times he made a half-blowing, half-sneezing effort to get rid of ; pulse 100. Ordered half a grain of the extract every hour and a half. In the evening the pulse was 92; the eyes had a peculiar hazy appearance, with pupils much contracted. His mother remarked that he had spent an easier day, and that he got some short snatches of sleep now-as the spasms, although very severe when they did come, were less frequent, having an interval of ten minutes or a quarter of an hour.

9th. Had much pain in the breast and back, also great uneasiness in the stomach; pulse 116; otherwise the symptoms the same as on last report; ordered three drops of dilute hydrocyanic acid every four hours, and half a grain of the ext. of Calabar bean every two hours. In the evening he felt easier.

10th. To-day the pulse fell to 80 and was very soft; he was much troubled with mucus in his throat, which he could not easily get rid of. Stopped the hydrocyanic acid- continued the half-grain of extract every two hours. He said he felt the need of the medicine about the end of the two hours. Pupils continued always very much contracted.

11th. The pulse was up to 100; spasms very easily excited by touching his back, and he felt so sensitive that the cold air reaching him, if the door of his room were opened, was sufficient to bring on a spasm. The Calabar bean to be continued, but the dose to be doubled every alternate two hours, so that he had half a grain at one time, and a whole grain at the next.

12th. Had delirium during the past night. Pulse 120; was afraid to put out his tongue in case of biting it; the muscles of the abdomen were very tense; still complained of pain in breast, back, and legs; ordered to continue the old dose of half a grain every two hours, but to omit the double dose, as I thought the delirium might be occasioned by it; sweating was very profuse.

In the evening I was sent for very hurriedly as be was thought dying, and on my arrival at the bedside I found bim quite insensible, foaming at the mouth, breathing laboured and stertorous, pulse almost imperceptible, countenance very livid, and he had all the appearance of being very near death. His mother told me that he had suffered very much more from the spasms throughout the day, and regretted much that he had not had any of the Calabar bean since I had seen him in the morning, owing to the druggist's supply having run short. Fortunately I had a small quantity in my pocket, which I kept in case of having to use it subcutaneously, and as he was quite unconscious and unable to swallow, I injected half a grain in solution under the skin. The epileptic symptoms gradually subsided, and he was again quite conscious in about half an hour. The

Calabar bean was continued as before in half-grain doses every two hours.

13th. Pulse 100; body much less rigid and spasms less severe; could protrude the tongue about half an inch, but was still afraid to do so; complained greatly of want of sleep.

17th. Since last report his symptoms have been gradually diminishing in severity, so I reduced the dose of the bean to one-fourth of a grain, and ordered a squill mixture, with camphor and dilute sulphuric acid, as he had loud mucus râles in the larger bronchi.

20th. During last night he had his first sound sleep since the commencement of his illness. Found him asleep at the time of my visit, and the muscular system quite relaxed. He awoke while I was standing at his bedside, and the back was immediately thrown into an arched position, which subsided to its natural state in a few seconds. Bean to be taken in quartergrain doses every four hours.

22nd. Pulse is now 60, tongue clean, feels his muscles stiff and sore, but can get up out of bed; and I had the satisfaction of seeing him walk, and also chew some food; he is evidently quite convalescent. Ordered him to stop taking his medicine.

This case of traumatic tetanus was marked by gradual progression; the symptoms being very slight during the period of accession, intensely severe at its height, and then gradually declining until recovery was established. The punctured wound, followed by exposure to cold, was evidently the exciting cause, and the first question to decide was, whether any removal of that cause could be effected by surgical treatment at the seat of the original injury. Amputation in tetanus is forbidden, unless the part to be operated on is in such a condition as to require it, independently of that disease; the more promising surgical treatment is the division high up of the main trunk of the nerve leading from the seat of the injury; but with reference to such a procedure in this case, I came to the conclusion that, as the spinal cord was already in a state of super-sensitiveness to outward impressions, any operation on the nerves leading thereto would be only likely to aggravate the disease, and I therefore contented myself by applying hot fomentations to the hand and arm, and sought for the medicine which would produce the most powerful sedative effect on the spinal cord. From what has been written by Drs. Christison, T. R. Fraser, and Ebenezer Watson, regarding the properties of the Calabar bean, I was led to decide on it as being the medicine most likely to afford relief in tetanus, and the foregoing case is an illustration of its valuable sedative action on the spinal cord and medulla oblongata. The occurrence of an epileptic fit in this case, after the accidental want of the drug for some hours, at the height of the disease, is

a remarkable circumstance; and it has led me to think that the Calabar bean may yet be found serviceable in the treatment of epilepsy, in which disease, so far as I have been able to learn, it has not yet been used.

Van der Kolk, in his work on Epilepsy, states that, for the rational treatment of that disease, it is necessary, after removing as far as possible any remote cause, which by its action on the medulla oblongata keeps up the "increased capacity for morbid reflex movement and discharge of the ganglionic cells," to "diminish the excessive sensibility of the medulla oblongata, and to moderate, if needful, the superabundant determination of blood to these parts." Now the physiological action of Calabar bean fulfils these indications, and it does so better than any other drug known, by its having not only a sedative action on the medulla oblongata and spinal cord, but also a similar effect on the circulatory system, and is therefore free from the objection of producing a state of congestion, which attends the administration of the most powerful sedatives of the nervous system. Actual experience in practice will alone determine its value as a curative agent in epilepsy; but its properties would lead us to hope that good results may yet be obtained from its use in that disease.

The only other remark I have to make in connexion with this case is, that in Sir Thomas Watson's work on the Practice of Physic, it is stated that, "in tetanus, there is no thirst, and seldom any accumulation of tough and stringy mucus in the fauces and about the angles of the mouth; but that in hydrophobia both these symptoms is always present." In this case of tetanus, thirst and accumulation of stringy mucns in the fauces were present in a marked degree, and it was a frequent question made to me by the patient what be could have to drink, as his thirst was so great, and his power of swallowing so much interfered with. I suppose that the presence of these symptoms, in this case, is to be attributed to the effects of the Calabar bean.-Edinburgh Medical Journal, May 1869, p. 989.

121. VOMITING OF PREGNANCY TREATED BY THE HYPODERMIC INJECTION OF MORPHIA.

By JOHN HARRISON, Esq., Congleton.

The vomiting in this case was most severe and distressing. There was seldom a longer interval than fifteen minutes between the paroxysms of sickness. The stomach would retain abso

lutely nothing.]

On April 13th, after having tried external applications, nutritive and sedative enemata, vaginal injections, and number

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less internal medicines, it occurred to me that hypodermic injections might be of service. I began with a solution of one grain of acetate of morphia in six minims of water, and injected one minim three times daily. At once the vomiting abated, and she gradually became stronger. The dose was increased to fourteen minims, but was only given twice in the day. This treatment was continued until July 1st, with occasional intermissions of one or two injections, that other remedies might be tried; but a tendency to relapse invariably occurred. I now determined to try if miscarriage could be induced by drastic purgatives and ergot. These means appeared to succeed. foetus was expelled, and the patient did well; but the gastric irritation continued, necessitating the continuance of the injections. However, on July 9th, I was able to reduce their strength and the frequency of their administration; and, on the 20th, discontinued them altogether. At this date, the menses returned, and the irritation of the stomach quite subsided. The patient was sent to the seaside, and is now quite well. She was reluctant to discontinue the injections, and was for a day or two depressed and hysterical, though not usually of this habit. She is more than ordinarily fat when well. She lost much flesh during the first part of her illness, but regained it soon after the injections were commenced. Fearing to establish a habit of opium-taking, the character of the injections was hidden from the patient. The skin of the forearms was pierced two hundred and sixty times. There was never any swelling or redness, except after two or three of the earlier operations, when the injection was accidentally endermic, rather than hypodermic. Suppuration never occurred. The bowels were sometimes a little constipated; and a slight disorder of the liver's functions was easily rectified by an aperient. The effect of the morphia was felt very soon after injection, in heightened spirits, toleration of food, and increased energy; but there was no marked drowsiness, contraction of pupils, or subsequent headache. — Brit. Med. Journal, April 3, 1869, p. 306.

122.-ON THE TREATMENT OF SUPPURATING JOINTS BY FREE INCISIONS.

By THOMAS BRYANT, Esq., Assistant-Surgeon to Guy's

Hospital.

The treatment of a disorganised or suppurating joint has ever been a source of difficulty to the surgeon, and the larger the articulation that is affected the more that difficulty has been experienced, for the suppuration of a large joint, such as the knee or hip, too often threatens life in some stage of its progress,

and the integrity of any joint, large or small, is, as a rule, compromised by suppuration.

How to preserve the natural movements of a diseased articulation is the first aim of the surgeon, and when that hope has gone his object is to save the limb. When this end can be obtained with a stiff joint, the result may usually be regarded as satisfactory, particularly in disease of the lower extremity, and even in the upper a cure by anchylosis is not so bad as some surgeons would lead us to believe. When neither of these ends appears probable, possible, or expedient, from the extent of the local disease, the general want of power of the patient, or the necessities of the individual case, the question of operation comes before the surgeon, and he has to decide whether amputation of the limb, resection of the joint, or incision into the articulation is to be performed. To work out the many points involved in the solution of these questions is a task of difficulty, and a form of practice which is applicable to one joint may be inexpedient to apply to another.

This difficulty is doubtless due to the different value which surgeons place on different forms of practice, and the estimation with which they regard natural processes. One surgeon, having intense faith in natural processes in the cure of disease, and particularly joint disease, would attempt to save a limb that another would condemn, regarding any practice as wrong that interferes with a natural recovery, as long as any reasonable hope exists of securing such a result, and believing that a cure by anchylosis, however acquired and however long a time may be passed in securing it, is worth the attempt. A second surgeon, having stronger faith in surgical treatment, would excise a joint, believing it to be inexpedient to waste time for a natural cure, even when it may be gained, when by excision he believes an equally good, if not a better, result can be secured in a shorter period; whilst a third surgeon, looking upon both forms of practice as too protracted and uncertain, would remove the diseased part by amputation, in the belief that a more certain result and a more rapid recovery would be secured by such a process.

In brief, a case of disease of a joint that one surgeon would attempt to cure with anchylosis, a second would excise, and a third amputate--the two former schools amputating a limb only when all hopes of saving it by less severe measures have been proved futile.

In the present paper it is not my intention to consider the expediency of practising excision of a joint. On a former occasion I have fairly shown that in the knee it is only justifiable in exceptional cases. In its own place the subject of excision of other joints will meet with due attention, although I may admit

VOL. LIX.

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