FATAL CASE OF IDIOPATHIC TETANUS IN A EUROPEAN. By J. Fayeek, M.D., C.S.I. On the 27th of March, 1870, I 'was requested to see Mr. 36 years, of stout frame, S. , a Greek gentleman, aged dark hair and anaemic lymphatic temperament, though complexion. lie had returned to India about fifteen months ago, after a visit of three years to Europe, having previously resided for six years in Calcutta, during which time his health had been During his last visit to Europe he
D.
with^
moderately good.
suffered from some severe abdominal disorder, probably enteritis, but he had regained his health when he returned to Calcutta. I found him suffering from a slight feverish attack, for which I ordered a simple diaphoretic, and enjoined quiet and rest
at home for the day. He complained also of a pain in the right as the stethospectoral region, which was apparently muscular, thoracic mischief. For this I recomcope did not indicate any mended a sinapism and some simple,embrocation. The weather had during the previous day or two become very hot, and a dry south-westerly wind was blowing. On the 28th, he was better, but not well enough to go to his _
office; he was advised to remain at home. I observed that his very close and warm, as the windows had all been kept carefully closed; and recommended more ventilation. He said that the pain in the chest was almost gone. I again made a most careful examination, and could detect no sign of either hepatic or pulmonic disorder. I recommended a better diet and some wine. room was
106
THE INDIAN MEDICAL GAZETTE.
On the
29th, -when I went to see him, his servants said he better, and had gone to his office. On the 30th, he called on me at about 11 a.m., and said he was not feeling well; he had a sensation of stiffness in his neck, which he attributed to a chill, the result of going out into the open air from his warm room, when he was perspiring freely; otherwise he was better, had no fever, and his bowels were open, but he had had a restless night, and he looked anxious and uneasy. I ordered an anodyne liniment, and recommended him was
to avoid exposure to currents of air. In the evening I received a note saying that he was not better, and requesting me to go and see him. I did so, and found him alarmed and anxious about his condition. He was restless and uneasy, complaining of stiffness in the neck and jaws, and difficulty of swallowing, but, withal, no pain. lie looked dark under the eyes; his skin was moist, with cold sweat; and his pulse about 90?. He could open his mouth, but imperfectly, and there seemed to be general rigidity of all the muscles of mastication and deglutition. I ordered hot fomentations, an anodyne embrocation, and sedatives. I saw him again at 7-30 p.m. and remained some time watching him anxiously. I prescribed Caunabis indica and chloroform internally, with hot stupes to the neck and jaws, which gave some relief. He was thirsty, and drank iced-water pretty freely, but with some spasm; he tried to take soup but very little was swallowed. The rigidity of the neck and occasional spasms of the masseters was increasing ; the head was drawn backwards and carried in a peculiarly stiff and erect position. My suspicions were now confirmed, and as I could find no history of any traumatic origin, it was evident that idiopathic tetanus was rapidly setting in. I expressed my fears for the result to his friend, and suggested further advice. Meanwhile, the fomentations and medicines were continued, and beef-tea administered frequently. The attempt to swallow it was always attended by spasm. The effort to expectorate viscid mucus had the same effect. Drs. C. Palmer and Partridge saw him, and it was decided that the medicines should be continued. Belladonna liniment applied to the neck, and nourishment given frequently. The bowels to be again acted on by enemata, and if the difficulty of swallowing became greater, the medicines to be given by enema. Nutrient enemata were also ordered, and the administration of chloroform at intervals prescribed. Notwithstanding treatment, the tetanic spasms rapidly increased with renewed intensity. He was much exhausted after each, and his body bathed with cold sweat. The countenance became livid and distorted, as the respiratory and laryngeal muscles were involved, and during the paroxysms opisthotonos was severe. The pulse became rapid and feeble, at times very irregular and intera as for time, mittent, pausing though the heart itself shared in the general muscular spasm. His consciousness remained, he occasionally tried to speak, and asked the nurse to open a window. The least touch brought on the spasm, which rapidly involved the abdominal and thoracic muscles, and left him quite exhausted. The last and fatal paroxysm occurred at about 11-30, and at i to 12 he died, completely exhausted by its violence. The pulse had ceased, it returned again for a moment, and then ceased altogether. Idiopathic tetanus in the adult European is a rare form of the disease, and comparatively seldom witnessed. This was one of the most severe and rapid cases I have seen. The only cause that could be assigned was the sudden exposure when the a to relatively cold atmosphere, body was relaxed by the heat of a warm room, and when the constitution after a slight febrile attack. The was somewhat depressed atmospheric influence at the time was no doubt evil, and favorable to the development and rapid course of acute disease. The setting in of the extreme heat is always most trying to the European constitution, and at such times disease has a tendency to be rapid as well as acute. Idiopathic tetanus is not I have observed that it uncommon among the natives of India. has a greater tendency to occur at the changes of the seasons, when there are great and sudden alternations in temperature. It is not, as a general rule, so fatal as the traumatic form of the disease, and recoveries are not uncommon; although, as in the present case, it is frequently very severe and rapidly fatal.
[May 2,
1870.
D.
with^
moderately good.
suffered from some severe abdominal disorder, probably enteritis, but he had regained his health when he returned to Calcutta. I found him suffering from a slight feverish attack, for which I ordered a simple diaphoretic, and enjoined quiet and rest
at home for the day. He complained also of a pain in the right as the stethospectoral region, which was apparently muscular, thoracic mischief. For this I recomcope did not indicate any mended a sinapism and some simple,embrocation. The weather had during the previous day or two become very hot, and a dry south-westerly wind was blowing. On the 28th, he was better, but not well enough to go to his _
office; he was advised to remain at home. I observed that his very close and warm, as the windows had all been kept carefully closed; and recommended more ventilation. He said that the pain in the chest was almost gone. I again made a most careful examination, and could detect no sign of either hepatic or pulmonic disorder. I recommended a better diet and some wine. room was
106
THE INDIAN MEDICAL GAZETTE.
On the
29th, -when I went to see him, his servants said he better, and had gone to his office. On the 30th, he called on me at about 11 a.m., and said he was not feeling well; he had a sensation of stiffness in his neck, which he attributed to a chill, the result of going out into the open air from his warm room, when he was perspiring freely; otherwise he was better, had no fever, and his bowels were open, but he had had a restless night, and he looked anxious and uneasy. I ordered an anodyne liniment, and recommended him was
to avoid exposure to currents of air. In the evening I received a note saying that he was not better, and requesting me to go and see him. I did so, and found him alarmed and anxious about his condition. He was restless and uneasy, complaining of stiffness in the neck and jaws, and difficulty of swallowing, but, withal, no pain. lie looked dark under the eyes; his skin was moist, with cold sweat; and his pulse about 90?. He could open his mouth, but imperfectly, and there seemed to be general rigidity of all the muscles of mastication and deglutition. I ordered hot fomentations, an anodyne embrocation, and sedatives. I saw him again at 7-30 p.m. and remained some time watching him anxiously. I prescribed Caunabis indica and chloroform internally, with hot stupes to the neck and jaws, which gave some relief. He was thirsty, and drank iced-water pretty freely, but with some spasm; he tried to take soup but very little was swallowed. The rigidity of the neck and occasional spasms of the masseters was increasing ; the head was drawn backwards and carried in a peculiarly stiff and erect position. My suspicions were now confirmed, and as I could find no history of any traumatic origin, it was evident that idiopathic tetanus was rapidly setting in. I expressed my fears for the result to his friend, and suggested further advice. Meanwhile, the fomentations and medicines were continued, and beef-tea administered frequently. The attempt to swallow it was always attended by spasm. The effort to expectorate viscid mucus had the same effect. Drs. C. Palmer and Partridge saw him, and it was decided that the medicines should be continued. Belladonna liniment applied to the neck, and nourishment given frequently. The bowels to be again acted on by enemata, and if the difficulty of swallowing became greater, the medicines to be given by enema. Nutrient enemata were also ordered, and the administration of chloroform at intervals prescribed. Notwithstanding treatment, the tetanic spasms rapidly increased with renewed intensity. He was much exhausted after each, and his body bathed with cold sweat. The countenance became livid and distorted, as the respiratory and laryngeal muscles were involved, and during the paroxysms opisthotonos was severe. The pulse became rapid and feeble, at times very irregular and intera as for time, mittent, pausing though the heart itself shared in the general muscular spasm. His consciousness remained, he occasionally tried to speak, and asked the nurse to open a window. The least touch brought on the spasm, which rapidly involved the abdominal and thoracic muscles, and left him quite exhausted. The last and fatal paroxysm occurred at about 11-30, and at i to 12 he died, completely exhausted by its violence. The pulse had ceased, it returned again for a moment, and then ceased altogether. Idiopathic tetanus in the adult European is a rare form of the disease, and comparatively seldom witnessed. This was one of the most severe and rapid cases I have seen. The only cause that could be assigned was the sudden exposure when the a to relatively cold atmosphere, body was relaxed by the heat of a warm room, and when the constitution after a slight febrile attack. The was somewhat depressed atmospheric influence at the time was no doubt evil, and favorable to the development and rapid course of acute disease. The setting in of the extreme heat is always most trying to the European constitution, and at such times disease has a tendency to be rapid as well as acute. Idiopathic tetanus is not I have observed that it uncommon among the natives of India. has a greater tendency to occur at the changes of the seasons, when there are great and sudden alternations in temperature. It is not, as a general rule, so fatal as the traumatic form of the disease, and recoveries are not uncommon; although, as in the present case, it is frequently very severe and rapidly fatal.
[May 2,
1870.
