TETANUS.*

BY JAMES S. RAWLINS, M.D.

DANCYVILLE, TENN.

I AM induced to report this case for several reasons. First, on account of its prolonged and aggravated character and happy recovery. Second, this disease has rarely been before this association since the discovery of its specific bacillus by Nicolaier and the introduction of the antitoxin treatment, and a discussion of the merits of this as well as other methods of treatment is desirable.

The patient, Anderson Wrenshaw, white, male, aged 10 years, while at play stuck a stick in the dorsum of his foot near the heel. The stick, which was about an inch long, pointed, and as large as an ordinary lead pencil, broke off and was retained in the wound.

On June 27 he applied for treatment, and was found with the usual symptoms of tetanus-stiffness of neck and back, with sardonic features. Upon questioning his father, a highly intelligent clergyman, I found that there had been some stiffness about his neck and back for twenty-four hours or longer, which was regarded as an approaching attack of mumps, other members of his family having recently had the disease, which would make the period of incubation since the reception of wound about six days. With the assistance of Dr. R. B. Davis he was completely anesthetized and a deep incision made through the old wound, which had closed, and the fragment of a retained piece of wood about half an inch long removed. The wound was cleansed, swabbed out with carbolic acid, and dressed with an ethereal solution of iodoform. The patient was ordered to a darkened and absolutely quiet room, and was given to open his bowels 5 grains of calomel and bi-carb. soda each, to be followed by a saline cathartic, or an enema if it did not act in a reasonable time. There was also ordered 8 grains of hydrate of chloral and 16 grains of bromid of potassium every three hours until quiet or asleep.

On the following morning, June 28, upon visiting him we found that he had passed a restless night, with tonic spasm of muscles of trunk and neck, and was threatened upon the least noise or excitement with general convulsions. Pulse 120, temperature 1011°F.

*Read before Tri-State Med. Assn. (Miss. Ark. & Tenn.) Memphis, Nov. 20, 1901

The wound was again dressed under chloroform, swabbing out the cavity and dressing with iodoform gauze. Treatment continued as before, increasing the chloral hydrate to 10 grs. and the bromid of potassium to 20 grains every three hours, with directions to push the chloral and bromid to hypnotism if necessary to prevent general convulsions, also to have all the concentrated nourishment he could possibly take.

Upon the third day, finding the chloral and bromid insufficient to prevent the spasmodic waves which frequently passed over the patient's body, chloroform by inhalation was used whenever a spasm threatened. While the patient was constantly in a state of opisthotonos, and frequently in an arch resting upon his occiput and heels, he also was frequently subjected to violent clonic spasmodic waves which could be only kept in abeyance or lightened by the inhalation of chloroform, which was kept by his bed and ready for inhalation. at all times.

Fourth day, treatment continued as before. Commenced rectal alimentation, on account of inability to take food by the mouth.

Fifth day, nervousness had increased so that the least noise, light or touch would bring on convulsions, axillary temperature 1023°F., pulse 130 to 140, and at times imperceptible.

Sixth day, the patient was showing so much prostration, with pulse so feeble, it was decided to discontinue the chloral and bromid and substitute morphin and atropia, which was given, gr. morphin, atropia, to be repeated every three hours until it produced some narcotism. Under its use the pulse improved, but the atropia producing some hallucinations, had to be given less frequently-every six hours.

On the ninth day of treatment, having procured some antitetanic serum, we used the first dose of 10 cubic centimeters, which was repeated every six hours, until four doses had been given, at the same time continuing the previous treatment.

I will not pursue the treatment of this case from day to day, but the same course of treatment was kept up, chloroform as needed, morphin and atropia as much as could be safely given, persistent alimentation, and catheterism as needed, as he had been unable to void his urine since we commenced the use of morphin.

On the twelfth night of his attack he had a very violent convulsion involving his diaphragm, and but for the presence of Dr. Davis, who resorted to artificial respiration, would, no doubt, have died.

From this time his improvement commenced, which was very gradual, almost imperceptible, chloroform having to be used frequently to prevent spasms, until the sixteenth day of attack. The morphin and atropia was suspended, by gradual reduction, on the twenty-fourth day of attack. He was able to stand on his feet on the thirtieth day, but his muscles, especially those of his legs, were easily startled, and subjected to jerks and spasms for some time after.

For some time he had a bed sore on the back of his head, the result of continued opisthotonos.

The average amount of morphin required, after getting under its influence, was 13 gr. per day. The average amount of chloroform per day, judiciously used, was about 2 oz.

In the treatment of this case we endeavored to carry out the following principles:

1. Isolate the patient.

2. Cleanse the area of infection to prevent the continued absorption of the alkaloidal poisons.

3. Antagonize the poisons that have already been absorbed by the use of injections of antitoxin.

4. Combat the spasms by chloral, morphin and chloroform. 5. Maintain the strength of the patient, and attend to the patient's bladder and bowels.

The value of antitetanic serum not being sufficiently affirmed, as the antitoxin treatment has been in diphtheria, I did not feel disposed to use it, except as a last resort, or as an auxiliary treatment, and did not commence its use as soon as I would again under similar circumstances. In this case, it nothing more can be said for it, it at least was harmless, not even producing an induration at the points of insertion, and while given at a period when the poison, no doubt, had spent itself in the production of organic lesions, still, the father of the patient, an eminent clergyman, who has had a great deal of sick-room experience, is very positive that after the second dose of serum he could perceive a decided improvement, or giving way, as he terms it, of some of the most violent symp

toms.

In the treatment of another case, in addition to the course pursued, recognizing that the disease in its incipiency is a local one, and that the germs do not sporulate even at a moderately

low temperature - 55°F.- I would, in addition to cleansing and wound disinfection, attempt their destruction by injections into the wound and surrounding tissues of a solution of carbolic acid or bichlorid of mercury, and at the same time, during the early stage, keep applied to the wound a refrigerant mixture, in order to reduce the local temperature below the degree of segmentation, thereby preventing their growth and the development of their toxins.

As to the use of antispasmodics, I think that chloral and bromid of potassium should be confined to the first stage or few days of the disease. In addition to the difficulty of their administration, due to bulk and bad taste, they are too depressing to the circulation to be continued, in the large doses required, beyond a few days. Of this class, chloroform I consider the remedy par excellence, to be used by inhalation, at all stages, without fear or reserve. It has no bad after effects, and improves the heart's action by relaxing muscular spasm and opening up the arterial conduits. The patient, who is generally sensible, turns to it as his only hope from impending death. But anticipate the spasm, if possible, as respiration is too shallow after the muscles become fixed in spasms for the remedy to do any good.

One more point and I have finished-the nomenclature of this disease. Some even recent authors still use the terms “traumatic" and "idiopathic tetanus," and ascribe the idiopathic type to exposure to cold, sleeping on damp ground, excessive fatigue, etc. All of these so-called idiopathic cases are no doubt due to some hidden or overlooked traumatic infection through which the germ has gained access to the system, but has been successfully resisted by the phagocytes, until some cause, such as cold or excessive fatigue, depresses the vitality of the individual, lowering the resisting power of the body cells, when the bacteria, or their tox-albumins, gain the ascendancy and produce the symptoms known as tetanus. This also accounts for the milder course of this so-called idiopathic type. It is known of this disease that the longer the stage of incubation, the milder the attack. A large number of these cases may have successfully resisted the infection for quite a while, until it became so attenuated as to produce only

a mild attack, when the depressing causes placed it in the

ascendency.

In conclusion, I wish to state that I was very ably assisted in the treatment of this case by my friend, Dr. R. B. Davis, of Dancyville, and to whose watchful care in carrying out the details of treatment the recovery of the patient is to a large extent due. The immense amount of attention required can hardly be estimated, when every hypodermic injection, catheterism and nutrient enema had to be given under chloroforin for several weeks. I am also under obligations to my friends, Dr. Powell, of Eurekaton, and Dr. Ware, of Stanton, for a visit each and valuable suggestions.

Discussion.

Dr. John B. Murphy, Chicago: I have nothing special to offer on the subject of tetanus, but the more I see of it the more I dread it. Twenty years ago, when tetanus was treated by nerve stretching, I thought I could do something for it and had several recover, but later developments showed that this method of treatment was as fallacious as any other. We have two forms of tetanusacute and chronic. In the chronic form there is a long period of incubation, with mild onsets and long periods between the opisthotonus; while in the acute form, where the incubation period is short and it comes on very actively, the chances of recovery are hopeless. Chloroform is certainly the treatment for the convulsions. When we use tetanic serum as a prophylactic, or in treatment of the early symptoms, we may hope to have some good results.

Dr. W. A. Evans, Chicago: I can only add some points made in observation of the use of serum in the early stages of tetanus. It is then only that we can hope for benefit from its use. Tetanus may arise from nail wounds made around stables, but many of those who receive such wounds never develop the disease. I agree with Dr. Rawlins in the use of chloroform until the convulsions have been overcome, and also that the trouble is a local one due to a specific organism.

Dr. F. D. Smythe, Memphis: I have had two cases of tetanus under my care in the last two months. Both cases appeared in men of middle age, and both had compound fracture at the ankle. The wounds were covered with dirt. In the first case the wound was thoroughly cleansed, but tetanus was contracted and he died on the eighth day. In the second case, amputation was advised but declined. Later he developed tetanus and died.

Dr. W. D. Haggard, Nashville: I can add nothing to what has already been said on this subject. I have had some experience with this disease and its serum treatment, but I lost both cases that I treated.

case:

Dr. W. C. Dunaway, Little Rock, Ark.: One year ago I had the following A boy twelve years of age stuck a nail in his left heel; his mother washed his heel off with soap and water and a little turpentine. Later the place festered and she picked it with a pin. The wound seemed to heal up. Three weeks