Tetanus
TETANUS (from Gr. rtlvw, I stretch, on account of the tension of the fibres of the affected muscles), or LOCKJAW, a disease caused by the bacilli Tetani (see PARASITIC DISEASES). The home of these bacilli is the earth, and so it comes about that if a man is thrown off his bicycle and grazes his ungloved hand upon the road, or running without shoes cuts his foot, there is a considerable chance of the bacilli entering the wound and giving him lockjaw. It is popularly thought that wounds in the region of the thumb are most often followed by the disease, but this is not a fact. Wounds about the thumb are of common occurrence, but they are not, in proportion, more often the starting point of tetanus.
Acute traumatic tetanus is very deadly, and up to the present time nothing has been discovered to check or guide its almost certainly fatal course. It often picks out the young and vigorous as its victims the athlete, for instance, who meets with some mishap in the field or on the road, the gardener who pricks his hand, the swimmer who cuts his foot, the wounded soldier on the field of battle. The violent muscular contractions are distressingly painful; and the brain remaining perfectly clear throughout, the unhappy individual feels that the vicelike gripping of his muscles is steadily exhausting him and bringing him down. The spasms of tetanus differ from those caused by the administration of strychnine in that the muscles are all the time hard from rigid contraction, the acute spasmodic attacks being superadded, as it were. In poisoning by strychnine the muscles are quite relaxed between the spasmodic attacks. , Tetanus may follow a mere prick or scratch or a severe surgical operation. It not seldom complicates burns, gunshot wounds and injuries caused by the untimely explosion of fireworks. It may be met with in the woman in child-bed or in the newly-born infant. But wherever it occurs it is due to the one cause to the reception into some wounded surface of the specific germs.
In hot countries tetanus is more common and more acute than it is in temperate climes, and a case has been recorded in which a man in the West Indies cut his hand on a broken plate at dinner and was dead of tetanus before the day was out. It is easy to see that the germs are more likely to undergo virulent cultivation in warm earth than in cold. It was formerly the custom to speak of idiopathic tetanus that is to say, of the disease occurring without any wound having been received. But modern teaching is to the effect that there must have been some wound, however slight, by which the germs found entrance. Rheumatic tetanus is as unreal a disease as that just mentioned. The germs themselves do not wander from the wound to multiply in the blood as in infecting diseases, but remaining at the wound elaborate a terribly poisonous substance (a toxin) which makes its way along the nerve-trunks to the spinal cord. Even prompt amputation, however, is likely to prove ineffectual as regards cure, for the germs in the wound have in this growth set free so virulent a poison (toxin) that the nerves of the voluntary muscles all over the body are hopelessly under its influence.
The first symptom of the disease is discomfort in the back of the neck; the man waking up in the morning, for instance, complains of " stiff neck " and of obscure pains, and wonders if he has been lying in a draught. Then the muscles of the jaw and of the face become affected, there being a difficulty in opening the mouth, and the corners of the mouth are drawn downwards and backwards, and fixed in that position (risus sardonicus). The jaw is so firmly set that it is impossible to pass anything between the teeth. All food, therefore, has to be fluid, and being poured into the pouch of the cheek, finds its way into the mouth by the serviceable gap which exists behind the wisdom-teeth. Soon, however, a difficulty in swallowing comes on because of the muscles of the throat being involved. The muscles of the abdomen becoming contracted are rigidly fixed, and on laying the hand upon the front of the abdomen they feel as " hard as a board." The muscles of the limbs are also attacked with fearful cramps, and, last of all, the muscles of the chest are involved. Though all these muscles are in a continuous state of contraction, spasmodic contractions, as already remarked, come on in addition, and occasionally with such distressing energy that the patient is doubled up forwards, backwards, or sideways, and, may be, some of the muscles tear across. The patient is bathed in perspiration, and sinks worn out and exhausted, or, perchance, slowly suffocated by the locking of the muscles of respiration.
As regards the prospect of recovery in tetanus it may be said that when the symptoms break out acutely within a week of the reception of an injury the prospect of recovery is extremely remote. If they occur within ten days the prospects are bad. But if there is an interval of three weeks or a fortnight before their occurrence the case may be regarded more hopefully.
In the treatment of tetanus the first thing to do is to try to make the wound by which infection has taken place surgically clean. For though a wound free from the germs of suppuration may be the incubating place of the bacilli of tetanus, still in most cases there is also an invasion of septic germs, and the double infection makes the action of the tetanic poison the more virulent. If the local conditions are such that it is impossible to cleanse the wound, the free use of the knife or of the cautery or of pure carbolic acid may be resorted to, or an amputation may be performed. But even the early amputation of the infected part may not avail for the reason that the germs in the wound have already set free a lethal dose of their toxin.
The wound having been cleansed the further treatment of the disease demands absolute quiet in a darkened room. There must be no slamming of the door, shaking of the bed, or the sudden bringing in of a light, for any act such as this might cause the outbreak of a violent spasm. Morphia may be given by the hypodermic syringe, and if the spasms are causing great distress chloroform may be administered; indeed, in certain severe cases it may be necessary to keep the patient almost continuously under its influence. If there is difficulty in swallowing fluid, rectal feeding must be resorted to. Though at present one is unable to speak enthusiastically or with confidence about the antitoxin treatment of lockjaw, still it is a method which should certainly be given trial and that early. The tetano-antitoxin is prepared from the blood of animals which have been rendered immune to repeated injections of the poison elaborated by the cultivation of the tetanus bacilli. The bacilli themselves are not injected, the injections being rendered sterile. By passing the sterile injections into one of the lower animals the blood of that animal prepares an antidote to them known as an antitoxin.
The antitoxin may be injected into the nerve trunks or into the sheath of the spinal cord or of the brain. But inasmuch as the nerves and the nerve-cells are under the influence of the toxin before the antitoxin is administered as evidenced by the occurrence of the symptoms the injection-treatment has but a poor chance of producing a good effect. (E. O.*)
Note - this article incorporates content from Encyclopaedia Britannica, Eleventh Edition, (1910-1911)
