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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 cardiac systole is such that the ventricle palwith striking illustrations of the almost mag- pitates in its efforts to contract effectually. ical effects of digitalis in the pulmonary en- Such a condition is commonly seen in the gorgement 'of mitral disease: many can also "chronic Bright's disease without albumintell of cases where digitalis failed to afford re-uria,” so well described by Dr. Mahomed and lief under these circumstances, or even in- others. Here digitalis does harm, for the arcreased the respiratory embarrassment. teries are already full to the risk of apoplexy.

Under these circumstances, of mitral lesion, Indeed this last accident has followed the adno matter what form, with embarrassed res- ministration of digitalis under these circumpiration, the best results are obtained by ad- stances. The full artery, then, it is to be reministering also strychnine, a well recognized membered, is a contra-indication, just as much "respiratory stimulant." Here, the effect of as an empty artery is an indication, for the ad. the digitalis upon the right ventricle, and that ministration of digitalis, whether the heart be of the strychnine upon the respiratory centre, diseased or not. work together for good with most satisfactory In conclusion, the indication, then, for the results. The good effects of this combination, use of digitalis, is not a murmur in the heart, are conclusively demonstrated in those cases nor a certain form of valvular lesion, nor tuwhere digitalis given alone fails to do good; multuous action, nor yet rapidity of action, but where the addition of strychnine at once but whenever it is desirable to fill the arteries maks a striking alteration for the better. The and empty the teins. proper relation of digitalis to stimulants of the respiratory centre is a matter far from being Dr. Felty-In a subject of so great importunderstood generally by the profession. ance 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 th 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 anæs- Dr. Ketchersid- Digitalis is one of our most thetic, is what I took home with me, with a useful drugs if rightly used. To use it intelgreat deal of interest, as being entirely new to ligently, it must not be forgotten that digitalis

I have always regarded ammonia as the increases arterial tension, and thereby debest remedy, but I cannot gainsay the author- creases nutrition. This latter applies espeity of Prof. Wood. The specific effect of dig- cially to the heart-muscle itself. Therefore italis upon the vagus, and the respective heart the drug must be used, but limited as to time, ganglia, as well as the sympathetic nerves, or else you exhaust the heart-muscle. My exrenal, and brain centres, is still an open ques- perience teaches me that the tincture of digittion. Ammonia, brandy and whisky, all act alis gives the best and most reliable results. chiefly by stimulating the sympathetic heart Dr. Daugherty, President-I have used dig. ganglia and paralyzing the inhibitory centre, italis a great deal, but not always with satisknown by flushed condition of the skin, which faction. The potency of the remedy depends is due to dilatation of the blood vessels. I on the reliability of its properties. I have would ask Dr. Dewees to answer,

given two to three-drop doses of the tincture How digitalis acts upon the heart?

every two to three hours, and in a short time In what diseased condition of the heart I found I had a tetanized heart. Then again, is it indicated?

I have given large doses with no noticeable 3. If it is to be given in all cases of mitral effects. Ringer tells us that digitalis acts disease, regurgitation, or aortic stenosis?

chiefly on the left side of the heart, noting no 4. If any difference, tell when to give and apparent effect upon the right side. This when to withhold digitalis ?

would explain the phenomena of its good Dr. Austin-I think digitalis acts a little effects in filling the arteries. There is so slow, and ammonia quicker, and I feel confi- much blood in the body, which if equally disdent of having seen good results from the tributed throughout the blood vessels, as in use of ammonia, in those cases.

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 anæsthetic 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 hypertroply, hypodermatic injection of brandy in one-half it is indicated. But when there is compensadrachm doses, repeated eight times, at inter- tory hypertrophy, then it is contra-indicated. vals of three to five minutes the first few in- I know of no better distinction or indication jections, then every ten to fifteen minutes, than those brought forward by Dr. Dewees, on with successful results.

this subject I would ask Dr. Dewees whether the tinc

Dr. Dewees-In concluding this discussion ture, Auid extract, or the alkaloid digitaline, I shall first endeavor to answer the queries are all equally efficacious to produce the char- propounded by Dr. Felty: acteristic effects of the digitalis on the heart?

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 4.

I have defined when to give the potent produces increased heart-power, as well as re- remedy under discussion; it now remains to sistance at the periphery, whereby nutrition answer when to withhold the same. This is of the heart-muscle is decreased. In other chiefly summoned up by three diseased conwords, digitalis increases inhibition and stimu- ditions of the heart, viz. : Simple hyperlates the cardiac-motor centre, and with full trophy, pericarditis and fatty heart. I might lethal effects finally paralyzes the cardiac-add under the head of when to give digitalis, ganglia by over stimulation, arresting the that its value in the condition of what is heart in systole. It therefore must follow that known as an irritable heart, is well known to digitalis does not increase the nutrition of the all of extended experience. This condition is heart, but overworks it. This has been very due to over-exertion or exhaustion, and is properly noticed by Dr. Ketchersid in his re oftenest presented in soldiers, heavy laborers, marks, while he also gave a safe rule for its first stage of pneumonia and other inflammaadministration when he said "digitalis must tions, scarlet fever, congestion, headache, be used, but limited as to time, or else you ex- hemicrania, delirium tremens, mania, venous haust the heart's muscle."

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 erial 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. (6) In undoubtedly alike produce the same characsimple dilatation of the heart, without com- teristic effect. But experience has demonspensatory hypertrophy, digitalis will restore trated that the tincture and the infusion are the heart to its size and vigor, enabling the the two most reliable preparations. Dr. Wood muscle to be better nourished, whereby that advises the use of the tincture hypodermaticcompensatory hypertrophy is built up, which ally in heart-tailure from the anæsthetic. 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 anæsthesia, we have the depression resulting in my paper.

from the toxic effect of the anæsthetic upou 3. Thus, I trust, that I have conclusively the nerve-centres. Digitalis is undoubtedly shown that digitalis is to be given in mitral likewise useful in this condition ; nevertheand aortic diseases, whenever the condition less, owing to the nerve-centres being free indicating the use of digitalis manifests itself, from poisonous depression, we are more likely otherwise niever.

to find good effects here from warmth, nitroglycerine, 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 Bilroth says an ulcer is a wounded surface tonics, producing their effect quickly and re- which shows no tendency to heal. Accordlieving peripheral resistance.

ing 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 This definition is in contra-distinction to alterations of position and artificial respira- the definition for necrosis, which is a death of tion.” He concludes, therefore, as follows: tissue in visible masses, without the forma“The rule for the proper treatment of acci- tion of pus, and in which the histological eledents during anæsthesia can be summed up ments of the tissues retain their identity. in a very few words:

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

The part swells, and an elevation above the down as due to chloroform and ether, have surrounding surface is seen, and is now primbeen produced by the alcohol which has been arily designated an abscess. If the infiltration given for the relief of the patient.”

be near the center of the cornea, it is gener

ally round; if situated near the margin of the Corneal Ulcers,

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.

is surrounded with a grayish cloud, and fre

quently we see grayish lines, deeply seated, Read before the Topeka Academy of Medicine stretching from its margin to the periphery of and Surgery, October 7. 1890.

the cornea. It is formed by the destruction

of the cellular elements and the inter-cellular BY R. S. MAGEE, M. D., TOPEKA, KANSAS,

substance of the cornea, serous and plastic ON OPHTHALMOLOGY AND OTOLOGY IN THE infiltration and leucocytes.

The epithelium covering the abscess, be

cause of the stretching, becomes thinned, and Physicians practically agree as to what an on the slightest provocation from irritation ulcer is, and whether any wounded surface is a break occurs in the continuity of the tissues to be so regarded; but to give a definition of and it becomes an ulcer.





This has increased the liability to infection. To relieve pain. Only a short time before it was protected by 2. To impede and check destructive tissue Nature's antiseptic wardrobe, but it is now metamorphosis. exposed and permits the free ingress of pyo- 3. To encourage the reparative process. genic germs, and is soon swarming with In the atonic or indolent ulcer there is little myriads of parasites.

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 Should it perforate posteriorly it descends delicate manipulation into the different indiinto the bottom of the anterior chamber, and vidual tissue layers, carrying it just so far as it is called hypopyon. This usually signifies is necessary. the intensity of the process and calls for ac- The introduction of this valuable local anæstive measures.

thetic has done away with the unpleasant Ulcers involving the superficial layers of features connected with the galvano-cautery, the cornea leave no opacity. Opacities are the viz.: 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 irregu- 2. The suspension of the cauterization too lar way in which the light is reflected from soon. the multiplied surfaces.

A few minutes after the instillation of a few The management of one of these cases, so drops of a 5 per cent. solution of cocoaine, long as it maintains its special suppurative there is complete anæsthesia of the corneal character, 'is always a cause of anxiety and layers, so that the approach of the red-hot annoyance to the surgeon. For not only is loop, or its repeated application (which is there danger of perforation leaving adherent usually accompanied by considerable hissing leucoma and permanent opacity of the cornea, and sizzing) causes no painful sensation. 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 pro- and with the right applies the heated loop to cess extending stiil farther, it is liable to cause the infected zone, making and breaking the the complete functional destruction of the current by the simple pressure of a button on eye.

the handle of the electrode. The main indications to be met in the treat- In a short time we observe a surprising ment of corneal ulcers are:

change. The adjacent corneal tissue gains in

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