tetanus, and has referred to the participation of the reflected function at the onset of this disease. CURLING (a) considers it as a simple functional disturbance, the seat of which is the tractus motorius of the spinal marrow.

[I have seen in two cases of tetanus thin plates of bone upon the arachnoid coat of the spinal marrow, and in another similar plates of cartilage. These cases I dissected, and the preparations are in St. Thomas's Museum. But I have examined many other cases in which no such appearance presented itself, nor indeed any other which would have been considered disease, had not the attention been especially directed to it. Hence I am fully disposed to concur with LAWRENCE, that "we are at a loss, we are unable to point out with any degree of clearness, in what the derangement of the spinal cord consists; nor can we show, in any definite manner, as far as our examinations have hitherto gone, any distinct or clear derangement of that part." (p. 587.)-J. F. S.]

376. The remote causes of tetanus are very various. It is mostly connected with wounds of fibrous ligamentous structures (1), accompanied with tearing, bruising, partial injury and exposure of nerves; with wounds of joints, of the face, neck, fingers, toes, of the spermatic cord (2) ; it usually begins during the suppurative period, and even during or after the scarring of the wound. Foreign bodies into the wound (3), especially splinters of bone, ligatures of arteries, if a nerve be included in the ligature, are all to be considered as not unfrequent causes of tetanus (4). Likewise hot seasons of the year, cold, frequent change of the temperature, especially in low districts and in the neighbourhood of rivers, and the influence of a moist, cold, foul air upon nerves after their exposure by the separation of sloughs, emotions of the mind, especially terror. Young rustics are especially subject to tetanus.

[(1) The cases (of tetanus) which I have seen," says JOHN HUNTER, “ from wounds, were those of the tendons, for these parts heal less readily, and the constitution is much weakened by wounds of such parts, so that sometimes a limb will waste from such a cause, -wounds being much more irritable here than in other parts, and particularly when attended with loss of blood. Nothing produces irritability more than a great loss of blood, especially when accompanied with a wound, and with this disposition of constitution. The wounds producing it are either considerable or slight: the first is a predisponent, the second an immediate cause. When I have seen it from the first, it was after the inflammatory stage, and when good suppuration was come on; in some where it had nearly healed, and the patient was considered healthy, under the disease as well as before. Some have had locked jaw after the healing was completed. In such I have supposed the inflammation was the predisponent cause, rendering the nervous system irritable as soon as it was removed. * * * In the case of slight wounds there must already exist a predisposition, which only requires an immediate cause to bring it into action. The disease oftener arises from slight wounds than large ones, which may partly, but not entirely, arise from such being most frequent." (pp. 585, 86.)

(2) To these TRAVERS adds:- Ligature of the funis umbilicalis; of the entire spermatic cord, and the anterior crural nerve. The former is common in hot climates; the two latter I have myself seen." (p. 294.)

(3) JOHN HUNTER relates a remarkable instance of this kind. "A man had a locked jaw about a fortnight after a nail entered the sole of his foot, which he did not at the time regard as of any consequence, the wound not being larger than that from bleeding, and not attended with any pain, inflammation, or hardness. He died; and after death I found a black line continued to a hard body under the skin, which could be dissected out almost like a lymphatic gland, and was found to be a bit of leather, surrounded by coagulable lymph; the black line was the mark of the nail." (p. 586.) (4) TRAVERS says he "never knew nor heard of a clean incised wound inflicted without concussion, as by a surgeon's knife, in operation, producing tetanus, whatever was the structure divided." (p. 294.) SAMUEL COOPER, however, states that " in St. Bartholomew's Hospital, it once followed the operation of removing the breast." (p. 1230.) After amputation it has also occasioually occurred, and the melancholy death of the late Earl of DARNLEY was from tetanus consequent on having accidentally chopped off two of his toes with an axe.]

(a) Above cited.

[376* The diagnosis of tetanus from hydrophobia especially has been well given by J. L. BARDSLEY. In tetanus the stiffness and immobility of the lower jaw is present, and scarcely to be overcome by any effort during almost the entire course of the disease; in hydrophobia the spasms are always clonic, i.e., always of brief duration, and succeeded by a period of complete relaxation, generally of many hours' duration, in the beginning of the disease, unless provoked by attempts to swallow. In very rare forms of tetanus, however, guttural spasms on attempting to drink, dread of fluids and their rejection when introduced, do occur. In tetanus there is rarely a discharge of saliva, which is a very marked symptom of hydrophobia, and thirst is as rare in the former as it is common in the latter. In tetanus the mind is almost always clear to the last; in hydrophobia, almost from the beginning, numberless deviations from the usual habits of thought and action indicate an incipient stage of mental aberration, which often passes on to delirium or raging madness. The countenance in tetanus differs from that in hydrophobia by the natural character of the eye and the general appearance of suffering; whilst in the latter the eye is preternaturally bright and glistening, and the face often exhibits frightful convulsions. Tetanus scarcely ever presents the laborious panting respiration, the tremor of all the muscles, the intolerant sensibility of the surface and organs of sense, which occur in hydrophobia. Tetanus seems to occur almost any time after the injury, but hydrophobia chiefly from the thirtieth to the sixtieth day.

It

376** The prognosis is always extremely unfavourable in traumatic tetanus, and Dr. O. BEIRNE (a) states, that of two hundred cases which he saw not a single one recovered. IIENNEN says::-"I have never been fortunate enough to cure a case of acute symptomatic tetanus: in some instances of the chronic species I have effected or witnessed a cure.”(p. 245.) may be taken as a rule that the danger of the patient is in proportion to the acuteness of the symptoms; whilst the more chronic they become, the greater hope may be entertained. As far as my own opportunities of observation permit me to form an opinion, I should say, that cases which pass over the seventh day, in general terminate favourably. Two cases, under such circumstances, we have had in St. Thomas's Hospital during the last twelve or fourteen mouths. When the disease also is simple trismus the prognosis is more encouraging than when tetanus sets in.-J. F. S.]

377. In the treatment of tetanus, the remote causes must be specially attended to, and, if they be in the wound, as foreign bodies, torn or tied nerves, and so on, they must be removed by enlarging the wound, or by some other way according to the rules of art. With this object is also the cauterization of the wound, and even the amputation of the limb itself, to be proposed (LARREY) (b).

DUPUYTREN (c) considers amputation in confirmed tetanus as useless.

378. For the further treatment a vast number of remedies have been proposed, more especially besides the antispasmodic means, opium in large doses, (when it cannot be introduced by the mouth, it may be by clysters, or even by injection of small doses of the watery extract of opium into the crural or median vein, musk, camphor, tincture of cantharides, laurel water, prussic acid (1), tobacco, oil of turpentine, arsenic, colchicum (d), and the like. STUTZ recommends the alternate internal and external use (a) Dublin Hospital Reports, vol. iii. (c) Leçons Orales de Clinique Chirurgicale, vol. ii. p. 611

(b) Above cited, vol. i. p. 271.

(d) PERCY and LAURENT; in Dictionnaire des Sciences Médicales, vol. xxv. p. 31.

of opium, and of vegetable potash; besides also, bark, naphtha, and other stimulating or strengthening remedies, the use of the cold and warm bath. General blood-lettings, and in large quantity, are recommended by many, the internal and external use of mercury till salivation commences, cauteries in the nape of the neck and in the neighbourhood of the spine.

(1) KLEIN (a) first employed prussic acid in tetanus, but without result; he gave as much as 180 drops of ITTNER'S prussic acid in the four-and-twenty hours, and only observed it produce an easier death. TREZWART (Medical Recorder, 1825, Oct.) in one case, in which indeed very many untoward circumstances operated together, injected into the skin up to four drops in a short space of time, (twenty drops of the acid being diluted in three ounces of water,) and after each time he noticed a cessation of the cramp, although death ensued.

SMITH (b) recommends colchicum, from sixteen successful cases, nine of which were traumatic tetanus, which he observed in Hayti. After having removed the costiveness by softening clysters and castor oil, he applied leeches or the cupping-glass along the whole length of the spine, and then laid compresses dipped in a strong solution of muriate of ammonia along the whole spine. He gave half a drachm of the vinous tincture of colchicum, increasing it every half hour till vomiting or purging took place, upon which the remedy was discontinued. If colic and faintness came on, he gave afterwards liq. ammon. acet. 3ss., morph. acet. gr.ss.; in symptoms of collapse he put aside the narcotic, and applied warm poultices to the limbs.

[Some years ago I was shown by a West Indian friend the report, in some Jamaica medical journal, (perhaps that in which SMITH's paper is, though, unfortunately, I cannot recollect it,) of a case of traumatic tetanus which was successfully treated by making long and deep incisions on either side of the ridge of the spine, from which free bleeding ensued, and afterwards the wounds were freely cauterized with caustic potash. Severe as this practice may seem to be, I am disposed to think it more likely to be successful than any other, if it be admitted that the spinal marrow reflects upon the general system, the irritation which has been set upon it by the local injury.-J. F. S.]

379. Neither of the preceding modes of treatment have yet been determined by general experience. The selection and union of the remedies must be determined according to the peculiarity of the case, according to the continued or speedy course of the disease, the constitution of the patient, the severity of the symptoms, and the condition of the wound. Experience is most in favour of blood-letting, of the internal use of calomel with opium or morphia, mercurial friction and warm bathing. Blood-letting is specially applicable to young country persons, at the beginning of the disease, in violent tension of the muscles, very red countenance, great dread of light, small pupil, but particularly when accompanied with inflammatory fever or any local inflammation. Cupping also along the spine may be used. In congestion of blood, in any organ, from severe contraction, the application of leeches may be needful; also about the wound, if very painful and inflamed, and, at the same time, an anodyne plaster may be put on. Only at the onset may the cold bath be used to subdue the disease commencing in the nervous system: at a later period the warm bath is preferable; the decided relief which is thereby produced is, however, only transitory. If a congestive condition, or erythysm, rather resemble in its course and symptoms tetanus, antispasmodic means, as opium, with camphor, musk, STUTZ's treatment, prussic acid, must be employed, either with or immediately after antiphlogistic treatment. If there be shivering, the opium must be given in form of a diaphoretic.

Opium must be employed in largely increasing doses. No narcotism occurs even when eight, ten, and even twenty grains have been given every two hours. The consequent costiveness must be overcome by clysters composed of infusion of senna with sulphate of magnesia.

(a) Heidelberger klinische Annalen.

(b) Jamaica Physical Journal.

[I must confess that the cases of cure of this disease, related as having followed any one plan of treatment, are by no means satisfactory. I have seen opium, tobacco, bleeding, mercury to salivation, and other remedies employed, and also have known of a case or two left without treatment, and the results in all cases the same,-fatal In the extremely few cases which have recovered with one treatment or other, I therefore presume that nature has had more to do with it than the doctor, as she has when the cases have been left alone and recovered. At present our treatment of tetanus is completely empirical and has entirely failed; the only rule upon which we act being to repeat the same plan in the second under which the first case has recovered or been relieved; or, if the treatment have been unsuccessful, to adopt some other practice for the next case. One mode of proceeding, however, must be deprecated, viz., that of plunging the patient into a cold bath, which I once witnessed during my apprenticeship; the result was, that the patient was almost immediately lifted out-dead.—J. F. S.]

SECOND CHAPTER.-ON WOUNDS IN PARTICULAR.

I.-OF WOUNDS OF THE HEAD.

QUESNAY, Précis de diverses Observations sur le Trépan dans des cas douteux; in the Mémoires de l'Académie de Chirurgie, vol. i. p. 188.

DEASE, WILLIAM, Observations on Wounds of the Head, &c. Dublin, 1760. 8vo. POTT, P., Observations on the Nature and Consequences of Wound and Contusions of the Scalp, Fractures of the Skull, Concussions of the Brain, &c. London, 1760. 8vo. -and in his Chirurgical Works, edited by EARLE. London 1790. 3 vols. 8vo.

SMUCKER, Chirurgische Wahrnemungen. Berlin, 1774. Vol. I. DESAULT, Treatise on Wounds of the Head; in his Euvres Chirurgicales par XAV. BICHAT. 3 vols. Paris, 1812. 8vo.

ABERNETHY, Surgical Observations on Injuries of the Head; in his Surgical Works, vol. ii. p. 1. London, 1815.

8vo.

LOUVRIER, Prize Question. Ist die Durchbohrung der Hunschaale bei Kopfaerletzungen nothwendig oder nicht? u. s. w. Wien., 1800. 4to.

MURSINNA, Prize Question. Ibid. Wien. 1800. 4to.

BECK, Beobactungen und Bemerkungen über die Kopfaerletzungen; in Heidelberg. klinischen Annalen. Vol. III. Part III. 4to.

MYNORS, R., A History of the Practice of Trepanning the Skull and the After-treatment; with Observations on a new Method of Cure. London, 1785. 12mo. SCHREGER, über den Verband bei Schädelverletzungen. Erlangen, 1810. SUITZER, E., Conspectus instrumentorum quæ ad trepanationem adhibita. Accedente novo trepanationis apparatu. Hafnia, 1828. 8vo.

4to.

VON KERN, V., über die Verletzungen am Kopfe und die Durchbohrung der Heinschaalle. Wien.

BRODIE, B. C., Pathological and Surgical Observations relating to Injuries of the Brain in the Med.-Chir. Trans, vol. xiv. part ii. p. 325.

SCHINDLER, H. B., über die Indication zur Trepanation, in Chirurgischer Hinsicht. Ein Beitrag zur Lehre von den Kopfverletzungen; in Heidelberger klinischen Annalen, vol. viii. p. 1.

VON WALTHER, PH., über die Trepanation nach Kopvferletzungen; in the Journal für Chirurgie u. Augenheilkunde, vol. xvi. p. 1; ibid., vol. xvii. p. 1.

GAMA, Traité des Plaies de tête et de l'Encephalité, principalement de celle qui leur est consecutive. 2nd Edit. Paris, 1835.

VELPEAU, De l'Opération du Trépan dans les Plaies de tête. Paris, 1834. Compare also the works of SABATIER, RICHTER, BOYER, ZANG, and A. COOPER. 380. Wounds of the Head (Vulnera Capitis) are among the most difficult and most important objects of Surgery. Their great importance depends

on the injury of the brain, which either occurs at the same time as the wound itself, or comes on afterwards. They must therefore be considered under a double point of view, in so far as the various coverings of the brain are injured, or diseased affections of the organ itself are thereby produced. In the former view are distinguished, 1. Injuries of the soft parts upon the skull; 2. of the skull itself; 3. of the membranes, and of the brain itself. The diseased conditions which they produce in the brain itself are, 1. Concussion; 2. Inflammation; 3. Compression of the brain.

381. All kinds of injuries may occur in the soft parts upon the skull: they may either simply penetrate through the skin, through the aponeurotic covering, through the frontal, temporal, and occipital muscles, or into the pericranium. Incised wounds require union, according to the ordinary rules, which, after the hair in the immediate neighbourhood has been shaved off, may be effected by sticking plaster and a proper bandage. Bleeding from the temporal, frontal, or occipital artery, may be stanched either by the proper union of the wound and compression of the artery against the bone, or more certainly by tying the vessel. The healing soon follows, under proper treatment. From improper and especially from irritating treatment, from the unsatisfactory condition of the patient, from catching cold, and so on, especially in persons of a bilious constitution, a considerable swelling not unfrequently arises in wounds penetrating only the scalp, which spreads over the whole head and face, the ears and eyelids; it is not very tender to the touch, retains the impress of the finger, its yellowish red colour, as in erysipelas, fades on pressure with the finger, but soon returns, and is connected with fever, headache, disposition to vomit, irritation of the brain, delirium, and coma. These symptoms are, under proper treatment, generally not dangerous, the wound looks well; blood-letting and gentle purging, with simple treatment of the wound, avoiding all irritation, in general speedily remove them, and the skin scales off.

382. If the aponeurosis of the skull and the pericranium be injured, there frequently arises, particularly in stabs, from inflammation of these fibrous structures, an elastic, reddish swelling, painful to the touch, generally less extensive than in the former case, but always connected in its aftercourse with extensive erysipelas, with a doughy state of the integument, with severe headache, fever, loss of sleep, and delirium. Suppuration, with destruction of the cellular tissue, quickly ensues, in which case, if the pericranium be attacked, it separates to a great extent from the skull, and the inflammation may be propagated to the dura mater. In this case, both general and local blood-letting, with purgatives and cold application, to the head, must be simultaneously applied. The most certain modes however, of preventing all dangerous symptoms, or of setting them aside, is to make cuts very early into the swelling, for the purpose of discharging the collected fluid and the dead cellular tissue. Warm applications and poultices may here also be employed very advantageously.

383. Flap Wounds of the Coverings of the Skull, even when a considerable portion of the bone is laid bare, must always, after careful cleansing of the flaps, be closely brought together with sticking plaster and with some stitches (1). Charpie and a compress are to be laid upon the flaps, and their connexion assisted with a suitable head-bandage. In most cases the flaps unite completely, but many only in part. If suppuration take place, a proper outlet must be provided for the pus; if a fluctuating swelling form, it must be opened at once, and the union of the flaps assisted by proper