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.]
{560} 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,[19] and 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.
[Footnote 19: Of 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 the {561} larger 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.”
[Footnote 20: If 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, {562}
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).
Puerperal Tetanus.
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.
Its TREATMENT is 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
thrombosis[21] will, almost of necessity, render any medication of no
value.
[Footnote 21: Such 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 the PROGNOSIS is exceedingly grave. The {563}
mortality-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]
[Footnote 22: As 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.]
Tetanus Neonatorum.
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 races[23] and 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.
[Footnote 23: Wallace, 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 inflammations[24] and 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.
[Footnote 24: Mildner 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).
{564} 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]
[Footnote 25: H. 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]
[Footnote 26: Parrot 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, the PROGNOSIS is 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.[27] It has been very exceptional to have 20 per cent.[28] of
{565} recoveries, or even 15;[29] and the non-fatal cases have almost
invariably been those in which the disease appeared late and in mild
form.
[Footnote 27: 80 per cent. of the cases collected by Hartigan
(207—165).]
[Footnote 28: 8 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.]
[Footnote 29: 5 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 from 1/12
to 1/6 gr. 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,[30] and
(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.
[Footnote 30: Monti, 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 quiet[31] the child; to thoroughly
airing,[32] warming, and disinfecting the lying-in room; and to
overcoming, as far as may be possible, the evil influences of
unfavorable atmospheric and climatic conditions.
[Footnote 31: In 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).]
[Footnote 32: By 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.]
{566}
DISORDERS OF SPEECH.
BY EDWARD P. DAVIS, A.M., M.D.
Development of Speech.
The study of speech, a complex function, enlisting at once the
activities of mind and body, invites the physician to enter alike the
domains of the psychologist and physiologist.
Distinguishing man from beast, articulate expression has its
foundation in purely mental phenomena; its successful accomplishment
requires the reflex mechanism common to man and beast.
Let us consider as concisely as possible the physiology of speech.
DEVELOPMENT OF SPEECH IN THE INDIVIDUAL.—The earliest observation has
noted in the common name of the new-born child its speechless
condition; it is the infant, or not-speaking being. Born with a
nervous system in a highly unstable condition, the babe is a most
favorable recipient of the many impressions which stream upon it from
all sides. With sight and hearing undeveloped, the field of early
infantile impressions is limited to hunger, need of sleep, and
cutaneous impressions. Speech under such conditions is inarticulate,
an animal cry, unconscious and without intelligence. But with the
growth of the cerebrum the child's environment suggests to the
embryonic intelligence its primal impression. The parental relation is
dimly apprehended, and designations of the father and mother are
uttered in scarcely articulate sounds.
Sight and hearing open extensive fields of sensation, and with their
development begin the primal, physical impressions from which proceed
the emotions. The acoustic and optic centres of perception become
established, and the mental formation of symbols and signs, an
imitative process, marks the stage of childish cerebration, beyond
which the savage often does not proceed. The symbolic function is the
basis of language and of pictorial representation; as man requires the
trade medium of the symbol for the interchange of his ideas, so his
legal tender appears with the first emergence of mental enterprise.
The hieroglyphic and the onomatopoetic word are as old as humanity.
The co-ordinating mechanism of speech is of equal development. With
the growth of the child the varied impressions of education, of
surroundings, of heredity, all are influencing speech. With mental
growth, stimulated by these numerous impressions, comes the gradual
mental habit of forming ideas after certain models—of trading, so to
speak, in the coin of the country, of making and using a vocabulary.
Intuition, {567} induction, and deduction are established, the general
nervous function of memory develops, observations are made, and mind
and body, master and instrument, enter upon full activity.
PHYSIOLOGY OF NORMAL SPEECH IN THE ADULT.—Let us consider normal
speech in the adult. From a purely mental aspect speech is not
included in the nervous reflexes. The conception before the individual
may arise without sight or sound, it may be the object of the mental
processes only; but if it is to be communicated, or transferred from
the subjective to the objective, it calls into play the denotative
faculty or facultas signatrix.
As we are cognizant through the senses of phenomena only, so we
communicate only phenomena, or more particularly symbols; the spoken
or written word, the gesture, are necessary to make ideas tangible to
another mind. The symbolic faculty, then, is the mental faculty most
concerned in speech.
Cerebral localization has not included this faculty in its areas; it
is assigned to the anterior cortex, which as yet is the indiscriminate
site of the formation of ideas. The idea conceived, the symbol formed,
the motor area whose integrity is essential, is found in the region
commonly known as Broca's convolution, the posterior third of the left
third frontal convolution. This region is especially connected with
the corona radiata coming from the corpus striatum, with the corpus
striatum and the anterior portion of the internal capsule: like the
anterior, or motor, cornua of the spinal cord, it possesses giant, or
branching, nerve-cells; its anatomy would assign to it a motor
function. Its blood-supply is derived through the inferior frontal
branch of the Sylvian vessel, whose occlusion in a case cited by
Charcot was followed by complete aphasia.