motor derangements which are associated with excessive hydrochloric acid. Akim Peretz" found large doses of almond oil, 51-100 grammes daily, curative of the pains and hyperchlorhydria. Dr. Wold Bachman," in the medical clinic of Prof. Runeberg at Helsingfors, finds that fat, butter, cream, added to other foods, lessens markedly the excessive hydrochloric secretions. The starchy foods form five-sixths of our diet, and to keep up the weight and heat of a young adult female" doing only the lightest work, a minimum of 292 grammes carbohydrates, 54 grammes proteid, and 29 grammes fat must be taken and assimilated; if this amount of carbohydrates is not assimilated the body fat will be consumed to keep up the animal heat, and when the fat is gone the albuminous fluids and tissues will be consumed until 30 to 40 per cent of the total weight is lost, and death ensues. Preparations of malt and diastase aid in the digestion of the starchy food, and are valuable when used with the fats, and, when the fats cannot be tolerated by the stomach, are invaluable alone. In obstinate cases of anemia (excluding the pernicious variety) a combination of fatty food, malt extract, rest in bed, and massage, has rarely failed to produce a prompt and durable removal of all the symptoms of anemia. I have not much faith in iron for anemia. The reported improvement after the use of iron in many patients by blood count, and hæmoglobin estimation cannot be doubted, but other clinical symptoms of anemia frequently remain. In anemia with debility and neurasthenis, there is an over-excitability of nearly all the organs; the inhibitory power of the nervous system is weakened. In this condition food slightly irritating or even normal, over-stimulates the gastric secreting cells, and there is produced an excessive amount of hydrochloric acid, which prevents the proper digestion of starchy food by the saliva during the first period of digestion in the stomach. This disturbs the motor function (the prompt evacuation of the food into the intestine), and the general debility is still further increased; and this in its turn increases the debility reaction of the nervous system; a vicious circle is formed. We find by experiment that one hour's massage will immediately increase the red-blood cells, in samples of drawn blood, 10 to 90 per cent, in anemia. The condition returning in a few hours, repeated massage is followed by a more lasting improvement, until, after several weeks of massage treatment, with milk diet, we find a permanent improvement in the blood-cell count as well as in all the other clinical signs of anemia. The first temporary improvement is due to the increase in bloodpressure, as shown above; the secondary and permanent improvement is due to the improved digestion, principally of starchy food, the result of the soothing effect of the massage on the excited gastric nerves. 1895. New York, 1898. 1893. 1 Geo, Herschell: "Indigestions," page 45. London, * Hans Hertz: “Die Storungen des Verdanungs Apparates," page 211. Berlin, 1898. Georges Hayem: Op. cit., page 256. 'Georges Hayem: Op. cit. 8 Van Valzah: Op. cit. Sajous' Year-Book. 1891. 10 Abelman in "Boas' Darmkrankheiten," page 42. 1899. 11 46 Wagner's Pathology," page 523. 12 Wratsch (Russian), No. 3, 1899. 13 Zeitschrift fur Diat. und Phys. Therapeut. 1899. 14 Wratsch, No. 4, 1898. 15 Archiv. der Verdauungskrankheiten, page 336. 1899. Michael Foster: Physiology. 1236 Market street. THE SUBARACHNOIDEON INJECTION OF COCAIN WITH REPORT OF CASES. By A. W. MORTON, M. D., San Francisco. Professor of Surgery and Clinical Surgery in College of Physicians and Surgeons; Surgeon to the City and County Hospital. Since my paper entitled, "Is the Subarachnoid Injection of Cocain the Preferable Anesthesia Below the Diaphragm ?" which was presented to the Clinical Society in October, I have made some slight changes in the technic and have a few more cases to report. Since Tuffier reported his one hundred and thirty cases to the International Medical Congress at Paris in August, it has been tried in most every large clinic in the country. The reason for this is that every surgeon realizes the many dangers and com plications which arise from general anesthesia. The fact that it is being used by so many surgeons in preference to general anesthesia is ample proof that there is room for improvement. As to the action of cocain many theories have been advanced. We recognize that it acts as a powerful stimulant, producing increased muscular and mental power, stimulating the heart's action and having the same effect on the respiration, only in a more powerful degree. When used in the subarachnoideon space the sensory tracts of the cord are anesthetized, but the other portions of the cord do not seem much affected as the motor and tactile sensations are unimpaired. The action of the cocain injection on the cord is one which has caused much criticism of the method from a theoretical standpoint. It has been shown by Nicolettio's experiments on animals that there are no pathological lesions of the cord or nervous system following its use in toxic doses. We have never found any neurotic symptoms following its use in our cases after the patient recovered from the shock of the operation, When cocain enters the system by a mucous membrane or hypodermically, it not only has its local action of anesthetizing the nerves of sensation in the part, but it is carried by the circulation to the centers, which govern the heart and lungs. It is then we see its toxic action, so much dreaded, and it is for that reason we use a tourniquet when operating on the extremities to prevent it from entering the general circulation. Experiments on animals, performed by Messo and Aduco, by injecting cocain into the fourth ventricle, have shown that it destroys the life by paralyzing the respiration, I am of the opinion that the cocain introduced into the subarachnoideon space does not enter the circulation, but passes directly from the space through the lymph channels of the nerves into the sensory columns of the cord which connect with the subarachnoideon врасе. It has been proven by Lewandowsky, by injecting ferro-cyanate of sodium or strychnia into the subarachnoideon space, that it entered the nerves and structures of the cord without passing into the general circulation. If these experiments be true, it is rational to suppose that the cocain enters the nerves without passing into the circulation for the following reasons: First, the rapidity with which anesthesia is produced; second, the small dose which is required to produce anesthesia-from two-tenths to three-tenths of a grain; in other methods of using the drug it is often administered from one-half to two grains; third, because of its local action; fourth, the anesthesia extending as much above the point of injection as the fluid passes in the canals; fifth, no symptoms of the toxic properties of the drug. If this be the action of the drug when used in the subarachnoideon space we would not expect to find the toxic properties of the drug that we get when it enters the general circulation. We have found in many of the cases in which we have made the puncture and injected the cocain that we have a class of symptoms, such as rapidity of pulse, nausea, vomiting, headache, cramps of the limbs, etc., which we at first attributed to the toxic properties of the cocain, but we now think that it is due to a form of spinal shock which may be brought about by the puncture, or by the disturbance of the cerebro-spinal centers through the introduction of the fluid which is foreign to the locality. I do not think it is due to the increased tension of the extra amount of fluid injected into the space, or the passage of a few drops from the space, as I find it will sometimes arise in either case. It has been proven by Marx that the injection of fifteen minims of salt solution in the lumbar puncture will produce the same chain of symptoms, except the anesthesia. - I have very little anxiety as to cocain poisoning, for reasons mentioned, but should the symptoms arise which I have not seen in my cases it would be necessary to stimulate respiration by hypodermic doses of atropine and by artificial respiration. You will often have a certain amount of spinal shock. I have never considered it grave enough to use any medication, but at one time gave a dose of strychnia. The general treatment of shock would apply in these cases. The great danger in spinal anesthesia is sepsis. This can be prevented by being surgically clean or aseptic, and every precaution must be taken in sterilizing the operator's hands, the back of the patient, the syringe and the cocain. It is best to use a glass syringe and piston, which can be easily sterilized, as I have recommended in my former article. The needle must be strong enough so that it can be introduced without bending. The cocain must be sterile and fresh. It cannot be boiled, as that destroys the drug. It is an easy matter to sterilize the cocain by bringing the solution to a temperature of 80° C. for fifteen minutes for five or six times, which renders it sterile, as was suggested by Tuffier, but the solution soon becomes old and may form poisonous substances. Dr. Riley has prepared for me the crystals of cocain by sterilizing in a glass tube or small vial, which can be closed by bringing the tube to a point, or corked with a cement around the cork, which can be opened by breaking the point of the tube, or heating and removing the cork, then add the required amount of sterile water to make a two-per-cent solution. The solution is taken from the tube into the syringe. I think this is a decided improvement, as you can always make a fresh solution, which is very important. The crystals of hydrochlorate of cocain are sterilized by bringing them to 145° C. for ten minutes. I find that they are sterile, and the heat does not injure the anaesthetic properties of the drug. When making the puncture we have the patient sit on the table with his limbs over the side. By having an assistant place his fingers on the crests of the ilium, the spine of the fourth lumbar vertebra will be found on a line connecting the two crests; then, holding the finger on the spine, have the patient bend forward to separate the laminæ, select a point about half an inch below, either to the left or right side, then anesthetize the skin by a spray of ethyl chloride, then introduce the needle at the point sprayed, letting the point be directed to the canal. The distance will vary as to the muscular development of the patient, generally about two inches. If the point strikes a lamina, change the direction of the point. I can always tell when in the space by diminished resistance to the needle, but the only true way is to see the cerebro-spinal fluid pass. Should it not pass, the needle is obstructed by blood or fiber of tissue; remove and examine and repeat. In fleshy people you will sometimes find difficulty in locating the fourth lumbar vertebra, as it is difficult to find the crests. I may introduce the needle between the fifth lumbar and the sacrum, or between the third and fourth lumbar; either of these spaces are just as satisfactory as the one mentioned. Should there be a curvature of the spine it may require a little perseverance on the part of the operator. When the fluid passes I only allow a drop or two to pass, at once connecting the syringe and introducing the fluid slowly; then remove needle and close with sterile collodion, and let the patient take the reclining position; in from three to eight minutes anesthesia will be complete, |