Of late years use has been made, either alone or in combination with opium or chloral, of the bromides, especially that of potassium, which in full dose unquestionably diminishes reflex irritability, lessens the sensibility of the peripheral nerves, and moderates excessive body-heat. Under its influence mild cases of tetanus have recovered and more severe ones been somewhat relieved, and it has the decided advantage over the other drugs that have been noticed of not being a direct cause of death even when given in large dose—as much in some instances as six, seven, or nearly eight drachms a day. Knecht found that of 10 cases treated with chloral and the bromide, 9 got well; and Kane, of 21 to whom such a combination was given, only 5 died (23.8 per cent.); but the number of cases is too small to make conclusions deduced therefrom of any special value. Voisin reports a case (in which it should be noted the spasms began in parts near the wound, and that on the fourteenth day after the receipt of the gunshot injury of the right thigh) that had for eleven days been treated without effect with chloral in large quantity, which at the end of that time was put upon drachm ij doses of the bromide, with three hypodermics a day of about ½ gr. of morphia each: in three days decided improvement had taken place, and in four days more the patient was well.
The sedative and sustaining action of alcohol has many times been taken advantage of in the treatment of this affection. The administration of wines or spirits in large amounts has certainly been found of much service, though it will seldom or never be necessary to give wine, as Rush advised, “in quarts, and even gallons, daily.” 80 per cent. of recoveries appear to have taken place in the 33 cases that Yandell found to have been treated with stimulants; but, on the other hand, of Poland's 15 cases treated with wine, 75 per cent. died: here, again, the numbers are too few to make any deduced conclusions of much value.
As tetanus (or at least tetanoid spasm) has at times been observed as a consequence of malarial poisoning, and successfully treated with quinine, this remedy has occasionally been employed in cases not dependent upon paludism, but very generally to no purpose.
Fowler's solution of arsenic in doses of from 5 to 20 minims every two, three, or four hours has been believed by certain of our American surgeons (Hodgen, Prewitt, Byrd) to be of service.
Because of the supposed origin of the disease in peripheral nerve-inflammation or irritation, operative procedures have many times been adopted to interrupt the conduction or remove the part.
Amputation, which was so highly commended by Larrey, is now recognized as of no service in the severer and more acute cases, and as unnecessary mutilations in the chronic ones; and if performed in those of intermediate severity, when recovery takes place it will generally be difficult or impossible to determine of how much benefit the operation really was, and in some at least of the fatal cases the result can fairly be attributed to the amputation itself. When the disease is associated with an extensive lesion of an extremity, there can be no objection to the removal of the damaged part (if performed early), except that it may by the added shock still further weaken the patient and render him less able to hold out against the tetanus. In cases of severe spasms limited to the muscles of the injured limb (and such are frequently said to be of tetanus) amputation is often strongly indicated, and not seldom is the only treatment that will afford relief. During our late war “amputation was resorted to in 29 instances after incipient tetanic symptoms; 10 of the cases resulted favorably, and in several instances it is noted that the symptoms ceased after the operation.”18 Of Yandell's 17 cases, 60 per cent. recovered.
18 Medical and Surgical History of the War of the Rebellion.
As there is here, apparently, recovery in 34.5 per cent. of the gunshot cases treated by amputation (nearly one-fifth of all the non-fatal cases reported)—a very gratifying degree of success, and one that might properly encourage the resorting to this method of treatment—somewhat careful analysis may well be made of the 7 cases the histories of which are given. In 2, shell wounds of the foot, operated upon by the same surgeon, the disease appeared while the men were still upon the field. Of one of them it is stated that “there was but little hemorrhage, but the shock was excessive and tetanic symptoms were present;” and of the other, that “the peculiarities in the case were that symptoms of tetanus were quite marked, with great exhaustion.” There are certainly good reasons for believing that these two cases were not of tetanus, but of simple convulsive movements from shock and anæmia. Of the remaining 5 cases, the symptoms manifested themselves on the fourteenth, nineteenth, twenty-first, thirty-fifth, and fifty-fourth day after the receipt of the wound. One of the patients (in whom the disease was longest delayed), having a much inflamed and suppurating compound fracture of the bones of the forearm, “was suddenly seized with a chill followed by threatening tetanus,” and amputation was made the following day. In another (thirty-fifth day case) the “arm became much swollen and symptoms of tetanus ensued, including stiffening of the jaws, great pain and restlessness, and irritable pulse;” two days later the limb was removed, and “all symptoms of tetanus disappeared after the operation.” In another (twenty-first day) the man when admitted into hospital, one month after the date of the injury, stated that “he was first taken with trismus about a week before.” “As he was certainly getting worse every day,” the forearm was removed forty days after the receipt of the wound and nearly three weeks after the commencement of the tetanic symptoms. Other remedies employed after the operation (brandy, chloroform, and blisters to the spine) doing no good, drachm ss doses of the tr. cannabis indica were given every two hours, “under which the patient slowly improved.” In another case (nineteen days) the symptoms were those of tetanus; the amputation was made on the following day; twenty-four hours later “rigidity of the muscles had partly disappeared, and improvement continued until the patient was entirely relieved.” In the remaining case (fourteen days) the first symptoms of tetanus “were relieved by active purgatives, calomel, etc. Three days later the symptoms returned,” and on the next day “tetanus supervened in its usual form.” Five days afterward “the leg was amputated at the middle third, after which the tetanus subsided and the patient made a rapid and good recovery.”
In all of these five cases the disease appeared so long after the receipt of the wound that the chances were that if it was tetanus recovery would take place without regard to the treatment adopted; and of two some doubt may properly be entertained as to their real nature, there being present in both much inflammation—in one an initial chill, and in the other restlessness, great pain, and an irritable pulse. If the unpublished histories of the other three cases are similar to those given, these reported ten successful amputations can affect but little, or not at all, the previously entertained opinion of the real value of this method of treatment—that it is destructive to part, dangerous to life, and only very exceptionally, if ever, curative of the disease.