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sure. The foot and toes were red in color, but presented no alteration upon change of posture. Cutaneous sensibilities to temperature and pain were normal. Medicines, hot-air treatment, and baths were without avail, under which regimen he remained for two years. At the end of this time a gangrenous ulceration appeared upon the great toe, and was soon fol- lowed by a similar area upon the toe adjacent. The symptoms enumerated above persisted. It was noted that at this time there was no dorsalis pedis pulse to be felt upon tljat side. No note was made of other pulses in that extremity. _ The foot was amputated through the ankle. During a period of nine months subsequently the wound refused to heal. The leg was then amputated above the knee, and from the proximal stump of the popliteal artery was drawn a long, white, 740 MEDICAL RECORD. [Nov. 10, 1906 canalized thrombus three inches in length. The wound was closed, and healing ensued. At the present time, five years after the ampu- tation through the thigh, he again complains of great pain in the stump, together with a deep •cyanosis. He was free from pain until a year ago. There is Is Toprol A Beta Blocker no pulsation in the femoral artery of that side. An attempt was made to feel the external iliac pulse per rectum, but the vessel could not be reached. The patient now, and for the past year, has had pains of similar character in the right foot and toes. There is little or no change of color, and no change with foot dependent. The dorsalis pedis pulse on the right side is absent. The fem- oral pulse is palpable, and apparently not dimin- ished. There is no other determinable vascular disease. There is neither albumin nor sugar in the urine, nor has there at any time been hema- turia. Generic Name For Toprol Unfortunately, there was no further exam- ination made of the amputated extremity. Case II. — A. G. Tall, slender male. Russian Jew, age twenty-eight years. Peddler by occupa- tion since landing in this country two years ago. Previous to that time had been a farmer. Parents living and healthy, as are also four brothers and Generic Name For Toprol Xl three sisters. Smokes moderately, and has never used alcohol. Has never had syph- ilis. Has always been well in recent years until onset of present complaint. About one and a half years ago began to have anginal attacks in calf of left leg; the pain would extend to the foot and toes, and sometimes would last Toprol Xl Vs Metoprolol Tartrate for several days without cessation. There was nothing to be seen upon the leg or foot to account for the pain, which was deep-seated, and difficult to locate exactly. It was described as of a boring and burning char- acter. Various salves and baths were prescribed for the pain without avail. For seven or eight months the pain has dimin- ished in the leg, but persists, and is worse in the foot and toes. During the past four months the pain has been extreme and constant in the large toe and toe adjacent. An ulceration has devel- oped upon the great toe, and the distal three- quarters of the foot has assumed a dull red color. This color persists in horizontal and pendant posi- Toprol Xl Generic Name tions. The ulceration Toprol Xl 50 Mg Recall upon the great toe is upon the under inner surface, and towards the tip. It refuses to granulate. There is no pulsation in the dorsalis pedis artery on this side, nor can pulsa- tion be felt in the popliteal with leg flexed at right angles. The femoral pulse is good. The reflexes are normal, as are also the cu- taneous sensibilities to pain, touch, and tempera- ture. No blood pressure estimation could be made, owing to the absence of a pulse at the periphery. Otherwise the patient's general con- •dition is good. There is no further evidence of arterial change. The patient was told the serious nature of his apparently slight affection, and Toprol Xl Vs Metoprolol was advised to remain in the horizontal position. He was given nitorglycerin and iodide of potassium. In the course of ten days of care in hospital his pain was very severe, and had to be controlled by opiates. Meanwhile, the ulceration upon the great toe extended and became foul, and the adjacent toe became first cyanosed, and then black. Both toes were amputated. During the course of the suc- ceeding two and a half weeks the wound sloughed. the edges became black for a considerable dis- tance, Toprol Xl Beta Blocker and a foul, yellowish discharge exuded from the wound. The leg was amputated above the knee. The wound healed by primary union. Examination of the amputated extremity re- vealed the dorsalis pedis artery Is Toprol Xl A Beta Blocker entirely obliter- ated, represented by a fibrous strand. No canal was demonstrable. The posterior tibial contained almost throughout its length a canalized lamel- lated thrombus. With the artery laid open this thrombus was found not particularly adherent, and could be raised from the vessel wall at any point. The vessel wall itself was not much altered. The popliteal artery itself, up to the level of the amputation, was also occupied by Toprol Xl Generic Equivalent thrombus, but dififering materially from that in the posterior tibial artery. This thrombus was evidently formed by blood clot. It was reddish in color, it was not canalized, and was also only lightly adherent to vessel wall. The thrombus was partly organized. The symptomatology of this condition is so well demonstrated in the foregoing cases that lit- tle need be added. The likelihood of error seems to be to confuse this disease with Raynaud's disease, but with little care both the symptoms and Toprol Xl Generic Recall course of the disease will be found to be entirely different. Michels and Weber have re- cently reported a case almost identical with my first. Their report includes a careful study of the microscopic findings. The cases reported by Arkwright and Dunlop, if at all instances of this disease, are complicated. The question of etiology is still obscure Toprol Xl Coupon and speculative. Friedlander considers injury and exposure to cold important factors. Wwedensky believed there was an un- derlying neuritis, upon which fs imposed an arteritis. Metoprolol Tartrate Vs Toprol Xl Sternberg assumes injuries applied to a weakened and depressed vascular system, and Hollis suggests that by the repeated impact of foreign particles against the sides of a small artery, a state of irritation or "molecular unrest" is estab- lished within certain endothelial cells. None of these theories quite satisfies the conditions. It would seem that if the cause were endarterial, Cost Of Toprol Xl such as a toxin conveyed by the blood stream, its action would not be selective to a certain arterial distribution. If there be extravascular agencies their nature still remains obscure. The two cases cited above would rather suggest that the disease in its onset is peripheral, inasmuch as the obliter- ation was farthest advanced in the distal parts. The disease is slowly progressive, and is Generic For Toprol Xl not cured by amputation, as is evidenced by the re- currence in the amputation stump of Case I. Toprol Xl 100 Mg Wwedensky believed the condition to occur only in Russian and Polish Jews. Michels and Weber also comment upon this fact, the case reported by them having occurred also in that race. My two cases are both Russian Jews. A. Pearce Gould, in The Second Lettsomian Lecture, cites several cases, but no mention is made of this fact. I have failed to find anything racial that might predispose Jews to arterial changes. The ergot in the use of rye bread seems to play no role. It is to be hoped that modern research in artery-vein anastomosis may find a fruitful application in this disease. BIBLIOGRAPHY. Jaesche : Laiigcnbcck's Archiv, Vol. VI. 'Burvow -Mrchow's Archiv, Vol. XXXVIII. Friedlander : Ueber Arteritis Obliterans : Centralblatl fitr die mrdiciiiischot JVisseiisclmfteit, No. 4. 1876. Winiwater : Ueber cine ei.a;enthumliche Form von Endar- teriti!! luid Endopblebitis init Gangran des Fusses; Archiv fiir klinischc Chirurgic, Vol. XXITI. Sternberg: Wiener kliitischr Wochenschrift, Nos. 7,7 and 39. Nov. lo, 1906] MEDICAL RECORD. 741 Wwedensky : Archiv fur klinische Chirurgie, Vol. LVII. Von Zoege-Manteufftl : Archiv fur klinische Chirurgie, Vol. XIII; and Deutsche Zcitschrift fiir Chirurgie, Vol. XLVII. Bunge: Archiv fiir klinische Chirurgie, Vol. LXIII. Wulff: Deutsche Zeitschrift fiir Chirurgie, Vol. Metoprolol Vs Toprol Xl LVIII. Von Toprol Generic Equivalent Wartburg: Beitriige cur klinischen Chirureie, Vol. XXXV. A. Pearce Gould: Second Lettsomian Lecture, Lancet, Vol. I., 1902; Transactions Clinical Society, London, Vol. XVII. and Vol. XXIV. Hadden : Transactions Clinical Society, London, Vol. XVII. Spencer : Transactions Clinical Society, London, Vol. XXXI. Arkwright: Lancet, Vol. II., 1902. Dunlop : Lancet, Vol. I., 1903. Michels and Weber: British Medical Journal, 1905. 18 East Sixtieth Street. nurse of St. Luke's Hospital. Even should future research not accord to them the honor of priority, they deserve credit for having revived an old method of resuscitating the apparently dead new- born in the city of Denver, where this method was certainly unknown. Has oxygen ever been used, or its use suggested, in resuscitation of the drowned? 14a Court Place. THE I'SE OF OXYGEN IN .ASPHYXIA NEONATORUM. ByC. d. spivak, .\i.d., Toprol Xl Vs Generic DENVER. COLO.

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