in the thorax, and the act of respiration takes other words, the rise in the bulk of urine tells place normally about 18 times per minute. in the most unmistakble manner that the action By such "tidal" air the "residual" air is kept of the drug is filling the arteries. Thus, in fairly pure. But when the thoracic space is dropsy, when the bulk of urine is low, and the encroached upon either by air in emphysema, specific gravity is high, then digitalis is preconnective tissue in cirrhosis, diminution of eminently useful. When albuminuria is presthe calibre of the air tubes from thickening of ent from venous engorgement in heart failure, the bronchial lining membrane, or by en- digitalis will often be followed by its disapgorgement of the blood vessels in mitral dis- pearance. As the arteries are filled the veins ease; then the respiration must be more fre- are depleted; the albumen, which tells of quent in order to keep the residual air fairly venous congestion, disappears as this state of pure. The stimulus to respiration is the the veins is relieved; as the arteries are filled effect of venus blood, laden with carbonic the bulk of urine rises.

acid, upon the respiratory centre in the me- Before I conclude, let me say a few words dulla. When there is an excess of carbonic in regard to another condition in which digitacid in the blood circulating in this centre, alis is sometimes given with injurious effects, then the respiratory efforts are increased in which contrasts with the foregoing conditions, vigor until the excess of carbonic acid is got viz.: The hypertrophied, gouty heart often rid of. The right ventricle being embarras- palpitates when there is arteriole spasms, and sed it is not usually enough to give digitalis the larger arteries are tense and full of blood. to increase the energy of the contractions of The resistance offered by this full arterial the right ventricle. Though, of course, all system to the onward flow of the blood at the medical men of much experience have met with striking illustrations of the almost magical effects of digitalis in the pulmonary engorgement of mitral disease: many can also tell of cases where digitalis failed to afford relief under these circumstances, or even in creased the respiratory embarrassment.

Under these circumstances, of mitral lesion, no matter what form, with embarrassed respiration, the best results are obtained by administering also strychnine, a well recognized "respiratory stimulant." Here, the effect of the digitalis upon the right ventricle, and that of the strychnine upon the respiratory centre, work together for good with most satisfactory results. The good effects of this combination, are conclusively demonstrated in those cases where digitalis given alone fails to do good; but where the addition of strychnine at once maks a striking alteration for the better. The proper relation of digitalis to stimulants of the respiratory centre is a matter far from being understood generally by the profession.

cardiac systole is such that the ventricle palpitates in its efforts to contract effectually. Such a condition is commonly seen in the 'chronic Bright's disease without albuminuria," so well described by Dr. Mahomed and others. Here digitalis does harm for the arteries are already full to the risk of apoplexy. Indeed this last accident has followed the administration of digitalis under these circumstances. The full artery, then, it is to be remembered, is a contra-indication, just as much as an empty artery is an indication, for the ad. ministration of digitalis, whether the heart be discased or not.

In conclusion, the indication, then, for the use of digitalis, is not a murmur in the heart, nor a certain form of valvular lesion, nor tumultuous action, nor yet rapidity of action, but whenever it is desirable to fill the arteries and empty the veins.

DISCUSSION.

Dr. Felty-In a subject of so great importance as this, we must feel it our duty to enter Digitalis is also a diuretic. Whenever the heartily into an earnest discussion. Dr. Debulk of urine rises after its administration, wees, in my opinion, is deserving of praise then I know digitalis is doing good. The and credit for bringing this timely topic, and bulk of urine is the index of arterial fullness. the very able manner in which he has preWhen the arteries are filled by the action of sented the same. That digitalis was, next to digitalis the bulk of urine is increased. In strychnine, the best drug at our command to

counteract the depressing effects of the anæsthetic, is what I took home with me, with a great deal of interest, as being entirely new to me. I have always regarded ammonia as the best remedy, but I cannot gainsay the authority of Prof. Wood. The specific effect of digitalis upon the vagus, and the respective heart ganglia, as well as the sympathetic nerves, renal, and brain centres, is still an open question. Ammonia, brandy and whisky, all act chiefly by stimulating the sympathetic heart ganglia and paralyzing the inhibitory centre, known by flushed condition of the skin, which is due to dilatation of the blood vessels. I would ask Dr. Dewees to answer,

I. How digitalis acts upon the heart?

2.

In what diseased condition of the heart is it indicated?

3. If it is to be given in all cases of mitral disease, regurgitation, or aortic stenosis?

4. If any difference, tell when to give and when to withhold digitalis?

Dr. Austin-I think digitalis acts a little slow, and ammonia quicker, and I feel confident of having seen good results from the use of ammonia, in those cases.

Dr. Ketchersid-Digitalis is one of our most useful drugs if rightly used. To use it intelligently, it must not be forgotten that digitalis increases arterial tension, and thereby decreases nutrition. This latter applies especially to the heart-muscle itself. Therefore the drug must be used, but limited as to time, or else you exhaust the heart-muscle. My experience teaches me that the tincture of digitalis gives the best and most reliable results.

1

Dr. Daugherty, President-I have used digitalis a great deal, but not always with satisfaction. The potency of the remedy depends on the reliability of its properties. I have given two to three-drop doses of the tincture every two to three hours, and in a short time I found I had a tetanized heart. Then again, I have given large doses with no noticeable. effects. Ringer tells us that digitalis acts chiefly on the left side of the heart, noting no apparent effect upon the right side. This would explain the phenomena of its good effects in filling the arteries. There is so much blood in the body, which if equally distributed throughout the blood vessels, as in the normal state, will cause to fill the arteries Dr. Blesh-The topic is timely, and has and veins to a moderate degree, but when been very interesting food for my mind, in the venous congestion takes place it is at the explain and simple manner presented. I feel pense of the blood in the arteries, which then really profited, to the extent that I know more become proportionately empty. To restore about the indications for the use of digitalis this normal equilibrium of the circulation, by than ever before. Recently, under the obser- filling the arteries and proportionately emptyvation and assistance of one of the members ing the veins, digitalis does undoubtedly prove here present, I was giving the anaesthetic of the greatest service. Therefore digitalis is (ether) in a case where abdominal hysterect-indicated whenever there is a weakness of the omy was performed. Suddenly there occurred left ventricle. If you have dilatation of left alarming depression, and I resorted to the ventricle, without compensatory hypertrophy, hypodermatic injection of brandy in one-half it is indicated. But when there is compensadrachm doses, repeated eight times, at intervals of three to five minutes the first few injections, then every ten to fifteen minutes, with successful results.

tory hypertrophy, then it is contra-indicated. I know of no better distinction or indication than those brought forward by Dr. Dewees, on this subject

Dr. Dewees-In concluding this discussion I shall first endeavor to answer the queries propounded by Dr. Felty:

I would ask Dr. Dewees whether the tincture, fluid extract, or the alkaloid digitaline, are all equally efficacious to produce the characteristic effects of the digitalis on the heart? 1. Digitalis, in medium doses, acts upon If not, what preparation of the drug is to be the heart-according to the most approved most relied upon? Also whether heart physiological experimentations-by stimulatfailure, complicated with shock, is likewise best treated by digitalis? In these latter cases ing the cardiac-motor ganglia, the inhibitory I have found the aromatic spirits of ammonia apparatus, and the vaso-motor centres, conto give good results. tracting the arterioles, thereby producing a

great rise in arterial tension. Thus digitalis produces increased heart-power, as well as resistance at the periphery, whereby nutrition of the heart-muscle is decreased. In other words, digitalis increases inhibition and stimulates the cardiac-motor centre, and with full lethal effects finally paralyzes the cardiacganglia by over stimulation, arresting the heart in systole. It therefore must follow that digitalis does not increase the nutrition of the heart, but overworks it. This has been very properly noticed by Dr. Ketchersid in his remarks, while he also gave a safe rule for its administration when he said "digitalis must be used, but limited as to time, or else you exhaust the heart's muscle."

4. I have defined when to give the potent remedy under discussion; it now remains to answer when to withhold the same. This is chiefly summoned up by three diseased conditions of the heart, viz.: Simple hypertrophy, pericarditis and fatty heart. I might add under the head of when to give digitalis, that its value in the condition of what is known as an irritable heart, is well known to all of extended experience. This condition is due to over-exertion or exhaustion, and is oftenest presented in soldiers, heavy laborers, first stage of pneumonia and other inflammations, scarlet fever, congestion, headache, hemicrania, delirium tremens, mania, venous engorgements; dropsy, renal and cardiac, and 2. It is not the disease, but the condition even in hemorrhage from a large surface as in of the heart, which defines the indication for menorrhagia, or hemorrhagic diathesis; in the use of digitalis. This condition is an un- which latter it often acts as a hemostatic. balanced state of the normal equilibrium of Here the good effect is due to the fact that the arterial and venous blood circulating in digitalis produces prolonged systolic power, the blood vessels in the body, i. e., when the and likewise prolonged diastole, whereby the veins are abnormally full and the arteries ab- weak muscles are empowered to do more normally empty. Whenever this condition work, just as one powerful blow of the blackarises, regardless of the kind of disease of the smith's hammer drives a nail further than a auricular, ventricular, or aortic orifices, then, larger number of weak blows of a child, though and then only, is digitalis indicated. Now the same amount of energy may have been this condition may arise. (a) In mitral dis- expended. ease, when the heart becomes rapid and feeble, In answering Dr. Blesh, I will first say with and respiration impaired; here digitalis, by Dr. Dougherty, that "the potency of the virtue of its effects upon the heart, does mod- remedy depends upon the reliability of its erate pulmonary hyperæmia and engorge- properties," which if alike contained in the ment, by giving the auricle time to empty various preparations of the drug named, would itself through the obstructed orifice. (b) In undoubtedly alike produce the same characsimple dilatation of the heart, without com- teristic effect. But experience has demonspensatory hypertrophy, digitalis will restore the heart to its size and vigor, enabling the muscle to be better nourished, whereby that compensatory hypertrophy is built up, which alone can offer prolonged life to the afflicted. In heart-failure, complicated with shock, (c) In dilatation of the right side of the heart we have an altogether different state to deal with incompetency of the tricuspid-valves, it with; here we have the nerve-centres stunmay be employed. (d) In aortic disease, ned or depressed, without any toxic element when compensatory hypertrophy has not set in the blood, while in the heart-failure during in, as well as in aortic stenosis, as explained anesthesia, we have the depression resulting in my paper.

trated that the tincture and the infusion are the two most reliable preparations. Dr. Wood advises the use of the tincture hypodermatically in heart-tailure from the anesthetic.

from the toxic effect of the anaesthetic upon 3. Thus, I trust, that I have conclusively the nerve-centres. Digitalis is undoubtedly shown that digitalis is to be given in mitral and aortic diseases, whenever the condition indicating the use of digitalis manifests itself, otherwise never.

likewise useful in this condition; nevertheless, owing to the nerve-centres being free from poisonous depression, we are more likely to find good effects here from warmth, nitro

glycerine, ether, nitrite of amyl., alcohol, it is about as difficult as it is to define inflamammonia, caffeine, strophanthus, atropine, mation. etc., as these agents are cardiac stimulants and tonics, producing their effect quickly and relieving peripheral resistance.

Bilroth says an ulcer is a wounded surface which shows no tendency to heal. According to this definition, every large granulating In regard to the reliance on brandy or al- wound which halts in its progress towards a cohol, the experiments of Prof. Wood and R. cure may be regarded as an ulcer. Dubois, prove "that alcohol intensifies the But the following definition best meets the influence of chloroform and ether, and lessens requirements: An ulcer is the result of the the fatal dose." Prof. Wood, in his experi- death or destruction of tissue in invisible ments, included the more important remedies masses, in which the histological elements of which have been used by clinicians for the the tissues lose their identity with the formaaverting of threatened death during anæsthe- tion of pus as a result of molecular disinsia, viz., ether, alcohol, ammonia, nitrate of tegration. amyl, digitalis, atropine and caffeine; also alterations of position and artificial respiration." He concludes, therefore, as follows: "The rule for the proper treatment of accidents during anesthesia can be summed up in a very few words:

This definition is in contra-distinction to the definition for necrosis, which is a death of tissue in visible masses, without the formation of pus, and in which the histological elements of the tissues retain their identity. An ulcer is always preceded by a stage of

"Avoid the use of all drugs except strych- inflammation, accompanied by cell proliferanine, digitalis and ammonia.

tion and cellular infiltration of the surround

"Give the tincture of digitalis hypodermic- ing tissues. Leucocytes appear coming from ally. Draw out the tongue and raise up the the neighboring vessels, and in the corneal angle of the jaw, and see that the respiration tissue, if there be any lesion of the epithelis not mechanically impeded. ium, they may come from the conjunctival "Invert the patient briefly and temporarily. sac. They force their way along the numer"Use forced artificial respiration promptly, ous canals, and in so doing take on an oblong, and in prostrated cases employ external curved or spindle shape. They appear in rows, warmth and stimulation of the surface by the and under focal illumination, constitute the dry electric brush, etc.; and, above all, re- fine straight lines which are so often seen member that some, at least, and probably after wounds. many, of the deaths which have been set down as due to chloroform and ether, have been produced by the alcohol which has been given for the relief of the patient."

Corneal Ulcers,

The part swells, and an elevation above the surrounding surface is seen, and is now primarily designated an abscess. If the infiltration be near the center of the cornea, it is generally round; if situated near the margin of the cornea it coincides with its contour. Its color

WITH SPECIAL REFERENCE TO THEIR TREAT- at first gray, becomes yellowish. The abscess

MENT WITH THE GALVANO-CAUTERY.

Read before the Topeka Academy of Medicine and Surgery, October 7. 1890.

BY R. S. MAGEE, M. D., TOPEKA, KANSAS, LECTURER ON OPHTHALMOLOGY AND OTOLOGY IN THE KANSAS MEDICAL COLLEGE.

Physicians practically agree as to what an ulcer is, and whether any wounded surface is to be so regarded; but to give a definition of

is surrounded with a grayish cloud, and frequently we see grayish lines, deeply seated, stretching from its margin to the periphery of the cornea. It is formed by the destruction of the cellular elements and the inter-cellular substance of the cornea, serous and plastic infiltration and leucocytes.

The epithelium covering the abscess, because of the stretching, becomes thinned, and on the slightest provocation from irritation a break occurs in the continuity of the tissues and it becomes an ulcer.

This has increased the liability to infection. Only a short time before it was protected by Nature's antiseptic wardrobe, but it is now exposed and permits the free ingress of pyogenic germs, and is soon swarming with myriads of parasites.

2. To impede and check destructive tissue metamorphosis.

3. To encourage the reparative process. In the atonic or indolent ulcer there is little or no pain. This variety requires active Two processes are now at work, the repar- stimulation. While on the other hand the irative and the destructive; the one antagon- ritable ulcer requires no stimulation, particuistic to the other, the destructive process larly in the acute stage. usually predominating. In this case it is termed It is our aim in this paper to speak of the a suppurating ulcer. When the reparative merits of the galvano cautery in the treatment process predominates it is termed a proliferat- of corneal ulcers. ing ulcer.

The application of a red-hot platinum tip The contents of the abscess are sometimes to the cornea, appears at first thought to be liquid and are absorbed, no break occurring dangerous and hazardous to the safety of the in the surface. At other times it is so thick eye. Before the days of cocoaine, the actual that the contents are not evacuated on punc- cautery was so used in eye diseases, yet it was The pus in the abscess may spread be- unsatisfactory, nevertheless its importance tween the lamellæ, and extend to the lower was fully recognized. But cocoaine has had portions of the cornea, assuming the form of a significant influence on the success of the an arc, and it is known as an onyx. operation, facilitating and admitting of a more delicate manipulation into the different individual tissue layers, carrying it just so far as is necessary.

Should it perforate posteriorly it descends into the bottom of the anterior chamber, and it is called hypopyon. This usually signifies the intensity of the process and calls for active measures.

The introduction of this valuable local anæsthetic has done away with the unpleasant features connected with the galvano-cautery, viz.:

Ulcers involving the superficial layers of the cornea leave no opacity. Opacities are the result of the changes already described by 1. The cauterization of a strip of healthy which the homogeneity of the tissues is im- corneal tissue from an inadvertent movement paired. As an analogy, we find when glass of the patient on the approach of the heated is reduced to powder, it becomes white; water loop, or a sudden turn of the eyeball on the as foam, or crystallized into snow is no longer application of the heat. transparent. The cause of this is the irregular way in which the light is reflected from the multiplied surfaces.

2. The suspension of the cauterization too soon.

A few minutes after the instillation of a few drops of a 5 per cent. solution of cocoaine, there is complete anæsthesia of the corneal layers, so that the approach of the red-hot loop, or its repeated application (which is usually accompanied by considerable hissing. and sizzing) causes no painful sensation.

The management of one of these cases, so long as it maintains its special suppurative character, is always a cause of anxiety and annoyance to the surgeon. For not only is there danger of perforation leaving adherent leucoma and permanent opacity of the cornea, but in a considerable proportion of cases, the The operation requires no aid from an aspus makes its way into the deeper parts of sistant. With the thumb and index finger of the cornea, causing onyx, or when it per- the left hand, the operator separates the lids, forates, hypopyon, and the suppurative process extending still farther, it is liable to cause the complete functional destruction of the

eye.

The main indications to be met in the treatment of corneal ulcers are:

and with the right applies the heated loop to the infected zone, making and breaking the current by the simple pressure of a button on the handle of the electrode.

In a short time we observe a surprising change. The adjacent corneal tissue gains in