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symptom of malaria. So, thinking that was what I had to deal with, I put her on a malarial treatment. She began having these symptoms about three or four weeks ago and gradually grew weaker. She said when she took a short walk, just around the square, her husband would have to support her before they got back to the house, especially when she got to the steps; then afterward she seemed to have something in front of her eyes. She could not see well for a few minutes.

May 2d I saw her, and still continued my malarial treatment; and on the afternoon of the 2d she began to complain of some cramps in limbs, but not severe. So, thinking that they would soon disappear, I paid but little attention to them. On May 3d saw her about 9 A. M. She was then complaining of about the same symptoms as before, except a little nauseated. I at once discontinued the use of the iron she was on, thinking that had nauseated her a little. I saw her again that afternoon, and she was very much nauseated, could not even retain water on her stomach. I then discontinued all of my present treatment, and tried hot water to quiet her stomach without any results, so then put her on sodii bicarbonatis and aquæ menthæ pip. a 2 ounces, teaspoonful every five minutes, and succeeded in quieting her nausea by bedtime that night; and after this she had nothing until I saw her the next morning (May 4th) when I received a message about 4 o'clock A. M. to call at once, that she was worse. I responded at once, and upon my arrival found her eyes fixed, mouth a little open, teeth showing, stiffness in the back of neck, and the fingers of both hands were contracted very firmly down in the palms of the hands, so much so that they could not be removed. These contractions were clonic; at times she could straighten the fingers out almost full length. All during these contractions the patient was thoroughly conscious. Her tongue was swollen and a little protruded, which interfered with her talking to some extent. All these symptoms came on gradually. So then I decided that I had something more serious than malaria. Dr. J. W. Guest was called in consultation at this time, and we together proceeded to make a thorough examination of every organ, and to inquire more fully into the previous history of the case. We found the lungs, heart, liver, and every organ in a good condition, except the heart was still weak. But upon examining further into the previous history of the case we learned that she had been on strychnia in tablet form, one thirtieth grain each, for eight months four times a day. She said they were prescribed for her for nervousness. So, after hearing this,

and knowing that every other organ of the body was in good condition, and the symptoms we had while they indicated strychnia poisoning they were not that of acute poisoning. We then decided that we had a case of chronic strychnia poisoning, caused by an overaccumulation of the drug, with a gradual outburst. We then gave her hypodermatically one eighth grain pilocarpine mur. at 11 o'clock A. M., and ordered soapsuds enemas every two hours, and in about an hour she was perspiring profusely. At 12 o'clock she was removed to the Norton Infirmary. Upon her arrival there pulse was 122, temperature 100.2°; by evening temperature fell to 99.2°, and pulse was 114. Kept up the enemas all day, each returning well colored, and particles of fecal matter in them. Profuse perspiration continued from the one dose of pilocarpine until 9 P. M. Hare states the sweating period is from three to five hours, but this lasted ten hours.

Kidneys acted normally, about four or five times a day. Night of the 4th slept very little; in no pain, but could not go to sleep. She never did complain of a single pain from this on. Morning of the 5th, very restless, still very weak. Ordered nourishment and whisky by the mouth every two hours, also .or grain nitroglycerine hypodermatically every four hours and enemas stopped. Very nervous all day, but became quiet about bedtime. Temperature ranging from 98° to 99.6°; pulse 110 to 120. Night 5th slept fairly well. I saw her early on 6th, she was feeling very well. Contractions in hands all disappeared, eyes about natural, but teeth still showing some, and tongue swollen still; pulse very weak; patient delirious. Ordered nourishment and whisky same, and gave nitroglycerine every two hours. At 1:30 urinated involuntarily; constipated very badly, given five grains of calomel, followed by Sedlitz powder every two hours, until moved. Three powders were taken before calomel acted. Had four large, dark, thin stools, last one only partly formed. On 6th pulse range 108 to 120, temperature 98° to 98.2° in axilla, respiration 20 to 28. Slept ten to twenty minutes at a time during the day, and fairly well that night. On morning of the 7th very restless, and complaining of being tired, and some headache. Continued whisky with my nitroglycerine and nourishment the same. Patient very restless up to I P.M., then slept a great deal during the afternoon, but only a few minutes at a time. The case was seen by Dr. J. W. Guest once a day in consultation, and each time she was examined thoroughly for complications and to see if another diagnosis could be made, but without any

results each time. On 7th temperature range 97.2° to 97.6°, pulse 96 to 108, respiration 20 to 24. Night of the 7th slept about four hours, still urinating involuntarily. Morning of 8th still delirious, pulse 98, temperature 97.6°, constipated; slept a great deal during the day; treatment the same. Tongue heavily coated, fetid breath, blue lips. Given five grains calomel at 3:30 P. M., followed in two hours with Sedlitz powder; bowels moved at 7 P. M.; and from this time until 9 A. M. of the 9th bowels moved twelve times, each stool large, dark and soft, but not watery, last two involuntary. 8th, pulse range was 98 to 104, very weak, temperature 98.2° to 98. ̊4; respiration 30 to 34. Night of the 8th very little rest. Morning of the 9th pulse 98, temperature 97°, respiration 34 and weaker. Ordered nourishments and stimulants the same. Very restless for a few minutes at a time. At 9 o'clock began to menstruate, and more restless; ordered one sixth grain morphia hypodermatically and repeated with one eighth grain at 10:30 A. M. All during the day kidneys and bowels acted involuntarily. Refused nourishment for the first time, had always taken every thing given her. Slept about an hour from the morphine. 9th, pulse range 98 to 109, temperature 97° to 100.6°; respiration 24 to 36. Night of the 9th slept only a few minutes, restless. Morning of the 10th pulse 104, very weak. Ordered stimulants the same, nourishments refused often. At 5 A. M. very restless; at 6 A. M. bowels began to move every half hour. At 9:30 A. M. ordered chalk mixture, half an ounce every half hour until bowels were checked. Bowels continue to move constantly up to 1 P. M., in that time moved fourteen times-all copious, involuntary, thin, and light in color; by this time pulse weaker than ever before, patient unconscious. At 3:45 P. M. Very restless; ordered one sixth grain morphia. At 5:30 P. M. profuse perspiration; at 8:30 convulsion five minutes, another at 10 P. M. three minutes; ordered morphia one eighth grain. At 11:15 still perspiring profusely; at 12:50 convulsion one minute and a half; ordered another one eighth grain of morphia. Night of the 10th no rest at all. 10th, pulse range from 100 to 116, temperature 98.8° to 100.4°; respiration 32 to 34. Morning of the 11th, between 2:10 A. M. and 6:40 A. M. had seven convulsions, lasting from one and a half to four minutes. At 4:15 given an eighth grain morphia; at 7:30 A. M. severe convulsion followed by profuse perspiration; convulsions continued every four minutes until 7:40 A. M., when she died in a convulsion.

I only saw her in one convulsion (the last one); each muscle seemed

to be contracting separately, eyelids and muscles of the face in a constant state of contraction. The case was such an unusual one that I have consulted all the literature I could find in regard to it, and could only find the following (Hare): If the onset is gradual some stiffness of the back of the neck and uneasy startings may precede the general nerve storm. Flint, Loomis, and Pepper say nothing at all about the gradual (chronic) poisoning.

LOUISVILLE.

Reports of Societies.

LOUISVILLE MEDICO-CHIRURGICAL SOCIETY.*

Stated Meeting, April 22, 1898, the President, Frank C. Wilson, M. D., in the chair.

Perforative Appendicitis. Dr. A. M. Vance: This perforated gangrenous appendix was removed from a young lady, nineteen years of age, last Wednesday.

The patient, who up to this time had been perfectly well, was taken with pain in the right iliac fossa on Monday night at eleven o'clock, the symptoms gradually increasing in severity until I saw her at eleven o'clock Wednesday, and operated upon her at three o'clock the same afternoon. At the time I saw her she had a pulse of 140 to the minute, temperature 102° F. I advised immediate operation, and she was taken to St. Joseph Infirmary for the purpose. The appendix was found surrounded by considerable thin and very foul pus. Some few adhesions had occurred, and the appendix was ruptured at its base. The impression was so great that there was complete inactivity of the bowel. To overcome this she was given five drops of croton oil immediately after being taken off the operating-table. Her bowels moved the same night, and I believe we must say that it was through the influence of timely operation and croton oil that her life was saved.

I think croton oil is the best agent to administer in these cases where there is already more or less paresis and inactivity of the bowel and we want to secure immediate drainage through the intestinal

tract.

Discussion. Dr. A. M. Cartledge: Have you seen any especial gastric irritation from the administration of croton oil?

Stenographically reported for this journal by C. C. Mapes, Louisville, Kentucky.

Dr. A. M. Vance: I have never seen any gastric irritation from croton oil given in cases such as I have mentioned. I do not give it in capsule, but it is mixed with some non-irritating medium, the tongue is drawn out and the mixture deposited on the base of the tongue with a spatula, a little water being always given afterward. I believe it is better to give croton oil in these cases in four- or five-drop doses, by the method I have indicated, than to administer it in smaller doses more frequently repeated in capsule or other form, as has been recommended. by different authorities.

Dr. L. S. McMurtry: Dr. Baldy has had some disastrous results from the administration of croton oil in cases of septic peritonitis where there was difficulty in moving the bowels. He said very positively in his recent paper that he would never administer another dose of croton oil under those circumstances; that his experience satisfied him it was dangerous. He has had a very large experience in abdominal surgery and is a very judicious man, and I would suggest that Dr. Vance look the subject up from Dr. Baldy's standpoint. As Dr. Vance has administered croton oil a great many times with gratifying results, of course that experience is reliable and trustworthy, but there may be some features in connection with the subject which a more extended experience would develop.

Dr. A. M. Cartledge: As I understand Dr. Vance he has found croton oil successful in moving the bowels in desperate cases of appendicitis where there was great distension and in which we have formerly used salines, calomel, etc., with no result. In view of this fact, as the vast majority of those cases will die promptly if the bowels are not moved, simply from fecal toxemia, paresis, toxemia from the colon bacillus, etc., if croton oil will prove effective we can well afford to take the chances of the danger it may entail as the patient will die otherwise. Where there is great distension and where other purgatives fail, and it is a question of purging the patient or death will supervene, croton oil is undoubtedly a valuable remedy, and I shall in future administer it in such desperate cases.

Dr. A. M. Vance: The operation was finished at 3:30 o'clock in the afternoon; croton oil was given immediately afterward, and the patient had a fecal evacuation at nine o'clock in the evening. Her pulse was 150 when she went on the table, and when the operation was completed it was slightly lower, and altogether the case was such an extreme one that immediate drainage by the intestinal tract seemed

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