to the denuded epithelial cells from the tubules which are capable of forming casts three times as large as when the cells remained intact. I have devoted most of my time in discussing the hyaline variety, but for the lack of time have said little concerning the other very important forms. I will, however, make a few remarks relative to the granular cast. This cast, though a very important one, is some times misleading and does not always indicate an active destructive process within the kidney structure, as for example, suppose a few red blood corpuscles, leucocytes or mucous corpuscles should become broken down, all of which may occur in the practically normal kidney; now this token down material or granular detritus may adhere to or become incorporated into hyaline casts, either within the tubules, in the pelvis or ureters, to say nothing of the various crystals and urates that may be a probable factor in the formation of this cast. All of the above facts should be borne in mind, and we should not be too previous in pronouncing that the kidney is undergoing destructive change by observing the presence of a granular cast. For the above reasons I regard an epithelial cast of much more serious import than a granular one whose significance is not always a certainty. Abstracts. ADRENALIN IN THE TREATMENT OF THE CARDIAC TOXEMIA OF PNEUMONIA. The writer, Henry L. Elsner, M. D., of Syracuse, N. Y. (New York Medical Journal, Jan. 2, 1904), directs attention to the appalling mortality of pneumonia due to the resulting cardiac toxemia. The prime factor in this disease is a toxemia with obstruction in the pulmonary circuit, leading to cardiac asthenia. Marked changes occur in the right half of the heart, with far-reaching degenerative changes in the muscle, heartclots, and vasomotor paralysis. Three remedies meet the indications presented by the circulatory changes due to paralysis of the vasomotor centers, the dilated condition of the arteries and the weakened heart. These are strychnine, digitalis and suprarenal extract or adrenalin, its active principle. Adrenalin acts on the heart and blood vessels favorably; it does not act on the vasomotor center. Hence, it may be used to assist strychnine. When the vasomotor center is exhausted and blood pressure study proves the inefficiency of strychnine, adrenalin may still be administered, and, in some cases which seem unpromising when combined with the method of stimulation about to be suggested, we may carry the patient beyond the critical period to a safe recovery. Suprarenal extract, or adrenalin, has seemed to the author to act as a needed food in all infections where there is danger of myocardial degeneration. He reports a case of pneumania, in a woman, the mother of five children, in whom it had been impossible to raise a continually lowering blood pressure with strychnine. The systolic blood pressure was almost immediately raised by the repeated administration at short intervals of fifteen minims of a one to one thousand solution of adrenalin hypodermatically, and the patient was saved. LOCAL ANESTHESIA.* BY F. GREGORY CONNELL, M.D., Local anesthesia is usually accomplished by freezing or by the injection of cocain or analogous preparations. The former is most unsatisfactory, owing to the pain of the freezing and thawing and the tissue changes which it causes. The chief reason for the existence of the cocain substitutes is the danger with cocain of systemic poisoning from its absorption. Out of 250 reported cases of cocain poisoning, thirteen terminated fatally. The author himself had three cases of evil effects in a series of fifty cocain injections, while in a series of over eighty cases in which Beta-Eucain was the anesthetic used, no such symptoms were manifest. Beta-Eucain has for its most characteristic and advantageous features the following: (a) Non-toxicity, the fatal dose being between 6 and 7 grains per 2 1-5 pounds of body weight; there is practically no possibility of such a dose being injected in the course of an ordinary anesthesia. (b) It may be *Abstracted from the Annals of Surgery, Dec. 1903.. sterilized by heat without the loss of any of its properties. (c) It will not deteriorate or decompose with keeping, and, (d) It will not increase the tendency to hemorrhage to any marked degree; vasomotor paralysis and secondary hemorrhage occur less frequently than with cocain. These points have been most influential in placing Beta-Eucain as the local anesthetic of choice, and its use is being rapidly increased. The author further advocates infiltration anesthesia according to Schleich and that according to Braun, the latter combining adrenalin with cocaine or Eucain for this purpose. This combination has the advantage of a hemostatic action and of intensifying the anesthesia. Regional anesthesia is also highly recommended. It is the injection of a 1 per cent. to 3 per cent. anesthetic solution into the sensory nerve that supplies the field of operation, usually at a convenient point between the central nervous system and the site of operative interference, though in some cases the nerves may be injected when exposed in the operative wound. A combination of infiltration and regional methods is usually employed, the former for the skin and the superficial parts and the latter by the direct injection into the nerve. When it is inconvenient to expose the nerve by dissection, an injection into the perineural tissue will, as a rule, be found ample and sufficient. The injection should be made into the region of the nerve to be interfered with and the nerve surrounded by what Matas terms an "anesthetic atmosphere." This "blocking," as shown by the splendid work of Crile and of Cushing on the subject of shock, also prevents centripetal impulses from reaching the center, thus removing one of the most important if not the chief cause of shock. The advantages of local over general anesthesia are readily apparent. The former should be used as an adjuvant to, when not possible as a supplanter of, the latter. As Von Mikuliczs has said, "the question of to-day is not which is the safer anesthetic, chloroform or ether, but in what cases can local anesthesia be substituted for anesthesia by inhalation." ARSENAURO.-Continued use of this most excellent preparation in diabetes has given the utmost satisfaction. From no other preparation or combination have we obtained such material results. Furthermore, in chorea, neurasthenia, and like pathological conditions involving the nervous system, it has proven most valuable. EXODIN, A NEW PURGATIVE.* BY PROF. WILHELM EBSTEIN, OF GÖTTINGEN. Exodin, the diacetylrufigallic-acid-tetramethyl-ether, is a yellow powder melting at 180 to 190 C. It is odorless and tasteless, insoluble in water and with difficulty dissolved in alcohol. Since Jan. 13, 1903, I have experimented wtih it very extensively in the University and in my private clinic as well. as in consulting practice. This paper is based upon numerous histories of more or less obstinate constipations in males and females of all ages. The remedy never causes unpleasant by-effects, such as dyspeptic symptoms or eructations. It usually acts in from 8 to 12 hours. The unpleasant diarrheal discharges produced by many otherwise effective purgatives are absent in Exodin. In most cases the first passages are mushy and even solid. In the course of the next few hours there are usually from one to three more passages, the last being not infrequently thin. The faeces preserve their natural color. In extremely rare cases the first evacuations are diarrheal; entirely watery discharges were hardly ever observed. Once in a while the remedy may be ineffectual, but this is wholly exceptional. The action of Exodin is midway between laxative and purgative. It can be used as an evacuant in simple constipation in otherwise healthy persons and also when sluggishness of the bowels is an accidental complication or a part of some other affection. In pregnancy, even during the first two months, Exodin has when all other laxatives failed proved very efficacious and harmless, effecting evacuation of abundant stools without any trouble. The use of the drug at intervals showed that it is always equally active whenever readminis tered. (A table here appended shows the action of the drug in 18 typical cases.) For obvious reasons, a universal purgative suitable for all faecal retentions, will probably never be discovered. But the properties which Exodin exhibits enable me to welcome it as a most valuable purgative. To find the indications for constipation remedies requires especially a careful abdominal examination. In my book on *From the Göttingen University Medical Clinic. Read before the Göttingen Medical Society, Dec. 3, 1903; abstracted from the Deutsche Medizinische Wochenschrift, Jan. 1, 1904. Chronic Constipation I have gone fully into all the points involved. There is too much routine prescribing done here; those who are perpetually talking and writing against quackery must not forget the importance of depriving the quacks of their weapons. Too much must not be demanded of Exodin. We cannot expect the intestines to react at once to the purgative in cases of old chronic coprostasis which is kept up by hard and dried scybalae accumulated in the large intestines; or in spastic constipations in which the spasm of the intestinal muscles prevent defecation; or where paralytic conditions cause the retention. When the intestinal canal is weakened, its refusal to perform its functions becomes more and more obstinate as we irritate it, either by large doses of mild purgatives or by the always reprehensible method of employing so-called drastic evacuants. When hardened faecal masses are accumulated in the large bowel and purgatives are ineffectual, the so-called high-oil enemata are indicated. But the acid content of the oil, increased though it is in the gut, is not infrequently unable to irritate the large intestine sufficiently to cause the expulsion of the faeces. To aid in this, I employ purgatives which I call "propellers" and which are extremely important in the treatment of chronic coprostasis. A proper combination of the oil with them must be made, care being taken to strengthen and not to weaken the intestinal action. In my book on Chronic Constipation I gave a list of the propellers at that time known to me. The result of very extensive experimentation with Boudard's ricinine pills has caused me to reject them. But Exodin has done me excellent service as a "propeller;" since I use it for that purpose I have completely given up calomel and castor oil. Frequently 15-grain doses of the remedy sufficed with oil enemata to secure satisfactory evacuations. (A table showing the results obtained in six cases of coprostasis in which 15grain doses of Exodin was used with oil enemata of up to 10 ounces, is appended. Over purgatin and emodin (see my report on both remedies in the Therapie d. Gegenwart, January, 1902) Exodin has the advantage of greater efficiency, results being obtained with smaller doses. Besides, it does not make the urine staining, to which women, for readily understood reasons, so strongly object. |