Chapter M: M——, was a stout Irish woman about forty years of age. She had (4)

IV. The antagonistic muscles to those affected by cramp are made to hold the instrument, while the cramped muscles are left entirely free.

{542} But one instrument acts in this manner—viz. the bracelet invented by Von Nussbaum,[129] which consists of an oval band of hard rubber to which the pen-holder is attached. The bracelet is held by placing the thumb and the first three fingers within it and strongly extending them.

[Footnote 129: _Aerztliches Intelligenzblatt_, Munich, 1883, No. 39.]

The inventor claims great success by its use alone, as the weakened muscles are exercised and strengthened and the cramped muscles given absolute rest.

Résumé of Treatment.—In the complicated cases of copodyscinesia rest of the affected parts, as far as the disabling occupation is concerned, must be insisted upon: this should be conjoined with the use of the galvanic descending stabile current, combined with rhythmical exercise of the affected muscles and of their antagonists, and massage. Where there is evidence of a peripheral local congestion or inflammation, this must be attended to; for instance, if there is congestion of the nerves, or neuritis, flying blisters or the actual cautery should be applied over the painful spots, followed by the galvanic current. Where there is paralysis of one or more muscles, with evidence of interference of nerve-supply, the faradic current may be used with advantage.

Evidences of constitutional disease should lead to the employment of the treatment suitable for those affections.

RÉSUMÉ OF 43 CASES OF TELEGRAPHERS' CRAMP.

Age at time of onset:
Under 20 years . . . . . . . . . . . . . . . . . . 7
Between 20 and 30 . . . . . . . . . . . . . . . . 25
" 30 and 40 . . . . . . . . . . . . . . . . 7
Doubtful . . . . . . . . . . . . . . . . . . . . . 4--43

Average age . . . . . . . . . . . . . . . . . 23.94 years.
" " of males . . . . . . . . . . . . . 24.22 "
" " of females . . . . . . . . . . . . 20.66 "

Average length of time before the disease appeared after the
commencement of telegraphing was—
In males . . . . . . . . . . . . . . . . . . 7.27 years.
" females . . . . . . . . . . . . . . . . . 4 "
The shortest period being . . . . . . . . . 6 months.
The longest " " . . . . . . . . . 20 years.

Left arm implicated in . . . . . . . . . . . . . . . 21
(Not counting case with amputation of right arm) . . 1
Never used left arm . . . . . . . . . . . . . . . . 8
Left arm not affected, although used . . . . . . . . 12
Doubtful . . . . . . . . . . . . . . . . . . . . . . 1--43

Percentage with left arm implicated . . . . . . . . 63.63

No. of cases with difficulty in telegraphing only . 9
" " " " writing " . 0
" " " " telegraphing most . 22
" " " " writing " . 11
" " " " both alike . . . . . 1--43

Use of tobacco or alcohol:
No effect in . . . . . . . . . 14
Bad " " . . . . . . . . . 16
Good " (in moderation) " . . . . . . . . . 3
Don't use either . . . . . . . . . . . . . . . . 10--43 {543}

Flushings in arm or face during work in . . . . . . 22
Brittleness of nails " . . . . . . 5
Emotional factor present " . . . . . . 29
Sympathetic movements in other parts " . . . . . . 9
Pain in back during work " . . . . . . 18
Trouble in performance of other acts " . . . . . . 19
Pain on pressure over nerve or muscle " . . . . . . 13

Cramp of flexor group of muscles:
In writing only . . . . . . . . . . . . . . . . 0
" " most . . . . . . . . . . . . . . . . 3
" telegraphing only . . . . . . . . . . . . . 1
" " most . . . . . . . . . . . . . 5-- 9
Cramp of extensor group of muscles:
In writing only . . . . . . . . . . . . . . . . 0
" " most . . . . . . . . . . . . . . . . 0
" telegraphing only . . . . . . . . . . . . . 4
" " most . . . . . . . . . . . . . 7--11
Doubtful as to character of cramp . . . . . . . . . . 11
No cramp . . . . . . . . . . . . . . . . . . . . . . 12--43

Manner of telegraphing:
Arm resting on table . . . . . . . . . . . . . . . 22
" raised from " . . . . . . . . . . . . . . . 12
Alternating one with the other . . . . . . . . . . 7
Doubtful . . . . . . . . . . . . . . . . . . . . . 2--43

Manner of writing:
Arm movement . . . . . . . . . . . . . . . . . . . 13
Finger movement . . . . . . . . . . . . . . . . . . 6
Combination of the two . . . . . . . . . . . . . . 24--43

{544}

TETANUS.

BY P. S. CONNER, M.D.

Tetanus (_τεινω_, to stretch) is a morbid condition characterized by tonic contraction of the voluntary muscles, local or general, with clonic exacerbations, occurring usually in connection with a wound. Cases of it may be classified according to cause (traumatic or idiopathic); to age (of the new-born and of those older); to severity (grave and mild); or to course (acute and chronic), this latter classification being the one of greatest value.

Though known from the earliest times, it is in the civil practice of temperate regions of comparatively rare occurrence, and even in military surgery has in recent periods only exceptionally attacked any considerable proportion of the wounded.

Occurring in individuals of all ages, the great majority of the subjects of it are children and young adults. Women seem to be decidedly less liable to it than men. That this is due to sexual peculiarity may well be doubted, since the traumatic cases are by far the most numerous, and females are much less often wounded than males. The traumatisms of childbed are occasionally followed by it (puerperal tetanus).

That race has a predisposing influence would appear to be well established; the darker the color, the greater the proportion of tetanics. Negroes are especially likely to be attacked with either the traumatic or idiopathic form.

Atmospheric and climatic conditions, beyond question, act powerfully in, if not producing at least favoring, the development of tetanus. Places and seasons in which there is great difference between the midday and the midnight temperature, the winds are strong, and the air is moist, are those in which the disease is most prevalent; and it is because of these conditions that the late spring and early autumn are the periods of the year when cases are most often seen.[1]

[Footnote 1: In his account of the Austrian campaign of 1809, Larrey wrote: “The wounded who were most exposed to the cold, damp air of the chilly spring nights, after having been subjected to the quite considerable heat of the day, were almost all attacked with tetanus, which prevailed only at the time when the Reaumur thermometer varied almost constantly between the day and the night by the half of its rise and fall; so that we would have it in the day at 19°, 20°, 21°, and 23° above zero (75°-84° F.), while the mercury would fall to 13°, 12°, 10°, 9°, and 8° during the night (50°-61° F.). I had noticed the same thing in Egypt.”]

Cold has, from the time of Hippocrates, been regarded as a great predisposing if not exciting cause, and the non-traumatic cases have been classed together as those a frigore. It is not, however, the exposure to simply a low temperature that is followed by the disease, but to cold combined with dampness, and quickly succeeding to a temperature decidedly {545} higher, as in the cool nights coming on after hot days in tropical regions, or in the spring and fall seasons of temperate latitudes, or in the cold air blowing over or cold water dashed upon a wound or the heated skin. That such cold, thus operating, does most usually precede the attack of tetanus is unquestionable; and it has by many been held that without it no traumatism will be followed by the disease. Observers generally are agreed, with Sir Thomas Watson, that “there is good reason for thinking that in many instances one of these causes (wound and cold) alone would fail to produce it, while both together call it forth.”

In the low lands of hot countries (as the East and West Indies) the disease is very frequently met with, at times prevailing almost epidemically; and, on the other hand, it is rare in dry elevated regions and in high northern latitudes, as in Russia, where during a long military and civil experience Pirogoff met with but eight cases. Trismus nascentium would seem to be an exception to the general rule of the non-prevalence of tetanus in places far north, since, _e.g._, it has been at different periods very common in the Hebrides and the small islands off the southern coast of Iceland. But these localities, from their peculiar position, are not extremely cold, and their climate is damp and variable; so that, even if the lockjaw of infants be accepted as a variety of true tetanus, the geographical exception indicated is but an apparent one.

Traumatic cases are greatly more numerous than idiopathic, and no class of wounds is free from the possibility of the supervention of tetanus. Incised wounds are much less likely to be thus complicated than either of the other varieties, though operation-wounds of all sorts, minor and major, have been followed by this affection. So frequently has it been associated with comparatively trivial injuries that it has become a common belief that the slighter the traumatism the greater the danger of tetanus. That this is not true the records of military surgery abundantly show. Wounds of the lower extremity are much graver in this respect than those of the upper. Injuries of the hand and feet, especially roughly punctured wounds of the palmar and plantar fasciæ (as, _e.g._, those made by rusty nails), have long been regarded as peculiarly liable to develop the disease, and accidents of this nature always give rise to the fear of lockjaw. Though there can be no question but that more than one-half of the cases of tetanus in civil life are associated with wounds of these localities, yet the number of such injuries is so much greater than of those of other parts of the body that the special liability of the subjects of them to become tetanic may well be questioned. In this connection it is a significant fact that during our late war of perhaps 12,000 or 13,000 wounds of the hand, only 37 were followed by tetanus, and of 16,000 of the foot, but 57. A few years ago numerous cases of tetanus were observed in our larger cities complicating hand-wounds produced by the toy pistol—injuries that were often associated with considerable laceration of the soft parts, and generally with lodgment of the wad.

Not even the complete cicatrization of a wound altogether protects against the occurrence of the disease, the exciting cause of which, under such circumstances, is probably to be found in retained foreign bodies or pent-up fluids.

ETIOLOGY.—Almost universally regarded as an affection of the central nervous system, inducing a heightened state of the reflex irritability, {546} though some have maintained that the reflex excitability of the medulla and the cord is actually lessened, how such affection is produced is unknown; and it is an unsettled question whether it is through the medium of the nerves or the vessels, whether by ascending inflammation, by reflected irritation, or by the presence of a septic element or a special micro-organism in the blood.

That the disease is due to ascending neuritis finds support in the congested and inflamed state of the nerves leading up from the place of injury (affecting them in whole or in part, it may be in but a few of their fibres), and in the inflammatory changes discoverable in the cord and its vessels. But time and again thorough and careful investigation by experienced observers has altogether failed to detect any alterations in the nerves or pathological changes in the cord, other than those that might properly be attributed to the spasms, the temperature, or the drugs administered. The symptoms of acute neuritis and myelitis (pain, paralyses, and later trophic changes) are not those which are present in cases of tetanus. The evidences of inflammation of the cord are most apparent, not in that portion of it into which the nerves from the wounded part enter, but, as shown by Michaud, so far as the cellular changes in the gray matter are concerned, always in the lumbar region, no matter where the wound may be located.

The much more generally accepted theory of reflex neurosis is based upon the association of the disease with “all forms of nerve-irritation, mechanical, thermal, chemical, and pathological;” upon the direct relation existing between the likelihood of its occurrence and the degree of sensibility of the wounded nerve;[2] in the, at times, very short interval between the receipt of the injury and the commencement of the tetanic symptoms; in the local spasms unquestionably developed by nerve-pressure and injury; in the primary affection of muscles at a distance from the damaged part; in the already-referred-to absence of the structural lesions of inflammation; and in the relief at times afforded by the removal of irritating foreign bodies, the temporary cutting off of the nerve-connection with the central organs, or the amputation of the injured limb. But that something more than irritation of peripheral nerves is necessary to the production of tetanus would seem to be proved by the frequency of such irritation and the rarity of the disease; by the not infrequent prolonged yet harmless lodgment of foreign bodies, even sharp and angular ones, against or in nerves of high sensibility;[3] by the primary affection of the muscles about the jaws, and not those in the neighborhood of the wound; by the almost universal failure to produce the affection experimentally, either by mechanical injuries or by electrical excitations; by certain well-attested instances of its repeated outbreak in connection with a definite locality, a single ship of a squadron, a particular ward in a hospital, or even bed in a ward; by the usual absence of that pain which is the ordinary effect of nerve-irritation; and by the small measure of success which has attended operations, even when early performed, {547} permitting the taking away of foreign bodies pressing upon or resting in a nerve, interrupting the connection with the cord, or altogether removing the wound and its surroundings. Even in the idiopathic cases—many of which, it would at first sight appear, can be due only to reflected irritation—another explanation of the mode of their production may, as we will see, be offered.

[Footnote 2: According to Gubler, the danger is greatest in wounds of parts containing numerous Pacinian corpuscles.]

[Footnote 3: Heller has reported a case in which a piece of lead was lodged in the sheath of the sciatic nerve. Though chronic neuritis resulted, the wound healed perfectly. Two years later, after exposure while drilling, the man was seized with tetanus and died of it.]

The so-called humoral theory would find the exciting cause of the 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.]

{554} 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.[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.