CASES OF TRAUMATIC
By
TETANUS
(AMPUTATION.)
J. Fayreh, M.D.
Case I.?Shekh Tez Ally, a Mahomedan coolie, aged 30, admitted on the 23rd October, 1871, with a lacerated wound of the end of the right great toe, caused by a carriage wheel passing over it. The wound was dressed and the foot placed at rest on a splint. On the '25th symptoms of gangrene of the injured part A grain of opium was given every 4th hour. were evident. On the 27th the toe was partially amputated, the distal and articular surfaces of the first phalanges were removed. The wound progressed'favorably, but on the 3rd November, symptoms of tetanus set in, though not so violently. Rigidity of the muscles of the neck and back, and the peculiar tetanic expression, were the first indications of its invasion. Hydrate of chloral in 15 grain doses and foetid enemata were ordered to be given every 6 hours. The On the 5th the tetanic symptoms became more severe. remainder of the first phalanx was now removed, and the wound dressed with an opium solution. The dose of hydrate of chloral was also increased to 20 grains. Nutritious food and wine were freely administered. His pulse varied from 90 to 95, and temperature from 99? to 101?. He was able to take food and medicine, as the trismus was less severe than the general tetanic spasm in the limbs, neck and trunk. After the operation the tetanic symptoms gradually abated and the wound healed rapidly. He is now, on the 14th December, perfectly well, and only remains in hospital as the stump is still tender and he walks with difficulty. Case II.?Gunesh, a Hindoo coolie, aged 41, admitted into the Medical College Hospital on the 11th October, 1871, with tetanic symptoms. Trismus and opisthotonos had set in four days before admission, and were apparently due to a wound in the end of the left index finger, which had nearly cicatrized. On the 12th the distal phalanx including the cicatrizing wound was removed, and tincture cannabis gtt. xx, with chloroform gtt. xv. were ordered every 4 hours, the bowels to be relieved by enemata. On the 13th the hydrate of chloral, in doses of gr. xv. every 4 hours, was prescribed, and the wound dressed with opium lotion. On the 14th the opisthotonos increased, the fits being more frequent and severe. The dose of hydrate of chloral was now increased to gr. xxv., and chloroform liniment was rubbed into the back after hot fomentations frequently applied. On the 20th the tetanic fits had much abated, and he was able to open his mouth and take food more freely. His strength had meanwhile been supported by nutritious diet and wine. The pulse varied from 96 to 100, the temperature from 98J to 100?. By the 23rd the tetanic spasms had almost disappeared, the wound had nearly cicatrized. The dose of hydrate of chloral He gradually was now decreased in quantity and frequency. improved, although rigidity and myalgia remained. For some days he walked with difficulty, with the aid of a stick, and his countenance presented a peculiarly aged and distorted appearanee, the result of muscular spasm; his figure became bent and aged in appearance. He was finally discharged, cured, on 10th November, 1871. Cass III.?11. R. , an East Indian student, aged 16, was admitted on the 6th November, 1871, with a small cicatrizing wound on the dorsum of the right foot, said to have been caused by the fulling of a beef bone on it. On the 7th the symptoms of tetanus, trismus and pain in the back set in. Hydrate of chloral, gr. xv. every 4 hours, was ordered after his bowels had been thoroughly relieved. On the 8th severe tetanic fits occurred, and the cicatrix above mentioned was then carefully dissected away. The wound was dressed with cpium lotion. The dose of hydrate of chloral was increased to 25 grains. He was diligently supported by wine and nutritious diet. On the 9th the tetanic fits becoming more severe, the dose of hydrate of chloral was again increased to 30 grains, and occasional inhalation of chloroform was ordered. The fits were distinctly opisthotonos. From this date his temperature began to rise from 99? to 103?5. His pulse during these days varied between 112 and 116. From the 11th the fits became still more severe, at longer intervals. The muscles of the jaw contracting to such a degree that he was unable to take any liquid food, nutrient enemata were ordered. Gradually the spasms became more violent, and the temperature rose to .104?. He died suddenly during a fit on the 17th November, 1871. No post-mortem allowed. was
?
36
THE INDIAN MEDICAL GAZETTE.
Remarks.?Cases 1 and 2 recovered from well-marked symptoms of traumatic tetanus after amputation of the wounded part in which the disease originated. In the third case removal of the cicatrix was not successful, the disease progressed, and the patient died. In two cases there could be no doubt that the origin of the disease was completely removed, for as the wound was situated on the digits, and those parts were amputated, the injured afferent nerves, viz., those which conveyed the evil influence to the nerve centres, were necessarily divided. The source of disturbance being removed, the symptoms subsided and the patients I have on a former occasion recorded a similar case recovered. in which a favorable issue resulted, and those now noted tend to prove that if the part, whence the irritation sets out, and which if allowed to remain, excites that peculiar polar condition of the cord which results in the waste of nerve force, tetanus, be removed early, the perturbation though great, is not necessarily permanent, and may subside. Though no one would hesitate to amputate a finger or toe in such a case, most would hesitate to apply the same treatment in the case of a limb, uutil the symptoms of tetanic spasm became so severe as to leave no doubt as to the greater danger incurred from the disease ; unfortunately it is then too late ; the disease is thoroughly established, and amputation is as powerless to remove the results as any other remedy. In so desperate a disease as traumatic tetanus, the most desperate remedies are justifiable, and I would suggest the advantage of resorting to amputation, even of a leg, on the earliest invasion of the symptoms. Amputation, I am quite aware, has often been practised and with unfavorable results, but I am inclined to believe that it has not, as a general rule, been resorted to early enough to give it a fair chance of success. No one would recommend amputation of the limb if the peccant nerve could be isolated and divided, as in the case of that leading from a finger or a toe. In a wound of the leg or arm it is almost impossible to indicate the branch or trunk that is the conductor of mischief to the centre ; and therefore to secure its division the whole limb must be removed. The hydrate of chloral may have had something to say to the recovery in these cases, but I have not found it successful except as euthanasia, in these cases.
[Febeuaey 1,
1872.
By
TETANUS
(AMPUTATION.)
J. Fayreh, M.D.
Case I.?Shekh Tez Ally, a Mahomedan coolie, aged 30, admitted on the 23rd October, 1871, with a lacerated wound of the end of the right great toe, caused by a carriage wheel passing over it. The wound was dressed and the foot placed at rest on a splint. On the '25th symptoms of gangrene of the injured part A grain of opium was given every 4th hour. were evident. On the 27th the toe was partially amputated, the distal and articular surfaces of the first phalanges were removed. The wound progressed'favorably, but on the 3rd November, symptoms of tetanus set in, though not so violently. Rigidity of the muscles of the neck and back, and the peculiar tetanic expression, were the first indications of its invasion. Hydrate of chloral in 15 grain doses and foetid enemata were ordered to be given every 6 hours. The On the 5th the tetanic symptoms became more severe. remainder of the first phalanx was now removed, and the wound dressed with an opium solution. The dose of hydrate of chloral was also increased to 20 grains. Nutritious food and wine were freely administered. His pulse varied from 90 to 95, and temperature from 99? to 101?. He was able to take food and medicine, as the trismus was less severe than the general tetanic spasm in the limbs, neck and trunk. After the operation the tetanic symptoms gradually abated and the wound healed rapidly. He is now, on the 14th December, perfectly well, and only remains in hospital as the stump is still tender and he walks with difficulty. Case II.?Gunesh, a Hindoo coolie, aged 41, admitted into the Medical College Hospital on the 11th October, 1871, with tetanic symptoms. Trismus and opisthotonos had set in four days before admission, and were apparently due to a wound in the end of the left index finger, which had nearly cicatrized. On the 12th the distal phalanx including the cicatrizing wound was removed, and tincture cannabis gtt. xx, with chloroform gtt. xv. were ordered every 4 hours, the bowels to be relieved by enemata. On the 13th the hydrate of chloral, in doses of gr. xv. every 4 hours, was prescribed, and the wound dressed with opium lotion. On the 14th the opisthotonos increased, the fits being more frequent and severe. The dose of hydrate of chloral was now increased to gr. xxv., and chloroform liniment was rubbed into the back after hot fomentations frequently applied. On the 20th the tetanic fits had much abated, and he was able to open his mouth and take food more freely. His strength had meanwhile been supported by nutritious diet and wine. The pulse varied from 96 to 100, the temperature from 98J to 100?. By the 23rd the tetanic spasms had almost disappeared, the wound had nearly cicatrized. The dose of hydrate of chloral He gradually was now decreased in quantity and frequency. improved, although rigidity and myalgia remained. For some days he walked with difficulty, with the aid of a stick, and his countenance presented a peculiarly aged and distorted appearanee, the result of muscular spasm; his figure became bent and aged in appearance. He was finally discharged, cured, on 10th November, 1871. Cass III.?11. R. , an East Indian student, aged 16, was admitted on the 6th November, 1871, with a small cicatrizing wound on the dorsum of the right foot, said to have been caused by the fulling of a beef bone on it. On the 7th the symptoms of tetanus, trismus and pain in the back set in. Hydrate of chloral, gr. xv. every 4 hours, was ordered after his bowels had been thoroughly relieved. On the 8th severe tetanic fits occurred, and the cicatrix above mentioned was then carefully dissected away. The wound was dressed with cpium lotion. The dose of hydrate of chloral was increased to 25 grains. He was diligently supported by wine and nutritious diet. On the 9th the tetanic fits becoming more severe, the dose of hydrate of chloral was again increased to 30 grains, and occasional inhalation of chloroform was ordered. The fits were distinctly opisthotonos. From this date his temperature began to rise from 99? to 103?5. His pulse during these days varied between 112 and 116. From the 11th the fits became still more severe, at longer intervals. The muscles of the jaw contracting to such a degree that he was unable to take any liquid food, nutrient enemata were ordered. Gradually the spasms became more violent, and the temperature rose to .104?. He died suddenly during a fit on the 17th November, 1871. No post-mortem allowed. was
?
36
THE INDIAN MEDICAL GAZETTE.
Remarks.?Cases 1 and 2 recovered from well-marked symptoms of traumatic tetanus after amputation of the wounded part in which the disease originated. In the third case removal of the cicatrix was not successful, the disease progressed, and the patient died. In two cases there could be no doubt that the origin of the disease was completely removed, for as the wound was situated on the digits, and those parts were amputated, the injured afferent nerves, viz., those which conveyed the evil influence to the nerve centres, were necessarily divided. The source of disturbance being removed, the symptoms subsided and the patients I have on a former occasion recorded a similar case recovered. in which a favorable issue resulted, and those now noted tend to prove that if the part, whence the irritation sets out, and which if allowed to remain, excites that peculiar polar condition of the cord which results in the waste of nerve force, tetanus, be removed early, the perturbation though great, is not necessarily permanent, and may subside. Though no one would hesitate to amputate a finger or toe in such a case, most would hesitate to apply the same treatment in the case of a limb, uutil the symptoms of tetanic spasm became so severe as to leave no doubt as to the greater danger incurred from the disease ; unfortunately it is then too late ; the disease is thoroughly established, and amputation is as powerless to remove the results as any other remedy. In so desperate a disease as traumatic tetanus, the most desperate remedies are justifiable, and I would suggest the advantage of resorting to amputation, even of a leg, on the earliest invasion of the symptoms. Amputation, I am quite aware, has often been practised and with unfavorable results, but I am inclined to believe that it has not, as a general rule, been resorted to early enough to give it a fair chance of success. No one would recommend amputation of the limb if the peccant nerve could be isolated and divided, as in the case of that leading from a finger or a toe. In a wound of the leg or arm it is almost impossible to indicate the branch or trunk that is the conductor of mischief to the centre ; and therefore to secure its division the whole limb must be removed. The hydrate of chloral may have had something to say to the recovery in these cases, but I have not found it successful except as euthanasia, in these cases.
[Febeuaey 1,
1872.
