C. Handfield Jones
1867 The Lancet  
626 hour afterwards the exhibition of the tincture of Calabar bean was commenced in regular and increasing doses; concurrently opiates were given in large and frequent doses, and this treatment was maintained to the termination of the case. On the 29th a very decided improvement was remarked. He could open his mouth, so as to show his tongue, which was clean; he suffered only occasionally from a slight spasm when he opened his mouth, or was disturbed in any way ; the abdominal muscles remained
more » ... l muscles remained tense, and he complained of twinges of pain now and then, in this situation as well as in the back. The pulse was soft, 100; the pupils were contracted. On May 1st he was worse, and unable to open his mouth; twitchings and tremblings of the limbs generally and quiet delirium were observed, also paroxysms of slight opisthotonos whenever he attempted to drink. The pupils were small, and the pulse was very weak, 112. Nearly the same symptoms, but more faintly manifested, continued till his death at two o'clock in the morning of May 3rd, being twelve days from the commencement of his malady. He had been sedulously fed -with beef-tea, brandy-and-egg, &c., and had taken in all 666 minims of liq. morphine, 240 minims of liq. opii, and 830 minims of tincture of Calabar bean. Autopsy.—A small cicatrix was discovered over the matrix of the left thumb-nail. The arachnoid membrane was thickened and semi-opaque, and the ventricular and subarachnoid 'spaces contained more fluid than usual. The lungs were cons'ested and the heart flaccid. There were some armarentiv recent ecchymoses in the substance of the psoas and pectoral muscles. Mr. Lockhart Clarke, who examined the spinal cord, reported: " Nothing unusual in appearance to the naked eye, except an increase of vascularity in the grey substance and a soft or flaccid state of the cervical enlargement. Disintegrations of some portions of the cord, but to a much less extent and degree than in many other cases examined." CASE 4.-G. C. B--, a man aged twenty-eight, was admitted July 17th, 1865, with a contused foot, upon which, six days previously, a heavy stone had fallen. The last phalanx of the second toe was black, and rather a deep sore was observed on the dorsum of the last two phalanges of the fourth toe, and the nail was absent. At one P.M. on the 21st he complained of some stiffness about the jaw, and upon examination the masseter muscles were found to be rigid. At two A.M. on the 22nd the stiffness of jaw had so much increased that he could not separate his teeth more than a line or two, and he spoke of some stiffness in the back. At ten A.M. ice-bags were applied to the spine. At three P.M. paroxysms of opisthotonos were observed every six or seven minutes; his intellect was clear; his pulse weak and irregular, 96. (A tobacco enema had just been administered, but the greater portion had returned.) At half-past ten P.M. a solution of one grain of morphia was injected into his axilla, and he was asleep in twenty-six minutes. At two A.M. on the 23rd he was awake again. Only three paroxysms had seized him since the injection of the morphia ; the pupils were contracted; during his sleep his mouth had been observed to be open. At three A.M. the ice-bags were removed ; he took some beef-tea, and seemed altogether better. Half a grain of morphia was injected. At six o'clock his pulse was 130, and his pupils were much contracted. Since the last injection he had slept soundly for some time, and had experienced but three or four paroxysms. Another half-grain of morphia was injected. At half-past ten the spasms were observed to be more frequent and prolonged; his pulse was 144, and his pupils were much contracted. He had slept for one hour after the last injection, which was again repeated. At half-past two P.M. the spasms were frequent, the pupils contracted, and the pulse was 120, weak. He was sweating a good deal, and had slept for an hour and a half. The morphia was repeated. At half-past five he had slept for an hour; he could protrude his tongue to the full extent. The spasms continued frequent. He felt better; his pulse was 140, and his pupils were contracted. The morphia was repeated. At eight P.M. the spasms were more frequent; the pulse was 132. The morphia was repeated. At nine o'clock he was sleeping. At twelve the morphia was repeated. At four o'clock on the morning of the 24th he was worse. He had, however, slept for some time after the last injection. The morphia was repeated, and again at nine A.M. Death -took place at half-past ten A.M., or 69à hours from the first observation of the convulsive disease. Autopsy.—The brain was congested. The lungs were full of blood, and the bronchial tubes much stained. From Mr. Lockhart Clarke, who examined the spinal cord, I learned that "the cord was rather soft throughout, but the grey substance not particularly red," and that " slight disintegration of some portions of the cord " was observed. In conclusion, I should like to remark that it would give me much pleasure to read published accounts of the symptoms and treatment of the cases of tetanus which have occurred during the last few years at the other London hospitals. Independent reports of unselected cases would, I am convinced, be very useful. Either we are quite in the dark as to the treatment of this fearful disease, or it is in its nature completely intractable. Let us hope the latter supposition is not the correct one; and, still more, let us endeavour, if the former supposition be correct, to put an end to our darkness, for it is very terrible. In the cases which I have narrated the drugs given produced their physiological effects, and probably checked or toned down the more vehement manifestations of the disease ; but there they stopped. The application of ice-bags to the spine had no perceptible result.
doi:10.1016/s0140-6736(02)51768-2 fatcat:hgj2nv7ykjejrfzvdwhoeqvko4