solution (1 in 40); a rubber drainage tube was inserted, and the edges of the wound were brought into perfect coaptation and held there by silk sutures; a Lister's dressing was then applied and the limb put up on a single inclined plane. Owing to the semi-anchylosed condition of the hip-joint and the shortness of the upper fragment, and also the very small size of the ends of the bones, I found great difficulty in getting the bones into proper position, and in keeping them there during the after treatment of the case. The operation which was a very difficult one, occupied three hours, and was performed under a spray of carbolic acid, and with strict antiseptic precautions. On the after noon of the day after the operation, his temperature rose to 100°, and on the afternoon of the second day it stood at 102°. From this time it began to gradually decline until the 17th day of October, the fith day after the operation, when it stood normal and remained so. On the 14th of October, I removed the blood-stained dressing under the spray; the wound looked well; there was no discharge from it. Owing to the close proximity of the edge of the splint to the wound, I found it impossible to dress it antiseptically without disturbing the parts; and to overcome this difficulty I removed the inclined plane and applied a Crofft's splint to the anterior aspect of the limb, extending from the ankle to about two inches above the highest point of the crest of the ilium; and a thin narrow wooden splint, well padded, to its posterior aspect, extending from the tuber ischii to the ankle; and to doubly secure the bones in position, I applied over Crofft's splint, one of malleable iron, 1 inch by of an inch, extending from a little below the knee to about three inches above the crest of the ilium, and shaped to fit the limb. These were held firmly in position by plaster of Paris bandage, a trap being left to dress the wound, and the whole was suspended in a Salter's swing.

On the 19th day of October, the eighth day after the operation, I again dressed the wound under the spray, and found union had taken place by first intention, except a small portion in the centre of the wound. There was a little discharge of pus from the opening, and it continued to discharge a little until about the middle of November following. On the 21st of November the splints were removed and firm bony union found to have taken

place. A spica of plaster of Paris was now put on and the patient allowed to go about the ward on crutches. On the 1st of January, the plaster bandage was taken off, and a Thomas' splint for hip-joint disease substituted for it. On the 16th of Januaay he was discharged cured. The limb was about 33 inches shorter than its fellow. Patient objected to have any attempt made to restore motion in the knee joint. motion in the knee joint. At the time of writing this article he is able to walk without crutches.

NOTES ON ACETANILIDE.*

BY J. B. M'CONnell, m.d. Professor Materia Medica and Therapeutics, University Bishop's College, Montreal.

Acetanilide or antifebrin, although one of the latest additions to the list of antipyretics, can hardly be looked upon now as an untried remedy. The frequent references to it in the medical periodicals indicate that it has had extensive trial.

There have been of late so many new therapeutic agents, or new applications of those already in use, heralded forth as great gains in the treatment of disease, and which have, after a brief existence, been found wanting, and disappeared like meteors below the therapeutic horizon; that the great mass of the profession are prone to regard new remedies with some suspicion; hence my apology for relating, so limited, an experience with this remedy, is that we may be favored with the views of the members of this Society who may have tested its actions.

In August, 1886, Drs. Cahn and Hepp, of Prof Kussmaul's clinic, Strasburg, published in the Centralblatt für Klinische Medicin a resumé of what they had discovered as being the actions of acetanilide. The drug, which may be prepared by the application of heat toaniline acetate, had already in 1853 been produced by Gerhardt, by the action of aniline on acetylchloride, or anhydrous acetic acid. It is a white, scaly powder, resembling santonin; odorless, slightly pungent, insoluble in cold water, sparingly in hot, but readily in alcohol. It melts at 113° C. and distils unchanged at 292° C., is neither acid nor alkaline, and resists the majority of reagents. It belongs to the group phenylacetamides or acetanilides, wholly different from those

*Read before the Medico Chirurgical Society, Montreal, on October, 29th 1887.

Patient

CASE I. Boy aged 12, typhoid. Oct. 20th, 1.30 p.m., ninth day of fever, pulse 120, temperature 1041; five grs. reduced temperature to 984° in three hours. This dose acted in the same manon the 21st and 22nd. Did not again rise above 102°, and gradually declined.

CASE II. has a similar record, and also Case XVI.

CASE III.-Young lady, aged 29 years, mild typhoid. Sept. 11th, tenth day; has had troublesome headache since she became ill, and could not sleep during last two nights. Six grs. acetanilide were given at 10 p.m. Patient fell asleep in fifteen minutes and slept all night, and was free from pain when she awakened; it returned the two following days, but was slight.

CASE IV. Lad, aged 12, typhoid. On March 28th, the twenty-seventh day of fever, temperature was 1043, Six grs. acetanilide caused a profuse perspiration and slight cyanosis. Subsequently 4 grs. reduced the temperature below normal; 3 grs. was found to be a sufficient dose. After April 1st, temperature gradually came down to normal. CASE V.-Young lady, aged 19, mild typhoid. The severe headache was also promptly relieved by 6 grs. acetanilide; did not return.

CASE VI.-Boy, aged 9, double lobar pneumonia. June 13th, pulse 144, respirations 48, temperature 105; 5 grs. acetanilide reduced temperature to normal in three hours. In five hours after dose, pulse 120, temperature 1003, respirations 32. 14th, 1 p.m., pulse 140, respirations 44, temperature 106; at 2 p.m., 5 grs. were given; at 5 p.m., temperature 973°, and at 9.30, pulse 132, temperature 102, respirations 36. 16th, 5 grs. at 2 p.m.

CASE VII.-Septicemia (Puerperal). aged 37, her first child. Forceps used and artificial extraction of placenta; antiseptic uterine douches were used and iodoform suppositories. Temperature was not high until the tenth day; 104°; on the eleventh day 8 grs. acetanilide reduced temperature to normal. Did not rise again above 102°; curette used on the thirteenth day; in two days after, temperature was normal, with slightevening exacerbations.

CASE VIII.-Young man, aged 23, pneumonia (double). On Oct. 16th, sixth day, pulse 120, respirations 64, temperature 1033°; 8 grs reduced temperature, causing profuse perspiration. 17th, 1 p.m., temperature 1023; 8 p.m., temperature 993, pulse 90, respirations 36.

CASE X. has much the same record as case IX. CASE XI.-Puerperal Septicemia. Patient confined in a house where there was a case of erysipelas in next room. All antiseptic precautions were observed, but next day temperature was 1051°; uterine douches of corrosive sublimate, followed by carbolic acid and then iodoform suppositories were used; 8 grs. acetanilide brought temperature to normal, with profuse sweating. This dose was repeated on the two following days, after which there was no further elevation of temperature.

CASE XII-Nervous headache, lady aged 28, had lasted two days; 5 grs. acetanilide gave complete relief in about two hours. Same results in two subsequent attacks.

CASE XIII,-Erysipelas. Boy aged 15. Oct. 27th, noon, 7 grs acetanilide were administered; temperature was 1041°. In three hours temperature was still 103; 8 grs. were then given; in two hours temperature was 102°. 28th, 2.30 p m., pulse 110, temperature 1053°; 15 grs. acetanilide were given. In 3 hours temperature was 100°; in 4 hours after, respirations 20, temperature 993; perspiration has ceased. For several days these large doses were required to keep temperature down; no fever Nov. 2nd.

CASE XIV. Lady, aged 22, one day ill. Severe headache, general soreness, pains in back, anorexia, coated tongue, and temperature 1043; 8 grs.

acetanilide at 10 p.m., purgative in morning. Went asleep shortly after taking powder. Temperature next day normal; no headache; feeling quite well.

In CASE XV, typhoid, young man aged 21, half-hour record of temperature was kept on the two occasions when it was administered, with results similar to Case IX.

The latest accepted theory as to the cause of fever, according to H. C. Wood, Macalister, of Glasgow, and others is, that it is a disturbance of calorification in which through the nervous system, heat production and heat dissipation are both affected; that there is a nervous centre which inhibits the production of heat and a thermogenic centre (located by Aronsohn and Sachs at the inner side of the corpus striatum), which excites tissue change; that heat dissipation is regulated by the vaso-motor nerves; that temperature is no indication of the amount of fever, as heat production may be normal, but elevation of temperature result from diminished heat loss, and we may have increased heat production (pyrexia), butowing to accelerated heat loss, no elevation of tempera ture, hyperpyrexia ensues when heat production is increased, with lessened heat loss

etc.

Antipyretics act either by lessening the produc tion of heat, as quinine, salicylic acid and the cardiac and vascular depressants, or by increasing the loss of heat, as alcohol, sudorifics, antipyrin, Acetanilide belongs to the latter group. From the reports of these cases we can learn That acetanilide in proper doses will, in the elevation of temperature of typhoid fever, pneumonia, erysipelas, septicemia, and doubtless other febrile states, bring about a state of apyrexia, or a subnormal temperature if the dose is larger, in from two to four hours; the temperature beginning to fall usually in from ten to fifteen minutes after its administration, instead of an hour, as hitherto usually reported; the reduction is ordinarily 5° or 6°, and may be over 8° (Case VI. 8). The dose varies from 6 to 15 grs. for an adult, is easy of administration and best given in wine or simple elixir. In an hour or two after the lowest temperature the dose produces is reached, it again begins to rise and in four to eight hours may be as high as before the dose was taken; or it may not run as high again for several days, or even throughout the illness.

sion.

Idiosyncrasy or individual susceptibility to the action of acetanilide varies considerably, and in cases where there is not any apparent evidence for anticipating dissimilar effects. Disease also exercises a modifying influence. Cases of erysipelas require larger than ordinary doses. Hence it is advisable to begin with small doses and increase, if necessary, until the quantity which will bring It the temperature down to normal, is learned. first stimulates the vaso-motor (constrictor) system, leading to increased arterial tension, quickly followed by dilatation of the cutaneous arterioles, thus permitting increased radiation of heat; perspiration immediately supervenes and the temperature rapidly declines, with lowered arterial tenIt is an analgesic, giving speedy relief in neuralgic pain and headache, being especially serviceable in the headache present in the early stages of typhoid fever. It is also a reliable hypnotic and nervous sedative in the sleeplessness and exciteability of febrile states. It doubtless, in over doses, as evidenced by cyanosis, inhibits the respiratory functions of the blood, probably as has been explained, by so modifying the hæmoglobin, that less oxygen is conveyed by the corpuscles, and ished oxidation resulting in lessened heat proa state of internal asphyxia ensues; the diminduction. It has no influence in shortening the course of zymotic affections; hence in typhoid, would not consider its administration indicated unless the evening temperature was over 103° F., the dose to be repeated every six hours as necesdoses are given; on the contrary, it is almost an No untoward effects result when proper invariable remark of patients taking the remedy that they feel better, and in a state of apyrexia, may experience hunger. Even in over doses the temporary cyanosis is quickly recovered from without any evil result.

sary.

ON THE NECESSITY FOR A MODIFICATION OF CERTAIN PHYSIOLOGICAL DOCTRINES REGARDING THE INTERRELATIONS OF NERVE AND MUSCLE. BY THOMAS W. POOLE, M.D., LINDSAY, ONT.*

THE CHEYNE-STOKES RESPIRATION.

What seems a lower depth of absurdity, if possible, has yet to be reached in the explanations of the Cheyne-Stokes respiration. I quote here from Dr. L. Sansom's "Physical Diagnosis of the

International Medical Congress, held in Washington, * Read before the Physiological Section of the Ninth September, 1887.

Heart," (a) by whom Traube's theory on this subject is said to be "the most plausible." According to Traube, "the first thing which occurs is the establishment of a condition of impaired irritability of the respiratory centre through mal-oxygenation; the long respiratory arrest gives time for the accumulation of carbonic acid in excess in the blood. Arrived at a certain maximum this begins to stimulate, slowly and imperfectly at first and afterwards in increasing degrees, the centre, so that it develops the respiratory efforts till they culminate in dyspnea. Then as the centre ceases to be stimulated or becomes exhausted, dyspnoea again supervenes."

It will be observed that here the deficiency of oxygen and subsequently the presence of carbonic acid are made to play opposite and antagonistic parts! The lack of oxygen (instead of stimulating the medulla, as supposed by Dr. M. Foster) first enfeebles the respiratory centre, in the medulla, and then the same blood, still deficient in oxygen, but now loaded with carbonic acid, counteracts the previous depression, and tones up the weak nerve centre, so that ere long it displays extraordinary activity. But, unfortunately, this ex hilarating pabulum--carbonic acid-is exhausted, and the nerve centre resumes its former feebleness till a new supply can be procured. The physiologist is certainly quite impartial, and allows the rivals to have their "innings," turn about. How such nonsense as this "most plausible theory" could find a place in physiological literature seems explicable only on the exigency of the hypothesis so long in vogue.

soon

Filehne's theory in explanation of this state is more complicated, and at least equally absurd. Instead of the respiratory centre being stimulated (as Traube says), it is the vasomotor centre which is excited by the presence of carbonic acid. Arterial contraction follows till "a gradually increasing anemia of the respiratory centre" is brought about. This anemic condition excites the respiratory centre "and inspiration becomes more and more deep," till oxygen is supplied to the blood; "the arterial spasm is thus relieved," owing to the freshly oxygenated blood failing to stimulate the vasomotor centre (so as to contract the arteries), as the carbonic acid had previously done. With

(a) P. 37.

the relief of arterial spasm, and a consequent normal dilation of the arteries, "the anemia of the respiratory centre passes off, and with it the exaggerated impulse to respiration, and breathing once more becomes superficial." (b) In other words the respiratory centre functionates best when it is supplied not only with non-arterialized blood, but when it has too little even of that; as soon as the anemia passes off, and this nervous centre gets a fair supply of blood, it ceases to act-suspends business-till the better times of bad blood and deficient blood come round again, when it is moved to activity once more!

There is still another explanatory theory to be noticed, which I find referred to editorially in the CANADA LANCER for February, 1886: "Bramwell, who follows the teaching of M. Foster and others, supposes that the respiratory centre consists of two portions, one accelerating (or motor), and one inhibitory. He further believes that these two portions are acted on in opposite directions by the blood, whether arterial or venous. Thus while venous blood stimulates the discharging cells of the centre and depresses the inhibitɔry portion, arterial blood acts in exactly the opposite direction." At the close of the period of apaœд, the discharging portion of the centre is stimulated by the venous blood," with its excess of carbonic acid, and this same blood, at the same time is depressing the rival, or inhibitory part of the centre. The motor or discharging portion of the centre triumphs; respiration becomes established and even exaggerated. Unhappily, the victor fails

to "hold the fort." As soon as the blood becomes "fully oxygenated," the "inhibitory portion becomes stimulated and gradually overpowers the discharging portion," so that "the respirations grow weaker and weaker until the state of apnoea results." Then the suspension of breathing restores the venous character of the blood and accumulates a store of carbonic acid, the stimulation of which reanimates the centre previously depressed by the presence of oxygen in the blood. Such appears to be the scope of this theory.

In this, as in the previous explanations, arterial blood is made to play the part of a depressor and paralyzer of the respiratory process, which it is constantly tending to arrest; but while paralyzing

(b) P. 137.