For a history of the different names and symptoms of this disease, I beg leave to refer the reader to practical books, particularly to Doctor Cullen's First Lines. My only design in this inquiry, is to deliver such a theory of the disease, as may lead to a new and successful use of old and common remedies for it.

All the remote and predisposing causes of the tetanus act by inducing preternatural debility, and irritability in the muscular parts of the body. In many cases, the remote causes act alone, but they more frequently require the co-operation of an exciting cause. I shall briefly enumerate, without discriminating them, or pointing out when they act singly, or when in conjunction with each other.

I. Wounds on different parts of the body are the most frequent causes of this disease. It was formerly supposed it was the effect only of a wound, which partially divided a tendon, or a nerve; but we now know it is often the consequence of lÆsions which affect the body in a superficial manner. The following is a list of such wounds and lÆsions as have been known to induce the disease:

1. Wounds in the soles of the feet, in the palms of the hands, and under the nails, by means of nails or splinters of wood.

2. Amputations, and fractures of limbs.

3. Gun-shot wounds.

4. Venesection.

5. The extraction of a tooth, and the insertion of new teeth.

6. The extirpation of a schirrous.

7. Castration.

8. A wound on the tongue.

9. The injury which is done to the feet by frost.

10. The injury which is sometimes done to one of the toes, by stumping it (as it is called) in walking.

11. Cutting a nail too closely. Also,

12. Cutting a corn too closely.

13. Wearing a shoe so tight as to abrade the skin of one of the toes.

14. A wound, not more than an eighth part of an inch, upon the forehead.

15. The stroke of a whip upon the arm, which only broke the skin.

16. Walking too soon upon a broken limb.

17. The sting of a wasp upon the glands penis.

18. A fish bone sticking in the throat.

19. Cutting the navel string in new-born infants.

Between the time in which the body is thus wounded or injured, and the time in which the disease makes its appearance, there is an interval which extends from one day to six weeks. In the person who injured his toe by stumping it in walking, the disease appeared the next day. The trifling wound on the forehead which I have mentioned, produced both tetanus and death, the day after it was received. I have known two instances of tetanus, from running nails in the feet, which did not appear until six weeks afterwards. In most of the cases of this disease from wounds which I have seen, there was a total absence of pain and inflammation, or but very moderate degrees of them, and in some of them the wounds had entirely healed, before any of the symptoms of the disease had made their appearance. Wounds and lÆsions are most apt to produce tetanus, after the long continued application of heat to the body; hence its greater frequency, from these causes, in warm than in cold climates, and in warm than in cold weather, in northern countries.

II. Cold applied suddenly to the body, after it has been exposed to intense heat. Of this Dr. Girdlestone mentions many instances, in his Treatise upon Spasmodic Affections in India. It was most commonly induced by sleeping upon the ground, after a warm day. Such is the dampness and unwholesome nature of the ground, in some parts of that country, that “fowls (the doctor says) put into coops at night, in the sickly season of the year, and on the same soil that the men slept, were always found dead the next morning, if the coop was not placed at a certain height above the surface of the earth[48].” It was brought on by sleeping on a damp pavement in a servant girl of Mr. Alexander Todd of Philadelphia, in the evening of a day in which the mercury in Fahrenheit's thermometer stood at 90°. Dr. Chalmers relates an instance of its having been induced by a person's sleeping without a nightcap, after shaving his head. The late Dr. Bartram informed me, that he had known a draught of cold water produce it in a man who was in a preternaturally heated state. The cold air more certainly brings on this disease, if it be applied to the body in the form of a current. The stiff neck which is sometimes felt after exposure to a stream of cool air from an open window, is a tendency to a locked jaw, or a feeble and partial tetanus.

III. Worms and certain acrid matters in the alimentary canal. Morgagni relates an instance of the former, and I shall hereafter mention instances of the latter in new-born infants.

IV. Certain poisonous vegetables. There are several cases upon record of its being induced by the hemlock dropwort, and the datura stramonium, or Jamestown weed of our country.

V. It is sometimes a symptom of the bilious remitting and intermitting fever. It is said to occur more frequently in those states of fever in the island of Malta, than in any other part of the world.

VI. It is likewise a symptom of that malignant state of fever which is brought on by the bite of a rabid animal, also of hysteria and gout.

VII. The grating noise produced by cutting with a knife upon a pewter plate excited it in a servant, while he was waiting upon his master's table in London. It proved fatal in three days.

VIII. The sight of food, after long fasting.

IX. Drunkenness.

X. Certain emotions and passions of the mind. Terror brought it on a brewer in this city. He had been previously debilitated by great labour, in warm weather. I have heard of its having been induced in a man by agitation of mind, occasioned by seeing a girl tread upon a nail. Fear excited it in a soldier who kneeled down to be shot. Upon being pardoned he was unable to rise, from a sudden attack of tetanus. Grief produced it in a case mentioned by Dr. Willan.

XI. Parturition.

All these remote and exciting causes act with more or less certainty and force, in proportion to the greater or less degrees of fatigue which have preceded them.

It has been customary with authors to call all those cases of tetanus, which are not brought on by wounds, symptomatic. They are no more so than those which are said to be idiopathic. They all depend alike upon irritating impressions, made upon one part of the body, producing morbid excitement, or disease in another. It is immaterial, whether the impression be made upon the intestines by a worm, upon the ear by an ungrateful noise, upon the mind by a strong emotion, or upon the sole of the foot by a nail; it is alike communicated to the muscles, which, from their previous debility and irritability, are thrown into commotions by it. In yielding to the impression of irritants, they follow in their contractions the order of their predisposing debility. The muscles which move the lower jaw are affected more early, and more obstinately than any of the other external muscles of the body, only because they are more constantly in a relaxed, or idle state.

The negroes in the West-Indies are more subject to this disease than white people. This has been ascribed to the greater irritability of their muscular systems, which constitutes a part of its predisposing cause. It is remarkable that their sensibility lessens with the increase of their irritability; and hence, Dr. Moseley says, they bear surgical operations much better than white people.

New-born infants are often affected by this disease in the West-Indies. I have seen a few cases of it in Philadelphia. It is known by the name of the jaw-fall. Its causes are:

1. The cutting of the navel string. This is often done with a pair of dull scissors, by which means the cord is bruised.

2. The acrimony of the meconium retained in the bowels.

3. Cold air acting upon the body, after it has been heated by the air of a hot room.

4. Smoke is supposed to excite it, in the negro quarters in the West-Indies.

It is unknown, Dr. Winterbottom informs us, among the native Africans in the neighbourhood of Sierra Leone.

I am aware that it is ascribed by many physicians to only one of the above causes; but I see no reason why it should not be induced by more than one cause in infants, when we see it brought on by so many different causes in grown people.

The tetanus is not confined to the human species. It often affects horses in the West-Indies. I have seen several cases of it in Philadelphia.

The want of uniform success in the treatment of this disease, has long been a subject of regret among physicians. It may be ascribed to the use of the same remedies, without any respect to the nature of the causes which produce it, and to an undue reliance upon some one remedy, under a belief of its specific efficacy. Opium has been considered as its antidote, without recollecting that it was one only, of a numerous class of medicines, that are all alike useful in it.

Tetanus, from all its causes, has nearly the same premonitory symptoms. These are a stiffness in the neck, a disposition to bend forward, in order to relieve a pain in the back, costiveness, a pain about the external region of the stomach, and a disposition to start in sleep. In this feeble state of the disease, an emetic, a strong dose of laudanum, the warm bath, or a few doses of bark, have often prevented its being completely formed. When it has arisen from a wound, dilating it if small or healed, and afterwards inflaming it, by applying to it turpentine, common salt, corrosive sublimate, or Spanish flies, have, in many hundred instances, been attended with the same salutary effects.

The disease I have said is seated in the muscles, and, while they are preternaturally excited, the blood-vessels are in a state of reduced excitement. This is evident from the feebleness and slowness of the pulse. It sometimes beats, according to Dr. Lining, but forty strokes in a minute. By stimulating the wound, we not only restore the natural excitement of the blood-vessels, but we produce an inflammatory diathesis in them, which abstracts morbid excitement from the muscular system, and, by equalizing it, cures the disease. This remedy I acknowledge has not been as successfully employed in the West-Indies as in the United States, and that for an obvious reason. The blood-vessels in a warm climate refuse to assume an inflammatory action. Stimuli hurry them on suddenly to torpor or gangrene. Hence the danger and even fatal effects of blood-letting, in the fevers which affect the natives of the islands, a few hours after they are formed. But widely different is the nature of wounds, and of the tension of the blood-vessels, in the inhabitants of northern countries. While Dr. Dallas deplores the loss of 49 out of 50 affected with tetanus from wounds, in the West-India islands, I am sure I could mention many hundred instances of the disease being prevented, and a very different proportion of cures being performed, by inflaming the wounds, and exciting a counter morbid action in the blood-vessels.

When the disease is the effect of fever, the same remedies should be given, as are employed in the cure of that fever. I have once unlocked the jaw of a woman who was seized at the same time with a remitting fever, by an emetic, and I have heard of its being cured in a company of surveyors, in whom it was the effect of an intermittent, by large doses of bark. When it accompanies malignant fever, hysteria, or gout, the remedies for those forms of disease should be employed. Bleeding was highly useful in it in a case of yellow fever which occurred in Philadelphia in the year 1794.

When it is produced by the suppression of perspiration by means of cold, the warm bath and sweating medicines have been found most useful in it. Nature has in one instance pointed out the use of this remedy, by curing the disease by a miliary eruption on the skin[49].

If it be the effect of poisonous substances taken into the stomach, or of worms in the bowels, the cure should be begun by emetics, purges, and anthelmintic medicines.

Where patients are unable to swallow, from the teeth of the upper and lower jaw pressing upon each other, a tooth or two should be extracted, to open a passage for our medicines into the throat. If this be impracticable or objected to, they should be injected by way of glyster.

In the locked jaw which arises from the extraction of a tooth, an instrument should be introduced to depress the jaw. This has been done by a noted English dentist in London, with success.

As the habit of diseased action often continues after the removal of its causes, and as some of the remote causes of this disease are beyond the reach of medicine, such remedies should be given as are calculated, by their stimulating power, to overcome the morbid or spasmodic action of the muscles. These are:

1. Opium. It should be given in large and frequent doses. Dr. Streltz says he has found from one to two drachms of an alkali, taken in the course of a day, greatly to aid the action of the opium in this disease.

2. Wine. This should be given in quarts, and even gallons daily. Dr. Currie relates a case of a man in the infirmary of Liverpool, who was cured of tetanus, by drinking nearly a quarter cask of Madeira wine. Dr. Hosack speaks in high terms of it, in a letter to Dr. Duncan, and advises its being given without any other stimulating medicine.

3. Ardent spirits. A quack in New-England has lately cured tetanus, by giving ardent spirits in such quantities as to produce intoxication. Upon being asked his reason for this strange practice, he said, he had always observed the jaw to fall in drunken men, and any thing that would produce that effect, he supposed to be proper in the locked jaw.

4. The BARK has of late years been used in this disease with success. I had the pleasure of first seeing its good effects in the case of Colonel Stone, in whom a severe tetanus followed a wound in the foot, received at the battle of Germantown, in October, 1777.

5. The COLD BATH. This remedy has been revived by Dr. Wright of Jamaica, and has in many instances performed cures of this disease. In one of two cases in which I have used it with success, the patient's jaw opened in a few minutes after the affusion of a single bucket of water upon her body. The disease was occasioned by a slight injury done to one of her toes, by wearing a tight shoe. The signals for continuing the use of the cold bath, are its being followed by a slight degree of fever, and a general warmth of the skin. Where these do not occur, there is reason to believe it will do no service, or perhaps do harm. We have many proofs of the difference in the same disease, and in the operation of the same medicine, in different and opposite climates. Dr. Girdlestone has mentioned the result of the use of the cold bath in tetanus in the East-Indies, which furnishes a striking addition to the numerous facts that have been collected upon that subject. He tells us the cold bath uniformly destroyed life, in every case in which it was used. The reason is obvious. In that extremely debilitating climate, the system in tetanus was prostrated too low to re-act, under the sedative operation of the cold water.

6. The WARM BATH has often been used with success in this disease. Its temperature should be regulated by our wishes to promote sweats, or to produce excitement in the blood-vessels. In the latter case it should rise above the heat of the human body.

7. The OIL OF AMBER acts powerfully upon the muscular system. I have seen the happiest effects from the exhibition of six or eight drops of it, every two hours, in this disease.

8. A SALIVATION has been often recommended for the cure of tetanus, but unfortunately it can seldom be excited in time to do service. I once saw it complete the cure of a sailor in the Pennsylvania hospital, whose life was prolonged by the alternate use of bark and wine. The disease was brought on him by a mortification of his feet, in consequence of their being frost-bitten.

9. Dr. Girdlestone commends BLISTERS in high terms in this disease. He says he never saw it prove fatal, even where they only produced a redness on the skin.

10. I have heard of ELECTRICITY having been used with advantage in tetanus, but I can say nothing in its favour from my own experience.

In order to ensure the utmost benefit from the use of the above remedies, it will be necessary for a physician always to recollect, that the disease is attended with great morbid action, and of course each of the stimulating medicines that has been mentioned should be given, 1st, in large doses; 2dly, in succession; 3dly, in rotation; and 4thly, by way of glyster, as well as by the mouth.

The jaw-fall in new-born infants is, I believe, always fatal. Purging off the meconium from the bowels immediately after birth has often prevented it from one of its causes; and applying a rag wetted with spirit of turpentine to the navel-string, immediately after it is cut, Dr. Chisholm says, prevents it from another of its causes which has been mentioned.

This disease, I have said, sometimes affects horses. I have twice seen it cured by applying a potential caustic to the neck under the mane, by large doses of the oil of amber, and by plunging one of them into a river, and throwing buckets of cold water upon the other.

I shall conclude my observations upon the tetanus with the following queries:

1. What would be the effects of copious blood-letting in this disease? There is a case upon record of its efficacy, in the Medical Journal of Paris, and I have now in my possession a letter from the late Dr. Hopkins of Connecticut, containing the history of a cure performed by it. Where tetanus is the effect of primary gout, hysteria, or fever, attended with highly inflammatory symptoms, bleeding is certainly indicated, but, in general, the disease is so completely insulated in the muscles, and the arteries are so far below their par of excitement in frequency and force, that little benefit can be expected from that remedy. The disease, in these cases, seems to call for an elevation, instead of a diminution, of the excitement of the blood-vessels.

2. What would be the effect of extreme cold in this disease? Mr. John Hunter used to say, in his lectures, “Were he to be attacked by it, he would, if possible, fly to Nova-Zembla, or throw himself into an ice-house.” I have no doubt of the efficacy of intense cold, in subduing the inordinate morbid actions which occur in the muscular system; but it offers so much violence to the fears and prejudices of sick people, or their friends, that it can seldom be applied in such a manner as to derive much benefit from it. Perhaps the sedative effects of cold might be obtained with less difficulty, by wrapping the body in sheets, and wetting them occasionally for an hour or two with cold water.

3. What would be the effect of exciting a strong counter-action in the stomach and bowels in this disease? Dr. Brown of Kentucky cured a tetanus by inflaming the stomach, by means of the tincture of cantharides. It has likewise been cured by a severe cholera morbus, induced by a large dose of corrosive sublimate. The stomach and bowels, and the external muscles of the body, discover strong associations in many diseases. A sick stomach is always followed by general weakness, and the dry gripes often paralyze the muscles of the arms and limbs. But further, one of the remote causes of tetanus, viz. cold air, often shows the near relationship of the muscles to the bowels, and the vicarious nature of disease in each of them. It often produces in the latter, in the West-Indies, what the French physicians call a “crampe seche,” or, in other words, if I may be allowed the expression, a tetanus in the bowels.

4. A sameness has been pointed out between many of the symptoms of hydrophobia and tetanus. A similar difficulty of swallowing, and similar convulsions after it, have been remarked in both diseases. Death often takes place suddenly in tetanus, as it does in hydrophobia, without producing marks of fatal disorganization in any of the internal parts of the body. Dr. Physick supposes death in these cases to be the effect of suffocation, from a sudden spasm and closure of the glottis, and proposes to prevent it in the same manner that he has proposed to prevent death from hydrophobia, that is, by laryngotomy[50]. The prospect of success from it appears alike reasonable in both cases.

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