CAFFEINE.

BY SIMON FLEXNER, PH. G.

The phenomenal success of antipyrin as an agent for reducing temperature has, it seems, stimulated inquiry into the properties of allied compounds, and even into compounds widely removed from it chemically. Antifebrin is the latest announced discovery in this direction, and, if reports are true, it will demand a large part of the attention now given to antipyrin. Its discovery is announced by Drs. Cahn and Hepp, of Strasburg, and it was experimentally tried in the medical clinic of Prof. Kussmaul, of the same place. As regards its discovery, it does not appear to be new. It is identical with phenyl-acetamid or acetanilide, prepared as long ago as 1853 by Gerhardt. However, the present discoverers have materially increased its chances for recognition and employment by the profession, by the adoption of the significant name, "antifebrin," in place of the chemical title.

Antifebrin is a clean, white, odorless pow. der, imparting a slight burning sensation to the tongue when placed on it. It is almost insoluble in cold water, dissolves with difficulty in hot water, but is freely soluble in alcohol and alcoholic liquids, such as wine. It possesses neither acid nor basic properties, and it is not easily affected by reagents.

Experiments on dogs and guinea-pigs are said to prove that it is innocuous in relatively large doses. The authors have experimented with the remedy in a number of febrile trou bles, among others typhoid fever, erysipelas, acute articular rheumatism, pulmonary phthisis, and septicemia, and state that the results obtained were very satisfactory. It is recommended to be given in doses varying from four to fifteen grains, shaken in water, dissolved in wine, or inclosed in wafers.

A max

imum dose of thirty grains per diem was not exceeded. It is stated that in promptness, duration and extent of action, one quarter of a gram (about four grains) corresponds to one gram of antipyrin-in general terms antife

The effect of the drug upon the temperature is noticed at the end of about one hour, and attains its maximum usually in about four hours, passing off, according to the size of the dose, in three to ten hours. The action of antifebrin manifests itself externally by a reddening of the surface and moderate perspira tion. The patient sometimes complained of a cold feeling, but at no cold feeling, but at no time was a decided chill noticed. The pulse-rate falls proportionately to the temperature. Nausea was never caused by even large doses. Should the claims on behalf of antifebrin be confirmed, they will establish a point of some theoretical importance. Heretofore the compounds possessed of antipyretic properties have belonged to the class of phenols, that is, carbolic acid, hydro-quinone, resorcin, and salicylic acid, or have been bases, such as quinine, kairine, antipyrin, and thalline, while antifebrin is a neutral body and chemically widely removed from either group.

as

Ethoxy-caffeine is a derivation of caffeine, and has just been studied in conjunction with other members of the caffeine group, by Prof. W. Filehne, of Erlangen. He regards the addition of the ethyl group to the caffeine affording a peculiar narcotic influence on the brain and spinal cord. It causes stupefaction and paralysis without affecting the circulation, or to any great extent the motor apparatus. In man it causes no effects in a dose of three grains, but after doses of four and a half to seven and a half grains the arterial tension is raised (the pulse increasing two to six beats. per minute), the face reddens, sweating and a soporous state sets in. Doses of seven and a half to eleven grains produce severe headache and coma. Doses of one and a half to seven and a half grains cause a somewhat sounder sleep than normally present, still larger doses disturbing the sleep. Filehne advocates its use in cases of megrim. Dujardin-Beaumetz, convincing himself of the correctness of Filehne's observations on the derivations of caffeine ("Therapeutic Gazette, Sept. 15, 1886) tried ethoxy-caffeine in a number of affections marked by cephalagia. In order to

The results obtained in megrim were highly satisfactory. In one case the drug was given in a dose of about one grain at the height of the paroxysmal pain in the head, with the effect of removing entirely the pain in two hours. In four other cases the pain was abated in less than one hour. Dujardin-Beaumetz advises giving no larger doses than three grains, since seven grains can produce gastric cramps, nausea, and even cerebral disturbances. In cases of prosopalgia the drug served likewise to bring relief and cause sleep. Dujardin-Beaumetz finally assumes that ethoxy-caffeine presents the therapeutical and physiological effects of caffeine in a modified manner, and that it owns a pronounced seda tive or narcotic action, allowing of its advantageous substitution for caffeine in cases of megrim.

MENTAL AND NERVOUS DISEASES.

BY C. H. HUGHES, M. D.

the

Dr. Mickle said he found distinct microscopical change in the elements of the medulla oblongata in one case,and felt scarcely justified in absolutely connecting this change with the production of Cheyne-Stokes respiration. But recently Lizzonni found in one case chronic inflammatory changes ascending the vagi, with blood extravasation into the lymphatic spaces of the perineurium and endoneurium. The whole length of the right nerve, periphery only of the left was affected. In the medulla oblongata itself were small foci, chiefly on the right side, and beneath the ependyma at the longitudinal furrow of the calamus. similar lesion affected the upper half of the medulla oblongata in another case (uremic), but the vagi were normal. Referring to cases of that kind, the most likely theory as regards the nervous condition appeared to be that the respiratory center of the medulla ob

A

II. THE TREATMENT OF EPILEPSIA. III. THE CLASSIFICATION OF INSANITY. IV. DISEASE BACK OF THE PONS VAROLII. V. SURGICAL NEUROTHERAPY BASED ON CEREBRAL LOCALIZATION.

VI. A REMARKABLE CASE OF SUICIDE.

THE PATHOLOGY OF CHEYNE-STOKES RESPI

RATION.

At the February meeting of the British Medico Psychological Association, Dr. Wm. Julius Mickle, author of the most exhaustive

tient perception. There was also another theory, viz., that there was anesthesia of the mucosa of the lungs. In one of the cases mentioned the blood-vessels of the medulla oblongata had the same changes in their walls as those of the cerebral cortex had; but that was a case in which there was a generalized vascular lesion. It was a case in which there was a general arterial disease of which the kidney disease at first was merely one part, and the morbid state of the arteries of the

kidneys aggravated the conditions which gave rise to the arterial atheroma, the arterial disease in this case leading to atrophy. The renal

arteries participated in the general change, and their alteration affected an organ, which, in consequence of that, had its excreting power lessened. These were the cases following arterial disease, and although differences existed, they might come to closely resemble primary renal disease; but if they were compared at different stages with renal cases which really gave rise to cardiac and arterial changes, the differences were great. Those differences did exist, and, in the case mentioned, the only other point was that there was some granular change in the nuclear nerve centers in the medulla oblongata. There one had the damaged nerve center. As to the state of the nerve centers involved, local vascular dilatation might occur, and, occurring paroxysmally, would cause cessation of respiration by keeping the medulla oblongata over supplied with blood. If there was blood of a good quality, and the blood vessels of the medulla oblongata were in a dilated condition, there was, temporarily, no call on the respiratory center, for that center was not stimulated to call forth renewed movements. These were cases which were not due to changes in the pneumo-gastric nerves themselves. Those that were, were usually associated with some lessening of the sentient function of the lungs.

THE TREATMENT OF EPILEPSIA.

The treatment of epilepsy is a subject always of such practical interest that its discussion is never mal apropos. We give place therefore to the following discussion of this subject, not however to endorse all that is said, but to lay before the readers of the RE VIEW many practical features of the management of many phases of this disease in briefer space than is usually occupied in the discussion of so much of the subject, and to present the rationale for the employment of some of the newer remedies and procedures in the disease as it is gener treated. Leszynsky (Quarterly Bullet of Medicine) thus presents the subject xtracted and abbreviated from the Cinc nati Lancet Clinic: Sees no advantage in treating epileptics as a

"class," but believes they should be managed individually, therefore he permits them to use starches, sugars, etc., excepting patients who cannot easily digest them.

Their diet should be regulated with the view to restrict the amount of food and at the same time to avoid any article which in the experience of the patient has been found to be indigestible.

The use of glonoin in one per cent solution has in his hands frequently failed to produce any physiological effect. He therefore prescribes nitro-glycerine in the form of Fraser's tablets, each containing 1-100 of a grain.

In petit-mal, where the bromide alone has failed, the addition of belladonna has proved of unquestionable benefit. In many cases ergot is a valuable adjunct, especially in those cases accompanied by hallucinations, or paroxysms of mania. In epilepsy due to inherited or acquired syphilis, the use of antisyphilitic remedies should not be forgotten.

If we remember that epileptics frequently die while in the condition of status, the importance of suitable treatment while this state exists cannot be over-estimated

In a number of instances where previous attacks had been known to have occurred, the administration of an emetic, followed by a brisk purge, had frequently proved successful in aborting the attack.

In some cases in the beginning the convul sions may be controlled by the administra tion of large doses of chloral per anum; but, after the attack had fairly started, chloral seems to have very little influence, excepting to intensify the exhaustion.

The inhalation of chloroform controls the convulsions during its application, but they are only held in abeyance, to return with ap parently renewed vigor shortly after the inhalation is

discontinued. The use of morphine subcutaneously seems to possess some power in controlling the paroxysms, but it has to be injected in such large doses that it appeared to hasten the death of the pa tient from exhaustion.

In some cases pressure over the carotid

arteries seems to have temporarily checked the convulsions at their onset.

Where marked cyanosis is present, he has found venesection of the greatest benefit by relieving the passive cerebral and pulmonary congestion. At the same time the ice cap and counter-irritation to the nucha had been resorted to with apparent advantage.

Owing to the frequency of dysphagia, and occasionally the complication of severe vomiting, the nutrition and stimulation of the patient when death from exhaustion becomes imminent, are very difficult.

Our only hope then is in the administration of nutritive and stimulating enemata.

Nitrite of amyl, in this class of cases, has proved ineffectual, if not injurious.

The use of this drug is undoubtedly valuable for the purpose of aborting a paroxysm in cases of ordinary epileptic seizures where a distinct aura is experienced, but after the convulsion is established its administration invariably complicates matters. The mechanism of its action is very simple; vaso-motor spasm of the cerebral vessels, which is the initial symptom of an epileptic convulsion, is relieved, and the vessels become dilated.

During the condition of status, owing to the almost continuous tonic contraction of the muscles of the neck, the return circulation from the brain is obstructed and venous congestion follows. This is the state which is so decidedly relieved by venesection, and where the inhalation of nitrite of amyl does positive harm.

THE CLASSIFICATION OF INSANITY.

Dr. Heinrich Schuele in his recent treatise on the special pathology and therapy of the insane in Von Ziemssen's Handbuch der speciellen Pathologie und Therapie, xvI., Band, 3 Auflage, Leipzig, 1886, gives the following classification which, as the subject is just now engaging special attention because of the endeavor of the late Antwerp Congress of Psychiatry to enacta uniform and correct system of classification, we present in full:

2. Psychoses of the feeble brain (Cerebropsychoses).

(a) The severe forms of Mania: Furor, Mania gravis.

(b) Insanity in its acute, chronic and
atonic forms.

(c) Acute primary dementia. Variety,
stupor with hallucinations.
(d) Hysterical, epileptic, and hypochon-
driacal insanity. Varieties: (a) Pe-
riodical circular and alternating Psy-
choses; (b) mental disorders follow-
ing non-cerebral bodily affections
(febrile, puerperal, etc.) together
with those from intoxication.

3. Pernicious conditions of brain-exhaustion.

(a) Acute brain-exhaustion of a dangerous character. Acute Delirium. (b) Chronic brain-exhaustion of a destructive character (Degeneration)— the classical General Paralysis. 4. Psychical cerebral disorders. Psychoses following sub-acute and chronic organic affections of the brain (diffuse and local)— modified General Paralysis.

II. Psychoses of defective organo psychical constitution.

(a) Hereditary neuroses. Variety, transitory psychoses.

(b) Simple hereditary insanity-the insanity of imperative conceptions (Maladie du doute et du toucher). Variety, litigation insanity (Queru lantenwahnsinn).

(c) Delusional Insanity (original Verruecktheit).

(d) Degenerative hereditary insanitymoral insanity.

(e) Idiocy.

DISEASE BACK OF THE PONS VAROLII.

Dr. W. W. Ireland, in his retrospect of

German Neurology for the Journal of Mental Science for April, gives the following instruc tive record from the pages of Neurologisches Centralblatt for 1885, Nos. 16 and 17, being an analysis, made by Mierzejewsky and Rosenbach, for the Journal, of pons varolii disease symptoms:

In a patient, a man of thirty-four years of age, the symptoms were paralysis of the right facial, the face on that side being immovable and the right eye not being closed. The paralyzed muscles were more affected than those of the opposite side by the galvanic and faradic current. There was no paralysis of the extremities, though the patient's gait was weak and tottering, and he yielded a little to the left side. The knee clonus was wanting on both sides. There was paralysis of the external rectus of the right eye, and the left eye. ball could not be turned inwards beyond the middle line. This paralysis of the external rectus, and paresis or imperfect action of the internal rectus, were observed not only in as. sociated movements of both eyes, but also when the patient looked at an object with one eye alone. There was double vision. The pupils of both eyes were dilated, and the visual power diminished, and on being examined with the ophthalmoscope neuro retinitis was observed. The intelligence and memory were unaffected, but he was troubled with giddi. ness and pain, especially at the back of the head, with nausea, progressive weakness and fever. These last symptoms were probably due to phthisis pulmonalis of an inflammatory type. The patient died thirty-five days after admission to the hospital at St. Petersburg. There was found a tumor about the size of a horse-pistol bullet, occupying the back of the pons and the floor of the fourth ventricle. It lay on the right side, and had pushed to the opposite side the raphe and left half of the pons. The tumor was a glioma, rich in vessels, and sharply separated from the nervous tissue. It had caused chronic inflammation and destruction of the nuclei of the sixth and seventh pairs on the right side, and in a lesser degree of some adjoining parts.

number of cases in which paralysis of the sixth pair was associated with that of the facial nerve of the same side. They explain this combination by quoting the researches of Duval, who showed that a part of the fibers of the facial come from the same nucleus as the sixth pair. They regard facial paralysis with loss of power to turn out the eye, as indicating lesion of the posterior part of the pons and the floor of the fourth ventricle. They regard increased excitability to galvanic and faradic currents, with slow contraction of the muscles, as a proof that the facial paralysis is not peripheral. In facial paralysis following disease of the pons, the atrophy of the muscles supplied by the seventh pair is generally confined to the lower muscles of the face. Dr. Mierzejewsky maintains that the combined symptoms observed in his patients, paralysis of the external rectus with imperfect action of the internal rectus muscle, have been repeatedly observed with disease of the nucleus of the sixth nerve and integrity of the deep origin of the ganglion of the third pair (oculo-motor). While admitting that there must be some physiological connection between the sixth pair and the innervation of the internal rectus muscle, Drs. Mierzejewsky and Rosenbach consider that this connec tion has not yet been satisfactorily explained. Most authors who describe similar cases confine themselves to the statement that lesions of the nucleus of the sixth pair paralyze the movements of both eyes towards the side of the injury, which they explain by the assumption that the said nucleus presides over the outward motion of the eyeball on the injured side, and also over the associated sideward movements of both eyes. This explanation fully suits those cases in which the paresis of the rectus internus in the opposite eye is remarked only with associated movements of the eyes sidewards; but they observe that such cases are exceptions, and that in most cases the motor power of the internal rectus is directly injured independently of the other eye. It is also worthy of remark that in most observations of the kind, while there is complete