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Full text of "Tetanus : lecture delivered at the College of Physicians and Surgeons, Chicago"

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' ^ BY 


Milwaukee, wis., 

Surgeon to Milwaukee Hospital, Proeessor of 
Principles and Practice of Surgery and 
Clinical Surgery. 



x/ €^arY 



V,. BY 

N. SENN, M. D., 

Milwaukee, Wis., 

Surgeon to Milwaukee Hospital, Professor of 
Principles and Practice of Surgery and 
Clinical Surgery. 


Gentlemen: Having finished the sub¬ 
ject of wound infective disease proper, I shall 
call your attention this evening to a more in¬ 
frequent wound complication, in which the 
symptoms point towards the cerebro-spinal 
centres as the primary and principal seat of 
the disease. This disease constitutes one of 
the most terrible in the long list of surgical 
affections, and up to the present time is 
wrapped in a great deal of obscurity. I 
refer to tetanus. Terrible, from the great 
mortality attending it, and from the intense 
suffering with which it is accompanied; ob¬ 
scure, because from the present standpoint of 
pathology, we are still in ignorance as far as 
its essential nature is concerned. Tetanus, I 
will define as being a disease of the nervous 
system, due to infection of a specific charac¬ 
ter, combined in many instances with peri¬ 
pheral irritation of a sensitive nerve; it is 
characterized by spasm of definite muscular 
groups, and attended by a continued form of 
fever. If I include the adjective “infective” 
( 3 ) 


in tetanus, it is more on account of reasoning 
by analogy than positive pathological or 
clinical demonstration; nevertheless analogy 
should teach us that the well-marked period 
of incubation between the supposed time of 
infection and the development of the active 
symptoms resemble other forms of infective 
diseases very closely. That the direct cause 
of tetanus is due to a specific microbe, is 
claimed by a number of the most eminent 
writers, and further study and research will 
undoubtedly substantiate its infectious char¬ 
acter. This disease is not a new one, inas¬ 
much as it was well known to and described 
by Hippocrates, who recognized both an idio¬ 
pathic and traumatic form, the latter of 
which he referred to wounds, abrasions, and 
to various pathological conditions indepen¬ 
dently of traumatism. Most all of the old 
classical works contain lengthy chapters on 
this subject, which reflect the most diverse 
opinions concerning its nature and etiology, 
which have been promulgated by different 
authors at various times. 

In considering its geographical distribu¬ 
tion, it has been observed that it is more fre¬ 
quently met with in the torrid zone, and 
more especially in India and South America. 
Statistics also show that in these countries 
the disease is noted for the gravity of its 


symptoms and its greater mortality. In 
speaking of race influence, it can be stated 
that the colored races, as a rule, are more 
subject to it, and when suffering from the 
disease, it is usually attended by a greater 
mortality. Age appears to exert a predis¬ 
posing influence, as after exclusion of tetanus 
neonatorum, at least 40 per cent, have oc¬ 
curred in patients 10 to 30 years of age. In 
order to prepare you for a pathological de¬ 
scription of this affection, I shall call your 
attention to a form of toxic tetanus produced 
by the introduction into the circulation of 
certain chemical poisons. There is, how'- 
ever, this difference between this form of 
tetanus and traumatic tetanus ; that in the 
former case the active symptoms of the dis¬ 
ease make their appearance immediately 
after the poison has been brought in contact 
with the cerebro-spinal centres by the circu¬ 
lating blood. There is no period of incuba¬ 
tion ; no premonitory stage. The tetanic 
symptoms are well marked and fully devel¬ 
oped as soon as the toxic effects of the drug 
have manifested themselves. The agents in 
our materia medica which are known to pro¬ 
duce certain forms of tetanus, are strych¬ 
nine, brucin, ergotine, and thebain; the 
forms of tetanic convulsions, however, vary 
according to the drug which has been ad- 


ministered. Taking strychnine poisoning as 
a type of toxic tetanus, we find that the 
pathological conditions are always referable 
to vascular changes in the brain and spinal 
cord—changes marked by an increased af¬ 
flux of blood, by an active hvpenemia or 
congestion, which later result in morpholog¬ 
ical changes indicative of the first symptoms 
of inflammation. Experiment has estab¬ 
lished the fact that the reflex action attend¬ 
ing toxic tetanus is the result of excessive 
innervation from the spinal cord. If the 
spinal cord in an animal is crushed at a cer¬ 
tain point, tetanic convulsions will only take 
place in the muscles supplied by the nerves 
from the intact portion of the cord. If, 
again, you should divide the posterior roots 
of the spinal cord near their exit from the 
spinal canal, or the posterior columns of the 
cord, there will be no response to the toxic 
irritation in the muscles supplied by the 
nerves which have been divided, or below 
the section of the cord. Furthermore, if 
previous to the intoxication you should re¬ 
move the brain, the pons, or even the me¬ 
dulla oblongata, the toxic effect of the drug 
will not be impaired, showing conclusively 
that 'the tetanic convulsions or spasms are 
the direct result from the toxic effect of the 
drug upon the spinal cord. 


In considering tetanus as it presents itselt 
to the physician and surgeon, we still recog¬ 
nize an idiopathic and traumatic form. By 
the term “ idiopathic,” I mean a tetanus un¬ 
attended or preceded by an appreciable 
traumatism. Traumatic tetanus, on the 
other hand, as its name indicates, is that 
which follows an injury. We place great 
stress upon the fact that there must have 
been somewhere a loss of continuity of sur¬ 
face, an infection atrium, as we term it, 
through which the specific germs gained en¬ 
trance into the circulation. In many cases 
of so-called idiopathic tetanus, the traumatic 
lesion may have been so slight as to elude 
detection at the time when the disease made 
its appearance, and yet the traumatism may 
have been the direct and only cause of the 
disease. Of the seven hundred cases col¬ 
lected by Thamhayn, the disease had a well- 
defined traumatic origin in six hundred 
cases, while in the remaining one hundred 
cases there was no apparent evidence of pre¬ 
vious injury found, and they were conse¬ 
quently classified as belonging to the spon¬ 
taneous variety. To impress upon you the 
necessity of looking carefully for the source 
of infection in doubtful cases, I will briefly 
refer to a case that recently came under my 
observation, where from the history of the 


case I thought I was dealing with a genuine 
case of idiopathic tetanus. The patient was 
a child five or six years of age, who had 
been ill for several days when it came under 
my care. The case presented all the symp¬ 
toms of a mild type of tetanus, and in the 
absence of traumatism as a cause, I consid¬ 
ered it as a typical case of so-called idio¬ 
pathic tetanus. I had trismus, opisthotonos, 
and a mild form of continued fever with 
considerable disturbance in the function of 
the vascular system. After treating the 
case for a week or so, I accidentally one day 
found an exceedingly tender point in the 
sole of the right foot, which corresponded to 
a small cicatrix. On questioning more 
closely, the patient finally admitted having 
stepped upon a nail some time before, an 
accident which had been entirely overlooked 
by the parents and forgotten by the patient. 
Unless by accident the primary cause had 
been detected, this case would have been 
considered as belonging to the idiopathic 
variety, when in fact it was a well marked 
but mild case of traumatic tetanus. I sim¬ 
ply make this allusion to put you on your 
guard in cases of so-called idiopathic tetanus, 
to search diligently and unceasingly for a 
tangible primary cause, as a slight injury or 
obscure cause of peripheral irritation might 


be easily overlooked, which would lead to an 
incorrect interpretation of the etiology of 
the disease. There may be such a thing as 
idiopathic tetanus, without any apparent 
breach of surface, as specific germs may pos¬ 
sibly gain entrance into the circulation 
through an intact mucous membrane in the 
same manner as in other instances of wound 
infective diseases, the microbes finding in 
the cerebro-spinal centres a favorable place 
of localization and reproduction. Future 
research, however, will have to verify or 
contradict this supposition. 

In considering the exciting causes of tet¬ 
anus, I will allude first to peripheral irrita¬ 
tion. Before the infective nature of tetanus 
was recognized, it was generally considered 
that the disease was invariably the direct 
result of peripheral irritation. Clinical ex¬ 
perience has demonstrated the important 
bearing of irritation of sensitive nerves, at 
least as a determining cause, inasmuch as 
in 380 cases reported by Thamhavn, it was 
found that 75 per cent, of them were the 
result of injury to the fingers, toes, hands, 
and feet—localities where we have an abun¬ 
dant supply of sensitive nerve filaments, 
so that it may be accepted as a well 
known and established fact that injuries of 
the hands and feet are more prone to be fol- 


lowed by tetanus than wounds in any other 

Another form of peripheral irritation, 
aside from the traumatic, are pathological 
conditions due to inflammation, which affect 
the sensitive nerves the same as when the 
irritation is produced by an injury. Tetanus 
produced in this manner has been observed 
as a complication in pleuritis, pneumonia, 
metritis; in fact, as a result of pathological 
conditions which involve in the same manner 
an extensive area of sensitive nerves as the 
effects of traumatism. In the idiopathic form 
of tetanus, authors still recognize a central 
lesion or point of irritation independently of 
any peripheral or eccentric pathological irri¬ 
tation. By this I mean central irritation by 
pathological conditions involving directly the 
brain or spinal cord, independent of trau¬ 
matism. Cases have been observed in the 
post-mortem room where well marked patho¬ 
logical conditions existed in the brain and 
spinal cord, independent of either traumatic 
pathological peripheral irritation, where dur¬ 
ing life the characteristic symptoms were 
well marked. These cases may serve to ex¬ 
plain the theory that the specific germs of 
tetanus once introduced into the system may 
have a special elective affinity for the nerve 
centres, and may there manifest their toxic 


influence by producing pathological condi¬ 
tions which induce tetanic spasms. Specific 
infection, then, must be recognized as the 
most important and essential factor in the 
etiology of tetanus. Recent literature on 
this subject seems to have established the 
fact, that like wound infective diseases, 
tetanus is simply an expression of a specific 
form of intoxication, which implicates, prin¬ 
cipally, the cerebro-spinal centres, the result 
of the introduction of specific microbes. 
This hypothesis does not lack analogy in dis¬ 
eases which are marked by a well-defined 
period of incubation, where a certain time 
elapses between the introduction of the virus 
and the active development of the symptoms; 
in other words, diseases preceded by a period 
of incubation, in contradistinction to diseases 
which are caused by the introduction of a 
formed chemical poison, means simply that 
the germs introduced at the time when the 
injury was inflicted keep on multiplying 
until a sufficient number of them have been 
generated in the system, when the toxic ef¬ 
fects are announced by the active develop¬ 
ment of symptoms. If tetanus were the re¬ 
sult of the introduction into the system of a 
pre-formed or chemical poison, the active 
stage of the disease would commence as soon 
as the poison had entered the circulation, 


which evidently has never been the case. If, 
however, a certain period elapses from the 
time of supposed infection until the active 
development of the disease, we recognize the 
fact by well demonstrated analogy that these 
specific germs have been introduced into the 
system, and have found a favorable soil for 
their growth and multiplication in the cen¬ 
tral nervous system until their direct toxic 
effects are manifested by tetanic convulsions. 
The period of incubation in tetanus is not as 
well marked and definite sis in some other 
infectious diseases, but the same can be said 
of other affections where there can be no 
doubt concerning their microbic origin, hy¬ 
drophobia, for instance. The most charac¬ 
teristic symptom of tetanus consists in tonic 
spasm of certain well-defined muscular 
groups, as a rule, the affection following in a 
descending direction. We will, for the sake 
of convenience, assume that tetanus has fol¬ 
lowed a compound comminuted fracture of 
the leg, and will describe the symptoms in 
their proper order. About the fifth or sixth 
day (the earliest period of incubation) our 
patient will probably complain of a certain 
ill-feeling in the broken limb, marked by 
irregular jerking; if, at the same time, he 
complains of general malaise, loss of appe¬ 
tite, of symptoms indicative of infection, we 


should realize that these premonitory symp¬ 
toms are but the precursors of the gravest of 
all wound complications—tetanus. If these 
early symptoms are followed a little later by 
the appearance of trismus, there can be no 
further doubt as to the nature of the disease. 
By trismus, I mean a contraction of the mus¬ 
cles of mastication, as evidenced bv difficulty 
in opening the mouth. Going still further 
down, other muscular groups are implicated, 
and we have what is known as opisthotonos, 
a bending backwards of the body in contra¬ 
distinction to emprosthotonos, a bending of 
the body in the opposite direction. If the 
muscles on one side of the chest are 
affected, we have pleurosthotonos; if still 
further, all the muscles in the body (usually 
the extensors, however,) are affected, and the 
entire body becomes rigid, we have ortho- 
totonos. If the muscular spasms have be¬ 
come well developed, involving the area of 
the respiratory muscles, we expect an impair¬ 
ment of the function of respiration. By 
spasmodic contraction of the muscles con¬ 
cerned in that function, respiration becomes 
imperfect on account of the constant rigidity 
of the muscles which are active in producing 
the respiratory movements. 

The temperature is increased in almost 
every case, the rise depending upon the in- 


tensity of* the infection, the acuity of the 
attack, and especially the rapidity with 
which the disease progresses. A limited area 
of muscular rigidity and a slight rise in tem¬ 
perature, are favorable prognostic indications. 
In some instances the temperature has been 
found unusually high. A temperature of 
108°, even 110°, as observed by Wunderlich 
and Billroth, denotes great danger, and is 
almost without exception followed by a fatal 
termination. These authors have placed 
stress upon the importance of temperature 
in tetanus, watching its rise in the axilla at 
different times of the day, and observing that 
an increase of temperature beyond 104° or 
105° is usually followed by death. Another 
curious fact has been noticed, and that is an 
increase in temperature after death. Wun¬ 
derlich explains the high temperature in tet¬ 
anus by assuming a loss of function, or a loss 
of control of the heat moderators in the 
brain, the heat centres being impaired by the 
direct action of the poison upon this particu¬ 
lar portion of the cerebral mass. The post- 
mortal rise in temperature has been attributed 
by Fick and Huppert to evolution of heat 
during the coagulation of the myosin. The 
sensorium usually remains unimpaired to the 
last, showing distinctly that that portion of the 
brain concerned in that function remains un- 


impaired, that the disease for some unknown 
reason expends itself upon the motor tracts, 
and especially upon that portion of the cere- 
bro-spinal system connecting the brain and 
spinal cord, the medulla oblongata. When 
the spasms are severe and prolonged, the 
respiration becomes impaired, the pulse small 
and rapid, and the surface of the body is 
bathed with a profuse perspiration. As the 
disease progresses, evidences of capillary 
stasis become more and more apparent, the 
eyes are suffused, and the visible mucous mem¬ 
branes livid; the tongue is coated, appetite 
diminished, and the bow T els are obstinately 
constipated; all causes of peripheral irritation, 
as a draft of air, loud noises, etc., will pro¬ 
voke easily a repetition of spasmodic attacks. 

The first attempt at an intelligent explan¬ 
ation of the morbid anatomy af tetanus w 7 as 
offered by Rokitansky, who found on exam¬ 
ining the nerves supplying the injured part 
evidences of inflammation in the nerve it¬ 
self, and hence described the disease as a 
form of neuritis, a neuritis ascendens. As 
proof of this view of the disease he de¬ 
scribed the pathological conditions found in 
the affected nerves as consisting in an exuda¬ 
tion between the nerve fibres, granular de¬ 
generation and hyaline changes in the nerve 
fibres themselves, finally resulting in com 


plete disorganization and disintegration. He 
regarded the disease essentially as a “ neuritis 
ascendens,” the morbid process commencing 
in the nerve at the point of injury, and ex¬ 
tending by continuity to the cerebro-spinal 
centres. All pathologists agree that the 
brain and spinal cord are always found in a 
state of congestion, but some go still further 
—Lockhart, Clarke, and Dickinson, for in¬ 
stance, asserted that the brain was not only 
hvpersemic, but that there was an actual in¬ 
flammation of the cortex of the brain itself, 
resulting in granular disintegration. Others 
have found, on examining the spinal cord, 
pathological changes well marked in that 
portion of the nervous system, consisting of 
hypersemia, extravasation, softening, in¬ 
creased proliferation of connective tissue, de¬ 
generation of the anterior and posterior col¬ 
umns. Tyson, on the other hand, found in 
two cases well marked degeneration of the 
central canal and disintegration of the pos¬ 
terior columns of the cord. Aufrecht found 
cellular atrophy in the anterior and posterior 
cornua of the cord and granular degenera¬ 
tion of the gray substance of the cord. 
From all that I have stated it appears evi¬ 
dent that so far no unanimity exists among 
pathologists in localizing the central lesion, 
but from what we have learned it becomes 


apparent that the most constant pathological 
changes are found in the upper portion of 
the spinal cord. 

In considering the diagnosis, particular 
attention should be paid to the history of 
the case, fully eliciting the possibility of any 
previous traumatism or infection serving as 
a tangible cause. In cases of spasm of 
definite groups of muscles, we should ascer¬ 
tain the existence or absence of fever by the 
use of the thermometer. 

Although no uniform pathological condi¬ 
tion appears to have been found character¬ 
istic of tetanus, the weight of evidence points 
towards the spinal cord as the central seat of 
the lesion, in this respect showing a resem¬ 
blance to hydrophobia, an affection which it 
simulates in many respects. 

Muscular spasm resulting from a neurotic 
source and limited to a group of muscles 
unattended by general infection, is not 
marked by rise in temperature. If, on the 
other hand, we have muscular spasm at¬ 
tended by an increase of temperature (par¬ 
ticularly if we have reason to believe that it 
is the result of previous traumatism or infec¬ 
tion), the case becomes suspicious, and merits 
a scrutinizing examination. In tetanus, as 
a rule, the muscles on the extensor side are 
affected, while in cases of inflammatory dis- 


ease in bones and joints, the contractions oc¬ 
cur on the flexor side. 

In the differential diagnosis, consider the 
possibility of toxic tetanus from poisoning 
with strychnine or any of that class of rem¬ 
edies which are known to produce tetanic 
spasms. The mental condition of the pa¬ 
tient and the surrounding circumstances of 
the case will aid you greatly in eliminating 
uch a cause. In strychnine poisoning, 
orthotonos is produced as soon as the drug 
has been absorbed, and tetanic spasms of 
muscular groups pass in a descending direc¬ 

Hysteria may simulate tetanus, but you 
must remember that your hysterical patient 
cannot, for any length of time, maintain 
muscular spasm limited to definite muscular 
groups. The pupils of the eyes in tetanus 
are generally contracted, and the tempera¬ 
ture is increased, while in hysteria both of 
these symptoms are absent. 

The next disease which may be mistaken 
for tetanus is cerebro-spinal meningitis. If 
an epidemic of this disease prevails in your 
locality, carefully consider the differential 
diagnosis. In cerebro-spinal meningitis the 
symptoms point equally to an affection of the 
base of the brain, while brain symptoms 
proper do not belong to the clinical history 


of tetanus; hence, you will encounter symp¬ 
toms in the former which point towards an 
active inflammation of the meninges of the 
brain, as well as of the spinal cord. If the 
disease has lasted for a sufficient length of 
time, you will look for the symptoms aside of 
muscular spasm which characterize cerebro¬ 
spinal meningitis. Basilar meningitis is at¬ 
tended by symptoms indicating irritation at 
the base of the brain; and as it is almost al¬ 
ways of a tubercular nature, you will care¬ 
fully inquire into the history of the case, and 
concomitant tubercular lesions. 

The last disease which it might be mistaken 
for is hydrophobia. The muscular spasms 
in hydrophobia are more of a clonic charac¬ 
ter, and remain limited to the muscles of 
deglutition and respiration. In the progno¬ 
sis you must be guided, in the first place, by 
the extent of the central lesion, as evidenced 
by the number of muscular groups affected. 
If the central irritation is circumscribed, 
only a limited number of muscular groups 
are affected, and when this is the case, we 
are usually dealing with a mild form, of the 
disease. If, on the other hand, in the early 
history of the disease there is rigidity of an 
-extensive muscular area, the disease is a 
grave one ; and more particularly if at the 
same time, as will likely be the case, there is 
a high temperature. Time is one of your 


most important elements in rendering a prog¬ 
nosis. Hippocrates always considered the 
prognosis dubious the first four days. Severe 
cases may terminate fatally from the second 
to the sixth day, usually, so that time gained 
after the sixth day, with the symptoms re¬ 
maining stationary, the prognosis becomes 
more favorable as time increases. In the 
mild cases of tetanus, terminating in recov¬ 
ery, it may take weeks and sometimes months 
before all muscular rigidity has disappeared. 
I have observed several severe and acute 
cases where within forty-eight hours after the 
commencement of the first symptoms, death 
occurred; but after the sixth day, with symp¬ 
toms remaining stationary, the surgeon’s hope 
increases as time elapses. 

Another important point is the probable 
eause of the disease. If the injury has been 
slight, infection limited, the disease assuming 
a mild type, your prognosis may be favor¬ 
able ; but should the symptoms develop them¬ 
selves incidental to injuries grave in them¬ 
selves, the prognosis becomes correspondingly 
serious, so that in tetanus attending severe 
lesions, followed by traumatic infection of 
other types, attended, perhaps, by septicaemia 
or pyaemia, our prognosis always must be un¬ 
favorable ; in other words, if there is no pos¬ 
sibility of removing the primary cause or 


source of infection or irritation, the prognosis 
increases in gravity. 

Like in all other forms of wound infective 
diseases, the prophylactic treatment is the 
most important. Practically, it is important 
to recognize the microbic origin, and insti¬ 
tute early and efficient treatment in accord¬ 
ance with this supposition. I therefore, 
again, emphasize the necessity of adopting 
aseptic measures in the treatment of wounds, 
with a view not only of preventing suppur¬ 
ation, but also other forms of infection. 
There can be no question but that since the 
introduction of antiseptic surgery tetanus 
has been uncommon. The clinical fact is 
patent that it is prone to follow injuries 
where a foreign body has remained in the 
wound, and where subsequently from this 
cause there is greater danger of infection on 
the one hand, and peripheral irritation on 
the other ; this is especially true of injuries 
about the hand. It is therefore of para¬ 
mount importance to treat slight injuries of 
the hand, and more especially 4th of July 
injuries, which so frequently end in tetanus, 
with the greatest care. No matter how 
trifling the injury may be, disregard in this 
direction has only too often been followed by 
the most serious consequences. A small 
Wound of the hand when neglected may serve 


as aii avenue for the ingress of germs, which 
according to their action may destroy life in 
a variety of ways. If necessary, enlarge 
the wound, search carefully for foreign 
bodies, if there is reason to believe that they 
are present; take plenty of time to secure 
an aseptic condition for the wound, and con¬ 
duct the subsequent treatment on strictlj 
antiseptic principles. If- suppuration should 
take place, be sure to secure efficient drain¬ 
age, and resort to frequent antiseptic irriga¬ 
tions. By following these directions you 
will not only have the satisfaction of secur* 
ing the most favorable condition for the heal¬ 
ing of the wound, but you will have, at the 
same time, carried out the most efficient pro¬ 
phylactic treatment against tetanus. 

In the curative treatment, we consider 
first the importance of removing the source 
of infection and irritation. If a foreign 
body remains in the wound, search diligently 
for it, and if possible remove it. If the in¬ 
jury is attended by inflammation, burrowing 
of pus, destruction of tissue underneath the 
skin, secure ample and efficient drainage; 
in other words, convert the wound, as near 
as you can, from a septic into an aseptic 
condition. If we are dealing with a painful 
or tender cicatrix, which by producing 
peripheral irritation may determine tetanic 


spasms, it is proper to excise it. We can 
readily conceive that the infection may have 
been so mild as to produce only slight 
changes in the spinal cord, which but for 
some peripheral irritation would not have 
resulted in muscular spasms, and these are 
the cases where the removal of the exciting 
cause of’the spasms is followed by a cure. 
I recollect a case of a mild form of tetanus, 
the result of a slight injury at the distal ex¬ 
tremity of the index finger, which left a 
painful, tender scar, where the trismus was 
always increased by pressure, and which 
yielded promptly to removal of the exciting 

Another practical point in the treatment 
is the consideration of the propriety of am¬ 
putation. If we are dealing with a com¬ 
pound comminuted fracture of the leg or 
a rra, attended by all the symptoms of wound 
infection, and if present indications point 
towards the fact that the limb, independently 
of the existence of this complication, could 
not be saved, it is only rational to resort to 
amputation. It is, however, proper to state 
that in the great majority of the cases thus 
treated the tetanus continued unabated after 
the operation, and only in exceptional cases 
has life been saved by this procedure. Rec¬ 
ognizing the fact that according to Rokitan- 


sky’s theory, tetanus simply means “ an as¬ 
cending neuritis from the point of injury to 
the spinal cord,” attempts have been made to 
arrest the progress of the disease by inter¬ 
rupting the nerve above the disease by nerve 
section, but results have shown that this op¬ 
eration had no effect in modifying the ter¬ 
mination of the disease. You will readily 
understand why, if you assume its central 
location and its infective character. If tet¬ 
anus were simply a “ neuritis ascendens,” 
we might reasonably expect to arrest the 
progress of the disease by division of the 
nerve trunk, by making the section through 
healthy tissue on the proximal side of tbe 
inflamed portion of the nerve. Granted 
that this operation would be efficient in pre¬ 
venting extension of the inflammatory pro¬ 
cess, it would not be applicable in all in¬ 
stances, from the inability of the surgeon to 
locate the disease with sufficient accuracy. 
Imagine an injury involving the palm of the 
hand, where we have filaments of different 
nerves implicated; it would be difficult if not 
impossible to ascertain in every case which 
nerve trunk was the seat of irritation. Tak¬ 
ing it for granted that the neuritis is simply 
a local expression of the nerve injury, and 
that the real cause of tetanus consists in a 
specific infection, expending itself upon the 


brain and spinal cord, all efforts at correct¬ 
ing or curing the disease by submitting 
nerve trunks to operative measures are in 
discord with the true pathology of the dis¬ 
ease. A somewhat similar and more recent 
operation for the same object as nerve section, 
we find in nerve stretching. For the last 
few years it has become the operation for all 
obscure nervous diseases, such as locomotor 
ataxia and central irritation of various 
kinds; consequently it is not surprising that 
it has been resorted to in the treatment of 

Benedict collected twenty-four cases of 
traumatic tetanus treated by nerve-stretch¬ 
ing, of which number four recovered. I have 
stated that the disease in the milder form 
shows a tendency to cure itself; consequently, 
all operative measures which have been re¬ 
sorted to for the purpose of arresting its pro¬ 
gress must be accepted with a great deal of 
caution, inasmuch as statistics have shown, 
on the whole, that twenty-five per cent, have 
recovered without operative interference by 
the ordinary treatment; consequently, we 
have no proof that these four cases would 
not have recovered without nerve-stretching. 
All the possible good that can accrue from 
operations on nerve-trunks is simply to in¬ 
terrupt the nerve-current between the central 


disease and the peripheral irritation, and in 
many instances it is impossible to decide 
which of the larger trunks connects the two. 

The medical treatment consists in the ad¬ 
ministration of drugs which are known to 
relieve muscular spasm. In animals tetan- 
ized with strychnine the spasms are promptly 
relieved by injecting hydrate of chloral into 
the veins. Woorara has been given with a 
view of relieving muscular spasm. On ac¬ 
count of the potency of this remedy, its ef¬ 
fects must be carefully watched and its use 
promptly suspended as soon as its physio¬ 
logical action becomes apparent. It is best 
administered hypodermatically. Bromide of 
potassium in large doses is well known to 
cause cerebral anaemia, and on this account 
it should be given to relieve the hvperaemia 
which is always present in the cerebro-spinal 
centres. A combination best adapted to ful¬ 
fil the two most urgent indications, to relieve 
cerebral and spinal congestion and to over¬ 
come muscular spasm, are chloral and bro¬ 
mide of potassium. The remedies should be 
given in large doses, frequently repeated, un¬ 
til the desired result has been obtained. In 
severe cases, chloroform should be adminis¬ 
tered by inhalation with a view of relieving 
urgent symptoms; cold drafts of air, noise, 
and all forms of peripheral irritation, should 


be carefully excluded from the patient’s 
room, for the purpose of securing rest, and 
with a view of not aggravating reflex spasm. 
Alcoholic stimulants and external heat are 
indicated when the heart’s action has become 
feeble from general capillary stasis.