1875 The Lancet  
194 the country. He very foolishly went out for a drive on s wet day, caught cold, and had to return home nearly as bad as before. On July 27th, when I again saw him, I found that, in addition to his old ailments, he had an attack of pleurisy on the right side. This was somewhat circumscribed, although for the extent of about three square inches there were decided dulness and aegophony. 28th.-I found him better. He had slept well from a half-drachm dose of chloral, and his symptoms altogether
more » ... d improved, with this exception-at which I was not a little alarmed,-that his pulse had mounted up to 185, and was exceedingly feeble. 29th.-Pulse still 185; but he had again slept well, was cheerful, and asked to be allowed to get up. He was rather displeased because I would not allow it, and he seemed also surprised that I should think it necessary to visit him oftener than once a day. I had again put him on bark and ammonia, but finding in the evening that the pulse continued persistently above 180, and as I could discover no adequate cause to account for it, I again requested that Dr. H. Jones should see him with me. Dr. Jones suggested a pill every four hours of one grain of camphor and half a grain of opium, to continue the bark and ammonia, and i s'ive a crettv liberal allowance of brandv. I July 30th.-Pulse same as before, although otherwise h continues to improve. All his rheumatic pains had dis appeared, and the pleuritic effusion had diminished. Th action of the heart was so rapid, and its impulse so feeble that it was difficult, or indeed impossible, to ascertain it exact physical condition. Slst.-He had slept well, felt better in every way, an< was still most anxious to get up, which, of course, I woul( not allow. The pulse was still above 180. I now stoppe( the ammonia, and gave him a draught, containing half I drachm of tincture of digitalis, every four hours. August 1st.-Pulse down to 140 this morning, and con valescing in every respect. The digitalis to be continued as before. 2nd.-Pulse had fallen to 100 this morning. Digitalis tc be continued. 3rd.-Pulse 90; he has so much improved in every respeci that I allowed him to get up. I now stopped the half-drachm doses of the digitalis, and gave him instead a mixture of tincture of muriate of iron and tincture of digitalis, ten minims of each, thrice a day. From this time forward his recovery was most satisfactory, and in about a week afterwards he was able to attend to business. He has continued well ever since, and stated when I saw him lately (Oct. 10th) that he never felt bp'ttfr-It would be difficult to find a case in which the tonic influence of digitalis over a weak heart is better illustrated than in this. For four days the pulse continued above 180, and so feeble that it was really very difficult to count it. Stimulants -brandy, ammonia and bark, camphor, and opium-were freely administered without the slightest effect being produced. And yet within a few hours after the digitalis was commenced-when not more than two drachms of the tincture had been taken-the pulse was reduced by 40 beats, and its volume and strength greatly increased. Within the next twenty-four hours it was further reduced by 40 beats, and ultimately brought down to its normal standard. Dr. Handfield Jones, in his valuable work on "Functional Nervous Disorders," mentions several cases of unusually rapid pulse. The number of these cases was seven, and he states that " in all the disorder wasparoxysmal, the attacks lasting from a few hours to two or three weeks." " In four the attacks terminated abruptly and suddenly, the patients being able to tell the exact moment of their cessation." A number of other symptoms, as 11 anxiety, irregular, hurried, wheezy, or difficult breathing, sense of suffocation, lancinating pain at the heart," &c., are mentioned as being associated with the special. one-of rapid pulse. In the above case, however, the peculiarity was, that the establishment of the rapid pulse was coincident with a marked improvement in all the other symptoms, so much so that the patient was not a little annoyed at my solicitude. PRESIDENCY SURGEON, 3RD DISTRICT, BOMBAY. A EURASIAN boy, aged about thirteen years, of good constitution and active habits, but dull of apprehension by his teacher's account, was admitted into hospital on Oct. 21st, 1874. He says that his teacher was in the habit of frequently caning him over the right hand, and three days previous to his coming to the hospital the fingers of the same hand became stiff and numb, and he had also slight trismus. He afterwards stated that he had an imposition to do on the 19th, which he did at night while lying on his stomach, and straining to catch the light from the gas burner. He then first felt the pain in the chest, did not do his imposition, and was caned on the hand and wrist. There was no wound or abrasion of the skin. The usual symptoms of tetanus were present, the peculiar facial expression being very marked; but two peculiarities were noticeable-namely, (1) the paroxysms of tetanic spasm commenced at the diaphragm, then affected the fingers of the right hand, flexing them, and afterwards extended to the muscles of the abdomen and legs ; (2) his deglutition was easy, as regards liquid nourishment, throughout the course of the disease, though he could not open his mouth more than half an inch for several days. The main predisposing cause in this case seems to have been an irritable state of system induced by the combined influence of physical and mental depression-perhaps, too, heat (as the boy was very fond of flying kites, and every spare moment was devoted to this amusement in the heat of the sun) had some share in it; but the direct exciting cause seems to have been the caning by his master over his right wrist and palm of the hand, though there were no marks of bruise, &c. Treatment consisted internally of ten minims of tincture of cannabis indica and five grains of bromide of potassium every third hour, and twelve grains of hydrate of chloral three times a day, and inhalation of chloroform as often as the urgency of the spasms required, but the patient was never put completely under its influence. No opium was given internally, nor any hypodermic injections of its preparations were used. He was kept apart in a room by himself, and great care was taken as regards cold draughts of air, glare, noise, &c. The diet was very generous, consisting of chicken broth with Gillon's extract of chicken and strong beef-tea, to which was added Liebig's extract of meat; milk, eggs, isinglass, jellies, blancmange, &c., were also given. His wine was increased to the extent of twenty to twenty-two ounces in the twenty-four hours, and it had no intoxicating effect on him, nor did the six to eight ounces of brandy he took-I may add that at the commencement of each attack of tetanic spasm he cried out, 11 Oh, my hand !" and soon after his body was generally straightened out and stiff, the recti and masseters being quite rigid. Sometimes opisthotonos occurred. No spinal tenderness was noticed. There was no history of worms, and constipation was not troublesome throughout. Although he took thirty-six grains of hydrate of chloral during the day, there were no delusions. The skin acted freely throughout. On the third day he seemed to be sinking, the pulse being then 120, the respiration 32. and the temperature 1000; and again on the sixth day, when the pulse was 72, the respiration 20, and the temperature still 100°. Again, on the ninth day, when spasms were frequent, breathing suffocative, and he could only rest in the semi-recumbent posture, as the spasms came on he cried out, n My hand !" and slid down the pillows on to the bed, with his body straightened out like a board. From this time until Nov. 21st he varied, sometimes appearing to be sinking, and again rallying; and I believe he was simply kept alive by stimulants frequently administered, amounting to a large quantity in twenty-four hours, and careful and unremitting nursing. I omitted saying that on Nov. 20th Dr. Denison Mackenzie,
doi:10.1016/s0140-6736(02)47225-x fatcat:qstxv5gudnaftn6a7rvob6ze2m