Schleisner says that trismus nascentium carries off in Iceland an incredible number-sixty-four per cent. of the children born, dying of it between the fifth and twelfth day. Dr. McLean makes a similar statement concerning its frequency in St. Kilda, one of the Western Hebrides. The predominance of high temperature is regarded by surgeons generally as originating a tendency to traumatic tetanus. The dark races-the East Indian and the negro-are also considered specially liable to it.

The exciting cause of idiopathic tetanus is exposure to severe cold, or alternations of temperature, with predominating influence of cold aud moisture. Williams says that "tumbling boys are frequently seized with this complaint." I do not understand why. But cases occur not rarely in a spontaneous manner, without any discoverable source. Trismus nascentium does not seem to me to be always satisfactorily accounted for. Traumatic tetanus presents itself very irregularly. Its relation to the condition of the wound has been carefully inquired into, but has been very variously stated. It is said to be more likely to supervene if any foreign body remain in the wound; if there be comminution of fractured bone; if a nerve be included in any ligature employed. Larrey thinks the detachment of the eschar a critical point of time.

Toxic tetanus has followed the action of poisons very different, if not opposite in their apparent influences; that of strychnine, which polarizes, and, as we are told by Elliotson, of tobacco, in enema one of our most potent relaxants, which depolarizes; and of sulphuretted hydrogen, as in Williams's cases, which does not resemble either.

Symptomatic tetanus displays a similar want of relevancy with the maladies of which it has formed an event or sequel, and from whose morbid actions it has most obscurely originated.

Autopsy. Examinations post mortem, repeated with indefinite frequency and great care, have disclosed no characteristic lesion. In idiopathic cases, nothing has been discovered. In the traumatic, Williams, Gerhard, and numerous authorities, assert the same thing. "The morbid appearances are far from uniform," says Prof. Miller, of Edinburgh. "The brain seldom shows aught amiss, unless it be an unusual amount of serum. The spinal cord usually evinces manifest congestion, more especially at the origin of the nerves. The lungs are congested. The nerves at and leading from the part injured, show vascularity, enlargement, and other inflammatory signs, acute and chronic. Myelitis induces symptoms of tetanic character; but this is altogether different from true tetanus."

Pathology. It is probably correct to refer it exclusively to the spinal cord as its seat. Magendie divided this column into as many sections as there are vertebræ in the animal, and found that strychnine still continued to render it tetanic. Yet it is not easy to set aside the statements of so competent an observer as Dr. Sims in reference to trismus nascentium and its dependence upon cerebral oppression and injury. Its elements are graphically set down by Romberg, as "spasm of the muscles supplied by the cerebro-spinal nerves, and permanent exaltation of the reflex function." It does not appear so clearly, how

ever, as he maintains, that all the forms and varieties of tetanus are identical in nature. We ascribe idiopathic or spontaneous tetanus to cold and moisture chiefly; but traumatic tetanus, which is so constant an attendant upon wounds and operations in tropical climates, is comparatively rare in colder countries. Larrey had an appalling proportion of cases among those wounded at the battle of the Pyramids; while after the battle of Eylau, under exposure to extreme cold and great hardship, very few were attacked.

Diagnosis. Its relations with rheumatism, hysteria, epilepsy, and hydrophobia, have been dwelt on. Rheumatic stiffness of jaws and limbs are associated with other symptoms, and do not present the exalted reflex action upon which Romberg lays greatest stress. Hysteria sometimes simulates tetanus, as every other disease almost, very closely; yet the phenomena are capricious and inconsistent.

The tetanoid form of epilepsy is transient, and followed by the coma of that dreaded malady. Hydrophobia has been by some regarded as tetanus, or as a form of hysteria, mingled with tetanoid symptoms. The history of the case will distinguish it. In tetanus the physical agitation is usually associated with remarkable clearness, calmness, and steadiness of mind; the hydrophobic sufferer undergoes indescribable tumults, both mental and bodily. In myelitis, which resembles it somewhat, the "exaltation of reflex action is wanting."

Prognosis. This is universally considered very unfavorable. It has been usual to regard idiopathic as less fatal than traumatic tetanus; but Mr. Peet, who saw more of it than any other writer, says that it is more severe and destructive. The only case I ever met with died. As to trismus nascentium, I must acknowledge, with many others, I have never seen a case recover; I have seen numerous cases among negro infants, and but one white. The rapidity of progress in the early stages, the rapid recurrence of the more violent or convulsive struggles, the dysphagia and dyspnoea, these are the menacing signs. A distinction has been attempted of the disease into acute and chronic, which, if it could be made clearly, would assist us somewhat. It is commonly said, that if a patient survives nine days, he will recover. I have seen no traumatic case die after that time. Yet we must not hastily pronounce a favorable opinion even in protracted instances; in an apparently mild attack, a single spasm may prove fatal suddenly. Such was the termination of the spontaneous case I spoke of above, after lasting more than a fortnight, and exhibiting considerable alleviation.

The period of incubation is not determined. McGregor says it does not extend beyond twenty-two; Blane says, twenty-eight days. A case is on record of seizure on the twenty-sixth day after the injury. It may supervene with great promptness; some affirm, within twenty

four hours.

Treatment.-I am almost disposed to echo here the desponding declarations of McGregor, and those who, with him, regard the disease as indomitable. Not that we have not on record many instances of recovery from tetanus. Numerous examples of such are reported in which the cure is ascribed to venesection, to opium, to mercury, to the

cold bath, to hot and vapor baths, to cannabis Indica, to belladonna, to tobacco, to the salts of iron, to turpentine, to cantharides, to exposure to cold and wet night air, to moxibustion, and to ice applied along the spine.

The French seem to have carried venesection, cupping, and leeching, to the greatest extent. Many pounds of blood have been rapidly taken from patients with alleged success. I have seen the lancet used often and freely without any benefit, and, indeed, some of the more recent authorities pronounce it injurious.

Of opium, the tolerance is prodigious. I have seen ounces of laudanum drank like wine at brief intervals, without any effect whatever. Bennett tells us of a case in which twenty grains of opium were given every three hours for several days together. I would administer the tincture always as advised in similar circumstances previously; Abernethy found thirty grains of the drug undissolved in the stomach of a man dead of tetanus.

Mercurials have been widely eulogized. The only two cases that ever recovered under my exclusive care were early and profusely salivated, and kept so for many days. One had been shot through the elbow; his arm being near the muzzle of the gun, the whole load went "clean" through the joint like a bullet. The other was the little boy referred to above, as attacked after a fall without wound or apparent bruise.

Two patients are recorded to have died in the cold bath; one by Larrey, the other by Elliotson. The event was probably determined by their reluctance and struggle. Such was the fate of one who was ordered the warm bath by Chalmers; he resisted violently, and died before he touched the water.

The cannabis Indica has been favorably spoken of by several physicians in Europe and America; but Peet, who gives reports of 260 cases in seven years, in the hospital under his care, and who enjoyed the best opportunities of experiment with it, active and fresh, in its native East, declares it to be "no better than other narcotics." Prof. Miller records "three fortunate cases under its use," and says that he has "seen it fail to cure, but never to relieve." He prescribes it in doses of three grains of the extract, or thirty drops of the tincture every half hour, hour, or two hours. The system is very tolerant of it, as of opium. The amount of testimony in its favor is large and increasing.

Iron is a remedy extolled by Elliotson, who had two cases recover while taking the sesquioxide in enormous quantities, ad libitum, and had eight others reported to him.

Belladonna, and, indeed, all other narcotics, have been employed freely, and eulogized. Tobacco alone does not seem to find in the system, in tetanus, any greater tolerance than under other circumstances. It relaxes profoundly, and is said to have proved promptly fatal.

Turpentine and cantharides have been used as revulsives to excite straugury. The former is also serviceable as a purgative, and by its

intoxicating quality. I saw a protracted case, treated with it by a friend, recover slowly.

Chloroform, since its discovery, has been very extensively and freely resorted to. It will always relieve the present suffering more or less. Some allege that its ultimate influence is injurious; but this, I think, is not proved. I am strongly impressed with favorable views of its influence as an efficient palliative and anesthetic; and must hope, too, that with it, we shall thus retard the progress of a case, and somewhat improve the chances of recovery.

A very heroic method of treatment was carried into execution in the neighborhood of Charleston by the late Dr. Ffirth, who, it is said, repeatedly found it effectual. It was a harsh moxibustion with the ordinary cautery. Pledgets of cotton, steeped in turpentine, were laid all along the spine on both sides, from the neck to the sacrum, and set fire to; after they had burnt away, the lines along which they had been arranged were still further seared by the hot iron. Pot hooks, as being of convenient shape, were employed for the purpose, in the only case I ever saw treated in this horrid way. The patient, a stout young fellow, died very soon after, whether from fright, or struggle, or the disease.

It is generally understood that tetanus proves fatal by exhaustion merely. To prevent this, stimulants were formerly administered in indefinite quantities. Wine and brandy may, in most cases, be taken ad libitum, like opium, without intoxication. But more recently, a still greater stress is laid upon the necessity of sustaining the strength by frequent supplies of nutritious food. Peet, whom I have already quoted and referred to, as more familiar with the disease than any other authority, takes occasion to say that he does not regard "any one course of treatment as better than another, except so far as it takes care to keep up the patient by proper feeding."

MYELITIS, Spinitis, Spinal Meningitis.-This is happily a disease of rare occurrence. It may present itself in the acute or chronic form. It is recognized by uneasiness at first, soon increasing into severe pain along the spine, which is intolerant of pressure generally, but especially at some point; there is fever, with quick frequent pulse; the patient cannot bear to be moved. After an uncertain time, there comes on opisthotonos, the head being drawn strongly backwards, with severe clonic spasms occasionally involving a greater or less portion of the muscular system; trismus sometimes, but I think not generally; the breathing is hurried and irregular, the countenance anxious, the spirits desponding; the tongue is furred and red, often with nausea. Death may ensue within a few days or a week, but the case is usually pro. tracted, the patient sinking at last exhausted with suffering.

Autopsy shows engorgement of the medulla spinalis or its membranes, or of both; with effusion of serum or pus, subarachnoid; or infiltration and softening of the cord.

The treatment-which has not been generally successful-is by active depletion, general and local; mercurials and opium have been freely administered; relaxation and subdual of inflammation attempted by

the antimonials, with nit. potassæ; cold applications are made at first, and afterwards counter-irritants of the severest character, even the actual cautery employed along the back.

In a case of chronic spinitis or myelitis which came at a late period under my care, ascribed, somewhat doubtfully, to a fall upon the rounded stones of a street pavement which hurt the vertebræ of the loins, there had supervened attacks of tetanoid spasm, at first few and distant, but increasing in frequency, abruptness and severity. They were irregular and at varying intervals, affecting sometimes one part of the body-one set of muscles, and sometimes another. There was never any trismus or lockjaw. The appetite, digestion, and general health held out for a surprising length of time, but at last yielded gradually, and the patient sunk worn out with his protracted agony. All efforts for his relief were tried in vain. Chloroform alone seemed to be of any service. He was aware usually of an approaching paroxysm, and eagerly resorted to its inhalation, thus relaxing the painful spasm.

CEREBRO-SPINAL MENINGITIS.-I know no preferable place to assign to a disease known by this title, which has of late years shown itself as a local epidemic in many separate districts of our country, of which several well-written monographs have appeared in our journals, and a valuable compendious history is given us by Dr. Condie in his recent editions of Barlow's and Watson's Practice.

It usually invades with a chill, succeeded by great febrile excitement, the headache being intense from the first with severe pain down the back, and in the limbs. The countenance, often flushed, expresses surprise or wildness and terror; there is vertigo; the pupils of the eyes are generally dilated; sometimes, however, they are contracted, and, it is affirmed, may be in opposite states, one dilated and the other contracted. The patient is very restless, moaning or uttering plaintive cries; the breathing, at first hurried, soon becomes slow and oppressed and even stertorous; the speech thick and inarticulate. After an uncertain, but brief period, tetanoid spasms come on, being readily excited; there is hyperesthesia, with muscular rigidity. Opisthotonos is the usual form, but it is sometimes pleurosthotonos or emprosthotonos. Tympanitis and constipation are present, with palsy of the bladder and lower extremities. In the last stage there is coma; the tongue is dark and dry, with sordes on mouth and teeth; the bladder is distended with constant stillicidium of urine, and involuntary fecal discharges take place.

The prognosis is unfavorable, and the proportion of deaths large. Complication with erysipelas has been frequently met with, and greatly increases the mortality.

The diagnosis is said to be readily made by the tetanoid symptoms. The duration of the cases varies from 24 hours to six or seven days. Autopsy exhibits lesions of the whole cerebro-spinal column. There is inflammation with thickening of the membranes, with deposit of a creamy pus between the arachnoid and pia mater; the brain is of pink