With respect to the causes of tetanus, "it must ever be regarded," says Dr. Gregory (' Theory and Practice of Med.'), " as a very singular fact in pathology, that an affection of so peculiar a character as this should have its source in causes apparently so dissimilar; that the puncture of a nerve, the laceration of a tendon, or an extensive burn, should bring on the same kind of nervous affection as that which is the occasional consequence of cold." Every description of wound, no matter how inflicted, or in what part, or in what stage, may be the occasion of tetanic symptoms which form the species denominated traumatic. Cases are on record wherein the patient was attacked with the disease in consequence of a bite on the finger from a tame sparrow ; in which it supervened on the mere stroke of a whip-lash under the eyes, though the skin was not broken ; in which it was occasioned by a small fish-bone sticking in the pharynx ; by a alight solution of con tinuity in the external ear from a musket-shot ; by the application of a seton to the thorax ; by the stroke of a cane across the back of the neck ; by a blow on the hand from the same instrument ; by the extraction of a tooth, &e. In short, according to Sir James M'Grigor, " it occurs in every description and in every stage of wounds, from the slightest to the most formidable, from the healthy and the slough ing, from the incised and the lacerated, from the most simple and the most complicated." Next in frequency to wounds as an exciting cause of tetanus is exposure to cold and damp ; indeed there are but very few cases of true idiopathic tetanus which are referrible to any other. The irritation of worms and other disordered states of the alimentary canal have been considered by some authors as the cause of tetanic affections. To generate this form of disease, however, it would appear that a certain pretlisporition is also requisite, and it is doubtless the same with that which operate. as an accessoryws of the traumatic tetanus'. The predisposition to totenie affections is given, in the first place, by warm climates and warm Demons. Within the tropics therefore it prevails to an extent unheard of in colder latitudes. Secondly,tetanue is chiefly observed to prevail when the atmosphere is much loaded with moisture, and particularly where this has suddenly succeeded to a long course of dry and sultry weather. Even in this country exposure to the cold and damp air of the night has occaaionally been followed by an attack of tetanus. In tropical climates children are particularly subject to this complaint, and with a few peculiarities which, though producing no specific difference, have been thought sufficient to con stitute a variety known by the name of trirmus nascentium. The disease in this case is vulgarly known by the absurd name of falling of Mt jar. It occurs chiefly between the ninth and fourteenth day after birth, and seldom after the latter period. Without any febrile Ames aion, and often without any perceptible cause whatever, the infant sinks into an unnatural weariness and drowsiness, attended with frequent yewninga, and with a alight difficulty of moving the lower jaw. This last symptom takes place in some instances sooner, in others later, and soon increases in intensity. Even while the infant is yet able to open its mouth, there is occasionally an inability to suck or swallow. By degrees the lower jaw becomes rigid, and totally mists the introduction of food. There is no painful sensation, but the skin assumes a yellow hue, the eyes appear dull, the spasms often extend over the body, and in two or three days the disease proves mortal.
The prognosis of this disease is mainly to be determined by the nature of the exciting cause, and by the type of the seizure. Tetanus of the idiopathic kind has certainly been cured in a larger proportion of cases than that which follows external injury. The type of Sthe disease as acute or chronic is a no less important guide as to the probable termination. It may be said that recovery in a case of acute tetanus is almost, if not altogether, hopeless : the chronic form, how ever, is of a much milder character. The usual termination of the disease may be stated to occur on the third or fourth day ; and if the patient survives that time, there are good hopes of his recovery ; it is rarely protracted beyond the eighth day. Mr. Cooper, however, mentions (' Surg. Diet') that he had a patient (who had been wounded, and suffered amputation of the thigh) who lingered five weeks with chronic tetanus before be died.
The dissection of patients who have died of tetanus has thrown little or no light upon the real nature of the complaint, as is indeed the case in almost all spasmodic or neuralgic disorders. Sometimes slight effusions are found within the cranium, but in general no morbid appearance whatever can be detected within the head. There is always more or less of an inflammatory appearance in the oesophagus, and in the villous coat of the stomach about the cardia. These appearances, however, are common to a great number of diseases, and are uniformly met with in every case of rapid or violent death. Besides the redness and increased vascularity of these parts, Baron Lerrey found the pharynx and oesophagus much contracted, and covered with a viscid reddish mucus. He also found numerous lure brici in the bowels of several of the patients who died ; but this, as Mr. Cooper remarks, could only be an accidental complication, and not a cause. In several cases Dr. ll'Arthur found the intestines much inflamed ; and in two of them a yellow waxy fluid, of a peculiar offensive smell, covered their internal surface; but whether the in flammation was primary, or only a consequence of the pressure of the abdominal muscles, which contract so violently in this disease, ho is unable to decide. (' Med. Chits Trans.,' voL vii., p. 475.) The treatment of tetanus is confessedly a subject of infinite difficulty, as the disease frequently baffles every mode of practice, and, in certain instances, gets well under the employment of the very same remedies which decidedly fail in other similar cases. Upon the whole it will probably be universally admitted that no effectual remedy for tetanus has yet been discovered, as every plan has occasionally succeeded, and every plan has still more frequently failed. An excellent abstract of the opinions of the ancients on this point is given by Mr. Adams in his Notes to Paulus iEgineta.
Tho general principle of euro, as 'Dr. Good remarks, is far more easily explained than acted upon : it Is that of taking off the local irritation, wherever such exists', and of tranquillising the nervous erethiem of the entire system. The former of these two objects is of great importance in the locked-jaw, or trismus, of infants; for, by removing the viscid and acrimonious moconium, or whatever other irritant is lodged in the stomach or bowels, we can sometimes effect a speedy cure without any other medicine. Castor oil in by far the best aperient on this occasion, and it may be given both by the mouth and by injections. If this, however, do not succeed, we should have recourse to powerful anodyne. : of those the beat is opium, which should be administered in doses of from three to five drops of the tincture, according to the ago of the sealant. Opium has also been more extensively resorted to in the cases of adults than almost any other remedy ; and Dr. Good, Dr. Gregory, and others profess that it is that on which they place their chief, if not their only rellance. To give it a fair chance of success, we must begin Its use from the earliest appearance of tetanic symptoms. It must be given in very large doses; and these doses must be repeated at such short intervals as to keep the system constantly under the influence of the remedy. It is astonishing to observe how the human body, when labouring under a tetanio disease, will resist the operation of this and other remedies, which, in its healthy state; would have been more than sufficient to overpower and destroy It. It is advisable to begin with fifty drops of laudanum, and to repeat this at intervals of two or three hours, or even oftener if the urgency of the symptoms require it, until some effect has bocu produced on the spasms. In tho early stage of the disease we -are to bear in mind the approaching closure of the jaw and difficulty of deglutition; and our remedies are accord ingly to be pushed before such serious obstacles to their administra tion arise. When they have occurred, and are found to bo insuperable, opiate enemata and frictions may be tried; but we must not anticipate much benefit from such feeble moans. Such are Dr. Gregory's remarks ; but Dr. Symonds considers that the employment of opium is recommended chiefly by systematic writers, and for theoretical, rather than for practical reasons; while most of those who give the results of their own experience express the greatest dissatisfaction with the remedy.