HEALTH TEST FOR UNDERGRADUATES

420 CURARE

AND

SPASM

longer

action has led to the

synthesis

of

quinine

metho-

chloride, a substance with a curare-like action when THE deadly arrow poison of the South American given either by mouth or injection. In dogs it produces, Indians has been known to science for a hundred years ; in addition, a considerable drop in blood-pressure and but of the vine from the bark

supplies

Strychnos toxifera,

of which curare is obtained, have been difficult to come by, and the therapeutic uses of the drug have not been sufficiently wide to enforce its production on a large scale. Curare acts by paralysing the neuromuscular mechanism and in toxic doses produces death by respiratory paralysis ; if respiration can be maintained large doses can be tolerated. Attempts have been made to use it in the treatment of convulsive states (such as epilepsy, rabies, chorea, strychnine poisoning and various tics) ever since 1867 ; it was used as early as 1924 in spastic paralysis, and in the last ten years it has been tried for tetanus convulsionsand parkinsonian rigidity. Lately it has been used for patients about to undergo leptazol shock therapy, to prevent the danger of fractures and other injuries occurring during the convulsion ; Bennett, who introduced this preliminary curarisation, now finds it indispensable in preventing complications of convulsive therapy.2 Results in other conditions have not been striking so much as suggestive. The effects of the drug soon wear off, so that any relief it gives is short-lived. Intravenously it produces its maximum effect within about 4 minutes from the start of injection and this passes off in the course of 15-20 minutes ; symptoms following its injection mimic those of myasthenia gravis. The patient complains first of hazy vision, after which bilateral ptosis appears followed in turn by relaxation of the face, tongue and jaws, weakness of the neck muscles, the spinal muscles, and the legs and arms. and finally by shallow respiration due to weakness of the intercostal muscles and diaphragm. The muscle groups become weak in the same order as those of a myasthenia gravis patient, and even the snarling smile appears ; symptoms are quickly counteracted by injections of prostigmine, epinephrine or leptazol. It seems possible, therefore, that curare may throw some light on the xtiology of myasthenia. Bennett treated 12 severe cases of spastic paralysis in children with curare, 10 mg. per 20 lb. body-weight, given by injection on alternate days over 3-8 months. He found that it produced a transient relaxing effect on the spasticity and reduced incoordination, athetosis and dysarthria ; most of the children progressed well while under treatment-one, for example, was able to tolerate plaster casts and extension to overcome fixed deformities thanks to the drug. He also reports temporary relief of painful spasm in cases of postencephalitic dystonia and arrest of movements, for the period of action of the drug, in athetosis and Huntington’s chorea. Even such transient relief, it seems, is welcome to the patients. The need is clearly for a drug with similar but prolonged action. Until recently investigation of curare has been hampered by the difficulty of obtaining the vine and by the varying curare content of plants brought from different areas. In 1938 Mr. R. C. Gill by overcoming the prejudices of the local witch doctors was able to bring back from South America the largest supply ever gathered,3 and methods of standardising it were later simplified. Bennett quotes the opinion of Burman that a relaxing effect of curare on spastic muscles is maintained long after other effects have disappeared. Though he cannot confirm this finding Bennett reports that if a second injection of curare is given to animals within 1-5 hours of the first dose, less curare will be needed to produce paralysis ; and the same is true of patients. This suggests retention of active alkaloid in the body after the main symptoms have passed off. Search for a curare substitute with a Cole, L. B. Lancet, 1934, ii, 475 ; and West, R. Ibid, 1936, i, 12. 2. Bennett, A. E. Amer. J. med. Sci. 1941, 202, 102. 3. White Water and Black Magic, New York, 1940. 1.

respiration. It has been used successfully a curare substitute for patients undergoing convulsant therapy, however ; and in spastic patients 10-15 mg. per kg. of body-weight produces effects identicalunfortunately even in their transience-with those of Bennett has treated 8 cases of spastic athetosis curare. and 1 of Huntington’s chorea with oral doses of 3-4 g. diminished as

daily, with jective, relief. HEALTH

some

objective,

and

considerable

sub-

TEST

FOR UNDERGRADUATES THREE years ago the council of Sheffield University offered a free medical examination to all its studentson entrance. The scope and extent of the examination was drawn up after consultation with the Medical Research Council, and a form was designed for the guidance of the examinee which might be of statistical use in the future to the anthropologist. The examination was optional, and the number of students who have availed themselves of it has been disappointingly smallnot more than The council has now decided to make the examination compulsory from the.beginning of next October. While in the other faculties it will be limited to what is contained in the present form, in the of medical aspirants, something more will be case required-namely, an X-ray examination of the chest. Nor is that all. The student of medicine will have to undergo a second X-ray examination of the chest, together with a sedimentation test, when he begins his clinical studies, and again at the end of his second clinical year. The object of this repeated examination of the chest is twofold : it will benefit the student himself, and it will prevent him carrying infection to- the patients with whom he will be in daily contact. This may be a small step in furtherance of Sir Charles Wilson’s wider proposals in the Times of March 21.

0%.

SEQUEL

TO

HEAD

INJURY

HEAD injury has been taken seriously in this war. Centres have been established at which neurosurgeons and neuropsychiatrists can deal with it at all stages, in a model partnership. One of the chief fruits of this organisation has been the recognition of how much can be done to forestall invalidism if doctors will remember relevant platitudes’and put them constantly into practice. At a meeting of the Section of Neurology of the Royal Society of Medicine on March 19 to discuss the differential diagnosis and treatment of postcontusional states, one postcontusional state was singled out as of prime importance-that late condition in which headache, irritability, fatigue, dizziness and perhaps anosmia are the common symptoms, entailing much disability which may be of very long, even lifelong, duration. Much of this is

preventable, as the speakers emphasised. Group Captain C. P. Symonds defined the postcontusional state, for practical purposes, as that of the patient who has reached the ambulant stage after brain injury.- He may be first seen at this stage without any adequate clinical record being available to give such essential information, for example, as the duration of unconsciousness or the patient’s previous constitution and pretraumatic personality. These may be difficult to estimate, and in the necessarily hurried initial examination may not have been inquired into, but they throw much light on the

causation and nature of the postcontusional condition. Whereas air encephalography and some other special procedures may do no good or tell nothing worth knowing, discovery of psychopathic trends in the patient’s personality may make clear the persistence of symptoms for which physical damage would not account. To interpret this too simply as indicating the need for differential