THE PREVENTIVE TREATMENT OF TETANUS. BY T. W. SIMMONS, M.D., OF HAGERSTOWN, MD. FROM THE MEDICAL NEWS, December 31, 1892. [Reprinted from The Medical News, December 31, 1892.] THE PREVENTIVE TREATMENT OF TETANUS.1 By T. W. SIMMONS, M.D., OF HAGERSTOWN, MD. The fact of the incurability of tetanus, together with the theory that its cause lies in a specific bac- terium, has suggested to me the importance and feasibility of the preventive treatment of the dis- ease. It was after smallpox had defied all manner of curative treatment for over eight hundred years that Edward Jenner was moved to the discovery and adoption of a preventive treatment that not only fulfilled its mission in preventing that loathsome and dreaded disease, but is to-day emulated in other fields of scientific research. Pasteur, as did Jenner, but recently demonstrated the wonderful influence of preventive treatment by inoculation, the latent or incubative period of hydrophobia affording a favorable opportunity in which preventive treatment is brought to bear. Bites by rabid animals on the head and face furnish the most certain hydrophobic results, as shown by a mortality, it is alleged, of from 80 to 88 per cent., which is claimed as having been reduced under 1 Delivered before the Washington County Medical Society of Maryland, November g, 1892. 2 Pasteur's preventive treatment to 3 per cent. If true, this is a most wonderful life-saving result. While I do not propose to prevent tetanus by in- oculation, as did Behring and Kitasato, I desire to remind you of the great success that has attended pre- ventive treatment in those dreadful diseases that have so signally defied all human efforts to cure. But I do claim that tetanus should be classified with such fatal and incurable diseases, and that there is a pre- ventive treatment for it as simple and feasible as that of smallpox or hydrophobia, and even more so. Tetanus and hydrophobia resemble each other in many prominent respects, so much so that surgical writers generally differentiate them that confusion in diagnosis may not arise; they, however, differ in other important respects that are seldom considered, viz., tetanus is much more common than hydro- phobia, and the mortality from it yearly is far greater. In the New York Medical Record of August last I find that the Massachusetts State Board of Health declared that little over 100 deaths from hydro- phobia have occurred in that State within the last half-century. In an experience of over thirty years I have never seen a case of hydrophobia, nor have I ever, to use the expression of a professional friend, met with a physician who has seen one; yet I have seen and treated a number of cases of tetanus all of which have terminated fatally. May I not, then, ask how so much more prominence and importance should be given to the prevention of hydrophobia than to that of tetanus? For example, a boy is bitten by a rabid dog. The news is promptly heralded throughout the country, and per- 3 haps abroad. He is doubtless hurried off to a Pasteur institute somewhere for preventive treatment; great anxiety is manifested for his safety, etc. But sup- pose that boy wounds the sole of his foot, and goes home crying to his mother, when upon inspection it is found that he has trodden upon a rusty nail that was lying in the street or garden, and that this had penetrated deeply into his foot. What is thought of it? What is done? Nothing, perhaps, beyond the tying of a piece of bacon rind about it with a rag ; and yet this very wound, from the nature of our past experience, may be fraught with as much danger as the one made by the rabid dog. The specific bacterium of tetanus, it is claimed, was discovered by Nicolaier, Rosenbach, and Kita- sato, and is represented to be a large, slender, motile rod, with sporulations at one extremity, giving it a characteristic drumstick shape. It is anaerobic by nature, and found to exist in the dirt and dust of the street, in the garden, in the stable-yard, upon nails, iron rakes, forks, splinters, thorns, etc., these constituting the most usual means of introducing it into the body. When once in a wound it im- mediately sets to work and produces, as it is said, ptomains, tetanotoxin, spasmotoxin, etc., the active viruses which, when absorbed into the system, give rise to that terrible disease, tetanus. This theory has been accepted, I believe, by all surgical authors of the present day, to the exclusion of that of traumatism of sensitive or motor nerves. The fact that the feet and hands are more exposed to this class of injuries explains their frequent asso- ciation with tetanus, and not the injury of their 4 numerous nerves. The specific bacilli do not pass beyond the point of introduction. They are not, it is said, found in the blood or tissues generally, but are confined to the focus of infection. There they make their abode for reproduction of their kind, and for the distillation of that virus which is slowly but surely absorbed into the system with all its fearful consequences. In the face of this representation of indisputable facts, is it not clear that our plain and unhesitating duty is to kill those deadly bacilli while ensconced within their narrow confines, and before infection takes place ? To do this, as I before said, is most simple and feasible. The technique that I have adopted is as follows: I remove all foreign sub- stances from the wound, and thoroughly cleanse the surface about it with a probe or olive-pointed hypo- dermatic needle, made of gold, about two inches long, and something larger than an ordinary hypo- dermatic needle. Such a needle has been made for me by F. Arnold & Son, of Baltimore. With this needle attached to an ordinary syringe I inject into the wound, if painful or sensitive, a four per cent, solution of cocaine, which is allowed to remain until its full effects are produced. I then draw out what may remain within the wound, and with the same instrument inject the following : Argenti nitratis ..... grs. v. Aquae Or, Hydrarg. chloridi corrosiv. . . . grs. ij. Acidi carbolici ..... grs. xv. Alcoholis 5ss. 5 The alcohol is used here instead of water, because it diffuses more rapidly throughout the wound, and it is of great importance that the injection should reach the full depth of the puncture. This procedure, after the use of the cocaine solution, is painless, and the wound is thereby rendered far more comfortable. One injection, if well and deeply applied, will be sufficient. This operation should be performed as soon after the injury as possible, and surely before its lumen begins to close by granu- lations. It is, of course, presumed from what I have said, that the wound to which this operation is applicable is a punctured one, within reach, and as you well know, this kind of wound is commonly at tendant upon tetanus-infection. My experience in the preventive treatment has been entirely satisfac- tory, as far as it could be judged, for while it is true that all punctured wounds may not be infected by specific bacteria, yet their presence should always be feared, and this simple operation never omitted, as it removes all possibility of danger, and besides has the advantage of relieving pain and soreness, and promotes rapid healing of the wound. So common has it become to disregard these punctured wounds, particularly such as occur in the ordinary course of life, that I feel that their importance and danger should be emphasized and proclaimed. Parents and teachers should instruct the children under their care of the absolute danger of such iniuries when neglected. While it would be impossible at all times to anticipate the danger that might attend upon small and trivial wounds, as they often give 6 rise to the most unexpected and terrible develop- ments, yet, to treat such as are more pronounced and suspicious I feel confident in saying would save many more lives than any curative treatment proposed. The Medical News. Established in 1843. A WEEKL YMEDICAL NEWSPAPER. Subscription, $4.00 per Annum. The American Journal OF THE Medical Sciences. Established in 1820 A MONTHLY MEDICAL MAGAZINE. Subscription, $4.00 per Annum. COMMUTATION RATE, $730 PER ANNUM. LEA BROTHERS & CO PHILADELPHIA.