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Let us consider the pharmacology of adrenalin. From personally conducted experiments I am positive that the drug is practically inert when given by the mouth for systemic affects. It is destroyed in the stomach. That it may have local effects on the blood vessels of the mouth, esophagus and stomach we must admit. What are its effects when administered hypodermically? It has a powerful action on the circulatory system. This action can be divided into two parts, the action on the heart and the action on the peripheral blood vessels, and the result of these actions is an enormous increase in the arterial blood pressure. The action on the heart is a resultant of stimulation of the vagus which causes a slowing of the best and a direct action on the muscle of the heart, causing a strengthened systole and a less complete diastole. The action on the peripheral vessels is a direct one resulting in a marked contraction. The most characteristic action of adrenalin on the circulatory system is the rapidity with which the action disappears, lasting not longer than a few minutes. Now, knowing the action of adrenalin on the circulatory system how can we conceive of a more pernicious drug in pulmonary hemorrhage. What is better adapted to wash away the clot obstructing the bleeding vessel-nature's remedy. I cannot see the least indication for adrenalin in internal hemorrhage unless one can apply the drug directly to the bleeding vessel. And even then who would attempt arterial hemostasis with it?

After adrenalin probably the next greatest offender is ergot. Its physiological action in causing contraction of the arterioles and increased blood pressure is too well known to need description. We forget the fact, however, that the pulmonary system of vessels is poorly supplied with vasomotor nerves and muscles, and that the offending vessel is situated in a pathological tissue, and usually has diseased walls.

I doubt if any good is caused by the agent and from the increased blood pressure; I can see how harm might result. Of the vast army of drugs known as internal styptics, viz., tannic acid, gallic acid, lead acetate, etc., they are a delusion and a snare. They do no good, can do no good, and from deranging the stomach may possibly do harm.

Have we then any agents that may favorably influence an internal hemorrhage. I think we have drugs that at least theoretically should do good. I refer to the nitrite series. Let us consider nature's methods of stopping a profuse hemorrhage. Who has not seen the syncope and faintness from loss of blood. This is nature's way of reducing blood pressure, so that a clot may form at the bleeding point.

As is well known, the nitrites lower blood pressure by causing a dilatation of the peripheral vessels, chiefly those of the head and neck, skin and splanchine areas. This is a resultant of direct action on the vessel walls. There are three chief members of the nitrite group, amyl nitrite, nitroglycerine, and sodium nitrite. While the physiological action of these drugs are very similar they differ in the rapidity of their action and the length of time the action lasts. The rapidity of action is greatest in amyl nitrite, less in nitroglycerin, and least in sodium nitrite. The length of time of the action is just the reverse, however, being longest in sodium nitrite. In these three drugs I believe we possess agents for doing good in pulmonary hemorrhage, and their action is entirely due

to their effect in lowering arterial pressure, and thus giving nature a chance to form a clot. The action of these three drugs is comparatively evanescent, a fact that I don't believe is generally appreciated by the profession. For example, I find that to get any lasting effect from nitroglycerine it has to be administered at about hourly intervals. Another fact that is not generally recognized is that there is quickly formed a tolerance for these drugs and that the dose has soon to be increased in order to get the desired effect.

A patient with pulmonary hemorrhage should of course be put to bed. As to his position in bed I think there is little to be said. Let him take the position in which he can most easily bring up blood. I have ofttimes found lying on the stomach with the head at the edge of the mattress best. As to the use of ice I cannot say I have ever seen any positive results. Yet the sucking of bits of ice is appreciated by most patients, and can certainly do Lo harm.

To relieve cough is always an indication and know of nothing better for this than morphine hypodermically. Liquid foods should be sparingly allowed for the first twenty-four hours to forty-eight hours.

I have ofttimes been struck with the number of pulmonary and cerebral hemorrhages that occur during the early morning hours. I never knew the cause until Howell by experimentation showed that there are great fluctuations in the peripheral blood pressure during those hours. It seems to be due to the fact that the vasomotor center in regaining its control, after relaxation during sleep, does so at first spasmodically. Perhaps this fact could be used to good advantage in prophylaxis.

This then I believe is a rational way of treating pulmonary hemorrhage, viz., reassure the patient as much as possible, few die from the hemorrhage. Put the patient to bed and give morphine bypodermically. If seen early while actively bleeding give inhalations of amyl nitrite. Later give nitroglycerine gr. 1-100 hypodermically, or sodium nitrite gr. 1 per os frequently enough to keep the blood pressure between 100 and 125 mg. of mercury pressure. Don't use adrenalin.

INFECTIONS.

James Burke, M. D., Manitowoc, Wis.

NFECTIONS form the bulk of our practice; a lapse of physiologic function always precedes the onset of all infectious diseases; the blood and fluids are tinctured in some manner so as to make the blood and fluids a good culture medium for the invading organism; the bowel movements have not been regular and frequent enough to carry off the poisons naturally eliminated through that avenue; the kidneys, per haps, had not the normal blood pressure to excrete the urea and other waste products normally excreted by these organs. The cause of the deficiency of the blood pressure to the kidneys and other secreting glands of the body may be overstraining of the physical or mental powers, in legit

imate avocations, in the morbid pursuit of pleasure, sometimes in the search of revenge; in a general way, the piling up of the numerous little sins against nature. We many times unwittingly place ourselves in the power of our microbic foes, and in the like manner, by bad physiologic behavior, we turn the benevolent digestive ferments, which converts our food into the right kind of nourishment, into a changed product closely resembling proteid poison, with the consequent result of having our ingested food digested in such an improper manner, as to become a danger to life, rather than a sustaining, reconstructive pabulum.

The products of indifferent digestion are stored up in the tissues, and but a very small part of it can form a part of us; the longer this bad nutritional condition persists, the nearer we approach the precipice, the gully of which is disease, and into which we are daily liable to be precipitated.

The first logical step in the cure of this or allied conditions of indifferent health is to clear out the bowel with proper doses of sulphate of magnesium or sodium; next use small oft repeated doses of podophyllin, emetine, juglandin, leptandrin or colocynthin to change the leucomains in the walls of the intestines into non-poisonous products. These leucomains or intestinal toxins are chemically related to the alkaloids and most other active principles of our common plant medicines; the toxins are nearly always incomplete chemical substances seeking, as it were, to find an allied simple entity from which they can chemically abstract what they need to make of them a complete chemical product; on completion they are promptly carried out of the body by the normal excretory organs. All toxins are promptly neutralized by the administration of the proper vegetable alkaloids, if the chemistry of the active principle is thoroughly isolated by good laboratory chemical processes.

By the proper correction of the intestinal toxins, we cut short the supply from which most of the systemic leucomains derive their source.

In the readjustment stage, while neutralizing the intestinal toxins, the administration of the sulphocarbolates or acetozone or alphozone, or some one of the aromatic antiseptics, assist materially in allowing the bowels to assume their normal calibre, by preventing gaseous distension, and securing a better flow of blood to the bowel wall and its secreting glands, leading to a better quality of the digestive ferments and a correspondingly better digestion of the ingested food.

Circulatory regulation in disease demands our best attention by the use of digitalin when a systemic toxin causes a paresis of the arterioles as presented by a rapid, soft pulse; the use of veratrine when a systemic or local toxin causes a full bounding pulse; strychnine to neutralize the asthmatic leucomain; sanguinarine to neutralize the toxin causing an abnormal sensibility-lowered sensibility of the nerves governing the respiratory organs. It simplifies medication of the sick to dispense the measured doses in tablet and granule form. Reliability and uniformity of strength is always found.

POST-OPERATIVE JAUNDICE.

Emory Lanphear, M. D., Ph. D., LL. D., St. Louis, Mo.

Professor of Surgery in the Hippocratean College of Medicine.

AUNDICE following operation may be due to (1) trouble with biliary tract; (2) septic infection; (3) acute yellow atrophy of liver; (4) jaundice unrecognized before operation.

(1) From the first to the third day after a perfectly aseptic operation jaundice may appear, especially if there has been much vomiting; a jaundice accompanied by the presence of bile in the urine and other symptoms of cholecystitis: "catarrhal jaundice." This may be due to the anesthetic, though how chloroform or ether may set up an acute cholecystitis is not explainable. Possibly latent trouble in the gall-bladder may be aroused by the vomiting from the anesthetic into making itself recognizable; or it may be the trouble is due to simple biliary retention by re-. flex irritation.

This variety of jaundice is of benign character, disappearing in a few days-in from six to ten days after free bowel-movements have been secured.

The best treatment is a half centigram (1-6 grain) of calomel every half hour until ten or twelve doses are taken; followed by a bottle of citrate of magnesia or a good dose of other saline laxative. Then a few days on phosphate of sodium, t.i.d., and a light diet will complete the cure. But the patients who suffer from post-operative "catarrhal" jaundice should be told that there may be trouble in later years from a gall-stone, unsuspected before the operation, which was the cause of this attack, it being temporarily driven into the duct by efforts at vomiting.

(2) More often, however, the yellowness of the skin is dependnet upon septic infection. This darkening of the skin, however, does not appear until later than the simple, catarrhal form; commonly not until the sixth to twelfth day. It is especially likely to occur in connection with septic pneumonia; and when it so appears it is to be regarded as an indication of a fatal termination. In most instances other signs of sepsis will be present and the yellow skin be of minor importance.

The treatment is, naturally, that for septicemia in general; eliminative and supportive, with absolutely perfect drainage of wound if possible.

(3) Acute yellow atrophy of the liver is a condition which very rarely follows the prolonged use of chloroform, the theory of its production being that the chloroform is retained in the liver in large quantities, combining with the lecithin and cholesterin therein present. Pregnant women, past the fourth month of gestation, are more often affected than any other patients. It may occur as the direct result of sepsis, but cases have been reported without septic infection. By some it has been believed to occur only in patients suffering from syphilis, but two of my cases were in non-leutic subjects.

The trouble begins with continued nausea and other signs of gastric irritation, icterus making its appearance on the third day or later; and by the time the skin becomes quite yellow the patient is semi-comatose with restlessness (i.e., stupor with delirium) and even mild mania may be pres

ent. Soon after this convulsions may appear and fatal coma supervene. Recovery is exceedingly rare; though a few cases have been known to present the typical symptoms of jaundice, marked diminution of the liverdulness, pain in region of liver, bloody vomiting, bloody stools, nosebleed, stupor, subnormal temperature, etc., and yet not end in death. Jaundice may be very pronounced; yet in cases of speedy dissclution there may be time for only a slight change in color. The spleen is usually enlarged. Hemorrhagic ecchymoses in the skin have been noted.

Nutrient
Small

Treatment consists of thorough evacuation of the bowels followed by large doses of phenosulphonates (sulphocarbolates) of zinc and sodium, naphthalin or salicylate of phenol (salol) every hour or two. enemata are of importance. Diuretics are especially indicated. doses of calomel (half centigram, grain one-sixth) every hour are highly praised. For the restlessness gram doses of bromide of sodium, either by mouth or rectum, prove most satisfactory. When stupcr becomes marked bypodermoclysis is to be employed; a liter (a quart) of normal salt solution to be injected in buttocks or breasts twice daily.

(4) It is a peculiar fact that sometimes the existence of jaundice is not suspected until the first incision is made. Then the intense yellowness of the fat and the tendency to bleed excessively shows that icterus is present, though the discoloration of skin and conjunctiva had not been sufficiently decided to attract attention. While this condition of affairs is not strictly a post-operative jaundice the friends of the patient will so regard it, because the yellow color soon becomes intensified; and they will be exceedingly anxious.

So far as the surgeon is concerned it means chiefly more care in hemostasis. Not only is there great tendency to bleed during the operation, but oozing from the wound may give trouble for days afterward; notably so when drainage is practised. To check this 4 grams (60 grains) of chloride of calcium may be given by rectum three times a day until the ndency to bleed is arrested. To the wound itself a solution of antipyrin to 50) may be applied freely; but tight packing generally controls the ozing.

THE NEW ANESTHETIC, WITH OBSERVATIONS FROM ITS USE IN ONE HUNDRED AND FIFTY CASES OF BOTH MAJOR AND MINOR SURGERY.*

Clinton R. Lytle, M. D., St. Joseph, Mo.

Ex-Interne Ensworth Hospital.

N picking up a May number of the Journal of Medicine, and noticing Dr. George A. Black's article on "A New Anesthetic," as studied from nine cases of minor surgical work, I will offer observations on the Lanphear or Abbott compound anesthetic tablets, as gathered from its use in about 150 cases operated on in the Ensworth Hospital. Its use

*Read before the St. Joseph-Buchanan County Medical Society, June 12, 1907.

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