remarkable in consequence of the extreme rapidity (if the reporter's data are given correctly), with which the tetanus ran through its brief and fatal course.

CASE XIX.-A patient, in her fifth confinement, was attacked during labour with much flooding. On examining, Mr Finucane found the placenta attached to the cervix uteri, and in consequence, proceeded to extract the child, which was still-born, by the operation of turning. Four days aftewards she had a violent rigor, followed by perspiration, which returned slightly on the following day. On the evening of this (the fifth day after delivery), the patient began to complain of stiffness about the articulations of the jaw, with pain in the back part of the head and neck. Early on the following morning the lower jaw was found completely fixed, and the patient was suffering under complete opisthotonos, the body resting on the heels and occiput. Every attempt to drink excited violent spasms, and the patient died in a few hours. The tetanus ran throughout its fatal course in little more than fifteen hours.

The Caesarean operation has, from the earliest annals of French surgery up to the present time, been performed many times in Paris. The present distinguished Professor P. Dubois has himself, I believe, operated on eight patients. But it is a remarkable fact, that not a single instance of recovery from the Cæsarean section is known to have ever occurred in the French capital. The case in which the patient survived for the longest time, at least of late years, was one operated upon in 1839, and where ultimately the woman died of tetanus, seventeen days after the performance of the Cæsarean section. The following are the principal points connected with this instance of the disease::

CASE XX. On the 22d January 1839, Professor Dubois extracted a living child by the Cæsarean operation from a deformed dwarf. Febrile and inflammatory symptoms speedily set in; but by the 31st these had, in a great measure, disappeared; the pulse was 110, and the patient's appetite had returned. The patient's state continued to improve still more up to the 5th February, or till the fourteenth day after the operation, when general uneasiness and stiffness in the movements of the jaw came on. The masseter muscles were

soon affected with violent contractions; the poor patient was unable to drink; and the symptoms of tetanus became clearly established. The disease continued up to the 9th (the tetanus affecting principally the muscles of the jaw and neck); fits of suffocation supervened, and the patient at last sunk on the seventeenth day after delivery, and the fourth after the first commencement of the tetanic symptoms.

At the time the tetanus began, the abdominal wound was already completely healed, except at its lower angle. On dissection, the original wound in the uterus was found closed, not by the union of the edges of the cut uterus, but by their close adhesion to the ante

rior wall of the abdomen, to the posterior wall of the bladder, and to a fold of intestine. Several small abscesses existed among the peritoneal adhesions. In the spinal marrow nothing was found except a very slight and doubtful softening at one point.1

In the following instance of tetanus supervening in a patient who had been previously the subject both of a surgical operation and of parturition, it is difficult to say whether the fatal attack of tetanic disease belongs to the class of surgical or of obstetric cases, or pertains to either. The disease set in at an unusual distance of time after parturition, and at a still longer date after the surgical operation.

CASE XXI. In 1809, Mülder of Gröningen excised the knee-joint of an adult female, in whom articular disease had been of long standing. Great irritative fever followed at the end of nine days; and, later, she suffered intensely from the knee, and from hectic fever. At the lapse of two months after the operation, she was delivered of twins, and ultimately she died from tetanus, seven weeks after delivery, and fifteen weeks after the operation for excision.2

Let me make one further remark before closing this list of instances of puerperal tetanus. Occasionally cases of death from tetanus after delivery are referred to in English official and tabular records, without any special details in regard to them being given. The following two or three instances are examples of this remark, and afford additional evidence of the fact that puerperal tetanus is not so very rare as the total silence of obstetric works on this subject might lead us à priori to suppose.

CASE XXII.-The late Dr Merriman, in his Synopsis of Difficult Parturition, has published a table (p. 339) of the causes of death in childbed, among 10,190 attended by one physician. There occurred 107 maternal deaths in this long list of deliveries. One of these puerperal deaths is noted as having been produced by "locked jaw." But no particulars are given.

CASES XXIII., XXIV. From the Fourth Annual Report of the Registrar-General, it appears that, in the course of the year 1840, 140 of the inhabitants of England and Wales died of tetanus. The sex of the patients, in 116 of these cases, is given in the Report. Of these 116 patients, ninety-six were males, and twenty were females. The causes which led to the attacks of tetanus, in this long list of cases, are, of course, not specified. But, incidentally, it is stated in the Report (p. 224) that two of the deaths from tetanus occurred after parturition, "lock-jaw caused by childbirth" being reported in two cases

1 Lancet, for 29th February 1840, p. 821-852.

2 Wachter's Dissertatio de Articulis Extirpandis. Groningen. 1810.

in which the patients were aged " 34 and 35 years." Thus, out of the twenty cases of fatal tetanus among females during that year, two at least, or 1 in 10, were cases of puerperal tetanus.

The relative frequency or rarity with which tetanus occurs in obstetrical, as compared with surgical practice, could perhaps be properly ascertained by an analysis of the official returns given in for a few years to the Registrar-general of all deaths from this disease. And certainly the investigation would form an interesting point of inquiry in puerperal pathology.

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 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.

1 Membrana decidua-" Proprie est, membrana uteri interna, quæ post conceptionem intumesit et crassescit, usque ad tertium circiter graviditatis mensem, etc."-See Krummacher's Dissertatio Circa Velamenta Ovi Humani, 1790. 2 Practice of Medicine, vol. ii., p. 746.

NEW SERIES.-NO. L. FEBRUARY 1854.

P

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 singly 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 strychine 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, etc., 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 to 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 toxicologically 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

1 See details in the works on Toxicology. Thus, in a boy poisoned by false angustura bark (which contains both brucine and strychine) Professor Emmert found that when "he touched the patient's arm, in order to feel his pulse, a sudden and violent Tetanic spasm intervened; the eyelids opened wide; the eyes projected rigidly and immoveably; the lower jaw was firmly compressed against the upper one; both lips separated from one another, so that the front teeth were exposed; the different muscles of the face were tense; the extremities were extended and rigid; and the spinal column and the head were violently drawn back."-Romberg's Manual, vol. ii., p. 129.

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, etc.,), 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 means 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" (p. 29).

Out, however, of the preceding list of twenty-four cases of obstetrical tetanus, only three recovered (Nos. XIII., XIV., and XV.); 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 his article on Tetanus, in the Cyclopedia of Practical Medicine (Vol. IV., p. 874), Dr Symonds of Bristol speaks of the first of these cases in the following words :

CASE XXV." We remember (says Dr Symonds) attending a young woman, who was seized with lock-jaw soon after delivery of a stillborn and premature foetus; but the affection readily gave way to a turpentine injection, and we looked upon it as a mere sympathetic accident."

The other case of recovery from puerperal tetanus, which I have