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22nd. Has had a somewhat better night, without any severe paroxysm; but the body is still perfectly rigid, and the pain is as severe in the thighs; less perspiration; pulse, sixty. Tinct. aconiti, TT|,viij 2ndis horis.
23rd. Remains much the same, but his appearance is better; to have a turpentine enema, and to take Fleming's tincture of aconite, T\[vs every two hours, as before.
24th. The pain in thighs continues so severe that an enema containing ff[x of tinct. aconiti was ordered, but it did not relieve him. In other respects he is doing well. He has lost the active spasms, but the chronic rigidity is as great; pulse, sixty; has no sensations of pricking in the hands, or any unusual feelings in the body generally. An ointment pf one part of ext. belladonna and two of opium was ordered to be rubbed into the thighs, and this gave him some relief.?
From this time the improvement was progressive, the countenance becoming more natural, and the pain and anxiety diminishing. The pulse remained steadily at from sixty to sixty-five, but he had no symptom indicative of the large quantity of aconite he was taking. On the 27th the medicine was given every four hours only; on the 28th he could open the mouth a little; the aconite was given every six hours, and on the 29th three times a-day. He continued to take the medicine to this extent till the 4th of October, when it was left off altogether. At this time he could feed himself and move his limbs freely; the pain had entirely left him; the abdominal muscles were still tense; the countenance natural. A little hardness about the abdomen remained for some timo longer, and it was not till about the 10th that he could open his mouth freely. He was kept in the hospital till the 2nd of November, and was discharged in perfect health.
There are some points connected with the treatment in this case which seem to me worthy of special remark. The disease did not show itself in a severe form. The symptoms set in gradually, and some days elapsed, after the stiffness in the neck was first felt, before any active spasm appeared. The severity of some of the paroxysms may possibly be attributable to the strychnine. Altogether the case may perhaps be regarded as a favourable one from the beginning, though experience teaches us that even the mild and protracted cases are too frequently fatal. It must be remembered, also, that the past year has been remarkable for the number of recorded cases of recovery from traumatic tetanus. Within ten weeks previous to the occurrence of the attack now recorded, no less than three cases of recovery were published in the 'Medical Times and Gazette;' one under the care of Mr. Cock and Dr. Wilks at Guy's Hospital, in which the cannabis indica was given; one at St. Thomas's under Mr. Simon, in which nicotine was largely used; and one at the London, which Mr. Curling treated with ether inhalation, and opium.
Admitting that the greatest care must in every instance be taken to guard against that common and natural error of attributing to treatment the credit of a favourable termination which nature alone might have achieved, and that there are few modes of practice which have not, at one time or another, been followed by recovery, there appear to me sufficient grounds for believing that in the present instance aconite did exercise a control over the disease. Before considering this question, however, it may be well to advert to the effect of the strychnine. In the American journals there are records of several cases of traumatic tetanus which had been apparently cured by this powerful medicine, and I had determined on the first opportunity to test its efficacy. The dose in which the strychnine was given was sufficient to induce speedily the muscular contractions characteristic of the poison. Thes spasmodic twitchings of the hands and arms, which are rarely present save in the severest forms of tetanus were frequent, especially on the patient's awakening from the short dozes into which he fell from time to time. Possibly, too, the severer and nearly fatal paroxysms which occurred at thia period might be partly due to the strychnine. But, so far as could be observed, the effects upon the disease, which are stated in the American cases to have taken place upon the establishment of the symptoms of strychnine poisoning, were not present. There certainly was no remission of the tetanic symptoms after those produced by the medicine had passed off. On the contrary, the disease appeared to be increasing in violence, and I therefore gave up this mode of treatment and resumed the use of the aconite. My colleague, Dr. Goodfellow, called my attention to a case which he had seen, and which is related in the 'Lancet' for 1846, where the effects of aconite were very marked. The patient was under the care of Mr. Page in the Carlisle Infirmary. The disease was caused by the irritation of a gun-shot wound of the fore-arm, and the symptoms, which increased rapidly after their first appearance, were severe. On the third day after the stiffness in the jaw had been noticed, Mr. Page began the use of Fleming's tincture of aconite, and it was continued for thirty days in greater or less quantity according to the recurrence of the symptoms, which for the last fortnight were of a very mild character, and were only severe for the first six days after the medicine was given. But it is remarkable that on all occasions the symptoms were subdued after the aconite had been fairly given. For example, on the day on which the tincture was first given "the tetanic spasms were constant and severe; the muscles of the abdomen were rigid and unyielding, and those of the inferior extremity were so stiff as to render it very difficult to flex the limbs. At noon, a turpentine injection having been first administered, three minims of the tincture of aconite (Fleming's) were given, the effect of which became very speedily manifest, and in half an hour there was an almost total remission of the muscular spasm. Three P.m.—The pain and spasms having again returned with increased intensity, producing a slight degree* of opisthotonos, four minims of the tincture were administered, which produced the same speedy and marked effects as the former dose. Six P.m.—The patient has been comparatively easy since the last dose, but there is now an evident disposition to relapse. Four minims to be given immediately, and to be repeated every hour until some decided effect is produced, the patient, of course, being carefully watched, in order that the remedial measures may be adopted should symptoms of poisoning become apparent. Ten P.m.— Three doses have been given—in all nineteen minims between twelve and eight o'clock; at present there is a complete cessation of the pain as spasms, which, however, did not yield until after the third dose had been taken. The system is now evidently under the influence of the aconite." And so during the continuance of the disease, though at times bo was alarmingly affected by the medicine, the severe tetanic symptoms were constantly subdued.
In the present case, as in that related by Mr. Page, the questions may fairly be raised, whether the disease really yielded to the aconite, or whether a recovery would not have taken place under any other recognised plan, or even without treatment at all? Of course no answer can be given to the latter suggestions; but there are, I think, strong grounds for believing that the aconite was in this case the efficient agent. Dr. Fleming has described accurately and minutely the physiological effects of this poison on the system, and his statements have been corroborated by all subsequent observers. I frequently use the ordinary tincture in doses of from four to eight minims three times a day, and with this quantity the peculiar effects of the aconite usually manifest themselves speedily. Dr. Fleming says, that after a five minim dose* has been given there is a feeling of warmth, first in the stomach, then over the body, with numbness, tingling, and a sense of distention of the lips and tongue. There is a sense of tingliug also at the tips of the fingers; slight muscular weakness, with indisposition for exertion, mental or bodily; weakness of pulse; and diminished frequency of pulse and respiration are also observed. If a second dose of five minims be given two hours after, the tingling extends along the arms, and the sensibility of the surface is impaired; the pulse becomes still lower and less frequent. There is great muscular debility, with giddiness and confusion of sight, and the person sinks into a lethargic condition, evinces great disinclination to be disturbed, although he rarely falls asleep, and complains much of chilliness, particularly in the extremities, which are cold to the touch. . On the administration of five minims more, two hours after the last dose, these symptoms are greatly increased —lancinating pains in the joints are felt occasionally, headache, vertigo, and dimness of vision more marked. The pulse sometimes falls very low, but more frequently rises to seventy or eighty, and becomes small, weak, and probably irregular. The surface is moist and stiil more reduced in temperature. Sickness may now come on. Beyond
* Br. Fleming's tincture la more than twice as strong as that of the London Pharmacopoeia. (See Fleming on Aconite. London, 1848.)
this the experiment is attended with great risk. Many other symptoms are at times produced; and Dr. Christison has mentioned griping and diarrhoea as occasionally present. In some cases, too, Dr. Fleming has noticed that great insensibility to the influence of the remedy is manifested.
Now there is one fact which must always be borne in mind in administering narcotic and antispasmodic, as well as some other remedies. 80 long as their effect on the system is the arrest of some morbid action, so long, as a general rule, will their ordinary physiological influence on the system be suspended. I know no better illustration of this than in the action of opium on phagedajna. I have for years past relied exclusively on this remedy; and the only guide which I have followed in respect to the amount of the opium to be given has beenthe effect upon the disease, its arrest, and the return of healthy action. Thus, from a scruple to forty grains of opium have not unfrequently been daily given to patients unaccustomed to its use, without the manifestation of any one symptom characteristic of the influence of the medicine upon the system. There has been neither drowsiness nor torpidity of the bowels, nor loss of appetite, nor contraction of pupil; in short, excepting that the local diseaso has been subdued and healthy action restored, there has been nothing to indicate that the patients were taking what under ordinary circumstances would have proved dangerous quantities of the drug. Sir Henry Holland has remarked, in relation to the effect of opium when given for the relief of acute pain or spasmodic action, that " It would seem, however vague the expression, that the medicine, expending all its specific power in quieting those disorders of the nervous system, loses at the time every other influence on the body. Even the sleep peculiar to opium appears in such instances to be wanting." That this is the case in tetanus itself, as in other painful nervous affections, is too well known to require comment; and such instances are familiar to all practitioners. And so with other medicines perhaps, as in the case of calomel in pericarditis, in which disease, as Dr. Latham and Dr. Seymour have pointed out, enormous amounts of the drug will be borne without the system becoming affected; or in that of iron in erysipelas, where the remedy exerts its almost specific influence only when given in quantities tar greater than are necessary to produce an ordinary alterative or tonic effect.
On the conviction, then, that our limit to the use of medicines in some forms of disease is not to be fixed by the t>oundaries within which they must for safety be restricted in healthy states of the body, the aconite was in this case given in larger quantity daily than has perhaps ever before been tolerated. One drachm of Fleming's tincture, equal in strength to «ore than double the quantity of the best pharmacopceal tincture, was taken continuously for three days; and wo find that in the course of ten days, three drachms of the pharmacopceal tincture and five drachms of Fleming's tincture were taken without the manifestation of any effect on the system, except the rapid lowering of the pulse from 135, and its steady maintenance at 60 in the minute, the patient's natural pulse being from 75 to 80. But from the time when the pulse began to fall, the boy had no convulsion, and there was a progressive diminution of the chronic rigidity. In Mr. Page's case, although the effects of the aconite upon the system were after a time very marked, yet it was seen that very large quantities were tolerated before they were induced. Thus, "on the loth December, this patient took irf eight hours nineteen minims of Fleming's tincture; on the 16th, thirty-two minims in fourteen hours; on the 17th, twenty-five minims in seven hours; and on the 20th, twenty minims in two hours.
It seems to me that in these cases we must adopt one of two conclusions—either that the patients, as is sometimes the case even in man, were not susceptible of the influence of aconite, or that the energy of the poison was held in check by the disease, which physiologically implies generally that the disease was controlled by the medicine. It is quite contrary to all that is known of the action of aconite, to suppose that the system had in so short a time become tolerant of the poison, nor can the notion be entertained that the medicine was not absorbed. The potency of the tincture employed in the present case was unquestionable; the tip of the finger moistened with it and applied to the tongue, produced at once tingling and numbness, with slight sensation of giddiness.
To determine whether in the present instance there existed" any idiosyncrasy which gave the lad immunity from the effects of this agent, some trials were made on him about three weeks after ail the symptoms of the disease had disappeared. On the 28th of October, five minims of Fleming's tincture were given and repeated in two hours. No effect followed the first dose. Shortly after the second dose, he complained of headache and pain in the bowels. He went to bed and said he felt chilly, but the skin was found to be hot and moist. The pulse was quickened. Next morning, he had a little diarrhoea, and all the disorder disappeared. No satisfactory conclusion was arrived at, for all these symptoms might have arisen from an accidental attack of indigestion. On the 30th, the tincture was again given in the same way. No effect was produced, and he was not conscious that he had taken anything. On November 1st, a trial was again made, with directions that if no effect followed the second dose, a third should be given two hours after it. After the third dose, the symptoms of aconite poisoning were very marked. The forehead was cold and clammy; he complained of great chilliness, though the body under the bedclothes was warm and perspiring profusely; the pulse was quickened and irregular. The headache and pains in the bowels were again present, and he complained of tingling sensations in the arms and hand, and in other parts of the body. On the following morning he was as well as usual. It was clear, then, that larger quantities than ordinary were required to produce the usual effects; but those effects were produced actively enough when a certain quantity was taken. While the tetanus was present, he took the same doses every two hours for days together, and no one can doubt that a far less amount must have proved fatal had the disease not been present. Still, the slowness with which the aconite acted will explain why so much more was borne in this case than in that recorded by Mr. Page.
The question naturally arises, why should stress be laid on the fact of such large quantities of aconite being tolerated, when, as is so well known, opium and other narcotics are taken in enormous quantities without effect in this disease 1 But have we not really been seeking from opium results which it is not calculated to effect? All the foregoing remarks apply undoubtedly to opium and other narcotics. In most cases they will be borne to an extraordinary extent before their effects are manifested. But experience has proved what our knowledge of the action of opium would lead us to expect, that but little effect is produced by it upon the essential character of the disease. If the opium relieve pain and induce sleep, it tends to prolong life by taking away some secondary causes of exhaustion, and therefore m chronic cases has no doubt often saved the patient by helping to sustain the system until the disease has worn itself out. In no instance, however, that I am aware of, is there any evidence that it has directly arrested the muscular spasm. The action of opium and that of aconite are quite distinct from one another. Opium is primarily a stimulant, and although if applied directly to muscular tissue it paralyses it, yet its effect on the muscular system, when acting through general absorption, is principally the result of coma, the exercise of the will over the muscles being more or less removed. Not unfrequently, and especially from morphia, convulsions are present similar to those of tetanus. Its influence is exerted on the brain especially, little, if at all, on the spinal cord. But the primary and peculiar effect of aconite, conium, Ac., is muscular paralysis, the brain being only secondarily affected, the influence of the poison being exerted mainly on the cord.
As, then, all the phenomena of tetanus indicate an affection of the cord, an irritation giving rise to muscular spasm, the pain being merely a consequence of it, we should naturally look for relief to those agents which diminish the irritability of that part of the nervous centres which controls the reflex muscular actions, not to those which act on the brain or diminish sensibility. In Mr. Page's case, we have distinct evidence that the muscular spasm was controlled by the aconite, and infercntially I should assume that the same must have been the case in the present instance.
In the following case, my colleague, Dr. Stewart, employed conium, which the investigations of Dr. Christisod have shown to act, like aconite, primarily on the spinal cord The form used was the extract prepared by Taylor. Many of the extracts in common use are, as is well known, nearly inert.
A mari was admitted into the hospital on the 7th August, 1858, with severe and frequent paroxysms of tetanus, and with permanent locked jaw. The symptoms had set in eight days before. On the 10th, he began to take Taylor's extract of conium, and continued its use in five grain doses every two hours, and afterwards every hour, until the 26th. During this period, he took no less than two ounces and a half of the strongest form of extract, without any indication whatever of the physiological effect of conium, but with simply a gradual diminution of the tetanic symptoms. This of course was not an instance of the poison remaining unabsorbed in the stomach, as has been seen at times with opium. I should consider that here the agency of the conium was directed towards the counteraction of the morbid condition, and that hence its normal effects were not manifested.
The object of the foregoing remarks is to induce those who have the opportunity to give a full and complete trial to aconite and other medicines which have a like effect on the nervous system. In looking over the records of cases in which such agonts have been given, it appears that generally the ordinary doses have been administered at long intervals. It has been by some assumed that because no benefit has been derived from them when so employed, that therefore no good was to be expected from them at all. There is a feeling, too, very prevalent, that though cases of tetanus sometimes recover, yet that the remedies employed have little to do with such a result. Nor is this surprising, considering the disappointment which has so often followed the more extended use of medicines which at first seemed to promise favourably. The same disappointment will perhaps follow the future employment of aconite. But in a disease so terrible and hopeless as tetanus, any encouragement, however slight, will be acceptable.
There is one other point in the treatment of tetanus to which allusion may be made. It has been generally taught that free action of the bowels should be kept up by means of powerful purgatives. From cases recently reported, indeed, this course does not appear to be now so generally the rule as formerly. My own belief is that excepting as a preliminary step to remove any matters which may be lodging in the bowels at the time of the attack, no benefit attends the practice, and that often harm is done by keeping up irritation in the alimentary canal, when our object should be to ensure as quiescent a state of the whole system as possible. In a case under my care last year, in which the symptoms were very mild, although it terminated fatally after nearly a month's duration, the bowels were allowed to remain quiet for the first nine days, purgative medicine was then given, and a free action of the bowels obtained, but the general symptoms were aggravated, and this was the case whenever the purgatives were used. Great relief is found from the use of enemata, however, especially those with turpentine. In the present case, the bowels were emptied by this means two or three times only during sixteen days.
On Syphilitic Inoculation. By Henry Lee, Surgeon to King's College Hospital and to the Lock Hospital.
Ok the 10th of October, 1853, I had the honour of reading before the London Medical Society a paper on the mode of action of morbid poisons, and of the syphilitic poison in particular. I then attempted to demonstrate that the absorbents were not the means by which poisons were ordinarily received into the blood, and that in those cases where the evidence was most conclusive of great excitement in the absorbent system, there was comparatively little danger of the poison being received, as such, into the general system. I endeavoured to show that the absorbent glands were, in fact, placed as seutinels in different parts of the .lymphatic vessels, and that they had the power of