
 
 12 
 13* 
 
 2 mos. 
 
 10 days. 
 
 9 wks. 
 
 + 
 + 
 + 
 
 + 
 + 
 
 * The animal showed no symptoms. 
 
 t The animal showed typical symptoms but recovered. 
 
 The reaction is stated in terms of the standard recommended by the Ameri- 
 can Public Health Association for the standardization of the reaction of culture 
 medium. Phenolphthalein was used as the indicator. 
 
ERNEST C. DICKSON 83 
 
 The reaction of the contents of the cans was acid in every case, varying from 
 1.7 to 3.2 per cent; and pure cultures of B. hotulinus were recovered from six 
 of the cans. 
 
 The animals were kept under close observation for about 3 weeks and were 
 then returned to the stock cages for used animals, as I was not aware that the 
 appearance of symptoms of the poisoning might be delayed beyond that time, 
 and that animals which became emaciated and died in from 6 to 8 weeks were, 
 in fact, suffering from the effects of the toxin. It is therefore probable that 
 several of the animals which are marked with an asterisk in Table II should be 
 included among the positive cases, as they died and were discarded without my 
 knowledge. 
 
 A number of the animals showed the typical symptoms of botulism, and post- 
 mortem examination showed the macroscopic changes which were described by 
 van Ermengem (34, 86, 87). Histologic examination showed multiple hemor- 
 rhages (Fig. 7.) and thrombi (Figs. 9, 11, and 14) of the type which was observed by 
 Ophiils (99) in almost all the cases. The distribution and appearance of the 
 hemorrhages and thrombi have been discussed in another section of this report. 
 
 The investigation established three important facts concerning the 
 toxin of Bacillus hotulinus: (1) that it will develop in a medium con- 
 sisting- of cooked string beans to which no animal protein has been 
 added; (2) that it will develop in a medium which gives an acid reac- 
 tion to phenolphthalein; and (3) that when animals die from the 
 effects of poisoning with the toxin, a peculiar type of thrombosis is to 
 be found in the blood vessels of various portions of the body. 
 
 Infusions Prepared from Vegetables. 
 
 The infusions were prepared from canned string beans, canned 
 peas, caimed corn, caimed asparagus, and fresh artichokes, respec- 
 tively. In all, the method of preparation was the same. The 
 material was boiled until it was soft and was then strained and 
 kneaded through cheese-cloth. The reaction of the fluid was ad- 
 justed to about 0.2 per cent alkaline to phenolphthalein, and 1 per 
 cent glucose was added. The medium was sterilized by fractional 
 sterilization, and the cultures were covered with albolene and incu- 
 bated in the dark at 28°C. 
 
 Infusion of Canned String Beans {Table III). — B. hotulinus grew readily in 
 the string bean infusion and produced a moderate amount of gas and the char- 
 acteristic butyric acid odor. The experiments showed results similar to those 
 
84 
 
 BOTULISM 
 
 TABLE III. 
 Results with Infusion Prepared from Canned String Beans, Stratus I and II. 
 
 Strain No. 
 
 Age of 
 culture. 
 
 Guinea 
 pig No. 
 
 Rabbit No. 
 
 Cat No. 
 
 Died. 
 
 Hemor- 
 rhage. 
 
 Thrombus. 
 
 • I 
 
 11 days. 
 
 16* 
 
 17* 
 
 
 
 
 
 I 
 
 ? 
 
 17t 
 
 18J 
 
 
 6 wks. 
 
 — 
 
 — 
 
 
 
 
 
 14 
 
 4 " 
 
 + 
 
 + 
 
 I 
 
 16 days. 
 
 
 19* 
 
 15* 
 
 
 
 
 
 
 
 
 . 16 
 
 6 " 
 
 + ■ 
 
 • + 
 
 ri 
 
 ? 
 
 18 
 
 
 
 25 days. 
 
 + 
 
 + 
 
 II 
 
 18 days. 
 
 
 20 
 
 
 6 wks. 
 
 + 
 
 — 
 
 * The animal showed no symptoms. 
 
 t The animal showed symptoms but recovered. 
 
 X The animal was killed. There were no symptoms. 
 
 obtained in the series with canned string beans, and proved that Strain II is also 
 able to produce a virulent toxin in medium prepared from string beans (Fig. 15). 
 The addition of glucose to the medium and the adjustment to an alkaline reaction 
 did not appear to cause any appreciable difference in the virulence of the toxin. 
 
 TABLE rV. 
 
 Results with Infusions Prepared from Canned Peas and Canned Corn, Strains I, 
 
 II, and III. 
 
 Medium 
 and strain. 
 
 AgeoJ 
 culture. 
 
 Amount 
 injected. 
 
 Guinea 
 pig No. 
 
 Rabbit 
 No. 
 
 Cat No. 
 
 Died. 
 
 Hemor- 
 rhage. 
 
 Thrombus. 
 
 Peas. 
 
 
 cc. 
 
 
 
 
 
 
 
 I 
 
 1 mo. 
 
 1.5 
 
 19 
 
 
 
 2 wks. 
 
 + 
 
 _ 
 
 II 
 
 1 '^ 
 
 2 
 
 20 
 
 
 
 18 days. 
 
 — 
 
 + 
 
 II 
 
 1 '' 
 
 1.5 
 
 21 
 
 
 
 6 " 
 
 + 
 
 + 
 
 II 
 
 1 " 
 
 5 
 
 
 
 17 
 
 5 wks. 
 
 + 
 
 + 
 
 II 
 
 1 '' 
 
 4.5 
 
 
 
 18 
 
 17 days. 
 
 + 
 
 + 
 
 III 
 
 1 '' 
 
 1 
 
 
 
 19 
 
 4 " 
 
 — 
 
 + 
 
 III 
 
 1 *' 
 
 0.5 
 
 
 
 20 
 
 2 " 
 
 — 
 
 + 
 
 III 
 
 1 " 
 
 1 
 
 22 
 
 
 
 18 hrs. 
 
 + 
 
 P.T. 
 
 III 
 
 1 '' 
 
 2 
 
 
 21 
 
 
 18 " 
 
 _ 
 
 ii 
 
 III 
 
 1 '' 
 
 1 
 
 
 
 21 
 
 2 days. 
 
 — 
 
 
 
 Corn. 
 
 
 
 
 
 
 
 
 
 Ill 
 
 1 '' 
 
 1.5 
 
 23 
 
 
 
 18 hrs. 
 
 + 
 
 + 
 
 III 
 
 1 ** 
 
 3 
 
 
 22 
 
 
 18 " 
 
 _ 
 
 + 
 
 III 
 
 1 " 
 
 1 
 
 
 
 22 
 
 2 days. 
 
 + 
 
 + 
 
 III 
 
 6 wks. 
 
 
 
 
 23 
 
 3 " 
 
 + 
 
 + 
 
 P.T.] 
 
 ndicates f 
 
 )rethroml 
 
 Dus stage 
 
 
 
 
 
 
ERNEST C. DICKSON 
 
 85 
 
 Infusion of Canned Green Peas {Table IV). — The experiments of this series 
 showed that B. botulinus will grow readily and will produce its toxin in a medium 
 prepared from cooked green peas. In cultures of Strains I and II the virulence of 
 the toxin was comparatively low, but in cultures of Strain III it was moderately 
 high, the relative degree of virulence being approximately the same as occurs 
 in cultures of the same strains in beef or pork infusion. In experiments with 
 Strain IV, which are not yet completed, it was found that virulence of its toxin 
 in peas medium was almost as high as in cultures of Strain III. 
 
 The odor of the peas culture is characteristic, there is much gas formation, 
 the bacilli and spores are present in large numbers, and the toxin produces the 
 typical symptoms and pathological changes in animals (Fig. 16). A chicken 
 which was fed a small amount of the toxin developed the typical symptoms of 
 botulism, which cannot be distinguished from those of limber-neck, and died 
 within 36 hours. 
 
 Infusion of Canned Corn {Table IV). — The experiments showed that cooked 
 green corn is also a suitable medium for the growth of B. botulinus and for the 
 development of its toxin. The virulence of the toxin of Strain III was moderately 
 high, and injections into animals, and feeding experiments in chickens showed 
 that the typical symptoms and thrombosis are produced. The incomplete series 
 
 TABLE V. 
 
 Results with Strain III in Artichokes, Asparagus, Apricots, and Peaches. 
 
 Medium. 
 
 Age ot 
 culture. 
 
 Amount 
 injected. 
 
 Guinea 
 pig No. 
 
 Rabbit 
 No. . 
 
 Died. 
 
 Hemor- 
 rhage. 
 
 Thrombus- 
 
 Artichokes 
 
 6 wks. 
 
 6 " 
 
 2 mos. 
 2 " 
 2 " 
 2 " 
 6 wks. 
 6 " 
 2 mos. 
 2 " 
 2 " 
 2 " 
 2 " 
 2 " 
 6 wks. 
 6 " 
 
 2 
 3 
 2 
 3 
 2 
 3 
 2 
 3 
 2 
 3 
 2 
 3 
 2 
 3 
 2 
 3 
 
 24 
 
 25 
 26 
 27 
 28 
 29 
 30 
 31 
 
 23* 
 
 24 
 
 25 
 
 26 
 
 27* 
 
 28 
 
 29 
 
 30* 
 
 days 
 4 
 
 1 
 2 
 1 
 2 
 7 
 
 19 
 3 
 
 1 
 2 
 3 
 4 
 5 
 
 + 
 + 
 
 + 
 + 
 
 + 
 + 
 
 + 
 + 
 + 
 + 
 + 
 
 + 
 
 ti 
 
 
 u 
 
 _ 
 
 „ 
 
 + 
 
 
 + 
 
 ti 
 
 + 
 
 
 
 it 
 
 + 
 
 ti 
 
 P.T. 
 
 it 
 
 
 Apricot stones 
 
 it it 
 
 Peaches 
 
 P.T. 
 
 + 
 
 it 
 
 
 
 it 
 
 _ 
 
 ti 
 
 
 
 
 * The animal showed no symptoms. 
 P. T. indicates prethrombus stage. 
 
86 BOTULISM 
 
 of investigations with Strain IV showed that the toxin of that strain was also 
 produced in a high degree of virulence. There was no investigation of Strains 
 I and 11 in corn medium. 
 
 Infusion of Canned Asparagus {Table V). — The investigations with infusions 
 of asparagus were confined to cultures of Strain III, and showed that a relatively 
 virulent toxin is produced. The injected animals developed the typical symp- 
 toms of botulism and their tissues showed the characteristic thrombus formation 
 and hemorrhages. 
 
 Infusion of Artichokes {Table V). — The investigation of artichoke medium was 
 also confined to a study of cultures of Strain III, but they showed that the toxin 
 may be formed in sufficient quantities to kill susceptible animals. The experi- 
 ments were repeated at an interval of several months, and the results were the 
 same in both series. 
 
 Infusions Prepared from Fruits. 
 
 The media from fruits were prepared in the same way as the infusions of vege- 
 tables, and fresh pears, peaches, and apricots were used. The stones of the 
 apricots and peaches were crushed, and added to the fruit while it was boiling. 
 One lot of medium was prepared from crushed apricot stones, from which all the 
 fruit pulp had been removed. The preparation and incubation of the culture 
 tubes were the same as in the vegetable infusion cultures. 
 
 Infusion of Pears. — Tubes of pear infusion were inoculated with Strain III of 
 B. hotulinus and allowed to incubate for over 2 months. FUms from the tubes 
 showed no evidence of the bacilli or spores, and injection into animals failed to 
 produce any symptoms. 
 
 Four cans of commercially preserved pears were inoculated with Strain I and 
 allowed to remain at room temperature for several months. When the cans were 
 opened, pure cultures of B. botulinus were obtained from three of them, but injec- 
 tion into animals did not produce any symptoms. 
 
 Infusion of Peaches {Table V). — The investigation in peach infusion was con- 
 fined to cultures of Strain III, and a single series of experiments was performed. 
 The experiments showed that the toxin may be formed in peach infusion in suffi- 
 cient quantities to produce the typical symptoms and thrombosis in susceptible 
 animals. A series of cans of preserved peaches has been inoculated, but suffi- 
 cient time has not elapsed for the completion of the investigation. 
 
 Infusion of Apricots {Table V). — Two series of experiments were performed 
 with cultures of Strain III in apricot infusions, and in both it was shown that 
 the toxin may be formed in sufficient quantities to produce the characteristic 
 S3anptoms and lesions in animals. 
 
 The cultures in an infusion of crushed apricot stones developed a toxin which 
 was even more virulent than that which was produced in an infusion of the whole 
 fruit, and which caused the typical symptoms and pathological changes of 
 botulism in guinea pigs and rabbits (Fig. 8). 
 
ERNEST C. DICKS02Sr 
 
 87 
 
 The cultures of B. botulinus in cans of preserved apricots are not yet ready for 
 study. 
 
 Experiments with Media Prepared from Pork and Beef. 
 
 The media that were used in this series of experiments were pre- 
 pared according to the formulas recommended by van Ermengem (34, 
 86) and Leuchs (114). The beef infusion (van Ermengem) contained 
 1 per cent sodium chloride, 1 per cent peptone, and 2 per cent glu- 
 cose, whereas the pork infusion (Leuchs) contained 0.5 per cent sodium 
 chloride, 1 per cent peptone, and 1 per cent glucose. The bacteria 
 grew rapidly and developed virulent toxins in both, but no accurate 
 comparative study was made of the toxin-producing power of the 
 bacteria in the two media. The cultures were covered with albolene 
 and incubated at 28°C. in the dark. 
 
 Experiments with Glucose Beef Infusion {Tables VI, VII, and VIII). — ^The 
 growth of all the strains of B. botulinus in van Ermengem 's medium was profuse, 
 
 TABLE VI. 
 Results tn Glucose Beef Infusion {van Ermengem' s Medium) , Strains I and II. 
 
 strain No. 
 
 Age of 
 culture. 
 
 Amount 
 injected. 
 
 Guinea 
 pig No. 
 
 Rabbit 
 No. 
 
 Cat No. 
 
 Died. 
 
 Hemor- 
 rhage. 
 
 Thrombus. 
 
 • 
 I 
 
 16 days. 
 
 cc. 
 2 
 
 32 
 
 
 
 7 days. 
 
 + 
 
 -t- 
 
 I 
 
 16 " 
 
 S 
 
 
 31t 
 
 
 2 mos. 
 
 — 
 
 -h 
 
 I 
 
 6 " 
 
 5 
 
 33 
 
 
 
 5 wks. 
 
 -1- 
 
 + 
 
 I 
 
 6 « 
 
 5 
 
 34 
 
 
 
 4 days. 
 
 + 
 
 -f- 
 
 I 
 
 7 wks. 
 
 3.5 
 
 
 32* 
 
 
 
 
 
 I 
 
 7 " 
 
 5 
 
 
 
 24 
 
 6 wks. 
 
 — 
 
 + 
 
 I 
 
 5 " 
 
 3 
 
 
 3i 
 
 
 24 days. 
 
 -1- 
 
 + 
 
 I 
 
 S " 
 
 S 
 
 
 
 25 
 
 16 " 
 
 - 
 
 4- 
 
 II 
 
 6 " 
 
 2 
 
 35 1 
 
 
 
 
 
 
 II 
 
 6 " 
 
 S 
 
 
 34 
 
 
 6 wks. 
 
 — 
 
 — 
 
 II 
 
 6 " 
 
 3 
 
 36 
 
 
 
 5 " 
 
 — 
 
 — 
 
 II 
 
 2 mos. 
 
 3.5 
 
 
 35 
 
 
 5 days. 
 
 + 
 
 -h 
 
 II 
 
 2 " 
 
 5 
 
 
 
 26 
 
 2 mos. 
 
 — 
 
 — 
 
 II 
 
 2 " 
 
 3.5 
 
 
 36* 
 
 
 
 
 
 II 
 
 2 " 
 
 S 
 
 
 
 27 
 
 2 mos. 
 
 -f- 
 
 -f- 
 
 II 
 
 2 " 
 
 S 
 
 
 
 28 
 
 15 days. 
 
 -1- 
 
 + 
 
 * The animal showed no symptoms. 
 
 t The animal showed symptoms but recovered. 
 
 X The animal was kUled. There were no symptoms. 
 
88 
 
 BOTULISM 
 
 and the toxin production was relatively high. The mediuin became cloudy in 
 from 48 to 72 hours, but within a week began to clear and the bacilli settled to 
 the bottom of the tube. There was a moderate amount of gas formation and a 
 very strong butyric acid odor. Toxin could be demonstrated in about 3 or 4 
 
 TABLE VII. 
 Results in Glucose Beef Infusion, Strains III and IV. 
 
 Strain No. 
 
 Age of 
 culture. 
 
 Amount 
 injected. 
 
 Guinea 
 pig No. 
 
 Rabbit 
 No. 
 
 Cat No. 
 
 Died. 
 
 Hemor- 
 rhage. 
 
 Thrombus. 
 
 Ill 
 
 25 days. 
 
 cc. 
 
 1 
 
 37 
 
 
 
 1 day. 
 
 
 
 III 
 
 25 " 
 
 3 
 
 
 37 
 
 
 1 " 
 
 — 
 
 P.T. 
 
 III 
 
 25 " 
 
 4 
 
 
 
 29 
 
 7 days. 
 
 - 
 
 + 
 
 III 
 
 16 " 
 
 F. 1 
 
 38 
 
 
 
 18hrs. 
 
 — 
 
 — 
 
 III 
 
 16 " 
 
 F. 3 
 
 
 38 
 
 
 20 " 
 
 + 
 
 P.T. 
 
 III 
 
 16 " 
 
 F. 5 
 
 
 39 
 
 
 2 days. 
 
 + 
 
 it 
 
 m 
 
 16 " 
 
 F. 8 S. 
 
 
 
 30 
 
 4 " 
 
 — 
 
 + 
 
 III 
 
 16 " 
 
 F. 1 
 
 
 
 31 
 
 2 " 
 
 + 
 
 + 
 
 III 
 
 6 wks. 
 
 F. 0.001 
 
 39 
 
 
 
 18 hrs. 
 
 + 
 
 P.T. 
 
 III 
 
 6 " 
 
 F. 0.002 
 
 40 
 
 
 
 18 " 
 
 + 
 
 ti 
 
 III 
 
 6 " 
 
 F. 0.0002 
 
 41 
 
 
 
 20 " 
 
 + 
 
 — 
 
 III 
 
 6 " 
 
 F. 0,0005 
 
 
 iO 
 
 
 2 days. 
 
 + 
 
 — 
 
 III 
 
 6 " 
 
 F. 0.0055 
 
 
 41 
 
 
 4 " 
 
 — 
 
 + 
 
 III 
 
 6 " 
 
 1.5 
 
 
 
 32 
 
 5 " 
 
 + 
 
 + 
 
 III 
 
 6 " 
 
 1 
 
 
 
 33 
 
 5 " 
 
 + 
 
 + 
 
 IV 
 
 4 " 
 
 5 
 
 
 
 34 
 
 2 wks. 
 
 — 
 
 + 
 
 IV 
 
 6 " 
 
 2 
 
 
 42 
 
 
 18 hrs. 
 
 + 
 
 P.T. 
 
 IV 
 
 6 " 
 
 2 
 
 
 43 
 
 
 18 " 
 
 — 
 
 tc 
 
 IV 
 
 6 " 
 
 2 
 
 
 44 
 
 
 18 " 
 
 — 
 
 — 
 
 IV 
 
 6 " 
 
 2 
 
 
 45 
 
 
 18 " 
 
 + 
 
 P.T. 
 
 IV 
 
 6 " 
 
 F. 2 
 
 
 46 
 
 
 18 " 
 
 + 
 
 u 
 
 TV 
 
 6 " 
 
 F. 1.5 
 
 42 
 
 
 
 18 " 
 
 + 
 
 tl 
 
 IV 
 
 6 " 
 
 0.002 
 
 
 47 
 
 
 ? 
 
 + 
 
 — 
 
 IV 
 
 6 " 
 
 0.004 
 
 
 
 35 
 
 3 days. 
 
 + 
 
 — 
 
 IV 
 
 6 " 
 
 0.001 
 
 
 48 
 
 
 20 hrs. 
 
 + 
 
 4- 
 
 F. indicates filtered; S., repeated injections. 
 P. T. indicates prethrombus stage. 
 
 days, but it required at least 3 or 4 weeks for the maximum virulence to be 
 reached. 
 
 The virulence of the toxins of Strains I and II in glucose beef infusions was 
 extremely low as compared with that of Strains III and IV. A comparison of 
 
ERNEST C. DICKSON 
 
 89 
 
 Tables VI and VII shows that whereas in Strains I and 11 from 3 to 5 cc. of the 
 infusion were necessary to produce death in animals in from several days to 6 
 weeks or 2 months, in Strain III 0.0002 cc. would kill a guinea pig, and in Strain 
 IV 0.001 cc. would kill a rabbit within 24 hours. But in spite of the great dif- 
 ferences in the degrees of virulence, the pathological lesions are identical in 
 poisoning from all the strains, provided that the injections of the toxins of 
 Strains III and IV are small enough to allow the animals to live for from 2 to 4 
 days or longer (Figs. 10, 12, and 17 to 20). 
 
 TABLE VIII. 
 Results of Injecting Dogs with Glucose Beef Infusion Cultures, Strains III and IV. 
 
 Strain No. 
 
 Dog No. 
 
 Age of culture. 
 
 Amount 
 injected. 
 
 Died. 
 
 Hemorrhage. 
 
 Thrombus. 
 
 Ill 
 
 1 
 
 2 mos. 
 
 cc. 
 
 5 
 
 2 days. 
 
 
 + 
 
 III 
 
 2 
 
 2 " 
 
 F. 3 
 
 2 " 
 
 + 
 
 + 
 
 III 
 
 3 
 
 2 " 
 
 F. 1 
 
 3 " 
 
 + 
 
 + 
 
 IV 
 
 4 
 
 2 " 
 
 F. 2.3 S. 
 
 R.* 
 
 
 
 III 
 
 S 
 
 2 " 
 
 F. 0.85 S. 
 
 16 days. 
 
 
 
 + 
 
 * R. indicates recovery. The animal was very ill for 2 weeks. Symptoms 
 tjfpical. The recovery was slow. 
 
 F. indicates filtered toxin; S., repeated injections. 
 
 Dogs have been found to be susceptible to the toxins of Strains III 
 and IV in glucose beef infusion cultures. The susceptibility is com- 
 paratively low compared with guinea pigs and rabbits, and is slightly 
 lower than that of cats, but the pathological changes are the same as in 
 the other susceptible animals. 
 
 Experiments with Glucose Pork Infusion {Table IX). — Cultures of Strains I, 
 II, and III were examined, and in all the toxin had developed. The toxins of 
 Strains I and 11 were of very low virulence as compared with those of Strain III, 
 and corresponded closely to those in the glucose beef infusion, but the toxin of 
 Strain III was relatively low in comparison with the glucose beef infusion cul- 
 tures of Strain III. The symptoms and pathological changes were the same as 
 were produced in the other media. 
 
90 
 
 BOTULISM 
 
 TABLE IX. 
 Results in Glucose Pork Infusion {Leuchs Medium), Strains I, II, and III. 
 
 Strain No. 
 
 Age of 
 culture. 
 
 Amount 
 injected. 
 
 Guinea 
 pig No. 
 
 Rabbit 
 No. 
 
 Cat No. 
 
 Died. 
 
 Hemor- 
 rhage. 
 
 Thrombus. 
 
 I 
 
 8 days. 
 
 cc. 
 
 1.5 
 
 43t 
 
 
 
 
 
 
 I 
 
 8 " 
 
 S 
 
 
 49* 
 
 
 
 
 
 I 
 
 8 " 
 
 5 
 
 
 
 36* 
 
 
 
 
 I 
 
 6 " 
 
 1 
 
 44 
 
 
 
 6 days. 
 
 + 
 
 + 
 
 I 
 
 6 wks. 
 
 3 
 
 
 50 
 
 
 17 " 
 
 + 
 
 + 
 
 I 
 
 6 " 
 
 5 
 
 
 
 37 
 
 2 mos. 
 
 + 
 
 + 
 
 I 
 
 6 " 
 
 3 
 
 
 51 
 
 
 20 days. 
 
 + 
 
 + 
 
 I 
 
 6 " 
 
 S 
 
 
 
 38 
 
 2 mos. 
 
 — 
 
 + 
 
 II 
 
 6 days. 
 
 ■ 2 
 
 45t 
 
 
 
 
 
 
 II 
 
 6 " 
 
 4 
 
 
 52* 
 
 
 
 
 
 11 
 
 6 " 
 
 5 
 
 
 
 39* 
 
 
 
 
 II 
 
 6 " 
 
 1 
 
 46 
 
 
 
 9 days. 
 
 + 
 
 P.T. 
 
 11 
 
 6 " 
 
 3 
 
 
 53{ 
 
 
 5 wks. 
 
 — 
 
 + 
 
 III 
 
 6 wks. 
 
 5 
 
 
 
 40 
 
 2 days. 
 
 + 
 
 + 
 
 HI 
 
 6 " 
 
 II.V. 
 
 
 54 
 
 
 5 " 
 
 + 
 
 + 
 
 III 
 
 6 " 
 
 3 
 
 
 55 
 
 
 8 " 
 
 + 
 
 + 
 
 III 
 
 6 " 
 
 1.5 
 
 
 
 41 
 
 7 " 
 
 — 
 
 + 
 
 III 
 
 7 " 
 
 1 
 
 
 
 42 
 
 5 " 
 
 — 
 
 + 
 
 * The animal showed no symptoms. 
 
 t The animal showed symptoms but recovered. 
 
 X The animal was killed. There were no symptoms. 
 
 P. T. indicates prethrombus stage. 
 
 r. V. indicates intravenous injection. 
 
 Experiments with Vital Staining Methods. 
 
 Four rabbits were injected with a solution of carmine, according to the method 
 described by Kiyono (142), and were inoculated with aglucose beef infusion toxin 
 of Strain III. All developed the typical symptoms of botulism, and their tissues 
 showed the characteristic hemorrhages and thrombosis. There was no evidence 
 of carmine granules in the endothelial cells of the blood vessels which contained 
 thrombi, or in the nerve cells of the nuclei of the cranial motor nerves or of the 
 anterior horns of the spinal cord. 
 
 Four cats .and one rabbit were injected with trypan blue according to the 
 method described by Goldmann (143), and were inoculated with a glucose beef 
 infusion culture of Strain III. The animals were killed during an illness which 
 was typically botulism, and the tissues were immediately hardened in situ by 
 intraaortic perfusion with 20 per cent formalin. Microscopic examination was 
 
ERNEST C. DICKSON 91 
 
 made of frozen sections, and of paraffin preparations. The typical hemorrhages 
 and thrombi were found in the tissues, but there was nothing abnormal in the 
 endothelial cells of the vessels which contained thrombi, and there was no evi- 
 dence of pigment granules in the ganglion cells of the central nervous, system. 
 
 Experiments to Determine Whether There Is a Direct Action of the 
 Toxin upon the Muscles. 
 
 In 1874 Piirckhauer (145) advanced the theory that the results of sausage- 
 poisoning could best be explained by assuming that there is a direct toxic action 
 upon the muscles, and that the disturbances in the musculature are not second- 
 ary to changes in the central nervous system. He drew attention to the fact 
 that there is an inhibition of glandular secretions, and believed that these could 
 also be explained by the direct action of the toxin upon the secreting cells. He 
 argued that the order in which the symptoms of botuHsm develop, and the dif- 
 ferences that are found in the mild and severe cases afford strong support to his 
 theory that the muscles are directly aQected. In the milder cases there may be 
 only disturbances of vision due to paralysis of the intrinsic muscles of the eyes, 
 and in the more severe cases the eye symptoms usually appear first. Involve- 
 ment of the extrinsic muscles of the eyes, of the muscles of the pharynx, larynx, 
 and gastrointestinal tract appear later. In the more severe cases there is weak- 
 ness of the heart muscle and of the skeletal muscles, and in fatal cases death is 
 frequently due to cardiac failure. 
 
 Piirckhauer attempted to explain the regularity with which the symptoms 
 develop in a definite sequence, by assuming that the damaging effect of the toxin 
 is first manifested in the more delicate muscles of the body, and that the order in 
 which the larger muscles are damaged is dependent upon their size. The ex- 
 tremely delicate muscles of the iris are therefore among the first to suffer, and 
 any interference with their action is immediately recognized by the patient. 
 The muscles of the orbit, pharynx, larynx, and gastrointestinal tract are relatively 
 small and are also damaged early, but the heart muscle, which is large, is affected 
 comparatively late. He believed that the skeletal muscles would also lose their 
 function if the toxin could act sufficiently long, but he pointed out that the pa- 
 tients usually died from cardiac failure before the skeletal muscles became in- 
 volved. He drew attention to the fact that there is an absence of facial expres- 
 sion even when there is no paralysis of the facial nerve, and he beliSved that this, 
 as well as the general muscular weakness, was an indication of a definite lesion 
 in the muscle tissue. He recalled that Kerner had described excessive rigor 
 mortis in the bodies of patients who had died of sausage poisoning and he believed 
 that this was also evidence that the muscles had been damaged. 
 
 A short series of experiments was performed to determine whether 
 the toxin of Bacillus botulinus has any direct action upon muscle and 
 
92 BOTULISM 
 
 other types of protoplasm. An extremely powerful toxin of Strain 
 III was used, and the experiments were all thoroughly controlled. 
 
 Experiment 1. — Different varieties of bacteria were grown in association with 
 B. botuUnus in glucose beef infusion culture, and were allowed to remain until a 
 highly virulent toxin was developed. There was no apparent damage to the 
 associated bacteria. 
 
 Experiment 2. — Strips of frogs' ph^rynges were placed in a filtered infusion in 
 which there was a virulent toxin, and the activity of the ciliary movement was 
 determiiied by placing small pieces of cork upon the surface and estimating the 
 distance they were carried within a certain time. There was no inhibition of 
 ciliary activity in the strips which were immersed in the toxin, and their move- 
 ments were continued for as long a time as in control strips which were placed in 
 a similar infusion which did not contain any toxin. 
 
 Experiment 3. — The gastrocnemii muscles of a frog were placed in parallel 
 in an electric circuit, with the terminal wires embedded in the muscle. One 
 muscle was immersed in a filtered glucose beef infusion culture of B. botulinus 
 and the other was placed in glucose beef infusibn (of the same lot as the culture) 
 in which there was no toxin. The muscles were fatigued by intermittent stimula- 
 tion with a tetanizing current which was of equal strength in both muscles. The 
 muscle which was immersed in toxin did not fatigue any sooner than the control, 
 and after a period of rest it responded fully as well as did the control. 
 
 Experiment 4. — Small muscles from the thighs of a guinea pig were arranged 
 in the same manner as were the frogs' muscles, and were kept at body tempera- 
 ture by immersing the apparatus in a water bath. The results of stimulation 
 were the same as in the experiments with frogs' muscles. 
 
 Experiment 5. — Two guinea pigs of equal weight were selected, and one was 
 injected with a lethal dose of the botulinus toxin. When the animal was so ill 
 that it was unable to use its hind legs, corresponding muscles were taken from the 
 thighs of the poisoned and the normal guinea pigs and suspended in modified 
 Locke's solution in the same manner as in the previous experiments. The 
 muscles were kept at body temperature by immersing the apparatus in a water 
 bath. The muscle of the poisoned animal did not fatigue any sooner than the 
 muscle of the normal animal, and after a period of rest it responded fully as well 
 as did the other. 
 
 The investigation was not pursued further, as it seemed clear that 
 the toxin of Bacillus botulinus (Strain III) had no direct poisonous 
 action upon the protoplasm of bacteria, frog epithehal cells, frog 
 muscle, and guinea pig muscle. 
 
CRITICAL REVIEW. 
 
 The important facts that have been established by my investiga- 
 tions are four in nimiber: (1) that botuHsm is endemic in the United 
 States and is of comparatively frequent occurrence on the Pacific 
 Coast; (2) that the toxin of Bacillus botulinus may form in a medium 
 which is of purely vegetable composition ; (3) that there is apparently 
 a close relation between the botuhsm of human beings and a certain, 
 hitherto unexplained, illness of domestic fowl; and (4) that the botu- 
 linus toxin produces characteristic lesions in the body, in the form of 
 thrombosis in the blood vessels of many of the organs. 
 
 Previous to 1913, there was only one report in the available Ameri- 
 can Hterature for 20 years in which the diagnosis had been made, but 
 a review of the literature on food-poisoning revealed three other out- 
 breaks in which the illness was probably due to the botulinus toxin. 
 Since the beginning of 1913 there have been twelve recorded out- 
 breaks of food-poisoning in which the symptomatology of botulism 
 has been recognized, and of these twelve series of cases, eight have 
 occurred in California and one in Oregon. There is little doubt that 
 many other outbreaks of botulism have passed unrecognized during 
 this time. I have incomplete records of a case in Hornbrook, Cali- 
 fornia, in which a woman died of "bulbar paralysis" and nearly 100 
 of her chickens died from limber-neck within a few days. Dr. E. F. 
 Holbrook of San Jose, California, told me that he had seen two similar 
 cases before he treated the one which I have recorded (Outbreak 4), 
 and Dr. Bine and Dr. Lartigau of San Francisco have treated three 
 patients who were probably cases of botulism. Dr. Phillips of Palo 
 Alto recalls five cases of poisoning from canned beans which he saw 
 in Amador County, California, and Curfman referred to five similar 
 case which were observed in Colorado. In these, and probably in 
 many other similar cases, a diagnosis of botulism was not made, and 
 the Bureaus of Vital Statistics contain few records of cases in which 
 botulism was given as the cause of death. If, however, it were pos- 
 sible to trace all the cases in which "ptomaine poisoning" has been 
 
 93 
 
94 BOTULISM 
 
 given as the cause of death, I have little doubt that botulism would 
 be found to occupy an important position in the mortality list of the 
 preventable diseases. 
 
 The result of the investigation which has the greatest economic 
 importance is the demonstration that botulism may be produced by 
 the ingestion of spoiled canned vegetables and fruits. This type of 
 food-poisoning has been considered to be one of the specific meat 
 intoxications, and of the five reported outbreaks which occurred in this 
 country previous to 1914, four were attributed to poisoning by food of 
 animal origin. Of the eleven more recent outbreaks of botulism, how- 
 ever, there is only one in which the poisoning was traced to meat. In 
 three the source of the poison was not determined, but in seven it was 
 definitely traced to home-canned vegetables or fruit, and in one it was 
 traced to commercially canned vegetables. Four of the outbreaks 
 were due to poisoning by canned string beans, one by canned green 
 corn, one by canned asparagus, and one by apricots which had been 
 canned without sugar. 
 
 In the cases which were recorded by Wilbur and Ophiils and in 
 those of Outbreak 1 of my series, there seemed to be no doubt as to 
 the diagnosis of botuKsm, as the clinical picture was complete; but it 
 was not until the occurrence of Outbreaks 2 and 4, in December, 1915, 
 and January, 1916, respectively, that the diagnosis was fully estab- 
 lished by the recovery of Bacillus botulinus from remnants of the 
 discarded food. More recently, in February, 1917, a third strain of 
 Bacillis botulinus was recovered from a can of string beans which was 
 of the same lot that had been responsible for the poisoning in Out- 
 break 7; and one can therefore conclude that the poisoning from the 
 vegetables is, indeed, dependent upon the toxin of Bacillus botulinus. 
 
 In all the recorded cases in which canned vegetables or fruits have 
 been responsible for the poisoning, the food has not been cooked after 
 it was removed from the can. Three of the victims in my series tasted 
 small portions from the cans of string beans and corn to determine 
 whether they were spoiled, and one drank the fluid from a jar of 
 asparagus. In two instances the canned string beans were served as 
 salad, and in one the apricots were served as dessert. 
 
 The fact that boiling will destroy the toxin was illustrated in Out- 
 break 3, where the mother died after drinking the fluid from the freshly 
 
ERNEST C. DICKSON 95 
 
 Qpened can of asparagus, and the son escaped illness although he ate a 
 portion of the asparagus after it had been -cooked. 
 
 The virulence of the toxin in vegetables is very great in some cases. 
 Two women died after merely tasting string beans and corn, respec- 
 tively, to determine whether they were good, and one woman became 
 ill after tasting beans. In Outbreak 1 all the patients died after 
 eating home-canned apricots, and in Outbreak 7 four died and 
 three were ill after eating string bean salad. In Wilbur and Ophiils' 
 series, eleven out of twelve patients recovered after eating string bean 
 salad, but with the exception of this one series, all the, outbreaks 
 which have been caused by vegetables or fruits have shown an ex- 
 tremelyhigh mortality. 
 
 My experimental work has shown that the strains of Bacillus hotu- 
 linus which were isolated from the vegetables are not different in their 
 action from stock strains which were obtained in New York, and 
 which, presumably, were recovered from meat. The stock strains, I 
 and II, produced virulent toxins in medium prepared from string beans 
 and green peas, and the symptoms and pathological changes that were 
 produced in animals were identical with those produced by my newly 
 isolated strains, III, IV, and V. The expe'riments have also shown 
 that various fruits and vegetables may be suitable media for the de- 
 velopment of the botulinus toxin, as positive results were obtained in 
 media prepared from string beans, green peas, green corn, artichokes, 
 asparagus, apricots, and peaches. 
 
 It is a point of considerable importance that foodstuffs which are 
 contaminated with the toxin of Bacillus botulinus may not appear 
 sufficiently spoiled to ensure their being discarded. The vegetables 
 usually have an unpleasant odor and may show bubbles of gas on the 
 surface, but they are not apt to be discolored or soft, and may even 
 appear to be especially well preserved. It should be thoroughly 
 understood that an extremely virulent toxin may produce but little 
 change in the appearance of the food, and the common practice of 
 tasting canned stuff to see whether it is fit for use should be dis- 
 couraged. All canned food should be discarded if there is any indica- 
 tion that it is even slightly spoiled (this is even more important with 
 home-canned food), and under no circumstances should it be eaten or 
 even tasted before it has been cooked. 
 
96 BOTULISM 
 
 That the method which is usually employed in canning vegetables 
 and fruits at home is not efi&cient is proved by the frequency with 
 which a larger or smaller proportion of the finished product becomes 
 spoiled. The average housewife knows nothing concerning the habits 
 of bacteria or of the significance of the spores in spore-bearing bac- 
 teria; and she has no conception of the importance of thorough 
 sterilization. With the older method of preserving with sugar the 
 danger was not so great, as it is probable that even a moderate amount 
 of sugar inhibits the development of the toxin, but in the process of 
 canning without sugar the greatest care is necessary to ensure that all 
 the bacteria and spores are destroyed. 
 
 The usual method which is adopted in the home-canning process is 
 somewhat as follows: The jars or cans are prepared by filling them 
 with boiling water and allowing them to stand for a few minutes; it is 
 seldom that they are kept in boiling water for a time sufiicient to kill 
 any spores that may be present. The fruit or vegetables are washed, 
 and are placed in the jars, often without having been previously 
 cooked, as it is known that too much boiling will cause the material 
 to soften and to lose its fresh appearance. The jars are filled with 
 water and placed in a large container, frequently a wash-boiler, and 
 allowed to steam for 2 or 3 hours, or perhaps longer. They are then 
 removed from the boiler, sealed, and stored away. 
 
 Such a process of canning is entirely inadequate when no sugar or 
 other preservative is added to inhibit bacterial action. The amount of 
 moist heat that is necessary to kill bacterial spores varies with the dif- 
 ferent varieties of bacteria and many spores will withstand a tempera- 
 ture below that of the actual boiling point for a considerable length of 
 time. Wolffhugel and Hueppe (146) investigated the cause of the 
 spoiling of canned meats which had been presumably sterilized after 
 being canned, and they found that if a can which contained 2,735 
 gm. of meat was kept immersed in boiling water for 3 hours, the tem- 
 perature in the center of the can did not rise above 92°C. ; and that if 
 a can one-quarter as large was treated in the same way the temperature 
 in the center did not rise above 98°C. Many bacterial spores will 
 withstand this temperature for a considerable length of time, and in 
 the method of sterilization which is in common use by the housewife, 
 it is probable that the temperature in the center of the jars is not even 
 as high as was obtained by Wolffhiigel and Hueppe. 
 
ERNEST C. DICKSON 97 
 
 The United States Department of Agriculture' advocates that the 
 method of fractional sterilization should be used in the canning of 
 fruits and vegetables at home, but the advice is not generally heeded. 
 However, fractional sterilization, as it is usually carried out, is not 
 sufficient to kill the spores of Bacillus botulinus, as was shown in 
 the report of Wilbur and Ophtils (99). The instructions for frac- 
 tional sterilization of canned goods direct that the jars should be 
 left unsealed until after the last sterilization, in order that the 
 spores may germinate and thus become susceptible to the second 
 and third applications of heat. Bacillus botulinus is a strict anaer- 
 obe, and if the jars are left open in the interim between sterilizations 
 the spores will not generate, and are therefore not susceptible to 
 the later process of sterilization. It is only with steam under pres- 
 sure that the spores of Bacillus botulinus can be surely destroyed, 
 and it is doubtless due to their efficient methods of steriUzation 
 that the commercial canners of foods have not been troubled with this 
 form of food-poisoning in vegetables. A number of the housekeeping 
 magazines are advocating the use of small autoclaves in the home 
 kitchen, and if these are used the danger of infection with Bacillus 
 botulinus will be greatly reduced; but with the methods of home- 
 canning which are now in general use, the process is always attended 
 with danger of food-poisoning of this virulent tj^e. 
 
 The demonstration that domestic fowl, chickens and turkeys, 
 develop an iUness which in every way corresponds to limber-neck is 
 also of interest. Piirckhauer (145) recorded that ducks had been 
 poisoned after eating remnants of the poisonous sausages which had 
 caused the Ulness of his patients, but van Ermengem (34, 86) reported 
 that chickens are not susceptible, although pigeons are extremely sus- 
 ceptible to the toxin of Bacillus botulinus. In four of the outbreaks 
 which are reported in my series, in the one which was recorded by 
 Sheppard, and in the suspected outbreak at Hornbrook, California, 
 varying numbers of chickens died after an iUness in which the symp- 
 toms were those of limber-neck. Moreover, in the two instances in 
 Escondido, California, where spoiled string beans were thrown out, 
 
 8 Experiment Station Work XXVI, prepared by True, A. C, U. S. Dept. 
 Agric, Farmer's Bull. 262, 1906. Breazeale, J. F., Canning vegetables in the 
 home, V. S. Dept. Agric, Farmer's Bull. 359, 1909. 
 
98 BOTULISM 
 
 and in one at Hanford, California, where spoiled corn was discarded, 
 numbers of chickens, and, in one instance, several turkeys, developed 
 the same symptoms after eating the discarded food. Limber-neck is 
 supposed to be due to the ingestion of spoiled meat which is fed to the 
 chickens, but it is known that chickens and turkeys can eat putrefying 
 meat without suffering any injury. My experiments have shown that 
 the typical symptoms of limber-neck may be produced by feeding 
 chickens with the toxin of Bacillus botulinus, and it is reasonable to 
 suppose that even when the symptoms follow the ingestion of spoiled 
 meat, it is Bacillus botulinus which is responsible for the poisoning. 
 
 In this connection it is interesting to note that Saunders (147) has attempted 
 to correlate poliomyelitis in himian beings and limber-neck in chickens, and that 
 he believes that the two are identical. In an elaborate series of experiments he 
 found that the larvae of the green fly {Lucilia c<Bsar) are capable of transmitting 
 a virulent toxin, which he believes to be the toxin of poliomyelitis, within 3 days 
 after the fly had become contaminated from carrion flesh, and he concluded that 
 poliomyelitis in human beings is due to ingestion of larvae from, an infected fly. 
 
 Saunders recorded series of cases in which horses, mules, cattle, sheep, hogs, 
 opossums, and buzzards had been known to develop paralysis at the same time 
 that chickens were affected with limber-neck, and he attributed the cause for 
 the development of the illness to the ingestion of infected carrion and to the 
 activity of the green fly. He mentioned that the poisoning could not be due to 
 the botulinus toxin because "the dog is absolutely resistent to the hotulismus 
 toxin," and recorded specific instances in which dogs had contracted the disease 
 after eating the carcasses of chickens which had died of limber-neck. 
 
 My experiments have shown that dogs are not immune to the action 
 of the botulinus toxin, and there are at least two recorded cases in which 
 dogs became paralyzed after eating the food which had caused botu- 
 lism in human beings. 
 
 In 1866 Niedner (106) recorded that a dog became paralyzed and died after 
 eating the remnants of a poisonous sausage, and in the record of Outbreak 1 of 
 this report it is stated that a dog became paralyzed after eating a portion of 
 the discarded apricots, material which was responsible for the production of 
 botuUsm in five persons, and of limber-neck in a number of chickens. In a 
 recent report Buckley and Shippen (148) recorded that dogs are not susceptible 
 to large doses of the toxin of the strain which was isolated from cheese in the New 
 England States, but they administered the toxin by mouth only, whereas I used 
 subcutaneous injections exclusively. Further study is therefore necessary before 
 it is certain whether there is actually a difference in the effect of the two toxins. 
 
ERNEST G. DICKSON 99 
 
 There is no record that hogs are susceptible to the toxin of Bacillus 
 boiulinus; in fact in Outbreak 2 it was noted that a number of hogs 
 which ate a portion of the discarded corn failed to show any symptoms 
 of illness, although a large number of chickens which also ate some of 
 the corn developed limber-neck, and died. 
 
 Curfman (103) recorded that a number of burros which ate the remnants of 
 the food which had caused the poisoning in his series, died after showing similar 
 symptoms to thpse that were observed in the human cases, and Buckley and 
 Shippen (148) reported that they had succeeded in -producing an illness some- 
 what analogous to forage-poisoning in horses and donkeys. Leuchs (114) and 
 Wassermann (149) have shown that horses are susceptible to botulism and that 
 they may be used in the production of antitoxic sera, and Kempner (128) showed 
 that goats are also susceptible. Schneidemiihl (150) believed that the milk 
 sickness of calves is due to the action of the botulinus toxin, but in so far as I 
 have been able to learn, his theory has not been confirmed. 
 
 Whether the paralysis which Saunders has described was due to the 
 toxin of Bacillus botulinus must remain an unsettled question. It is 
 certain, however, that the botulinus toxin produces symptoms of 
 paralysis in human beings, monkeys, horses, goats, dogs, cats, rabbits, 
 guinea pigs, white mice, turkeys, chickens, and pigeons; and it is an 
 interesting fact that Bail (151) has shown that various species of flies 
 are capable of acting as carriers of Bacillus botulinus. 
 
 The occurrence of thrombi in Wilbur and Ophiils' fatal case (99) 
 and in three of the fatal cases of my series, and the uniformity with 
 which thrombi are found in animals which have died from experi- 
 mentally produced botulism, establish beyond all possibility of doubt 
 that thrombosis is a pathological process which is characteristic of 
 poisoning with the toxin of Bacillus botulinus. But as to the cause of 
 the thrombus formation and the importance of the thrombi, in so far 
 as the clinical manifestations are concerned, very little is known at the 
 present time. 
 
 A striking feature of the clinical course of botuHsm is the uniformity 
 with which the signs of involvement of the central nervous system 
 always develop in the same sequence, whether the poisoning is so 
 severe that it rapidly progresses to a fatal termination, or whether it is 
 so mild that only the initial signs and symptoms are produced. The 
 muscles that receive their motor nerve supply from the cranial motor 
 
100 BOTULISM 
 
 nerves are the ones which suffer most, and it is not uncommon, 
 indeed it is the rule, to find partial or complete paralysis of some or all 
 of them. On the other hand, it is extremely uncommon to find paraly- 
 sis of muscles which receive their motor nerve supply from the spinal 
 cord, although there is usually incoordination of muscular movement 
 and very marked muscular weakness. The muscles which are sup- 
 pKed by the third cranial nerve are the first to be affected and the 
 initial neurogenic symptoms are usually disturbances of vision. The 
 fourth cranial nerve may escape injury, but usually the fourth and 
 sixth are very early involved. Impairment of the ninth, tenth, and 
 twelfth nerves is soon evident, and the patients complain of difficulty 
 in moving the tongue, and in talking and swallowing. The onset of 
 constipation, which is probably partly dependent upon involvement of 
 the vagus nerve, may be delayed for several hours after the appearance 
 of the eye symptoms. Impairment of function of the muscles supplied 
 by the fifth and seventh nerves is less frequently observed, but is 
 not rare. In very mild cases the neurogenic signs may not develop 
 beyond impairment of the muscles supplied by the oculomotor nerve, 
 but in the more severe the time which elapses between the various 
 manifestations may be very short. The clinical picture is essentially 
 that of a bulbar paralysis, with the earliest symptoms indicating 
 injury high up in the brain stem, and death usually is caused by 
 respiratory or cardiac failure. 
 
 The sensory nerves and the mentality of the patients are usually 
 unimpaired. There may be some disturbance of the sense of taste 
 but this is probably largely due to the inhibition of the salivary secre- 
 tion, and disturbances of the olfactory, optic, and auditory nerves are 
 very rare. The patients frequently complain of dizziness and head- 
 ache, but otherwise the sensorium is not affected. 
 
 Metabolism is apparently inhibited as the temperature is usually 
 subnormal and the patients are extremely susceptible to cold. The 
 rapid emaciation may be partly due to the effect of the toxin, but is 
 largely dependent upon the fact that the patients are unable to 
 swallow food. 
 
 A satisfactory explanation for this peculiar combination of symptoms and 
 signs has not yet been established. Kerner (7) believed that the toxin acted 
 primarily upon the sympathetic nervous system, to which it was carried directly 
 
ERNEST C. DICKSON 101 
 
 from the stomach. He stated that there was no effect upon the muscles which 
 were supplied by nerves which come directly from the brain, even though they 
 pass through the thorax, where the sympathetic system was most severely dam- 
 aged, but that the signs of involvement were constantly found in muscles in which 
 the nerve supply is closely associated with branches of the sympathetic system. 
 Weiss (9) believed that the action of the toxin was not primarily exerted upon 
 the sympathetic system, but that the changes in the central nervous system were 
 secondary to changes that were produced in the blood, and Miiller (81) stated 
 that the majority of authors agreed with Weiss. Purckhauer (145) thought that 
 the manifestations of botulism could be more readily explained by assuming that 
 the toxin acted directly upon the protoplasm of the muscle cells and glandular 
 secreting cells, and that the central nervous system was not primarily involved. 
 
 Marinesco's (136) demonstration of degeneration processes in the nerve cells 
 of the motor nuclei in animals which had succumbed to botulism, appeared to 
 have furnished anatomical proof that the paralysis is dependent upon lesions 
 which are produced in the motor ganglion cells. His observations were confirmed 
 by several authors. Ossipoff (137), Kempner and Pollack (115), and Romer 
 and Stein (138) found similar changes in the brains and cords of animals in 
 which they produced the intoxication experimentally, and Paulus (19) observed 
 them in the brain of a person who had died from botulism. These authors be- 
 lieved that the toxin of B. botulinus has some specific afiinity for the ganglion 
 cells of cranial motor nuclei, and that the paralysis of the specific groups of mus- 
 cles is thereby explained. 
 
 There are certain points, however, in which the deductions which were drawn 
 by Marinesco and those who followed him, are not conclusive. Marinesco (136) 
 observed that the greatest damage occurred in the cells of the anterior horns of 
 the spinal cord, and that the cells of the meduUa and pons were less severely 
 damaged. He found some change in the nerve cells in the peduncles, but none 
 was seen in those of the cerebral hemispheres. OssipoS (137) agreed that the 
 nerve cells of the spinal cord were more seriously damaged, especially in the 
 regions which supply the muscles of the extremities, but he found that the Pur- 
 kinje cells of the cerebral hemispheres were also changed. 
 
 The distribution of these lesions, as described by Marinesco and 
 Ossipoff, does not correspond to the distribution of the motor paraly- 
 sis or to the order in which the various muscle groups are affected. 
 The earhest clinical sign, and one of the most constant, is due to the 
 involvement of the third cranial nerve, the nucleus of which is in the 
 region where Marinesco found the least severe nerve cell changes. 
 It is true that Romer and Stein (138) found changes in the cells of the 
 unpaired median nucleus of the third nerve, and it is unfortunate that 
 they did not record the relative amount of cell change in that area and 
 
102 BOTULISM 
 
 in the spinal cord, but Ossipoff and Marinesco agreed that the lesions 
 in that part of the brain stem are less severe than in the cord. More- 
 over, the muscles of the trunk, especially of the extremities, are rarely 
 paralyzed, although the most severe nerve cell lesions occur in the por- 
 tions of the cord which supply them, and it is difficult to understand 
 why, if the nerve cells which are most severely damaged, do not pro- 
 duce paralysis of their corresponding muscles, it should be assumed 
 that those in which the lesions are less sev ere should be held responsible 
 for the paralysis of the muscles which they supply. Kempner and 
 Pollack (115) observed the nerve cell changes in the animals which 
 they examined but could not find any relationship between the severity 
 of the clinical symptoms and the degree of disintegration in the nerve 
 cells. Moreover, they noted that the lesions of the cells were still 
 demonstrable for several weeks after the clinical symptoms had entirely 
 disappeared, and it is difficult to understand how this could be if the 
 muscular paralysis is dependent upon the changes in the nerve cells. 
 In anterior poliomyelitis there is an analogous condition to that which 
 was assumed to be the case in botuhsm, in that the muscular paralysis 
 is dependent upon destruction of the motor nerve cells of the anterior 
 horns of the spinal cord, but in poliomyelitis the effects of the nerve 
 cell damage persist after the patient recovers from the acute illness, 
 and certain muscles or groups of muscles remain paralyzed. In pa- 
 tients who have recovered from severe intoxications with the botulinus 
 toxin, there is no persisting paralysis of the affected muscles — another 
 fact which raises doubt as to the accuracy of the deductions of 
 Marinesco and his followers. 
 
 Ophiils' (99) observation that the blood vessels of the brain and 
 meninges contained thrombi which were more numerous around the 
 base of the brain, appeared to give sufficient anatomical explanation 
 for the symptoms that were observed, and were of especial interest 
 because the nerve cells of the basal ganglia did not show any of the 
 changes which were described by Marinesco and others. The thrombi 
 seemed to give sufiicient anatomical explanation for the distri- 
 bution of the muscular involvement and for the peculiar variations 
 in the severity of the symptoms which were observed in his case. A 
 study of the fatal human cases of my series would seem to bear this 
 •out, as in all but one there were numerous thrombi in the blood ves- 
 
ERNEST C. DICKSON 103 
 
 sels and an absence of changes in the structure o: the nerve cells of 
 the cerebral motor nuclei. 
 
 At the time that I published my preliminary report (141), my 
 observations had been confined to the effects of a toxin of relatively 
 ]ow virulence, which did not cause the death of the animals until 
 there had been sufl&cient time for the full development of the thrombi. 
 The almost constant thrombosis in the blood vessels of the brain led 
 me to believe that the whole clinical and pathological picture, in so 
 far as the central nervous system was concerned, was to be explained 
 by the presence of the thrombi which obstructed the blood vessels, 
 and. that the disturbances of the function of the muscles and the 
 occasional lesions in the nerve cells were dependent upon an insuffi- 
 cient flow of blood to the brain tissue. But even then it was difficult 
 to understand why the symptoms shou d always appear in practically 
 the same order and why there is no Involvement of the sensory nerves. 
 It was easy to believe that in the more severe intoxications, the 
 severity of the symptoms and the fatal termination could be explained 
 by a more extensive and rapid formation of thrombi in the region of 
 the vital centers, but it was difficult to explain why the region of the' 
 nuclei of the third cranial nerve should always be the first affected, 
 and why there is never any break in the sensory fiber tracts. The 
 distribution of the thrombi is not confined to any restricted portion 
 of the body, but occurs in all the organs, and in the meninges of the 
 cerebrum, cerebellum, and cord as well as around the brain stem. 
 It is therefore inconceivable that the vessels in the region of the oculo- 
 motor nuclei, on both sides, should always be the seat of the earliest 
 thrombus formation, and that only the motor nuclei should be in- 
 volved in the secondary ischemic degeneration. 
 
 When I obtained Strains III and IV of Bacillus botulinus, each of 
 which produces a highly virulent toxin, which, in minute doses, will 
 kill a guinea pig or a rabbit within 24 hours, it soon became evident 
 that the animals could develop extremely severe symptoms which 
 were quite typical, and die, and not show any thrombosis in the 
 blood vessels of the brain or meninges. In many, it is true, there 
 was evidence of what has been described as the prethrombus stage 
 of thrombosis, but this was evidently not sufficient to cause an ob- 
 struction of the flow of blood that would lead to degeneration of the 
 
104 BOTULISM 
 
 tissues of the brain. In other cases, moreover, no evidence of the 
 prethrombus stage could be found, and the only conclusion that 
 could be drawn is that the symptoms of the botidinus intoxication 
 are dependent upon some other factor than is indicated by anatomical 
 change in the motor ganglion cells, or by thrombosis in the blood 
 vessels which supply them. 
 
 Just what this other factor is remains unexplained. It is, of course, 
 possible to say that there is some specific selective action which 
 affects certain groups of the motor ganglion cells, but that is, to say 
 the least, an unsatisfactory explanation. It is possible that the 
 toxin acts, as does belladonna, upon the terminal end-plates of certain 
 nerves, and the close resemblance between the effects of the botulinus 
 toxin and those of the administration of belladonna suggest that this 
 may be true. In cases which have been poisoned with the toxin of 
 Bacillus botulinus, the pupils are dilated, the secretions are dimin- 
 ished, and the movements of the gastrointestinal tract are inhibited, 
 and, moreover, the administration of eserine will cause a contraction 
 of the dilated pupil, and pilocarpin will cause the salivary secretion 
 to be reestablished, although the effect of both drugs is only tempor- 
 ary. But in botulinus-poisoning there is paralysis of striated muscle 
 fibers as well as of unstriated fibers, although only certain groups of 
 striated muscle fibers are involved, and it remains to be shown 
 whether it is possible that the toxin may produce such a peculiar com- 
 bination of effects by acting on the terminal nerve endings or on the 
 synapses in the course of the peripheral nerve fibers. 
 
 The action of the toxin on the blood vessels is marked and constant. 
 The vessels are widely dilated, and, in addition to the thrombosis, 
 there are mmierous hemorrhages in various portions of the body. 
 Ophiils (99) suggested that the dilatation of the blood vessels might 
 be due to the action of the toxin on the smooth muscle fibers in the 
 walls, either directly, or through the mediiom of the vasomotor nerves. 
 It seems probable that the latter explanation is correct. The pres- 
 ence of hemorrhages indicates that there is some direct damage to 
 the endothehum of the blood vessels, and this, together with the 
 slowing of the blood stream, due to the dilatation of the vessels, may 
 explain the tendency to thrombosis. It does not explain, however, 
 the peculiar cellular type of the thrombus which usually is packed 
 with polymorphonuclear leukocytes. 
 
ERNEST C. DICKSON 105 
 
 No characteristic lesions, other than the hemorrhages and throm- 
 bosis, were found in the abdominal and thoracic viscera. The 
 appearance of the tissues was as van Ermengem described, except 
 that ther'e was no evidence of an inflammatory process. The liver and 
 kidneys showed parench)anatous degeneration, and in some instances 
 there was evidence of hemorrhage into the glomerular capsule, but 
 there was no evidence of any process which was secondary to the 
 thrombosis. In the lungs the thrombi were especially munerous, 
 and they were usually associated with areas of bronchopneumonia, 
 but they may occur in lungs in which there is no pneumonia and 
 there is no apparent causal relationship between the two processes. 
 
 As a result of my investigation, therefore, I have been forced to 
 conclude that the method in which the toxin of Bacillus botulinus 
 acts upon the tissues is unknown. It is probable that there is a 
 direct damage to the endothelial cells of the blood vessels, and that 
 the hemorrhages and thrombosis are secondary to that damage. 
 It is also probable that when degeneration occurs in the cells of the 
 central nervous system, it is an ischemic degeneration due to the 
 presence of thrombi in the blood vessels which supply the part. But 
 the evidence is against the explanation that the clinical symptoms 
 are dependent upon the lesions which Marinesco described in the 
 nerve cells of the brain and cord, or that they are secondary to throm- 
 bosis in the vessels of the central nervous system. 
 
CONCLUSIONS. 
 
 1. Botulism is endemic in the United States and is comparatively 
 common in the Pacific Coast States. 
 
 2. It is not essentially a meat poison but may also occur in canned 
 vegetables and fruits. 
 
 3. The methods which are usually employed in the home-canning 
 of vegetables and fruits are unsafe. 
 
 4. All home-canned vegetables should be cooked before they are 
 eaten. 
 
 5. Botulism is a frequent cause of the so called limber-neck of 
 domestic fowl, and it may be responsible for certain types of paralysis 
 of various kinds of domestic animals, including dogs. 
 
 6. The occurrence of limber-neck in domestic fowl, if it has devel- 
 oped after they have eaten refuse from the kitchen, may be an indica- 
 tion for the prophylactic administration of the botulinus antitoxin 
 to all persons who have eaten the suspected food. 
 
 7. Thrombosis in the blood vessels of various organs of the body 
 is a characteristic lesion which is produced by the action of the toxin 
 of Bacillus hotulinus. 
 
 8. The cause of the symptoms of botulism and the way in which 
 the paralysis of the various muscles is produced are unknown. 
 
 9. The normal habitat of Bacillus botulinus and the way in which 
 the vegetables become contaminated are unknown. It is possible 
 that the bacillus is normally present in the intestinal contents of 
 the hog, and that the vegetables become infected when hog manure 
 is used as fertihzer. 
 
 10. A campaign of education should be instituted in order that 
 all who practise the home-canning of fruits and vegetables may be 
 informed of the danger of infection with Bacillus botulinus. 
 
 106 
 
ERNEST C. DICKSON 107 
 
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 62. Emmert, C. F., Dissertatio inauguralis medica de venenatis acidi borussici 
 
 in animalia effectibus, Tiibigen, 1805, cited from Schlossberger (13), 
 p. 730. 
 
110 BOTULISM 
 
 63. Kuhn, C. G., Versuche und Beobachtungen iiber die Kleesaure, das Wurst- 
 
 und das Kasegift, Leipsic, 1824. 
 
 64. Ruble, cited from MuUer (81), xxi, 322. 
 
 65. Cormack and Corneliani, cited from Schlossberger (13), p. 730. 
 
 66. Jaeger, Z. Staatsarzneik., 1823, vi, 471, cited from Miiller (81), xxi, 341. 
 
 67. Buchner, Z. Staatsarzneik., 1823, vi, 472, cited from Miiller (81), xxi, 341; , 
 
 Toxikologie, 1st edition, cited from Schlossberger (13), p. 735. 
 
 68. Kastner, K. W. G., Z. Staatsarzneik., 1823, vi, 470. 
 
 69. Bodenmiiller, Ueber Wurstvergiftung, Wurt. Cor.-BL, 1834, No. 38, ab- 
 
 stracted in Schmidt's Jahrb., 1835, v, 287. 
 
 70. Tritschler, Wurt. Cor.-BL, xii. No. 13, cited from MuUer (81), xxi, 343. 
 
 71. Lussana, Omodei's Ann. med., Marzo, 1845, cited from MuUer (81), xxi, 
 
 343. 
 
 72. Liebig, Die Chemie in ihrer Anwendung auf Agricultur und Physiologie, 
 
 5th edition, 1843, 472, cited from Schlossberger (13), p. 738. 
 
 73. Heller, Arch, physiol. u. path. Chem. u. Micr., July, 1853, cited from Miiller 
 
 (81), xxi, 357. 
 
 74. van den Corput, Memoire du poison qui se developp dans les viandes, et les 
 
 boudins fumes, Brussells, 1855, cited from Miiller (81), xxi, 357. 
 
 75. Wittig, Arch. Pharm., 1856, Vrtljschr. iv, cited from Kaatzer (22), p. 74. 
 
 76. Kasper, Arch. Pharm., 1858, Vrtljschr. xiii, cited from Kaatzer (22), p. 74. 
 
 77. Zenker, F. A., Ueber die Trichinen-Krankheit des Menschen, Arch. path. 
 
 Anat., 1860, xviii, 561. 
 
 78. Virchow, Darstellung der Lehre von den Trichinen, 1864, cited from Kaat- 
 
 zer (22), p. 74. 
 
 79. Husemann, Toxicologie, Suppl.-Bd., 1866, cited from Kaatzer (22), p. 74. 
 
 80. Rupprecht, B., Die Trichinenkrankheit im Spiegel der Hettstadter Endemie 
 
 betrachtet, 1864, cited from Miiller (81), xxi, 358. 
 
 81. Miiller, Das Wurstgift. (Ten chapters.), Deutsch. Klin., 1869, xxi, 321; 
 
 1870, xxii, 27. 
 
 82. Ehrenberg, A., Ueber einige in einem Falle von sogenannter "Wurstver- 
 
 giftung, aus dem schadlichen Materiale dargestellte Faulnissbasen, sowie 
 iiber einige, durch die Thatigkeit eines besonderen, in gleichen Materiale 
 aufgefundenen. Bacillus gebildete Zersetzungs-Producte, Z. physiol. Chem., 
 1887, xi, 239. 
 
 83. Nauwerck, C., Ueber WmstveTgiitung, Munch, med. Woch., 1886, xxxiii, 538. 
 
 84. Redner, cited from Nauwerck (83), p. 538. 
 
 85. van Ermengem, E., Untersuchungen iiber Falle von Fleischvergiftung mit 
 
 Symptomen von Botulismus, Centr. Bakteriol., Ite Abt., 1896, xix, 442. 
 
 86. van Ermengem, E., Ueber einen neuen anaeroben Bacillus und seine Be- 
 
 ziehungen zum Botulismus, Z. Eyg. u. Infektionskrankh.^ 1897, xxvi, 1. 
 
 87. van Ermengem, E., Der Bacillus botulinus und der Botulismus, in Kolle, W., 
 
 and von Wassermann, A., Handbuch der pathogenen Mikroorganismen, 
 Jena, 2nd edition, 1912, iv, 909. 
 
ERNEST C. DICKSON 111 
 
 88. Ornstein, O., Ein Fall von Botulismus, Z. Chemother ap., Orig., 1913, i, 458. 
 
 89. Seelye, H. H., Atropia-poisoning from eating turkey, Med. Rec, 1894, xlv, 
 
 14. 
 
 90. Herzog, A. W., Turkey and ptomaine, Med. Rec, 1894, xlv, 155. 
 
 91. Spiller, W. G., Neuritis from the ingestion of putrefying pork, Phil. Poly- 
 
 din., 1898, vii, 455. 
 
 92. Lewis, W. M., A case of ptomaine poisoning, South. Calif. Pracl., 1899, xiv, 
 
 464. 
 
 93. Jellinek, E. O., On ptomaine poisoning, Calif. State J. Med., 1902-03, i, 121; 
 
 A report of three cases of ptomaine poisoning, Pacific Med. J., 1903, xlvi, 
 110. 
 
 94. Anderson, M., Ptomain poisoning; a case, Woman's Med. J., 1904, xiv, 153. 
 
 95. Bryant, W. S., Deaf-mutism and ptomaine poisoning, Ty. Am. Otol. Soc, 
 
 1905, ix, 32. 
 
 96. Sheppard, C, Report of three cases of fatal ptomaine poisoning, South. Calif. 
 
 Pract., 1907, xxii, 370. 
 
 97. Peck, G. W., Ptomaine poisoning; report of eleven fatal cases at Sawtelle, 
 
 California, South. Calif. Pract., 1910, xxv, 121. 
 
 98. Stiles, P. G., A case of apparent food-poisoning of the type known as 
 
 botulism or allantiasis, /. Am. Med. Assn., 1913, Ixi, 2301. 
 
 99. Wilbur, R. L., and Ophiils, W., Botulism. A report of food-poisoning ap- 
 
 parently due to eating of canned string beans, with pathological report of 
 a fatal case, Arch. Int. Med., 1914, xiv, 589. 
 
 100. Williams, T. M., personal communication. 
 
 101. Frost, L. C., Meat poisoning with report of cases. Am. Med., 1915, n. s. x, 85. 
 
 102. Lancaster, W. B., A case of botulism, Tr. Am. Ophth. Soc, 1916, xiv, 648; 
 
 Ophthalmoscope, 1916, xiv, 588. 
 
 103. Curfman, G. H., Botulism, Colorado Med., 1917, xiv, 35. 
 
 104. Lebert, cited from Miiller (81), xxi, 381. 
 
 105. Ruge, S., Ein Fall von Papilloretinitis bei Botulismus, Klin. Monatshl. 
 
 Augenh., 1902, xl, 408. 
 
 106. Niedner, Ein Fall von Wurstvergiftung, BerL^lin. Woch., 1866, iii, 2. 
 
 107. Wertheim, E., Ein Fall von Velumlahmung infolge von Botulismus, Arch. 
 
 Laryngol. u. Rhinol., 1902-03, xiii, 454. 
 
 108. Eichenberg, F., Ueber Vergiftung durch Wurstgift, Inaugural dissertation, 
 
 Gottingen, 1880, abstracted in Schmidt's Jahrb., 1881, cxci, 8. 
 
 109. Fischer, cited from Erben (48), p. 849. 
 
 110. Lochte, Die Amtsarztliche Beurtheilung der Fleischvergiftung (Botulismus), 
 
 Deutsch. Vrtljschr. of. Gsndhtspflg., abstracted in Jahresh. ges. Med., 
 1903, i, 591. 
 
 111. Novy, F. G., Food poisons, in Osier, W., and McCrae, T., Modern medicine, 
 
 New York, 2nd edition, 1914, ii, 450. 
 
 112. Konstansoff, S. V., cited from Novy (HI), p. 453. 
 
 113. Gaffky, G. J. A., cited from Leuchs (114). 
 
112 BOTULISM 
 
 114. Leuchs, J., Beitrage zur Kentniss des Toxins uild Antitoxins des Bacillus 
 
 hotuUnus, Z. Hyg'., 1910, Ixv, 55. 
 
 115. Kempner, W., and Pollack, B., Die Wirkung des Botulismustoxins (Fleisch- 
 
 giftes) und seines specifischen Antitoxins auf die Nervenzellen, Deutsch. 
 med. Woch., 1897, xxiii, 505. 
 
 116. von Hibler, E., in Fischer, G., Untersuchungen iiber die pathogenen Anaero- 
 
 ben, Jena, 1908. 
 
 117. Harrass, P., Zur Frage der aeroben Ziichtung sogenannter obligat-anaerober 
 
 Bakterien, Milnch. med. Woch., 1906, liii, 2237. 
 
 118. Tarozzi, G., Ueber ein leicht in aerober Weise ausfiihrbares Kulturmittel 
 
 von einigen bis jetzt fur strenge Anaeroben gehaltenen Keimen, Centr. 
 Bakteriol., lie AM., Orig., 1905, xxxviii, 619. 
 
 119. Forssman, J., Cenlr. Bakteriol., 1901, xxix, cited from van Ermengem (87), 
 
 p. 923. 
 
 120. Vaillard, L., and Rouget, J., Note au sujet de Fetiologie du tetanos, Ann. 
 
 Inst. Pasteur, 1893, vii, 755. 
 
 121. Pelzl, 0., Ueber Botulismus, Wien. klin. Woch., 1904, xvii, 864. 
 
 122. Brieger and Kempner, W., Beitrag zur Lehre von der Fleischvergiftung, 
 
 Deutsch. med. Woch., 1897, xxiii, 521. 
 
 123. Kempner, W., and Schepilewsky, E., Ueber antitoxische Substanzen gegen- 
 
 iiber dem' Botulismusgift, Z. Hyg., 1898, xxvii, 213. 
 
 124. Lippmann, H., Ueber lokale Immunisierung der Eingangspforten von In- 
 
 fektionen, Med. Klin., 1910, vi, 1477, abstracted in Centr. Bakteriol., 
 Ite Abt., Ref., 1911, xlix, 549. 
 
 125. Forssman, J., Beitrage zur Kenntnis der Bakteriologie des Botulismus 
 
 (Lunds Universitets Arsskrift, 1900), abstracted in Centr. Bakteriol., 
 he Abt., 1901, xxix, 541. 
 
 126. Roux and Borrel, abstracted in Centr. Bakteriol., cited from Forssman (125), 
 
 p. 541. 
 
 127. Kob, M., Beitrag zur Kenntnis des Botulismus, Med. Klin., 1905, i, 84. 
 
 128. Kempner, W., Weiterer Beitrag zur Lehre von der Fleischvergiftung. Das 
 
 Antitoxin des Botulismus, Z. Hyg. u. Infektionskrankh., 1897, xxvi, 481. 
 
 129. Forssman, J., and Lundstrom, E., Sur la marche de la courbe d'antitoxine 
 
 dans I'immunisation active centre le botulisme, Ann. Inst. Pasteur, 1902, 
 xvi, 294. 
 
 130. Forssman, J., Studien iiber die Antitoxinbildung bei aktiver Immunisierung 
 
 gegen Botulismus, Centr. Bakteriol., Ite AU., Orig., 1905, xxxviii, 463. 
 
 131. Tchitchkine, A., Essai d'immunisation par la voie gastro-intestinale centre 
 
 la toxine botulique, Ann. Inst. Pasteur, 1905, xix, 335. 
 
 132. Herman, Serumdiagnose bei Fleischvergiftungen, Zehnter internationaler 
 
 Kongressfiir Hygiene und Dermographie zu Paris, 1900, Deutsch. Vrtljschr. 
 off. Gsndhtspflg., 1900, xxxii, 710, abstracted in Centr. Bakteriol., Ite Abt., 
 1901, xxix, 706. 
 
ERNEST C. DICKSON 113 
 
 133. Leuchs, J., Bacillus botulinus. (Immunitat.), in KoUe, W., and von Wasser- 
 
 mann, A., Handbuch der pathogenen Mikroorganismen, Jena, 2nd edition, 
 1912, iv, 939. 
 
 134. van Hasselt, A. W. M., in Henkel, J. B., Handbuch der Giftlehre, Braun- 
 
 schweig, 1862, pt. 2, 146. 
 
 135. van der Stricht, O., Nouvelles recherches sur la genese des corpuscules 
 
 rouges et des globules blancs du sang, Arch. Biol., 1892, xii, 199, cited 
 from van Ermengem (86), p. 48. 
 
 136. Marinesco, G., Pathologie generale de la cellule nerveuse; lesions secondaires 
 
 et primitives, Presse mid., 1897, v, 41. 
 
 137. Ossipoff, V. P., Influence de I'intoxication botulinique sur le systeme nerveux 
 
 central, Ann. Inst. Pasteur, 1900, xiv, 769. 
 
 138. Romer, P., and Stein, L., Experimenteller Beitrag zur Frage nach dem Sitz 
 
 und Wesen der Accomodationsparese bei bakteriellen Intoxikatioris- 
 krankheiten. Die Accomodationsparese, Arch. Ophth., 1904, Iviii, 291. 
 
 139. Komotzki, W., Experimentelle Untersuchungen iiber die Wirkung des 
 
 Botulismus-Toxins auf die inneren Organe, Virchows Arch. path. Anat., 
 1911, ccvi, 179. 
 
 140. Bogomolez, A., Ueber die Hypersekretion von Lipoidsubstanz durch die 
 
 Rinde der Nebennieren bei experimentellem Botulismus, Z. Immunitats- 
 forsch., Orig., 1910-11, viii, 35. 
 
 141. Dickson, E. C, Botulism, an experimental study. A preliminary report, 
 
 /. Am. Med. Assn., 1915, Ixv, 492. 
 
 142. Kiyono, K., Die vitale Karminspeicherung, Jena, 1904. 
 
 143. Goldmann, E. E., Die aussere und innere Sekretion des gesunden und 
 
 kranken Organismus im Lichte der "vitalen Farbung," Beitr. klin. Chir., 
 1909, Ixiv, 192. 
 
 144. MacCurdy, J. T., and Evans, H. M., Experimentelle Lasionen der Central- 
 
 nervensystems, untersucht mit Hilfe der vitalen Farbung, Berl. klin. 
 Woch., 1912, xlix, 1695. 
 
 145. Piirckhauer, H., Zur Casuistik der Allantiasis, /I ecz//. Int.-BL, 1877, xxiv, 245. 
 
 146. Wolffhtigel and Hueppe, Ueber das Eindringen der Hitze in dafe Fleisch bei 
 
 seiner Zubereitung, Mitt. k. Gsndhtsamte., 1881, i, 395. 
 
 147. Saunders, E. W., The green fly {Lucilia Casar) as the universal destroyer 
 
 of motor function and of life, /. Arkansas Med. Soc, 1915-16, xii, 6. 
 Saunders, E. W., Meisenbach, R., and Wisdom, W. E., The causation and 
 prevention of infant paralysis, J. Missouri Med. Assn., 1913-14, x, 305. 
 
 148. Buckley, J. S., and Shippen, L. P., Preliminary report on the relation of 
 
 anaerobic organisms to forage poisoning, /. Am. Vet. Med. Assn., 1917, 1, 
 809. 
 
 149. Wassermann, cited from Leuchs (133). 
 
 150. Schneidemiihl, Ueber Botulismus beim Menschen und die sogenannte Ge- 
 
 burtsparalyse bei Rindern, Centr. Bakteriol., he Abt., 1898, xxiv, 577. 
 
 151. Bail, O., Versuche iiber eine Moglichkeit der Entstehung von Fleischver- 
 
 giftungen, Hyg. Rundschau, 1900, x, 1017. 
 
114 BOTULISM 
 
 References Which Haw Not Been Cited. 
 
 1. Christison, R., A treatise of poisons, in relation to medical jurisprudence, 
 
 physiology, and the practice of physic, Edinburgh, 2nd edition, 1832, 557. 
 
 2. Paulus, Neue Beitrage zur Geschichte der Vergiftung durch yerdorbene 
 
 Wurstmasse, Heidelb. Ann., 1834, x, Heft. 3, abstracted in Schmidt's 
 Jahrb., 1835, vi, 22. 
 
 3. von Faber, Ueber Wurstvergiftungen, WUrt. Cor.-BL, 1854, No. 33, abstracted 
 
 in Schmidt's Jahrb., 1855, Ixxxv, 36. 
 
 4. Boehm, R., Wurstvergiftung, Botulismus, Allantiasis, in von Ziemssen, H., 
 
 Handbuch der speciellen Pathologic und Therapie, 1876, xv, 235; Trans- 
 lation, Cyclop. Pract. Med. N. Y., 1878, xvii, 535. 
 
 5. Reisz, P., Sieben Falle von Wurstvergiftung (Botulismus), Wien. med. Presse, 
 
 1891, xxxii, 1862. (Report of the use of eserine and pilocarpin.) 
 
 6. Brosch, A., Zur Casuistik der Fischvergiftung, Wien. klin. Woch., 1896, ix, 
 
 219. (Report of poisoning from oysters. Symptoms similar to those of 
 botulism.) 
 
 7. Dieudonne, A., Bacterial food poisoning, translation by Bolduan, New York, 
 
 1909, 62. 
 
 8. Dickson, E. C, Botulism, its occurrence in California, Calif. State J. Med., 
 
 1916, xiv, 143. 
 
 9. Dickson, E. C, Botulism, Proc. Soc. Exp. Biol, and Med., 1916, xiv, 47. 
 
 10. Dickson, E. C, Botulism. A cause of limber-neck in chickens, /. Am. Vet. 
 Med. Assn., 1917, 1, 612. 
 
EXPLANATION OF PLATES. 
 Plate 1. 
 
 Fig. 1. Bacillus hotulinus. The film is from a slant agar culture which had 
 grown for 1 week. Note the bacilli without spores, the club-shaped and spindle- 
 shaped, spore-bearing bacilli, and the numerous spores. 
 
 Fig. 2. R. L., Stanford University Series. This is one of the thrombi in the 
 case which was described by Ophiils (99), and is in a vein of the cerebral 
 meninges. 
 
 The patient died 13 days after she had eaten the string bean salad. 
 
 Plate 2. 
 
 Fig. 3. Mrs. R., Outbreak 4 of my series. The thrombus is in a vein of the 
 cerebral meninges. Note the accumulation of leukocytes. 
 
 The patient died 5 days after she had tasted the string beans. 
 
 Fig. 4. Mrs. R. The thrombus is in an artery in the lungs. Note the accu- 
 mulation of leukocytes at one end of the thrombus. Adjacent is a bronchus 
 which shows purulent bronchitis. There was a marked bronchopneumonia. 
 
 Plate 3. 
 
 Fig. 5. Mrs. M. P., Case 2, Outbreak 7 of my series. The thrombus is in a vein 
 in the cerebral meninges. Note the small number of leukocytes. 
 
 The patient died 7 days after she had eaten the string bean salad. 
 
 Fig. 6. Mrs. M. P. The thrombus is in a vein in a trabecula of the spleen. 
 Note the absence of leukocytes. 
 
 Plate 4. 
 
 Fig. 7. Rabbit 13, Series 1914-15. The hemorrhages are in the tissue of the 
 brain stem in the region of the fourth ventricle, and near the origin of the pedun- 
 cle. There were typical thrombi in the blood vessels. 
 
 The animal received 5 cc, intraperitoneal injection, of fluid from can of string 
 beans. No. 10, which had been inoculated from Strain I, 12 months previously. 
 
 Fig. 8. Guinea Pig 29, Series 1916-17. The hemorrhage is in the lung, and 
 in addition to the large area there are many red blood corpuscles scattered through 
 the adjacent air spaces. 
 
 The animal received 2 cc, subcutaneous injection, of an apricot stone infusion 
 culture of Strain III. It died in about 24 hours after the injection. 
 
 US 
 
116 BOTULISM 
 
 Plate S. 
 
 Fig. 9. Cat 3, Series 1914-15. The thrombus is shown under high power, 
 and is in a vein in one of the deep sulci of the cerebrum. Note the thick bands 
 of fibrin and the dense accumulation of leukocytes. 
 
 The animal received 2 cc, intraperitoneal injection, of the fluid from can of 
 string beans, No. 6, which had been inoculated with Strain I, 3 months previously. 
 
 Fig. 10. Rabbit 35, Series 1915-16. The thrombus is in a vein in the cere- 
 bral meninges. Note the accumulation of leukocytes and the masses of con- 
 glutinated blood platelets. 
 
 The animal received 3.5 cc, subcutaneous and intraperitoneal injections, of 
 a 2 month beef infusion culture of Strain II. It died 5 days after the injection. 
 
 Plate 6. 
 
 Fig. 11. Rabbit IS, Series 1914-15. The thrombus is in a vein of the cere- 
 bral meninges. Note the clumping of the leukocytes and the whorled arrange- 
 ment of the fibrin in the center of the vein. 
 
 The animal received 5 cc, intraperitoneal and subcutaneous injections, of 
 fluid from can of string beans. No. 12, which had been inoculated with Strain I 
 12 months previously. 
 
 Fig. 12. Cat 31, Series 1916-17. The thrombus is in the central vein of a 
 liver lobule. 
 
 The animal received 1 cc, subcutaneous injection, of a beef infusion culture of 
 Strain III. 
 
 Plate 7. 
 
 Fig. 13. Cat 29, Series 1916-17. Note the parenchymatous degeneration of 
 the epithelium of the kidney tubules and the exudate in the clefts of Bowman's 
 capsules. Some of the glomerular clefts contained red blood corpuscles. 
 
 The animal received 4 cc, subcutaneous injection, of a 25 day culture of Strain 
 III in beef infusion. It died 7 days after the injection. 
 
 Fig. 14, Cat 12, Series 1914-15. The thrombi are in veins and an artery in 
 the space between the lower surface of the posterior lobe of the cerebrum and the 
 upper surface of the stem. Note the dense accumulations of leukocytes.' 
 
 The animal received 5 cc, subcutaneous and intraperitoneal injection, of fluid 
 from can of string beans. No. 12, which had been inoculated with Strain I, 12 
 months previously. 
 
 Plate 8. 
 
 Fig. 15. Cat 14, Series 1915-16. The thrombus is in a vein of the cerebellar 
 meninges. Note the dense accumulation of leukocytes. 
 
 The animal received 4 cc, intraperitoneal injection, of a 14 day bean infusion 
 culture of Strain I. It died 4 weeks after the injection. 
 
ERNEST C. DICKSON 117 
 
 Fig. 16. Cat 20, Series 1916-17. The thrombus is in a vein in the meninges 
 of the cord. Note the small mass of thrombus with thick bands of fibrin and ac- 
 cumulation of leukocytes, and also the loose fibrin in the outer portion of the vein. 
 
 The animal received 0.5 cc, subcutaneous injection, of a pea infusion culture 
 of Strain III. It died 2 days after the injection. 
 
 Plate 9. 
 
 Fig. 17. Cat 25, Series 1915-16. The thrombus is in a vein in the cerebral 
 meninges. Note the accumulation of leukocytes. 
 
 The animal received 5 cc, intraperitoneal injection, of a 5 week beef infusion 
 culture of Strain I. It died 16 days later. 
 
 Fig. 18. Guinea Pig 33, Series 1915-16. The thrombus is in one of the pos- 
 terior cerebral arteries. Note the absence of leukocytes. 
 
 The animal received 5 cc, intraperitoneal injection, of a 6 day culture of Strain 
 I in beef infusion. 
 
 Plate 10. 
 
 Fig. 19. Rabbit 35, Series 1915-16. The thrombus is in an artery of the 
 cerebral meninges. Note the relatively few leukocytes, and the small round 
 mass of conglutinated blood platelets at one end of the thrombus. 
 
 The animal received 3.5 cc, subcutaneous injection, of a 2 month beef infusion 
 culture of Strain II. It died 5 days after the injection. 
 
 Fig. 20. Cat 35, Series 1916-17. The thrombus is in an artery in the cere- 
 bral meninges. Note the relatively small number of leukocytes and the absence 
 of dense bands of fibrin. 
 
 The animal received 0.004 cc, subcutaneous injection, of a beef infusion cul- 
 ture of Strain IV. It died 3 days after the injection. 
 
MONOGRAPH NO. 8. 
 
 PLATE 1. 
 
 
 Fig. 1. 
 
 Fig. 2. 
 
 (Dickson: Botulism.) 
 
MONOGRAPH NO. 8. 
 
 PLATE 2. 
 
 1/^ 
 
 • iff .^HK^' " * ' 
 
 
 
 Fig, 3. 
 
 Fig. 4 
 
 (Dickson: Botulism.) 
 
MONOGRAPH NO. 8. 
 
 PLATE 3. 
 
 Fig. 5. 
 
 Fig. 6. 
 
 (Dickson: Botulism.) 
 
MONOGRAPH NO. 8. 
 
 PLATE 4. 
 
 Fig. 8. 
 
 (Dickson: Botulism.) 
 
MONOGRAPH NO. 8. 
 
 PLATE 6. 
 
 It.' S .'* ,•-'■. • b- ... 
 
 Fig. 9. 
 
 Fig. lU. 
 
 (Dickson: Botulism.) 
 
MONOGRAPH NO. 8. 
 
 PLATE 6. 
 
 Fig. 12. 
 
 .Dickson: Botulism.) 
 
MONOGRAPH NO. 8. 
 
 PLATE 7. 
 
 Fig. 14. 
 
 (Dickson: Botulism.) 
 
MONOGRAPH NO. 8. 
 
 > >*•-*♦. 
 
 Fig. 15. 
 
 PLATE 8. 
 
 Fig. 16. 
 
 (Dickson: Botulism.) 
 
MONOGRAPH NO. 8. 
 
 PLATE 9. 
 
 Fig. 17. 
 
 Fig. 18. 
 
 (Dickson: Botulism.) 
 
MONOGRAPH NO. 8. 
 
 Fig. 19. 
 
 '^-^^^^^/^ 
 
 PLATE 10. 
 
 Fig. 20. 
 
 (Dickson: Botulism.) 
 
MONOGRAPHS OF THE ROCKEFELLER INSTITUTE FOR 
 MEDICAL RESEARbH 
 
 Uflder the head ot Mono^ibpks of The Rockefeller InstiMe for Medi- 
 cal Raearch aire published from time to time scientific papers which are so 
 ejctcnsive, or require such elaborate illustrations, as to reader them un- 
 suitable {or current periodical issues. The Monographs are published at 
 irregular periods, deter^iined by the available vmaterial' on hand. The 
 'puMciation dfnevc monographs is advertised on the cover of The Journal^ 
 of Experimehtal Medicine. 
 
 - "^ " Monograph No. 1. 
 
 (Issued June 30, 1910.) 
 
 SIMON ELEXNER and J. W. JQBLING. Studiies upon a transpkhtable rat 
 tumor. Plates 1-16. J. W. JOBLING. The biology of a mixed 
 tumor of the rat. MAUD L. MENTEN. Experiments on the jn- 
 fluence of radium bromide on a cardnoinatous tumor of the rat. 
 T.Wi JOBLING. Spontaneous tumors of the mouse. Plates 17-28. 
 J. W. JOBLING. Transplantation experinaeiits ip^ Uacacus rhesus 
 with a carcinomatous teratoma from man. 
 
 Monograph No. 2. ' ,, 
 ; (Issued February IS, 1911.) 
 
 WILLIAM TRAVIS HOWARD and OSCAR T.SGHULTZ. Studies in the 
 biology of tumor cells. Plates 1-6. , 
 
 ^ V —'■:■,. Monograph No. 3. , 
 
 , : (Issued March IS, 1911.) ^ "^ - 
 
 BENJAMIN J. TERRY. Chemo-therapeutic trypanosoitip studies ;with 
 special reference to thfi immunity following eyre. " / 
 
 ,- Monograph No. 4. 
 
 (issued June i24, 1912.) 
 
 FRANCIS. W^;PEABODY, GEORGE DRAPER, and A. R. DOCHEZ. A clinical 
 J study of acute poliomyelitis^ Plates 1-13. 5 L 
 
 Monograph Np.^-S. ' 
 
 (Issued geptemiber 27, 191S.) 
 
 J. P. SECONDS. Studies in BacUltls wdchii, with special reference to 
 classification and to its relation to diarrhea. _; "^ 
 
 Monograph' No. 6. 
 (Issued January 31, 1916.) 
 
 JAMES L. STODDARD and ELLIOTT C. CUTLER. Torula infection in man. 
 Plates 1-9. : 
 
 Monograph No. 7. - ' 
 
 (Issued October 16, 1917.) 
 
 OSWALD T AVERY, H. T. CHICKERING, RUFUS COLE, and A. R. DOCHEZ. 
 Acute lobar pneumonia. Prevention and serum treatment; Plates 
 
 "".■ -1-3: - "•" "■/' -■ . ■" '■; _ ;- ■ '-/ 
 
 Monograph No. 8. , 
 
 / (issued July 31, 1918;) , 
 
 ERNEST C. DICKSON. Botulism. Aclinical and experimental studyV 
 
 .':'-■■ ,;, Hates 1-10. ']'' ' ' ,,; - 
 
 - Monog;raph No. 9. ' y. 
 
 ,.-';''• '. ":' ■' v.. ' (In, press.) , -^ 
 
 JAMES' HOWARD BROWN: The use of blood agar for the study of 
 
 streptococci, Plates 1-36. 
 -'-" Monographs will • be sent postpaid oh a,pplication, at $1 .00 each; pay- 
 able" in advance by check Or ttiohey order. ■/ 
 
THE JOURNAL OF EXPERIMENTAL MEDJfCINE 
 
 EDrtBD BY 
 
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