hair pins, and held them in position by each strip, was passed one of the threads, threads tied at the back of the neck. still uncut beyond each knot, and this thread being tied to the other, attached the loop through the skin and trachea closely to the end of the plaster strip. When both pieces of plaster were thus attached, traction was made very gently on both sides (one after the other) to a degree to distend the wound and leave a fully sufficient aperture for the ad mission of air and the expulsion of secretions, and of the débris of the disease, but carefully avoiding such a degree of traction as should at all endanger a cutting through by the thread of the edges of either the tracheal or cutaneous wounds. Each plaster strip was then laid smoothly and closely around the side and back of the neck, its end laying on the shoulder. The end aimed at is to make a sufficient opening to allow the admission of an ample supply of air and to steadily main By referring to the "Transactions of the American Medical Association" for the year 1878, quite an extensive and interesting article, "Tracheotomy without Tubes," by Henry A. Martin, of Boston, will be found. He writes, "In performing tracheotomy for membranous croup, during the last sixteen years," (prior to 1878) "I have entirely dispensed with the canule or tubes so generally considered indispensable." In his first operation he "stitched the edge of the trachea and the skin together on each side with silver wire, and attached each stitch to a piece of old elastic garter carried around the back of the neck." In later operation "Various devices," he says, "were contrived and tested, but abandoned, to replace the elastic band," and it was not till the fourth, a perfectly successful case, that I perfected the operation, or attain that opening till the processes of nature least so nearly approached perfection, as to be willing to present it to the consideration and criticism of the profession." For the convenience of readers, it may be well to describe the operation in the words of Dr. Martin. After opening the trachea and checking hemorrhage, he says, "I introduced a single silk suture into each side of the wound. Each thread passed through the middle of the incised portion of the trachea at about one-eighth of an inch from its edge and through the skin at a corresponding point, and at about one quarter of an inch from the line of incision. The two edges of the trachea and skin were then approximated by tying them together, not so tightly as to at all incur the danger of "cutting through" the tissues, but sufficiently to produce, when both sides were thus treated, a gaping of the tracheal wound and the establishment thus of an elliptical orifice. Two strips of good rubber plaster, which does not require heat to render it adhesive, were prepared, half an inch wide and about a foot long. A quarter of an inch from one end each of these was doubled on itself so that the adhesive surfaces came in contact. Through a puncture in the middle of this strengthened portion of shall remove the obstruction in the natural passages. Some nine or ten days elapsed before air passed perceptibly through the natural outlet, and nearly twenty before it passed freely." The above are the details of the operation. For further elaboration I will refer readers to Dr. Martin's article. This operation is one Dr. Wm. A. Byrd, of this city, has used, in cases requiring tracheotomy, for the last eight years, and has improved it in this manner. Dr. Martin speaks of the difficulty in passing the needle through the edge of the tracheal wound in cases in which the trachea is deeply situated. To obviate this, Dr. Byrd devised a needle with the eye very near the point, and with three-eighths of an inch of the point bent upon itself in such a manner as to make a tenaculum. The accompanying cut, which is also in the July, 1881, number of Walsh's Retrospect, will explain the needle. though never having performed Martin's operation myself, I have seen it performed several times by Dr. Byrd, and have had a practical insight regarding its merits. bears out fully all the advantages Dr. Martin claimed for it, viz.: Al It First. Requiring no apparatus, and therefore Second. A larger and less impeded opening is maintained, permitting the escape of shreds of membrane, mucus, etc., that would "block up" the canula. Third. The continual and repeated irritation from the presence of the canula and their removal and re-introduction to the lining membrane of the trachea is entirely avoided. These conclusions are essentially the same as those arrived at by Dr. Bell. As an illus. tration of conclusions, No. 2, a fatal case of tracheotomy in which the tube was used, may be related. In 1878 Dr. Byrd performed the operation upon a man, æt. 50 years, for edema glottidis. The tube was introduced and the case left in charge of a physician as nurse. Unfortunately both the patient and physician fell asleep. The physician was at length awakened by the struggles of the patient; too late, however, to be of any service, as death resulted within a few minutes. Removing and examining the tube, it was found entirely blocked up by mucus and small pieces of exudation. In this case had the tube been dispensed with, and Martin's operation performed, a large and free opening would have existed through which the material that blocked up the tube could have been easily ejected, and the chances for the recovery of the patient very materially increased. The constant attendance of a physician, in cases in which Martin's operation has been performed, is not at all necessary, as a non-medical person will answer quite as well and be able to meet all requirements. TRANSLATION. non as a desirable sequence to the personal experimentation of Dr. Hammond, I respectfully ask for space in your paper for the following translation. It can hardly be necessary to advert to the salient fact of¿Dr. Hammond's reticence on the very important renal phenomena, which, from the minute and valuable notes presented by Dr. Bignon, would seem to be the chief characteristic of the therapeutic properties of cocaine, when administered in large doses. Are we to ascribe the silence of Dr. Hammond, in relation to the urinary excretions, to idiosyncratic delicacy, or to some disparity in the chemical constituency of the substances respectively employed by him and the Peruvian experimentor? Dr. H. is not wont to be parsimonious in expenditure of ink and "foolscap," nor is he a negligent observer of instructive parts; it is therefore to be hoped that he will not overlook the desirability of some further details, especially bearing on the apparent disaccord between his experience and that of Dr. Bignon. TRANSLATED FROM THE SPANISH. The experiments made on dogs, which were the subject of my last communication, proved the possibility of attentively observing, without danger to man, the physiological action of cocaine. With this object, finding myself in perfect health on May 12, last, I took, each hour from 7 o'clock A. M. to 5 P. M., 5 centigrams of cocaine in capsules (5.6 grain). At noon, desiring to take breakfast, I omitted the dose. Being convinced that a careful study of the urine would enable me to discover the physiological process, I decided to urinate every hour, and to analyze each emis. sion. I absorbed 50 centigrams of the alkaloid in 11 hours (7 grains). This quantity is equal to the maximum ingested daily by PHYSIOLOGICAL ACTION OF COCAINE. Indian veteran workers at the chaccha, and BY JOS. WORKMAN, M. D., TORONTO, CAN. El Mentor Medico, of Lima, Peru, among other articles of great merit, publishes the above, and as the readers of the WEEKLY REVIEW may regard the facts given by Dr. Big the cocoa Indian workers (coqueros); when the habit has reached its climax they absorb a gramme daily, and perhaps more. In the table which I shall presently exhibit, the result of my experimentation will be given; I now proceed to interpret them. The acceleration of the pulse and the remarkable increase in the quantity of urea excreted in a given period of time, are both quite evident. It cannot be asserted that this element consisted exclusively of urea, as for determining the quantity, I employed the classic process of the hypobromide, and it is evident that the quantity of nitrogen obtained represents, in addition to urea, other nitrogenous products of elimination, as creatin, allantoin, sarcosin, etc. I should also observe that the error due to the presence of marine salt (muriate of soda) was not corrected. But all these errors detract nothing from the interest of the experiment, the sole object of which was to discover whether there is, in a general way, any augmentation of the excretion, when cocaine has been ingested. It is easy to see by the table, that the acceleration of the vital processes is not transient, as it was prolonged during six or eight hours after swallowing the medicant; so that having taken my last dose at 5 P. M., my pulse at midnight was still abmormal (80 instead of 66 or 68). No sensible rise of temperature was observable, for at 5 P. M., the time of greatest intensity, the axillary temperature was 37.3 centig,r the normal being 36.8 or 37° (? error). The general physiological effects were but slightly pronounced: a little of headache, a slight cerebral excitement, which permitted me to work till midnight with increased activity and without sleepiness. My sleep from that time to 6 A. M. was sound, without agitation, dreams or nightmare. In the end I felt a little fatigue, or tiredness in the joints. I had no sensation of hunger or thirst, nor had I anorexia. I took a hearty breakfast, and I experienced no change in the sense of taste or smell; in fine I had not the least stomachic or intestinal digestive disorder. There was no vertigo or hallucination. Dilatation of the pupil was well marked, but not great. At 6 P. M., I was examined by Dr. J. Costello, who observed a slight acceleration in the movements of the heart, 20 respirations instead of my normal 15 or 16, and 102 pulsations per minute; he did not observe any cerebral disturbance, and I took care to detail to him, at this time, the conclusions which seemed to me deducible from my observances through the day, so that he might better judge of the state of my mental faculties. The quantity of urine hourly discharged had served to reveal, and, per se, almost to explain, the action of cocaine. I desire to draw special attention to this point. As soon as the quantity of cocaine absorbed had become notable (20 to 25 centigrams3 to 3 grains), there was a decrease in the quantity of urine excreted. This suspension of the excretion was transient; it ceased at the sixth hour from commencing the ingestion of cocaine, and it was followed by a very notable reaction (diuresis). The demonstration of this phenomenon is very complete in this table. In fact the omission of the hourly dose at mid-day was shown by a marked increase in the quantity of urine at 2 P. M.; but at 8 and is, three and four hours after the last dose, the quantity assumed extraordinary propor tions; from 69 cubic centimeters at 7 P. M., it had increased at 8 to 369, and at 9, to 367 cc. 9 P. M., that The diuresis aided with all possible energy to remedy the disorders caused by the cocaine, and it was only after this timely crisis that the pulse began to slow, as well as the increased products of excretion to diminish. The phenomenon of the temporary suspension of the renal functions, was represented by the quantity, not by the quality, of the liquid, as regards the products excreted; and having been only transient, it might have passed unnoticed, though it was well marked. (?., was this the fact with Dr. Hammond). The like fact was realized by another person who took 10 centigrams in one dose, to suppress hiccough; he felt only an imperious necessity to urinate (after two hours, and he voided a great quantity of pale urine, of chlorotic aspect, and very low density. It is evident that in this patient, the action of the cocaine can be explained only as that of a simple diuretic, and had the urine been sent to a chemist for analysis, he might, on finding a very small quantity of the products of excretion in it, have ascribed to the cocaine a moderating action over the processes of nutrition, that is an action the very reverse of the real one. Thus it is that the divergencies of different authors may be explained: sity Den Urea 18 0.85 directly, when the dose administered has been large enough to produce so great an anuria as to leave in the system an accumulation of the toxic products of the urine, sufficient to produce death;] this, however, always occurs with the characters of uremic poisoning. 6. If the diuresis permits the rapid disappearance of the toxic symptoms, the stimulant action persists much longer (twenty-four 17 0.88 hours) and during all this time the phenomena of oxidation continue to exceed the normal 23 0.88 medium, that is disassimilation continues. In summary: Cocaine acts in two ways. 16 0.88 0.66 21 0.68 24 1.28 7.00 A. M.. 0.05 66 8.00 0.05 68 9.00 0.05 72 0.05 70 25 1.29 25 1.45 25 1.47 1.82 21 1.31 1. By decreasing the renal secretion, and if the dose is sufficient, by totally suppressing it during the time required for disappearance of the more grave uremic symptoms, thus even causing death in a very few minutes.. 2. By increasing the products of oxidation (urea, uric acid, etc). Consequently, if The weight of the author was 89 kilograms the dose is great, both classes of action (decrease in the secretion, and activity in the *Query.-How much fluid did the author process of oxidation) co-act, and both at the and his age 43 years. drink at dinner? From the experiment made on dogs and on man, it is deduced: 1. That the alkaloid cocaine, obtained in my process, by benzine, and which I have called a therapeutic pure cocaine, produces only transient physiological effects in aggregate quantity of 0.30 @ 0.50 centigrams, by the stomach, on the condition that it be taken in fractional doses, (5 centigrams per hour, in capsules.) 2. That it acts chiefly on the renal secretion, diminishing it, and by preventing in part the elimination of the products of oxidation, thus producing the primary symptoms of a slight uremia. 3. That in large doses it produces anuria, and consequently grave uremic disturbances, (nervous attacks, convulsions, etc). 4. That the paralizing action of cocaine disappears in two or three hours after the absorption of the alkaloid, and that it is followed by an abundant diuresis which frees the organism, and is all the more active, the more complete has been the anuria. same time contribute to the causation of the uremic fatal accidents in a very short time. This is the danger from large doses. If, on the contrary, the quantity be fractioned, and the time necessary for reaction (diuresis) is allowed, death does not take place, unless at the end of a great wasting of the organism, produced by slow denutrition (the cachectic state of the cocainomanos or coqueros). Such are my conclusions from labors extended over a year. I have proceeded with them in a very determinate order. 1. I sought for a more simple method than was before known, of extracting the alkaloid. 2. I studied the different salts already known, and, finding defects in them, I sought for one without any fault, as I found in it the benzoate which I describe. 3. Once in posession of the alkaloid, and having proved its solubility in the stomach, I commenced my physiological experiments on dogs, instead of frogs, guinea pigs and rats, the only animals before employed. 4. Finally, I employed the same system 5. That cocaine is not toxic, unless in- of experimenting on myself. There still remain, however, for elucida- WEEKLY MEDICAL REVIEW, tion, numerous questions, and the first is, in what form is the alkaloid eliminated? I cannot but feel assured that it does not remain in the urine in its alkaloid state; for EDITED BY THE MEDICAL PRESS AND LIBRARY ASSOCIATION Contributions for publication should be sent to Dr. I. N. Love, I have failed to detect it by the usual reagents; Secretary Executive Committee, Cor. Grand and Lindell Aves. and as some of these readily show one centigram of cocaine in a liter of liquid, it may be asserted that cocaine, ingested to the extent of 50 centigrams in 12 hours, did not exist in this urine. Dr. Moreno Maiz says that it is eliminated in part in its alkaloid state, by the urine, and he states, as proof of this, that the urine of a guinea pig, poisoned with cocaine, when it was evaporated and injected into a rat, the animal died with the same symptoms as are observed in poisoning with cocaine. Well, as I believe I have proved that the symptoms of poisoning by cocaine are but the symptoms of uremic poisoning, it is evident the proof given by its author is deficient. It should be observed that urea is not the only product of dissimilation, whose quantity is increased by the administration of cocaine; I have been enabled to prove that uric acid is also in excess; and as regards the other products of excretion, it is probable that they also may be found in excess, and that among them will be found benzoic and hippuric acids as products resulting from the breaking up of the alkaloid. In fine, we should examine whether the toxic alkaloids of the urine are not in greater quantities than those given by Lautier and Bouchar.d Lastly, there will remain for investigation the clinical results of the internal employment of cocaine, in diseases in which a great influence has been attributed to denutrition, such as diseases of the cerebro spinal system. To solve all the questions will not be the achievement of a simple individual, and besides, many of them pertain to scientific de partments, which I am not permitted to touch. It only remains for me to hope that some of our colleagues will complete the study, of which I have indicated hardly the primary lines. All remittances and communications pertaining to Advertise. ments or Subscriptions should be addressed to J. H. CHAMBERS, 914 LOCUST STREET, St. Louis, Mo. SATURDAY, DECEMBER 18, 1886. THE DIFFUSION-ELECTrode. In the Neurologische Centralblatt, No. 10, 1886, is contained an article by Prof. Albert Adamkiewicz that treats of novel methods of electro-therapeutics. The doctor mentions the importance accorded the galvanic current in the treatment of neuralgias. The constant current,especially in the influence of its anode, is a powerful sedative in the painful excitations of nerve-tracks. In this good influence, however, the current is by no means reliable. Therefore, it occurred, whether a combination of the current with the action of some medicament could not result in a summation of power of relief that would be followed by a corresponding increase of therapeutic success. Experiments by Wagner, that have been recited to the readers of the REVIEW, show that an anode electrode, saturated with a solution of cocaine, through which a moderate constant current is passed, brings about an intense anesthesia of the skin. The relatively high price of cocaine and the limited area of anesthesia so secured, led Adamkiewicz to experiment with chloroform in conjunction with the galvanic current. His first experiments showed that a simple electrode saturated in chloroform would not answer. The drug evaporated so rapidly, and repeated saturation was impracticable and unfavorable to continuous cataphoresis, which is requisite in order to secure complete anesthesia. To meet these shortcomings, Adamkiewicz constructed an electrode that holds, at one loading, an amount of chloroform adequate to |