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Diagnostic features of tetanus (lockjaw) noted by ancient Hellenistic and Roman era medical writers1 were also seen by Middle Egyptian physicians around 1550 bc. The Edwin Smith papyrus in the collection of the New York Academy of Sciences discusses 33 cases of cranial, facial, jaw, neck, and spinal cord injuries used as teaching exercises, possibly for military surgeons.2
Case 7 deals with a surgeon’s second examination of a patient who had a gaping wound to the head, exposing the tepau, explained by a gloss as being something like leather between the bones of the skull, and previously identified as either the falx cerebri or frontal sinus, but perhaps most plausibly to be identified with protruding dura mater swollen by a subdural haematoma visible through broken pieces of the fractured skull, treated with topical analgesic and anointed or dusted with sterile dressing.3 Injuries to the dura mater, the outermost layer of‘the meninges (netnet),4 had a possibility of healing following debridement, but since the surgeon’s first visit, the head wound has become infected and malodorous, and the patient cannot open his mouth because the risus sardonicus of lockjaw has set in.5
“If you find in that patient that his flesh has developed heat under the wound which is in the tepau of his skull. That man, he has developed toothache under the site of that injury. You put your hand on him and you find his brow is wet with sweat. The muscles (metu) of his neck are taut, his face is flushed, his teeth and his back (sic). The odour inside his braincase (hn, literally ‘box, chest’) is like sheep/goat excrement. His mouth is bound, his eyebrows drawn, his face as if he was weeping.”
“Second diagnosis and prognosis: You shall then say concerning him ‘one having a gaping wound in his head extending to the bone and penetrating the tepau of his skull. He has developed toothache; his mouth is bound; he suffers stiffness of his neck. Therefore do not treat the ailment”.