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.[12] Though, 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 100-2/5° 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.
[Footnote 12: Few 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.
{555} 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,[13] the 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.[14] The 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, water {556} or 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.
[Footnote 13: In a case of Lisfranc's, in twenty-six days venesection
was made nineteen times, and seven hundred and seventy-two leeches
were applied.]
[Footnote 14: An 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 (6/10 gr.) 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.[15] In 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, {557} 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.
[Footnote 15: Of 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 from 1/6 to 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),[16] according 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.
[Footnote 16: E. 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 substance {558} of 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,[17] since 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.
[Footnote 17: Beck 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 10 {559} cases 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.”[18] Of Yandell's 17 cases, 60 per cent.
recovered.
[Footnote 18: _Medical and Surgical History of the War of the
Rebellion_.