Tetanus also, being a spasm, takes place from the muscles of the body,
and more particularly those about the spine, being as it were congealed
by a cold humour, fixing both within and without; and hence they are
incapable of bending themselves. But when the parts of the body are
bent forwards, the affection is called emprosthotonos; when backwards,
opisthotonos; and, when the parts are stretched equally both ways, the
affection is called tetanus. Pelops says that these affections consist of
a tension and contraction of the muscles and nerves about the neck, by
which stooping, nodding, and turning of the head are performed; that if
the affection be seated in the posterior muscles of the neck, the disease
is, from this circumstance, called opisthotonos; when in the anterior,
emprosthotonos; and if both are affected, tetanus. The cause, he says, is
a flatus, and thick and nebulous air filling the muscles. He says that it
is very cold and congealed, and that this is the cause of the difficulty
of motion; and that, therefore, dry fomentations, and not moist, are most
suitable to them. And these are the varieties of tetanus. “But,” he adds,
“the cure of all is the same, and does not change with the varieties.
Wherefore, the most potent remedy for them all is a fever supervening,
when there was none at the commencement.” The symptoms are a moaning
respiration, pulse rare and small, and sometimes a sardonic laugh comes
on; the face is red, and their eyes appear larger than natural; their
urine is either wholly suppressed, or it resembles common water, or is
somewhat bloody, and contains certain bubbles; the belly is dried up;
they cannot sleep; and often, from the violence of the spasms, they are
in danger of falling out of their beds; they sometimes have singultus,
and pains in the head, or between the shoulders and loins; and some have
tremors. The disease is occasioned sometimes, though rarely, by fatigue,
by lying upon the ground, lifting of weights, a fall, a wound, a burn,
and a blow, or any other thing which can bring on such an injury of the
nerves. The disease is to be cured like convulsions from depletion.
_The cure of the varieties of tetanus._ In treating tetanic spasms, we
must begin with phlebotomy, and wrapping the parts in wool which has
been dipped in oil, namely, the Sicyonian and castor with old oil; or a
broad bladder containing hot oil may be applied to the tendons. Cupping,
with scarifications, is to be applied; for dry cupping is hurtful. The
neck, both sides of the spine, the muscular parts of the breast, the
hypochondria, and the region of the bladder or kidneys, should be cupped.
We must not be sparing of the detraction of blood, nor yet take away
too much at a time, but at intervals. The sweats should be absorbed by
the wool dipped in oil, lest the patient happen to catch cold. If the
attack of tetanus continue long, the patient must be put into a hip-bath
of oil twice a day, but not allowed to remain long in it; for, of all
applications, the bath of oil is the most debilitating. Let him drink
tepid hydromel boiled to the one half; and the robust may take a drachm
of opopanax; or, if not so much, three oboli, or at least one obolus,
if we are afraid of its proving injurious to the stomach. We must also
give gum ammoniac; or the Cyrenaic juice, to the size of a tare, made
up with well-boiled honey, may be swallowed. Two spoonfuls of the root
of laserwort may be given in three cyathi of honied water, or in its
decoction; or one drachm of myrrh, in honied water, or the decoction of
hyssop. But the least dangerous and most effectual remedy is castor, to
the extent of two or three spoonfuls, in divided doses. And it will do
no harm, if you give it after a meal; but the drink and the other things
should be taken slowly and by degrees; for if swallowed with difficulty,
the drink regurgitates at the nose, the violent agitations of which bring
on convulsions. The anus should be smeared with oil of rue, along with
opopanax, and the same things are to be given in a clyster. The affusion
of cold water being, as Hippocrates says, exceedingly hazardous, and,
for that reason, I suppose, rejected by succeeding authorities, we too
are disposed to condemn.
_A liniment._ Of nard (valerian), one sextarius; of wax, oz. ij; of
malabathrum, of amomum, of storax, and of mastich, of each, oz. j;
of castor, of adarce, of euphorbium, of pepper, of each, oz. j; of
spikenard, of opobalsam, of each oz. j.
_A potion for opisthotonos._ Of the root of panacea, of white pepper,
of costus, of myrrh, of poppy juice, equal parts. Give to the size of
the vetch called _aracus_ at bedtime. It is also a remedy for orthopnœa.
Let the diet be attenuant, of easy diffusion, and by all means not
excrementitious.
* * * * *
COMMENTARY. Consult all the works referred to in the preceding Section;
also, Celsus (iv, iii); Haly Abbas (Theor. ix, 10, 11, Pract. v, 31);
Alexander Aphrodisiensis (Prob. i, 53.)
Hippocrates, Plato, Galen, Horatianus, and Avicenna agree in stating
that a fever coming on tends to remove the tetanic affection. Cælius
Aurelianus seems to question the truth of this ancient aphorism.
According to Hippocrates, tetanus generally proves fatal within
four days, or, if not, recovery takes place. He disapproves of the
cold affusion in cases of traumatic tetanus (Aph. v, 21); Alexander
Aphrodisiensis, however, speaks rather favorably of it.
Aëtius, Oribasius, and Nonnus, like our author, recommend bleeding,
emollient fomentations, and the bath of oil. Archigenes (ap. Aëtium)
directs the bath to be prepared by adding a fifth part of oil to the
water.
The treatment recommended by Celsus is judicious and not unlike our
author’s. He expresses himself hesitatingly about venesection, and
forbids the early use of wine. He approves of opening the bowels.
Aretæus says that tetanus is a painful spasm, sometimes proving speedily
fatal, and always difficult to cure. Like the moderns, he mentions
the three varieties of it, namely, emprosthotonos, opisthotonos, and
tetanus. The disease, according to his account, may arise from a variety
of causes, such as a wound of a muscular or nervous part, abortion, and
excessive cold. When it arises from the two causes first mentioned, it
is said to be generally fatal. His description of it is given in his
usual graphic manner. He advises the physician not to compromise himself
by meddling with the case when the disease is fairly established. His
treatment is altogether soothing and relaxant. He recommends us to lay
the patient upon a soft warm bed, and, from whatever cause the complaint
arise, to begin with abstracting blood from the arm. Then soft liquid
food is to be given, and the whole body wrapped in wool moistened with
some calefacient oil; or bladders half filled with tepid oil are to be
applied to the parts most affected. He directs us to cup the back part
of the neck, but cautions against exciting irritation by the application
of heat. To the wound he recommends suppurative applications containing
frankincense, turpentine-rosin, and the like; for he remarks (and the
fact is confirmed by the experience of the late M. Larrey, who recommends
a similar mode of practice) that, when tetanus supervenes, the sore
becomes dry. He praises castor and assafœtida as antispasmodics; and,
if these cannot be swallowed, they are to be given in an injection. He
advises also hiera to be given in an injection.
Cæelius Aurelianus enumerates nearly the same causes as Aretæus, and
describes all the symptoms of the disease with the greatest precision.
His treatment also is nearly the same as that of Aretæus, namely,
emollient applications to the neck, venesection, and oily clysters.
He even enjoins the bath of oil, which has fallen into disuse in
modern practice, most probably solely on account of the expense with
which it would be attended. He also permits sometimes the use of the
common bath, but not of cold water. He allows wine in certain cases.
He condemns Hippocrates for giving both wine and emetics, and having
recourse to venesection, without due discrimination. He blames him also
for recommending the affusion of cold water, inasmuch as he himself had
pronounced cold to be injurious to the nerves, bones, &c. Galen, however,
remarks, in his Commentary upon this Aphorism of Hippocrates (sect, v,
21), that cold, in this case, is not the direct cause of the benefit
derived from this remedy, but (if we understand him right) that the shock
which it imparts to the system proves beneficial, by rousing the vital
heat and energies of the patient. Hippocrates, however, as stated above,
forbade the cold affusion in traumatic tetanus. Our author’s opinion of
this practice is just such as the profession in general now entertain,
after it has received another trial upon the recommendation of the late
Dr. Currie. (See ‘Medical Reports,’ and Larrey’s ‘Mémoires de Chirurgie’,
t. 1.)
Octavius Horatianus recommends bleeding, emollient applications,
purgative clysters, the tepid bath, antispasmodics, and _soporifics_. The
use of the last-mentioned class of remedies does not appear to have been
sufficiently understood by the ancients; at all events they were less
partial to them in this case than the moderns.
The Arabians enjoin nearly the same treatment as the Greeks. Avicenna
and Mesue join the preceding authorities in recommending strongly the
use of castor and assafœtida as antispasmodics. Avicenna, like all the
others, praises the bath of oil. Serapion speaks of a bath prepared
with emollient herbs. Haly Abbas describes minutely the two varieties
as occasioned by repletion and inanition. For the former, he approves
of purging with hot drastic purgatives, of rubbing the part affected
with hot oils, and of using the warm bath with friction after it. He
also approves of castor. For the other variety, he praises the affusion
of plain water in which lettuces, barley, &c. have been boiled. He
recommends the internal use of milk and other demulcents, and the bath of
oil, and rubbing the body with oil of violets. The treatment recommended
by Alsaliaravius is very similar. Rhases mentions Hippocrates’ proposal
of the cold affusion; but, like our author, he rather disapproves of it.
He himself recommends bleeding, when there are symptoms of repletion,
emollient applications to the neck, the bath of oil, the application
of leeches to the part affected, purging with aloes, &c. and the
administration of antispasmodics, such as castor, assafœtida, and the
like.