No. A J \ BOSTOH/ Medical Library Association, 19 BOYiys\pN PLACE, • •TO , r J** !-*& i v AN INAUGURAL DISSERTATION. ON THE ANIMATING PRINCIPLE, orANIMA MUNDI; HOW AFFORDED, AND HOW ACTING IN MAN ; AND HOW ACTED UPON IN THAT DISEASE COMMONLY DENOMINATED, TETANUS or LOCK-JAW. READ AND DEFENDED AT A PUBLICK EXAMINATION, Held by the MEDICAL PROFESSORS, before the Rev. JOSEPH WILLARD, S. T. D. President, AND Ti^GOlERNORS OF THE UNIVERSITY AT CAMBRIDGE, FOR THE DEGREE OF BACHELOR IN MEDICINE, JULY 3d. 1795. By FREDERICK MAY, A.M. " LIVES THRO'' ALL LIFE, EXTENDS THRO' ALL EXTENT, SPREADS UNDIVIDED, OPERATES UNSPENT." POPE. 'Bottom FROM THE PRESS OF WILLIAM SPOTSWOOD, N0^, MARLBO ROUGH-STREET. 1795- / T O John "Warren, m. d, 2c 7 ] tanus undoubtedly is a proper generick dif- tindion, and as a " fpaftick rigidity of the body," applies equally to that difeafe which arifes from pundure, and that which arifes from cold. But as they are fpecifi- cally different, both in refped to their caufe and cure, as will be fhown, they ought to be confidered as diftind fpecies. But Doc- tor Cullen confounds them under a diftind genus of trifmus, and fpecies of trauma- ticus. In his elements of the theory and pradice of phyfick, inftead of thefe nume- rous divifions, he has taken the fimple title tetanus, and makes the genus trifmus, and all the fpecies of the two genera, varieties only of this one genus. But with deference, I fufped, that in the former work too com- plex, in the latter too fimple, he equally errs. The locking of the jaw, the opifthotonos, the epifthotonos, and the lateralis undoubt- edly are varieties only of the fame difeafe. But to confound that fpecies which arifes from cold, that from pundure, and that which is proper to infants, is departing from the plan of a nofological arrangement, founded on fpecifick differences. 1 fhould therefore think it more proper to have but [ 18 ] one genus, tetanus, and three fpecies, via. a pundura, a frigore, and nafcentium. The tetanus a pundura is the fubjed of this differtation, and its nature is now to be examined. This is clearly fpafmodick. But it is a term which requires explanation. Spafm is an unequal, and morbid flow of the animating principle uncontrolled by the will ; fo that fome mufcles are more largely fupplied than others: hence, the balance is deftroyed, and unequal motion is produced. CAUSE. I fhall not, as ufual, diftinguifh and de- fcribe the various predifponent, exciting, remote, and proximate caufes. If I can dif- cover one fimple caufe, and trace its man-" ner of ading in producing fuch terrible ef- fects, I fhall think it fufftcient. That fpe- cies now under confideration, I believe in- variably arifes from the lefion of a nerve, or tendon, moft commonly from pundure. The wounding inftrument, a nail for in- ftance, difarranges the exquifite texture of the nerve, or tendon. If fuppuration could [ 19 ] take place, it w7ould probably remove the offending caufe. But there are two obfta- cles to this procefs. The wound of the in- teguments is net fufficientto produce fup- puration ; and it confequently heals by the firft intention. Again, there is not fenfi- ble heat, nor fluid enough in the nerve, to produce it of itfelf. As the offending caufe cannot be removed by the ufual means of fuppuration, it remains, and continues to ad. The difeafe is now upon the nerve, and it is a difarrangement of the texture of the nerve, from the ftimulus of the caufe. This difarrangement impedes the vibration of the animating fluid, and in fad makes the nerve a non-condudor. As the caufe - remains, the effeds increafe, and the dif- arrangement of texture infidioufly creeps along the courfe of the nerve, until it af- fects that whole fyftem of nerves. What I mean by " that fyftem of nerves," is all the nerves of the fame fpecies. If it is a nerve which goes to a flexor mufcle, all the nerves that pafs to flexor mufcles are af- feded in the fame way. The ufual term for the appearance of the difeafe is ten or twelve days ; but it varies in various ha- C 2 t 20 ] bits, and from various caufes. The moft fruitful fource of it is the wound of a flexor nerve, or tendon in the bottom of the foot, or palm of the hand. An explanation of this variety, I prefume, will apply to all the others. EFFECTS. In defcribing its effeds, I fhall give a concife hiftory of the difeafe ; and as the fymptoms will appear fo decided as to allow of no poffible miftake in the diag- noftick, and as unfortunately our progno- ftick muft be always unfavourable, I think it unneceffary to be particular on thofe branches of medical fcience. The vibration and circulation of the fluid being impeded in the flexor nerves, and propagated to the brain, the extenfor mufcles will be more largely fupplied with the animating principle. Hence an ine- quality, and hence the fpafm. It com- monly makes its appearance by firft affed- ing the extenfor mufcles neareft the fenfo- rium. The firft fymptom of complaint is ufually a flight ftiffnefs of the neck, make- [ ii 1 ing it difficult for the patient to turn his head. The jaw next ftiffens, the neck be- comes rigid, and there is fome difficulty of deglutition. The fpafm now extends down the. fpine, recurvating the back as far as poflible. The mufcles of the extre- mities next become fpafmodick, rigidly ex- tending them. Thefe fymptoms are too violent to be cOnftant; and they com- monly remit, only, to return with redou- bled violence. In this cafe of remiffion, they originate from the fcrobiculus cordis, fhooting back to the fpine, and then be- coming general. This fymptom is confider- ed as pathognomonick of the difeafe. The fphinders of the excretories are likew7ife affeded in the latter part of the diforder. Sometimes in a remiffion, when the jaw is relaxed, a fudden fpafnl takes the protru- five mufcles of the tongue, thrufts it out, and before it can be returned, the jaw flies too, and wounds it in a moft fhocking manner. The patient is now in fo irrita- ble a fituation, that he cannot drink, fpeak, or move without exciting moft vio- lent fpafms. And what greatly aggravates the difeafe. is, that the appetite is good. c 3 [ 2* ] without the power of taking food ; and the reafon unimpaired, and fenfibility ra- ther increafed: fo that the patient is fully fenfible of his miferable fituation, and inevitable fate. In this ftage of the difor- der, the extremities are obftinately extend- ed, the back recurvated, the jaw locked, deglutition deftroyed, the forehead wrin- kled, the nofe drawn up, and the cheeks back, exhibiting a countenance moft fright- fully diftrefling, by fome called the rifus fardonicus As yet it has affeded only the mufcles of voluntary motion. But now the vital parts are in danger. Refpiration is performed with difficulty ; the pulfe ex- hibits fymptoms of a fpafmodick affedion on the arterial fyftem ; and if the difeafe is not foon checked in its courfe, an obftinate fpafm takes fome vital organ, the heart for inftance, and death immediately enfues. In this laft ftage of the difeafe, the brain ex- hibits appearances of the fame nature as was fuppofed to exift on the nerves; and the fame deftrudion of the texture of the nerve, has extended to the * brain, become * This I think is proved by a cafe under my own obser- vation, which I will relate. I once examined the brain ol t 23 ] univerfal, and completely deftroyed its or- ganization, and fundion. This is the courfe wThich the difeafe ufu- ally takes ; but there are many varieties, as I have before obferved. Sometimes the pa- tient is bent forwards, when it is denomi- nated opifthotonos ; fometimes fideways, when it is called lateralis ; and not unfre- quently the fpafm is of the clonick nature. Thefe however are no fpecifick alterations of the diforder. The peculiarities are, that it is unattended with fever, difarrangement of reafon, or lofs of appetite. But thefe are eafily accounted for. The fpafm exifts only on the voluntary fundions; the vital are uninjured until the laft ftage, which is by far the fhorteft. Thus much for its feat, nature, caufe and effeds. Its cure will now be attended a perfon who died of this diforder. The veffels were crowded with blood ; fo that in a tranfverfe feftion of the brain, which naturally would exhibit nothing but the corti- cal and medullary fubftances uncoloured, in this cafe, dis- covered an immenfe number of little red points, like the extremities of fmall arteries. The texture of the brain likewife was deftroyed, fo that the organized parts were fcarcely difcernible ; and in fact the whole appeared to be in a ftate of complete folution. C4 [ 2+ J to, which is by far the moft important, by far the moft inexplicable. CURE. Various theorifts, and various praditi- oners have adopted various plans of treat- ment. But in no cafe except one, which I have feen, heard, or read of, where the difeafe arofe from pundure, and the jaw had become locked, have I ever known it to be cured. And although in the great number of pradical papers preferved in me- dical commentaries, we find the virtues of particular remedies highly extolled for the cure of this difeafe ; yet; when we read the hiftories, we do not find a confirmed cafe of the tetanus a pundura cured by thefe medicines. The profellion, however, ge- nerally agree in this one indication, to pro- duce a fuppuration in the firft inftance, by an incifion in the wounded part. This undoubtedly is the moft effedual ; for by freely laying open the pundured part, the injured nerve is enabled, and folicited, to throw off the irritating injury, and recover its tone. Some, at the approach of the dif- . [ 25 .] eafe, have tried the * fame expedient, but with little fuccefs : for until the fuppura- tion takes place, it is only adding a frefh irritation to the one already exifting ; and and when-it does fuppurate, the difeafe is commonly too far advanced to yield to a to- pical remedy. Others more bold have am- putated the part above the injury. This is ftriking more at the root. The feat of irritation is removed at once ; and if the difeafe has not yet become general, if there is fufheient vigour in the fyftem, which is aftifted by medicine, the balance may be reftored. Mercury, thecold bath, the warm bath, bark, and opium have all been in repute, and all failed. The introdudion of f mer- cury for the cure of this difeafe, probably was more for experiment, than for any an- tifpafmodick quality which it poffeffes. It was therefore firft tried in the Weft Indies, in that fpecies which arifes from cold and * In two cafes in which I have known this method tried, it has failed. + Recommended byDr. Donald Monro in the Edinburgh phyfical and literary eflays. [ 26 ] is very frequent and fatal among the ne- groes, in which its evacuant, and diapho- retick qualities were very ferviceable. But as this is not the fpecies now under confi- deration, and as in the tetanus from punc- ture, it has had frequent and fair trials with- out fuccefs, no further attention will be paid to it. The cold bath is highly extoll- ed by Dodor James Curry '* in the memoirs of the London Medical Society : but he acknowledges, that out of feven cafes, two only w7ere affifted by it; and in thefe two, the difeafe did not arife from the in- jury of a nerve, or tendon, but from cold; therefore it is inapplicable. The warm bath undoubtedly is a palliative, but too inefficacious to remove the complaint. The bark, with the afliftance of wine and other ftimuli, has been w7armly recom- mended by Dodor Benjamin Ruin of Phi- ladelphia, who with his ufual ingenuity. fuppofes that relaxation is the predifpo- nent, and a want of inflammation in the wounded part, is the proximate caufe of the difeafe. Stimulants therefore, both exter- * Vol. III. [ 27 ] nal and internal, he thinks a furc remedy. Of the * three cafes which he relates, I do not think a conclufive argument can be drawn in favour of the remedy. The firft arofe from a gunfhot wound, which as there muft have been a large furface expofed, and probably a fuppuration, I do not conceive to be near fo dangerous. However, it is to be noted, that bliftering, and mercury were ufed at the fame time, which per- haps are entitled to as much merit as the bark, at leaft it leaves room for indecition. The fecond related arofe from cold, and is therefore foreign from our fubjed. And the third certainly cannot be confidered as a tetanus, for the complaints came on the day after the injury, when the wound was painful, and in a recent ftate, fo that dilat- ing it procured relief. We next come to the confideraticn of opium. This excellent medicine has by many been extolled as the moft efficacious + Memoirs of the London medical fociety. voK i. Thefe are the only obfervations which I have ever feen of ofDoaor Ruth's, on this difeafe. Perhaps further ob- fervation may have eftablithed or altered his opinion. [ 23 ] in the cure of this difeafe. It is the remedy Dodor Cullen chiefly depends upon ; and it has undoubtedly fometimes checked an approaching tetanus, but it more frequently fails. Whether it ads as a ftimulant or fedative, is left to the enthufiafts of the con- tending fyftems to difpute upon. But the probability is, that it ads firft as a ftimu- lent, afterwards as a fedative; and its ef- feds will prove the propofition. If it is given in fmall quantities, the fymptoms in- crcafe ; and even if the dofe is fufficiently large, its firft operation evidently increafes the fpafms ; and it is always obfervable, that unlefs it produces a remiffion, the dif- eafe is aggravated. But when it does pro- cure relief, the ufual fedative effeds appean When ufed therefore, it ought to be a;iven in fuch quantities, as to procure fpecdy re- lief, and repeated fo frequently, as to pre- vent a return of the fpafms. But when the difeafe is fixed, it moft frequently, and I believe always fails. These are the moft important medicines that have been ufed in this difeafe, of which opium undoubtedly has the pre-eminence, [ 29 J but I doubt whether either of them deferve much confidence. We have a remarkable * cafe in the memoirs of the American aca- demy of arts and fciences, ably related by a gentleman who ftridly attended to it. In this cafe all the before mentioned medicines were ufed, and what is fingular, all with palliative, but none with permanent effeds. The* mode of treatment moft probable to fucceed would be, it is generally agreed, in the firft inftance or at the time of punc- ture, if it is fufpeded that a tendon or nerve is injured, freely to lay open the part, and apply fomentations and cataplafms, to fo- licit a fuppuration. But if this is negleded and the difeafe comes on, at the firft ap- proach of the fymptoms, the part fhould be amputated. If it is only a toe or finger, it may be done without much deformity. But even if it is a large extremity which is wounded, when it is decidedly the difeafe, t amputation ought not to be deferred. I * The cafe of Dr. Edmund Wyer, related by Aaron Dexter, M. d. in vol 11. + I have feen this fucceed in two inftances, one from punaure when the fpafms had already feized the neck, jaw, and pharynx: the other a tetanick diathefisfrom de- nuded tendons. [ 3° 1 would fuggeft, whether if a ftream of elec- tricity could be kept pafling through thofe nerves which are difeafed, or non-conduct- ors, it would not be ferviceable. But the medicine moft to be depended upon, is to- bacco. It has fucceeded in one cafe ; and iro.n its nature and effed in that, it bids fair to produce the moft certain relief; and if there is a fpecifick, to be the one. Wri- ters on the materia medica have given it the qualities of being highly ftimulant, anodyne, and narcotick. Its eminent qual- ities in relieving that moft obftinate fpafm of the abdominal ring, which embraces the intei'Une in the hernia is a high recommen- dation of its antifpafmodick virtues. Its firft adion, when introduced into the fyf- tem, is highly ftimulant; but its tranfition is almoft immediate to being extremely de- bilitant. Its adion is chiefly on the volun- tary fundions; and without affcding the mind as fpirit or opium, it produces nni- verfalrelaxation, and proflration of ftrcngth. So powerful is it, that a fmall leaf of tobac- co dipped in fpirit, and applied to the fur- face of the body, is attended with the moft debilitating effeds. Thus the moft emi- [ 3' ] nent quality of tobacco is antifpafmodick 5, and if it can be rendered probable, that its effeds are fimilar on the difeafe in queftion, I hope at leaft it will operate as a hint for a further trial. Although new propofitions may be fupported by arguments, yet fad alone will eftablifh them. 1 fhall therefore endeavour to corroborate this plan of treat- ment, by the relation of a cafe to which I ftridly attended. * HISTORY^ A girl, nine years old, ran a nail into her foot, juft over the flexor tendon of the fecond toe. In twelve days fhe complain- ed of a ftiff-neck and jaw, and difficulty of fwallowing. She was likewife obferved frequently to fall backwards. As the caufe was then unknown, and the fymp- toms indefinitely defcribed, it was attri- buted to worms, which fhe had before been troubled with. Accordingly acathar- tick of rhubarb, and calomel was prefcribed. The next day, the fpafms were more fixed, and fhe was unable to fit up. In this fitu- [ 32 ] ation file was vifited by a gentleman of the firft eminence, who immediately and de- cidedly declared it to be a tetanus. He ad- vifed opium to be given in large and fre- quent dofes. Fler neck had now become very rigid, her jaw quite ftiff, and fhe was bent back as far as poffible. The opium was given three days with unremitted at- tention. At firft it gave a little relief, re- laxed the fpafms, and procured reft. But it foon became lefs.and lefs efficacious, untill fhe would take a dofe * fufficient to con- quer the ftouteft man without the leaft fa- vourable effed. On the fifth day, fhe was in a ftate of the moft obftinate rigidity; her forehead wrrinkled, her cheeks drawn back to her ears, exhibiting a moft diftreff- ing countenance, her neck firmly drawn back, her back recurvated, her limbs ex- tended, and deglutition deftroyed. She had taken no nourifhment for four days, nor evacuated either urine or fceces. She had likewife the true pathognomonick fymp- tom of the exacerbation of the fpafm from the fcrobiculus cordis : and the leaft exer- tion either to fpeak, fwallow, or move, or * Sixty drops of liquid laudanum every three hours, t 33 ] even the moft trifling noife in the room, produced violent fpafms. In this ftage of the diforder, fhe was immerfed in the warm bath, which produced fo great relaxation, that fhe drank freely, paffed her urine, and evacuated her fceces. Although the wTarm bath was fo ferviceable whilft in ufe, yet when out of it, the fpafms returned with redoubled violence. This however was ufed two days, until it was found likewife to have become perfedly inefficacious. In this fituation fhe muft undoubtedly' foon have been loft, had it not have been fug- gefted by the gentleman before mentioned, my honoured preceptor, to try tobacco. From its nature and effed on the healthy fubjed, wre judged it would be ufeful. Ow- ing to indifpofition, he was unable to attend to it himfelf, but advifed me to make a fair experiment. To adminifter it by the mouth was impoflible, for the power of deglutition was deftroyed. I therefore made a * ftrong decodion and injeded it into the redum. Never did I watch the operation of a medi- cine with more anxiety, and never did I fee * Two ounces of tobacco limmered in a half pint of water. t.34 3 fuccefs with more fatisfadion. For a few- moments after injedion, there was an exa- cerbation of the fpafms; but very foon a favourable change w7as obferved, and they vanifhed almoft entirely for twelve hours : at which period the enema was repeated with the like, though more permanent fuc- cefs. After repeating it four times in the fpace of forty eight hours, fhe was perfedly free from all fpafmodick affedions, and no complaint remained but debility, and a vo- racious appetite. . In every dodrine which refpeds the health of man, candour and the love of truth oblige us to relate, as well the fads which militate againft it, as thofe which fupport it. I fhall therefore mention a cafe in which the ufe of tobacco was apparently injurious. Since writing the preceding pages, I was invited tp fee a black man, who was in the laft ftage of a fetanus;-. >' the caufe of which' was, probably, a liquid cauftick applied to'a carious tooth/ The difeafe had appeared at the ufual time, been treated in the ufual way, yet increafed with the moft violent rapidity. It wras the t Vj } fourth day when I faw hi in. The rifu$ fardonicus, the recurvated fpine, extended limbs, deftroyed deglutition, an obftinate fpafm on the fphinders, and the origin of the fpafms from the fcrobiculus cordis, in- dicated the thorough poffeffion which it had taken of the voluntary organs: but the con- vulfed refpiration, and the fpafmodick pulfe more ftrongly indicated approaching diffo- lution. Flis * phyfician faid he confidered him as completely dead, as if his pulfe had ceafed to vibrate. I mentioned tobacco, which, although he had tried it the night before without fuccefs, he thought moft promifing, and therefore direded a ftrong decodion to be made, and adminiflered in the form of an enema ; and I tarried to attend to its operation. It immediately in- creafed the fpafms, refpiration became ex- tremely laborious, the pulfe quick, irregu- lar, and fpafmodick, .and in about half an hour, a fpafm feized his heart, even whilft I was feeling his pulfe, and death enfued. I immediately extraded the tooth, found the carious cavity crouded full of lint, the * Doftor Whipple. [ 36 ] furface of the cavity of a black appearance; and the enamel deftroyed round its edges. In this cafe the firft, or ftimulant effed of the tobacco, Was evidently too much for the patient; and he funk under the increafe of the fpafms. It ought not however to operate againft it as a remedy, for thefe two reafons. In the firft place, it was not ufed until the laft ftage of the diforder, when the fpafms had feized the vital organs. The fecond reafon, which to fome perhaps who have not feen demonftrable proofs, may appear whimfical, is, that medicine, and difeafe do not have the fame operation on black, as on the white fpecies. I have feen, and heard in thefe people of fo many inftances of deception, where rational prog- nofticks wrere formed, and of the fallacy of medicine which in other cafes had fucceed- ed, that I am fully convinced of a material and effential difference of organization and conftitution. Thefe it is hoped will account for the ill-fuccefs of tobacco in this laft cafe. THE END. s k -. ?r NexL Hist / All* 4