Chapter M: M——, was a stout Irish woman about forty years of age. She had (5)

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_.

As there is here, apparently, recovery in 34.5 per cent. of the 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.

Ferrier distinguishes just adjacent to this centre the motor centres for the tongue and mouth and upper extremities, showing an anatomical association of the processes of articulate and written speech.

But purely motor impulses comprise only a portion of the phenomena of speech. The external world must be brought into relation with the mind, and this is done through the perceptions. We may say that perceptions are apprehended sensations, and this apprehension demands a localized field of cerebral activity, as well as the motor energies. It seems natural enough that experiment should have located (Ferrier) perceptive, visual, and acoustic centres in the posterior cortical areas and temporo-sphenoidal lobes—that the motor and perceptive areas should be contiguous and sharing a common blood-supply.

The perceptive visual centre is found to occupy the occipital lobes, while the acoustic centre occupies the whole length of the first temporo-sphenoidal convolution.

As motor impulses found a path to the motor ganglia, and finally to the cord, so the course of sensory perceptive impressions can be traced back through the posterior internal capsule and through the optic thalami to the sensory columns of the medulla and cord.

Intuitive and sense perception, even when reinforced with motor power, cannot result in articulation. The mechanism of speech requires a co-ordinating centre, and this basal phonic centre of Kussmaul is located in the medulla near the origin of the hypoglossal and facial nerves. From the medulla proceed the nerves supplying the machinery of {568} phonation, the superior laryngeal nerve to the mucous membrane of the larynx and to the crico-thyroid muscle, the most important muscle of phonation. The remaining laryngeal muscles are supplied by the recurrent laryngeal; the motor processes of articulation are guided by the hypoglossal, facial, and fibres of the glosso-pharyngeal.

The larynx is a reed, with the addition of numerous resonance-cavities producing abundant overtones. It may be considered as a box composed of two segments, the lower of which has vertical motion upon the joint at the posterior junction of the superior and inferior segments. By this motion the tongue of the reed (vocal cords, stretching antero-posteriorly from lower segment to junction with upper segment) is tightened or relaxed, the vibratory blast of air coming through the trachea from the lungs. The superior aperture of the tube is guarded by the epiglottis and false vocal cords. As auxiliaries are the pharyngeal, oral, and nasal cavities, with the associated bony cavities of the skull, the soft palate acting as a movable partition or switch, the hard palate as a sounding-board or resonance-surface. The reed is applicable to the production of musical sounds; the tongue, lips, and teeth are required for the checks in those sounds, constituting the consonants or division utterances.

The curious phenomenon of the falsetto voice is thought by Helmholtz to be produced by the attenuation of the true cords and the vibration of their thinned edges.

DEVELOPMENT OF LANGUAGE.—The study of language demonstrates its origin to have been largely in exclamations and imitative sounds, from which our vowels can easily have arisen. The growth of all synthetic language illustrates the aggregation of accessory sounds about the primitive root-sound, while the common tendency to the insertion of consonants shows their addition to the primitive vowels. That the long vowels should have undergone countless modifications from the physical peculiarities and environment of those speaking them is but natural, for the number of vowels remaining in actual use in any language is not large. Consonants serve to make more clear by their separation of vowel-sounds the meaning to be conveyed; their development resulted from vowel changes, and their number is small.

The written characters of language represent only the usage of the majority. Individual speech and pronunciation vary as greatly as do languages themselves, and it is evident that the speech of any individual is as truly peculiar as his physical conformation.

To recapitulate, we find ideas, the material of speech, formed in the cerebral cortex. Speech-volition becomes motor impulse at Broca's convolution; such impulse passes along the internal capsule to the corpus striatum, where it is co-ordinated probably in the formation of syllables, thence to the medulla, whence the mechanism of the larynx receives its co-ordinated stimulation.

Disorders of Speech.

The classification of the disorders of speech should depend on the anatomical site of the lesions by which they are occasioned. Broadly {569} speaking, speech disorders resolve themselves into those of the formative apparatus for ideas and symbols and those of the purely co-ordinating and conducting mechanism. Abbreviating the schedule of Potter, we may say that the disorders of speech may be included in three classes—alalia, or lack of speech; paralalia, defective speech, the stammering of most observers; and dyslalia, difficult speech or stuttering.

The anatomy of the blood-supply of the speech-centres affords some explanation of alalia. The Sylvian artery will be remembered as the feeder of the speech-centres—an artery often the source of hemorrhage, as Charcot suggests, from the angle at which it leaves the carotid. Ducrot explains the frequency of left-sided softening and hemorrhage from the manner of origin of the left carotid, its axis being more nearly that of the ascending aorta and furnishing a ready channel for cardiac clots. In regard to the relative frequency of peripheral and central hemorrhage, Andral and Durand-Fardel cite 119 cases, of which but 17 were in the anterior or posterior lobes. It is admitted that cerebral lesions are largely those of the circulatory system, and the fact that such lesions result in the suspension of the activity of restricted areas is due to the circumstance that the cerebral arteries are terminal vessels giving off no anastomosing branches and supplying restricted areas only. With blood-supply so arranged it is not difficult to understand how the different portions of the motor centres may be separately involved, and thus the motor functions of speech may become singly at fault.

Inability to remember words and inability to form the motor impulses necessary for speech or writing are the common forms of alalia or aphasia, the former being known as amnesic, the latter as ataxic, alalia. In addition, we may cite the failure of cerebral power occurring in general softening, in microcephalic brains, and the curious instances of voluntary silence from some strong belief or prejudice. Instances of the gradual resumption of cerebral function after its loss are not wanting; and, occurring where subsequent post-mortem examinations reveal a limited area of destruction of brain-tissue, they afford examples of the vicarious performance of cerebral functions by contiguous areas.

The phenomena of amnesic alalia are commonly seen in cases of recovery from cerebral hemorrhage, cerebral injury, and severe febrile affections. Numerous cases are recorded where the memory of things themselves remained, but the faculty of denoting them had been destroyed.

Kussmaul distinguishes here two conditions: 1st, where the word is entirely effaced from memory, 2d, where it still remains, but its association with that which it represents is suppressed. Cases of the second class are the most frequent, the fundamental part which the association of ideas plays in mental activity and the extent to which memory is dependent on association explaining this fact. A marked example of the failure of the denotative faculty lies in the cases of forgetfulness of one's own name, as described by Crichton in the case of an ambassador at the Russian court, who was obliged to say to his companion, when visitors asked his name, “For Heaven's sake, tell me what I call myself!” Piorry mentions the case of an aged priest who after right-sided paralysis lost entirely the use of substantives; wishing to ask for his hat, the word _hat_ failed him utterly, and he was obliged to express himself in the remaining parts of speech: “Give me that which I place upon the {570} ——;” but the word _head_, denoting the object most commonly in relation with the _hat_, was wanting also. When either hat or head was mentioned he spoke the word without difficulty.

Instances of failure in linguistic faculty are not uncommon. Witness a case, reported by Proust, of an Italian who after long residence in France, though understanding his native tongue, could speak only in French. Cases in which after acute disease one language is gone entirely while several others are retained are not wanting. A striking case of amnesic alalia was that of Lordat, a French physician, who thus described his malady: “I find myself deprived of the value of all words. If any words remain to me, they become useless, because I can no longer remember the manner in which I must co-ordinate them to express my thoughts. I am conscious that I recognize all ideas, but my memory does not suggest a word. In losing the memory of the meaning of spoken words I have lost that of their visible signs.”

Fortunately, these cases are among the more tractable of cerebral disorders. Bristowe has reported a case wherein elementary instruction in speech-formation was tried with marked success. The patient, aged thirty-six, after a violent cerebral disturbance without traumatism became paraplegic, speechless, and deaf. Gradual recovery ensued until, seven months after his first illness, he was admitted into St. Thomas's Hospital in the following condition: Numbness and paresis in left leg, less in left arm; special senses healthy; no incontinence; some pain about head and neck; complete loss of speech. It was found that the patient was very intelligent, wrote legibly, could make all kinds of voluntary movements with lips, tongue, and teeth, and was capable of vocal intonation; articulation alone was lacking.

The law of the evolution of language designates as primitive forms of word-signs those words affirming qualities, while those denoting relative positions are of secondary formation (Whitney.) Remembering, also, the fact that amnesia in general “is a regression from the new to the old, from the complex to the simple, from the voluntary to the automatic, from the least organized to the best organized,”[1] we are able to understand the cause of amnesic alalia, and also the steps of the process of recovery, in which the inverse order is observed.

[Footnote 1: Ribot, _Diseases of Memory_.]

Amnesic alalia can hardly be regarded as susceptible of treatment other than as a general neurasthenia. Though we may develop memory by cultivating the association of ideas and by repetition, yet, regarding it as a general function of the nervous system, it is evident that recovery from its disorders is conditioned by the general vigor of the nervous centres. A partial recovery usually occurs in such cases; complete recovery is more infrequent.

Ataxic alalia, the failure of the motor powers of speech, occurs in all forms of general paralysis, most typically in bulbar paralysis. This disease is fully described in the standard works on neurology. Ataxic alalia will also occur in disseminated sclerosis, posterior spinal sclerosis, dementia paralytica, and cretinism. It forms in general disorders an instructive symptom, and is to be distinguished by a tremulous utterance and by facial spasm from the hesitation of the stammerer and from the convulsive utterance of the stutterer.

{571} Paralalia embraces all abnormalities of speech, from trivial mannerisms to difficulties in the utterance of certain letters, including those painful defects which depend upon physical malformations.

The free discussion of paralalia would cover the domain of elocution; the physician is called upon to advise in those cases only where either a physical malformation is evident or the difficulty experienced by the patient in enunciating certain letters has led to a suspicion of the existence of malformation. The former cases lie in the province of the surgeon; the latter come within the scope of those elocutionists, speech-trainers, and instructors who hope to cure stammering and stuttering.

Discrimination between stammering and stuttering will give the physician a basis for judgment from which he can reasonably offer encouragement in many cases and avoid the creation of false hopes in others. As a cardinal point of difference, it will be remarked that in the case of the stutterer the muscles of phonation are thrown into a state of spasm when speech is attempted, while in the stammerer their movements are merely lacking in proper co-ordination. It may also be observed that the respiration of the stammerer is marked by irregular contractions of the diaphragm, which render the expiratory blast of air irregular in its delivery. In the stutterer the spasm is pronouncedly laryngeal and facial. The nervous embarrassment of the stutterer is proverbial, and is increased by excitement, while a moderate degree of excitement, stimulating respiration, greatly improves the speech of the stammerer.

Whispering, a difficult respiratory act, exaggerates the stammerer's fault, but the spasm of the stutterer is often relaxed by the diminished pressure of whispered breath.

As articulation is effected by the larynx and the oral organs, the stutterer makes his spasmodic articulation particularly noticeable, while the stammerer finds little difficulty in the utterance of words. _R_, _L_, _S_, and other letters whose enunciation demands the continued expiratory blast, are imperfectly uttered by the stammerer, while these letters when joined to a long vowel-sound occasion little or no difficulty for the stutterer.

TREATMENT.—It follows that if stammering is recognized as inco-ordinate enunciation, owing largely to irregular action of the diaphragm, any training of the respiratory muscles which will ensure a regular delivery of the expiratory air will improve this defect. It follows, then, that the treatment of stammering resolves itself into careful attention to general hygiene, associated with such persistent respiratory and vocal gymnastics as shall effectually develop regularity, depth, and co-ordination of action on the part of all the muscles concerned in the act of respiration. Drugs will be of service only as aids to the correction of errors in the essential physiological functions. In the child the powers of imitation may be enlisted to effect a cure, and the familiar fact that the habits of childhood are easily formed would indicate this as the best time for treatment.

Childhood once passed, however, the steadiness of purpose of the adult is requisite to break up a confirmed habit, and active treatment should be deferred until after adolescence. Most important in all cases are judicious moral influences exerted by those about the patient, the ridicule so often visited upon the unfortunate stammerer being most harmful in its consequences. The many tricks and devices so often employed in these {572} cases are of use simply by varying the monotony of vocal drill; they may be employed or abandoned as the judgment of the physician may dictate.

Regarding the prognosis in these cases, it follows that with a fairly developed and healthful nervous system, reinforced by proper mental and physical hygiene, the stammerer's case is far from hopeless in the hands of a patient and intelligent physician.

An unfavorable prognosis would be demanded by hereditary defects and vices of the nervous system, by the lack of general nervous vitality, by enfeeblement of the will and the mental tone of the individual, by advanced age, and by irremediable hygienic conditions. Under favorable conditions recovery should be the rule.

DYSLALIA OR STUTTERING.—Recalling to mind the points of difference between stuttering and stammering, it becomes evident that while the prospect of success in the treatment of the stammerer is often favorable, the case of the stutterer presents such difficulties as render it too frequently hopeless.

We may liken the confirmed stutterer to those rare cases of chorea which defy treatment, and to those cases of hereditary deterioration of the nervous system where the most patient and painstaking care fails to overcome the defect. The laryngeal and facial spasms depend upon no malformation for their exciting cause; hence surgery fails to remedy the defect. Drugs which are given with hope of invigorating the nervous system have only a general tonic influence, while the motor depressants and antispasmodics find but partial success. We must again rely upon hygiene, and also upon those aids to enunciation which come from rhythmical associated movements, such as stamping with the foot, beating time with the hand, the employment of a sing-song tone, or other modes of specially rhythmic enunciation. The sing-song mode of utterance is a familiar resource with parents in attempting to aid a stuttering child, and the measured forms of articulation offer the only vocal drill that possesses any permanent value. It is especially essential in the stutterer's case that the patient be protected from ridicule and from all disturbing emotions: the burden of difficult speech is sufficient to greatly depress the nervous system without the added suffering of emotional distress. It is evident that childhood, characterized as it is by especial instability of the nervous system, is the period when we can hope for the best results from care and training; the long-formed habits of the adult are rarely broken.

We have thus traced the disorders of speech to their origin as symptoms of grave central lesions of the nervous system, as results of heredity or of a general neurasthenic condition; very rarely are they dependent upon malformations of the organs of speech.

The treatment of such malformations, when they occur, is largely unsatisfactory and is seldom curative.

The thorough treatment of those speech disorders that are not susceptible of surgical aid would embrace such mental and physical hygiene and training as should ensure the formation of a thoroughly conceived vocabulary and its co-ordinated expression by words either spoken or written. The study of expression in its highest forms would necessarily conduct the investigator far into the realm of the plastic, harmonic, and literary arts.

{573}

ALCOHOLISM.

BY JAMES C. WILSON, M.D.

DEFINITION.—Alcoholism is the term used to designate collectively the morbid phenomena caused by the abuse of alcohol.

SYNONYMS.—Alcoholismus, Ebrietas, Ebriositas, Temulentia, Drunkenness, Delirium potatorium, Mania potatorium, Delirium tremens, Chronic alcoholic intoxication, Dipsomania; _Ger._ Trunkenheit, Trunksucht; _Fr._ Ivresse, Ivrognerie.