Manual of Surgery Volume I Part 13

One of the most constant symptoms is a copious perspiration, the patient being literally bathed in sweat. The urine is diminished in quant.i.ty, but as a rule is normal in composition; as in other acute infective conditions, alb.u.men and blood may be present. Retention of urine may result from spasm of the urethral muscles, and necessitate the use of the catheter.

The fits may cease some time before death, or, on the other hand, death may occur during a paroxysm from fixation of the diaphragm and arrest of respiration.

_Differential Diagnosis._--There is little difficulty, as a rule, in diagnosing a case of fulminating teta.n.u.s, but there are several conditions with which it may occasionally be confused. In _strychnin poisoning_, for example, the spasms come on immediately after the patient has taken a toxic dose of the drug; they are clonic in character, but the muscles are relaxed between the fits. If the dose is not lethal, the spasms soon cease. In _hydrophobia_ a history of having been bitten by a rabid animal is usually forthcoming; the spasms, which are clonic in character, affect chiefly the muscles of respiration and deglut.i.tion, and pa.s.s off entirely in the intervals between attacks.

Certain cases of _haemorrhage into the lateral ventricles_ of the brain also simulate teta.n.u.s, but an a.n.a.lysis of the symptoms will prevent errors in diagnosis. _Cerebro-spinal meningitis_ and _basal meningitis_ present certain superficial resemblances to teta.n.u.s, but there is no trismus, and the spasms chiefly affect the muscles of the neck and back. _Hysteria and catalepsy_ may a.s.sume characters resembling those of teta.n.u.s, but there is little difficulty in distinguis.h.i.+ng between these diseases. Lastly, in the _tetany_ of children, or that following operations on the thyreoid gland, the spasms are of a jerking character, affect chiefly the hands and fingers, and yield to medicinal treatment.

#Chronic Teta.n.u.s.#--The difference between this and acute teta.n.u.s is mainly one of degree. Its incubation period is longer, it is more slow and insidious in its progress, and it never reaches the same degree of severity. Trismus is the most marked and constant form of spasm; and while the trunk muscles may be involved, those of respiration as a rule escape. Every additional day the patient lives adds to the probability of his ultimate recovery. When the disease does prove fatal, it is from exhaustion, and not from respiratory or cardiac spasm. The usual duration is from six to ten weeks.

#Delayed Teta.n.u.s.#--During the European War acute teta.n.u.s occasionally developed many weeks or even months after a patient had been injured, and when the original wound had completely healed. It usually followed some secondary operation, _e.g._, for the removal of a foreign body, or the breaking down of adhesions, which aroused latent organisms.

#Local Teta.n.u.s.#--This term is applied to a form of the disease in which the hypertonus and spasms are localised to the muscles in the vicinity of the wound. It usually occurs in patients who have had prophylactic injections of anti-tetanic serum, the toxins entering the blood being probably neutralised by the antibodies in circulation, while those pa.s.sing along the motor nerves are unaffected.

When it occurs in the _limbs_, attention is usually directed to the fact by pain accompanying the spasms; the muscles are found to be hard and there are frequent twitchings of the limb. A characteristic reflex is present in the lower extremity, namely, extension of the foot and leg when the sole is tickled.

_Cephalic Teta.n.u.s_ is another localised variety which follows injury in the distribution of the facial nerve. It is characterised by the occurrence on the same side as the injury, of facial spasm, rapidly followed by more or less complete paralysis of the muscles of expression, with unilateral trismus and difficulty in swallowing. Other cranial nerves, particularly the oculomotor and the hypoglossal, may also be implicated. A remarkable feature of this condition is that although the muscles are irresponsive to ordinary physiological stimuli, they are thrown into spasm by the abnormal impulses of teta.n.u.s.

_Trismus._--This term is used to denote a form of tetanic spasm limited to the muscles of mastication. It is really a mild form of chronic teta.n.u.s, and the prognosis is favourable. It must not be confused with the fixation of the jaw sometimes a.s.sociated with a wisdom-tooth gumboil, with tonsillitis, or with affections of the temporo-mandibular articulation.

_Teta.n.u.s neonatorum_ is a form of teta.n.u.s occurring in infants of about a week old. Infection takes place through the umbilicus, and manifests itself clinically by spasms of the muscles of mastication. It is almost invariably fatal within a few days.

_Prophylaxis._--Experience in the European War has established the fact that the routine injection of anti-tetanic serum to all patients with lacerated and contaminated wounds greatly reduces the frequency of teta.n.u.s. The sooner the serum is given after the injury, the more certain is its effect; within twenty-four hours 1500 units injected subcutaneously is sufficient for the initial dose; if a longer period has elapsed, 2000 to 3000 units should be given intra-muscularly, as this ensures more rapid absorption. A second injection is given a week after the first.

The wound must be purified in the usual way, and all instruments and appliances used for operations on tetanic patients must be immediately sterilised by prolonged boiling.

_Treatment._--When teta.n.u.s has developed the main indications are to prevent the further production of toxins in the wound, and to neutralise those that have been absorbed into the nervous system. Thorough purification with antiseptics, excision of devitalised tissues, and drainage of the wound are first carried out. To arrest the absorption of toxins intra-muscular injections of 10,000 units of serum are given daily into the muscles of the affected limb, or directly into the nerve trunks leading from the focus of infection, in the hope of "blocking"

the nerves with ant.i.toxin and so preventing the pa.s.sage of toxins towards the spinal cord.

To neutralise the toxins that have already reached the spinal cord, 5000 units should be injected intra-thecally daily for four or five days, the foot of the bed being raised to enable the serum to reach the upper parts of the cord.

The quant.i.ty of toxin circulating in the blood is so small as to be practically negligible, and the risk of anaphylactic shock attending intra-venous injection outweighs any benefit likely to follow this procedure.

Baccelli recommends the injection of 20 c.c. of a 1 in 100 solution of carbolic acid into the subcutaneous tissues every four hours during the period that the contractions persist. Opinions vary as to the efficiency of this treatment. The intra-thecal injection of 10 c.c. of a 15 per cent. solution of magnesium sulphate has proved beneficial in alleviating the severity of the spasms, but does not appear to have a curative effect.

To conserve the patient's strength by preventing or diminis.h.i.+ng the severity of the spasms, he should be placed in a quiet room, and every form of disturbance avoided. Sedatives, such as bromides, paraldehyde, or opium, must be given in large doses. Chloral is perhaps the best, and the patient should rarely have less than 150 grains in twenty-four hours. When he is unable to swallow, it should be given by the r.e.c.t.u.m.

The administration of chloroform is of value in conserving the strength of the patient, by abolis.h.i.+ng the spasms, and enabling the attendants to administer nourishment or drugs either through a stomach tube or by the r.e.c.t.u.m. Extreme elevation of temperature is met by tepid sponging. It is necessary to use the catheter if retention of urine occurs.

HYDROPHOBIA

Hydrophobia is an acute infective disease following on the bite of a rabid animal. It most commonly follows the bite or lick of a rabid dog or cat. The virus appears to be communicated through the saliva of the animal, and to show a marked affinity for nerve tissues; and the disease is most likely to develop when the patient is infected on the face or other uncovered part, or in a part richly endowed with nerves.

A dog which has bitten a person should on no account be killed until its condition has been proved one way or the other. Should rabies develop and its destruction become necessary, the head and spinal cord should be retained and forwarded, packed in ice, to a competent observer. Much anxiety to the person bitten and to his friends would be avoided if these rules were observed, because in many cases it will be shown that the animal did not after all suffer from rabies, and that the patient consequently runs no risk. If, on the other hand, rabies is proved to be present, the patient should be submitted to the Pasteur treatment.

_Clinical Features._--There is almost always a history of the patient having been bitten or licked by an animal supposed to suffer from rabies. The incubation period averages about forty days, but varies from a fortnight to seven or eight months, and is shorter in young than in old persons. The original wound has long since healed, and beyond a slight itchiness or pain shooting along the nerves of the part, shows no sign of disturbance. A few days of general malaise, with chills and giddiness precede the onset of the acute manifestations, which affect chiefly the muscles of deglut.i.tion and respiration. One of the earliest signs is that the patient has periodically a sudden catch in his breathing "resembling what often occurs when a person goes into a cold bath." This is due to spasm of the diaphragm, and is frequently accompanied by a loud-sounding hiccough, likened by the laity to the barking of a dog. Difficulty in swallowing fluids may be the first symptom.

The spasms rapidly spread to all the muscles of deglut.i.tion and respiration, so that the patient not only has the greatest difficulty in swallowing, but has a constant sense of impending suffocation. To add to his distress, a copious secretion of viscid saliva fills his mouth. Any voluntary effort, as well as all forms of external stimuli, only serve to aggravate the spasms which are always induced by the attempt to swallow fluid, or even by the sound of running water.

The temperature is raised; the pulse is small, rapid, and intermittent; and the urine may contain sugar and alb.u.men.

The mind may remain clear to the end, or the patient may have delusions, supposing himself to be surrounded by terrifying forms. There is always extreme mental agitation and despair, and the sufferer is in constant fear of his impending fate. Happily the inevitable issue is not long delayed, death usually occurring in from two to four days from the onset. The symptoms of the disease are so characteristic that there is no difficulty in diagnosis. The only condition with which it is liable to be confused is the variety of cephalic teta.n.u.s in which the muscles of deglut.i.tion are specially involved--the so-called teta.n.u.s hydrophobicus.

_Prophylaxis._--The bite of an animal suspected of being rabid should be cauterised at once by means of the actual or Paquelin cautery, or by a strong chemical escharotic such as pure carbolic acid, after which antiseptic dressings are applied.

It is, however, to Pasteur's _preventive inoculation_ that we must look for our best hope of averting the onset of symptoms. "It may now be taken as established that a grave responsibility rests on those concerned if a person bitten by a mad animal is not subjected to the Pasteur treatment" (Muir and Ritchie).

This method is based on the fact that the long incubation period of the disease admits of the patient being inoculated with a modified virus producing a mild attack, which protects him from the natural disease.

_Treatment._--When the symptoms have once developed they can only be palliated. The patient must be kept absolutely quiet and free from all sources of irritation. The spasms may be diminished by means of chloral and bromides, or by chloroform inhalation.

ANTHRAX

Anthrax is a comparatively rare disease, communicable to man from certain of the lower animals, such as sheep, oxen, horses, deer, and other herbivora. In animals it is characterised by symptoms of acute general poisoning, and, from the fact that it produces a marked enlargement of the spleen, is known in veterinary surgery as "splenic fever."

The _bacillus anthracis_ (Fig. 27), the largest of the known pathogenic bacteria, occurs in groups or in chains made up of numerous bacilli, each bacillus measuring from 6 to 8 in length. The organisms are found in enormous numbers throughout the bodies of animals that have died of anthrax, and are readily recognised and cultivated. Sporulation only takes place outside the body, probably because free oxygen is necessary to the process. In the spore-free condition, the organisms are readily destroyed by ordinary germicides, and by the gastric juice. The spores, on the other hand, have a high degree of resistance. Not only do they remain viable in the dry state for long periods, even up to a year, but they survive boiling for five minutes, and must be subjected to dry heat at 140 C. for several hours before they are destroyed.

[Ill.u.s.tration: FIG. 27.--Bacillus of Anthrax in section of skin, from a case of malignant pustule; shows vesicle containing bacilli. 400 diam.

Gram's stain.]

_Clinical Varieties of Anthrax._--In man, anthrax may manifest itself in one of three clinical forms.

It may be transmitted by means of spores or bacilli directly from a diseased animal to those who, by their occupation or otherwise, are brought into contact with it--for example, shepherds, butchers, veterinary surgeons, or hide-porters. Infection may occur on the face by the use of a shaving-brush contaminated by spores. The path of infection is usually through an abrasion of the skin, and the primary manifestations are local, const.i.tuting what is known as _the malignant pustule_.

In other cases the disease is contracted through the inhalation of the dried spores into the respiratory pa.s.sages. This occurs oftenest in those who work amongst wool, fur, and rags, and a form of acute pneumonia of great virulence ensues. This affection is known as _wool-sorter's disease_, and is almost universally fatal.

There is reason to believe that infection may also take place by means of spores ingested into the alimentary ca.n.a.l in meat or milk derived from diseased animals, or in infected water.

#Clinical Features of Malignant Pustule.#--We shall here confine ourselves to the consideration of the local lesion as it occurs in the skin--_the malignant pustule_.

The point of infection is usually on an uncovered part of the body, such as the face, hands, arms, or back of the neck, and the wound may be exceedingly minute. After an incubation period varying from a few hours to several days, a reddish nodule resembling a small boil appears at the seat of inoculation, the immediately surrounding skin becomes swollen and indurated, and over the indurated area there appear a number of small vesicles containing serum, which at first is clear but soon becomes blood-stained (Fig. 28). Coincidently the subcutaneous tissue for a considerable distance around becomes markedly dematous, and the skin red and tense. Within a few hours, blood is extravasated in the centre of the indurated area, the blisters burst, and a dark brown or black eschar, composed of necrosed skin and subcutaneous tissue and altered blood, forms (Fig. 29). Meanwhile the induration extends, fresh vesicles form and in turn burst, and the eschar increases in size. The neighbouring lymph glands soon become swollen and tender. The affected part is hot and itchy, but the patient does not complain of great pain.

There is a moderate degree of const.i.tutional disturbance, with headache, nausea, and sometimes s.h.i.+vering.

If the infection becomes generalised--_anthracaemia_--the temperature rises to 103 or 104 F., the pulse becomes feeble and rapid, and other signs of severe blood-poisoning appear: vomiting, diarrha, pains in the limbs, headache and delirium, and the condition proves fatal in from five to eight days.

_Differential Diagnosis._--When the malignant pustule is fully developed, the central slough with the surrounding vesicles and the widespread dema are characteristic. The bacillus can be obtained from the peripheral portion of the slough, from the blisters, and from the adjacent lymph vessels and glands. The occupation of the patient may suggest the possibility of anthrax infection.

[Ill.u.s.tration: FIG. 28.--Malignant Pustule, third day after infection with Anthrax, showing great dema of upper extremity and pectoral region (cf. Fig. 29).]

[Ill.u.s.tration: FIG. 29.--Malignant Pustule, fourteen days after infection, showing black eschar in process of separation. The dema has largely disappeared. Treated by Sclavo's serum (cf. Fig. 28).]

_Prophylaxis._--Any wound suspected of being infected with anthrax should at once be cauterised with caustic potash, the actual cautery, or pure carbolic acid.

_Treatment._--The best results. .h.i.therto obtained have followed the use of the anti-anthrax serum introduced by Sclavo. The initial dose is 40 c.c., and if the serum is given early in the disease, the beneficial effects are manifest in a few hours. Favourable results have also followed the use of pyocyanase, a vaccine prepared from the bacillus pyocyaneus.

By some it is recommended that the local lesion should be freely excised; others advocate cauterisation of the affected part with solid caustic potash till all the indurated area is softened. Graf has had excellent results by the latter method in a large series of cases, the dema subsiding in about twenty-four hours and the const.i.tutional symptoms rapidly improving. Wolff and Wiewiorowski, on the other hand, have had equally good results by simply protecting the local lesion with a mild antiseptic dressing, and relying upon general treatment.

The general treatment consists in feeding and stimulating the patient as freely as possible. Quinine, in 5 to 10 grain doses every four hours, and powdered ipecacuanha, in 40 to 60 grain doses every four hours, have also been employed with apparent benefit.