b'\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n1 \n\n\n\n- \n\n\n\n\n\n\n\n\n\n\n\n\n\'</! \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n1 \n\n\n\nJ \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\xc2\xbb \n\n\n\n\n\n\n^ tf \n\n\n\nw ^ \n\n\n\nv- v \n\n\n\nV \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\ns a\\ \n\n\n\n\xe2\x96\xa0tf . Jt \n\n\n\n\n\n\n- \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n/ ;- \n\n\n\n\n\n\n\n\n\n<5 -^ \n\n\n\n\n\n\n\n\n\n^ \xe2\x96\xa0* \n\n\n\n# N \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n- % \n\n\n\n\n\n\n\n\n\n\n\n\n" \n\n\n\no \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\xe2\x96\xa0 ^ \xe2\x96\xa0 \n\n- \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n%, \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n*A \n\n\nV* \n\n\n< 1 1 \n\n\n\n\n\n\n\\\xc2\xb0 ^- \n\n\n\n\n\n\nC7 i \n\n\n\nAnesthesia and Anesthetics \n\n\n\nGENERAL AND LOCAL \n\n\n\nFOR PRACTITIONERS AND STUDENTS \nOF MEDICINE AND DENTISTRY \n\n\n\nBY \n\nJOSEPH M. PATTON, M. D. \n\nProfessor of Internal Medicine, Chicago Policlinic ; Clinical Professor \n\nof Diseases of the Chest, Medical Department \n\nUniversity of Illinois \n\n\n\nSECOND EDITION, REVISED AND ENLARGED \n\n\n\nIllustrated \n\n\n\nCHICAGO \nCLEVELAND PRESS \n\niqo6 \n\n\n\n\' \n\n\n\nLIBRARY ef CONGRESS \nTwe Copies Received \n\nSiP 14 *906 \nCefyfif ht Entry \n\nCUSS/^a XXc, N. \n\nCOPY 8. \n\n\n\n\n\n\nCopyright 1906 \n\nBY THE \n\nCLEVELAND PRESS \n\nCHICAGO \n\n\n\nPREFACE TO THE SECOND EDITION. \n\n\n\nThe commendation which has been given this work, and the \nearly necessity for a second edition leads the author to assume \nthat it fills fairly well the requirements of those for whom it was \nwritten. The growing realization of the importance of a thor- \nough knowledge of the practical application of anaesthetic agents, \na branch to which entirely too little attention is required by our \nmedical schools, is keeping pace with advancements in the field \nof anaesthesia and the special methods and intentions of its\'em- \nployment. \n\nThe past few years have been prolific of methods to improve \nthe means of inducing satisfactory narcosis with a minimum of \nrisk, and also have developed more definite knowledge of the \nphysiologic and toxic effects of anaesthetic agents. We have at- \ntempted to incorporate in this edition the advancement in our \nknowledge of general anaesthesia, and such improvement in meth- \nods of application as have been thoroughly tested and are of ac- \nknowledged utility. \n\nSome slight changes have been made in the arrangement of \nthis volume, and new matter has been added on delayed chloro- \nform poisoning, scopolamine-morphine anaesthesia, status thymi- \ncus, ethyl chloride, spinal anaesthesia, stovaine, and the use of \nadrenalin in connection with spinal and local anaesthesia. \n\nWith appreciation of the reception accorded this work the \nauthor trusts that the second edition will be as kindly received as \nwas the first. J. M. P. \n\n\n\nPREFACE. \n\n\n\nThis book is not intended as a treatise on anaesthesia, or anaes- \nthetics, its limitations being too pronounced. Neither has it any- \nthing original to set forth. Its production was impelled rather \nfrom the want of a work on this subject sufficiently concise to fit \nthe opportunities of the average student or busy practitioner, yet \ncomplete enough to afford a fair and impartial resume of our \npresent knowledge of this important subject. \n\nThe rather extensive literature of the past decade on the sub- \nject of anaesthesia attests a growing realization of the importance \nof more accurate knowledge of anaesthetics and their administra- \ntion. The growing tendency to relegate the administration of \nanaesthetics to those who are more or less expert in their admin- \nistration is even now extending beyond hospital service and into \nprivate practice, and the necessity in our medical colleges of both \ninstruction and practice in the administration of anaesthetics is \nbeing recognized. Instead of regarding the anaesthetist as the \nleast important factor in the successful outcome of a surgical pro- \ncedure, it is understood that in some instances, at least, his may \nbe a responsibility equal to, if not greater than, that of the opera- \ntor himself. In other words, many of the accidents and complica- \ntions of, and sequences to, the administration of anaesthetics may \nbe avoided by intelligent and skillful administration. \n\nCredit is given in the text to those whose authority has been \nabstracted. It remains only for the author to acknowledge the \ncourtesy of Dr. Elgin MaWhinny, of the Northwestern Dental \nSchool, who has written the chapter on Local Anaesthetics in Den- \ntistry ; and that of Dr. L. L. Skelton, professor of physiology in \nthe Chicago College of Dentistry, for revising and offering sug- \ngestions to the chapter on the physiology of anaesthesia. \n\nJ. M. P. \n\n\n\nCONTENTS. \n\n\n\nPART I. \n\nGENERAL ANESTHESIA AND ANESTHETICS. \n\nCHAPTER I. \n\nHistorical, \xe2\x80\x94 Origin of term Anaesthesia \xe2\x80\x94 Ancient beliefs, investiga- \ntions and writers \xe2\x80\x94 Volatile narcotics \xe2\x80\x94 Methods of early part of seven- \nteenth century \xe2\x80\x94 Hypnotism \xe2\x80\x94 Use of gases leading to discovery of anaesthe- \nsia \xe2\x80\x94 Humphrey Davy \xe2\x80\x94 Faraday and ether \xe2\x80\x94 Hubbard and nitrous oxide \xe2\x80\x94 \nDr. Long \xe2\x80\x94 Wells \xe2\x80\x94 Jackson and Morton \xe2\x80\x94 Guthrie and chloroform \xe2\x80\x94 Simp- \nson and chloroform \xe2\x80\x94 Investigations of chloroform \xe2\x80\x94 Colton and gas-con- \ntroversies \xe2\x80\x94 Work of Clover \xe2\x80\x94 "Glasgow Committee" \xe2\x80\x94 Hyderabad commis- \nsion \xe2\x80\x94 Later investigations \xe2\x80\x94 Spinal anaesthesia \xe2\x80\x94 Sequential anaesthesia. \n\nCHAPTER II. \n\nGeneral Physiology. \xe2\x80\x94 Nature of general anaesthesia \xe2\x80\x94 Character of \nagent \xe2\x80\x94 Entrance into organism \xe2\x80\x94 Absorption \xe2\x80\x94 Elimination \xe2\x80\x94 Dyspnoea \xe2\x80\x94 \nBlood changes \xe2\x80\x94 Effect on nervous system, on respiration, on muscular sys- \ntem, on heart \xe2\x80\x94 Stages of anaesthesia. \n\nCHAPTER III. \n\nThe Selection of a General Anesthetic with Reference to the \nComparative Danger of the Agent Employed. \xe2\x80\x94 Development of practical \nknowledge regarding administration \xe2\x80\x94 Nitrous oxide \xe2\x80\x94 Oxygen \xe2\x80\x94 Chloro- \nform \xe2\x80\x94 Ether \xe2\x80\x94 Comparative statistics \xe2\x80\x94 Condition of subject \xe2\x80\x94 Method of \nadministration \xe2\x80\x94 A. C. E. mixture \xe2\x80\x94 Comparative figures. \n\nCHAPTER IV. \n\nThe Selection of an Anesthetic with Reference to the Patient. \xe2\x80\x94 \nPhysical condition and danger \xe2\x80\x94 Sexes \xe2\x80\x94 Age \xe2\x80\x94 Infants and young children \n\xe2\x80\x94 Old people \xe2\x80\x94 General condition \xe2\x80\x94 Debility \xe2\x80\x94 Plethora \xe2\x80\x94 Alcoholic subjects \n\xe2\x80\x94 Drug habitues \xe2\x80\x94 Tobacco users\xe2\x80\x94 Menstruation \xe2\x80\x94 Pregnancy \xe2\x80\x94 Frequent \nanaesthetization \xe2\x80\x94 Pathologic conditions of blood, of respiratory tract, of \nheart and blood vessels \xe2\x80\x94 Abdominal conditions \xe2\x80\x94 Exhaustion \xe2\x80\x94 Shock \xe2\x80\x94 Col- \nlapse \xe2\x80\x94 Status thymicus \xe2\x80\x94 Kidney diseases \xe2\x80\x94 Diabetes \xe2\x80\x94 Nervous diseases. \n\nCHAPTER V. \n\nThe Selection of an Anesthetic with Reference to the Opera- \ntion. \xe2\x80\x94 Short operations \xe2\x80\x94 Operations on brain and spinal cord \xe2\x80\x94 Ophthalmic \noperations \xe2\x80\x94 Operations on face, jaws, lips, tongue, palate, tonsils, nose and \nnasopharynx \xe2\x80\x94 Extraction of teeth \xe2\x80\x94 Laryngeal operations \xe2\x80\x94 Neck exclusive \n\n\n\nVI CONTENTS \n\nof air tract \xe2\x80\x94 Chest \xe2\x80\x94 Brain \xe2\x80\x94 Abdomen \xe2\x80\x94 Rectum and genito-urinary organs \n\xe2\x80\x94 Gynecological operations \xe2\x80\x94 Obstetric operations \xe2\x80\x94 Operations on extremi- \nties. \n\nCHAPTER VI. \n\nBefore the Administration of an Anaesthetic. \xe2\x80\x94 Time of Day \xe2\x80\x94 Diet \n\xe2\x80\x94 Disinfection of mouth \xe2\x80\x94 Bowels \xe2\x80\x94 Bladder \xe2\x80\x94 Medicine \xe2\x80\x94 Cocaine solution \xe2\x80\x94 \nStrychnia \xe2\x80\x94 Morphine and atropine \xe2\x80\x94 Physical examination \xe2\x80\x94 General con- \ndition \xe2\x80\x94 Temperature of room \xe2\x80\x94 Ventilation \xe2\x80\x94 Clothing of patient \xe2\x80\x94 Postures \nduring induction \xe2\x80\x94 Moving patients \xe2\x80\x94 Appliances and remedies \xe2\x80\x94 Aseptic \nprecautions. \n\nCHAPTER VII. \n\nPosture During Anaesthesia. \xe2\x80\x94 Respiratory difficulty from faulty pos- \nture \xe2\x80\x94 Circulatory trouble from position \xe2\x80\x94 Interference with operation \xe2\x80\x94 \nPosture for extraction of teeth \xe2\x80\x94 For operations about oral cavity, head, \netc., larynx, trachea, neck, ophthalmic operations, chest, abdomen, kidney, \ngenito-urinary organs. \n\nCHAPTER VIII. - \n\nNitrous Oxide. \xe2\x80\x94 Nature \xe2\x80\x94 Preparation \xe2\x80\x94 Commercial service \xe2\x80\x94 Physio- \nlogical effects and action \xe2\x80\x94 Administration \xe2\x80\x94 Dangers of administration \xe2\x80\x94 \nAdministration of definite quantities of nitrous oxide and air \xe2\x80\x94 Adminis- \ntration of nitrous oxide and indefinite quantities of air \xe2\x80\x94 Adminstration of \nnitrous oxide and oxygen. \n\nCHAPTER IX. \n\nEther. \xe2\x80\x94 Discovery \xe2\x80\x94 Nature \xe2\x80\x94 Impurities \xe2\x80\x94 Physiological effects and ac- \ntion, first stage, second stage, third stage \xe2\x80\x94 Toxic effects \xe2\x80\x94 After effects \xe2\x80\x94 \nDangers of administration \xe2\x80\x94 The administration, by the open system, par- \ntially closed system, close method \xe2\x80\x94 Oxygen and ether \xe2\x80\x94 Rectal etherization \n\xe2\x80\x94 Proper extent of anaesthesia \xe2\x80\x94 Management of accidental conditions inci- \ndent to the period of administration \xe2\x80\x94 Clinical conclusions. \n\nCHAPTER X. \n\nChloroform. \xe2\x80\x94 Discovery \xe2\x80\x94 Nature \xe2\x80\x94 Impurities \xe2\x80\x94 Physiological effects \nand action, first stage, second stage, third stage \xe2\x80\x94 Toxic effects \xe2\x80\x94 Physio- \nlogical action \xe2\x80\x94 Lethal effects \xe2\x80\x94 After effects \xe2\x80\x94 Dangers of administration \xe2\x80\x94 \nThe administration \xe2\x80\x94 Management of complications \xe2\x80\x94 Delayed, chloroform \npoisoning. \n\nCHAPTER XI. \n\nScopolamine-morphine Anaesthesia.\xe2\x80\x94 Physiologic effects \xe2\x80\x94 Method of \nemployment. \n\nCHAPTER XII. \n\nEthyl Bromide. \xe2\x80\x94 Discovery \xe2\x80\x94 Physiological effects \xe2\x80\x94 Dangers of ad- \nministration. Ethyl Chloride. \xe2\x80\x94 Nature \xe2\x80\x94 Use as anaesthetic \xe2\x80\x94 Character of \nanaesthesia \xe2\x80\x94 Application. Bichloride of Methylene \xe2\x80\x94 Nature \xe2\x80\x94 Introduc- \n\n\n\nCONTENTS Vli \n\ntion as anaesthetic \xe2\x80\x94 Character of anaesthesia \xe2\x80\x94 Dangers \xe2\x80\x94 Method of admin- \nistration. Ethidene Dichloride \xe2\x80\x94 Nature \xe2\x80\x94 Use as anaesthetic \xe2\x80\x94 Dangers \xe2\x80\x94 \nMethod of administration. Amylene \xe2\x80\x94 Nature \xe2\x80\x94 Effects \xe2\x80\x94 Character of an- \naesthesia \xe2\x80\x94 Dangers. Pental \xe2\x80\x94 Use as anaesthetic \xe2\x80\x94 Effects. Other Agents. \n\nCHAPTER XIII. \n\nSpinal Anaesthesia \xe2\x80\x94 Effects : \xe2\x80\x94 After effects \xe2\x80\x94 Complications \xe2\x80\x94 Failure \xe2\x80\x94 \n\nContra-indications \xe2\x80\x94 Mortality \xe2\x80\x94 Solution and dose \xe2\x80\x94 Technique. Stovaine \nin spinal anaesthesia. \n\nCHAPTER XIV. \n\nMixtures for Anaesthesia. \xe2\x80\x94 Principle\xe2\x80\x94 A. C. E. mixture \xe2\x80\x94 Billroth\'s \nmixture \xe2\x80\x94 Chloroform and ether, 2 parts chloroform and 1 part ether, 1 \npart chloroform and 4 parts ether, 1 part chloroform and 3 parts ether, 1 \npart chloroform and 2 parts ether \xe2\x80\x94 Chloroform and alcohol \xe2\x80\x94 Schleich\'s \nmixture \xe2\x80\x94 Somnoform. \n\nCHAPTER XV. \n\nSequences of Anaesthetics. \xe2\x80\x94 Nitrous oxide-ether-Chloroform-ether \xe2\x80\x94 \nA. C. E.-ether \xe2\x80\x94 Ether-chloroform \xe2\x80\x94 Ethyl chloride-ether \xe2\x80\x94 Other sequences. \n\nCHAPTER XVI. \n\nAfter the Administration of an Anesthetic. \xe2\x80\x94 After Depression \xe2\x80\x94 \nRapidity of recovery \xe2\x80\x94 General management \xe2\x80\x94 Diet \xe2\x80\x94 Vomiting \xe2\x80\x94 Bronchial \nand pulmonary symptoms \xe2\x80\x94 Etiology of lung complications \xe2\x80\x94 Statistics of \npost anaesthesia pneumonia \xe2\x80\x94 Embolic pneumonia \xe2\x80\x94 Gangrene and abscess \nof lungs \xe2\x80\x94 Paralysis \xe2\x80\x94 Anuria. \n\nPART II. \n\nLOCAL ANESTHESIA AND ANESTHETICS. \n\nCHAPTER XVII. \n\nLocal Anesthesia. \xe2\x80\x94 General considerations \xe2\x80\x94 Application to special \noperations and regions \xe2\x80\x94 Cocaine \xe2\x80\x94 Cocaine hydrochloride \xe2\x80\x94 Local infiltra- \ntion method, technique \xe2\x80\x94 Regional paraneural infiltration, technique \xe2\x80\x94 Re- \ngional intraneural method \xe2\x80\x94 Other local anaesthetic agents \xe2\x80\x94 Eucaine A. \xe2\x80\x94 \nEucaine B. \xe2\x80\x94 Tropa cocaine hydrochloride \xe2\x80\x94 Holocain \xe2\x80\x94 Nirvanin \xe2\x80\x94 Ortho- \nform \xe2\x80\x94 Aneson \xe2\x80\x94 Ethyl chloride \xe2\x80\x94 Liquid air \xe2\x80\x94 Novocaine \xe2\x80\x94 Stovaine \xe2\x80\x94 Alypin. \n\nCHAPTER XVIII. \n\nLocal Anesthetics in Dentistry. \xe2\x80\x94 Objections to general anaesthesia \n\xe2\x80\x94 Gradual increase in employment of local agents \xe2\x80\x94 Conclusions regarding \ncocaine \xe2\x80\x94 Chloretone \xe2\x80\x94 Technique of injecting \xe2\x80\x94 Orthoform \xe2\x80\x94 Cocaine for \nanaesthetizing tooth pulp \xe2\x80\x94 Cocaine by cataphoresis \xe2\x80\x94 Stovaine. \n\n\n\nILLUSTRATIONS \n\n\n\nFig. . Page. \n\nChart showing relation of clanger rate to age 40 \n\n1. Hewitt\'s modification of Mason\'s gag 52 \n\n2. Trendelenberg\'s Trachea Tampon, canula and inhaler 53 \n\n3. Westmoreland\'s mouth gag 66 \n\n4. Rosier\'s mouth gag .\' 66 \n\n5. Denhart\'s gag 66 \n\n6. Mason\'s gag 66 \n\n7. Heister\'s gag 67 \n\n8. Plain oral screv? 67 \n\n!). Mathieus\' tongue forceps ....... 67 \n\n10. Heuce\'s tongue forceps 67 \n\n11. Daintree\'s adjustable mouth prop 67 \n\n12. Soft-rubber bite-blocks 67 \n\n13. Postures for anaesthesia 69-70 \n\n14. The S. S. White gasometer 74 \n\nin. Diagram of White gasometer 75 \n\n16. Universal gas stand 70 \n\n17. White\'s Inhaler 81 \n\n18. Mouth piece and Inhaler 82 \n\n19. Anaesthetic Inhaler (Hillard) 85 \n\n20. Goldan\'s stop cock 91, 92, 93 \n\n21. Diagram of Goldan\'s stop cock 94 \n\n22. Goldan\'s apparatus for N 2 and 95 \n\n23. White\'s apparatus for N 2 and 96 \n\n24. Allis\' Inhaler 108 \n\n25. Fowler\'s modification of Allis\' Inhaler 109 \n\n26. Clover\'s Inhaler 110 \n\n27. Section of Clover\'s Inhaler at "O" Ill \n\n28. Section of Clover\'s Inhaler at "F" 112 \n\n29. Diagram of Air Current in Clover\'s Inhaler 113 \n\n30. Bennett\'s Inhaler I. \xe2\x80\x94 ether 114 \n\n31. Bennett\'s Inhaler II. \xe2\x80\x94 gas 115 \n\n32. Bennett\'s Inhaler III. \xe2\x80\x94 gas and ether 116 \n\n33. Junker Inhaler 137 \n\n34. Esmarch Inhaler 139 \n\n35. Skinner mask 140 \n\n36. Pierpont\'s folding chloroform inhaler 141 \n\n37. Schimmelbusch-Esmarch Inhaler 141 \n\n38. Plain ether drop bottle 141 \n\n39. Hahn\'s drop bottle 141 \n\n40. Gwathmey\'s vapor-inhaler 142 \n\n41. Annandale\'s tracheal canula and tube 144 \n\n42. Fell\'s apparatus for inflation 149 \n\n43. Richardson\'s double bellows for forced respiration 150 \n\n44. Needles and syringe for spinal anaesthesia 167 \n\n45. Diagram of vertebra 168 \n\n46. Coming\'s needle 169 \n\n47. Sitting posture for spinal anaesthesia 170 \n\n48. Iliac crests 171 \n\n49. Needle entering opposite 4th spine 172 \n\n50. Tuffier\'s syringe and needle 173 \n\n51. Method of inserting needle in spine 174 \n\n52. Stone\'s mask for Schleich\'s solution 1S1 \n\n53. Somnoform Inhaler 183 \n\n54. Tube diagram, somnoform Inhaler 183 \n\n55. Hewitt\'s modification of Clover\'s Inhaler, for N 2 and ether 186 \n\n56. Gwathmey gas-ether Inhaler 187 \n\n57. Diagram of Gwathmey Inhaler 1SS \n\n58. Dawbarn\'s Inhaler 190 \n\n59. Ethyl chloride tube 213 \n\n\n\nPART I. \n\nGeneral Anaesthesia and \nAnaesthetics. \n\n\n\n\nCHAPTER I. \n\nHISTORICAL. \n\nThree achievements stand out in the records of the last cen- \ntury which for the direct mitigation of human ills and indirect \ninfluence upon the advancement of medical science have no paral- \nlels in the history of medicine. It is hardly necessary to say \nthat these achievements are vaccination, anaesthesia, and antisep- \nsis. \n\nAnaesthesia is the term that was given by Dr. Oliver Wendell \nHolmes to denominate that lethargic state which had from time \nimmemorial been at once the hope and the despair of medical \nsavants, and the successful induction of which he apostrophized \nas follows : "Nature herself is working out the primal curse \nwhich doomed the tenderest of her creatures to the sharpest of \nher trials ; but the fierce extremity of suffering has been steeped \nin the waters of forgetfulness, and the deepest furrow in the \nknotted brow of agony has been smoothed forever." This Death \nof Pain, this medical will-o\'-the-wisp, had for centuries eluded \nthe grasp of medical investigators -ever since the Great Physician \n"caused a deep sleep to fall upon Adam; and he slept; and he \ntook one of his ribs and closed up the flesh instead thereof." \n\nThe anticipation of a pain-destroying agent was a medical \ndream, older, more persistently pursued, and more enticing than \nthe fancies of the fabled lotus-eaters. No other possibility in \nmedicine ever held forth such allurement to the surgical patient, \nof whose feelings on the approach of the surgeon Tennyson \nwrote, "Sent a chill to my heart when I saw him come in at the \ndoor." \n\nThe belief in and the search after some agent by which \npain might be annihilated is as old as medicine itself. The fact \nthat though the ancients employed various devices to annul pain \nthe eighteenth century was not marked by any advance in this \ndirection, notwithstanding its eminent medical men, has been a \nsubject of comment. The atmosphere of mysticism, charms, in- \ncantations and charlatanism that surrounded the early history of \n\n\n\n12 HISTORICAL \n\npain-destroying agents tended to discredit the whole matter, and \nill part, at least, explains why the age that produced Sydenham \nand Pare was barren in this respect. Then too, must be taken \ninto consideration the religious ideas, based on the primeval curse, \nwhich were prevalent at that time and against which Simpson \nwaged such an energetic and convincing campaign. \n\nIn Homer\'s Odyssey there is reference to a drug used by Helen \nas a nepenthe or narcotic, "a drug to lull all pain and anger and \nbring forgetfulness of every sorrow." The nature of the nepenthe \nof Helenwhich "Immediately she (Helen) dropped into the wine \nof which they drank," is unknown, but it is believed by some \nto have been onjnm . Dioscorides and Pliny, about the begin- \nning of the Christian era, described the Memphis stone which \ngave forth soporific fumes. The former describes the use of \na decoction of the root of the Atropa Mandagora in wine: "And \nsome making decoctions in wine of the ro*Dis^\xc2\xb1o_a third, this be- \ning strained is put past. Using one wine-glassful in the case of \nthe sleepless and those suffering excessive pain, and in the case \nof those on whom they wish to produce insensibility when cut or \nburnt." Dioscorides further describes the hypnotic effects of \nmandrak e roots on shepherds, and the analgesic properties of \nthe decoction as used by physicians. This drug, according to \nTheodoric, when mixed with other narcotics and inhaled caused \na deep sleep from which the patient could only be aroused by \nthe fumes of vinegar. The Romans used mandrak e to stupefy \ncriminals at the time of crucifixion, though probably the material \nused was a compound of several drugs. Mandrake was used as \na surgical anaesthetic down to the thirteenth century, and its \nemployment is mentioned by Galen. Lucian makes several ref- \nerences to mandagora : "But do you think he has been so dosed \nwith mandagora as to hear those things, and not to know?" \xe2\x80\x94 \n"Adversus Indnctum," 23 ; "You sleep as if through mandagora." \n\xe2\x80\x94 "Timon," 2. \n\nAccording to Foy, the schools both of the Eastern and Western \nCalifates were familiar with and employed mandagora. Its prop- \nerties were described by Avicenna, Averhoes, Paulus, Aetius, \nIsodorus, Serapion, Celsus, and others. They employed it as a \nhypnotic and analgesic in various ways. Mandrake has been \nused to relieve the pains of labor, and Dr. Sylvester suggested \n\n\n\nHISTORICAL 13 \n\nthat it was for such a purpose that Rachel begged the mandrake \nfrom Ruben. \n\nIn the third century a Chinese surgeon Hoa-tho, is said to \nhave employed some sort of anaesthetic drug, and in the thir- \nteenth century da Lucca, a Tuscan surgeon, employed an oil by \ninhalation. The Assyrians compress ed the vessels of the neck \nby a band before practicing circumcision. \n\nWith the introduction into Europe, by the Moslems, of the \nprocess of distillation, we find the employment of volatile prepa- \nrations for the purpose of relieving pain. Giabattista Porta \n(1589), a surgeon of Naples, tells of volatile drugs, \xe2\x80\x94 an essence \nof hyoscyamus, solanum, poppy, and belladonna, kept in leaden \nvessels \xe2\x80\x94 which drugs produced sleep upon inhalation : "Thereby \nhe would be buried in a most profound slumber, nor be aware of \nwhat had been done to him." Vigo tells of producing insensi- \nbility by "smelling of a sponge wherein opium is." Theodorico, \nson of Ugone da Lucca (born in the middle of the twelfth cen- \ntury), tells of an oil de lateribus prepared and used by his father, \nwhich by inhalation alone put patients asleep on occasions of \npainful operations. He further describes the substance used with \nthe somniferous sponge of da Lucca as consisting of opium, mul- \nberry juice, hyoscyamus, mandagora, wood ivy, lettuce seeds, \ndock seeds, and water hemlock. In this mixture a sponge is \nboiled. For use it was soaked in hot water and applied to the \nnostrils. A sponge dipped in vinegar was applied to the nos- \ntrils to awaken the patient, or the juice of the root of fenngrek \nwas thrown into the nostrils. \n\nThe principle of the inhalation of volatile substances is very \nancient. Aphrodite threw herself on a bed of lettuce in order to \nmitigate her grief for the death of Adonis. \n\nJ jidia n hemp is an old remedy for pain, and was used to stu- \npefy criminals. Herodotus mentions a custom of the Scythians of \ninhaling the fumes of a certain kind of hemp. Indian hemp was \nused as an analgesic even earlier than mandrake. M. Julien laid \nbefore the French Academy of Medicine a manuscript called \nKo-Kin-i-ting which contained the information that Ho-tho \ngave a preparation of hemp (ma-yo) to patients, who became \ninsensible as if "drunk, or deprived of life," and who, when re- \nvived, had not felt the slightest pain during the operation. \n\n\n\n14 HISTORICAL \n\nThe name "haschish," by which Indian hemp was known in \nthe Orient, is said to have given rise to the term assassin (liter- \nally, eater of haschish) because an Arab Sheikh fed the drug \nto his followers in order to produce delightful sensations which \nhe induced them to believe he could obtain for them eternally if \nthey would carry out his bloodthirsty designs. Simpson thought \nthe nepenthe of Homer was a species of Indian hemp. \n\nReference to the poetry of the sixteenth and seventeenth cen- \nturies shows that drugs of this nature were well known at that \nperiod. Thus : "Bringeth his patient in a senseless slumber,"\xe2\x80\x94 \nDu Bartas ; also, "Will stupefy and dull the sense awhile." . . \n. . \'\'locking up the spirits a time." \xe2\x80\x94 Shakespeare. Chumappe \n(1534) alludes to the use of soporific preparations at that period, \nBoerhaave\'s anaesthetic powder is said to have consisted of oil \nof cinnamon, oil of cloves, citron peel, sugar, red coral, and \nopium. A dose was given one hour before operation, and an- \nother one-quarter of an hour before if necessary. Brooke (1562), \nfrom whom Shakespeare was supposed to have derived much in- \nspiration for his "Romeo and Juliet" (1597), in his "Tragical \nHistorye of Romeus and Julietta," etc., describes friar Laurence \nas a great searcher of nature\'s secrets and a maker of "divers \nsoporiferous simples" which would bring the "receiver into such \na sleepe and burieth so deeply the senses and other spirits of \nlife, that the cunningest Phistian will judge the party dead." \nAlso, "When the operation is perfect and done hee returneth into \nhis first estate." \n\nMarlowe, in The Jew of Malta, refers to the mandagora thus : \n\n"I drank of poppy and cold mandrake juice, \nAnd being asleep, belike they thought me dead, \nAnd threw me o\'er the walls." \n\nEven as late as Mrs. Browning we have the following : \n"Have the pigmies made you drunken \nBathing in mandagora ?" \n\nIn the early part of the seventeenth century Valverdi, an \nItalian, practised compression of the vessels of the neck in or- \nder to produce unconsciousness, a procedure undertaken by the \nancient Assyrians at the time of circumcision. Compression of the \nvagi, of the limb to be operated on, of the nerve supplying the \n\n\n\n\xc2\xab \n\n\n\nHISTORICAL 15 \n\npart to be operated on, have all been recommended and prac- \ntised. Dorsey, Mott, Norris, and others tell of their more or \nless successful use of opium or whisky, or both, to produce some \ngreater or less degree of insensibility to pain during operations. \n\nHypnotism was known to the ancient Egyptians, Persians, \nand Indians, and it is thought by some that they may have used \nit for the purposes of surgical anaesthesia. Simpson quotes the \nlines of Middleton (1617) : \n\n\'Til imitate the pities of old surgeons \n\nTo this lost limb\xe2\x80\x94 who ere they show their art \n\nCast me asleep, then cut the diseased part." \n\nGreatrakes (1661), by means of passes over the subject\'s body \nproduced a magnetic sleep. Greatrakes was a celebrated Irish \n"stroker" who was called to England tc treat Lady Conway, of \nWarwickshire. He obtained considerable notoriety. \n\nIn 1766 Anthony Mesmer appeared with his theory of "Ani- \nmal Magnetism." In 1839 a Frenchman named Potet introduced \nhypnotism into London under the name of mesmerism. He was \nsupported by Dr. John Elliotson of the University College Hos- \npital, who was subsequently ruined because of his advocacy of \nmesmerism. The British physicians, Simpson, Liston, Braid, and \nEdsaile, of Calcutta, were more or less successful in experi- \nmenting with hypnotism. Edsaile is said to have employed hyp- \nnotism in connection with rather severe surgical operations. The \nancient Greek physicians must have recognized the principle of \nhypnotism, for in the Greek Anthology we have : "Touching \nthem with his hands he (the physician) quickly makes them \nwhole." \n\nAlthough sulphuric ether was discovered by Valerius Cordus \nin the year 1540 (though by some its discovery is attributed to \nthe Arabian chemist Djafar Yeber), hydrogen by Cavendish in \n1766, nitrogen by Rutherford in 1772, oxygen by Priestly in 1774, \nand nitrous oxide by Priestly in 1772 or 1776, it was not until the \nclose of the eighteenth century that these gases began to be em- \nployed in any manner likely to lead to the discovery of their \nanaesthetic properties. The inhalation of ether for the relief of \nasthma was recommended by Pearson, of Birmingham, in 1795. \nBeddoes organized a "Pneumatic Institute" at Clifton in 1798 for \n\n\n\nl6 HISTORICAL \n\nthe treatment of pulmonary diseases by the inhalation of gaseous \nand vaporized medicaments. Thornton and others also employed \nlike medication about the same period. In 1799 or 1800 Mr. \nHumphrey Davy, then an assistant of Dr. Beddoes, discovered \nby personal experiment that nitrous oxide gas would relieve tooth- \nache and other pains, and suggested its use for the production of \nanaesthesia. He described its effects as "uneasiness being swal- \nlowed up for a few minutes by pleasure." Although he does not \nappear to have carried its administration far enough to produce \nunconsciousness, he nevertheless recognized the possibilities of \nnitrous oxide gas in this direction, and recommended its employ- \nment in "surgical operations in which no great effusion of blood \ntakes place." \n\nIn the early part of the past century the effect of nitrous \noxide gas was known to many, and the gas was inhaled for diver- \nsion by the students of the University of Pennsylvania. "Ether \nfrolics" were an amusement of the time among young people. \n\nIn 1S18 Faraday pointed out that ether when inhaled had \neffects similar to laughing gas, as the following from the Eng- \nlish Quarterly Journal of Science and Arts, which is attributed \nto him, shows : "When the vapor of ether mixed with common \nair is inhaled it produces effects very similar to those occasioned \nby nitrous oxide. ... By the imprudent inspiration of ether \na gentleman was thrown into a very lethargic state, which con- \ntinued with occasional periods of intermission for more than \nthirty hours." \n\nIn October, 1888, Dr. O. P. Hubbard read a paper before the \nNew York State Medical Association, in which he detailed the \ncircumstances of the administration of nitrous oxide gas to his \nbrother and others at Rome, Oneida county, N. Y., in November, \n1 82 1. During one of the exhibitions a young man was found \nin an adjoining room lying completely unconscious beside the \ngasometer. He was removed and soon recovered from the un- \nconscious state. \n\nPereiras\' work on Materia Medica (1839), described the an- \naesthetic properties of ether when inhaled, and in 1842 Dr. Craw- \nford W. Long, of Georgia, who is said to have learned from a \nnegro servant named Wichita that complete unconsciousness had \nresulted some time previously in a negro lad whom his companions \n\n\n\nHISTORICAL 17 \n\nhad forcibly compelled to inhale some ether, employed ether while \nremoving a tumor. He had used it for the relief of pain, and \nsubsequently to this operation he repeated his experiments, and \ndemonstrated the use of ether to his brother physicians. He ap- \npears to have been conservative in his exploitation of the use of \nether, and while directly in the line of success the world at large \nwas not made to recognize this until after he was forestalled by \nMorton in the practical application of ether as a general surgical \nanaesthetic. Dr. Long is regarded by many, especially in the \nSouthern States, as the discovererof ansesthesia. (A statue of \nDr. Long is to be placed in analTatWashington, D. C, reserved \nfor the statues of two distinguished men from each State. The \nstatue is a memorial from the physicians of the State of Georgia.) \n\nIn December, 1844, Dr. Horace Wells, a dentist of Hartford, \nConn., observed while attending a popular lecture given by a \nMr. Colton, a chemist, that a Mr. Cooley while under the influ- \nence of laughing gas struck and injured his limb without suffer- \ning any pain. He at once experimented upon himself, and sub- \nmitted to the extraction of an aching tooth, at the hands of a \ncolleague named Rigg, while under the influence of nitrous oxide \ngas. He successfully repeated the experiment upon others, and \ninstituted what he called a "new era in tooth-pulling." \n\nIn company with a former pupil, W. T. G. Morton, he at- \ntempted to give a demonstration in Boston in 1844. The attempt \nfailed, according to Wells, because of the premature withdrawal \nof the gas. The crowd of practitioners and students present were \nfrank and unrestrained in their expressions of disapproval, \nand the disappointment resulting from this failure induced an \nillness from which Wells never recovered. He explained his dis- \ncovery before the French Academy of Sciences in 1846, and \ndied in New York, in 1848. It is said he opened a vein while \nin his bath.* \n\nWilliam Thomas Green Morton was born in Massachusetts, \nstudied dentistry in Baltimore, and was a successful practitioner \nin Boston. He experimented with drugs and with hypnotism in \nconnection with the painless extraction of teeth, and as we have \nseen was associated with -Wells in his investigations of nitrous \noxide gas. After the failure of the experiment \xe2\x96\xa0 of Wells he \nabandoned gas and tried chloric ether with unsatisfactory re- \n\n*Interesting articles related to the Wells-Morton-Jackson-Long con- \ntroversy have been published .by W. J. Morton, M. D., of New York, in \nthe Post Graduate, 1905, and by William Sedgwick, M. R. C. S., of En- \ngland, in the Medical Times and Hospital Gazette, 1903. These articles \nrepresent different views of the controversy, but otherwise contain noth- \ning essentially different from the facts contained in this chapter. \n\n\n\nl8 HISTORICAL \n\nsuits. At the suggestion of his preceptor Dr. Charles Jackson \xe2\x80\x94 \nMorton being at that time a student of medicine \xe2\x80\x94 a physician \nof Boston, but best known as a geologist and chemist, he expe- \nrimented with sulphuric ether, beginning his experiments on ani- \nmals. His success in this direction encouraged him to make a \npersonal experiment, and in September, 1846, he inhaled ether \nfrom a handkerchief while sitting in his operating chair. He \nwas unconscious for several minutes, and on regaining conscious- \nness he was so elated by his success that he decided to again in- \nhale the drug and submit to an extraction while under its influ- \nence. At this moment the door bell rang and he admitted a man \nnc\'tned Eben Frost whose face was bandaged and who was in \nthat state of mingled hope and consternation so familiar to all \ndental surgeons. He asked if it were not possible to mesmerize \nhim, and readily consented to inhale ether when assured that it \nwas superior to mesmerism. To the joy of the operator and the \nastonishment of the patient the attempt was perfectly successful, \nand thus was accomplished the first operation under ether anaes- \nthesia. \n\nMorton then proceeded to obtain an opportunity for the public \ndemonstration of the practicability of anaesthesia. This was fur- \nnished him in the surgical amphitheater of the Massachusetts Gen- \neral Hospital in Boston, on October 16, 1846, where the unsuc- \ncessful demonstration by Wells had taken place two years before. \nThe surgeon in charge was Dr. John C. Warren, to whom great \ncredit is due for placing the opportunity in Morton\'s hands in \nspite of the previous failure in this direction. The operation was \nthe removal of a vascular tumor from the left side of the neck \nof a young man who was described in the records as "Gilbert \nAbbott, aged twenty, single, painter." The Harvard MedicaL \nclass was present, also several prominent physicians and surgeons. \nThe exhibition of the anaeesthetic was a complete success, so much \nso that Dr. Warren turned to those present and said, "Gentle- \nmen, this is no humbug."* \n\nThe fame of the wonderful new agent and of its discoverer \nspread rapidly, and then came Dr. Jackscn, jealous of the fame \nof Morton and anxious to participate- in the benefits of the dis- \ncovery, with a claim as to the rights of discovery, basing his \nclaim on the assertion that he had been aware of the power of \n\n*The formal announcement to the medical profession of this discovery \nwas made by Dr. H. J. Bigelow in a paper read before the Academy of \nArts and Sciences, on November 3rd, and before the Boston Society of \nMedical Improvement on November oth, and published in the Boston. \nMedical and Surgical Journal, November 18, 1846. \n\n\n\nHISTORICAL 19 \n\nether since 1842. He had suggested the drug to Morton, and un- \ndoubtedly had advised him as to its nature and the best methods \nof administration, but beyond this his claim was groundless. \nAnd here Morton made the mistake of his life, \xe2\x80\x94 an attempt to \npatent the agent under the name "letheon" and to keep its nature \nsecret. As he was not a graduate in medicine he was not tech- \nnically bound to observe that rule of medical ethics which from \nthe beginning of medicine has forbidden the adoption of such \na course in relation to matters which are of benefit to common \nhumanity, yet how different might have been the result to him- \nself if he had held himself bound by this rule, the^ breaking of \nwhich forfeited him the esteem and sympathy of the medical \npublic which would have been of incalculable value in the contro- \nversy which followed. \n\nMorton was anxious to silence Jackson as to the nature of \nether which he had attempted the impossible task of disguis- \ning with aromatics, and to this end he recognized the rights of \nJackson in his application for letters patent. Jackson, dissatisfied \nwith his share of the bargain, attempted to pose at the sole \ndiscoverer, and thus arose an acrimonious controversy which con- \ntinued long after the death of Jackson in an asylum. The mat- \nter was subsequently investigated by a Congressional committee \nwhose report substantiated the claims of Morton. \n\nMorton\'s attempt at secrecy was unavailing. The world at \nlarge knew that \'\'letheon" was simply ether. Dr. Bigelow soon \nbecame aware of its nature and spread the news in England. The \npublic disregarded the patent proceedings. Indeed the gove*n- \nment representatives in the army and navy ignored the effort to \nsecure patent papers, and an attempt to secure a grant of $100,- \n000 to Morton from the government failed largely through the \nantagonism of Jackson supported by the connection of his name \nwith the patent papers. A testimonial of $50,000 from England \nalso failed because of the doubt arising through the same influ- \nences, while a French prize was divided equally between Morton \nand Jackson. \n\nMorton\'s life was clouded by a feeling of resentment against \nthe public whose position he mistook for ingratitude. Such hon- \nors as he received did not obviate the ill health largely due to the \nbickerings which continued over the rights of discovery, and \n\n\n\n20 \' HISTORICAL \n\nwhich resulted in his death in 1868. To-day Morton is generally \nregarded, and his memory is honored, as the true discoverer of \nthe practicability of ether as an anaesthetic. Had he followed the \nexample of the other great discoverers in the field of medicine \nhe would have had as little cause for complaint.* \n\nUpon a monument erected by the citizens of Boston over the \ngrave of Morton is the following inscription : \n\nWilliam T. G. Morton, \nInventor and revealer of anaesthetic inhalation, \nBy whom pain in surgery was averted and annulled; \nBefore whom in all time surgery was agony, \nSince whom science has control of pain. \n\nNo medical discovery was ever more readily adopted than the \nuse of anaesthesia. It was at once taken up in England, and sur- \ngical operations were performed under it\'s use by Dr. Boot and \n* by Listen in December, 1846. Dr. J. Y. Simpson immediately \n! adopted ether in obstetric practice. He soon discovered the diffi- \nculties which attend its administration and which were not so \navoidable then as now, and began experimenting in order to find a \nbetter agent. The unpleasant odor which ether gave to his clothes \nalso induced Simpson to try other agents. He wrote : "I found \nthat no busy obstetric practitioner could extensively employ sul- \nphuric ether without inevitably carrying about with him, and upon \nhis clothes, an odor so disagreeable to many other patients and \nother houses, as to make his presence there aught but desirable." \nHimself and his assistants, Drs. Keith and Duncan, inhaled va- \nrious substances experimentally. Mr. Waldie, a chemist of Liv- \nerpool, suggested to Simpson that chloroform, a constituent of \n"chloric ether," might be tried with benefit. Chloric ether was at \nthat time used as a carminative, and consisted of chloroform \nand rectified spirit. Mr. Waldie, in an article on the "Medicinal \nHistory of Chloroform" (1847), states that as far as he knows \nchloroform was introduced into England about 1838. A pre- \nscription was presented at Apothecaries Hall, Colquitt street, \nLiverpool, for filling, one ingredient was chloric ether which was \nunknown there. The chemist found the formula for chloric ether \nin the United States Dispensatory, and prepared some. The prop- \n\n\n\n*Dr. W. J. Morton remarks (1905) : "The discovery of anaesthesia, \nwhile a boon to the world, was a tragedy to its author, and to his family." \n\n\n\nHISTORICAL \n\n\n\n21 \n\n\n\nerties of chloric ether pleased Dr. Formby, who introduced it into \nLiverpool practice. Waldie states that while he was in Scot- \nland, in October (1847), Simpson asked him regarding some \nagent that would answer his purpose, and Waldie suggested \nchloric ether, promising to prepare some on his return to Liver- \npool and send it to Simpson. He was delayed, however, and in \nthe meantime Simpson procured some in Edinburgh. \n\nAttempts to anaesthetize with chloric ether had failed. Chlo- \nroform was described as a "curious liquid" discovered almost \nsimultaneously by Guthrie, Soubeiran, and Leibig in 1831, and \nchemically described by Dumas in 1835. In March, 18^7, Flou- \nrens, the French chemist, described the effects\' of chloroform on \nanimals. Guthrie, of Brimfield, Mass., then residing at Sackett\'s \nHarbor, N. Y., obtained what is now known as chloroform, \nthough he supposed he had discovered an easy and cheap pro- \ncess of making what was known as "Dutch liquid," a preparation \nof the Dutch chemists, or ethane dichloride, which greatly* resem- \nbled the substance discovered by Guthrie. He therefore used \nthe term chloric ether in referring to the preparation which he \nhad discovered. Guthrie is said to have noticed in the American \nJournal of Science and Art a statement by a correspondent to \nthe effect that a mixture of alcohol and chloride of olefiant gas \n(then recently discovered) was an agreeable and diffusible stim- \nulant. This led to his experiments, and in May, 1831, he sent \nto Mr. Sillman, the editor of the Journal mentioned, an article \nentitled, "A Spiritous Solution of Chloric Ether," which was pub- \nlished in October, 183 1. A later and more complete account de- \nscribing his method was published in January, 1832, and is re- \nferred to by Pereira (Pharmaceutical Journal). Soubeiran\'s ac- \ncount was published in January, 1832. Leibig\'s account was \npublished in November, 1831 (Foy), or not until 1832 (Pereira). \n\nSamuel Guthrie was born in 1782, was a surgeon in the U. \nS. Army in 1812, and died in 1848, just as the fame of chloro- \nform as an anaesthetic became widespread. The recognition of \nhis position as the discoverer of chloroform is largely due to \nthe Chicago Medical Society, and recognition as such has at last \nbeen accorded him by his brethren of the Jefferson county, New \nYork, Historical Society. \n\nIn Sillman\'s Journal, of January, 1832, is related an instance \n\n\n\n22 HISTORICAL \n\nof the use of chloroform by inhalation by Prof. Ives, of Yale \nCollege. It was also used by Dr. Nathan B. Ives for asthma, \ncough, quinsy, etc. \n\nSimpson determined to try chloroform, and did so on the \nfourth of November, 1847, with the result that himself and co- \nexperimenters awoke from temporary unconsciousness to find \nthemselves upon the floor, under under the table. Simpson read \na paper before the Medico-Chirurgical Society, on November \n10th, detailing cases in which he had already used the anaesthetic \nsuccessfully, and by the 15th of November he had administered \nchloroform to about fifty individuals without any bad results. \nIn 1870, Simpson, in a letter to Dr. Jacob Bigelow, of Boston, \nstated that "the first case of an anaesthetic operation under chlo- \nroform occurred in Edinburg on the 15th of November, 1847." \nThe first operation under ether in England is said to have been \nthe extraction of some teeth by a dentist, a Mr. Robertson, of \nLondon, in 1846, at the request of Dr. Boot. \n\nSimpson regarded chloroform as "more portable, more man- \nageable and powerful, more agreeable to inhale, and less excit- \ning" than ether, and an agent giving greater "control and com- \nmand over the superinduction of the anaesthetic state." For years \nSimpson fought an earnest and persistent fight against medical \nconservatism, religious bigotry, and confused public opinion. And \nthe rapid introduction of the use of anaesthetics in Great Britian \nis largely due to his successful advocacy of its cause. In none of \nthe writings or public utterances of Simpson is there to be \nfound any acknowledgment of the credit due to Guthrie or Ives \nfor the discovery or employment of chloroform. \n\nChloroform, which at first was regarded as an anaesthetic \nwithout danger, became almost the sole anaesthetic agent in use \nin Great Britain and the Continent. In the United States ether \nheld its own as a safe and reliable agent for general surgical an- \naesthesia. Occasional deaths under chloroform and the seem- \ning inexplicable cause of these fatalities brought about a realiza- \ntion of -the dangers of chloroform as an anaesthetic, as well as a \nstate of doubt and confusion as to which agent was the better. \n\nIn 1858 Snow published a work on chloroform and other \nanaesthetics in which he claimed that chloroform fatalities are \ngenerally due to primary cardiac paralysis from the inhalation of \n\n\n\nHISTORICAL 23 \n\ntoo concentrated vapor. Though subsequent investigations tend \nto prove that there is some primary interference with respira- \ntion, the conclusions of Snow are by many regarded as correct. \n\nClover, who published an account of his chloroform inhaler \nin 1862, experimented with both chloroform and ether with the \nconclusion that ether was the safer drug. In 1864 the Royal \nMedical and Chirurgical Society appointed a committee to in- \nvestigate chloroform, which reported in favor of Snow\'s conclu- \nsions, and recommended a mixture of alcohol, chloroform and \nether which was originally proposed by Dr. Geo. Harley, and was \nknown as the A. C. E. mixture. Claude Bernard, Richardson and \nothers investigated the question, and in 1867 Richardson intro- \nduced bichloride of methylene, which as an anaesthetic had a \nshort life. The same year saw the Junker inhaler for chloroform, \nwhich proved of special value in surgery of the mouth, throat, \nand nose. \n\nAbout this time Colton, the lecturer who gave Wells his inspir- \nation regarding nitrous oxide gas, revived the interest in this gas. \nHe had formed an association in New York for performing den- \ntal work with the use of gas, and his reports stimulated the in- \nterest of dental surgeons. \xe2\x96\xa0 He visited Paris in 1867 and gave \ndemonstrations before Dr. Evans, the well known exponent there \nof modern dentistry. Dr. Evans demonstrated the use of gas \nin London in 1868, and the Odontological Society then issued a \nvery favorable report on the use of the gas about eight months \nlater. Nitrous oxide gas has since, maintained the first place as \nan anaesthetic for use in modern dental practice. Its utility in \nthis connection and also, in some respects, in general surgery, \nhas been much enhanced by the success of Dr. E. Andrews, of \nChicago, in 1868, in obtaining a non-asphyxial form of anaes- \nthesia by the combined use of oxygen and nitrous oxide gas. \n\nThe work of Clover in demonstrating the advantages of air- \nlimitation in administering ether, of the advantage of the use \nof nitrous oxide gas as a preliminary to etherization, and his im- \nproved methods of administering nitrous oxide gas, did much to \nlessen the popularity of chloroform. \n\nHeated controversies arose as to the relative merits and de- \nmerits of chloroform and ether. Investigations into the physi- \nological action and lethal manifestations of chloroform were be- \n\n\n\n24 HISTORICAL \n\ngun. The teaching of Syme and the Edinburgh school was that \nchloroform never produced primary depression of the heart. The \nreport of the "Glasgow" committee of the British Medical Asso- \nciation in 1876 stated that blood pressure and cardiac action were \ndistinctly lowered under chloroform ; that respiration generally \nceased before cardiac action, and that primary cardiac paralysis \nmight occur. \n\nTo settle this dispute the first Hyderabad commission was ap- \npointed. The funds being furnished by the Nizam of Hydera- \nbad at the suggestion of Surgeon-Major Lawrie, who upheld the \nteachings of Syme. The conclusions of the commission, after nu- \nmerous experiments,, were in accordance with the Edinburgh \nschool, and were not accepted by the profession at large. A \nsecond commission, whose report appeared in 1891, essentially \ncorroborated the conclusions of the first commission. Eminent \nphysiologists soon demonstrated errors in the technical work of \nthese commissions, and independent investigations by Wood, \nHare, Hill, MacWilliam and others go to show that the fall \nof arterial tension is largely, if not wholly, due to the effect of \nchloroform upon the heart, and that even though respiration \nceases before the heart action, the principle element in chloro- \nform syncope is the effect upon the circulation. \n\nThe report of the Committee on Anaesthetics of the British \nMedical Association, rendered in 1900, states that ether is sin- \ngularly free from danger in healthy subjects, and that in the \nlarge majority of cases of danger from chloroform the symp- \ntoms are those of primary failure of the circulation. \n\nIn the early days of anaesthesia the almost sole object was to \nprevent pain during operations, without regard to partial con- \nsciousness or physical disturbances on the part of the patient. \nLater on it became evident that total unconsciousness could read- \nily and safely be induced even if it were necessary to repeat the \nadministration of the anaesthetic. The possibility of prolonged \nand complete anaesthesia gradually came to be realized, and at \nthe present time it is possible to rapidly induce complete anaes- \nthesia and continue it for an indefinite period without any of the \nexcitement and disturbance which was formerly so familiar a \nfeature of the administration of general anaesthetics. \n\nAmong others of the many substances that have been more or \n\n\n\nHISTORICAL 25 \n\nless used for the purpose of anaesthesia since the discovery of the \npractical application of the ones already considered in the induc- \ntion of the anaesthetic state are a few that have obtained more or \nless recognition. Ethyl bromide, discovered by Serullas, in 1827, \nwas introduced as an anaesthetic by Nunneley, of Leeds, in 1849. \nEthidene dichloride, discovered by Regnault, was first used by \nSnow for anaesthetic purposes. Amylene, discovered by Balard, \nin 1844, was fi rst employed by Snow. Pental, nitrogen, ethyl \nchloride, methyl oxide, ethylene or olefiant gas, and other sub- \nstances have been employed as anaesthetics. \n\nA few years ago a method of anaesthesia was introduced \nas a substitute for general anaesthesia. It is generally known as \nBier\'s method, but should be, it is claimed, attributed to Cor- \nning, of New York. This method is by medullary cocainization \nby the sub-arachnoid injection in the lumbar region of a solu- \ntion of cocaine. Though this method is not one of complete \ngeneral anaesthesia it is of interest in this connection as a sub- \nstitute for general anaesthesia in severe operations where local an- \naesthesia through local injections is not possible. This method has \nhad considerable employment since its introduction, but it is not \nyet determined that it will retain a place as a reliable and satis- \nfactory method of anaesthesia. \n\nThose who have employed this method most agree as to its utility in \nselected subjects, and for certain operations. Certain improvements in \nthe technique appear to have increased its applicability. The most im- \nportant of these advances are the use of stovaine instead of cocaine, and \nthe addition to the anaesthetic of some suprarenal preparation. \n\nWithin the last few years there has been a distinct tendency toward the \nemployment of the sequential administration of anaesthetics, using one of \nthe short term agents for the induction of the narcosis. Thus the nitrous \noxide-ether sequence, the ethyl chloride-ether sequence, the chloroform- \nether sequence, or the somnoform-ether sequence. By this method in- \nduction is short, excitement is obviated, saturation of the system is avoid- \ned, recovery is hastened, and complications are few. It is also becoming- \nmore and more recognized that in the administration of chloroform \ntechnique that permits of the effectual use of a low percentage vapor is \nimportant because of the greatly lessened danger, and the comparative \nfreedom from after effects and complications. \n\n\n\nCHAPTER II. \n\nGENERAL PHYSIOLOGY. \n\nGeneral anaesthesia may be defined as a state of intoxication of \nthe body in which there is suspended consciousness of more or \nless rapid induction and recovery, during which the vital reflexes \nare not affected, and which, aside from the anaesthetic period, \naffects tissue life and function to the least possible extent. \n\nThere are many agents capable of producing, in one way or \nanother, an anaesthetic state more or less approximating that de- \nfined above, the principal ones of which will be considered here- \nafter. \n\nAn agent suitable for general anaesthesia must possess cer- \ntain characteristics. It must be capable of inducing general in- \nsensibility to pain, and in surgical anaesthesia it must hold in \nabeyance muscular power also. It must be possible of introduc- \ntion into the circulation without great difficulty or marked un- \npleasantness or danger to the subject. Its physiological effects \nmust not be so rapidly acquired or so intense as to interfere with \nthe control of its effects by the administrator. Its elimination \nmust be complete, and sufficiently rapid to allow of an early re- \nturn to the normal condition upon the discontinuance of the ad- \nministration. Such agents as nitrous oxide, chloroform, ether, \nand bromide of ethyl fulfill these requirements more or less com- \npletely. \n\nAs a rule the toxicity of the agent increases directly with \nthe rapidity with which anaesthesia may be induced, and accord- \ning to Magill the toxicity of the agent increases in direct ratio \nto concentration of carbon in the radical of the agent. The \naddition of oxygen to the hydrocarbon molecule while not in- \ncreasing the toxicity of the agent renders the induction of anaes- \nthesia slower. The combination of a halogen with the organic \nradical increases toxicity which multiplies directly with the num- \nber of elements of the halogen introduced into the molecule, \nand also directly with the density and weight of the halogen in \nquestion. Chloroform, by means of the hyperchlorination of its \nmolecule, is possessed of marked toxic properties which are partly \ncompensated for by its active anaesthetic powers. If bromine in \n\n\n\nGENERAL PHYSIOLOGY 2J \n\nequal number of atoms be substituted for chlorine the resulting \nbromide is possessed of greater toxicity. The halogens of great \natomic weight may increase the toxicity of the molecules so as \nto render them dangerous even in the smallest quantities. \n\nThe entrance of the anaesthetic into the organism is accom- \nplished, in those organisms possessing a circulatory system, by \nabsorption. The introduction of the agent may be effected by \nits local application to the skin. This method may be effective \nin cold blooded animals as shown by Bernard in the case of \nfrogs, because their elimination is slow. In warm blooded ani- \nmals the more rapid elimination prevents this method from be- \ning effective. The stomach\' and rectum may be used as chan- \nnels for the introduction, but for evident reasons this method is \nunreliable. The respiratory tract presents the best and most \navailable channel for the introduction of anaesthetic agents be- \ncause of the large area of the pulmonary capillary net-work of \nvessels, and the rapidity with which the blood from the lungs \nreaches that part of the organism upon which the chief effects \nof the anaesthetic are manifested, \xe2\x80\x94 the central nervous system. \n\nThe absorption of the anaesthetic from the pulmonary capil- \nlaries will depend on the tension of the agent in the air and its \nsolubility in the blood. The former will vary with the temper- \nature of the air and the barometric pressure. The absorption of \nthe anaesthetic from the air in the alveoli is governed by the phys- \nical laws which control the interchange of gases between the \nalveoli and the blood. A prominent necessary factor in this pro- \ncess is the diffusion of air in the pulmonary alveoli. This diffu- \nsion of air is increased in proportion as the tidal air may be in- \ncreased. In quiet respiration the tidal air is estimated as equal to \n500 cm., and the alveolar capacity which is equal to from 2,000 \nto 3,000 cm. after respiration, may be changed about three and \na half times between the extremes of forced inspiration and forced \nexpiration. As the effect of all anaesthetics during the initial \nperiod of inhalation is to increase the depth of respiration the in- \nfluence of the factor of diffusion of air in the alveoli as related to \nthe interchange of gases between the alveoli and the blood is in- \ncreased during this period of anaesthesia. \n\nSnow stated the proposition that, as the relation of the pro- \nportion of vapor in the air breathed is to the proportion of vapor \n\n\n\n28 GENERAL PHYSIOLOGY \n\nthe air will contain if saturated at the blood temperature, so is \nthe proportion of vapor absorbed to the proportion the blood will \ndissolve. \n\nThe amount of anaesthetic absorbed is greater when the tem- \nperature of the air inhaled is high than when it is low, and the \namount of anaesthetic necessary to produce a certain degree \nof anaesthesia is correspondingly less as is shown by the records \nof the amount of chloroform necessary to produce anaesthesia \nin hot countries. Chloroform also appears to be less dangerous \nin warm climates. A study of chloroform mortality by Thomas \nR. Evans shows that the majority of deaths occurred during the \ncold season. H. C. Wood thinks this is due to the more rapid \nelimination of chloroform in hot climates. \n\nThe fact that the quantity of chloroform necessary to induce \nanaesthesia may vary with the temperature of the inspired air is \nno indication that a greater or less amount of the anaesthetic is \nnecessary to affect the neurons. So far as the effect of an anaes- \nthetic agent on the nerve centers is concerned it depends on the \nfacility with which the agent may reach the center, and the length \nof time it may be retained there. \n\nThe pulmonary tract constitutes the chief channel for the \nelimination of anaesthetics. Elimination also takes place through \nthe glands of the gastric mucosa, and through other glands. The \ngastric elimination is in a measure the cause of vomiting, espe- \ncially of that which occurs during the early part of the recovery \nfrom anaesthetics, and the recovery is usually rapid after vomiting \nhas occurred. While it is not positively determined whether an- \naesthetics undergo any decomposition during their presence in the \nblood, elimination is more or less freely carried on by the respira- \ntory tract according to the freedom of the air tract from obstruc- \ntion, the depth and efficiency of respiration, the nature of the \nanaesthetic agent, and the method of administration. \n\nGenerally the amount of C0 2 eliminated is decreased. Rumpf \nfound a decrease of 40 per cent, in the respiratory exchanges, \nand Richet found a decrease of 50 per cent, in the elimination of \nC0 2 in chloralized dogs. Bert\'s experiments with chloroform show \na progressive diminution in O absorbed and of C0 2 given off, \nthe difference being considerably greater with the latter than with \nthe former. Lorrain Smith has shown that dyspnoea from change \n\n\n\nGENERAL PHYSIOLOGY 2Q. \n\nin the gaseous composition of the blood may be due to a deficiency \nof oxygen (O-dyspncea) and is characterized by frequent respira- \ntory movements (hyperpncea), vigorous inspirations, long dura- \ntion, severity, rise in blood pressure, and motor disturbance. \xe2\x80\x94 \nsymptoms similar to those of the initial period of anaesthesia, \nand in which they are directly related to the exclusion of O, espe- \ncially with those agents which do not induce narcosis rapidly \nenough to exclude such symptoms, such as ether or chloroform. \n\nAgain dyspnoea may be due to an excess of carbonic acid \nC0 2 -dyspncea) and be characterized by slow respiratory rate, \nlength and vigor of expiration, expiratory pause, and absence \nof motor disturbance, \xe2\x80\x94 symptoms similar to those of too deep \nor prolonged narcosis, especially in the late stages of anaesthesia. \n\nThe changes produced in the blood by anaesthetics are not \nfully understood, but generally speaking are not important. Al- \nterations in the corpuscles have been described and are said to \noccur in the pulmonary capillaries. Richet states that blood \nwhich contains an anaesthetic in solution preserves, when shaken \nwith air, its full ability for fixing oxygen. \n\nDa Costa and Kalteyer have demonstrated that the anaesthetic \nstate, the period preceding, and the period following, produces \nblood concentration. They conclude that: i. The character of \nthe change is usually a polycythaemia ; rarely, an oligocythaemia. \n\n2. The nature of this polycythaemia is best explained by a les- \nsening of the watery elements of the plasma, thereby reducing \nthe total volume of the sanguinis and causing concentration. \n\n3. The three important factors incident to the polycythaemia \nare: (a) The period of preparatory operative treatment; (b) \nthe anaesthetic state; and (c) the post-operative stage. 4. The \nblood inspissation is, as a rule, most pronounced just after the \ntermination of the anaesthetic stage. 5. The haemoglobin is \nalways reduced absolutely. Apparent increase is never parallel \nwith the rise in red blood cells. We must consider that ether- \nization produces increased haemolysis, and that in nature\'s efforts \nto rapidly replace the blood cells the regenerated cells are im- \nperfectly supplied with haemoglobin. 6. The duration of the \nanaesthetic state, and the amount of ether, influences the blood \nchanges. 7. The amount of blood loss does not seem to affect \nthe blood. 8. Whenever oossible one or more blood examina- \n\n\n\n30 GENERAL PHYSIOLOGY \n\ntions should be made before giving an anaesthetic, and before pre- \nparatory treatment is instituted. On account of the haemolysis, \nshown by the fall in corpuscular haemoglobin after operation, a \nvery low percentage of haemoglobin must be regarded as a con- \ntraindication to general anaesthesia. \n\nThe nervous system shows the first and most marked effects \nof an anaesthetic, and the most highly organized part of this \nsystem is first and chiefly affected. The other economic systems \nare usually not affected to any important extent. There is \nirritation, depression, and finally paralysis of the nervous sys- \ntem. The cerebral cortex, the cerebellum and ganglia of the \nbase, the sensory tracts and centers of the cord, the cerebro- \nspinal motor tracts and centers, and the respiratory and cardiac \ncenters seem to be affected in the order mentioned. \n\nIn the induction stage there may be analgesia without com- \nplete unconsciousness. This, according to Dastre, is due to the \nanaesthetic affecting the sensory nuclei of the cord or cerebral \nganglia before the cortical areas are involved. Other physiol- \nogists think the interruption is in the cortical areas. Analgesia \nwithout unconsciousness in the later stages of anaesthesia is rare \nbut occurs in exceptional instances. Sight is usually lost before \nhearing. \n\nThe motor system is first excited, then depressed and paraly- \nsed. The centers of complex co-ordinate movement are first \naffected, then those governing ordinary muscle movements, and \nfinally the automatic centers of respiration and circulation are \ninvolved. \n\nThe exact nature of the changes in the central nervous sys- \ntem which result in anaesthesia are not fully understood. The \nsimilarity of the symptoms to those of sleep, both in relation to \nanaesthesia and other characteristics has led to the supposition \nthat the conditions were analogous, but the intimate nature of \nboth conditions is not sufficiently understood to warrant a defi- \nnite conclusion in this respect. .Even if we accept the theory that \nsleep is not so much the result of changes, within the neurons \nfrom any agent, as the effect of change in the dentritic processes \nwhich connect the individual neurons, we are no nearer a direct \nsolution of the nature of the conditions. The effect of an anaes- \nthetic on the nerve centers is temporary, and whether the effect \n\n\n\nGENERAL PHYSIOLOGY 3 1 \n\nis due to a change in the protoplasm of the nerve cells induced \nby the anaesthetic in the blood, or whether the anaesthetic produces \nits effect by interfering with processes of oxidation which are \nnecessary to the functional integrity of the nerve, centers is im- \npossible at present to state. \n\nIn this connection, however, the phenomena attending disor- \ndered action of neurons under the influence of anaesthetic agents \nmay be better understood, and the condition of the anaesthetized \nsubject be more readily appreciated by the anaesthetizer if it be \nborne in mind that the neuronic groups undergo gradual and suc- \ncessive development in complexity, involving, in relation to func- \ntion, respectively those governing respiration and circulation, the \norganic reflexes, the special reflexes, and co-ordination \xe2\x80\x94 sensory, \nmotor, motor-sensory association, consciousness, and ideatory. \nThe structural stability of these centers is greater in the oldest \ncenters, while those neuronic groups developed last show least \nstability. \n\nNeuronic complexity or integrity is associated with high \nlecithin and fat compounds. These compounds are least stable \nin the highest neurons or those of latest development. The hydro- \ncarbon compounds (anaesthetics) displace H 2 or dissolve the fat \ncompounds, and first affect those groups which are of least sta- \nbility, i. e., those of latest development. The hydrocarbon com- \npounds are therefore anaesthetic in proportion to their ability to \naffect lecithin and fat compounds, and their effect on the neuronic \ngroups is in inverse order to the developmental stability of these \ngroups. \n\nMany years ago Bibro and Harles attempted to explain the \naction of anaesthetics on the basis of their soluble action on fats, \nand the richness of the nervous system in fat-like constituents. \nHermann arrived at similar conclusions in regard to narcosis be- \ncause of the presence of lecithin in the red blood cells, and the \naction of anaesthetics in dissolving these cells. Meyer, of Vienna, \ninstituted experiments to determine what element of truth lay in \nthese hypotheses, and recently (Oct., 1905) stated two conclu- \nsions before the Harvey Society, of New York, as follows : "The \nnarcotizing substance enters into a loose physio-chemical combi- \nnation with the vitally important lipoids of the cell, perhaps with \nthe lecithin, and in so doing changes their normal relationship to \n\n\n\n2,2 GENERAL PHYSIOLOGY \n\nthe ether cell constituents, through which an inhibition of the \nentire cell chemism results. It also becomes evident that narcosis \nimmediately disappears as soon as the loose, reversible combina- \ntion, dependent on the solution tension, breaks up. It follows \nfurther that substances chemically indifferent, as the volatile sat- \nurated hydrocarbons, can act as narcotics." From experiments \nalong similar lines Overten comes to similar conclusions with \nMeyer regarding the nature of narcosis. \n\nMoore and Roaf recently produced additional proof before \nthe Royal Society of their conclusions that anaesthetics form un- \nstable compounds or aggregates with the proteids of the tissue \ncells, and that anaesthesia is due to paralysis of the chemical ac- \ntivities of the protoplasm as a result of these combinations. These \nunstable compounds or aggregates only persist as long as the \npressure of the anaesthetic in the blood is maintained. \n\nThe effect of anaesthetics on the respiration vary exceedingly \naccording to the nature of the agent, the type of the subject, and \nthe manner of administration. There is a local irritant action on \nthe respiratory passages, more marked with some agents than \nwith others. This results in more or less obstruction to breath- \ning from spasm or swelling. As the inhalation proceeds stimu- \nlation of the respiratory centers causes quicker and deeper breath- \ning. Irregular forms of breathing may occur from too little \noxygen, as in the close administration of volatile agents, or \nfrom C0 2 dyspnoea, as in rebreathing during the administration, \nor from psychical causes. So-called "physiological apncea" may \noccur with oxygen and nitrous oxide and, at times, with other \nagents. Cheyne-Stokes breathing may be present in old people \nor in debilitated subjects under anaesthesia. Stertor is due to \nrespiratory obstruction. The term stertor is applied to the snor- \ning sounds of respiration under anaesthesia. It is generally \ncaused by vibration of the tongue against the pharyngeal wall, \nand has been termed pharyngeal stertor. Other forms of ster- \ntor described are : Nasal, buccal, palatine, laryngeal, and mu- \ncous stertor. \n\nThe muscular phenomena present under anaesthesia are \nchiefly : Nervous manifestations, conscious or sub-conscious Vol- \nuntary movements, unconscious excitement movements, tonic \nspasm, clonic spasm, co-ordinate movements under deep anaes- \nthesia, fine tremor, and reflex movements. \n\n\n\nGENERAL PHYSIOLOGY 33 \n\nReflex movements are of importance as guides to the state \nof anaesthesia. They are exaggerated during the earlier stages \nof the administration, become diminished as anaesthesia is \nreached, and during surgical anaesthesia most of the reflexes are \nlost, while during toxic conditions the reflexes are absent. The \ncorneal, laryngeal, pharyngeal, vesical, rectal, and genital re- \nflexes are maintained longest. The power of the spinal cord to \ntransmit sensory impulses is maintained late. The vaso-motor \ncenters maintain their power late. The cardiac accelerator and \ninhibitory centers are supposed to be more irritable under light \nthan deep anaesthesia, but their action may not be abolished un- \nder profound anaesthesia. The respiratory centers may remain \nactive to reflex stimulation under the most profound anaesthesia. \n\nThe heart action is stimulated and quickened during the first \nstages of anaesthesia, and the blood pressure, as a rule, is raised. \nLater the heart\'s action becomes less excitable, and varies from \nincidental influences. Under complete anaesthesia there may be \nsome degree of cardiac dilatation. In the stage of bulbar paral- \nysis the heart\'s action is feeble, irregular, imperceptible, and \nthere is paralysis of the cardiac ganglia and of the automatic \npower of the myocardium. \n\nThe more or less gradual occurrence of the effects produced \nby anaesthetics has led to describing the effects as occurring in \n\xe2\x96\xa0certain stages. Such division is more arbitrary in the case of the \nrapid agents than with the slower ones. Clinically we recog- \nnize three stages with more or less definiteness. Some observ- \ners have divided the same periods into four stages. Physiolog- \nically we must add to the three clinical stages a fourth, that of \nbulbar paralysis. The following division given by Hewitt fairly \nrepresents in a general way the sequel of events. 1st stage : Stage \n\xe2\x80\xa2of disordered consciousness and analgesia ; 2d stage : Stage of \nunconscious reflex activity ; 3d stage : Stage of surgical anaes- \nthesia or coma ; 4th stage : Stage of bulbar paralysis. \n\n\n\nCHAPTER III. \n\n\n\nTHE SELECTION OF A GENERAL ANAESTHETIC WITH REFERENCE TO \n\nTHE COMPARATIVE DANGERS OF THE AGENTS \n\nEMPLOYED. \n\nThe development and dissemination of knowledge regarding \nthe practical administration of anaesthetics has gradually abro- \ngated the bias formerly shown by various observers toward this \nor that anaesthetic, and it is now recognized that the exclusive \nemployment of one anaesthetic is unjustifiable. The minimum of \ndanger is secured by recognizing the following factors in rela- \ntion to safety : The adaptability of the agent to the individual \nto be anaesthetized; the relation of the anaesthetic to the nature \nof the operation to be performed ; the proper technique to be \nused with the agent selected with regard to the above consid- \nerations ; and the experience and skill of the administrator. \n\nWith reference purely to the comparative dangers of the agent \nemployed in routine or ordinary practice without regard to spe- \ncial conditions, we have to consider which anaesthetic is most \nfree from danger to life in an abstract way. As far as actual \ndanger to life is concerned, nitrous oxide gas is undoubtedly the \nsafest anaesthetic known. Hewitt, in a search through medical \nand dental journals covering a period of forty years, found rec- \nords of only thirty deaths, several of which were not due to the \nanaesthetic directly. Nitrous oxide and oxygen is possibly less \ndangerous even than the pure gas, though the difference is slight. \nGoldman, Gardner, and others endorse the safety of nitrous ox- \nide with or without oxygen. No fatalities are recorded with the \nlatter combination. The limitations of nitrous oxide in relation \nto general surgery, however, causes our chief interest in this con- \nnection to center in those agents more suitable for producing pro- \nlonged anaesthesia. Of these agents the decision is mainly be- \ntween ether and chloroform. \n\nWe find that in different countries, in different sections of \nthe same country, in individual cities, and in individual hospitals \nthat surgeons differ as to the choice between ether and chloro- \nform according as their experience has been greater with the \n\n\n\nTHE SELECTION OF A GENERAL ANAESTHETIC \n\n\n\n35 \n\n\n\none than with the other. In the Eastern States ether is generally \npreferred, while in the Southern States and in some of the West- \nern States chloroform is mostly used. In Germany chloroform \nwas usually employed until within the last ten years when ether \nhas been largely used owing chiefly to the influence of Gurlt\'s \nshowing. In England chloroform was for a long time the chief \nanaesthetic but of late years ether has been gaining in use. \n\nStatistics regarding the relative fatality of anaesthetics are \nunreliable because of the impossibility of excluding various con- \ntributory causes. They may be regarded as roughly indicative \nof the relative dangers of anaesthetics. Some of the leading sta- \ntistics are as follows : \n\n\n\nAnaesthetic \n\n\n\nChloroform \nEther \n\n\n\nChloroform. \nEther \n\n\n\nChloroform \n\nEther \n\nBichloride ot Methylene \nCnloroforn and Ether.. . \n\n\n\nChloroform \n\nEther and Gas and Ether. \n\n\n\nChloroform \nChloroform \n\n\n\nChloroform \nEther \n\n\n\nAdministra \ntions \n\n\n\n30.162 \n8.43 1 \n\n524.507 \n314,738 \n\n152,260 \n92,815 \n10,000 \n11,176 \n\n30,87; \n27,916 \n\n\n\n22,656 \n133,122 \n\n\n\n13.393 \n".595 \n\n\n\nDeaths Death Rate Reported by \n\n\n\n161 \n21 \n\n\n\n1-3,196 \n1-8,43 1 \n\n1-3.258 \n1-14.987 \n\n1-2,873 \n\n1,23,204 \n\n1-5,000 \n\n1-5.558 \n\n1-1,470 \n1-6,979 \n\n\n\n1-5,664 \n1-2,894 \n\n\n\n1-744 \n1-765 \n\n\n\nRichardson, of \nLondon, (\'92 ). \n\nJullard, of Ge- \nneva, (1S91). \n\nOrmsb", of \nDublin, \n(1877). \n\n\n\nSt. Bartholo- \nmew\'s Hospi- \ntal, London, \n(\xe2\x80\xa276-96). \n\nGerman Surg. \nSociety, (1890) \n\nKorte, of Ger- \nmany, (1894). \n\nBritish Med. \nAss\'n., (1900). \n\n\n\nIn India where choloform appears to be less dangerous than \nin colder countries Neve recorded 78,407 administrations with \nbut three deaths. The ratio of cases of danger to the total admin- \nistrations in the report of the British Medical Association (1900), \nwas 1.030 per cent, for chloroform, and 0.304 per cent, for ether. \n\nEther appears to be generally recognized as absolutely the \nsafest anaesthetic after nitrous oxide gas. Its stimulant effect on \nthe heart and respiration, and the fact that evident and early \nrespiratory difficulty is almost always present in case of danger, \nare strong factors in its safety. \n\nMore careful discrimination in the selection of anaesthetics \n\n\n\n36 THE SELECTION OF A GENERAL ANAESTHETIC \n\nthan was formerly employed leads to the position emphasized by \nMikulicz, that abstract safety is not now the only question, but \nthat the practical points are : In which cases shall general an- \nesthesia be substituted for local anaesthesia ; what is the safest \ngeneral anaesthetic for the individual and operation in question ? \n\nA half century\'s experience with anaesthetics has brought \nthe conviction that improper selection of the agent, and lack of \nskill and judgment in the administrator constitute a large share \nof the dangers from any anaesthetic. So far as available knowl- \nedge is to be gained from statistics it points to greater danger \nfrom chloroform than from ether. Failure of both heart and \nrespiration, without any discoverable cause, are more frequent \nunder chloroform than under ether. Chloroform in healthy indi- \nviduals may cause fatty degeneration in the heart, liver, and kid- \nneys, which may be responsible for late deaths after chloroform \nanaesthesia. Such changes are rare and slight from ether. On \nthe other hand post-anaesthetic complications, such as pneumonia, \nacute oedema, or thrombosis with or without embolism of the peri- \npheral veins of the lower extremities, are more frequent from \nether than from chloroform. \n\nThese facts are the cause of the difference of opinion on the \nrelative safety of these two agents. \n\nCbese subjects, and alcoholics take ether badly, and in these \nchloroform may be the safest and best anaesthetic. In some sub- \njects, and for long operations, and with an inexperienced admin- \nistrator, ether is generally safer. In healthy subjects presenting \nno special indications for other anaesthetics, ether is undoubtedly \nsafer than chloroform. \n\nThe importance of the method of administration, and the \nskill of the administrator in relation to the danger of any anaes- \nthetic is being more and more recognized. The greater safety of \nnitrous oxide and oxygen over the gas alone is recognized, but the \ndifference is too slight to offset the greater skill necessary to \nadminister the combined agents. \n\nThe semi-open methods of administering ether are safer than \nthe close methods, especially in the hands of inexperienced per- \nsons. \n\nIn administering chloroform the drop method is generally- \nrecognized as the safest, and most anaesthetists agree with Sippel \n\n\n\nTHE SELECTION OF A GENERAL ANAESTHETIC 7>7 \n\nthat the complicated methods of administering chloroform do not \neliminate its dangers. Individual peculiarities in regard to the \namount of chloroform necessary to produce narcosis render va- \nrious forms of apparatus more or less unsatisfactory. \n\nThe A. C. E. mixture probably should occupy an interme- \ndiate position with ether and chloroform as regards safety. There \nare special conditions in which it may be the agent of choice. The \nshort term anaesthetics, such as bromide of ethyl, under certain \nconditions may be the anaesthetic of choice both from the stand- \npoint of convenience and of safety. \n\nGenerally speaking anaesthetics present a higher danger rate \nduring the winter than during the summer months. The differ- \nence with choloroform is slight while with ether it is somewhat \nhigher than with chloroform, owing somewhat to the greater like- \nlihood of post-anaesthetic complications affecting the respiratory \norgans when ether has been the agent employed. With the other \nanaesthetics the difference between winter and summer as regards \nthe danger rate is unimportant. \n\nThere is a growing tendency within the last few years to se- \nlect one of the short term anaesthetics for short operations, or to \nemploy a sequence of agents. The following comparative sta- \ntistics are from the figures of Seitz, and of Konstanz : \n\nPental, I in 200. \n\nChloroform, 1 in 3,000. \n\nEther, 1 in 5,000. \n\nEthyl bromide, 1 in 8,000. \n\nEthyl chloride, 1 in 16,000. \n\n\n\nCHAPTER IV. \n\nTHE SELECTION OF THE ANAESTHETIC WITH REFERENCE TO THE \n\nPATIENT. \n\nThere are many considerations with reference directly to the \npatient which have an important bearing on the question of the \nbest anaesthetic to employ in individual cases. The popular belief \nthat absolutely healthy subjects are the best for anaesthetic ad- \nministration is not strictly true. If the dangers from an anaes- \nthetic were always of toxic origin then they would probably be \nstrictly related to the general physical condition of the subject. \nBut the asphyxial dangers which are intercurrent with the ad- \nministration are more frequent and pronounced in certain types \nof individuals which represent the more robust subjects. We find, \ntherefore, that persons whose general health and physical condi- \ntion is not up to the standard as a rule take anaesthetics with less \ndisturbance, and the administration presents fewer cases of dan- \nger, than is the case with more healthy subjects. Persons with \nadvanced organic disease will show an increase in the incidence \nrate of dangers and complications over healthy subjects, but the \ndifference is not so marked as has been supposed, especially when \nthe anaesthetic has been intelligently selected with reference to \nthese special conditions. \n\nSex. There is a distinct difference both in the effects and \nin the danger rate from general anaesthetics in the two sexes. \nFemales, generally, are more easily anaesthetized and exhibit a \nlower danger rate, than males, although emotional disturbances \nare more frequent in women. The difference is much less marked \nat the extremes of life than during the period of middle life, \nwhile strong and masculine women, and weak and effeminate men \nexhibit the characteristics of males and females respectively re- \ngarding anaesthetization. \n\nAnaesthetics are more commonly associated with dangers and \ncomplications in males than in females. Chloroform is said to \nbe about twice as dangerous in males as in females. Ether is \nslightly more dangerous in females than in males, and while its \ncomplications are more frequent in ma 1 \xe2\x80\xa2 they are generally \n\n\n\nTHE ANAESTHETIC AND THE PATIENT 39 \n\nslight. The A. C. E. mixture is more dangerous in males than \nin females, but the difference is less marked than with chloro- \nform. The relative dangers and complications of gas and ether \nare the same as with ether. \n\nAccording to the report of the British Medical Association \n(1900), the ratio of danger is as follows, the danger rate of gas \nand ether being taken as a unit : \n\nMALES. \n\nChloroform 7-J07 \n\nEther i .205 \n\nGas and Ether 1 . \n\nA. C. E. Mixture 2.854 \n\nFEMALES. \n\nChloroform 2.040 \n\nEther 1 . 144 \n\nGas and Ether . . 1 . \n\nA. C. E. Mixture 1.191 \n\nAge. If we take anaesthetics collectively and exclude the \nperiod of infancy, we find that the dangers increase pari passu \nas age increases. Chloroform is most dangerous during infancy \nand after thirty years of age, and least dangerous from ten to \nthirty years. Ether is less dangerous to infants than chloroform, \nand its period of greatest danger is from fifty to seventy years \nof age. \n\nAnaesthesia has been safely produced in an infant of a few \ndays, and in centenarians, but these extremes of life are dan- \ngerous periods for anaesthesia, and careful selection of agents is \nnecessary. \n\nIn infants and young children nitrous oxide gas is an unsat- \nisfactory and dangerous anaesthetic because of the liability of \nasphyxial troubles. Combined with oxygen the dangers are less. \nIn children above six years of age nitrous oxide may be valuable \nas a preliminary agent to ether as this plan obviates the stage \nof excitement usually so marked in children under ether. Chlo- \nroform is a popular anaesthetic for children because of the read- \niness with which anaesthesia may be produced, the comparative \nfreedom from excitement, and its less irritating effect on the \nupper respiratory tract. While chloroform is more readily taken \nby children and is less liable in them to cause respiratory and \n\n\n\n40 \n\n\n\nTHE ANESTHETIC AND THE PATIENT \n\n\n\ncirculatory embarrassment than ether, and should such trouble \narise remedial measures are more effective in children than in \nadults, yet chloroform is not so free from danger in children as \nhas been supposed. In infants the ready induction and tranquil \nnature of the narcosis may be misleading. Ether may be given \nto children v>ith plenty of air and will be taken much better than \nis generally supposed. It is undoubtedly safer than chloroform. \nNevertheless, if chloroform is very carefully given by the drop \nmethod, and care be exercised to withdraw the chloroform as soon \n\n\n\nDANGER RATE \n\npen cent. \n\n\nAGE PERIODS \n\n\nri - ! \n\n\n1 -5 \n\n\n5-10 \n\n\n10-15 \n\n\n15-20 \n\n\n20-30 \n\n\n30-+0 \n\n\n+0-50 \n\n\n50-60 \n\n\n60-70 \n\n\n70-80 \n\n\n80-90 \n\n\n3 \n2 6 \n\n1-5 \n\n05 \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\nA \n\n\n\n\nL_ \n\n\n\n\n\n\n\n\n\n\n\n\n\n\nA \n\n\n\n\n\n\n/\\ \n\n\n\n\nr \n\n\n\n\n\n\n\n\n\n\n\n\n/ \n\n\n/ \\ \n\n\nV \n\n\n\n\n\' \\ \n\n\n1 \n\n\n\\ \n\n\n\n\n\xe2\x96\xa0/\\ \n\n\n\n\n\n\n\n\n/ \n\n\n\n\n/ \n\n\n\n\n\n\n\n\n\n\nV \n\n\n\' \\ \n\n\n\n\n\n\n\n\n\n\ni \n\n\n\' \n\n\n/ \\ \n\n\n\\ \n\n\n\\ \n\n\n\n\n\n\n.<** \n\n-" \n\n\n\'s**\xc2\xbb \n\n\n\xe2\x96\xa0\xe2\x80\xa2\xe2\x80\xa2\xc2\xbb.\xe2\x80\x9e\xe2\x80\xa2>\xe2\x80\xa2 \n\n\n.^*-~\'~ \n\n\n\n\ni \n\n\n\n\n\n\n\\ \n\n\n\n\n\nChloroform. \n\nErher \n\nGes & Efher".. \n\n\n\nto Report of British \n\n\n\nChart showing relation of age to danger rate, according \n\nMed. Ass\'n, 1900. \n\nas struggling or crying shows signs of ceasing, there will be \ncomparatively little danger in the use of chloroform in children. \n\nSome anaesthetists prefer chloroform, some ether, some the \nA. C. E. mixture, and some the chloroform-ether, or A. C. E.- \nether sequence, for children. It is generally conceded that ether \nis safer in children than chloroform, though it is not so easy of \nadministration. \n\nOld people take anaesthetics better, comparatively, than per- \nsons in middle life. They are less subject to muscular spasm, \nhave fewer respiratory difficulties, and require less of the anaes- \nthetic. In the absence of senile lesions of the heart and obstruc- \ntive conditions of the lungs they take ether well. The A. C. E.- \n\n\n\nTHE ANESTHETIC AND THE PATIENT 4I \n\nether sequence is recommended as being better than the nitrous \noxide-ether sequence. Nitrous oxide is not as safe in elderly \npeople as in middle life, and in senile subjects should be given \nwith oxygen. Chloroform is a satisfactory anaesthetic as far \nas facility of induction is concerned. It is not relatively as dan- \ngerous as in children if organic disease be not advanced. Some \nanaesthetists use chloroform or A. C. E. mixture as routine agents \nin persons over 60 years old, just as others the A. C. E. mixture \nin children under 10 years. The chart (Page 40) shows the re- \nlation of age to the danger rate. \n\nGeneral condition. Persons of a highly excitable tempera- \nment, and nervous, irritable people are generally troublesome to \nanaesthetize. Muscular phenomena are more apt to be manifested \nthan in subjects of more equable temperament. It may be im- \npossible to completely abolish the reflexes in excitable subjects, \nand may be dangerous to attempt to carry the narcosis far \nenough to do so. In hysterical subjects the corneal reflex may \nbe absent even though anaesthesia be not fully induced. \n\nNitrous oxide is a good agent in excitable subjects provided \nthe narcosis is long enough to answer the purpose, or the nitrous \noxide-ether sequence may be used with benefit. \n\nThe A. C. E. mixture is often very satisfactory in neurotic \nsubjects. The so-called interrupted ether narcosis is also a very \nsatisfactory method. The administration is simply interrupted \nwith sufficient frequency and regularity so as not to abolish com- \npletely the reflexes. This is sometimes confused with the use of \nmorphia or with local anaesthesia. \n\nAncemic, debilitated, or cachectic subjects usually require \nless anaesthetic than robust subjects. All anaesthetics should be \ngiven without much limitation of air to these patients. Nitrous \noxide with oxygen, interrupted ether narcosis, A. C. E. -ether, or \nchloroform-ether sequence may be used. Profound anaesthesia \nshould be avoided. \n\nVigorous, healthy and plethoric subjects require more anaes- \nthetic, exhibit more muscular and general excitement, and rel- \natively sustain a higher danger rate than less healthy subjects. \nFlorid subjects require considerable anaesthetic and should be \nkept deeply anaesthetized to prevent reflex disturbances. The \n\n\n\n4 2 THE\' ANAESTHETIC AND THE PATIENT \n\namount of air must be limited, and with nitrous oxide it may be \nnecessary to induce a marked degree of cyanosis. \n\nObese subjects do not tolerate well any method of administra- \ntion admitting of but little air. The A. C. E. mixture or chloro- \nform is therefore best tolerated, though in some instances the \nchloroform-ether sequence is most satisfactory. \n\nAlcoholic subjects usually require a large amount of anaes- \nthetic. The stage of excitement is prolonged, muscular and re- \nflex movements are marked and persistent, and muscular relax- \nation may not be complete. Nitrous oxide and oxygen is not \nsatisfactory, and even with the pure gas it may be impossible to \nsecure complete anaesthesia. If chloroform be used care must \nbe exercised during the stage of muscular rigidity and excite- \nment. The A. C. E.-ether sequence is often advantageous in these \nsubjects.* \n\nDrug habitues are generally more sensitive to the action of \nanaesthetics, and if the administration should closely follow the \nuse of some drug, especially morphine, great care should be ex- \nercised. \n\nTobacco users may take anaesthetics badly, both because of \nirritable conditions of the upper air passages, and because of the \ndegree of muscular spasm, especially of the muscles of the jaws, \nand obstructive breathing likely to ensue in excessive users of \ntobacco. \n\nMenstruation. While it is customary not to administer anaes- \nthetics during menstruation, owing to a possible disturbing effect \nupon this function, there is no special objection to so doing if \noccasion requires, and the presence of the menstrual flow has \nno bearing on the selection of an anaesthetic. \n\nPregnancy. The pregnant state presents no special contrain- \ndication to the administration of an anaesthetic, at least in the ear- \nlier months. Nitrous oxide should not be given after the fifth \nmonth. Abortion has followed its use in women not five months \npregnant. If used at all it is best in combination with oxygen. \nIn the late months of pregnancy we may use chloroform, the \nA. C. E. mixture, or the A. C. E.-ether sequence. Care should be \nexercised in preparing the patient in order to prevent after-vom- \niting. \n\n*McCardie recommends a few days\' rest in bed before operation for \nalcoholic subjects, Vi grain of morphine the night before operation, and, \nif chloroform is to be used, an injection of morphine and atropine twenty \nminutes before the operation begins. \n\n\n\nTHE ANESTHETIC AND THE PATIENT 43 \n\nLactation presents no contraindication to general anaesthesia, \nand no special indications for particular agents. \n\nFrequent anesthetization may develop a lack of sensitiveness \nto anaesthetics, and such subjects may grow progressively harder \nto anaesthetize. They are likely to exhibit marked signs of irri- \ntability such as vomiting, swallowing, coughing, and obstructive \nbreathing. \n\nPathologic conditions. The lymphatic diathesis, a condi- \ntion characterized by enlarged tonsils, lymph follicles and glands, \nof the follicles at the base of the tongue, of the spleen, of the \nthymus gland, probably of the heart from dilatation, and asso- \nciated or not with tubercular glandular enlargement, also with \nnaso-pharyngeal growths, is a condition liable to be associated \nwith sudden, dangerous syncope or with death under chloroform. \nIn this condition ether is safer and otherwise probably more sat- \nisfactory. The nitrous oxide-ether sequence may be used. \n\nCondition of the blood. Hamilton Fish says that safety in \nanaesthesia, and operative procedures, is dependent first on a \nhaemoglobin percentage over and above that required for its nor- \nmal duties ; and a normal or increased number of polynuclear \nneutrophiles. He states that in individuals whose blood presents \na haemaglobin percentage of 50 or less, the anaesthetic vapor \nproduces an increased pathological condition by forced abstrac- \ntion of oxygen from the tissues ill-conditioned to part with it. \nMikulicz does not operate when the haemoglobin percentage is \nunder 30 per cent. Da Costa and Kalteyer think operation dan- \ngerous with a percentage of haemoglobin below fifty per cent. \n\nMorbid growths of the mouth, tongue, palate, tonsils, phar- \nynx, or epiglottis are liable to cause trouble from muscu- \nlar enlargement under close methods of administration. Nitrous \noxide and oxygen is therefore much safer than the pure gas. \nThe nitrous oxide-ether sequence may be used. In some in- \nstances chloroform is the best agent if carefully administered. \n\nIn laryngeal diseases and chronic stenosis of the upper air \ntract chloroform, according to Semon, is preferable as ether in- \ncreases the dyspnoea and liability to pulmonary complications. \nHewitt thinks chloroform the only admissable anaesthetic in such \ncases, and that the depth of anaesthesia should be in inverse ra- \ntio to the degree of obstruction. Light degrees of obstruction \n\n\n\n44 THE ANAESTHETIC AND THE PATIENT \n\ndo not interfere with the administration, but marked degrees of \nobstruction render anaesthesia dangerous, the work of respiration \ndepending on muscles which are incapable of overcoming the \nresistance to breathing. Respiratory arrest may occur even \nthough the corneal reflex be present. In paralysis of the ab- \nductors of the vocal cords it may be necessary to keep the chin \npulled forcibly away from the sternum in order to prevent ob- \nstruction from approximation of the vocal cords. The question \nof tracheotomy and the administration of chloroform through \nthe tube should be considered in all cases of stenosis of the \nupper air passages from disease or pressure. \n\nDiseases of the bronchi, kings, or plenrce, do not, as a rule, \nafford such direct indications as is given by the nature and length \nof the proposed operation. Patients with affections of the respir- \natory tract do not show as great a tendency to reflex manifes- \ntations as do other subjects, and the difficulties attending anes- \nthetization in chronic cases are relatively not so great as in acute \ncases because the lungs accommodate themselves to the altered \nconditions. If the operation is short, nitrous oxide and oxygen \nmay be used, though as with all anaesthetics profound anaesthe- \nsia should be avoided. Ether may be used in comparatively short \noperations, and if cyanosis and expiratory difficulty arises the \nether may be changed to chloroform or the A. C. E. mixture. In \nshort operations chloroform or the A. C. E. mixture are probably \nbest. In recent inflammatory states, especially if the heart is \nnot as good as could be wished, the A. C. E. -ether sequence is \nto be recommended. In acute lung troubles Silk prefers chlo- \nroform, while in those not in the acute stage he prefers the \nA. C. E. mixture, subsequently increasing the percentage of ether. \nPatients with chronic pleurisy, fibroid phthisis, or emphysema \nusually take ether well. The report of the British Medical As- \nsociation (1900), calls attention to the comparative freedom from \ndanger in the lung cases, especially those of phthisis. Cases of \nacute or chronic bronchitis, or acute tuberculosis with marked \ncatarrhal conditions are safer from after-complications if chlo- \nroform be used. \n\nDiseases of the heart and blood vessels. Variations in the \npulse rate do not, as a rule, modify the danger rate from anaes- \nthetics, providing the pulse is strong and full. Cases with a \n\n\n\nTHE ANESTHETIC AND THE PATIENT 45 \n\npulse rate as low as 25 per minute have been successfully anaes- \nthetized. The pulse usually becomes more rapid. A pulse above \n100 per minute usually slows under anaesthesia, unless the rate \nbe due to shock or exhaustion, when it will rise in rate under \nthe anaesthetic. An irregular pulse may become rhythmical under \nanaesthesia, and in any event usually improves in its rhythm. \nAllorrhythmia may be sustained or may disappear under anaes- \nthesia. \n\nFunctional disturbances of the heart do not affect, to any \nappreciable extent, the danger rate of anaesthetics. Valvular af- \nfections do not, as a rule, affect the danger rate only in so far \nas they modify the dynamic integrity of the heart muscle. The \ncondition of the myocardium is the vital question, and the only \ndirect relation to the danger rate which a specific valvular affec- \ntion may have is through its tendency to develop myocardial ina- \nbility. According to H. C. Wood, "The key to the situation is not \nthe valvular lesion, but the condition of the muscle, and ether is \nthe anaesthetic of choice." Finney says, "In the myocardial affec- \ntions only do anaesthetics exert any marked bad effect. In the \nvalvular diseases their influence is very slight, but yet appreci- \nable. In the functional disturbances they are insignificant." If \ncompensation is good there is no great liability to danger. \nMarked degrees of mitral or pulmonary stenosis, and of aortic \nregurgitation not fully compensated for, are probably most often \nassociated with danger. Danger will also be present in direct \nratio to excess of dilatation. The great difficulty is to judge \naccurately as to the condition of the heart muscle. This is at \ntimes most difficult to do, as it is possible for degeneration to be \npresent to a serious extent without definite physical alteration \nin the heart. On the other hand if compensation be good the \neffect of any anaesthetic will often be to improve the circulation, \neven though marked physical alterations have taken place in the \nheart. \n\nEther is generally considered the safest anaesthetic in heart \ndisease. Nitrous oxide and oxygen is recommended by some, \nbut it is doubtful if nitrous oxide in any form should be em- \nployed in cases of myocardial disease. Hewitt recommends A. \nC. E. mixture and the A. C. E.-ether sequence. Chloroform is gen- \nerally condemned, though if properly administered by the drop \n\n\n\n40 THE ANAESTHETIC AND THE PATIENT \n\nmethod it is not as dangerous in cardiac disease as is generally \nsupposed. I have administered chloroform to subjects in whom \nthere was every reason to expect trouble, so far, at least, as pre- \nvious knowledge of the condition of the heart muscle would in- \ndicate, and yet have had no serious trouble. Wood thinks the \nshock from a severe surgical operation would be more fatal to \na fatty heart than the effect of a general anaesthetic. This is \nundoubtedly true, for many patients with advanced fatty or other \ndegeneration of the heart muscle have been anaesthetized without \nuntoward symptoms. Chronic interstitial or granular degenera- \ntion of the heart muscle, resulting from vascular degenera- \ntion, are probably the most dangerous cardiac conditions as re- \nlated to general anaesthesia, aside from recent dilatation or the \nadvanced stages of the hyposystolic period of chronic cardio- \npathies. All methods of administration should be cautiously con- \nducted and plenty of air admitted. \n\nChronic vascular disease of sclerotic or atheromatous nature \nwith high arterial tension is probably more dangerous under \nether than under chloroform or A. C. E. mixture ; as these condi- \ntions occur late in life there is not so great a tendency to re- \nflex disturbances under chloroform and this agent is correspond- \ningly safer. In markedly atheromatous subjects there may be \nslightly increased danger from cerebral haemorrhage, which Hew- \nitt thinks is lessened by using A. C. E. mixture or chloroform in \npreference to ether. Ether is strongly contraindicated in sub- \njects who have suffered previous attacks of apoplexy. Care must \nbe exercised to prevent straining, coughing, or struggling by pro- \nceeding slowly with the anaesthetic, especially in cases of aneurism. \nIn intrathoracic aneurism chloroform should always be used in \npreference to ether. \n\nPatients with venous thrombus should not be moved more \nthan can be helped. Struggling and excitement must be avoided. \nChloroform, A. C. E. mixture, or A. C. E.-ether sequence are in- \ndicated. \n\nAbdominal conditions such as peritonitis, intestinal obstruc- \ntion, ascites, ovarian cysts, etc., may mechanically alter the type \nof respiration to the thoracic type. Anaesthetics must be carefully \ngiven. Chloroform, A. C. E. mixture or the chloroform-ether, \nor A. C. E.-ether sequence may be used, the change being made as \n\n\n\nTHE ANAESTHETIC AND THE PATIENT \\*J \n\nthe abdominal tension is relieved, light anaesthesia being em- \nployed before this. Patients with marked acute intestinal ob- \nstruction are bad subjects for anaesthetics. The stomach is fre- \nquently not empty, they are often under the influence of stimu- \nlants or morphine, they vomit readily, and syncope and collapse \nare frequent. Nitrous oxide is not admissable, chloroform, or \nA. C. E. mixture are preferable. Ether, or A. C. E. -ether se- \nquence may be admitted with whichever agent is employed. \n\nExhaustion, shock, and collapse are frequently present when \nthe necessity for anesthetization arises. As a rule such patients \nrequire small amounts of anaesthetic, especially when there is \nexhaustion from chronic disease. The pulse is generally im- \nproved by the anaesthetic, but marked depression may follow \nits withdrawal. Ether, cautiously given, by an open inhaler, is \nsatisfactory, or chloroform by the drop method may be used. In \nshock and collapse the increase in the danger rate is somewhat \ngreater than with exhaustion alone. This increase seems to \napply somewhat more to chloroform than to ether, and the lat- \nter agent either alone or preceded by chloroform or A. C. E. mix- \nture is most generally used. McCardie thinks that ether is \nstrongly indicated in shock or collapse. \n\nKidney disease has long been supposed to contraindicate the \nadministration of ether. Opinion is much divided on this point, \nthough prolonged etherization is generally discouraged. Wood \nsays that Thomas A. Emmet was first to report cases of anuria \nfollowing ether narcosis in individuals suffering from chronic \nBright\'s disease, but we know that chloroform may have the \nsame effect. He* thinks both are contraindicated in advanced \nnephritis, but prefers ether if anaesthesia be necessary. Many \nobservations on the effect of these drugs on the kidneys show \nthat albumen and casts are found in about 25 per cent, of the \ncases. The percentage is slightly higher after ether but the \nchanges from chloroform appear to be more profound. Some \nauthorities think that ether is contraindicated in kidney disease, \nsome prefer the A. C. E. mixture. Kemp thinks that about 5 per \ncent, of ether cases are fatal from renal complications. On the \nother hand Buxton and Levy are not satisfied that ether exerts \nunfavorable effects on the kidneys when properly administered. \n\n\n\n4^ THE ANAESTHETIC AND THE PATIENT \n\nOpinion and statistics vary so greatly on this point that a definite \nconclusion cannot at present be stated. \n\nAccording to Thompson\'s experiments the volume of urine \nis diminished during- ether narcosis in the majority of instances. \nThe depressing effect is more marked than with chloroform, and \narrest of secretion occurs more readily. The after effect of ether \nis similar to chloroform but less marked, and the freest secretion \noccurs about three hours after stopping the anaesthetic. The ef- \nfect of chloroform upon the output of nitrogen does not so close- \nly correspond to its influence en the secretion as is the case with \nether, the latter increasing the amount of nitrogen with a dimin- \nished flow. The escape of leucocytes into the urine, and the ex- \ncretion of chlorides is increased with ether, but the latter is of \nshorter duration than with chloroform. \n\nFull narcosis with the A. C. E. mixture diminishes the urine, \nbut less so than with ether or chloroform. The excretion of ni- \ntrogen is not so much lessened as the volume of urine. The \nchlorides are increased more than with ether, but less so than \nwith chloroform. The effect of the mixture closely resembles \nthat of ether. \n\nStatus Thy miens. The post mortem examination some years \nago, in Vienna, of subjects dying suddenly under chloroform, and \nwithout apparent cause, determined the presence of a certain \npathologic complex which was termed the "lymphatic diathesis, \nor status thymicus." This condition is present most often in chil- \ndren or voung people, and according to Kolisko is characterized \nby: \n\n1. Persistent or enlarged thymus gland. \n\n2. Enlarged lymph glands, general or local. \n\n3. Adenoid growths in the naso-pharynx, enlarged tonsils, \nenlarged lymph structures at the base of the tongue, enlarged \nfollicles in the stomach and intestines. \n\n4. Acute cardiac dilatation \xe2\x80\x94 narrow aorta. \n\n5. Often an enlarged thyroid and spleen. \n\nAccording to McCardie the lymphatic diathesis is often asso- \nciated with tuberculous manifestations. Halsted remarks that \nsuch patients "generally show the constitutional and local results \nof nasal obstruction. Many of them are of the flabby type, and \nall have weak hearts, poor blood, impaired lungs, and resist shock \nand disease much less strono-lv than do others." \n\n\n\nTHE ANAESTHETIC AXD THE PATIENT 49 \n\nCompetent observers have shown that the status lymphaticus \nis a pathological entity, and according to Elake it is characterized \nclinically by lowered vitality, or unstable equilibrium of vital \nforce, and accidents or disturbances otherwise unimportant, such \nas slight injury or anaesthesia, may precipitate failure of the heart \nand respiration. \n\nWhile there have been instances of death under ether anaes- \nthesia in subjects of this diathesis, the greater number of deaths \nhave been under chloroform. Ether is therefore regarded as the \nbest agent for these subjects, and if chloroform is to be employed \nit should only be after the use of preliminary stimulant treat- \nment. \n\nDiabetes. The unqualified statement is often made that dia- \nbetics take anaesthetics well, but the experience of most observers \nagree with the statements of Pavy, that in diabetics who are in \ngood condition with little or no sugar in the urine, the adminis- \ntration of anaesthetics is attended with no special risk, but in \nthose who show large amounts of sugar the administration of \nanaesthetics especially for protracted operations is liable to be fol- \nlowed by diabetic coma. The patient, therefore, should have \ncareful preliminary treatment; the anaesthetic should be chosen \nwith a view to avoiding excitement, after-vomiting and compli- \ncations ; the administration should be made as short as possible. \nEastes says that diabetics take ether and chloroform well. Prob- \nably the latter or the A. C. E. mixture is safest for these patients. \n\nNervous diseases. Subjects with cerebral abscess, tumor, \nintracranial haemorrhage, depressed fractures, etc., or who are \ntoxic from various causes, may be sufficiently comatose that very \nlittle if any anaesthetic will be necessary. Hewitt calls attention \nto the fact that patients with tumor may show a tendency to \nrespiratory failure due to increased intracranial tension, and in \nthem even slight anaesthesia may entirely suspend respiration. \n\nRespiratory disturbances are liable to occur in subjects of \nchronic nervous disease. Epileptic subjects may be safely anaes- \nthetized. There may be a tendency to muscular spasm, or epi- \nleptic paroxysm may occur during the early part of the adminis- \ntration. Ether is probably the best agent generally for patients \nwith nervous disease. \n\nAccording to Savage, the insane take anaesthetics well, and \ntake the various anaesthetics with equal safety. Chloroform pro- \nduces marked after-effects in maniacal subjects, severe maniacal \nattacks being not uncommon. \n\n\n\nCHAPTER V. \n\nTHE SELECTION OF AN ANAESTHETIC WITH REFERENCE TO THE \n\nOPERATION. \n\nThe bearing of the operation to be performed on the selection \nof the anesthetic is chiefly through the facts that certain anaes- \nthetics are better adapted to the performance of certain opera- \ntions than are others ; that more profound anesthesia is necessary \nfor some surgical procedures than for others ; that certain opera- \ntive measures affect the respiration and circulation more than \nothers ; and that in certain postures some anesthetics are more \nlikely to cause respiratory or circulatory disturbances during \noperative proceedings than are others. \n\nRespiration, which is usually deeper and quicker under an- \naesthesia, may become obstructed from surgical manipulations in \noperations about the air passages, or from the effect of the stim- \nulation of operative measures on other portions of the body. \n\nThe circulation may become depressed (surgical shock) from \nhaemorrhage, prolonged surgical measures, or from reflex inhi- \nbition from the surgical proceeding, as in skin incisions, etc., \nduring light anesthesia, especially with chloroform. Hewitt be- \nlieves that surgical shock from reflex causes also occurs with \nprofound anesthesia, and that such a degree of narcosis does \nnot protect against shock. He favors the view that ether is \nmore protective than chloroform against reflex inhibition of the \ncirculation. \n\nIn patients in a condition of shock or collapse ether is gen- \nerally preferred as being more stimulating to the respiration and \ncirculation than other agents. \n\nShort operations may be performed under the short-term an- \nesthetics, as nitrous oxide, pure or with oxygen, ethyl chloride, \netc. Prolonged operations, especially abdominal operations \nshould be performed under ether or chloroform. \n\nFor operations where complete muscular relaxation is neces- \nsary ether is most reliable, though at times it may be necessary to \nfollow with chloroform in order to secure relaxation. \n\nBrain and spinal cord. Chloroform is generally preferred. In \nspina bifida in infants ether is preferred by some. \n\n\n\nTHE ANESTHETIC AND THE OPERATION ej \n\nOphthalmic operations. Chloroform is preferred by many. \nThe high death rate from chloroform in ophthalmic practice is \npartly due to the position of the head which favors obstruction \nto breathing, from mucus, saliva, retracted tongue, etc., also to \nthe difficulty of maintaining an even degree of narcosis. Ether \nis preferred by some, especially in strabismus operations in chil- \ndren. The A. C. E. mixture, chloroform, or these in sequence \nwith ether, may be advisable. For enucleation of the eye-ball the \npatient\'s general condition will determine the anaesthetic. When \nin elderly people, ether is safest. McCardie recommends gas \nand oxygen in squint operations in subjects above ten years, \nenough oxygen being given to obviate congestion. \n\nOperations on the face, jazvs, lips, tongue, palate, tonsils, \nnose, and naso-pharynx. If these operations are short, not ex- \nceeding 30 or 40 seconds, the short-term anaesthetics, such as \nnitrous oxide, or ethyl chloride, may be used. If a little longer \nanaesthesia is necessary nitrous oxide and oxygen may be used. \nIf an available period of from 1 to 5 or 10 minutes is desired \na single administration of ether, possibly preceded by chloro- \nform or A. C. E. mixture, will often answer. If longer anaesthesia \nthan this is necessary the ether-chloroform sequence recommended \nby Hewitt, White, and others, is useful. The former recom- \nmends deep anaesthesia by ether, suspension until slight con- \njunctival reflex, swallowing, or cough, appears, control these by \ncautiously giving chloroform, begin operation as reflexes dis- \nappear. Keep up a moderately deep anaesthesia. Many oper- \nators prefer chloroform alone. * \n\nIn those cases where the anaesthetic is best administered \nthrough a mouth or nose tube chloroform may be given from \nsome inhaler, such as the Junker, to which a tube is attached \nand passed through the nose into the pharynx, or it may be \npassed into the side of the mouth, or a gag with a tube attach- \nment may be used {vide Fig. 1). \n\nIn operations upon the palate and throat some object to \nether because of the greater vascularity under its influence. How- \nard claims that ether does not increase haemorrhage in throat \noperations. In stenotic conditions of the air passages ether is \nnot admissable because of obstructive congestion. Chloroform \nshould be used. For adenoid growths some prefer chloroform \n\n*Rockey, of Oregon, describes an ingenious device extemporized for \nuse in resecting the jaw. The mouth tube was an ovarian trocar, the \ninhaler a Politzer air bag with the top cut off and gauze fastened over it. \nTwo thumb holes in the sides sufficed for controlling the air. With the \ntube in the throat, the tongue held well forward, and the mouth packed \nwith gauze, the instrument answered perfectly. Chloroform or any volatile \nagent may be sprinkled on the gauze. \n\n\n\nr 2 TJiE ANAESTHETIC AND THE OPERATION \n\n(Semon), or the A. C. E. -ether sequence (McCardie), or nitrous \noxide, gas-ether, chloroform, A. C. E., or ether for quick opera- \ntions, and nitrous oxide-ether, or, in children under 4 or 5 years, \nchloroform for longer operations (Hewitt). \n\nFor tonsillotomy, gas-ether or chloroform-ether sequence may \nbe given in the dorsal position and the patient propped up for \noperation. \n\nFor the extraction of teeth. Nitrous oxide is the recognized \nanaesthetic. It may be used with or without oxygen as circum- \nstances dictate. If a longer available period is desired than usu- \nally is the case, one of the methods of prolonging nitrous oxide \n\n\n\n\nFig. 1.\xe2\x80\x94 Hewitt\'s Modification of Mason\'s gag. \n\nFig. 1. Bent metal tubes are brazed to the arms of an ordinary Mason\'s \ngag. To one of these tubes the tubing from a Junker\'s inhaler is attached. \nThe chloroform is thus transmitted along the tube to the back of the \nthroat. The gag should be adjusted far back in the mouth. \n\nanaesthesia may be used, as described under the administration \nof the gas. If the operation is a prolonged one the nitrous oxide- \nether sequence is probably the best. Chloroform should not be \nused unless in some exceptional cases. \n\nOperations on the larynx and trachea. Chloroform is gen- \nerally the best anaesthetic. Some prefer the A. C. E. -ether-chloro- \nform sequence. In excision of the larynx, thyrotomy, etc., a \npreliminary tracheotomy will probably be performed, and the \nanaesthetic (chloroform) should be administered from some such \napparatus as the Junker inhaler by means of a tube passed into \nthe tracheotomy tube a short distance. If the Trendelenberg air \nball around the tracheotomy tube is employed (vide Fig. 2) \nthere will be no trouble from the entrance of blood into the \ntrachea during the chief operation. \n\nChloroform alone should be used for intra-laryngeal opera- \n\n\n\nTHE ANESTHETIC AND THE OPERATION 53 \n\ntions in children when done under general anaesthesia. The pre- \nvious local use of a dilute solution of cocaine will diminish bleed- \ning, salivation, and obviate the necessity of profound anaesthesia. \n\nTracheotomy and laryngotomy should be done under chloro- \nform alone if there is any difficulty of breathing. If there is \nnot difficulty of breathing the A. C. E.-ether, or nitrous oxide- \nether sequence may precede the chloroform if desirable, \n\nOperations on the neck exclusive of the air tract. These oper- \nations are likely to be prolonged, and important vessels and \nnerves are disturbed. Surgical shock is likely to be manifested. \nAs deep anaesthesia as is compatible with safety should be main- \ntained, as coughing, straining, etc., increases the vascularity and \ninterferes with the operator. Ether increases the vascularity \n\n\n\nFig. 2.\xe2\x80\x94 Trendelenburg\'s Trachea Tampon, Canula, and Inhaler. \n\nFig. 2. A trachea canula, the distal end of which is covered for about \nhalf an inch with a rubber sheath or bag surrounding the tube. The space \nbetween the sheath and canula is rendered air-tight and connected by a \nslender tube with a rubber air-forcing bulb. \n\nBy this means the bag may be inflated and as it is circular, and the tube \nin the center, it may completely fill the space between the canula and the \ntracheal walls, thus preventing a flow of blood below the tube. To the \ntube opening an inhaling apparatus is attached when desired, to facili- \ntate the administration of an anaesthetic. \n\nduring the earlier part of the operation, but if given with plenty \nof air the effects, in this respect, are not markedly different from \nthose of chloroform. Dyspnoea may be present in thyroid en- \nlargement and be due to pressure. If pressure is marked chlo- \nroform should be used, and light anaesthesia maintained, as pres- \nsure atrophy of the cartilages may have occurred and complete \nabolition of muscular tone may cause kinking or displacement \n\n\n\n54 THE ANESTHETIC AND THE OPERATION \n\nof the trachea. In the worst cases local anaesthesia should be used, \nor a previous injection of morphine followed by light chloro- \nform anaesthesia. In dissecting operations for diseased glands \ngas and ether may be used at first and a change made to chloro- \nform as the operation begins. Some operators prefer chloro- \nform for all operations upon the thyroid gland. \n\nOperations upon the chest. The anaesthetic for these opera- \ntions will depend on the condition of the patient. Chloroform \nis most convenient for the operator, but in many cases ether is \npreferable. The greater the interference with respiration the \nlighter should be the anaesthesia. \n\nIn chronic empyema the opposite lung has had time to adapt \nitself to the changed conditions, and the A. C. E.-ether-chloroform \nsequence may be used. In acute cases light anaesthesia under \nchloroform or one of its mixtures should be used. If the posi- \ntion will allow, gas and oxygen may be used in some cases. A \nfull hypodermic dose of strychnia should be used previous to \nthe administration in these cases. \n\nOperations on the brain. The patient\'s general condition will \ndetermine the anaesthetic to be used. Ether is adapted to com- \nparatively young subjects. There is less liability to secondary \nhaemorrhage after ether than after chloroform. For elderly \npeople, or very fat subjects, chloroform or the A. C. E. mixture \nmay be best. The chloroform-ether sequence may be used in \npatients in fairly good condition. Some prefer the gas-ether- \nchloroform, or the ether-chloroform sequence. Because of the \ncondition of many of these patients anaesthesia should be con- \nducted with care. With marked coma very little anaesthetic may \nbe necessary. \n\nAbdominal operations. These operations are generally more \nor less serious. The patient\'s condition is likely to be unfav- \norable ; unpleasant effects during operation may interfere mark- \nedly with the surgical manipulations, and after-effects are likely \nto occur. Profound anaesthesia, as a rule, is necessary. Shock- \nis likely to result from operations on the organs in the upper \nportion of the abdominal cavity from traction on their attach- \nments or from manipulation of the peritoneum. Shock is also \nlikely to follow manipulation of the intestines in intestinal or \nhernia operations. In these cases there are advantages in the \n\n\n\nTHE ANAESTHETIC AND THE OPERATION 55 \n\nstimulant qualities of ether. Surgeons differ much as to the rel- \native value of ether and chloroform in abdominal operations. \nEther has, in some quarters, been counted out of abdominal op- \nerations because of the venous engorgement and the labored \nbreathing it causes. The advantage of its stimulant action is \nsupplemented by the safety of pushing it to the full abolition of \ninconvenient reflexes. The supposed tendency of ether to favor \nlung complications, which are very troublesome in patients with \nabdominal wounds, is probably offset by the Trendelenburg posi- \ntion so common now with most operators. This position also \nlessens venous congestion and interference with operative meas- \nures by the character of the breathing. \n\nEther or A. C. E. mixture are probably safest as routine agents, \nchloroform, or the gas-ether-chloroform sequence is satisfactory \nin the hands of experienced administrators. The A. C. E. mixture \nis good for children, elderly people, or those whose general con- \ndition is unsatisfactory. The ether-chloroform sequence is pre- \nferred by some if the operation is to prove a long one. In cases \nwith great abdominal distention great care is necessary. The pa- \ntient will usually be in the semi-recumbent position and unable to \nlie down. The A. C. E. mixture is recommended as being adapted \nto these cases. In intestinal obstruction anaesthesia may be dan- \ngerous if regurgitative vomiting should occur. The A. C. E. mix- \nture with very light anaesthesia may be used. In some cases \nlocal anaesthesia may be safest, especially if the stomach is full \nof fluid and cannot be emptied by artificial means. \n\nOperations on the rectum and ge nit o -urinary tract. These \noperations usually demand a deep narcosis because of the sen- \nsitive condition of the parts and the nervous state of the patients. \nOperation should not be begun until profound anaesthesia has \nbeen induced. Ether is generally best because of the stimula- \ntion against shock and because of the thorough relaxation under \nits use. Ether is best for circumcision in weak children be- \ncause of the shock of the operation. In operations on the bladder \nwhere distention is necessary the active breathing induced by \nether may render it inadmissable, and chloroform or A. C. E. \nmixture advisable. In rectal surgery ether is much the safest \nagent because of the shock. The weak, nervous subject is most \n\n\n\nc5 THE ANAESTHETIC AND THE OPERATION \n\nlikely to show bad effects at the time of the operation or after- \nward. \n\nIn operations on the kidney ether is preferable to chloroform \nif the organs are healthy, because of the shock. When the kid- \nneys are diseased the A. C. E. mixture or chloroform is recom- \nmended by many observers. The nitrous oxide-ether-chloroform \nsequence is recommended by McCardie when the kidneys are fairly \nhealthy, and chloroform, or any of its mixtures, if the kidneys \nare seriously affected. \n\nGynecological operations. Women take anaesthetics better \nthan men, and particularly chloroform, therefore its mixtures are \nadapted to these operations. Ether may be used in strong sub- \njects w T ith advantage. The chloroform-ether sequence is satisfac- \ntory. \n\nObstetric operations and parturition. Chloroform is the most \ngenerally used anaesthetic in this connection. Women under these \ncircumstances bear chloroform so well that there is a general \nfeeling of confidence in its safety, possibly a little over-rated for \nseveral deaths have been reported from chloroform given dur- \ning labor, or for obstetric operations. Ether is recommended by \nsome as being the proper agent for the full anaesthesia necessary \nfor turning, craniotomy, instrumental delivery, etc., but never- \ntheless chloroform is so much more convenient, and, being rela- \ntively safe, it will probably continue to be chiefly used. \n\nDuring labor chloroform should be given to produce an anal- \ngesia only. It should not be given if pains are feeble and irreg- \nular, when small doses retard labor, or when marked respira- \ntory difficulty is present. Its administration should not be be- \ngun until distinct labor pains have appeared. A small quantity \nis given when the pain is approaching, just enough to relieve \nthe severe part of the pain and to deepen respiration. The chlo- \nroform should be withdrawn as the pain begins to subside, and \nthe patient should be allowed to recover from the effects of the \ndrug in the interval of the pains. The general opinion is that \nprofound narcosis increases the liability to uterine inertia and \nthe danger of post-partum haemorrhage. Most obstetricians rec- \nommend that consciousness should be allowed to return during \nthe expulsion of the foetus because of the liability of rupture of \nthe perineum. \n\n\n\nTHE ANAESTHETIC AND THE OPERATION 57 \n\nAmong the reasons assigned for the comparative freedom \nfrom accident of chloroform anaesthesia during labor are these: \nThat the element of fear of the anaesthetic is displaced by the \nwoman\'s suffering and her desire for relief; that physiological \nhypertrophy of the heart protects against circulatory failure ; that \nthe deeper respiration and expulsive efforts prevent asphyxial \ndifficulties and promote the pulmonary circulation and the \nemptying of the right heart; that high abdominal pressure pre- \nvents vaso-motor dilatation. \n\nIt is doubtful if the condition of the heart has any marked \nbearing on this question. The other causes may all have some \neffect. \n\nOperations on the extremities, such as reduction of fractures \nand dislocations, examination and treatment of anchylosed and \npainful joints, are better managed with anaesthesia by ether than \nby chloroform because of the complete relaxation under ether, \nand the safety of pushing ether to its fullest extent. Chloro- \nform has proven dangerous in this class of cases, particularly in \ninjuries of the joints and bones as the patients are not always \nin the best condition for its administration. \n\n\n\nCHAPTER VI. \n\nBEFORE THE ADMINISTRATION OF AN ANAESTHETIC. \n\nThere are certain considerations of importance preliminary \nto the administration of an anaesthetic which bear more or less \ndirectly on the success. \n\nTime of day. The morning hours from 8 to 10 o\'clock are \ngenerally considered the best for the administration. Statistics \nshow that the danger and complication ratios for chloroform are \nlowest during the first quarter of the day, and increase progress- \nively as the day advances. Of course other factors have \nmuch to do with this, but, all things considered, the morning \nhours are probably the safest for all anaesthetics. The stom- \nach is empty, and the patient has not had the most of the day \nto worry about the operation. From I to 2 p. m. is probably the \nnext best time for the administration, providing nothing has \nbeen eaten for breakfast except tea and toast. \n\nDiet. Where the administration occurs in the morning the \npatient should not be allowed any breakfast. Ordinary, light \nmeals may be taken the day before, but nothing after 8 p. m. \nthe previous evening. Hearty meals taken the day before are \napt to remain partially undigested, especially if the patient is \nworrying over the operation. If the administration is fixed for \n1 or 2 p. m., tea or milk and toast may be taken at 8 a. m., and \nnothing afterward. When the administration is set for 11 or \n12 o\'clock, or for 4 or 5 in the afternoon, patients should be in- \nstructed not to eat their usual breakfast or luncheon. For the \nformer hour a light breakfast of coffee and toast may be given \nat 7 a. m., while for the latter hour a light breakfast about 9 130 \nor 10 o\'clock will answer.* \n\nThese regulations of diet do net apply to the administration of \nnitrous oxide gas with as much force as they do to other an- \naesthetics. Although it is best to allow 2 or 3 hours to intervene \nbetween the taking of food and the administration of nitrous ox- \nide, it is often taken shortly after food without trouble. When \nnitrous oxide is administered with air or oxygen the period pre- \nvious to the administration should be governed by the same diet- \netic rules as apply to other anaesthetics. \n\n*In the preliminary dietetic management it has been largely the custom \nto withhold liquids as well as solids, thus placing the patient on the oper- \nating table with small pulse, diminished urinary secretions, and in poor \ncondition to eliminate poisonous material. Hess has shown that ether is \nexcreted from the blood to the stomach, causing vomiting by irritation. \nBoth acceleration of excretion of the ether, and prevention of vomiting \nmay be accomplished by free administration of water up to the time of \ngoing to operation, and as soon afterward as possible. \n\n\n\nBEFORE THE ADMINISTRATION OF AN ANESTHETIC 59 \n\nIn weak and exhausted patients it is not best to restrict \nthe diet too much. In young and robust subjects the administra- \ntion will proceed better if they have been fasting for 6 or 8 hours, \nbut in weak patients it is best not to allow them to remain long \nwithout food. If the administration is set for the early morn- \ning hours, a little beef tea, soup or milk should be given during \nthe night. When the circulation is particularly weak an enema \nof beef tea and brandy should be given half an hour before \nthe administration. The rectal, subcutaneous, or intravenous in- \njection of normal salt solution may be advisable or necessary.* \nPreliminary rectal feeding may be necessary in some cases. \nSome surgeons wash out the stomach before abdominal section \nfor obstruction, or previous to operations for appendicitis. \n\nCushing recommends feeding with sterilized liquid food .and \nwater for several days in preparation for extensive operations \non the stomach and intestines in order to lessen the liability to \nafter infection. \n\nCareful disinfection of the mouth and pharynx previous to the \nadministration is recommended as a preventive of post-opera- \ntive lung complications. \n\nBowels. It is important that the bowels should be evacuated \nbefore the administration, and in certain subjects and operations \nit is very necessary. Where the operation does not involve the ab- \ndominal or pelvic regions a saline purgative given the morning \nbefore operation will be sufficient. In abdominal or pelvic oper- \nations a free purgative may be given 24 or 36 hours before the \nadministration, and an enema or colonic flushing the morning of \nthe operation. Robust subjects may be purged freely with ben- \nefit, but weak and debilitated persons should not be given hydra- \ngogue cathartics before operation. \n\nBladder. The bladder should always be emptied immediately \nbefore the administration, especially in young subjects and when \nnitrous oxide gas is to be employed. \n\nMedicine. The local application of cocaine solution to the \nnose and throat to prevent irritation, cough, holding the breath, \nand reflex syncope has been practised, and while these conditions \ncan be, in a measure, controlled by this means, the method is \nobjectionable because of the clanger of cocaine poisoning. The \nimportance of such applications is lessened by the doubt of the \n\n*Villaneuve recommends the subcutaneous injection of 400 gms. of \nsalt solution the day before operation to prevent vomiting during or after \noperation. \n\n\n\n6o BEFORE THE ADMINISTRATION OF AN ANAESTHETIC \n\npossibility of the occurrence of fatal syncope from the irritative \neffect of chloroform. \n\nAlcohol has often been given by the mouth as a general stim- \nulant before operations. Its use in this way is objectionable as it \nis apt to interfere with the induction of anaesthesia. As a pre- \nliminary routine measure it should be discouraged. \n\nStrychnia. The hypodermic administration of strychnia pre- \nvious to the anaesthesia has been recommended and is a good \ngeneral practice in debilitated subjects, especially when there \nis a weak heart. From one-thirtieth to one-twenty-fifth of a \ngrain may be given half an hour before the administration. \n\nMorphine and atropine. Nussbaum, as early as 1863, injected \nmorphia during anaesthesia to relieve after-pain and discomfort. \nIn 1861 Pitha reported a successful anaesthesia with belladonna \nand chloroform in a patient who had resisted chloroform alone. \nLabbe and Guyon (about 1872) are said to be the first who used \nmorphine before the administration with the idea of enhancing \nthe action of chloroform. \n\nThis so-called mixed method of anaesthesia has been more or \nless employed up to the present time. There is still much differ- \nence of opinion as to its relative merits and demerits. \n\nKappeler, who used mixed anaesthesia extensively, concluded \nthat the anaesthesia is quieter, the stage of excitement shorter, \n"tolerance" is acquired with less muscular disturbance, asphyx- \nial symptoms are less marked, and vomiting is more frequent \nthan without morphine. He injects the morphine about 20 or \n30 minutes before the inhalation. Demarquay thought mor- \nphine contraindicated in weak subjects. Wyeth recommends mor- \nphine with chloroform to stimulate the heart and quiet the patient. \n\nMorphine, in properly selected cases, especially in connection \nwith the administration of chloroform, gives good results. The \ndose should be from one-sixth to one-fourth of a grain, given \nfrom 20 to 30 minutes before the administration of the anaes- \nthetic. The previous habits of the patient in regard to drugs of \nthis nature should be ascertained, bearing in mind that the habit- \nual use of morphine renders the patient more susceptible to- \nthe action of anaesthetics, especially of chloroform. Morphine has \nbeen used in connection with cerebral surgery with good effect, \nbut the difficulty of estimating its effects in this class of cases \n\n\n\nBEFORE THE ADMINISTRATION OF AN ANAESTHETIC 6l \n\nhas induced most operators to discourage its use. In cases in \nwhich it is difficult to secure the usual degree of muscular relaxa- \ntion during anaesthesia morphine will prove of benefit. \n\nWhen morphine has been given as little of the anaesthetic should \nbe used as possible. The corneal reflex should be preserved, \nand an analgesic rather than an anaesthetic state should be aimed \nat. There is not so much danger in an incomplete state of anaes- \nthesia where morphine has been used as where it has not. \n\nJullard advised the use of morphine before etherization. He \nrecommends the previous use of the drug in order to ascertain \nthe susceptibility of the patient. Kappeler states that he had \nmany failures and more excitement when using morphine with \nether. \n\nDastre and others used the combination of morphine and \natropine in order to lessen the liability of cardiac inhibition. \nBlake uses atropine to diminish secretion and to stimulate respir- \nation in ether narcosis. Reinhard uses both drugs in ether nar- \ncosis to inhibit hypersecretion of mucus, giving the injection \nan hour before the administration. Braun believes that a suffi- \ncient dose of atropine to affect the amount of mucus would be \ndangerous. Becker condemns the use of atropine. He thinks \nthe secretion of mucus can be reduced by adding 20 drops of \noleum pumilionis (one of the turpentine oils). The use of atro- \npine in sufficient quantity to affect the secretion of mucus would \nin most patients increase the danger of anaesthesia. A dose of \none one-hundred and fiftieth of a grain in conjunction with mor- \nphine does not appear to be objectionable, nor does it appear to \nhave any special advantage unless it may be in certain patients, to \noffset the action of morphine in adding to the after-effects of the \nanaesthetic. \n\nMixed narcosis while of undoubted advantage has also dan- \ngers. If care is not exercised in the amount of anaesthetic given \nthe patient may pass into too deep narcosis before the adminis- \ntrator is aware of it. Very little anaesthetic may be necessary \nto produce deep anaesthesia. It is well for the administrator to \ninform himself as to whether the patient has had morphine before \nhe begins the administration.* \n\nPhysical examination. It is not uncommon for the admin- \nistrator to see his patient for the first time just as the adminis- \n\n*See additional matter on mixed narcosis at the end of this chapter. \n\n\n\n62 BEFORE THE ADMINISTRATION OF AN ANAESTHETIC \n\ntration is about to begin. He is thus afforded no opportunity \nto recognize any physical condition which might modify the \nmanner or extent of the administration. The objection is offered \nthat questioning and examination of the patients unduly alarms \nand excites them, but such a result is more often due to lack \nof tact in such an investigation rather than to the examination \nitself. Generally patients will feel reassured when such a course \nis properly pursued. \n\nGeneral condition. The general appearance and bearing of the \npatient is to be noted. The presence or absence of nervousness, \nexcitement, or hysterical manifestations is to be observed. The \ncharacter of the subject\'s movements if he walks to the opera- \nting table, the position he assumes on the table, the tendency to \nassume a propped-up position such as would be natural in emphy- \nsema, chronic pneumonia, cardiac lesions, etc., may all be noted. \nThe general condition of nutrition, the apparent age, the gen- \neral physique, should be observed. Robust, young persons may \ngive some trouble. Fat, flabby, alcoholic subjects may be diffi- \ncult to anaesthetize. Florid subjects will show a marked degree of \ncyanosis under such an anaesthetic as nitrous oxide gas. \n\nPhysical examination of the chest. This should always be \nmade, particularly of the heart, and of the whole chest if diffi- \nculty in respiration is observed. Limitations of the respiratory \ncapacity from diseases of the lungs or pleurae should be looked \nfor. Stenosis or obstruction of any part of the respiratory tract \nmay be noted by causing the patient to respire deeply. The heart \nshould be palpated for enlargement or misplacement, irregularity, \netc., and the stethoscope should be used to detect murmurs, irreg- \nular action, and especially the character of the first and second \nsounds and their relative intensity as indicating the presence or \nabsence of muscular disease. The condition of the arteries should \nbe noted as to the presence or absence of sclerosis or atheroma. \nThe abdomen should be inspected and palpated for any condition \ninterfering with abdominal respiration and the action of the dia- \nphragm. The reaction of the pupils to light should be observed \nso that any peculiarity in this respect may not be attributed to \nthe anaesthetic. The nose, mouth, and throat should be inspected \nrelative to obstruction of the nares, artificial teeth, plates, loose \nteeth, quids of tobacco, loose tartar, and in children, pieces of \n\n\n\nBEFORE THE ADMINISTRATION OF AN ANAESTHETIC 6$ \n\ncandy which may be given by some well-meaning relative just \nbefore the administration. \n\nTemperature of the room. The temperature of the room \nshould be about 70 degrees F. and the air should be compara- \ntively dry. Warm temperature favors vaporization and elimina- \ntion. Low temperature has the opposite effect. It may be diffi- \ncult to anaesthetize in low temperature. Richardson believed that \nsyncope and pulmonary oedema were more frequent under chlo- \nroform where the air was charged with moisture. \n\nVentilation. The room should be well ventilated and free \nfrom draughts. In small, badly ventilated rooms lighted by open, \nartificial lights special difficulty may arise in administering chlo- \nroform (vide p. 147). \n\nClothing of patient. For the administration of all anaes- \nthetics the clothing of the patient should be warm and loose. \nFor the administration of nitrous oxide gas it is necessary to see \nthat nothing constricts the neck, chest, or abdomen. Collars \nshould be removed, neck-bands loosened, waists unhooked, cor- \nsets unfastened, belts removed. These precautions are often neg- \nlected because of the trouble and of the short duration and rela- \ntive safety of this anaesthetic, but they should never be neg- \nlected. \n\nWith chloroform and ether there is more or less reduction of \nbody temperature during anaesthesia, and this is often added to \nby carelessness in properly dressing the patient or in keeping \nhim properly covered during the anaesthesia, or by covering large \nareas of the surface of the body with towels wet with moist anti- \nseptic solution. The patient should be dressed in warm under- \nclothing, warm stockings, and should be kept, whenever possi- \nble, covered with warm blankets. In special cases hot water \nbottles should be in readiness, or a hot water bed or table may \nbe used. \n\nPosture during induction. As a rule it is best to induce \nanaesthesia with the patient in the dorsal position with a pillow \nunder the head and none under the shoulders. If the subject \nsuffers from bronchitis, asthma, emphysema or other causes of \ndifficult breathing it may be necessary to have a pillow under \nthe shoulders, at least during the induction. The head should \nbe kept in line with the body. In administering nitrous oxide \n\n\n\n64 BEFORE THE ADMINISTRATION OF AN ANAESTHETIC \n\ngas in the sitting position it is important to keep the head in \nline with the body, and to prevent the patient from throwing \nthe head too far backwards. \n\nThe induction of chloroform anaesthesia should not be attempt- \ned in the sitting position if possible to avoid it. The lateral \nposition may be used for the induction if advisable. \n\nMoving of patients. It is best to anaesthetize the patient on \nthe table upon which the operation is to be performed if pos- \nsible, and not to move him more than is necessary. Statistics \nshow that many of the difficulties and dangers arising during \nanaesthesia are incident to moving the patient or changing the \nposition during anaesthesia. In those cases where it is necessary \nto move the patient after anaesthesia has been induced he should \nbe fully anaesthetized and kept so while being moved as vomiting \nor spasm is more likely to occur if the patient is moved under \nlight anaesthesia. \n\nAppliances and remedies. Before beginning the adminis- \ntration certain appliances and remedies should be within easy \nreach in case of necessity. A mouth gag may be necessary to \nkeep the jaws apart (Figs. 3, 4, 5, 6, 7), or if difficulty is exper- \nienced in separating the jaws some form of mouth opener is \nnecessary (Fig. 8). A tongue forceps for drawing forward or \nmaking traction on the tongueshould be at hand (Figs. 9, io),oran \nordinary artery forceps may be used. Mouth props for separating \nthe teeth are at times necessary (Figs. 11, 12). A basin should \nbe at hand in case of vomiting, and a couple of towels to be used \nfor keeping the mouth, face, and pillow free from mucus. \n\nInstruments for the performance of tracheotomy should be \nat hand. In hospital practice there should be appliances for \nlung inflation, the introduction of saline solution, and for the ad- \nministration of oxygen gas \n\nStrychnia, digitaline, ammonia, ether, atropine, alcohol, \nwhisky for hypodermic injection should be at hand, nitrite of \namyl for inhalation may be useful. \n\nAseptic precautions. All apparatus used by the adminis- \ntrator should be kept as nearly aseptic as possible, and the ad- \nministrator should be careful to thoroughly clean his hands and \nnails. In some cases, such as surgery of the face, head, nose, \nmouth, throat, neck, or shoulders, all appliances used by the \n\n\n\nBEFORE THE ADMINISTRATION OF AN ANAESTHETIC 05 \n\nadministrator should be sterilized, and the administrator should \nbe personally as careful as the operator in this regard. \n\nDuring the last few years there has been a greater tendency \nto employ some form of preliminary treatment, or a mixed form \nof narcosis than formerly. McCardie says that preliminary drug \ntreatment applies particularly to chloroform, as ether is a suffi- \ncient stimulant in itself. He advises strychnia before operation, \ngiving it either for a few days previously, or immediately before \nin an alcoholic medium. He thinks it should be combined with \natropine. \n\nAtropine paralyzes the ends of the vagi in the heart, stimu- \nlates the heart, and, in moderate doses, increases the force of the \nsystole. It stimulates the vaso-motor center, raises blood pres- \nsure, and prevents stimulation of the vagi by chloroform. Ac- \ncording to Crile atropine, hypodermically, is a sufficient protec- \ntion against cardiac inhibition in operations in the "inhibition \narea" in the larynx, and in such operations as might cause me- \nchanical stimulation of the vagi. \n\nAtropine alone is not advised for chloroform anaesthesia, as it \ncauses excitement, and does not allow of economy of chloroform. \n\nHewitt advises that the susceptibility of the patient be learned \nif morphine be given before chloroform or ether. Morphine \nshould be avoided in operations on the chest and abdomen be- \ncause it hinders cough, and causes vomiting and constipation. \nIt may be very useful in operations about the throat and for \ngoitre. It should be deeply injected, with massage to insure quick \nabsorption. \n\nCocaine, it is claimed, will guard the heart almost as well as \natropine when given hypodermically. The local application of \none-half per cent, solution will prevent the reflex impulses in the \nlaryngeal area of inhibition within thirty seconds. Nerve func- \ntion may be entirely "blocked\'\' by the local application of co- \ncaine. It appears to prevent splanchnic shock. \n\nEvenkhofT\'s "strychnin-chloroform narcosis" consists in the \nadministration of 1-60 to 1-30 grain of strychnia before anaesthe- \nsia, in order to obtain a satisfactory blood pressure. If this is not \nobtained in from five to eight minutes, 1-100 to 1-60 more should \nbe injected. \n\n\n\n\n66 \n\n\n\nBEFORE THE ADMINISTRATION OF AN ANAESTHETIC \n\n\n\n\n\n\nBEFORE THE ADMINISTRATION OF AN ANAESTHETIC 6? \n\n\n\n\nFig. 7.\xe2\x80\x94 Heister\'s Gag. \n\n\n\n\n\nFig. 9.\xe2\x80\x94 Mathieu\'s Tongue Forceps. \n\n\n\nFig. 8.\xe2\x80\x94 Plain \nOral Screw. \n\n\n\n\nFig. 10.\xe2\x80\x94 Houze\'s Tongue Forceps. \n\n\n\n\n\n\nFig. 12.\xe2\x80\x94 Soft Rubber Bite-Block (White Dent. Co.) \n\n\n\nFig. 11.\xe2\x80\x94 Daintree\'s \nAdjustable Moutli \nProp. \n\n\n\nCHAPTER VII. \n\nPOSTURE DURING ANAESTHESIA. \n\nThe posture of the patient during anaesthesia is determined \nby the nature of the operation, the anaesthetic to be used, and \nthe general condition of the patient. Faulty positions are likely \nto increase the danger rate of anaesthetics from complications dur- \ning anaesthesia and from after-effects. They also interfere with \nthe performance of the operation. \n\nRespiratory difficulties may arise from positions favoring the \naccumulation of mucus, saliva, blood, etc., in the fauces, as in \nthe semi-recumbent position. Flexion of the head produces ob- \nstructive stertor. Complete extension of the head may favor \nthe entry of foreign substances into the larynx, producing at- \ntempts at coughing, swallowing, etc. The prone or latero-prone \nposition may interfere with the expansion of the lung and \ncause asphyxia. The dorsal position may not be possible if \nthere is much pressure on the diaphragm from below. In diseases \nof the lungs or pleurae the lateral position with the patient on \nthe sound side may be dangerous. In fat, elderly people, and \nin dyspnceic subjects the lithotomy position may produce difficulty \nwith respiration. \n\nDifficulties with the circulation are not usually due to posture \nexcept as they may occur secondarily to respiratory disturbance \nfrom posture. Chloroform and its congeners are generally sup- \nposed to favor primary syncope where the sitting position is \nassumed, and while this danger is probably over-rated, provided \nthe respiration be watched and the anaesthesia be not too pro- \nfound or prolonged, it is best not to give chloroform in the sit- \nting position if it can be avoided. \n\nFaulty posture may interfere with the performance of the \noperation by favoring jerky, irregular respiration, coughing, vom- \niting, straining, muscular rigidity, etc. After-effects may also be \ndue to faulty positions allowing the passing of mucus, blood, \npus, etc., into the larynx, trachea, or stomach. \n\nThe extraction of teeth. The sitting position is the usual one. \nThe feet are so disposed that they cannot become entangled in \nthe apparatus or chair, or the heels used as a support to the \n\n\n\n\nF\\g. 13- A. -Postures for Anaesthesia. 1.\xe2\x80\x94 Dorsal position: face to one side. 2.\xe2\x80\x94 Lateral position. \n\n3.\xe2\x80\x94 Prone position. \n\n\n\nPOSTURE DURING A X. EST H ESI A \n\n\n\n\nFig. 13-B.\xe2\x80\x94 Postures for Anaesthesia. 4.\xe2\x80\x94 Sitting position. 5.\xe2\x80\x94 Sitting position: \nbent forward. 6.\xe2\x80\x94 Trendelenburg\'s position. \n\nbody. The head should be in line with the body and as vertical \nas possible. The head may be lowered after anaesthesia is in- \nduced if necessary. When chloroform or the A. C. E. mixture is \nemployed the dorsal position should be used. \n\nOperations about the mouth, nose, pharynx, face, or jaws. \nAny of the various positions ordinarily in use may be employed \nfor these operations. When possible the posture should be such \nas to allow of the free escape of blood from the mouth. The \nhead should be kept in line with the body. The anaesthesia \nshould not be so profound as to completely abolish the laryn- \ngeal and pharyngeal reflexes. Small sponges attached to holders \n\n\n\nPOSTURE DURING ANAESTHESIA J\\ \n\nshould be at hand to keep the mouth and throat free from blood, \nespecially if the dorsal position is used. The dorsal position with \nthe head extended obstructs and interferes with coughing and \nswallowing and tends to increase haemorrhage. The lateral \nposition is best for the administrator, though" in some cases the \noperator prefers the dorso-lateral. The semi-recumbent or \n"propped-up" position, with or without extension of the head, \nis a good one for the operator in operations on the tongue, jaws \netc., but is not adapted to maintaining an even and unembarrassed \nform of anaesthesia. The sitting position is very convenient for \nrhinological operations. There is no risk in using gas or ether, \nor the ether-chloroform sequence, in this position. Chloroform \nalone should not be used with the sitting position unless neces- \nsary \xe2\x80\x94 as in the removal of laryngeal growths in children. \n\nThe bent-forward position is adapted to the removal of \npost-nasal adenoids. Ether or nitrous oxide-ether sequence may \nbe used with the dorsal or sitting position, and the patient tilted \nforward for the operation. \n\nThe Trendelenburg posture may be used for these operations. \nIt draws blood away from the larynx, but favors haemorrhage. \nIt is used by some surgeons for hare-lip and cleft-palate opera- \ntions, also for operations en the naso-pharynx. The lateral and \ndorso-lateral positions are adapted for operations on the lips and \ncheeks, jaws, antrum, etc. For operations on the tongue the \nlateral, latero-prone, or the semi-recumbent positions are mostly \nused. For removal of the tonsils Hewitt recommends the dorsal \nposition with nitrous oxide-ether, or A. C. E. -ether sequence, and \nthe patient is placed in the sitting position for operation, or the \nsitting position may be used altogether. In nasal operations the \ndorsal, lateral, dorso-lateral, or sitting position may be used. \n\nOperations on the larynx and trachea. The dorsal position \nwith the shoulders slightly raised and the head somewhat ex- \ntended, or the Trendelenburg positions, should be used. For \nintra-laryngeal operations, when done under general anesthe- \nsia, chloroform should be used in the dorsal position, and the \npatient then placed in a chair with the head slightly extended. \n\nFor operations on the neck the dorsal position with the shoul- \nders slightly raised is preferable. \n\nFor operations on the brain the dorsal or lateral positions are \n\n\n\nj 2 POSTURE DURING ANAESTHESIA \n\nbest. For operations on the spinal cord the prone or latero-prone \nposition is convenient but may favor asphyxial complications. \n\nFor ophthalmic operations the dorsal or semi-recumbent posi- \ntions are generally used. \n\nFor operations on the chest zvalls, pleura or lung the position \nshould be such as not to interfere with the expansion of the \nhealthy lung. The prone or semi-prone position is likely to inter- \nfere with the respiration and should not be adopted unless nec- \nessary. The anaesthesia should be induced in the most favorable \nposition, and watch kept for unfavorable effects following change \nin position. Recent cases in which the lung has not had time \nto accommodate itself to the changed conditions are most likely \nto cause trouble. Pleuritic effusions may be aspirated with the \npatient in the semi-recumbent, dorsal, or sitting position. \n\nAbdominal operations are adapted, as a rule, to the Trendelen- \nburg posture. The head should be kept in line with the body, or \nturned very slightly to one side. Obstructed breathing from \nspasm of the masseters or from flexion of the head may cause \nactive movements of the diaphragm which interfere with the \noperation. The Trendelenburg position may be contraindicated \nin cases of great abdominal distention, at least during the early \npart of the operation. The dorsal position is best adapted to \nsome cases. Bloodgood thinks the Trendelenburg position. les- \nsens the dangers of lung complications in cases where from the \nnature of the operation, disease, or the patient\'s condition, lung \ncomplications are to be feared. This position, as with the low \nposition of the head (Roser\'s position), undoubtedly tends to \nprevent the passage of secretions, blood or pus, or foreign bodies, \ninto the respiratory tract. \n\nIn operations on the kidney the latero-prone or prone posi- \ntion is used. \n\nIn genito-urinary operations, rectal operations, gynaecological \noperations by the vaginal route, obstetrical operations, etc., the \nlateral, dorsal, or lithotomy positions will be used as necessary. \n\n\n\nCHAPTER VIII. \n\nNITROUS OXIDE. \n\nNitrogen monoxide, protoxide of nitrogen, nitrous oxide, \n"laughing gas," has a cheminal formula of N 2 0. It was first pre- \npared by Priestley about 1772 or 1776. It is a colorless, trans- \nparent, feebly refractive gas with a sweetish odor and taste. \nIts sp. gr. is 1.527. When pure it is devoid of irritant prop- \nerties. Water at o\xc2\xb0C. dissolves a little more than its own volume \nof the gas, the solubility diminishing as the temperature of the \nwater increases. Nitrous oxide gas was first liquefied by Faraday \nin 1823. Liquefaction takes place under a pressure of 30 atmos- \npheres at o\xc2\xb0C. The resultant liquid is colorless, very mobile \nbody with a sp. gr. of .9369, which commercially is obtained in \nmetal cylinders furnishing 100, 250, 450 gallons of gas accord- \ning to capacity. The pressure in these cylinders is said to some- \ntimes reach nearly 1,000 pounds to the square inch. The cylin- \nders are subjected to a test pressure of 3,000 pounds to the square \ninch. Seven and one-half ounces of liquid nitrous oxide will \nfurnish about 25 gallons of gas. The gas is usually pure, but is \nsaid to sometimes contain other oxides of nitrogen and chlorine. \nIt is stored for use in gas bags holding about eight gallons, or in \ngasometers (Figs. 14, 15). The intense cold produced by the \nconversion of the liquid into gas may produce solidification \naround the outlet of the interior of the cylinder and interfere \nwith the proper working except when they are constructed so as to \navoid this. \n\nNitrous oxide gas is not easily decomposed, a considerable \ntemperature being necessary to split it into component elements. \n\nPhysiological effects and action. Properly administered \nnitrous oxide gas can be respired without special discomfort or \ndanger up to a certain point. In administration the gas is \nforced, and the stage of excitement is very brief. The time con- \nsumed in producing deep anaesthesia with pure gas and care in \nexcluding air will vary from 20 seconds to 2 minutes, accord- \ning to the age and constitution of the subject. The length of \ntime which the anaesthetic state will last from a single inhala- \ntion period will vary from 15 seconds to 45 seconds. This is \n\n\n\n74 \n\n\n\nNITROUS OXIDE \n\n\n\n\nFig. 14.\xe2\x80\x94 Gasometer (White Dent. Co.) \n\nFig. 14. The socket (A) of the stand is for large cylinders. The \nreversible clamp (B) fits the large cylinders on one side, and on the other \nthe small cylinders. The side which fits small cylinders has a flange (C) \non which sits the cylinder. A set-screw (D) holds the cylinder firmly in \nposition. The reservoir (E) is filled with water to the bead (K). \n\nAt the bottom of the reservoir, where the inhaler tubing is attached, \nis a piston valve (G), placed there for absolute security against waste \nwhen operations are suspended with the receiver full of gas. At the \nopposite side (not seen in cut) is a pipe to which the cylinder yoke is \nconnected by means of rubber tubing (L). Near the top of the reservoir \nis a wooden fork (H), to support the inhaler when not in use. The bell \n(F) works on the guide-rod (I). \n\n\n\nNITROUS OXIDE \n\n\n\n75 \n\n\n\ni WATC* tlttf] \n\n\n\n\nro $a\xc2\xbb eri\'HOim \' \n\n\n\nFig. 15.\xe2\x80\x94 Diagram of White Dent. Co.\'s Gasometer. \n\nknown as the period of available anesthesia in dental practice. \nReturn to consciousness is very abrupt, often sufficiently so to \nsurprise the subject in attitudes quite unusual to him. \n\nNitrous oxide narcosis is obtained so quickly that it is difficult \nto arrange its manifestations into groups. The initial sensa- \ntions are usually agreeable and exhilarating. There is subjective \ndizziness, noises in the ears, tingling and loss of body sensation. \nIllusions are present and may result in mental exhilaration or de- \npression, or in pugnaciousness. Generally unconsciousness is \n\n\n\n76 . NITROUS OXIDE \n\nreached before the subject can speak. There is an irresistible \ndesire to inhale deeply, and the respirations are deeper and \nquicker than normal. The pulse is fuller and more rapid than \nusual. As unconsciousness is reached disturbed psychical condi- \ntions may arise, especially if the subject be disturbed, roughly \nhandled, or if the operation be begun too early. He may shout \nor may exhibit co-ordinate or inco-ordinate movements. Dreams \nmay occur, pleasant or unpleasant, \xe2\x80\x94 the latter are said to occur \nmore often under the gas alone than when it is combined with \noxygen. The respiration is quick and deeper than normal, and \nthe pulse is still full but grows more rapid and may be from no \nto 160 per minute. The conjunctivas are sensitive and the pupils \ngradually dilate. The eyelids twitch and separate showing the \neye-ball and giving the eyes a protruded appearance. The skin, \nwhich first shows pallor, becomes, in florid persons, dusky and \nlivid, or deeply cyanosed. The jaws become set. The respiration \nwhich has fairly well maintained its rhythm now becomes \narrhythmical, showing that the subject is fully anaesthetized, a \npeculiar stertor from intermittent elevations of the larynx is \nmanifested. Deep stertor may be present, and clonic spasms of the \nthoracic and abdominal muscles may occur. Stertor may be \nabsent and irregularity of respiration may be caused by these \nmuscular spasms. Rarely the respiration becomes feeble with \nprolonged stridulous expiration. These manifestations show thai \nthe administration has proceeded far enough. The extremities \nmay or may not remain relaxed. Clonic contractions of various \ngroups of muscles may occur, and tonic contractions of the mus- \ncles of the neck or back are sometimes seen even to the condi- \ntion of opisthotonos. Micturition and defecation are not un- \ncommon. In deep anaesthesia the superficial plantar reflex is lost, \nbut the deep patellar reflex is not. The pupils are usually widely \ndilated but may not be or may even be contracted. Post-anaes- \nthesial dilatation of the pupils may occur. The corneal reflex is \nusually maintained. The conjunctival reflex may disappear and \nis not a reliable guide to the state of anaesthesia. . \n\nWith the withdrawal of the anaesthetic the respiration rapidly \nassumes its usual rhythm and the pulse drops suddenly in rate, \nthe subject rapidly returning to consciousness. The pulse may \nafterwards be rapid from mental conditions or from pain. \n\n\n\nNITROUS OXIDE J J \n\nAmong the recognized after-effects of nitrous oxide anaesthe- \nsia are headache, dizziness, nausea, vomiting, faintness, hysterical \nattacks, hallucinations, stupor, catalepsy, hemiplegia, and even \ninsanity. Temporary glycosuria, diabetes, and retinal haemor- \nrhage have been known to occur. \n\nLethal doses of nitrous oxide gas produce, death by asphyxia- \ntion. The heart beat may continue for several minutes after res- \npiration ceases. The latter is said to be due to muscular spasm. \nThe right heart cavities are found full of blood and the left cav- \nities relatively empty. \n\nIt was formerly thought that the phenomena attending the \nadministration of nitrous oxide gas were all asphyxial or anoxae- \nmic in character, depending on want of oxygen, but the observa- \ntions of E. Andrews, and of Paul Bert showed that anaesthesia \ncould be produced without asphyxial conditions by the conjoined \nuse of nitrous oxide gas and oxygen. Nitrous oxide must there- \nfore possess some anaesthetic properties aside from its asphyxial \npowers. On the other hand the phenomena can not all be special \nor non-anoxaemic because by the addition of oxygen the stertor, \nepileptiform movements, and the cyanosis may be obviated with- \nout interfering with anaesthesia. \n\nThe anaesthetic property of nitrous oxide is thought by some \nto be due to a deoxidizing action on the usual process of oxidi- \nzation occurring in nerve cells, and similar to that of other anaes- \nthetics. \n\nThe blood changes occurring during anaethesia with gas are \nnot thoroughly understood. The gas is very soluble in blood, \nand there is a great reduction in the oxygen in the blood. (Ex- \nperiments have shown that after breathing nitrous oxide for a \nperiod of 105 seconds that there is a reduction of the oxygen of \nthe blood from 21 to 5.2 vol. per cent.) The blood pressure is \nraised, and later falls with the appearance of respiratory embar- \nrassment. There is contraction of the renal vessels and dimi- \nnution in the secretion of urine. Slight albuminuria may occur \nwith complete anaesthesia. \n\nTHE ADMINISTRATION. \n\nThe universal employment of nitrous oxide gas in dental \nsurgery attests the fact that with very few exceptions this agent \nis the best for use in dental practice. In operations which re- \n\n\n\n78 NITROUS OXIDE \n\nquire not more than a few seconds no other anaesthetic can com- \npare with nitrous oxide either in safety, efficiency, or in con- \nvenience. Colton originally urged the exclusion of air in nitrous \noxide anaesthesia, and the advisability of administration with \nan inhaler fitted with inspiratory and expiratory valves. He aft- \nerward showed the advisability of allowing air to be breathed \nin connection with the gas in cases where a little more time \nwas necessary than in ordinary dental operations, and devised in- \nhalers for use under such circumstances. \n\nAndrews\' observations regarding the administration of oxy- \ngen and gas, and Paul Bert\'s researches along this line brought \nabout the conclusions now recognized, that by the use of cei- \ntain amounts of atmospheric air a better form of anaesthesia can \nbe obtained than with pure gas, especially for occasions demand- \ning one or two minutes of anaesthesia, and that with oxygen \nand gas a still more satisfactory form of anaesthesia may be ob- \ntained. The more complicated apparatus, and the greater skill \nand experience necessary to obtain satisfactory results with these \nmethods have restricted their use, and the pure nitrous oxide \nanaesthesia remains the most universal method of administration. \nThe various methods of administration which may be em- \nployed are : The administration of pure nitrous oxide ; of defi- \nnite quantities of nitrous oxide and air ; of nitrous oxide and in- \ndefinite quantities of air : of definite quantities of nitrous oxide \nand oxygen at ordinary atmospheric pressure ; of the same under \nincreased atmospheric pressure (Paul Bert\'s system) ; of nitrous \noxide and varying quantities of oxygen at ordinary atmospheric \npressure. \n\nFor the administration of pure nitrous oxide gas for ordinary \ndental operations the patient should be seated in an operating \nchair in a comfortable position. Care should be taken that the \nsubject\'s legs cannot become entangled in the chair or apparatus \nin case of muscular contractions, nor a purchase be obtained for \nthe feet should opisthotonos occur. The head should be in line \nwith the body, and as vertical as possible. If a vertical position \nof the head is not satisfactory to the operator, then it should be \nkept in that position during the induction of anaesthesia by a \ncushion which can be quickly removed as full anaesthesia is \nreached. \n\n\n\nNITROUS OXIDE \n\n\n\n\nPig. 16.\xe2\x80\x94 Universal Gas Stand (White). \n\n\n\n8o NITROUS OXIDE \n\nFig. 16. The base is of iron, with a coned socket for the reception of the \ncylinders. The upright carries a yoke connection for the valve of the cylin- \nder, an arm for the support of the gas-bag, and a wood fork at the top for \nholding the inhaler when not in use. Attached to the fork by means of a \nchain is a wood ring for the support of the inhaler tubing. The base is \nheavy to assure solidity and firmness on the floor. The coned socket \nprovides for Medium and Large Cylinders, the latter sitting in the upper \npart and the former passing down to the bottom. For the Small Cylin- \nders a pedestal casting is provided which sits in the coned socket, with \ncatches to hold it firmly to the base. \n\nThe yoke connection, 10, has a short up and down swing to accom- \nmodate itself to the cylinder neck. It is also adjustable upon the up- \nright. As shown it is in position for the Small and Medium Cylinders. \nFor the Large Cylinders.it can be raised by loosening the set-screw 12 (a \ncountersunk spot will be found on the rod to receive the set-screw in the \nnew position). The cylinder is held securely in the yoke by tightening \nthe screw 14. Be sure there is a leather washer on the yoke nipple, to \nmake a tight joint between the yoke connection and the cylinder. The \nwood wheel-key 15Y operates both the yoke screw 14 and the valve of the \ncylinder. A quarter turn releases the yoke screw. \n\nIn short operations it may be desirable to introduce a bite- \nblock, or mouth-prop, before anaesthetizing in order to avoid de- \nlay in opening the mouth after anaesthesia is produced. In long \noperations this may not be desirable. If the block or prop should \nslip it is probably best to stop the administration and readjust \nthe block. In some cases it may be desirable to introduce a gag \nbefore administering gas, in which case it is necessary to be care- \nful to prevent the admission of air along the arms of the gag. \n\nBefore beginning the administration be sure that there is a \nsufficient quantity of gas. Ordinarily not more than six or eight \ngallons will be needed, and children will usually need but three \nor four, but. it is best to have an ample reserve. \n\nRun some gas through the apparatus (Fig. 16) and fill the \nbag about two-thirds full of gas and shut off the cylinder valve. \nSee that the valves in the inhaler are working properly. If the \npatient has a beard, moisten the hair about the mouth before \napplying the face-piece. Explain to the patient that there is no \ndanger or suffering connected with the administration of gas ; \nand show him how to breathe deeply and regularly through the \nmouth. Apply the face-piece and see that it fits properly by \nhaving the patient respire air in and out through the valves be- \nfore turning on the gas (Fig. 17), explaining meanwhile to the \npatient that he is simply breathing air. The regular sound of \n\n\n\nNITROUS OXIDE \n\n\n\n8l \n\n\n\nthe valves will show that the face-piece fits properly (Fig. 18). \nThe pneumatic face-piece is probably the most easily adjusted \nand satisfactory. \n\nIf the face-piece fits properly and the patient is breathing \nfreely the gas should be turned on. The bag at this time should \nbe about two-thirds full, and should be kept nearly full through- \nout the administration by allowing a small amount of gas to \n\n\n\n\nFig. 17.\xe2\x80\x94 Inhaler No, 3. (White Dent. Co.) \n\nFig. 17. The sectional view shows the internal construction. An open- \ning, B, underneath the body of the Inhaler adm;ts the gas through a similar \nopening, A, in a sliding tube GG, fitting inside of and projecting beyond the \nrear portion of the main body. The projecting portion is perforated for \nthe admission of air, and its outer end is closed by a cap. At the inner end \nof the sliding tube is a coil spring EE, abutting against a shoulder in the \nbody of the Inhaler. This spring holds the sliding tube in the position \nshown in the cuts, closing the inlet B when the gas is not being used. \nPressure on the cap compresses the spring, closes the perforations for the \nadmission of air, and brings the opening A over B, affording a free flow \nof gas to the mouth-piece through the inhaling valve. The sliding tube is \nprevented from rotating by the screw-pin D, which works in a slot, C. The \ninhaling and exhaling valves \xe2\x80\x94 the former internal, the latter external \xe2\x80\x94 \nconsist of two thin disks of mica, FF, which are inclosed in circular open \ncages. The inhaling valve is opened in respiration by being drawn against" \nthe front of the cage, the exhaling valve being closed by the pressure of \nthe outside air. In expiration both disks are thrown against the further \n\xe2\x96\xa0ends of the cages, opening the exhaling and closing the inhaling. \n\n\n\n82 \n\n\n\nNITROUS OXIDE \n\n\n\n\nFig. 18.\xe2\x80\x94 No. 3 Inhaler and Flexible Mouthpiece. (White Dent. Co.) \n\n\n\nenter from the reservoir, with a slight positive pressure, except \nin children and weak persons. Excitement should be controlled \nby increasing the pressure in the bag, as the disturbance will \n\n\n\nNITROUS OXIDE 83 \n\nprobably be due to admission of air, which is not likely to occur \nunder higher pressure. A slight amount of air is often of advan- \ntage in children and weak people. \n\nThere has been considerable argument as to the propriety and \nadvantage of rebreathing of gas, or to-and-fro breathing directly \nin and out of the bag. Hygienically it is, of course, objection- \nable, and obviously not admissable in the early stage of admin- \nistration, but is said to have advantages during the latter part \nof the inhalation period in that it leads to a longer available pe- \nriod of anaesthesia, and, while taking a little longer to produce \ncomplete anaesthesia and being followed by a slower return to \nconsciousness, it produces no bad effects. It would seem, how- \never, that improvements in the technique of administration will \npractically obviate this somewhat objectionable method. \n\nUnpleasant effects are often due to the operator beginning \nwork too soon, or to his attempting to accomplish too much \nduring a single period of available anaesthesia. The latter is \noften so short that but a single extraction can be effected while \nit lasts, though an ordinary operator can usually extract two \nteeth or roots while the patient is completely unconscious. \n\nThe following directions by Turner for anaesthesia for ex- \ntraction are useful : Food should be limited to good beef-tea \ntaken about two hours before anaesthesia. The patient should \nnot come straight from violent exertion. Undo all tight cloth- \ning about throat, chest, waist and abdomen. Seat the patient \ncomfortably, body relaxed, in straight line with head, neither \ntoo far back nor depressed, in such a position that with prop in \nposition blood or teeth will pass into floor of mouth. Support \nhead by a rest under the occiput, or nape of neck. Support the \nhead on side for extractions from upper jaw, and support lower \njaw for lower teeth. If operator supports lower jaw himself, \nthen press on front of condyle on side operated on, to prevent \ndislocation. When patient is reviving see that no blood is swal- \nlowed or inhaled. If necessary to push head forward, push \nwhole body. Let patient come around quietly. If gas is fol- \nlowed by ether, do not give too much air at first. Patients should \nlie down for awhile or take it easy for rest of day, as gas causes \nstrain on the heart. Unfit subjects are people with degenerated \narteries ; fat people ; people with heart or pulmonary trouble. The \n\n\n\n\xc2\xa3>4 NITROUS OXIDE \n\nadmission of some air does away with much of the asphyxial \nstrain. \n\nShould the operator require more time than is obtainable \nby a single period of inhalation, the administrator has several \ncourses open to him. He may reapply the face-piece before con- \nsciousness returns, and this is advisable when the patient\'s head \ncan be maintained in the vertical position, so that blood will flow \ninto the floor of the mouth and not into the throat, and if quickly \ncarried out results in no unpleasant effects ; again, he may allow \na return to consciousness and repeat the inhalation, though \ndouble administration is more often followed by nausea and vom- \niting when there has intervened an interval of consciousness ; \nhe may keep up a continuous inhalation by means of a mouth- \ntube (Fig. 19), or nose-piece which allows more or less air dur- \ning inhalation, a method which is said to give satisfactory an- \naesthesia, but which is more difficult of application and demands \nmore resistance than other methods. McCardie, of Birmingham, \nuses a tube about the size of an ordinary ovariotomy canula for \nprolonging nitrous oxide anaesthesia. The gas is briskly passed \ninto the mouth during extractions, the nose being closed by \nthe fingers or by a special clip. The administration is conducted \nin the ordinary manner by a face-piece till the patient is uncon- \nscious. By this method the whole mouth can be cleared of teeth \nwithout any pain, except in powerful subjects who require more \nprofound anaesthesia in order to abrogate reflex movements.* \nGardner highly recommends a method which he has personally \nexperienced, consisting of administering gas through a small \nnose-cap containing two small metal tubes attached to rubber \ntubes leading to a gas bag behind the patient\'s head. The pa- \ntient usually breathes through the nose, but even if he breathes \nthrough the mouth anaesthesia is readily induced. Though there \nis complete anaesthesia, there is not so marked effect of the drug \nas there is with the ordinary method, cyanosis being less, \npupils not so dilated, the eye often remaining mobile, and the \ncondition being more one of marked drowsiness than one of \ncoma. Again, the operator may administer oxygen with nitrous \noxide ; or again, he may prolong the anaesthesia by the use of a \nsmall quantity of ether, providing the stomach is empty and \ncare be taken to prevent blood from getting into the throat. \n\n*McCardie recommends the Patterson-Coleman apparatus for the con- \ntinuous administration of gas. The anaesthesia is continued through the \nnose piece portion of the apparatus. He thinks it superior to other \nmethods. \n\n\n\nNITROUS OXIDE \n\n\n\n3S \n\n\n\n\nFig. 19.\xe2\x80\x94 Anaesthetic Inhaler (Hillard). \n\nFig. 19. A method of prolonging nitrous oxide anaesthesia in dental \npractice by means of an additional gas tube leading from the bottles to a \ncatheter, which is passed through one of the patient\'s nostrils. (D \xe2\x80\x94 A). \nThe administration is conducted in the usual way with stop-cock and face- \npiece until the patient has lost consciousness, then taking the precaution \nthat the ordinary gas bag is full, and choosing the end of an inspiration \nthe face-piece is removed; the nasal tube (A) is rapidly passed (this can \nbe done during a single expiration), the face-piece is re-applied, and the \npedal stop-cock is turned so that the gas now flows only through the nasal \ntube. At this stage the inhalation is continued by both nasal tube and \nface-piece up to full anaesthesia. The face-piece is now finally removed, \nthe operation is begun, and narcosis is maintained by the nasal tube alone. \nTo prevent the return of consciousness, the netted bag (B) must be kept \nfully distended, the gas being supplied at considerable pressure. It is \nclaimed that 10 or 12 teeth can easily be extracted during the available \nanaesthesia. \n\n\n\nS6 NITROUS OXIDE \n\nDisagreeable after-effects are, of course, more common from \nthe latter method than from a double administration of the gas. \n\nTHE DANGERS OF ADMINISTRATION. \n\nThe dangers of nitrous oxide anaesthesia arise practically al- \nways from primary interference with respiration, due to spas- \nmodic obstructive stertor or to muscular spasm of the thoracic \nor abdominal muscles. There is marked cyanosis, the eyes are \nwidely open, the eyeballs turned up and the pupils widely dilated. \nthe pulse is usually small and rapid and generally continues for \nsome time after cessation of respiration, but may show early \narrest in weak, debilitated persons. Elderly people especially \nmay develop obstructed breathing from engorgement of the \ntongue. Abnormal conditions of the upper air passages favor \nrespiratory embarrassment. Foreign bodies in the air passages. \nsuch as blood, mucus, pus, vomited material, morbid growths, \nteeth, instruments or material, etc., are sources of danger. , \n\nWhile syncope and faintness are not uncommon as manifes- \ntations of the period of returning consciousness, it is doubtful \nif they occur from primary cardiac failure. \n\nSimultaneous failure of heart and respiration is very rare, but \nmay occur in patients with cardiac, mediastinal, or cardiopul- \nmonary lesions. In this instance the circulation is not well main- \ntained up to the period of stertor, but becomes feeble early. \nThere is bluish pallor and the respiration is shallow instead of \nstertorous and irregular. \n\nTHE ADMINISTRATION OF DEFINITE QUANTITIES OF NITROUS OX- \nIDE AND air. \xe2\x80\x94 The admission of indefinite quantities of air at ir- \nregular intervals has long been practiced during nitrous oxide an- \naesthesia with the effect of prolonging the anaesthetic state. Hewitt, \nof London, experimented with definite quantities of air and nitrous \noxide administered by means of a specially constructed gas- \nometer by which any. desired percentage of the gases could be \nadministered. He found that anaesthesia could be induced by \nthis means, providing the amount of air did not exceed 30 \nper cent. With a small amount of air the symptoms were similar \nto those from the pure gas. The inhalation period increased in \ndirect relation to the raise in the percentage of air. The dura- \ntion of available anaesthesia was longer than after nitrous oxide \nalone. With from 3 to 5 per cent, of air convulsive movements \n\n\n\nNITROUS OXIDE 87 \n\nwere more marked than with nitrous oxide alone, while with \nhigher amounts of air these phenomena decreased and were ab- \nsent with 30 per cent, of air. The same was true of lividity and \ncyanosis. Hewitt explains this on the ground that with no \nair obstructive stertor cuts short the inhalation of gas before the \nblood is sufficiently saturated to produce muscular convulsion. \nStertor was progressively lessened with increase in air. Reflex \nmovements were less marked than with pure gas. The best gen- \neral results were with from 14 to 22 per cent, of air. The best \nmixture for men, was from 14 to 18 per cent, of air, and for \nwomen and children, from 18 to 22 per cent, of air. \n\nThe administration of nitrous oxide and indefinite \nquantities of air. \xe2\x80\x94 Indefinite quantities of air may be adminis- \ntered with nitrous oxide alternately or concurrently. The effects \nwill vary according to the quantity of air admitted. In the al- \nternate administration the administrator anaesthetizes with \nnitrous oxide in the usual manner until partial or complete nar- \ncosis is induced, and then shutting off the gas allows the pa- \ntient to breathe a few breaths of air and then returns to the \nnitrous oxide. In this alternate manner the administration pro- \nceeds until sufficiently deep anaesthesia is produced for dental \noperations, or, in general surgery, until the operation is com- \npleted. In the concurrent use of air and gas the two are \nbreathed simultaneously, sufficient air being allowed to enter to \nobviate asphyxial manifestations. \n\nIn this country, especially, many variations of this method \nhave been practiced during the last twenty-five years in order \nto produce satisfactory anaesthesia for more or less lengthy op- \nerations. Dr. George Brush, of Brooklyn, employed an inhaler \nwith a sliding air valve, and quite lengthy operations were per- \nformed under the anaesthesia thus induced. \n\nFor comparatively short operations when absolute muscular \nrelaxation is not an essential this method can be made efficient, \nbut for operations demanding complete muscular relaxation it \nis not so satisfactory as the use of ether or chloroform. \n\nThere are few or no after-effects from this form of adminis- \ntration, and in special cases and subjects it may be used, though \nit is not always possible to obtain a strictly non-asphyxial form \nof anaesthesia. \n\n\n\n88 NITROUS OXIDE \n\nThe amount of air admitted may be increased with the length \nof the anaesthetic stage, the indications being obtained by close \nattention to the patient\'s condition. \n\nThe difficulty with this method of administration is to admit \nenough oxygen to prevent asphyxial symptoms and yet secure \nenough nitrous oxide to insure complete anaesthesia. This diffi- \nculty arises largely from the large percentage of nitrogen in the \nair. Thus if we admit sufficient air to afford a high enough per- \ncentage of oxygen to prevent anoxaemic conditions the displace- \nment cf gas will be so great, owing to the amount of nitrogen \nin the air, that anaesthesia will not be complete. \n\nThe administration of nitrous oxide gas and oxygen. \xe2\x80\x94 \n\nIn 1868 Dr. E. Andrews, of Chicago, employed oxygen in \nconnection with nitrOus oxide gas and produced a non-asphyxial \nform of anaesthesia. But little attention was paid to his obser- \nvations and this method of anaesthetization attracted small no- \ntice until Paul Bert published his experiments along the same \nline about 1878. Bert concluded that satisfactory anaesthesia by \nthis means could only be effected by increasing the atmospheric \npressure, but the observations of other experimenters have \nshown that increased pressure is not necessary for anaesthesia \nunder this method, although it may increase the effects. In \nBert\'s method the patient, administrator and bag were placed in \nan air-tight metal compartment, and the gas with 15 per cent. \nof oxygen was administered under a pressure of 89.5 cm. M. \nMartin modified this by employing 12 per cent, of oxygen and \na pressume of no cm. \n\nUnder this method respiratory disturbance, cardiac irregu- \nlarity, and asphyxia were slight, but it is not clear that this sys- \ntem has great advantage over other methods of administration. \nThe apparatus is expensive and cumbersome, and the increased \npressure a source of more or less discomfort to the operator and \nassistants. \n\nHewitt has experimented with the administration of nitrous \noxide with definite amounts of oxygen, and while this system has \ndisadvantages, being difficult of application, varying require- \nments for individual subjects, and impossibility of varying the \npercentage of oxygen according to the indications arising during \nthe administration, which interfere with its practical utility, nev- \n\n\n\nNITROUS OXIDE 89 \n\nertheless the effects of certain known percentages of oxygen \nafford us a knowledge upon which basis we can predicate in the \nadministration of oxygen with nitrous oxide gas for prolonged \noperations. \n\nHewitt\'s deductions are as follows: The inhalation period \nlengthens as the percentage of oxygen rises ; deep anaesthesia is \nobtained even when the amount of oxygen equals that of at- \nmospheric air; the duration of anaesthesia is longer than with \nnitrous oxide and air ; the longest available period of anaesthesia \n(50.1 seconds) is obtained with 7 per cent, of oxygen; with 6 \nper cent, and over of oxygen there are no convulsive move- \nments ; with 11 per cent, of oxygen there is no lividity; with \nfrom 2 to 6 per cent, of oxygen stertor is irregular or is replaced \nby regular snoring, which becomes less marked with higher \npercentages of oxygen, and disappears altogether with 20 per \ncent, of oxygen ; phonated sounds are less common with nitrous \noxide and oxygen than with nitrous oxide and air ; they are likely \nto occur with very small or with very large percentages of oxy- \ngen ; reflex and excitement movements obtain with 10 per cent, \nor more of oxygen and may be pronounced with from 5 to 7 per \ncent., or in females with from 7 to 9 per cent, of oxygen. \n\nUnquestionably the most successful way of employing nitrous \noxide and oxygen is the administration at ordinary atmospheric \npressure of nitrous oxide with a varying proportion of oxygen. \nUp to the present time this method has not been widely used, but \nwith improved apparatus and more general recognition of its \nadvantages in properly selected cases, together with increasing \nskill in its administration, it will, no doubt, become much more \ngenerally employed. \n\nThe anaesthesia induced by this method is particularly adapt- \ned to the demands of dental operations, the average of the avail- \nable period of anaesthesia as given by Hewitt being 44 seconds, \nalthough it varies greatly. The inhalation period is given as av- \neraging 1 10.5 seconds. \n\nIn general surgery the use of gas and oxygen is somewhat \nlimited. While it is not difficult to maintain unconsciousness, it \nis not always possible to secure the deep anaesthesia required for \nmany operations, such as plastic operations or rectal or vaginal \nsurgery. For lengthy operations it is a difficult system of an- \n\n\n\n(JO NITROUS OXIDE \n\naesthesia to maintain, but for slight operations about the mouth, \nnose or throat it is quite applicable. It is also useful for short, \nsecondary operations or for painful redressing where very tem- \nporary anaesthesia is desirable. \n\nThe best subjects for this method of anaesthesia are young \nwomen, weak, elderly and middle-aged women, and debilitated \nmen of middle life. Young men, robust adults, and alcoholic \npersons are not good subjects for this method. \n\nThe effects of nitrous oxide and oxygen are similar to those \nof the pure gas, with the difference that the respiratory difficul- \nties of the initial stage are more or less absent. Consciousness is \nmaintained slightly longer than with gas, and the period between \nthis and the establishment of available anaesthesia is also some- \nwhat longer. Excitement may be present, but may be stopped \nby cutting off the oxygen. The respiration may be deep and \nrapid and may change suddenly to quiet or imperceptible breath- \ning. It gradually becomes quiet, with slight snoring. When \ndeep anaesthesia is reached the subject appears as if in natural \nsleep. Stertor is absent unless the quantity of oxygen is too \nsmall to be of any benefit. Spasm of the muscles of the chest \nand abdomen is not present. There is little tendency to con- \ngestive obstruction of the upper air passages. The color of the \nface is pale or florid. Cyanosis is usually absent. The pulse is \nrapid, but is not so small as under nitrous oxide anaesthesia. Ac- \ncording to Broadbent there is lowering of tension from periph- \neral dilatation. Cardiopathic patients take nitrous oxide and \noxygen very well as compared with other anaesthetics. The eyes \nare usually closed. The eyeballs are fixed and may be turned to \none side or the other. Marked dilatation of the pupils is not \ncommon. The conjunctival reflex is usually absent, while the \ncorneal reflex is retained except in protracted anaesthesia. An- \naesthesia is evidenced by regular breathing, slightly snoring in \ncharacter; by relaxation of the arms; by loss cf conjunctival re- \nflex, and by fixed eyeballs. \n\nIn administering nitrous oxide and oxygen the patient should \nbe in a sitting position, with the head in line with the body and \nnot extended. If the recumbent position is necessary, as in gen- \neral surgery, the lateral position is probably the best, and a flat \ncouch or operating table should be used. The same preliminary \n\n\n\nNITROUS OXIDE \n\n\n\n91 \n\n\n\nattention should be given to apparatus and patient as in the use \nof gas alone. Special attention should be given to the fit of the \nface-piece, as it is even more important in using both agents \nthat the face-piece should fit closely than it is in using gas alone. \n(Figs. 20-23.) \n\nWhen the patient is breathing air freely the gas, with a small \npercentage of oxygen, is turned on. If too much oxygen is used \n\n\n\n\nFig. 20.\xe2\x80\x94 Goldan\'s Stop Cock. \n\nFigs. 20. 21, 22. The gas stop-cock (Fig. 20-I) contains two valves. \nThe inspiratory valve is set in an inner cylindrical tube, which works by a \nhandle through a right-angled slit in an external cylinder supporting the \nexpiratory valve superiorly, and inferiorly giving attachment to the gas- \nbag for gas alone, or the inverted Y-shaped tube for gas and oxygen. \nThe valves themselves are made of thin sheet hard rubber, and are there- \nfore indestructible. When the handle is turned down to the point indi- \ncated by "air" (see Fig. 1 diagrammatic plate, Fig. 21) the gas-bag is closed \nby means of the obturating function of the inner tube ; when the handle is \nturned upward to the place indicated by "gas" air is excluded and gas is \ninhaled by means of the inspiratory valve. Expirations of the patient pass \nout through the expiratory valve ; at the same time the inspiratory valve is \nclosed. \n\nWhen the handle is pushed backward to the place indicated by "no \nvalves" the valves are thrown out of action ; the patient then breathes \nback and forth into the gas-bc.g. This feature is used only with the gas \nand ether method. \n\n\n\nQ2 NITROUS OXIDE \n\nat first excitement may arise. If pure gas is given at first it may \nbe difficult to modify its effects without giving too much oxygen. \nAfter a few seconds the oxygen indicator of the apparatus may \nbe turned to 3 or 4, etc. \n\nIn young or anaemic subjects the amount of oxygen may be \nincreased more quickly than in healthy, robust adults. \n\nThe gas bags should be kept equally distended. The bag con- \ntaining the nitrous oxide will, of course, demand more atten- \ntion than the oxygen bag. Signs of excitement indicate less \n\n\n\n\nThe essential part of the gas and oxygen apparatus is an inverted Y- \nshaped tube (Fig. 20-II) attaching to the lower part of the valved stop- \ncock. It will be noticed that the right arm of the tubes is somewhat longer, \nto accommodate a revolving obturator which regulates the quantity of \noxygen. This arm of the tube is so constructed that when the obturator \nis fully open it represents exactly one-half that of the nitrous oxide arm; \nif so used it would represent exactly S3 1-3 per cent of oxygen. It may \nbe said that anaesthesia is never possible with such a large percentage of \nthis gas. Graduations are accurately marked on the surface of the tube as \n1-2, 1-4, 1-8, 1-16, 1-32, representing respectively about 33, 25, 12, 6, and 3 \nper cent of oxygen; these graduations have always reference to the op- \nposite tube. The surface of the oxygen tube has also small depressions \ninto which the metal spring slips when the oxygen is turned on; this \npermits the use of the apparatus without taking the attention of the admin- \nistrator from the patient. \n\n\n\nNITROUS OXIDE \n\n\n\n93 \n\n\n\n\nOPEN : -,*. 83 \\V CLOSE) \n\n\n\nhg.m: \n\n\n\nFig. 20-111 shows the obturator, which opens by revolving from right \nto left. The small opening represents about 6 per cent of oxygen. The \nvertical arm of the Y is the mixing-chamber for the two gases. \n\nTwo separate gas-bags are used, and by this means their respective dis- \ntention may be more easily seen than with the single bag with septum. \nFrom four to six feet of rubber tubing connect the cylinders and gas-bags \nfor transmission of the gases. The cylinders shown are the small portable \nones of English manufacture, with foot attachment. Fig. 22 represents \nthe gas and oxygen apparatus complete. There are two cylinders for ni- \ntrous oxide and one for oxygen, for the reason that a far greater quantity \nof nitrous oxide is used than of oxygen. The face-pieces of different \nsizes may be obtained of rubber, celluloid, or metal, with inflatable rims. \n\nIn order to obtain perfect results with nitrous oxide and oxygen par- \nticular attention must be given to the following points : \n\n1. The apparatus must be in perfect working order and always tested \nby the administrator himself. \n\n2. A sufficient supply of bcth gases at hand. \n\n3. Atmospheric air must be rigidly excluded. In patients with beards \nthe nostrils may be closed ; the mouth-tube may be used instead of the \nface-piece or the beard thoroughly moistened with water. \n\n4. The patient should be prepared as for any surgical anaesthetic. \n\n5. The gas-bags should never be fully inflated, but between one-half \nand two-thirds full. In this way the pressure of the gases is kept more \nnearly equal. \n\n6. Oxygen should not be turned on immediately the administration \nbegins, but sufficient nitrous oxide inhaled to replace the oxygen existing \nin the blood ; three to six breaths will he sufficient. \n\nOxygen should be admitted gradually and in quantity determined en- \ntirely by the patient\'s condition, remembering cyanosis calls for more \noxygen; evidences of excitement and returning consciousness meaning \nthat less oxygen is required. In using the gases in long narcosis the taps \nof especially the nitrous oxide cylinders are apt to freeze, owing to the \ntransition of the gas from the liquid to the gaseous state, the cylinders be- \ncoming covered with frost; to avoid this a towel wrung out of boiling \nwater should be placed about the tap, but not about the cylinder itself. \n\nThe patient should always be placed upon the operating-table in the \nposition in which the operation is to be performed ; any position may be \nemployed, providing it will not interfere with the anaesthesia. \n\n\n\n94 \n\n\n\nNITROUS OXIDE \n\n\n\nBREATHED AIR \n\n\n\n\nFig. 2 \n\n\n\ni \\ i \n\n\n\n\nREBREATHED \nGAS \n\nFig. 21.\xe2\x80\x94 Diagram of Goldan\'s Stop Cock. \n\nFig. 21. Dotted lines indicate external part of stop-cock, heavy lines \nand shaded part, internal tube. Arrows indicate direction of inspiration \nand expiration. The valves are indicated by shaded lines. A. Inspira- \ntory valve. B. Expiratory valve. C Index handle. D. Right-angled slit. \nP. Proximal end of stop-cock, attaching face-piece. X. Handle turned \ndown; air breathed. X2. Handle turned up; gas breathed. X3. Handle \nturned up and back; gas breathed back and forth into gas-bag. \n\noxygen. In from twenty to twenty-five seconds the indicator \nmay be brought up to six or seven, which will probably be suffi- \ncient for dental operations. In longer surgical operations a \nprogressive increase in the amount of oxygen is generally ad- \nvisable. \n\nOperative proceedings may begin within from two to three \nminutes of the application of the face-piece. \n\n\n\nNITROUS OXIDE \n\n\n\n93 \n\n\n\n\n"\'Jsaiisa \n\n\n\n~^M?\'$V \' .\xe2\x80\xa2\'\xe2\x96\xa0\'"\xe2\x96\xa0 \n\n\n\nFig. 22.-Goldan\'s Apparatus for N 2 and O. (Am. Jour. Med. Sci., June. 1901.) \n\n\n\n06 \n\n\n\nNITROUS OXIDE \n\n\n\n\nFig. 23.\xe2\x80\x94 Apparatus for N 2 and O (White Dent. Co.). \n\n\n\nNITROUS OXIDE g? \n\nFig. 23. One cylinder contains Pure Oxygen. \n\nThe other cylinder is filled with Nitrous Oxide. \n\nThere are rubber bags, of different colors to avoid confusion ; black \nfor Nitrous Oxide and red for Oxygen. \n\nThere are keys which open the valves of the cylinders and allow the \ngas to fill the bags through the tubes. \n\nAnother set of valves being closed, the gas remains in the bags. By \nopening one Nitrous Oxide is admitted to mixing chamber, from which it \nflows through the covered rubber tube to the Inhaler. \n\nWhen it is desired to combine Pure Oxygen with the Nitrous Oxide, \nopen valve, which admits Oxygen to the Mixing Chamber, and both \nflow together to the Inhaler. \n\nThis valve with its indicator plate is designed especially to enable \nthe operator to follow out Dr. Hewitt\'s method, and to this end the valve \naperture is enlarged regularly as the handle is turned from 1 to 10; beyond \nthis the valve operates as an ordinary valve and may be opened to the \nfull size of the tubing. It must be understood, however, that in using the \nindicator plate exact and predetermined percentages of the two gases are \nneither practical nor desirable. \n\nThere is a convenient handle by which the apparatus, which balances \nnicely, may be carried. \n\nFor compactness in transportation, the rod which supports the Inhaler \nmay be run down to the level of the Mixing Chamber. \n\nThe Cylinder for Oxygen is always red. \n\nThe Cylinder for Nitrous Oxide is black, and there need be no mistake \nin placing them in the apparatus. \n\nThe cock O should be opened wide and the oxygen valve indicator P \nplaced at, say 2, before the inhaler is applied to the patient\'s face. After \nthe patient breathes air freely through the inhaler, shut off the air and \nthen turn on the gas by pressing the spring valve K on the inhaler ; at the \nsame moment the assistant should open cock F to permit nitrous oxide to \nflow from the cylinder B to bag D. The indicator may then be advanced \nto 3, 4, 5, etc. \n\nPure Oxygen may be administered in a moment by simply closing cock \nO and throwing cock P full open. \n\nIn regulating the amount of oxygen admitted, the effects \nmust be anticipated and the amount increased or diminished be- \nfore the actual effect of such action is evidenced in the condi- \ntion of the patient. The physical state of the patient should also \nbe borne in mind, oxygen being sparingly used with those sub- \njects who resist the anaesthetic, and rather freely with those who \ndo not \xe2\x80\x94 such as children and delicate persons, also in subjects \nwith pulmonary or bronchial difficulties. During long adminis- \ntrations it may be advisable to admit a breath of air occasionally. \nIf there is troublesome stertor more oxygen should be given and \nthe lower jaw bt brought forward. A mouth-prop may be ad- \nvisable in general surgical operations. \n\n\n\n98 NITROUS OXIDE \n\nThere are no special dangers connected with the administra- \ntion of nitrous oxide and oxygen. So far as this method has \nbeen employed it seems to be remarkably free from danger. \n\nRecovery from the narcosis induced by this method takes \nsomewhat longer than from nitrous oxide alone, but is satisfac- \ntory, and there are usually no after-effects of importance. \n\n\n\nCHAPTER IX, \n\nETHER. \n\nEther, ethyl oxide, ethylic ether, vinous ether, sulphuric \nether has a chemical formula of C 4 H 10 O. It is said to have \nbeen discovered by Valerius Cordus about 1540, and was called \nby him "Oleum Vitrioli Dulce." \n\nEther fortior \xe2\x80\x94 stronger ether \xe2\x80\x94 is composed of about 94 per \ncent, ethyl oxide, and about 6 per cent, of alcohol containing a \nlittle water. Its specific gravity should be not higher than 0.725 \nat 6o\xc2\xb0 F. All formulas for the preparation of ether agree in ob- \ntaining it from the action of sulphuric acid on alcohol. The \nterm ether is used in relation to the grade recognized by the \nU. S. Pharmacopoeia (sp. gr., 0.725 to 0.72S), which corresponds \nto the pure ether (^Ether purificatus) of the British Pharmaco- \npoeia, which has a sp. gr. of 0.720. \n\nEther is a thin liquid, very diffusive, transparent, highly vol- \natile, with a characteristic, refreshing, pungent odor and sweet- \nish, burning taste, a slightly bitter after-taste, and a neutral re- \naction. It is soluble in all proportions in alcohol, chloroform, \nbenzol, benzin, fixed and volatile oils, and in eight times its vol- \nume of water at 6o\xc2\xb0 F. Its boiling point is about 98.6 F. Ether \nis highly inflammable, and a mixture of ether vapor and air is \nviolently explosive when ignited. These properties of ether \nshould be remembered when administering it in the vicinity of \nartificial light, or in pouring it from one receptacle to another. \nSerious burns have resulted from attempting to use the actual \ncautery about the mouth under complete anaesthesia with ether. \n\nLight blue litmus paper moistened with water should not be \nchanged when immersed in ether for ten minutes. If 10 c. c. of \nether be poured in portions on\' blotting paper and evaporated \nspontaneously, no foreign odor should be perceptible after the \nlast trace of ether has evaporated. When 20 c. c. of ether are \nshaken up in a graduated tube with 20 c. c. of water just pre- \nviously saturated with ether, the etherial layer upon separation \nshould not measure less than 19.8 c. c. (absence of undue amount \nof alcohol and water). If 10 c. c. of ether be shaken occasionally \nwithin one hour with 1 c. c. of potassium hydrate test solution, \n\nLOFC. \n\n\n\nIOO ETHER \n\nno color should be developed (absence of aldehyde, etc.). It \nether be agitated with carbon disulphide it becomes milky and \nturbid if water is present. \xe2\x80\x94 Boettger. One per cent, or more of \nalcohol may be detected by agitating ether with a fragment of \naniline-violet, no color being produced if free from alcohol. \xe2\x80\x94 \nStefanelli. Lieben\'s test for alcohol, founded on formation \nof iodoform from alcohol and not from ether, is the most deli- \ncate test for alcohol. The ether may be shaken with water \nwhich removes the alcohol ; the aqueous extract is then warmed, \na few crystals of iodine are added, and as much caustic potash \nas is necessary to render the solution colorless ; after standing \na few hours a precipitate of iodoform will form. One part of \nalcohol in 2,000 may be detected by this method. Tests are \ngiven for methylated ether, acetic acid, sulphuric acid, and hy- \ndrogen peroxide, but it is not necessary to consider them here. \n\nPhysiological effects and action. \xe2\x80\x94 As an anaesthetic ether \nis much stronger than nitrous oxide, and not as powerful as \nchloroform. The toxicity of ether is comparatively slight. Prom- \ninent characteristics of ether are its stimulant nature to the cir- \nculation, respiration, nervous system, and glandular system, and \nits irritant quality to the respiratory mucous membrane. The \ntoxicity of ether being slight, it is necessary to administer it in \na more or less concentrated form in order to produce complete \nanaesthesia. It is freely eliminated, mostly by the lungs, and its \neffects are graduated by the degree of concentration of the \nvapor inhaled ; that is, by the amount of air admitted during the \nadministration. When little or no air is admitted during the in- \nduction of the anaesthetic state it is possible to anaesthetize with \npractically no manifestations of excitement, and the stages of \nanaesthesia, more clearly defined under more open methods of \nadministration, are not therefore so manifest. \n\nFirst stage. \xe2\x80\x94 Owing to the pungent nature and irritant char- \nacter of ether, the first inhalations will cause a free secretion of \nmucus in the fauces, and a choking and suffocating sensation \nwill occur if the vapor is too concentrated. The patient will push \naway the inhaler or try to move his head away from it. Repeated \nacts of swallowing may take place. A sense of fullness and pres- \nsure in the head, noises in the ears, warmth, tingling, or a pleas- \nant numbness of the body may be felt. The pulse is quickened. \n\n\n\nETHER \n\n\n\n101 \n\n\n\nthe respiration is accelerated, somewhat jerky, and deeper than \nnormal. The pupils are somewhat dilated, and quite mobiie. \n\nSecond stage. \xe2\x80\x94 As the administration proceeds conscious- \nness is lost slowly or abruptly. While there may be response to \nquestions or to stimulation, the answers will be irresponsible. \nMemory is lost, and actions are not rational. Hallucinations \nmay be present. Laughing, singing, struggling may occur, es- \npecially in robust subjects who require considerable ether, or if \nthe administration is not pushed rapidly enough. A degree of \nmuscular strength may be exerted under these conditions which \nis quite surprising, and is frequently exaggerated if attempts \nto restrain the patient are made. There is usually more or less \ntonic muscular contraction, which later may become clonic, or, \nexceptionally, there may be fine muscular tremors. The face is \nflushed, perspiration breaks out freely on the forehead, face and \nbody. The conjunctivae become injected. Slight cyanosis may \nappear. Mucus and saliva are freely secreted, especially in \nyoung and robust subjects. The pulse is bounding and more \nrapid than normal. The breathing is more or less irregular from \nmuscular spasms. There may be temporary suspension of res- \npiration in muscular subjects. There may be disconnected at- \ntempts at articulation, muttering, or only respiratory noises, or \ngroans, clenching of the teeth, and attempts at swallowing may \nresult from spasm of the masseter or laryngeal muscles, espe- \ncially if the vapor be too concentrated. \n\nAs the anaesthetic state becomes deeper the muscles become \nrelaxed. The respiratory muscles and the muscles of the upper \nair passages are insensitive to reflex stimulation from the irrita- \ntion of the vapor, and the patient passes into the so-called third \nstage of anaesthesia. \n\nThird stage. \xe2\x80\x94 At this time the respiration becomes for- \ncible, regular, and there is more or less stertor. There is more \nor less rattling from pharyngeal and laryngeal mucus. The \ncorneae are not sensitive. The extremities are relaxed, and com- \nplete anaesthesia is reached. There may be some spasm of the \nmasseter muscles. The respiration is quicker than normal. Ster- \ntor may have a nasal character if the tongue is against the phar- \nyngeal vault, as is common. The pulse is usually slower than in \nthe earlier stages. It is full, bounding and regular, and may be \n\n\n\n102 ETHER \n\nfrom 90 to 120 per minute in ordinary cases. Arterial pressure \nis normal or slightly below normal. The face is flushed, and \nthe vascularity of the tissues of the upper part of the body is in- \ncreased. Marked perspiration is frequent, and a rash may appear \non the surface of the body. The pupils are usually moderately \ndilated. Under deep anaesthesia they may be markedly dilated, \nand in rare instances may be contracted. \n\nThe eyeballs are usually fixed in the horizontal plane. They \nshow loss of associated movement, or co-ordinate action may be \npreserved. In lengthy administration there is more or less de- \npression of the vital forces, and the body temperature is some- \nwhat lowered. \n\nToxic effects. \xe2\x80\x94 When an overdose of ether is administered \nrespiration shows signs of failure. The conjunctivae become in- \nsensitive. The pupils are dilated. The eyelids become separated. \nThe skin is ashy pale. The pulse is weak and slower, but the \nchange is not nearly so apparent as with respiration, which in \nsome cases loses its stertor and becomes more and more feeble \nand finally ceases entirely. There may be prolonged, wheezy ex- \npiration with short, shallow inspiration, or the breathing may \nbe very irregular, jerky and gasping. It is almost universally \nthe case that when respiratory failure occurs the circulation is \nstill of sufficient integrity to insure the success of properly per- \nformed efforts at resuscitation. The experiments of Linder- \nmann, of Moscow, on animals, show that when death occurs from \ntoo prolonged or concentrated etherization there is always con- \ngestion and oedema of the lungs present. \n\nTemporary arrest of respiration from reflex stimulation of the \nperipheral ends of the vagi and pneumogastric nerves may mark \nthe initial stage of etherization. Observers generally note a \nstimulation of the circulation. Kemp\'s experiments on animals \nshowed a raise in general arterial pressure. Mac William claims \nthere is a general but slight fall in arterial pressure, and that \ncardiac dilatation is slight or absent except when ether is sud- \ndenly pushed in administration. According to Harley, the action \nof ether in interfering with the absorption of oxygen and the \nelimination of carbonic acid is not nearly so great as that of chlo- \nroform. Van Lerber claimed that ether has little or no effect on \nthe haemoglobin, and that spectroscopic examination does not \n\n\n\nETHER IQ3 \n\nshow increase in urobilin from corpuscular disintegration. Da \nCosta, however, claimed that ether causes a marked diminution \nof the haemoglobin. \n\nAccording to Kemp, ether produces a special contraction of \nthe arterioles of the kidneys, and has a damaging effect on the \nsecreting cells of the organ, with diminution of kidney volume, \nmore or less suppression of secretion, and albuminuria not due \nto diminished tension. Other observers claim that these effects \nupon the kidney are not constant, and only appear under too \nrapid administration. \n\nA number of years ago Lawson Tait observed, while operat- \ning on a case of vesico-vaginal fistula, that when the ether was \npushed the trickling of urine from the ureter ceased, indicating \nsuppression of the kidney function, and therefore the dangerous \nnature of ether in- kidney disease. Thomas and Kemp have since \ndemonstrated the same fact by experiments on animals, and con- \nclude that ether is dangerous in renal diseases, and particularly \nso if there is a tendency to pulmonary oedema. In fifty cases ex- \namined by Blake ether produced albuminuria or increased it \nwhen already present. \n\nHooper, of Boston, has shown that under light anaesthesia, \nstimulation of the recurrent laryngeal nerve produces adduction \nof the vocal cords, while under deep anaesthesia it produces ab- \nduction. \n\nThe after effects of etherization are more marked and un- \npleasant than those of other general anaesthetics. Recovery from \nthe effects may be rapid or slow. When the patient is an- \naesthetized in the lateral, prone position, and is not saturated \nwith large quantities of ether, recovery is usually rapid and sat- \nisfactory. A too free use of ether may be followed by prolonged \nstupor, slight cyanosis, and weak pulse. Slight cyanosis is usual- \nly corrected when the throat is cleared of mucus by coughing or \nvomiting. Ether leaves a disagreeable taste in the mouth, and \nits odor is present in the breath for some time. Moderate, sud- \nden, expulsive vomiting usually occurs. It ceases quickly, may \nbe repeated once or twice, and usually occurs before the patient \nhas fully regained consciousness, leaving the patient quietly \nasleep. There may be repeated attacks of vomiting after pro- \nlonged anaesthesia in certain subjects. Haematemesis may rarely \n\n\n\n104 ETHER \n\noccur, but is unusually slight and unimportant. Haemoptysis is \nquite rare, and may or may not be significant. Bronchitis, usual- \nly mild in degree, is not uncommon after etherization, particu- \nlarly in predisposed subjects or after prolonged administration. \n\nPneumonia is more frequent after etherization than was for- \nmerly thought. According to Anders it occurs once in 300 \ncases. Ether pneumonia is usually lobular in character. Lobar \npneumonia sometimes occurs after etherization, but in this event \nit is not clear that there is direct relation between the etheriza- \ntion and the pneumonia, unless it be the effect of etherization \nin producing better conditions in the respiratory tract for the \ndevelopment of organisms which are already present. Prescott \nbelieves that ether cannot cause true lobar pneumonia. He cites \ntwo cases in 40,000 ether inhalations. In the lobular pneumo- \nnias, which are the most frequent, it is likely that the extra se- \ncretion of mucus, the interference with the action of the res- \npiratory muscles and the diaphragm, especially in abdominal \noperations, in connection with which pneumonia is most fre- \nquent, the pain and coughing all favor the occurrence of aspira- \ntion pneumonia, as suggested by Czerny. It has been thought \nthat the chilling of the respiratory tract produced by the rapid \nevaporation of the ether was the cause of the pneumonia ; also \nthat chilling of the surface of the patient\'s body during operation \nwas responsible, or that the pneumonia might be due to the di- \nrect irritant action of impurities in the ether, or to the ether it- \nself, or to infection from the inhaler. We do not, however, com- \nprehend the relation of lowered vitality of the tissues from pro- \nlonged etherization (relative) to the presence of organisms in the \nrespiratory tract. \n\nThe question of ether pneumonia was introduced by ?,Ir. \nLucas, of Guy\'s Hospital, London. Prescott, of Boston, found \nthree cases of acute lobar pneumonia in 46,000 etherizations. \nSilk, of London, 13 of pneumonia in 5,000 cases. Gurlt, 30 cases \nin 52,177. Of 15 cases of ether pneumonia in Johns Hopkins \nHospital, 15 were lobular in character, and 79 per cent, followed \nabdominal operations. \n\nAlbuminuria appears in some instances after etherization. \nObservers vary greatly in their estimate of the proportion of \ncases, \xe2\x80\x94 all the way from a quarter of one per cent, to two or three \n\n\n\nETHER I0 5 \n\nper cent. \xe2\x80\x94 of a considerable number of cases in which previous \nalbuminuria was absent. Kemp argues in favor of rather fre- \nquent appearance of renal complications after ether, while Bux- \nton and Levy are not satisfied that, properly administered, ether \nexerts injurious effects upon the kidney. The preponderance of \nevidence is in favor of etherization as an aetiological factor in \nrenal disease in a certain unknown small proportion of cases. \n\nHysterical, neurotic or alcoholic subjects may exhibit mental \nexcitement, or even mania or dementia. Chorea has also been \nnoted. Cerebral haemorrhage has been reported as an effect of \netherization, and Murchison reported jaundice as following \netherization. \n\nThe dangers connected with the administration of ether to \nhealthy subjects are almost nil. It is claimed that only one in \nfifteen thousand persons who inhale ether die, and that ether is \nonly one-fifth as dangerous as chloroform. The combined sta- \ntistics of Gurlt, of Berlin, and Juillard, of Geneva, give 341,058 \ncases of ether inhalation, with 23 deaths. In the report of \nCommittee of the British Medical Association of 1900, there is \ngiven 4,595 cases of ether inhalation, with 14 cases of danger, \nwhich include 6 fatal cases, none of which are regarded as being \nsolely due to the anaesthetic. Partial occlusion of the upper air \ntract may result from too much ether, but also occurs with mod- \nerate anaesthesia. Spasmodic cessation of respiration from tonic \nspasm of the chest muscles may occur with incomplete as well as \nwith deep anaesthesia. The respiration may suddenly cease be- \nfore or during a properly induced anaesthesia. The chest is rigid- \nly fixed and resists any efforts to induce expansion or contrac- \ntion. In some cases respiration is resumed spontaneously. In \nothers death may follow if artificial means are not successful. \nLaryngeal spasm with high-pitched, sibilant inspiration, and \nmore or less cyanosis may occur, but rarely arrests respiration, \nand, as a rule, does not last long. Temporary embarrassment of \nrespiration may occur during the period of recovery just pre- \nceding vomiting. It is usually not attended with depression of \nthe circulation. \n\nPrimary cardiac failure from the effects of ether per se is an \nextremely rare event in moderately healthy subjects. In some \ncases under operations which entail a severe degree of surgical \n\n\n\n106 ETHER \n\nshock, death may occur under ether from primary cardiac syn- \ncope. In persons with weak, dilated hearts, or advanced myo- \ncardial degeneration, death may be from cardiac failure even \nthough signs of respiratory failure be present, the asphyxial state, \ntogether with the strain of vomiting or struggling being a suffi- \ncient additional tax on an incompetent heart to insure death \nfrom cardiac syncope. In eleven cases of death under anaesthe- \nsia in which ether was employed, either alone or in conjunction \nwith other anaesthetics, included in the report of the Anaesthetics \nCommittee of the British Medical Association, rendered in 1900. \nnot one was attributed entirely to the ether. Brooks, of New \nYork, recently reported an instance of death from etherization in \nwhich respiration ceased suddenly two or three minutes before \nthe heart stopped. Autopsy failed to disclose evident cause of \ndeath. Brooks attributes death to the action of the drug on the \nganglion cells of the respiratory center. \n\nForeign bodies, such as blood, pus, vomited matter, etc., may \nenter the larynx or trachea and constitute a source of danger. \n\nThe administration. Ether may constitute the sole agent \nused for the administration \xe2\x80\x94 the usual method adopted, \xe2\x80\x94 or it \nmay be given as a constituent of a mixture containing other an- \naesthetics \xe2\x80\x94 the so-called anaesthetic mixtures, such as the A. C. E. \nmixture ; or it may be administered in sequence with other agents \n\xe2\x80\x94 the so-called method of anaesthetic sequences. \n\nThe present consideration has reference solely to the use of \nether as the only agent employed for the administration. \n\nAs a rule the administration of ether is carried to the point \nof complete anaesthesia. In relatively few instances this may not \nbe necessary. Twelles claims that two-thirds of all operations \nmay be performed under a method that has been used in Vienna, \nin which the patient is kept on the borderland between awakening \nand the stage of excitement (the "ether rausch" or "ether drunk") \nby using from 10 to 30 c. c. of a mixture of ether and balsamic \noil inhaled through an ether mask. Analgesia is said to follow \nfrom ten to fifteen deep inhalations, and the operation can be \ncommenced within a minute of the beginning of the administra- \ntion. The practicability of this method, however, remains to \nbe demonstrated. It is not adapted to excitable and highly nervous \npersons. \n\n\n\nETHER IO7 \n\nWhen possible it is best to begin the administration with the \npatient upon the operating table, or at least not to lift or haul \nthe subject about after anaesthesia is induced. The posture of \nthe patient during the administration will, of course, vary with \nthe demands of the operation, but the prone position with the \npatient upon the side or back and the head turned slightly to one \nside is, generally speaking, to be preferred. The irritating effects \nof ether upon the membrane of the fauces, and the choking sen- \nsation incident to the beginning of its inhalation should be ex- \nplained to the patient. He should also be instructed to breathe \ndeeply and regularly through the mouth. \n\nThe manner of administration will vary with the method \nadopted and the kind of inhaler employed. Inhalers are of \nvaried designs, many of which exemplify much more ingenuity \nthan practicability. The simplest inhaler which will answer for \nthe method of anaesthesia employed is always the best, and the \ninexperienced administrator should employ the simplest appa- \nratus, such as the open inhalers. \n\nEther is generally administered according to the so-called open \nmethod, the partially closed or semi-open method, or the close \nmethod. It may also be administered in conjunction with oxygen \nand may be administered per rectum. \n\nBy the open system of administration an abundance of air \nIs allowed during the entire period of administration. The ether \nis poured in small quantities on a folded napkin or handkerchief, \nor on a mask inhaler of gauze or lint which is held quite close \nto the mouth or nose. It is difficult to induce complete anaesthe- \nsia by this method, and its use is adapted only to very young \nchildren, weak or exhausted subjects, or to persons who have \n"been for some time under the influence of ether and who there- \nfore do not require much to continue the anaesthetic state. \n\nBy the partially closed or semi-open method of adminis- \ntration the amount of air admitted is limited to a greater or less \nextent, and the expired air and vapor escapes, no re-breathing \ntaking place. There are many varieties of inhalers applied to \nthis method of administration. The earliest and simplest was \nmade by folding a towel into a cone shape and placing a sponge \nor piece of gauze in the apex. A simple and efficient inhaler of \nthis kind may be extemporized by doubling a towel over two \n\n\n\nio8 \n\n\n\nETHER \n\n\n\nor three layers of newspaper, folding over and pinning down the \nedges and one end, pressing the open end into an oval shape, and \nloosely packing the upper part of the interior with gauze or a \nsponge. Inhalers for this method of administration are made \nof metal, felt, mackintosh, or leather, with open or perforated \napices. If the apex is not closed the ether may be poured on \nin small quantities as may be necessary without removing the \ninhaler from the face, sufficient air being obtained through the \napparatus. Representative types of this class of inhalers are the \nAllis (Figs. 24, 25) and the Blake inhalers, while the Goldan \ninhaler represents a simple form- adapted for either open or close \nadministration. \n\nIt is well to rub a little vaseline on the lips and adjacent por- \ntions of the face of the patient in order to avoid the irritation \nof the ether. Two or three drachms of ether are poured in the \ninhaler which is held a short distance from the face until the \npatient gets accustomed to the sensation of inhaling the vapor. \n\n\n\n*\xc2\xbbVW V SU\\T*s WtoVV*. \n\n\n\n\n\nFig. 24.\xe2\x80\x94 Allis\' Inhaler with Detachable Metal Corer. \n\nFig. 24. A metallic frame-work large enough to cover the lower por- \ntion of the face and so fenestrated as to admit the introduction of a large \nnumber of cloth partitions. These partitions are formed from a gauze \nbandage by. weaving the cloth back and forth through the fenestrae in the \nsides of the frame. Although the instrument is only about 4 inches in \nlength and from 2 to 3 in width, it requires about three yards of gauze \nbandage to form the partitions. The whole is surrounded by a nickel- \nplated cover held in place by suitable spring clips. This arrangement pro- \nvides an instrument durable, portable, inexpensive, and easily sterilized. \nOne end of the external covering is so arranged as to fit closely the con- \ntour of the face. The apparatus allows the free admission of air from \nabove, and as the evaporating surface is large, rapid vaporization and \netherization follows. The quntity of ether may be replenished as fast as \ndesired by pouring it upon the outer surface of the exposed gauze edge. \n\n\n\nETHER \n\n\n\nIO9 \n\n\n\nToo sudden inhalation of strong vapor will cause coughing, hold- \ning of the breath, choking, or a distressful sensation of suffoca- \ntion. As the patient becomes accustomed to the vapor and is \nbeginning to lose consciousness the amount of air is restricted \nand the strength of the ether vapor inhaled is gradually in- \ncreased. Careful attention should be given at this time to the \nrespiration and to the larynx. The rhythm of the respiration \nis usually somewhat irregular because of swallowing, and tem- \nporary spasmodic closure of the larynx is apt to occur if vapor \nbe too strong. The larynx soon loses its sensibility and the \nbreathing becomes regular. If excitement becomes marked, as \nis likely at this time, it may be controlled by pushing the admin- \nistration \xe2\x80\x94 a much safer procedure with ether than with chlo- \n\n\n\nW^^mm^j^maffl \n\n\n\n\nFig. 25.\xe2\x80\x94 Fowler\'s Modification of Allis\' Inhaler. \n\nroform at a corresponding period of administration with the \nlatter agent. In robust, vigorous subjects and in alcoholic per- \nsons a larger quantity of ether will be necessary to prevent ex- \ncitement and to maintain deep anaesthesia than will be required in \ndebilitated subjects. The longer the administration lasts the \nsmaller will be, as a rule, the quantity of ether necessary to pro- \nlong the anaesthesia. If the patient is not allowed to partially \nrecover from the effects of the ether during the administration \nvomiting will not be liable to occur. Much more ether is re- \nquired by the semi-open system than by the close method with \n\n\n\nno \n\n\n\nETHER \n\n\n\nbag inhalers, and excitement and struggling are more liable to \noccur. It is thought by some that there is also greater liability \nto subsequent respiratory affections. Nevertheless, for many sub- \njects, and for a great many operations the semi-open system of \n\n\n\n\nFig. 26. \n\n\n\n-Clover\'s Portable Regulating Ether Inhaler (original pattern).\xe2\x80\x94 After \nHewitt. \n\n\n\nFig. 26. F is the face-piece ; E is reservoir through which air current \npasses; B is a rubber bag. The patient breathes back and forth into the \nbag. There are no valves and no arrangement for admitting fresh air. \nThe face-piece fits tightly to the tube T which connects with a shaft pass- \ning through the reservoir. The mounting of bag B fits into the other end \nof this shaft. The current of air is regulated in passing over the ether by- \nrevolving the reservoir on the tube T. The reservoir is charged at the \nfunnel-shaped tube FT. \n\n\n\nETHER \n\n\n\nIII \n\n\n\nadministration is preferable. The moderately experienced admin- \nistrator will certainly encounter less difficulty in anaesthetizing by \nthis method, and it is therefore the most popular and widely em- \nployed system. \n\nBy the close method of administration the amount of air \nadmitted is restricted and under control, and the expired air is \nrebreathed to a greater or less extent. The names of Smith, \nof New York ; Porta, of Pavia ; and Morgan, of Dublin, are \nconnected with the introduction of inhalers adapted to this \n\n\n\n\nFig. \n\n\n\n-Sectional view of Clover\'s Inhaler. Indicator at "O."\xe2\x80\x94 After Hewitt. \n\n\n\nFigs. 27, 28. Shows the reservoir F and tube T in section. E is a \nsphere tunnelled by shaft S into which T fits. E holds the ether which is \nentered at tube FT closed by stopper St. One-half of the sphere is covered \nby a cap C. The space between C and E is filled nearly with water which \nprevents the inhaler from becoming too cold. In the shaft there are four \nlarge openings, two (O) on upper wall, and two (O\') on lower. These \nallow communication between interior of shaft and ether reservoir. The \nshaft contains a sloping diaphragm D closing one-half of the shaft. The \ntube T passes into the shaft S and has a beveled end which fits close \nagainst the diaphragm of the shaft. It has an indicator (i) pointing to fig- \nures on the reservoir. With the indicator at "O" the air current on in- \nspiration will take the course shown in Fig. 27. With the indicator at \n"F" the air current on inspiration will take the course shown in Fig. 28. \n\n\n\n112 \n\n\n\nETHER \n\n\n\nmethod of administration. The Clover inhaler (Figs. 26, 29), in- \ntroduced in 1876, may be regarded as the type of the bag \ninhalers used in this method. The Packard inhaler, the Ben- \nnett inhaler (Figs. 30-32), and other modifications of similar \nnature embody the principles of the original Clover inhaler.* \nYoung has suggested an improvement in the use of bag inhalers \nwhich consists in using a linen bag instead of the rubber one. A \nclean bag can be used for each patient, as the rubber bag gets foul \nand cannct well be cleaned. Other advantages claimed are : Less \n\n\n\n\nFig. 28.-Sectional view of Clover\'s Inhaler. Indicator at "F."\xe2\x80\x94 After Hewitt. \n\ninitial disturbance, no asphyxia or cyanosis, and if a change to \nchloroform is desired it can be dropped on the bag without chang- \ning the face-piece. Slight disadvantages are : Longer inhalation \nperiod required for anesthetization (average, ten minutes), and \nincreased quantity of ether required (about one ounce for every \nten minutes). In the administration by this method attention \nshould be given to the following points : See that the face-piece \nfits properly; in beginning the administration direct the patient \nto breathe through the mouth regularly and deeply; leave the \nindicator at "air" and allow to-and-fro breathing from the bag \n\n*Hess, formerly anaesthetist to Bellevue Hospital, says that a compari- \nson of the use of the Allis with the Bennett inhaler shows the consump- \ntion of one ounce of ether with the latter, to eight or ten ounces with the \nformer, and that a better and safer type of anaesthesia is obtained with \nthe Bennett apparatus. \n\n\n\nETHER J 13 \n\nfor a few seconds in order to partly fill the bag with air, and to \nsee that the bag expands and contracts properly with respira- \ntion, keeping the face-piece closely applied during expiration; \ngradually turn the indicator towards "ether" every two or three \nrespirations. As anaesthesia becomes effected ether may be ad- \nmitted rather more freely; coughing, swallowing, and holding \nthe breath indicate less ether and more air ; excitement indicates \nmore ether and less air. If there be stertor the face-piece should \nbe raised and a breath or two of air allowed. As the adminis- \ntration is prolonged more air may be admitted without affecting \nthe anaesthesia; slight cyanosis is present as a rule during the \nbeginning of the administration. In the later stage cyanosis \nindicates more air; marked stertor, deep cyanosis, difficult \nbreathing, and forced expiration call for more air at once. The \nsigns of anaesthesia are regular, snoring breathing, lost corneal \n\n\n\n\nTBT \n\n\n\n\nIndicator at \'3\' Indicator at \'f or \'Full\' \n\nFig. 29.\xe2\x80\x94 Diagram of Air Currents in Clover\'s Inhaler.\xe2\x80\x94 After Hewitt. \n\nFig. 29. Diagram of air current passing over ether in Clover\'s Portable \nInhaler when indicator points to "O", "i", "2", "3", and "F". Four lines \nrepresents the full current. \n\nIn preparing to use Clover\'s inhaler secure a properly fitting face-piece, \nturn the indicator to "1" or :< 2" ; pour in one and one-half ounces of ether; \nreplace the plug ; turn back the indicator to "O" ; blow once through the \napparatus to remove odor of ether, and attach the bag. \n\n\n\nH4 \n\n\n\nETHER \n\n\n\n\nFig. 30.\xe2\x80\x94 Bennett\'s Inhaler for Ether. \n\nFigs. 30, 31, 32. I. Ether Inhaier. \xe2\x80\x94 Take the ether chamber apart by \nremoving the thumb-screw. Pack the wire cage (in situ) firmly with dry \ngauze. It will hold a piece one yard wide and ten or twelve inches long. \nDo not allow the ends of the gauze to interfere with the mechanism of \nthe inhaler. Turn the index to the upward limit (full ether) and pour \nfrom one-half to one ounce of ether upon the gauze \xe2\x80\x94 one -half through \nthe face-piece, the other half through the chimney at the top of the ether \nchamber. Now turn the index to the downward limit (full air) and at- \ntach the bag. The rubber cushion of the face-piece should be moderately \ninflated. The air tap at a and at c should be closed. Apply the face-piece \nduring several expirations, so as to distend the bag moderately; then keep \nthe inhaler applied and turn the index at once to the line between air and \nether. Now turn the index toward ether, about one-sixteenth inch every \ntwo or three inspirations, or as slowly as necessary to avoid the effects of \ntoo strong ether fumes. In about one minute the index will have been \nmoved forward one-fourth to one-third the distance between the line above \nreferred to and the upward limit. Occasional inspirations of air should \nnow be given by removing the inhaler from the face, and the index should \nbe moved more gradually forward until complete anaesthesia is present. \nThis is accomplished in from two to five minutes in average patients. \nWhen the index has reached a little more than one-half the distance from \nthe line to the upzeard limit full ether is on and the index should be at \nonce moved to the upward limit. The administration consists chiefly in \nthe regulation of two factors: 1. The air supply, and, 2, The ether supply. \n\n1. The Air Supply. \xe2\x80\x94 During the induction of anaesthesia the air sup- \nply should be limited as above ; enough should be given, however, to pre- \nvent more than slight cyanosis. Patients differ greatly in the amount of \nair they require with ether, and the air supply must be regulated in ac- \ncordance with the following facts : The tap c being closed, if a is opened \nslightly the patient will rereive little air and much ether; if fully opened \nhe will receive much air and little ether. The tap a being closed, if c is \nopened slightly the patient will receive little air and much ether; if fully \nopened, he will receive much air and much ether. \n\n2. The Ether Supply. \xe2\x80\x94 At the beginning, the ether chamber should \nbe charged, as above, with from one-half to one ounce of ether, according \n\n\n\nETHER \n\n\n\n115 \n\n\n\nto the patient, and this will usually be sufficient to induce complete anaes- \nthesia. It is best to continue the administration with the index turned to \nthe upward limit, and from one-half to one drachm of ether every two or \nthree minutes will be found enough for the average patient. Ether may \nbe added, (1) through the face-piece, (2) through the chimney, or (3) \nthrough the revolving disc on the side of the ether chamber: (1) is prefer- \nable in usual cases, (2 or 3) is of great advantage when it is inconvenient \nto remove the inhaler from the face. \n\n\n\n\nFig. 31.\xe2\x80\x94 Bennett\'s Inhaler for Gas. \n\nII. Gas Inhaler. The tap c being fully opened, the bag is filled with \ngas from the cylinder through the rubber tube supplied with the inhaler. \nThe aperture d should be fully open. The rubber cushion of the face- \npiece should be moderately inflated. The face-piece should be applied so \nperfectly that the valves act well, the inspired air entering at e and the \nexpirations escaping at d. Upon closing the tap e, gas will be drav/n from \nthe bag on inspiration, escaping at d on expiration. As soon as the inhala- \ntion begins, a flow of gas sufficient to keep the bag moderately full should \nbe turned on from the cylinder. The inhalation is to be conducted on the \nprinciples of gas administration. Air may be admitted- as necessary by \nopening the tap e. \n\nreflex, and relaxed muscles. The regulation of the ether and \nair supply during the continuance of the anaesthesia will depend \non the nature of the patient. Vigorous and alcoholic subjects \nrequire much more ether than weak or very young individuals. \nThe amount of ether required is, as a rule, in inverse proportion \nto the length of the administration. \n\nThe conjoined use of oxygen and ether has not had wide \nemployment. It is claimed to possess marked advantages by \nsome, and by others said not to have any special advantage ex- \ncept in certain cases. In employing this method the tube from \nan oxygen cylinder is connected with any inhaler adapted for \nthe purpose \xe2\x80\x94 such as the Packard inhaler, and a greater or \n\n\n\nn 6 . ETHER \n\nless percentage of oxygen is admitted along with the ether. This \nmethod is adapted to persons with chest lesions and very weak \nhearts, emphysema, indurative pleurisy or mediastinitis, pulmon- \nary sclerosis and advanced tuberculosis of the lungs. These con- \nditions, especially when associated with secondary myocardial \nchanges may render such a system of anesthetization advisable, \nthough even here some people prefer a chloroform mixture such \nas the A. C. E. mixture, providing the heart is not seriously com- \npromised. \n\nDr. Dudlev Buxton recommends the use of oxygen and ether \n\n\n\n\nFig. 32.\xe2\x80\x94 Bennett\'s Inhaler for Gas and Ether. \n\nIII. Gas and Ether. \xe2\x80\x94 The ether inhaler is charged with ether and ar- \nranged as described in I., the bag being omitted. The gas inhaler is ar- \nranged as described in II., the bag being completely filled with gas and dis- \nconnected from the tube at the stop-cock f, which is to be closed. The \ngas inhaler is now connected with the chimney of the ether inhaler. The \nface-piece being perfectly applied, the tap e is closed and gas is breathed \nthrough valves. When the gas bag has been two-thirds or three-fourths \nemptied, the aperture d is closed by turning the thumb-screw of the gas \ninhaler. Gas is now breathed back and forth. The patient is at this time \nunconscious, or nearly so, and ether is to be turned on as described in I., \nthough somewhat faster. In about one minute signs of complete gas anaes- \nthesia will appear if the face-piece has been well applied (cyanosis, jerky, \nsnoring respiration, twitching movements in the extremities) and are to be \nmet by opening the tap e for two or three respirations. The tap is again \nclosed and the inhalation of gas, plus ether, is continued \xe2\x80\x94 an occasional \nbreath or two of air being allowed. In this way the gas anaesthesia sub- \nsides, while the ether narcosis becomes complete. After about one and \none-half minutes the gas may be discontinued, the gas inhaler and bag \nshould be removed and the ether bag substituted. The administration \nnow proceeds as described under I. \n\n\n\nETHER 117 \n\n"In cases in which the induction presents unusual difficulties from \ndyspnoea, spasm, cough, holding of the breath, struggling with \ncyanosis, in alcoholics, and in persons of feeble vitality. The re- \npeated filling of the bag with oxygen removes all difficulty, and \nrapidly induces a profound and quiet anaesthesia. The narcosis \nso obtained can be insured when using ether by itself, as the hyper- \noxidation of the tissues enables more ether to enter the circula- \ntion than could otherwise occur without danger to the nervous \ncenter hampered by deoxidized blood." This method is endorsed \nby Gardner, who says he finds muscular relaxation more complete \nunder this combination than with ether alone. \n\nRectal etherization was introduced by Roux in 1847. It was \nemployed with the object of obviating the usual method of ad- \nministration in operations about the mouth and nose, or pharynx. \nThe best method of introducing the ether is that of Malliere, who \nconnected the ether bottle with a rubber tube which was intro- \nduced into the rectum, and the ether bottle surrounded with water \nat a temperature of 122 F., and the ether allowed to gradually \nenter the rectum. About 2 ounces of ether was usually needed. \nIn a few minutes the patient can taste the ether, and drowsi- \nness is felt. Excitement is rare. There may be prolonged stupor \nand asphyxial symptoms, with contracted pupils. Diarrhoea and \nmelaena may follow. Weir, of New York, has reported an in- \nstance of melaena followed by death in a child after rectal ether- \nization. W. T. Bull, of New York, reported seventeen cases of \nrectal etherization, with melaena in seven. Aside from these ap- \nparent objections, this method of etherization has advantages in \ncertain cases, but under such liabilities it cannot be recommended \nexcept in rare instances. \n\nThe proper extent of anaesthesia to be maintained during the \noperation will depend on several circumstances. Too light an- \naesthesia during the early stages is apt to be accompanied by ex- \ncitement, muscular movement or spasm, vomiting, etc. The third \nstage of anaesthesia should be maintained during the earlier part \nof operations. Later it may not be necessary to maintain so deep \na state of narcosis. The amount of ether necessary to maintain \ndeep anaesthesia will vary with the characteristics of the subject, \nand the nature of the operation. In some subjects the reflexes \nare difficult to abolish and much ether may be required. Again, \n\n\n\nIl8 ETHER \n\nin some persons analgesia sufficient for minor operations may be \nsecured, even though the reflexes are present. There is not the \nsame danger of reflex failure of the circulation under light ether- \nization that exists under the same state of anaesthesia from chloro- \nform. The administrator, therefore, may keep the subject under \nas light anaesthesia as is compatible with no modification of the \nsigns of the anaesthetic state by the operative procedures. In order \nto do this he must carefully observe the state of the respiration, \nthe lid-reflex, the pupils, swallowing movements, and the degree \nof muscular relaxation. The respiration is the most reliable guide. \nThe more ether given, the deeper, quicker, and more stertorous \nthe breathing will be. Diminution in the amount of ether beyond \nthat amount necessary for complete anaesthesia will be marked \nby inaudible breathing and absence of stertor. Expiratory puf- \nfing of the lips is also an indication of full anaesthesia. Slight \nobstructive breathing is often present under light anaesthesia and \nis remedied by pushing the lower jaw forward. It may or may \nnot be necessary to maintain a stertorous form of breathing in \ncertain instances. Prolonged, forcible expiration, tracheal, or \nlaryngeal rales indicate less ether. \n\nThe lid-reflex is a good guide in many cases. The corneal re- \nflex is often present when the conjunctival reflex is absent. The \nlatter is temporarily abolished by repeated testing. Whether it \nis advisable to keep the lid-reflex abolished depends on the sub- \nject and on the operation. In some cases it is quite possible to \nhave sufficient analgesia without abolishing the reflex. Generally \nit is best to abolish the reflex, especially in operations on the skin, \nabdomen, rectum, vagina, etc. In some operations, and in weak, \ndebilitated subjects, it is often not necessary. \n\nThe pupils afford more or less reliable information as to the \nstate of anaesthesia. In the third stage they lose their mobility and \nacquire a degree of contraction depending on the peculiarities of \nthe subject. The average pupil of complete anaesthesia is about \n3-J to 4j mm. in diameter. Where the administrator has observed \nthe size of pupil present 15 or 20 minutes after the beginning of \nthe administration, and under full anaesthesia in a given subject, \nhe is prepared to draw inferences from variations from this as a \nstandard. If the amount of ether be too small to maintain full \nanaesthesia the pupil will contract and the patient will show other \n\n\n\nETHER II9 \n\nsigns of recovering, such as swallowing or other muscular move- \nments. If too much ether is given, the pupil will dilate. In some \ncases the pupil will dilate under reflex stimulation from the opera- \ntion if the anaesthesia is too light. This may happen in operations \non sensitive tissues, or in neurotic individuals. It is distinguished \nfrom toxic dilatation from too much ether by the presence or \nabsence of other signs, such as lid-reflex, or by the effect of \nless ether. If the pupil becomes small with less ether the dilata- \ntion was due to too deep anaesthesia ; if it becomes dilated with less \nether the dilatation was due to reflex stimulation. Thus the pupil \nmay be about 3J mm. under full anaesthesia, and may dilate to \n5 mm. from reflex irritation during certain phases of the operation \nand slight anaesthesia ; it may contract to 3J mm. under more \nether or absence of reflex irritation, and later dilate from the toxic \neffect of too much anaesthetic. \n\nSwallowing movements may be an early indication of return- \ning consciousness when the breathing has been regular, deep, and \nstertorous. They may precede vomiting, and the latter may be \nprevented by increasing the ether, if swallowing is observed or \nfelt with the fingers on the larynx.. \n\nMuscular movements of the arms and legs are often an early \nevidence of too light anaesthesia, and like alterations of the pupils \nmay occur from reflex irritation. Their indications are much the \nsame, though more erratic and less reliable. \n\nThe management of accidental conditions incidental \nto the period of administration. \xe2\x80\x94 A certain class of subjects \nare more likely to exhibit accidental conditions of more or less \ndanger during the administration than are others (page 41). Like- \nwise certain operations are more frequently accompanied by man- \nifestations of a dangerous nature than others (page 49). Never- \ntheless in all instances the administrator must be on the watch \nfor, and prepared to meet any unusual condition that may arise. \n\nAt the beginning of administration irregular or inefficient \nbreathing may result from too strong vapor, and a little air may \nbe necessary. In some subjects fear, nervousness, or stubborn- \nness may be the cause of inefficient breathing. Patience, firmness \nand encouragement on the part of the administrator will accom- \nplish much. Interference with respiration may occur from the \ntongue becoming applied against the pharyngeal wall after the \n\n\n\n120 ETHER \n\npatient is completely unconscious, and it may be necessary to open \nthe mouth and pull the tongue forward with forceps. Unusual \nnervous or muscular excitement may be controlled by pushing \nthe ether \xe2\x80\x94 a proceeding not dangerous at this stage in moderately \nhealthy or vigorous persons. Muscular rigidity may persist even \nthough unconsciousness is complete. It may disappear in some \ncases if more air be allowed. It may be necessary to give large \namounts of ether with plenty of air in order to overcome rigidity. \nThe breathing through the mouth should be unobstructed. In \nsome cases it may be necessary to give a little chloroform in order \nto relieve muscular rigidity, and to resume the ether afterward. \nMuscular tremor, most common in muscular subjects under ether, \nespecially in the limbs if exposed, may be relieved by changing \nthe position of the limbs, or by increasing the amount of ether. \n\nCoughing usually occurs early in the administration from too \nconcentrated vapor, especially in subjects with irritable throats \nfrom the use of alcohol and tobacco. It does not occur during \ndeep anaesthesia. It is preceded by attempts at swallowing. Oc- \ncasional coughing may not be objectionable if there be blood or \nmucus in the respiratory passages. It is not always possible to \nprevent coughing, and in some operations when the act interferes \nwith the operator it may be necessary to resort to chloroform. \n\nHiccough is rare, but is likely to occur during abdominal op- \nerations. The depth of anaesthesia has little influence on hic- \ncough. \n\nSneezing may be troublesome, and if not relieved by pushing \nthe ether the nasal region may be sprayed with a dilute solution \nof cocaine. \n\nVomiting is frequently troublesome and occurs under light \nanaesthesia, usually during the induction period or during the re- \ncovery from full anaesthesia. It is objectionable for evident rea- \nsons and may be dangerous. Vomiting is most likely to occur in \nalcoholic, robust young men and in weak women with irritable \nstomachs and sluggish livers. The secretion, during anaesthesia, \nof a large amount of saliva and mucus produces vomiting. The \nquicker and more completely the subject is brought under the \nanaesthetic the less liabilitv there will be to vomiting. Once fully an- \naesthetized the subject can usually be kept from vomiting by in- \ncreasing the amount of ether, should swallowing, high-pitched \n\n\n\nETHER 121 \n\nrespiration, or a dilated pupil with good conjunctival reflex be \nobserved. If vomiting cannot be prevented, the patient\'s head \nshould be turned well to one side and the opposite shoulder \npropped up. If the teeth are clenched the mouth should be forced \nopen and the lower jaw pushed forward. \n\nThe respiratory difficulties arising during etherization are due, \nin the early stages of administration, to some interference with the \nentry and exit of air. While during deep anaesthesia respiratory \ntroubles may arise from interruption of the function of the res- \npiratory center from an overdose of ether or from other causes. \nIt should be borne in mind that during the induction of anaes- \nthesia muscular movements, especially of the diaphragm, may sim- \nulate those of respiration in cases where there is some obstruc- \ntion to breathing. The air current should be heard or felt, or its \neffects on the bag of the inhaler observed in order to be sure \nthat the patient is breathing. \n\nObstructed breathing from spasm of the muscles of the upper \npart of the respiratory tract may be remedied by pushing the lower \njaw forward, pulling the chin forward from the sternum and up- \nward, and by extending the head over the end of the operating \ntable. It may be necessary to introduce a mouth-gag, open the \nmouth and pull the tongue forward from the pharynx. If breath- \ning is not resumed, strong traction should be made on the tongue, \nand the chest should be compressed. Crile calls attention to the \nfact that dangerous inhibitory phenomena may attend the too sud- \nden and forcible traction of the tongue during anaesthesia, cy- \nanosis, collapse, and failure of the heart and respiration becom- \ning suddenly pronounced. The effect on the heart is produced by \nmechanical irritation of the vagi and is prevented or relieved by \natropine. The effect on the respiration is through mechanical \nstimulation of the superior laryngeal nerve and is not relieved by \natropine. Where the trouble is due to mucus it will generally be \nrelieved by coughing and swallowing, which will come on if the \nadministration be suspended. In very rare instances in fat sub- \njects of a powerful build, spasm may be so intense and swelling \nso great that the air tract is closed entirely, and laryngotomy \nmay be necessary. This, with Sylvester\'s method of artificial res- \npiration, will generally bring relief. Inflation of the lung through \na tube introduced into the larynx may be necessary, using the \n\n\n\nj 22 ETHER \n\nmouth, a bellows, or the Fell-O\'Dwyer apparatus. As the imme- \ndiate cause of death is from overdistention of the right heart, \nvenesection may be of service. \n\nObstructed breathing may arise from various foreign sub- \nstances in the air passages. In operations about the mouth and \nthroat blood may enter the larynx and trachea and cause sudden \nor gradual obstruction of the breathing. If moist expiratory \nrales are heard the administration should be stopped and careful \nsponging with a coarse-meshed sponge practiced. This may be \nfollowed by forcible compression of the chest and abdomen, in- \nversion of the patient, artificial respiration, keeping the mouth \nopen and the tongue pulled forward. The rectum may be \nstretched, and ether poured on the abdomen. Laryngotomy may \nbe necessary and suction through a tube introduced into the \ntrachea may be tried. Lung inflation may be useful. \n\nVomited material may enter the trachea. In rare instances it \nmay be impossible to prevent this occurrence. If vomiting is prob- \nable the head should be kept turned to one side, the opposite shoul- \nder elevated, and the mouth kept open by a gag. Should trouble \narise from this source the measures enumerated above should be \napplied. \n\nMucus and saliva or pus may be troublesome, though usually \nit may be obviated by close atttention to the anaesthetic and its \nregulation. The mucus should be frequently sponged from the \nfauces, and if trouble arises the above line of treatment is in- \ndicated. \n\nCertain postures in which it may be necessary to place the \npatient for certain operations may aid in obstructing breathing. \nThe remedy is obvious. Certain pathologic states of the organs \nwithin the chest or abdomen may tend to produce interference with \nrespiration. In these cases moderate anaesthesia only is permis- \nsible. \n\nGeneral spasm of the respiratory muscles is an infrequent \nform of respiratory disturbance in ether anaesthesia. It is neither \nso frequent or dangerous as in chloroform anaesthesia. It may \narise during the stage of excitement, or from the reflex impres- \nsion from surgical procedures \xe2\x80\x94 such as skin incisions, or as a \nsequence to obstruction of the air tract. When the rigidity of \nthe chest from such spasm does not subside spontaneously, the \n\n\n\nETHER I23 \n\nmouth should be opened, tongue traction made and artificial res- \npiration employed. If these fail, laryngotomy should be per- \nformed and lung inflation practiced. \n\nRespiratory failure from an overdose of the anaesthetic is rare \nin etherization. Sudden arrest is not as frequent as with chloro- \nform. Shallow, imperceptible respiration, and stridulous expira- \ntion, especially if associated with dusky pallor, lost conjunctival \nreflex, and weak or irrregular pulse, are the danger signs. In \netherization, if such signs occur, the pulse usually remains of suf- \nficient integrity to insure a response to artificial respiration if \npromptly applied. Fuller consideration of this matter will be \nfound under chloroform (p. 147). \n\nRespiratory failure from cerebral anaemia, or from reflex \ncauses arising during operation is not so frequent under ether \nas with chloroform anaesthesia. Inversion of the body, artificial \nrespiration and hypodermic injection of strychnia (about one- \ntwentv-fifth of a grain) are of service. \n\nFailure of the circulation is uncommon under ether, but may \noccur from the same causes as in chloroform anaesthesia (p. 150). \nVarious impaired conditions of the general health, pathological \nchanges in the blood or in various organs may predispose to fail- \nure of the circulation under etherization, as may also psycholog- \nical conditions, mental disturbances, or the posture of the patient \nduring anaesthesia. Food in the stomach, spasmodic arrest of \nbreathing, vomiting, the operation and the effect of the anaes- \nthetic on the cardio-vascular system may all induce failure of the \ncirculation in certain cases. The management of this condition \nwill be considered under chloroform (p. 150), as it is most fre- \nquent under that anaesthetic. Ante-mortem heart thrombus has \nbeen reported as a cause of death during etherization. Such a \ncause could not, of course, be recognized, nor its effects obviated. \n\nThe clinical conclusions arrived at in regard to ether by the \nlast committee on anaesthetics of the British Medical Associa- \ntion are to the effect that complications are more frequent in males \nthan in females, but are slightly more dangerous in females than \nin males ; that ether alone, or preceded by gas or A. C. E. mixture, \nis singularly free from danger in healthy patients ; that the minor \ndifficulties of administration due to laryngeal irritation and se- \ncretion of mucus are more frequent under ether than under other \n\n\n\n124 \n\n\n\nETHER \n\n\n\nanaesthetics ; that struggling is most frequent under ether alone, \nbut rarely leads to danger ; that vomiting during recovery is most \ncommon with ether, but is usually transient; that bronchitis is \nmore common after ether than after chloroform \n\n\n\nCHAPTER X. \n\nCHLOROFORM. \n\nChloroform, also called trichlor-methane, dichlorinated chlo- \nride of methyl, and perchloride of formyl, was discovered by Dr. \nSamuel Guthrie, of Sackett\'s Harbor, N. Y., in 1831, and about \nthe same time by Soubeiran, of France, and by Liebig, of Ger- \nmany. Its real chemical composition was determined in 1834 by \nDumas. Guthrie evidently obtained in a pure state the substance \nnow known as chloroform, though he supposed it to be the well- \nknown oily liquid of the Dutch chemists which it greatly resem- \nbled, and which was known as "Dutch liquid," or ethane dichlo- \nride. He therefore used the term chloric ether, thinking he had \ndiscovered a cheap and easy process for obtaining ethane dichlo- \nride. \n\nChloroform is a liquid consisting of from 99 to 99.4 per cent, \nby weight of absolute chloroform, and from 0.6 to 1 per cent, of \nalcohol. It is a compound of one atom of carbon, one atom of hy- \ndrogen, and three atoms of chlorine. It has a chemical formula \nof C H Cl 3 . Its simplest theoretical derivation is from the action \nof chlorine on marsh gas (methane) C H 4 , whence it has been \ncalled trichlor-methane. Practically, chloroform is produced from \nalcohol by the action of chlorinated lime, from alcohol by an alka- \nline hydrate, or, of late years, chiefly by the distillation of acetone \nwith chlorinated iime. \n\nChloroform is a heavy, clear, colorless, volatile and diffusible \nliquid with an ethereal, penetrating odor, and a burning taste. Its \nsp. gr. should not be below 1.490 at 15 C (59 F.). It is volatile \neven at low temperatures, and boils at 60 to 6i\xc2\xb0 C. (141 to 141. 8\xc2\xb0 \nF.). It is not inflammable, but its heated vapor burns with a \ngreenish flame. \n\nChloroform has marked solvent properties. It is soluble in 200 \ntimes its volume of cold water, and in all proportions in alcohol, \nether, benzol, benzin, and in fixed and volatile oils. It is liable to \ndecomposition by sunlight, and even by diffused daylight, hence \nshould be kept in well-stoppered, colored glass containers. \n\nChloroform may contain alcohol and ether, both of which lower \nits sp. gr. If its density is less than 1.38 it will float instead of \n\n\n\n126 CHLOROFORM \n\nsinking in a mixture of equal weights of concentrated sulphuric \nacid and water after it has cooled. \n\nAbsolutely pure chloroform is liable to decomposition, and a \nsmall amount of alcohol is necessary to preserve it. It is said that \none-tenth of one per cent, is sufficient. It is claimed that when \npurified by Pictet\'s freezing process the presence of alcohol is not \nnecessary to the preservation of chloroform. \n\nThere has been much discussion in regard to the presence of \nimpurities in chloroform and their relation to dangerous symptoms \nor fatal conditions arising during the use of chloroform as an an- \naesthetic. There is no definite knowledge on this point, and as \nsuch symptoms and conditions arise from the use of chloroform \nof known absolute purity, it is not possible to be explicit in this \nconnection. \n\nChloroform should have the sp. gr. and boiling point already \nmentioned. It should be transparent and colorless. It should be \nabsolutely neutral to test-paper and its odor should be non-irritat- \ning. \n\nIf alcohol be present in chloroform it may be detected, accord- \ning to M. Mialke, by dropping small quantities of chloroform \ninto distilled water. If the chloroform is pure it remains trans- \nparent at the bottom of the glass, while if only a small per cent, \nof alcohol is present the globules will be milky. Soubeiran ad- \nvised the agitation of chloroform and almond oil in a tube, when, \nif pure, the chloroform remains clear, while with 5 or 6 per cent, \nof alcohol it becomes milky. \n\nThe following official tests may be used : Pour 20 c. c. of chlo- \nroform on clear, odorless filter paper laid flat on a narrow glass \nor porcelain plate. Rock gently until chloroform is entirely evap- \norated. No foreign odor should remain, and the paper should be \nnearly odorless as compared with new, odorless filter paper ; shake \n10 c. c. of chloroform with 20 c. c. of distilled water and allow \ncomplete separation. The water should be neutral to litmus paper \nand should not be affected by silver nitrate test-solution (absence \nof chlorides), or by potassium iodide test-solution (absence of \nchlorine) ; place about 5 c. c. of chloroform in a test tube with a \ncapacity of about 10 c. c.,add about 4 c. c. of perfectly clear barium \nhydrate test-solution without agitation, cool the test-tube and set \naside in a dark place for six hours. No film should be visible \n\n\n\nCHLOROFORM 127 \n\nat the line of contact of the two liquids (absence of products of \ndecomposition in chloroform which may otherwise be pure). \n\nThere are other tests and methods of purification which are \nnot necessary to consider here, as reliable manufacturers now fur- \nnish a pure article of chloroform. \n\nPhysiological effects and action. \xe2\x80\x94 The inhalation of chlo- \nroform vapor is not as unpleasant as the inhalation of ether. Its \nodor is rather agreeable than otherwise, while the taste is pun- \ngent and sweetish. \n\nDuring the first stage there is little sense of suffocation un- \nless the vapor be too concentrated. Swallowing, choking, and \nholding the breath usually do not occur unless the vapor be strong \nenough to irritate the larynx. There is a general feeling of warmth \nand exhilaration, pressure and fullness in the head, noises in the \ncars and similar effects common to the initial stage of anaesthesia \nby other agents. The breathing is somewhat deeper and quicker. \nThe pulse is quickened and full. The pupils are usually some- \nwhat dilated. The first stage is short compared with that of ether- \nization, and may be devoid of symptoms other than the deeper, \nquicker breathing, and the more rapid pulse. \n\nThe second stage is marked by flushed or pale countenance, \nirregular, jerky respiration, a greater or less degree of excite- \nment, especially in muscular, alcoholic, nervous or hysterical sub- \njects. Talking, shouting, swearing, gesticulating, attempts to \nrise, movements of the arms and legs, holding of the breath, etc., \nare not uncommon. The patient may be easily aroused at this \nperiod, though sensibility to pain is decidedly lessened. The \nsense of taste and smell are abolished, though that of touch may \nremain. The sense of sight may be abnormally acute or may be \nsubject to illusions. In some cases none of these symptoms are \npresent, and the patient passes gradually and gently on to com- \nplete unconsciousness. Muscular rigidity may or may not be \nmarked. It is most frequent in muscular or alcoholic subjects. \nTonic or clonic spasm may occur. Fine tremor is rare. Holding \nthe breath, tonic or clonic spasm may occur from too rapid ad- \nministration. Struggling or excitement, on the other hand, may \nresult from too rapid administration. A proper medium may di- \nrect the patient on to the quiet, easy, snoring respiration of full \nanaesthesia. In exceptional cases the respiration is rapid and deep \n\n\n\n128 , CHLOROFORM \n\nthroughout this stage. There may be loud stertor, which, how- \never, does not indicate deep anaesthesia. The pulse varies greatly. \nIt may be very slightly accelerated, regular and soft. Again, it \nmay be rapid. The rate, regularity and fullness of the pulse de- \npend largely on the conditions arising during the administration. \nInterference with respiration from any cause, coughing, vomit- \ning, etc., will produce variations in the pulse. The pulse may \nbecome quite small and feeble and slow just preceding the act of \nvomiting. Syncope may occur from vomiting. The probability \nof its occurrence and its dangers are less in vigorous subjects. \nThe pupils are usually more or less dilated, and react slowly or \nnot at all to light. They may be moderately or decidedly con- \ntracted Movements of the eyeballs may occur from spasm. \nNystagmus may be present. \n\nThe respiration, instead of gradually acquiring the regular \ncharacter of full anaesthesia, may become shallow or imperceptible, \nand be accompanied by pallor and feeble pulse. Hewitt considers \nthis condition a result of too sparing administration and an in- \ndication of a tendency to vomit, and that it could be obviated by \na careful continuance of the anaesthetic. In some instances this \nis probably the case, and in others these symptoms are indications \nof failing respiration. In some cases, especially in children, there \nmay be all the appearances of complete anaesthesia and yet sensa- \ntion may not be abolished. This is liable to occur if a patient is \nkept for some time under chloroform before operation is begun, \nand under these conditions dangerous, reflex, respiratory spasm \nor cardiac syncope may develop. \n\nIn some cases the patient may not exhibit the respiratory or \nother signs of complete anaesthesia, may answer direct questions, \nrepeat words, or even have an indistinct realization of what is \ngoing on and yet be sufficiently insensible to pain as to submit to \noperation without complaint. The corneae at this time may be \ninsensitive, though the lid-reflex can generally be obtained. \n\nThe third stage of chloroform anaesthesia is usually marked \nby regular, soft, slightly snoring respiration. The face may be \nslightly flushed or pale. Pallor may be shown if there is a tend- \nency to vomit. Slight obstructive interference with breathing \nmay cause slight cyanosis. Usually cyanosis is absent, as plenty of \nair is allowed during this stage of the administration. The face \n\n\n\nCHLOROFORM 129 \n\nusually becomes pale after the administration has been continued \nfor some time. There is usually complete muscular relaxation. \nRigidity at this stage is rare. There is slight reduction of the \nbody temperature. The secretion of mucus and saliva is rarely \nsufficient to cause annoyance. The eyeballs may be fixed in the \nhorizontal plane or may be slowly movable. As a rule the move- \nments are not co-ordinate. Loss of associated movement may be \nan indication of complete anaesthesia. The pupils are usually con- \ntracted. They are decidedly smaller than the ether pupil, meas- \nuring on the average, according to Hewitt, 2-J\' mm. They are \nmore or less responsive to light, and react to the anaesthetic. A di- \nlated pupil may indicate returning consciousness or may indicate \nincreasing narcosis. The lid-reflex, as a rule, is absent, though \nthere may be exceptions to this rule. \n\nThe pulse is generally well sustained under properly conducted \nadministration. It is slower than under etherization, as a rule, \nand may be at the normal rate or even considerably less. The \npulse tension is diminished, and in weak subjects the pulse may \nbe feeble or almost imperceptible, though here the pulse is usually \nstronger during deep anaesthesia than during the second stage. \nRetching, vomiting, and respiratory disturbances affect the pulse, \ncausing it to become more feeble and sometimes irregular. A \nmarkedly slow pulse may indicate too deep anaesthesia. A nor- \nmally slow pulse will usually continue slow under deep anaesthesia. \nKappeler states that in twenty patients of various ages the de- \ncline in pulse rate varied from four to thirty beats per minute. \nThere is a more or less rapid and maintained fall of blood pressure. \n\nIn some cases the respiration, while satisfactory, will be quiet \nand inaudible. There may be loud stertor, especially in plethoric \nsubjects, if the anaesthetic be pushed. Inspiratory, laryngeal \nstridor may be present. The breathing generally is more quiet, \niess deep, and its general character less evident than with ether, \ntherefore it is not as reliable a guide under chloroform as under \nether anaesthesia. \n\nThe toxic effects of chloroform inhalation are shown by \nmarked pallor, cold perspiration, feeble or imperceptible pulse and \nvery shallow respiration. The respiration may stop suddenly or \ngradually. The pulse may show signs of failure before it ceases, \nor an apparently good pulse may stop suddenly without warning. \n\n\n\n13\xc2\xb0 CHLOROFORM \n\nThe pulse usually stops before respiration ceases, or at least be- \ncomes affected before respiration. Death may occur soon after \nthe beginning of the inhalation, and at that time is probably due \nto paralysis of the cardiac ganglia, which for unknown reasons \nmay be abnormally susceptible. Death may occur in the stage \nof muscular rigidity which precedes complete muscular relaxation, \nand be due to tetanic rigidity of the respiratory muscles, interfer- \nence with the pulmonary circulation, and venous engorgement of \nthe right side of the heart, respiration ceasing before the heart. \xe2\x80\x94 \nRichardson\'s epileptiform syncope. This difficulty is not so liable \nto arise under chloroform as under the open methods of etheriza- \ntion. Death may occur from respiratory paralysis during the \nstage of relaxation, though this is not common from chloroform. \nCardiac paralysis may occur during complete insensibility from \nparalysis of the motor ganglia. The heart suddenly stops, respira- \ntion continuing for a short time. General depression from the \nanaesthetic, plus surgical shock or the shock of accident, may \nresult in death at the time of the inhalation or afterward. \n\nThe physiological action of chloroform is more energetic \nand prolonged upon protoplasm than is that of ether. Waller\'s \nestimate of the relative toxicity of ether and chloroform upon \nisolated nerves is as i : 7. Locally, the action of chloroform is ir- \nritant. It destroys the contractility of muscle tissue, causing \n\'\'chloroform rigidity." It produces structural changes in muscle \ntissue (Bernard). It is solvent to the essential ingredient of \nnerves and nerve centers (Brunton). \n\nThe subcutaneous injection of chloroform has a local anaes- \nthetic effect, but owing to slow absorption and free elimination \ngeneral anaesthesia is not produced. The latter state may be pro- \nduced by intravenous injection. Snow has calculated that the \nblood of the adult necessarily contains from 12 to 24 minims of \nchloroform, according to the degree of anaesthesia, and for the \narrest of respiration 36 minims are necessary. It has been found \nthat with atmospheres containing from 2 to 4 per cent, of chloro- \nform there is little risk, but with above 5 per cent, there are alarm- \ning symptoms. \n\nThe respiratory center is first stimulated by chloroform, this \nis followed by depression and finally by paralysis. The depress- \ning effect of chloroform on respiration is more marked on expira- \n\n\n\nCHLOROFORM 131 \n\ntion than on inspiration. Beside the toxic effect of chloroform \non the respiratory center, we have to consider, in respiratory fail- \nure from chloroform toxaemia, the additional factors of loss of \nblood pressure from cardiac depression, and the effect of obstruct- \nive interference with respiration. \n\nIn regard to the respiratory interchange of gases under chlo- \nroform, there is less oxygen absorbed and less carbonic acid ex- \nhaled, though according to some observers there is increase in the \namount of the latter. \n\nThe blood changes due to chloroform are not definitely under- \nstood. It is generally conceded that there is diminution in the \ncapacity of the blood to absorb oxygen and to give off carbonic \nacid. Also that there is some degree of disintegration of the red \nblood cells. \n\nThe effect of chloroform on the blood-pressure and heart has \nreceived much attention, which has resulted in diverse opinions. \nThe Committee of the Royal Medical and Surgical Society, Gas- \nkell and Shore, and MacWilliam in some instances, found a pri- \nmary rise, followed by a fall, in blood-pressure. The Glasgow \ncommittee found a fall in blood-pressure, while Wood and Hare \nfound an initial fall, followed by a rise, in blood-pressure. Most \nobservers agree that the fall of blood-pressure is due to the effect \nof chloroform on the heart and not to its effect on the vaso-motor \ncenter. \n\nThe effect of chloroform on the heart itself has caused much \ndiscussion. The views of the Hyderabad commission to the ef- \nfect that not only was the primary fall in blood-pressure due to \nthe effect on the vaso-motor center, but that the heart was never \nprimarily affected, is generally disregarded at present. The ob- \nservations of Wood and Hare, Gaskell and Shore, Hill and Bar- \nnard, MacWilliam, and others, tend to show that chloroform di- \nrectly depresses the heart, and that when respiration ceases before \nfinal stoppage of the heart the primary depression of the heart\'s \naction is the essential and probably the initial factor in death \nfrom chloroform. Experiments on animals show that chloroform \nproduces dilatation of the heart. Physiologists claim that reflex \ntemporary inhibition of the heart by irritation of the nerve end- \nings in the upper respiratory tract by chloroform is not gen- \nerally dangerous, and may even be in a sense conservative. Phys- \n\n\n\n1 32 CHLOROFORM \n\niologists also state that chloroform injected into the veins de- \npresses the heart, and injected into the carotid arteries causes \nparalysis of the respiratory and vaso-motor centers. Hill has \nshown that when a chloroformed subject is changed from a hor- \nizontal to an upright position there is a greater fall in arterial \npressure than would occur without chloroform. This has a direct \nbearing on the question of posture, and the moving of chloro- \nformed subjects. \n\nSalivary secretion is usually slightly increased during the early \nstage of chloroform inhalation and diminished during deep an- \naesthesia. \n\nChloroform affects the kidney action much less than ether. \nThe kidney secretion is generally fair unless there is marked de- \npression of the circulation. Albuminuria is rare except after pro- \nlonged narcosis. \n\nThe repeated administration of chloroform to animals pro- \nduces fatty changes in various organs and tissues. \n\nAfter death from chloroform the heart will usually be found \nsomewhat dilated and the right cavities full of blood, the left side \nbeing comparatively empty. If death has occurred after a gradual \nadministration without any asphyxial element, the heart may be \nrelaxed and empty, and the lungs not especially congested. If \ndeath occur after marked asphyxial conditions there will be \nmarked congestion of the lungs, overdistention of the right heart, \nwith but little blood in the left side. In cardiopathic subjects death \nmay occur before marked alterations, due to the administration, \ntake place. If arrest of respiration occurs during or at the end \nof inspiration the lungs will contain more blood than when such \narrest occurs during expiration (Hill). According to Kunkel, the \nheart arrested by chloroform always stops in diastole. Various \nobservers state that the blood after death from chloroform is of a \ndeep cherry color, and more fluid than usual. According to Fran- \nkel and others, the tissue elements of the heart, liver and kidneys \nundergo coagulation necrosis, and there are deposits of pigment \nin the parenchyma of the kidneys and liver. \n\nThe after effects from chloroform inhalation vary consid- \nerably, according to the nature of the administration and the char- \nacter of the symptoms during the period of inhalation. When \nthe administration has been properly and carefully conducted and \n\n\n\nCHLOROFORM 1 33 \n\nthe subject has taken the anaesthetic without difficulty, the re- \ncovery will be uneventful, the patient passing into a quiet sleep, \npossibly preceded by slight retching or vomiting. If the chloro- \nform has been exhibited with too much conservatism or there \nhas been unpleasant manifestations during its inhalation, there \nmay be marked pallor, weak pulse, nausea, or vomiting. Gastric \ndisturbance is more frequent after ether than after chloroform, \nbut the vomiting of the ether is more transient and less liable to \nrecur than that occurring after chloroform. Severe and prolonged \nvomiting is more common after chloroform. Depression of the \ncirculation is a more common after effect from chloroform than \nfrom ether. \n\nBronchial inflammation and pneumonia are rare after chloro- \nform, though they may occur in predisposed subjects. Mental \ndisturbances may occur in predisposed subjects. Jaundice may \nbe a rare after-effect. Some observers have claimed that albu- \nminuria is frequent after chloroform, but this is not generally \nconceded. L. G. Guthrie believes that a condition similar to acute \nyellow atrophy of the liver may be a fatal after-effect in children. \n\nThe dangers arising during chloroform administration \nmay be due to the toxic action of the drug, or may be such as arise \nduring the administration of any anaesthetic. More or less dan- \nger may result from obstruction of the breathing, from nervous \narrest of respiration in excitable subjects, or from obstruction \ndue to spasm, swelling of the upper respiratory tract, or ob- \nstructive interference of the tongue, though such causes are in- \nfrequent under chloroform. Spasm of the respiratory muscles, \nforeign substances in the air tract, as enumerated under ether \n(p. 122), may cause danger. Vomiting is not frequent, but dan- \ngerous vomiting is relatively more frequent under chloroform \nthan under ether. Interference with lung expansion from tight \nclothing, the posture, morbid states, respiratory spasm, and inter- \nference with lung expansion through operative measures may \ncause danger. Paralytic arrest of breathing may occur from too \nlarge a dose of the anaesthetic, from reflex inhibition from oper- \native measures, from cerebral anaemia, and it is claimed in part \nfrom morphine administered previous to inhalation. \n\nFailure of the circulation may result from such predisposing \ncauses as morbid conditions of the heart, lungs, blood, renal dis- \n\n\n\n134 CHLOROFORM \n\nease, mental disturbance, sitting posture, food in the stomach, or \nfrom respiratory embarrassment from various causes, vomiting, \nthe operation, or from the effect of chloroform on the heart and \nvascular system. \n\nThe clinical evidence regarding chloroform gathered by the \nAnaesthetics Committee of the British Medical Association (1900) \nis to the effect that chloroform is about twice as dangerous in \nmales as in females ; it is most dangerous during infancy, and least \ndangerous from the tenth to the thirtieth years ; chloroform is the \nmost dangerous anaesthetic in conditions of good health, and while \nleast safe in grave conditions, the disparity here is less marked. \nWhen danger occurs from chloroform, in the large proportion of \ncases the symptoms are of primary circulatory failure. Imperfect \nanaesthesia is the cause of danger in a large number of cases. \nHewitt calls attention to the important fact that a large propor- \ntion of the conditions of danger during chloroform administration \nare not connected with an overdose, relatively speaking, of the \nanaesthetic. He finds that of 130 chloroform deaths reported in the \nLancet, and British Medical Journal, from 1880 to 1889, inclu- \nsive, 54 took place very early, either before operation or during \nshort or trivial operations. Comte collected 232 cases of death. \nThe time of death was specified in 224 instances, and in 50 per \ncent, occurred before anaesthesia was complete. Hewitt combines \n101 cases given by Kappeler and 109 cases reported by the Com- \nmittee of the Royal Medical and Chirurgical Society in 1864, and \nfinds that the time of death was specified in 75 cases, in 90 per \ncent, of which death occurred within the first fifteen minutes. \nThe report of the Anaesthetics Committee of the British Medical \nAsssociation (1900) gives 13,393 chloroform cases in which com- \nplications of some degree arose in 3.270 per cent. There were \n120 dangerous cases, with 18 deaths. The combined statistics \nof Gurth, of Berlin, and Juillard, of Geneva, give 691,329 cases of \nchloroform inhalation, with 224 deaths. Chloroform is generally \nregarded as being about five times as dangerous as ether. \n\nThere are various factors which constitute a source of danger \nduring chloroform inhalation besides the toxic action of the drug \nitself. Psychical causes may contribute towards danger or death \nearly in the administration. Cases have been reported by various \nobservers of death apparently due to fright alone before the ad- \n\n\n\nCHLOROFORM 1 35 \n\nministration had begun. It is a fact, however, that the cases of \n"fright syncope" are practically limited to cases where chloroform \nwas employed, and we must therefore regard psychical influences \nas merely a more potent contributory cause under chloroform than \nunder other anaesthetics. Reflex cardiac inhibition from the effect \nof concentrated vapor on the mucous surface of the upper res- \npiratory tract was a favorite theory of French observers as to the \ncause of early manifestations of danger. It is not generally ad- \nmitted that this cause is effective. Holding the breath, laryngeal \nspasm, and asphyxial conditions from irritation by the vapor are \nprobably rare, being in most instances due to obstruction or to the \neffect of the agent on the respiratory center or on the muscles of \nrespiration. It is generally believed that shock due to the com- \nmencement of operation may produce dangerous or fatal syncope. \nHewitt believes that such a cause rarely is fatal, if ever, and calls \nattention to the fact that skin incisions under light anaesthesia al- \nmost invariably stimulate both respiration and circulation. Never- \ntheless, many observers have found signs of collapse coincide with \nthe beginning of operation. \n\nIn the list of fatal chloroform cases given in the report of the \nBritish Medical Association Committee already alluded to there \nare some instances where the pulse and respiration failed either \ncoincidently or successively at the moment of the beginning of \noperative procedures. \n\nReflex arrest of respiration from spasm is more likely to occur \nunder chloroform during surgical measures than with other an- \naesthetics. Vomiting may cause depression of the heart and pos- \nsibly fatal syncope. Dangerous vomiting during anaesthesia is \nsaid to be more frequent under chloroform than other anaesthetics. \nEpileptiform spasm may be dangerous, especially in muscular sub- \njects. Clonic spasm is not uncommon early in the administration, \nwhich may indicate a need for more anaesthetic. Clonic move- \nments of the arms and pectoral muscles indicate a necessity for \nmore air (Hewitt). Laryngeal spasm, shown by high-pitched \ninspiratory stridor, may occur during anaesthesia by chloroform, \napart from the local effect of the drug as a cause. It is thus more \ncommon under chloroform than under ether, and represents a \ndangerous degree of anaesthesia. \n\nPathological states, posture, idiosyncrasy on the part of the \n\n\n\nI36 CHLOROFORM \n\npatient, and late surgical shock may all be factors in the produc- \ntion of dangerous symptoms. \n\nChloroform toxaemia from an overdose may result through too \nconcentrated vapor, exaggerated breathing of vapor not unusually \nconcentrated, and through some unusual susceptibility on the part \nof the subject. The result may be simultaneous stoppage of both \npulse and respiration, or the pulse at the wrist may stop before \nrespiration ceases, or the pulse may be still perceptible when res- \npiration ceases. In pure chloroform toxaemia the respiration \nceases before the heart action. We may not be able to feel the \nradial pulse or even to hear the heart beat if the lungs are full of \nair. This does not prove, however, that the heart has actually \nstopped. The failure of heart action is the primary and essential \nfeature of death from chloroform toxaemia. If this condition \nshould supervene upon a carelessly rapid administration, death \nmay come too suddenly to allow of any recognition of the se- \nquence of the symptoms. Toxic conditions following a more \ngradual administration show shallow, slow, gasping, jerky or ir- \nregular respiratory action with cessation of abdominal and tho- \nracic movements. The symptoms which indicate the approach of \ntoxsemic conditions are : impaired respiration, slow, feeble pulse, \nbecoming irregular and often imperceptible ; no lid-reflex ; separa- \ntion of eyelids ; upturned eyeballs ; considerable or marked dila- \ntation of the pupils ; marked pallor of skin. \n\nDeaths from chloroform are marked by sudden heart failure \nfollowing upon respiratory interference, which may in some in- \nstances be comparatively slight ; and by toxaemic conditions of the \ncardiac nervous mechanism, or possibly in some degree of the \nmyocardium itself. \n\nFor the administration of chloroform the patient should be \nin the recumbent position ; the sitting position should not be used \nif it can be avoided. The patient should not be moved or the \nposition changed after administration is begun unless absolutely \nnecessary. The patient should be reassured, informed as to the \nnature of the sensations produced by the inhalation, and instructed \nhow to breathe. \n\nThe administration of chloroform may be conducted by ad- \nministering the vapor of chloroform with air or with oxygen. \nThe latter method was introduced by Neudorfer, of Vienna, who \n\n\n\nCHLOROFORM \n\n\n\nl 2>7 \n\n\n\nadministered mixed oxygen and chloroform vapor through a \nclosely fitting face-piece. Junker\'s inhaler has also been used by \npumping oxygen from a bag attached to the hand bellows through \nthe chloroform. This method of administering chloroform has \nnot been much used and is of doubtful advantage.* \n\nThe toxic nature of chloroform demands that it should be ad- \nministered with plenty of air, and that any method or apparatus \nemployed for its administration should afford ample facility for \nthe admission of plenty of air at a moment\'s notice. Simpson, \nwho introduced chloroform as an anaesthetic, used a handker- \nchief folded in a cup-shape, into the hollow of which a small \namount of chloroform was poured. \' Later he employed a folded \ncloth or towel, and still later a single layer of cloth laid over the \npatient\'s mouth and nose, upon which the chloroform was dropped. \nThis method corresponds to the drop method used with the Es- \nmarch or Skinner mask, so widely in use at the present time. \n\nSnow\'s experiments with definite amounts of chloroform vapor \nled him to devise an inhaler by which the percentage of chloro- \nform vapor could be regulated at about 4 or 5 per cent. Clover \n\n\n\n\nFig. 33.\xe2\x80\x94 Junker\'s Inhaler. \n\nFig. 33. An anaesthetic bottle (a), which is connected by rubber tubes \nto the face-piece (b), and an air bellows (c), to the latter of which is \nattached an equalizing rubber ball (d), covered with netting, to prevent \nover-distension. \n\nThe anaesthetic bottle is graduated, so that the amount of the anaes- \nthetic consumed is known. To the stopper of the bottle there is a hook \nattached, by which it may be hung from the anaesthetist\'s coat. \n\n*Flux, of London, has devised a modification of the Junker inhaler. \nA cylinder contains wadding upon which chloroform is poured. A bulb \naspirates air through the wadding and drives it through a tube connected \nwith a nose or mouth tube. An opening in the cylinder will admit air to \ndilute the chloroform vapor if desired. It is portable and convenient. \n\n\n\n138 CHLOROFORM \n\nalso devised an inhaler which would give from 3J to 4J per cent, \nof chloroform vapor. Many other inhalers have been devised \nalong these lines. They have the objection of a closely fitting face- \npiece, which adds to the dangers of producing complete anaesthe- \nsia by their use. The Junker inhaler, which has been much em- \nployed, especially in England (Fig. 33), consists of a bottle to \ncontain chloroform, a loosely fitting face-piece, a hand bellows, \nand tube connections. Air is pumped through the chloroform in \nthe bottle and into the face-piece, carrying with it an indefinite \npercentage of chloroform. A cloth mask may be used instead of \nthe ordinary leather or vulcanite face-piece, which will allow of \ndropping chloroform on the mask if a more concentrated vapor is \nnecessary. The Junker inhaler is not a safe inhaler for children, \nand though when carefully used it may lessen the risks from \nchloroform inhalation, several deaths have occurred under its use. \nHewitt has modified the Junker inhaler to some advantage. Such \nan apparatus as the Junker may be very useful in operations about \nthe mouth, nose, or pharynx, where, especially if the actual cautery \nis to be used, ether is not available. In these operations the vapor \nmay be introduced through a nose or mouth-tube, such as Hewitt\'s \nmodification of Mason\'s gag. In such operations the advantage \nof such inhalers is most evident. In ordinary surgery they de- \nmand too much attention, the constant pumping is troublesome, \nasphyxial conditions are as liable to arise as with other methods \nof administration, and in some cases profound anaesthesia cannot \nbe induced. \n\nMany kinds of inhalers have been devised. There are combi- \nnation inhalers, like the Packard inhaler or the Bennett inhaler, that \nmay be used for either gas, ether or chloroform ; or inhalers like \nHiddens\' that are only suitable for chloroform.* \n\nThat the simplest method of administration is the best is a \nmore forcible truth in relation to chloroform than any other an- \naesthetic, for the reason that any inhaler other thaxi the very sim- \nplest is objectionable. The method which will produce a satis- \nfactory analgesia with the least amount of chloroform is the best, \nand this can undoubtedly be accomplished by the drop method \non a mask or a single layer of cloth or lint. This is practically \nthe method of Simpson, improved. Simpson at first considered \nchloroform as a perfectly safe anaesthetic, and recommended it to \n\n*In England the Harconrt Chloroform Inhaler is much used, while in \nGermany the Braun Chloroform Inhaler is popular. In France the Gig- \nliementi Oxygen-Chloroform Inhaler is used. These inhalers represent \nlate advances in the accurate administration of anaesthetics. \n\n\n\nCHLOROFORM \n\n\n\n139 \n\n\n\nbe used "powerfully and speedily," in order to avoid excitement. \nLater he modified his method more in accordance with present \nusage. \n\nThe difficulty of estimating the percentage of chloroform in- \nhaled in this method has been considered its weak point. Snow, \nwho estimated that the inhaled vapor should not exceed a strength \nof 5 per cent., calculated that 9.5 per cent, might be given off \nfrom a folded cloth wet with chloroform at 70 F. Lister esti- \nmated that a moistened cloth held close to the face gave off but \n4.5 per cent. Sansom claimed that at 60 to 64 F. it was possible \nto inhale 13 per cent, of vapor with but one dram of chloroform \npoured upon lint. That it is practically impossible to estimate \nthe percentage of vapor inhaled is evident when we consider the \nnature of the fabric used, the number of its folds, the extent of \n\n\n\n\nFig. 34. \xe2\x80\x94 Esmarch\'s Inhaler. \n\nFig. 34. A simple with frame shaped to fit the contour of the face \naround the mouth and nose; one end of the frame is curved to form a \nhandle by which the apparatus may be held in place. Over this framework \nis stretched a knitted or woven fabric, the texture of which is of such a na- \nture as to admit of the free passage of air. The chloroform may be \ndropped upon the mask from a small flask containing a cork through which \na suitable drop tube is passed. This tube reaches nearly to the bottom of \nthe bottle and is curved so that all of the chloroform in the container may \nbe dropped from the tube. The mouth of this drop tube is closed by a \nsuitable cap that the chloroform vapor may not escape from the flask when \nnot in use. Air to replace the chloroform is admitted by a second tube \nalso passing through the cork. \n\n\n\n140 . CHLOROFORM \n\nsurface wet with chloroform exposed to the air, the proximity of \nthe fabric to the patient\'s mouth and nose, the temperature of the \nair, the movement of air about the inhaler, and the rate and force \nof the patient\'s breathing. That Lister recognized the uncertain \nelement of a large surface of several folds of cloth is shown by \nhis adoption of the method of drawing the corner of a towel \nthrough a safety-pin in such a way as to form a cup-shaped in- \nhaler, practically the same as the Esmarch inhaler.* \n\nWith any inhaler which embodies the principles of the mask, \nor the drop method, it is possible to graduate the percentage of \n\n\n\n\nFig. 35.\xe2\x80\x94 Skinner\'s Mask. \n\nvapor inhaled so as to secure the most effective narcosis with the \nleast element of danger, and with a comparatively small amount \nof chloroform. \n\nA thin napkin, a piece of lint, or a single layer of a moderately \nheavy handkerchief may be stretched across the separated thumb \nand forefinger of the administrator and held close to the sub- \nject\'s mouth, or it may be laid across this and a space an inch and \na half square kept moistened with chloroform. A corner of towel \ndrawn through a safety-pin makes a very convenient mask for in- \nhalation. The Esmarch inhaler (Fig. 34) may be used with a \nsingle layer of gauze, cotton cloth, or flannel, but in very warm \nweather it is well to have a heavier material or two layers of light \ncloth. The Skinner mask (Fig. 35) is a similar form of inhaler. \nIn using lint Hewitt recommends making a concave fan-shaped \nmask by folding once over a piece of lint 11 inches long by 7 \ninches wide so that when folded it measures 7x5^ inches. Pinch \n\n*A discussion before the Brit. Med. Ass. (1904) developed the follow- \ning conclusions: (1) That the best way to insure safety during chloro- \nform anaesthesia is by continuous inhalation of a low per cent, vapor; (2) \nthat in most instances a 2 per cent, vapor will induce and, continue surgi- \ncal anaesthesia; (3) that after the first incision the percentage can be \nlowered with safety and advantage. An absolutely satisfactory method of \ncontrolling the percentage of chloroform vapor has not yet been devised. \n\n\n\nCHLOROFORM \n\n\n\nI 4 I \n\n\n\n\nFig. 37.\xe2\x80\x94 Schimmelbusch-Esmarch Inhaler. \n\n\n\nFig. 36.\xe2\x80\x94 Pierepont\' Folding Chloroform \nInhaler. \n\n\n\n\n\nFig. 39.\xe2\x80\x94 Hahn\'s Drop Bottle. \n\n\n\nFig. 38.\xe2\x80\x94 Plain Ether Drop Bottle \n\n\n\n142 \n\n\n\nCHLOROFORM \n\n\n\n\nFig. 40. \xe2\x80\x94 The Gwathmey vapor-inhaler. \n\n\n\nFig. 40. This inhaler was devised by Gwathmey, of New York, for the \npurpose of administering a known percentage of vapor. Chloroform or \nether may be given singly or combined in any proportion, and oxygen or \nair may be added or subtracted as desired, with or without change in the \npercentage of anaesthetic. The mask is identical with the Esmarch mask. \nJt fits the face correctly, and has a hollow rim to allow the vapor to es- \ncape. The mask is covered with four layers of gauze, over which is a layer \nof oiled silk or rubber tissue. A small opening is cut in the center so \nthat during induction a few drops of chloroform can be added if desirable, \nas with vigorous alcoholics. \n\nThe inhaler gives a maximum of two per cent, vapor, with a minimum \nof one-tenth per cent. It consists of three ounce-bottles, each of which \ncontains four tubes of different lengths. These tubes represent four de- \ngrees of vapor strength. The mask not being air tight prevents the pos- \nsibility of an overdose. \n\nThe advantages claimed are : a pleasant induction stage, absence of a \nstage of excitement, a normal pulse rate, no disturbance of respiration, \nno throat or bronchial rales, complete muscular relaxation, absence of after \neffects, a chloroform vapor of known percentage with attenuated air and \noxygen, to which attenuated ether vapor may be added if desirable, also \nthe possibility of changing the vapor percentage with the same flow of \noxygen or air. \n\n\n\nCHLOROFORM j^? \n\nup the free double edge between the fingers and run a safety-pin \nthrough the gathered edge. \n\nIn using the drop method and mask inhaler one may employ \nthe graduated 2-ounce bottle with spring stopper arrangement \nfor dropping the chloroform (Figs. 38, 39), or, if this is not at \nhand, an ordinary 2-ounce bottle may be used. A longitudinal \ntrough is cut in the cork of a sufficient depth and width to ac- \ncommodate a couple of strands of cotton twine, which should be \nlong enough to reach well into the bottle and a couple of inches \noutside. When the bottle is tightly corked the cotton acts as a \nwick and the chloroform can be shaken from the end of the string \nor the string can be trailed across the mask, thus supplying the \nchloroform as fast as may be desirable. In some instances it is \nnecessary to administer an anaesthetic through a tracheal opening. \nFor such cases Annandale uses a full-sized tracheotomy tube, with \nits upper end extended one-half inch above the shield (Fig. 41). \nIt is fitted with a cap having a right-angled tube connection, which \nmay be connected by a rubber tube with a glass containing the \nchloroform or ether upon some cotton wool. Chloroform is the \nagent preferred. The chloroform is held directly over the mouth \nof the tube until the patient is anaesthetized. The cap is then \nplaced on the tube and connected with the rubber tube and the \nadministration continued. \n\nIn administering chloroform the mask should not be held \nclose to the face at first, and only a few drops of chloroform \nshould be used, but after the first few inhalations the mask should \nbe brought closer and its surface kept wet. If there is chok- \ning, coughing, or holding the breath the mask may be lifted but \nnot entirely withdrawn. The administrator should endeavor \nto maintain the happy medium between too much and too little \nchloroform. If too little is given, coughing, swallowing, holding \nthe breath, struggling and vomiting may occur, and may be \nprevented by more chloroform. With some subjects it may be \nnecessary to keep the mask wet most of the time, especially in \nvigorous or alcoholic patients. In children much less will usu- \nally be required. The average quantity for an ordinary adult \nwill be from 10 to 16 drachms for the first hour, and less as the \nadministration lengthens. \n\nIt has been claimed that syncope is liable to occur from too \n\n\n\n144 \n\n\n\nCHLOROFORM \n\n\n\nmarked intermittance in the administration. Incomplete anaes- \nthesia appears to be associated with complications of all de- \ngrees of severity, much more so under chloroform than under \nether. Vomiting, which is often an evidence of incomplete chlo- \nroform anaesthesia, may be the starting point of other compli- \ncations of both the respiration and circulation. \n\nIt is very important that the requisite degree of anaesthesia \nshould have been reached before the operation commences, and \nthat this should be maintained during the operation. Attempts \nto hasten the recovery from the anaesthetic by shaking the \npatient or flipping with a towel should not be made. \n\nChildren are very sensitive to the irritations of chloroform \n\n\n\n\nAnnandale\'s Trachea Canula and Tube. \n\n\n\nFig. 41. A full-size silver tracheotomy-tube, with its upper end ex- \ntended about Yz in. beyond its shield, is employed. There is a silver cap \nhaving a short tube of silver projecting at right angles, and to the small \nend of this cap a rubber tube can be connected. Fig. 41-I shows the \ntracheotomy-tube with the cap fitted upon it. This cap can be turned to \neither side, thus permitting the India-rubber tube to project on the side \nwhich will be most convenient to the operator. India-rubber tubing of the \ndiameter of about V 2 in. is used. One end of this tube is fastened to the ap- \nparatus ; the other end is placed in a tumbler containing a small piece of \nabsorbent wool at the bottom, upon which chloroform or ether is from time \nto time sprinkled. The whole apparatus is shown in Fig. 41-II. Annan- \ndale prefers to use chloroform. In beginning the administration the cap \nis taken from the tracheal tube, and the chloroform is held directly over \nthe tube until the patient is anaesthetized, but when the time for operation \nhas come the cap is put in place and the anaesthetic is given as shown in \nFig. 41-I. In order to prevent blood or vomited matters entering the air- \npassages, it may be advisable to introduce a piece of sponge into the \ntrachea above the tracheotomy-wound. \n\n\n\nCHLOROFORM j^r \n\nvapor. They are likely to hold the breath at the beginning of \ninhalation or after unconsciousness is reached. Very little chlo- \nroform should be used at first, and the mask should be approach- \ned to the face cautiously. If the child cries the inhalation is \nmore rapid and the mask should be withdrawn immediately \nthere are indications of ceasing to cry. Immediately after the \ncrying stage children may pass into an apparent state of anaes- \nthesia with contracted pupils, insensitive corneae, relaxed mus- \ncles, feeble pulse, and irregular respiration. The chloroform \nshould be stopped, the lips briskly rubbed with a dry towel, and \nthe child otherwise stimulated. A little ether administered on \nthe mask may cause immediate improvement in both pulse and \nrespiration. \n\nChildren may be chloroformed while asleep by holding a \nmask several inches above the face and allowing a drop of \nchloroform at a time to be inhaled, approaching the mask to the \nface very gradually. Children are favorable subjects for chloro- \nform by reason of their freedom from diseases of the heart, \nlungs, or kidneys. Nevertheless, chloroform is not so free from \ndanger in children as many suppose. This has been attributed \nto the fact that their reflex action is more excitable and more \nquickly abolished by anaesthetics. Corneal and conjunctival \nreflexes are not, therefore, as reliable as in the adult. \n\nAs the patient comes fully under the anaesthetic the breath- \ning will be regular and audible with soft snoring. Swallowing \nmovements may be present, and if slight may be recognized by \nthe fingers on the larynx. They may indicate recovery from the \nanaesthetic and a necessity for more. Absence of lid-reflex is \nan important sign of anaesthesia, but is not as reliable a guide \nas in etherization. Whether or not the administrator should \nstrive to keep the lid-reflex abolished will depend on the man- \nner in which the patient takes the anaesthetic, and on the nature \nof the operation. In weak or elderly people, and in short oper- \nations it is not necessary or advisable to completely abolish lid- \nreflex, while in robust subjects, or in abdominal operations it is \ngenerally necessary to do so. \n\nThe pupils will average a greater degree of contraction than \nwith ether narcosis. A dilated pupil is a guide to returning con- \nsciousness except when it is due to too deep narcosis. A few \n\n\n\nI46 CHLOROFORM \n\ndrops of chloroform given when the pupil is dilating from recov- \nery, is followed after a few respirations by contraction. The \ndelay in this action makes it important that one should be cer- \ntain as to the cause of the dilatation before administering more \nchloroform. If the dilatation is associated with conjunctival \nreflex it may be taken to indicate more chloroform. If it is as- \nsociated with absence of conjunctival reflex it may indicate less \nchloroform until contraction or reflex appears. \n\nThe color of the face, usually somewhat flushed at the be- \nginning, becames more or less pale. Marked pallor is usually \nindicative of poor circulation though this is not always the case \nCyanosis always indicates a need for more air. Pallor with \nlight anaesthesia may indicate the approach of vomiting. \n\nThe respiration is generally considered to be the most impor- \ntant guide to the state of the anaesthesia. Some anaesthetists \nclaim that the respiration should be the guide first, last, and all \nthe time. The administrator should try to maintain the soft, \nregular, snoring breathing. Withdrawal of the chloroform usu- \nally results in quiet, inaudible breathing, while increasing the \nchloroform may cause increased stertor. When snoring can- \nnot be heard it may often be produced by pressing the lower jaw \nbackward. In some cases the breathing may be inaudible and \nyet absent lid-reflex, a moderate contraction of the pupils, and \nmuscular relaxation will testify to complete anaesthesia. On the \nother hand, in order to not mistake absence of stertor for too \ndeep anaesthesia, one must watch for slight lid-reflex, expira- \ntory noise, swallowing, or slight tonic muscular spasm, contract- \ned pupil, and absence of pallor as indications of too light anaes- \nthesia. \n\nIn some cases the amount of chloroform necessary- to obtain \nthe requisite degree of anaesthesia will produce shallow, inefficient \nrespiration with moderate cyanosis and slow, regular pulse. The \npatient can be usually roused from this condition by friction of \nthe cheeks and lips with a dry towel. \n\nHigh-pitched inspiratory laryngeal stridor may necessitate \nwithdrawal of the anaesthetic. Cheyne-Stokes breathing may be \npresent in weak subjects under deep anaesthesia and indicate a \ntoo deep narcosis or a change to some other anaesthetic. \n\nThe pulse should be observed from time to time. It often \n\n\n\nCHLOROFORM 1 47 \n\nbecomes weak just before vomiting. After anaesthesia has been \nestablished with a regular, slow pulse, changes in the pulse, if \nthe corneal reflex is absent, are of importance. A slow, feeble : \npulse with absent lid-reflex indicates less chloroform. It is well \nto observe the facial, temporal, and superior coronary pulse, as. \nat times, a better idea can be obtained from these vessels of \nthe state of the circulation. \n\nIt has been the experience of some administrators of chloro- \nform, that while conducting the administration in a small, illy- \nventilated room artificially lighted by a naked flame, they have \nbecome affected with more or less severe, irritation of the air \npassages, dyspnoea, coughing or faintness. This may affect \neverybody in the room including the patient, but more often the \nadministrator only is the one to suffer. Zweifel has reported a \nfatal case of bronchitis and pneumonia attributed to this cause. \nIterson, Fischer and others, have reported on this peculiarity o$ \nchloroform. That the fumes are acid is apparent from the fact \nthat they may be neutralized by the liberation of ammonia in \nthe room by suspending cloths saturated with the alkali. It \nis claimed that the irritation is due to the formation of phos- \ngene, and hydrochloric acid gases. Breandat claims that the \ncombustion of chloroform gives rise to hydrochloric acid, and \nan acrid and acid oil.* \n\nThe management of the complications incident to the \nadministration of chloroform. The management of the more \ncommon difficulties such as excitement, spasm or movements, \nnervous or obstructive interference with respiration, coughing, \nhiccough, sneezing, vomiting, foreign bodies in the air passages, \nmucus or saliva, the effects of posture, laryngeal spasm, gen- \neral spasm of the respiratory muscles, etc., is along the same \nlines as when they occur under etherization (p. 121, et seq.). \n\nRespiratory arrest from an over dose of anaesthetic usually \noccurs gradually, the breathing becoming more and more shal- \nlow, though in some cases it may be jerky, gasping, and irreg- \nular. In rare instances the breathing may stop with great sud- \ndenness. Feeble, shallow respiration is not important as long \nas the pulse and color are good and the lid-reflex is maintained. \nWhen the breathing shows signs of arrest the anaesthetic should \nbe stopped, friction of the lips and cheeks used, and rhythmical \n\n*Armand and Bertier say that this gas is manifested by a whitish \nvapor\xe2\x80\x94 csrbonyl chloride or phosgene (COCI2)\xe2\x80\x94 a very irritating sub- \nstance to mucous membranes, and dangerous to the patient because the \nirritant effect is wanting. The symptoms are cyanosis and respiratory \nsyncope. \n\n\n\nI48 - CHLOROFORM \n\npressure of the chest or sternum made with each expiration. \nThe inhalation of oxygen is useful, though regarded indiffer- \nently by many. Ammonia to the nostrils, or ice in the rectum \nmay be used. Flicking the chest with a wet towel is sometimes \npracticed. \n\nIf the respiration stops entirely as shown by cyanosis, ab- \nsence of all movements of the thorax or abdomen and no air \nmovement from the mouth or nose, artificial respiration should \nbe resorted to at once. This is regarded by many as the only \nmeans of any great promise. Sylvester\'s method, or Marshall \nHall\'s method may be used, the former preferred. In using \nSylvester\'s method the patient is drawn along the operating \ntable till his head is extended over its end, or he is placed cross- \nwise on the bed in a similar position. If the patient is sitting \nhe should be laid on the floor and the shoulders sufficiently ele- \nvated to allow of extension of the head. A mouth gag and \ntongue traction may be used in order to be sure that no ob- \nstruction to free breathing exists. The administrator stands or \nkneels at the patient\'s head and grasping his arms at the elbows \npresses them firmly against the sides of his chest for 2 or 3 \nseconds, then brings them toward the operator, extending them \nin the long axis of the patient\'s body for 2 or 3 seconds. The \nmanceuver is then repeated at the rate of about 15 times a min- \nute. Artificial respiration should be persisted in for sometime \nas recovery may follow its continued employment. \n\nMarshall Hall\'s method is performed by placing the patient \nface downward on the table or floor with a pillow or folded \nquilt under his chest and one arm under his head. He is gently \nrolled on his side and back again about 15 times a minute, pres- \nsure being made on his back when he is in the prone position. \n\nThere are other methods but these are most commonly em- \nployed. Inflation of the lungs by mouth to mouth inflation, or by \nbellows, or by the Fell-O\'Dwyer apparatus may be of benefit \n(Figs. 42, 43). \n\nFaradism of the phrenic nerves may be used. Duchenne \ndemonstrated its action in causing contraction of the diaphragm. \nThe electrodes may be placed over the lower end of the scale- \nnus anticus muscle, and the outer edge of the sterno-mastoid mus- \ncle which should be drawn inward. The current is turned on \n\n\n\nCHLOROFORM \n\n\n\n149 \n\n\n\nfor a few seconds causing contraction of the diaphragm. Ex- \npiration may be assisted by compression of the thorax and ab- \ndomen. The application of electricity to the region of the \ndiaphragm has been effective in some cases. Respiratory fail- \nure from cerebral anaemia demands the same measures, to- \ngether with inversion of the body. Drugs are of questionable \nvalue in these cases, but should be used while more active meas- \nures are being tried, especially in those most dangerous cases \nwhere the heart and respiration fail together. Strychnia is the \nmost effective drug. It is recommended by H. C. Wood in \nthese conditions as a respiratory stimulant. It should be given \nhypodermically in doses of from one-thirtieth to one-twentieth \nof a grain with or without brandy. \n\n\n\n\nFig. 42. \xe2\x80\x94 Fell\'s Apparatus for Lung Inflation. \n\nFig. 42. Fell\'s apparatus consists of a hand bellows connected by a \nsuitable hose with an air-control valve and face-shield. \n\nBy properly working the bellows while making finger pressure on the \nvalve, the lungs may be filled to their full capacity, after which the air is \npermitted to escape by natural means by releasing the pressure. For the \nnext inspiration, pressure with the fingers is again, made. \n\n\n\njcq CHLOROFORM \n\nDepression of the circulation from general or local diseases, \nmental states, posture, food in the stomach, vomiting, or asphyx- \nial causes during or after operation from spasm of the larynx, \netc., are managed as in anaesthesia of any kind. In failure of \nthe circulation from surgical shock or haemorrhage the head \nand shoulders should be lowered, a hot water or alcoholic enema \ngiven, strychnia injected, saline intravenous injection given, and \nwarmth to the body used. \n\nThe pulse may show primary failure suddenly or gradually. \nWhen the administrator is satisfied that the trouble is primarily \nwith the circulation he should stop the anaesthetic, use friction \nof the face and lips, partially invert the patient, use artificial \nrespiration, inject strychnia, digitalin, strophanthin, ether, etc. \nWhen the circulation is so weak that there is no bleeding from \nthe wound the anaesthetic should always be stopped. If the \npulse is not perceptible, a mouth gag may be introduced, tongue \ntraction made, artificial respiration, partial or complete inver- \nsion, rhythmical compression of the chest, percussion of the \npraecordial area with the tips of three fingers about once a sec- \nond may all be tried. Electricity, like drugs, is of doubtful \nvalue, and should be given over to an assistant, the administra- \ntor devoting his time to posture, artificial respiration, compres- \nsion of the chest, etc. Electricity may be applied to the region \n\n\n\n\nFig. 43. \xe2\x80\x94 Richardson\'s Double Bellows for Forced Respiration. \n\nFig. 43. Richardson\'s Double Bellows consists of two elastic bulbs, \nto each of which a rubber tube is attached, the two terminating in a single \ntube. The rubber bulbs are so regulated by valves that air may be forced \ninto the lungs by the compression of one and withdrawn by the compres- \nsion of the other. When in use, the single terminal tube is introduced into \none nostril, the other nostril and the mouth being closed. By alternately \ncompressing %st one bulb and then the other, the respiratory current \nmay be artificially established. In actual operation this appliance has not \nproved successful to any great extent. \n\n\n\nCHLOROFORM 151 \n\nof the apex beat, one pole being over the fourth dorsal ver- \ntebra. In some instances remarkable results have been ob- \ntained from inversion of the patient, and the pulse has been ob- \nserved to come and go with change in posture. Some cases \nappear to have been utterly hopeless from the start, but resus- \ncitative measures should be persisted in until it is clear that \nno possibility of recovery remains. \n\nMankowski finds, from experiments on animals, that the in- \njection of a 1 per cent preparation of suprarenal extract into the \njugular vein stimulates the heart and respiration and prevents \nthe fall of blood pressure from chloroform narcosis. Its pre- \nliminary administration before anaesthesia has been advised. Hob- \nday advises the use of hydrocyanic acid as a better and quicker \nrespiratory stimulant than strychnia. In animals, I mm. of \nScheele\'s acid was dropped on the back of the tongue for every \n7 or 8 pounds of body-weight of the animal. Bernard consid- \ners hydrocyanic acid a dangerous antidote for chloroform. \n\nMassage of the heart in chloroform syncope has been em- \nployed in a number of recorded cases. According to Kemp and \nGardner it was first used in the human subject by Prus, though \nthey give credit to Schaff for its introduction. Keen has em- \nployed it in one successful and one unsuccessful case. There \nare three methods: (i) Compression of the heart between the \nhands, one outside the chest, and the other directly upon the \nheart after abdominal section but without the pericardium being \nopened ; (2) the same, but with open pericardium, the heart being \nseized inside the sac; (3) resection of ribs, incision of pericar- \ndium, and seizure of the heart in both hands with rhythmical \ncompression. \n\nThese methods are necessarily extreme and their limitations \nare not yet strictly defined. \n\nDELAYED CHLOROFORM POISONING. \n\nDuring the past few years considerable attention has been \ngiven a condition of toxaemia developed after anaesthesia which \nwas recognized as long ago as 1850, by Guthrie, who said in \n1862, "It is no longer doubted that there is such a thing as chronic \npoisoning by chloroform \xe2\x80\x94 that is the drug when it does kill does \nnot always kill immediately, but that hours, days or even weeks \nmay elapse during which the person anaesthetized remains con- \n\n\n\nI52 CHLOROFORM \n\ntinuously under the influence of the poison to which he at length \nsuccumbs." This condition has been described under various \nnames by different writers for the past ten or fifteen years. It \nusually follows the administration of chloroform, but has occurred \nafter ether. It is most often encountered in young subjects, chil- \ndren especially. The symptoms appear in from eight or ten hours \nto five or six days after the administration of the anaesthetic. The \nusual interval is between twenty-four and forty-eight hours. \n\nThe symptoms are those of more or less profound toxaemia, \nand may be varied. In the majority of cases marked cerebral \nsymptoms are present, such as great restlessness, delirium, apathy. \nThese are followed by coma. The temperature may range from \nnormal to 103 or 104 F. The urine contains organic acids, and \nsometimes amido acids (leucin and tyrosin). Among the pro* \nnounced symptoms may be mentioned sweet odor of breath, de- \nlirium, rapidly fatal coma (Brewer), air hunger \xe2\x80\x94 deep breathing, \nbright red mucous membranes (Kussmaul, Bevan-Favill), \nCheyne-Stokes respiration, cold extremities, vomiting, collapse, \nweak and rapid pulse, cyanosis, absence of fever until just before \ndeath, coma, acetone in breath and urine (Brackett, Stone, Low) ; \ngreat restlessness with clear mind, followed by coma and death \n(Stocker) ; piercing cries, shrieks, grinding teeth, tossing, strug- \ngling, irregular or dilated pupils, flushed face, anxiety, tremor, \nloss of consciousness, apathy, vomiting of material like dregs of \nbeef tea (Guthrie). \n\nThe predisposing causes appear to be youth, sex (male, 9; \nfemale, 18), personal idiosyncrasy (Offergeld), various kinds of \nintoxications as drug or intestinal, psychological causes as fright, \nhomesickness, starvation, sepsis, certain conditions of pregnancy, \nfatty changes associated with infantile paralysis, diabetes, carci- \nnoma, anaemia, and prolonged anaesthesia. \n\nThe post mortem findings show fatty degeneration or infiltra- \ntion of the liver, fatty degeneration of the heart, various changes \nof nephritis, fatty degeneration of the muscles of the lower limbs, \nand other associated changes. The important alterations are those \nfound in the liver \xe2\x80\x94 fatty degeneration and necrosis of the cells \xe2\x80\x94 \nas a result of which toxins develop, either because of the cell \nchanges or because of the influences of the latter upon the func- \ntion of the cells to eliminate. Wells defines it as follows: "Chloro- \n\n\n\nCHLOROFORM 153 \n\nform poisoning, in common with a number of closely related c< n- \nditions characterized by intoxication and marked changes in the \nliver (acute yellow atrophy, phosphorus poisoning, certain septi- \ncaemias, and some cases of puerperal eclampsia) probably ail de- \npend on the effect on the liver of poisons that destroy the syn- \nthetic functions of the liver cells without destroying their autolytic \nferments. Autolysis of the liver cells follows with resulting al- \nterations in the liver structure, and the appearance of products of \nautolysis (amido acids and various other organic acids) in the \nblood and urine. It is possible that in chloroform and in phos- \nphorus poisoning, at least, it is the oxidizing enzymes that are \nparticularly involved, accounting for the marked fatty changes \nthat are present in these conditions." \n\nThe prevention of this condition lies especially in the avoid- \nance of chloroform in such conditions as appear to be coanected \nwith its occurrence, in avoiding long continued anaesthesia, which \nappears to be concerned in its production in some instances, and \npossibly in combining oxygen with chloroform in lengthy opera- \ntions when the latter agent is employed, or in substituting oxygen \nand nitrous oxide gas. \n\n\n\nCHAPTER XI. \n\nSCOPOLAMINE-MORPHINE ANAESTHESIA. \n\nThis method is a mixed form of anaesthesia which has been \nmuch employed since Schneiderlein, in 1900, reported his results \nfrom its use in insane patients. \n\nScopolamine is not a new drug, but has been used for a num- \nber of years to some extent. It is an alkaloid of scopolia camio- \nlica, a plant of the solanacese. Its name is said to be derived \nfrom that of the Italian botanist Scopoli. The hydrobromide of \nscopolamine is said to be chemically identical with hydrobromide \nof hyoscine, and while there is some diversion of opinion on this \npoint, it is so regarded in the U. S. Pharmacopoeia, and may \nat least be regarded as isomeric with it. Its formula is C 17 , H 21 , \nN0 4 , H Br, -f-3H 2 0. It occurs in crystals, is a sedative, and \nhas a mydriatic action somewhat similar to atropine. The simi- \nlarity of its physiological action to that of hyoscine should be \nborne in mind. The hydrobromate of scopolamine prepared by \nMerck is recommended, and does not differ materially from the \nhydrobromide. \n\nThe physiologic effects of scopolamine as given by Stein- \nbuechel are as follows : \n\n1. Small doses stimulate the vaso-motor nerves and raise \nblood pressure. Large doses lower blood pressure by influencing- \nthe cardiac excito-motor mechanism. \n\n2. The pulse is not much influenced by small doses. Large \ndoses cause a vagus pulse. \n\n3. The cerebral cortex, under the influence of scopolamine, \nis less excitable when stimulated by the faradic current. Sleep is \ninduced, but not analgesia. \n\n4. Respiration is not affected by small doses. Large doses \nslow the breathing. \n\n5. There is a marked diminution in the secretions of sweat, \nmucus, and saliva. \n\n\n\nSCOPOLAMINE-MORPHINE ANESTHESIA 1 55 \n\n6. Mydriasis occurs in many instances where the drug is not \ninstilled into the eye. \n\n7. The motor-end apparatus of the intestines is paralyzed. \nThe tone of the splanchnic system is increased. \n\n8. Excretion of scopolamine takes place by way of the kid- \nneys. \n\nGiven alone scopolamine does not cause analgesia, but when \ncombined with morphine it causes anaesthesia sufficient for many \nslight operations, while as a preliminary to a general anaesthetic \nit reduces the necessary amount of the latter and favorably affects \nthe character of the narcosis. The combination is not illogical, \nas Crile has proven that morphine greatly lessens the intensity of \nthe afferent nerve impulses going to the vaso-motor center, and \nthus reduces shock. The additional effect of scopolamine, through \nits action on the vaso-motor nerves and blood pressure, makes the \ncombination effectual. \n\nSince the observations of Schneiderlein, Bios and Korff have \nimproved the method of administration and the dosage. Their \nmethod as followed by Ries, Israel, Zinke and others, is as fol- \nlows: One-fiftieth of a grain of scopolamine hydrobromate and \none-half a grain of morphine are dissolved in three drams of dis- \ntilled water. This should be freshly prepared as scopolamine in \nsolution is unstable. One-third of this amount is injected two \nand a half hours before operation. The second portion is injected \none and a half hours before operation, and the remainder is in- \njected half an hour previous to beginning the operation. \n\nThe patient becomes sleepy after the first injection, very \ndrowsy after the second, and is scarcely sensitive to pain by the \ntime for the third injection, though sensitive to touch. Anaes- \nthesia is obtained by half an hour after the third injection. If it \nis not complete a very small amount of any geneial anaesthetic \nwill suffice, and the stage cf excitement is practically eliminated. \nIt is claimed that this method is safe for cardiac or renal patients, \nand that there are few or no after effects. \n\nSharp says that if scopolamine deserves a place among anaes- \nthetics it is without doubt in combination with chloroform, the \ninconstancy of its action rendering it impracticable alone or sim- \nply with morphine. According to Seelig, who has employed \nscopolamine in various operations, giving one one-hundredth of \n\n\n\n156 SCOPOLAMINE-MORPHINE ANAESTHESIA \n\na grain with one-sixth of a grain of morphine, one-half an hour \nbefore operation, and using the Bennett inhaler, specially modified \nfor the purpose, he is thoroughly satisfied with the method. \n\nFlatau, Israel, Dork, Sexton and others have reported deaths \nwhere this form of anaesthesia was employed, yet in most of \nthese instances it is not certain to what extent the scopolamine- \nmorphine combination was to blame. In a review of the subject \nDe Maurans cites an instance where the patient showed dyspnoea \nand cyanosis about half an hour after the second injection, and \ndied about five hours afterward with symptoms of asphyxia. In \nmost of the fatalities there have been dyspnoea, cyanosis, and \nCheyne-Stokes respiration. \n\nThis method of anaesthesia is undoubtedly not without dan- \nger, and has its limitations. Its exact position cannot as yet be \ndefined, the burden of proof still resting upon its advocates. \n\n\n\nCHAPTER XII. \n\nETHYL BROMIDE. \n\nEthyl bromide, hydrobromic ether, bromhydric ether, is a \ncolorless, volatile liquid with a fragrant odor and a hot, sac- \ncharine taste, and a bitter after-taste. It was discovered by \nSerullus, in 1827. Its sp. gr. is 1.420, and its boiling point is \n104 F. It decomposes rapidly on exposure to light and air, \nand when ignited burns with a fine, green, smokeless flame with \nthe separation of bromine vapor. It is sparingly soluble in \nwater, and freely so in strong alcohol and in ether. It should \nevaporate from the hand quickly and absolutely without resi- \ndue, and with a distinct feeling of cold ; when washed with \nwater the washings should be neutral, and without change with \nthe addition of silver nitrate; no discoloration should be caused \nby the addition of concentrated sulphuric acid. \n\nEthyl bromide was introduced as an anaesthetic by Nunneley, \nof Leeds, in 1865. It was extensively used by Dr. Lewis, of \nPhiladelphia, in 1879-80. A death in his practice, and one in \nthat of Dr. Marion Sims, of New York, together with argu- \nments tending to prove that the drug paralyzed the heart, caused \nit to fall into disuse. According to Schleich ethyl bromide would \nbe an ideal anaesthetic if the advantage of boiling-point were \nsufficient to offset the danger of the bromine. \n\nThe physiological effects of ethyl bromide are rapidly acquired \nand are not specially unpleasant. The odor is not disagreeable \nnor is the vapor particularly irritating to the air passages. The \nstage of excitement is very short or absent altogether, and mus- \ncular rigidity is not marked or is absent. The face is usually \nflushed, the ears quite red, and the conjunctivae injected. The \npupils are more or less dilated. The heart action is rapid, and \nthe pulse increased in force. The respiration is quicker than \nnormal and becomes slightly snoring or stertorous. Tendency \nto irregularity of breathing or arrest of breathing has not been \nnoticed. Embarrassed respiration may occur from free secre- \ntion of mucus. Nausea and vomiting is rare, but appears more \noften in women than in men. \n\n\n\nI58 ETHYL BROMIDE \n\nProperly administered, insensibility may be induced in about \nfive minutes (Levis) ; 66 seconds (Chisholm). \n\nThe duration of anaesthesia is rather brief, \xe2\x80\x94 46 seconds (Silk). \nand the recovery is rapid, so much so as to constitute in some \ninstances, an objection. If the administration is continued be- \nyond two or three minutes, or if the inhalation is repeated there \nis more likelihood of after effects. \n\nAfter effects are usually absent if the administration has not \nbeen prolonged. Headache, nausea, or even vomiting may fol- \nlow. Depression and faintness have occurred. Hysterical man- \nifestations have been noted. \n\nThe dangers of the administration of ethyl bromide are prob- \nably not great if a pure drug is employed and the administra- \ntion properly carried on. Wood, of Philadelphia, regarded \nethyl bromide as a cardiac depressant. Trumbull and Gowers. \nof Philadelphia, regarded it as safe and prompt.* \n\nThe death rate is unknown, and how far the drug was to \nblame in those deaths that have occurred under its use is ques- \ntionable. \n\nThe administration of bromide of ethyl should not be under- \ntaken for lengthy operations. It is adapted only for dental sur- \ngery or general surgical proceedings of not over three minutes\' \nduration, though operations lasting for considerable time have \nbeen performed under its use. Chisholm thought it unequaled \nfor ophthalmic surgery. \n\nThe inhalation should be conducted much as with ether, the \ndrug being promptly given without much air at first. From \none to one and a half drachms is the quantity usually necessary \nto induce unconsciousness. The inhalation may be conducted \nwith a towel or napkin, as with chloroform, or any ether inhaler \nmay be used. Herz, a dentist of Vienna, used a simple mask, \nsuch as the Skinner, with cotton inserted upon which he poured at \nfirst about half an ounce of the drug, using more later if desir- \nable. \n\nIf soft snoring, or insensitive cornese do not promptly appear, \nthe pulse and respiration should be looked to carefully. When \ncomplete unconsciousness is produced the inhalation must be \ninterrupted. The inhalation may be repeated, but as before \n\n^According to Cole respiration, in animals, stops before the heart, and \ntherefore the breathing rather than the pulse should be watched. \n\nHallberg suggests that the danger of ethyl bromide lies largely in its \nhigh specific gravity. \n\n\n\nETHYL CHLORIDE I 59 \n\nstated, unpleasant effects are more likely to follow repeated in- \nhalations. \n\nEthyl bromide is very portable, requires no apparatus for the \nadministration, is rapid in effect, its inhalation produces no spe- \ncially disagreeable symptoms, and the recovery is rapid. On \nthe other hand it decomposes readily, is not suitable for lengthy \noperations, is not as safe as nitrous oxide, and after effects are \nliable to occur. Kempter urges a more extensive use of ethyl \nbromide in minor surgery. He says German statistics show but \n16 deaths in 60,000 administrations. A fresh preparation is nec- \nessary. He pours from 1 to 3 drachms into a cone which is \nnot removed until anaesthesia is induced. No air is admitted. \nAnaesthesia lasts from 1 to 2 minutes. \n\nFowler favors ethyl bromide preliminary to ether. The cone \nneed not be changed. Krusen thinks ethyl bromide an ideal \nanaesthetic in obstetric and gynaecological practice. \n\nETHYL CHLORIDE. \n\nEthyl chloride is a colorless, mobile liquid with a pleasant \nodor. It has a formula of C 2 H 5 CI. It boils at 12. 5 C. (Re- \ngnault), and is quite soluble in alcohol. So dissolved it may be \nkept in tightly corked bottles from which ethyl chloride may be \nobtained by gently heating (vide P. 197).* \n\nThe anaesthetic properties of ethyl chloride were said to have \nbeen recognized by Flourens and others. It was recommended \nby Richardson in 1867 as a good anaesthetic. Within the last \nthree years it has been used by German, French and American \nobservers for surgical operations of short duration, and for den- \ntal purposes. Tuttle, of New York, has, of late, used ethyl \nchloride in 230 cases of short-term anaesthesia. He has never \nobserved any serious symptoms. It may be used with an ordi- \nnary chloroform inhaler. It is convenient and safe for opera- \ntions lasting not over ten minutes. General muscular relaxa- \ntion is not as complete as under ether. Nausea is sometimes \npresent but soon ceases. Alcoholic subjects appear to bear \nethyl chloride very well. \n\nLothiessen, of Innsbruck, used ethyl chloride in 1896, pro- \nducing complete anaesthesia in one minute. The drug was \nsprinkled on an Esmarch mask. The patient recovered in a \nfew seconds. He has since used it many times with no unto- \n\n\n\n*Ethyl chloride is commonly prepared by acting on ethyl alcohol with \nhydrochloric acid gas, the yield being increased by the addition of zinc \nchloride, which probably acts by abstracting water from the alcohol. It \nshould be free from water, foreign chlorides, acids, aldehydes, ether, \nalcohol, and organo-metallic substances. \n\n\n\nl6o ETHYL CHLORIDE \n\nward effects. From 8 to 10 grammes were necessary for short \noperations. \n\nAn inhaler devised by Bruer, and resembling Clover\'s inhaler, \nis said to be the best for the administration of ethyl chloride. \nAbout 3 to 5 grammes of the drug are sprinkled on the gauze., \nthe patient is told to breathe quietly, and the face-piece is \npressed closely to the mouth and nose so as to be air-tight. \nThe above quantity of the drug will be sufficient for about 3-4 \nminutes, and if longer narcosis is desired more must be added. \nThe drug may be sprayed on the gauze of an inhaler from a tube \nof ethyl chloride. \n\nAnaesthesia is induced in about a minute and a half. Excite- \nment is generally absent. Corneal and pupillary reflexes are \nusually preserved. The eye-balls may be movable, and the eyes \nappear to notice. The pulse rate may be slower, but otherwise \nthe pulse is not affected. The conclusions of Konig as to the \ninfluence of ethyl chloride on blood pressure are as follows : \nWith a proper amount of air there is no diminution of blood pres- \nsure, though narcosis may be complete ; in some instances there \nmay be a fall of blood pressure from vagus irritation. Section \nof the vagi raises the blood pressure ; when a proper amount of \nair is not allowed lethal depression of the blood pressure and \nrespiratory paralysis follow. The respiration is more rapid than \nnormal. Cyanosis is rare. The muscular system is not always \nrelaxed. The duration of anaesthesia may be prolonged by using \nmore of the drug from time to time. Recovery is rapid, and \nafter effects not important. Vomiting has occurred in a few \ninstances. \n\nEthyl chloride is not suitable for lengthy operations, but \nappears to be quite available for dental and short-term surgical \noperations. \n\nLotheissen states (1900) that statistics show that ethyl chlo- \nride stands next to chloroform as regards mortality. Mackie \nrecommends ethyl chloride in nasal surgery. Ware, from a \nconsiderable experience, concludes that ethyl chloride is rela- \ntively safe ; its danger point is not as readily or suddenly reached \nas is that of chloroform; it does not show the remote dangers \nof ether, and asphyxia, when it occurs, is easily relieved by arti- \nficial respiration. \n\n\n\nETHYL CHLORIDE l6l \n\nOn the continent ethyl chloride has practically replaced ethyl \nbromide and is being- largely used for short dental operations in- \nstead of nitrous oxide. In this country it is becoming more and \nmore used. McCardie recommends the Ormsby ether inhaler for \nethyl chloride, and uses 60 gramme graduated tubes which emit \na larger spray than usual. The induction period is from ^ to 1 \nminute, and the available period about 1*4 minutes. Excitement \nis absent, color improved, pulse normal, and respiration stimu- \nlated. Stertor is usually present with deep anaesthesia. Recovery \nis rapid and complete. He has had no trouble in 400 adminis- \ntrations, and advises ethyl chloride for dental work, ear and throat \nwork by expert operators, and for short operations of ten to fif- \nteen minutes where it may be superior to ether, chloroform or \ngas. For children it is a perfect anaesthetic for short operations, \nas there is no cyanosis, undue bleeding, convulsions, or as rapid \nrecovery as with gas. \n\nMurray has administered ethyl chloride to 150 infants under \none year of age. The youngest was five days old. She regards it \nas very suitable for short operations (5 to 15 minutes) in chil- \ndren. Three c.c. are sprayed into the inhaler for children a few \nweeks old, and five c.c. for those of six months or more. The \nmask is held so as to admit some air at first. When anaesthesia \nis produced more air is given. When narcosis is to be continued \nnie mask should be lifted occasionally for air. \n\nAccording to Hillard ethyl chloride requires the greatest care \niu its administration, and in skilled hands is relatively "safe" \nwhen only small amounts are exhibited. It is potentially a very \nlethal agent and several deaths have occurred, since its reintro- \nduction, from its use. Unpleasant effects are very much more \ncommon and severe than after nitrous oxide, headache, sickness \nand collapse being the chief sequelae. He advises anaesthesia not \nsooner than three hours after eating, a closed inhaler with a wide \nbore, and sponge so adjusted as to act as a screen to prevent in- \nhalation of too concentrated vapor. The average dose for an \nadult is 5 c.c. applied for from 20 to 60 seconds, and 3 c.c. for a \nchild given for 15 to 40 seconds. The signs of anaesthesia are, us- \nually, in the order of their appearance : deep stertorous breathing, \nfixed globes, dilated pupils, and loss of ocular reflexes. \n\nThese views, it is evident, are those of one not favorably im- \n\n\n\nl62 BICHLORIDE OF METHYLENE \n\npressed with the advantages of ethyl chloride, particularly in. \ncomparison with his favorite short-term agent, nitrous oxide. \nMillard further says that ethyl chloride has but a limited field in \ndental surgery, and is not likely to replace nitrous cxide, which \nshould be used for simple operations. While for operations last- \ning more than three minutes it is better to give gas by the con- \ntinuous method, using the nasal tube, or to follow the gas by \nether. The treatment of dangerous symptoms should be directed \ntowards restoring respiration, because ethyl chloride kills by par- \nalyzing the respiration with the chest in a position of over-disten- \ntion. \n\nBICHLORIDE OF METHYLENE. \n\nMethylene, methyl dichloride, or bichloride of methylene \n(CH 2 Cl 2 ), is one of the marsh gas (CH 4 \xe2\x80\x94 methane) series. \nThe chloride of methyl (CH 3 CI) has been used for local an- \naesthesia by freezing. It has been claimed that bichloride of \nmethylene is simply a mixture of chloroform and methylic alcohol. \n\nBichloride of methylene was introduced as an anaesthetic by \nRichardson in 1867. It is difficult to preserve, and expensive \nto obtain pure. It has a low boiling point. According to Rich- \nardson anaesthesia is reached more quickly than with chloro- \nform, is more prolonged, recovery is more rapid, and there are \nno after effects. Spencer Wells expressed himself very fav- \norably towards the drug as having fewer drawbacks than any \nother known anaesthetic. Buxton thought its dangers differed \nonly in degree from those of chloroform. H. M. Lyman says \nthe effects are similar to those of chloroform ; that four cubic \ncentimeters produce insensibility. There are no unpleasant \neffects with returning consciousness, and vomiting is less fre- \nquent than after chloroform. \n\nThe dangers of the administration of bichloride of methylene \nare not accurately known. It is probably not less, and by some \nis considered more, dangerous than chloroform. \n\nAndrews, of Chicago (1877), gave one death in 7,000 inhala- \ntions ; Coles, of Virginia, gave two deaths in 10,000 inhalations. \n\nWells used the Junker inhaler for administering methylene. \nStrahan, of New York, has used a napkin for the administration \nIn one case the anaesthesia was continued for 45 minutes, and" \none and a half ounces of the drusr were consumed. \n\n\n\nETHIDENE DICHLORIDE 163 \n\nETHIDENE DICHLORIDE. \n\nEthidene dichloride, dichlorethene, monochlorethyl-chloride, \nchlorinated chloride of ethyl (CH 3 CH Cl 2 ) was first prepared \nby Regnault by the action of chlorine on ethyl chloride. It has \nan ethereal odor, and a sweet, biting taste. Sp. gr. 1.2. Boils \nat 1 35 to 150 F. It is soluble in alcohol and in ether ; and is \ninsoluble in water. It is metameric with Dutch liquid or ethyl- \nene dichloride. \n\nAs an anaesthetic, dichloride of ethidene was first used by \nSnow. Binz considered it preferable to chloroform. Anaesthe- \nsia is produced somewhat quicker than with chloroform, while \nthe amount of drug consumed is somewhat greater. The pulse \nand respiration are less changed than with chloroform, and slow \npulse and rapid breathing are generally absent. Excitement is \ngenerally not marked, though struggling may at times be pres- \nent. Clover recorded 1,877 cases of the inhalation of ethidene : \n287 of which were for major operations. He usually anaes- \nthetized with nitrous oxide by the Clover inhaler for gas and \nether, ethidene being gradually added when the patient was \npartly under. Struggling was rare, though there was some \ntwitching. Stertor and dilated pupils appeared quickly. Air \nwas then admitted as required. \n\nThe Junker inhaler has been used for the administration, and \nit has also been conducted with a towel or piece of lint. \n\nThe dangers of the administration of ethidene are not fully \nunderstood. Some four or five deaths have been reported un- \nder its use, but in how far they were due to the anaesthetic itself \nis doubtful. Ringer thought that ethidene and chloroform were \nequally poisonous to the heart. The drug is probably more \nstimulating than chloroform, but less so than ether, and has gen- \nerally been regarded as not more safe than chloroform and de- \ncidedly less so than ether. \n\nThe after effects of ethidene are usually not marked. Vom- \niting may occur, but ceases sooner than after chloroform. Nau- \nsea and headache may occur (Sauer). The recovery from ethi- \ndene is usually prompt and satisfactory. \n\nAMYLENE. \n\nAmylene, pentylene, pentene, (C 5 -H 10 ) is a colorless, thin, \nvolatile liquid with a pungent, unpleasant odor, and little taste. \n\n\n\n164 PENTAL \n\nIt was discovered by Balard in 1844, an d was first used by Snow, \nfor anaesthetic purposes. It is a rather indefinite compound, \nisomeric with several substances. Its sp. gr., as used by Snow. \nwas .659 at 56 F. The boiling point varies from 30 to 62 C. \n(Duroy). Pure amylene has a boiling point of 38 C. (Duroy). \n"Pental," is a name applied to a pure form of amylene introduced \nby Mering, and used by German dental surgeons. \n\nAmylene is not very soluble in the blood and patients re- \ncover very rapidly from its effects. The anaesthesia is there- \nfore transient. Dilute vapor does not induce anaesthesia. Lid- \nreflex is not always abolished. Muscular spasm may or may \nnot be present. The pulse and respiration are increased in fre- \nquency and force. The pupils may be unchanged. The face is \nflushed, and there is perspiration. Snow used from 3 to 4 \ndrachms to anaesthetize, with about a 15 per cent, vapor. \n\nThe dangers appear to be much the same as with chloro- \nform. Two fatal cases in Snow\'s practice, together with the \ntransient nature of the anaesthesia discouraged its use, which \nhas never become general. The after effects are not marked. \nNausea and vomiting may exceptionally occur. \n\nPENTAL. \n\nPental has been used in Germany in dental practice. Some \nkind of inhaler on the order of the Clover inhaler is used. Two \nor three drachms of pental are placed in the reservoir, the bag \nis attached, and the patient\'s expirations are allowed to partly \nfill the bag. The indicator is first opened as the face-piece is \napplied. The patient breathes to-and-fro for about 40 seconds, \nthe indicator being gradually pushed more and more open. The \ninhalation period lasts about 40 seconds, during which there is \nflushed face, dilated pupils, open eyes, fixed eye-balls, no con- \njunctival reflex, quick pulse, rapid, labored breathing, slight \ncyanosis, and may be marked muscular contractions. The avail- \nable period of anaesthesia lasts about one minute. The face- \npiece is removed after about 40 seconds, and the operation be- \ngun. \n\nSeveral fatalities have occurred under pental, and other cases \nwith dangerous symptoms have been reported. After effects \nare usually absent. It is difficult to see what advantages amyl- \nene or pental possess over nitrous oxide or chloroform. \n\n\n\nPENTAL 165 \n\nAmong the other agents which have from time to time been \nused for producing anaesthesia, but which have various disad- \nvantages, and which are inferior to those already considered, may \nbe mentioned nitrogen, methyl oxide, ethylene (olefiant gas), \nethyl nitrate, amyl chloride, amyl hydride, tetra-chloride of \nmethane, aldehyde, bisulphuret of carbon, benzene, turpentine., \netc. \n\n\n\nCHAPTER XIII. \n\nSPINAL ANAESTHESIA. \n\nThis method of producing anaesthesia is generally spoken of \nas Bier\'s method, or Quincke\'s method. It properly should be \nattributed to Corning, of New York (Spinal Anaesthesia and \nLocal Medication of the Cord, New York Medical Journal, \nOctober 31, 1885). Its introduction as a means of anaesthesia \nis chiefly owing to Bier and Quincke.* \n\nEffects. Acording to Tuffier the effects are as follows : \nAnalgesia appears in from four to ten minutes, quickest in young \nsubjects. It lasts from 30 to 50 minutes with doses of from 5 \nto 15 milligrammes; with doses of from 15 to 25 milligrammes \nit lasts from one hour to one hour and forty minutes. The an- \naesthesia is accompanied by prickling in the toes and calves, and \nnumbness of the lower limbs. Analgesia begins in the extrem- \nities and progressively ascends involving the umbilical region \nlast. It disappears in reverse order to its appearance. \n\nAccording to Crile injections into the subarachnoid space \ncause displacement similar to that of fluid in a capillary tube. \nThe injection of a cocain solution colored with methylene blue \ninto the lumbar region stained the entire cord and under sur- \nface of the brain within thirty seconds, and all the localized func- \ntions of the cord and medulla were rapidly anaesthetized. There \nwas marked fall in blood pressure and interference with respi- \nration within a few seconds. Position affected the rapidity of \nthe occurrence of these manifestations little if at all, and \nthe operator has little if any control over the extent of anaesthe- \nsia produced by subarachnoid injection. \n\nThe general symptoms observed during analgesic and post- \nanalgesic periods are : Sweating, some dilatation of the pupils, \nnausea, trembling, headache, vomiting, shivering, and tachy- \ncardia. They may be absent with small doses. \n\nEucaine b, alpha eucaine, and tropacocaine have been used \nbut do not appear to have special advantages. Kopfstein re- \nports fever, headache, and collapse after using alpha eucain. \n\nAfter effects. These are less marked and unpleasant than \n\n\xe2\x99\xa6According to Meyer, of New York, Bier says that he had not the \nslightest idea that Corning had discovered spinal anaesthesia. \n\n\n\nSPINAL ANESTHESIA \n\n\n\nl67 \n\n\n\nafter general anaesthesia. Nausea and vomiting occurs in from \n20 to 40 per cent. of. the cases. Headache, pain in the legs, \ndelirium, paralysis of the sphincters, and collapse may occur. \n\nComplications. Late complications are absent as a rule. \n\nFailure to produce anaesthesia occurs in some cases, and can- \nnot always be attributed to faulty technique. It may be neces- \nsary to give a general anxsthetic. \n\nContraindications. Conditions which render general anaesthe- \nsia dangerous also bear the same relation to spinal anaesthesia. \nIt should not be employed in children under 12 years. It \nshould not be used when absolute muscular relaxation is neces- \nsary. It is contraindicated in most mental conditions. Some \nregard spinal anaesthesia as safer in kidney disease than general \n\n\n\na <**\xe2\x96\xa0 \n\n\n\n\nFig. 44. \xe2\x80\x94 Coming\'s Original Needles and Syringe. \n\nanaesthesia, but this is not yet proven. It should not be used for \noperations lasting over one hour, or for those in which compli- \ncations are likely to arise and prolong the operation beyond \nthis period. \n\nMortality. The mortality of spinal anaesthesia is not known. \nSuch deaths as have occurred cannot be attributed solely to \nthe method of anaesthesia. Statistics, up to date, are inconclu- \nsive. It should not be used when local anaesthesia is possible. \n\nThe solution and dose. The solution used should be weak \n(a one or two per cent, solution). It should be freshly pre- \npared, sterilized by heating several times in a water bath at a \ntemperature not exceeding 6o\xc2\xb0 C. The majority of operators \nuse a two per cent solution of cocaine as employed by Tuffier. \n\n\n\n[68 \n\n\n\nSPINAL ANAESTHESIA \n\n\n\nA quantity not to exceed 15 mgm. is injected. This quantity \nmay be exceeded but is likely to be followed by after effects. \n\nAccording to Matas the solution should be made as follows : \n"Five tablets each containing 1-5 grain of cocaine hydrochlo- \nrate, 1-40 grain of morphine hydrochlorate, 1-5 grain of sodium \nchloride are dropped into 100 minims of hot distilled water and \ndissolved. The solution is again sterilized by the fractional \nmethod. Twenty minims of this solution represent one-fifth \nof a grain of cocaine, one-fortieth of a grain of morphine, and \n\n\n\n\nFig. 45. \xe2\x80\x94 Diagram of Vertebra. \n\none-fifth of a grain of sodium chloride. The syringe, which con- \ntains 30 minims, is filled with the solution and 22 minims are \ninjected. The excess of 2 minims is allowed for waste. The \nsolution should always be used warm, about 90 to ioo\xc2\xb0 F." \nFie claims that this method is very satisfactory. \n\nTechnique. Coming\'s original method differed from that \nused by later authorities. He used for measurement a fine \nneedle, three inches long, provided with a handle and a sliding \nnut (Fig. 44-1)). This needle was introduced half an inch to \n\n\n\nSPINAL ANESTHESIA 169 \n\none side of the spinous process of the tenth dorsal vertebra until \nthe bone was reached. The nut was then slid down until it \nrested on the spine and was fastened by the screw. Fig. 45 \nshows this needle and gives the exact distance between the skin \nand the cord. A hollow needle (Fig. 44-a), with a sliding nut \nfixed at the proper distance, and attached to a syringe (Fig. \n44-c) filled with cocaine solution ; is thrust between the spinous \nprocesses of the tenth and eleventh dorsal vertebrae and the \nsolution injected. Later Corning discarded the needle used \nfor measurement and employed a delicate trocar containing a \nfine needle (Fig. 46), and used the sitting position instead of \nthe lateral for the operation. The needle is introduced slowly \n\n\n\n\nFig. 46. \xe2\x80\x94 Coming\'s Needle. \n\nuntil a few drops of spinal fluid escapes, when the injection is \nmade. \n\nBier and Quincke used the lateral position, and a thin hollow \nneedle wiLh a stopper. After the appearance of the cerebro- \nspinal fluid the solution is introduced with a Pravaz syringe. \nThe technique is as follows: \n\nPlace the patient on his side, round his back by flexing the \nlegs on the thighs and the thighs on the abdomen and place a \ncushion underneath the flank. This will widen the spaces be- \ntween the spinous processes of the vertebrae. The lumbar re- \ngion is cleansed. The posterior, inferior iliac spines are lo- \ncated and joined by a line which passes the level of the fifth \nlumbar vertebra. Below this line will be found the sacro- \nlumbar fossa, and from this point count the lumbar spinous pro- \ncesses until the third or fourth lumbar interspace (the point of \nelection) is reached. This point is marked with iodine, and \nrendered anaesthetic by ethyl chloride or some other local an- \naesthetic. The spinous process corresponding to the space \nelected (third or fourth lumbar) is located, and keeping the \nfinger on the process, the needle, which should be strong and \nthree or four inches long, is inserted one-half cm. to the outer \nside (right or left) cf the median line. The needle is held by \nthe thumb and index finger of the right hand and gently pushed \n\n\n\n170 \n\n\n\nSPINAL ANAESTHESIA \n\n\n\nfrom behind forward, from below upward, and from without in- \nward, the obliquity of the needle inward and upward being \nslight. The needle is most likely to be arrested by the supe- \nrior lamina of the space it is traversing, if so it should, be \nslightly withdrawn and its direction changed. The external \norifice of the needle must be watched, for as soon as the needle \ntraverses the inter-laminar space it enters the sub-arachnoid \nspace, and the spinal fluid will escape. Cocaine must not be \ninjected unless this escape of spinal fluid takes place. When \n8 to 10 drops of fluid have escaped the injection is made very \n\n\n\n\nFig. 47. \xe2\x80\x94 Sitting Position. \n\nslowly. When the needle is withdrawn the point of injection \nis sealed with collodion. \n\nThe technique cf lumbar puncture may, at times, be difficult \nIn obese or muscular subjects palpation of the spinous pro- \ncesses of the lumbar vertebrae is difficult. The sitting position \nis better than the lateral. The needle should be introduced \nslowly, and the appearance of the spinal fluid alone should be \nregarded as evidence that the needle has penetrated the canal \nVery little spinal fluid should be allowed to escape. About one \nminute should be consumed in injecting the solution. The \n\n\n\nSPINAL ANESTHESIA \n\n\n\n171 \n\n\n\nneedle should be left in place after the injection for five or ten \nminutes. Repeated injections have been made, but are con- \nsidered dangerous. Surgical cleanliness should be carefully \nobserved. The skin may be previously anaesthetized by the \nSchleich infiltration method, or by the ethyl-chloride spray, but \nthis is considered unnecessary by most operators. The needles \nand syringes should be kept exclusively for this purpose and \nshould be carefully sterilized and tested before using. \n\nThe location of the puncture. The inter-vertebral space be- \ntween the third and fourth, or fourth and fifth, lumbar verte- \n\n\n\n\nFig. 48. \xe2\x80\x94 Iliac Crests\'. \n\n\n\nbrae is usually selected. Chipauit used the space between the \nfifth lumbar vertebra and the sacrum, which is also preferred by \nRodman. Corning first used the space between the eleventh \nand twelfth dorsal vertebrae, but later preferred that between the \nfourth and fifth lumbar vertebrae. Tait and Cagliari, of San \nFrancisco, have injected as high as the sixth cervical space, but \nmost authorities condemn injections higher than the second \nlumbar vertebra. \n\nPosition and method. The lateral position and technique \n\n\n\nTJ2 \n\n\n\nSPINAL ANESTHESIA \n\n\n\nalready described may be used. Matas recommends the method \nemployed by Tuffier, and first used by Quincke. \n\nThe patient is seated on a table with his back to the opera- \ntor (Fig - . 47). His hands resting on his thighs support his \ntrunk. The trunk is held nearly upright with the spine as \nstraight as possible. The highest points of the iliac crests \nposteriorly are now identified (Fig. 48), and a horizontal line \n\n\n\n\nFig. 49. \xe2\x80\x94 Needle Entering Opposite Fourth Spine. \n\nconnecting these points is drawn across the spine. The tip \nof the fourth lumbar spine touches this line. The canula is \nentered at a point just below and to the outer side of the junc- \ntion of this line with the fourth spine (Fig. 49). The skin at \nthis point and for a quarter of an inch to the right of the median \nline may be infiltrated with a few drops of Schleich\'s cocaine \nsolution No. 1 or No. 2. A Pravaz syringe, as used by Tuf- \n\n\n\nSPINAL ANAESTHESIA 173 \n\nfier, may be employed (Fig. 50), with a platinum needle 8 cm. \nlong, and a lumen of 6 mm. The various methods of insert- \ning the needle are shown in Fig. 51. \n\nGuinard claims to have succeeded in suppressing all after \neffects of medullar cocainization by using a solution of cocaine \nin the rachidian liquid of the patient, 60 to 80 drops of this \nliquid are collected in a sterilized bottle, and 6 or 7 drops of a \nconcentrated solution of cocaine (about 1 centigramme to 2 \ndrops of water) are added and the whole slowly injected. \n\nThe following account of the method of A. W. Morton, of \nSan Francisco, is taken from his article on "The Sub-Arachnoid \nInjection of Cocaine for Operations on the Upper Part of the \n\n\n\n\nFig. 50. \xe2\x80\x94 Tuffler\'s Needle and Syringe. \n\xe2\x80\xa2 Body," read at the fifty-third annual meeting of the American \nMedical Association, (Jour. Am. Med. Assn.) \n\n"Chemically pure cocain hydrochlorate is sterilized by expos- \ning the crystals to dry heat 300 F. for fifteen minutes, then in- \nclose in sterile tubes, or sealed envelopes, in proper doses until \ntime for use. The dose varies from 0.3, 0.4 or 0.5 of a grain, de- \npending on the locality, whether in the lower extremities, \ntrunk, or head. This is the maximum dose for a strong person ; \nyoung or old persons will take a smaller dose. \n\n"I use the Lures syringe, which has a glass piston, and grad- \nuated barrel, and is readily sterilized, and always in working \norder. The needle is made of steel wire tubing No. 19 gauge, \nand three inches long; the bevel is short, with the concave \nportion of it dulled, to prevent cutting plug of skin and ob- \nstructing needle. The needle is kept in a saturated solution \nof carbonate of sodium to prevent rusting. \n\n"The patient is placed in the reclining position on either side, \nwith body curved forward, to separate the spinous processes; \nthe spinous process of the fourth lumbar vertebra is located by \nbeing on an imaginary line connecting the crest of the ilia. \n\n\n\n174 \n\n\n\nSPINAL ANAESTHESIA \n\n\n\nThe space just between the third or fourth lumbar vertebra is \nfrozen with ethyl chlorid, after being thoroughly cleansed. The \nneedle is introduced just beneath the spine in the median line, \nwith the point of it directed upward, and introduced until it \nmeets with diminished resistance, or fluid passes. Should the \nneedle be obstructed, it can be opened by having the patient \ncough, using stylet, or making suction with syringe attached, \nat which time a drop of cerebro-spinal fluid will pass. Then \nplace the finger over the end of the needle and connect the \n\n\n\n\nFig. 51. \xe2\x80\x94 Method of Puncture for Spinal Drainage. \n\nFog. 51. Methods of puncture for spinal drainage: A. Quincke\'s method; \nB. Warfan\'s; C. Chipault\'s ; D. Turner\'s\xe2\x80\x94 after Matas, modified from \nChipault. \n\nsyringe, which has 0.3 of a grain of cocain in it, with piston \nclosed, and gradually withdraw the piston, until the syringe is \nhalf filled with cerebro-spinal fluid, which readily dissolves the \ncocain ; then gradually return the solution into the space by \npressing the piston. \n\n"Should the analgesia be desired in the upper extremities, \nintroduce the needle in the third space, and use the same \nmethod as above, except the dose should be 0.4 to 0.5 of a grain \nof cocain, and introduce as rapidly as the piston of the syringe \ncan be pressed, then withdraw the needle and seal with collo- \ndion. \n\n"The analgesia will be complete for operations in the lower \n\n\n\nSPINAL ANAESTHESIA 175 \n\nextremities in from three to five minutes, and for operations \nin the upper part of the body, in from fifteen to twenty-five min- \nutes ; the analgesia lasts from one to three hours, and I have \nseen it last five hours." \n\nStovaine. This drug, which has come into use for spinal an- \naesthesia, was brought publicly before the profession by Four- \nneau, a French chemist, by whom it was named, in 1904. It had \nbeen tried by Reclus as a local anaesthetic a few months before, \nand about the same time Chaput used it for spinal anaesthesia. \nThe drug is a hydrochlorate of amyleine, and is derived from \ntertiary amylic alcohol. It crystallizes in flakes resembling co- \ncaine. It is very soluble, and it is said that solutions will stand \na temperature of 115 C. for twenty minutes. It is credited with \nbeing a vaso-dilator, and with having antithermic action. It \nslows the pulse, contracts the pupils,, causes flushing, but not \npallor. There is no dyspnoea, oppression or excitement, or ten- \ndency to syncope. It is said to be as efficient as cocaine, but \nmuch less toxic, and can be given in larger doses if required. \nLethal doses for animals cause paresis of the hind legs, tonic fol- \nlowed by clonic spasms of a violent nature, coma, and death. \n\nChaput uses from two to eight centigrammes for spinal anaes- \nthesia, and maintains that good results can always be obtained \nfor operations below the umbilicus ; that the length of the an- \naesthesia varies with the amount of the drug injected. Young \nadults require rather large closes. He does not advise Stovaine \nfor persons over sixty -five years old, but if used the dose should \nbe small. After effects noted are : slow pulse, nausea, perspira- \ntion, pallor, mental distress, headache, rise of temperature, neu- \nralgia, vomiting. These results, however, are not so severe as \nfrom cocaine. Chaput maintains that the advantages of stovaine \nover cocaine are so marked that it should always have the prefer- \nence. \n\nSonnenburg arrives at conclusions similar to those of Chaput, \nand holds that operations as high as the costal arch may be done \npainlessly by the use of stovaine. His age limits are fourteen and \nsixty. \n\nTurner considers the anaesthetic properties of stovaine as good \nas those of cocaine, and thinks its use an important advance. He \n\n\n\n1^6 SPINAL ANAESTHESIA \n\nuses a ten per cent, solution of stovaine with sodium chloride. \nOn the continent this is supplied in ampuls of half a c.c. con- \ntaining- five centigrammes of stovaine. Bier advises the addition \nof adrenalin because the specific gravity of the solution is then \nnearer that of the spinal fluid, and there is therefore less danger \nof headache or spinal neuralgia, and the anaesthesia will last \nlonger. \n\nAccording to A. E. Halsted spinal anaesthesia is of great \nvalue when from chronic disease of the lungs, heart or kidneys \ngeneral anaesthesia is contraindicated, and when the operation \nis on the lower half of the body. Ordinary heart lesions are not \na contraindication. It should not be employed with hysterical \nwomen, insane persons, young children, where idiosyncrasy to \ncocaine exists, and only when it can be explained to the patient \nand the co-operation of the latter obtained. Its objections, more \nor less valid, are that immediate and remote changes may be con- \nsiderable, the production of surgical anaesthesia and its dura- \ntion are somewhat uncertain, attempts at introducing the agent \nmay fail, and there may be important after effects. These ob- \njections may be generally avoided by proper care and technique. \n-Halsted employs the method of Tuffier and advises the use of \nLuers syringe and needle (a platinum needle with short bevel \npoint and dull edges. The syringe is entirely of glass). An \namount of spinal fluid equal to the quantity of the injection is \nallowed to escape, or Morton\'s method of placing dry, sterile co- \ncaine in the syringe and dissolving it in the fluid withdrawn, \nwhich is then replaced, may be used. Halsted injects from 15 to \n20 minims of a two per cent, solution freshly prepared at the \ntime of the operation. The duration of the analgesia is from \nthirty minutes to three hours or longer. It is not safe to count \non more than one and one-half hours. \n\n\n\nCHAPTER XIV. \n\nMIXTURES FOR ANESTHESIA. \n\nMixtures of alcohol, chloroform and ether, chloroform and \nether, and chloroform and alcohol have been more or less ex- \ntensively employed with the object of obtaining anaesthesia with \na less concentrated vapor, and of obviating depression of the cir- \nculation. The addition of ether to chloroform, or to chloroform \nand alcohol, produces a better and more uniform circulation \nduring anaesthesia than is the case with chloroform alone. The \ndifference in the boiling point, and in the volatility of the constit- \nuents of these mixtures renders it difficult to control the pro- \nportion of the various vapors inhaled. Ellis devised an ap- \nparatus in which the ingredients were separate and the vapors \nwere mixed in the desired proportions during the administra- \ntion. This apparatus was too complicated for general use. The \ndifficulty is overcome to some extent by using such proportion of \nthe different ingredients as will evaporate in the same time at the \nsame temperature. Or, by using only small quantities of the \nagent at a time, and as frequently repeating the dose as the pre- \nvious one evaporates. \n\nTHE A. C. E. MIXTURE. \n\nOf the various mixtures used for anaesthetic purposes the \nA. C. E. mixture, consisting of I part of alcohol, 2 parts of chlo- \nroform, and 3 parts of ether, has been the most extensively used. \nIt was originally suggested by Harley. According to Martindale, \nby using alcohol of a sp. gr. of .795, chloroform of a sp. gr. of \n1.497, an d ether of a sp. gr. of .720, uniform volatility will be \nsecured. The mixture should be freshly prepared, and kept in \nwell-corked bottles. \n\nWhen inhaled the odor of the mixture is not unpleasant. The \neffects are more similar to those of chloroform than of ether, \nthough partaking of the peculiarities of both. Thus there is \ndeeper and more audible respiration than with chloroform, while \nconcentrated vapor will produce swallowing, coughing, holding \nthe breath more readily than chloroform. There is more saliva \nthan with chloroform, and less than under ether. \n\nThe administration should be conducted with an Esmarch or \n\n\n\n1 78 \n\n\n\nMIXTURES FOR ANAESTHESIA \n\n\n\nan open cone inhaler. Plenty of air must be allowed, and small \nquantities of the mixture used at a time. If attempts at vomiting \noccur the anaesthetic should be carefully continued. From five to \nten minutes should be allowed for the induction of anaesthesia. \nRegular, stertorous breathing, no lid-reflex, muscular relaxation, \nfixed eyeballs, and moderate contraction of the pupils indicate a \nproper degree of anaesthesia. According to Hewitt, a dilated pupil \nwith distinct lid-reflex allows of more anaesthetic if desirable, but \na dilated pupil with insensitive corneae indicates withdrawal until \nthe pupil contracts or lid-reflex appears. High-pitched, crowing \nbreathing as a rule indicates withdrawal and friction of the lips. \nQuiet breathing, tendency to rigidity, swallowing, marked con- \ntraction of the pupils, indicate too light anaesthesia. \n\nThe A. C. E. mixture is regarded by many anaesthetists as one \nof the best agents for routine use. It is well adapted for old or \nfat people, emphysematous subjects, and those suffering from \nbronchitis, asthma, pleurisy, chronic diseases of the lungs, and in \ncardiopathic patients. It is recommended by Hewitt for cases of \nmitral stenosis. It is advantageous for cases of abdominal disease, \nand is well adapted for use with children.* \n\nThe after-effects of the A. C. E. mixture are, as a rule, un- \nimportant. Vomiting may occur. The dangers of its administra- \ntion are similar to those of chloroform, although not nearly so \ngreat. A number of deaths have occurred under its use, but they \ncannot all be attributed entirely to the agent. Kemp thinks that \nthe A. C. E. mixture exhibits the effects of chloroform on the \nheart, and of ether on the kidneys, and sees no good reason for \nemploying the mixture. \n\nbillroth\'s mixture. \n\nThis mixture consists of i part of alcohol, 3 parts of chloro- \nform, and I part of ether. It has been used considerably in Ger- \nmany. Its administration and effects do not differ materially from \nthose of chloroform, except that the circulation is better, and there \nrarely is any after vomiting. \n\nCHLOROFORM AND ETHER. \n\nVarious proportions of chloroform and ether have been used. \nThey should never be administered by closed or bag inhalers. \nSmall and frequently repeated doses are best. \n\nTWO PARTS OF CHLOROFORM AND THREE OF ETHER. This IS the \n\n\n\n*McCardie profers Silk\'s metal hospital inhaler for mixture of chloro- \nform and ether. He thinks E,G better than A.C.E., as alcohol is expensive \nand only wets the sponge. \n\n\n\nMIXTURES FOR ANESTHESIA IJC) \n\nsame as the A. C. E. mixture, without the alcohol. It is recom- \nmended by Hewitt, who says there is less excitement and more \nsatisfactory recovery than with the A. C. E. mixture. He thinks \nthat if small quantities be used repeatedly, and with a proper in- \nhaler, that no difficulty will arise with this mixture or with the \nA. C. E. mixture. The administration is governed in all respects \nby the rules which apply to the A. C. E. mixture. \n\nTWO PARTS OF CHLOROFORM AND ONE OF ETHER. This mixture \n\nis recommended by Fuster. It should be freshly prepared. No \nspecial inhaler is necessary. A wire frame covered with flannel \nmay be used. When the patient is breathing quietly, 4 or 5 drops \nare poured on the inhaler. When this has evaporated 6 or 8 more \nare poured on at the moment of inspiration. Two or three such \ndoses are given during the first minute, and if well taken, three \nor four are given during the second minute, by which time op- \neration may be begun. If there is any evidence of pain, a few \nmore drops may be given with the next inspiration. Anaesthesia \nis produced in from two to five minutes, and may be continued for \na long time by administering 3 or 4 drops from time to time. Ex- \ncitement is rare, vomiting unusual, and the circulation well main- \ntained. \n\nOne part of chloroform and four parts of ether. \xe2\x80\x94 This \nmixture has been used experimentally mostly. Its effects are very \nsimilar to those of ether. \n\nOne part of chloroform and three parts of ether. \xe2\x80\x94 This \nmixture, known as the Vienna mixture, has been quite extensive- \nly used in some parts of Europe, and is said to be very satisfac- \ntory. It has not been much employed in this country. \n\nOne part of chloroform and two parts of ether. \xe2\x80\x94 This \nmixture is similar in its effects to the A. C. E. mixture. It has \nnot been much employed. \n\nCHLOROFORM AND ALCOHOL. \n\nEqual parts of chloroform and alcohol have been used by San- \nsom, and by Snow. Usually, however, a lesser proportion of al- \ncohol has been employed. Vigorous subjects are difficult or im- \npossible to anaesthetize with a large proportion of alcohol. Such \nmixtures should be administered in the same manner as chloro- \nform. \n\n\n\nl8o . MIXTURES FOR ANAESTHESIA \n\nschleich\'s MIXTURE. \n\nSchleich introduced this mixture in 1898. It consists of chlo- \nroform, ether, and petroleum ether, united in such proportions \nand in accordance with the temperature of the patient, that ab- \nsorption and elimination will be balanced and no accumulation be \npossible. A narcotic which evaporates quickly is eliminated quick- \nly. One evaporating slowly is eliminated slowly and becomes \ndangerous. The lower the boiling point of the agent the more \nrapid the evaporation, and vice versa. \n\nSchleich found that when the boiling point of the agent is \nhigher than the body temperature the amount necessary to secure \nanaesthesia is less than when the boiling point equals the body tem- \nperature, and that the resulting narcosis is deeper. Also that it is \npossible to mix ethers having different boiling points in various \nproportions and to obtain a desired boiling point and to regulate \nit according to the proportion of each used. He recommends \nthree mixtures which may be prepared by the anaesthetist. \n\nPetroleum ether is best for modifying the action of chloro- \nform, diluting the other materials. It does not interfere with the \naction of the other drugs, and can be given in large doses without \ncausing- disturbance. The mixture may be administered as are \nother agents. Care must be exercised as to the amount used. \nThirty gms. of Mixture No. 1 is an average amount for 20 min- \nutes or less. An ordinary towel and paper inhaler will answer. \nFor prolonged operations Mixture No. II. may be used, and a \nsmaller amount will be necessary. \n\nMixture No. I. consists of chloroform, 45 parts; petroleum \nether, 15 parts; sulphuric ether, 180 parts, and boils at 38 C. \n100.4 F.). \n\nMixture No. II. consists of chloroform, 45 parts; petroleum \nether, 15 parts; sulphuric ether, 150 parts, and boils at 40 C. \n(i04\xc2\xb0F.). \n\nMixture No. III. consists of chloroform, 30 parts ; petroleum \nether, 15 parts ; sulphuric ether, 80 parts, and boils at 42 C. ( 107.6 \nF.). Petroleum ether should boil at 60 to 65 C. (140 to 149 F.). \n\nRodman used the Schleich mixture in 700 cases in the Mount \nSinai Hospital in New York. He concludes that it is more pleas- \nant to inhale than ether, but not as compared with chloroform. It \nrequires from 15 to 20 minutes to induce anaesthesia. A mask is \n\n\n\nMIXTURES FOR ANESTHESIA 181 \n\nnecessary (Fig-. 52), and must be saturated at the beginning, \nwhich is apt to burn the face. Excitement is less than with chlo- \nroform or ether. Relaxation is more marked than under ether. \nReflexes are lost early, especially the conjunctival reflex, which \nis therefore not a good guide. The pulse is slow, the pupils di- \nlated, and the respiration diminished. Cyanosis is present. If \ncare is not exercised cyanosis increases, breathing is shallow and \ninfrequent, the pulse is rapid and of low tension, and the patient \nstops breathing. Nausea and vomiting is as frequent afterward as \nwith chloroform or ether, and recovery is not any more rapid. The \neffect on the lungs and kidneys are as marked as with ether. Rod- \nman claims that Schleich\'s mixture is inferior to both chloroform \nand ether. \n\nGarrrigues has employed this method, using solution No. L, \nand changing to No. II. if anaesthesia is not induced in ten min- \nutes. He concludes that the mixtures are easily taken, may be \nused in all cases where general anaesthesia is not contraindicated, \nanaesthesia is induced quickly and maintained with small quan- \ntities of the agent, there is little mucus, rarely vomiting, scarcely \nany tendency to cyanosis, no bad effect on the kidneys, only slight \nweakness of the heart, not as much danger to respiration as \nwith ether or chloroform, and the mixture is adapted for general \nusage. \n\n\n\n\nFig. 52. \xe2\x80\x94 Stone\'s Mask for Schleich\'s Solution. \n\nFig. 52. Stone\'s mask for Schleich\'s solution is shaped like half an \negg shell. Its rim is covered with a circular, rubber cushion adjusting \nthe mask closely to the face. The cushion is inflated by a special tube and \nstop-cock. The air required for respiration is admitted through a ->^-inch \nopening in the center of the mask. This pattern is for use in ordinary po- \nsitions. For Sim\'s position a special inhaler should be used, one in which \nthe opening is placed on the right side of the mask instead of the center. \nThe inner portion of the mask is supplied with twelve layers of japanned \nbibulous paper, such as is used by dentists. This is held in place by two \nspring wires. The latter serve not only to hold the paper in a compact \nmass, but to prevent them from resting against the nose. The latter fea- \nture is necessary as the solution is destructive to the skin when long in \ncontact with it. \n\n\n\nl82 SOMNOFORM \n\nSOMNOFORM. \n\nSomnoform is the trade name for a mixture of chloride of \nethyl, 60 per cent., chloride of methyl, 35 per cent., and bromide \nof ethyl, 5 per cent. This mixture was devised by Rolland, of \nFrance, and presented by him at the Congress of the Association \nFrancaise pour l\'avancement des Sciences, held in 1901. Since \nthen this mixture has obtained extensive use in Europe, Great \nBritain, and somewhat so in this country. \n\nA somewhat similar mixture, ethyloform (B. Kuhn) con- \ntains 45 per cent, ethyl chloride, 45 per cent, methyl chloride, and \n10 per cent, ethyl bromide. It has not been widely employed. \nAlso anesthol (Meyer) a mixture of ethyl chloride, chloroform \nand ether. \n\nSomnoform is supposed to be governed in its entry, transit, \nand exit from the body by much the same conditions as those af- \nfecting the action of oxygen. It increases arterial tension and \nthe rate of the heart, and is said to produce changes in the neuron \nwhich vary in different portions of the brain. According to Rol- \nland "somnoform has an elective action on the cells of Purkinje, \nthus suppressing sensivity to pain and temperature \xe2\x80\x94 its passage \nthrough the cerebellum ; and when there is saturation or excess \nof the anaesthesia the pyramidal cells are impressed determining \nloss of consciousness." \n\nThis mixture has been employed chiefly in dental surgery, and \nas the primary agent in the sequential administration of anaes- \nthetics, especially in connection with ether. It is not unpleasant, \nits action is rapid (induction about thirty seconds) and lasts from \nforty-five to seventy-five seconds. Recovery is very rapid, and \nthere are few if any after effects. During the administration \nocular movements cease in about twenty seconds, slight lateral \nnystagmus is usually present, the eyelids droop, pupils become \ndilated, and soft snoring may ensue. The conjunctival reflex is \ngenerally lost. There is usually complete muscular relaxation, \nthough rigidity may be present, in some persons. If only short \nanaesthesia is desired the patient may be told to hold his arm up, \nand as soon as it drops the inhaler may be removed. Or, the \noperator may slowly move his fingers in front of the patient\'s \neyes, and as soon as the gaze becomes "fixed"\xe2\x80\x94 does not follow \nthe fingers \xe2\x80\x94 the inhaler may be removed. If this is done as soon \n\n\n\nSOMNOFORM \n\n\n\n183 \n\n\n\n\nFig. 53- \xe2\x80\x94 Somnoform Inhaler. \nE. De Trey & Sons, Phila. \n\n\n\nFig. 54. \xe2\x80\x94 Tube diagram, \nSomnoform Inhaler. \n\n\n\nFig. 53. At one end is the face piece with a pneumatic rubber pad and \na transparent celluloid cone. At the other end is a rubber bag, the ca- \npacity of which is about two gallons. The face piece communicates with \nthe bag through a short metal tube, shaped at right angle and having the \nproper openings for the supply of air and Somnoform. It also contains \nthe breaking device for the sealed glass capsules and a wire frame in spiral \nform (S), around which is wound the absorbent lint. Somnoform is \nprojected from the bottle straight into "e" and is absorbed by the lint "/." \nIf capsules are used the necks of same can be fractured in the tube "t" \nthe broken portion being caught in the perforated cup "c," it is thus im- \npossible for the broken tip of the capsule to enter the face piece. Fig. 54. \n\n\n\nl84 \xe2\x80\xa2 SOMNOFORM \n\nas consciousness is lost, from fifty to sixty seconds of anaesthesia \nis obtained. Deeper narcosis may be secured by retaining the in- \nhaler for a slightly longer period. After effects are mostly due \nto faulty administration. Nausea is said to follow in about one \nper cent, of the administrations. \n\nThe administration of somnoform should be conducted with \na closed inhaler, as there must be absolute control of air. A \nspecial inhaler has been devised for somnoform which possesses \nseveral advantages (vide Fig. 53). It requires less of the agent \nwith a proper inhaler, and as a rule the best effects are obtained \nwith small quantities. Somnoform is furnished in sealed glass \ncapsules, each of which contains sufficient for one administration. \n\nGrav, of Melbourne, advises that in administering somnoform \nthe face mask should not be applied perfectly close for the first \nfour or five seconds, but after four or five inhalations it should \nbe applied tightly, and all air excluded until the anaesthesia is \ncomplete. He says that anaesthesia is thus reached in from twenty \nto fifty seconds, and will last from one to five minutes. Follow- \ning the anaesthesia there is a period of analgesia lasting from one \nto five minutes, during which the operation may be continued. \nFrom five to twenty teeth have been extracted by this method, \nand the anaesthetic may be reapplied two or three times if neces- \nsary. He has not prolonged the anaesthesia more than five min- \nutes, but others have kept it up for twenty minutes. The aver- \nage quantity used by Gray was 3 c.c. \n\nAccording to Cole the respiration rather than the pulse should \nbe watched in giving somnoform, for there is no danger of pri- \nmary cardiac syncope from inhibition of the heart through stimu- \nlation of the cardio-inhibitory centre, as is the case with chloro- \nform. \n\n\n\nCHAPTER XV. \n\nSEQUENCE OF AN /ESTHETICS. \n\nThe following of one anaesthetic agent by another with the \nsame patient at the same administration is a method of anaesthesia \nwhich in certain subjects, or for particular operations, may be of \nconsiderable advantage. There are a number of these sequential \nmethods of anaesthesia, but certain of them are worthy of special \nattention. \n\nTHE NITROUS OXIDE-ETHER SEQUENCE. \n\nThis method was introduced by Clover. It has since found \nconsiderable employment in Great Britain and in this country. \nBrown and Kelly, of Baltimore, report 300 anaesthetizations by \nthis method. The advantages over ether alone are : More rapid \ninduction of anaesthesia, less irritating inhalation, less struggling \nand excitement, less risk, less ether absorbed, quicker recovery, \nand fewer after-effects. The fact that both agents demand little \nair makes the change from one to the other comparatively easy. \n\nThe administration may be conducted by a closed inhaler suit- \nable for the administration of both agents, such as the Ormsby, \nClover-Hewitt (Fig. 55), Bennett, or Packard inhalers (vide \np. 114), or the gas may be given by the White dental inhaler, and \nwhen unconsciousness is reached ether may be substituted by \nusing an ordinary cone inhaler. The latter method is of advan- \ntage in operations about the throat. It has the objection, which \nHewitt considers serious when using it in adults, that at the \nmoment of change from gas to ether or during the first inhalations \nof ether there is an interruption of the breathing which may lead \nto dangerous spasm of the upper respiratory tract. This is most \nlikely to occur with robust or alcoholic subjects. In children it \nis not likely to happen, and in them this method is simple and \nvaluable. The Clover-Hewitt inhaler with the Hewitt stop-cock \nis recommended by Hewitt. The gas bag holds two gallons and is \nreplaced by the ordinary bag of the Clover inhaler when anaes- \nthesia is induced. The ether may be placed in the inhaler after \nthe patient is insensible to its odor, and the transition from gas \nto ether is gradually made by opening the ether indicator slowly. \n\n\n\n1 86 \n\n\n\nSEQUENCE OF ANAESTHETICS \n\n\n\nThe gas bag may be filled in another room, and the patient need \nnot see it. The noise of gas escaping from a cylinder is obviated. \nThe patient should be fully anaesthetized before ether is admit- \nted or there will be holding of the breath, spasm of the masseters, \nand struggling or excitement. When stertor is present a breath \nor two of air may be given. \n\n\n\n\nFig. 55- \xe2\x80\x94 Hewitt\'s Modification of Clover\'s Inhaler, for N 2 and Ether. \n\nFig- 55- Hewitt\'s modification of Clover\'s inhaler was designed for the \nsuccessive administration of nitrons oxide gas and ether. It has the fol- \nlowing modifications from Clover\'s: (1) The air-way is much larger; (2) \nThe central tube rotates within the fixed reservoir; (3) The face-piece is \nscrewed into the ether reservoir so that the latter cannot be unexpectedly \ndetached from the former; (4) The ether reservoir can be adjusted, with the \npatient in any position, so that ether may be poured into it without remov- \ning the inhaler from the patient\'s face. There are two separate inner tubes \nwhich are made to revolve as one tube by the indicating handle which fits \ninto each. \n\nThe nitrous oxide-ether sequence has gained in popularity in \nmany hospitals in all sections of this country in the last few \nyears, and is being largely employed except when ether is contra- \nindicated. Kelly says this method possesses so many advantages, \nand so few disadvantages, to both patient and operator, that it \nhas become indispensable to his operative technique. \n\n\n\nSEQUENCE OF ANAESTHETICS \n\n\n\n187 \n\n\n\nChamberlain advocates this sequence, and uses the Bennett \ninhaler. He precedes the inhalation of the gas by allowing the \npatient to breathe through an Esmarch inhaler the vapor of a \nfew drops of oil of peppermint or a drachm of alcoholic solution \nof menthol. This lessens bronchial irritation, suffocation and ex- \n\n\n\n\nFig. 56. \xe2\x80\x94 Gwathmey Gas-Ether Inhaler. \n\nFig. 56. This inhaler is light (26 ounces), portable and convenient. \nThe valves are of steel with brass springs, and may be removed and re- \nplaced, and the inhaler can be sterilized. Economy of the agent is a \nfeature of its use. The gas cylinder and bag of other inhalers is done \naway with by placing one more tube in the ether cylinder, with the in- \nspiratory valve in it, and placing the expiratory valve on the face-piece. \nThis practically places the gas within the ether chamber. The same bag \nis used for gas and ether. \n\n\n\ncitement. The time of induction is lessened by this sequence \n(average four minutes in 385 cases). The quantity of ether used \nis much less, and after effects are correspondingly obviated. \n\nVan Hook strongly advises the nitrous oxide-ether sequence. \nThe gradual changing is the ideal method. He uses a simple cap \ncontaining gauze saturated with ether, which is applied to the \n\n\n\n1 88 \n\n\n\nSEQUENCE OF ANESTHETICS \n\n\n\ngas inhaler at the proper moment, no air being admitted until \nthe patient is under the ether. \n\nGwathmey has devised a gas-ether inhaler which is a modifi- \ncation of the Bennett inhaler (vide Figs. 56, 57). It can be used \nfor ether or gas alone or for the gas-ether sequence. \n\n\n\n^fi \n\n\n\n\nFig- 57- \xe2\x80\x94 Diagram of Gwathmey Inhaler. \n\n\n\nA. Inspiratory valve. \n\nB. Expiratory valve. \n\nC. C. Tube for to-and-fro breathing \n\nD. Tap for turning on and off the gas, admitting air when necessary; \nand also for pouring ether into chamber. \n\nE. E. Openings to ether chamber. \n\nF. Tap for admitting air through face-piece. \n\nTHE CHLOROFORM-ETHER SEQUENCE. \n\nThis method has been considerably employed because the agree- \nable odor of chloroform adapts it for use as an initial agent, and \nbecause no special apparatus is necessary for administration. The \nobjection is raised that a large proportion of chloroform fatalities \n\n\n\nSEQUENCE OF ANAESTHETICS 189 \n\noccur during the initial stage of its administration, and therefore \nthe risk is practically as great as when chloroform is used for the \nentire period of anaesthesia. It is not necessary, however, to carry \nthe chloroform far enough to entail these dangers, and if care \nis exercised the risk is much less than with chloroform alone. \n\nThe administration of the chloroform should be conducted on \nan Esmarch mask by the drop method of Prince. As soon as un- \nconsciousness is reached the ether is substituted. Any ether in- \nhaler may be used, or the ether may be given by the drop method \non the mask by using a thicker covering for the mask, such as \ntwice the thickness of gauze necessary for chloroform. The \nchange from chloroform to ether can thus be made gradually, \nand often without any difficulty. Retching, vomiting, struggling, \netc., may occur if the change is made too early or if too little an- \naesthetic be given. Post-anaesthetic retching and vomiting is \nusually no more frequent or severe than under chloroform alone. \n\nTHE A. C E.-ETHER SEQUENCE. \n\nThis method has been largely used and is considered by many \nto be much superior to the previous method because less liable \nto cause unpleasant or dangerous symptoms during the induction \nof anaesthesia. It appears to be a particularly satisfactory method \nof anaesthesia in persons who are generally regarded as unsatis- \nfactory subjects. \n\nThe administration may be conducted in the same manner as \nw r ith the chloroform-ether sequence. Hewitt recommends for \nadults, first the mask and drop-bottle, then the Rendel inhaler \nwith half a drachm of the mixture from time to time, and finally \nthe Ormsby inhaler with ether, and in children the mask until \nrespiration is deep and regular, then the Clover inhaler with \nether, the indicator being turned to "i." Rowell endorses prac- \ntically the same method as being the safest routine method in \nchildren. \n\nTHE ETHER-CHLOROFORM SEQUENCE. \n\nThis method is employed when ether is not well borne, or \nwhen there is danger in using chloroform as an initial agent. It \nmay also obviate to some extent the danger of complications \nwhich attend the continued use of ether in lengthy operations. \n\nIn changing from ether to chloroform it is important to make \nthe change under the proper depth of narcosis. Coughing, swal- \n\n\n\n190 \n\n\n\nSEQUENCE OF ANESTHETICS \n\n\n\nlowing, or a moderate sensitiveness of the cornese indicate a \nproper condition for the change. Struggling or excitement will \nbe aggravated by the change, and spasm is more liable to result. \nIf too deep narcosis is present the change may result in toxic con- \nditions. The respiratory tract should be free from mucus or \nblood when the change is made, as the quieter respiration under \nchloroform may be affected by their presence. \n\n\n\n\nFig. 58. \xe2\x80\x94 Dawbarn Inhaler. \n\nThis illustration does not show the relative size of the thin rubber \nair-bag, which is large enough for the tidal air of the largest man. \n\n\n\nTHE ETHYL CHLORIDE-ETHER SEQUENCE. \n\nThis method of anaesthesia has steadily gained in use during \nthe past few years. Its comparative safety, together with its \nfreedom from disagreeable symptoms during induction, and from \n\n\n\nSEQUENCE OF ANESTHETICS I9I \n\nunpleasant or serious after effects makes it preferred by many \nover the gas-ether sequence. Any good closed inhaler which will \nallow of perfect control of air may be used for this method. \nDawbarn advises the simple and cheap ether inhaler known by \nhis name, which embodies the principles of the Clover air-bag \ninhaler (vide Fig. 58). \n\nDawbarn drops into the bag of this inhaler a couple of tubes \nof ethyl chloride (Squibbs), each of which contains 5 c.c, and \neach tube is wrapped separately in a little gauze secured by an \nelastic band. When everything is ready, and the face piece is in \nposition, one of these tubes is broken through the bag, and thus \nall waste of vapor is avoided. The other tube may be used or \nnot, as necessary. As soon as the patient is asleep the ether cage \n(containing a crumpled handkerchief wet with ether) is slipped \ninto place, and the ether anaesthesia begins, at first being mingled \nwith the ethyl chloride vapor. \n\nVarious other sequences have been adopted with the object of \nsecuring the best and safest features pertaining to each agent \nand applying them to the particular stage of anaesthesia to which \nthey are adapted. Thus we have the nitrous oxide-ether-chloro^ \nform sequence, the A. C. E. -ether-chloroform sequence, and the \nchloroform-ether-chloroform sequence. Properly applied, these \nchanges may be of much utility in special circumstances. \n\nEthyl bromide-chloroform, A. C. E. -chloroform, ether-A. C. \nE., nitrous oxide-ethidene dichloride, nitrous oxide and oxygen- \nether, are sequences which have been more or less used, but which \ndo not call for special mention, unless it be that the ethyl bromide- \nchloroform sequence has been warmly advocated by some observ- \ners, who emphasize its advantages if care is taken to secure per- \nfectly pure ethyl-bromide. The dangers of the chloroform in- \nduction period are done away with and the narcosis is safely and \neasily continued with chloroform, of which very small quantities \nare necessary. In like manner the use of somnoform preliminary \nto either ether or chloroform has become popular with those w T ho \nbelieve this mixture is superior to ethyl chloride. \n\n\n\nCHAPTER XVI. \n\nAFTER THE ADMINISTRATION OF AN ANESTHETIC. \n\nThe duties of the anaesthetist do not cease with the ending of \nthe administration. He should remain by the patient until con- \nsciousness has at least in part returned, or until the patient is \nasleep, and in case the patient sleeps quietly immediately after the \noperation, the administrator or some competent person should \nbe on hand when he awakes in order to combat any troublesome \nconditions that may arise. \n\nImmediately after the operation the patient should be turned \non his side. The room should be kept dark and quiet to encour- \nage sleep. The temperature of the room should be about 75 F. \nToo free ventilation and drafts of air should be avoided. The \npatient\'s head should be kept low and he should be covered with \na blanket. The stimulation of the circulation from an anaesthetic, \nespecially ether, is followed by more or less depression during \nrecovery, and in w r eak subjects it is advisable to surround the \npatient with hot water bottles, which should be wrapped in flannel \nto prevent injury to the surface of the body. \n\nThe rapidity of recovery will depend on the degree of narcosis, \nthe length of the administration, the degree of surgical shock, \nthe nature of the anaesthetic agent, and the nervous character of \nthe subject. When the anaesthetic is withdrawn from a fully an- \naesthetized subject the first evidence of recovery will be the dim- \ninution of stertor, if it is present, and the appearance of quiet \nbreathing. The lid-reflex or swallowing movements, or both, next \nappear. The pupils grow smaller, or may dilate if the patient is \ndisturbed, or if vomiting is imminent. The eyeballs become mo- \nbile. The breathing may be slightly obstructed from swallowing. \nExpiratory, moaning, or inspiratory noise may be present, and \ncoughing or retching and vomiting may follow. Immediately \nafter the operation the patient should be turned on his side, with \nthe head low and in the median line. If the subject has been \nin a sitting posture, as for dental or oral surgery, he should be \nbent forward to allow blood to escape from the mouth, and after- \nward placed in the lateral, recumbent position. If retching oc- \ncurs the lower jaw should be pushed well forward. \n\n\n\nAFTER THE ADMINISTRATION OF AN ANESTHETIC 1 93 \n\nFaintness, syncope, and weak pulse are generally due to nausea \nand vomiting. They may, however, be due to the patient\'s gen- \neral condition, weak heart, or to shock from the operation. It \nhas been claimed that degenerative changes in the heart muscle \nmay be instituted by the anaesthetic, and that syncope and cardiac \nfailure may occur from this cause in patients whose hearts were \npreviously healthy. This is exceedingly doubtful. It is possible that \nin some degrees of myocardiac degeneration the anaesthetic may \nrender the heart muscle weaker for some time subsequent to the \noperation, even if difficulty was not apparent at the time of the \noperation. Yet, in most cases of chronic muscular disease of the \nheart, if the dynamic condition is fair at the time of anaesthesia, \nthe after-effects on the circulation will be unimportant. \n\nNo food should be allowed for at least five hours after an- \naesthesia. If the stomach feels badly, a few sips of clear, strong \ncoffee may be given half an hour after the patient is fully con- \nscious. \n\nIf the patient feels very prostrated, sipping hot water for a few \nminutes at a time will act as a good stimulant. If the after-taste \nof ether is complained of, a small slice of lemon, or some orange \njuice will relieve it. If the patient is hungry, a little food may \nbe given about four or five hours after the administration. A \nlittle meat broth or soup, or some beef extract, such as somatose, \nLiebig\'s extract or Armour\'s extract. I have found the Mos- \nquera liquid extract given quite hot to be very satisfactory. Seltzer \nand milk may be preferred in some cases. \n\nVomiting is the most troublesome condition and the hardest \nto control in some instances. If the patient has been properly \nprepared for the operation by giving a purgative, and by keeping \nthe stomach empty, vomiting is not as likely to occur as if these \nprecautions are neglected. If the patient is too deeply narcotized, \nif the anaesthesia is prolonged, if blood or mucus enters the stom- \nach, or if the patient is moved or disturbed during the early period \nof recovery, there will be greater liability to vomiting. Robust \nchildren and women, and bilious, over-fed men, are most liable to \nvomiting. Patients operated on early in the day are less liable \nto vomiting than those operated on late in the afternoon. Certain \noperations, such as abdominal or pelvic operations, are more \n\n\n\n194 AFTER TJIE ADMINISTRATION OF AN ANAESTHETIC \n\nliable to be followed by vomiting than are operations about the \nupper portion of the body. \n\nThe kind of anaesthetic and its purity will influence the tend- \nency to vomiting. Nitrous oxide, ethyl chloride, and ethyl bro- \nmide are less often followed by vomiting than are other anaesthet- \nics. Ether produces transient vomiting more often than chloro- \nform, but persistent vomiting is more frequent after chloroform.* \n\nMany remedies have been recommended for the treatment of \nvomiting, but it is not always possible to tell what will be effica- \ncious. Ochsner recommends a napkin wet with vinegar laid over \nthe nostrils, an ice bag over the phrenic nerve, sips of hot water \nevery 15 minutes, occasional sips of strong coffee, small pieces \nof ice in the mouth, and, in persistent cases, hot enemata of nor- \nmal salt solution. Hunter Robb advises one or two teaspoonfuls \nof toast water every 20 minutes by mouth for 6 to 12 hours. The \nhead should be kept low, on level with body or only slightly ele- \nvated. Vomiting usually stops in from 18 to 20 hours. If it \ncontinues after the third day, and if the fluid is expelled without \neffort, the vomiting is likely due to peritonitis. It may be re- \nlieved by two or three drachms of very hot water containing ten \ngrains of bicarbonate of soda, repeated every hour or two. Light \nmustard plaster may be placed over the epigastrium. It may be \nnecessary to wash out the stomach. The vomiting from peritonitis \nis hard to control. It is made worse by the administration of \ndrugs. Treatment of the accompanying constipation and tympany \nmay relieve the vomiting. It may be necessary to inject morphine \nover the epigastrium to relieve retching. \n\nBonney divides the vomiting after pelvic operations into irri- \ntative, neurotic, obstructive, and peritonitic. Irritative vomiting \nis due to gastritis from the anaesthetic. No food should be given \nby the mouth. Nutrient enemata may be given. If the vomiting \nis not severe, peptonized milk and lime water may be given, or \none dram of bicarbonate of soda in three ounces of hot water \none-half hour before food, or bismuth and bicarbonate of soda \nevery three hours may be taken. For bilious vomiting, one dram \ndoses of bicarbonate of soda should be used. For neurotic vom- \niting, a little brandy in the food, and moral suasion, with mustard \nto the epigastrium. Soap and water enemata are very useful in \nall forms of vomiting. \n\n\n\n*In some hospitals the stomach pump is used in all cases, if possible, \nbefore the patient regains consciousness. As much material as possible is \naspirated in this way, and while vomiting is not prevented, always, it is \nlessened in severity. \n\n\n\nAFTER THE ADMINISTRATION OF AN ANAESTHETIC 195 \n\nIn some cases the procedure used by Joos for vomiting during \nanaesthesia may b^ beneficial \xe2\x80\x94 compression of the phrenic nerve \nand the vagus on the left side immediately above the sternal end \nof the clavicle, by the thumb, the hand laying flat on the thorax \nparallel with the clavicle. \n\nBlumfeld advises lavage of the stomach with plain water for \nafter-vomiting, and Lenevitch advises the same proceeding with \nlukewarm alkaline solutions. In neurotic subjects an enema of 20 \nto 25 grains of potassium bromide in three or four ounces of \nwater may be useful. For persistent vomiting we may try one \nminim doses of tincture of iodine every two hours, or one-third of \na grain of zinc oxide three or four times daily, or one-two-hun- \ndredth of a grain of permanganate of potash on an empty stomach, \nor one drachm every 15 minutes of a mixture of 4 drops of creo- \nsote to 2 ounces of lime-water, or teaspoonful doses every hour of \n2 ounces of lime-water containing- 1 grain of carbolic acid, or one- \nhalf grain doses of menthol in liquid vaseline, or one-eighth grain \ndoses of cocaine, repeated as necessary. Persistent nausea may \noften be relieved by small amounts of champagne, or by 1 or 2 \ngrain doses of oxalate of cerium. \n\nBronchial and pulmonary symptoms may arise from the pres- \nence of foreign substances in the respiratory tract. In these cases \ndiagnosis may be difficult, and the result may be fatal if opera- \ntion does not give relief. Bronchitis occurs in rare instances, and \nespeciallv when there has been an attack just previous to the an- \nesthetization. Pneumonia occurs in a varying proportion of cases. \nIts relation to the anaesthesia is not exactly determined (vide p. \n104) . According to Van Beck, the use of ether in Czerny\'s clinic \nhas been restricted because of its injurious effects upon the res- \npiratory tract. The occurrence of pneumonia after anaesthesia \nmay easily be overlooked, as there is frequently absence of chill, \nand slight or irregular rise in temperature. The physical signs \nare also apt to be atypical. Most of the cases occur during cold \nweather, and the change from a warm operating room to a cold \ncorridor may have its causative effect. Again, a deep and pro- \nlonged narcosis may tend to favor the occurrence of pneumonia. \nThe pneumonia usually appears within the first 24 hours succeed- \ning the administration of the anaesthetic. \n\nThe lung complications after anaesthesia which were formerly \n\n\n\nig6 AFTER THE ADMINISTRATION OF AN ANESTHETIC \n\nthought to occur only after ether or chloroform are known to \noccur after any form of anaesthesia, even after local anaesthe- \nsia. The statistics of Chevers and Ericksen show that these com- \nplications were much more frequent in pre-antiseptic days than at \npresent. Aufrecht found that lung complications followed the use \nof chloroform, but not as frequently as they did the use of ether. \nMikulicz (German Congress of Surgery, 1901) gave 1,007 \nlaparotomies and operations for goitre under general anaesthesia, \nwith 7.5 per cent, of pneumonia and a mortality of 3.4 per cent. \nAlso 273 laparotomies (local anaesthesia), with 12.8 per cent, of \npneumonia, and a mortality of 4.8 per cent. Operations on the \nneck, mouth, jaws, and chest also seem to favor the development \nof pneumonia. Mikulicz is inclined toward general anaesthesia \nin these cases, and favors chloroform unless there is some contra- \nindication to its use. Ether is more dangerous because it is more \nirritating to the respiratory passages and because it increases the \nsecretion of mucus.* \n\nRegarding the aetiology of lung complications after operation, \nthe conclusions of Geralanos may be accepted. The irritant action \nof the agent on the respiratory tract and the hypersecretion \n(ether) ; the toxic effect of the agent on the blood vessels, result- \ning in hyperaemia, oedema of the lungs, secondary heart effects, \ndue to both chloroform and ether, especially the latter. This con- \ndition favors hypostatic pneumonia, diminishes local resistance to \ninfection which may occur by inspiration, infected emboli, or by \nbacteria in the blood ; the inspiration of infected material from se- \ncretions of the mouth and pharynx, or vomitus ; infected or non- \ninfected emboli from thromboid vessels (usually veins) from the \nregion of operation ; chilling, fright or shock from the operation, \nwith or without haemorrhage, all lower resistance. Prolonged nar- \ncosis, exposure of the chest or peritoneal cavity reduce temper- \nature ; general weakness of the patient lowers resistance ; interfer- \nence with respiration and expectoration by pain or wound or by \ntight bandages. \n\nAcute oedema of lungs, according to Lindemann, occurs from \ntoxic dilation of the blood vessels and hyperaemia of the lung \ntissue. \n\nEmbolic pneumonia is independent of the general narcosis \nand is due to the nature of the operation and of the disease. In \n\n\n\n*Dawbarn says that chilling of the lungs from the use of a cone, Allis \ninhaler, or some such method, is the chief cause of pneumonia after anaes- \nthesia, and that the rebreathed, lung-warmed ether of the Clover air-bag \nprinciple should have received clearer recognition in this connection. Be- \nsides, it saves the necessity of administering so much ether, which favors \nquick and uncomplicated recovery. \n\n\n\nAFTER THE ADMINISTRATION OF AN ANAESTHETIC I97 \n\nstrangulated hernia and ileus of other forms the mesenteric veins \nmay be thrombosed beyond the seat of the constriction even \nthough the bowel be not gangrenous. When the constriction is \nremoved emboli may form and pass to the lungs. The emboli may \nbe infected ; or, if not, the infarct produced may become infected \nfrom organisms already in the bronchi, or from the blood. Emboli \nmay form in any operation when there is thrombosis either before \nor after operation. They are most common in connection with \nlaparotomies, may be secondary to phlebitis of the lower extrem- \nities, which sometimes occurs after laparotomies. \n\nGangrene and abscess of the lungs are rare after operation. \nThey are due to inspiration of infected material, or to infected \nemboli. \n\nIn weak, debilitated subjects the dressings should be loose, the \npatient should be encouraged to inspire deeply and to expecto- \nrate, the mouth and pharynx should be kept clean, especially if \nthe patient vomits. If there is much pain small doses of morphine \nare advisable. Abdominal distention should be prevented. The \nposition of the patient should be changed frequently, and the head \nand shoulders should be slightly raised. \n\nVarious paralyses may occur from pressure incident to certain \noperations. They are usually transient in character. Leszynsky \nbelieves that paralysis is due to lesion of the nerve trunk and is \na peripheral paralysis from pressure, extension, elevation, unnec- \nessary position, etc. Flatau thinks that in anaemia and in arterio- \nsclerosis cases the paralysis is central. Bloodgood noted five in- \nstances of paralysis of the upper extremities in about five hundred \noperations. In each case the pectoral muscles had been divided, \nallowing of greater extension of the extremity than usual. The \nprecautions to be taken are obvious and are important, as the re- \ncovery may be tedious. \n\nAnuria after anaesthesia is considered by some observers due \nto the effect of large doses of the agent in modifying the flow \nof blood through the kidneys. Exposure of the patient\'s body, \nand reflex disturbance from operations on the genito-urinary \ntract are also considered factors producing anuria. The thera- \npeutic indications are : Strychnia and digitalis if the circulation \nis depressed ; normal salt solution per rectum or under the skin ; \n\n\n\n198 after the administration of an anaesthetic \n\nand nitroglycerine if sclerotic conditions of the vessels indicate \nthe possible presence of vascular spasm. \n\nThe special after-effects of the individual anaesthetics have \nbeen mentioned under their respective causes and need not be re- \npeated here. \n\n\n\n\n\n\nPART II. \n\nLocal Anaesthesia and \nAnaesthetics. \n\n\n\n/ \n\n\n\nCHAPTER XVII. \n\nLOCAL. ANAESTHESIA. \n\nThe local employment of anaesthetic substances or mixtures, \nor of cold in the form of ice or freezing mixtures, as well as con- \nstriction of the parts, has long been practised for anaesthetic pur- \nposes. Little was accomplished in this direction, however, until \nRichardson introduced the hand-ball spray method of using ether \nfor the purpose of local anaesthesia. This method consists in di- \nrecting an atomized current of ether against the part to be oper- \nated on. The rapid evaporation of the ether produces an intense \ndegree of cold which freezes the part. The chief objections to \nthis method are the pain caused by its application to sensitive tis- \nsues, and the burning sensation which follows resumption of func- \ntion by the nerves and vessels of the part. The ether used for this \npurpose should have a sp. gr. not to exceed 0.723. \n\nRhigolene, the lightest liquid known, is more effective than \nether, but is difficult to handle because of its great volatility. It \nis a product of the fractional distillation of petroleum. \n\nThese agents have had but a limited application for minor sur- \ngical operations. Since the introduction of cocaine, however, as \na local anaesthetic agent the field for this method of anaesthesia \nhas enlarged until at present, with the exception of certain op- \nerations on the organs and cavities of the body, most of the major \noperations come within the possibilities of local anaesthesia. There \ncan be no question but that general anaesthesia is very frequently \nused where local anaesthesia would answer. This is specially true \nin regard to short operations when the dangers of general anaes- \nthesia, and its post-operative complications, might be largely \navoided by the employment of local anaesthesia, particularly as in \nthe last few years the technique, effectiveness, and applicability of \nlocal anaesthesia has been immensely improved. \n\nIn regard to prolonged operations involving considerable \nshock, the most recent observations show that the expectation that \nlocal anaesthesia would prove less dangerous than general anaes- \nthesia is not warranted. While local anaesthesia is possible in this \nclass of operations, shock is just as severe or more so under local \n\n\n\n202 LOCAL ANAESTHESIA \n\nas under general anaesthesia, and post-operative complications ap- \npear to be about as frequent and as fatal. \n\nThe frequency and fatality of post-operative pneumonia and \nother lung complications in connection with operations on the \nstomach and intestines by local anaesthesia is greater, according \nto the statistics of Mikulicz, than after general anaesthesia. The \nshock, fright, and unpleasant conditions arising from the con- \nscious state of the patient renders these prolonged, tedious opera- \ntions very trying under local anaesthesia. \n\nThese conditions, together with the difficulty of obtaining com- \nplete muscular relaxation in some cases, militates against local \nanaesthesia in this class of operations, unless it could be proven \nthat both primary and secondary dangers were practically ob- \nviated.* \n\nIn relation to the selection of methods, Mikulicz says that the \nquestion now is in which class of cases shall general narcosis be \nsubstituted for local anaesthesia ; that in one group of cases the \nindications for local anaesthesia are absolute. In this group should \nbe included all operations which can properly be performed under \nlocal anaesthesia, whether a general anaesthetic is contraindicated \nor not, such as minor operations, tracheotomy, gastrostomy, etc. \nIn another group is placed those operations in which there is yet \ndoubt as to the safer method of anaesthesia, such as major opera- \ntions on the stomach and intestines, free and strangulated hernia, \ngoitre, etc. \n\nFor reasons already mentioned most surgeons place operations \non the organs within the abdomen as unsuitable for local anaes- \nthesia. Bloodgood places reducible hernia in the doubtful group \nbecause of the difficulty of completing the operation in some cases \nunder local anaesthesia, and thinks that in patients where a gen- \neral anaesthesia is contraindicated, the operation should be per- \nformed under local anaesthesia or not at all. Strangulated hernia \nhe places under the group indicating local anaesthesia. \n\nIn operations for goitre the special dangers of general anaes- \nthesia, and the success of such operators as Kocher with local an- \naesthesia, influence many surgeons to include operations for struma \nin the group indicating local anaesthesia. \n\nCOCAINE. \n\nCocaine (C 17 H 20 N0 4 ) is an alkaloid obtained from the \n\n*According to Braun a good local anaesthetic should possess the fol- \nlowing characteristics: (i) It must, in proportion to its local anaesthetiz- \ning power, be less toxic than cocaine; (2) it must not irritate or damage \nthe local tissues to the smallest extent; (3) it must be\'fairly stable, solu- \nble in water, and should be capable of sterilization by heat without change \nor alteration of its action ; (4) it should be capable of combination with \nsuprarenal extract without interference with the action of the latter; \n(5) it should be capable of being rapidly and completely taken up by mu- \ncous membrane. \n\n\n\nLOCAL ANAESTHESIA 203 \n\nerythroxylon coca, N. O. Linaceae. The name coca is derived \nfrom the Aymara (Indian) word khoka, signifying "plant" (or \ntree, i. e., the specially favored one). The plant grows to a height \n\xe2\x80\xa2of six or eight feet, has bright green leaves, and bears small, white \nflowers. It resembles the blackthorn. The natives of Peru and \nneighboring provinces cultivate the shrub. The Spanish found \nthe natives of Peru familiar with the narcotic properties of the \nplant. The leaves were dried in the sun, and mixed with a little \nlime to form a preparation for chewing, something like the betel \nleaf of the East. Under its stimulus the natives were able to per- \nform tasks requiring great endurance. Prescott says, "Even food \nthe most invigorating is less grateful to him than his loved nar- \ncotic." According to Clnsius, the Indians stated that while using \ncoca neither hunger or thirst annoyed them, while their strength \nand vigor were maintained. \n\nThe use of coca did not become general until after Pizarro \nravaged the country. Previous to this time, during the reign of \nTupac Inca Yupangin, the most renowned of the "children of the \nsun," and of his son, Huayno Copac, during whose reign Vasco \nNunez de Balboa took possession of the new continent from a \n^\'peak of Darien", in the name of Ferdinand and Isabella, and \ntip to the time of the overthrow of Atohuallpa, the plant was re- \nserved for the use of the Incas, the coca plantations or "cocals" \nbeing owned by the state. \n\nThe continued use of coca forms a habit similar to the opium \nhabit. Appetite is lost, digestion weakened, and an inordinate de- \nsire for animal food follows. Then follow boils, dropsical swell- \nings, foetid breath, pale lips, discolored teeth, dim, sunken eyes, \nyellow, discolored skin, and the coquero becomes as pitiable an ob- \nject as the most confirmed opium habitue. \n\nThe effects of coca depend on the presence of the alkaloid \ncocaine, which has basic properties and combines with acids to \nform salts. It crystallizes in prisms which are transparent and \ncolorless when pure. It is slightly soluble in water, and in alco- \nhol, and freely soluble in ether. It has a bitter taste, and its salts \nare more bitter than the alkaloid itself. Coca contains, beside \nthe alkaloid, an aromatic oil "hygrine", discovered by Lossen in \n1862, which has an alkaline reaction and a biting taste, but is with- \n\n\n\n204 LOCAL ANESTHESIA \n\nout therapeutic virtue. Coca is slightly astringent from the pres- \nence of a tannic acid. \n\nCocaine was discovered by Gordeke in 1855, and called ery- \nthroxyline. It was afterward named cocaine by Niemann, who first \nstudied carefully its physiological action. \n\nCocaine hydrochlorate occurs in colorless, transparent crys- \ntals, or as a white, crystalline powder, without odor, with a slight- \nly bitter taste, and produces on the tongue a tingling sensation fol- \nlowed by a numbness. It is soluble at 59 F. ( I5\xc2\xb0C.) in 0.48 parts \nof water, and in 3.5 parts of alcohol. \n\nThe local anaesthetic action of cocaine when applied to the skin, \nmucous membranes, wounds, or ulcerating surfaces, became \nknown soon after its discovery in 1855, and was noted by Morenoy \nand Maiz, in 1862, and by von Aurep in 1883. Roller, of Vienna, \ndemonstrated its value, especially in ophthalmic practice, in 1884, \nand Noyes, of New York, who observed his demonstrations, pub- \nlished them in this country. \n\nLocally applied, cocaine produces anaesthesia, and a condition \nof anaemia due to contraction of the arterioles. Solutions do not \naffect the intact skin. Personal idiosyncrasy markedly affects the \naction of cocaine. Alarming depression has followed the use of a \nfew drops of a 4 or 6 per cent, solution in the eye, or in the nasal \npassages, or the use of as little as one-eighth of a grain hypo- \ndermically, and death has followed moderate doses. It is not ac- \ntively toxic, and some persons can take large doses without ill \neffects. \n\nThe experiments of Crile, of Cleveland, show that in animals \nunder the effects of cocaine or eucaine exposure or manipulation of \nthe intestines, mechanical irritation of sensitive tissues, manipula- \ntion of the larynx, stimulation of the vagi, operations on the \nlarynx and other portions of the body produced little or none of \nthe fall of blood pressure which characterized such procedures \nin the control animals. The vessels of the splanchnic area are \nsmaller and much less congested in the cocainized animals. \n\nThe effects of cocaine on the circulation were, first, a rise in \nblood pressure, followed by a fall ; and later a gradual rise. The \ninhibitory action of the vagus is partially or wholly suspended. \nThe vaso-motor reflexes are lessened. The circulation is less re- \nsponsive to stimulation. \n\n\n\nLOCAL ANAESTHESIA 205 \n\nA small dose acts as a stimulant to the respiration ; a medium \ndose diminishes the length of the respiratory stroke ; large doses \ncause gradual diminution of the respiration. Some degree of tol- \nerance is acquired by successive doses, and general anaesthesia is \nmore difficult to induce in animals under the influence of these \ndrugs. \n\nIn ophthalmological practice anaesthesia is first induced in the \nconjunctiva and cornea, and may be produced by 2 per cent, solu- \ntions, though 5 per cent, solutions act quicker, and are suitable for \nthe deeper structures. Prolonged contact, wounds, or incisions \naid the diffusion of the anaesthetic. Simple congestion does not \nmaterially hinder the action of the anaesthetic, though chronic \nchanges retard its effects. Where such changes are present, or \nwhen operative procedures have recently preceded the use of the \nanaesthetic, its action may be aided by the preliminary use of a so- \nlution of adrenalin. \n\nSome mydriasis occurs from the action of cocaine, reaches its \nmaximum in about one hour, and disappears in from two to three \nhours. The pupil remains sensitive to light (Koller). Accommo- \ndation is moderately affected. \n\nIn the surgery of the naso-pharynx, larynx, urethra, bladder, \netc., solutions of from 4 to 6 per cent, are necessary, and danger- \nous conditions are therefore more likely to arise. More caution is \nbeing exhibited in its use in these connections, and eucaine b. is \nbeing much substituted for cocaine, as being less toxic, while \nequally anaesthetic. \n\nCrile emphasizes the importance of the local application of \ncocaine solution to the larynx or pharynx (2 per cent.) , along with \nthe hypodermic use of atropine to prevent reflex inhibition of the \nheart and respiration. \n\nLegrand recommends a mixture of cocaine and ethyl chloride, \nwhich is used as a spray. In five minutes the ethyl chloride is \nevaporated and leaves the cocaine on the surface as a whitish de- \nposit. It is useful in making painful applications to ulcerating sur- \nfaces, or to skin lesions. \n\nLocal Infiltration Method. \xe2\x80\x94 This method of producing \nlocal anaesthesia by infiltrating the skin with an anaesthetic solution \nwas introduced by Halsted and Hall, who experimented in this \ndirection in 1884 and 1885. Schleich, for whom this method is \n\n\n\n20b LOCAL ANESTHESIA \n\nusually named, and who fully developed the method, published \nhis first results about four years later. Liebrich, Halsted, and \nSchleich have shown that an artificial cedema of the tissues, es- \npecially of the papillary layer of the skin, produces slight anaes- \nthesia, but not analgesia. Halsted (1885) found it possible to com- \npletely anaesthetize the skin to any extent by subcutaneous injec- \ntion of water, and employed this process for minor operations. \nThis anaesthesia did not extend beyond the boundary of the weal, \nand did not always disappear as hyperemia appeared. Halsted \nfound normal salt solution less painful than water. \n\nSchleich demonstrated the possibility of perfect and painless \nanaesthesia by infiltration with weak solutions of cocaine (0.1 per \ncent, or less). Success depends on the proper infiltration of the \nskin, and other tissues as they are dealt with. Extensive opera- \ntions and dissections may be performed by this method because \nof the dilute nature of the solutions and the freedom with which \nthey may be used without danger of toxic effects. \n\nMost authorities advise a 0.1 per cent, solution, or less, \nof cocaine for infiltration. Some think that morphine is \nnot necessary for the success of the anaesthesia, and for \nextensive operations omit the morphine and dilute with \nsterile salt solution as the operation proceeds. The solutions \nshould be sterilized by repeated heating in a water bath, or in a \nsteam sterilizer (fractional method). Matas drops the tablet pre- \npared by manufacturers into boiled water, and heats the solution \nnearly to the boiling point two or three times. This is a simple \nand practical method. Many authorities state that boiling injures \nthe anaesthetic qualities of cocaine solutions, but when carefully \nsterilized there appears to be no injury to their properties.* \n\nTechnique. \xe2\x80\x94 The success of the infiltration depends on the \nproper production of a weal. The first injection is somewhat pain- \nful, and a fine needle should be used. It should be introduced \nin a slightly oblique direction, and the fluid injected into the skin, \nand not beneath it, so as to produce an elevation of the epidermis, \nwhich becomes white from anaemia. The first weal should be \nlarge. The needle may be thrust beneath the skin, injecting the \nfluid as it proceeds, or it can be withdrawn and introduced just \nwithin the border of the weal so as to cause no pain, and a suc- \ncession of weals produced of sufficient extent for the necessary in- \n\n*When large areas are to be anaesthetized a solution of sodium chloride \n(0.5 gramme to 100 c.c. of distilled water is the best menstrum. 100 to \n250 c.c. of this solution will generally be enough. The maximum amount \nof drug to be used has been placed at about 0.17 gramme of cocaine in \ncombination with adrenalin. 0.30 gramme of eucaine, and 0.25 of stovaine. \n\n\n\nLOCAL ANAESTHESIA 207 \n\ncisions. If several syringes are at hand the infiltration can be \nmade rapidly. It is sometimes of advantage to further oedematize \nthe area by injections of sterile salt solution. As the nerve trunk, \nfilaments, and the vessels of the deeper tissues are also painful, \nit is necessary, in deep operations, to oedematize the deeper tissues \nby infiltrating them in the same manner. Experienced operators \nknow just what tissues to infiltrate. If one is not sure it is best \nto infiltrate the tissues before dividing them. \n\nCombined with other methods next to be considered, exten- \nsive operations are possible that could not be performed by this \nmethod alone. Tearing or traction of the tissues causes more pain \nthan to cut them. \n\nDiminished resistance of infiltrated tissues, infection, suppura- \ntion, necrosis, and imperfect healing of wounds so infiltrated are \nnot to be feared if proper precautions are taken. If the tissues \nabout vessels are infiltrated before dividing the vessels, haemostasis \ncan be obtained. Pain from suturing of wounds can be prevented \nby reinfiltration from the margin of the skin incisions. \n\nRegional Paraneural Infiltration. \xe2\x80\x94 This method was in- \ntroduced by Halsted, Hall, and Corning, in 1884 an -d 1885. It \nwas extensively used by Oberst, and is generally known by his \nname. It consists in infiltration of the tissues about the peripheral \nnerves supplying the part to be operated on, and above the point \nof operation. It was first used for operations about the fingers \nand toes, but as the technique improved has been extended to op- \nerations on the entire extremities, and for areas of the head, neck \nand trunk.* \n\nTechnique. \xe2\x80\x94 An Esmarch, elastic constriction bandage is \nplaced upon the toes, foot, ankle, leg, thigh, fingers, wrist, fore- \narm, or arm, as the case may be, a short distance above the seat \nof the operation. Corning was the first to employ the Esmarch \nbandage in connection with this method of anaesthesia. It was \nfirst used to allow of the deep injection of stronger solutions or \nlarger amounts than is ordinarily used, and which are sometimes \nnecessary with this method. There is less danger of toxic effects \nwhen the constriction is used, and when the bandage is left on for \nfrom one-half to one hour the injection appears to lose its toxic \neffects, according to some observers, because of some action of \nthe tissues upon the drug. Some authorities claim that the Es- \n\n*Pennington advises regional anaesthesia in operations for ano-rectal \ndiseases, and uses the following solution : Beta eucain lactate, 0.2 ; sodium \nchloride, 0.75; suprarenal chloride solution, 0.65; distilled water, 100.0. \nFor the deep structures, to block off the nerves, he uses a No. 17 gauge \nneedle 2 l / 2 to 3 inches in length, blunt pointed, with holes in the sides, in \norder to avoid injury to the blood vessels. \n\n\n\n208 LOCAL ANAESTHESIA \n\nmarch bandage is unnecessary, but the majority believe in its good \neffect. \n\nWalsendorf, in 1676, produced anaesthesia by simple constric- \ntion of the limb, and Esmarch states that he performed painless \noperations on the fingers and toes by means of constriction. \n\nThe application of the bandage is rather painful, which is less \nif the constriction is just sufficient to occlude the vessels, and a \nbroad band is used. The deep injection is made just below the \nbandage, and the tissues about the nerve are infiltrated. The num- \nber of injections will depend en the number of nerves to be an- \naesthetized. The region supplied by these nerves becomes anaes- \nthetic in from five to ten minutes, and the anaesthesia lasts long \nenough for operative procedures. The bandage should be left on \nfor one-half hour or more if strong solutions have been used. \nIf weak solutions have been injected the bandage may be re- \nmoved at once. The weaker solutions are adapted to the com- \nbined use of this method with direct injection of the nerve, and \nlocal infiltration of the. skin. The bandage may here be discarded, \nor may be removed as soon as the operation is completed. \n\nThe Regional Intraneural Method. \xe2\x80\x94 By this method the \nnerve trunk is exposed by the infiltration method, and then in- \njected with a 0.5 to 1 per cent, solution of cocaine. Cushing\'s \nmethod was to inject the nerve as it was exposed during the dis- \nsection. He perfected his method especially for hernia opera- \ntions. When this method is properly performed all afferent im- \npulses are checked. The method was suggested by Crile and \nMatas particularly for amputations and operations on the extrem- \nities.* \n\nAccording to Bieberfield, cocaine is necessary in this method, \nand solutions of from 0.25 to 0.5 per cent, are advisable. \n\nCrile has performed major amputations with this method, and \nsays the technique is based on the fact that "nerve trunks may \nbe safely and effectually subjected to a physiologic \'block\' by in- \njecting cocaine or eucaine in a comparatively weak solution, and \nthat arteries may be, with entire safety, temporarily closed with- \nout injury to their walls." He exposes the nerve trunks under local \nanaesthesia and injects their sheath and then their substance with \na 0.5 per cent, solution of cocaine, just sufficient to cause a local- \nized swelling. Shock is almost wholly avoided because all afferent \n\n*Bodine sees no reason why all major surgery of the extremities should \nnot be done by Coming\'s nerve-blocking method of injecting directly into \nthe nerves supplying the limb. He thinks this method prevents shock, \nas claimed by Crile and Matas. Bodine uses a solution of one grain of \ncocaine in one ounce of sterile salt solution to infiltrate the skin and to \ncocainize nerve trunks. For subdermic infiltration this is diluted to 1-1000 \nby using half of normal salt solution. He thinks that two-thirds of a \ngrain of cocaine is safe for an adult. \n\n\n\nLOCAL ANAESTHESIA 2CO. \n\nimpulses are blocked, shock being due to afferent impulses, occa- \nsioned by operation or injury. General anaesthesia only slightly \nmodifies these afferent impulses, abolishing those for pain, but \nnot controlling those for the vaso-motor, respiratory, or cardiac \nmechanism. Cocaine or eucaine absolutely blocks afferent im- \npulses and wholly prevent reflex inhibition, as in operations about \nthe larynx or pharynx. Hypodermically they diminish shock in \noperations about the splanchnic area, and diminish the effects of \noperation on or exposure of this area. \n\nThe preliminary use of a hypodermic dose of morphine of \nfrom one-eighth to one-fourth of a grain before local anaesthesia \nby any method is recommended. \n\nBagot produces local anaesthesia by a mixture of cocaine and \nspartein sulphate. The latter is used to counteract the depressing \neffect of cocaine. He uses powders, each containing three-fifths \nof a grain of cocaine and three-fourths of a grain of spartein, and \ndissolves one powder in 15 drops of boiling water, and another in \n30 drops of boiling water. Fifteen drops of the weaker solution \nare injected in the part to be operated on, and in 7 or 8 minutes \nthe remaining fifteen drops are injected. The wound is touched, \nfrom time to time, with the stronger solution. \n\nOTHER LOCAL ANAESTHETIC AGENTS. \n\nEucaine a, or Alpha eucaine (C 19 H 27 N0 4 ). \xe2\x80\x94 Forms \nglossy prisms melting at 104 C. Because of the insolubility of \nthe base the hydrochloride is usually employed. Eucaine hydro- \nchloride is soluble in the proportion of 1 in 10 parts of water. It\' \nhas local anaesthetic properties like cocaine. It is not decomposed \nby heat during sterilization. It was supposed to have less action \non the heart than cocaine, but has been practically discarded be- \ncause of its general toxic properties, which resemble those of \nstrychnia poisoning. In ophthalmic practice it produces consid- \nerable pain and burning, and because of this is sometimes com- \nbined with cocaine (cocaine hydrochloride, eucaine hydrochloride, \naa. 0.05 gm., aqua., 5 gm.). As a nose and throat application a \n5 to 10 per cent, solution may be used. \n\nEucaine B, or Beta eucaine (C, 5 H 21 N0 2 HCL). \xe2\x80\x94 The \nhydrochloride of benzoyl \xe2\x80\x94 vinyl \xe2\x80\x94 diacetonalkamin, used as a sub- \nstitute for cocaine. The crystals are soluble in water and are not \n\n\n\n2IO LOCAL ANESTHESIA \n\ndecomposing on heating. It melts at 263 C. (505.4 F.) It is \ncompletely free from irritating properties, is less toxic than co- \ncaine, and is said to be 3.75 times less toxic than eucaine a. \n\nEucaine b. was introduced by Silex in 1897. It is the most sat- \nisfactory substitute for cocaine as yet obtainable. It is not equal \nto cocaine in its anaesthetic qualities, but is distinctly less toxic. \nWhen large amounts of weak solutions are required, eucaine b. is \nrecommended by many. For the urethra and bladder it can be \nused in 4 per cent, solutions to considerable amounts, and is em- \nployed in preference to cocaine. About the nose and throat it is \nsafer than cocaine. In Oberst\'s paraneural infiltration, and for \noperations high up on the extremities, it may be used in stronger \nsolutions than cocaine with safety. For intraneural injections a \nsolution of 1 per cent, may be used extensively, which might be \ntroublesome with cocaine. In ophthalmic practice eucaine b. is not \nas satisfactory as cocaine. Schleich believes that if operations can \nbe performed with 0.1 per cent, or less of cocaine, it is the bet- \nter agent, and that if toxic symptoms appear during the operation \neucaine b. should be substituted. Reclus says the advantages of \neucaine b. are : It can be sterilized by boiling ; the solution is \nstable ; it is much less toxic than cocaine. He makes the patient \nlie down after using a 1 per cent, solution of cocaine, which is un- \nnecessary when eucaine b. is used. \n\nHeinzle says eucaine b. is the best agent. The solutions should \nbe used at the body temperature. He employs 1 part of eucaine b., \n8 parts of sodium chloride, and 100 parts of distilled water. \n\nEucaine b. is used in sterilized solutions up to 2 per cent. The \nanaesthesia may be in some instances as complete as that of co- \ncaine, and more rapid, but does not last so long. It is less irritant \nand toxic than cocaine. There is often a decided burning sen- \nsation for an hour or so after its use.* \n\nTropa-Cocaine Hydrochloride (bensoyl-pseudo-tropein) is \nan alkaloid derived from the small-leaved coca plant of Java. It \nwas first isolated by Giesel. and is identified with the pseudo- \ntropein of hyoscyamus by Liebermann, who prepared it synthet- \nically. It occurs as white needles, melting at 27i\xc2\xb0C. (519.8 F.), \nand is readily soluble in water. According to Ferdinande and \nChadbourne a 2 or 3 per cent, solution produces more rapid, re- \n\n*Parker maintains that infiltration fluids to be practical anaesthetics \nmust contain about 1 per cent, of cocaine or eucaine, and .5 per cent, of \nsalt. He advises the following solution : Cocaine hydrochlorate or eu- \ncaine, .1; sodium chloride, .6; suprarenal extract (i-ioco), 5. to 10.; dis- \ntilled water, to make 100. Salt, cocaine or eucaine can be obtained in \ntablets convenient for making solutions which should always be freshly \nprepared. The solution of adrenalin is probably the best, and should be \nkept in a tightly corked bottle. \n\n\n\nLOCAL ANAESTHESIA \n\n\n\n211 \n\n\n\nliable and less toxic anaesthesia than cocaine. Tropa-cocaine was \nalso advocated by Curtis. \n\nHolocain. \xe2\x80\x94 Obtained by uniting molecular quantities of phe- \nnacetine and para-phenetidin with separation of water. It forms \ninsoluble crystals, melting at 12 1\xc2\xb0 C. The hydrochloride is usual- \nly employed; this forms bitter-tasting crystals, soluble in cold \nwater to the extent of 2\\ per cent. It has been used in ophthal- \nmology as a substitute for cocaine. Two or three, drops of a 1 per \ncent, solution is generally sufficient to produce anaesthesia in from \n15 seconds to 10 minutes. Most ophthalmologists regard it as \nmuch inferior to cocaine. Pouchet rejects holocain because of \nwant of uniformity in its action. \n\nNirvanin. \xe2\x80\x94 This synthetical product is chemically related to \northoform. It appears as white prisms, which are fully soluble \nin water, melt at 185 , and give a violet color with ferric chloride. \nA 5 per cent, solution instilled into the eye causes complete anaes- \nthesia after temporary irritation of the conjunctiva. Upon less \nsensitive mucous membranes the solution is not irritating, but \ndoes not produce such complete anaesthesia. Used subcutaneous- \nly, the effect is complete and prolonged. It is used subcutaneous- \nly in from 2 to 5 per cent, solutions. It is said to be less toxic \nthan orthoform, and according to Luxenburger is only one-tenth \nas toxic as cocaine. Elsberg states that nirvanin is three times \nless toxic than eucaine. Nirvanin is a stable compound, and may \nbe boiled without deterioration. Compared with cocaine, Floeck- \ninger states, nirvanin is less toxic, is anti-bactericidal, its anaes- \nthetic effects are more prompt and prolonged, there is less danger \nof drug habit, and after pain is absent when the injection is prop- \nerly performed. Other authorities are not so favorably impressed \nwith nirvanin. Diedrichson regards it as not altogether harmless. \n\nThe following formula is recommended for use on mucous \nmembranes, or for subcutaneous injections : \n\n\n\nR / \n\n\n\nNirvanin \nSodii chloridi \nAqua cLstil. (sterile) \n\nM. \n\n\n\ngr. ij (gm 0.13) \ngr. i (gm 0.06) \nf. d.ij (gm 8.00) \n\n\n\nAccording to Matas, nirvanin and eucaine b. are the only \nagents that deserve to be classed as succedanea of cocaine. Be- \n\n\n\n212 LOCAL ANAESTHESIA \n\n\'cause of their lesser toxicity, their stability under sterilization, and \nfor other reasons they may be used with advantage along or in \nconjunction with cocaine, and while not superseding cocaine, they \nhave contributed to the widening field of local anaesthesia. \n\nOrthoform. \xe2\x80\x94 This synthetic compound occurs as a white, \nvoluminous, odorless, and tasteless powder. It is permanent, and \nnon-hygroscopic, very slightly soluble in water, and soluble in \nether. By some it is said to be non-toxic, but untoward effects \nhave been observed by Wunderlich, Katz, and others. According \nto Luxenberger, orthoform is compatible with iodoform, dematol \nurophen, aristol, calomel, salicylic acid, carbolic acid, lysol, lead- \nwater, boric acid, alumen acetate, ichthyol, turpentine, iodine, and \ncopper sulphate. Chemical changes occur in connection with bis- \nmuth subnitrate, potassium permanganate, and silver nitrate. Pre- \ncipitation occurs when orthoform is combined with bichloride of \nmercury, or formaldehyde. Antipyrine triturated with orthoform \nis converted into a semi-liquid. Orthoform hydrochloride forms \na soluble, crystalline salt, and though anaesthetic is not adapted to \nsubcutaneous injection. \n\nOwing to its insolubility orthoform is not adapted to subcu- \ntaneous use, though it may be so used suspended in oil. Its in- \nsolubility minimizes the danger of toxic effects. It has little ef- \nfect on the intact skin, though a lanolin ointment if well rubbed \nin will relieve skin irritations. Applied to open wounds or ulcer- \nations, as a dusting powder, or in a 10 or 20 per cent, ointment, \nanaesthesia follows and lasts for two or three hours. \n\nThe chief use of orthoform is to relieve painful lesions of the \nsurface of the body, or of the mucous membranes, to relieve the \npain of cancer, to relieve painful cystitis when used by irriga- \ntion, in painful conditions of the ear, eye, larynx, etc. In gastral- \ngia and painful stomach disorders it may be used in doses of from \nJ\\ to 15 grains (0.50 to 1 gm.) Dreyfus uses orthoform to pow- \nder wounds made under the Schleich infiltration method of an- \naesthesia. \n\nAccording to Cheatham the results obtained with orthoform \nat the Munich surgical clinic are as follows: 1. Loss of sensation \noccurs on the average in from 3 to 5 minutes after application, \nwhether as a powder or as a 10 per cent, or 20 per cent, ointment. \n2. The anaesthetic action continues on the average for about 3c \n\n\n\nLOCAL ANAESTHESIA 213 \n\nhours, in many cases even for 3 or 4 days. 3. Diminution of \nsecretion is always observed, a valuable feature in transplanta- \ntions, or in inoperable cancer of the face. 4. Two ounces weekly, \napplied to a carcinoma, demonstrated its non-toxic nature. 5. An- \ntiseptic properties were not demonstrated, though purulent dis- \ncharges ceased after its application. \n\nAneson. \xe2\x80\x94 This is a trade name for a watery solution of \nacetone-chloroform, which has sufficient anaesthetic power for \nsome operations, though it is not equal to a 5 per cent, solution \nof cocaine. It has been used in ophthalmology, nasal, laryngeal, \ndental, and minor surgery, in 1 or 2 per cent, solutions. The so- \nlution is colorless, does not affect the iris or irritate the eyes. It \ncauses no ill effects when injected in quantities of several Pravaz \nsyringefuls. It is recommended by Mosbacher as a substitute for \ncocaine because it is always sterile, is less toxic, and causes no \nafter pains. Sternberg says it is non-toxic and non-irritant, and \nproduces anaesthesia quicker than cocaine." \n\nEthyl Chloride. \xe2\x80\x94 Ether chloratus, chlor-ethyl, monochlor- \nethane (C 2 H 5 CI), also called chelen or kelene. Produced by \nthe action of dry hydrochloric acid gas on absolute alcohol. At \nordinary temperature it constitutes a gas which is easily con- \ndensed to a liquid, boiling at io\xc2\xb0 C (50 F.). Because of the \nintense cold (about 35 C.) produced by its evaporation, it is used \nas a local anaesthetic. For this purpose it is obtained commer- \ncially in small hermetically sealed tubes (Fig. 59), terminated by \na capillary point. When used this point is broken off and the \ntube held in the hand, the warmth of the hand being sufficient to \nexpel the liquid through the small opening in a stream which is di- \nrected on the surface which it is desired to anaesthetize. Ethvl \nchloride occasions considerable pain, especially to sensitive tissues. \nIt is adapted for small surgical or dental operations, and has been \n\n\n\n\nFig- 59- \xe2\x80\x94 Ethyl Chloride Tube. \n\nFig. 59. Ethyl chloride is, as a rule, contained in small tubes or cylin- \nders constructed either of glass or metal and provided with screw caps. \nEach of these contains a sufficient quantity of the agent for from ten to \nfifteen minor surgical operations. \n\n\n\n214 LOCAL ANAESTHESIA \n\nused somewhat for therapeutic purposes. Ethyl chloride is in- \nflammable and should not be used near an open flame. \n\nLiquid Air. \xe2\x80\x94 As a local anaesthetic for minor operations liquid \nair is recommended by Campbell, also as a cauterizing agent in va- \nrious local conditions. The reaction from the freezing occurs in \nabout 20 minutes and is attended by marked hyperemia. Accord- \ning to MacFayden and S. Roland, after the exposure of various \nbacteria to a temperature of \xe2\x80\x94 190 C for a period of seven days \nin liquid air, no alteration was observed in their structure, and \nthere was no change observed in their virulence except that they \ngrew a trifle more slowly. According to White, the repeated ap- \nplication of liquid air serves as an antiseptic through inhibiting \nbacterial action. He recommends it as a local anaesthetic which \ncauses only slight tingling, the only precaution being to freeze \nthe part solid. \n\nThe spray gives relief in intestinal and trifacial neuralgia, and \nin sciatica. Boils, buboes, and carbuncles may be aborted in their \nearly stages if thoroughly frozen, and specific, chancroidal, and \nvaricose ulcers heal promptly if treated twice a week by freezing. \n\nNovocains. Novocaine is a aminobenzoyl diaethyl amino- \naethenol, and exists as a chloride. It is soluble in water, stable, \nand can be boiled. The lethal dose for animals is less than that \nof cocaine or stovaine. According to Braun it is a powerful local \nanaesthetic with transient action, and no reaction in the tissues. \nCombined with suprarenin it is intensely anaesthetic and durable. \nThe action of the latter is increased, and the combination, in his \nopinion, is better than cocaine and suprarenin, and is less toxic \nthan any other known anaesthetic. He thinks the character of \nits action is on a level with that of cocaine, while the fact that \nnovocaine can be sterilized by boiling and the solution will keep \nfor a long time gives it an advantage. Braun\'s solutions ranged \nfrom one-quarter of one per cent, to two per cent., suprarenin \nbeing added. No unpleasant side-effects were noted. \n\nStovaine. Stovaine (vide p. 175) has been used as a local \nanaesthetic with varying satisfaction. Reclus tried it in 1893. He \nused twice as strong doses as of cocaine without bad results. \nChaput considers it inferior to cocaine as a local anaesthetic. \nChiene says it is not superior to eucaine B and hemisine. Sin- \nclair says stovaine is not as lasting as cocaine, produces intoxi- \n\n\n\nLOCAL ANAESTHESIA 215 \n\ncation, that a two per cent, solution causes chronic edema and \ngangrene, that it interferes with healing, and that it is a danger- \nous and unreliable drug. Luke says that the one disadvantage \nof stovaine is that it cannot be used with adrenalin because of \ngangrene of the skin. \n\nAccording to Braun stovaine is stable, and can be sterilized \nby heat. The hyperaemia caused by it is not completely controlled \nby adrenalin. It is only slightly less toxic than cocaine, and its \naction is weaker. Endermic and subcutaneous injections irritate \nthe tissues and cause actual damage. Five to ten per cent, solu- \ntions cause gangrene. On the other hand Marchetti has employed \nstovaine as a local anaesthetic with uniformly good results. He \nthinks it much less toxic than cocaine, doubts the advisability of \nthe routine combination with adrenalin, but advises stovaine alone \nfor skin incisions, and the combination for the deeper tissues. \n\nIn the face of such contradictory and unsatisfactory testimony \nit is difficult to see why stovaine should replace other better \nknown and more reliable local anaesthetics. \n\nAlypin. According to Braun this drug has very high anaes- \nthetic power, especially when combined with suprarenalin, the \naction of which on the vessels is not interfered with. Its toxicity \nis less than that of cocaine, but it produces irritation and local \ndamage to the tissues. Koellner thinks that while in ophthalmic \npractice it is not superior to cocaine, it is worthy of use. One \ndrop of a five per cent, solution will produce anaesthesia, when \napplied to the conjunctiva, sufficient for superficial operations. \nIt is rapid, does not contract the vessels, and does not produce \nmydriasis or disturbances of accommodation. \n\nThe addition of adrenalin to solutions for local anaesthesia is \ngenerallv recommended for its effect in prolonging the anaesthe- \nsia, lessening hemorrhage, and clearing the field of operation. \nWhen vaso-constrictor glandular products are added to the agent \nemployed the local anaesthesia takes longer to develop. This has \nthe advantage that the edema produced by the injection has time \nto subside, thus clearing the field of operation. It is advised by \nsome not to use adrenalin in the solution used for cutaneous anal- \ngesia because of its slower action, but to combine it with the solu- \ntion used for deep injection, as in Schleich\'s solution for deeper \n\n\n\n2l6 LOCAL ANAESTHESIA \n\nanesthesia. About twenty minutes should then be allowed before \noperating". \n\nAccording- to Parker solutions of this kind are best prepared \nby placing tablets of cocaine and salt in distilled water in proper \nproportion, boil until sterile, make up loss of evaporation by add- \ning sterile water, let solution cool, and add proper amount of \nadrenalin solution. A pinkish color after standing does not injure \nthe solution. \n\n\n\nCHAPTER XVIII. \n\nLOCAL ANAESTHETICS IN DENTISTRY. \n\nIt is probably true that there is no subject of more interest to \nthe dental profession than that of anaesthesia. Most of the opera- \ntions upon the teeth, jaws and adjacent parts are painful to a \ngreater or less degree. The dentist\'s immediate field of operation \nis supplied by the branches of the fifth pair of nerves, perhaps the \nmost sensitive of any in the human body, and especially is this \ntrue regarding pain, which is the only sensation conveyed by the \ntooth pulp. Add to this the fact that patients usually present \nthemselves in a high state of nervous excitement, due to fearful \nanticipations, a condition in which a slight hurt is magnified in \nthe pain centers so that the consequent effect upon the strength \nand nervous make-up of the patient is often very serious. \n\nPeople do not like to be hurt, and are seeking painless opera- \ntions. It is also true that the majority of operators can render \nbetter service when they know they are not hurting their patients. \nA rule, then, that I would like to lay down is : When work can \nbe done successfully, painlessly, without seriously endangering the \nhealth of the patient, it is advisable. \n\nAny agent that has for its object the relief of pain is worthy \nof our careful study. Most strictly dental procedures come under \nthe head of minor operations. General anaesthetics can only be \nused in serious, prolonged dental operations, such as removal of \ntumors, cancers, necrosis, reduction of fractures, cleft-palate, \nhare-lip, the extraction of a large number of teeth, and the like. \n\nThe objections to their use for dental purposes are : \n\n1. The difficulty of keeping the patient under during opera- \ntions on the mouth. \n\n2. The necessary recumbent position often seriously inter- \nferes with the operator and makes difficult the flushing of the \nwound without much blood, pus or other debris being swallowed. \n\n3. Dangers to life or health from the anaesthetic. We are \nnot justified in using such an agent except where very necessary. \n\n4. After sickness, vomiting often endangers the success of \noperations. \n\nThe reader is referred to the chapter on general anaesthet- \n\n\n\n2l8 LOCAL ANESTHETICS IN DENTISTRY \n\nics for a full discussion of the subject, including methods of ad- \nministering. The only special requirement for dental purposes is \na carefully fitted mouth prop. \n\nNitrous oxide gas is very largely used by the dental profes- \nsion, and, indeed, very satisfactorily in those cases for which it \nis adapted. The transitory nature of the anaesthesia limits its \nusefulness to very short operations. The Hurd and other similar \nmethods, by which a certain amount of air or oxygen is mixed \nwith the gas, have a larger range of usefulness. The advantage \nbeing that anaesthesia can safely be prolonged from five to fifteen \nminutes, but even with this it cannot be used in many operations \non the teeth themselves because of the need of dryness and asep- \ntic conditions that are so essential to success. However, wherever \nnitrous oxide can be used, it is perhaps our safest agent, its one \nobjection being the necessity of rendering the patient unconscious. \n\nThe subject of local anaesthetics has elicited more experimen- \ntation and discussion on the part of the dental profession than \nany other subject in recent years. At first their use was given \nover to the quack, but gradually the demand for their employment \nbecame so great that a few daring ones took up the subject and \ntried to study out the best method of using them with greatest \nsuccess and least danger to the patient, until to-day I feel safe \nin saying that these agents are used in one way or another by a \nvast majority of the profession. \n\nFirst come the use of so-called freezing mixtures, made up \nprincipally of ethyl bromide, ethyl chloride, rhigolene, and other \nlight petroleum ethers which hold in solution various agents. \nThey are usually kept in a small glass tube with such thin walls \nthat the heat of the hand will expand the contents so as to cause \na fine spray to rush from the end of the tube, where a valve is \nplaced which can be opened. The method of using is to direct this \nspray on the mucous membrane on and around the field of op- \neration until blanching of the part appears. Care must be had not \nto use too long, or destruction of the soft tissue will result. They \nare fairlv useful for small operations, such as lancing abscesses. \n\nMany use for this same purpose solutions containing carbolic \nacid, menthol, calabar bean, peppermint in sulphuric ether, and \napply with a pledget of cotton with, I think, some satisfaction. \n\nThe greatest success from local anaesthetics comes from the use \n\n\n\nLOCAL ANAESTHETICS IN DENTISTRY 219 \n\nof agents which are employed in various per cent, solutions by \nmeans of .hypodermic injection directly into the soft tissue. \nAmong such agents I only wish to mention three, viz., cocaine \nhydrochlorate, beta-eucaine hydrochlorate, and chloretone. The \nfirst has been used longest and has been, in the hands of the \nwriter, most successful. \n\nFor the general physiological action of these drugs the reader \nis referred to the chapter on local anaesthetics. I simply wish to \nmention here the results of many hundred experiments with co- \ncaine and eucaine conducted on dogs, guinea pigs and rabbits, as \nwell as in a clinical practice extending over a period of twelve \nyears. At the outset, I want it understood that my statements \nonly apply to operations in the mouth where injections are made \nthrough the mucous membrane, \xe2\x80\x94 for I recognize that the nature \nof the tissue into which injections are made, has much to do with \nresults. My conclusions are as follows : \n\n1. Cocaine is more toxic than beta-eucaine. \n\n2. Cocaine is more anaesthetic than beta-eucaine. \n\n3. Cocaine is more rapid in its action. \n\n4. Cocaine solutions are more irritating to tissue. \n\n5. Cocaine is less dangerous in its action upon the heart. \n\n6. Cocaine is not constant in its effects \xe2\x80\x94 you cannot tell \nwho will be most susceptible. \n\n7. Beta-eucaine acts almost always the same on different in- \ndividuals. \n\n8. Cocaine solutions will not keep long and cannot be boiled, \nwhile beta-eucaine solutions can be sterilized by boiling and are \nfairly stable. \n\n9. When danger symptoms arise from cocaine administration, \nthey are more easily counteracteed than when they arise from \nbeta-eucaine. \n\n10. Cocaine local effects are more lasting than beta-eucaine. \nMany dentists report cases of severe local irritant poisoning \n\nfrom cocaine hydrochlorate, but from my observations I would \nsay this is due to an impure drug, unclean syringe, or infection \nfrom some source. \n\nI do not wish to convey the idea that cocaine is not a dangerous \ndrug when used in dental practice, but I wish to affirm that if \nproperly used in reasonable physiological quantities, in correct \n\n\n\n220 LOCAL ANAESTHETICS IN DENTISTRY \n\nsolution, its dangers are not great, and its local anaesthetic ef- \nfects almost ideal. The same can be said of beta-eucaine, but in \nmy hands the greatest success, everything considered, has been \nobtained from use of cocaine. \n\nOf all the agents recommended to counteract the baneful \nsystemic effects of cocaine, I find none to equal nitroglycerin, al- \nthough caffein, coffee, morphine, atropine and strychnine are rec- \nommended and are of value. The trouble with them is they are \ncomparatively slow in action, and therefore should be given fifteen \nto thirty minutes before cocaine is administered. When trouble \narises it is like sending a horse to catch the lightning express, but \nnitroglycerin acts more rapidly and can be given in the cocaine so- \nlution with good results. Cocaine acts best for dental injections \nwhen used in a I per cent, solution, with nitroglycerin added. I \nfind that if the solution is made in sterilized peppermint water with \njust a trace of thymol it will keep nicely and seems to be slightly \nmore anaesthetic. Beta-eucaine is used in a 2 per cent, aqueous \nsolution and can be boiled. \n\nChloretone is a comparatively new agent recommended for \nlocal anaesthetic purposes. It is quite harmless and can be used \nin almost unlimited quantities. It is not soluble to exceed 1 per \ncent, in water, which is the solution recommended. The writer \nhas had but negative results from use of this agent, although \nmany claim splendid success with it. \n\nA very important point to be remembered is the value of me- \nchanically rilling the tissue with the solution used. When you suc- \nceed in raising up a small white button with each injection you can \nfeel assured of success. The method of using these agents for \nthe extraction of useless teeth and roots is as follows : \n\n1. Have your cocaine or eucaine in perfect solution. \n\n2. Have solution sterile or antiseptic. \n\n3. Have your syringe aseptic. I like to use an all metal one \nwhich can be boiled. It should have a large finger guard and \nplunger rest and be arranged so as to tell exactly how much is \ngiven. \n\n4. Have all air out of the syringe. \n\n5. Always clean the surface through which you wish to \ninject. \n\n\n\nLOCAL ANESTHETICS IN DENTISTRY 221 \n\n6. Make your injection into the dense gum tissue first; then \ndeep into the periosteum on all sides of the tooth to be extracted. \n\n7. Wait until effect takes place before beginning to operate. \n\n8. Have additional means at hand to meet dangerous symp- \ntoms should they arise. \n\n9. Do not use more than one-sixth of a grain of cocaine, or \none-third of a grain of eucaine at one time. \n\nThe combination of cocaine and chloretone seems to promise \ngood results. The chloretone seems to counteract the dangerous \neffects of cocaine on the heart and respiration. Suprarenal extract \nin connection with cocaine solution is very useful for operations \non soft tissues of the mouth. \n\nOrthoform. \xe2\x80\x94 A local anaesthetic in the form of a light gray \npowder. It is very sparingly soluble, and hence its use is limited \nto those cases where the powder can be applied direct. It is very \nuseful in painful alveolar sockets after teeth are extracted. There \nis no danger of poisoning because it dissolves so slowly that little \nenters the circulation at one time. \n\nCocaine is used in painful pus pockets to anaesthetize the sur- \nrounding tissue, thereby making possible the scaling of teeth with \nlittle pain. It is used in a 4 per cent, solution injected by means \nof a long platinum needle directly into the pockets. Care should \nbe taken to pack absorbent cotton around the tooth to absorb any \nescaping excess, thus avoiding getting it back in the throat. \n\nA 1 per cent, solution is injected in the gum around a tooth to \nrender painless the preparation of sensitive cavities for filling, also \ninto the gum to relieve the pain of putting on clamps to hold the \ndam in place; especially is this useful when the gum has to be \nforced down on the tooth to get the dam over the margin of cav- \nities. \n\nCocaine and eucaine are both employed to relieve pain of ex- \ncavating: sensitive cavities and to anaesthetize the tooth pulp so it \ncan be removed immediately. The process now mostly used for \nthis last purpose is to place the dam, remove the superficial de- \ncay, outline the cavity, then moisten a small pledget of cotton \nwith water or alcohol or ether and touch this to the finely pow- \ndered cocaine or beta-eucaine, when sufficient will adhere ; place \nthis in the cavity and take a piece of soft rubber larger than the \ncavity and with a blunt instrument gently force the cocaine into \n\n\n\n222 LOCAL ANAESTHETICS IN DENTISTRY \n\nthe tooth with a sort of pumping motion \xe2\x80\x94 renew your agent from \ntime to time and get a complete exposure of the pulp as soon as \npossible, when little difficulty will be experienced in completely \nanaesthetizing the pulp so it can be removed painlessly. \nThe objections to this method are : \n\n1. When pulps are congested it only works partially. \n\n2. The time taken to do it painlessly. \n\n3. The haemorrhage following. \n\nIn many cases it is advisable to use it, and as a general practice \nit is growing in favor. \n\nThe same method is employed for sensitive dentine except \nthat no exposure is made. \n\nThere was a time a few years ago when the profession went \nwild over the use of cocaine by means of the cataphoric apparatus, \nwhich is a machine so arranged to measure and control electric \ncurrent as to be able to pass a small amount through the cavity \nin a tooth. It is used in connection with cocaine as above de- \nscribed \xe2\x80\x94 the positive electrode is placed on the cotton in the cavity \nand the negative electrode on the cheek or held in the hand. This \nmethod is now practically abandoned in favor of the others men- \ntioned. \n\nStovaine. Quite recently the instillation of a solution of \nstovaine has been highly recommended for the extraction of \nteeth. It has not been sufficiently used, however, to demonstrate \nany superiority over other agents for this purpose. An inconsider- \nable amount of pain may accompany its employment, and no sub- \nsequent indisposition results. \n\n\n\nINDEX. \n\n\n\nAbdominal conditions and anaesthesia, 46 \nA. C. E. mixture, 177 \n\n\xe2\x80\x94 ether sequence, 180 \n\nrelative safety of, 37 \nAcute cedema of lungs after anaesthesia, \n\n196 \nAdministration the, and time of day, 58 \n\nand alcohol, 60 \n\nand appliances and remedies, 64 \n\nand aseptic precautions, 64 \n\nand diet, 58 \n\nand medicine, 59 \n\nand morphine and atrophine, 60 \n\nand moving of patients, 64 \n\nand physical examination, 61, 62 \n\nand posture during induction, 63 \n\nand state of bladder, 59 \n\nand state of bowels, 59 \n\nand strychnia, 60 \n\nand temperature of room, 63 \n\nand ventilation, 63 \nAFTER THE ADMINISTRATION, 192 \n\nanuria, 197 \n\nbronchial and pulmonary symptoms, \n195 \n\nemholic pneumonia, 196 \n\nparalyses, 197 \n\npneumonia, 195 \n\nvomiting, 193 \nAlbuminuria after etherization. 104 \nAlcoholic subjects and anaesthesia, 42 \nAMYLENE, 163 \n\nnature and properties of, 164 \n\ndangers of, 164 \nAnaesthesia, available period of, 75 \n\ngeneral physiology of, 26 \n\nhistory of, 11 \n\nlocal, 201 \n\nstages of, 33 \nANAESTHETIC THE, AND THE PA- \nTIENT, 38 \n\nage, relation of, 39 \n\nblood states, relation of, 13 \n\ngeneral condition, relation of, 41, 62 \n\nheart diseases, relation of, 44 \n\nkidney diseases, relation of, 47 \n\nlung diseases, relation of, 44 \n\nlaryngeal diseases, relation of, 43 \n\nmorbid growths, relation of, 43 \n\npathologic conditions, relation of, 43 \n\nsex, relation of, 38 \n\nvascular disease, relation of, -\'6 \nANAESTHETIC THE, AND THE OPE- \nRATION, 50 \nANAESTHETICS, COMPARATIVE DAN- \nGERS OF, 34 \nAnaesthetics, absorption of, 27 \n\nanalgesia from, 30 \n\nblood changes from, 29 \n\ncharacteristics of, 26 \n\nCheyne-Stokes breathing in, 32 \n\neffect on heart\'s action, 33 \n\neffect on reflexes, 33 \n\neffect on vaso-motor center, 33 \n\neffects on nervous system, 30 \n\neffect on respiration, 32 \n\nelimination of, 28 \n\nintroduction of, 27 \n\n\n\nmuscular phenomena from, 32 \n\nstertor from, 32 \n\ntoxicity of, 26 \nAnders observations of nitrous oxide, \n\n77, 88 \nAneson as a local anaesthetic, 213 \nAnuria after anaesthesia, 197 \nArtificial respiration, 148 \nAvailable period, 75 \n\nBEFORE THE ADMINISTRATION, 58 \nBert\'s observations on nitrous oxide, 77. \n\n88 \nBICHLORIDE OF METHYLENE, 162 \n\nadministration of, 162 \n\nintroduction of, 162 \n\nmortality of, 162 \n\nnature and properties of, 162 \nBillroth\'s mixture, 178 \nBronchial and pulmonary symptoms af- \nter anaesthesia, 195 \nCarbonic acid, elimination of, 28 \nCataphoresis in dentistry, 222 \nCharacteristics of anaesthetics, 26 \nChest, examination of, 62 \nCheyne-Stokes breathing, 32 \nChloretone in dentistry, 220 \nChloric ether, 20 \nChloroform and alcohol, 179 \nChloroform and ether mixtures, 178 \nCHLOROFORM, 125 \n\nadministration of, 136 \n\nadministration of by drop method, 143 \n\nafter effects from, 132 \n\nclinical evidence regarding, 134 \n\ndangers from administration of, 133 \n\ndelayed poisoning from, 151 \n\ndiscovery of, 21, 125 \n\nduring labor, 56 \n\neffect on heart and blood pressure, 131 \n\neffect on kidneys, 132 \n\neffect on respiratory center, 130 \n\nfatalities from, 134 \n\nheart after death from, 132 \n\nimpurities and tests, 126 \n\nphysiological effects and action of, 127 \n\nproperties of, 125 \n\nreflex cardiac arrest from, 135 \n\nreflex respiratory arrest from, 135 \n\nrelative toxicity of, 36 \n\nrespiratory arrest from overdose of, \n147 \n\nstages of anaesthesia, 127, 128 \n\ntoxaemia from overdose of, 136 \nChloroformization, condition of pulse \nduring, 146 \n\nmanagement of complications of, 147 \n\nof children, 145 \n\nreflexes during, 145 \n\nrespiratory condition during, 146 \nCocaine, discovery of, 204 \n\nfor local anaesthesia, 202 \n\nhistory of, 203 \n\nin dentistry, 219 \n\nnature and effects of, 204 \nComparative dangers of anaesthetics, 35 \nComplications, managament of, 147 \nDentistry, nitrous oxide for, S3 \n\ncataphoresis in, 222 \n\n\n\n224 \n\n\n\n130 \n\n\n\n111 \n115 \n\n\n\n101 \n\n\n\ncocaine in, 210 \n\nchloretone in, 220 \n\nethyl bromide in, 158 \n\nethyl chloride in, 151) \n\northoform in, 221 \n\npental in, 164 \n\nstovaine in, 222 \nDelayed chloroform poisoning, 151 \nDiabetes and anaesthesia, 4\'.i \nDrug users and anaesthesia, 42 \nDutch liquid, 21, 125 \nDyspnoea, forms of, 20 \nEmbolic pneumonia after anaesthesia, \n\n106 \nEpileptiform syncope, Richardson\'s, \nETHER, 99 \n\nadministration of, 100 \n\nafter effects of, 103 \n\nclinical conclusions regarding, 123 \n\nclose method of administration of, \n\nconjoined use of oxygen and ether, \n\ndiscovery of, 15, \xc2\xa39 \n\neffects on kidneys of, 103 \n\nopen system of administration of, \n\npartially closed system of administra- \ntion of, 107 \n\nphysiological effects and action of, 100 \n\nproperties of. \'.:!> \n\nrelative safety of, 30 \n\nstages of anaesthesia by, 100, 101 \n\ntests for impurities in, 100 \n\ntoxic effects of, 102 \nEtherization, accidental conditions of, \n110 \n\nalbuminuria after, 104 \n\ncardiac failure from, 105, 123 \n\ncerebral haemorrhage from, 105 \n\ndangers from, 105 \n\njaundice after, 105 \n\nnervous symptoms after, 105 \n\npneumonia after, 104 \n\nproper extent of, 117 \n\nrectal, 117 \n\nreflexes during, 118 \n\nrespiratory failure from, 123 \nEther-chloroform sequence, 189 \nETHYL BROMIDE, 157 \n\nadministration of, 158 \n\ndangers of, 158 \n\ndis-overy of, 157 \n\nphysiological effects, 157 \n\nnature and introduction of, 157 \nETHYL CHLORIDE, 150 \n\nas local anaesthetic, 213 \n\nadministration of, 160 \n\nconclusions in regard to, 160 \n\nnature and properties of, 159 \nEthvl-chloride-ether sequence, 100 \nETIIIDEXE DICHLORIDE, 163 \n\nadministration, 163 \n\ndangers of, 163 \n\nintroduction of, 163 \n\nnature and properties of, 163 \nEucaine a, as local anaesthetic, 209 \nEucaine b, as local anaesthetic, 209 \n"\'Fright sj^ncope" from chloroform. 135 \nErequent anaesthesia, 43 \nGeneral condition and the administra- \ntion, 62 \nHeart disease and anaesthesia, 44 \nHeart, massage of in svncope, 151 \nHISTORY OF ANESTHESIA, 11 \nHolocain as local anaesthetic, 211 \nHypnotism, 15 \n\n\n\nIndian hemp, 13 \n\nKidney disease and anaesthesia. 4 7 \n\nKidneys, effects of ether on, 103 \n\neffects of chloroform on, 132 \nLactation and anaesthesia, 43 \nLarynx, diseases of, and the anaesthetic, \n\n43 \nLOCAL ANAESTHESIA, 201 \n\naneson for, 213 \n\ncocaine for, 204 \n\nethyl chloride for, 213 \n\neucaine a for, 209 \n\neucaine b for, 209 \n\nholocain for, 211 \n\nliquid air for, 214 \n\nlocal infiltration method for, 205 \n\nmethods, selection of, 202 \n\nnirvanin for, 211 \n\northoform for, 212 \n\npost-operative pneumonia after, 202 \n\nregional intraneural method for, 208 \n\nregional paraneural method for, 207 \n\nstovaine in, 206, 214 \n\nsuprarenal extract in, 207, 210, 215 \n\ntropa-cocaine hvdrochloride for, 210 \nLOCAL ANESTHETICS IN DENTIS- \nTRY, 217 \n\nagents employed, 218 \n\ncataphoresis for, 222 \n\nchloretone for, 220 \n\nconclusions regarding cocaine, 210 \n\nfor sensitive tooth pulp, 222 \n\nmethod of employment, 220 \n\nobjections to their use, 217 \n\northoform, 221 \nLung diseases and the anaesthetic, 44 \nMenstruation and anaesthesia. 42 \nMesmerism, 15 \nMixed narcosis, 60, 61 \nMoving patients during administration, \n\n64 \nMIXTURES FOR ANESTHESIA, 177 \n\nA. C. E. mixture, 177 \n\nBillroth\'s mixture, 178 \n\nchloroform and ether, 178 \n\nchloroform and alcohol, 170 \n\nSchleich\'s mixture, 180 \n\nsomnoform, 182 \nNervous disease and anaesthesia, 40 \nNirvanin as a local anaesthetic, 211 \nNITROUS OXIDE, 73 \n\nAncrews\' observations of, 77, 88 \n\nadministration of, 77 \n\nafter effects of, 77 \n\nblood changes from, 77 \n\ndangers of administration of, 86 \n\ndefinite quantities of nitrous oxide and \nair, 86 \n\ndiscovery of, 15, 73 \n\nindefinite quantities of nitrous oxide \nand air, 87 \n\nlethal effects of, 77 \n\nnature and properties of, 73 \n\noxygen and nitrous oxide, 88 \n\nPaul Bert\'s system of administration \nof, 77, 88 \n\nphysiological effects and action of, 73 \n\nrelative safety of, 36 \n\nsequence, nitrous oxide-ether, 185 \n\nTurner\'s method of administration for \nextraction, 83 \nObesity and anaesthesia, 42 \nOld people and anaesthesia, 40 \nOperations on the abdomen, 54 \n\n\n\n225 \n\n\n\nbrain and spinal cord, 49, 54 \n\nchest, 54 \n\ndental, 52 \n\nface, jaws, nose, etc., 51 \n\ngynecological, 56 \n\nlarynx and trachea, 52 \n\nneck exclusive of air tract, 53 \n\nobstetric, 56 \n\nophthalmic, 51 \n\nrectum and genito-urinary tract, 55 \n\nthe extremities, 57 \n\ntonsils, 52 \nOrthoform as local anaesthetic, 212 \n\nin dentistry, 221 \nOxygen and ether, conjoined use of, 115 \n\nand nitrous oxide, 88 \nParalyses after anaesthesia, 11)7 \nPathologic conditions and anaesthesia, 43 \nPENTAL, 164 \n\nadministration of, 164 \n\ndangers of, 164 \nPhysical examination, 61, 62 \nPhysiological effects of nitrous oxide, 73 \nPneumonia after etherization, 104 \nPneumonia after anaesthesia, 105 \nPosture during anaesthesia, 68 \n\nfor extraction of teeth, 68 \n\nfor operations on brain, 71 \n\nfor operations on chest, 72 \n\nfor operations on abdomen, 72 \n\nfor operations on kidneys, 72 \n\nfor operations on face, mouth, etc., 70 \n\nfor operations on larynx and trachea. \n71 \n\nfor operations on neck, 71 \n\nfor ophthalmic operations, 72 \nPosture during induction, 63 \nRegional intraneural infiltration, 208 \nRegional paraneural infiltration, 207 \nRespiration, artificial, 148 \nRhigolene, 201 \nSchleich\'s mixture, 180 \nSelection of a general anaesthetic, 34 \n\n\n\nSEQUENCE OF ANESTHETICS, 1S7> \n\nA. C. E.-ether sequence, 189 \n\nchloroform-ether sequence, 188 \n\nether-chloroform sequence, 18! \n\nethyl chloride-ether sequence, 190 \n\nnitrous oxide-ether sequence, 185 \n\nother sequences, 101 \n\nsomnoform, 182 \nSCOPOLAMINE-MORPIIINE AN\\EK- \n\nTHESIA, 154 \n\nphysiologic effects of, 1~>4 \n\nemployment of, 155 \nSPIRAL ANAESTHESIA, 25, 166 \n\nafter effects of, 166 \n\nBier and Quincke\'s method for, 169 \n\ncomplications of, 167 \n\ncontraindications for, 167 \n\nComing\'s method for, 168 \n\ndangers of, 167 \n\neffects of, 166 \n\nfailure of, 167 \n\nlocation of puncture for, 171 \n\nMatas\' solution for, 168 \n\nmortality of, 167 \n\nposition and method for, 171 \n\nsolution and dose for, 167 \n\nstovaine in, 175 \n\ntechnique of, 168 \n\nTuffier\'s method for, 172 \nStatistics of fatalitv, 35 \n\nstovaine, 175, 206, 214, 222 \n\nslatus thymicus, 48 \nSuprarenal extract in chloroform narco- \nsis, 151 \n\nin local anaesthesia, 207, 210, 215 \nSurgical shock and anaesthesia, 47 \nTobacco users and anaesthesia, 42 \nToxicity of anaesthetics, 26 \nTropa-cocaine as local anaesthetic, 210 \nTurner\'s method for extraction, 83 \nVascular disease and anaesthesia, 44 \nVomiting after anaesthesia, 193 \nYoung persons and anaesthesia, 39 \n\n\n\nSEP 14 1906 \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\nX \xc2\xabL\' \n\n\n\n\n\n\ns \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n.#\' \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n-c >" \n\n\n\n\n\' \n\n\n\n\n\n\nr> o \n\n\n\n^ V*" \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\nf V % \n\n\n\n\n\n\n\n\n\nl : ^ \n\n\n\nr>. \n\n\n\n\n\n\n\xc2\xa3 \n\n\n\n\n\n\n\xe2\x96\xa0>. .^ \n\n\n\n^ \n\n\n\n\n\n\nA^ " \' \n\n\n\nkV \' - \n\n\n\n\n\n\n\nV \n\n\n\n\xe2\x96\xa0^^ \n\n\n\n\n\n\n<\\ \n\n\n\n\n\n\n\n\n\no \n\n\n\n\n\n\n\n\n\nV- \n\n\n\nO. \n\n\n\n\\"&" * \n\n\n\n\n\n\n\n\n\nV> <^ \n\n\n\n<". \'\xc2\xab \n\n\n\n\n\n\n>0 o \n\n\n\n\xe2\x80\xa2 / \n\n\n\n> -t: \n\n\n\n\\^ N \n\n\n\nlV </> \n\n\n\n^ <c* v \n\n\n\n.V ^ \n\n\n\n\n\n\n\n\n\n\n^ /\' \n\n\n\n*. \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\nAT \n\n\n\n^ "% \n\n\n\n*-, \n\n\n\n** v ^ \n\n\n\n\n\n\n0- s \n\n\n\n<\\ \n\n\n\n^ V* \n\n\n\n^ ^ \n\n\n\n,0o \n\n\n\n\n\n\nH \xe2\x96\xa0/; \n\n\n\n>v* ^ \n\n\n\nv 0o \n\n\n\nV V \n\n\n\n\n\n\n\n\n\n"V \n\n\n\n\n\n\n\n\n\n\n\n\nOlV \n\n\n\nV\' \n\n\n\n\n\n\n\n\n\n^ ^ \n\n\n\n\n\n\n\n\n\n\n\n\nL ^. \n\n\n\nA \n\n\n\n\n\n\n^ : \n\n\n\n^ c y \n\n\n\n\n\n\ns \n\n\n\n\n\n\n'