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A CASE OF TRAUMATIC TETANUS TREATED BY SUBCUTANEOUS INJECTION OF CALABAR BEAN.
834
appeared under medical treatment. The second attack com- tions. The dressing often proves curative, even when the menced about eight weeks previous to admission, appearing patient is only able to make use of it at night; but of course in the same manner and order as before ; but this time the it is more quickly and more certainly successful if it is worn palmar surfaces of the fingers were implicated as well as continuously. It should be removed from time to time for the above-mentioned parts. the purpose of cleansing it, and of wiping the skin; and if, Appearances CM odHttssMH.—On the left hand the eruption as often happens, the tender skin in the vicinity of the implicated its dorsal surface, as well as the dorsal surfaces eruption is abraded and raw, a little benzoated zinc ointand sides of the fingers : these parts were considerably in- ment may be applied with advantage. filtrated, covered with
a serous exudation, and the seat of excoriations. The right hand presented similar appearances, but the infiltration of the skin on its dorsal surface was much more marked. The eruption was extremely itchy, and was rapidly extending. The patient’s general health was good. He was ordered to procure a pair of indiarubber gloves, and to wear them constantly for a fortnight. On Jan. 6th, 1869, the disease had in most parts completely disappeared, a faint reddish blush only being left He was ordered to on the sites of the previous eruption. continue the use of the gloves for another fortnight, and then to return, which, however, he failed to do. (Reported by Mr. J. D. Walker.) CASE 3. Eeze;-4ft capitis.-Louisa Waged four years z’ and eight months, admitted to the Glasgow Skin Dispensary June 2Sth, 1869. Her father stated that the eruption first made its appearance when she was three months old, and disappeared about three months thereafter. She remained well till after an attack of scarlatina at the age of a year and a half, when it reappeared, since which time she had never been altogether free of it. - AppecH’cMMes on admission.-The eruption implicated the external ears and the whole of the scalp. These parts were very red, much infiltrated, exuded an abundance of clear serum, and were studded with crusts. The patient complained of great irritation of the skin and of burning heat. She looked rather delicate, but her digestive organs were in good order, although the year before she had been troubled with worms. Various remedies had been tried, but to little purpose. She was ordered a vulcanised india-rubber cap, which was to be worn constantly. On July 15th the infiltration of the skin and the exudation had completely disappeared, the itching and burning heat were almost gone, and a faint red blush was all that remained of the previous eruption. The india-rubber cap was continued. The patient did not return. (Reported by Mr. Robert Sinclair.) CASE 4. ItT2’v7ib02GS disease of the toes, q-c.-A young lady, aged about twenty, consulted me in 1868 with regard to an attack of lupus, of old standing, implicating the tip of the It was of the non-ulcerating variety. She had also nose. a strumous eruption on each foot, on and around the toes, associated with several small ulcerations, and covered for the most part with thick hardened epidermis. Under treatment the nose recovered perfectly, and the eruption on the toes improved, but the skin remained very thick and hard, and would not yield to the remedies employed. She was therefore ordered to cover these parts with vulcanised indiarubber. This was on April 13th, 1869. She made use of a piece of a tobacco-pouch for each foot, and at her next visit, on April 28th, the thick, hardened epidermis had almost entirely disappeared, and the toes had nearly resumed their normal appearance. She was ordered to continue the use of the india-rubber for a considerable time. CASE 5. Pru1.itus senilis.-A gentleman, aged about sirlyfive, of a spare habit of body, whose general health was fair, with the exception of a marked tendency to constipation, and who had the advantage of plenty of out-door exercise,. consulted me on account of intolerable itching over the whole body, that malady which is described under the title of pruritus senilis, and which has no connexion, as some would have us believe, with phtheiriasis corporis, the disease due to the presence of lice, and which is so common in old persons. His skin was the seat of a pruriginous eruption, the result of the scratching in which he indulged, and the irritation of the skin interfered much with his sleep. After a trial of other means, which were only very partially successful, he procured, at my request, a complete underdress of vulcanised india-rubber cloth, on commencing to wear which the itching and eruption completely disappeared. This treatment is useful also in cases of prurigo and ichthyosis, and probably in most obstinate localised eruptions. It possesses this advantage, too, that it does not interfere with the simultaneous use of other local applica-
numerous
A
CASE OF TRAUMATIC TETANUS TREATED BY SUBCUTANEOUS INJECTION OF CALABAR BEAN. BY WILLIAM
HAINING, M.D.,
HOUSE-SURGEON TO THE GENERAL
INFIRMARY,
CHESTER.
THE following notes of a case of traumatic tetanus treated by subcutaneous injection of Calabar bean may, it is thought, be not without interest, as exemplifying the beneficial effect of the remedy as well as the safety with which it may be administered in doses hitherto regarded as dangerously large. J. R-,aged twenty-nine, a strong, healthy-looking labourer, of steady habits, was admitted into the General Infirmary, Chester, under the care of Mr. Watson, on the 1st of June, 1869, his right foot having been completely crushed under the wheels of a locomotive engine. The lower half of the leg being quite emphysematous, and the veins, as high as the inner side of the knee, presenting a varicose appearance, amputation was deemed unadvisable at the lower third of the leg, and was performed by an anterior and posterior 8a.p at the " seat of election." Although a good deal of blood had been lost by the patient, he progressed very favourably until the seventh day after the operation, when the lower border of the anterior flap assumed a gangrenous appearance, which rapidly spread until in a few days the whole flap sloughed off on a level with the exposed end of the tibia. The posterior flap, which remained quite healthy, was then firmly strapped forward, and the process of cicatrisation proceeded very favourably from below, the edge of the anterior flap remaining for three weeks hard and abruptly defined. On the evening of the l7th slight stiffness about the neck was complained of ; and on the following morning the mouth could be opened scarcely wide enough to admit of the tip of the tongue being protruded, the neck being so rigid that the head could not be bent forwards or turned to either side. The face bore the usual tetanic expression of great sufering, although the patient was conscious of nothing more than slight uneasiness. Towards evening there was a good deal of twitching in the muscles of the stump, and a very perceptible amount of opisthotonos. The strapping was removed from the wound; the bowels, which had not been opened for two days, were freely opened; and one-grain doses of the extract of Calabar bean were given every three hours. On the 20th, the symptoms having increased in severity, the doses were doubled in strength, each being followed, in rather less than an hour, by complete relaxation of the jaw. On the 22nd the abdominal muscles were very rigid, the back arched, and the stump twitching violently; but three-grain doses of the attract completely relieved all spasm. During. the night, however, there was a great deal of nausea, with occasional vomiting; and as, on the following morning, the mouth was’ so firmly closed th3/ù o food could be taken until about on hour after each dose of the medicine, the subcutaneous was-substituted for th3 internal administration of the remedy, an injection of half a grain producing a more speedy but less permanent effec than the dose of three grains. The -injections were gradually increased in strength until, or., the 8th July, they amounted to forty-one grains within little more than twenty-four hours; the largest individual dose being six grains. On the 29th June they were pTtrposely omitted for ten houB%. at the end of which time tha patient was in a very distressed condition, the jaws being firmly cliached, the. abdomen as hard as a board, and th-body so arched that it rested entu’ay ou
835 An injection of three grains gave complete relief abdomen, and left thigh, but in the latter situation their effect did not seem to be either so well marked or so rapidly in about seven minutes. On the 4th of July the last ligature came away, and on produced. The total quantity of extract used between the 18th of the same evening, and once again two days afterwards, the left leg became cold and numb, feeling, asthe patient ex- June and the 19th of July wasafew grains over ten pressed it, ,quite dead ;" but there was no obstruction of drachms, the preparation ordered being that made acthe arterial circulation through it. Just before the spasms cording to the British Pharmacopoeia. As the doses rebegan to be severe, micturition was imperfectly performed, quired were sufficiently large to justify doubts as to the the urine being expelled painfully and in sudden jets. From purity of the extract used, specimens were obtained from the 7th till the 12th the injections were required from three different firms, whose names ought to be a guarantee seven to nine times in the course of twenty-four hours, their that their preparations were as genuine as the present irfrequency being ruled by the permanence of their effect. regular commercial supply of the bean will allow. That a few small abscesses should result. from over 140 There was no complete trismus after the 4th, although opisthotonos continued gradually to return in from two to punctures is scarcely surprising, although the solution infour hours after each injection, by the puncture of which it jected was made slightly alkaline by the addition of bicarwas always momentarily increased. On the 13th there was bonate of potash, and was in that condition found to be less irritating than when merely neutralised by carbonate of a decided remission in the severity of all the symptoms, accompanied by slight delirium, and a rather tympanitic con- soda. dition of the abdomen. On the 14th the tympanitis was From the results obtained in this case it may not be too very distressing, the opisthotonos being slight; but the much to infer that in tetanus the administration of Calabar abdominal symptoms gradually subsided after the repeated bean should not in any case be limited to effect mitigation use of turpentine enemata. The doses of extract, which of the symptoms, but should be perseveringly continued in had been much lessened from the 13th, were on the 19th doses gradually increasing in frequency as well as in magaltogether discontinued; and from this date the patient nitude, until either the tetanic spasms are completely overmade such uninterrupted progress that on the 24th he was come, or the physiological effects of the drug are manifested able to be out of bed, feeling very weak and shaky, it is to a dangerous degree. Once having obtained complete retrue, but quite free from all tetanic symptoms, and with laxation, it seems far from improbable that, in a large prothe stump, which had cicatrised very slowly, and from which portion of cases, careful, free repetition of the doses on the a small exfoliation from the tibia had been extracted, comreturn of the least appearance of spasm, may enable us to pletely healed over. A day or two before the occurrence of maintain complete control over the symptoms, until their the tympanitis a number of small wen-like abscesses ap- cause becomes much enfeebled or is altogether removed. Note.-Since the foregoing notes were written, the papeared over the chest and left arm, where the injections had been most frequently made, but they speedily healed up tient, from the breaking of one of his crutches, fell heavily after having been evacuated by puncture. Besides the on his stump, bruising it .very much, and cutting it transCalabar bean no other drug was employed, the patient’s versely through the whole breadth of the cicatrix, so that strength being maintained by a good nourishing diet, for the end of the tibia was exposed. Owing to the great extent which there was a tolerable appetite after the action of the of cicatrised surface, the process of reunion proceeded very bean had been fairly established. slowly, and was further delayed by the exfoliation of a. It can scarcely be doubted that this was a case of tetanus, small piece from the end of the exposed bone. Three weeks of no very mild type. The onset of the symptoms, eighteen after the accident, he was enabled to leave the hospital for days after amputation, was somewhat sudden, and, occurring the country, and there is now but a small extent of surface several days after removal of the anterior flap, when the unhealed, whilst his general health, as evidenced by his stump appeared to be healing kindly, it was certainly un- physical appearance, seems better than it has ever been.* General Infirmary, Chester, September, 1869. expected. The cause of the disease was probably connected with the delay in the separation of the ligatures, as well as with the irritation which results from the change occurring in the condition of the muscular and nervous tissues during the process of cicatrisation. In the A7nericarc .7btM")t6 for THE ASSERTED SUPERIORITY OF NEW last October a case is reported in which tetanus occurred HOSPITALS. three weeks after a double amputation, when the stump BY J. MATTHEWS DUNCAN, M.D. had quite healed up, except at the point at which the ligatures came out, the symptoms, after two days’ duration, IT is now alleged that newness is a quality so essential abating on removal of the ligatures. In the present case, the three ligatures came away respectively on the twenty- to a good infirmary that, in future, hospital buildings should sixth, twenty-eighth, and thirty-third days after the ope- be in the form of cottages, so cheaply constructed that they ration ; and though a decided remission of the symptoms took place within a week after removal of the last one, it may be periodically destroyed, or built of such materials as might be rather too much to say that it was consequent iron plating, that they may be taken down periodically and upon it, as by that time the process of cicatrisation was reconstructed in a new locality, and thus keptalways new. fom-nleted. Rebuilding becomes necessary for any hospital when its The antagonistic effect of the remedy upon the well- materials become wasted from age and wear and tear, or its marked trismus and opisthotonos was immediate and combecome antiquated. This is the case, at preplete. The arched back, painfully tense abdomen, quivering arrangements of the sent, Royal Infirmary of Edinburgh. It is not to limbs, and anxious countenance, were generally relieved in from five to ten minutes after each injection, by comfort- this kind of rebuilding that we are told to look for permaable decubitus, a feeling of drowsy ease, and during the nent newness and sanitary improvement. It is to a frenight by short snatches cf sleep. The frequency of the Ii quent demolition and rebuilding in a new locaiity, " every injections, as well as their strength, was so regulated by few years.’’careful attention as to keep the spasms thoroughly under This is a change in hospital arrangements so enormous, control. For this purpose repetition of the injections was necessary, sometimes every two hours, at other times not leading to so great expense, involving such great difficulties, oftener than once in six hours. During the whole of the * I have quite recently (December) had further experience of the value time the patient was under the influence of the bean the of the above treatment in the ease of a hemiplegic woman of sixty, who was gradually sinking from the effects of extensive scorching of the arms and pupils were very much contracted, the skin was bathed in body. The occurrence of trismus interfering with deglutition, and arresting and free evacuations were obtained from perspiration, daily the cough and profuse expectoration incident to a severe attack of bronthe bowels. The effect of one or two of the larger doses, chitis, rendered suffocation imminent. The injection of three grains of the administered when the symptoms were not so severe, was to, extract, at intervals in the course of an hour, enabled the mouth to be so opened that the administration of the remedy was continued per orem produce nausea and vomiting, involuntary purgation, and a freely until the unavoidable termination occurred. The state of euthanasia by it was preceded was to the attendants not less than to the patient a feeling of great depression, with. fibrillary spasms of thei which relief when contrasted with the previous semimuscles, especially those of the face, -marked slowing ofF source of unspeakable condition in which each painfully-drawn gasp was expectedthe pulse, and most profuse perspiration. The injections’ asphyxiated almost hoped-to be the last. were made over both arms audshoulder4 and over the chest,, t Edinburgh Medical Journal, March, 1869, p. 817.
left leg.
,
’
,
appeared under medical treatment. The second attack com- tions. The dressing often proves curative, even when the menced about eight weeks previous to admission, appearing patient is only able to make use of it at night; but of course in the same manner and order as before ; but this time the it is more quickly and more certainly successful if it is worn palmar surfaces of the fingers were implicated as well as continuously. It should be removed from time to time for the above-mentioned parts. the purpose of cleansing it, and of wiping the skin; and if, Appearances CM odHttssMH.—On the left hand the eruption as often happens, the tender skin in the vicinity of the implicated its dorsal surface, as well as the dorsal surfaces eruption is abraded and raw, a little benzoated zinc ointand sides of the fingers : these parts were considerably in- ment may be applied with advantage. filtrated, covered with
a serous exudation, and the seat of excoriations. The right hand presented similar appearances, but the infiltration of the skin on its dorsal surface was much more marked. The eruption was extremely itchy, and was rapidly extending. The patient’s general health was good. He was ordered to procure a pair of indiarubber gloves, and to wear them constantly for a fortnight. On Jan. 6th, 1869, the disease had in most parts completely disappeared, a faint reddish blush only being left He was ordered to on the sites of the previous eruption. continue the use of the gloves for another fortnight, and then to return, which, however, he failed to do. (Reported by Mr. J. D. Walker.) CASE 3. Eeze;-4ft capitis.-Louisa Waged four years z’ and eight months, admitted to the Glasgow Skin Dispensary June 2Sth, 1869. Her father stated that the eruption first made its appearance when she was three months old, and disappeared about three months thereafter. She remained well till after an attack of scarlatina at the age of a year and a half, when it reappeared, since which time she had never been altogether free of it. - AppecH’cMMes on admission.-The eruption implicated the external ears and the whole of the scalp. These parts were very red, much infiltrated, exuded an abundance of clear serum, and were studded with crusts. The patient complained of great irritation of the skin and of burning heat. She looked rather delicate, but her digestive organs were in good order, although the year before she had been troubled with worms. Various remedies had been tried, but to little purpose. She was ordered a vulcanised india-rubber cap, which was to be worn constantly. On July 15th the infiltration of the skin and the exudation had completely disappeared, the itching and burning heat were almost gone, and a faint red blush was all that remained of the previous eruption. The india-rubber cap was continued. The patient did not return. (Reported by Mr. Robert Sinclair.) CASE 4. ItT2’v7ib02GS disease of the toes, q-c.-A young lady, aged about twenty, consulted me in 1868 with regard to an attack of lupus, of old standing, implicating the tip of the It was of the non-ulcerating variety. She had also nose. a strumous eruption on each foot, on and around the toes, associated with several small ulcerations, and covered for the most part with thick hardened epidermis. Under treatment the nose recovered perfectly, and the eruption on the toes improved, but the skin remained very thick and hard, and would not yield to the remedies employed. She was therefore ordered to cover these parts with vulcanised indiarubber. This was on April 13th, 1869. She made use of a piece of a tobacco-pouch for each foot, and at her next visit, on April 28th, the thick, hardened epidermis had almost entirely disappeared, and the toes had nearly resumed their normal appearance. She was ordered to continue the use of the india-rubber for a considerable time. CASE 5. Pru1.itus senilis.-A gentleman, aged about sirlyfive, of a spare habit of body, whose general health was fair, with the exception of a marked tendency to constipation, and who had the advantage of plenty of out-door exercise,. consulted me on account of intolerable itching over the whole body, that malady which is described under the title of pruritus senilis, and which has no connexion, as some would have us believe, with phtheiriasis corporis, the disease due to the presence of lice, and which is so common in old persons. His skin was the seat of a pruriginous eruption, the result of the scratching in which he indulged, and the irritation of the skin interfered much with his sleep. After a trial of other means, which were only very partially successful, he procured, at my request, a complete underdress of vulcanised india-rubber cloth, on commencing to wear which the itching and eruption completely disappeared. This treatment is useful also in cases of prurigo and ichthyosis, and probably in most obstinate localised eruptions. It possesses this advantage, too, that it does not interfere with the simultaneous use of other local applica-
numerous
A
CASE OF TRAUMATIC TETANUS TREATED BY SUBCUTANEOUS INJECTION OF CALABAR BEAN. BY WILLIAM
HAINING, M.D.,
HOUSE-SURGEON TO THE GENERAL
INFIRMARY,
CHESTER.
THE following notes of a case of traumatic tetanus treated by subcutaneous injection of Calabar bean may, it is thought, be not without interest, as exemplifying the beneficial effect of the remedy as well as the safety with which it may be administered in doses hitherto regarded as dangerously large. J. R-,aged twenty-nine, a strong, healthy-looking labourer, of steady habits, was admitted into the General Infirmary, Chester, under the care of Mr. Watson, on the 1st of June, 1869, his right foot having been completely crushed under the wheels of a locomotive engine. The lower half of the leg being quite emphysematous, and the veins, as high as the inner side of the knee, presenting a varicose appearance, amputation was deemed unadvisable at the lower third of the leg, and was performed by an anterior and posterior 8a.p at the " seat of election." Although a good deal of blood had been lost by the patient, he progressed very favourably until the seventh day after the operation, when the lower border of the anterior flap assumed a gangrenous appearance, which rapidly spread until in a few days the whole flap sloughed off on a level with the exposed end of the tibia. The posterior flap, which remained quite healthy, was then firmly strapped forward, and the process of cicatrisation proceeded very favourably from below, the edge of the anterior flap remaining for three weeks hard and abruptly defined. On the evening of the l7th slight stiffness about the neck was complained of ; and on the following morning the mouth could be opened scarcely wide enough to admit of the tip of the tongue being protruded, the neck being so rigid that the head could not be bent forwards or turned to either side. The face bore the usual tetanic expression of great sufering, although the patient was conscious of nothing more than slight uneasiness. Towards evening there was a good deal of twitching in the muscles of the stump, and a very perceptible amount of opisthotonos. The strapping was removed from the wound; the bowels, which had not been opened for two days, were freely opened; and one-grain doses of the extract of Calabar bean were given every three hours. On the 20th, the symptoms having increased in severity, the doses were doubled in strength, each being followed, in rather less than an hour, by complete relaxation of the jaw. On the 22nd the abdominal muscles were very rigid, the back arched, and the stump twitching violently; but three-grain doses of the attract completely relieved all spasm. During. the night, however, there was a great deal of nausea, with occasional vomiting; and as, on the following morning, the mouth was’ so firmly closed th3/ù o food could be taken until about on hour after each dose of the medicine, the subcutaneous was-substituted for th3 internal administration of the remedy, an injection of half a grain producing a more speedy but less permanent effec than the dose of three grains. The -injections were gradually increased in strength until, or., the 8th July, they amounted to forty-one grains within little more than twenty-four hours; the largest individual dose being six grains. On the 29th June they were pTtrposely omitted for ten houB%. at the end of which time tha patient was in a very distressed condition, the jaws being firmly cliached, the. abdomen as hard as a board, and th-body so arched that it rested entu’ay ou
835 An injection of three grains gave complete relief abdomen, and left thigh, but in the latter situation their effect did not seem to be either so well marked or so rapidly in about seven minutes. On the 4th of July the last ligature came away, and on produced. The total quantity of extract used between the 18th of the same evening, and once again two days afterwards, the left leg became cold and numb, feeling, asthe patient ex- June and the 19th of July wasafew grains over ten pressed it, ,quite dead ;" but there was no obstruction of drachms, the preparation ordered being that made acthe arterial circulation through it. Just before the spasms cording to the British Pharmacopoeia. As the doses rebegan to be severe, micturition was imperfectly performed, quired were sufficiently large to justify doubts as to the the urine being expelled painfully and in sudden jets. From purity of the extract used, specimens were obtained from the 7th till the 12th the injections were required from three different firms, whose names ought to be a guarantee seven to nine times in the course of twenty-four hours, their that their preparations were as genuine as the present irfrequency being ruled by the permanence of their effect. regular commercial supply of the bean will allow. That a few small abscesses should result. from over 140 There was no complete trismus after the 4th, although opisthotonos continued gradually to return in from two to punctures is scarcely surprising, although the solution infour hours after each injection, by the puncture of which it jected was made slightly alkaline by the addition of bicarwas always momentarily increased. On the 13th there was bonate of potash, and was in that condition found to be less irritating than when merely neutralised by carbonate of a decided remission in the severity of all the symptoms, accompanied by slight delirium, and a rather tympanitic con- soda. dition of the abdomen. On the 14th the tympanitis was From the results obtained in this case it may not be too very distressing, the opisthotonos being slight; but the much to infer that in tetanus the administration of Calabar abdominal symptoms gradually subsided after the repeated bean should not in any case be limited to effect mitigation use of turpentine enemata. The doses of extract, which of the symptoms, but should be perseveringly continued in had been much lessened from the 13th, were on the 19th doses gradually increasing in frequency as well as in magaltogether discontinued; and from this date the patient nitude, until either the tetanic spasms are completely overmade such uninterrupted progress that on the 24th he was come, or the physiological effects of the drug are manifested able to be out of bed, feeling very weak and shaky, it is to a dangerous degree. Once having obtained complete retrue, but quite free from all tetanic symptoms, and with laxation, it seems far from improbable that, in a large prothe stump, which had cicatrised very slowly, and from which portion of cases, careful, free repetition of the doses on the a small exfoliation from the tibia had been extracted, comreturn of the least appearance of spasm, may enable us to pletely healed over. A day or two before the occurrence of maintain complete control over the symptoms, until their the tympanitis a number of small wen-like abscesses ap- cause becomes much enfeebled or is altogether removed. Note.-Since the foregoing notes were written, the papeared over the chest and left arm, where the injections had been most frequently made, but they speedily healed up tient, from the breaking of one of his crutches, fell heavily after having been evacuated by puncture. Besides the on his stump, bruising it .very much, and cutting it transCalabar bean no other drug was employed, the patient’s versely through the whole breadth of the cicatrix, so that strength being maintained by a good nourishing diet, for the end of the tibia was exposed. Owing to the great extent which there was a tolerable appetite after the action of the of cicatrised surface, the process of reunion proceeded very bean had been fairly established. slowly, and was further delayed by the exfoliation of a. It can scarcely be doubted that this was a case of tetanus, small piece from the end of the exposed bone. Three weeks of no very mild type. The onset of the symptoms, eighteen after the accident, he was enabled to leave the hospital for days after amputation, was somewhat sudden, and, occurring the country, and there is now but a small extent of surface several days after removal of the anterior flap, when the unhealed, whilst his general health, as evidenced by his stump appeared to be healing kindly, it was certainly un- physical appearance, seems better than it has ever been.* General Infirmary, Chester, September, 1869. expected. The cause of the disease was probably connected with the delay in the separation of the ligatures, as well as with the irritation which results from the change occurring in the condition of the muscular and nervous tissues during the process of cicatrisation. In the A7nericarc .7btM")t6 for THE ASSERTED SUPERIORITY OF NEW last October a case is reported in which tetanus occurred HOSPITALS. three weeks after a double amputation, when the stump BY J. MATTHEWS DUNCAN, M.D. had quite healed up, except at the point at which the ligatures came out, the symptoms, after two days’ duration, IT is now alleged that newness is a quality so essential abating on removal of the ligatures. In the present case, the three ligatures came away respectively on the twenty- to a good infirmary that, in future, hospital buildings should sixth, twenty-eighth, and thirty-third days after the ope- be in the form of cottages, so cheaply constructed that they ration ; and though a decided remission of the symptoms took place within a week after removal of the last one, it may be periodically destroyed, or built of such materials as might be rather too much to say that it was consequent iron plating, that they may be taken down periodically and upon it, as by that time the process of cicatrisation was reconstructed in a new locality, and thus keptalways new. fom-nleted. Rebuilding becomes necessary for any hospital when its The antagonistic effect of the remedy upon the well- materials become wasted from age and wear and tear, or its marked trismus and opisthotonos was immediate and combecome antiquated. This is the case, at preplete. The arched back, painfully tense abdomen, quivering arrangements of the sent, Royal Infirmary of Edinburgh. It is not to limbs, and anxious countenance, were generally relieved in from five to ten minutes after each injection, by comfort- this kind of rebuilding that we are told to look for permaable decubitus, a feeling of drowsy ease, and during the nent newness and sanitary improvement. It is to a frenight by short snatches cf sleep. The frequency of the Ii quent demolition and rebuilding in a new locaiity, " every injections, as well as their strength, was so regulated by few years.’’careful attention as to keep the spasms thoroughly under This is a change in hospital arrangements so enormous, control. For this purpose repetition of the injections was necessary, sometimes every two hours, at other times not leading to so great expense, involving such great difficulties, oftener than once in six hours. During the whole of the * I have quite recently (December) had further experience of the value time the patient was under the influence of the bean the of the above treatment in the ease of a hemiplegic woman of sixty, who was gradually sinking from the effects of extensive scorching of the arms and pupils were very much contracted, the skin was bathed in body. The occurrence of trismus interfering with deglutition, and arresting and free evacuations were obtained from perspiration, daily the cough and profuse expectoration incident to a severe attack of bronthe bowels. The effect of one or two of the larger doses, chitis, rendered suffocation imminent. The injection of three grains of the administered when the symptoms were not so severe, was to, extract, at intervals in the course of an hour, enabled the mouth to be so opened that the administration of the remedy was continued per orem produce nausea and vomiting, involuntary purgation, and a freely until the unavoidable termination occurred. The state of euthanasia by it was preceded was to the attendants not less than to the patient a feeling of great depression, with. fibrillary spasms of thei which relief when contrasted with the previous semimuscles, especially those of the face, -marked slowing ofF source of unspeakable condition in which each painfully-drawn gasp was expectedthe pulse, and most profuse perspiration. The injections’ asphyxiated almost hoped-to be the last. were made over both arms audshoulder4 and over the chest,, t Edinburgh Medical Journal, March, 1869, p. 817.
left leg.
,
’
,