after wounds in military practice, it becomes very difficult to explain how, in any instance, when once the infection has occurred and the disease is in full course, amputation of a wounded limb, or the extraction of a missile or other substance in contact with a wounded nerve, nerve section, or any local surgical proceeding, can ever lead to a cessation of the tetanic symptoms; and yet it is well known there have been, though rarely, undoubted instances in which such operations have been followed by relief and ultimate recovery. It is recorded in the Surgical History of the United States War (vol. iii. p. 821) that amputation was resorted to in 29 instances after tetanic symptoms appeared, and that a favourable result ensued in 10 of these cases, while it was noted in several instances that the symptoms ceased after the operation. The difficulties indeed appear insuperable when endeavours are made to reconcile the agency of this reputed cause of tetanus with all the clinical conditions under which the disease has followed gunshot injuries on different occasions in naval and military practice. The investigations regarding the bacillus tetani, however, can hardly be regarded as complete. Some eminent pathologists have stated it to be doubtful, from a pathological point of view, whether it can be regarded as the exciting agent of the disease.41

Causes of tetanus in armies reviewed. A reconsideration of all the circumstances under which traumatic tetanus has occurred in military hospitals seems to point to the fact that several causes have generally acted in combination in favouring the production of the disease. In addition to local sources of irritation from circumstances connected with the wounds themselves, there has probably been a special predisposition on the part of the patients to the affection; while, further, certain extrinsic agencies have contributed to the onset of the disease, especially great alternations of temperature with strong currents of damp air. When tetanus has attacked wounded patients in a considerable proportion, the personal susceptibility of the subjects of the disease seems to have been sometimes aggravated, or even induced, by nosocomial influences, particularly by an unwholesome condition of the atmosphere in which the wounded men have been placed. It is a noticeable fact that whenever tetanus has been recorded as having existed in an epidemic form among bodies. of troops, the presence of other diseases indicative of an insalubrious state of things has been mentioned also. At the various periods when tetanus was a common affection in the Peninsular hospitals, it appears from Sir J. M'Grigor's report that contagious typhus, hospital gangrene, dysentery, and other allied diseases were also prevailing in an aggravated degree. How far a specific micro-organism is the essential parent in producing the disease seems at least to require further proof.

some cases.

Course followed by tetanus in gunshot wounds. Tetanus sometimes occurs as a complication of a gunshot wound in quite an unexpected and sudden manner, speedily assuming its severest forms of manifestation ; while, in other cases, both its invasion and progress are comparatively gradual and slow. The sudden and intense forms of tetanus more particularly belong to hot climates. They do not seem to have been met with in any large proportion among the cases which have occurred during modern wars in Europe. As observed by surgeons, in recent years, the attack of tetanus has been not unfrequently preceded by some general indications of constitutional disturbance, as loss of appetite, torpidity of the bowels, uneasiness, and mental depression. Some fresh pain or more stiffness about the wound has been noted in But when these premonitory symptoms have occurred, there has been nothing special about them to indicate the serious disease of which they were the forerunners. The first indications of the disorder that usually excite the suspicions of the surgeon as to their cause are either spasmodic contractions near the seat of injury, or, what has happened more frequently, stiffness about the jaw or neck, which the patient at the onset has probably attributed to cold or rheumatism. With this latter symptom there is generally some difficulty in mastication and swallowing. These symptoms become more and more marked, while those of diaphragmatic spasm, with great pain at the scrobiculus cordis, and difficult respiration, are next added. The tetanic spasms extend to the muscles of the body and the extremities, especially the lower extremities, varying in intensity in different parts according to circumstances. The rigidity becomes greater, so much so that the jaw becomes completely locked,' and the spasms recur at more frequent intervals as the disease advances. The muscles of the arms are usually the last seized, unless the wound has been in one of the upper extremities, when the muscular contractions appear more early in them. The muscles which have become affected hardly ever, if ever, become loosened into a state of complete relaxation; but, while more or less rigid and contracted, they pass into sudden uncontrollable paroxysms of still more violent contraction. These aggravated spasms appear at more frequent intervals, and are generally attended by pain of a very severe character. Sleeplessness is a general concomitant of the disease. The bowels remain constipated, urine scanty, micturition sometimes painful. Death sometimes follows an attack of violent spasm, or results from exhaustion, or, it has been stated, more frequently occurs during an attack of suffocation from spasm of the muscles of respiration.

Period of its occurrence. The time at which a gunshot wound may become complicated by tetanus is variable. It may follow a wound quickly, or many days may elapse before it appears. By some this interval has been spoken of as a period of incubation;

but the length of time which passes before the attack occurs may well depend upon accidental circumstances, as much as the attack itself. There is a prevailing belief that the more speedily tetanus occurs after a wound, the more certain is it to terminate fatally; while the more prolonged the period, the more chance is there of recovery. Mr. Poland, in illustration of this point, has mentioned that of 277 collected cases of tetanus, 130 occurred previous to the tenth day after the injury, and of these 101 died; 126 cases from the tenth to the twenty-second day, and of these 65 died; 21 cases above twenty-two days, and of these 8 died.42 These observations overthrow the conclusion which Sir J. M'Grigor mentions the Peninsular surgeons had come to that if tetanus does not occur for twenty-two days from the date of the wound the patient is safe. The following case, the particulars of which were given to me by Surgeon Applin of the Royal Artillery, shows that tetanus supervening on a wound may not manifest itself until some months after its occurrence, long after the wound has become healed. The subject of it was a younger brother of Dr. Applin. His gun exploded while he was out shooting, and the top of his left thumb was carried away. Amputation was performed, and on the wound becoming healed, he returned to his studies. Nearly four months afterwards trismus suddenly appeared, and he expired on the following day during a severe fit of opisthotonos. This case somewhat resembles one of a patient in Guy's Hospital related by Mr. Morgan. A sailor had a lacerated wound of the thumb; it had been transfixed by a piece of teak wood. The wound healed perfectly. About two months afterwards a painful neuralgic affection of the muscles of the thumb came on; tetanus followed, and he died. On dissection, two small splinters were found in the abductor muscle against a branch of the radial nerve.

Cause of the general immunity from tetanus in the Crimean war.-To what circumstances are we to attribute the comparative immunity from tetanus which the wounded of the Crimean armies, English, French, and Russians, enjoyed, notwithstanding the wretched state of the troops during considerable periods of the war? Certainly the contrast between the proportionate number of cases which were met with during the Crimean war, and the numbers which have been recorded in previous wars, is very remarkable. I am inclined to attribute the absence of tetanus from the field hospitals principally to the following circumstances: the free circulation of fresh air from the sea over the elevated and well-drained plateau on which the armies were encamped; the fact that the wounded were treated in separate tents or huts; and probably also to a generally simpler treatment of the wounds themselves than had been formerly in vogue. But the active circulation of pure, and at most seasons comparatively dry air, was probably the most efficient preventive

of the disease. Improved hygienic arrangements, wider separation of beds, allotment of more cubic space, with greater. purity of surrounding air, have undoubtedly contributed to the diminution of tetanus in recent wars, as they have done also to the prevention of hospital gangrene and other allied diseases among the wounded of armies. The polluted conditions of the general hospitals during the early campaigns of the present century have been very strongly animadverted upon by distinguished surgeons. So the prevalence of tetanus in Lucknow in 1857 may be in a great measure explained by the circumstances of the troops-hemmed in as they were by the enemy, overworked, and subjected to all kinds of depressing influences, mental and bodily, in a tropical climate; while the hospitals were not only unavoidably placed amid extremely insanitary surroundings, but had become internally infected by the emanations of the many wounded who were successively and without intermission placed in them. The comparative rarity of tetanus among the wounded in modern naval engagements has, no doubt, also been due to the greater attention which has been given to hygienic arrangements, since the importance of due sanitation has been better understood by commanding officers. Dr. Dickson, Physician to the Fleet, read a paper before the Medico-Chirurgical Society upon cases of tetanus that he had observed among soldiers of the expeditionary forces against New Orleans in 1815, and, in doing so, referred to the diminished proportions of the disorder in the engagements of that period on the West India station as compared with the proportions in previous wars in the same climate. He was led to attribute this difference chiefly to improved hygienic circumstances. He concluded his remarks by the following summary: I trust I am therefore justified in inferring that to the improvements in the medical and surgical treatment of wounds; in cleanliness and ventilation, avoiding at the same time exposure to currents of cold air or sudden changes of temperature; in fine, to superior comforts, diet, and accommodation, and particularly to the greater attention paid to the state of the bowels, may be attributed the great infrequency of tetanus of late in the West Indies when compared with former wars.' 43 The superior comforts, diet, and treatment would have hardly had much influence in lessening the tetanus, without the improved ventilation and greater cleanliness mentioned by Dr. Dickson; for, destitute of good accommodation, good diet, and comforts, as the troops in the Crimea were in their first winter, there was no prevalence of tetanus then. The few cases of tetanus which did occur among the wounded took place at the time when the troops, and especially the wounded among them, had everything that could be desired in these respects.

Tetanus in its acute and chronic forms.-Larrey, in his first

memoir on tetanus, divided the disease into acute and chronic tetanus, and this division has been generally accepted since as a practically useful one. There does not appear to be, however, any essential difference in nature between the two forms of the disease. The acceleration and severity of the symptoms in the one case, and their relatively slow progression in the other, appear to be only indicative of a more or less powerful exciting cause, or of a more or less susceptible state on the part of the patient. But repeated observation has shown that when the intense symptoms occur which characterise the disease in its acute form, it is almost without exception fatal; while, when it presents a more chronic character, in a certain proportion of the cases, though only a small one, it is amenable to treatment, and recovery ensues. Hennen, whose opportunities of observing the disease were very extensive, owing to his having had charge of some of the most important surgical hospitals in the Peninsula between 1811 and 1814, and of the large Jesuits' Hospital at Brussels after the battle of Waterloo, wrote, 'I have never been fortunate enough to cure a case of acute tetanus; in some instances of the chronic species I have effected or witnessed relief.' 44 The records regarding tetanus during the prolonged United States war equally show that the recoveries mainly occurred in cases of a chronic description. In nineteen cases of recovery noted in the Surgical History of the war the disease lasted from nine to forty-nine days. The lesson taught by the experience of this war was, on the whole, that the later the disease showed itself after the injury, and the longer its duration, the better were the prospects of life being saved.

CHAPTER VII

ERYSIPELAS AFTER GUNSHOT WOUNDS

General remarks.-The occurrence of erysipelatous inflammation in a gunshot wound is a complication which formerly was a subject of much dread among surgeons of military hospitals; not only on account of its direct effects on the particular wounded men attacked by it, and its liability to spread to the wounds of other patients, but also on account of the difficulty of eradicating it from hospitals which circumstances did not permit to be emptied of patients and thoroughly disinfected.

Experience of it in war.-Erysipelas was one of the constant scourges of military hospitals during the early wars of the present century, but since those days it has gradually lessened in frequency, almost in proportion as the evils of overcrowding and the import