(Received May 4; revision accepted for publication June 30, 1970.)
A.B. formerly was assistant professor of psychiatry, University of Pennsylvania School of Medicine,
Philadelphia, Pennsylvania.
PRESENT ADDRESS: Dana Division of Child Psychiatry, Hadassah Medical Organization, P.O.B. 499, Ierusalem, Israel.
PEDIATRICS, Vol. 47, No. 1, Part 1, january 1971
PREDICTING
THE
RESPONSE
OF
CHILDREN
WITH
LEARNING
DISABILITIES
AND
BEHAVIOR
PROBLEMS
TO
DEXTROAMPHETAMINE
SULFATE
The Clinical
Interview
and
the
Finger
Twitch
Test
Avner Barcai, M.D.
Department of Child Psychiatry, Hadassah Hebrew Medical School, Jerusalem, Israel
ABSTRACT. This is a clinical study using a
phe-nomenological, office practice approach to diagnose
the hyperkinetic child who responds with
im-proved concentration and organization of his
men-tal facilities to the amphetamines. The combination
of anamnestic items, information from the teacher, and the clinical interview were found to be effec-tive in correctly predicting approximately 85% of
behaviorally disturbed children who would
re-spond favorably to the stimulating drugs. The
fin-ger twitch test and a list of selected questions,
which could be used by the pediatrician in his
office, were found to lead to a weighted, non-infer-ential assessment of the child’s mental status, as a
help in determining the advisability of prescribing
the stimulant for some behaviorally disturbed
chil-dren. Pediatrics, 47:73, 1971. HYPERKINETIC
CHILDREN, AMPHETAMINE RESPONDERS, BEHAVIOR
DISORDERS, FINGER TWITCH TEST, PREDICTIVE CLINI-CAL INTERVIEW.
T
HE use of drugs in treating childhoodemotional disorders has enjoyed
in-creasing popularity over the past decades.
Among the first successful
psychopharma-cological agents to be used in children were
the stimulating drugs.13 In hyperkinetic
children, these agents were observed to
ne-lieve enuretic episodes, to treat sexual
prob-lems of active children, to reduce
hyperac-tivity in children with behavior problems
and bring about an improvement in their
behavior and schoolroom adjustment, and to
improve certain psychometric test scores.42#{176}
Only one controlled study questioned the
effectiveness of the stimulants;21 this study,
though carefully done, involved retarded
children, and the dose of medication was
rather small.
There is no standard set of objective tests
available to establish which children with
behavior problems would respond to
stimu-lants, and most authors depend on the
re-ports of parents concerning certain
behav-ior in order to reach their diagnosis.12’15’16’”
The literature, however, seems to be
singu-larly lacking in information derived directly
from the clinical interview with the
hyper-active child. This report is an attempt to fill
this gap by using a phenomenological office
practice approach to the diagnosis of the
amphetamine responder. Features of the
cognitive apparatus of the amphetamine
responder will be described and compared
with those of children suffering from similar
behavior and learning problems who were
amphetamine non-responders.
SUBJECTS, METHODS,
AND
RESULTS
The author was a participant in a project
which attempted to evaluate the efficacy of
dextroamphetamine sulfate in the treatment
of misbehaving children with learning
problems.22 The children were students in
two public elementary schools serving a
predominantly Negro population of very
low socioeconomic class who were
charac-terized by the problems usually associated
with that class : overcrowding, broken
fami-lies, and poor physical surroundings.
With the cooperation of the school
ad-ministration, the fifth and sixth grade
74
TABLE I
PREDICTION OF RESPONSE TO DEXTROAMPHETAMINE
SULFATE USING TEACH ERS’ QUESTIONNAIRES,
FINGEI6 TwITch TEST, AND INTERVIEW AS PRroNosTIc INDICES
. . Prediction Prediction
Prediction
Correct Incorrect
l)rug responders 21
Non-responders 15 1
Equivocal 9 5
Total 45 8
presented problems in academic
achieve-ment or classroom behavior. A
question-name covering learning abilities, scholastic
achievement, behavior or conduct
prob-lems, peer relations, social standings, and
special symptoms was completed for each
child by his teacher.#{176}
Sixty children were originally referred, of
which seven dropped out before the study
began. The remaining 53 children were
in-terviewed individually for about 30 minutes
(
A.B.
),
after which a prediction concerningtheir expected response to the drugs was
made in a separate file. They were later
di-vided randomly into two groups and
treated for two 6-week periods, the first
with dextroamphetamine sulfate capsules
(
20 mg, daily, at 8 A.M.)
and the latter witha placebo, in a double-blind crossover study
to measure the effect of this drug on their
behavior and academic achievements.22
The response of the students to the
medi-cation was evaluated by their teachers, who
were ignorant of our methodology. Every 6
weeks they reported behavioral changes
and described the children’s present status
as compared with their original difficulties.
A month after the completion of the drug
study, when all medication had been
dis-continued for 4 weeks, the teachers
ne-eval-uated the subjects, using the following
criteria:
a More complete information on the
question-naires submitted by the teachers has been published by Conners, et al.”
1. Did not change at all.
2. Improved considerably at some period
of medication, but regressed noticeably
when the drug was discontinued (definitely
seems to need medication).
3. Moderate improvement at some
pe-nod of medication and maintained some of
the improvement into the post-study
pe-nod.
4. Improved and does not need
addi-tional help.
This evaluation was added in order to
val-idate the information from earlier
ques-tionnaires and to minimize a positive
Haw-thorne effectf which might have developed
during the study as a result of the teachers’
positive expectations. The final
determina-tion of each child’s response to the
amphet-amines was made by two staff members
who were not directly connected with the
study. Their decision was reached by
exam-ining the two questionnaires completed
during the study and comparing them with
the follow-up data (interobserver
agree-ment was 95%).
Of
the 53 subjects, 23 were found to beamphetamine responders. These children
improved more on the drug than on the
pla-cebo and demonstrated gross deterioration
following the discontinuation of
medica-tion.
The second group of 16 children became
worse while taking the drugs, improved on
placebo, on did not change at all; these
chil-dren were considered non-responders.
The third group of 14 children did not
demonstrate a clear-cut pattern. They
im-proved more on active medication than on
t An effect of improvement in performance. It
is the result of unintended intervention in an area
unrelated to the issue being studied, as a result of
heightened interest by the participants in the
ex-penment. It is derived from experimentation with
intensity of light and its effect on worker’s
per-formance at the Hawthorn Electric Company in
the U.S.A. There it was found that, as a result of
the creation of experimental condition and
invest-ment of interest, worker’s performance improved
even when lighting conditions were far below
ARTICLES 75
* Equivocal response to riextroamphetamine.
placebos, and maintained at least part of
the improvement after medication had been
discontinued. This group was considered to
be equivocal responders
(
these childrenmight have responded to the
euphoria-pro-ducing effect of amphetamines, which
might have materialized latent cognitive
abilities23 supported and maintained by
positive feed-back from teachers).
Of the 37 children who could be clearly
categorized by their responses to
stimu-lants, the clinician’s predictions were found
to be correct for 21 of the 23 responders
and for 15 of the 16 non-responders
(
TableI
)
. For the group which respondedequivo-cally, predictions were correct in only 65%
of the children. Thus, the physician’s
pre-dictive ability based on information from
the clinical interview, together with the
teachers’ questionnaires, was around the
80% mark. This high rate of prediction
sug-gests the importance of the interview as a
di-agnostic tool.
THE CLINICAL INTERVIEW
The 53 children involved in the study
were interviewed in alphabetical order by a
child psychiatrist (A.B.
)
for approximately30 minutes in a structured interview. The
questionnaire listing the child’s difficulties
was available to the examiner. The
inter-view opened with each child being asked
about his classroom problems and then
pro-ceeded with the structured pant which
in-cluded the following items.
The Finger Twitch Test
The child was told that we were going to
play a game, whose goal was to discover
how long he could sit without moving his
hands or fingers. The observer and child
were seated opposite each other, their
hands hung between their knees and their
heads fell forward on their chests. The
child was asked to leave his hands in a
non-mal position with the fingers moderately
flexed. The interval between the beginning
of the test and the appearance of the first
twitch of a finger or hand was measured by
a stop watch. The type of movement
de-fined as a finger twitch is an abrupt, jerky
movement which has two characteristic
components :
(
1)
a rather brisk, fastmove-ment of a finger or hand about 1 to 2 cm
from its original position, which occurs
more frequently up or down than laterally:
(
2)
a slow return to the original position.This choreiform jerk is reminiscent of
nys-tagmus with its fast and slow components.
Slow athetoid movements or fine tension
tremor are assumed to be of a different
etiology and were disregarded in that test.
(
The idea of using the finger twitch test asa diagnostic tool was proposed only after 23
children had already been interviewed;
thus, it was performed on 30 subjects only.)
The finger twitch appeared in 29 out of
TABLE II
TIME (IN SECONDS) FROM THE BEGINNING OF TEST UNTIL THE APPEARANCE OF FIRsT FINGER TWITCH
Respond ers or Equivocal (n=21)
Non-responders (n=9)
9 5
10 s2
10 34
10 35
15 3.5
15 40
15 40
17 45
18 60
0 20 20 20
21*
25* 25 25 25 30*
45*
45*
Total 440 346
Mean 20.95 38.44
S.D. 9.85 9.86
SliM 2.15 3.29
t=4.455
19 4 0 16
4 19 II) 6
S 15 14 2
8 15 13 3
8 15 12 4
7 16 12 4
.0() 1
.01
.02
.05
.0.5
.03
OC-76
TABLE III
‘FIlE PRESENCE OF MENTAL STATUS ITEMS IN THE DRUG RESPONDERS AND THE NON-RESPONDERS AND THEIR STATISTICAL RELEVANCE
.%Ienlal Stafus Category
Excessive body movement
Ability to abstract and use imagination
constructively
Adjustment to societal values and abil-ity for future planning
Sense of perspective and tile ability to
transcend
Good language ability
Planning-correlation between future
cupation and the three wishes
Drug Responders
ltem Not
Manifest Manifest
Non-responders
item Not Manifest Manifest
p
Localization of security-taking friend
versus family member to the moon
Father at home
Positive evaluation of popularity standing
N.S. = not significant.
13 10
10 13
13 10
U 4 N.S.
10 6 N.S.
9 7 N.S.
the 30 children before 1 minute had elapsed
(Table II). In the combined groups of drug
responders and equivocal responders it
ap-peared as early as 9 seconds, and in all but
two it appeared before 30 seconds had
passed. The minimal time before the
ap-pearance of the twitch was 25 seconds in
the group of non-responders, and in only
one did it appear before 30 seconds.
(
It isinteresting to note that the equivocal
ne-sponders were lumped in the 25 seconds and
above range.
)
The cut-off point of 30sec-onds for the age range of 11 to 12 years
al-lowed for only 10% of false positive and
false negative responses. The difference
be-tween mean time of appearance of the
ne-sponders
(
20.95 seconds)
and thenon-re-sponders (38.44 seconds
)
is statisticallysignificant beyond p > .001.
The Interview
The amount of motility during the
inter-view was compared to expected body
movements for this age group for the same
time span. Motility, especially movements
of the hands, turning of the body in the
chair, and head turning, was increased
among the drug responders, while all 16
children who were non-responders did not
exhibit excess motility during the interview.
(
The differences between the groups aresignificant beyond the .001 level.)
Each child was asked the following
ques-tions:
“What do you want to be when you
grow up?”
“If you had three wishes, what would
they be?”
ARTICLES 77
there for 6 months, and you could take only
one person with you, whom would you
take?”
“What kinds of things do you think you
might need to take with you if you were to
go to the moon and stay there for 6
months?”
“Are you a happy or a sad child?”
“Why?”
“Do you have friends? How many? What
kind of a guy/girl is your best friend?”
“Make up a story for me.”
The child’s answers were recorded and
examined, and the following judgments
were recorded
(
Table III).1. The child’s ability to use
(
a) abstractconcepts and (b
)
the level of hissophistica-tion and imagination were assessed.
An-swers to the question ‘What things would
you take to the moon weighed
heav-ily in assessing the child’s abstract abilities.
Answers such as “oxygen, food in tubes,
ra-dio to contact earth, special spacesuit, and
space equipment” indicated an ability to
transcend immediate daily needs on this
imaginary trip; they included the important
realization that traveling to the moon
means new circumstances which demand
different solutions and were thus given a
l)ositive score. The concentration on
im-mediate needs such as “food,” “water,” or
“I don’t know,” were then scored as lacking
sophistication. The differences between the
groups were significant beyond p > .01
level.
2. The child’s concepts regarding social
values and his ability to plan were assessed
as either well or poorly developed. In part,
judgment concerning these abilities was
ex-tracted from the total interaction between
examiner and child, and from the child’s
an-swers, which included his manifested
abil-ity to plan for the future, evidence of his
ability to delay gratification, respect for
so-cial institutions such as parents and
teach-ers, recognition of the negative aspects of
violence and respect for compromise as a
solution for interpersonal conflicts. In
adcli-tion, a positive approach toward help,
inter-est in school and future achievements, and
manifest respect for other people’s feelings
also contributed to a positive score. The
dif-ferences between the groups were
signifi-cant beyond p > .02.
3. The child’s ability to deal with his life
via perspective and distancing was
evalu-ated. The ability to detach himself from the
immediate environmental pressures
(
in-eluding the interview
)
and to transcendand observe them from another vantage
point were important parameters. The
ab-sence of perspective and the existance of
concreteness,
of a literal approach thatin-cluded the inability to become interested in
issues beyond their immediate life
expeni-ences, were given a negative score. The
dif-ferences between the groups were
signifi-cant byond p > .05.
4. The important elements of the child’s
language ability were determined by his
age-related proficiency in the appropriate
use of syntax and idiomatic English, the use
of
complex sentences, and the presentationof several ideas connected by an inner
thread. When sentences were short,
chop-ped, or not meaningfully connected; when
continuity of subject material was lacking;
and when poor handling of syntax and
grammar were apparent, the score was
neg-ative. The differences were significant
be-tween the groups beyond p > .05.
5.
The child’s planning ability wasas-sessed by looking for a relationship
be-tween his projected occupation and his
three wishes. A positive relationship was
deemed present when a child who wanted
to become a baseball player wished for
im-proved catching ability or the possession of
a baseball glove, or when a child who
wanted to become a pilot wished for an
air-plane model. The absence of a relationship
was scored negatively. The differences
be-tween
the groups were significant beyond p > .05.6. The child’s localization and level of
se-cunity was assessed. The frequency of the
wish to take a family member to the moon
78
Differences between the groups were not
significant.
7. The presence or absence of father
liv-ing in the home was noted. Differences
were not significant.
8. The child’s social standing was rated
according to his statement concerning his
popularity. Differences between the groups
were not significant.
DISCUSSION
The Finger Twitch Test
This test was a modification of the
cho-reiform movements test used by Prechtl
and Stemmer24 and Wolf and Hurwitz.25
Prechtl and Stemmer24 believe that the
on-gin of the choreiform syndrome is an injury
to the putamen or the caudate nucleus, and
they postulate that this damage was caused
by a disturbance of the oxygen supply to
the brain at birth on later. They refer to
Lederer and Ederer26 and Hassler’s data27
to support the hypothesis that the
hypenki-netic syndrome should be regarded as a
variant of a noncortical cerebral palsy.
Laufer and his cowonkersl6,l7 also
hypothe-size sub-cortical damage in hyperkinetic
children, which they localize in the
dience-phalon. This idea of subcortical lag of
mat-uration4’5 or damage28 gains indirect
sup-port from Bunks,29 who demonstrated that
children with hyperkinetic behavioral
dis-orders who had surface EEC abnormalities
did not respond to the amphetamines as
well as those who did not have cortical EEG
disturbances. It is common clinical
knowl-edge that among the most notorious and
grave difficulties manifested by these
chil-dren are those of attention span and
con-centration, faculties mediated by the system
responsible for arousal and focusing,
namely, the subcontical reticular activating
system. Thus, we wonder whether the
men-tal difficulties of these children on the one
hand and the choreiform twitch on the
other are the manifestation in two
path-ways
(
mental and muscular)
of the samedisorder-lack of age adequate control. The
issue of age adequacy and of maturation
with age is documented from two different
vantage points. It is clinically accepted that
the hyperkinetic syndrome spontaneously
disappears around the ages of 14 to 17
seem to spontaneously recede.15’17 In
addi-tion, Wolff and Hunwitz,25 using a
30-sec-ond cut-off time for the children they
tested, found that the incidence of the
cho-reiform syndrome was 47.3% in Camp
We-diko, whose occupants were 9 to 13 years
old, and to 38.6% at the Reception Center,
Youth Service Board, where the delinquents
were 13 to 17 years old. We tend to interpret
this drop in incidence to mean that the
choreiform syndrome might be age
de-pendent.
Thus, it would seem imperative to
estab-lish normative data for the choneiform
fin-ger twitch for different ages. It is quite
pos-sible that the 30-seconds cut-off point,
which was found predictive of response to
the stimulants for children aged 10 to 12
years in our study, might be different for
younger or older children. Whether the
cho-reiform movements syndrome by itself is
predictive of children malfunctioning is
open to question, with opinions ranging
from pro30’31 to con.32 However, in those
children manifesting behavior or learning
problems, it was found to possess a
predic-tive diagnostic value concerning their
re-sponse to the stimulating drugs.
The Clinical Interview
Laufen and Denhoff16 state, “history has
been the most valuable item in making the
diagnosis.
. .
.“ They describe the symptomsof hyperactivity, short attention span and
poor power of concentration, variability,
impulsiveness and inability to delay
gnatifi-cation, irritability, explosiveness, and poor
school work, as essential to the diagnosis. In
the anamnesis, Knobell2 characterizes the
hyperkinetic syndrome by the existence of
at least seven out of nine behavior traits
re-ported by adults: aggnessivity, impulsivity,
ARTICLES 79
excessive demands, poor capacity to sustain
an effort, poor school performance, and
poor peer relationships.
The population of children described in
this report consisted almost exclusively of
such children as described by their
teach-ens. However, an attempt to medicate the
total group would have produced enough
drug failures to render the physician rather
skeptical concerning the efficacy of the
am-phetamines in the treatment of this
syn-drome. The addition of observable
inter-view information together with the finger
twitch test helped to differentiate this
het-erogeneous group into stimulant responders
and non-responders. It is hoped that the
cu-mulative information described might
ben-efit the physician confronted with such
problems by placing more accurate
diag-nostic tools leading to selective treatment in
his hands.
SUMMARY
A clinical study using a
phenomenologi-cal office practice approach to the diagnosis
of the hyperkinetic child who responds to
dextroamphetamine sulfate has been
pre-sented. The finger twitch test and a list of
selected questions leading to a weighted,
noninferential assessment of the child’s
mental status has been presented. The
com-bination of information which includes
items from his history, information from his
teacher, and a clinical interview has been
found to be effective in the prediction of
the response of the behaviorally disturbed
child to dextroamphetamine sulphate.
REFERENCES
1. Bradley, C. : The behavior of children
receiv-ing Benzedrine. Amer. J. Psychiat., 94:577, 1987.
2. Reifenstein, E. C., and Davidoff, E. :
Benze-drine sulfate therapy: The present status.
New York
J.
Med., 39:42, 1939.3. Lourie, R. S. : Psychoactive Drugs in pediat-rics. PEDIATRICS, 34:691, 1964.
4. Bender, L., and Cottington, F. : The use
of amphetamine sulfate (Benzedrine ) in
child psychiatry. Amer.
J.
Psychiat., 99:116,1942.
5. Bender, L., and Faretra, C.: Organic therapy
in pediatric psychiatiy. Dis. Nerv. Syst., 22
(4):11O, 1961.
6. Bradley, C. : Benzedrine and Dexedrine in
treatment of children’s behavior disorders.
PEDIATRICS, 5:24, 1950.
7. Bradley, C., and Green, E. : Psychometric
per-formance of children receiving amphetamine
(Benzadrine) sulfate. Amer. J. Psychiat., 97:
388, 1940.
8. Bradley, C., and Bowen, M. : Amphetamine
(Benzadrine) therapy of children’s behavior
disorders. Amer.
J.
Orthopsychiat., 11:92,1941.
9. Chess, S.: Diagnosis and treatment of the
hy-peractive child. New York J. Med., 60:2379,
1960.
10. Conners, C. K., and Eisenberg, L. : The effects
of methylphenidate on symptomatology and
learning in disturbed children. Amer. J.
Psy-chiat. 120:458, 1963.
11. Eisenberg, L., Lachman, R., Molling, P. A.,
Lockner, A., Mizelle, J. D., and Conners,
C. K. : A psychopharmacologic experiment in
a training school for delinquent boys:
Meth-ods, problems, findings. Amer. J.
Orthopsy-chiat., 33:431, 1963.
12. Knobel, M.: Psychopharmacology for the
hy-perkinetic child, dnyamic considerations. Arch. Gen. Psychiat., 6: 198, 1962.
13. Knobel, M., and Lytton, C.
J.
: Diagnosis andtreatment of behavior disorders in children.
Dis. Nerv. Syst., 20(8) :334, 1959.
14. Knobel, M., Wohnan, M. B., and Mason, E.:
Hyperkinesis and organicity in children.
Arch. Gen. Psychiat., 1 :310, 1959.
15. Laufer, M. : Cerebral dysfunction and behavior
disorders in adolescents. Amer.
J.
Orthopsy-chiat., 32:501, 1962.
16. Laufer, M. W., and Denhoff, E. : Hyperkinetic
behavior syndrome in children. J.Pediat., 50:
463, 1957.
17. Laufer, M. W., Denhoff, E., and Solomons, C.:
Hyperkinetic impulse disorder in children’s
behavior problems. Psychosomatic Med., 19:
38, 1957.
18. Molitch, M., and Sullivan, J. P.: Effect of
Benzedrine sulfate on children taking the
new Stanford Achievement Test. Amer. J.
Orthopsychiat., 7:519, 1937.
19. Molitch, M., and Poliakoff, S. : The effects of
Benzedrine Sulfate on enuresis. Arch. Pe-diat., 54:499, 1937.
20. Roland, S. I. : Essential nocturnal enuresis
treated with dextroamphetamine sulfate.
J.
Urol., 71(2):216, 1954.
21. McConnell, T. R., and Cromwell, R. L. :
amphet-(so
DEXTROAMPHETAMINE AND LEARNINGamine drug administration on the activity
level of retarded children. Amer.
J.
MentDefic., 68:647, 1964.
22. Conners, C. K., Eisenberg, L., and Barcai, A.:
Effect of dextroamphetamine on children.
Studies on subjects with learning disabilities
and school behavior problems. Arch. Gen
Psychiat., 17:478, 1967.
23. Schachter, S., and Singer, J. E. : Cognitive,
so-cial, and physiological determinants of
emo-tional state. Psychol. Rev., 69:379, 1962.
24. Prechil, H. F. R., and Stemmer, C.
J.:
Thechoreiform syndrome in children. Develop.
Med. Child. Neurol. 4:119-127, 1962.
25. Wolff, P. H., and Hurwitz, I. : The Choreiform
Syndrome. Develop. Med. Child Neurol., 8:
160, 1966.
26. Lederer, E., and Ederer, S. :
Hypermotilitats-neurose im Kindesalter. Jb. Kinderheilk.,
143:257, 1934.
27. Hassler, R. : Die Extrapyramidalen
Rindensys-teme und die Zentrale Regelung der
Moto-rik. Deutsch. Z. Nervenheilk., 175:233,
1956.
28. Clement, S. D., and Peters, J. E.: Minimal
brain dysfunctions in the school-age child:
Diagnosis and treatment. Arch. Gen.
Psy-chiat., 6:185, 1962.
29. Burks, H. F.: Effects of amphetamine therapy
on hyperkinetic children. Arch. Gen.
Psy-chiat., 11:604, 1964.
30. Stemmer, C. J.: Choreatiforme
Bewegunson-rust. University of Groningen, Doctoral The-sis, 1964.
31. Prechtl, H. F. R.: Prognostic values of
neuro-logical signs in the newborn infant. Proc.
Roy. Soc. Med., 58:3, 1965.
32. Rutter, M., Graham, P., and Birch, H. C. :
In-terrelations between the choreiform
syn-drome, reading disability and psychiatric
disorder in children of 8-li years.
De-velop. Med. Child Neurol., 8: 149, 1966.
DR. RICHARD MEAD AND HIS REMEDY FOR THE BITE OF A MAD DOG
Perhaps the best known English physician of
the first half of the eighteenth century was Dr.
Richard Mead (1673-1754) . His regimen for
the treatment of a patient bitten by a mad dog
was widely used, not only in England but also
in the United States. Dr. Mead’s name was so
revered that few physicians dared to question
the efficacy of his regimen until Dr. James
Mease (1771-1846) of Philadelphia who in
1792
wrote
that Mead’s management of rabiddog bites, cited below, was “totally useless.”1
Take Ash coloured Ground Liverwort four
drachms, Black Pepper two drachms, mix them
to-gether into a fine powder: This is to be divided
into four doses, whereof one is to be taken in warm
milk in a morning fasting, for four mornings
sue-cessively; after this the person must be put into a
cold bath, pond, or river, for thirty days together,
early in the morning, and before breakfast: he is to
remain in it with his head above water not longer
than half a minute. The wound should be
continu-ally fomented with a pickle made with Vinegar
and Salt, as warm as it can be borne.2
NOTED B T. E. C., Jn., M.D.
REFERENCES
1. Mease,
J.
: An Inaugural Dissertation on theDis-ease Produced by the Bite of a Mad Dog or
Other Rabid Animal. Philadelphia: Thomas
Dobson, p. 106, 1792.
2. Theobald, J.: Every Man His Own Physician,
