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mencing the treatment before the doctor comes; and if sufficient promptitude be used, the disease will be strangled in its birth. I have had some striking instances of this in my own practice. I had a valued servant who had some severe attacks before I knew her. She complained one morning to her mistress that she felt premonitory symptoms. I at once sent her to bed and put her upon routine treatment. She had every symptom of the fully developed disease except the joint swelling and pain. Her perspiration was so acid that, although the ventilation was right, it was perceptible to the nose a flight of stairs from her room. In three days she was about her work again. I make it a rule to give into my patients' hands the alkaline prescription, and impress upon them the importance of commencing with it immediately they recognize the symptoms. In three or four other cases I know the disease has thus been nipped in the bud, and severe illness averted. I firmly believe the key to the puzzle why in some hands alkalies fail is, that the doses are too small and time is lost. Small doses are useless. This large amount of alkali does, I think, tend to blood impairment; but full doses of the ammonio-citrate of iron soon restore the red particles. The ammonio citrate is, in most cases (where astringency is not wanted) the best iron-salt we have.

I rarely, if ever, prescribe any other form of blister except the liquid preparation. It has every advantage over other forms: notably, it never fails to rise over the exact area you desire. Early blisters control joint mischief, but under full alkaline treatment they are not wanted; and it should be remembered that the amount of pain a blister gives-ab initio usque ad finem -is not insignificant, and where movement is already synonymous with agouy they needlessly add to it.

Another remark I desire to make, and that is the relapse, which is a specific feature, and a very ugly one, in this disease, is often in defiance of all the care that may be taken. Does full alkaline treatment predispose to this? I cannot say; but this I know, that in relapse the alkaline treatment is of greatly diminished value. The helm is either answered very much more slowly or not at all. I have now such a case under my care; and I find that the immediate application of a band of liquid blister, about the size of a French (green) bean, two inches above the joint, is then of great value. Directly the patient feels the least joint pain, he himself paints on the blister. In such cases there is generally a much lower and more chronic inflammatory action, and the liquid blister, with iron and iodide of potassium, gives slow but satisfactory results.-Lancet, May 1, 1869, p. 598.

119.-CASE OF TETANUS TREATED BY BROMIDE OF
POTASSIUM.

By ROBERT BROWN, Esq., Carlisle.

[The patient was a boy 12 years of age. About the end of September suppuration commenced around the root of the thumb nail, and terminated in the death and removal of the nail. On October 4th he fell asleep on the grass, and awoke stiff and chilly. There was slight stiffness of the neck next day, and on October 8th there was rigidity of the spine and stiffness of the jaws.] When admitted, two men carried him, perfectly rigid and bent, by the shoulders and lower extremities, from the cab to the ward.

State on admission. He complains of stiffness in the back, neck, and jaws; of pain in the neck, especially along the course of the sterno-mastoid muscles, and of great thirst. The sterno-mastoids, together with the muscles of the back and abdominal recti, are very tense. He can move his jaws apart about of an inch. During a paroxysm of pain and spasm, one of which occurred shortly after admission, he cried loudly, rested on his occiput and heels, and his countenance distinctly presented the "risus sardonicus." Pulse 112, irregular. Skin hot and dry. Bowels inactive. Ordered injection of warm water. To have milk, beef-tea, arrow-root. Potass. bromid. gr. xx. every second hour.

13th October, vesp. Last night the bowels were freely moved; he slept little, but was quiet and easy. Has taken liquid nourishment freely. Paroxysms have been frequent and painful during the night; to-day they have occurred very often since 5 p.m. The boy perspires freely; can move his jaws apart fully of an inch. Pulse irregular, and so feeble that the beats cannot be accurately counted. Urine normal in quantity and quality. Potass bromid. gr. xx. every hour.

15th, vesp. Patient during the early part of last two nights has suffered from severe paroxysms, occurring on an average four in the hour, and accompanied with a sense of choking, but after 1 a. m. he has become easier, and has slept a good deal. Since 5 p.m. to-day, paroxysms have occurred on an average 3 to 6 during the hour, though before that time he had been free from them, and had slept for three hours, being awakened however, to take his medicine, &c. Pulse 78, stronger, but still irregular. He perspires freely. Bowels acted after an injection for first time since night of admis

sion.

16th. Patient slept well during the night till 3 a m., when a paroxysm seized him, and almost threw him out of bed-such was its severity; it caused intense pain, and a wound of the tongue, by the sudden snapping together of his jaws. This morning he has taken milk and arrowroot for breakfast: lies quite easy, and perfectly freely free from pain, often dosing in sleep, with his mouth open fully an inch. He had to-day fifteen paroxysms in twelve hours. Tongue thickly coated with white fur. Breath foetid. Bowels inactive.

17th. Last night at 1.30 a.m., the house-surgeon was summoned by the nurse, and found the boy convulsed in a violent paroxysm. His arms were violently contracted, the sardonic grin well marked; opisthotonos extreme; breathing hurried and laboured; blood and saliva streaming from the mouth; tongue bitten in two places; face livid. The paroxysm lasted for three minutes, and subsequently he lay for half-an-hour exhausted and prostrate. This morning he is easy, and sleeps hour after hour. Ordered injection. Hydrarg. subchlor.. gr. ii.; pulv. rhei, gr. vi. M. et. ft. pulv.

18th. Patient had two violent and a few slight paroxysms during the night. Bowels acted twice. Pulse 84-89, weak. Ordered sherry 3ss every fourth

hour.

Vesp. During the day has had twenty-four paroxysms in twelve hours. 21st. Patient has passed easy nights, and slept well since last report. Yesterday he slept nearly the whole day, being awakened every hour to take medicine. During the night there occurred fifteen paroxysms in four hours. To-day he thinks the stiffness in the neck is disappearing. Potass. brom. every second hour. Sherry 3x. daily.

24th, vesp. The boy has progressed rapidly and favourably since the 21st. Has slept a great deal, and perspired freely, odour of sweat being fœtid. Today he has been restless, and has suffered from three paroxysms in six hours, though he was free from them in the morning. Pulse 86, regular. Ordered an injection of warm water, which brought away a large, dark, fœtid stool.

26th. Progress very satisfactory till 3 a.m. (this morning), when he became restless, and suffered from paroxysms frequently, on an average three an hour. This morning he looks haggard, and, during the spasmodic attacks, the sardonic grin, the opisthotonos, with the clenching of the jaws, and contractions of the arms, and pain in the neck are as well marked as on the 18th and 19th, when he took the paroxysms most frequently. Pulse feeble and irregular. Ordered whisky zii. R. Potass. bromid. gr. xx. every hour. Ordered sherry, 3 vi.

27th. Has become much easier, suffers less pain during a spasm, and sleeps hour after hour, save when he has to take his stimulants, fluid nutriment, or medicine which he does with avidity.

2 p.m. The house-surgeon was summoned by the boy's screams, and fund him almost out of bed in a violent paroxysm-the nurse had left the war i for a moment. Ordered an enema.

1st November. Since the last paroxysm recorded, the boy has only had

four, which occurred on the 29th. Improvement rapid. He sleeps well, and eats voraciously. Pulse 96, weak.

Vesp. To-day he has had three paroxysms, one of which took place after an ineffectual attempt to sit up in bed.

6th. Has had no paroxysm since last report, when he began to take the bromide every second hour. Pulse 90. Improves daily. He still wears the facial grin, and complains of pain along the course of the sterno-mastoids, especially when he moves his head. Bewels acted freely. R. Potass. brom. gr. xx. every third hour.

10th. The boy improves rapidly, and without relapse. For the last two days he has been out of bed, and sitting on a chair; if he attempts to walk, he stumps along on his heels. Has still a broad grin, and stiffness in back and legs. His articulation is imperfect, owing to the rigid muscles. To discontinue whisky. Diet common; eggs ii. Sherry vi. Ę. Potass. bromid. gr. xx. ter in die.

25th. In a very satisfactory state.

2nd December. Discharged cured-Edinburgh Med. Journal, May, 1869, p. 993.

120.-CASE OF TRAUMATIC TETANUS; RECOVERY UNDER THE USE OF THE CALABAR BEAN.

By ALEXANDER J. MacArthur, Anstruther.

[The patient was a man aged 24, whose symptoms seemed to be excited by exposure to cold following the receipt of a punctured wound in the hand.] On visiting him I found, on examination, that he had increased pain along the margins of the ribs, and also a feeling of stiffness in the neck and jaws, which I recognised as being the commencement of tetanus, and feared that he would fall a victim to that disease. He was ordered to bed, and to have one-eighth of a grain of the extract of Calabar bean; but as the druggist here had none of it--owing, as he said, to its being a remedy never inquired for two days elapsed before it could be obtained from Edinburgh. In the meantime, I prescribed 8 grains of the ext. of conium every 2 hours, which dose, as it had no apparent effect, was doubled on the following day; and he was also ordered hydrarg. subchlorid. ii. grs., pulv. jalap xx. grs., which acted freely on the bowels. On the 4th of January, the day the Calabar bean arrived, the symptoms of tetanus were fully developed, and his condition was a very painful one. The appearance of his countenance was remarkable, from the lip being dragged into a kind of grin; his voice had a guttural sound, and it was difficult to make out what he said, as he had no power of articulation, from the lips and lower jaw being fixed. He complained of constant pain in the breast along the margin of the cartilages of the ribs, and in the back, about the lower dorsal vertebræ. There was not much arching of the back at this time; but on touching the part where he complained of pain, he was immediately thrown into a state of rigid spasm, with the back much bent backwards; this condition subsided in a few seconds. The abdominal muscles felt very tight, and he had pains in the groins and legs. His whole body was quite rigid, so that it was impossible for him to sit up in bed. He had lividity of the face, lips, and tongue, difficulty of breathing, and a short spasmodic cough, giving him great pain in the breast and back. The heart's sounds were normal; the pulse 88. His jaws were capable of being separated during the short intervals of spasm about a quarter of an inch, and he could only protrude the tip of his tongue. He begged of me to give him something to ease his breast and back, and, as he felt hungry and could not eat, he was very anxious to have something to appease his appetite. He was ordered milk, egg-flip, and arrowroot. He felt, on attempting to swallow anything, as if he would choke; for as soon as the fluid came to the pharynx a spasmodic action was set up which forced it back, and only very small quantities could be got over his throat at a time. He was now to have one-eighth of a grain of the extract of Calabar bean every hour.

6th January. Symptoms the same as at last report, with the exception that the pulse was 80, soft, and he said he felt a little easier in about a quarter of an hour after each dose of the medicine, at which times he could swallow a little better. I ordered the dose to be increased to one-sixth of a grain every hour.

7th. Complained very much of the frequent spasms, which occurred every three or four minutes, and had increased pain over the shoulders and in the legs; pulse 84, soft. To have one-fourth of a grain of extract every hour. In the evening the pulse was 120.

8th. The tongue which was loaded with a thick fur, could be protruded about a quarter of an inch; it was bitten on the edge by the teeth, owing to the sudden spasmodic closure of the jaw; the back was very much arched, and perspiration was profuse. He had great thirst, and a gurgling sound from the throat, arising out of a collection of stringy mucus, which at 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 he was thought dying, and on my arrival at the bedside I found him quite insensible, foaming at the mouth, breathing laboured and stertorous, pulse alınost 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 mucous râles in the larger bronchi.

20th. During last night he had his first sound sleep since the commence

ment 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 subsi ded to its natural state in a few seconds. Bean to be taken in quarter-grain 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 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 systern, 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 are always present." In this case of tetanus, thirst and accumulation of stringy mucus in the fauces were present in a marked degree, and it was a frequent question made to me by the patient what he 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.

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