COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00035106 Columbia ©ntoeisitp mtijeCttptfJtogork College of $fjpsicians anb burgeons Htbrarp •.'.>.*,' H ■ MtU 9fl IP ■ ■ i Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/anaestheticstheiOObuxt tf ANAESTHETICS ANESTHETICS USES AND ADMINISTRATION BY DUDLEY WILMOT BUXTON, M.D., B.S. MEMBER OF THE ROYAL COLLEGE OF PHYSICIANS; MEMBER OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND; ADMINISTRATOR OF ANAESTHE- TICS AND LECTURER IN UNIVERSITY COLLEGE HOSPITAL, THE .NATIONAL HOSPITAL FOR PARALYSIS AND EPILEPSY, QUEEN'S SQUARE, AND THE DENTAL HOSPITAL OF LONDON SECOND EDITION PHILADELPHIA P. BLAKISTON, SON & Co No. 1012 Walnut Street 1892 -Of If !*- PREFACE TO SECOND EDITION. In the present edition the bulk of the matter has been recast, and materially added to, with a view to increase its utility. The uniformly kind aud sugges- tive criticisms of the first edition have aided me, and I have in many cases adopted improvements proposed by correspondents and reviewers, notably by supplying woodcuts of most of the apparatus described. In my former edition, the descriptions were given almost in the ipsissima verba of the inventors, as it appeared to me that they, if anyone, should know how to describe their own ideas. In the present edition these de- scriptions have, however, been altered to render them it is hoped more plain. When opinions are at variance about the action of an anaesthetic, or the value of a method, I have en- deavoured to present the arguments fairly, but as VI PREFACE. the book is intended rather as a practical manual than as a disputatious treatise, all discussions have necessarily been curtailed. While many of the illus- trations are original, some are lent by the courtesy of the firms who make the apparatus they depict, or are placed at my disposal by the kindness of pro- fessional colleagues, and to all of these I tender my thanks. 82 Mortimer Street, Cavendish Square, W. June, 1892. PREFACE TO FIRST EDITION. The introduction of anaesthetics, which has done so much to rob surgery of its horrors, alike for the patient and the operator, has created a great demand for per- sons capable of administering these pain- destroying agents, without unfortunately exciting, as a rule, so great a sense of responsibility in the administrator as his difficult and dangerous duties should render obligatory. It is surprising that surgeons who have witnessed the attempts of novices to give anaesthetics, should hold any view save that no one is capable of safely giving any anaesthetic unless he has been carefully taught and has obtained considerable experience. Personally, I do not believe that the perusal of any book will enable a medical man to do more than learn the rudiments of anaesthetising ; but a book may be of Ylil PREFACE. undoubted service to the thoughtful student or practi- tioner, in enabling him to appreciate the dangers inci- dent to, the caution necessary in anaesthetising, and to grasp the rationale of the various methods of pro- cedure. Unfortunately, the subject of anaesthetics has for some years escaped the notice of the scientific side of the profession, and has as a natural result been rele- gated to the dcmain of routine. In this book, which has been written purely from the stand-point of every day practice, 1 have attempted to indicate that the matter dealt with has a scientific as well as a work-a-day aspect, and that he who desires to be more than a mechanical (and hence dangerous) administrator of anaesthetics, must be scientifically, as well as practically, educated in his art. TABLE OF CONTENTS. CHAPTER I. PAGE Historical — Nepenthes— Anaesthetics among the Egyptians, Assyrians, and Chinese — Opium — Cannabis indica— Carbonic dioxide — Ansesthesia by compression of blood-vessels — Ditto of nerves — Mesmerism — Hypnotism — Humphry Davy and nitrous oxide — Horace Wells' use of gas — Its introduction into London — Discovery of ether — Morton and ether — First administration of ether in London — Simpson's employment of chloroform as an anaesthetic — Flouren's researches — Snow— Clover's work — Pollock and Haward's work — The "Glasgow Committee" — The Nizam of Hyderabad — The Hyderabad Commission . . . . . .1 CHAPTER II. Pekpaeation of a patient for an anesthetic and choice of the an/Esthetic — Best time for giving anaesthetics — Directions about food — Dietary — Choice of anaesthetic for infants and children — For adults — For persons with puimon- CONTENTS. PAGE ary disease — Heart disease — Renal disease — Arterial disease — For the aged — In collapse — For pregnant women — For operations about month, nose, pharynx — For operations on the eyes — On the thorax — In abdominal surgery — In parturition . . . . . . .14 CHAPTER III. Nitrous oxide gas — Chemical and physical properties — Prepar. ation — Impurities— Physiological action — Vegetable kingdom — Animal kingdom — Human subject — In general surgery — In dental surgery — Apparatus required — Dudley Buxton's apparatus — Clover's inhaler — Administration of — Special in- struments, gags, mouth openers, dental props, tongue forceps, &c. — After effects — Dangers attending administra- tion — Their treatment— Is nitrous oxide dangerous ? — to pregnant women — The aged — In lung disease — In hearts dis- ease—Deaths from — Paul Bert's method— Dr. Hewitt's oxy- gen and nitrous oxide mixture . . . . 27 CHAPTER IV. Ether — Discovery — Chemical and physical properties— Its uses — Physiological action —Methods of administration— Inhalers — EfFects of ether inhalation— Rectal etherisation — Dangers and accidents to respiration, to heart, &c. — Treatment — After effects of ether — Treatment ... . f>7 CONTENTS. XI CHAPTER V. PAGE Chloroform — Its discovery — Chemical and physical properties — Preparation — Impurities — Tests — Physiological action — Upon the human subject — Administration of — Clover's ap- paratus — Inhalers— Snow's, Sansom's, Junker's, Dudley Buxton's, Krohne's — The open method — Method by hypo- dermic injection — Method of definite mixtures— Complica- tions under chloroform — Syncope — Treatment — Interference with respiration — Mechanical — Vital — Treatment — Entrance of foreign bodies into air passages under chloroform — Treat- ment — After-effects of chloroform; vomiting; hysteria; jaundice; albuminuria; astigmatism; insanity . . 94 CHAPTER VI. Amtlene — Chemical and physical properties — Preparation — Phy- siological action — Mode of administration — After effects and dangers— Tneir treatment — Ethidene chloride— Physical and chemical properties— Physiological action — Methods of administration— Accidents and after effects — Hydrobrouic ether — Chemical and physical properties — Physiological action — Cases in which suitable — Dangers from complica- tions under — Their treatment ..... 131 Xll CONTENTS. CHAPTEK YII. PAGE Anesthetic mixtures— A. C. E. mixture — Vienna mixture— Linbart's mixture — Methylene — Billroth's mixture — Martin- dale's A. C. E. mixture — Method of employing the A. C. E. mixture — After effects — Eichardson's mixture— Methods of employment for other mixtures — Their relative values and dangers — Morphine and chloroform — When applicable — Method of administration — Dangers — Chloroform, morphine, and atropine mixture— Morphine and ether, its advantages and drawbacks— Chloroform and amyl nitrite— Mode of application — Uses — Drawbacks— Physiological action — Chlo- roform and chloral— Mode of application— Advantages and drawbacks — Chloroform, chloral, and morphine — Cocaine and chloroform— Chloral hydrate and ether— Mode of employ- ment — Dangers of— Nitrous oxide and ether . . . 142 CHAPTER VIII. ANESTHETICS in obstetric practice — Choice of anaesthetic — Stage in labour when to be used— In normal labour — Rules guiding administration — Objections considered — Method of administration — Obstetric operations— For turning — For ex- traction by forceps— Craniotomy — Hour-glass contraction — After effects— Treatment . . . . .lei CONTENTS. Xlll CHAPTEE IX. PAGE Anaesthetics in Special Surgery — In Brain Surgery— In Ophthalmic practice — For operations ahout the Mouth, Jaws, and Respiratorytract — Rectal Etherisation in Oral Surgery — For removal of Post-nasal Adenoids — In Dental Surgery — Thoracic Surgery — In Abdominal Surgery — In Rectal Sur- gery . . . . . . . .162 CHAPTEE X. Accidents of anesthesia and how to treat theji — Foreign bodies in air passages —Artificial teeth — Gags — Sponges — Precautions against such accidents — Dangers from posture of patient — Paralysis of respiratory centre — Treatment of accidents — Tracheotomy — Spasm of Jarynx — Laryngotomy — Artificial respiration — Sylvester's method — Howard's method — Accidents due to syncope — Treatment — Apoplectic seiz- ures — Epileptic seizures — 'Hysterical seizures . . . 171 CHAPTEE XI. Local Anesthesia — Cocaine — Physical properties and prepar- ations—Physiological action — Method of employment — As a paint, by instillation, as a spray, hypodermically — Coming's method — Indication for use of cocaine in ophthalmic prac- tice—In operations about the larynx, pharynx — In minor surgery— Operation on the urino-generative tract — In Dental Surgery — In major operations — Accidents and after effects of XIV CONTENTS. PAGE Cocaine — Their treatment — Fatalities under Cocaine — Bra- cine — Drumine — Ether spray — Mode of application— Disad- vantages— Chloride of Methyl — Local anaesthesia by alcohol — Ditto by carbolic acid — Ditto by electricity— Ditto by rhigoline — Ditto by Bisulphide of Carbon . , . 180 CHAPTEE XII. Medico-legal aspects of the administration of anaesthetics — Administrations without consent, an assault — Charges of malpraxis — Commission of crimes under anaesthetics — Can an anaesthetic be administered without consent ? — Anaesthetising possible during sleep— Attempted rape under anaesthetics — Erotic hallucinations under anaesthetics — Robbery under anaesthetics — Testimony of anaesthetised persons unsatis- factory — Death under anaesthetics — Relative mortality under various anaesthetics — Responsibility of anaesthetist — Un- qualified persons criminally responsible — Dentists and anaes- thetics — Death from nitrous oxide gas — P. M. appearances — Deaths from ether — P. M. appearances — Detection of ether by analysis— Deaths due to chloroform — P. M. appearances — Detection of chloroform — Analysis of the tissues — Self-indul- gence in anaesthetics — Insanity following from the adminis- tration of anaesthetics ...... 100 Indkx ......... 217 ANESTHETICS. Hi CHAPTEB I. HlSTOKICAL. Means for producing surgical anaesthesia were practi- cally unknown until Wells introduced, nitrous oxide, Morton employed ether, and Simpson chloroform. ' With the first employment of these three agents com- mences the history of artificial anaesthesia, although from very early times attempts were made to attain painlessness during surgical operations. ^Nepenthes or sedative draughts to relieve severe pain are mentioned in the Odyssey — -Helen seeks to "drown 1 sense of woe" and assuage the sufferings of Menelaus. In Egypt, Cannabis Indica,^he modern aschish, and other drugs, were similarly used. The Assyrians and ancient Chinese seem to have employed various drugs with a view of relieving the pain of ounds and such rough surgery as was practised among them.\ Opium, Cannabis Indica, carbonic di- oxide, and deadly nightshade, were advocated in various forms to achieve this object. jPliny and Dioscorides describe several methods in vogue among the Eomans and other nations for benumbing parts subjected to ^i^ ... . . . incision and cauterisation. Memphis marble, for exam- ple, was finely powdered and applied to the part, while on the addition of vinegar a gas was given off (carbonic B 2 ANESTHETICS. dioxide) "which rendered the part slightly anaesthetic. Various members of the Euphorbiacere, Mandr agora, and Solanaceous plants, were also employed as infu- sions, which being drunk induced some narcotism. Attempts at anaesthesia by inhalation were very early practised. The Scythians burned Cannabis Indica and inhaled its fumes, to alleviate pain. In more modern times little advance was made until the present century. Most surgeons were contented to put their patients deeply under opium. In 1G61, Ny Greatrakes, a professional "stroker," also practised an- aesthetic mesmerism. He performed before Charles II. In a M.S. dated twenty years later, one, Denis Papin, wrote that he possessed the means whereby he could abrogate all painful sensations during a surgical opera- tion, but what his method was, is left unexplained. * In the 16th and 17th centuries Valverdi and others operated upon patients stupefied by compression of the carotid arteries, so depriving the brain of blood. In this practice they seem to have been anticipated by the Assyrians, who are reported to have compressed the vessels of the neck to render painless the operation of circumcision. James Moore, an English surgeon, in 1784 revived a suggestion, originally made by Ambroise Pare, that compression of the nerve-trunks should be practised before cutting the areas supplied by them, and John Hunter actually took advantage of the plan, and amputated a leg in St. George's Hospital after firmly compressing the crural and sciatic nerves. Mr. Moore i spr< sed himself satisfied with the result. A departure in an entirely new direction was made by Meemer and his followers, who averred that patients thrown into the " magnetic state " (i.e. hypnotised) HISTORICAL. 6 could be surgically treated without any pain or incon- venience. Long before Mesmer lived, a belief had been current that the natural magnet possessed powers which were both curative of disease and capable of establishing anaesthesia. Thus Cardan (1584) recounts how the magnet could be employed to abrogate pain. The germs of the facts now known and accepted under the terms animal magnetism or hypnotism bore a fruit- ful harvest of windy words, Paracelsus, Glocenius, Burgrave, and others, contributing largely thereto. By Anthony Mesmer (born 1734) however, the matter was advanced from theory to practice, and although we may carp at Mesmer as a charlatan and quack, we must accord to him a meed of gratitude for establishing upon a practical basis a science which before his age was lost in useless verbiage. In 1766, Mesmer published his work, "The Influence of the Planets in the Cure of Disease," which maintained that the celestial orbs exercised, by means of "animal magnetism" — an all- pervading fluid, an influence benign or malign on human beings. Fourteen years later, in conjunction with a Jesuit called Father Hell, Mesmer undertook the cure of disease by means at first of the magnet and steel tractors, but finally of manual passes. The plaudits which at first greeted him in Vienna were ere long changed for the most hostile treatment, the learned bodies of his own and other countries treating his writings with contempt and himself with contumely. Leaving Vienna, Mesmer exploited Paris, where he founded the widely famed hospital whereat were treated a great number of patients. In 1785 a royal commission was appointed to enquire into Mesmer's pretentions, but this and subsequent commissions unfortunately con- b 2 4 ANAESTHETICS. fused the issues iu question, and while they decided that Mesuier aud his immediate adherents were unworthy of credence, they failed to discriminate the substratum of truth underlying their teaching and practice. After Mesiner's downfall the subject was kept before the world by the practice of the Marquis de Puysequr and the somnambulists. In 1829, Cloquet amputated a breast, the patient being rendered insensible through having been thrown into the hypnotic state. Elliotson, a firm believer in the practical uses of animal mag- netism in surgery, employed it on several occasions with success. Braid, of Manchester, in 1841 made considerable trial of what he called the neurhyp- notic trance as a means of producing surgical anaes- thesia. Similar experiments were carried out in India by Dr. Esdaile, who performed no less than three hundred operations upon patients in the hypnotic state. Spasmodic attempts have from time to time been made to revive th«j practice of hypnotism for the induction of anaesthesia with but partial success. It has been found that while only a certain number of persons are capable of being completely hypnotised, eve*, these as a rule require several seances under the hands of the magnet- iser before the requisite degree of insensibility to pain is attained. Again, the mental state thus called into existence is in a large number of cases highly preju- dicial to physical and moral well-being, and hence the consensus of opinion at present goes rather adversely to the employment of hypnotism in anaesthetic practice, save in very exceptional circumstances and under <• fully guarded conditions. In the 18th century the history of discoveries con- cerning anaesthetic methods becomes merged in that HISTORICAL. 5 of the progress of chemical research. Hales, Lavoisier, Priestley, and Cavendish, opened up rich stores of know- ledge by their discoveries among the gases. Oxygen, nitrogen, nitric oxide, were prepared and closely studied, and, in 1772, Priestley added nitrous oxide gas to the list. Pneumatic chemistry, till then unknown, became the absorbing theme among chemists, while physicians sought to bring the recent discoveries to account by pressing these gases into the service of medicine. Dr. Becldoes in 1798, assisted with finances by Wedgwood the renowned potter, inaugurated his Pneumatic Insti- tution at Clifton, where he proposed to treat phthisis and many other diseases by inhalations of various gases. ' The Pneumatic Institute is interesting mainly be- cause its first superintendent was Humphry Davy, who prosecuted therein his researches concerning nitrous oxide and other gases. In 1799, Davy discovered that " as nitrous oxide, in its extensive operation, appears capable of destroying physical pain, it may probably be used with advantage during surgical operations in which no great effusion of blood takes place." Davy substan- fciated his statements by most careful experiments upon + he lower animals, extending Hales' research, which had been confined to mice, and demonstrating many facts the practical uses of which were not appreciated for more than forty years later. But his philosophic mind did not content itself with limiting his experiments here ; he actually inhaled the gas and found its influ- ence to assuage the pains of toothache, and in his " Eesearches " are recorded his own sensations and the behaviour of others after inhaling nitrous oxide gas. Early in the nineteenth century Dr. Hickmann sng- O ANESTHETICS. gested that a painless mode of operating might be achieved by the patients' inhaling carbonic acid gas, but his proposal met with scant favour. The discovery made by Davy was not brought within the field of practical application until Horace Wells, a dentist of Hartford, Connecticut, conceived the idea of using nitrous oxide gas as an anaesthetic for tooth ex- traction. Wells went to a popular lecture delivered before the inhabitants of Hartford by a Mr. Colton, an itinerant lecturer on chemistry. During the perform- ance one of the audience inhaled an impure sample of gas and became very excited. In the course of his gyrations this individual wounded his leg but felt no pain, a circumstance of which Wells was not slow to take notice. The following day, Dec. 11th, 1814, Mr. Colton at the request of Wells administered gas to him, and during the ensuing unconsciousness, a Mr. Riggs, another dentist, extracted a molar from Wells' jaw. After successfully employing gas as an anaesthetic among his own patients, Wells essayed a public demonstration in the operating theatre of the Boston General Hospital. The individual upon whom this experiment was tried was not rendered completely unconscious, and gave unequivocal signs of having felt pain. This failure not only ruined Wells, who died in great poverty not long afterwards, but discredited nitrous oxide as an anaesthetic. Colton subsequently induced various dentists to ex- periment, and in 18G7 he was able to give a record of 20,000 successful cases. In 1868* the anaesthetic pro- * Colton while in Paris met with a well-known dentist, Dr. Evans, mainly to whose energy and munificence Colton's apparatus travelled to London, where the merits of nitrous oxide gas were brought before the English faculty. HISTORICAL. 7 perties of nitrous oxide gas were successfully demon- strated at the Dental Hospital of London, and a committee of the leading English dentists was formed. The two reports published by these gentlemen, and read before the Odontological Society of Great Britain, spoke in warmest praise of the agent, and practically established its claims as a safe and efficient anaesthetic for short operations, in spite of considerable opposition on the part of certain members of the medical pro- fession, who denounced nitrous oxide as dangerous and unsatisfactory. C Ether is said to have been discovered by an Arabian hemist, Djabar Yeber, and its method of manufacture by Dr. Michael Morris. As an anaesthetic, however, it is commonly held to be due to American enterprise. It was fairly well known, and its properties recognised, as early as 1785, when Dr. Pearson, of Birmingham, em- ployed it as an inhalation for asthma, and early in the present century it was used in the treatment of phthisis. In 1818 a paragraph appeared in the Journal of Science and the Arts, which although unsigned is generally sup- posed to have emanated from the pen of Faraday ; it runs : — "When the vapour of ether is mixed with com- mon air and inhaled, it produces effects very similar to those occasioned by nitrous oxide." Then follows an account of an experience with ether ; a gentleman who inhaled became " lethargic," and so remained for thirty hours. Facts about the narcotic properties of ether were rapidly brought to light, and the writings of Oriila, Broclie, Giacomini, and Christison, all give more or less accurate accounts of the stupefying effects of ether. About the year 1840 it was a common trick at lectures and among medical students to inhale ether-vapour in 8 ANESTHETICS. order to induce exhilaration. A number of lads were indulging in this pastime in the outskirts of Anderson, S. C, and to stimulate further their mirth seized upon a negro boy and forced him to inhale ether, pressing the vapour upon him until he became deeply narcotised and apparently dead. In an hour, however, to the delight of his tormentors, the negro resumed conscious- ness. This scene impressed itself so deeply upon one of the lads, named TVilhite, that when three years subsequently he became the pupil of a Dr. Long, of Jefferson, Jackson County, U. S. A., he narrated to him his experiences of ether. As a result Dr. Long in 1842 administered ether to a patient, and while he was narcotised removed a small tumour. The same sur- geon employed ether as an anaesthetic on several sub- sequent occasions with a like success, but somehow the matter did not attract any particular notice. Other medical men also about this time employed ether for surgical anaesthesia. A student named William Clarke, in 1842, administered ether at Kochester, New York, to a patient for tooth extraction, and Dr. Marcy, an American, operated upon an etherised patient in 1844. However, the employment of ether as an anaesthetic is more usually associated with the name of Morton, a dentist of Boston. William T. G. Morton was a pupil of Horace Wells, and from his master he gathered his first impressions concerning artificial anaesthesia. It would subserve no useful purpose to open up the miserable quarrels and recriminations which have been connected with Morton and his share in the introduc- tion of ether as an anaesthetic. I will, therefore, merely state the facts as far as I can do so without bias, and after reading both sides of the controversy. HISTORICAL. 9 Wells made Morton his partner in a dental practice he proposed to start in Boston. The removal from Hartford to Boston was consequent upon a discovery Horace Wells had made of some solder with which he hoped to achieve great things. To confirm his own estimate of the value of this solder he called iu a Dr. Jackson, a scientific chemist, who expressed a favour- able opinion. However, the partners soon fell out, and Wells returned to Hartford, leaving Morton in Boston. The latter asked Wells for information as to the pro- duction of nitrous oxide, and was by him referred to Dr. Jackson. It was suggested by the chemist that trial should be made of sulphuric ether instead of laughing-gas, since it was more easily obtained. Act- ing upon the suggestion, ether was given and teeth were extracted without pain. This success was followed by a public demonstration, October 17th, 1846, in the Massachusetts General Hospital, when Morton adminis- tered ether, and Dr. Warren, a well known surgeon, proceeded to operate. The experiment was repeated, and each time proved a remarkable success. In England, the first administration of ether took place in Gower Street, London, close to University College Hospital, "when Mr. Kobertson, a dentist, gave ether and removed some teeth. This took place Dec. 19th, 1846, at the house of Dr. Boot. On December 21st, Liston amputated through the thigh in University College Hospital, the patient being etherised. Dr. Snow, early in 1847, commenced the successful administration of ether in St. George's Hospital, but upon the introduction of chloroform he gave up ether for its more savoury but less safe rival. On January 19th, 1847, Dr. (afterwards Sir James 10 ANESTHETICS. Young) Simpson administered ether to a woman in childbirth. Notwithstanding favourable experiences of many, ether was not rendered popular for some years subsequently. The methods in vogue for its adminis- tration were far from satisfactory; man}' patients never got beyond the stage of exhilaration and wild excite- ment, and their struggles and bacchanalian shouts were pronounced highly embarrassing to the presiding surgeon. These considerations led Liston and other eminent surgeons to regard ether with suspicion, and made them diffident in invoking its aid to their assist- ance. However, up to the time of Simpson's world- famed pamphlet, Xotice of a new ancestlietic agent as a substitute for sulphuric etJier in surgery and midwifery, November, 1847, ether was slowly but surely winning its way as a safe and trusty anaesthetic. With, how- ever, the introduction of chloroform, came the coup de t/race to ether. With an almost incredible rapidity chloroform supplanted her elder sister, not only in Great Britain but almost throughout the world ; in America, however, many surgeons still clung to ether. The story of the introduction of chloroform is soon told. Sir James Y. Simpson, not wholly satisfied with ether, in obstetric practice, ashed Mr. Waldie, the .Master of the Apothecaries' Hall of Liverpool, if he, as a practical pharmacist, knew a substance likely to be of service in producing anaesthesia. Mr. Waldie being acquainted with the composition of " chloric ether," suggested that its " active principle," chloroform, should be prepared from it and used, lie never carried out his promise to prepare some, and so the desired sub- stance was obtained in Edinburgh, and Simpson ex- perimenting found its use perfectly satisfactory. This HISTORICAL. 11 favourable opinion he expressed in his paper read before the Medico- Chirurgical Society of Edinburgh, Nov. 10th, 1847. On Nov. 15th, 1847, Simpson performed at Edin- burgh his first operation, the patient being under the influence of chloroform. It is curious to note how narrowly several persons escaped discovering the value of chloroform as an anaesthetic. Thus, chloric ether, a twelve per cent, solution of chloroform (by volume) in spirits of wine, was employed by Dr. Bigelow, of Boston, but without success. Jacob Bell, of London, however, actually produced insensibility by its use as an inhala- tion, and Sir William Lawrence the surgeon employed it with some success alike in private and hospital prac- tice. Chloric ether was also used at St. Bartholomew's and the Middlesex Hospitals, but the great uncertainty of its action and the expense of procuring large supplies effectually prevented chloric ether from gaining ground as an an aesthetic. Chloroform was experimental^ studied by Elourens in 1847, but no practical uses were made of his work. For some while chloroform was believed to be a " safe anaesthetic," an impression to which the language of Simpson's pamphlet rather lent itself, although certainly no explicit statement to that effect can be found. Unhappily this belief re- ceived a rude shock when on January 28th, 1848, a death from chloroform was reported at a place near Newcastle-on-Tyne. This untoward occurrence was soon followed by other deaths, and men's minds be- came anxious. At this pass Snow, with that earnest- ness and acumen which characterised all he undertook, commenced his researches into the subject. In 1848, Snow published his "Experimental papers on narcotic vapours." 12 ANESTHETICS. -.Although he improved upon the methods in vogue for the exhibition of ether by the invention of his inhaler, Snow did not advocate at all strongly the merits of that vapour over other narcotics. In 1847 he perfected his chloroform inhaler, being actuated by the belief that this anaesthetic kills through being used in too con- centrated a vapour. Snow's experience, like that of most others, made him regard chloroform as dangerous, and so in 1856 he was tempted to investigate amylene, which he found to deserve his good opinion. A Com- mittee appointed by the Koyal Medical Chirurgical Society of Great Britain tendered their report in 1864, which strongly insisted upon the danger of chloroform and the inconvenience of ether as then administered. Therein were embodied many suggestions, some of which Clover, who had then achieved a high reputation as an anaesthetist, was not slow in carrying to a prac- tical issue. In 1862 he had constructed and published an account of his chloroform apparatus by which he regulated the percentage of vapour administered. Pollock and Warrington Haward in this country were keenly alive to the dangers of chloroform, and they lost no opportunity of urging the use of ether, an advocacy for which we must always feel grateful. But as time went on Clover was less and less inclined to use chloro- form. For minor operations he found nitrous oxide gas given by his apparatus to answer best, and he was led to seek some means of prolonging anaesthesia so obtained. This he achieved by the employment of gas in combination with ether, for which he soon de- vised an admirable apparatus, described in the British Medical Journal in 1876. Subsequently his portable regulating ether inhaler was introduced, and it was HISTORICAL. 13 mainly by the compactness and efficiency of this instru- ment that the practical question, how to give ether rapidly and safely, became answered. In 1879 the British Medical Association undertook to re-investigate the question of the relative safety of the various anaes- thetics, and appointed a committee to carry out experi- ments. The conclusions to which this, the " Glasgow Committee," arrived were in favour of ether, as they found chloroform lowered the blood tension and de- pressed the action of the heart. In 1889 the Nizam of Hyderabad, at the suggestion of Surgeon- Major Laurie, granted a considerable sum of money to re-investigate the question, and the first Hyderabad ComTnission, working upon small mammals in India, came to con- clusions more favourable to chloroform. As these investigations were not held convincing by English experts, a second Hyderabad Commission, in which Dr. Lauder Brunton assisted, went over the ground again, and corroborated the results before obtained. These experiments are considered at length in the chapter dealing with chloroform. It is undesirable to enter further into detail. The subsequent history of anaesthetics is mainly that of attempts to introduce fresh substances or to modify the modes of administering the old ones. But few note- worthy advances can be mentioned : Snow, Clover, Richardson, in this country, Claude Bernard, Paul Bert, in France, with others, have devoted much time and labour to the scientific questions connected with anaesthesia, but any account of such labours, to be in- telligible, would occupy more space than can here be devoted to the subject. 14 ANESTHETICS. CHAPTEE II. Preparation of a Patient and Choice of an Anaes- thetic. Although the anaesthetist seldom has the choice of time given to him, the selection of a suitahle hour for the operation is not a matter of indifference in adminis- tering an anesthetic. The effect of anaesthetisation upon the robust may be considered trifling and transi- ent, yet when the person anaesthetised is an invalid, and either weakly or highly neurotic, it is certainly not so. Individuals are more liable to after-effects of an unpleasant character when their bodily condition is one of nervous exhaustion and lowered vitality. It is then inadvisable, unless over-riding circumstances should exist, to give an anaesthetic after a prolonged fast — for instance, in the early morning before food has been taken. Similarly, it is inadvisable to select an ad- vanced hour of the evening when the body will be spent with a day of activity or suffering. Further, an anaes- thetic should not be given within three hours after a meal of solids, as a full stomach impedes the produc- tion of narcosis and leads to vomiting. This last occurring during partial narcosis may occasion fatal Lents through solids being drawn into the trachea. It is well, therefore, to select the period of greatest vital activity, and this is found in most persons in the morn- ing or early afternoon. Arrange for a light meal of soft and easily digested matters to be taken three PEEPAEATION OF PATIENT. 15 hours* before the surgeon should arrive. This may consist of milk foods, strong beef- tea, or jellies, etc., varying with the time of the day and the choice of the patient. Weakly persons with feeble heart-action will certainly do well to take a little good brandy or whisky (one or two table-spoonfuls in an equal quantity of milk or water) half an hour or so prior to the operation, though it is not wise to make the administration of stimulants before an anesthetic a matter of routine. In every instance it is recommended that the bowels be cleared overnight with a purge. The following is a condensed form of a useful regimen to be adopted at the time of an operation : — Operation at 9 a.m. Beef-tea or thin corn flour to be given at 6 a.m. Operation at 9 a.m., completed by 10; if sickness occur very hot water may be given in sips from a feeder or porcelain spoon. At 2 p.m. Brand's or Edge's essence of beef in jelly ; if much thirst ice may be sucked, or iced soda and milk taken. If very prostrate from vomiting, iced brandy and soda water. At 6 p.m. a light meal of fish. Operation at 2 p.m. Breakfast at 8, tea, coffee or cocoa, bread and milk, fish, no meat. Beef- tea, if desired, at 10.30. Operation at 2, over at 3. Bread and milk or biscuit and tea or cocoa at 7 p.m. * It is well, unless the patient be in a very feeble state of health, to adopt Clover's rale, and give the last meal five or six hoars before the operation. 16 ANAESTHETICS. "When nitrous oxide alone is given, these elaborate details maybe omitted, though even then it is well, with children especially, to see that they pass water before being anaesthetised, as urination is often performed unconsciously whilst under the influence of gas. A patient about to be anaesthetised should be placed in the recumbent position, excepting cases of dental operations under nitrous oxide. The clothing should be carefully loosened, corsets quite undone, neck bands left open, and waist belts and strings removed. It is important that the patient be as comfortably posed as circumstances will permit, for while tranquillity of mind and body go far to assist in the production of narcosis, anxiety and uneasiness will greatly retard its accom- plishment. He should now be asked to open his mouth, and a quick glance given to ascertain if any artificial dentures or an obturator, etc., be worn. Such, if present, must be removed with as little an- noyance to the patient as possible. A further step may be taken in reassuring him by a few cheery words, and if necessary, directions as to how he is to take the anaesthetic. Such instructions are often of real service by giving him something about which to think. When, however, the anaesthetic is once well on the way, quietness and silence must be maintained ; noise especially in the case of nitrous oxide — militates con- siderably against easy and tranquil anaesthetisation. The choice of an Anaesthetic must depend on 1. The condition of the patient. 2. The necessities of the operation. * The question with whom lies the choice of the anaesthetic is con- sidered in detail in Chapter XII. PREPARATION OF PATIENT. 17 Ether, either in succession to nitrous oxide according to Clover's method, or given by itself, is the best and safest anaesthetic for general purposes, and should be adopted as the routine method of producing unconsci- ousness before operations. There are, however, con- ditions which are often held as justifying a deviation from this routine, and these are noticed below. It may be pointed out, however, that, although apparently a long list, these conditions really represent a very small minority of cases when compared with the great num- ber of instances in which ether should unhesitatingly be adopted. , Children. — Infants and young children bear chloroform well, and resent having their mouth and nose covered by a face piece, an objection, although by no means an insuperable one, to the use of ether. In many instances also ether produces much bronchial trouble, so that a better anaesthetic in these cases is the A. C. E. mixture, or one of chloroform and alcohol. Children about five or six years of age should be given gas and ether, unless they are notably the subjects of respiratory trouble. They will probably strongly rebel against having the face piece applied, so that if it be desirable to avoid " a scene," the mixtures of chloroform, alcohol, and ether, may be substituted and given by the open method. E thy dene dichloride is advocated for chil- dren by some, but experience proves that it is not taken more readily and does not appear to be in any way safer in its action than chloroform. Although the use of chloroform is unquestionably attended with happy results in the case of children, it must be remem- bered that deaths from this agent are by no means con- c 18 ANESTHETICS. fined to adults. It cannot, therefore, be too strongly impressed upon the mind that children run a risk, and probably as great a risk, in chloroform narcosis as do adults. Pulmonary Disease. — Persons of early adult and adult life should have ether given to them, provided always they are free from pronounced pul- monary affections and renal diseases. With regard to asthmatics, and those suffering from chronic cough, dyspnoea, or emphysema, the A. C. E. mix- ture should be tried, but if the ether in this still gives distress, its quantity may be decreased, or the Vienna compound used instead. And should the pati- ent suffer greatly from the exclusion of air, through the employment of an inhaler, chloroform can be given by the open method, as that substance will not only pro- duce anaesthesia but will obviate asthmatic seizures. For the subject of chronic bronchial disease the choice of an anaesthetic should be made solely by consideration of his symptoms. In the presence of much dyspnoea, diluted chloroform will be found far preferable to ether. Emphysematous individuals with large (bullock's) hearts are always anxious cases requiring great nicety of treatment. On the one hand lies the possible dan- ger of ether producing a water- logged condition of the rigid chest, and on the other a more than probable danger of syncope through the depressant action of chloroform on the enfeebled, dilated heart. In this dilemma I have found the A. C. E. mixture to answer well, though it needs careful watching, as many and grave symptoms may occur during its use. Among persons who have but one available working lung — as when the other is bound by pleuritic adhesions subse- PREPARATION OF PATIENT. 19 quent to effusion, or when one is compressed by an effusion or empyema — the choice of an anaesthetic be- comes one of difficulty. In such cases ether is badly borne, and chloroform diluted with alcohol is preferable. And again, the heart, in these cases being often so pressed upon or displaced, is intolerant of further de- pressing effects ;* hence extreme caution will be found necessary. Renal Disease. — Where the kidneys are much damaged and there is considerable danger of suppression of urine, ether is by many held to be contra- indicated. Certainly in many instances no such untoward result has been brought about ; still, perhaps it is well to sub- stitute the A. C. E. mixture for ether, for those patients who are the subjects of pronounced renal disease. Arterial disease, if present in any grave degree, whether fibroid or due to senile change when far ad- vanced, is a contra-indication for the giving of pure ether. The blood pressure would be increased by this substance, the heart's work augmented, and consider- able strain imposed upon the diseased arterial walls by which they become in danger of rupture — a result liable to occur in the brain and leading there to the gravest consequences. For the aged, that is for those over 60 years of age, chloroform is commonly held to be preferable to ether and in many instances this is true. It is, however, true only because persons past middle life are often the subjects of chronic bronchial trouble ; they are also fre- quently diseased in their vascular systems, and upon * Any sudden change in the posture of the patient is dangerous and must be avoided. On this subject see the article on etherisation by the rectum Chapter IV. c 2 20 ANESTHETICS. that account liable to be injuriously affected by ether. Old persons too, like infants, are susceptible to a bron- chial and laryngeal irritability which ether excites, producing in some distressing cough, dyspnoea, and exhaustion. However, for aged and feeble subjects with weak hearts and depressed vitality, ether, notwith- standing the drawbacks alluded to above, is beyond doubt the best anaesthetic. In conditions of collapse, e.g., railway smashes, guu- shot wounds, strangulated hernia?, ruptured viscera, or conditions when the vitality has sunk very low, as in the case of carcinoma affecting the oesophagus, pylorus, and causing chronic starvation ; also in collapse due to severe hemorrhages or other causes, or provoked by high temperatures, it may be necessary to i)er- form an operation^ and it will usually be desirable to administer an anesthetic. Ether if properly adminis- tered is, I am sure, the best and safest anaesthetic for these cases. It should be given from a Clover's inhaler as when that apparatus is properly handled there need be no dyspnoea or impediment to respiration. Very little anaesthetic is required, and the mask may be taken off during inspiration every three or four respira- tions. When there is very considerable respiratory trouble complicating the case, the A. C. E. mixture may be substituted for ether and given either by means of an Allis' inhaler, a cone, or upon lint. Still, ether is par excellence the anaesthetic, as it not only produces narcosis, but stimulates the heart and aids the circula- tion. In Moici5i;s cordis. — It often becomes a question as to what anesthetic should be employed in cases of organic heart disease. To answer this question we have to con- PREPARATION OF PATIENT. 21 sider firstly, the various forms of valvular disease, and secondly, the conditions of hypertrophy, atrophy, and muscular degeneration, as well as the pericardial condi- tions which interfere with cardiac function. Valvular disease of the heart, except when incom- petency at the aortic orifice occurs, does not, per se, greatly affect the prognosis about the safety or danger of giving an anaesthetic, although the changes brought about in the vessels, tissues, and organs of the body in general through such lesions will possibly do so. In- deed, it is a fact that in but few cases of deaths from an anaesthetic have the valves of the heart been found dis- eased at the necropsy. Degenerations of the myocardium. — When the heart muscle has undergone structural changes, the danger in producing anaesthesia is greatly increased. Any altera- tion in the respiratory or vascular systems induced by anaesthetics imposes an extra strain upon the already weakened and diseased heart — one which it is unable to sustain ; hence supervenes syncope. When the heart trouble is not complicated by pulmonary engorge- ment, oedema or hydrothorax, — is in short largely com- pensated, — ether should be given and a Clover's inhaler employed. It has been suggested that a cone or towel is safer in these cases, but I cannot think this to be the case, since with a Clover's inhaler you can, by fre- quently removing the mask or refilling the inhaler bag, give any degree of dilution of ether you require. When pronounced pulmonary trouble exists and ether cannot be borne, the A. C. E. mixture should be given. Should nitrous oxide be administered in morbus cordis ? I think yes, but if the case is one of advanced disease and the organ is working feebly, it is wise to 22 ANESTHETICS. supplement the nitrons oxide by allowing it to pass over ether-vapour. This plan has in my hands answered most admirably. Chloroform, whether pure or diluted, cannot be given to persons having diseased hearts without increasing the risk of syncope, which under any circumstances the)' must run. Hypertrophied hearts are in practice usually dilated hearts, and being so are muscularly at a disadvantage. The same rules given for guidance above will serve here. Some highly nervous, excitable persons are much terrified by the application of a face piece, and indeed in some few cases the mental distress and terror thus excited may be sufficient to occasion serious indisposi- tion. In cases such as these it is especially useful to employ the A. G. E. mixture upon lint, replacing it by ether from Clover's inhaler so soon as the patient is sufficiently dazed as not to perceive the alteration. Pregnant women take all forms of anaesthetics well, but if excitable and nervous as they are apt to be, it is better to avoid the coughing and straining which may follow the employment of ether. It will be found, however, that unless very nervous, women in this con- dition take nitrous oxide followed by ether well— nor are they more liable to after trouble than at other times — in all such instances, as little of the anaesthetic should be given as is consistent with true anaesthesia, since it is manifestly important to avoid vomiting. From the surgeon's point of view — to decide upon the choice of an anaesthetic is difficult, as it is impossible to lay down hard and fast rules where there will be always conflicting considerations. OPERATIONS. 23 Operations about the Head, Face, Trachea and Eespiratory Tract. Brief operations about the mouth, nose, or pharynx, such as the extraction of teeth, excision of tonsils, opening of abscesses, tearing off mucous polypi, etc., can often be performed under nitrous oxide. With this agent from *5 to 1 minute of unconsciousness can be expected. If the operation is likely to occupy more than this time, and if the cautery is not to be used, gas with ether should be employed, as this combination will prolong anaesthesia. In operations accompanied by severe haemorrhage, but which do not need much time, the gas and ether mixture possesses an advantage, inas- much as the patient rapidly resumes consciousness, and so the danger of blood being drawn through the trachea into the respiratory tract will be avoided. In operations for the removal of post-nasal adenoid growths, I have for some years extensively used gas and ether with success. Some specialists prefer chloroform for such cases (i.) because a more profound and lasting anaesthesia is thus obtained, (ii.) because less violent bleeding takes place at the time of the operation. On the other hand, the rapid resumption of consciousness under ether cer- tainly minimises the danger of blood entering the lungs. When the operation is likely to prove a prolonged one, chloroform will be more satisfactory to the operator. Staphyloraphy necessitates the mouth being open, and it is a matter of consideration that the operator should have free and uninterrupted access to the buccal cavity. To effect this, the patient can be put under the influence of chloroform and maintained so by anaesthe- 24 ANESTHETICS. tising through the nostril (as described in Chap. V.). The same procedure answers for operations about the tongue. (See also Chap. IV). Removal of the upper or lower jaw should be performed under chloroform, as the cautery is often requisite and the use of a face piece impossible. In extensive removals of growths about the jaws, it is fre- quently advisable to perform a preliminary tracheotomy, and then give the anaesthetic through a Trendelenburg's tube, at the same time plugging the pharynx. Operations upon the larynx, e.g., thyrotomy, will re- quire a preliminary tracheotomy, and in these cases I prefer to keep up the anaesthesia by a Junker's inhaler to the afferent tube of which is fixed a catheter. By this means the amount of chloroform given can be more safely adjusted than when a Halm's tube and funnel are employed. In all the above mentioned cases in which chloroform is mentioned as being more con- venient an alternative method exists, namely, rectal etherisation. Operations about the eyes require extreme narcosis, absolute immobility and freedom from coughing being essential. Nitrons oxide and ether, provided the ether be pushed very far, answer well ; there is of course the possibility of ether exciting a fit of coughing, which, should the case be one of excision of a cataract, and should a preliminary iridectomy have been already done, may lead to forcible extrusion of the vitreous. But this can only arise when the patient is not suffici- ently under the anaesthetic. There is less fear of coughing with the use of the A. C. E. mixture. In excision of the eyeball, where coughing is not of such moment, ether may be used, and should be pushed ABDOMINAL SURGERY. 25 to deep narcosis before proceeding with an operation. For passing probes or slitting lip the lacrimal canals, gas is not satisfactory, as the jactitation interferes with the operator; here the use of gas and ether answers every purpose by obviating involuntary movements. For operations about the thorax, a mixture (A. C. E.) is usually more advantageous than chloroform or ether when given alone, so that where there is especial reason for fearing the respiratory difficulty of ether, this agent should be substituted. For tapping in cases of pleuritic effusion, gas is sufficient. Chloroform in cases of empyema seems peculiarly liable to dangerous results, the heart is usually hampered and respiration abnor- mally performed ; several deaths have resulted from chloroform given in such cases. It is in these operations that rectal etherisation seems likely to be of very great service. (See Etherisation by the Rectum). Abdominal Surgery. In dissecting operations, when tranquillity of respira- tion is desired, as in operating for the radical cure of hernia in young children, a mixture, methylene, A. C. E., &c, must be employed instead of ether, but for all prolonged and exhausting operations ether should be given unless strongly contra-indicated. Thus I have found for caesarian sections, ovariotomies, hysterec- tomies and ablation of the kidney, ether if carefully given answers very well. In Labour. There is a consensus of opinion in favour of chloro- form in these cases, based partly upon the assumption 26 ANESTHETICS. that this agent is comparatively safe for parturients, and partly upon the more agreeable character of the substance. This assumption, however, is open to doubt, for chloroform cannot be in any way deemed freer from danger in childbirth than at any other time. If chloroform be employed it should not be entrusted to the hands of a nurse or other person unless skilled in its use. The various mixtures answer well in assuaging the pangs of childbed, and are probably safer than chloroform. Ether, though advocated by some, is dis- advantageous in these cases, as it may provoke strain- ing, coughing, sickness, and headache, but for general obstetric operations, and especially where the patient is exhausted and needs stimulating, ether may be usefully employed. In short it may be said that chloroform or the A. C. E. mixture may be employed as an anodyne in labour, ether when surgical anaesthesia is necessary. * In my private practice I have met with cases of women who after trying' chloroform preferred to take ether in their confinements, stat- ing that it produced more exhilaration and general feeling of well- being, while it assuaged their pangs more efficiently than chloroform. NITROUS OXIDE GAS. 27 CHAPTEE III. Niteous Oxide Gas — Laughing Gas or Simply "Gas." Chemical and Physical Properties. — Nitrous Oxide Gas [N 2 0] is a colourless body almost devoid of odour. It possesses a neutral reaction and consists of nitrogen and oxygen in chemical union, thus differ- ing from the air, which is composed of these gases in mechanical mixture. Nitrous oxide gas possesses well- defined anaesthetic properties, which appear to be quite distinct from the asphyxial symptoms frequently ac- companying its administration. This gas agrees with oxygen in many of its chemical properties ; thus, it sup- ports combustion when ignited bodies are plunged into it. At a pressure of fifty atmospheres and a tempera- ture of 44*6° F. (7° C), it becomes liquefied, and ad- vantage is taken of this to enable the gas to be carried about in iron or steel bottles, these latter occupying less space. Nitrous oxide is decomposed at a red heat, but shows no tendency to undergo change at lower levels of tem- perature. Cold water dissolves more than its own volume of this gas, while hot water dissolves less, hence it is advantageous to collect it over water at 15° C. Alcohol takes it up in a still larger proportion. Preparation. — Granulated nitrate of ammonia is pounded to ensure its being finely divided, and is placed in a strong glass retort. The capacity of the generator should be one pint to allow of safe decomposi- 28 ANESTHETICS. tion of three -quarters of a pound of uitrate of ammonia, one quart for that of two pounds. One pound of the salt will make thirty gallons of nitrous oxide gas. The generator is then carefully heated in a sand bath or over a bun sen, after being connected by tubing with wash bottles of at least the capacity of a quart, as indi- cated in the figure. At 226 3 F. the salt melts ; at 460° F. it gives off gas, and the temperature must not exceed this by many degrees, otherwise nitric oxide will come over, contaminating the laughing gas. The nitrous Frc 1. — Apparatus for the preparation of Nitrous Oxide Gas. a. Generator, b. Bunsen's burner. 1 to 4. Wash bottles, c. Delivery tube to be connected with a reservoir for storing the gas. oxide should bubble over, not boil over, not more than thirty gallons being allowed to volatilise in an hour. It is well to have a self-regulating gas jet, which is lowered as the temperature rises too much and viae versa. Bottle no. 1 nearest the retort, which may with advantage be placed in cold water, answers the pur- pose of catching the drippings which come over from the generator ; it contains clean cold water almost up to the lower end of the long tube. This tube is per- NITROUS OXIDE GAS. 29 foratod in order to break up the gas as it jmsses over, and to ensure its being washed out thoroughly. In bottle no. 2 about four ounces of ferrous sulphate are placed, and water to a few inches added. Bottle no. 3 contains a stick of potash, and water also added. It is sometimes advisable to use an additional bottle or two containing simply water for washing the gas fur- ther. Having traversed these bottles the gas is received into the gasometer, which should have a capacity of 30 or 40 gallons. When nitrous oxide is stored in bottles, special apparatus will be needed to force the gas in under the pressure of fifty atmospheres. The impurities to which nitrous oxide is liable are : — Sulphates. Chlorides. Other oxides of nitrogen, which produce coughing and feeling of suffocation. Oil (from lubrication of apparatus) which gives a rancid nauseous smell to the gas. To test for these impurities, let the gas bubble through solutions of barium chloride, which will precipi- tate sulphates, and through solutions of nitrate of silver, which will precipitate chlorides, while the other adul- terations will be detected by the nose. Purification of nitrous oxide is of undoubted import- ance, as was shown in the earlier days of anaesthesia, when the most bizarre symptoms were constantly aris- ing, many, if not all of which, were traceable to foreign products being contained in the gas employed. Some persons prefer the freshly prepared gas, but liquefied gas stored in bottles gives results practically as good. 30 ANAESTHETICS. Physiological Action of Nitrous Oxide — The Vege- table Kingdom. It appears to suspend rather than extinguish vitality. Seeds will not germinate but remain uninjured when kept in it an indefinite period. Seeds, if sprouting, cease to develop when placed in an atmosphere of this gas, but resume their growth when again placed in the air. Jolyet and Blanche found that plants placed in nitrous oxide gas cease to absorb carbonic dioxide, and do not increase in size. When oxygen is allowed to mix with the nitrous oxide the seeds germinate, and the plants grow. The Animal Kingdom. Cold-blooded animals die in an atmosphere of nitrous oxide in two hours. This contrasts with what ob- tains when the same creatures are placed in indif- ferent gases, such as hydrogen or nitrogen, for under these circumstances death does not occur for three hours and is preceded by stupor but not true analgesia. Kappeler has shown that frogs placed in it lose reflexes after a very few minutes, whereas the reflexes persist for several hours when the frogs are placed in an in- different gas, e.g., nitrogen (Goldstein). Sir Humphry Davy, in his careful research, showed that small mam- mals and birds soon die in it, although when it is mixed with oxygen they live until the oxygen tension sinks to 6 per cent., as a gainst a carbonic dioxide ten- sion of 12 per cent. Exposed to such measures the animals remain sensitive to the last, and it may be PHYSIOLOGICAL ACTION OF NITROUS OXIDE. 31 stated generally that mixtures of nitrous oxide with other gases under normal pressure are useless for anaesthetic purposes. Animals placed in non-respirable indifferent gases become convulsed before death ; this does not obtain when they are made to respire nitrous oxide. Their respirations simply grow more and more shallow, and finally cease without any of that besom de respirer which is elicited when simple deprivation of oxygen is prac- tised. Krishaber experimenting with rabbits found a marked acceleration of the rate of the pulse, with increased force at first in the heart beat. Subsequently where anaesthesia was determined some retardation occurred, while the cardiac rhythm became less regular. Ee- spiration was accelerated and death resulted in two or three minutes. He performed control experiments by ligaturing the trachea. In these cardiac rhythm re- mained unchanged until after the fourth minute, when the heart beats grew irregular, and ceased at times varying from seven to eleven minutes. The animals remained sentient to the very last. I have repeated these experiments, using dogs and cats in preference to rabbits because these last are peculiarly liable to fright, and this disturbs the rhythm alike of the heart and respiration, and in the main my results agree with Krishaber's. While dogs die in from two to three minutes in nitrous oxide, they do not succumb to as- phyxia for five ; under nitrous oxide they grow wholly insentient in from fifteen to thirty seconds, while in asphyxia consciousness to pain only ceases with life. Under nitrous oxide I found the heart little affected until the respiration was gravely interfered with, and 32 ANESTHETICS. then it gradually failed before totally stopping. The creatures seemed under the gas to sink to sleep, and from sleep to pass into death, while when asphyxiated they struggled from first to last. In the Human Subject. It is probable that this gas when administered pure, and not mixed with oxygen, enters the blood by diffus- ing through the thin walls of the air-cells in the lungs. In the blood, a small quantity is dissolved, but the bulk is connected in some loose way with the blood constitu- ents, probably being associated more or less closely with the albumins and albuminoids of the liquor san- guinis and corpuscles. According to Hermann nitrons oxide destroys the red blood corpuscles. The effect of shaking arterial blood with nitrous oxide gas is to darken it, showing that nitrous oxide gas is able to displace oxygen. But whatever union does take place is very unstable, as blood parts at once with its nitrous oxide when left in free contact with oxygen or air. Under nitrous oxide, the respiration becomes slowed and shallow, and, if the gas be pushed, a complete ces- sation of respiratory movements eventually takes place. The amount of tissue change occurring in nitrous oxide narcosis is lessened, and so the quantity of carbonic dioxide which the lungs give off is diminished. Sub- sequently to the administration, the exhalation of car- bonic dioxide is increased. The heart beats quietly, fully and regularly under this gas, the pulsations are somewhat slowed in profound narcosis. There is, however, but very slight danger of heart failure result- PHYSIOLOGICAL ACTION OF NITROUS OXIDE. 66 ing from inhalation. In animals killed by nitrous oxide gas the heart goes on beating even after the respirations have quite stopped. It is therefore less important to watch the pulse than the respiration. Blood-pressure is somewhat lowered except in the brain and cord, the vaso- motor system of different areas being, it would appear, diversely affected. This lessened pressure is, however, but slight. In some observations I made upon this subject, I found that while asphyxia caused diminution of the bulk of the brain and cord, nitrous oxide produces so great an enlargement as to force out the cerebro- spinal fluid. There can be no doubt these changes are vaso- motor in origin, and explain many of the nervous phenomena elicited in persons narcotised by nitrous oxide. The great distension of the vessels must press upon the nerve-cells and fibres both of the brain and cord, and so interfere with their function. (Physiologi- cal Action of Nitrous Oxide, Transactions of Odontoloyi- cal Society, vols, xviii. and xix.). In a recent essay, Dr. George Johnson has sought to establish the contention that nitrous oxide acts wholly or mainly as an asphyxiant. The experiments upon which he bases his belief, however, appear to have been made without due care being taken to eliminate con- current asphyxia. His statement that the pulse under nitrous oxide is diminished, and even becomes imper- ceptible, is utterly opposed to my experience. Since nitrous oxide has to be given under ordinary circum- stances without access of air or oxygen, asphyxial sym- ptoms will eventually supervene, but these come on subsequently to true anesthesia and need never be pro- duced. The peculiar muscular effects of nitrous oxide D 34 ANESTHETICS. gas which constitute "jactitations " are very different irom an epileptiform convulsion to which this writer has compared them. In cases of true epileptics to whom I have given nitrous oxide, jactitations have assumed their normal form, and sometimes a regular epileptic fit has occurred subsequently to the recovery of conscious- ness. It would seem reasonable to suppose that, were the nitrous oxide anaesthesia a simple asphyxial state culminating in an epileptiform fit, in the cases to which I have just referred, the epileptic fit should follow directly or even replace the jactitation. Again, in per- sons who take nitrous oxide together with oxygen either simply or under pressure (Paul Bert), no asphyxial symptoms develop, and yet a more or less complete anaesthesia is attained. The senses of a person passing under nitrous oxide are at first rendered somewhat more acute, after which follows a condition of analgesia. During the first stage of unconsciousness, a loose tooth may be extracted without pain, although the patient has a vague idea that something is being done. A few seconds later, and the individual is profoundly unconscious and insen- sitive to all his external surroundings. Irregular dis- charges of nervous energy frequently show themselves at this stage in jactitations of the arms and legs. If the gas continues to be respired, the limbs become rigid, the rigidity being every second or two broken by a sudden contraction of the flexors. Rhythmic tremors of hands and arms are occasionally elicited. More rarely the whole body of the patient arches forward like a bow (opisthotonos) jerking him out of the chair. This condition is especially liable to occur in children. The muscles soon relax and remain flaccid. The degree of PHYSIOLOGICAL ACTION OF NITROUS OXIDE. 35 rigidity and the amount of jactitation vary in different cases; children show jactitation early, and the move- ments of the limbs are more marked in them than in adults. The superficial reflexes are abolished, that of the patella tendon, however, persists ; and in many cases ankle clonus is developed under nitrous oxide. The pupil usually undergoes wide dilatation when com- plete anaesthesia is attained, however this phenomenon is not absolutely constant and cannot be taken as an indication of danger. During the condition of hyperesthesia which pre- cedes anaesthesia, the subject is often affected by hallu- cinations, frequently of an erotic nature, and the im- pressions then received remain firmly imprinted upon the brain. The difficulty of convincing persons that such impressions are not realities should lead every •administrator to secure independent evidence of his actions while his patient is unconscious. The bladder and even the rectum may be involuntarily emptied under nitrous oxide, and hence it is always wiser to allow patients to pass urine beforehand. As a rule the alimentary tract is unaffected by nitrous oxide, and nausea, vomiting, and bilious derangement, rarely occur after its administration. However, some persons through nervousness swallow the gas, and this causing distension of the stomach may give rise to a reflex vomiting. In view of the possible occurrence of this trouble, it is well for patients to abstain from food immediately before taking nitrous oxide gas. Later effects, which are said in some instances to * For further particulars on this point see a paper by the authoron "Ankle Clonus under Nitrous O.cide/' Brit. Med. Jour., Sep. 24th " 1837. . D 2 36 ANESTHETICS. ensue from the gas, are various functional derangements of the nervous system, tinnitus aurium, headache, and amaurosis, but these conditions occur only with the most exceptional rarity. The Administration of Nitrous Oxide Gas and the Purposes for which Applicable. When used alone, nitrous oxide gas produces a period of anaesthesia which seldom exceeds a minute. Many persons, and especially children, pass out of the con- dition of unconsciousness with very great celerity, and in them the anaesthetic stage cannot be relied upon for longer than 15 or 30 seconds. General Surgery. Nitrous oxide has been used for prolonged operations, by narcotising with this gas, then letting the patient almost resume consciousness, and again applying the face piece and administering the gas. Dr. Carnochan removed a breast, the patient being kept under nitrous oxide for sixteen minutes. And the same surgeon per- formed other major operations with the same anaesthetic. Mr. Bailey tells me he kept a patient unconscious for forty minutes while a surgeon removed a malignant growth from a male breast. As a rule, when nitrous oxide is administered more than once at one sitting, headache and malaise are liable to ensue. For the opening of abscesses, whitlows, and car- buncles; for the insertion of setons ; the tapping of DENTAL, SURGERY. 37 antral abscesses ; the removal of portions of the uvula, tonsils, or nasal polyps ; for cauterising, and possibly for the passing of Eustachian and other catheters, and the slitting up of the lacrimal canals, nitrous oxide may be need. Tenotomy, divisions of fascias, breaking down adhesions in and about joints, and divisions of fistulas, may be undertaken with this agent, but as a rule it will be found better in such cases to supplement its use with that of ether. Many other operations of minor surgery can be carried through under nitrous oxide, and it is possible, by judicious management, to prolong anaesthesia for several minutes by administering the gas again and again ; such a practice, however, cannot be commended as it is liable to produce headache, faintness, and great discomfort to the patient. Dental Surgery. Nitrous oxide alone, or combined with a very small dose of ether in the manner to be described hereafter, is the safest and best anaesthetic for this branch of surgery. When nitrous oxide is used alone and pushed to the point of stertor and jactitation, two or three teeth may be extracted at one sitting, and expertness in operating may enable even more to be done. Abnor- mality of the teeth or mouth may render extraction so difficult as to prevent the successful removal of one tooth at a sitting, and in all instances care should be taken to avoid promising the extraction of more than two or three unless the case be manifestly an easy one. If the extracting be kept up too long, pain will be felt, 3S ANESTHETICS. aud the patient complain that he could feel the removal of every tooth ; to obviate such complaints, an operator would do wisely to place himself in the hands of his anaesthetist, who should generally be better able to judge what may be done with impunity. Unless some special reason exist for desiring to extract several teeth at one sitting, it is advisable to let the patient attend twice or thrice rather than to subject him to more than one administration on the same day. Extracting a number of teeth simultaneously produces more or less severe shock. Apparatus Required. I. Apparatus for giving nitrous oxide alone. — The apparatus I find to answer best is one which is here figured (fig. 2), and which has been made for me by Mr. Blennerhassett, of London. Its main peculiari- ties are that (1) it is provided with an efficient ; ' silencer" (K) which ensures absolute quietude, (2) it is adapted for gas only, and so offers no temptation to the admin- istrator to give " only a whiff of ether," (3) it possesses a special contrivance to filter the air, and, if necessary, to impregnate the gas with aromatic or other vapours. It consists of the usual tripod (A), used because it is so portable and compact ; this supports a steel bottle containing fifty gallons of compressed nitrous oxide (/>). To the outlet pipe (a) of this bottle is fixed the silencer (A), which checks all the hissing and spluttering of gas, and from this a wide-calibred mohair tube conducts the gas into the ordinary Cattlin's bag (0). Another tube is attached to this, which communicates with a chamber made in metal and opened or closed by a valve, per- APPARATUS REQUIRED. 39 mitting either air or nitrous oxide gas to enter. In this chamber (D) are placed morsels of fine honey- combed sponge or teased- out medicated cotton- wool. Fig. 2. — Dr. Dudley Buxton's Apparatus for giving nitrous oxide, (A) Tripod. (B) Steel b( ttle containing liquefied nitrous oxide. (C) India-rubber bag. (D) Chamber containing sponge, cotton- wool, etc. (£") Face piece fitted with (/*') cap expiration valve. (G) Tube for inflating the air cushion. (/) Hook attaching tube to administrator's button hole. (K) Quieter. 40 ANESTHETICS. These substances can be moistened with lavender water, eau de Cologne, or with sal volatile, or liq. ammonias dil. — if a stimulating action is needed. The ordinary Clover's face piece (E) is attached by a bent metal tube, and provided with an expiration valve of peculiar construction (F). In cases when the breath or buccal exhalations are likely to be infective, * as, for example, in phthisis, syphi- lis, quinsy, etc., the use of cotton-wool steeped in a ger- micide, such as tercbene, is desirable. The cotton- wool is a perfect air filter, and so prevents all infection of the Cattlin's bag and obviates any fear there might be of infecting the next patient. When the ordinary appara- tus is used grave fears of such infection must always arise. The use of a drop or two of eau de Cologne or lavender water sprinkled over the morsels of sponge is most convenient. It gives a pleasant odour, which children especially appreciate, and will, if permitted to sniff at it before the gas is turned on, allow one to give the first dose of gas — always the initial step which is difficult — and so pave the way to ultimate success. In conditions of extreme weakness or the " feeling faint," which so often attacks ladies about to have a tooth out, sal volatile, eau de Cologne, or liq. ammon. dil. is of service. It need hardly be added that other aromatic substances or stimulating vapours may be employed in the same manner. The use of the silencer and the agreeable scent of the perfumed gas, as a rule, make * The danger of infection was pointed out some time ago by a cor- respondent to tlie Journal of tlm llritish, Dental Association, who recommended that a fresh Cattlin's bag should be used after each case. This somewhat expensive precaution is rendered unnecessary by my simple contrivance. APPARATUS REQUIRED. 41 nervous patients willing to inhale gas freely, and obvi- ate the distressing noises in the head and horrible dreams which were often determined by the hissing of the gas, and which are always intensified in the hyper- sesthetic stage of anesthesia. II. Gas in combination -with ether. — In cases in which more time is required than nitrous oxide gives, the use of ether — but in conjunction with the gas — is to be recommended. The apparatus which I have found most serviceable is what was called Clover's Gas and Ether Inhaler, although since Mr. Clover's time many useful alterations have been made in its construction. The gas supply is derived from a steel bottle (fig. 3, B), fixed as before in a tripod, and the gas traverses an india-rubber tube (m) to the inhaler (D). This is shewn in fig. 3. The apparatus is so arranged that gas can be given alone, or if ether also is needed, by turning a tap (k) the gas passes directly into the re- ceiver (C) containing ether, and having traversed it and passed over the surface of the ether, escapes into the face piece (P) along a tube (n). The amount of admix- ture of gas and ether is regulated by another tap (o) . The whole apparatus is light, and is suspended by a hook (i) from the administrator's buttonhole. The advantages of this apparatus are : — 1. The absolute control the administrator possesses over the strength of vapour with which he is working ; thus he would commence the administration with pure gas, then permit some gas to play over the ether, and by degrees permit full ether vapour without exciting spasm or coughing. 2. Its great simplicity and portability. It has been * The apparatus is made by Messrs. Mayer and Meltzer, of London. 42 AX-ESTHETICS. termed unsightly and cumbersome, but no one familiar with its use would find it either the one or the other. 3. It is the only inhaler in which the gas is made to actually traverse the ether. Via. 3. — Apparatus for the administration of nitrous oxide and ether (After Mr. Clover.) When ether only is used the same apparatus is equally satisfactory. In either apparatus the gas supply is controlled by APPARATUS REQUIRED. 43 the foot, which, placed upon the foot piece (/) rotates it from right to left to turn the gas on, and from left to right to turn it off. Some persons prefer to have the bottles placed horizontally, thus obviating the necessity for the tripod. In this case the exit valve is so situated that a foot piece placed on the long axis of the bottle regulates the supply. When gas only is required it is always well to have two bottles yoked side by side and connected by an ordinary junction, so that when one bottle becomes empty, the valve of the second is opened and the supply of gas is not interrupted. When ether is to be given in succession to nitrous oxide the apparatus figured (p. 42) is used. The pati- ent is rendered unconscious with gas, and as soon as the quiet rhythm of respiration assures us that such is the case the stop cock is turned into the long axis of the bag, and the indicator, which is seen in the figure as standing midway between the letter G and E on the dial plate (o), is slowly rotated from G where it stands when gas only is being given. As this indicator passes from G towards E, more and more ether vapour passes into the face piece, until when it stands at E no fresh gas supply is permitted and the patient breathes pure ether vapour. The india-rubber tube, the ends of which are figured g and m, is then detached at m, but the tap which is there placed is left open to permit air to enter the bag and dilute the ether vapour. To complete the description, we have only to mention that the cushioned face piece used by Clover and sup- plied with a single expiratory valve is as convenient as any. u ANAESTHETICS. Should a supplemental bag be used, the face piece must be provided with an aperture to which this acces- sory can be adjusted. The stop-cock in this arrange- ment is kept shut until the residual air of the lungs is presumably exhausted, when it is opened, the finger is Fig. 4. — A. Expiratory Valve. B. Inspiratory Tube which gears on to Cattliu's Bag. C. Supplemental Bag. D. Cap to cover Mount when the Ether or Supplemental Bag is not used. placed upon the expiratory valve and the patient al- lowed to breathe backward and forward into the bag. When desirable, however, it is a simple matter to con- vert the Cattlin's bag itself into a supplemental bag, by APPARATUS REQUIRED. 45 placing a finger upon the expiratory valve, and so caus- ing the patient to expire back into the Cattlin as well as inspiring from it. Where a gasometer is kept, a modification of the above apparatus is in use. A long tube screws on to the efferent pipe of the gasometer, conveying the gas to a bag of 2 or 3 gallons' capacity. This may be con- nected directly with a face piece or conveyed to it by another length of tubing, and by using a three-way- cock it is easy to combine this apparatus in gear with Clover's smaller ether inhaler. As face pieces are almost universally employed in the United Kingdom, it is scarcely worth while to describe the mouth pieces sometimes used in America. Briefly, we may say, they are flute-like in shape and are taken between the teeth. The nose is slightly pinched while the patient draws in the gas through the opening in the flute piece. The employment of supplemental bags (see fig. 4, C) has been advocated by Mr. Braine. The bag fits on the face piece and is guarded by a tap. The patient, having presumably emptied his lungs by a few very deep inspirations, is allowed to breathe to and fro into the supplemental bag, the tap of which is turned to allow gas to enter. The gas supply and the expiratory valve are closed. It may be necessary to empty the bag and refill from the reservoir. Those who employ the supplemental bag claim for it that it is economical and produces a slightly more prolonged period of un- consciousness. The disadvantages are — it is liable to produce headache, it takes longer to get the patient well off, and it is, I believe, opposed to the knowledge we now possess of the physiological action of nitrous 46 AX-ESTHETICS. oxide gas, since it gives a mixed narcosis partly as- phyxial and partly due to the gas inhaled. Another apparatus for the giving of nitrous oxide, Fig. 5.— BarUi'ts portable gasometer for liquid nitrous oxide. nnd one useful to persons who desire to keep a supply always ready in their rooms, is figured above. (Fig. 5)- The Administration. Various adjuncts are used, such as gags, mouth open- ers, mouth props, the oral spoon, tongue forceps. THE ADMINISTRATION. 47 Gags. — Various forms are in use, the one made for me has special advantages from the facility it offers for rapid removal and rej)lacement. It consists in replac- ing the screw-fixing arrangement by a ratchet as is seen in the figure. By putting the finger upon the free end of the ratchet and pressing it backwards as one does a trigger, the ratchet is released and the gag closes. To open it, it is only necessary to press the handles together and the Fig. 6. — Gag fitted with ratchet arrangement. (Mayer and Meltzer). ratchet will automatically gear and prevent closing of the mouth. I find it safer to wire the tube pads on to the ends of the gag ; this prevents their casting loose in the mouth, and is easily accomplished when the pads are changed, as should frequently be done. The ratchet arrangement can be used with long or short handles, personally I prefer the latter. The usual form of gag (Mason's) is figured p. 48. A very convenient gag has. been devised by my friend Mr. Gowan, which combines the advantages of a sure gag and a mouth opener in cases in which the teeth are sufficiently apart to allow its insertion. It acts by turning the millhead from left to right, and fixes itself 48 ANESTHETICS. without requiring any screw. This gag is as ingenious as it is useful. Fig. 7. — Mason's Gag (improved by Croft). Fig. 8. — Gowan's Gag. By revolving the disc a to the right or left the gag is opened or closed. The disc being eccentric, no screw is required for adjusting the gag. Of mouth dilators, or more accurately openers, Heister's, figured below, is the best. It possesses enormous power, so it must be used with care. Its THE ADMINISTRATION. 49 employment is of course indicated in cases of severe trismus, partial ankylosis, etc. The blades may be inserted either in a gap caused by the previous ex- Fig. 9. — Mouth Opener (Reister's). traction of a tooth, and if possible between the molars. If placed between incisors the risk is run of forcing these teeth out of their sockets. Dental props. — Many kinds are in use. Mr. Clover employed those made of hard wood, but, although very convenient and not liable to slip, they are apt to get chopped and split. The cleanest and nicest I know are those figured below and made of vulcanite. I have them made in six sizes. Fig. 10.— Mouth Props. The mouth prop spoken highly of by Mr. A. S. Underwood and figured below is also useful. (Fig. 11). 50 ANESTHETICS. All loose props should be tied with fishing gut, and a long piece made to hang out of the mouth. Although spring and mechanical props are objection- able upon the general ground of their liability to get out of order or to break, yet some kinds are useful, and I subjoin illustrations of some of the best. Fio. 11. A central prop, fixing upon the anterior teeth with a rotating arm, permits of operations upon one or other side of the mouth according to the necessities of the case. A very convenient form is figured below. Fig. 12.— Weller's Gag. THE ADMINISTRATION. 51 It possesses an easily working screw, which permits of very nice adjustment. The plates should rest upon more than one tooth in each jaw. Dr. Frederick Hewitt's prop is also useful. (Fig. 13). No mouth prop or cork should he placed in the mouth without being first securely tied to a counterpoise which hangs out of the mouth, and prevents the prop becom- ing wedged in the larynx or oesophagus in the event of its slipping. The few minutes spent in carefully Fig. 13. adjusting the prop between the teeth should not be grudged, as the after success of the operation depends largely upon the security obtained in this manoeuvre. It should be adopted as a general rule, when possible, that the dental prop be placed not further forward than the bicuspids. Fig. 14. The mouth spoon (fig. 14), made for me by Messrs. Ash, is safer than its archetype, the invention of Mr. T. S. Carter, in that the shank of the spoon in that in- e 2 52 ANESTHETICS. struinent is liable to separate from the bowl, and then a risk is run of the detached bowl getting impacted in the gullet or windpipe. By carrying the shank to the distal end of the bowl as in my pattern, this danger is obviated. The use of the oral spoon is to catch any teeth or roots which may fall out of the forceps. Bi- cuspids are especially apt to spring out of the beaks. The spoon is held below the seat of operation, care being taken not to allow it to get in the way of the operator. The tongue forceps (fig. 15) figured below needs no special description. A tracheotomy case should always be at hand when an anaesthetic is to be administered. We will now describe some special manoeuvres which are resorted to in the administration of nitrous oxide, when the mouth is open as is necessary in dental opera- tions. The prop should be carefully fixed in the oppo- site side of the mouth to that upon which the operation is to take place, and a glance cast round for artificial dentures, or an obturator, which if present must be removed. The patient is now to be reassured by a few cheering words, and directed to breathe freely. It is well to allow a nervous subject to take several very deep inspirations before applying the face j)iece, as these clear the lungs and divert the attention from a supposed horror of "taking gas." The Cattlin bag is quietly filled by turning the toothed foot piece under the foot. The face piece is then lightly applied to the patient's face, and retained by just enough pressure to prevent the escape of gas or the entrance of air. In a second or two, the patient becomes accustomed to the face piece, and is then instructed to take a very deep THE ADMINISTRATION. 53 breath. At the instant of inspiration the stop-cock is turned so that the patient breathes in the nitrous oxide from the Cattlin's bag. During the administration it Fig. 15. is important to keep the bag full of gas, and to do this the foot must from time to time be turned and gas be allowed to flow from the bottle into the bag. It is well 54 ANESTHETICS. to open the ingress of gas during inspiration and close it during expiration. After the first fifteen or twenty seconds, that is, after the lungs are presumably filled with nitrous oxide, and when gas is gaining tension in the blood, slight duski- ness of the skin appears, the ears and finger tips darken, consciousness, however, being fully present for ten or fifteen seconds longer. In half a minute the patient's power of receiving impressions and reasoning upon them is greatly interfered with, and in a few seconds later all consciousness is lost. At this stage, incautious acts such as touching the conjunctiva, making loud noises, or roughly handling the patieut may lead to his com- pletely regaining consciousness. In from forty-five seconds to a minute after the application of the face piece, the pupils will usually dilate, the eyes becoming dull and expressionless, while there may be strabismus. The conjunctival reflex will persist, and if the face piece be removed at this stage, the return to consciousness will be rapid. There is, as a rule, time for the extrac- tion of one tooth, if fairly loose, but not of more. When the inhalation is not checked at this time, further signs of deeper anaesthesia appear. In about a minute and a quarter, the breathing grows stertorous, muscular movements of the hands and feet supervene, and the conjunctival reflex is lost. The eyeballs begin to oscillate, and if the gas be still inhaled the breathing becomes slowed and even intermittent. Should it stop for more than fifteen seconds (Clover), air must at once /iven. At this period of deep anaesthesia there is great stress imposed upon the heart, so that the pulse should be watched, and if it flag all further administra- tion should cease. The patient is now ready for openi- THE ADMINISTRATION. 55 tion, and it is not wise to attempt to push nitrous oxide beyond this point. Further inhalation of gas and air intermittently by means of a tube passed through the nose and down the naso-pharynx has been suggested as enabling the anaes- thetist to maintain unconsciousness for operations about the mouth ; but it is a method hardly to be commended, and one which presents few if any advantages over that of prolonged anaesthesia with ether impregnating nitrous oxide, as above described. Patients vary in the time they require to become anaesthetised by nitrous oxide, and even the same in- dividual will differ at various times, being influenced by general health, nervousness, or exhaustion from pain. The Committee appointed by the OdontologicaJ Society of Great Britain found the following averages to ob- tain : — Males Females Children (under 15) Time Going off. 1 min. 21 sec. 1 „ 16 „ 1 >i boils about 102° F. (38-8 G.) (Watts), although the boil- ing point varies somewhat : it burns with a luminous white flame. Hardly soluble in water, it is freely so in alcohol and ether. When mixed with air it explodes on heating, and therefore should not be used in near proximity to flame. Preparation. — Zinc chloride in concentrated solu- tion is heated with amylic alcohol to 266° F., distilled from a water-bath over caustic potash and afterwards rectified. Physiological action. — Snow made some experi- ments with this substance, and found small animals required a 10 per cent, vapour before losing conscious- ness, that 20 per cent, produced deep insensibility, while 25 per cent, could be respired with perfect safety. With 10 per cent, the " second stage " of anaesthesia is pro- duced, i.e., the mental faculties without being sus- pended are impaired ; occasionally patients remember k 2 132 ANAESTHETICS. what occurs during this period, and partial anaesthesia exists. Snow stated that " over -narcotism of the heart with paralysis of its muscle " could he attained with amylene, hut that sudden death from this cause was less liahle to occur than with chloroform. He found also that 40 per cent, of amylene would he required to effect such a mode of death. In 1856, Snow employed amylene to produce general anaesthesia. He found it occasioned little or no sick- ness. The anaesthesia appeared with great rapidity, sometimes hefore consciousness was lost ; the recovery was speedy and usually unaccompanied by headache, giddiness, or other unpleasant symptoms. Dr. Snow did not push the narcotism far enough to induce coma ; in most of his patients the ciliary reflex persisted (thus contrasting with the effects of chloroform). The in- duction of narcosis by this agent is tranquil. Save in exceptional cases amylene produces complete muscular relaxation. The pulse is increased in frequency, espe- cially during the earlier stage of amylene narcosis. Re- spiration is quickened as under ether. The pupils re- main of natural size, unless the anaesthetic he pushed, when they dilate. The face flushes and sometimes perspiration bursts out, hut the salivary and bronchial secretions are not augmented. A tendency to hilarity evinces itself in some persons just as they are passing into the second stage. Mental excitement is usually absent. Rigidity and struggling seldom occur under amylene, a fact which Snow believed was due to the slighter degree of narcosis needed to induce anaesthesia when that substance was employed. The great volatility (great as ether), and the slight solubility of amylene, make its liberation from the blood very rapid ; hence AMYLENE. 133 recovery from the effects of the drug takes place with great celerity. In some persons laughter and singing are provoked, but these phenomena usually pass off if the amylene be withheld for one or two inspirations. The Glasgow Commission failed to obtain satisfactory anaesthesia with amylene. More recently this substance has been used in Germany under the name of Pental with, it would seem, encouraging results. Mode of administration, —The vapour of amy- lene must be of such a strength as to induce anaesthesia in three minutes ; if a weaker vapour be used, no matter how long it is persevered with, it will fail to produce an effect. Snow employed the same inhaler as for chloroform (see p. 111). The patient once well under, Snow re- applied the inhaler every half minute, otherwise he found consciousness returned. Amylene may be given in a cone, or by the open method ; the last, however, is not well adapted for its exhibition, on account of its extreme volatility. Snow, suggested the dosimetric system for amylene. After-effects and dangers. — Snow found the after-effects were fewer and less severe than those subse- quent to chloroform or ether. Sickness occurred twice only out of 238 cases ; headache was slight and transi- ent ; hysterical symptoms were shown by a few women. Two deaths occurred in Snow's practice, the 144th and the 238th cases, and were attributed b} r him to the patients inhaling too strong a vapour (30 per cent.) of amylene. In Snow's opinion the variation of the boil ing point in different specimens fully accounts for these unhappy fatalities. Thudichum asserts that the sam- ples employed by Snow in these cases really contained no amylene, but only intermediate hydrocarbons. 13-4 ANESTHETICS. Treatment. — The steps requisite to avert such accidents are similar to those described under " Acci- dents during the administration of chloroform." i t> Ethidene Chloride. Ethidene Chloride (ethidene dichloride), more pro- perly ethilidene chloride, C 2 H 4 C1 2 , has a sp. gr. 1-189, and boils at about 136-4° F. (58° C), (sp. gr. 1-182 and B.P. 59° C. Dastre) ; this boiling point is not, however, uniform. It was first prepared by Kegnault by the action of chlorine upon chloride of ethyl. Clover used samples with a sp. gr. of 1-225 and B.P. 239° F. (115° C). According to Watts, it is identical with monochlorinated chloride of ethyl, C 2 H 4 C1.C1, which possesses a boiling point of 04° C. and a sp. gr. 1-174 at 17° C. It is a colourless transparent oily fluid, tasting and smelling like chloroform. It is prepared from aldehyde by acting upon it with pentachloride of phosphorus. It is also formed as a bye-product in the preparation of chloral, and separated by distillation and subsequent fractionation. Insoluble in water, it is freely taken up by alcohol, chloroform, ether, and oils. It is less inflammable than chloroform. It is difficult to preserve, as in contact with air it rapidly decomposes and becomes acid in reaction and useless for anesthetic purposes. Dr. Snow was the first to employ this anaesthetic in England (June 20th, 1851), and it was subsequently used extensively by Clover, who I believe, until the time of his death, entertained a very high opinion of it. In Germany, Liebreich, Langenbeck, Sauer, and Steflen, have used it and published records of cases. ETHIDENE CHLORIDE. 135 Physiological action. — The Committee of the British Medical Association carefully worked out this subject. Frogs compelled to inhale the vapour become rapidly- narcotised (4 minutes). Their hearts, however, beat on unaffected for twenty- six minutes. Warm-blooded animals speedily passed under the in- fluence of this ether (4 minutes), and remained nar- cotised without the failure of the heart. Being exposed and watched while artificial respiration was maintained, the heart showed some slowing, but without any mate- rial weakening. In an experiment made to compare ethidene with chloroform, a dog was narcotised with ethidene and the cardiac movements studied. While under this agent no interference with the rhythm was observed ; when, however, chloroform was substituted, the right heart grew distended and dark, and rapid depreciation of cardiac force occurred. The Committee concluded "practically a dog will live for a lengthened period in a state of complete anaesthesia under the in- fluence of ethidene dichloride, whilst it will die in a short time when chloroform is used." Blood-pressure is slightly lowered by ethidene, the lowering taking place quite gradually, but after a while a partial recovery occurs, which is assumed to be due to the heart accommodating itself to the influence of the narcotic. Respiration is slowed and may become spasmodic and jerky, persisting even when the heart has percep- tibly ceased to beat. Upon human beings, ethidene exercises the following effects : — At first a pleasurable glow extends over the whole body, then within a minute or two the senses are 13G ANESTHETICS. confused, and often singing or whistling is induced. Some muscular rigidity then appears and anaesthesia follows. Patients take a longer time to recover con- sciousness than when chloroform is used, but they ex- perience fewer after-effects. Thus, as soon as they come to, they can stand or walk (Clover) and are able to express themselves with clearness. No headache actually follows, vomiting is present after about one- third of the cases of major, and one-twentieth of minor, operations. This vomiting is less severe than that which follows chloroform and does not persist so long. There is sometimes a little convulsive twitching. As the patient passes into unconsciousness, his breath- ing grows stertorous and his pupils dilate, but if air be now admitted, the stertor will pass off and the pupils resume their normal size. The pulse is liable to flag under ethidene, and hence caution is needed in its em- ployment. In the fatal cases recorded, the patient died from heart failure, the myocardium being pathologically fatty. Methods of administration. — Mr. Clover, who gave ethidene 1877 times with but one death, recom- mended administrators to commence the inhalation with nitrous oxide, and then to prolong anaesthesia by ethidene contained in his ether inhaler. Of course the initiation with gas is matter of choice. When given from an ether inhaler (see article, Ether) the anaesthetic should be pushed until after the stage of struggling has passed ; subsequently it should be given far more spar- ingly, the inhaler being lifted from the face every third or fourth inspiration for the admission of fresh air. The patient becomes anaesthetised in three to five min- utes. Dilatation of the pupil and stertor are signs HYDROBROMIC ETHER. 137 indicative of the necessity of reducing the amount of anaesthetic given. The Glasgow Committee gave ethi- dene hy the open method upon a towel. Ethidene is also given through Junker's inhaler, or Snow's chloroform inhaler may be substituted. Accidents and after-effects.— These are similar in kind to those treated under the article Chloroform, to which the reader is referred, (see also Accidents of Anaesthesia, Chap. X.). At least two deaths have occurred during the use of this anaesthetic. Hydrobromic Ether. Hydrobromic ether (bromide of ethyl) C 2 H 5 Br, sp. gr. 1-4783, boils at 104° F. (40-7° C). It is a colourless translucent liquid, with a neutral reaction, ethereal smell, and a pungent sweet taste with a somewhat burning after-flavour. It is ignited with difficulty, and burns with a green, smokeless flame emitting an odour of hydrobromic acid (Lowig). It is prepared by dis- tilling alcohol (ethylic) with either bromine, hydro- bromic acid or bromide of phosphorus. It is only slightly soluble in water, but freely so in ether or alcohol. Serullas discovered this substance in 1827, but to Nunneley, of Leeds, we are indebted for its re- cognition as an anaesthetic (1849). It was again brought into notice in 1865 by Nunneley, but eventually he gave up its use mainly owing to the extreme difficulty of obtaining it pure and on account of its great cost. Dr. Squire gave the results of his ex- perience of its use in 1881, and Dr. B. "W. Bichardson, a 138 ANAESTHETICS. staunch supporter of this agent, wrote (Asclepiad, 1885) favourably of its claims, and urged that pure samples were free from the dangers which arise with the com- mercial bromide. Physiological action. — Eabuteau has made care- ful researches upon the subject. Seeds not germinating are unaffected by it but do not germinate ; plants die when placed in its atmosphere after a very short ex- posure. Frogs become deeply anaesthetised when im- mersed in watery solutions. Upon human beings it produces unconsciousness and anaesthesia in one minute, and complete muscular relaxation in two or three minutes. No suffocation or laryngeal irritation appears to exist, although there is much congestion of the head and neck, and an increased secretion of mucus which may give trouble. The breathing is quickened, the pulse accelerated, and the heart's action somewhat weakened. The pupils dilate. Keturn to consciousness after withdrawal of the ether is very prompt. Vomiting is said to occur frequently during the administration, and even to continue for some hours succeeding. Blood-pressure, according to Wood, is slightly re- duced by small, and very considerably by large, quanti- ties. Where death ensues it is due to cardiac failure (Wolff and Lee) ; but these statements are denied by some observers. Ott believes ethyl bromide kills by direct action upon the respiratory centre, and does so whether injected subcutaneously or inhaled. The heart failure, he thinks, is secondary to the respiratory trouble. Method of administration. — Ethyl bromide must be given like ethyl oxide (Sulphuric Ether), air being excluded. Turnbull, who has made careful CASES FOR ETHYL BROMIDE. 139 study of this substance, insists upon tli3 necessity of quickly getting the patient under the influence of the vapour. An Allis's inhaler answers very -well, or an Ormsby's apparatus. The inhalation must be stopped when palatine stertor or loss of conjunctival reflex occurs (Silk). There is said to be less struggling than with ether, but violent struggling certainly does in some instances take place. Owing to the great rapidity with which consciousness returns, extreme attention is needed on the part of an anaesthetist to maintain narcosis. The respiration and pulse require watching throughout the administration. No prolonged operation must be attempted under ethyl bromide, forty minutes being the limit of time during which it may be safely administered. Cases suitable for Ethyl Bromide. Short operations and those of minor sur- gery. — In dental operations the rapidity with which the patient shakes of! narcosis renders ethyl bromide of little more value than nitrous oxide, while it would not seem to equal it in safety. The use of this substance in dental practice has recently been strongly advocated in Germany, and Dr. Silk using it in the Dental Depart- ment of Guy's Hospital speaks favourably of it. The frequency of more or less unpleasant after-effects which he states occurred among his patients would seem to detract from its value in this branch of surgery. In obstetric practice it is said by Dr Laurence Turnbull to be of the utmost utility, since it rapidly induces uncon- sciousness and the patient as speedily regains her senses. It must not be forgotten, however, that when 140 ANAESTHETICS. bromide of ethyl is given iu small doses, much mus- cular spasm results, which is not desirable in Reconcile- ments. Dangers resulting from the use of Hydro- bromic Ether. — Richardson, entertaining a very high opinion of ethyl bromide as an anaesthetic, denies that fatalities have followed its employment. Eight deaths are stated to have resulted from its administra- tion, but some of these were in reality due to impurities contained in the sample used. Dastre points out that pure hydrobromic ether has a sweet ethereal smell, but when impure the odour is most unpleasant. According to Dr. Laurence Turnbull, most of the ethyl bromide sold is impure, containing free bromine, carbon bromide (CoBrJ, phosphorus, and bromoform. Further, this substance is very unstable and readily decomposes, liberating free bromine. The presence of these bodies renders the impure ethyl bromide singularly dangerous, and until we can be sure of the purity of any given sample I think we are scarcely justified in its use for anaesthetic purposes. Complications. Muscular spasm may be so pronounced as to interfere with respiration. Excitement instead of insensibility may appear. Persistent vomiting has been recorded as follow- ing its employment. Persistent nausea also occurs even when vomiting does not occur. Heart failure may occur. Various degrees of faintnees and collapse not infrequently follow its use (Silk). COMPLICATIONS. 141 In no case is it safe to continue the administration of this anaesthetic for more than forty minutes. (Dr. Laurence Turnbull). Treatment. — The directions given elsewhere (Chap. X.) apply to the recovery of the apparently dead from ethyl bromide. Thus, artificial respiration must be re- sorted to at once, and the mouth and pharynx cleared of secretion without delay. Amyl nitrite may be tried. 142 ANAESTHETICS, CHAPTER VII. Anesthetic Mixtures. These are of two classes : — 1. Admixtures of members of the alcohol or ethereal series. 2. Alcoholic or ethereal anaesthetics with alkaloids or other bodies. The following are the best known and most useful members of the first class : — The A. C. E. Mixture. — Compound of 1 part alcohol, sp. gr. -888, 2 parts chloroform, sp. gr. 1*497, and 3 parts ether, sp. gr. *735. The Vienna Mixture. — 1 part of chloroform to 3 of ether. The Mixture recommended by Linhart : 1 part alco- hol, 4 chloroform. Methylene. — Methylic alcohol 30 per cent, and 70 per cent, chloroform (Regnauld and Villejean). Billroth's Mixture. — 3 parts chloroform, 1 each of alcohol and ether. The A. C. E. mixture, which was originally pro- posed by Dr. George Harley, is strongly recommended by the Anaesthetic Committee of the Royal Medico- Chirurgical Society of London. They speak of its action as midway between that of chloroform and ether. It has been largely used in England, and although not without objections, is a good substitute in many cases when ether cannot be taken. The main drawback to the employment of this and all other mixtures is that the substances employed in their formation do not ANAESTHETIC MIXTURES. 143 evaporate in the ratio in which the fluids are mixed, and hence it is impossible to be quite sure what per- centage vapour of chloroform is being inhaled. To obviate this difficulty, Ellis proposed to blend the vapours of alcohol, chloroform and ether, in a specially constructed apparatus, and so administer a true vapour mixture to the patient. The arrangement he used is too complicated for practical purposes, and his method has never been received with much favour. In three chambers, known weights of the anesthetics were evaporated ; these chambers could at will be made to communicate with a common chamber, and from this the patient was anaesthetised. Mr. Martindale has proposed an admirable volumetric mixture, the ingredients of which evaporate almost uni- formly. It consists of absolute alcohol, sp. gr. '795, 1 volume, chloroform, sp. gr. 1*498, 2 volumes, pure ether, sp. gr. *720, 3 volumes. Method of employment. — This may be given in a Clover's ether-inhaler, a cone, or even by the open method. I find Allis' inhaler also answers well, and recently have employed Krohne's cone fitted with the feather respiration register (p. 116) and have found it very successful and pleasant to manipulate. Junker's inhaler, fitted with the flannel mask, is very convenient for giving the A. C. E. mixture, especially to children. With the open method, much ether vapour escapes into the surrounding air, causing inconvenience and delay in the onset of insensibility, and further rendering the mixture relatively rich in chloroform while deficient in ether. No special directions are needed if the chapters upon chloroform and ether administration have been read. The fact that chloroform is present 144 ANESTHETICS. in the mixture makes it obligatory that plenty of air be allowed the patient, to effect which the cone or inhaler should frequently be raised from his face. Both re- spiration and pulse must be carefully noted, as fainting and asphyxial troubles may occur during the employ- ment of the A. C. E. mixture. After-effects are much the same as those of chloro- form or ether. Deaths have occurred during the use of the A. C. E. mixture. Richardson's mixture consists of 2 parts alcohol, 2 parts chloroform and 3 of ether. Dr. Kichardson states that this mixture works very well, and that he has never lost a case during its employment. The Vienna mixture (1 part chloroform, 3 of ether), stated to have been employed eight thousand times without a casualty, may be given practically in the same way as ether, save that care must be taken that the patient shall respire fresh air at frequent in- tervals. Linhart's mixture is administered similarly to chloroform ; the same care and watchfulness being necessary, as most of the risks of chloroform are pre- sent with its use. Methylene or "bichloride of methylene" — so called, but which is stated by Eegnauld and Villejean to be merely a mixture of methylic alcohol and chloro- form similar to Linhart's mixture above given. It consists of methylic alcohol 30 per cent, and chloroform 70 per cent. The so-called "liquid of Eegnauld" consisted of 80 per cent, chloroform, 20 per cent, methylic alcohol. The Glasgow Committee found methylene possessed no definite and constant boiling point, a fact further ANESTHETIC MIXTURES. 115 corroborating the assertion of the French chemists. It was also pointed out by this committee that the physiological behaviour of this body was identical with that of chloroform. I have found, experimenting upon the frog's heart, that methylene and chloroform affect the heart in precisely the same way and give identical cardiograms. But, in explaining the diverse results at which various observers have arrived, we must remem- ber that although the boiling points of methylic alcohol and chloroform are not very wide apart, yet the con- stituents of this mixture evaporate at varying tempera- tures, so that at the end of the dose pure chloroform is given up, while at the beginning only a small percent- age of it is present in the evaporating alcohol. It is more agreeable than ether, possessing the fragrant smell of chloroform. Its safety is probably only that of diluted chloroform, and many deaths have followed its use. Dr. Eichardson, the first who introduced methylene into English practice, writing in the Asclepiad (1884), adhered to his original statements in favour of methy- lene. He holds that although many samples are mere mixtures, yet pure bichloride of methylene is anaesthe- tic. This is absolutely denied by the French chemists cited above, who state that the pure substance (bi- chloride of methylene) is not an anaesthetic, but a powerful convulsant, and proves fatal to animals in a few seconds. Methods of employment. — Although methylene may be given by the open method, it is more commonly administered from a Junker's inhaler (see description page 113). Methylene acts precisely like chloroform, and its use is fraught with dangers which differ not in 146 ANESTHETICS. kind, but in degree, from those present when chloro- form is used. Both the respiration and pulse must be sedulously watched, and the utmost vigilance displayed to avoid accumulation of vapour in the lungs. With the use of an inhaler, it is most important to avoid pushing the narcosis too far. When a patient has once become un- conscious, the amount of air blown over (Junker's appa- ratus) should be much lessened, thus he can easily be kept anesthetic with a very small percentage of methy- lene vapour. It must, however, be borne in mind that methylene being diluted chloroform, the subject is apt to regain consciousness somewhat more rapidly than during the use of simple chloroform. The after-effects of methylene are those following the use of chloroform, they are, however, often less severe. Billroth' s mixture (chloroform 3 parts, alcohol and ether each 1 part), is but little known or employed in England. It contains a high percentage of chloro- form, and hence needs careful handling. It should be administered either by the open method, or if an inhaler be used, Junker's or the simple fianuel cap will answer. In either case the patient must be allowed plenty of fresh ah*. Similar dangers are imminent, and precautions needed, as in the administration of chloroform. Deaths have occurred during the use of Billroth 's mixture. CHLOROFORM AND MORPHINE. 147 Mixture of Chloroform or Ether with Alkaloids, ETC. Chloroform and morphine (Nussbaum). — Nuss- batim, of Munich, was the first to employ this mixture method in Germany (1873), although Claude Bernard had studied the method experimentally some years (1869) previously, having had occasion to give mor- phine to a dog recovering from chloroform. Injections of morphine, gr. -§- to -|, or in some cases more, hypo- dermically, half an hour before giving an inhalation of chloroform, are stated to possess the following advan- tages : — Less chloroform is needed, while the stupor is more prolonged. If the morphine be given immediately before, it in some cases prolongs the period of excitement. Drunkards, and persons who show little amenity to chloroform, soon pass under its influence after a dose of morphine. The patient is usually more completely relaxed and passive, the breathing is quieter, and it is stated (Kappeler) that the depressant action upon the heart is diminished. The stage of excitement is shortened, and cerebral circulation while under morphine is markedly lessened, so that for operations involving the opening of the meninges and the cutting of the brain substance, this combination is most valuable. Excitable persons about to be anaesthetised will often be calmed by morphine. Upon the other hand, vomiting is more frequent when morphine is used. Poncet, from a wide experi- ence during the Franco-Prussian war, abandoned the method, owing to the frequency with which prolonged l 2 148 ANESTHETICS. stupor, and dangerous depression of the temperature occurred after its use. Morphine in some produces great excitement, and this by the addition of chloroform may be magnified to a very inconvenient extent. "When this combination is employed, it is important to restrict the amount of chloroform given ; indeed when the patient is once fairly narcotised, very little more chloroform will be needed unless the operation be a very prolonged one. Care must be exercised that only a weak vapour is used, since the patient w m take but little notice of its pungency, and so one of the usual safeguards is lost. Caution must also be displayed in employing this mixture when severe haemorrhage is likely to take place into the pharynx, as the patient is not easily roused, and the danger of blood entering the lungs is increased. According to Eegnier there is a grave danger, due to the morphine lessening the elimination of the chloro- form and so leading to over-dosage. He lost one patient when this method was used, and regards it as rather increasing the patient's chance of mishap from the chloroform. Dastre points out also the liability there is to respiratory failure under its use. Demarquay has very justly indicated that the chief dangers of this method of mixed anaesthesia lie in want of caution in not limiting the dose ; large injec- tions of morphine preceding chloroform administration certainly have a danger of producing asphyxia through paralysis of the respiratory centre. Morphine, atropine and chloroform (Dastre and Morat). — It was pointed out some years ago that atro- pine in paralysing the vagus might be a valuable anti- MORPHINE AND ETHER. 149 dote to chloroform, by preventing reflex inhibition of the heart through the par vagum. I have found the addition of gr. T i^ of atropine to gr. J of morphine to be an advantage, when that last alkaloid is employed synergetically with chloroform. This plan which goes by the name of the Dastre Morat method in France is said by its inventors to be safer than Nussbaum's method. Aubert, of Lyons, employed it in practice and speaks well of it. The injection is made 15 or 30 minutes before the com- mencement of the operation. The mixture Dastre recommends is Morph. Hydrochlor. 10 centigrm., Atropin. Sulph. 5 milligrm., Aq. destilh 10 grammes, one cubic centimetre or 1*5 c.c. being injected. The use of atropine in this way is said to lessen the after- sickness, and to abrogate salivation and bronchial secretion. Morphine and ether. — It has been proposed to exhibit morphine before ether, similarly as before chloroform, but the method possesses disadvantages in its liability to induce prolongation of the stage of excitement. It may induce very violent struggling and increase the after-headache, prostration, and vomiting. Kappeler, who has experimented with this mixed method, states that he has completely failed in several cases in which he attempted to narcotize patients with ether subsequently to hypodermic injections of morphine. It is not, however, clear whether Kappeler's results should be considered quite so absolute as his state- ments would lead one to suppose. Certainly in cases at University College Hospital in which the method was employed, no great struggling or inconvenience was observed. 150 ANAESTHETICS. Chloroform and amyl nitrite (" Chloramyl," Sanford). — x\inerican physiciaus have employed this mixture and speak well of it, and Dr. Kichardson in this country has lent it his support. It is claimed that chloroform, when mixed with nitrite of amyl, loses many of its dangers, and is more ngreeable to take. The proportions recommended are 3ij., to the pound (Sanford), and nxxvi. to the ounce (L. B. Balliet). Dr. Sanford states that unless a very pure sample of chloroform is obtained the mixture is liable to become milky and to give unsatisfactory re- sults. He also suggests that when the administration of the mixture is likely to be very much prolonged, that it is well to use less nitrite of amyl in the latter stages of the operation. Upon the other hand, we are compelled to recognise that such a mixture possesses several undeniable objec- tions. In the first place the sp. gr. of chloroform is 1*497, that of nitrite of amyl, -877, so no permanent mixture can be maintained, a drawback which even a suggestion to "shake the bottle well before use" does not abrogate. Again, nitrite of amyl cannot, as is asserted, be considered a physiological antagonist of chloroform, for the following reasons : — Nitrite of amyl lowers blood pressure by producing paralysis of either the muscular coatings of the vessels or of the vasomotor ganglia controlling them. After an initial fillip to the heart's action it depresses, and may if pushed even cause syncope. In the lower animals after the use of nitrite of amyl, the heart muscle becomes after a time paralysed. Further, the respiratory centre is depressed, while the motor centres in the spinal cord are para- lysed. It would thus appear that so far from nitrite CHLOROFORM AND CHLORAL. 151 of amyl opposing the depressant action of chloroform, it probably acts similarly, and by adding it to that nar- cotic we are still more prejudicing the patient's chances of recovery. If it be urged that successful cases of administration stultify any such theoretical reasoning, the answer lies in a consideration that, firstly, the combination was probably never a mixture and so the patient inhaled chloroform and little if any of the amyl nitrite ; and, secondly, that just as we find very many persons whose hearts withstand the stress of chloroform depression, so many would survive the still greater depression of chloroform to which is added amyl nitrite. I cannot find records of any instances in which pro- longed anaesthesia was maintained by this mixture. In brief operations it would be at its best ; but then it is in lengthy operations that the depressant action of chloroform is to be most feared. Method of employment. — The method of em- ploying this mixture is similar to that of chloroform. Chloroform and chloral. — The preliminary giv- ing of chloral was first suggested by Forne ; it is said to curtail the period of excitement and to produce an anaesthesia comparable to that which ensues when morphine is used in conjunction with chloroform. Dose. — Perrin used as large a dose of chloral as gr. 45 for adults (three grammes) before chloroforming. An alternative plan has been suggested, viz., to divide the dose, giving half by the mouth and half by the rectum. Children of course would require a much smaller dose. I cannot think the advantages which are alleged for this method in any way counterbalance the dangers which undoubtedly attend its employment. Chloral 152 ANESTHETICS. acts so markedly upon the heart that it is upon that score alone a deleterious drug to be used with chloro- form. Dastre gives as much as two to five grammes of chloral an hour before administering the chloroform by inhala- tion. He explains the action of the agents thus : — the chloral behaving as an hypnotic composes the patient to sleep, and the tranquility and lethargy of the patient enable the administrator to maintain true anaesthesia by the use of a small quantity of chloroform. Other combinations of chloroform, e.g., that of Von Mering (Chloeoform one volume, Dimethylacetal two volumes) ; that of Dr. Wachsmuth (Berlin), who adds one-fifth part of oil of turpentine to his chloroform, have hardly received sufficient trial for any authorita- tive opinion to be given concerning their use. Von Mering claims that with his combination there is no failure of respiration or heart, and no lowering of blood pressure ; while Dr. Wachsmuth states that the addi- tion of turpentine to chloroform does away with any fear of heart failure. Chloral, morphine and chloroform (Trelat). — In cases in which it is desired to obtain some degree of analgesia without absolute loss of consciousness, Pro- fessor Trelat has employed a mixture of four to nine grammes of hydrate of chloral, twenty to forty grammes of syrup of morphine in 120 grammes of water. This is divided into two doses which are swallowed at an in- terval of fifteen minutes (Dastre). "When sufficiently drowsy the patient is subjected to operation. In cases in which complete anaesthesia is required, chloroform is inhaled after the patient has gone to sleep from the dose. The method may be CHLOEAL HYDEATE AND ETHEE. 153 deserving of trial in some exceptional cases, but the same objections may be urged against it as apply to the method of Forne. Cocaine and chloroform (Obalinski). — The plan recommended is to allow the patient to inhale chloro- form in the ordinary way until he is slightly under its influence, and then to inject cocaine hypodermically. The dose is given as two to five centigrammes of a three per cent, solution. It is claimed that a very small quantity of chloroform suffices to effect general anaes- thesia, and that the after-effects, vomiting, nervous ex- citement, and " upset " are less liable to occur. It has also been asserted, but I think upon insufficient evi- dence, that cocaine and chloroform act antagonistically upon the heart, and hence there is less fear of cardiac syncope when they are combined. The extreme un- certainty of cocaine and the alarming symptoms to which it not infrequently gives rise, should, I think, make one very cautious in the employment of Obalin ski's method. Chloral hydrate and ether. — Kappeler used chloral hydrate in forty grain doses (children half this quantity) as a preliminary to the inhalation of ether. The duration of anaesthesia was prolonged and the re- covery retarded, while vomiting, headache, and pro- stration, were more severe than when ether only was employed. Priestley Smith (Heath's Dictionary of Surgery, Art, Cataract) gives fifteen to twenty grains of chloral hydrate twenty minutes before administering ether, and finds this practice answers well in operations for cataract. A death (Lyman) has followed the use of this com- bination. 15-4 ANESTHETICS. Nitrous oxide and ether. — This combination is fully described under " Nitrous Oxide," p. 41. It is the best method of producing general anaesthesia. When complete unconsciousness has been attained by giving nitrous oxide, the duration may be prolonged by allowing the gas to pass through the ether ; or by turning off the gas altogether, the patient may be kept anaesthetised by ether for a lengthened period. Clover's Gas and Ether Apparatus enables one to regulate the supply of gas or ether with a nicety and precision unattained by any other instrument. The dangers and precautions incident to this method are those fully described in the chapters upon Nitrous Oxide Gas and Ether. ANESTHETICS IN OBSTETRIC PRACTICE. 155 CHAPTEE VIII. Anesthetics in Obstetric Practice. ^Vhether or not an anaesthetic should be administered in parturition is for the accoucheur to decide. In eases which are considered suitable, it becomes the anesthetist's duty to render his aid. Choice of anaesthetics, stage -when to be administered, etc. — As a rule chloroform is pre- ferable to ether, unless an operation is to be performed, or unless the patient is greatly depressed by hsernor- rhage or shock. The A. C. E. mixture also answers admirably in obstetric practice. Snow advised that chloroform should be withheld until the os uteri was fully dilated and well marked expulsive pains had appeared. He, however, made an exception to this rule, when during an earlier stage the pains were very severe. Spiegelberg, in summing up the advantages of an anaesthetic in obstetric surgery, says chloroform not only allays the pangs of childbirth, but checks bearing- down and diminishes the tension of the abdominal and pelvic muscles as well as that of the uterus. He fur- ther extols its use in neuralgia and cramps occurring during parturition. In normal labour little chloroform is needed ; if a very dilute vapour is inhaled the patient sinks into a quiet sleep, and her sensibility to pain is decreased. The uterine contractions are unaffected, but alihough during the pains the woman may groan and turn over, 156 AX-ESTHETICS. yet her complaints are but slight, and as soon as the pain passes off sleep again comes on. Rules guiding the administration : — 1. Quietude in the room is essential; fresh air should from time to time be admitted, and the patient's posture should be unconstrained. 2. Chloroform should be commenced when the labour is in its second stage if the pains are very severe, but if they are not it is best to wait until the foetal head is on the perineum. As a rule the chloroform should not be given during the in- tervals between the pains, unless the severity of the pains is very great, or it is deemed advisable to induce deep anaesthesia for the performance of an obstetric operation. 3. For nervous women and those who dread pain, also in cases w 7 hen the perinaeum is very rigid, chloroform should be used, as it relaxes the peri- naeal structures and so is most beneficial. 4. "When the patient becomes excited by the chloro- form, if it is considered really essential that she should be anaesthetised, it must be pushed to com- plete narcosis. 5. "When the labour is protracted and the patient is to be kept anaesthetic, it is necessary to discontinue the inhalation from time to time, otherwise an injurious accumulation of the drug will take place. G. "When an obstetric operation becomes necessary deep anaesthesia must be obtained (Charpentier). 7. When heart, lung, or kidney disease exists in a parturient, the production of anaesthesia may be dangerous, and its advisability must be settled upon the same general principles which guide us in deciding upon like cases in surgical anaesthesia. ANAESTHETICS IN OBSTETRIC PRACTICE. 157 8. It is necessary when the patient is kept semi- narcotised to carefully guard against over- disten- sion of her bladder. 9. It is inexpedient to awaken the patient to con- sciousness by artificial means, e.g., slapping with a wet towel. 10. "When the foetal head bears on the perineum, give the anaesthetic more freely, as it relieves the in- creased pain and also relaxes the maternal passages, and lessens the danger of tearing the perinaeum. 11. If the patient is depressed or the pains are slug- gish during the administration, an occasional stimu- lant may be administered. 12. In cases where the anaesthetic appears to inter- fere with the progress of labour, it may be neces- sary to suspend its use for a time and re-apply it after an interval, or even to withdraw it altogether. If a meal has been recently partaken, avoid chloro- form, the sickness likely to follow will impede delivery. Objections. — These, although strenuously urged by some, are probably more theoretical than real. 1. Chloroform is said to increase the mortality alike among mothers and children. Statistics certainly negative this statement. It has been averred that the danger to the parturient is in direct proportion to the amount of pain experienced, and since chloroform minimises this, it lessens the ac- tual danger of childbirth. 2. It is asserted that it protracts the labour. Unless pushed to the degree of deep narcosis chloro- form does not interfere with uterine contractions. In experimental researches upon animals this point has 158 ANESTHETICS. been fully proved, and lias recently been corroborated in a striking manner by Dr. Milne Murray, of Edinburgh. Deep narcosis renders the voluntary abdominal mus- cles lax, and so interferes with expulsive efforts. Very deep narcosis also paralyses the uterine muscular tissue. On the other hand a womb, exhausted by frequent and ineffectual contractions, will often under chloroform regain tone and resume vigorous expulsive movements. 3. Rupture of the perinseum is said to follow more commonly when chloroform is used. I have never seen satisfactory proof of this allegation, and can find no valid reason why such an accident should be associated with the anesthetic state. 4. Complications are asserted to be more liable to occur when it is used. This point was carefully investigated by the Chloroform Committee of the Royal Medico- Chirurgical Society, and it was found that chloroform when properly administered does not predispose to inflammation, puerperal convul- sion, apoplexy, or other mishap ; indeed, as it promotes relaxation of the maternal passages, it is beneficial. Opinions differ as to whether it predisposes to imper- fect contraction of the uterus and so to post partum haemorrhage. This question is greatly influenced, firstly by the degree of narcosis arrived at, and secondly by the length of time allowed to elapse before its use, as well as that during which it is employed. Prolonged use of small doses may be more harmful in this respect than deep narcosis arrived at rapidly and not main- tained for more than a few minutes. It is also highly important that the patient's respiration should be free and unhampered by her posture. Lactation is not in- juriously affected ; the child is in no way injured. METHOD OF EXHIBITION. 159 Convalescence is not only not delayed, but is in poiut of fact actually hastened by the use of chloroform. This statement is made upon good authority, and is probably explained by the fact that by the use of chloro- form the nervous system is protected from shock. (Sansom). Method of exhibition. — "When chloroform is em- ployed the open method probably is the best, admitting as it does plenty of air, the countenance being readily seen. A little chloroform may be sprinkled upon a piece of folded lint, or on a towel. Some practitioners let the patient hold a piece of lint or a cup inhaler so that when she grows drowsy the improvised inhaler drops from the hand. Care must be taken that the face does not fall over the chloroformed cloth, or the breathing become impeded by the pillow or bedding. "When deep anaesthesia is required it is best to have a skilled administrator." (Chloroform Committee). When chloroform or the A. C. E. mixture is adminis- tered by a person who gives himself up solely to this duty, the use of Junker's inhaler fitted with the flannel cap (see p. 114) possesses the advantage that there is less escape of vapour into the room, the air of which keeps purer. When a less elaborate and more portable apparatus is desired, Krohne's cone with respiration indicator is very good, as it allows the administrator to see the breathing is beiug properly performed, even when the posture of the patient renders it difficult for him to see the thoracic movements. In the First Stage of Labour, chloroform or the A. C. E. mixture, if required at all, should be given intermittently and in small quantities. As a rule the first stage of narcosis is deep enough. The 160 ANESTHETICS. patient is conscious, but only slightly alive to painful sensations. If any excitement and disorderly con- duct follow, the patient must be allowed to recover her self-control. Some persons need more chloroform than others, so that the administrator must decide each case upon its own merits and further must be guided by his own observations, and not influenced solely by the patient's cry of " Give me some more." Women fre- quently repeat this phrase when almost unconscious and unaware of preferring any request. In the Second Stage, chloroform should be given only during the pains, and then merely to slight nar- cosis, since the woman needs the use of the abdominal muscles. At the stage of labour when the head is traversing the perinseum, deeper narcosis is needed to relax the soft parts, whilst at the last as the head emerges through the vulva, chloroform should be freely administered. "When Instrumental Procedure is requisite deeper narcosis is needful, and especial caution is required in order to prevent the patient being made simply ex- cited and rigid, a condition alike dangerous to the mother and child. In this stage the anaesthetic must be pushed and true anaesthesia obtained. Obstetric Operations. For Turning and instrumental deliveries, if an anaesthetic is employed, deep anaesthesia is requisite and may either be obtained by chloroform, the A. C. E. mixture or ether. The London Committee approved the first named, but mainly on account of the greater AFTER-EFFECTS. 161 ease with which it was then exhibited. Since our modern appliances for giving ether are so improved this reason can have no weight. In deep narcosis from chloroform the parturient is placed in the same danger as for any surgical operation. It is sometimes urged against ether that it does not relax the uterine tissue so effectually as chloroform. If this objection is valid it tells also the other way, as hemorrhage would under such circumstances be less likely to be severe. The ether effect passes off more rapidly. The A. C. E. mixture is largely used in operative obstetric practice and answers remarkably well. It is best given in Junker's inhaler or from Krohne's cone. For extraction by forceps narcosis sufficiently deep to keep the patient quiet is needed. Craniotomy.— The narcosis must be deep. Hour-glass contraction.— Retained placenta, Here complete relaxation is necessary and so the anes- thetic must be pushed. Puerperal convulsions. — Chloroform is indicated in all cases of convulsions associated with labour. It is, however, contra -indicated in apoplectic seizures. After Effects. Vomiting is rare ; faintness, excitement, headache have sometimes been manifested, but as a rule few un- pleasant results follow the use of chloroform for child- birth. M 162 ANESTHETICS. CHAPTER IX. Anesthetics in Special Surgery. Brain Surgery. — The method which answers best when the brain itself is made the subject of operation, is to administer a dose of morphine, beneath the skin, either one quarter of an hour before the operation, and subsequently to administer chloroform, or to inject the morphine as soon as the chloroform has deadened the patient's sensibility. It is necessary to get the patient completely anaesthetised, but when once this is achieved very little more chloroform is needed. Ether pro- duces too much vascular excitement in the meninges and brain substance, and so is contra-indicated in these cases. Anesthetics in Ophthalmic Practice. Since the introduction of cocaine, many operations about the eye are performed without the employment of general anaesthesia. The extreme steadiness and immobility needful in these delicate operations require very deep narcosis, and so it is the administrator's duty to push whatever vapour he is using until profound narcosis is obtained. The operator must not be allowed * I am indebted to my friend and colleague Mr. Victor Horsley, F.R.S., for this method in Brain Surgery; I have employe! it for these ca.-ea with great success. ANAESTHESIA FOR OPERATIONS. 163 to commence his manipulation until the patient is not only absolutely unconscious and flaccid, but shows not the slightest inclination to cough, vomit, or struggle. It must be kept in constant remembrauce, that the very salvation of the eye depends upon the unflinching im- mobility of the person of the patient. The nature of the anaesthetic used is of less importance than is the way in which it is employed. Anaesthesia for Operations about the Mouth, Jaws, and eespiratory tract. Chloroform is preferred (1) because under its use the narcosis is deeper and more prolonged ; (2) its vapour is not easily ignited ; (3) it can be conveniently given through the nose and so can be given without being an inconvenience to the operator. In the removal of sequestra from the jaws, excision of epuhdes, tapping antral abscess, etc., no very deep narcosis is requisite and the patient may be kept suffi- ciently quiet by the use of chloroform given by the open method. During the removal of the upper jaw, the patient must be kept deeply under the anaesthetic for the skin incisions, and this may be done by first nar- cotising by the open method and by subsequently keeping up the supply of chloroform through a tube introduced into the free nostril and fed with chloro- formised air from a modified Junker. When the skin flaps and soft parts are freely divided and dissected up, the patient must be allowed to recover sufficiently to cough and so prevent blood entering the larynx, al- m2 164 ANAESTHETICS. though he must be sufficiently anaesthetic not to struggle. The management of these cases needs constant care and some judgment. The dangers the chloroformist has to guard against are — entrance of blood, teeth, por- tions of growth, spicules of bone, etc., into the larynx ; the patient passing into the second stage of chloro- formisation and growing restive, excited and so violent as to interrupt the progress of the anaesthetic. He should see that the haemorrhage is directed out of the mouth, that the tongue is not allowed to fall back, that the air enters and leaves the glottis freely. If the patient's respiration is embarassed from entrance of blood into the air passages, the tongue must be drawn right out of the mouth, all blood mopped away, and failing relief from this, laryngotomy must be performed and the tube sucked free from clots, etc. Inversion may be needed. Removal of the lower jaw may often be done almost completely while the patient is under ether, chloroform being administered only just at last when in the course of the operation the mouth is opened. This is an admirable method. In excision of the tongue.— Chloroform admin- istered through a nasal tube should be relied upon and much the same precautions with regard to haemorrhage taken, as in anaesthetising for removal of the jaws. "When much haemorrhage occurs, the patient must be guarded from deep narcosis. By the use of Dr. F. Hewitt's gag, p. 114, the nasal tube can be dispensed with. Staphyloraphy is best performed under chloro- form, which is preferably administered through the nostril. Care must be taken that the nasal tube does not get into KECTAL ETHERISATION IN OEAL SURGERY. 165 the operator's way, and to avoid this possibility, a flexible catheter should be used. The haemorrhage being, as a rule, slight and easily controlled, there is no parti- cular fear of blood trickling down the trachea, and further, as quietness is very desirable in the patient, full surgical narcosis should be maintained. However, with careful management and with frequent interrup- tion of the operation, ether or the A. C. E. mixture may be used. Warrington Haward, to whose powerful ad- vocacy the ether propaganda owes so much, speaks highly of ether in staphyloraphy. Operations on the respiratory tract, laryn- gotomy or tracheotomy is usually performed when the patient is under chloroform as the rapid movements under ether interfere with the surgeon. Excision of the larynx, thyrotomy requiring a preliminary tracheotomy, may be performed, chloro- form being given by sprinkling it on a flannel stretched across a funnel, connected with a Halm's tube, or by directing a catheter over the outlet of the Halm's tube, and pumping through it chloroformed air from a Junker's inhaler. An alternative is given below. Kectal Etherisation in Oral Surgery. My experience of this method is so far so favourable that I should say for removal of the tongue, the jaws, and for staphyloraphy, especially for excision of the larynx, the rectal etherisation is far more convenient for the operator, and more effectual in the anaesthesia it produces than the plans named above in which chloroform is used. The operation can be proceeded 166 ANESTHETICS. with without a break, and the after-effects to the patients appear as a rule to be less troublesome and less lasting than when the anaesthetic is given by the air passages. In cases in which much blood is likely to be thrown into the buccal cavity, careful watch will have to be taken that it is efficiently sponged out, and does not enter the windpipe. If the anaesthetist is engaged in watching the apparatus at the foot of the operating table, another observer should be stationed at the head to watch this point closely. In all these cases the inverted posture of Langenbeck may be usefully employed. The method, however, admirable as it is, is certainly not free from dangers peculiar to itself. Eemoval of Post-Nasal Adenoids. Growths in the post -nasal region, when removed through the mouth, give rise to troublesome bleeding. Chloroform, preferred by many surgeons, possesses the disadvantage that the patient remains longer under its influence, and so it is less easy to avoid blood enter- ing the air passages. The additional time is by some deemed an advantage, as it permits of longer manipu- lation in the mouth. I have found that when it is undesirable to use chloroform, the A. C. E. mixture in succession to gas answers fairly well in these cases. It does not excite as much haemorrhage as ether, and the patient can, if necessary, be again and again anaesthe- tised, after emptying his mouth of blood, until the operation is complete. By this method there is not much fear of blood being sucked into the larynx. ANAESTHETICS IN DENTAL SURGERY. 167 Ether possesses the disadvantage of producing much congestion, and so increases to an annoying degree the haemorrhage incident upon operations for the removal of post nasal growths. Still, if properly managed, ether answers very well for these cases. Of course where the cautery is used in the nasal passages, ether must not be used. Anesthetics in Dental Surgeey. The operations for which an anaesthetic is usually needed are : — Extraction of teeth. Lancing the gums, and tapping the antrum. Extirpation of the dental pulp. Filling when the dentine is abnormally sensitive. In tooth extraction, nitrous oxide gas — alone, or with ether after the manner introduced and advocated by Clover — is the safest and most convenient anaesthetic. The administrator stands to the left side of the patient and carefully fixes his prop (gag)° either on the side opposite that from which the teeth are to be drawn, or between the central mcisors — thus allowing room on each side. The patient is then anaesthetised (see section "Nitrous Oxide"), and when quite un- conscious, the face-piece is withdrawn, and the patient's head steadied and moved into the most convenient pos- ture for the dentist. Care has to be taken that the tooth, or a fragment from a broken forceps, does not fall back into the larynx, and that the tongue is not pushed back by the operator and the patient's breathing impeded. * In this case great care must be taken to avoid the teeth being loosened or forced out of their sockets by the prop. 168 ANESTHETICS. As a rule, it is inadvisable to administer gas twice to the same patient at one sitting, but if such a thing is done warning of probable after-headache should be given. "Where prolonged anaesthesia is required, ether may be given, and the ordinary precautions taken as for etherisation in general surgery. Chloroform should never be given to a patient sitting upright in a dental chair. If it is deemed wise to employ that agent, the patient should be seen at his own home, and in bed, and the anaesthetic administered with the usual caution. For special dangers of anaesthetics in dental surgery see Nitrous Oxide, under accident, p. 57, and Accidents of Anaesthesia, Chap. X. Thoracic Surgery. In the surgical treatment of empyema some diffi- culty frequently arises in the choice of the anaesthetic. Chloroform has in a good many instances caused dan- gerous and even fatal results from syncope, while ether sets up severe cough and respiratory distress. The A. C. E. mixture when it can be borne answers well, but must be given in a very dilute vapour ; even then it is liable to provoke distressing cough. This state of things is rendered worse by the lateral posture which the exigencies of the operation may require. It is sometimes a good plan in very severe cases, i.e., when grave fears exist, owing to the condition of the heart and lungs, to push the anaesthetic to only the first stage, as far as possible maintaining a state of analgesia, and always stopping short of true anaesthesia. To combat these difficulties I have employed the method of rectal ANAESTHESIA IN ABDOMINAL SURGERY. 169 etherisation (q. v.) in thoracic surgery and have been pleased with the results especially in the case of children. When the empyema communicates with a bronchus great care must be taken that the patient does not become sufficiently deeply narcotised to hinder free coughing up of the pus in his lungs. Any ten- dency to cyanosis should be accepted as a signal to lessen the depth of the narcosis, and provided care has been taken in the initial etherisation this is easily effected in the rectal method. Anesthesia in Abdominal Surgery. Complete relaxation of the recti and other abdominal muscles is imperative ; great quietude and freedom from hurried respiration, coughing, and vomiting, are also necessary for operations upon the abdominal parietes or viscera. To ensure these points, chloroform, the A. C. E. mixture, or methylene, are most suitable. During the incision through the parietes, the patient must be kept fully under the anaesthetic, subsequently a lesser degree of narcotism is needed until the final skin sutures are put in, when deeper anaesthesia will again be requisite. Great care must be taken, however, that the patient is not allowed to recover sufficiently for the supervention of vomiting. In cases in which a large tumour or collection of fluid or gas is removed from the abdomen, and the heart — previously displaced — is allowed suddenly to right itself, there is especial danger of syncope, and precaution against this must be taken. 170 ANESTHETICS. Rectal Surgery. All operations about the anus and rectum are not only very painful, but excite reflex straining and spasm. In anaesthetising for such operations, profound narcosis is needful. The combination of gas and ether in most cases answers well, although it is necessary to give enough ether to induce absolute muscular flaccidity, snoring respiration, and widely dilated pupils — and further, to maintain deep narcosis to the end of the operation. ACCIDENTS OF ANAESTHESIA. 171 CHAPTEE X. The Accidents of Anaesthesia, and How to Treat Them. I. Those connected with Respiration. Foreign bodies may become loose in the mouth, and either get sucked into the larynx and thence enter the trachea, or become impacted, and set up laryngeal spasm. False teeth.— Small plates are especially danger- ous, whilst obturators and pivots may also become sources of peril. During operation, teeth or pieces chipped off teeth may fall back, and even portions of epitheliomatous or other growth, blood clot, vomited undigested solid food, gags, portions of snapped off forceps, and bits of sponge, may obstruct breathing. When the tongue is partially removed, the stump is liable to fall back and cover the glottis, and similarly after removal of a portion of the lower jaw, the whole tongue may be carried back by its own weight. This may also occur in deep narcosis, even when the jaw is intact. The finger inserted in the mouth during tooth extraction, often pushes the tongue right back, and unless this is noticed and remedied, complete occlusion of the air -way occurs. Precautions. — Kemove all loose bodies from the mouth before operation. Let the patient avoid any solid food on the day of operation. Never operate 172 ANESTHETICS. again until the first tooth extracted is known to be out of the mouth ; and be careful that the forceps are freed from the tooth just removed, before employing it again. Gags and sponges must be securely tied to a long string. When possible, the head should be placed on its side, to obviate the effect of the weight of the tongue in carrying it back, and also to facilitate the expulsion of blood. Sometimes a Carter's oral spoon held in the mouth during tooth extraction prevents teeth flying back and being drawn into the larynx. Vomited matters. — -When through the exigencies of the case or through inadvertence, food has been taken within a few hours of the administration of an anaesthetic vomiting is pretty sure to occur, either when the operation is proceeding or as the patient is com- mencing to regain consciousness. There is great danger lest vomited matters be drawn back into the larynx, leading to asphyxia.* Respiration may also be hampered by the posture of the patient, by pressure upon his chest from instru- ments, assistants leaning upon him, or by tight ban- daging. When placed prone or upon the side, feeble people, those who are fat or emphysematous, or who * The following case illustrates this danger. A hospital patient requiring a minor operation was instructed to abstain from food and I resent himself in the evening for the house surgeon to operate. The operation was performed — the patient being skilfully anaesthetised by a resident, but during recovery he vomited, and large masses of undigested meat were taken from the mouth. Asphyxia being im- minent laryngotomy was performed, but the patient died, and the necropsy showed a mass of meat had entered the trachea, and lay at its bifurcation occluding the bronchi. It transpired the man had in spite of explicit directions to the contrary partaken of a heavy meat dinner just before coming to the hospital. TREATMENT. 173 have fluid in their chests — one lung being more or less hampered, must be carefully watched, as the mechanical interference with breathing in these cases has caused fatal accidents. All general anaesthetics eventually paralyse the re- spiratory centre in the medulla oblongata, and so cause cessation of breathing; but some act more rapidly, and provoke spasm of the glottis by the impact of their too strong and pungent vapour upon its delicate mucous membrane. In this way no air enters the lungs, al- though irregular thoracic movements persist. Spasm of the larynx certainly may occur from ether or chloro- form vapour, and, it is stated, from nitrous oxide gas. As a rule the spasm passes rapidly off, being relieved by the admission of air, but it may be sufficiently severe to need laryngotomy. Chloroform also acts upon the larynx in another way whereby the air- passage becomes occluded ; namely, by the closure of the arytaeno-epiglottidean folds. In this case respira- tory movements persist although no air enters the chest. Patients may be actually asphyxiated by the admin- istrator excluding all air ; and this may occur with any inhaler unless care is taken and the colour of the face watched. Treatment. — The foreign body, if still free in the mouth, should be dislodged by bending the head for- ward and sweeping the buccal and pharyngeal cavities with the finger. The tongue should not be pulled forward, otherwise the tooth, or whatever it is, will enter the trachea. Should the finger feel the body fixed, its removal must be attempted with oesophageal forceps or with a snare. A slap on the back often 174 ANESTHETICS. helps the expulsion of the offending substance. Inver- sion should also be practised, although if the body has already passed the larynx there is danger of its impac- tion in it giving rise to spasm. Should this occur, or should suffocation be imminent from other reasons, the windpipe must at once be opened as follows : — - The operator feels with his finger for the cricoid car- tilage, and makes his incision through the skin and subcutaneous structures for a distance of two and a half inches vertically downwards making the cricoid cartilage the centre of this incision. The assistant draws open the wound with blunt hooks, taking care to pull equally on the two sides, as it is all important that the surgeon should have the middle line well defined for him. Vertical incisions are then made until the deeper structures are divided. The fascia uniting the edges of the sterno -thyroid muscles has to be sought and divided. This done, some veins, the thyroid plexus, come into view, and may be held aside with hooks, but should they be large, clamp forceps may be used to secure them before section, and they can later on be tied at leisure. The isthmus of the thyroid body may present and hide the trachea, but after dividing its fascia, it can readily be hooked down out of the way. The trachea reached, it is well cleaned with a blunt director and fixed by means of a sharp hook introduced between the rings to the side of the middle line, and with its point looking upward. The trachea is then freely opened by introducing the knife from, below, and slitting upwards two or three of the tracheal rings, even the cricoid cartilage may be divided, then the aperture held freely open by means of blunt hooks. Succussion, or better, tickling the tracheal mucous membrane with TKEATMENT. 175 a feather will induce violent expiratory efforts, and may provoke expulsion of the foreign body by coughing. Further measures, such as the introduction of fine for- ceps, snares and so forth, are matters hardly within my province to describe. The main object of tracheotomy in these cases is to ensure an air- way should the laryn- geal space be closed by spasm, excited by the foreign body either impacted or coughed against it. The opera- tion itself greatly increases a chance of the patient's coughing up the object, because the artificial opening is insensitive and offers an unobstructive outlet, whereas the sensitive larynx closes as soon as touched, and so effectually prevents the coughing out of the foreign body. After the foreign body has been removed a small dossil of wet lint should be placed over the opening. When mechanical impediment to respiration is not due to a foreign body in the air passages, the tongue must be drawn forward with forceps, until it protrudes well out of the mouth, while at the same time the head is thrown back to straighten the respiratory tract. This treatment will usually be effectual when the tongue or larynx is the cause of non- entrance of air. "When spasm of the larynx results from adminis- tering an anaesthetic, and persists after drawing for- wards the tongue and hooking up the larynx, laryngo- tomy must at once be performed. No formal operation is needful, the surgeon at once incising the crico-thyroid membrane and maintaining open the aperture so made. It is suggested by some that inhaling chloroform relaxes the spasm, but it is of course useless to adopt such measures if the rima is quite occluded, as no vapour will enter, and valuable time is being lost. 176 ANESTHETICS. If, after the upper air- ways have been cleared and rendered patent by the manoeuvres above cited, the breathing still remains unsatisfactory, artificial respira- tion must be at once practised by one of the following methods. Sylvester's Method. The tongue being drawn forcibly out of the mouth, and the air-ways seen to be clear of obstruction, the head is to hang back, with the neck extended, and the tongue held firmly out of the mouth. The operator stands behind the patient and grasps the arms near the axillse in such a way as to evert them and render the pectorales majores tense. He first presses the arms into the sides so as to compress the thorax and expel air, whilst at the same time an assistant should make pressure upon the abdomen to prevent the in- creased intra -thoracic pressure from forcing down the diaphragm. Next, he firmly drags the arms away from the sides, everting them and lifting the patient as the arms become about A5° beyond the head ; finally, he carries the arms back to a line with the head. He pauses to allow air to rush freely into the lungs, and then brings the arms down to the sides as before. This process he repeats twelve or sixteen times in one minute. The way the arms are grasped is important. When they are held below the elbows, it is not possible to open out the chest as effectively as when the plan above indicated is followed. * The method described is modified by the introduction of the essential features of the plans proposed by Pacini and Bain. ACCIDENTS. 177 The diagrams given below illustrate this method ot inducing artificial respiration. Fig. 27. — Artificial Respiration — Inspiration. Fig. 28. — Artificial Respiration — Expiration. Howard's Method Can be usefully employed, supplementally to Sylves- ter's. It is also of value when the patient's chest is rigid. Dr. Howard insists strongly upon the full ex- tension of the head upon the trunk that the air -ways may be thoroughly straightened out. The patient is between the operator's knees. The latter, who faces him, applies his hands so as to grasp the free margin of the thorax, his thumbs resting upon the xyphoid cartilage. The patient's arms are drawn above his head. The operator presses upwards and inwards towards the diaphragm, gradually bending over the 178 ANESTHETICS. patieDt so that all the weight of his body aids in com- pressing the thorax. After steady pressure for some seconds with a sudden push-up the operator throws himself back into his posture, while the resiliency of the lungs causes their expansion. The process is re- peated twelve or sixteen times a minute. All measures in artificial respiration must be adopted quietly, firmly, and slowly ; since crowding, hurry, fuss and inexpertness, are very dangerous. Life may be restored after an hour's artificial respiration. II. Accidents connected with the Heart and Blood- Vessels. Syncope may occur as the result of fright, or be caused by sudden impact of a strong vapour upon the air-passages. This occurs in the early stages of the administration, and is shown by pallor of countenance and failure of pulse. Treatment. — The patient should at once be placed supine, the legs and arms raised, and the head dropped below the level of the trunk ; all clothing loosened ; smelling salts, liq. ammonia fort, (with caution), or burnt feathers be put to the nostrils ; and the prae- cordium rubbed with a warm hand. Sulphuric ether may be hypodermically injected over the heart, and nitrite of amyl capsules be smashed and the patient made to inhale the vapour. If the breathing flag, arti- ficial respiration must be at once practised. An enema of brandy — ^ ss. in 3 ii. of warm beef- tea or gruel or starch — may be tried. When the patient has recovered sufficiently to swallow, hot strong coffee with a tea- spoonful of Cognac should be given. The most stringent ACCIDENTS. 179 injunctions must be laid down that the horizontal pos- ture be maintained until the heart has quite recovered itself. Syncope from shock occurring later on may arise from prolonged operation, or loss of blood, or over- taxing of the heart due to respiratory difficulties. Chloroform, given over a lengthened period, also de- presses the heart and may determine syncope. The treatment rehearsed above applies also to these cases ; in them it is usually more common to find a gradual heart-failure occurring, and giving warning of trouble. Respiration also is especially liable to flag at the same time as the heart fails. It is especially neces- sary to have resort to artificial respiration early, both on these accounts and because that measure even by itself will frequently steady the heart and restore its rhythm. In all syncopal attacks, while the above measures are being adopted, an assistant should pour cold water over the face and chest, and dash the latter with a towel-end, wrung out in ice-cold water. Apoplectic seizures. — Besides ceasing from all interference and placing the patient supine, little can be done, and directions would not be in place in the present manual. Epileptic seizures The patient should be laid down, his tongue be guarded from being bitten, and his clothing loosened, the only interference justified is to be directed towards restraining the patient from doing himself any injury. Hysterical seizures should be treated in a similar way to that indicated above (epileptic seizures). n 2 180 ANAESTHETICS. CHAPTEE XI. Local Anaesthesia. It has been sought to obtain local anaesthesia without disturbance of the mental faculties, and this object has been consummated with partial success in three ways. (1) By drugs painted and injected at the situation desired to be rendered anaesthetic. (2) By cold. (3) By electricity. The most usual means of producing local anaesthesia by drugs is the use of cocaine. This, the active prin- ciple of the leaves of Erythroxylon Coca, a plant culti- vated in Bolivia, Peru, the Andes, and Argentina, has, since 1880, come into use for producing local insensi- bility to pain. It is employed commonly in two ways : a, as a paint over mucous or cutaneous surfaces, and b, by subcutaneous injection. Physical Properties, Preparations, etc The Erythroxylon Coca (cuca) leaves have been known for very many years as a stimulant, and cocaine was first isolated by Gardeke (1855) who called it erythroxy- Jine. It was rediscovered in 1857 by S. 11. Percy of New York, who, besides isolating the active principle of erythroxyline, described the property it possessed of deadening the sensibility of the tongue ; Niemann in 18G0 also noticed its anaesthetic properties. Lossen two years later recognised the true composition of the sub- PHYSICAL PROPERTIES, ETC. 181 stance and gave it the formula C 17 H 21 N0 4 . It was not until Karl Roller, in 1884, induced Dr. Brettauer to demonstrate the anaesthetic properties of the hydro- chlorate of the alkaloid before the Ophthalmological Congress meeting in Heidelberg that it became gener- ally recognised as a local analgesic. The alkaloid cocaine (C 17 H 21 N0 4 ) has a bitter taste ; forms crystals ; is with difficulty soluble in water (1 in 700 or more), more so in alcohol (1 in 20), freely so in chloroform or ether, also in melted vaseline, castor oil, &c. Pure cocaine, or the hydrochlorate, gives no colora- tion, or a very faint evanescent yellow one, with concen- trated cold sulphuric acid. It may readily be recog- nised by its crystals, which are colourless monoclinic prisms. Cocaine readily undergoes chemical changes in its composition, so that solutions for use should be made fresh as required. "With benzoic, citric, hydro- bromic, sulphuric, tannic, oleic, and hydrochloric acids, cocaine forms salts, respectively, the benzoate, citrate, hydrobromate, sulphate, tannate, oleate,° hydrochlorate, of cocaine, which possess the advantage of being easily soluble in water, and so readily employed for hypoder- mic injection. Aqueous solutions of these salts should not be kept any length of time, as they are liable to become contaminated by the growth of a fungus which occasions deleterious effects upon the patient. The addition of boric acid, carbolic acid, or chloroform has been suggested to prevent such fungoid growth, but these cannot be relied upon to promote the object in view. Cocaine acts as a general anaesthetic when so over- whelming a dose is taken as to bring the animal taking * A saturated solution of cocaine in oleic acid. 182 ANESTHETICS. it to the point of death. Its true action is that of an analgesic and this is due not to the vaso-rnotor con- striction which it establishes, but to its influence upon the sensory nerve endings. If an area is rendered anaemic and analgesic by cocaine, the subsequent in- jection of pilocarpine will abrogate the anaemia while the analgesia remains unaffected. Arloing has shown the same thing by dividing the sympathetic of a rabbit on one side, the animal having been previously cocain- ised, hypervascularity could thus be seen to exist sim- ultaneously with analgesia. The hydrochlorate is the salt which in solution is most commonly used ; it forms acicular or lamellar crystals. It is soluble in half its weight of water, but ireely taken up by glycerine or spirit, and unlike co- caine is insoluble in ether or fats. It is liable to grow fungi. The proposed addition of boric or other anti- septics seems, as in the case of cocaine itself, useless as a means of checking the production of fungus. Physiological Action of Cocaine Upon the Heart and Blood Vessels. It is a much disputed point what action cocaine exercises upon the lowest organisms, ferments, infu- soria, &c, but it would seem to behave as a true anaes- thetic, producing temporary arrest of function in plants and arrest of movement in the lower forms of animal existence without destroying life ; if, of course, the dose employed be not excessive (Charpcntier). In cold-blooded animals cocaine, whether applied to the heart itself, circulated through the detached PHYSIOLOGICAL ACTION OF COCAINE. 188 ventricle, or injected into the circulation, slows the rhythm, and depresses the beat, finally arresting the heart in diastole. Its depressant action upon the heart is shown by the accompanying cardiogram (Fig. 27). It was taken while the detached heart of a frog was per- fused with a competent fluid containing cocaine (1 in 2000) in a Eoy's tonometer. Cocaine also interferes with cardiac innervation, de- creasing in a very marked degree the excitability, for while it abolishes " make" contractions, "break" con- tractions persist. Although both auricles and ven- tricles are influenced, the latter are more interfered with, and cease to beat before auricular rhythm is arrested (Van Anrep). The blood-vessels are but little, if at all, affected by cocaine unless it be applied locally as a paint, and in this case it is doubtful how far the action is really characteristic of the drug. In warm-blooded animals, an initial increase in rapidity of the heart's beat occurs, the heart's action is weakened, but usually recovers and is said to sur- vive the cessation of respiration (Van Anrep). Vagal inhibition is also much depressed and even lost ; blood pressure is greatly lowered, though this is preceded by an initial and transient increase of pressure. Cocaine does, however, produce a very marked de- pressing action upon the human heart. Many persons after even small doses become pallid and complain of extreme faintness, while the heart's action grows weak and irregular, the radial pulse becoming almost indis- tinguishable, Blood pressure is at first lowered but subsequently increased. Cocaine in large doses (and we must remember that what constitutes a large dose 184 ANESTHETICS, ® ■4J _c d "8 • ■A a H "3 o O o o 4H o r3 c j3 Lu "3 o ^5 !- T3 *3 ci tj .2 '3 %- bo pq a C3 O cj & a S-i • o s >» *-* Li' 2 W EH d . o nd ■fl CO ri Tbfl . — i p o o £ h SH 'o O o w £ jTd eB "fl T3 5 fa o > O - H o u o | d — l # o OS B Cl TJ o o d 6 £ £ £ '5 fc v* PHYSIOLOGICAL ACTION OF COCAINE. 185 varies greatly among different individuals) renders re- spirations more rapid, irregular and shallow, and finally will asphyxiate by stopping respiration alto- gether. In human beings, marked dyspnoea and breathlessness may follow its use. Convulsions and epileptiform seizures, due, it is said (Durdufi), to vasomotor irritation producing anaemia of the brain, occur after toxic doses. Death, according to Mosso, occurs from tetanic contraction of the dia- phragm. The nervous system is much affected by cocaine. The peripheral nerves of sense become anaesthetic over the area into which cocaine has been injected, the anaesthesia extending just so far as the drug traverses the tissues. Dastre very aptly terms cocaine the "curare " of the sense nerves. Painting over the skin may, if it be sufficiently thin to permit of absorption, lead to a like result but in lesser degree, since but slight absorption occurs by cutaneous surfaces. The motor nerves are usually only affected by large doses, but in some persons comparatively small doses have induced paresis or paralysis lasting for hours or even days. Ptyalism occurs leading to dryness of the mouth and fauces. Peristalsis is increased and vomit- ing and borborygmi follow its use. The other secre- tions of the alimentary tract are lessened. The urea and phosphoric acid excretion is increased by it (Fleischer). Cocaine increases destruction of tissue and by a constant repetition of this process leads finally to physiological ruin. Mydriasis and pro- ptosis are usual among warm-blooded animals. Upon warm-blooded animals cocaine produces great hyper- excitation of the muscular system and marked agi- 186 ANAESTHETICS. tation, a large dose may at first simulate strychnine in its action, causing muscular tremblings, convulsive movements and spasms. Although the mind at first will remain clear, there is usually a tendency to garrulity, followed by great anxiety and feelings of unaccountable distress. Lan- guor, muscular weakness, and lassitude, will then take possession of the patient, who becomes haunted by most fantastic hallucinations. Some persons simply experience slight elation, or it may be drowsiness, but loquacity is the most usual symptom. Cocaine would appear to produce an hyperexcitability of the spinal cord evincing itself in muscular tremblings and twitchings (Dastre) ; a similar condition of the medulla accounts for the vaso- motor and respiratory disturbance, while (Richet) an increased excitability in the cortex brings about convulsions, &c. In fine the effect on the nervous system may be summed up in the words of Dastre, who says that while the drug para- lyses the terminations of the sensory nerves, it excites all other parts — nerve trunks, spinal cord, medulla, en- cephalon and sympathetic chain. Cocaine produces at first a slight rise in body tem- perature. It is eliminated by the kidneys, and often produces albuminuria or glycosuria, accounted for by Van Anrep as the result of the partial paralysis of respiration, which the drug occasions. No attempt has been made to describe at all fully the symptoms which characterise poisoning by cocaine. These are bizarre to a degree, and may be grouped as (1) more or less heart failure with a remarkable lower- ing of blood pressure, paling of the skin and mucous METHODS OF EMPLOYMENT. 1ST membranes ; (2) great dyspnceic distress from failure of respiration ; (3) impairment of mental faculties and even unconsciousness, or in some cases catalepsy. Con- vulsions may occur, or a loss of movement in various groups of muscles. While such symptoms usually occur only after the injection of a considerable dose of co- caine, they may follow the use of quite a small quantity. Eetention of urine, protracted insomnia, and prolonged anorexia are also recorded (Kiimmer). Methods of Employment. 1. Instillation into the eye. 2. Painting over mucous surfaces. 3. Subcutaneous injections. Whatever method be adopted, it should be remem- bered that a dose of one grain will in a large number of persons produce unpleasant if not dangerous sym- ptoms, half a grain is a safer dose, though even this may in many people give rise to trouble. As a paint, 20 per cent, solution is used, weaker pre- parations being of little value over cutaneous surfaces. Several coats are necessary, and even then as a rule anaesthesia will not extend much deeper than the true skin. When employed for mucous surfaces, especially if there be any likelihood that some of the solution may be swallowed, a dilution to 10 per cent, should be adopted. In laryngoscopic examination Semon uses a 20 per cent, solution, painting the pharynx with it, and this he finds will enable the patient to submit tran- quilly to prolonged and painful laryngoscopy. In ophthalmic practice it is well to instil a few drops 188 ANAESTHETICS. of a 4 per cent, solution into the conjunctiva, repeating the instillation two or three times at brief intervals, and then waiting from five to ten minutes before operating. If the manipulation takes long, it will be necessary to repeat the process from time to time. Cocaine is also employed as a spray in an atomiser, a 4 per cent, solution being used. Most marked effects, both local and constitutional, follow the use of cocaine when injected hypodermically. Used in this way, its action is more rapid and more persistent than when applied as a paint or an ointment. A 10 or 20 per cent, solution is usually employed, and from 2 to 5 minims injected at the site of operation. As the effect may pass off before surgical interference has been completed, it will often be necessary to inject a second or third dose during the operation. Great care must be taken to avoid the injection entering a vein, as it is probable that many of the deaths following the use of cocaine have resulted from this accident. From five to ten minutes must be allowed to elapse after injection before the knife is inserted. Another and useful method of administration suit- able for eye work is the placing of an easily soluble cocaine tablet (B.P., 1885) in the oculo-facial fold of the conjunctiva. A convenient and very admirable means of using cocaine for a throat spray is the atomiser figured below, invented by W. J. Miller. Dr. Leonard Corning, of New York, proposes yet another method of using cocaine. He first marks out with crayon the superficial veins, to obviate a possi- bility of puncturing them, and next exsanguinates the limb with an elastic bandage and Esmarch's cord. He METHODS OF EMPLOYMENT. 189 then injects superficially three to five drops of a 1 or 2 per cent, solution of cocaine hydrochl orate immediately above the cord. After waiting until the skin is anaes- thetic, he injects the deeper tissues with a solution of the same strength, making twenty or more punctures according to the area to he rendered insensitive. Dr. Corning then applies a tourniquet at the upper limit of the anaesthetic zone, and after a few minutes operates. Fig. 33. — Miller's Atomiser. This elaborate procedure is based upon the theory that by checking the venous return, he prevents a de- portation of the anaesthetic from the area of injection, while dilution of the drug by blood is also lessened. In other words it is assumed that cocaine, instead of being rapidly absorbed into the circulation, is by this method able slowly to permeate the tissues and exert its paralysing action upon the peripheral nerve endings. 190 ANESTHETICS. Dr. Corning also employs specially constructed rings and haemostatic clamps, to effect the same " incarcera- tion of the anaesthetic." The method may prove ser- viceable when cocaine is used, hut, as we have indicated, the employment of frequent and numerous injections of the drug are not devoid of danger. In estimating the value of this theory also, due regard must be had to the consideration that a limb surrounded by tight cords or a tourniquet is thus rendered to some extent insensi- tive, a fact which may account for Dr. Corning finding only small doses of cocaine requisite. Eobson, Rummer and others who have tried the method speak well of it. Indications for the use of Cocaine. Accounts of the effects differ so widely, that it is wholly impossible to do more than indicate the class of cases in which cocaine has been recommended as an efficient anaesthetic. In ophthalmic jn'actice. Cataract operations. Eemoval of foreign bodies. Laceration. Iridectomy. Iridodesis. Sclerotomy. Slitting up the canaliculi. To this list some surgeons add tenotomy for strabis- mus, and extirpation of the eyeball. Many minor eye operations have been purposely omitted. Even in the above named cases, cocaine must not be too implicitly trusted, for it fails with INDICATIONS FOK THE USE OF COCAINE. 191 some individuals, and no means exist which enable us to determine beforehand when it will succeed or fail. Panophthalmitis has followed its use for eye operations. When employed for extirpation of the globe or teno- tomy, instillation is not sufficient, and subconjunctival injection is necessary. In many cases patients com- plain that the division of the deeper structures causes much pain in spite of cocaine. The presence of glau- coma is a contra-indication to the use of cocaine, in- deed according to Javal its constant use may cause a glaucomatous condition. Although advocated for operations undertaken to remove foreign bodies from the cornea, &c, cocaine possesses a serious drawback, inasmuch as it induces flaccidity of the eyeball, and so seriously impedes operative measures. Operations about the Larynx, Pharynx, etc. — Ulceration of epiglottis, scraping. Eemoval of polyps from larynx. Cutting off the uvula. Catheterising of the Eustachian tubes. Eemoval of polyps from the nose or ear. Cauterising the nasal meatuses. Excision of the Tongue has been attempted, but without uniform success. Abscesses, boils, and carbuncles may be opened, and many of the small operations classed under minor surgery performed, after the injection of cocaine. Operation on the Urino- generative Tract. — The injection of a few drops of a two per cent, solution into the urethra is said to render catheterisation painless, but this is only true when no stricture exists. In like manner the operations of lithotrity and litholapaxy may 192 ANESTHETICS. be undertaken after an injection of cocaine, a stronger solution (five per cent.) in these cases will better answer the purpose. 7;? Dental Surgery. The adjustment of clamps and separators. The introduction of wedges. The application of ligatures for the rubber. The manipulation of deep cervical edges of cavi- ties, whether for excavating, filling, trimming or polishing. The removal of tartar in pyorrhoea alveolaris. The modelling of sensitive and irritable mucous membranes. For this purpose a paint of a 10 per cent, solution is used, or a spray of 2 or 4 per cent, according to the degree of sensibility manifested by the parts. For lancing and excising gum-tissue. For the relief of pain after extraction, though cocaine is usually inadequate to accomplish this. For anaesthetising pulps before extirpation. For obtunding sensitive dentine (results are not upon the whole satisfactory). Many observers have come to the conclusion that cocaine is a failure when employed to effect painless tooth extraction ; small doses are inadequate, and larger ones too frequently give rise to constitutional derange- ment, which is always prejudicial and often alarming. As a rule, a grain is needed to anaesthetise sufficiently to permit of extraction, and ten minutes must be al- lowed to elapse before applying the forceps. Many patients are greatly terrified by the pricking of the hypodermic syringe. It is best to inject by three punc- tures, one on the lingual, and two on the labial aspect ACCIDENTS ATTENDING THE USE OF COCAINE. 193 of the tooth. One of these being before, and one be- hind the prominent ridge on the buccal alveolus, they will correspond to the roots of the tooth to be extracted. Messrs. Cunningham and Hern (Odont. Trans., vol. xix.) have published some carefully noted cases in which cocaine used for dental purposes has given rise to very unsatisfactory if not alarming results. Major Opeeations. A few surgeons have undertaken section of bones, clamping of haemorrhoids, circumcision, &c, but the successes recorded are not such as to justify the use of cocaine in these operations, unless under most excep- tional circumstances. In all these cases, repeated and large doses of cocaine have to be injected, and therefore we cannot be sure that most disastrous constitutional effects may not follow. We have moreover to remem- ber, that a conscious patient is always more or less a terrified one, and so not in a favourable frame of mind for surgical proceedings. Accidents and After-Effects attending the use of Cocaine, with their Treatment. Severe headache, palpitation, failure of the heart, with repeated attacks of fainting, precordial pain, and sensation of stifling, and inability to obtain sufficient air, may be experienced even after small doses. Tingling, formication, muscular weakness, vertigo, and muscular inco-ordination, cold sweats, utter pros- o 194 ANESTHETICS. tration, and extreme drowsiness, are also not uncommon symptoms. Muscular movements almost amounting to convulsions may occur, and in some persons persistent pendulous oscillations of the head follow the use of cocaine, greatly disturbing the operations (dental), which it was sought to achieve. Nausea and vomiting sometimes occur, together with cramping pains in the abdomen. These untoward symptoms may last several hours, or pass off in less than one ; they may be slight, or so serious as to cause the greatest alarm. The most usual after-effects are persistent nausea, headache, anorexia, sleeplessness, derangement of di- gestion, and great mental depression. Treatment. — A careful watch being kept over the patient, any signs of heart failure or insufficient re- spiration must be at once treated. The patient is to be placed on his back, his arms and legs raised, his head hanging below the level of his body, and all cloth- ing loosened about the neck, chest, and waist, while cold air is admitted. If he can swallow, a teaspoonful of sal volatile in half a wineglass of water should be given in sips. Strong smelling salts should be sniffed, the prfficordium and front of the chest dashed with a wet cold towel, and sinapisms put to the calves of the legs and nape of the neck. If he cannot swallow, brandy should be rubbed with a finger over the tongue, the inside of lips and mouth. Subsequently, small doses — half a teaspoonful of brandy — should be given every ten minutes until pallor disappears. Nitrite of amyl in capsules, or three drops on a handkerchief, may be held to the nose. Warm tea and hot coffee give a patient comfort after ACCIDENTS ATTENDING THE USE OF COCAINE. 195 the syncope lias passed off, and will also relieve head- ache. As a rule, absolute quiet in the prone position, with sal volatile, will bring a patient round without the aid of alcoholic stimulants and the more heroic treatment detailed above. Should respiration become greatly hampered, arti- ficial means should be at once adopted to maintain breathing. Cocaine has no distinct antidote, although marked physiological antagonism exists between this substance and morphine. Skinner has suggested the use of atropine, Mosso that of chloral, to counteract the con- vulsive properties of cocaine. Several fatal cases of cocaine poisoning have occurred. In the case of Professor Colomnine's patient 23 gr. proved fatal, this dose having been injected into the rectum in order to allow of scraping an ulcer. In another case death resulted from 3 j. of a 20 per. cent, solution introduced into the urethra as a preliminary to internal urethrotomy. Swabbing out the larynx with a two per cent, solution has also proved fatal (Dr. W. H. Long quoted by Dr. J. B. Mattison). This patient was aged 33 and had nearly died previously as a result of the application of a 4 per cent, solution to his larynx. Dr, Mattison, of Brooklyn, has also re- ported fifty cases in which death seemed imminent, and in several cases actually followed the use of even small doses. These cases comprise those of persons for whom cocaine sprays, injections, painting of mucous surfaces, instillations in the conjunctiva, had been used, also of stuffing cocaine-moistened pledgets into carious teeth. Brucine, and a substance called drumine, have o2 196 ANAESTHETICS. been suggested as local anaesthetics, but the former is little used, while drumine has been shown to be oxalate of lime prepared from a euphorbiaceous plant and to be devoid of anaesthetic properties. Other Methods for producing Local Anaesthesia. Fig. 31.— Dr. Richardson's Ether Spray. Ether Spray (Dr. B. W. Kichardson). — The wood- cut explains the simple mechanism of this useful con- trivance. A bottle containing specially prepared ether, is traversed by an air current propelled by a hand ball so valved as to admit, but not allow the escape of air save by its traversing the ether. The second ball which is covered with net, acts as a reservoir. Air forced into the ether atomises it through a delicate tube, causing it to escape in a fine spray. Ether impinging upon the skin or mucous membrane causes so rapid an evaporation from its surface, that its heat is abstracted * Richardson recommends anhydrous ether, sp. gr. 0*720, mixed with an f qual part of hydride of amyl (Rhigolene). METHODS FOR LOCAL ANAESTHESIA. 197 with sufficient rapidity to numb the part, thus paralys- ing the terminations of the sensory nerves. The anaesthesia is confined to the skin and is very transient. Recovery of sensation when the spray ceases to work, is often accompanied with very painful smarting and tingling. The great drawback of the method is that the instruments and skin get thickly coated with ice which obscures the parts, rendering the use of the knife almost impossible. Further, under ether spray it is difficult to see and secure blood-vessels, and painful to do this when the anaesthesia has passed off. Unless care be taken, the skin may be so much frozen that a slough like that of frost-bite will follow. Chloride of Methyl (CH 3 C1).— Another method of rendering tissue insensitive by refrigeration is that obtained by allowing the liquid chloride of methyl to drop upon the skin or mucous membrane. It possesses a boiling point of — 23 3 C, is capable of being kept in the liquid state in metal bottles under a high pressure. There is some slight danger in using it, namely, that unless the action is kept carefully under control, and this is not easy, there may be severe injury to the vitality of the tissue subjected to its influence. Alcohol has been used to produce local anaesthesia. It possesses the property of removing sensation to pain, while tactile sense persists. Alcohol is cooled by placing it in ice and salt, to ten degrees or so, below freezing point, and the part to be numbed is then placed in it. The use of alcohol for anaesthetic pur- poses is not advisable except as a make- shift. Carbolic acid painted over the skin possesses some benumbing power, but its effect does not penetrate at all deeply, and is disadvantageous inasmuch as the tissue touched is damaged by the caustic action of the acid. 198 ANESTHETICS. Faradic currents directed for some minutes through an area of skin or mucous membrane, are held by a few to produce anaesthesia. At one time this method was in vogue among dentists ; it has now fallen into disuse. A recent attempt has been made to revive this plan, an improved apparatus being employed, but the success achieved seems to have been so slight as to make it hardly necessary to particularise its features. Rhigolene, a product of the distillation of petroleum, was introduced by Richardson, who employed it instead of ether in his atomising spray. Rhigolene has a sp. gr. of '625 ; it is one of the most volatile substances known, and so needs to be kept in strong, well-stop- pered bottles. The uses and precautions described under the head, "local anaesthesia — Ether " apply to rhigolene. Bisulphide of carbon, although an effectual local anaesthetic, when used from a spray or by irrigation, possesses the insuperable disadvantages of having a dis- gusting odour and of being a potent poison. MEDICO-LEGAL ASPECTS. 190 CHAPTER XII. Medico-Legal Aspects of the Administeation of Anaesthetics. The administration of an anaesthetic to a patient who is not a minor, against his will, constitutes an assault. When a patient has voluntarily submitted himself to be anaesthetised, he may, under the influence of terror, dur- ing an early stage of the proceedings attempt to pre- vent further narcosis ; he is then not sufficiently guided by his reason, and the administrator is bound in the patient's interest to take his own course. The anaesthetist, like any other medical man, is liable to prosecution for malpraxis ; it then rests with him to prove that whatever steps he took were adopted after due consideration and because he believed them to be the best he could follow for the benefit of his patient. Such questions as the following might arise : — Did the anaesthetist undertake a duty which knowledge, skill, and experience had qualified him to fulfil '? Did he employ the most suitable agent according to his view of the exigencies of the case ? and did he administer it with due skill and after the most approved method ? Did he possess himself of all necessary facts with regard to the patient's bodily condition ? and did he make due allowance for these in the treatment which he pursued ? And, in the event of an accident of any kind, did he adopt the right and appropriate treatment 200 ANAESTHETICS. indicated in such an emergency ? and was this done with due promptitude ? Anaesthetics have been employed to assist in the per- petration of various crimes upon the person narcotised. Thus, an anaesthetic may he given, it is alleged, with- out the consent of a person ; or when given with his or her consent to effect a lawful procedure, advantage may be taken of the anaesthetised person's helpless con- dition to perpetrate a crime. Can an anaesthetic be administered without consent ? Firstly, can this be done whilst a person is awake and in full possession of his senses ? Formerly many cases came into the law courts in which the complain- ant alleged that a handkerchief saturated with chloro- form was waved before his face and unconsciousness followed immediately. This we now know to be an impossibility ; a period of time varying from two to twelve or more minutes must elapse before an indivi- dual succumbs to chloroform, and during this time fresh supplies of the anaesthetic would be needed. Further, chloroform in most cases produces so much excitement, that one person would find it a difficult matter to keep the victim sufficiently still to complete the anaesthesia, and would hardly do so without much noise and disarrangement of the victim's clothing. Further, unless food is avoided before the anaesthetic is given, vomiting is very liable to occur, and with it a return to consciousness. It is often alleged by the supposed victim that he, or she, was conscious of what was transpiring, but was powerless alike to speak or resist. Such statements must be received with the utmost caution. It is true that Pean records cases in which patients, though ren- MEDICO-LEGAL ASPECTS. 201 dered analgesic by ether, retained their consciousness as to what was in course of proceeding. Cases like Pean's must be so exceptional that one is tempted to believe the anaesthetic was administered very imper- fectly, and that faith in the assurance of the surgeon did the rest. Snow also admits the possibility of persons imperfectly chloroformed being conscious and yet powerless to resist. In attempts at criminal violence under an anaesthetic administered without the victim's consent — fear, excitement, and struggles, would all be against the possibility of arriving at loss of voluntary power without deep narcosis. It is very doubtful whether a person, be he an expert or not, could nar- cotise a waking adult against his will unless there existed a very unusual disproportion between the strength of the two individuals. In the case of E. v. Snarey, the prosecutrix alleged that she had been ren- dered insensible instantly by something being held over her face upon an handkerchief, and that in that condition she had been violated. This contention could not in a present state of knowledge be admitted by experts. However, in a parallel case, that of White v. Howarth, the prosecutrix made a similar assertion, and added that she was aware of what was going on but was unable to resist. Although the time required to thoroughly anaesthetise a patient is longer when chloroform is used, than when ether is employed, yet, from the highly irritating nature of ether vapour it is less easy to administer to an un- willing patient than chloroform. And further, it requires the use of some apparatus entirely excluding air, and is hence less easy to manipulate by non- experts. In general it may be affirmed, that if chloro- 202 ANESTHETICS. form can only be used for criminal purposes with difficulty, with ether such attempts would prove still less easy. Can a Peeson be Anaesthetised duking Sleep '? Dolbeau made careful experiments with reference to this subject, and his conclusions are certainly consonant with the experience of most skilled anaesthetists. He first attempted to anaesthetise four persons during sleep. Three were awakened in the process. In his second series of cases four persons out of six awakened, and in his third series only three persons awakened out of nine to whom he administered chloroform while sleeping. Dr. Turnbull asserts that either chloroform or ether may be given during sleep without awakening the subject of the experiment. I have no doubt that chloroform may in many cases be so administered, but am less sure about ether ; in either case certain condi- tions must be present to ensure success. Only the greatest care, skill, and familiarity with the anaesthetic used would suffice, and then we must predicate the subject to be a sound sleeper. But it is highly im- probable that a novice in anaesthetics would succeed in such an attempt. A further question arises, upon which evidence may be sought, and that is whether in the event of his es- caping capture, it is possible to prove the person at- tempting to administer an anaesthetic with criminal in- tent was one skilled in its use. To determine this offers some difficulties. The presence of apparatus, the method in which lint or a handkerchief is folded, ATTEMPTED RAPE UNDER ANAESTHETICS. 203 or blistering of the lips and nose from allowing the chloroform to drop upon the face, may offer a clue. If ether be employed we may be sure that the person using it possessed some knowledge, and had resort to an apparatus, since ether given by the open method seldom if ever carries the patient beyond a stage of delirious excitement producing bellicose struggles such as would effectually prevent the accomplishment of any criminal design. Anaesthetics have been given to assist in the com- mittal of robbery, rape and mutilation. What has been said above leaves little to add with regard to robbery. Attempted Kape under Anesthetics. Many cases have now been reported in which the prosecutrix has affirmed that a dentist or surgeon has violated her person while she was under the influence of an anaesthetic. So frequent are such charges that the greatest care should be taken on the part of an opera- tor in order to ensure the presence of a third person, at least within ear-shot, and preferably within sight of the administration. No administrator of an anaesthetic is safe from having such a charge preferred against him, and if he and his supposed victim are alone, it is simply a case of word against word. Further, the woman may be enceinte at the time of the alleged rape, and may subsequently give birth to an infant whose parentage she may find it convenient to fasten upon the medical man. But it is not only designing bad women who bring such charges. Modest, virtuous, and refined gentle- 204 ANESTHETICS. women have been prosecutrices in these cases. The cause for this remarkable and deplorable state of things is fortunately not far to seek. Chloroform, ether, nitrous oxide gas, cocaine, and possibly also the other carbon compounds employed in producing anaesthesia, j)Ossess the property of exciting sexual emotions, and in many cases produce erotic hallucinations. It is un- doubted that in certain persons sexual orgasm may occur during the induction of anaesthesia. Women, especially when suffering from ovarian or uterine irrita- tion, are prone to such hallucination, and it is almost impossible to convince them after their recovery to con- sciousness that the subjective sexual sensation is not of objective existence. It is stated that women at their menstrual periods are more prone to erotic hallucina- tions than at other times, a fact which may be borne in mind. A case cited by Dr. Kichardson will illustrate this statement. A young lady had chloroform adminis- tered to her by the doctor in the presence of a dentist and of the young lady's mother and father. After the tooth had been extracted, and the patient became con- scious, she steadfastly affirmed that she had been criminally assaulted by the dentist, and to this state- ment she adhered although the four persons present in the room strove to disabuse her mind. In considering the evidence in such cases, the follow- ing points need especial attention : — Nature of the anasthetic. — Chloroform, ether, and the other members of the carbon anaesthetic series, cer- tainly render persons wholly unable to protect them- selves from any personal ill-usage. The body of the anaesthetised patient is, however, rendered utterly flaccid, and is a dead weight. If then there is any question of DEATH UNDER AN ANAESTHETIC. 205 moving the body, as for example, from a dental chair, and again back into the chair, it must be remembered that such an undertaking would be exceedingly diffi- cult for one individual however strong, and could hardly be accomplished without causing much disar- rangement of clothing. On the other hand, if the offence was alleged to have been committed when the patient was under the influence of nitrous oxide gas, it would have to be borne in mind that the effect of this gas is to produce first muscular rigidity and subsequently violent jactitation. Further, unconsciousness only persists for about half a minute, or in exceptional cases a trifle longer, and the patient regains her senses with control over her muscles all at once. This being so it is exceedingly improbable that even a premeditated and skilfully planned attempt at violation would be successful if made under nitrous oxide gas. A caution is needed about admitting the evidence of a person only just recovered from an anaesthetic. The following case illustrates this: — A dentist appealed to a friend to extract a tooth. Under gas he struggled so violently that the operation was not performed, but as he came to, he reproached his friend most bitterly, telling him he had felt the whole pain of the extraction and was even then suffering torture. Death under an Anaesthetic. It becomes requisite to decide whether the death was suicidal, accidental, or due to an anaesthetic given by a second person, and then whether that individual was an expert or not. Persons frequently employ chloro- 206 ANESTHETICS. form as an anodyne, and many deaths have resulted from the stopper coming out of the bottle, the contents escaping upon the patient's pillow. The presence of a phial near the corpse might point to self-administra- tion. Ether is not used similarly, and is not selected by suicides. One death from nitrous oxide gas is re- corded from America. A dentist whilst under the in- fluence of drink, placed himself in his chair and turn- ing on the gas held the face-piece over his mouth and nose. In the morning he was found dead and the gasometer empty. It is important to carefully search for evidence as to how the anaesthetic was administered, as this may determine whether it was done secundum artem or unskilfully. The enquiry into a death supposed to be from an anaesthetic commences with the question — was it due to the narcotic, or to haemorrhage, shock, exhaustion, or some other mischance following surgical interfer- ence. The mode of death due to chloroform, ether, and other agents is described under the heading chloroform, &G. The choice of the anesthetic would have to be justi- fied ; thus were chloroform given for a simple tooth extraction in lieu of the safer agent nitrous oxide gas, and were the patient to succumb, the administrator could with reason be severely censured for subjecting his patient to such an unnecessary danger. All anaesthetics are dangerous. In the hands of one skilled in their use this danger is minimised ; but what- ever may be individual uses and opinions, the general consensus of belief places anaesthetics in the following order of safety : — nitrous oxide gas when used for short TABLE SHOWING DEATH-EATE. 207 operations ; ether ; chloroform. Other substances are not used sufficiently often to make statistics reliable, but the following table gives a rough estimate of their danger.* Table Showing Death- bate under the Various Anaes- thetic Bodies. Chloroform (Coles, Virginia) ,, (Eichardson) ... ,, Baudens (during Crimean War) ,, War of Secession ,, Lawrie (Hyderabad) ,, Juilliard (Geneva) . Ether (Andrews) f „ Juilliard (Geneva) ... ,, Lee (Chicago) Nitrous oxide gas Amylene Hydrobromic ether A.C.E. Mixture, No. not ascertainable^ Methylene mixture 1 It must be added that Scotland presents a series of statistics much more favourable to chloroform ; thus out of 36,500 administrations at the Edinburgh Infir- * No great stress can be laid upon sucb figures, as in many cases a death occurred very early in the career of an anaesthetic, and this rendered further trials of it inadvisable. f Probably too low an estimate. X Eichardson states erroneously that no death has occurred under A.C.E. mixture. Dr. Eeeve, of Dayton, Ohio, reports 3 deaths. Deaths. Administrations. 53 152,260 1 2500 to 3000 in 1 10,000 1 11,448 45,000 161 524,507 1 23,204 1 14,987 4 92,816 1 100,100 2 238 2 (?) 5000 208 ANESTHETICS. mary during ten years, only one death has been re- corded. Inquiries recently made have revealed that several deaths from chloroform have occurred at the various surgical centres of Scotland, so that the above estimate can no longer be taken as a reliable statement of the death-rate from chloroform. Dr. McEwen gives his own results at Glasgow (com- puted, not recorded) as 11,886 cases of anesthetics, 500 of which were ether cases. He makes various deductions from his total and regards 10,000 with one death as his chloroform record. Sir George Macleod mentions 15,000 cases with one death, and Dr. Buchanan 9,000 with one death. This gives the total of 34,000 with 3 deaths, or 1 in 11,000 about, for three leading Scotch surgeons. Questions of responsibility when the patient dies under an anesthetic may involve those as to whether the most suitable anesthetic was given him. Some- times a patient refuses one anesthetic, preferring another ; here the administrator clearly cannot shirk responsibility, but must give that agent which he deems best, without regard to the whim of the patient. In the converse case, when death occurs during the admin- istration of an anesthetic which the patient declined to take until persuaded, cajoled, or cheated into so doing, the anesthetist would have to show that his special knowledge guided him in making his selection, which although it led to a fatal result, was in point of fact, the best he could do for the patient. In the employment of a new or untried anesthetic, very grave responsibility would rest with the administrator unless he very fully and clearly explained the possible results, and obtained the patient's consent to the experiment. MEDICO-LEGAL ASPECTS. 209 A question which we have not yet considered arises — who in the eye of the law is qualified to administer an anaesthetic ? At present some uncertainty exists upon the point, owing to discretionary power being left to the operator to assume the so-called responsibility of the anaesthetic. Thus butlers, coachmen, dispensers, and various unqualified persons are frequently permitted to give the anaesthetic, or as the phrase is, "keep it going," while the surgeon besides operating is supposed to exercise a general supervision over the administra- tor's proceedings. If any accident happens, the cer- tificate is duly signed by the surgeon, and the coroner's court admits the principal's evidence. It cannot be doubted that to give any individual an anaesthetic sub- jecting him to a minimum of danger is all one person can do, and can only be accomplished by those specially instructed and experienced in anaesthetics. "Were an action for damages raised upon a death occurring under the above named circumstances, there is little doubt that the persons proceeded against would be heavily mulcted, since nothing short of the utmost emergency could justify the proceeding. Eecently an action for malpraxis was taken out in a Colonial court against a medical man who lost a patient whilst he was administering chloroform. The question rested upon whether the anaesthetic was rightly and skilfully given, which being taken as proved, the court decided the case in favour of the medical man. How far dentists practising with or without the L.D.S. diploma are legally justified in administering anaesthetics is a moot point. Many hold that the L.D.S. confers a right to the administration of nitrous oxide gas, but no other form of anaesthetic. In the p 210 MEDICO-LEGAL ASPECTS. United Kingdom no trial case has, I believe, been con- tested. The ground for this affirmation that licentiates in dental surgery possess such a right has no legal basis, but has grown out of the belief that the use of nitrous oxide gas is part and parcel of the dentist's business, and that so he has a right to employ it. This, however, applies with equal force to all registered dental practitioners. Probably the issue would hinge, in the present ambiguous condition of the law, rather upon the previous experience and recognised skill of the person administering the anesthetic, than upon bare qualification. Thus, could it be shown that a registered practitioner, after two or three thousand successful administrations, met with an accident, in spite of all due care and precaution, he would probably be in a better position than would a well qualified prac- titioner, who met with a fatality presumably through mal- adroitness, if it were shown that he had never ob- tained a practical experience in anaesthetising. In any case a person would be open to grave cen- sure, if not liable for malpraxis, were he to undertake the administration of an anaesthetic, and operate single-handed, unless it could be shown that to do so was a necessity, no help being accessible. It has been made a subject of much debate with whom rests the responsibility of the choice of the anaesthetic, the surgeon who operates, or the anaes- thetist who gives the chloroform or ether, &c. ? Clearly this must depend entirely upon the under- standing which exists between the two. If the anaes- thetist is called in as an expert to decide what anaes- thetic is best for any given patient, his must be the whole responsibility ; while if he is present simply as an DEATHS FROM NITROUS OXIDE GAS. 211 assistant to the surgeon to give in the best possible way an anaesthetic which is named by the latter, his responsibility can extend only so far as the actual ad- ministration is concerned. If the two disagree the surgeon insisting upon an anaesthetic which the anaes- thetist conscientiously believes will jeopardise the patient's life, the surgeon cannot cover the anaesthetist, and the latter has but one course to adopt, namely, to retire from the case. As, however, the experience of the surgeon will probably equal that of his colleague, and as the patient is his, it is a grave step for any anaesthetist to adopt, and could only be justified in most extreme cases. Death from Nitrous Oxide Gas. The deaths which have occurred when the patient had inhaled or was inhaling the gas, cannot be imputed to any specific action it exercised. In some cases heart failure occurred upon the patients, resuming conscious- ness before the operation ivas completed, and in others respiration was interfered with by gags slipping and setting up laryngeal spasm. In a recent case death occurred in an elderly lady who wore extremely tight corsets, whose heart was diseased and whose stomach contained food. The gas was also administered twice. Unquestionably there is danger if the patient is al- lowed to feel pain, especially in operations upon the fifth pair of nerves, but little if any when the gas is given fully and the operator warned to desist before consciousness returns. The P.M. appearances are simply those of death from syncope, or death from asphyxia. p 2 212 DEATH FROM ETHER. Death from Ether. If viewed before death, the individual will be found to be lethargic or comatose, breathing slowly, deeply, and with stertor, the skin pale and cold and covered with clammy sweat. The exposed mucous membranes will be purplish ; the face livid ; the pulse quick, soft, small, and compressible. Complete muscular relaxa- tion gives the body a flaccid doughy feel. The eye is fixed and glassy, and usually smeared with a thick film of mucus, the pupil is dilated and insensitive to light. The body temperature is depressed several degrees below normal. If the vapour has been inhaled, a much smaller dose is needed than when ether is swallowed. The effects given above may be brought on in from three to five minutes. Six drachms to an ounce are necessary to produce narcotism when swallowed. Post-mortem appearances. — If examined within twenty- four hours after death, the brain, lungs, liver, spleen or kidneys, upon being cut give a strong ethereal smell. The blood is dark and thick, although still fluid. The lungs are congested posteriorly and filled with aerated spumous fluid in front (Taylor). The bronchial mucous membrane is reddened from injection throughout its entire extent. The cerebral and spinal vessels are found congested, and the meninges stained. Ether when swallowed has not caused death in the human subject (Taylor). Orfila, experimenting upon dogs, found the mucous membrane of the stomach of a blacky-red colour, acutely inflamed by a lethal dose of ether. DEATH FROM CHLOROFORM. 213 The duodenum was also red and inflamed, the heart contained black blood which was partly coagulated. The detection of ether by analysis. — Ether in liquid is distilled from the stomach contents and led through a glass tube containing asbestos moistened by a mixture of sulphuric acid and saturated solution of bichromate of potash. The asbestos turns green. Its odour is also characteristic ; ether burns with a smoky yellow flame; it is only slightly soluble in water. The tissues. —In recent examinations the odour is characteristic. Since but little ether is absorbed by the blood, and of this little some is converted into aldehyde (Taylor), it is almost impossible to separate ether from it or the solid tissues by distillation. Death from Poisoning by Chloroform May occur through inhaling the vapour or drinking the fluid. If examined before death the individual will be comatose, breathing stertorously with slow, shallow respirations. The skin will be cold and blanched, the face livid, the lips ashen in hue, the pulse imperceptible, and the pupils may be widely dilated, but insensitive to light. Muscular flaccidity is present, but epileptiform convulsions often occur. Post-mortem appearances. — In cases of death from chloroform the appearances reported vary veiy much, and this is probably due to the confusion present in the minds of many persons concerning the con- nexion of cause and effect. Thus death from asphyxia, fear, shock, and so on, are attributed to chloroform ; and further, the autopsies are seldom made soon enough 214 DEATH FROM CHLOROFORM. to be of any value, while sufficient note is seldom taken of the stage in which death occurred. We should ex- pect the cadaveric appearances presented in the first stage to differ widely from those found in the last stage, and yet in but few records have I been able to find any information bearing directly upon this point. In the earlier stage chloroform congests the vessels of the brain and cord, and so this condition, although inconstant, is sometimes found. The lungs are usually deeply congested, the heart empty, flaccid, or containing a little fluid blood. In some cases the right heart is full, even to distension, of dark fluid blood (asphyxia) . The blood remains fluid, it is very dark and is said occasionally to contain bub- bles of gas (Taylor). Snow, analysing thirty-four cases, describes visceral engorgement, but in some instances he found the lungs normal. Casper denies that any of the features pictured above are pathognomonic of chloroform poisoning. When the drug is swallowed it produces gastro-enteritis, and pathological appearances resulting from this would be seen post-mortem. Detection of chloroform. — The odour very soon passes off. Dr. Taylor failed to detect any in the blood half an hour after administration. Analysis of the blood also fails to reveal any evidence after half an hour. Analysis of the tissues.— The substance sup- posed to contain chloroform is placed in a flask, one end of which is in a hot-water bath, the other communi- cating with a tubulure which is heated by a flame. The bath is raised to 160° while the tube is heated to redness. Chloroform vapour driven off by the heat of the water bath is split up as it traverses the tube, SELF-INDULGENCE IN ANAESTHETICS. 215 chlorine and hydrochloric acid being set free. The vapour reddens blue litmus, precipitates solutions of nitrate of silver, and liberates iodine from iodide of potassium which is tested in the usual way with starch paper. Self-Indulgence in Anesthetics. A "habit" has been unhappily created for most forms of anaesthetics. Thus, some persons become ad- dicted to self- administration of chloroform ; others to that of ether ; others again to that of chloral ; while cocaine also has its victims. It is not within the scope of the present work to describe the proper modes of treating the slaves of such unfortunate habits, but merely to draw attention to them, that medico-legal questions arising out of such depraved practices may receive due notice. Nitrous oxide gas, although pre- senting greater difficulties to self- administration, has yet led some weakly principled persons to practise self- induction of anaesthesia by its aid. The possibility of the subject of an inquiry — in cases of supposed suicide or murder by anaesthetics — being an habitue of one of them, should not be allowed to drop out of mind. Insanity following the Administration of Anesthetics. Among persons predisposed to insanity the adminis- tration of anaesthetics may, in certain rare cases, deter- mine an attack of mania. "It is the fact of the temporary disturbance of function, and not the means by which this is produced, which is of most impor- 216 INSANITY FOLLOWING ANESTHETICS. tance " (Savage). It is stated upon the high authority of Dr. Savage that chloroform, ether, nitrous oxide gas, and indeed any anaesthetic, is capable of so interfering with brain functions, that the delirium of commencing narcosis may become reproduced upon the patient's recovering from the sway of the anaesthetic, and may either persist as intractable mania or pass off after ex- pending its violence in a sharp but transient maniacal seizure. This liability was also noted in 1865 by various speakers at the meeting of the Superintendents of American Institutions for the Insane, at least as far as chloroform and ether were concerned. The possi- bility of such a result ensuing upon the administration of an anaesthetic to a person either highly neurotic or coming from a family in which insanity has been developed, should be borne in mind when such indivi- duals are examined with a view to ascertain their fitness for anaesthetisation. INDEX. ABDOMINAL surgery, 25, 169 A. C. E. mixture, 142 administration of, 143 after effects, 144 Martindale's, 143 Richardson's, 144 Accidents under anaesthetics, 171 Adenoids, post-nasal, anaesthetics, in removal of, 23, 166 Administration of nitrous oxide gas, 36 amylene, 133 chloroform, 109 ether, 84 ethideno, 136 hydrobromic ether, 138 mixtures (see Chapter VII.) Aged persons, choice of anaesthetics for, 19 Albuminuria after chloroform, 130 Alcohol for local anaesthesia, 197 Allis's ether inhaler, 82 Amylene, 131 Anaesthetics, abuse of, 215 Anaesthetising during sleep, 202 Apparatus, Clover's, for nitrous oxide gas, 42 Bert's, 63 Dudley Buxton's, 39 Hewitt's, 78 Apoplectic seizures, 179 Arterial disease, choice of anaesthe- tics in, 19 Artificial respiration, 176 Howard's method, 177 Silvester's method, 176 Asphyxia, under chloroform, 125 treatment of, 126 Asthmatics, choice of anaesthetics for, 18 Astigmatism after chloroform, 130 ""DEBT'S, Paul, method of giving -*— ' nitrous oxide gas, 63 Billroth's mixture, 142, 146 Bisulphide of carbon as a local anaes- thetic, 198 Brain surgery, anaesthetics in, 162 Brain tumours, ether contra-indi- cated, 70 Braine, Mr., on supplemental bags, 45 Bromide of ether (see Hydrobromic ether), 137 Brucine, 195 Buxton, Dudley, researches on ni- trous oxide, 33 apparatus for giving nitrous oxide, 39 chloroform inhaler, 113 gag, 47 mouth-props, 49 oral net spoon, 51 218 INDEX. CARBOLIC acid for local anaes- thesia, 197 Children, choice of anaesthetic for, 17 Chloral hydrate and chloroform mixed, as an anaesthetic, 151 Chloral hydrate and ether mixed, as an anaesthetic, 153 "Chloramyl," 150 Chloric ether, as an anaesthetic, 10 Chloroform, administration of, 109, 116, 121 after effects of, 129 and chloral hydrate, 151 and cocaine, 153 and dimethylacetal, 152 and morphine, 147 and tui'pentine, 152 chemistry of, 9-1 chloral and morphine, 152 dangers under, 122 death from, 213 detection of, in tissues, 214 discovery of, 94 impurities in, 96 inhalers, Clover's, 109 Dudley Buxton's, 113 Junker's, 112 Sansom's, 111 Snow's, 111 physiological action of, 97 post-mortem appearances, 213 preparation of, 94 recommended by Simpson, 10 tests for, 96 pimple inhaler, 115 with atropine and mor- phine, 148 with nitrite of amyl, 150 Choice of anaesthetic in general Bur- gory, 16 Clover's gas and ether inhaler, 41 c hlo roform inhaler, 109 Clover's ether inhaler, 74 (modified by Hewitt), 78 addition to, by Dr. Shepherd, 77 Cocaine, 180 accidents from, 193 after effects of, 193 and chloroform, 153 Coming's method of using, 188 iu dental surgery, 192 in major operations, 193 in operations on larynx and pharynx, 191 in ophthalmic practice, 190 methods of employment-, 187 physical properties, 180 physiological action of, 182 treatment of accidents under, 194 salts of, 181 when to be used, 190 Consciousness under anaesthetics, 200 Craniotomy, anaesthetics for, 16L Crimes, commission of, under anaes- thetics, 200 ~pvEATH under anaesthetics, 205 •*—' Dental surgery, anaesthetics in, 37, 107 Dentists, can they legally give anaes- thetics ? 2U9 Diet, before and after anaesthetics, 15 Dimethylacetal and chloroform, 152 Drumine, 195 ELECTRICITY (see Faradism), 198 Emphysematous persons, anaesthe- tics for, 18 INDEX. 219 Empyema, choice of anaesthetics for, 163 Epilepsy, treatment of fits under chloroform, 179 Ether, accidents under, 88 after effects, 91 and chloral mixed, as an anaes- thetic, 153 and morphine mixed, as an anaesthetic, 149 and nitrous oxide, 41, 154 by the rectum, 86 chemistry of, 67 coughing caused by, 90 dangers of, 88 death from, 212 detection of, in tissues, 213 discovery of, 07 for infants, 70 impurities of, 68 in collapse, 91 inhaler, Allis's, 83 Clover's, 74 cone, 81 Ormsby's, 81 Eendle's, 84 methods of administration, 73 physiological action, 70 poisoning by, 212 [212 post-mortem appearances after respiration, dangers to, 88 spray, 196 suggested as an anaesthetic by Faraday, 7 the heart, dangers to, under, 89 treatment of accidents under, 89 used as an auaesthetic by Morton, 9 vomiting caused by, 90 when inapplicable, 69 ^thidene chloride (dichloride), 134 administration, 136 Ethidene dangers of, 137 Eye, operations on, anaesthetics for } 24, 162 FARADISM, 198 Fontaine's, Dr., nitrous oxide chamber, 65 Foreign bodies in mouth, dangers from under nitrous oxide, 58, 171 in mouth, treatment, 59, 173 entrance of, into air passages under chloroform, 127 GAGS, 47 General Surgery, nitrous oxide in, 36 Glottis, spasm of, 173 Glycosuria after chloroform, 130 Govvan's gag, 48 "] |~EART, disease of, choice of -* — *- anaesthetics in, 20 Hewitt's gas and ether inhaler, 79 prop, 51 Hiccough, under ether, treatment of, 93 Howard's method of artificial respi- ration, 177 Hyderabad Commission, 13 Hydrobromic ether, accidents from, 140 administration of, 138 complications under, 140 discovery of, 137 physiological action of, 138 properties of, 137 treatment of, 141 when applicable, 139 220 INDEX. Hypnotism, 4 Hysterical seizures under anaesthe- tics, 128, 129, 179 INDULGENCE, self-, in anaesthe- tics, 215 Inhalers, 42, 75, 78, 79, 80, 81, 83, 84, 113,115, 116 Insanity caused by anaesthetics, 215 after chloroform, 130 ■JAUNDICE after chloroform, 130 " Jaws, operations on, anaesthe- tics for, 24, 69, 87, 163, 165 Junker's inhaler, 112 IZ IDNEY, diseases of, choice of i\. anaesthetics in, 19 Krohne and Sesemann's, feather re- spiration register, 115 feather respiration register cone, 116 LABOUR, administration of anaes- thetics during, 159 anaesthetics in, 155 reputed objections to anaesthe- tising in, 157 rules for anaesthetising in, 156 Laryngotomy, 175 Larynx, spasm of, 175 Linhart's mixture, 142, 144 Lister's, Sir Joseph (the Scotch) method of giving chloroform, 116 Local a naesthesia, 180 ~]\ JALPRAXIS in anaesthetising, Medico legal aspects of anaesthetics, 199 Methylene, 142, 144 administration of, 145 after effects of, 146 dangers of, 146 deaths under, 145 employment of, 145 Methods of employing nitrite of amyl and chloroform, 150 Miller's cocaine atomiser, 189 Morphine and chlorolorm, 147 and ether, 149 Mortality under anaesthetics, 207 Mouth-opener, 49 Mouth-props (dental), 49 Mutilation under anaesthetics, 203 NAUSEA and vomiting under ether, 92 Neurotic persons, choice of anaes- thetics for, 22 Nitrite of amyl and chloroform, 150 Nitrous oxide, administration, 36 applied to anaesthesia by Horace Wells, 6 discovery, 5 in general surgery, 36 Nitrous oxide gas, after effects, 59 chemistry of, 27 dangers of, 57 deaths under, 63, 211 duration of narcosis under, 55 in advanced age, 61 in dental surgery, 37 in heart disease, 62 in lung disease, 61 in phthisis, 61 in pregnancy, 60 INDEX. 221 Nitrous oxide gas physiological action of, 30 preparation of, 27 when to be used, 36 Nitrous oxide and ether, 41, 154 Nussbaum's mixture, 147 OBALINSKFS method, 153 Obstetric operations, after effects, anaesthetics in, 161 anaesthetics in, 160 practice, choice of anaes- thetics in, 25 Operations, choice of anaesthetic, for particulars, 23, et seq. Ophthalmic surgery (see Eye) Oral net spoon, 51 Ormsby's ether inhaler, 81 Oxygen and nitrous oxide mixed, Bert's method, 63 Oxygen and nitrous oxide mixed, Hewitt's method, 64 T)AKTURITION {see Labour) -*- Pericardial disease, choice of anaesthetic in, 21 Physiological action of amylene, 131 chloroform, 97 cocaine, 182 ether, 70 ethidene chloride, 135 hydrobromic ether, 138 nitrous oxide gas, 30 Pregnancy, choice of anaesthetic in, 22, 25, 153 Preparation of patient for anaesthe- tic, 14 Puerperal convulsions, chloroform in, 161 QUALIFICATION for adminis- tering anaesthetics, 209 EAPE, attempted under an anaes- thetics, 203 Rectal surgery, anaesthetics for, 170 etherisation, 86 Rhigolene, local anaesthetic, 19S Robbery, attempted, during anaes- thesia, 203 Respiratory centre, paralysis of, 173 Respiration, artificial, 176 dangers to under chloroform, 125 disturbances of under anaesthe- tics, 172 treatment of, 126 Responsibility in anaesthetising, 210 C DIPSON, Sir James Y., advocacy ^-' of chloroform, 94 Sansom's inhaler, Lll Self-indulgence in anaesthetics, 215 Snow's inhaler, 111 Staphyloraphy, anaesthetics in, 23, 164 Stertor under nitrous oxide gas, 55 Supplemental bag for nitrous oxide, 44 disadvantages of, 44 Sylvester's method of artificial re- spiration, 176 Syncope under chloroform, 122, 17S treatment, 123, 178 from shock, 179 222 INDEX. THORAX, operations on, anses- thetics for, 25, 16S Tongue, dangers from, under chloro- form, 126 excision of, anaesthetics for, 164 forceps, 53 treatment, 126 Tracheotomy, 1/4 Treatment of accidents during anaes- thesia, 173 Trelat's method, 152 Turpentine and chloroform, 152 "YTASCULAR feebleness, nitrous * oxide gas in, 61 Vienna mixture, 142, 144 Vomiting under chloroform, 129 "TTTELLER'S gag, 50 CATALOGUE No. 7. JULY, 1892. A CATALOGUE OF Books for Students. INCLUDING THE ? QUIZ-COMPENDS ? CONTENTS. PAGE PAGE New Series of Manuals, 2,3,4,=; Anatomy, . 6 Pathology, Histology, . . 11 Biology, . 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Containing many new Prescriptions, a list of over 50 Formulae, conforming to the U. S. Pharma- copoeia, and Directions for making Artificial Human Milk, for the Artificial Digestion of Milk, etc. Illus. " The merits of the book are many. Aside from the praiseworthy work of the printer and binder, which gives us a print and page that delights the eye, there is the added charm of a style of writ- ing that is not wearisome, that makes its statements clearly and forcibly, and that knows when to stop when it has said enough. The insertion of typical temperature charts certainly enhances the value of the book. It is rare, too, to find in anj' text-book so many topics treated of. All the rarer and out-of-the-way diseases are given consideration. This we commend. It makes the work valuable." — Archives of Pedriatics , July , /Sqo. " The author has avoided the not uncommon error of writing a book on general medicine and labeling it ' Diseases of Children,' but has steadily kept in view the diseases which seemed to be incidental to childhood, or such points in disease as appear to be so peculiar to or pronounced in children as to justify insistence upon them. * * * A safe and reliable guide, and in many ways admirably adapted to the wants of the student and practitioner." — American Journal of Medical Science. " Thoroughly individual, original and earnest, the work evi- dently of a close observer and an independent thinker, this book, though small, as a handbook or compendium is by no means made up of bare outlines or standard facts." — The Therapeutic Ga- zette . " As it is said of some men, so it might be said of some books, that they are 'born to greatness.' This new volume has, we believe, a mission, particularly in the hands of the younger members of the profession. In these days of prolixity in medical literature, it is refreshing to meet with an author who knows both what to say and when he has said it. The work of Dr. Goodhart (admirably conformed, by Dr. Starr, to meet American require- ments) is the nearest approach to clinical teaching without the actual presence of clinical material that we have yet seen." — New York Medical Record. Prioe of each Book, Cloth, $3.00 ; Leather, $3.50. THE NEW SERIES OF MANUALS. No. 6. PRACTICAL THERAPEUTICS. FOURTH EDITION, WITH AN INDEX OF DISEASES. Practical Therapeutics, considered with reference to Articles of the Materia Medica. Containing, also, an Index of Diseases, with a list of the Medicines applicable as Remedies. By Edward John Waring, m.d., f.r.c.p. Fourth Edition. Rewritten and Re- vised by Dudley W. Buxton, m.d., Asst. to the Prof, of Medicine at University College Hospital. " We wish a copy could be put in the hands of every Student or Practitioner in the country. In our estimation, it is the best book of the kind ever written." — N. Y. Medical Journal . " Dr. Waring's Therapeutics has long been known as one of the most thorough and valuable of medical works. The amount of actual intellectual labor it represents is immense. . . . An in- dex of diseases, with the remedies appropriate for their treatment, closes the volume." — Boston Medical and Surgical Reporter. " The plan of this work is an admirable one, and one well calcu- lated to meet the wants of busy practitioners. There is a remark- able amount of information, accompanied with judicious comments, imparted in a concise yet agreeable style." — Medical Record. No. 7. MEDICAL JURISPRUDENCE AND TOXICOLOGY. THIRD REVISED EDITION. By John J. Reese, m.d., Professor of Medical Jurispru- dence and Toxicology in the University of Pennsyl- vania ; President of the Medical Jurisprudence Society of Phila. ; Third Edition, Revised and Enlarged. "This admirable text-book." — Amer.Jour. of Med. Sciences. " We lay this volume aside, after a careful perusal of its pages, with the profound impression that it should be in the hands of every doctor and lawyer. It fully meets the wants of all students He has succeeded in admirably condensing into a handy volume all the essential points." — Cincinnati Lancet and Clinic. " The book before us will, we think, be found to answer the ex- pectations of the student or practitioner seeking a manual of juris- prudence, and the call for a second edition is a nattering testimony to the value of the author's present effort. The medical portion of this volume seems to be uniformly excellent, leaving little for adverse criticism. The information on the subject matter treated has been carefully compiled, in accordance with recent knowledge. The toxicological portion appears specially excellent. Of that por- tion of the work treating of the legal relations of the practitioner and medical witness, we can express a generally favorable ver- dict." — Physician and Surgeon, Ann Arbor, Mich. Price of each Book, Cfoth, $3,00; Leather, $3.50. 6 STUDENTS' TEXT-BOOKS AND MANUALS. ANATOMY. Macalister's Human Anatomy. 816 Illustrations. A new Text-book for Students and Practitioners, Systematic and Topo- graphical, including the Embryology, Histology and Morphology of Man. With special reference to the requirements of Practical Surgery and Medicine. With 816 Illustrations, 400 of which are original. Octavo. Cloth, 7.50; Leather, 8.50 Ballou's Veterinary Anatomy and Physiology. Illustrated. By Wm. R. Ballou, m.d., Professor of Equine Anatomy at New York College of Veterinary Surgeons. 29 graphic Illustrations. i2mo. Cloth, 1.00; Interleaved for notes, 1.25 Holden's Anatomy. A manual of Dissection of the Human Body. Fifth Edition. Enlarged, with Marginal References and over 200 Illustrations. Octavo. Bound in Oilcloth, for the Dissecting Room, $4.50. " No student of Anatomy can take up this book without being pleased and instructed. Its Diagrams are original, striking and suggestive, giving more at a glance than pages of text description. * * * The text matches the illustrations in directness of prac- tical application and clearness of detail." — New York Medical Record. Holden's Human Osteology. Comprising a Description of the Bones, with Colored Delineations of the Attachments of the Muscles. The General and Microscopical Structure of Bone and its Development. With Lithographic Plates and Numerous Illus- trations. Seventh Edition. 8vo. Cloth, 6.00 Holden's Landmarks, Medical and Surgical. 4th ed. Go., 1.25 Heath's Practical Anatomy. Sixth London Edition. 24 Col- ored Plates, and nearly 300 other Illustrations. Cloth, 5.00 Potter's Compend of Anatomy. Fifth Edition. Enlarged. 16 Lithographic Plates. 117 Illustrations. See Page 14. Cloth, 1. 00; Interleaved for Notes, 1.25 CHEMISTRY. Bartley's Medical Chemistry. Second Edition. A text-book prepared specially for Medical, Pharmaceutical and Dental Stu- dents. With 50 Illustrations, Plate of Absorption Spectra and Glossary of Chemical Terms. Revised and Enlarged. Cloth,2.so Trimble. Practical and Analytical Chemistry. A Course in Chemical Analysis, by Henry Trimble, Prof, of Analytical Chem- istry in the Phila. College of Pharmacy. Illustrated. Fourth Edition, Enlarged. 8vo. Cloth, 1.50 Mf&~ See Paget 2 to j for list 0/ Students' Manuals . STUDENTS' TEXT-BOOKS AND MANUALS. 7 Chemistry : — Continued. Bloxam's Chemistry, Inorganic and Organic, with Experiments. Seventh Edition. Enlarged and Rewritten. 281 Illustrations. Cloth, 4.50 ; Leather, 5.50 Richter's Inorganic Chemistry. A text-book for Students. Third American, from Fifth German Edition. Translated by Prof. Edgar F. Smith, ph.d. 89 Wood Engravings and Colored Plate of Spectra. Cloth, 2.00 Richter's Organic Chemistry, or Chemistry of the Carbon Compounds. Illustrated. Second Edition. Cloth, 4.50 Symonds. Manual of Chemistry, for the special use of Medi- cal Students. By Brandreth Symonds, a.m., m.d., Asst. Physician Roosevelt Hospital, Out- Patient Department ; Attend- ing Physician Northwestern Dispensary, New York. 12010. Cloth, 2.00 Leffmann's Compend of Chemistry. Inorganic and Organic. Including Urinary Analysis. Third Edition. Revised. Cloth, 1. 00; Interleaved for Notes, 1.25 Leffmann and Beam. Progressive Exercises in Practical Chemistry. i2mo. Illustrated. Cloth, 1.00 Muter. Practical and Analytical Chemistry. Fourth Edi- tion. Revised, to meet the requirements of American Medical Colleges, by Prof. C. C. Hamilton. Illustrated. Cloth, 2.00 Holland. The Urine, Common Poisons, and Milk Analysis, Chemical and Microscopical. For Laboratory Use. Fourth Edition, Enlarged. Illustrated. Cloth, 1.00 Van Niiys. Urine Analysis. Illus. Cloth, 2.00 ■Wolff's Applied Medical Chemistry. By Lawrence Wolff, m.d., Dem. of Chemistry in Jefferson Medical College. Clo., 1.00 CHILDREN. Goodhart and Starr. The Diseases of Children. Second Edition. By J. F. Goodhart, m.d., Physician to the Evelina Hospital for Children; Assistant Physician to Guy's Hospital, London. Revised and Edited by Louis Starr, m.d., Clinical Professor of Diseases of Children in the Hospital of the Univer- sity of Pennsylvania; Physician to the Children's Hospital, Philadelphia. Containing many Prescriptions and Formulae, conforming to the U. S. Pharmacopoeia, Directions for making Artificial Human Milk, for the Artificial Digestion of Milk, etc. Illustrated. Cloth, 3.00; Leather, 3.50 Hatfield. Diseases of Children. By M. P. Hatfield, m.d., Professor of Diseases of Children, Chicago Medical College. Colored Plate. i2mo. Cloth, 1.00; Interleaved, 1.25 See pages 14 and IS for list of ? Quiz- Comp ends? 8 STUDENTS' TEXT-BOOKS AND MANUALS. Children: — Continued. Starr. Diseases of the Digestive Organs in Infancy and Childhood. With chapters on the Investigation of Disease, and on the General Management of Children. By Louis Starr, m.d., Clinical Professor of Diseases of Children in the Univer- sity of Pennsylvania. Illus. Second Edition. Cloth, 2.25 DENTISTRY. Fillebrown. Operative Dentistry. 330 Illus. Cloth, 2.50 Flagg's Plastics and Plastic Filling. 4th Ed. Cloth, 4.00 Gorgas. Dental Medicine. Fourth Edition. Cloth, 3.50 Harris. Principles and Practice of Dentistry. Including Anatomy, Physiology, Pathology, Therapeutics, Dental Surgery and Mechanism. Twelfth Edition. Revised and enlarged by Professor Gorgas. 1028 Illustrations. Cloth, 7.00 ; Leather, 8.00 Richardson's Mechanical Dentistry. Fifth Edition. 569 Illustrations. 8vo. Cloth, 4.50; Leather, 5.50 Sewill. Dental Surgery. 200 Illustrations. 3d Ed. Clo., 3.00 Taft's Operative Dentistry. Dental Students and Practitioners. Fourth Edition. 100 Illustrations. Cloth, 4.25 ; Leather, 5.00 Talbot. Irregularities of the Teeth, and their Treatment. Illustrated. 8vo. Second Edition. " Cloth, 3.00 Tomes' Dental Anatomy. Third Ed. "191 Illus. Cloth, 4.00 Tomes' Dental Surgery. 3d Edition. 292 Illus. Cloth, 5.00 Warren. Compend of Dental Pathology and Dental Medi- cine. Illustrated. Cloth, 1. 00; Interleaved, 1.25 DICTIONARIES. Gould's New Medical Dictionary. Containing the Definition and Pronunciation of all words in Medicine, with many useful Tables etc. J^ Dark Leather, 3.25 ; y 2 Mor., Thumb Index, 4.25 Harris' Dictionary of Dentistry. Fifth Edition. Completely revised by Prof. Gorgas. Cloth, 5.00; Leather, 6.00 Cleaveland's Pronouncing Pocket Medical Lexicon. Small pocket size. Cloth, red edges .75 ; pocket-book style, 1.00 Longley 's Pocket Dictionary. The Student's Medical Lexicon, giving Definition and Pronunciation, with an Appendix giving Abbreviations used in Prescriptions, Metric Scale of Doses, etc. 241110. Cloth, 1. 00; pocket-book style, 1.25 EYE. Hartridge on Refraction. 5th Edition. Illus. Cloth, 2.00 Swanzy. Diseases of the Eye and their Treatment. 158 Illustrations. Fourth Edition. Cloth, 3 00 Fox and Gould. Compend of Diseases of the Eye and Refraction. 2d Ed. Enlarged. 71 Illus. 39 Formulae. Cloth, 1. 00; Interleaved for Notes, 1.25 4&- See Pares 2 to 5 for list 0/ Students' Manuals. STUDENTS' TEXT-BOOKS AND MANUALS. 9 ELECTRICITY. Bigelow. Plain Talks on Medical Electricity. Cloth, i.oo Mason's Compend of Medical Electricity. Cloth, i.oo Steavenson and Jones. Medical Electricity. A Practical Handbook. Just Ready. Illustrated. i2mo. Cloth, 2.50 HYGIENE. Coplin's Practical Hygiene. By W. M. L. Coplin, Adjunct Professor of Hygiene, Jefferson Medical College, Philadelphia. Illustrated. In Press. Parkes' (Ed. A.) Practical Hygiene. Seventh Edition, en- larged. Illustrated. 8vo. Cloth, 4.50 Parkes' (L. C.) Manual of Hygiene and Public Health. Second Edition. i2mo. Cloth, 2.50 Wilson's Handbook of Hygiene and Sanitary Science. Seventh Edition. Revised and Illustrated. Cloth, 3.25 MATERIA MEDICA AND THERAPEUTICS. Potter's Compend of Materia Medica, Therapeutics and Prescription Writing. Fifth Edition, revised and improved. See Page 15. Cloth, 1.00; Interleaved for Notes, 1.25 Biddle's Materia Medica. Eleventh Edition. By the late John B. Biddle, m.d. Revised by Clement Biddle, m.d., 8vo, illustrated. Cloth, 4.25; Leather, 5.00 Potter. Handbook of Materia Medica, Pharmacy and Therapeutics. Including Action of Medicines, Special Thera- peutics, Pharmacology, etc. By Saml. O. L. Potter, m.d., m.r.c.p. (Lond.), Professor of the Practice of Medicine in Cooper Medical College, San Francisco. Third Revised and Enlarged Edition. 8vo. Cloth, 4.00; Leather, 5.00 White and Wilcox. Materia Medica, Pharmacy, Phar- macology, and Therapeutics. A Handbook for Students. By Wm. Hale White, m.d., p.r.c.p., etc., Physician to and Lecturer on Materia Medica, Guy's Hospital. Revised by Reynold W. Wilcox, m.d., Professor of Clinical Medicine at the New York Post Graduate Medical School, Assistant Physician Bellevue Hospital, etc. American Edition. In Press. MEDICAL JURISPRUDENCE. Reese. A Text-book of Medical Jurisprudence and Toxi- cology. By John J. Reese, m.d., Professor of Medical Juris- prudence and Toxicology in the Medical Department of the University of Pennsylvania ; President of the Medical Juris- prudence Society of Philadelphia ; Physician to St. Joseph's Hospital ; Corresponding Member of The New York Medico- legal Society. Third Edition. Cloth, 3.00 ; Leather, 3.50 £&• See pages 14 and 13 for list of ? Quiz- Comp ends f 10 STUDENTS' TEXT-BOOKS AND MANUALS. NERVOUS DISEASES. Gowers. Manual of Diseases of the Nervous System. A Complete Text-book. By William R. Gowers, m.d., Prof. Clinical Medicine, University College, London. Physician to National Hospital for the Paralyzed and Epileptic. Second Edition. Revised, Enlarged, and in many parts Rewritten. With many new Illustrations. Octavo. Vol. I. Diseases of the Nerves and Spinal Cord. 616 pages. Cloth, 3.50 Vol. II. Diseases of the Brain and Cranial Nerves. General and Functional Diseases. Nearly Ready. Ormerod. Diseases of Nervous System, Student's Guide to. By J. A. Ormerod, m.d., Oxon.,F.R.c.p. (London), Member Path- ological, Clinical, Ophthamological, and Neurological Societies, Physician to National Hospital for Paralyzed and Epileptic and to City of London Hospital for Diseases of the Chest, Demon- strator of Morbid Anatomy, St. Bartholomew's Hospital, etc. With 75 Wood Engravings. Cloth, 2.00 OBSTETRICS AND GYNECOLOGY. Davis. A Manual of Obstetrics. By Edw. P. Davis, Dem- onstrator of Obstetrics, Jefferson Medical College, Philadelphia. Colored Plates, and 130 other Illustrations. i2mo. Cloth, 2.00 Byford. Diseases of Women. The Practice of Medicine and Surgery, zs applied to the Diseases and Accidents Incident to Women. By W. H. Byford, a.m., m.d., Professor of Gynaecology in Rush Medical College and of Obstetrics in the Woman's Med- ical College, etc., and Henry T. Byford, m.d., Surgeon to the Woman's Hospital of Chicago. Fourth Edition. Revised and Enlarged. 306 Illustrations, over 100 of which are original. Octavo. 832 pages. Cloth, 5.00; Leather, 6.00 Lewers' Diseases of Women. A Practical Text-book. 139 Illustrations. Second Edition. Cloth, 2.50 Parvin's Winckel's Diseases of Women. Second Edition. Including a Section on Diseases of the Bladder and Urethra. 150 Illus. Revised. See page 3. Cloth, 3.00; Leather, 3.50 Morris. Compend of Gynaecology. Illustrated. Cloth, 1.00 Winckel's Obstetrics. A Text-book on Midwifery, includ- ing the Diseases of Childbed. By Dr. F. Winckel, Professor of Gynaecology, and Director of the Royal University Clinic for Women, in Munich. Authorized Translation, by J. Clifton Edgar, m.d., Lecturer on Obstetrics, University Medical Col- lege, New York, with nearly 200 handsome Illustrations, the majority of which are original. 8vo. Cloth, 6.00; Leather, 7.00 Landis' Compend of Obstetrics. Illustrated. 4th edition, enlarged. Cloth, 1.00; Interleaved for Notes, 1.25 Galabin's Midwifery. By A. Lewis Galabin, m.d., f.r.c.p. 227 Illustrations. See page 3. Cloth, 3.00; Leather, 3.50 t&~ See Paget 2 to 5 for list of New Manuals. STUDENTS' TEXT-BOOKS AND MANUALS. 11 PATHOLOGY. HISTOLOGY. BIOLOGY. Bowlby. Surgical Pathology and Morbid Anatomy, for Students. 135 Illustrations. i2mo. Cloth, 2.00 Davis* Elementary Biology. Illustrated. Cloth, 4.00 Gilliam's Essentials of Pathology. A Handbook for Students. 47 Illustrations. i2mo. Cloth, 2.00 *#* The object of this book is to unfold to the beginner the funda- mentals of pathology in a plain, practical way, and by bringing them within easy comprehension to increase his interest in the study of the subject. Gibbes' Practical Histology and Pathology. Third Edition. Enlarged. i2mo. Cloth, 1.75 Virchow's Post-Mortem Examinations. 3d Ed. Cloth, 1.00 PHYSICAL DIAGNOSIS. Fenwick. Student's Guide to Physical Diagnosis. 7th Edition. 117 Illustrations. i2mo. Cloth, 2.25 Tyson's Student's Handbook of Physical Diagnosis. Illus- trated. 12D10. Cloth, 1.25 PHYSIOLOGY. Yeo's Physiology. Fifth Edition. The most Popular Stu- dents' Book. By Gerald F. Yeo, m.d., f.r.c.s., Professor of Physiology in King's College, London. Small Octavo. 758 pages. 321 carefully printed Illustrations. With a Full Glossary and Index. See Page 3. Cloth, 3.00; Leather, 3.50 Brubaker's Compend of Physiology. Illustrated. Sixth Edition. Cloth, 1. 00; Interleaved for Notes, 1.25 Stirling. Practical Physiology, including Chemical and Ex- perimental Physiology. 142 Illustrations. Cloth, 2.25 Kirke's Physiology. New 12th Ed. Thoroughly Revised and Enlarged. 502 Illustrations. Cloth, 4.00; Leather, 5.00 Landois' Human Physiology. Including Histology and Micro- scopical Anatomy, and with special reference to Practical Medi- cine. Fourth Edition. Translated and Edited by Prof. Stirling. 845 Illustrations. Cloth, 7.00 ; Leather, 8.00 " With this Text-book at his command, no student could fail in his examination." — Lancet. Sanderson's Physiological Laboratory. Being Practical Ex- ercises for the Student. 350 Illustrations. 8vo. Cloth, 5.00 PRACTICE. Taylor. Practice of Medicine. A Manual. By Frederick Taylor, m.d., Physician to, and Lecturer on Medicine at, Guy's Hospital, London ; Physician to Evelina Hospital for Sick Chil- dren, and Examiner in Materia Medica and Pharmaceutical Chemistry, University of London. Cloth, 4.00; Leather, 5.00 >|f$ a ' See pages 14 and IS for list 0/ ? Quiz-Compends f 12 STUDENTS' TEXT-BOOKS AND MANUALS. Practice : — Continued. Roberts' Practice. New Revised Edition. A Handbook of the Theory and Practice of Medicine. By Frederick T. Roberts, m.d., m.r.c.p., Professor of Clinical Medicine and Therapeutics in University College Hospital, London. Seventh Edition. Octavo. Cloth, 5.50 ; Sheep, 6.50 Hughes. Compend of the Practice of Medicine. 4th Edi- tion. Two parts, each, Cloth, 1.00; Interleaved for Notes, 1.25 Part i. — Continued, Eruptive and Periodical Fevers, Diseases of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, Kidneys, etc., and General Diseases, etc. Part ii. — Diseases of the Respiratory System, Circulatory System and Nervous System ; Diseases of the Blood, etc. Physicians' Edition. Fourth Edition. Including a Section on Skin Diseases. With Index. 1 vol. Full Morocco, Gilt, 2.50 From John A. Robinson, M.D., Assistant to Chair of Clinical Medicine ,now Lecturer on Materia Medica, Rush Medical Col- lege, Chicago. " Meets with my hearty approbation as a substitute for the ordinary note books almost universally used by medical students. It is concise, accurate, well arranged and lucid, . . . just the thing for students to use while studying physical diagnosis and the more practical departments of medicine." PRESCRIPTION BOOKS. Wythe's Dose and Symptom Book. Containing the Doses and Uses of all the principal Articles of the Materia Medica, etc. Seventeenth Edition. Completely Revised and Rewritten. Just Ready. 32010. Cloth, 1. 00; Pocket-book style, 1.25 Pereira's Physician's Prescription Book. Containing Lists of Terms, Phrases, Contractions and Abbreviations used in Prescriptions Explanatory Notes, Grammatical Construction ot Prescriptions, etc., etc. By Professor Jonathan Pereira, m.d. Sixteenth Edition. 32010. Cloth, 1. 00; Pocket-book style, 1.25 PHARMACY. Stewart's Compend of Pharmacy. Based upon Remington's Text-book of Pharmacy. Third Edition, Revised. With new Tables, Index, Etc. Cloth, 1.00 ; Interleaved for Notes, 1.25 Robinson. Latin Grammar of Pharmacy and Medicine. By H. D. Robinson, ph.d., Professor of Latin Language and Literature, University of Kansas, Lawrence. With an Intro- duction by L. E. Sayre, ph.g., Professor of Pharmacy in, and Dean of, the Dept. of Pharmacy, University of Kansas. i2mo. Cloth, 2.00 SKIN DISEASES. Anderson, (McCall) Skin Diseases. A complete Text-book, with Colored Plates and numerous Wood Engravings. 8vo. Cloth, 4.50; Leather, 5.50 Van Harlingen on Skin Diseases. A Handbook of the Dis- eases of the Skin, their Diagnosis and Treatment (arranged alpha- betically). By Arthur Van Harlingen, m.d.. Clinical Lecturer on Dermatology, Jefferson Medical College ; Prof, of Diseases of the Skin in the Philadelphia Polyclinic. 2d Edition. Enlarged. With colored and other plates and illustrations. i2mo. Cloth, 2.50 J1&- See pages 2 to 5 for list 0/ New Manuals. STUDENTS' TEXT-BOOKS AND MANUALS. 13 SURGERY AND BANDAGING. Moullin's Surgery. 500 Illustrations (some colored), 200 of which are original. Cloth, net 7.00; Leather, net 8.00 Jacobson. Operations in Surgery. A Systematic Handbook for Physicians, Students and Hospital Surgeons. By W. H. A. Jacobson, b.a. Oxon., f.r.c.s. Eng. ; Ass't Surgeon Guy's Hos- pital ; Surgeon at Royal Hospital for Children and Women, etc. 199 Illustrations. 1006 pages. 8vo. Cloth. 5.00; Leather, 6.00 Heath's Minor Surgery, and Bandaging. Ninth Edition. 142 Illustrations. 60 Formulae and Diet Lists. Cloth, 2.00 Horwitz's Compend of Surgery, Minor Surgery and Bandaging, Amputations, Fractures, Dislocations, Surgical Diseases, and the Latest Antiseptic Rules, etc., with Differential Diagnosis and Treatment. By Orville Hokwitz, b.s., m.d., Demonstrator of Surgery, Jefferson Medical College. 4th edition. Enlarged and Rearranged. 136 Illustrations and 84 Formulae. i2mo. Cloth, 1.00; Interleaved for the addition of Notes, 1.25 *#* The new Section on Bandaging and Surgical Dressings, con- sists of 32 Pages and 41 Illustrations. Every Bandage of any importance is figured. This, with the Section on Ligation oi Arteries, forms an ample Text-book for the Surgical Laboratory. Walsham. Manual of Practical Surgery. Third Edition. By Wm, J. Walsham, m.d., f.r.c.s., Asst. Surg, to, and Dem of* Practical Surg, in, St. Bartholomew's Hospital ; Surgeon to Metropolitan Free Hospital, London. With 318 Engravings. See Page 2. Cloth, 3.00; Leather, 3.50 URINE, URINARY ORGANS, ETC. Holland. The Urine, and Common Poisons and The Milk. Chemical and Microscopical, for Laboratory Use. Illus- trated. Fourth Edition. 12010. Interleaved. Cloth, 1.00 Ralfe. Kidney Diseases and Urinary Derangements. 42 Illus- trations. i2mo. 572 pages. Cloth, 2.75 Marshall and Smith. On the Urine. The Chemical Analysis ot the Urine. By John Marshall, m.d., Chemical Laboratory, Univ. of Penna; and Prof. E. F. Smith, ph. d. Col. Plates. Cloth, 1. 00 Memminger. Diagnosis by the Urine. Illustrated. Cloth, 1. 00 Tyson. On the Urine. A Practical Guide to the Examination of Urine. With Colored Plates and Wood Engravings. 7th Ed. Enlarged. i2mo. Cloth, 1.50 Van Niiys, Urine Analysis. Illus. Cloth, 2.00 VENEREAL DISEASES. Hill and Cooper. Student's Manual of Venereal Diseases, with Formulas. Fourth Edition. i2mo. Cloth, 1.00 See pages 14 and if for list of f Quiz- Cotnpends f NEW AND REVISED EDITIONS. PQUIZ-COMPENDS? The Best Compends for Students' Use in the Quiz Class, and when Pre- paring for Examinations. Compiled in accordance with the latest teachings of promi- nent lecturers and the most popular Text-books. They form a most complete, practical and exhaustive set of manuals, containing information nowhere else col- lected in such a condensed, practical shape. Thoroughly up to the times in every respect, containing many new prescriptions and formulae, and over two hundred and fifty illustrations, many of which have been drawn and engraved specially for this series. The authors have had large experience as quiz-masters and attaches of colleges, with exceptional opportunities for noting the most recent advances and methods. Cloth, each $1.00. Interleaved for Notes, $1.25. No. 1. HUMAN ANATOMY, "Based upon Gray." Fifth Enlarged Edition, including Visceral Anatomy, formerly published separately. 16 Lithograph Plates, New Tables and 117 other Illustrations. By Samuel O. L. Potter, m.a., m.d., m.r.c.p. (Lond.), late A. A. Surgeon U. S. Army, Professor of Practice, Cooper Medical College, San Fran- cisco. Nos. 2 and 3. PRACTICE OF MEDICINE. Fourth Edi- tion. By Daniel E. Hughes, m.d., Demonstrator of Clinical Medicine in Jefferson Medical College, Philadelphia. In two parts. Part I. — Continued, Eruptive and Periodical Fevers, Diseases of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, Kidneys, etc. (including Tests for Urine), General Diseases, etc. Part II. — Diseases of the Respiratory System (including Phy- sical Diagnosis), Circulatory System and Nervous System; Dis- eases of the Blood, etc. *** These little books can be regarded as a full set of notes upon the Practice of Medicine, containing the Synonyms, Definitions, Causes, Symptoms, Prognosis, Diagnosis, Treatment, etc., of each disease, and including a number of prescriptions hitherto unpub- lished. No. 4. PHYSIOLOGY, including Embryology. Sixth Edition. By Albert P. Brubaker, m.d., Prof, of Physiology, Penn'a College of Dental Surgery ; Demonstrator of Physiology in Jefferson Medical College, Philadelphia. Revised, Enlarged, with new Illustrations. No. 5. OBSTETRICS. Illustrated. Fourth Edition; By Henry G. Landis, m.d., Prof, of Obstetrics and Diseases of Women, in Starling Medical College, Columbus, O. Revised Edition. New Illustrations. BLAKISTON'S ? QUIZ-COMPENDS ? No. 6. MATERIA MEDICA, THERAPEUTICS AND PRESCRIPTION WRITING. Fifth Revised Edition. With especial Reference to the Physiological Action of Drugs, and a complete article on Prescription Writing. Based on the Last Revision of the U. S. Pharmacopoeia, and including many unofficinal remedies. By Samuel O. L. Potter, m.a., m.d., m.r.c.p. (Lond.), late A. A. Surg. U. S. Army ; Prof, of Practice, Cooper Medical College, San Francisco. Improved and Enlarged, with Index. No. 7. GYNAECOLOGY. A Compend of Diseases of Women. By Henry Morris, m.d., Demonstrator of Obstetrics, Jefferson Medical College, Philadelphia. 45 Illustrations. No. 8. DISEASES OF THE EYE AND REFRACTION, including Treatment and Surgery. By L. Webster Fox, m.d., Chief Clinical Assistant Ophthalmological Dept., Jefferson Med- ical College, etc., and Geo. M. Gould, m.d. 71 Illustrations, 39 Formulae. Second Enlarged and improved Edition. Index. No. 9. SURGERY, Minor Surgery and Bandaging. Illus- trated. Fourth Edition. Including Fractures, Wounds, Dislocations, Sprains, Amputations and other operations ; Inflam- mation, Suppuration, Ulcers, Syphilis, Tumors, Shock, etc. Diseases of the Spine, Ear, Bladder, Testicles, Anus, and other Surgical Diseases. By Orville Horwitz, a.m., m.d., Demonstrator of Surgery, Jefferson Medical College. Revised and Enlarged. 84 Formulas and 136 Illustrations. No. 10. CHEMISTRY. Inorganic and Organic. For Medical and Dental Students. Including Urinary Analysis and Medical Chemistry. By Henry Leffmann, m.d., Prof, of Chemistry in Penn'a College of Dental Surgery-, Phila. Third Edition, Revised and Rewritten, with Index. No. 11. PHARMACY. Based upon " Remington's Text-book of Pharmacy." By F. E. Stewart, m.d., ph. g., Quiz-Master at Philadelphia College of Pharmacy. Third Edition, Revised. No. 12. VETERINARY ANATOMY AND PHYSIOL- OGY. 29 Illustrations. By Wm, R. Ballou, m.d., Prof, of Equine Anatomy at N. Y. College of Veterinary Surgeons. No. 13. DENTAL PATHOLOGY AND DENTAL MEDI- CINE. Containing all the most noteworthy points of interest to the Dental student. By Geo. W. Warren, d.d.s., Clinical Chief, Penn'a College of Dental Surgery, Philadelphia. Illus. No. 14. DISEASES OF CHILDREN. By Dr. Marcus P. Hatfield, Prof, of Diseases of Children, Chicago Medical College. Colored Plate. Bound in Cloth, $1. Interleaved, for the Addition of Notes, $1.25. J5^ I> These books are constantly revised to keep up with the latest teachings and discoveries, so that they contain all the new methods and principles. No series of books are so complete in detail, concise in language, or so well printed and bound. Each one forms a complete set of notes tipon the subject under consideration. Illustrated Descriptive Circular Free. JUST PUBLISHED. GOULD'S NEW Medical Dictionary compact. CONCISE. PRACTICAL. ACCURATE. COMPREHENSIVE UP TO DATE. It contains Tables of the Arteries, Bacilli, Gan- glia, Leucomaines, Micrococci, Muscles, Nerves, Plexuses, Ptomaines, etc., etc., that will be found of great use to the student. Small octavo, 520 pages, Half-Dark Leather, . #3.25 With Thumb Index, Half Morocco, marbled edges, 4.25 From J. M. DaCOSTA, M. D., Professor of Practice and Clinical Medicine, Jefferson Medical College, Philadelphia. "I find it an excellent work, doing credit to the learning and discrimination 0/ the author." *** Sample Pages free. A COLUMBIA UNIVERSITY This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE 1 C2B638IM50 B98 1892 COLUMBIA UNIVERSITY LIBRARIES Ihsl.stx) RD 81 B98 1892 C.1 Anaesthetics. 2002284677