THE PRACTITIONERS' MONTHLY. DETROIT MEDICAL JOURNAL VOL.. III. MAY, 1903. ^-««-«,.«_ ^^- ^ ^EDITOR : FRANK BURR TIBBALS COLLABORATORS : AUGUSTUS WRIGHT IVES, M. D. JOSEPH SiLL, M. Dl /.HENRY JASPER HaTK/Z, M. D ON THE BLOOD PRESSURE IN SURGERY, Geo. W. Crile, M. D.; - - - - - 37 DIAGNOSIS AND TREATMENT OF DISEASES OF THE NOSE AND THROAT, AND THEIR RELATION TO GENERAL MEDICINE, Willis S. Anderson, M. D.; - - - - 52 ACUTE DILATATION OF THE STOMACH, W. M. Harvey, M. D.; . - - - - 56 EDITORIAL; ._--_- 63 EDITORIAL NOTES; ----- 65 PROGRESS OF MEDICAL SCIENCE; - - 67 BOOK REVIEWS; - - - - - 71 ADVERTISING INDEX; -. - - - XI DETROrr MEDICAL J0URNALO» PUBLISHERS. 103 and 105 Miami Avenue, = = DETROIT, MICH. CNTERED AT THE POST OrPICE At DCTROIT. MICH., AS SKeOND CI ASS MATTCR HAY STH, 1S01. t-^T^ i s SURGICAL SHOCK is reduced to a minimum by high rectal injections of BQVENINE combined with an equal quantity of salt solution to render absorption more rapid. It should be heated to 7o°F, and administered prior to, during, and subsequent to operation. The quantity should *be suited to the individual case, varying from two to six ounces of e^ch. Bovinlne improves the heart action and circulation at once ; its sustaining effect is continuous for two to three hours. The blood which has become non-aerated through ether administration is oxygenated by the introduction of a fresh supply, and is rapidly restored to normal con- dition. To this fact is due the power of BOV/NiNE to prevent the thirst, nausea, and emesis, which usually follow anaesthesia. Its wonderfully nourishing, supporting, and healing properties render it a necessary adjunct to the operating room. Reports of numerous cases are cited in our scientific treatise on Hsematherapy. It is yours for the asking. The Bovinine Company, 75 West Houston Street, NEW YORK, ^^^ *w>i.^ DETROIT MEDICAL JOURNAL. A REMARKABLE BURN TREATMENT BY F. M. ROBBINS, M. D., West Springfield, Mass. For some years I have used your preparation, Glyco-Thymo- llne with most satisfactory re- sults. My practice has been for twenty-flve years in a manu- facturing town which is also something of a railroad center. This means many traumatic in- juries and much minor surgery. Lilce all practitioners, I have run the gamut of drugs and preparations looking for the ideal dressing. I have found in Glyco-Thymoline all of the properties necessary. It is sol- vent, antiseptic, analgesic, de- odorant, fosters cell growth and granulation and stimulates reso- lution. When used with slciU and reason Glyco-Thymoline never fails me. My object in writing is to report my success- ful use of Glyco-Thymoline in a burn of the third degree. Miss X. Y., aged twenty, a healthy and well nourished young. woman, met with a pain- ful accident which almost cost her her life. While carrying a lighted lamp it slipped from her hand and exploded between her feet. The hot air or violence, 1 know not what, carried her outer garments above her head so that the underclothes alone were ignited. She sustained serious, it was thought fatal, burns from the ankle to the abdomen and lesser burns on the trunk to the breast. I saw her nine days after the accident. There had been three physicians in attendance. The patient was sinking and had been since the accident. The prognosis seemed to be death In twenty-four to thirty-six hours. She had not slept to speak of and was thoroughly exhausted. Large sloughs were separating from the calves and back part of the thighs. I immediately stripped off all the dressings and thoroughly cleansed the wounds with a 25 per cent, solution of Glyco- Thymoline and then dressed the wounds wiin a 50 per cent, solu- tion. Within half an hour the patient dropped into a peaceful sleep. The first call was made Sept. 9th, and the patient was dis- charged Oct. 18th, 1901, healed. For a, short time after she left her bed she was compelled to use crutches, but in a few weeks the complete use of her limbs returned, contrary to the expectation of all who saw her condition. She had not only been spared her life but the free use of her limbs. I say un- qualifiedly that Glyco-Thymo- line saved this girl's life and is the most phenomenal case of this nature in a case unusually full of violent cases. The most remarkable feature of the case is the fact that her flesh is both smooth and firm. There is almost an entire ab- sence of scars and cicatricial tissue. THE ALKALINITY OF BLOOD StRUM GLYCO- . THYMOLINE ^^, . (KRESS) ASEPTIC ALKALINE. ALTERATIVE A Purgative Mucous Membrane INDICATED IN ALL CATARRHAL CONDITIONS HASTENS RESOLUTION FOSTERS CELL GROWTH SAMPLES AND IITERAIURE ON APPLICATION NASAL a DOUCHE KRESS & OWEN COMPANY. 210 Fulton St., New York. f t k t k t ? f s < < I ? f f f X k ? k II DETROIT MEDICAL JOURNAL. Morrison's Surgical Pad. . i THe Best Most Convenient and Most Practical THe Davidson Rubber Co. i 19 Milk Street, BOSTON. MASS. ►♦♦^-♦♦♦^^^ DETROIT MEDICAL JOURNAL. Ill He Has Two Good Legs ONE MADE BY NATURE THE OTHER BY MARKS Read What He Says : A. A. MARKS:— Dear Sir: I wish you to know how many days the leg you made for me worked during the year 1899. You see that it exceeds more working days of ten hours each than there are working days in the year. If you know of anybody with an artificial leg who has turned out more days' work than I have firing a big coal engine, remembering that I have to wallc two miles to work and two miles from work, making four miles every day in addition to my work, let me know who he Is, that I may compare with him. During the month of January L worked 407 hours; February, 292; March, 358; April, 325; May, 280; June, 316; July, 337; August, 376; September, 337; October, 391; November, 375; December, 337. ... If you will add up the number of hours you will find it amounts to 4131, or more than 410 days for the year, and y6u know there are only 313 working days in the year; so I have worked a year and ninety-six days in the year 1899, wearing your artificial leg every hour of that time, and it has not cost me one cent for repairs. It is as good now as It ever was. The engine that I am firing is one of those big ones that hauls coal from the mines to Pottsville— No. 148. In enclose a photograph of my en- gine, where you can see me at my post of duty. I get all over her with the same ease that I ever did. Sometimes I climb on top of the ooiler while in motion. I can tell you more about what I am doing with my leg if you want it. The hard use I am giving your 'leg -"nd the excelelnt wear It is giving prove it to be the best in the world. I am, respectfully yours, FRANK FAUST, Pottsville, Pa. This demonstrates that a man may lose a leg In an accident and yet fire a locomotive. A treatise contining SCO pages, with 800 Illustrations and newly Illustrated Measuring Sheet, sent gratis. Address I A. A. MARKS, 701 Broadway, NEW YORK. ♦ ♦ ♦ ♦ ADVICE INFANT FEEDING \ThG PROBLEM of ARTIFICIAL FOOi FOR BABIES can never be perfectly solved until cow's milk that is absol uiely L pure can be obtained with never failing regularity and positive I surety. This will probably never be, because even the very best I methods of dairy inspection have been proven unreliable. I Physicians who have studied tlie subject most carefully de- j dare that cow's milk, Pasteurized or Sterilized in [ARNOLD'^ MILK STERILIZER AMD PASTEURIZER [Is the only practical solution of the problem. This Sterilizer is I the most easily used and the only one that makes the process cer- [ tain. No otlier agency has done so much toward preventing the I bowel troubles that come with summer ; no other invention has [done so much toward lessening infant mortality. Its moderate [ price puts it within the reach of all. The printed matter and reviews by leading specialists, which we would like to send you witliout oTiarRe, will convince you of I the advisability of rei-onnnending this 8terilizfr in every home Iwhere a baby is to be fed. Please write for it. All reputable [Druggists can supply Arnold'm Storlllxer and Pasteurixer. WllmoiOasileSk Co. lOEImSt. Rochester,M. Y. ♦ TKe Most Eminent Diagnosticians Use and RecoxnmencI Bowles' Stethoscope =====($4.00) Net Made and "VITKolesaled Only by GEORGE: P. PILLING «K2>»-€MS^-«-®-»kS>»--(s>»<5--«-®-«»<£>»<5>«- -® superior to all others for the following reasons : 1st. It adapts Itself to every movement of the body, giving strong and even support. 2nd. It produces warmth without irritation or sweating, as it is perfectly ventilated. 3rd. In pregnancy, corpulency, tumors or other cases of enlargement of abdomen. It supports weight of body from the backbone, relieving the sinews of their overwork. 4th. Its easy appliance (lace and draw on over head of feet). 5th. It is cheap, durable; it can be washed when soiled, proper care being taJten to cleanse in luke-warm water and dry In shade. In ordering give largest measure of the abdo- men. PRICES: inches wide ^a.OO fa.oo Silk Finish f4.00 " fS.OO Double Rubber f3.00 f».(H> .f4.UO THE Empire Elastic Rnrirlna-P^ specially Adapted OdllUcl^C for Varicose Veins We invite the attention of the Medical and Surgical profession to the various merits combined in our bandages. Ist. ITS POROSITY— Xhe greatest in the "EMPIRE." It never causes itching, rash •r ulceration under the bandage. 2nd. ITS ELASTICITY, which will en- able the surgeon or nurse to put it on at any required tension, and which will follow a swelling up or down as the case may be, a feature unknown to any other bandage. 3rd. ITS ABSORBENT PROPERTIES— Greatest in the Empire. 4th. ITS EASY APPLICATION to any part of the body, not being necessary to fold over, as with other bandages as it fol- lows itself with equal uniformity around any part of the abdomen. 5th. ITS SELF-HOLDING QUALITIES —No bother with pins, needles and thread, or string, eo tiresome to surgeons, as simply tucking the end under the last fold insures its permanent stay, until its removal for purpose of cleanliness. 6th. The only bandage that is SU- PERIOR TO THE ELASTIC STOCKING for varicose veins. SEND $1 FOR 3 IN. by 5 YD. BANDAGE ON APPROVAL. The Empire Imbilical Truss' Is an Abdominal Supporter with Button Inserted at Navel Is made of the same material and possesses the same merits as the Empire Elastic Bandage and Empire A dominal Supporters, and it is pronounced by all who have seen it to be the best in the world. ALL OUR GOODS ARE SENT FREE BY MAIL UPQN RECEIPT OP PRICE AND MONEY REFUNDED IF NOT SATIS- FACTORY. PRICES : Infant, hard pad $1.25 Infant, soft pad $150 Children, hard pad 2.50 Children, soft pad 3.09 Adult, hard pad 4.00 Adult, soft pad......... 5.00 ALL ABOVE PRICES ARE NET TO PHYSICIANS. Manufactured by . . Empire Mfg. Co. LoclportTv/iVA. -Q^ DETROIT MEDICAL, JOURNAL. XIII (-1 t-i The dream of yesterday is the reality of today — the prophecy of the 18th century is fulfilled in s>6c Oldsmobile '^'^ The Best Thing on Wheels'' Price $650.00 Each working part is made from materials of the highest grade finished and fit- ted with mathematical accuracy. The entire construction is simple, practical and easily understood-no complications- '' Nothing to watch but the road.'' The premier position of the Oldsmobile is maintained by progress — its sterling merit is the result of 23 years of practical ex- perience in gasolene motor and auto- mobile construction. The pioneer Run- about of America and the most widely imitated Automobile in the world. Call on any of our 58 selling agencies or write *"or illustrated book to Dept 15 Olds Motor "Works Detroit, MicK. XIV DETROIT MEDICAL. JOURNAL. ¥- • t The Hastings & Mcintosh t J Truss Company Manufacturers of all kinds of ¥• Hard Rubber, Elastic Covered ITRU S SES| Abdominal and Uterine Supporters, Shoulder Braces, Crutches, Elastic Hosi^ ery and Body Belts, and Sole Makers of the Celebrated DR. HclNTOSH NATUR- AL UTERINE SUPPORTER, for Home and Export Trade. 912 WALNUT ST., PHIUDELPHIA, PA. t. S. A. ^jf*>f3f3f>*-*)f*Jfjf)f)f*Jf>f)f*Jfjf)f*)f)fjf)*-Jf*l|-** H. P. ENGELN & CO., Mfrs Ma) Apparatus Our spark Induction Coils can be connected with any Incandescent Lamp Sockets Tliey are guaranteed against any break-down. 90 PROSPECT STREET. CLEVELAND, 0. J DETROIT MEDICAL JOURNAL. XV PacKa^ed ii:\ T^vo Sizes — Fotir and Sixteen Ounces SPECIFY AN ORIGINAL PACKAGE — NOT SOLD IN BULK For liberal samples address Dept. M,, ~l THE UPJOHN COMPANY MAKERS OF FINE PHARMACEUTICALS Kalamazoo, Mich. Ne^v YorK, N. Y. \J. S. A. ORIGINATORS OF THE FRIABLE PILL. XVI DETROIT MEDICAL. JOURNAL. W. SCHEIDEL&CO. CHICAGO, ILL. Our Coils Are Fully Guaranteed. Not tHe CKeapest, But tHe Best. COIL5 THE J. F. HARTZ CO., DETROIT REPRESENTATIVES, 103 and 105 Miami Ave., Detroit, Mich. Telephone 616. lEJ.F. HARTZ CO., Ltd., CANADIAN REPRESENTATIVES, 2 Richmond St., East, TORONTO, ONT. CAN BE OPERATED ON ALTERNATING OR DIRECT CURRENT. Our Coils are the most efficient on the market, and can be operated with a minimum current consumption. For radiographic work the time of exposure is the shortest to date. As the spark length is absolutely under control of the operator, tubes can be used for any length of time. The primary current can be varied according to the vacuum of the tube. All parts interchangeable, and insulated with a semi-flexible insulation guaranteed not to harden with age. Our Coils will operate in any climate, during any weather inclem- encies, and are simple of manipulation. "Workmanship, material and finish are the best. (We manufacture Coils of all sizes for any voltage from 500 volts D. C. down.) WE ALSO MANUFACTURE ULTRA-VIOLET HIGH FREQUENCY APPA- RATUS, ATTACHABLE TOCOILS OR STATIC MACHINES. SPECIALLY " ADAPTED FOR EXTERNAL OR INTERNAL TREATMENT. Our Goods Are Protected by Patents. Be^ware of Ctieap Imitations. DETROIT MEDICAL JOURNAL. XVU ♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦ DOCTOR PHELPS An authority and leader in Orthopedic Surgery, speaking of the Ambulatory Pneumatic Splint In the treatment of Leg, Thigh and Hip Fractures said : "It is the culmination of the evolution of the treatment that we have been going through." This appliance is by far the best, as well as the cheapest, dressing in the mark- et. The same appliance is adjustable to any adult, and is used many times on different cases. Write for clinical reports, prices and discounts. .(0. 164-166 East Randolph St., CHICAGO. CARRIED IN STOCK BY J. F. HARTZ CO. Woodward Ave., DETROIT, MICH. ►♦♦♦♦♦♦♦♦♦»»♦♦♦♦♦♦♦♦♦♦»♦♦♦♦♦♦♦ Galloway Surgical Operating P;iH * C1.V* PATENTED With or without hot water back- rest. Perfect Drain- age and Cleansing. Ample Operating Room at Tip of Rims. No Crease where Bottom Joins the Rims. Ample Capacity. Sizes, 20x44 inches and 24x44 inches. The^e Rubber Oper- ating Pads are equally well adapted for Per- ineal or for Surgical Work. Write for De- scriptive Circular. Made by The B. r. Akron Rubber Works. With a mo- ment's Manipu- lation the Sur- geon Can Form the Fie xible Drainage Con- duit of any Gallon ay Surgical Operating Pad into A Deep Trough, A Shal- low Trough, A Curved Trough, A T i g h t-end Trough, or a Flat Surface for Cleansing. OOODRICn CO. AKRON, O. Naw York, Chicago. Philadelphia, 66-68 Reade St. 141 Lake St. 922 Arch St. Boston, Buffalo, Detroit, 157 Summer St. 9 W. Huron St. 80 E. Congress St. San Francisco, Mm Denver, London, 392 Mission St., 1444 Curtis St. 7 Snow Hill, E. C. The Very Thing', Doctor, You have been looking for ever since Sterilizers have been in use. Glog'au's AlcoHol-Gas Stove MADE IN GERMANY A boon as a Sterilizer, for the Sick- Room, Light Housekeeping or wherever gas is not available or desirable. Makes its own gas, is portable, uses only 2 cents worth of alcohol in an hour. Is odorless, wickless and weighs only 7^^ ounces. Will support a vessel weighing 100 lbs. It cannot explode; can be upset without spilling the alcohol and never gets out of order. Sent aixy^vHere, express prepaid, on receipt of $1.00. U/>e GlogaU Co., 21 Qulncy St., CHicago. i XVIII DETROIT MEDICAL JOURNAL. ?- & A True NutritiveTonic /^olden's Liquid Beef Tonic lifts the patient out of a state of extreme depression, and restores the organs to a condition where they are strong enough to respond to further medication. It is a true nutritive -tonic -stimulant, powerful in its appetite- creating and system -invigorating properties. It is of the greatest service to physicians in dealing with those troublesome, obstinate, chronic cases of depression, which otherwise refuse to respond. See that your patient gets the genuine Colden's Liquid Beef Tonic. Sold by druggists generally. Samples free to physicians. THE CHARLES N. CRITTENTON CO. SOLE AGENTS FOR THE UNITED STATES 115-117 FULTON STREET, NEW YORK =9 4 You can get all the surgical instruments you need in your practice, of the latest design and licst quality, of any make, absolutely free, if you buy your Pharmaceuticals from us. Iiigical Mraroerts Free j8^ tAe adoption qf^ K^yS direct order flan We are Exclusively a Pharmaceutical House and our prices are Lower Than Those of Other Reliable Manufacturers Only the best and purest inRredients, scientific knowledge and skill, enter into our products. Our discounts are large because we operate on an extensive scale. RAY'S DIRECT ORDER PLAN means:— We secure all orders through correspondence employing no salesmen, or detail men, thus saving 20 per cent, of the total cost of getting busmess; therefore, over and above all regular discounts we credit our customers with 20 per cent, of the net amount of every purchase and use that money to buy the instrument you want. Your instrument credit is redeemable on each order, or can accumulate, just as you choose. We neither make nor sell instruments, but purchase them outright from the manufacturer. CATALOGUE WITH DISCOUNTS MAILED ON REQUEST. THE l^Y CHEMICAL Co, ,^ MA//c/rAcn//^///c p//A/?MAc/5rs^„,„^ i?£r/iO/r, Af/c/f^^^i The Detroit Medical Journal. Vol. II L MAY, J903 No. 2. ON THE BLOOD PRESSURE IN SURGERY.* By GEORGE W- CRILE. M. D., Cleveland, Ohio. The study of the effect of operations, injuries, drugs and disease upon the blood- pressure is a natural sequence of medi- cal science, and seems to be one of the leading features of the trend of medicine of to-day. Physiology is vying with an- atomy and pathology as a practical and useful branch of medicine. Although the methods of determining the blood-pres- sure as yet only approximately accurate, much useful and reliable information may be obtained. The sphygmo-manometer often gives information that could not otherwise be secured. In scarcely any other condition is the use of this instrument more important than in shock and collapse. Since these play so important a role in both medicine and surgery, some of the more recent studies on these subjects will be first con- sidered. Blood-pressure determinations in the operating-room and in certain acute infectious complications are of im- portance and some considerations of shock and collapse may give point to the clinical observations to be given later on. Collapse. For the purpose of this paper the term collapse is applied to the cases of the more sudden fall of the blood-pressure from hemorrhage, from asphyxia, from injuries of the vaso-motor center, or from failure of the cardiac action. These con- ditions represent suspension of function rather than exhaustion of centers. There being no exhaustion, stimulants may be of value. As an illustration : — If one an- imal is subjected to such a degree of shock (exhaustion of the vaso-motor cen- ter) as to produce a sufficient accumula- tion of the blood in the veins (intraven- *Read before the' Wayne County Medical So- ciety, April 23, 1903. Detroit, Mich., May 15, 1903. ous hemorrhage) to cause a decline in the blood-pressure to 24 mm., and if an- other animal is subjected to an extra- vascular or ordinary hemorrhage, until the blood-pressure has been reduced an equal degree, it would be impossible, on the symptoms alone, to make a differen- tial diagnosis. Yet, in the one case, stim- ulants could have no effect because the vaso-motor center is exhausted, and in the other the effect might be marked be- cause the center is not exhausted. In the animal with the exhausted vaso-motor center (or shock), saline solution could be of little assistance, but in the animal subjected to ordinary hemorrhage, and having a normal vaso-motor center, sa- line infusion might be of marked assist- ance. In collapse, direct therapeutic stimulants may be extremely useful. Shock. In shock the essential phenomenon is a diminution of the blood pressure. Since there are no demonstrable lesions in the fatal cases, and no later effects in those that recover, we will assume exhaustion, rather than structural lesion, to be the cause of this fall. It must, then, be au exhaustion of the cardiac muscle, of the cardiac centers, of the nerve muscular mechanism, of the blood vessels or of the vaso-motor center. (a) Is it due to fatigue, or exhaustion of the cardiac mechanism? The heart, as an organ, is noted for the large amount of labor it may perform without fatigue. In shock, on account of the diminishea blood-pressure, there is even less work for the heart muscle to do than in the nor- mal state. In a series of experiments after the animal had been reduced to a degree of shock, presumably fatal, the blood-pressure was, by special means, Vol. 3, No. 2. 38 ON THE BLOOD-PRESSURE IN SURGERY raised much higher than normal. The heart then performed its normal function. There was then no material fatigue of the heart muscle. (b) Is there fatigue of the cardio-in- hibitory center? In experiments in which the animal had been reduced to a degree of shock, presumably fatal, the blood-pressure was by special means raised to the normal ; then, on manipula- tion of the laryngeal mucosa, a normal reflex inhibition of the heart was induced. The cardio-inhibitory center, and its per- ipheral nerve mechanism were, there- fore, not exhausted. That tHe cardio- accelerator mechanism remains active; in every degree of shock, is constantly evi- denced by the increasing rapidity of the heart until the inauguration of the phe- nomena of death. In a series of experi- ments, the heart was isolated from the nervous system by severing both vagi and both accelerantes ; shock in such an- imals was as readily produced as in the centrals. We may then exclude the heart and its nerve mechanism as factors in the primary causation of shock and look to the loss of peripheral resistance as the essential factor. The loss of peripheral resistance may be due to (a) An ex- haustion of the peripheral nerve vascular mechanism, — the anatomical periphery, or (b) An exhaustion of the vaso-motor center. In a series of experiments in which both vagi and both accelerantes had been severed, a physiologic dose of curare given, and artificial respirations maintained, the animals were reduced to such a degree of shock that the vaso- motor center gave the usual physiolog'c proof of exhaustion. Varying doses of adrenalin were then given. The blood- pressure rose proportionally to the dose, even much higher than the normal. Fa- tigue of the blood-vessels may then be excluded. That the vaso-motor center becomes exhausted in complete shock, is indicated by the absence of any rise in the blood-pressure on electrical stimula- tion of the sciatic nerve, or burning of the paw. or by giving a physiologic dose of strychnin, or by deepest asphvxia. each of which causes stimulation of the vaso-motor center. Cocainizing the vaso- motor center, or severing the cord just below the medulla, causes a fall in the blood-pressure to about the same level as that of profound shock. We may then conclude that shock is essentially an ex- haustion or break-down of the vaso-mo- tor center. From this standpoint then let us consider the vaso-motor stimulants such as strychnin. In forty-eight experi- ments, it was found that strychnin in therapeutic doses does not cause a rise in the blood-pressure. In another series in which the dose was gradually increas- ed until the convulsive stage was reach- ed, a remarkable rise occurred. Was this rise due to the muscular contractions of the convulsions? No, since an equal or greater rise occurred when convulsions were prevented by preliminary injections of curare; the centers presiding over the vaso-muscular system and voluntary muscular system seem to be equally sus- ceptible to the action of strychnin. Was the rise partly due to a simultaneous stimulation of the heart? No, since strychnin caused an equal rise in the blood-pressure in animals, in which both vagi and bth accelerantes had been pre- viously severed, thereby isolating the heart, and a paralyzing dose of curare given. It was, therefore, a pure vaso- motor stimulant. A brilliant stimulant indeed, sometimes doubling the normal blood-pressure and lasting from thirty minutes to several hours. Each succeed- ing physiologic dose caused less effect and after from two to four doses, no ap- preciable effect was obtained. The blood- pressure in the meantime had fallen, and at last had reached the same level as in most profound shock. It was at this stage, not possible by reactions, such as electric stimulation of the sciatic nerve, burning of the paw, by deepest asphyxia, or by a study of the terminal tracings, to distinguish between these animals and the animals in profound traumatic shock. The vaso-motor center in each was ex- hausted. It was, in effect, shock pro- duced by strychnin. The effect upon the function of the vaso-motor center seemed to be the same, whether the stimulation was mechanical and external, as in in- juries or operation, or internal, as from strychnin. Conversely, in a series of ex- periments in which strychnin was given in various degrees of shock in such dosage as to cause a stimulation, the ef- fect was proportional to the degree of shock, — i. e., when but little shock was GEO. W. CRILE, M. D. 39 present, a marked effect from strychnin was obtained, and when most profound there was no effect. In the intervening degrees, the effects were proportional, but after giving the strychnin, the ani- mals not yet in complete shock always passed into a deeper degree of shock. Later in the research, it is found that the most convenient and certain method of producing shock for experimental pur- poses, is by the administration of phy- siologic doses of strychnin. The treat- ment of shock, then, by therapeutic tor center. Turning to cardiac stimu- lants, we must first consider how much influence upon the blood-pressure an in- crease in the force and frequency of the heart-beats has. Even in normal animals, when the peripheral resistance is at its best, an increase in the force and fre- quency of the heart-beats has but a lim- ited effect in increasing the blood-pres- sure. In a series of experiments in which the vaso-motor center was reduced to varying degrees of exhaustion, and the vagi severed — thereby increasing the .,,.-.'!». ' i I ■■■• ■'■"•M-,;, ,^,^7^#^«^^V^\^V^»V^N>.^;" '.%■■ -VMVvv^ ; ■>•,.■•■ ■i'.Vi".*'.»-i ■■■■'■-*''"^''*^V"" ' 'se^isatsiHsete^' f^lCj:/."'';''! - R.' 1^ ^^^^^^^^^^^^^^^^^^^^1 BSj^l^^S^^^B ^, ..•'>«';''£3WB B l^i^: R^l^ ^ ™ Fig. I. ETHER-CURARE.— Animal reduced to profound shock. Burning the paw, stimulating the sciatic nerve and administering physiologic doses of strychnin caused no change in the blood- pressure. After this the blood-pressure was raised higher than normal by injecting adrenalin. doses of strychnin is inert, and in physiologic doses dangerous. It then follows that treatment of shock by vaso- motor stimulants in the form of drugs, is on precisely the same basis as treatment by burning the animal or crushing his paws, or by subjecting it to injury or operation, — it would seem to be as rea- sonable to treat strychnin shock by ad- ministering traumatism as traumatism by strychnin. What has been said of strychnin may be assumed to apply equally well in the case of other stimulants of the vaso-mo- force and frequency of the heart-beats — the rise in the blood-pressure sustained an inverse ratio to the degree of exhaus- tion, and in the cases in which the vaso- motor center was entirely exhausted, the blood-pressure was not raised by an in- crease of the force and frequency of the heart-beats. An artificial circulating ap- paratus was then arranged so that the peripheral resistance was represented by the atmospheric pressure in a cylinder which contained an elastic bag filled with water and communicating by means of tubing with an artificial heart on the out- 40 ON THE BLOOI>PRESSURE IN SURGERY side. In this rough way the force and frequency of the heart-beats, and the peripheral resistance could be increased or diminished at will. It was not possi- ble by any increase in the force and fre- quency of the artificial heart-beats, to raise and maintain the artificial blood- blood. This would leave but a limited range of possibilities for heart-stimu- lants. In another series of experiments, car- diac stimulants, particularly digitalis, were tested. It was found that as the peripheral resistance was lowered, the Fig. II. MEDUL-LA COCAINIZED.— Note the resemblance between this curve and that of pro- found shock. H^y0l^mHf^^*iff>^^^''^\''^^^^ y^-*"WM Fig. III. BOTH VAGI AND ACCEL.ERANTES SEVERED.— On Injecting curare a great fall in the blood-pressure occurred. The animal was in COLLAPSE, not SHOCK. Note the striking effect of Injecting strychnin. Note also the lesser effect on Injecting the second dose, and no effect In later Injections. pressure more than lo mm. The velocity of the circulation was, of course, much increased. On the other hand, any change in the peripheral resistance was attended by an equal change in the blood-pressure. From the standpoint of physics, as well as physiology, it would seem that the peripheral resistance (vaso-motor action) fixes the gauge for the height of the blood-pressure, while the heart supplies the force necessary for circulating the effect upon the blood-pressure was di- minished and when complete exhaustion of the vaso-motor center existed, the car- diac stimulants had no influence what- ever upon the blood-pressure. Other drugs which are, in practice, generally included in the class of stimulants, such as alcohol and nitro-glycerin and amyl nitrite were studied at length. • No justi- fication could be found for classifying these drugs as stimulants. In the case GEO. W. CRILE, M. D. 41 of alcohol, in not a single instance was there a sustained improvement in the blood-pressure, or in the respiration. On the contrary, the most constant and the most marked effect upon the blood-pres- sure was a decline. The rapidity and the extent of the decline were proportional to the depth of the shock, and the dosage circulation was more sudden than in the control animals. If the foregoing be true, it is obvious that in true shock the use of stimulants acting upon the vaso-motor, the cardiac and other centers of the medulla, are either inert or harmful. In considering other mothods of controlling the blood- Fig. IV. The terminal tracing of a normal animal reduced to shock by strychnin. Fig. V. ETHER-Curare.— Both vagi and accelerantes severed. Animal reduced to such a de- ffree of shock that stimulation of the sciatic nerve caused only a slight rise in the blood-pressure. On administering a physiologic dose of strychnin, the blood-pressure was raised to about the normal. The rise continued about twenty-flve minutes, when it gradually fell. Then, on repeating the dose, no rise occurred, and on stimulating the sciatic nerve and burning the paw no rise occurred. The strychnin completed the exhaustion of the vaso-motor center. of alcohol. In all the experiments upon nitro-glycerin, when any effect was noted, it was an immediate fall in the blood- pressure. This occurred in every degree of shock. A compensatory rise equal to the fall followed in most instances. The rising curve was usually more gradual than the falling. Most of the animals showed a marked degree of toleration. On the whole, nitro-glycerin acted un- favorably in shock. As in digitalis and alcohol, when considerable dosage had been given, the final break-down of the pressure, normal saline solution demands consideration. Normal saline adminis- tered intravenously or subcutaneously, is a purely mechanical aid to the circula- tion, which temporarily increases the blood-pressure. The solution in any con- siderable quantity is not retained in the blood-vessels, but is eliminated at a rate proportional to the rate of administration through the same tissues that normally absorb water, mainly the alimentary tract. That the blood does not tolerate much dilution with normal saline, was 42 ON THE BLOOD-PRESSURE IN SURGERY shown also by repeated observations up- on the number of corpuscles, and the amount of hemoglobin during its admin- istration. The accumulation of saline solution in the walls, and in the lumen of the stomach and of the intestines, in the peritoneal cavity, and in the liver, after approximately 320 cc. per kilo has of the solution. Saline solution has a limited range of usefulness. It is obvi- ous, then, that to increase and sustain the blood-pressure when the vaso-motor cen- ter is exhausted, it is necessary to create a peripheral resistance either by a drug acting upon the blood-vessels themselves, or by mechanical pressure. Adrenalin in ■. ■»iw%,itiu'*.*>*a'*«sBg«3pP' .i;ia.«s«aai!«3atfftaiasKJS^ Fig. VI. NORMAL ANIMAL.— Note the gradual sustained rise in the blood-pressure, followine the injection of digitalis. Pig. VII. PROFOUND SHOCK.— Note the negative effect of therapeutic doses of digitalis. been given, causes so much abdominal distension as to progressively hinder and finally prevent the excursions of the diaphragm, and the moveable ribs, caus- ing death from respiratory failure. In the cases of pure shock, i. e., in cases in which the vaso-motor center has been ex- hausted, and no blood has been lost, the rise in the blood-pressure, even during its administration, if prolonged, is not sustained, on account of the loss of the peripheral resistance and the elimination the normal animal or in any degree of shock, caused a marked, and, in sufficient dosage, an enormous rise in the blood- pressure. This rise occured when tlic vaso-motor center was proven to have been exhausted ; when it was cocainized ; and when it was destroyed ; it occurred when in addition both vagi and both ac- celerantes had been severed, and the an- imal was under the influence of curar,e4_ In larger doses, a marked inhibitory tion upon the heart was noted. This GEO. W. CRILE. M. D. 43 immediately relieved by the injection of atropin. It was finally found that the most effective method of administration was by a continuous intravenous infu- sion in salt solution, varying in strength and with the muscular system paralyzed with curare, it followed that if these ob- servations were correct, a decapitated an- imal must be kept alive during a certain period of time. An ordinary laboratory Fig. VIII. ANIMAL IN MODERATE SHOCK. —Note the fall in blood-pressure on injecting alco- hol. ^■■^<'»%l»»*»i***««l*^^ ■^■"■-*^ Fig. IX. Note the negative effect of the administration of alcohol in an animal in but light shock. from I to 50,000 or 100,000. After the experimental research seemed to have shown that adrenalin and salt solution thus administered could maintain the cir- culation with a heart isolated from the nervous system by section of both vagi and both accelerantes, with the vaso-mo- tor center exhausted (complete shock). dog was decapitated. Adrenalin and sa- line solution were immediately and con- tinuously administered. It was foiyid that the blood-pressure could be con- trolled at will. The beheaded animal lived (?) 10 and ^ hours and finally died of air emboli, produced by the artificial respiration. On beheading animals, the 44 ON THE BLOOD-PRESSURE IN SURGERY primary fall in the blood-pressure was approximately the same as in profound shock. Owing to rapid oxidation in the tissues, adrenalin is found to be more effective when given intravenously, and since it is even more rapidly oxidized in the blood, it should be given continuously. It is found to be most conveniently given in saline solution from a burette, the rate of flow being controlled by a screw-cock at- tached to the rubber tube. The circula- tory phenomena should be under contin- Fig. X. ANIMAL IN SHOCK.— Note the fall in blood-pressure on administering: nitro-glycerine. uous observation by means of a tono- manometer, and palpation of the pulse. In considering external pressure as a means of supplying a peripheral resist- ance, it is well to bear in mind that when the vaso-motor center is becoming ex- hausted, the blood accumulates in the veins — especially in the large venous trunks. The condition m^y be described as an intravenous hemorrhage. Now, pressure applied uniformly upon the skin from the periphery toward the center over an area containing such intravenous hemorrhage, causes the blood to flow on toward the heart just as the normal vas- cular tone does. After numerous experi- ments with devices including water-baths and pneumatic chambers, in which it was attempted to devise a method of supply- ing an artificial peripheral resistance, a rubber suit was found to be the most practical. The suit is made of a double layer of specially constructed rubber, and when inflated, gives a uniform pressure upon the surface, producing an artificial peripheral resistance. The inflation is ac- complished by means of a bicycle pump, and may be varied at will. Regardless of the posture of the patient, a considerable portion of the blood may be delivered to the right heart, thereby preventing, to a certain degree, the continuance or de- velopment of cerebral anemia. By means of this suit, the blood-pressure may be, within a range of 25 to 60 mm., mercury, placed under the operator's control. The pneumatic suit has been employed in many clinical cases, and the effects stud- ied by means of the Riva-Rocci sphygmo- manometer. After having considered the means of controlling the blood-pressure in cases in which there is exhaustion of the vaso-motor center (shock), and in cases in which there has been a tem- porary suspension of the heart, or of the vaso-motor center (collapse), it remains to consider the control of the blood-pres- sure in cases in which the vaso-motor center, the cardiac centers, the heart it- self, and the respirations have all ceased to-show any functional activity — that is to say, when the animal is apparently dead. In a series of experiments, obser- vations were made upon the use of elec- tricity ; upon needling the heart ; upon massaging the heart; upon making rhythmical pressure upon the thorax over the heart; upon the injection of strych- nin, ammonia, and other drugs into the chamber of the heart and the heart mus- cle; upon artificial respiration; upon the administration of salt solution intraven- ously; on rapidly alternating the posture of the animal, head up and head down, — all of these methods were employed sing- ly and in various combinations, but in no instance did we find it possible to resus- citate the animal after more than 58 sec- onds, after the last beat of the heart. The most favorable results were ob- tained by combinations of rhythmic pres- sure upon the thorax over the heart ; ar- tificial respiration ; and intravenous si line infusion. But unless the heart ai the vaso-motor center resumed action, the blood-pressure could be raised anc GEO. W. CRILE, M. D. 45 sustained to but a very limited degree. During the experiments upon the decapi- tated dog, it was observed that adrenalin acted upon the blood-vessels after the circulation had ceased. It was then planned to kill the animals by asphyxia, give artificial respiration, make rhythmic pressure upon the thorax over the heart, and at the same time, administer adrena- lin in saline solution into the jugular vein. By this means, adrenalin, through the feeble artificial circulation, could be brought into contact with the walls of the blood-vessels, causing their contraction, thereby increasing the blood-pressure, which in turn would re-establish the coronary circulation, which in turn would probably set up an action of the heart. By this method, animals apparently dead for various periods up to 15 minutes, were restored to conscious life again. Even dogs electrocuted by a shock of 2,300 volts of an alternating current, were re- suscitated. Summary. Surgical shock is an exhaustion of the vaso-motor center. Neither the heart muscle, nor the cardio-inhibitory center, nor the cardio-accelerator center, nor the respiratory center, are other than second- arily involved. Collapse is due to a sus- pension of the function of the cardiac or of the vaso-motor mechanism. In shock, therapeutic doses of strychnin are inert, physiologic doses dangerous or fatal. If not fatal, increased exhaustion follows. There is no practical distinction to be made between external stimulation of this center, as in injuries and operation, and internal stimulation by vaso-motor stimulants, as by strychnin. Each in suf- ficient amount produces shock; and each, with equal logic, might be used to treat the shock produced by the other. Stim- ulants of the vaso-motor center are con- tra-indicated. Cardiac stimulants have but a slight range of possible usefulness, and may be injurious. In collapse, stim- ulants may be useful because the centers are not exhausted. Saline infusion in shock has a limited range of usefulness. In collapse it may be effective. The blood tolerates but a limited dilution with saline solution. Elimination takes place through the channels of absorption. Its accumulation in the splanchnic area, may be sufficient to fix the diaphragm and the moveable ribs, causing death by respira- tory failure. Saline infusion, in shock, raises, but cannot sustain the blood-pres- sure. Adrenalin acts upon the heart and blood-vessels. It raises the blood-pres- sure in the normal animal ; in every de- gree of shock; when the medulla is co- cainized; and in the decapitated animal. It is rapidly oxidized by the solid tissue and by the blood. Its effects are fleeting; it should be given continuously. By this means the circulation of the decapitated dog was maintained 10 and ^ hours. In excessive dosage there is a marked stimulation of the vagal mechanism. The pneumatic rubber suit provides an artificial peripheral resistance without in- jurious side effects, and gives a control over the blood-pressure within a range of from 25 to 60 mm., mercury. Physiologic rest; posture, heat, artifi- cial peripheral resistance, guarded use of adrenalin and particularly when there has been considerable hemorrhage, normal saline solutions are the most reliable means of combating shock, — but preven- tion is the best cure. By combined use of artificial respira- tion, rhythmic pressure upon the thorax, and adrenalin injected into the jugular vein, animals which were apparently dead as long as 15 minutes were resusci- tated. The control of the blood-pressure is almost equal to the control of life itself. A Study of the Changes in the Blood-Pressure During Surgical Operations. Operations On The Head. Trephining. Incising the scalp caused no notable change in the blood-pressure. Separating the periosteum over a consid- erable area of bone by means of a perios- teotome, caused a slight irregularity. Cutting through the bone by means of a mallet and a chisel, was followed by some irregularity, though no marked change. Irritation of the dura mater caused a fall with considerable irregularity. In an operation for securing hemor- rhage from a branch of the meningeal, a considerable manipulation was necessary. In order to control the hemorrhage dur- ing the removal of more skull, gauze was packed between the skull and dura some distance beyond the margin of the bone; this caused a very considerable fall in the blood-pressure. Exploring the brain by 46 ON THE BLOOD-PRESSURE IN SURGERY means of a slender probe for a tumor, caused no appreciable change. A similar observation was made in exploring both lobes of the cerebellum in like manner, for a tumor. The incision of the dura mater with a sharp knife caused no ap- preciable change. Sponging, with pres- sure, caused the most marked fall. In operations for the removal of the of making the was practically dura caused an pressure and an Separating, with the branches and ganglion, caused intracranial dissection nil. Elevating the irregular fall in the increase in the pulse. considerable gentleness, the body of the no marked change. Elevating the tempero-sphenoidal lobe in order to give room for the exposure Fig. XI. ANIMAL IN PROFOUND SHOCK.— Continuous Infusion of saline solution Note the Rradual rise in the blood-pressure, the Increase in the pulse-wave, the absence of vaso-mo'tor undula- tions, and, after a certain period, a decline in the blood-pressure eQua.l to the rise. Fig. XII. SPINAL CORD AND MEDULLA COCAINIZED.— Strychnin caused no rise, except- ing the slight one Incident to the convulsions. Note the prompt and marked rise on injecting adrenalin. Gasserian ganglion, the blood-pressure and the pulse showed marked variations without any considerable net change un- til the skull was opened. In both cases in which these observations were made, the common carotid artery was closed, and the hemorrhage up to the point and the removal* of the ganglion, caused a marked rise in the blood-pressure, and an almost corresponding fall in the pulse- rate. During this part of the operation there was some oozing ; against this, adrenalin tampons were used. A con- siderable rise in the blood-pressure in GEO. W. CRILE, M. D. 47 one case followed, clue probably to ab- sorption of adrenalin. In both cases the posterior root was entirely exposed in a clear field, so that the effect of evulsion could not be noted. It was found in each case that when the root was entirely isolated, and in clear view, the weight of irritation of the dura mater and the pres- sure upon the brain caused a rapid fall. The amount of shock in operation upon the head was proportionate to the manip- ulation, the pressure upon the brain, the hemorrhage, and the duration of the op- eration. Pig. XIII. Note the decisive rise in the blood pressure on injecting adrenalin. Note the inhibi- tion of the heart from over-stimulation by adrenalin. Note the prompt relief by giving atropin. Pig. XIV. The first abrupt fall was incident to the decapitation of the dog. Note the absolute control over the blood-pressure obtained by continuous infusion of adrenalin. The irregularity in the curve was due to an adjustment of the rate of flow. This decapitated animal lived (?) lOVa hours. the ganglion was sufficient to break it at the moment it was picked up to be sever- ed with scissors. The most rapid fall in the blood-pres- sure in the cerebral group occurred in a case in which there was rapid hemor- rhage from the meningeal artery, which was controlled by gauze packing. The combined effect of the hemorrhage, the Operations in the Mouth. In bloodless excision of the tongue there was but little change in the blood- pressure or the pulse. Operations on the Neck. Tracheotomy. Asphyxia caused a very marked rise in the blood-pressure, and a slowing of the pulse-rate. In one case 48 ON THE BLOOD-PRESSURE IN SURGERY the unusual opportunity presented itself of making observations upon the blood- pressure just before and during the devel- opment of asphyxia. The blood-pressure rose abruptly to 220 mm. Immediately ed; under these conditions, opening the box of the larynx, explorations of the in- terior of the larynx, and even laryngec- tomy caused no marked change in the blood-pressure. In one instance while upon opening the trachea and giving ar- dissecting out glands lying close to it, tificial respiration, the blood-pressure the superior laryngeal nerve was subject fell to 140 mm., and the pulse became to traction ; this was attended by an im- Fig. XV. Curve of blood-nressure four hours after decapitation. Fig. XVI. DEATH FROM ASPHYXIA.— Tlie drum was stopped in the middle of the tracing. After a lapse of ten minutes, artificial respiration, rhythmic pressure upon the thorax over the heart, and Intravenous infusion of adrenalin were simultaneously begun. The animal was resuscitated. more rapid than normal. The character of the pulse both as to quality and rate underwent as rapid changes as the blood- pressure. Tracheotomy under cocain in the ab- sence of asphyxia is attended by no spec- ial changes in the blood-pressure. In all laryngeal operations during the time blood-pressure determinations have been made, the laryngeal mucosa and the superior laryngeal nerves were cocainiz- mediate fall in the blood-pressure, and a marked slowing of the heart. Both were due to reflex inhibition from me- chanical stimulation. In one instance, a papilloma, which filled the entire box of the larynx, and extended up to and over the entire under surface of the epiglottis, was removed without any marked change in the blood- pressure. In operations for the removal of tumors GEO. W. CRILE, M. D. 49 of the neck, shock was proportionate to the loss of blood, and to the mechanical insult to the tissues, to the manipulation of certain nerve trunks and to the dura- tion. In removing tumors of the parotid gland, it was found in two instances that division of the vagus caused no effect upon the blood-pressure, or the pulse; but rough manipulation and traction caused a considerable change. Observa- tions were made upon eleven resections of the vagus. Dissections involving ex- posure and manipulation of the sympa- * ^ Figr. XVil. PROPOUND COIJLAPSB.— Note the marked rise in pressure following the injection •f a physiological dose of strychnin. Pig. XVIII. CURARE: VAGI AND ACCELERANTES SEVERED— PROFOUND SHOCK.— Note the negative effect of repeated injections of strychnin. while dissecting them out of their bed in the deep angle behind the jaw, a mark- ed and sudden fall occurred in the blood- pressure, and in the pulse-rate. As soon as the change was noted the area was packed with cocain. After this by more careful manipulation, and from the ef- fects of the cocain, the tumors were re- moved without producing further depres- sion. Excision of such muscles as the sterno- mastoid caused no marked change. Quick thetic nerve trunks caused an increase in the pulse-rate. Resection of the trachea and of the esophagus caused no marked change. There were no immediate effects follow- ing temporary or permanent closure of the common carotid artery. Observations upon the blood-pressure during the removal of five bronchial car- cinomata, in which all the structures above mentioned were removed en bloc. 50 ON THE BLOOD-PRESSURE IN SURGERY gave the opportunity for making these observations. In the removal of bronchial cysts but little change in the blood-pressure was noted. In operations for the removal of tubercular glands the amount of shock was proportional to the vitality of the patient, the duration of the operation, the amount of blood lost, and the amount of mechanical irritation. In a case of sarcoma projecting from the thorax into the lower portion of the neck, exhibiting a misleading amount of mo- bility, removal was attempted. It was not discovered until the dissection had proceeded so far that hemorrhage under- neath and behind the tumor could not be controlled, that it should have been re- garded as an inoperable case. In pushing this dissection to its conclusion, the cla- vicle was resected, and the pleural cavity opened. In this operation a rapid decline in the blood-pressure was noted. In the manipulation for dislodging the tumor from its deep bed, the brachial plexus was roughly manipulated, several trunks severed, and great hemorrhage incurred. During this time the blood-pressure fell rapidly to 68 mm.; the pneumatic rubber suit was then inflated, bringing the pres- sure to no mm., at which point it was maintained during the remainder of the operation. In the removal of large tumors of the neck and head in which hemorrhage was controlled by closing the carotid artery with a special clamp, in which a prelim- inary injection of atropin to protect against reflex inhibition of the heart was given ; in which sharp dissection and gentle retraction, instead of blunt dissec- tion was largely made; and in which, when branches of the vagi were involved, inhibitory impulses were prevented by the use of cocain, comparatively little shock was encountered. In all these serious operations the rub- ber suit was put on before beginning, and as occasion demanded the blood-pressure was supported so as to be maintained at a certain level. Thorax. Excision of the breast for carcinoma in middle-aged subjects was attended by only moderate changes. The blood-pres- sure sometimes showed a decline toward the close of the operation, and the pulse became proportionately accelerated. In an elderly patient a marked fall was noted. In the complete dissection of the axilla, particularly when the large blood-vessels and the nerve trunks are involved in the dissection, the principle change in the blood-pressure was noted, — the net re- sult of which was an irregular decline. Dissection with a sharp knife, with minimum traction, caused the least change. Rough sponging, blunt dissec- tion, and strong retraction caused the most marked change. Abdomen, Observations were made during pylo- rectomy, partial gastrectomy, gastroen- terostomy, enteroenterostomy, choledo- chotomy, cholecystotomy, cholecytect- omy, appendectomy, resection ©f the cecum and resection of the large and the small intestine. It was found that the amount of shock was directly proportion- ate to the amount of traumatism inflicted upon the peritoneum. Injury of the mu- cous membrane of the hollow viscera did not seem to be capable of producing shock. Exposure to the air, manipulation, and sponging, caused a fall in the blood-pres- sure and a rise in the pulse-rate. This was noted in packing the abdominal cav- ity with gauze. Flushing out the cavity also caused a decline in the blood-pres- sure. The most marked effect was noted during the exploration of the abdominal cavity in the development of the field of operation, separating adhesions, and bringing tumors into the wound. In operations involving only a small segment of the intestine, although consid- erable time was occupied, there was but little change in the pressure, after the first effect had worn off. This was true only when the remainder of the peritoneal cavity was kept free from irritation ; — as for example, during the application of the sutures in an anastomosis there was but slight change in the pressure. The same is true in appendicectomy. During the technique for removal of the appendix but little change was noted. In operations such as resection of gangrenous bowel, in strangulated hernia, the extensive washing and sponging of the field to remove infection was attend- ed by a considerable decline in the blood- GEO. W. CRILE, M. D. 51 pressure. The manipulation which caused the changes in the blood-pressure in almost every instance caused an increase in the respiration. The most striking effects were noted in operations in the upper portion of the peritoneal cavity, near the diaphragm. The lower portion of the abdominal cav- ity showed less reaction. In all the ab- dominal operations above mentioned the net tendency of the changes in the blood- pressure was towards a decline. In some instances a temporary rise appeared, but this usually gave way to a greater de- cline. On the female genital organs observa- tions were made during operations for resection of the ovaries, removal of ovar- ian tumors, excision of the tubes for pyo- salpinx, myomectomy, hysterectomy — both abdominal and the vaginal-dilating and curetting, and plastic operations up- on the vagina and peritoneum. In almost every instance the immediate effect of manipulation of these organs in health and disease was a rise in the blood-pres- sure. This rise usually continued during the period of manipulation and was pro- portionate to the traumatism adminis- tered. The most marked rise was noted in the cases of large fibroid tumors, in which considerable difficulty, owing to impaction and adhesion, was experienced in raising the tumor from its bed. Similar results were noted in opera- tions upon the perineum and the vagina. Divulsion of the sphincter ani caused a very marked rise in the blood-pressure, and some increase in the pulse-rate. The respirations were markedly increased in depth and in rhythm. During manipula- tion of the sigmoid, respiration was ^ al- ways increased, particularly its inspira- tory phase. This also occurred in dila- ting the cervix. Genito-Urinary System. Blood - pressure determinations were made during nephrectomy, nephrotomy, nephrorrhapy, and suturing of the ureter. During the removal of a large inflamed carcinoma of the kidney, the blood-pres- sure fell rapidly. In nephrorrhapy and incising the kidney but slight effects were noted. Testicles. In dissecting a firmly adherent sac of a scrotal hernia, marked fall in the blood- pressure was noted. In excising a thick- ened hydrocele sac the same was noted. In all manipulations when any effect was noted it was a fall. In amputation of the penis in an elderly subject the fall was marked. During careful dissection of the enlarged veins of a varicocele no effect was noted. Spinal Column. Blood-pressure determinations in two laminectomies under cocain anaesthesia were made. Incising the skin, fascia, mus- cles and the bones caused no appreciable change in the pressure. On exposing and exploring the membranes of the cord, a marked fall in the blood-pressure occur- red. In one case the exploration extended from the fifth cervical to the axis. It was found that the deep tissues of the back over the middle line have but few sen- sory nerve. No cocain was required in the division of the deepest fascia, the sepa- ration of the deepest muscles, the division of the spinous processes and the laminae, and in exploration of the dura mater with the exception of the points of exit of the sensory nerve roots. The slightest con- tact with a sensory nerve root caused an intolerable electric pain. There was quite a tendency to compensation following the fall in the blood-pressure on opening the canal and making mechanical contact with the dura. Hernia. In operations for inguinal hernia no ef- fect was noted except in those in which there was adhesion of the sac to the spermatic cord, necessitating considera- ble manipulation. In such cases a fall in pressure was noted. This fall was prob- ably due to the excitation of the charac- teristic depressor nerve mechanism of the part. In operation for ventral hernia no spec- ial changes in blood-pressure were noted, except in the cases requiring considerable peritoneal manipulation. Extremities. Stretching the sciatic nerve caused a marked and irregular rise in the blood- pressure and an increase in the pulse-rate. Operating on the soft parts caused an ir- regularity in the pressure, more particu- larlv a rise. Some of the cases of most profound shock were caused by heavy in- 52 DIAGNOSIS AND TREATMENT OF DISEASES jury of the limbs — as in railway acci- dents. In an amputation of the shoulder joint, in which the trunks of the brachial plexus were cocainized, thereby "blocking" the afferent impulses due to operative injury, no material change in the blood-pressure was noted. Operations Under Cocain. In abdominal operations under cocain not so much alteration in the blood-pres- sure was noted as in operations under general anaesthesia. This was noted in an operation for typhoid perforation in a boy of twelve ; in a case of cholecystectomy for gallstone in a woman of seventy; in two cholecystotomies in young adults during typhoid ; in a gastrotomy with ex- ploration of the esophagus ; in colostomy ; and in other laparotomies. If there was momentary pain or fear the blood-pres- sure usually rose irregularly. The less amount of shock in these oper- ations under cocain was probably due to several factors; there was no depressing effect of a general anaesthetic ; the opera- tions did not necessitate much manipula- tion; and the same precaution against causing pain — minimum manipulation — was just as effective against shock. In the instances in which either pain or fear caused a rise in the blood-pressure, a later decline was noted. Operations up- on the area supplied by "nerve trunks," subjected to cocain "block" produce no shock. In all inter-varacico-scapular am- putations in which the brachial plexus is "blocked" by cocain there was no shock. 275 Prospect Street, Cleveland, Ohio. SOME POINTS IN THE DIAGNOSIS AND TREATMENT OF DISEASES OF THE NOSE AND THROAT, AND THEIR RELATION TO GENERAL riEDICINE.* By WILLIS S. ANDERSON, M. D.. Detroit, Mich. Assistant to the chair in Laryngology, Detroit College of Medicine; Laryngologist to the Har- per Hosi>ltal Polyclinic, Etc. The writer in choosing this broad sub- ject expects to call attention only to a few conditions that have a bearing on general medicine, and to indicate, in a brief way, some points now commonly overlooked which may aid in interpreting these diseases. The physiology of nasal breathing and its importance to the general health is not sufficiently appreciated. The old di- vision of the nose, into an upper i3ifactory and a lower respiratory portion, has mis- led many. If we study the current of air, in its passage through a normal nose, in ordinary breathing, we find that it passes in an arched direction from its en- trance at the vestibule of the nose, up- ward and backward by the side of the middle turbinal, and emerges into the naso-pharnyx at its upper portion. The current of air does not pass through the cavity opposite the inferior turbinal, as is often believed. This can be demonstrat- •Read before the Wayne County Medical So- ciety, April 9. 1903. ed by allowing a person to inhale some light non-irritating powder, and noting that the powder is carried to the upper portion of the nasal cavity, that the mid- dle turbinal is covered with powder, while the inferior is comparatively free. The practical bearing of this fact is that, many times, a comparatively insignificant obstruction at the upper portion may in- terfere with free breathing, and give rise to distressing symptoms. The fact that by forced breathing air can be made to pass through the lower portion of the nose is no sign that it does so during quiet breathing. An enlarged middle turbinal pressing against the septum, at its upper portion, will leave considerable space beneath for forced breathing, yet these patients are mouth breathers, and often suffer considerable impairment of general health as a consequence. A wo- man consulted the writer complaining of pain over the root of the nose, radiating into the left eye; of shortness of breath on exertion; of palpitation of the heart OF THE NOSE AND THROAT 53 and general malaise. All of the symp- toms disappeared after removal of the middle turbinal of the left side. The close proximity of the ethmoid cells to the middle turbinal, and the fre- quent involvement of the cells should make us remember that many obscure symptoms, referred to the head and eyes, may be of nasal origin. Orbital abscess is frequently due to suppurative disease of the sinuses. Hoople calls attention to intra-nasal pressure as an etiologic factor in affections of the ocular muscles. Con- junctivitis, affections of the lids, or lachrymal duct, may have as an import- ant etiologic factor nasal disease, and, un- less corrected, treatment directed to the ocular condition will be fruitless. Adenoid vegetations in the vault of the pharynx are recognized more often than formerly, yet many do not seem to have a clear idea of the necessity of their re- moval when they interfere with free nasal breathing. A child nearly deaf was brought to me and an examination re- vealed the vault nearly filled with these growths, yet the family physician told the parents she would outgrow them. It is over a year since I made the examina- tion, and I was recently informed by the teacher of the child that the hearing is almost completely lost. This seeming neglect on the part of the parents would be criminal were it not for the fact they were guided, or rather misguided, by their family physician. This brings up the question as to what can be done for deaf children toward restoring their hear- ing by tlie proper treatment of the naso- pharynx. The writer has given some at- tention to the causes of deaf-mutism in children, and finds that quite a large per centage can be, or could have been bene- fited by proper treatment directed to the nose and throat. Our city supports a department for the teaching of deaf mutes by the lip-reading method. Only a cursory examination of these pupils is necessary in order to show how prevalent catarrhal affections are among them. It is not necessary that the naso-pharynx be completely filled with the adenoid growths that they may interfere with nasal breathing, or cause deafness. The close relation between the middle ear and the naso-pharynx is now so well recognized, that the problem of the suc- cessful treatment of the ear resolves it- self frequently into the ability to relieve the naso-pharyngeal lesions. Asthma has for its exciting cause some lesion in the nose, in the large majority of cases. Some observers believe that all cases are due to nasal irritation. While this would seem an extreme view, the fact is that many cases can be permanent- ly benefited, or entirely cured by proper treatment directed to the nose. The writer had recently under observation a young man, who had suffered from asth- ma the greater portion of his life. The symptoms all disappeared after the an- terior ends of both middle turbinals were removed, and the inferior one on the right side cauterized. After the opera- tions he was able to breathe through both nostrils freely, something he had not done before in years. Turning our attention to the pharnyx we find interesting relations between the throat and general systemic conditions. The tonsils, which have always been a fruitful source for discussion, take on a new interest when we consider them as portals through which various infections take place. The close relation between rheumatism and tonsillar inflammation is now generally recognized, but that acute endorcarditis, pericarditis and pleurisy may follow an acute follicular tonsillitis is not generally appreciated, nor that an attack of an acute articular rheumatism may be ushered in by acute tonsillitis. One ought always to examine the heart in every case of acute tonsillitis. Quinsy sore throat is recognized as a rheumatic 54 AND THEIR RELATION TO GENERAL MEDICINE affection. These facts help in the treat- ment of acute tonsillar affections . Large doses of the salicylates, with codeine will lessen the fever and pain in quinsy, and if used early will many times abort an attack and prevent suppuration in the peritonsillar tissue. As a treatment of acute tonsillitis it is very satisfactory. In chronically enlarged tonsils we have a number of affections traceable to them. The crypts of the tonsils afford an ex- cellent lodging-place for particles of food, which, together with the secretions into the crypts, supply the proper medi- um in which innumerable pathogenic organisms thrive. The decomposing ma- terial gives a foul odor to the breath, in- terferes with normal digestion and may cause gastric disturbance. Absorption of septic material from these crypts causes infection of the lymphatic glands of the neck, with enlargement and possibly sup- puration. When enlargement of the glands of the neck exists one should seek for the point of infection. This may be found to be due to disease of the ear, nose, naso-pharynx, tonsil, teeth or larynx. The most frequent cause is disease of the tonsils. The tonsils may not be very much diseased and yet, if examined care- fully with a bent probe, diseased crypts will often be found, forming blind pouch- es, through which infection may take place. A case of this kind may be cited in which a young man had an enlarge- ment of a single lymphatic gland, which had existed for months. An examina- tion of the tonsil on the corresponding side revealed only a slight hypertrophy, but with a probe a crypt was detected which formed a deep pocket and con- tained cheesy material. This crypt was destroyed with the galvano-cautery and the enlarged gland disappeared without other treatment. Tubercular infection of the lungs is now believed, in many cases, to find its point of entrance through dis- eased tonsils. In all cases of suspected lung disease one should examine careful- ly for diseased tonsillar crypts. The treatment of these tonsils depends upon the conditions present. Large tonsils ought always to be removed. Small ton- sils where only one or two crypts are in- volved may be successfully treated by the galvano-cautery. A bent electrode should be passed to the bottom of the crypt and the pocket converted into a furrow m the same way as any fistulous tract. This allows healing to take place from the bot- tom, with obliteration of the crypt. An error is sometimes made in cauterizing the surface only. This often results in the closure of the opening with the form- ation of a retention cyst, or an abscess. Considerable attention has been given, during recent years, to the study of the lingual tonsil. This tonsil is an aggrega- tion of lymphoid follicles, similar in structure of the faucial tonsils, situated at the base of the tongue, in the space just anterior to the epiglottis. The lingual tonsil may be affected in a manner sim- ilar to the other tonsils. Disease of the lingual tonsil occurs usually in adults, children being rarely affected. In this respect it is the opposite of affections of the faucial tonsil. We may have acute inflammation, abscess, or chronic hyper- trophy as in other tonsils. There are a few conditions often met with which have a practical bearing upon general medicine. Dilatation of the veins at the base of the tongue frequently causes very annoying symptoms. They can be readi- ly recognized by examining the base of the tongue with a laryngoscopic mirror. The dilated veins will be seen radiating over the base of the tongue. This local condition gives rise to various symptoms ; such as sensation of foreign body, the constant desire to clear the throat, dry hacking cough, tickling in the throat, rapid exhaustion of the voice after use, or constant hoarseness. Perhaps the most alarming symptom which may re- WILLIS S. ANDERSON, M. D. B6 suit from this lesion is the raising of blood, due to the rupture of small veins at the base of the tongue. The hemor- rhage may be profuse. This symptom always suggests lung disease both to pa- tient and physician. Several cases have been referred to the writer as cases of pulmonary hemorrhage, where examina- tion showed the bleeding to come from a ruptured vein at the base of the tongue. These cases are quickly cured by proper treatment. Hypertrophy of the lingual tonsils gives rise to similar symptoms in a more aggravated form. Besides the ordinary ones there is a group of pecuHar nervous symptoms, somewhat hysterical in na- ture, that might be grouped under the term globus hystericus. Some of these patients suffer from a sense of suffocation and constriction around the throat. The symptoms are usually increased by ex- citement and fatigue. Tumors of this region are occasionally found. Perhaps the one most important to remember is the accessory thyroid gland which may develop at the base of the tongue. The occurrence of these tumors can readily be explained when we recall the com- munication which exists, in the embryo, between the thyroid gland and the base of the tongue, known as the thyro-glossal duct. When these tumors exist there is usually an atrophy of the thyroid gland in the neck, although this is not detect- able in all cases. The writer has seen one of these lingual goitres during the past year with Dr. E. L. Shurly. The case was a young girl wnth a large tumor at the base of the tongue, interfering with breathing and deglutition. No atrophy of the thyroid gland could be detected. The tumor was skillfully removed by means of the cold snare, through the mouth. One of the interesting points in this case is that the girl, after about three weeks, developed myxoedcma, which was controlled bv thvroid extract. These tumors are harmless except as they en- danger life by their size. Before remov- ing them one ought to have in mind the possibility of the supervention of myxoe- dema. If time permitted us to study other diseases of the throat in relation to sys- temic aflfections, we should find a number of conditions depending upon, or at least, influenced by the condition of the general system. Among those most prominent would be syphillis, rheumatism, lithemia and gastric disturbances. In some cases in which it is impossible to satisfactorily explain the condition of the patient by the local appearance of the throat, one will find by examining the heart, lungs or urine a clew that will aid in interpret- ing and successfully relieving the local distress. The opprobrium so often hurled at the medical profession that we can not cure catarrh, finds its justification, in the fact that so little attention is given to- wards making a careful examination, without which neither a working diagno- sis can be made, nor successful treatment instituted. Most of the diseases of the nose and throat can be cured if a proper under- standing of the causes which underlie the affection is appreciated. The more serious malignant and tubercular diseases are usually incurable, but their course can be modified and the patient benefited by proper treatment. Atrophy of the mucous membrane of the respiratory tract is very rebellious to treatment; but even these cases can be markedly im- proved, and if the change in the mucous membrane is not too pronounced, all the disagreeable symptoms can be overcome. 912 Chamber of Commerce. Dr. Koch, the tuberculosis expert, is in Rhodesia to investigate the cattle disease there. He believes that the disease is tuberculous in character. 56 ACUTE DILATATION OF THE STOMACH ACUTE DILATATION OF THE STOMACH.* By W. M. HARVEY, M. D., Detroit. Mich, Acute dilatation of the stomach has, up to the present, scarcely received the attention it deserves. It is of the great- est interest to both physician and sur- geons, since it may be met with by either at times when it is least expected. In medicine, acute dilatation may be occasionally met with as a primary con- dition, but more often it occurs as a com- plication of some pre-existing disease. In surgery, the condition may follow operations upon any part of the body, and may rapidly cause a fatal termination of cases which otherwise appear to be doing well. Typical cases are characterized by their sudden onset, by vomiting an enor- mous amount of fluid, and by very se- vere general symptoms, which, too, often terminate fatally within a few days. Clinically, acute dilatation of the stom- ach may occur to some degree without giving rise to any definite symptoms, and the condition will then only be made out by careful physical examination. In the severe cases of acute dilatation, the stomach symptoms suddenly form the predominant clinical feature, and the original disease becomes, for the time being, of secondary importance. The onset is nearly always sudden. The patient who is either apparently in usual health or suffering from some illness which appears to be taking its usual course, is suddenly seized with vomiting and discomfort, amounting in some cases to severe pain in the abdomen. This sudden onset is, as a rule, a striking feature of the disease. Pain in the ab- domen and tenderness are both frequent- ly met with, and may lead to the belief that the case is one of peritonitis, for which it has often been mistaken. Vomiting appears to be nearly always •Read before the Detroit College of Medicine. present, and is generally the first symp- tom to which attention is drawn. Tlie fluid expelled is variously described, as of a greenish, brownish color, and is usu- ally thin and watery. In some cases it appears to contain bile, and in others matter from the small intestines, and under these circumstances it may become very offensive. The vomiting at first is usually very frequent, but occasionally intermissions of various length occur, and lead to the idea — unfortunately too often an er- roneous one — that the patient is getting better. The cessation of vomiting, when it occurs, is no doubt due to the muscu- lar coat becoming paralyzed. Probably this so in most cases, especially toward the end ; in others, where the intermis- sions are not of long duration, it may be that it is due to a temporary cessation of secretion of fluid into the stomach cavity. Dilatations of the stomach are pro- duced by two etiological factors : First — Mechanical stenosis of the pylorus. Second — Complete or relative weakness of the muscular walls^ or forces. The mechanical factors which lead to the stenosis, or occlusion of the pylorus, are situated either in the wall of the stomach itself or extend to it from with- out. Among the most frequent causes of the former class, and of great importance, are carcinoma and cicatrical contraction, whether this be due to direct cicatrization of an ulcer or produced by inflammatory processes following ulcer or gastritis. Cicatrization is usually due to ulcers situated near the pylorus, the healing uf which causes not alone a stenosis but al? frequently a thickening of the pylorus, which may even be palpated through the abdominal walls and which may be mis- taken for a malignant growth. Congeni- I W. M. HARVEY, M. D. 57 tal stenosis of the pylorus may also be in- cluded among the mechanical constric- tions. The second cause for dilatation of the stomach arises from weakening of the muscular tissue, due either to excessive demands upon the muscle and its gradual relaxation, or to insufficient nourishment of the contractile elements of the gastric walls. The weakening of the walls of the stomach is brought about not only by overloading the stomach with improper quantities of solid foods, with which the muscle is unable to cope, but also by the abnormal production' of gases in the stomach. As might be expected, the distended stomach gives rise to a swelling of the abdomen. The swelling is not uniform, but fills chiefly the left half and lower part of the abdomen; the right hypo- chondrium sometimes appears to be flat- tened. This swelling, which is of diag- nostic value, is not, however, quite con- stant. No doubt the abdominal swelling varies with the vomiting, especially in cases in which there is a large quantity of fluid in the stomach. I have had cases in which the swelling would disappear after removing the fluid with a stomach- tube. Peristaltic waves of contraction but very seldom occur, and their absence op- poses the theory that the dilatation is due to pyloric obstruction. On palpation, a sense of fluctuation and a succussion splash may be obtained. Both these signs, and more especially the latter, often afford valuable aid in diagnosis ; but it must be remembered that they will not always be present, since in some cases there may be but little fluid in the stom- ach, especially during the early period of the disease. When present, however, these signs are of undoubted value, and, in a great many cases, determine the di- agnosis. Percussion will show the stom- ach resonence to be greatly increased, but the note will, of course, be greatly inter- ferred with when there is much fluid. Per- cussion as a means of diagnosis is most important in those cases where there is no succussion splash or fluctuation, and a careful examination by this method will often reveal the early stages and less se- vere forms of the disease. The symptoms of dilatation of the stomach, as a general thing, develop slow- ly. Dyspeptic troubles are the first to appear and they may last for years; in fact, may be the only symptoms of a well- marked case of dilatation. The general symptoms are those of collapse, the pulse is small and very rapid, the respirations are frequent and the temperature low — usually subnormal. The patient com- plains of great thirst, which is usually ac- counted for by the excessive vomiting of fluid. Vomiting is a characteristic sypm- tom. At first this occurs quite frequent- ly and very soon after eating, being to a certain extent a therapeutic effort of the organism to relieve itself of the excess of the ingesta, while a portion is retained in the stomach. Later, the vomiting occurs less frequently in proportion to the in- creasing relaxation of the walls of the stomach and as the quantity of collected matter to be evacuated becomes greater. Finally the vomiting ceases entirely. Then either the obstructing neoplasm has ulcerated, again opening the passage inta the intestines, or the walls of the stomach have become paralyzed. The clinical relations of the gastric juice in dilatation of the stomach depend upon the cause of the dilatation. Should a cancer be present, we would find a marked deviation from the normal stan- dard. If, on the other hand, we have to- deal with cicatrical contraction of the pylorus atonic conditions of the muscular fibers, or hypersecretion, we find almost without an exception, either the usual or increased quantities of hydrochloric acid,. 58 ACUTE DILATATION OF THE STOMACH peptone, and propeptone, and the peptic action is satisfactory, though usually somewhat slow. However, the secretion is complicated by the fermentation which takes place in the stomach and causes secondary decomposition of the stomach contents. It is very apparent that the different disturbances of function react one upon the other. The development of the prod- uct of decomposition paralyzes the mus- cularis, and this paralysis favors the stag- nation and with it the further decomposi- tion of the ingesta. These are but a few of the conditions from which a very appreciable dilation of the stomach may occur. Some people that have an abnormally large stomach, which causes them little or no trouble, may live for years. But some day this compensation fails and then suddenly, or An a short time, all the symptoms of dila- tation of the stomach appear. As the disease progresses, the nutrition is affected more and more. The hands and feet become a bluish red, cold and moist, while the face not infrequently becomes reddened by the development of acne pustules and marked congestion of the capillaries. While vomiting occurs less frequently, the foul smelling evacua- tions and flatulence are increased. The pressure of the dilated stomach causes displacements of all the neighbor- ing organs, especially the heart, lungs, liver and intestines, and interferes with their functions. Dyspnoea and palpitation are increased according to the extent to which the diaphragm is forced upwards by the stomach filled with ingesta or distended by gases. The bowels are, as a rule, slug- gish, and can be moved only by enemata or active cathartics, and the stools then are hard masses mixed with water and mucus. Not only is absorption scanty or check- ed in the stomach, but it must also be diminished in the intestines, which are but insufficiently provided with chyme from the stomach at long intervals. This is especially true with the absorption of water, causing a dryness of the muscular and nervous tissues and of the skin. Many suggestions have been made to account for the dilatations, but no single one of them can be said to give a com- pletely satisfactory explanation of all the cases. There are two distinct factors to be accounted for: (i) The cause of the paralytic condition of the stomach walls whereby they are unable to expel their contents; and (2) the mechanism which gives rise to the excessive secretion, which in many instances plays such an important part in the disease. It has been thought that the excessive secretion is the primary factor and that the stomach dilates as a direct conse- quence of large quantities of fluid being poured into it. It is, of course, a difficult matter to establish precisely the relation- ship which exist between the distension and the secretion, but it is probable that they must be looked upon as two distinct processes. The most likely explanation seems to be that the stomach wall becomes paral- yzed and then later on the organ becomes distended with gas or excessive secretion. Moreover, the fact that excessive secre- tion is not present in every case makes it impossible to consider it as the primary cause. Some further information regarding the relationship between the two process- es may also be obtained from the consid- eration of cases of chronic dilitation which depend upon pyloric obstruction. In many of these there is a very great secretion, just as there is in acute cases, j Hemmeter, for instance, mentions a case of dilation of the stomach, due to malignant growth of the pylorus, in which 6n two occasions the stomach was W. M. HARVEY, M. D. 59 washed and emptied as thoroughly as possible, and the patient for forty-eight hours afterwards was fed by the rectum and all nourishment by the mouth stop- ped. At the expiration of this time, on the first occasion 545 cc. of fluid were drawn off, and on the second 500 cc. In such cases as this the increased secretion is obviously secondary to the dilatation, as it also frequently is in cases ofchronic dilatation which are not due to obstruc- tion; and it seems, therefore, that the in- creased secretion is an accompaniment of the dilatation, rather than a cause of it, and that there may, perhaps, be some cor- relation between the two conditions being followed by excessive secretions. Very likely their relative importance varies, in acute cases, for there can be no doubt that excessive secretion, where present, adds greatly to the gravity of the situa- tion, but there does not seem to be any clear proof that excessive secretion can act as the dilating force unless there is at the same time some paralysis of the stora- ach walls. The view that there is some obstruc- tion of the pylorus, whether permanent or spasmodic, must fall to the ground in face of the fact that dilatation of the whole part of the duodenum is so fre- quently present, and, moreover the vomit in severe cases clearly contains bile. It is, however, quite possible that the diffi- culty which the stomach meets with in getting rid of its contents is sometimes further intensified after distension has taken place, by some rotation at the pylorus which occurs as a result of dis- tension. Another objection to the theory of ob- struction, whether at the pylorus or in the duodenum, is the fact that peristaltic waves of contraction have, with one ex- ception, never been recorded, to my knowledge. The frequency with which the duodenum shares in the distention has given rise to the suggestion that an obstruction must in these cases exist a little below the stomach, and this idea is further strengthened by the very abrupt termination of the dilatation, which sud- denly passes into collapsed intestines, thus producing a condition of things ex- actly similar to that arising from obstruc- tion of the intestines from bands or other well known causes. The constricting force, in many cases (according to some writers), has been thought to be the superior mesenteric artery, which has through some mechan- ical conditions within the abdomen, be- come pulled upon. The conditions neces- sary for the production of the dragging about by the displacement of the col- lapsed intestines into the pelvis, which is supposed to put such a tension upon the mesentery that the superior mesenteric artery becomes converted into a con- stricting force, which obliterates the lu- men of the duodenum. In the first place, it apparently requires a very considerable amount of force to produce obstruction in this way, though this varies with the direction in which traction is made, the least force being apparently needed when traction is made in the exact axis of the artery. With the patient lying on the back, the weight or the intestines will, for the most part, be supported by the posterior wall of the abdomen, and it is only when they are completely collapsed, and have all slipped into the pelvis, that there would be any likelihood of a sufficient force being ex- erted upon the mesentery; and even then, unless they hung as a dead weight over the edge of the pelvis, it would be unlike- ly that sufficient stretching of the mesen- tery would take place to produce this effect. Against the view that constriction oc- curs through the medium of the superior rnesenteric artery is the fact that the po- sition of the apparent obstruction, as shown by the dilatation terminating ab- «0 ACUTE DILATATION OF THE STOMACH ruptly in collapse, is not a constant one. In some cases it is only the first part of the duodenum that is distended, while in others the distention has extended along the jejunum. Again, if the extreme dila- tation of the stomach is to be put down as a direct result of intestinal obstruction produced by pressure of an external band, such as the superior mesenteric artery, it must surely be supposed that, to produce this intense and protracted vomiting, the obstruction must be a very complete ne, and on this supposition it would be ex- pected that the bowels would be uniform- ly and completely constipated, as they are in other cases, suth as strangulated hernia, for instance. There is constantly a tendency to con- stipation, but it is by no means either a constant or complete symptom, and in severe cases there have been actions of the bowels, often excessive, all through the sickness. I have in mind one case in which the intestines contained fluid simi- lar to that in the stomach. All these points are against the theory that there is any tight stricture such as might be supposed to exist from pressure of the firm, cord-like superior mesenteric artery upon the bowel. If a stricture at the junction of the duodenum and jejunum can be produced by prolapsed viscera as easily as some seem to think, it is certainly rather curi- oue that, considering the frequency of prolapsed viscera, acute dilatation of the stomach is not of more frequent occur- rence. The view that a paralysis of the stom- ach walls is the primary event in acute dilatation has received considerable sup- port, and it must be confessed that it is one which seems to give the most satis- factory explanation in most cases. That a paralytic condition of the stom- ach is present I think few will deny; the only question to be solved is, whether or i-ot the paralysis is a primary affection of the stomach or is secondary to an ob- struction lower down. It is probable that paralysis may be produced by local interference with the nerves of the stomach, while in other in- stances it apparently arises through some remote effects upon the central nervous system — the subject, be it noted, being nearly always in a very debilitated condi- tion. As soon as the walls of the stomach have become paralyzed the vicus will be- come distended either by gas or fluid. It may be a little difficult to account for the presence of gas, but, however it may ar- rive, the fact remains that stomachs are freuqently found distended with it. By its mode of occurrence, the suddenness and volume of its generation and its in- nocence of taste or odor, it is clearly marked off from the foul wind generated by the fermentation of food. It is cer- tainly produced in some way by the agency of the nervous system. There is, then, no special difficulty in tmderstanding that if under any circum- stances the walls of the stomach are paralyzed, an overdistention by air may easily take place. Once distention has taken place, many secondary conditions may arise. The pressure on the surround- ing viscera is very great, and secondary obstruction of the bowels might, it would seem, be produced without much difficul- ty. Without wishing to deny it or in the least minimize the importance of second- ary obstruction caused by the distended stomach, there is no obvious reason, if a primary paralysis is assumed to take place in the stomach — as there seems good reason to suppose is the case — why we should suppose the paralysis neces- sarily to be precisely confined to the stomach. The nervous connections be- tween the vagi and abdominal plexus are very complex and it is not impossible that the paralysis which involves the stom- W. M. HARVEY, M. D. 61 ach may also extend a variable distance along the intestines, and if this were so, the variations of the places at which the distended bowel terminates would be ac- counted for. It is, of course, possible and indeed, likely, that different cases arise from dif- ferent causes, and as methods of treat- ment, in order to be successful, must as far as possible depend on causation, it will be well for the present to bear in mind the different possible ways in which the condition may be likely to arise, rath- er than to fix one's attention upon any one particular cause, to the exclusion of all others. Acute dilatation of the stomach may run a rapid course and often terminate fatally in a few days. In most cases the acute symptoms are present more or less from first to last; in a few there are re- missions of some hours and sometimes for longer, which makes it appear likely that recovery is possible; but, unfortun- ately, this idea is too often delusive, and all the active symptoms recur with un- abated violence. The cessation of vomit- ing alone must not be taken as an indica- tion of im£rovement, for, as I have al- ready stated, vomiting frequently ceases a few hours before death and is probably a sign of absolute paralysis of the stom- ach walls and exhaustion of the patient. In such cases the cessation of vomiting is often quickly followed by increased ab- dominal distention, a sure sign that relief of vomiting is only a false indication of improvement. The prognosis is extremely bad in a great many cases, and the disease in its typical form must be looked on as one of the most formidable met with in medicine and surgery. It is almost certain, however, that the prognosis is not as bad as it looks, for up to the present, of course, with few excep- tions, only the most severe cases have re- ceived any attention. One may, I think. feel quite sure that types of more moder- ate severity occur which end in complete recovery; and no doubt when the disease comes to be more carefully looked after all variations of severity will be met with and the percentage of recovery will be much greater. A study of the recorded cases of acute dilatation seems to show that treatment has hitherto met with but little success; but this should not discourage further ef- forts, more especially at it seems probable that many cases of severity have recov- ered, and in some instances almost cer- tainly as the result of timely treatment. In cases in which there is vomiting due to excessive secretion, the most obvious indication is to empty the stomach by means of a tube, and this should be done as soon as possible after the diagnosis is made. The vomiting in these cases is the natural attempt of the stomach to rid itself of its burden, but without artificial aid it is often unable to accomplish its task successfully, and in the later stages of the disease, when exhaustion sets in, the stomach ceases to empty itself and the distention often becomes extreme. It is, therefore, most important to aid the stomach in its efforts in this direction by passinga soft tube and drawing off its contents; great relief in this way may be obtained, and in a great many cases recovery is greatly assisted if it is not due entirely to this method of treatment. The possibility of the dilatation being due to, or perhaps increased by, one of the forms of obstruction should be borne in mind and, with a view of relieving it, changes in the position of the patient should be tried. The prone position should be first tried and, if this does not give relief and the patient is not too ill, the knee-elbow position may be adopted. All nutrition should be given by the rectum and the tendency to collapse met by hypodermic injections of strychnia; 62 ACUTE DILATATION OF THE STOMACH it is in most cases useless giving medicine by the mouth, as there can be no reason- able prospect of it being absorbed. Some of the more serious general symptoms are probably produced by loss of the large uqantities of fluid which are secreted, and this loss should be counter- acted by injections of saline solutions into the rectum, or by transfusion. The diet in dilatation of the stomach should be as limited as possible. We must restrict the use of fluids as much as we can. Give the patient as much nour- ishment as is possible to give in the smallest quantity possible, avoid thin soups, large quantities of alcoholic bever- ages, mineral and other waters, also tea and coffee in any amount. As the treatment will extend for months and even years, we must content ourselves with a dry diet; all easily fer- menting food stuff should be avoided. In severe cases nourishment may be given in the form of enemata or suppositories of peptone, the use of which can be con- tinued for months if necessary. HCl in large doses you will find of great value in all forms of dilatation of the stomach which are not dependent upon atony of the muscles. In atonic conditions, strychnine sulp. or ext. nux vomica are used with good results, it has been proved that they in- crease the production of HCl acid. The cathartics have been proved to play an important part in therapy of gas- tric dilatation and they no doubt stimu- late the gastric peristalsis, not only in evacuating the intestines but the stom- ach as well. Next to washing out the stomach, I consider we get more good from a course of massage and Faradization than an> other source. Massage, if intelligently applied, forces the contents of the stom- ach into the intestines and in this way dilates the pylorus by means of mechani- cal pressure. Cold applications have a tonic effect upon the muscle fibres of the stomach. In a few cases of well marked dilata- tion I have obtained good results from having the patients wear an abdominal bandage. In this way the relaxed ab- dominal muscles are supported and thus the movements of the stomach and in- testines are facilitated. In all cases in which laparotomy is re- sorted to, it should be performed with an eye to the form of obstruction, anil spec- ial attention should be paid to relieving any kind of pressure effects ; for although these may not necessarily be the primary causes they are, no doubt, in many cases secondary conditions of great import- ance, often resulting directly from a dis- tended stomach. Whatever be the cause of the disten- tion and paralysis, whether it depends primarily on nervous or mechanical causes, as the dilation in most cases ex- tends only to the end of or a little below the duodenum, a communication between the stomach and jejunum will, when all else has failed, provide a continuous drainage from the stomach into the bowel below the seat of dilatation, and presum- ably, therefore, below the paralysis. 270 Woodward Avenue. For the first time in history, the sur- geon-general has been obliged to adver- tise for applicants to the medical corps of the navy. Circulars have been sent out to a number of the leading medical institutions. By the end of the year there will be more than fifty vacancies in the corps. The legislature of New Mexico has ex- empted from taxation for the period of eight years each sanitarium building in the territory built in that time. This enactment is the result of plans on the part of promoters to interest capital in the establishment of a sanitorium to cost several hundred thousand dollars. EDITORIAL 63 Detroit Hedical Journal A MONTHLY EPITOME OF PRACTICE AND THERAPEUTICS FRANK BURR TIBBALS, M. D., Editor COLLABORATORS AUGUSTUS WRIGHT IVES, M. D. JOSEPH SILL, M. D. HENRY JASPER HARTZ, M. D. WALTER CHANNING BOYNTON, Business Manager. Note.— W« do not assume responsibility for the opinions of contributors. The management cannot undertake to return rejected manu- script unless full postage for the purpose is submitted with the contribution. Address all communications to 103 and 105 Miami Avenue, Detroit, Michigan, U. S. A. VoL 3. DETROIT, MICHIGAN, MAY, 1903. No. 2 THE SAJOUS DISCOVERY. In the Philadelphia Medical Journal of March 7, 1903, appears a rather revolution- ary article by Dr. Sajous, on the "Ductless Glands." The facts therein stated are new and startling and, if proved true, very val- uable, giving to the medical world know- ledge of the nature of the vital processes, without which, as he says: "Medicine can never hope to be ranked as a branch of ap- plied science." Practically all that has been known to date is that the oxygen inhaled is returned as carbonic acid gas; the intermediate pro- cesses we do not know. Dr. Sajous tells us this, tells us "how the cellular elements, out of which all tissues are built, utilize oxygen." It is now, as is well known, taught in all the leading physiologies that the oxygen is taken from the alveolar air and loosely combined chemically with the hemoglobin of the red blood cell, changing it from a meth- to an oxy-hemoglobin, from a purple to a scarlet hue. We have been taught that the plasma was the carrier, by diffusion as well as by loose chemical combination of the carbon dioxid returned to the lungs from the tissue ; certain radical experiments seemed to prove this. In this paper Dr. Sajous informs us that : "When the venous blood reaches the alveoli, the marked af- finity of the adrenal secretion in the plasma for the oxygen causes it to absorb this gas from the alveolar air," (forming what he names adrenoxin) thus forcibly driving the carbon dioxid from the blood plasma. The red cells, now bathed in this oxygen- laden medium, absorb of this oxygen, and act simply as "storage cells." To the anterior pituitary body he gives the office of governing (through the nerv- ous system), the functional activity of the adrenals and the thyroid bodies, producing as they do a stimulating, iodine-laden secre- tion, the function of raising to their high- est efficiency the vital activity of all tissues. Thus he connects functionally these three bodies, the anterior pituitary, the adrenals, and the thyroids, forming what he has named the "adrenal system," having for its purpose: "To sustain physiological oxidation, and the metabolic activity of all tissues." "It has thus become apparent," he says, "that while exophthalmic goitre is the re- sult of adrenal over-activity, myxedema and its infantile form, cretinism, are due to adrenal insufficiency." But here as in all intoxications, the phy- siologic action of drugs or of bacterial toxins, * * have proved to be results of excessive or reduced functional activity, not of the thyroid, adrenals, or anterior pituitary body as individual organs but as related organs." Dr. Sajous regards the posterior pituitary body as the "general center of the nervous system," a co-worker with its mate, the an- terior, which secures oxygenation of the blood through the adrenal system, while the posterior body adjusts the functional activity of all organs through the nervous system. All toxics, we now find, either stimulate or depress the anterior pituitary body, and through it the adrenal system. Whether this toxic be called a toxin, a poison or a remedy, the phenomena of adrenal hyper- or hypo-activity always appear. He shows 64 EDITORIAL that a toxic dose of quinin, or arsenic, the symptoms of cholera, etc., ■ are similar to those following a double adrenalectomy, while in tuberculosis, pneumonia and many another diseases, he organ primarily at fault is the anterior pituitary body. "In fact," he says, "vulnerability to any disease, whether inherited or acquired, means in- sufficiency of this organ, that is to say, the adrenal system, because as a result of the impairment of this organ, we have reduced oxidation, entailing impaired metabolism and nutrition of all structures, including the heart."' This w^ould seem to greatly simplify the practice of medicine and ther- apeutics, for in all wasting diseases, all hypo- conditions, proper adrenal stimula- tion seems indicated. Indicated, however, in connection with the administration of alkaline salts, for he claims, and he lays great stress upon this, "that steadily as the febrile process advances, the alkaline salts are consumed and being inadequately re- newed," (due to anorexia, etc.,) "the vital and defensive functions are increasingly hampered until life ceases." This applies not only to different fevers, but to uremic poisoning, puerperal eclampsia, etc., during which "as is well known, patients decmeii to be in extremis, have been practically re- suscitated by the use of an alkalino solu- tion." For the first time, we believe, the writer has given to the world the exact functions of the various forms of leukocytes. He finds that they all, cell-substance and nu- cleus, contain an intricate canalicular sys- tem through which the adrenoxin pene- trates to the phosphorus contained in large quantity in the nucleus. The neutrophilic leukocytes, the phagocytes, constituting three-fourths of the white cells, "ingest proteids, certain hydrocarbons, sugar and starch in the digestive canal and convert them into peptone, myosinogen, and fibri- nogen granules." Here is food for the medical profession as well as for these neutrophiles. The eosinophilic leukocytes elaborate hemoglobin from the proteids, bilimbin, and iron, ingested by their parent cells, the neutrophiles ; they take part in the formation of the epithelium of the pulmon- ary alveoli, and supply the underlying plasma with hemoglobin. This also we had not known. * The basophilic leukocytes form myelin, the active principle of which, lecithin, com- bines with adrenoxin to develop nervous energy. Trypsin according to him, is almost en- tirely formed in the splenic vein, and taken directly to the liver, to act as an antitoxic and germicidal secretion, instead of being manufactured in and by the pancreas, as has been supposed, to be poured, not into the portal circulation directly, but into the intestinal canal, there to convert the pro- teids into peptones. Furthermore we find that fatty degener- ation wherever found, is mainly due to the accumulation in any tissue of partly oxi- dized fibrinogen, produced by a faulty ad^ renal system. Dr. Sajous states that nervous energy is generated and set free by the combina- tion of the lecithin of the myelin sheath with the adrenoxin of the plasma contained in the axis-cylinder. If the article contained only one or two entirely new facts it would be easier to grasp, but here is a collection of a dozen or more fundamentally new ideas, answering at once many of the vexed questions of physiology and pathology. If all or many of these statements stand the test of ex- periments and time, it will necessitate the re-writing of our physiologies, pathologies and books on practice and therapeutics; will greatly simplify them all, placing them on a more scientific basis, remove the term vital phenomena, and show as he says : "Where the taper bums that we call life." Seldom, if ever, has so much that is both new and true been given to the world at once. We have generally been compelled EDITORIAL NOTES U5 to be satisfied with one new important dis- covery at a time. If all that Dr. Sajous says be true, it seems to us, that not since the days of the discovery of the circulation of the blood has so much of value been given to the medical world, adding greatly to the lustre of the already celebrated name of Dr. Charles E. de M. Sajous. OUR NEW HOME. We have now permanently located the offices of the Detroit Medical Journal on the first floor of the new four-story building recently erected by the J. F. Hartz Co. at Nos. 103 and 105 Miami Avenue. Here we shall have all modern facilities for editing and publishing the Journal in the best manner possible. We extend to our friends in the profession a most cordial in- vitation to pay us a visit when they are in the city, and to make headquarters with us. We are as much at your service in our office as we are in the Journal itself. With new quarters, adequate for our needs, new and improved methods of hand- ling the mailing-list and the mechanical work of publication, we shall endeavor to increase the value of the Journal as steadily as we have tried to do in the past. We take this opportunity to extend to our contribu- tors and other supporters our hearty thanks for their co-operation, and to express the hope that they will continue to be with us. The 39th annual report of Harper Hos- pital (Detroit) shows that 2,443 patients were admitted to the institution in 1902, an increase of 319 over the year 1901. In the main building, 2,320 patients were treated, in the diphtheria building 115, in the scarlet fever building 122, and in the department for out-of-door patients 1,877 — a grand total of 4,434 patients. Prescrip- tions to the number of 10,164 were furnish- ed. A number of gifts were received, which will make the work of equipping the hospital in a thoroughly efficient manner much more easy. li^DIToIQAL Milwaukee wants the American Medi- cal Association to meet in the Wisconsin city in 1904. The association held its annual meeting of 1893 in Milwaukee. The medical boards of Indiana, Ohio, Kansas, Wisconsin, Iowa and Michigan, have finally effected an agreement by which physicians who have successfully passed an examination in one of the states may practice in any one of the six with- out further examination. Dr. Pierre Paul Emile Roux, sub-di- rector of the Pasteur Institute at Paris, has been awarded the Osiris prize of $20,000 for his work with diphtheria serum. The prize was awarded by the Institute of France, and the decision giv- ing the award to Dr. Roux was unani- mous. Dr. Ira Remsen, president of Johns Hopkins University, was elected vice- president of the national academy of sciences at Washington, D. C, on April 23 last. This left a vacancy in the office foreign secretary, which was filled by electing Prof. Simon Newcomb, of Wash- ington, D. C. Leland Stanford, Jr. University, at Palo Alto, Cal., is suffering in much the same way that Cornell did recently. There is an epidemic of typhoid at the institution, and more than 100 cases are reported. Impure milk is said to be the cause of the trouble, which is certainly serious enough. In connection with New York's work among her consumptive poor there is con- templated the building of a solarium on 66 EDITORIAL NOTES Blackwell's Island, to be used an an ad- junct to the tuberculosis ward of the Manhattan Hospital. The proposed build- ing is to be one story high, 200x24 feet and with verandahs around all four sides. The thirteenth annual meeting of the American Electro-Therapeutic Association, will be held at Atlantic City, N. J., on September 22, 23, and 24 next. Since its organization in 1890, the association has gone steadily forward, and has devoted its attention to a scholarly, scientific investiga- tion of what may prove to be one of the greatest curative measures of all time. Dr. George B. Russell, Dr. Morse Stewart and Dr. Hermann Kiefer, three of the oldest members of the medical pro- fession in Wayne County, were pleasantly banqueted by the Wayne County Medical Society on May 14. The banquet was given at the society's rooms in the Stevens block and was an enjoyable affair. A num- ber of the older physicians throughout the state were present. . John D. Rockefeller has added another worthy enterprise to his list of benevo- lences. It is not the Chicago university this time, but an Institute of Medical Re- search. Mr. Rockefeller has signed con- tracts for the purchase of a tract of land on East River, New York City, extending from Sixty-fourth to Sixty-seventh street and work on the new institute will be be- gun August I. A trifle less than $700,000 was paid for the land alone, an dit is evi- dent that Mr. Rockefeller intends to do what he proposes along broad and gener- ous lines. Gov. Pennypacker, of Pennsylvania, has signed a bill making it against the law for any one to sell cocaine, or any patent or proprietary medicine containing cocaine to an habitual user of cocaine, without a physi- cian's prescription. The penalty is made a fine of $100.00 or six months' imprison- ment. The question of the cocaine evil is one that is attracting considerable atten- tion, and there appears to be abundant need for a law of some kind to provide a penalty for the indiscriminate sale of the drug. Whether or not the provisions of the new Pennsylvania law are proper for the case remains to be seen. Dr. William T. Councilman, of the Har- vard Medical School, has announced that he has discovered the cause of small-pox. It has been determined that the cause is a micro-organism, which serves to relate the disease to malaria and to segregate it from the diseases caused by bacteria. The an- nouncement is the result of findings in an investigation pursued by Drs. Councilman, George Burgess Magrath, assistant in path- ology, and Walter Ramsden Brinckerhoff, of the City Hospital staff of Boston. The Boston board of health co-operated with the investigators during the recent epidemic of small-pox in Boston. The official con- firmation of this announcement by Dr. Councilman himself is awaited with some impatience. Congress at its last session provided for an increase of 150 numbers in the Medical Corps of the navy of the United States, of which 25 are to be appointed every year for six years. The regular per- centage of vacancies from retirements, resignations and other causes is about ten per annum, so that 35 vacancies a year may reasonably be figured on. Ex- aminations to determine the fitness of can- didates for admission are conducted at Mare Island, Cal., and at Washington, D. C, and the board of examiners is in con- tinuous session. The examinations are competitive, and the only requirements for trial are that a candidate shall be between the ages of 21 and 30, and a citizen of the United States of good moral character. PROGRESS OF MEDICAL SCIENCE 67 PR0QRE55 OF flEDICAL SCIENCE SURGERY AND GYNECOLOQY. Gant {New York Medical Journal, April i8, 1903), advocates the treatment of dis- eases of the rectum in the office rather than in the hospital and under local rather than general anaesthesia. A 3 per cent, B. eucaine solution or externally the ethyl chloride spray may be used. In this way haemorrhoids, external or internal, fissure, ulcer or fistula proctitis and, in fact, all minor diseases of the rectum and onus, may be painlessly and satisfactorily treated and cured, without interfering materially with the business or pleasure of the patient. He performs valvotomy by applying a valve clamp which cuts its way out by pressure necrosis in from four to six days, leaving the severed edges of the valve widely separated. IngersoU Olmsted {Philadelphia Medical Journal, March 21, 1903), reports 12 cases of goitre successfully operated under in- filtration anaesthesia following Kocher's method, briefly as follows : A bowed incision is made with its con- vexity downward, across the tumor from the outer surface 61 one sternomastoid muscle to the other, extending through all the tissues down to the muscles of the neck, and this flap is