TETANUS.
The mortality of tetanus has been reduced during the progress of the late war to a remarkable extent. The incidence of the disease amongst the wounded has fallen according. to Bruce, from 16 per 1,000 in 1914 to under 2 in 1917, and the mortality in those affected has been still more markedly influenced. All authorities agree that these results are due to the prophylactic injections of the Antitetanus Serum. The War Office Committee ruled that as soon as possible after the reception of a wound one-third of the ordinary phial should be injected subcutaneously or intramuscularly; this corresponds to 500 U.S.A. units. Absorption being twice as rapid by the latter route, this should be selected when any delay has occurred. With this dose there is practically no danger of anaphy laxis; the immunity lasts for about pp days. In extensive septic wounds the injections were repeated every week for four times. When a secondary operation is necessary, a prophylactic injection should be given 4S hours previously. When tetanus developed in spite of the injections, it was very often localised, in which case by treatment with larger doses of the serum its mortality was nil; when generalised tetanus developed, the mortality was reduced to per cent. After the supervention of symptoms the daily dose should not b- less than io,000 units, but three times this amount is usually employed.
There is still divergency of opinion about the best route. Dean re commends the intravenous method and minimises the danger of ana phylaxis by the following plan: 5 c.c. of the serum are mixed with 5o c.c. normal saline, of which r c.c. is injected into the veins, after four minutes 3 c.c., two minutes later io c.c., and after another two minutes 25 c.c. The desired full dose is administered half an hour later, supplemented by further doses by the spinal and muscular routes. The Tetanus Com mittee ruled against the intravenous route, and Leishman and others condemn the spinal route. The intramuscular and next the subcutaneous have the greatest amount of support, the intracerebral and intraneural being by common consent reserved for the most desperate cases.
Once the symptoms of tetanus have appeared after injury 30,000 units should be injected, and the patient should be put to bed upon a good mattress, in a dark, quiet room, to which only the physician, nurses and one or two of his most intimate friends are allowed access. Cotton-wool is placed in his ears to keep out sounds. a thick carpet being spread upon the floor. The importance of absolute stillness and protection from cold draughts is doubtless very great. and the patient should only be permitted to speak when absolute necessity dictates.
Alimentation is of vital importance. Liquid nutritious foods are to be poured into the mouth. Stimulants are indicated in full doses in the majority of cases, and where swallowing is impossible or very difficult, rectal feeding by strong, peptonised broths may be resorted to. As this often proves unsatisfactory, Rose's method of giving Chloroform twice a day may be resorted to, and when complete anaesthesia has been ob tained the stomach may be filled through a rubber tube with nutritious liquid food. Hypodermic injections of Olive Oil and of solution of Glucose have been employed to supplement others forms of feeding.
Upon the second and succeeding days, till all symptoms disappear, ro,000 units should be given daily, and in desperate cases twice this amount, the routes being varied from time to time.
Constipation may be left alone, as purgatives do a great deal more harm than good. Some authorities condemn hot baths, whilst others extol their usefulness. Diaphoretics and diuretics are called for to hasten the elimination of the poison.
Sterilisation by local antiseptics and excision, thorough and radical, of the tissues around the wound have replaced the former practice of amputating the limb in which the wound was located. It is also essential that all peripheral irritation should he met by soothing or anodyne dressings, to which antiseptics should be added. Some authorities speak highly of the plan of dressing the wound with dry pulverised Antitetanic Serum.