Nerve-section, first made by Hicks in 1797, and nerve-stretching, first performed by Vogt in 1867—reason for which can be found only in the neuritis (or, much more strongly, the reflex-neurosis) theory of the disease—has not been followed by relief in any unusually large proportion of cases,19 and should be practised only when the affected nerve is clearly indicated, when there is much pain in the wound, or when a distinct aura proceeds therefrom. In determining what nerve shall be divided or stretched regard may with advantage be had to Wood's symptom—to wit, the development of pain when pressure is made upon the nerve-trunk, branches from which terminate in the wound.
19 Of section, 21 cases, 10 deaths—i.e. 47 per cent. (Poncet); of stretching, 46 cases, 36 deaths—i.e. 78.2 per cent. (Harte).
Arloing and Tripier strongly advised total neurotomy (i.e. division of all the nerves going to the damaged part), and that high up—an operation that must be followed by extensive paralysis; not, however, permanent, they claim; in six months, at the latest, the power of motion being regained. This period is altogether too limited, as has been proved more than once. Fayrer reports having seen a case in which the hand was permanently crippled. It is to be noted that in most of these nerve-operation cases that terminate in recovery the tetanic spasms in the other parts of the body do not cease at once, but often quite slowly, and in the larger number of them internal medication of some kind is steadily employed. The removal of foreign bodies from the wound, the freeing of nerves from constricting ligatures, the division of the parts around containing nerve-fibres, and cauterization of the unhealed surface—each has at times proved beneficial, and the first two should always be early resorted to if the necessity therefor exists, no matter what views may be entertained respecting the nature and cause of the disease.
Tracheotomy, first proposed by Physick and later advised by Marshall Hall, has rarely proved of service, since the dyspnœa generally depends upon causes other than spasm of the laryngeal muscles. Verneuil, however, has recently stated that he has saved several lives by this operation.
Careful analysis of reported cases clearly indicates that neither in drug nor operation has a cure for tetanus as yet been found. Almost without exception “in the fully-developed cases all remedial measures fail, and the cases run on unchecked to a fatal termination;” and with the subjects of such acute attacks the physician, in the words of Aretæus, “can merely sympathize.” If not quickly overpowered by the violence of the seizure, and if he can be sufficiently supported, the patient may recover; and if there is late appearance, slow development, and infrequent and limited spasms, he probably will do so, whatever may be the treatment adopted.
“The first indication,” wrote John Hunter, “should be to strengthen the system;” and in the fulfilment of this indication food is of prime importance:20 “many patients perish from too much medication and too little feeding” (Agnew). Stimulants and hypnotics indirectly yet powerfully sustain the strength, and the removal of sensory irritants, as light and noise, by lessening the frequency of the spasms contributes to the production of the desired result, since in the convulsed muscles themselves there are developed substances that cause contraction. “Quiet and warmth are indispensable.” Fecal accumulations can but irritate, and therefore an early action through enema or mild drug should, if possible, be secured. As has been happily said by Labbé, “one must treat the tetanics, not tetanus.”
20 If necessary, fluids may be administered by means of a tube passed through the nose, or given by the rectum.
If little can be done to cure, much can be done to prevent. The influence of predisposing causes (anxiety, care, excesses, paludism) is to be counteracted as far as may be; the hygienic surroundings of the wounded are to be rendered as favorable as possible; especially is proper ventilation to be secured, and exposure to cold and rain avoided. Whether or not one believes with Rose that the disease depends not on the kind of wound, but on its treatment (“the earlier it is treated in the most careful manner the less frequently do we have tetanus”), there can be no question as to the great advantage to be derived from the thorough cleansing of the wound, the removal of irritating foreign bodies, the securing of free drainage, and the lessening of the amount of inflamed and dying tissue. The marked diminution in the number of cases observed in the last thirty years, as compared with that of a century or three-quarters of a century ago, is the direct result, we may well believe, of improved treatment of wounds and the wounded. The greater danger of slight injuries very possibly lies in their liability to be neglected or mistreated, and the special gravity of punctured wounds of the hand and foot in the anatomical obstacles presented to the ready outflow of blood, serum, or pus. In the exceedingly fatal toy-pistol wounds is it not in the decomposing débris of the lacerated tissues, or in the retained wad saturated with the secretions, that the danger lies of the development of tetanus, and not in nerve-irritation or any peculiar character of the injury? Certainly in the only case I have myself seen, in which the disease was not developed, the damaged hand was kept under hot water from the time it was hurt until healing was complete, and free drainage was from the first maintained.
Tetanus is reported to have appeared notwithstanding the associated injury was antiseptically dressed; but in modern wound-treatment, with its cleanliness, its protection of the damaged part, its infrequent manipulations, and its power to diminish inflammation and prevent decomposition, lies, we may well believe, the means of reducing to a minimum the danger of occurrence of those spasms that, once developed, are of “exceedingly painful nature, very swift to prove fatal, but not easy to be removed” (Aretæus).