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TETANUS, in all its varieties, is a spasm of an exceedingly painful nature, very swift to prove fatal, but neither easy to be removed. They are affections of the muscles and tendons about the jaws; but the illness is communicated to the whole frame, for all parts are affected sympathetically with the primary organs. There are three forms of the convulsion, namely, in a straight line, backwards, and forwards. Tetanus is in a direct line, when the person labouring under the distention is stretched out straight and inflexible. The contractions forwards and backwards have their appellation from the tension and the place; for that backwards we call Opisthotonos; and that variety we call Emprosthotonos in which the patient is bent forwards by the anterior nerves. For the Greek word τόνος is applied both to a nerve, and to signify tension.

The causes of these complaints are many; for some are apt to supervene on the wound of a membrane, or of muscles, or of punctured nerves, when, for the most part, the patients die; for, "spasm from a wound is fatal." And women also suffer from

this spasm after abortion; and, in this case, they seldom recover. Others are attacked with the spasm owing to a severe blow in the neck. Severe cold also sometimes proves a cause; for this reason, winter of all the seasons most especially engenders these affections; next to it, spring and autumn, but least of all summer, unless when preceded by a wound, or when any strange diseases prevail epidemically. Women are more disposed to tetanus than men, because they are of a cold temperament; but they more readily recover, because they are of a humid. With respect to the different ages, children are frequently affected, but do not often die, because the affection is familiar and akin to them; striplings are less liable to suffer, but more readily die; adults least of all, whereas old men are most subject to the disease, and most apt to die; the cause of this is the frigidity and dryness of old age, and the nature of the death. But if the cold be along with humidity, these spasmodic diseases are more innocent, and attended with less danger.

In all these varieties, then, to speak generally, there is a pain and tension of the tendons and spine, and of the muscles connected with the jaws and cheek; for they fasten the lower jaw to the upper, so that it could not easily be separated even with levers or a wedge. But if one, by forcibly separating the teeth, pour in some liquid, the patients do not drink it but squirt it out, or retain it in the mouth, or it regurgitates by the nostrils; for the isthmus faucium is strongly compressed, and the tonsils being hard and tense, do not coalesce so as to propel that which is swallowed. The face is ruddy, and of mixed colours, the eyes almost immoveable, or are rolled about with difficulty; strong feeling of suffocation; respiration bad, distension of the arms and legs; subsultus of the muscles; the countenance variously distorted; the cheeks and lips tremulous; the jaw quivering, and the teeth rattling, and in certain rare cases even the ears are thus affected. I myself have beheld

this and wondered! The urine is retained, so as to induce strong dysuria, or passes spontaneously from contraction of the bladder. These symptoms occur in each variety of the spasms.

But there are peculiarities in each; in Tetanus there is tension in a straight line of the whole body, which is unbent and inflexible; the legs and arms are straight.

Opisthotonos bends the patient backward, like a bow, so that the reflected head is lodged between the shoulder-blades; the throat protrudes; the jaw sometimes gapes, but in some rare cases it is fixed in the upper one; respiration stertorous; the belly and chest prominent, and in these there is usually incontinence of urine; the abdomen stretched, and resonant if tapped; the arms strongly bent back in a state of extension; the legs and thighs are bent together, for the legs are bent in the opposite direction to the hams.

But if they are bent forwards, they are protuberant at the back, the loins being extruded in a line with the back, the whole of the spine being straight; the vertex prone, the head inclining towards the chest; the lower jaw fixed upon the breast bone; the hands clasped together, the lower extremities extended; pains intense; the voice altogether dolorous; they groan, making deep moaning. Should the mischief then seize the chest and the respiratory organs, it readily frees the patient from life; a blessing this, to himself, as being a deliverance from pains, distortion, and deformity; and a contingency less than usual to be lamented by the spectators, were he a son or a father. But should the powers of life still stand out, the respiration, although bad, being still prolonged, the patient is not only bent up into an arch but rolled together like a ball, so that the head rests upon the knees, while the legs and back are bent forwards, so as to convey the impression of the articulation of the knee being dislocated backwards.

An inhuman calamity! an unseemly sight! a spectacle painful even to the beholder! an incurable malady! owing to the distortion, not to be recognised by the dearest friends; and hence the prayer of the spectators, which formerly would have been reckoned not pious, now becomes good, that the patient may depart from life, as being a deliverance from the pains and unseemly evils attendant on it. But neither can the physician, though present and looking on, furnish any assistance, as regards life, relief from pain or from deformity. For if he should wish to straighten the limbs, he can only do so by cutting and breaking those of a living man. With them, then, who are overpowered by the disease, he can merely sympathise. This is the great misfortune of the physician.

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