Postmortem Appearances.
—These are rarely distinctive. In most instances there are evidences at least of hyperemia, if not of more active changes, in the upper portions of the cord. Less often slight changes have been noted in the brain, consisting, in some measure, of disintegration and softening. Evidences of ascending neuritis in the nerve trunks leading to the injured area have been claimed in some instances. Few if any distinctive postmortem changes can be described as due to this disease.
Diagnosis.
—The diagnosis should be made as between strychnine poisoning, hysteria, hydrophobia, tetany, and, in the beginning, from pharyngitis, tonsillitis, etc. When the disease is fully developed it is not likely to be mistaken for anything else.
Tetanus may be simulated by hysteria, but in this event the phenomena will be so uncertain, and the evidences of organic disease so essentially lacking, that it is not likely that mistake can occur.
Treatment.
—If any case can be imagined in which efficient treatment is most urgently demanded it is one of tetanus. In scarcely any disease, however, is drug treatment so unsatisfactory. In the rare instances in which patients have recovered it is questionable whether it is not due to individual resistance rather than to medication. Treatment may be subdivided into local, constitutional, and specific. If there is still an open suppurating or discharging wound, it is, of course, essential to cleanse this out, basing this advice in some measure upon general principles—largely upon the fact, already stated, that ordinarily only the immediate surroundings of such a wound are found infected by the bacilli themselves. Consequently thorough scraping, excising, and cauterization, either with powerful caustics or the actual cautery, are indicated. Since the specific germ is an anaërobe, hydrogen dioxide may be used locally with great advantage, mainly because it oxidizes the albuminous material upon which the bacilli thrive. If it is in a finger or toe, amputation may be the simplest method of eradicating the local lesions.
Constitutional treatment may be divided into nutrition and medication. The tendency too often in these cases is to be careless or indefinite with regard to the excretions and the nutrition of the patient. If, for instance, each attempt at catheterization throws him into convulsions, the bladder may become overdistended and burst. So, too, there is apprehension usually in regard to fecal evacuations. At the same time these patients are allowed to almost starve because of the difficulty of feeding them. It is advisable to resort to chloroform to permit the introduction of the stomach tube—through the nostrils, if necessary—by which nutrition may be introduced into the stomach without causing the violent convulsions that would occur without an anesthetic. At the same time the catheter may be used.
In the way of active medication there is no agent so efficacious for controlling the tetanic spasms as chloroform, which may be administered occasionally, or more or less continuously, according to the wishes of the attendant. By its use the severest spasms can be kept in abeyance, and the horrible character of the disease somewhat mitigated. Of the other medicaments used, most of them are of the nature of nerve sedatives, such as chloral, the bromides, Calabar bean, cannabis indica, opium, etc. Hot-air baths or diaphoretics, by which copious perspiration may be induced, have yielded good results.
Specific treatment means in these instances taking advantage of the well-known properties which the blood serum of an animal artificially immunized against the disease possesses. This is in accordance with experimental labors with a number of different diseases, of which tetanus is one. It is, in effect, similar to the serum therapy of diphtheria.