Tetanus

“ It has been customary with authors to call all those cases of tetanus, which are not brought on by wounds, symptomatic. They are no more so than those which are said to be idiopathic. They all depend alike upon irritating impressions, made upon one part of the body, producing morbid excitement, or disease in another. ”

“ In tetanus, as in diphtheria, the organisms producing the poison, Lf found in the body at all, are developed only at the seat of inoculation; they do not make their way into the surrounding tissues. In this we have an explanation of the fact that all the earlier experiments with the blood from tetanus patients gave absolutely negative results. It is sometimes stated that the production of tetanus toxin in a wound soon ceases, owing to the arrest of the development of the bacillus, even in cases that ultimately succumb to the disease. ”

“ There is nothing in the post-mortem examination which leads me to think that deceased died from tetanus proper. I think that granules upon the spinal cord, such as I have heard described, would not be likely to cause tetanus. I have not heard of cases treated by Mr. Travers. In animals to which strychnine has been administered I cannot say that I have observed what you call an intolerance of touch; but by touching them the spasms are apt to be excited. That sensibility to touch continues as long as the operation of the poison continues. ”

“ It will show that both in traumatic and idiopathic tetanus the disease commences with the milder symptoms, which gradually progress towards the development and final completion of the attack. When once the disease has commenced, it continues without intermission, although, as in every other form of malady, the paroxysms will be from time to time more or less intense. In the case of tetanus from strychnine it is not so. ”

“ TETANUS (from Gr. τείνω, I stretch) , a disorder of the nervous system, consisting in an increased reflex excitability of the spinal cord and manifesting itself by painful tonic spasm of the voluntary muscles throughout the body. The disease shows itself under various conditions. It occasionally occurs, particularly in tropical countries, without apparent cause, and has thus been known to affect numbers of persons simultaneously (idiopathic tetanus) . It is sometimes observed in new-born children (trismus neonatorum) and in parturient women (puerperal tetanus) . ”

“ In hot countries tetanus is more common and more acute than it is in temperate climes, and a case has been recorded in which a man in the West Indies cut his hand on a broken plate at dinner and was dead of tetanus before the day was out. It is easy to see that the germs are more likely to undergo virulent cultivation in warm earth than in cold. It was formerly the custom to speak of idiopathic tetanus—that is to say, of the disease occurring without any wound having been received. ”

“ In the case of tetanus we have another disease affecting the nerve-centres of the body, and although many authentic cases have been cited in which the treatment with anti-tetanic serum has been entirely successful, a great many instances have occurred in which it has been of no avail at all, more especially when the disease has obtained a firm hold on its victim. ”

“ Tetanus occurs in man and horses most commonly, though it may affect other animals. There is usually a wound, often an insignificant one, which may occur in any part of the body. The popular idea that a severe cut between the thumb and the index finger leads to tetanus is without scientific foundation. As a matter of fact, the wound is nearly always on one or other of the limbs, and is infected simply because they come more into contact with soil and dust than does the trunk. It is not the locality of the wound nor its size that affects the disease. ”

“ Serjeant Shee: In idiopathic tetanus the patient is always uncomfortable for some time before the attack. The appetite is not much affected. He complains more of the muscles of his neck. He may within twelve hours of a serious attack preserve his relish for food. I never heard a patient complain of want of appetite. I have known cases of idiopathic tetanus in which the first paroxysm occurred in bed. I have known this disease occur to women after confinement or miscarriage. Sometimes one of the premonitory symptoms is a difficulty in swallowing. ”

“ The tetanus is not confined to the human species. It often affects horses in the West-Indies. I have seen several cases of it in Philadelphia.
The want of uniform success in the treatment of this disease, has long been a subject of regret among physicians. It may be ascribed to the use of the same remedies, without any respect to the nature of the causes which produce it, and to an [256] undue reliance upon some one remedy, under a belief of its specific efficacy. ”

“ In 1894 came the use of an antitoxin in cases of the disease, and, in 1895, 42 cases were reported, with 27 recoveries. It cannot be said that any one of the diverse preparations of tetanus-antitoxin, up to this present time, has triumphed over the disease. Tetanus is of all diseases the hardest to reckon with: the first sign of it is the last stage of it; there is no warning, nothing, it may be, but a healed scratch, till the central nervous system is affected with sudden and rapidly advancing degeneration of certain cells. ”

“ The proportion of cases of idiopathic to traumatic tetanus is about one-third. I have seen not less than forty cases in the hospital at Calcutta. That disease is not considered to be so fatal as traumatic tetanus, but I have found that it is equally so. It is commonly found in children—both native and European. It takes place about the third day after birth. It will also be occasioned by cold in the climate of India. In infants there is a more marked symptom of lockjaw than in traumatic tetanus. In adults there is no difference between the symptoms of the two diseases. ”

“ There are other forms of tetanus which produce death, and which arise from other causes than the taking of strychnine, but there is a wide difference between the various forms of the same disease, which prevents the possibility of mistake. ”

“ The acute form is very fatal, but in the mild or subacute form the chance for making a recovery is good.
Tetanus Is a Preventable Disease. It may be largely prevented by the careful disinfection of wounds, and the use of anti-tetanic serum. In most localities the proper treatment of the wound is a sufficient preventive measure, but in localities and stables where the disease is common the anti-tetanic serum should be used. Ordinary cleansing of a wound, as practiced by most stockmen, is not sufficient to destroy the bacillus of tetanus. ”

“ Ardern’s description of a case of traumatic tetanus is very interesting, because it contains so many elements that are familiar in the history of this affection. The fact that it occurred in a gardener from a hook, so likely to be infected with tetanus bacilli from hay or grass, and that the wound was made where the thumb joins the hand and where, as we know now, the construction of the tissues is so favourable to that burying of the tetanus bacilli away from the free oxygen of the air, giving it a chance to grow anaerobically, all show the disease exactly as in our own time. ”

“ It has been observed that, quite apart from size, animals exhibit different degrees of susceptibility. Frogs kept at their ordinary temperature are exceedingly insusceptible, but when they are kept warm it is possible to tetanize them, though only after a somewhat prolonged incubation period, such as is met with in very chronic cases of tetanus in the human subject. In experimentally-produced tetanus the spasms usually commence and are most pronounced in the muscles near the site of inoculation. ”

“ Chronic Tetanus.#--The difference between this and acute tetanus is mainly one of degree. Its incubation period is longer, it is more slow and insidious in its progress, and it never reaches the same degree of severity. Trismus is the most marked and constant form of spasm; and while the trunk muscles may be involved, those of respiration as a rule escape. Every additional day the patient lives adds to the probability of his ultimate recovery. When the disease does prove fatal, it is from exhaustion, and not from respiratory or cardiac spasm. ”

“ In the treatment of tetanus the first thing to do is to try to make the wound by which infection has taken place surgically clean. For though a wound free from the germs of suppuration may be the incubating place of the bacilli of tetanus, still in most cases there is also an invasion of septic germs, and the double infection makes the action of the tetanic poison the more virulent. If the local conditions are such that it is impossible to cleanse the wound, the free use of the knife or of the cautery or of pure carbolic acid may be resorted to, or an amputation may be performed. ”

“ Dr. Currie relates a case of a man in the infirmary of Liverpool, who was cured of tetanus, by drinking nearly a quarter cask of Madeira wine. Dr. Hosack speaks in high terms of it, in a letter to Dr. Duncan, and advises its [260] being given without any other stimulating medicine.
3. Ardent spirits. A quack in New-England has lately cured tetanus, by giving ardent spirits in such quantities as to produce intoxication. ”

“ The details are often unprintable. They have eight cases of tetanus at No.— Stationary, and five have died.
All the patients at No.— have been inoculated against tetanus to-day. They have it in the French Hospitals too. ”

“ I gave her instantly a dose of Passiflora. The convulsions subsided, and she has never had one since. I continued the use of the medicine in small doses for a few days. I have used it in treating tetanus in horses—a disease usually considered as inevitably fatal to [Pg 268] that noble animal. It has never failed to cure the horse. * * During the late war, my son, Dr. J. H. Phares, had occasion many times to prescribe the Passiflora for tetanus in horses, with one invariable result—prompt, perfect, permanent cure. He fortunately saw no case in man. ”

“ Muscle curve of strychnine tetanus in a frog with artificial oxygen-free circulation. Lower line indicates seconds. Upper line indicates stimulation by induction shocks. A—A single shock produces a long tetanic contraction. B—In a more advanced stage each shock produces a tetanus only of short duration. C—In a still more advanced stage each shock brings about only a single contraction if the stimuli do not succeed each other too rapidly. If they succeed more rapidly, as, for instance, in a faradic current, only the first shock is effective. ”

“ Can you form any judgment as to the cause of death in Cook’s case?—I cannot. No conclusion or inference can be drawn from the degree or kind of the contractions of the body after death.
Lord Campbell: Can you not say, from the symptoms you heard, whether death was produced by tetanus, without saying what was the cause of tetanus?
Witness: Hypothetically I should infer that he died of the form of tetanus which convulses the muscles. Great varieties of rigidity arise after death from natural causes. The half-bent hands and fingers are not uncommon after natural death. ”

“ Is there one single symptom in the statement made in the depositions by Elizabeth Mills and Mr. Jones which may not be classed under one of the varieties of convulsions which Dr. Copland describes? It is not for me to suggest a theory; but the gentlemen whom I shall call before you—men of the highest eminence in their profession, and not mere hospital surgeons, who have seen nothing of this nature but traumatic tetanus—will tell you that Mr. Cook’s symptoms were those of general convulsions, and not of tetanus. ”

“ They found that the germ of tetanus had been introduced into the fluid before the bottle was opened at Malkowal, and they thought it probable that this might have occurred owing either to insufficient sterilization or to the process of filling the bottle from a larger flask having been performed with defective precautions. They also expressed the opinion that carbolic acid was a valuable agent in restraining tetanus growth when added to plague prophylactic, and they, therefore, thought that its omission was a grave mistake. ”

“ Cross-examination continued: Might not the irritation of a syphilitic sore, by wet, cold, drink, mercury, and mental excitement, lead to tetanic symptoms?—I do not think that that is very likely. The irritation which is likely to produce tetanus is the sore being exposed to friction, to which syphilitic sores in the throat are not exposed. I should class tetanus arising from the irritation of a sore as “traumatic.” Cases very rarely occur which it is difficult to class as either “traumatic” or “idiopathic.” I should class tetanus arising from irritation of the intestines as “idiopathic.” ”

“ Irritation of the limbs produces tetanus. There is, at the same time, increased secretion from the skin. The breathing is irregular. In large doses there is paralysis and death. The heart is found arrested in diastole. The fatal dose for a frog is 50 mgrms.; but 1 mgrm. will produce symptoms of illness. In dogs there is paralysis, convulsions, vomiting, and difficult breathing. ”

“ Traumatic tetanus very frequently occurs in hospitals—in fact, it often supervenes upon the operations of the surgeon; but the persons to give you correct information upon idiopathic tetanus are the general practitioners who enjoy the confidence of families, and who have the opportunity of visiting at their dwellings, both rich and poor, when they are attacked by any of those convulsive diseases or fits which heads of families and brothers and sisters are so careful not to disclose to the world at large. ”