as real (so far as the patient, as a moral being, is concerned) as in any other case; for the absolute force of their external cause is but one of many concurring influences for the regulation of their intensity. There is a tendency to the grouping of muscular contractions; and by their frequent association, habits (of physiologic and pathologic character) are formed. It may be that, in the breaking of these habits, chloroform will prove of service.

The inhalation of an anesthetic agent can do little more than relieve the symptoms, when there is, under-lying them, some organic disease; but in other cases, where the concatenation of such phenomena constitutes the whole disease, (or the whole which we are able yet to recognise), it is possible that much more may be accomplished. For whilst in the former class we can only prevent some of the effects of morbid processes, which are themselves beyond our reach, in the latter class we may remove the whole. Pathology has not yet advanced to the perfect discrimination of these two classes of disease; but there are grounds for hope that by the discovery and careful application of some experimental processes we may be able to place the phenomena of nervous disorders among the class of objective symptoms. Were this accomplished, we should have the same kind, and perhaps eventually the same degree of certainty, in their diagnosis, that we have now with regard to diseases of the chest.-Lancet, Oct. 29, 1853, p. 411.

29.-ON TETANUS FOLLOWING LESIONS OF THE UTERUS, ABORTION, AND PARTURITION.

BY PROF. J. Y. SIMPSON, Edinburgh.

Dr. Robert Reid, in his work 'On the Nature and Treatment of Tetanus, &c.,' states that "injuries or derangements of internal organs do not appear to have much tendency to produce this affection. Indeed (he adds), I have not been able as yet to find any case recorded of true tetanus which arose from internal injury, whether in the alimentary canal or elsewhere."

[From a series of twenty-four cases, Dr. Simpson proves that traumatic tetanus does occasionally supervene as a secondary obstetrical disease. He then enters upon the]

Nature of Puerperal Tetanus.-It will be granted, I believe, by all pathologists that the existence of an injury or wound upon the external parts of the body is by far the most common cause of tetanus. After abortion and parturition we have the existence, upon the interior of the uterus, of a similar state of lesion. All authorities seem now generally agreed as to the facts (1) that the human decidua is, as was maintained in the last century by Krummacher, the thickened and hypertrophied mucous membrane of the uterus, (2) that the epithelial or superficial layer of it separates from its basement or

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outer layer in abortion and after delivery-and (3) that this separation or solution of continuity of tissue, as well as the rupture of the organic attachments of the placenta from the uterus, leaves the interior of this organ so far in the condition of an external wound, or with a new or raw surface for the time being exposed. Obstetrical tetanus has, in this respect, an exciting cause essentially similar to surgical tetanus. And perhaps the great reason why this state of lesion of the interior of the uterus does not more frequently give rise to tetanus is simply this, that the uterus is itself principally, or indeed almost entirely, supplied by nerves from the sympathetic system, while apparently, as stated by Mr. Curling and other pathologists, tetanus is an affection far more easily excited by lesions of parts supplied by nerves from the cerebro-spinal system, than by lesions of parts supplied by nerves from the sympathetic system.

Tetanus is known to follow wounds very various in their degree and severity. "Whether (says Professor Wood) the wound is trifling or severe seems to be of little consequence," as far as regards the supervention of secondary tetanus. By what pathological mechanism a wound or lesion of a part can, under any circumstances, lead on to an attack of tetanic disease, is an inquiry regarding which we as yet possess little information; and in this respect, the production of obstetrical tetanus is not more obscure than the production of surgical tetanus.

The disease, when developed, essentially consists of an exalted or superexcited state of the reflex spinal system, or of some segment or portion of that system. What circumstances in midwifery or surgery might possibly, whether single or in combination, produce this state, and so produce traumatic tetanus? In relation to this question I will venture to make one or two hypothetical remarks.

1. We have in obstetric pathology evidence almost amounting to certainty that the analogous superexcitable state of the cerebro-spinal system of nerves which gives rise to eclampsia or puerperal convulsions is generally produced by the existence of a morbid poison in the blood. And it seems not impossible that the generation of a special blood poison, at the site of the wound or elsewhere, may sometimes in the same way give rise to obstetrical and surgical tetanus. We know, indeed, that the introduction into the blood of particular vegetable poisons, is capable of exciting an artificial disease quite analogous to tetanus. Brucine and strychnine have both of them, as is well known, this effect. Abundant experiments upon the lower animals, and cases of poisoning in the human body have amply proved this. Tetanus is a frequent disease from wounds, &c., in the horse and lower animals. Would it not, in relation to the possible humoral origin of the disease, be worthy of trial whether the blood of an animal dying of tetanus is ever capable by transfusion of infecting another animal with the same malady? The experiment is said to have succeeded with a disease having many analogies with tetanus, viz., hydrophobia. But,

2. We know further, with regard to the tetanizing effects of strychnine and brucine, that these agents do not necessarily require to circulate in the blood in order to produce their special effects. In the lower animals, when strychnine or brucine is applied directly in the spinal cord, tetanic effects instantly follow; and in all probability, when they are introduced into the blood, they produce their tetanizing consequences, by being carried in the current of the circulation to the cord thus texicologically influencing it, as if they were primarily applied to it. Centric irritation, or centric morbid conditions of the cord (and, it may be, of the cerebro-spinal system), may lead on, according to these experiments, to tetanic disease, independently of any morbid state of the blood. And, if the observations of Sims, Harrison, and others, are correct as to the occasional mechanical origin of Trismus Nascentium from pressure and displacement of the occiput upon the medulla oblongata, we have, in this obstetrical instance, tetanus resulting, as it certainly sometimes does under other circumstances,-from direct injuries, or affections of the nervous centres.

3. The appropriate and specific affection of the spinal cord, or cerebro-spinal system, constituting traumatic tetanus, would appear to be sometimes, if not always, a condition excited by some influence propagated upwards along the nerves, from the seat of the injury or wound to the central portions of the nervous system. In proof of this, we have the fact that occasionally (as in cases published by Hicks, Murray, Larrey, &c.,) but not often, the artificial division of the nervous communication between the seat of the wound and the nervous centres has arrested the disease, when performed in a very early stage of the attack. What the nature of the transmitted influence may be, we have no reason at present of judging. But we have analogies for the transmission itself in some of the phenomena of electrical induction and propagation. And, let me further add, that the symptoms of tetanus assimilate themselves very greatly to a rapid succession of electrical or galvanic currents transmitted peripherally from a nervous trunk or centre to the sets of muscles affected.

At the present time various physiologists are busy with recondite inquiries into the laws pertaining to the electro-motive powers of the nervous and muscular systems of the body. When our knowledge of these laws is more advanced, physicians will, perhaps, be able to deduce from them a truer and juster pathology of tetanus and other convulsive diseases.

Treatment of Puerperal Tetanus.—According to Mr. Curling, tetanus is not only less frequent in women than in men, but it is also "less fatal in the female than in the male sex."

Out, however, of the preceding list of twenty-four cases of obstetrical tetanus, only three recovered, and these under opposite modes of management. There are two other cases on record of the successful termination of puerperal tetanus. The two instances I allude to have

been reported by Dr. Symonds and Dr. Currie. The true tetanic character of both cases may perhaps admit of some doubt.

In obstetrical tetanus, no kind of local treatment to the seat of the original uterine lesion could be well applied, or would probably be of any avail, if applied. And, as to constitutional means, perhaps the most important are,—

1st. The greatest possible quietude and isolation of the patient from all irritation, corporeal or mental, during the course, and for some time even after the resolution of the disease.

2nd. The special avoidance of painful and generally impracticable attempts at opening the mouth in order to swallow; but sustaining the strength of the patient, and allaying thirst by enemata, or by fluids applied to the general surface of the body.

3rd. If there is any well-grounded hope of irritating matters lodged in the bowels, acting as an exciting or aggravating cause, to sweep out the intestinal canal at the commencement of the disease with an appropriate enema.

4th. To relax the tonic spasms of the affected muscles, and diminish the exalted reflex excitability of the spinal system by sedatives, or antispasmodics; with the prospect of either directly subduing this morbid reflex excitability; or of warding off the immediate dangers of the disease, and allowing the case to pass on, from an acute and dangerous attack, to a sub-acute, and far more hopeful and tractable form of the malady.

Various sedatives and antispasmodics have been recommended to fulfil this last most vital and important indication in the treatment of tetanus as belladonna, stramonium, hemlock, henbane, musk, camphor, Indian hemp, hydrocyanic acid, valerian, camphor, &c. Perhaps the two drugs of this class that have hitherto been most used, and relied upon, are opium by the mouth, and tobacco by enema. But certainly we have no decided evidence of the beneficial effects of opium, even in the most heroic doses; and it seems doubtful even if this and other such medicines are readily or at all absorbed from the stomach and upper part of the intestinal canal in cases of acute tetanus. Tobacco in the form of enema has doubtlessly often acted most favourably in arresting the spasms; but it is a drug the action of which is not easily or safely kept up with that degree of constancy which is required in acute tetanus. Latterly the antispasmodic action of sulphuric ether and chloroform has been repeatedly employed to allay that exalted state of the reflex nervous system, and to relax that resulting tonic contraction of the maxillary and other muscles, which constitute the essence of tetanus. Medical men may yet discover therapeutic agents (to be introduced into the body by inhalations or otherwise), the action of which will be as directly anti-tetanic in their effects, as strychnine is directly tetanic in its properties; and such agents-if they were otherwise innocuous-would form the proper remedies for tetanus. Here, as elsewhere, in future medicine

physicians will probably seek for therapeutic remedies in the same way, and upon the same principles, as toxicologists search for antidotes to poisons. Chloroform in sufficient doses acts as a direct sedative upon the reflex nervous system, and upon exalted muscular contractility. In consequence of this action, it affords us one of our surest and most manageable means of allaying common convulsive attacks; and it has now also, according to the reports in periodical medical literature, been repeatedly successful in the treatment of traumatic tetanus, whilst it has apparently also repeatedly failed in subduing the more acute forms of the disease. Perhaps some of the failures have arisen from the patient not being kept sufficiently deeply and continuously under the action of the drug. If used in tetanus its action will require to be sustained for many hours, or oftener perhaps for many days. And there is abundant proof of the safety with which its continuous action may be kept up under proper care and watching. For instance, a few months ago I saw, with Dr. Combe, a case of convulsions of the most severe and apparently hopeless kind in an infant of six weeks. The disease at once yielded, and ultimately altogether disappeared under the action of chloroform, which required to be used almost continuously for thirteen days; as much as 100 ounces of the drug being used during the period. After all tendency to convulsions at last ceased, the little patient rapidly grew, and is at the present moment a strong, healthy child. In a case of the successful treatment of traumatic tetanus by Dr. Dusch, about sixty ounces of chloroform were employed. Let me close these remarks with a case of puerperal tetanus treated with chloroform.

[The following case is related by Professor Lawrie, of Glasgow, in a letter to Dr. Simpson.]

"Mrs. B., a fine young woman, æt. twenty-four, in the third month of her third pregnancy, miscarried on the 4th of this month (Jan. 1854). She lost a considerable quantity of blood, and required plugging, cold, and pressure, but was so well on Sunday the 8th that I ceased my attendance. On Thursday the 12th she complained of stiffness about the neck and lower jaw, but not suspecting the nature of her illness, she did not send for me till late on Saturday the 14th. I found trismus well marked-the spasm not extending beyond the neck-and the pulse nearly natural. Every attempt to swallow gave great pain, and produced a spasm in the muscles of the neck and larynx, which threatened instant suffocation. I forbad all attempts at swallowing, ordered nutritive enemata with 50 or 100 drops of laudanum every six hours, and pectra to the neck, with aconite and chloroform. There was little change till the night of Monday the 16th, when the pulse had risen to 120, and the spasms had greatly increased, but had hardly extended beyond the neck; deglutition was impossible. I immediately exhibited chloroform, which acted admirably, and gave instant relief. I taught her husband