Ext. Filicis Liq. 3ii Mucil. Acac. 3ss Infus, Kusso. Zii. No portions of the worm were found in the evacuations, which owing to the action of Kamala, were quite free. The only inconvenience experienced from the combination was nettle-rash and a sense of lassitude. The urine, as on other occasions, after taking male fern, was observed to be remarkably dark coloured; it was hoped that by following up the treatment by a combination of tænicides, each in full doses, the vitality of the worm would have at length succumbed. I had great confidence in Kamala for tape-worm, having formerly used it largely with much success. But this hope was not realised. On December 12, seven weeks and three days from the last expulsion, portions of worm were again observed in the fæces. I now directed the patient, after having fasted in the usual way, to take the following draught, and if it did not purge, a dose of castor oil soon afterwards : Spir. Terebinth. iii T. Hyoscy. 3ss Aquæ Chl. ad. Zii. Free evacuations, containing the worm, together with the longsought after head were soon caused by the draught alone. The hookless flat-shaped head at once proved the worm to be Tænia media cannellata. This worm is much more difficult of expulsion than Tænia solium. My opinion, confirmed by this case, in which Kamala and extract of male fern were given in unusually large doses without destroying the worm, has long been that of all tænicides the old-fashioned one, oil of turpentine, is the most potent. But turpentine in large doses is not free from inconvenience, or even danger to life; I know of one death caused by its injurious action on the kidneys. This danger can be greatly diminished, if not altogether averted, by the precaution of giving a purga tive, if the turpentine does not itself very speedily act upon the bowels. TWO CASES OF VIOLENT CHOREA, ILLUSTRATING THE ADMINISTRATION OF CHLORAL HYDRATE IN LARGE DOSES. BY ROBERT BRIDGES, M.B., OXON. THE lamentable issue of several cases of chorea treated by frequent small or moderate doses of chloral hydrate, and the failure of this use of the drug in other affections where I have had opportunities of observing the facts, led me almost to believe that there must be something specially dangerous in this manner of giving chloral; I fancied too that this effect was due to the effect of chloral on the nervous system when it did not produce sleep, and that it was possible that its action in the sleeping and waking states of the body might be very different, and in consequence of this opinion I determined to use it in such doses that its narcotic power should have a fair trial. I do not know that chloral may not be specially fit to oppose the nervous disturbance in chorea, but I am sure that it owes much of its value to its power as a narcotic. The disease is naturally suspended during sleep, and therefore a drug which produces sleep is plainly indicated. For by procuring sleep, not only is the actual disease lessened in quantity, but the continuity and habit of it are broken, remission and rest are obtained, with the opportunity for the natural repair and reproduction of worn or injured parts, while time also is gained, in which the malady may die out of itself, or be made to yield to remedies of a tonic nature. If these considerations are of any weight, it is plain that chloral should be given in chorea in doses that will cause sound sleep and it must follow the rule for the administration of narcotics at night-time, rather than wait upon the convenience of the physician, who is apt to reckon it as a drug that must be watched in its action, and therefore given by day. In illustration of these remarks I have only two clinical observations to record, but they are both of successful cases. The principle of treatment in each was to administer the chloral so that the patient should get about ten hours' sound sleep in the twentyfour. With this intent a dose of gr. xxx. was administered, and this would have been repeated, as much, or half as much, or less, according to the circumstances if the patient had not slept. Then immediately on waking a second dose was given, in proportion to the ascertained effect, less or more as the patient had slept well or ill, but in any case less than at first: and on waking again, another dose less than the second, and so on till the amount of sleep required had been obtained, when the chloral was discontinued till the next night. Of the two patients thus treated, one was cured completely in one day: the other had a few choreic movements only left on the third day. In each case I gave a preliminary dose of gr. xv. to discover any idiosyncrasy. The pulse, which was difficult to count, I do not record, because statements concerning its force are liable to inaccuracy: but in neither case was the pulse ever so affected by the chloral as to become feeble. Stated not to The first case was M. B., aged eighteen, might be taken for a girl of fourteen or fifteen. Neglected and dirty. Fourth attack, the first eight years ago, the last three years ago. have had rheumatism or scarlet fever. This attack said to have begun eighteen days ago. When seen on the eighteenth day, the patient was in a febrile condition. Labial herpes, body heat 101°. Limbs much bruised: right foot a little swelled and tender. Systolic murmur heard over heart (auscultation very difficult). Universal choreic movements of great violence; inability to stand or speak; no difficulty in swallowing fluids. Patient said to be much worse by night than by day; and able to make herself understood by day. Said to have slept one hour last night. Ordered liquor arsen. mv. ter die. 19th day. No improvement; has slept one or two hours in the last twenty-four. Morphia hydrochl. gr. injected sub cutaneously; no result.-9 P.M., slept one hour after chloral gr. xv.—11. P.M., morphia subcutaneously; slept ten minutes. 20th day.—Much the same at 7 P.M., chloral hydrate, gr. XXX. After this patient slept till 12.30 midnight. At 12.30, chloral hydrate, gr. x. Slept till morning of 21st day.-11.30 A.M., chloral hydrate, gr. v. The choreic movements being entirely ceased, it was thought well to protract the patient's sleep a little longer. 22nd day.-Temperature fallen below normal. There seemed to be some wrist drop, as if from fatigue of extensors. Convalescence on tonics uninterrupted. The second case was A. W., servant girl, aged twenty, looks somewhat younger. Complexion dark. This is the second bad attack: had another five years ago; has had one or two lesser attacks. No history of rheumatism, nor heart murmur. Menstruation had ceased for last two months, had previously been scanty. Has been ill with this attack for six weeks; it has got Total inability to speak; has eaten nothing for the last few days choreic movements universal and very violent : expression insane; constant grinding of the teeth, with fits of crying. worse. Patient held 1st day of treatment.-10 P.M., chloral gr. xxx. down till she became quiet; went to sleep in about twenty minutes, slept without waking till 11.30 P.M., and remained quiet till 2 A.M., when I saw her and gave her gr. x. Slept till 4.30, and then off and on till 2nd day.-11.30 A.M., when she was wide awake and less disturbed. 10 P.M., gr. xxv., and gr. x. when she woke. This kept her asleep all night, and on 3rd day. She was much quieter. 10 P.M., gr. XXV., followed by gr. x., followed by gr. v. Slept till morning. 4th day.-Much better. further dose was needed. with a very mild attack of chorea. night, and was better each day. I saw her several times afterwards, and she was never free from a slight twitching of one hand; but this was scarely noticeable. Her general health was so much improved that I did not recognise her. It will be seen that this patient took only 140 grains 10 P.M., gr. xx., followed by gr. v. No in the course of four nights, and the first patient only 45 in one night. I have never attempted the cure of mild attacks of chorea in this way, and have not had any further opportunity for proving it in severe cases. These two occurred in Dr. Black's wards at St. Bartholomew's Hospital, and I wish to thank him for his approval of my treatment, and for his permission to publish the result. |