Recovery is usually slow. Even in the non-traumatic cases the period of convalescence very seldom is less than two months, and, as has been truly said, “it is a very mild case that the patient is well of in thirty days.” More or less stiffness of the muscles usually continues for many weeks; in one case (Currie's) “his features retained the indelible impression of the disease;” and Copland reports having seen a man who had had tetanus nine years before, whose jaws were still permanently locked. Relapses may easily be brought on by exposure or slight imprudences, and such secondary attacks not infrequently prove fatal. The earlier and more severely dysphagic symptoms are manifested, the more grave the prognosis; and the sooner disturbances of respiration are shown, the speedier the death, since spasm of the respiratory muscles, in the words of Aretæus, “readily frees the patient from life.” Generally stated, “the more powerful the contractions, the greater the irritation and the danger;” and the longer the delay of involvement of the respiratory muscles, the more favorable the prognosis. The occurrence of strabismus is of grave import (Wunderlich), as might be expected, since only in very severe cases or in the later hours are the deep muscles of the eye affected by spasm. The manifestation of delirium (which is rare, and sometimes, if not generally, due to over-medication) indicates with almost absolute certainty a speedy death.
The pulse-rate and temperature, especially the latter, afford prognostic indications of value.
A rapid pulse is an unfavorable symptom; and if at the same time it is feeble and irregular, the probabilities of an early death are very great.12Though, as has already been stated, the temperature often varies but slightly from the normal, even in acute and rapidly fatal cases, yet when the thermometer does not indicate a body-heat of over 100° F. the prognosis is unquestionably more favorable than when it is two or more degrees higher; and there is certainly much truth in the opinion (Arloing and Tripier) that as long as the rectal temperature is not above 1002/5° F. (38° C.) the prognosis is favorable; whereas when it rises the prognosis at once becomes much more grave, few patients recovering in whom it reaches 103° F. Oscillations of temperature are of no prognostic value, good or bad.
12Few at the present time share Parry's belief, that “if in an adult the pulse by the fourth or fifth day does not reach 100 or perhaps 110 beats in a minute the patient almost always recovers,” and “if, on the other hand, the pulse on the first day is 120 or more in a minute, few instances will be found in which he will not die.”
Death usually occurs suddenly, from spasm of the external respiratory muscles or of those of the larynx, but it may be consequent upon a slow strangulation, upon exhaustion (as it frequently is in the chronic cases), or even upon heart rupture, as in a patient of Dujardin-Beaumetz.
How far the age of the patient affects the prognosis cannot be very definitely stated. The prevalent opinion (entertained as long ago as the time of Aretæus), that the disease is less dangerous in the middle part of life than as either extreme is approached, is probably an erroneous one. Yandell, from the analysis of the cases he had collected, found that the mortality was greatest in children under ten, and least in individuals between ten and twenty years old. Kane's statistics would place the time of greatest danger in the early adult period, from the age of twenty to that of thirty-five or forty.
In traumatic cases the location of the wound does not seem to materially influence the death-rate. As occurring during our late war, those associated with injuries of the upper extremity were the least, and of the head, face, and neck the most, fatal, but the difference in the mortality rates was but 8.4 per cent. (86.8:95.2 per cent.). It has long been believed that wounds of parts supplied by the cranial nerves are not only less often followed by tetanus than those of other regions, but that the disease when present is of a less fatal character. Of the 10 cases of the peculiar head-tetanus already referred to, collected by Bernhardt, 6 died (60 per cent.).
TREATMENT.—For the relief of tetanus agents of most diverse action and power have been employed, intended to control inflammation, allay nervous irritability, arrest spasm, and sustain the general strength; and operations have been performed with the view to destroy nerve-conduction, remove external irritants, change the character of the associated wound, or take away the originally damaged part. Much of the confusion and uncertainty that have prevailed respecting the therapeutic treatment has doubtless arisen from the want of distinct separation of the idiopathic from the traumatic cases, because of incorrect diagnosis, or through an unwarranted assumption of the general applicability of a method of medication found advantageous in individual cases of perhaps rheumatic, malarial, or meningeal disease.
Regarding the affection as inflammatory, the older surgeons treated it antiphlogistically, and until within comparatively recent times bloodletting and mercury were largely employed. General and local bleedings, resorted to as far back as the time of Hippocrates, were not seldom made in excessive amounts,13the patient occasionally surviving both the disease and the treatment. The mercurials were pushed until profuse ptyalism was produced—a condition which could but add to the distress (because of the great difficulty experienced in clearing the throat and mouth), and likely to induce and increase the severity of the convulsive seizures. Combined with opium, calomel was formerly held in high repute, and numerous recoveries have been attributed to such treatment—recoveries, however, almost always of cases of chronic character and no great severity. Should the mycotic origin of the disease ever be demonstrated, there will be good reason, in its well-known destructive action upon minute organisms, for the administration of the mild or corrosive chloride of mercury. Cold baths and affusions have sometimes caused entire relaxation of the spasms, leaving the patient as supple as a glove, and not seldom have been followed by muscular ruptures or sudden death.14The local application of ice to the spine has been credited with many cures, particularly of cases of the non-traumatic variety, and benefit has seemed to follow the employment of ether or rhigoline spray. Hot baths, wateror air, general or local, have been largely used from the time of Paré down, and the induced free perspiration has in some instances seemed to have been of service, as have the medicinal agents acting as sudorifics, of which jaborandi has of late been the one ordinarily employed. “To relieve the contractions and provoke sweating are the two principal bases of treatment,” wrote Martin de Pedro. But it should not be forgotten that in many of the more severe and rapidly-fatal attacks profuse sweating is characteristic of the disease.
13In a case of Lisfranc's, in twenty-six days venesection was made nineteen times, and seven hundred and seventy-two leeches were applied.
14An interesting and frequently-mentioned case is reported by Sir James McGrigor. A soldier having tetanus (unusually severe) was “during the first part of the day drenched with rain, the thermometer standing at 52°, but after ascending one of the highest mountains in Galicia the snow was knee-deep and the thermometer below 30°. The patient was exposed to this inclement weather from six o'clock in the morning till ten at night, when he arrived half starved to death, but perfectly free from every symptom of tetanus.”
All violent depleting measures should be abstained from, since in the acute attacks they can do no good, and in the more chronic ones can only increase the general debility; and it is from exhaustion that the subjects of these latter usually die.
To lessen the reflex irritability, to quiet the muscular spasms, and support the patient are the prime indications; to fulfil which every agent in the materia medica that has, or has been supposed to have, any sedative action upon the nervous system has been employed, as well as remedies directly controlling muscular movements. Of the greater number of such it may be truly said, “They have the same value, and the best of them is good for nothing” (Giraldes).
At the present time the medicinal agents that are deserving of consideration are tobacco, the anæsthetics, curare, conium, cannabis indica, calabar, opium, chloral, and the bromides.
Tobacco, that in virtue of its depressant action so powerfully relaxes the muscles, was until the introduction of the anæsthetics largely employed and regarded with much favor, but of late years has rarely been used, inhalations of chloroform or ether securing more rapid and complete relaxation, with far less danger to the patient. Nicotine, in doses of from a fraction of a minim to a full minim (6/10gr.) by the mouth, or two by the rectum (Houghton), has been given instead of the tobacco infusions with equally good effects, and of course the same dangers of producing fatal collapse.
The anæsthetics, chloroform and ether, have been frequently administered, but although muscular relaxation and sleep have been thereby secured, the natural progress of the disease toward a fatal termination has not been materially affected: death has at times been directly and suddenly produced, and not infrequently, though the inhalations have lessened suffering, they have seemed to hasten the end.
Curare, which “powerfully impairs and destroys the conductivity of motor nerves,” and of which, consequently, much was hoped at one time, has proved to be of but little value.15In order that benefit may follow its administration the agent must be given in large doses and until a decided impression is made upon the innervation of the muscles of respiration, great danger meanwhile existing of producing asphyxia, for the relief of which artificial respiration must be instituted. McArdle of Dublin, in reporting recently a successful case of the acute variety in which gr. ⅔ was given every fifth hour, suggested the combination of curare and pilocarpine, “in the hope that the cardiac and respiratory trouble produced by the former might be prevented by the latter.” Uncertain in composition, cumulative in action, “dangerous, difficult to manage,and variable in its effects,” curare is not, so far as has as yet been determined, an agent to be recommended in the treatment of tetanus.
15Of Demme's 22 cases, 14 died (63.6 per cent.); of Busch's 11 cases, 6 died (54.5 per cent.); and in 51 cases collected by Knecht the mortality-rate was 49 per cent.
Conium, the action of which is much akin to that of curare, and which primarily is upon the terminal portions of the motor nerves, has been occasionally employed—successfully in two cases by Christopher Johnson of Baltimore, who gave it hypodermically in doses of from1/6to 2 minims every one, two, or three hours. In two other cases under the care of the same surgeon death took place, but the remedy seemed to have acted beneficially in relieving the spasms and relaxing the tonic rigidity.
Calabar bean—which produces a paralyzing action on the spinal cord, abolishing its reflex functions, and later “diminishes and destroys the conductivity of the motor nerves”—though apparently of service in certain cases (almost all of them, however, in young subjects and of chronic character), has proved to be of little or no more value than other less dangerous agents. It was first clinically employed by Vella in the Italian war of 1859. Of the 39 cases in Yandell's table, 39 per cent. recovered; of the 60 in Knecht's, 45 per cent.; and of the 60 collected by H. C. Wood, 55 per cent. It may be administered by the mouth, the rectum, or subcutaneously in doses (of the extract) of from ⅓ gr. to 2 grs. every quarter hour, half hour, hour, or two hours (Ringer gave 4 grs. in an hour),16according to the violence of the symptoms, being stopped when there is produced “vomiting, diarrhœa, or a rapid small pulse and clammy sweat.” Yet its beneficial action in severe cases is only manifested when it has been “pushed to the extent of rendering the patient collapsed, the temperature of his body falling perhaps to 94° or 95° F., the pulse being hardly perceptible at the wrist” (Macnamara); under which circumstances there is about as great risk of death from the treatment as from the disease itself. Always, fever is a contraindication to its employment.
16E. Watson gave to a patient in the course of forty-three days the equivalent of 1026 grs. of the solid extract, a tincture of the powdered bean being largely employed.
Cannabis indica, originally used by the East Indian surgeons, and believed by them to have a powerful influence in controlling the tetanic spasms, has proved much less efficacious in cases occurring in Europe and this country, perhaps because of the unreliable character of the extract used; though of 42 cases of the traumatic variety treated in the Chadnie Hospital at Calcutta in five years (1865-69), 62 per cent., and of 39 idiopathic cases 40 per cent., died, and of Chuckerbutty's 13 cases in India, 6 (i.e.46 per cent.) died. Of the 25 cases in Yandell's table, the mortality-rate was 36 per cent. If given, it should be in doses of from ½ to 2, or even 4, grs. of the extract, or minim 15 to drachm j of the tincture, every two or three hours. Having a strong hypnotic action, it is to this probably that the beneficial effects of its administration are due, rather than to its secondary influence upon sensation and muscular movements.
Of all the sedatives and narcotics, opium has been longest and most often used, and in so far as it relieves pain and causes sleep it is of service. Like the other agents, it must be administered in large doses, reference being had to the effect produced and not to the number of grains given. The difficulty of swallowing even the liquid preparations has of late years made the hypodermic injections of morphia the favorite mode of administering the drug. Demarquay has advised that the solution (1 part to 50 of water) should be thrown deeply into the substanceof the affected muscles, as near as possible to the place of entrance of their supplying nerves; the result being to especially relieve the trismus and allow of the taking of food. Fayrer in India found opium-smoking of advantage. The mortality-rate of the 185 cases tabulated by Yandell treated with opium was 43 per cent., but, as is true of the other drugs that have been referred to, it is chiefly if not wholly in the mild and chronic cases that the beneficial effects have been observed.
So far as has yet been determined, chloral is our most valuable drug in the treatment of tetanus, as it is in that of the allied condition of strychnia-poisoning—not because of any direct antidotal action, but by reason of its producing sleep, lessening the reflex irritability of the spinal cord, and diminishing the violence and frequency of the muscular spasms, thus enabling the patient to keep alive until the morbid state can spontaneously disappear. Given usually by the mouth or the rectum, it has been administered hypodermically (as much as 5 grs. at a time by Salter) or, as proposed by Oré, thrown directly into a vein. If it is true, as has been claimed, that its beneficial effect is due entirely to the sleep secured (not infrequently after waking up the spasms return with increased violence), the drug should be administered in doses sufficiently large and repeated to maintain a continuous slumber. Verneuil (whose therapeutic formula has three terms, rest, warmth, sleep) has found that while with certain patients a drachm a day is enough, to others four times as much must be given, and directs that the chloralic coma be continued for about twenty days. Further experience may show that small doses may suffice to secure the needed quiet—as,e.g., the 40 grs. at bedtime, with, if necessary, 30 grs. more at midday, recommended by Macnamara. Such small doses are far safer than the enormous ones that have at times been employed,17since chloral can exert a powerful toxic influence upon the circulatory and respiratory centres, death being almost always due to arrest of respiration, though in tetanic cases it may be the effect of slight spasm upon a heart the enfeebled state of which is indicated by a very rapid and thready pulse. The intravenous injections expose the patient further to the risk of the formation of clots and plugging of the pulmonary artery, several instances of which accident have already been reported, though this method of treatment has but seldom been employed. The death-rate of those treated by chloral alone was 41 per cent. in the 134 cases analyzed by Knecht, and 41.3 per cent. of the 228 tabulated by Kane.
17Beck is reported to have given 420 grs. in three and a half hours, and Carruthers 1140 grs. in six days; both patients recovered—Beck's after a continuous sleep of thirty hours. In one case the chloral sleep was maintained without interruption for eight days, from 250 to 300 grains a day being given; and in another, which also recovered, over 3000 grs. were taken in the course of thirty-eight days.
Of late years use has been made, either alone or in combination with opium or chloral, of the bromides, especially that of potassium, which in full dose unquestionably diminishes reflex irritability, lessens the sensibility of the peripheral nerves, and moderates excessive body-heat. Under its influence mild cases of tetanus have recovered and more severe ones been somewhat relieved, and it has the decided advantage over the other drugs that have been noticed of not being a direct cause of death even when given in large dose—as much in some instances as six, seven, or nearly eight drachms a day. Knecht found that of 10cases treated with chloral and the bromide, 9 got well; and Kane, of 21 to whom such a combination was given, only 5 died (23.8 per cent.); but the number of cases is too small to make conclusions deduced therefrom of any special value. Voisin reports a case (in which it should be noted the spasms began in parts near the wound, and that on the fourteenth day after the receipt of the gunshot injury of the right thigh) that had for eleven days been treated without effect with chloral in large quantity, which at the end of that time was put upon drachm ij doses of the bromide, with three hypodermics a day of about ½ gr. of morphia each: in three days decided improvement had taken place, and in four days more the patient was well.
The sedative and sustaining action of alcohol has many times been taken advantage of in the treatment of this affection. The administration of wines or spirits in large amounts has certainly been found of much service, though it will seldom or never be necessary to give wine, as Rush advised, “in quarts, and even gallons, daily.” 80 per cent. of recoveries appear to have taken place in the 33 cases that Yandell found to have been treated with stimulants; but, on the other hand, of Poland's 15 cases treated with wine, 75 per cent. died: here, again, the numbers are too few to make any deduced conclusions of much value.
As tetanus (or at least tetanoid spasm) has at times been observed as a consequence of malarial poisoning, and successfully treated with quinine, this remedy has occasionally been employed in cases not dependent upon paludism, but very generally to no purpose.
Fowler's solution of arsenic in doses of from 5 to 20 minims every two, three, or four hours has been believed by certain of our American surgeons (Hodgen, Prewitt, Byrd) to be of service.
Because of the supposed origin of the disease in peripheral nerve-inflammation or irritation, operative procedures have many times been adopted to interrupt the conduction or remove the part.
Amputation, which was so highly commended by Larrey, is now recognized as of no service in the severer and more acute cases, and as unnecessary mutilations in the chronic ones; and if performed in those of intermediate severity, when recovery takes place it will generally be difficult or impossible to determine of how much benefit the operation really was, and in some at least of the fatal cases the result can fairly be attributed to the amputation itself. When the disease is associated with an extensive lesion of an extremity, there can be no objection to the removal of the damaged part (if performed early), except that it may by the added shock still further weaken the patient and render him less able to hold out against the tetanus. In cases of severe spasms limited to the muscles of the injured limb (and such are frequently said to be of tetanus) amputation is often strongly indicated, and not seldom is the only treatment that will afford relief. During our late war “amputation was resorted to in 29 instances after incipient tetanic symptoms; 10 of the cases resulted favorably, and in several instances it is noted that the symptoms ceased after the operation.”18Of Yandell's 17 cases, 60 per cent. recovered.
18Medical and Surgical History of the War of the Rebellion.
As there is here, apparently, recovery in 34.5 per cent. of the gunshot cases treated by amputation (nearly one-fifth of all the non-fatal cases reported)—a very gratifying degree of success, and one that might properly encourage the resorting to this method of treatment—somewhat careful analysis may well be made of the 7 cases the histories of which are given. In 2, shell wounds of the foot, operated upon by the same surgeon, the disease appeared while the men were still upon the field. Of one of them it is stated that “there was but little hemorrhage, but the shock was excessive and tetanic symptoms were present;” and of the other, that “the peculiarities in the case were that symptoms of tetanus were quite marked, with great exhaustion.” There are certainly good reasons for believing that these two cases were not of tetanus, but of simple convulsive movements from shock and anæmia. Of the remaining 5 cases, the symptoms manifested themselves on the fourteenth, nineteenth, twenty-first, thirty-fifth, and fifty-fourth day after the receipt of the wound. One of the patients (in whom the disease was longest delayed), having a much inflamed and suppurating compound fracture of the bones of the forearm, “was suddenly seized with a chill followed by threatening tetanus,” and amputation was made the following day. In another (thirty-fifth day case) the “arm became much swollen and symptoms of tetanus ensued, including stiffening of the jaws, great pain and restlessness, and irritable pulse;” two days later the limb was removed, and “all symptoms of tetanus disappeared after the operation.” In another (twenty-first day) the man when admitted into hospital, one month after the date of the injury, stated that “he was first taken with trismus about a week before.” “As he was certainly getting worse every day,” the forearm was removed forty days after the receipt of the wound and nearly three weeks after the commencement of the tetanic symptoms. Other remedies employed after the operation (brandy, chloroform, and blisters to the spine) doing no good, drachm ss doses of the tr. cannabis indica were given every two hours, “under which the patient slowly improved.” In another case (nineteen days) the symptoms were those of tetanus; the amputation was made on the following day; twenty-four hours later “rigidity of the muscles had partly disappeared, and improvement continued until the patient was entirely relieved.” In the remaining case (fourteen days) the first symptoms of tetanus “were relieved by active purgatives, calomel, etc. Three days later the symptoms returned,” and on the next day “tetanus supervened in its usual form.” Five days afterward “the leg was amputated at the middle third, after which the tetanus subsided and the patient made a rapid and good recovery.”
In all of these five cases the disease appeared so long after the receipt of the wound that the chances were that if it was tetanus recovery would take place without regard to the treatment adopted; and of two some doubt may properly be entertained as to their real nature, there being present in both much inflammation—in one an initial chill, and in the other restlessness, great pain, and an irritable pulse. If the unpublished histories of the other three cases are similar to those given, these reported ten successful amputations can affect but little, or not at all, the previously entertained opinion of the real value of this method of treatment—that it is destructive to part, dangerous to life, and only very exceptionally, if ever, curative of the disease.
Nerve-section, first made by Hicks in 1797, and nerve-stretching, first performed by Vogt in 1867—reason for which can be found only in the neuritis (or, much more strongly, the reflex-neurosis) theory of the disease—has not been followed by relief in any unusually large proportion of cases,19and should be practised only when the affected nerve is clearly indicated, when there is much pain in the wound, or when a distinct aura proceeds therefrom. In determining what nerve shall be divided or stretched regard may with advantage be had to Wood's symptom—to wit, the development of pain when pressure is made upon the nerve-trunk, branches from which terminate in the wound.
19Of section, 21 cases, 10 deaths—i.e.47 per cent. (Poncet); of stretching, 46 cases, 36 deaths—i.e.78.2 per cent. (Harte).
Arloing and Tripier strongly advised total neurotomy (i.e.division of all the nerves going to the damaged part), and that high up—an operation that must be followed by extensive paralysis; not, however, permanent, they claim; in six months, at the latest, the power of motion being regained. This period is altogether too limited, as has been proved more than once. Fayrer reports having seen a case in which the hand was permanently crippled. It is to be noted that in most of these nerve-operation cases that terminate in recovery the tetanic spasms in the other parts of the body do not cease at once, but often quite slowly, and in thelarger number of them internal medication of some kind is steadily employed. The removal of foreign bodies from the wound, the freeing of nerves from constricting ligatures, the division of the parts around containing nerve-fibres, and cauterization of the unhealed surface—each has at times proved beneficial, and the first two should always be early resorted to if the necessity therefor exists, no matter what views may be entertained respecting the nature and cause of the disease.
Tracheotomy, first proposed by Physick and later advised by Marshall Hall, has rarely proved of service, since the dyspnœa generally depends upon causes other than spasm of the laryngeal muscles. Verneuil, however, has recently stated that he has saved several lives by this operation.
Careful analysis of reported cases clearly indicates that neither in drug nor operation has a cure for tetanus as yet been found. Almost without exception “in the fully-developed cases all remedial measures fail, and the cases run on unchecked to a fatal termination;” and with the subjects of such acute attacks the physician, in the words of Aretæus, “can merely sympathize.” If not quickly overpowered by the violence of the seizure, and if he can be sufficiently supported, the patient may recover; and if there is late appearance, slow development, and infrequent and limited spasms, he probably will do so, whatever may be the treatment adopted.
“The first indication,” wrote John Hunter, “should be to strengthen the system;” and in the fulfilment of this indication food is of prime importance:20“many patients perish from too much medication and too little feeding” (Agnew). Stimulants and hypnotics indirectly yet powerfully sustain the strength, and the removal of sensory irritants, as light and noise, by lessening the frequency of the spasms contributes to the production of the desired result, since in the convulsed muscles themselves there are developed substances that cause contraction. “Quiet and warmth are indispensable.” Fecal accumulations can but irritate, and therefore an early action through enema or mild drug should, if possible, be secured. As has been happily said by Labbé, “one must treat the tetanics, not tetanus.”
20If necessary, fluids may be administered by means of a tube passed through the nose, or given by the rectum.
If little can be done to cure, much can be done to prevent. The influence of predisposing causes (anxiety, care, excesses, paludism) is to be counteracted as far as may be; the hygienic surroundings of the wounded are to be rendered as favorable as possible; especially is proper ventilation to be secured, and exposure to cold and rain avoided. Whether or not one believes with Rose that the disease depends not on the kind of wound, but on its treatment (“the earlier it is treated in the most careful manner the less frequently do we have tetanus”), there can be no question as to the great advantage to be derived from the thorough cleansing of the wound, the removal of irritating foreign bodies, the securing of free drainage, and the lessening of the amount of inflamed and dying tissue. The marked diminution in the number of cases observed in the last thirty years, as compared with that of a century or three-quarters of a century ago, is the direct result, we may well believe, of improved treatment of wounds and the wounded. The greater danger of slight injuries very possibly lies in their liability to be neglected or mistreated,and the special gravity of punctured wounds of the hand and foot in the anatomical obstacles presented to the ready outflow of blood, serum, or pus. In the exceedingly fatal toy-pistol wounds is it not in the decomposing débris of the lacerated tissues, or in the retained wad saturated with the secretions, that the danger lies of the development of tetanus, and not in nerve-irritation or any peculiar character of the injury? Certainly in the only case I have myself seen, in which the disease was not developed, the damaged hand was kept under hot water from the time it was hurt until healing was complete, and free drainage was from the first maintained.
Tetanus is reported to have appeared notwithstanding the associated injury was antiseptically dressed; but in modern wound-treatment, with its cleanliness, its protection of the damaged part, its infrequent manipulations, and its power to diminish inflammation and prevent decomposition, lies, we may well believe, the means of reducing to a minimum the danger of occurrence of those spasms that, once developed, are of “exceedingly painful nature, very swift to prove fatal, but not easy to be removed” (Aretæus).
As met with after abortion or labor at term, tetanus presents no special peculiarities in course, treatment, or termination. Of very rare occurrence in temperate regions, it is often met with in hot countries in women of the darker-colored races. Grief, anxiety, overwork, and profuse hemorrhage predispose to it, as do obstetrical operations and the retention of pieces of the placenta. Unlike the ordinary puerperal affections, it is more common in the country and in private practice than in cities and hospitals. Rather elderly women are more often attacked than are those younger. First and second pregnancies are the more dangerous if completed; later ones if abortion occurs. Abortion in the earlier months, especially in the third, is most likely to be followed by the disease (Garrigues). Ordinarily manifesting itself within ten days after labor, it has been known to occur after an interval of a month.
Hysteria, eclampsia, and especially tetany, may be mistaken for it. The latter affection, which generally attacks young women, may occur at any time during pregnancy or lactation—tetanus only within a comparatively few days after delivery.
ItsTREATMENTis the same as that of ordinary tetanus, care being taken to remove from the uterus as speedily as possible any contained foreign body. Antiseptic irrigations may prove of service, though it is doubtful if their employment can accomplish much after the commencement of the spasms. Aveling has thought that transfusion might perhaps be of benefit.
The occurrence of intracranial congestions, hemorrhages, and venous thrombosis21will, almost of necessity, render any medication of no value.
21Such as were found upon autopsy in the case reported by Macdonald, and believed by him to be the essential lesions of the disease.
Under all circumstances thePROGNOSISis exceedingly grave. Themortality-rate of the cases after abortion collected by Garrigues was 92 per cent. (25—23), and of those after labor 84.37 per cent. (32—27).22
22As indicating the extreme gravity of tetanus occurring in connection with a wound of the genital tract, it may be noticed that of 17 cases after ovariotomy collected by Parvin, 16 died, 94.1 per cent., and of 24 cases tabulated by Olshausen, 23 died, 95.83 per cent.
From the earliest times it has been known that newly-born children are occasionally the subjects of trismus and generalized spasms, and that those thus affected usually die.
More common among the darker races23and in warm countries (though some of the southern races and tribes are almost or altogether free from it), it has been for years together endemic in places far north (e.g.the islands of Heimacy and St. Kilda), and a veritable scourge in certain lying-in hospitals (e.g.Dublin, Stockholm, St. Petersburg). Occasionally it has prevailed epidemically.
23Wallace, however, found that in the Medical College Hospital at Calcutta the disease occurred proportionably more frequently in the children of European than of native mothers, though the actual number of cases among the latter was very much the greater.
Attacking usually the children of the poor, others have not been altogether exempt from it, though unquestionably “it is most often seen where the mothers of the children are very young or very poor or very worthless” (Mosely). Rarely appearing before the third day, it as rarely occurs after the twelfth, generally manifesting itself within the first week.
Its cause has been thought to be navel-string injuries; inflammation of the umbilical arteries or vein; reflected irritation from the skin, the bowels, or the external genitals; uræmic encephalopathy; cold and dampness; defective ventilation; and indirect pressure upon the cerebellum and the medulla.
The supposed causative umbilical lesions have time and again been found in young infants presenting none of the symptoms of the disease; and the same is true of the vessel inflammations24and of the reflex irritations. Atmospheric and climatic states and the hygienic condition of the child and its surroundings, however much they may contribute to the development of the affection, cannot be regarded as directly producing it; though experience has shown (as in the lying-in hospitals before referred to) that by securing proper care of the children, by improving the ventilation, and by preventing overcrowding, its prevalence may be very greatly diminished.
24Mildner of Prague reports that in 46 fatal cases of inflammation of the umbilical vein, convulsions occurred in but 5, and in these the spasms were not like those of tetanus.
Forty years ago Marion Sims believed that he had discovered the exciting cause in “pressure exerted on the medulla oblongata and its nerves, the result most generally of an inward displacement of the occipital bone,” occasionally, though rarely, of the parietal. That intracranial pressure may give rise to tetanic symptoms is beyond question, seizures identical with those of tetanus having been observed in connection with tumors of the cerebellum (Hughlings Jackson), as also trismus, confined even to one side (Wernicke).
In some cases without doubt the occipital depression is secondary, the result of intracranial shrinkage; and even if primary, there may be no lockjaw.25
25H. G. Lyttle of New York recently reported the case of a child two months old whose occipital bone was depressed and overlapped by the parietals, in which there had been no trismus, though the child had slight convulsive movements of the hands and rolling of the eyes.
Parrot regarded the disease as a form of eclampsia, the uræmic encephalopathy manifesting itself as one or other of the three varieties recognized (by Cederschjöld) a half century ago—viz. trismus, tetanus, and ordinary eclampsia. The articular rigidity, especially noticeable in the temporo-maxillary joint, he held to be largely independent of the convulsive tonicity of the muscles, and due in no small measure to induration of the overlying soft parts, such hardening being the result of that loss of fluid which, as it affects the body in general, produces the rapid and extreme emaciation which is so characteristic of the disease.26
26Parrot adds: “In the new-born in a state of health great difficulty is experienced in separating the jaws, the muscles that bring them together having, relatively, considerable power, and the infants making quite an active resistance when one attempts to separate them. It follows that when a pathological state exaggerates this tendency it may be thought that we have to do with a veritable trismus.”
Though there is at times a prodromal period of restlessness and fretfulness, usually the disease is first indicated by an inability to nurse, the nipple being eagerly seized upon, but quickly dropped—an action that may be regarded as almost pathognomonic. Swallowing, difficult from the first, soon becomes impossible. The lower jaw in the earlier hours in many cases is dropped, but nearly always well-marked trismus is more or less quickly developed, at first intermittent, but later persistent. Opisthotonos in some degree is almost certain to be present, and in a large proportion of cases the tetanic convulsions become generalized, clonic exacerbations occurring as often as every half hour or hour, and capable of being induced at any time by pressure upon the abdomen (Morrison), or indeed by any external irritation, noise, touch, draft of air, etc.
All observers have noticed the peculiar cry, or rather whine, of the little patient. The bowels have in some cases been constipated, in others diarrhœa has been present. The temperature is generally decidedly elevated, and has been known to reach 111.2° F. Usually in from twelve to twenty-four or thirty-six hours collapse occurs, and the child speedily dies; though the fatal result may be deferred for a number of days or suddenly produced at any moment by spasm of the respiratory muscles.
Upon autopsy there has generally been found hyperæmia of the brain and cord with extravasations (commonly perithecal) in the spinal canal, occasionally in the meninges of the brain and in the ventricles. Very probably, as in true tetanus, these vascular conditions are the effect, and not the cause, of the spasms; and sometimes, doubtless, they are hypostatic.
As usually observed and commonly treated, thePROGNOSISis very bad. Whether occurring in India or in Iceland, in the Rotunda Hospital in Dublin or in the Foundling Hospital in St. Petersburg, in the negro cabins of our Southern States or in New York or Washington, the subjects of it almost always die, generally in from six to forty-eight hours.27It has been very exceptional to have 20 per cent.28ofrecoveries, or even 15;29and the non-fatal cases have almost invariably been those in which the disease appeared late and in mild form.
2780 per cent. of the cases collected by Hartigan (207—165).
288 out of 40 cases tabulated by Smith; 8 out of 42 in the Stockholm Lying-in Hospital in 1834. It is very probable that these latter were cases of infantile meningitis.
295 out of 34 cases reported by Wallace from the Medical College Hospital of Calcutta.
When treated by manipulation and position, as recommended by Marion Sims, the chances of recovery seem to be very much greater. Even in the acute cases under the care of Sims, of Wilhite, and of Hartigan, death occurred only in those seen late, after extravasations had taken place.
The Sims's method consists simply in releasing the overlapped occipital bone by manipulation (or, if that fails, by an operation), and then placing the child so that the head shall rest flat upon its side, the face looking directly toward the horizon. The success attending this postural treatment has been so remarkable that the practitioner cannot be justified in failing to determine the relative positions of the occipital and parietal bones and to keep the head resting upon its side.
Of the medicinal agents that have been administered (the same as those employed in ordinary tetanus), calabar and chloral have of late years been the favorites, chloral to-day standing highest in professional estimation. Calabar is best given hypodermically in doses of from1/12to1/6gr. of eserine; chloral, either by the mouth (½ to 1½ or 2 grs.) or preferably by the rectum (2 to 4 grs.), either drug being pushed until relaxation takes place and sleep is secured, or toxic symptoms become so grave as to compel suspension of the treatment. Though favorable results have rarely followed such medication,30and (with but few exceptions) only in late-developed and mild cases that very possibly would have gotten well of themselves; yet as recovery from an acute attack has occasionally been reported, at least the chloral treatment should be instituted in every case not found to be promptly relieved by change of position of the head.
30Monti, however, reported 11 recoveries out of 16 cases treated with calabar (68.75 per cent.), 3 out of 5 in his own practice; and Widerhofer was credited in 1871 with 6 recoveries in the 10 or 12 cases that he treated with chloral.
Whatever views may be entertained as to cause or nature, it is to measures that will prevent development that we must chiefly look for relief from this lockjaw of infants, that even in our own country annually carries off a great number of children—25,000, as estimated by Hartigan. If mechanically produced, its occurrence should be rendered impossible by having the child's head from the time of birth properly placed, and at regular intervals changed in position. If defective hygiene, personal and social, is the one common and constant condition wherever the disease prevails, then due regard should be had to dressing the umbilical (and perhaps the preputial) wound; to bathing, clothing, and keeping quiet31the child; to thoroughly airing,32warming, and disinfecting the lying-in room; and to overcoming, as far as may be possible, the evil influences of unfavorable atmospheric and climatic conditions.
31In these new-born children, though the reflex irritability is less than in those older, the response to irritation is very much greater, because of the lessened inhibitory power at this age (Soltmann).
32By increasing the air-supply and lessening the number of beds the mortality at the Rotunda was in seven years reduced from about 1 in 7 to about 1 in 19 of the children born.