disease in a special morbific agent developed in the secretions of the
unbroken skin or the damaged tissues of the wound, or introduced from
without and carried by the blood-stream to the medulla and the cord,
there to produce such cell-changes as give rise to the tetanic
movements. It finds support in the unsatisfactory character of the
neural theories; in the strong analogy in many respects of the
symptoms of the disease to the increased irritability and muscular
contractions of hydrophobia and strychnia-poisoning, or those produced
by experimental injections of certain vegetable alkaloids; in the
recent discoveries in physiological fluids, as urine and saliva, of
chemical compounds,[4] and in decomposing organic matter of ptomaïnes
capable of tetanizing animals when injected into them; in the
rapidly-enlarging number of diseases known to be, or with good reason
believed to be, consequent upon the presence of peculiar microbes; in
the more easy explanation by it than upon other theories of the
ordinary irregularity and infrequency of its occurrence, its
occasional restriction within narrow limits, and its almost endemic
prevalence in certain buildings and even beds; in the extreme gravity
of acute cases and the protracted convalescence of those who recover
from the subacute and chronic forms; in the very frequent failure of
all varieties of operative treatment; and in the success of
therapeutic measures just in proportion to their power to quiet and
sustain the patient during the period of apparent elimination of a
poison or development and death of an organism.
[Footnote 4: Paschkie in some recent experiments found that the
sulphocyanide of sodium applied in small quantities caused a tetanic
state more lasting than that caused by strychnia.]
This theory is as yet unsupported by any positive facts. Neither
septic element nor peculiar microbe has been discovered.[5] Failure
has attended all efforts to produce the disease in animals by
injecting into them the blood of tetanics. There is no testimony
worthy of acceptance of the direct transmission of the disease to
those, either healthy or wounded, coming in contact with the tetanic
patient; nor can much weight be attached to such reports as that of
Betoli of individuals being attacked with it who had eaten the flesh
of an animal dead of it.
[Footnote 5: Curtiss of Chicago thought that he had found a special
organism, but further investigation showed that it was present in the
blood of healthy members of the family and in the water of a
neighboring pond.]
The ordinary absence of fever has been thought to prove the
incorrectness of this theory, but increased body-heat is not a symptom
of rabies or strychnia-poisoning, of the tetanic state following the
injection of ptomaïnes, or of cholera—a disease very probably
dependent upon the presence and action of a bacillus. Martin de Pedro,
regarding the affection as rheumatic in character, located it in the
muscles themselves, there being produced, through poisoning of the
venous blood, a muscular asphyxia.
{548} MORBID ANATOMY.—The pathological conditions observed upon
autopsy in the wound, the nerves, the central organs, and the muscles,
have been so various and inconstant that post-mortem examinations have
afforded little or no definite information respecting the morbid
anatomy of the disease. Many of the reported lesions have
unquestionably been dependent upon cadaveric changes or defective
preparation for microscopic study. The wound itself has been found on
the one hand healthy and in due course of cicatrization,[6] on the
other showing complete arrest of the reparative process (“the sores
are dry in tetanus,” wrote Aretæus),[7] or even gangrenous, with
pus-collections, larger or smaller, in its immediate vicinity, usually
in connection with retained foreign bodies.
[Footnote 6: Of one of Hennen's cases it is reported that “the life of
the patient and the perfect healing of the wound were terminated on
the same day.”]
[Footnote 7: Morrison seventy years ago wrote: “Wounds from which
there is a copious discharge of bland pus are seldom or never followed
by this disease;” and as a rule this is true.]
The nerves in and about the injured area have often been found
reddened and swollen, their neuroglia thickened and indurated, and
blood extravasated at various points. At times, even when to the naked
eye healthy, microscopic examination has shown one or a few of the
constituent bundles inflamed. But repeatedly the most thorough search
has failed to find any departure from the normal state, and the same
appearances of congestion and inflammation are not seldom observed
when there has been no tetanic complication. In an interesting case
reported by Michaud the sciatic in the uninjured limb presented the
same neuritic lesions as that of the wounded side.
In the cord and the medulla vascular congestion has been the condition
most generally seen, associated not infrequently with hemorrhages and
serous effusions—a condition occasionally absent, and when present
due, it is probable, in great measure, perhaps wholly, to the muscular
spasms, or consequent in part upon post-mortem gravitation of the
fluids. Increase in the amount of the connective tissue of the white
columns of the cord (thought by Rokitansky to be the essential lesion
of the disease); disseminated patches of granular and fluid
disintegration (to which Lockhart Clarke called attention in 1864);
atrophy of the cells, especially those of the posterior gray
commissure; nuclear proliferation; changes in the color, form, and
chemical reaction of the ganglion-cells; dilatation and aneurismal
swellings of the vessels, with development of granulation-masses in
their walls; and changes in the sympathetic ganglia,—such have been
the reported lesions. But each and every one has at times been
absent—at times been discovered in the bodies of those dead of other
diseases. Some of the changes have without doubt been produced after
death; some perhaps have been but errors of observation.
The muscles have been found healthy in appearance and constitution;
discolored, softened, and the seat of blood-extravasations large and
small; undergoing the vitreous degeneration; and ruptured, the
laceration affecting a few fibres or the entire thickness of one or
more muscles, as the rectus abdominis, the muscles of the neck, those
in the vertebral gutter, and even the heart. The rigor mortis appears
at once or very soon, thus confirming Brown-Séquard's observation,
that cadaveric rigidity is “quick in coming on and quick in passing
off in direct proportion to the amount {549} of long-continued violent
action which preceded death.” The visceral congestions that have been
observed cannot be regarded as in any way peculiar, but as due simply
to the muscular spasms and the mode of dying.
It is probably by chemical and microscopical examinations of the
blood, and, much more, the solids and fluids of the damaged part or
the secretions of the skin in the non-traumatic cases, that the cause
of this obscure affection is to be discovered, and not from study of
the nerves, the cord, and the brain; which study up to the present
time has only shown that “tetanus has no morbid anatomy, except
perhaps its traumatic cause and the asphyxial congestions resulting
from it.”
SYMPTOMS.—Following the receipt of a wound, tetanus may be developed
quickly or only after many days, cases of more or less credibility
being on record of immediate appearance, and of an elapsed interval of
one, two, three, even seven months (in a case occurring during our
late war). Doubt, however, may very properly be entertained as to the
true tetanic character of some at least of these very long-delayed
cases, or of their dependence upon the previous traumatism. The very
common belief that after the lapse of three weeks no fear of the
disease need be entertained is unquestionably an erroneous one, but
the danger certainly is slight when the wounded person has escaped for
twenty-two entire days. In by far the larger proportion of cases the
outbreak occurs between the fifth and fifteenth days after injury—in
about two-thirds, according to Yandell's, or about four-fifths,
according to Joseph Jones's and Otis's statistics.
Not infrequently for a day or two before any distinct evidences of the
disease are manifested there is prodromal malaise, associated at
times, but by no means constantly, with unusual sensitiveness, or even
positive pain, in the wound and slight muscular twitching in its
vicinity. In the larger number of cases the first symptoms noticed are
stiffness about the jaw, more or less difficulty in opening the mouth,
and perhaps slight interference with deglutition, the patient feeling
as if he had taken cold; such symptoms often appearing early in the
morning after waking from the night's sleep. With more or less
rapidity well-marked trismus comes on, the jaws being locked, the
corners of the mouth retracted, and the lips either firmly closed or
separated so as to uncover the teeth, producing the peculiar grin long
known as the risus sardonicus.
In rare cases it is the depressors, and not the elevators, of the
lower jaw that are in a state of contraction, the mouth consequently
being kept wide open. The forehead is wrinkled, the eyes staring, the
nose pinched, and not seldom there is the facial expression of old
age. The voice is altered and swallowing is difficult. Occasionally
the spasms of the muscles of deglutition are so intense as to be the
principal tetanic symptom, such dysphagic or hydrophobic (Rose)
tetanus very generally proving fatal. In a few cases, after wounds of
the face and head, these violent spasms have been found associated
with facial paralysis, almost always, if not always, on the injured
side; such paralysis having been present in at least one case (Bond's)
in which throat-spasm was wanting, the wound being in the
temporo-parietal region. Often there is early felt in greater or less
intensity pain, as from pressure, in the epigastrium, piercing through
to the back—a symptom by some regarded as pathognomonic, and due
without doubt to contraction of the diaphragm.
{550} From the region of the jaw the disease passes on to successively
attack the muscles of the neck, the back, the abdomen, the chest, the
lower, and, last of all, the upper, extremities, those of the forearm
long after those of the arms. The muscles of the fingers, of the
tongue, and those of the eyeball are very late if at all affected, the
tongue probably never being tonically contracted. The anterior
abdominal wall is broadened, depressed, and hard. In the
fully-developed acute cases the whole body is rigid, remaining
perfectly straight (orthotonos), arched backward (opisthotonos),
forward (emprosthotonos), or laterally (pleurosthotonos), according as
the muscular tension is balanced or greater on one side than another.
The action of the extensors being usually the more powerful, backward
bending (opisthotonos) to a greater or less extent is the ordinary
condition; but only in rare and extreme cases is the contraction such
as to curve the body like a bow and keep it supported upon the occiput
and heels. Frequently the bending is not specially noticeable except
in the neck. Emprosthotonos is rare, and pleurosthotonos has been so
seldom observed that its very existence has been denied. Occasionally,
in well-marked cases of opisthotonos, there is some associated lateral
arching, due rather to voluntary efforts on the part of the patient
(for the purpose of obtaining relief) than to tetanic contraction.
Larrey's opinion that the location of the wound (behind, in front, or
on the side) determined the direction of the curving has been proved
to be incorrect. Except in a small proportion of cases to the
persistent tonic spasm[8] there is added convulsive seizures of the
affected muscles, developed upon any, even the slightest, peripheral
excitation of the reflex irritability, as by a movement, a touch, a
draft of air, a bright light, a sudden noise, an attempt at
swallowing, etc. The frequency of these clonic exacerbations and their
intensity vary much, being severer and coming on closer together in
the grave acute cases and in the later stages of those terminating
fatally. They may occur only once in several hours or four, five, or
more times in a single hour, each spasm lasting from but a few seconds
to a minute or two. During its continuance the suffering is intense,
both from the pain of the contraction and the experienced sense of
suffocation. Between the paroxysms there is usually but little pain,
the sensation being rather one of tension or pressure. Occasionally
cessation of spasms and complete relaxation of all muscular
contraction suddenly take place six, eight, or twelve hours before
death, the patient quickly passing into a state of collapse.
[Footnote 8: This is not, in reality, a state of uninterrupted spasm,
but one of very numerous, quickly-repeated muscular contractions, as
many even as six hundred and sixty per minute (Richelot).]
Throughout the whole course of the disease the mind remains clear,[9]
except in the later stages of a few cases; and then the existing
delirium or coma is often, it is probable, an effect of the treatment
that has been employed. Except in the more chronic cases the patient
is generally unable to sleep, and even when fortunate enough to do so
the tonic spasm may not relax. In other than the mildest attacks there
is usually noticed a marked increase, local or general, of the
perspiration; such sweating {551} being a much more prominent symptom
of the disease as met with in tropical than in temperate regions.
[Footnote 9: “The brain alone in this general invasion has appeared to
us to constantly preserve the integrity of its functions down to the
very last moment of existence, so that the unfortunate subject of this
disease is, as it were, an eye-witness of his own death” (Larrey).]
The pulse, which is normal in the earlier stages, may later be but
little increased in frequency (except during the exacerbations, when,
small and compressible, its beats may run up to 140, 160, or even 180
per minute), or it may become progressively feebler and more rapid as
the case advances toward the fatal termination. The irregularity often
noticed during the convulsive seizures is doubtless owing to the
muscular contractions so compressing the vessels as to hinder the
passage of the blood through them. That the heart itself is not
tetanically contracted would seem to be proved by its regular quiet
action during anæsthesia.
The body-heat varies greatly in different cases, the temperature being
oftentimes normal, or even subnormal, until toward the very last. Not
infrequently, even in severe and fatal cases, it is not increased more
than two or three degrees, and quite rarely, except just before death,
does it rise much above 103° F. Exceptionally, very high temperatures
have been observed; I have myself seen one of 108° F. an hour before
death. Prévost had a patient whose axillary temperature was 110¾° F.
Lehmann reports a heat of 111.9° F. just before death, and in one of
Wunderlich's cases the temperature (that three hours earlier was
103.5° F.) fifteen minutes before death was 110.1° F., and at death
112.5° F., with a further post-mortem rise of more than a degree
(113⅔° F.)—a phenomenon that has been observed in a number of cases.
This increased temperature of tetanus is not of inflammatory origin
(except as a part of it, at times, may be due to intercurrent
affections, especially a broncho-pneumonia), but depends doubtless
upon a combination of causes, among them the violent muscular spasms,
and, more particularly, the disturbance of the regulating heat-centre
or centres from the alterations of their blood-supply in quantity and
quality.
The bowels are usually constipated, because of the little food taken,
the profuse sweating, the tonic spasms of the abdominal muscles, and
the contraction of the external sphincter and the levator ani, the
muscular coat of the bowel, like all the other involuntary muscles,
remaining unaffected.
Micturition, generally infrequent because of scanty secretion, may or
may not be disturbed. In many cases it is true, as written by Aretæus,
“the urine is retained so as to induce strong dysuria, or passes
spontaneously from contraction of the bladder,” though it is the
external muscles, and not the bladder itself, the contraction of which
produces the retention or the discharge; which latter is of rare
occurrence.
DIAGNOSIS.—When fully developed, with all its characteristic symptoms
present, tetanus cannot, or at least ought not to, be mistaken for
anything else; yet a study of reported cases will show that errors of
diagnosis have been made, and because of such errors various methods
of treatment have been given undue credit as curative measures.
Wound-spasms, clonic in character, of different degrees of severity,
beginning in and confined to the muscles of the injured part or limb
(even of the lower segment of the upper extremity), have not seldom
been regarded as tetanic, which they certainly are not; and recovery
having taken place, it has been attributed to the adopted treatment,
operative or therapeutic. The comparatively few cases in which,
primarily located in the vicinity {552} of the wound, these traumatic
spasms have become generalized in strict accordance with Pflüger's
laws, or, much more rarely, passing over the intervening parts of the
body, have seized upon the muscles of the jaw and neck, may perhaps,
for want of accurate knowledge of the essential nature of tetanus, be
regarded as a variety of the disease; but it is much to be regretted
that observers and reporters have not clearly separated them from the
cases of true tetanus (or the commonly met-with variety of tetanus) in
which the first or first important symptoms are always in connection
with the muscles whose nerves take origin in the medulla oblongata, no
matter where the wound may be located or whether there is any wound at
all. Not a few of the idiopathic cases may justly be regarded as of
tetany, that “little tetanus” in which the spasms always proceed from
the periphery toward the centre; are especially likely to affect the
forearms and the fingers, forming in their contractions the
obstetrical hand; are followed by periods of complete relaxation; can
be brought on by compression of the main artery or nerve of the limb,
or by light tapping of the affected area; may cause a rigid state of
the trunkal muscles or even well-marked opisthotonos; are associated
with impairment or paralysis of sensation; may last for a few minutes
or for hours; and sooner or later spontaneously cease, a fatal
termination of the affection being exceedingly rare.
Hysterical spasms may strongly simulate those of tetanus, and such
attacks have without doubt been wrongly diagnosticated, the cases
going to swell the number of those successfully treated by one remedy
or another. They ought, however, to be readily recognized if due
consideration be had of the age and character of the patients, the
history of the attack, and the order and nature of the symptoms
themselves, especially their frequent limitation to one member
(preferably a leg), the absence of consciousness during the attacks,
the long and uninterrupted rest at night, their more or less often and
prolonged complete intermissions.
Cerebro-spinal meningitis, because of the developed stiffness of the
neck and retraction of the head, the orthotonos, or even well-marked
opisthotonos, the epigastric pressure-pain, the occasional trismus,
and rigidity with reflex convulsive movements of the muscles of the
extremities, may, and doubtless has been, mistaken for tetanus; but
its generally epidemic prevalence, the headache, the cutaneous
hyperæsthesia, the temperature, and the other well-known symptoms of
the disease ought to suffice for its ready determination.
Strychnia-poisoning has many symptoms in common with tetanus, but
there is an absence of the wound which is generally associated with
the latter affection, a much more rapid development of severe
convulsions, and a quickly-appearing opisthotonos. The spasms from the
commencement affect the extremities, producing early contractions of
the muscles of the hands and feet, and only later those of the jaw.
Complete intermissions of greater or less length usually occur, and
either death or marked amelioration of pain and spasm follows in a
comparatively short time.
Hydrophobia, the dysphagic symptoms of which are like those at times
observed in tetanus, has its peculiar wound of origin and protracted
period of incubation, its absence of trismus or general tonic muscular
contractions, its usual dread of water and inability to swallow
fluids, its attendant restlessness, and its frequently-observed
delirium, the entire {553} aggregation of symptoms being
characteristic of itself and nothing else except the simulating
nervous affections occasionally developed in individuals bitten by
rabid or supposed rabid animals.
PROGNOSIS.—As declared by Hippocrates, “the spasm that comes on after
the receipt of a wound is a frequent cause of death.” Violent acute
cases, developing early, are excessively dangerous; and there is much
truth in Poland's declaration that “there is scarcely a
well-authenticated instance of recovery on record.” Taking all the
traumatic cases together as met with in military and civil hospitals,
the death-rate may safely be placed at not less than 80 per cent. Of
1332 cases reported from the wars of the last thirty years, and
occurring in six large hospitals during the last twenty years, 1060
proved fatal—_i.e._ 79.6 per cent.[10]
[Footnote 10: Crimean war, 23—21, 91 per cent.; Confederate army,
(Sorrel), 66—60, 91 per cent.; U. S. army, 505—451, 89.3 per cent.;
Italian war (Demme and Chenu), 176—162, 91 per cent.; Franco-German
war (Poncet), 316—181, 57.28 per cent. (omitting Richter's 224 cases
with only 107 deaths, the mortality of the remaining 92 cases (74) was
80 per cent.); St. Thomas's Hospital, 43—24, 55.8 per cent.; St.
George's Hospital, 30—21, 70 per cent.; St. Bartholomew's Hospital,
63—47, 74.6 per cent.; Guy's Hospital, 60—51, 85 per cent.;
Pennsylvania Hospital, 26—20, 76.9 per cent.; Boston City Hospital,
24—22, 91.6 per cent. The mortality-rate at Guy's (85 per cent.) is
almost the same as that given by Poland for the period from 1825 to
1858 (86.1 per cent.).]
As met with in private practice, under favorable hygienic
surroundings, a decidedly larger percentage of recoveries probably
takes place—how much larger cannot be even approximately determined,
since, as a rule, only those cases which get well are reported, but
few patients come under the care of any single observer, and the
chances of error in diagnosis are much greater than in a large general
hospital. The mortality rate of the idiopathic cases is very much
lower (not exceeding perhaps 25 or 30 per cent.), localized trismus
being “never mortal, though it may last for a number of weeks”
(Poncet). That recovery should take place much more frequently in
cases of this variety than in those associated with wounds might be
anticipated, since, as a rule, they are more chronic in their course;
the attacks are less frequent; if generalized, the spasms do not
involve all the muscles at once, but by progressive seizures and
relaxations; and they less often and less severely affect the muscles
of respiration. The earlier the disease shows itself after the receipt
of a wound (other things being equal), the stronger the likelihood of
a fatal termination; and, for obvious reasons, the more powerful, more
general, and more quickly repeated the spasms, the greater is the
danger. The larger part of the deaths occur within the first week, a
majority by the fifth day; all experience tends to show that there was
much truth in the Hippocratic observation, that “such persons as are
seized with tetanus die within four days, or if they pass these they
recover.” From the end of the first week on, the chances of recovery
rapidly increase day by day, and after the second week there is but
little danger of a fatal termination, though death may take place
(from exhaustion usually) after the lapse of several weeks, six or
more.[11] I have myself seen it occur on the thirty-seventh day.
[Footnote 11: Of the 358 cases reported in the _Medical and Surgical
History of the War of the Rebellion_, the duration of which was known,
64.8 per cent. died within five, and 83.5 per cent. within ten days.
Of 327 cases reported by Poland and Hulke, 56 per cent. died within
the earlier, and 83.5 per cent. the later, period. Of Richter's cases,
76.6 per cent. died within five days. Of 170 cases tabulated by
Yandell, 53 per cent. died within the first four days, and 77 per
cent. within nine days.]