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From the preceding remarks, it cannot be expected that any arbitrary rules of dosage can be laid down. For an adult, one grain of the extract by stomach, or one-third of a grain by subcutaneous injection will be generally sufficient to commence with. This should be repeated in two hours, when its effects will usually have passed off, and the succeeding doses may be modified according to the experience that will thus be gained. When used by subcutaneous injection, the dose of extract should be carefully mixed with ten or fifteen minims of water. This mixture has always an acid reaction which is sometimes so decided as to produce slight irritation of the cellular tissue; but this can be avoided by carefully neutralizing the mixture with a solution of carbonate of soda. Suppositories, made with oil of theobroma and white wax, may be employed when administration by the anus is desired. Each of these should contain two grains of extract. For children, we must be guided by the general rule of employing, according to age, one-third or one-fourth, or even less, of the above doses. It will be found necessary to repeat these doses frequently-every hour, every hour-and-a-half, or every two or three hours-and, of course, the severity of the disease and the effect of the remedy will be the best indications for this. The great object is to produce as quickly as possible, and then to maintain, the physiological effect of physostigma in diminishing reflex excitability. The doses must, therefore, be continued in increasing quantities until this physiological effect is produced, or until the sedative action of the drug on the circulation is carried to a dangerous extreme, or until constant nausea and vomiting compel us to desist.

This nausea is, I believe, due to the action of physostigma in causing energetic contractions of the stomach and intestines. To this cause may also be referred a peculiar epigastric sensation, which is one of the first symptoms of the action of this drug, whether it be administered by the stomach or subcutaneously, and which is always relieved by eructation. The catharsis that physostigma causes-probably an advantageous effect in tetanus-is another result of this intestinal contraction, though it is also due to an increase of secretion by the intestinal glands.

Another physiological effect of physostigma is excessive perspiration. This is most strikingly observed when a large dose is administered by subcutaneous injection. It may be of some importance in the treatment of tetanus, for sudorifics are vaunted as reliable remedies for this disease; but, as I am at a loss to understand why perspiration should in itself prove beneficial, I mention it only as an indication that physostigma is affecting the system.

It might reasonably be expected that the active principle of physostigma -eseria-should be valuable in tetanus, and especially for administration by subcutaneous injection. It is, however, an alkaloid that is very difficult to prepare, and, as far as my knowledge of its properties is concerned, it appears to be somewhat unstable. There is, besides, but little advantage in employing a more active remedy than the extract of physostigma.

In these observations, no distinction has been drawn between the traumatic and idiopathic varieties of tetanus. As far as treatment is concerned, they only differ in this, that the traumatic variety is usually the more severe and acute, and that it, therefore, generally demands a very energetic and active employment of the remedy.

I have avoided all discussion of subsidiary measures, as these are not included in the subject of the present communication.

Chorea. As the principal indications for the therapeutic use of physostigma have been already mentioned, its employment in chorea may be very briefly considered. Dr. George Harley was, I believe, the first to use physostigma in this disease. His case occurred at the end of 1863, and was a successful one. Since then, three successful cases have been published by Dr. John Ogle; and I have seen others in which successful results were attributable, in great measure, to the use of this drug.

The disease is one of such protean form, that it is impossible to advise the use of one remedy for all cases. It must, however, be admitted that in the great majority of cases involuntary contractions occur of such a char

acter as to demonstrate an exaggerated condition of the reflex motor function of the cord. The want of co-ordination in the movements by which this disease is characterised, is dependent, not only on imperfect voluntary contractions, but also-and sometimes in great degree-on involuntary contractions. The latter are obviously the results of either a stimulus supplied by the exercise of volition, or of one supplied by the voluntary movements themselves, acting through afferent nerves on an abnormally excitable condition of the reflex centres. We have seen that the action of physostigma is to diminish such a condition.

The treatment of this disease will rarely require to be so active or energetic as that recommended for tetanus. Physostigma should be administered either in the form of powder or of tincture. From three to six grains of powder, thrice or four times daily, may be given to children, and from ten to twenty grains, as frequently, to adults. The Pharmacopoeia does not contain a tincture, but a formula for an efficient and sufficiently active one has been published. It may be given to children in doses of from five to fifteen minims, and to adults of from twenty to thirty minims.

However promising the treatment of chorea by physostigma may appear, the experience we yet possess is much too limited to allow us to arrive at any decided opinion as to its value.-Practitioner, Aug. 1868, p. 76.

19.-A CASE OF ACUTE TRAUMATIC TETANUS TREATED SUCCESSFULLY WITH EXTRACT OF CALABAR BEAN.

Under the care of Mr. ASHDOWN, at the Northampton General Infirmary. [The patient, 33 years of age, was a labourer, who had received a wound half an inch in length on the scalp and a second on the left ear from a fall off a coal stack. A fortnight after this the first symptoms of tetanus appeared.]

On admission (October 3rd), the tetanic aspect was strongly marked. The forehead was permanently wrinkled, and the angles of the mouth retracted. The teeth could be separated about half an inch. The respiration was quick, and chiefly thoracic; the abdominal muscles were tense and unyielding to pressure; the back was arched, and its muscles rigid; as also were those of the legs, the arms alone being freely moveable. The skin was bathed in perspiration; and the chief complaint was in pain at the pit of the stomach. There was a slight appearance of suppuration about the wound on the left ear, but that on the scalp cicatrised. The urine was retained. Pulse 114. He was ordered to take one-sixth of a grain of extract of Calabar bean in a drachm of water every half-hour; and to have strong beef-tea, milk, eight ounces of port wine, and four ounces of brandy.

In the evening, the pulse had fallen to 94; but the paroxysms came on every few minutes, and were produced immediately by any disturbance. He had been fed by means of a piece of gutta-percha tubing passed to the back of the tongue and attached to an ordinary feeder, and seemed to have no difficulty in swallowing. His urine was removed by a catheter.

On the 4th, the patient's condition was but little altered, though the pain was not quite so severe, and at times he had been able to move his legs slightly. On the 5th, after a visit from his friends, he was much worse; violent paroxysms coming on every few minutes, and the muscles appearing even more rigid than previously. The pupils were rather dilated, and freely influenced by light. The dose of the extract was increased to one-third of a grain, and the wine and brandy doubled in amount.

October 6th. He had vomited several times, and was not in the least improved. The medicine was stopped, and one-third of a grain of extract of Calabar bean, dissolved in eighteen minims of water, ordered to be injected every two hours under the skin. The effect of the first subcutaneous injection was very marked. In about five minutes, the legs, which had been previously perfectly rigid and immoveable, became flaccid and freely moveable by the patient; the abdominal muscles became less tense; and the arching

of the spine disappeared. The pupils also contracted, and the pulse sank to 82. The effects lasted between two and three hours, and all the symptoms then reappeared. Beef tea and brandy enemata were ordered to be used every four hours.

October 7th. The vomiting had been less frequent, but had not entirely ceased. Every subcutaneous injection, which had been given regularly every three hours during the night, had been followed by an almost complete remission of the symptoms, lasting for about two hours. In the evening, each dose was increased to half a grain.

October 8th. He passed a restless night, though he had not been in so much pain, and had for the first time been able to dispense with the aid of the catheter. Vomiting had ceased; and several eggs had been taken, beaten up with wine. The beef-tea and brandy enemata were therefore omitted. Eggs ad libitum, and a bottle of sherry daily were ordered. The dose of extract of Calabar bean was increased to three-fourths of a grain in each injection, to be given at intervals of two hours only, or as soon as the effect of the previous injection had passed off.

October 9th. The injections had been continued every two hours, and their influence in preventing the muscular rigidity and spasms remained unabated; the only muscles not perfectly relaxed were those of the abdomen and back. The pupils were much contracted, and the patient had been at times very delirious. He continued to take plenty of nourishment. The urine contained a large quantity of phosphates. As the injections occasioned much pain and inflammation in the cellular tissue, and the solution was found to be acid, a few drops of liquor potassæ were added to it. The solution thus obtained was more perfect, and produced less pain.

October 10th. During the night, as the patient was very delirious, and the pulse had risen to 148-effects supposed to depend on an over-dose of the medicine the injections were stopped for seven hours. This morning the muscles were as rigid as ever; and the paroxysms, which had almost ceased, again increased in frequency. The injection was ordered to be continued as before. In the evening, the pulse had fallen to 125; but the injections had been required every two hours, the effect not lasting so long as previously. October 11th. The dose was increased to one grain at similar intervals. October 12th. One-third of a grain of morphia was ordered to be injected subcutaneously every night with that of Calabar bean; as the latter, notwithstanding its influence in subduing the spasms and rigidity of the muscles, did not secure sleep, and the night had been restless and disturbed.

October 13th. He slept well all night after the morphia injection was given; and this morning there was a marked improvement. The pulse 94; the countenance flaccid, and not expressive of suffering; the muscular rigidity less; and paroxysins infrequent. He took twelve eggs and two bottles of sherry in twenty-four hours.

October 15th. As the skin was becoming tender from the numerous injections, and the severity of the disease was evidently subsiding, they were omitted, and suppositories containing a grain and a quarter of extract of Calabar bean were ordered to be applied every two hours; the morphia to be continued every night.

From this time, the patient gradually improved, the suppositories acting very favourably; but it was not until November 1st that all the rigidity of the muscles had finally and permanently disappeared, and convalescence was established. Up to this time, the suppositories had been continued, though at gradully increasing intervals. A few small subcutaneous abscesses formed at the sites of some of the injections, but they gave little trouble; and he was discharged well on November 30th.

Remarks. The result of this case-which, though not, perhaps, of the acutest type, was one of very great severity-shows that the plan of treatment adopted is deserving of a more extended trial; for, though the Calabar bean does not appear to exercise any direct curative action in the sense of cutting short the disease, it is impossible to doubt its influence in controlling the more urgent and dangerous symptoms. The superior advantages of the

hypodermic method of administering the extract of Calabar bean were in this case very obvious; for in this way relaxation of the spasmodically contracted muscles was very rapidly and invariably produced, even when the dose was extremely small; while, when administered by the mouth, only a large dose exercised any obvious influence, and its further continuance was contraindicated by the sickness caused by it. It was noted that the extract of Calabar bean, when rubbed up with water, formed a very acid solution; and that the addition of a few drops of liquor potassa, without interfering with its efficiency, produced a more perfect solution, and one not producing pain at the time of injection, or inflammation in the cellular tissue subsequently.-British Med. Journal, March 21, 1868, p. 274.

20.-ON THE PATHOLOGY AND TREATMENT OF EPILEPSY. By Dr. GRORGE JOHNSON, Physician to King's College Hospital.

To what extent do the phenomena of an epileptic fit admit of explanation? In a fully developed epileptic fit, there are two chief phenomena to be explained; these are loss of consciousness and convulsions. The loss of consciousness, until within a very recent period, has generally been supposed to be a result of congestion of the nervous centres, and especially of the cerebrum. But this explanation is inconsistent with the fact, that the epileptic loss of consciousness comes on in a moment at the very commencement of the attack, when there is no evidence of congestion, and when the face is usually pale from anæmia. The congestion follows the loss of consciousness; and the explanation of its occurrence appears to be this. The convulsion implicates the respiratory muscles; the blood, therefore, being imperfectly aërated, is impeded in its passage through the lungs; it consequently accumulates in the right side of the heart and in the veins. The congestion, therefore, is a secondary venous congestion; and, at the time when this congestion has reached its greatest height, there is often a commencing return of consciousness. Obviously, then, this congestion is not the cause of epileptic loss of consciousness. This retrograde venous engorgement is the cause of the ecchymoses beneath the skin and the conjunctiva, which often occur during a fit, and of the hemorrhage into the substance or upon the surface of the brain, which happily is a much less frequent accident.

A number of facts point to the conclusion, that both the loss of consciousness and the convulsions of epilepsy are the result of sudden and extreme anæmia of the brain.

In man, and in most, if not in all, warm-blooded animals, a rapid and very copious hemorrhage usually causes convulsions. Kussmaul and Tenner state (On Epileptic Convulsions from Hemorrhage, New Sydenham Society, 1859), that, in numerous cases of dogs, cats, and rabbits, they observed, without a single exception, violent and general convulsions preceding death from loss of blood. In order to produce this result, the hemorrhage must be rapid. If it occurs slowly, so that the vital powers are gradually consumed, death then occurs with swooning, drowsiness, and delirium, without convulsions.

The same observers found that an interruption in the supply of blood to the head of a rabbit, by ligature or compression of the arteries, produces epileptic fits as surely as hemorrhage does. In about one hundred rabbits, they ligatured or compressed the carotids and subclavians, from which, be it remembered, the vertebrals proceed, and in every instance except that of one very old, lean, and feeble rabbit, convulsions occurred. In order to produce convulsions, it was necessary to close all the four arteries which supply the brain. If but one carotid or one subclavian remained pervious, the animal was enfeebled and more or less paralysed, but not convulsed. And again, if during the height of a convulsion, the ligature is removed from one carotid, the convulsions generally cease immediately, and there is

of the spine disappeared. The pupils also contracted, and the pulse sank to 82. The effects lasted between two and three hours, and all the symptoms then reappeared. Beef tea and brandy enemata were ordered to be used every four hours.

October 7th. The vomiting had been less frequent, but had not entirely ceased. Every subcutaneous injection, which had been given regularly every three hours during the night, had been followed by an almost complete remission of the symptoms, lasting for about two hours. In the evening, each dose was increased to half a grain.

October 8th. He passed a restless night, though he had not been in so much pain, and had for the first time been able to dispense with the aid of the catheter. Vomiting had ceased; and several eggs had been taken, beaten up with wine. The beef-tea and brandy enemata were therefore omitted. Eggs ad libitum, and a bottle of sherry daily were ordered. The dose of extract of Calabar bean was increased to three-fourths of a grain in each injection, to be given at intervals of two hours only, or as soon as the effect of the previous injection had passed off.

October 9th. The injections had been continued every two hours, and their influence in preventing the muscular rigidity and spasms remained unabated; the only muscles not perfectly relaxed were those of the abdomen and back. The pupils were much contracted, and the patient had been at times very delirious. He continued to take plenty of nourishment. The urine contained a large quantity of phosphates. As the injections occasioned much pain and inflammation in the cellular tissue, and the solution was found to be acid, a few drops of liquor potassa were added to it. The solution thus obtained was more perfect, and produced less pain.

October 10th. During the night, as the patient was very delirious, and the pulse had risen to 148-effects supposed to depend on an over-dose of the medicine the injections were stopped for seven hours. This morning the muscles were as rigid as ever; and the paroxysms, which had almost ceased, again increased in frequency. The injection was ordered to be continued as before. In the evening, the pulse had fallen to 125; but the injections had been required every two hours, the effect not lasting so long as previously.

October 11th. The dose was increased to one grain at similar intervals. October 12th. One-third of a grain of morphia was ordered to be injected subcutaneously every night with that of Calabar bean; as the latter, notwithstanding its influence in subduing the spasms and rigidity of the muscles, did not secure sleep, and the night had been restless and disturbed.

October 13th. He slept well all night after the morphia injection was given; and this morning there was a marked improvement. The pulse 94; the countenance flaccid, and not expressive of suffering; the muscular rigidity less; and paroxysms infrequent. He took twelve eggs and two bottles of sherry in twenty-four hours.

October 15th. As the skin was becoming tender from the numerous injections, and the severity of the disease was evidently subsiding, they were omitted, and suppositories containing a grain and a quarter of extract of Calabar bean were ordered to be applied every two hours; the morphia to be continued every night.

From this time, the patient gradually improved, the suppositories acting very favourably; but it was not until November 1st that all the rigidity of the muscles had finally and permanently disappeared, and convalescence was established. Up to this time, the suppositories had been continued, though at gradully increasing intervals. A few small subcutaneous abscesses formed at the sites of some of the injections, but they gave little trouble; and he was discharged well on November 30th.

Remarks. The result of this case-which, though not, perhaps, of the acutest type, was one of very great severity-shows that the plan of treatment adopted is deserving of a more extended trial; for, though the Calabar bean does not appear to exercise any direct curative action in the sense of cutting short the disease, it is impossible to doubt its influence in controlling the more urgent and dangerous symptoms. The superior advantages of the

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