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The fatality of traumatic tetanus quoted in textbooks gives 70 to 80 per cent. of deaths. About 10 to 15 per cent. recover without the use of the antitoxin. The disease is more prevalent in the hot climates than in the temperate. Wells has found that the curve of deaths takes its upward start in May, reaching its maximum in July, and thence declines towards October. This is accounted for by Fourth of July accidents.

Richter in a collection of 717 cases of tetanus caused by various injuries of war surgery, records 631 deaths or a mortality of 88 per cent., with 40 recoveries, equaling 12 per cent.; of these 40, 13 were of milder variety. Behring gives for tetanus a mortality of 80-90 per cent. The records of the Bürger Hospital at Cologne give for tetanus a mortality of 62.5 per cent. Garrigues gives for 57 cases of puerperal tetanus a mortality of 84-92 per cent. Gowers gives for traumatic tetanus a mortality of 90 per cent. Dean gives for all cases in various London hospitals for a period of 16 years a mortality of 80 per cent.

In 1894 a special committee, appointed by the British Medical Journal, came to the conclusion that acute tetanus is incurable and that, although anodynes and hypnotics sometimes afford alleviation, there is known no remedy for it. They also found that, between 1875 and 1892, there occurred in England and Wales, 2,969 deaths from traumatic tetanus and between 18811892, 568 deaths from so-called idiopathic tetanus.

Stanton reported that as a result of Fourth of July accidents, 422 cases of tetanus developed and of these only seven recovered, a mortality of 98 per cent. Moschcowitz has collected since the introduction of antitoxin in 338 cases, mortality 43.2 per cent.

It should be noticed that the diagnosis in some of these cases reported is questionable ; also, that a much larger proportion of the recoveries from tetanus is published than of the fatalities, so that the mortality percentage should be taken with much allowance. Statistics are as yet too meager to justify a final opinion as to the practical value of serum therapy in tetanus, but it appears to be somewhat useful.

Several diseases can be diagnosticated by making a bacteriological examination of the pus from abscesses. In others, it may reveal the cause and character of the pathological process. There are a few diseases the specific organism of which can be diagnosticated with great probability by the exclusive use of the microscope. They include the ray-fungus of actinomycosis, the bacillus tuberculosis, the gonococcus and the bacillus of tetanus.

PROPHYLAXIS AND TREATMENT OF TRAUMATIC TETANUS.(1) Thorough cleansing of any wounds, received in barnyards, gardens or other places where the bacilli are likely to be present,

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also Fourth of July wounds, by vigorous operative measures and the removal of any foreign matter. Free drainage of the wounds and immediate injection of 10 to 20 c.c. tetanus antitoxin into the nerve trunk coming from that part is advised; (2) as a prophylactic measure in Fourth of July cases, the enactment of laws by congress, state legislature and municipalities, prohibiting the sale and manufacture of dangerous toys. Recently, Dolley has succeeded in producing the characteristic symptoms of tetanus (convulsions) by inoculating wads from blank cartridge into rats, guinea pigs and rabbits. Several years ago, my colleague, Dr. Frederick C. Busch, succeeded in cultivating the tetanus bacillus from the wad of a blank cartridge which had produced the wound in a fatal case of tetanus. Inoculation of this culture into rabbits produced tetanus. This, of course, does not prove that the bacilli were originally in the wad; (3) the injection of tetanus antitoxin as soon as tetanic symptoms become manifest. “In the human being the disease has made such headway when discovered and so much poison has already been elaborated that therapeutic success after injection of antitoxin is uncertain.” Wells says, "a patient who has just developed symptoms of tetanus is not just developing the disease, but is dying of it;" (4) symptomatic. The use of bromides and other hypnotics. All means to lessen spasms, as plugging ears of patient, darkening the room, and the like. The nutrition of the patient should be kept up.

The morphine-eucain treatment, recommended by Murphy, consists in the aspiration of few cubic centimeters of cerebrospinal fluid by lumbar punctures, followed by injection of 3 to 4 c.c. of a solution containing B-eucain, gr. 1/2, morphine sulphatis, gr. 13, sodium chloride, grs. 3, aqua distillata, ozs. 312, into the spinal canal. Injections should be repeated until the desired effect is produced.

The Russians inject strained sterile, freshly prepared emulsions of brain tissue (following the principle of Wasserman). Brain tissue has a specific affinity for this toxin. About 30 c.c. of the emulsion in salt solution is injected into the tissues in the region of the wound.

The Italians use Baccelli's carbolic acid treatment which consists of injecting subcutaneously 1 per cent. carbolic acid solution in sufficient quantities to make 5 grains in 24 hours.

The Matthews or cell catharsis (diuresis) treatment: large amounts of a solution containing sodii chloridi, gr. 55.5, sodii sulphatis, gr. 155, sodii citratis, grs. 51, calcii chloridi, grs. 2, aquae, pints 2, are injected. This solution is injected intravenously, in quantities up to 500 c.c. at each infusion, which should

be repeated twice in 24 hours. This method is effective in experimental tetanus.

The best results in the use of antitoxin have been attained by those who injected it into the spinal canal. According to Rogers it is necessary to scratch the cord or the nerve filaments with the point of the needle so that the antitoxin reaches the cord. In any case, it is not a question of the amount of antitoxin used, but the effect.

If a prophylactic injection of antitoxin could be administered in every case in which the occurrence of tetanus seemed at all likely, the disease would probably seldom develop.

I am indebted to Dr. Julius Ullman for the histories of some of the cases given.

REFERENCES. Moschcowitz. Studies from the Department of Pathology of the College of Physicians

and Surgeons, Columbia University. Vol. VII. 1899-1900. Moore, V. A. The Pathology of Infectious Diseases of Animals. 1902. P. 185. Stanton. Journal of American Medical Association. August 29, 1903. Prophylaxis and Treatment of Fourth of July Tetanus. Journal of American Medi

cal Association. June 18, 1904. No. 1621. Murphy. Journal of American Medical Association. August 13, 1904. P. 461. Rogers. Annals of Surgery. September, 1904. Vol. XL. No. 3. Pp. 418-419. Dolley. Journal of the American Medical Association. February 11, 1905.

DISCUSSION

Dr. C. M. Brown: It appears to me when we get a suspicious wound, the easiest way to treat it is to chloroform the patient, thoroughly cleanse and cauterise the wound with carbolic acid, and lightly. pack the same with iodoform gauze. At this time, and while the patient is under the anesthetic, the antitetanic serum should be injected. Merck's dry serum dissolved in distilled water is the most convenient form to use and is quite harmless.

I have been very much interested in the Matthews treatment. Prof. Loeb experimented with it on animals under control. He injected three times the toxic dose of tetanus toxin, followed by saline solution, which produced free cell catharsis and diuresis, washing out the toxin from the cells. Results were good, but I believe the method has not, as yet, been tried upon man. I believe it is the consensus of opinion of the best authorities, that the antitoxin, to be of service late in the disease or after the symptoms begin to develop, must be injected directly in the subdural or subarachnoid spaces.

Dr. N. G. RUSSELL: A review of statistics shows that there was a considerable advance made in the care and prophylaxis of this disease before the advent of the antitoxin treatment. Prior to 1782, in one Dublin hospital there were about 2,900 deaths from tetanus to 17,000 births; while in Berlin, in 1870, the death rate from this disease in obstetric practice was only about 12 per 1,000. Since the use of antiseptics this has been reduced so that in 1900 there were only 2 per 1,000.

War statistics show a varying frequency but a steady lowering of the death rate, even before the general use of antiseptics. The disease is still too prevalent, as shown by the number of cases reported in New York city alone. In 1899, I think there were 73 deaths reported.

The mortality has been much lowered since the beginning of the use of antitoxin. Reports show a loss of only 30 or 40 per cent. of cases under antitoxin treatment, while the general average under other treatment is about 60 to 80 per cent.

The best results seem to come from large doses of antitoxin given early, before the beginning of symptoms. No other remedy seems to be of much use.

Could not a diagnosis be made early in a suspected case by making a culture from the wound, heating it to 80° C., and thus isolating the organism? Would - the application of ice to the wound inhibit growth? The disease will not develop in the frog unless the animal be kept at a temperature of 37° C.

Dr. F. W. Barrows: In my reading I could find nothing to add to this discussion. I remember watching with anxiety two cases; neither developed tetanus however. One case was a penetrating gunshot wound with fracture of two metacarpal bones, considerable laceration, and extremely dirty. This was a boy 12 years old. Treatment consisted of irrigation with 6 to 8 quarts of hot antiseptic solution, 1 to 6 or 8,000 sublimate, and then lysol. At close of second day a dry dressing was applied with powdered antitoxin. Prophylaxis is the most important phase of this question and we can reduce danger from tetanus while looking for legislation, by education. The fight against tuberculosis has much improved since this question of education began fifteen or twenty years ago. So it will be with toy pistols and the antiseptic treatment of wounds. Education by the doctor would reduce the danger materially. Legislation will come much sooner if preceded by a campaign of education. I am a strong believer in education as a prophylactic.

Dr. F. C. Busch: The tetanus toxin is supposed to reach the cord where it exercises its specific effect, by way of the motor nerve fiber. This may account for part of the period of incubation. It has been suggested and the suggestion has been acted upon, to resect the nerves leading to the point of inoculation; this, however, would hardly seem efficacious since the poison has already been absorbed by the blood and lymph and has entered other nerve fibers, whence it may be carried to the cord.

DR. JAMES E. King: My interest in tetanus centers around catgut as a source of infection. The possibility of its being an

infecting agent is evident. Prepared from the intestinal tract of the sheep the possibility of the spores and bacilli being incorporated in its substance, it only requires the absorption of the catgut in a wound to liberate the germ and spore under the best conditions to favor the development. Several years ago an epidemic of tetanus broke out in one of the western cities. It occurred only in operative cases and investigation discovered that it was in those cases where the catgut, prepared by a certain manufacturer, had been used. Dr. McKee having mentioned my connection with his case I feel at liberty to speak of it further. I had his case under my care during his absence; it developed the disease in a typical manner. The patient had done so nicely that for several days I had not seen her. A high pulse' and a tendency to a set jaw prompted the interne to ask me to see her. I learned that the day preceding she had complained of a “stiff neck," but the bed being near a window it was supposed to be a cold and no importance attached to it. The following day when I saw her the diagnosis was very simple. Antitoxin and carbolic acid were both used in generous dose, but without effect. I took this case to be one of catgut infection. Experimental laboratory work easily finds the agent that will kill spore and germ, but in preparing catgut the strength of the catgut must be maintained and the agents and chemicals that will destroy the germ will too often destroy the usefulness of the suture. I have not found any record of experiments with catgut to determine the possibility of destroying the tetanus spore and, personally, I feel that there is a wide and useful field for some one to work in.

One manufacturer comes nearer to a perfect sterilisation of catgut than any of the methods I know anything about. The catgut to be prepared is first sterilised to kill what germs there may be. The catgut then passes through a process by which any spores are supposed to be developed and then resterilised to destroy the bacilli so produced. It is the resistance of the spore that renders killing of the tetanus germ difficult. Of the simpler methods I should suspect that the iodine method gives the best chance of killing the tetanus germ in catgut.

DR. L. BRADLEY DORR: I have seen two cases of gunshot wound causing tetanus,-one on the hand and another being an abrasion on side of neck; the first, the seventh day, and the second the eighth. Antitoxin and carbolic acid were used, and both patients recovered.

A doctor from Colden telephoned me sometime ago that he had a case of tetanus infection from a vaccine wound. By early treatment the patient got well also.

DR. GROVER W. WENDE: I have had no experience with tetanus except while studying under Professor Peck in the hospital at Prague. At this time there occurred an epidemic in the Lying-in Hospital. Many of the patients died, including a couple

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