LIBRARY OF CONGRESS. 
 
 Shelf.. :TI~>898 
 
 UNITED STATES OF AMERICA. 
 
THE 
 
 ADVANTAGES AND ACCIDENTS ■ 
 
 OF 
 
 ARTIFICIAL ANESTHESIA: 
 
 A MANUAL OF ANESTHETIC AGENTS, 
 
 AND THEIR 
 
 EMPLOYMENT in the TREATMENT of DISEASE. 
 
 BY 
 
 V 
 
 LAURENCE TURNBULL, M.D., Ph.G., 
 
 Aural Surgeon to Jefferson Medical College Hospital; Physician to the Department of Diseases of the 
 
 Eye and Ear, Howard Hospital, Philadelphia ; Fellow of the American Association for the 
 
 Advancement of Science, and of the American Medical Association, etc., etc.; 
 
 Honorary Meruberof the State of Maryland and Districtof Columbia 
 
 Dental Association, and of the Meigs and Mason 
 
 Medical Society of Ohio. 
 
 SECOND EDITION, REVISED AND ENLARGED, 
 
 WITH TWENTY-SEVEN ILLUSTRATIONS 
 
 PHILADELPHIA: 
 
 LINDSAY AND BLAKISTON. 
 1879. 
 
 t 
 
Entered according to Act of Congress, in the year 1879, by 
 
 LAURENCE TURNBULL, M.D., Ph.G., 
 
 In the Office of the Librarian of Congress. All rights reserved. 
 
 PHILADELPHIA: 
 
 DrcKSON * Girling, Printers, 
 16 and 18 N. Fifth St. 
 

 (■ 
 
 "If America had contributed nothing more to the stock 
 of human happiness than anaesthetics, the world would owe 
 her an everlasting debt of gratitude." 
 
 S. D. Gross.* 
 
 * An address delivered, Philadelphia, April 10th, 1879, at a banquet tendered to Prof. S. D. 
 Gross, M.D., by his professional friends, in commemoration of his having completed his fifty-first 
 year in the medical profession. 
 
PREFACE TO THE SECOND EDITION. 
 
 The rapid sale of a large edition of this work in the 
 short period of one year, shows the appreciation with 
 which it has been received by the medical and dental press 
 and professions. Its success has induced the author to 
 revise the subject matter and rewrite several of the articles. 
 To make the volume more worthy of the favor of the pro- 
 fession, a number of new and original experiments have 
 been made; especially with hydrobromic ether. The 
 boiling points and relative time of evaporation of the 
 several agents employed in mixed anaesthetics, and the best 
 proportion in which ether, alcohol, and chloroform should 
 be united, have been determined ; also a continuation of the 
 experiments on the action of anaesthetics on the blood, the 
 use of the spectroscope in relation to anaesthetics, more 
 especially nitrous oxide. 
 
 In this second edition there will be found many more 
 practical suggestions as to the employment of anaesthetics 
 that are safe, and the rules for their adoption or reasons for 
 the rejection of some of them in different cases, grouped, 
 and made convenient, so that the student can memorize 
 them, and be fully prepared for any emergency. As has 
 been well observed in a review of this work by the dis- 
 tinguished editor of the Dental Cosmo*, "When trouble 
 comes to a patient from any cause during the anaesthetic 
 state, it is not a good time to hunt up information." 
 
6 PREFACE TO THE SECOND EDITION. 
 
 The new table of deaths from chloroform which has 
 been added, and in the preparation of which much- time 
 and labor has been expended, will be found of special 
 interest and vital importance in regard to the sex, age, 
 character of ojDeration, time at which the patient died, 
 quantity of chloroform used, and form of apparatus em- 
 ployed, general condition of patient, prominent symptoms 
 of chloroform-poisoning, causes of death and post-mortem 
 appearances. A new ether inhaler has been described and 
 illustrated, which has been, and is now, employed in the 
 clinical service of Jefferson College Hospital. 
 
 A bibliography published in the first edition has been 
 omitted, but additional old or new works which were not 
 then introduced, or cannot be found mentioned in the body 
 of this w T ork, have been printed for reference. 
 
 A historical sketch of the discovery of anaesthesia at the 
 end of the previous edition has also been omitted, as more 
 space has been devoted to the subject in our introduction, 
 but full references to all the authorities on the subject have 
 been given. 
 
 There has been introduced a notice of the metric system 
 in accordance with the recommendations of the "American 
 Medical Association " at its last meeting, at Atlanta, in May, 
 1879 ; also a table of the Centigrade, and Fahrenheit ther- 
 mometric scales. More space has likewise been assigned to 
 the physiological and therapeutic action of anaesthetics in 
 disease. In most of the instances where a remedy has been 
 recommended, the authority has been quoted, or we have 
 tested its therapeutic value in an extensive private practice, 
 or in the daily clinics of two large public institutions. 
 
 It was found impossible to acknowledge, in every in- 
 stance, the source from which all contained facts have been 
 
PREFACE TO THE SECOND EDITION. 7 
 
 obtained, but in the majority of instances we have endeav- 
 ored to give credit to every original worker in the field of 
 progress. 
 
 The author desires to acknowledge many courtesies at the 
 hands of several eminent members of the profession, but he 
 is especially indebted to his son, Dr. Charles S. Turnbull 
 and to Dr. Charles E. Sajous, resident physician of Howard 
 Hospital. 
 
 1502 WALNUT STREET, 
 June, 1879. 
 
PREFACE TO THE FIRST EDITION. 
 
 This little work was originally written by the Author as 
 a report for a medical society, and was subsequently ex- 
 tended to its present form to supply a want that evidently ex- 
 ists at the present day, for a convenient hand-book on the ad- 
 ministration of the various anaesthetics, that the practitioner 
 of medicine or dentistry can consult to enable him to de- 
 cide which one he can best employ. Many valuable books 
 have, unquestionably, been written on the subject of anaes- 
 thetics , but as far as the writer's observation extends, none 
 of a practical character have appeared within the last few 
 years. Much useful matter in relation to sulphuric ether, 
 nitrous oxide, and chloroform, employed as anaesthetics, 
 has accumulated within this period, but this valuable in- 
 formation is contained in various monographs, journals, etc., 
 where, associated with what is extraneous, it is unprofitable 
 to the busy practitioner. 
 
 The object of this work may be stated to be : — 
 
 First. To give in as concise a manner as possible a descrip- 
 tion of the most available agents that may be successfully 
 and safely employed as anaesthetics. 
 
 Second. To present the chief chemical tests of the purity 
 of each substance considered, with its composition, physical 
 characters, and medical properties. 
 
 Third. To exhibit the best methods of administering the 
 various anaesthetics, to give careful directions, and to state 
 
PREFACE TO THE FIRST EDITION. 9 
 
 the precautions to be taken to avoid risk to the life of the 
 patient. 
 
 Fourth. To note the personal experience of the author, 
 his assistants and friends, with the various forms of anaes- 
 thetics and inhalers in use, with a selection of the most ap- 
 proved of them, not withholding, however, the objections 
 and experiments of other reliable investigators. 
 
 Fifth. To compare the relative mortality from all the an- 
 aesthetics now employed, endeavoring to assist the reader i n 
 forming a fair and candid opinion on this most important 
 subject, which is now, and has for so long a period, occu- 
 pied the attention of the public as well as of the medical 
 profession. 
 
 To conclude are added practical hints on Local Anaesthe- 
 sia, the use of the various anaesthetics in the practice of 
 medicine; the Medico-Legal Nature and Importance of An- 
 aesthetics, with a brief History of the discovery of Artificial 
 Anaesthesia. 
 
 1502 WALNUT STREET, 
 March, 1878. 
 
CONTENTS. 
 
 INTEODUCTION. 
 
 Anaesthetics of the Ancients, .... Page 13 
 
 .List of the Principal agents that will produce anaesthetic sleep, 17 
 
 CHAPTER I. 
 
 General Anaesthetics— Alcohol and Ethyl Alcohol. Methylic Alcohol 
 for inhalation ; mode of action ; its resemblance to Chloroform. 
 
 Page 18-23 
 
 CHAPTER II. 
 
 Ether— The ordinary methods of administering: towel, cone, sponge, 
 or bag. Test when patient is fully under its influence. Physio- 
 logical action of ether. Cautions in regard to solid food before 
 etherization. Cases in which ether should not be employed as 
 an anaesthetic. The three stages of etherization. Sulphuric ether 
 — Always gives warning. Use of air, artery forceps, artificial 
 respiration in fainting, etc. Statistics in reference to death. 
 Experiments by the sphygmograph. Primary and secondary 
 effects. Table of deaths from ether. Abstract of report of Boston 
 Committee. Inflammability. Conclusions of Author. 
 
 Page 24-61 
 
 CHAPTER III. 
 
 Ethers which have anaesthetic properties. Acetic ether. Experiments 
 by Dr. H. C.Wood on animals, etc. Formic ether. Byasson's con- 
 clusions in regard to it. Hydriodic ether. Properties and objections 
 to its use. Methylic ether. Dr. Richardson's experiments with it. 
 Bichloride of methylene. Observations upon it by Dr. Jones of Cork, 
 Dr. Taylor and Spencer Wells of London. Iodide of Methyl. Amy- 
 lene. Bromide of ethyl, or hydrobromic ether. Properties. Mode 
 of preparation, and experiments by the writer. Chloride and bi- 
 chloride of ethylene. Oxygen, nitrogen and hydrogen gases as 
 anaesthetics. Page 62-86 
 
 CHAPTER IV. 
 
 Chloroform, chemical composition, impurities, tests— physiological 
 action. Toxicological effects. Employment of chloroform in labor. 
 
CONTENTS. 11 
 
 M. Pichard. Congress at Geneva. Drs. Lusk, Wilson, and Smith. 
 Statistics of death from chloroform. Table of one hundred and sixty 
 deaths, with comments. Nitrite of amyl. Effects of nitrite of amy 1 
 as an antidote to chloroform, observations and cases, by Drs. Bur- 
 rail, Lane, and Munde. Richardson on physiological action of nitrite 
 of amyl. Mixed narcosis. Use of morphia before inhalation of chlo- 
 roform. Therapeutical applications. Page 87-144 
 
 CHAPTER V. 
 
 Mixtures of chloroform, ether, and alcohol. First death reported 
 from mixture of ether and chloroform. Composition of various 
 mixtures. Boiling points and relative time of evaporation of the 
 several anaesthetic agents. Opinions of Dr. Washington Atlee and 
 Prof. Maisch concerning mixtures. How chloroform is altered by 
 mixing with alcohol, etc. Recent deaths from chloroform and 
 ether mixed. Chloroform combined with alcohol in parturition. 
 The comparative effects of the early state of anaesthesia with ether 
 and chloroform. Page 145-158 
 
 CHAPTER VI. 
 
 Nitrous oxide gas as an anaesthetic. Mode of preparation, chemical 
 constitution, gasometer, inhaler, and mode of purifying nitrous 
 oxide gas. The advantages of the gas being recently prepared. 
 Class of cases for inhalation. Difficulties and dangers, with mode 
 of treatment. Liquid nitrous oxide in cylinders. Physiolog- 
 ical action of nitrous oxide. Experiments and observations by 
 Doctors Evans, of Paris, M. Buisson, Doctors McQuillen, Thomas, 
 Robert Amory, George Johnson, and the writer. Mode of 
 action of anaesthetics by Doctors C. Binz, H. Ranke, Claude Ber- 
 nard, and Committee British Medical Association. Investigations 
 upon the protoxide of nitrogen by Drs. Jolyet and T. Blanche. The 
 spectroscope and its relations to nitrous oxide. Experiments of 
 Doctors Waterman, J. G. Richardson, Wm. M. Hodges, C. S. Turn- 
 bull, and the writer. Niti'ous oxide gas in dental and minor sur- 
 gery. M. Paul Bert on the use of a mixture of nitrous oxide and 
 oxygen gases. Deaths from the inhalation of nitrous oxide. 
 
 Page 159-205 
 
 CHAPTER VII. 
 
 Hydrate of Chloral. Chemical composition. Tests of purity from 
 taste and odor. An abstract of original and selected observations 
 on, and experiments with, hydrate of chloral on animals and man 
 by the writer. M. Vulpian, injections into the veins. Physiological 
 effects on man and animals. Dr. Bouchut on hydrate of chloral as 
 an Anaesthetic for Children. M. Couty on death of animals from Hy- 
 drate of Chloral. Corroborative experiments by the writer. Prof. 
 Or6 of Bordeaux on intravenous injection of Chloral Hydrate. Ad- 
 vantages and risks by De Neffe, Van Wetter, Warlomont, Besnier 
 and Vulpian. Cases of recovery from large doses of hydrate of 
 chloral, and in certain cases death following moderate quantities. 
 
12 CONTENTS. 
 
 Delirium tremens produced by chloral hydrate. Case of Dr. Da 
 Costa reported by Dr. Woodbury. Discussion on the subject of chlo- 
 ral by members of the Philadelphia County Medical Society. Dr. Ar- 
 buckle's experiments with Chloral and with narcotics. Its influence 
 on the retinal circulation. Chloral hydrate— poisoning by, and 
 means to prevent or treat. Therapeutic effects of Hydrate of Chloral 
 on traumatic tetanus, nausea of pregnancy, eclampsia and convul- 
 sions, retention of urine, migraine, chorea, diphtheria, Local anaes- 
 thetic application and counter irritation with Hydrate of Chloral. 
 Butylchloral-hydrate. Use of and experiments by Liebreich. 
 
 Page 206-231 
 
 CHAPTER VIII. 
 
 Inhalers of Hawksley, Hearn, Cheatham, Lente, Allis, Morgan, Rich- 
 ardson, Angrove, and Clover for ether. Inhalers of Allis and Skin- 
 ner for chloroform. Inhaler of Thomas for nitrous oxide gas. In- 
 halers of J. F. Clover, F. R. C. S., and Codman & Shurtleff for nitrous 
 oxide gas and ether. Morgan's inhaler for Bichloride of Methylene. 
 
 Page 232-259 
 
 CHAPTER IX. 
 
 Bon will's method of anaesthesia. Analgesic effects of rapid breathing. 
 Carbonic oxide gas. Carbonic acid gas. Tetrachloride of carbon. 
 Carbolic acid. Anaesthesia of the larynx. Local anaesthesia in 
 odontalgia. Faradic anaesthesia. Bromoform. Local anaesthetics. 
 Richardson's method of local ansesthesia,with apparatus. Freezing 
 mixtures. Extract eucalyptus, morphia, etc. Page 260-273 
 
 CHAPTER X. 
 
 The legal responsibility of physicians in the administration of anaes- 
 thetics. Medico-legal relations of anaesthetics. Case in Philadel- 
 phia of a surgeon dentist. The important question whether chloro- 
 form can be administered for criminal purposes? Cases in France, 
 England, and the United States. Dr. N. L. Folsom, R. M. Denig. 
 Chloroform as a poison. Experiments of A. Martin Ewald, Hitzig, 
 C. Bernard and Binz. Ethers; their action as poisons. Ether 
 intoxication. Page 274-290 
 
 CHAPTER XL 
 
 GENERAL CONCLUSIONS. 
 Alcohol preparations. Treatment of poisoning by ether. Inhalation 
 and internal administration. Precautions in its inhalation. Bi- 
 chloride of methylene. Hydrobromic ether; use and new mode of 
 preparation; conclusions. Ethidene dichloride. Oxygen, hydro- 
 gen, and nitrogen gases. Dr. Gray's experiments with oxygen gas. 
 On the use of anaesthetics, especially chloroform, in dental opera- 
 tions. Treatment of chloroform poisoning. Chloroform and chloral 
 in poisoning by strychnia, On the choice of anaesthetics. Another 
 death from chloroform. Bibliographical list of papers and works 
 on anaesthetics. The Metric system. Page 291-314 
 
ARTIFICIAL ANAESTHESIA. 
 
 INTRODUCTION. 
 
 ANAESTHETICS OF THE ANCIENTS. 
 
 The ancient Greeks, it is stated, possessed a plant called 
 mandrake. It belonged to the same family of plants as the 
 belladonna, or deadly nightshade. From the root of this 
 plant was extracted, by means of wine, a narcotic which 
 was employed by them as an anaesthetic. Lucius Apuleius, 
 who lived about 160 A. D., and of whose works eleven 
 editions were republished in the fourteenth and fifteenth 
 centuries, says "that if a man has to have a limb mutilated, 
 sawn, or burnt, he may take half an ounce of mandragora 
 wine, and whilst he sleeps the member may be cut oft' 
 without pain or sense." To prove that this was true, Dr. 
 B.W. Richardson, of London, after a lapse of five centuries, 
 obtained a fine specimen of mandragora root, and made 
 mandragora wine and tested it, and found it was a nar- 
 cotic having precisely the properties that were anciently 
 ascribed to it. He found that in animals it would produce 
 even the sleep of Juliet, not for thirty or forty hours, a term 
 that must be accepted as a poetical license, but easily for the 
 four hours namec,! by Dioscorides; and, on awakening, there 
 was an excitement which tallied with the same phenomenon 
 that was observed by the older physicians. Another fact 
 was noticed by the ancients, that many volatile substances 
 acted more promptly by inhalation than by the stomach, 
 and this form of medication was employed in Greece, Rome, 
 and Arabia. By their published works, the knowledge of 
 these facts was extended to other parts of the world. 
 
 In China, in ancient times, the word ma-yo meant not 
 only Indian hemp, but anaesthetic medicine; other sub- 
 stances besides hemp entered into these benumbing recipes, 
 
14 ARTIFICIAL ANESTHESIA. 
 
 such as the datura, a solan aceous plant, probably identical 
 with the atropia mandragora ; also aconite, hyoscyamus, 
 etc. Some of these drugs forni constituents of the formula 
 said to be employed by kidnappers of children, and robbers, 
 and are therefore naturally forbidden in China, at the pres- 
 ent, to be sold or employed. 
 
 The Indian hemp, under the name bhang,v?as extensively 
 used by the Mohammedans and others in Central Asia. 
 The most wonderful properties are ascribed to it. " Taken 
 in excess, the spirits and demons may be seen ; it confers 
 prophetic powers ; it is sometimes taken by persons wishing 
 to indulge in spiritualism, and it is used as an antidote to 
 forgetfulness." (Dudgeon.) 
 
 Theodoric, about the year 1298, gives elaborate directions 
 how to prepare a " spongia somnifera" by boiling it dry in 
 numerous strong narcotics, and afterwards moistening it 
 for inhalation before operations. 
 
 Opium was also employed in later years (prior to surgical 
 operations), and was found one of the best of narcotics for 
 the relief of pain and for producing insensibility, but was 
 not free from danger. 
 
 On September 3d, 1828, M. Girardin read, to the Academy 
 of Medicine of Paris, a letter addressed to His Majesty 
 Charles X, describing surgical anaesthesia by means of 
 "inhaled gases." 
 
 Richerand suggested drunkenness in reducing disloca- 
 tions; and patients, while dead drunk, have been operated 
 upon painlessly. Larry, after the battle of Eylau, found 
 in the wounded, who required amputations, a remarkable 
 insensibility, owing to the intense cold, this being the first 
 use of cold as an anaesthetic. 
 
 A strong impulse was given to the study and application 
 of the " different kinds of airs and gases " by the discovery 
 of oxygen by Priestley and Scheele, in the middle of the last 
 century, and numerous experiments were made by physi- 
 cians with it. Another still more practical result was ob- 
 tained by Sir. Humphrey Davy, and published in 1800. 
 " That nitrous oxide appears capable of destroying physical 
 pain, and may be used with advantage during surgical op- 
 erations. ' ' This valuable and practical suggestion remained 
 without fruit for a long time, and the surgeons, physicians, 
 
INTRODUCTION. 15 
 
 and accoucheurs still employed alcohol in some form, or 
 opium and its salts, to deaden as far as possible the sensibil- 
 ity to pain during their various operations. It was not until 
 1844 that an effort was made in the Uuited States by Dr. 
 Wells, of Hartford, who experimented with it in fifteen 
 cases with varying success ; but he employed too small a 
 quantity of the gas. In April, 1848, Dr. Bigelow, of Boston, 
 demonstated its value in surgery by performing an excision 
 of the breast, using sixty gallons of the gas. But the crown- 
 ing result was obtained in 1846 by Dr. Morton, in the Mass- 
 achusetts General Hospital, when it was demonstrated suc- 
 cessfully that the inhalation of "ether" was so capable of 
 deadening the sensibility of the nervous system, that any 
 operation, no matter how painful, could be performed and 
 the patient not suffer from its effects. It was also proven 
 that ether was safe and like the wine that Juliet drinks, the 
 action of which the Friar Lawrence so well describes : — 
 
 "Through all thy veins shall run 
 A cold and drowsy humour, which shall seize 
 Each vital spirit; for no pulse shall keep 
 His natural progress, but surcease to beat: 
 No warmth, no breath, shall testify thou liv'st; 
 The roses in thy lips and cheeks shall fade 
 To paly ashes; thy eyes' windows fall, 
 Like death when he shuts up the day of life; 
 Each part, deprived of supple government, 
 Shall stiff, and stark, and cold appear like death : 
 And in this borrow'd likeness of shrunk death 
 Thou shalt remain full two and fortj' hours, 
 And then awake as from a pleasant sleep." 
 
 This most valuable agent required but to be inhaled for a 
 few minutes, when the patient, being in a pleasant frame 
 of mind, would thus remain asleep; and after a more or 
 less prolonged operation, " would awake and inquire if the 
 diseased limb were still there, and could be told that the 
 offending member was gone, without his knowledge." 
 
 No one can form, even at the present day, a just estimate 
 of the true value of the various anaesthetics, or express in 
 words their wonderful and extended application to the 
 relief of human suffering. 
 
 To the general surgeon it gives the opportunity of operat- 
 ing in grave cases of disease and injury, without which, the 
 death of the patient would be inevitable. It also affords, by 
 
16 ARTIFICIAL ANAESTHESIA. 
 
 the immediate relief from pain, the power to manipulate 
 the broken or injured parts with facility, and thus obtain 
 a correct diagnosis in the most obscure diseases and painful 
 accidents. 
 
 To the obstetrician and gynaecologist it is useful in assuag- 
 ing the terrific pain of labor, and makes the dreaded instru- 
 ments a blessing in disguise. In the diagnoses and treatment 
 of abdominal diseases, it gives precision and almost marvel- 
 lous results, and in the removal of large masses or tumors 
 great freedom from the dreadful effects of shock to the 
 nervous system. For the ophthalmic surgeon the anaesthe- 
 tic reduces the sensibility of the eye so that it can be touched 
 with impunity, and severe and dangerous operations can be 
 performed upon this delicate and sensitive organ without 
 pain and with much less risk. 
 
 Again, in the removal of foreign bodies from the eye or 
 ear, particularly in children, by the use of the anaesthetic 
 all spasm is relieved, and the act is accomplished without 
 injury. The profound sleep gives a most favorable oppor- 
 tunity to the aural surgeon to perforate the membrana 
 tympani, cut the minute tendon of the tensor tympani 
 muscle, or perforate the mastoid cells. 
 
 There are some thirty substances which are of so volatile 
 a character, that they can be employed in producing anaes- 
 thesia. The following is a 
 
 LIST OF THE PRINCIPAL AGENTS THAT WILL PRODUCE 
 ANAESTHETIC SLEEP OR LOCAL ANAESTHESIA. 
 
 Nitrous oxide gas. j Chloride of methyl gas. 
 
 Carbonic oxide gas.f Bichloride of methylene. 
 
 Carbonic acid gas.* Terchloride of formyl, or chloro- 
 
 Bisulphide of carbon.* form. 
 
 Light carburetted hydrogen.* i Tetrachloride of carbon.* 
 (Hydride of methyl, or marsh Bromoform. 
 
 gas.) Heavy carburetted hydrogen 
 
 Methylic alcohol. gas.*. 
 
 Methylic ether gas. (defiant gas or ethylene.) 
 
 * Those agents having the stars affixed are not safe for inhalation, 
 and are more fitted for producing local anaesthesia. 
 
 f Carbonic oxide has been used as a local anaesthetic to cancerous 
 or raw surfaces ; but, when inhaled, it is a powerful narcotic poison. 
 Owing to its superior affinity, it displaces the oxygen in the red blood- 
 corpuscles, and unfits them for the functions of respiration. 
 
INTRODUCTION. IT 
 
 Ethylio, or absolute ether. 
 
 (Sulphuric ether.) 
 Chloride of ethyl. 
 Bichloride of ethylene. 
 
 (Dutch liquid.) 
 Bromide of ethylene. 
 
 Bromide of ethyl, or hydrobromic 
 
 ether. 
 Hydride of amyl.* 
 Amylene.* 
 Benzole.* 
 
 Turpentine spirit.* 
 Gasoline.* 
 
 And ail of the liquid chlorides, bromides, and iodides of alcoholic 
 radicals. 
 
 Those anaesthetics which are employed at the present 
 day, in the practice of medicine, may be reduced in number 
 to four; namely, alcohols, ethers, chloroform, and nitrous 
 oxide. These. can be employed alone, or mixed in various 
 proportions. They can be reduced to a still smaller number, 
 viz., nitrous oxide gas, and alcohol of various grades of power, 
 as each of the eleven alcohols will, by the chemical action of 
 an acid, produce its ether or chloroform. 
 
 * Those agents having the stars affixed are not safe for inhalation, 
 and are more»fitted for producing local anaesthesia. 
 
18 ARTIFICIAL ANAESTHESIA. 
 
 CHAPTER I. 
 
 General Anaesthetics— Alcohol and Ethyl Alcohol. Methylic Alcohol 
 for inhalation ; mode of action ; its resemblance to Chloroform. 
 
 It has long been recognized as a fact that, when persons 
 are under the controlling influence of alcohol, either in the 
 form of wine, gin, whiskey, or brandy, they may be cut, 
 bruised, or even have their bones broken, without expressing, 
 or experiencing much, if any pain. Alcohol was very early 
 employed by surgeons to produce immunity from the pain of 
 the knife, long before any true anaesthetic was discovered. 
 Dr. John Lynk* states that he has long employed alcohol 
 as an anaesthetic, and that he has gradually learned to ap- 
 preciate it more and more, using it now almost entirely in 
 his surgical operations. He has not as yet tried it in a cap- 
 ital operation, but has employed it, in the proportion of 
 about one pint for a strong adult, in tablespoonful doses 
 every twenty minutes in an amputation of the finger, 
 extraction of teeth, in a case of severance of the posterior 
 tibial nerve ; with the use of chloroform, also, ligation of 
 radial and ulnar artery, in which he only used two drachms 
 of chloroform and one pint of whiskey. This latter oper- 
 ation he thinks served to demonstrate the value of the 
 whiskey as an anaesthetic, leaving the other functions, 
 especially the heart, in a more normal condition than by 
 the chloroform alone, which he states, was proven by the 
 styong pulsations of the heart after the chloroform had been 
 withdrawn. 
 
 We have tried the inhalation of whiskey, but owing to its 
 mixture with water and fusel oil and other carbonaceous 
 products, it will not produce anaesthesia rapidly. If rye 
 whiskey be pure and strong, and free from water and other 
 products, it will produce anaesthesia if applied with the 
 atomizer or by inhalation. 
 
 * Cincinnati Lancet and Observer, May, 1876. 
 
METHYLIC ALCOHOL. 19 
 
 ETHYL ALCOHOL (C 2 H 5 OH). 
 
 This compound is manufactured on a large scale, and is 
 the most important body of the whole group, being the 
 starting point for the preparation of all the other ethyl 
 compounds. Ethyl alcohol, or spirits of wine, is obtained 
 by the vineous fermentation of the sugar in the various 
 grains, a decomposition taking place in the dilute solution 
 of sugar in the presence of yeast, by which the greatest por- 
 tion of the sugar is resolved into carbon-dioxide and ethyl 
 alcohol. 
 
 C 6 H 12 6 =2C0 2 2C 2 H G 0. 
 
 In England the " proof spirit " of the excise contains 50.8 
 per cent, by weight of alcohol, and has, at 15.5° (60° F.), the 
 specific gravity of 0.920. Owing to the high duty ou pure 
 spirit, the government allows the sale of a mixture of ninety 
 parts of strong spirit and ten parts of crude wood spirit, 
 called "methylated spirit," for manufacturing and scientific 
 purposes ; this being, therefore, a mixed carbonaceous com- 
 pound not fitted to produce a pure ether. Ethyl unites with 
 dry chlorine acid gas, and forms ethyl chloride, C 2 H 5 C1. ; 
 also with bromine, sodium, and iodine, forming ethers. 
 
 In the United States, alcohol is usually obtained by the 
 distillation of rye, barley, corn, or wheat whiskey. Thus 
 obtained, it is a clear liquid, containing more or less water, 
 which by redistillation, in conjunction with lime, becomes 
 what is known as absolute alcohol. It is difficult to inhale 
 pure alcohol (ethylic), as it cause* great irritation of the 
 throat and spasm of the glottis,; but if diluted with water 
 and thus inhaled, anaesthesia will be produced as before 
 stated. 
 
 There are two other alcohols which are found in commerce, 
 one called methylic, and the second amylic alcohol. The 
 methylic alcohol is obtained by the dry distillation of wood, 
 and the amylic by the distillation of potatoes. They are 
 both used for adulteration and for commercial purposes. 
 
 METHYLIC ALCOHOL, 
 
 Pyroxide spirit, or wood spirit, as this has been differently 
 called, has been known for about sixty-two years, and when 
 analyzed by Messrs. Dumas and Peligot, it was found to 
 
20 ARTIFICIAL AX.ESTHESIA. 
 
 contain 37.5 per cent, of carbon, 12.5 per cent, of hydrogen, 
 and 50 per cent, of oxygen. When pure, it remains clear in 
 the atmosphere. It has an aromatic smell and taste, with 
 slight acidity, and boils at 140° F. According to the ex- 
 periments of Dr. B. W. Richardson, of London, this alco- 
 hol, owing to its volatile nature, may be exhibited freely by 
 inhalation, in the same manner that chloroform is adminis- 
 tered. It then enters the blood by being carried with the 
 air that is inspired into the pulmonary tract, and thus into 
 the air vesicles ; here it is absorbed into the circulation by 
 the minute blood-vessels which make their way from the 
 heart through the lungs, and which ramify upon the vesi- 
 cles. By administering the vapor of methylic alcohol in 
 this way, its effects are rapidly developed, for it condenses 
 quickly in the blood, is carried rapidly into the left side of 
 the heart, and thence is distributed by the arteries over the 
 whole body, as quickly as can be condensed and absorbed. 
 
 This alcohol is recommended by Dr. Richardson, and he 
 has obtained better results from its use than from the heavier 
 or ethylic spirit. It is much more rapid in its action, and 
 much less prolonged in its effects than common alcohol; 
 and, what is of more importance, it demands the least pos- 
 sible ultimate expenditure of animal force for its elimination 
 from the body. According to the same authority the lighter 
 the alcohol, therefore, cceteris paribus, the less injurious its 
 action. When inhaled, its effects are developed in four 
 distinct stages. 
 
 First stage, there is excitement, flushing of the body, and 
 dilatation of the pupils ; after a time there follows languor, 
 and the muscular movements become irregular. 
 
 Second stage, muscular prostration, and labored breath- 
 ing, attended by deep sighing movements and rolling over 
 of the body. 
 
 Third stage, complete insensibility to pain, with uncon- 
 sciousness to all external objects, with inability to exert any 
 voluntary muscular power. The breathing now becomes 
 embarrassed and blowing, with bronchial rales, due to the 
 passage of air through fluid that has accumulated in the 
 finer bronchial passages. The heart and lungs, however, 
 even in this stage, retain their functions, and therefore re- 
 covery will take place if the conditions for it be favorable. 
 
ALCOHOL AS A LOCAL ANAESTHETIC. 21 
 
 Also, if the body be touched or irritated in parts, there will 
 be a response of motion, not from any knowledge or con- 
 sciousness, but from reflex action. During all these stages 
 there is no violent convulsive action, but, step by step, a 
 reduction of temperature, so at last the loss of heat will 
 become dangerous, for the cool body cannot throw off the 
 water freely, and therefore fluid collects in the lungs and 
 there is a risk of suffocation, as from drowning. If the 
 administration of the methylic spirit be continued when 
 the third degree has been reached, there is a last stage, 
 which is that of death. The two remaining nervous centres 
 which feed the heart and respiration cease simultaneously 
 to act, and all motion is over. If, however, after the third 
 stage of insensibility the administration of methylic spirit 
 be stopped, recovery from the insensibility and prostration 
 will invariably take place on one condition, that the body 
 be kept warm for seven hours. * 
 
 There is but little doubt that this sudden reduction of 
 temperature is one cause of death after the administration 
 of ether and chloroform. The patient is apparently all right, 
 and is transferred to the ward from the warm operating 
 room ; no special means are employed to keep up the tem- 
 perature, and gradually the patient sinks into an unconscious 
 state, from the fluid which collects, and dies from congestion 
 of the lungs, the result of neglect. 
 
 A memoir recently presented to the French Academy 
 states that injurious effects are often produced by the con- 
 tinued inhalation of vapor of 'methyl alcohol ; for example, 
 on workmen who are using it. 
 
 ALCOHOL AS A LOCAL ANAESTHETIC. 
 
 In the use of snow or ice there is more or less pain in the 
 part until it is frozen. By substituting cold alcohol the 
 parts can be. immersed in it for a long time, so as to deprive 
 them of ordinary sensibility; and, although the faintest 
 touch can be perceived, cutting or pricking them can be 
 well borne. 
 
 * On Alcohol. A course of six Canton Lectures, delivered before the 
 Society of Arts (London, 1875, by Benj. W. Richardson, INI. A., M. D., 
 F. R. S.). 
 
22 ARTIFICIAL ANAESTHESIA. 
 
 Alexis Horvath, of KiefF, * states :— 
 
 " Knowing the painful sensation experienced by immer- 
 sion of the hand in water at a temperature of 0. C, I was 
 much astonished to not experience the same sensation with 
 the hand in alcohol, the temperature of which had been 
 reduced to — 5° C. 
 
 " The discovery of this curious fact, which was made by 
 me as early as 1869, led me to undertake some experiments, 
 of which I give briefly the results. 
 
 " When the finger is held in sulphuric ether or mercury 
 at the temperature of —3° C, the same painful sensation is 
 experienced as when it is immersed in water at zero C. 
 
 " On the other hand, when we plunge the finger, even for 
 a longer time, into alcohol or glycerine at the temperature 
 of — 5° C, we feel no pain. 
 
 "A prick in the finger, while it is immersed in cold alco- 
 hol, produces no pain, and only a sensation of contact, thus 
 proving that there is a distinction between the sense of tact 
 and that of pain, and affording us the means of proving it. 
 It is seen thus that pain is not the sense of tact intensified, 
 but rather an altogether different sensation. 
 
 11 These experiments demonstrate that it is not merely the 
 cold that plays a part in the production of anaesthesia, but 
 also the liquid employed; in this regard the various liquids 
 act differently. Inasmuch as death following severe burns 
 is partly attributed to the intense pain wmich accompanies 
 them, I was led to utilize alcohol in their treatment. I have 
 had numerous occasions to recognize its efficaciousness — 
 among others, in a child burnt in the hand (to the second 
 degree); the pains disappeared at once on plunging the 
 hand into alcohol, to reappear again on its withdrawal. 
 Moreover, I observed that burns submitted to this treatment 
 were cured in much less time than those treated otherwise. 
 
 "Anaesthesia by cold (according to the methods of Rich- 
 ardson, etc.), though known and appreciated for a long 
 time, is relatively little employed, solely on account of the 
 inconveniences of the procedure. These inconveniences, 
 joined to the above observations, have led me to attempt 
 
 * Gazette des Hopitaux, No. 105, September 10th, 1878. 
 
ALCOHOL AS A LOCAL ANESTHETIC. 23 
 
 anaesthesia by cold in grand operations, and in extensive 
 burns located elsewhere than in the extremities." 
 
 I have repeated these experiments, and can corroborate 
 the main facts, i. e., regarding the loss of sensibility. When 
 a finger, upon which there was a felon, was immersed in 
 alcohol of 20° F., it could be manipulated with impunity ; 
 whereas, before the immersion, the member was so sensitive 
 that the slightest touch caused excruciating pain. 
 
 ' ' Freezing the skin with ether spray sometimes tempor- 
 arily removes sciatica or neuralgia, but the relief generally 
 is but temporary. The skin, or mucous membrane, when 
 sufficiently frozen to permit of a painless operation, becomes 
 pale, shrunken, tallowy-looking, and feels as if oppressed 
 with a great weight. Whilst recovering the natural condi- 
 tion, the frozen tissues tingle and smart, sometimes so 
 intensely as to exceed the pain of the operation." — Ringer. 
 
24 ARTIFICIAL ANAESTHESIA. 
 
 CHAPTER II. 
 
 Ether— The ordinary methods of administering: towel, cone, sponge, 
 or bag. Test when patient is fully under its influence. Physio- 
 logical Action of Ether. Cautions in regard to Solid Food before 
 Etherization. Cases in which Ether should not be employed as 
 an Anaesthetic. The three stages of Etherization. Sulphuric Ether 
 —Always gives Warning. Use of Air, Artery Forceps, Artificial 
 Respiration in Fainting, etc. Statistics in Reference to Death. 
 Experiments by the Sphygmograph. Primary and Secondary 
 Effects. Table of Deaths from Ether. Abstract of Report of Boston 
 Committee. Inflammability. Conclusions of Author. 
 
 ETHYL OXIDE, ETHYL ETHER, ^h} " 
 
 This body, commonly called "ether," is manufactured 
 on a large scale by heating a mixture of strong alcohol and 
 concentrated sulphuric acid to 140°. The reaction takes 
 place in two stages : in the first, ethyl sulphuric acid and 
 water are formed : — 
 
 C0H5 ) r v 1 H") (-I/-V C9H5 "I r,/-» , H ) ,-w 
 
 H J 0+ h; S0 4 - - h j ;^0 4 + h )0. 
 
 The ethyl sulphuric acid acts at 140° upon another molecule 
 of alcohol ; hydrogen and ethyl change places, and ether and 
 sulphuric acid are formed : — 
 
 C-2 Hj ) y^ , C2H5 ) /-v H) Qj.-w C2H5 ) /~v 
 
 H / fe °4+ H } u -H} b0 4+C 2 H 5 j U ' 
 
 The ether and the water produced are distilled off, whilst 
 the sulphuric acid remains behind, ready to convert another 
 quantity of alcohol into ether. 
 
 The ordinary ether sold has a specific gravity of 0.750. 
 "When shaken with an equal quantity of water it loses \ of 
 its volume. Ether fortior should have a specific gravity of 
 0.728, and will not, when shaken with an equal bulk of 
 water, lose more than -} of its volume. If pure, ether will 
 not redden litmus paper. 
 
 The specific gravity of chemically pure ether is 0.713— 
 0.725, and its boiling point 95° F. A test tube filled with it 
 
WASHED SULPHURIC ETHER. 2o 
 
 and held in the warm hand should boil on the addition of 
 fragments of broken glass. In hot countries, like India and 
 our own, or in the close wards of a hospital, if preserved in 
 imperfectly stoppered bottles, ether will absorb oxygen and 
 forms acetic acid, becomes impure, and is therefore unsuit- 
 able for inhalation. 
 
 Ether does not mix with water, but is slightly soluble in 
 it ; it mixes readily with alcohol. 
 
 The ether which is most generally employed in Philadel- 
 phia, and, indeed, throughout the United States, is that 
 manufactured by the reliable firm of Powers & Weightnian, 
 and it is uniformly of most excellent quality. The ether of 
 Dr. Squibb, of Brooklyn, N.Y., is resorted to; it is of higher 
 price and is freer from water, and, we think, is more apt to 
 produce irritation if used too freely; this can be obviated by 
 moistening, with warm water, the sponge cone, or inhaling 
 apparatus. If in doubt about the purity of your ether, 
 agitate it with lime-water and then decant it before using. 
 
 Ether by inhalation was resorted to for years to induce a 
 state of exhilaration, when a small quantity was mixed with 
 a very large quantity of air. The great invention of Dr. 
 Morton was to cause complete insensibility to pain without 
 danger, causing true anaesthesia, this being graduated by 
 increasing the quantity of ether and diminishing the supply 
 of air until the insensibility be completely obtained, without 
 how T ever passing the limits in which stupor could be arrested 
 short of danger. 
 
 The ordinary method in use of administration of the first 
 discovered ancesthetic, namely, (cashed sulphuric ether, is as 
 folloivs: — 
 
 An inhaler is made by folding a towel into a large cone or 
 bag, and then placing a coarse sponge in its apex. Ether is 
 then poured upon it with a free hand — half an ounce or 
 more at a time — and repeated as necessary by removing the 
 cone from the patient's mouth to renew the supply of ether. 
 The lower part of the face, mouth, and nose is covered with 
 the cone, so as to exclude most of the air, and allow the 
 patient to till his lungs with more or less diluted ether 
 vapor, depending on the care with which the cone is applied. 
 There will be, at the beginning of the inhalation, attempts 
 
26 ARTIFICIAL ANESTHESIA. 
 
 to struggle, on account of the irritating nature of the ether, 
 which are to be gently, but firmly restrained, using as little 
 force as possible, and only one or two inspirations of pure air 
 allowed ; subsequently complete quiescence usually follows, 
 and the patient passes into a profound state of insensibility. 
 If, however, the face become livid or very pale, the cone is 
 lifted entirely away for a time until this condition disappears. 
 In delicate persons, it is well to notice any unusual slowness 
 or intermittence of the pulse. One of the best tests of the 
 patient being fully under the influence of the ether, is when 
 the conjunctival surface of the eye can be touched with 
 impunity, and the arm can be raised and will fall as if par- 
 alyzed. Dr. Snow states that he found the eye sensible to 
 light in all stages of etherization. 
 
 PHYSIOLOGICAL ACTION OF ETHER. 
 
 The functions of the cerebrum or brain are affected before 
 those of other portions of the nervous system. After a more 
 prolonged inhalation the anterior or motor centres soon fail 
 to respond to mechanical irritation, yet the functions of the 
 medulla-oblongata are performed. 
 
 If the inhalation of ether is still further carried on, ac- 
 cording to Flourens, the sensory, and finally the motor, 
 functions of the medulla-oblongata are involved, and death 
 occurs from a paralysis of the respiratory centres. Longet 
 states that he found the sensory functions abolished very 
 early, but he has never failed in any stage of the narcosis 
 from ether to get a response from the anterior part of the 
 cord by employing powerful galvanic currents. 
 
 Ether should not be inhaled immediately after a full meal, 
 indeed it is better to take only a biscuit or cracker and a 
 glass of wine or a teaspoonful of brandy and water, or a 
 scruple of bromide of potassium in water, half an hour be- 
 fore, always avoiding for several hours previously the risk 
 and annoyance of a full stomach. Nothing like hard boiled 
 eggs, ham, or beef should ever be allowed a feeble patient 
 before inhalation for twenty-four hours. If nourishment is 
 necessary, let it be of a liquid character ; as solid food, not 
 digested, has been the cause of death in more than one 
 person. 
 
 Perfect quiet should be enjoined on all around the patient, 
 
WHEN ETHER SHOULD NOT BE EMPLOYED. 27 
 
 as noises, or even loud talking, interfere with the perfect 
 and rapid action of the anaesthetic. Nothing like a tight 
 band or garment should prevent the free action of the throat, 
 chest, or interfere with the muscles of respiration. False 
 teeth should always be laid aside until after the inhalation 
 is over. There are a few 
 
 CASES IN WHICH ETHER SHOULD NOT BE 
 EMPLOYED AS AN ANAESTHETIC. 
 
 These we shall endeavor to enumerate. The first class is in 
 very aged persons with emphysema, hypertrophy of the 
 heart, fatty heart, or great valvular lesion. The second class 
 are those who are known to faint from very slight causes. 
 The third class are habitual drunkards, or persons who 
 drink in small quantities frequently each day. The fourth 
 class is from limited action of the lungs by adhesions from 
 old pleurisy, or pneumonia, or irritation of the mucous 
 membrane with excessive secretion. 
 
 In anaesthesia by ether, the real danger to be avoided is 
 over-inebriation. It may be divided into three stages. 
 
 First stage, of exhilaration; second stage, that of stupor 
 with snoring, or complete insensibility, which, with care, 
 can be gradually increased or diminished with safety; third, 
 dangerous state, that of coma with stertor, or the patient 
 becomes livid with true asphyxia, or may alternate between 
 Jividity, with a falling pulse, with apjmrently alarming 
 indications. 
 
 There are a certain class of patients that pass into an 
 almost profound state of unconsciousness without these 
 distinct stages, while others require two or three assistants 
 to hold them while inhaling, and have a wild excited stage, 
 then pass, after a longer or shorter time, into the stage of 
 stupor; these latter are termed by those who are familiar 
 with the administration of anaesthetics "bad etherizers," 
 and here comes the importance of experience. Indeed, no 
 one should be trusted with the inhalation unless he has 
 passed through a course of instruction; for, unless great 
 discretion is shown in giving or withdrawing the agent, the 
 result may be fatal, while, with proper care, even in these 
 bad cases, you may ultimately reach a stage of stupefaction, 
 and all go well. The following case illustrates another class : 
 
28 ARTIFICIAL ANJESTHESIA. 
 
 October 4th, 1877, Jefferson College Hospital. In a case of 
 mastoid disease, in which I perforated the bone and opened 
 the cells, niy friend, Dr, Allis, administered the ether, the 
 patient made but little effort at respiration ; and, after con- 
 suming from six to eight ounces of ether for a full half hour 
 without producing the true anaesthetic result, we had to 
 resort to the use of chloroform, pure and alone. This is not 
 the first case in which, in the hands of even the most careful 
 administrators, the ether has not produced the desired result, 
 and we are under the necessity of resorting to the use of the 
 more dangerous agent; but this must not be done until a 
 full and free trial of the milder and safer agent, always in 
 careful hands, and only in the most important and very 
 painful operations. 
 
 SULPHURIC ETHER AS AN ANAESTHETIC 
 
 Is not altogether free from danger, but it always gives 
 warning before it causes the death of the patient. The 
 countenance should be watched, and the difficulty in breath- 
 ing promptly attended to the moment the face assumes a 
 purple, dusky, or extremely pale hue. The first thing to be 
 done is to remove the inhaling apparatus, and admit fresh 
 air ; if this is not sufficient, draw forward the tongue by 
 means of a pair of artery forceps, or a napkin or handkerchief 
 wrapped around it ; also, draw forward and support the jaw. 
 If these means should fail to reestablish a healthy action of 
 the lungs and cause due oxygenation of the blood, resort at 
 once to artificial respiration, by means of Marshall Hall's 
 metliod, or mouth of the physician to that of the patient, or 
 by the use of a small pair of hand bellows, or air-bag and 
 nozzle having its valve on the side or base. 
 
 A careful examination was conducted by the Royal Med- 
 ical Chirurgical Society of London into the comparative 
 merits of ether and chloroform, by means of the hemadyna- 
 mometer in testing the effects on the heart's action and the 
 influence of these agents upon it. The report states : " The 
 essential difference between the action of chloroform and 
 ether is to be found in the effect produced upon the heart. 
 The first operation of both agents is to stimulate the heart 
 and augment the force of its contractions; but, after this, 
 chloroform dejrresses the heart's action, whereas ether ap- 
 
EXPERIMENTS BY THE sl'Ii YGMOGllAPH. 29 
 
 pears* to exert but little influence upon the muscular move- 
 ments of that organ." 
 
 The general accuracy of these results, although tested by 
 so comparatively coarse an instrument, is borne out by 
 careful experiments made with the sphygmograph by the 
 late Dr. Morgan,* of Dublin, who, with this delicate instru- 
 ment, made numerous observations which are here given, 
 and concludes as follows : " I have taken all but one of these 
 examines (eight cases) as. the most unpropitious, occurring 
 in patients of diminished health and vitality, yet it is 
 evident that the most perfect anaesthesia could be invoked 
 under the influence of ether, with an absolute stimulating 
 effect on the circulation ; and that the condition of insensi- 
 bility could be maintained for a considerable time, yet there 
 was no material alteration of the ' pulse writing,' and the 
 most perfect sense of security was established. It is, there- 
 fore, established that ivhile chloroform exerts ei depressing 
 influence on the heart, ether exerts a stimulating one, and 
 theit chloroform in the most dangerous." 
 
 Fig. 2. 
 
 Fig. 1 represents the pulse of a female patient, aged twenty- 
 five, who had been confined to bed for five months; pulse 
 writing taken before etherization. 
 
 Fig. 2 represents it during its full influence. It will be 
 seen that the heart power indication was rather stronger 
 during etherization than before. 
 
 * The Dangers of Chloroform and the safety and Efficiency, of Ether, 
 etc., by J. Morgan, M. D., E. R. C. S.. Professor of Surgical and Descrip- 
 tive Anatomy, Royal College of Surgeons, Ireland, etc. London. 1872, 
 p. 28. 
 
30 
 
 ART I FICIA L ANvESTH ESIA. 
 Fig. 3. 
 
 Another instance of a female, aged seventeen, also long; 
 confined in bed. The contrast of fig. 3, taken before ether- 
 
 ization, and of fig. 4, during profound etherization, is notable; 
 the*elevation of the pulse line showing the Stimulating pro- 
 perty of the ethereal influence. 
 
 Fisr. 
 
 Fig. o represents the excited pulse writing of a small and 
 nervous female, previous to etherization and operation. 
 
 Fig. 6. 
 
 Fig. 6 represents the pulse writing of the same patient 
 
 when steadied by etherization. The contrast is remarkably 
 
 favorable. 
 
 Fig. 7. 
 
 Fig. 7 represents the pulse writing of a healthy young 
 man, of twenty-two, previous to operation for artificial pu- 
 pil; an affection which had not interfered with his general 
 health. 
 
ABSTRACT OF REPORT OF BOSTON COMMITTEE. 31 
 
 Fig. 8. 
 
 Fig. 8 represents the same when taken under full etheriz- 
 ation, and after the completion of the operation. A com- 
 parison of this pulse writing with that of the natural soft 
 pulse will be ample evidence of the safety of etherization 
 in its action on the heart. 
 
 ALLEGED DANGERS WHICH ACCOMPANY THE 
 
 INHALATION OF THE VAPOR OF 
 
 SULPHURIC ETHER.* 
 
 Had we space, we should be very glad to copy the whole 
 of this able pamphlet, but we must be content to give the 
 conclusions which accompany it. We had, before receiving 
 it, copied from Dr. Taylor on Poisons all the cases reported 
 by him; but we found, on carefully reading it, that his 
 cases were included in the appendix to the report of the 
 Boston Society. In justification of the conclusions Arrived 
 at by the committee, there are presented in this report forty- 
 one cases, gathered from every available source up to the 
 year 1861, the date of publication. 
 
 "The general conclusions which have been arrived at by 
 your committee may be summed up as follows : — 
 
 "1st. The ultimate effects of all anaesthetics show that 
 they are depressing agents. This is indicated both by their 
 symptoms and by the results of experiments. No anaesthetic 
 should, therefore, be used carelessly, nor can it be adminis- 
 tered without risk by an incompetent person. 
 
 "2d. It is now widely conceded, both in this country and 
 in Europe, that sulphuric ether is safer than any other an- 
 aesthetic, and this conviction is gradually gaining ground. 
 
 " 3d. Proper precautions being taken, sulphuric ether will 
 produce entire .insensibility in all cases, and no amesthetic 
 requires so few precautions in its use. 
 
 * Report of a Committee of the Boston Society for Medical Improve- 
 ment on the Alleged Dangers -which accompany the Inhalation of Sul- 
 phuric Ether, pp. 30. Boston: David Clapp, 334 Washington Street. 1861. 
 
32 ARTIFICIAL ANAESTHESIA. 
 
 u 4th. There is no recorded case of death, known to the 
 committee, attributed to sulphuric ether, which cannot be 
 explained on some other ground equally plausible, or in 
 which, if it were possible to repeat the experiment, insensi- 
 bility could not have been produced and death avoided. 
 This cannot be said of chloroform. 
 
 11 5th. In view of all these facts, the use of ether in armies, 
 to the extent which its bulk will permit, ought to be obliga- 
 tory, at least in a moral point of view. 
 
 " 6th. The advantages of chloroform are exclusively those 
 of convenience. Its dangers are not averted by its admixture 
 with sulphuric ether in any proportions ; the combination 
 of these two agents cannot be too strongly denounced as a 
 treacherous and dangerous compound. Chloric ether, being 
 a solution of chloroform in alcohol, merits the same con- 
 demnation." 
 
 INFLAMMABILITY OF ETHER. 
 
 Two accidents have come to our knowledge in which the 
 ether was ignited, and, although causing no actual injury, 
 produced much fear and confusion. The first was where a 
 bottle -of ether was accidentally broken and ignited while 
 Dr. William Hunt was operating, during the night, at the 
 Pennsylvania Hospital. The second occurred while Dr. 
 William H. Pancoast was applying the actual cautery to a 
 patient at the Jefferson' College Hospital clinic during the 
 day. Dr. Bigelow,* of Boston, in commenting upon the 
 inflammability of the vapor of ether, observes, "Its practi- 
 cal safety is doubtless partly owing to the fact that the air, 
 cooled by its evaporation, establishes a downward current.'' 
 This is due to the greater density of ether vapor, for whilst 
 the ether itself has a specific gravity of .728, its vapor has 
 2.568 for its specific gravity ; and this fact may be readily 
 noted by observing the downward currents of vapor when 
 pouring from one bottle to another. 
 
 By combining the statistics collected in the United States 
 by Dr. Andrews, of Chicago, and those of England by Dr. 
 Richardson, of London, we obtain the mortality caused by 
 ether (up to 1872), such as four deaths in 92,815, or one to 
 23,204. 
 
 * Boston Medical and Surgical Journal. 
 
TABLE OF DEATHS FROM ETHER. 33 
 
 Dr. C. Dawson, 41 - of Leeds, England, has furnished the 
 following- list of deaths from ether from 1873 to 1877, and I 
 have added those of 1878: — 
 
 TABLE OF DEATHS FROM ETHER, BY CAWTLEY 
 DAWSON, L. R. C. P., M. R, C. S., LEEDS. 
 
 The following analysis of the reports of deaths under ether 
 is drawn up, not with the intention of comparing them with 
 those under chloroform, it being assumed that the former 
 has fully established itself as by far the safer anaesthetic, 
 but with the object of gathering all the information they 
 afford, and learning, if possible, all the preventable dangers, 
 so as to improve the results. If we are satisfied that, al- 
 though the percentage of deaths from ether is apparently 
 below that of deaths from chloroform, we can yet improve 
 by experience, and help to raise still further, though in a 
 small measure, the science of anaesthesia towards the high 
 standard of perfect safety which, we trust, is its ultimate 
 position, it is not enough that we read reports of fatal cases 
 at the times they appear in our journals, but we must again 
 and again recall them, place them side by side, compare 
 them with one another, and so scrutinize their every 
 feature with untiring zeal, that, if possible, we may trace 
 certain marks running throughout them, and become 
 so intimate with those marks as to be able to recognize 
 their earliest appearance or prevent their appearance alto- 
 gether. 
 
 The above table includes, in the last five years, all, or 
 nearly all, the deaths that have taken place in this country 
 under the administration of ether; yet when we rind them 
 alone amounting to thirteen, though that number compares 
 well with the number of deaths under chloroform, we feel 
 that either we are not perfect in the art of its administration, 
 or it is not the absolutely safe anaesthetic that we have been 
 repeatedly told it is. 
 
 Let us examine the essential features of these thirteen 
 deaths, together with rive others that are reported in the 
 same journals to have occurred in America, and compare 
 the eighteen cases with each other. 
 
 ;: See British Medical Journal, March 2d, 1878. 
 
34 ARTIFICIAL ANAESTHESIA. 
 
 1. A woman, aged 45, was to be operated upon for fatty 
 tumor on the back, at the West London Hospital on Feb. 
 18th, 1873. Chloroform was first given on lint, and, the 
 pulse becoming irregular, ether was substituted. It became 
 full and regular again, but suddenly stopped, the face at the 
 same time being " dusky red." The ether used was pure; 
 its specific gravity .700. One ounce of it was given ; it was 
 administered on a sponge in the apex of a cone made of felt, 
 the sponge having been previously wrung out in warm 
 water. The post mortem examination revealed nothing to 
 account for death ; all the organs were fairly healthy, except 
 both lungs being gorged with blood. 
 
 2. An old patient had a cancerous submaxillary gland 
 successfully removed under ether. Shortly afterwards, con- 
 fusion and stupidity were observed, which deepened into 
 unconsciousness with local convulsive seizures, and death 
 supervened forty hours after the operation. Thepost mortem, 
 examination showed nothing to account for the mental 
 symptoms. The chest was not examined. 
 
 3. S. S., aged 62, was to be operated upon at the Women's 
 Hospital, in Birmingham, for ovarian tumor. After about 
 five drachms of ether had been administered, she became 
 satisfactorily unconscious, but suddenly appeared to revive, 
 opening her eyes, and passing urine; the pupils were largely 
 dilated, and the pulse could not be felt. Some subjective 
 efforts at respiration were made* but they ceased, and Sil- 
 vester's method of artificial respiration and other means of 
 resuscitation were adopted without avail. At the post mor- 
 tem examination, the cavities of the heart were found to 
 contain a small quantity of dark blood; the other organs 
 were healthy, except the ovaries and uterus; the state of the 
 lungs is not reported. The anaesthetic used was a mixture 
 of McFarlane & Co.'s anhydrous ether, and Hearon, Squire 
 & Frances' bichloride of methylene. 
 
 4. David Newman, aged 14, had iridectomy performed for 
 corneitis. Ether was given in a cone of spongio-piline. 
 Before the operation was commenced, alarming symptoms 
 presented themselves — great struggling, opisthotonos, and 
 feeble pulse. The administration of ether Avas discontinued ; 
 the pulse improved, and the operation was performed. 
 Afterwards, the pulse and breathing stopped altogether, and 
 
TABLE OF DEATHS FROM ETHER, 35 
 
 the patient died. The post mortem examination showed the 
 right cavities of the heart to be full of dark fluid blood, the 
 left nearly empty, and the lungs congested with bright red 
 blood. ■ 
 
 5. An old man was etherized by Mr. McGill, of Leeds, in 
 1873, and operated upon for hernia. Wild delirium set in 
 afterwards ; the patient tore oft' the dressings, oi^ened the 
 wound, and tore out some of his intestines. 
 
 6. J. F., aged 1G, was etherized for operation upon diseased 
 bone in the hand on April 3d, 1875. Four drachms of Rob- 
 bins' ether were poured upon some lint in a folded towel. 
 The patient inhaled it rapidly, with no cough and with very 
 little struggling. In four minutes he was ready for operation, 
 when respiration suddenly ceased, the face became pale, the 
 pupils dilated, and the pulse imperceptible. At the post 
 mortem examination, the heart was found not to be weak, 
 and the lungs not congested. 
 
 7. On January 23d, 1875, a man was placed under ether at 
 the Cancer Hospital, London. He was thin and pallid, yet 
 moderately healthy. Partial insensibility was first obtained 
 by nitrous oxide ; then ether, of the British Pharmacopazia, 
 and specific gravity .735, was given in a cone of lint covered 
 with oiled silk. After a slight struggle, the patient got 
 under its influence. In live minutes the face became dusky, 
 the respiration shallow, a gurgling sound in the throat was 
 heard, and an effort was 'made to expel blood; the pulse, 
 however, remained remarkably good. Breathing ceased, 
 though Silvester's method was tried ; and still the pulse 
 kept beating for some minutes. At the post mortem exami- 
 nation, the general blood was found dark, fluid, and con- 
 taining bubbles like those of air. The lungs were fully 
 inflated, and grey. The right auricle was collapsed, and 
 the ventricle empty ; the left ventricle nearly so. A clot of 
 blood was found in the trachea. 
 
 8. A patient at the Homoeopathic College, New York, was 
 etherized for operation upon a necrosed jaw. The pulse was 
 watched all the time by another physician. The face sud- 
 denly became blue, and the respiration ceased. 
 
 9. The Chicago Medical Journal and Examiner related a 
 case of the Charitable Eye and Ear Infirmary in Illinois. A 
 man, aged 74, was operated upon for cataract by Dr. Holmes. 
 
36 ARTIFICIAL ANAESTHESIA. 
 
 The patient inhaled the ether quietly till halt* a pound had 
 been used; when a violent coughing commenced, which was 
 followed by extreme lividity of the face and cessation of 
 breathing". The ether was discontinued, and, by appropriate 
 means, respiration was reestablished ; the lividity partially 
 disappeared, and the action of the heart became stronger. 
 Without any more ether, the operation was concluded. 
 Again the patient ceased to breathe; the face became more 
 livid and the pulse very weak till death ensued, in spite of 
 renewed efforts to avert it. 
 
 10. The Boston Medical and Surgical Journal gave the 
 particulars of a case in which Dr. Sinclair incised the os 
 uteri for dysmenorrhea. The patient had been a teacher. 
 She was operated upon at a private hospital on July 19th, 
 1S7G. The ether was given on a towel, and, when the patient 
 became unconscious, the doctors present, wishing to be en- 
 gaged with the operation, entrusted the continuance of the 
 etherization to a female. When they turned their attention 
 again to the patient's condition, the breath and the pulse 
 were found to have ceased. At the postmortem examination, 
 engorgement of the pulmonary artery was found, 
 
 11. On September 15th, 1S76, a man, aged 28, had his right 
 leg amputated for compound fracture, at Guy's Hospital, by 
 Mr. HoAv.se. The house-surgeon began with chloroform; 
 and, when the patient was completely under its influence, 
 substituted ether. After the operation was finished, ami as 
 the effects of the ether were passing off, retching came on, 
 and the pulse became feeble. A little brandy was given. 
 Almost immediately afterwards, the patient began to vomit 
 and became blue in the face. A large piece of undigested 
 meat was removed from the back of the mouth; still no air 
 entered the lungs; other pieces of food were removed from 
 the entrance to the larynx with no better results. Tracheo- 
 tomy was performed, and artificial respiration and other 
 means were attempted ; but the patient died. At the 2>ost 
 mortem examination, the larynx and trachea were found 
 full of partially digested food. 
 
 12. The American Journal of Medical Science for October, 
 1876, reported v a case of death after ether. The patient, 19 
 years old, had contra cted chest and lungs seriously restricted 
 by adhesions, which 1 ound them down in all directions. 
 
TABLE OF DEATHS FROM ETHER. 37 
 
 The ether was administered for twenty minutes ; death 
 followed about two hours afterwards. At the post mortem 
 examination, bronchial mucus, pulmonary and pleural ser- 
 ous effusion, were found. 
 
 13. The Boston Medical and Surgical Journal reported 
 another ease of death under ether. It was of an old woman 
 in whom cerebral haemorrhage was afterwards found. 
 
 14. A man, aged 69, was etherized by Clover's apparatus, 
 for strangulated hernia, at the London Hospital. He com- 
 menced by inspiring only his own expired air for about 
 thirty seconds ; then he had the ether given in the proportion 
 of from a quarter to a half for a minute. He struggled, and 
 breathed the ether badly; the mouth-piece, therefore, was 
 frequently removed from his face. The amount of ether was 
 diminished, and, as his lips were blue, it was entirely discon- 
 tinued; his breathing improved a little, hut was not quite 
 satisfactory. The pulse became weaker and weaker, and 
 finally stopped ; respiration, however, continuing for thirty 
 seconds or more. At the 2^ost mortem examination, the heart 
 was found flaccid, the left ventricle uncontracted, the lungs 
 extremely emphysematous, the bronchi tilled with muco- 
 purulent matter, and other morbid changes were seen. 
 
 1"). A patient, aged 56, had to he operated upon for a syphil- 
 itic caries of the leg, at the East Suffolk Hospital. Bichloride 
 of methylene was first administered; and, as the patient did 
 not readily succumb, methylated ether was substituted. 
 The patient soon became unconscious ; hut, recovering un- 
 duly quickly, the bichloride of methylene was resumed. 
 Great struggling and peculiar epileptiform convulsions 
 ensued, followed by tonic spasm; this spasm relaxed; the 
 breathing became stertorous; the pulse failed; and death 
 supervened. There was no 2>ost mortem examination. 
 
 16. At the Moorfields Hospital, in August, 1807, a very 
 stout woman, aged 46, was to be operated upon for cataract. 
 A modification of Clover's apparatus was used ; forty minims 
 of chloroform were added to the ether to prevent the choking 
 sensation. The reporter of the case proceeds to say : "She 
 had only breathed the mixture for one minute, when the 
 face became livid, and she could, therefore, hardly have been 
 under the influence of the anaesthetic. The pulse and res- 
 piration continued fully four minutes after all anaesthetics 
 
38 ARTIFICIAL ANAESTHESIA. 
 
 had been discontinued." The anaesthetic had been applied 
 on and off for some time after the first alarm. At the post 
 mortem examination the heart was found flaccid and empty; 
 the mitral valve contracted ; the walls in a state of fatty de- 
 generation ; the lungs emphysematous, and congested with 
 blood. 
 
 17. Dr. Robert Saundby gave ether with Ormsby's inhaler 
 to a case at Birmingham on October 4th, 1877. .M. C, aged 
 35, had contracted knees. At 12.45 P. M. ether was com- 
 menced; only an ounce was used. There were no alarming 
 incidents; very little stertor; no cyanosis; and the respira- 
 tions were regular and full. Afterwards, the patient was 
 carried out of the theatre across an open court for fifty yards, 
 though well wrapped up. At 2.45 P. M., one hour and a 
 half after leaving the theatre, the patient suddenly became 
 alarmingly ill, cyanotic, and pulseless. Rules were heard 
 over the chest. At 4.1o P. M. he died. At the post mortem 
 examination, oedema was found in the membranes of the 
 brain; no thrombus in the pulmonary artery ; the heart was 
 healthy, containing a little blood in the right auricle ; the 
 ventricles were contracted; the lungs were pale and (edema- 
 tous; the other organs were healthy. The ether used was 
 of the specific gravity 720 722. 
 
 18. At Lincoln, Miss S.. aged 45, was etherized by Dr. 
 Mitchinson tor an operation upon .a cancer of the breast. 
 Half an ounce of brandy was given first. At three o'clock, 
 pure sulphuric ether was administered by means of an in- 
 haler, formed of a bag of muslin covered with a leather case, 
 which had a valve at the apex and a larger one at the lower 
 edge; the valves were open, and air was allowed free ingress 
 and egress. Another doctor's finger was on the pulse of the 
 patient all the time. Half-an-ounce having been poured into 
 the inhaler, Dr. Mitchinson held it lightly over the patient's 
 face; immediately, she spoke as if half unconscious, and 
 with two more inhalations became turgid about the face, 
 and her hands pinched and white; there was no pulse. The 
 tongue was dragged forward, and several forcible inspirations 
 resulted; they, however, became less and less till 3.15, when 
 she died. At the post mortem examination, the heart was 
 found covered with fat; the right ventricle contained an 
 ounce of fluid blood, the left was firmly contracted and 
 
TABLE OF DEATHS FROM ETHER. 39 
 
 empty; the muscular coat was one-twelfth of an inch thick. 
 The base of the right lung contained a considerable quantity 
 of fluid blood, and the base of the left a smaller quantity ; 
 there was cancerous deposit in both lungs. 
 
 The following eighteen cases, which show, primd facie, 
 their causes and modes of death, may be at once taken out 
 of the list, viz. : — 
 
 No. 2, the old man, who, after the anaesthetic effects of 
 ether had passed away, had not the strength to rally, but 
 passed through the stages of confusion, stupidity, uncon- 
 sciousness, and coma successively within two days. 
 
 Nos. 3 and 15, the ether being in the one case mixed with, 
 and in the other replaced by, bichloride of methylene. 
 
 No. 5, in which Robbins' ether was used, for Dr. Richard- 
 son says it is not pure ether, but a mixture of amyl hydride 
 and anhydrous ether ; it is useful in producing local anaes- 
 thesia by the spray-machine for which it is manufactured, 
 being of a low boiling point and specific gravity, and it is 
 directly dangerous when inhaled. 
 
 No. 11, in which the trachea was found filled with food. 
 
 Nos. 12 and 14, where previous pulmonary trouble was 
 just aggravated by means of the ether. 
 
 Nine cases still remain, in which ether appeared to play 
 no secondary part, nor even to be assisted by any untoward 
 condition or circumstance; and the question immediately 
 follows: What killed these patients? They who admit That, 
 although tether is safer than chloroform, it is not absolutely 
 safe, answer "asphyxia;" whilst all others, including those 
 who assert the absolute safety of ether, give no answer at 
 all. 
 
 It may be an advantage to draw up the essential particu- 
 lars of these nine cases in a table, so that we may the more 
 readily compare them altogether, and consider the following- 
 points: — 
 
 A. The important facts reported in these cases. 
 
 B. The probable conclusions deduced from the facts. 
 
 C. A theory explaining the facts and the deductions, 
 i). The best method of the administration of ether. 
 
40 
 
 ARTIFICIAL AN.ESTHKS r A. 
 
 a.n£ 5 
 
 C5— fcfi 
 
 o 
 
 
 O = 
 © - 
 
 P H 
 
 
 -a o £; c 
 
 III 111 
 
 a » a o> 'a £ 
 
 5B J5 OB OB 02 : 
 OJ-g Cv- 0) 03 
 
 o »^ © 5 ? ? ® ? 
 
 « a«2 g~ ~ i § "t 
 
 O fe fe Pi 
 
 as 
 
 0) O. 
 
 9 2 
 
 •£ © 
 
 «3 
 
 §"31 
 
 
 '- / 
 
 _ _. — >■* CS 
 
 ffi 
 
 •_ 
 
 1. 
 
 ^ 
 
 .■ 
 
 
 CI 
 
 ■"-; ] 
 
 ft 
 
 ir. 
 
 it 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 u 
 
 £^ 
 
 c 
 
 
 
 
 
 ■r 
 
 '- 
 
 tc 
 
 ■f. 
 
 
 
 
 
 — i 
 
 ,9 
 
 of 
 
 
 s 
 
 * 
 
 
 if. 
 
 a 
 
 * 
 
 p 
 
 
 
 
 
 • 
 
 
 
 Ph 
 
 K 
 
 
 
 
 X 
 
 -/. 
 
 c" 
 
 --t t(h 1-- ' ac 
 
 CS 
 
 - 
 
 (- 
 
 ,_ 
 
 r. 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 X 
 
 
 
 
 
 
 
 
 
 
 
 
 X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 fc 
 
 
 
 
 
 
 
 \ 
 
 8 
 
 
 
 
 « 
 
 !>4 
 
 
 
 c 
 
 „c 
 
 s. 
 
 
 
 +J 
 
 
 
 1 
 
 "3 
 
 ~E 
 
 
 S 
 
 0) 
 
 ~ ® 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 >i « 
 
 
 
 <; 
 
 
 
 
 -H w> 
 
 
 
 
 • ~ 
 
 
 
 
 >> 
 
 
 
 
 +3 
 
 
 
 ce 
 
 
 
 
 r*> 
 
 £ 
 
 
 
 
 
 
 
 
 © 
 
 
 
 
 
 
 
 *a 0) 
 
 c 
 
 
 
 a c 
 
 0) 
 
 
 
 
 
 
 
 N 
 
 3 g 
 
 
 
 0) " — 
 
 £ 5 
 
 
 
 'be .{J 
 
 £ 2 
 
 
 
 42 a 
 
 ■g •* 
 
 f. 
 
 m 
 
 fj 
 
 © ~ 
 c-r 
 
 .HI 
 
 , ,, >^o# 
 
 «i 
 
 ^ 
 
 ^ +3 
 
 ?H§1 
 
 «! 
 
 i 
 
 ,, i ® ,, 
 
 .-, £-§-? 
 
 a 
 
 ^* 
 
 0-; .- 
 
 
 I 
 ^ 
 
 
 ■g® 
 
 s©o'2 
 
 
 
 5 £ 
 
 if's'S* 
 
 
 
 
 
 5- 
 
 
 o c 
 
 l|Sg 
 
 O 
 
 
 73 
 £© 
 
 "So ® £ 
 
 
 
 ©Tl 
 
 eg ■£ OJ+J 
 
 
 
 
 
 H 
 
 
 .2 5 
 
 •-SS £ 
 
 /. 
 
 
 c/. r: 
 
 tj eg 60 a 
 
 i 
 
 
 +3 += 
 
 "y +-> -^ S 
 
 
 
 tt'Tc 
 
 <S bcM^ 
 
 
 
 
 
 
 
 p3p2 
 
 SSs 
 
 
 
 
 A 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 o 
 
 
 
 
 +a O 
 
 
 
 45._ 
 
 ■O e S 
 
 
 
 
 9 be ^ 
 
 
 
 ® -r 
 
 cf. - 
 
 Is s 
 
 
 B 
 
 ,£ "- ••:• 
 
 • ff-S.-g 
 
 
 * 
 
 it " 
 
 C g 3 — 
 
 
 
 "3 i? 
 
 
 
 s 
 
 f'~* ■+-> v 
 
 
 
 
 
 
 
 1^0 
 
 S"5 jj.S 2 
 
 
 
 
 
 
 
 
 
 
 '*■ 2 - 
 
 s*^p -^ 
 
 
 
 
 
 
 
 
 
 
 
 ~f bl"F 
 
 z ~ " "/- >-. 
 
 
 
 ' •_ — 
 
 
 
 
 
 B 5 "3 is ^ 
 
 
 
 
 
 
 
 j w ^ , — 
 
 ■— .— — _ 
 
 
 ~c~ 
 
 — i — 1- A 
 
 r: rr - l~ X 
 
 
 Y- 
 
 
 _ _ — _ 
 
TABLE OF DEATHS FROM ETHER. 41 
 
 a. The important facts. — They are easily recognized in 
 looking over the table of the nine cases. 
 
 1. Ether was inhaled in various yet limited quantities, 
 from three inhalations of it up to as many as would consume 
 half-a-pound on a towel ; and then produced the symptoms 
 ending in death. It was diluted with various quantities of 
 atmospheric air, and given in various methods. 
 
 2. The face was reported to be " dusky," " blue," " dusky 
 red," "livid," "cyanotic," or "turgid" in seven of the nine 
 cases, and never said to be "white" or "pale;" in the other 
 two, the color is not reported at all. 
 
 3. In seven cases the heart did not cease till some time 
 had expired after the commencement of the alarming symp- 
 toms, and after the ether had been discontinued; the intervals 
 varying from four minutes to three hours. In those of which 
 the notes were comprehensive, we read that the pulse re- 
 mained feeble, weak, or good, for a longer or shorter length 
 of time after the ether had been discontinued, or after the 
 alarm had been taken ; in the other two cases, no certainty 
 on that point can be gathered. 
 
 4. The lungs were reported to have been gorged with 
 blood in. five cases, and the pulmonary artery in the sixth. 
 In another, the trachea contained a elot of blood; and, of 
 the remaining three, two cases were not reported at all, and 
 one case only (No. 17), in which the patient died three hours 
 after the ether-inhalation was over, were the lungs altogether 
 41 pale," and even then they were " eedematous." 
 
 B. Two Deductions seem to follow from these facts. 
 
 1. The fatal effects of ether do not depend upon any directly 
 poisonous property of its own. 
 
 2. These cases died by "asphyxia." 
 
 Is not the former deduction indicated by the facts that the 
 quantities of ether given in these cases were various and 
 often small, and the proportions of its mixture with air, as 
 well as the methods of its administration, also various? And 
 is it not further borne out by the experience of so many eases 
 in which ether has been given in large quantities with the 
 smallest possible amount of atmospheric air, and still the 
 patients have to all appearances been perfectly safe? 
 
 Some cases might bv quoted, such as those which caused 
 
42 ARTIFICIAL ANAESTHESIA, 
 
 men like Dr. Joy Jeffreys to affirm the belief of American 
 surgery that ether is absolutely safe ; but one will suffice. 
 Mr. Furneaux Jordan related a case in which the ether was 
 pushed to an extreme degree, on account of the marked and 
 uncontrollable tremor of the muscles rendering the operation 
 doubly difficult. The ansesthetiser, Mr. Priestley Smith, 
 when requested by Mr. Jordan to give the patient more 
 ether, remarked "that the man was as much under the 
 influence of ether as it was possible to effect." 
 
 The second conclusion, that asphyxia was the mode of 
 death, is, to my mind, irresistible from the dusky face, the 
 shallow respiration, the interval between the commencement 
 of the alarming symptoms and death, the engorged lungs, 
 and other signs reported in most of the cases. 
 
 C. A Theory explaining these facts and reconciling these 
 conclusions. — The intense cold produced by the ether under 
 certain circumstances causes the small blood-vessels of the 
 lungs to contract, and so offer such degree of resistance to 
 the right ventricle of the heart as to stop it, if it be weak or 
 wearied, and embarrass it, if it be strong; and, by watching 
 the symptoms from this point of view, we are likely to be 
 able to cope with the dangers as they may arise, or even 
 (may we hope?) to prevent their occurence entirely. 
 
 Assuming that the deductions under the head b are logic- 
 ally based upon known facts, we are driven into a corner 
 out of which only such a theory as this can help us. 
 
 The asphyxia by which these deaths occur cannot be said 
 to be brought on by any interference with the nerves or 
 nerve-centres directly concerned in respiratory movements, 
 i. e., by paralysis of respiratory muscles, like the asphyxia 
 from carbonic dioxide poisoning ; nor, on the other hand, 
 by any mechanical interference with the air-passages, as the 
 asphyxia from hanging or drowning ; but must be from 
 interference with the chemical process of the aeration of the 
 blood in the air-cells and blood-vessels surrounding them. 
 This interference is not due to the want of oxygen, because 
 none of these cases show that oxygen was absent ; but most 
 of them show the reverse, pure atmospheric air having been 
 breathed for some time before death. It must, then, be the 
 result of the insufficiency of the circulatory action of the 
 
TABLE OF DEATHS FROM ETHER. 43 
 
 Wood, in the capillary vessels of the lungs, to do their share 
 in carrying on respiration. What obstructs this circulation? 
 It cannot be that the blood is poisoned with ether; for, in 
 one case (No. 18), three inhalations only had been taken, 
 and in another (No. 16) the ether had been administered 
 for one minute only. It must be from some property of ether 
 which comes into action in certain circumstances; and, 
 when we call to mind its power of producing intense cold 
 under some conditions, we venture to inquire into the like- 
 lihood of that property being the cause of asphyxia. Suppose 
 it to be true. Ether, in its administration, becomes a vapor 
 by absorbing a fixed amount of heat from surrounding media, 
 generally the atmosphere, and in that condition is inhaled 
 into the larger bronchial tubes, and then becomes mixed 
 with the residual air in the smaller tubes and alveolar 
 spaces. From them it is absorbed into and dissolved by the 
 blood, becoming a fluid again virtually in that act, and 
 therefore giving oft' a certain amount of latent heat. This 
 heat diffuses itself through the body as well as the ether, 
 and probably much faster, the latter having to be pushed 
 on to other parts by the continued addition of more ether 
 behind. This process goes on as long as ether is added. 
 When its administration is discontinued or interrupted for 
 any reason, and pure air allowed to enter the lungs, the 
 current of osmosis between the blood in the capillaries of 
 the lungs and the contents of the air-cells is reversed. The 
 ether, having now to change from the state of fluid to that 
 of vapor again, reabsorb* the amount of heat it gave off on 
 its entrance into the blood. If the air which has just entered 
 the lungs be warm, the abstraction of heat for the reevapor- 
 ation of the ether will not be felt by the lungs, though it is 
 sudden and local; but if, on the other hand, that fresh air 
 be cold, whether on account of its passing through or close 
 to an ice-cold instrument, rendered so by the action of the 
 ether, or from the room being cold, or from the patient 
 having been put into a cold place, though well wrapped 
 up, the amount of heat required suddenly by the ether 
 on its returning to the atmosphere will be more ; and 
 the lung-tissue, not having stored up the heat, the ether 
 brought to it will, upon this sudden demand, become so 
 cold as to cause a violent contraction of its arterioles. Such 
 
44 ARTIFICIAL ANAESTHESIA. 
 
 an amount of obstruction, from this contraction of a large 
 number of vessels, without anastomoses or diverticula, 
 resists the right side of the heart ; that, unless the latter 
 has an immense margin of strength, failure in its function 
 is the result, and the patient dies in a space of time varying 
 with the amount of resistance and the amount of strength 
 the right ventricle possesses. If the death were rapid, there 
 would be engorgement of the main branches of the pulmon- 
 ary artery and the right side of the heart. But the heart 
 may be able to overcome this obstruction ; then the capill- 
 aries of the lungs become engorged, the chemical process 
 in respiration becomes impeded, and the vis a fronte more 
 or less lost. Here is another and, perhaps, greater resistance 
 to the heart ; and the latter, wearied out now, might fail. 
 In this case, death would be more delayed than in the 
 former ; the pulse might be felt to become more and more 
 feeble. Afterwards the lungs would be found engorged with 
 blood, and the right side of the heart might be full of dark 
 blood, or the reverse. 
 
 But a strong heart might be supposed to overcome even 
 this second resistance; then the engorged capillaries would 
 throw out a quantity of serum into the air-cells and the sur- 
 rounding tissues ; that in the air-cells becoming frothy and 
 being expectorated; that in the tissues, perhaps, after some 
 time becoming reabsorbed, or possibly causing so much diffi- 
 culty in the acts of respiration as to constitute the last straw 
 and break the camel's back, by ottering such embarrassment 
 to the exhausted heart that the patient at last succumbs. 
 
 d. The Best Method of the Administration of Ether. — My 
 own experience consists principally in having administered 
 anaesthetics for Mr. Pridgin Teale's cases in private, with 
 very few exceptions, during the last year and a half. In 
 those cases, except with very young children, ether has 
 nearly always been administered. At first we used the 
 sponge, covered with mackintosh; then the American 
 framework, with the bandage weaved in it ; next, Clover's 
 larger apparatus ; lastly, Clover's smaller and more recent 
 inhaler. I haA T e also used Ormsby's inhaler a few times. 
 
 In my opinion, Clover's smaller inhaler is the best; it is 
 made by Meyer & Meltzer, Great Portland Street. It is 
 
TABLE OF DEATHS FROM ETHER. 45 
 
 composed of an ether chamber and water chamber, together 
 in a circular vessel ; a bag that can be detached ; and a face 
 piece, which likewise can be detached, and which rotates, 
 when fixed to the vessel, for the purpose of regulating the 
 amount of ether-vapor; it has no valves or sponge. It 
 possesses the following advantages : — 
 
 1. There is no struggling or resistance on the part of the 
 patient, however terrified or prejudiced he may be; the 
 ether being invariably breathed with comfort, and in many 
 cases with even a sense of pleasure. 
 
 2. The amount of ether-vapor can be carefully regulated 
 to a nicety without lifting the machine from the patient's 
 face, and, consequently, it is easy to keep a patient on the 
 very borderland of insensibility for any length of time. 
 
 3. The ether being economized, and not being dissipated 
 into the surrounding atmosphere, there is not only a better 
 chance of fresh air if needed for the patient, but there is 
 more comfort to the operator and his assistants, and espe- 
 cially to the aneesthetiser, who, with other contrivances, 
 often inhales a large share of the vapor himself, and in 
 consequence suffers many a headache. There is also a 
 considerable saving of ether; an ounce and a half usually 
 being sufficient for half an hour, when formerly eight, nine, 
 or more ounces were used. 
 
 4. There is none of that bronchial mucus which gave, 
 with other instruments, so much trouble at the time of 
 inhalation, and which was often followed by bronchitis, 
 and in some instances by death. 
 
 5. When consciousness has so far returned that the patient 
 can recognize, and even speak sensibly, the sensibility to 
 pain is still so numb that an operation may be concluded, 
 sutures put in, and dressings applied, without the slightest 
 sign of pain from the patient. 
 
 6. The comfort to the patient, silencing his resistance and 
 calming his mind, the ease with which the anaesthetiser 
 can administer and regulate the ether without the distraction 
 caused by the patient's struggles, or the etherized atmos- 
 phere, or the repeated application to an ether-bottle for 
 fresh supplies, and the equable temperature at which the 
 ether-vapor can be kept, combine together to insure the 
 greater safety to the patient. 
 
 3 
 
46 ARTIFICIAL ANAESTHESIA. 
 
 The following are the details of the method of adminis- 
 tering ether with the above-mentioned machine which I 
 have adopted, keeping in view and acting upon the theory 
 spoken of under the division c of this paper ; and Mr. Teale 
 expresses himself well satisfied with the practical results 
 that continue uninterruptedly under his observation. 
 
 1. Never allow any solid food, milk, or spirits to enter the 
 patient's stomach for six hours beforehand. 
 
 2. See that the room is well warmed. 
 
 3. Detach the bag and face-piece from the metal vessel of 
 the machine ; warm the vessel by placing it in a basin of 
 hot water an inch deep ; pour an ounce and a half of methy- 
 lated ether, specific gravity .714, into the ether-chamber; 
 put the face-pieee to the vessel, and rotate it so that the 
 indicator points to "no ether." Let the patient breathe 
 through the vessel without the bag into the air, so that he 
 gets only a flavor of the ether ; his nervousness and fear 
 will by this means be soon allayed, and confidence gained. 
 Avoid giving him the choking sensation until he becomes 
 numb to the ether ; by giving him, the ether slowly at first, 
 imperceptibly and gradually increasing it, the bag being 
 placed to the vessel, and so stealing over his sensitiveness 
 until he is quite "numb;" then proceed rapidly to full 
 ether, without any atmospheric air. Watch the respiration 
 closely : if it be at all embarrassed, give one breath of fresh 
 air, and resume the ether, at first weak, but increase it as 
 before. He will soon be under its influence ; then reduce 
 the proportion of ether by the regulator, so as to keep him 
 just beyond the boundary line of sensibility ; give him one 
 breath of fresh air occasionally. Continue to watch the 
 respiration closely. After the operation, do not place the 
 patient suddenly into a cold room or passage, even if he be 
 warmly clothed. 
 
 DEATHS UNDER ETHER.* 
 
 A coal porter, over fifty years of age, was admitted into 
 the London Hospital for strangulated hernia. Taxis having 
 been used, and the symptoms unrelieved, the house-surgeon 
 administered ether, using not more than an ounce and a 
 
 * British Medical Journal, May 18th, 1878. 
 
REMARKS ON DR. DAWSON'S THEORY. 47 
 
 half in all ; the patient came under the influence rapidly 
 and without difficulty. The local examination was then 
 proceeded to, with respiration regular and pulse good. 
 About six minutes after the inhalations began, a sudden 
 spasmodic inspiration was heard as if he were choking. 
 His tongue was drawn out, but respiration had ceased, al- 
 though his pulse continued to beat for another half minute. 
 Silvester's artificial respiration was employed, but no spon- 
 taneous inspiratory effort followed. During the artificial 
 respiration, some fcecal matter came up into the mouth. 
 
 At the post-mortem, the left ventricle* was found con- 
 tracted; heart healthy. The lungs were extremely con- 
 gested. There was fcecal staining of the oesophagus and 
 larynx, but no such matter had been drawn into the lungs. 
 The kidneys were granular. 
 
 G. W. Callander, Esq., stated to the writer that just prior 
 to his leaving London for a visit to the United States, a 
 death took place at St. Bartholomew's hospital on the ad- 
 ministration of ether (kind of ether not known, but what 
 is usually employed in England, which is a mixture of two 
 or three ethers). This death took place prior to any opera- 
 tion ; the man had been received into the hospital for an 
 intestinal trouble. 
 
 REMARKS ON DR. DAWSON'S THEORY. 
 
 We cannot agree with the Doctor that the cold has any- 
 thing whatever to do with the fatal results, as we have 
 never found the skin or pulse to fail under ether until the 
 inhalation had stopped ; then the skin became moist, 
 clammy, and cold; and, if exposed, collapse of the lungs. 
 If the system is not able to remove the moisture from the- 
 skin, the lungs must suffer, and the patient dies. 
 
 In many persons, the lungs contain so little residual air, 
 that the ether-vapor fills them almost entirely, not only 
 depriving the blood of its required oxygen, but also pro- 
 ducing its special influence upon the brain and nerves of 
 sensation and motion. It is true that no apparatus now at 
 our disposal entirely prevents air from reaching the lungs ; 
 but the great difficulty lies generally in the sponge or towel 
 used becoming so wet with the watery vapor, that a perfectly 
 air-tight covering for the mouth and nose is formed, neces- 
 
48 ARTIFICIAL ANAESTHESIA. 
 
 sarily producing asphyxia if left too long. Ether, like water, 
 may also fill the trachea, preventing the air from reaching 
 the lungs, as" often noticed in drowned persons, the trachea 
 being found full of water; undoubtedly the prime cause of 
 death. 
 
 We have a beautiful exemplification of the action of the 
 oxygen of the air in the human body, in the elimination 
 of poisons in the transient operation of moderate doses of 
 alcohol, ether, chloroform, opium, strychnia, prussic acid, 
 snake poison, etc., etc., in all of which the real question of 
 life or death is one of time ; for if the fatal results do not 
 speedily follow the absorption of the poison (as in chloro- 
 form, strychnia, snake-bite, or prussic acid) into the blood, 
 the patient gradually recovers from its effects, and the most 
 effectual- treatment consists in the maintenance of artificial 
 respiratory movements. Ether always gives timely warning. 
 
 ETHER versus CHLOROFORM. 
 
 Prof. Ringer {Handbook of Therapeutics, seventh edition, 
 pp. 344, London, 1878) says : "Ether for many years preceded 
 chloroform as a general anaesthetic. At the present time, 
 there is in this country much contention as to the relative 
 merits of chloroform and of ether ; and ether bids fair rapidly 
 to take the place of chloroform. " 
 
 Pure sulphuric ether is, Avithout doubt, the most perfect 
 anaesthetic we possess for use by the physician and the 
 general surgeon. The proofs of its safety are full and com- 
 plete. In the city of Philadelphia alone it has been used, 
 with but one exception, since its introduction in 1840, up to 
 the year 1878. In these thirty-two years, at least from three 
 to five times a day it has been employed by the nine hundred 
 and sixty-seven regular physicians. These 11,660 days, 
 multiplied by three, would give us 34,980 administrations 
 without a single primary death, and only one recorded 
 secondary death.* 
 
 If sulphuric ether is made from pure materials, and 
 washed with care, it is superior to all other anaesthetics in 
 its freedom from irritation of the stomach, and in protracted 
 and dangerous operations, provided the usual caution is 
 
 * American Journal of Medical Science. 
 
LOCAL ANESTHESIA AND ANAESTHETICS. 49 
 
 observed — i. e., not to take any solid food, except a biscuit 
 or cracker, with a glass of wine, or a small quantity of 
 brandy or whiskey and water, for six hours prior to the 
 inhalation. 
 
 To show that it can be used for the most delicate operations 
 on the eye, it is stated by Dr. Carter, the distinguished oph- 
 thalmic surgeon of London, that he employs ether with 
 perfectly satisfactory results in all operations on the eye as 
 regards the spasm of the muscles, and without the appear- 
 ance of any symptoms to indicate a possibly prejudicial 
 action. This testimony is corroborated by all the ophthal- 
 mic surgeons of our city. 
 
 In our own experiments, where a small quantity of liquid 
 food had been taken before the inhalation, the proportion 
 of cases in which vomiting occurred was only one in fifty. 
 Dr. David Webster, of New York, states, in his cases taken 
 indiscriminately, and not adopting the important caution, 
 "that vomiting occurred once in forty-two cases." In thirty 
 persons etherized by the late Dr. J. Morgan, of Dublin, 
 sickness of the stomach occurred in only two cases. In 
 twenty-six reported by Surgeon-Major Porter with the ether 
 made in England, by the action of sulphuric acid on alcohols 
 made from potato and wood spirit, vomiting occurred in ten 
 cases, owing to its impurities. 
 
 "Again, from the annual report of Professor Bardeleben's 
 clinic in Berlin, for 1876-7, we learn that deaths from chlo- 
 roform occurred in that year four times among twelve to 
 fifteen hundred narcoses; in all four cases, a small amount 
 of chloroform was used when death occurred. These acci- 
 dents, as well as an exceedingly large number of troublesome 
 narcoses, caused the Professor to abandon chloroform, and 
 used chloral and ether. All narcoses have since been free 
 from complications. "* 
 
 LOCAL ANESTHESIA AND ANESTHETICS. 
 
 The method of local anaesthesia proposed by Dr. Benjamin 
 W. Richardson is the one most generally adopted. The 
 process consists in directing ether on a given surface of the 
 body, the strongest, freed from alcohol and water, in minute 
 
 * Chicago Medical Journal and Examiner, October, 1878. 
 
50 ^ ARTIFICIAL ANAESTHESIA. 
 
 division or spray, mixed more or less with atmospheric air. 
 This is accomplished by means of a hand-spray, an article 
 which has become very popular in diffusing the various 
 perfumed waters in a room. The apparatus consists of a 
 bottle to contain the ether; through a perforated cork a 
 double tube is passed, one extremity of the inner part of 
 which goes to the bottom of the bottle ; above the cork a 
 tube connected with the bellows (a rubber bag) pierces the 
 outer part of the double tube, and communicates by a small 
 aperture at the inner end of the cork with the interior of 
 the bottle. The inner tube for delivering the ether runs 
 upwards to the extremity of the outer tube. 
 
 When the two rubber bags or bellows are compressed by 
 the hand, a double current of air is produced ; one current 
 descending and pressing upon the ether, forcing it along 
 the inner tube, and the other ascending through the outer 
 tube and playing upon the column of ether as it passes from 
 the inner tube. 
 
 RHIGOLENE, 
 
 A product obtained by the distillation of petroleum, is also 
 used for local anaesthesia; it is the lightest of all know n liquids, 
 its specific gravity being .625; it boils at 70°. This local 
 anaesthesia, which is produced by the evaporation of these 
 volatile liquids, which produce intense cold, can be used 
 with advantage in minor surgery. It should never, by 
 these agents, affect a large surface; nor should it be long 
 applied, else it will freeze and destroy the tissue, so that the 
 death of the part may take place. 
 
 Dr. Letamendi* .has discovered a new mode of utilizing 
 the anaesthetic effects of ether-spray. After applying Rich- 
 ardson's spray -producer for about two minutes, in which he 
 employs perfectly neutral sulphuric ether, the skin has by 
 this time become red, and is the seat of a disagreeable sen- 
 sation of cold, but no sensation of burning in the part. If 
 at this moment an incision, eight to ten millimetres long, 
 is made with a convex bistoury in the centre of the reddened 
 part, not being carried deeper than the papillary layer of 
 the cutis, immediately the incision is made there is suddenly 
 
 * Archives de Physiologie, November, 187.". 
 
LOCAL ANAESTHESIA BY ETHER SPRAY. 51 
 
 produced an anaemic zone, which enlarges outwards from 
 the point incised. 
 
 If the spray is again directed for a few seconds on the 
 part which has thus become ansemic, the region becomes 
 perfectly bloodless and completely anaesthetic. The tissues, 
 when cut, are like frozen fat, and have lost their elasticity. 
 Around the white circle there is a zone, in which the anae- 
 mia is not absolute. The spray directed on this zone speedily 
 makes the anaemia and consequent anaesthesia complete; 
 the anaesthesia can thus be carried around or along a limb. 
 
 The theory brought forward by Dr. Letamendi to account 
 for the effect of the slight incision is, that the cold produced 
 by the ether causes relaxation, and consequently dilatation of 
 the vessels. The incision produces a sudden reaction, which 
 converts the extreme dilatation into extreme contraction. 
 The practical advantage is, that anaesthesia is obtained 
 without a prolonged application of the ether-spray. 
 
 ANESTHETIC MIXTURE. 
 fy. Sulphuric ether, fgj. 
 
 Pulv. camphorae, 5iv.— M. 
 
 Dissolve. 
 
 On applying this mixture for a minute or two to the part 
 where a superficial operation is to be practised, local anaes- 
 thesia is temporarily produced. 
 
 EXCISION OF CANCER OF THE BREAST BY 
 SCISSOR-CUTTING UNDER ETHER-SPRAY, 
 BY DR. BENJAMIN W. RICHARDSON. 
 
 " The nature of the tumor was sufficiently clear. It was 
 a hard scirrhus, of the size of a small hen's egg, loosely held 
 in the gland, with no adhesions to the muscular structure 
 beneath. The family history of the patient confirmed the 
 diagnosis; her mother had suffered from scirrhus of the 
 breast. The diagnosis left no doubt respecting the proper 
 mode of treatment ; there could be no hesitation in advising 
 that the abnormal growth, while it was yet easily movable 
 and removable, should be excised, and to this advice the 
 patient gave a willing assent. But now the question of the 
 administration of an anaesthetic came under consideration. 
 The action of the heart of this lady was so intermittent and 
 irregular, and the power of her heart was so reduced, that 
 
52 ARTIFICIAL ANAESTHESIA. 
 
 the slightest external impression influenced it in its motion ; 
 she belonged, in a word, to that population which is prone 
 to die suddenly from chloroform and the other narcotic 
 vapors. Under these circumstances, I proposed to the patient 
 that the tumor should be excised under local anaesthesia ; 
 and, that the failure of the process, if failure should follow 
 the recommendation, might fall upon me entirely, I per- 
 formed the operation myself. 
 
 " I operated on the 8th of May last, in the following man- 
 ner. The patient having been placed in a semi-recumbent 
 position on a narrow couch, I directed Mr. W. Perkins, who 
 very efficiently conducted the local anaesthesia, to direct 
 gentl3 r over the tumor a large spray of common ether, so as 
 to chill thoroughly, but not to freeze the skin. \ let him 
 maintain this for a period of five minutes, then T handed 
 to him another tube and bottle for spraying over the already 
 chilled part the light fluid called anaesthetic ether, a com- 
 pound of ether of specific gravity .720 with hydride of amyl. 
 A few moments' application of this lighter ether was suffi- 
 cient to render the whole of the breast frozen like a bard 
 snowball; for a minute longer, that the deeper structures 
 might become equally chilled, the spray was continued. 
 When the structures were thus prepared, instead of using 
 a scalpel for cutting, as in the ordinary way, I made the 
 required incisions through the skin with a pair of small, 
 strong, sharp, sligbtly-curved scissors. Commencing the 
 incision by an angular cut at the outer margin of the part 
 to be excised, I carried the lower blade of the scissors deeply 
 into the breast, with the edge of the blade everted ; in this 
 way I cut the lower flap; then, commencing at the same 
 angle, T cut in the same manner the upper flap. The rapidity 
 and ease with which these incisions through the hardened 
 tissues were made, struck me most favorably; the incisions 
 were deep enough to enable me to grasp the tumor firmly 
 with the left hand. I now laid down the ordinary sharp- 
 cutting scissors, and with a pair of strong, slightly curved, 
 tooth-edged scissors, I proceeded to cut on each side of the 
 tumor until I could fairly lift it up ; then, by a few strokes 
 made with the same scissors underneath, I cleared it com- 
 pletely away. The operation lasted precisely three minutes, 
 and was unattended, during the whole time, by the escape 
 
THE EFFECT OF LOCAL ANAESTHESIA. 53 
 
 of blood. The diseased mass removed, I had the ether-spray 
 withdrawn, in order to see if any vessels would bleed during 
 reaction from the freezing ; there was a little oozing of blood, 
 which quickly subsided, and one artery was tied, both ends 
 of the ligature being cut off close to the vessel. The wound, 
 Carefully cleaned with a soft, damp sponge, was closed ; 
 the edges of it were secured with five sutures ; a pledget of 
 cotton-wool, charged with styptic colloid, was placed over 
 the wound; and a lint-pad and firm bandage completed the 
 dressing. The patient passed a good night after the opera- 
 tion ; she was allowed to rise and go into the drawing-room 
 on the following clay ; and as she exhibited no rise of tem- 
 perature beyond 99° F., and that only for a few hours, and 
 suffered from not one untoward symptom, the dressing was 
 left untouched until the 13th of May, when, on removing it, 
 the wound was found healed throughout its entire extent. 
 The sutures were removed a few days later, when the line 
 of incision was found fairly closed, without a particle of 
 discharge or interruption of healing at any point. During 
 the whole of the operation the patient did not utter a single 
 expression of pain. 
 
 "'The effect of the local anaesthesia. — It is certain that in 
 this ease the local method afforded everything that could 
 be desired in the way of amesthesia. It saved all acute 
 pain; it saved the patient the dread of death during the 
 insensibility from a general anaesthetic, and it enabled me 
 to proceed in our task without a thought as to the immediate 
 safety of the patient. I may say more for it still : it war- 
 ranted me in recommending the operation. I should cer- 
 tainly not have advised any friend of mine, whose heart 
 was in the same condition of irritability and irregular ner- 
 vous supply, to inhale an anaesthetic vapor, to the fatal 
 effects of which such conditions of the circulation are so 
 favorable. Applying, then, this same rule to a patient, 
 who in putting his life into my hands makes his life for 
 the time mine, I should consider it actually wrong to re- 
 commend a risk I would not myself accept; but, taking- 
 ad vantage of the local method, I had no occasion to suggest 
 a danger of any kind, while I secured my patient the 
 benefits of anaesthesia. I saved her the dread of death 
 from the effects of a general anaesthetic; I saved her pos- 
 
54 ARTIFICIAL ANAESTHESIA. 
 
 sibly the symptoms of after- vomiting and faintness ; and I 
 saved myself and my colleagues, during the operation, the 
 anxiety that ever attends the administration of a general 
 anaesthetic to persons in whom disease of the heart is fore- 
 known. 
 
 "The method of cutting with scissors. — Local anaesthesia 
 has many disadvantages ; it is more troublesome than 
 general anaesthesia as a detail of practice ; and, as it leaves 
 the consciousness alive, it fails at times in preventing the 
 fears of the patient. But hitherto the greatest difficulty 
 in operating under it, has been the obstacle of cutting 
 through the hard, frozen, insensible part ; the resistance to 
 incision by the best cutting knife, and especially to dissec- 
 tion by the knife, is such that I have seen the most skillful 
 surgeons troubled by it; and I have never been able to 
 complain of the objection that has been made to the method 
 on this ground. The difficulty is now overcome by the 
 process of scissor-cuttiug which I have here introduced. 
 The advantage of the scissors over the scalpel will be at 
 once proved by any one who will take a thick, firm 
 structure, the cover of a book, for example, and try to cut 
 through it; with the best of scalpels he will be troubled, 
 but with scissor blades he will cut with the utmost facility, 
 if the blades be well set. So, in cutting through the frozen 
 animal tissue, the parts can be divided as rapidly as may 
 be wished with the scissor blades, with perfect accuracy of 
 incision, and as deeply as may be desired ; the cutting is 
 also made without any downward pressure, by which pain 
 of pressure is saved ; also in deep dissection the tissues, 
 frozen as they are exposed, can be divided more easily than 
 by the knife, for the harder they are solidified the easier 
 they are divided by the scissor blades. In a word, I believe 
 that every cutting operation, in which local anaesthesia is 
 practicable, may be performed neatly and effectively by 
 scissor-cutting, and that a much larger number of operations 
 may now be painlessly carried out under the local method. 
 
 "Some little attention requires to be paid to the instru- 
 ments used. The scissors for superficial or skin cutting 
 should be exquisitely sharp, neat, and strong ; and I prefer 
 them slightly curved. For deep cutting, where there are 
 many blood-vessels, the tooth-edged cutters are valuable; 
 
INTERNAL ADMINISTRATION OF ETHER. 55 
 
 these pierce, crush, and divide at the same time, and they 
 save blood. For other purposes, as for division of a sinus, 
 some modifications are required, and Messrs. Krohne&Sese- 
 mann are now making for me a case of in struments for th e spe- 
 cial purpose of operation in the method under consideration. 
 "Effect of the operation, on the heart, in the case related. — 
 No fact is more instructive in the history of the patient 
 recorded in this paper, than the beneficial effect produced 
 on the functions of the heart by the operation. In this 
 instance, the cardiac irregularity and irritability were 
 purely due to irregular nervous supply, to nervous irritation 
 and consequent muscular exhaustion. The irritation might 
 have been in part due to the mental anxiety which naturally 
 accompanies the disease, or it might have been due to the 
 irritation of the tumor, and have been reflex in character. 
 Whichever view be correct, the result of the operation was 
 curative; and, as the case is typical of a class of phenomena 
 of disease, the lesson it teaches is extended far beyond it as 
 an individual illustration. It shows that so soon as the 
 heart obtains rest from the persistent nervous thrill that 
 invades it, its muscular tone returns, and its irregular 
 motion and excitability cease. Thus by operating early for 
 the removal of cancer, the surgeon acts as physician also, 
 and prolongs the general life by removing the local disease. 
 I am convinced I have seen patients suffering from cancer 
 die from the mental and local irritation of the disease long 
 before any development of the malady has advanced to kill 
 by destruction of the part or organ involved ; I infer, there- 
 fore, thatif, without any danger to life from general anaes- 
 thesia, we can remove external malignant growths painlessly 
 and promptly, so soon indeed as they are detected, we shall 
 bring art, effectively, to the defeat even of cancer."* 
 
 * Prof. Billroth expresses himself as follows: "Local anaesthetics, 
 which have for their object temporary blunting of the pain in the part 
 to be operated upon, by application of a mixture of ice and saltpetre 
 or salt, have been abandoned, or rather they have never been generally 
 received. Recently these attempts have again acquired a general in- 
 terest, as it seemed that a suitable method of local anaesthesia had at 
 last been found: Dr. B. W. Richardson, by means of a pure spray 
 blown against the spot in the skin, and such cold is here induced that 
 all sensation is lost. After procuring some of this ether (hydramyl- 
 ather) from England, I was satisfied of its perfect action. In a few 
 
■56 ARTIFICIAL ANAESTHESIA. 
 
 GASOLINE. 
 
 This is a new and cheap agent as a local anaesthetic, and 
 will answer all the purposes of ether at one-fourth the cost. 
 
 Dr. C. J. Essig, in the Dental Cosmos for November, states 
 that the following preparation has given uniform satisfaction 
 as a local anaesthetic: — 
 
 Jfr. Pulv. camphoree, 5iv. 
 
 Etheris sulphuris, f 5iv. — M. 
 Sig. Apply to the gum, surrounding the tooth to be extracted, with 
 a pledget of cotton, until the gums turn white, when the tooth can be 
 extracted with very little pain. 
 
 INTERNAL ADMINISTRATION. 
 
 Exhibited internally, sulphuric ether is an excellent 
 diffusible stimulant. It sinks in water, and is best admin- 
 istered mixed with spermaceti and sugar, or in mucilage 
 of gum arabic; its taste is hot, pungent, and irritating, and 
 when placed in the mouth, ears, nose, or rectum, pain is 
 produced. It dissolves in alcohol, whiskey, or brandy; and 
 when required as a powerful stimulant, as in fainting, ex- 
 haustion, or collapse, this is an excellent method for admin- 
 istering i t. In using it for some time, it is best given enclosed 
 in capsules. 
 
 Gout. — In sudden attacks of gout in the stomach or intes- 
 tines, a useful mixture is the following: — 
 
 Tfr. Spiritus vini gallici, 
 
 ^Ether. aa fSj.— M. 
 
 Sig. Dose, one teaspoonful in sugar and ice-water, repeated until 
 relief is afforded. 
 
 This same preparation will be found valuable in sjmsm of 
 the stomach, or intestines, or heart. Ether has been proved 
 useful in tape-ivorm, alone or combined with the oleo-resin 
 
 seconds the skin became chalky white and absolutely without sensa- 
 tion, but the effect hardly extends through a moderately thick cutis; 
 and, if the ether be still blown against the cut surface, the frozen tissues 
 cannot be distinguished from each other, and the knife, being coated 
 with ice, will no longer cut. Hence, even in this most perfect form, 
 local anaesthesia can only be used advantageously in a few minor 
 operations. My former dread, that healing of the wound would be 
 essentially interfered with by this freezing of the part, has been shown 
 to be groundless." — Fourth German edition, translated by C. E. Hack- 
 ley, A. M., M. I>., New York, 1879, p. 21. 
 
THERAPEUTIC VALUE OF ETHER. . 57 
 
 of the male fern. The patient must live upon milk and a 
 little bread for one day, and the following morning, fasting, 
 take the full dose: — 
 
 p. Oleo resinse Filicis, 5ss. 
 
 vEther. f5j. 
 
 Mucilag. acacise, ad. ft. f 5ss. — M. 
 
 This is to be repeated in three hours ; in the evening food 
 can be taken, to be followed with a full dose of castor oil 
 with twenty drops of spirits of turpentine. Some French 
 authorities prefer to give f 5iss. of ether alone, administered 
 at once, and followed in two hours by the purgative. 
 
 Ether is also one of our most potent remedies in hysteria, 
 especially when associated with valerian, assafcetida, 
 musk, or camphor. In the first with the fluid extracts, as 
 follows : — 
 
 I*. yEther. 
 
 Valerian, ex. fluid, aa i'5j.— M. 
 Sig. A teaspooni'ul every hour. 
 
 In the second it is mixed with the tinctures as follows: — 
 
 1*. .Ether. 
 
 Tinct. AssafoeticUe, aa Sj. 
 , Mucilag. acacise, Sj. — M. 
 
 Sig. A teaspooni'ul every hour until relieved. 
 
 With musk : — 
 
 Jfr. Moschus, aij. 
 
 -Ether. 
 
 Mucilag. acacia?, aa f Sj. — M. 
 Sig. A teaspoon fill every hour. 
 
 With camphor, ether is not only useful in hysteria, but 
 all forms of "nervousness" in dysmenorrhea, diarrhoea, 
 cholera, abnormal sexual excitement, epilepsy, hysterical, 
 puerperal, and strychnic convulsions. Camphor with ether 
 is best administered as follows:— 
 
 9:. Vitelli ovi; Sij. 
 
 Pulv. camphorse, 5ij. 
 yEther. Sij.— M. 
 
 Add the ether to the camphor, and then the emulsion; administer 
 in tablespoonful doses every two hours. 
 
 Cure of Sciatica by subcutaneous injections of ether. — Dr. C. 
 G. Comegys reports, in the Cincinnati Lancet and Observer, 
 the successful treatment of a case of sciatica by means of 
 
58 ARTIFICIAL ANAESTHESIA. 
 
 hypodermic administration of ether,, and that, too, after 
 almost every other thing had been tried. He first gave 
 fifteen drops, which was followed immediately by great pain, 
 but which soon passed off. The injection, in increasing 
 doses up to thirty drops, was repeated morning and evening 
 for three days, when the patient was discharged cured. No 
 local injury resulted ; the injections were made in the ordi- 
 nary superficial method, and not deep. 
 
 According to Zuelzer, ether can be used as a stimulant in 
 small doses by hypodermic injections. He states that the 
 symptoms of collapse are relieved by it, and abscesses are 
 rare; the quantity recommended is one cubic centimetre, 
 or about sixteen minims. 
 
 Asthma. — Inhalation of ether is very valuable to obtain 
 relief in spasmodic asthma, and obtain sleep for the patient. 
 It can be employed alone, or associated with tinctura digi- 
 talis or conium. The ordinary dose of the ether if from ten 
 to forty minims, and the tincture of digitalis from ten to 
 thirty minims. 
 
 The Ether-spray in Post-partum Hemorrhage. — Mr. W. 
 Handsel Griffiths, of Dublin, reports in the Practitioner the 
 use of the ether-spray in two cases of post-partum hemorr- 
 hage, in which the usual means of arresting the flow had 
 been resorted to without effect. He directed the spray over 
 the abdominal walls, along the spine, and over the genitals; 
 in both cases the uterus contracted immediately, and hemorr- 
 hage ceased. 
 
 Coryza and Obstinate Hoarseness. — Drs. Chapman and 
 Physick recommended the vapor of equal parts of Hoffman's 
 anodyne or compound spirits of sulphuric ether with equal 
 parts of laudanum in cases of recent catarrh, in coryza, and 
 obstinate hoarseness, by inhalation.* 
 
 Chorea. — A jet or hand spray of sulphuric ether, free from 
 alcohol, applied to the spine will relieve the most violent 
 spasmodic or convulsive attack of chorea, with the subse- 
 quent use of Fowler's solution, five to ten drops three times 
 a day in water, and occasional application of the galvanic 
 current to the spine. > 
 
 * I have also employed one-quarter grain of sulphate of morphia in 
 the place of the laudanum, making a more elegant preparation, and 
 with good success. 
 
ETHER IN DEATH AGONY AND IN VIVISECTIONS. 59 
 
 Nervous Aphonia, or Temporary Loss of Voice. — The 
 vapor of ether has been highly recommended as a most 
 valuable remedy in hysterical or nervous loss of voice. It 
 has been the means of discovering malingerers, who were 
 supposed or stated to be deaf and dumb,* and who, as soon 
 as they came under its anaesthetic influence, were able both 
 to hear and speak. 
 
 Diphtheritic Angina, or Pseudo-Membranous Croup. — 
 Cases of diphtheritic angina have been treated with success 
 by inhalations of ether and steam. 
 
 Whooping-Cough. — Ether alone by inhalation is extremely 
 useful in the relief of whooping-cough ; and a combination 
 of ether sixty parts, chloroform thirty parts, and turpentine 
 one part, has been found a most successful remedy, by con- 
 fining the patient to his room, and making him, at every 
 access of coughing, place before his mouth a small piece of 
 cloth, folded several times, and wet with a teaspoonful of the 
 mixture. f This remedy I have used with most gratifying 
 results, at the same time employing, between the paroxysms, 
 extract belladonna and quinine sulph. internally,' with the 
 inhalation of diluted carbolic acid in the patient's room. 
 
 ETHER IN MITIGATION OF THE AGONIES 
 OF DEATH. 
 
 I avail myself of the reported trials of the late John C. 
 Warren, M. D.,t "On the use of ether in mitigating the 
 agonies of death," and his reasons for employing it in a free 
 and decided manner. He says : — 
 
 " I am fully aware that the agony in the dissolution of the 
 bond between the bodily frame and its spiritual tenant is 
 not so great as it is believed to be ; for, having questioned a 
 great number of persons passing through the last stage of 
 earthly existence, whether they suffered pain, the answer 
 has been almost uniformly in the negative ; and on inquiring 
 what sensation was experienced, the reply has been such as 
 
 * See Turnbull's Manual of Diseases of the Ear, pp. 312-315. Phila- 
 delphia: J. B. Lippincott & Co. 
 
 t American Practitioner, July, 1875. 
 
 t Etherization, with Surgical Remarks by John C. Warren, M. D., 
 Emeritus Professor of Anatomy and Surgery University of Cambridge, 
 Surgeon at Massachusetts General Hospital, Boston. William D. 
 Ticknor & Co., Boston, 1847, pp. 70. 
 
60 ARTIFICIAL ANAESTHESIA. 
 
 to lead me to consider it an undefinable sense of discomfort. 
 The intellectual faculties appear to be so clouded and con- 
 fused, that they are unable to take cognizance of the agitation 
 which convulses the physical organization. 
 
 " There are, however, exceptional cases, in which there is 
 great bodily suffering ; and there is in all men an instinctive 
 dread of the pains of death. If we find the means of pre- 
 venting or relieving these pains, the great change may be 
 viewed without horror, and even with tranquillity. He 
 who would experience a real euthanasia should not, however, 
 trust merely to the virtues of ether, but should also have 
 settled his accounts with this world, and be well prepared 
 to settle those of the future. 
 
 "In illustration of the practice alluded to may be men- 
 tioned the case of a lady, who died of dysentery in the 
 summer of 1847, at the age of ninety. She had been my 
 patient more than forty years; and during that time, besides 
 heavy domestic calamities, had undergone a number of at- 
 tacks of pleurisy, one of pericarditis, a severe and protracted 
 bleeding from the stomach, with symptoms of malignant 
 disease of this organ. She was once dangerously poisoned 
 by eating partridge ; moreover, by a fall she had a fracture 
 of the neck of the thigh-bone, and soon after her restoration 
 was attacked with senile mortification of the foot, from 
 which, having suffered months of intense pain, she wholly 
 recovered. 
 
 "Very temperate in her eating and drinking, and of a 
 religious character, she was cheerful notwithstanding all 
 these visitations ; appeared to enjoy life more as she grew 
 older, went out freely, and made two or three excursions 
 into the country within a few weeks of her last illness. 
 
 "The dysenteric attack, which terminated her career, 
 accompanied with symptoms of unusual severity, was only 
 relieved for a very short time by the use of opium. After 
 more than two weeks of illness, violent pain occurred in one 
 of the feet, with discoloration, ending in gangrene. The 
 pain of mortification suddenly ceasing under the use of 
 opium, that of the abdomen returned, with convulsive 
 twitchings of the limbs; and other remedies failing to miti- 
 gate these symptoms, inhalation of ether was employed with 
 perfect relief. 
 
ETHER IN DEATH AGONY AND IN VIVISECTIONS. 61 
 
 11 From the first inhalation to the period of her death five 
 days elapsed, during which a considerable number of ether- 
 izations were used, and with such effect that, as soon as any 
 suffering occurred, she desired ether. In the intervals, her 
 mind was clear.; she arranged such worldly matters as re- 
 mained unsettled, received the consolations of religion, and 
 finally, under ethereal influence, her spirit imperceptibly 
 took its flight. 
 
 " Vivisections.— An excellent use of ether may be made 
 in regard to animal vivisections. The people of this country, 
 in common with their English progenitors, have always 
 viewed the torturing of living animals for scientific purposes 
 with invincible repugnance. Great has been the sacrifice 
 of improvement in physiology and surgery which this sen- 
 timent has cost the medical profession. Ether enables us 
 to lull the sensibilities of the victim, tranquilly pursue the 
 natural workings of the internal organs, and the changes 
 which take place from experimental applications; while 
 the student of surgery can accustom himself to those gushes 
 of the vital fluid, which, in the human body, are viewed 
 with so much terror by the unpractised. Animals of any 
 size may be etherized in a box, or by covering the head with 
 an india-rubber sack, into which a mixture of ether and 
 atmospheric air is forced." 
 
 Vivisections with Ether and Chloroform.— Prof. 
 SchifT, of Florence, states : " In our experiments, that is, in 
 more than three thousand cases, we have adopted etheriza- 
 tion with a view to preserve the life of animals ; and that, 
 with few exceptions, indicated elsewhere (Memoir on the 
 Laryngeal Nerve), not a single case of death occurred. On 
 the other hand, chloroform has cost us a considerable num- 
 ber of animals when I have wished to push anaesthesia to 
 its ultimate stage." 
 
62 ARTIFICIAL ANESTHESIA. 
 
 CHAPTER III. 
 
 Ethers which have anaesthetic properties. Acetic Ether. Experim ents 
 by Dr. H. C.Wood on animals, etc. Formic Ether. Byasson's con- 
 clusions in regard to it. Hydriodic Ether. Properties and object ions 
 to its use. Methylic Etlier. Dr. Richardson's experiments with it. 
 Bichloride of Methylene. Observations upon it by Dr. Jones of Cork, 
 Dr. Taylor and Spencer Wells of London. Iodide of Methyl. Amy- 
 lene. Bromide of Ethyl, or Hydrobromic Ether. Properties. Mode 
 of preparation, and experiments by the writer. Chloride and Hi- 
 chloride of Ethylene. Oxygen, Nitrogen and Hydrogen Gases as 
 anaesthetics, 
 
 ACETIC ETHER (C 2 H 5 C 2 H 3 2 ). 
 
 Acetic ether is colorless, and has an agreeable odor and 
 burning taste. Specific gravity 0.85); boiling point 165°. 2 F. 
 If kept in contact with air, and in the presence of Mater, 
 free acetic acid is formed. According to Dr. H. ('.Wood, 
 in pigeons and rabbits it produces perfect unconsciousness 
 without as much previous struggling as when sulphuric 
 ether is used, and has the advantage over that compound of 
 being less inflammable; on the other hand, its volatility is 
 less. No experimenter has employed this ether on man to 
 produce anaesthesia. 
 
 FORMIC ETHER (C 2 H 5 CH0 2 ). 
 
 Formic ether is a colorless liquid, recalling the odor of 
 rum, and having an agreeable taste. Specific gravity 
 0.915; density 62.8; boiling point 127°,3 F. It dissolves in 
 nine parts of water and all proportions in alcohol, ether, 
 fixed and volatile oils. Byasson made some experiments 
 with it on animals, and found that this ether decomposed 
 into alcohol and alkaline formiates through the alkalies of 
 the blood. When inhaled, it lowers the temperature and 
 induces asphyxia. 
 
 HYDRIODIC ETHER (C 2 H 6 I). 
 
 Hydriodic ether is a colorless non-inflammable liquid, 
 having a peculiar ethereal odor and taste, soluble in alcohol, 
 
ETHERS WITH ANAESTHETIC PROPERTIES. 
 
 (53 
 
 and nearly insoluble in water. It boils at 158°. 5 F.; specific 
 gravity of liquid at 32°, 1.9755. Exposed to the air and light 
 it liberates iodine and becomes brown, which irritates the 
 nostrils and causes laehrymation, and is sometimes employed 
 by inhalation to bring the system under the influence of 
 iodine in chronic bronchitis and phthisis. 
 
 METHYLIC ETHER (CH 3 } 2 0. 
 
 Methylic ether is a colorless and very inflammable gas, 
 heavier than air, of an oppressive odor. It is soluble in 
 water, wood spirit, alcohol, and ether. A saturated solution 
 in ether, at 32° F., has been recommended by Dr. H. W. 
 Richardson, who experimented upon himself, and found 
 that there was no preliminary spasm excited in the larynx 
 or elsewhere. The pulse arose to ninety-six, and the anaes- 
 thesia was perfect; yet he objected to it, because it rapidly 
 volatilizes from its solution, and on account of its unpleasant 
 odor. Dr. Carter states: "In Dr. Richardson's own hands, 
 I have seen the various (new) ethers act perfectly well, pro- 
 ducing complete unconsciousness and relaxation of muscle 
 without either struggling or sickness, and without unpleas- 
 ant symptoms of any kind; but I cannot judge how far such 
 results may have been due to the qualities of the agents 
 employed, how far due to specially skillful or careful admin- 
 istration, or how far to the state of the patients themselves."* 
 
 BICHLORIDE OF METHYLENE (CH 2 C1 2 ). 
 
 Bichloride of methylene was discovered in 1840, but was 
 introduced by Dr. B. W. Richardson in LS(i7. For some 
 years it has received the fullest trials at Moorfields Oph- 
 thalmic Hospital, London, where they now use, almost 
 exclusively, sulphuric ether.' Within the two years' trial of 
 the bichloride of methylene in the hospital above referred 
 to, two deaths occurred without any indication of danger 
 from the state of the pulse or heart; in the last instance of 
 death, it occurred from the exhibition of one drachm and a 
 
 * In specific gravity, boiling point, etc, we have followed Prof.W"m. 
 Allen Miller's Elements of Chemistry, Part III, Organic Chemistry 
 (London: Longman, Green, Reader & Dyer, fourth edition, 1869), or 
 Prof. Mai sch's National Dispensatory (Philadelphia: H. C. Lea, 1879). 
 
64 ARTIFICIAL ANESTHESIA. 
 
 half of methylene to a healthy sailor, aged twenty-seven 
 years. It has been employed not only in short operations, 
 but also in such operations as ovariotomy. " Of this agent, 
 Dr. Jones,* of Cork, has had considerable experience, having 
 used it constantly for all minor operations in hospital and 
 private practice for over seven years. Hard drinkers or old 
 tipplers bore this form of anaesthetic badly, and on some 
 occasions he has been alarmed and compelled to desist from 
 its administration ; he also found it to be dangerous in old 
 cases of chest affection. His mode of administration was in 
 a conical gauze bag lined with flannel, and containing a 
 small sponge." 
 
 Mode of preparation. — Bichloride of methylene is both 
 difficult and expensive to make. It is prepared by heating 
 one part of methylic alcohol, two parts of common salt, and 
 three parts of sulphuric acid, and passing the gas through 
 water into a glass globe, into which chlorine gas is conducted 
 at the same time. The globe is drawn out below so as to 
 form a thin tube, which passes into one tubulure of a Woulfe 
 bottle, the second tubulure being connected by means of a 
 bent glass tube with a second Woulfe bottle, this second 
 bottle being placed in ice ; the other tubulure of this second 
 bottle is connected with a flask cooled by means of a freezing 
 mixture. The liquid which is condensed in the Woulfe 
 bottles is chiefly chloroform, while that in the flask is 
 almost pure methylene dichloride, or bichloride of methy- 
 lene. 
 
 Bichloride of methylene is a colorless fluid, having an 
 odor much like that of chloroform. It is pleasant to inhale 
 as a vapor, and produces very little irritation of the fauces 
 and air-passages. Its specific gravity is 1.344, and its boiling 
 point 105° F. From its easier evaporation, it requires freer 
 administration than chloroform ; and because of its denser 
 vapor, less quantity than ether. 
 
 I had a small quantity of it prepared by Dr. W. H. Greene, 
 a competent chemist ; and even with all his care the speci- 
 men contained chloroform. Its boiling point was 105° F. 
 Bichloride of methylene has no action on test-paper, is 
 
 * Medical Responsibility in the Choice of Anaesthetics. By H. M. 
 Jones, M. D., Surgeon to Cork Ophthalmic Hospital. Cork, 1876. 
 
BICHLORIDE OF METHYLENE. 65 
 
 soluble ill alcohol and ether, and is frequently mixed with 
 other ethers in England, this being easily accounted for by 
 the difficulty in making it, and its cost. These various 
 mixtures give us a clue to its unequal character in regard to 
 safety, in the hands of different experimenters. Its vapor 
 has a density of 3.012, and burns with a bright flame. It 
 has been tested by the late Dr. Washington Atlee, who did 
 not find it as satisfactory as his mixture of ether and chloro- 
 form. Six deaths have occurred from its use. There is no 
 doubt that it has many of the dangerous qualities of chloro- 
 form, as it belongs to the same chemical family, and death 
 results from syncope, with dilated pupils. 
 
 The bichloride of methylene is employed in the Samaritan 
 Free Hospital, of London ; and the officer in charge of the 
 anaesthetic states it to be very satisfactory. Junker's form 
 of apparatus is used for its administration. The mortality 
 from this agent is two in ten thousand, or one to live thou- 
 sand. .... 
 
 As I have stated above, the strongest advocate for the 
 bichloride of methylene or chloromethyl is Mr. J. Spencer 
 Wells,* who believes that with this agent he has had all the 
 advantages of complete anaesthesia, with fewer drawbacks 
 than any other; this is his experience of five years, and of 
 three hundred and fifty serious operations. He gives it 
 diluted with air by Junker's apparatus, and, from his doubts 
 of its composition, we suspect what he employs to be a mix- 
 ture of methylic alcohol and chloroform. These are his own 
 words: "Whatever may be its chemical composition, wl tether 
 it is chloroform mixed with some spirit or ether, or whether 
 it is really bichloride of methylene, I am still content with 
 the effects of the liquid sold under that name." 
 
 Dr. Taylorf also states that " a mixture of chloroform and 
 ether has been sold as bichloride of methylene. On shaking 
 this mixture with water, the chloroform is separated and 
 sinks." He reports three deaths from this agent, and the 
 allegation, therefore, that the vapor possesses any greater 
 degree of safety than chloroform in surgical practice, is nor 
 supported by facts. 
 
 ::: Meeting of British Medical Association, 1st; 
 f On Poisons, op. cit, p. 629. 
 
66 ARTIFICIAL ANAESTHESIA. 
 
 DEATH FROM THE BICHLORIDE OF METHYLENE. 
 
 Case 1. — A death from bichloride of methylene took place 
 at the Ipswich Hospital, England, which affords a remarkable 
 illustration of the relative safety of that drug and of ether. 
 The patient was fifty-six years of age, and was to have had a 
 necrosed bone removed from his leg. He was first given 
 the methylene, which was changed for ether, for some cause 
 which is not stated, but which may have been some alarming 
 symptom produced by the methylene. Having taken the 
 ether with safety until anaesthesia was obtained, the opera- 
 tion was proceeded with ; but, the patient being allowed to 
 wake too soon, the methylene was again resorted to; in 
 fifteen seconds he was dead. No ^>ost mortem examination 
 was made, but some ingenious person hazarded a guess that 
 there had been unobserved apoplexy; and the jury, happy 
 at any alternative except condemnation, adopted the hint, 
 and voted the death accidental, and the medical officers free 
 of all blame. A most unsatisfactory case in all its aspects, 
 and one which should please the medical officers inculpated 
 less than any one else; such a fatality may be hidden away 
 by such a verdict, but no one can be satisfied, without evi- 
 dence, that the case was not one of anaesthetic manslaughter. 
 — Medical Press, London. 
 
 Case 2. Pharmaceutical Journal, 1871, p. 875. Male, set. 
 forty. Given during an operation on the eye ; result, death 
 in five minutes. Post mortem, congestion of the lungs. 
 
 Case 3. Pharmaceutical Journal, 1871, p. 875. Male. In- 
 haled c,iss; result, death rapid. Post mortem, no special 
 post mortem appearances. 
 
 Case 4. Lancet, October 23d, 1869, p. 582. Mr. Marshall. 
 Male, let. thirty-nine; ^iss. The man was sitting in a chair 
 during the time of administration, and preparing for an 
 operation. Symptoms, pupils slightly dilated ; no stertor or 
 lividhy of countenance ; result, death. 
 
 Case 5. One of the most painful cases of death from the 
 vapor of methylated ether occurred in the Birmingham 
 Hospital, England, under Mr. Tait. A patient was about 
 to undergo the operation of ovariotomy; five drachms of 
 methylated ether in vapor were administered, to her on a 
 fold of a towel, by the resident medical officer. The pulse 
 suddenly stopped, the pupils became dilated, and respiration 
 
HYDROBROMIC ETHER AS AN ANAESTHETIC. 6/ 
 
 ceased ; all efforts at restoration were fruitless. On inspec- 
 tion, the heart and all the other organs were healthy, exeept 
 the ovary.— Lancet, July 5th, 1873, p. 23. 
 
 IODIDE OF METHYL (CH 3 I). 
 
 Tliis compound was discovered by Dumas and Peligot in 
 1835, and is made by combining phosphorus, iodine, and 
 methylic alcohol. A safer and more agreeable preparation 
 of it is made, according to Wanklyn, by mixing iodide of 
 potassium and anhydrous methylic alcohol in a retort, in 
 equivalent proportions ; dry chlorine gas is passed into the 
 mixture, which is then distilled, and the distillate agitated 
 with water and rectified. 
 
 Iodide of methyl is a colorless liquid of an ethereal odor. 
 Specific gravity, 2.199, at 32° F. ; it boils at 110° F., and 
 burns with difficulty , giving off violet vapors. This agent 
 was proposed in 1868 by Dr. B.W. Richardson as an ames- 
 thetic, but was found by him and by Prof. Simpson as unsafe. 
 It has been recommended as a local anaesthetic in cancerous 
 cases. 
 
 AMYLENE. 
 
 The vapor of this liquid was introduced by the late Dr. 
 Snow as a substitute for the vapor of chloroform. It pro- 
 duces a loss of sensibility without causing complete coma or 
 BtUpor. Its use has already led to at least two deaths, and 
 is, according to Dr. Taylor,-' not so safe an agent as chloro- 
 form vapor for surgical purposes. The only appearance met 
 with in one fatal case was an emphysematous state of the 
 lungs, or excessive dilatation of the air-cells {Medical Times 
 and Gazette, April 4th and 18th, 1857, pp. 332, 3<sl), and in 
 the other a distension of the right cavities of the heart with 
 dark fluid blood. There was no congestion of the brain, 
 and no smell of aniylene perceptible in the body. — Medical 
 Time* and Gazette, August 8th, 18o7, p. 133. 
 
 BROMIDE OF ETHYL OR HYDROBROMIC ETHER 
 
 (C 2 H 5 Br). 
 
 Bromide of ethyl (C 2 H 5 Br), or " hydrobromic ether," is a 
 
 colorless liquid, with an agreeable odor; it boils at about 
 
 *On Foisons, op. cit. p. 627. 
 
68 ARTIFICIAL ANESTHESIA. 
 
 40°.7 C. (105°.8 P.)i lias a density of J. 419 at 15° C. (59° P.); 
 the boiling point and density are, therefore, intermediate 
 between those of chloroform and sulphuric ether. 
 
 Properties. — Transparent and colorless liquid, heavier 
 than water (Serullas) ; specific gravity 1.40 (Lowig), 1.4733 
 at 0° (Pierre) ; vapor density 3.754 (R. Marchand J. per cm. 
 188); very volatile ; boiling point 40°. 7 C. when the baro- 
 meter stands at 757 mm. (Pierre) ; has a strong ethereal odor 
 and pungent taste (Serullas). According to Lb wig, its taste 
 is strongly and disagreeably sweetish, with a somewhat 
 burning after-taste. The vapor, when inhaled, exerts an 
 anaesthetic action, like chloroform (Robin, Compt. Read. 
 xxxii. 669). It is sparingly soluble in water, but mixes in 
 all proportions with alcohol and ether. 
 
 Decompositions. — 1. Vapor of hydrobromic ether passed . 
 through a glass tube at a low red heat is resolved into ethy- 
 lene and hydrobromic acid gas. 2. It burns with difficulty, 
 but with a beautiful green flame, which does not smoke, a 
 strong odor of hydrobromic acid being at the same time 
 evolved. 3. It is not decomposed by nitric acid, oil of vitriol, 
 or potassium. 4. With ammonia it yields hydrobromate of 
 ethylamine. 
 
 Bromide of ethyl absorbed by the respiratory passages 
 produces, according to M. Rabuteau,* of Paris, absolute 
 anaesthesia as rapidly, or even more rapidly, than chloro- 
 form. This result has been established with frogs, rabbits, 
 dogs, etc. After five minutes' (sometimes after two minutes' ) 
 inhalation, by means of a sponge saturated in bromide of 
 ethyl, dogs were completely anaesthetized ; the animals 
 recovered more rapidly than when chloroform was used. 
 
 Bromide of ethyl is not caustic, nor even irritant, when 
 compared to chloroform ; it can be ingested without diffi- 
 culty, and applied without danger, not only subcutaneously, 
 but to the external auditory meatus and to the mucous mem- 
 branes. In this respect it is preferable to chloroform, which 
 is very caustic, and to sulphuric ether, of which the ingestion 
 is nearly impossible. Introduced into the human stomach 
 in doses of from fifteen to twenty drops, bromide of ethyl 
 does not produce anaesthesia as when absorbed in sufficient 
 
 * Comptes Rendus, vol. lxxxiii. p. 129-J; Pharm. Journ. and Trans. 
 
HYDROBROMIC ETHER AS AN ANAESTHETIC. 69 
 
 quantity by the respiratory passages ; it soothes pain, tends 
 to induce sleep, and does not disturb the appetite. 
 
 This hydrobromic ether is sparingly soluble in water, and 
 water shaken with it acquires a pleasant taste and odor; 
 frogs placed in water so saturated undergo" anaesthesia in 
 ten or fifteen minutes. It is eliminated nearly entirely, if 
 not completely, by the respiratory passages, whatever may 
 have been the mode of absorption ; at most, only traces of it 
 are found in the urine when it has been introduced into the 
 stomach, and an extremely small quantity can be detected 
 in that secretion when it has been inhaled. Bromide of 
 ethyl does not decompose in the organism to form an alka- 
 line bromide. Bromide of ethyl is an anaesthetic agent, 
 possessing properties intermediate between those of chloro- 
 form, bromoform, and ether. 
 
 I was the first to experiment with this ether upon man. It 
 was prepared for me by Prof. J. P. Remington of this city, and 
 subsequently in larger quantity by Dr.W. II. Greene. This 
 ether was discovered by Berullas in 1827. It is produced by 
 action of bromine on alcohol in the presence of phosphorus. 
 
 The method which Mr. Remington first employed was 
 that of the celebrated chemist De Vrij, by distilling four 
 parts pulverized bromide of potassium, with five parts of a 
 mixture, of two parts strong sulphuric acid and one part 
 alcohol of ninety-six per cent. The Professor then made the 
 second sample of hydrobromic ether by a modification of 
 Person ne's process, replacing the phosphorus by amor- 
 phous phosphorus; but we found that the preparation had 
 a phosphoric taste and odor, and contained minute particles 
 of amorphous phosphorus. This amount of phosphorus 
 produced brain disturbance, and a peculiar odor of mustard 
 noticeable in the breath of those who inhaled it. 
 
 My first experiment was with a small quantity, and subse- 
 quently I used twenty-two ounces. I found it was colorless, 
 with an agreeable odor and pleasant taste: the boiling point 
 40°.9 C, and its density heavier than water. When inhaled, 
 it produced more of the agreeable effects of chloroform, and 
 did not increase the pulse over its normal beat, whilst its 
 action was very rapid. In the second state (because the 
 ether first prepared was not pure, i. e., free from traces of 
 phosphorus) it caused an intermission of the pulse every 
 
70 ARTIFICIAL ANAESTHESIA. 
 
 .second heat. Three teaspoonfuls were added to a pint of 
 water, and they sank to the bottom in globules ; and upon 
 being shaken, they were in part diffused without producing 
 any change in the color of the water. A large-sized lively 
 frog was then placed in this pintof water thus charged, and 
 he made numerous endeavors to get out of it, and it required 
 twenty minutes before he was fully under its influence. 
 The anaesthetic effect was most profound; even his heart 
 could just be felt making a most feeble effort, and his respir- 
 ations entirely ceased, as far as I could judge; he was per- 
 feetly relaxed; the extremities became a livid-red color, and 
 apparently lifeless, and no pinching or pricking was felt by 
 him. After the frog had been removed, he remained in this 
 state for fifty-eight minutes, and then began to make some 
 slight movements; and, when the hour was up, was able 
 to move about in a languid manner. 
 
 I made the following experiment with it in the ear: — 
 A teaspoonful was mixed with one of glycerine and water, 
 and was placed in the ear of a patient who was suffering 
 from otalgia. The patient stated it gave her some pain, 
 with a feeling of heat; but these sensations soon passed 
 away, and her pain was relieved. No inflammation or caus- 
 tic effects resulted from its use in the auditory canal, which 
 was very irritable. I attempted to use a small quantity of 
 chloroform on cotton in the same ear, but it could not be 
 borne in contact even for a few seconds, it caused so much 
 distress and irritation of the parts. A third use of it was by 
 inhalation, on a patient about to undergo a painful operation ; 
 it induced a slight feeling of nausea, and she was very rapidly 
 brought under its influence, and it did not produce the inter- 
 mission in the pulse as in the first case. 
 
 I administer hydrobromic ether by the mouth, triturated 
 with glycerine, gum-arabic in powder, or a small portion of 
 spermaceti, as it is so much heavier than water, and its 
 effect upon the mucous membrane is slightly irritating if 
 not given properly (mixed), as it produces a feeling of 
 warmth, and, as usual, eructation of gaseous ether. 
 
 I>. Ether Hydrobromic, xxlTV. 
 ( rlycerime, fSss. 
 
 Acacise pulv. oii. 
 
 M.— Aqua font, fSss. 
 
 Sig. f5i. ter diem. 
 
HYDROBROMIC ETHER AS AN AX. ESTHETIC. 71 
 
 It lias the soothing effects of the bromides on the brain, and 
 the same effects in relieving headache, ringing' in the ears, 
 or tinnitus aurium, i. e.,when there is no permanent organic 
 change in the ear. Tt has all the properties of sulphuric 
 ether in relieving eolie, flatulence, and hysteria, also asthma 
 and spasmodic cough. I have employed the hydrobromic 
 ether by inhalation, and as intra-tympanal injected vapor 
 in a number of cases in tinnitus aurium, where, in the most 
 of the cases the noises were of a nervous character, i. e., the 
 result of functional disturbance, with success; but as the 
 great majority of these cases of tinnitus arise and are kept 
 up by an altered condition of the middle ear,* the result of 
 excessive secretion of cerumen, blood, mucus, or pus, these 
 latter conditions must be relieved by local and general treat- 
 ment in conjunction with the hydrobromic ether, etc. I 
 prefer the hydrobromic ether to nitrite of amyl or hydro- 
 bromic acid, there being less risk than with the first, and 
 because of its having yielded better results than the acid in 
 my hands. The following cases will serve to illustrate its 
 advantage over chloroform as an anaesthetic, and for the 
 relief of tinnitus before referred to. 
 
 Case 1.— March loth, 1878. JuniataW.,aged eighteen; resi- 
 dence Pennsylvania; father living; mother died of congestion 
 of the brain. General health good ; both ears affected; ear 
 most affected was the left ; duration, three years; presumed 
 cause, cold ; lived near a damp mill ; has also suffered from 
 scarlet fever and measles; has no pain in the ears, but has 
 a rustling and pumping noise in her head. The only treat- 
 ment which she has had prior to visiting me, was washing 
 out by syringing the ears. The meatus of both sides were 
 free from even the normal secretion of cerumen ; membrana 
 tympani of both ears opaque, dull, sunken, and without any 
 light spot; eustachian tubes narrowed ; pharyngeal orifices 
 swollen, and the swollen mucous membrane on edges dis- 
 posed to close the faucial opening ; nostril of the left side 
 swollen and collapsed. Hearing distance of right ear, four 
 feet with a watch of thirty feet; hearing distance of left ear, 
 seven inches with the same watch. Stopping the ear pro- 
 
 * Tinnitus Aurium: Causes unci Treatment. By L. Turnbull; 2cl 
 edition. J. B. Lippincott & Co., 1876. 
 
72 ARTIFICIAL ANAESTHESIA. 
 
 duces dizziness; is subject to vertigo from slight causes; 
 has chronic pharyngitis. 
 
 Diagnosis. — Chronic catarrh of middle ear and tubes, with 
 congestion of labyrinth and semicircular canals, etc. 
 
 Treatment. — Careful use of eustachian catheter to inflate 
 middle ear to remove the mucus; attention to throat by 
 means of spray of carbolic acid, extract of pinus canadensis, 
 etc. Used bromide of potassium for some time without 
 much effect upon the noises, but with an improvement in 
 the hearing of the defective ear to double the hearing dis- 
 tance by the 27th of March. The alkaline treatment was 
 then changed to extract of belladonna, ergot, and hydro- 
 bromic acid, which was continued until May with less 
 vertigo, but the noises continued. As her memory was 
 more or less affected, the treatment was then changed to a 
 solution of phosphoric acid as a lemonade ; the eustachian 
 tubes were touched at their orifices with a solution of nitrate 
 of silver, of forty grains to the ounce of water, by means of 
 the author's eustachian forceps, and then medicated and 
 washed out through the nose by a solution of chloride of 
 sodium. The hearing further improved to three feet, and 
 the whole condition of the young person was improved ; 
 she had, however, still these noises. During May the spray 
 of chloroform, nitrite of amyl, sulphuric ether, and hydro- 
 bromic ether, were all at different times passed into the 
 middle ear by means of the eustachian catheter, and were 
 inflated freely by means of Politzer's air-bag fitting to the 
 orifice of the catheter. None of them even improved or 
 relieved the noises except the hydrobromic ether; when 
 fully under the influence of this agent the noises all disap- 
 peared, and after the effects had passed away she had not 
 the distress in her head or heart which she had under the 
 influence of chloroform, neither had she the disposition to 
 faint which was produced by chloroform. Her recovery 
 from the anaesthetic influence of the hydrobromic ether was 
 prompt and complete, while it required fully one hour to 
 recover from the chloroform, after which, for a whole day, 
 she felt faint and distressed. 
 
 Case 2.— April, 1878. T. L., aged fifty-seven, of Philadel- 
 phia, a gentleman of means, who has suffered from pericard- 
 itis, with irregular action of the heart, also with flatulent 
 
HYDROBROMIC ETHER. t6 
 
 dyspepsia and distressing pains in the lower bowels and 
 rectum. He has had to resort to large doses of anodynes, 
 with carminatives, for relief, and has had to be placed, at 
 times, under the influence of sulphuric ether and chloroform; 
 but the former agent always, from the first, caused great 
 distress, clammy skin, and cough, owing to oppression fol- 
 lowing their use ; with the latter, by distress in his head 
 and heart, and intense throbbing of the vessels of the brain. 
 I placed this patient three different times under the influence 
 of hydrobromic ether, with entire relief to his pain and less 
 distress of his heart, and more rapid elimination of the drug 
 from his system. 
 
 Case 3. — September, 1877. Jas. W. H., aged twenty-one, 
 a mechanic, while making some alterations in my house, 
 had been suffering with acute periostitis of the jaw, and, 
 owing to exposure to cold, the inflammation became so in- 
 tense and distressing that he had to give up his work. On 
 examination it was found to involve the antrum highmo- 
 rianum, and I feared pus had formed in it. I proposed at 
 once to extract the tooth, and cut down to the bone; he was 
 very timid and nervous, heart irregular and pulse fluttering, 
 and desired to have an anaesthetic. Fearing the effects of 
 chloroform, and the long period consumed in such cases by 
 the administration of sulphuric ether, I proposed this new 
 agent to him, and he agreed to it. I placed upon an Allis' 
 inhaler f5iij of hydrobromic ether, and, although he breathed 
 it with great irregularity, in the course of three minutes he 
 was fully under its influence. I extracted the tooth, and 
 cut through the bone into the antrum, which incision was 
 followed by a free discharge of blood and pus without his 
 evincing the least indication of pain. His recovery was in 
 about the same time as was consumed in the administration, 
 and it was so complete that he was able to resume his occu- 
 pation after an hour's rest. He had no vomiting, not even 
 nausea following it. 
 
 Case 4.— M. P., aged twenty-three years, student of medi- 
 cine ; health perfect, pulse sixty-eight, respiration normal, 
 not at all nervous. On an empty stomach, inhaled, by an 
 Allis inhaler, f5iiss of hydrobromic ether, producing com- 
 plete anesthesia in two minutes and a half; pulse not 
 influenced in the least, temperature normal, respiration but 
 
74 ARTIFICIAL ANESTHESIA. 
 
 slightly accelerated. !So complete was the influence of the 
 anaesthetic that the cornea could be touched with the tinker 
 without causing motion of the eyelids. Snoring loudly. 
 From the time of discontinuing the administration to com- 
 plete consciousness just two minutes, so that he was able 
 to walk and talk coherently ; had, after rising from the 
 recumbent posture, slight vomiting of mucus. 
 
 Case 5. — With two drachms of hydrobromic ether com- 
 pletely anaesthetized a child of six years of age in about 
 three minutes. While fully under its influence, slit up both 
 canaliculi.and introduced Bowman's probes, without evi- 
 dence of pain ; consciousness returned immediately after. 
 The ether was withdrawn during the operation ; no vomiting 
 or other bad symptoms. 
 
 Case 6. — After the administration of about four drachms 
 of hydrobromic ether, Allis' inhaler, secured sufficient anaes- 
 thesia to lacerate a soft cataract in a child three years of age. 
 No other anaesthetic during the operation. Xo bad symp- 
 toms, no vomiting, and rapid return to consciousness. 
 
 Case 7. — Administered to a woman, by Allis' inhaler, 
 hydrobromic ether. This patient was feeble, but heart nor- 
 mal ; subject to bronchial asthma; stomach was fortunately 
 empty. Complete anaesthesia was induced in three minutes, 
 and kept up for five minutes, during removal of cystic tumor 
 from her head; after operation there was slight vomiting of 
 mucus. 
 
 Case 8. — A woman, aged twenty-five, with a peculiar 
 hyper-sensitiyeness of the whole alimentary tract, with ex- 
 cessive torpidity of the bowels, retroversion of the uterus, 
 and neuralgia of the splanchnic nerves, with dreadful suf- 
 fering. With a little less than one ounce of hydrobromic 
 ether there was produced complete anaesthesia in four 
 minutes, long enough for placing of a pessary to relieve the 
 above symptoms. During the administration the pulse was 
 but slightly accelerated ; return of consciousness was accom- 
 panied 1 >y excessive gagging and vomiting of large quantities 
 of mucus, great burning in stomach and throat, severe 
 headache, cold perspiration, weak and rapid pulse, all of 
 which continued for twenty-four hours, with more or less 
 severity. Both sulphuric ether and chloroform had previ- 
 ously, on several occasions, produced similar symptoms, 
 
HYDROBROMIC ETHER. 75 
 
 but not so .severely. Many of the distressing symptoms in 
 this ease were owing to the peculiar sluggishness of the 
 intestines, due to the irritation caused by congestion and 
 change of position of the uterus, and this extending to the 
 ovaries, and passing up to the sensory nerves of that organ, 
 thence to the nerve centres, whence it was reflected down 
 to the splanchnics. At the time they are thus excited, and 
 simultaneously with the arrest of the peristaltic action, the 
 blood-pressure rises in the aorta and its branches, from the 
 blood being driven out of the intestinal vessels by their 
 contraction. In such eases large doses of opium would be 
 the best remedy in pills of one grain, twice a day, with hot 
 fomentations over the abdomen as a laxative. 
 
 Case 9. — Child three years old, and perfectly healthy ; 
 had lacerated soft palate by running into it a pointed piece 
 of wood. Two slight sprinklings of hydrobromic ether on 
 a napkin sufficiently relaxed the patient, and produced such 
 temporary anaesthesia as to permit touching of cornea and 
 thorough examination and stitching of the wound, and full 
 examination of fauces. 
 
 Cask 10.— March 21st, 1879, Dr. Wm. M. A., ;et, twenty- 
 three, was suffering the intense pain caused by a furunculous 
 abscess in the anterior wall of the meatus auditoris. He had 
 used leeches over the same region, and had lost a consider- 
 able amount of blood; hence his condition was not the best, 
 as he was weakened by the loss of blood as well as by pain. 
 Administered hydrobromic ether upon a towel. 
 
 "A small quantity of hydrobromic ether was placed on a 
 towel, and by taking long inspirations, and expiring in the 
 same manner, T was very soon under the effects; I could 
 hold up the towel to my face no longer, and my hands 
 dropped down to my side. Dr. Charles Turnbull then used 
 the knife: I could feel it grate as he cut, but I experienced 
 no pain. I do not think there was a total loss of conscious- 
 ness, as 1 could see and hear what was going on around me. 
 The hydrobromic ether did not have the nasty smell of the 
 sulphuric ether. 1 had often taken this ether for purposes of 
 experiment, and when I came out I most always had head- 
 ache for some hours after. The after-effects of hydrobromic 
 ether in my case, after the first rive minutes, were nothing." 
 
 Case 11. — 0. E., aged twenty years; abscess of left lachry- 
 
F6 
 
 ARTIFICIAL ANAESTHESIA. 
 
 mal sac. Inhaled f5ii on a towel; when under the influence 
 of the hydrobromic ether hands fell to side as with Dr. A. ; 
 pulse 120 after operation, and before 100, and after first five 
 inspirations 160. Stood up after operation (i. e., opening 
 and putting in a tent of linen), and said he felt the cut — the 
 cold steel — but no pain ; and after moving about, felt nothing 
 from the ether. No sickness nor giddiness. 
 
 Case 12. — Mary Adams, set. twenty-five years, single, was 
 suffering from the great deformity of symmetrical tumors of 
 a large size on both ears, as may seen by figure 0. They had 
 
 been removed six years previous, but had again returned of 
 increased size. As the tumors involved the whole of the lobe 
 and part of the helix and antitragus, it required tedious dis- 
 section to save all the skin and get rid of the fibrous tumor,* 
 
 * See page 135, A Clinical Manual of the Diseases of the Ear, by the 
 writer, for a full account of the cause and pathology of these tumors. 
 
USE OF HYDROBROMIC ETHER. 77 
 
 which was almost as hard as cartilage, and avoid deformity. 
 The patient was under the influence of sulphuric ether for 
 one hour, and eight ounces were employed. With the second 
 she passed more quickly under the influence of the hydro- 
 bromic ether, and the operation was completed in half an 
 hour, stitching and everything, with the use of two ounces 
 of the ether. The incisions both healed by first intention, 
 and the patient has no appearance of the deformity, with 
 both ears of smaller size but very natural appearance. 
 
 Case 13. — March 25th, 187!). Same patient, Mary Adams. 
 The operation was performed by Dr. L. Turnbull, assisted 
 by Drs. Angney, Samuel R. Sterling, and C. S. Turnbull. 
 The case was carefully watched, in order to test the influence 
 of the hydrobromic ether on the pulse, respiration, general 
 condition, etc., of the woman. Before the operation the 
 pulse was 100 and the respiration 28, but this was somewhat 
 excessive, and was doubtless caused by the patient running 
 up and down two flights of stairs several times just before 
 the hydrobromic ether was given; her normal pulse is 72, 
 and respiration 20. Dr. C. S. Turnbull counted 160 for first 
 minute, 100 for the fourth, 1(50 for the sixth, 100 for eighth ; at 
 the sixth minute the respiration was 30; from the fifth to 
 tenth minute there was muscular rigidity. Pulse at twenti- 
 eth minute, 84 beats in minute; twenty-two minutes, i)() ; 
 twenty-five minutes, 100; thirty minutes, 90. Head and 
 face were cold, and there was some perspiration after the 
 ether was withdrawn. She said she felt no pain, although 
 at times there was a state of muscular rigidity ; the patient 
 also stated that she did not feel so badly after this ether 
 had been withdrawn as she did after she took the sulphuric 
 ether, on the previous occasion, for removal of the same kind 
 of tumor from the other ear. The hydrobromic ether was 
 given while the woman was in a sitting posture, and she 
 Avas able after its removal to take off her shoes and go to bed 
 without any assistance ; she was not able to do this after 
 the other operation. The pupils did not seem to be influ- 
 enced. This second operation took one-half the time of the 
 first. 
 
 Case 14.— Miss E. G.,set. seventeen. It was noticed, March 
 loth, 1879, that the walls of external meatus were slightly 
 swollen, but there was no pain; and on 19th furunculous 
 
<3 ARTIFICIAL AX.ESTHES1A. 
 
 abscess was diagnosed just within external meatus, which 
 was so much swollen that even the smallest speculum could 
 not be introduced, there also being considerable pain. Ap- 
 plied in the external ear a piece of cotton saturated with warm 
 wine of opium, and directed same to be continued every few 
 hours, with applications of cloths wrung out of hot water. 
 During the time for the next three days she suffered very 
 much, when she again presented herself at the clinic, and 
 she was immediately given, by inhalation from a folded 
 towel, f5ij of hydrobromic ether, under the influence of 
 which she passed without the least difficulty of respiration 
 or any muscular resistance whatever; the time occupi.ed 
 did not exceed three minutes. The ether was now suspended 
 and the abscess oj)ened by Dr. L. Turnbull, the incision 
 being made down to the bone ; the part bled very freely. 
 Hemorrhage was encouraged by injections of warm water, 
 when the patient recovered consciousness, but with slight 
 hysterical symptoms, which very soon passed off. After 
 bleeding had ceased, a warm application of wine of opium 
 was made, and the same treatment directed to be continued 
 as prescribed on 19th hist. ; she was given a prescription of 
 quinia and strychnia sulph., guarded with a little hydro- 
 bromic acid. Patient returned to-day (2 2d) looking very 
 much improved, and stated that yesterday she did not suffer 
 from sick stomach nor headache, and was only affected with 
 slight drowsiness during remainder of day, and slept well 
 during the night, having no necessity to make use of the 
 opiate prescription given her to take in case of insomnia. 
 The meatus but slightly swollen, and by no means as pain- 
 ful as yesterday, but still precluding the introduction of the 
 speculum. 
 
 Case 15. — E. S., patient in Jefferson Medical College Hos- 
 pital, superintendent of construction train on Pennsylvania 
 railroad, has suffered with pain and inflammation in right 
 ear since December, 1878, extending upwards over right side 
 of cranium, and downwards over right mastoid region and 
 neck. In December last was exposed to inclement weather, 
 when soon thereafter the trouble appeared. Pain severest 
 in afternoon ; sleep greatly disturbed ; tongue coated and 
 bowels constipated. Previous health good; never before 
 had a discharge from ears ; no history of syphilis ; speculum 
 
CONCLUSIONS CONCERNING HYDROBROMIC ETHER. 79 
 
 examination reveals polypoid tumor, situated deep within 
 and rilling the right auditory canal, with a semi-purulent 
 inodorous discharge; swelling and redness of mucous mem- 
 brane, with exquisite pain upon pressure; hearing affected. 
 March 26th, Dr. Laurence Turnbull decided upon removal 
 of tumor, and, after consultation with Prof. S. D. Gross, the 
 patient was anaesthetized by Dr. Drake with hydrobromic 
 ether ; and Dr. Turnbull introduced ear speculum, passing 
 a wire-loop over the tumor, and twisted it from its base, 
 followed with but little hemorrhage. About one ounce of 
 the hydrobromic ether was used in producing complete in- 
 sensibility, and the time consumed in doing so was about 
 five or six minutes. During the administration of the an- 
 aesthetic, the pulse increased to eighty-four for the first two 
 minutes, and ninety-six was reached during the last two 
 minutes; breathing was not interrupted, nor was there any 
 unpleasant effects after its use. Time consumed in removal 
 of the tumor, about one minute or an additional half. Pa- 
 tient was ordered perfect quietness, with one-quarter grain 
 of morphia under the skin and a blister over the swelling, 
 with iron and quinine internally. 
 
 Conclusions. — From the fourteen cases first rejDorted in my 
 work before referred to, and the seven new cases, making 
 twenty-one in all, I would deduce the following: — 
 
 Shortest time taken to place a patient 
 under the anaesthetic influence, 
 
 Longest time, 
 
 Average time, 
 
 Smallest quantity of hydrobromic ether, two inhalations 
 from sprinkled handkerchief. 
 
 Largest quantity of hydrobromic ether employed, two 
 ounces. 
 
 Vomiting occurred in three cases after the administration ; 
 excitement (hysterical) in two cases ; prostration in one case, 
 but no alarm felt concerning the patient's life ; no asphyxia 
 nor fainting. 
 
 It will be noticed that, as vet, I have not resorted to its 
 
 mutes. 
 
 Seconds. 
 
 
 
 30 
 
 5 
 
 00 
 
 1 
 
 30 
 
 
 00 
 
80 ARTIFICIAL ANAESTHESIA. 
 
 use in a protracted operation. The advantage of this agent 
 is the rapidity of its elimination from the system by the 
 respiratory passages. 
 
 Action on the lower animate.— Rabbits and dogs are with 
 difficulty brought under the influence of chloroform. Hy- 
 drobromic ether produces absolute anaesthesia with rabbits, 
 dogs, and frogs, much more rapidly than chloroform does. 
 With chloroform the shortest time required to place a small 
 dog under anaesthetic influence was two minutes and thirty 
 seconds; while with hydrobromic ether the shortest time 
 with the same animal was but two minutes, and in from 
 two to five minutes the animal had recovered all its powers. 
 With a tin inhaler and a sponge saturated with bromide of 
 ethyl dogs can be completely anaesthetized. With frogs, a 
 sponge saturated with the same is placed under a bell-glass; 
 water can be so charged with this variety of ether that a 
 frog can absorb it through the skin; this requires a much 
 longer time. 
 
 Action on man. — There is but very slight increase of the 
 pulse <>r the arterial tension. There is a pricking feeling of 
 the skin at the elbow and in the hands, with a rapid loss of 
 power to move; the brain is comparatively free; pupils not 
 affected ; skin in some few instances cold and moist, but in 
 the majority of cases natural. It differs from ordinary ether 
 in the stage of excitement being short, the sedation and 
 subsequent elimination rapid, in certain patients leaving a 
 peculiar odor of mustard about the body of the patient; this 
 I think was owing to a decomposition of the phosphorus. 
 
 BICHLORIDE OF ETHYLENE (C 2 H 4 Ch 2 ). 
 
 (DITCH LIQUID.) 
 
 Bichloride of ethylene is a colorless, oily liquid, having 
 an ethereal odor resembling that of chloroform and a sweet- 
 ish taste; specific gravity 1.270, boils at 185° F. ; sparingly 
 soluble in water, and freely soluble in alcohol and ether; 
 it is inflammable, and burns with a yellow flame with a 
 green border. This agent, when tested by Prof. Simpson, 
 was found so irritating to the throat that it could not be 
 used long enough to induce the anaesthetic state. By the 
 action of chlorine upon Dutch liquid a number of chlorinated 
 
ETHIDENE DICHLORIBE. 81 
 
 compounds may be obtained, which are isomeric with the 
 chlorinated compounds. 
 
 ETHIDENE DICHLORIDE AS AX ANAESTHETIC. 
 
 The following cases and remarks are given in the Medical 
 Times and Gazette, January 18th, 1879, by Mr. Thomas Bird, 
 M. R. C. S. E. :— 
 
 Case 1. — Man, aged nineteen ; a nervous patient. Pulse 
 high at the commencement of the administration (98); in 
 two minutes the pulse was 120, described as "full and 
 bounding;" in the fourth minute it fell to 98, and the 
 operation (tattooing opaque cornea) was commenced; in the 
 eighth minute the pulse fell to 76 — the anaesthetic was dis- 
 continued, the operation being finished; in the ninth and 
 commencement of the tenth minutes the patient sjx>ke, and 
 answered the question as to where he lived. One drachm 
 and a half of the ethedene dichloride had been used. 
 
 Cask 2. — A woman, aged fifty. In four minutes iridec- 
 tomy was commenced, and finished in the fifth minute; 
 in five minutes and a half the patient slightly moved her 
 head in answer to question, and retched at the end of the 
 fifth minute. The pulse 90 at the commencement; fell to 
 SO, and never again exceeded 94. 
 
 Cask .°>.— A child, aged three months. In this case, owing 
 to the age of the patient, although I gave the anaesthetic in 
 the same way, I gave it very slowly and cautiously. In 
 three minutes iridectomy was performed; the child recov- 
 ered perfectly in seven and a half minutes. Pulse not taken. 
 
 In the three following cases Mr. C. J. Parke, one of the 
 four who had kindly assisted me, now took the apparatus, 
 Avhile I took the pulse and general observations myself; 
 hitherto I had been quite satisfied with the breathing. 
 
 Case 4. — A child, aged two years and nine months. Time 
 of operation, four minutes and a quarter ; half a drachm used. 
 
 Case 5. — Boy, aged thirteen. One minute and a quarter, 
 patient amesthetized ; pulse 108. Amesthetic discontinued 
 at the end of the fifth minute; a drachm and a half used. 
 Pulse became fuller and more compressible at the end of the 
 fourth minute. Sick afterwards. 
 
 Case 6.— A man, aged twenty. This patient was under 
 
82 ARTIFICIAL ANAESTHESIA. 
 
 the anaesthetic sixteen minutes ; the operation was extirpa- 
 tion of eyeball.' Pulse reached 110, with some slight excite- 
 ment and conscious struggling, until and when completely 
 anaesthetized, in the ninth minute, the face was flushed as 
 after nitrite of amy 1 ; the pulse fell to 72. The anaesthetic 
 had been given as fast as possible, with the Junker appara- 
 tus ; five drachms were used altogether ; length of time of 
 administration, sixteen minutes. Pupil was contracted till 
 the end of administration, but responded to light. 
 
 Remarks. — Ethidene dichloride is hardly distinguishable 
 from chloroform in appearance or odor, except that it may 
 be a little sweeter and less pungent ; of the latter there is 
 no doubt, as the method of administration showed in com- 
 parison with chloroform and methylene bichloride. The 
 intelligence seems confused almost immediately, the ordin- 
 ary reflex phenomena remaining apparently a longer time 
 than with either chloroform or methylene bichloride. When 
 these patients were deeply anaesthetized, as in cases 1 and 6, 
 the breathing was affected, becoming spasmodic and shallow 
 (similar to that which I have noticed with animals under 
 acetal, with which I have brought a mouse's respirations 
 down to forty, followed by complete recovery); the pulse low- 
 ered, though much fuller in character and more compressible. 
 All presented the appea ranee of a strong stimulant to the 
 heart's action at the commencement of the administration ; 
 with regard to sickness, only one was actually sick. I think 
 the anaesthetic is a good one for children, as being less rapid 
 and pungent in its effect than usual.* 
 
 * The Scientific Grants Committee of the British Medical Associa- 
 tion have received from a special committee a repor.t (British Medical 
 Journal,. lanuary 4th and 25th, 1879) upon the action of this anaesthetic, 
 in which it is claimed that dichloride of ethidene presents all the 
 advantages of ether, without any of its disadvantages; and that the 
 following opinion of Steffen, given inBuiz's Evidence of Therapeutics, 
 p. 39, is correct in most particulars : " It is said to have the following 
 advantages over chloroform, which it resembles in its ultimate action, 
 namely, a pleasanter smell, the power of producing narcosis more rap- 
 idly, as well as without excitement or vomiting, more rapid recovery 
 without after-effects, and altogether less danger." In their experience, 
 narcosis has not been produced more rapidly than with chloroform ; 
 but rapidity of narcosis depends very much on the mode of adminis- 
 tration. 
 
OXYGEN, HYDROGEN, AND NITROGEN GASES. 83 
 
 CHLORIDE OF ETHYLENE— ANAESTHETIC 
 FOR CHILDREN. 
 
 The Hospital Gazette gives a notice of Prof. Demme's 
 article on this subject in the Central Zeitung fur Kinderheil- 
 kunde, September 1, 1878. The chloride of ethylene (which 
 chloride not stated), highly recommended as a safe anaes- 
 thetic by Dr. Liebreich, was used in twenty cases. While 
 under its influence a child of eighteen months had a sudden 
 and severe attack of asphyxia, which made it necessary to 
 resort to the use of artificial respiration. (The Professor in 
 this case may have used the chloride of ethyl, formerly 
 known as muriatic ether, the effects of which are almost 
 identical with sulphuric ether.) 
 
 OXYGEN, HYDROGEN, AND NITROGEN GASES 
 AS ANAESTHETICS. 
 
 In a notice of the author's work, it was stated that Dr. Gray, 
 of Richmond, Va., had published in August, 1874, some ob- 
 servations regarding pure oxygen as an anaesthetic for short 
 operations. I at once wrote to the Doctor, who sent me his 
 paper, adding the following remark: "It is % my purpose 
 to continue my experiments with oxygen gas this winter, 
 and I shall be happy to furnish you with a statement of 
 results." 
 
 I have carefully read the article referred to, and found 
 that the Doctor had made six experiments with the gas, the 
 only test cases being in two patients. The first, a colored 
 boy, took three gallons; pulse 80, respiration 24, temperature 
 98° F. In one minute and a half the pulse rose to 104, very 
 feeble and intermitting; patient profoundly unconscious. 
 Dr. Wood extracted one root, a superior molar ; no complaint 
 whatever was made, nor was there the slightest evidence 
 or symptom of pain. The remaining two roots were now 
 quickly taken out, with a scarcely audible groan on the part 
 of the patient. In two and a half minutes he was fully 
 reinstated, and said he did not know when the tooth was 
 taken out ; that his first sensation u was pleasant," the last 
 "like that other gas," alluding to nitrous oxide, which he 
 had taken on a former occasion. He remained seated in the 
 
s 4 ARTIFICIAL ANAESTHESIA. 
 
 dental chair, and in ten minutes his pulse was SO, regular ; 
 respiration 16, temperature (interclavicular space) 101° F. 
 
 In the sixth experiment, Dr. Wood administered to Mrs. 
 A. B. two gallons of the same gas, and while under its 
 influence extracted eight anterior inferior teeth (tempera- 
 ture, pulse, or respiration not taken). The lady declared 
 she "suffered no pain whatever." 
 
 These were the only minor surgical operations undertaken 
 under the influence of the gas. In the other four cases the 
 true effects of the gas were manifest, i. c, slight exhilara- 
 tion but no intoxication, lips and forehead purple, partial 
 asphyxia, and in one case great cardiac excitement differing 
 from that of nitrous oxide gas, with which the gentleman 
 was very familiar, having frequently inhaled it. 
 
 I feel satisfied from these experiments,* and those of 
 Pfluger and others .reported by Prof. Carpenter, that pure 
 oxygen gas is not a true anaesthetic. He states : * " The res- 
 piration of pure oxygen for short periods, seven to seventeen 
 minutes in man, produces no effect either in the rapidity of 
 the pulse nor upon the temperature of the bod}-, and scarcely 
 any more of this gas is absorbed than, under ordinary cir- 
 cumstances, which, as Pfluger has shown, is owing to the 
 fact that arterial blood is charged, normally, with nine-tenths 
 of the whole amount of oxygen it can take up. In small 
 chambers the whole of the oxygen is used; but if the cham- 
 ber be large, the amount of carbonic acid produced proves 
 fatal before the complete consumption of the oxygen. Thus, 
 Bert observed that when an animal was placed in an atmos- 
 phere of pure oxygen, with no provision for the removal 
 of the carbonic acid eliminated, death took place when the 
 proportion of this gas amounted to from twenty-six to thirty 
 per cent., although the quantity of oxygen (seventy to eighty 
 per cent.) was still found; when all the carbonic acid elimi- 
 nated was removed, death occurred in mammals when the 
 amount of oxygen had fallen to two per cent., and in birds 
 when it was reduced to between three and four per cent. 
 He further found that animals made to breathe oxygen at a 
 pressure of five or six atmospheres, or which are exposed 
 
 * Effect s of respiration of pure oxygen. Carpenter's Principles of 
 Human Physiology, 1876. p. 403. 
 
OXYGEN GAS AS AN ANJESTHETIC. 85 
 
 to ordinary air at a pressure of twenty atmospheres, fall into 
 violent convulsions which last even after the pressure has 
 been reduced to the normal. It would therefore appear 
 that the oxygen, in entering the body at this high pressure, 
 forms one or more compounds with some of its constituents, 
 acting like strychnia." 
 
 Nitrogen and hydrogen may be considered as indifferent 
 gases, proving fatal in a state of purity by permitting the 
 accumulation of carbonic acid in the blood ; as the carbonic 
 acid replaces the oxygen, patients become livid, and to every 
 external sign utterly insensible. All the true anaesthetics 
 produce more or less asphyxia, but must have another pro- 
 perty, that of producing exhilaration or intoxication. 
 
 Having read with pleasure the experiments of Dr. A. H. 
 Smith, of New York, on oxygen gas, I addressed him the 
 following note, which explains itself; also, his answer. 
 
 Philadelphia, November 25th, 1878. 
 
 Dr. Andrew H. Smith, 
 
 Dear Sir: — In the second edition of my little work on 
 "Anaesthesia," I am desirous of giving some definite infor- 
 mation in regard to oxygen gas ; and having read with 
 pleasure your experiments originally published in the New 
 York Medical Record of January 2d, 1871, would be glad to 
 be informed if you noticed any positive anaesthetic effects 
 from its inhalation, as claimed by Dr. Gray, of Richmond, 
 Va., and published by the Virginia Medical Monthly for 
 August, 1874. 
 
 Yours, etc., 
 
 L. TUBNBULL. 
 
 110 East Thirty-eighth Street, 
 
 New York, November 26th. 
 Br. L. Turnrull, 
 
 Dear Sir : — I have your note of yesterday, and gladly 
 respond to your inquiry. 
 
 In all my experiments with oxygen, and I often gave it 
 very freely, I never observed any anaesthetic effect. I have 
 not means of referring to Dr. Gray's article, but I suspect 
 that in cases in which anaesthesia has been observed while 
 oxygen was being inhaled, it was due to a number of very 
 
86 ARTIFICIAL ANAESTHESIA. 
 
 deep inspirations succeeding each other rapidly, which we 
 all know will produce a slight degree of anaesthesia even 
 when common air is respired. I have often breathed pure 
 oxygen for several minutes at a time, without experiencing 
 anything more than a slight sensation of pressure or weight 
 above the eyes ; a few patients have complained of slight 
 giddiness. 
 
 I transmit with this a copy of my pamphlet* on oxygen, 
 which you may not have seen. 
 
 Yours, sincerely, 
 
 ANDREW H. SMITH. 
 
 * Oxygen Gas as a Remedy in Disease; second edition. New York: 
 D. Appleton <fc Co., pp. 50, 1870. 
 
CHLOROFORM. 
 
 CHAPTER IV. 
 
 Chloroform, chemical composition, impurities, tests— Physiological 
 action. Toxicological effects. Employment of Chloroform in labor. 
 M. Pichard. Congress at Geneva. Drs. Lusk, Wilson, and Smith. 
 Statistics of death from Chloroform. Table of one hundred and sixty 
 deaths, with comments. Xitrite of Amyl as an antidote to Chloro- 
 form, observations and cases, by Drs. Richardson, Burrall, Lane, and 
 Munde. Mixed narcosis. Use of Morphia before inhalation of Chloro- 
 form. Therapeutical applications. 
 
 CHLOROFORM. 
 
 Chloroform; dichlorinated chloride of methyl; terehlo- 
 ride of formyl, CHCP. Chloroform was discovered in 1831 
 almost simultaneously by Soubeiran in France, Liebig of 
 Germany, and Guthrie of Sackett's Harbor, New York. Its 
 true constitution was discovered by Dumas, in 1834. 
 
 The ordinary method of preparing chloroform is by the 
 distillation of alcohol with chloride of lime. In its pure 
 state it is a transparent and colorless liquid, having a specific 
 gravity of 1.499; it has a pleasant and penetrating odor, and 
 a sweet, fiery taste. It decomposes when exposed to air 
 and light, with the formation of chlorine and hydrochloric 
 acid, and becomes unfitted for inhalation ; it should be kept 
 in tin cases, in a dark place or under water. According to 
 Prof. Maiseh,* if pure chloroform is reduced to 1.484 with 
 one per cent, of alcohol, it remains unaltered in diffused 
 light for years, and for ten hours in direct sunlight, provided 
 all moisture has been excluded. The products of the decom- 
 position have the suffocating odor of phosgene gas, COCT-. 
 Partially decomposed chloroform may be restored to its 
 original purity by agitating it with a solution of sodium 
 carbonate, and rectifying it over lime. AVhen chloroform is 
 shaken with an equal bulk of sulphuric acid, no color should 
 be imparted to either liquid, even after remaining in contact 
 
 National J >i*pensatory. article Chloroform, p. 398. 
 
88 
 
 ARTIFICIAL ANAESTHESIA . 
 
 for twenty-four hours ; when it is agitated witJi an aqueous 
 solution of nitrate of silver, a white precipitate of chloride 
 of silver is not produced, providing the chloroform be pure. 
 
 Chloroform prepared from wood-spirit is specifically light- 
 er, and has an empyreumatic odor from acids or chlorinated 
 oils; and gives rise, when inhaled, to unpleasant sensations, 
 with prostration and headache. Many chloroform accidents 
 are doubtless due to impurities in the drug. A French 
 chemist, M. Perrin, states that commercial chloroform, in 
 France, has become much less reliable and more dangerous 
 of late years ; sleep is often difficult to get with it, and he 
 mentions some cases in which the attempt had to be given 
 up, after trying successively the drug procured in several 
 shops ; it often produces disorder of the stomach, moreover 
 (vomiting, etc.), and twice in his recent experience it caused 
 a state of apparent death, which was followed by extreme 
 exhaustion. 
 
 Impure chloroform is recognized by the disagreeable odor 
 it leaves after evaporation on a cloth which has been mois- 
 tened with it, and by the yellow or brown color which it 
 imparts to pure oil. A new test has lately been introduced 
 for chloroform made from methylated spirit. It consists 
 in mixing a solution of nitrate of silver (seventeen to one 
 thousand) with ten times its volume of chloroform, and 
 allowing it to stand for a few days, shaking it now and then ; 
 when, if methylated spirit (not up to standard of 128 to 130° 
 C.) has been used, a deposit of*a reddish-brown color will 
 be found at the bottom of the vessel ; with chemically pure 
 chloroform there is no coloration. The smallest quantity 
 of chloroform can be easily detected by adding to the liquid 
 to be tested a monaniine'(or aniline) and an alcoholic solu- 
 tion of caustic potash ; when it is present in large quantities, 
 the peculiar odor of carbylamine is given off at once, or 
 after gently heathlg* when only traces are present. Pure 
 chloroform placed upon oil of vitriol produces a contact- 
 surface, convex downwards; impure chloroform gives a 
 plane contact-surface. To detect the presence of alcohol a 
 little chromic acid must be added to it, which will cause the 
 chloroform to become green if alcohol be present; or, if a 
 solution of molybdic acid in sulphuric acid be added, to 
 become blue. Chloroform dissolves slightly in water, im- 
 
PHYSIOLOGICAL ACTION OF CHLOROFORM. 89 
 
 parting its sweet taste to the liquid ; it mixes in all propor- 
 tions with alcohol. 
 
 PUR LFIED CHLOROFORM— PHYSIOLOGICAL 
 • ACTION. 
 
 When one per cent, of chloroform is mixed with four or 
 five per cent, of atmospheric air, it becomes charged with it, 
 and in this form it is usually employed as an anaesthetic. 
 It should be administered by means of a starched napkin, 
 folded into a funnel shape, or by an inhaler,* held closely 
 over the nostrils and mouth during inspiration, and in a 
 reclining position. Its effects are divided into three stages. 
 The first effect observed is a peculiar sensation of fullness, 
 similar to the action of alcoholic stimulants, with a feeling* 
 of weight in the cerebrum ; acceleration of the pulse, but no 
 great increase in the heart's action ; blunted sensibility and 
 more or less tinnitus aurium. This first stage varies as a 
 rule; it is generally short, but in intemperate persons it 
 may be long and violent. In the second stage, which is 
 that of complete anaesthesia, consciousness ami sensibility 
 are abolished, pulse slow and breathing regular; the entire 
 muscular system is relaxed. These two stages sometimes 
 run together. The third stage is one usually ushered in by 
 stertorous, noisy, and "catchy' 1 breathing, with weak ir- 
 regular pulse, shallow and less frequent respiration, and 
 dilated pupil, which is apt to be followed by collapse and 
 death. 
 
 Death usually occurs by asphyxia, owing to the closure of 
 the glottis, or to paralysis of the laryngeal muscles; or it 
 may be induced by cardiac syncope, or absorption into the 
 blood and nerve tissue, producing entire alteration of the 
 nervous tissues. 
 
 What has experimentation determined definitely in re- 
 gard to the action of chloroform ? 
 
 The action of chloroform on the brain is, first, congestion ; 
 but when there is complete anaesthesia, it produces decided 
 anaemia in man and animals (Carter). The muscular ex- 
 citement of the second stage is, according to the experiments 
 of Bert, purely physical ; and there is, during the production 
 
 * See descriptions of various forms at the end of this volume. 
 
90 ARTIFICIAL ANAESTHESIA. 
 
 of anaesthesia, a steady lowering of reflex action. Chloroform 
 at first induces contraction, and afterwards dilatation of the 
 pupil (Dogiel). During the first half minute of the inhalation 
 of chloroform, there is a progressive lowering of the arterial 
 pressure (English Chloroform Committee). Chloroform 
 injected into the jugular vein instantly arrests the heart's 
 action (Glover). Chloroform alone produces no other alter- 
 ation than contraction of the red blood-disks (Boettcher) ; 
 if, however, air be admitted to blood containing chloroform, 
 the red corpuscles rapidly disappear, dissolving in the serum, 
 out of which, after a time, hsematin crystalizes. One au- 
 thority (Husemann) states that, after anaesthesia, bile .acids 
 appear in the blood; and Bert has found that the oxygen of 
 the blood undergoes an increase during anaesthesia. During 
 the action of chloroform the tenrperature falls, the circula- 
 tion is retarded, and the skin gives off less insensible per- 
 spiration (Sheinesson). According to the recent experiments 
 of Ranke, which we have before referred to and repeated, on 
 several small animals (and this is also the view of the late 
 Claude Bernard), the nature of the action of chloroform upon 
 the nerve cell is slight coagulation, but if the animal was 
 killed with the chloroform there was hardening of the nerve 
 trunks and entire change, in which evident coagulation of 
 the albumenoid tissues took place ; if chloroform was mixed 
 with blood not exposed to the air, there was no change ex- 
 cept contraction, either shown under the microscope or bj- 
 spectrum analysis — this we* have repeatedly determined in 
 the frog, rabbit, pigeon, and in the blood of several of the 
 experimenters present, drawn and not exposed to the air. 
 
 TOXICOLOGICAL EFFECTS. 
 
 Chloroform is the most potent and dangerous of anaesthe- 
 tics, and is the only one in which death may occur at any and 
 every stage by inhalation ; unlike ether, it kills so suddenly 
 that neither skill nor care can guard against a fatal result. 
 Prof. Silliman says : " The main disadvantage of chloroform 
 is its high boiling point, requiring a great amount of vital 
 force to eliminate it from the body, so that it is probably 
 never eliminated entirely by the lungs, but only with the 
 
 * Drs. J. D. Thomas and L. Turnbull. 
 
TOXICOLOGICAL EFFECTS OF CHLOROFORM. 91 
 
 aid of all excreting organs, any deficiency or derangement 
 of which may consequently lead to such suppression of elim- 
 ination that the nervous system may be overwhelmed with 
 consequent arrest of their activity." (Silliman's Lecture, 
 1871.) A recent writer* states that all anaesthetics kill 
 during the first stage, or "the air may be very highly 
 charged, even saturated, with either of these substances, so 
 much so that, owing to its puugency, it cannot be breathed, 
 and, if forced upon the patient, stifles and suffocates him in 
 exactly the same manner as would brimstone or matches 
 burned under his nostrils ; death would thus occur without 
 either chloroform or ether having entered the body." The 
 writer gives no proof in favor of this theory, which is not 
 based on facts, as in all anaesthetics death in the majority of 
 cases occurs in the second or third stage (see tables), and it 
 is very rare for it to occur in the first, except from chloroform 
 mixture or from chloroform itself. 
 
 Owing to the danger which accompanies its use, chloro- 
 form should not be used when other anaesthetics are avail- 
 able ; or under the especial circumstance that, without it, 
 the shock of the operation might kill the patient. In 
 military surgery, it becomes at times absolutely necessary ; 
 and in the hold of ships, especially those of iron, where the 
 temperature is very high, it is resorted to on account of its 
 rapidity of action, smallness of quantity required, cheapness, 
 small bulk in transportation, and the less risk of explosion 
 and ignition. In obstetrics, chloroform is used with com- 
 parative safety to the mother, although a few deaths have 
 been reported; but from our observations taken in three 
 carefully watched cases, all fatal to the infant, conclusions 
 have been drawn that in long and instrumental labors ether, 
 although not so pleasant, is much safer to the child. 
 
 The symptoms which usually occur as precursors of death 
 are a sudden paleness or lividity of the countenance, with 
 shallow breathing, stertor, loss of or a quick and weak pulse, 
 tossing about of the patient, delirium, convulsions or coma. 
 
 vSchiff {V Imparziale) arrived at the following conclusions, 
 after more than five thousand experiments, as to the differ- 
 
 * Medical Times and Gazette, London, and Missouri Dental Journal, 
 August 15th, 187S, p. 469. 
 
92 ARTIFICIAL ANAESTHESIA. 
 
 ence of anaesthesia by ether or chloroform; "Ether paralyzes 
 first the respiration, and after that the blood-vessels and the 
 heart ; while chloroform can paralyze the heart and blood- 
 vessels at once, without previously paralyzing the respiration. 
 Artificial respiration with the latter agent is, then, useless, 
 as oxygenation has ceased; compression of the abdominal 
 vessels, and lowering of the head, may be of advantage. 
 Chloroform can cause death at the first inspiration. Ether 
 
 EXPERIMENTATION OX DEATH FROM 
 CHLOROFORM. 
 
 '.' The first series of experiments I remember to have made 
 were commenced in the years 1850 and 1851, and had refer- 
 ence to the mode and cause of death under chloroform. At 
 the time named, chloroform had been in use a little over 
 two years for preventing the pain of surgical operations, 
 and already nineteen deaths in man had occurred from it. 
 
 "These calamities had produced very painful and anxious 
 feelings amongst medical men, and my researches had for 
 their intention the elucidation of many points of practical 
 importance. The mode of procedure was to narcotize the 
 animals, with various degrees of rapidity, with varying 
 percentages of chloroform-vapor in the atmosphere, and 
 during various atmospherical conditions ; to note carefully 
 the phenomena produced on the heart and on the respira- 
 tion, and the duration of the four stages of narcotism. In 
 some instances the animals — rabbits were usually subjected 
 to experiment — were allowed to recover; in other instances 
 the narcotism was continued to death. When the narcotism 
 was made to be fatal, the immediate cause of death was 
 noted, and the body left until the rigidity of death could be 
 recorded; then all the organs were carefully inspected, in 
 order to see what was the condition of the lungs, the heart,, 
 the brain, the spinal cord. 
 
 " The results obtained by these inquiries were of direct 
 practical value; by them I showed, in various lectures and 
 papers, the following major facts: — 
 
 "1. That the cause of the fatality from chloroform does not 
 occur, as was at first supposed, from any particular mode of 
 administration of the narcotic. 
 
MODE AND CAUSE OF DEATH FROM CHLOROFORM. 93 
 
 " 2. That chloroform will kill, in some instances, when the 
 subject killed by it exhibits, previous to administration, no 
 trace of disease or other sign by which the danger of death 
 can be foretold. 
 
 ' ' 3. That the condition of the air at the time of administra- 
 tion materially influences the action of the narcotic vapor ; 
 that the danger of administration is much less when the air 
 is free from watery vapor, and the temperature is above 60° 
 but below 70° F. 
 
 " 4. That- there are four distinct modes of death from chlo- 
 roform, and that when the phenomena of death from its 
 application appear, they are infinitely more likely to pass 
 into irrevocable death than from some other narcotics that 
 may be used in lieu of chloroform. 
 
 " 5. That all the members of the group of narcotic vapors 
 of the chlorine series, of which chloroform is the most 
 prominent as a narcotic, are dangerous narcotics, and that 
 chloroform ought to be replaced by some other agent equally 
 practical in use and less fatal. 
 
 ' ' 6. That so long as it continues to be used there will always 
 be a certain distinct mortality arising from chloroform, and 
 that no human skill in applying it can divest it of its dangers. 
 
 " That knowledge of this kind respecting an agent which 
 destroys one person out of every two thousand five hundred- 
 who inhale it, was calculated to be useful, no reasonable 
 mind, I think, can doubt. To me, who, many hundred 
 times in my life, have had the solemn responsibility of ad- 
 ministering chloroform to my fellow-men, it was of so much 
 value that I should have felt it a crime if I had gone blindly 
 on using so potent an instrument without obtaining such 
 knowledge." — Benjamin W. Richardson, in "Nature." 
 
 MM. Budin and Coyne contribute' to the Archives de 
 Physiologie, No. 1, 1875, a communication on the condition 
 of the pulse in anaesthesia. From their observations and 
 researches they draw the following conclusions: — 
 
 1. The administration of chloroform causes a series of 
 modifications in the pupil, which bear a relation to the state 
 of sensibility. 
 
 2. During the period of excitation the pupil is dilated. 
 
 3. This period passed, the pupil becomes progressively 
 contracted, remaining sensible to excitations. 
 
94 ARTIFICIAL ANAESTHESIA. 
 
 4. During the period of profound surgical anaesthesia two 
 phenomena on the part of the pupil are constantly observed : 
 1, an absolute immobility of this organ ; 2, a state of contrac- 
 tion. There is a relation between the absolute insensibility 
 of the subject and the contraction with immobility of the 
 pupil ; between the return of sensibility and the dilatation 
 with mobility of this organ. 
 
 '5. The state of the pupil may, then, from the point of 
 view of sensibility, serve as a guide in the administration 
 of chloroform. 
 
 6. Gradual dilatation of the pupil supervening during an 
 operation indicates that anaesthesia is less profound, and 
 that sensibility is returning. 
 
 7. During operations of long duration, if it is desired that 
 the patient should be completely insensible, the anaesthesia 
 should be so managed that the pupils should remain con- 
 stantly contracted and immobile. 
 
 8. Efforts at vomiting may bring about dilatation of the 
 pupil, cause insensibility to disappear, and bring about awak- 
 ening ; it annihilates in part the effects of the anaesthetic. 
 
 9. It is important not to confound true chloroform anaes- 
 thesia with asphyxic anaesthesia ; the latter causes different 
 phenomena on the part of the pupil. 
 
 10. The condition of the iris, although it may Serve as a 
 guide for the direction of anaesthesia, does not indicate the 
 imminence of accidents. The pulse, the respiration, and 
 the general condition of the patient, must be carefully 
 watched by the administrator of chloroform. 
 
 SchifT* sought and found in the movement of the pupil 
 an aesthesiometer to determine the sensibility, especially in 
 curarized animals. With curarized dogs and cats every 
 irritation of the sensory nerves in any part of the body 
 resulted in a dilatation of the pupil, even when the irritation 
 caused no pain, and excited only the tactile sensibilities, 
 such as touching of the skin ; the greater the sensibility, the 
 greater the dilatation of the pupil. The dilatation manifested 
 itself after the quickest and gentlest touch, which could not 
 have changed the blood pressure ; there Avas no other sign 
 of feeling, hence the dilatation of the pupil is the best re- 
 
 * La pupilla come estesiometro. Imparzial, 1874. 
 
CONDITION OF PUPIL IN CHLOROFORM NARCOSIS. <>•-> 
 
 action of* sensibility. Sehiff has thus attained important 
 results in regard to the sensibilities of different organs and 
 tissues that have hitherto been left in doubt. Irritation of 
 any of the tissues, even muscles and tendons, will cause the 
 pupil to dilate more or less. Of the spinal cord only the 
 posterior columns are sensitive; an electric current applied 
 to the gray matter of the cord, or to the anterior and lateral 
 column, may cause a rise in the blood pressure, but it will 
 not cause dilatation of the pupil. 
 
 There is some sensibility in the anterior four-tifths of the 
 cerebrum, but none in the cerebellum. Electric currents in, 
 the intestines produced no dilatation, but -mechanical irrita- 
 tion did. The dilatation of the pupil upon the irritation of 
 the sensibilities is effected through the cervical sympathetic ; 
 it is suspended after its division, as well as the division of 
 the medulla oblongata. In the brain is the change of the 
 sensitive impression into the motor impulse. On the re- 
 moval of the portion of the brain anterior of the corpora, 
 striata, the reflex action upon the pupil becomes slower; 
 but on the entire removal of the brain the iris responds only 
 to the impression of light, but not on irritation of sensibility.. 
 
 The condition of the pupil during chloroform narcosis,. 
 according to Sehiff, differs widely from Budin's observation. 
 In the commencement of the narcosis, and until complete 
 relaxation, Sehiff found entire dilatation of the pupil, and 
 that through the active contraction of the dilator or radiating 
 fibres. Myosis does not continue in dogs (except sometimes 
 in a very late stage of the experiment) long after a general 
 muscular relaxation denotes great danger, or after death 
 having ensued. Of eleven dogs which were chloroformed 
 to the lowest blood pressure, or nearly to death, in four only 
 was there a moderate contraction of the pupil, and never so 
 stroMg as Budin states it to be. The dilatation which en- 
 sued, after sensible irritation, was only of short duration. 
 Sehiff concludes that the moment for operation, as indicated 
 by Budin, is just the most unfavorable one, for all reaction 
 upon sensible irritation is then extinct. There is a period 
 in chloroform narcosis when all feeling of pain ceases, but 
 consciousness is not entirely gone, when incisions or sawing 
 of bones are perceived as mere tactile impressions, for the 
 sensation of pain is conveyed to the brain through the gray 
 
96 ARTIFICIAL ANAESTHESIA. 
 
 matter of the spinal cord ; but the tactile impressions through 
 the white matter of the posterior columns, which, being less 
 vascular, do not so readily succumb to anaesthesia, and re- 
 tain their function a little longer. Budin seems to have 
 confounded impression from contact with sensation of 
 pain. 
 
 Schiff refers to many observers who, like himself, have 
 found the pupil of man and animals dilated during chloro- 
 form narcosis, but Budin has also many endorsers who saw 
 the pupil contracted while in deep narcosis of chloroform. 
 From these diametrically opposite results, we must conclude 
 that chloroform does not act on all animals alike, and, fur- 
 ther, that the different brands of chloroform are of unequal 
 purity. 
 
 O. Liebreich, the distinguished chemist, maintains that 
 when, on inhalation of chloroform, dilatation of the pupil 
 ensues, that the chloroform is mixed with bodies of the bi- 
 chloride series,which have the property of dilating the pupil, 
 with final transition into the dangerous contraction stage. 
 
 Other anaesthetics which affect the pupil are mentioned 
 by Schiff. It occurs in inhalation of nitrate of amyl that 
 sensibility is retained, as manifested by the cries of animals, 
 and yet the pupil does not dilate on irritation of sensibility, 
 the very reverse in chloroform. Chloral exhibits the opposite 
 effect of chloroform on the pupil, namely, a very strong con- 
 traction, a true myosis, without a preceding dilatation. The 
 reflex dilatation upon irritation of sensibility ceases entirely, 
 although other manifestations of pain continue for a while 
 longer. Inhalations of chloroform which were made after 
 an injection of chloral in a dog, brought about a slow dilata- 
 tion of a strongly-contracted pupil.* 
 
 Speaking of deaths from chloroform at the very commence- 
 ment of the inhalation, an able reviewer* has stated. that 
 ''These sudden deaths are purely the result of emotion, a 
 snapping of the vital cords strained to their utmost tension 
 by the arrival of the long-dreaded moment for the operation. 
 
 * Translated by Dr. S. Pollak, St. Louis, from Prof. A. Nagel's Yearly 
 Review of the Progress of Ophthalmology. St. Louis Medical Journal, 
 March, 1879. 
 
 f Anaesthetics, a Review in American Journal of Medical Sciences, 
 January, 1867, p. 167, signed J. C. R. 
 
SUDDEN DEATHS FROM CHLOROFORM. 97 
 
 Such sudden deaths during or just before an operation have 
 always been known, and many reported." 
 
 I do not agree with the writer, else the same result would 
 have followed when ether or nitrous oxide is employed. It 
 is the same profound impression of this most dangerous of 
 anaesthetics. Fright and apprehension will blanch the 
 cheek, act upon the heart of feeble persons with cardiac 
 troubles, but it cannot destroy so many strong, robust, and 
 healthy subjects merely through moral fear. The reviewer 
 has collected from different sources a number of interesting 
 cases worthy of publication, but these will not prove the 
 proposition, for the greatest number of deaths have occurred 
 in the most trifling operations. 
 
 DEATH AT OUTSET OF ADMINISTRATION. 
 
 A death from chloroform occurred at the Toronto General 
 Hospital on July 18th. A woman, aged twenty-five, was 
 about to be operated upon for some uterine trouble, and but 
 a few drops of the anaesthetic had been given when she 
 suddenly died. She had taken chloroform previously, and 
 had had no unpleasant symptoms. At the post mortem, 
 fatty degeneration of the right ventricle was assigned as the 
 cause of death." 
 
 A FEW ILLUSTRATIONS OF THE MODE OF 
 DEATH FROM CHLOROFORM. 
 
 Deaths from Self Administration.— Dr. GustavJu- 
 dell, privat-docent and chemical assistant in Prof. Laube's 
 clinic at Erlangen, was, on October 26th, found dead in his 
 bed. He had been accustomed to take chloroform at night, 
 as a remedy for sleeplessness, by which lie was much 
 troubled, and a bottle containing the anaesthetic was found 
 near him. It appears that vomiting was excited by the 
 chloroform, but that he was too deeply narcotized to fully 
 eject the contents of his stomach, so that portions of food 
 remained in the trachea and caused death by suffocation. f 
 
 M. Bachelet, a young student of medicine, a son of the 
 Professor of History at Rouen, having suffered from an in- 
 
 * ( anadian Journal of Medical Sciences, August, 1877. 
 
 f Clinic, December 16th, 1870. From British Medical Journal. 
 
98 ARTIFICIAL ANESTHESIA. 
 
 tolerable toothache, endeavored to allay the pain by taking 
 chloroform; but, having- swallowed too large a quantity, he 
 almost immediately fell to the ground as an inert mass. 
 Notwithstanding every effort, he shortly after died.* 
 
 Deaths in the Dental Chair. — In the month of Feb- 
 ruary, 1878, a Miss Wilson died in a dentist's chair in 
 Brooklyn, after the extraction of ten teeth under the influ- 
 ence of two doses of chloroform. The coroner's jury, in 
 summing up the evidence, gave as its opinion that the 
 hapless woman died from asphyxia, caused by the use of 
 chloroform, and they condemned the use of anaesthetics in 
 dental operations. We do not wonder that dentists who 
 are not always familiar with the number of fatal cases of 
 death from the inhalation of chloroform employ it, when 
 they see it recommended by some of the most distinguished 
 surgeons of the land, in the face of the almost constant 
 deaths from its direct influence; these latter are the culpable 
 ones, for they sin against the knowledge of its fatal charac- 
 ter. If no other ainesthetic could be found, there might be 
 some reason for their willful misrepresentations. Where 
 ether and nitrous oxide can be had almost perfectly safe, 
 why should such a dangerous agent be recommended? 
 
 A case occurred at Railway, N. J., on the 5th of January. 
 A lad, aged fourteen, inhaled chloroform from a napkin 
 prior to the extraction of a tooth; immediately after the 
 extraction, there was a gasp for breath, a dee]) sigh, the 
 head rolled on one side, and the boy was dead. 
 
 On Tuesday evening, March 22d, 1878, Mrs. William Neely, 
 a resident of Hatboro, Montgomery comity, Pennsylvania, 
 came to this city, in company with her husband, for the 
 purpose of having some teeth extracted. On Wednesday 
 morning she went to the office of Dr. Winslow, on Tenth 
 street above Race, and stated to him that she desired to 
 have several teeth taken out and wished to take chloroform, 
 but being in delicate health she was uncertain as to the 
 advisability of doing so. The Doctor told her there was not 
 any danger, and he administered the opiate, first for one 
 minute, and then for a minute and a half, taking the usual 
 precautions for the safety of his patient. After he had ad- 
 
 Medical Times and Gazette. January 7th, 18/, 
 
DEATHS FROM CHLOROFORM. 99 
 
 ministered the last dose, he found she did not return to 
 consciousness, and despatched a messenger for Dr. E. B. 
 Jackson, a few doors above, who pronounced the lady dead; 
 Dr. Samuel W. Gross was also sent for, who made an exam- 
 ination of the lady, and expressed the opinion that she had 
 died from heart disease. 
 
 The coroner's physician, Dr. Henry C. Chapman, testified 
 that lie had mnde & jwst mortem examination on the body of 
 the deceased on March 20th, at No. 224 North Tenth street. 
 On opening the chest found the lungs in a healthy condition, 
 the heart soft and flabby, and a blood-clot adhering to the 
 right side of the heart organs. In answer to questions from 
 the coroner and jury, witness stated that before adminis- 
 tering either chloroform or ether the physician or dentist 
 administering it should on all occasions make a careful ex- 
 amination, and ascertain whether or not any heart-trouble 
 existed. He thought that the deceased had been suffering 
 from disease of the heart previous to having the chloroform 
 administered by Dr. Winslow, as the clot adhering to the 
 heart gave evidence of having been there for some time, 
 and thought that she must have been unhealthy. From 
 the flabby condition of the heart, the chloroform, in the 
 opinion of witness, must have directly acted upon that 
 organ. He thought that ether was less dangerous than 
 chloroform ; very few cases of death have resulted from the 
 former, while hundreds of cases are recorded as having re- 
 sulted fatally by the latter. 
 
 H. (I. Winslow, M. D., residing at No. 224 North Tenth 
 Street, on being sworn, testified that the deceased came to 
 his office at noon on March 20th, for the purpose of having 
 some teeth extracted ; he asked her whether or not she was 
 well, and she answered yes. He administered chloroform 
 and extracted three teeth, she at the time being in a recum- 
 bent position ; after extracting the three teeth, she came to 
 and complained of feeling the pain. He administered more 
 chloroform on a napkin, which he placed in close proximity 
 to her nose, but not close enough to come in contact with 
 the face, and she again sank into insensibility ; in pulling 
 an eye-tooth, after having administered the chloroform the 
 second time, it broke off, and in attempting to remove the 
 remaining portion he found that respiration had ceased with 
 
100 ARTIFICIAL ANAESTHESIA. 
 
 his patient. He applied the usual remedies, consisting of 
 electricity, throwing water in her face, and made every 
 effort to secure an artificial respiration, hut it was useless, 
 as she ceased breathing ; witness summoned Drs. Jackson 
 and Gross, but when they arrived she had expired. Witness 
 stated that he had used chloroform for a number of years, 
 but never had anything serious to result from its use ; he 
 would not have administered it to Mrs. Neely if she had 
 informed him that she was suffering from heart disease; 
 the quantity of chloroform given to the deceased was about 
 half an ounce. He has used both ether and nitrous oxide 
 gas, and was of the opinion that there was as little danger 
 in using chloroform as either of the former. 
 
 Mrs. Elizabeth Edgar, residing at 1836 Columbia Avenue, 
 testified that she accompanied the deceased to the office of 
 Dr. Winslow on the 20th of last month, and stated that he 
 (Dr. Winslow) made no examination as to the condition of 
 the deceased further than that he asked her whether or not 
 she was healthy, and she responded in the affirmative': he 
 administered the chloroform on two different occasions, a 
 very short time intervening between administering it the 
 first and second time. 
 
 The Verdict. — The testimony having all been received, the 
 case was given to the jury, who retired for deliberation ; 
 after an absence of a short time, they returned and rendered 
 the following verdict : — That the said Elizabeth Xeely came 
 to her death, March 20th, 1878, at Xo. 224 North Tenth street, 
 by chloroform administered by Dr. H. ( !. Winslow ; and 
 they further find that Dr. Winslow is guilty of criminal 
 ignorance, in administering so powerful a remedy, in not 
 having made any examination of his patient. 
 
 The Dentist Cemuredby the Coroner. — After quiet had been 
 restored, Coroner Gilbert, in addressing the accused, spoke 
 as follows: — "Dr.Winslow, before discharging this case I 
 must perform a duty which I owe to the community as 
 their representative in this office, and that is to censure you 
 for using so dangerous a remedy as chloroform in so trifling 
 an operation as the extraction of teeth, more especially when 
 you have at your own command a much safer substitute in 
 sulphuric ether, and a perfectly harmless one in nitrous 
 oxide gas. You are not only to be censured for using chlo- 
 
• DEATHS FROM CHLOROFORM. 101 
 
 roforni in such a case, but using it without having previously 
 made a careful examination into the physical condition of 
 the various organs of your patient's system. Chloroform is 
 a most powerful sedative, and far more dangerous to life 
 than any of the other anaesthetics ; on this account, a num- 
 ber of the hospitals have prohibited its use. The medical 
 profession have almost unanimously settled down to the 
 opinion that it should only be used in capital orjerations, 
 and then only after the most careful examination . Although 
 the verdict of the jury and this censure w^ill not bring back 
 the mother to the little ones, or the wife to her husband, it 
 may be the means of directing the attention of dental sur- 
 geons to a more careful use of chloroform, and the commun- 
 ity, who are the parties most interested, to the great danger 
 attending its use, and thus, perhaps, avoid similar accidents 
 in future. In concluding, Coroner Gilbert committed the 
 accused to await the action of the grand jury." 
 
 I addressed a note to the coroner in regard to the action of 
 the grand jury, and received the following reply: — 
 
 Philadelphia, March 22d, 1879. 
 Dear Sir : 
 
 The grand jury ignored the bill in the Winslow case. 
 Very respectfully, 
 
 W. K. GILBERT. 
 To L. Turnbull, M. D. 
 
 Death in Surgical Operation.— Dr.. W. P. Mills, of 
 Brownsville, Mo., reports the following death in the St. Louis 
 Medical and Surgical Journal of June, 1878 : — 
 
 "A few days ago I was requested to operate on a boy, aged 
 sixteen years, for congenital phimosis. He was chloroformed 
 by Dr. A. J. Parsons, who has often administered chloro- 
 form by inhalation ; and, by the way, he is very cautious 
 in the administration of this potent drug. Notwithstanding 
 the great prudence, caution, and the general manner in 
 which it was administered, just as the operation was com- 
 pleted, and without any indication of danger whatever, 
 instantaneously — almost as quick as the explosion of gun- 
 powder — respiration ceased, and a livid color overspread his 
 face; and in spite of all the usual restoratives, he was soon 
 dead — in fact, it seemed as if he was struck dead in an 
 instant. Immediately upon the supervention of these 
 
102 ARTIFICIAL AN.KSTIIKSIA. 
 
 alarming symptoms, his head was lowered, cold water 
 thrown into his face, and artificial respiration induced; 
 under the influence of this treatment some improvement 
 was manifested, and for a few seconds it seemed that the 
 danger was over, but suddenly all the alarming symptoms 
 before described were again exhibited, and death was the 
 inevitable result. Not more than three drachms of chloro- 
 form was used, and of this not more than one and a half 
 or two drachms were actually inhaled ; and the patient was 
 not deeply under its influence at any time during the oper- 
 ation, which, as a matter of course, was very brief. Nitrite 
 of aniyl, electricity, and hypodermic injections of whiskey 
 were all brought into requisition, but, as the sequel proved, 
 were of no avail. 
 
 " The most noteworthy feature of the case was the very 
 sudden supervention of the alarming symptoms ; for, accord- 
 ing to my information in regard to chloroform poisoning, 
 there is generally some warning given of its deleterious 
 influence." 
 
 Quantity of Chloroform found in the Blood of 
 Patients after Death.— MM. Perrin and Lalleniand* 
 found that — the blood being taken as the standard, repre- 
 senting 1 — the brain contained 3.02 parts, the liver 2.08, and 
 the muscles 0.10. 
 
 Period of Administration ok Chloroform at which 
 Death occurred (Sansomf):— 
 
 Before full effects 50 
 
 During full effects, ....... 52 
 
 Not stated, . . . 7 
 
 109 
 Sex — Men more subject to Death than Women: — 
 
 Snow gives the proportion of 3 to 2 
 
 tvidd ■ " " 4tol 
 
 Sansom and the Chloroform Committee 2.S to 1, and 72 
 
 males to 37 females. 
 A.ge — Largest proportion ok Deaths during Mii>- 
 
 [)LE AGE. — Children have shown great immunity, and yet 
 
 thev also die from its effects. 
 
 Traite d'Anesthesie Chirurgicale. Paris, 1863, 8vo. 
 Chloroform: its Action and Administration. London, LS62 
 
chloroform poisoning. 103 
 
 Kind of Operation in which Death occurred by 
 the Administration of Chloroform:— 
 Operations of minor importance, as extraction of teeth, 88 
 
 Capital operations, . 
 
 Reduction of dislocations, 6 
 
 Delirium tremens and mania, .... 4 
 
 Natural labor, ......... 2 
 
 109 
 
 The quantity of chloroform necessary to produce death is 
 very variable. As small a quantity as from seventy-five to 
 one hundred drops has caused death, and yet, in a recent 
 case which has come under our notice, as much as three 
 pounds were employed in twelve hours, and no serious 
 results followed to the mother in confinement, but the 
 infant died from the profound narcosis. 
 
 Dr. Taylor, of London, in his work on Poisons,* states 
 that "Fatal cases have been jn'oportioually much more 
 numerous from the use of chloroform-vapor than even from 
 (the impure) ether-vapor employed in England." After 
 relating a number of fatal eases, in which as small a quan- 
 tity as a drachm of chloroform in vapor produced death 
 suddenly, he remarks: " It is not necessary that this theory, 
 that a fatty and flabby heart is the true cause of death, he 
 brought forward to explain the fatal results — they are simply 
 cases of poisoning." Then he relates that death of a hearty 
 man took place on the operating table of a London hospital 
 in three minutes, from two drachms of chloroform given in 
 vapor; the gentleman who administered it had given it 
 previously to three or four hundred patients, it was on this 
 occasion candidly admitted that the body was quite healthy. 
 This is the reason why so many eminent ami conscientious 
 surgeons have given up the use of chloroform, except in rare 
 cases, for fear such a catastrophy might occur. A recent 
 case of death from chloroform, in which a distinguished 
 Southern surgeon f met with his first fatal case, followed, 
 however, an operation on a diseased subject. This surgeon, 
 during the war, is reported to have administered chloroform 
 fifteen thousand times without one death. 
 
 On Poisons, opt. cit. pp. 621, 622. f Prof. McGuire. 
 
104 ARTIFICIAL ANAESTHESIA. 
 
 We also know, from private information furnished by one 
 of the most careful and reliable surgeons of our city, of fatal 
 cases of death from chloroform which have never seen the 
 light of day ; and we feel sure that there are other such cases 
 which have occurred on the battle-field, at sea, and on the 
 railroads, following severe shock, and that the patients died, 
 not from the injury, but from the narcotic effects of this 
 most powerful poison, administered before reaction had 
 taken place. These statements are not made from mere hear- 
 say, but were received in confidence from surgeons of high 
 rank in the army and navy, and who were in active service 
 during the late war. 
 
 What are the means to be resorted to, to prevent death 
 from this agent, when it is found absolutely necessary to 
 resort to its use? 
 
 What is, then, the chief clanger to be apprehended, and 
 how do ice prevent closure of the glottis, fainting, and fail- 
 ure of the puls< / 
 
 Stop the administration of the chloroform. 
 
 Lower the head, and elevate the feet above the level of 
 the body, and remove what mucus may collect in the mouth ; 
 draiv out the tongue and elevate the jaw. 
 
 Administer five to ten drops of nitrite of amyl, dropped 
 from a bottle on a piece of cloth and held to the nose. If 
 the patient makes no effort at breathing, force it up the 
 nostrils by means of a small hand-spray - ) compressing and 
 expanding the chest by manipulation with elbows to the 
 side. This should be continued until the heart acts. 
 
 If there is still increased evidence of asphyxia, owing to 
 falling back of the tongue and closure of the glottis, seize 
 the tongue with a dry napkin wrapped around it, or with 
 a catch-forceps, and pull it forwards until its tip is well 
 between the teeth, and hold it there. 
 
 Give the patient plenty of fresh air, by opening the win- 
 dows, fanning, use flagellation, etc. 
 
 If these means fail, commence artificial respiration at once. 
 
 Apply a galvanic or Faradayic current along the course of 
 the pneumogastric nerve, through the diaphragm, and even 
 to the heart, by means of electrodes of metal, containing 
 sponges which can be moistened with hot salt water. 
 
 Let the assistants or nurses rub each extremity briskly 
 
WHAT TO DO FOR CHLOROFORM POISONING. 105 
 
 with a hot towel ; sprinkle the face, by the fingers, with ice 
 water, and insert a lump of ice in the rectum, or inject 
 whiskey or brandy into the rectum or into the skin hypo- 
 dermically. 
 
 As soon as the patient can swallow, stimulate with brandy, 
 whiskey, and aromatic spirits of ammonia ; adding, if for a 
 female, the ammoniated tincture of valerian. 
 
 After successful resuscitation, dry the skin ; give the pa- 
 tient warm beef-tea and milk ; apply warmth around the 
 body for seven or eight hours by means of hot-water bottles, 
 heated bricks, bags of hot salt, etc. 
 
 Prof. Silliman thinks the best treatment in impending 
 death from chloroform is the introduction of air, heated to 
 130° F., into the lungs by artificial respiration, by means of 
 bellows. 
 
 T. Hughes, M. D., in London Lancet of November 2d, 
 says : " If I were about to be placed under the influence of 
 chloroform, I would say, ' Never mind my pulse, never 
 mind my heart ; leave my pupil to itself. Keep your eye 
 on my breathing ; and if it becomes embarrassed to a grave 
 extent, take an artery forceps and pull my tongue well out.' 
 It was the observance of this simple yet all-important rule 
 that enabled the late Mr. Syme to say that he never lost a 
 single case from chloroform, although he gave it in five 
 thousand cases. Prof. Lister lias done much to enforce this 
 rule of practice, and to him is due the credit of pointing out 
 the modus operandi of this proceeding. He was the first, 
 as far as I am aware, who explained that its action is not 
 mechanical, but is exerted chiefly through the nervous 
 system." 
 
 Prof. Schiff warns surgeons not to continue an operation 
 immediately on a patient's recovery from the excessive 
 action. of anaesthetics, but to wait until respiration has been 
 energetically restored, otherwise a new and generally fatal 
 asphyxia may be produced. 
 
 It is well to remember that anemia of the brain is second- 
 ary to the cessation of the heart's action, and that to restore 
 vitality to the brain requires that the heart's action be re- 
 stored. For the purpose there is nothing better than elec- 
 tricity, and the use of it is to be continued, not only for a 
 few moments, but for three or four hours. In cases of opium 
 
106 ARTIFICIAL ANAESTHESIA. 
 
 narcosis, some have recovered after the use of the Faradayie 
 current during fifteen consecutive hours, and it is well 
 worthy of trial for as long a period in a case of chloroform 
 poisoning. 
 
 APPEARANCES AFTER DEATH FROM 
 CHLOROFORM. 
 
 In our table of deaths from chloroform the details, as far 
 as known, are given, but the ehief^post mortem effects pro- 
 duced by death after chloroform are congestion of the brain 
 and mucous membranes of the air-passages and alimentary 
 canal; the bronchia are filled with mucus. 
 
 EMPLOYMENT OF CHLOROFORM IN LABOR. 
 
 M. Pichaud read a paper before the International Medi- 
 cal Congress of Geneva {Gazette Medicate, October 20, 1877), 
 in which he advanced the following conclusions, which are 
 not generally approved of by the majority of gynaecologists: 
 
 1. The employment of anaesthetics is, as a general rule, 
 advisable in natural labor. 
 
 2. The principal substances which have been used for 
 this purpose up to the present time: chloroform, amylene, 
 laudanum, morphia hypodermically, chloral by the mouth 
 and by injection. 
 
 3. Of these, chloroform seems to be preferable. 
 
 I. It should be administered according to the method of 
 Snow, that is, in small doses at the beginning of each pain, 
 its administration being suspended during the intervals. 
 
 5. It should never be pushed to complete insensibility, but 
 the patient should be held in a state of semi-anaesthesia, so 
 as to produce a diminution of the suffering. 
 
 6. The general rule is never to administer chloroform ex- 
 cept during the period of expulsion ; but in certain cases of 
 nervousness and extreme agitation, it is advantageous not 
 to wait for the complete dilatation of the os uteri. 
 
 7. Experience has shown that anaesthetics do not arrest the 
 contractions of the uterus or abdominal muscles, but that 
 they weaken the natural resistance of the perineal muscles. 
 
 8. The use of anaesthetics has no unpleasant effect on the 
 mind of the mother or upon the child. 
 
 9. In lessening the suffering, anaesthetics render a great 
 
CHLOROFORM JX PARTURITION. 107 
 
 service to those women who dread the pain ; they diminish 
 the chances of the nervous crises which are caused during 
 labor by the excess of suffering; they make the recovery 
 more rapid. 
 
 10. They are especially useful to calm the great agitation 
 and cerebral excitement, which labor often produces in every 
 nervous woman. 
 
 11. Their employment is indicated in natural cases until 
 the pains are suspended or retarded by the suffering caused 
 by maladies occurring previous to or during labor, and in 
 those cases where irregular and partial contractions occasion 
 internal and sometimes continuous pain without causing 
 progress of the labor. 
 
 12. In a natural labor, chloroform should never be used 
 without the consent of the woman and her family. 
 
 The experience of British practitioners is generally under- 
 stood to have disposed them to regard the use of chloroform 
 in labor as a proceeding of the highest utility and moment ; 
 and, according to the mode and limits of inhalation practised 
 in the circumstances, practically free from danger. It is 
 none the less important, therefore, to notice the opposite 
 views entertained by others; and to speak of France, where 
 chloroform in labor has not yet become acclimated, and 
 where medical science generally has for the last quarter of 
 a century fallen into the background. Dr. William T. Lusk, 
 of New York, read before the American ( fynaecological So- 
 ciety an interesting paper on the necessity of " Caution in 
 the use of Chloroform during Labor," in which he expressed 
 his belief that " not a small number of persons have quietly 
 abandoned chloroform as a pain-stilling agent, because some 
 incident in their practice has led them to suspect that, in 
 spite of statistics, it possesses dangerous properties." The 
 author divides his subject according to the following heads: 
 
 1. Deep anaesthesia, carried to the point of complete aboli- 
 tion of consciousness, in some cases weakens uterine action, 
 and sometimes suspends it altogether. 
 
 2. Chloroform, even given in the usual obstetrical fashion, 
 namely, in small doses, during the pains only, and after the 
 commencement of the second stage, may, in exceptional cases, 
 so far weakt n uterine action as to create the necessity for 
 resorting to ergot or forceps. 
 
108 ARTIFICIAL ANAESTHESIA. 
 
 3. Patients in labor do not enjoy any absolute immunity 
 from the pernicious effects of chloroform. 
 
 4. Chloroform should not be given in the third stage of 
 labor. The relative safety of chloroform ceases with the birth 
 of the child. 
 
 5. The more remote influence of large doses of chloroform, 
 during labor, upon the puerperal state, is a subject thai calls 
 for further investigation and inquiry. 
 
 Dr. Playfair* thinks -that chloroform inhalation is too 
 indiscriminately used, and says that he has observed the 
 pains alter and become less effectual. After chloroformi- 
 zation, and when it is prolonged, he thinks it favors post 
 partum hcemorrhage. 
 
 In arecent case which came under the writer's notice, where 
 three pints of chloroform had been employed in tedious 
 labor, there was great retardation ; and ultimately, when 
 the forceps were applied, the infant was so narcotized from 
 the effects of the chloroform that every means employed to 
 restore it failed. 
 
 Dr. Colling reported in the Boston Medical and Surgical 
 Journal of January 11th, 1876, a case of death by chloroform 
 in parturition. The patient was a primipara, aged twenty- 
 two. The labor was proceeding well, and the head was 
 apparently on the point of emerging, when the patient had 
 a slight convulsion. Chloroform was administered, and the 
 pains returned ; and, still later, the administration was re- 
 peated. The head was gotten -away, and the uterus was 
 contracting well, when a tremor occurred, the pulse ceased, 
 and the patient was dead. 
 
 CHLOROFORM AS AN ANAESTHETIC FOR 
 CHILDREN. 
 
 Prof. Demme, in the Central Zeitung fur Kinder he ilkunde 
 of September 1st, 1S79, gives his experience in the use of 
 chloroform as an anaesthetic for children, which corresponds 
 in part with our own observations and experiments. He 
 says : "Its action is quicker, more reliable, and in no way 
 more dangerous." This last expression must, Ave think, be 
 modified, for deaths have followed its administration in 
 
 * British Medical Journal, November 9th, 187S. 
 
DEATHS FROM CHLOROFORM IN CHILDREN. 
 
 109 
 
 children in 
 
 several instances, ( 
 
 )f which the following is a 
 
 list*:— 
 
 
 
 
 Date. 
 
 Sex. 
 
 Age. 
 
 Operation. 
 
 1849, 
 
 Boy, 
 
 12, 
 
 Amputation. 
 
 1850, 
 
 — 
 
 1, 
 
 Nsevus. 
 
 1857, 
 
 Boy, 
 
 9, 
 
 Tumor of scapula. 
 
 (< 
 
 " 
 
 5, 
 
 Tumor of back. 
 
 1858, 
 
 (< 
 
 8, 
 
 .Strabismus. 
 
 (i 
 
 u 
 
 11, 
 
 Injury of toe. 
 
 1859, 
 
 Girl, 
 
 7£, 
 
 Hip disease. 
 
 1861, 
 
 Boy, 
 
 ' , 
 
 Laryngitis. 
 
 " 
 
 " 
 
 ' 8, 
 
 Deformity from burn. 
 
 1865, 
 
 — 
 
 o 
 
 Amputation of finger, 
 
 1866, 
 
 Boy, 
 
 4.!, 
 
 Retention of urine. 
 
 " 
 
 i i 
 
 11, 
 
 Lithotomy. 
 
 1867, 
 
 Girl, 
 
 9, 
 
 Strabismus. 
 
 u 
 
 Boy, 
 
 8, 
 
 " 
 
 1869, 
 
 Girl, 
 
 «, 
 
 " 
 
 1870, 
 
 Boy, 
 
 11, 
 
 Iridectomy. 
 
 1871,- 
 
 i< 
 
 8, 
 
 Dressing wound. 
 
 K 
 
 u 
 
 12, 
 
 Extracting teeth. 
 
 THE USE OF CHLOROFORM IN REGARD TO 
 
 NATIONALITY AND RACE. 
 Dr. M. F. Coonles, of Louisville, Kentucky, writes in the 
 American Bi-iveekly of September 14th, 1878 : " The Irish, as 
 a class, will take more chloroform and be longer in yielding 
 to its influence than any other nationality. The behavior 
 of Americans is similar to that of the Irish ; they possess 
 great power of resistance, but yield to the influence of the 
 anaesthetic with more ease and take less of it. The Germans 
 yield to chloroform with but little trouble ; it is not an 
 infrequent occurrence to see them become anaesthetized 
 without a struggle. They rarely make any demonstration ; 
 if they do, it is usually in the form of rapid conversation or 
 song. The negro is more easily influenced by chloroform 
 than either of the before mentioned races; they usually be- 
 come anaesthetized very readily; in many instances they 
 sing and pray while inhaling." 
 
 * Collected for me by Dr. O. H. Allis. See also table of deaths from 
 chloroform. 
 
110 ARTIFICIAL ANAESTHESIA. 
 
 These observations were taken m fifty -seven cases, of 
 which the Doctor kept an accurate record. 
 
 TOLERANCE OF CHLOROFORM BY THE USE OF 
 AMMONIACAL INHALATIONS. 
 
 Some patients are dangerously affected by chloroform 
 inhalations; while, in others, tolerance is obtained with 
 considerable difficulty. It may also happen that chloroform, 
 although obviously indicated, could not be employed on ac- 
 count of severe cardiac complication. 
 
 Professor Occhim had a patient, requiring the removal of 
 a large calculus, who was much enfeebled by a chronic 
 suppuration, and whose pulse was irregular and thready. 
 Under these discouraging circumstances, the Professor em- 
 ployed the preventative effects of ammoniacal inspirations 
 as a stimulant to the nervous and vascular systems, and a 
 very large calculus was extracted without difficulty or dis- 
 turbance of these systems ; the patient made a good recovery. 
 M. Occhim made several experiments on patients laboring 
 under cardiac difficulties in their various stages, and thus 
 confirmed the conclusions at which he arrived at, i. e., that 
 the tolerance of chloroform can be ensured by the prevent- 
 ative use of ammoniacal inhalations.* 
 
 THE INFLUENCE OF CLIMATE ON THE USE OF 
 CHLOROFORM. 
 
 The following extracts, in reference to the use of chloro- 
 form, were taken from letters received from two distinguished 
 surgeons in the South. The first is from Dr. Landon B. 
 Edwards, editor of the Virginia Medical Monthly , dated Rich- 
 mond, Va,, October 21st, 1878:— 
 
 My dear Doctor : 
 
 It is one of the most peculiar facts that I have ever 
 known in medical practice — the difference of experience in 
 Europe and the North with chloroform and ether, as com- 
 pared with that at the South. I don't understand the high 
 rate of mortality with chloroform elsewhere ; or else, I 
 cannot explain the low rate of mortality at the South from 
 
 * Medical Examiner, April 2-5th, 1878, and Medical News and Library, 
 July, 1878. 
 
INFLUENCE OF CLIMATE. Ill 
 
 the same agent. Anaesthetics are used for more trivial 
 affections and surgical operations in the South than in the 
 North ; and, of course, for all grave troubles, many obstet- 
 rical cases, etc. Even during the war, when we Confederates 
 were not using Squibb 's, or a chloroform having the repu- 
 tation of such purity, our preference was for chloroform, 
 although of home manufacture, and I know of no army 
 surgeon in the Confederate service who had any occasion 
 to regret his preference for it ; of course, some accidents may 
 have occurred with it, but I do not recall any fatality directly 
 or solely attributed to it. But it seems to me almost every 
 practitioner of eminence in the North has knowledge of 
 some fatality from chloroform. Were a fatal case from 
 anaesthetics to occur in any of our small cities or towns, it 
 would become wide-spread news. 
 
 Yours truly, 
 
 LANDON B. EDWARDS. 
 
 The second, dated October 26th, 1878, is from Dr. A. W. 
 Calhoun, an eminent ophthalmic and aural surgeon of 
 Atlanta, Ga., who administered chloroform even in the 
 removing of tonsils, etc., without fear: — 
 
 My dear Doctor : 
 
 My recent experience has also taught me that it is per- 
 fectly safe, and oftentimes very desirable, to give chloroform, 
 at least to the extent of enabling you to begin the operation 
 without resistance on the part of the patient. 
 
 I am, etc., 
 
 A. W. CALHOUN. 
 
 There may be something in the difference in the boiling- 
 point of chloroform in the South, and in the fact of the air 
 being more heated and stimulating. 
 
 CONCLUSIONS IN REFERENCE TO THE USE OF 
 CHLOROFORM. 
 
 In what class of cases can chloroform be employed with 
 safety? 
 
 In my own experience and after my experiments, I would 
 limit the use of this most potent of all the anaesthetics to 
 very yoimg children, or those who are weak, strumous, or 
 
112 ' ARTIFICIAL ANAESTHESIA. 
 
 overgrown ; to puerperal eclampsia, in very violent convul- 
 sions, in male adults, or in females during delivery, where 
 rapidity of dilatation of the os uteri is*absolutely necessary 
 to save the mother's life. 
 
 In some rare eases of painful operation, where, after con- 
 tinued efforts, no complete insensibility can be produced by 
 ether, I would feel justified in the use of a small portion of 
 chloroform on a clean sponge or inhaler. By a reference to 
 the recent cases of deaths from this agent, I am fully satisfied 
 that no amount of care or precaution, or mode of adminis- 
 tration, or amount inhaled, will prevent, in certain cases, 
 the fatal result ; and yet physicians and others will resort 
 to the use of chloroform on account of its pleasant taste and 
 odor, rapidity of action, cost, and comparative bulk. 
 
 In the recent admirable work on surgery by Erichseu,* 
 he discussed the question, Do anaesthetics influence the rate 
 of mortality after operation? and concludes by stating: " I 
 am inclined to believe that the rate of mortality has increased 
 since the use of anaesthetics in operative surgery." Again, 
 "I cannot but think that chloroform does exercise a noxious 
 influence on the constitution, and does lessen the prospect 
 of recovery in certain states of the system, more especially 
 when the blood is in an unhealthy state." He states the 
 most dangerous condition in which to administer chloroform 
 is that in which, in consequence of renal disease, the blood 
 is loaded with urea ; in such cases epileptiform convulsions 
 are readily induced. 
 
 In the recent work of Professor Billroth,! of Vienna, he 
 states : "Recently, ether has come more into use on account 
 of the number of deaths from chloroform. I now use a 
 composition of three parts chloroform, one sulphuric ether, 
 and one absolute alcohol, which seems less dangerous than 
 chloroform." 
 
 There have already been two hundred and ten deaths from 
 chloroform faithfully recorded and reported (see first edition 
 of this work, Philadelphia, 1878). Most of these occurred in 
 the hands of the most experienced surgeons, and many of 
 them in large hospitals where every appliance was to be had 
 
 * The Science and Art of Surgery, p. 42. Philadelphia: H. C. Lea, 
 1878. 
 
 t From the Fourth German Edition. 
 
■ »lt] Mult' 
 ... Boy. 
 
 TABLE OF DEATH 
 
 S FROM CHLOROFORM FROM 1869 TO [8/9. 
 
 A1 „i,NIsTi:.\T..|i. Ymm VI 
 
 CAUSE OP DEATH, 
 
 iiiiiin- milium:,- 
 
 otherwise healthy ; 
 
 
 liiliiKlliiii Jmif 
 
 it,, i.< i \. ...... i ■■■■■■ m.i. ri,i!..-i, iphin, March 
 
 i ., i . ;■ ■ laminated i 
 
 ■ . 
 n load 
 Iftll ri-ht 
 W.L.kly t-hilil.. .11. t. -iJ.-i.ld 
 
370 DEATHS FROM CHLOROFORM. 113 
 
 and all the known means employed to prevent death. There 
 are also a large number of deaths unreported which, like 
 fatal operations in surgery, never see the light of day, and 
 are therefore of no use to warn the careful observer. 
 
 The number of deaths from chloroform, contained in the 
 accompanying table, which have occurred up to date,* 
 numbering one hundred and sixty, when added to the two 
 hundred and tenf before reported, make the ghastly sum 
 total, reported and fully authenticated, of three hundred 
 and seventy. It will be seen, by a glance at the table, how 
 and why deaths from chloroform have occurred ; and how 
 unsatisfactorily, in most of the cases, the facts connected 
 with the circumstances have been reported. 
 
 COMMENTS UPON THE TABLE OF DEATHS 
 FROM CHLOROFORM. 
 
 Date when Death occurred prom Chloroform.— 
 The number of deaths in the cold months were forty-seven, 
 and against this we have forty-seven deaths during April, 
 May, June, July, and August, showing but little difference 
 in regard to temperature. 
 
 Sex. — We find there are seventy deaths in males, and 
 twenty-nine in females. Our results agree with those of 
 Sansom. 
 
 Age. — Number of cases over twenty-one, fifty-six; under 
 it, nine, the youngest of which was three (No. 157), then 
 follows one at six, eight, eleven, twelve, fourteen, fifteen, 
 sixteen, and eighteen years. 
 
 Character of the Operation for which the Chlo- 
 roform was administered. — In many instances the 
 chloroform was employed for trifling ailments, which could 
 have been relieved by less hazardous means, or in surgical 
 operations of minor importance, as follows : facial neuralgia, 
 asthma, headache, toothache, sleeplessness, uterine trouble, 
 etc. Of the operations, there were fourteen cases of extrac- 
 tion of teeth ; then follows introduction of catheter, extrac- 
 tion of thorn, amputations of fingers and toes, hydrocele, 
 
 * The author desires to acknowledge his obligations to Dr. C. S. 
 Turnbull for valuable assistance in the preparation of this table, also 
 to Dr. H. F. Sterling for collecting cases. 
 
 t Medical News and Library, Philadelphia, up to 1869. 
 
114 ARTIFICIAL ANAESTHESIA. 
 
 removal of dead bone, dressing of fractures, tumors of small 
 size, fissure of anus, cataract, iridectomy, and strabismus ; 
 many of which could have been performed without an anaes- 
 thetic, or if this was insisted upon, sulphuric ether, hydro- 
 bromic ether, or nitrous oxide, could have been employed. 
 
 The time at which the Patient died.— In twenty- 
 four instances before the operation, sixty-one during, and 
 only ten after the operation. 
 
 The Quantity of Chloroform Employed. — The 
 smallest quantity employed was a few drops in case No. 
 142; then in case No. 21 fifteen to twenty drops, in case No. 
 156 forty drops, case No. 28 six minims, and in eight cases 
 one drachm only was employed ; in twelve cases, two 
 drachms ; from half an ounce to one ounce in most of the 
 other cases, with one exception, in which it was stated a 
 large amount, in case No. 20, was employed. 
 
 Form of Apparatus.— In nine cases a towel or napkin 
 was used ; in two, upon lint and sponge ; one in the sitting 
 posture ; in one, large amount carelessly administered ; one 
 lying on abdomen. 
 
 Condition of Patient.— The first most prominent con- 
 dition of a patient was the habitual employment of chloro- 
 form (three), either to induce sleep, relieve pain, or in most 
 instances as an intoxicant, at first in moderate quantity and 
 then increasing it, forgetting its fatal nature. The second 
 condition was its fatal effects upon persons of an intemperate 
 habit (three), anaemic (two), or disease of heart, or broken 
 down in general health. On the other hand, however, 
 many are cut down in a perfectly healthy condition, after 
 the heart has been examined and considered all right (five). 
 
 Symptoms. — The most prominent symptoms of chloroform 
 poisoning will be found to be the fainting of the patient, fail- 
 ure of the pulse, heart's action, and ceasing of the respiration, 
 stertorous breathing, face livid, convulsive movements, and 
 dilatation of the pupil. 
 
 The Cause of Death. — Out of twenty-seven cases, the 
 majority of deaths is stated to be from collapse (in fourteen 
 cases), from shock (two), syncope (one), asphyxia (three), 
 from disease or paralysis of the heart (five), chloroform 
 poisoning (two). 
 
 Post Mortem Appearances. — Heart affections seem to> 
 
DEATHS FROM CHLOROFORM. 115 
 
 have been the chief causes for death reported. Fatty de- 
 generation of the heart was found in seventeen cases ; other 
 cardiac lesions, nine cases. An examination of our table 
 will prove the sad but positive fact that a large number of 
 patients who die from chloroform were healthy prior to 
 taking the fatal dose to relieve them of some trifling ailment 
 or for a minor surgical operation. (The results confirm the 
 experiments of Schiff, who stated that in more than five 
 thousand cases that chloroform paralyzes the heart and 
 blood vessels at once without previously paralyzing the 
 respiration.) Thirty cases were either healthy, or post mor- 
 tem results were negative ; in one case the patient had been 
 carefully examined, and no disease of heart or lungs was 
 found to exist ; one had inhaled chloroform the day before. 
 In two cases, from vomiting, followed by deep inspiration, 
 the food was found drawn into the trachea ; in one, trache- 
 otomy of no avail ; in the other case, patient died alone 
 .(self-administered). In many of the cases the post mortem 
 conditions are given in detail, as though they were patho- 
 logical changes. 
 
 CHLOROFORM GIVES BUT LITTLE WARNING !— The ra- 
 pidity with which patients die from it is as follows : — 
 
 1 patient, instantly, struggling stage, . . died in 1 second. 
 
 1 " suddenly, " 1 £ minute. 
 
 1 " "2 " 
 
 1 " "3 " 
 
 4 " " 5 
 
 1 " . . " .6 
 
 4 " "10 
 
 2 " " 15 
 
 2 " " afew" 
 
 Schiff also confirms the results in this table, as he, too, 
 has found death to occur from chloroform at the first inspi- 
 ration. 
 
 NITRITE OF AMYL (C 5 H xl N0 2 ). 
 
 This valuable drug was discovered by Balard in 1844, and 
 within the last few years nitrite of amyl has assumed con- 
 siderable importance as a remedy in all spasmodic affections, 
 and as an antidote to chloroform poisoning. The first notice 
 
116 ARTIFICIAL ANAESTHESIA. 
 
 of its effects was by Professor Guthrie, who, while distilling 
 nitrite of amyl from amy lie alcohol, observed that the vapor, 
 when inhaled, quickened his circulation, and made him 
 feel as if he had been running. There was flushing of his 
 face, rapid action of the heart, and difficult breathing. 
 
 Perfectly pure nitrite of amyl can only be obtained by 
 many careful distillations. It boils constantly at 96° C, 
 while specimens examined by Dr. Greene, of this city, were 
 found to have boiling points ranging between 60° and 180° 
 C. Such products, he observes, have never been rectified ; 
 one specimen had not entirely distilled at 220° ; another con- 
 tained about ten per cent, of water, twenty-five per cent, of 
 amyl nitrite (90° to 100° C), and the remainder was com- 
 posed almost entirely of unaltered amylic alcohol. 
 
 If the nitrite of amyl is made from amylic alcohol, it 
 should be that which passes after two or three fractionations 
 between 128° and 132° C, the difficulty of not obtaining it 
 pure enough being due to a faulty process or carelessness in . 
 its rectification. 
 
 A very fair yield of nitrite of amyl may be obtained by 
 the action of potassium nitrite and sulphuric acid. The 
 potassium nitrite may be easily made by maintaining potas- 
 sium nitrate for some time at a dull red heat. It is then 
 heated with amylic alcohol in a flask on a water bath, and 
 sulphuric acid, diluted with its volume of water, gradually 
 added. The nitrite of amyl distills over regularly with some 
 vapor of water. After washing the product with a solution 
 of potassium carbonate, and drying it with solid potassium 
 carbonate, it is again distilled, and all that passes below 100° 
 C. may be retained. 
 
 Four ounces of commercial nitrite re-distilled by Dr. 
 GreCne, to obtain for me a pure specimen, yielded less than 
 one ounce. This accounts for the very variable effects ob- 
 served by the different observers. For my part, I have, at 
 times, been very much disappointed in it, and on examina- 
 tion of the drug, obtained from a first-class store, it was 
 found to be amylic ether, with only a small proportion of 
 the nitrite of amyl. 
 
 The same difficulty is experienced in Great Britain in 
 obtaining pure nitrite of amyl, as may be seen by the 
 following : 
 
EFFECTS OF NITRITE OF AMYL. 117 
 
 "The purity of this drug was discussed before the British 
 Pharmaceutical Society, in September, 1878, by Mr. D. B. 
 Dott. His paper embodied the results of an examination of 
 several samples of nitrite of amyl procured from different 
 makers, with the view of ascertaining the degree of purity 
 of the article in the market. The samples examined had a 
 specific gravity varying from .864 to .876, the proper specific 
 gravity being .877. By a single rectification they gave a 
 yield of 6.7, 11.5, 33.3, 47.5, and 65.0 per cent, respectively, 
 boiling at 90° to 100° C, while a sample prepared by the 
 author in the ordinary way gave 85.0 per cent. One of the 
 samples had an odor quite distinct from that of genuine 
 nitrite of amyl, and produced little effect on the heart's 
 action by the inhalation of its vapor. It will thus be seen 
 that there is a great variation in the quality of the amyl 
 nitrite of different makers, and that some of it is of very 
 inferior quality. The author considers that some standard 
 .of purity less rigid than that of the Pharmacopoeia ought to 
 be adopted, as it is impossible to prepare a nitrite of anryl 
 boiling constantly at 205° .F. Indeed, there seems to be 
 some doubt as to whether that is really the correct boiling 
 point. The process for preparing nitrite of amyl by passing 
 nitrous acid gas through amylic alcohol is held to be the 
 best, being decidedly preferable to that by the direct action 
 of nitric acid on the alcohol." 
 
 EFFECTS OF NITRITE OF AMYL. 
 
 There is a very great difference in the effects which nitrite 
 of amyl, chemically pure, produces in different persons. I 
 know of two persons who cannot approach it without 
 immediately experiencing a feeling of distress in the region 
 of the heart, accompanied by a sense of faintness. Another, 
 after one whiff", swung around, and would have fallen to the 
 ground if support had not been at hand. In my own case, 
 I can inhale it with impunity, and it requires five to ten 
 seconds before flushing of the face, disturbance of the heart, 
 or giddiness are induced. 
 
 When first employed it was with the greatest amount of 
 care, and was supposed to be very dangerous, but we have 
 not found it to be so, nor have we as yet known of a single 
 death from it, when used as a therapeutic agent. 
 
118 ARTIFICIAL ANAESTHESIA. 
 
 In a case of spasm of the glottis, following pneumonia, I 
 employed inhalations of the nitrite of amyl, in the form of 
 the glass globules, " pearls of nitrite of amyl," with success, 
 much to the relief of the patient. 
 
 While traveling during the summer of 1877, I met a well- 
 known gentleman of Philadelphia, the late Mr. E. Bonsell,* 
 who was affected with angina pectoris. A vial of nitrite of 
 amyl was his constant companion for several years. Every 
 little while he would inhale its vapor with decided benefit 
 and relief. He had done so for many months without the 
 least deleterious effect. 
 
 In another case this remedy completely failed, and hypo- 
 dermic injections of morphia had to be resorted to during 
 the attacks. 
 
 In most of cases it is best administered lying down. 
 Women are more susceptible to its effects than men. Given 
 internally, with mucilage and an aromatic, it will at times 
 produce nausea ; generally an irritation of the throat. This 
 is increased by the impurity of the drug. 
 
 Taking into consideration the different idiosyncrasies and 
 susceptibilities, it is better in all cases to begin with the 
 minimum dose, say one drop, and gradually increase if w T ell 
 tolerated. It should never be trusted to the patient until its 
 effects upon his system are well known. 
 
 NITRITE OF AMYL AS AX ANTIDOTE TO 
 CHLOROFORM. 
 
 Dr. Rurrall, of New York, has recapitulated the experi- 
 ments performed upon cats and dogs by others and himself, 
 and set the amyl down as an agent which should always be 
 in the armamentarium of the medical man, who went pre- 
 pared to meet any emergency that might arise while pro- 
 ducing amesthesia with chloroform. 
 
 Dr. W. L. Lane has repeated numerous exi>eriments on 
 animals with the nitrite of amyl, and states: "When in- 
 haled in small quantities, it produces recovery from chloro- 
 form insensibility by dilating the arterioles of the brain, and 
 thus removing the cerebral anaemia due to the chloroform. 
 It also helps to produce recovery from the chloroform in- 
 
 *He 
 
 died at the advanced age of eighty-two during 1879. 
 
SUCCESSFUL RESUSCITATION BY AMYL NITRITE. 119 
 
 sensibility by raising the temperature, which is always 
 lowered by chloroform, and by removing the paralysis of 
 the heart due to chloroform. This action is well seen by 
 the nitrite of amyl making the heart's beats fewer and 
 sounds louder. This action of the nitrite of amyl in flush- 
 ing the face and eyes, causes increased heat, and makes 
 the heart beat slower, but with an irregular action, as we 
 have experienced in our own person, in doses of two mini- 
 mis and a half by inhalation." 
 
 Dr. Lane also states, by way of caution, that where the 
 pure nitrite of amyl is inhaled in large quantities, instead 
 of producing recovery from chloroformic insensibility, it 
 not only retards it, but it may cause death by paralysis and 
 over distension of the heart and engorgement of the venous 
 system. In large doses (inhaled) it produces a fall of tem- 
 perature. 
 
 FIVE SUCCESSFUL CASES OF RESUSCITATION 
 OF THREATENED DEATH FROM CHLORO- 
 FORM. 
 
 Dr. Minnie, in American Journal Medical Sciences, Jan- 
 uary 4, 1878, states: "The beneficial effects of nitrite of 
 amyl in stimulating the heart, and thus permitting the con- 
 tinued administration of ether (in an operation for ovariot- 
 omy), were witnessed by all the physicians present, and 
 are unquestionable. He also state* that two cases of resus- 
 citation from chloroform syncope by amyl-nitrite have been 
 reported by Dr. Pilcher in his report on croup and diptheria ,- 
 and very recently* I find a case published in which the in- 
 halation of the nitrite of amyl, which fortunately was at 
 hand, according to the testimony of physicians present, re- 
 vived the patient from sudden chloroform collapse, and 
 saved her life." 
 
 The editor of the British Medical Journal says: "We 
 have received the following interesting report for publica- 
 tion from a physician : — 
 
 " On the 9th instant I was asked by a professional friend 
 to administer chloroform to a patient of his, from whom he 
 was about to remove a fatty tumor situated in the left lum- 
 bar region. The patient in question was about forty-nine 
 
 * British Medical Journal, August 18, 1877. 
 
120 ARTIFICIAL ANAESTHESIA. 
 
 years of age, married, the mother of several children, of 
 thin, spare habit, but otherwise in good health. She was 
 nervous, and apprehensive of the result, entreating me not 
 to give her too much chloroform. Having previously ex- 
 amined the heart and found all sounds normal, I gave her 
 about two teaspoonfuls of brandy undiluted ; and after 
 waiting a few minutes and placing her in a recumbent 
 posture, I commenced the administration. The chloroform 
 I used was Duncan & Flockhart's, upon the purity of which 
 we can always depend. T poured a measured drachm upon 
 a piece of lint enveloped in a towel. I held it some little 
 distance from her mouth and nose, and let her inhale 
 slowly. My friend noted her pulse, whilst I carefully 
 watched the respiration. The first dose did not produce 
 any effect, and I then used another drachm, which soon 
 caused a good deal of excitement, incoherent talking, and 
 struggling, the patient striving several times to snatch the 
 inhaler from my hand. This gradually subsided, and she 
 appeared to be passing into the third stage of anaesthesia, 
 when she made an abortive attempt to vomit, raised her 
 head from the pillow, and, to my friend's great alarm, the 
 pulse flickered and stopped altogether. She gave a gasp, 
 foam gathered on her lips, her jaw became rigid, and to all 
 appearance she was dead. I immediately withdrew the 
 chloroform, my friend dashed some cold water in her face 
 and pulled her tongue forward, whilst I commenced artifi- 
 cial respiration, after Marshall Hall's method, but without 
 success. We then poured some nitrite of amyl on lint, and 
 held it to her nostrils. In such emergencies it is impossible 
 to judge the flight of time correctly, but I should say in ten 
 seconds there was a flushing of the face, the pulse was 
 again felt, and, to our great joy, the all important function 
 of respiration was again restored, the woman being rescued 
 apparently from the very embrace of death." 
 
 An English journal reports a case of threatened death 
 from chloroform, in which the patient was resuscitated by 
 the inhalation of a few drops of nitrite of amyl. The indi- 
 cation for the use of amyl is furnished by the sudden failure 
 of the pulsed 
 
 * Medical Record, May 25th, 1«7S. 
 
FAILURE OF AMYL NITRITE TREATMENT. 121 
 
 A case of the successful use of nitrite of amyl in a case of 
 chloroform narcosis is reported by Doctor Rums R. Hinton, 
 in the Philadelphia Medical Times, of January 31st, 1875. 
 
 DEATH FROM CHLOROFORM NARCOSIS.— FAIL- 
 URE OF NELATON'S METHOD, AND OF THE 
 AMYL NITRITE TREATMENT. 
 
 Dr. Hugh M. Taylor, of Richmond, Virginia, reports the 
 following case in the Virginia Medical Monthly, of May, 
 1878:— 
 
 "Professor McGuire has requested me to report the fol- 
 lowing death from chloroform, which occurred a few days 
 ago in his practice. As far as I can learn, it is the second 
 death from this agent which has occurred in our city, and 
 is one of the very few recorded by our Southern surgeons: — 
 "The patient was a gentleman from North Carolina, set. 
 41 years. Twelve or fourteen months ago he received a 
 violent blow upon his perineum by being thrown upon the 
 pommel of a saddle. His urethra was ruptured; this was 
 followed by urinary infiltration, abscesses, resulting in. the 
 loss of the entire penis, and part of the scrotum. Since 
 that time he has been a very great sufferer, and had become 
 entirely dependent upon anodynes, frequently taking as 
 much as two grains of the sulphate of morphia a day. 
 During the last six months of his sickness, he has spent 
 most of his time in bed or in the recumbent position. 
 
 "On the day of operation, April 20th, 1878 (Doctors Cun- 
 ningham, Ross, Leech, Maclin, and Carroll co-operating), 
 Squibb's purified chloroform was administered, for the pur- 
 pose of making a direct outlet for the urine by external 
 perineal urethrotomy. The administration of the anaes- 
 thetic was begun while the patient was in his bed. He was 
 then put upon a table in the lithotomy position, and the 
 table was drawn near an open window, occupying a position 
 directly between the open window and an open door. I 
 noticed, when giving him chloroform in his bed, that he 
 was not easily brought under its influence. Some delay 
 occurred in the first part of the operation in consequence of 
 the extensive undermining of the tissues and burrowing of 
 the urine and pus, leaving a great number of false passages, 
 and rendering it tedious to get a guide of any sort into the 
 
122 ARTIFICIAL ANAESTHESIA. 
 
 bladder. During this stage of the operation, he was not 
 kept fully under the chloroform. After some effort, the con- 
 tinuation of the urethra was found, and an. instrument 
 passed into the bladder. The administrator then carried 
 the anaesthesia far enough to allow the operation to be fin- 
 ished. He had done this, and had taken the chloroform 
 away for a few seconds, when we were all startled by one or 
 two stertorous respirations, and then followed an entire ces- 
 sation of respiratory effort. 
 
 "In less time than I can tell it, his tongue was drawn for- 
 ward with a tenaculum ; his feet were raised, and his head 
 was lowered; water was dashed in his face; his cheeks 
 smacked; nitrite of amyl held to his nose. As none of 
 these aroused him, he was quickly placed on the table and 
 artificial respiration resorted to. Dr. Ross and I raised and 
 depressed his arms, while Doctors McGuire and Cunning- 
 ham compressed his thorax. Let me here remark that I 
 am sure in this case the death was not from asphyxia or the 
 impregnation of his blood with carbonic acid. The efforts 
 at artificial respiration were eminently successful. As the 
 arms were raised, the air rushed into his lungs, producing a 
 stertor as natural as life— and then when the thorax was 
 compressed, the blowing sound of exit was plainly heard. 
 Indeed, these artificial inspirations and expirations were so 
 strikingly normal as to deceive me for some time into 
 believing them vital. During this time whiskey was 
 injected into his rectum ; amyl occasionally held to his nose, 
 and the foot of the table elevated. Only once during our 
 prolonged efforts to resuscitate him was there the least token 
 of returning animation, and that was when the first dash of 
 cold water struck his face. Then he gasped feebly — but 
 once. His features from the first were blanched and blood- 
 less ; he carried to his grave the finger marks produced by 
 slapping him ; his pupils were both widely dilated ; his lips 
 blue. He had been under the influence of chloroform for 
 about three-quarters of an hour— at no time very profoundly. 
 During this time he took about gj of Squibb's purified 
 chloroform. The large quantity of anodynes which he had 
 accustomed himself to, and the extreme sensitiveness of the 
 parts manipulated, rendered it difficult to anaesthetize him. 
 He had taken chloroform twice before he came to the city, 
 
FAILURE OF AMYL NITRITE TREATMENT. 123 
 
 and this latter trouble, viz., inability to completely affect 
 him, was noticed upon both occasions. 
 
 ' ' In reviewing the case, we conclude that death was brought 
 about through syncope ; that amyl had no effect in replen- 
 ishing the anaemic blood vessels of the brain ; and that at 
 least one case has happened when its antidotal virtues were 
 not at all noticeable ; that the result was of sudden occur- 
 ence, and of speedy termination ; that his pulse was good a 
 very few seconds before, and that the artificial respiration 
 would have oxygenated any quantity of carbonized blood 
 with which his lungs might have been surcharged; that 
 the administrator was in no manner to blame, as he fulfilled 
 his part with the utmost care and skill. The verdict of all 
 present was 'that death was caused by chloroform; but 
 that the same was carefully and judiciously administered.' " 
 
 Being desirous of knowing some obscure points in regard 
 to the way in which the nitrite had been used, I wrote to 
 Doctor Taylor, addressing the following questions : — Did the 
 nitrite of amyl produce a flushing of the face, action of the 
 heart, and difficult breathing when you employed it your- 
 self? Did you use a tube to force it up the nostrils when the 
 breathing had ceased? How many drops were employed? 
 Was it in capsules or dropped from a bottle? 
 
 The Doctor kindly replied as follows : — 
 
 Richmond, May 31st, 1878. 
 Doctor Ttjrnbukl, 
 
 Dear Sir: — Your letter, dated May 20th, found me 
 out of the city for a few days. I am very glad to answer 
 your inquiries. You say that " Professor Nelaton's method 
 will sometimes fail, especially when morphia has been used 
 with the chloroform." No morphia was given at the time, 
 with the chloroform. It was during his sickness that large 
 quantities had been administered. In regard to the amyl 
 used, it was made by Squibb, and was, I think, pure. I am 
 sorry I cannot find a sample of it to send you for examina- 
 tion. It was dropped from a bottle upon a handkerchief. 
 The number of drops were not ascertained. No tube was 
 introduced into the nose. 
 
 Very respectfully, etc., 
 
 HUGH M. TAYLOR. 
 
124 ARTIFICIAL ANAESTHESIA. 
 
 DEATH FROM CHLOROFORM IN WHICH THE 
 
 NITRITE OF AMYL WAS EMPLOYED 
 
 WITHOUT SUCCESS. 
 
 Death from chloroform April 29th, 1879, by W. P. Mills, 
 M. D.,* of Brownsville, Mobile. I was requested to operate 
 on a boy aged 16 years, for congenital phimosis. He was 
 chloroformed by Dr. A. J. Parsons, who has often adminis- 
 tered chloroform by inhalation, and, by the way, be is very 
 cautious in the administration of this potent drug. Notwith- 
 standing the great prudence, caution, and the general man- 
 ner in which it was administered, just as the operation was 
 completed, and without any indication of danger whatever, 
 instantaneously — almost as quick as the explosion of gun- 
 powder — respiration ceased, and a livid color overspread his 
 face, and in spite of all the usual restoratives, he was soon 
 dead ; in fact it seemed as if he was struck dead in an instant. 
 Immediately, upon the supervention of these alarming 
 symptoms, bis bead was lowered, cold water thrown into- 
 his face, and artificial respiration induced. Under the 
 influence of this treatment some improvement was mani- 
 fested, and for a few seconds it seemed that the danger was 
 over, but suddenly all the alarming spmptoms before 
 described were again exhibited, and death was the inevitable 
 result. Not more than three drachms of chloroform was 
 used, and of this not more than one and a half or two 
 drachms were actually inhaled, and the patient was not 
 deeply under its influence at any time during the operation, 
 which, as a matter of course, was very brief. Nitrite of 
 amyl, electricity, and hypodermic injections of whiskey 
 were all brought into requisition, but, as the sequel proved r 
 were of no avail. The most noteworthy feature of the case 
 was the very sudden supervention of the alarming symp- 
 toms, for according to my information in regard to chloro- 
 form poisoning, there is generally some warning given of 
 its deleterious influence." 
 
 * Saint Louis Medical and Surgical Journal, June, 1878, p. 492. 
 
 Note.— I do not think the doctor was justified in the use of so power- 
 ful an anaesthetic to risk his patient's life in so trifling an operation. 
 Evidently the nitrite of amyl was not employed until the patient had 
 become unable to inhale it. The conclusions are not the most recent, 
 as a careful reading of our table of deaths from it, will show. It gives- 
 hut little warning before it kills the patient. 
 
NITRITE OF AMYL. 125 
 
 PHYSIOLOGICAL EFFECTS OF NITRITE OF 
 AMYL. 
 
 In 1861-2, Dr. B. W. Richardson, of London, made a 
 careful and prolonged study of the action of this singular 
 body, and discovered that it produced its effect by causing 
 an extreme relaxation, first of the blood-vessels, and after- 
 wards of the muscular fibres of the body. In 1863 Dr. 
 Richardson employed it as an anaesthetic, but soon discov- 
 ered that it was not a true anaesthetic ; nor does it produce 
 unconsciousness until its other effects are fully developed, — 
 a feeling of sickness and distress. The blood in both sets of 
 vessels acquires a brownish color. At first it quickens the 
 respiration, but its prolonged use retards the movements of 
 the chest and lowers animal temperature. According to 
 the experiments of Droz,* when it causes death in the 
 lower animals, the first effect is great restlessness. The 
 animal sneezes and struggles to get away ; the respiration 
 becomes quickened and fuller, and occasionally stops. Fol- 
 lowing this are alternating tonic and clonic contractions in 
 the extremities, and even the face ; then opisthotonos, 
 shivering, involuntary excretions, vomiting and coma. 
 Post mortem results are not very marked, except the dark 
 color of the blood and the dilated, engorged heart, death 
 being produced apparently by paralysis of this organ. To 
 such an extent did this agent relax, that it would even 
 overcome the tetanic spasm produced by strychnia, and re- 
 lieve the most agonizing of known human maladies, — 
 angina pectoris. Even tetanus has been subdued by it in 
 two instances. In asthma, my own experience coincides 
 with that of others that it will, in certain spasmodic forms, 
 instantly arrest the paroxysm. An exceedingly convenient 
 mode of carrying the drug is by means of thin glass glob- 
 ules of nitrite of amyl, containing respectively r^iiss and 
 n^v. When required, one of the bulbs is broken in a hand- 
 kerchief or towel, and its contents immediately inhaled. I 
 have employed this agent in spasmodic ear cough, also in 
 tinnitus aurium, in which there is spasm of the muscles of 
 the ear bones, or spasmodic contraction of the capillaries, 
 
 * Arch de Physiologie, Sep., 1873. Translated by Dr. F. Woodbury, 
 Medical Times, Nov. 22, 1873. 
 
 8 
 
126 ARTIFICIAL ANESTHESIA. 
 
 in which ease I directed the patient to carry a small glass- 
 stoppered bottle, and to inhale rive or six drops on a hand- 
 kerchief, or even hold the nose for a second to the month of 
 the bottle containing a small quantity. 
 
 In an article by Dr. Aug. Ladendorf,* writing from the 
 Sachsenberg Lunatic Asylum, where his observations, em- 
 bracing more than forty cases, were made, partly upon sane 
 person's and partly on those recovering from different psy- 
 choses. The time selected was generally from three to five, 
 p. in. , or after eight p. m. , thus avoiding times when a normal 
 rise of temperature might be expected. The thermometer was 
 placed in the mouth, between the cheek and the superior 
 maxilla, — a space almost shut off by the tongue from the 
 nasal respiratory tract. The readings were made by the 
 help of a lens magnifying six times, so that by using a 
 thermometer divided into tenths it was possible to recog- 
 nize, without much chance of error, T ^oth of a degree Cen- 
 tigrade, equal to ^th of a degree of Fahrenheit nearly. 
 The general result is that the temperature always rises 
 after the inhalation. Many circumstances affect the amount 
 of this rise, such as the quantity of vapor inhaled, the sur- 
 rounding atmosphere, the contraction of blood-vessels, in- 
 dividual peculiarities, etc. So that two persons with the 
 same initial temperature may show differences of 0.53° 
 C, equal to 0.95° F. It is, however, interesting that this 
 rise can generally be demonstrated for from one to two 
 hours, for this explains the beneficial and continued effects 
 of the remedy in disease. A table of thirty-six cases is 
 given, with the temperatures observed, the differences, their 
 maxima and remarks. The smallest maximal elevation 
 of temperature was 0.1° C, equal to 0.2° F. nearly (in 
 three cases); the highest maximal rise was 1.88° C, equal 
 to 3.38° F. (one case); the mean rise was 0.39 C, equal 
 to 0.7° F. (thirty-six cases) ; or, in other words, the tem- 
 perature rises rather more than half a degree Fahren- 
 heit after the inhalation of nitrite of aniyl. This elevation 
 is very evident in the course of the second minute of inha- 
 lation. The purer the preparation inhaled, the more evi- 
 dent thfe effect. The effect on the pmoils was not very uni- 
 i 
 
 * No. 43 of the Berliner Klinische Wochenschrift. 
 
NITRITE OFAMYL. 127 
 
 form. In all the cases when simultaneous observations 
 were made, the axillary temperature rose correspondingly. 
 Horatio Wood (American Journal of the Medical Sciences, 
 cxxiii.) and Pick ( Ueber das Amy in it r it und seine Therapeu- 
 tische Anwendung, Versuch, 13) observed a fall of tempera- 
 ture in animals; but perhaps this resulted from the mode 
 of experimenting. Hostermann's account of the pulse 
 ( Wiener Med. Woehenschrift, 1872, Nos. 46, 47, 48) is con- 
 firmed by these experiments. These effects probably have 
 a common cause, not mere dilatation of the vessels. 
 
 In a careful examination of all experiments made with 
 the nitrite of amyl on man, I have not met with a single 
 case of death from it, owing, I think, to the great care with 
 which it has been employed. Two cases are recorded by 
 Sanders and Samelsohn of sudden collapse, skin cold, 
 clammy, and pulse threadlike and slow, face pale, and yet 
 consciousness was retained, and both cases recovered. 
 
 OX THE USE OF ATROPINE IN CHLOROFORM 
 
 NARCOSIS. 
 
 Prof. J. A. Larabee,* of St. Louis, Ky., was called to see a 
 patient who had inhaled one ounce of chloroform. The 
 patient was seen four or five hours after, when in a state of 
 collapse, and every known means had been resorted to to 
 restore the heart's action, but all in vain. He injected one- 
 tenth of a grain of atropine hypodermically. This par- 
 tially restored the heart's action, and in one half hour's 
 time the same was repeated ; and still later, to stimulate the 
 respiration, one-tenth of a grain of atropine was injected. 
 Four hours later the pulse and respiration had recovered 
 their tone. 
 
 ICE AS A MEANS OF PREVENTIING NARCO- 
 SIS FROM CHLOROFORM. 
 
 Another means of treating threatening narcosis caused 
 by chloroform is recommended by M. Baillee, of Belgium. 
 It consists of the introduction of a small piece of ice into 
 the rectum. A moderate degree of pressure suffices to over- 
 come the resistance of the sphincter. The ice melts in the 
 
 * Medical Record, May 25, 1S7S. 
 
128 ARTIFICIAL ANAESTHESIA. 
 
 intestine, and immediately excites a deep inspiration, which 
 is followed by the re-establishment of natural respiration 
 and of the cardiac functions. 
 
 NITRITE OF AMYL AND CHLOROFORM 
 AS AN ANAESTHETIC. 
 
 L. B. Balliet, in the Medical and Surgical Reporter, 
 says : — 
 
 "In my practice of over twenty-four years I have, until 
 recently, used chloroform as an anaesthetic in all surgical 
 cases and convulsions of children. The past six months, 
 with the object of lessening the dangers of asphyxia by this 
 powerful anaesthetic, I added to the ounce of chloroform 
 sixteen drops of nitrite of amyl. The result thus tar is 
 apparently most satisfactory. Nevertheless, further careful 
 tests are needed to fully confirm my views of this combina- 
 tion as a safe anaesthetic. I therefore ask surgeons to give 
 this a fair trial, and report their experiences in regard to its 
 action on the heart, respiration and circulation, and com- 
 pare it carefully with the symptoms produced when chloro- 
 form alone is used. I shall still continue the use of this 
 compound anaesthetic, but may vary the proportions of the 
 nitrite of amyl in particular cases." 
 
 Dr. George E. Sanford publishes in the Medical Record of 
 October 5th, 1878, the following article on "chloramyl, a 
 new anaesthetic, and an improved inhaler: " — 
 
 ''Having had considerable experience in the administra- 
 tion of the various anaesthetics in use at the present day, 
 viz., chloroform, ether, etc., and not feeling satisfied with 
 the safety, or rather unset fety of chloroform, or with the 
 many faults of sulphuric ether, which so nearly counterbal- 
 ance its comparative safety as to preclude its use in favor of 
 chloroform in many cases, I have therefore experimented 
 with various compounds in the hope of discovering a new 
 and better anaesthetic. 
 
 "Early in the month of April, 1877, while treating an 
 asthmatic patient with the nitrite of amyl, I became im- 
 pressed with the idea of augmenting the heart's action with 
 this drug, and thereby preventing the tendency to syncope 
 and asphyxia, from paralysis of the heart, in cases of chlo- 
 roform narcosis. 
 
NITRITE OF AM YL AND CHLOROFORM MIXTURE. 129 
 
 "I then be^an a series of experiments upon animals, first 
 administering chloroform and then the nitrite of amyl. 
 Then I began to mix them for use, aiming to get such a pro- 
 portion of the amyl as would just counteract the paralytic 
 effect of the chloroform. I found that while pure chloro- 
 form (Squibbs') would mix readily with the nitrite of amyl, 
 producing a fine, clear solution, the chloroform of other 
 manufacturers Avas unsatisfactory, leaving a milky solution 
 of unpleasant odor. Continuing my experiments, I came 
 to the conclusion that a quarter of an ounce of the nitrite of 
 amyl to the pound of Squibbs' chloroform was about the 
 proper strength, and that the combination was far safer 
 for general anaesthetic purposes than chloroform uncom- 
 bined; indeed, in my hands, and in those of others, so far as 
 tried, it seems to be fully as safe as sulphuric ether, and far 
 more pleasant in its administration, possessing ail of the 
 advantages of pure chloroform, but without its dangers. 
 
 "Upon becoming satisfied of the value of my discovery, I 
 named it chloramyl. I first administered chloramyl to per- 
 sons in June, 1877, as follows: — June 6th, I administered the 
 compound to Charles Detriek, a young, healthy man, for 
 the purpose of dressing a badly crushed thumb, both the 
 patient and bystanders being wonderfully pleased with its 
 operation. Next, June 16th, I gave it for amputation of a 
 finger; then, June 18th, for extraction of a tooth; since 
 which time I have employed it (chloramyl) in a great 
 variety of cases in both surgical and obstetrical practice. I 
 find that patients usually take it better than chloroform 
 alone, and so far there has not been the first indication of 
 danger from its use. In exhibiting chloramyl the patient's 
 face becomes flushed much sooner than. with chloroform; 
 but press the drug right along and the countenance does not 
 become pale. Both the heart's action and respiration are 
 kept up thoroughly throughout the anaesthesia. I have 
 given this prescription to several physicians, and induced 
 them to try the chloramyl, with the most satisfactory results. 
 I have also (last month) communicated the same to Profes- 
 sors Maclean, Dunster, and Frothingham, of Michigan 
 University; and have reported my discovery to the Cayuga 
 County, New York, Medical Society. 
 
 '•Having noticed lately several communications in the 
 
130 ARTIFICIAL ANESTHESIA. 
 
 columns of the Record, from Dr. F. A. Burrall and others, 
 on the use of amyl nitrite as an antidote to chloroform in 
 cases of poisoning, I concluded to publish my discovery. 
 As Dr. Burrall states in his article in the Record of July 20th, 
 ' With our present knowledge of the antidotal properties of 
 amyl nitrite in relation to chloroform, it is but justice to our 
 patients to have it at hand when chloroform is adminis- 
 tered.' I agree with him that we should have it at hand, 
 but not in a separate bottle, to use after the danger has be- 
 come imminent, but (as it produces no ill effects) mixed with 
 chloroform, in such a proportion as to prevent the approach 
 of danger, by both syncope and asphyxia ; for such I claim 
 to be the effect of this combination, and as such I give 
 chloramyl to the medical profession, asking that it may be 
 given a full and fair trial, and trusting that it may become 
 the humble instrument in other hands of saving human life. 
 Not that I would detract from the honors due the inventor 
 of chloroform, for it was a grand invention ; but if we can 
 relieve its administration from the embarrassment and dan- 
 ger which have heretofore attended its use, will it not indeed 
 be a great boon to humanity? 
 
 " The formula I use for chloramyl is — 
 
 I*. Squibbs' chloroform, i lb. 
 
 Nitrite of amyl, Sii.— M. 
 
 " But I would suggest that the amount of nitrite of amyl 
 be diminished in long and tedious operations, and on farther 
 trial it may prove best to vary the proportions, the point 
 aimed at being to use just sufficient amyl nitrite to counter- 
 act the paralytic effect of the chloroform." 
 
 Doctor F. A. Burrall a short time after expressed his opinion 
 in the following words, alluding to Doctor Sandford's com- 
 munication, and addressing the editor of the Medical 
 Record : — 
 
 "The communication in your number of October oth, 
 1878, from Doctor George E. Sandford, is of decided interest, 
 both as affording a hope that the dangers of chloroform may 
 be diminished, and also as related to one of the most inter- 
 esting branches of practical medicine. I refer to the 
 simultaneous employment of antagonistic drugs. Those 
 who have read Fothergill's recent work on the Antagonism 
 of Medicines will be impressed with the truth of the author's 
 
MIXTURE OF TURPEXTIXE AND CHLOROFORM. 131 
 
 remark that this counteraction of medicinal agents ' prom- 
 ises to be the most potent and, withal, the most precise subj ect 
 connected with therapeutics.' " 
 
 In a paper read before the Southern Michigan Medical 
 Association, July 13th, 1875, by W. N. Smart, M. D., of 
 Hudson, Michigan, he thus refers to an experiment in which 
 chloroform and nitrite of amyl were administered together, 
 and which may be interesting in this connection : — 
 
 "Gave a half-grown kitten a mixed vapor of chloroform 
 and nitrite of amyl, containing about forty-nine parts of the 
 former to one of the latter. I gave this by placing chloro- 
 form and amyl, in the above proportion, in a thick cloth 
 sack, which was drawn over the head and held close around 
 the neck, the chloroform and amyl being renewed several 
 times, in order to insure a strong vapor. The effect pro- 
 duced by breathing this vapor for fifteen minutes is a rapid, 
 though deep inspiration ; a rapid and rather feeble action of 
 the heart; an inability to co-ordinate movements; a very 
 slight degree of anaesthesia, and a species of intoxication 
 resembling that produced by alcohol." 
 
 How far chloramyl will answer as a safe substitute for 
 chloroform can only be determined by experiment. Since 
 it is estimated that one death occurs in about twenty-five . 
 or twenty-seven hundred administrations of chloroform, it is 
 evident that some time must elapse before the comparative 
 merits of any new anaesthetic can be considered as established. 
 For the present it seems to me that humanity and science 
 alike require that when chloroform is used as an anaesthetic, 
 the nitrite of amyl should be at hand as one of the remedies 
 whose efficiency is to be tested in case of impending danger. 
 
 THE USE OF A MIXTURE OF OIL OF TURPEN- 
 TINE AND CHLOROFORM IN THE PREVEN- 
 TION OF CHLOROFORM NARCOSIS. 
 
 In the Vierteljahrschrift fur Gericht Med., Doctor Wach- 
 smuth, of Berlin, makes the important statement that if 
 one-fifth part of oil of turpentine is added to chloroform, the 
 latter can be administered to the fullest anaesthesia without 
 the slightest risk, as the turpentine -prevents, by its stim- 
 ulating properties, the pulmonic paralysis, which is the 
 proximate cause of death in fatal chloroform narcosis. 
 
132 ARTIFICIAL ANAESTHESIA. 
 
 I employed this mixture in two eases, in which I could 
 not use ether, and it answered the purpose very well, but as 
 the operations were not protracted, further trials will be 
 necessary, as in small doses it produces stimulation of the 
 nervous system, but paralyzing effect when large quantities 
 are administered. 
 
 THERAPEUTIC USES OF NITRITE OF AMYL. 
 
 Dr. S. Weir Mitchell of this city was the first to employ 
 inhalations of nitride of amyl in epilepsy, and he reported 
 a number of successful cases. Others have followed with 
 results not quite as satisfactory. In our own cases we found 
 it to be useful, but not curative. .It modifies the intensity 
 of the attacks, especially when they come close together. 
 
 Dr. Brunton first employed nitrite of amyl in angina 
 pectoris, and found it more effective than any other remedy 
 in this painful and dangerous disease. Since then it has 
 been largely used with signal success, although in an occa- 
 sional case the relief is only temporary. 
 
 At a discussion upon the effects of the nitrite of amy], 
 before the Medico-Psychological Society of Berlin,* Dr. Sol- 
 ger had used the nitrite of amyl in a case of unilateral 
 clonic spasm in a child without success. Chloroform used 
 in the same case caused the convulsions to disappear for 
 some time. The effect of chloroform seemed to be antag- 
 onistic to that of nitrite of amyl. The vessels of the pia 
 matter exposed in a rabbit under the influence of chloro- 
 form were seen to be contracted, while upon inhalation of 
 the nitrite they became enlarged. Dr. Jastrowitz used the 
 nitrite of amyl with good results in asthma, but in the case 
 of melancholia and other forms of insanity without bene- 
 ficial effect. Inhalation of the drug causes disagreeable 
 dizziness. He would not, therefore, use it in cases of vertigo. 
 His impression was that hyperoemia of the brain did not 
 extend throughout that organ, since, in patients who had 
 used the remedy for some time, hyperoemia of the optic pa- 
 pilla could not be observed either during inhalation or in 
 the intervals. Dr. J. mentioned cases illustrating the 
 danger sometimes attending the inhalation of the nitrite 
 
 * Wein Medical Press. Feb. 28, ls75 ? and Medical Times. April 24, 1875- 
 
NITRITE OFAMYL IN THERAPEUTICS. 133 
 
 and the necessity of caution in its employment. In these 
 cases sudden collapse followed its use. He had subsequently 
 met with Schuller's experiments, showing that a marked 
 contraction of the vessels of the pia followed the usual dila- 
 tation. He had also observed that certain patients volun- 
 tarily alluded to the fact that objects appeared of a yellow 
 color subsequent to the use of the nitrite. 
 
 In "flushings of heat," or " heats," which so frequently 
 trouble women at the change of life, or caused occasionally 
 by the sudden arrest of menstruation, the action of nitrite 
 of amyl, according to Ringer, is very marked, preventing 
 or greatly diminishing" the profuse perspiration and conse- 
 quent prostration. It is said to be useful in sick headache 
 and in preventing sea-sickness. It is stated to have arrested 
 a paroxysm of intermittent fever when inhaled during the 
 cold stage in the dose of four drops. In a case also of syn- 
 cope in a man affected with cardiac dilatation and hyper- 
 tropy, the inhalation produced relief. 
 
 Doctor J. Michel, of Hamburg,* lias made a series of ex- 
 periments with this remedy, in tinnitus auri.um, and came 
 to the conclusion that it was especially suggested in that 
 form accompanied by hypertrophic changes in the middle 
 ear, and in affections of the labyrinth. He was led to em- 
 ploy this remedy from its well-known sedative action upon 
 the sympathetic system, especially the vaso motor nerves, 
 and the fact that many forms of tinnitus are caused not only 
 by an increased intra-labyrinthine pressure, but occur as the 
 result of nervous irritation, not only of the auditory nerve 
 but in branches of the fifth, of a neuralgic character or 
 trophic type of changes. The remedy was employed in 
 twenty-five cases by himself, and in six cases by Doctor 
 Urbantschitsch. More or less improvement occurred in 
 nineteen cases; among these were three in which the tinni- 
 tus disappeared entirely from one ear, and in another case 
 was somewhat diminished. From one to five drops of the 
 remedy were inhaled at a sitting. The inhalation was con- 
 tinued during the appearance of the usual symptoms— flush- 
 ing of the face, injection of the blood vessels of the eve etc. 
 
 by 
 
 » On the use of the nitrite of amyl in diseases of the ear. Translated 
 C . J. Blake, M. D., Arch. Ophth. and Otol., New York, 1878. 
 
134 ARTIFICIAL ANAESTHESIA. 
 
 and suspended on the occurrence of vertigo. In all, the 
 cases improved ; the tinnitus was increased during the period 
 of inhalation. 
 
 I have employed this agent in various forms of tinnitus 
 aurium in a large number of cases ; some were benefitted, 
 but the majority were not improved, this being in part due, 
 I think, to the impurity of the agent employed. 
 
 MIXED NARCOSIS. 
 
 " During the past two or three weeks," says the Lancet, 
 December 1, " a novel mode of producing anesthesia, called 
 mixed narcosis (gemischte narkosc), has been employed by 
 Thiersch of Leipzig, whereby insensibility to pain may be 
 procured without the total abolition of consciousness. The 
 credit of the discovery is ascribed to Prof. Nussbaum of 
 Munich. Although suitable for all kinds of operations, it 
 is especially serviceable for operations about the mouth and 
 jaws, in which blood is apt to flow into the trachea, or down 
 the oesophagus into the stomach, and subsequently to cause 
 vomiting. In some cases of the removal of the upper jaw 
 lately performed by Thiersch, the patient allowed the blood 
 to accumulate for a while at the back of the pharynx, and 
 then spat it completely out when asked to do so; and we 
 are informed that in one instance the patient watched with 
 evident interest, the motion of the saw that was dividing 
 his upper jaw-bone. 
 
 " A subcutaneous injection of morphia, from a quarter to 
 half a grain, is given as soon as the patient is placed upon 
 the operating table, and immediately afterward the admin- 
 istration of chloroform is commenced. After inhalation for 
 about five minutes the operation may usually be begun, but 
 the chloroform must be renewed at intervals. The patients 
 loose all sensibility to pain, but evidently retain a consider- 
 able degree of consciousness and control of voluntary move- 
 ments.. Within the last month mixed narcosis has been 
 employed five times successfully, as far as the annihilation 
 of pain is concerned, and without any bad effects." 
 
 The dose of morphia which is given in the communica- 
 tion in the Lancet is too large for safety, as there are many 
 persons on whom even one-quarter of a grain of morphia 
 hypodermically will act as a powerful poison, while half a 
 
CHLOROFORM IN THERAPEUTICS. 135 
 
 grain even produces death. The injection of morphia 
 should be small, say from one-eighth to one-quarter, and 
 this should be given, according to Claude Bernard, from 
 forty minutes to one hour before the chloroform is employed. 
 The question should always be put to the patient, Have you 
 ever employed morphia, and if so, what effect has it upon 
 you ? The great advantage claimed for this method is that 
 the stage of excitement is rendered always nil, and less 
 chloroform is needed to induce sleep than under ordinary 
 circumstances. It must always be borne in mind that 
 nausea aud vomiting are not uncommon at the commence- 
 ment if the morphia is quickly absorbed. This, with the 
 vomiting which accompanies chloroform, will, we fear, be 
 apt to complicate a delicate operation, and then you have 
 the double risk of two such poisonous agents. 
 
 CHLOROFORM IX THERAPEUTICS. 
 
 Internal use in Substance or Vapor. — Chloroform is used 
 in medicine both, for its stimulant and narcotic properties, 
 to increase force, subdue spasm, and relieve suffering. Given 
 in large doses it abolishes pain and contraction, paralyzes 
 muscle and nerve, profoundly depresses force, and leads to 
 death. The largest amount of chloroform inhaled by one 
 person was one hundred and twelve and a half drachms in 
 one day; another took one pound in five days; recovery 
 has occurred after the swallowing of two ounces of chloro- 
 form. 
 
 After the continuance of the habit of chloroform-taking 
 the following symjitoms generally appear, in the following 
 order: (1) 'sleeplessness of a most distressing character, and 
 only to be overcome by abstinence from chloroform; (2) 
 deafness; (3) apathy and disinclination to society and to 
 conversation ; (4) tremulousness of the hands. 
 
 Experience shows that frequent chloroform inhalation is 
 like "dram-drinking." Its effects are similar to those of 
 alcoholism, and it will produce symptoms resembling 
 mania-a-potu. In the report of the committee of the Medi- 
 cal and Chirurgieal Society of London, it is stated that a 
 man who had been accustomed to the use of enormous doses 
 of chloroform to relieve asthma, frequently inhaling forty 
 drachms a day, was reported to have had this appearance 
 
136 ARTIFICIAL ANJESTHESIA. 
 
 " on his admission to the hospital; he seemed in a constant 
 state of dullness, or like a person intoxicated.'' 1 
 
 Chloroform, by its wonderful power over pain and muscu- 
 lar spasm, has been employed in cases of poisoning by stry- 
 chnia, with decided success ; even should it, as was proved, 
 have no antidotal action, it is of great service in relieving 
 the fearful suffering, reducing the pulse to its natural stand- 
 ard, and causing respiration to become more easy. Another 
 important matter is that, under chloroform or ether anaes- 
 thesia, the tetanic convulsions from the strychnia are so 
 controlled that nutritive enemata may be administered and 
 retained. 
 
 Chloroform is valuable in the treatment of acute mania, 
 chorea, and convulsions, especially in children, also in 
 puerperal convulsions ; it has proved to be an efficient 
 remedy in our hands in procuring sleep. In cases of delir- 
 ium tremens, in the reduction of hernia, and the diagnosis 
 of abdominal tumors, chloroform will be found most valu- 
 able. 
 
 The late Dr. Snow relates an interesting case of a scientific 
 man who became insane and refused to take food. It was 
 found that if chloroform were given, and food offered during 
 the wakeful stage, the patient would take it; chloroform 
 was, therefore, administered before every meal for a long 
 period. It has also been employed in -the delirium of fever 
 in cases where the patient has been worn out, in spasmodic 
 diseases of the air passages, spasm of the glottis, laryngeal 
 cough, spasmodic croup, and whooping-cough when in very 
 dilute vapor. 
 
 Dr. Sansom has found great value from the use of chloro- 
 form in several cases of phthisis. The same authority states 
 that in some cases of chronic bronchitis, in acute bronchitis, 
 and in pneumonia, when danger may occur from stasis of 
 blood in the lungs themselves, it is not advisable to employ 
 chloroform by inhalation. In paroxysmal and violent 
 cough (combined with morphia, glycerine, and water) it 
 is often very beneficial ; and in the early part of the 
 treatment of asthma, thirty to fifty drops inhaled from a 
 handkerchief relieve the spasm, induce narcosis, and pre- 
 vent the paroxysms. 
 
 Dr. Hyde Salter, the great authority in the treatment of 
 
CHLOROFORM IN THERAPEUTICS. 137 
 
 spasmodic asthma, says : " The inhalation of chloroform is,. 
 beyond doubt, one of the most powerful methods of treat- 
 ment of the asthmatic paroxysm that we possess. ' ' Properly 
 diluted, the vapor is not pungent; and instead of increasing 
 any tendency to spasm, at once relaxes it. Dr Baiter has 
 never seen any bad effects from chloroform administered in 
 the height of a paroxysm of asthma, and persons sound 
 asleej) may be chloroformed without their being awakened. 
 Anaesthesia cannot, however, be produced in any one par- 
 tially awake, or even lightly sleeping, without their know- 
 ledge. 
 
 One of the secondary effects of the prolonged use of 
 chloroform in asthma is an increase of the asthmatic tend- 
 ency. The use of chloroform must no more be allowed to 
 become a habit than the use of opium. We have repeated 
 this experiment in seven cases of.asthma, and. although we 
 felt some apprehension, still no disagreeable symptoms 
 presented themselves, and 'the patient was relieved of the 
 attack; but it returned, and, fearing its injurious influence, 
 we substituted hydrate of chloral during the paroxysms, 
 especially when sleeplessness occurred. Patients vary in 
 the benefit which they derive from chloroform; in some, 
 small quantities not only relieve the urgent distress, but 
 also prevent its recurrence. The congestive chills of the 
 South, or the cold stage of intermittent fever, may be short- 
 ened, so as to gain time for the introduction of quinine into 
 the system, by the inhalation of chloroform, Dose, twenty 
 drops, sprinkled on a fine net, permeable to the air, and 
 repeated several times until the effect required is produced. 
 
 In epilepsy, the inhalation of chloroform lias been found 
 valuable, especially in the treatment of injuries and frac- 
 tures, the result of epileptic attacks. It will also be found 
 useful internally in the same disease, in combination with 
 the bromides of potassium, sodium, calcium, and iron, with 
 or without strychnia. 
 
 In neuralgia, a few inspirations of chloroform-vapor from 
 a towel or handkerchief (sometimes enveloped in a cone of 
 paper, flannel, or metal, for convenience of administration 
 and to regulate evaporation) will often relieve the severe 
 pain, almost magically. If the suffering be not of a serious 
 character, and the affection be moderate in its extent, the 
 
138 ARTIFICIAL ANESTHESIA. 
 
 relief may be permanent. If the stimulant effect should be 
 desired over a larger portion of the body, the following 
 liniment can be employed with advantage: — 
 
 • Ji. Chloroformi , fgjss. 
 
 Pulveris camphorae, Sj. 
 
 Spirit us terebinthinse, fSss. 
 
 Olei lavandulse, tt^xx. 
 
 Olei oliva?, fsij.— M. 
 
 The camphor to be broken in small pieces, and dissolved 
 in the chloroform and turpentine; the olive oil should then 
 be warmed, and added gradually. Ointment for topical use 
 in neuralgia : in the proportion of from five to fifteen of 
 chloroform to thirty parts lard. By means of a speculum, 
 the vapor of chloroform may also be carried into the vagina 
 or rectum, remaining for ten minutes; or we may use a 
 mixture of equal parts of the chloroform liniment, of the 
 Pharmacopoeia, and the officinal camphorated soap lini- 
 ment, for the same purpose. 
 
 Chloroform has been found extremely valuable in all 
 cases of colic, and will often assuage even pain of colica 
 pictonum; this is due to its local anodyne and stimulant 
 carminative action. In flatulent distension of the stomach 
 equal parts of chloroform and camphor will be found bene- 
 ficial. In diarrhoea, after the removal of the irritating agent, 
 equal parts of chloroform and alcohol, with a portion of the 
 tincture of opium and capsicum, may be administered with 
 great benefit. In insomnia, where pain prevents the 
 patient from sleeping, the following mixture will often 
 prove useful :— 
 
 fy. Morphia? muriatis, gr. iss. 
 
 Alcoholis, 
 
 Chloroformi, aa fgss. 
 
 Tr. cardamomi comp. fsjss.— 31. 
 Sig. A dessertspoonful at bedtime to be taken in milk. 
 
 In nervous headache the accompanying prescription will 
 often produce a happy effect: — 
 
 fy. Acidi nitro-muriatici diluti, f3ij. 
 
 Strychnine, gr. %—"%.. 
 Alcoholis, 
 
 Chloroformi, aafSiij. 
 
 Tinct. zingiberis, f5iij. 
 
 Aquae, • q. s. ad ft. fgiii.— M. 
 
 Sig. A tcaspoonful in water three times daily. 
 
CHLOROFORM IN THERAPEUTICS. 139 
 
 In combination with quinia, chloroform may be given 
 where there is marked tendency to frequent chills. The 
 following formula would be very appropriate for malarial 
 manifestation in a child, say three or four years of age : — 
 
 1^. Quiniae sulph., gr. xxiv. 
 Mucilago acacise, t'Sij. 
 Chloroform!, lr^xx. 
 
 Syr. Tolutani, f5iv. 
 Aq. cinnamonii, q. s. ad fsiij.— ]\I. 
 Sig. A teaspoonful every hour while free from fever. 
 
 In certain forms of chorea and epilepsy, the combination 
 of bromide of potassium and chloroform will be found 
 valuable : — 
 
 I*. Potassii bromidi, gr. xv. 
 
 Tinct. conii, rr^xxx. 
 
 Chloroform i, m xx. 
 
 Tinct. Valerianae ammoniatis, m x. 
 Aquse camphorse, fsj. 
 
 Sig. For one dose, to be repeated every six or twelve hours. 
 
 In some cases advantage is obtained by adding strychnia 
 to this mixture in the dose of one-sixtieth to one-thirtieth 
 of a grain, omitting the conium and the valerian. 
 
 The following are a few of the preparations of chloroform : 
 
 1. Tinctura chloroformi comp., B. P. (chloroform, recti- 
 fied spirits, comp. tinct. of cardamon ; one in ten). Dose, 
 n\,xx-lx ; for internal use, to relieve pain and spasm. 
 
 2. Linimentum chloroformi (chloroform gij, camphor 
 liniment gij, olive oil §iv). 
 
 3. Mistura chloroformi (chloroform §ss, camphor pulv. 
 gr. ix, yolk of one egg, water gvi). Add chloroform and 
 camphor, rubbing them up well ; then add the egg by de- 
 grees to form a nice mixture. Dose, a tablespoonful every 
 hour. 
 
 External use.— Powerful agents act on the skin more 
 effectually when dissolved in chloroform, as they promote 
 the cutaneous absorption, and the addition of an equal 
 quantity of alcohol hastens the process ; so that when we 
 desire to limit the anodyne effect to a small spot, we may 
 apply a solution of camphor in chloroform, of equal parts 
 by weight, or as a still more powerful sedative :— 
 
140 ARTIFICIAL ANESTHESIA. 
 
 Jjk. Morphia* sulphatis, gr. viij. 
 Atropue sulphatis, gr. iv. 
 Alcoholis, 
 
 Chloroformi, aa Sij.— M. 
 
 Sig. To be applied with a camel's hair brush. 
 
 Two other agents might be added for facial and dental 
 neuralgia : Ext, gelseminum* fld., gtt. iij every three or four 
 hours; or, butyl-chloral hydrate in pills, three grs. every 
 three or four hours. 
 
 This prescription r in facial or sub-occipital neuralgia, 
 should not be spread over a large surface at one time, as 
 both the atropia and the morphia are more readily absorbed 
 after this solution in chloroform. Strychnia, aconitia, or 
 quinia may also be combined with chloroform in a similar" 
 manner. A very good plan is to cover a cup with linen 
 and drop a portion of the chloroform or the mixture on its 
 surface, and hold it in contact with the painful part for a 
 few seconds. This will often produce a good result in 
 pleurodynia or neuralgia of the chest wall. In more severe 
 general neuralgia, I have on several occasions been obliged 
 to keep the patient gently under the influence of chloroform 
 for a considerable time until the person obtains sleep, or the 
 pain has been entirely relieved. If the neuralgia, in the 
 form of hemicrania or sciatica, should be of malarial origin, 
 we may resort at first to the following mixture:— 
 
 l^r. Veratrise, gr. v. 
 
 Morphise sulphatis, gr. iij. 
 
 Linimenti chloroformi, f5ij.— M. 
 Fiat lotio. 
 
 The part to be rubbed with this lotion during the paroxysm 
 of pain, while two-grain pills of quinia sulphas are given 
 every hour until its physiological effects are produced. 
 Cinchonidia may be substituted in three-grain doses if the 
 patient cannot take the quinia. 
 
 This same treatment, in conjunction with quinine, will 
 often relieve sciatica. In earache or toothache, two or three 
 drops on a small piece of cotton-wool introduced into the 
 ear or tooth will occasionally cause complete relief; if too 
 large a quantity is used, it will cause redness, smarting, and 
 
 * The effects of this remedy should be carefully watched. 
 
CHLOROFORM IN THERAPEUTICS. 141 
 
 even blister. Equal parts of chloroform and opium or creo- 
 sote are also useful in toothache. When mixed with an 
 equal quantity of camphor, it forms one of the most valuable 
 agents to relieve the local pain of sprains, etc. In cancer, 
 where the skin is broken, leaving a foul and irritable sore, 
 the surface may be deodorized and the pain temporarily 
 relieved by the use of the hand-spray playing the vapor on 
 the raw surface. The pain of other forms of cancer, such 
 as of the os uteri, rectum, and mammary gland, may be also 
 relieved by application of the same agent. In the photo- 
 phobia of scrofulous ophthalmia, a few drops of chloroform 
 held in the palm of the hand, close to the irritable eye, will 
 cause the child to bear the light with less pain. In the 
 itching of the ear, nose, and rectum, in which we have 
 urticaria, lichen, or prurigo, the annoyance may be allayed 
 by the use of an ointment composed of half a drachm of 
 chloroform to an ounce of lard (it must be kept in a ground- 
 stoppered bottle). 
 
 Pruritus Vulvae. — In this most persistent, troublesome, 
 and annoying disease, we have found chloroform useful 
 in combination with carbolic acid and soap liniment, as 
 follows : — 
 
 ]#. Acidi carbolici, gtt. xii-xxiv. 
 
 Chloroformi, f5ij. 
 
 Ol. olivae, 
 
 Linimenti saponis, aafSij.— M. 
 Apply with a soft sponge to the affected parts. 
 
 Chloroform dissolves entirely in vaseline, and furnishes 
 a homogeneous product of convenient consistency without 
 the addition of wax :— 
 
 Jfc. Chloroform, iv grammes. 
 Vaseline, xx " 
 
 Equal parts of vaseline, chloroform, and ether, give a 
 jelly, which constitutes one of the most active liniments in 
 English therapeutics. 
 
 Both of the above preparations are useful in neuralgias, 
 cancer of the rectum and uterus, and are increased in value 
 by the addition of hydrate of chloral, five grammes, or 
 camphor, three grammes. This latter agent has to be pul- 
 verized and added to the vaseline, heat being applied until 
 the camphor completely disappears, and stirring until cold. 
 
 9 
 
142 ARTIFICIAL ANAESTHESIA. 
 
 In urticaria, lichen, eczema, and true prurigo, the follow- 
 ing ointment will not only allay the itching effectively, but 
 with care will cure these skin affections. 
 
 P;. Hydrg. preecip. alb. 5ss. 
 
 Liq. carbonis deterg. rn xx. 
 
 Chloroforirri, 5ss. 
 
 Vaseline, 5i.— M. 
 Sig. Apply locally. 
 
 CHLORODYNE. 
 
 ANODYNE, SEDATIVE, ANTI-SPASMODIC, AND DIAPHORETIC. 
 
 This preparation produces anodyne, sedative, anti-spas- 
 modic, and diaphoretic effects of other opiates, without 
 giving rise to the nausea, prostration, loss of appetite, and 
 depression of spirits, which are so apt to follow the use of 
 the latter, and are sometimes so distressing as to preclude 
 the employment of such articles where they would other- 
 wise be strongly indicated. It must, however, be prescribed 
 with the greatest caution, and never unless the particular 
 preparation is specifically stated. 
 
 J£fc. Morph. sulph. grs. lxiv. 
 
 Alcohol, ninety-five per cent. fSxii. 
 
 Chloroform purif. ' # fgvi. 
 
 Acid, sulph. Ar. qs. 
 
 Ext. cannab. Indica (Allen's), 5ss. 
 
 Oleoresina capsicum, gtt. xij. 
 
 Hydrocyanic acid (Scheele"s), gtt. xcvi.— M. . 
 Shake together the morph., alcohol, and chloroform, then add acid 
 sulph. q. s.; shake well until it becomes clear, then add capsicum, 
 ext. cannab. Ind. and hydrocyanic acid. The dose for children, of 
 from five to ten years, is from five to eight drops in water, repeated 
 every three hours ; dose for adult, fifteen to thirty drops. Each tea- 
 spoonful contains one gr. morph. sulph., one-half gr. Indian hemp, 
 one and a half drops of Scheele's acid, equal to nearly four drops of 
 U. S. P. acid. 
 
 The importance of not trusting to the patient's judgment 
 is very necessary, and the quantity which is to be taken 
 in the twenty-four hours must be stated, and the intervals 
 between each dose, carefully given. From 1863 to 1867, four 
 deaths were caused by this compound. According to Mr. G. 
 Smith,* the English preparation is thus constituted :»— 
 
 * London Lancet, 187C, vol. 1, p. 72. 
 
CHLOROFORM IN THERAPEUTICS. 143 
 
 P. 
 
 Chloroform, 
 
 3iv. 
 
 Muriate of morphia, 
 
 gr. xx. 
 
 Ether (rectified), 
 
 f5ij. 
 
 Oil of peppermint, 
 
 TT\viii. 
 
 Prussic acid, 
 
 5vi. 
 
 Mixture of gum arabic, 
 
 Si. 
 
 Treacle, 
 
 Siv.— M, 
 
 It will be noticed that there is no uniformity in this com- 
 pound, which should not be the case, and pharmaceutists 
 should adhere to either one or the other of these formulas, 
 and not add to or take from them, marking the one the 
 English, and the other the American preparation, and its 
 manufacturer. 
 
 EARACHE.— CHLOROFORM VAPOR. 
 
 National Medical Review, February, 1879.— Dr. James E. 
 Morgan stated, during a discussion on otitis, that he had 
 often promptly relieved the distressing earache of children 
 by filling the bowl of a common new clay pipe with cotton 
 wool, upon which he dropped a few drops of chloroform, 
 and inserting the stem carefully into the external canal, 
 and adjusting his lips over the bowl, blew through the pipe, 
 forcing the chloroform vapor upon the membrana tympani. 
 Dr. J. Ford Thompson had also accomplished the same re- 
 lief upon similar principles. This same result we have 
 often attained by means of cotton .saturated with chloro- 
 form in a glass tube, or surrounding the cotton with a 
 second layer so as not to come in contact with the surface 
 of the meatus. 
 
 CHLOROFORM DURING DELIVERY. 
 
 Dr. Wilson, of Baltimore, dissents from the views of Dr. 
 Lusk as to the danger of using chloroform in obstetric 
 cases. See p. 107. 
 
 Dr. Albert H. Smith, of Philadelphia, thinks that chloro- 
 form is to be preferred to ether in those cases in which a 
 rapid anaesthesia is desired. 
 
 Dr. Ringer* gives it as his opinion, " that it is not neces- 
 sary to obtain complete unconsciousness, but to give only 
 sufficient chloroform to dull the pains. If this recommend- 
 
 * See article Chloroform, Opt. Cit., p. 342; Chloral, p. 357. 
 
144 ARTIFICIAL ANAESTHESIA. , 
 
 ation is disregarded, and the anaesthetic is- pushed to the 
 stage of complete unconsciousness, it weakens the contrac- 
 tion of the womb and retards delivery. It is true that 
 even if only slight unconsciousness is produced, the uterine 
 contractions are probably somewhat weakened." 
 
 Dr. Play fair thinks that chloral acts far better than chlo- 
 roform inhalation, as chloral does not lessen the strength 
 of the contraction, whilst it greatly lessons the suffering* 
 Moreover, it is chiefly applicable at a period when chloro- 
 form cannot be used — that is, towards the termination of 
 the first stage. Dr. Playfair gives fifteen grains, and re- 
 peats the dose in about twenty minutes, and again repeats 
 the dose, if necessary. 
 
 The following communication was received too late to be inserted 
 under Ether. 
 
 Dr. E. L. Holmes has observed three cases, in which severe neuralgia 
 was experienced immediately on recovering consciousness, after full 
 anaesthesia from ether. In the case of a young woman to whom ether 
 was given for a strabismus operation, the neuralgia,with some numb- 
 ness and paralysis of motion in the outer portion of the left fore arm 
 and fingers, was extreme; this continued three months, when the 
 patient passed from observation. In a second case, a woman of middle 
 age, the neuralgia in the left arm and shoulder continued more than 
 three months before it ceased. In the case of the third patient, also a 
 woman, the neuralgia was quite severe for some weeks^in the shoulder 
 and neck. 
 
 The late Dr. E. H. Clarkefof Boston, a few years since stated to the 
 writer that he had observed several similar cases. 
 
MIXED ANESTHETICS. 145 
 
 CHAPTER V. 
 
 Mixtures of Chloroform, Ether, and Alcohol. First death reported 
 from mixture of Ether and Chloroform. Composition of various 
 mixtures. Boiling points and relative time of evaporation of the 
 several anaesthetic agents. Opinions of Dr. Washington Atlee and 
 Prof. Maisch concerning mixtures. How Chloroform is altered by 
 mixing with Alcohol, etc. Recent deaths from Chloroform and 
 Ether mixed. Chloroform combined with Alcohol in parturition. 
 The comparative effects of the early state of anaesthesia with Ether 
 and Chloroform. 
 
 The various mixtures of chloroform with ether and 
 alcohol, were used as means of escaping the danger of 
 chloroform. They first received their impulse from the 
 report of the Chloroform Committee of the Medical Chirur- 
 gical Society of London, who declared their superiority in 
 point of. safety. M. Perrin* gives an account of the first 
 death known at that time to have taken place under a 
 given mixture of ether and chloroform, and gives the 
 credit to the chloroform as being improperly administered, 
 and Snow says the patient died of hemorrhage; but our 
 reading of the case, carefully reported by Dr. R. Crockett, f 
 leaves the decided impression that chloroform arrested the 
 heart's action, induced vomiting, and caused a stoppage 
 of respiration. The following is an abstract of the im- 
 portant facts in the case, and is interesting as the first 
 death from the mixture: — "A sprightly little boy, five 
 years of age, was brought to the doctor to have a fatty 
 tumor removed from his back. The tumor commencing at 
 a point at its inferior termination, opposite the last rib, 
 about two and a half inches to the right of the spinous pro- 
 cesses, and extending obliquely upwards, crossing the spine 
 
 * Trait6 d' Anesthesia Chirurgicale, Par Maurice Perrin, Professeur 
 agr£ge a l'Ecole Imperiale de Medicine et de Pharmacie Militaire, etc. 
 A Ludger Lallemand, Professeur agrege k l'Ecole Imperiale de Medi- 
 cine et de Pharmacia Militaries, etc. Paris, 1863, 8vo., pp. 668. 
 
 f American Journal of Medical Sciences, July, 1857, 284-5. 
 
146 ARTIFICIAL ANESTHESIA. 
 
 seven inches, requiring two elliptical incisions nine inches 
 long for its removal." The operation was commenced at 
 9.30 A. M., April 4th, and the dissection was rapidly exe- 
 cuted, stopping to ligate a large artery that was early di- 
 ' vided; the remaining arteries were compressed as they 
 were divided. The tumor was quickly removed, and a 
 ligature applied to the last artery, being the sixth in num- 
 ber. While sponging the wound, the boy began to vomit, 
 and on examining the wrist he was found to be pulseless. 
 Dr. K., who had charge of the anaesthetic and pulse, re- 
 plied that " the pulse had never given way until he began 
 to vomit." He ejected a small portion of the contents of 
 the stomach. He was immediately placed in the "prone 
 position," as recommended by Dr. Marshall Hall ; the finger 
 was introduced into the mouth to be certain that the tongue 
 had not fallen back so as to obstruct the glottis, or the en- 
 trance of air into the wind-pipe, and the extremities were 
 rubbed with aqua ammonia. The patient died three or 
 four minutes from the commencement of the vomiting. 
 "He lost probably four ounces of blood, certainly not ex- 
 ceeding six." There was no post mortem examination. 
 
 The anaesthetic we used was a mixture of washed ether, 
 four parts, and one of chloroform, obtained from the late 
 Frederick Brown of Philadelphia, whose character is a 
 sufficient guarantee that they were pure. Every prepara- 
 tion for the operation having been made, the administration 
 of the anaesthetic was commenced by Dr. Crockett, observ- 
 ing all the precautions so fully recommended by Erich sen, 
 p. 78, of his " Operative Surgery." As soon as anaesthesia 
 was induced, the sponge was confided to Dr. Kincannon, 
 who held his finger all the while on the patient's pulse. 
 The doctor concludes, "I have lately employed this anaes- 
 thetic freely, formerly having used ether alone. As yet I 
 have not seen a case of death reported from ether, or this 
 mixture of it with chloroform, that I can now recollect. 
 Are there any such reported? I fear all the deaths from 
 anaesthesia are not reported." Five deaths from the use of 
 this mixture have been published, two having occurred 
 very recently. 
 
 The chief object of these anaesthetic mixtures is the 
 avoidance of the danger from shock, or from the depressing 
 
MIXED ANESTHETICS. 147 
 
 influence upon the heart-action, which chloroform most 
 certainly exerts, and which ether and alcohol prevent. The 
 committee before . referred to proposed the following mix- 
 tures : — 
 
 A. Alcohol lPart. 
 
 Chloroform, 2 " 
 
 Ether, 3 " 
 
 B. Chloroform, 1 " 
 
 Ether, 4 " 
 
 C. Chloroform, 1 " 
 
 Ether, . . • 2 " 
 
 Dr. Samson's mixture* is equal parts by measure of chlo- 
 form and absolute alcohol. The introduction of alcohol, 
 which plays an important part in the mixture, was, accord- 
 ing to the doctor, due to Dr. Harley. The committee says 
 it is by " the uniform blending of the ether and chloroform, 
 when combined with alcohol, and probably the more equa- 
 ble escape of the constituents in vapor." The chloroform 
 is the potent agent, and the others chiefly adjuvants, vehi- 
 cles, and diluents of the chloroform. 
 
 Dr. Sansom gives the following testimony as to the stim- 
 ulating effects of alcohol in counteracting the depressing 
 influence of chloroform. In my own experiments I have 
 found that alcohol has had the greatest effect in sustaining the 
 heart action during the influence of the chloroform. I can 
 particularly recollect one instance in which alcohol was 
 administered in vapor to a frog, after it was impossible to 
 cause death by any strength of chloroform vapor. In re- 
 commending this mixture before the Obstetrical Society of 
 London, Dr. Sansom went one step farther, and stated that 
 this mixture gives off a proportion of chloroform vapor in 
 a given time almost exactly half of that which is given off 
 by chloroform pure and simple. This result is not confirmed 
 by any experiments of his published. 
 
 What are the objections to anaesthetic mixtures? 
 
 1. The length of time required for the production of com- 
 plete anaesthesia. 2. The probability of entire sensibility 
 not being abolished. 3. The unequal rate of evaporation 
 or vaporization of the fluids. 
 
 * Chloroform: its Action and Administration. By Arthur Sansom, 
 M. B., London. 
 
148 ARTIFICIAL ANAESTHESIA. 
 
 There is not any doubt but that the process is slower and 
 attended with more excitement by the mixed fluids than by 
 chloroform alone. The second objection cannot be sustained. 
 The third is the ' ' element of danger. ' ' It was first advanced 
 by Snow. He says : " When ether is combined with chlo- 
 roform, the result is a combination of the undesirable qual- 
 ities of both agents without any compensating advantage," 
 and the clanger is because the operator, toward the end of 
 the process, may be giving a pure chloroform when he 
 thinks he is giving the weaker mixture of vapors. Dr« 
 Ellis* endeavored to prove this, and states: "Out of the 
 six or seven minutes occupied by the evaporation of the 
 half drachm of fluid, the first was occupied chiefly by the 
 ether, the next three by the chloroform with a little alcohol, 
 and the last by the alcohol alone. In an inhaler the patient 
 would have breathed, for one-fifth of the time, chiefly the 
 vapor of ether, for the next three-fifths that of chloroform 
 with a little alcohol, and at last only the vapor of a minute 
 quantity of alcohol," pp. 24, 25. These results are not 
 stated as obtained by actual experiments, and they depend, 
 first upon the purity of the agents employed ; second, upon 
 the boiling point, which has a great influence upon the re- 
 sults, for the more volatile the fluid, the greater will be 
 the variation. I here give the boiling point of the most 
 important anaesthetics. 
 
 The temperature which is constant for the same substance, 
 under the same atmospheric pressure, is called the boiling 
 point. 
 
 The following are the agents employed as anaesthetics in 
 the form of vapor, the boiling points being given for the 
 mean pressure of 760 millimetres : 
 
 Protoxide of nitrogen, —88° 
 
 Carbonic acid, — 78° 
 
 Chloride of Ethyl v. pure ether -11° 
 
 Common ether, 35° 
 
 Chloroform, ' 63° 
 
 Alcohol, 78° 
 
 Oil of turpentine, 157° 
 
 A difference of pressure of 0.25 centimeter will cause a dif- 
 
 * On the Safe Abolition of Pain in Labor and Surgical Operations, 
 1866, by Anaesthesia and Mixed Vapors. By Robert Ellis, Surgeon 
 Accoucheur, London. 1866, pp. 80. 
 
ANAESTHETIC MIXTURES. 149 
 
 ference in the boiling of water one-tenth of a degree. The 
 boiling point is also influenced by dissolving in a fluid a sub- 
 stance more volatile than itself (as ether and chloroform) ; 
 it increases the boiling point in proportion to the amount 
 dissolved. The temperature of the atmosphere has a power- 
 ful influence on these volatile agents, as it is a well-known 
 chemical fact that the saturability of the air increases vastly 
 with the increase of temperature, and the capacity of the air 
 for aqueous vapor is doubled with each 27° of temperature 
 Fahrenheit. Sulphuric ether at 60° F., and thirty inches of 
 the barometer expands two parts of the air into three, and 
 forms, therefore, at that temperature and pressure, one-third 
 of the air inhaled into the lungs of a patient. Under the 
 same circumstances chlorform expands fourteen parts of air 
 into fifteen, and consequently the vapor of chloroform con- 
 stitutes one-fifteenth part of the air inhaled. 
 
 The following experiments were made October 30th, 1878, 
 so as to determine the time required for each of the agents 
 to evaporate on a given surface of tissue paper suspended in 
 the air at a temperature of 70° F., one drop of each being 
 carefully measured by the same dropping machine. The 
 time was accurately kejot by my son, Dr. C. S. Turnbull, 
 and the results served to confirm the rough experiments 
 made before the Dental Convention at Washington, D. C, 
 on October 10th, 1878, and proved the facts stated in the 
 author's first edition of this work. I have always found 
 that when such a mixture was poured upon the inhaler, 
 the most volatile spirit will arise first, then the next, and 
 so on, leaving the least easily evaporated upon the inhaler. 
 Another important fact was proven, and which was before 
 referred to, that the alcohol employed in the mixtures with 
 chloroform in England, also the ethers made from such 
 alcohols, are much inferior to those made in this country 
 from grain, not from wood or potatoes. These latter are 
 slow in evaporation, and are mixtures themselves contain- 
 ing a large amount of carbonaceous products. 
 
 The following are the results obtained after numerous ex- 
 periments with as many of the agents employed in the 
 various mixtures, and obtained from the reliable establish- 
 ments of Powers & Weightman, Bullock & Crenshaw, 
 "\\ v ycth & Bro., and J. P. Remington: 
 
150 ARTIFICIAL ANAESTHESIA. 
 
 Alcohol, absolute, 95° ("W. <fe Bro.) 1 min. 24 seconds. 
 
 Alcohol, common, (W. & Bro.), 10 " 00 " 
 
 Chloroform (P. & W.), 00 " 24 " 
 
 Ether (Squibb's), 00 " 12 " 
 
 Ether, common, 0.750 (P. &. W), ' . 00 " 24 
 
 Ether Hydrobromic (R), 00 " 12 " 
 
 Methylic alcohol (B. & C), 1 " 00 
 
 ♦Potato spirit (B. & C), 12 " 00 
 
 Temperature, 70° F. 
 Barometer, 30.08. Time, 2 P. M. 
 
 Besides the danger from inhaling the chloroform pure and 
 simple, there is another to be prevented, that is, to get rid of 
 the watery vapor, from the mixture and also from the lungs 
 of the patient, which collects on the sponge. If the napkin 
 or inhaler gets close to the patient's mouth and nose it will 
 most effectually prevent air from reaching the lungs. How 
 is this to be prevented? By squeezing out the sponge, nap- 
 kin, lint, or if an inhaler is employed that cannot thus be 
 treated, casting it aside, and taking a clean napkin, with as 
 much starch in it as possible, so as to keep it in shape. It 
 may again be inquired which is the best mixture to employ in 
 ordinary surgical operations when it is absolutely necessary 
 to employ such mixtures. The mixture C, in midwifery. 
 Mixture A, or, as it is familiarly known, ACE or "ace of 
 spades mixture, "the most agreeable of all. In the operation 
 for ovariotomy I prefer the C mixture, as also advised by the 
 late Dr. Washington Atlee; the volume of the two agents 
 are so different that they ought to be mixed by weight, not 
 by measure, else the chloroform will be much in excess, as 
 it is a little over twice the weight of ether. In employing 
 alcohol it should be as near to absolute as possible, and free 
 from color, smell or taste. The ether should be almost 
 anhydrous, pure, full strength, and well washed. 
 
 Dr. Atlee was of the opinion that there is a chemical union 
 of the ether and chloroform; and Professor Maisch, of this 
 city, found that, if this mixture was exposed to the light, a 
 change took place which rendered the mixture not fit for 
 the purposes of inhalation; it therefore should be kept 
 from the light, and mixed just before being employed. 
 
 Perfectly dry chloroform decomposes but slowly, even in 
 direct sunlight, but the presence of water, which always 
 
 * Fassed through charcoal by W. & Bro. 
 
MIXED ANAESTHETICS. 151 
 
 exists in alcohol and ether, and the action of light at the 
 same time causes chloroform to decompose into formic and 
 hydrochloric acids. CHCl 3 +2H 2 0=CH 2 2 +3 HCL. 
 
 I have had charge of the anaesthetic mixture (one part by 
 measure of chloroform, and two of washed sulphuric ether) 
 in an operation by Dr. Washington L. Atlee, during the 
 successful removal of on ovarian tumor weighing forty 
 pounds, and have also assisted him in three cases in which 
 others gave this same mixture, with good results, and with 
 no apparent risk to the safety of the patients. 
 
 Dr. Atlee always administers the anaesthetic after the 
 patient is upon the operating table, and one individual has 
 charge of and is responsible for it. . In his three hundred 
 ovariotomies he informed me he had never lost a patient by 
 the anaesthetic. 
 
 The mixture is given in almost every instance by means 
 of the starched towel. 
 
 At my suggestion, Dr. Greene made the following experi- 
 ments, to determine the best proportion in which ether and 
 chloroform could be mixed : When ether and chloroform 
 are mixed there is an elevation of temperature, and the 
 greatest heat is produced when the mixture is made in equiva- 
 lent proportions ; that is, by weight, about nine and one- 
 quarter parts of ether to thirteen and one-quarter parts 
 of chloroform. As the chloroform is more than twice as 
 heavy as ether, the volumes w T ould be about one and four- 
 tenths chloroform to two of ether. But little contraction 
 in volume takes place, and it may be considered that mole- 
 cular combination takes place between the chloroform and 
 ether. The mixture begins to boil at fifty to fifty-one 
 degrees C, and may be separated into its constituents by 
 fractional distillation ; but when allowed to evaporate spon- 
 taneously, as when used as an anaesthetic, both liquids pass 
 into vapor simultaneously. 
 
 Whatever mixture is employed, nothing will obviate 
 the necessity of care in the administration, and above all 
 not to give more of the agent than is absolutely neces- 
 sary to keep the patient free from pain; not one drop 
 more, for, like all potent medicines which we employ, 
 an excessive dose is sure to kill, and unless we have 
 before gauged the patient's powers, let caution be our guide 
 
152 ARTIFICIAL ANAESTHESIA. 
 
 in the administration of so powerful an anaesthetic. In our 
 anxiety to see the various steps of an operation, we must not 
 saturate the sponge or lean over the patient, and by accident 
 suffocate him. It is, unfortunately, too much the practice 
 to entrust the inhaling apparatus to some inexperienced 
 hand, who, perhaps, never before administered an anaes- 
 thetic, and even in some hospitals to the youngest assistant 
 surgeon or dresser. It has been well observed by Perrin : 
 " We believe we shall render a veritable service if we pop- 
 ularize the idea that anaesthesia should be observed and 
 studied at the hospital with as much care as every other 
 subject of practical medicine." Sansom also says, "The 
 administrator should be experienced ; several hospital com- 
 mittees have acted wisely in appointing a chloroformist, a 
 measure which is not of less value to the operating surgeon 
 than it is to the benefit of the patient. One who adminis- 
 ters chloroform in any case should confine himself exclu- 
 sively to the task he has undertaken, and should constantly 
 mark the symptoms." What are the symptoms of dan- 
 ger? The failure of the pulse, irregularity of the respi- 
 ration, and the blanched countenance, and, as beautifully 
 expressed by an old writer* in reference to successful ad- 
 ministration of anaesthetics," Proceed steadily but cautiously 
 to the end in view. He makes haste slowly, and with a 
 boldness tempered by wisdom, carries his patient down into 
 the dark valley which borders on death, drowns human 
 agonies in the water of Lethe, and triumphs in the crown- 
 ing gloiy of his art." 
 
 AN ABSTRACT OF THE REPORTS OF RECENT 
 
 DEATHS FROM A MIXTURE OF ETHER 
 
 AND CHLOROFORM. 
 
 The mortalhy caused by a mixture of chloroform and 
 ether given by inhalations is 2 to 11.176, or 1 to 5.588. 
 
 A death of a lady had occurred in the practice of Dr. 
 Eastham, a dentist of Boston, causing much excitement in 
 professional circles. The death had taken place about noon, 
 but very few, except those particularly interested, were 
 
 * I. C. R, Am. Jour. Med. Sci. 1867, p. 190. 
 
DEATHS FROM CHLOROFORM AND ETHER MIXTURES. 15S 
 
 aware of it till the next day. The coroner, Dr. Ainsworth, 
 who was called in directly after the accident, formed a jury 
 of physicians and apothecaries, and ordered an autopsy. 
 This was made the next morning by Dr. R. H. Fitz, pathol- 
 ogist to the Massachusetts General Hospital; and on the 
 same day the jury met, and, having viewed the body, ad- 
 journed until the 14th. The anaesthetic was either chloro- 
 form or a mixture of chloroform and ether. The latter 
 proved to be the one used. The jury met again on the 14th, 
 and, having heard a part of the evidence, readjourned till 
 the evening of Wednesday the 19th. Instead of death 
 resulting from ether, it was, as proven by analysis, due to 
 chloroform, and the coroner's jury presented the following 
 verdict: — "Death was caused by the inhalation of chloro- 
 form, administered in a mixture of chloroform and ether.'' 
 
 Dr. Henry Buren, of Chicago,* gives the following version 
 of a death which took place in that city from the inhalation 
 of a mixture of ether and chloroform :— 
 
 Mrs. B., aged 32, American, had suffered from fistulae in 
 ano for six months. On the 22d of November last, I oper- 
 ated on her, finding at this time two artificial openings into- 
 the rectum, one on either side of the anus. Dr. A. Groesbeck 
 administered the anaesthetic, which consisted of equal parts 
 of sulphuric ether and chloroform. The operation was per- 
 formed in a few seconds. The patient exhibited no alarm- 
 ing symptoms while under the influence of the anaesthetic, 
 and revived in the usual time. 
 
 On the, morning of the 30th of November, eight days 
 after the operation, I desired to make a thorough examina- 
 tion of the wounds and renew the dressing, and in this, as 
 in some of the previous dressings, the patient insisted upon 
 partial immunity from pain. To this end I commenced to 
 administer upon a napkin two parts of sulphuric ether and 
 one of chloroform. After a few inhalations the patient 
 became violently intoxicated, and resisted, with great force, 
 all efforts to quiet her, demanding in the language of one in 
 delirium, to be let alone. I immediately ceased to adminis- 
 ter the anaesthetic, and with great effort prevented her from 
 jumping from the bed. The face became at first turgid, the 
 
 * Chicago Medical Journal, February, 1878. 
 
154 ARTIFICIAL ANESTHESIA. 
 
 whole body convulsive, and in a few seconds the patient 
 was dead. 
 
 All of the means usually resorted to, were employed to 
 restore action of the vital functions ; artificial respiration, 
 elevating the lower extremities, dashing cold water in the 
 face, drawing forward the tongue, spirits of ammonia ap- 
 plied to the nostrils, and, finally, a galvanic battery, which 
 was conveniently at hand, but to no avail. 
 
 I have to say in justice to the record of this case, that the 
 patient had for many years habitually partaken of opium. 
 At the time of her unfortunate death, she could take at each 
 dose, from two to three grains of morphia. During the 
 time she was under my care, one half grain doses of mor- 
 phia were prescribed at proper intervals, but she asserted 
 that this quantity did not sufficiently support her, and 
 through her nurse, and by stealth, she secured additional 
 quantities from the neighboring drug stores, and took the 
 same daily without my knowledge or consent. 
 
 I am now of the opinion that the patient had taken an 
 unusually large dose of morphia on the morning of her 
 death, and that the combined influence of this overdose, 
 and the additional paralyzing effects of the anaesthetic, 
 caused cardiac syncope, and that this was the cause of 
 death. 
 
 A wpman aged forty-six, extremely fat, and of slow intel- 
 ligence, although having complained of shortness of breath, 
 was not known to be the subject of organic heart disease. 
 She was to be operated upon for senile cataract. A mixture 
 of chloroform and ether, in a modified Clover's apparatus, 
 was being administered by the house surgeon. From the 
 commencement of the administration, respiration was no- 
 ticed to be shallow, but there was struggling. The pulse 
 was feeble, but not intermittent. There was some slight 
 lividity of cheeks and forehead. Chloroform was at once 
 removed and a few whifTs of pure ether administered as a 
 stimulant. Other means for circulation were tried, but in 
 vain ; the patient died. At the post mortem examination 
 the heart was found flaccid and empty ; the mitral valve was 
 contracted; the aortic valves were incompetent; kidneys 
 fatty and granular.— (Med. Times and Gazette, August 18th, 
 1S76.) 
 
MIXED ANESTHETICS IN PARTURITION. 155 
 
 A more recent case of death from a mixture of ether and 
 chloroform is reported in the Philadelphia Medical Times, 
 March 15, 1879, by I. A. Cleary, Assistant Surgeon U. S. A. 
 Private H. D. B., Co. 19, U. S. Infantry, aged 33, large, 
 robust, addicted to liquor. Injury of middle ringer, right 
 hand, resulting in gangrene ; decided to amputate. A mix- 
 ture of equal jDarts of ether and chloroform {weight or 
 measure not stated). Two ounces whiskey were given ten 
 minutes prior to inhalation. The anaesthetic was adminis- 
 tered on a piece of lint covered with a small towel held 
 square. He personally administered the mixture, while the 
 steward observed the pulse; air was freely admitted; he 
 inhaled freely. About two drachms were first poured on 
 the cloth, but with no apparent effect (he, evidently, receiv- 
 ing nothing but ether). Shortly after about the same quan- 
 tity was poured on ; he observed that "he did not feel it." 
 After a time about the same quantity was again poured on. 
 A further quantity was poured on the cloth (say in all 5 vl ii) 
 when he began to laugh, followed by attempts to articulate, 
 and made strong gesticulations of his arms. He now 
 passed to a state of unconsciousness, when the pulse was 
 not perceived. This was followed by relaxation and death. 
 At once the anaesthetic was removed, cold water dashed in 
 the face. He adds, " everything I ever heard of, saw or read, 
 appropriate for such a case was done, but to no effect." He 
 states as the cause of death, paralvsis of the heart. (I think 
 it was syncopy from the chloroform.) 
 
 MIXTUKE OF CHLOROFORM AND ALCOHOL AS 
 AN ANAESTHETIC IN PARTURITION. 
 
 Dr. A. H. Halberstadt, of Pottsville, Pennsylvania, read 
 before the Medical Society of the State of Pennsylvania, in 
 May, 1878, a paper on "Anaesthesia in Parturition," and 
 after some general remarks on the advantages of this mix- 
 ture, says:— "I would submit the following conclusions 
 drawn from at least one thousand cases under my own 
 observation and management: 
 
 "1st. That the parturient state is the only condition of 
 the system during life in which anaesthetics, judiciously 
 administered, are entirely devoid of danger. 
 
 "2d. That the physiological action of chloroform, ether, 
 
156 ARTIFICIAL ANAESTHESIA. 
 
 and alcohol in a woman during labor is not identical with 
 that in an ordinary subject in a dental chair, or upon the 
 surgeon's table, and from the history of such administration, 
 free from a single well-authenticated case of death, with 
 statistics showing its superiority over venesection, opium, 
 etc., in the desperate emergencies attending irregular labors, 
 as eclampsia, it is fair to infer that this agent is an especial 
 therapeutic indication for parturient women, and should 
 be so regarded in all labors where by its use the pains of 
 the second and third stages could be obviated, and this, too, 
 to the ultimate benefit of the mother, and safety of the 
 child. 
 
 " 3d. That in puerperal eclampsia it is especially indicated, 
 because of its direct, rapid, and general action, controlling 
 nervous physiological irregularities, exciting secretion, re- 
 laxing the os and perineum, and, in short, so preparing the 
 parts as to aid the accoucheur in his manipulations for the 
 essential emptying of the uterus, to accomplish which, ven- 
 esection, opiates, purgation, counter irritation, etc., either 
 singly or combined, bear to anaesthetics the relation of 
 mere fractions to a grand whole. 
 
 4 '4th. Its application is universal ; no diseased condition 
 of the heart or lungs at all likely to exist where pregnancy 
 can occur, should forbid its use — for where has & post mortem 
 examination revealed a dilated and weak right heart from 
 fatty degeneration in the body of a pregnant woman at 
 full term f 
 
 "5th. That in view of its known therapeutic action and 
 safety in the small quantity required to produce narcosis, 
 no use of the forceps, version, nor obstetric operation of any 
 moment should be performed without it ; not only to save 
 the patient from shock and its consequences, but because of 
 the great saving of time and labor, and, in most instances, 
 the assistance it affords the operator. 
 
 ' ' 6th. Owing to the fact that uterine contractions are often 
 lessened by the administration, it is always important to 
 precede it by an oxytocic, in all labors and at any stage, 
 when the pains are slight, so as to increase their force, and 
 as also to guard against post partum hemorrhage — a very 
 infrequent occurrence where such precaution is taken. 
 
 "7th. Accidents to the unemptied bladder, ruptures of 
 
EARLY STAGE OF ETHER AND CHLOROFORM. 157 
 
 perineum, and sphincter ani may be prevented, as well as 
 death of the child in prolapsus of the cord by the facilities 
 afforded for rapid delivery, especially in prumpara. 
 
 " 8th. That in no instance have I seen narcosis of the child 
 attributable to the anaesthetic. 
 
 "9th. Without any special reason, excepting the common 
 disagreeable feature of ether, and the supposed risk of chlo- 
 roform, I have generally used the mixture proposed by the 
 Medico-Chirurgical Society of London, consisting of ether 
 three parts, chloroform two parts, and alcohol one part, 
 being careful as to the quality of the preparation, and having 
 them recently mixed. With this combination I have never 
 been disappointed, or regretted its use ; and, in truth, nearly 
 all the troublesome cases I have had after the labor were 
 those in which, for some reason, the anaesthetic was not 
 used." 
 
 The first proposition of the doctor is not an absolute fact, 
 as in this work there are cases reported of death from the 
 effects of anaesthetics in the parturient state. In the second, 
 we would state that we have seen more than one death from 
 anaesthesia of the child. We agree in part with the doctor 
 in his third jjroposition, but great care must be taken in 
 ascertaining if there is disease of the kidneys, heart or lungs, 
 the administration of chloroform or its mixtures in these 
 cases being exceedingly dangerous. In the seventh proposi- 
 tion, we are of the opinion that the accidents enumerated 
 are more likely to occur when the brain is not cognizant of 
 the action of the hands of the accoucheur, or perhaps, of the 
 destruction by the forceps of the soft parts of the mother or 
 child. 
 
 It is well to be remembered that there is a stage in the use 
 of one of these agents when it can be used wi.th comparative 
 safety, and in regard to the other we state the fact on an 
 experience of a close and careful observer. 
 
 EARLY STAGE OF ETHERIZATION. 
 
 Early stage of anaesthesia by ether, pupils are contracted, 
 but when there is complete anaesthesia the pupils become 
 dilated, and the respiration is slow and deep. 
 
 A peculiar effect of etherization, which has been early 
 noticed and published by a careful writer and experimenter 
 
 10 
 
158 ARTIFICIAL ANAESTHESIA. 
 
 of this city, the late Doctor J. F. B. Flagg,* and which re- 
 sult has been confirmed by us and by others, is stated as 
 follows : — 
 
 "There is a particular point of etherization produced by 
 a few deep inhalations, which if improved at the moment 
 (slight operations can be performed) will leave the patient 
 in full possession of all his faculties with the single excep- 
 tion of the sense of pain, and particularly the consciousness 
 of touch is as acute as under ordinary circumstances, if not 
 quickened." 
 
 In our own experiments in this stage the sense of sound and 
 vision was always very active. If, however, the patient is 
 roused from his first anaesthetic sleep by the pain of the knife, 
 or a sudden noise, or a rough touch, it is always found more 
 difficult to cause such a patient to pass into a profound state of 
 insensibility by means of the ether. Yet, if a patient will 
 not breathe the ether properly when it is required for an 
 operation, it will sometimes do good to prick or scratch the 
 surface with a knife, and then insist upon the patient 
 breathing the ether so as to get rid of the pain. 
 
 EARLY STAGE OF CHLOROFORMIZATION. 
 
 There is also a period in chloroform narcosis when all 
 feeling of pain ceases, but consciousness is not entirely gone 
 when incisions or sawing of bones are perceived as mere 
 tactile impressions, for according to Schiff, the sensation of 
 pain is conveyed to the brain through the gray matter of the 
 spinal cord; but the tactile impression through the white 
 matter of the posterior columns, which, being less vascular, 
 do not so readily succumb to amesthesia, and retain their 
 function a little longer. 
 
 * Ether and chloroform. By J. F. B. Flagg, M. D. Philadelphia,. 
 Lindsay & Blakiston, 1851, p. 89. 
 
NITROUS OXIDE GAS. 159 
 
 CHAPTER VI. 
 
 Nitrous oxide gas as an. anaesthetic. Mode of preparation, chemical 
 constitution, gasometer, inhaler, and mode of purifying nitrous 
 oxide gas. The advantages of the gas being recently prepared. 
 Class of cases for inhalation. Difficulties and dangers, with mode 
 of treatment. Liquid nitrous oxide in cylinders. Physiolog- 
 ical action of nitrous oxide. Experiments and observations by 
 Doctors Evans, of Paris, M. Buisson, Doctors McQuillen, Thomas, 
 
 • Robert Amory, George Johnson, and the writer. Mode of 
 action of anaesthetics by Doctors C. Binz, H. Ranke, Claude Ber- 
 nard, and Committee British Medical Association. Investigations 
 upon the protoxide of nitrogen by Doctors Jolyet and T. Blanche. 
 The spectroscope and its relations to nitrous oxide. Experiments of 
 Doctors Waterman, J. G. Richardson, Wm. M. Hodges, C. S. Turn- 
 bull, and the writer. Niti'ous oxide gas in dental and minor 
 surgery. M. Paul Bert on the use of a mixture of nitrous oxide and 
 oxygen gases. Deaths from the inhalation of nitrous oxide. 
 
 NITROUS OXIDE GAS. 
 
 In entering upon the subject of nitrous oxide it is not my 
 purpose to go into its discovery, early history, etc., as a short 
 statement is made in another part of this work, and numer- 
 ous references are given for those that are interested. This 
 anaesthetic can be employed in a few operations in surgery ; 
 these are, extraction and surgical operations on the teeth and 
 gums. With it the ophthalmic surgeon can operate for ordi- 
 nary strabismus, or removal of small tumors, or even enucle- 
 ate the diseased eyeball. It is very valuable in examining the 
 urethra for stricture, and even the cutting of an impervious 
 stricture has been performed with success. Necessary manip- 
 ulation for recent luxation, in stiff joint, and tenotomy of 
 tendons for the relief of club foot, etc., have all been per- 
 formed while under its influence, and in conjunction with 
 sulphuric ether almost all surgical operations can be per- 
 formed. 
 
 My chief object will be to treat of this anaesthetic in its 
 practical relation in connection with dentistry. I am in- 
 debted for most of my facts to Dr. J. D. Thomas, of this city, 
 the highest American authority on this subject. 
 
160 
 
 ARTIFICIAL ANAESTHESIA. 
 
 Fi<r. 10. 
 
NITROUS OXIDE GAS. 
 
 161 
 
 Mode of Preparation and Chemical Composition. — Nitro- 
 gen monoxide or nitrous oxide gas (NO — N 2 0) is prepared 
 from the nitrate of ammonia, which resolves itself into the 
 gas and water, thus : — 
 
 N0 3 NH 4 =IHO, OH+2NO. 
 
 The nitrate of ammonia is a crystalline salt, but for con- 
 venience of introduction into the retort, should be in a 
 granulated form, which can be obtained of the manufactur- 
 ing chemist. 
 
 The second important matter is to be furnished with a 
 convenient gasometer, an illustration of which is seen at 
 Fig. 10, and these can be obtained from the various dental 
 depots.* Having obtained one of these gasometers, care is 
 required in the selection of the bottles for washing and 
 Fig. 11. purifying the gas. Fig. 11 represents a 
 
 very good form, which is furnished with 
 perforated rubber cork and glass tubes 
 bent at right angles. The long tube is 
 pierced with small holes at the bottom to 
 compel the breaking up of gas and so 
 insure its more thorough washing. In 
 purifying the gas some employ a solution 
 of sulphate of iron in one bottle and pure 
 water in the other two. To remove 
 chlorine gas, which is sometimes present, 
 and can be noticed by its green color and 
 irritating vapor upon the respiration, a 
 small stick of caustic potash is added to 
 one of the bottles containing the water. 
 
 When no chemical agents are em- 
 ployed in the purification of the gas it 
 should be well washed through fresh water, and allowed to 
 stand for some few hours over the water in the gasometer, 
 to remove any impurities that may have passed over. 
 
 Fig. 10 represents the gasometer in position. The holder 
 is first filled with water to within one and a half or two 
 inches of the top ; while this is being done take off the 
 weights and open all the spigots, to allow the air to pass out 
 
 Samuel S. Write, Philadelphia, Nov/ York, Boston, and Chicago. 
 
162 ARTIFICIAL ANESTHESIA. 
 
 and the receiver to remain in position. When the holder 
 is rilled, close the spigot and arrange the weights ; it is then 
 ready to receive the gas. The wash-bottles are placed as 
 represented in the cut, Nos. 1,2, and 3, which are connected 
 one with the other, and to the retort and gasometer, by 
 means of rubber tubing. The first bottle, No. 1, is placed 
 next to the retort, and is simply used to catch the drip result- 
 ing from condensed vapor. 
 
 The long pipe of bottle No. 1 must not dip under the 
 water, for the tubing thereby becomes choked .with dense 
 vapor, and the free passage of gas is interrupted. 
 
 Into wash-bottle No. 2 place about four ounces of sulphate 
 of iron, and add sufficient water to cover the end of the dip- 
 pipe, about one and a half to two inches. 
 
 Into wash bottle No. 3, Fig. 11, it is unnecessary to place 
 anything but fresh water; yet some, fearing the chlorine, 
 add a stick of caustic potash. 
 
 Sufficient water should be employed to cause the pipe 
 which dips into the water to sink the same depth as it does 
 in No. 2. ' 
 
 When the bottles are prepared, connect them by the piece 
 of rubber tubing B, and to the spigot of the gasometer. If 
 they are arranged j)ropeiiy, a current of air, blown into the 
 tube intended to connect with the retort, will cause the water 
 to bubble in the wash bottles, Nos. 2 and 3, and if the spigot 
 A is open, the receiver will commence to ascend. 
 
 Having the bottles in readiness and properly connected, 
 place the quantity of nitrate of ammonia, which will be re- 
 quired, into the retort (oue pound of the granulated salt will 
 produce about thirty gallons of the gas). D is a stove-like 
 arrangement heated by gas-burners, with a sand-bath for 
 holding and heating the retort. Connect the retort with the 
 long pipe of the first bottle by the rubber tubing, and then 
 open the spigot of the gasometer. 
 
 The heat must be applied gradually, first to melt the am- 
 monia, about 226° F., and then to cause it to boil, and give 
 off gas at 460° F., and so regulate this heat as to keep it boil- 
 ing at 460° F. to 480° F., until it is nearly all decomposed. 
 When the gas has ceased to come over, take a cloth and dis- 
 connect the retort from the tubing, and close the spigot of 
 the gasometer. 
 
NITROUS OXIDE GAS. 163 
 
 The inhaling tube is attached to the spigot at the top of 
 the holder. There is a register which shows the number of 
 gallons of the gas in the receiver. 
 
 The water and solutions contained in the wash-bottles 
 should be changed after each operation, and the water in the 
 holder once in a month. When nitrous oxide s:as is thus 
 obtained, it is colorless, almost inodorous, of a sweetish taste. 
 The chemical decomposition is as follows: — nitrate of ammo- 
 nia resolves itself into nitrous oxide gas and water ; thus, 
 N0 3 NH 4 =OH>2NO. The heat necessary to cause active 
 evolution of gas is stated to be 460° F., and this heat should 
 be kept up, else a portion of the salt will sublime. The heat 
 should never be allowed to rise above 482° F., as the nitric 
 oxide is apt to be given off in the form of an orange-colored 
 vapor. To determine the proper temperature a thermom- 
 eter is prepared which can be passed into the cork and into 
 the retort, so that no risk need be incurred by the introduc- 
 tion of poisonous materials into the gas. 
 
 Nitrous oxide gas as a liquid,* and as such is sold in form 
 of cylinders. 
 
 Test of the purity of their liquid nitrous oxide is the 
 appearance of the gas, and its freedom from red fumes as it 
 comes from the retort, and the smell. 
 
 The complete apparatus consists of an iron cylinder con- 
 taining at least one hundred gallons (usually more) of nitrous 
 oxide, liquefied, to which is attached, by means of a nickel- 
 plated union, the necessary tubing, gas-bag, and inhaler; 
 nickel-plated wrench and key; the whole inclosed in a 
 stout morocco case. 
 
 The inhaling tubing is made of the best material known 
 for the purpose. 
 
 The gas-bags are made of stout muslin, thoroughly coated 
 on both sides with pure "steam vulcanized" Para rubber. 
 
 Their parts are all cemented together before putting them 
 in the heater, insuring a strong vulcanized seam. 
 
 The advantage of this method of construction is seen at 
 once. If accidently cut or burnt, or mutilated on the outer 
 surface, they are still good and serviceable, as the inner coat- 
 ing remains intact, and will prevent all leaking. 
 
 * "History of discovery and mode of preparation of Liquefied 
 Nitrous Oxide." Dental Cosmos, vol. xx., No. 3. 
 
164 ARTIFICIAL ANESTHESIA. 
 
 After this brief description of the process of its manufac- 
 ture, as it has been set forth, I would remark that some use 
 the fused and others the granulated nitrate of ammonia, I 
 consider the granulated preferable only from the facility 
 with which you can fill the retort. After the gas is made, it 
 should stand over water from seven to ten hours before using, 
 but this will do little toward insuring absolute purity of the 
 gas ; neither will washing it through solutions of iron and 
 potash purify it perfectly. Should there be chlorine pres- 
 ent (which is the poisonous element) in the ammonia, I 
 have found that no amount of washing through solutions 
 will obliterate it. The ammonia should always be tested 
 before using, which is done by dissolving about a teaspoon- 
 ful in half a tumbler of distilled water, and applying a few 
 crystals of the nitrate of silver. If the ammonia be pure, 
 the solution will remain perfectly clear ; but should chlo- 
 rine be present, it will show a clouded appearance, and the 
 ammonia must be discarded altogether. 
 
 Next to pure gas, a perfect inhaler is the most essential 
 object to the successful administration of nitrous oxide. It 
 must be one with a tube large enough to admit the gas so 
 freely that the most nervous, as well as patients with weak 
 lungs, can inhale through it without exertion, and it must 
 be perfectly air-tight. The majority of inhalers are so con- 
 structed that it is only with using great effort that patients 
 can supply the lungs to their natural capacity, causing 
 them to struggle for air, or to go to sleep with such feelings 
 of suffocation and depression that they will drift into dreams 
 of the most frightful character, and become almost unman- 
 ageable in their excitement, 
 
 It is necessary that the valves should be perfectly air- 
 tight, so as to administer the gas free from any atmospheric 
 air, one breath of which is sufficient to dilute to or three of 
 the gas ; and should there be a continual supply through the 
 valves, it will require three times the quantity of gas. and 
 the anaesthesia so produced will be of such a nature as not 
 to render the patient utterly oblivious to the effects of the 
 operation. 
 
 Inhalers which cover the face or any part of it are objec- 
 tionable. In cases of gentlemen with beard, it is impossible 
 to give the gas without the admission of some air. In in- 
 
ADMINISTRATION OF NITROUS OXIDE GAS. 165 
 
 stances such as harelip, or where, from swelling or other 
 cause, the muscles of the jaws become so contracted as to 
 render it impossible to pass the mouthpiece between the 
 teeth, I would recommend Dr. Barker's rubber hood, which 
 is soft and pliable, and answers admirably in such cases, 
 though not desirable for universal use. The color of the 
 ' blood, as shown through the mucous membrane of the lips, 
 is one of the principal guides to the condition of the patient 
 during the inhalation of the gas ; and if they are covered 
 from view by the hood or otherwise, • we have lost that 
 means of rendering success to the operation. 
 
 Unlike chloroform and ether, the muscles of the patient 
 become rigidly contracted while under the influence of ni- 
 trous oxide in a large number of cases, which render the 
 use of props indispensable. These are made of hard wood 
 of various sizes, and have strings attached to assure the pa- 
 tient against the possibility of swallowing them, and are 
 placed in the mouth on the side opposite from where the 
 tooth is to be extracted. By their use one has a fair oppor- 
 tunity to perform the operation to his entire satisfaction ; 
 but without them there is danger of the patient bruising 
 and possibly breaking the front teeth by biting so hard upon 
 the mouthpiece, with the probability of recovering from the 
 effects of the gas before the mouth can be gotten open suffi- 
 ciently wide to admit of the extraction of a tooth, or of an 
 operation upon the mouth. 
 
 Nitrous oxide must always be fresh to insure success, 
 though some have recommended it after it has stood over 
 water one or two weeks, and even a month, but it is imprac- 
 ticable. 
 
 Dr. Rand, the late professor of chemistry at Jefferson 
 Medical College, advocated the use of old gas ; and to practi- 
 cally demonstrate the difference, some gas was allowed to 
 stand for two weeks. Dr. Thomas then invited him to test 
 between that and the new. He also invited his assistants, 
 Drs. Green and Smith, and tested by inhaling with deep 
 inspirations to the full eapaciey of the lungs, first of the new, 
 then the old, and it required five times the quantity of the 
 old to produce the same effect as with the new, which proved 
 quite convincing. Besides requiring an excessive quantity, 
 the anaesthesia produced by old gas is not so complete, but 
 
166 ARTIFICIAL ANAESTHESIA. 
 
 the patient will generally receive some undefined impres- 
 sion of the operation, and will often complain of giddiness 
 and a fulness in the head, and a feeling generally of malaise 
 for the balance of the day. With fresh gas, sickness will 
 never occur, except with patients of very delicate organiza- 
 tions, such as are easily disturbed by nervous excitement, 
 and those who are affected by the sight of blood or the con-, 
 templation of a wound of any kind. 
 
 In its pure state the gas may be given to almost any one, 
 if judiciously administered, for Dr. Thomas has given it to a 
 large number of patients afflicted with heart disease and 
 'Consumption, also to cases subject to epilepsy, St. Vitus' 
 dance, persons of apoplectic tendency, and women advanced 
 in pregnancy, and have never yet met with any but the 
 most satisfactory results. 
 
 Among the difficulties which may be met with as having 
 the appearance of danger in administering nitrous oxide, 
 the most common is constriction or spasm of the glottis or 
 "swallowing the tongue." The use of the prop cannot be 
 overestimated in such cases. The patient becomes very 
 dark in the face ; there is a violent exertion of the diaphragm, 
 and he presents every indication of approaching asplryxia, 
 which by having the mouth well propped open, is very 
 readily relieved by catching hold of the tongue with a dry 
 napkin and pulling it out of the mouth, and at the same 
 time raising the body forward. As soon as the patient has 
 taken two or three inspirations the tension is relaxed, and 
 recovery will take place. I recall a case of this sort some 
 time, ago- in Exeter, England, where the patient died. 
 
 Another formidable symptom of danger is when your 
 patient is attacked with syncope while under the influence 
 of the gas. Be sure the air passages are open by pulling the 
 tongue forward. Then, the })atient being in a sitting posture, 
 bring the head and body forward with considerable violence, 
 which will invariably prove sufficient. You may, however, 
 meet cases which will require more effective remedies. The 
 object is first to get the head on a level or below the heart, 
 so the blood may flow freely to the brain, which is done by 
 laying the patient on the floor ; then throw cold water by 
 
 * Described in "The Dental Cosmos," May, 1873. 
 
PHYSIOLOGICAL ACTION OF NITROUS OXIDE GAS. 167 
 
 the tumblerful violently in the face. The most effectual 
 remedy is to place the ringer far down the throat, which 
 will produce involuntary retching, and is the most efficient 
 action to bring about restoration, after which you treat the 
 patient as any ordinary case of fainting, giving a little brandy, 
 and allowing him to lie on the lounge until he has become 
 strong enough to walk in the fresh air, when he will soon 
 recover completely. 
 
 In the hands of so skilful and careful an operator as Dr, 
 Thomas, no great risk attends the employment of this 
 anaesthetic ; but those who are less skilful and are inexperi- 
 enced should reject cases of great physical exhaustion, or 
 patients with a feeble or fatty heart. The distension of the 
 right cavities which accompanies the disappearance of the 
 radial pulse, and the general lividity of the features, may be 
 attended with some degree of risk, and the danger must be 
 increased when, the muscles of the trunk and limbs being 
 convulsed', the pressure of the contracting muscles upon the 
 veins drives the blood forcibly towards the right cavities of 
 the heart, and so adds to their distension. 
 
 PHYSIOLOGICAL ACTION OF NITROUS OXIDE 
 
 GAS. 
 
 The marked resemblance between the effects produced 
 by nitrous oxide and those resulting from asphyxia were 
 observed by the earlier experimenters with ether ; and a 
 few eminent physiologists at once expressed this opinion. 
 But at the present day it is not very generally entertained. 
 
 The following is a summary of the various facts bearing 
 on the subject,— i.e., in regard to the physiological action of 
 nitrous oxide : — 
 
 It would seem that this accumulated evidence is not suffi- 
 cient to show that the anaesthesia produced by the inhala- 
 tion of nitrous oxide is simply asphyxia. Nitrous oxide 
 gas produces in man, even when mixed with air, a feel- 
 ing of exhilaration, which would indicate that it is not 
 merely a passive agent. " Dr. Evans,* of Paris, states 
 that he can call to mind no word in modern medical litera- 
 ture which is used with less defmiteness of meaning, and 
 
 * Physiological action of nitrous oxide gas, by Thomas W. Evans, 
 M. D., D.D.S., Paris, France. 
 
168 ARTIFICIAL ANAESTHESIA. 
 
 which is more frequently misused, than this word, asphyxia. 
 Understanding, however, by the word asphyxia, the condi- 
 tion which arises from an insufficient oxygenation of the 
 blood, or from the accumulation in the blood of carbonic 
 acid, he is by no means inclined to regard such conditions 
 as identical with that produced by the inhalation of nitrous 
 oxide. If there is a close resemblance between these, he 
 states, there are also marked differences. 
 
 Nitrogen, when inhaled, is supposed to act upon the ani- 
 mal economy solely by the exclusion of oxygen. Nitrogen, 
 when taken into the lungs, gives rise to no feeling of exhil- 
 aration, but to malaise and a sense of impending suffoca- 
 tion, and only occasions symptoms of narcosis and insensi- 
 bility after an interval of time considerably greater than 
 that usually found necessary when nitrous oxide is used. 
 
 In animals, after death following the inhalation of nitro- 
 gen, Dr. Evans has generally found less venous congestion, 
 particularly of the portal system, than is to be observed after 
 death from nitrous oxide. The blood is also lighter in 
 color, and the liver nearly normal in appearance. 
 
 There is, however, one condition strikingly similar to 
 that observable after death from nitrous oxide, — i. e., the 
 condition of the lungs. These organs are found neither 
 voluminous nor collapsed, of a light pink or rose color, and 
 generally with one or more small circular, well-defined ec- 
 chymotic spots, usually on their posterior surface. These 
 spots, the ecchymoses sous pleurales of French writers, are 
 considered by Briand and Chande as peculiar to death by 
 suffocation, and as distinguishing that kind of asphyxia 
 from the asphyxia of drowning, hanging, and strangula- 
 tion. The phenomena occasioned by the presence of car- 
 bonic acid were then carefully studied by experiments by 
 Dr. Evans. This gas when pure is irrespirable ; the mix- 
 ture which he employed was thirty per cent of carbonic and 
 seventy of common air. This mixture, when inhaled, pro- 
 duces the peculiar effects of carbonic acid, — loss of power 
 of motion, loss of conscious sensation, and finally death. 
 The insensibility is not preceded by a period of excitement, 
 such as is witnessed during the inhalation of ether, and 
 more especially of nitrous oxide. Again, the after effects 
 following a prolonged inhalation of carbonic acid are ob- 
 
INHALATION OF CARBONIC ACID. 169 
 
 served, — the sense of weariness, headache, loss of appetite, 
 nausea, etc. ; none of these signs of nervous disturbance 
 are commonly seen after inhalation of nitrous oxide. This 
 is an important difference, not only practically, but phy- 
 siologically. 
 
 After death from, nitrogen or nitrous oxide, the lungs are 
 moderately crepitant, and the blood which escapes from an 
 incision is more or less full of gas bubbles. In case of death 
 produced by nitrous oxide, the bubbles will be found in the 
 bronchial ramifications mixed with mucus, and in one or two 
 instances, Dr. Evans found the trachea filled with rusty, 
 frothy fluid, so common after drowning as to have been 
 referred to by Dr. Riedell as almost pathognomonic of that 
 cause of death. The local effects of nitrous oxide were found 
 to be less marked than those produced by carbonic acid. 
 They both act upon the blood-corpuscles so as to darken 
 them. The lividity upon the lips, and the darkening of the 
 mucous surfaces seen every day in the operating room 
 after administrations of nitrous oxide are the result of this 
 action. The inhalation of nitrous oxide is followed by an 
 increased exhalation of carbonic acid ; so is the inhalation 
 of ether, chloroform, etc. Soon, however, according to M. 
 Buisson, if the inhalation be continued, the exhalation of 
 carbonic acid falls below the normal proportion to be found 
 in expired air. 
 
 While it is perfectly evident that nitrous oxide has a strong 
 affinity for the blood-corpuscles, it may usurp the place of 
 oxygen in them, and prevent for a time that combination of 
 oxygen with the hsematin upon which the red color of the 
 corpuscles is presumed to depend. Chemistry has not yet 
 shown that it is decomposed in the blood, or exerts any of 
 the chemical properties of oxygen on the constituent 
 elements of the blood. 
 
 The conditions which obtain after the inhalation of 
 nitrous oxide, ether, chloroform and other anaesthetics, are, 
 specific toxical properties, which first stimulate, then narco- 
 tize, then destro}- nervous action : by (a) an interference 
 more or less marked with the oxygenation of the blood, and 
 the consequent imperfect accomplishment of certain chem- 
 ico-vital processes; by (6) a retention in the blood of a por- 
 tion of the usual pulmonary exhalations: the two latter and 
 
170 ARTIFICIAL ANESTHESIA. 
 
 secondary conditions always finally co-operating with 
 the specific action of the anaesthetic in the production of 
 narcosis, the arrest of innervation, and in the suspension of 
 every functional movement for a time with a rapid return 
 to health. Latterly it has been disproved both by experi- 
 ment and observation, i. e., the theory which for a time 
 prevailed in the United States, "that nitrous oxide acts 
 upon the blood as an oxygenating agent. ' ' No experimental 
 proof has yet been furnished that nitrous oxide is decom- 
 posed in the blood, or forms chemical combinations with it. 
 It enters into the blood as nitrous oxide, and as such is elimi- 
 nated. It will naturally be inferred from this statement 
 that the presence of nitrous oxide in the blood is not indi- 
 cated by the appearance (except change of color), as before 
 stated. This was very conclusively proven by the late Dr. 
 J. H. McQuillen, Professor of Physiology in Philadelphia 
 Dental College, which proofs are here given with the 
 illustrations. 
 
 Dr. Thomas, of this city, of theColton Dental Association, 
 placed his whole apparatus, with a large supply of recently 
 made pure nitrous oxide gas, at the disposal of Dr. McQuil- 
 len and myself, and we repeated the experiments (see p. 
 176) in confirmation of the facts: that the gas had no posi- 
 tive poisonous qualities; second, that the blood-corpuscles 
 were changed neither in form nor color under the micro- 
 scope, and nitrous oxide is only known by the change of 
 color, and even this varies much in individuals. A full 
 report will be found at the end of his original communication. 
 
 The late Dr. McQuillen placed this communication at my 
 disposal, with the cuts to illustrate it, and made such modi- 
 fications of it as time and his mature judgment would seem 
 to have dictated. 
 
 ACTION OF ANESTHETICS ON THE BLOOD- 
 CORPUSCLES.* 
 
 In the October number of the Dental Cosmos, 1808, a re- 
 port was presented of a series of experiments performed on 
 
 * Republished in the Boston Medical and Surgical Journal ; Monthly- 
 Microscopical Journal, London; Deutsche Klinick, Berlin; Dental 
 Cosmos, March, 1869; Correspondenz Blattiur Zahnarzte; Giornale di 
 Correspondenza del Dentisti; Le Progres Dentaire. 
 
PHYSIOLOGICAL ACTION OF NITROUS OXIDE GAS. 171 
 
 a number of animals, with the view of ascertaining 
 whether the assertion made by Dr. B. Ward Richardson, 
 that nitrous oxide, even under the most delicate manipula- 
 tion, would prove destructive to life, could be possible. 
 These experiments, which clearly demonstrated the asser- 
 tion to be unfounded, were not performed in private, but in 
 the presence of a number of gentlemen whose experience 
 in the use of anaesthetics and whose scientific knowledge 
 made them competent judges. First performed before the 
 members of the Odontographic Society of Pennsylvania, 
 they were repeated, after an interval of three weeks, on the 
 same animals, in the presence of the members of the Bio- 
 logical and Microscopical Section of the Academy of Natu- 
 ral Sciences. 
 
 A month subsequent to the last-named occasion, one of 
 these animals, a rabbit, in the presence of a number of gen- 
 tlemen, was placed under the influence of nitrous oxide, 
 and kept in a profound state of narcosis for one hour and 
 five minutes, by alternating atmospheric air and nitrous 
 oxide, removing the inhaler ever and anon for that purpose. 
 Without question the animal could have been kept in the 
 same condition double or treble the time without injury to 
 it, for in a few minutes after removing the anaesthetic en- 
 tirely, the animal was restored to consciousness, and leaped 
 from the table to the floor, and for a number of weeks after 
 this ran about my premises in a healthy and lively condition. 
 
 On examination, no perceptible difference was observable 
 in the blood-corpuscles under the microscope, even after 
 this lengthened exposure to the anaesthetic, when compared 
 with the blood of another rabbit, which was not under its 
 influence. This result induced me to examine into the 
 statements made by Dr. Sansom relative to the action of ' 
 anaesthetics on the blood-corpuscles, in his highly interest- 
 ing and able work on chloroform. * 
 
 Prior to giving a description of my experiments in this 
 direction, it may be proper to briefly refer to the prevalent 
 theories on the physiological action of anaesthetics; also to 
 the experiments performed and conclusions arrived at by 
 
 ♦Chloroform, its actions and administrations. By Arthur Ernest 
 Sansom, M.B., London. Lindsay & Blakiston, Philadelphia. 
 
172 ARTIFICIAL ANAESTHESIA. 
 
 Dr. Sansoni. The view generally entertained is that first 
 suggested by Flourens, that these agents act directly upon 
 the nerve centres, producing regular and progressive modi- 
 fications in the functions of the brain and spinal axis, first 
 affecting the cerebral hemisphere, then the power of co-or- 
 dination in the cerebullum, then the conduction of sensa- 
 tion and motion in the spinal chord, and lastly, if the agent 
 is pushed so far as to decidedly impress the medulla oblon- 
 gata, suspension of respiration and circulation. 
 
 Dr. John Snow, regarding this theory as erroneous, and 
 recognizing ether, chloroform, and other anaesthetics as 
 non-supporters of combustion, advanced the theory that 
 these agents, interfering with the introduction of oxygen 
 into the system, induced their effect by the suspension of 
 oxygenation. He therefore asserted that "narcotism is 
 suspended oxygenation." This view is embraced and 
 strongly advocated by Dr. B. W. Richardson, and in Eng- 
 land apparently is being very generally adopted by writers 
 on this subject. Dr. Kidd is, however, a prominent excep- 
 tion. 
 
 Dr. Sansom, accepting this theory, and knowing that 
 nitrous oxide is not only an anaesthetic, but a supporter of 
 combustion, recognized the necessity of presenting some- 
 thing more conclusive in the support of the view than had 
 heretofore been offered. He therefore, in a paper read before 
 the Royal Medical and Chirurgical Society, in 1861, as the 
 result of certain experiments performed on the blood-cor- 
 puscles of man and animals out of the body, attributed the 
 influence exerted by anaesthetics on the nervous system to 
 their acting directly upon the blood corpuscles, by modify- 
 ing their form and integrity, and indirectly upon the nerv- 
 ous system through this altered condition of the blood, by 
 interfering with its oxygenation. In this work he describes 
 a series of six experiments. Placing on glass slides, under 
 a quarter-inch object glass, human and frog's -blood, and 
 subjecting them to the direct contact of alcohol, ether, and 
 chloroform, which resulted quickly in the disintegration of 
 the blood-corpuscles, leaving nothing but their nuclei and 
 debris of the walls of the corjmscles. From these experi- 
 ments on blood out of the body, he states in the work re- 
 ferred to: — " The effect, therefore, of these agents upon the 
 
PHYSIOLOGICAL ACTION OF NITROUS OXIDE GAS. 173 
 
 blood is solution — destruction. At first there is a change 
 induced in the cell itself, and upon the nucleus in the case 
 of frog's blood. The globuline of the blood is acted upon 
 as it were by a caustic. Finally the blood-corpuscle is 
 destroyed and the coloring matter set free." . . . From the 
 foregoing facts and other considerations, the author con- 
 siders that certain conclusions in regard to the action of an- 
 aesthetics are warrantable. Anaesthetics are agents which, 
 when absorbed into the circulation, exert an influence upon 
 the blood. They are shown to have the power of altering 
 its physical character and physical properties. By an action 
 upon its constituent (proteinous) elements, they tend to 
 alter and by a profounder action to destroy its organic 
 molecules. Its physical perfection being interfered with, 
 its function is held in abeyance; the changes which con- 
 tribute to constitute perfect life are retarded. Narcosis en- 
 sues, and is due, not to the influence of a circulating poison T 
 but to the influence of an altered blood. Further on, he 
 adds : "Narcotism (or, to speak more particularly, chloro- 
 form narcotism) is due not to a special poison that ' mounts 
 up to the brain,' but to an altered blood. Then ' narcotism 
 is a suspended oxygenation.' Whatever produces, to a cer- 
 tain extent, insufficient aeration of the blood, produces 
 narcosis; and whatever produces narcosis, produces, by- 
 some means or other, imperfect aeration of the blood." 
 
 In drawing these conclusions, of an altered condition of 
 the blood, from appearances presented by the blood out of 
 the body, Dr. Sansom evidently leaves it to be inferred that 
 somewhat if not exactly analogous results are produced on 
 the corpuscles in the body, when human beings or animals 
 are under the influence of anaesthetics by inhalation. After 
 a patient, oft repeated series of experiments performed by 
 me during the past three months, not only on blood out of 
 the body, but also in cases in which human beings and 
 animals have been placed under the influence of ether, 
 chloroform, and nitrous oxide, and the blood drawn from 
 them prior to and after the administration of these agents 
 has been carefully examined and compared, the results ob- 
 tained compel me to take very decided exceptions to such 
 conclusions being justifiable in the premises. 
 
 First Series.— The experiments were as follows :— In my 
 
174 
 
 ARTIFICIAL ANESTHESIA. 
 
 Frog's blood placed upon the 
 slide, and chloroform brought 
 in direct contact with it. 
 
 examinations of the blood of man and animals, when ether 
 
 and chloroform were brought 
 in direct contact with it out 
 of the body, under a fifth ob- 
 jective, the discharge of the 
 nuclei and the disintegration 
 of the corpuscles have invaria- 
 bly occurred, and in the frog 
 leaving a result similar to that 
 which is presented in the ac- 
 companying drawing (Fig. 12) 
 from one of my specimens, 
 wherein it will be observed 
 that the field is occupied by 
 the nuclei, debris of disin- 
 tegrated globuline and corpus- 
 cles, in which the change of 
 form, size, and other characteristics are most striking. 
 
 Second Series. — On placing, however, two glass slides con- 
 taining frog's blood over watch-crystals, one holding chlo- 
 roform and the other ether, and covering them with glass 
 finger-bowls for half an hour, thus exposing one to an 
 atmosphere of ether, and the other of chloroform, I found, 
 on removing the bowls, and permitting the bloody sides of 
 the slides to remain downward, until all the ether and 
 chloroform, had evaporated, that no disintegration or marked 
 change in the form of the corpuscles was observable under 
 the microscope, on comparing them with the blood of a frog 
 unaffected by an anaesthetic. This forcibly demonstrates 
 the difference between exposure to direct contact and the 
 vapor of chloroform or ether, even out of the body. 
 
 Third Series.— Over and again in the presence of a num- 
 ber of gentlemen I have placed frogs under the influence 
 of ether, chloroform, and nitrous oxide, and examined their 
 blood-corpuscles immediately after without finding any dis- 
 integration or change in the form of the corpuscle. In one 
 instance, a frog was so completely narcotized by chloroform 
 that it died ; the thorax of the animal was opened, the lungs 
 cut out, and the blood obtained directly from that organ, 
 and even here, where, if the inference of an altered blood 
 was correct, there 4 should have been discharge of nuclei, dis- 
 
ACTION OF ANAESTHETICS UPON THE BLOOD. 
 
 175 
 
 Corpuscles from the lungs of a 
 frog which died under the in- 
 fluence of chloroform. 
 
 integration, or marked change Fig. 13. 
 
 in the form of the corpuscle, 
 nothing of the kind was 
 evident, as will be seen by 
 the accompanying illustra- 
 tion, drawn from the slide on 
 which the blood was placed. 
 (Fig. 13.) As already intima- 
 ted, the experiments in this 
 direction have been prosecuted 
 on every available occasion 
 within the past few months ; 
 and I have not confined my- 
 self to frogs, but, in the course 
 of vivisections on a large num- 
 ber of animals (rabbits, dogs, cats, and pigeons), to illustrate 
 my course of lectures on physiology this winter, when these 
 animals have been placed under the influence of ether or 
 chloroform, their blood has been examined and no change 
 in the form of the corpuscle has been evident. 
 
 Fourth Series. — The examination of the blood of a number 
 of human beings, drawn prior to and after having been 
 under the influence of ether, chloroform, or nitrous oxide, 
 
 has yielded similar results, as 
 will be evident from the ac- 
 companying illustration of the 
 blood, obtained from a patient 
 (Fig. 14) while under the in- 
 fluence of chloroform. Any 
 one accustomed to microscop- 
 ical examinations will recog- 
 nize the normal characters of 
 the corpuscles, so far as it is 
 possible to present them in a 
 woodcut. 
 
 In conclusion, although it 
 is not my intention in this 
 communication to engage in 
 an extended inquiry relative to how anaesthetics produced 
 their effects, it seems to me that the above experiments 
 demonstrate that we are not warranted in denying that 
 
 Fig. 14. 
 
 Corpuscles of a patient under 
 the influence of chloroform. 
 
176 ARTIFICIAL ANAESTHESIA. 
 
 these agents act directly upon the nerve centres. All the 
 phenomena, indeed, attendant upon their administration, 
 the gradual exaltation of the cerebral functions followed by 
 the progressive impairment and temporary suspension of 
 the special senses, the loss of co-ordination on the part of the 
 cerebellum, and when the agent is pushed too far, the arrest 
 of respiration and circulation through the decided impres- 
 sion made upon the medulla oblongata, seem to favor this 
 hypothesis, in contradistinction to the theory that anaesthe- 
 sia is due to suspension of oxygenation. 
 
 Experiments luith Nitrous Oxide by the late Doctor McQmtr 
 len, and Doctors Thomas and TurnbuU, December, 1877. — A 
 large-sized frog was placed under a glass jar holding five 
 quarts of pure nitrous oxide, and kept there sixteen minutes. 
 With the exception of some change in the color of the skin, 
 there was no apparent impression made the first five minutes, 
 as he jumped about when the jar was moved in the pneumatic 
 trough. After that he assumed the position of sitting on the 
 bottom of the jar, and maintained it until removed from the 
 jar, when he was found in a semi-torpid state with the eyes 
 wide open. On touching the eyes gently, the lids closed, and 
 then opened immediately ; the leg was retracted on pricking 
 it with a pin. Two minutes after removal from the jar, he 
 moved slowly about the floor, and ten minutes later hopped 
 from a table on to the floor. After remaining out for thirty- 
 five minutes, he was again placed under the jar, in a fresh 
 supply of gas, and kept there for thirty minutes ; on being 
 removed he presented the same semi-torpid condition, and 
 recovered from it in two minutes. In twenty minutes he 
 was a third time placed in fresh nitrous oxide, and remained 
 there fifteen minutes, with the same results as the previous 
 trials ; the confinement for one hour, in all, to the influence 
 of nitrous oxide not having made any marked impression 
 on him. Examined under one-fifth objective and B eye- 
 piece, the blood-corpuscle presented no disintegrative dis- 
 charge of nuclei, or change of form. 
 
 A small-sized rabbit was kept under nitrous oxide for two 
 minutes, and in one minute after was completely restored 
 to consciousness. He was then kept under the gas for five 
 minutes consecutively, and recovered in one and a half min- 
 utes. After this, for twenty minutes off and on, the animal 
 
PHYSIOLOGICAL ACTION OF NITROUS OXIDE. 1 1 I 
 
 was under the influence of the gas. In three minutes after 
 removal from it he was running around the room as though 
 nothing had occurred. The biood examined under the 
 microscope gave no evidence of disintegration of the blood- 
 corpuscles. 
 
 To test the quality of the gas used, Doctors McQuillen, 
 Thomas, and Turnbull inhaled it, and each one was com- 
 pletely under its anaesthetic influence. 
 
 If we assume that the influence of anaesthetics is depend- 
 ent not upon a direct action on the nerve centres, but upon 
 an altered condition of the blood and the suspension of oxy- 
 genation, we must apply the same principle to all diffusible 
 stimulants. 
 
 It will be noticed that it was in 1868 Dr. McQuillen pub- 
 lished his experiments upon nitrous oxide. On the 7th of 
 December, 1869, Dr. Jeannel read a paper* before the French 
 Academy of Medicine, on the protoxide of nitrogen or ni- 
 trous oxide as an anaesthetic agent. He states that there is 
 no record of a fatal case from the use of the drug, notwith- 
 standing its frequent application. He reported a number 
 of careful personal experiments. He dwells at some length 
 upon the rapidity with which the effects of this drug pass 
 away, followed by the proper exercise of the natural func- 
 tions, and concludes that his own and M. Limouzin's ex- 
 periments authorize the presumption that this gas is an 
 anaesthetic much less 'dangerous than ether or chloroform. 
 
 In August, 1870, Dr. Robert Amory published a number 
 of experiments on man and animalsf to show the physi- 
 ological action of nitrous oxide, He commences his experi- 
 ments with this proposition : — 
 
 "I have not, as yet, been able to find how the peculiar 
 effects of this so-called anaesthetic agent are explained ; nor 
 has any one directly stated that the action may be explained 
 by an accumulation of carbonic acid in the blood. A direct 
 proof of this supposition it would be a difficult matter to 
 give. An approximate idea I have attempted to show by a 
 few experiments." 
 
 After making his experiments, which he gives in a table 
 
 * Gaz. Hebdomadaire, 1869, p. 786. 
 
 t New York Med. Journal, August. 1370. Republished by James 
 Campbell, Boston, 1870. 
 
178 ARTIFICIAL ANAESTHESIA. 
 
 at page 13 (see pamphlet), he observes: — !'Now if we ex- 
 amine this table carefully, we should merely compare the 
 figures in the last column with each other, as also the effects, 
 produced by this agent upon the same animal. If we do so, 
 we shall find that the gas diminishes the amount of carbonic 
 acid exhaled by almost one-half. This, then, would lead us 
 to suppose that the effects produced by inhaling this gas 
 may be due to the accumulation of carbonic acid in the 
 blood ; but a plausible explanation is that the oxygenation 
 of the blood is prevented, and carbonic acid, the result of 
 combustion, is withheld; the effects are by no means so 
 rapid as when the agent is inhaled. Again, I do not quite 
 accept a theory which supposes that an accumulation of 
 carbonic acid in the blood will cause asphyxia and death in 
 twenty minutes." At page 18 there is a paragraph which 
 strongly corroborates Dr. McQuillen's experiments. "Two 
 or three times it has happened to me, when I had thought 
 an animal dead from asphyxia, after the inhalation of this 
 gas, to be surprised by voluntary respiration recurring after 
 I had removed the muzzle. In fact, I have now two dogs 
 alive who have not respired for one whole minute several 
 times when undergoing an experiment. Never has an ani- 
 mal died unexpectedly, and it was always very difficult for 
 me to cause asphyxia, if the smallest modicum of air passed 
 into the lungs." 
 
 At page 29 the author finally states:— " Having proceeded 
 thus far in my writing, I came across, accidentally, a lecture 
 of Professor George Johnson, in the number of the Medical 
 Times and Gazette for April 3, 1869. I was exceedingly sur- 
 prised to see a confirmation of his theory in regard to the 
 anaesthetic action of nitrous oxide. What he had arrived 
 at by careful reasoning, I have been able to obtain by actual 
 experiment. For example, he says : — 
 
 'Nitrous oxide is a rapidly-acting anaesthetic, causing 
 complete unconsciousness in less than a minute. At a high 
 temperature it is an oxidizing agent, but at the temperature 
 of the body it gives up no oxygen, but is exhaled again 
 unchanged. When inhaled in place of atmospheric air, it 
 rapidly replaces the oxygen of the blood, and, this being 
 done, the functions of the brain are completely suspended, 
 and there is a state of profound coma, which quickly passes 
 
PHYSIOLOGICAL ACTION OF NITROUS OXIDE. 1T C : 
 
 off when air is again allowed to enter the lungs. . . There 
 is no reason* to conclude that the inhalation of either nitrous 
 oxide or nitrogen causes an accumulation of carbonic acid 
 in the blood.' Before this, he says :— ' To produce oxidation 
 of the brain, there must be (1) a free current of blood through 
 the capillaries of the brain ; (2) the blood must be duly 
 aerated or oxygenized ; (3) the blood must be unmixed with 
 any material which prevents or impedes the giving up of 
 oxygen from the blood to tissues.' " 
 
 Then our author and experimenter says :— 
 
 " If we accept these three rules for the preservation of the 
 nerve functions, of course, if one be wanting, the nerve 
 functions are suspended. Now the experiments XIV, XV, 
 and XVI, taken in connection with the accompanying 
 sphygmographic traces (which are given), show an increase 
 of capillar tension, with, as Ave should suppose, increased 
 arterial pulsations, but finally arrest of capillary pulsation 
 in the brain. At this stage anaesthesia occurs. When the 
 pulsation recommences and the tension falls, consciousness 
 sets in. This effect, then, is a violation of Rule 1. Again, 
 the blood having no oxygen to give up in the capillary sys- 
 tem, there is a violation of Rule 3." 
 
 We do not think either Dr. Johnson or Dr. Amory has 
 proven his propositions by facts ; the one resorts to theory 
 alone, and the other to supposition after experiments, by 
 supposing an increased number of arterial pulsations, which 
 is not proven, as the pulse before inhalation is increased in 
 frequency by the nervous excitement, and always decreases 
 when the patient has begun to inhale the nitrous oxide. 
 This fact has been recently proven by a large number of 
 experiments. 
 
 We are fully convinced by experiments on animals and 
 man that when death occurs, it is the result of syncope, 
 caused by a capillary stasis of the blood, and the true anaes- 
 thetic action was discovered by Flourens that nitrous oxide 
 acts directly upon the nerve centres, producing regular and 
 progressive modifications in the functions of the brain and 
 spinal axis, first affecting the cerebral hemisphere, then the 
 cerebellum, and lastly, medulla oblongata, with suspension 
 of respiration and circulation. 
 
 * Vide experiments Nos. I, IV, etc 
 
 % 
 
180 ARTIFICIAL ANAESTHESIA. 
 
 MODE OF ACTION OF ANAESTHETICS. 
 We have already given our own results and those of 
 others as to how anaesthetics act under the several agents, 
 viz. — ether, chloroform, nitrous oxide gas, and chloral. 
 Their true action is still a subject of dispute, and I avail 
 myself of the recent investigations of Dr. C. Binz, of Bonn, 
 and of Heinrich Ranke, to further illustrate this complex 
 subject. Binz concludes an article on the official sleep-pro- 
 ducing substances in the Archivfur Experimentale, JPathu. 
 Pharm., by saying that these agents possess the power of 
 producing a kind of eoagulation on the substance of the 
 cerebral cortex, whilst other agents, though nearly allied to 
 the former in chemical composition, do not possess this 
 power. Morphia, chloral, ether, and chloroform possess, 
 these latter maintain, a strong affinity for the substance of 
 the cortex of the brain in man ; and when they are intro- 
 duced into the blood, they enter into combination with the 
 cerebral substance, opposing or impeding the disintegration 
 of the living substance, and thus rendering it unfit to dis- 
 charge the functions required of it in the living state. In a 
 paper on the subject in the Centralblatt, Aug. 25th, 1877, 
 Heinrich Ranke* observes that protracted study of the 
 effects of the anaesthetics has led him to very similar con- 
 clusions in 1S(>7. He has found that the action of chloro- 
 form, ether, and amylene on frogs first produces a condition 
 in which, just as in poisoning by curare, no contraction can 
 be induced in muscle by any kind of irritation applied to 
 the motor nerves, though the muscular tissue itself reacts to 
 direct stimulation, and the current in the nerve remains 
 constant both in force and direction. In a later stage of the 
 anaesthesia, the muscular tissue itself ceases to respond to 
 the most powerful induction currents, though its proper 
 electro-motor force remains un weakened ; and lastly, at a 
 still more advanced stage, the whole muscular tissue of the 
 body passes into a condition of rigor. He has further found 
 that a solution either of albumen from the brain or of myo- 
 sin from muscle in very weak salt and water is precipitated 
 by the vapor of the three above-named anaesthetics, and 
 that their power of producing muscle rigor in the case of 
 muscle depends on the coagulation of the myosin. 
 
 * Translated in the London Lancet, November 24, 1877. 
 
MODE OF ACTION OF ANESTHETICS. 181 
 
 Additional experiments have lately been instituted by 
 Ranke, which demonstrated that not only chloroform and 
 chloral hydrate, when injected into the arteries, caused 
 rapid stiffening of the muscles, but that the same influence 
 was exerted by ether, amylene, bromoform, and bromohy- 
 drate ; whilst when tannin, cupric sulphate, mercury chlo- 
 ride, ferric sulphate, or spirits of wine were injected, though 
 strong fibrillar contractions occurred, and coagulation of 
 the blood followed by death, in no instance was rigor pro- 
 duced. Idoform indeed appears to form an exception to the 
 •conclusion that the rigor producing action of the anaesthetics 
 is something peculiar to them, for it is not known to possess 
 anaesthetic properties. If injected in solution in ether, 
 rigor is immediately produced, but ether has itself a stiffen- 
 ing action on muscle. Nevertheless, Ranke thinks he can 
 distinguish between the action of the idoform, which is im- 
 mediate and tense, and that of the ether, which comes on 
 later and is less powerful ; and he attributes the failure of 
 the idoform to act as an anaesthetic to its insolubility merely, 
 which, as it were, masks its proper action. Ranke was un- 
 able to find that solutions of morphia were able to exert 
 any coagulating inrl uence on muscle, either within or without 
 the vessels. It may be asked what relation does the action 
 of these agents on the muscle bear to the process of anaes- 
 thesia, and in reply Ranke observes that anesthetization 
 obviously cannot depend on such a complete coagulation as 
 admits of no further change, since the effects produced by 
 anaesthetic agents are but transitory. But it is very con- 
 ceivable that an action which in its final stages leads to co- 
 agulation of albumen, may, in its earlier stages, render, to a 
 certain extent, fixed and immovable the albuminous mole- 
 cules in the ganglion cells of the brain, and afterwards in 
 nerve and muscle ; the effect passing off with the removal 
 of the cause. 
 
 This same hypothesis was maintained by the late Claude 
 Bernard on similar grounds, several years prior to the pub" 
 lication of even that of H. Ranke. The editor of the Lan- 
 ce^adds: "It would have been exceedingly interesting if 
 the view of Binz, to the effect that morphia acts also as a 
 coagulating agent upon the ganglion cells could be corrob- 
 orated ; since, if such were the case, it would tend to show 
 
182 ARTIFICIAL ANAESTHESIA. 
 
 that the various kinds of anaesthetics act essentially in the 
 same manner. 
 
 A committee appointed by theBritish Medical Association 
 reports as follows, in the British Medical Journal of Jan- 
 uary 4th, 1879 :— 
 
 With reference to the physiological action of anaesthetics, 
 our attention has been mainly occupied with three inquiries, 
 viz. : — 1st. The changes, if any, produced in the gases of the 
 blood ; 2d. The changes effected in the gases of respiration ; 
 and 3d. The effects of anaesthetics on nervous conduction, 
 and on mental phenomena, as observed on man. All of 
 these experiments have been of a very laborious character, 
 involving the use of complicated apparatus, and the methods 
 employed can yield satisfactory results only after consider- 
 able practice. 
 
 First. The effect on the gases of the bloocl. — The blood 
 was collected by means of a graduated tube filled with mer- 
 cury and provided with a glass stop-cock at each end. The 
 upper end was placed in communication with the aorta or 
 the inferior vena cava of a rabbit (immediately after it had 
 been deeply anaesthetized), by means of a canula, and by 
 opening the stop-cocks, the blood flowed in at the upper end , 
 replacing the mercury which escaped at the lower extremity 
 of the tube. It was thus possible to mix the blood without 
 any admixture of air. The small portion of the tube above 
 the stop-cock was then washed, and filled with a boiled 
 solution of salt, and attached by an India rubber tube to the 
 tube entering the receiver of a Pfliiger's air pump. The 
 lower end of the tube containing the blood was then inserted 
 in mercury. On opening the stop-cock of the receiver and 
 those of the tube containing the blood, the mercury in the 
 vessel below displaced the blood, which flowed into the 
 enhausted receiver, frothing and" evolving gas. The gas 
 was collected in the usual manner, and carbonic acid and 
 oxygen were successively estimated by known methods. 
 Some boiled solution of tartaric acid was then allowed to 
 enter the receiver, and displaced a further quantity of car- 
 bonic acid, which was in turn collected and estimated. A 
 sufficient number of experiments have not as yet been made 
 to permit of giving results. 
 
 Second. The effect on the air breathed. — The gases of res- 
 
PHYSIOLOGICAL ACTION OF ANAESTHETICS. 183 
 
 piration were analyzed as follows : — The animal was placed 
 in a tin box with glass sides, provided with a lid of thick 
 brass plating above, fitting over a square hole, and secured 
 tightly by means of a washer of India rubber, and eight 
 strong screw nuts. Very great difficulty was experienced 
 in procuring an air-tight joint, but the above means proved 
 the best. Air, deprived of carbonic acid by passing through 
 potash solution, and then dried over sulphuric acid, entered 
 the box by means of a tube at one side, and drawn off at 
 the other through a tube filled with calcium chloride, and 
 then passed through a set of bulbs filled with a solution of 
 caustic potash. The increase of weight of the bulbs in a 
 given time gave the amount of carbonic acid expelled. An 
 attempt Avas also made to estimate oxygen by passing the 
 air, after absorption of carbonic acid, over a strong solution 
 of ammonia ; enough of that gas is carried over to insure the 
 combination of all the free oxygen with the hydrogen of the 
 ammonia, when the mixture was passed over red hot cop- 
 per. Caustic baryta was used to absorb the water formed. 
 The residue consists of a mixture of baryta and nitrogen, 
 and after removal of the ammonia by sulphuric acid, the 
 remaining nitrogen is so pure that it does not tarnish melted 
 sodium when a stream is directed against it. 
 
 The amount of carbonic acid accordingly is given by in- 
 crease of weight in the potash bulbs, and that of the oxygen 
 by increase of weight of the tube filled with caustic baryta, 
 after multiplication by eight and division by nine, to re- 
 duce water to oxygen, — for water contains eight-ninths of its 
 weight of oxygen. 
 
 After ascertaining the normal amount of carbonic acid 
 exhaled and of oxygen absorbed by an animal in a 
 given time, it was removed from the box, anaesthetized, 
 again placed in the box, and the gases of respiration estima- 
 ted. Without giving detailed results (which should have 
 been done) it may be stated that the effect of anaesthesia 
 with chloroform is to increase the amount of carbonic acid 
 exhaled within a given time. 
 
 Third. Effects on Nervous Phenomena. — Several curious 
 facts have been elicited with regard to the effects of small 
 doses of chloroform and ether on the rapidity of nervous 
 and mental processes. By a refined method of experiment- 
 
184 ARTIFICIAL ANESTHESIA. 
 
 ing with Regnatt's chronograph, it was ascertained that a 
 few respirations of air containing chloroform or ether pro- 
 duced remarkakle retardation in the time of signalling back 
 that a visible impression had been perceived, although the 
 person operated upon was quite unconscious of any such 
 delay. These experiments are interesting chiefly from a 
 psy-chological point of view. 
 
 Investigations upon the protoxide of nitrogen* by Drs. 
 Jolyet and T. Blanche, which appeared in the Archives 
 de jPJtysiologie, for July, of the same year: — 
 
 '■ In view of the conflicting opinions regarding the phy- 
 siological effects of nitrous oxide gas, none of which can 
 at the present time be considered as established, Messrs. 
 Jolyet and Blanche have recently instituted a series of 
 experiments to determine with precision the following 
 questions : — 
 
 "a. Can the protoxide of nitrogen be regarded as a sup- 
 porter of respiration? 
 
 " b. Has it anaesthetic or other qualities capable of being 
 utilized in medicine? 
 
 " c. Is the protoxide of nitrogen a respirable gas for plants 
 and animals ? 
 
 "Plants. — We endeavored first to determine whether grain 
 would germinate in a medium of pure protoxide of nitrogen, 
 and, if germination had already commenced, whether it 
 would continue under these conditions. From the experi- 
 ments of Saussure it is known that the germination and 
 development of plants are impossible in a medium contain- 
 ing no oxygen; seeds never sprouting in nitrogen, hydro- 
 gen, carbonic acid, etc. We then came to consider whether 
 nitrous oxide — a gas unstable and rich in oxygen — would 
 be able by that oxygen to support the respiration of plants. 
 We therefore placed seeds of cress and barley upon a damp 
 letter-paper in an atmosphere of pure protoxide of nitrogen. 
 At the end of nine clays in one experiment, and five days 
 
 * Philadelphia Medical Times of September 27th, 1873, translated by 
 Dr. Frank Woodbury. < 
 
 Note.— In republishing this article at this time, it is to satisfy a 
 desire on my part to withhold no experiments that will throw light 
 upon the action of this important agent, although not agreeing with 
 the conclusions herein expressed. 
 
 
INVESTIGATIONS UPON PROTOXIDE OF NITROGEN. 185 
 
 in another, the seeds had not even commenced to sprout; 
 while other seeds, under the same conditions, but in ordi- 
 nary atmospheric air, entered into complete germination 
 as soon as the third day. Permitting then a small portion 
 of air to enter the receiver where the seeds had notsprouted r 
 we saw, in both cases, germination produced in two or three 
 days. 
 
 " In other experiments we have placed seeds in the act of 
 sprouting in pure nitrous oxide; the development was 
 arrested, and again resumed when a portion of air was 
 allowed to enter the receiver. We have proved further that 
 in protoxide of nitrogen plants do not exhale carbonic 
 acid. 
 
 ' ' From these different experiments we believe that we may 
 conclude that the oxygen of the protoxide of nitrogen can- 
 not be utilized by plants for respiration ; and if the contrary 
 has been asserted, it is because the gas experimented upon, 
 not being perfectly pure, contained a small quantity of 
 oxygen, and we know that a very small quantity of oxygen 
 only is needed for the commencement of germination. 
 
 "Animals. — Frogs were placed, for comparison, in receivers 
 containing respectively pure protoxide of nitrogen, carbonic 
 acid, carbonic oxide hydrogen, and nitrogen. While those 
 plunged in hydrogen, nitrogen, and carbonic oxide only 
 expired after two or three hours' stay in these gases, exhib- 
 iting at the termination stupor and drowsiness (as Jean 
 Muller had already proved), those placed in carbonic acid 
 were seized at once, and died quickly. The frogs placed in 
 the nitrous oxide succumbed at the end of two hours' ex- 
 posure to the gas. 
 
 "We placed a sparrow under ajar containing twenty-five 
 litres of protoxide of nitrogen, where death took place at the 
 end of thirty seconds. One placed for comparison in a jar 
 containing hydrogen, died in the same time. 
 
 "A guinea-pig inspiring pure nitrous oxide by the trachea 
 died in two and a half minutes. 
 
 "In the same way a rabbit died suddenly at the end of two 
 minutes and twenty-four seconds of respiration of pure 
 nitrous oxide. 
 
 " From these experiments, and others which we will not 
 here recall, we are compelled to say that chemically-pure 
 
186 ARTIFICIAL ANAESTHESIA. 
 
 protoxide of nitrogen cannot support respiration in animals 
 or plants. We may, therefore, here repeat the remark made 
 above, that if certain authors have believed themselves able 
 to demonstrate that this gas is one which can support respir- 
 ation, it is because they experimented with impure nitrous 
 oxide, containing a quantity more or less great of oxygen, 
 according to the time more or less long that the animals 
 lived in the gaseous compound. 
 
 "6. Does the protoxide of nitrogen possess any specific 
 properties? 
 
 '•If pure nitrous oxide is not able to support respiration in 
 plants and animals, is it a gas inert, like hydrogen or 
 nitrogen ? Or, on the contrary, being very soluble (water 
 dissolving four-fifths of its volume), will it enter into the 
 circulation by the way of absorption, and dissolving in a 
 greater or larger amount of blood, be carried to the nervous 
 centres, there to produce peculiar effects, stupor, anaesthe- 
 sia, etc.? 
 
 " With this in view we have studied the phenomena pre- 
 sented when animals are made to breathe pure nitrous ox- 
 ide, or an artificial atmosphere of pure protoxide of nitro- 
 gen and oxygen. 
 
 " Frogs placed in pure protoxide of nitrogen exhibit the 
 following phenomena : After three or four minutes, more 
 or less marked diminution in the respiratory movements of 
 the throat and sides, soon followed by stupor and drowsi- 
 ness, from which he rouses himself at intervals more or less 
 prolonged. The animal spontaneously, or following excita- 
 tion, makes a few respirations, and if placed on his back 
 regains his natural position, and soon resumes his former" 
 stupor. In this condition the frog remains perfectly sensi- 
 ble to pinching of his toes, sensibility which can be proved 
 after the expiration of forty-five minutes in the gas. 
 
 4 'A guinea-pig was made to breathe, by the trachea, from 
 a bag containing eight litres of pure nitrous oxide. Thirty- 
 five seconds after, the animal was perfectly sensible to 
 pinching of his paws. After forty-five seconds respiration 
 was labored, but sensibility remained intact. On allowing 
 the animal to breathe air freely, he revived in a few seconds. 
 
 " Half an hour later the same animal was again made to 
 breathe the pure nitrous oxide gas. After one minute and 
 
PROTOXIDE OF NITROGEN. 187 
 
 forty-five seconds, sensibility was still preserved ; after two 
 minutes and tweiit3 T seconds it was extinguished ; and death, 
 supervened in two minutes and thirty seconds from the time 
 the experiment was commenced. 
 
 "A rabbit was made to respire pure protoxide of nitrogen. 
 After one minute and forty-five seconds the animal struggled 
 and showed signs of asphyxia, but sensibility was proved to 
 resist. On withdrawing the nitrous oxide and allowing him 
 to breathe the air the animal rapidly recovered. 
 
 "In another experiment upon the rabbit, sensibility ex- 
 isted even after two minutes and twenty-four seconds ; at 
 this moment the respiration terminated abruptly, but we 
 were able to restore the animal to life after some moments 
 of artificial respiration. 
 
 "The preceding experiments show that pure protoxide of 
 nitrogen produces asphyxia with all its signs. Having no- 
 ticed that anaesthesia occurred at the moment the animal's 
 arterial blood became black (and knowing that when ani- 
 mals are subjected to asphyxia anaesthesia takes place as 
 soon as the arterial blood only contains two or three per 
 cent, of oxygen), in order not to attribute to nitrous oxide 
 the concomitant anaesthesia, which may be attributed to 
 pure and simple asphyxia, we have made the following ex- 
 periments. 
 
 " We added protoxide of nitrogen and oxygen in different 
 proportions, so that the mixed gases contained eighteen to 
 twenty-one per cent, of nitrous oxide. In this way the 
 animal had at his disposal a quantity of oxygen almost 
 equal to that existing in atmospheric air, while at the same 
 time the combination was sufrieientlj- rich in nitrous oxide 
 to produce its specific effects, if it really possessed any. 
 
 "Frogs remaining twenty-four hours in a mixture of four- 
 fifths protoxide of nitrogen and one-fifth oxygen did not 
 present a single appreciable phenomenon ; sensibility when 
 the toes were pinched was very evident. 
 
 " Two other frogs, after remaining five days in a receiver 
 containing three hundred cubic centimetres of oxygen to 
 sixty per cent, and one litre of pure nitrous oxide, did not 
 show at the end of this time either stupefaction or anaesthesia. 
 
 "At twenty minutes past five o'clock we placed two spar- 
 rows for comparison, the one under a bell jar containing 
 
188 ARTIFICIAL ANAESTHESIA. 
 
 air, the other under a similar jar containing oxygen and 
 nitrous oxide in proportion of the gases of the atmosphere. 
 
 " Seven o'clock. — There was some trouble in respiration 
 noticed equally in both birds. 
 
 " Half past seven. — We left the sparrows panting, puffed 
 out, and both alike. 
 
 " Nine o'clock. — We found the birds dead. 
 
 "On making an analysis of the air remaining in the jars, 
 we found in the one containing air : — 
 
 Carbonic acid, 11 per cent.- 
 
 Oxygen, 6 " " 
 
 " In the one containing nitrous oxide and oxygen : — 
 
 Carbonic acid, 12 per cent. 
 
 Oxygen, 5.8 " " 
 
 "At twenty minutes to three, p. m., we put a sparrow into 
 a mixture of four litres of nitrous oxide and six hundred 
 cubic centimetres of oxygen. At half past three, p. m., the 
 same ; no change in the appearance of the bird. 
 
 " Four o'clock, p. m. — He commenced to pant. We then 
 collected the gas. in the jar, which gave 9.2 per cent, of car 
 bonic acid on analysis. The bird rapidly recovered. 
 
 "At quarter to seven, p. m., we placed a sparrow under a 
 two-litre receiver, containing nitrogen and nitrous oxide in 
 the proportion of eighteen to eighty-two per cent. The bird 
 remained quiet until quarter to eight, p.m., when his respi- 
 ration became labored. When seen at nine, p. m., he was 
 panting, and death took place at quarter past nine, p. m. 
 The analysis of the gas in the jar gave twelve per cent, 
 of carbonic acid and three per cent, of oxygen. 
 
 "A small dog was made to breathe a mixture of protoxide 
 of nitrogen and oxygen in the proportion of atmospheric 
 air. By means of a caoutchouc muzzle and the valves of 
 Muller, he only inspired the gas contained in the bag, the 
 expirations going outside, so that there could be no compli- 
 cation from asphyxia by the carbonic acid. The animal 
 breathed this mixture for twenty -two minutes, during all of 
 which time he remained insensible without stupor or drow- 
 siness ; galvanization of his sciatic nerve by a feeble current 
 produced pain, and when he was called he gave signs of 
 attention . 
 
PROTOXIDE OF NITROGEN. 189 
 
 "These experiments show, therefore, that animals are able 
 to breathe an artificial atmosphere containing eighteen to 
 twenty per cent, of oxygen and sixty to eight}' per cent, of 
 nitrous oxide, during a time sufficiently long, without show- 
 ing any manifest phenomena, and, above all, without ex- 
 hibiting anaesthesia. 
 
 "As the protoxide of nitrogen is very soluble in water, 
 which dissolves four-fifths of its volume, it was of interest 
 to discover what quantity of it was in solution in the blood 
 of those animals which breathed the artificial atmosphere, 
 and nevertheless showed no diminished sensibility, for 
 comparison with that in the blood of animals breathing 
 pure nitrous oxide, taken at the moment aiiEesthesia ap- 
 peared, in order to decide what share in this phenomenon to 
 attribute to the nitrous oxide. It is also equally important 
 to determine the quantity of oxygen existing in the blood 
 at the same moment. 
 
 " But we will first show rapidly the method of analysis of 
 the gases of the blood which we have employed and have 
 used also in the analysis of the mixed gases, composed of 
 oxygen, nitrous oxide, and nitrogen. 
 
 "We have adopted the following, which M. Grehaut 
 kindly pointed out for us : — 
 
 " The mixture to be analyzed, composed of oxygen, protox- 
 ide of nitrogen, and nitrogen, is introduced into the eudio- 
 meter. 
 
 " Let v = the volume of the mixed gases,x = the oxygen, 
 y= the nitrous oxide, and z=the nitrogen ; then we have — 
 x+y+z=v. 
 
 " By introducing a quantity of hydrogen b, we have in the 
 eudiometer v+b. Now, if a spark be passed through this, 
 the remainder may be expressed by r, and the amount lost 
 will equal v+b — r. 
 
 " But x of oxygen combines with 2x of hydrogen to form 
 water, making a loss of 3x ; y of the nitrous oxide contains 
 one-half y of oxygen, which combines with y of nitrogen,*, 
 only y of hydrogen disappearing; we have then — 
 
 v+b— r=3x+y. 
 
 * (According to Bloxam, when NO is decomposed, it gains half a 
 volume,— two volumes of NO containing two volumes of N, and one 
 ofO'.— Tr.) 
 
 12 
 
190 ARTIFICIAL ANESTHESIA. 
 
 " We add to r a volume d of oxygen, and there is in the re- 
 ceiver a volume r+d ; on passing the spark, there remains 
 r 1 ; r+d — r 1 is the second volume disappearing, of which two- 
 thirds are hydrogen, which we will call e. 
 
 "Having introduced a volume b of hydrogen, theb — e=the 
 hydrogen used in the first combustion. But x of oxygen 
 required 2x of hydrogen, and y of the protoxide of nitrogen 
 used y of hydrogen ; therefore — 
 
 b— e=2x+y. 
 
 "It remains to resolve these three equations with three 
 unknown quantities : — 
 
 x+y+z=v. 
 3x+y =v+b— r. 
 2x-fy =b— e. 
 
 "From which the values of x, y, and z are easily deter- 
 mined. 
 
 "This said, we will relate some experiments with the 
 analysis of the gases of the blood determined in the preced- 
 ing manner. 
 
 " A dog breathing the surrounding air through the valves 
 of Muller had in one hundred cubic centimetres of arterial 
 blood — 
 
 Carbonic acid, 48.8 per cent- 
 Oxygen, 21 " 
 
 Nitrogen, 2 " 
 
 "He was then made to breathe from a bag containing a 
 gaseous mixture of sixty-two per cent, of nitrous oxide, 
 twenty-one per cent, of oxygen, and seventeen per cent, of 
 nitrogen. The animal took seven minutes and thirty 
 seconds to inspire fifty litres of this mixture ; and during 
 all this time his eye remained sensitive, and he took notice 
 when his toes were pinched. The analysis of the gases of 
 the blood made then, gave for each one hundred cubic 
 centimetres of red arterial blood — 
 
 Carbonic acid, 46 per cent- 
 Oxygen, 19.7 " 
 
 Nitrous oxide, 29 " 
 
 Nitrogen, 0.3 
 
 " The same animal, having rested half an hour, was made 
 to breathe pure nitrous oxide gas for one minute and forty- 
 
ANALYSIS OF THE GASES OF THE BLOOD. 191 
 
 five seconds ; he was then much troubled in his breathing, 
 but still remained sensible. On making then an analysis of 
 the dark arterial blood, we found — 
 
 Carbonic acid, 37 per cent. 
 
 Oxygen, 5.2 " 
 
 Nitrons oxide, 28.1 " 
 
 Nitrogen, , 0.7 " 
 
 "A second dog, breathing in the manner already ex- 
 plained from a bag of nitrous oxide, was found to be in- 
 sensible at the eye and to pinching after three minutes. 
 The analysis of the gases of the blood then made gave for 
 each one hundred cubic centimetres of very dark arterial 
 blood — 
 
 Carbonic acid, 3<>.6 per cent. 
 
 Oxygen, 3.3 
 
 Nitrous oxide, 34.6 " 
 
 "A third dog, breathing the nitrous oxide from a bag, was 
 still somewhat sensible at the third minute ; was found 
 completely insensible to the electrization of the sciatic nerve 
 after four minutes. Analysis of the black arterial blood 
 then gave — 
 
 Carbonic acid, 34 per cent. 
 
 Oxygen, 0.05 " 
 
 Nitrous oxide 37 " 
 
 " We might here relate other experiments, but think that 
 these will be sufficient to enable us to draw the following 
 conclusions : — 
 
 "When there is in the arterial blood of dogs that breathe 
 an artificial atmosphere of protoxide of nitrogen and oxygen, 
 almost the same quantity of nitrous oxide in solution as 
 that found in the same animals breathing, until asphyxiated, 
 pure protoxide of nitrogen, we cannot attribute the anaes- 
 thesia which then appears to the presence of the nitrous 
 oxide in the arterial blood. The cause of the anaesthesia is 
 naturally found to be the result of asphyxia, from the pri- 
 vation, more or less complete, of oxygen from the arterial 
 blood. We know, in short, that when there is no more 
 than two or three per cent, of oxygen in the arterial blood 
 anaesthesia commences to appear. — (P. Bert.) 
 
 "We conclude our article with the following propositions : 
 
 " The protoxide of nitrogen, chemically pure, is not able to 
 sustain respiration in animals any more than in plants ; the 
 
192 ARTIFICIAL ANESTHESIA. 
 
 combustion in which respiration consists not being suffi- 
 ciently energetic to decompose the nitrous oxide gas. 
 
 "Breathed pure by animals, the protoxide of nitrogen is an 
 asphyxiating gas, which produces death, with all the usual 
 signs of asphyxia, by strangulation, or by respiration of the 
 inert gases (nitrogen and hydrogen), and in almost the same 
 time. 
 
 "Breathed pure, if the nitrous oxide produces anaesthesia, 
 it is by privation of oxygen from the blood, insensibility 
 showing itself when the arterial blood commences to have 
 only from two to three per cent, of oxygen. The arterial 
 blood is then very black, and contains thirty to forty per 
 cent, protoxide of nitrogen. 
 
 "Animals are able to live by breathing an atmosphere of 
 protoxide of nitrogen and oxygen in the proportion of the 
 gases in the air, the nitrous oxide replacing the nitrogen, 
 without producing troubles of sensibility. The arterial 
 blood then contains thirty to thirty-five per cent, of protox- 
 ide of nitrogen. Birds plunged in a similar confined atmo- 
 sphere behave like those placed under a bell-jar of the same 
 capacity containing air, and die after haviug nearly equally 
 consumed the oxygen in the receivers and formed as much 
 carbonic acid. 
 
 " The protoxide 'of nitrogen being an irrespirable gas, and 
 possessing none of the anaesthetic properties that have been 
 attributed to it, its employment can only be dangerous, and 
 should be, under that title, proscribed from medical practice." 
 
 THE SPECTROSCOPE, AND ITS RELATIONS TO 
 ANAESTHETICS. 
 
 A recent writer, Dr. Waterman,* who has experimented 
 with this beautiful instrument, states the following :— 
 
 " Through the agency of the spectroscope has been sup- 
 plied the missing link to our chain of reasoning. The 
 shadowy field of theories has been cleared up, the laws gov- 
 erning the relations of anaesthetics in contact with the blood 
 current have been ascertained, and rational progress has 
 
 * The Beauties of the Spectroscope, and its Relations to Amesthet- 
 ics. Proceedings of Am. Den. Con. and Southern Den." Ass. and the 
 Den. Ass. of Md. Held at Oakland, Garrett County, Md., August, 1877. 
 Baltimore: Innes & Co., Printers. 
 
THE SPECTROSCOPE KS" ANAESTHETICS. 193 
 
 been made to insure safe ancesthetlcs. I have abiding faith. 
 in the progress of chemical science that it will finally point 
 out an agent, from the almost inexhaustible materials at its 
 command, that will satisfy all ends of surgical requirements, 
 — an anaesthetic that, while it will annihilate temporarily 
 all sensation, will leave consciousness and vitality intact." 
 
 We shall now pass to the article on nitrous oxide gas, and 
 let our readers judge for themselves of the rational progress 
 made, and the clearing up of theories by positive experiments 
 justifying or not the condemnation of this, the only anaes- 
 thetic as yet discovered which possesses such a wonderful 
 record. We will give our experiments and observations, and 
 while quoting from others in regard to the injurious effects, 
 have not withheld any of all the well-authenticated cases of 
 deaths from this agent. 
 
 " It has been demonstrated by Herrman, and verified by 
 Hoppe Seyler, Gorup Besanez and W. Preyer, that nitrous 
 oxide gas possesses a keen affinity for oxodized blood, as 
 well as for artificial oxy-haemato-crystalline in solution. 
 The affinity is so strong that when a current of this gas is 
 passed through a solution saturated with carbonic oxide 
 haemato-crystalline, the carbonic oxide is driven out by the 
 nitrous oxide, which takes its place volume for volume. 
 
 " When a current of nitrous oxide gas is forced through a 
 slightly alkaline solution of heemato-crystalline, the solution 
 loses its dichroism and assumes a slight cormoisin red color. 
 When the solution is placed before the spectroscope, we ob- 
 serve that in proportion that the gas exerts its influence, the 
 two bands between D-and E fade away, and disappear finally 
 altogether ; and there is a moment, says Preyer, ' when the 
 spectrum is continuous.' 
 
 " The disappearance of these blood-bands means here, as 
 it means in other instances, disappearance of oxygen from 
 the blood, or complete deoxidation, and unless a fresh sup- 
 ply is speedily furnished, suffocation must ensue. 
 
 u As the action of nitrous oxide gas upon the blood solution 
 continues, soon after the fading away of the two bands, two 
 new bands appear resembling the oxy-blood bands, but dif- 
 fering from them in position and depth of shading,— they 
 are paler and more blurred in outlines. 
 
 " I before told you that when blood is simply deprived of 
 
194 ARTIFICIAL ANAESTHESIA. 
 
 its oxygen, the blood reduction band would follow the dis- 
 appearance of the two oxidized broad bands, and that then 
 the simple contact of atmospheric air with such deoxidized 
 blood solution would suffice to cause the reappearance of the 
 two oxygen blood-bands. 
 
 "But we see here that instead of Stokes' band, two en- 
 tirely new bands have made their appearance, and when 
 the blood, saturated with the nitrous oxide, is then submit- 
 ted to the action of reducing agents, the broad band of 
 Stokes, as a reduction band, can no longer be produced at 
 all, proving that a more permanent change has taken place 
 in the vital chemistry of the blood. 
 
 " When a current of nitrous oxide gas is passed through 
 a solution not made previously alkaline, still further changes 
 take place. Here a portion of the nitrous oxide gas rapidly 
 oxidizes at the expense of the oxygen of the blood, and 
 forms hyponitric acid. Preyer holds that this hyponitric 
 acid unites with the hannato-cryst. of the blood in its nas- 
 cent state. Like all acids, it alters and suspends the coagu- 
 lability of the blood, and initiates other important chemical 
 and optical changes. This event is marked by the appear- 
 ance of an absorption in red to the left of D, from the 53° 
 on Preyer's scale towards D, and another one between b and 
 F. I look upon the appearance of this absorption in red as 
 an indication that hyponitric acid has formed and has united 
 with the blood. We already learned that all acids, cyanic 
 acid excepted, causes a decomposition of the blood, and its 
 product is hsematine. 
 
 " Now let us logically apply all these ascertained facts to 
 our case in hand, in order to learn how this gas produces its 
 effects upon the economy. 
 
 " It deprives the blood of its oxygen, and enters into a 
 close combination with its crystallizable material ; so bound, 
 it disables this latter to absorb oxygen from the air, or to 
 supply it to the oxidizable tissues of the economy. 
 
 "In Preyer's experiments we have seen that the dogs, 
 when permitted to inhale oxygen at the highest stage of the 
 dyspnoea, they became rapidly as well as ever. Not so after 
 the inhalation of nitrous oxide gas. A certain effect upon 
 the blood has taken place, often unimportant and transient, 
 at other times more permanent and grave, sufficient at times 
 
NITROUS OXIDE GAS. 195 
 
 to endanger life itself. We have also seen that under favor- 
 able conditions kyponitric acid is formed, which causes a 
 decomposition of the haemato-crystalline into hsematine, — 
 a substance which is not capable of sustaining life. Thus 
 we are forced to acknowledge that the application of this 
 gas is far from being safe and harmless ; that on the contrary 
 it is pregnant with grave consequences. 
 
 "Having fully pointed out to you the manner in which 
 nitrous oxide gas affects the blood, it must serve you as a 
 type for all those agents which deprive the blood of its oxy- 
 gen, and form stable crystalline compounds with the haemato- 
 crystalline, whereby its life-function is gravely impaired, 
 and under certain conditions forever lost. 
 
 "In case of accident with nitrous oxide our indications 
 are confined to narrow limits. We must try to economize 
 the still intact blood-corpuscles, and by transfusion, and es- 
 pecially by artificial respiration, to favor a full and long 
 supply of oxygen to sustain the little flame of life. Elec- 
 tricity may be used to keep up the muscular action of the 
 heart and lungs. We may thus succeed to ozonize the ac- 
 cumulated nitrous oxide, and to eliminate it from the system. 
 POrowsky has thus succeeded in some almost hopeless cases 
 of poisoning with carbonic oxide, and the procedure seems 
 to me well adapted also in cases of poisoning with nitrous 
 oxide gas." 
 
 Has the gentlemen proven the proposition he has started 
 with ? We think not. If experiments are carefully made 
 and facts proven, we are bound to receive those facts, but 
 not the theories in which he states that nitrous oxide gas 
 "deprives the blood of its oxygen, and enters into a close 
 combination with its crystallizable material; so bound, it 
 disables this latter to absorb oxygen from the air, or to sup- 
 ply it to the oxidizable tissues of the economy." The fol- 
 lowing experiments were undertaken to prove or disprove 
 the results Dr. Waterman describes as being obtained by 
 the spectroscope. 
 
 Rene Benoit, of Montpellier,* gives the' following results 
 of his studies on transformations of the spectrums of the 
 blood by alcohol, ether, chloroform, and sulphuret of car- 
 
 * Spectroscopic studies of the Blood— 1S08, p. 88. 
 
196 ARTIFICIAL ANAESTHESIA. 
 
 bon: — "We know that* alcohol coagulates the albuminoid 
 substance of the blood. This change is probably not accom- 
 panied by any alteration of the coloring matter, because 
 Valentin* has seen the characteristic bands in alcohol, 
 which had been used for the preservation of anatomical 
 preparations. In this case that matter had evidently not 
 been dissolved, because when the globules of a pale rose in 
 suspension in the liquid were in rej^ose in the bottom of 
 the vase, the bands disappeared even when the liquid still 
 preserved a slight yellow tint. Ether, chloroform, sul- 
 phuret of carbon, alkaline salts, and neutral salts in general 
 dissolve, but modify in no way the appearance of the spec- 
 trums of the blood." 
 
 The following experiments in the course of spectroscopic 
 studies of the blood by the action of reagents were made by 
 Professor J. G. Richardson, of the University of Pennsyl- 
 vania, Dr. Wm. M. Hodges, of New York, Dr. C. S. Turn- 
 bull, of Philadelphia, and the writer. 
 
 Pigeon. — Respiration thirty-eight ; pulse — unable to count 
 — from one hundred and eighty-two to two hundred and 
 ten. Was rendered insensible in twenty seconds, and had 
 quite recovered in one minute. 
 
 JRabbit. — Blood identical with human blood under micro- 
 spectroscope previous to nitrous oxide administration. Res- 
 piration one hundred and thirty-eight; pulse one hundred 
 and sixty. Was affected in forty seconds, and completely 
 insensible in two minutes. All heart action ceased in 
 one minute and forty-five seconds. There was no change in 
 the blood under the spectrum after death ; little or no 
 change in the brain; perhaps, slightly anaemic; heart's 
 color natural. 
 
 Drs. L. Turnbull and Thomas took the gas, and their 
 blood showed no change. By passing nitrous oxide through 
 the blood, the death-line spoken of was barely visible, but 
 after adding sulphide of ammonium it was clearly seen. 
 
 "From the above w T e may conclude," says Professor 
 Richardson, "that the amount of pure nitrous oxide neces- 
 sary to induce anaesthesia in man, by inhalation, does not 
 
 * Valentin: Der Gebrauch der Spectroskopes zur physiologisclien 
 und arzlichen Zwecken, 1863. 
 
NITROUS OXIDE GAS. 197 
 
 so affect the blood as to cause any alteration of the two well- 
 known bands in the green portion of the spectrum. In 
 other words that the microspectroscope gives no evidence 
 that radical change in the Inemato-crystalline is produced by 
 the inhalation of nitrous oxide gas, such as that prepared 
 by Dr. Thomas, of Philadelphia." 
 
 Dr. Taylor* states that spectral analysis has been applied 
 to the examination of poisoned blood ; but even this delicate 
 method of research has failed to throw any satisfactory light 
 on the changes produced by poisons in this liquid. 
 
 NITROUS OXIDE GAS IN DENTAL AND 
 MINOR SURGEfRY. 
 
 For the use of the dentist and in minor operations, noth- 
 ing has as yet been discovered offering the safety and other 
 advantages which this gas possesses, administered directly 
 from the gasometer. Since the introduction of a liquid form 
 of nitrous oxide, one of the great drawbacks to its extended 
 use has been done away with, as in this form it can be kept 
 in iron cylinders for any length of time. When wanted the 
 necessary quantity is allowed to pass in the bag carefully, 
 avoiding the introduction of water or atmospheric air. 
 
 Dr. J. J. Colton f did much by his personal efforts and 
 writings to popularize the use of nitrous oxide in dentistry, 
 and it has been employed in Philadelphia by the Doctors 
 Thomas in some fifty-eight thousand four hundred cases 
 (since 1860), giving an average of nearly six thousand five 
 hundred per year without a single death. Of this large 
 number but very few cases exhibited unpleasant after- 
 effects, not more than three in a thousand. 
 
 This accumulative evidence in our city alone is sufficient 
 to prove, as I have before stated (see opt. cit., p. 242), that 
 the inhalation of nitrous oxide does not produce pure 
 asphyxia or entire privation of oxygen, but that it merely 
 interferes in a more or less marked manner with the oxy- 
 genation of the blood, having also a specific action in its 
 anaesthetic properties. 
 
 * On poisons, p. 63. Philadelphia, H. C. Lea. 
 
 tThe Physiological Action of Nitrous Oxide Gas as shown by ex- 
 periments upon man and the lower animals, together with suggestions 
 as to its safety j uses and abuses. By J. J. Colton, A. M., M. D. Phila- 
 delphia : S. S.White, 1871, p. 32. 
 
19S ARTIFICIAL ANESTHESIA. 
 
 Nitrous oxide is not decomposed in the blood, nor does it 
 form a chemical combination with it. Our own experiments 
 and those of others have proven that it enters the blood in 
 its pure state, and is. eliminated in the same condition by 
 the skin, kidneys, and lungs with only a diminution in 
 quantity. It has no positive poisonous action on the blood- 
 corpuscles, their color not being in the least altered under 
 the microscope, nor does it cause any chemical decomposi- 
 tion. It does not produce death by preventing the escape 
 of carbonic acid gas, for if the expired air, loaded with 
 nitrous oxide, be passed into lime-water a carbonate of lime 
 is precipitated. 
 
 It is, however, stated by some observers, that it combines 
 with the lnemaglobin, and this is said to be proven by the 
 spectroscope. 
 
 After numerous experiments and observations on man 
 and animals, I have arrived at the following conclusions: — 
 
 1st. Nitrous oxide gas has a very limited range when 
 given alone, owing to the rapidity of its action and still 
 more rapid elimination. 
 
 2d. It acts directly upon the cerebrum and muscular appa- 
 ratus almost simultaneously. 
 
 3d. It produces regular and progressive modiricatian in 
 the action of the heart and capillaries of the skin, and if 
 carried to a greater extent it affects the spinal axis, and 
 lastly the cerebellum and medulla oblongata with suspen- 
 sion of resjDiration, circulation, and, finally, death. 
 
 4th. Death in no case occurs without premonitory symp- 
 toms, and if respiration should cease for even a half to one 
 minute, resuscitation is yet possible. 
 
 The rapidity of the pulse is generally increased, as shown 
 by a record of one hundred cases taken and recorded by Dr. 
 Thomas, it having reached as high as one hundred and 
 forty-four in one case, and one hundred and twenty-eight 
 in several others. In a few there was little or no change. 
 
 M. Paul Bert, who has perseveringly sought for a means 
 of obtaining surgical anaesthesia which shall be effective 
 and harmless, and who has already given the Society of 
 Biology the results of his experiments upon the physiolog- 
 ical action of protoxide of nitrogen, has tried substituting a 
 mixture of this gas with ox3 T gen, without compression, for 
 
DEATHS FROM NITROUS OXIDE GAS. 199 
 
 the ordinary pure gas. This mixture contained eighty-five 
 parts of protoxide of nitrogen with fifteen parts of oxygen ; 
 a bird could live in this mixture forty-eight hours. 
 
 The first operation, for ingrowing nail, was performed by 
 M. Leon Labbe. The patient was a girl aged twenty. She 
 easily fell asleep, without any stage of excitement, she only 
 presented some slight phenomena of contraction of muscles. 
 The nail was extirpated without the patient making a move- 
 ment. She awoke almost as soon as the mouthpiece of the 
 inhaling apparatus was withdrawn. So far was she from 
 being depressed, that she could walk at once, and asked to 
 •eat. — Le Progres Medical, 22 fevrier, 1879. 
 
 In another case the patient was made to breathe not pure 
 nitrous oxide, but a mixture of equal parts of nitrous oxide 
 and air, under a pressure of two atmospheres. Hy this 
 devise the normal quantity of air is supplied to the patient 
 ^s well as the requisite dose of gas. The results obtained 
 from experiments on dogs show that the breathing and cir- 
 culation goes on normally while the animal is rendered 
 quite insensible by this method, and on withdrawing the 
 gas it recovers all its faculties after a few breaths. This 
 is an important discovery, but it has the practical failing 
 of, at present at least, requiring a special chamber to be con- 
 structed for the operation. In the case of hospitals, how- 
 ever, this will not be difficult to obtain. 
 
 DEATHS FROM THE INHALATION OF 
 NITROUS OXIDE. 
 
 We only know of one instance in this city of supposed 
 death from this anaesthetic agent, and in this case it was 
 subsequently discovered that one of the cork props, which 
 had no securing-string attached, was found at the post 
 mortem examination in the larynx of the patient. 
 
 Second case. — In June, 1872, in the Dental Cosmos, was 
 an editorial by James W. White, M. D., on a death alleged 
 to have resulted from the inhalation of nitrous oxide gas 
 administered by Dr. Newbrough, of New York, at whose 
 office the death occurred, and by whom the following (sum- 
 mary) of evidence was made before the coroner's jury. The 
 patient, a middle-aged lady, desired the extraction of seven 
 or eight front teeth, which were loose. Dr. Newbrough 
 
200 ARTIFICIAL ANESTHESIA. 
 
 advised that their removal would be so easy that an anaes- 
 thetic would be unnecessary ; but the patient insisted that 
 she could not submit to the operation without it. Dr. New- 
 brough then procured a six-gallon bag of nitrous oxide gas ; 
 but the patient seemed equally fearful of anaesthesia as well 
 as pain, and as soon as she made the inhalation, rejected the 
 bag anddeclared her willingness to have the operation per- 
 formed without it. At sight of the forceps her courage 
 again failed her, and she decided once more to try the gas. 
 She took one inhalation, and again rejected it. By this 
 time so much of the gas had escaped from the bag that the 
 doctor replenished it. Of this she took two inhalations, and 
 peremptorily refused to have anything more to do with it, 
 declaring her determination to submit to the operation. 
 The teeth were then extracted. "Immediately," says the 
 doctor, "she fainted; her head dropping over sideways." 
 The face rapidly became livid, and, finally, purple; respi- 
 ration falling to about fifteen per minute. In about thirteen 
 minutes, notwithstanding the prompt application of the gal- 
 vanic battery and efforts to assist respiration, death ensued. 
 
 Dr. Otis, summoned by Dr. Newbrough, arriving in about 
 ten minutes after the fainting, testified that he continued 
 the usual restorative treatment for forty-five minutes, when 
 death ensued. At post mortem, found no disease of the 
 heart ; brain perfectly exsanguined in every part ; no fluid 
 in any of the ventricles ; one lung was more engorged than 
 the other, but healthy. As the testimony was. very discord- 
 ant in several particulars, we shall give only the conclusions 
 of Dr. W., who carefully sifted the whole testimony : — 
 
 " In view of these discordant theories, it may seem pre- 
 sumptuous to express an opinion ; but the conviction of the 
 writer, based on personal experience, repeated hundreds of 
 times, as well as on observation and reflection, is that nitrous 
 oxide, when inhaled, acts primarily by a specific stimulant 
 effect on the centres of innervation (over-stimulation and 
 consequent depression, if continued), and secondarily by 
 ■preventing the oxygenation of the blood." 
 
 The various opinions held by different observers doubtless 
 owe much of their diversity to the considerations of the 
 phenomena presenting at different stages of the toxical in- 
 fluence of the agent. 
 
DEATHS FROM NITROUS OXIDE GAS. 201 
 
 That the inhalation of nitrous oxide continued, produces 
 by some method of action, no matter what its primary effect, 
 progressive depression of vital functions, which tends to 
 death, and in which the anaesthesia, or temporary uncon- 
 sciousness sought, is a more or less clearly defined step in 
 the downward path, there is no doubt. 
 
 Without discussing the processes of its manufacture, or 
 the means by which its purity may be determined, or the 
 best methods for its administration, suffice it to say, that 
 immunity from danger can at the best be assured only by an 
 intelligent and watchful guard, that its exhibition be sus- 
 pended while yet the centres governing respiration and 
 circulation are not too profoundly impressed. 
 
 Of the case under discussion, the inference seems entirely 
 justified, that death was not caused by nitrous oxide gas, for 
 the simple reason (if the evidence can be relied upon) that 
 not enough was inhaled to produce such a result on any 
 theory of its action. Nor was there any fact established by 
 the jyost mortem to justify such a conclusion ; while the tes- 
 timony renders it entirely probable that the cause of death 
 was nervous shock, from dread of pain and apprehension of 
 fatal effect from the inhalation of an anaesthetic agent. 
 
 It may be remarked, however, that an examination by 
 the coroner as to the possible lodgment of an extracted 
 tooth in the air passages would have eliminated that from 
 the list of uncertainties. 
 
 Death from Nitrous Oxide. — The following case is reported 
 in the Medical Times and Gazette of April 7th. As it is of 
 considerable importance, on account of the extended use of 
 the anaesthetic, we quote it in full. 
 
 "An inquest was held last week, at Manchester, on the 
 bodj' of Mr. George Morley Harrison, aged fifty-three, a 
 surgeon in good practice, and formerly lecturer on Medical 
 Jurisprudence at the Manchester Royal School of Medicine, 
 who died whilst under the influence of nitrous oxide gas, 
 administered at his own request previous to having a tooth 
 extracted by a neighboring dentist. Mr. Harrison, it ap- 
 pears, being unnerved and excited, partly from the suffering 
 he had undergone, and partly owing to the want of proper 
 food, which the condition of his mouth had prevented him 
 from taking, insisted on the inhalation being pushed until 
 
-0:2 ARTIFICIAL ANAESTHESIA. 
 
 lie should snore, and— for, at any rate, part of the time — 
 held the mouth-piece in his own hand, and inspired very 
 vigorously. The first attempt at extraction was made before 
 he was fully insensible, and was abandoned until more of 
 the gas had been given. Eventually, however, two teeth 
 were removed. The patient did not appear to be coming 
 round properly after the operation, and the dentist, taking 
 alarm, sent for medical assistance. On the arrival of a sur- 
 geon, Mr. Harrison was pronounced to be quite dead. At 
 the x>08t mortem examination there was found some fat 
 about the heart ; the cavities on the right side were dis- 
 tended with blood, while those on the left side were empty. 
 The lungs on both sides were gorged with dark blood. All. 
 the other organs were healthy. 
 
 " The jury came to the conclusion that the deceased 'died' 
 from syncope, during the administration of nitrous oxide 
 gas for the extraction of teeth, whilst laboring under fatty 
 degeneration of the heart.' " 
 
 .Post mortem in the above cane of death from nitrous 
 oxide*— "The examination of the body took place seven- 
 teen hours after death. Rigor mortis was well marked, and 
 there was considerable post mortem lividity. There was a 
 good deal of fat beneath the skin, in the omentum, upon the 
 external surface of the heart, and in the usual localities. 
 The heart and pulmonary artery were opened in situ. The 
 right side of the heart was distended with fluid blood ; the 
 left side was empty. There were two or three slight patches. 
 of atheroma in the aorta, and upon one of the aortic valves. 
 There was some little evidence of fatty changes in the 
 slightly altered color and consistence of the walls of the 
 heart. The coronary arteries were examined and found 
 free from disease. The mucous membrane lining the trachea 
 and bronchi was congested. Some mucus was found in 
 these tubes, but no blood or other foreign body. There was 
 distinct thickening of the aryteno-epiglottidean folds and 
 of the vocal cords. The lungs on both sides were gorged 
 with dark fluid blood ; at the left apex there was an old 
 fibrous cicatrix. The liver was.enlarged, its tissue was very 
 friable, and of a dirty yellowish-white color. The kidneys 
 
 * Medical Times and Gazette, April 28th, 1877. 
 
DEATHS FROM NITROUS OXIDE GAS. 203 
 
 were full of blood ; otherwise perfectly healthy. The bones 
 of the skull were of unusual thickness. The visceral arach- 
 noid was thickened and opaque. On removing the brain a 
 large quantity of cerebro-spinal fluid made its escape, and 
 the cornua of the ventricles were found dilated. The brain- 
 substance was healthy, and its vessels full of blood." 
 
 In this sad case a most valuable life was sacrificed almost 
 at the patient's own request. jSTo man has any right to do 
 as a patient desires, or allow him to be the judge of the 
 quantity of an anaesthetic he should inhale, as a patient 
 under such circumstances is not a competent judge. 
 
 The following are some observations of that veteran chlo- 
 roformist, Mr. J. F. Clover, on this interesting case, ad- 
 dressed to the editor of the British Medical Journal: — 
 
 11 Sik : In the Times of Good Friday last there appeared 
 a notice taken from the Manchester JE.vaminer of a death 
 under nitrous oxide gas. The following was the verdict of 
 the coroner's jury : — ' Died from syncope, during the admin- 
 istration of nitrous oxide gas for the extraction of teeth, 
 while laboring under fatty degeneration of the heart.' 
 
 " The details of so unusual an event would be highly inter- 
 esting to the medical profession, to enable them to judge of 
 the safety or danger of the anaesthetic used. To form a cor- 
 rect opinion, we should at least know how long the inhaler 
 was applied, the order and manner in which the move- 
 ments of the heart and respiration became affected, and 
 what had been swallowed previously. 
 
 " The verdict was probably inaccurate in stating that the 
 syncope oocurred during the administration of the gas, as no 
 symptoms of danger were noticed until after the extraction 
 of the second tooth. 
 
 "The most probable explanation of this sad case is that the 
 extractions were difficult, and that the patient, on recover- 
 ing from the effect of the gas, was susceptible to the shock 
 of a severe operation; and that this shock, and not the gas, 
 was the cause of the syncope, which structural disease of the 
 heart rendered fatal. Unfortunately, it appears that no 
 third person was present, and we cannot expect the neces- 
 sary evidence from the operator, whose attention was other- 
 wise directed. 
 
 "Those whose opinions of the effects of nitrous oxide- 
 
204 ARTIFICIAL ANAESTHESIA. 
 
 are formed by inferences from Reid's Experiments on As- 
 phyxia, and some cases of cardiac distress, first complained 
 of after inhaling gas, will blame the latter. Those who 
 daily witness the continuance of the circulation, in spite 
 of the blood being black from the gas, and the cheerful and 
 speedy recovery from it, will conclude that so unusual a re- 
 sult must have depended upon the peculiarity of the pa- 
 tient, whose heart was found in a state sufficiently diseased 
 to account for sudden death/' 
 
 As this work was passing through the press, my attention 
 was called to the fatal results following the inhalation of 
 nitrous oxide in the case of Mr. Samuel P. Sears, the oper- 
 ator being Mr. Jose R. Brunet, D.D.S.* 
 
 A death from nitrous oxide occurred at Exeter, which we 
 have before referred to. (See p. 166.) The gas was adminis- 
 tered by Dr. F. F. Mason for the purpose of the painless extrac- 
 tion of a large upper molar tooth. The lady, Miss Wyndham, 
 was about thirty- eight years of age, in good health. Her 
 physician, Dr. Pattison, was present. Gas from the same 
 source had been administered to other patients, so that its 
 quality could not be impugned. She took the gas in the 
 usual way, without any symptoms to excite uneasiness. At 
 the proper degree of insensibility, the gas was stopped, and 
 the tooth extracted. It was not until after the operation 
 was completed that anything unusual happened ; her face 
 suddenly became livid, and the features began to swell, and 
 she seemed to be quite unconscious. She breathed two or 
 three times, and in a few moments her pulse ceased to beat. 
 All attempts to restore her were fruitless. 
 
 " There was no obstruction to the air-passages, and the 
 tongue was protruded, while she still respired." 
 
 So far as we have been informed, the medical profession 
 of Philadelphia has never known of any injurious results 
 from the inhalation of nitrous oxide gas. 
 
 Nitrous oxide is the safest of all anaesthetics. The statis- 
 tics of the Cotton Dental Association t claims to have anses- 
 
 * Dental Times, vol. i., page 157, New York, 18H4. See also Instruc- 
 tions in Nitrous Oxide, by Geo. T. Barker, D.D.S., Phila., 1870, p. 56. 
 
 f The Relative Dangers of Anaesthesia, by E. Andrews, A.M., M.D., 
 Professor of Surgery, Chicago Medical College. Chicago : Robert Fer- 
 gus' Sons, 1870, page 12. 
 
133,400 SAFE ADMINISTRATIONS OF NITROUS OXIDE. 205 
 
 thetized about seventy-five thousand patients up to 1870 
 without any death. If the fifty-eight thousand four hun- 
 dred cases (1869) of the Drs. Thomas is added, it makes one 
 hundred and thirty-three thousand four hundred up to 1879, 
 and no deaths. 
 
 THERAPEUTIC APPLICATION OF NITROUS 
 OXIDE. 
 
 Neuralgia, uncomplicated, will sometimes be relieved by 
 a few inhalations of nitrous oxide gas. 
 
 Nervous Aphonia. — This peculiar form of loss of the power 
 over the voice, usually the result of hysteria, will be much 
 improved by the patient inhaling a sufficient amount of the 
 nitrous oxide gas to produce a partial loss of sensation and 
 muscular relaxation. 
 
 Local paralyses have been benefited, where there was no 
 brain lesion, by the gentle stimulation by the first stage of 
 the gas, or the tingling and stimulating effect On the mus- 
 cles. 
 
 Asthma. — This disease, when of a spasmodic character, 
 is often much improved, by causing the patient to pass into 
 the stage of relaxation, employing it every other day for a 
 week or two. 
 
 Epilejisy. — When this disease is not the result of an or- 
 ganic change in the brain, spine, or other portion of the 
 nervous system, but the result of some peripheral or reflex 
 action, benefit will ensue by the use of the gas for weeks. 
 It should be administered two or three times a week only, 
 to produce the stimulating effects of the first stage of anaes- 
 thesia. 
 
 My friend, Dr. George J. Zigler,* has found the solution 
 of the gas in water of much utility in disease of the lungs, 
 kidneys, and other diseases of this class. 
 
 * See his work on the subject. 
 
206 ARTIFICIAL ANAESTHESIA. 
 
 CHAPTER VII. 
 
 Hydrate of Chloral. Chemical composition. Tests of purity from 
 taste and odor. An abstract of original and selected observations 
 on, and experiments with, Hydrate of Chloral on animals and man 
 by the writer. M. Vulpian, injections into the veins. Physiological 
 effects on man and animals. Dr. Bouchut on Hydrate of Chloral as 
 an anaesthetic for children. M. Couty on death of animals from Hy- 
 drate of Chloral. Corroborative experiments by the writer. Prof. 
 Or6 of Bordeaux on intravenous injection of Chloral Hydrate. Ad- 
 vantages and risks by De Neffe, Van Wetter, Warlomont, Besnier 
 and Vulpian. Cases of recovery from large doses of Hydrate of 
 Chloral, and in certain cases death following moderate quantities. 
 Delirium tremens produced by Chloral Hydrate. Case of Dr. Da 
 Costa reported by Dr. Woodbury. Discussion on the subject of Chlo- 
 ral by members of the Philadelphia County Medical Society. Dr. Ar- 
 buckle's experiments with Chloral and with narcotics. Its influence 
 on the retinal circulation. Chloral Hydrate — poisoning by, and 
 means to prevent or treat. Therapeutic effects of Hydrate of Chloral 
 on traumatic tetanus, nausea of pregnancy, eclampsia and convul- 
 sions, retention of urine, migraine, chorea, diphtheria. Local anaes- 
 thetic application and counter irritation with Hydrate of Chloral. 
 Butylchloral-hydrate. Use of and experiments by Liebrech. 
 
 CHLORAL.— HYDRATE OF CHLORAL 
 (C 2 HC1 3 O. H 2 0). 
 
 Chloral (anhydrous) is a thin, oily liquid, but is rapidly 
 converted into a white powder. It is produced by the action 
 of dry chlorine on absolute alcohol, aldehyd and hydro- 
 chloric acid are formed, and by the continuous action of dry 
 chlorine, a complicated reaction takes place, and chloral 
 (trichloraldehyde) is found. The impure chloral is purified 
 by distilling it with its weight of sulphuric acid (Squibb), 
 combining the distillate partly with water, rectifying over 
 a mixture of lime and calcium carbonate, and hydrating 
 this second distillate by adding water. While hot, the mass 
 is poured upon plates, covered with a bell-glass, and allowed 
 to crystallize as pure hydrate of chloral. Chloral hydrate 
 should be a white solid, never greenish, in crystals or flakes, 
 or rhomboidal plates ; taste like that of stale melon, pungent 
 and disagreeable, with a chlorous odor, while that of the 
 
HYDRATE OF CHLORAL. 207 
 
 impure is more pungent. It should dissolve with some 
 difficulty in cold, but more freely in hot, water, requiring 
 equal parts by weight for a perfect solution. If pure, the 
 solution will keep for months, but if there are impurities, it 
 soon becomes acid, and should not be employed. This is 
 soon determined by litmus paper. The presence of hydro- 
 chloric acid may be detected by the addition of a few drops 
 of sulphuric acid and solution of nitrate of silver. A white 
 cloud will be formed should hydrochloric acid be present. 
 The presence of organic materials in hydrate of chloral is 
 detected by warming it with sulphuric acid, which acquires 
 a brown color. At the present time impure chloral hydrate 
 is manufactured at various parts in Europe /and the Uni- 
 ted States, and is sold at prices to suit the individual. 
 Chloral hydrate is readily purified by. recrystallization from 
 carbon disulphide. 
 
 Chloral hydrate which is not perfectly pure may some- 
 times be observed to become acid. This increase of acidity 
 is not due to the decomposition of chloral hydrate itself, but 
 to the decomposition of an accompanying impurity (chloro- 
 carbonic acid), and sets free hydrochloric acid. When this 
 occurs in the stomach it gives rise to great irritation, and 
 when it occurs in the blood it causes great constitutional ex- 
 citement, and is apt to produce nervous excitement, which 
 state of excitation overcomes the hypnotic effects. 
 
 Owing to the excessive alkalinity of the blood in typhoid 
 fever, ten grains of chloral hydrate will often suffice to pro- 
 duce hypnotic effects, while in the state of excitement of 
 delirium tremens twenty to thirty grains are necessary ; by 
 hypodermic injection, fifteen grains. 
 
 The following conclusions are drawn from our experi- 
 ments and observations, and after a perusal of the most re- 
 cent literature upon this interesting subject.* 
 
 1. The physiological action of hydrate of chloral is to pro- 
 duce sleep, due to direct action of the drug upon the cere- 
 brum. 
 
 2. Its symptoms are analogous to those produced by chlo- 
 roform, but they are not identical. 
 
 * Original Observations and Experiments with Hydrate of Chloral, 
 by Laurence Turnbull, M.D., Medical and Surgical Reporter, August 
 24, 1872, aad August 31, 1872. 
 
208 ARTIFICIAL ANAESTHESIA. 
 
 3. Only very large doses of chloral produce anaesthesia. 
 
 Dr. Amory, of Massachusetts, has proven that chloral hy- 
 drate does not decompose in the blood, and that its effects 
 are not therefore due to chloroform. He was not able to de- 
 tect chloroform in the blood exctrea, etc., of animals pois- 
 oned by chloral hydrate. These experiments have been 
 confirmed by Lewisson and Rajewsky. 
 
 4. There are three degrees of the operation of chloral on 
 animals and man, as shown by our own experiments. 
 
 The first degree 'is a feebly soporific, and slightly nervous 
 sedative action. 
 
 The second degree is an intense soporific action, with 
 diminution of sensibility. At this period there is a deep 
 sleep of variable duration, without an apparent impairment 
 of the principal functions of life, with great reduction of 
 temperature of the whole body, but above all of the auditory 
 canal. 
 
 The third degree is complete anaesthesia, with total loss of 
 general sensibility and voluntary muscular power. Death 
 may follow this degree of action, from interference with or 
 arrest of the functions of the respiratory apparatus or heart, 
 as was seen in our experiments upon animals. 
 
 5. Death takes place last at the heart. 
 
 6. In typhoid and typhus fevers we must commence and 
 continue with small doses. Five grains is the average quan- 
 tity required, to be repeated until sleep is induced. 
 
 7. It increases the flow of the menstrual fluid. 
 
 8. Large doses of the hydrate of chloral are apt to cause 
 much disturbance of the stomach, and are therefore best 
 given by the rectum. 
 
 9. In gout and rheumatism, chloral must be mixed with 
 an excess of alkali, potassa or soda, to obtain the best results. 
 
 10. Males require a larger dose than females. 
 
 11. It is very valuable in diseases of little children, but 
 care must be exercised to commence with small doses— gr. 
 iji. for each month — and it should be mixed with nothing 
 but water and simple syrup, as it is so apt to change and 
 become worthless in contact with organic matter. 
 
 12. Hydrate of chloral will be found useful in phthisis, 
 and even some forms of acute affections of the lungs, but 
 not when the heart is involved. 
 
THERAPEUTICAL USE OF CHLORAL HYDRATE. 209 
 
 13. It is a most valuable agent in nervous affections. 
 
 14. In affections of the eye its use requires care, as it 
 causes swelling and redness and excessive flow of watery 
 secretions, with obscuration of the vision and irritation of 
 the retina. Dr. C. S. Turnbull has recently inquired into 
 this subject, and after consulting intelligent inebriates, states 
 as a fact that inveterate drinkers soon learn the deleterious 
 effects of chloral hydrate upon their eyes, and plead for its 
 omission in the soporific or stimulating substitutes pre- 
 scribed for delirium tremens, etc. 
 
 15. In sunstroke or heat toxaemia, it is a most valuable aid 
 to produce sleep in that restless state after reaction produced 
 by frictions of ice and ice-water to the head and body. 
 
 16. In tetanus it has been found a most valuable agent in 
 arresting the fearful paroxysms and giving the patient rest, 
 and assisting materially to the cure, causing a relaxation to 
 the affected muscles, and counteracting the effects of the 
 spasm. It is best to administer it by the rectum, as the pa- 
 tient can rarely swallow on account of spasm. 
 
 17. In cases of impending death from poisonous doses of 
 chloral, the system should be supported by heat, food, and 
 artificial respiration, with stimulation and small doses of 
 strychnia. 
 
 18. It has been found a most valuable agent in acute 
 mania, combined with the bromide of potassium, and in the 
 paralysis of the insane, dysmenorrhoea and tinnitus aurium. 
 
 19. Comparatively, trials prove it more valuable in mani- 
 acal cases in producing sleep than tincture of hyoscyamus 
 or bromide of potassium, but it may advantageously be 
 given with these agents. 
 
 20. Chloral is very useful in the convulsions of children 
 (when there is no severe affection of the bronchi, heart, or 
 lungs), but care must be employed not to administer it if the 
 infant or child is very an?emic or in an exhausted condition, 
 as in the case of a wasting disease. 
 
 21. The necropsy in case of death from hydrate of chloral 
 shows anaemia of the brain, acute oedema of the lungs, hy- 
 peremia of the abdominal organs, and dark fluid blood in 
 the vessels. 
 
 22. Chloral hydrate has been found by us very useful in 
 certain forms of asthma, given in a full dose during the 
 
210 ARTIFICIAL ANAESTHESIA. 
 
 paroxysm, but not when there is feeble heart or emphysema 
 of the lungs. 
 
 23. Chloral in weak solution is a useful antiseptic in re- 
 moving odor and cleansing the ear in fetid otorrhoea, 
 ulcers, etc. 
 
 CHLORAL AS AN ANAESTHETIC. 
 
 If a solution of chloral be injected into the vein of a dog 
 in a quantity sufficient to produce a profound sleep, com- 
 plete anaesthesia is produced. The movements of the heart 
 and of respiration continue. Occasionally, especially if the 
 injection has been rapid, the respiratory movements sud- 
 denly cease, the heart continuing to beat for some minutes. 
 Commonly the breathing recommences if artificial respira- 
 tion is maintained for a few minutes, or if the trunk be 
 faradized, intermittently, about twenty times a minute. It 
 is sometimes necessary to continue this respiration for ten 
 or twenty minutes before the spontaneous movements re- 
 commence. Occasionally this respiratory syncope, as it is 
 termed by M. Vulpian, occurs only some time after the in- 
 jection and during an experiment, perhaps in consequence 
 of the traumatic* irritation. 
 
 Another accident which may occur in dogs under the in- 
 fluence of chloral is the more or less sudden arrest of the 
 heart's action, either during the intravenous injection or 
 during an experiment involving irritation of the sensory 
 nerves. The respiratory movements continue for some 
 seconds after the heart ceases to beat. It is very rarely that 
 the cardiac contraction can be restored by faradization em- 
 ployed at the moment at which the heart has ceased to beat. 
 Cardiac syncope is certainly sometimes due to the reflex 
 influence of nerves irritated during an operation, but occurs 
 as a result of this irritation much more readily in animals 
 under the influence of an anaesthetic than in those which 
 are not, or which are under the influence of curara. The 
 comparative immunity from this accident which is presented 
 by currarised animals is no doubt to be attributed to the in- 
 fluence of the poison in moderating the action of the pneu- 
 mogastrics upon the heart. 
 
 From the phenomena mentioned above, it is evident that 
 
CHLORAL AS AN ANESTHETIC. 211 
 
 the respiratory centre suffers remarkably in animals under 
 the influence of anaesthetics, and especially under that of 
 chloral. A slight increase in the quantity of chloral in the 
 circulation, or a reflex influence may arrest its action. So 
 also with the cardiac centre. If the experiment of faradiz- 
 ing the pneumogastrics is repeated upon animals under the 
 influence of chloral, it is found that the stimulation of the 
 central ends of the divided nerves arrests the movements 
 of respiration, just as in an animal of the same kind under 
 normal conditions ; but whereas in the latter the respiratory 
 movements go on again spontaneously and easily in most 
 cases, in spite of the continuance of the stimulation, they 
 do not return spontaneously in dogs under the influence of 
 chloral, and the animals die unless the faradization is 
 stopped and artificial respiration employed, either alone or 
 with the addition of intermitting faradization of the trunk. 
 Sometimes a few seconds' faradization of the superior seg- 
 ments of the vagus nerve is sufficient to produce this arrest. 
 Thus under these conditions we may have, on faradization 
 of the central ends of the divided pneumogastrics, the same 
 effect which M. Paul Bert has observed in animals not chlo- 
 ralized, sudden death. If the experiment is repeated in the 
 same dog, the same result may be obtained two or three 
 times, but no more. It is subsequently impossible thus to 
 cause a persistent arrest of respiration. The spontaneous 
 movements return after a suspension of a greater or less 
 duration, although the faradization of the superior extremi- 
 ties of the vagi is continued. If in the same complete chlo- 
 ralization, the peripheral extremities of the pneumogastrics 
 are faradized, the heart is arrested in diastole just as in ani- 
 mals under normal conditions, and, what is rarely observed 
 otherwise, it may be permanently arrested if the stimula- 
 tion is prolonged for a short time. 
 
 These experiments illustrate very strikingly the phe- 
 nomena which are sometimes observed in man, and they 
 are of especial value in their proof of the influence which 
 traumatic irritation may have in arresting the action of a 
 centre depressed by the influence of an anaesthetic. But 
 the experiments stop just where we would like them to go 
 on. The differences in this respect, if any, which are to be 
 observed between etcher and chloroform is a point of great 
 
212 ARTIFICIAL ANAESTHESIA. 
 
 practical importance, and on which we hope M. Vulpian 
 may be able to furnish us with further information.* 
 
 At the Medical Congress held at Brussels, in 1876, Dr. 
 Bouchut observed that "he took that opportunity of again 
 directing attention to the fact that children can be placed in 
 a state of absolute anaesthesia by means of chloral given by 
 the mouth in doses of three or four grammes, and without 
 producing pyrosis, gastritis, vomiting or diarrhoea. It com- 
 mences a quarter of an hour after the injection of the chlo- 
 ral, and is complete at the end of an hour. If at this period 
 an abscess be opened, caustic applied, or a tooth extracted, 
 the sleeping child may .heave a sigh or move a limb, and 
 again become immovable, waking up four hours afterwards 
 quite unconscious of what has passed. ' ' This is a new proof 
 of the difference which exists in the action of certain medi- 
 cinal substances in adults and children. 
 
 Mr. Couty, of Paris, rinds that when animals are killed 
 by chloroform, ether, or chloral, the muscles and motor 
 nerves retain their irritability much longer than when 
 death is produced by bleeding, compression of the heart, 
 or asphyxia. This is especially marked in the case of chlo- 
 ral. We have repeated these experiments with chloral on 
 frogs, and showed the results before the Philadelphia County 
 Medical Society, and published the results in the Philadel- 
 phia Medical and Surgical Reporter. Mr. Couty considers 
 the cause of this phenomena to consist not on any action of 
 the anaesthetics on the spinal chord, but in a direct modifica- 
 tion of the nerves'and muscles by. them through the blood, 
 similar to that which occurs in poisoning by carbonic oxide. 
 
 Prof. Ore, of Bordeaux, has introduced the intravenous 
 injection of chloral as a means of producing general anaes- 
 thesia ; he employs the following formula : — 
 ^.—Hydrate of Chloral, 10 grammes, 
 Distilled water, 30 grammes. 
 
 A graduated hypodermic syringe is employed, gold trocar 
 and canula. A band is placed on the arm above the point 
 selected, and when the vein has become prominent it is 
 pierced through the skin, and fifty centigrammes are to be 
 injected after removing the band. If anaesthesia is not 
 produced, one gramme is added at a time until the patient 
 
 * London Lancet. 
 
HYDRATE OF CHLORAL. 213 
 
 ■complains of a strong inclination to sleep, when the canula 
 is withdrawn. From six to ten grammes are stated to be 
 required for an adult. The author adds this caution : It is 
 an indispensable precaution to have an electrical or gal- 
 vanic apparatus at hand, in order to arouse the patient from 
 his insensibility bypassing a current along the course of the 
 pneumogastric nerve. Advantages : Absence of stage of ex- 
 citement, and of nausea and vomiting ; accurate gradua- 
 tions of dose, absolute characters of the anesthesia, muscu- 
 lar relaxation and prolonged blunting of the patient's sen- 
 sibility, which protects him from shock. Risks : Thrombo- 
 sis and embolism, irregularity of the heart's action, presence 
 of blood and albumen in the urine, and above all, risk of 
 fatal syncope and death. 
 
 At the seance of the Societe Medicale des Hopitaux, held 
 in June, 1874, M. Bacquoy reported a case of hydrophobia, 
 in which he had exhibited the drug by this method; it pro- 
 duced profound slumber, and the patient awoke able to 
 drink without spasms, but on the following day he died in 
 the midst of a violent tetanic convulsion. The syringe con- 
 tained one gramme of chloral dissolved in ten of water, and 
 ten syringefuls were given in one hour and a half, followed 
 by- "chloro formic excitation." The injections were again 
 repeated in one hour, thirteen grammes of chloral being 
 injected. 
 
 At a late meeting of the Paris Academy of Sciences, M. 
 Ore forwarded particulars of two fresh cases of anaesthesia 
 produced by the intravenous injection of hydrate of chloral. 
 In one case the object proposed was to scoop out the tibia on 
 account of caries of the bone, the other was for the operation 
 of ovariotomy. Anaesthesia in both cases was complete, 
 and was neither accompanied nor followed by an y accident 
 which could be attributed to the chloral. M. Ore took the 
 opportunity to point out the means of neutralizing the pos- 
 sible acidity of the chloral, a circumstance which might 
 possibly bring on coagulation of the blood in the veins. For 
 this purpose it is sufficient to dissolve one gramme of car- 
 bonate of soda in ten grammes of distilled water, and to add 
 two or three drops of this solution to a solution of one 
 gramme of chloral in four of water.* 
 
 * London Medical Record, January 6th, 1875. 
 
214 ARTIFICIAL ANAESTHESIA. 
 
 The success which has attended a small series of some 
 twenty cases of intravenous injection of chloral seems to 
 have rendered some practitioners overbold ; and the worst 
 is that they do not always perceive the cause of fatal results 
 when these have been produced. In a note to Professor 
 Or6, of Bordeaux, the originator of this practice, Doctor 
 Lande, relates a case of ovariotomy, in which sleep was in- 
 duced in the space of thirteen minutes, after twenty-five 
 grammes of an aqueous solution of chloral, containing rive 
 grammes of chloral, had been injected. The insensibility 
 produced was absolute, and the operation, owing to adhe- 
 sions which had to be ruptured with the hand, lasted about 
 half an hour. The patient soon began to sink, and she 
 died in little more than an hour after the operation had been 
 commenced. There was a moderate amount of hemorrhage, 
 which, in the ansemic condition of the patient, the reporter 
 considers sufficient to account for death. Such a conclusion, 
 however, M. Jeannel observes, reporting on the case in the 
 Union Medicale, will certainly be disputed, since it is far 
 more probable that death arose from the influence of the 
 anaesthetic directly introduced into the circulation, the 
 effects of which could be neither modified nor arrested. 
 "The whole therapeutical history of chloral," he adds, 
 "should teach us to emplo3 T it with the greatest cau- 
 tion." 
 
 Chloral hydrate has been found to produce in the hands 
 of Jolly slight symptoms of vascular paralysis, and he 
 recommends that these should be noted. It is, therefore? 
 best to employ the remedy temporarily. He also takes note 
 of the fact that habitual drinkers of chloral are now almost 
 as frequently met with as opium and morphia eaters. 
 
 In the experiments of Dr. E. Mendel, of Berlin, it was 
 found that doses of chloral hydrate sufficient to produce 
 sleep reduced the temperature of the external auditory 
 canal. Morphia has a like quality. 
 
 Ore was the first to inject chloral into the veins in tetanus ; 
 he suggests to use the same procedure as an ana?sthetic in 
 surgical operations. It is condemned by the learned 
 societies of France as unwarrantably dangerous. Neverthe- 
 less, experiments were continued by Ore, De Neffe, and Van 
 Wetter with good results, without any of the dreaded 
 
SUBCUTANEOUS INJECTIONS OF CHLORAL. 215 
 
 dangerous consequences, such as embolism, phlebitis, 
 hematuria. 
 
 Warlomont {Des injections intra-veineuses de chloral 
 comme agent oV anozthesie chirurglcale. Ann. oVocul) dis- 
 cusses the advantages and disadvantages of the injection of 
 chloral into the veins, as an anaesthetic in surgery. His 
 own experience extends to eleven successful cases. More 
 than thirty are reported without an unfavorable result. 
 "All roses, but thorns will follow." Among his observa- 
 tions are two on the eye; an enucleation, and an extraction 
 of cataract, both with aged people (68 and 74 years). One of 
 these cases was affected with chronic bronchitis and em- 
 physematous lung, yet this condition was no obstacle to the 
 successful result. The advantages of the anaesthesia by 
 intra-venous injection of chloral are: — Prompt and positive 
 effect; accuracy of the dose; anaesthesia is followed by a 
 protracted, quiet sleep; absence of an exciting stage; 
 absence of vomiting, and compatibility with derangement 
 of respiratory organs. 
 
 The disadvantages are : — Difficulty of execution ; necessity 
 of utmost care and caution ; the long duration of the effects 
 of the application ; possibility of embolism, phlebitis, hema- 
 turia, and intensity and long continuance of its effect, with- 
 out the possibility of counteracting it. 
 
 Subcutaneous injections of chloral. — M. Besnier lays special 
 stress on the necessity of burying the point of the needle in 
 the subcutaneous tissue; he introduces the needle alone, 
 watches it to see if any blood escapes (in which case he 
 punctures in another place), and only finishes the operation 
 when he is certain that the fluid will not be forced into a 
 vein. In cases of sciatica, he injects on the first day one 
 syringeful over the point of exit of the nerve, and another 
 over the middle of its course. On the following, day he 
 makes another injection over the external poplitis. It is in 
 tic douleureux, however, that he looks for the most valuable 
 services from the injections. — Lyon Med. 
 
 M. Vulpian, in a communication made to the Acad, de 
 Med. (June 2d), states that he has very frequently resorted 
 to intra-venous injections of chloral as a means of producing 
 anaesthesia in animals, so as to facilitate vivi-sections ; and 
 that very often in dogs hematuria resulted and there was 
 
216 ARTIFICIAL ANAESTHESIA. 
 
 found very great renal congestion manifested by redness 
 and ecchymoses in the substance of the kidney. He sus- 
 pects the same effect might be induced in the human species, 
 thus giving rise to lesions of the kidneys, which might be- 
 come permanent, and, perhaps, result in BrigmVs disease. 
 —{Arch. Gen., July, 1874.) 
 
 CHLORAL HYDRATE. 
 
 Chloral hydrate has been employed in hundreds of thou- 
 sands of cases by medical men without producing but very 
 few deaths, yet in the hands of persons not in the profes- 
 sion several deaths have followed its indiscriminate use, or 
 rather abuse. According to Dr. B. W. Richardson, the 
 maximum dose is ninety grains, and with one hundred and 
 forty the sleep would be dangerous. Yet deaths have been 
 reported from sixty to one hundred, or even forty-five grains, 
 but, as stated before, not ordered by a medical man, except 
 in one or two instances. In recent cases reported by Mr. 
 B. Browning, recovery took place after the use of one hun- 
 dred grains, and as much as seven pounds has been used, 
 in increasing doses, by one individual, without any very 
 injurious results. 
 
 On the other hand, Dr. Fuller (Lancet, March, 1871) reports 
 a case of death following the administration of thirty grains 
 in a healthy young lady ; and Dr. iSchwaighofer, of Vienna, 
 records (Irish Hospital Gazette, 1873) a similar result from 
 the same dose in a drunkard. Dr. Dixon, of Springfield, 
 Illinois, reports in the Philadelphia Medical and Surgical 
 Reporter a case of delirium tremens, in which the patient 
 took two hundred and forty grains of hydrate of chloral in 
 three and a half hours with the most satisfactory results. 
 Dr. Carroll, U. S. A., also reports, in the Philadelphia Med- 
 ical Times, the death of a patient, who took, with suicidal 
 intent, four hundred and eighty grains chloral hydrate. 
 
 The following interesting case of delirium tremens, under 
 the care of Dr. Da Costa, was reported by Dr. Frank Wood- 
 bury* :— 
 
 "Mr. A., thirty-five years of age, American, a man of 
 
 * At a meeting of Philadelphia County Medical Society, April 10th, 
 1878, and published in Medical and Surgical Reporter. 
 
HYDRATE OF CHLORAL. ^17 
 
 fortune and indulgent in his habits, had been always a free 
 liver. Without preparation, he was induced to absolutely 
 resign all alcoholic stimulants. Shortly afterwards he 
 sought medical advice for sleeplessness and nervousness. 
 He was ordered chloral, and found it very soothing in doses 
 of twenty or thirty grains at night. Being pleased with the 
 effect of the prescription, he discontinued his visits to Dr. 
 Da Costa, and, of his own accord, had the medicine repeatedly 
 renewed, gradually increasing the frequency and the amount 
 of the dose, so that he constantly took from a drachm to a 
 drachm and a half daily. He kept up this practice for sev- 
 eral months, all the time being free from medical supervi- 
 sion. Although he was remonstrated with by several mem- 
 bers of his family on this new indulgence, he considered the 
 remedy not injurious to him, and as he liked the calming 
 effects from it, he could not be dissuaded from its use. After 
 continuing the chloral thus for a period not short of four 
 months, he lessened the dose, and then stopped rather 
 abruptly. The consequence was that his weakened nerv- 
 ous system showed signs of great disturbance, and an attack 
 of characteristic delirium tremens supervened, with the 
 wildest fancies and great sleeplessness. The pulse was feeble 
 and moderately accelerated; the first sound of the heart 
 was weak. There was general prostration of the muscular 
 system, and much tendency to sweating. No odor of chlo- 
 roform was detected in his breath, and of course, no alcohol. 
 He complained of nausea and loss of appetite ; his tongue 
 was coated. One of the prominent features in the case was 
 a disposition to leave his bed and walk about the room, 
 while the muscular weakness was strikingly shown in the 
 fact that he was very soon fatigued. However, it required 
 a man to watch over him constantly, to prevent his leaving 
 the bed and trying to escape from his room. The case per- 
 fectly recovered, though slowly, under the use of small 
 doses of morphine, a nourishing diet, and a moderate 
 amount of alcoholic stimulants. 
 
 " It is not my intention to make any remarks upon this 
 interesting case, but simply to present it in the hope of con- 
 trasting it with the experience of others. I may state, how- 
 ever, that a somewhat similar case of delirium tremens has 
 been reported by Dr. Elliot {Lancet, 1853, 1, 754)." 
 
218 ARTIFICIAL ANESTHESIA. 
 
 On the other hand, Dr. Laurence Turnbull, in his recent 
 work on Anaesthesia,* reports a case in which he " directed 
 the employment of chloral hydrate in medicinal doses, for 
 one year, as a sedative and narcotic, and the only disagree- 
 able result complained of by the patient was that it caused 
 a hot feeling, with free perspiration, as if she were in a hot 
 bath. It was withdrawn at the end of that time without 
 producing the least disturbance of the brain, inflammation 
 of the skin, or loss of memory or intelligence;" and he in- 
 clines to the opinion that " other causes besides the hydrate 
 of chloral may have produced some of the recorded results." 
 
 At a conversational meeting held at the Hall of the Col- 
 lege of Physicians, Philadelphia, April 10th, 1878, the sub- 
 ject of "Chronic Chloral Poisoning" was discussed, and 
 Dr. M. O'Hara recalled a case of chloral poisoning in a 
 man occurring on one of the steamers while crossing the 
 Atlantic. He was intemperate, and being unable to get his 
 supply of alcohol, took to drinking chloral instead. The 
 effects were very much like those of alcohol, as he had an 
 attack of delirium tremens, which lasted for several days. 
 There was no loss of muscular power in this case. 
 
 Dr. Bidlack had a case of nervous disorder, who took half 
 an ounce of chloral hydrate during the night, using up four 
 ounces in the course of one week, and absolutely without 
 bad effects. Another case took it in ordinary doses for more 
 than a year, without any but good results, but he has re- 
 cently lost sight of the patient, and does not know of his 
 present condition. 
 
 Dr. Benjamin Lee said that when chloral was first intro- 
 duced, while it was still somewhat of a curiosity, he gave a 
 mixture, containing ten grains to the ounce, to a lady just 
 starting for the South, to relieve nervousness and inability 
 to sleep. She took the first dose the night before sailing. 
 He had given her very strict directions, cautioning her not 
 to exceed the dose of five grains, as he had not then posi- 
 tively determined what the ordinary dose should be. Very 
 shortly after her arrival at her home, he received letters 
 from her telling of the delightful effects of the remedy. 
 
 * Advantages and Accidents of Artificial Anaesthesia, by Laurence 
 Turnbull, M.D., Philadelphia, 1877. Page 128, first edition. 
 
HYDRATE OF CHLORAL. 219 
 
 She had voluntarily increased the dose, and was depending 
 upon it. She returned as usual the following winter to 
 Philadelphia, when he found that she was habitually tak- 
 ing from fifteen to twenty grains every night. As she was 
 doing well in other respects, he did not consider it advisable 
 to interfere immediately. At the end of eighteen months 
 of the daily use of the chloral, probably never exceeding 
 twenty grains in the twenty-four hours, she began to com- 
 plain of conjunctivitis and smarting of the eyes. By ad- 
 vice the dose was diminished, when the irritation at once 
 disappeared. He concluded that this conjestion of the pal- 
 pebral conjunctiva was only one of the effects of the long- 
 continued use of the remedy. After this she again passed 
 from notice, and resumed the chloral in large doses. She 
 again returned, complaining of pains in the wrists, located 
 in the radial arteries, which was probably connected with a 
 cardiac disturbance from the action of the remedy upon the 
 unstriped muscular fibre of the heart. Upon discontinuing 
 the chloral the pain in the wrists ceased. This was the 
 second indication that the chloral was doing harm. The 
 patient is still under observation. 
 
 Dr. Samuel R. Skillern had given large doses without 
 bad results. One case in particular he recalled, where a 
 hypnotic was needed to relieve restlessness accompanying 
 paralysis following apoplexy. Less than one hundred and 
 twenty to one hundred and thirty grains, in the course of 
 the evening, would frequently have no effect whatever, and 
 the patient must have averaged at least a drachm each 
 night for nearly a year. The man finally died, but there 
 was no evidence that chloral hastened his death. 
 
 Dr. W. R. D. Blackwood had a patient to whom he was 
 giving chloral in half drachm doses, for the relief of neural- 
 gia. For five months he has taken thirty grains three times 
 daily, combined with bromide of potassium. For two weeks 
 he took one drachm of chloral three times a day, and the 
 only bad effect noticed was a conjunctivitis confined to the 
 left side. The chloral was finally stopped abruptly, but no 
 evil effects followed. There were no nervous symptoms, 
 and no muscular tremors or weakness ; in two days later he 
 was able to walk down stairs. 
 
 Dr. James Collins spoke of a case that came under his care 
 
220 ARTIFICIAL ANESTHESIA. 
 
 in 1870. An old gentleman, suffering from chronic cystitis and' 
 enlarged prostate, obtained great benefit from one or two 
 full doses of chloral daily. He was subject to suppression 
 of urine, and at such times he complained of uncomfortable 
 feelings after the medicine, with hot face, flushes of heat, 
 etc., but as soon as the kidneys began to work this would 
 pass away. The dose was increased to twenty-four grains. 
 The speaker had used the drug frequently, but had never 
 seen any bad effect when the kidneys were acting well. 
 
 Dr. Charles K. Mills believed that an explanation of the 
 unsatisfactory results reported may be found in the fact that 
 there are two classes of nervous cases; in one there is 
 cerebral anemia, in the other congestion ; in one the chloral 
 does good, in the other not. He had found that where an 
 idiosyncrasy against morphia existed, a previous dose of 
 chloral would prevent any bad symptoms. 
 
 Dr. R. A. Cleeman reported a case where a dose of chloral 
 always produced conjunctivitis in both eyes. 
 
 Dr. M. O'Hara recommended chloral as especially valu- 
 able in relieving the cough of phthisis, giving at a dose four 
 grains of chloral with five drops of laudanum, and one 
 drachm of syrup of lactucarium. 
 
 Dr. Laurence Turnbull thought that the chloral not only 
 acted upon the conjunctival surface, but also upon the retina 
 in certain cases, causing dimness of vision of a temporary 
 character. This effect could be avoided, in his opinion, by 
 combining with the chloral a salt of potassa. In dis- 
 eases of the kidney it cannot be readily eliminated, and its 
 effect is more marked and continuous. This may serve as 
 an explanation of those cases where ordinary doses are fol- 
 lowed by alarming symptoms. 
 
 THE USE OF CHLORAL IN ALCOHOLISM. 
 
 Dr. Fiirstner, of Vienna, is quoted by the London Medical 
 JZecord, on this subject, as follows: — 
 
 ' ' In the first published cases of delirium tremens treated by 
 chloral, its favorable action was not always very marked ; 
 sometimes its effect was temporary, sometimes altogether 
 absent ; in some of the cases toxic symptoms were caused, and 
 it soon became evident that the dose necessary to produce the 
 desired result varied with i n very wide limits. It must never 
 
CHLORAL IN ALCOHOLISM. 221 
 
 be forgotten that many patients, Avhen they first come under 
 treatment, still have a large quantity of uneliminated alcohol 
 in the system. Though the general symptoms of depression , 
 caused by large doses of alcohol, are often not very marked 
 in habitual topers, still the condition of the pulse deserves 
 the most careful consideration in deciding the dose of chloral 
 to be given. Certain patients, not necessarily weak and 
 emaciated, but apparently robust, muscular persons, often 
 have a remarkably small, frequent, compressible, occasion- 
 ally irregular pulse, with great faintness of the heart sounds, 
 and a less degree of motor restlessness than usual. The 
 author has repeatedly satisfied himself by necropsies that 
 these symotoms are not due to any disease of the heart ; they 
 must, therefore, have a central cause. Having regard to 
 the facts that chloral has been proved experimentally to 
 have, in large doses, a paralyzing action on the heart and 
 vaso-motor centres, and that several published cases show 
 that chloral has had a pernicious effect in alcoholism, it is 
 necessary to be most careful in the administration of chloral 
 in the cases just described. The author believes that cases 
 of sudden death in delirium tremens, after the administra- 
 tion of chloral, are to be explained by the combined cumu- 
 lative action of alcohol and chloral upon the vital centres in 
 the medulla. It may be urged against this theory that sud- 
 den death is by no means uncommon in this disease, even 
 when no chloral has been given ; Dr. Furstner believes that 
 in these cases the alcohol has, of itself, been sufficient to stay 
 the functional activity of the vital centres ; it is, therefore, 
 most important not to increase this danger when it threat- 
 ens, by administering chloral. All patients who, though 
 apparently robust, have the small, frequent and compressi- 
 ble pulse described above, without other complications, are 
 treated by Furstner without chloral ; they are secluded if 
 they cannot be kept in a general ward, and small doses of 
 wine and spirits are given with good results. 
 
 INFLUENCE OF CHLORAL HYDRATE ON THE 
 CIRCULATION OF THE FUNDUS OF THE EYE. 
 Dr. I. H. Arbuckle ( West Biding, England, Lunatic Asy- 
 lum Reports* vol. v.) finds that the following substances — 
 
 * Quoted by Ringer, Handbook of Therapeutics, page 334. 
 
 14 
 
222 ARTIFICIAL ANAESTHESIA. 
 
 nicotia, atropia, hyoscyamia, aconitia, nitrite of aniyl, prus- 
 sic acid, strychnia, morphia, picrotoxine, hydrate of chloral 
 — pushed even to a fatal dose, do not in any way affect the 
 circulation of the fundus of the eye. His observations were 
 made on rabbits, and the results he obtained were, with re- 
 spect to some of these agents, confirmed by experiments on 
 man. Hence the statement, hitherto generally received, that, 
 the retinal circulation corresponds with the cerebral circula- 
 tion, changes in one always implying changes in the other, 
 must be accepted with caution. 
 
 POISONING BY HYDRATE OF CHLORAL 
 AND ITS TREATMENT. 
 
 In a case seen recently by Dr. J. Milner Fothergill, of 
 London, of complex lung and heart mischief, to which was 
 added chloral poisoning, the good effects of strychnia, con- 
 firming Dr. Liebreich's observations, were well marked. 
 The patient was almost at once relieved from the attack of 
 dyspnoea, in the middle of the night, to which he had long 
 been subject. By the use of strychnia during the day, a 
 narcotic pill at bed-time is often deprived of its tendency to 
 produce nocturnal dyspnoea. We might add that strychnia, 
 in combination with ammonia and senega, might be found 
 very useful in the after-treatment of congestion of the lungs, 
 from the excessive use of sulphuric ether and alcohol ; it is 
 surely worthy of trial. 
 
 Hydrate of chloral, when given in large doses, sometimes 
 causes dangerous symptoms, followed by sudden death. 
 Several instances are recorded of medical men who have 
 taken it incautiously, and have died from its effects ; two 
 cases are reported in the Medical Times and Gazette, 1871, 
 vol. i, p. 367, and of late they have become numerous. The 
 deaths have been sudden, and no remarkable symptoms 
 have preceded dissolution, as observed by Dr. Taylor. The 
 person has passed at once from sleep into death. One case 
 proved suddenly fatal by causing paralysis of the heart {Lan- 
 cet, 1871, vol. i, p. 440). "In the fatal cases which have 
 occurred, the principal appearances noted were congested 
 state of the brain and its membranes. ' ' Doctors Taylor and 
 Tuke have given it as their opinion, based upon one case, 
 that the long-continued use of chloral might have produced 
 
 
CHLORAL POISONING AND ITS TREATMENT. 223 
 
 a diseased condition of the brain, which, by the sudden 
 withdrawal of the narcotic, might have caused the accus- 
 ation of murder (a man in a fit of passion, for some trivial 
 cause throws a petroleum lamp at his wife, which ignites 
 her dress, and death is the result, by burning). I have 
 directed the employment of chloral hydrate in solution in 
 medicinal doses for one year as a sedative and narcotic, and 
 the only disagreeable result complained of by the patient 
 was that it caused a hot feeling, with free perspiration, as if 
 she were in a hot bath ; it was withdrawn at the end of that 
 time without producing the least disturbance of the brain, 
 inflammation of the skin, or loss of memory or intelligence. 
 We have had no fatal cases, therefore, I believe that other 
 causes besides the hydrate of chloral may have produced 
 some of the recorded results. 
 
 In the treatment of poisonous doses of the hydrate of chloral 
 the stomach-pump should be used, and the stomach well 
 washed out with a decoction of green tea. The same treat- 
 ment as for poisoning by opium is indicated," i. e. , employ the 
 physiological antidotes, such as atropia and strychnia in 
 hypodermic injections of the T ^o to -^ of a grain. Maintain 
 artificial respiration for several hours. If necessary, employ 
 the galvanic or faradayic current. Administer for six or seven 
 hours brandy and beef tea, in mucilage of gum acacia, per rec- 
 tum. "When consciousness returns, keep the patient moving, 
 and apply flagellations and frictions to the body. When able 
 to swallow give brandy, beef tea, coffee, effervescing drinks. 
 The patient must be closely watched by an attendant. 
 
 In cases of chronic poisoning by chloral: — First apply 
 warmth, and furnish warm air. Second, sustain the body 
 by an abundance of food, especially warm milk, with a 
 little lime-water, and stimulants, say every two or three 
 hours, one or two ounces of brandy or whiskey to half a pint. 
 
 THERAPEUTIC EFFECTS OF HYDRATE 
 OF CHLORAL. 
 
 Chloral in Traumatic Tetanus. — Chloral has been found to 
 be exceedingly valuable in relieving and curing cases of 
 tetanus and trismus. There have been, up to June, 1879, 
 forty-one cases of tetanus treated by this agent, in which 
 there has been twenty-six recoveries, and fifteen deaths. 
 
224 
 
 ARTIFICIAL ANAESTHESIA. 
 
 Reported Bi 
 
 Mode of Treatment. 
 
 Ill 
 
 W. B. Cluness 
 
 M. Verneuil 
 
 (MM. Dubreuil, Lavaux, 
 
 ( andOnimus 
 
 Dr. Dufour, 
 
 M. Guyon 
 
 M. Le Fort 
 
 Mr.Tay 
 
 E. R. Denton 
 
 Thos. G. Duncan 
 
 Preston Peter 
 
 John W. Ogle 
 
 Mr. Croft 
 
 Mr. Paget.., 
 
 J. Suydam Knox. 
 
 C. Macnamara. 
 
 M. Garni es 
 
 Dr. Widerhofer 
 
 F. Auchenthaler. 
 
 Dr. Beck* 
 
 Dr. R, J. Levis.... 
 Dr. Wm. Hunt.... 
 
 Dr. J. C.Ross 
 
 Dr. Vela plan a 
 
 Dr. H. G. Below.. 
 
 Chloral alone 
 
 Chloral alone 
 
 Chloral and continuous ) 
 
 current. J 
 
 Chloral alone 
 
 Chloral alone 
 
 Chloral alone 
 
 Chloral alone 
 
 Chloral, belladonna, and 
 
 potas. bromid 
 
 Chloral and Calabar bean 
 Chloral and Calabar bean 
 Chloral, belladonna, and 
 
 ice to spine 
 
 Chloral alone 
 
 Chloral alone 
 
 Chloral alone 
 
 Chloral alone 
 
 Chloral alone. 
 
 Chloral alone. 
 
 Chloral alone. 
 Chloral alone. 
 Chloral alone. 
 Chloral alone. 
 Chloral alone. 
 Chloral alone. 
 Chloral alone. 
 
 I 41 
 
 15 26 
 
 Dr. O. Liebreichf states that chloral does not act by 
 removing the cause of tetanus, but simply by counteracting 
 its effects, and that its use must therefore be persisted in, 
 so long as the muscular spasm continues to recur. 
 
 Chloral hydrate in obstinate vomiting of pregnancy. — Dr. 
 H. J. Robinson, of Jacksonville, Florida, writes to a friend of 
 mine that he has used with success hydrate of chloral in 
 two drachm doses, and repeated in an hour or two if neces- 
 sary, in obstinate vomiting of pregnancy when the stomach 
 ejected everything, and sleep was almost impossible. It 
 furnished relief and sleep for four to six hours, and was 
 gratefully appreciated. It could be mixed with starch or 
 gum water, so as to not irritate the living membrane of the 
 bowels. 
 
 * Table in part compiled by Dr. Joseph R. Beck, Fort Wayne, 
 Indiana. 
 
 t Berliner Wochenschrift, No. 43, 1870. 
 
THERAPEUTICAL USE OF HYDRATE OF CHLORAL. 225 
 
 Chloralin Eclampsia.— Dr. J. Masten,* of Whitfield, Penn- 
 sylvania, reports a case of eclampsia succesfully treated 
 with chloral hypodermically. He remarks : — 
 
 "I found my patient with strong convulsive movements 
 of the facial muscles and muscles of the extremities, and 
 was informed by her attendants that this was the second, 
 and a very severe convulsion. Failing to procure either 
 chloroform or ether, I felt that I was in very close quarters, 
 with a responsible and dangerous case on my hands, and 
 that the pulse, which was very weak and fluttering, forbade 
 the use of the lancet. 
 
 "Being thrown entirely upon my own resources, and con- 
 sidering myself justified in using any remedy that offered a 
 hope of success, I immediately dissolved what I judged to 
 be ten grains of chloral hydrate in a small quantity of 
 water, and injected it subcutaneously in the left leg. The 
 convulsive movements soon ceased, and I was gratified 
 beyond expression to see my patient begin to rally, although 
 nearly half an hour passed before she could control the mus- 
 cles of deglutition, after which I administered the chloral, 
 in combination with bromide of potash, about ten grains 
 each, every hour. There was complete blindness for over 
 an hour, but no symptoms of a return of the convulsions 
 until seven a. m., of the 24th. She then informed me that 
 the pain in her stomach was returning, and that she was 
 getting blind again, precursor to a third convulsion. I 
 commenced crowding the chloral and bromide, and the 
 attack was warded off. 
 
 "There was no return of the convulsions, nor any symp- 
 toms, after this period. It was not until three days after 
 confinement that she realized that her labor *had taken 
 place. I saw the patient on the second day of June, and 
 found her getting along fully as well as in previous con- 
 finements. 
 
 I attribute the good results in this case to the prompt 
 administration of the chloral hypodermically. I was unable 
 to examine the urine for albumen, from the fact that, from 
 the first convulsion until forty-eight hours after, there was 
 complete suppression of urine." 
 
 * Medical and Surgical Reporter. 
 
226 ARTIFICIAL ANESTHESIA. 
 
 This agent has been found useful in all general convul- 
 sions and spasmodic diseases, which depend on direct dis- 
 turbance of the central nervous system, but is contra-indi- 
 cated in hysterical convulsions, owing to the initial excite- 
 ment which is so often present. It is best to avoid it also, 
 or give it with great caution, in ulcerations of the primce 
 vice, in gouty states, in typhoid fever (see our experiments), 
 and in disturbances of the circulation. (Liebreich.) Chlo- 
 ral hydrate should be given with great caution to patients 
 with cardiac disease. (Rosenstein.) 
 
 Fothergill points out the fact that in an anaemic condition 
 of the nervous centres chloral is contra-indicated ; and Da 
 Costa advises caution in its administration, and remarks 
 that " in cases of cardiac debility, and in dilation, or much 
 obstruction of the heart, it is generally contra-indicated." 
 
 A distinguished alienist, Dr. Given, who has a private 
 institution (" Burn-brae," Clifton, Delaware Co., Pa.) for the 
 treatment of the insane, informs the writer that chloral hy- 
 drate has been found by him very valuable in various forms 
 of insanity in procuring sleep and allaying nervous agitation. 
 
 Dr. Kerlin, chief physician of the Training School for 
 Feeble-Minded Children, at Media, Delaware Co., Pa., com- 
 bines the chloral with bromide of potassium in chorea, epi- 
 lepsy, and various forms of nervous disturbance in children, 
 with the most happy results, — i.e., in procuring refreshing 
 sleep. 
 
 Retention of urine relieved by Chloral — Dr. Tidd reports 
 the case of a young woman, in the ninth month of preg- 
 nancy, who had not urinated for twenty-four hours, as a 
 result of which the bladder was enormously distended. 
 Catheterization was tried, but failed, in consequence of the 
 swelling and of the deviation of the urethra. Puncture of 
 the bladder was proposed, but the patient refused to consent 
 to it. Ten grains of chloral were then ordered every half- 
 hour. It produced a deep sleep, during which the patient 
 passed unconsciously an enormous quantity of urine. The 
 evacuation commenced five minutes after the second dose of 
 the solution. The retention did not return, and seven days 
 later the patient was delivered of a healthy child. — Jour, de 
 Med. de Bordeaux. 
 
 Chloral in Migraine. — Dr. Seure, in the Bull de Therapeu- 
 
THERAPEUTIC ACTION OF HYDRATE OF CHLORAL. 227 
 
 tique, strongly recommends the administration of chloral in 
 enema, on the occurrence of the paroxysms of migraine, 
 having found it almost infallible, and exempt from the dis- 
 advantages attendant on other modes of giving this sub- 
 stance, and far preferable to the employment of morphia, 
 quinine, etc., for the same purpose. He gives, according to 
 the sex or robustness of the patient, from one and a half to 
 three grammes in a glass of tepid water, the effect of the 
 chloral being rendered still more prompt by the addition of 
 a tablespoonful of brandy. If a sense of burning in the 
 rectum is excited, this maybe prevented by adding the yolk 
 of an egg, or by substituting tepid milk for the water. When, 
 as in some persons, there is difficulty in retaining the enemata, 
 the quantity of the liquid may be diminished, and a drop or 
 two of laudanum added. 
 
 Chloral Hydrate in Chorea. — In the treatment of chorea 
 sleep is of the first importance, and it should be quiet and 
 long-continued. According to the most recent experience, 
 hydrate of chloral has proved an extraordinarily valuable 
 remedy in the treatment of chorea, especially in cases where 
 the violence of the jerkings interferes with sleep, or the 
 sleep is itself disturbed by spasms at night. If the intensity 
 of the movements exhaust the patient at night, it is well to 
 give a dose or two during the day, in order to secure a few 
 hours of sleep. This usually comes very speedily, and the 
 muscular disturbance is soon quieted. 
 
 In conjunction with this remedy our best authorities ad- 
 vise full doses of Fowler's solution of arsenic. For many 
 years it has been given with the best effect and with no bad 
 consequences, double the doses mentioned in the text-books 
 —namely, from five to eight drops of Fowler's arsenical 
 solution for children from eight to ten years old, and from 
 eight to twelve drops for adults, three times a day. It is 
 best to give this preparation not by drops, but mixed with 
 aromatic water and syrup. 
 
 Hypnotics and anaesthetics may be entirely dispensed with 
 in slight and moderate cases of chorea, but they are of great 
 value in extreme cases, where the excessive muscular re>t- 
 lessness and sleeplessness threaten to exhaust the organism. 
 Von Ziemssen* decidedly prefers chloral hydrate; it almost 
 
 * Practice of Medicine. Ziemssen. 
 
228 ARTIFICIAL ANESTHESIA. 
 
 always acts promptly and surely. By day or night a dose 
 of from fifteen to eighty grains is followed by quiet sleep 
 and cessation of the muscular activity. 
 
 Other authors have recommended chloral hydrate in se- 
 vere cases, as " Freriehs," " Gairclner," " J. Russel," " Bou- 
 chut and Verdalle. ' ' 
 
 u Gairdner " saw a case of chorea in a girl of eight years, 
 who took by mistake a dose of sixty instead of thirty grains 
 of chloral hydrate, and after recovery from her intoxication 
 was found to have entirely lost her chorea, "Frerichs" 
 gave it in the dose of eighty grains to a male of seventeen 
 years with severe chorea, The result was a refreshing sleep 
 of five hours. " Russell " obtained good results in the fifth 
 month of pregnancy, after bromide of potassium had been 
 given in large doses without success. " Bouchut's " patient 
 of fourteen and a half years, with chorea and dementia, took 
 forty-five graius a day for twenty-seven days, making in all 
 somewhat over two and a half ounces, spent almost the 
 whole time in sleep, and suffered no visible bad results from 
 the chloral. Improvement appeared from the fifth day of 
 the use of the chloral, and the case was complete on the 
 twenty-eighth day. " Verdalle's " patient of eleven took 
 very nearly three ounces in fifteen days. The improvement 
 began to appear on the first day the medicine was given, or 
 the fourteenth of the disease. In certain forms of chorea, 
 either associated with or depending upon a rheumatism or 
 tuberculosis, benefits have been derived by associating the 
 hydrate of chloral w r ith actecca racemossa in the form of 
 tincture, fifteen mimims ter a die. 
 
 Chorea treated successfully by injections of hydrate of chlo- 
 ral, by Drs. Goltzand Auger, after eserine and subcutaneous 
 injections of morphia had been tried. — This drug cannot be 
 employed subcutaneously, owing to its tendency to produce 
 locarirritation, whilst when given in the form of mixture 
 or syrup it occasions nausea. When introduced into the 
 large intestines it does not produce any remarkable sensa- 
 tion of burning, or any secondary symptoms. They com- 
 menced with the administration of forty-five grains of chlo- 
 ral twice a day in the form of enemata. Only slight improve- 
 ment occurred at first, and they increased the dose to sixty 
 grains twice a day. Under this treatment, complete recov- 
 
ANAESTHETIC APPLICATION OF CHLORAL. 229 
 
 ery, which was not followed by any relapse, took place in 
 fifteen days.* 
 
 Use of Chloral in Diphtheria. — Dr. Rokitansky (Medicin- 
 i&che-CMrurgische Randscltau, November, 1878) has used 
 fifty per cent, solution of chloral in three cases of diphtheria 
 which had resisted the usual remedies, such as salicylic acid, 
 carbolic acid, etc., and every time with the same results. 
 The solution was applied every half hour with a camel's 
 hair brush, and caused but very little pain except in one 
 case, where the tongue was' thickly covered with a layer 
 of diphtheretic matter. 
 
 After the solution had been applied three times, — i.e., one 
 hour and a half after the first application — large pieces of 
 membrane could be easily removed with the brush. The 
 underlying portion of the mucous membrane was red, and 
 covered with fine granulations. As soon as the normal 
 tissue could be seen, weaker solutions of chloral were grad- 
 ually used, during the week, at the end of which the pa- 
 tients entirely recovered. — London Medical Record Decem- 
 ber 15, 1878. 
 
 LOCAL ANESTHETIC APPLICATION OF HY- 
 DRATE OF CHLORAL. 
 
 Camphor and chloral when mixed in equal parts form a 
 thick oleaginous and transparent liquid which, according to 
 Prof. Howell of this city, is one of the best local anaesthet- 
 ics he has ever employed. I have made this beautiful pre- 
 paration, and have made numerous satisfactory experiments 
 with it in relieving pain when applied locally. 
 
 Dr. Wm. J. Tocher recommends the following for a cam- 
 phor-chloral liniment, which has a powerful anti-neuralgic 
 action : Chloral hydrate and camphor, of each one ounce ; 
 glycerine six ounces. Powder the camphor, using a few 
 drops of rectified spirits, mix with the chloral and allow to 
 stand until the mixture becomes liquid, adding glycerine.f 
 
 CHLORAL AS A COUNTER-IRRITANT. 
 Among the many uses to which chloral has been put, we 
 have not met before with the following from the Bulletin 
 
 * Practioner, December, 1876. 
 
 f London Medical Record, January 15th. 1S78. 
 
230 ARTIFICIAL ANAESTHESIA. 
 
 Therapeutique : Made into a mass with gum tragacanth, 
 spread on a paper and applied to the skin, it will produce a 
 blister without pain ; applied as powder on cotton, it causes 
 a painful burning sensation. By the former method a por- 
 tion is absorbed and the patient falls asleep. Its action is 
 not so uniform as cantharides, but as a mild visicant, or an 
 agreeable revulsive, the writer would recommend such chlo- 
 ral paper to physicians, the more so as it will keep for 
 months without losing its activity, if well prepared. 
 
 BUTYLCHLORAL HYDRATE. 
 
 When I described this agent in my first edition, it was 
 termed croton-chloral ', but since ( 1875) it has been determined 
 that it is triehlorbuiylaldehyd, which is butylaldehyd 
 C 4 H 8 0, with 3H replaced by 3C1. The hydrate contains a 
 little over nine per cent, of water. It is prepared by passing 
 chlorine gas into acetic aldehyd placed in a refrigerating 
 mixture, dissolving the dry mass, after distillation, in hot 
 water, allowing it to crystallize. It crystallizes from the 
 water in thin white scales of a silky lustre, is freely soluble 
 in alcohol and hot water, but not soluble in cold water. 
 The alkalies decompose it. 
 
 Administered to animals, it produces amesthesia with 
 some degree of excitement. If the dose be large, it destroys 
 the animal by arresting the action of the heart. In man 
 it produces anaesthesia, sleep, and relief of pain in doses of 
 from ten to thirty grains, the sensibility of the skin of the 
 face being first affected, and then the lower extremities, 
 followed by sleep which is deep and lasting, if not disturbed, 
 for two hours. 
 
 Its taste is like chloral hydrate, acid and disagreeable, 
 leaving its impression on the throat, and is not to be disguised. 
 It has received a reputation for the cure of neuralgia of the 
 fifth pair, and especially in that most painful form, tic 
 douloureux. It has no advantages in other forms of neural- 
 gia, insomnia, nervous headache, or as a palliative in dys- 
 menorrhoeal neuralgia over the hydrate of chloral. It is 
 very difficult to obtain it pure. By some good authorities it 
 is stated to be entirely unsatisfactory in its results, having 
 produced in their hands excitement, irritation of the throat, 
 nausea, and vomiting. 
 
BUTYLCHLORAL HYDRATE. 231 
 
 Dr. Oscar Liebreich, who introduced -this valuable agent 
 into the service of medicine, has made a series of experi- 
 ments with butylchloral upon rabbits and the human sub- 
 ject, which are reported in the Centralbl. f. d. Med. Wis- 
 sensch. This distinguished authority found that in animals 
 it produced anaesthesia of the head without loss of sensibility 
 of the rest of the body ; and^in man anaesthesia of the fifth 
 nerve only. 
 
 To a child aged four and a half years, after trials had been 
 made with smaller doses, 2.5 grm. of butychloral were given 
 in sweetened water. It soon fell into a sleep, from which it 
 could be aroused by pinching its arms, falling again into 
 slumber as soon as the irritation ceased. Irritation of the 
 cornea, however, had no effect, and it appeared to be entirely 
 without sensation. This want of sensibility was noticed 
 even when the child was roused from sleep ; but the nasal 
 mucous membrane, on thejother hand, was sensitive. To 
 lunatics five grm. were given, and sleep, with anaesthesia, 
 produced while the patients remained seated upon their 
 chairs, to such an extent were the sensibility and reflex 
 irritability of the body maintained. Contrary to expectation , 
 this remedy has afforded but slight relief in cases of tic dou- 
 loureux, but he recommends it as affording temporary 
 relief in trigemminal neuralgia. 
 
 In the transactions of Medical Society of the State of 
 Pennsylvania, vol. xii, part i, 1878, in the report of Com- 
 mittee of Revision of the U. S. Pharmacopoea, " Croton 
 Chloral" through Dr. H. H. Smith, was not recommended 
 for introduction into the list of therapeutic agents. We are 
 of the opinion that "croton chloral" has been hastily de- 
 nounced because most of the drug used must have been 
 impure to have caused all that is charged against it. 
 
 Ringer* says croton chloral is, perhaps, the most efficacious 
 remedy in facial neuralgia. In neuralgia due to carious 
 teeth, in facial neuralgia in old people, in whom the disease 
 is most obstinate and severe, it is alike beneficial. 
 
 * Hand book of therapeutics, Ringer, 1879. 
 
282 ARTIFICIAL ANAESTHESIA. 
 
 CHAPTER VIII. 
 
 Inhalers of Hawksley, Hearn, Cheatham, Lente, Allis, Morgan, Rich- 
 ardson, Angrove, and Clover for ether. Inhalers of Allis and Skin- 
 ner for chloroform. Inhaler of Thomas for nitrous oxide gas. In- 
 halers of J. F. Clover, F. R. C. S., and Codman & Shurtleff for nitrous 
 oxide gas and ether. Bon will method of anaesthesia by rapid respi- 
 rations. 
 
 Most of the inhalers in use are made with the object of 
 heating' the anaesthetic used, to furnish a large evaporating 
 surface or to serve the purpose of allowing an admixture of 
 atmospheric air with the gas or liquid to be inhaled. 
 
 HAWKSLEY INHALER. 
 
 It consists of "a glass vessel capable of holding ten 
 ounces of ether, with an inlet valve for air, and its 
 sliding tube is graduated in ounces for the purpose of 
 measuring the quantity of ether consumed. A pipe con- 
 veys the vapor to the face-piece, the edge of which is sur- 
 rounded by a water cushion to secure exact adaptation. 
 There is also a shutter valve for regulating the admission of 
 air, either at the beginning of an operation or during its 
 course. It has also an additional pipe, furnished with a 
 valve, which conveys the expired vapor to the floor." This 
 latter is a useful addition, when employed in a hospital 
 where a large number of patients are to be etherized in suc- 
 cession, so that the ether is not diffused in the air around 
 the operator. When in use, the vessel in which the ether 
 is contained is immersed in water, heated to 100°, which 
 promotes a more rapid and equable evaporation of the ether. 
 ' ' Ether boils at about 90° ; but before the quantity contained 
 in the vessel has reached that point, the temperature of the 
 surrounding water will have fallen." This is a valuable 
 inhaler; it is too complicated for every-day use by the 
 physician or surgeon, but will be found very useful in large 
 hospitals, and cause a great saving in the amount of ether 
 employed. 
 
 In the most recent ether inhaler invented by a gentleman 
 
HEARN'S ETHER INHALER. 
 
 233 
 
 of great practical experience, it has -two most ■ positive 
 advantages ; there is no waste of ether or diffusion in the 
 room; second, the cloth can be removed and the water 
 pressed out of it, and again employed, being free from all 
 moisture and carbonic acid. 
 
 HEARN'S ETHER INHALER 
 
 Is named after its inventor, Dr. Joseph W. Hearn, of this 
 city, who has had an extended experience in the administra- 
 
 tion of anaesthetics. 
 Fig. 15. 
 
 The inhaler, Fig. 15, 
 has its outer case A made 
 of thin sheet metal, hav- 
 ing the lower edge, which 
 comes in contact with the 
 face, covered with rub- 
 ber. 
 
 Inside of this case a 
 screen of wire gauze B is 
 fitted, which comes op- 
 posite the lower joint, as 
 at A. 
 
 The lint or canton flan- 
 nel upon which the ether 
 is poured is shown at C, 
 and is held in place be- 
 tween the wire gauze 
 screen B and the funnel 
 shaped top D. 
 
 The object of this in- 
 haler is to furnish an 
 undiluted ether vapor, 
 and prevent, as it should 
 when ether is used, the 
 patients inhaling the sur- 
 rounding atmosphere. 
 The time required to pro- 
 duce complete anaesthe- 
 sia, in ordinary cases, is 
 from five to eight min- 
 utes. 
 
 Another object of the inhaler is economy; it rarely re- 
 
234 
 
 ARTIFICIAL ANESTHESIA. 
 
 quiring more thrn two or three ounces of ether to produce 
 the full effect, for which reason it is especially adapted to 
 hospital use. The apparatus, by confining the ether vapor, 
 prevents in a great degree the impregnation of the atmos- 
 phere in the room." If the patient needs air the inhaler 
 can be withdrawn between every second or third inspiration. 
 Almost all American surgeons employ ether in the various 
 operations, even for the most delicate, viz., on the eye and 
 ear. In Great Britain and Ireland, the surgeons for a time 
 employed chloroform to the almost entire exclusion of ether, 
 but within the last few years the subject of the greater dan- 
 ger in the use of chloroform has excited much attention, 
 and many of them have changed their views, especially since 
 the visit of Dr. B. J. Jeffries, of Boston, Massachusetts. 
 
 CHEATHAM'S ETHER INHALER. 
 
 This operates by replenishing the evaporating surface 
 without removing it from the face. A patient cannot be 
 etherized as quickly with it as with the common cone, but 
 with much less ether, and by it you avoid the disagreeable 
 effects of having the ether permeating every part of the office 
 or house in which it is used. Its convenience of application 
 is also quite obvious. The ease with which the face-piece 
 (being paper) can be removed immediately after use and 
 thrown away is, I think, a strong recommendation in its 
 favor. 
 
 The'apparatus consists of a tin cup (Fig. 16, A) holding in 
 
 Fig. 16. 
 the inside a sponge as an evaporating surface, and con- 
 nected from the top by rubber tubing with the bottle that 
 contains the anaesthetic. This tube has attached to its dis- 
 
ETHER INHALERS. 
 
 235 
 
 tal end a cap D, that will fit over the neck of almost any 
 bottle, thus doing away with Lente's graduated bottle. 
 
 Mode of using the Inhaler. — Make a cone of paper, cut 
 the top off, so when the tin cup, A, is slipped inside the top 
 of the cup it will protrude a line or two from the top of 
 cone. Place tin cup, B, over both cup and cone, screw it 
 down tightly by means of nut, C, and you have the cone 
 held tightly. Attach tube to top of cup, and the apparatus 
 is complete. The smaller the cone, the more quickly you 
 can get the patient under the influence of the anaesthetic. 
 I would suggest after the cone is in position, the bottom 
 should be trimmed, leaving a part of it (we shall call it the 
 back part) that is intended to go over the chin, three inches 
 longer than the cup, and sloping forwards and upwards, 
 leaving the front part, intended to go over the nose, about 
 an inch longer than cup. E gives an inside view of cup, A.* 
 
 DR. LENTE'S ETHER INHALER. 
 
 As early as 1866, Dr. Lente invented a form of inhaler, but 
 which has recently been modified. See Fig. 17. The pres- 
 ent improved instrument re- 
 sembles very much the face- 
 piece of " Waldenburg's ap- 
 paratus for the inhalation of 
 condensed and rarefied air. 
 The idea of using sheet brass 
 and the india-rubber air- 
 cushion was taken from it. 
 The air-cushion, however, 
 proved a failure, and the inven- 
 tor substituted hair for stuffing 
 the cushion, which he states 
 retains sufficient of its rotund- 
 ity to fit the face air-tight. 
 
 Mode of employing this form 
 of Inhaler.— A piece of sheet lint is stuffed Into the cone, a 
 piece of wire or whalebone is slipped in, so as to keep the 
 lint in place and prevent its touching the face. The lint is 
 
 * These various forms of Inhalers are made by S. S.White, Snowden 
 Gemng, or Kolbe, instrument makers, of this city; also George Tie- 
 mann & Co., of New York, and by Codman & Shurtlifr, of Boston 
 
236 
 
 ARTIFICIAL ANAESTHESIA. 
 
 saturated with ether and placed over the face. There is an 
 opening, fitted with a cork stopper at the apex, large enough 
 to admit air. This is usually closed, but if it is found 
 necessary, the stopper can be removed. The ether can be 
 poured in at this opening without removing the apparatus 
 from the patient's face. Its cleanliness is perfect, as a dif- 
 ferent piece of lint ought to be employed each time. 
 ALLIS' IMPROVED ETHER INHALER. 
 
 
 Fig. 18.— Instrument complete. 
 
ALLIS' ETHER INHALER. 
 
 237 
 
 We present below cuts of the apparatus of Dr. Allis for 
 the administration of ether. This instrument has been in 
 use in the United States and Europe for the past four years, 
 and may be said to have won a place among the standard 
 instruments. 
 
 This and the following cuts are two-thirds the size of the 
 manufactured instrument. 
 
 The instrument was first exhibited before the Philadel- 
 phia county Medical Society on October 14th, 1874, and de- 
 scribed in a paper upon anaesthetics, published in the Phila- 
 delphia Medical Times, No. 162. It is now made simpler 
 and stronger than the first that were offered to the profes- 
 
 Fig. 19. 
 
 Description of the Inhaler.— It consists'of a metallic frame' 
 sufficiently large to cover the lower part of the face. The 
 bars are nearly a quarter of an inch broad, 'leaving a quar- 
 
 15 
 
238 
 
 ARTIFICIAL ANESTHESIA. 
 
 ter of an inch between each and its fellow. The spaces are 
 made by a punch, which removes a section from a solid 
 sheet of metal. It will thus be seen that there can be no 
 danger of the bars giving way, as they would were they 
 soldered upon a band. 
 
 In Fig. 20 we reproduce Fig. 19, with a bandage partly 
 laced between the bars. It has been passed from side to 
 
 Fig. 20. 
 
 side, dividing the instrument into parallel sections. On 
 the right, a part of the bandage may be seen rolled up. 
 When the bandage has been passed between all the bars, 
 and the hood or cover put on (Figs. 18 and 21), one can look 
 through the instrument from end to end, as there is a space 
 
ALLIS' ETHER INHALER. 239 
 
 of nearly a quarter of an inch between the several sections 
 of the bandage. 
 
 The advantages of this mode of construction are : — 
 
 1st. It gives the patient (Fig. 21) the freest access of air. 
 It is a mistake to think that air must be excluded. All that 
 is necessary is that the air should be saturated with the va- 
 por of ether. 
 
 2d. It affords a series of thin surfaces upon which the 
 ether can be poured, and from which it will almost instantly 
 evaporate. In this respect it differs from the sponge, which 
 retains the ether in a fluid state much longer. Should the 
 bandage become soiled a new one can be inserted in a few 
 minutes. 
 
 3d. By leaving the instrument open at the top, the sup- 
 ply can be kept up constantly if desired ; and as ether vapor 
 is heavier than air, there is no loss by not covering it. The 
 top should never be covered. 
 
 Mode of using the Inhaler : — 
 
 1st. Place a towel beneath the chin of the patient, as 
 experience has taught that a towel should always be within 
 reach in administering anesthetics. 
 
 2d. Place the instrument over the face, covering the nose 
 and chin, and let the patient breathe through it before any 
 ether is applied. This will convince him that he is not to 
 be deprived of air. 
 
 3d. Begin with, literally, a few drops of ether ; this will 
 not irritate the larynx. Add, in a few seconds, a few drops 
 more, and as soon as the patient is tolerant of the vapor, 
 increase it gradually to its fullest effect.* 
 
 4th. When the patient is fully influenced it is well to add 
 a few drops at short intervals, and thus keep up a gradual 
 anaesthetic effect. 
 
 The advantages of the Inhaler : — 
 
 1st. It presents a large surface for the liberation of ether 
 
 Note. — A draw slip is furnished with each instrument, — the sug- 
 gestion of Dr. W. W. Keen, Surgeon to St. Mary's Hospital. This pre- 
 vents the bandage from being soiled, and can itself be changed in a 
 few seconds. 
 
 * When the effect of the anaesthetic is apparent, a single layer of a 
 coarse towel may be laid over the nose and mouth, and the instru- 
 ment replaced. This is a wise precaution against vomiting or spit- 
 ting. 
 
240 
 
 ARTIFICIAL ANAESTHESIA. 
 
 vapor. The partitions are made of thin bandage, and the 
 air coming to both sides of each layer, sets the ether vapor free 
 more rapidly than is possible in the use of a towel or sponge. 
 
 2d. It is open at the top, and ether can be added con- 
 stantly if desired, and in small quantities, without remov- 
 ing from the face. The sponge and towel both require re- 
 moval, and the ether is usually poured on them in quantities. 
 
 3d. The ether vapor falls by its weight, as it is heavier 
 than the air ; and as the instrument fits the face the patient 
 gets the full advantage of it. 
 
 4th. It does not cover the patient's eyes, does not terrify 
 him, and he often passes under its influence without- a 
 struggle. 
 
 5th. By its proper use the laryngeal irritation may be 
 wholly avoided, the anaesthetic effect as easily gained as is 
 possible with the use of ether, a great economy of ether and 
 great comfort to the patient J 
 
 Dr. G. H. Coburn, late resident physician of Howard -Hos- 
 
ALLIS* ETHER INHALER. 241 
 
 pital, carefully recorded all the cases, at my request, occur- 
 ring during the years 1875-6, in which this form of Allis' 
 inhaler was employed in the various surgical operations 
 performed in the institution. It was found by him that the 
 shortest time required to produce complete anaesthesia in a 
 young female patient was three minutes, and the amount of 
 ether employed was only one fluid ounce. The longest 
 period required in an adult female was seven minutes, and 
 the amount of ether used two ounces and a half. The doc- 
 tor did not notice in any of the cases but slight redness of 
 the eyes. In a few instances there was a hysterical ten- 
 dency among the females. If solid food had been taken, 
 vomiting would follow, but after liquid or light forms of 
 nourishment, vomiting was very rare, not more than one in 
 fifty cases. In temperate males the time for full anaesthe- 
 sia was from five and a half to eight minutes. Ether con- 
 sumed, minimum quantity two ounces, maximum, three 
 ounces. 
 The objections to this form of apparatus are: — 
 1st. That the exhaled vapor is not conveyed to the floor, but 
 is diffused in the air, to be breathed by the operator and his 
 assistants. For a single operation, this is not of much im- 
 portance, but where there are a number of cases the arrange- 
 ment is not conducive to the comfort of the operator. 
 
 2d. The bandage of muslin across the bottom becomes 
 clogged with moisture and saliva, and at times by discharges 
 from the stomach, and cannot be so readily removed. 
 
 3d. Owing to the peculiar arrangement of the muslin 
 strips, it is tedious when it is required for a number of 
 patients to remove or replace them. 
 
 In a conversation with Dr. Allis, he stated that he con- 
 sidered the chief merit of his instrument was, that it 
 thoroughly and instantaneously liberated the ether, and 
 that while there was.not the least impediment to respiration, 
 yet ail the air was impregnated with the anaesthetic. 
 
 Neither ether nor chloroform can be inhaled in the pure 
 state. 
 
 It is always atmospheric air, impregnated with the anaes- 
 thetic, that sustains life and produces anaesthesia. 
 
 The expression "give him nothing but ether, exclude the 
 air," are only relative terms ; they simply mean saturate the 
 
242 ARTIFICIAL ANJESTHESIA. 
 
 air as much as possible with the ether. Permit the patient 
 to have no fresh air, but compel him to breathe air charged 
 with ether. 
 
 Now, in Allis' apparatus there is no chance for the ether 
 to remain in its fluid state, but exposed as it is on a thin 
 stratum of muslin it yields its anaesthetic principle promptly. 
 
 When he first employed his instrument, bystanders would 
 suggest that it be closed at the top, so as to permit no escape 
 of ether. 
 
 This will show that the true laws of ether were overlooked ; 
 ether- vapor, while it will diffuse itself throughout an entire 
 room, is of greater specific gravity than atmospheric air and 
 tends to the floor. 
 
 To close this apparatus at the top, would necessitate in- 
 gress of air at the part surrounding the mouth, for air must 
 be admitted. 
 
 If it be excluded at the bottom and left open at the top, 
 the advantage of having a constant supply of ether drop- 
 ping upon the folds is very great. 
 
 Some suggested that the frozen moist vapor that is seen 
 at the top of the instrument indicates a waste of ether, but 
 the small quantity used and the rapidity with which anaes- 
 thesia can be effected, are complete refutations of this. 
 
 The untidiness can be entirely avoided with a little care. 
 
 The late Dr. Morgan, of Dublin, has comparatively tested 
 the cone and sponge with the inhaler, and finds that the 
 time is not only much longer in the first form of apparatus, 
 but the effects also far less satisfactory both as to the tem- 
 porary and after condition of the patient. 
 
 Mr. Morgan, Surgical Registrar at St. George's Hospital, 
 London, has suggested a modification of the felt cone ordi- 
 narily in use in this and other hospitals in England. 
 
 " The instrument consists of a cone of felt, in the apex of 
 which a piece of sponge is fixed, on which the ether is 
 poured. This is fitted into a case of metal surrounded by an 
 outer one of similar shape, but sufficiently large to leave a 
 space between them through which the expired air can 
 freely circulate before it escapes. There are two valves, 
 acting in opposite directions; one admitting the air, which 
 passes through the sponge moistened with ether ; the other, 
 through which it escapes into the chamber between the two 
 
MORGAN'S ETHER INHALER. 243 
 
 metal cones. The close application of the instrument to the 
 face is secured by means of the India-rubber cushion, which 
 is filled with air by the tap, so that all the air inspired must 
 pass through the valve. The warmth produced by the air 
 which circulates between the two cones prevents the ether 
 on the sponge from freezing, and the vapor which escapes is 
 carried off by a tube to any distance which may be desired. 
 The quantity of ether required in this apparatus is much 
 smaller than in the ordinary cone; and the advantage it 
 thus possesses, as well as the safety and freedom from ether- 
 vapor obtained by the administrator, render it superior to 
 other similar apparatus. Several American surgeons, whose 
 knowledge and experience of ether are generally recognized, 
 have expressed considerable approbation of this invention. 
 It is manufactured and sold by Messrs. Blaise & Co., 67 St. 
 James Street." 
 
 The following results* were obtained by the use of Mor- 
 gan's inhaler : — 
 
 REPORT OF EXPERIMENTS WITH ETHER IN TWENTY-SIX 
 
 CASES, f 
 
 Shortest time taken to place a patient under the 
 
 anaesthetic influence, 3 min. 30 seconds. 
 
 Longest time, 24 " " 
 
 Average time, 8 " 10 " 
 
 Average time under influence, 19 " " 
 
 Smallest quantity of ether used in one case, . 2 ounces 4 drachms. 
 
 Largest, 9 " 
 
 Average, 5 " 1 " 
 
 Vomiting occurred in eleven cases during or after the ad- 
 ministration of the drug. Excitement occurred in seven 
 cases to a marked degree during or after administration of 
 the drug. (Does our experimenter mean resistance as ex- 
 citement, or, if in a female, as hysterical excitement?) The 
 anaesthetic was invariably given on an empty stomach. The 
 ether was given by Morgan's inhaler. Ether was analyzed 
 and found to be perfectly pure, s. g. 720.2 at 64° F. 
 
 * Those who have used both the English and American ethers state 
 that the former gives less favorable results than our washed ether, 
 aether fortior, U. S. P. 
 
 T By Surgeon-Major Porter, Assistant Professor of Military Surgery. 
 London : 1875. 
 
244 ARTIFICIAL ANAESTHESIA. 
 
 ETHER INHALER OF DR. RICHARDSON. 
 
 In 1873 Dr. B. Willis Richardson,* of Dublin, designed 
 and employed a simple form of ether inhaler for use in hos- 
 pital practice. The ether box, of metal, has a capacity of 
 three ounces, with an oval air-opening half an inch long, 
 and about an eighth of an inch from its upper margin. By 
 rotating the lid, which has a similar shaped opening in its 
 side, the admission of air can be easily regulated. At the 
 beginning of the inhalation, the inner opening may be fully 
 exposed and gradually covered. The ether box communi- 
 cates with the face piece by means of a tube an inch in 
 length and one inch and a half in diameter, the ether-box 
 opening of the tube being two-thirds closed by a fixed 
 diaj)hragm. This prevents the fluid ether from passing into 
 the tube when the patient is in the horizontal position. 
 The face-piece opening of the tube has a diameter of one 
 inch. The tube itself, in order to increase the evaporating 
 surface, should be nearly filled with soft cotton candlewick, 
 having, when in use, one end submerged in the fluid ether. 
 The inhaler may be made of silvered copper or of block tin, 
 but the margin of face-piece should be formed of flexible 
 metal and covered with morocco leather. 
 
 "This inhaler the inventor states to be simple in form and 
 moderate in price, and designed as a substitute for the towel 
 and sponge, in the use of which there is much waste of 
 ether, a matter in hospital economy that may be of some 
 importance." 
 
 Dr. Richardson has employed and prefers anhydrous sul- 
 phuric ether, because it was found to produce the most 
 rapid anaesthesia. 
 
 DR. ANGROVE'S HANDY ETHER INHALER.f 
 
 This gentleman states that in England there is a great 
 
 want felt just at present for an effective, handy and cheap 
 
 inhaler. He has endeavored to supply this want. His 
 
 iuhaler " consists of a cylinder, on which fits, by a bayonet 
 
 * Description and illustration of an ether inhaler, etc. By B. "W. 
 Richardson, F.R.C.S.I. John Falconer, Dublin, 1873. 
 
 f The description of a handy ether inhaler. By W. T. Angrove, 
 House Surgeon to the Yarmouth Hospital. "London Lancet," March, 
 1877, p. 123. 
 
CLOVER'S ETHER INHALER. 245 
 
 joint, a cap, around the rim of which are attached several 
 stout wires. The top of the cap is perforated with holes, 
 and through the middle is inserted a long metal tube reach- 
 ing nearly to the bottom of the cylinder. One end of an 
 air-tight silk reservoir is fastened to the cap, and the other 
 to the flexible tube, which is also attached to the mouth- 
 piece. The flexible tube runs through the reservoir, and is 
 directly connected with the metal tube. The inside of the 
 cylinder is lined with felt, and a couple of turns of the same 
 material are wound round the wires, thus presenting three 
 surfaces for the evaporation of the ether. Having filled the 
 reservoir with air, an ounce of ether is poured into the 
 cylinder through the nozzle ; this diffuses itself all over the 
 felt. The mouth-piece is then applied to a patient ; he is 
 told to ' draw in his breath ; ' the vapor he inspires comes 
 from the reservoir, passes through the holes in the cap, over 
 the evaporating surfaces of felt, and up through the whole 
 length of tube ; he expires the same vapor which passes 
 back to the reservoir, and becomes re-charged with ether 
 during the next inspiration. The inventor further states 
 he has completely anaesthetized several individual patients 
 in a little over one minute, one in forty seconds. An ounce 
 of ether is sufficient to keep a patient about ten minutes." 
 
 The cylinder is five inches high and three in diameter. 
 The reservoir holds about a pint and a half. The length of 
 the tube can be made according to taste. To show that 
 they are still at sea in England in regard to ether inhalers, 
 I will conclude this part of my subject by giving a descrip- 
 tion of one of the latest invented, from the British Medical 
 Journal. 
 
 THE PORTABLE REGULATING ETHER INHALER 
 OF J. T. CLOVER, F. R. C. S. 
 
 "In the British Medical Journcd of July 15th, 1876, I de- 
 scribed an apparatus for giving laughing gas and ether sep- 
 arately or combined. Experience in more than three thou- 
 sand cases iu which I have used it convinces me that the 
 administration of ether may be made far less unpleasant to 
 the patient, and equally effective and safe, by first giving 
 enough gas to render the patient unconscious of its taste. 
 
 V The arrangement of the apparatus enables one to cause 
 
246 ARTIFICIAL ANAESTHESIA. 
 
 the patient to breathe directly into and out of a bag, or 
 partly or entirely through a vessel containing liquid ether. 
 Even without gas, it is very efficient, inasmuch as it gives 
 the power of varying and of sustaining the strength of the 
 vapor. I have used it a great many times without gas, and 
 rind it as safe as any other way of giving ether, whilst the 
 risk of coughing and sickness is much lessened. 
 
 " The plan of excluding fresh air until insensibility has 
 been induced, and admitting it very sparingly afterwards, 
 has now been extensively tried in various ways, and, so far 
 as I know, it is practically free from the danger of causing 
 serious obstruction to the pulmonary circulation and over- 
 distention of the right cavities of the heart. Of course, air 
 cannot be indefinitely excluded, but the pulse and respira- 
 tion give timely notice when air is required. A single arti- 
 ficial respiration of fresh air in these cases affords more re- 
 lief than several such respirations when the apnoea has 
 resulted from an overdose of ether or chloroform. The 
 reason for this is, that in the former case the symptoms 
 depend chiefly on the want of oxygen, and in the latter 
 upon the presence of a substance which has not only en- 
 tered the blood, but has penetrated the tissues of the body. 
 If the apparatus be overheated, or if the ether be turned on 
 too quickly, the ordinary coughing and struggling would, 
 of course, be produced. The apparatus, however, requires 
 a little more attention to temperature and other details, and 
 is rather too complicated for general use. I have made 
 several attempts to avoid the necessity of warming it. This 
 can be effected by having the ether vessel surrounded by a 
 larger quantity of water at the ordinary temperature, but 
 then the size and weight of the inhaler becomes objection- 
 able. Better success attended modifications of the instru- 
 ment having the ether vessel placed close against the face- 
 piece, so as to receive more warmth from the patient's breath 
 and from the hand of the administrator. 
 
 " I am greatly indebted to Messrs. Mayer and Meltzer for 
 their patience and ingenuity in carrying out my ideas, and 
 my present object is to call attention to a portable regulating 
 inhaler made by them. Its advantages are these : 1. It has 
 no valves ; 2. It supplies the vapor so gradually that pa- 
 tients breathe quietly ; 3. It produces sleep in two minutes ; 
 
CHLOROFORM INHALERS. 247 
 
 4. It does not require fresh ether during the continuance of 
 an operation ; 5. The recovery from a short operation is 
 more speedy than with most other inhalers ; 6. It does not 
 need to be warmed before it is used ; 7. No sponge or felt is 
 required ; 8. Ether left in the inhaler can be saved for an- 
 other time. 
 
 " The face-piece is edged with an air-cushion. The ether 
 vessel and water chamber rotate upon the mouth of the 
 face-piece. When the instrument is first applied, the stop- 
 per should be towards the patients forehead, and now he 
 breathes in and out of the bag directly. As the ether vessel 
 is turned round, the air is obliged to enter the ether cham- 
 ber and pass through it before it reaches the bag ; and when 
 the vessel is turned half round, so that the stopper is oppo- 
 site the patient's chin, all the air going in and out of the 
 bag must pass through the ether vessel. Two ounces of 
 ether (specific gravity 735) are enough for a long operation. 
 Usually an ounce and a half is the proper charge. The 
 opening for supplying the ether is arranged to prevent an 
 excessive quantity being supplied, but to guard against the 
 possibility of a few drops escaping through the inner open- 
 ings, there are two recesses made to catch them, and pre- 
 vent the liquid ether from reaching the patient's lips. 
 
 " The ether vessel is spherical in shape, and one half is 
 surrounded by a closed water compartment to prevent the 
 ether from becoming too cold. The bag need not be much 
 distended when in use, and can be kept on one side so as 
 not to obstruct the light in operations on the eye. The in- 
 strument is intended for giving ether without gas, but by 
 connecting the bag with a supply of nitrous oxide, it forms 
 a tolerably efficient substitute for the gas and ether inhaler 
 above mentioned." 
 
 CHLOROFORM INHALERS. 
 
 A simple form of inhaler for the administration of chlo- 
 roform, devised by Dr. Allis, of this city.* See Fig. 22. 
 
 " It consists merely of two tin cones soldered aj^ex to apex, 
 with a tube projecting from the upper or receiving cone 
 into the lower. Around the base of the larger cone apiece 
 
 * Philadelphia Medical Times, No. 162. 
 
248 ARTIFICIAL ANAESTHESIA. 
 
 of linen is tied. When the instrument is to be used, a 
 towel is properly folded and pinned around the larger cone, 
 presenting, when complete, a cone of sufficient size to cover 
 neatly the mouth and nose. 
 
 "This cannot be called an inhaler with any more propri- 
 ety than can a towel or a napkin ; but 
 while it resembles the latter in principle, 
 it has in practice very many and import- 
 ant advantages. 
 
 "1. The chloroform falls through the 
 tube upon a single layer of linen to both 
 sides of whicl* the air has ready access, 
 and is accordingly instantly evaporated. 
 
 ' ' 2. Every drop is conveyed to the pa- 
 tient. 
 
 "3. A few drops at a time are all that Fi<*. 22. 
 
 are ever required, and all the patient can 
 breathe with comfort. 
 
 "4. The dropping may be more or less constant, as the 
 instrument need not be removed from the face, and by 
 means of a ' dropper ' (see Fig. 21), the operator can gauge 
 the amount to the necessities of the case. 
 
 " 5. The anaesthetic influence is gained gradually, imper- 
 ceptibly and rapidly, and with a minimum amount of chlo- 
 roform. I seldom use more than a drachm and a half in 
 adults. 
 
 "6. As only a few drops need be added at a time, the 
 danger must be far less than when an indefinite quantity 
 is poured on from a bottle at once. 
 
 "7. There is no exclusion of the air, but the air that is 
 breathed is impregnated with a fresh supply of chloroform. 
 
 "8. The time consumed is usually from three to ten 
 minutes. 
 
 "9. The influence once obtained may be easily main- 
 tained. 
 
 " We have used this repeatedly for nearly four years,'and 
 have found it all that we could desire. 
 
 u It is exceedingly convenient as a frame work about 
 which to pin the towel, and as a receiver of the chloroform, 
 and so simple in construction that any tinsmith could make 
 or repair it should it be broken." 
 
SKINNER'S CHLOROFORM INHALING APPARATUS. 24& 
 
 SKINNER'S CHLOROFORM INHALING 
 APPARATUS. 
 
 This consists of a wire frame (like those employed in Ger- 
 many) ; it is in the form of a scoop net, which, when in use, 
 is covered with a thin flannel or domette drawn tight. 
 There is an accompanying green glass bottle for the chloro- 
 form, with a stopper and cap, and on removal of which a 
 tubular stopper is fitted so as to use it for a dropper. 
 
 Directions for adjusting. — Adjust the domette cover by 
 passing the handle of the inhaler through the slit up to the 
 hinge ; then draw the India-rubber opening over the wire 
 frame, keeping the side on which the facial or horizontal 
 wire is, looking upwards. 
 
 Adjust the horizontal or facial wire (under the domette), 
 and keep it in position until you have unfolded the handle. 
 See that the small notch in the hinge extremity of the 
 handle receives the facial wire and fixes it ; then turn the 
 instrument over, and fix the nut or bolt beneath the 
 handle. 
 
 There are two domette covers with each instrument- 
 When- soiled, or, indeed, after administering chloroform to 
 any patient, a fresh cover should always be put on. 
 
 Directions for using. — Never charge the bottle with over 
 three fluid ounces of chloroform, namely, to the top of the 
 tell-tale or slit in the leather cover, otherwise the contents 
 will not flow freely enough when wanted. 
 
 In adjusting the tubular stopper see that it is firmly "sent 
 home" with a turn, so that there will be no likelihood of its 
 falling out during use — an accident which hitherto has not 
 happened. 
 
 The inhaler or mask is to be held with the left hand, close 
 to or more or less distant from the nose and mouth of the 
 patient, whilst the chloroform bottle, with the small glass 
 cap removed, is to be held in the right hand, and its con- 
 tents are to be poured in a stream over the surface of the 
 domette (while in situ over the face of the patient) in such 
 quantities as the administrator may think advisable — in 
 fact, the bottle is to be used the same as a watering-pot for 
 flowers. But it is necessary to bear in mind that, in conse- 
 quence of the peculiar construction of the stopper, only from 
 
250 ARTIFICIAL ANAESTHESIA. 
 
 fifteen to thirty minims can flow at one inversion of the 
 bottle; air must be re-admitted, either by a fresh inversion, 
 or by shaking the bottle while in the inverted position, in 
 order to re-establish and keep up the flow when necessary. 
 The instrument in its present form has been used most 
 extensively to induce the deepest anaesthesia in capital 
 operations. In the more violent forms of mania, epilepsy, 
 and delirium tremens, it has also been extensively used. It 
 has been used in dentistry, in general surgery, and in mid- 
 wifery, in all conceivable positions of the body; but the 
 back and sides are the positions most to be preferred, as re- 
 gards rapidity of effect, economy of the anaesthetic, and the 
 safety of the patient. In point of economy alone, this appa- 
 ratus saves at least sixty per cent, of chloroform more than 
 any other practical method of successful administration. 
 
 THOMAS' NITROUS OXIDE INHALER. 
 
 The Thomas inhaler, Fig. 23, is turned from a piece of 
 vulcanized rubber, eight inches long by three inches square, 
 leaving the mouth-piece one inch and a half across. The 
 diameter of the opening is a little more than one-half an 
 inch, with stopcock in the centre, in which is the inhaling 
 
 ENTRANCE 
 
 EXIT lll|ip> Pl£C£ 
 
 Fig. 23. 
 
 valve, which is constructed of a simple piece of rubber dam 
 secured by a pin to a stoppel, in which are three oblong 
 apertures, as is the inhaling valve at the extremity of the 
 inhaler. The aperture being of sufficient size, is made not 
 to obstruct the free passage of the nitrous oxide gas, the 
 valves are three-quarters of an inch in diameter, and the 
 stopple is of vulcanized rubber. His method of using it is 
 described under nitrous oxide, page 164. 
 
INHALER FOR NITROUS OXIDE GAS AND ETHER. 251 
 
 CLOVER'S INHALER FOR NITROUS OXIDE GAS 
 AND ETHER. 
 
 The following is a description of the apparatus of Dr. 
 Clover : — 
 
 " The apparatus consists of a thin bag, oval in shape, and 
 fifteen inches long ; at one end connected with the ether 
 vessel, at the other with the face-piece. Inside the bag 
 there is a flexible tube also connected with the face-piece 
 and ether vessel. 
 
 ' ' By turning the regulator (Re) the patient is made to 
 breathe either directly into the bag, or indirectly through 
 the tube or ether vessel. 
 
 " When the letter G is visible, the way to the gas bag is 
 open ; when the letter E is visible, the only way to the bag 
 is through the tube and ether vessel ; so that the more the 
 regulator is turned toward E, the more ether is given, and 
 vice versa. 
 
 " The other vessel contains a reservoir of water to pre- 
 vent the temperature of the ether becoming too low ; this 
 is to be kept full. 
 
 " The ether vessel is to be rather more than half filled, 
 the precise point being marked against the glass gauge. A 
 thermometer inside this gauge tells the temperature of the 
 ether. Before using it, the vessel should be dipped into a 
 basin of warm water, and rotated until the thermometer 
 stands at about 68°. 
 
 " If the room be cold, and if the patient have thin cheeks 
 and large whiskers, the temperature may be 73°. 
 
 "It is important that the face-piece should fit closely 
 against the face. Those made by Mayer, of solid leather 
 framework supporting a collar of inflated india-rubber, are 
 the best, but sometimes they require to be warmed before 
 using. Forgiving nitrous oxide only the regulator is turned 
 to G. The stopcock of the ether vessel is closed. 
 
 " This vessel is hooked upon the strap round the neck. 
 The strap is adjusted so that the ether vessel stands at a 
 higher level than the face-piece. 
 
 " The gas being turned on by rotating the foot key with 
 the foot, the gas bag is kept filled as fast as it is emptied by 
 the patient. When the latter breathes out, the supply of 
 
252 ARTIFICIAL ANAESTHESIA. 
 
 the gas is stopped, and after the bag is fully distended, 
 the escape-valve opens, and allows the expired gas to escape. 
 
 " If the shape of the patient's face prevent the face-piece 
 from fitting closely, the escape-valve should be closed by 
 pressing it with the finger. Enough gas will escape be- 
 neath the face-piece during the expiration. But the bag, 
 being slightly distended, will yield the gas so abundantly, 
 that no air will be drawn in at the same place during the 
 inspiration. 
 
 " If ether is to be used without gas, the gas-tube should 
 be taken off the ether vessel, the regulator should be turned 
 to G, and the face-piece should be first applied to the face 
 during an expiration, and be held rather closer during ex- 
 piration than during inspiration. 
 
 " It is important not to oblige the patient to inhale after 
 the bag is empty, because the barometric pressure of air on 
 the ether being diminished, the vapor would increase in 
 strength, and make the patient cough or perhaps vomit. 
 
 " The regulator is gradually turned towards E, and thus 
 the way is opened to the inner tube. The air breathed 
 through it carries vapor from the vessel into the distal end 
 of the bag. 
 
 ' ' As soon as one-half of the air passes through the ether 
 vessel, the vapor becomes strong enough to cause insensi- 
 bility in about two minutes, usually without any coughing. 
 As the movement of swallowing is excited by a too strong, 
 although less pungent, atmosphere than is generally needed 
 to excite coughing, it should be watched for, and the regu- 
 lator slightly turned back if it occur. 
 
 " By far the easiest and least unpleasant way of getting 
 a patient ready for a surgical operation is to use gas and 
 ether combined, the gas being given pure during four or 
 five respirations, and the ether gradually added as above 
 described. 
 
 " The supply of gas should cease when the ether is turned 
 on ; but if during the operation we have admitted so much 
 fresh air that the patient seems conscious of the taste of 
 ether, we may, instead of increasing the ether, give a lib- 
 eral supply of gas until the patient is tranquil. 
 
 " I find less sickness and less complaint of the taste of 
 ether afterwards than when ether is used alone. 
 
CITROUS OXIDE GAS AND ETHER. 253 
 
 "In operations on the eye, the muscular twitching and 
 panting character of the breathing during the first few 
 minutes of insensibility are objectionable ; but if the opera- 
 tion be not commenced for five minutes, and the ether 
 given as strong as it can be taken without exciting a cough, 
 the patient begins to breathe stertorously , and now the face- 
 piece may be removed every third or fourth inspiration, 
 and as the stertor goes off, the eye will become quite 
 steady. 
 
 " I am, however, so well satisfied with a modification of 
 my chloroform apparatus, by which I can give as much of 
 ether or chloroform as I like, that when I have a choice, I 
 prefer using these for cataract operations, and for the liga- 
 ture of deep-seated arteries, etc. 
 
 "With respect to vomiting, I think it most important 
 that the patient should have an empty stomach, and prefer 
 that neither food nor drink of any kind should be taken 
 for from four to six hours beforehand. 
 
 "There is less sickness after operations if done before 
 breakfast. 
 
 " In using this apparatus, as in using others, the breath- 
 ing and the pulse should be kept under observation. 
 
 " Whenever we see a patient swallow, it is probable he is 
 taking the vapor stronger than is necessary, and the regu- 
 lator should be turned back slightly. 
 
 " If the patient cough violently, remove the face-piece, 
 and be sure that the apparatus has not been overheated or 
 filled with ether above the proper level. 
 
 "As soon as any muscular twitchings, like those of pa- 
 ralysis agitans, are seen, give about a fourth of an inspira- 
 tion of fresh air, and do not keep the face-piece quite close 
 to the face till the twitchings have nearly ceased. 
 
 " I have never seen any harm result from the condition 
 which causes these movements. If air were not given, they 
 would increase, and then stop ; the respiration would be- 
 come intermittent, and some time after this the heart 
 would cease to beat. 
 
 " The fact that death may be produced if signs of danger 
 are disregarded applies to all anaesthetics. 
 
 "Whenever the breathing becomes jerking, sobbing, or 
 intermittent, the face-piece should be removed, but applied 
 
 16 
 
254 ARTIFICIAL ANAESTHESIA. 
 
 directly the breathing loses that character, unless the pulse 
 is much depressed. 
 
 "It is much less important to watch the pulse whilst 
 giving gas and ether than in giving chloroform ; but it is 
 desirable, for when it decidedly loses power, we may safely 
 admit a little fresh air, and thus anticipate the need of re- 
 moving the face-piece to a greater extent on account of 
 muscular twitching or stertor. 
 
 " If the finger be taken from the pulse to do something 
 else, I would give a little air, unless the patient had only 
 just begun to inhale, or was evidently but slightly under 
 the angesthetic. 
 
 "Practical suggestions: — 
 
 "As the apparatus would be injured by an excited patient 
 taking hold of it, it is as well to have an assistant near in 
 case of need. 
 
 " It is a good plan to replace a handkerchief over a patient's 
 eyes, and keep it there until he is asleep, and apply it again 
 when he is about to awake. 
 
 "In operations on the rectum, it is desirable that the band- 
 age required for keeping him on his side should be applied 
 before giving the gas. 
 
 ' ' Sudden distension and bursting of the gas-bag or gas-tube 
 can scarcely happen when the gas rarefier is used ; but if 
 this be not used, or if the gas-bottle have become frozen, it 
 is desirable to warm the bottle, and in doing so, the top end 
 should be more warmed than the other. 
 
 "Whenever there is much difficulty in getting the face- 
 piece adjusted, it may be necessary to arrange a handker- 
 chief or towel so that the air drawn in under the face-piece 
 may be nearly the same as that which was breathed out. 
 
 "In conclusion, the advantages of the apparatus are 
 these : — 
 
 "1. It lessens the waste of ether, and consequently the 
 odor of ether about the house. 
 
 "2. The patient usually goes to sleep without any strug- 
 gling, and is ready to be operated on in from one to two 
 minutes. 
 
 "3. The percentage of ether need not be so high as to pro- 
 duce coughing or swallowing, and it can be made stronger 
 or weaker, as we wish, by merely turning a regulator. 
 
ETHER AND NITROUS OXIDE GAS. 255 
 
 "Lastly, patients recover rapidly, with less delirious ex- 
 citement and less sickness, than if ether be given in the 
 usual way." 
 
 In April, 1877, Dr. F. X. Otis, of New York, exhibited 
 Clover's apparatus for administering ether and nitrous ox- 
 ide, and remarked that it had given him the best satisfac- 
 tion of any apparatus he had ever employed, for anaesthesia 
 was readily produced without a struggle upon the part of 
 the patient. It could be used for the administration of 
 laughing-gas without producing any of that dreadfully suf- 
 focative appearance so commonly attending its use by the 
 methods usually employed. He thought well of prefacing 
 the ether by the use of a moderate amount of nitrous 
 oxide. 
 
 Death under the administration of nitrous oxide and ether. 
 — " A death has recently taken place in London, at Univer- 
 sity College Hospital, during anaesthesia from nitrous oxide 
 gas and ether, being, we believe, the first fatal case which 
 has occurred in this country that can be attributed to this 
 combination of anaesthetics. The patient was a woman 
 fifty-five years of age, who was admitted to the hospital in 
 consequence of strangulated femoral hernia. When admit- 
 ted she was in a very weak and exhausted condition from 
 constant vomiting, the hernia having been strangulated for 
 over forty-eight hours. She was taken into the operating- 
 theatre, and gas and ether administered by means of Clov- 
 er's apparatus. In about four minutes she was well under 
 the influence of the anaesthetic, without having exhibited 
 any previous excitement. Taxis was then applied, when 
 almost immediately the patient became pale and recom- 
 menced vomiting stercoraceous matter. At the same time 
 the respiration became weak, and the pulse at the wrist im- 
 perceptible. The doors and windows of the theatre were at 
 once thrown open, and artificial respiration was carried on 
 for a few minutes. As no obvious benefit resulted, an enema, 
 containing three ounces of brandy, was administered. 
 Fumes of strong ammonia were applied to the nostrils, and 
 ammonia injected into the right median basilic vein, but all 
 without any good result, and the patient died within about 
 ten minutes from the onset of the alarming symptoms. At 
 
256 ARTIFICIAL ANAESTHESIA. 
 
 the autopsy, stercoraceous matter was found in the trachea 
 and right bronchus. The right side of the heart and the 
 large veins were full of dark fluid blood. The ventricular 
 walls were thin and flabby, and the cavities slightly dilated. 
 The left ventricle was empty. The arch of the aorta pre- 
 sented numerous patches of atheroma."* 
 
 Sir Henry Thompson recommends Mr. Clover's plan of 
 administering nitrous oxide gas for thirty seconds and then 
 ether, f 
 
 INHALER FOR NITROUS OXIDE GAS OR ETHER 
 OF CODMAN AND SHURTLEFF, OF BOSTON. 
 
 I have received a beautiful inhaler from the above firm, 
 through the politeness of S. S. White & Co., of Philadel- 
 phia. 
 
 The points for which they claim superiority are : — 
 
 " 1st. Durability ; being made of metal, they are not liable 
 to be easily broken, as so frequently happens to the hard- 
 rubber inhalers, and as they are nickel-plated they retain 
 their brilliant polish without change. 
 
 "2d. For convenience both to the patient and operator. 
 With one hand the latter can apply the inhaler, and open 
 or close the two-way stopcock, leaving the other hand at 
 liberty to control the patient, or for such exigencies as may 
 occur. As the elastic hood covers both nose and mouth, 
 the patient is saved the necessity of having the nostrils closed 
 either by clamps or the fingers — a part of the operation al- 
 ways very disagreeable, and to very sensitive patients posi- 
 tively frightful, as it produces a feeling of suffocation. 
 
 "Cleanliness. The rubber hood, which alone comes in 
 contact with the face, is easily removed and replaced, and 
 as all the other parts are either metal or hard rubber the 
 whole instrument can be kept perfectly pure by washing, 
 which is a point of great importance to the comfort of the 
 patient. 
 
 "4th. Durability and accurate working of the valves." 
 
 Upon this, perhaps, more than anything else, depends 
 the successful administration of anaesthetics. If the ex- 
 
 * Medical Times and Gazette, March 17th, 1877. 
 f London Lancet, Januax-y 8th, 1876. 
 
NITROUS OXIDE GAS AND ETHER INHALER. 
 
 257 
 
 haling valve does not quickly and perfectly close while the 
 gas is being inhaled, air is taken with it, and the gas is so 
 much diluted that it very much delays or wholly prevents 
 the desired effect. 
 
 If, on the other hand, the inhaling valve does not work 
 properly, the patient breathes back into the reservoir a mix- 
 ture of nitrous oxide and air. 
 
 Fig. 24 is the inhaler with a hard rubber mouth-piece, A. 
 The metal hood, B, is used for nitrous oxide gas. 
 
 I 4 SHURTIEFF, 
 BOSTON. 
 
 Fig. 24. 
 
 Fig. 25 is the inhaler for nitrous oxide gas. A, metallic 
 hood, containing, B, flexible rubber hood, covering both 
 
 Fig. 25. 
 
 nose and mouth ; C, exhaling valve ; D, two-way stopcock ; 
 I, packing, through which a silk cord passes ; G, sliding- 
 joint, where J is detached to connect the ether ivsc rvoir ; J 
 contains the inhaling valve. 
 
 Fig. 26, the inhaler arranged for using ether. Fh:s differs 
 from Fig. 25 only in the addition of the hollow splere, F, 
 which contains a course sponge, on which th i ether is. 
 poured through the opening, G ; H, cover closing the :eser- 
 voir when not in use. This part is attached at the sliding- 
 
258 
 
 ARTIFICIAL ANAESTHESIA. 
 
 joint, E, and will fit most inhalers made by Codman & 
 Shurtleff during the last three years. By this arrangement 
 waste of ether by evaporating is prevented, and it is stated 
 that less than half the quantity is required to produce or 
 keep up anaesthesia. 
 
 The operator also escapes breathing so much of the ether 
 as he is compelled to do when using it from a sponge or 
 napkin. . 
 
 Fisr. 21). 
 
 EXPERIMENTS MADE AVITH THE INHALER OF C'ODMAN & 
 SHURTLEFF, BOSTOX. 
 
 First experiment with new inhaler, November 1st, 1876, 
 with three patients, two males and one female. 
 
 In each was tested the ether attachment : two were un- 
 able to make the valve act quickly ; in the third the opera- 
 tion of inhalation was a success, the exhaling valve acting 
 with each respiration by a click. 
 
 Nov. 2d. Second experiment, two females and one male. 
 With the females the soft rubber covering for the mouth, 
 nose, and face fitted admirably. With the male the rubber 
 cover could not be made to fit air-tight, owing to his having 
 a beard, but it worked more satisfactorily. If the distance 
 from the ether supply and the mouth-piece is shortened, the 
 ether passes much more rapidly in the case of a patient who 
 is feeble. 
 
 The exhaling valve should be screwed tightly, else it is 
 apt in handling to become loose and will drop out. 
 
 Third experiment. Dr. Thomas has demonstrated that 
 the gag was not suitable, for it should not project out of the 
 
NITROUS OXIDE GAS AND ETHER INHALER. 259 
 
 mouth to prevent its perfect closure. Second, it did not fit 
 into the teeth. 
 
 I have received the following reply, from the makers, to a 
 report of my experiments : — 
 
 " Sir : We have received yours of the 3d. In regard to the 
 fit of the rubber to the patient's face, we have had no com- 
 plaints, except where the beard in male persons has pre- 
 vented close contact, and in cases of children where the 
 face is too small to fit the rubber. In the former class of 
 cases the beard may be wet with water, or that failing, the 
 mouth-piece used instead of the flexible face-hood, which is 
 the plan to be pursued with children. 
 
 " We have adopted this.style of face-hood in preference to 
 the English pattern , that having an air tube attached to the 
 metal hood, as being as well or better adapted to a great 
 number of faces and not liable to get out of order, as that is 
 almost sure to do after a few months' use, and as being re- 
 movable for cleansing or removal without any expense or 
 delay. 
 
 " The Centennial Judges, who took ample opportunity to 
 examine this inhaler, refer to it in the report accompanying 
 the award to us of the highest prize, in the following 
 terms, viz. : ' The novelty of design of the inhaler, perfec- 
 tion of its' execution, and general suitability to the rapid and 
 safe administration of anaesthetics.' " 
 
 MORGAN'S INHALER FOR BICHLORIDE OF 
 METHYLINE. 
 
 Mr. T. C.Morgan employs " a perforated cardboard frame 
 covered with flannel and fitted with lappets, to lie over the 
 face so as to completely exclude air. Two drachms of the 
 bichloride of methyline are put into the inhaler, and it is 
 so closely held before the face as to allow no air to be breathed 
 except what passes through the flannel. In less than two 
 minutes the patient is usually completely insensible. An- 
 other drachm is then put into the inhaler and given as re- 
 quired." He does not care to watch the pulse, though this is 
 sometimes much retarded. He watches the lips and breath- 
 ing. When the lips become white and bloodless, he stops 
 the administration, fearing pallor, not lividity, for patients 
 die from syncope, not coma. 
 
260 ARTIFICIAL ANAESTHESIA. 
 
 CHAPTER IX. 
 
 Bon will's method of anaesthesia. Analgesic effects of rapid breathing. 
 Carbonic oxide gas. Carbonic acid gas. Carbolic acid. Tetrachlor- 
 ide of carbon. Anaesthesia of the larynx. Local anaesthesia in 
 odentalgia. Faradic anaesthesia. Bromoform. Local anaesthetics. 
 Richardson's freezing mixture. Extract eucalyptus, morphia, etc. 
 
 BONWILL'S METHOD OF ANAESTHESIA. 
 
 The method of diminishing sensibility by rapid respira- 
 tion proposed by W. G. A. Bonwill, D.D.S., of Philadelphia. 
 It is described by Dr. A. Hewson in the Philadelphia Med- 
 ical Times, March 4th, 1876. 
 
 "You have, all of you, I have no doubt, experienced the 
 effects of rapid and deep respirations, after violent running, 
 or blowing hard to ignite a fire, especially the confusion of 
 sight and bewilderment of mind. These Dr. Bonwill recog- 
 nized many years ago, associated with numbness of sensient 
 nerves, as dependent on the rapidity of the respirations. 
 Pursuing the subject he has brought it to practical use in 
 his profession — that of dentistry — in which he uses it con- 
 stantly to diminish the sensitiveness of dentine, and even to 
 produce such insensibility as to allow of the extraction of a 
 molar tooth without pain. Of the latter I have had a demon- 
 stration in my own family, which has led me to the study 
 of the subject myself, and with the most gratifying results. 
 I have used it in stitching wounds, in handling over-sensi- 
 tive parts, and in probings and the like." He then relates 
 the case of a medical gentleman who tried the experiment 
 with success who had no recollection afterwards of a "pin 
 sticking him, much less of its having been firmly imbedded 
 in his flesh, as he found it when he had ceased the rapid 
 respirations, and the anaesthetic effect had passed off." 
 
 His second trial was upon a boy in the receiving ward of 
 the Pennsylvania Hospital. The boy had fallen upon the 
 ice an hour previously, and had sustained a severe injury of 
 his left wrist. The doctor directed him at once to try the 
 
ANALGESIC EFFECTS OF RAPID BREATHING. 261 
 
 rapid respirations. This, in two minutes and a half by the 
 watch, caused some dizziness in the boy's head, when the 
 doctor picked up the limb and moved it about with the 
 utmost freedom, diagnosing a bad sprain of the wrist, and 
 the absence of fracture. When the boy was recovering he 
 took to crying, on account, he said, of the dizziness and con- 
 fusion he had experienced. Nothing, remarked the doctor, 
 could have been more satisfactory than this case in its re- 
 sults. Dr. Bonwill claims that a much smaller quantity of 
 ether, chloroform or nitrous oxide is required to produce 
 complete anaesthesia, if rapid respiration is employed for 
 one or two minutes prior to the use of these agents; this he 
 states is corroborated by experiments of Professor Garretson, 
 of this city. 
 
 ANALGESIC EFFECTS OF RAPID BREATHING. 
 
 Dr. Addinell Hewson, of this city, communicates an in- 
 teresting paper on the history of nitrous oxide gas as an 
 anaesthetic, and on the analgesic effects of rapid breathing 
 (Transactions of International Medical Congress, 1876). 
 
 CARBONIC OXIDE GAS. 
 
 When carbon in the form of charcoal is burned with an 
 insufficient supply of oxygen or atmospheric air, it is con- 
 verted into carbonic oxide, CO ; if there is a full supply of 
 air, it yields carbonic acid. 
 
 As I have before stated, carbonic oxide has been employed 
 as a local anaesthetic to cancerous or ulcerated surfaces, but 
 when inhaled, as it often is in mines and by accident, and 
 sometimes by design for suicidal purposes in confined apart- 
 ments in which charcoal is burned, it is a powerful narcotic 
 poison. Owing to its superior affinity, it displaces the oxy- 
 gen in the blood corpuscles, and unfits them for the func- 
 tions of respiration. Carbonic oxide, which gives the blood 
 a light red color, produces a spectrum with two absorption- 
 bands similar to those of normal blood. The red and violet 
 rays are more completely absorbed than in the spectra of 
 normal blood, but with a strong solution of the red coloring 
 matter the results are similar. — {Preyer.) 
 
 This gas is interesting to physicians as being one of the 
 most successful agents employed to destroy animal life, and 
 
262 ARTIFICIAL ANESTHESIA. 
 
 is employed by the " Society for the Prevention of Cruelty 
 to Animals," of our city, to get rid of the superabundant 
 dogs which infest a large city during the summer months. 
 
 Illustration of the mode of killing dogs by the carbonic 
 oxide gas* — The place in which the act is accomplished is a 
 small brick building twelve feet six inches long, eleven feet 
 wide, and twelve feet high, containing two rooms, one on 
 the ground floor, and one above it. The lower rooms run 
 along the whole width of the building, eleven feet, and is 
 fourteen feet five inches broad, a partition of brick separat- 
 ing it from the rest of the space beneath. At the east end 
 it is two feet eight and one-quarter inches high, its roof or 
 top being a little higher than the floor of the room above ; 
 the incline of the roof upwards to the window makes that 
 end of the room four feet four and one-half inches high ; the 
 incline was made to allow more light and an examination 
 of the process of killing. One window is four feet three and 
 one-half inches long, and one foot five and one-quarter inches 
 wide. The two others are three feet five and one-half 
 inches long, and two feet six inches wide; each of these 
 windows has a sash of glass and one of wire; the sashes lift 
 in and out. The window on the top is one foot four inches 
 square. The floor is of brick, and the floor, ends and sides, 
 are covered with cement to make the room air-tight. 
 
 In the two stoves in the room above the gas is generated; 
 they are known as the Rosebud pattern, No. 13, holding 
 about one-half a bushel of charcoal each ; each has a pipe 
 twenty -two feet six inches in length, with a cross pipe run- 
 ning into the chimney. This length of pipe is necessary 
 that the gas may be cooled before reaching the animals. 
 There are four valves or dampers in the pipes — two in the 
 cross pipes, and two just above them in the main pipes. 
 There are also valves at the end of each pipe where it enters 
 the lower, room ; these valves are opened and shut by the 
 pulleys (which are not connected with anything else) ; they 
 are "ground seat valves," six inches outside diameter, or in 
 other words, to fit a six inch pipe ; they are made of copper. 
 
 Mode of killing. — The fire is started, having the dampers 
 
 * This mode was adopted by the Society in 1874, on the recommend- 
 ation of Mr. Coleman Sellers. 
 
CARBONIC ACID GAS. 263 
 
 turned so as to send all the smoke and heat up the chimney. 
 When the fires are well ignited, the dogs are taken into the 
 lower room by the window, and the wire sashes are put on. 
 As soon as the blue blaze of the carbonic oxide gas is seen in 
 the fires, the windows of the lower room are shut, the 
 dampers are reversed, so as to send the gas into the lower 
 room, and the valves are opened at the end of the pipes, so 
 as to draw the gas more rapidly down, making a draft by 
 opening one inch or two of the window at one end. In the 
 course of from one to three minutes, the dogs fall insensible 
 with a peculiar cry, and very soon cease to breathe ; they 
 are allowed to remain from eight to ten minutes, to be sure 
 that life is entirely extinct. 
 
 CARBONIC ACID GAS. 
 
 Carbonic acid gas has been used in a few instances as a 
 local anaesthetic, but it requires great care not to allow the 
 patient to inhale it excejDt very much diluted with air. It 
 is made by the action of dilute sulphuric or hydrochloric 
 acid on marble dust or carbonate of lime ; also by the action 
 of equal parts of bicarbonate of sodium and tartaric acid in 
 water. In order to facilitate its local application a special 
 apparatus is required, such as a siphon bottle armed with an 
 elastic tube, through which the gas is allowed to pass to the 
 parts to which it is applied. A strongly charged bottle of 
 carbonic acid water will answer the same purpose. The late 
 Professor Dewees, of Philadelphia, recommended it in car- 
 cinoma uteri ; it is as useful in cancer of the rectum and 
 other parts. 
 
 Physiological action. — Dogs can breathe a mixture of one 
 part of carbonic acid to nine of atmospheric air with safety, 
 producing an anaesthetic sleep, audit can even be increased 
 to one third ; but when the gases are used in ecmal propor- 
 tions, and kept up for some time, death ensues, preceded by 
 labored respiration, complete muscular relaxation, and slight 
 spasms. According to M. Demarquay - : when the proportion 
 of carbonic acid to oxygen is as three to one, the first effect 
 is convulsions, followed by complete ansesthesia, even of 
 exposed nervous trunks, followed by death, if kept up. 
 
 * American Journal Medical Science, Oct., 1865, p. 497. 
 
264 ARTIFICIAL ANAESTHESIA. 
 
 THE ACTION OF CARBONIC ACID ON MAN. 
 
 If this gas is well diluted with air, or in water, cider or 
 wine, its gas is not only respirable but agreeable, and will 
 often relieve sickness of the stomach. When inhaled it pro- 
 duces an anaesthetic effect. In a young man who died in 
 the Grotto of Pyrmont, there was no congestion of the face, 
 the pupil was dilated, and the cornea brilliant; the brain 
 was deeply congested, and the lungs distended, but not en- 
 gorged. When the body or part is exposed to its action for 
 some time the sensibility of the skin is diminished, but if a 
 wound or ulcer be exposed to its direct influence it reddens 
 it, and produces a smarting pain. 
 
 TETRACHLORIDE OF CARBON. 
 
 Both the bisulphide of carbon and the tetrachloride were 
 at one time employed as anaesthetics, and the first was de- 
 scribed by the late Professor Simpson as a rapid and power- 
 ful anaesthetic ; but after experimenting with them it was 
 found that they both produced great depression, disagree- 
 able visions, followed by giddiness and obstinate vomiting. 
 The anaesthetic effect was found to be very transient, pro- 
 ducing in animals both tonic and clonic convulsions. 
 
 They have fallen into disuse except as local anaesthetics 
 in neuralgia and various local pains. 
 
 ACIDUM CARBOLICUM IMPURUM, U. S. 
 
 This is only employed externally or for disinfecting pur- 
 poses. 
 
 ACIDUM CARBOLICUM— CARBOLIC ACID. 
 
 Pure carbolic acid is a crystaline solid, which becomes 
 liquid by the heat of the hand. The dose is from one to 
 two grains. 
 
 OFFICINAL PREPARATIONS, U. S. 
 
 Glyceritum acidi carbolici (acid §ij by weight; glycerine 
 half a pint). Dose nvv-x. 
 
 Unguentum acidi carbolici (5i to %\). 
 
 Suppositoria acidi carbolici (each gr.i.). 
 
 Auqua acidi carbolici (glycerite of carbolic acid f5x, water 
 q. s." ad ft. Oj.). 
 
CARBOLIC ACID. 265 
 
 ANTIDOTES TO POISONING WITH CARBOLIC 
 ACID. 
 
 Carbonate of lime, sodium or magnesia with lime water, 
 and linseed oil, exvacuation of the stomach with stomach 
 pump, with abundance of flour or starch and warm water. 
 
 CARBOLIC ACID AS A LOCAL ANAESTHETIC. 
 
 Carbolic acid if applied to the skin at first is painful, but 
 after a time this feeling passes away, and leaves the surface 
 in such a state that even the actual cautery can be applied 
 with impunity. 
 
 In some instances, I have simply painted the parts with a 
 strong solution, or, when I desired to make one long incision, 
 a line was drawn with a brush, charged with the liquefied 
 crystals of the acid. 
 
 The following letter from Doctor Levis will speak for 
 itself:— 
 
 My Dear Doctor : 
 
 "I have not any particular method of applying car- 
 bolic acid as a local anaesthetic, but have suggested varied 
 uses of it. My application is always made with the dele- 
 quesced crystals of carbolic acid, sometimes liquefied by 
 heat, and, more frequently, by the addition of a very small 
 quantity of glycerine. 
 
 "One effective anaesthetic use is its application imme- 
 diately after the actual cautery, and all pain is thus pre- 
 vented. In cases of extensive burn of the surface and 
 extremities, involving a very large area of skin, and where 
 changes of the dressing would cause much suffering, I have 
 directed that almost the entire body be simply wrapped in a 
 linen sheet saturated with slightly carbolized oil. For this 
 purpose linseed oil, from its viscid character, is probably the 
 best. 
 
 "I always treat hydrocele with carbolic acid inject- 
 ion. This was my first original plan. The procedure is to 
 first enter the jioint of a hypodermic syringe into the serous 
 sac ; then, with an ordinary trocar and canula, draw off the 
 water. Then the liquefied carbolic acid is injected with the 
 hypodermic syringe. The operation is absolutely painless, 
 and much more certain in results than when tincture of 
 
266 ARTIFICIAL ANAESTHESIA. 
 
 iodine is used. The point of the hypodermic syringe is 
 first entered because such entrance would not be practicable 
 after the fluid is evacuated. I inject two ordinary hypo- 
 dermic syringefuls, equal to about 5i of delequesced crystals. 
 The inflammation which follows is not above the proper 
 plastic grade, and the results are excellent. 
 
 "Truly yours, 
 "March 27th, 1879. " R. J. LEVIS. 
 
 Dr. Turnbull." 
 
 Cure of Haemorrhoids by Carbolic acid by injections. — The 
 following are the rules of Prof. Andrews : — * 
 
 1. Inject only internal piles. 
 
 2. Use at first dilute solutions, stronger ones only when 
 these fail. 
 
 3. Treat one pile at a time, allowing four to ten days be- 
 tween the operations. 
 
 4. Inject from one to six drops (hypodermic syringe), 
 smearing the membrane with cosmoline to protect its sur- 
 face against dripping. 
 
 5. Confine the patient to bed the first day, and subse- 
 quently in case of any severe symptoms. 
 
 Poisoning by the external application of Carbolic acid. — 
 Prof. Kiister, at the last meeting of the Association of Ger- 
 man Surgeons, entered the lists against the use of carbolic 
 aci d in antiseptic surgery. This assault has been supported by 
 Langenbeck(i?er£mer klin. Wochen., No. 28, 1878) and others. 
 Children and delicate women are the chief sufferers from 
 carbolic acid intoxication. The symptoms are, in the case 
 of adults, nausea, vomiting and headache ; but in children 
 the effects are more severe, — the temperature falling below 
 normal, the pulse being extremely weak and the body cov- 
 ered with a cold sweat, the phenomena of collapse. 
 
 It has been ascertained recently by Baumann, that if ani- 
 mals to whom carbolic acid had been previously adminis- 
 tered are treated by sodic sulphate, a harmless compound of 
 of phenol and sulphuric acid is formed. These results of 
 experiments on animals have been confirmed by observa- 
 tions on man. Thus it has been found that the symptoms 
 
 * The St. Louis Medical and Surgical Journal, St. Louis, 1879, p. 356. 
 
ANAESTHESIA OF THE LARYNX. 267 
 
 of carbolic acid poisoning are relieved by the administration 
 of sodic sulphate. If this salt is given when the urine be- 
 comes dark-colored, it at once arrests the toxic phenomena, 
 so that, if desired, the carbolic dressings can be renewed. 
 
 CARBOLIC ACID. 
 In 1864, two eminent French physiologists, M. M. Grati- 
 olet and Lemaire, published a most interesting paper on the 
 action of carbolic acid in arresting putrefaction ; and they 
 have made the important observation that, whilst it does 
 not interfere with chemical fermentation, such as the con- 
 version of amygdaline into hydruret of benzoil, and the 
 conversion of myronic acid by myrosyne, it completely ar- 
 rests all vegetable and animal fermentations, which arise 
 from ciwptogamic life. 
 
 THERAPEUTIC PROPERTIES OF CARBOLIC 
 ACID. 
 
 Ulcers. — To be applied in different degrees of solution, 
 according to the character of the ulcer, carbuncle, and ill- 
 conditioned sores. 
 
 Fistula.— To be applied by means of a pledget of patent 
 lint or wax bougie carrying it to the bottom. 
 
 Haemorrhoids. — As early as January, 1864, Mr. Thomas 
 Turner states, in the London Lancet, "that the action of 
 carbolic acid is mainly to corrugate, and therefore to oblit- 
 erate, the sac of the piles." 
 
 Otorrhoea. — In fetid discharges from the ear, nose, throat, 
 or rectum, it may be advantageously used, in the proportion 
 of one part of carbolic to forty of water. Its action is first 
 stimulating to the blood vessels, causing sanious discharges 
 to become healthy pus. Even when there is caries, or ul- 
 ceration of the bone, it effects healing of the part, and in 
 necrosis it promotes exfoliation of the dead portion. 
 
 ANAESTHESIA OF THE LARYNX. 
 
 There exists a vast difference in individuals in regard to 
 the use of any form of instrument in the throat or in the 
 larynx. With some there is no discomfort, and they will 
 allow almost any manipulation without distress, gagging 
 or vomiting. In the great majority of patients with di- 
 seased throat, larynx, or pharynx, the compressing of the 
 
268 ARTIFICIAL ANAESTHESIA. 
 
 base of the tongue, or the introduction of the mirror to illu- 
 minate any part of these delicate organs, induces most dis- 
 tressing spasmodic action of the parts. It therefore becomes 
 important to discover some means or remedy to prevent this 
 difficulty in laryngoscopy and rhinoscopy. 
 
 Numerous agents have been suggested, but some of them 
 are hazardous, owing to the risk of swallowing them, also 
 because of the property which the mucous membrane has 
 of absorbing such potent agents as morphia, chloroform, 
 either by hypodermic medication or by inhalation. 
 
 From our own experience and experiments, we prefer the 
 use of ice in small pieces, or the following preparation of 
 
 tannic acid : — 
 
 Tfc. Acidi tannici, 5ii. 
 Glycerini, fsiij. 
 Spts. vini rectif, fSij. 
 Mix by heat the tannic acid and glycerine, and when cool add the 
 alcohol. 
 
 This mixture is to be applied with a soft brush to the 
 parts for several days before the operation, as the constant 
 introduction of the brush with the tannin upon it soon de- 
 stroys the great sensibility. 
 
 The following are a few of the remedies which have been 
 employed to produce anaesthesia of the larynx : — 
 
 A few inhalations of chloroform or ether have been re- 
 commended by Sir David Gibb. Prof. Turk proposes the 
 application of a solution composed of three grains of sul- 
 phate of morphia dissolved in one drachm of concentrated 
 acetic acid mixed with half an ounce of chloroform, to be 
 applied by means of a soft brush before operating. Oertel 
 and Cohen recommend the application to the larynx of a 
 saturated solution of bromide of potassium, while it is also 
 administered, by the mouth, in from one to five grain doses 
 dissolved in water. More recently, Gibb has suggested the 
 bromide of ammonium as a substitute for bromide of potas- 
 sium. Prof. Schrotter, more bold than all the others, has 
 published the following method : — 
 
 " The evening before the operation, the glottis is painted 
 with pure chloroform about a dozen times, and an hour 
 afterwards with a solution of muriate of morphia, gr. xij. 
 to two drachms of distilled water. During the use of the 
 morphia, the patient must not swallow his saliva (this is al- 
 
LOCAL ANAESTHETICS. 269 
 
 most impossible) ; indeed, after each use of the brush he 
 considers it prudent to let him gargle his throat with a solu- 
 tion of tannic acid. Early the next morning the operation 
 can be undertaken. If, however, the patient be still sensi- 
 tive, the whole proceeding must be repeated. 
 
 Prof. Gerhardt recommends as an anaesthetic to the lar- 
 ynx the painting of the laryngeal mucous membrane with 
 a solution of colchicum. 
 
 LOCAL ANESTHESIA IN ODONTALGIA. 
 
 Toothache has numerous causes. The chief form in 
 which local anaesthetics are employed, is when there is a 
 very sensitive dentine, or exposure of the pulp, or "nerve 
 of the tooth." 
 
 The first agent in point of importance is chloroform, alone 
 or associated with tincture of aconite, the part, before mak- 
 ing the application, to be perfectly dry, and the mixture 
 placed upon a particle of absorbent cotton, and then pressed 
 on with care, covering the cotton with soft wax. Prof. J. 
 E. Garretson advises the chloroform to be mixed with the 
 following agents : — 
 
 9*. Chloroformi. 
 
 Tinct. opii, aa f 5ss. 
 
 Tinct. iodini. 
 
 Liq. plumbi subacet., aaf3i. 
 
 This is applied by saturating a small piece of cotton and laying it 
 loosely in the cavity. 
 
 For the toothache of little children, nothing has been as 
 useful in our hands as — 
 
 Jji. Alumnis oij. 
 
 ^Etheris chlor. fsj. — M. 
 To be applied on cotton after shaking the mixture. 
 
 A mixture of equal parts of chloroform and ether will 
 answer the same purpose. 
 
 The following formulae for the relief of toothache in the 
 adult are strongly recommended — 
 
 IjL Chloroformi. 
 
 Tinct. benzoici aa fSij. 
 Tinct. aconiti f 5ss.— M. 
 Immerse a piece of cotton in the liquid, and introduce it into the 
 cavity of the aching tooth. 
 
 17 
 
270 ARTIFICIAL ANAESTHESIA. 
 
 fy. Chloroformi. 
 
 Creosoti (or- diluted carbolic acid) aa Sss. 
 Vini opii. 
 
 Tinct. benzoici aa foijss.— M. 
 
 To be introduced into the cavity of the aching tooth. 
 
 LOCAL ANAESTHESIA. 
 
 FARADAIC ANAESTHESIA. 
 
 The faradaic or interrupted galvanic current, or the two 
 combined, have been at times employed to produce local 
 anaesthesia. The experiments which I have made with this 
 agency have impressed me with the idea that much of its in- 
 fluence was mental, yet careful observers like Dr. Beard and 
 others think differently, and recommend it for operations 
 in minor surgery, by directing a strong faradaic current, 
 should be directed through the parts. 
 
 ANAESTHETIC ACTION OF BROMOFORM. 
 
 Bromoform (CHB 3 ) is produced by the simultaneous 
 action of bromine and caustic potash on wood spirit, alcohol 
 or acetone, also by the action of bromine on acetic, citric or 
 malic acid; and by decomposing bromine with alkalies. It 
 is one of the impurities of hydrobromic ether. 
 
 Properties. — It is a limpid liquid, sp. gr. 2°. 13, having an 
 agreeable odor, and saccharine taste. 
 
 Dr. Rabuteau reported to the Biological Society, of Paris, 
 some cases, showing that the application of bromoform to 
 the skin produces anaesthesia without the revulsive and 
 painful effects of the application of chloroform. — Gazette 
 Hebdom. , de Medecine et de Chirurgie. 
 
 DR. B. W. RICHARDSON'S METHOD OF 
 LOCAL ANAESTHESIA. 
 
 Dr. Greenhalgh performed csesarean section, in which 
 local anaesthesia was employed by Dr. Richardson's method. 
 The advantages of the local method were these: — (seep. 49.) 
 Also American Journal Medical Science, July, 1876, p. 227. 
 
 LOCAL ANESTHETICS. 
 
 FREEZING MIXTURES. 
 
 The most common of these is a mixture of equal parts of 
 snow or pounded ice and salt, which produces a degree of 
 
LOCAL ANAESTHETICS— FREEZING MIXTURES. 
 
 271 
 
 cold of about 16° F. The salt causes the ice to melt, and the 
 water dissolves the salt, so that both rapidly become liquid, 
 in consequence of which a large amount of heat is absorbed. 
 By employing it in an elastic bag, like that of Chapman, it 
 will be found of great utility in all superficial incisions. If 
 the snow or pounded ice is mixed with common salt in 
 alternate layers, and placed in a gauze bag, a more profound 
 impression may, in from fifteen to twenty minutes, be pro- 
 duced, and the tissues can be completely frozen if permitted* 
 to remain for one hour, and even a deep-seated tumor can 
 be removed without any pain from the knife. It is well to 
 examine the operation of the mixture, as the parts may be- 
 come frost-bitten. 
 
 A much more powerful freezing mixture is formed by 
 mixing together three parts of crystallized chloride of cal- 
 cium and two parts of snow. The first will freeze water, 
 the second will freeze mercury. Another mode, where ice 
 cannot be had, is to mix together finely powdered Glauber's 
 salt and the common muriatic acid of commerce. Nitre 
 cools water in which it is dissolved, eight or ten degrees ; 
 one part of chloride of potassium dissolved in four parts of 
 water, also cools it to the same amount. 
 
 Fig. 27. 
 
 Note.— A piece of ice wrapped in a thin cloth, and applied to the 
 part where the trochar is to enter.has been recommended in aspiratien. 
 
272 ARTIFICIAL ANAESTHESIA. 
 
 The form of apparatus, Fig. 27, is employed for local anaes- 
 thesia, produces so much cold by atomizing ether that it 
 freezes the skin, and even the deeper tissues. It is used by 
 Dr. B. W. Richardson, of London, or with Rhigoline as 
 described by Dr. H. J. Bigelow, of Boston, or with gasoline 
 as employed in Philadelphia. It consists of the elastic 
 bulb D, which, with its valves, serve to force air into the 
 elastic chamber C, which, alternately expanding and con- 
 tracting, supplies a steady stream of air to the atomizing 
 tubes A, which are of metal, one branch of which dips into 
 the bottle B containing the ether, and the inner tube for 
 delivering the ether runs upwards to the extremity of the 
 outer tube. The ether must be directed on the surface, and 
 must be the strongest, therefore free from alcohol and water. 
 When the parts are properly frozen they become pale, 
 shrunken, and tallowy looking, and when cut, like frozen 
 fat. 
 
 "When the rubber bag D is compressed by the hand, the 
 reservoir bulb is rilled, and a double current of air is pro- 
 duced ; one current descending and pressing upon the ether, 
 forcing it along the inner tube, and the other ascending 
 through the outer tube, and playing upon the column of 
 ether as it passes from the inner tube. The ether which is 
 used in England for producing local anaesthesia is a mixture 
 of amyl hydrate and anhydrous ether; it has a low boiling 
 point and specific gravity, and is dangerous when inhaled. 
 The best form of ether to employ for local anaesthesia is Dr. 
 Squibbs' anhydrous, which is almost free from alcohol and 
 water, and gives the best results. 
 
 EXTRACT OF EUCALYPTUS. 
 
 This agent is recommended as a local anaesthetic in dental 
 operations and toothache. Apply one drop on cotton to the 
 sensitive dentine just before excavating for filling.* 
 
 MORPHIA. 
 
 When sulphate of morphia is applied to the skin, even in 
 the solution of three or four grains to the drachm, it has but 
 little effect in relieving pain ; but if the cuticle is removed, 
 
 * Boston Medical and Surgical Journal. 
 
HYPODERMIC ADMINISTRATION OF MORPHIA. 273 
 
 it then may be dusted over the surface with much better 
 result. 
 
 Professor Konig says that he has combined the hypoder- 
 mic administration of morphia with chloroform in a large 
 number of cases with favorable results. It is seldom neces- 
 sary to give more than from one-sixth to one- third of a 
 grain. 
 
 If a solution of sulphate of morphia, one grain to the 
 drachm of water, be made, and one-fourth injected by a 
 hypodermic syringe, under a part to be operated upon, it 
 will produce local anaesthesia. 
 
274 ARTIFICIAL ANAESTHESIA. 
 
 CHAPTER X. 
 
 The legal responsibility of physicians in the administration of anaes- 
 thetics. Medico-legal relations of anesthetics. Case in Philadel- 
 phia of a surgeon dentist. The important question whether chloro- 
 form can be administered for criminal purposes? Cases in France, 
 England, and the United States. Dr. N. L. Folsom, R. M. Denig. 
 Chloroform as a poison. Experiments of A. Martin Ewald, Hitzig, 
 C. Bernard and Binz. Ethers; their action as poisons. Ether 
 intoxication. 
 
 ON THE LEGAL RESPONSIBILITY OF PHY- 
 SICIANS IN THE ADMINISTRATION OF 
 ANAESTHETICS. 
 
 It is a noted fact that when anaesthetics are trusted in 
 the hands of an educated and careful surgeon, the mortality 
 from their use is reduced to the minimum. The individual 
 who administers the anaesthetic should have nothing else 
 to do; his hands, eyes and mind should be on this alone. 
 In our hospitals clinical assistants should be instructed in 
 the chemical, physiological and toxicological nature of an- 
 aesthetic agents, and after being thoroughly trained in their 
 use and in the means of resuscitation, receive a certificate of 
 competency. It is too often the case that valuable lives are 
 placed, as it were, in the hands of young men who have no 
 proper knowledge of their use, and who do not appreciate 
 the great responsibility under which they are laboring. 
 Such a powerful agent as chloroform or its compounds 
 should be handled with skill, judgment and discretion, 
 fully realizing that on the exercise of these depends the life 
 of the patient. There is no doubt that many deaths have 
 been caused through the want of this proper knowledge and 
 experience. Who is at fault in this? It is, as a rule, the fault 
 of the operating surgeon, who, in a general way, considers 
 this as a secondary matter, and trusts the anaesthetic to any 
 person who may be with him. To the experienced eye 
 signs of danger are almost always evident, the disturbed, ster- 
 torous or shallow respiration, the pulse, the pallid or leaden 
 hue of the skin, the fluttering heart. 
 
ANAESTHETICS CONSIDERED MEDICO-LEGALLY. 275 
 
 We repeat it, that a physician or a surgeon in administering 
 chloroform or its compounds, is responsible for the life of 
 the patient, and it would be well for some of them if a law 
 were enacted compelling them to employ the least fatal 
 anaesthetic, unless some idiosyncrasy on the part of the 
 patient did not allow of the use of such an agent, or one less 
 dangerous. Again, in our navy, especially on board steam- 
 ers, and in countries where the average temperature is 80° 
 F. or over, chloroform might be allowed, but in the army, 
 as well as in the navy, only in capital or very painful or 
 extensive operations, this exception being enforced by a rule. 
 
 As well observed by Professor Hamilton,* of New York : — 
 "The very annihilation of sensation itself impairs the 
 health of the organs of the body ; he had no question about 
 it, and often, during the administration of these agents, 
 nothing but God's providence prevents them from being 
 plunged into eternity. But, on the other hand, there are 
 many things to be said in favor of its use. The main lesson 
 to be learned is caution." 
 
 " Daniel S. Riddle, Esq., said, as regards the enactment 
 of further laws on this subject, it was not necessary. There 
 are sufficent laws already. The difficulty is in enforcing 
 them. If there is carelessness on the part of the doctor, 
 he should be held responsible. It is the same with lawyers. 
 It belongs to the profession of medicine to say whether 
 these agents have been carelessly used ; and if they have 
 been carelessly used, it is their duty to produce as well as 
 indicate the person who uses these great powers carelessly. 
 'If we lawyers,' he remarked facetiously, 'find out that 
 you are carelessly using these things, it is our duty to pitch 
 in.' 
 
 "Mr. Coroner Ellinger thought it would be a hard matter 
 to hold doctors responsible, because it is hard to state scien- 
 tifically where the responsibility can rest. It ought at 
 least to be shown that there was conscious negligence in the 
 performance of duty. The condition of the patient should 
 be taken into account, and that must be left to the discre- 
 tion and knowledge of the attending surgeon. He thought 
 
 * Journal of Nervous and Mental Diseases. Chicago, 111. Neuro- 
 logical correspondence. 
 
276 ARTIFICIAL ANESTHESIA. 
 
 that the medical student ought to be taught the danger of 
 the agent he employs, how and when to use it judiciously, 
 and he should be required to secure a certificate to the effect 
 that he has been so instructed before being let loose upon 
 the public. The public would then know that he possesses 
 a knowledge of the agent which he employs. Besides, the 
 physician would be conscious of a certain moral responsi- 
 bility, for he held that the moral responsibility which every 
 medical gentleman must feel is greater than the responsi- 
 bilities placed upon him by the laws of the land." 
 
 " Jacob F. Miller, Esq., agreed with those who advocated 
 care in the use of these agents. Man is living in the midst 
 of dangerous forces, and will continue to use them, though 
 of necessity many deaths occur. But in order to rest a case 
 against the user, it is necessary to show negligence. Negli- 
 gence is the gist of the action. The physician, surgeon, or 
 lawyer, contracts for the ordinary skill and care of his pro- 
 fession. He does not contract for any extraordinary skill. 
 The law does not hold him anymore responsible than that. 
 It would be unreasonable to do so, because few persons 
 could safely practice their profession ; and if any person 
 should use anaesthetics, and the patient should die, that is 
 not sufficient to charge him with the responsibility. He 
 thought that all would admit that if a man not having the 
 ordinary skill of his profession, should by unskillful admin- 
 istration of anaesthetics cause the death of the patient, he 
 should be prevented from doing further damage by a suit 
 for malpractice. Would it not be better to stop him by 
 such procedure ? Shall a man be allowed to use such dan- 
 gerous forces just as he pleases — let the consequences be 
 what they may ? People consult physicians because they 
 say they have the requisite skill to use these things. They 
 hold themselves out to the community as having this skill, 
 and they ought to possess it ; if they do not, and harm re- 
 sults from it, they ought to be held responsible. The cor- 
 oner says that physicians are actuated by moral responsi- 
 bility, which is just no responsibility at all. The quack 
 will go on with his practices until he is stopped by the law. 
 Where is his moral responsibility? What does he care? 
 His practices only go to show that he has no moral respon- 
 sibility. That lawyers should check such practices is due 
 
ANAESTHETICS CONSIDERED MEDICO-LEGALLY. 277 
 
 to the profession, to the, public and to God. But before they 
 take a case of malpractice, they ought to be convinced that 
 there is malpractice. It may be all very well to say that 
 negligence is the gist of an action. If it cannot be shown 
 that there is negligence, the case should not be taken ; for 
 when the case arrives at the courts, you must show that the 
 defendant is guilty of neglect, and that is done by calling 
 upon a physician who is able to say where negligence has 
 been committed, and that he is guilty of it. This evidence 
 is necessary ; lawyers cannot get along without it." 
 
 " Mr. Max F. Eller spoke of the fact that, for any action, 
 as many ' experts ■ could be obtained by one side as the other, 
 provided enough money is paid for such expert testimony. 
 Some will say the patient should have been notified of the 
 danger; others that he ought not. Some will say the 
 chloroform killed him ; others, not. For that reason he 
 thought that before making any more laws regarding the 
 proper administration of anaesthetics, those which already 
 exist should be administered in a better manner, and phy- 
 sicians should be a little more careful how they administer 
 anaesthetics. 
 
 11 Mr. Eller referred to the popular fallacy that chloroform 
 could be used successfully for the purpose of affecting rob- 
 bery. He thought that that delusion ought to be dispelled, 
 for the time between the actual administration of chloroform 
 and the period of annihilation of sensation is sufficiently 
 long to render the accomplishment of the object impossible. 
 Such a plea is used by criminals to shield themselves from 
 the consequences of their own crimes." 
 
 A correspondent of the Societe d J Hygiene et de Medicine 
 Legal, having been interrogated as a judicial expert as to 
 "whether the employment of narcotics in the liquid or 
 gaseous state can produce an anaesthesia so profound that 
 violation of the persons to whom it has been given may be 
 perpetrated without awakening them," gave an affirmative 
 answer. 
 
 M. Dolbeau, apropos to this judgment, made a series of 
 researches, the results of which were laid before the society 
 at a recent session. He limits the question to the employ- 
 ment of chloroform, and starts with the following proposi- 
 tion : — 
 
278 ARTIFICIAL ANAESTHESIA. 
 
 " Can chloroform in vapor be administered to a person 
 who is sleeping naturally, to the production of anaesthesia, 
 without awakening him?" 
 
 In M. Dolbeau's experiments the chloroform was given 
 in the usual manner, on a cone held an inch or so above the 
 nostrils, so as to enable a constant view of the countenance. 
 
 In the first series of experiments three patients out of four 
 were wakened by the chloroform inhalations ; in the second 
 series, four out of six ; in the third, only three out of nine. 
 
 It is not without interest to observe the increasing pro- 
 portion of subjects anaesthetized ; the manual dexterity ac- 
 quired by the experiments is not without influence upon 
 the results obtained. Accordingly, as a result of his experi- 
 ments, M. Dolbeau believes himself authorized to formulate 
 the following conclusions : — 
 
 Scientifically, it is difficult, but often possible, to cause in- 
 sensibility by means of chloroform in persons who are 
 sleeping a natural sleep. Certain precautions — the employ- 
 ment of a perfectly pure agent and experience — are also 
 conditions which favor the attempt at anaesthesia. 
 
 It is probable that certain subjects are absolutely refrac- 
 tory — that is to say, that it is impossible to anaesthetize them 
 without taking every precaution. Others, on the contrary, 
 particularly young children, submit easily to anaesthesia, 
 without having been awakened by the irritation produced 
 by the anaesthetic agent in the air passages. 
 
 From a criminal point of view, it is certain that chloro- 
 form, administered to sleeping individuals, may facilitate 
 the perpetration of certain crimes. It is, however, prob- 
 able that the conditions favorable to anaesthesia are rarely 
 found on the occasion of criminal attempts. Injustice, the 
 expert should declare that it is possible, but not easy, to 
 render a person who sleeps, so insensible, by chloroform 
 that the said person might become the victim of any vio- 
 lence. — La Tribune Medicale, No. 323, 1874. 
 
 The responsibility attending the use of anaesthetics is of 
 great importance to medical men, as frequently their per- 
 sonal and professional reputation is at stake; it is therefore 
 always better in the administration of an anaesthetic to a 
 female to have some reliable person present. This is 
 especially necessary when ether or chloroform is employed. 
 
THE CRIMINAL USE OF ANAESTHETICS. 279 
 
 During the early period of my medical career, soon after 
 graduating, I had in my Quiz class a young ambitious 
 dental surgeon, one of the most gentle and amiable of men, 
 who was desirous of obtaining the medical degree, which 
 he ultimately attained. Soon after this the man was mar- 
 ried, and settled in this city, and acquired a large business. 
 At that time it was common for the dentist to administer 
 the anaesthetics in their office, in the extracting of teeth, 
 etc. He had a young female patient to whom he adminis- 
 tered chloroform alone, and who afterwards stated that he 
 had taken improper liberties with her person during this 
 state. This case caused great excitement in our city, and 
 the public sympathy was with the young female, and a suit 
 was instituted in which damages were claimed. The case 
 was argued by distinguished lawyers on both sides, and vo- 
 luminous testimony taken. The judge charged the jury, 
 and the sentence was ten years' imprisonment. Subse- 
 quently the sentiment of the community changed, and it 
 believed that it was all the result of her vivid imagination, 
 and that she was laboring under a delusion. The majority 
 of physicians and dentists signed a petition, and the sen- 
 tence was remitted, but his professional prospects were 
 ruined. 
 
 It is stated by Taylor,* "That the vapors of ether and 
 chloroform have been criminally used in attempt at rape. 
 In a case which occurred in France, a dentist was convicted 
 of this crime upon a woman to whom he had administered 
 the vapor of ether." JSfow this may be just such a case as 
 the one in our own city. Ether, from its disagreeable taste 
 and irritating vapor, would be much more difficult to ad- 
 minister forcibly and against the will of a patient. The 
 numerous stories of anaesthesia by simply placing a few 
 drops on a handkerchief under the patient's nose or mouth, 
 are in the majority of cases perfectly absurd, as the shortest 
 time required to bring a patient fully under the influence 
 of either of these drugs, even when forcibly held in contact, 
 is from two to ten minutes, and if subsequent rough hand- 
 ling takes place the patient is at once roused up to make re- 
 
 * Taylor's Medical Jurisprudence, English edition, London, I860, p. 
 1006. 
 
280 ARTIFICIAL ANAESTHESIA. 
 
 sistance by struggling. We were once called to a woman 
 who had been in the habit of employing chloroform by in- 
 halation from a small bottle to cause sleep ; she accidentally 
 when in a drowsy state let the open bottle drop on the pil- 
 low, and its contents saturated the covering, and she with 
 her face in it. But instead of making her sleep soundly, it 
 produced most distressing nausea, and her family were 
 awakened by her efforts at vomiting, and so her life was 
 saved, she not being able to arouse sufficiently to get rid of 
 the offending matter, and which would have lodged in her 
 trachea, or the contents of the stomach might have been 
 brought into the bronchial tubes by a deep inspiration, and 
 thus have caused suffocation. 
 
 The former case in Philadelphia settled the important 
 point in the minds of medical men of this city that this in- 
 complete unconsciousness does not coexist with complete 
 motor and sensory anaesthesia, and therefore anaesthetics 
 are employed without any fear in all important operations. 
 These observations are in part corroborated by two learned 
 authors in a recent and most admirable work* on medical 
 jurisprudence, in which they state: — 
 
 "A question of some importance to the medical jurist 
 naturally occurs here, namely, ' Whether chloroform can be 
 administered for improper purposes f ' We know, however, 
 that comparatively, the insensibility from chloroform (and 
 more slowly from ether) vapor is only slowly induced. It 
 would be difficult, therefore, to administer chloroform forci- 
 bly and against the will, while, of course, the stories of im- 
 mediate anaesthesia produced by it are but idle fables. Still, 
 it might be administered to persons asleep without much 
 difficulty {Lancet, October 5th, 1872, p. 514, and October 12th, 
 1872, p. 549), and this seems the only possible condition 
 under which it could be conveniently used for improper 
 purposes, unless considerable force was employed to prevent 
 the person struggling, which, under ordinary circumstances, 
 would be an almost insurmountable difficulty to its use." 
 
 The following case (reported in the Philadelphia Medical 
 Times, December 22d, 1877), which quite lately occurred in 
 
 * Forensic Medicine and Toxicology. By W". Bathhurst Wood, M« 
 D., F.R.C.P., and Charles Maymott Tidy, M.B., F.C.S. Lindsay & 
 Blakiston, 1877, p. 457. 
 
CRIMINAL USE OF CHLOROFORM. 281 
 
 England, more completely confirms our own observations 
 and experiments on this important subject: — 
 
 "A case of the utmost importance to the whole profession, 
 not in Great Britain only, but everywhere, was tried before 
 Mr. Justice Hawkins, at the assizes at Northampton, on the 
 9th of November. It was a charge against a surgeon's 
 assistant of criminal assault — of rape upon a patient when 
 under the influence of chloroform. If there is a dastardly 
 crime, it is to take advantage of a woman's helpless uncon- 
 sciousness to violate her person. And so 'the magistrate 
 thought, who sent the accused to jail on the 14th of Septem- 
 ber, declining to hear anything in his favor, and resolutely 
 refusing to accept bail. The charge was that a married 
 woman, named Child, went to the surgery of her family 
 medical attendant to have her teeth operated upon. She 
 had been there a day or two before, but the attempt to put 
 her under chloroform then failed. A second attempt was 
 rather more successful. She evidently had some peculiari- 
 ties or idiosyncrasies in relation to chloroform, for he gave 
 it for an hour and yet she was never sufficiently under its 
 influence to admit of the operation being performed. She 
 was accompanied by a friend — a Miss Fellows. At the end 
 of the hour Miss Fellows went out of the room and saw Mr. 
 Child. In a quarter of an hour Miss Fellows returned. 
 The prosecutor maintained that on Miss Fellow's return she 
 was quite conscious, but unable- to speak. Finding it im- 
 possible to perform the operation, the accused accompanied 
 the prosecutrix and her friend home. So far Mrs. Child 
 had been unable to speak, but shortly after the accused left 
 the house she complained to her husband that he had taken 
 advantage of the absence of Miss Fellows to assault her 
 criminally. Next day, when the accused called, he was 
 told about what she had said, and he replied that she was 
 laboring under a delusion. Under cross-examination Mrs. 
 Child said that she told the accused that if he would admit 
 the offence and quit the town (Birmingham) she would for- 
 give him. This the accused declined to do, denying that he 
 had committed any offence. He was then given in custody. 
 The prosecutrix stated that the offence was perpetrated im- 
 mediately after Miss Fellows left the room ; that the prisoner 
 went upon his knees and then assaulted her. Miss Fellows 
 
282 ARTIFICIAL ANAESTHESIA. 
 
 stated that on her return she found Mrs. Child in precisely 
 the same position in the chair which she occupied when 
 she went out of the room. Such were the facts of the case. 
 It was quite clear that there had been either an assault com- 
 mitted, or that the woman was under the influence of a very 
 pronounced delusion. The whole of the accused's conduct 
 was in favor of the latter hypothesis. But in such a matter, 
 where no third person was present, the statement of one of 
 the two parties concerned must be taken. When a woman 
 whose character was apparently without blemish (for in 
 cross-examination no attempt was made to call her reputa- 
 tion in question) makes a definite charge against a man of 
 assaulting her under circumstances which permitted of such 
 an assault, the law could only send the case to a jury. In 
 the meantime the unfortunate surgeon's assistant was sent 
 to prison. 
 
 "When the case came to be tried a large number of medical 
 men of repute came forward voluntarily to aid the accused's 
 defence, and did this quite gratuitously. The chief witness 
 for the defence was Dr. B. W. Richardson, F.R.S., whose 
 celebrity is world-wide. As is well known, Dr. Richardson 
 has studied anaesthetics very carefully and for many years. 
 He stated that there were four stages or degrees in which 
 chloroform operated. The first stage was that in which 
 consciousness was not lost ; there was resistance and a desire 
 for air. In the second, consciousness is lost, but the opera- 
 tion is impossible, the patient screaming, often without 
 provocation. The third stage is that of complete uncon- 
 sciousness, and where all rigidity is lost. This is the stage 
 which permits of operation. In his opinion the patient was 
 in the second stage ; the third never having been reached. 
 He stated that in his own experience he had known persons 
 in this second stage to have delusions as to what had taken 
 place during that time. He related a number of cases, and 
 stated that the fact of such delusions being induced by 
 chloroform was one of the earliest Objections raised to its 
 adoption. He related one case where the patient, a female r 
 was being operated upon by a dentist, and alleged that the 
 dentist criminally assaulted her. And this she persisted in, 
 though her father, her mother, Dr. Richardson, and the 
 ientist's assistant were all present throughout the whole 
 
SUPPOSED CRIMINAL USE OF CHLOROFORM. 283 
 
 time. She persisted in her conviction long after the effects 
 of the chloroform had passed away; and Dr. Richardson 
 said she was probably of that belief still. This evidence of 
 Dr. Richardson's was corroborated by the experience of Dr. 
 Hawksby, of London, and by Dr. Saimdby and Mr. J. F. 
 West, of Birmingham. The judge asked the jury if it was 
 necessary to sum up, and they replied it was unnecessary — 
 they were already agreed upon a verdict of acquittal. Mr. 
 Justice Hawkins pointed out that such a verdict would not 
 be the slightest imputation upon the absolute sincerity of 
 the prosecutrix, who, no doubt, firmly believed every word 
 of what she had said. He then congratulated the accused 
 upon having had an opportunity of fully vindicating him- 
 self from the charge preferred, and said that the verdict 
 of acquital did not mean that there was insufficient evidence, 
 but that the accused was entirely cleared of any imputation 
 in respect to the charge preferred against him. There could 
 be no doubt the prosecutrix labored under a delusion. The 
 accused was then discharged from custody, having been in 
 prison two months for no offence. It is not merely that this 
 unfortunate man was imprisoned for two months for an 
 imaginary offence, but that any man who is present when 
 a woman is being put under chloroform is liable to have the 
 same charge brought against him, that gives this case its 
 gravity and importance. 
 
 "Such being the case, it becomes necessary that a little 
 more should be known amidst the profession, as well as 
 the laity, as to the occurrence of erotic sensations in woman. 
 The subject is not a very pleasant one, but that is no reason 
 why it should not be investigated. If it is a fact, and there 
 is no doubt about this, that women when being put under 
 chloroform are liable to those erotic sensations which they 
 experience from sexual intercourse, the sooner the fact is 
 generally known the better. It is just the mystery which 
 surrounds such facts that permits such a monstrous hard- 
 ship as that mentioned above to be a possibility at all. Of 
 course it is obvious enough to any one that it is a delicate 
 matter to inquire into the subjective sensations of women. 
 But if these subjective sensations take the practical form of a 
 charge of rape, two months in jail, and a trial by jury, they 
 pass from the domain of sentiment and enter that of stern 
 
284 ARTIFICIAL ANAESTHESIA. 
 
 reality. Few, comparatively few, of the profession seem to 
 be aware that women are subject to conditions and sensations 
 identical with those associated with the sexual act, which 
 arise quite subjectively and without any extrinsic stimulus. 
 The delusion of St. Catharine that the devil visited her 
 every night and enjoyed her person when she was asleep 
 and could offer no resistance, is no unique experience, but 
 one common enough to woman. Every one familiar with 
 asylum work knows that a certain percentage of women 
 patients have the delusion, among others, that the medical 
 superintendent comes nightly to their bed and violates their 
 person during sleep. Of course there is no foundation of 
 any kind for such a delusion, except the subjective sensations 
 of the woman herself. How strongly such a delusion, how- 
 ever, may be fixed in a woman's mind is evidenced by the 
 case related by Dr. Richardson, where the woman persisted 
 in her belief though her own father and mother, as well as 
 others, were present, and where such assault was physically 
 impossible. Such being the case, it behooves every man 
 who is to be present with a woman when she is to be placed 
 under chloroform to see that there is at least one other per- 
 son present, and that, too, the whole time, without inter- 
 mission, during which the woman is under the influence of 
 chloroform, and that such other precautions be taken as will 
 preclude the possibility of such a charge being raised. That 
 Mrs. Child charged this unlucky man in good faith need 
 not be questioned for a moment. She was far from being 
 hostile to him, for she offered if he would avow his guilt 
 and leave the town she would forgive him. The charge was 
 not pressed from any rancorous spite; that is abundantly 
 clear. But it is equally clear that something had occurred 
 to that woman which she interpreted into the sexual act, 
 and that this was so firmly fixed in her consciousness, that 
 it could not be dislodged. It becomes necessary then that 
 the subjective sensations of woman should be investigated, 
 and made the subject of scientific observations ; and seeing 
 that they exist, they must have a scientific value ; and that no 
 prudishness should prevent attempts being made to ascertain 
 what the actual facts are, and what is 'their interpretation." 
 The following is the experience of Dr. N. L. Folsom, of 
 Portsmouth, New Hampshire, in the same line :— 
 
MEDICO-LEGAL RELATIONS OF CHLOROFORM. 285 
 
 "In 1854a clergyman's sister came to my office for the 
 purpose of taking ether and having a tooth extracted, and 
 brought her brother's wife with her. I began to administer 
 the ether to the patient, and whilst renewing it she got 
 away from me, and seemed alarmed and offended. I did 
 not attempt to compel her to breathe any more ether, but 
 urged her to take it, and so also did her brother's wife, but 
 she would take no more. She had the impression, so her 
 brother told me, that I attempted to violate her, and that 
 his wife assisted me. It was a long time afterward before 
 she would fully give up that she was mistaken in the mat- 
 ter."* 
 
 We are almost certain, after a number of careful experi- 
 ments, that chloroform and ether can be administered in 
 sleep, so as to produce the first stage of anaesthesia, and can 
 be carried to full completion or total unconsciousness. Still 
 this is rare without disturbing the patient's stomach, caus- 
 ing nausea, or irritation of the lungs, with risk of sudden 
 death, by its dense vapor, and thus rousing him or her to 
 consciousness, or a condition in which the patient can resist 
 its influence if the party is willing to make the effort. An- 
 other important point is that loud talking or handling, even 
 in some cases the slightest touch or pain in any way, will 
 cause the patient to start and rouse him to resist. In the 
 case of ether the patient can almost always see indistinctly, 
 and in some instances is able to talk during the anaesthetic 
 state. 
 
 Dr. R. M. Denig,f of Columbus, Ohio, in an article on the 
 Medico-legal Relations of Chloroform, propounds the fol- 
 lowing queries : — 
 
 "1. Can they be administered successfully to persons 
 during natural sleep without awakening them? 
 
 "2. Can they be forcibly administered for criminal pur- 
 poses in opposition to the will of the person to whom they are 
 given? 
 
 " 3. Can a person give competent testimony as to what 
 occurred during the anaesthetic state?" 
 
 His general conclusions are, that it cannot be used suc- 
 cessfully for felonious purposes, and that a person in the 
 
 * Medical and Surgical Reporter, January 12, 1877. 
 T Ohio Medical Recorder, January, 1877. 
 
 18 
 
286 ARTIFICIAL ANESTHESIA. 
 
 anaesthetic state is not a competent witness. He gives the 
 following example : — 
 
 " Most of you are cognizant of a transaction which took 
 place in our city a few years since, and which for a time 
 produced the wildest consternation. Two employes in the 
 service of an express company were said to have been chlo- 
 roformed during sleep, the keys to the safe abstracted from 
 their pockets, and the safes robbed of their valuable con- 
 tents. A sponge which bore the decaying fumes of chlo- 
 roform was found near the head of one of the messengers, 
 etc. The whole thing was well gotten -up, and was calcu- 
 lated to deceive even the most incredulous, and excite a 
 sympathy in behalf of persons who had not only been 
 robbed, but nearly strangled. In less than a week, how- 
 ever, the possession of large sums of money led to the ar- 
 rest of the supposed chloroformed individuals, and to their 
 incarceration in the Ohio State prison." 
 
 SOME PHENOMENA OF ANAESTHESIA BY PRO- 
 TOXIDE OF NITROGEN. 
 Mr. F. W. Braine, in a paper on this subject {British 
 Medical Journal, January 23d, 1869), observes: "It is curi- 
 ous to remark how often, as unconsciousness comes on, the 
 ruling idea is one of noise and motion combined. Some 
 patients think they are seated in, or running after, an omni- 
 bus, but many more imagine themselves in a railway car- 
 riage, traveling faster and faster, till they suddenly seem 
 to enter a dark tunnel, and then all is a blank to them. 
 Sensual emotions are not unfrequently excited in both 
 sexes. A man who had been married about three months 
 stated, on awakening, that he had been dreaming of his 
 wife ; and an unmarried hysterical girl certainly gave evi- 
 dence, by her movements, that she was quite aware of one 
 of the duties of married life ; and moreover, in this case, 
 the idea was still present when she was able to speak, for 
 she addressed the administrator in terms far fonder than the 
 occasion warranted, while another girl, who had behaved in 
 a similar manner, said, ' I hope I have not said anything 
 naughty.' Both of these cases brought forcibly to one's 
 recollection many trumped-up cases of felonious assault, 
 and how extremely inadvisable it is to have recourse to an- 
 aesthesia without a third person being in the room." 
 
MEDICO-LEGAL RELATIONS OF NITROUS OXIDE. 287 
 
 " At a recent meeting of the Odontological Society, it was 
 stated that the nitrous oxide had been administered in a 
 few cases of pregnancy, but delivery not having at that 
 time taken place in any one of these cases, the condition of 
 the foetus in utero was unknown. A lady, one of the above 
 cases, whom I put fully under the influence of the gas 
 twice during the eighth month, has just been confined with 
 a fine healthy boy ; so that, in this case at least, the gas 
 cannot have interfered with the nutrition of the child, for 
 it weighed at birth eleven pounds and a half. 
 
 11 When administered to a girl, aged nineteen, with cavi- 
 ties in the apices of both lungs, the patient was insensible 
 at the end of forty-five seconds. The respiration suddenly 
 became very shallow and panting, while instead of the rosy 
 hue which generally appears over the face and lips on the 
 removal of the face-piece, the lips and face became more 
 dusky before the red tint appeared ; the pulse was not 
 affected, but the respiration, for more than half an hour 
 afterwards, was very shallow and hurried." 
 
 CHLOROFORM— ITS ACTION AS A POISON. 
 
 Chloroform is an irritating poison. In a case quoted 
 by Taylor,* an individual swallowed four ounces. He was 
 able to walk a considerable distance after taking this large 
 dose, but subsequently fell into a state of coma. The pupils 
 were dilated, the breathing was stertorous, the skin cold, 
 pulse imperceptible, and there was general convulsions. 
 He recovered in five days. {Medical Gazette, vol. 47, page 
 675.) A second case reported swallowed nearly two ounces 
 and recovered ; and a third swallowed two ounces, but he 
 died in six hours afterwards. In this case the pupils were 
 fully dilated, the breathing was stertorous, and the skin 
 covered with a cold perspiration. On inspection, the lungs 
 were found much engorged with blood, and there were 
 some apoplectic effusions in these organs. The stomach 
 was slightly inflamed in patches, and the mucous mem- 
 brane was softened. {American Journal Medical Sciences, 
 October, 1866, page 571.) A physician set. 57, swallowed 
 three ounces of chloroform. He immediately began to 
 
 * On Poisons, Philadelphia, 1875, page 618. 
 
288 ARTIFICIAL ANESTHESIA. 
 
 stagger, as if intoxicated. He vomited and sunk into a 
 deep stupor, and was in a state of complete anaesthesia. 
 His skin was pale and tolerably warm ; the muscles were 
 relaxed, the breathing short, and the action of the heart 
 weak and intermittent. In about fourteen hours sensibility 
 returned. Acute gastritis ensued, with rapid collapse, and 
 proved fatal in twenty-nine hours from the time the chloro- 
 form was taken. {American Journal Medical Science, Jan- 
 uary, 1870, page 276.) 
 
 Treatment. — In poisoning from liquid chloroform, the 
 stomach pump and emetic should be resorted to. If evi- 
 dence of suspension of the action of the heart (syncope) ex- 
 ists, there should be a free exposure of the face to a current 
 of air, compression of the chest and artificial respiration, 
 with warm applications to the chest, with active friction 
 and stimuli externally and by the rectum. The poles of a 
 galvanic battery applied to the chest and side of the neck 
 with sponges dipped in hot water should be used. Spirit of 
 ammonia aromata has been found useful when injected 
 hypodermically, and strychnia in the same way, to act upon 
 the respiration. This must be given in minute doses, and 
 great care must be given to the gastritis and disturbance of 
 the liver, which are apt to follow in the convalescence of the 
 patient. 
 
 ETHERS ADMINISTERED INTERNALLY. 
 
 Ethers as a class are poisons, and if taken into the 
 stomach in very large quantities will produce death. Still 
 they can be employed for a long period without dangerous 
 action on the heart and respiration. The habitual use of 
 ether ruins the digestion and causes chronic disturbance of 
 the nervous sj^stem (see cases subsequently reported), and 
 this has been confirmed by E. Martin Ewald, of Berlin. 
 
 In dogs, whose brains are exposed, the vigorous inhala- 
 tion of ether soon renders that organ completely insensible 
 to the electrical current. (Hitzig.) 
 
 After introducing ether into a dog's stomach, Claude Ber- 
 nard observed an immediate secretion of a large quantity 
 of pancreatic juice. There was vascular congestion of the 
 intestine, and its secretions became more abundant, while 
 absorption was accelerated. The chyle vessels were strongly 
 
INFLUENCE OF ETHERS ON DIGESTION. 289 
 
 injected, which must be explained by the abundance of 
 pancreatic juice present in the bowel (Binz), when fat in 
 fine subdivision is introduced, and the consequently in- 
 creased facility with which it could be absorbed. 
 
 If the blood be examined (Binz) after twenty drops of 
 ether have been taken, the colorless corpuscles in it are 
 found to be twice as numerous as usual. It is probable that 
 here also ether has a direct action on the abdominal glands, 
 and especially the spleen. 
 
 ETHER INTOXICATION. 
 
 "A few years ago there was published in the Reporter* 
 the ' confessions of an ether inhaler,' a member of our own 
 profession, for whom it subsequently became our sad duty 
 to sign a certificate of insanity. 
 
 "We are reminded of this by a paper in the London Med- 
 ical Record, by Dr. Ewald, of Berlin, on a somewhat sim- 
 ilar case. It is that of a man aged thirty-two, who was 
 lately admitted into the Charite Hospital, under Professor 
 Frerichs, suffering from general debility and trembling of 
 the muscles. On inquiry, it was found that he was notori- 
 ous in Berlin for intoxicating himself with ether, his abuse 
 of which had reduced him to his present miserable condi- 
 tion. He was originally temperate, and had been a univer- 
 sity student, passing all his examiuations with credit; he 
 was, however, of a mystical turn of mind. Unfortunately, 
 a little more than nine years ago, there fell into his hands a 
 medico-popular treatise, in which the use and effects of 
 ether, used medicinally, were described, and a glowing ac- 
 count was given of its effect in quickening the creative 
 power of the mind. He procured about two or two and a 
 half ounces of sulphuric ether, and inhaled it from a hand- 
 kerchief; the result being to produce insensibility for about 
 a quarter of an hour, during which time he imagined that 
 he lived for an indefinite time, and traveled over whole 
 worlds. This condition, however, he was not again able to 
 induce in so high a degree. Becoming gradually more and 
 more addicted to his habit, he no longer confined himself 
 to indulging himself in his own room, but with his ether- 
 ized handkerchief before his face, he wandered through the 
 
 * Medical and Surgical Reporter. 
 
290 ARTIFICIAL ANESTHESIA. 
 
 streets, purchasing small quantities of ether at the druggists' 
 shops, until, at last, he became, so great a nuisance to them 
 that many of them closed their doors against him. He was 
 also turned out of his lodgings, on account of the annoyance 
 produced by the smell of his breath, and became a houseless 
 wanderer, reduced in means and in health. In the hospital 
 there was no indication that his mind was affected; his 
 memory was not impaired ; his style of speaking was fluent. 
 On one occasion an attempt was made to produce complete 
 anaesthesia. For this purpose more than seven ounces were 
 required; the ether being given by an inhaler, and loss 
 being prevented by closing in the apparatus with cotton- 
 wool. No sooner, however, was the inhalation stopped, 
 than the state of insensibility passed off. He was then 
 allowed to take the ether in his own way, by inhaling it 
 from a handkerchief. Given in this way, it produced a 
 stage of excitement, during which he danced about the 
 room, talked nonsense, and appeared much pleased, but 
 there was no true narcotism. It was not thought justifiable 
 to subject him to other experiments with ether, as it was 
 desirable to break through his habit. It is interesting, that 
 his susceptibility to the action of cannabis indica was not 
 impaired. This drug was given as a substitute for ether, 
 and on the first occasion, too large a dose having been given, 
 the result was the production of phantasms, such as are in- 
 duced by the smoking of hasheesh." 
 
 The late Dr. Morgan, of Dublin, states that ether is em- 
 ployed in certain portions of' Ireland as a substitute for 
 whiskey. 
 
 A case has come under the writer's notice in which a pa- 
 tient began the use of sulphuric ether in teaspoonful doses, 
 as a nervine ordered by a physician, and ultimately in- 
 creased the dose to one pint per day. When informed of its 
 injurious character, she had lost her appetite, and suffered 
 gastric disturbance ; she gradually diminished the quantity 
 and was able to give it up after a month or two. The only 
 effect it had upon her was to give her apparent strength to 
 go on with her teaching of music. Large quantities of 
 ether have been taken internally, and, so far as we have 
 been able to learn, no death has yet occurred from its use in 
 this way. 
 
ALCOHOLIC PREPARATIONS. 291 
 
 CHAPTER XL 
 
 GENERAL CONCLUSIONS. 
 Alcohol preparations. Treatment of poisoning by Ether. Inhalation 
 and internal administration. Precautions in its inhalation. Bi- 
 chloride of Methylene. Hydrobromic ether; use and new mode of 
 preparation; conclusions. Ethidene dichloride. Oxygen, hydro- 
 gen, and nitrogen gases. Dr. Gray's experiments with oxygen gas. 
 On the use of anesthetics, especially Chloroform, in dental opera- 
 tions. Treatment of chloroform poisoning. Chloroform and Chloral 
 in poisoning by Strychnia. On the choice of anaesthetics. Another 
 death from Chloroform. Bibliographical list of papers and works 
 on anaesthetics. The Metric system. 
 
 ALCOHOL-SPIRIT OF THE SPECIFIC 
 GRAVITY 0.835, U. S. 
 
 OFFICINAL PREPARATIONS, U. S. 
 
 Alcohol dilutum. — Diluted one-half with water. 
 
 Alcohol fortius. — Spirit of the specific gravity 0.817. 
 
 Spiritus vini gallici (brandy).— About fifty per cent, of 
 alcohol. 
 
 Spiritus frumenti (whiskey). — About fifty per cent, of 
 alcohol. 
 
 ANTIDOTES. 
 
 The treatment of poisoning by any form of alcohol, or its 
 compounds, is removing all the spirit from the stomach by 
 an emetic of mustard and hot water, or if the stomach will 
 not act employ stomach pump. Cold water or ice to the 
 head, strong coffee, stimulants, galvanic current, and arti- 
 ficial respiration. 
 
 POISONING FROM ALCOHOL. 
 
 In chronic alcoholic poisoning withdraw stimulants, and 
 substitute the following mixture, to be given about the time 
 of the strong craving for a drink. 
 
 9?. Potassii bromidum, 5ij. 
 Tinctura capsicum, fSss. 
 Syr. limonis. 
 
 Aqua menthse pip., aaSj.— M. 
 
 Sig.— A tablespoonful about twelve o'clock M. in water, with a 
 cracker. Abundance of good, rich, well-seasoned food, and the mix. 
 ture at bed time, to procure sleep. 
 
292 ARTIFICIAL ANESTHESIA. 
 
 ETHER. 
 
 OFFICINAL PREPARATIONS, U. S. 
 
 iEther. fortior. — Specific gravity 0.728 for inhalation and 
 internal administration. 
 Spiritus setheris compositus. Hoffmann's anodyne. 
 
 PRECAUTIONS. 
 
 Ether should never be inhaled after a full meal, not only 
 to avoid the annoyance of vomiting in the midst of the 
 operation, but also the danger of asphyxia by some of the 
 vomited matter dropping or running into the larynx and 
 trachea. If nourishment is necessary let it be of a liquid 
 character. Perfect quietude should exist around the patient. 
 Clothing should be perfectly loose so as to not interfere with 
 respiration. False teeth should always be laid aside. The 
 inflammability of ether should be remembered as well as the 
 density of its vapor (2.568), for this density, although insur- 
 ing comparative safety around a light, will cause it to ignite 
 if the light be even some distance under it. Examine and 
 record condition of the patient's heart and lungs, and in 
 suspicious cases all the organs. In holding a patient down 
 during the stage of excitability, do so firmly, at the same 
 time allowing the limbs as much freedom of motion as pos- 
 sible. Being held in a vice like grasp frightens the patient, 
 and has caused dislocation, and even fractures. 
 
 • DANGERS IN THE ADMINISTRATION OF ETHER. 
 
 Ether is not altogether free from danger, but it always 
 gives warning before it causes the death of the patient. The 
 ultimate effects of anaesthetics show that they are all depress- 
 ing agents. It will produce entire insensibility in all cases, 
 with little or no risk, if administered by a competent person. 
 The countenance should be watched, and the difficulty of 
 breathing promptly attended to. The moment the face as- 
 sumes a purple, dusky, or extremely pale hue, remove 
 the inhaling apparatus and admit fresh air. If not sufficient, 
 draw the tongue forward with a pair of artery forceps, or by 
 a towel wrapped around it, at the same time keeping the 
 mouth open by pressing on each side of the jaw with bent 
 thumb and index fingers, pressing the cheeks between the 
 te eth or gums. If the arrest of respiration be due to the pres- 
 
THE ADMINISTRATION OF ETHER. 293 
 
 once of vomited matter in the larynx, the head should be 
 turned quickly and lowered below the level of the table. This 
 precaution should always be taken when vomiting occurs. 
 If these means should fail, Marshall Hall's method of arti- 
 ficial respiration should be employed, or a small air-bag or 
 bellows with a nozzle might be used, inflating the lungs, 
 then withdrawing the instrument and pressing firmly but 
 steadily on the chest, this being repeated not more than 
 eighteen times per minute. An enema of equal parts of 
 brandy and luke-warrn water should be given at the same 
 time. A towel soaked in ice-water slapped two or three 
 times on the chest and face, will sometimes succeed where 
 other means have failed. 
 
 ADMINISTRATION. 
 
 An inhaler is made by folding a towel into a large cone 
 or bag, and then placing a large sponge in its apex. Ether 
 is then sprinkled upon it with a free hand, half an ounce or 
 more at a time, and repeated if necessary by renewing the 
 supply of ether. The lower part of the face, mouth, and 
 nose, is covered with the cone, so as to exclude most of the 
 air, and allow the patient to fill his lungs with more or less 
 diluted ether vapor, depending on the care with which the 
 cone is applied. There will be at the beginning of the in- 
 halation attempts to struggle, which are to be gently re- 
 strained. Quiescence gradually comes on, the patient pass- 
 ing into profound insensibility. If, however, the face be- 
 come very pale or livid, the inhaler should be set aside 
 until this condition disappears. The patient is considered 
 as ready for the operation when the arm, when raised, will 
 fall as if paralyzed, or when the orbicularis palpebrarum 
 muscle will not respond to irritation, or the conjunctival 
 surface of the eye can be touched with impunity. Early 
 stage of anaesthesia by ether pupils are contracted, but when 
 there is complete anaesthesia the pupils become dilated, and 
 the respiration is slow and deep. 
 
 If the operation is to be a prolonged one, when the patient 
 is fully under the influence of the anaesthetic, holding the 
 inhaler one-half inch or so from the patient's face will allow 
 enough air to reach the lungs to insure perfect safety, and 
 enough ether to hold him completely under its influence. 
 
294 ARTIFICIAL ANESTHESIA. 
 
 BICHLORIDE OF METHYLENE. 
 
 Introduced by Prof. Richardson in 1867. A colorless fluid, 
 having an odor much like that of chloroform. Pleasant 
 to inhale as a vapor, producing very little irritation of the 
 fauces and air passages. From its easier evaporation, it re- 
 quires freer administration than chloroform, and because of 
 its denser vapor, less quantity than ether. Six deaths have 
 occurred from its use. It has many of the dangerous quali- 
 ties of chloroform, and death results from syncope, with di- 
 lated pupils. 
 
 HYDROBROMIC ETHER. 
 
 This ether has been employed by me, and in several cases 
 with success, since my first report on page 79, and in the case 
 somewhat delayed (see Smith case) ; also a case of success- 
 ful removal of diseased toe-nail, by Dr. Drake of this city, 
 and a cyst of the hyoid bone, by Dr. S. W. Gross before 
 the class at Jefferson College Hospital. The ether was given 
 by myself and the pulse was under the care of Dr. Levis, 
 who kindly sent me the following letter in reference to it, 
 when I desired an expression of his opinion in regard to it. 
 
 "April 28th, 1879. 
 " My Dear Doctor:— My impressions of the hew anaes- 
 thetic were decidedly in its favor. The circulation was not 
 depressed, mental excitement did not occur, and respiration 
 continued to be normal. 
 
 11 1 would be much gratified with the opportunity of see- 
 ing more cases of its use. Where can I obtain a supply 
 of it? " Truly yours, 
 
 "R. J. LEVIS." 
 
 I find that hydrobromic ether exposed to the air and light 
 changes in color, becoming at first yellow, then yellowish- 
 brown. But this does not interfere with its anaesthetic 
 qualities, but produces a more aromatic or peppery taste ; it 
 should therefore be free from alcohol and water, and kept 
 from the light. Dr. Greene, before leaving for Paris, furnished 
 me with his method of preparation, which I have appended > 
 so that any careful pharmaceutist can make it : — 
 
 ' ' Coarsely powdered potassium bromide is heated with sul- 
 phuric acid, diluted with its volume of water in a flask or 
 retort, and when vapors of hydrobromic acid begin to be 
 
MODE OF PREPARING HYDROBROMIC ETHER. 295 
 
 disengaged, alcohol is allowed to flow in slowly, as in the 
 preparation of ether. Ethyl bromide distills over with water 
 and some alcohol. It is decanted, agitated with water to 
 remove alcohol, and dried with potassium carbonate. It 
 needs no other purification." 
 
 IDEOPATHIC POST-AURICULAR PERIOSTITIS, 
 OPERATION AND RELIEF UNDER HY- 
 DROBROMIC ETHER. 
 
 REPORTED BY W. D. FEIDDER. 
 
 In case No. 15 (page 76), before reported, it was necessary 
 to perform an operation, and the following notes were made 
 by Mr. D. W. Feidler, one of my assistants at Jefferson Col- 
 lege Hospital ear clinic. " The patient at No. X took gij of 
 hydrobromic ether by inhalation in the presence of Prof. 
 S. D. Gross, and the result was that the patient was only 
 drunk, and would not inhale properly (as observed Dr. 
 Gross, ' he was as stiff as a poker ' ) . The nurse then brought 
 a fresh supply, and by the use of gj he was fully under its 
 influence in forty seconds, when he was as limber as a rag. 
 Dr. Turnbull made a long incision down to the bone and 
 into the body of the sterno-cleido-mastoid muscle without 
 the slightest indication of pain, with very free hsemorr- 
 hage, but no pus and no roughness of the bone, but with 
 great relief to the patient's head and pulse. The temperature 
 being reduced from 102° to 99°. Patient fully recovered after 
 six weeks in the hospital." 
 
 Remarks by Dr. Turnbull. — This patient was in the same 
 condition as the one before referred to. (See page 28.) When 
 pure ether was administered by Dr. Allis, the patient con- 
 sumed eight ounces and was not relaxed, and the doctor 
 had to employ chloroform before I was able to perforate the 
 mastoid cells. 
 
 Conclusions in regard to hydrobromic ether as an anaes- 
 thetic in twenty-five cases, being an additional four cases 
 since my report on page 79. 
 
 Shortest time taken to place a patient Minutes. Seconds, 
 under its anaesthetic influence, . 40 
 
 Longest time, 6 40 
 
 Longest time under its influence, . 60 
 
 Largest quantity consumed, eight ounces. 
 
296 ARTIFICIAL ANESTHESIA. 
 
 With one patient out of the new cases there was vomiting, 
 as the patient had taken dinner before the operation. This 
 was the little girl operated on by Dr. Samuel W. Gross. 
 
 ETHIDENE DICHLORIDE. 
 
 The Scientific Grants Committee of the British Medical 
 Association have received from a special committee a re- 
 port, in which it is claimed that this anaesthetic presents all 
 the advantages of ether, without any of its disadvantages. 
 Mr. Thos. Bird, M. R. C. S. E., thinks it a good anaesthetic 
 for children. 
 
 OXYGEN 
 
 Is not a true anaesthetic. 
 
 OXYGEN, HYDROGEN AND NITROGEN. 
 It has been found that animals are capable of respiring 
 oxygen gas for a long period of time without other apparent 
 effect than increased liveliness and augmented appetite. 
 Oxygen gas, when respired by man, to the extent of twenty- 
 nine to thirty quarts, produces little effect. Any insensibil- 
 ity produced by the inhalation of nitrogen or hydrogen and 
 rarefied air, is due to deficiency of oxygen, of which as- 
 phyxia is the result ; or perhaps it may be produced by the 
 analgesic effect. \ 
 
 OXYGEN GAS AS AN ANAESTHETIC. 
 In the early part of this work (see page 83), I stated that 
 Dr. Gray, of Richmond, intended to continue his experi- 
 ments with oxygen gas,* and I now (June Sth) give his con- 
 clusions, which he has kindly sent me. After employing 
 it in six cases of teeth extraction, in none of which was 
 there profound anaesthesia, only its first stage, he states : — 
 " On both occasions the gentlemen present fully concurred 
 with me that oxygen gas is undoubtedly anaesthetic for two 
 or three minutes after withdrawal of the gas. It will be 
 noted that the drawing of the last teeth in all the patients 
 gave pain. That oxygen gas is not anaesthetic to the same 
 degree as nitrous oxide, we equally agree." 
 
 ON THE USE OF ANAESTHETICS, ESPECIALLY 
 CHLOROFORM, IN DENTAL OPERATIONS. 
 
 I have before me the proceedings of two dental associ- 
 
 * Published by Richmond, Va., Medical Monthly, June, 1879. 
 
CHLOROFORM IN DENTAL OPERATIONS. 297 
 
 ations, both containing as members, gentlemen of culture, 
 having a medical as well as a dental education, while there 
 were present to aid them medical men who had given the 
 subject of anaesthetics careful study, who had much experi- 
 ence, and had performed numerous experiments with the 
 various agents employed. 
 
 The president, in opening the discussion, at a meeting of 
 the British Odontological Society, stated, that the subject 
 for discussion was, " The use of Chloroform in Dental Oper- 
 ations,' ' and that it had been suggested by the editor of the 
 British Medical Journal, in commenting upon the death of 
 a child two years and a half old, in May, 1878, from the ef- 
 fects of chloroform administered to facilitate a dental oper- 
 ation. He concluded his remarks on the case with the 
 following query : Is it ever right to give chloroform for 
 dental purposes ? We wish the Odontological Society would 
 pronounce an authoritative opinion on the subject, and were 
 they to do so, absolutely forbid it." 
 
 After a full and free discussion, "the president said that 
 all who had spoken had agreed that the use of chloroform 
 in dental operations could not be absolutely forbidden, but 
 that it should be restricted to very exceptional cases. Mr. 
 Charles Tomes added some very practical suggestions ; 
 he said it should only be given at the patient's own house, 
 and with the patient in a recumbent position. His own 
 opinion was that a previous consultation with the medical 
 attendant of the patient was also desirable. He proposed 
 that the society should adopt these suggestions in the form 
 of a resolution, thus : — ' That it is the opinion of the society 
 that the use of chloroform in dental practice should be re- 
 stricted to very exceptional cases, that it should only be 
 given at the patient's own house, and with the patient in a 
 recumbent position, and that whenever circum stances will 
 admit of it, a previous consultation with a qualified medi- 
 cal practitioner is highly desirable. ' This resolution not hav- 
 ing been passed, the president said he would be sorry to urge 
 the society to come to a definite conclusion against their 
 inclinations. No doubt practitioners in London and other 
 large towns were more favorably situated as regarded the 
 facility of obtaining advice and assistance than were their 
 brethren in the country, and it was possible that an unfair 
 
298 ARTIFICIAL ANAESTHESIA. 
 
 use might occasionally be made of the resolution by the legal 
 profession. He would not, therefore, press it. It was the 
 less necessary since all the speakers had agreed that though 
 the use of chloroform might be occasionally justifiable, it 
 was very undesirable to use it in any case where the services 
 of other and safer anaesthetics could be made available, and 
 he felt sure that the strong conviction of the danger and re- 
 sponsibility attached to the use of chloroform which had 
 been expressed by some of the speakers would have great 
 influence with the profession." 
 
 Thus we see that the British Odontological Society would 
 not or could not pass an authoritative opinion on this all im- 
 portant question. We find the same disposition on the part 
 of an American society* to continue using chloroform in 
 dental operations, notwithstanding the dangers offered by 
 this agent. Its chairman, Dr. J. J. Caldwell, of Baltimore 
 (not a dentist), after preparing a careful report ending with 
 a list of the various anaesthetics, gives the following 
 opinion : — ' ' Of these, preference has been given to sulphuric 
 ether, chloroform, and nitrous oxide gas, both as regards 
 safety and efficiency. It is well to know which is the safest, 
 and, at the same time, the best for the purpose of the dentist. 
 This knowledge can only be obtained by experiments, and 
 experiments thus far have proven adverse to the use of chlo- 
 roform, ' ' 
 
 "Death at the hands of the dentist is, relatively speaking, 
 much more common than at the hands of the surgeon, when 
 chloroform is used. The explanation seems to be found in the 
 fact that anaemia of the brain is induced by the drug, which 
 assuredly depresses all the vital functions, and this anaemia 
 inducing syncope, is again reflected on the heart, inducing 
 paralysis of that organ ; then, with the two legs of the great 
 tripod of Bichat taken away, the catastrophe is precipitated. 
 Hence decubitus must be insisted upon." 
 
 Dr. Thompson, a distinguished dental surgeon, who is 
 chairman of the Committee on Anaesthetics of the society 
 for the years 1879-80, stated the following:— "In past years 
 when the subject of anaesthetics had been taken up, it seemed 
 to have fallen through of itself. It is a subject that should 
 
 * Maryland and District of Columbia Dental Association, Washing- 
 ton, D. C, October 8th, 1878. 
 
NITROUS OXIDE, AND ITS ANTIDOTE. 299 
 
 never be dropped without complete exhaustion. We are re- 
 miss in our duty if we allow it to go with anything short of ex- 
 haustion. The practice of anaesthesia is one that should com- 
 mand a great deal of study and caution. It has been stated 
 here to-day that we can do a great deal of injury to our patients 
 by not giving enough as well as by giving too much. That is 
 true. Timidity dulls perception, but boldness in the exhi- 
 bition of anaesthetics enables the operator to exercise more 
 caution. 
 
 " He who gives nitrous oxide indiscriminately runs a risk 
 of killing his patient at any time. In administering an an- 
 aesthetic we can have some indication of trouble, and this 
 must be recognized. We also know that from idiosyncrasy 
 often ensues failure. There are some diseases that must be 
 attended to previous to bringing to a condition of anaesthesia. 
 
 "A patient came to me claiming to be perfectly healthy, but 
 there was a lymphatic appearance that made me suspect 
 that all things were not right. The physician said, 'Go 
 on; it is all right.' We gave her gas, and the first few in- 
 spirations went on very nicely. Some more, and she 
 showed indications of serious heart trouble. I stopped the 
 gas and used the battery. She revived, but, after a little, 
 went off again, showing that it was not the gas that was the 
 sole cause. 
 
 "Now, relative to the restoration from anaesthetics, I have 
 found nitrite of amyl of extreme importance. I had a case 
 where the patient was given up as dead, when by the exhi- 
 bition of nitrite of amyl full resuscitation occurred." 
 
 Dr. Hodgkin says: — "A resume of the attitude of the pro- 
 fessions of medicine and dentistry on the subject of anaes- 
 thetics and their value and action may here be given, and 
 as dentists you are naturally so strongly interested in the 
 subject as to justify an expectation that this will be com- 
 plete, and yet it is a difficult thing to do ; for science, though 
 so exact, is yet variant in the enunciation of her dogmas 
 through her chosen apostles. The unanimity of division be- 
 tween the northern and southern sections of our land 
 on the relative dangers of ether and chloroform is well 
 known . The wave which seemingly threatened the destruc- 
 tion of the chloroformites was driven back by the accident 
 of the late Civil War, which proves that the large percent- 
 
300 ARTIFICIAL ANESTHESIA. 
 
 age of deaths at the hands of those using chloroform in civil 
 hospital cases, did not occur in the field and under average 
 war circumstances. The advocates of ether still cling to 
 that drug as the anaesthetic, claiming for it exemption from 
 fatal effects in all but foregone cases." 
 
 The report of the chairman was followed by a report of 
 the president, Dr. B. F. Coy, a well-known dental surgeon, 
 of Baltimore, which we are unable to give in full for want 
 of space, but which contains the following statement: — 
 "Nitrous oxide gas, especially the condensed gas in cylin- 
 ders, answers nearly all the purposes for the dental surgeon, 
 but tedious operations on the bones of the face require an 
 agent more durable in its effects; then use the best chloro- 
 form and no mixture with ether (p. 56)." Again, in con- 
 clusion, he states: — "An experience of over thirty years in 
 the use of anaesthetics without accident or serious untoward 
 symptoms, secures the right to speak warmly upon a sub- 
 ject that has given the human race the greatest blessing in 
 surgery, of which they have been the recipients in ancient 
 or modern times." In summing up the discussion in which 
 the writer took part, Dr. Coy states: — "I did not expect to 
 speak upon this subject, as it was well discussed. My ex- 
 perience with the condensed nitrous oxide gas has been very 
 satisfactory. I have never had a patient show any ill effects 
 from its use. I have given chloroform very often, and a 
 great many times the posture necessary was a sitting one. 
 I have sometimes found it necessary to throw my patient 
 back into a horizontal position. ... I have, of late, 
 made use of nitrite of amyl as a restorative in the use of 
 chloroform, and for establishing the action of the heart, when 
 becoming too much depressed, with good effects." 
 
 Now, in carefully sifting this evidence, what do we find? 
 First. — That chloroform is not absolutely necessary for 
 any or all the ordinary operations in dental surgery; except, 
 in a few tedious or rare instances, or where the actual cau- 
 tery is employed. This powerful and dangerous agent, 
 chloroform, should never be given unless a medical assistant 
 be present, and the following means at easy command : — 
 A bottle of nitrite of amyl, a portable galvanic or faradic 
 battery, liquor amnion, fort., ice, a pair of catch-forceps, and 
 an air-bag with nose-piece, to carefully inflate the lungs. It 
 
ANESTHETICS IN DENTAL SURGERY. 801 
 
 should never be given in the dental chair, but always in the 
 reclining position. Pure sulphuric ether has been since its 
 discovery, and is now, employed by the dental profession of 
 New York and Philadelphia in all operations in dental 
 surgery, without accident and with perfect satisfaction. 
 Mr. Charles Tomes, of London, reported that, in a visit 
 to a New York hospital, he had seen several cases of cleft 
 palate who were successfully operated upon under ether 
 and kept under its influence without impeding in the least 
 the movements of the operating surgeon. All danger from 
 bleeding was obviated by laying the patient on his side, so 
 that the blood could run into the cheek and out at the angle 
 of the mouth. After this evidence of what was possible, he 
 might be pardoned for thinking that the adaptation of ether 
 to dental requirements was merely a question of manage- 
 ment." 
 
 The following is the opinion of Dr. J. E. Garretson, ex- 
 pressed in a letter to the writer in 1878, on this important 
 subject; and there is no one in this city who has more 
 experience or better opportunities for testing the value of 
 the agents of which we write, in a class of operations the 
 most difficult to manage under anaesthetic impression. . 
 
 " I cannot doubt that the circulation of the book will be 
 large. Anaesthetics in surgical practice is a subject of the 
 greatest consequence. Let me express my gratification at 
 the special care with which you have presented the matter 
 of chloroform. While using chloroform more or less every 
 day out of sheer necessity, yet I am not less afraid of it than 
 had Faust occasion to be of his convenient agent Mephisto- 
 pheles. Certain it is I never allow myself to be caught 
 alone with it. What prayer was to the savant's devil, ether 
 is to chloroform. I play the one against the other. " 
 
 "Concerning the healing of wounds under the employ- 
 ment of chloroform and ether, I am emphatic in my convic- 
 tions of an evil residing in the former ; to the fact of such 
 evil I had my attention first directed during the war. Flaps 
 glaze but poorly under the chloroform impression, when 
 compared with that of ether. Force at large seems to be 
 debilitated. I desire to be put on record as condemning the 
 use of chloroform wherever the surgeon can get along with- 
 out it." 
 
 19 
 
302 ARTIFICIAL ANAESTHESIA. 
 
 An equally able surgeon, well known for his extensive 
 knowledge of every department of surgery, gave the fol- 
 lowing testimony in the discussion before referred to, in the 
 Odontological Society of Great Britain.* 
 
 " Mr. Jonathan Hutchinson said he could, from personal 
 experience, testify to the superiority of nitrous oxide gas 
 over other anaesthetics. He would allow any one who had 
 had some experience in the use of the gas to give it to him, 
 but he would only take ether from a thoroughly qualified 
 person, and would not allow any man living to give him 
 chloroform. He had used both ether and chloroform largely ; 
 he had lost one patient from chloroform eighteen years ago, 
 and had had many alarming cases ; he had seen fatal cases 
 also under the care of others. During the last six years he 
 had almost invariably used ether, and during that time he 
 had not had a single alarming case. He strongly disap- 
 proved of some of the complicated inhalers now in use, in 
 which, for the sake of economising ether, the patient was 
 made to re-inhale his own breath, thus taking in a quantity 
 of carbonic acid as well as ether. In the only bad cases 
 connected with ether which he had seen, some such appa- 
 tus had been used. He greatly preferred a simple leather 
 mouth-piece, perforated at the top, with a sponge and towel 
 inside ; in this way the patient got plenty of air and plenty 
 of ether. There certainly were a few cases in which chlo- 
 roform was preferable, viz., for old people and very young 
 children. Old people over sixty did not always recover 
 readily from ether narcosis. He had met with several 
 cases in which there had been alarming continuance of in- 
 sensibility, and in one case death seemed to be partly due 
 to this cause. Chloroform seemed to be less dangerous than 
 ether to old people ; and in the case of infants there seemed 
 to be practically no danger at all, while it was most dan- 
 gerous to young people. At the hospital in Moorrields there 
 used to be, on an average, a death from chloroform every 
 year, and they were nearly always young people operated 
 upon for strabismus. Chloroform was certainly more con- 
 venient in some respects and pleasanter to take than ether. 
 
 * British Journal of Dental Science, and American Journal of Den- 
 tal Science, Baltimore, April, 1S79. 
 
CHLOROFORM & CHLORAL IN STRYCHNIA-POISONING. 303 
 
 Patients who had tried both almost invariably preferred the 
 former; but he thought it criminal to place a patient in 
 danger of losing his life by giving chloroform, when ether 
 had been found to be so much safer." 
 
 " The president asked Mr. Hutchinson whether he did 
 not think that dental operations presented some peculiar 
 features which entitled them to special consideration." 
 
 " Mr. Hutchinson said he could not call to mind any 
 points in which dental operations differed materially from 
 those in general surgery ; he thought that the opinions he 
 had expressed would apply equally well to them." 
 
 TEEATMENT OF POISONING BY CHLOROFORM, 
 OR CHLOROFORM NARCOSIS. 
 
 Prof. Gross 1 s Method.— The surface of the chest should be 
 smartly slapped with the fringe of a towel clipped in ice 
 water ; a piece of ice introduced into the rectum ; the head 
 must be lowered and the legs elevated, and ammonia held 
 to the nose, an assistant meanwhile practicing artificial 
 respiration. (See also page 104. The means to be resorted to 
 to prevent death from chloroform.) 
 
 Mr. Clover* finds, in spite of all his care, that chloroform 
 will cause the action of the heart to fail, and he is not so 
 wedded to it that he will allow his patient to be killed by it. 
 But he states, " remove the chloroform and administer ether 
 vapor for a few inspirations," (or what is still better, as re- 
 commended by the late Dr. Sansom,f continue with the ether 
 until the operation is finished.) 
 
 Dr. Clover also remarks, "The mixture of nitrite of 
 amyl with chloroform has been strongly advocated recently 
 
 * A Guide to Therapeutics and Materia Medica. By Robert Farqu- 
 harson, M. D. Second American edition. Enlarged and adapted to 
 the U. S. P. by Frank Woodbury, M. D., physician to the German 
 Hospital, Philadelphia. Philadelphia: H. C. Lea, 1879, p. 208. 
 
 t Antagonism of Chloroform and Ether.— Dr. Greenhalgh 
 stated at the meeting of the Obstetrical Society of London (February 
 7th, 1866), that he had requested the late Dr. Sansom to administer 
 chloroform to a lady during the removal of a large polypus from the 
 uterus. Shortly after the administration of the chloroform, and before 
 complete anaesthesia was induced, her pulse began to falter, her 
 breathing became embarrassed, and her countenance livid. Dr. .San- 
 som, without delaying the inhalation, substituted ether with the best 
 results. Dr. Greenhalgh begged to ask that gentleman if he had 
 
304 ARTIFICIAL ANAESTHESIA. 
 
 by Dr. Sandford, an American physician. I have tried it 
 in a dozen cases, and rind that it produces insensibility rap- 
 idly; and if the anaesthetic is then removed, the recovery 
 is very satisfactory, but when the inhalation is continued 
 for three or four minutes, there seems to be nearly as much 
 subsequent depression." 
 
 CHLOROFORM AND CHLORAL IN POISONING 
 BY STRYCHNIA. 
 
 A large and poisonous dose of strychnia produces symp- 
 toms very closely resembling those of tetanus, but are more 
 strongly marked and rapidly reach their maximum. The 
 symptoms usually come on in twenty minutes to half an 
 hour, and are not usually delayed beyond an hour. The 
 first symptoms are general uneasiness, with restlessness 
 and soreness of the limbs; shooting pains, like electric 
 shocks, occur in various parts of the body, often first in the 
 back and down the arms and legs. Tetanic and paroxysmal 
 contraction of the muscles soon set in — in my experiments 
 with frogs, cats, rats, and dogs, it acts at once — and these 
 symptoms grow rapidly worse, and make the body rigid 
 while the paroxysm lasts. 
 
 If the dose has been large the paroxysm is usually very 
 severe. In one case, in which a woman had taken half a 
 grain by mistake, there was thirty-seven or more paroxysmal 
 contractions of the muscles, and the respiratory movements 
 at times were almost completely arrested, so that her face 
 became bloated and livid, the jugular veins standing out in 
 the neck, and the eyes staring and prominent. Each of 
 these spasmodic attacks lasted from a few seconds to a 
 minute, and then ceased. The mind of the patient was un- 
 adopted a similar practice in other cases with good effects ; and, if so, 
 whether he considered that the vapor of ether could be regarded as 
 an antidote to the evil consequences of chloroform, and whether he 
 could offer any physiological explanation of how such beneficial 
 effects are brought about. Dr. Sansom replied that it was his constant 
 practice to administer ether if in any case where chloroform seemed to 
 produce a depressing effect; indeed, usually in prolonged operations he 
 thus maintained the anaesthesia. The substitution, or rather addition, 
 was never attended by any return of sensation. He always found the 
 plan answer admirably; it certainly restored the force of the circula. 
 tion. — (Medical Times and Gazette, February, London, 1866.) 
 
CHLORAL IN STRYCHNIA-POISONING. 305 
 
 affected, and the suffering was intense. Any movement, 
 sometimes the slightest, would excite a paroxysm. My 
 patient recovered under the use of chloroform and animal 
 charcoal, and careful watching and sustaining of her 
 strength. Usually a fatal termination is due either to ex- 
 haustion from the repeated convulsions, or to asphyxia from 
 spasm of the muscles of the chest, which is obviated by 
 insufflation. Strychnia tetanizes, neither through the brain 
 muscles nor nerves, but through the spinal chord. 
 
 Treatment. — The antidote to poisoning by chloral is 
 strychnia (see page 223) ; and, vice versa, chloral has 
 been found antagonistic to strychnia. Chloral modifies the 
 strychnia symptoms to a great extent, and the first agent, 
 therefore, to administer in poisoning by strychnia, is chlo- 
 ral, and then chloroform by inhalation to relieve tetanic 
 rigidity. The chloral is given in doses of at least twenty 
 grains by the mouth ; or sixty grains in starch water by in- 
 jections, by the rectum. The fatal closure of the jaws takes 
 place in a few minutes, if the dose be a large one ; if smaller, 
 in five or six hours. The minimum quantity of strychnia 
 required to destroy life in man is about one half a grain. 
 If the patient be able to swallow, administer copious draughts 
 of warm water with tannic acid in solution, or strong oak- 
 bark tea, as this renders the strychnia inert. The stomach 
 pump is useful, but it can rarely be used, owing to the effort 
 to pass the tube into the stomach causing violent spasm. 
 
 Prof. Husemann, of Gottingen, has been engaged in a long 
 series of observations on the antagonistic and antidotal ac- 
 tion of drugs. Some of his investigations, which relate es- 
 pecially to chloral, are translated for the London Lancet, 
 vol. i, 1879, p. 382, from the Archiv. fur Exper. Pathologie ; 
 and although we find but little that is new, yet some of the 
 confirmatory facts are worthy of publication. He says, 
 " Chloral hydrate is known to act as an antidote to strych- 
 nine, lessening the spasm, and even preventing death. It 
 has a similar action in the case of the mixture of strychnine 
 bases sold under the name of brucia, and also against the 
 opium alkaloid thebaia, which simultaneously tetanizes and 
 lessens sensibility. The spasms produced by chloride of am- 
 monium diminish under the employment of non-fatal doses 
 of chloral hydrate, and can, indeed, be completely stojDped." 
 
306 ARTIFICIAL ANAESTHESIA. 
 
 (For the specific effects of hydrate of chloral, see conclu- 
 sions on page 207.) 
 
 ON THE CHOICE OF ANAESTHETICS. 
 
 For all minor operations in surgery, at the house of the 
 patient or in private office (when the cost of the anaesthetic 
 is of no consequence, and where disagreeable odor is to be 
 avoided), nothing has yielded us such satisfactory results as 
 hydrobromic ether. For all dental operations (except tedi- 
 ous and protracted dissections on the mouth), the safest 
 anaesthetic is nitrous oxide gas, which, in its results, is ex- 
 hilarating and most satisfactory, and with but little effort 
 produces complete insensibility to pain, and is most rapidly 
 eliminated from the system. For dangerous and protracted 
 operations, the agent which has been employed in this city 
 and in the United States is the pure ether; the proofs of its 
 safety are full and complete. Chloroform, as an anaesthetic, 
 has a long and painful record of valuable lives lost from the 
 time of its introduction to the present day, so that no one 
 is justified in using it unless the ordinary agents specified 
 above fail him, or unless he has to employ the actual cautery; 
 even with little children it is not absolutely safe,- and a re- 
 ference to the body of this work will show that numerous 
 deaths follow its use. 
 
 Every combination of chloroform, its various modes of 
 administration in both large and small quantities and mixed 
 with other agents, have been experimented with, but those 
 who have employed it most have, when its positive fatal 
 action is seen, had at last to resort to ether. 
 
 EFFECTS OF SUDDEN REDUCTION OF TEMPER- 
 ATURE AFTER ANAESTHESIA. 
 
 In a careful study of the secondary causes of death from 
 ethers and chloroform and their compounds, one important 
 symptom has impressed the writer, that is, the almost uni- 
 form reduction of temperature preceding death. This 
 occurs after important and protracted operations, and often 
 is hastened by careless removal from the warm, nay hot, im- 
 pure atmosphere of the operating-room to the adjoiningward, 
 
 * See page 109, deaths from chloroform in children ; also, table of 
 deaths from this agent, page 113. 
 
DEATH FROM CHLOROFORM. 307 
 
 exposing the damp, warm skin to the contact of a sudden 
 cool atmosphere. Again, the attendant should be a medical 
 man of experience, who should watch the case until reaction 
 is fully established, and see that the nurse keeps the patient 
 warm for at least six or seven hours, and administers both 
 stimulants and nourishment. If these means are neglected 
 and the skin of the patient is chilled, gradually he sinks 
 into an unconscious state, from fluids which collect in the 
 bronchi, lungs, and kidneys, and dies; mucous secretion and 
 serous effusions suffocating the patient. If bronchitis remains 
 after reaction, treat it by means of small and repeated doses 
 of spirits of ammonia in mucilage of gum arabic, with sen- 
 ega ; also, counter-irritation by means of lotion of oil of tur- 
 pentine and soap liniment. 
 
 Now we come to the conclusions concerning this matter. 
 " What is the number of recorded cases of deaths from chlor- 
 oform?" says Farquharson, the latest English authority. 
 " Fatal accidents from chloroform have become so alarming- 
 ly frequent of late — the total number, according to Bartho- 
 low, amountingto five hundred — that some surgeons even 
 consider its use unjustifiable. ' ' We have no doubt there have 
 been more than five hundred. We desire, however, to be 
 within bounds, and only print those cases that have been 
 fully authenticated. The number of deaths from chloroform 
 contained in our table on page 113, when added to those 
 already given in this paper, make the ghastly sum total of 
 three hundred and seventy. Just as the last of these pages 
 were passing through the press, comes the sad news of 
 another painful death by chloroform, a true case of paralysis 
 of the heart, making three hundred and seventy-one. The 
 following is the published report of the case : — 
 
 "Mr. John K. Cornwall," about forty-five years old, 
 and apparently in fair general health, was suffering from 
 an ailment that required the repetition, after the lapse of 
 two years, of a painful surgical operation. He told Dr. 
 Chambers that he could not bear the pain without taking an 
 anaesthetic. He greatly preferred chloroform to ether, be- 
 cause the latter, he said, made him sick. Dr. Chambers 
 told him that if he insisted on taking chloroform he must 
 
 * New York Times, May 16th, 1879: 
 
308 ARTIFICIAL ANAESTHESIA. 
 
 call in another physician of experience. This led to the 
 attendance of Prof. Louis A. Stimson. 
 
 " Mr. Cornwall purchased the chloroform himself. At 
 two and a half o'clock, on Thursday afternoon, May 15th, 
 1879, all was in readiness. Under the advice of both of the 
 physicians, the patient was induced to make an attempt to 
 undergo the operation without the chloroform, but at the 
 very beginning his courage failed. He was then told to lie 
 on a bed, because a reclining position of the body is usually 
 viewed as safer than an upright one for the administration 
 of chloroform. Dr. Chambers poured not more than half a 
 spoonful of the liquid on a towel, and laid the moistened 
 part over Mr. Cornwall's mouth and nostrils, at the same 
 time telling him to breathe naturally, as though the towel 
 was not there. Prof. Stimson, assuming the part requiring 
 the greater amount of experience, held his fingers on the 
 patient's pulse, which was beating regularly. There were 
 barely three inhalations of the chloroform when Prof. 
 Stimson discovered that the pulse had suddenly stopped. 
 The towel was at once removed, but after a brief fluttering 
 of his breath it stopped. Artificial respiration was tried, 
 but without success. Previously a few drops of nitrite of 
 amyl were put on a piece of cloth and placed at his nostrils, 
 but either because there was not enough breath to carry its 
 vapor into the lungs, or from some other cause, it failed to 
 have any effect. Nitrite of amyl usually causes an imme- 
 diate quickening of the heart's movement, and is therefore 
 recommended as an antidote to the dangerous effects of chlo- 
 roform. 
 
 " The two physicians at last gave up hope of their pa- 
 tient's recovery, and sent for his wife, who had been per- 
 suaded to go on a visit to a friend to remain during the oper- 
 ation. Dr. Edward G. Janeway, one of the commissioners 
 of the Health Department, was called to assist Drs. Stimson 
 and Chambers in making a, post mortem examination. All 
 the organs of the body were examined, but in none was 
 there found, on the first examination, any mark of disease 
 or irregularity that could have caused death. Then Dr. 
 Janeway sent for a microscope in order to make a closer ex- 
 amination. No fatty degeneration had been observable 
 with the naked eye, but with the instrument the substitu- 
 
BIBLIOGRAPHICAL LIST. 309 
 
 tion of fat in place of muscular fibre could be seen plainly. 
 This substitution of fat serves to weaken the muscular 
 action of the heart and to make it irregular. 
 
 " Coroner Croker was summoned by Dr. Chambers, and 
 Deputy Coroner McWhinnie viewed the body. A permit of 
 burial was granted by the coroner listening to the state- 
 ments of the three physicians. The cause of death reported 
 to the Bureau of Vital Statistics was ' fatty degeneration of 
 the heart.' It is explained by Dr. Chambers that, though 
 the fatty degeneration had not yet made progress enough to 
 cause death under ordinary circumstances, yet it had been 
 able to do so under the first accelerating effects of the chlo- 
 roform. Commissioner Janeway told Dr. Chambers that 
 no physician could possibly have discovered the condition 
 of Mr. Cornwall's heart from observations made before 
 death. Mrs. Cornwall, and a brother and a brother-in-law 
 of the dead man, say they believe the physicians did the 
 best they could have done under the circumstances. The 
 burial permit was granted, 'pending an inquest;' but it is 
 said there will be no inquest because Coroner Croker judges 
 that the allegations of three reputable physicians, Commis- 
 sioner Janeway, Prof. Stimson, and Dr. Chambers, as to the 
 cause of death , make the holding of a formal inquiry un- 
 necessary." 
 
 BIBLIOGRAPHICAL LIST OF PAPERS OR WORKS 
 
 ON ANAESTHETICS, WHICH HAVE NOT 
 
 BEEN QUOTED IN THE BODY 
 
 OF THIS WORK. 
 
 Lente, F. D., New York. — "Dangers of Anaesthetics," 
 New York Journal of Medicine, 1856. One of the first efforts 
 to warn against the danger of chloroform inhalations. 
 
 Dugas^ Louis A., Augusta, Ga. — "Local Anaesthesia," 
 Southern Medical and Surgical Journal, vol. for 1855-6. 
 
 Ob/tost, John, Binghamton, N. Y. — "Amylene as an 
 Anaesthetic," Transactions Medical Association of Southern 
 New York. 
 
 Newman, Wm. Henry, Denver, Col.— In 1870, in per- 
 forming ovariotomy, he employed (probably for the first 
 time) carbolic acid as a local anaesthetic. 
 
310 ARTIFICIAL ANAESTHESIA. 
 
 Dabney, Wm. Cecil, Charlottesville, Va.— " Nitrite of 
 Amyl as an Antidote to Chloroform." 
 
 Doughty, Wm. Henry, Augusta, Ga.— " Carbolic Acid 
 as an Anaesthetic," Southern Medical and Surgical Journal, 
 1859-60. 
 
 Kunst, Albert Henry, Weston, W. Va.— " The Use of 
 Chloral in Insanity," Medical and Surgical Reporter, 1870, 
 and "Its Use in Orbital Neuralgia, as an Anaesthetic in the 
 Removal of an Atheromatous Tumor, or in Subcutaneous 
 Injections for Convulsions in Consumption," Medical and 
 Surgical Reporter, April. 1870, February, 1871. 
 
 Cubbertson, Howard, Zanesville, Ohio.—" The Sin of 
 Anaesthesia in Midwifery," the prize essay of Ohio State 
 Medical Society, 1862. 
 
 Dawson, B. F., New York. — " The Use and Comparative 
 Merits of the Bichloride of Methylene as an Anaesthetic," 
 American Journcd of Obstetrics, 1874 ; Neiv York Medical 
 Record, May, 1874, vol. 9, p. 202. 
 
 The following works can be found at the Library, Surgeon 
 General's office, Washington, D. C. :— 
 
 Brombergker. — Latin dissertation on Sulphuric Ether. 
 
 Eckstein. — ' ' Chloroform. ' ' 
 
 Forbes, John.—" On Etherization in Surgery and Prac- 
 tical Medicine." 
 
 Hayward.— " Comparative Value of different Anaesthe- 
 tic Agents." 
 
 Lente. — " Ether and Chloroform as Anaesthetics." 
 
 MortoN. — " Proceedings in regard to Medical Testimony, 
 etc." 
 
 Murphy. — " Chloroform in Practice of Midwifery." 
 
 Nussbaum. — "Anesthetica," in Billroth's "Handbuchof 
 Surgery." 
 
 Roberts. — "Death from Chloroform." 
 
 Simpson.— "Anaesthesia," historical letter on the discov- 
 ery. 
 
 Smith, Truman.— " Examination of the Question of 
 Anaesthesia Discovery." 
 
 Snow. — "On Chloroform," a new edition, and a memoir 
 by B. W. Richardson, London, 1858. 
 
ON THE DISCOVERY OF ANAESTHESIA. 311 
 
 Squibb. — ' ' Anaesthetics. ' ' 
 
 Waldie. — " Introduction of Chloroform into Anaesthet- 
 ics." 
 Walker. — " Report of Committee on Memorials." 
 Warren. — " Some Account of the Discovery of Ether." 
 Weles. — " Discoverer of Anaesthesia." 
 Wise, R. Stanton.—" Chloroform in Midwifery." 
 
 See a full account of the discovery of modern anaesthesia 
 by Prof. H. G. Bigelow in " A Century of American Medi- 
 cine " (H. C. Lea, published 1876). Also, "Discovery of 
 Anaesthesia," by Dr. J..M. Sims, Virginia Medical Monthly, 
 May, 1877; and the "History of Modern Anaesthetics," by 
 Sir James Simpson, of Edinburgh. This distinguished 
 physician discovered the anaesthetic properties of chloro- 
 form, and employed it first in year 1847. (James Campbell 
 & Co., Boston, Mass.) 
 
 KENTUCKY THE FIRST STATE OF THE UNION 
 
 IN WHICH ANAESTHESIA WAS EMPLOYED 
 
 IN THE OPERATION OF OVARIOTOMY. 
 
 "In October, 1846, sulphuric ether, or letheon, as then 
 called, was first employed as a pain-destroyer in a surgical 
 operation by Dr. Warren, of Boston. Only one operation 
 of ovariotomy in this country was performed during this 
 year, which was by Dr. John L. Atlee, before the date above 
 given. In 1847 Dr. Robert Thompson performed the only 
 operation for that year ; but no mention is made of the fact 
 that letheon was employed. Both operations unsuccessful. 
 In November, 1847, Prof. Simpson, of Edinburgh, employed 
 for the first time chloroform as an anaesthetic. On March 
 15th, 1848, Dr. Clay, of Manchester, England, performed 
 his first ovariotomy under the influence of chloroform — 
 successful. On March 21st, six days afterwards, Mr. H. Gr. 
 Potter, of Newcastle, performed a similar operation under 
 the influence of chloroform — unsuccessful. On April 6th, 
 sixteen days later, Dr. Henry Miller, of Louisville, Ky., 
 performed in that city ovariotomy under the influence of 
 chloroform, upon a woman from the State of Indiana — 
 successful : second case in the world under anaesthesia. 
 
312 ARTIFICIAL ANAESTHESIA. 
 
 During this year there were three other ovariotomies per- 
 formed in this country, though they were after Dr. Miller's ; 
 only one of the three was successful."* 
 
 NOTES ON THE USE OF NITROUS OXIDE AS AN 
 ANAESTHETIC IN STRABISMUS OPERATIONS. 
 
 BY DR. ARTHUR MATHEWSON, BROOKLYN, N.Y. 
 
 In these five cases the patient was seated in a dentist's 
 operating chair, tipped back as far as possible, and the gas 
 drawn from the apparatus of Johnston Bros. (1260 Broadway, 
 New York), for the use of the liquid nitrous oxide. This 
 has an inhaler fitted with a valve, so that atmospheric air 
 can easily be admitted, and a cup-shaped cover to go over 
 mouth and nose. The patient in each case went quietly 
 under the influence of the anaesthetic without any of the 
 suffocating sensatious caused by ether. Vomiting occurred 
 in two of the cases. There was no unpleasant after-effects. 
 There was in some of the cases a blue and livid color of the 
 face, which passed off on admission of air. Blood very dark, 
 with scarcely any bleeding while the lividity continued. 
 Full muscular relaxation did not accompany the anaesthesia 
 in all the cases, but this was not an inconvenience, as it 
 might prove in cataract and other operations. The mini- 
 mum and maximum quantities of gas consumed in these 
 cases were seven and twenty gallons, at a maximum cost of 
 one dollar, f 
 
 THE METRIC OR DECIMAL SYSTEM. 
 
 . The Metric System has been legalized in the United States 
 and Great Britain, employed by other civilized nations, and 
 is rapidly becoming an essential part of the international 
 language of science. It has been adopted for the profession 
 of this country in the recent meeting of the American 
 Medical Association (June, 1879). Although our work is not 
 printed in this system, we have given the subjoined tables 
 and scales with rules, so that any one can reduce the apoth- 
 ecaries weights ; also the thermometric scales.^ 
 
 * Dr. Nathan Bozeman, Medical Record, New York, June 7th, 1879. 
 •f Abstract from Transactions of the American Ophthalmological 
 Society, New York, 1878. 
 
 $ Chicago Medical Journal and Examiner, September, 1879. 
 
THE METRIC SYSTEM. 
 
 313 
 
 THE METRIC SYSTEM IN MEDICINE. 
 
 Old Style. Metric. 
 
 n\J or gr. j equals .... 06 Gm. 
 
 f3Jor3J "...... 4 
 
 m or Sj " ^ .... 32 
 
 The decimal line, instead of points 
 makes errors impossible. 
 
 As .06 (Drug) is less than a grain, while 
 4 and 32 (Vehicle) are more than the 
 drachm and ounce, there is no danger of 
 giving too large doses of strong drugs. 
 
 C. C. (cubic centimetres) used for Gms. 
 (grammes) causes an error of 5 per cent. 
 (excess.) A teaspoonful is usually 5 Gms. ; 
 a tablespoonful, 20 Gms. 
 
 Two examples will illustrate the mode 
 of writing prescriptions. 
 
 fy. Extr. Coloc. Comp. Siss. 
 
 Extr. Colch. Acet. gr. xii. 
 
 Extr. Digitalis, gr. vi.— M. 
 
 Make into twenty-four pills. 
 Sig. One pill every three hours.* 
 
 would in metric terms be written : — 
 
 Gm. 
 ]pt. Extr. Coloc. Comp. 6 ' 
 
 Extr. Colch. Acel. | 75 
 
 Extr. Digitalis, I 36. 
 
 Make into twenty-four pills. 
 
 or the following prescription : — 
 
 Yfc. Potassii Bromidi, Sj. 
 
 Elix. Aurantii, ft. gviii.— M. 
 
 * 
 Sig. A tablespoonful once or twice a day.f 
 
 would in metric terms be written : — 
 
 #. 
 
 Potassii Bromidi, 
 Elix. Aurantii, 
 
 32 Gm. 
 256. C. C. 
 
 M. 
 
 * A valuable gout pill. 
 
 t In cases of disturbance of the brain or in 
 chronic alcoholism. 
 
 _l iicrui 
 
 Centigrade 
 Scale. 
 
 45° 
 
 Fahrenheit 
 
 Scale. 
 —113° 
 
 
 112° 
 
 44° 
 
 111° 
 
 
 110° 
 
 43° 
 
 1(9° 
 
 42° 
 
 108° 
 
 
 107° 
 
 41° 
 
 106° 
 
 
 105° 
 
 40° 
 
 104° 
 
 
 103° 
 
 39° 
 
 102° 
 
 
 101° 
 
 38° 
 
 100° 
 
 37° 
 
 99° 
 
 
 98° 
 
 36° 
 
 97° 
 
 
 96° 
 
 35° 
 
 95° 
 
 
 94° 
 
 34° 
 
 93° 
 
 
 92° 
 
 33° 
 
 91° 
 
 32° 
 
 90° 
 
 
 89° 
 
 31°- 
 
 87° 
 
 30°- 
 
314 
 
 ARTIFICIAL ANAESTHESIA. 
 
 METRIC MEASURES OF LENGTH. 
 
 Millimeter, 
 
 0.001 of a Meter, . . 
 
 0.03937 in. 
 
 Centimeter, 
 
 0.01 
 
 (( u 
 
 0.39370 " 
 
 Decimeter, 
 
 0.1 
 
 it a 
 
 3.93707 " 
 
 Meter, . . . 
 
 1. 
 
 Meter, . . . 
 
 39.37079 " 
 
 Decameter, 
 
 . 10. 
 
 Meters, . . . 
 
 393.70790 " 
 
 Hectometer, . 
 
 . 100. 
 
 (i 
 
 3937.07900 " 
 
 Kilometer, . . 
 
 . 1000. 
 
 i< 
 
 39370.79000 " 
 
 
 METRICAL WEIGHTS. 
 
 
 Milligramme, . 
 
 0.001 of a Gram, . . 
 
 0.015 gr. 
 
 Centigramme, 
 
 0.01 
 
 it K 
 
 0.154 " 
 
 Decigramme, . 
 
 0.1 
 
 U (( 
 
 1.54S u 
 
 Gram, . . . 
 
 1. 
 
 Gram, . . . 
 
 15.432 " 
 
 Decagramme, . 
 
 . 10. 
 
 Grams, . . . 
 
 154.323 " 
 
 Hectogramme, 
 
 . 100. 
 
 k 
 
 1543.234 " 
 
 Kilogramme, . 
 
 . 1000. 
 
 <( 
 
 15432.348 " 
 
 The exact equivalents of the grain, drachm, and ounce 
 (troy) in grams; of the gram in grains; of the minim, 
 fluidrachm, and fluidounce in cubic centimeters; and of the 
 cubic centimeter in minims, are as follows : — 
 
 1 grain, troy, is equal to 0.065 — gram. 
 
 1 drachm, troy, is equal to 3.888 — grams. 
 
 1 ounce, troy, is equal to 31.103 + grams. 
 
 1 gram is equal to 15.43234874 grains troy. — Prof. Miller.. 
 
 (1 avoirdupois pound is equal to 453.592 + grams.) 
 
 (1 avoirdupois ounce is equal to 28.350 + grams.) 
 
 1 minim is equal to 0.062 — cubic centimeter. 
 
 1 fluidrachm is equal to 3.697 — cubic centimeters. 
 
 1 fluidounce is equal to 29.573 — cubic centimeters. 
 
 1 cubic centimeter is equal to 16.231 + minims. 
 
 (1 meter is equal to 39.370432 inches). — Capt. Clarke^ 
 
INDEX. 
 
 ACETIC Ether, anaesthetic pro- 
 perties of, 62; experiments by 
 Dr. H. C. Wood, 62. 
 
 Acid Carbolic, antidotes to poi- 
 soning with, 265; application 
 after actual cautery, 265 ; as a 
 local anaesthetic, 265; experi- 
 ments by M. M. Gratiolet and 
 Lemaire, 267 ; in arresting pu- 
 trefaction, 267; in fistula, 267; in 
 otorrhoea, 267; in ulcers, 267; 
 injection in hemorrhoids, 266 ; 
 injection in hydrocele, 265 ; of- 
 ficinal preparations, 264; pois- 
 oning by the external applica- 
 tion, 266; properties of, 264; 
 therapeutic properties, 267. 
 
 Acid Carbonic Gas, local anaes- 
 thetic, 263; physiological ac- 
 tion of, 268. . 
 
 After-treatment of anaesthetized 
 patient from alcohol, 21 ; chlo- 
 ral, 223; chloroform, 21, 105; 
 ether, 21, 28. ' 
 
 Alcohol, as a local anaesthetic, 21 ; 
 as an anaesthetic by inhala- 
 tion, 18 ; and chloroform, 147 ; 
 ether and chloroform mix- 
 tures, 145; ethyl or spirits of 
 wine, '19; experiments by 
 Alexis Horvath, 22; experi- 
 ments by author, 23; in its 
 various forms, as brandy, 
 whiskey, gin, 18; in the form 
 of absolute, in United States, 
 19; in the form of "proof 
 Spirit" in England, 19 ; methy- 
 lic, or pyroxide, or wood spir- 
 it, 19; experiments by Dr. B. 
 W. Richardson, 20. 
 
 Alcoholism, the use of chloral in, 
 220. 
 
 Allis' Dr., chloroform inhaler, 
 description of, 247 ; ether in- 
 haler, description of, 237 ; ad- 
 vantages of, 239; experiments 
 at "Howard Hospital," 241; 
 objections answered, 242; ob- 
 jections to the apparatus, 241. 
 
 Alleged dangers which accom- 
 pany inhalation of alcohol, 
 21 ; of anaesthetic mixtures, 
 132 ; chloroform, 91 ; ether, 27, 
 31; ethidene dichloride, 82; 
 ethylene chloride, 83; nitrous 
 oxide, 199; nitrous oxide and 
 ether, 255. 
 
 Ammenorrhoea, chloral hydrate 
 in, 208. 
 
 Amyl Nitrite of, and chloroform 
 as an anaesthetic, 128, 129; as 
 an antidote to chloroform, 
 104, 118; experiments by Dr. 
 Brunton, 132; experiments by 
 Laden dorf in forty cases of 
 different psychoses, 126 ; of J. 
 J. Michel, 133; of Dr. S. Weir 
 Mitchell, 132; of Dr. Solger, 
 132; failure of in chloroform 
 narcosis, 121 ; physiological 
 and therapeutic effects, 125. 
 Amory Dr., experiments with 
 nitrous oxide, 179; chloral hy- 
 drate, 208. 
 Amylene, discovery of and use 
 by Dr. Snow, 67 ; not a safe an- 
 aesthetic, 67. 
 Anaesthesia artificial, by alco- 
 hol, 18; by formic ether, 62; 
 by hydrobromic ether, 67 ; by 
 
316 
 
 INDEX. 
 
 chloral, 210; by chloroform, 
 89 ; discovery of, 15, 311 ; effects 
 of sudden reduction of tem- 
 perature, 306 ; ether, 25; ethi. 
 dene dichloride. 81 ; ethylene 
 bichloride, 80; methylic alco- 
 hol, 19; methylene bichlor- 
 ide, 63; nitrite of amyl and 
 chloroform, 128 ; nitrogen gas, 
 83 ; nitrous oxide, 286 ; oxygen 
 gas, 83. 
 
 Anaesthetics of the ancients, 13 ; 
 chloral, 207; chloroform, 89; 
 ether, 26, 28 ; and nitrous ox- 
 ide in dental surgery, 173 ; 
 in the blood, 182, 192; air 
 breathed in, 182; the brain 
 and nervous system, 180; ner- 
 vous phenomena, 183; their 
 medico-legal aspect, 274 ; mod- 
 ern, 15; on the choice of, 306 ; 
 in dental surgery, 296 ; list of, 
 16 ; effects of sudden reduction 
 of temperature in, 306 ; which 
 is the safest to choose, 306. 
 
 Analgesic effects of rapid breath- 
 ing, 261. 
 
 Angina, diphtheritic or pseudo- 
 membranous croup, treat- 
 ment of by ether, 59. 
 
 Angina pectoris, nitrite of amyl, 
 hypodermic injection of mor- 
 phia, 118. 
 
 Antagonism of chloroform and 
 ether, note page 303. 
 
 Antidote to poisoning with car- 
 bolic acid, 265; chloroform, 
 118; chloral, 222; strychnia, 305. 
 
 Aphonia, or temporary loss of 
 voice, treatment by ether, 59; 
 nervous, by nitrous oxide, 203. 
 
 Asphyxia from chloroform, 89, 
 104 ; ether, 41 ; formic ether, 
 62; nitrous oxide, Evans, Dr., 
 experiments, 16S; Reid's ex- 
 periments, 204. 
 
 Asthma spasmodic, treatment of 
 by chloroform, 137; chloral 
 hydrate, 137, 209; nitrite of 
 amyl, 125; nitrous oxide gas, 
 205. 
 
 Atlee (the late), Dr. Washington 
 L., his success with mixed an- 
 aesthetics, 150. 
 
 Atropine in chloroform narcosis, 
 127. 
 
 BERNARD, Claude, mode of ac- 
 tion of anaesthetics, 181. 
 
 Bert, M. Paul, on nitrous oxide, 
 198. 
 
 Benoit, Rene, studies on the 
 spectrum of the blood, 195. 
 
 Bibliographical list of papers or 
 works on anaesthetics, 309. 
 
 Bichloride of Ethylene, 80. 
 
 Bichloride of Methylene, 63; 
 deaths from, 66; discovery 
 and introduction, 64 ; use of 
 by Dr. Jones, of Cork, 64; by 
 Dr. Richardson, 63; inhaler 
 for, 259. 
 
 Bird, Mr. Thomas, experiments 
 with dichloride of ethidene, 
 81. 
 
 Binz, Dr. C, mode of action of 
 anaesthetics, 180. 
 
 Blood,action of anaesthetics upon, 
 90; nitrite of amyl, 125. 
 
 Bonwell's method of anaesthesia, 
 260. 
 
 Brandy or wine, use of prior to 
 an anaesthetic, 26. 
 
 Bromide of Ethyl, or Hydrobro- 
 mic Ether, 67 ; properties, de- 
 composition, 68; use by M. 
 Rabuteau, on animals, 68; by 
 author, on man, 69, 295. 
 
 Bromide of Potassium, prior to 
 the anaesthetic, 26. 
 
 Bromoform, mode of preparation, 
 properties, etc., 270; Dr. Rabu- 
 teau on its local action, 270. 
 
 Brunet, case of fatal results fol- 
 lowing inhalation of nitrous 
 oxide, 204. 
 
 Budin and Coyne on the condi- 
 tion of the pupil in anaesthe- 
 sia from chloroform, 93. 
 
 Butylchloral, chemical composi- 
 tion, mode of preparation, 
 230; Dr. Oscar Liebreich on, 
 231 ; Dr. H. H. Smith's report 
 
INDEX. 
 
 317 
 
 on its use, 231; on animals, 
 230; Ringer on its value, 231; 
 use of it in children, 231. 
 
 CANCER, use of chloroform in 
 abrasions of the skin, 141 ; of 
 the breast, excision of under 
 ether spray, 51; form of ap- 
 paratus, 271. * 
 
 Carbolic Acid, antidotes to poi- 
 soning with, 265; as a local an- 
 aesthetic, 265; impure for exter- 
 nal use and disinfection, 264; 
 officinal preparations, 264 ; 
 action of heat upon, and dose 
 of, 264 ; therapeutic properties, 
 267. 
 
 Carbonic Acid Gas, in cancer of 
 rectum, uterus, etc., 263 ; on 
 man, mode of deatlj, from, 
 264; as a local anaesthetic, 263; 
 physiological action of, 263. 
 
 Carbonic Oxide Gas, action on an- 
 imal life, 262 ; as a local anaes- 
 thetic, 261; narcotic poison, 
 261. 
 
 Carter Dr., on the use of ether in 
 operations on the eye, 49. 
 
 Chloral Hydrate, action in ty- 
 phoid fever, 207; in delirium 
 tremens, 207 ; advantages and 
 disadvantages of subcutane- 
 ous injections of, 215; anhy- 
 drous, 206; as an anaesthetic 
 injected into the veins, 210; 
 as a local anaesthetic, 229 ; as a 
 counter-irritant, 230 ; causes 
 swelling and redness of the 
 eye, 209 ; children can be placed 
 in a state of absolute anaesthe- 
 sia by it, 212; causes the mus- 
 cles and motor nerves to retain 
 their irritability after death, 
 212; conclusions drawn from 
 experiments and observations, 
 207; disturbs the stomach in 
 large doses, 208; fatal and non- 
 fatal doses, 216; how produced, 
 206 ; impurities, how detected, 
 207; in alcoholism, 220; influ- 
 ence on the circulation of the 
 fundus of the eye, 221; in gout 
 
 and rheumatism.givenwith an 
 alkali, 208; in paroxysms of 
 tetanus, 209 ; in small dose for 
 children, 208 ; in acute mania, 
 209; intravenous injection of, 
 212; increases flow of men- 
 strual fluid, 208 ; in solution a 
 valuable antiseptic, 210; ne- 
 cropsy in death from, 209 ; not 
 decomposed in the blood, 208 ; 
 purified, 206 ; subject to de- 
 composition. 207 ; treatment of 
 impending death from, 209; 
 therapeutic effects of, 223 ; use- 
 ful in asthma, 209; useful in 
 convulsions of children, 209; 
 useful in phthisis, 208; valuable 
 in nervous affections, 209 ; val- 
 uable in sun-stroke or heat 
 toxaemia, 209. 
 Chloroform, 87 ; administration 
 of, 89; and alcohol, 155; and 
 ether, 145; and nitrite of amyl 
 as an anaesthetic, 128 ; experi- 
 ments on death from, 92 ; an- 
 tidotes for poisoning by, 118, 
 127; anaesthetic for children, 
 108; followed by death, 109; 
 asthma, treatment by, 137; 
 appearance after death from, 
 106 ; boiling point, 148 ; chem- 
 ical tests, 88; causing syncope, 
 303; chills, action of in, 139; 
 combined with ether in ovari- 
 otomy, 150; criminal use of, 279; 
 dangers of, in renal disease, 
 112; when given too rapidly, 
 106; fatty heart, 115; deaths, 
 table of, 113 ; during labor, 108 ; 
 early stage of administration, 
 158; external and internal use 
 of, 138; in dental operations, 
 296; inhalers, 247; in poison- 
 ing by strychnia, 304; its ac- 
 tion as a poison, 28; treat- 
 ment; 303; mixtures for an- 
 aesthesia, 150; narcosis with 
 morphia, 134; Prof. Gross' 
 method of treatment, 303; 
 method of resuscitation, 104; 
 neuralgia, treatment with, 
 
 20 
 
318 
 
 INDEX. 
 
 137; on the pupil in its vari- 
 ous anaesthetic stages, 93; 
 poisonous action of, 104; pre- 
 paration, mode of, 87; prepa- 
 rations for internal use, 139; 
 physiological action of, 89 ; on 
 the blood, 90 ; on the brain, 180 ; 
 purified by sodium carbonate, 
 87 ; therapeutic use, 135 ; chlo- 
 roform versus ether, 48. 
 
 Cholera, ether with camphor, in, 
 57. 
 
 Chorea, chloroform in, 136 ; brom- 
 ide of potassium in,139; chloral 
 hydrate in, 227; hand spray of 
 ether, 58; Fowler's solution 
 in, 58 ; strychnia in, 58. 
 
 Colic, simple and apictonum, 
 chloroform in, 138. 
 
 Chlorodyne, anodyne, and anti- 
 spasmodic, 142; death from, 
 142. 
 
 Coryza, ether comp. in its treat- 
 ment, 58. 
 
 Cystitis chronic, chloral hydrate 
 in, 220. 
 
 DAVY Sir Humphrey, experi- 
 ments with nitrous oxide gas, 
 14. 
 
 Dawson Dr. C, table of deaths 
 from ether, 33. 
 
 Death agonies, ether in mitiga- 
 tion of, 59. 
 
 Deaths from amylene, 67; chlo- 
 ral, 216; chloroform, 113; chlo- 
 roform and ether, 152; nitrous 
 oxide gas, 199; nitrous oxide 
 and ether, 255. 
 
 Delirium of fever, delirium tre- 
 mens, chloroform in, 136. 
 
 Dental operations, use of anaes- 
 thetics in, 296. 
 
 Diarrhoea, treatment by chloro- 
 form, 138; ether and camphor, 
 57 ; chloroform and camphor, 
 138. 
 
 Dichloride of Ethidene, 81. 
 Dioscorides on the wine of man- 
 
 dragora root, 13. 
 Diphtheria, chloral hydrate in, 
 229. 
 
 Dogs, mode of killing them by 
 carbonic oxide gas, 262. 
 
 Dudgon on the use of Indian- 
 hemp, 14. 
 
 Dutch liquid, objections to its use 
 as an anaesthetic, 80. 
 
 Dysmenorrhcea, ether with cam- 
 phor, 57; chloral hydrate in, 
 209. 
 
 EARACHE, chloroform in, 143. 
 
 Ear-cough, nitrite of amyl, 125. 
 
 Eclampsia, chloral hydrate, 225. 
 
 Eczema, chloroform ointment, 142. 
 
 Ether as an anaesthetic, 28, 292; al- 
 leged dangers from, 31 ; cases in 
 which ether should not be em- 
 ployed as an anaesthetic, 27; 
 dangers from its inhalation, 28; 
 deaths from, 40; difference from 
 chloroform, 28 ; experiments 
 with the sphygmograph, 29; 
 inflammability of, 32; intoxi- 
 cation from, 289; ordinary mode 
 of inhalation, 28, 297; officinal 
 preparations, 292; precautions 
 in its inhalation, 292; physio- 
 logical action, 26; proofs of its 
 safety in Philadelphia, 48; poi- 
 son treatment of, 288; stimu- 
 lating influence on the heart, 
 29; tests of its purity, etc., 24; 
 tests of complete anaesthesia, 
 26; versus chloroform, 48. 
 
 Epilepsy, chloroform in, 137; ni- 
 trite of amyl, 137 ; nitrous oxide, 
 205. 
 
 Etherization, early stage of, 157. 
 
 Ethidene dichloride, as an anaes- 
 thetic, 81. 
 
 Ethylene chloride, anaesthetic for 
 children, 83; asphyxia caused 
 by it, 83. 
 
 Eucalyptus extract for local anaes- 
 thesia, 272. 
 
 FACIAL Neuralgia, chloroform 
 in, 140; butylchloral in, 231. 
 
 Fistula, carbolic acid, 267. 
 
 Flatulent dyspepsia, chloroform, 
 138. 
 
 Flushings of heat, nitrite of amyl 
 in, 133, 
 
INDEX. 
 
 319 
 
 Formic ether properties, etc., 62; 
 as an anaesthetic, 62 ; obj ections 
 as an anaesthetic, 63. 
 
 Freezing the skin by ether (Rich- 
 ardson), 49, 272; Ringer, 23; Bill- 
 roth, 55; Beglow, 272. 
 
 GASOLINE as a local anaesthetic, 
 17, 55. 
 
 Glottis, spasm of, from chloro- 
 form, 89. 
 
 Gout, ether in sudden attacks of, 
 56 ; chloral hydrate in, 208. 
 
 HEADACHE, hydrobromic ether, 
 71; sick, treatment by nitrite 
 of amyl, 133. 
 
 Hemicrania, chloroform in, 140. 
 
 Hemp, Indian, uses of as an anaes- 
 thetic, 14. 
 
 Hernia, reduction of, chloroform, 
 136. 
 
 Hoarseness, compound spirits of 
 ether, 58. 
 
 Hooping Cough, mixture of chlo- 
 roform, ether, and spirits of 
 turpentine, 59. 
 
 Horvath on local anaesthesia with 
 alcohol, 22. 
 
 Hydrate of chloral, see Chloral 
 Hydrate, 207. 
 
 Hydriodic ether as an anaesthetic, 
 62. 
 
 Hydrobromic Ether, 67, 294; action 
 on animals, 70 ; as an anaesthe- 
 tic, 67-79; conclusions, 79, 295; 
 on man, 72; pulse, 76, 77; new 
 mode of preparation, 294. 
 
 Hydrogen Gas as an anaesthetic, 
 83. 
 
 Hypodermic injection of morphia 
 in conjunction with chloro- 
 form, 273, 134. 
 
 Hysteria, ether in combination, 
 57. 
 
 ICE, snow and salt for local anaes- 
 thesia, 271 ; as a means of pre- 
 venting narcotism from chlo- 
 roform, 127. 
 
 Inhalation of chloroform, 89; 
 ether, 25, 293 ; mixtures of chlo- 
 roform, ether and alcohol, 145 ; 
 nitrous oxide gas, 165. 
 
 Inhalers, Allis' chloroform, 247; 
 Allis' ether, 236; Angrove's 
 ether, 244; Cheatham's ether, 
 234; Clover's chloroform, ether 
 and nitrous oxide gas, 251; 
 Clover's ether, 245 ; Codman & 
 Shurtleff 's ether and nitrous 
 oxide, 256; Hawksley's ether, 
 232 ; Hearn's ether, 233 ; Lente's 
 235 ; Meyer and Meltzer small- 
 er ether, 246; Morgan's ether, 
 242; Morgan's, T. C, for bichlo- 
 ride of methylene, 259; Rich- 
 ardson's ether (B. Willis, of 
 Dublin), 244. 
 
 Insane, the treatment of, with hy- 
 drate of chloral, 226. 
 
 Insanity, chloroform treatment, 
 136. 
 
 Insomnia from nervousness, hy- 
 drate of chloral, 209. 
 
 Intermittent fever, arrest of par- 
 oxysm with nitrite of amyl, 133. 
 
 Iodide of Methyl, 66. 
 
 Itching of ear, nose, or rectum, 
 treatment by chloroform, 141. 
 
 JOLYET and Blanche, experi- 
 ments with protoxide of nitro- 
 gen, 184, 192. 
 
 Johnson Prof. George, his theory of 
 the action of nitrous oxide, 178. 
 
 KIDD, on sex in death from chlo- 
 roform, 102. 
 
 LARYNGEAL cough, chloroform, 
 136. 
 
 Laughing Gas, see Nitrous Oxide. 
 
 Letamendi Dr., a new method of 
 utilizing the anaesthetic effects 
 of ether spray, 50. 
 
 Lichen, ointment for, 142. 
 
 Liniment, chloroform and cam- 
 phor, 138. 
 
 Local anaesthesia by alcohol, 21; 
 carbolic acid, 205; chloral hy- 
 drate, 229 ; ether, 272 ; ice, mor- 
 phia, gasoline, 56; rhigoline, 
 49-56; ether, 23-51. 
 
 Local anaesthesia, Faradaic anaes- 
 thesia, Dr. Beard on, 270; effects 
 of, 53; Richardson's, 51; ob- 
 jections to ether by Ringer, 23. 
 
320 
 
 INDEX. 
 
 MALINGERERS ether, in detec- 
 tion of, 59. 
 
 Mania acute, chloral hydrate with 
 bromide of potassium, 209. 
 
 Mandragora wine, 13. 
 
 Ma-yo, or Indian hemp, 13. 
 
 McQuillan, action of anaesthetics 
 on the blood corpuscles, 170. 
 
 Migraine, chloral hydrate, 227. 
 
 Metric system in medicine, 311. 
 
 Metric system in lengths, 312. 
 
 Medico-legal relations of anesthet- 
 ics, 274 ; of chloroform, 285 ; by 
 Dr. R. M. Denig, 286; ether, 
 284; by Dr. N. L. Folson, 285; 
 nitrous oxide, 286; Mr. F. W. 
 Braine, 286. 
 
 Methylene Bichloride, discovery, 
 trials as an anaesthetic, mode 
 of preparation, 63, 296. 
 
 Methyl-iodide, 66. 
 
 Mixtures of chloroform, ether and 
 alcohol, 145, 152, 155. 
 
 Mixed anaesthetics, 151. 
 
 Morton Dr., crowning results with 
 ether, 15. 
 
 Morphia with chloroform, 134, 273. 
 
 Morphia as a local anaesthetic, 
 273.. 
 
 Morphia and chloral hydrate to 
 prevent bad effects of morphia, 
 220. 
 
 Mortality statistics, ether, 33-44; 
 chloroform, 113; mixed anaes- 
 thetics, 152; nitrous oxide gas, 
 199. 
 
 NARCOSIS, mixed, 134. 
 
 Nervous headache, chloroform for, 
 138. 
 
 Neuralgia, chloroform in, 137-139; 
 after ether, 144; uncomplicated, 
 nitrous oxide for, 205; chloral 
 hydrate for, 219. 
 
 Nitrite of Amyl in anginapectoris, 
 125; in asthma, 125; anaesthetic, 
 125-129; as an antidote to chlo- 
 roform, 104; number of success- 
 ful cases, 119; cardiac dilata- 
 tion, 133; failure of amyl treat- 
 ment in chloroform narcosis, 
 121; failure of in epilepsy, 
 
 132, impurities of, 116; mcde 
 of administration, 118-125; 
 physiological action on ani- 
 mals, 118-125; physiological 
 action on man, 117-125; prepa- 
 ration, 116; properties and ef- 
 fects of, 117; successful treat- 
 ment in chloroform narcosis, 
 119; therapeutic uses, 132-3; 
 tinnitus aurium, 132. 
 
 Nitrous Oxide Gas, advantages of 
 being prepared fresh, 165 ; cases 
 of disease in which it can be 
 given, 166; cases of death sup- 
 posed to have been caused by 
 it, 199 ; caution in case of feeble 
 heart, 167; difficulties and dan- 
 gers,166; experiments in dental 
 and- minor surgery, 205; experi- 
 ments by Dr. Evans, of Paris, 
 188; experiments of Drs. B.W. 
 Richardson and Sansom, 172; 
 experiments of Drs. Snow and 
 Sansom, 172; experiments of 
 Dr. McQuillen, 174; experi- 
 ments of Drs. McQuillen, 
 Thomas and Turnbull, 176; ex- 
 periments of Drs. Jeannel and 
 Emory, 177; experiments of 
 Drs. Jolyet and T. Blanche, 
 184; experiments with the 
 spectroscope, 192; gasometer, 
 with inhaler, etc., 162; how it 
 differs from nitrogen carbonic 
 acid, 169; mode of making, 
 250; its action on the blood 
 corpuscles, 170 ; mode of pre- 
 paration, purification, 161; 
 mode of purifying, 163; on its 
 use as an anaesthetic in stra- 
 bismus operations, 311; opera- 
 tions in surgery, where em- 
 ployed, 139; physiological ac- 
 tion of, 167; therapeutic ap- 
 plication of, 205; unlike chlo- 
 roform and ether, 165. 
 
 ODONTALGIA, local anaesthesia 
 in, 269. 
 
 Ointments of chloroform, 141. 
 
 Otorrhcea foetid, carbolic acid in, 
 267; hydrate of chloral in, 210. 
 
INDEX. 
 
 321 
 
 Ovariotomy, bichloride of methy- 
 lene in, 64, 65, 66; chloroform 
 and ether, 150 ; deaths from bi- 
 chloride of methylene, 66 ; first 
 time chloroform was used in 
 United States, 312. 
 
 Oxide of Ethyl, 24. 
 
 Oxygen Gas as an anaesthetic, 83 ; 
 experiments by Dr. Gray, 296. 
 
 POISONING, by alcohol (chronic), 
 291; chloral, and treatment, 41, 
 222; chloroform, 113, 286; treat- 
 ment, 104. 
 
 Poisoning by strychnia, chloro- 
 form in, 136. 
 
 Post-partum hemorrhage, ether 
 spray, 58. 
 
 Pleurodynia or neuralgia of the 
 chest walls, chloroform for, 140. 
 
 Prurigo, ointment for, 142. 
 
 Pruritus vulvoe, treatment by 
 chloroform, etc., 141. 
 
 Pulse in 140 cases of inhalation of 
 nitrous oxide, 198. 
 
 Pupil in anaesthesia, Budin, Coyne, 
 and Schiff, 92, 95. 
 
 Pupil in chloroform (Dogiel), 90; in 
 ether, action of light upon, 26. 
 
 Pain reliever, chloral and camphor 
 mixture, 229. 
 
 Paralysis of the insane, chloral for, 
 209; local, nitrous oxide gas 
 for, 205. 
 
 Photophobia, chloroform for, 141. 
 
 Phthisis, chloral and chloroform 
 in, 207, 136, 220. 
 
 RESTLESSNESS accompanying 
 paralysis, 219. 
 
 Resuscitation from threatened 
 death from chloroform, 119. 
 
 Retention of urine, chloral hydrate 
 for, 226. 
 
 Richerand, suggesting drunken- 
 ness as a means to reduce dis- 
 locations, 14. 
 
 Ringer Dr., on chloroform during 
 delivery, 143. 
 
 Ringing in the ears, hydrobromic 
 ether for, 71. 
 
 Rheumatism, chloral hydrate with 
 alkalies, 208. 
 
 Rhigolene as a local anaesthetic, 
 272. 
 
 Richardson B. W., of London, 
 opinion concerning Bobbins' 
 ether, 39 ; experiments with 
 nitrite of amyl, 125; method of 
 local anaesthesia, 49, 270; appar- 
 atus, 272. 
 
 SANSOM Dr., when to stop the 
 administration of chloroform, 
 303. 
 
 Schiff, conclusions after more 
 than five thousand experi- 
 ments as to difference of an- 
 aesthesia by ether or chloro- 
 form, 92. 
 
 Scheele, discovery of oxygen gas, 
 14. 
 
 Sciatica, cure of by subcutaneous 
 injections of ether, 57 ; freezing 
 the skin with ether, 23. 
 
 Sea sickness, nitrite of amyl, 133. 
 
 Sexual excitement, abnormal, 57. 
 
 Sick Headache, nitrite of amyl, 
 133. 
 
 Skinner's chloroform inhaling ap- 
 paratus, 249. 
 
 Smith Dr. Andrew H., experi- 
 ments with oxygen gas, 85. 
 
 Snow Dr., on sexes in death from 
 chloroform, 102. 
 
 Spasms, unilateral in children, 
 chloroform, 132. 
 
 Spasm of the glottis, chloroform, '• 
 136; nitrite of amyl, 118; of 
 the stomach, intestines, or 
 heart, 56. 
 
 Spasmodic cough, chloroform, 136". 
 
 Spectroscope, and its relations to 
 anaesthetics, 192. 
 
 Spectral analysis of poisoned 
 blood by Dr. Taylor, 197. 
 
 Sprains, chloroform and camphor 
 in, 141. 
 
 Sub-occipital neuralgia, chloro- 
 form, 140. 
 
 Sunstroke or heat toxemia, chlo- 
 ral hydrate, 209. 
 
 Syme's method ot preventing 
 death from chloroform, 105. 
 
 Symptoms of danger from chlo- 
 
322 
 
 INDEX. 
 
 roform, 91; chloral, 222; chlo- 
 ride of ethidene, 83 ; ether, 28 ; 
 mixed anaesthetics,152; methy- 
 lene bichloride, 66; nitrous ox- 
 ide, 166. 
 
 Syncope from chl©roform, 89; 
 ether, 27 ; treatment by nitrite 
 ofamyl, 133; nitrous oxide, 197. 
 
 TABLE of anaesthetics, 16, 17 ; of 
 deaths from chloroform, 113; of 
 deaths from mixed anaesthet- 
 ics, 152-155 ; of deaths from 
 chloroform in children, 109-113; 
 of deaths from ether, 33, 40 ; of 
 cases traumatic tetanus, 71. 
 
 Tapeworm, ether alone or com- 
 bined for, 224. 
 
 Tetanus, chloral hydrate hypoder- 
 mically, 209. 
 
 Tetrachloride of Carbon, local an- 
 aesthetic, 264. 
 
 Thomas Dr., the late, his inhaler 
 for nitrous oxide, 250. 
 
 Thomas Dr. J. D., on nitrous oxide, 
 159; number of cases since 1876, 
 197. 
 
 Tinnitus aurium, treatment of by 
 amyl nitrite, 133; hydrobromic 
 ether, 71. 
 
 Toxicological effects of chloroform, 
 90. 
 
 Toothache, use of chloroform in, 
 140, 269. 
 
 Traumatic tetanus, chloral in, 223. 
 
 Therapeutic application of carbolic 
 acid, 267; ether, 57; chloral 223; 
 hydrobromic ether, 70; chloro- 
 form, 135; nitrous oxide, 205. 
 
 Thermometry, a comparison of 
 Centigrade and Fahrenheit 
 scales, 312. 
 
 Valentin on the characteristic 
 bands in alcohol, 196. 
 
 Vaseline, chloroform and ether in 
 combination with, 141. 
 
 Vertigo, nitrite of amyl, 132. 
 
 Vivisections, chloroform, 61 ; ether, 
 60. 
 
 Vomiting, obstinate, of pregnancy, 
 chloral hydrate, 224; occurrence 
 of in ether inhalation, 47 ; pre- 
 vention of in nitrous. oxide and 
 ether, 253. 
 
 WARREN Dr. John C, on the 
 use of ether in the agonies of 
 death, 59; on ether in vivisec- 
 tions, 60. 
 
 Waterman, experiments with the 
 spectroscope, 192. 
 
 Winslow Dr., his case of death 
 from chloroform, 98; trial by 
 the coroner and verdict, 100; 
 action of the grand jury, 101. 
 
 Wyndham Miss, death from ni- 
 trous oxide, 204. 
 
 ERRATA. 
 
 On page 93, on fourth line from the bottom, for " pulse " read " pupil." 
 On page 145, for "Anaesthesia" read "Anaesthesie;" for " Medicine" read 
 "Me'decine;" for "Imperiale" read " Imperiale ; " for " Medicine " 
 read " M6decine ; " for " Pharmacia " read " Pharmacie ; " for "Mili- 
 taries" read " Militaires." 
 On page 147, eleventh line from the top, for Dr." Samson" read " Sansom." 
 On page 155, on twenty-seventh line, for " syncopy " read " syncope." 
 On page 177, for " Hebdomadaire " read " Hebdomidare." 
 
B3T THE S-A-UVCE AUTHOR. 
 
 A CLINICAL MANUAL 
 
 OF 
 
 DISEASES OF THE EAR, 
 
 INCI/UDING THE 
 
 ANATOMY, PHYSIOLOGY, PATHOLOGY, AND TREATMENT. 
 
 By Laurence Turnbull, M. D., 
 
 Aural Surgeon Jefferson Medical College Hospital ; Physician to the Department of the Eye and Ear, 
 Howard Hospital, Philadelphia. 
 
 8vo. 500 pages. 106 illustrations. Pull Indes, etc. Price reduced to $4. 
 
 From the Boston Medical and Surgical Journal. 
 "Sound, clear, and eminently practical'in all its parts." 
 
 From the Detroit Review of Medicine. 
 " A book of great value to all, both specialist and general practi- 
 tioner." 
 
 From the Atlanta Medical and Surgical Journal. 
 " Dr. Turnbull's book will be of great service to all who purpose to 
 keep pace with the progress in this department of our profession. 
 Every physician should have it." 
 
 From the St. Louis Medical and Surgical Journal. 
 "On the whole, the work is a valuable one, and such as we can 
 recommend." 
 
 From the Cincinnati Lancet and Observer. 
 " Take it altogether, we think our readers cannot do better than to 
 place a copy of ' Turnbull's Manual of the Diseases of the Ear ' in their 
 library for reference." 
 
 From the Canada Lancet. 
 "The work deserves well of the profession, and will, no doubt, sooner 
 or later find a place in every reading man's library." 
 
 From the Philadelphia Medical and Surgical Reporter. 
 "The book, as a whole, is ihe very best work on aural complaints, 
 for the general practitioner, with which we are acquainted." 
 
 ■&§~For sale by booksellers generally, or will be sent by mail, postage 
 paid, on receipt of the price. 
 
 J. B. LIPPINCOTT & CO., Publishers, Philadelphia.