Shock is essentially a diminution of blood pressure. It is an exhaustion or fatigue either of the cardiac muscle, of the cardiac centers, of the blood vessels, or of the vasomotor center. The loss of peripheral resistance is the essential factor in shock. Quoting from Dr. Geo. Crile, of Cleveland, Ohio, who has done much original work on the method of controlling blood pressure, the vaso-motor stimulants, such as strychnin, nitroglycerin, amyl nitrite, etc., do not cause a rise in blood pressure. Dr. Crile claims, and has conducted experiments purporting to establish his claim, that these drugs are not only inert but are positively harmful in surgical shock. Continuing, he says, in considering other methods of controlling the blood pressure, normal saline solution demands consideration. Normal saline administered intravenously or subcutaneously is a purely mechanical aid to the circulation, which temporarily increases the blood pressure. That the blood does not tolerate much dilution with normal saline is shown also by repeated observations upon the number of corpuscles and the amount of hemoglobin during its administration. Saline solution has a limited range of usefulness. It is obvious then that to increase and sustain the blood pressure when the vasomotor center 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 causes a marked and, in sufficient doses, an enormous rise in the blood pressure. It has been found that the most effective method of administration is by a continuous intravenous infusion in salt solution, varying in strength from one to fifty thousand to one to one hundred thousand. By this means adrenalin is brought into contact with the walls of the blood vessels, causing their contraction, thereby increasing the blood pressure. Adrenalin acts upon the heart and blood vessels; it raises the blood pressure in the normal animal in every degree of shock.

A peripheral resistance may be accomplished mechanically by the application of a double layer pneumatic rubber suit, which, when inflated, gives a uniform pressure upon the body surface. Such appliances are expensive and perishable.

Personally, I have had but little experience with the use

of adrenalin in shock, but Crile's report of his uniformly good results in a series of two hundred cases is strong evidence in its favor. This much is certain, the use of strychnia, nitroglycerin, and even salt solution in profound shock have in my hands proved inefficacious, and for the sake of humanity the time is ripe for something better.

How happy is he born or taught
That serveth not another's will;
Whose armor is his honest thought
And simple truth his utmost skill.

TETANUS-REPORT OF A CASE-RECOVERY.*

GEO. R. LIVERMORE, M. D.
MEMPHIS.

ON December 12, 1903, I was called to Binghamton, Tenn., to see a boy, ten years of age, who had accidentally shot himself in the left leg with a shotgun. The little fellow was standing on the front porch of his home, with his shotgun in his hand. It slipped from his hand and fell, stock first, down the steps. He stooped to catch it, the gun was discharged and the lead, composed of mixed shot (varying in size from number 10 to small buckshot), entered his left leg about four inches. below the knee. Both the tibia and the fibula were shattered and a portion of the lead, after passing entirely through the leg, entered the left thigh posteriorly, about three inches above the knee, and ploughed its way four inches upward, just beneath the fascia lata. The boy was profoundly shocked; pulse 140 and very weak; upper portion of face grave, lower smiling; and when asked if suffering, said, "No, I feel fine."

I immediately gave him a hypodermic of strychnin, gr. 1-60, morphin gr. 1-8. Under chloroform anesthesia, it was found that the anterior and posterior tibial arteries were severed and both bones shattered, hence amputation was clearly the only course to pursue, but owing to the shock, it was deemed best to delay the operation till reaction had set in. Therefore the arteries were ligated, the wounds cleansed and packed with iodoform gauze, wet with a 1 to 4000 bichloride solution and a splint applied. A saline and whiskey enema was given and ordered continued every sixth hour, alternating with strychnin gr. 1-60. The following day his temperature was 100°F., and pulse 140, and when on the third day after his injury, his * Read before Memphis and Shelby County Medical Society, April 5, 1904.

pulse still remained high and he was growing weaker and could retain nothing on his stomach, I decided to operate. My friend, Dr. J. L. McLean, was called in consultation and concurred with me; so at 3.30 P. M. with Dr. McLean's assistance, I amputated the leg at its upper fourth, sawing the tibia just below the anterior superior spine. The wound above the knee was cleansed, swabbed with pure carbolic acid and alcohol and packed with iodoform gauze wet with bichloride solution (1 to 4000). A posterior splint was applied to prevent contraction of the knee. After the operation, his pulse was 160 and very feeble, so an infusion of normal salt solution, one pint, was given in the left median basilic vein. Owing to his inability to retain anything on his stomach since his accident, while still under the influence of the anesthetic, I washed out his stomach with a weak bicarbonate of soda solution and ran into it, through the stomach-tube, half an ounce of a saturated solution of sodium phosphate. This acted very satisfactorily, as he did not vomit after this operation. At 6.30 P. M. his temperature rose to 1071°F. per rectum. He was delirious and very restless. A hypodermic of codein sulphate, gr., quieted him somewhat, and by sponging him with iced water, his temperature was reduced in about two hours to 100°F. His pulse was so rapid and feeble it could not be counted. The post-operative treatment consisted of hypodermics of strychnin, gr. 1-60, digitalin, gr. 1-100, every six hours, enemata of saline solution, three ounces, whiskey, one and onehalf ounces, every six hours. His diet consisted of panopepton liquid peptonoids, milk, soups, etc. He was also fed by rectum, as he took very little nourishment by mouth. The day following the operation his temperature was 102°F., and pulse 140. The wound was examined, but showed no evidence of infection. His temperature and pulse continued in the neighborhood of 102°F. and 140, respectively. Repeated examinations of the blood were negative for both malaria and typhoid, and his temperature was unaffected by quinin. Careful examination of the lungs, heart, urine, etc. failed to account for the temperature. His condition remained unchanged till the afternoon of December 22nd, ten days after his accident, when he complained of pain about the angles of the jaws. Temperature was 101°F., pulse 144. As he had kept an ice-bag almost constantly on his head and throat, I at first thought the pain due to this, and as there was no further complaint on the following morning, I felt certain that such was the case; but when I saw him on the morning of December 24th his temperature was 1013°F., and pulse 140; he could open his jaws. only about half an inch, and upon attempting to smile, there

was slight risus sardonicus. I made the diagnosis of tetanus, and came at once to the city to procure some antitetanic serum. Dr. McLean was again called in consultation and confirmed my diagnosis, so I began the administration of the antitoxin at once, giving him 10cc. subcutaneously in the right thigh, at 4 P. M. I used the antitetanic serum prepared by Parke, Davis & Co. The sutures were removed from the stump, and both wounds swabbed with pure carbolic acid and alcohol and a wet bichloride dressing applied. I ordered sodium bromide, gr. v, chloral, gr. jjj, given if necessary. This was given once during the night, and the patient rested fairly well. He had no pain and no spasms, and except for the stiffness of the jaws, there was no muscular rigidity.

December 25th. Muscles of neck contracted and hard, head slightly drawn backward. Temperature 100°F., pulse 140. 10cc. serum given at 8 A. M., and 5 P. M.

December 26th. Condition about the same. Temperature 101°F., pulse 144. Muscles of neck more contracted. 10cc. serum given at 9 A. M. and 5 P. M.

December 27th. Patient passed a restless night and had his first muscular spasm. Temperature 101°F., pulse 140. Spasms were irregular, averaging one every half hour. Serum given 10 A. M., 4 P. M. and 10 P. M.

December 28th. Spasms a little less frequent. Patient can open his jaws wider, muscles of neck less contracted and general condition seems improved. Temperature 100°F., pulse 138. Serum given 4 A. M., 10 A. M. and 6 P. M.

December 29th. Spasms less frequent. Serum given 12.30 A. M., 8.30 A. M. and 3 P. M. Temperature 100°F., pulse 138. December 30th. General condition about the same. Had 8 or 10 spasms during the day. Serum given 12.30 A. M., 8.30 A. M. and 5 P. M. Temperature 99°F., pulse 136.

December 31st. Patient can move head and jaws freely, but there is still some hardness about the muscles at back of neck. Spasms very irregular, perhaps had two or three during the day. Temperature 991°F., pulse 140. Serum given 12.30 A. M., 8.30 A. M. and 10.30 P. M.

Gen

January 1st, 1904. Temperature 99°F., pulse 140. eral condition much improved. There was no spasm and no other symptom of tetanus, so I stopped the injections of the antitetanic serum. Up to this time he had received twentythree injections of serum of 10cc. each.

January 2nd. General condition about the same. said he felt fine. Temperature 101°F., pulse 135.

Vol. 24-18

Patient

January 3rd. Temperature 102°F., pulse 145. Condition unchanged. No cause found to account for temperature.

January 4th. Temperature 103°F., pulse 140 at 9 A. M. Temperature 104°F., pulse 144 at 4 P. M. No evidence of return of tetanus. Blood again examined for typhoid and malaria with negative results. I thought temperature was due to reaction from the antitetanic serum.

January 5th. His temperature dropped to 100°F., pulse 136. General condition unchanged, save that his left thigh was slightly flexed, and when I attempted to extend it, there was marked lordosis. Movement of jaws and neck perfectly free.

January 6th. Temperature 100°F., pulse 132. Flexion of left thigh increased ; jaws and neck still unaffected, but owing to the marked contraction and hardening of the thigh muscles I deemed it best to begin the administration of the antitetanic serum again. Injections of 10cc. each were given at 6 P. M. and 12 M. Both wounds were again swabbed with pure carbolic

acid and alcohol.

January 7th. Flexion of left thigh more marked. Temperature 100°F., pulse 130. Serum given at 7 A. M. and 6 P. M.

January 8th. Temperature 101°F., pulse 132. Return of spasms, which came on irregularly; he had about five during the day. Left thigh flexed to a right angle. Serum given 9 A. M., 5 P. M. and 20cc. at 12 P. M.

January 9th. Temperature 100°F., pulse 132. Condition slightly improved. Serum given 8:30 A. M., 4:30 P. M. and 12

P. M.

January 10th. Temperature 1013°F., pulse 128. Condition about the same. Serum given 8:30 A. M. 5 P. м. and 12 м. January 11th. Spasms more frequent. Patient in an extremely nervous and weakened state. Refused all nourishment, but was finally induced to take a milk-shake by threatening to feed him by rectum. Temperature 100°F, pulse 132. Serum given at 8:30 A. M., 5 P. M., and 20cc. at 12 P. M.

January 12th. Temperature 100°F., pulse 136. General condition improved. Spasms much less frequent and contraction of the left thigh less marked. Serum given at 8:30 A. M., 5 P. M. and 12 M.

January 13th. Temperature 1003°F., pulse 140. Condition improved. No spasms and contraction of the left thigh less marked. Serum given 8 A. M. and 8:30 P. M.

January 14th. Temperature 100°F., pulse 135. Condition still improving. Serum given at 10 A. M.

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