GEN. I. SPEC. VII. Tetanus. Description. The other varieties also than trismus less frequent when strictly Nor are either of the other varieties, in any degree, so frequent as trismus, except where they form a subsequent Entasia part of the general chain of morbid action. My observ- Tetanus. ant friend Dr. Hennen, confesses that during the whole period of his superintending the British hospitals in Spain he never met with but one case of emprosthotonus, and even this he describes as an incurvation that rather approached it than constituted the disease itself. "It was observed," says he, "at the same time and in the hospital, with the various degrees of trismus: rigid spasms of almost every muscle of the body, and violent periodical convulsions, all from similar injuries to that in which it was produced."* same idiopathic. affection of the muscles. From the complicated manner, indeed, in which teta- Tetanus a peculiarly nus shows itself, and its anomalous attack upon different complicated sets of muscles at the same time, it seems in many instances to put all the subordinate divisions of classification at defiance. It is, in truth, for the most part a mixed disease, affecting various and opposite sets of muscles; and this in many cases so equally that the spastic action of the flexors just balancing that of the extensors, "the patient," to adopt the language of Dr. Lionel Clarke, "seems often to be braced between opposite contractions". It is to this form, indeed, that this last very intelligent writer has limited the name of tetanus as that to which it applies most emphatically. Like Dr. Hennen, he asserts that he had never seen a single case of genuine emprosthotonus; and that of the other two varieties of which he treats, the opisthotonus and proper tetanus, the former occurs most frequently. curvation. In episthotonus or TETANIC RECURVATION the sym- Tetanic reptoms sometimes show themselves suddenly, but more commonly advance slowly and imperceptibly: the patient Description. mistaking the uneasy stiffness which he feels about the shoulders and cervical region for a crick in the neck, produced by cold and rheumatism. The stiffness, however, * Military Surgery, p. 247. 8vo. Edinb. 1820. increasing, he finds it impossible to turn his head on either side without turning his body: he cannot open his jaws without pain, and he has some difficulty in swallowing. A spastic and aching traction now suddenly darts at times towards the ensiform cartilage, and thence strikes through to the back, augmenting all the previous symptoms to such a degree that the patient is no longer able to support himself, and is compelled to take to his bed. The pathognomic symptom in this variety is the spasm under the sternum which is perpetually increasing in vehemence; and, instead of returning, as at first, once in two or three hours, returns now every ten or fifteen minutes. Immediately after which all the host of concomitant contractions renew their violence and with additional severity: the head is forcibly retracted, and the jaws snap with a fixation that rarely allows them to be afterwards opened wide enough to admit the little finger. This vehemence of paroxysm may not, perhaps, last longer than for a few minutes or even seconds: but the spastic action prevails so considerably, even through the intervals, that it is difficult for an attendant to bend the contorted limbs into any thing like an easy or reclined position. The breathing is quick and laborious, and the pulse, though calmer and less hurried, small and irregular. The face is sometimes pale, but oftener flushed, the tongue stiff and torpid but not much furred; the whole countenance evinces the most marked signs of deep distress, and swallowing is pertinaciously abstained from, as accompanied with great difficulty and often producing a sudden renewal of the paroxysms. The last stage of the disease is truly pitiable. The spasms return every minute and scarcely allow a moment's remission. The anterior muscles join in the spastic action, but the power of the posterior is still dominant; and hence while every organ is literally on the rack from the severity of the antagonism, the spine is more strongly recurvated than ever, and forms an arch over the bed, so that the patient rests only on the back part of the head and on the heels. During the exacerbation of the spasms, the lower extremi GEN. I. SPEC. VII. Tetanus. Both thigh bones have been broken from the violent contraction of the flexor ties, even while they continue rigid, are so violently jerked, that the utmost attention is necessary to prevent the pa- Entasia tient from being projected from his bed: and Desportes Tetanus. gives a case in which both the thigh bones were broken from the violent contraction of the flexor-muscles during a momentary remission of the extensors*; similar results to which we shall have occasion to notice hereafter. The tongue is in like manner darted spasmodically out of the mouth, and the teeth snapped suddenly and with muscles. great force; so that unless a spoon covered with soft rags, or some other intervening substance, is introduced between the teeth at such periods, the tongue must be miserably bitten and lacerated. The exertion is so laborious that the patient sweats as in a hot bath: and the heat has in some instances been raised to 110° Fahrenheit. The pulse is at this time small, and irregular: the heart throbs so violently that its palpitations may be seen; the eyes are sometimes watry and languid; but more commonly rigid and immoveable in their sockets: the nostrils are drawn upward, and the cheeks backward towards the ears, so that the whole countenance assumes the air of a cynic spasm or sardonic grin, while a limpid or bloody froth bubbles from the lips. There is sometimes delirium, but this is not common: the patient is worn out under this laborious agony in a few hours; though more usually a general convulsion comes to his relief, and he sinks suddenly under its assault. Description. Spastic action con In the ERECT TETANUS, in which there is a balance Erect of spastic action between the anterior and posterior sets of tetanus. muscles, the progress of the disease is not essentially dif ferent. The march of the spastic action, however, varies in some degree, as we have already observed, in almost siderably every instance from trismus to tetanus, and from one modification of tetanus to another: yet the course we have now described is that which chiefly takes place where the disease advances in something of a regular and uninterrupted progress. Its danger and duration are com- Proguesties. * Hist. des Maladies de St. Domingue, u. p. 171. varies. GEN. I. SPEC. VII. Entasia General principle of cure two fold: tu take off tion, and tranquillize erethism of the system. The first of portance in the lockedjaw of great im infants. monly to be estimated from the degree of violence of the incursion. Where this is very severe the patient rarely survives the third day, and is sometimes cut off on the second, or even in six and thirty or four and twenty hours. But, where the attack is less acute, the patient may continue to suffer for a week before he reaches his tragic termination. If he have strength enough to survive the ninth day he commonly recovers, for the paroxysms diminish in violence, the intervals of remission are longer, and the muscles being generally more relaxed he is able to take a little nourishment. Through the whole period there is an obstinate costiveness, partly from want of food in the stomach, but chiefly from an association of the mouths of the intestinal excernents in the spasmodic constriction. The general principle of cure is far more easily expressed than carried into execution. It is that of taking off the local irritation, wherever such exists, and of tranlocal irrita- quillizing the nervous erethism of the entire system. The first of these two objects is of great importance in the lockedthe general jaw or trismus of infants; for by removing the viscid and acrimonious meconium, or whatever other irritant is lodged in the stomach or bowels, we can sometimes effect a speedy cure without any other medicine. Castor oil is by far the best aperient on this occasion, and it may be given both by the mouth and in injections. But if this do not succeed we should have recourse to powerful anodynes; and of these the best by far is opium, which should be administered from three to five drops in a dose, according to the age of the patient. Musk and the host of antispasmodics have been tried so often with so little success that it is not worth while to put the smallest dependence upon them: nor has the warm or cold bath produced effects sufficiently general or decisive, to allow us to lose any time in trusting to their operation. They may be employed, however, as auxiliaries; but our sheetanchor must be opium, which if the spastic action have made much advance when we first see the patient, should instantly be employed in conjunction with the prescribed Modes of accomplish ing this object. GEN. I. SPEC. VII. aperient. By taking off the constriction from the intesti- In trismus or tetanus from wounds or sores, the local irritation is not so easily subdued: nor is its removal of so much importance, though in no case of small moment. But, generally speaking, the spastic action is, in these instances, as much dependent upon constitutional, as upon topical irritability, and when it has been once excited it will run through its career, whether the local cause continue or not. It is owing chiefly to this fact that the best and most active plan of cure so often fails of success; and the most cautious practitioners hesitate in their prognostications, whatever be the march of symptoms, for the first four or five days. "From the state of the pulse," says Dr. Hennen, " I have derived no clue to either the proper treatment or the probable event: it has, in the cases I have met with, been astonishingly unaffected. From the state of the skin I have been left equally in the dark. Sweating, which some have imagined critical, I have seen during the whole course of the disease, and attended with a most pungent and peculiar smell, while in others it has never appeared at all: and suppuration, which is generally interrupted, I have seen continue unaffected by the spasms. Even the process of healing, which, it would be reasonable to conclude, should be altogether put a stop to, has gone on apparently uninfluenced by the disease and in the most severe case I ever saw, which occurred after a shoulder-joint amputation, sent into Elvas from before the lines of Badajos, the life of the patient and the perfect healing of the wound were terminated on the same day." So powerfully does the constitutional irritability operate in many cases after the the disease has once displayed its hideous features, and render the local treatment of subordinate importance. Tetanus. Treatment of trismus or tetanus from wounds or sores. Spastic action here as much dependent stitutional as topical irritability: upon con and hence often con tinues after the latter has ceased. Hence the culty of prognosti great diffi cation. however, In numerous instances, however, a change in the con- Local imdition of the wound has produced a beneficial result; and provement, hence various means have been resorted to for the purpose of effecting such a change, as local bleeding, anodyne often highly favourable: |