the complaint. When I say this I speak with some little hesitation of the effects of belladonna and conium, both of which remedies I have seen apparently useful. I remember when at Paris some years ago hearing Trousseau give a lecture on this disease and warmly recommend belladonna. On another occasion he was declaring that there was no drug in the Pharmacopoeia equal to strong coffee, and on a third occasion he was vaunting the new gymnasium at the Hospital for Sick Children as the best therapeutic agent he knew. I mention this to show you that there really is no specific treatment for the disease. I might say that we thought we saw some benefit in one case after the use of cannabis indica, but none whatever in four cases in which we tried the physostigma.

I believe I can tell you something very positive about the treatment of chorea, and I only wish I was enabled to make the same boast in reference to some other diseases. Many years ago, seeing that every medicine in the Pharmacopoeia as well as several others out of it, were said to be equal to the cure of chorea, I determined to watch the disease untrammelled by medicine, and I found that in many cases a speedy recovery took place without the administration of any medicine whatever. The cases which did best were the severe ones, excepting always those which were of the most violent and acute description. The first case which I watched was a little girl who had severe chorea; she was too bad to be able to stand, and was obliged to have sideboards to her bed to prevent her wriggling out of it. This child began to improve in a day or two, and went out well in a month. This is only one example of several of the same kind. I take it that the patient, being subject to constant excitement or improper treatment at her own home, has her disease there perpetuated, whereas when brought to the hospital, being under the influence of strangers who endeavour to make her suppress the movements, and by the additional advantage of good living, she begins to recover. I should say that a weakened condition of the nervous centres being at the root of the malady, good nourishment and the tonic plan are necessary. After having learned the fact that the tendency of the disease is towards recovery as soon as all the circumstances which formerly surrounded the pa tient were removed, I soon afterwards learned that the cure is expedited by tonic medicines of the mineral kind, and this is the experience of the majority of the profession. I have put the treatment before you in this way to prevent you supposing that such remedies as iron or zinc act in any specific manner; they are useful, but operate as nervine tonics. I believe Dr. Elliotson many years ago acquired great fame by his success in the treatment of chorea, his remedy, as you know, being the red oxide of iron. We still give it, and it is one of the best of remedies; our children very willingly take half-drachm doses in treacle. Probably an equally favourite remedy here is the zinc-in fact, it is the medicine most commonly given, beginning with grain doses, and increasing to any amount, as a scruple three times daily. A favourite remedy of my late colleague Dr. Hughes was rhubarb steeped in port wine; the children were thus well kept up at the same time that the stomach and bowels were improved in condition.

One

In very chronic cases, and those where a part of the body only is affected, medicines are of little use. In some of these electricity has sometimes been curative; in some cases shower-baths have acted with the best success. writer has advocated the use of liniments, as of chloroform, to the spine. Often nothing less than a thorough change of scene will suffice to break the habit. If this opportunity do not occur, gymnastic exercises are of use. They not only strengthen the muscles and nerves, but they break the bad habit; they convert in fact, an irregular movement into a regular one. If the arms are constantly moving, and are then employed in grasping a beam for swinging, a new and altered condition of the whole machinery accrues, and in time the habitual irregular actions are worn out. I am sorry that we have not a gymnasium here, and therefore all I am able to do is to order my patients a skipping rope. I believe the only method by which the chorea, which at one time prevailed in religious houses, was sometimes able to be cured was by LIX.--5

making the ladies dance to the notes of music.-Medical Times and Gazette, Feb. 6, 1869, p. 136.

24. ON THE USE OF INDIAN HEMP IN CHOREA.

By Dr. DOUGLAS, Vice-President of the Medico-Chirurgical Society of Edinburgh. Dr. Russell Reynolds, who writes one of the most recent, and one of the best expositions of the value of this remedy, tells us, as the result of a manifestly practical and thoughtful experience, that "it is a soporific, anodyne, and antispasmodic; and that it relieves pain and spasm; that it does not leave behind it headache nor vertigo; nor does it impair the appetite, nor confine the bowels."

[The patient, a girl 13 years of age, was admitted into the Chalmers Hospital on the 15th of October last. A month previous to admission she had been taken with an attack of rheumatic fever. No symptoms of cardiac inflammation occurred. The choreal action had existed about a fortnight.]

During the day immediately succeeding her admission, a rapid change occurred in the degree of the choreal movements, and in the state of the heart's action. The latter became so disturbed, feeble, and excited, with feeble arterial pulse, as to cause serious anxiety for the safety of the patient, and at the same time the choreic agitation increased with such violent restlessness and rolling in bed that excoriation occurred over the sacrum and both nates, while contortion of the features and tossing of the extremities, especially when their movement was attempted, continued excessive. The articular effects of rheumatism decreased, temperature became more natural, the urine healthy, but the bowels became torpid. The arsenic was persevered with, and a few 30-grain doses of bromide of potassium were given. Each dose was followed by a short period of quiescence, but, on the 20th, the excitement of the heart's action became so alarming that 25-minim doses of tincture of Indian hemp were administered, followed by apparently marked, but only transient abatement of the spasmodic movement, which, as Dr. Hogg, the resident physician, reported, seemed to recur subsequently with increasing and distressing severity.

On the following day-that is, the sixth of her residence in the hospitalher condition seemed desperate, chiefly on account of the protracted and uncontrollable hurry of the heart's action. She was ordered to have six minims of the tinct. cannabis every hour, the arsenic and other remedies being intermitted. The bowels were now well regulated, the excoriations of the back and nates had increased so as to form superficial sloughs of considerable extent, the pulse was small and so rapid as not to be counted, and the heart's action was still feeble, rapid, and disturbed. She had four ounces of brandy per day. On the following day, having had twenty doses of the tincture, there was marked and increasing improvement. The violence of the tossing and rolling had dininished materially, though still it was necessary to have her secured in bed to prevent her falling or rolling over. From this time till the 15th day of her residence in the hospital, the tincture was administered from hour to hour, and she continued to make daily and progressive improvement. At that date (the 28th) she had been free of all the more violent spasmodic movements for two days; the heart's action was quiet, pulse about 80, appetite good, bowels regular. She still presented a degree of the peculiar grimace, with awkwardness in protruding the tongue, and in movement of the arms and hands. There was great mental lethargy, with languor and exhaustion, which made it impossible for her to be out of bed.

The tincture of hemp was now discontinued, and arsenical solution in four minim doses resumed.

The subsequent progress of the case, though tedious, and so far disappointing, may be told in a few sentences. On the 1st of November, and on several occasions during the rest of that month, there occurred a renewal of the choreal state, which had not indeed absolutely disappeared, though it

was often so trivial, and even absent as to encourage the hope of an early recovery. Arsenic was perseveringly employed, with a carefully-regulated diet and general management, but on each occasion, of which three were noted, when an exacerbation of the choreic condition arose, a marked abatement of the muscular action resulted from the administration of small and hourly repeated doses of tincture of hemp, relief sometimes arising so speedily as within six or eight hours. On one occasion the improvement was not detected for three or four days.

In the beginning of December, rheumatic symptoms recurred with slight febrile action and articular pains and renewal of choreic agitation. At the same time, marked excitement of the heart's action was renewed, and now, for the first time, a faint soft diastolic murmur, indicative of aortic regurgitation, was with difficulty perceived. A weak solution of acetate and nitrate of potash was administered, and grain doses of opium four or five times in twenty-four hours. Pain and fever abated, but not the spasmodic movement, and on the third day afterwards six-minim doses of tincture of hemp were given every two hours, followed by an immediate decrease of the chorea, which at once declined to the slightest degree in two or three days.

The patient now presented more marked indications of returning health. The state of mental lethargy into which she had early lapsed was now passing off; her appetite was revived, and on the 20th December she was able to be out of bed and to walk with assistance. Small doses of the iodide of potassium with the infusion of quassia were given, and improvement went on uninterruptedly; she did not, however, cast off the choreic jerk and awkwardness till the second week of January, 1869. She has since had a very comfortable convalescence, but the diastolic murmur noted above continues strongly developed.

The impression which the case leaves on my mind is, that cannabis has a peculiar value and power in controlling the irregular movements of chorea, which ever and again are terribly distressing, and possibly even dangerous, to the patient; and it would be of no small moment to determine the extent and limit of its influence, and to ascertain whether or not choreic action, even in slighter cases, might not be moderated by this remedy.

As to the mode of administering the remedy, small and frequent doses proved both safe and effective, and great advantage appeared to arise from increasing the frequency of the dose rather than its amount. Believing, as I do, that cannabis indica is a remedial agent of value in many and various maladies, I am prepared to recommend this mode of seeking its effects by frequent rather than by larger doses at longer intervals. Such a mode of prescribing it has not been usual; but I find, quoted from an American source, the account of a case of hiccup treated in this way by eight-drop doses of a fluid extract, administered hour by hour, in which recovery from an attack that had defied treatment for five days took place in a few hours.-Edinburgh Medical Journal, March 1869, p. 777.

25. THE CALABAR BEAN IN ACUTE TRAUMATIC TETANUS AND STRYCHNIA POISONING.

By WILLIAM ALEXANDER, Esq., Dundonald, Ayrshire.

[The first of the two cases mentioned in the following article was a boy eleven years of age, in whom symptoms of tetanus appeared eighteen days after a wound of the hand by a chaff-cutting machine. Next day the report is:]

August 6th, noon. Opens mouth better, but with an effort. Tongue very brown. Marked opisthotonos, with frequent spasms, involving the entire body. Spasms excited on touching him or approaching his bedside. Cannot move himself in bed. Powders have operated once. Has had four doses Indian hemp. Pulse 130. To begin now with the following:

B. Ext. physostigmat. venenos. grs. viij.; sp. vin. rect. 3ss.; syrup. simp. 3ij.; aq. fontan. 3iss. M. solve.

A teaspoonful to be taken in water every hour. To have beef tea and milk for diet.

8 p.m. Much in the same state. No more action from bowels. Head very much retracted. Back extremely bent. Abdomen flat and tense. Frequent spasms. Pulse 130. Repeat the purgative powders.

The

7th, 8 a.m. Slept sound during the night, vomited occasionally. spasms and opisthotonos continue, but have not increased in severity. Has had sixteen doses of the extract since noon yesterday, the last about an hour and a half ago. Pupils slightly contracted. Opens mouth better, and puts out tongue, which is still very brown. Pulse 110, soft. No action from bowels.

8 p.m. Had his extract every hour and a half up to one p.m., since which he has only had two doses. The contracted pupils, and jerking pulse at midday caused me to lengthen the interval between the doses. Opisthotonos with spasms continue. Pulse 90, soft. Breathing, calin, easy. No action from bowels since yesterday morning at eight o'clock. Had senna infusion to-day at four p.m., of which he vomited a part. Gave an enema of soap and water, which acted freely.

8th, 9 a.m. The spasms with opisthotonos were very severe after I left him last night. His father, who watched him most faithfully, had instructions to give the extract every hour, if necessary, and having done so, the boy was much relieved by midnight, and now continues so, though the spasms and opisthotonos are still present. Since one o'clock this morning he has slept for nearly two hours. Opens mouth much better, and puts out tongue well. Tongue very brown. Abdominal muscles relaxed. Pulse 96, soft and rather weak. To have sherry to-day, as he felt weak when his bowels were moved twice during the night. Stools very dark and foetid. Finished his first bottle of the extract in solution about an hour ago, having thus taken eight grains of the extract in forty-five hours.

[During the rest of this day and the next the extract was given every hour, except when asleep. On the evening of the ninth an attempt made to give his extract at longer intervals was followed by a recurrence of the spasms and opisthotonos. By the 11th of August he seemed improving, but losing strength somewhat. He continued varying from day to day, the Calabar bean being given as before. Recovery ensued.]

The boy was most carefully watched by the parents, who had a discretionary power given them to lengthen the interval between the doses when the symptoms warranted them to do so; but in the various attempts they made it was invariably found necessary to resume its use every hour, or every hour and a half. In these circumstances, although the case might be looked upon as cured on the 19th, still I thought it advisable to keep up the action of the Calabar bean for some time longer, lest the spasms should return, and the treatment be prolonged. Although the spasms and opisthotonos were in this case severe enough, yet they never reached that degree of suffering which I have witnessed in former cases, all of which terminated fatally. Nevertheless, I look upon it as a case of acute traumatic tetanus, taken in the incipient stage of the disease, and so thoroughly controlled by the action of the bean, that the more violent symptoms could not manifest themselves. I have every confidence in the action of the bean for relieving the spasms, even though it may not be always successful in curing a case.

In August of this year another case of traumatic tetanus came under my care, and was treated in the same way with a like favourable result.

G. B., aged 12 years, August 6th, had slight trismus, with inability to project his tongue. Complains of pain in each side of throat and over dorsal spine, not aggravated by pressure or percussion, and also of uneasiness at junction of upper with middle third of sternum on left side. On walking, his gait is unsteady, and, on turning round, he is observed to stagger, a thrill, as it were, passing through the body at the same time. Face has nothing of the tetanic appearance, and yet the expression is not natural; he looks as if he

were about to cry, and does so when questions are put to him. Pulse 66, tongue slightly coated. Has a very small cicatrized incised wound, a quarter of an inch in length, in point of right thumb, and a small punctured wound in sole of left foot, neither of which have been of any depth. No other injury is apparent or admitted, except that, in play, with other boys, he was rolled over by one of them, and has felt the pain in left side of sternum ever since. About three weeks ago, during the very hot weather, he suddenly became giddy, sick, and faintish, and was supposed by his parents to have a threatening of sunstroke, but had no treatment. Ordered him an active aperient, and to await the development of other symptoms.

August 7th. More evidence of tetanus setting in. Slight spasms, involving limbs, with more rigidity of jaw. Medicine has acted well. Stools brown, pulse 66. Repeat the purgative powder. Ordered the following:

R. Ext. physostigmat. venenos. grs. viij.; sp. vin. rect., 3 ss.; tinct. valerian., 3i.; syrup. simp., 3i; aquæ, iss. M. Solve.

A teaspoonful every two hours.

8th, 9 a.m. Having vomited the first spoonful of the extract, and the symptoms being slight, only half the quantity was given, and at long intervals during the night; but this morning the spasms are more frequent and severe. Belly tense and hard. Pulse 78, soft. Ordered the teaspoonful every hour, with discretionary power to allow a longer interval between the doses if necessary.

9th, 10 a.m. Had a teaspoonful of the extract every hour yesterday till four p.m., when he slept for five hours, and on awaking with a spasm, got it every hour during night. Slept none during night. Complains occasionally of the pain in cervical, but more commonly in dorsal region. Has pain now in epigastrium. Trismus continues, and spasms come on every hour causing him to cry out with the pain. Abdomen very flat and tense. Bowels opened twice; stools very dark and offensive. Pulse 78, soft. Breathing easy. Vomited several times during night, as often after his food as his medicine. Cannot now lie in bed, but sits in semi-erect position, propped up with pillows, head bent forward-emprosthotonos. Continue the extract every hour, and give purgative powder at night.

11th, 10a.m. Has gone on in the same way, the spasms with pain in back and epigastrium, recurring every hour, till this morning at one o'clock, when his attendant became afraid to give the extract so frequently, and the spasms have since increased in severity and number, the cries of the boy during the spasms being painful to listen to. Ordered ice bags to spine, and to have the extract every hour, with the purgative at night.

[We omit the reports of the case until Sept. 8th.]

8th, noon. Been free from spasms since the 3rd instant, and had none of the extract since the morning of the 6th till last night at twelve o'clock, and again this morning at 8.25, having on these two occasions complained of pain in dorsal region, with slight spasms, probably the result of over-exertion or fatigue, as he has been out of bed daily since the 3rd, and on the 6th sat up all day and exerted himself more than he had done. Is at present free from pain. Slight bending forward of dorsal vertebræ is visible when he sits or stands. Walks with a stiffness at hip and ankle-joint, but able to go out of doors to-day, leaning on an arm. Tongue clean. Pulse 72. Bowels regular; stool natural. Belly fuller.

13th. Is now quite well.-Glasgow Medical Journal, Nov. 1863, p. 41.

26.-CASE OF TETANUS, WITH REMARKS.

By Dr. E. WATSON, Professor of Physiology, Anderson's University, and Surgeon to the Royal Infirmary, Glasgow.

On the 26th of June, 1868, I was asked by Dr. Fergus to see a patient of his who was affected with tetanus. I found that the disease had been coming on for some days, and that its cause was very obscure. The patient was a