The doses of morphia were aimed at the amount necessary for producing decided relief; but this relief was often of short duration, and so the dose had to be repeated again and again on certain days. The following notes are copied from the record which was kept from October 26th onwards :

As already stated, the symptoms of obstruction gave way in a very marked form on October 31st, and it was hoped that the illness had come to a favourable termination. But although the pains had ceased about midday on the 31st October, the patient was found in a very prostrate condition on November 1st, notwithstanding that he had had a good night's sleep without any morphia. There had, indeed, been a little more tendency than usual to sickness or retching, and on this account the food given by the mouth had been curtailed even further, but it seemed to me that most of the exhausted and sunken or collapsed appearance arose from the want of the morphia. My assistant, instructed all along to be guided in his doses by the amount of pain present, not unnaturally supposed that as all paroxysms had ceased no more need be given. Accordingly, on October 31st, he had had 3 grains at 1.40 A.M., and 2 grains at 11.30 A.M., but none after that time; so that when seen at the visit hour next day nearly twenty-four hours had elapsed without his usual stimulant. Acting on this idea, he was

ordered at once a grain of morphia by the skin, and this was to be repeated if it seemed to agree. The effect of his first dose was to render the patient much more comfortable; and the 3 grains noted on the 1st November were really given as a stimulant. This was gradually reduced, although, on some days, a return of the pain demanded larger quantities; and the sudden rise from six to sixteen grains, with a return of the violent spasmodic pains, was borne without any unusual narcotism.

The effect of the large doses of morphia on this patient seemed to consist almost solely in relieving the abdominal spasms and pain. Even the pupils were not contracted. At first it was supposed that the tolerance of the morphia and the absence of contraction in the pupils might be due to the simultaneous administration of pretty full doses of belladonna; but in a subsequent part of the illness, when both the internal and external use of this drug was stopped, there was no change observed in this respect.

Two peculiar symptoms may be mentioned here as possibly connected with the prolonged use of morphia in large doses in this case, although there is no real evidence that any such connection existed. The one was the occurrence of patches of anæsthesia on the thighs; this was noticed only towards the end of the case, but had existed for some little time; indeed the patient had frequently complained of want of sensation in his legs and feet, but during the height of the illness little attention was paid to this, as it was thought to depend very likely on the tension and pressure in the abdomen. In December, however, a very definite area was found to be devoid of sensation on the anterior aspect of the left thigh, and a similar but slighter defect existed on the right; the defective sensation was so great that the needle of a subcutaneous syringe could be introduced in this place without its being perceived by the patient.

The other feature referred to was the appearance of patches of bluish discoloration on the skin of the belly, back, and legs; they seemed to be due to ecchymosis; they were noticed first early in November; they persisted even after death, and are noticed in the pathological report as numerous livid spots and patches on the skin of the trunk and limbs.

The question of surgical interference was frequently and anxiously considered during the progress of this case. It was formally raised as early as October 18th, when I sought the advice of my medical and surgical colleagues. The nature of the mischief was at that time so obscure, and the proper surgical procedure so doubtful, that I could not see my way to recommend any operation. The points which guided me were the following:-the evidently incomplete nature of the obstruction, as small motions were occasionally obtained by the enemata, and the absence of any very violent or fæcal vomiting.. This seemed to me to leave little hope of a successful issue if the abdomen were opened and the obstruction searched for, as proposed by one of the surgeons; and in view of the nature of the case, as now known, this operation would have been very disappointing.

The other operation proposed, opening the bowel in the right groin so as to relieve the distended intestine of its contents, seemed to me, in view of the incomplete obstruction, apt to aggravate the danger to the patient and lead, in all probability, to no real cure. In view of the ultimate issue of the case, it may be admitted that this operation might have relieved the patient of his paroxysms of pain more efficiently than was possible by means of morphia; perhaps the relief thus obtained might have counterbalanced the grave inconveniences of an artificial anus, and, as the case was beyond the possibility of a cure, the risk in this respect may be almost set aside,

ON THE EXHIBITION OF PURGATIVES IN TETANUS.

BY ALFRED BOON, F.R.C.S.

St. Kitts, West Indies.

ON referring to the section on tetanus in the works on medicine and surgery within my reach, I find them, whatever else they may differ about, almost unanimous in recommending active purgation as one of the leading points in the treatment of the disease. When details are gone into, croton-oil, or calomel, or some other energetic drug is suggested, and, to assist it in its action, enemata are recommended by some writers.

Now the first few cases of tetanus treated by me in the West Indies had their full share of calomel and jalap and croton-oil, and so on. They all died. About this time I looked carefully through the notes of a great number of cases of tetanus, and I observed that in many cases the patient had been doing very well until it had occurred to the surgeon that his bowels wanted opening, whereupon a dose of some powerful purgative, followed so frequently as to be more than a mere coincidence by an exacerbation of all the symptoms often speedily ending in death. Coupling this with my own experience, I came to the conclusion that this traditional treatment was altogether a mistake. Since then I have treated many cases of tetanus without purgatives, and have had the satisfaction of seeing a large proportion of them recover.

The following extract from a lecture delivered by Mr. Skey many years ago throws some light on the origin of this method of treating the disease. He says, "I remember a case of tetanus treated by Mr. Abernethy in St. Bartholomew's Hospital with. calomel and jalap, in doses of from one grain to five. The case was a severe one, and arose, if I recollect rightly, from a wound

about the hand. The man's bowels were greatly constipated. The purgatives, given every three hours in repeated doses, at length operated freely, producing several offensive evacuations. Relief from the spasm followed, and the man recovered. Mr. Abernethy from that time henceforth in his surgical lectures recommended to his pupils the adoption of the particular agent he had himself found so successful in the above case, attributing the disease to a constipated condition of the alimentary canal. And yet tetanus is a rare affection, while constipation in every form and degree is of common occurrence." Exactly so.

I consider the question of the administration of purgatives in tetanus to be of some importance; indeed, when the want of success that too often follows our efforts to combat this disease is remembered, any discussion opening up new ground with regard to its treatment cannot fail to be of interest. I have had some experience in the matter, and it is without hesitation that I protest against the present plan of indiscriminately administering violent purgatives.

We have but to look at the modus operandi of these drastic purgatives. Their effect is produced "by a direct or local action on the mucous membrane of the digestive canal, in the same manner as irritating or indigestible articles of food occasion diarrhoea." Now it is admitted that a tetanic patient should be carefully guarded from every external source of irritation, for it is well known to those who have seen anything of the disease that the least noise, flash of light, or in short anything that makes a sudden and distinct impression on the patient's sensorium, will bring on a spasm which may be fatal, and must at any rate help to exhaust the strength; for instance, I have known the cold fingers of the surgeon feeling the pulse give rise to a severe spasm.

This being so, it is matter for surprise that drugs acting in the manner indicated above should be so persistently recommended and prescribed.

Not many years ago it was proposed, and actually carried into practice, that the whole of the patient's spine should be blistered; and I believe that one or two patients actually recovered in spite of this treatment. Probably, nowadays, no one would venture to propose the rubbing in of croton-oil liniment into the back of a tetanic patient; yet there is no