thors often put stuff in their books more to fill up than to benefit people who try to follow them? Haven't the books often said that certain remedies are beneficial, and haven't we given them day after day or week after week without the slightest improvement in the patient? Don't we forget sometimes that the authors are only men? That we are also men? That we have as good right to think and apply ourselves and find out for ourselves as they? And it is easy to write and easy to get it printed and easy to make mistakes? But what I insist on is that if an author says a certain thing, and our observation says the opposite, we shall not follow him but follow our own sense. An author may not necessarily have had better opportunity for application of therapeutic measures than we have. Our minds have as good right to do some clinical experimenting as an author or any one else. It is our duty to gainsay any author's dictum if from our actual observation we prove him to be mistaken. And it is our duty to add our mite to the sum total of clinical knowledge if we have anything of special value to offer to our fellow practitioners. I have no doubt that we all have some specially good formulae that would be of great value to the rest of us if we were not too modest to present them to the profession.

I would like to earnestly protest against the common practice of ascribing great virtue to certain lines of treatment in ephemeral cases. There is such a tremendous tendency for a person to get

well without treatment that if he is let alone, he will often get well as quickly without treatment as with it. Too many times we see some treatment highly extolled, whereas, if the patient had been given rest and food and light, he would have recovered equally as soon.

But what we want is to know that a certain procedure not only ameliorates but cuts short certain conditions. When we know that certain results follow the use of certain remedies every time, we can go to the bedside with a certain knowledge that we can give relief when most needed. After innumerable cases of good results along certain lines, our confidence in the application of drug medication to the treatment of disease grows stronger and stronger, and we feel that there is indeed something in the practice of medicine better than the nihilistic teaching of some of the authors. It is a great pleasure to see uniform and positive action from certain lines of treatment. It puts renewed and higher aspirations into our work. It makes us feel that ours is not a cold abysmal gulf of uncertainty; it makes us optimists. It gives us energy for renewed efforts. Finally, nothing adds to our high ideals so much as do the positive permanent results worked out from our application of therapeutic measures to the treatment of disease.

PHYSOSTIGMINE.

BY

W. C. ABBOTT, M. D., Chicago, Ill.

Eserine or physostigmine is one of the most interesting alkaloids in the entire list. Its qualities are so distinct and so important that it would be widely employed were these better known. With the ob

ject of calling attention to the properties of this valuable agent I present the following resume of its literature.

Physostigma contains at least two other alkaloids, one of which is only known to "resemble strychnine," the other exerting an action similar to that of eserine. Since

physostigmine induces paresis of the pharyngeal constrictors by a local action. Harnack considers the effect manifested a direct action on the secretory gland cells and the muscular fibers, but others attribute it to an action on the peripheral nerveendings.

these exist in varying proportions it is evident that they seriously modify the action of the plant-drug, imparting a degree of uncertainty to it altogether out of place when dealing with so powerful an agency. For this reason the crude preparations scarcely made any impression on practice, but the profession began at once with the alkaloid, there being none of the "habit obstacle" in its way. But in proportion to the quantity of calabarine that may chance to be present, physostigma is more stimulant and less sedative than physostigmine.

Given in small doses-gr. 1/100 or less to an adult-physostigmine exerts a preliminary stimulant action, causing muscular twitching and increasing the irritability and the force of the muscular fibers. The pulse is slowed and vascular tension raised, respiration accelerated. The most decided effect is manifested on the musculature of the stomach, intestines, bladder, ureters, uterus and bronchi, all which are stimulated powerfully. The tears, saliva, perspiration, mucus and pancreatic juice are increased. The pupil is contracted but the eye accommodated for near vision.

In larger doses physostigmine slows and weakens respiration, slows the heart still more and relaxes vascular tension, depresses the nerve centers, and kills by paralyzing the center of respiration. The action on the heart is a direct one and is not exerted by stimulating inhibition. Marked sedation approaching collapse has followed single hypodermic doses of gr. I 50. The general muscular force is decidedly weakened but the action on the involuntary muscular fibers and on secretion is increased. The temperature is slightly lowered, more especially that of the surface. When taken by the mouth

Physostigmine commences to display an evident action within five minutes, and by that time may be detected in the urine, by which it is mainly eliminated. The maximum of action occurs in thirty minutes and subsides within an hour unless sustained by repeated doses. Van Renterghem took gr. 1/100 every hour for five doses during the forenoon. By noon he felt slight vertigo, anorexia, non-painful gastric and intestinal peristalsis, coolness of surface, at 12.30 energetic bowel movements and vomiting without nausea, pulse reduced from 79 to 64, sweating, and by 2.30 all symptoms had passed away.

In one case when marked depression followed a hypodermic dose of gr. 1/50, relief followed promptly and permanently when the patient took a little glonoin, atropine and strychnine. The symptoms closely resembled those following an overdose of muscarine.

From this review of the physiologic action of physostigmine we see why it failed in epilepsy, chorea and tetanus, aggravating the convulsive tendency in each. In cases of strychnine poisoning animals die sooner if treated with physostigmine. The control of the central nervous system is weakened in these maladies, and the only benefit arises from the increase of elimination.

In the treatment of the morphine habit Dr. Waugh has obtained decided benefit from physostigmine in cases where the pupil is dilated after the morphine has

been stopped, but only then. The alkaloid so completely replaces morphine then that the patient can not detect the substitution. Yet this effect can be secured only from doses of not above gr. 1/100 twice each 24 hours, and the relief does not endure more than an hour, after each dose. It affords an interval of perfect peace then.

Physostigmine is the best remedy for flatulence due to intestinal paresis, and for intestinal torpor. It has recently been employed to clear the bowels before and after operations in the abdominal cavity, with excellent results. Dr. John L. Sagerson reports its use in two cases of fecal vomiting; in one it acted well but the patient was too far gone for recovery; in the other "the change was wonderful," and recovery ensued which was attributed mainly to this remedy. Subbotin found it useful in fecal impactions. With it Maschka cured a case of diarrhea with flatulence due to intestinal catarrh. With atropine to combat intestinal inhibition and strychnine to incite the nervous centers, physostigmine is a valuable remedy for intestinal torpor, and if not misused in too large doses plays an important part in curing this condition and the many ills dependent thereon.

Shoemaker finds this combination useful for the digestive troubles of women at the change of life; and in dilatation of the stomach. He denies its deleterious action in tetanus, and says more than half the cases recover under it. It should be pushed to full effect. In chorea, epilepsy and progressive paralyses, great improvement has followed its use. It has been applied successfully in infantile convulsions after chloroform had failed; and in tic, twitching of the orbicularis, writers'

cramp, obstinate hiccough; and Ringer and Murrell reported temporary improvement or arrested progress of paraplegia attributed to myelitis. They also found improvement follow its use in locomotor ataxia. Murrell succeeded with it in controlling the night-sweats of phthisis. De Giovanni combined it with ergotin for renal hemorrhages, with benefit.

In bronchitis, pulmonary congestion and pneumonia, Shoemaker found physostigmine useful by lowering the excitability of the vagus and the activity of the heart and respiration. Its tonic action on the bronchial musculature renders it of value in some cases of asthma and emphysema.

Experiment has demonstrated a decided. antagonism between physostigmine and atropine on the one hand and pilocarpine on the other. Either of these might be utilized as antidote in case of poisoning, but atropine is preferable. The speedy elimination of physostigmine renders fatal poisoning impossible if respiration can be sustained.

The contradictions in the early reports upon this agent were due, as Wood justly states, to the presence of varying quantities of calabarine in the samples tested. Those of later date are to be attributed to the undiscriminating manner in which the alkaloid has been employed in any and all cases and conditions of any given disease. Take epilepsy, for example-the primary stimulant action of small doses at the beginning of a paroxysm would ensure its occurrence; whereas the eliminant effect would tend to prevent subsequent explosions. Cases requiring depression of spinal activity and reflex excitability would be benefited by this potent agent; while the lessening of cerebral control it induces would make worse such cases as strych

nine would benefit. Until remedies are applied with a nice comprehension of the exact pathologic disorders of function presented by each case we may expect such contradictory views.

Since physostigmine is a remedy that gets to work so speedily and is so quickly eliminated it is especially one well suited for the intensive method of dosage, a minute dose being administered every ten to thirty minutes until the exact desired effect has been secured. It partakes of the safety of veratrine, aconitine, gelseminine and pilocarpine in that it can not accumulate.

A CASE OF HYSTERICAL MUTISM.1

BY

MARCUS NEUSTAEDTER, M. D., Ph. D., Attending Neurologist New York University and Bellevue Hospital Medical College; Clinic and Out-patient Department Bellevue Hospital, New York.

Although this affection is known to us under this terminology ever since science treats of hysteria, it has been frequently mistaken, as in my own case, for a variety of diseases. Charcot was the first one to call attention to this disease as a pathognomonic sign of a functional disorder and not as it was hitherto understood to be a pure simulation; but to Krieshaber and Kussmaul we Owe the scientific analysis of the modus operandi of the causes and progress of the disorder. Cartaz under the direction of Charcot catalogued the first twenty reported cases and after him Mendel, Dubois, Dutil, Gottstein and others reported similar cases.

'Presented to the Section of Neurology and Psychiatry of the N. Y. Academy of Medicine,

April 11th, 1910.

Sex.

Its

The malady occurs frequently. age or race constitute no exception. Among the causes we may mention traumatism, emotion, fright and worry. etiology is that of hysteria. In a great majority of cases the patient becomes suddenly mute, rarely it arises out of aphonia insidiously. The patient cannot articulate and while he simulates an effort to speak, as a matter of fact, he makes no attempt. His lips are perfectly immovable. Charcot nicely puts it when he says: "The hysterical mute is muter than mute, for the deafmute can articulate some sounds, but the hysterical mute can do apparently nothing." On examining the larynx we find no paralysis. In a paralysis we can observe some whispering, here not even this is a possibility. They feel a heavy tongue, that some impediment is in the buccal cavity.

Alongside of hysterical mutism we find some or many stigmata of hysteria, such as anaesthesia, dyschromatopsia or achromatopsia, concentric diminution of visual fields or reverse color field vision, globus hystericus, etc. The intelligence of the patient is entirely intact, he understands everything. The duration of this disease varies. In some it lasts days, in others weeks or months. Oppenheim speaks of cases reported lasting years. The cure is spontaneous. Treatment is suggestive only. This I shall illustrate in my case, which, on account of its peculiarity, I thought worth while reporting.

M. G., male, 40 years old, Austrian, married, tailor. Wife insane for the last seven years. Family history negative. Patient denies alcoholism or syphilis but smokes heavily. With the exception of pneumonia which he contracted ten years ago, was always well. Four years

, 1910

, Vol. V.,

ago, while at work, he claims to have been struck between his shoulder blades, taken quite unawares. This shock suddenly rendered him mute, from which he recovered after four hours. He felt as though the tongue was like a "heavy stone in his mouth." Two years after this accident he had a quarrel, during which he became mute for one day, again recovering spontaneously. About two years after this quarrel, he again quarreled and became mute. This time the condition lasted two days, from which attack he recovered spontaneously. A year ago he had some difficulty with his employer and after a violent quarrel became mute for fourteen days. This time I was called in to see him. I was told that the man was dying, that he did not partake of any food for two days and did not drink any water for a day, that in one hospital the case was diagnosed as a cerebral hemorrhage and in another as a laryngeal tuberculosis. The patient was lying in bed in an asthenic condition, refusing to move and perfectly mute. No focal signs or symptoms of an organic condition were discovered. Complete anaesthesia of the head and neck was present and upon being commanded to rise from bed, he at once responded. A glass of water was handed to him, which he drank with relish, after I had placed a strychnine tablet upon his tongue-this I did in the nature of a suggestion. After this he was able to say "yes." On the next morning the patient was brought to my office where I assured him most emphatically that he would speak within a few minutes. An application of the galvanic current along the course of the vagi in the neck made him speak at once. From that time on he was well until a week ago, when after a quarrel he again became

In a

There is very little to add to the serum treatment of gonorrheal arthritis since my publication in 1909.2 I will take a few minutes, however, in order to discuss. some points which I think are extremely important in the treatment of gonorrheal joints with anti-gonococcic serum. given case of arthritis, coexisting with or following, a gonococcus infection in some other part, usually the urethra, we must endeavor to determine whether the joint trouble is caused by the invasion of the joint or its membranes by the germ, or merely by its toxins. If the former condition exists, namely, that the joint or its membranes are invaded by the germ, antigonococcic serum has been worthless in our hands, just as it has in the treatment of all other infections with the gonococcus, such as urethritis, prostatitis, epididymitis, and so forth. As far as I know, clinically these two conditions are difficult to dif

'Read before the Chicago Orthopedic Society, March 10, 1910.

etc.

Illinois Medical Journal, June, 1909, pp. 643,