The most hopeful of remedies is antitoxin. More lives can be saved by this preparation, if used early and freely, than by any other known remedy. Moschcowitz, in 1900, collected 338 cases, with a mortality of 40 per cent. In many of these cases it was not used early. It is of importance, however, to use it at the very outset, and to repeat its use as soon or as often as may be indicated by any exacerbation of symptoms. In one instance under my observation twenty-three phials of antitoxin were used before muscle rigidity subsided; in another case double this amount was used. Without quoting figures it is safe to say that the former great mortality rate of tetanus has been reduced at least 50 per cent. by its use, and that further reduction can be effected by its early and prolonged use.
The use of antitoxin nowise takes away the necessity for proper physical care of the laceration or the wound. Every particle of affected tissue should be cut away, all the principles of physical cleanliness adhered to, and proper antiseptics used.
When the antitoxin is used in the presence of the disease it should be injected into the spinal canal, as it is known that the cerebrospinal fluid may contain a considerable amount of the toxin and is of itself highly poisonous. Therefore after inserting the needle into the canal it is well to withdraw a considerable amount of the fluid before injecting the antitoxin. If this method is pursued the material is brought into more immediate contact with the anterior horns of the cord than could be effected in any other way. After withdrawing all the fluid that will run through the needle without applying the syringe—probably 150 to 200 Gm.—10 to 15 Cc. of the antitoxin may be slowly injected, the process consuming from three to five minutes. Then a further injection should be made along some of the large nerve trunks, preferably those leading to the part involved. This injection should be made with a finer needle, such as that with which cocaine solution is injected during anesthesia for the prevention of shock. This is a more effective and less serious matter than trephining the skull for the injection of fluid upon the surface of the brain. This may be done while the patient is under the influence of the anesthetic administered for the purpose of giving proper attention to the wound. The antitoxin should be injected into the nerve trunks after their exposure. At the same time it is well to make intravenous saline injections at more than one point. After from twelve to fifteen hours the injection of antitoxin and perhaps of saline solution should be repeated, if necessary, under such light anesthesia as can be produced by ethyl chloride. Recently a substitute for antitoxin has been suggested in an emulsion of brain tissue which has been shown to have a specific affinity for the tetanus toxin. It has been seen that when these two substances have been thoroughly shaken together the toxin is removed from the fluid and confined in harmless form within the brain-tissue cells.
In injecting the antitoxin into the spinal canal no harm will ensue if a little blood flow through the needle, showing that the cord itself has been touched.
When there is need to employ this material the brain of a freshly killed small animal should be removed under antiseptic precautions. 10 Gm. or 15 Gm. should be emulsified in about 30 Cc. of sterile salt solution, which should then be strained through a sterile cloth under light pressure. This is then injected as near the wound as possible and the procedure repeated every day as long as indicated. This method can only be expected to neutralize toxin that has not yet entered the nerve cells. Nevertheless, Russian observers have reported thirteen recoveries out of sixteen instances in which the method was practised.
When no other means are at hand a 1 per cent. carbolic acid solution may be injected after the same fashion, using such an amount that about five grains are administered during twenty-four hours to an adult. This is the method especially favored by the Italians, and is due especially to Baccelli.
Matthews has devised a method which seems quite effective in experimental animals. It consists of the use of a solution of the following: Sodium chloride 4 Gm., sodium sulphate 10 Gm., sodium nitrate 3 Gm., calcium chloride 14 Cgm., water 1000 Cc. This is intended for intravenous injection, and must be introduced very slowly. The performance should be repeated twice during the first twenty-four hours and once each succeeding twenty-four hours. It produces profound diuresis, i. e., a washing out of tissue cells, as he calls it.
HYDROPHOBIA.
Hydrophobia is an acute specific or infectious disease, as far as known never originating in man, but transmitted to him, usually through the bite or by inoculation from the saliva of a rabid animal—in this country usually the dog, although the wolf, the cat, the skunk, and even certain of the domestic poultry, are capable of conveying the disease. Chickens are said to be immune save when their vital resistance is lowered by starvation. Chicken blood injected into other animals seems to antidote the virulence of the virus. It can also be inoculated in other animals, like rabbits. The virus is ordinarily conveyed in the saliva of the rabid animal. This may be wiped off as the teeth of the animal pass through the clothing of the injured individual; consequently, infection does not certainly follow such bites. But those upon exposed portions of the body, where animals generally bite, are almost invariably followed by infection. Hydrophobia is frequently spoken of as rabies, sometimes as lyssa. While rare in this country, it is by no means uncommon in Central Europe, especially perhaps in Russia, where bites from infuriated wolves are common. In the United States infection comes almost invariably from the rabid dog, in which this disease presents two types.
The so-called furious form is that which is marked by frenzy and canine madness, the objective symptoms being more pronounced and alarming, though not less dangerous than the other variety. After the period of incubation, which varies considerably, these animals show depression and uneasiness, and even thus early their saliva is infectious. Their sense of hunger becomes perverted; they exhibit unusual tastes, secrete saliva abundantly, which becomes very tenacious and even frothy, exhibit a dry and edematous condition of the faucial mucous membranes; the character of the bark is altered, while they are usually infuriated at the sight of other dogs. In this stage there is usually insensibility to pain. Finally, come more or less paralysis of deglutition, quickened respiration, dilated pupils, and frenzy and madness of manner, by which they attack indiscriminately men and other animals. To this stage of furious excitation succeeds one of paralysis, and death follows from exhaustion. These manifestations usually last about a week.