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C7 i 
 
 Anesthesia and Anesthetics 
 
 GENERAL AND LOCAL 
 
 FOR PRACTITIONERS AND STUDENTS 
 OF MEDICINE AND DENTISTRY 
 
 BY 
 
 JOSEPH M. PATTON, M. D. 
 
 Professor of Internal Medicine, Chicago Policlinic ; Clinical Professor 
 
 of Diseases of the Chest, Medical Department 
 
 University of Illinois 
 
 SECOND EDITION, REVISED AND ENLARGED 
 
 Illustrated 
 
 CHICAGO 
 CLEVELAND PRESS 
 
 iqo6 
 
 ' 
 
LIBRARY ef CONGRESS 
 Twe Copies Received 
 
 SiP 14 *906 
 Cefyfif ht Entry 
 
 CUSS/^a XXc, N. 
 
 COPY 8. 
 
 
 Copyright 1906 
 
 BY THE 
 
 CLEVELAND PRESS 
 
 CHICAGO 
 
PREFACE TO THE SECOND EDITION. 
 
 The commendation which has been given this work, and the 
 early necessity for a second edition leads the author to assume 
 that it fills fairly well the requirements of those for whom it was 
 written. The growing realization of the importance of a thor- 
 ough knowledge of the practical application of anaesthetic agents, 
 a branch to which entirely too little attention is required by our 
 medical schools, is keeping pace with advancements in the field 
 of anaesthesia and the special methods and intentions of its'em- 
 ployment. 
 
 The past few years have been prolific of methods to improve 
 the means of inducing satisfactory narcosis with a minimum of 
 risk, and also have developed more definite knowledge of the 
 physiologic and toxic effects of anaesthetic agents. We have at- 
 tempted to incorporate in this edition the advancement in our 
 knowledge of general anaesthesia, and such improvement in meth- 
 ods of application as have been thoroughly tested and are of ac- 
 knowledged utility. 
 
 Some slight changes have been made in the arrangement of 
 this volume, and new matter has been added on delayed chloro- 
 form poisoning, scopolamine-morphine anaesthesia, status thymi- 
 cus, ethyl chloride, spinal anaesthesia, stovaine, and the use of 
 adrenalin in connection with spinal and local anaesthesia. 
 
 With appreciation of the reception accorded this work the 
 author trusts that the second edition will be as kindly received as 
 was the first. J. M. P. 
 
PREFACE. 
 
 This book is not intended as a treatise on anaesthesia, or anaes- 
 thetics, its limitations being too pronounced. Neither has it any- 
 thing original to set forth. Its production was impelled rather 
 from the want of a work on this subject sufficiently concise to fit 
 the opportunities of the average student or busy practitioner, yet 
 complete enough to afford a fair and impartial resume of our 
 present knowledge of this important subject. 
 
 The rather extensive literature of the past decade on the sub- 
 ject of anaesthesia attests a growing realization of the importance 
 of more accurate knowledge of anaesthetics and their administra- 
 tion. The growing tendency to relegate the administration of 
 anaesthetics to those who are more or less expert in their admin- 
 istration is even now extending beyond hospital service and into 
 private practice, and the necessity in our medical colleges of both 
 instruction and practice in the administration of anaesthetics is 
 being recognized. Instead of regarding the anaesthetist as the 
 least important factor in the successful outcome of a surgical pro- 
 cedure, it is understood that in some instances, at least, his may 
 be a responsibility equal to, if not greater than, that of the opera- 
 tor himself. In other words, many of the accidents and complica- 
 tions of, and sequences to, the administration of anaesthetics may 
 be avoided by intelligent and skillful administration. 
 
 Credit is given in the text to those whose authority has been 
 abstracted. It remains only for the author to acknowledge the 
 courtesy of Dr. Elgin MaWhinny, of the Northwestern Dental 
 School, who has written the chapter on Local Anaesthetics in Den- 
 tistry ; and that of Dr. L. L. Skelton, professor of physiology in 
 the Chicago College of Dentistry, for revising and offering sug- 
 gestions to the chapter on the physiology of anaesthesia. 
 
 J. M. P. 
 
CONTENTS. 
 
 PART I. 
 
 GENERAL ANESTHESIA AND ANESTHETICS. 
 
 CHAPTER I. 
 
 Historical, — Origin of term Anaesthesia — Ancient beliefs, investiga- 
 tions and writers — Volatile narcotics — Methods of early part of seven- 
 teenth century — Hypnotism — Use of gases leading to discovery of anaesthe- 
 sia — Humphrey Davy — Faraday and ether — Hubbard and nitrous oxide — 
 Dr. Long — Wells — Jackson and Morton — Guthrie and chloroform — Simp- 
 son and chloroform — Investigations of chloroform — Colton and gas-con- 
 troversies — Work of Clover — "Glasgow Committee" — Hyderabad commis- 
 sion — Later investigations — Spinal anaesthesia — Sequential anaesthesia. 
 
 CHAPTER II. 
 
 General Physiology. — Nature of general anaesthesia — Character of 
 agent — Entrance into organism — Absorption — Elimination — Dyspnoea — 
 Blood changes — Effect on nervous system, on respiration, on muscular sys- 
 tem, on heart — Stages of anaesthesia. 
 
 CHAPTER III. 
 
 The Selection of a General Anesthetic with Reference to the 
 Comparative Danger of the Agent Employed. — Development of practical 
 knowledge regarding administration — Nitrous oxide — Oxygen — Chloro- 
 form — Ether — Comparative statistics — Condition of subject — Method of 
 administration — A. C. E. mixture — Comparative figures. 
 
 CHAPTER IV. 
 
 The Selection of an Anesthetic with Reference to the Patient. — 
 Physical condition and danger — Sexes — Age — Infants and young children 
 — Old people — General condition — Debility — Plethora — Alcoholic subjects 
 — Drug habitues — Tobacco users— Menstruation — Pregnancy — Frequent 
 anaesthetization — Pathologic conditions of blood, of respiratory tract, of 
 heart and blood vessels — Abdominal conditions — Exhaustion — Shock — Col- 
 lapse — Status thymicus — Kidney diseases — Diabetes — Nervous diseases. 
 
 CHAPTER V. 
 
 The Selection of an Anesthetic with Reference to the Opera- 
 tion. — Short operations — Operations on brain and spinal cord — Ophthalmic 
 operations — Operations on face, jaws, lips, tongue, palate, tonsils, nose and 
 nasopharynx — Extraction of teeth — Laryngeal operations — Neck exclusive 
 
VI CONTENTS 
 
 of air tract — Chest — Brain — Abdomen — Rectum and genito-urinary organs 
 — Gynecological operations — Obstetric operations — Operations on extremi- 
 ties. 
 
 CHAPTER VI. 
 
 Before the Administration of an Anaesthetic. — Time of Day — Diet 
 — Disinfection of mouth — Bowels — Bladder — Medicine — Cocaine solution — 
 Strychnia — Morphine and atropine — Physical examination — General con- 
 dition — Temperature of room — Ventilation — Clothing of patient — Postures 
 during induction — Moving patients — Appliances and remedies — Aseptic 
 precautions. 
 
 CHAPTER VII. 
 
 Posture During Anaesthesia. — Respiratory difficulty from faulty pos- 
 ture — Circulatory trouble from position — Interference with operation — 
 Posture for extraction of teeth — For operations about oral cavity, head, 
 etc., larynx, trachea, neck, ophthalmic operations, chest, abdomen, kidney, 
 genito-urinary organs. 
 
 CHAPTER VIII. - 
 
 Nitrous Oxide. — Nature — Preparation — Commercial service — Physio- 
 logical effects and action — Administration — Dangers of administration — 
 Administration of definite quantities of nitrous oxide and air — Adminis- 
 tration of nitrous oxide and indefinite quantities of air — Adminstration of 
 nitrous oxide and oxygen. 
 
 CHAPTER IX. 
 
 Ether. — Discovery — Nature — Impurities — Physiological effects and ac- 
 tion, first stage, second stage, third stage — Toxic effects — After effects — 
 Dangers of administration — The administration, by the open system, par- 
 tially closed system, close method — Oxygen and ether — Rectal etherization 
 — Proper extent of anaesthesia — Management of accidental conditions inci- 
 dent to the period of administration — Clinical conclusions. 
 
 CHAPTER X. 
 
 Chloroform. — Discovery — Nature — Impurities — Physiological effects 
 and action, first stage, second stage, third stage — Toxic effects — Physio- 
 logical action — Lethal effects — After effects — Dangers of administration — 
 The administration — Management of complications — Delayed, chloroform 
 poisoning. 
 
 CHAPTER XI. 
 
 Scopolamine-morphine Anaesthesia.— Physiologic effects — Method of 
 employment. 
 
 CHAPTER XII. 
 
 Ethyl Bromide. — Discovery — Physiological effects — Dangers of ad- 
 ministration. Ethyl Chloride. — Nature — Use as anaesthetic — Character of 
 anaesthesia — Application. Bichloride of Methylene — Nature — Introduc- 
 
CONTENTS Vli 
 
 tion as anaesthetic — Character of anaesthesia — Dangers — Method of admin- 
 istration. Ethidene Dichloride — Nature — Use as anaesthetic — Dangers — 
 Method of administration. Amylene — Nature — Effects — Character of an- 
 aesthesia — Dangers. Pental — Use as anaesthetic — Effects. Other Agents. 
 
 CHAPTER XIII. 
 
 Spinal Anaesthesia — Effects : — After effects — Complications — Failure — 
 
 Contra-indications — Mortality — Solution and dose — Technique. Stovaine 
 in spinal anaesthesia. 
 
 CHAPTER XIV. 
 
 Mixtures for Anaesthesia. — Principle— A. C. E. mixture — Billroth's 
 mixture — Chloroform and ether, 2 parts chloroform and 1 part ether, 1 
 part chloroform and 4 parts ether, 1 part chloroform and 3 parts ether, 1 
 part chloroform and 2 parts ether — Chloroform and alcohol — Schleich's 
 mixture — Somnoform. 
 
 CHAPTER XV. 
 
 Sequences of Anaesthetics. — Nitrous oxide-ether-Chloroform-ether — 
 A. C. E.-ether — Ether-chloroform — Ethyl chloride-ether — Other sequences. 
 
 CHAPTER XVI. 
 
 After the Administration of an Anesthetic. — After Depression — 
 Rapidity of recovery — General management — Diet — Vomiting — Bronchial 
 and pulmonary symptoms — Etiology of lung complications — Statistics of 
 post anaesthesia pneumonia — Embolic pneumonia — Gangrene and abscess 
 of lungs — Paralysis — Anuria. 
 
 PART II. 
 
 LOCAL ANESTHESIA AND ANESTHETICS. 
 
 CHAPTER XVII. 
 
 Local Anesthesia. — General considerations — Application to special 
 operations and regions — Cocaine — Cocaine hydrochloride — Local infiltra- 
 tion method, technique — Regional paraneural infiltration, technique — Re- 
 gional intraneural method — Other local anaesthetic agents — Eucaine A. — 
 Eucaine B. — Tropa cocaine hydrochloride — Holocain — Nirvanin — Ortho- 
 form — Aneson — Ethyl chloride — Liquid air — Novocaine — Stovaine — Alypin. 
 
 CHAPTER XVIII. 
 
 Local Anesthetics in Dentistry. — Objections to general anaesthesia 
 — Gradual increase in employment of local agents — Conclusions regarding 
 cocaine — Chloretone — Technique of injecting — Orthoform — Cocaine for 
 anaesthetizing tooth pulp — Cocaine by cataphoresis — Stovaine. 
 
ILLUSTRATIONS 
 
 Fig. . Page. 
 
 Chart showing relation of clanger rate to age 40 
 
 1. Hewitt's modification of Mason's gag 52 
 
 2. Trendelenberg's Trachea Tampon, canula and inhaler 53 
 
 3. Westmoreland's mouth gag 66 
 
 4. Rosier's mouth gag .' 66 
 
 5. Denhart's gag 66 
 
 6. Mason's gag 66 
 
 7. Heister's gag 67 
 
 8. Plain oral screv? 67 
 
 !). Mathieus' tongue forceps ....... 67 
 
 10. Heuce's tongue forceps 67 
 
 11. Daintree's adjustable mouth prop 67 
 
 12. Soft-rubber bite-blocks 67 
 
 13. Postures for anaesthesia 69-70 
 
 14. The S. S. White gasometer 74 
 
 in. Diagram of White gasometer 75 
 
 16. Universal gas stand 70 
 
 17. White's Inhaler 81 
 
 18. Mouth piece and Inhaler 82 
 
 19. Anaesthetic Inhaler (Hillard) 85 
 
 20. Goldan's stop cock 91, 92, 93 
 
 21. Diagram of Goldan's stop cock 94 
 
 22. Goldan's apparatus for N 2 and 95 
 
 23. White's apparatus for N 2 and 96 
 
 24. Allis' Inhaler 108 
 
 25. Fowler's modification of Allis' Inhaler 109 
 
 26. Clover's Inhaler 110 
 
 27. Section of Clover's Inhaler at "O" Ill 
 
 28. Section of Clover's Inhaler at "F" 112 
 
 29. Diagram of Air Current in Clover's Inhaler 113 
 
 30. Bennett's Inhaler I. — ether 114 
 
 31. Bennett's Inhaler II. — gas 115 
 
 32. Bennett's Inhaler III. — gas and ether 116 
 
 33. Junker Inhaler 137 
 
 34. Esmarch Inhaler 139 
 
 35. Skinner mask 140 
 
 36. Pierpont's folding chloroform inhaler 141 
 
 37. Schimmelbusch-Esmarch Inhaler 141 
 
 38. Plain ether drop bottle 141 
 
 39. Hahn's drop bottle 141 
 
 40. Gwathmey's vapor-inhaler 142 
 
 41. Annandale's tracheal canula and tube 144 
 
 42. Fell's apparatus for inflation 149 
 
 43. Richardson's double bellows for forced respiration 150 
 
 44. Needles and syringe for spinal anaesthesia 167 
 
 45. Diagram of vertebra 168 
 
 46. Coming's needle 169 
 
 47. Sitting posture for spinal anaesthesia 170 
 
 48. Iliac crests 171 
 
 49. Needle entering opposite 4th spine 172 
 
 50. Tuffier's syringe and needle 173 
 
 51. Method of inserting needle in spine 174 
 
 52. Stone's mask for Schleich's solution 1S1 
 
 53. Somnoform Inhaler 183 
 
 54. Tube diagram, somnoform Inhaler 183 
 
 55. Hewitt's modification of Clover's Inhaler, for N 2 and ether 186 
 
 56. Gwathmey gas-ether Inhaler 187 
 
 57. Diagram of Gwathmey Inhaler 1SS 
 
 58. Dawbarn's Inhaler 190 
 
 59. Ethyl chloride tube 213 
 
PART I. 
 
 General Anaesthesia and 
 Anaesthetics. 
 
CHAPTER I. 
 
 HISTORICAL. 
 
 Three achievements stand out in the records of the last cen- 
 tury which for the direct mitigation of human ills and indirect 
 influence upon the advancement of medical science have no paral- 
 lels in the history of medicine. It is hardly necessary to say 
 that these achievements are vaccination, anaesthesia, and antisep- 
 sis. 
 
 Anaesthesia is the term that was given by Dr. Oliver Wendell 
 Holmes to denominate that lethargic state which had from time 
 immemorial been at once the hope and the despair of medical 
 savants, and the successful induction of which he apostrophized 
 as follows : "Nature herself is working out the primal curse 
 which doomed the tenderest of her creatures to the sharpest of 
 her trials ; but the fierce extremity of suffering has been steeped 
 in the waters of forgetfulness, and the deepest furrow in the 
 knotted brow of agony has been smoothed forever." This Death 
 of Pain, this medical will-o'-the-wisp, had for centuries eluded 
 the grasp of medical investigators -ever since the Great Physician 
 "caused a deep sleep to fall upon Adam; and he slept; and he 
 took one of his ribs and closed up the flesh instead thereof." 
 
 The anticipation of a pain-destroying agent was a medical 
 dream, older, more persistently pursued, and more enticing than 
 the fancies of the fabled lotus-eaters. No other possibility in 
 medicine ever held forth such allurement to the surgical patient, 
 of whose feelings on the approach of the surgeon Tennyson 
 wrote, "Sent a chill to my heart when I saw him come in at the 
 door." 
 
 The belief in and the search after some agent by which 
 pain might be annihilated is as old as medicine itself. The fact 
 that though the ancients employed various devices to annul pain 
 the eighteenth century was not marked by any advance in this 
 direction, notwithstanding its eminent medical men, has been a 
 subject of comment. The atmosphere of mysticism, charms, in- 
 cantations and charlatanism that surrounded the early history of 
 
12 HISTORICAL 
 
 pain-destroying agents tended to discredit the whole matter, and 
 ill part, at least, explains why the age that produced Sydenham 
 and Pare was barren in this respect. Then too, must be taken 
 into consideration the religious ideas, based on the primeval curse, 
 which were prevalent at that time and against which Simpson 
 waged such an energetic and convincing campaign. 
 
 In Homer's Odyssey there is reference to a drug used by Helen 
 as a nepenthe or narcotic, "a drug to lull all pain and anger and 
 bring forgetfulness of every sorrow." The nature of the nepenthe 
 of Helenwhich "Immediately she (Helen) dropped into the wine 
 of which they drank," is unknown, but it is believed by some 
 to have been onjnm . Dioscorides and Pliny, about the begin- 
 ning of the Christian era, described the Memphis stone which 
 gave forth soporific fumes. The former describes the use of 
 a decoction of the root of the Atropa Mandagora in wine: "And 
 some making decoctions in wine of the ro*Dis^±o_a third, this be- 
 ing strained is put past. Using one wine-glassful in the case of 
 the sleepless and those suffering excessive pain, and in the case 
 of those on whom they wish to produce insensibility when cut or 
 burnt." Dioscorides further describes the hypnotic effects of 
 mandrak e roots on shepherds, and the analgesic properties of 
 the decoction as used by physicians. This drug, according to 
 Theodoric, when mixed with other narcotics and inhaled caused 
 a deep sleep from which the patient could only be aroused by 
 the fumes of vinegar. The Romans used mandrak e to stupefy 
 criminals at the time of crucifixion, though probably the material 
 used was a compound of several drugs. Mandrake was used as 
 a surgical anaesthetic down to the thirteenth century, and its 
 employment is mentioned by Galen. Lucian makes several ref- 
 erences to mandagora : "But do you think he has been so dosed 
 with mandagora as to hear those things, and not to know?" — 
 "Adversus Indnctum," 23 ; "You sleep as if through mandagora." 
 — "Timon," 2. 
 
 According to Foy, the schools both of the Eastern and Western 
 Califates were familiar with and employed mandagora. Its prop- 
 erties were described by Avicenna, Averhoes, Paulus, Aetius, 
 Isodorus, Serapion, Celsus, and others. They employed it as a 
 hypnotic and analgesic in various ways. Mandrake has been 
 used to relieve the pains of labor, and Dr. Sylvester suggested 
 
HISTORICAL 13 
 
 that it was for such a purpose that Rachel begged the mandrake 
 from Ruben. 
 
 In the third century a Chinese surgeon Hoa-tho, is said to 
 have employed some sort of anaesthetic drug, and in the thir- 
 teenth century da Lucca, a Tuscan surgeon, employed an oil by 
 inhalation. The Assyrians compress ed the vessels of the neck 
 by a band before practicing circumcision. 
 
 With the introduction into Europe, by the Moslems, of the 
 process of distillation, we find the employment of volatile prepa- 
 rations for the purpose of relieving pain. Giabattista Porta 
 (1589), a surgeon of Naples, tells of volatile drugs, — an essence 
 of hyoscyamus, solanum, poppy, and belladonna, kept in leaden 
 vessels — which drugs produced sleep upon inhalation : "Thereby 
 he would be buried in a most profound slumber, nor be aware of 
 what had been done to him." Vigo tells of producing insensi- 
 bility by "smelling of a sponge wherein opium is." Theodorico, 
 son of Ugone da Lucca (born in the middle of the twelfth cen- 
 tury), tells of an oil de lateribus prepared and used by his father, 
 which by inhalation alone put patients asleep on occasions of 
 painful operations. He further describes the substance used with 
 the somniferous sponge of da Lucca as consisting of opium, mul- 
 berry juice, hyoscyamus, mandagora, wood ivy, lettuce seeds, 
 dock seeds, and water hemlock. In this mixture a sponge is 
 boiled. For use it was soaked in hot water and applied to the 
 nostrils. A sponge dipped in vinegar was applied to the nos- 
 trils to awaken the patient, or the juice of the root of fenngrek 
 was thrown into the nostrils. 
 
 The principle of the inhalation of volatile substances is very 
 ancient. Aphrodite threw herself on a bed of lettuce in order to 
 mitigate her grief for the death of Adonis. 
 
 J jidia n hemp is an old remedy for pain, and was used to stu- 
 pefy criminals. Herodotus mentions a custom of the Scythians of 
 inhaling the fumes of a certain kind of hemp. Indian hemp was 
 used as an analgesic even earlier than mandrake. M. Julien laid 
 before the French Academy of Medicine a manuscript called 
 Ko-Kin-i-ting which contained the information that Ho-tho 
 gave a preparation of hemp (ma-yo) to patients, who became 
 insensible as if "drunk, or deprived of life," and who, when re- 
 vived, had not felt the slightest pain during the operation. 
 
14 HISTORICAL 
 
 The name "haschish," by which Indian hemp was known in 
 the Orient, is said to have given rise to the term assassin (liter- 
 ally, eater of haschish) because an Arab Sheikh fed the drug 
 to his followers in order to produce delightful sensations which 
 he induced them to believe he could obtain for them eternally if 
 they would carry out his bloodthirsty designs. Simpson thought 
 the nepenthe of Homer was a species of Indian hemp. 
 
 Reference to the poetry of the sixteenth and seventeenth cen- 
 turies shows that drugs of this nature were well known at that 
 period. Thus : "Bringeth his patient in a senseless slumber,"— 
 Du Bartas ; also, "Will stupefy and dull the sense awhile." . . 
 . . ''locking up the spirits a time." — Shakespeare. Chumappe 
 (1534) alludes to the use of soporific preparations at that period, 
 Boerhaave's anaesthetic powder is said to have consisted of oil 
 of cinnamon, oil of cloves, citron peel, sugar, red coral, and 
 opium. A dose was given one hour before operation, and an- 
 other one-quarter of an hour before if necessary. Brooke (1562), 
 from whom Shakespeare was supposed to have derived much in- 
 spiration for his "Romeo and Juliet" (1597), in his "Tragical 
 Historye of Romeus and Julietta," etc., describes friar Laurence 
 as a great searcher of nature's secrets and a maker of "divers 
 soporiferous simples" which would bring the "receiver into such 
 a sleepe and burieth so deeply the senses and other spirits of 
 life, that the cunningest Phistian will judge the party dead." 
 Also, "When the operation is perfect and done hee returneth into 
 his first estate." 
 
 Marlowe, in The Jew of Malta, refers to the mandagora thus : 
 
 "I drank of poppy and cold mandrake juice, 
 And being asleep, belike they thought me dead, 
 And threw me o'er the walls." 
 
 Even as late as Mrs. Browning we have the following : 
 "Have the pigmies made you drunken 
 Bathing in mandagora ?" 
 
 In the early part of the seventeenth century Valverdi, an 
 Italian, practised compression of the vessels of the neck in or- 
 der to produce unconsciousness, a procedure undertaken by the 
 ancient Assyrians at the time of circumcision. Compression of the 
 vagi, of the limb to be operated on, of the nerve supplying the 
 
« 
 
 HISTORICAL 15 
 
 part to be operated on, have all been recommended and prac- 
 tised. Dorsey, Mott, Norris, and others tell of their more or 
 less successful use of opium or whisky, or both, to produce some 
 greater or less degree of insensibility to pain during operations. 
 
 Hypnotism was known to the ancient Egyptians, Persians, 
 and Indians, and it is thought by some that they may have used 
 it for the purposes of surgical anaesthesia. Simpson quotes the 
 lines of Middleton (1617) : 
 
 'Til imitate the pities of old surgeons 
 
 To this lost limb— who ere they show their art 
 
 Cast me asleep, then cut the diseased part." 
 
 Greatrakes (1661), by means of passes over the subject's body 
 produced a magnetic sleep. Greatrakes was a celebrated Irish 
 "stroker" who was called to England tc treat Lady Conway, of 
 Warwickshire. He obtained considerable notoriety. 
 
 In 1766 Anthony Mesmer appeared with his theory of "Ani- 
 mal Magnetism." In 1839 a Frenchman named Potet introduced 
 hypnotism into London under the name of mesmerism. He was 
 supported by Dr. John Elliotson of the University College Hos- 
 pital, who was subsequently ruined because of his advocacy of 
 mesmerism. The British physicians, Simpson, Liston, Braid, and 
 Edsaile, of Calcutta, were more or less successful in experi- 
 menting with hypnotism. Edsaile is said to have employed hyp- 
 notism in connection with rather severe surgical operations. The 
 ancient Greek physicians must have recognized the principle of 
 hypnotism, for in the Greek Anthology we have : "Touching 
 them with his hands he (the physician) quickly makes them 
 whole." 
 
 Although sulphuric ether was discovered by Valerius Cordus 
 in the year 1540 (though by some its discovery is attributed to 
 the Arabian chemist Djafar Yeber), hydrogen by Cavendish in 
 1766, nitrogen by Rutherford in 1772, oxygen by Priestly in 1774, 
 and nitrous oxide by Priestly in 1772 or 1776, it was not until the 
 close of the eighteenth century that these gases began to be em- 
 ployed in any manner likely to lead to the discovery of their 
 anaesthetic properties. The inhalation of ether for the relief of 
 asthma was recommended by Pearson, of Birmingham, in 1795. 
 Beddoes organized a "Pneumatic Institute" at Clifton in 1798 for 
 
l6 HISTORICAL 
 
 the treatment of pulmonary diseases by the inhalation of gaseous 
 and vaporized medicaments. Thornton and others also employed 
 like medication about the same period. In 1799 or 1800 Mr. 
 Humphrey Davy, then an assistant of Dr. Beddoes, discovered 
 by personal experiment that nitrous oxide gas would relieve tooth- 
 ache and other pains, and suggested its use for the production of 
 anaesthesia. He described its effects as "uneasiness being swal- 
 lowed up for a few minutes by pleasure." Although he does not 
 appear to have carried its administration far enough to produce 
 unconsciousness, he nevertheless recognized the possibilities of 
 nitrous oxide gas in this direction, and recommended its employ- 
 ment in "surgical operations in which no great effusion of blood 
 takes place." 
 
 In the early part of the past century the effect of nitrous 
 oxide gas was known to many, and the gas was inhaled for diver- 
 sion by the students of the University of Pennsylvania. "Ether 
 frolics" were an amusement of the time among young people. 
 
 In 1S18 Faraday pointed out that ether when inhaled had 
 effects similar to laughing gas, as the following from the Eng- 
 lish Quarterly Journal of Science and Arts, which is attributed 
 to him, shows : "When the vapor of ether mixed with common 
 air is inhaled it produces effects very similar to those occasioned 
 by nitrous oxide. ... By the imprudent inspiration of ether 
 a gentleman was thrown into a very lethargic state, which con- 
 tinued with occasional periods of intermission for more than 
 thirty hours." 
 
 In October, 1888, Dr. O. P. Hubbard read a paper before the 
 New York State Medical Association, in which he detailed the 
 circumstances of the administration of nitrous oxide gas to his 
 brother and others at Rome, Oneida county, N. Y., in November, 
 1 82 1. During one of the exhibitions a young man was found 
 in an adjoining room lying completely unconscious beside the 
 gasometer. He was removed and soon recovered from the un- 
 conscious state. 
 
 Pereiras' work on Materia Medica (1839), described the an- 
 aesthetic properties of ether when inhaled, and in 1842 Dr. Craw- 
 ford W. Long, of Georgia, who is said to have learned from a 
 negro servant named Wichita that complete unconsciousness had 
 resulted some time previously in a negro lad whom his companions 
 
HISTORICAL 17 
 
 had forcibly compelled to inhale some ether, employed ether while 
 removing a tumor. He had used it for the relief of pain, and 
 subsequently to this operation he repeated his experiments, and 
 demonstrated the use of ether to his brother physicians. He ap- 
 pears to have been conservative in his exploitation of the use of 
 ether, and while directly in the line of success the world at large 
 was not made to recognize this until after he was forestalled by 
 Morton in the practical application of ether as a general surgical 
 anaesthetic. Dr. Long is regarded by many, especially in the 
 Southern States, as the discovererof ansesthesia. (A statue of 
 Dr. Long is to be placed in analTatWashington, D. C, reserved 
 for the statues of two distinguished men from each State. The 
 statue is a memorial from the physicians of the State of Georgia.) 
 
 In December, 1844, Dr. Horace Wells, a dentist of Hartford, 
 Conn., observed while attending a popular lecture given by a 
 Mr. Colton, a chemist, that a Mr. Cooley while under the influ- 
 ence of laughing gas struck and injured his limb without suffer- 
 ing any pain. He at once experimented upon himself, and sub- 
 mitted to the extraction of an aching tooth, at the hands of a 
 colleague named Rigg, while under the influence of nitrous oxide 
 gas. He successfully repeated the experiment upon others, and 
 instituted what he called a "new era in tooth-pulling." 
 
 In company with a former pupil, W. T. G. Morton, he at- 
 tempted to give a demonstration in Boston in 1844. The attempt 
 failed, according to Wells, because of the premature withdrawal 
 of the gas. The crowd of practitioners and students present were 
 frank and unrestrained in their expressions of disapproval, 
 and the disappointment resulting from this failure induced an 
 illness from which Wells never recovered. He explained his dis- 
 covery before the French Academy of Sciences in 1846, and 
 died in New York, in 1848. It is said he opened a vein while 
 in his bath.* 
 
 William Thomas Green Morton was born in Massachusetts, 
 studied dentistry in Baltimore, and was a successful practitioner 
 in Boston. He experimented with drugs and with hypnotism in 
 connection with the painless extraction of teeth, and as we have 
 seen was associated with -Wells in his investigations of nitrous 
 oxide gas. After the failure of the experiment ■ of Wells he 
 abandoned gas and tried chloric ether with unsatisfactory re- 
 
 *Interesting articles related to the Wells-Morton-Jackson-Long con- 
 troversy have been published .by W. J. Morton, M. D., of New York, in 
 the Post Graduate, 1905, and by William Sedgwick, M. R. C. S., of En- 
 gland, in the Medical Times and Hospital Gazette, 1903. These articles 
 represent different views of the controversy, but otherwise contain noth- 
 ing essentially different from the facts contained in this chapter. 
 
l8 HISTORICAL 
 
 suits. At the suggestion of his preceptor Dr. Charles Jackson — 
 Morton being at that time a student of medicine — a physician 
 of Boston, but best known as a geologist and chemist, he expe- 
 rimented with sulphuric ether, beginning his experiments on ani- 
 mals. His success in this direction encouraged him to make a 
 personal experiment, and in September, 1846, he inhaled ether 
 from a handkerchief while sitting in his operating chair. He 
 was unconscious for several minutes, and on regaining conscious- 
 ness he was so elated by his success that he decided to again in- 
 hale the drug and submit to an extraction while under its influ- 
 ence. At this moment the door bell rang and he admitted a man 
 nc'tned Eben Frost whose face was bandaged and who was in 
 that state of mingled hope and consternation so familiar to all 
 dental surgeons. He asked if it were not possible to mesmerize 
 him, and readily consented to inhale ether when assured that it 
 was superior to mesmerism. To the joy of the operator and the 
 astonishment of the patient the attempt was perfectly successful, 
 and thus was accomplished the first operation under ether anaes- 
 thesia. 
 
 Morton then proceeded to obtain an opportunity for the public 
 demonstration of the practicability of anaesthesia. This was fur- 
 nished him in the surgical amphitheater of the Massachusetts Gen- 
 eral Hospital in Boston, on October 16, 1846, where the unsuc- 
 cessful demonstration by Wells had taken place two years before. 
 The surgeon in charge was Dr. John C. Warren, to whom great 
 credit is due for placing the opportunity in Morton's hands in 
 spite of the previous failure in this direction. The operation was 
 the removal of a vascular tumor from the left side of the neck 
 of a young man who was described in the records as "Gilbert 
 Abbott, aged twenty, single, painter." The Harvard MedicaL 
 class was present, also several prominent physicians and surgeons. 
 The exhibition of the anaeesthetic was a complete success, so much 
 so that Dr. Warren turned to those present and said, "Gentle- 
 men, this is no humbug."* 
 
 The fame of the wonderful new agent and of its discoverer 
 spread rapidly, and then came Dr. Jackscn, jealous of the fame 
 of Morton and anxious to participate- in the benefits of the dis- 
 covery, with a claim as to the rights of discovery, basing his 
 claim on the assertion that he had been aware of the power of 
 
 *The formal announcement to the medical profession of this discovery 
 was made by Dr. H. J. Bigelow in a paper read before the Academy of 
 Arts and Sciences, on November 3rd, and before the Boston Society of 
 Medical Improvement on November oth, and published in the Boston. 
 Medical and Surgical Journal, November 18, 1846. 
 
HISTORICAL 19 
 
 ether since 1842. He had suggested the drug to Morton, and un- 
 doubtedly had advised him as to its nature and the best methods 
 of administration, but beyond this his claim was groundless. 
 And here Morton made the mistake of his life, — an attempt to 
 patent the agent under the name "letheon" and to keep its nature 
 secret. As he was not a graduate in medicine he was not tech- 
 nically bound to observe that rule of medical ethics which from 
 the beginning of medicine has forbidden the adoption of such 
 a course in relation to matters which are of benefit to common 
 humanity, yet how different might have been the result to him- 
 self if he had held himself bound by this rule, the^ breaking of 
 which forfeited him the esteem and sympathy of the medical 
 public which would have been of incalculable value in the contro- 
 versy which followed. 
 
 Morton was anxious to silence Jackson as to the nature of 
 ether which he had attempted the impossible task of disguis- 
 ing with aromatics, and to this end he recognized the rights of 
 Jackson in his application for letters patent. Jackson, dissatisfied 
 with his share of the bargain, attempted to pose at the sole 
 discoverer, and thus arose an acrimonious controversy which con- 
 tinued long after the death of Jackson in an asylum. The mat- 
 ter was subsequently investigated by a Congressional committee 
 whose report substantiated the claims of Morton. 
 
 Morton's attempt at secrecy was unavailing. The world at 
 large knew that ''letheon" was simply ether. Dr. Bigelow soon 
 became aware of its nature and spread the news in England. The 
 public disregarded the patent proceedings. Indeed the gove*n- 
 ment representatives in the army and navy ignored the effort to 
 secure patent papers, and an attempt to secure a grant of $100,- 
 000 to Morton from the government failed largely through the 
 antagonism of Jackson supported by the connection of his name 
 with the patent papers. A testimonial of $50,000 from England 
 also failed because of the doubt arising through the same influ- 
 ences, while a French prize was divided equally between Morton 
 and Jackson. 
 
 Morton's life was clouded by a feeling of resentment against 
 the public whose position he mistook for ingratitude. Such hon- 
 ors as he received did not obviate the ill health largely due to the 
 bickerings which continued over the rights of discovery, and 
 
20 ' HISTORICAL 
 
 which resulted in his death in 1868. To-day Morton is generally 
 regarded, and his memory is honored, as the true discoverer of 
 the practicability of ether as an anaesthetic. Had he followed the 
 example of the other great discoverers in the field of medicine 
 he would have had as little cause for complaint.* 
 
 Upon a monument erected by the citizens of Boston over the 
 grave of Morton is the following inscription : 
 
 William T. G. Morton, 
 Inventor and revealer of anaesthetic inhalation, 
 By whom pain in surgery was averted and annulled; 
 Before whom in all time surgery was agony, 
 Since whom science has control of pain. 
 
 No medical discovery was ever more readily adopted than the 
 use of anaesthesia. It was at once taken up in England, and sur- 
 gical operations were performed under it's use by Dr. Boot and 
 * by Listen in December, 1846. Dr. J. Y. Simpson immediately 
 ! adopted ether in obstetric practice. He soon discovered the diffi- 
 culties which attend its administration and which were not so 
 avoidable then as now, and began experimenting in order to find a 
 better agent. The unpleasant odor which ether gave to his clothes 
 also induced Simpson to try other agents. He wrote : "I found 
 that no busy obstetric practitioner could extensively employ sul- 
 phuric ether without inevitably carrying about with him, and upon 
 his clothes, an odor so disagreeable to many other patients and 
 other houses, as to make his presence there aught but desirable." 
 Himself and his assistants, Drs. Keith and Duncan, inhaled va- 
 rious substances experimentally. Mr. Waldie, a chemist of Liv- 
 erpool, suggested to Simpson that chloroform, a constituent of 
 "chloric ether," might be tried with benefit. Chloric ether was at 
 that time used as a carminative, and consisted of chloroform 
 and rectified spirit. Mr. Waldie, in an article on the "Medicinal 
 History of Chloroform" (1847), states that as far as he knows 
 chloroform was introduced into England about 1838. A pre- 
 scription was presented at Apothecaries Hall, Colquitt street, 
 Liverpool, for filling, one ingredient was chloric ether which was 
 unknown there. The chemist found the formula for chloric ether 
 in the United States Dispensatory, and prepared some. The prop- 
 
 *Dr. W. J. Morton remarks (1905) : "The discovery of anaesthesia, 
 while a boon to the world, was a tragedy to its author, and to his family." 
 
HISTORICAL 
 
 21 
 
 erties of chloric ether pleased Dr. Formby, who introduced it into 
 Liverpool practice. Waldie states that while he was in Scot- 
 land, in October (1847), Simpson asked him regarding some 
 agent that would answer his purpose, and Waldie suggested 
 chloric ether, promising to prepare some on his return to Liver- 
 pool and send it to Simpson. He was delayed, however, and in 
 the meantime Simpson procured some in Edinburgh. 
 
 Attempts to anaesthetize with chloric ether had failed. Chlo- 
 roform was described as a "curious liquid" discovered almost 
 simultaneously by Guthrie, Soubeiran, and Leibig in 1831, and 
 chemically described by Dumas in 1835. In March, 18^7, Flou- 
 rens, the French chemist, described the effects' of chloroform on 
 animals. Guthrie, of Brimfield, Mass., then residing at Sackett's 
 Harbor, N. Y., obtained what is now known as chloroform, 
 though he supposed he had discovered an easy and cheap pro- 
 cess of making what was known as "Dutch liquid," a preparation 
 of the Dutch chemists, or ethane dichloride, which greatly* resem- 
 bled the substance discovered by Guthrie. He therefore used 
 the term chloric ether in referring to the preparation which he 
 had discovered. Guthrie is said to have noticed in the American 
 Journal of Science and Art a statement by a correspondent to 
 the effect that a mixture of alcohol and chloride of olefiant gas 
 (then recently discovered) was an agreeable and diffusible stim- 
 ulant. This led to his experiments, and in May, 1831, he sent 
 to Mr. Sillman, the editor of the Journal mentioned, an article 
 entitled, "A Spiritous Solution of Chloric Ether," which was pub- 
 lished in October, 183 1. A later and more complete account de- 
 scribing his method was published in January, 1832, and is re- 
 ferred to by Pereira (Pharmaceutical Journal). Soubeiran's ac- 
 count was published in January, 1832. Leibig's account was 
 published in November, 1831 (Foy), or not until 1832 (Pereira). 
 
 Samuel Guthrie was born in 1782, was a surgeon in the U. 
 S. Army in 1812, and died in 1848, just as the fame of chloro- 
 form as an anaesthetic became widespread. The recognition of 
 his position as the discoverer of chloroform is largely due to 
 the Chicago Medical Society, and recognition as such has at last 
 been accorded him by his brethren of the Jefferson county, New 
 York, Historical Society. 
 
 In Sillman's Journal, of January, 1832, is related an instance 
 
22 HISTORICAL 
 
 of the use of chloroform by inhalation by Prof. Ives, of Yale 
 College. It was also used by Dr. Nathan B. Ives for asthma, 
 cough, quinsy, etc. 
 
 Simpson determined to try chloroform, and did so on the 
 fourth of November, 1847, with the result that himself and co- 
 experimenters awoke from temporary unconsciousness to find 
 themselves upon the floor, under under the table. Simpson read 
 a paper before the Medico-Chirurgical Society, on November 
 10th, detailing cases in which he had already used the anaesthetic 
 successfully, and by the 15th of November he had administered 
 chloroform to about fifty individuals without any bad results. 
 In 1870, Simpson, in a letter to Dr. Jacob Bigelow, of Boston, 
 stated that "the first case of an anaesthetic operation under chlo- 
 roform occurred in Edinburg on the 15th of November, 1847." 
 The first operation under ether in England is said to have been 
 the extraction of some teeth by a dentist, a Mr. Robertson, of 
 London, in 1846, at the request of Dr. Boot. 
 
 Simpson regarded chloroform as "more portable, more man- 
 ageable and powerful, more agreeable to inhale, and less excit- 
 ing" than ether, and an agent giving greater "control and com- 
 mand over the superinduction of the anaesthetic state." For years 
 Simpson fought an earnest and persistent fight against medical 
 conservatism, religious bigotry, and confused public opinion. And 
 the rapid introduction of the use of anaesthetics in Great Britian 
 is largely due to his successful advocacy of its cause. In none of 
 the writings or public utterances of Simpson is there to be 
 found any acknowledgment of the credit due to Guthrie or Ives 
 for the discovery or employment of chloroform. 
 
 Chloroform, which at first was regarded as an anaesthetic 
 without danger, became almost the sole anaesthetic agent in use 
 in Great Britain and the Continent. In the United States ether 
 held its own as a safe and reliable agent for general surgical an- 
 aesthesia. Occasional deaths under chloroform and the seem- 
 ing inexplicable cause of these fatalities brought about a realiza- 
 tion of -the dangers of chloroform as an anaesthetic, as well as a 
 state of doubt and confusion as to which agent was the better. 
 
 In 1858 Snow published a work on chloroform and other 
 anaesthetics in which he claimed that chloroform fatalities are 
 generally due to primary cardiac paralysis from the inhalation of 
 
HISTORICAL 23 
 
 too concentrated vapor. Though subsequent investigations tend 
 to prove that there is some primary interference with respira- 
 tion, the conclusions of Snow are by many regarded as correct. 
 
 Clover, who published an account of his chloroform inhaler 
 in 1862, experimented with both chloroform and ether with the 
 conclusion that ether was the safer drug. In 1864 the Royal 
 Medical and Chirurgical Society appointed a committee to in- 
 vestigate chloroform, which reported in favor of Snow's conclu- 
 sions, and recommended a mixture of alcohol, chloroform and 
 ether which was originally proposed by Dr. Geo. Harley, and was 
 known as the A. C. E. mixture. Claude Bernard, Richardson and 
 others investigated the question, and in 1867 Richardson intro- 
 duced bichloride of methylene, which as an anaesthetic had a 
 short life. The same year saw the Junker inhaler for chloroform, 
 which proved of special value in surgery of the mouth, throat, 
 and nose. 
 
 About this time Colton, the lecturer who gave Wells his inspir- 
 ation regarding nitrous oxide gas, revived the interest in this gas. 
 He had formed an association in New York for performing den- 
 tal work with the use of gas, and his reports stimulated the in- 
 terest of dental surgeons. ■ He visited Paris in 1867 and gave 
 demonstrations before Dr. Evans, the well known exponent there 
 of modern dentistry. Dr. Evans demonstrated the use of gas 
 in London in 1868, and the Odontological Society then issued a 
 very favorable report on the use of the gas about eight months 
 later. Nitrous oxide gas has since, maintained the first place as 
 an anaesthetic for use in modern dental practice. Its utility in 
 this connection and also, in some respects, in general surgery, 
 has been much enhanced by the success of Dr. E. Andrews, of 
 Chicago, in 1868, in obtaining a non-asphyxial form of anaes- 
 thesia by the combined use of oxygen and nitrous oxide gas. 
 
 The work of Clover in demonstrating the advantages of air- 
 limitation in administering ether, of the advantage of the use 
 of nitrous oxide gas as a preliminary to etherization, and his im- 
 proved methods of administering nitrous oxide gas, did much to 
 lessen the popularity of chloroform. 
 
 Heated controversies arose as to the relative merits and de- 
 merits of chloroform and ether. Investigations into the physi- 
 ological action and lethal manifestations of chloroform were be- 
 
24 HISTORICAL 
 
 gun. The teaching of Syme and the Edinburgh school was that 
 chloroform never produced primary depression of the heart. The 
 report of the "Glasgow" committee of the British Medical Asso- 
 ciation in 1876 stated that blood pressure and cardiac action were 
 distinctly lowered under chloroform ; that respiration generally 
 ceased before cardiac action, and that primary cardiac paralysis 
 might occur. 
 
 To settle this dispute the first Hyderabad commission was ap- 
 pointed. The funds being furnished by the Nizam of Hydera- 
 bad at the suggestion of Surgeon-Major Lawrie, who upheld the 
 teachings of Syme. The conclusions of the commission, after nu- 
 merous experiments,, were in accordance with the Edinburgh 
 school, and were not accepted by the profession at large. A 
 second commission, whose report appeared in 1891, essentially 
 corroborated the conclusions of the first commission. Eminent 
 physiologists soon demonstrated errors in the technical work of 
 these commissions, and independent investigations by Wood, 
 Hare, Hill, MacWilliam and others go to show that the fall 
 of arterial tension is largely, if not wholly, due to the effect of 
 chloroform upon the heart, and that even though respiration 
 ceases before the heart action, the principle element in chloro- 
 form syncope is the effect upon the circulation. 
 
 The report of the Committee on Anaesthetics of the British 
 Medical Association, rendered in 1900, states that ether is sin- 
 gularly free from danger in healthy subjects, and that in the 
 large majority of cases of danger from chloroform the symp- 
 toms are those of primary failure of the circulation. 
 
 In the early days of anaesthesia the almost sole object was to 
 prevent pain during operations, without regard to partial con- 
 sciousness or physical disturbances on the part of the patient. 
 Later on it became evident that total unconsciousness could read- 
 ily and safely be induced even if it were necessary to repeat the 
 administration of the anaesthetic. The possibility of prolonged 
 and complete anaesthesia gradually came to be realized, and at 
 the present time it is possible to rapidly induce complete anaes- 
 thesia and continue it for an indefinite period without any of the 
 excitement and disturbance which was formerly so familiar a 
 feature of the administration of general anaesthetics. 
 
 Among others of the many substances that have been more or 
 
HISTORICAL 25 
 
 less used for the purpose of anaesthesia since the discovery of the 
 practical application of the ones already considered in the induc- 
 tion of the anaesthetic state are a few that have obtained more or 
 less recognition. Ethyl bromide, discovered by Serullas, in 1827, 
 was introduced as an anaesthetic by Nunneley, of Leeds, in 1849. 
 Ethidene dichloride, discovered by Regnault, was first used by 
 Snow for anaesthetic purposes. Amylene, discovered by Balard, 
 in 1844, was fi rst employed by Snow. Pental, nitrogen, ethyl 
 chloride, methyl oxide, ethylene or olefiant gas, and other sub- 
 stances have been employed as anaesthetics. 
 
 A few years ago a method of anaesthesia was introduced 
 as a substitute for general anaesthesia. It is generally known as 
 Bier's method, but should be, it is claimed, attributed to Cor- 
 ning, of New York. This method is by medullary cocainization 
 by the sub-arachnoid injection in the lumbar region of a solu- 
 tion of cocaine. Though this method is not one of complete 
 general anaesthesia it is of interest in this connection as a sub- 
 stitute for general anaesthesia in severe operations where local an- 
 aesthesia through local injections is not possible. This method has 
 had considerable employment since its introduction, but it is not 
 yet determined that it will retain a place as a reliable and satis- 
 factory method of anaesthesia. 
 
 Those who have employed this method most agree as to its utility in 
 selected subjects, and for certain operations. Certain improvements in 
 the technique appear to have increased its applicability. The most im- 
 portant of these advances are the use of stovaine instead of cocaine, and 
 the addition to the anaesthetic of some suprarenal preparation. 
 
 Within the last few years there has been a distinct tendency toward the 
 employment of the sequential administration of anaesthetics, using one of 
 the short term agents for the induction of the narcosis. Thus the nitrous 
 oxide-ether sequence, the ethyl chloride-ether sequence, the chloroform- 
 ether sequence, or the somnoform-ether sequence. By this method in- 
 duction is short, excitement is obviated, saturation of the system is avoid- 
 ed, recovery is hastened, and complications are few. It is also becoming- 
 more and more recognized that in the administration of chloroform 
 technique that permits of the effectual use of a low percentage vapor is 
 important because of the greatly lessened danger, and the comparative 
 freedom from after effects and complications. 
 
CHAPTER II. 
 
 GENERAL PHYSIOLOGY. 
 
 General anaesthesia may be defined as a state of intoxication of 
 the body in which there is suspended consciousness of more or 
 less rapid induction and recovery, during which the vital reflexes 
 are not affected, and which, aside from the anaesthetic period, 
 affects tissue life and function to the least possible extent. 
 
 There are many agents capable of producing, in one way or 
 another, an anaesthetic state more or less approximating that de- 
 fined above, the principal ones of which will be considered here- 
 after. 
 
 An agent suitable for general anaesthesia must possess cer- 
 tain characteristics. It must be capable of inducing general in- 
 sensibility to pain, and in surgical anaesthesia it must hold in 
 abeyance muscular power also. It must be possible of introduc- 
 tion into the circulation without great difficulty or marked un- 
 pleasantness or danger to the subject. Its physiological effects 
 must not be so rapidly acquired or so intense as to interfere with 
 the control of its effects by the administrator. Its elimination 
 must be complete, and sufficiently rapid to allow of an early re- 
 turn to the normal condition upon the discontinuance of the ad- 
 ministration. Such agents as nitrous oxide, chloroform, ether, 
 and bromide of ethyl fulfill these requirements more or less com- 
 pletely. 
 
 As a rule the toxicity of the agent increases directly with 
 the rapidity with which anaesthesia may be induced, and accord- 
 ing to Magill the toxicity of the agent increases in direct ratio 
 to concentration of carbon in the radical of the agent. The 
 addition of oxygen to the hydrocarbon molecule while not in- 
 creasing the toxicity of the agent renders the induction of anaes- 
 thesia slower. The combination of a halogen with the organic 
 radical increases toxicity which multiplies directly with the num- 
 ber of elements of the halogen introduced into the molecule, 
 and also directly with the density and weight of the halogen in 
 question. Chloroform, by means of the hyperchlorination of its 
 molecule, is possessed of marked toxic properties which are partly 
 compensated for by its active anaesthetic powers. If bromine in 
 
GENERAL PHYSIOLOGY 2J 
 
 equal number of atoms be substituted for chlorine the resulting 
 bromide is possessed of greater toxicity. The halogens of great 
 atomic weight may increase the toxicity of the molecules so as 
 to render them dangerous even in the smallest quantities. 
 
 The entrance of the anaesthetic into the organism is accom- 
 plished, in those organisms possessing a circulatory system, by 
 absorption. The introduction of the agent may be effected by 
 its local application to the skin. This method may be effective 
 in cold blooded animals as shown by Bernard in the case of 
 frogs, because their elimination is slow. In warm blooded ani- 
 mals the more rapid elimination prevents this method from be- 
 ing effective. The stomach' and rectum may be used as chan- 
 nels for the introduction, but for evident reasons this method is 
 unreliable. The respiratory tract presents the best and most 
 available channel for the introduction of anaesthetic agents be- 
 cause of the large area of the pulmonary capillary net-work of 
 vessels, and the rapidity with which the blood from the lungs 
 reaches that part of the organism upon which the chief effects 
 of the anaesthetic are manifested, — the central nervous system. 
 
 The absorption of the anaesthetic from the pulmonary capil- 
 laries will depend on the tension of the agent in the air and its 
 solubility in the blood. The former will vary with the temper- 
 ature of the air and the barometric pressure. The absorption of 
 the anaesthetic from the air in the alveoli is governed by the phys- 
 ical laws which control the interchange of gases between the 
 alveoli and the blood. A prominent necessary factor in this pro- 
 cess is the diffusion of air in the pulmonary alveoli. This diffu- 
 sion of air is increased in proportion as the tidal air may be in- 
 creased. In quiet respiration the tidal air is estimated as equal to 
 500 cm., and the alveolar capacity which is equal to from 2,000 
 to 3,000 cm. after respiration, may be changed about three and 
 a half times between the extremes of forced inspiration and forced 
 expiration. As the effect of all anaesthetics during the initial 
 period of inhalation is to increase the depth of respiration the in- 
 fluence of the factor of diffusion of air in the alveoli as related to 
 the interchange of gases between the alveoli and the blood is in- 
 creased during this period of anaesthesia. 
 
 Snow stated the proposition that, as the relation of the pro- 
 portion of vapor in the air breathed is to the proportion of vapor 
 
28 GENERAL PHYSIOLOGY 
 
 the air will contain if saturated at the blood temperature, so is 
 the proportion of vapor absorbed to the proportion the blood will 
 dissolve. 
 
 The amount of anaesthetic absorbed is greater when the tem- 
 perature of the air inhaled is high than when it is low, and the 
 amount of anaesthetic necessary to produce a certain degree 
 of anaesthesia is correspondingly less as is shown by the records 
 of the amount of chloroform necessary to produce anaesthesia 
 in hot countries. Chloroform also appears to be less dangerous 
 in warm climates. A study of chloroform mortality by Thomas 
 R. Evans shows that the majority of deaths occurred during the 
 cold season. H. C. Wood thinks this is due to the more rapid 
 elimination of chloroform in hot climates. 
 
 The fact that the quantity of chloroform necessary to induce 
 anaesthesia may vary with the temperature of the inspired air is 
 no indication that a greater or less amount of the anaesthetic is 
 necessary to affect the neurons. So far as the effect of an anaes- 
 thetic agent on the nerve centers is concerned it depends on the 
 facility with which the agent may reach the center, and the length 
 of time it may be retained there. 
 
 The pulmonary tract constitutes the chief channel for the 
 elimination of anaesthetics. Elimination also takes place through 
 the glands of the gastric mucosa, and through other glands. The 
 gastric elimination is in a measure the cause of vomiting, espe- 
 cially of that which occurs during the early part of the recovery 
 from anaesthetics, and the recovery is usually rapid after vomiting 
 has occurred. While it is not positively determined whether an- 
 aesthetics undergo any decomposition during their presence in the 
 blood, elimination is more or less freely carried on by the respira- 
 tory tract according to the freedom of the air tract from obstruc- 
 tion, the depth and efficiency of respiration, the nature of the 
 anaesthetic agent, and the method of administration. 
 
 Generally the amount of C0 2 eliminated is decreased. Rumpf 
 found a decrease of 40 per cent, in the respiratory exchanges, 
 and Richet found a decrease of 50 per cent, in the elimination of 
 C0 2 in chloralized dogs. Bert's experiments with chloroform show 
 a progressive diminution in O absorbed and of C0 2 given off, 
 the difference being considerably greater with the latter than with 
 the former. Lorrain Smith has shown that dyspnoea from change 
 
GENERAL PHYSIOLOGY 2Q. 
 
 in the gaseous composition of the blood may be due to a deficiency 
 of oxygen (O-dyspncea) and is characterized by frequent respira- 
 tory movements (hyperpncea), vigorous inspirations, long dura- 
 tion, severity, rise in blood pressure, and motor disturbance. — 
 symptoms similar to those of the initial period of anaesthesia, 
 and in which they are directly related to the exclusion of O, espe- 
 cially with those agents which do not induce narcosis rapidly 
 enough to exclude such symptoms, such as ether or chloroform. 
 
 Again dyspnoea may be due to an excess of carbonic acid 
 C0 2 -dyspncea) and be characterized by slow respiratory rate, 
 length and vigor of expiration, expiratory pause, and absence 
 of motor disturbance, — symptoms similar to those of too deep 
 or prolonged narcosis, especially in the late stages of anaesthesia. 
 
 The changes produced in the blood by anaesthetics are not 
 fully understood, but generally speaking are not important. Al- 
 terations in the corpuscles have been described and are said to 
 occur in the pulmonary capillaries. Richet states that blood 
 which contains an anaesthetic in solution preserves, when shaken 
 with air, its full ability for fixing oxygen. 
 
 Da Costa and Kalteyer have demonstrated that the anaesthetic 
 state, the period preceding, and the period following, produces 
 blood concentration. They conclude that: i. The character of 
 the change is usually a polycythaemia ; rarely, an oligocythaemia. 
 
 2. The nature of this polycythaemia is best explained by a les- 
 sening of the watery elements of the plasma, thereby reducing 
 the total volume of the sanguinis and causing concentration. 
 
 3. The three important factors incident to the polycythaemia 
 are: (a) The period of preparatory operative treatment; (b) 
 the anaesthetic state; and (c) the post-operative stage. 4. The 
 blood inspissation is, as a rule, most pronounced just after the 
 termination of the anaesthetic stage. 5. The haemoglobin is 
 always reduced absolutely. Apparent increase is never parallel 
 with the rise in red blood cells. We must consider that ether- 
 ization produces increased haemolysis, and that in nature's efforts 
 to rapidly replace the blood cells the regenerated cells are im- 
 perfectly supplied with haemoglobin. 6. The duration of the 
 anaesthetic state, and the amount of ether, influences the blood 
 changes. 7. The amount of blood loss does not seem to affect 
 the blood. 8. Whenever oossible one or more blood examina- 
 
30 GENERAL PHYSIOLOGY 
 
 tions should be made before giving an anaesthetic, and before pre- 
 paratory treatment is instituted. On account of the haemolysis, 
 shown by the fall in corpuscular haemoglobin after operation, a 
 very low percentage of haemoglobin must be regarded as a con- 
 traindication to general anaesthesia. 
 
 The nervous system shows the first and most marked effects 
 of an anaesthetic, and the most highly organized part of this 
 system is first and chiefly affected. The other economic systems 
 are usually not affected to any important extent. There is 
 irritation, depression, and finally paralysis of the nervous sys- 
 tem. The cerebral cortex, the cerebellum and ganglia of the 
 base, the sensory tracts and centers of the cord, the cerebro- 
 spinal motor tracts and centers, and the respiratory and cardiac 
 centers seem to be affected in the order mentioned. 
 
 In the induction stage there may be analgesia without com- 
 plete unconsciousness. This, according to Dastre, is due to the 
 anaesthetic affecting the sensory nuclei of the cord or cerebral 
 ganglia before the cortical areas are involved. Other physiol- 
 ogists think the interruption is in the cortical areas. Analgesia 
 without unconsciousness in the later stages of anaesthesia is rare 
 but occurs in exceptional instances. Sight is usually lost before 
 hearing. 
 
 The motor system is first excited, then depressed and paraly- 
 sed. The centers of complex co-ordinate movement are first 
 affected, then those governing ordinary muscle movements, and 
 finally the automatic centers of respiration and circulation are 
 involved. 
 
 The exact nature of the changes in the central nervous sys- 
 tem which result in anaesthesia are not fully understood. The 
 similarity of the symptoms to those of sleep, both in relation to 
 anaesthesia and other characteristics has led to the supposition 
 that the conditions were analogous, but the intimate nature of 
 both conditions is not sufficiently understood to warrant a defi- 
 nite conclusion in this respect. .Even if we accept the theory that 
 sleep is not so much the result of changes, within the neurons 
 from any agent, as the effect of change in the dentritic processes 
 which connect the individual neurons, we are no nearer a direct 
 solution of the nature of the conditions. The effect of an anaes- 
 thetic on the nerve centers is temporary, and whether the effect 
 
GENERAL PHYSIOLOGY 3 1 
 
 is due to a change in the protoplasm of the nerve cells induced 
 by the anaesthetic in the blood, or whether the anaesthetic produces 
 its effect by interfering with processes of oxidation which are 
 necessary to the functional integrity of the nerve, centers is im- 
 possible at present to state. 
 
 In this connection, however, the phenomena attending disor- 
 dered action of neurons under the influence of anaesthetic agents 
 may be better understood, and the condition of the anaesthetized 
 subject be more readily appreciated by the anaesthetizer if it be 
 borne in mind that the neuronic groups undergo gradual and suc- 
 cessive development in complexity, involving, in relation to func- 
 tion, respectively those governing respiration and circulation, the 
 organic reflexes, the special reflexes, and co-ordination — sensory, 
 motor, motor-sensory association, consciousness, and ideatory. 
 The structural stability of these centers is greater in the oldest 
 centers, while those neuronic groups developed last show least 
 stability. 
 
 Neuronic complexity or integrity is associated with high 
 lecithin and fat compounds. These compounds are least stable 
 in the highest neurons or those of latest development. The hydro- 
 carbon compounds (anaesthetics) displace H 2 or dissolve the fat 
 compounds, and first affect those groups which are of least sta- 
 bility, i. e., those of latest development. The hydrocarbon com- 
 pounds are therefore anaesthetic in proportion to their ability to 
 affect lecithin and fat compounds, and their effect on the neuronic 
 groups is in inverse order to the developmental stability of these 
 groups. 
 
 Many years ago Bibro and Harles attempted to explain the 
 action of anaesthetics on the basis of their soluble action on fats, 
 and the richness of the nervous system in fat-like constituents. 
 Hermann arrived at similar conclusions in regard to narcosis be- 
 cause of the presence of lecithin in the red blood cells, and the 
 action of anaesthetics in dissolving these cells. Meyer, of Vienna, 
 instituted experiments to determine what element of truth lay in 
 these hypotheses, and recently (Oct., 1905) stated two conclu- 
 sions before the Harvey Society, of New York, as follows : "The 
 narcotizing substance enters into a loose physio-chemical combi- 
 nation with the vitally important lipoids of the cell, perhaps with 
 the lecithin, and in so doing changes their normal relationship to 
 
2,2 GENERAL PHYSIOLOGY 
 
 the ether cell constituents, through which an inhibition of the 
 entire cell chemism results. It also becomes evident that narcosis 
 immediately disappears as soon as the loose, reversible combina- 
 tion, dependent on the solution tension, breaks up. It follows 
 further that substances chemically indifferent, as the volatile sat- 
 urated hydrocarbons, can act as narcotics." From experiments 
 along similar lines Overten comes to similar conclusions with 
 Meyer regarding the nature of narcosis. 
 
 Moore and Roaf recently produced additional proof before 
 the Royal Society of their conclusions that anaesthetics form un- 
 stable compounds or aggregates with the proteids of the tissue 
 cells, and that anaesthesia is due to paralysis of the chemical ac- 
 tivities of the protoplasm as a result of these combinations. These 
 unstable compounds or aggregates only persist as long as the 
 pressure of the anaesthetic in the blood is maintained. 
 
 The effect of anaesthetics on the respiration vary exceedingly 
 according to the nature of the agent, the type of the subject, and 
 the manner of administration. There is a local irritant action on 
 the respiratory passages, more marked with some agents than 
 with others. This results in more or less obstruction to breath- 
 ing from spasm or swelling. As the inhalation proceeds stimu- 
 lation of the respiratory centers causes quicker and deeper breath- 
 ing. Irregular forms of breathing may occur from too little 
 oxygen, as in the close administration of volatile agents, or 
 from C0 2 dyspnoea, as in rebreathing during the administration, 
 or from psychical causes. So-called "physiological apncea" may 
 occur with oxygen and nitrous oxide and, at times, with other 
 agents. Cheyne-Stokes breathing may be present in old people 
 or in debilitated subjects under anaesthesia. Stertor is due to 
 respiratory obstruction. The term stertor is applied to the snor- 
 ing sounds of respiration under anaesthesia. It is generally 
 caused by vibration of the tongue against the pharyngeal wall, 
 and has been termed pharyngeal stertor. Other forms of ster- 
 tor described are : Nasal, buccal, palatine, laryngeal, and mu- 
 cous stertor. 
 
 The muscular phenomena present under anaesthesia are 
 chiefly : Nervous manifestations, conscious or sub-conscious Vol- 
 untary movements, unconscious excitement movements, tonic 
 spasm, clonic spasm, co-ordinate movements under deep anaes- 
 thesia, fine tremor, and reflex movements. 
 
GENERAL PHYSIOLOGY 33 
 
 Reflex movements are of importance as guides to the state 
 of anaesthesia. They are exaggerated during the earlier stages 
 of the administration, become diminished as anaesthesia is 
 reached, and during surgical anaesthesia most of the reflexes are 
 lost, while during toxic conditions the reflexes are absent. The 
 corneal, laryngeal, pharyngeal, vesical, rectal, and genital re- 
 flexes are maintained longest. The power of the spinal cord to 
 transmit sensory impulses is maintained late. The vaso-motor 
 centers maintain their power late. The cardiac accelerator and 
 inhibitory centers are supposed to be more irritable under light 
 than deep anaesthesia, but their action may not be abolished un- 
 der profound anaesthesia. The respiratory centers may remain 
 active to reflex stimulation under the most profound anaesthesia. 
 
 The heart action is stimulated and quickened during the first 
 stages of anaesthesia, and the blood pressure, as a rule, is raised. 
 Later the heart's action becomes less excitable, and varies from 
 incidental influences. Under complete anaesthesia there may be 
 some degree of cardiac dilatation. In the stage of bulbar paral- 
 ysis the heart's action is feeble, irregular, imperceptible, and 
 there is paralysis of the cardiac ganglia and of the automatic 
 power of the myocardium. 
 
 The more or less gradual occurrence of the effects produced 
 by anaesthetics has led to describing the effects as occurring in 
 ■certain stages. Such division is more arbitrary in the case of the 
 rapid agents than with the slower ones. Clinically we recog- 
 nize three stages with more or less definiteness. Some observ- 
 ers have divided the same periods into four stages. Physiolog- 
 ically we must add to the three clinical stages a fourth, that of 
 bulbar paralysis. The following division given by Hewitt fairly 
 represents in a general way the sequel of events. 1st stage : Stage 
 •of disordered consciousness and analgesia ; 2d stage : Stage of 
 unconscious reflex activity ; 3d stage : Stage of surgical anaes- 
 thesia or coma ; 4th stage : Stage of bulbar paralysis. 
 
CHAPTER III. 
 
 THE SELECTION OF A GENERAL ANAESTHETIC WITH REFERENCE TO 
 
 THE COMPARATIVE DANGERS OF THE AGENTS 
 
 EMPLOYED. 
 
 The development and dissemination of knowledge regarding 
 the practical administration of anaesthetics has gradually abro- 
 gated the bias formerly shown by various observers toward this 
 or that anaesthetic, and it is now recognized that the exclusive 
 employment of one anaesthetic is unjustifiable. The minimum of 
 danger is secured by recognizing the following factors in rela- 
 tion to safety : The adaptability of the agent to the individual 
 to be anaesthetized; the relation of the anaesthetic to the nature 
 of the operation to be performed ; the proper technique to be 
 used with the agent selected with regard to the above consid- 
 erations ; and the experience and skill of the administrator. 
 
 With reference purely to the comparative dangers of the agent 
 employed in routine or ordinary practice without regard to spe- 
 cial conditions, we have to consider which anaesthetic is most 
 free from danger to life in an abstract way. As far as actual 
 danger to life is concerned, nitrous oxide gas is undoubtedly the 
 safest anaesthetic known. Hewitt, in a search through medical 
 and dental journals covering a period of forty years, found rec- 
 ords of only thirty deaths, several of which were not due to the 
 anaesthetic directly. Nitrous oxide and oxygen is possibly less 
 dangerous even than the pure gas, though the difference is slight. 
 Goldman, Gardner, and others endorse the safety of nitrous ox- 
 ide with or without oxygen. No fatalities are recorded with the 
 latter combination. The limitations of nitrous oxide in relation 
 to general surgery, however, causes our chief interest in this con- 
 nection to center in those agents more suitable for producing pro- 
 longed anaesthesia. Of these agents the decision is mainly be- 
 tween ether and chloroform. 
 
 We find that in different countries, in different sections of 
 the same country, in individual cities, and in individual hospitals 
 that surgeons differ as to the choice between ether and chloro- 
 form according as their experience has been greater with the 
 
THE SELECTION OF A GENERAL ANAESTHETIC 
 
 35 
 
 one than with the other. In the Eastern States ether is generally 
 preferred, while in the Southern States and in some of the West- 
 ern States chloroform is mostly used. In Germany chloroform 
 was usually employed until within the last ten years when ether 
 has been largely used owing chiefly to the influence of Gurlt's 
 showing. In England chloroform was for a long time the chief 
 anaesthetic but of late years ether has been gaining in use. 
 
 Statistics regarding the relative fatality of anaesthetics are 
 unreliable because of the impossibility of excluding various con- 
 tributory causes. They may be regarded as roughly indicative 
 of the relative dangers of anaesthetics. Some of the leading sta- 
 tistics are as follows : 
 
 Anaesthetic 
 
 Chloroform 
 Ether 
 
 Chloroform. 
 Ether 
 
 Chloroform 
 
 Ether 
 
 Bichloride ot Methylene 
 Cnloroforn and Ether.. . 
 
 Chloroform 
 
 Ether and Gas and Ether. 
 
 Chloroform 
 Chloroform 
 
 Chloroform 
 Ether 
 
 Administra 
 tions 
 
 30.162 
 8.43 1 
 
 524.507 
 314,738 
 
 152,260 
 92,815 
 10,000 
 11,176 
 
 30,87; 
 27,916 
 
 22,656 
 133,122 
 
 13.393 
 ".595 
 
 Deaths Death Rate Reported by 
 
 161 
 21 
 
 1-3,196 
 1-8,43 1 
 
 1-3.258 
 1-14.987 
 
 1-2,873 
 
 1,23,204 
 
 1-5,000 
 
 1-5.558 
 
 1-1,470 
 1-6,979 
 
 1-5,664 
 1-2,894 
 
 1-744 
 1-765 
 
 Richardson, of 
 London, ('92 ). 
 
 Jullard, of Ge- 
 neva, (1S91). 
 
 Ormsb", of 
 Dublin, 
 (1877). 
 
 St. Bartholo- 
 mew's Hospi- 
 tal, London, 
 (•76-96). 
 
 German Surg. 
 Society, (1890) 
 
 Korte, of Ger- 
 many, (1894). 
 
 British Med. 
 Ass'n., (1900). 
 
 In India where choloform appears to be less dangerous than 
 in colder countries Neve recorded 78,407 administrations with 
 but three deaths. The ratio of cases of danger to the total admin- 
 istrations in the report of the British Medical Association (1900), 
 was 1.030 per cent, for chloroform, and 0.304 per cent, for ether. 
 
 Ether appears to be generally recognized as absolutely the 
 safest anaesthetic after nitrous oxide gas. Its stimulant effect on 
 the heart and respiration, and the fact that evident and early 
 respiratory difficulty is almost always present in case of danger, 
 are strong factors in its safety. 
 
 More careful discrimination in the selection of anaesthetics 
 
36 THE SELECTION OF A GENERAL ANAESTHETIC 
 
 than was formerly employed leads to the position emphasized by 
 Mikulicz, that abstract safety is not now the only question, but 
 that the practical points are : In which cases shall general an- 
 esthesia be substituted for local anaesthesia ; what is the safest 
 general anaesthetic for the individual and operation in question ? 
 
 A half century's experience with anaesthetics has brought 
 the conviction that improper selection of the agent, and lack of 
 skill and judgment in the administrator constitute a large share 
 of the dangers from any anaesthetic. So far as available knowl- 
 edge is to be gained from statistics it points to greater danger 
 from chloroform than from ether. Failure of both heart and 
 respiration, without any discoverable cause, are more frequent 
 under chloroform than under ether. Chloroform in healthy indi- 
 viduals may cause fatty degeneration in the heart, liver, and kid- 
 neys, which may be responsible for late deaths after chloroform 
 anaesthesia. Such changes are rare and slight from ether. On 
 the other hand post-anaesthetic complications, such as pneumonia, 
 acute oedema, or thrombosis with or without embolism of the peri- 
 pheral veins of the lower extremities, are more frequent from 
 ether than from chloroform. 
 
 These facts are the cause of the difference of opinion on the 
 relative safety of these two agents. 
 
 Cbese subjects, and alcoholics take ether badly, and in these 
 chloroform may be the safest and best anaesthetic. In some sub- 
 jects, and for long operations, and with an inexperienced admin- 
 istrator, ether is generally safer. In healthy subjects presenting 
 no special indications for other anaesthetics, ether is undoubtedly 
 safer than chloroform. 
 
 The importance of the method of administration, and the 
 skill of the administrator in relation to the danger of any anaes- 
 thetic is being more and more recognized. The greater safety of 
 nitrous oxide and oxygen over the gas alone is recognized, but the 
 difference is too slight to offset the greater skill necessary to 
 administer the combined agents. 
 
 The semi-open methods of administering ether are safer than 
 the close methods, especially in the hands of inexperienced per- 
 sons. 
 
 In administering chloroform the drop method is generally- 
 recognized as the safest, and most anaesthetists agree with Sippel 
 
THE SELECTION OF A GENERAL ANAESTHETIC 7>7 
 
 that the complicated methods of administering chloroform do not 
 eliminate its dangers. Individual peculiarities in regard to the 
 amount of chloroform necessary to produce narcosis render va- 
 rious forms of apparatus more or less unsatisfactory. 
 
 The A. C. E. mixture probably should occupy an interme- 
 diate position with ether and chloroform as regards safety. There 
 are special conditions in which it may be the agent of choice. The 
 short term anaesthetics, such as bromide of ethyl, under certain 
 conditions may be the anaesthetic of choice both from the stand- 
 point of convenience and of safety. 
 
 Generally speaking anaesthetics present a higher danger rate 
 during the winter than during the summer months. The differ- 
 ence with choloroform is slight while with ether it is somewhat 
 higher than with chloroform, owing somewhat to the greater like- 
 lihood of post-anaesthetic complications affecting the respiratory 
 organs when ether has been the agent employed. With the other 
 anaesthetics the difference between winter and summer as regards 
 the danger rate is unimportant. 
 
 There is a growing tendency within the last few years to se- 
 lect one of the short term anaesthetics for short operations, or to 
 employ a sequence of agents. The following comparative sta- 
 tistics are from the figures of Seitz, and of Konstanz : 
 
 Pental, I in 200. 
 
 Chloroform, 1 in 3,000. 
 
 Ether, 1 in 5,000. 
 
 Ethyl bromide, 1 in 8,000. 
 
 Ethyl chloride, 1 in 16,000. 
 
CHAPTER IV. 
 
 THE SELECTION OF THE ANAESTHETIC WITH REFERENCE TO THE 
 
 PATIENT. 
 
 There are many considerations with reference directly to the 
 patient which have an important bearing on the question of the 
 best anaesthetic to employ in individual cases. The popular belief 
 that absolutely healthy subjects are the best for anaesthetic ad- 
 ministration is not strictly true. If the dangers from an anaes- 
 thetic were always of toxic origin then they would probably be 
 strictly related to the general physical condition of the subject. 
 But the asphyxial dangers which are intercurrent with the ad- 
 ministration are more frequent and pronounced in certain types 
 of individuals which represent the more robust subjects. We find, 
 therefore, that persons whose general health and physical condi- 
 tion is not up to the standard as a rule take anaesthetics with less 
 disturbance, and the administration presents fewer cases of dan- 
 ger, than is the case with more healthy subjects. Persons with 
 advanced organic disease will show an increase in the incidence 
 rate of dangers and complications over healthy subjects, but the 
 difference is not so marked as has been supposed, especially when 
 the anaesthetic has been intelligently selected with reference to 
 these special conditions. 
 
 Sex. There is a distinct difference both in the effects and 
 in the danger rate from general anaesthetics in the two sexes. 
 Females, generally, are more easily anaesthetized and exhibit a 
 lower danger rate, than males, although emotional disturbances 
 are more frequent in women. The difference is much less marked 
 at the extremes of life than during the period of middle life, 
 while strong and masculine women, and weak and effeminate men 
 exhibit the characteristics of males and females respectively re- 
 garding anaesthetization. 
 
 Anaesthetics are more commonly associated with dangers and 
 complications in males than in females. Chloroform is said to 
 be about twice as dangerous in males as in females. Ether is 
 slightly more dangerous in females than in males, and while its 
 complications are more frequent in ma 1 • they are generally 
 
THE ANAESTHETIC AND THE PATIENT 39 
 
 slight. The A. C. E. mixture is more dangerous in males than 
 in females, but the difference is less marked than with chloro- 
 form. The relative dangers and complications of gas and ether 
 are the same as with ether. 
 
 According to the report of the British Medical Association 
 (1900), the ratio of danger is as follows, the danger rate of gas 
 and ether being taken as a unit : 
 
 MALES. 
 
 Chloroform 7-J07 
 
 Ether i .205 
 
 Gas and Ether 1 . 
 
 A. C. E. Mixture 2.854 
 
 FEMALES. 
 
 Chloroform 2.040 
 
 Ether 1 . 144 
 
 Gas and Ether . . 1 . 
 
 A. C. E. Mixture 1.191 
 
 Age. If we take anaesthetics collectively and exclude the 
 period of infancy, we find that the dangers increase pari passu 
 as age increases. Chloroform is most dangerous during infancy 
 and after thirty years of age, and least dangerous from ten to 
 thirty years. Ether is less dangerous to infants than chloroform, 
 and its period of greatest danger is from fifty to seventy years 
 of age. 
 
 Anaesthesia has been safely produced in an infant of a few 
 days, and in centenarians, but these extremes of life are dan- 
 gerous periods for anaesthesia, and careful selection of agents is 
 necessary. 
 
 In infants and young children nitrous oxide gas is an unsat- 
 isfactory and dangerous anaesthetic because of the liability of 
 asphyxial troubles. Combined with oxygen the dangers are less. 
 In children above six years of age nitrous oxide may be valuable 
 as a preliminary agent to ether as this plan obviates the stage 
 of excitement usually so marked in children under ether. Chlo- 
 roform is a popular anaesthetic for children because of the read- 
 iness with which anaesthesia may be produced, the comparative 
 freedom from excitement, and its less irritating effect on the 
 upper respiratory tract. While chloroform is more readily taken 
 by children and is less liable in them to cause respiratory and 
 
40 
 
 THE ANESTHETIC AND THE PATIENT 
 
 circulatory embarrassment than ether, and should such trouble 
 arise remedial measures are more effective in children than in 
 adults, yet chloroform is not so free from danger in children as 
 has been supposed. In infants the ready induction and tranquil 
 nature of the narcosis may be misleading. Ether may be given 
 to children v>ith plenty of air and will be taken much better than 
 is generally supposed. It is undoubtedly safer than chloroform. 
 Nevertheless, if chloroform is very carefully given by the drop 
 method, and care be exercised to withdraw the chloroform as soon 
 
 DANGER RATE 
 
 pen cent. 
 
 AGE PERIODS 
 
 ri - ! 
 
 1 -5 
 
 5-10 
 
 10-15 
 
 15-20 
 
 20-30 
 
 30-+0 
 
 +0-50 
 
 50-60 
 
 60-70 
 
 70-80 
 
 80-90 
 
 3 
 2 6 
 
 1-5 
 
 05 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 A 
 
 
 L_ 
 
 
 
 
 
 
 
 A 
 
 
 
 /\ 
 
 
 r 
 
 
 
 
 
 
 / 
 
 / \ 
 
 V 
 
 
 ' \ 
 
 1 
 
 \ 
 
 
 ■/\ 
 
 
 
 
 / 
 
 
 / 
 
 
 
 
 
 V 
 
 ' \ 
 
 
 
 
 
 i 
 
 ' 
 
 / \ 
 
 \ 
 
 \ 
 
 
 
 .<** 
 
 -" 
 
 's**» 
 
 ■••».„•>• 
 
 .^*-~'~ 
 
 
 i 
 
 
 
 \ 
 
 
 Chloroform. 
 
 Erher 
 
 Ges & Efher".. 
 
 to Report of British 
 
 Chart showing relation of age to danger rate, according 
 
 Med. Ass'n, 1900. 
 
 as struggling or crying shows signs of ceasing, there will be 
 comparatively little danger in the use of chloroform in children. 
 
 Some anaesthetists prefer chloroform, some ether, some the 
 A. C. E. mixture, and some the chloroform-ether, or A. C. E.- 
 ether sequence, for children. It is generally conceded that ether 
 is safer in children than chloroform, though it is not so easy of 
 administration. 
 
 Old people take anaesthetics better, comparatively, than per- 
 sons in middle life. They are less subject to muscular spasm, 
 have fewer respiratory difficulties, and require less of the anaes- 
 thetic. In the absence of senile lesions of the heart and obstruc- 
 tive conditions of the lungs they take ether well. The A. C. E.- 
 
THE ANESTHETIC AND THE PATIENT 4I 
 
 ether sequence is recommended as being better than the nitrous 
 oxide-ether sequence. Nitrous oxide is not as safe in elderly 
 people as in middle life, and in senile subjects should be given 
 with oxygen. Chloroform is a satisfactory anaesthetic as far 
 as facility of induction is concerned. It is not relatively as dan- 
 gerous as in children if organic disease be not advanced. Some 
 anaesthetists use chloroform or A. C. E. mixture as routine agents 
 in persons over 60 years old, just as others the A. C. E. mixture 
 in children under 10 years. The chart (Page 40) shows the re- 
 lation of age to the danger rate. 
 
 General condition. Persons of a highly excitable tempera- 
 ment, and nervous, irritable people are generally troublesome to 
 anaesthetize. Muscular phenomena are more apt to be manifested 
 than in subjects of more equable temperament. It may be im- 
 possible to completely abolish the reflexes in excitable subjects, 
 and may be dangerous to attempt to carry the narcosis far 
 enough to do so. In hysterical subjects the corneal reflex may 
 be absent even though anaesthesia be not fully induced. 
 
 Nitrous oxide is a good agent in excitable subjects provided 
 the narcosis is long enough to answer the purpose, or the nitrous 
 oxide-ether sequence may be used with benefit. 
 
 The A. C. E. mixture is often very satisfactory in neurotic 
 subjects. The so-called interrupted ether narcosis is also a very 
 satisfactory method. The administration is simply interrupted 
 with sufficient frequency and regularity so as not to abolish com- 
 pletely the reflexes. This is sometimes confused with the use of 
 morphia or with local anaesthesia. 
 
 Ancemic, debilitated, or cachectic subjects usually require 
 less anaesthetic than robust subjects. All anaesthetics should be 
 given without much limitation of air to these patients. Nitrous 
 oxide with oxygen, interrupted ether narcosis, A. C. E. -ether, or 
 chloroform-ether sequence may be used. Profound anaesthesia 
 should be avoided. 
 
 Vigorous, healthy and plethoric subjects require more anaes- 
 thetic, exhibit more muscular and general excitement, and rel- 
 atively sustain a higher danger rate than less healthy subjects. 
 Florid subjects require considerable anaesthetic and should be 
 kept deeply anaesthetized to prevent reflex disturbances. The 
 
4 2 THE' ANAESTHETIC AND THE PATIENT 
 
 amount of air must be limited, and with nitrous oxide it may be 
 necessary to induce a marked degree of cyanosis. 
 
 Obese subjects do not tolerate well any method of administra- 
 tion admitting of but little air. The A. C. E. mixture or chloro- 
 form is therefore best tolerated, though in some instances the 
 chloroform-ether sequence is most satisfactory. 
 
 Alcoholic subjects usually require a large amount of anaes- 
 thetic. The stage of excitement is prolonged, muscular and re- 
 flex movements are marked and persistent, and muscular relax- 
 ation may not be complete. Nitrous oxide and oxygen is not 
 satisfactory, and even with the pure gas it may be impossible to 
 secure complete anaesthesia. If chloroform be used care must 
 be exercised during the stage of muscular rigidity and excite- 
 ment. The A. C. E.-ether sequence is often advantageous in these 
 subjects.* 
 
 Drug habitues are generally more sensitive to the action of 
 anaesthetics, and if the administration should closely follow the 
 use of some drug, especially morphine, great care should be ex- 
 ercised. 
 
 Tobacco users may take anaesthetics badly, both because of 
 irritable conditions of the upper air passages, and because of the 
 degree of muscular spasm, especially of the muscles of the jaws, 
 and obstructive breathing likely to ensue in excessive users of 
 tobacco. 
 
 Menstruation. While it is customary not to administer anaes- 
 thetics during menstruation, owing to a possible disturbing effect 
 upon this function, there is no special objection to so doing if 
 occasion requires, and the presence of the menstrual flow has 
 no bearing on the selection of an anaesthetic. 
 
 Pregnancy. The pregnant state presents no special contrain- 
 dication to the administration of an anaesthetic, at least in the ear- 
 lier months. Nitrous oxide should not be given after the fifth 
 month. Abortion has followed its use in women not five months 
 pregnant. If used at all it is best in combination with oxygen. 
 In the late months of pregnancy we may use chloroform, the 
 A. C. E. mixture, or the A. C. E.-ether sequence. Care should be 
 exercised in preparing the patient in order to prevent after-vom- 
 iting. 
 
 *McCardie recommends a few days' rest in bed before operation for 
 alcoholic subjects, Vi grain of morphine the night before operation, and, 
 if chloroform is to be used, an injection of morphine and atropine twenty 
 minutes before the operation begins. 
 
THE ANESTHETIC AND THE PATIENT 43 
 
 Lactation presents no contraindication to general anaesthesia, 
 and no special indications for particular agents. 
 
 Frequent anesthetization may develop a lack of sensitiveness 
 to anaesthetics, and such subjects may grow progressively harder 
 to anaesthetize. They are likely to exhibit marked signs of irri- 
 tability such as vomiting, swallowing, coughing, and obstructive 
 breathing. 
 
 Pathologic conditions. The lymphatic diathesis, a condi- 
 tion characterized by enlarged tonsils, lymph follicles and glands, 
 of the follicles at the base of the tongue, of the spleen, of the 
 thymus gland, probably of the heart from dilatation, and asso- 
 ciated or not with tubercular glandular enlargement, also with 
 naso-pharyngeal growths, is a condition liable to be associated 
 with sudden, dangerous syncope or with death under chloroform. 
 In this condition ether is safer and otherwise probably more sat- 
 isfactory. The nitrous oxide-ether sequence may be used. 
 
 Condition of the blood. Hamilton Fish says that safety in 
 anaesthesia, and operative procedures, is dependent first on a 
 haemoglobin percentage over and above that required for its nor- 
 mal duties ; and a normal or increased number of polynuclear 
 neutrophiles. He states that in individuals whose blood presents 
 a haemaglobin percentage of 50 or less, the anaesthetic vapor 
 produces an increased pathological condition by forced abstrac- 
 tion of oxygen from the tissues ill-conditioned to part with it. 
 Mikulicz does not operate when the haemoglobin percentage is 
 under 30 per cent. Da Costa and Kalteyer think operation dan- 
 gerous with a percentage of haemoglobin below fifty per cent. 
 
 Morbid growths of the mouth, tongue, palate, tonsils, phar- 
 ynx, or epiglottis are liable to cause trouble from muscu- 
 lar enlargement under close methods of administration. Nitrous 
 oxide and oxygen is therefore much safer than the pure gas. 
 The nitrous oxide-ether sequence may be used. In some in- 
 stances chloroform is the best agent if carefully administered. 
 
 In laryngeal diseases and chronic stenosis of the upper air 
 tract chloroform, according to Semon, is preferable as ether in- 
 creases the dyspnoea and liability to pulmonary complications. 
 Hewitt thinks chloroform the only admissable anaesthetic in such 
 cases, and that the depth of anaesthesia should be in inverse ra- 
 tio to the degree of obstruction. Light degrees of obstruction 
 
44 THE ANAESTHETIC AND THE PATIENT 
 
 do not interfere with the administration, but marked degrees of 
 obstruction render anaesthesia dangerous, the work of respiration 
 depending on muscles which are incapable of overcoming the 
 resistance to breathing. Respiratory arrest may occur even 
 though the corneal reflex be present. In paralysis of the ab- 
 ductors of the vocal cords it may be necessary to keep the chin 
 pulled forcibly away from the sternum in order to prevent ob- 
 struction from approximation of the vocal cords. The question 
 of tracheotomy and the administration of chloroform through 
 the tube should be considered in all cases of stenosis of the 
 upper air passages from disease or pressure. 
 
 Diseases of the bronchi, kings, or plenrce, do not, as a rule, 
 afford such direct indications as is given by the nature and length 
 of the proposed operation. Patients with affections of the respir- 
 atory tract do not show as great a tendency to reflex manifes- 
 tations as do other subjects, and the difficulties attending anes- 
 thetization in chronic cases are relatively not so great as in acute 
 cases because the lungs accommodate themselves to the altered 
 conditions. If the operation is short, nitrous oxide and oxygen 
 may be used, though as with all anaesthetics profound anaesthe- 
 sia should be avoided. Ether may be used in comparatively short 
 operations, and if cyanosis and expiratory difficulty arises the 
 ether may be changed to chloroform or the A. C. E. mixture. In 
 short operations chloroform or the A. C. E. mixture are probably 
 best. In recent inflammatory states, especially if the heart is 
 not as good as could be wished, the A. C. E. -ether sequence is 
 to be recommended. In acute lung troubles Silk prefers chlo- 
 roform, while in those not in the acute stage he prefers the 
 A. C. E. mixture, subsequently increasing the percentage of ether. 
 Patients with chronic pleurisy, fibroid phthisis, or emphysema 
 usually take ether well. The report of the British Medical As- 
 sociation (1900), calls attention to the comparative freedom from 
 danger in the lung cases, especially those of phthisis. Cases of 
 acute or chronic bronchitis, or acute tuberculosis with marked 
 catarrhal conditions are safer from after-complications if chlo- 
 roform be used. 
 
 Diseases of the heart and blood vessels. Variations in the 
 pulse rate do not, as a rule, modify the danger rate from anaes- 
 thetics, providing the pulse is strong and full. Cases with a 
 
THE ANESTHETIC AND THE PATIENT 45 
 
 pulse rate as low as 25 per minute have been successfully anaes- 
 thetized. The pulse usually becomes more rapid. A pulse above 
 100 per minute usually slows under anaesthesia, unless the rate 
 be due to shock or exhaustion, when it will rise in rate under 
 the anaesthetic. An irregular pulse may become rhythmical under 
 anaesthesia, and in any event usually improves in its rhythm. 
 Allorrhythmia may be sustained or may disappear under anaes- 
 thesia. 
 
 Functional disturbances of the heart do not affect, to any 
 appreciable extent, the danger rate of anaesthetics. Valvular af- 
 fections do not, as a rule, affect the danger rate only in so far 
 as they modify the dynamic integrity of the heart muscle. The 
 condition of the myocardium is the vital question, and the only 
 direct relation to the danger rate which a specific valvular affec- 
 tion may have is through its tendency to develop myocardial ina- 
 bility. According to H. C. Wood, "The key to the situation is not 
 the valvular lesion, but the condition of the muscle, and ether is 
 the anaesthetic of choice." Finney says, "In the myocardial affec- 
 tions only do anaesthetics exert any marked bad effect. In the 
 valvular diseases their influence is very slight, but yet appreci- 
 able. In the functional disturbances they are insignificant." If 
 compensation is good there is no great liability to danger. 
 Marked degrees of mitral or pulmonary stenosis, and of aortic 
 regurgitation not fully compensated for, are probably most often 
 associated with danger. Danger will also be present in direct 
 ratio to excess of dilatation. The great difficulty is to judge 
 accurately as to the condition of the heart muscle. This is at 
 times most difficult to do, as it is possible for degeneration to be 
 present to a serious extent without definite physical alteration 
 in the heart. On the other hand if compensation be good the 
 effect of any anaesthetic will often be to improve the circulation, 
 even though marked physical alterations have taken place in the 
 heart. 
 
 Ether is generally considered the safest anaesthetic in heart 
 disease. Nitrous oxide and oxygen is recommended by some, 
 but it is doubtful if nitrous oxide in any form should be em- 
 ployed in cases of myocardial disease. Hewitt recommends A. 
 C. E. mixture and the A. C. E.-ether sequence. Chloroform is gen- 
 erally condemned, though if properly administered by the drop 
 
40 THE ANAESTHETIC AND THE PATIENT 
 
 method it is not as dangerous in cardiac disease as is generally 
 supposed. I have administered chloroform to subjects in whom 
 there was every reason to expect trouble, so far, at least, as pre- 
 vious knowledge of the condition of the heart muscle would in- 
 dicate, and yet have had no serious trouble. Wood thinks the 
 shock from a severe surgical operation would be more fatal to 
 a fatty heart than the effect of a general anaesthetic. This is 
 undoubtedly true, for many patients with advanced fatty or other 
 degeneration of the heart muscle have been anaesthetized without 
 untoward symptoms. Chronic interstitial or granular degenera- 
 tion of the heart muscle, resulting from vascular degenera- 
 tion, are probably the most dangerous cardiac conditions as re- 
 lated to general anaesthesia, aside from recent dilatation or the 
 advanced stages of the hyposystolic period of chronic cardio- 
 pathies. All methods of administration should be cautiously con- 
 ducted and plenty of air admitted. 
 
 Chronic vascular disease of sclerotic or atheromatous nature 
 with high arterial tension is probably more dangerous under 
 ether than under chloroform or A. C. E. mixture ; as these condi- 
 tions occur late in life there is not so great a tendency to re- 
 flex disturbances under chloroform and this agent is correspond- 
 ingly safer. In markedly atheromatous subjects there may be 
 slightly increased danger from cerebral haemorrhage, which Hew- 
 itt thinks is lessened by using A. C. E. mixture or chloroform in 
 preference to ether. Ether is strongly contraindicated in sub- 
 jects who have suffered previous attacks of apoplexy. Care must 
 be exercised to prevent straining, coughing, or struggling by pro- 
 ceeding slowly with the anaesthetic, especially in cases of aneurism. 
 In intrathoracic aneurism chloroform should always be used in 
 preference to ether. 
 
 Patients with venous thrombus should not be moved more 
 than can be helped. Struggling and excitement must be avoided. 
 Chloroform, A. C. E. mixture, or A. C. E.-ether sequence are in- 
 dicated. 
 
 Abdominal conditions such as peritonitis, intestinal obstruc- 
 tion, ascites, ovarian cysts, etc., may mechanically alter the type 
 of respiration to the thoracic type. Anaesthetics must be carefully 
 given. Chloroform, A. C. E. mixture or the chloroform-ether, 
 or A. C. E.-ether sequence may be used, the change being made as 
 
THE ANAESTHETIC AND THE PATIENT \*J 
 
 the abdominal tension is relieved, light anaesthesia being em- 
 ployed before this. Patients with marked acute intestinal ob- 
 struction are bad subjects for anaesthetics. The stomach is fre- 
 quently not empty, they are often under the influence of stimu- 
 lants or morphine, they vomit readily, and syncope and collapse 
 are frequent. Nitrous oxide is not admissable, chloroform, or 
 A. C. E. mixture are preferable. Ether, or A. C. E. -ether se- 
 quence may be admitted with whichever agent is employed. 
 
 Exhaustion, shock, and collapse are frequently present when 
 the necessity for anesthetization arises. As a rule such patients 
 require small amounts of anaesthetic, especially when there is 
 exhaustion from chronic disease. The pulse is generally im- 
 proved by the anaesthetic, but marked depression may follow 
 its withdrawal. Ether, cautiously given, by an open inhaler, is 
 satisfactory, or chloroform by the drop method may be used. In 
 shock and collapse the increase in the danger rate is somewhat 
 greater than with exhaustion alone. This increase seems to 
 apply somewhat more to chloroform than to ether, and the lat- 
 ter agent either alone or preceded by chloroform or A. C. E. mix- 
 ture is most generally used. McCardie thinks that ether is 
 strongly indicated in shock or collapse. 
 
 Kidney disease has long been supposed to contraindicate the 
 administration of ether. Opinion is much divided on this point, 
 though prolonged etherization is generally discouraged. Wood 
 says that Thomas A. Emmet was first to report cases of anuria 
 following ether narcosis in individuals suffering from chronic 
 Bright's disease, but we know that chloroform may have the 
 same effect. He* thinks both are contraindicated in advanced 
 nephritis, but prefers ether if anaesthesia be necessary. Many 
 observations on the effect of these drugs on the kidneys show 
 that albumen and casts are found in about 25 per cent, of the 
 cases. The percentage is slightly higher after ether but the 
 changes from chloroform appear to be more profound. Some 
 authorities think that ether is contraindicated in kidney disease, 
 some prefer the A. C. E. mixture. Kemp thinks that about 5 per 
 cent, of ether cases are fatal from renal complications. On the 
 other hand Buxton and Levy are not satisfied that ether exerts 
 unfavorable effects on the kidneys when properly administered. 
 
4^ THE ANAESTHETIC AND THE PATIENT 
 
 Opinion and statistics vary so greatly on this point that a definite 
 conclusion cannot at present be stated. 
 
 According to Thompson's experiments the volume of urine 
 is diminished during- ether narcosis in the majority of instances. 
 The depressing effect is more marked than with chloroform, and 
 arrest of secretion occurs more readily. The after effect of ether 
 is similar to chloroform but less marked, and the freest secretion 
 occurs about three hours after stopping the anaesthetic. The ef- 
 fect of chloroform upon the output of nitrogen does not so close- 
 ly correspond to its influence en the secretion as is the case with 
 ether, the latter increasing the amount of nitrogen with a dimin- 
 ished flow. The escape of leucocytes into the urine, and the ex- 
 cretion of chlorides is increased with ether, but the latter is of 
 shorter duration than with chloroform. 
 
 Full narcosis with the A. C. E. mixture diminishes the urine, 
 but less so than with ether or chloroform. The excretion of ni- 
 trogen is not so much lessened as the volume of urine. The 
 chlorides are increased more than with ether, but less so than 
 with chloroform. The effect of the mixture closely resembles 
 that of ether. 
 
 Status Thy miens. The post mortem examination some years 
 ago, in Vienna, of subjects dying suddenly under chloroform, and 
 without apparent cause, determined the presence of a certain 
 pathologic complex which was termed the "lymphatic diathesis, 
 or status thymicus." This condition is present most often in chil- 
 dren or voung people, and according to Kolisko is characterized 
 by: 
 
 1. Persistent or enlarged thymus gland. 
 
 2. Enlarged lymph glands, general or local. 
 
 3. Adenoid growths in the naso-pharynx, enlarged tonsils, 
 enlarged lymph structures at the base of the tongue, enlarged 
 follicles in the stomach and intestines. 
 
 4. Acute cardiac dilatation — narrow aorta. 
 
 5. Often an enlarged thyroid and spleen. 
 
 According to McCardie the lymphatic diathesis is often asso- 
 ciated with tuberculous manifestations. Halsted remarks that 
 such patients "generally show the constitutional and local results 
 of nasal obstruction. Many of them are of the flabby type, and 
 all have weak hearts, poor blood, impaired lungs, and resist shock 
 and disease much less strono-lv than do others." 
 
THE ANAESTHETIC AXD THE PATIENT 49 
 
 Competent observers have shown that the status lymphaticus 
 is a pathological entity, and according to Elake it is characterized 
 clinically by lowered vitality, or unstable equilibrium of vital 
 force, and accidents or disturbances otherwise unimportant, such 
 as slight injury or anaesthesia, may precipitate failure of the heart 
 and respiration. 
 
 While there have been instances of death under ether anaes- 
 thesia in subjects of this diathesis, the greater number of deaths 
 have been under chloroform. Ether is therefore regarded as the 
 best agent for these subjects, and if chloroform is to be employed 
 it should only be after the use of preliminary stimulant treat- 
 ment. 
 
 Diabetes. The unqualified statement is often made that dia- 
 betics take anaesthetics well, but the experience of most observers 
 agree with the statements of Pavy, that in diabetics who are in 
 good condition with little or no sugar in the urine, the adminis- 
 tration of anaesthetics is attended with no special risk, but in 
 those who show large amounts of sugar the administration of 
 anaesthetics especially for protracted operations is liable to be fol- 
 lowed by diabetic coma. The patient, therefore, should have 
 careful preliminary treatment; the anaesthetic should be chosen 
 with a view to avoiding excitement, after-vomiting and compli- 
 cations ; the administration should be made as short as possible. 
 Eastes says that diabetics take ether and chloroform well. Prob- 
 ably the latter or the A. C. E. mixture is safest for these patients. 
 
 Nervous diseases. Subjects with cerebral abscess, tumor, 
 intracranial haemorrhage, depressed fractures, etc., or who are 
 toxic from various causes, may be sufficiently comatose that very 
 little if any anaesthetic will be necessary. Hewitt calls attention 
 to the fact that patients with tumor may show a tendency to 
 respiratory failure due to increased intracranial tension, and in 
 them even slight anaesthesia may entirely suspend respiration. 
 
 Respiratory disturbances are liable to occur in subjects of 
 chronic nervous disease. Epileptic subjects may be safely anaes- 
 thetized. There may be a tendency to muscular spasm, or epi- 
 leptic paroxysm may occur during the early part of the adminis- 
 tration. Ether is probably the best agent generally for patients 
 with nervous disease. 
 
 According to Savage, the insane take anaesthetics well, and 
 take the various anaesthetics with equal safety. Chloroform pro- 
 duces marked after-effects in maniacal subjects, severe maniacal 
 attacks being not uncommon. 
 
CHAPTER V. 
 
 THE SELECTION OF AN ANAESTHETIC WITH REFERENCE TO THE 
 
 OPERATION. 
 
 The bearing of the operation to be performed on the selection 
 of the anesthetic is chiefly through the facts that certain anaes- 
 thetics are better adapted to the performance of certain opera- 
 tions than are others ; that more profound anesthesia is necessary 
 for some surgical procedures than for others ; that certain opera- 
 tive measures affect the respiration and circulation more than 
 others ; and that in certain postures some anesthetics are more 
 likely to cause respiratory or circulatory disturbances during 
 operative proceedings than are others. 
 
 Respiration, which is usually deeper and quicker under an- 
 aesthesia, may become obstructed from surgical manipulations in 
 operations about the air passages, or from the effect of the stim- 
 ulation of operative measures on other portions of the body. 
 
 The circulation may become depressed (surgical shock) from 
 haemorrhage, prolonged surgical measures, or from reflex inhi- 
 bition from the surgical proceeding, as in skin incisions, etc., 
 during light anesthesia, especially with chloroform. Hewitt be- 
 lieves that surgical shock from reflex causes also occurs with 
 profound anesthesia, and that such a degree of narcosis does 
 not protect against shock. He favors the view that ether is 
 more protective than chloroform against reflex inhibition of the 
 circulation. 
 
 In patients in a condition of shock or collapse ether is gen- 
 erally preferred as being more stimulating to the respiration and 
 circulation than other agents. 
 
 Short operations may be performed under the short-term an- 
 esthetics, as nitrous oxide, pure or with oxygen, ethyl chloride, 
 etc. Prolonged operations, especially abdominal operations 
 should be performed under ether or chloroform. 
 
 For operations where complete muscular relaxation is neces- 
 sary ether is most reliable, though at times it may be necessary to 
 follow with chloroform in order to secure relaxation. 
 
 Brain and spinal cord. Chloroform is generally preferred. In 
 spina bifida in infants ether is preferred by some. 
 
THE ANESTHETIC AND THE OPERATION ej 
 
 Ophthalmic operations. Chloroform is preferred by many. 
 The high death rate from chloroform in ophthalmic practice is 
 partly due to the position of the head which favors obstruction 
 to breathing, from mucus, saliva, retracted tongue, etc., also to 
 the difficulty of maintaining an even degree of narcosis. Ether 
 is preferred by some, especially in strabismus operations in chil- 
 dren. The A. C. E. mixture, chloroform, or these in sequence 
 with ether, may be advisable. For enucleation of the eye-ball the 
 patient's general condition will determine the anaesthetic. When 
 in elderly people, ether is safest. McCardie recommends gas 
 and oxygen in squint operations in subjects above ten years, 
 enough oxygen being given to obviate congestion. 
 
 Operations on the face, jazvs, lips, tongue, palate, tonsils, 
 nose, and naso-pharynx. If these operations are short, not ex- 
 ceeding 30 or 40 seconds, the short-term anaesthetics, such as 
 nitrous oxide, or ethyl chloride, may be used. If a little longer 
 anaesthesia is necessary nitrous oxide and oxygen may be used. 
 If an available period of from 1 to 5 or 10 minutes is desired 
 a single administration of ether, possibly preceded by chloro- 
 form or A. C. E. mixture, will often answer. If longer anaesthesia 
 than this is necessary the ether-chloroform sequence recommended 
 by Hewitt, White, and others, is useful. The former recom- 
 mends deep anaesthesia by ether, suspension until slight con- 
 junctival reflex, swallowing, or cough, appears, control these by 
 cautiously giving chloroform, begin operation as reflexes dis- 
 appear. Keep up a moderately deep anaesthesia. Many oper- 
 ators prefer chloroform alone. * 
 
 In those cases where the anaesthetic is best administered 
 through a mouth or nose tube chloroform may be given from 
 some inhaler, such as the Junker, to which a tube is attached 
 and passed through the nose into the pharynx, or it may be 
 passed into the side of the mouth, or a gag with a tube attach- 
 ment may be used {vide Fig. 1). 
 
 In operations upon the palate and throat some object to 
 ether because of the greater vascularity under its influence. How- 
 ard claims that ether does not increase haemorrhage in throat 
 operations. In stenotic conditions of the air passages ether is 
 not admissable because of obstructive congestion. Chloroform 
 should be used. For adenoid growths some prefer chloroform 
 
 *Rockey, of Oregon, describes an ingenious device extemporized for 
 use in resecting the jaw. The mouth tube was an ovarian trocar, the 
 inhaler a Politzer air bag with the top cut off and gauze fastened over it. 
 Two thumb holes in the sides sufficed for controlling the air. With the 
 tube in the throat, the tongue held well forward, and the mouth packed 
 with gauze, the instrument answered perfectly. Chloroform or any volatile 
 agent may be sprinkled on the gauze. 
 
r 2 TJiE ANAESTHETIC AND THE OPERATION 
 
 (Semon), or the A. C. E. -ether sequence (McCardie), or nitrous 
 oxide, gas-ether, chloroform, A. C. E., or ether for quick opera- 
 tions, and nitrous oxide-ether, or, in children under 4 or 5 years, 
 chloroform for longer operations (Hewitt). 
 
 For tonsillotomy, gas-ether or chloroform-ether sequence may 
 be given in the dorsal position and the patient propped up for 
 operation. 
 
 For the extraction of teeth. Nitrous oxide is the recognized 
 anaesthetic. It may be used with or without oxygen as circum- 
 stances dictate. If a longer available period is desired than usu- 
 ally is the case, one of the methods of prolonging nitrous oxide 
 
 Fig. 1.— Hewitt's Modification of Mason's gag. 
 
 Fig. 1. Bent metal tubes are brazed to the arms of an ordinary Mason's 
 gag. To one of these tubes the tubing from a Junker's inhaler is attached. 
 The chloroform is thus transmitted along the tube to the back of the 
 throat. The gag should be adjusted far back in the mouth. 
 
 anaesthesia may be used, as described under the administration 
 of the gas. If the operation is a prolonged one the nitrous oxide- 
 ether sequence is probably the best. Chloroform should not be 
 used unless in some exceptional cases. 
 
 Operations on the larynx and trachea. Chloroform is gen- 
 erally the best anaesthetic. Some prefer the A. C. E. -ether-chloro- 
 form sequence. In excision of the larynx, thyrotomy, etc., a 
 preliminary tracheotomy will probably be performed, and the 
 anaesthetic (chloroform) should be administered from some such 
 apparatus as the Junker inhaler by means of a tube passed into 
 the tracheotomy tube a short distance. If the Trendelenberg air 
 ball around the tracheotomy tube is employed (vide Fig. 2) 
 there will be no trouble from the entrance of blood into the 
 trachea during the chief operation. 
 
 Chloroform alone should be used for intra-laryngeal opera- 
 
THE ANESTHETIC AND THE OPERATION 53 
 
 tions in children when done under general anaesthesia. The pre- 
 vious local use of a dilute solution of cocaine will diminish bleed- 
 ing, salivation, and obviate the necessity of profound anaesthesia. 
 
 Tracheotomy and laryngotomy should be done under chloro- 
 form alone if there is any difficulty of breathing. If there is 
 not difficulty of breathing the A. C. E.-ether, or nitrous oxide- 
 ether sequence may precede the chloroform if desirable, 
 
 Operations on the neck exclusive of the air tract. These oper- 
 ations are likely to be prolonged, and important vessels and 
 nerves are disturbed. Surgical shock is likely to be manifested. 
 As deep anaesthesia as is compatible with safety should be main- 
 tained, as coughing, straining, etc., increases the vascularity and 
 interferes with the operator. Ether increases the vascularity 
 
 Fig. 2.— Trendelenburg's Trachea Tampon, Canula, and Inhaler. 
 
 Fig. 2. A trachea canula, the distal end of which is covered for about 
 half an inch with a rubber sheath or bag surrounding the tube. The space 
 between the sheath and canula is rendered air-tight and connected by a 
 slender tube with a rubber air-forcing bulb. 
 
 By this means the bag may be inflated and as it is circular, and the tube 
 in the center, it may completely fill the space between the canula and the 
 tracheal walls, thus preventing a flow of blood below the tube. To the 
 tube opening an inhaling apparatus is attached when desired, to facili- 
 tate the administration of an anaesthetic. 
 
 during the earlier part of the operation, but if given with plenty 
 of air the effects, in this respect, are not markedly different from 
 those of chloroform. Dyspnoea may be present in thyroid en- 
 largement and be due to pressure. If pressure is marked chlo- 
 roform should be used, and light anaesthesia maintained, as pres- 
 sure atrophy of the cartilages may have occurred and complete 
 abolition of muscular tone may cause kinking or displacement 
 
54 THE ANESTHETIC AND THE OPERATION 
 
 of the trachea. In the worst cases local anaesthesia should be used, 
 or a previous injection of morphine followed by light chloro- 
 form anaesthesia. In dissecting operations for diseased glands 
 gas and ether may be used at first and a change made to chloro- 
 form as the operation begins. Some operators prefer chloro- 
 form for all operations upon the thyroid gland. 
 
 Operations upon the chest. The anaesthetic for these opera- 
 tions will depend on the condition of the patient. Chloroform 
 is most convenient for the operator, but in many cases ether is 
 preferable. The greater the interference with respiration the 
 lighter should be the anaesthesia. 
 
 In chronic empyema the opposite lung has had time to adapt 
 itself to the changed conditions, and the A. C. E.-ether-chloroform 
 sequence may be used. In acute cases light anaesthesia under 
 chloroform or one of its mixtures should be used. If the posi- 
 tion will allow, gas and oxygen may be used in some cases. A 
 full hypodermic dose of strychnia should be used previous to 
 the administration in these cases. 
 
 Operations on the brain. The patient's general condition will 
 determine the anaesthetic to be used. Ether is adapted to com- 
 paratively young subjects. There is less liability to secondary 
 haemorrhage after ether than after chloroform. For elderly 
 people, or very fat subjects, chloroform or the A. C. E. mixture 
 may be best. The chloroform-ether sequence may be used in 
 patients in fairly good condition. Some prefer the gas-ether- 
 chloroform, or the ether-chloroform sequence. Because of the 
 condition of many of these patients anaesthesia should be con- 
 ducted with care. With marked coma very little anaesthetic may 
 be necessary. 
 
 Abdominal operations. These operations are generally more 
 or less serious. The patient's condition is likely to be unfav- 
 orable ; unpleasant effects during operation may interfere mark- 
 edly with the surgical manipulations, and after-effects are likely 
 to occur. Profound anaesthesia, as a rule, is necessary. Shock- 
 is likely to result from operations on the organs in the upper 
 portion of the abdominal cavity from traction on their attach- 
 ments or from manipulation of the peritoneum. Shock is also 
 likely to follow manipulation of the intestines in intestinal or 
 hernia operations. In these cases there are advantages in the 
 
THE ANAESTHETIC AND THE OPERATION 55 
 
 stimulant qualities of ether. Surgeons differ much as to the rel- 
 ative value of ether and chloroform in abdominal operations. 
 Ether has, in some quarters, been counted out of abdominal op- 
 erations because of the venous engorgement and the labored 
 breathing it causes. The advantage of its stimulant action is 
 supplemented by the safety of pushing it to the full abolition of 
 inconvenient reflexes. The supposed tendency of ether to favor 
 lung complications, which are very troublesome in patients with 
 abdominal wounds, is probably offset by the Trendelenburg posi- 
 tion so common now with most operators. This position also 
 lessens venous congestion and interference with operative meas- 
 ures by the character of the breathing. 
 
 Ether or A. C. E. mixture are probably safest as routine agents, 
 chloroform, or the gas-ether-chloroform sequence is satisfactory 
 in the hands of experienced administrators. The A. C. E. mixture 
 is good for children, elderly people, or those whose general con- 
 dition is unsatisfactory. The ether-chloroform sequence is pre- 
 ferred by some if the operation is to prove a long one. In cases 
 with great abdominal distention great care is necessary. The pa- 
 tient will usually be in the semi-recumbent position and unable to 
 lie down. The A. C. E. mixture is recommended as being adapted 
 to these cases. In intestinal obstruction anaesthesia may be dan- 
 gerous if regurgitative vomiting should occur. The A. C. E. mix- 
 ture with very light anaesthesia may be used. In some cases 
 local anaesthesia may be safest, especially if the stomach is full 
 of fluid and cannot be emptied by artificial means. 
 
 Operations on the rectum and ge nit o -urinary tract. These 
 operations usually demand a deep narcosis because of the sen- 
 sitive condition of the parts and the nervous state of the patients. 
 Operation should not be begun until profound anaesthesia has 
 been induced. Ether is generally best because of the stimula- 
 tion against shock and because of the thorough relaxation under 
 its use. Ether is best for circumcision in weak children be- 
 cause of the shock of the operation. In operations on the bladder 
 where distention is necessary the active breathing induced by 
 ether may render it inadmissable, and chloroform or A. C. E. 
 mixture advisable. In rectal surgery ether is much the safest 
 agent because of the shock. The weak, nervous subject is most 
 
c5 THE ANAESTHETIC AND THE OPERATION 
 
 likely to show bad effects at the time of the operation or after- 
 ward. 
 
 In operations on the kidney ether is preferable to chloroform 
 if the organs are healthy, because of the shock. When the kid- 
 neys are diseased the A. C. E. mixture or chloroform is recom- 
 mended by many observers. The nitrous oxide-ether-chloroform 
 sequence is recommended by McCardie when the kidneys are fairly 
 healthy, and chloroform, or any of its mixtures, if the kidneys 
 are seriously affected. 
 
 Gynecological operations. Women take anaesthetics better 
 than men, and particularly chloroform, therefore its mixtures are 
 adapted to these operations. Ether may be used in strong sub- 
 jects w T ith advantage. The chloroform-ether sequence is satisfac- 
 tory. 
 
 Obstetric operations and parturition. Chloroform is the most 
 generally used anaesthetic in this connection. Women under these 
 circumstances bear chloroform so well that there is a general 
 feeling of confidence in its safety, possibly a little over-rated for 
 several deaths have been reported from chloroform given dur- 
 ing labor, or for obstetric operations. Ether is recommended by 
 some as being the proper agent for the full anaesthesia necessary 
 for turning, craniotomy, instrumental delivery, etc., but never- 
 theless chloroform is so much more convenient, and, being rela- 
 tively safe, it will probably continue to be chiefly used. 
 
 During labor chloroform should be given to produce an anal- 
 gesia only. It should not be given if pains are feeble and irreg- 
 ular, when small doses retard labor, or when marked respira- 
 tory difficulty is present. Its administration should not be be- 
 gun until distinct labor pains have appeared. A small quantity 
 is given when the pain is approaching, just enough to relieve 
 the severe part of the pain and to deepen respiration. The chlo- 
 roform should be withdrawn as the pain begins to subside, and 
 the patient should be allowed to recover from the effects of the 
 drug in the interval of the pains. The general opinion is that 
 profound narcosis increases the liability to uterine inertia and 
 the danger of post-partum haemorrhage. Most obstetricians rec- 
 ommend that consciousness should be allowed to return during 
 the expulsion of the foetus because of the liability of rupture of 
 the perineum. 
 
THE ANAESTHETIC AND THE OPERATION 57 
 
 Among the reasons assigned for the comparative freedom 
 from accident of chloroform anaesthesia during labor are these: 
 That the element of fear of the anaesthetic is displaced by the 
 woman's suffering and her desire for relief; that physiological 
 hypertrophy of the heart protects against circulatory failure ; that 
 the deeper respiration and expulsive efforts prevent asphyxial 
 difficulties and promote the pulmonary circulation and the 
 emptying of the right heart; that high abdominal pressure pre- 
 vents vaso-motor dilatation. 
 
 It is doubtful if the condition of the heart has any marked 
 bearing on this question. The other causes may all have some 
 effect. 
 
 Operations on the extremities, such as reduction of fractures 
 and dislocations, examination and treatment of anchylosed and 
 painful joints, are better managed with anaesthesia by ether than 
 by chloroform because of the complete relaxation under ether, 
 and the safety of pushing ether to its fullest extent. Chloro- 
 form has proven dangerous in this class of cases, particularly in 
 injuries of the joints and bones as the patients are not always 
 in the best condition for its administration. 
 
CHAPTER VI. 
 
 BEFORE THE ADMINISTRATION OF AN ANAESTHETIC. 
 
 There are certain considerations of importance preliminary 
 to the administration of an anaesthetic which bear more or less 
 directly on the success. 
 
 Time of day. The morning hours from 8 to 10 o'clock are 
 generally considered the best for the administration. Statistics 
 show that the danger and complication ratios for chloroform are 
 lowest during the first quarter of the day, and increase progress- 
 ively as the day advances. Of course other factors have 
 much to do with this, but, all things considered, the morning 
 hours are probably the safest for all anaesthetics. The stom- 
 ach is empty, and the patient has not had the most of the day 
 to worry about the operation. From I to 2 p. m. is probably the 
 next best time for the administration, providing nothing has 
 been eaten for breakfast except tea and toast. 
 
 Diet. Where the administration occurs in the morning the 
 patient should not be allowed any breakfast. Ordinary, light 
 meals may be taken the day before, but nothing after 8 p. m. 
 the previous evening. Hearty meals taken the day before are 
 apt to remain partially undigested, especially if the patient is 
 worrying over the operation. If the administration is fixed for 
 1 or 2 p. m., tea or milk and toast may be taken at 8 a. m., and 
 nothing afterward. When the administration is set for 11 or 
 12 o'clock, or for 4 or 5 in the afternoon, patients should be in- 
 structed not to eat their usual breakfast or luncheon. For the 
 former hour a light breakfast of coffee and toast may be given 
 at 7 a. m., while for the latter hour a light breakfast about 9 130 
 or 10 o'clock will answer.* 
 
 These regulations of diet do net apply to the administration of 
 nitrous oxide gas with as much force as they do to other an- 
 aesthetics. Although it is best to allow 2 or 3 hours to intervene 
 between the taking of food and the administration of nitrous ox- 
 ide, it is often taken shortly after food without trouble. When 
 nitrous oxide is administered with air or oxygen the period pre- 
 vious to the administration should be governed by the same diet- 
 etic rules as apply to other anaesthetics. 
 
 *In the preliminary dietetic management it has been largely the custom 
 to withhold liquids as well as solids, thus placing the patient on the oper- 
 ating table with small pulse, diminished urinary secretions, and in poor 
 condition to eliminate poisonous material. Hess has shown that ether is 
 excreted from the blood to the stomach, causing vomiting by irritation. 
 Both acceleration of excretion of the ether, and prevention of vomiting 
 may be accomplished by free administration of water up to the time of 
 going to operation, and as soon afterward as possible. 
 
BEFORE THE ADMINISTRATION OF AN ANESTHETIC 59 
 
 In weak and exhausted patients it is not best to restrict 
 the diet too much. In young and robust subjects the administra- 
 tion will proceed better if they have been fasting for 6 or 8 hours, 
 but in weak patients it is best not to allow them to remain long 
 without food. If the administration is set for the early morn- 
 ing hours, a little beef tea, soup or milk should be given during 
 the night. When the circulation is particularly weak an enema 
 of beef tea and brandy should be given half an hour before 
 the administration. The rectal, subcutaneous, or intravenous in- 
 jection of normal salt solution may be advisable or necessary.* 
 Preliminary rectal feeding may be necessary in some cases. 
 Some surgeons wash out the stomach before abdominal section 
 for obstruction, or previous to operations for appendicitis. 
 
 Cushing recommends feeding with sterilized liquid food .and 
 water for several days in preparation for extensive operations 
 on the stomach and intestines in order to lessen the liability to 
 after infection. 
 
 Careful disinfection of the mouth and pharynx previous to the 
 administration is recommended as a preventive of post-opera- 
 tive lung complications. 
 
 Bowels. It is important that the bowels should be evacuated 
 before the administration, and in certain subjects and operations 
 it is very necessary. Where the operation does not involve the ab- 
 dominal or pelvic regions a saline purgative given the morning 
 before operation will be sufficient. In abdominal or pelvic oper- 
 ations a free purgative may be given 24 or 36 hours before the 
 administration, and an enema or colonic flushing the morning of 
 the operation. Robust subjects may be purged freely with ben- 
 efit, but weak and debilitated persons should not be given hydra- 
 gogue cathartics before operation. 
 
 Bladder. The bladder should always be emptied immediately 
 before the administration, especially in young subjects and when 
 nitrous oxide gas is to be employed. 
 
 Medicine. The local application of cocaine solution to the 
 nose and throat to prevent irritation, cough, holding the breath, 
 and reflex syncope has been practised, and while these conditions 
 can be, in a measure, controlled by this means, the method is 
 objectionable because of the clanger of cocaine poisoning. The 
 importance of such applications is lessened by the doubt of the 
 
 *Villaneuve recommends the subcutaneous injection of 400 gms. of 
 salt solution the day before operation to prevent vomiting during or after 
 operation. 
 
6o BEFORE THE ADMINISTRATION OF AN ANAESTHETIC 
 
 possibility of the occurrence of fatal syncope from the irritative 
 effect of chloroform. 
 
 Alcohol has often been given by the mouth as a general stim- 
 ulant before operations. Its use in this way is objectionable as it 
 is apt to interfere with the induction of anaesthesia. As a pre- 
 liminary routine measure it should be discouraged. 
 
 Strychnia. The hypodermic administration of strychnia pre- 
 vious to the anaesthesia has been recommended and is a good 
 general practice in debilitated subjects, especially when there 
 is a weak heart. From one-thirtieth to one-twenty-fifth of a 
 grain may be given half an hour before the administration. 
 
 Morphine and atropine. Nussbaum, as early as 1863, injected 
 morphia during anaesthesia to relieve after-pain and discomfort. 
 In 1861 Pitha reported a successful anaesthesia with belladonna 
 and chloroform in a patient who had resisted chloroform alone. 
 Labbe and Guyon (about 1872) are said to be the first who used 
 morphine before the administration with the idea of enhancing 
 the action of chloroform. 
 
 This so-called mixed method of anaesthesia has been more or 
 less employed up to the present time. There is still much differ- 
 ence of opinion as to its relative merits and demerits. 
 
 Kappeler, who used mixed anaesthesia extensively, concluded 
 that the anaesthesia is quieter, the stage of excitement shorter, 
 "tolerance" is acquired with less muscular disturbance, asphyx- 
 ial symptoms are less marked, and vomiting is more frequent 
 than without morphine. He injects the morphine about 20 or 
 30 minutes before the inhalation. Demarquay thought mor- 
 phine contraindicated in weak subjects. Wyeth recommends mor- 
 phine with chloroform to stimulate the heart and quiet the patient. 
 
 Morphine, in properly selected cases, especially in connection 
 with the administration of chloroform, gives good results. The 
 dose should be from one-sixth to one-fourth of a grain, given 
 from 20 to 30 minutes before the administration of the anaes- 
 thetic. The previous habits of the patient in regard to drugs of 
 this nature should be ascertained, bearing in mind that the habit- 
 ual use of morphine renders the patient more susceptible to- 
 the action of anaesthetics, especially of chloroform. Morphine has 
 been used in connection with cerebral surgery with good effect, 
 but the difficulty of estimating its effects in this class of cases 
 
BEFORE THE ADMINISTRATION OF AN ANAESTHETIC 6l 
 
 has induced most operators to discourage its use. In cases in 
 which it is difficult to secure the usual degree of muscular relaxa- 
 tion during anaesthesia morphine will prove of benefit. 
 
 When morphine has been given as little of the anaesthetic should 
 be used as possible. The corneal reflex should be preserved, 
 and an analgesic rather than an anaesthetic state should be aimed 
 at. There is not so much danger in an incomplete state of anaes- 
 thesia where morphine has been used as where it has not. 
 
 Jullard advised the use of morphine before etherization. He 
 recommends the previous use of the drug in order to ascertain 
 the susceptibility of the patient. Kappeler states that he had 
 many failures and more excitement when using morphine with 
 ether. 
 
 Dastre and others used the combination of morphine and 
 atropine in order to lessen the liability of cardiac inhibition. 
 Blake uses atropine to diminish secretion and to stimulate respir- 
 ation in ether narcosis. Reinhard uses both drugs in ether nar- 
 cosis to inhibit hypersecretion of mucus, giving the injection 
 an hour before the administration. Braun believes that a suffi- 
 cient dose of atropine to affect the amount of mucus would be 
 dangerous. Becker condemns the use of atropine. He thinks 
 the secretion of mucus can be reduced by adding 20 drops of 
 oleum pumilionis (one of the turpentine oils). The use of atro- 
 pine in sufficient quantity to affect the secretion of mucus would 
 in most patients increase the danger of anaesthesia. A dose of 
 one one-hundred and fiftieth of a grain in conjunction with mor- 
 phine does not appear to be objectionable, nor does it appear to 
 have any special advantage unless it may be in certain patients, to 
 offset the action of morphine in adding to the after-effects of the 
 anaesthetic. 
 
 Mixed narcosis while of undoubted advantage has also dan- 
 gers. If care is not exercised in the amount of anaesthetic given 
 the patient may pass into too deep narcosis before the adminis- 
 trator is aware of it. Very little anaesthetic may be necessary 
 to produce deep anaesthesia. It is well for the administrator to 
 inform himself as to whether the patient has had morphine before 
 he begins the administration.* 
 
 Physical examination. It is not uncommon for the admin- 
 istrator to see his patient for the first time just as the adminis- 
 
 *See additional matter on mixed narcosis at the end of this chapter. 
 
62 BEFORE THE ADMINISTRATION OF AN ANAESTHETIC 
 
 tration is about to begin. He is thus afforded no opportunity 
 to recognize any physical condition which might modify the 
 manner or extent of the administration. The objection is offered 
 that questioning and examination of the patients unduly alarms 
 and excites them, but such a result is more often due to lack 
 of tact in such an investigation rather than to the examination 
 itself. Generally patients will feel reassured when such a course 
 is properly pursued. 
 
 General condition. The general appearance and bearing of the 
 patient is to be noted. The presence or absence of nervousness, 
 excitement, or hysterical manifestations is to be observed. The 
 character of the subject's movements if he walks to the opera- 
 ting table, the position he assumes on the table, the tendency to 
 assume a propped-up position such as would be natural in emphy- 
 sema, chronic pneumonia, cardiac lesions, etc., may all be noted. 
 The general condition of nutrition, the apparent age, the gen- 
 eral physique, should be observed. Robust, young persons may 
 give some trouble. Fat, flabby, alcoholic subjects may be diffi- 
 cult to anaesthetize. Florid subjects will show a marked degree of 
 cyanosis under such an anaesthetic as nitrous oxide gas. 
 
 Physical examination of the chest. This should always be 
 made, particularly of the heart, and of the whole chest if diffi- 
 culty in respiration is observed. Limitations of the respiratory 
 capacity from diseases of the lungs or pleurae should be looked 
 for. Stenosis or obstruction of any part of the respiratory tract 
 may be noted by causing the patient to respire deeply. The heart 
 should be palpated for enlargement or misplacement, irregularity, 
 etc., and the stethoscope should be used to detect murmurs, irreg- 
 ular action, and especially the character of the first and second 
 sounds and their relative intensity as indicating the presence or 
 absence of muscular disease. The condition of the arteries should 
 be noted as to the presence or absence of sclerosis or atheroma. 
 The abdomen should be inspected and palpated for any condition 
 interfering with abdominal respiration and the action of the dia- 
 phragm. The reaction of the pupils to light should be observed 
 so that any peculiarity in this respect may not be attributed to 
 the anaesthetic. The nose, mouth, and throat should be inspected 
 relative to obstruction of the nares, artificial teeth, plates, loose 
 teeth, quids of tobacco, loose tartar, and in children, pieces of 
 
BEFORE THE ADMINISTRATION OF AN ANAESTHETIC 6$ 
 
 candy which may be given by some well-meaning relative just 
 before the administration. 
 
 Temperature of the room. The temperature of the room 
 should be about 70 degrees F. and the air should be compara- 
 tively dry. Warm temperature favors vaporization and elimina- 
 tion. Low temperature has the opposite effect. It may be diffi- 
 cult to anaesthetize in low temperature. Richardson believed that 
 syncope and pulmonary oedema were more frequent under chlo- 
 roform where the air was charged with moisture. 
 
 Ventilation. The room should be well ventilated and free 
 from draughts. In small, badly ventilated rooms lighted by open, 
 artificial lights special difficulty may arise in administering chlo- 
 roform (vide p. 147). 
 
 Clothing of patient. For the administration of all anaes- 
 thetics the clothing of the patient should be warm and loose. 
 For the administration of nitrous oxide gas it is necessary to see 
 that nothing constricts the neck, chest, or abdomen. Collars 
 should be removed, neck-bands loosened, waists unhooked, cor- 
 sets unfastened, belts removed. These precautions are often neg- 
 lected because of the trouble and of the short duration and rela- 
 tive safety of this anaesthetic, but they should never be neg- 
 lected. 
 
 With chloroform and ether there is more or less reduction of 
 body temperature during anaesthesia, and this is often added to 
 by carelessness in properly dressing the patient or in keeping 
 him properly covered during the anaesthesia, or by covering large 
 areas of the surface of the body with towels wet with moist anti- 
 septic solution. The patient should be dressed in warm under- 
 clothing, warm stockings, and should be kept, whenever possi- 
 ble, covered with warm blankets. In special cases hot water 
 bottles should be in readiness, or a hot water bed or table may 
 be used. 
 
 Posture during induction. As a rule it is best to induce 
 anaesthesia with the patient in the dorsal position with a pillow 
 under the head and none under the shoulders. If the subject 
 suffers from bronchitis, asthma, emphysema or other causes of 
 difficult breathing it may be necessary to have a pillow under 
 the shoulders, at least during the induction. The head should 
 be kept in line with the body. In administering nitrous oxide 
 
64 BEFORE THE ADMINISTRATION OF AN ANAESTHETIC 
 
 gas in the sitting position it is important to keep the head in 
 line with the body, and to prevent the patient from throwing 
 the head too far backwards. 
 
 The induction of chloroform anaesthesia should not be attempt- 
 ed in the sitting position if possible to avoid it. The lateral 
 position may be used for the induction if advisable. 
 
 Moving of patients. It is best to anaesthetize the patient on 
 the table upon which the operation is to be performed if pos- 
 sible, and not to move him more than is necessary. Statistics 
 show that many of the difficulties and dangers arising during 
 anaesthesia are incident to moving the patient or changing the 
 position during anaesthesia. In those cases where it is necessary 
 to move the patient after anaesthesia has been induced he should 
 be fully anaesthetized and kept so while being moved as vomiting 
 or spasm is more likely to occur if the patient is moved under 
 light anaesthesia. 
 
 Appliances and remedies. Before beginning the adminis- 
 tration certain appliances and remedies should be within easy 
 reach in case of necessity. A mouth gag may be necessary to 
 keep the jaws apart (Figs. 3, 4, 5, 6, 7), or if difficulty is exper- 
 ienced in separating the jaws some form of mouth opener is 
 necessary (Fig. 8). A tongue forceps for drawing forward or 
 making traction on the tongueshould be at hand (Figs. 9, io),oran 
 ordinary artery forceps may be used. Mouth props for separating 
 the teeth are at times necessary (Figs. 11, 12). A basin should 
 be at hand in case of vomiting, and a couple of towels to be used 
 for keeping the mouth, face, and pillow free from mucus. 
 
 Instruments for the performance of tracheotomy should be 
 at hand. In hospital practice there should be appliances for 
 lung inflation, the introduction of saline solution, and for the ad- 
 ministration of oxygen gas 
 
 Strychnia, digitaline, ammonia, ether, atropine, alcohol, 
 whisky for hypodermic injection should be at hand, nitrite of 
 amyl for inhalation may be useful. 
 
 Aseptic precautions. All apparatus used by the adminis- 
 trator should be kept as nearly aseptic as possible, and the ad- 
 ministrator should be careful to thoroughly clean his hands and 
 nails. In some cases, such as surgery of the face, head, nose, 
 mouth, throat, neck, or shoulders, all appliances used by the 
 
BEFORE THE ADMINISTRATION OF AN ANAESTHETIC 05 
 
 administrator should be sterilized, and the administrator should 
 be personally as careful as the operator in this regard. 
 
 During the last few years there has been a greater tendency 
 to employ some form of preliminary treatment, or a mixed form 
 of narcosis than formerly. McCardie says that preliminary drug 
 treatment applies particularly to chloroform, as ether is a suffi- 
 cient stimulant in itself. He advises strychnia before operation, 
 giving it either for a few days previously, or immediately before 
 in an alcoholic medium. He thinks it should be combined with 
 atropine. 
 
 Atropine paralyzes the ends of the vagi in the heart, stimu- 
 lates the heart, and, in moderate doses, increases the force of the 
 systole. It stimulates the vaso-motor center, raises blood pres- 
 sure, and prevents stimulation of the vagi by chloroform. Ac- 
 cording to Crile atropine, hypodermically, is a sufficient protec- 
 tion against cardiac inhibition in operations in the "inhibition 
 area" in the larynx, and in such operations as might cause me- 
 chanical stimulation of the vagi. 
 
 Atropine alone is not advised for chloroform anaesthesia, as it 
 causes excitement, and does not allow of economy of chloroform. 
 
 Hewitt advises that the susceptibility of the patient be learned 
 if morphine be given before chloroform or ether. Morphine 
 should be avoided in operations on the chest and abdomen be- 
 cause it hinders cough, and causes vomiting and constipation. 
 It may be very useful in operations about the throat and for 
 goitre. It should be deeply injected, with massage to insure quick 
 absorption. 
 
 Cocaine, it is claimed, will guard the heart almost as well as 
 atropine when given hypodermically. The local application of 
 one-half per cent, solution will prevent the reflex impulses in the 
 laryngeal area of inhibition within thirty seconds. Nerve func- 
 tion may be entirely "blocked'' by the local application of co- 
 caine. It appears to prevent splanchnic shock. 
 
 EvenkhofT's "strychnin-chloroform narcosis" consists in the 
 administration of 1-60 to 1-30 grain of strychnia before anaesthe- 
 sia, in order to obtain a satisfactory blood pressure. If this is not 
 obtained in from five to eight minutes, 1-100 to 1-60 more should 
 be injected. 
 
66 
 
 BEFORE THE ADMINISTRATION OF AN ANAESTHETIC 
 
BEFORE THE ADMINISTRATION OF AN ANAESTHETIC 6? 
 
 Fig. 7.— Heister's Gag. 
 
 Fig. 9.— Mathieu's Tongue Forceps. 
 
 Fig. 8.— Plain 
 Oral Screw. 
 
 Fig. 10.— Houze's Tongue Forceps. 
 
 Fig. 12.— Soft Rubber Bite-Block (White Dent. Co.) 
 
 Fig. 11.— Daintree's 
 Adjustable Moutli 
 Prop. 
 
CHAPTER VII. 
 
 POSTURE DURING ANAESTHESIA. 
 
 The posture of the patient during anaesthesia is determined 
 by the nature of the operation, the anaesthetic to be used, and 
 the general condition of the patient. Faulty positions are likely 
 to increase the danger rate of anaesthetics from complications dur- 
 ing anaesthesia and from after-effects. They also interfere with 
 the performance of the operation. 
 
 Respiratory difficulties may arise from positions favoring the 
 accumulation of mucus, saliva, blood, etc., in the fauces, as in 
 the semi-recumbent position. Flexion of the head produces ob- 
 structive stertor. Complete extension of the head may favor 
 the entry of foreign substances into the larynx, producing at- 
 tempts at coughing, swallowing, etc. The prone or latero-prone 
 position may interfere with the expansion of the lung and 
 cause asphyxia. The dorsal position may not be possible if 
 there is much pressure on the diaphragm from below. In diseases 
 of the lungs or pleurae the lateral position with the patient on 
 the sound side may be dangerous. In fat, elderly people, and 
 in dyspnceic subjects the lithotomy position may produce difficulty 
 with respiration. 
 
 Difficulties with the circulation are not usually due to posture 
 except as they may occur secondarily to respiratory disturbance 
 from posture. Chloroform and its congeners are generally sup- 
 posed to favor primary syncope where the sitting position is 
 assumed, and while this danger is probably over-rated, provided 
 the respiration be watched and the anaesthesia be not too pro- 
 found or prolonged, it is best not to give chloroform in the sit- 
 ting position if it can be avoided. 
 
 Faulty posture may interfere with the performance of the 
 operation by favoring jerky, irregular respiration, coughing, vom- 
 iting, straining, muscular rigidity, etc. After-effects may also be 
 due to faulty positions allowing the passing of mucus, blood, 
 pus, etc., into the larynx, trachea, or stomach. 
 
 The extraction of teeth. The sitting position is the usual one. 
 The feet are so disposed that they cannot become entangled in 
 the apparatus or chair, or the heels used as a support to the 
 
F\g. 13- A. -Postures for Anaesthesia. 1.— Dorsal position: face to one side. 2.— Lateral position. 
 
 3.— Prone position. 
 
POSTURE DURING A X. EST H ESI A 
 
 Fig. 13-B.— Postures for Anaesthesia. 4.— Sitting position. 5.— Sitting position: 
 bent forward. 6.— Trendelenburg's position. 
 
 body. The head should be in line with the body and as vertical 
 as possible. The head may be lowered after anaesthesia is in- 
 duced if necessary. When chloroform or the A. C. E. mixture is 
 employed the dorsal position should be used. 
 
 Operations about the mouth, nose, pharynx, face, or jaws. 
 Any of the various positions ordinarily in use may be employed 
 for these operations. When possible the posture should be such 
 as to allow of the free escape of blood from the mouth. The 
 head should be kept in line with the body. The anaesthesia 
 should not be so profound as to completely abolish the laryn- 
 geal and pharyngeal reflexes. Small sponges attached to holders 
 
POSTURE DURING ANAESTHESIA J\ 
 
 should be at hand to keep the mouth and throat free from blood, 
 especially if the dorsal position is used. The dorsal position with 
 the head extended obstructs and interferes with coughing and 
 swallowing and tends to increase haemorrhage. The lateral 
 position is best for the administrator, though" in some cases the 
 operator prefers the dorso-lateral. The semi-recumbent or 
 "propped-up" position, with or without extension of the head, 
 is a good one for the operator in operations on the tongue, jaws 
 etc., but is not adapted to maintaining an even and unembarrassed 
 form of anaesthesia. The sitting position is very convenient for 
 rhinological operations. There is no risk in using gas or ether, 
 or the ether-chloroform sequence, in this position. Chloroform 
 alone should not be used with the sitting position unless neces- 
 sary — as in the removal of laryngeal growths in children. 
 
 The bent-forward position is adapted to the removal of 
 post-nasal adenoids. Ether or nitrous oxide-ether sequence may 
 be used with the dorsal or sitting position, and the patient tilted 
 forward for the operation. 
 
 The Trendelenburg posture may be used for these operations. 
 It draws blood away from the larynx, but favors haemorrhage. 
 It is used by some surgeons for hare-lip and cleft-palate opera- 
 tions, also for operations en the naso-pharynx. The lateral and 
 dorso-lateral positions are adapted for operations on the lips and 
 cheeks, jaws, antrum, etc. For operations on the tongue the 
 lateral, latero-prone, or the semi-recumbent positions are mostly 
 used. For removal of the tonsils Hewitt recommends the dorsal 
 position with nitrous oxide-ether, or A. C. E. -ether sequence, and 
 the patient is placed in the sitting position for operation, or the 
 sitting position may be used altogether. In nasal operations the 
 dorsal, lateral, dorso-lateral, or sitting position may be used. 
 
 Operations on the larynx and trachea. The dorsal position 
 with the shoulders slightly raised and the head somewhat ex- 
 tended, or the Trendelenburg positions, should be used. For 
 intra-laryngeal operations, when done under general anesthe- 
 sia, chloroform should be used in the dorsal position, and the 
 patient then placed in a chair with the head slightly extended. 
 
 For operations on the neck the dorsal position with the shoul- 
 ders slightly raised is preferable. 
 
 For operations on the brain the dorsal or lateral positions are 
 
j 2 POSTURE DURING ANAESTHESIA 
 
 best. For operations on the spinal cord the prone or latero-prone 
 position is convenient but may favor asphyxial complications. 
 
 For ophthalmic operations the dorsal or semi-recumbent posi- 
 tions are generally used. 
 
 For operations on the chest zvalls, pleura or lung the position 
 should be such as not to interfere with the expansion of the 
 healthy lung. The prone or semi-prone position is likely to inter- 
 fere with the respiration and should not be adopted unless nec- 
 essary. The anaesthesia should be induced in the most favorable 
 position, and watch kept for unfavorable effects following change 
 in position. Recent cases in which the lung has not had time 
 to accommodate itself to the changed conditions are most likely 
 to cause trouble. Pleuritic effusions may be aspirated with the 
 patient in the semi-recumbent, dorsal, or sitting position. 
 
 Abdominal operations are adapted, as a rule, to the Trendelen- 
 burg posture. The head should be kept in line with the body, or 
 turned very slightly to one side. Obstructed breathing from 
 spasm of the masseters or from flexion of the head may cause 
 active movements of the diaphragm which interfere with the 
 operation. The Trendelenburg position may be contraindicated 
 in cases of great abdominal distention, at least during the early 
 part of the operation. The dorsal position is best adapted to 
 some cases. Bloodgood thinks the Trendelenburg position. les- 
 sens the dangers of lung complications in cases where from the 
 nature of the operation, disease, or the patient's condition, lung 
 complications are to be feared. This position, as with the low 
 position of the head (Roser's position), undoubtedly tends to 
 prevent the passage of secretions, blood or pus, or foreign bodies, 
 into the respiratory tract. 
 
 In operations on the kidney the latero-prone or prone posi- 
 tion is used. 
 
 In genito-urinary operations, rectal operations, gynaecological 
 operations by the vaginal route, obstetrical operations, etc., the 
 lateral, dorsal, or lithotomy positions will be used as necessary. 
 
CHAPTER VIII. 
 
 NITROUS OXIDE. 
 
 Nitrogen monoxide, protoxide of nitrogen, nitrous oxide, 
 "laughing gas," has a cheminal formula of N 2 0. It was first pre- 
 pared by Priestley about 1772 or 1776. It is a colorless, trans- 
 parent, feebly refractive gas with a sweetish odor and taste. 
 Its sp. gr. is 1.527. When pure it is devoid of irritant prop- 
 erties. Water at o°C. dissolves a little more than its own volume 
 of the gas, the solubility diminishing as the temperature of the 
 water increases. Nitrous oxide gas was first liquefied by Faraday 
 in 1823. Liquefaction takes place under a pressure of 30 atmos- 
 pheres at o°C. The resultant liquid is colorless, very mobile 
 body with a sp. gr. of .9369, which commercially is obtained in 
 metal cylinders furnishing 100, 250, 450 gallons of gas accord- 
 ing to capacity. The pressure in these cylinders is said to some- 
 times reach nearly 1,000 pounds to the square inch. The cylin- 
 ders are subjected to a test pressure of 3,000 pounds to the square 
 inch. Seven and one-half ounces of liquid nitrous oxide will 
 furnish about 25 gallons of gas. The gas is usually pure, but is 
 said to sometimes contain other oxides of nitrogen and chlorine. 
 It is stored for use in gas bags holding about eight gallons, or in 
 gasometers (Figs. 14, 15). The intense cold produced by the 
 conversion of the liquid into gas may produce solidification 
 around the outlet of the interior of the cylinder and interfere 
 with the proper working except when they are constructed so as to 
 avoid this. 
 
 Nitrous oxide gas is not easily decomposed, a considerable 
 temperature being necessary to split it into component elements. 
 
 Physiological effects and action. Properly administered 
 nitrous oxide gas can be respired without special discomfort or 
 danger up to a certain point. In administration the gas is 
 forced, and the stage of excitement is very brief. The time con- 
 sumed in producing deep anaesthesia with pure gas and care in 
 excluding air will vary from 20 seconds to 2 minutes, accord- 
 ing to the age and constitution of the subject. The length of 
 time which the anaesthetic state will last from a single inhala- 
 tion period will vary from 15 seconds to 45 seconds. This is 
 
74 
 
 NITROUS OXIDE 
 
 Fig. 14.— Gasometer (White Dent. Co.) 
 
 Fig. 14. The socket (A) of the stand is for large cylinders. The 
 reversible clamp (B) fits the large cylinders on one side, and on the other 
 the small cylinders. The side which fits small cylinders has a flange (C) 
 on which sits the cylinder. A set-screw (D) holds the cylinder firmly in 
 position. The reservoir (E) is filled with water to the bead (K). 
 
 At the bottom of the reservoir, where the inhaler tubing is attached, 
 is a piston valve (G), placed there for absolute security against waste 
 when operations are suspended with the receiver full of gas. At the 
 opposite side (not seen in cut) is a pipe to which the cylinder yoke is 
 connected by means of rubber tubing (L). Near the top of the reservoir 
 is a wooden fork (H), to support the inhaler when not in use. The bell 
 (F) works on the guide-rod (I). 
 
NITROUS OXIDE 
 
 75 
 
 i WATC* tlttf] 
 
 ro $a» eri'HOim ' 
 
 Fig. 15.— Diagram of White Dent. Co.'s Gasometer. 
 
 known as the period of available anesthesia in dental practice. 
 Return to consciousness is very abrupt, often sufficiently so to 
 surprise the subject in attitudes quite unusual to him. 
 
 Nitrous oxide narcosis is obtained so quickly that it is difficult 
 to arrange its manifestations into groups. The initial sensa- 
 tions are usually agreeable and exhilarating. There is subjective 
 dizziness, noises in the ears, tingling and loss of body sensation. 
 Illusions are present and may result in mental exhilaration or de- 
 pression, or in pugnaciousness. Generally unconsciousness is 
 
76 . NITROUS OXIDE 
 
 reached before the subject can speak. There is an irresistible 
 desire to inhale deeply, and the respirations are deeper and 
 quicker than normal. The pulse is fuller and more rapid than 
 usual. As unconsciousness is reached disturbed psychical condi- 
 tions may arise, especially if the subject be disturbed, roughly 
 handled, or if the operation be begun too early. He may shout 
 or may exhibit co-ordinate or inco-ordinate movements. Dreams 
 may occur, pleasant or unpleasant, — the latter are said to occur 
 more often under the gas alone than when it is combined with 
 oxygen. The respiration is quick and deeper than normal, and 
 the pulse is still full but grows more rapid and may be from no 
 to 160 per minute. The conjunctivas are sensitive and the pupils 
 gradually dilate. The eyelids twitch and separate showing the 
 eye-ball and giving the eyes a protruded appearance. The skin, 
 which first shows pallor, becomes, in florid persons, dusky and 
 livid, or deeply cyanosed. The jaws become set. The respiration 
 which has fairly well maintained its rhythm now becomes 
 arrhythmical, showing that the subject is fully anaesthetized, a 
 peculiar stertor from intermittent elevations of the larynx is 
 manifested. Deep stertor may be present, and clonic spasms of the 
 thoracic and abdominal muscles may occur. Stertor may be 
 absent and irregularity of respiration may be caused by these 
 muscular spasms. Rarely the respiration becomes feeble with 
 prolonged stridulous expiration. These manifestations show thai 
 the administration has proceeded far enough. The extremities 
 may or may not remain relaxed. Clonic contractions of various 
 groups of muscles may occur, and tonic contractions of the mus- 
 cles of the neck or back are sometimes seen even to the condi- 
 tion of opisthotonos. Micturition and defecation are not un- 
 common. In deep anaesthesia the superficial plantar reflex is lost, 
 but the deep patellar reflex is not. The pupils are usually widely 
 dilated but may not be or may even be contracted. Post-anaes- 
 thesial dilatation of the pupils may occur. The corneal reflex is 
 usually maintained. The conjunctival reflex may disappear and 
 is not a reliable guide to the state of anaesthesia. . 
 
 With the withdrawal of the anaesthetic the respiration rapidly 
 assumes its usual rhythm and the pulse drops suddenly in rate, 
 the subject rapidly returning to consciousness. The pulse may 
 afterwards be rapid from mental conditions or from pain. 
 
NITROUS OXIDE J J 
 
 Among the recognized after-effects of nitrous oxide anaesthe- 
 sia are headache, dizziness, nausea, vomiting, faintness, hysterical 
 attacks, hallucinations, stupor, catalepsy, hemiplegia, and even 
 insanity. Temporary glycosuria, diabetes, and retinal haemor- 
 rhage have been known to occur. 
 
 Lethal doses of nitrous oxide gas produce, death by asphyxia- 
 tion. The heart beat may continue for several minutes after res- 
 piration ceases. The latter is said to be due to muscular spasm. 
 The right heart cavities are found full of blood and the left cav- 
 ities relatively empty. 
 
 It was formerly thought that the phenomena attending the 
 administration of nitrous oxide gas were all asphyxial or anoxae- 
 mic in character, depending on want of oxygen, but the observa- 
 tions of E. Andrews, and of Paul Bert showed that anaesthesia 
 could be produced without asphyxial conditions by the conjoined 
 use of nitrous oxide gas and oxygen. Nitrous oxide must there- 
 fore possess some anaesthetic properties aside from its asphyxial 
 powers. On the other hand the phenomena can not all be special 
 or non-anoxaemic because by the addition of oxygen the stertor, 
 epileptiform movements, and the cyanosis may be obviated with- 
 out interfering with anaesthesia. 
 
 The anaesthetic property of nitrous oxide is thought by some 
 to be due to a deoxidizing action on the usual process of oxidi- 
 zation occurring in nerve cells, and similar to that of other anaes- 
 thetics. 
 
 The blood changes occurring during anaethesia with gas are 
 not thoroughly understood. The gas is very soluble in blood, 
 and there is a great reduction in the oxygen in the blood. (Ex- 
 periments have shown that after breathing nitrous oxide for a 
 period of 105 seconds that there is a reduction of the oxygen of 
 the blood from 21 to 5.2 vol. per cent.) The blood pressure is 
 raised, and later falls with the appearance of respiratory embar- 
 rassment. There is contraction of the renal vessels and dimi- 
 nution in the secretion of urine. Slight albuminuria may occur 
 with complete anaesthesia. 
 
 THE ADMINISTRATION. 
 
 The universal employment of nitrous oxide gas in dental 
 surgery attests the fact that with very few exceptions this agent 
 is the best for use in dental practice. In operations which re- 
 
78 NITROUS OXIDE 
 
 quire not more than a few seconds no other anaesthetic can com- 
 pare with nitrous oxide either in safety, efficiency, or in con- 
 venience. Colton originally urged the exclusion of air in nitrous 
 oxide anaesthesia, and the advisability of administration with 
 an inhaler fitted with inspiratory and expiratory valves. He aft- 
 erward showed the advisability of allowing air to be breathed 
 in connection with the gas in cases where a little more time 
 was necessary than in ordinary dental operations, and devised in- 
 halers for use under such circumstances. 
 
 Andrews' observations regarding the administration of oxy- 
 gen and gas, and Paul Bert's researches along this line brought 
 about the conclusions now recognized, that by the use of cei- 
 tain amounts of atmospheric air a better form of anaesthesia can 
 be obtained than with pure gas, especially for occasions demand- 
 ing one or two minutes of anaesthesia, and that with oxygen 
 and gas a still more satisfactory form of anaesthesia may be ob- 
 tained. The more complicated apparatus, and the greater skill 
 and experience necessary to obtain satisfactory results with these 
 methods have restricted their use, and the pure nitrous oxide 
 anaesthesia remains the most universal method of administration. 
 The various methods of administration which may be em- 
 ployed are : The administration of pure nitrous oxide ; of defi- 
 nite quantities of nitrous oxide and air ; of nitrous oxide and in- 
 definite quantities of air : of definite quantities of nitrous oxide 
 and oxygen at ordinary atmospheric pressure ; of the same under 
 increased atmospheric pressure (Paul Bert's system) ; of nitrous 
 oxide and varying quantities of oxygen at ordinary atmospheric 
 pressure. 
 
 For the administration of pure nitrous oxide gas for ordinary 
 dental operations the patient should be seated in an operating 
 chair in a comfortable position. Care should be taken that the 
 subject's legs cannot become entangled in the chair or apparatus 
 in case of muscular contractions, nor a purchase be obtained for 
 the feet should opisthotonos occur. The head should be in line 
 with the body, and as vertical as possible. If a vertical position 
 of the head is not satisfactory to the operator, then it should be 
 kept in that position during the induction of anaesthesia by a 
 cushion which can be quickly removed as full anaesthesia is 
 reached. 
 
NITROUS OXIDE 
 
 Pig. 16.— Universal Gas Stand (White). 
 
8o NITROUS OXIDE 
 
 Fig. 16. The base is of iron, with a coned socket for the reception of the 
 cylinders. The upright carries a yoke connection for the valve of the cylin- 
 der, an arm for the support of the gas-bag, and a wood fork at the top for 
 holding the inhaler when not in use. Attached to the fork by means of a 
 chain is a wood ring for the support of the inhaler tubing. The base is 
 heavy to assure solidity and firmness on the floor. The coned socket 
 provides for Medium and Large Cylinders, the latter sitting in the upper 
 part and the former passing down to the bottom. For the Small Cylin- 
 ders a pedestal casting is provided which sits in the coned socket, with 
 catches to hold it firmly to the base. 
 
 The yoke connection, 10, has a short up and down swing to accom- 
 modate itself to the cylinder neck. It is also adjustable upon the up- 
 right. As shown it is in position for the Small and Medium Cylinders. 
 For the Large Cylinders.it can be raised by loosening the set-screw 12 (a 
 countersunk spot will be found on the rod to receive the set-screw in the 
 new position). The cylinder is held securely in the yoke by tightening 
 the screw 14. Be sure there is a leather washer on the yoke nipple, to 
 make a tight joint between the yoke connection and the cylinder. The 
 wood wheel-key 15Y operates both the yoke screw 14 and the valve of the 
 cylinder. A quarter turn releases the yoke screw. 
 
 In short operations it may be desirable to introduce a bite- 
 block, or mouth-prop, before anaesthetizing in order to avoid de- 
 lay in opening the mouth after anaesthesia is produced. In long 
 operations this may not be desirable. If the block or prop should 
 slip it is probably best to stop the administration and readjust 
 the block. In some cases it may be desirable to introduce a gag 
 before administering gas, in which case it is necessary to be care- 
 ful to prevent the admission of air along the arms of the gag. 
 
 Before beginning the administration be sure that there is a 
 sufficient quantity of gas. Ordinarily not more than six or eight 
 gallons will be needed, and children will usually need but three 
 or four, but. it is best to have an ample reserve. 
 
 Run some gas through the apparatus (Fig. 16) and fill the 
 bag about two-thirds full of gas and shut off the cylinder valve. 
 See that the valves in the inhaler are working properly. If the 
 patient has a beard, moisten the hair about the mouth before 
 applying the face-piece. Explain to the patient that there is no 
 danger or suffering connected with the administration of gas ; 
 and show him how to breathe deeply and regularly through the 
 mouth. Apply the face-piece and see that it fits properly by 
 having the patient respire air in and out through the valves be- 
 fore turning on the gas (Fig. 17), explaining meanwhile to the 
 patient that he is simply breathing air. The regular sound of 
 
NITROUS OXIDE 
 
 8l 
 
 the valves will show that the face-piece fits properly (Fig. 18). 
 The pneumatic face-piece is probably the most easily adjusted 
 and satisfactory. 
 
 If the face-piece fits properly and the patient is breathing 
 freely the gas should be turned on. The bag at this time should 
 be about two-thirds full, and should be kept nearly full through- 
 out the administration by allowing a small amount of gas to 
 
 Fig. 17.— Inhaler No, 3. (White Dent. Co.) 
 
 Fig. 17. The sectional view shows the internal construction. An open- 
 ing, B, underneath the body of the Inhaler adm;ts the gas through a similar 
 opening, A, in a sliding tube GG, fitting inside of and projecting beyond the 
 rear portion of the main body. The projecting portion is perforated for 
 the admission of air, and its outer end is closed by a cap. At the inner end 
 of the sliding tube is a coil spring EE, abutting against a shoulder in the 
 body of the Inhaler. This spring holds the sliding tube in the position 
 shown in the cuts, closing the inlet B when the gas is not being used. 
 Pressure on the cap compresses the spring, closes the perforations for the 
 admission of air, and brings the opening A over B, affording a free flow 
 of gas to the mouth-piece through the inhaling valve. The sliding tube is 
 prevented from rotating by the screw-pin D, which works in a slot, C. The 
 inhaling and exhaling valves — the former internal, the latter external — 
 consist of two thin disks of mica, FF, which are inclosed in circular open 
 cages. The inhaling valve is opened in respiration by being drawn against" 
 the front of the cage, the exhaling valve being closed by the pressure of 
 the outside air. In expiration both disks are thrown against the further 
 ■ends of the cages, opening the exhaling and closing the inhaling. 
 
82 
 
 NITROUS OXIDE 
 
 Fig. 18.— No. 3 Inhaler and Flexible Mouthpiece. (White Dent. Co.) 
 
 enter from the reservoir, with a slight positive pressure, except 
 in children and weak persons. Excitement should be controlled 
 by increasing the pressure in the bag, as the disturbance will 
 
NITROUS OXIDE 83 
 
 probably be due to admission of air, which is not likely to occur 
 under higher pressure. A slight amount of air is often of advan- 
 tage in children and weak people. 
 
 There has been considerable argument as to the propriety and 
 advantage of rebreathing of gas, or to-and-fro breathing directly 
 in and out of the bag. Hygienically it is, of course, objection- 
 able, and obviously not admissable in the early stage of admin- 
 istration, but is said to have advantages during the latter part 
 of the inhalation period in that it leads to a longer available pe- 
 riod of anaesthesia, and, while taking a little longer to produce 
 complete anaesthesia and being followed by a slower return to 
 consciousness, it produces no bad effects. It would seem, how- 
 ever, that improvements in the technique of administration will 
 practically obviate this somewhat objectionable method. 
 
 Unpleasant effects are often due to the operator beginning 
 work too soon, or to his attempting to accomplish too much 
 during a single period of available anaesthesia. The latter is 
 often so short that but a single extraction can be effected while 
 it lasts, though an ordinary operator can usually extract two 
 teeth or roots while the patient is completely unconscious. 
 
 The following directions by Turner for anaesthesia for ex- 
 traction are useful : Food should be limited to good beef-tea 
 taken about two hours before anaesthesia. The patient should 
 not come straight from violent exertion. Undo all tight cloth- 
 ing about throat, chest, waist and abdomen. Seat the patient 
 comfortably, body relaxed, in straight line with head, neither 
 too far back nor depressed, in such a position that with prop in 
 position blood or teeth will pass into floor of mouth. Support 
 head by a rest under the occiput, or nape of neck. Support the 
 head on side for extractions from upper jaw, and support lower 
 jaw for lower teeth. If operator supports lower jaw himself, 
 then press on front of condyle on side operated on, to prevent 
 dislocation. When patient is reviving see that no blood is swal- 
 lowed or inhaled. If necessary to push head forward, push 
 whole body. Let patient come around quietly. If gas is fol- 
 lowed by ether, do not give too much air at first. Patients should 
 lie down for awhile or take it easy for rest of day, as gas causes 
 strain on the heart. Unfit subjects are people with degenerated 
 arteries ; fat people ; people with heart or pulmonary trouble. The 
 
£>4 NITROUS OXIDE 
 
 admission of some air does away with much of the asphyxial 
 strain. 
 
 Should the operator require more time than is obtainable 
 by a single period of inhalation, the administrator has several 
 courses open to him. He may reapply the face-piece before con- 
 sciousness returns, and this is advisable when the patient's head 
 can be maintained in the vertical position, so that blood will flow 
 into the floor of the mouth and not into the throat, and if quickly 
 carried out results in no unpleasant effects ; again, he may allow 
 a return to consciousness and repeat the inhalation, though 
 double administration is more often followed by nausea and vom- 
 iting when there has intervened an interval of consciousness ; 
 he may keep up a continuous inhalation by means of a mouth- 
 tube (Fig. 19), or nose-piece which allows more or less air dur- 
 ing inhalation, a method which is said to give satisfactory an- 
 aesthesia, but which is more difficult of application and demands 
 more resistance than other methods. McCardie, of Birmingham, 
 uses a tube about the size of an ordinary ovariotomy canula for 
 prolonging nitrous oxide anaesthesia. The gas is briskly passed 
 into the mouth during extractions, the nose being closed by 
 the fingers or by a special clip. The administration is conducted 
 in the ordinary manner by a face-piece till the patient is uncon- 
 scious. By this method the whole mouth can be cleared of teeth 
 without any pain, except in powerful subjects who require more 
 profound anaesthesia in order to abrogate reflex movements.* 
 Gardner highly recommends a method which he has personally 
 experienced, consisting of administering gas through a small 
 nose-cap containing two small metal tubes attached to rubber 
 tubes leading to a gas bag behind the patient's head. The pa- 
 tient usually breathes through the nose, but even if he breathes 
 through the mouth anaesthesia is readily induced. Though there 
 is complete anaesthesia, there is not so marked effect of the drug 
 as there is with the ordinary method, cyanosis being less, 
 pupils not so dilated, the eye often remaining mobile, and the 
 condition being more one of marked drowsiness than one of 
 coma. Again, the operator may administer oxygen with nitrous 
 oxide ; or again, he may prolong the anaesthesia by the use of a 
 small quantity of ether, providing the stomach is empty and 
 care be taken to prevent blood from getting into the throat. 
 
 *McCardie recommends the Patterson-Coleman apparatus for the con- 
 tinuous administration of gas. The anaesthesia is continued through the 
 nose piece portion of the apparatus. He thinks it superior to other 
 methods. 
 
NITROUS OXIDE 
 
 3S 
 
 Fig. 19.— Anaesthetic Inhaler (Hillard). 
 
 Fig. 19. A method of prolonging nitrous oxide anaesthesia in dental 
 practice by means of an additional gas tube leading from the bottles to a 
 catheter, which is passed through one of the patient's nostrils. (D — A). 
 The administration is conducted in the usual way with stop-cock and face- 
 piece until the patient has lost consciousness, then taking the precaution 
 that the ordinary gas bag is full, and choosing the end of an inspiration 
 the face-piece is removed; the nasal tube (A) is rapidly passed (this can 
 be done during a single expiration), the face-piece is re-applied, and the 
 pedal stop-cock is turned so that the gas now flows only through the nasal 
 tube. At this stage the inhalation is continued by both nasal tube and 
 face-piece up to full anaesthesia. The face-piece is now finally removed, 
 the operation is begun, and narcosis is maintained by the nasal tube alone. 
 To prevent the return of consciousness, the netted bag (B) must be kept 
 fully distended, the gas being supplied at considerable pressure. It is 
 claimed that 10 or 12 teeth can easily be extracted during the available 
 anaesthesia. 
 
S6 NITROUS OXIDE 
 
 Disagreeable after-effects are, of course, more common from 
 the latter method than from a double administration of the gas. 
 
 THE DANGERS OF ADMINISTRATION. 
 
 The dangers of nitrous oxide anaesthesia arise practically al- 
 ways from primary interference with respiration, due to spas- 
 modic obstructive stertor or to muscular spasm of the thoracic 
 or abdominal muscles. There is marked cyanosis, the eyes are 
 widely open, the eyeballs turned up and the pupils widely dilated. 
 the pulse is usually small and rapid and generally continues for 
 some time after cessation of respiration, but may show early 
 arrest in weak, debilitated persons. Elderly people especially 
 may develop obstructed breathing from engorgement of the 
 tongue. Abnormal conditions of the upper air passages favor 
 respiratory embarrassment. Foreign bodies in the air passages. 
 such as blood, mucus, pus, vomited material, morbid growths, 
 teeth, instruments or material, etc., are sources of danger. , 
 
 While syncope and faintness are not uncommon as manifes- 
 tations of the period of returning consciousness, it is doubtful 
 if they occur from primary cardiac failure. 
 
 Simultaneous failure of heart and respiration is very rare, but 
 may occur in patients with cardiac, mediastinal, or cardiopul- 
 monary lesions. In this instance the circulation is not well main- 
 tained up to the period of stertor, but becomes feeble early. 
 There is bluish pallor and the respiration is shallow instead of 
 stertorous and irregular. 
 
 THE ADMINISTRATION OF DEFINITE QUANTITIES OF NITROUS OX- 
 IDE AND air. — The admission of indefinite quantities of air at ir- 
 regular intervals has long been practiced during nitrous oxide an- 
 aesthesia with the effect of prolonging the anaesthetic state. Hewitt, 
 of London, experimented with definite quantities of air and nitrous 
 oxide administered by means of a specially constructed gas- 
 ometer by which any. desired percentage of the gases could be 
 administered. He found that anaesthesia could be induced by 
 this means, providing the amount of air did not exceed 30 
 per cent. With a small amount of air the symptoms were similar 
 to those from the pure gas. The inhalation period increased in 
 direct relation to the raise in the percentage of air. The dura- 
 tion of available anaesthesia was longer than after nitrous oxide 
 alone. With from 3 to 5 per cent, of air convulsive movements 
 
NITROUS OXIDE 87 
 
 were more marked than with nitrous oxide alone, while with 
 higher amounts of air these phenomena decreased and were ab- 
 sent with 30 per cent, of air. The same was true of lividity and 
 cyanosis. Hewitt explains this on the ground that with no 
 air obstructive stertor cuts short the inhalation of gas before the 
 blood is sufficiently saturated to produce muscular convulsion. 
 Stertor was progressively lessened with increase in air. Reflex 
 movements were less marked than with pure gas. The best gen- 
 eral results were with from 14 to 22 per cent, of air. The best 
 mixture for men, was from 14 to 18 per cent, of air, and for 
 women and children, from 18 to 22 per cent, of air. 
 
 The administration of nitrous oxide and indefinite 
 quantities of air. — Indefinite quantities of air may be adminis- 
 tered with nitrous oxide alternately or concurrently. The effects 
 will vary according to the quantity of air admitted. In the al- 
 ternate administration the administrator anaesthetizes with 
 nitrous oxide in the usual manner until partial or complete nar- 
 cosis is induced, and then shutting off the gas allows the pa- 
 tient to breathe a few breaths of air and then returns to the 
 nitrous oxide. In this alternate manner the administration pro- 
 ceeds until sufficiently deep anaesthesia is produced for dental 
 operations, or, in general surgery, until the operation is com- 
 pleted. In the concurrent use of air and gas the two are 
 breathed simultaneously, sufficient air being allowed to enter to 
 obviate asphyxial manifestations. 
 
 In this country, especially, many variations of this method 
 have been practiced during the last twenty-five years in order 
 to produce satisfactory anaesthesia for more or less lengthy op- 
 erations. Dr. George Brush, of Brooklyn, employed an inhaler 
 with a sliding air valve, and quite lengthy operations were per- 
 formed under the anaesthesia thus induced. 
 
 For comparatively short operations when absolute muscular 
 relaxation is not an essential this method can be made efficient, 
 but for operations demanding complete muscular relaxation it 
 is not so satisfactory as the use of ether or chloroform. 
 
 There are few or no after-effects from this form of adminis- 
 tration, and in special cases and subjects it may be used, though 
 it is not always possible to obtain a strictly non-asphyxial form 
 of anaesthesia. 
 
88 NITROUS OXIDE 
 
 The amount of air admitted may be increased with the length 
 of the anaesthetic stage, the indications being obtained by close 
 attention to the patient's condition. 
 
 The difficulty with this method of administration is to admit 
 enough oxygen to prevent asphyxial symptoms and yet secure 
 enough nitrous oxide to insure complete anaesthesia. This diffi- 
 culty arises largely from the large percentage of nitrogen in the 
 air. Thus if we admit sufficient air to afford a high enough per- 
 centage of oxygen to prevent anoxaemic conditions the displace- 
 ment cf gas will be so great, owing to the amount of nitrogen 
 in the air, that anaesthesia will not be complete. 
 
 The administration of nitrous oxide gas and oxygen. — 
 
 In 1868 Dr. E. Andrews, of Chicago, employed oxygen in 
 connection with nitrOus oxide gas and produced a non-asphyxial 
 form of anaesthesia. But little attention was paid to his obser- 
 vations and this method of anaesthetization attracted small no- 
 tice until Paul Bert published his experiments along the same 
 line about 1878. Bert concluded that satisfactory anaesthesia by 
 this means could only be effected by increasing the atmospheric 
 pressure, but the observations of other experimenters have 
 shown that increased pressure is not necessary for anaesthesia 
 under this method, although it may increase the effects. In 
 Bert's method the patient, administrator and bag were placed in 
 an air-tight metal compartment, and the gas with 15 per cent. 
 of oxygen was administered under a pressure of 89.5 cm. M. 
 Martin modified this by employing 12 per cent, of oxygen and 
 a pressume of no cm. 
 
 Under this method respiratory disturbance, cardiac irregu- 
 larity, and asphyxia were slight, but it is not clear that this sys- 
 tem has great advantage over other methods of administration. 
 The apparatus is expensive and cumbersome, and the increased 
 pressure a source of more or less discomfort to the operator and 
 assistants. 
 
 Hewitt has experimented with the administration of nitrous 
 oxide with definite amounts of oxygen, and while this system has 
 disadvantages, being difficult of application, varying require- 
 ments for individual subjects, and impossibility of varying the 
 percentage of oxygen according to the indications arising during 
 the administration, which interfere with its practical utility, nev- 
 
NITROUS OXIDE 89 
 
 ertheless the effects of certain known percentages of oxygen 
 afford us a knowledge upon which basis we can predicate in the 
 administration of oxygen with nitrous oxide gas for prolonged 
 operations. 
 
 Hewitt's deductions are as follows: The inhalation period 
 lengthens as the percentage of oxygen rises ; deep anaesthesia is 
 obtained even when the amount of oxygen equals that of at- 
 mospheric air; the duration of anaesthesia is longer than with 
 nitrous oxide and air ; the longest available period of anaesthesia 
 (50.1 seconds) is obtained with 7 per cent, of oxygen; with 6 
 per cent, and over of oxygen there are no convulsive move- 
 ments ; with 11 per cent, of oxygen there is no lividity; with 
 from 2 to 6 per cent, of oxygen stertor is irregular or is replaced 
 by regular snoring, which becomes less marked with higher 
 percentages of oxygen, and disappears altogether with 20 per 
 cent, of oxygen ; phonated sounds are less common with nitrous 
 oxide and oxygen than with nitrous oxide and air ; they are likely 
 to occur with very small or with very large percentages of oxy- 
 gen ; reflex and excitement movements obtain with 10 per cent, 
 or more of oxygen and may be pronounced with from 5 to 7 per 
 cent., or in females with from 7 to 9 per cent, of oxygen. 
 
 Unquestionably the most successful way of employing nitrous 
 oxide and oxygen is the administration at ordinary atmospheric 
 pressure of nitrous oxide with a varying proportion of oxygen. 
 Up to the present time this method has not been widely used, but 
 with improved apparatus and more general recognition of its 
 advantages in properly selected cases, together with increasing 
 skill in its administration, it will, no doubt, become much more 
 generally employed. 
 
 The anaesthesia induced by this method is particularly adapt- 
 ed to the demands of dental operations, the average of the avail- 
 able period of anaesthesia as given by Hewitt being 44 seconds, 
 although it varies greatly. The inhalation period is given as av- 
 eraging 1 10.5 seconds. 
 
 In general surgery the use of gas and oxygen is somewhat 
 limited. While it is not difficult to maintain unconsciousness, it 
 is not always possible to secure the deep anaesthesia required for 
 many operations, such as plastic operations or rectal or vaginal 
 surgery. For lengthy operations it is a difficult system of an- 
 
(JO NITROUS OXIDE 
 
 aesthesia to maintain, but for slight operations about the mouth, 
 nose or throat it is quite applicable. It is also useful for short, 
 secondary operations or for painful redressing where very tem- 
 porary anaesthesia is desirable. 
 
 The best subjects for this method of anaesthesia are young 
 women, weak, elderly and middle-aged women, and debilitated 
 men of middle life. Young men, robust adults, and alcoholic 
 persons are not good subjects for this method. 
 
 The effects of nitrous oxide and oxygen are similar to those 
 of the pure gas, with the difference that the respiratory difficul- 
 ties of the initial stage are more or less absent. Consciousness is 
 maintained slightly longer than with gas, and the period between 
 this and the establishment of available anaesthesia is also some- 
 what longer. Excitement may be present, but may be stopped 
 by cutting off the oxygen. The respiration may be deep and 
 rapid and may change suddenly to quiet or imperceptible breath- 
 ing. It gradually becomes quiet, with slight snoring. When 
 deep anaesthesia is reached the subject appears as if in natural 
 sleep. Stertor is absent unless the quantity of oxygen is too 
 small to be of any benefit. Spasm of the muscles of the chest 
 and abdomen is not present. There is little tendency to con- 
 gestive obstruction of the upper air passages. The color of the 
 face is pale or florid. Cyanosis is usually absent. The pulse is 
 rapid, but is not so small as under nitrous oxide anaesthesia. Ac- 
 cording to Broadbent there is lowering of tension from periph- 
 eral dilatation. Cardiopathic patients take nitrous oxide and 
 oxygen very well as compared with other anaesthetics. The eyes 
 are usually closed. The eyeballs are fixed and may be turned to 
 one side or the other. Marked dilatation of the pupils is not 
 common. The conjunctival reflex is usually absent, while the 
 corneal reflex is retained except in protracted anaesthesia. An- 
 aesthesia is evidenced by regular breathing, slightly snoring in 
 character; by relaxation of the arms; by loss cf conjunctival re- 
 flex, and by fixed eyeballs. 
 
 In administering nitrous oxide and oxygen the patient should 
 be in a sitting position, with the head in line with the body and 
 not extended. If the recumbent position is necessary, as in gen- 
 eral surgery, the lateral position is probably the best, and a flat 
 couch or operating table should be used. The same preliminary 
 
NITROUS OXIDE 
 
 91 
 
 attention should be given to apparatus and patient as in the use 
 of gas alone. Special attention should be given to the fit of the 
 face-piece, as it is even more important in using both agents 
 that the face-piece should fit closely than it is in using gas alone. 
 (Figs. 20-23.) 
 
 When the patient is breathing air freely the gas, with a small 
 percentage of oxygen, is turned on. If too much oxygen is used 
 
 Fig. 20.— Goldan's Stop Cock. 
 
 Figs. 20. 21, 22. The gas stop-cock (Fig. 20-I) contains two valves. 
 The inspiratory valve is set in an inner cylindrical tube, which works by a 
 handle through a right-angled slit in an external cylinder supporting the 
 expiratory valve superiorly, and inferiorly giving attachment to the gas- 
 bag for gas alone, or the inverted Y-shaped tube for gas and oxygen. 
 The valves themselves are made of thin sheet hard rubber, and are there- 
 fore indestructible. When the handle is turned down to the point indi- 
 cated by "air" (see Fig. 1 diagrammatic plate, Fig. 21) the gas-bag is closed 
 by means of the obturating function of the inner tube ; when the handle is 
 turned upward to the place indicated by "gas" air is excluded and gas is 
 inhaled by means of the inspiratory valve. Expirations of the patient pass 
 out through the expiratory valve ; at the same time the inspiratory valve is 
 closed. 
 
 When the handle is pushed backward to the place indicated by "no 
 valves" the valves are thrown out of action ; the patient then breathes 
 back and forth into the gas-bc.g. This feature is used only with the gas 
 and ether method. 
 
Q2 NITROUS OXIDE 
 
 at first excitement may arise. If pure gas is given at first it may 
 be difficult to modify its effects without giving too much oxygen. 
 After a few seconds the oxygen indicator of the apparatus may 
 be turned to 3 or 4, etc. 
 
 In young or anaemic subjects the amount of oxygen may be 
 increased more quickly than in healthy, robust adults. 
 
 The gas bags should be kept equally distended. The bag con- 
 taining the nitrous oxide will, of course, demand more atten- 
 tion than the oxygen bag. Signs of excitement indicate less 
 
 The essential part of the gas and oxygen apparatus is an inverted Y- 
 shaped tube (Fig. 20-II) attaching to the lower part of the valved stop- 
 cock. It will be noticed that the right arm of the tubes is somewhat longer, 
 to accommodate a revolving obturator which regulates the quantity of 
 oxygen. This arm of the tube is so constructed that when the obturator 
 is fully open it represents exactly one-half that of the nitrous oxide arm; 
 if so used it would represent exactly S3 1-3 per cent of oxygen. It may 
 be said that anaesthesia is never possible with such a large percentage of 
 this gas. Graduations are accurately marked on the surface of the tube as 
 1-2, 1-4, 1-8, 1-16, 1-32, representing respectively about 33, 25, 12, 6, and 3 
 per cent of oxygen; these graduations have always reference to the op- 
 posite tube. The surface of the oxygen tube has also small depressions 
 into which the metal spring slips when the oxygen is turned on; this 
 permits the use of the apparatus without taking the attention of the admin- 
 istrator from the patient. 
 
NITROUS OXIDE 
 
 93 
 
 OPEN : -,*. 83 \V CLOSE) 
 
 hg.m: 
 
 Fig. 20-111 shows the obturator, which opens by revolving from right 
 to left. The small opening represents about 6 per cent of oxygen. The 
 vertical arm of the Y is the mixing-chamber for the two gases. 
 
 Two separate gas-bags are used, and by this means their respective dis- 
 tention may be more easily seen than with the single bag with septum. 
 From four to six feet of rubber tubing connect the cylinders and gas-bags 
 for transmission of the gases. The cylinders shown are the small portable 
 ones of English manufacture, with foot attachment. Fig. 22 represents 
 the gas and oxygen apparatus complete. There are two cylinders for ni- 
 trous oxide and one for oxygen, for the reason that a far greater quantity 
 of nitrous oxide is used than of oxygen. The face-pieces of different 
 sizes may be obtained of rubber, celluloid, or metal, with inflatable rims. 
 
 In order to obtain perfect results with nitrous oxide and oxygen par- 
 ticular attention must be given to the following points : 
 
 1. The apparatus must be in perfect working order and always tested 
 by the administrator himself. 
 
 2. A sufficient supply of bcth gases at hand. 
 
 3. Atmospheric air must be rigidly excluded. In patients with beards 
 the nostrils may be closed ; the mouth-tube may be used instead of the 
 face-piece or the beard thoroughly moistened with water. 
 
 4. The patient should be prepared as for any surgical anaesthetic. 
 
 5. The gas-bags should never be fully inflated, but between one-half 
 and two-thirds full. In this way the pressure of the gases is kept more 
 nearly equal. 
 
 6. Oxygen should not be turned on immediately the administration 
 begins, but sufficient nitrous oxide inhaled to replace the oxygen existing 
 in the blood ; three to six breaths will he sufficient. 
 
 Oxygen should be admitted gradually and in quantity determined en- 
 tirely by the patient's condition, remembering cyanosis calls for more 
 oxygen; evidences of excitement and returning consciousness meaning 
 that less oxygen is required. In using the gases in long narcosis the taps 
 of especially the nitrous oxide cylinders are apt to freeze, owing to the 
 transition of the gas from the liquid to the gaseous state, the cylinders be- 
 coming covered with frost; to avoid this a towel wrung out of boiling 
 water should be placed about the tap, but not about the cylinder itself. 
 
 The patient should always be placed upon the operating-table in the 
 position in which the operation is to be performed ; any position may be 
 employed, providing it will not interfere with the anaesthesia. 
 
94 
 
 NITROUS OXIDE 
 
 BREATHED AIR 
 
 Fig. 2 
 
 i \ i 
 
 REBREATHED 
 GAS 
 
 Fig. 21.— Diagram of Goldan's Stop Cock. 
 
 Fig. 21. Dotted lines indicate external part of stop-cock, heavy lines 
 and shaded part, internal tube. Arrows indicate direction of inspiration 
 and expiration. The valves are indicated by shaded lines. A. Inspira- 
 tory valve. B. Expiratory valve. C Index handle. D. Right-angled slit. 
 P. Proximal end of stop-cock, attaching face-piece. X. Handle turned 
 down; air breathed. X2. Handle turned up; gas breathed. X3. Handle 
 turned up and back; gas breathed back and forth into gas-bag. 
 
 oxygen. In from twenty to twenty-five seconds the indicator 
 may be brought up to six or seven, which will probably be suffi- 
 cient for dental operations. In longer surgical operations a 
 progressive increase in the amount of oxygen is generally ad- 
 visable. 
 
 Operative proceedings may begin within from two to three 
 minutes of the application of the face-piece. 
 
NITROUS OXIDE 
 
 93 
 
 "'Jsaiisa 
 
 ~^M?'$V ' .•'■'"■ 
 
 Fig. 22.-Goldan's Apparatus for N 2 and O. (Am. Jour. Med. Sci., June. 1901.) 
 
06 
 
 NITROUS OXIDE 
 
 Fig. 23.— Apparatus for N 2 and O (White Dent. Co.). 
 
NITROUS OXIDE g? 
 
 Fig. 23. One cylinder contains Pure Oxygen. 
 
 The other cylinder is filled with Nitrous Oxide. 
 
 There are rubber bags, of different colors to avoid confusion ; black 
 for Nitrous Oxide and red for Oxygen. 
 
 There are keys which open the valves of the cylinders and allow the 
 gas to fill the bags through the tubes. 
 
 Another set of valves being closed, the gas remains in the bags. By 
 opening one Nitrous Oxide is admitted to mixing chamber, from which it 
 flows through the covered rubber tube to the Inhaler. 
 
 When it is desired to combine Pure Oxygen with the Nitrous Oxide, 
 open valve, which admits Oxygen to the Mixing Chamber, and both 
 flow together to the Inhaler. 
 
 This valve with its indicator plate is designed especially to enable 
 the operator to follow out Dr. Hewitt's method, and to this end the valve 
 aperture is enlarged regularly as the handle is turned from 1 to 10; beyond 
 this the valve operates as an ordinary valve and may be opened to the 
 full size of the tubing. It must be understood, however, that in using the 
 indicator plate exact and predetermined percentages of the two gases are 
 neither practical nor desirable. 
 
 There is a convenient handle by which the apparatus, which balances 
 nicely, may be carried. 
 
 For compactness in transportation, the rod which supports the Inhaler 
 may be run down to the level of the Mixing Chamber. 
 
 The Cylinder for Oxygen is always red. 
 
 The Cylinder for Nitrous Oxide is black, and there need be no mistake 
 in placing them in the apparatus. 
 
 The cock O should be opened wide and the oxygen valve indicator P 
 placed at, say 2, before the inhaler is applied to the patient's face. After 
 the patient breathes air freely through the inhaler, shut off the air and 
 then turn on the gas by pressing the spring valve K on the inhaler ; at the 
 same moment the assistant should open cock F to permit nitrous oxide to 
 flow from the cylinder B to bag D. The indicator may then be advanced 
 to 3, 4, 5, etc. 
 
 Pure Oxygen may be administered in a moment by simply closing cock 
 O and throwing cock P full open. 
 
 In regulating the amount of oxygen admitted, the effects 
 must be anticipated and the amount increased or diminished be- 
 fore the actual effect of such action is evidenced in the condi- 
 tion of the patient. The physical state of the patient should also 
 be borne in mind, oxygen being sparingly used with those sub- 
 jects who resist the anaesthetic, and rather freely with those who 
 do not — such as children and delicate persons, also in subjects 
 with pulmonary or bronchial difficulties. During long adminis- 
 trations it may be advisable to admit a breath of air occasionally. 
 If there is troublesome stertor more oxygen should be given and 
 the lower jaw bt brought forward. A mouth-prop may be ad- 
 visable in general surgical operations. 
 
98 NITROUS OXIDE 
 
 There are no special dangers connected with the administra- 
 tion of nitrous oxide and oxygen. So far as this method has 
 been employed it seems to be remarkably free from danger. 
 
 Recovery from the narcosis induced by this method takes 
 somewhat longer than from nitrous oxide alone, but is satisfac- 
 tory, and there are usually no after-effects of importance. 
 
CHAPTER IX, 
 
 ETHER. 
 
 Ether, ethyl oxide, ethylic ether, vinous ether, sulphuric 
 ether has a chemical formula of C 4 H 10 O. It is said to have 
 been discovered by Valerius Cordus about 1540, and was called 
 by him "Oleum Vitrioli Dulce." 
 
 Ether fortior — stronger ether — is composed of about 94 per 
 cent, ethyl oxide, and about 6 per cent, of alcohol containing a 
 little water. Its specific gravity should be not higher than 0.725 
 at 6o° F. All formulas for the preparation of ether agree in ob- 
 taining it from the action of sulphuric acid on alcohol. The 
 term ether is used in relation to the grade recognized by the 
 U. S. Pharmacopoeia (sp. gr., 0.725 to 0.72S), which corresponds 
 to the pure ether (^Ether purificatus) of the British Pharmaco- 
 poeia, which has a sp. gr. of 0.720. 
 
 Ether is a thin liquid, very diffusive, transparent, highly vol- 
 atile, with a characteristic, refreshing, pungent odor and sweet- 
 ish, burning taste, a slightly bitter after-taste, and a neutral re- 
 action. It is soluble in all proportions in alcohol, chloroform, 
 benzol, benzin, fixed and volatile oils, and in eight times its vol- 
 ume of water at 6o° F. Its boiling point is about 98.6 F. Ether 
 is highly inflammable, and a mixture of ether vapor and air is 
 violently explosive when ignited. These properties of ether 
 should be remembered when administering it in the vicinity of 
 artificial light, or in pouring it from one receptacle to another. 
 Serious burns have resulted from attempting to use the actual 
 cautery about the mouth under complete anaesthesia with ether. 
 
 Light blue litmus paper moistened with water should not be 
 changed when immersed in ether for ten minutes. If 10 c. c. of 
 ether be poured in portions on' blotting paper and evaporated 
 spontaneously, no foreign odor should be perceptible after the 
 last trace of ether has evaporated. When 20 c. c. of ether are 
 shaken up in a graduated tube with 20 c. c. of water just pre- 
 viously saturated with ether, the etherial layer upon separation 
 should not measure less than 19.8 c. c. (absence of undue amount 
 of alcohol and water). If 10 c. c. of ether be shaken occasionally 
 within one hour with 1 c. c. of potassium hydrate test solution, 
 
 LOFC. 
 
IOO ETHER 
 
 no color should be developed (absence of aldehyde, etc.). It 
 ether be agitated with carbon disulphide it becomes milky and 
 turbid if water is present. — Boettger. One per cent, or more of 
 alcohol may be detected by agitating ether with a fragment of 
 aniline-violet, no color being produced if free from alcohol. — 
 Stefanelli. Lieben's test for alcohol, founded on formation 
 of iodoform from alcohol and not from ether, is the most deli- 
 cate test for alcohol. The ether may be shaken with water 
 which removes the alcohol ; the aqueous extract is then warmed, 
 a few crystals of iodine are added, and as much caustic potash 
 as is necessary to render the solution colorless ; after standing 
 a few hours a precipitate of iodoform will form. One part of 
 alcohol in 2,000 may be detected by this method. Tests are 
 given for methylated ether, acetic acid, sulphuric acid, and hy- 
 drogen peroxide, but it is not necessary to consider them here. 
 
 Physiological effects and action. — As an anaesthetic ether 
 is much stronger than nitrous oxide, and not as powerful as 
 chloroform. The toxicity of ether is comparatively slight. Prom- 
 inent characteristics of ether are its stimulant nature to the cir- 
 culation, respiration, nervous system, and glandular system, and 
 its irritant quality to the respiratory mucous membrane. The 
 toxicity of ether being slight, it is necessary to administer it in 
 a more or less concentrated form in order to produce complete 
 anaesthesia. It is freely eliminated, mostly by the lungs, and its 
 effects are graduated by the degree of concentration of the 
 vapor inhaled ; that is, by the amount of air admitted during the 
 administration. When little or no air is admitted during the in- 
 duction of the anaesthetic state it is possible to anaesthetize with 
 practically no manifestations of excitement, and the stages of 
 anaesthesia, more clearly defined under more open methods of 
 administration, are not therefore so manifest. 
 
 First stage. — Owing to the pungent nature and irritant char- 
 acter of ether, the first inhalations will cause a free secretion of 
 mucus in the fauces, and a choking and suffocating sensation 
 will occur if the vapor is too concentrated. The patient will push 
 away the inhaler or try to move his head away from it. Repeated 
 acts of swallowing may take place. A sense of fullness and pres- 
 sure in the head, noises in the ears, warmth, tingling, or a pleas- 
 ant numbness of the body may be felt. The pulse is quickened. 
 
ETHER 
 
 101 
 
 the respiration is accelerated, somewhat jerky, and deeper than 
 normal. The pupils are somewhat dilated, and quite mobiie. 
 
 Second stage. — As the administration proceeds conscious- 
 ness is lost slowly or abruptly. While there may be response to 
 questions or to stimulation, the answers will be irresponsible. 
 Memory is lost, and actions are not rational. Hallucinations 
 may be present. Laughing, singing, struggling may occur, es- 
 pecially in robust subjects who require considerable ether, or if 
 the administration is not pushed rapidly enough. A degree of 
 muscular strength may be exerted under these conditions which 
 is quite surprising, and is frequently exaggerated if attempts 
 to restrain the patient are made. There is usually more or less 
 tonic muscular contraction, which later may become clonic, or, 
 exceptionally, there may be fine muscular tremors. The face is 
 flushed, perspiration breaks out freely on the forehead, face and 
 body. The conjunctivae become injected. Slight cyanosis may 
 appear. Mucus and saliva are freely secreted, especially in 
 young and robust subjects. The pulse is bounding and more 
 rapid than normal. The breathing is more or less irregular from 
 muscular spasms. There may be temporary suspension of res- 
 piration in muscular subjects. There may be disconnected at- 
 tempts at articulation, muttering, or only respiratory noises, or 
 groans, clenching of the teeth, and attempts at swallowing may 
 result from spasm of the masseter or laryngeal muscles, espe- 
 cially if the vapor be too concentrated. 
 
 As the anaesthetic state becomes deeper the muscles become 
 relaxed. The respiratory muscles and the muscles of the upper 
 air passages are insensitive to reflex stimulation from the irrita- 
 tion of the vapor, and the patient passes into the so-called third 
 stage of anaesthesia. 
 
 Third stage. — At this time the respiration becomes for- 
 cible, regular, and there is more or less stertor. There is more 
 or less rattling from pharyngeal and laryngeal mucus. The 
 corneae are not sensitive. The extremities are relaxed, and com- 
 plete anaesthesia is reached. There may be some spasm of the 
 masseter muscles. The respiration is quicker than normal. Ster- 
 tor may have a nasal character if the tongue is against the phar- 
 yngeal vault, as is common. The pulse is usually slower than in 
 the earlier stages. It is full, bounding and regular, and may be 
 
102 ETHER 
 
 from 90 to 120 per minute in ordinary cases. Arterial pressure 
 is normal or slightly below normal. The face is flushed, and 
 the vascularity of the tissues of the upper part of the body is in- 
 creased. Marked perspiration is frequent, and a rash may appear 
 on the surface of the body. The pupils are usually moderately 
 dilated. Under deep anaesthesia they may be markedly dilated, 
 and in rare instances may be contracted. 
 
 The eyeballs are usually fixed in the horizontal plane. They 
 show loss of associated movement, or co-ordinate action may be 
 preserved. In lengthy administration there is more or less de- 
 pression of the vital forces, and the body temperature is some- 
 what lowered. 
 
 Toxic effects. — When an overdose of ether is administered 
 respiration shows signs of failure. The conjunctivae become in- 
 sensitive. The pupils are dilated. The eyelids become separated. 
 The skin is ashy pale. The pulse is weak and slower, but the 
 change is not nearly so apparent as with respiration, which in 
 some cases loses its stertor and becomes more and more feeble 
 and finally ceases entirely. There may be prolonged, wheezy ex- 
 piration with short, shallow inspiration, or the breathing may 
 be very irregular, jerky and gasping. It is almost universally 
 the case that when respiratory failure occurs the circulation is 
 still of sufficient integrity to insure the success of properly per- 
 formed efforts at resuscitation. The experiments of Linder- 
 mann, of Moscow, on animals, show that when death occurs from 
 too prolonged or concentrated etherization there is always con- 
 gestion and oedema of the lungs present. 
 
 Temporary arrest of respiration from reflex stimulation of the 
 peripheral ends of the vagi and pneumogastric nerves may mark 
 the initial stage of etherization. Observers generally note a 
 stimulation of the circulation. Kemp's experiments on animals 
 showed a raise in general arterial pressure. Mac William claims 
 there is a general but slight fall in arterial pressure, and that 
 cardiac dilatation is slight or absent except when ether is sud- 
 denly pushed in administration. According to Harley, the action 
 of ether in interfering with the absorption of oxygen and the 
 elimination of carbonic acid is not nearly so great as that of chlo- 
 roform. Van Lerber claimed that ether has little or no effect on 
 the haemoglobin, and that spectroscopic examination does not 
 
ETHER IQ3 
 
 show increase in urobilin from corpuscular disintegration. Da 
 Costa, however, claimed that ether causes a marked diminution 
 of the haemoglobin. 
 
 According to Kemp, ether produces a special contraction of 
 the arterioles of the kidneys, and has a damaging effect on the 
 secreting cells of the organ, with diminution of kidney volume, 
 more or less suppression of secretion, and albuminuria not due 
 to diminished tension. Other observers claim that these effects 
 upon the kidney are not constant, and only appear under too 
 rapid administration. 
 
 A number of years ago Lawson Tait observed, while operat- 
 ing on a case of vesico-vaginal fistula, that when the ether was 
 pushed the trickling of urine from the ureter ceased, indicating 
 suppression of the kidney function, and therefore the dangerous 
 nature of ether in- kidney disease. Thomas and Kemp have since 
 demonstrated the same fact by experiments on animals, and con- 
 clude that ether is dangerous in renal diseases, and particularly 
 so if there is a tendency to pulmonary oedema. In fifty cases ex- 
 amined by Blake ether produced albuminuria or increased it 
 when already present. 
 
 Hooper, of Boston, has shown that under light anaesthesia, 
 stimulation of the recurrent laryngeal nerve produces adduction 
 of the vocal cords, while under deep anaesthesia it produces ab- 
 duction. 
 
 The after effects of etherization are more marked and un- 
 pleasant than those of other general anaesthetics. Recovery from 
 the effects may be rapid or slow. When the patient is an- 
 aesthetized in the lateral, prone position, and is not saturated 
 with large quantities of ether, recovery is usually rapid and sat- 
 isfactory. A too free use of ether may be followed by prolonged 
 stupor, slight cyanosis, and weak pulse. Slight cyanosis is usual- 
 ly corrected when the throat is cleared of mucus by coughing or 
 vomiting. Ether leaves a disagreeable taste in the mouth, and 
 its odor is present in the breath for some time. Moderate, sud- 
 den, expulsive vomiting usually occurs. It ceases quickly, may 
 be repeated once or twice, and usually occurs before the patient 
 has fully regained consciousness, leaving the patient quietly 
 asleep. There may be repeated attacks of vomiting after pro- 
 longed anaesthesia in certain subjects. Haematemesis may rarely 
 
104 ETHER 
 
 occur, but is unusually slight and unimportant. Haemoptysis is 
 quite rare, and may or may not be significant. Bronchitis, usual- 
 ly mild in degree, is not uncommon after etherization, particu- 
 larly in predisposed subjects or after prolonged administration. 
 
 Pneumonia is more frequent after etherization than was for- 
 merly thought. According to Anders it occurs once in 300 
 cases. Ether pneumonia is usually lobular in character. Lobar 
 pneumonia sometimes occurs after etherization, but in this event 
 it is not clear that there is direct relation between the etheriza- 
 tion and the pneumonia, unless it be the effect of etherization 
 in producing better conditions in the respiratory tract for the 
 development of organisms which are already present. Prescott 
 believes that ether cannot cause true lobar pneumonia. He cites 
 two cases in 40,000 ether inhalations. In the lobular pneumo- 
 nias, which are the most frequent, it is likely that the extra se- 
 cretion of mucus, the interference with the action of the res- 
 piratory muscles and the diaphragm, especially in abdominal 
 operations, in connection with which pneumonia is most fre- 
 quent, the pain and coughing all favor the occurrence of aspira- 
 tion pneumonia, as suggested by Czerny. It has been thought 
 that the chilling of the respiratory tract produced by the rapid 
 evaporation of the ether was the cause of the pneumonia ; also 
 that chilling of the surface of the patient's body during operation 
 was responsible, or that the pneumonia might be due to the di- 
 rect irritant action of impurities in the ether, or to the ether it- 
 self, or to infection from the inhaler. We do not, however, com- 
 prehend the relation of lowered vitality of the tissues from pro- 
 longed etherization (relative) to the presence of organisms in the 
 respiratory tract. 
 
 The question of ether pneumonia was introduced by ?,Ir. 
 Lucas, of Guy's Hospital, London. Prescott, of Boston, found 
 three cases of acute lobar pneumonia in 46,000 etherizations. 
 Silk, of London, 13 of pneumonia in 5,000 cases. Gurlt, 30 cases 
 in 52,177. Of 15 cases of ether pneumonia in Johns Hopkins 
 Hospital, 15 were lobular in character, and 79 per cent, followed 
 abdominal operations. 
 
 Albuminuria appears in some instances after etherization. 
 Observers vary greatly in their estimate of the proportion of 
 cases, — all the way from a quarter of one per cent, to two or three 
 
ETHER I0 5 
 
 per cent. — of a considerable number of cases in which previous 
 albuminuria was absent. Kemp argues in favor of rather fre- 
 quent appearance of renal complications after ether, while Bux- 
 ton and Levy are not satisfied that, properly administered, ether 
 exerts injurious effects upon the kidney. The preponderance of 
 evidence is in favor of etherization as an aetiological factor in 
 renal disease in a certain unknown small proportion of cases. 
 
 Hysterical, neurotic or alcoholic subjects may exhibit mental 
 excitement, or even mania or dementia. Chorea has also been 
 noted. Cerebral haemorrhage has been reported as an effect of 
 etherization, and Murchison reported jaundice as following 
 etherization. 
 
 The dangers connected with the administration of ether to 
 healthy subjects are almost nil. It is claimed that only one in 
 fifteen thousand persons who inhale ether die, and that ether is 
 only one-fifth as dangerous as chloroform. The combined sta- 
 tistics of Gurlt, of Berlin, and Juillard, of Geneva, give 341,058 
 cases of ether inhalation, with 23 deaths. In the report of 
 Committee of the British Medical Association of 1900, there is 
 given 4,595 cases of ether inhalation, with 14 cases of danger, 
 which include 6 fatal cases, none of which are regarded as being 
 solely due to the anaesthetic. Partial occlusion of the upper air 
 tract may result from too much ether, but also occurs with mod- 
 erate anaesthesia. Spasmodic cessation of respiration from tonic 
 spasm of the chest muscles may occur with incomplete as well as 
 with deep anaesthesia. The respiration may suddenly cease be- 
 fore or during a properly induced anaesthesia. The chest is rigid- 
 ly fixed and resists any efforts to induce expansion or contrac- 
 tion. In some cases respiration is resumed spontaneously. In 
 others death may follow if artificial means are not successful. 
 Laryngeal spasm with high-pitched, sibilant inspiration, and 
 more or less cyanosis may occur, but rarely arrests respiration, 
 and, as a rule, does not last long. Temporary embarrassment of 
 respiration may occur during the period of recovery just pre- 
 ceding vomiting. It is usually not attended with depression of 
 the circulation. 
 
 Primary cardiac failure from the effects of ether per se is an 
 extremely rare event in moderately healthy subjects. In some 
 cases under operations which entail a severe degree of surgical 
 
106 ETHER 
 
 shock, death may occur under ether from primary cardiac syn- 
 cope. In persons with weak, dilated hearts, or advanced myo- 
 cardial degeneration, death may be from cardiac failure even 
 though signs of respiratory failure be present, the asphyxial state, 
 together with the strain of vomiting or struggling being a suffi- 
 cient additional tax on an incompetent heart to insure death 
 from cardiac syncope. In eleven cases of death under anaesthe- 
 sia in which ether was employed, either alone or in conjunction 
 with other anaesthetics, included in the report of the Anaesthetics 
 Committee of the British Medical Association, rendered in 1900. 
 not one was attributed entirely to the ether. Brooks, of New 
 York, recently reported an instance of death from etherization in 
 which respiration ceased suddenly two or three minutes before 
 the heart stopped. Autopsy failed to disclose evident cause of 
 death. Brooks attributes death to the action of the drug on the 
 ganglion cells of the respiratory center. 
 
 Foreign bodies, such as blood, pus, vomited matter, etc., may 
 enter the larynx or trachea and constitute a source of danger. 
 
 The administration. Ether may constitute the sole agent 
 used for the administration — the usual method adopted, — or it 
 may be given as a constituent of a mixture containing other an- 
 aesthetics — the so-called anaesthetic mixtures, such as the A. C. E. 
 mixture ; or it may be administered in sequence with other agents 
 — the so-called method of anaesthetic sequences. 
 
 The present consideration has reference solely to the use of 
 ether as the only agent employed for the administration. 
 
 As a rule the administration of ether is carried to the point 
 of complete anaesthesia. In relatively few instances this may not 
 be necessary. Twelles claims that two-thirds of all operations 
 may be performed under a method that has been used in Vienna, 
 in which the patient is kept on the borderland between awakening 
 and the stage of excitement (the "ether rausch" or "ether drunk") 
 by using from 10 to 30 c. c. of a mixture of ether and balsamic 
 oil inhaled through an ether mask. Analgesia is said to follow 
 from ten to fifteen deep inhalations, and the operation can be 
 commenced within a minute of the beginning of the administra- 
 tion. The practicability of this method, however, remains to 
 be demonstrated. It is not adapted to excitable and highly nervous 
 persons. 
 
ETHER IO7 
 
 When possible it is best to begin the administration with the 
 patient upon the operating table, or at least not to lift or haul 
 the subject about after anaesthesia is induced. The posture of 
 the patient during the administration will, of course, vary with 
 the demands of the operation, but the prone position with the 
 patient upon the side or back and the head turned slightly to one 
 side is, generally speaking, to be preferred. The irritating effects 
 of ether upon the membrane of the fauces, and the choking sen- 
 sation incident to the beginning of its inhalation should be ex- 
 plained to the patient. He should also be instructed to breathe 
 deeply and regularly through the mouth. 
 
 The manner of administration will vary with the method 
 adopted and the kind of inhaler employed. Inhalers are of 
 varied designs, many of which exemplify much more ingenuity 
 than practicability. The simplest inhaler which will answer for 
 the method of anaesthesia employed is always the best, and the 
 inexperienced administrator should employ the simplest appa- 
 ratus, such as the open inhalers. 
 
 Ether is generally administered according to the so-called open 
 method, the partially closed or semi-open method, or the close 
 method. It may also be administered in conjunction with oxygen 
 and may be administered per rectum. 
 
 By the open system of administration an abundance of air 
 Is allowed during the entire period of administration. The ether 
 is poured in small quantities on a folded napkin or handkerchief, 
 or on a mask inhaler of gauze or lint which is held quite close 
 to the mouth or nose. It is difficult to induce complete anaesthe- 
 sia by this method, and its use is adapted only to very young 
 children, weak or exhausted subjects, or to persons who have 
 "been for some time under the influence of ether and who there- 
 fore do not require much to continue the anaesthetic state. 
 
 By the partially closed or semi-open method of adminis- 
 tration the amount of air admitted is limited to a greater or less 
 extent, and the expired air and vapor escapes, no re-breathing 
 taking place. There are many varieties of inhalers applied to 
 this method of administration. The earliest and simplest was 
 made by folding a towel into a cone shape and placing a sponge 
 or piece of gauze in the apex. A simple and efficient inhaler of 
 this kind may be extemporized by doubling a towel over two 
 
io8 
 
 ETHER 
 
 or three layers of newspaper, folding over and pinning down the 
 edges and one end, pressing the open end into an oval shape, and 
 loosely packing the upper part of the interior with gauze or a 
 sponge. Inhalers for this method of administration are made 
 of metal, felt, mackintosh, or leather, with open or perforated 
 apices. If the apex is not closed the ether may be poured on 
 in small quantities as may be necessary without removing the 
 inhaler from the face, sufficient air being obtained through the 
 apparatus. Representative types of this class of inhalers are the 
 Allis (Figs. 24, 25) and the Blake inhalers, while the Goldan 
 inhaler represents a simple form- adapted for either open or close 
 administration. 
 
 It is well to rub a little vaseline on the lips and adjacent por- 
 tions of the face of the patient in order to avoid the irritation 
 of the ether. Two or three drachms of ether are poured in the 
 inhaler which is held a short distance from the face until the 
 patient gets accustomed to the sensation of inhaling the vapor. 
 
 *»VW V SU\T*s WtoVV*. 
 
 Fig. 24.— Allis' Inhaler with Detachable Metal Corer. 
 
 Fig. 24. A metallic frame-work large enough to cover the lower por- 
 tion of the face and so fenestrated as to admit the introduction of a large 
 number of cloth partitions. These partitions are formed from a gauze 
 bandage by. weaving the cloth back and forth through the fenestrae in the 
 sides of the frame. Although the instrument is only about 4 inches in 
 length and from 2 to 3 in width, it requires about three yards of gauze 
 bandage to form the partitions. The whole is surrounded by a nickel- 
 plated cover held in place by suitable spring clips. This arrangement pro- 
 vides an instrument durable, portable, inexpensive, and easily sterilized. 
 One end of the external covering is so arranged as to fit closely the con- 
 tour of the face. The apparatus allows the free admission of air from 
 above, and as the evaporating surface is large, rapid vaporization and 
 etherization follows. The quntity of ether may be replenished as fast as 
 desired by pouring it upon the outer surface of the exposed gauze edge. 
 
ETHER 
 
 IO9 
 
 Too sudden inhalation of strong vapor will cause coughing, hold- 
 ing of the breath, choking, or a distressful sensation of suffoca- 
 tion. As the patient becomes accustomed to the vapor and is 
 beginning to lose consciousness the amount of air is restricted 
 and the strength of the ether vapor inhaled is gradually in- 
 creased. Careful attention should be given at this time to the 
 respiration and to the larynx. The rhythm of the respiration 
 is usually somewhat irregular because of swallowing, and tem- 
 porary spasmodic closure of the larynx is apt to occur if vapor 
 be too strong. The larynx soon loses its sensibility and the 
 breathing becomes regular. If excitement becomes marked, as 
 is likely at this time, it may be controlled by pushing the admin- 
 istration — a much safer procedure with ether than with chlo- 
 
 W^^mm^j^maffl 
 
 Fig. 25.— Fowler's Modification of Allis' Inhaler. 
 
 roform at a corresponding period of administration with the 
 latter agent. In robust, vigorous subjects and in alcoholic per- 
 sons a larger quantity of ether will be necessary to prevent ex- 
 citement and to maintain deep anaesthesia than will be required in 
 debilitated subjects. The longer the administration lasts the 
 smaller will be, as a rule, the quantity of ether necessary to pro- 
 long the anaesthesia. If the patient is not allowed to partially 
 recover from the effects of the ether during the administration 
 vomiting will not be liable to occur. Much more ether is re- 
 quired by the semi-open system than by the close method with 
 
no 
 
 ETHER 
 
 bag inhalers, and excitement and struggling are more liable to 
 occur. It is thought by some that there is also greater liability 
 to subsequent respiratory affections. Nevertheless, for many sub- 
 jects, and for a great many operations the semi-open system of 
 
 Fig. 26. 
 
 -Clover's Portable Regulating Ether Inhaler (original pattern).— After 
 Hewitt. 
 
 Fig. 26. F is the face-piece ; E is reservoir through which air current 
 passes; B is a rubber bag. The patient breathes back and forth into the 
 bag. There are no valves and no arrangement for admitting fresh air. 
 The face-piece fits tightly to the tube T which connects with a shaft pass- 
 ing through the reservoir. The mounting of bag B fits into the other end 
 of this shaft. The current of air is regulated in passing over the ether by- 
 revolving the reservoir on the tube T. The reservoir is charged at the 
 funnel-shaped tube FT. 
 
ETHER 
 
 III 
 
 administration is preferable. The moderately experienced admin- 
 istrator will certainly encounter less difficulty in anaesthetizing by 
 this method, and it is therefore the most popular and widely em- 
 ployed system. 
 
 By the close method of administration the amount of air 
 admitted is restricted and under control, and the expired air is 
 rebreathed to a greater or less extent. The names of Smith, 
 of New York ; Porta, of Pavia ; and Morgan, of Dublin, are 
 connected with the introduction of inhalers adapted to this 
 
 Fig. 
 
 -Sectional view of Clover's Inhaler. Indicator at "O."— After Hewitt. 
 
 Figs. 27, 28. Shows the reservoir F and tube T in section. E is a 
 sphere tunnelled by shaft S into which T fits. E holds the ether which is 
 entered at tube FT closed by stopper St. One-half of the sphere is covered 
 by a cap C. The space between C and E is filled nearly with water which 
 prevents the inhaler from becoming too cold. In the shaft there are four 
 large openings, two (O) on upper wall, and two (O') on lower. These 
 allow communication between interior of shaft and ether reservoir. The 
 shaft contains a sloping diaphragm D closing one-half of the shaft. The 
 tube T passes into the shaft S and has a beveled end which fits close 
 against the diaphragm of the shaft. It has an indicator (i) pointing to fig- 
 ures on the reservoir. With the indicator at "O" the air current on in- 
 spiration will take the course shown in Fig. 27. With the indicator at 
 "F" the air current on inspiration will take the course shown in Fig. 28. 
 
112 
 
 ETHER 
 
 method of administration. The Clover inhaler (Figs. 26, 29), in- 
 troduced in 1876, may be regarded as the type of the bag 
 inhalers used in this method. The Packard inhaler, the Ben- 
 nett inhaler (Figs. 30-32), and other modifications of similar 
 nature embody the principles of the original Clover inhaler.* 
 Young has suggested an improvement in the use of bag inhalers 
 which consists in using a linen bag instead of the rubber one. A 
 clean bag can be used for each patient, as the rubber bag gets foul 
 and cannct well be cleaned. Other advantages claimed are : Less 
 
 Fig. 28.-Sectional view of Clover's Inhaler. Indicator at "F."— After Hewitt. 
 
 initial disturbance, no asphyxia or cyanosis, and if a change to 
 chloroform is desired it can be dropped on the bag without chang- 
 ing the face-piece. Slight disadvantages are : Longer inhalation 
 period required for anesthetization (average, ten minutes), and 
 increased quantity of ether required (about one ounce for every 
 ten minutes). In the administration by this method attention 
 should be given to the following points : See that the face-piece 
 fits properly; in beginning the administration direct the patient 
 to breathe through the mouth regularly and deeply; leave the 
 indicator at "air" and allow to-and-fro breathing from the bag 
 
 *Hess, formerly anaesthetist to Bellevue Hospital, says that a compari- 
 son of the use of the Allis with the Bennett inhaler shows the consump- 
 tion of one ounce of ether with the latter, to eight or ten ounces with the 
 former, and that a better and safer type of anaesthesia is obtained with 
 the Bennett apparatus. 
 
ETHER J 13 
 
 for a few seconds in order to partly fill the bag with air, and to 
 see that the bag expands and contracts properly with respira- 
 tion, keeping the face-piece closely applied during expiration; 
 gradually turn the indicator towards "ether" every two or three 
 respirations. As anaesthesia becomes effected ether may be ad- 
 mitted rather more freely; coughing, swallowing, and holding 
 the breath indicate less ether and more air ; excitement indicates 
 more ether and less air. If there be stertor the face-piece should 
 be raised and a breath or two of air allowed. As the adminis- 
 tration is prolonged more air may be admitted without affecting 
 the anaesthesia; slight cyanosis is present as a rule during the 
 beginning of the administration. In the later stage cyanosis 
 indicates more air; marked stertor, deep cyanosis, difficult 
 breathing, and forced expiration call for more air at once. The 
 signs of anaesthesia are regular, snoring breathing, lost corneal 
 
 TBT 
 
 Indicator at '3' Indicator at 'f or 'Full' 
 
 Fig. 29.— Diagram of Air Currents in Clover's Inhaler.— After Hewitt. 
 
 Fig. 29. Diagram of air current passing over ether in Clover's Portable 
 Inhaler when indicator points to "O", "i", "2", "3", and "F". Four lines 
 represents the full current. 
 
 In preparing to use Clover's inhaler secure a properly fitting face-piece, 
 turn the indicator to "1" or :< 2" ; pour in one and one-half ounces of ether; 
 replace the plug ; turn back the indicator to "O" ; blow once through the 
 apparatus to remove odor of ether, and attach the bag. 
 
H4 
 
 ETHER 
 
 Fig. 30.— Bennett's Inhaler for Ether. 
 
 Figs. 30, 31, 32. I. Ether Inhaier. — Take the ether chamber apart by 
 removing the thumb-screw. Pack the wire cage (in situ) firmly with dry 
 gauze. It will hold a piece one yard wide and ten or twelve inches long. 
 Do not allow the ends of the gauze to interfere with the mechanism of 
 the inhaler. Turn the index to the upward limit (full ether) and pour 
 from one-half to one ounce of ether upon the gauze — one -half through 
 the face-piece, the other half through the chimney at the top of the ether 
 chamber. Now turn the index to the downward limit (full air) and at- 
 tach the bag. The rubber cushion of the face-piece should be moderately 
 inflated. The air tap at a and at c should be closed. Apply the face-piece 
 during several expirations, so as to distend the bag moderately; then keep 
 the inhaler applied and turn the index at once to the line between air and 
 ether. Now turn the index toward ether, about one-sixteenth inch every 
 two or three inspirations, or as slowly as necessary to avoid the effects of 
 too strong ether fumes. In about one minute the index will have been 
 moved forward one-fourth to one-third the distance between the line above 
 referred to and the upward limit. Occasional inspirations of air should 
 now be given by removing the inhaler from the face, and the index should 
 be moved more gradually forward until complete anaesthesia is present. 
 This is accomplished in from two to five minutes in average patients. 
 When the index has reached a little more than one-half the distance from 
 the line to the upzeard limit full ether is on and the index should be at 
 once moved to the upward limit. The administration consists chiefly in 
 the regulation of two factors: 1. The air supply, and, 2, The ether supply. 
 
 1. The Air Supply. — During the induction of anaesthesia the air sup- 
 ply should be limited as above ; enough should be given, however, to pre- 
 vent more than slight cyanosis. Patients differ greatly in the amount of 
 air they require with ether, and the air supply must be regulated in ac- 
 cordance with the following facts : The tap c being closed, if a is opened 
 slightly the patient will rereive little air and much ether; if fully opened 
 he will receive much air and little ether. The tap a being closed, if c is 
 opened slightly the patient will receive little air and much ether; if fully 
 opened, he will receive much air and much ether. 
 
 2. The Ether Supply. — At the beginning, the ether chamber should 
 be charged, as above, with from one-half to one ounce of ether, according 
 
ETHER 
 
 115 
 
 to the patient, and this will usually be sufficient to induce complete anaes- 
 thesia. It is best to continue the administration with the index turned to 
 the upward limit, and from one-half to one drachm of ether every two or 
 three minutes will be found enough for the average patient. Ether may 
 be added, (1) through the face-piece, (2) through the chimney, or (3) 
 through the revolving disc on the side of the ether chamber: (1) is prefer- 
 able in usual cases, (2 or 3) is of great advantage when it is inconvenient 
 to remove the inhaler from the face. 
 
 Fig. 31.— Bennett's Inhaler for Gas. 
 
 II. Gas Inhaler. The tap c being fully opened, the bag is filled with 
 gas from the cylinder through the rubber tube supplied with the inhaler. 
 The aperture d should be fully open. The rubber cushion of the face- 
 piece should be moderately inflated. The face-piece should be applied so 
 perfectly that the valves act well, the inspired air entering at e and the 
 expirations escaping at d. Upon closing the tap e, gas will be drav/n from 
 the bag on inspiration, escaping at d on expiration. As soon as the inhala- 
 tion begins, a flow of gas sufficient to keep the bag moderately full should 
 be turned on from the cylinder. The inhalation is to be conducted on the 
 principles of gas administration. Air may be admitted- as necessary by 
 opening the tap e. 
 
 reflex, and relaxed muscles. The regulation of the ether and 
 air supply during the continuance of the anaesthesia will depend 
 on the nature of the patient. Vigorous and alcoholic subjects 
 require much more ether than weak or very young individuals. 
 The amount of ether required is, as a rule, in inverse proportion 
 to the length of the administration. 
 
 The conjoined use of oxygen and ether has not had wide 
 employment. It is claimed to possess marked advantages by 
 some, and by others said not to have any special advantage ex- 
 cept in certain cases. In employing this method the tube from 
 an oxygen cylinder is connected with any inhaler adapted for 
 the purpose — such as the Packard inhaler, and a greater or 
 
n 6 . ETHER 
 
 less percentage of oxygen is admitted along with the ether. This 
 method is adapted to persons with chest lesions and very weak 
 hearts, emphysema, indurative pleurisy or mediastinitis, pulmon- 
 ary sclerosis and advanced tuberculosis of the lungs. These con- 
 ditions, especially when associated with secondary myocardial 
 changes may render such a system of anesthetization advisable, 
 though even here some people prefer a chloroform mixture such 
 as the A. C. E. mixture, providing the heart is not seriously com- 
 promised. 
 
 Dr. Dudlev Buxton recommends the use of oxygen and ether 
 
 Fig. 32.— Bennett's Inhaler for Gas and Ether. 
 
 III. Gas and Ether. — The ether inhaler is charged with ether and ar- 
 ranged as described in I., the bag being omitted. The gas inhaler is ar- 
 ranged as described in II., the bag being completely filled with gas and dis- 
 connected from the tube at the stop-cock f, which is to be closed. The 
 gas inhaler is now connected with the chimney of the ether inhaler. The 
 face-piece being perfectly applied, the tap e is closed and gas is breathed 
 through valves. When the gas bag has been two-thirds or three-fourths 
 emptied, the aperture d is closed by turning the thumb-screw of the gas 
 inhaler. Gas is now breathed back and forth. The patient is at this time 
 unconscious, or nearly so, and ether is to be turned on as described in I., 
 though somewhat faster. In about one minute signs of complete gas anaes- 
 thesia will appear if the face-piece has been well applied (cyanosis, jerky, 
 snoring respiration, twitching movements in the extremities) and are to be 
 met by opening the tap e for two or three respirations. The tap is again 
 closed and the inhalation of gas, plus ether, is continued — an occasional 
 breath or two of air being allowed. In this way the gas anaesthesia sub- 
 sides, while the ether narcosis becomes complete. After about one and 
 one-half minutes the gas may be discontinued, the gas inhaler and bag 
 should be removed and the ether bag substituted. The administration 
 now proceeds as described under I. 
 
ETHER 117 
 
 "In cases in which the induction presents unusual difficulties from 
 dyspnoea, spasm, cough, holding of the breath, struggling with 
 cyanosis, in alcoholics, and in persons of feeble vitality. The re- 
 peated filling of the bag with oxygen removes all difficulty, and 
 rapidly induces a profound and quiet anaesthesia. The narcosis 
 so obtained can be insured when using ether by itself, as the hyper- 
 oxidation of the tissues enables more ether to enter the circula- 
 tion than could otherwise occur without danger to the nervous 
 center hampered by deoxidized blood." This method is endorsed 
 by Gardner, who says he finds muscular relaxation more complete 
 under this combination than with ether alone. 
 
 Rectal etherization was introduced by Roux in 1847. It was 
 employed with the object of obviating the usual method of ad- 
 ministration in operations about the mouth and nose, or pharynx. 
 The best method of introducing the ether is that of Malliere, who 
 connected the ether bottle with a rubber tube which was intro- 
 duced into the rectum, and the ether bottle surrounded with water 
 at a temperature of 122 F., and the ether allowed to gradually 
 enter the rectum. About 2 ounces of ether was usually needed. 
 In a few minutes the patient can taste the ether, and drowsi- 
 ness is felt. Excitement is rare. There may be prolonged stupor 
 and asphyxial symptoms, with contracted pupils. Diarrhoea and 
 melaena may follow. Weir, of New York, has reported an in- 
 stance of melaena followed by death in a child after rectal ether- 
 ization. W. T. Bull, of New York, reported seventeen cases of 
 rectal etherization, with melaena in seven. Aside from these ap- 
 parent objections, this method of etherization has advantages in 
 certain cases, but under such liabilities it cannot be recommended 
 except in rare instances. 
 
 The proper extent of anaesthesia to be maintained during the 
 operation will depend on several circumstances. Too light an- 
 aesthesia during the early stages is apt to be accompanied by ex- 
 citement, muscular movement or spasm, vomiting, etc. The third 
 stage of anaesthesia should be maintained during the earlier part 
 of operations. Later it may not be necessary to maintain so deep 
 a state of narcosis. The amount of ether necessary to maintain 
 deep anaesthesia will vary with the characteristics of the subject, 
 and the nature of the operation. In some subjects the reflexes 
 are difficult to abolish and much ether may be required. Again, 
 
Il8 ETHER 
 
 in some persons analgesia sufficient for minor operations may be 
 secured, even though the reflexes are present. There is not the 
 same danger of reflex failure of the circulation under light ether- 
 ization that exists under the same state of anaesthesia from chloro- 
 form. The administrator, therefore, may keep the subject under 
 as light anaesthesia as is compatible with no modification of the 
 signs of the anaesthetic state by the operative procedures. In order 
 to do this he must carefully observe the state of the respiration, 
 the lid-reflex, the pupils, swallowing movements, and the degree 
 of muscular relaxation. The respiration is the most reliable guide. 
 The more ether given, the deeper, quicker, and more stertorous 
 the breathing will be. Diminution in the amount of ether beyond 
 that amount necessary for complete anaesthesia will be marked 
 by inaudible breathing and absence of stertor. Expiratory puf- 
 fing of the lips is also an indication of full anaesthesia. Slight 
 obstructive breathing is often present under light anaesthesia and 
 is remedied by pushing the lower jaw forward. It may or may 
 not be necessary to maintain a stertorous form of breathing in 
 certain instances. Prolonged, forcible expiration, tracheal, or 
 laryngeal rales indicate less ether. 
 
 The lid-reflex is a good guide in many cases. The corneal re- 
 flex is often present when the conjunctival reflex is absent. The 
 latter is temporarily abolished by repeated testing. Whether it 
 is advisable to keep the lid-reflex abolished depends on the sub- 
 ject and on the operation. In some cases it is quite possible to 
 have sufficient analgesia without abolishing the reflex. Generally 
 it is best to abolish the reflex, especially in operations on the skin, 
 abdomen, rectum, vagina, etc. In some operations, and in weak, 
 debilitated subjects, it is often not necessary. 
 
 The pupils afford more or less reliable information as to the 
 state of anaesthesia. In the third stage they lose their mobility and 
 acquire a degree of contraction depending on the peculiarities of 
 the subject. The average pupil of complete anaesthesia is about 
 3-J to 4j mm. in diameter. Where the administrator has observed 
 the size of pupil present 15 or 20 minutes after the beginning of 
 the administration, and under full anaesthesia in a given subject, 
 he is prepared to draw inferences from variations from this as a 
 standard. If the amount of ether be too small to maintain full 
 anaesthesia the pupil will contract and the patient will show other 
 
ETHER II9 
 
 signs of recovering, such as swallowing or other muscular move- 
 ments. If too much ether is given, the pupil will dilate. In some 
 cases the pupil will dilate under reflex stimulation from the opera- 
 tion if the anaesthesia is too light. This may happen in operations 
 on sensitive tissues, or in neurotic individuals. It is distinguished 
 from toxic dilatation from too much ether by the presence or 
 absence of other signs, such as lid-reflex, or by the effect of 
 less ether. If the pupil becomes small with less ether the dilata- 
 tion was due to too deep anaesthesia ; if it becomes dilated with less 
 ether the dilatation was due to reflex stimulation. Thus the pupil 
 may be about 3J mm. under full anaesthesia, and may dilate to 
 5 mm. from reflex irritation during certain phases of the operation 
 and slight anaesthesia ; it may contract to 3J mm. under more 
 ether or absence of reflex irritation, and later dilate from the toxic 
 effect of too much anaesthetic. 
 
 Swallowing movements may be an early indication of return- 
 ing consciousness when the breathing has been regular, deep, and 
 stertorous. They may precede vomiting, and the latter may be 
 prevented by increasing the ether, if swallowing is observed or 
 felt with the fingers on the larynx.. 
 
 Muscular movements of the arms and legs are often an early 
 evidence of too light anaesthesia, and like alterations of the pupils 
 may occur from reflex irritation. Their indications are much the 
 same, though more erratic and less reliable. 
 
 The management of accidental conditions incidental 
 to the period of administration. — A certain class of subjects 
 are more likely to exhibit accidental conditions of more or less 
 danger during the administration than are others (page 41). Like- 
 wise certain operations are more frequently accompanied by man- 
 ifestations of a dangerous nature than others (page 49). Never- 
 theless in all instances the administrator must be on the watch 
 for, and prepared to meet any unusual condition that may arise. 
 
 At the beginning of administration irregular or inefficient 
 breathing may result from too strong vapor, and a little air may 
 be necessary. In some subjects fear, nervousness, or stubborn- 
 ness may be the cause of inefficient breathing. Patience, firmness 
 and encouragement on the part of the administrator will accom- 
 plish much. Interference with respiration may occur from the 
 tongue becoming applied against the pharyngeal wall after the 
 
120 ETHER 
 
 patient is completely unconscious, and it may be necessary to open 
 the mouth and pull the tongue forward with forceps. Unusual 
 nervous or muscular excitement may be controlled by pushing 
 the ether — a proceeding not dangerous at this stage in moderately 
 healthy or vigorous persons. Muscular rigidity may persist even 
 though unconsciousness is complete. It may disappear in some 
 cases if more air be allowed. It may be necessary to give large 
 amounts of ether with plenty of air in order to overcome rigidity. 
 The breathing through the mouth should be unobstructed. In 
 some cases it may be necessary to give a little chloroform in order 
 to relieve muscular rigidity, and to resume the ether afterward. 
 Muscular tremor, most common in muscular subjects under ether, 
 especially in the limbs if exposed, may be relieved by changing 
 the position of the limbs, or by increasing the amount of ether. 
 
 Coughing usually occurs early in the administration from too 
 concentrated vapor, especially in subjects with irritable throats 
 from the use of alcohol and tobacco. It does not occur during 
 deep anaesthesia. It is preceded by attempts at swallowing. Oc- 
 casional coughing may not be objectionable if there be blood or 
 mucus in the respiratory passages. It is not always possible to 
 prevent coughing, and in some operations when the act interferes 
 with the operator it may be necessary to resort to chloroform. 
 
 Hiccough is rare, but is likely to occur during abdominal op- 
 erations. The depth of anaesthesia has little influence on hic- 
 cough. 
 
 Sneezing may be troublesome, and if not relieved by pushing 
 the ether the nasal region may be sprayed with a dilute solution 
 of cocaine. 
 
 Vomiting is frequently troublesome and occurs under light 
 anaesthesia, usually during the induction period or during the re- 
 covery from full anaesthesia. It is objectionable for evident rea- 
 sons and may be dangerous. Vomiting is most likely to occur in 
 alcoholic, robust young men and in weak women with irritable 
 stomachs and sluggish livers. The secretion, during anaesthesia, 
 of a large amount of saliva and mucus produces vomiting. The 
 quicker and more completely the subject is brought under the 
 anaesthetic the less liabilitv there will be to vomiting. Once fully an- 
 aesthetized the subject can usually be kept from vomiting by in- 
 creasing the amount of ether, should swallowing, high-pitched 
 
ETHER 121 
 
 respiration, or a dilated pupil with good conjunctival reflex be 
 observed. If vomiting cannot be prevented, the patient's head 
 should be turned well to one side and the opposite shoulder 
 propped up. If the teeth are clenched the mouth should be forced 
 open and the lower jaw pushed forward. 
 
 The respiratory difficulties arising during etherization are due, 
 in the early stages of administration, to some interference with the 
 entry and exit of air. While during deep anaesthesia respiratory 
 troubles may arise from interruption of the function of the res- 
 piratory center from an overdose of ether or from other causes. 
 It should be borne in mind that during the induction of anaes- 
 thesia muscular movements, especially of the diaphragm, may sim- 
 ulate those of respiration in cases where there is some obstruc- 
 tion to breathing. The air current should be heard or felt, or its 
 effects on the bag of the inhaler observed in order to be sure 
 that the patient is breathing. 
 
 Obstructed breathing from spasm of the muscles of the upper 
 part of the respiratory tract may be remedied by pushing the lower 
 jaw forward, pulling the chin forward from the sternum and up- 
 ward, and by extending the head over the end of the operating 
 table. It may be necessary to introduce a mouth-gag, open the 
 mouth and pull the tongue forward from the pharynx. If breath- 
 ing is not resumed, strong traction should be made on the tongue, 
 and the chest should be compressed. Crile calls attention to the 
 fact that dangerous inhibitory phenomena may attend the too sud- 
 den and forcible traction of the tongue during anaesthesia, cy- 
 anosis, collapse, and failure of the heart and respiration becom- 
 ing suddenly pronounced. The effect on the heart is produced by 
 mechanical irritation of the vagi and is prevented or relieved by 
 atropine. The effect on the respiration is through mechanical 
 stimulation of the superior laryngeal nerve and is not relieved by 
 atropine. Where the trouble is due to mucus it will generally be 
 relieved by coughing and swallowing, which will come on if the 
 administration be suspended. In very rare instances in fat sub- 
 jects of a powerful build, spasm may be so intense and swelling 
 so great that the air tract is closed entirely, and laryngotomy 
 may be necessary. This, with Sylvester's method of artificial res- 
 piration, will generally bring relief. Inflation of the lung through 
 a tube introduced into the larynx may be necessary, using the 
 
j 22 ETHER 
 
 mouth, a bellows, or the Fell-O'Dwyer apparatus. As the imme- 
 diate cause of death is from overdistention of the right heart, 
 venesection may be of service. 
 
 Obstructed breathing may arise from various foreign sub- 
 stances in the air passages. In operations about the mouth and 
 throat blood may enter the larynx and trachea and cause sudden 
 or gradual obstruction of the breathing. If moist expiratory 
 rales are heard the administration should be stopped and careful 
 sponging with a coarse-meshed sponge practiced. This may be 
 followed by forcible compression of the chest and abdomen, in- 
 version of the patient, artificial respiration, keeping the mouth 
 open and the tongue pulled forward. The rectum may be 
 stretched, and ether poured on the abdomen. Laryngotomy may 
 be necessary and suction through a tube introduced into the 
 trachea may be tried. Lung inflation may be useful. 
 
 Vomited material may enter the trachea. In rare instances it 
 may be impossible to prevent this occurrence. If vomiting is prob- 
 able the head should be kept turned to one side, the opposite shoul- 
 der elevated, and the mouth kept open by a gag. Should trouble 
 arise from this source the measures enumerated above should be 
 applied. 
 
 Mucus and saliva or pus may be troublesome, though usually 
 it may be obviated by close atttention to the anaesthetic and its 
 regulation. The mucus should be frequently sponged from the 
 fauces, and if trouble arises the above line of treatment is in- 
 dicated. 
 
 Certain postures in which it may be necessary to place the 
 patient for certain operations may aid in obstructing breathing. 
 The remedy is obvious. Certain pathologic states of the organs 
 within the chest or abdomen may tend to produce interference with 
 respiration. In these cases moderate anaesthesia only is permis- 
 sible. 
 
 General spasm of the respiratory muscles is an infrequent 
 form of respiratory disturbance in ether anaesthesia. It is neither 
 so frequent or dangerous as in chloroform anaesthesia. It may 
 arise during the stage of excitement, or from the reflex impres- 
 sion from surgical procedures — such as skin incisions, or as a 
 sequence to obstruction of the air tract. When the rigidity of 
 the chest from such spasm does not subside spontaneously, the 
 
ETHER I23 
 
 mouth should be opened, tongue traction made and artificial res- 
 piration employed. If these fail, laryngotomy should be per- 
 formed and lung inflation practiced. 
 
 Respiratory failure from an overdose of the anaesthetic is rare 
 in etherization. Sudden arrest is not as frequent as with chloro- 
 form. Shallow, imperceptible respiration, and stridulous expira- 
 tion, especially if associated with dusky pallor, lost conjunctival 
 reflex, and weak or irrregular pulse, are the danger signs. In 
 etherization, if such signs occur, the pulse usually remains of suf- 
 ficient integrity to insure a response to artificial respiration if 
 promptly applied. Fuller consideration of this matter will be 
 found under chloroform (p. 147). 
 
 Respiratory failure from cerebral anaemia, or from reflex 
 causes arising during operation is not so frequent under ether 
 as with chloroform anaesthesia. Inversion of the body, artificial 
 respiration and hypodermic injection of strychnia (about one- 
 twentv-fifth of a grain) are of service. 
 
 Failure of the circulation is uncommon under ether, but may 
 occur from the same causes as in chloroform anaesthesia (p. 150). 
 Various impaired conditions of the general health, pathological 
 changes in the blood or in various organs may predispose to fail- 
 ure of the circulation under etherization, as may also psycholog- 
 ical conditions, mental disturbances, or the posture of the patient 
 during anaesthesia. Food in the stomach, spasmodic arrest of 
 breathing, vomiting, the operation and the effect of the anaes- 
 thetic on the cardio-vascular system may all induce failure of the 
 circulation in certain cases. The management of this condition 
 will be considered under chloroform (p. 150), as it is most fre- 
 quent under that anaesthetic. Ante-mortem heart thrombus has 
 been reported as a cause of death during etherization. Such a 
 cause could not, of course, be recognized, nor its effects obviated. 
 
 The clinical conclusions arrived at in regard to ether by the 
 last committee on anaesthetics of the British Medical Associa- 
 tion are to the effect that complications are more frequent in males 
 than in females, but are slightly more dangerous in females than 
 in males ; that ether alone, or preceded by gas or A. C. E. mixture, 
 is singularly free from danger in healthy patients ; that the minor 
 difficulties of administration due to laryngeal irritation and se- 
 cretion of mucus are more frequent under ether than under other 
 
124 
 
 ETHER 
 
 anaesthetics ; that struggling is most frequent under ether alone, 
 but rarely leads to danger ; that vomiting during recovery is most 
 common with ether, but is usually transient; that bronchitis is 
 more common after ether than after chloroform 
 
CHAPTER X. 
 
 CHLOROFORM. 
 
 Chloroform, also called trichlor-methane, dichlorinated chlo- 
 ride of methyl, and perchloride of formyl, was discovered by Dr. 
 Samuel Guthrie, of Sackett's Harbor, N. Y., in 1831, and about 
 the same time by Soubeiran, of France, and by Liebig, of Ger- 
 many. Its real chemical composition was determined in 1834 by 
 Dumas. Guthrie evidently obtained in a pure state the substance 
 now known as chloroform, though he supposed it to be the well- 
 known oily liquid of the Dutch chemists which it greatly resem- 
 bled, and which was known as "Dutch liquid," or ethane dichlo- 
 ride. He therefore used the term chloric ether, thinking he had 
 discovered a cheap and easy process for obtaining ethane dichlo- 
 ride. 
 
 Chloroform is a liquid consisting of from 99 to 99.4 per cent, 
 by weight of absolute chloroform, and from 0.6 to 1 per cent, of 
 alcohol. It is a compound of one atom of carbon, one atom of hy- 
 drogen, and three atoms of chlorine. It has a chemical formula 
 of C H Cl 3 . Its simplest theoretical derivation is from the action 
 of chlorine on marsh gas (methane) C H 4 , whence it has been 
 called trichlor-methane. Practically, chloroform is produced from 
 alcohol by the action of chlorinated lime, from alcohol by an alka- 
 line hydrate, or, of late years, chiefly by the distillation of acetone 
 with chlorinated iime. 
 
 Chloroform is a heavy, clear, colorless, volatile and diffusible 
 liquid with an ethereal, penetrating odor, and a burning taste. Its 
 sp. gr. should not be below 1.490 at 15 C (59 F.). It is volatile 
 even at low temperatures, and boils at 60 to 6i° C. (141 to 141. 8° 
 F.). It is not inflammable, but its heated vapor burns with a 
 greenish flame. 
 
 Chloroform has marked solvent properties. It is soluble in 200 
 times its volume of cold water, and in all proportions in alcohol, 
 ether, benzol, benzin, and in fixed and volatile oils. It is liable to 
 decomposition by sunlight, and even by diffused daylight, hence 
 should be kept in well-stoppered, colored glass containers. 
 
 Chloroform may contain alcohol and ether, both of which lower 
 its sp. gr. If its density is less than 1.38 it will float instead of 
 
126 CHLOROFORM 
 
 sinking in a mixture of equal weights of concentrated sulphuric 
 acid and water after it has cooled. 
 
 Absolutely pure chloroform is liable to decomposition, and a 
 small amount of alcohol is necessary to preserve it. It is said that 
 one-tenth of one per cent, is sufficient. It is claimed that when 
 purified by Pictet's freezing process the presence of alcohol is not 
 necessary to the preservation of chloroform. 
 
 There has been much discussion in regard to the presence of 
 impurities in chloroform and their relation to dangerous symptoms 
 or fatal conditions arising during the use of chloroform as an an- 
 aesthetic. There is no definite knowledge on this point, and as 
 such symptoms and conditions arise from the use of chloroform 
 of known absolute purity, it is not possible to be explicit in this 
 connection. 
 
 Chloroform should have the sp. gr. and boiling point already 
 mentioned. It should be transparent and colorless. It should be 
 absolutely neutral to test-paper and its odor should be non-irritat- 
 ing. 
 
 If alcohol be present in chloroform it may be detected, accord- 
 ing to M. Mialke, by dropping small quantities of chloroform 
 into distilled water. If the chloroform is pure it remains trans- 
 parent at the bottom of the glass, while if only a small per cent, 
 of alcohol is present the globules will be milky. Soubeiran ad- 
 vised the agitation of chloroform and almond oil in a tube, when, 
 if pure, the chloroform remains clear, while with 5 or 6 per cent, 
 of alcohol it becomes milky. 
 
 The following official tests may be used : Pour 20 c. c. of chlo- 
 roform on clear, odorless filter paper laid flat on a narrow glass 
 or porcelain plate. Rock gently until chloroform is entirely evap- 
 orated. No foreign odor should remain, and the paper should be 
 nearly odorless as compared with new, odorless filter paper ; shake 
 10 c. c. of chloroform with 20 c. c. of distilled water and allow 
 complete separation. The water should be neutral to litmus paper 
 and should not be affected by silver nitrate test-solution (absence 
 of chlorides), or by potassium iodide test-solution (absence of 
 chlorine) ; place about 5 c. c. of chloroform in a test tube with a 
 capacity of about 10 c. c.,add about 4 c. c. of perfectly clear barium 
 hydrate test-solution without agitation, cool the test-tube and set 
 aside in a dark place for six hours. No film should be visible 
 
CHLOROFORM 127 
 
 at the line of contact of the two liquids (absence of products of 
 decomposition in chloroform which may otherwise be pure). 
 
 There are other tests and methods of purification which are 
 not necessary to consider here, as reliable manufacturers now fur- 
 nish a pure article of chloroform. 
 
 Physiological effects and action. — The inhalation of chlo- 
 roform vapor is not as unpleasant as the inhalation of ether. Its 
 odor is rather agreeable than otherwise, while the taste is pun- 
 gent and sweetish. 
 
 During the first stage there is little sense of suffocation un- 
 less the vapor be too concentrated. Swallowing, choking, and 
 holding the breath usually do not occur unless the vapor be strong 
 enough to irritate the larynx. There is a general feeling of warmth 
 and exhilaration, pressure and fullness in the head, noises in the 
 cars and similar effects common to the initial stage of anaesthesia 
 by other agents. The breathing is somewhat deeper and quicker. 
 The pulse is quickened and full. The pupils are usually some- 
 what dilated. The first stage is short compared with that of ether- 
 ization, and may be devoid of symptoms other than the deeper, 
 quicker breathing, and the more rapid pulse. 
 
 The second stage is marked by flushed or pale countenance, 
 irregular, jerky respiration, a greater or less degree of excite- 
 ment, especially in muscular, alcoholic, nervous or hysterical sub- 
 jects. Talking, shouting, swearing, gesticulating, attempts to 
 rise, movements of the arms and legs, holding of the breath, etc., 
 are not uncommon. The patient may be easily aroused at this 
 period, though sensibility to pain is decidedly lessened. The 
 sense of taste and smell are abolished, though that of touch may 
 remain. The sense of sight may be abnormally acute or may be 
 subject to illusions. In some cases none of these symptoms are 
 present, and the patient passes gradually and gently on to com- 
 plete unconsciousness. Muscular rigidity may or may not be 
 marked. It is most frequent in muscular or alcoholic subjects. 
 Tonic or clonic spasm may occur. Fine tremor is rare. Holding 
 the breath, tonic or clonic spasm may occur from too rapid ad- 
 ministration. Struggling or excitement, on the other hand, may 
 result from too rapid administration. A proper medium may di- 
 rect the patient on to the quiet, easy, snoring respiration of full 
 anaesthesia. In exceptional cases the respiration is rapid and deep 
 
128 , CHLOROFORM 
 
 throughout this stage. There may be loud stertor, which, how- 
 ever, does not indicate deep anaesthesia. The pulse varies greatly. 
 It may be very slightly accelerated, regular and soft. Again, it 
 may be rapid. The rate, regularity and fullness of the pulse de- 
 pend largely on the conditions arising during the administration. 
 Interference with respiration from any cause, coughing, vomit- 
 ing, etc., will produce variations in the pulse. The pulse may 
 become quite small and feeble and slow just preceding the act of 
 vomiting. Syncope may occur from vomiting. The probability 
 of its occurrence and its dangers are less in vigorous subjects. 
 The pupils are usually more or less dilated, and react slowly or 
 not at all to light. They may be moderately or decidedly con- 
 tracted Movements of the eyeballs may occur from spasm. 
 Nystagmus may be present. 
 
 The respiration, instead of gradually acquiring the regular 
 character of full anaesthesia, may become shallow or imperceptible, 
 and be accompanied by pallor and feeble pulse. Hewitt considers 
 this condition a result of too sparing administration and an in- 
 dication of a tendency to vomit, and that it could be obviated by 
 a careful continuance of the anaesthetic. In some instances this 
 is probably the case, and in others these symptoms are indications 
 of failing respiration. In some cases, especially in children, there 
 may be all the appearances of complete anaesthesia and yet sensa- 
 tion may not be abolished. This is liable to occur if a patient is 
 kept for some time under chloroform before operation is begun, 
 and under these conditions dangerous, reflex, respiratory spasm 
 or cardiac syncope may develop. 
 
 In some cases the patient may not exhibit the respiratory or 
 other signs of complete anaesthesia, may answer direct questions, 
 repeat words, or even have an indistinct realization of what is 
 going on and yet be sufficiently insensible to pain as to submit to 
 operation without complaint. The corneae at this time may be 
 insensitive, though the lid-reflex can generally be obtained. 
 
 The third stage of chloroform anaesthesia is usually marked 
 by regular, soft, slightly snoring respiration. The face may be 
 slightly flushed or pale. Pallor may be shown if there is a tend- 
 ency to vomit. Slight obstructive interference with breathing 
 may cause slight cyanosis. Usually cyanosis is absent, as plenty of 
 air is allowed during this stage of the administration. The face 
 
CHLOROFORM 129 
 
 usually becomes pale after the administration has been continued 
 for some time. There is usually complete muscular relaxation. 
 Rigidity at this stage is rare. There is slight reduction of the 
 body temperature. The secretion of mucus and saliva is rarely 
 sufficient to cause annoyance. The eyeballs may be fixed in the 
 horizontal plane or may be slowly movable. As a rule the move- 
 ments are not co-ordinate. Loss of associated movement may be 
 an indication of complete anaesthesia. The pupils are usually con- 
 tracted. They are decidedly smaller than the ether pupil, meas- 
 uring on the average, according to Hewitt, 2-J' mm. They are 
 more or less responsive to light, and react to the anaesthetic. A di- 
 lated pupil may indicate returning consciousness or may indicate 
 increasing narcosis. The lid-reflex, as a rule, is absent, though 
 there may be exceptions to this rule. 
 
 The pulse is generally well sustained under properly conducted 
 administration. It is slower than under etherization, as a rule, 
 and may be at the normal rate or even considerably less. The 
 pulse tension is diminished, and in weak subjects the pulse may 
 be feeble or almost imperceptible, though here the pulse is usually 
 stronger during deep anaesthesia than during the second stage. 
 Retching, vomiting, and respiratory disturbances affect the pulse, 
 causing it to become more feeble and sometimes irregular. A 
 markedly slow pulse may indicate too deep anaesthesia. A nor- 
 mally slow pulse will usually continue slow under deep anaesthesia. 
 Kappeler states that in twenty patients of various ages the de- 
 cline in pulse rate varied from four to thirty beats per minute. 
 There is a more or less rapid and maintained fall of blood pressure. 
 
 In some cases the respiration, while satisfactory, will be quiet 
 and inaudible. There may be loud stertor, especially in plethoric 
 subjects, if the anaesthetic be pushed. Inspiratory, laryngeal 
 stridor may be present. The breathing generally is more quiet, 
 iess deep, and its general character less evident than with ether, 
 therefore it is not as reliable a guide under chloroform as under 
 ether anaesthesia. 
 
 The toxic effects of chloroform inhalation are shown by 
 marked pallor, cold perspiration, feeble or imperceptible pulse and 
 very shallow respiration. The respiration may stop suddenly or 
 gradually. The pulse may show signs of failure before it ceases, 
 or an apparently good pulse may stop suddenly without warning. 
 
13° CHLOROFORM 
 
 The pulse usually stops before respiration ceases, or at least be- 
 comes affected before respiration. Death may occur soon after 
 the beginning of the inhalation, and at that time is probably due 
 to paralysis of the cardiac ganglia, which for unknown reasons 
 may be abnormally susceptible. Death may occur in the stage 
 of muscular rigidity which precedes complete muscular relaxation, 
 and be due to tetanic rigidity of the respiratory muscles, interfer- 
 ence with the pulmonary circulation, and venous engorgement of 
 the right side of the heart, respiration ceasing before the heart. — 
 Richardson's epileptiform syncope. This difficulty is not so liable 
 to arise under chloroform as under the open methods of etheriza- 
 tion. Death may occur from respiratory paralysis during the 
 stage of relaxation, though this is not common from chloroform. 
 Cardiac paralysis may occur during complete insensibility from 
 paralysis of the motor ganglia. The heart suddenly stops, respira- 
 tion continuing for a short time. General depression from the 
 anaesthetic, plus surgical shock or the shock of accident, may 
 result in death at the time of the inhalation or afterward. 
 
 The physiological action of chloroform is more energetic 
 and prolonged upon protoplasm than is that of ether. Waller's 
 estimate of the relative toxicity of ether and chloroform upon 
 isolated nerves is as i : 7. Locally, the action of chloroform is ir- 
 ritant. It destroys the contractility of muscle tissue, causing 
 ''chloroform rigidity." It produces structural changes in muscle 
 tissue (Bernard). It is solvent to the essential ingredient of 
 nerves and nerve centers (Brunton). 
 
 The subcutaneous injection of chloroform has a local anaes- 
 thetic effect, but owing to slow absorption and free elimination 
 general anaesthesia is not produced. The latter state may be pro- 
 duced by intravenous injection. Snow has calculated that the 
 blood of the adult necessarily contains from 12 to 24 minims of 
 chloroform, according to the degree of anaesthesia, and for the 
 arrest of respiration 36 minims are necessary. It has been found 
 that with atmospheres containing from 2 to 4 per cent, of chloro- 
 form there is little risk, but with above 5 per cent, there are alarm- 
 ing symptoms. 
 
 The respiratory center is first stimulated by chloroform, this 
 is followed by depression and finally by paralysis. The depress- 
 ing effect of chloroform on respiration is more marked on expira- 
 
CHLOROFORM 131 
 
 tion than on inspiration. Beside the toxic effect of chloroform 
 on the respiratory center, we have to consider, in respiratory fail- 
 ure from chloroform toxaemia, the additional factors of loss of 
 blood pressure from cardiac depression, and the effect of obstruct- 
 ive interference with respiration. 
 
 In regard to the respiratory interchange of gases under chlo- 
 roform, there is less oxygen absorbed and less carbonic acid ex- 
 haled, though according to some observers there is increase in the 
 amount of the latter. 
 
 The blood changes due to chloroform are not definitely under- 
 stood. It is generally conceded that there is diminution in the 
 capacity of the blood to absorb oxygen and to give off carbonic 
 acid. Also that there is some degree of disintegration of the red 
 blood cells. 
 
 The effect of chloroform on the blood-pressure and heart has 
 received much attention, which has resulted in diverse opinions. 
 The Committee of the Royal Medical and Surgical Society, Gas- 
 kell and Shore, and MacWilliam in some instances, found a pri- 
 mary rise, followed by a fall, in blood-pressure. The Glasgow 
 committee found a fall in blood-pressure, while Wood and Hare 
 found an initial fall, followed by a rise, in blood-pressure. Most 
 observers agree that the fall of blood-pressure is due to the effect 
 of chloroform on the heart and not to its effect on the vaso-motor 
 center. 
 
 The effect of chloroform on the heart itself has caused much 
 discussion. The views of the Hyderabad commission to the ef- 
 fect that not only was the primary fall in blood-pressure due to 
 the effect on the vaso-motor center, but that the heart was never 
 primarily affected, is generally disregarded at present. The ob- 
 servations of Wood and Hare, Gaskell and Shore, Hill and Bar- 
 nard, MacWilliam, and others, tend to show that chloroform di- 
 rectly depresses the heart, and that when respiration ceases before 
 final stoppage of the heart the primary depression of the heart's 
 action is the essential and probably the initial factor in death 
 from chloroform. Experiments on animals show that chloroform 
 produces dilatation of the heart. Physiologists claim that reflex 
 temporary inhibition of the heart by irritation of the nerve end- 
 ings in the upper respiratory tract by chloroform is not gen- 
 erally dangerous, and may even be in a sense conservative. Phys- 
 
1 32 CHLOROFORM 
 
 iologists also state that chloroform injected into the veins de- 
 presses the heart, and injected into the carotid arteries causes 
 paralysis of the respiratory and vaso-motor centers. Hill has 
 shown that when a chloroformed subject is changed from a hor- 
 izontal to an upright position there is a greater fall in arterial 
 pressure than would occur without chloroform. This has a direct 
 bearing on the question of posture, and the moving of chloro- 
 formed subjects. 
 
 Salivary secretion is usually slightly increased during the early 
 stage of chloroform inhalation and diminished during deep an- 
 aesthesia. 
 
 Chloroform affects the kidney action much less than ether. 
 The kidney secretion is generally fair unless there is marked de- 
 pression of the circulation. Albuminuria is rare except after pro- 
 longed narcosis. 
 
 The repeated administration of chloroform to animals pro- 
 duces fatty changes in various organs and tissues. 
 
 After death from chloroform the heart will usually be found 
 somewhat dilated and the right cavities full of blood, the left side 
 being comparatively empty. If death has occurred after a gradual 
 administration without any asphyxial element, the heart may be 
 relaxed and empty, and the lungs not especially congested. If 
 death occur after marked asphyxial conditions there will be 
 marked congestion of the lungs, overdistention of the right heart, 
 with but little blood in the left side. In cardiopathic subjects death 
 may occur before marked alterations, due to the administration, 
 take place. If arrest of respiration occurs during or at the end 
 of inspiration the lungs will contain more blood than when such 
 arrest occurs during expiration (Hill). According to Kunkel, the 
 heart arrested by chloroform always stops in diastole. Various 
 observers state that the blood after death from chloroform is of a 
 deep cherry color, and more fluid than usual. According to Fran- 
 kel and others, the tissue elements of the heart, liver and kidneys 
 undergo coagulation necrosis, and there are deposits of pigment 
 in the parenchyma of the kidneys and liver. 
 
 The after effects from chloroform inhalation vary consid- 
 erably, according to the nature of the administration and the char- 
 acter of the symptoms during the period of inhalation. When 
 the administration has been properly and carefully conducted and 
 
CHLOROFORM 1 33 
 
 the subject has taken the anaesthetic without difficulty, the re- 
 covery will be uneventful, the patient passing into a quiet sleep, 
 possibly preceded by slight retching or vomiting. If the chloro- 
 form has been exhibited with too much conservatism or there 
 has been unpleasant manifestations during its inhalation, there 
 may be marked pallor, weak pulse, nausea, or vomiting. Gastric 
 disturbance is more frequent after ether than after chloroform, 
 but the vomiting of the ether is more transient and less liable to 
 recur than that occurring after chloroform. Severe and prolonged 
 vomiting is more common after chloroform. Depression of the 
 circulation is a more common after effect from chloroform than 
 from ether. 
 
 Bronchial inflammation and pneumonia are rare after chloro- 
 form, though they may occur in predisposed subjects. Mental 
 disturbances may occur in predisposed subjects. Jaundice may 
 be a rare after-effect. Some observers have claimed that albu- 
 minuria is frequent after chloroform, but this is not generally 
 conceded. L. G. Guthrie believes that a condition similar to acute 
 yellow atrophy of the liver may be a fatal after-effect in children. 
 
 The dangers arising during chloroform administration 
 may be due to the toxic action of the drug, or may be such as arise 
 during the administration of any anaesthetic. More or less dan- 
 ger may result from obstruction of the breathing, from nervous 
 arrest of respiration in excitable subjects, or from obstruction 
 due to spasm, swelling of the upper respiratory tract, or ob- 
 structive interference of the tongue, though such causes are in- 
 frequent under chloroform. Spasm of the respiratory muscles, 
 foreign substances in the air tract, as enumerated under ether 
 (p. 122), may cause danger. Vomiting is not frequent, but dan- 
 gerous vomiting is relatively more frequent under chloroform 
 than under ether. Interference with lung expansion from tight 
 clothing, the posture, morbid states, respiratory spasm, and inter- 
 ference with lung expansion through operative measures may 
 cause danger. Paralytic arrest of breathing may occur from too 
 large a dose of the anaesthetic, from reflex inhibition from oper- 
 ative measures, from cerebral anaemia, and it is claimed in part 
 from morphine administered previous to inhalation. 
 
 Failure of the circulation may result from such predisposing 
 causes as morbid conditions of the heart, lungs, blood, renal dis- 
 
134 CHLOROFORM 
 
 ease, mental disturbance, sitting posture, food in the stomach, or 
 from respiratory embarrassment from various causes, vomiting, 
 the operation, or from the effect of chloroform on the heart and 
 vascular system. 
 
 The clinical evidence regarding chloroform gathered by the 
 Anaesthetics Committee of the British Medical Association (1900) 
 is to the effect that chloroform is about twice as dangerous in 
 males as in females ; it is most dangerous during infancy, and least 
 dangerous from the tenth to the thirtieth years ; chloroform is the 
 most dangerous anaesthetic in conditions of good health, and while 
 least safe in grave conditions, the disparity here is less marked. 
 When danger occurs from chloroform, in the large proportion of 
 cases the symptoms are of primary circulatory failure. Imperfect 
 anaesthesia is the cause of danger in a large number of cases. 
 Hewitt calls attention to the important fact that a large propor- 
 tion of the conditions of danger during chloroform administration 
 are not connected with an overdose, relatively speaking, of the 
 anaesthetic. He finds that of 130 chloroform deaths reported in the 
 Lancet, and British Medical Journal, from 1880 to 1889, inclu- 
 sive, 54 took place very early, either before operation or during 
 short or trivial operations. Comte collected 232 cases of death. 
 The time of death was specified in 224 instances, and in 50 per 
 cent, occurred before anaesthesia was complete. Hewitt combines 
 101 cases given by Kappeler and 109 cases reported by the Com- 
 mittee of the Royal Medical and Chirurgical Society in 1864, and 
 finds that the time of death was specified in 75 cases, in 90 per 
 cent, of which death occurred within the first fifteen minutes. 
 The report of the Anaesthetics Committee of the British Medical 
 Asssociation (1900) gives 13,393 chloroform cases in which com- 
 plications of some degree arose in 3.270 per cent. There were 
 120 dangerous cases, with 18 deaths. The combined statistics 
 of Gurth, of Berlin, and Juillard, of Geneva, give 691,329 cases of 
 chloroform inhalation, with 224 deaths. Chloroform is generally 
 regarded as being about five times as dangerous as ether. 
 
 There are various factors which constitute a source of danger 
 during chloroform inhalation besides the toxic action of the drug 
 itself. Psychical causes may contribute towards danger or death 
 early in the administration. Cases have been reported by various 
 observers of death apparently due to fright alone before the ad- 
 
CHLOROFORM 1 35 
 
 ministration had begun. It is a fact, however, that the cases of 
 "fright syncope" are practically limited to cases where chloroform 
 was employed, and we must therefore regard psychical influences 
 as merely a more potent contributory cause under chloroform than 
 under other anaesthetics. Reflex cardiac inhibition from the effect 
 of concentrated vapor on the mucous surface of the upper res- 
 piratory tract was a favorite theory of French observers as to the 
 cause of early manifestations of danger. It is not generally ad- 
 mitted that this cause is effective. Holding the breath, laryngeal 
 spasm, and asphyxial conditions from irritation by the vapor are 
 probably rare, being in most instances due to obstruction or to the 
 effect of the agent on the respiratory center or on the muscles of 
 respiration. It is generally believed that shock due to the com- 
 mencement of operation may produce dangerous or fatal syncope. 
 Hewitt believes that such a cause rarely is fatal, if ever, and calls 
 attention to the fact that skin incisions under light anaesthesia al- 
 most invariably stimulate both respiration and circulation. Never- 
 theless, many observers have found signs of collapse coincide with 
 the beginning of operation. 
 
 In the list of fatal chloroform cases given in the report of the 
 British Medical Association Committee already alluded to there 
 are some instances where the pulse and respiration failed either 
 coincidently or successively at the moment of the beginning of 
 operative procedures. 
 
 Reflex arrest of respiration from spasm is more likely to occur 
 under chloroform during surgical measures than with other an- 
 aesthetics. Vomiting may cause depression of the heart and pos- 
 sibly fatal syncope. Dangerous vomiting during anaesthesia is 
 said to be more frequent under chloroform than other anaesthetics. 
 Epileptiform spasm may be dangerous, especially in muscular sub- 
 jects. Clonic spasm is not uncommon early in the administration, 
 which may indicate a need for more anaesthetic. Clonic move- 
 ments of the arms and pectoral muscles indicate a necessity for 
 more air (Hewitt). Laryngeal spasm, shown by high-pitched 
 inspiratory stridor, may occur during anaesthesia by chloroform, 
 apart from the local effect of the drug as a cause. It is thus more 
 common under chloroform than under ether, and represents a 
 dangerous degree of anaesthesia. 
 
 Pathological states, posture, idiosyncrasy on the part of the 
 
I36 CHLOROFORM 
 
 patient, and late surgical shock may all be factors in the produc- 
 tion of dangerous symptoms. 
 
 Chloroform toxaemia from an overdose may result through too 
 concentrated vapor, exaggerated breathing of vapor not unusually 
 concentrated, and through some unusual susceptibility on the part 
 of the subject. The result may be simultaneous stoppage of both 
 pulse and respiration, or the pulse at the wrist may stop before 
 respiration ceases, or the pulse may be still perceptible when res- 
 piration ceases. In pure chloroform toxaemia the respiration 
 ceases before the heart action. We may not be able to feel the 
 radial pulse or even to hear the heart beat if the lungs are full of 
 air. This does not prove, however, that the heart has actually 
 stopped. The failure of heart action is the primary and essential 
 feature of death from chloroform toxaemia. If this condition 
 should supervene upon a carelessly rapid administration, death 
 may come too suddenly to allow of any recognition of the se- 
 quence of the symptoms. Toxic conditions following a more 
 gradual administration show shallow, slow, gasping, jerky or ir- 
 regular respiratory action with cessation of abdominal and tho- 
 racic movements. The symptoms which indicate the approach of 
 toxsemic conditions are : impaired respiration, slow, feeble pulse, 
 becoming irregular and often imperceptible ; no lid-reflex ; separa- 
 tion of eyelids ; upturned eyeballs ; considerable or marked dila- 
 tation of the pupils ; marked pallor of skin. 
 
 Deaths from chloroform are marked by sudden heart failure 
 following upon respiratory interference, which may in some in- 
 stances be comparatively slight ; and by toxaemic conditions of the 
 cardiac nervous mechanism, or possibly in some degree of the 
 myocardium itself. 
 
 For the administration of chloroform the patient should be 
 in the recumbent position ; the sitting position should not be used 
 if it can be avoided. The patient should not be moved or the 
 position changed after administration is begun unless absolutely 
 necessary. The patient should be reassured, informed as to the 
 nature of the sensations produced by the inhalation, and instructed 
 how to breathe. 
 
 The administration of chloroform may be conducted by ad- 
 ministering the vapor of chloroform with air or with oxygen. 
 The latter method was introduced by Neudorfer, of Vienna, who 
 
CHLOROFORM 
 
 l 2>7 
 
 administered mixed oxygen and chloroform vapor through a 
 closely fitting face-piece. Junker's inhaler has also been used by 
 pumping oxygen from a bag attached to the hand bellows through 
 the chloroform. This method of administering chloroform has 
 not been much used and is of doubtful advantage.* 
 
 The toxic nature of chloroform demands that it should be ad- 
 ministered with plenty of air, and that any method or apparatus 
 employed for its administration should afford ample facility for 
 the admission of plenty of air at a moment's notice. Simpson, 
 who introduced chloroform as an anaesthetic, used a handker- 
 chief folded in a cup-shape, into the hollow of which a small 
 amount of chloroform was poured. ' Later he employed a folded 
 cloth or towel, and still later a single layer of cloth laid over the 
 patient's mouth and nose, upon which the chloroform was dropped. 
 This method corresponds to the drop method used with the Es- 
 march or Skinner mask, so widely in use at the present time. 
 
 Snow's experiments with definite amounts of chloroform vapor 
 led him to devise an inhaler by which the percentage of chloro- 
 form vapor could be regulated at about 4 or 5 per cent. Clover 
 
 Fig. 33.— Junker's Inhaler. 
 
 Fig. 33. An anaesthetic bottle (a), which is connected by rubber tubes 
 to the face-piece (b), and an air bellows (c), to the latter of which is 
 attached an equalizing rubber ball (d), covered with netting, to prevent 
 over-distension. 
 
 The anaesthetic bottle is graduated, so that the amount of the anaes- 
 thetic consumed is known. To the stopper of the bottle there is a hook 
 attached, by which it may be hung from the anaesthetist's coat. 
 
 *Flux, of London, has devised a modification of the Junker inhaler. 
 A cylinder contains wadding upon which chloroform is poured. A bulb 
 aspirates air through the wadding and drives it through a tube connected 
 with a nose or mouth tube. An opening in the cylinder will admit air to 
 dilute the chloroform vapor if desired. It is portable and convenient. 
 
138 CHLOROFORM 
 
 also devised an inhaler which would give from 3J to 4J per cent, 
 of chloroform vapor. Many other inhalers have been devised 
 along these lines. They have the objection of a closely fitting face- 
 piece, which adds to the dangers of producing complete anaesthe- 
 sia by their use. The Junker inhaler, which has been much em- 
 ployed, especially in England (Fig. 33), consists of a bottle to 
 contain chloroform, a loosely fitting face-piece, a hand bellows, 
 and tube connections. Air is pumped through the chloroform in 
 the bottle and into the face-piece, carrying with it an indefinite 
 percentage of chloroform. A cloth mask may be used instead of 
 the ordinary leather or vulcanite face-piece, which will allow of 
 dropping chloroform on the mask if a more concentrated vapor is 
 necessary. The Junker inhaler is not a safe inhaler for children, 
 and though when carefully used it may lessen the risks from 
 chloroform inhalation, several deaths have occurred under its use. 
 Hewitt has modified the Junker inhaler to some advantage. Such 
 an apparatus as the Junker may be very useful in operations about 
 the mouth, nose, or pharynx, where, especially if the actual cautery 
 is to be used, ether is not available. In these operations the vapor 
 may be introduced through a nose or mouth-tube, such as Hewitt's 
 modification of Mason's gag. In such operations the advantage 
 of such inhalers is most evident. In ordinary surgery they de- 
 mand too much attention, the constant pumping is troublesome, 
 asphyxial conditions are as liable to arise as with other methods 
 of administration, and in some cases profound anaesthesia cannot 
 be induced. 
 
 Many kinds of inhalers have been devised. There are combi- 
 nation inhalers, like the Packard inhaler or the Bennett inhaler, that 
 may be used for either gas, ether or chloroform ; or inhalers like 
 Hiddens' that are only suitable for chloroform.* 
 
 That the simplest method of administration is the best is a 
 more forcible truth in relation to chloroform than any other an- 
 aesthetic, for the reason that any inhaler other thaxi the very sim- 
 plest is objectionable. The method which will produce a satis- 
 factory analgesia with the least amount of chloroform is the best, 
 and this can undoubtedly be accomplished by the drop method 
 on a mask or a single layer of cloth or lint. This is practically 
 the method of Simpson, improved. Simpson at first considered 
 chloroform as a perfectly safe anaesthetic, and recommended it to 
 
 *In England the Harconrt Chloroform Inhaler is much used, while in 
 Germany the Braun Chloroform Inhaler is popular. In France the Gig- 
 liementi Oxygen-Chloroform Inhaler is used. These inhalers represent 
 late advances in the accurate administration of anaesthetics. 
 
CHLOROFORM 
 
 139 
 
 be used "powerfully and speedily," in order to avoid excitement. 
 Later he modified his method more in accordance with present 
 usage. 
 
 The difficulty of estimating the percentage of chloroform in- 
 haled in this method has been considered its weak point. Snow, 
 who estimated that the inhaled vapor should not exceed a strength 
 of 5 per cent., calculated that 9.5 per cent, might be given off 
 from a folded cloth wet with chloroform at 70 F. Lister esti- 
 mated that a moistened cloth held close to the face gave off but 
 4.5 per cent. Sansom claimed that at 60 to 64 F. it was possible 
 to inhale 13 per cent, of vapor with but one dram of chloroform 
 poured upon lint. That it is practically impossible to estimate 
 the percentage of vapor inhaled is evident when we consider the 
 nature of the fabric used, the number of its folds, the extent of 
 
 Fig. 34. — Esmarch's Inhaler. 
 
 Fig. 34. A simple with frame shaped to fit the contour of the face 
 around the mouth and nose; one end of the frame is curved to form a 
 handle by which the apparatus may be held in place. Over this framework 
 is stretched a knitted or woven fabric, the texture of which is of such a na- 
 ture as to admit of the free passage of air. The chloroform may be 
 dropped upon the mask from a small flask containing a cork through which 
 a suitable drop tube is passed. This tube reaches nearly to the bottom of 
 the bottle and is curved so that all of the chloroform in the container may 
 be dropped from the tube. The mouth of this drop tube is closed by a 
 suitable cap that the chloroform vapor may not escape from the flask when 
 not in use. Air to replace the chloroform is admitted by a second tube 
 also passing through the cork. 
 
140 . CHLOROFORM 
 
 surface wet with chloroform exposed to the air, the proximity of 
 the fabric to the patient's mouth and nose, the temperature of the 
 air, the movement of air about the inhaler, and the rate and force 
 of the patient's breathing. That Lister recognized the uncertain 
 element of a large surface of several folds of cloth is shown by 
 his adoption of the method of drawing the corner of a towel 
 through a safety-pin in such a way as to form a cup-shaped in- 
 haler, practically the same as the Esmarch inhaler.* 
 
 With any inhaler which embodies the principles of the mask, 
 or the drop method, it is possible to graduate the percentage of 
 
 Fig. 35.— Skinner's Mask. 
 
 vapor inhaled so as to secure the most effective narcosis with the 
 least element of danger, and with a comparatively small amount 
 of chloroform. 
 
 A thin napkin, a piece of lint, or a single layer of a moderately 
 heavy handkerchief may be stretched across the separated thumb 
 and forefinger of the administrator and held close to the sub- 
 ject's mouth, or it may be laid across this and a space an inch and 
 a half square kept moistened with chloroform. A corner of towel 
 drawn through a safety-pin makes a very convenient mask for in- 
 halation. The Esmarch inhaler (Fig. 34) may be used with a 
 single layer of gauze, cotton cloth, or flannel, but in very warm 
 weather it is well to have a heavier material or two layers of light 
 cloth. The Skinner mask (Fig. 35) is a similar form of inhaler. 
 In using lint Hewitt recommends making a concave fan-shaped 
 mask by folding once over a piece of lint 11 inches long by 7 
 inches wide so that when folded it measures 7x5^ inches. Pinch 
 
 *A discussion before the Brit. Med. Ass. (1904) developed the follow- 
 ing conclusions: (1) That the best way to insure safety during chloro- 
 form anaesthesia is by continuous inhalation of a low per cent, vapor; (2) 
 that in most instances a 2 per cent, vapor will induce and, continue surgi- 
 cal anaesthesia; (3) that after the first incision the percentage can be 
 lowered with safety and advantage. An absolutely satisfactory method of 
 controlling the percentage of chloroform vapor has not yet been devised. 
 
CHLOROFORM 
 
 I 4 I 
 
 Fig. 37.— Schimmelbusch-Esmarch Inhaler. 
 
 Fig. 36.— Pierepont' Folding Chloroform 
 Inhaler. 
 
 Fig. 39.— Hahn's Drop Bottle. 
 
 Fig. 38.— Plain Ether Drop Bottle 
 
142 
 
 CHLOROFORM 
 
 Fig. 40. — The Gwathmey vapor-inhaler. 
 
 Fig. 40. This inhaler was devised by Gwathmey, of New York, for the 
 purpose of administering a known percentage of vapor. Chloroform or 
 ether may be given singly or combined in any proportion, and oxygen or 
 air may be added or subtracted as desired, with or without change in the 
 percentage of anaesthetic. The mask is identical with the Esmarch mask. 
 Jt fits the face correctly, and has a hollow rim to allow the vapor to es- 
 cape. The mask is covered with four layers of gauze, over which is a layer 
 of oiled silk or rubber tissue. A small opening is cut in the center so 
 that during induction a few drops of chloroform can be added if desirable, 
 as with vigorous alcoholics. 
 
 The inhaler gives a maximum of two per cent, vapor, with a minimum 
 of one-tenth per cent. It consists of three ounce-bottles, each of which 
 contains four tubes of different lengths. These tubes represent four de- 
 grees of vapor strength. The mask not being air tight prevents the pos- 
 sibility of an overdose. 
 
 The advantages claimed are : a pleasant induction stage, absence of a 
 stage of excitement, a normal pulse rate, no disturbance of respiration, 
 no throat or bronchial rales, complete muscular relaxation, absence of after 
 effects, a chloroform vapor of known percentage with attenuated air and 
 oxygen, to which attenuated ether vapor may be added if desirable, also 
 the possibility of changing the vapor percentage with the same flow of 
 oxygen or air. 
 
CHLOROFORM j^? 
 
 up the free double edge between the fingers and run a safety-pin 
 through the gathered edge. 
 
 In using the drop method and mask inhaler one may employ 
 the graduated 2-ounce bottle with spring stopper arrangement 
 for dropping the chloroform (Figs. 38, 39), or, if this is not at 
 hand, an ordinary 2-ounce bottle may be used. A longitudinal 
 trough is cut in the cork of a sufficient depth and width to ac- 
 commodate a couple of strands of cotton twine, which should be 
 long enough to reach well into the bottle and a couple of inches 
 outside. When the bottle is tightly corked the cotton acts as a 
 wick and the chloroform can be shaken from the end of the string 
 or the string can be trailed across the mask, thus supplying the 
 chloroform as fast as may be desirable. In some instances it is 
 necessary to administer an anaesthetic through a tracheal opening. 
 For such cases Annandale uses a full-sized tracheotomy tube, with 
 its upper end extended one-half inch above the shield (Fig. 41). 
 It is fitted with a cap having a right-angled tube connection, which 
 may be connected by a rubber tube with a glass containing the 
 chloroform or ether upon some cotton wool. Chloroform is the 
 agent preferred. The chloroform is held directly over the mouth 
 of the tube until the patient is anaesthetized. The cap is then 
 placed on the tube and connected with the rubber tube and the 
 administration continued. 
 
 In administering chloroform the mask should not be held 
 close to the face at first, and only a few drops of chloroform 
 should be used, but after the first few inhalations the mask should 
 be brought closer and its surface kept wet. If there is chok- 
 ing, coughing, or holding the breath the mask may be lifted but 
 not entirely withdrawn. The administrator should endeavor 
 to maintain the happy medium between too much and too little 
 chloroform. If too little is given, coughing, swallowing, holding 
 the breath, struggling and vomiting may occur, and may be 
 prevented by more chloroform. With some subjects it may be 
 necessary to keep the mask wet most of the time, especially in 
 vigorous or alcoholic patients. In children much less will usu- 
 ally be required. The average quantity for an ordinary adult 
 will be from 10 to 16 drachms for the first hour, and less as the 
 administration lengthens. 
 
 It has been claimed that syncope is liable to occur from too 
 
144 
 
 CHLOROFORM 
 
 marked intermittance in the administration. Incomplete anaes- 
 thesia appears to be associated with complications of all de- 
 grees of severity, much more so under chloroform than under 
 ether. Vomiting, which is often an evidence of incomplete chlo- 
 roform anaesthesia, may be the starting point of other compli- 
 cations of both the respiration and circulation. 
 
 It is very important that the requisite degree of anaesthesia 
 should have been reached before the operation commences, and 
 that this should be maintained during the operation. Attempts 
 to hasten the recovery from the anaesthetic by shaking the 
 patient or flipping with a towel should not be made. 
 
 Children are very sensitive to the irritations of chloroform 
 
 Annandale's Trachea Canula and Tube. 
 
 Fig. 41. A full-size silver tracheotomy-tube, with its upper end ex- 
 tended about Yz in. beyond its shield, is employed. There is a silver cap 
 having a short tube of silver projecting at right angles, and to the small 
 end of this cap a rubber tube can be connected. Fig. 41-I shows the 
 tracheotomy-tube with the cap fitted upon it. This cap can be turned to 
 either side, thus permitting the India-rubber tube to project on the side 
 which will be most convenient to the operator. India-rubber tubing of the 
 diameter of about V 2 in. is used. One end of this tube is fastened to the ap- 
 paratus ; the other end is placed in a tumbler containing a small piece of 
 absorbent wool at the bottom, upon which chloroform or ether is from time 
 to time sprinkled. The whole apparatus is shown in Fig. 41-II. Annan- 
 dale prefers to use chloroform. In beginning the administration the cap 
 is taken from the tracheal tube, and the chloroform is held directly over 
 the tube until the patient is anaesthetized, but when the time for operation 
 has come the cap is put in place and the anaesthetic is given as shown in 
 Fig. 41-I. In order to prevent blood or vomited matters entering the air- 
 passages, it may be advisable to introduce a piece of sponge into the 
 trachea above the tracheotomy-wound. 
 
CHLOROFORM j^r 
 
 vapor. They are likely to hold the breath at the beginning of 
 inhalation or after unconsciousness is reached. Very little chlo- 
 roform should be used at first, and the mask should be approach- 
 ed to the face cautiously. If the child cries the inhalation is 
 more rapid and the mask should be withdrawn immediately 
 there are indications of ceasing to cry. Immediately after the 
 crying stage children may pass into an apparent state of anaes- 
 thesia with contracted pupils, insensitive corneae, relaxed mus- 
 cles, feeble pulse, and irregular respiration. The chloroform 
 should be stopped, the lips briskly rubbed with a dry towel, and 
 the child otherwise stimulated. A little ether administered on 
 the mask may cause immediate improvement in both pulse and 
 respiration. 
 
 Children may be chloroformed while asleep by holding a 
 mask several inches above the face and allowing a drop of 
 chloroform at a time to be inhaled, approaching the mask to the 
 face very gradually. Children are favorable subjects for chloro- 
 form by reason of their freedom from diseases of the heart, 
 lungs, or kidneys. Nevertheless, chloroform is not so free from 
 danger in children as many suppose. This has been attributed 
 to the fact that their reflex action is more excitable and more 
 quickly abolished by anaesthetics. Corneal and conjunctival 
 reflexes are not, therefore, as reliable as in the adult. 
 
 As the patient comes fully under the anaesthetic the breath- 
 ing will be regular and audible with soft snoring. Swallowing 
 movements may be present, and if slight may be recognized by 
 the fingers on the larynx. They may indicate recovery from the 
 anaesthetic and a necessity for more. Absence of lid-reflex is 
 an important sign of anaesthesia, but is not as reliable a guide 
 as in etherization. Whether or not the administrator should 
 strive to keep the lid-reflex abolished will depend on the man- 
 ner in which the patient takes the anaesthetic, and on the nature 
 of the operation. In weak or elderly people, and in short oper- 
 ations it is not necessary or advisable to completely abolish lid- 
 reflex, while in robust subjects, or in abdominal operations it is 
 generally necessary to do so. 
 
 The pupils will average a greater degree of contraction than 
 with ether narcosis. A dilated pupil is a guide to returning con- 
 sciousness except when it is due to too deep narcosis. A few 
 
I46 CHLOROFORM 
 
 drops of chloroform given when the pupil is dilating from recov- 
 ery, is followed after a few respirations by contraction. The 
 delay in this action makes it important that one should be cer- 
 tain as to the cause of the dilatation before administering more 
 chloroform. If the dilatation is associated with conjunctival 
 reflex it may be taken to indicate more chloroform. If it is as- 
 sociated with absence of conjunctival reflex it may indicate less 
 chloroform until contraction or reflex appears. 
 
 The color of the face, usually somewhat flushed at the be- 
 ginning, becames more or less pale. Marked pallor is usually 
 indicative of poor circulation though this is not always the case 
 Cyanosis always indicates a need for more air. Pallor with 
 light anaesthesia may indicate the approach of vomiting. 
 
 The respiration is generally considered to be the most impor- 
 tant guide to the state of the anaesthesia. Some anaesthetists 
 claim that the respiration should be the guide first, last, and all 
 the time. The administrator should try to maintain the soft, 
 regular, snoring breathing. Withdrawal of the chloroform usu- 
 ally results in quiet, inaudible breathing, while increasing the 
 chloroform may cause increased stertor. When snoring can- 
 not be heard it may often be produced by pressing the lower jaw 
 backward. In some cases the breathing may be inaudible and 
 yet absent lid-reflex, a moderate contraction of the pupils, and 
 muscular relaxation will testify to complete anaesthesia. On the 
 other hand, in order to not mistake absence of stertor for too 
 deep anaesthesia, one must watch for slight lid-reflex, expira- 
 tory noise, swallowing, or slight tonic muscular spasm, contract- 
 ed pupil, and absence of pallor as indications of too light anaes- 
 thesia. 
 
 In some cases the amount of chloroform necessary- to obtain 
 the requisite degree of anaesthesia will produce shallow, inefficient 
 respiration with moderate cyanosis and slow, regular pulse. The 
 patient can be usually roused from this condition by friction of 
 the cheeks and lips with a dry towel. 
 
 High-pitched inspiratory laryngeal stridor may necessitate 
 withdrawal of the anaesthetic. Cheyne-Stokes breathing may be 
 present in weak subjects under deep anaesthesia and indicate a 
 too deep narcosis or a change to some other anaesthetic. 
 
 The pulse should be observed from time to time. It often 
 
CHLOROFORM 1 47 
 
 becomes weak just before vomiting. After anaesthesia has been 
 established with a regular, slow pulse, changes in the pulse, if 
 the corneal reflex is absent, are of importance. A slow, feeble : 
 pulse with absent lid-reflex indicates less chloroform. It is well 
 to observe the facial, temporal, and superior coronary pulse, as. 
 at times, a better idea can be obtained from these vessels of 
 the state of the circulation. 
 
 It has been the experience of some administrators of chloro- 
 form, that while conducting the administration in a small, illy- 
 ventilated room artificially lighted by a naked flame, they have 
 become affected with more or less severe, irritation of the air 
 passages, dyspnoea, coughing or faintness. This may affect 
 everybody in the room including the patient, but more often the 
 administrator only is the one to suffer. Zweifel has reported a 
 fatal case of bronchitis and pneumonia attributed to this cause. 
 Iterson, Fischer and others, have reported on this peculiarity o$ 
 chloroform. That the fumes are acid is apparent from the fact 
 that they may be neutralized by the liberation of ammonia in 
 the room by suspending cloths saturated with the alkali. It 
 is claimed that the irritation is due to the formation of phos- 
 gene, and hydrochloric acid gases. Breandat claims that the 
 combustion of chloroform gives rise to hydrochloric acid, and 
 an acrid and acid oil.* 
 
 The management of the complications incident to the 
 administration of chloroform. The management of the more 
 common difficulties such as excitement, spasm or movements, 
 nervous or obstructive interference with respiration, coughing, 
 hiccough, sneezing, vomiting, foreign bodies in the air passages, 
 mucus or saliva, the effects of posture, laryngeal spasm, gen- 
 eral spasm of the respiratory muscles, etc., is along the same 
 lines as when they occur under etherization (p. 121, et seq.). 
 
 Respiratory arrest from an over dose of anaesthetic usually 
 occurs gradually, the breathing becoming more and more shal- 
 low, though in some cases it may be jerky, gasping, and irreg- 
 ular. In rare instances the breathing may stop with great sud- 
 denness. Feeble, shallow respiration is not important as long 
 as the pulse and color are good and the lid-reflex is maintained. 
 When the breathing shows signs of arrest the anaesthetic should 
 be stopped, friction of the lips and cheeks used, and rhythmical 
 
 *Armand and Bertier say that this gas is manifested by a whitish 
 vapor— csrbonyl chloride or phosgene (COCI2)— a very irritating sub- 
 stance to mucous membranes, and dangerous to the patient because the 
 irritant effect is wanting. The symptoms are cyanosis and respiratory 
 syncope. 
 
I48 - CHLOROFORM 
 
 pressure of the chest or sternum made with each expiration. 
 The inhalation of oxygen is useful, though regarded indiffer- 
 ently by many. Ammonia to the nostrils, or ice in the rectum 
 may be used. Flicking the chest with a wet towel is sometimes 
 practiced. 
 
 If the respiration stops entirely as shown by cyanosis, ab- 
 sence of all movements of the thorax or abdomen and no air 
 movement from the mouth or nose, artificial respiration should 
 be resorted to at once. This is regarded by many as the only 
 means of any great promise. Sylvester's method, or Marshall 
 Hall's method may be used, the former preferred. In using 
 Sylvester's method the patient is drawn along the operating 
 table till his head is extended over its end, or he is placed cross- 
 wise on the bed in a similar position. If the patient is sitting 
 he should be laid on the floor and the shoulders sufficiently ele- 
 vated to allow of extension of the head. A mouth gag and 
 tongue traction may be used in order to be sure that no ob- 
 struction to free breathing exists. The administrator stands or 
 kneels at the patient's head and grasping his arms at the elbows 
 presses them firmly against the sides of his chest for 2 or 3 
 seconds, then brings them toward the operator, extending them 
 in the long axis of the patient's body for 2 or 3 seconds. The 
 manceuver is then repeated at the rate of about 15 times a min- 
 ute. Artificial respiration should be persisted in for sometime 
 as recovery may follow its continued employment. 
 
 Marshall Hall's method is performed by placing the patient 
 face downward on the table or floor with a pillow or folded 
 quilt under his chest and one arm under his head. He is gently 
 rolled on his side and back again about 15 times a minute, pres- 
 sure being made on his back when he is in the prone position. 
 
 There are other methods but these are most commonly em- 
 ployed. Inflation of the lungs by mouth to mouth inflation, or by 
 bellows, or by the Fell-O'Dwyer apparatus may be of benefit 
 (Figs. 42, 43). 
 
 Faradism of the phrenic nerves may be used. Duchenne 
 demonstrated its action in causing contraction of the diaphragm. 
 The electrodes may be placed over the lower end of the scale- 
 nus anticus muscle, and the outer edge of the sterno-mastoid mus- 
 cle which should be drawn inward. The current is turned on 
 
CHLOROFORM 
 
 149 
 
 for a few seconds causing contraction of the diaphragm. Ex- 
 piration may be assisted by compression of the thorax and ab- 
 domen. The application of electricity to the region of the 
 diaphragm has been effective in some cases. Respiratory fail- 
 ure from cerebral anaemia demands the same measures, to- 
 gether with inversion of the body. Drugs are of questionable 
 value in these cases, but should be used while more active meas- 
 ures are being tried, especially in those most dangerous cases 
 where the heart and respiration fail together. Strychnia is the 
 most effective drug. It is recommended by H. C. Wood in 
 these conditions as a respiratory stimulant. It should be given 
 hypodermically in doses of from one-thirtieth to one-twentieth 
 of a grain with or without brandy. 
 
 Fig. 42. — Fell's Apparatus for Lung Inflation. 
 
 Fig. 42. Fell's apparatus consists of a hand bellows connected by a 
 suitable hose with an air-control valve and face-shield. 
 
 By properly working the bellows while making finger pressure on the 
 valve, the lungs may be filled to their full capacity, after which the air is 
 permitted to escape by natural means by releasing the pressure. For the 
 next inspiration, pressure with the fingers is again, made. 
 
jcq CHLOROFORM 
 
 Depression of the circulation from general or local diseases, 
 mental states, posture, food in the stomach, vomiting, or asphyx- 
 ial causes during or after operation from spasm of the larynx, 
 etc., are managed as in anaesthesia of any kind. In failure of 
 the circulation from surgical shock or haemorrhage the head 
 and shoulders should be lowered, a hot water or alcoholic enema 
 given, strychnia injected, saline intravenous injection given, and 
 warmth to the body used. 
 
 The pulse may show primary failure suddenly or gradually. 
 When the administrator is satisfied that the trouble is primarily 
 with the circulation he should stop the anaesthetic, use friction 
 of the face and lips, partially invert the patient, use artificial 
 respiration, inject strychnia, digitalin, strophanthin, ether, etc. 
 When the circulation is so weak that there is no bleeding from 
 the wound the anaesthetic should always be stopped. If the 
 pulse is not perceptible, a mouth gag may be introduced, tongue 
 traction made, artificial respiration, partial or complete inver- 
 sion, rhythmical compression of the chest, percussion of the 
 praecordial area with the tips of three fingers about once a sec- 
 ond may all be tried. Electricity, like drugs, is of doubtful 
 value, and should be given over to an assistant, the administra- 
 tor devoting his time to posture, artificial respiration, compres- 
 sion of the chest, etc. Electricity may be applied to the region 
 
 Fig. 43. — Richardson's Double Bellows for Forced Respiration. 
 
 Fig. 43. Richardson's Double Bellows consists of two elastic bulbs, 
 to each of which a rubber tube is attached, the two terminating in a single 
 tube. The rubber bulbs are so regulated by valves that air may be forced 
 into the lungs by the compression of one and withdrawn by the compres- 
 sion of the other. When in use, the single terminal tube is introduced into 
 one nostril, the other nostril and the mouth being closed. By alternately 
 compressing %st one bulb and then the other, the respiratory current 
 may be artificially established. In actual operation this appliance has not 
 proved successful to any great extent. 
 
CHLOROFORM 151 
 
 of the apex beat, one pole being over the fourth dorsal ver- 
 tebra. In some instances remarkable results have been ob- 
 tained from inversion of the patient, and the pulse has been ob- 
 served to come and go with change in posture. Some cases 
 appear to have been utterly hopeless from the start, but resus- 
 citative measures should be persisted in until it is clear that 
 no possibility of recovery remains. 
 
 Mankowski finds, from experiments on animals, that the in- 
 jection of a 1 per cent preparation of suprarenal extract into the 
 jugular vein stimulates the heart and respiration and prevents 
 the fall of blood pressure from chloroform narcosis. Its pre- 
 liminary administration before anaesthesia has been advised. Hob- 
 day advises the use of hydrocyanic acid as a better and quicker 
 respiratory stimulant than strychnia. In animals, I mm. of 
 Scheele's acid was dropped on the back of the tongue for every 
 7 or 8 pounds of body-weight of the animal. Bernard consid- 
 ers hydrocyanic acid a dangerous antidote for chloroform. 
 
 Massage of the heart in chloroform syncope has been em- 
 ployed in a number of recorded cases. According to Kemp and 
 Gardner it was first used in the human subject by Prus, though 
 they give credit to Schaff for its introduction. Keen has em- 
 ployed it in one successful and one unsuccessful case. There 
 are three methods: (i) Compression of the heart between the 
 hands, one outside the chest, and the other directly upon the 
 heart after abdominal section but without the pericardium being 
 opened ; (2) the same, but with open pericardium, the heart being 
 seized inside the sac; (3) resection of ribs, incision of pericar- 
 dium, and seizure of the heart in both hands with rhythmical 
 compression. 
 
 These methods are necessarily extreme and their limitations 
 are not yet strictly defined. 
 
 DELAYED CHLOROFORM POISONING. 
 
 During the past few years considerable attention has been 
 given a condition of toxaemia developed after anaesthesia which 
 was recognized as long ago as 1850, by Guthrie, who said in 
 1862, "It is no longer doubted that there is such a thing as chronic 
 poisoning by chloroform — that is the drug when it does kill does 
 not always kill immediately, but that hours, days or even weeks 
 may elapse during which the person anaesthetized remains con- 
 
I52 CHLOROFORM 
 
 tinuously under the influence of the poison to which he at length 
 succumbs." This condition has been described under various 
 names by different writers for the past ten or fifteen years. It 
 usually follows the administration of chloroform, but has occurred 
 after ether. It is most often encountered in young subjects, chil- 
 dren especially. The symptoms appear in from eight or ten hours 
 to five or six days after the administration of the anaesthetic. The 
 usual interval is between twenty-four and forty-eight hours. 
 
 The symptoms are those of more or less profound toxaemia, 
 and may be varied. In the majority of cases marked cerebral 
 symptoms are present, such as great restlessness, delirium, apathy. 
 These are followed by coma. The temperature may range from 
 normal to 103 or 104 F. The urine contains organic acids, and 
 sometimes amido acids (leucin and tyrosin). Among the pro* 
 nounced symptoms may be mentioned sweet odor of breath, de- 
 lirium, rapidly fatal coma (Brewer), air hunger — deep breathing, 
 bright red mucous membranes (Kussmaul, Bevan-Favill), 
 Cheyne-Stokes respiration, cold extremities, vomiting, collapse, 
 weak and rapid pulse, cyanosis, absence of fever until just before 
 death, coma, acetone in breath and urine (Brackett, Stone, Low) ; 
 great restlessness with clear mind, followed by coma and death 
 (Stocker) ; piercing cries, shrieks, grinding teeth, tossing, strug- 
 gling, irregular or dilated pupils, flushed face, anxiety, tremor, 
 loss of consciousness, apathy, vomiting of material like dregs of 
 beef tea (Guthrie). 
 
 The predisposing causes appear to be youth, sex (male, 9; 
 female, 18), personal idiosyncrasy (Offergeld), various kinds of 
 intoxications as drug or intestinal, psychological causes as fright, 
 homesickness, starvation, sepsis, certain conditions of pregnancy, 
 fatty changes associated with infantile paralysis, diabetes, carci- 
 noma, anaemia, and prolonged anaesthesia. 
 
 The post mortem findings show fatty degeneration or infiltra- 
 tion of the liver, fatty degeneration of the heart, various changes 
 of nephritis, fatty degeneration of the muscles of the lower limbs, 
 and other associated changes. The important alterations are those 
 found in the liver — fatty degeneration and necrosis of the cells — 
 as a result of which toxins develop, either because of the cell 
 changes or because of the influences of the latter upon the func- 
 tion of the cells to eliminate. Wells defines it as follows: "Chloro- 
 
CHLOROFORM 153 
 
 form poisoning, in common with a number of closely related c< n- 
 ditions characterized by intoxication and marked changes in the 
 liver (acute yellow atrophy, phosphorus poisoning, certain septi- 
 caemias, and some cases of puerperal eclampsia) probably ail de- 
 pend on the effect on the liver of poisons that destroy the syn- 
 thetic functions of the liver cells without destroying their autolytic 
 ferments. Autolysis of the liver cells follows with resulting al- 
 terations in the liver structure, and the appearance of products of 
 autolysis (amido acids and various other organic acids) in the 
 blood and urine. It is possible that in chloroform and in phos- 
 phorus poisoning, at least, it is the oxidizing enzymes that are 
 particularly involved, accounting for the marked fatty changes 
 that are present in these conditions." 
 
 The prevention of this condition lies especially in the avoid- 
 ance of chloroform in such conditions as appear to be coanected 
 with its occurrence, in avoiding long continued anaesthesia, which 
 appears to be concerned in its production in some instances, and 
 possibly in combining oxygen with chloroform in lengthy opera- 
 tions when the latter agent is employed, or in substituting oxygen 
 and nitrous oxide gas. 
 
CHAPTER XI. 
 
 SCOPOLAMINE-MORPHINE ANAESTHESIA. 
 
 This method is a mixed form of anaesthesia which has been 
 much employed since Schneiderlein, in 1900, reported his results 
 from its use in insane patients. 
 
 Scopolamine is not a new drug, but has been used for a num- 
 ber of years to some extent. It is an alkaloid of scopolia camio- 
 lica, a plant of the solanacese. Its name is said to be derived 
 from that of the Italian botanist Scopoli. The hydrobromide of 
 scopolamine is said to be chemically identical with hydrobromide 
 of hyoscine, and while there is some diversion of opinion on this 
 point, it is so regarded in the U. S. Pharmacopoeia, and may 
 at least be regarded as isomeric with it. Its formula is C 17 , H 21 , 
 N0 4 , H Br, -f-3H 2 0. It occurs in crystals, is a sedative, and 
 has a mydriatic action somewhat similar to atropine. The simi- 
 larity of its physiological action to that of hyoscine should be 
 borne in mind. The hydrobromate of scopolamine prepared by 
 Merck is recommended, and does not differ materially from the 
 hydrobromide. 
 
 The physiologic effects of scopolamine as given by Stein- 
 buechel are as follows : 
 
 1. Small doses stimulate the vaso-motor nerves and raise 
 blood pressure. Large doses lower blood pressure by influencing- 
 the cardiac excito-motor mechanism. 
 
 2. The pulse is not much influenced by small doses. Large 
 doses cause a vagus pulse. 
 
 3. The cerebral cortex, under the influence of scopolamine, 
 is less excitable when stimulated by the faradic current. Sleep is 
 induced, but not analgesia. 
 
 4. Respiration is not affected by small doses. Large doses 
 slow the breathing. 
 
 5. There is a marked diminution in the secretions of sweat, 
 mucus, and saliva. 
 
SCOPOLAMINE-MORPHINE ANESTHESIA 1 55 
 
 6. Mydriasis occurs in many instances where the drug is not 
 instilled into the eye. 
 
 7. The motor-end apparatus of the intestines is paralyzed. 
 The tone of the splanchnic system is increased. 
 
 8. Excretion of scopolamine takes place by way of the kid- 
 neys. 
 
 Given alone scopolamine does not cause analgesia, but when 
 combined with morphine it causes anaesthesia sufficient for many 
 slight operations, while as a preliminary to a general anaesthetic 
 it reduces the necessary amount of the latter and favorably affects 
 the character of the narcosis. The combination is not illogical, 
 as Crile has proven that morphine greatly lessens the intensity of 
 the afferent nerve impulses going to the vaso-motor center, and 
 thus reduces shock. The additional effect of scopolamine, through 
 its action on the vaso-motor nerves and blood pressure, makes the 
 combination effectual. 
 
 Since the observations of Schneiderlein, Bios and Korff have 
 improved the method of administration and the dosage. Their 
 method as followed by Ries, Israel, Zinke and others, is as fol- 
 lows: One-fiftieth of a grain of scopolamine hydrobromate and 
 one-half a grain of morphine are dissolved in three drams of dis- 
 tilled water. This should be freshly prepared as scopolamine in 
 solution is unstable. One-third of this amount is injected two 
 and a half hours before operation. The second portion is injected 
 one and a half hours before operation, and the remainder is in- 
 jected half an hour previous to beginning the operation. 
 
 The patient becomes sleepy after the first injection, very 
 drowsy after the second, and is scarcely sensitive to pain by the 
 time for the third injection, though sensitive to touch. Anaes- 
 thesia is obtained by half an hour after the third injection. If it 
 is not complete a very small amount of any geneial anaesthetic 
 will suffice, and the stage cf excitement is practically eliminated. 
 It is claimed that this method is safe for cardiac or renal patients, 
 and that there are few or no after effects. 
 
 Sharp says that if scopolamine deserves a place among anaes- 
 thetics it is without doubt in combination with chloroform, the 
 inconstancy of its action rendering it impracticable alone or sim- 
 ply with morphine. According to Seelig, who has employed 
 scopolamine in various operations, giving one one-hundredth of 
 
156 SCOPOLAMINE-MORPHINE ANAESTHESIA 
 
 a grain with one-sixth of a grain of morphine, one-half an hour 
 before operation, and using the Bennett inhaler, specially modified 
 for the purpose, he is thoroughly satisfied with the method. 
 
 Flatau, Israel, Dork, Sexton and others have reported deaths 
 where this form of anaesthesia was employed, yet in most of 
 these instances it is not certain to what extent the scopolamine- 
 morphine combination was to blame. In a review of the subject 
 De Maurans cites an instance where the patient showed dyspnoea 
 and cyanosis about half an hour after the second injection, and 
 died about five hours afterward with symptoms of asphyxia. In 
 most of the fatalities there have been dyspnoea, cyanosis, and 
 Cheyne-Stokes respiration. 
 
 This method of anaesthesia is undoubtedly not without dan- 
 ger, and has its limitations. Its exact position cannot as yet be 
 defined, the burden of proof still resting upon its advocates. 
 
CHAPTER XII. 
 
 ETHYL BROMIDE. 
 
 Ethyl bromide, hydrobromic ether, bromhydric ether, is a 
 colorless, volatile liquid with a fragrant odor and a hot, sac- 
 charine taste, and a bitter after-taste. It was discovered by 
 Serullus, in 1827. Its sp. gr. is 1.420, and its boiling point is 
 104 F. It decomposes rapidly on exposure to light and air, 
 and when ignited burns with a fine, green, smokeless flame with 
 the separation of bromine vapor. It is sparingly soluble in 
 water, and freely so in strong alcohol and in ether. It should 
 evaporate from the hand quickly and absolutely without resi- 
 due, and with a distinct feeling of cold ; when washed with 
 water the washings should be neutral, and without change with 
 the addition of silver nitrate; no discoloration should be caused 
 by the addition of concentrated sulphuric acid. 
 
 Ethyl bromide was introduced as an anaesthetic by Nunneley, 
 of Leeds, in 1865. It was extensively used by Dr. Lewis, of 
 Philadelphia, in 1879-80. A death in his practice, and one in 
 that of Dr. Marion Sims, of New York, together with argu- 
 ments tending to prove that the drug paralyzed the heart, caused 
 it to fall into disuse. According to Schleich ethyl bromide would 
 be an ideal anaesthetic if the advantage of boiling-point were 
 sufficient to offset the danger of the bromine. 
 
 The physiological effects of ethyl bromide are rapidly acquired 
 and are not specially unpleasant. The odor is not disagreeable 
 nor is the vapor particularly irritating to the air passages. The 
 stage of excitement is very short or absent altogether, and mus- 
 cular rigidity is not marked or is absent. The face is usually 
 flushed, the ears quite red, and the conjunctivae injected. The 
 pupils are more or less dilated. The heart action is rapid, and 
 the pulse increased in force. The respiration is quicker than 
 normal and becomes slightly snoring or stertorous. Tendency 
 to irregularity of breathing or arrest of breathing has not been 
 noticed. Embarrassed respiration may occur from free secre- 
 tion of mucus. Nausea and vomiting is rare, but appears more 
 often in women than in men. 
 
I58 ETHYL BROMIDE 
 
 Properly administered, insensibility may be induced in about 
 five minutes (Levis) ; 66 seconds (Chisholm). 
 
 The duration of anaesthesia is rather brief, — 46 seconds (Silk). 
 and the recovery is rapid, so much so as to constitute in some 
 instances, an objection. If the administration is continued be- 
 yond two or three minutes, or if the inhalation is repeated there 
 is more likelihood of after effects. 
 
 After effects are usually absent if the administration has not 
 been prolonged. Headache, nausea, or even vomiting may fol- 
 low. Depression and faintness have occurred. Hysterical man- 
 ifestations have been noted. 
 
 The dangers of the administration of ethyl bromide are prob- 
 ably not great if a pure drug is employed and the administra- 
 tion properly carried on. Wood, of Philadelphia, regarded 
 ethyl bromide as a cardiac depressant. Trumbull and Gowers. 
 of Philadelphia, regarded it as safe and prompt.* 
 
 The death rate is unknown, and how far the drug was to 
 blame in those deaths that have occurred under its use is ques- 
 tionable. 
 
 The administration of bromide of ethyl should not be under- 
 taken for lengthy operations. It is adapted only for dental sur- 
 gery or general surgical proceedings of not over three minutes' 
 duration, though operations lasting for considerable time have 
 been performed under its use. Chisholm thought it unequaled 
 for ophthalmic surgery. 
 
 The inhalation should be conducted much as with ether, the 
 drug being promptly given without much air at first. From 
 one to one and a half drachms is the quantity usually necessary 
 to induce unconsciousness. The inhalation may be conducted 
 with a towel or napkin, as with chloroform, or any ether inhaler 
 may be used. Herz, a dentist of Vienna, used a simple mask, 
 such as the Skinner, with cotton inserted upon which he poured at 
 first about half an ounce of the drug, using more later if desir- 
 able. 
 
 If soft snoring, or insensitive cornese do not promptly appear, 
 the pulse and respiration should be looked to carefully. When 
 complete unconsciousness is produced the inhalation must be 
 interrupted. The inhalation may be repeated, but as before 
 
 ^According to Cole respiration, in animals, stops before the heart, and 
 therefore the breathing rather than the pulse should be watched. 
 
 Hallberg suggests that the danger of ethyl bromide lies largely in its 
 high specific gravity. 
 
ETHYL CHLORIDE I 59 
 
 stated, unpleasant effects are more likely to follow repeated in- 
 halations. 
 
 Ethyl bromide is very portable, requires no apparatus for the 
 administration, is rapid in effect, its inhalation produces no spe- 
 cially disagreeable symptoms, and the recovery is rapid. On 
 the other hand it decomposes readily, is not suitable for lengthy 
 operations, is not as safe as nitrous oxide, and after effects are 
 liable to occur. Kempter urges a more extensive use of ethyl 
 bromide in minor surgery. He says German statistics show but 
 16 deaths in 60,000 administrations. A fresh preparation is nec- 
 essary. He pours from 1 to 3 drachms into a cone which is 
 not removed until anaesthesia is induced. No air is admitted. 
 Anaesthesia lasts from 1 to 2 minutes. 
 
 Fowler favors ethyl bromide preliminary to ether. The cone 
 need not be changed. Krusen thinks ethyl bromide an ideal 
 anaesthetic in obstetric and gynaecological practice. 
 
 ETHYL CHLORIDE. 
 
 Ethyl chloride is a colorless, mobile liquid with a pleasant 
 odor. It has a formula of C 2 H 5 CI. It boils at 12. 5 C. (Re- 
 gnault), and is quite soluble in alcohol. So dissolved it may be 
 kept in tightly corked bottles from which ethyl chloride may be 
 obtained by gently heating (vide P. 197).* 
 
 The anaesthetic properties of ethyl chloride were said to have 
 been recognized by Flourens and others. It was recommended 
 by Richardson in 1867 as a good anaesthetic. Within the last 
 three years it has been used by German, French and American 
 observers for surgical operations of short duration, and for den- 
 tal purposes. Tuttle, of New York, has, of late, used ethyl 
 chloride in 230 cases of short-term anaesthesia. He has never 
 observed any serious symptoms. It may be used with an ordi- 
 nary chloroform inhaler. It is convenient and safe for opera- 
 tions lasting not over ten minutes. General muscular relaxa- 
 tion is not as complete as under ether. Nausea is sometimes 
 present but soon ceases. Alcoholic subjects appear to bear 
 ethyl chloride very well. 
 
 Lothiessen, of Innsbruck, used ethyl chloride in 1896, pro- 
 ducing complete anaesthesia in one minute. The drug was 
 sprinkled on an Esmarch mask. The patient recovered in a 
 few seconds. He has since used it many times with no unto- 
 
 *Ethyl chloride is commonly prepared by acting on ethyl alcohol with 
 hydrochloric acid gas, the yield being increased by the addition of zinc 
 chloride, which probably acts by abstracting water from the alcohol. It 
 should be free from water, foreign chlorides, acids, aldehydes, ether, 
 alcohol, and organo-metallic substances. 
 
l6o ETHYL CHLORIDE 
 
 ward effects. From 8 to 10 grammes were necessary for short 
 operations. 
 
 An inhaler devised by Bruer, and resembling Clover's inhaler, 
 is said to be the best for the administration of ethyl chloride. 
 About 3 to 5 grammes of the drug are sprinkled on the gauze., 
 the patient is told to breathe quietly, and the face-piece is 
 pressed closely to the mouth and nose so as to be air-tight. 
 The above quantity of the drug will be sufficient for about 3-4 
 minutes, and if longer narcosis is desired more must be added. 
 The drug may be sprayed on the gauze of an inhaler from a tube 
 of ethyl chloride. 
 
 Anaesthesia is induced in about a minute and a half. Excite- 
 ment is generally absent. Corneal and pupillary reflexes are 
 usually preserved. The eye-balls may be movable, and the eyes 
 appear to notice. The pulse rate may be slower, but otherwise 
 the pulse is not affected. The conclusions of Konig as to the 
 influence of ethyl chloride on blood pressure are as follows : 
 With a proper amount of air there is no diminution of blood pres- 
 sure, though narcosis may be complete ; in some instances there 
 may be a fall of blood pressure from vagus irritation. Section 
 of the vagi raises the blood pressure ; when a proper amount of 
 air is not allowed lethal depression of the blood pressure and 
 respiratory paralysis follow. The respiration is more rapid than 
 normal. Cyanosis is rare. The muscular system is not always 
 relaxed. The duration of anaesthesia may be prolonged by using 
 more of the drug from time to time. Recovery is rapid, and 
 after effects not important. Vomiting has occurred in a few 
 instances. 
 
 Ethyl chloride is not suitable for lengthy operations, but 
 appears to be quite available for dental and short-term surgical 
 operations. 
 
 Lotheissen states (1900) that statistics show that ethyl chlo- 
 ride stands next to chloroform as regards mortality. Mackie 
 recommends ethyl chloride in nasal surgery. Ware, from a 
 considerable experience, concludes that ethyl chloride is rela- 
 tively safe ; its danger point is not as readily or suddenly reached 
 as is that of chloroform; it does not show the remote dangers 
 of ether, and asphyxia, when it occurs, is easily relieved by arti- 
 ficial respiration. 
 
ETHYL CHLORIDE l6l 
 
 On the continent ethyl chloride has practically replaced ethyl 
 bromide and is being- largely used for short dental operations in- 
 stead of nitrous oxide. In this country it is becoming more and 
 more used. McCardie recommends the Ormsby ether inhaler for 
 ethyl chloride, and uses 60 gramme graduated tubes which emit 
 a larger spray than usual. The induction period is from ^ to 1 
 minute, and the available period about 1*4 minutes. Excitement 
 is absent, color improved, pulse normal, and respiration stimu- 
 lated. Stertor is usually present with deep anaesthesia. Recovery 
 is rapid and complete. He has had no trouble in 400 adminis- 
 trations, and advises ethyl chloride for dental work, ear and throat 
 work by expert operators, and for short operations of ten to fif- 
 teen minutes where it may be superior to ether, chloroform or 
 gas. For children it is a perfect anaesthetic for short operations, 
 as there is no cyanosis, undue bleeding, convulsions, or as rapid 
 recovery as with gas. 
 
 Murray has administered ethyl chloride to 150 infants under 
 one year of age. The youngest was five days old. She regards it 
 as very suitable for short operations (5 to 15 minutes) in chil- 
 dren. Three c.c. are sprayed into the inhaler for children a few 
 weeks old, and five c.c. for those of six months or more. The 
 mask is held so as to admit some air at first. When anaesthesia 
 is produced more air is given. When narcosis is to be continued 
 nie mask should be lifted occasionally for air. 
 
 According to Hillard ethyl chloride requires the greatest care 
 iu its administration, and in skilled hands is relatively "safe" 
 when only small amounts are exhibited. It is potentially a very 
 lethal agent and several deaths have occurred, since its reintro- 
 duction, from its use. Unpleasant effects are very much more 
 common and severe than after nitrous oxide, headache, sickness 
 and collapse being the chief sequelae. He advises anaesthesia not 
 sooner than three hours after eating, a closed inhaler with a wide 
 bore, and sponge so adjusted as to act as a screen to prevent in- 
 halation of too concentrated vapor. The average dose for an 
 adult is 5 c.c. applied for from 20 to 60 seconds, and 3 c.c. for a 
 child given for 15 to 40 seconds. The signs of anaesthesia are, us- 
 ually, in the order of their appearance : deep stertorous breathing, 
 fixed globes, dilated pupils, and loss of ocular reflexes. 
 
 These views, it is evident, are those of one not favorably im- 
 
l62 BICHLORIDE OF METHYLENE 
 
 pressed with the advantages of ethyl chloride, particularly in. 
 comparison with his favorite short-term agent, nitrous oxide. 
 Millard further says that ethyl chloride has but a limited field in 
 dental surgery, and is not likely to replace nitrous cxide, which 
 should be used for simple operations. While for operations last- 
 ing more than three minutes it is better to give gas by the con- 
 tinuous method, using the nasal tube, or to follow the gas by 
 ether. The treatment of dangerous symptoms should be directed 
 towards restoring respiration, because ethyl chloride kills by par- 
 alyzing the respiration with the chest in a position of over-disten- 
 tion. 
 
 BICHLORIDE OF METHYLENE. 
 
 Methylene, methyl dichloride, or bichloride of methylene 
 (CH 2 Cl 2 ), is one of the marsh gas (CH 4 — methane) series. 
 The chloride of methyl (CH 3 CI) has been used for local an- 
 aesthesia by freezing. It has been claimed that bichloride of 
 methylene is simply a mixture of chloroform and methylic alcohol. 
 
 Bichloride of methylene was introduced as an anaesthetic by 
 Richardson in 1867. It is difficult to preserve, and expensive 
 to obtain pure. It has a low boiling point. According to Rich- 
 ardson anaesthesia is reached more quickly than with chloro- 
 form, is more prolonged, recovery is more rapid, and there are 
 no after effects. Spencer Wells expressed himself very fav- 
 orably towards the drug as having fewer drawbacks than any 
 other known anaesthetic. Buxton thought its dangers differed 
 only in degree from those of chloroform. H. M. Lyman says 
 the effects are similar to those of chloroform ; that four cubic 
 centimeters produce insensibility. There are no unpleasant 
 effects with returning consciousness, and vomiting is less fre- 
 quent than after chloroform. 
 
 The dangers of the administration of bichloride of methylene 
 are not accurately known. It is probably not less, and by some 
 is considered more, dangerous than chloroform. 
 
 Andrews, of Chicago (1877), gave one death in 7,000 inhala- 
 tions ; Coles, of Virginia, gave two deaths in 10,000 inhalations. 
 
 Wells used the Junker inhaler for administering methylene. 
 Strahan, of New York, has used a napkin for the administration 
 In one case the anaesthesia was continued for 45 minutes, and" 
 one and a half ounces of the drusr were consumed. 
 
ETHIDENE DICHLORIDE 163 
 
 ETHIDENE DICHLORIDE. 
 
 Ethidene dichloride, dichlorethene, monochlorethyl-chloride, 
 chlorinated chloride of ethyl (CH 3 CH Cl 2 ) was first prepared 
 by Regnault by the action of chlorine on ethyl chloride. It has 
 an ethereal odor, and a sweet, biting taste. Sp. gr. 1.2. Boils 
 at 1 35 to 150 F. It is soluble in alcohol and in ether ; and is 
 insoluble in water. It is metameric with Dutch liquid or ethyl- 
 ene dichloride. 
 
 As an anaesthetic, dichloride of ethidene was first used by 
 Snow. Binz considered it preferable to chloroform. Anaesthe- 
 sia is produced somewhat quicker than with chloroform, while 
 the amount of drug consumed is somewhat greater. The pulse 
 and respiration are less changed than with chloroform, and slow 
 pulse and rapid breathing are generally absent. Excitement is 
 generally not marked, though struggling may at times be pres- 
 ent. Clover recorded 1,877 cases of the inhalation of ethidene : 
 287 of which were for major operations. He usually anaes- 
 thetized with nitrous oxide by the Clover inhaler for gas and 
 ether, ethidene being gradually added when the patient was 
 partly under. Struggling was rare, though there was some 
 twitching. Stertor and dilated pupils appeared quickly. Air 
 was then admitted as required. 
 
 The Junker inhaler has been used for the administration, and 
 it has also been conducted with a towel or piece of lint. 
 
 The dangers of the administration of ethidene are not fully 
 understood. Some four or five deaths have been reported un- 
 der its use, but in how far they were due to the anaesthetic itself 
 is doubtful. Ringer thought that ethidene and chloroform were 
 equally poisonous to the heart. The drug is probably more 
 stimulating than chloroform, but less so than ether, and has gen- 
 erally been regarded as not more safe than chloroform and de- 
 cidedly less so than ether. 
 
 The after effects of ethidene are usually not marked. Vom- 
 iting may occur, but ceases sooner than after chloroform. Nau- 
 sea and headache may occur (Sauer). The recovery from ethi- 
 dene is usually prompt and satisfactory. 
 
 AMYLENE. 
 
 Amylene, pentylene, pentene, (C 5 -H 10 ) is a colorless, thin, 
 volatile liquid with a pungent, unpleasant odor, and little taste. 
 
164 PENTAL 
 
 It was discovered by Balard in 1844, an d was first used by Snow, 
 for anaesthetic purposes. It is a rather indefinite compound, 
 isomeric with several substances. Its sp. gr., as used by Snow. 
 was .659 at 56 F. The boiling point varies from 30 to 62 C. 
 (Duroy). Pure amylene has a boiling point of 38 C. (Duroy). 
 "Pental," is a name applied to a pure form of amylene introduced 
 by Mering, and used by German dental surgeons. 
 
 Amylene is not very soluble in the blood and patients re- 
 cover very rapidly from its effects. The anaesthesia is there- 
 fore transient. Dilute vapor does not induce anaesthesia. Lid- 
 reflex is not always abolished. Muscular spasm may or may 
 not be present. The pulse and respiration are increased in fre- 
 quency and force. The pupils may be unchanged. The face is 
 flushed, and there is perspiration. Snow used from 3 to 4 
 drachms to anaesthetize, with about a 15 per cent, vapor. 
 
 The dangers appear to be much the same as with chloro- 
 form. Two fatal cases in Snow's practice, together with the 
 transient nature of the anaesthesia discouraged its use, which 
 has never become general. The after effects are not marked. 
 Nausea and vomiting may exceptionally occur. 
 
 PENTAL. 
 
 Pental has been used in Germany in dental practice. Some 
 kind of inhaler on the order of the Clover inhaler is used. Two 
 or three drachms of pental are placed in the reservoir, the bag 
 is attached, and the patient's expirations are allowed to partly 
 fill the bag. The indicator is first opened as the face-piece is 
 applied. The patient breathes to-and-fro for about 40 seconds, 
 the indicator being gradually pushed more and more open. The 
 inhalation period lasts about 40 seconds, during which there is 
 flushed face, dilated pupils, open eyes, fixed eye-balls, no con- 
 junctival reflex, quick pulse, rapid, labored breathing, slight 
 cyanosis, and may be marked muscular contractions. The avail- 
 able period of anaesthesia lasts about one minute. The face- 
 piece is removed after about 40 seconds, and the operation be- 
 gun. 
 
 Several fatalities have occurred under pental, and other cases 
 with dangerous symptoms have been reported. After effects 
 are usually absent. It is difficult to see what advantages amyl- 
 ene or pental possess over nitrous oxide or chloroform. 
 
PENTAL 165 
 
 Among the other agents which have from time to time been 
 used for producing anaesthesia, but which have various disad- 
 vantages, and which are inferior to those already considered, may 
 be mentioned nitrogen, methyl oxide, ethylene (olefiant gas), 
 ethyl nitrate, amyl chloride, amyl hydride, tetra-chloride of 
 methane, aldehyde, bisulphuret of carbon, benzene, turpentine., 
 etc. 
 
CHAPTER XIII. 
 
 SPINAL ANAESTHESIA. 
 
 This method of producing anaesthesia is generally spoken of 
 as Bier's method, or Quincke's method. It properly should be 
 attributed to Corning, of New York (Spinal Anaesthesia and 
 Local Medication of the Cord, New York Medical Journal, 
 October 31, 1885). Its introduction as a means of anaesthesia 
 is chiefly owing to Bier and Quincke.* 
 
 Effects. Acording to Tuffier the effects are as follows : 
 Analgesia appears in from four to ten minutes, quickest in young 
 subjects. It lasts from 30 to 50 minutes with doses of from 5 
 to 15 milligrammes; with doses of from 15 to 25 milligrammes 
 it lasts from one hour to one hour and forty minutes. The an- 
 aesthesia is accompanied by prickling in the toes and calves, and 
 numbness of the lower limbs. Analgesia begins in the extrem- 
 ities and progressively ascends involving the umbilical region 
 last. It disappears in reverse order to its appearance. 
 
 According to Crile injections into the subarachnoid space 
 cause displacement similar to that of fluid in a capillary tube. 
 The injection of a cocain solution colored with methylene blue 
 into the lumbar region stained the entire cord and under sur- 
 face of the brain within thirty seconds, and all the localized func- 
 tions of the cord and medulla were rapidly anaesthetized. There 
 was marked fall in blood pressure and interference with respi- 
 ration within a few seconds. Position affected the rapidity of 
 the occurrence of these manifestations little if at all, and 
 the operator has little if any control over the extent of anaesthe- 
 sia produced by subarachnoid injection. 
 
 The general symptoms observed during analgesic and post- 
 analgesic periods are : Sweating, some dilatation of the pupils, 
 nausea, trembling, headache, vomiting, shivering, and tachy- 
 cardia. They may be absent with small doses. 
 
 Eucaine b, alpha eucaine, and tropacocaine have been used 
 but do not appear to have special advantages. Kopfstein re- 
 ports fever, headache, and collapse after using alpha eucain. 
 
 After effects. These are less marked and unpleasant than 
 
 ♦According to Meyer, of New York, Bier says that he had not the 
 slightest idea that Corning had discovered spinal anaesthesia. 
 
SPINAL ANESTHESIA 
 
 l67 
 
 after general anaesthesia. Nausea and vomiting occurs in from 
 20 to 40 per cent. of. the cases. Headache, pain in the legs, 
 delirium, paralysis of the sphincters, and collapse may occur. 
 
 Complications. Late complications are absent as a rule. 
 
 Failure to produce anaesthesia occurs in some cases, and can- 
 not always be attributed to faulty technique. It may be neces- 
 sary to give a general anxsthetic. 
 
 Contraindications. Conditions which render general anaesthe- 
 sia dangerous also bear the same relation to spinal anaesthesia. 
 It should not be employed in children under 12 years. It 
 should not be used when absolute muscular relaxation is neces- 
 sary. It is contraindicated in most mental conditions. Some 
 regard spinal anaesthesia as safer in kidney disease than general 
 
 a <**■ 
 
 Fig. 44. — Coming's Original Needles and Syringe. 
 
 anaesthesia, but this is not yet proven. It should not be used for 
 operations lasting over one hour, or for those in which compli- 
 cations are likely to arise and prolong the operation beyond 
 this period. 
 
 Mortality. The mortality of spinal anaesthesia is not known. 
 Such deaths as have occurred cannot be attributed solely to 
 the method of anaesthesia. Statistics, up to date, are inconclu- 
 sive. It should not be used when local anaesthesia is possible. 
 
 The solution and dose. The solution used should be weak 
 (a one or two per cent, solution). It should be freshly pre- 
 pared, sterilized by heating several times in a water bath at a 
 temperature not exceeding 6o° C. The majority of operators 
 use a two per cent solution of cocaine as employed by Tuffier. 
 
[68 
 
 SPINAL ANAESTHESIA 
 
 A quantity not to exceed 15 mgm. is injected. This quantity 
 may be exceeded but is likely to be followed by after effects. 
 
 According to Matas the solution should be made as follows : 
 "Five tablets each containing 1-5 grain of cocaine hydrochlo- 
 rate, 1-40 grain of morphine hydrochlorate, 1-5 grain of sodium 
 chloride are dropped into 100 minims of hot distilled water and 
 dissolved. The solution is again sterilized by the fractional 
 method. Twenty minims of this solution represent one-fifth 
 of a grain of cocaine, one-fortieth of a grain of morphine, and 
 
 Fig. 45. — Diagram of Vertebra. 
 
 one-fifth of a grain of sodium chloride. The syringe, which con- 
 tains 30 minims, is filled with the solution and 22 minims are 
 injected. The excess of 2 minims is allowed for waste. The 
 solution should always be used warm, about 90 to ioo° F." 
 Fie claims that this method is very satisfactory. 
 
 Technique. Coming's original method differed from that 
 used by later authorities. He used for measurement a fine 
 needle, three inches long, provided with a handle and a sliding 
 nut (Fig. 44-1)). This needle was introduced half an inch to 
 
SPINAL ANESTHESIA 169 
 
 one side of the spinous process of the tenth dorsal vertebra until 
 the bone was reached. The nut was then slid down until it 
 rested on the spine and was fastened by the screw. Fig. 45 
 shows this needle and gives the exact distance between the skin 
 and the cord. A hollow needle (Fig. 44-a), with a sliding nut 
 fixed at the proper distance, and attached to a syringe (Fig. 
 44-c) filled with cocaine solution ; is thrust between the spinous 
 processes of the tenth and eleventh dorsal vertebrae and the 
 solution injected. Later Corning discarded the needle used 
 for measurement and employed a delicate trocar containing a 
 fine needle (Fig. 46), and used the sitting position instead of 
 the lateral for the operation. The needle is introduced slowly 
 
 Fig. 46. — Coming's Needle. 
 
 until a few drops of spinal fluid escapes, when the injection is 
 made. 
 
 Bier and Quincke used the lateral position, and a thin hollow 
 needle wiLh a stopper. After the appearance of the cerebro- 
 spinal fluid the solution is introduced with a Pravaz syringe. 
 The technique is as follows: 
 
 Place the patient on his side, round his back by flexing the 
 legs on the thighs and the thighs on the abdomen and place a 
 cushion underneath the flank. This will widen the spaces be- 
 tween the spinous processes of the vertebrae. The lumbar re- 
 gion is cleansed. The posterior, inferior iliac spines are lo- 
 cated and joined by a line which passes the level of the fifth 
 lumbar vertebra. Below this line will be found the sacro- 
 lumbar fossa, and from this point count the lumbar spinous pro- 
 cesses until the third or fourth lumbar interspace (the point of 
 election) is reached. This point is marked with iodine, and 
 rendered anaesthetic by ethyl chloride or some other local an- 
 aesthetic. The spinous process corresponding to the space 
 elected (third or fourth lumbar) is located, and keeping the 
 finger on the process, the needle, which should be strong and 
 three or four inches long, is inserted one-half cm. to the outer 
 side (right or left) cf the median line. The needle is held by 
 the thumb and index finger of the right hand and gently pushed 
 
170 
 
 SPINAL ANAESTHESIA 
 
 from behind forward, from below upward, and from without in- 
 ward, the obliquity of the needle inward and upward being 
 slight. The needle is most likely to be arrested by the supe- 
 rior lamina of the space it is traversing, if so it should, be 
 slightly withdrawn and its direction changed. The external 
 orifice of the needle must be watched, for as soon as the needle 
 traverses the inter-laminar space it enters the sub-arachnoid 
 space, and the spinal fluid will escape. Cocaine must not be 
 injected unless this escape of spinal fluid takes place. When 
 8 to 10 drops of fluid have escaped the injection is made very 
 
 Fig. 47. — Sitting Position. 
 
 slowly. When the needle is withdrawn the point of injection 
 is sealed with collodion. 
 
 The technique cf lumbar puncture may, at times, be difficult 
 In obese or muscular subjects palpation of the spinous pro- 
 cesses of the lumbar vertebrae is difficult. The sitting position 
 is better than the lateral. The needle should be introduced 
 slowly, and the appearance of the spinal fluid alone should be 
 regarded as evidence that the needle has penetrated the canal 
 Very little spinal fluid should be allowed to escape. About one 
 minute should be consumed in injecting the solution. The 
 
SPINAL ANESTHESIA 
 
 171 
 
 needle should be left in place after the injection for five or ten 
 minutes. Repeated injections have been made, but are con- 
 sidered dangerous. Surgical cleanliness should be carefully 
 observed. The skin may be previously anaesthetized by the 
 Schleich infiltration method, or by the ethyl-chloride spray, but 
 this is considered unnecessary by most operators. The needles 
 and syringes should be kept exclusively for this purpose and 
 should be carefully sterilized and tested before using. 
 
 The location of the puncture. The inter-vertebral space be- 
 tween the third and fourth, or fourth and fifth, lumbar verte- 
 
 Fig. 48. — Iliac Crests'. 
 
 brae is usually selected. Chipauit used the space between the 
 fifth lumbar vertebra and the sacrum, which is also preferred by 
 Rodman. Corning first used the space between the eleventh 
 and twelfth dorsal vertebrae, but later preferred that between the 
 fourth and fifth lumbar vertebrae. Tait and Cagliari, of San 
 Francisco, have injected as high as the sixth cervical space, but 
 most authorities condemn injections higher than the second 
 lumbar vertebra. 
 
 Position and method. The lateral position and technique 
 
TJ2 
 
 SPINAL ANESTHESIA 
 
 already described may be used. Matas recommends the method 
 employed by Tuffier, and first used by Quincke. 
 
 The patient is seated on a table with his back to the opera- 
 tor (Fig - . 47). His hands resting on his thighs support his 
 trunk. The trunk is held nearly upright with the spine as 
 straight as possible. The highest points of the iliac crests 
 posteriorly are now identified (Fig. 48), and a horizontal line 
 
 Fig. 49. — Needle Entering Opposite Fourth Spine. 
 
 connecting these points is drawn across the spine. The tip 
 of the fourth lumbar spine touches this line. The canula is 
 entered at a point just below and to the outer side of the junc- 
 tion of this line with the fourth spine (Fig. 49). The skin at 
 this point and for a quarter of an inch to the right of the median 
 line may be infiltrated with a few drops of Schleich's cocaine 
 solution No. 1 or No. 2. A Pravaz syringe, as used by Tuf- 
 
SPINAL ANAESTHESIA 173 
 
 fier, may be employed (Fig. 50), with a platinum needle 8 cm. 
 long, and a lumen of 6 mm. The various methods of insert- 
 ing the needle are shown in Fig. 51. 
 
 Guinard claims to have succeeded in suppressing all after 
 effects of medullar cocainization by using a solution of cocaine 
 in the rachidian liquid of the patient, 60 to 80 drops of this 
 liquid are collected in a sterilized bottle, and 6 or 7 drops of a 
 concentrated solution of cocaine (about 1 centigramme to 2 
 drops of water) are added and the whole slowly injected. 
 
 The following account of the method of A. W. Morton, of 
 San Francisco, is taken from his article on "The Sub-Arachnoid 
 Injection of Cocaine for Operations on the Upper Part of the 
 
 Fig. 50. — Tuffler's Needle and Syringe. 
 • Body," read at the fifty-third annual meeting of the American 
 Medical Association, (Jour. Am. Med. Assn.) 
 
 "Chemically pure cocain hydrochlorate is sterilized by expos- 
 ing the crystals to dry heat 300 F. for fifteen minutes, then in- 
 close in sterile tubes, or sealed envelopes, in proper doses until 
 time for use. The dose varies from 0.3, 0.4 or 0.5 of a grain, de- 
 pending on the locality, whether in the lower extremities, 
 trunk, or head. This is the maximum dose for a strong person ; 
 young or old persons will take a smaller dose. 
 
 "I use the Lures syringe, which has a glass piston, and grad- 
 uated barrel, and is readily sterilized, and always in working 
 order. The needle is made of steel wire tubing No. 19 gauge, 
 and three inches long; the bevel is short, with the concave 
 portion of it dulled, to prevent cutting plug of skin and ob- 
 structing needle. The needle is kept in a saturated solution 
 of carbonate of sodium to prevent rusting. 
 
 "The patient is placed in the reclining position on either side, 
 with body curved forward, to separate the spinous processes; 
 the spinous process of the fourth lumbar vertebra is located by 
 being on an imaginary line connecting the crest of the ilia. 
 
174 
 
 SPINAL ANAESTHESIA 
 
 The space just between the third or fourth lumbar vertebra is 
 frozen with ethyl chlorid, after being thoroughly cleansed. The 
 needle is introduced just beneath the spine in the median line, 
 with the point of it directed upward, and introduced until it 
 meets with diminished resistance, or fluid passes. Should the 
 needle be obstructed, it can be opened by having the patient 
 cough, using stylet, or making suction with syringe attached, 
 at which time a drop of cerebro-spinal fluid will pass. Then 
 place the finger over the end of the needle and connect the 
 
 Fig. 51. — Method of Puncture for Spinal Drainage. 
 
 Fog. 51. Methods of puncture for spinal drainage: A. Quincke's method; 
 B. Warfan's; C. Chipault's ; D. Turner's— after Matas, modified from 
 Chipault. 
 
 syringe, which has 0.3 of a grain of cocain in it, with piston 
 closed, and gradually withdraw the piston, until the syringe is 
 half filled with cerebro-spinal fluid, which readily dissolves the 
 cocain ; then gradually return the solution into the space by 
 pressing the piston. 
 
 "Should the analgesia be desired in the upper extremities, 
 introduce the needle in the third space, and use the same 
 method as above, except the dose should be 0.4 to 0.5 of a grain 
 of cocain, and introduce as rapidly as the piston of the syringe 
 can be pressed, then withdraw the needle and seal with collo- 
 dion. 
 
 "The analgesia will be complete for operations in the lower 
 
SPINAL ANAESTHESIA 175 
 
 extremities in from three to five minutes, and for operations 
 in the upper part of the body, in from fifteen to twenty-five min- 
 utes ; the analgesia lasts from one to three hours, and I have 
 seen it last five hours." 
 
 Stovaine. This drug, which has come into use for spinal an- 
 aesthesia, was brought publicly before the profession by Four- 
 neau, a French chemist, by whom it was named, in 1904. It had 
 been tried by Reclus as a local anaesthetic a few months before, 
 and about the same time Chaput used it for spinal anaesthesia. 
 The drug is a hydrochlorate of amyleine, and is derived from 
 tertiary amylic alcohol. It crystallizes in flakes resembling co- 
 caine. It is very soluble, and it is said that solutions will stand 
 a temperature of 115 C. for twenty minutes. It is credited with 
 being a vaso-dilator, and with having antithermic action. It 
 slows the pulse, contracts the pupils,, causes flushing, but not 
 pallor. There is no dyspnoea, oppression or excitement, or ten- 
 dency to syncope. It is said to be as efficient as cocaine, but 
 much less toxic, and can be given in larger doses if required. 
 Lethal doses for animals cause paresis of the hind legs, tonic fol- 
 lowed by clonic spasms of a violent nature, coma, and death. 
 
 Chaput uses from two to eight centigrammes for spinal anaes- 
 thesia, and maintains that good results can always be obtained 
 for operations below the umbilicus ; that the length of the an- 
 aesthesia varies with the amount of the drug injected. Young 
 adults require rather large closes. He does not advise Stovaine 
 for persons over sixty -five years old, but if used the dose should 
 be small. After effects noted are : slow pulse, nausea, perspira- 
 tion, pallor, mental distress, headache, rise of temperature, neu- 
 ralgia, vomiting. These results, however, are not so severe as 
 from cocaine. Chaput maintains that the advantages of stovaine 
 over cocaine are so marked that it should always have the prefer- 
 ence. 
 
 Sonnenburg arrives at conclusions similar to those of Chaput, 
 and holds that operations as high as the costal arch may be done 
 painlessly by the use of stovaine. His age limits are fourteen and 
 sixty. 
 
 Turner considers the anaesthetic properties of stovaine as good 
 as those of cocaine, and thinks its use an important advance. He 
 
1^6 SPINAL ANAESTHESIA 
 
 uses a ten per cent, solution of stovaine with sodium chloride. 
 On the continent this is supplied in ampuls of half a c.c. con- 
 taining- five centigrammes of stovaine. Bier advises the addition 
 of adrenalin because the specific gravity of the solution is then 
 nearer that of the spinal fluid, and there is therefore less danger 
 of headache or spinal neuralgia, and the anaesthesia will last 
 longer. 
 
 According to A. E. Halsted spinal anaesthesia is of great 
 value when from chronic disease of the lungs, heart or kidneys 
 general anaesthesia is contraindicated, and when the operation 
 is on the lower half of the body. Ordinary heart lesions are not 
 a contraindication. It should not be employed with hysterical 
 women, insane persons, young children, where idiosyncrasy to 
 cocaine exists, and only when it can be explained to the patient 
 and the co-operation of the latter obtained. Its objections, more 
 or less valid, are that immediate and remote changes may be con- 
 siderable, the production of surgical anaesthesia and its dura- 
 tion are somewhat uncertain, attempts at introducing the agent 
 may fail, and there may be important after effects. These ob- 
 jections may be generally avoided by proper care and technique. 
 -Halsted employs the method of Tuffier and advises the use of 
 Luers syringe and needle (a platinum needle with short bevel 
 point and dull edges. The syringe is entirely of glass). An 
 amount of spinal fluid equal to the quantity of the injection is 
 allowed to escape, or Morton's method of placing dry, sterile co- 
 caine in the syringe and dissolving it in the fluid withdrawn, 
 which is then replaced, may be used. Halsted injects from 15 to 
 20 minims of a two per cent, solution freshly prepared at the 
 time of the operation. The duration of the analgesia is from 
 thirty minutes to three hours or longer. It is not safe to count 
 on more than one and one-half hours. 
 
CHAPTER XIV. 
 
 MIXTURES FOR ANESTHESIA. 
 
 Mixtures of alcohol, chloroform and ether, chloroform and 
 ether, and chloroform and alcohol have been more or less ex- 
 tensively employed with the object of obtaining anaesthesia with 
 a less concentrated vapor, and of obviating depression of the cir- 
 culation. The addition of ether to chloroform, or to chloroform 
 and alcohol, produces a better and more uniform circulation 
 during anaesthesia than is the case with chloroform alone. The 
 difference in the boiling point, and in the volatility of the constit- 
 uents of these mixtures renders it difficult to control the pro- 
 portion of the various vapors inhaled. Ellis devised an ap- 
 paratus in which the ingredients were separate and the vapors 
 were mixed in the desired proportions during the administra- 
 tion. This apparatus was too complicated for general use. The 
 difficulty is overcome to some extent by using such proportion of 
 the different ingredients as will evaporate in the same time at the 
 same temperature. Or, by using only small quantities of the 
 agent at a time, and as frequently repeating the dose as the pre- 
 vious one evaporates. 
 
 THE A. C. E. MIXTURE. 
 
 Of the various mixtures used for anaesthetic purposes the 
 A. C. E. mixture, consisting of I part of alcohol, 2 parts of chlo- 
 roform, and 3 parts of ether, has been the most extensively used. 
 It was originally suggested by Harley. According to Martindale, 
 by using alcohol of a sp. gr. of .795, chloroform of a sp. gr. of 
 1.497, an d ether of a sp. gr. of .720, uniform volatility will be 
 secured. The mixture should be freshly prepared, and kept in 
 well-corked bottles. 
 
 When inhaled the odor of the mixture is not unpleasant. The 
 effects are more similar to those of chloroform than of ether, 
 though partaking of the peculiarities of both. Thus there is 
 deeper and more audible respiration than with chloroform, while 
 concentrated vapor will produce swallowing, coughing, holding 
 the breath more readily than chloroform. There is more saliva 
 than with chloroform, and less than under ether. 
 
 The administration should be conducted with an Esmarch or 
 
1 78 
 
 MIXTURES FOR ANAESTHESIA 
 
 an open cone inhaler. Plenty of air must be allowed, and small 
 quantities of the mixture used at a time. If attempts at vomiting 
 occur the anaesthetic should be carefully continued. From five to 
 ten minutes should be allowed for the induction of anaesthesia. 
 Regular, stertorous breathing, no lid-reflex, muscular relaxation, 
 fixed eyeballs, and moderate contraction of the pupils indicate a 
 proper degree of anaesthesia. According to Hewitt, a dilated pupil 
 with distinct lid-reflex allows of more anaesthetic if desirable, but 
 a dilated pupil with insensitive corneae indicates withdrawal until 
 the pupil contracts or lid-reflex appears. High-pitched, crowing 
 breathing as a rule indicates withdrawal and friction of the lips. 
 Quiet breathing, tendency to rigidity, swallowing, marked con- 
 traction of the pupils, indicate too light anaesthesia. 
 
 The A. C. E. mixture is regarded by many anaesthetists as one 
 of the best agents for routine use. It is well adapted for old or 
 fat people, emphysematous subjects, and those suffering from 
 bronchitis, asthma, pleurisy, chronic diseases of the lungs, and in 
 cardiopathic patients. It is recommended by Hewitt for cases of 
 mitral stenosis. It is advantageous for cases of abdominal disease, 
 and is well adapted for use with children.* 
 
 The after-effects of the A. C. E. mixture are, as a rule, un- 
 important. Vomiting may occur. The dangers of its administra- 
 tion are similar to those of chloroform, although not nearly so 
 great. A number of deaths have occurred under its use, but they 
 cannot all be attributed entirely to the agent. Kemp thinks that 
 the A. C. E. mixture exhibits the effects of chloroform on the 
 heart, and of ether on the kidneys, and sees no good reason for 
 employing the mixture. 
 
 billroth's mixture. 
 
 This mixture consists of i part of alcohol, 3 parts of chloro- 
 form, and I part of ether. It has been used considerably in Ger- 
 many. Its administration and effects do not differ materially from 
 those of chloroform, except that the circulation is better, and there 
 rarely is any after vomiting. 
 
 CHLOROFORM AND ETHER. 
 
 Various proportions of chloroform and ether have been used. 
 They should never be administered by closed or bag inhalers. 
 Small and frequently repeated doses are best. 
 
 TWO PARTS OF CHLOROFORM AND THREE OF ETHER. This IS the 
 
 *McCardie profers Silk's metal hospital inhaler for mixture of chloro- 
 form and ether. He thinks E,G better than A.C.E., as alcohol is expensive 
 and only wets the sponge. 
 
MIXTURES FOR ANESTHESIA IJC) 
 
 same as the A. C. E. mixture, without the alcohol. It is recom- 
 mended by Hewitt, who says there is less excitement and more 
 satisfactory recovery than with the A. C. E. mixture. He thinks 
 that if small quantities be used repeatedly, and with a proper in- 
 haler, that no difficulty will arise with this mixture or with the 
 A. C. E. mixture. The administration is governed in all respects 
 by the rules which apply to the A. C. E. mixture. 
 
 TWO PARTS OF CHLOROFORM AND ONE OF ETHER. This mixture 
 
 is recommended by Fuster. It should be freshly prepared. No 
 special inhaler is necessary. A wire frame covered with flannel 
 may be used. When the patient is breathing quietly, 4 or 5 drops 
 are poured on the inhaler. When this has evaporated 6 or 8 more 
 are poured on at the moment of inspiration. Two or three such 
 doses are given during the first minute, and if well taken, three 
 or four are given during the second minute, by which time op- 
 eration may be begun. If there is any evidence of pain, a few 
 more drops may be given with the next inspiration. Anaesthesia 
 is produced in from two to five minutes, and may be continued for 
 a long time by administering 3 or 4 drops from time to time. Ex- 
 citement is rare, vomiting unusual, and the circulation well main- 
 tained. 
 
 One part of chloroform and four parts of ether. — This 
 mixture has been used experimentally mostly. Its effects are very 
 similar to those of ether. 
 
 One part of chloroform and three parts of ether. — This 
 mixture, known as the Vienna mixture, has been quite extensive- 
 ly used in some parts of Europe, and is said to be very satisfac- 
 tory. It has not been much employed in this country. 
 
 One part of chloroform and two parts of ether. — This 
 mixture is similar in its effects to the A. C. E. mixture. It has 
 not been much employed. 
 
 CHLOROFORM AND ALCOHOL. 
 
 Equal parts of chloroform and alcohol have been used by San- 
 som, and by Snow. Usually, however, a lesser proportion of al- 
 cohol has been employed. Vigorous subjects are difficult or im- 
 possible to anaesthetize with a large proportion of alcohol. Such 
 mixtures should be administered in the same manner as chloro- 
 form. 
 
l8o . MIXTURES FOR ANAESTHESIA 
 
 schleich's MIXTURE. 
 
 Schleich introduced this mixture in 1898. It consists of chlo- 
 roform, ether, and petroleum ether, united in such proportions 
 and in accordance with the temperature of the patient, that ab- 
 sorption and elimination will be balanced and no accumulation be 
 possible. A narcotic which evaporates quickly is eliminated quick- 
 ly. One evaporating slowly is eliminated slowly and becomes 
 dangerous. The lower the boiling point of the agent the more 
 rapid the evaporation, and vice versa. 
 
 Schleich found that when the boiling point of the agent is 
 higher than the body temperature the amount necessary to secure 
 anaesthesia is less than when the boiling point equals the body tem- 
 perature, and that the resulting narcosis is deeper. Also that it is 
 possible to mix ethers having different boiling points in various 
 proportions and to obtain a desired boiling point and to regulate 
 it according to the proportion of each used. He recommends 
 three mixtures which may be prepared by the anaesthetist. 
 
 Petroleum ether is best for modifying the action of chloro- 
 form, diluting the other materials. It does not interfere with the 
 action of the other drugs, and can be given in large doses without 
 causing- disturbance. The mixture may be administered as are 
 other agents. Care must be exercised as to the amount used. 
 Thirty gms. of Mixture No. 1 is an average amount for 20 min- 
 utes or less. An ordinary towel and paper inhaler will answer. 
 For prolonged operations Mixture No. II. may be used, and a 
 smaller amount will be necessary. 
 
 Mixture No. I. consists of chloroform, 45 parts; petroleum 
 ether, 15 parts; sulphuric ether, 180 parts, and boils at 38 C. 
 100.4 F.). 
 
 Mixture No. II. consists of chloroform, 45 parts; petroleum 
 ether, 15 parts; sulphuric ether, 150 parts, and boils at 40 C. 
 (i04°F.). 
 
 Mixture No. III. consists of chloroform, 30 parts ; petroleum 
 ether, 15 parts ; sulphuric ether, 80 parts, and boils at 42 C. ( 107.6 
 F.). Petroleum ether should boil at 60 to 65 C. (140 to 149 F.). 
 
 Rodman used the Schleich mixture in 700 cases in the Mount 
 Sinai Hospital in New York. He concludes that it is more pleas- 
 ant to inhale than ether, but not as compared with chloroform. It 
 requires from 15 to 20 minutes to induce anaesthesia. A mask is 
 
MIXTURES FOR ANESTHESIA 181 
 
 necessary (Fig-. 52), and must be saturated at the beginning, 
 which is apt to burn the face. Excitement is less than with chlo- 
 roform or ether. Relaxation is more marked than under ether. 
 Reflexes are lost early, especially the conjunctival reflex, which 
 is therefore not a good guide. The pulse is slow, the pupils di- 
 lated, and the respiration diminished. Cyanosis is present. If 
 care is not exercised cyanosis increases, breathing is shallow and 
 infrequent, the pulse is rapid and of low tension, and the patient 
 stops breathing. Nausea and vomiting is as frequent afterward as 
 with chloroform or ether, and recovery is not any more rapid. The 
 effect on the lungs and kidneys are as marked as with ether. Rod- 
 man claims that Schleich's mixture is inferior to both chloroform 
 and ether. 
 
 Garrrigues has employed this method, using solution No. L, 
 and changing to No. II. if anaesthesia is not induced in ten min- 
 utes. He concludes that the mixtures are easily taken, may be 
 used in all cases where general anaesthesia is not contraindicated, 
 anaesthesia is induced quickly and maintained with small quan- 
 tities of the agent, there is little mucus, rarely vomiting, scarcely 
 any tendency to cyanosis, no bad effect on the kidneys, only slight 
 weakness of the heart, not as much danger to respiration as 
 with ether or chloroform, and the mixture is adapted for general 
 usage. 
 
 Fig. 52. — Stone's Mask for Schleich's Solution. 
 
 Fig. 52. Stone's mask for Schleich's solution is shaped like half an 
 egg shell. Its rim is covered with a circular, rubber cushion adjusting 
 the mask closely to the face. The cushion is inflated by a special tube and 
 stop-cock. The air required for respiration is admitted through a ->^-inch 
 opening in the center of the mask. This pattern is for use in ordinary po- 
 sitions. For Sim's position a special inhaler should be used, one in which 
 the opening is placed on the right side of the mask instead of the center. 
 The inner portion of the mask is supplied with twelve layers of japanned 
 bibulous paper, such as is used by dentists. This is held in place by two 
 spring wires. The latter serve not only to hold the paper in a compact 
 mass, but to prevent them from resting against the nose. The latter fea- 
 ture is necessary as the solution is destructive to the skin when long in 
 contact with it. 
 
l82 SOMNOFORM 
 
 SOMNOFORM. 
 
 Somnoform is the trade name for a mixture of chloride of 
 ethyl, 60 per cent., chloride of methyl, 35 per cent., and bromide 
 of ethyl, 5 per cent. This mixture was devised by Rolland, of 
 France, and presented by him at the Congress of the Association 
 Francaise pour l'avancement des Sciences, held in 1901. Since 
 then this mixture has obtained extensive use in Europe, Great 
 Britain, and somewhat so in this country. 
 
 A somewhat similar mixture, ethyloform (B. Kuhn) con- 
 tains 45 per cent, ethyl chloride, 45 per cent, methyl chloride, and 
 10 per cent, ethyl bromide. It has not been widely employed. 
 Also anesthol (Meyer) a mixture of ethyl chloride, chloroform 
 and ether. 
 
 Somnoform is supposed to be governed in its entry, transit, 
 and exit from the body by much the same conditions as those af- 
 fecting the action of oxygen. It increases arterial tension and 
 the rate of the heart, and is said to produce changes in the neuron 
 which vary in different portions of the brain. According to Rol- 
 land "somnoform has an elective action on the cells of Purkinje, 
 thus suppressing sensivity to pain and temperature — its passage 
 through the cerebellum ; and when there is saturation or excess 
 of the anaesthesia the pyramidal cells are impressed determining 
 loss of consciousness." 
 
 This mixture has been employed chiefly in dental surgery, and 
 as the primary agent in the sequential administration of anaes- 
 thetics, especially in connection with ether. It is not unpleasant, 
 its action is rapid (induction about thirty seconds) and lasts from 
 forty-five to seventy-five seconds. Recovery is very rapid, and 
 there are few if any after effects. During the administration 
 ocular movements cease in about twenty seconds, slight lateral 
 nystagmus is usually present, the eyelids droop, pupils become 
 dilated, and soft snoring may ensue. The conjunctival reflex is 
 generally lost. There is usually complete muscular relaxation, 
 though rigidity may be present, in some persons. If only short 
 anaesthesia is desired the patient may be told to hold his arm up, 
 and as soon as it drops the inhaler may be removed. Or, the 
 operator may slowly move his fingers in front of the patient's 
 eyes, and as soon as the gaze becomes "fixed"— does not follow 
 the fingers — the inhaler may be removed. If this is done as soon 
 
SOMNOFORM 
 
 183 
 
 Fig. 53- — Somnoform Inhaler. 
 E. De Trey & Sons, Phila. 
 
 Fig. 54. — Tube diagram, 
 Somnoform Inhaler. 
 
 Fig. 53. At one end is the face piece with a pneumatic rubber pad and 
 a transparent celluloid cone. At the other end is a rubber bag, the ca- 
 pacity of which is about two gallons. The face piece communicates with 
 the bag through a short metal tube, shaped at right angle and having the 
 proper openings for the supply of air and Somnoform. It also contains 
 the breaking device for the sealed glass capsules and a wire frame in spiral 
 form (S), around which is wound the absorbent lint. Somnoform is 
 projected from the bottle straight into "e" and is absorbed by the lint "/." 
 If capsules are used the necks of same can be fractured in the tube "t" 
 the broken portion being caught in the perforated cup "c," it is thus im- 
 possible for the broken tip of the capsule to enter the face piece. Fig. 54. 
 
l84 • SOMNOFORM 
 
 as consciousness is lost, from fifty to sixty seconds of anaesthesia 
 is obtained. Deeper narcosis may be secured by retaining the in- 
 haler for a slightly longer period. After effects are mostly due 
 to faulty administration. Nausea is said to follow in about one 
 per cent, of the administrations. 
 
 The administration of somnoform should be conducted with 
 a closed inhaler, as there must be absolute control of air. A 
 special inhaler has been devised for somnoform which possesses 
 several advantages (vide Fig. 53). It requires less of the agent 
 with a proper inhaler, and as a rule the best effects are obtained 
 with small quantities. Somnoform is furnished in sealed glass 
 capsules, each of which contains sufficient for one administration. 
 
 Grav, of Melbourne, advises that in administering somnoform 
 the face mask should not be applied perfectly close for the first 
 four or five seconds, but after four or five inhalations it should 
 be applied tightly, and all air excluded until the anaesthesia is 
 complete. He says that anaesthesia is thus reached in from twenty 
 to fifty seconds, and will last from one to five minutes. Follow- 
 ing the anaesthesia there is a period of analgesia lasting from one 
 to five minutes, during which the operation may be continued. 
 From five to twenty teeth have been extracted by this method, 
 and the anaesthetic may be reapplied two or three times if neces- 
 sary. He has not prolonged the anaesthesia more than five min- 
 utes, but others have kept it up for twenty minutes. The aver- 
 age quantity used by Gray was 3 c.c. 
 
 According to Cole the respiration rather than the pulse should 
 be watched in giving somnoform, for there is no danger of pri- 
 mary cardiac syncope from inhibition of the heart through stimu- 
 lation of the cardio-inhibitory centre, as is the case with chloro- 
 form. 
 
CHAPTER XV. 
 
 SEQUENCE OF AN /ESTHETICS. 
 
 The following of one anaesthetic agent by another with the 
 same patient at the same administration is a method of anaesthesia 
 which in certain subjects, or for particular operations, may be of 
 considerable advantage. There are a number of these sequential 
 methods of anaesthesia, but certain of them are worthy of special 
 attention. 
 
 THE NITROUS OXIDE-ETHER SEQUENCE. 
 
 This method was introduced by Clover. It has since found 
 considerable employment in Great Britain and in this country. 
 Brown and Kelly, of Baltimore, report 300 anaesthetizations by 
 this method. The advantages over ether alone are : More rapid 
 induction of anaesthesia, less irritating inhalation, less struggling 
 and excitement, less risk, less ether absorbed, quicker recovery, 
 and fewer after-effects. The fact that both agents demand little 
 air makes the change from one to the other comparatively easy. 
 
 The administration may be conducted by a closed inhaler suit- 
 able for the administration of both agents, such as the Ormsby, 
 Clover-Hewitt (Fig. 55), Bennett, or Packard inhalers (vide 
 p. 114), or the gas may be given by the White dental inhaler, and 
 when unconsciousness is reached ether may be substituted by 
 using an ordinary cone inhaler. The latter method is of advan- 
 tage in operations about the throat. It has the objection, which 
 Hewitt considers serious when using it in adults, that at the 
 moment of change from gas to ether or during the first inhalations 
 of ether there is an interruption of the breathing which may lead 
 to dangerous spasm of the upper respiratory tract. This is most 
 likely to occur with robust or alcoholic subjects. In children it 
 is not likely to happen, and in them this method is simple and 
 valuable. The Clover-Hewitt inhaler with the Hewitt stop-cock 
 is recommended by Hewitt. The gas bag holds two gallons and is 
 replaced by the ordinary bag of the Clover inhaler when anaes- 
 thesia is induced. The ether may be placed in the inhaler after 
 the patient is insensible to its odor, and the transition from gas 
 to ether is gradually made by opening the ether indicator slowly. 
 
1 86 
 
 SEQUENCE OF ANAESTHETICS 
 
 The gas bag may be filled in another room, and the patient need 
 not see it. The noise of gas escaping from a cylinder is obviated. 
 The patient should be fully anaesthetized before ether is admit- 
 ted or there will be holding of the breath, spasm of the masseters, 
 and struggling or excitement. When stertor is present a breath 
 or two of air may be given. 
 
 Fig. 55- — Hewitt's Modification of Clover's Inhaler, for N 2 and Ether. 
 
 Fig- 55- Hewitt's modification of Clover's inhaler was designed for the 
 successive administration of nitrons oxide gas and ether. It has the fol- 
 lowing modifications from Clover's: (1) The air-way is much larger; (2) 
 The central tube rotates within the fixed reservoir; (3) The face-piece is 
 screwed into the ether reservoir so that the latter cannot be unexpectedly 
 detached from the former; (4) The ether reservoir can be adjusted, with the 
 patient in any position, so that ether may be poured into it without remov- 
 ing the inhaler from the patient's face. There are two separate inner tubes 
 which are made to revolve as one tube by the indicating handle which fits 
 into each. 
 
 The nitrous oxide-ether sequence has gained in popularity in 
 many hospitals in all sections of this country in the last few 
 years, and is being largely employed except when ether is contra- 
 indicated. Kelly says this method possesses so many advantages, 
 and so few disadvantages, to both patient and operator, that it 
 has become indispensable to his operative technique. 
 
SEQUENCE OF ANAESTHETICS 
 
 187 
 
 Chamberlain advocates this sequence, and uses the Bennett 
 inhaler. He precedes the inhalation of the gas by allowing the 
 patient to breathe through an Esmarch inhaler the vapor of a 
 few drops of oil of peppermint or a drachm of alcoholic solution 
 of menthol. This lessens bronchial irritation, suffocation and ex- 
 
 Fig. 56. — Gwathmey Gas-Ether Inhaler. 
 
 Fig. 56. This inhaler is light (26 ounces), portable and convenient. 
 The valves are of steel with brass springs, and may be removed and re- 
 placed, and the inhaler can be sterilized. Economy of the agent is a 
 feature of its use. The gas cylinder and bag of other inhalers is done 
 away with by placing one more tube in the ether cylinder, with the in- 
 spiratory valve in it, and placing the expiratory valve on the face-piece. 
 This practically places the gas within the ether chamber. The same bag 
 is used for gas and ether. 
 
 citement. The time of induction is lessened by this sequence 
 (average four minutes in 385 cases). The quantity of ether used 
 is much less, and after effects are correspondingly obviated. 
 
 Van Hook strongly advises the nitrous oxide-ether sequence. 
 The gradual changing is the ideal method. He uses a simple cap 
 containing gauze saturated with ether, which is applied to the 
 
1 88 
 
 SEQUENCE OF ANESTHETICS 
 
 gas inhaler at the proper moment, no air being admitted until 
 the patient is under the ether. 
 
 Gwathmey has devised a gas-ether inhaler which is a modifi- 
 cation of the Bennett inhaler (vide Figs. 56, 57). It can be used 
 for ether or gas alone or for the gas-ether sequence. 
 
 ^fi 
 
 Fig- 57- — Diagram of Gwathmey Inhaler. 
 
 A. Inspiratory valve. 
 
 B. Expiratory valve. 
 
 C. C. Tube for to-and-fro breathing 
 
 D. Tap for turning on and off the gas, admitting air when necessary; 
 and also for pouring ether into chamber. 
 
 E. E. Openings to ether chamber. 
 
 F. Tap for admitting air through face-piece. 
 
 THE CHLOROFORM-ETHER SEQUENCE. 
 
 This method has been considerably employed because the agree- 
 able odor of chloroform adapts it for use as an initial agent, and 
 because no special apparatus is necessary for administration. The 
 objection is raised that a large proportion of chloroform fatalities 
 
SEQUENCE OF ANAESTHETICS 189 
 
 occur during the initial stage of its administration, and therefore 
 the risk is practically as great as when chloroform is used for the 
 entire period of anaesthesia. It is not necessary, however, to carry 
 the chloroform far enough to entail these dangers, and if care 
 is exercised the risk is much less than with chloroform alone. 
 
 The administration of the chloroform should be conducted on 
 an Esmarch mask by the drop method of Prince. As soon as un- 
 consciousness is reached the ether is substituted. Any ether in- 
 haler may be used, or the ether may be given by the drop method 
 on the mask by using a thicker covering for the mask, such as 
 twice the thickness of gauze necessary for chloroform. The 
 change from chloroform to ether can thus be made gradually, 
 and often without any difficulty. Retching, vomiting, struggling, 
 etc., may occur if the change is made too early or if too little an- 
 aesthetic be given. Post-anaesthetic retching and vomiting is 
 usually no more frequent or severe than under chloroform alone. 
 
 THE A. C E.-ETHER SEQUENCE. 
 
 This method has been largely used and is considered by many 
 to be much superior to the previous method because less liable 
 to cause unpleasant or dangerous symptoms during the induction 
 of anaesthesia. It appears to be a particularly satisfactory method 
 of anaesthesia in persons who are generally regarded as unsatis- 
 factory subjects. 
 
 The administration may be conducted in the same manner as 
 w r ith the chloroform-ether sequence. Hewitt recommends for 
 adults, first the mask and drop-bottle, then the Rendel inhaler 
 with half a drachm of the mixture from time to time, and finally 
 the Ormsby inhaler with ether, and in children the mask until 
 respiration is deep and regular, then the Clover inhaler with 
 ether, the indicator being turned to "i." Rowell endorses prac- 
 tically the same method as being the safest routine method in 
 children. 
 
 THE ETHER-CHLOROFORM SEQUENCE. 
 
 This method is employed when ether is not well borne, or 
 when there is danger in using chloroform as an initial agent. It 
 may also obviate to some extent the danger of complications 
 which attend the continued use of ether in lengthy operations. 
 
 In changing from ether to chloroform it is important to make 
 the change under the proper depth of narcosis. Coughing, swal- 
 
190 
 
 SEQUENCE OF ANESTHETICS 
 
 lowing, or a moderate sensitiveness of the cornese indicate a 
 proper condition for the change. Struggling or excitement will 
 be aggravated by the change, and spasm is more liable to result. 
 If too deep narcosis is present the change may result in toxic con- 
 ditions. The respiratory tract should be free from mucus or 
 blood when the change is made, as the quieter respiration under 
 chloroform may be affected by their presence. 
 
 Fig. 58. — Dawbarn Inhaler. 
 
 This illustration does not show the relative size of the thin rubber 
 air-bag, which is large enough for the tidal air of the largest man. 
 
 THE ETHYL CHLORIDE-ETHER SEQUENCE. 
 
 This method of anaesthesia has steadily gained in use during 
 the past few years. Its comparative safety, together with its 
 freedom from disagreeable symptoms during induction, and from 
 
SEQUENCE OF ANESTHETICS I9I 
 
 unpleasant or serious after effects makes it preferred by many 
 over the gas-ether sequence. Any good closed inhaler which will 
 allow of perfect control of air may be used for this method. 
 Dawbarn advises the simple and cheap ether inhaler known by 
 his name, which embodies the principles of the Clover air-bag 
 inhaler (vide Fig. 58). 
 
 Dawbarn drops into the bag of this inhaler a couple of tubes 
 of ethyl chloride (Squibbs), each of which contains 5 c.c, and 
 each tube is wrapped separately in a little gauze secured by an 
 elastic band. When everything is ready, and the face piece is in 
 position, one of these tubes is broken through the bag, and thus 
 all waste of vapor is avoided. The other tube may be used or 
 not, as necessary. As soon as the patient is asleep the ether cage 
 (containing a crumpled handkerchief wet with ether) is slipped 
 into place, and the ether anaesthesia begins, at first being mingled 
 with the ethyl chloride vapor. 
 
 Various other sequences have been adopted with the object of 
 securing the best and safest features pertaining to each agent 
 and applying them to the particular stage of anaesthesia to which 
 they are adapted. Thus we have the nitrous oxide-ether-chloro^ 
 form sequence, the A. C. E. -ether-chloroform sequence, and the 
 chloroform-ether-chloroform sequence. Properly applied, these 
 changes may be of much utility in special circumstances. 
 
 Ethyl bromide-chloroform, A. C. E. -chloroform, ether-A. C. 
 E., nitrous oxide-ethidene dichloride, nitrous oxide and oxygen- 
 ether, are sequences which have been more or less used, but which 
 do not call for special mention, unless it be that the ethyl bromide- 
 chloroform sequence has been warmly advocated by some observ- 
 ers, who emphasize its advantages if care is taken to secure per- 
 fectly pure ethyl-bromide. The dangers of the chloroform in- 
 duction period are done away with and the narcosis is safely and 
 easily continued with chloroform, of which very small quantities 
 are necessary. In like manner the use of somnoform preliminary 
 to either ether or chloroform has become popular with those w T ho 
 believe this mixture is superior to ethyl chloride. 
 
CHAPTER XVI. 
 
 AFTER THE ADMINISTRATION OF AN ANESTHETIC. 
 
 The duties of the anaesthetist do not cease with the ending of 
 the administration. He should remain by the patient until con- 
 sciousness has at least in part returned, or until the patient is 
 asleep, and in case the patient sleeps quietly immediately after the 
 operation, the administrator or some competent person should 
 be on hand when he awakes in order to combat any troublesome 
 conditions that may arise. 
 
 Immediately after the operation the patient should be turned 
 on his side. The room should be kept dark and quiet to encour- 
 age sleep. The temperature of the room should be about 75 F. 
 Too free ventilation and drafts of air should be avoided. The 
 patient's head should be kept low and he should be covered with 
 a blanket. The stimulation of the circulation from an anaesthetic, 
 especially ether, is followed by more or less depression during 
 recovery, and in w r eak subjects it is advisable to surround the 
 patient with hot water bottles, which should be wrapped in flannel 
 to prevent injury to the surface of the body. 
 
 The rapidity of recovery will depend on the degree of narcosis, 
 the length of the administration, the degree of surgical shock, 
 the nature of the anaesthetic agent, and the nervous character of 
 the subject. When the anaesthetic is withdrawn from a fully an- 
 aesthetized subject the first evidence of recovery will be the dim- 
 inution of stertor, if it is present, and the appearance of quiet 
 breathing. The lid-reflex or swallowing movements, or both, next 
 appear. The pupils grow smaller, or may dilate if the patient is 
 disturbed, or if vomiting is imminent. The eyeballs become mo- 
 bile. The breathing may be slightly obstructed from swallowing. 
 Expiratory, moaning, or inspiratory noise may be present, and 
 coughing or retching and vomiting may follow. Immediately 
 after the operation the patient should be turned on his side, with 
 the head low and in the median line. If the subject has been 
 in a sitting posture, as for dental or oral surgery, he should be 
 bent forward to allow blood to escape from the mouth, and after- 
 ward placed in the lateral, recumbent position. If retching oc- 
 curs the lower jaw should be pushed well forward. 
 
AFTER THE ADMINISTRATION OF AN ANESTHETIC 1 93 
 
 Faintness, syncope, and weak pulse are generally due to nausea 
 and vomiting. They may, however, be due to the patient's gen- 
 eral condition, weak heart, or to shock from the operation. It 
 has been claimed that degenerative changes in the heart muscle 
 may be instituted by the anaesthetic, and that syncope and cardiac 
 failure may occur from this cause in patients whose hearts were 
 previously healthy. This is exceedingly doubtful. It is possible that 
 in some degrees of myocardiac degeneration the anaesthetic may 
 render the heart muscle weaker for some time subsequent to the 
 operation, even if difficulty was not apparent at the time of the 
 operation. Yet, in most cases of chronic muscular disease of the 
 heart, if the dynamic condition is fair at the time of anaesthesia, 
 the after-effects on the circulation will be unimportant. 
 
 No food should be allowed for at least five hours after an- 
 aesthesia. If the stomach feels badly, a few sips of clear, strong 
 coffee may be given half an hour after the patient is fully con- 
 scious. 
 
 If the patient feels very prostrated, sipping hot water for a few 
 minutes at a time will act as a good stimulant. If the after-taste 
 of ether is complained of, a small slice of lemon, or some orange 
 juice will relieve it. If the patient is hungry, a little food may 
 be given about four or five hours after the administration. A 
 little meat broth or soup, or some beef extract, such as somatose, 
 Liebig's extract or Armour's extract. I have found the Mos- 
 quera liquid extract given quite hot to be very satisfactory. Seltzer 
 and milk may be preferred in some cases. 
 
 Vomiting is the most troublesome condition and the hardest 
 to control in some instances. If the patient has been properly 
 prepared for the operation by giving a purgative, and by keeping 
 the stomach empty, vomiting is not as likely to occur as if these 
 precautions are neglected. If the patient is too deeply narcotized, 
 if the anaesthesia is prolonged, if blood or mucus enters the stom- 
 ach, or if the patient is moved or disturbed during the early period 
 of recovery, there will be greater liability to vomiting. Robust 
 children and women, and bilious, over-fed men, are most liable to 
 vomiting. Patients operated on early in the day are less liable 
 to vomiting than those operated on late in the afternoon. Certain 
 operations, such as abdominal or pelvic operations, are more 
 
194 AFTER TJIE ADMINISTRATION OF AN ANAESTHETIC 
 
 liable to be followed by vomiting than are operations about the 
 upper portion of the body. 
 
 The kind of anaesthetic and its purity will influence the tend- 
 ency to vomiting. Nitrous oxide, ethyl chloride, and ethyl bro- 
 mide are less often followed by vomiting than are other anaesthet- 
 ics. Ether produces transient vomiting more often than chloro- 
 form, but persistent vomiting is more frequent after chloroform.* 
 
 Many remedies have been recommended for the treatment of 
 vomiting, but it is not always possible to tell what will be effica- 
 cious. Ochsner recommends a napkin wet with vinegar laid over 
 the nostrils, an ice bag over the phrenic nerve, sips of hot water 
 every 15 minutes, occasional sips of strong coffee, small pieces 
 of ice in the mouth, and, in persistent cases, hot enemata of nor- 
 mal salt solution. Hunter Robb advises one or two teaspoonfuls 
 of toast water every 20 minutes by mouth for 6 to 12 hours. The 
 head should be kept low, on level with body or only slightly ele- 
 vated. Vomiting usually stops in from 18 to 20 hours. If it 
 continues after the third day, and if the fluid is expelled without 
 effort, the vomiting is likely due to peritonitis. It may be re- 
 lieved by two or three drachms of very hot water containing ten 
 grains of bicarbonate of soda, repeated every hour or two. Light 
 mustard plaster may be placed over the epigastrium. It may be 
 necessary to wash out the stomach. The vomiting from peritonitis 
 is hard to control. It is made worse by the administration of 
 drugs. Treatment of the accompanying constipation and tympany 
 may relieve the vomiting. It may be necessary to inject morphine 
 over the epigastrium to relieve retching. 
 
 Bonney divides the vomiting after pelvic operations into irri- 
 tative, neurotic, obstructive, and peritonitic. Irritative vomiting 
 is due to gastritis from the anaesthetic. No food should be given 
 by the mouth. Nutrient enemata may be given. If the vomiting 
 is not severe, peptonized milk and lime water may be given, or 
 one dram of bicarbonate of soda in three ounces of hot water 
 one-half hour before food, or bismuth and bicarbonate of soda 
 every three hours may be taken. For bilious vomiting, one dram 
 doses of bicarbonate of soda should be used. For neurotic vom- 
 iting, a little brandy in the food, and moral suasion, with mustard 
 to the epigastrium. Soap and water enemata are very useful in 
 all forms of vomiting. 
 
 *In some hospitals the stomach pump is used in all cases, if possible, 
 before the patient regains consciousness. As much material as possible is 
 aspirated in this way, and while vomiting is not prevented, always, it is 
 lessened in severity. 
 
AFTER THE ADMINISTRATION OF AN ANAESTHETIC 195 
 
 In some cases the procedure used by Joos for vomiting during 
 anaesthesia may b^ beneficial — compression of the phrenic nerve 
 and the vagus on the left side immediately above the sternal end 
 of the clavicle, by the thumb, the hand laying flat on the thorax 
 parallel with the clavicle. 
 
 Blumfeld advises lavage of the stomach with plain water for 
 after-vomiting, and Lenevitch advises the same proceeding with 
 lukewarm alkaline solutions. In neurotic subjects an enema of 20 
 to 25 grains of potassium bromide in three or four ounces of 
 water may be useful. For persistent vomiting we may try one 
 minim doses of tincture of iodine every two hours, or one-third of 
 a grain of zinc oxide three or four times daily, or one-two-hun- 
 dredth of a grain of permanganate of potash on an empty stomach, 
 or one drachm every 15 minutes of a mixture of 4 drops of creo- 
 sote to 2 ounces of lime-water, or teaspoonful doses every hour of 
 2 ounces of lime-water containing- 1 grain of carbolic acid, or one- 
 half grain doses of menthol in liquid vaseline, or one-eighth grain 
 doses of cocaine, repeated as necessary. Persistent nausea may 
 often be relieved by small amounts of champagne, or by 1 or 2 
 grain doses of oxalate of cerium. 
 
 Bronchial and pulmonary symptoms may arise from the pres- 
 ence of foreign substances in the respiratory tract. In these cases 
 diagnosis may be difficult, and the result may be fatal if opera- 
 tion does not give relief. Bronchitis occurs in rare instances, and 
 especiallv when there has been an attack just previous to the an- 
 esthetization. Pneumonia occurs in a varying proportion of cases. 
 Its relation to the anaesthesia is not exactly determined (vide p. 
 104) . According to Van Beck, the use of ether in Czerny's clinic 
 has been restricted because of its injurious effects upon the res- 
 piratory tract. The occurrence of pneumonia after anaesthesia 
 may easily be overlooked, as there is frequently absence of chill, 
 and slight or irregular rise in temperature. The physical signs 
 are also apt to be atypical. Most of the cases occur during cold 
 weather, and the change from a warm operating room to a cold 
 corridor may have its causative effect. Again, a deep and pro- 
 longed narcosis may tend to favor the occurrence of pneumonia. 
 The pneumonia usually appears within the first 24 hours succeed- 
 ing the administration of the anaesthetic. 
 
 The lung complications after anaesthesia which were formerly 
 
ig6 AFTER THE ADMINISTRATION OF AN ANESTHETIC 
 
 thought to occur only after ether or chloroform are known to 
 occur after any form of anaesthesia, even after local anaesthe- 
 sia. The statistics of Chevers and Ericksen show that these com- 
 plications were much more frequent in pre-antiseptic days than at 
 present. Aufrecht found that lung complications followed the use 
 of chloroform, but not as frequently as they did the use of ether. 
 Mikulicz (German Congress of Surgery, 1901) gave 1,007 
 laparotomies and operations for goitre under general anaesthesia, 
 with 7.5 per cent, of pneumonia and a mortality of 3.4 per cent. 
 Also 273 laparotomies (local anaesthesia), with 12.8 per cent, of 
 pneumonia, and a mortality of 4.8 per cent. Operations on the 
 neck, mouth, jaws, and chest also seem to favor the development 
 of pneumonia. Mikulicz is inclined toward general anaesthesia 
 in these cases, and favors chloroform unless there is some contra- 
 indication to its use. Ether is more dangerous because it is more 
 irritating to the respiratory passages and because it increases the 
 secretion of mucus.* 
 
 Regarding the aetiology of lung complications after operation, 
 the conclusions of Geralanos may be accepted. The irritant action 
 of the agent on the respiratory tract and the hypersecretion 
 (ether) ; the toxic effect of the agent on the blood vessels, result- 
 ing in hyperaemia, oedema of the lungs, secondary heart effects, 
 due to both chloroform and ether, especially the latter. This con- 
 dition favors hypostatic pneumonia, diminishes local resistance to 
 infection which may occur by inspiration, infected emboli, or by 
 bacteria in the blood ; the inspiration of infected material from se- 
 cretions of the mouth and pharynx, or vomitus ; infected or non- 
 infected emboli from thromboid vessels (usually veins) from the 
 region of operation ; chilling, fright or shock from the operation, 
 with or without haemorrhage, all lower resistance. Prolonged nar- 
 cosis, exposure of the chest or peritoneal cavity reduce temper- 
 ature ; general weakness of the patient lowers resistance ; interfer- 
 ence with respiration and expectoration by pain or wound or by 
 tight bandages. 
 
 Acute oedema of lungs, according to Lindemann, occurs from 
 toxic dilation of the blood vessels and hyperaemia of the lung 
 tissue. 
 
 Embolic pneumonia is independent of the general narcosis 
 and is due to the nature of the operation and of the disease. In 
 
 *Dawbarn says that chilling of the lungs from the use of a cone, Allis 
 inhaler, or some such method, is the chief cause of pneumonia after anaes- 
 thesia, and that the rebreathed, lung-warmed ether of the Clover air-bag 
 principle should have received clearer recognition in this connection. Be- 
 sides, it saves the necessity of administering so much ether, which favors 
 quick and uncomplicated recovery. 
 
AFTER THE ADMINISTRATION OF AN ANAESTHETIC I97 
 
 strangulated hernia and ileus of other forms the mesenteric veins 
 may be thrombosed beyond the seat of the constriction even 
 though the bowel be not gangrenous. When the constriction is 
 removed emboli may form and pass to the lungs. The emboli may 
 be infected ; or, if not, the infarct produced may become infected 
 from organisms already in the bronchi, or from the blood. Emboli 
 may form in any operation when there is thrombosis either before 
 or after operation. They are most common in connection with 
 laparotomies, may be secondary to phlebitis of the lower extrem- 
 ities, which sometimes occurs after laparotomies. 
 
 Gangrene and abscess of the lungs are rare after operation. 
 They are due to inspiration of infected material, or to infected 
 emboli. 
 
 In weak, debilitated subjects the dressings should be loose, the 
 patient should be encouraged to inspire deeply and to expecto- 
 rate, the mouth and pharynx should be kept clean, especially if 
 the patient vomits. If there is much pain small doses of morphine 
 are advisable. Abdominal distention should be prevented. The 
 position of the patient should be changed frequently, and the head 
 and shoulders should be slightly raised. 
 
 Various paralyses may occur from pressure incident to certain 
 operations. They are usually transient in character. Leszynsky 
 believes that paralysis is due to lesion of the nerve trunk and is 
 a peripheral paralysis from pressure, extension, elevation, unnec- 
 essary position, etc. Flatau thinks that in anaemia and in arterio- 
 sclerosis cases the paralysis is central. Bloodgood noted five in- 
 stances of paralysis of the upper extremities in about five hundred 
 operations. In each case the pectoral muscles had been divided, 
 allowing of greater extension of the extremity than usual. The 
 precautions to be taken are obvious and are important, as the re- 
 covery may be tedious. 
 
 Anuria after anaesthesia is considered by some observers due 
 to the effect of large doses of the agent in modifying the flow 
 of blood through the kidneys. Exposure of the patient's body, 
 and reflex disturbance from operations on the genito-urinary 
 tract are also considered factors producing anuria. The thera- 
 peutic indications are : Strychnia and digitalis if the circulation 
 is depressed ; normal salt solution per rectum or under the skin ; 
 
198 after the administration of an anaesthetic 
 
 and nitroglycerine if sclerotic conditions of the vessels indicate 
 the possible presence of vascular spasm. 
 
 The special after-effects of the individual anaesthetics have 
 been mentioned under their respective causes and need not be re- 
 peated here. 
 
 
PART II. 
 
 Local Anaesthesia and 
 Anaesthetics. 
 
 / 
 
CHAPTER XVII. 
 
 LOCAL. ANAESTHESIA. 
 
 The local employment of anaesthetic substances or mixtures, 
 or of cold in the form of ice or freezing mixtures, as well as con- 
 striction of the parts, has long been practised for anaesthetic pur- 
 poses. Little was accomplished in this direction, however, until 
 Richardson introduced the hand-ball spray method of using ether 
 for the purpose of local anaesthesia. This method consists in di- 
 recting an atomized current of ether against the part to be oper- 
 ated on. The rapid evaporation of the ether produces an intense 
 degree of cold which freezes the part. The chief objections to 
 this method are the pain caused by its application to sensitive tis- 
 sues, and the burning sensation which follows resumption of func- 
 tion by the nerves and vessels of the part. The ether used for this 
 purpose should have a sp. gr. not to exceed 0.723. 
 
 Rhigolene, the lightest liquid known, is more effective than 
 ether, but is difficult to handle because of its great volatility. It 
 is a product of the fractional distillation of petroleum. 
 
 These agents have had but a limited application for minor sur- 
 gical operations. Since the introduction of cocaine, however, as 
 a local anaesthetic agent the field for this method of anaesthesia 
 has enlarged until at present, with the exception of certain op- 
 erations on the organs and cavities of the body, most of the major 
 operations come within the possibilities of local anaesthesia. There 
 can be no question but that general anaesthesia is very frequently 
 used where local anaesthesia would answer. This is specially true 
 in regard to short operations when the dangers of general anaes- 
 thesia, and its post-operative complications, might be largely 
 avoided by the employment of local anaesthesia, particularly as in 
 the last few years the technique, effectiveness, and applicability of 
 local anaesthesia has been immensely improved. 
 
 In regard to prolonged operations involving considerable 
 shock, the most recent observations show that the expectation that 
 local anaesthesia would prove less dangerous than general anaes- 
 thesia is not warranted. While local anaesthesia is possible in this 
 class of operations, shock is just as severe or more so under local 
 
202 LOCAL ANAESTHESIA 
 
 as under general anaesthesia, and post-operative complications ap- 
 pear to be about as frequent and as fatal. 
 
 The frequency and fatality of post-operative pneumonia and 
 other lung complications in connection with operations on the 
 stomach and intestines by local anaesthesia is greater, according 
 to the statistics of Mikulicz, than after general anaesthesia. The 
 shock, fright, and unpleasant conditions arising from the con- 
 scious state of the patient renders these prolonged, tedious opera- 
 tions very trying under local anaesthesia. 
 
 These conditions, together with the difficulty of obtaining com- 
 plete muscular relaxation in some cases, militates against local 
 anaesthesia in this class of operations, unless it could be proven 
 that both primary and secondary dangers were practically ob- 
 viated.* 
 
 In relation to the selection of methods, Mikulicz says that the 
 question now is in which class of cases shall general narcosis be 
 substituted for local anaesthesia ; that in one group of cases the 
 indications for local anaesthesia are absolute. In this group should 
 be included all operations which can properly be performed under 
 local anaesthesia, whether a general anaesthetic is contraindicated 
 or not, such as minor operations, tracheotomy, gastrostomy, etc. 
 In another group is placed those operations in which there is yet 
 doubt as to the safer method of anaesthesia, such as major opera- 
 tions on the stomach and intestines, free and strangulated hernia, 
 goitre, etc. 
 
 For reasons already mentioned most surgeons place operations 
 on the organs within the abdomen as unsuitable for local anaes- 
 thesia. Bloodgood places reducible hernia in the doubtful group 
 because of the difficulty of completing the operation in some cases 
 under local anaesthesia, and thinks that in patients where a gen- 
 eral anaesthesia is contraindicated, the operation should be per- 
 formed under local anaesthesia or not at all. Strangulated hernia 
 he places under the group indicating local anaesthesia. 
 
 In operations for goitre the special dangers of general anaes- 
 thesia, and the success of such operators as Kocher with local an- 
 aesthesia, influence many surgeons to include operations for struma 
 in the group indicating local anaesthesia. 
 
 COCAINE. 
 
 Cocaine (C 17 H 20 N0 4 ) is an alkaloid obtained from the 
 
 *According to Braun a good local anaesthetic should possess the fol- 
 lowing characteristics: (i) It must, in proportion to its local anaesthetiz- 
 ing power, be less toxic than cocaine; (2) it must not irritate or damage 
 the local tissues to the smallest extent; (3) it must be'fairly stable, solu- 
 ble in water, and should be capable of sterilization by heat without change 
 or alteration of its action ; (4) it should be capable of combination with 
 suprarenal extract without interference with the action of the latter; 
 (5) it should be capable of being rapidly and completely taken up by mu- 
 cous membrane. 
 
LOCAL ANAESTHESIA 203 
 
 erythroxylon coca, N. O. Linaceae. The name coca is derived 
 from the Aymara (Indian) word khoka, signifying "plant" (or 
 tree, i. e., the specially favored one). The plant grows to a height 
 •of six or eight feet, has bright green leaves, and bears small, white 
 flowers. It resembles the blackthorn. The natives of Peru and 
 neighboring provinces cultivate the shrub. The Spanish found 
 the natives of Peru familiar with the narcotic properties of the 
 plant. The leaves were dried in the sun, and mixed with a little 
 lime to form a preparation for chewing, something like the betel 
 leaf of the East. Under its stimulus the natives were able to per- 
 form tasks requiring great endurance. Prescott says, "Even food 
 the most invigorating is less grateful to him than his loved nar- 
 cotic." According to Clnsius, the Indians stated that while using 
 coca neither hunger or thirst annoyed them, while their strength 
 and vigor were maintained. 
 
 The use of coca did not become general until after Pizarro 
 ravaged the country. Previous to this time, during the reign of 
 Tupac Inca Yupangin, the most renowned of the "children of the 
 sun," and of his son, Huayno Copac, during whose reign Vasco 
 Nunez de Balboa took possession of the new continent from a 
 ^'peak of Darien", in the name of Ferdinand and Isabella, and 
 tip to the time of the overthrow of Atohuallpa, the plant was re- 
 served for the use of the Incas, the coca plantations or "cocals" 
 being owned by the state. 
 
 The continued use of coca forms a habit similar to the opium 
 habit. Appetite is lost, digestion weakened, and an inordinate de- 
 sire for animal food follows. Then follow boils, dropsical swell- 
 ings, foetid breath, pale lips, discolored teeth, dim, sunken eyes, 
 yellow, discolored skin, and the coquero becomes as pitiable an ob- 
 ject as the most confirmed opium habitue. 
 
 The effects of coca depend on the presence of the alkaloid 
 cocaine, which has basic properties and combines with acids to 
 form salts. It crystallizes in prisms which are transparent and 
 colorless when pure. It is slightly soluble in water, and in alco- 
 hol, and freely soluble in ether. It has a bitter taste, and its salts 
 are more bitter than the alkaloid itself. Coca contains, beside 
 the alkaloid, an aromatic oil "hygrine", discovered by Lossen in 
 1862, which has an alkaline reaction and a biting taste, but is with- 
 
204 LOCAL ANESTHESIA 
 
 out therapeutic virtue. Coca is slightly astringent from the pres- 
 ence of a tannic acid. 
 
 Cocaine was discovered by Gordeke in 1855, and called ery- 
 throxyline. It was afterward named cocaine by Niemann, who first 
 studied carefully its physiological action. 
 
 Cocaine hydrochlorate occurs in colorless, transparent crys- 
 tals, or as a white, crystalline powder, without odor, with a slight- 
 ly bitter taste, and produces on the tongue a tingling sensation fol- 
 lowed by a numbness. It is soluble at 59 F. ( I5°C.) in 0.48 parts 
 of water, and in 3.5 parts of alcohol. 
 
 The local anaesthetic action of cocaine when applied to the skin, 
 mucous membranes, wounds, or ulcerating surfaces, became 
 known soon after its discovery in 1855, and was noted by Morenoy 
 and Maiz, in 1862, and by von Aurep in 1883. Roller, of Vienna, 
 demonstrated its value, especially in ophthalmic practice, in 1884, 
 and Noyes, of New York, who observed his demonstrations, pub- 
 lished them in this country. 
 
 Locally applied, cocaine produces anaesthesia, and a condition 
 of anaemia due to contraction of the arterioles. Solutions do not 
 affect the intact skin. Personal idiosyncrasy markedly affects the 
 action of cocaine. Alarming depression has followed the use of a 
 few drops of a 4 or 6 per cent, solution in the eye, or in the nasal 
 passages, or the use of as little as one-eighth of a grain hypo- 
 dermically, and death has followed moderate doses. It is not ac- 
 tively toxic, and some persons can take large doses without ill 
 effects. 
 
 The experiments of Crile, of Cleveland, show that in animals 
 under the effects of cocaine or eucaine exposure or manipulation of 
 the intestines, mechanical irritation of sensitive tissues, manipula- 
 tion of the larynx, stimulation of the vagi, operations on the 
 larynx and other portions of the body produced little or none of 
 the fall of blood pressure which characterized such procedures 
 in the control animals. The vessels of the splanchnic area are 
 smaller and much less congested in the cocainized animals. 
 
 The effects of cocaine on the circulation were, first, a rise in 
 blood pressure, followed by a fall ; and later a gradual rise. The 
 inhibitory action of the vagus is partially or wholly suspended. 
 The vaso-motor reflexes are lessened. The circulation is less re- 
 sponsive to stimulation. 
 
LOCAL ANAESTHESIA 205 
 
 A small dose acts as a stimulant to the respiration ; a medium 
 dose diminishes the length of the respiratory stroke ; large doses 
 cause gradual diminution of the respiration. Some degree of tol- 
 erance is acquired by successive doses, and general anaesthesia is 
 more difficult to induce in animals under the influence of these 
 drugs. 
 
 In ophthalmological practice anaesthesia is first induced in the 
 conjunctiva and cornea, and may be produced by 2 per cent, solu- 
 tions, though 5 per cent, solutions act quicker, and are suitable for 
 the deeper structures. Prolonged contact, wounds, or incisions 
 aid the diffusion of the anaesthetic. Simple congestion does not 
 materially hinder the action of the anaesthetic, though chronic 
 changes retard its effects. Where such changes are present, or 
 when operative procedures have recently preceded the use of the 
 anaesthetic, its action may be aided by the preliminary use of a so- 
 lution of adrenalin. 
 
 Some mydriasis occurs from the action of cocaine, reaches its 
 maximum in about one hour, and disappears in from two to three 
 hours. The pupil remains sensitive to light (Koller). Accommo- 
 dation is moderately affected. 
 
 In the surgery of the naso-pharynx, larynx, urethra, bladder, 
 etc., solutions of from 4 to 6 per cent, are necessary, and danger- 
 ous conditions are therefore more likely to arise. More caution is 
 being exhibited in its use in these connections, and eucaine b. is 
 being much substituted for cocaine, as being less toxic, while 
 equally anaesthetic. 
 
 Crile emphasizes the importance of the local application of 
 cocaine solution to the larynx or pharynx (2 per cent.) , along with 
 the hypodermic use of atropine to prevent reflex inhibition of the 
 heart and respiration. 
 
 Legrand recommends a mixture of cocaine and ethyl chloride, 
 which is used as a spray. In five minutes the ethyl chloride is 
 evaporated and leaves the cocaine on the surface as a whitish de- 
 posit. It is useful in making painful applications to ulcerating sur- 
 faces, or to skin lesions. 
 
 Local Infiltration Method. — This method of producing 
 local anaesthesia by infiltrating the skin with an anaesthetic solution 
 was introduced by Halsted and Hall, who experimented in this 
 direction in 1884 and 1885. Schleich, for whom this method is 
 
20b LOCAL ANESTHESIA 
 
 usually named, and who fully developed the method, published 
 his first results about four years later. Liebrich, Halsted, and 
 Schleich have shown that an artificial cedema of the tissues, es- 
 pecially of the papillary layer of the skin, produces slight anaes- 
 thesia, but not analgesia. Halsted (1885) found it possible to com- 
 pletely anaesthetize the skin to any extent by subcutaneous injec- 
 tion of water, and employed this process for minor operations. 
 This anaesthesia did not extend beyond the boundary of the weal, 
 and did not always disappear as hyperemia appeared. Halsted 
 found normal salt solution less painful than water. 
 
 Schleich demonstrated the possibility of perfect and painless 
 anaesthesia by infiltration with weak solutions of cocaine (0.1 per 
 cent, or less). Success depends on the proper infiltration of the 
 skin, and other tissues as they are dealt with. Extensive opera- 
 tions and dissections may be performed by this method because 
 of the dilute nature of the solutions and the freedom with which 
 they may be used without danger of toxic effects. 
 
 Most authorities advise a 0.1 per cent, solution, or less, 
 of cocaine for infiltration. Some think that morphine is 
 not necessary for the success of the anaesthesia, and for 
 extensive operations omit the morphine and dilute with 
 sterile salt solution as the operation proceeds. The solutions 
 should be sterilized by repeated heating in a water bath, or in a 
 steam sterilizer (fractional method). Matas drops the tablet pre- 
 pared by manufacturers into boiled water, and heats the solution 
 nearly to the boiling point two or three times. This is a simple 
 and practical method. Many authorities state that boiling injures 
 the anaesthetic qualities of cocaine solutions, but when carefully 
 sterilized there appears to be no injury to their properties.* 
 
 Technique. — The success of the infiltration depends on the 
 proper production of a weal. The first injection is somewhat pain- 
 ful, and a fine needle should be used. It should be introduced 
 in a slightly oblique direction, and the fluid injected into the skin, 
 and not beneath it, so as to produce an elevation of the epidermis, 
 which becomes white from anaemia. The first weal should be 
 large. The needle may be thrust beneath the skin, injecting the 
 fluid as it proceeds, or it can be withdrawn and introduced just 
 within the border of the weal so as to cause no pain, and a suc- 
 cession of weals produced of sufficient extent for the necessary in- 
 
 *When large areas are to be anaesthetized a solution of sodium chloride 
 (0.5 gramme to 100 c.c. of distilled water is the best menstrum. 100 to 
 250 c.c. of this solution will generally be enough. The maximum amount 
 of drug to be used has been placed at about 0.17 gramme of cocaine in 
 combination with adrenalin. 0.30 gramme of eucaine, and 0.25 of stovaine. 
 
LOCAL ANAESTHESIA 207 
 
 cisions. If several syringes are at hand the infiltration can be 
 made rapidly. It is sometimes of advantage to further oedematize 
 the area by injections of sterile salt solution. As the nerve trunk, 
 filaments, and the vessels of the deeper tissues are also painful, 
 it is necessary, in deep operations, to oedematize the deeper tissues 
 by infiltrating them in the same manner. Experienced operators 
 know just what tissues to infiltrate. If one is not sure it is best 
 to infiltrate the tissues before dividing them. 
 
 Combined with other methods next to be considered, exten- 
 sive operations are possible that could not be performed by this 
 method alone. Tearing or traction of the tissues causes more pain 
 than to cut them. 
 
 Diminished resistance of infiltrated tissues, infection, suppura- 
 tion, necrosis, and imperfect healing of wounds so infiltrated are 
 not to be feared if proper precautions are taken. If the tissues 
 about vessels are infiltrated before dividing the vessels, haemostasis 
 can be obtained. Pain from suturing of wounds can be prevented 
 by reinfiltration from the margin of the skin incisions. 
 
 Regional Paraneural Infiltration. — This method was in- 
 troduced by Halsted, Hall, and Corning, in 1884 an -d 1885. It 
 was extensively used by Oberst, and is generally known by his 
 name. It consists in infiltration of the tissues about the peripheral 
 nerves supplying the part to be operated on, and above the point 
 of operation. It was first used for operations about the fingers 
 and toes, but as the technique improved has been extended to op- 
 erations on the entire extremities, and for areas of the head, neck 
 and trunk.* 
 
 Technique. — An Esmarch, elastic constriction bandage is 
 placed upon the toes, foot, ankle, leg, thigh, fingers, wrist, fore- 
 arm, or arm, as the case may be, a short distance above the seat 
 of the operation. Corning was the first to employ the Esmarch 
 bandage in connection with this method of anaesthesia. It was 
 first used to allow of the deep injection of stronger solutions or 
 larger amounts than is ordinarily used, and which are sometimes 
 necessary with this method. There is less danger of toxic effects 
 when the constriction is used, and when the bandage is left on for 
 from one-half to one hour the injection appears to lose its toxic 
 effects, according to some observers, because of some action of 
 the tissues upon the drug. Some authorities claim that the Es- 
 
 *Pennington advises regional anaesthesia in operations for ano-rectal 
 diseases, and uses the following solution : Beta eucain lactate, 0.2 ; sodium 
 chloride, 0.75; suprarenal chloride solution, 0.65; distilled water, 100.0. 
 For the deep structures, to block off the nerves, he uses a No. 17 gauge 
 needle 2 l / 2 to 3 inches in length, blunt pointed, with holes in the sides, in 
 order to avoid injury to the blood vessels. 
 
208 LOCAL ANAESTHESIA 
 
 march bandage is unnecessary, but the majority believe in its good 
 effect. 
 
 Walsendorf, in 1676, produced anaesthesia by simple constric- 
 tion of the limb, and Esmarch states that he performed painless 
 operations on the fingers and toes by means of constriction. 
 
 The application of the bandage is rather painful, which is less 
 if the constriction is just sufficient to occlude the vessels, and a 
 broad band is used. The deep injection is made just below the 
 bandage, and the tissues about the nerve are infiltrated. The num- 
 ber of injections will depend en the number of nerves to be an- 
 aesthetized. The region supplied by these nerves becomes anaes- 
 thetic in from five to ten minutes, and the anaesthesia lasts long 
 enough for operative procedures. The bandage should be left on 
 for one-half hour or more if strong solutions have been used. 
 If weak solutions have been injected the bandage may be re- 
 moved at once. The weaker solutions are adapted to the com- 
 bined use of this method with direct injection of the nerve, and 
 local infiltration of the. skin. The bandage may here be discarded, 
 or may be removed as soon as the operation is completed. 
 
 The Regional Intraneural Method. — By this method the 
 nerve trunk is exposed by the infiltration method, and then in- 
 jected with a 0.5 to 1 per cent, solution of cocaine. Cushing's 
 method was to inject the nerve as it was exposed during the dis- 
 section. He perfected his method especially for hernia opera- 
 tions. When this method is properly performed all afferent im- 
 pulses are checked. The method was suggested by Crile and 
 Matas particularly for amputations and operations on the extrem- 
 ities.* 
 
 According to Bieberfield, cocaine is necessary in this method, 
 and solutions of from 0.25 to 0.5 per cent, are advisable. 
 
 Crile has performed major amputations with this method, and 
 says the technique is based on the fact that "nerve trunks may 
 be safely and effectually subjected to a physiologic 'block' by in- 
 jecting cocaine or eucaine in a comparatively weak solution, and 
 that arteries may be, with entire safety, temporarily closed with- 
 out injury to their walls." He exposes the nerve trunks under local 
 anaesthesia and injects their sheath and then their substance with 
 a 0.5 per cent, solution of cocaine, just sufficient to cause a local- 
 ized swelling. Shock is almost wholly avoided because all afferent 
 
 *Bodine sees no reason why all major surgery of the extremities should 
 not be done by Coming's nerve-blocking method of injecting directly into 
 the nerves supplying the limb. He thinks this method prevents shock, 
 as claimed by Crile and Matas. Bodine uses a solution of one grain of 
 cocaine in one ounce of sterile salt solution to infiltrate the skin and to 
 cocainize nerve trunks. For subdermic infiltration this is diluted to 1-1000 
 by using half of normal salt solution. He thinks that two-thirds of a 
 grain of cocaine is safe for an adult. 
 
LOCAL ANAESTHESIA 2CO. 
 
 impulses are blocked, shock being due to afferent impulses, occa- 
 sioned by operation or injury. General anaesthesia only slightly 
 modifies these afferent impulses, abolishing those for pain, but 
 not controlling those for the vaso-motor, respiratory, or cardiac 
 mechanism. Cocaine or eucaine absolutely blocks afferent im- 
 pulses and wholly prevent reflex inhibition, as in operations about 
 the larynx or pharynx. Hypodermically they diminish shock in 
 operations about the splanchnic area, and diminish the effects of 
 operation on or exposure of this area. 
 
 The preliminary use of a hypodermic dose of morphine of 
 from one-eighth to one-fourth of a grain before local anaesthesia 
 by any method is recommended. 
 
 Bagot produces local anaesthesia by a mixture of cocaine and 
 spartein sulphate. The latter is used to counteract the depressing 
 effect of cocaine. He uses powders, each containing three-fifths 
 of a grain of cocaine and three-fourths of a grain of spartein, and 
 dissolves one powder in 15 drops of boiling water, and another in 
 30 drops of boiling water. Fifteen drops of the weaker solution 
 are injected in the part to be operated on, and in 7 or 8 minutes 
 the remaining fifteen drops are injected. The wound is touched, 
 from time to time, with the stronger solution. 
 
 OTHER LOCAL ANAESTHETIC AGENTS. 
 
 Eucaine a, or Alpha eucaine (C 19 H 27 N0 4 ). — Forms 
 glossy prisms melting at 104 C. Because of the insolubility of 
 the base the hydrochloride is usually employed. Eucaine hydro- 
 chloride is soluble in the proportion of 1 in 10 parts of water. It' 
 has local anaesthetic properties like cocaine. It is not decomposed 
 by heat during sterilization. It was supposed to have less action 
 on the heart than cocaine, but has been practically discarded be- 
 cause of its general toxic properties, which resemble those of 
 strychnia poisoning. In ophthalmic practice it produces consid- 
 erable pain and burning, and because of this is sometimes com- 
 bined with cocaine (cocaine hydrochloride, eucaine hydrochloride, 
 aa. 0.05 gm., aqua., 5 gm.). As a nose and throat application a 
 5 to 10 per cent, solution may be used. 
 
 Eucaine B, or Beta eucaine (C, 5 H 21 N0 2 HCL). — The 
 hydrochloride of benzoyl — vinyl — diacetonalkamin, used as a sub- 
 stitute for cocaine. The crystals are soluble in water and are not 
 
2IO LOCAL ANESTHESIA 
 
 decomposing on heating. It melts at 263 C. (505.4 F.) It is 
 completely free from irritating properties, is less toxic than co- 
 caine, and is said to be 3.75 times less toxic than eucaine a. 
 
 Eucaine b. was introduced by Silex in 1897. It is the most sat- 
 isfactory substitute for cocaine as yet obtainable. It is not equal 
 to cocaine in its anaesthetic qualities, but is distinctly less toxic. 
 When large amounts of weak solutions are required, eucaine b. is 
 recommended by many. For the urethra and bladder it can be 
 used in 4 per cent, solutions to considerable amounts, and is em- 
 ployed in preference to cocaine. About the nose and throat it is 
 safer than cocaine. In Oberst's paraneural infiltration, and for 
 operations high up on the extremities, it may be used in stronger 
 solutions than cocaine with safety. For intraneural injections a 
 solution of 1 per cent, may be used extensively, which might be 
 troublesome with cocaine. In ophthalmic practice eucaine b. is not 
 as satisfactory as cocaine. Schleich believes that if operations can 
 be performed with 0.1 per cent, or less of cocaine, it is the bet- 
 ter agent, and that if toxic symptoms appear during the operation 
 eucaine b. should be substituted. Reclus says the advantages of 
 eucaine b. are : It can be sterilized by boiling ; the solution is 
 stable ; it is much less toxic than cocaine. He makes the patient 
 lie down after using a 1 per cent, solution of cocaine, which is un- 
 necessary when eucaine b. is used. 
 
 Heinzle says eucaine b. is the best agent. The solutions should 
 be used at the body temperature. He employs 1 part of eucaine b., 
 8 parts of sodium chloride, and 100 parts of distilled water. 
 
 Eucaine b. is used in sterilized solutions up to 2 per cent. The 
 anaesthesia may be in some instances as complete as that of co- 
 caine, and more rapid, but does not last so long. It is less irritant 
 and toxic than cocaine. There is often a decided burning sen- 
 sation for an hour or so after its use.* 
 
 Tropa-Cocaine Hydrochloride (bensoyl-pseudo-tropein) is 
 an alkaloid derived from the small-leaved coca plant of Java. It 
 was first isolated by Giesel. and is identified with the pseudo- 
 tropein of hyoscyamus by Liebermann, who prepared it synthet- 
 ically. It occurs as white needles, melting at 27i°C. (519.8 F.), 
 and is readily soluble in water. According to Ferdinande and 
 Chadbourne a 2 or 3 per cent, solution produces more rapid, re- 
 
 *Parker maintains that infiltration fluids to be practical anaesthetics 
 must contain about 1 per cent, of cocaine or eucaine, and .5 per cent, of 
 salt. He advises the following solution : Cocaine hydrochlorate or eu- 
 caine, .1; sodium chloride, .6; suprarenal extract (i-ioco), 5. to 10.; dis- 
 tilled water, to make 100. Salt, cocaine or eucaine can be obtained in 
 tablets convenient for making solutions which should always be freshly 
 prepared. The solution of adrenalin is probably the best, and should be 
 kept in a tightly corked bottle. 
 
LOCAL ANAESTHESIA 
 
 211 
 
 liable and less toxic anaesthesia than cocaine. Tropa-cocaine was 
 also advocated by Curtis. 
 
 Holocain. — Obtained by uniting molecular quantities of phe- 
 nacetine and para-phenetidin with separation of water. It forms 
 insoluble crystals, melting at 12 1° C. The hydrochloride is usual- 
 ly employed; this forms bitter-tasting crystals, soluble in cold 
 water to the extent of 2\ per cent. It has been used in ophthal- 
 mology as a substitute for cocaine. Two or three, drops of a 1 per 
 cent, solution is generally sufficient to produce anaesthesia in from 
 15 seconds to 10 minutes. Most ophthalmologists regard it as 
 much inferior to cocaine. Pouchet rejects holocain because of 
 want of uniformity in its action. 
 
 Nirvanin. — This synthetical product is chemically related to 
 orthoform. It appears as white prisms, which are fully soluble 
 in water, melt at 185 , and give a violet color with ferric chloride. 
 A 5 per cent, solution instilled into the eye causes complete anaes- 
 thesia after temporary irritation of the conjunctiva. Upon less 
 sensitive mucous membranes the solution is not irritating, but 
 does not produce such complete anaesthesia. Used subcutaneous- 
 ly, the effect is complete and prolonged. It is used subcutaneous- 
 ly in from 2 to 5 per cent, solutions. It is said to be less toxic 
 than orthoform, and according to Luxenburger is only one-tenth 
 as toxic as cocaine. Elsberg states that nirvanin is three times 
 less toxic than eucaine. Nirvanin is a stable compound, and may 
 be boiled without deterioration. Compared with cocaine, Floeck- 
 inger states, nirvanin is less toxic, is anti-bactericidal, its anaes- 
 thetic effects are more prompt and prolonged, there is less danger 
 of drug habit, and after pain is absent when the injection is prop- 
 erly performed. Other authorities are not so favorably impressed 
 with nirvanin. Diedrichson regards it as not altogether harmless. 
 
 The following formula is recommended for use on mucous 
 membranes, or for subcutaneous injections : 
 
 R / 
 
 Nirvanin 
 Sodii chloridi 
 Aqua cLstil. (sterile) 
 
 M. 
 
 gr. ij (gm 0.13) 
 gr. i (gm 0.06) 
 f. d.ij (gm 8.00) 
 
 According to Matas, nirvanin and eucaine b. are the only 
 agents that deserve to be classed as succedanea of cocaine. Be- 
 
212 LOCAL ANAESTHESIA 
 
 'cause of their lesser toxicity, their stability under sterilization, and 
 for other reasons they may be used with advantage along or in 
 conjunction with cocaine, and while not superseding cocaine, they 
 have contributed to the widening field of local anaesthesia. 
 
 Orthoform. — This synthetic compound occurs as a white, 
 voluminous, odorless, and tasteless powder. It is permanent, and 
 non-hygroscopic, very slightly soluble in water, and soluble in 
 ether. By some it is said to be non-toxic, but untoward effects 
 have been observed by Wunderlich, Katz, and others. According 
 to Luxenberger, orthoform is compatible with iodoform, dematol 
 urophen, aristol, calomel, salicylic acid, carbolic acid, lysol, lead- 
 water, boric acid, alumen acetate, ichthyol, turpentine, iodine, and 
 copper sulphate. Chemical changes occur in connection with bis- 
 muth subnitrate, potassium permanganate, and silver nitrate. Pre- 
 cipitation occurs when orthoform is combined with bichloride of 
 mercury, or formaldehyde. Antipyrine triturated with orthoform 
 is converted into a semi-liquid. Orthoform hydrochloride forms 
 a soluble, crystalline salt, and though anaesthetic is not adapted to 
 subcutaneous injection. 
 
 Owing to its insolubility orthoform is not adapted to subcu- 
 taneous use, though it may be so used suspended in oil. Its in- 
 solubility minimizes the danger of toxic effects. It has little ef- 
 fect on the intact skin, though a lanolin ointment if well rubbed 
 in will relieve skin irritations. Applied to open wounds or ulcer- 
 ations, as a dusting powder, or in a 10 or 20 per cent, ointment, 
 anaesthesia follows and lasts for two or three hours. 
 
 The chief use of orthoform is to relieve painful lesions of the 
 surface of the body, or of the mucous membranes, to relieve the 
 pain of cancer, to relieve painful cystitis when used by irriga- 
 tion, in painful conditions of the ear, eye, larynx, etc. In gastral- 
 gia and painful stomach disorders it may be used in doses of from 
 J\ to 15 grains (0.50 to 1 gm.) Dreyfus uses orthoform to pow- 
 der wounds made under the Schleich infiltration method of an- 
 aesthesia. 
 
 According to Cheatham the results obtained with orthoform 
 at the Munich surgical clinic are as follows: 1. Loss of sensation 
 occurs on the average in from 3 to 5 minutes after application, 
 whether as a powder or as a 10 per cent, or 20 per cent, ointment. 
 2. The anaesthetic action continues on the average for about 3c 
 
LOCAL ANAESTHESIA 213 
 
 hours, in many cases even for 3 or 4 days. 3. Diminution of 
 secretion is always observed, a valuable feature in transplanta- 
 tions, or in inoperable cancer of the face. 4. Two ounces weekly, 
 applied to a carcinoma, demonstrated its non-toxic nature. 5. An- 
 tiseptic properties were not demonstrated, though purulent dis- 
 charges ceased after its application. 
 
 Aneson. — This is a trade name for a watery solution of 
 acetone-chloroform, which has sufficient anaesthetic power for 
 some operations, though it is not equal to a 5 per cent, solution 
 of cocaine. It has been used in ophthalmology, nasal, laryngeal, 
 dental, and minor surgery, in 1 or 2 per cent, solutions. The so- 
 lution is colorless, does not affect the iris or irritate the eyes. It 
 causes no ill effects when injected in quantities of several Pravaz 
 syringefuls. It is recommended by Mosbacher as a substitute for 
 cocaine because it is always sterile, is less toxic, and causes no 
 after pains. Sternberg says it is non-toxic and non-irritant, and 
 produces anaesthesia quicker than cocaine." 
 
 Ethyl Chloride. — Ether chloratus, chlor-ethyl, monochlor- 
 ethane (C 2 H 5 CI), also called chelen or kelene. Produced by 
 the action of dry hydrochloric acid gas on absolute alcohol. At 
 ordinary temperature it constitutes a gas which is easily con- 
 densed to a liquid, boiling at io° C (50 F.). Because of the 
 intense cold (about 35 C.) produced by its evaporation, it is used 
 as a local anaesthetic. For this purpose it is obtained commer- 
 cially in small hermetically sealed tubes (Fig. 59), terminated by 
 a capillary point. When used this point is broken off and the 
 tube held in the hand, the warmth of the hand being sufficient to 
 expel the liquid through the small opening in a stream which is di- 
 rected on the surface which it is desired to anaesthetize. Ethvl 
 chloride occasions considerable pain, especially to sensitive tissues. 
 It is adapted for small surgical or dental operations, and has been 
 
 Fig- 59- — Ethyl Chloride Tube. 
 
 Fig. 59. Ethyl chloride is, as a rule, contained in small tubes or cylin- 
 ders constructed either of glass or metal and provided with screw caps. 
 Each of these contains a sufficient quantity of the agent for from ten to 
 fifteen minor surgical operations. 
 
214 LOCAL ANAESTHESIA 
 
 used somewhat for therapeutic purposes. Ethyl chloride is in- 
 flammable and should not be used near an open flame. 
 
 Liquid Air. — As a local anaesthetic for minor operations liquid 
 air is recommended by Campbell, also as a cauterizing agent in va- 
 rious local conditions. The reaction from the freezing occurs in 
 about 20 minutes and is attended by marked hyperemia. Accord- 
 ing to MacFayden and S. Roland, after the exposure of various 
 bacteria to a temperature of — 190 C for a period of seven days 
 in liquid air, no alteration was observed in their structure, and 
 there was no change observed in their virulence except that they 
 grew a trifle more slowly. According to White, the repeated ap- 
 plication of liquid air serves as an antiseptic through inhibiting 
 bacterial action. He recommends it as a local anaesthetic which 
 causes only slight tingling, the only precaution being to freeze 
 the part solid. 
 
 The spray gives relief in intestinal and trifacial neuralgia, and 
 in sciatica. Boils, buboes, and carbuncles may be aborted in their 
 early stages if thoroughly frozen, and specific, chancroidal, and 
 varicose ulcers heal promptly if treated twice a week by freezing. 
 
 Novocains. Novocaine is a aminobenzoyl diaethyl amino- 
 aethenol, and exists as a chloride. It is soluble in water, stable, 
 and can be boiled. The lethal dose for animals is less than that 
 of cocaine or stovaine. According to Braun it is a powerful local 
 anaesthetic with transient action, and no reaction in the tissues. 
 Combined with suprarenin it is intensely anaesthetic and durable. 
 The action of the latter is increased, and the combination, in his 
 opinion, is better than cocaine and suprarenin, and is less toxic 
 than any other known anaesthetic. He thinks the character of 
 its action is on a level with that of cocaine, while the fact that 
 novocaine can be sterilized by boiling and the solution will keep 
 for a long time gives it an advantage. Braun's solutions ranged 
 from one-quarter of one per cent, to two per cent., suprarenin 
 being added. No unpleasant side-effects were noted. 
 
 Stovaine. Stovaine (vide p. 175) has been used as a local 
 anaesthetic with varying satisfaction. Reclus tried it in 1893. He 
 used twice as strong doses as of cocaine without bad results. 
 Chaput considers it inferior to cocaine as a local anaesthetic. 
 Chiene says it is not superior to eucaine B and hemisine. Sin- 
 clair says stovaine is not as lasting as cocaine, produces intoxi- 
 
LOCAL ANAESTHESIA 215 
 
 cation, that a two per cent, solution causes chronic edema and 
 gangrene, that it interferes with healing, and that it is a danger- 
 ous and unreliable drug. Luke says that the one disadvantage 
 of stovaine is that it cannot be used with adrenalin because of 
 gangrene of the skin. 
 
 According to Braun stovaine is stable, and can be sterilized 
 by heat. The hyperaemia caused by it is not completely controlled 
 by adrenalin. It is only slightly less toxic than cocaine, and its 
 action is weaker. Endermic and subcutaneous injections irritate 
 the tissues and cause actual damage. Five to ten per cent, solu- 
 tions cause gangrene. On the other hand Marchetti has employed 
 stovaine as a local anaesthetic with uniformly good results. He 
 thinks it much less toxic than cocaine, doubts the advisability of 
 the routine combination with adrenalin, but advises stovaine alone 
 for skin incisions, and the combination for the deeper tissues. 
 
 In the face of such contradictory and unsatisfactory testimony 
 it is difficult to see why stovaine should replace other better 
 known and more reliable local anaesthetics. 
 
 Alypin. According to Braun this drug has very high anaes- 
 thetic power, especially when combined with suprarenalin, the 
 action of which on the vessels is not interfered with. Its toxicity 
 is less than that of cocaine, but it produces irritation and local 
 damage to the tissues. Koellner thinks that while in ophthalmic 
 practice it is not superior to cocaine, it is worthy of use. One 
 drop of a five per cent, solution will produce anaesthesia, when 
 applied to the conjunctiva, sufficient for superficial operations. 
 It is rapid, does not contract the vessels, and does not produce 
 mydriasis or disturbances of accommodation. 
 
 The addition of adrenalin to solutions for local anaesthesia is 
 generallv recommended for its effect in prolonging the anaesthe- 
 sia, lessening hemorrhage, and clearing the field of operation. 
 When vaso-constrictor glandular products are added to the agent 
 employed the local anaesthesia takes longer to develop. This has 
 the advantage that the edema produced by the injection has time 
 to subside, thus clearing the field of operation. It is advised by 
 some not to use adrenalin in the solution used for cutaneous anal- 
 gesia because of its slower action, but to combine it with the solu- 
 tion used for deep injection, as in Schleich's solution for deeper 
 
2l6 LOCAL ANAESTHESIA 
 
 anesthesia. About twenty minutes should then be allowed before 
 operating". 
 
 According- to Parker solutions of this kind are best prepared 
 by placing tablets of cocaine and salt in distilled water in proper 
 proportion, boil until sterile, make up loss of evaporation by add- 
 ing sterile water, let solution cool, and add proper amount of 
 adrenalin solution. A pinkish color after standing does not injure 
 the solution. 
 
CHAPTER XVIII. 
 
 LOCAL ANAESTHETICS IN DENTISTRY. 
 
 It is probably true that there is no subject of more interest to 
 the dental profession than that of anaesthesia. Most of the opera- 
 tions upon the teeth, jaws and adjacent parts are painful to a 
 greater or less degree. The dentist's immediate field of operation 
 is supplied by the branches of the fifth pair of nerves, perhaps the 
 most sensitive of any in the human body, and especially is this 
 true regarding pain, which is the only sensation conveyed by the 
 tooth pulp. Add to this the fact that patients usually present 
 themselves in a high state of nervous excitement, due to fearful 
 anticipations, a condition in which a slight hurt is magnified in 
 the pain centers so that the consequent effect upon the strength 
 and nervous make-up of the patient is often very serious. 
 
 People do not like to be hurt, and are seeking painless opera- 
 tions. It is also true that the majority of operators can render 
 better service when they know they are not hurting their patients. 
 A rule, then, that I would like to lay down is : When work can 
 be done successfully, painlessly, without seriously endangering the 
 health of the patient, it is advisable. 
 
 Any agent that has for its object the relief of pain is worthy 
 of our careful study. Most strictly dental procedures come under 
 the head of minor operations. General anaesthetics can only be 
 used in serious, prolonged dental operations, such as removal of 
 tumors, cancers, necrosis, reduction of fractures, cleft-palate, 
 hare-lip, the extraction of a large number of teeth, and the like. 
 
 The objections to their use for dental purposes are : 
 
 1. The difficulty of keeping the patient under during opera- 
 tions on the mouth. 
 
 2. The necessary recumbent position often seriously inter- 
 feres with the operator and makes difficult the flushing of the 
 wound without much blood, pus or other debris being swallowed. 
 
 3. Dangers to life or health from the anaesthetic. We are 
 not justified in using such an agent except where very necessary. 
 
 4. After sickness, vomiting often endangers the success of 
 operations. 
 
 The reader is referred to the chapter on general anaesthet- 
 
2l8 LOCAL ANESTHETICS IN DENTISTRY 
 
 ics for a full discussion of the subject, including methods of ad- 
 ministering. The only special requirement for dental purposes is 
 a carefully fitted mouth prop. 
 
 Nitrous oxide gas is very largely used by the dental profes- 
 sion, and, indeed, very satisfactorily in those cases for which it 
 is adapted. The transitory nature of the anaesthesia limits its 
 usefulness to very short operations. The Hurd and other similar 
 methods, by which a certain amount of air or oxygen is mixed 
 with the gas, have a larger range of usefulness. The advantage 
 being that anaesthesia can safely be prolonged from five to fifteen 
 minutes, but even with this it cannot be used in many operations 
 on the teeth themselves because of the need of dryness and asep- 
 tic conditions that are so essential to success. However, wherever 
 nitrous oxide can be used, it is perhaps our safest agent, its one 
 objection being the necessity of rendering the patient unconscious. 
 
 The subject of local anaesthetics has elicited more experimen- 
 tation and discussion on the part of the dental profession than 
 any other subject in recent years. At first their use was given 
 over to the quack, but gradually the demand for their employment 
 became so great that a few daring ones took up the subject and 
 tried to study out the best method of using them with greatest 
 success and least danger to the patient, until to-day I feel safe 
 in saying that these agents are used in one way or another by a 
 vast majority of the profession. 
 
 First come the use of so-called freezing mixtures, made up 
 principally of ethyl bromide, ethyl chloride, rhigolene, and other 
 light petroleum ethers which hold in solution various agents. 
 They are usually kept in a small glass tube with such thin walls 
 that the heat of the hand will expand the contents so as to cause 
 a fine spray to rush from the end of the tube, where a valve is 
 placed which can be opened. The method of using is to direct this 
 spray on the mucous membrane on and around the field of op- 
 eration until blanching of the part appears. Care must be had not 
 to use too long, or destruction of the soft tissue will result. They 
 are fairlv useful for small operations, such as lancing abscesses. 
 
 Many use for this same purpose solutions containing carbolic 
 acid, menthol, calabar bean, peppermint in sulphuric ether, and 
 apply with a pledget of cotton with, I think, some satisfaction. 
 
 The greatest success from local anaesthetics comes from the use 
 
LOCAL ANAESTHETICS IN DENTISTRY 219 
 
 of agents which are employed in various per cent, solutions by 
 means of .hypodermic injection directly into the soft tissue. 
 Among such agents I only wish to mention three, viz., cocaine 
 hydrochlorate, beta-eucaine hydrochlorate, and chloretone. The 
 first has been used longest and has been, in the hands of the 
 writer, most successful. 
 
 For the general physiological action of these drugs the reader 
 is referred to the chapter on local anaesthetics. I simply wish to 
 mention here the results of many hundred experiments with co- 
 caine and eucaine conducted on dogs, guinea pigs and rabbits, as 
 well as in a clinical practice extending over a period of twelve 
 years. At the outset, I want it understood that my statements 
 only apply to operations in the mouth where injections are made 
 through the mucous membrane, — for I recognize that the nature 
 of the tissue into which injections are made, has much to do with 
 results. My conclusions are as follows : 
 
 1. Cocaine is more toxic than beta-eucaine. 
 
 2. Cocaine is more anaesthetic than beta-eucaine. 
 
 3. Cocaine is more rapid in its action. 
 
 4. Cocaine solutions are more irritating to tissue. 
 
 5. Cocaine is less dangerous in its action upon the heart. 
 
 6. Cocaine is not constant in its effects — you cannot tell 
 who will be most susceptible. 
 
 7. Beta-eucaine acts almost always the same on different in- 
 dividuals. 
 
 8. Cocaine solutions will not keep long and cannot be boiled, 
 while beta-eucaine solutions can be sterilized by boiling and are 
 fairly stable. 
 
 9. When danger symptoms arise from cocaine administration, 
 they are more easily counteracteed than when they arise from 
 beta-eucaine. 
 
 10. Cocaine local effects are more lasting than beta-eucaine. 
 Many dentists report cases of severe local irritant poisoning 
 
 from cocaine hydrochlorate, but from my observations I would 
 say this is due to an impure drug, unclean syringe, or infection 
 from some source. 
 
 I do not wish to convey the idea that cocaine is not a dangerous 
 drug when used in dental practice, but I wish to affirm that if 
 properly used in reasonable physiological quantities, in correct 
 
220 LOCAL ANAESTHETICS IN DENTISTRY 
 
 solution, its dangers are not great, and its local anaesthetic ef- 
 fects almost ideal. The same can be said of beta-eucaine, but in 
 my hands the greatest success, everything considered, has been 
 obtained from use of cocaine. 
 
 Of all the agents recommended to counteract the baneful 
 systemic effects of cocaine, I find none to equal nitroglycerin, al- 
 though caffein, coffee, morphine, atropine and strychnine are rec- 
 ommended and are of value. The trouble with them is they are 
 comparatively slow in action, and therefore should be given fifteen 
 to thirty minutes before cocaine is administered. When trouble 
 arises it is like sending a horse to catch the lightning express, but 
 nitroglycerin acts more rapidly and can be given in the cocaine so- 
 lution with good results. Cocaine acts best for dental injections 
 when used in a I per cent, solution, with nitroglycerin added. I 
 find that if the solution is made in sterilized peppermint water with 
 just a trace of thymol it will keep nicely and seems to be slightly 
 more anaesthetic. Beta-eucaine is used in a 2 per cent, aqueous 
 solution and can be boiled. 
 
 Chloretone is a comparatively new agent recommended for 
 local anaesthetic purposes. It is quite harmless and can be used 
 in almost unlimited quantities. It is not soluble to exceed 1 per 
 cent, in water, which is the solution recommended. The writer 
 has had but negative results from use of this agent, although 
 many claim splendid success with it. 
 
 A very important point to be remembered is the value of me- 
 chanically rilling the tissue with the solution used. When you suc- 
 ceed in raising up a small white button with each injection you can 
 feel assured of success. The method of using these agents for 
 the extraction of useless teeth and roots is as follows : 
 
 1. Have your cocaine or eucaine in perfect solution. 
 
 2. Have solution sterile or antiseptic. 
 
 3. Have your syringe aseptic. I like to use an all metal one 
 which can be boiled. It should have a large finger guard and 
 plunger rest and be arranged so as to tell exactly how much is 
 given. 
 
 4. Have all air out of the syringe. 
 
 5. Always clean the surface through which you wish to 
 inject. 
 
LOCAL ANESTHETICS IN DENTISTRY 221 
 
 6. Make your injection into the dense gum tissue first; then 
 deep into the periosteum on all sides of the tooth to be extracted. 
 
 7. Wait until effect takes place before beginning to operate. 
 
 8. Have additional means at hand to meet dangerous symp- 
 toms should they arise. 
 
 9. Do not use more than one-sixth of a grain of cocaine, or 
 one-third of a grain of eucaine at one time. 
 
 The combination of cocaine and chloretone seems to promise 
 good results. The chloretone seems to counteract the dangerous 
 effects of cocaine on the heart and respiration. Suprarenal extract 
 in connection with cocaine solution is very useful for operations 
 on soft tissues of the mouth. 
 
 Orthoform. — A local anaesthetic in the form of a light gray 
 powder. It is very sparingly soluble, and hence its use is limited 
 to those cases where the powder can be applied direct. It is very 
 useful in painful alveolar sockets after teeth are extracted. There 
 is no danger of poisoning because it dissolves so slowly that little 
 enters the circulation at one time. 
 
 Cocaine is used in painful pus pockets to anaesthetize the sur- 
 rounding tissue, thereby making possible the scaling of teeth with 
 little pain. It is used in a 4 per cent, solution injected by means 
 of a long platinum needle directly into the pockets. Care should 
 be taken to pack absorbent cotton around the tooth to absorb any 
 escaping excess, thus avoiding getting it back in the throat. 
 
 A 1 per cent, solution is injected in the gum around a tooth to 
 render painless the preparation of sensitive cavities for filling, also 
 into the gum to relieve the pain of putting on clamps to hold the 
 dam in place; especially is this useful when the gum has to be 
 forced down on the tooth to get the dam over the margin of cav- 
 ities. 
 
 Cocaine and eucaine are both employed to relieve pain of ex- 
 cavating: sensitive cavities and to anaesthetize the tooth pulp so it 
 can be removed immediately. The process now mostly used for 
 this last purpose is to place the dam, remove the superficial de- 
 cay, outline the cavity, then moisten a small pledget of cotton 
 with water or alcohol or ether and touch this to the finely pow- 
 dered cocaine or beta-eucaine, when sufficient will adhere ; place 
 this in the cavity and take a piece of soft rubber larger than the 
 cavity and with a blunt instrument gently force the cocaine into 
 
222 LOCAL ANAESTHETICS IN DENTISTRY 
 
 the tooth with a sort of pumping motion — renew your agent from 
 time to time and get a complete exposure of the pulp as soon as 
 possible, when little difficulty will be experienced in completely 
 anaesthetizing the pulp so it can be removed painlessly. 
 The objections to this method are : 
 
 1. When pulps are congested it only works partially. 
 
 2. The time taken to do it painlessly. 
 
 3. The haemorrhage following. 
 
 In many cases it is advisable to use it, and as a general practice 
 it is growing in favor. 
 
 The same method is employed for sensitive dentine except 
 that no exposure is made. 
 
 There was a time a few years ago when the profession went 
 wild over the use of cocaine by means of the cataphoric apparatus, 
 which is a machine so arranged to measure and control electric 
 current as to be able to pass a small amount through the cavity 
 in a tooth. It is used in connection with cocaine as above de- 
 scribed — the positive electrode is placed on the cotton in the cavity 
 and the negative electrode on the cheek or held in the hand. This 
 method is now practically abandoned in favor of the others men- 
 tioned. 
 
 Stovaine. Quite recently the instillation of a solution of 
 stovaine has been highly recommended for the extraction of 
 teeth. It has not been sufficiently used, however, to demonstrate 
 any superiority over other agents for this purpose. An inconsider- 
 able amount of pain may accompany its employment, and no sub- 
 sequent indisposition results. 
 
INDEX. 
 
 Abdominal conditions and anaesthesia, 46 
 A. C. E. mixture, 177 
 
 — ether sequence, 180 
 
 relative safety of, 37 
 Acute cedema of lungs after anaesthesia, 
 
 196 
 Administration the, and time of day, 58 
 
 and alcohol, 60 
 
 and appliances and remedies, 64 
 
 and aseptic precautions, 64 
 
 and diet, 58 
 
 and medicine, 59 
 
 and morphine and atrophine, 60 
 
 and moving of patients, 64 
 
 and physical examination, 61, 62 
 
 and posture during induction, 63 
 
 and state of bladder, 59 
 
 and state of bowels, 59 
 
 and strychnia, 60 
 
 and temperature of room, 63 
 
 and ventilation, 63 
 AFTER THE ADMINISTRATION, 192 
 
 anuria, 197 
 
 bronchial and pulmonary symptoms, 
 195 
 
 emholic pneumonia, 196 
 
 paralyses, 197 
 
 pneumonia, 195 
 
 vomiting, 193 
 Albuminuria after etherization. 104 
 Alcoholic subjects and anaesthesia, 42 
 AMYLENE, 163 
 
 nature and properties of, 164 
 
 dangers of, 164 
 Anaesthesia, available period of, 75 
 
 general physiology of, 26 
 
 history of, 11 
 
 local, 201 
 
 stages of, 33 
 ANAESTHETIC THE, AND THE PA- 
 TIENT, 38 
 
 age, relation of, 39 
 
 blood states, relation of, 13 
 
 general condition, relation of, 41, 62 
 
 heart diseases, relation of, 44 
 
 kidney diseases, relation of, 47 
 
 lung diseases, relation of, 44 
 
 laryngeal diseases, relation of, 43 
 
 morbid growths, relation of, 43 
 
 pathologic conditions, relation of, 43 
 
 sex, relation of, 38 
 
 vascular disease, relation of, -'6 
 ANAESTHETIC THE, AND THE OPE- 
 RATION, 50 
 ANAESTHETICS, COMPARATIVE DAN- 
 GERS OF, 34 
 Anaesthetics, absorption of, 27 
 
 analgesia from, 30 
 
 blood changes from, 29 
 
 characteristics of, 26 
 
 Cheyne-Stokes breathing in, 32 
 
 effect on heart's action, 33 
 
 effect on reflexes, 33 
 
 effect on vaso-motor center, 33 
 
 effects on nervous system, 30 
 
 effect on respiration, 32 
 
 elimination of, 28 
 
 introduction of, 27 
 
 muscular phenomena from, 32 
 
 stertor from, 32 
 
 toxicity of, 26 
 Anders observations of nitrous oxide, 
 
 77, 88 
 Aneson as a local anaesthetic, 213 
 Anuria after anaesthesia, 197 
 Artificial respiration, 148 
 Available period, 75 
 
 BEFORE THE ADMINISTRATION, 58 
 Bert's observations on nitrous oxide, 77. 
 
 88 
 BICHLORIDE OF METHYLENE, 162 
 
 administration of, 162 
 
 introduction of, 162 
 
 mortality of, 162 
 
 nature and properties of, 162 
 Billroth's mixture, 178 
 Bronchial and pulmonary symptoms af- 
 ter anaesthesia, 195 
 Carbonic acid, elimination of, 28 
 Cataphoresis in dentistry, 222 
 Characteristics of anaesthetics, 26 
 Chest, examination of, 62 
 Cheyne-Stokes breathing, 32 
 Chloretone in dentistry, 220 
 Chloric ether, 20 
 Chloroform and alcohol, 179 
 Chloroform and ether mixtures, 178 
 CHLOROFORM, 125 
 
 administration of, 136 
 
 administration of by drop method, 143 
 
 after effects from, 132 
 
 clinical evidence regarding, 134 
 
 dangers from administration of, 133 
 
 delayed poisoning from, 151 
 
 discovery of, 21, 125 
 
 during labor, 56 
 
 effect on heart and blood pressure, 131 
 
 effect on kidneys, 132 
 
 effect on respiratory center, 130 
 
 fatalities from, 134 
 
 heart after death from, 132 
 
 impurities and tests, 126 
 
 physiological effects and action of, 127 
 
 properties of, 125 
 
 reflex cardiac arrest from, 135 
 
 reflex respiratory arrest from, 135 
 
 relative toxicity of, 36 
 
 respiratory arrest from overdose of, 
 147 
 
 stages of anaesthesia, 127, 128 
 
 toxaemia from overdose of, 136 
 Chloroformization, condition of pulse 
 during, 146 
 
 management of complications of, 147 
 
 of children, 145 
 
 reflexes during, 145 
 
 respiratory condition during, 146 
 Cocaine, discovery of, 204 
 
 for local anaesthesia, 202 
 
 history of, 203 
 
 in dentistry, 219 
 
 nature and effects of, 204 
 Comparative dangers of anaesthetics, 35 
 Complications, managament of, 147 
 Dentistry, nitrous oxide for, S3 
 
 cataphoresis in, 222 
 
224 
 
 130 
 
 111 
 115 
 
 101 
 
 cocaine in, 210 
 
 chloretone in, 220 
 
 ethyl bromide in, 158 
 
 ethyl chloride in, 151) 
 
 orthoform in, 221 
 
 pental in, 164 
 
 stovaine in, 222 
 Delayed chloroform poisoning, 151 
 Diabetes and anaesthesia, 4'.i 
 Drug users and anaesthesia, 42 
 Dutch liquid, 21, 125 
 Dyspnoea, forms of, 20 
 Embolic pneumonia after anaesthesia, 
 
 106 
 Epileptiform syncope, Richardson's, 
 ETHER, 99 
 
 administration of, 100 
 
 after effects of, 103 
 
 clinical conclusions regarding, 123 
 
 close method of administration of, 
 
 conjoined use of oxygen and ether, 
 
 discovery of, 15, £9 
 
 effects on kidneys of, 103 
 
 open system of administration of, 
 
 partially closed system of administra- 
 tion of, 107 
 
 physiological effects and action of, 100 
 
 properties of. '.:!> 
 
 relative safety of, 30 
 
 stages of anaesthesia by, 100, 101 
 
 tests for impurities in, 100 
 
 toxic effects of, 102 
 Etherization, accidental conditions of, 
 110 
 
 albuminuria after, 104 
 
 cardiac failure from, 105, 123 
 
 cerebral haemorrhage from, 105 
 
 dangers from, 105 
 
 jaundice after, 105 
 
 nervous symptoms after, 105 
 
 pneumonia after, 104 
 
 proper extent of, 117 
 
 rectal, 117 
 
 reflexes during, 118 
 
 respiratory failure from, 123 
 Ether-chloroform sequence, 189 
 ETHYL BROMIDE, 157 
 
 administration of, 158 
 
 dangers of, 158 
 
 dis-overy of, 157 
 
 physiological effects, 157 
 
 nature and introduction of, 157 
 ETHYL CHLORIDE, 150 
 
 as local anaesthetic, 213 
 
 administration of, 160 
 
 conclusions in regard to, 160 
 
 nature and properties of, 159 
 Ethvl-chloride-ether sequence, 100 
 ETIIIDEXE DICHLORIDE, 163 
 
 administration, 163 
 
 dangers of, 163 
 
 introduction of, 163 
 
 nature and properties of, 163 
 Eucaine a, as local anaesthetic, 209 
 Eucaine b, as local anaesthetic, 209 
 "'Fright sj^ncope" from chloroform. 135 
 Erequent anaesthesia, 43 
 General condition and the administra- 
 tion, 62 
 Heart disease and anaesthesia, 44 
 Heart, massage of in svncope, 151 
 HISTORY OF ANESTHESIA, 11 
 Holocain as local anaesthetic, 211 
 Hypnotism, 15 
 
 Indian hemp, 13 
 
 Kidney disease and anaesthesia. 4 7 
 
 Kidneys, effects of ether on, 103 
 
 effects of chloroform on, 132 
 Lactation and anaesthesia, 43 
 Larynx, diseases of, and the anaesthetic, 
 
 43 
 LOCAL ANAESTHESIA, 201 
 
 aneson for, 213 
 
 cocaine for, 204 
 
 ethyl chloride for, 213 
 
 eucaine a for, 209 
 
 eucaine b for, 209 
 
 holocain for, 211 
 
 liquid air for, 214 
 
 local infiltration method for, 205 
 
 methods, selection of, 202 
 
 nirvanin for, 211 
 
 orthoform for, 212 
 
 post-operative pneumonia after, 202 
 
 regional intraneural method for, 208 
 
 regional paraneural method for, 207 
 
 stovaine in, 206, 214 
 
 suprarenal extract in, 207, 210, 215 
 
 tropa-cocaine hvdrochloride for, 210 
 LOCAL ANESTHETICS IN DENTIS- 
 TRY, 217 
 
 agents employed, 218 
 
 cataphoresis for, 222 
 
 chloretone for, 220 
 
 conclusions regarding cocaine, 210 
 
 for sensitive tooth pulp, 222 
 
 method of employment, 220 
 
 objections to their use, 217 
 
 orthoform, 221 
 Lung diseases and the anaesthetic, 44 
 Menstruation and anaesthesia. 42 
 Mesmerism, 15 
 Mixed narcosis, 60, 61 
 Moving patients during administration, 
 
 64 
 MIXTURES FOR ANESTHESIA, 177 
 
 A. C. E. mixture, 177 
 
 Billroth's mixture, 178 
 
 chloroform and ether, 178 
 
 chloroform and alcohol, 170 
 
 Schleich's mixture, 180 
 
 somnoform, 182 
 Nervous disease and anaesthesia, 40 
 Nirvanin as a local anaesthetic, 211 
 NITROUS OXIDE, 73 
 
 Ancrews' observations of, 77, 88 
 
 administration of, 77 
 
 after effects of, 77 
 
 blood changes from, 77 
 
 dangers of administration of, 86 
 
 definite quantities of nitrous oxide and 
 air, 86 
 
 discovery of, 15, 73 
 
 indefinite quantities of nitrous oxide 
 and air, 87 
 
 lethal effects of, 77 
 
 nature and properties of, 73 
 
 oxygen and nitrous oxide, 88 
 
 Paul Bert's system of administration 
 of, 77, 88 
 
 physiological effects and action of, 73 
 
 relative safety of, 36 
 
 sequence, nitrous oxide-ether, 185 
 
 Turner's method of administration for 
 extraction, 83 
 Obesity and anaesthesia, 42 
 Old people and anaesthesia, 40 
 Operations on the abdomen, 54 
 
225 
 
 brain and spinal cord, 49, 54 
 
 chest, 54 
 
 dental, 52 
 
 face, jaws, nose, etc., 51 
 
 gynecological, 56 
 
 larynx and trachea, 52 
 
 neck exclusive of air tract, 53 
 
 obstetric, 56 
 
 ophthalmic, 51 
 
 rectum and genito-urinary tract, 55 
 
 the extremities, 57 
 
 tonsils, 52 
 Orthoform as local anaesthetic, 212 
 
 in dentistry, 221 
 Oxygen and ether, conjoined use of, 115 
 
 and nitrous oxide, 88 
 Paralyses after anaesthesia, 11)7 
 Pathologic conditions and anaesthesia, 43 
 PENTAL, 164 
 
 administration of, 164 
 
 dangers of, 164 
 Physical examination, 61, 62 
 Physiological effects of nitrous oxide, 73 
 Pneumonia after etherization, 104 
 Pneumonia after anaesthesia, 105 
 Posture during anaesthesia, 68 
 
 for extraction of teeth, 68 
 
 for operations on brain, 71 
 
 for operations on chest, 72 
 
 for operations on abdomen, 72 
 
 for operations on kidneys, 72 
 
 for operations on face, mouth, etc., 70 
 
 for operations on larynx and trachea. 
 71 
 
 for operations on neck, 71 
 
 for ophthalmic operations, 72 
 Posture during induction, 63 
 Regional intraneural infiltration, 208 
 Regional paraneural infiltration, 207 
 Respiration, artificial, 148 
 Rhigolene, 201 
 Schleich's mixture, 180 
 Selection of a general anaesthetic, 34 
 
 SEQUENCE OF ANESTHETICS, 1S7> 
 
 A. C. E.-ether sequence, 189 
 
 chloroform-ether sequence, 188 
 
 ether-chloroform sequence, 18! 
 
 ethyl chloride-ether sequence, 190 
 
 nitrous oxide-ether sequence, 185 
 
 other sequences, 101 
 
 somnoform, 182 
 SCOPOLAMINE-MORPIIINE AN\EK- 
 
 THESIA, 154 
 
 physiologic effects of, 1~>4 
 
 employment of, 155 
 SPIRAL ANAESTHESIA, 25, 166 
 
 after effects of, 166 
 
 Bier and Quincke's method for, 169 
 
 complications of, 167 
 
 contraindications for, 167 
 
 Coming's method for, 168 
 
 dangers of, 167 
 
 effects of, 166 
 
 failure of, 167 
 
 location of puncture for, 171 
 
 Matas' solution for, 168 
 
 mortality of, 167 
 
 position and method for, 171 
 
 solution and dose for, 167 
 
 stovaine in, 175 
 
 technique of, 168 
 
 Tuffier's method for, 172 
 Statistics of fatalitv, 35 
 
 stovaine, 175, 206, 214, 222 
 
 slatus thymicus, 48 
 Suprarenal extract in chloroform narco- 
 sis, 151 
 
 in local anaesthesia, 207, 210, 215 
 Surgical shock and anaesthesia, 47 
 Tobacco users and anaesthesia, 42 
 Toxicity of anaesthetics, 26 
 Tropa-cocaine as local anaesthetic, 210 
 Turner's method for extraction, 83 
 Vascular disease and anaesthesia, 44 
 Vomiting after anaesthesia, 193 
 Young persons and anaesthesia, 39 
 
SEP 14 1906 
 

 
 
 
 
 
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