In traumatic cases the location of the wound does not seem to materially influence the death-rate. As occurring during our late war, those associated with injuries of the upper extremity were the least, and of the head, face, and neck the most, fatal, but the difference in the mortality rates was but 8.4 per cent. (86.8:95.2 per cent.). It has long been believed that wounds of parts supplied by the cranial nerves are not only less often followed by tetanus than those of other regions, but that the disease when present is of a less fatal character. Of the 10 cases of the peculiar head-tetanus already referred to, collected by Bernhardt, 6 died (60 per cent.).
TREATMENT.—For the relief of tetanus agents of most diverse action and power have been employed, intended to control inflammation, allay nervous irritability, arrest spasm, and sustain the general strength; and operations have been performed with the view to destroy nerve-conduction, remove external irritants, change the character of the associated wound, or take away the originally damaged part. Much of the confusion and uncertainty that have prevailed respecting the therapeutic treatment has doubtless arisen from the want of distinct separation of the idiopathic from the traumatic cases, because of incorrect diagnosis, or through an unwarranted assumption of the general applicability of a method of medication found advantageous in individual cases of perhaps rheumatic, malarial, or meningeal disease.
Regarding the affection as inflammatory, the older surgeons treated it antiphlogistically, and until within comparatively recent times bloodletting and mercury were largely employed. General and local bleedings, resorted to as far back as the time of Hippocrates, were not seldom made in excessive amounts,13 the patient occasionally surviving both the disease and the treatment. The mercurials were pushed until profuse ptyalism was produced—a condition which could but add to the distress (because of the great difficulty experienced in clearing the throat and mouth), and likely to induce and increase the severity of the convulsive seizures. Combined with opium, calomel was formerly held in high repute, and numerous recoveries have been attributed to such treatment—recoveries, however, almost always of cases of chronic character and no great severity. Should the mycotic origin of the disease ever be demonstrated, there will be good reason, in its well-known destructive action upon minute organisms, for the administration of the mild or corrosive chloride of mercury. Cold baths and affusions have sometimes caused entire relaxation of the spasms, leaving the patient as supple as a glove, and not seldom have been followed by muscular ruptures or sudden death.14 The local application of ice to the spine has been credited with many cures, particularly of cases of the non-traumatic variety, and benefit has seemed to follow the employment of ether or rhigoline spray. Hot baths, water or air, general or local, have been largely used from the time of Paré down, and the induced free perspiration has in some instances seemed to have been of service, as have the medicinal agents acting as sudorifics, of which jaborandi has of late been the one ordinarily employed. “To relieve the contractions and provoke sweating are the two principal bases of treatment,” wrote Martin de Pedro. But it should not be forgotten that in many of the more severe and rapidly-fatal attacks profuse sweating is characteristic of the disease.
13 In a case of Lisfranc's, in twenty-six days venesection was made nineteen times, and seven hundred and seventy-two leeches were applied.
14 An interesting and frequently-mentioned case is reported by Sir James McGrigor. A soldier having tetanus (unusually severe) was “during the first part of the day drenched with rain, the thermometer standing at 52°, but after ascending one of the highest mountains in Galicia the snow was knee-deep and the thermometer below 30°. The patient was exposed to this inclement weather from six o'clock in the morning till ten at night, when he arrived half starved to death, but perfectly free from every symptom of tetanus.”
All violent depleting measures should be abstained from, since in the acute attacks they can do no good, and in the more chronic ones can only increase the general debility; and it is from exhaustion that the subjects of these latter usually die.
To lessen the reflex irritability, to quiet the muscular spasms, and support the patient are the prime indications; to fulfil which every agent in the materia medica that has, or has been supposed to have, any sedative action upon the nervous system has been employed, as well as remedies directly controlling muscular movements. Of the greater number of such it may be truly said, “They have the same value, and the best of them is good for nothing” (Giraldes).
At the present time the medicinal agents that are deserving of consideration are tobacco, the anæsthetics, curare, conium, cannabis indica, calabar, opium, chloral, and the bromides.
Tobacco, that in virtue of its depressant action so powerfully relaxes the muscles, was until the introduction of the anæsthetics largely employed and regarded with much favor, but of late years has rarely been used, inhalations of chloroform or ether securing more rapid and complete relaxation, with far less danger to the patient. Nicotine, in doses of from a fraction of a minim to a full minim (6/10 gr.) by the mouth, or two by the rectum (Houghton), has been given instead of the tobacco infusions with equally good effects, and of course the same dangers of producing fatal collapse.