COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD Dn«^ ^„HX64069125 RD81 T84 1 896 Artificial anaesthes Columbia Winibtv^it^ in tfje €it^ of j^eto Pork ^cftool of Bental anb C^ral ^utgerp 3^eferente Eilirarp -oo o ARTIFICIAL ANiESTHESIA. A MANUAL OF ANESTHETIC AGENTS AND THEIR EMPLOYMENT IN THE TEEATMENT OF DISEASE. BY LAURENCE TURNBULL, M.D., Ph.G., AURAL Surgeon to the Jefferson Medical College Hospital, Phila- delphia ; Late Honorary President to the Otological Subsec- tion OF THE British Medical Association, and of the Section of Laryngology and Otology of the American Medical Association. FOURTE EDITION. REVISED AND ENLARGED. WITH ILLUSTRATIONS. PHILADELPHIA : P. BLAKISTON^, SO^ & CO., No. 1012 Walnut Street. 1896. Entered according to Act of Congress, in the year 1896, by LAURENCE TURNBULL, M.D., In the office of the Librarian of Congress. All rights reserved. In 1847 the late Dr. Oliver Wendell Holmes created the words artificial ausesthesia, and wrote: "Nature herself is working out the primal curse which doomed the tenderest of her creatures to the sharpest of her trials ; but the fierce extremity of suffering has been steeped in the waters of forgetfulness, and the deepest furrow in the knotted brow of agony has been smoothed forever." " If America had contributed nothing more to the stock of human happiness than anaesthetics, the world would owe her an everlasting debt of gratitude." — The late Professor Samuel D. Gross. Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/artificialanstOOturn PREFACE TO THE FOURTH EDITION. Haying been informed by m.v publishers that it would be necessary to issue a Fourth edition of my " Manual of Anaes- thetics " this j-ear (1896), it has been my endeavor to bring the Tvhole subject of artificial anaesthesia and anaesthetics up to the present time, being careful to obtain all the most notable dis- coveries of the last six years. I have examined all the important works published during the interval, testing in almost every instance the new anaes- thetics, or modifications of the old, on mj^self or my friends, also the mechanical contrivances for their administration. In visiting Europe in 1892-3, met and acted with the Com- mittee on Anaesthetics of the British Medical Association at the meetings at Nottingham and London — at the former pre- sented a paper of statistics on the subject of anaesthetics. By special invitation — visited the Universities of Edinburgh and Glasgow to witness the Scotch method of administering chloro- form, a careful and conscientious statement of which I have endeavored to give. It is somewhat remarkable that the fourth edition of this book should be issued on the fiftieth anniversary of the dis- covery and introduction of ether (October 6, 1846). It is the one sj'stemic anaesthetic which has proved, during all these years, the most available and the most free from danger. Numerous valuable anaesthetics have been brought to the knowledge of the profession, but all had to gi\e place to ether. A careful study of its constituents and its mode of preparation, with a careful trial of its physiological efi'ects, have proved its value. Above all, its use in two hospitals with which we have been connected for a long time has never resulted in a death, VI PREFACE TO THE FOURTH EDITION. either in our own practice or in those operations in which we have assisted. Careless and inconsiderate individuals now and then bring discredit upon it, but in the majority of cases they should be blamed — and not the anaesthetic. No one should be allowed to administer any angesthetic without a cer- tain amount of tuition, and no one should receive a diploma until he has shown a knowledge of the chemical composition^ and physiological action of such anaesthetics. Efforts have been made to bring discredit upon ether. The investigations and experiments of Drs. J. Chalmers DaCosta, H. C. Wood and Carter have endeavored to prove that ether contains dangerous elements in the changes which it undergoes in the system. Also in the secondary changes which result in its after-effects, but these experiments require confirmation before being received by the profession. The action of chloro- form upon the heart, kidneys and liver, and the deleterious changes resulting from its use, have been confirmed by numer- ous observers and experimenters, both at home and abroad. We have given as complete as possible a series of tables of death from both ether and chloroform, obtained with much labor and trouble from all the reliable sources within reach, only regretting that they are not so perfect as could be desired. These tables fully confirm our original views, founded upon personal observation, viz., that ether is the safest systemic anaesthetic to be employed, and they further confirm the state- ments published upon the subject in the first edition of this work. I desire to acknowledge many courtesies at the hands of members of the medical, pharmaceutical, and dental professions. 255 South Seventeenth Street, Philadelphia, October, 1896. PEEFACE TO THE THIRD EDITION. The Author has endeavored, in this the Third Edition of his Manual, to make a thorough revision of the whole subject of Artificial Anaesthesia. The time, he thinks, has arrived, after forty-five j^ears' (1844-1889) trials, of these most wonder- ful and beneficent agents, by the medical and surgical profes- sion, to have some definite and positive opinion, as to their relative safety in the various operations, and the risks and re- sponsibility attending their use, in the healthy and diseased conditions of the human body. By a careful and conscientious study of each agent, its natu- ral and physiological characteristics, and peculiarities, each and every medical man can, and should, select the one which he knows and feels will be just suitable in the peculiar case on hand. By the discovery of true and positive local angesthetics, and by their careful use in all minor operations in surgery, much of the risk to life is prevented. All hopes have passed away — for the time being at least — that any one of the systemic ansesthetics is absolutely free from risk to life, for we now know, full well, that angesthesia carried to the efi'ect of a profound impression on the human subject, sufficient for a capital operation, is but a step from death. It has been proven in numerous cases that it requires but a slight excess in the quantity employed, perhaps a lack of atmospheric air, great fear or dread concerning operation or anaesthetic, the faulty or non-action of a deranged kidney or heart, perchance a careless administration, and the patient is dead. In making the additions and alterations to our Manual, necessary at the present day, many changes have led to an increase in the size of this book. We would advise all who are obliged to use anaesthetics to memorize the prominent points, so that when a case of emer- Vlll PREFACE TO THE THIRD EDITION. gency arises it will not be necessary to seek information in the book, and all necessary haste, worry and confusion would be avoided, knowing just what to do for the best interest of the suffering patient, nigh unto death. The indiscriminate and careless administration of the most powerful anaesthetic agents is the crying evil of the present day, and we feel sure that in the near future legislative action will be taken to prevent, under heavy penalty, any one from giving an anaesthetic, unless he or she be provided with a cer- tificate that they fully understand the chemical, physiological and medical agents they are about to employ, and have had experience in their use, under a competent surgeon, and have been subjected to a careful examination of the knowledge they have thus acquired. Human life is too valuable to be destroyed by incompetent administrators of such beneficent yet death-giving agents. The following is the most recent warning on this subject: "The announcement that the anaesthetist in a fatal case of chloroform narcosis, at Sydney, Australia, has been found guilty and sentenced to pay two hundred pounds damages, on the ground that the anaesthetic had been improperly adminis- tered, comes with rather a startling effect. While no conscien- tious man, be he lay or medical, will dispute the justice of such a verdict, when negligence is clearly proven, difficulties arise when such matters are adjudicated by a jury of persons, who, whatever their intelligence, are profoundlj^ ignorant of what constitutes negligence in this respect. "It would be but a step further for juries to enforce the opinion, which has been gaining ground, as to the advisability of giving chloroform at all, unless specially indicated. Still, this is a matter well within the discretion of the medical man, and it would be impolitic, as well as unjust, to fetter the exer- cise of that discretion by a fear of legal consequences. " Short of negligence, amounting to a criminal act, we cannot conceive of such a verdict in this country (England), and we sincerely hope that the example will not be the means of im- posing an additional horror to the life of medical men, who have enough to attend to in guarding themselves against vexa- PREFACE TO THE THIRD EDITION. IX tious actions for having signed lunacy certificates, and in avoid- ing the wiles of designing women with an eye to blackmail."* The subject of the administrations of ether per rectum still claims some interest. The author retains part of the literature on that subject, modifying and giving the most recent cases which have been reported. The application of such powerful agents by the rectum offers many objections to general use, although in some rare cases it can be resorted to with success when cocaine is neither admissible nor sufficiently powerful. In this edition of the work the author has retained the description and illustrations of the various inhalers. Some are not recommended as highly as others, but all have certain merits and demerits ; still, this department has been found of practical use in the saving of time to those who are not famil- iar with the various modifications made or work performed. The author desires to return thanks to Dr. Buxton for his kind- ness in allowing his publishers to furnish several illustrations of instruments and one of tracings, the former being in constant use and highly thought of by the physicians, surgeons and dentists of Great Britain, Here, also, he makes a general acknowledgment of having freely availed himself of Dr. Bux- ton's labor in original communications sent to him, knowing how much they will be appreciated by his professional brethren in this country, he "being administrator of anaesthetics in several London hospitals." The author desires to acknowledge many courtesies at the hands of several members of the medical profession. He is also indebted to the liberality of the S. S. White Den- tal Manufacturing Co., of this city, for the use of valuable cuts of instruments and apparatus. Also to Parke, Davis & Co., Detroit, Mich. The author's sole object has been to make this work a scien- tific yet practical and safe guide, no labor nor expense having been spared in attempting to accomplish this object. * Dr. E. Hart, British Medical Journal . 1502 Wal>"UT Street, Philadelphia, December, 1889. PREFACE TO THE SECOND EDITION. The rapid sale of a large edition of this work in the short period of one j^ear, shows the appreciation with which it has been received by the medical and dental press and professions. Its success has induced the author to revise the subject-matter and rewrite several of the articles. To make the volume more worthy of the favor of the profession, a number of new and original experiments have been made, especially with hydro- bromic ether. The boiling points and relative time of evapo- ration of the several agents employed in mixed anaesthetics, and the best proportion in which ether, alcohol and chloroform should be united have been determined ; also a continuation of the experiments on the action of anaesthetics on the blood," the use of the spectroscope in relation to anaesthetics, more espe- cially nitrous oxide. In this second edition there will be found many more prac- tical suggestions as to the employment of anesthetics that are safe, and the rules for their adoption or reasons for the rejection of some of them in different cases, grouped, and made conve- nient, so that the student can memorize them, and be fully prepared for any emergency. As has been well observed in a review of this work by the distinguished editor of the Dental Cosmos, "When trouble comes to a patient from any cause during the anaesthetic state, it is not a good time to hunt up information." The new table of deaths from chloroform which has been added, and in the preparation of which much time and labor have been expended, will be found of special interest and vital importance in regard J;o the sex, age, character of operation^ time at which the patient died, quantity of chloroform used, and form of apparatus employed, general condition of patient^ PREFACE TO THE SECOND EDITION. XI prominent symptoms of chloroform-poisoning, causes of death and post-mortem appearances. A new ether inhaler has been described and illustrated, which has been, and is now, emploj'ed in the clinical service of Jefferson College Hospital. A bibliograph}" published in the first edition has been omitted, but additional old or new works which were not then intro- duced, or cannot be found mentioned in the body of this work, have been printed for reference. A historical sketch of the discovery of anEesthesia at the end of the previous edition has also been omitted, as more space has been devoted to the subject in our introduction, but full references to all authorities on the subject have been given. There has been introduced a notice of the metric system in accordance with the recommendations of the ''American Med- ical Association " at its last meeting, at Atlanta, in May, 1879 ; also a table of the Centigrade and Fahrenheit thermometric scales. More space has likewise been assigned to the phj^sio- logical and therapeutic action of anaesthetics in disease. In most of the instances where a remedy has been recommended, the authority has been quoted, or we have tested its therapeutic value in an extensive private practice, or in the daily clinics of two large public institutions. It was found impossible to acknowledge, in every instance,, the source from which all contained facts have been obtained, but in the majority of instances we have endeavored to give credit to every original worker in the field of progress. The author desires to acknowledge many courtesies at the hands of several eminent members of the profession ; but he is espe- cially indebted to his son. Dr. Charles S. Turnbull, and others. 1502 Walnut Steeet, Philadelphia, June, 1879. PEEFACE TO THE FIRST EDITION. This little work was originally written by the Author as a report for a medical society, and was subsequently extended to its present form to supply a want that evidently exists at the present day, for a convenient hand-book on the administration of the various anaesthetics, that the practitioner of medicine or dentistry can consult, to enable him to decide which one he can best employ. Many valuable books have, unquestionably, been written on the subject of anaesthetics, but as far as the writer's observations extend, none of a practical character have appeared within the last few years. Much useful matter in relation to sulphuric ether, " nitrous oxide," and chloroform, emploj^ed as anaesthetics, has accumulated within this period, but this valu- able information is contained in various monographs, journals, otc, where, associated with what is extraneous, it is unprofit- able to the busy practitioner. The object of this work may be stated to be : First. To give in as concise a manner as possible a description of the most available agents that may be successfully and safely employed as anassthetics. Second. To present the chief chemical tests of the purity of each substance considered, with its composition, physical char- acters and medical properties. Third. To exhibit the best methods of administering the various anaesthetics, to give careful directions, and to state the precautions to be taken to avoid risk to the life of the patient. Fourth. To note the personal experience of the author, his assistants and friends, with angesthetics and the various forms of inhalers in use, with a selection of the most approved, not withholding, however, the objections, but noting the experi- ments of other reliable investigators. Fifth. To compare the relative mortality from all the anaes- thetics now employed, endeavoring to assist the reader in form- ing a fair and candid opinion of this most important subject, which has for so long a period occupied the attention of the public as well as the medical profession. 1502 Walnut Street, Philadelphia, March, 1878. TABLE OF CONTENTS. PART FIRST. CHAPTEE I. PAGE History of Ancient and Modern Anesthetics — The First Dis- coverer of Nitrous Oxide, 25-31 CHAPTER 11. The Discovery of Special Anaesthetics — Ether, Chloroform — The True Value of Anaesthetics — Theories of the Manner in which Anaesthetics Produce Their Effects — Local Ansesthetics — Cocaine — Eucaine— Eucaine Hydrochlorate, 31-40 PART SECOND. CHAPTEE III. Nitrous Oxide Gas, its Mode of Preparation and Chemical Com- position — Gasometer for Preparing Xitrous Oxide Gas — Iron Eetorts for Making Protoxide of Xitrogen Gas— Inhalers- Thomas' Nitrous Oxide Inhaler— Nitrous Oxide Inhaler- Inflatable Face Piece for Inhaler— An Improved Nitrous Oxide Gasometer — An Apparatus for Administration — Liquid Nitrous Oxide— A Seamless Gas Cylinder— Wall-Bracket for Gas Cylinders— Surgeon's Case— Surgeon's Upright Case — The Proper Method of Administering Nitrous Oxide Gas as an Anaesthetic — Clover's Apparatus for Nitrous Oxide and XIV TABLE OF CONTENTS. PAGE Ether — The Physical Properties and Physiological Action of Nitrogen Monoxide — Nitrous Oxide — Experiments with Nitrous Oxide by the late Drs. McQuillan, J. D. Thomas, and the Writer — The Spectroscope and its Eelations to Anaesthetics — Experiments with the Spectroscope — Additional Facts in Reference to the Physiological Action of Nitrous Oxide — • The Phenomena of So-called Asphyxia of Nitrous Oxide Narcosis — Conclusions of Experiments upon the Brain and Spinal Cord with Nitrous Oxide Gas — The Eeflexes under Nitrous Oxide — The Induction of Anaesthesia in Heart Failure from Nitrous Oxide — Eeviewiug Nitrous Oxide Experiments — Experiments with Nitrous Oxide on the Kidney — Sphygmo- graphic Tracings from Patients Under the Influence of Nitrous Oxide Gas — On Blood Alterations by Anaesthetic Agents — Conclusions — Nitrous Oxide in General Surgery — Nitrous Oxide and Oxygen as an Anaesthetic — Hewitt's Ap- paratus — Hewitt's New Simplified Portable Apparatus for Administering Nitrous Oxide and Oxygen — Important To Examine Oxygen Inlets — Lubricating Inner Drum — To Ex- amine Valves in Delivery Tubes — On Dr. Hewitt's Method ■of Using Nitrous Oxide and Oxygen as an Anaesthetic — Con- clusion of Dr. Hewitt — Observations on the Statements and Abstracts from Monograph of Dr. H. C. Wood — Experiments with Nitrous Oxide Gas and Nitrogen Gas — Oxygen and Car- bonic Acid — The After-Effects of Nitrous Oxide Gas — Acci- dents in Extracting Teeth Under Nitrous Oxide — Adminis- tering Nitrous Oxide to Children — Deaths Under Nitrous •Oxide — Died in a Dentist's Chair — Deaths from Nitrous Oxide Gas — Therapeutic Application of Nitrous Oxide — Therapeu- tics of Nitrous Oxide Gas According to Dr. A. M'Lane Ham- ilton — Dr. Colton on the Safety in Disease of Nitrous Oxide Gas — Disease of Lungs, Heart Disease, In Chorea, Hysteria, Epilepsy, Hysteria, Asthma, Paralysis, Cases of Epilepsy — Nitrous Oxide and Oxygen as an Anaesthetic in Labor — The Field Widening for the Use of Nitrous Oxide Gas — Citations •of a Few Chronic Cases Treated by Nitrous Oxide and Oxy- gen — On Insanity or Mental Disturbance Following an Opera- tion Where a Prolonged Use of an Anaesthetic had been Em- ployed — On the Action of Nitrous Oxide, and of the Mixture . of Nitrous Oxide and Oxygen — Experiments on Dogs, by H. C. Wood, M.D., 41-134 TABLE OF CONTENTS. XV PART THIED. CHAPTEE IV. (CHO.CHOH.) PAGE Alcohol, Different Kinds — The Alcohol Recognized by the U. S. Pharmacopoeia— Absolute and Dilute Alcohols — The Alcohol of Whiskey, Wine and Brandy — Amylic Alcohol — The Phys- iological Action of Alcohol — The Influence of Alcohol on the Kidney and Liver — Strychnine in Chronic Alcoholism — The Toxic Action of Alcohol on the Heart in Moderate Doses — Heat-producing and Waste-preventing Action of Alcohol — Conclusions as to the Physiological Action of Alcohol — Alcohol as an Anesthetic — Views of Eichardson, Link and Others — Toxicology Treatment of Acute Alcohol Poisoning, . . . 135-147 CHAPTEE V. Ethyl Ether, the Ether of Commerce — Ether Fortior, how Manufactured — Chemical Eeactiou — Chemical and Physical Properties — Determination of Purity — The Inhalation of Ether — Etherization Ansesthetic, Various Stages — Effects upon Different Individuals — Precautions to be Employed Before and After Using Ether as an Aneesthetic — Treatments of Dangerous Symptoms — Means to be Employed in Heart- failure, Collapse or Shock — Cases in which Ether Should Not be Employed as an Antesthetic — Physiological Action of Ether — Experiments with Atropine — Experiments on the Heart and Pulse Shown by Sphygmographic Tracings — The Action on the Brain, Heart and Circulation — Closed Cone as Inhaler — Dr. Allis's Improved Inhaler, its Various Forms for Ether — Clover's Small Portable Ether Inhaler — The Cone and its Modifications — Advantages of the Cone — Dr. Lente's Inhaler — Ormsby Inhaler — Hearn, Cheatham, Parkinson, Codman and Shurtleff, for Ether — Souchon's Auxiliary In- jector for uninterrupted Ansesthesia in Operations on the Face and Mouth, for Ether and Chloroform — Mixture of Chloroform and Ether the one which he Prefers — Proportions of Ansesthetic Vapor and Air at each Compression of the Bulb, by Hermann Fleck, Ph.D., Instructor of Chemistry in the Harrison Chemical Laboratory of University of Pennsyl- XVI TABLE OF CONTENTS. PAGE vania — Conclusions — On Tissue Changes in Cases of Sec- ondary Death After Ether, by Drs. H. C. Wood and William S. Carter — It is Possible to Have Death Produced by an Anaes- thetic some time after the Cessation of the administration and the Eeturn of Consciousness, by Drs. Wood and Carter — Ether by the Rectum — The Chief Danger from the Admin- istration of Ether per Rectum — Apparatus for the Adminis- tration of Ether per Rectum — Internal Administration of Ether in Gout, Spasm of Stomach, Heart or Intestines, Tape Worm, Hysteria, Post-Partum Haemorrhage — Sciatica by the Subcutaneous Injection of Ether — Asthma, Coryza, Obstinate Hoarseness — Ether as an Expectorant — Chorea, Nervous Aphonia, Diphtheritic Angina or Pseudo-Membranous Croup — Whooping-cough — Ether Intoxication — Cases of — The Use and Advantages of Ether in Vivisections — Vivisec- tions with Ether and Chloroform, 148-200 CHAPTER VI. Ethers with Anaesthetic Properties : Acetic, Formic, Methylic, Bichloride of Methylene, EthyJene, Bromide of Ethylene, Chlorhydrin, Bromoform, its use in Whooping-cough, Butyl Chloride, Methyl Iodide, Aldehyde, Acetic or Ethylic— Use of Pai-aldehyde in Sleeplessness — Chloral Hydrate, Its Use and Abuse — On the Value of Oxygen Gas in Prolonged Oper- ations in which Ether Has Been Administered as an Anaes- thetic—Ether or Chloroform, Which ?— Danger of Ether — Excessive Secretion, Asphyxia — The Danger of Nephritis, Nausea and Vomiting — Advantages and Dangers of Chloro- form : Non-inflammable — More Agreeable to Patient, More Enduring Anaesthetic Effect, Little Increase of Mucous Secretion, Easier of Administration— Dangers, They Are Im- mediate, if the Patients do not Die During the Administra- tion they are Comparatively Safe— Nearly Fifty Per Cent, of Deaths by Chloroform Occur at the Outset of the Adminis- tration—Chief Danger of Chloroform is Paralysis of Nervous System Governing Circulation and Respiration — Centres Taken by Surprise — Treacherous Irregularities of the Heart — Action in Chloroform, as Regards its Beats, is Especially Ominous — Patients who Breathe Irregularly Should be Anaes- thetized with the Utmost Care — A Rest to the Patient— On Blood — Alterations by Ether, by John C. DaCosta, M.D. — Haemoglobin, Heematoglobin, Haemocrystallin, Definition of TABLE OF CONTENTS. Xvii PAGE Each— The Amount in Mau, in Woman— The Diminution of the Amount of Oxyhaemoglobin- Alterations of the Shape of the Corpuscles and Diminution of Their Number— Detail of Twenty-eight Cases and Conclusions — The Influence of Anses- thetics on the Kidneys, More Especially Ether and Chloroform, Dr. H. C. Wood and his Son. Dr. George B. Wood— Choice of Anaesthetic for Ureemic Patients — Observations of the late Dr. Emmet, and William F. Norris — Dr. Lawson Tait, Eemarkable Case in which, the Ureters Being Exposed, it was found that the Continuous Administration of Ether Prevented the Secre- tion of Urine — Experiments on Dogs, it was found by Dr. George B. Wood that During the Administration of Ether as an Aneesthetic the Kidneys Became Markedly Congested — The Cells and Tufts and Corresponding Tubules were Those Primarily Afiected— The Failure of Fueter to Detect Changes in the Kidneys — Testimony of Dr. Guiteras Corroborative of the Eesults of Dr. Wood s Cases, 200-226 CHAPTEE VII. Hydrobromic Ether or Bromide of Ethyl — Properties— Mode of Preparation — Description of Physical and Chemical Qual- ities—Physiological Action — Experiments on Animals — Use as an Ansesthetic, Verneuil and Terrillon — Care Necessary in its Use— Mode of Employment — Use of by Dr. Koellicker — M. Bazy on Vomiting, which Earely Followed when Em- ployed Alone — Professor Wood's Eecent Views on this Sub- ject — Dr. Gillis's Claims for it— Proceeding of the Academy of Medicine of Paris— Case of Sudden Death Eeported by M. Suarez de Mendoza of Angers, and Eemarks, also Those of M. Terrier before the Societe de Chirurgie — Some Eecent Observations on Mixtures of Bromide of Ethyl — Their Dan- ger—Chemical Examination of One of Them— Examples of Impure Specimens of Bromide of Ethyl, by Professor Jungk — Deaths from the Same, by Dr. Levis, of Philadelphia, Dr. M. Sims, of New York — Professor E. E. Montgomery's Opinion of the Value of Ethyl Bromide in Obstetrics— Continued Use of— Extensively Employed by the Dentists of Germany, 227-238 XVlll TABLE OF CONTENTS. PART FOURTH. CHAPTER VIII. Chloroform — Mode of Preparation — An Improved Chloroform — Purified Chloroform — Mode of Administering Chloroform in the United States, England, France — Inhalers of Various Kinds — The Scotch Method in Detail — Remarks on the Con- clusions of the Hyderabad Commission — Report of Cases in which Chloroform Caused Death by Paralyzing the Heart First — Lancet Commission on Anaesthetics — Direction of Inquiry by Dr. Buxton and His Classification of Cases of Deaths from Chloroform — Geographical Distribution of Fatal- ities from Chloroform — Deaths in the South, in Scotland — Methods Employed for Administering Chloroform in which Death Followed — Causes Assigned for Death by Chloroform — The Amount of Chloroform in 100 Cubic Inches of Satu- rated Mixture — Air and Chloroform at Different Tempera- tures—Snow's Tablets — Pupillary Phenomena Observed in the Various Styles of Chloroform Narcosis — Dr. MacEwen, of Glasgow, on the Mistakes of Young Operators in Touching the Cornea — Stages of Chloroform Ansesthesia — Nelson on the Pupil as a Guide in Giving Chloroform — Toxicological Effects of Chloroform — Howard on Raising the Epiglottis — The Treatment of Arrested Respiration, by Drs. Martin and Hare, on Free and Patulous Nostrils — Conclusions — Addi- tional Facts as to Treatment of Dangerous and Fatal Symp- toms of Chloroform as an Ansesthetic— Sylvester's Method of Artificial Respiration on the Epiglottis in Chloroform — Accidents by Dr. A. E. Prince, New York— Resuscitation by Anal Dilatation, by Dr. L. C. Grosvenor, of Chicago, III. — Dr. Brunton on Chloroform, in the Discussion of Dr. Wood's Paper on Anaesthetics, Before the Berlin Congress — Recent Views in Regard to the Action of Chloroform, by Drs. Gas- kell and Short, of the University of London — Dr. Brunton in His Publication Giving Away the Whole Case of the Hyderabad Commission — Dr. Wood's Opinion and the Au- thor's, Resuscitation by Lingual Traction — Dr. J. Lawrence Hamilton's Views on Professor Laborde's labors — Dr. Bowles Has Shown that in Apparent Death from Drowning, in the Supine or Horizontal Position, the Paralyzed Tongue, by Let- PAGE TABLE OF CONTENTS. XIX PAGE ting its Base Drop Backwards, Thereby Blocks up the Pharynx — Dr. Hunter oa Eesuscitation by Means of his Specially Constructed Bellows — Dr. Champney's Experiments — Rhyth- mic Tractions of the Tongue in Accidents and in Asphyxia from Chloroform — M. Filiget's Case — Dr. Dennea, Neoplasm of the Larynx — Professor Masse's Case — Dr. Meniere's Case, and others, on the Influence of Chloroform in Producing Tissue Changes, such as Fatty Degeneration of the Heart, Diaphragm and Other Striated Muscles, and also of the Par- enchyma of the Liver and Kidneys, by Drs. Wood and Car- ter — Perils of Chloroform Administered in Dental Opera- tions — Chloroform Given Improperly — The Employment of Nitrite of Amyl— Want of Success, 239-292 CHAPTER IX. History, with Conclusions, from 1888 to 1895 Inclusive — The Pulse During Chloroform Ausesthesia — Conclusive Statements and Experiments of Dr. McWilliam in answer to Dr. Lawrie, On the Importance of Long-continued Artificial Respira- tion after Chloroform Asphyxia, in India — Conclusions as to Chloroform — Table of Deaths from Chloroform and Ether since the Hyderabad Commission — Notes Referring to the Table — Four Deaths from Chloroform in Reading, Pa., and . Vicinity — Note 5, Death from Chloroform of a Peculiarly Painful Character — Note 6, Deaths from Ether — Case of Death from Ether of Colonel E. F. Shepard, of New York — The Proper Method of Making Hospital Reports in Cases of Anaesthesia — Records and Report of Autopsy — The Deathly After-Eff'ects of Chloroform, by Dr. C. Thiem and Dr. P. Fischer — Observations and History of Original Experiments Prior to 1S80 — Primary Syncope from Chloroform, by Dr. Robert Kirk, of Edinburgh, with Cases, 293-329 CHAPTER X. Chloroform in Dental Surgery, by Frederic Hewitt, M.D. — I. Introduction — II. The Lines Upon Which the Inquiry was Conducted— III. Classification and Analysis of Cases— Table — Deaths in Connection with General Anaesthetics Adminis- tered for Dental Operations in Great Britain, 1880-1894 In- clusive, = 37— Sex — Age— General Condition— Preparation- Posture— Flexion of the Head upon the Sternum — Method of Administration and Quantity of Chloroform Used — XX TABLE OF CONTENTS. PAGE Nature of Operation — Relation of Dangerous Symptoms to Operation — Phenomena During Administration and Opera- tion—Fatal Phenomena— Post-Mortems, 329-338 CHAPTER XL Dr. Kreutzniann, Use of Mixture of Ether, Chloroform and Oxy- gen in San Francisco as Early as August, 1887 — Dr. Neudor- fer, of Vienna, Who Claims, on Theoretical G-rounds, that its Employment is Entirely Without Danger — Oxygen as an Antidote to Chloroform Cases, by Dr. Simeon Abrahams, of New York — Dr. Loyssel's Experiments with Pure Oxygen in Recalling Patients to Life When all Else Mas Failed — Dr. H. L. Northrop, of Philadelphia, His Reasons for the Admin- istration of Oxygen and Chloroform — Oxygen was an Anti- dote to Chloroform — Oxygenated Chloroform Apparatus — Chloroform and Oxygen, Use of it in Hospital Practice — Restricted to Children, Alcoholics and Short Operations — Ether has Been Given More Frequently than any Other Anaesthetic — Use by Prof. Montgomery — Oxygen Gas-Inhal- ing Apparatus of the S. S. White Co., 338-351 CHAPTER XII. Mixed Anaesthetics — Report of Chloroform Committee Med. Chir. Soc, London — Their Superiority in Point of Safety — M. Perrin's First Death — Snow's Opinion — Second Case Re- ported by Dr. R. Crockett — The Composition of the Various Mixtures by the Committee — The Introduction of Alcohol, by Dr. Harley — Dr. Sansom's Mixture — What are the Objec- tions to the Mixtures? — Boiling-Points of the Agents Em- ployed as Anaesthetics — Experiments of Drs. L. and C. S. Turnbull to Determine the Time Required for Evaporating Substances on Tissue Paper — Danger from the Water Pro- duced from Ether — The Inhalation of Chloroform and Ether a Cause of Aural Disease — Brief Extract of Experiments with a Mixture of Ether and Bromide of Ethyl and Chloro- form, Performed by Drs. Reichert, Turnbull and Thomas — Mixed Anaesthetics — Opinion of Dr. Wood — The Late Dr. Washington W. Atlee's Mixture — Recent Death from a Mix- ture of Ether and Chloroform — Other Deaths from the Mix- ture — How Shall Nitrous Oxide Gas and Ether be Adminis- tered? by Dr. Frederick W. Silk, of London— Mixtures of Nitrous Oxide, Ether, Chloroform and Alcohol for Inhala- tion, 351-370 TABLE OF CONTENTS. XXI PART FIFTH. CHAPTEE XIII. PAGE Local Anaesthesia and Anaesthetics — Various Local Anaes- thetics and the Eemarkable Effects, According to Dr. Lieb- reich — Electricity as a Local Anaesthetic, Alone or with Cocaine — Bonwell's Method — Dr. I. Corning, of New York, Perforating of the Skin, use of Cocaine Solution and Elec- trode, with the use of Compression — Electrical Osmosis for the Treatment of Living Dentine, by Henry W. Gillett, M.D., of Newport, E. I. — Definition of the Term — Use of the Se- lector Experiments, with Eesults Obtained, by Dr. Wm. I. Mor- ton, New York, with Guaiacol — Conclusions — Eesults Ob- tained by Dr. E. C. Kirk, of Philadelphia, and W. I. Younger — The Excellent Eesults from the Use of Guaiacocine, . . 371-383 PART SIXTH. CHAPTEE XIV. Local Anaesthetics — Coca Plant Leaves — Preparations, More Especially the Wine — Its Active Principle — Cocaine; its Action as a Stimulant of the Nervous System and Eetarder of Metamorphosis — Cocaine and its Salts Solutions — Tests of Purity — Cocaine Inebriety, 384-389 CHAPTEE XV. Experiments with Cocaine on Animals — The Physiological Ac- tion of Cocaine upon the Animal System, More Especially upon Dogs — Experiments with Professor Eeichert, on the Action of Cocaine on the Eye — Fatal Dose of Hydrochl orate of Cocaine, 389-395 CHAPTEE XVI. Cocaine Inebriation and Habit — Treatment — Deaths from Co- caine — Morbid Changes — Viau's Method of Employing Phenic Acid and Cocaine — Schleich's Infiltration Method of Using Local Anaesthesia by Cocaine — Used in Inflamed Parts — Cau- XXll TABLE OF CONTENTS. PAGE tion — Formulas Advocated by Schleich — Formatiou of the Cutaneous Wheals — Notes on the Danger of Sepsis in Ender- mic Injection — Infiltration Aufesthesia — On the Preparation of the Solution — Soluble Compressed Tablets — On the Use of Cocaine upon the Nasal Mucous Membrane Prior to and Dur- ing Anfesthesia, by Eosenberg and Gerster, 395-412 CHAPTER XVII. On the Use of Cocaine in the Teeth, Nose, Throat and Eyes — Was it Cocaine Poisoning? — The Use of Cocaine in the Nose and Throat — Cocaine in the Ear — Deaths from Cocaine, . 412-421 CHAPTER XVIII. Therapeutics of Cocaine — Gastritis Produced by an Irritating Poison Treated by Cocaine — Certain Affections of the Stomach — Cocaine in Persistent or Uncontrollable Vomit- ing — Cocaine in Lavage or Gavage — In Boulimic or Insatiable Hunger — Tetanus Treated by Morphia and Cocaine — Cocaine in Skin Disease, in the Treatment of Chilblain, in Intense Itching of the Skin, in Burns, in Anal-vulval Pruriency or Painful Herpes, in Cracked Nipples, in Acute Catarrh, Coryza or Cold in the Head, in Hay Fever or Rose Cold — Cocaine and Phosphate of Lime in Laryngeal Tuberculosis, in Whooping Cough — Cocaine and Resorcin in Whooping Cough — Mixture of Cocaine, Glycerine and Carbolic Acid in Cough and Chronic Pharyngitis — Cocaine for the Same by Insufflation and Inhalation, in Paroxysmal Sneezing, Rose Cold or Hay I*ever, in Asthma, 422-429 CHAPTER XIX. Cocaine in Catarrhal Conjunctivitis and Clyclitis, in Gonor- rhoeal Ophthalmia — Cocaine and Atropia for Iritis — Use of Hydrochlorate in Ear Disease — Eucaine Hydrochlorate ; its Physiological Action, Local Action, General Action of the Drug as a Local Anaesthetic in the Eye — Eucaine and Co- caine ; Directions for its Use in Dentistry — Report of Cases in Minor Surgery, 429-441 CHAPTER XX. Chloride of Ethyl ; its General Character and Chemical and Physical Properties — Discoveiy — Experiments of Clover — Mono-Chlorethane— Wigger's Anaesthetic Ether— Chloride of TABLE OF CONTENTS. XXlll PAGE Ethyl as a Local Anaesthetic— Objections to Powerful Re- frigerative Agents— Experiments with Chloride of Ethyl and Peutal by Dr. H. C. Wood and David Cerna, M.D.— Com- pounds, Phenol, Camphor, Menthol, and Eesorcin— Antipy- rine as a Local Ansesthetic, 441-453 CHAPTER XXL Local Anesthetics— Oil of Eucalyptus, Ether, Ehigolene, Methyl and its Chlorides, Hydrastine, Homatropiue and Ephedrine, Chlorohydrate, Brucine, Apomorphine, Hydro- chloras, Erythrophleiue or Haya-Caffeine— Caffeine, Helle- borine, Canadol, Menthol, Iodoform, lodol, Bromide of Ethyl, Bromide of Potassium, Ethyliodide, Chloral and Camphor as a Local Anaesthetic— Piper Methysticum and the Cocaine Molecule, Naphthaline, Quinine, Antipyretic and Anesthetic —Thymol, Sulphonal, Pyoktanin, Acid Trichloracetic, Aristol, Urethane, Trional and Tritronal Hypnal, 454-487 PART SEVENTH. CHAPTER XXII. A Supplement for the Student to Commit to Memory— Anes- thesia Derivation— Artificial Anesthesia— Ether— Chloro- form— Mixed Anesthesia— Nitrous Oxide— The Most Promi- nent Local Anesthetics- Antidotes to Cocaine— Precautions to be Taken in Administration of Chloroform, Ether and Nitrous Oxide— Electricity in Resuscitation, Asphyxia, Blood-Pressure, Cardiac Failure— x^dditional Means of Resus- citation During the Administration of Anesthetics— Konig's and Kelly's Methods, 488-499 CHAPTER XXIII. Experiments of Dr. H. C. Wood and Dr. Hobart A. Hare in Reply to the Hyderabad Commission, February, 1890— A Study of the Influence of Chloroform Upon the Circulation, by Dr. Hare and Dr. E. Q. Thornton — Lawrie and the Hy- derabad Chloroform Inhaler — Krohne and Seseman's Indica- tor Respirator Attachment; This they have also Attached XXIV TABLE OF CONTENTS. PAGE to Junker's Inhaler — Dr. Guereu on Prevention of the Ac- tion of Chloroform on the Heart — Dr. W. I. Fleming on Proneness of Dogs to Succumb to Chloroform — Dr. John Freeman, of Bristol, England, Eeasous for the Greater Safety of Ether as an Anaesthetic, 500-509 CHAPTER XXIV. Ansesthetics — Their Value in Disease — Which to Avoid and Those to Employ — In Disease of the Heart, in Disease of the Lungs, in Disease of the Kidneys — What to do First in Case of Danger — In What Class of Cases Can Chloroform be Em- ployed with Safety in Obstetrics — Opinions of the Late Dr. Fordyce Barker, of New York, and Dr. John N. Upsher, of Eichmond, Va., 509-515. CHAPTEE XXV. The Legal Eesponsibility of Physicians in the Administration of Ansesthetics — Opinions of the author, Daniel S. Eiddle, Esq., of New York ; Coroner Ellinger, Max F. Eller, Esq. — M. Dolbeau, of Paris; His Experiments with Chloroform on Patients When Asleep — Case in Philadelphia of Surgeon Dentist — Cases in France, England and the United States — Chloroform as a Poison — The Chloroform Habit, or Chloro- form by the Mouth — Hypnotic Anaesthesia and its Analogous States in their Various Aspects — Hypnotism as an Anaesthetic — Therapeutic Hypnotism — Eeport of the Committee of the British Medical Association to Investigate the Nature of the Phenomena of Hypnotism — Its Value as a Therapeutic Agent, and the Propriety of Using it, 516-538 ARTIFICIAL ANAESTHESIA. PART FIRST. CHAPTER I. History of Ancient and Modern Aiisesthetics. The ancient Greeks, it is stated, possessed a plant called mandrake, wliicli belonged to the same family as belladonna or deadly night-shade. From the root of this plant was extracted, by means of wine, a narcotic which was employed by them as an anaesthetic. Lucius Apuleius, who lived about 160 A.D. , and of whose works eleven editions were published in the four- teenth and fifteenth centuries, says, " that if a man has to have a limb mutilated, sawn or burnt, he may take half an ounce of mandragora wine, and whilst he sleeps the member may be cut off without pain or sense." To prove that this was true. Dr. B. W. Richardson, of London, after a lapse of five centuries, obtained a fine specimen of mandragora root, and, afcer making wine from it and testing it, found it was a narcotic having pre- cisely the properties that were anciently ascribed to it. He dis- covered that in animals it would produce even the sleep of Ju- liet, not for thirty or forty hours, a term that must be accepted as a poetical license, but for the four hours named by Dioscori- des ; and that, on awakening, there was an excitement which tallied with the same phenomenon that was observed by the older physicians. Another fact was noticed by the ancients — that many volatile substances acted more promptly when in- haled than when taken into the stomach, and the first-named form of medication was employed in Greece, Rome and Arabia. 26 ARTIFICIAL ANAESTHESIA. By the works published in those countries the knowledge of these facts was extended to other parts of the world. "He has eaten mandrake " was said of a very indolent and sleepy man, from the narcotic and stupefying properties of the plant, well known to the ancients. Cleopatra. — " Give me to drink mandragora That I might sleep out this great gap of time My Anthony is away." — Shakespeare, "Anthony and Cleopatra," act i., scene 5. In China, in ancient times, the word ma-yo meant not only Indian hemp but anaesthetic medicine ; other substances besides hemp entered into the benumbing recipes, such as the datura, a solanaceous or soothing plant, probably identical with the atropia or mandragora ; also aconite, hyoscyamus, etc. A wine of mandragora was used by the Romans to relieve the sufferings of the crucified, and was employed (down to the thirteenth cen- tury) as a surgical anaesthetic. Some of these drugs form con- stituents of the formula said to be employed by kidnappers of children and by robbers ; consequently their sale or employment is, at the present, prohibited in China. Dr. Dudgeon, of Pe- kin, writing in 1877, gave a flat contradiction to the extrava- gant stories current in Europe respecting the skilful use made by the early Chinese of benumbing drugs, and probably a more exact acquaintance with the fact would show that the practice of Grreece and Rome was not less elementary. Only in modern times and in the light of scientific teaching was it possible for anaesthetics to take their proper place as helpmates of the sur- geon in his art and as the grand alleviators of human suffering. Theodoric, about the year 1298, gives elaborate directions how to prepare a " spongia somnifera " by boiling it dry in nu- merous strong narcotics and afterwards moistening it for inhala- tion before operations. Opium was also employed in later years (prior to surgical operations), and was found the best narcotic for the relief of pain and for producing insensibility, although not free from danger. MODERN ANESTHESIA AND ANESTHETICS. 27 History of Modern Aiifs^stliesia and Ansestlietics. On September 3, 1828, M. Girardin read to the Academy of Medicine, of Paris, a letter addressed to His Majesty, Charles X., describing "surgical anaesthesia by means of inhaled gases." A strong impulse was given to the study and application of the "diflferent kinds of airs and gases" by the discovery of oxygen by Priestly and Scheele in the middle of the eighteenth century, and numerous experiments were made by physicians with the new gas. Pneumatic chemistry called into existence a new branch of therapeutics — pneumatic medicine, as it is named by its found- ers, who hoped to cure diseases, especially pulmonary tubercu- losis, by the inhalation of various gases and vapors. This has been again revived in our day. A "Medical Pneumatic Insti- tution " was set up at Clifton, in 1798, by Dr. Beddoes, which had huge reservoirs of gases for the use of patients. The cele- brated Humphrey Davy, who had then just served his appren- ticeship, was appointed superintendent. Though not success- ful in the immediate object for which it was founded, it was so in another sense ; for here Davy made his researches concern- ing nitrous oxide gas. In 1800 he discovered that when inhaled this gas produced a peculiar intoxicating effect, together with an irresistible propensity to muscular exertion, and often to laugh- ter, whence its popular name of "laughing gas." He also dis- covered its anaesthetic properties and successfully inhaled it himself to relieve the pain of cutting a wisdom tooth. He made numerous experiments with the gas on animals. In his account of these experiments there occurs this memorable and oft-quoted sentence : "As nitrous oxide in its extensive opera- tion appears capable of destroying physical pain, it may proba- bly be used to advantage during surgical operations in which no great effusion of blood takes place." Those desirous of pursu- ing the subject further should read his work entitled, "Re- searches, Chemical and Philosophical, Chiefly Concerning Nitrous Oxide." Strange to relate, notwithstanding their com- pleteness, nothing came of these remarkable observations. Their real import was not understood until nearly half a century later. 28 ARTIFICIAL ANAESTHESIA. The modern practice of anaesthesia, though it may have been benefited indirectly' by these experiments, was not the imme- diate outcome of any of them ; it originated to a large extent independently. The honor of making this discovery rests chiefly with four Americans — Horace Wells, William Morton, Charles Jackson and Crawford W. Long. One winter's night in December, 1844, a number of the in- habitants of Hartford, Connecticut, assembled to hear a lecture on nitrous oxide and other gases by Dr. Colton, a well-known popular lecturer, who tried the effect of the first-named gas on several of the audience. Among those present were Horace Wells and his friend, John M. Riggs, both dentists of that city. They noticed that a person under the influence of the gas was capa- ble of sustaining a severe injury of his leg without apparently feel- ing any pain. Wells was so impressed with this fact that on the following day he had the lecturer permit him to inhale the gas, and whilst under its influence he had a molar tooth extracted without feeling the least pain. As he recovered from the effects of the gas his first words were : "A new era in tooth-pulKng. " The modern practice of anaesthesia dates from this operation. Wells appears to have been unaware of Sir Humphrey Davy's experiments. He found the peculiar exhilarating effects de- scribed by Davy due to mixture of the gas with atmospheric air ; for when precautions had been taken to exclude the latter only anaesthetic effects ensued from its inhalation. Wells gave the- gas to more than a dozen of his patients and with complete success. Elated with this good fortune, he quickly obtained permission to make a public trial of it at the Massa- chusetts General Hospital. Unfortunately, the bag was re- moved too soon, and in the extraction of the tooth the patient uttered a piercing cry. The sceptical audience rudely hooted and hissed, and Wells was laughed at as an ignorant pretender. Now, Wells was a modest and retiring man ; he felt the insult deeply. Home he went, mortified and disgusted, yet both Wells and Riggs continued in their practice to administer the gas, but never afterwards resumed their experiments in public. After a few years Wells fell ill from vexation, and retired from his profession. Subsequently, he visited Europe as a picture MODERN ANAESTHESIA AND ANAESTHETICS. 29 dealer, then returned to the United States, became more and more unsettled in his mind, and finally died by his own hand in January, 1848. For a lon^f time Wells' just claims as the dis- coverer of modern anaesthesia were ignored ; indeed, we are only now beginning to do justice to his memory. He, at least, never attempted to make a secret of his great discovery nor to use it for selfish ends. "On making the discovery," says Wells, " I was so much elated respecting it that I expended my money freely and devoted my whole time for several weeks in order to present it to those who were best qualified to investi- gate and decide upon its merits, not asking or expecting any- thing for my services. I was desirous that it should be as free as the air we breathe. Judge, therefore, of my surprise, after the lapse of many months, when I was informed that two indi- viduals (Drs. Jackson and Morton) had claimed the discovery and made the application for a patent in their own names." We are happy to state that a chaste and handsome monu- ment, with a statue of Wells, has been erected at Hartford, Connecticut, with the following inscription : "Horace Wblls, who discovered Anaesthesia, December 10th, 1844." Much credit is due to Dr. McManus and other friends of Wells for their praiseworthy eiForts in this matter. I am glad to be able to present a likeness of Horace Wells, which, no doubt, will give pleasure to thousands who now profit by his valuable discovery. The use of nitrous oxide as an anaesthetic, for the time being, died with Wells, and the discovery was again in danger of being lost. Dr. Colton's praiseworthy efiforts to reintroduce the gas were vain until 1863, when he succeeded in inducing a few prac- titioners to try it. Its use spread rapidly, so that in 1867 — the j^ear of the International Exhibition in London — he was able to visit Paris with a record of 20,000 administrations without a single accident. He met with very little encouragement from the Paris faculty. However, in the spring of the following year, his apparatus was brought to London by Dr. Evans, the American dentist resident in Paris, who administered the gas before the 30 ARTIFICIAL ANESTHESIA. Staff of the Dental Hospital, and thus introduced the practice in that country.* In the United States nitrous oxide was well re- ceived ; and in 1870 Dr. Colton published in a medical journal, and afterwards in pamphlet form, the result of the physiological action of the gas in its practical application to the original dis- coveries of Davy, Wells and others, with a very large record of the successful extraction of teeth. Unfortunately, owing to the comparative feebleness of action of nitrous oxide gas, and its large gaseous bulk, the anaesthesia Plate 1. can only be maintained for a very limited period. Hence the employment of the gas has hitherto necessarily been restricted to short surgical operations. The late M. Paul Bert partially succeeded in overcoming this objection by giving instead of the pure gas a mixture with oxygen gas, in the proportion of 85 volumes of nitrous oxide to 15 volumes of oxygen, under in- creased atmospheric pressure in a special chamber constructed for this purpose. The necessity for the latter part of this pro- vision arises from the fact that when the mixture of the gases * The Journal of the British Dental Association. DISCOVERY OF ETHER AS AN ANESTHETIC. 31 is inhaled alone complete anaesthesia cannot be produced, owinfr to the full complement of nitrous oxide (45 volumes to 100 volumes of ox5'gen) not being taken into the lungs during res- piration. Under the increased pressure mentioned sufficient nitrous oxide is inhaled to produce anaesthesia and sufficient oxygen to prevent the supervention of asphyxia. Thus more or less prolonged anaesthesia can be maintained. After many ex- periments on animals this method has been tried at the Paris Hospital b}' Peau and others, but with partial success. It is not known whether it is emploj'ed in this country. The requi- site apparatus in its present form is too cumbrous and expensive for general use. A more compact apparatus has been invented by Dr. Hewitt, of London, and with it the nitrous oxide mix- ture can be kept up for some time, and thus a short operation, or the extraction of a number of teeth, etc. , can be undertaken.^ A full account will.be given under nitrous oxide. CHAPTER 11. The Discovery of Special Ansesthetics and the Theory of their Action — Local Anaesthesia and Anaesthetics — Chloroform — The True Value of Anaesthetics — Cocaine — Eucaiue Hydrochlorate. Ether. "Pereira," in his famous work, then as now a familiar text- book,! states, " The vapor of ether is inhaled .... to relieve the effects caused by the accidental inhalation of chlorine gas." Again, he writes, " If the air is too strongly impregnated with ether stupefaction ensues." The crowning result, however, was obtained in 1846 by Dr. Morton in the Massachusetts General Hospital, when it was demonstrated successfully that the in- halation of ether was so capable of deadening the sensibility of "-■• The Journal of the British Dental Association. t Lectures on Materia Medica and Therapeutics, vol. ii. 32 ARTIFICIAL ANESTHESIA. the nervous system that an operation, no matter how painful, could be performed without suffering to the patient. In the use of ether as an anaesthetic the first capital operation — that is, one involving one of the larger joints — was performed on October 17, 1846, by Dr. Warren, of Boston. A handsome sum of money should have been given both Dr. Wells and Morton for their devotion to the cause of suffering humanity, and this should still be done for their families. It gives me pleasure to be able to present a correct likeness (Plate 2) of Dr. Morton, who, though he erred, should long ago have been forgiven for his devotion to the introduction of one of the most valuable anaesthetic agents given to the profession and the public. Dr. Jackson, of Boston, claims to have suggested to Dr. Morton the use of ether as an anaesthetic in place of nitrous oxide. With regard to this, it may be stated that at a meet- ing of the Boston Academy of Arts and Sciences, where the matter was being discussed, the late Professor Louis Agassiz said to Dr. Jackson : "Did you make even one little experi- ment with ether?" and, after receiving a negative reply, added dryly; " It would have been better if you had." On another occasion Professor Agassiz said: " If Dr. Morton had killed his first patient would you (Jackson) have accepted the blame, just as now you ask for the honor?" Dr. Jackson was silent. The names of Morton and Jackson were, however, associated in an attempt to obtain a patent for the process, which was frowned upon by every right-minded physician and dentist. It seems that among other after-claimants, one, an estimable physician of (xeorgia. Dr. Crawford W. Long, awakened to the fact, only so late as 1849 (three years after anaesthetic inhala- tion by ether — 1846 — had been in universal practice), that it would be well to record in some medical journal the statement that he had "used ether by inhalation in surgical operations on several occasions " (as many as five in the course of as many years) prior to 1846. He accordingly, in December, 1849, pub- lished " an account of the first use of ether by inhalation as an anaesthetic in surgical operations." This communication, tardy as it was, Dr. Long very properly made in simple justice to DISCOVERY OF ETHER AS AN ANESTHETIC. 33 Plate 2. 34 ARTIFICIAL ANAESTHESIA. himself. No special attention was paid to it for reasons which will soon become apparent. He seems, indeed, merely to have desired to place himself on record in connection with this sub- ject in 1849. In 1877 this forgotten record is dragged from its obscurity and amplified and adorned into a patent of discovery. The interests of truth will be best served b}'' referring to Dr. Long's original text. One quotation will establish these points. We shall be brought straightway to the very pith of the case by the following summary, as given by himself, in his communica- tion of 1849, already referred to: "The result of my second experiment in etherization was such as led me to believe that the anaesthetic state was of such short duration that ether would only be applicable in cases in which its effects could be kept up by constant inhalation during the time of the performance of the operation. Under this impression, up to January, 1847, I had not used ether in but one case, in extracting teeth, and thus deprived myself of experimenting in the only class of cases which are of frequent occurrence in a country practice." Now, in the first place, the remarkable admissions contained in this sentence would be valueless if any subsequent experiments had taught Dr. Long more than he here enunciates ; but he never, of himself, learned more than this — for he distinctly states that he " was under the impression" embodied in this quotation until January, 1847, three months after the announcement of universal and practical anaesthesia in 1846. The writer still holds to the opinion expressed in his earlier editions, that the safest systemic anaesthetic in prolonged and capital operations is ether, and in this opinion he is upheld by the majority of surgeons, by a committee of the British Medical Association, the British Medical Journal, also by the chief journals of the United States. (See Conclusion.) It is unfortunately true that at the present day ether deaths occur more frequently from carelessness in administration and proportionately larger amount used than in years gone by. Sudden deaths were extremely rare, but are now more fre- quent, owing, we think, to, first, the use of a more powerful ether, and, second, to carelessness in employment, as in the case of a recently reported death, when six ounces were employed THE TRUE VALUE OF ANESTHETICS. 35 for a non-capital operation, whicli could have been performed under a local anaesthetic. One reason for employing so large a quantity' of ether is the strong desire to etherize the patient as rapidly as possible, and neglect to use the minimum quantity to keep the patient pro- foundly anaesthetized. In ether it is almost always the danger from interruption of the respiration, and secondarily interference with the heart's action, hence there is a chance for the use of artificial respiration. In such cases elevate the feet and lower the head until the face flushes and shows restoration of the heart's full action. Chloroform. Discovery of Chloroform. This valuable anaesthetic agent was first discovered in an im- pure state as "chloric ether," in 1831, by Samuel Guthrie, of Sackett's Harbor, N. Y. Little notice was taken of it until Soubieran and Liebig produced it in a pure state by the action of chlorine gas upon methyl chloride, a year after the discovery of the anaesthetic qualities of ether (1847). Professor Simpson, of Edinburgh, by his courage, brought chloroform into use upon the suggestion of Dr. Waldie, a chemist of Liverpool. Simpson found by experiment that a much smaller quantity of chloroform than of ether was required to produce profound anaesthesia, the former being more prompt in action and more agreeable to the patient both in taste and odor. Chloroform had, however, a great drawback in general use as an anaesthetic, in that it would without warning cause very sud- den death from cardiac syncope. The True Value of Anaesthetics. No one can form, even at the present day, a just estimate of the true value of the various anaesthetics or express in words their wonderful and extended application to the relief of human suffering. To the general surgeon it gives the opportunity of operating in grave cases of disease and injury, without which 36 , ARTIFICIAL ANESTHESIA. the death of the patient would be inevitable. It also aiFords, by the immediate relief from pain, the power to manipulate the broken or injured parts with facility, and thus obtain a correct diagnosis in the most obscure diseases and painful accidents. To the obstetrician and gynaecologist it is most valuable in assuaging the terrific pain of labor, and makes the dreaded in- strument a blessing in disguise. In the diagnosis and treatment of abdominal diseases it gives precision and almost marvellous results, and in the removal of large masses or ovarian tumors great freedom from the dreadful effects of shock to the nervous system. For the ophthalmic surgeon the local anaesthetic re- duces the sensibility of the eye so that it can be touched and cut with impunity, and severe and dangerous operations can be performed upon this delicate and sensitive organ without pain and with much less risk. Again, in the removal of foreign bodies from the eye or ear, particularly in children, by the use of the local anaesthetic all spasm is relieved and the act is accomplished without injury. The profound sleep gives a most favorable opportunity to the aural surgeon to perforate the membrane tympani, cut the minute tendon of the tensor tympani muscle, perforate the mastoid cells, open abscesses and remove intramural tumors from the brain. Theories of the Manner in Which Anaesthetics Pro- duce Theii" Effects. At the present day certain theories are ventured to explain the eflFects of general anaesthetics on the system : 1. That they act by retarding oxygenation and induce a true narcosis. 2. That they produce actual changes in the blood, thus caus- ing secondary inhibition of the function of the sensory nerve cells. 3. That they merely bring about cerebral anaemia, from which condition anaesthesia results. 4. That they have a direct action upon the nervous tissue itself. 5. There is no true similarity between the phenomena of true COCAINE. 37 anaesthesia and those of asphyxia ; the conditions are not iden- tical, and when asphyxia takes place, which occurs with all anaes- thetics, it is a complication which is to be avoided, especially with nitrous oxide, ether and chloroform. In regard to the second theory, it is admitted that certain anaesthetics, like chloroform and ether, produce changes in the blood and in the heart, and if carried too far these changes will become permanent ; thej^ however, are neither necessary nor essential to the production of true anesthesia. It is somewhat remarkable that the fate of almost all the claimants to the discovery of anaesthesia was so tragical. We have already referred to the sad end of Dr. Wells. Dr. Charles T. Jackson died at Somerville, Mass., after a seven j^ears' ill- ness, a disappointed man, although receiving an honorarium and medal from the G-overnment of France. Morton, having been reduced to poverty during the long twelve years in which he endeavored to wring from Congress and the courts recog- nition of his rights, died suddenly in New York City, in 1868, of cerebral congestion, brought on, it is said, by reading a work attacking his claims. How much more fortunate was Professor Simpson, of Edinburgh, whose introduction of chlo- roform won for him a baronetcy, the highest honors of his pro- fession, a statue in Edinburgh and a memorial bust in West- minster Abbey ! Long was the happiest. He died, comparatively little known, in 1878, a poor man, though now his statue, with that of Ogle- thorpe, will represent Georgia in the National Gallery at the Capitol. Owing to the bitter controversy that resulted from the claims of Wells, Morton and Jackson to the discovery of ether anaesthesia, a monument was erected in Boston with only the following inscription : "To commemorate the discovery that the inhalation of ether causes insensibility to pain. First proved to the world at the Massachusetts General Hospital, in Boston. October, A.D. MDCCCXLYI." Cocaine. After the prolonged use of the systemic anaesthetics, ether, chloroform and nitrous oxide, from 1846 to 1896, it has been 38 ARTIFICIAL ANAESTHESIA. found that with the free use of chloroform and ether, deaths would follow their use in the hands of even the most expe- rienced, careful and conscientious physicians and surgeons all over the world. The deaths from the third agent, nitrous ox- ide, were comparatively few ; but owing to the cost and the me- chanical apparatus required for its use, even with the addition of oxygen, but few surgeons would employ it in protracted operations. It was still a desideratum to find a local ancesthetic agent, that would be safe and could be employed in more or less extensive operations. In 1855, Gaedeke discovered in coca an alkaloid to which he gave the name " erythroxyline." This principle was first thoroughly studied by Dr. Albert Niemann, from whom it received the name "cocaine," and he found it to be a most valuable local angesthetic. The first to use it extensively was Dr. Karl Roller, of Vienna, who found it a local anaesthetic and of vital importance in operations upon the eye. His ex- periments and observations were received with enthusiasm all over the world, but especially by ophthalmic surgeons. Like every other new anaesthetic, it was applied in a great variety of methods, but with little knowledge of its true physio- logal action and in too strong solutions. We made a series of experiments with the drug, as early as May, 1889, in the labora- tory of the University of Pennsylvania, to determine its action, in conjunction with Professor Reichert. A dog weighing 8 kilo was injected with li grains of Merk's hydrochlorate of cocaine. Pulse 172, temperature 38.9, the amount of cocaine being at the rate of 2 centigrammes per kilo. Without going into detail, there were jerking movements of the muscles, intoxication, the pupils became dilated, balls promi- nent and hard from increased intra-ocular pressure. In the course of ten minutes, convulsions supervened, both clonic and tonic. When fully under the influence of the drug, sight and hearing seemed to be unimpaired until convulsions set in. In another experiment in a dog, weight 16^ kilo, pulse and temperature were the same. When the dose of the cocaine was doubled and the injection made near tlie spine, the brain be. came evidently very much affected and delirium was much more decided, with great excitement. Respiration very much more EUCAINE HYDROCHLORATE. 39 rapid, with panting and salivation. Ears thrown back, eyes protruding, balls hard, pupils dilated, with increased heat of body. The fatal dose in dogs was found by Dr. Reichert to be 0.03 gram per kilo. Subcutaneous injection produced local anaes- thesia at the point of application. When taken internally it appeared to act as a stimulant and in large doses had a para- lyzing action on the nerve centres. It affects, first, the cerebral hemisphere, next the medulla and afterwards the spinal cord. In spite of these and other careful observations, the drug was emploj^ed in large quantities and in very improper cases. Grradu- ally, as cases of poisoning took place, and even deaths followed, alarm was taken, and many, from fear, ceased to use it. In November, 1894, Dr. H. V. Wiirdemann brought to the notice of the American medical profession his experiments and conclusions obtained by following out Schleich's method and the line of experiments instituted a month before by Schleich, of Berlin, relative to the local anaesthetic properties of water associated with a minute quantity of cocaine, morphia and sa- line water. The success of this new method is due to the way in which the injection is made, as care is taken merely to affect the tissues to be involved in the operation, only a small radius being deadened by each quantity of solution. No tissue, either of bone or muscle, has yet shown resistance to aqueous anaesthesia if rightly followed. Cases are already being reported from parts of the United States, and so far the reports seem to be warmly favorable to the adoption of the new method in all surgery, at all events, in even the gravest class of operations. Eueaine Hydroclilurate. This is a new local anaesthetic, discovered in 1896, and a sub- stitute for cocaine, and it is stated by a number of good au- thorities to be free from some of the objections to cocaine. Like cocaine, eueaine is the methylester of a benzoj^lated oxy- piperidin carbonic acid. Its constitution is represented by the formula : 40 ARTIFICIAL ANESTHESIA. CfiH, — CO — — n - COOCH CH, CH3C C.H, C-CH3 CH, N. C.H3 The hydrochlorate of eucaine, which is to replace the hydro- chlorate of cocaine , has the following chemical constitution : CagH^^No^HCL. This new compound differs from cocalin* in that a methyl group is substituted in it for a hydrogen atom which is formed by the action of ammonia upon acetone. * Cocalin is poisonous. PAET SECOND. NITROGEN MONOXIDE— NITROUS OXIDE GAS (NO-N2O), CHAPTER III. Nitrous Oxide Gas — Mode of Preparation and Chenaical Composition — Gasometer and Inhaling from it — Liquid Mtrous Oxide and In- halers — Ansesthesia from Nitrous Oxide — Physiological Action of Nitrous Oxide Gas — Experiments with the Gas — Additional Facts in Reference to the Physiological Action of Nitrous Oxide. Nitrous Oxide Gas, its Mode of Pi'eparation and Clieniical Composition. As nitrous oxide gas was the first agent employed under the title of an anaesthetic we have placed it first on the list in this edition. It has powerful claims to our notice, first, that so few deaths have followed its careful and conscientious use, and, sec- ond, it is the most extensively employed of any one of the sys- temic angesthetics. Nitrogen monoxide, or nitrous oxide gas (NGr — N2O) is pre- pared from the nitrate of ammonia (this is now obtained from the waste products of gas works by the action of nitric acid) ; it is then purified, which process resolves it into the gas and water, thus : NO3NH4 = = N2O + 2 H2O. The nitrate of ammonia is a crystalline salt, but for conveni- ence of introduction into the retorts should be in granulated form, which can be obtained of the manufacturing chemist. 4 Plate 3 (Figs. 1,2, 3). Gasometer aud luhaler. GASOMETER FOR NITROUS OXIDE GAS. 43 Plate 4. Gasometer for Prepariiig^ Nitrous Oxide Gas. The most important apparatus to be furnished is a convenient reservoir or gasometer (this can be made bj' any intelligent tin- smith, as the dental depots do not now supply them, furnishing only the washing bottles, etc.), an illustration of which is seen at Plate 3, with Nos. 1 , 2 and 3 bottles. These can be obtained from the dental depots. Care is required in the selection of the bottles for washing and purifying the gas. Plate 4 represents the best form, which is furnished with per- forated rubber cork and glass tubes bent at right angles. The long tube which dips into the bottle is pierced with small holes at the bottom nozzle ; this agitates the gas, and so insures its more thorough washing. In puri- fying the gas some employ a solution of sul- phate of iron in bottle No. 1 , and pure water in the other two. To remove chlorine gas, which is sometimes present, and can be noticed by its green color and its irritating action upon the respiration, a small stick of caustic potash may be added to one of the bottles containing the pure water. When no chemical agents are employed in the puri- fication of the gas it should be well washed through fresh water and allowed to stand for some hours over the water in the gasometer, to remove any im- purities that may have passed over. Plate o represents the gasometer in position. The holder is first filled with water to within one and a half or two inches of the top ; while this is being done take ofi" the weights and open all the spigots, to allow the air to pass out, and the receiver to remain in position. The long pipe of bottle No. 1 must not dip under the water, for the tubing thereby becomes choked with dense vapor and the free passage of air is interrupted. Into wash-bottle No. 2 place about four ounces of sulphate of iron, and add sufficient water to cover the end of the dip-pipe, about one and a half to two inches. 44 Artificial anesthesia. Into wash-bottle No. 3 it is unnecessary to place anything but fresh water ; yet some, fearing the chlorine, add a stick of caustic potash. Sufficient water should be employed to cause the pipe, which dips into the water, to sink the same depth as it does in No. 2. When bottles are prepared, connect them with a piece of rub- ber tubing and to the spigot of the gasometer. If they are arranged properly a current of air blown into the tube, intended to connect with the retort, will cause the water to bubble in the wash-bottles Nos. 2 and 3, and if the spigot is open the re- ceiver will commence to ascend. Having the bottles in readiness, and properly connected, place the quantity of nitrate of ammonia which will be required into the retort (one pound of granulated salt will produce about thirty gallons of the gas). There is a stove-like arrangement heated by gas-burners, with a sand-bath for holding and heating the retort. Connect the retort with the long pipe of the first bottle by the rubber tub- ing, and then open the spigot of the gasometer. The heat must be applied graduall}'^, first to melt the am- monia, about 226° F. , and then to cause it to boil and give ofi" gas at 460° F. to 480° F. until it is nearly all decomposed. When the gas has ceased to come over take a cloth and dis- connect the retort from the tubing and close the spigot of the gasometer. The inhaling-tube is attached to the spigot at the top of the holder. There is a register which shows the number of gallons of the gas in the receiver. When the holder is filled, close the spigot and arrange the weights ; it is then ready to receive the gas. The wash-bottles are placed as represented in Nos. 1, 2, 3, which are connected one with the other, and to the retort and gasometer, by means of rubber tubing. The first bottle, No. 1, is placed next to the retort, and is simply used to catch the drip resulting from condensed vapor. The water and solutions contained in the wash-bottles should be changed once in a month. When nitrous oxide gas is thus obtained it is colorless, almost inodorous and of a sweetish taste. The chemical composition is as follows: Nitrate of ammonia IRON RETORTS FOR MAKING NITROGEN GAS. 45 resolves itself into nitrous oxide gas and water; thus NO3NH4 = N2O + 2 ll-iO. The heat necessary- to cause active evolution of gas is stated to be 460° F. , and this heat should be kept up, else a portion of the salt will sublime. The heat should never be allowed to rise above 482° F, , as the nitric oxide is apt to be given off in the form of an orange-colored vapor. In infinitesi- mal explosions, nitric oxide is a dangerous impurity, as it can- not be breathed unless very much diluted, and tends to suspend respiration and produce spasm of the muscles of inspiration. To determine the proper temperature a thermometer is prepared which can be passed into the cork and into the retort, so that no risk from superheating need be incurred by the introduction of poisonous materials into the gas. After the gas is made it should stand over water for a few hours, not longer, else endosmotic action will take place and weaken the gas before using. This will do little toward insur- ing absolute purity of the gas ; neither will washing it through the solutions of iron and potash purif\' it perfectly. Should there be chlorine present (which is the poisonous element) in the nitrate of ammonia no amount of washing through solutions will obliterate it. The ammonia should alwaj's be tested before using ; this is done by dissolving about a teaspoonful in half a tumbler of distilled water and applying a few crystals of nitrate of silver. If the ammonia be pure the solution will remain perfectly clear ; but should chlorine be present it will show a clouded appearance and impure ammonia, which must be dis- carded altogether. Iron Retorts for Making' Protoxide of Xitrogen Gas. Nitrous oxide for dental operations has come into general use, and dentists making their own nitrous oxide must have doubtless met with great difficulties in consequence of the breaking of the glass retorts. To obviate- this inconvenience, the idea has been suggested to use iron retorts. One can be made of rolled iron. 14 inches long by 6 inches wide, outside measure, of a quarter of an ijich thick, the joints being brazed together and perfectly air-tight. The bottom of the bottle is convex outside and concave inside, and the top opening is one 46 ARTIFICIAL ANESTHESIA. inch wide, with a threaded screw inside the mouth of the bottle. To this is attached a tube two feet long with a threaded screw to enable the unscrewing of the tube in order to put the nitrate of ammonia into the bottle. The iron tube is bent at a curve just above the mouth of the bottle, and is two feet long, and the other end of the tube being on a level with the moutli of the bottle, the bottle can be either suspended or placed over a gas-burner or on a fire and the receiver remain in position. The iron retort must be lined with porcelain. All gas must be purified before being employed, by the same method as above directed. Inhalers. Next to pure gas, a perfect inhaler is most essential to the successful administration of nitrous oxide. Thomas' Nitrous Oxide Inhaler. The Thomas Inhaler, Plate 5, used with gasometer, is turned from a piece of vulcanized rubber, eight inches long by three inches square, leaving the mouth-piece one inch and a half Plate 5. ENTRANCE \IA0UL JUiPi f ""^ MOUTH PIECE across. The diameter of the opening is a little more than one- half an inch with stOp-cock in the centre, in which is the inhal- ing valve. This is constructed of a simple piece of rubber dam secured by a pin to a stopple, in which are three oblong aper- tures which have the inhaling valve at the extremity of the in- haler. The aperture, being of sufficient size, is made so as not to obstruct the free passage of the nitrous oxide gas. The INHALER FOR NITROUS OXIDE. 47 valves are three-quarters of an inch in diameter, and the stopple is of vulcanized rubber. It must liave a tube large enough to admit the gas so freely that the most nervous, as well as patients with weak lungs, can inhale through it without exertion, and it must be perfectl}' air-tight. Some inhalers are so constructed that it is only by using great effort, that patients can supply air to the lungs to the amount of their natural capacity, causing them to struggle or go into the anaesthetic sleep with such feelings of suffocation and depres- sion, that they will drift into dreams of the most frightful char- acter, and become almost unmanageable in their excitement. Nitrous Oxide Inhaler. This inhaler* is the simplest, cleanest, most convenient, most effective ever used for the administration of nitrous oxide. It is almost entirely automatic in its action, and requires the use of but one hand, the inlet valve being opened by a slight pressure of the thumb, so that the gas can be turned on without the patient's knowledge. Upon the removal of the pressure, the valve closes automatically and shuts off the gas. The sectional view shows the internal construction. An open- ing, B, underneath the body of the inhaler admits the gas through a similar opening, A, in a sliding tube, GG, fitting in- side of and projecting beyond the rear portion of the main body. The projecting portion is perforated for the admission of air, and its outer end is closed by a cap. At the inner end of the sliding tube is a coil spring, E E, abutting against a shoulder in the body of the inhaler. This spring holds the sliding tube in the position shown in the cuts, closing the inlet, B, when the gas is not being used. Pressure on the cap compresses the spring, closes the perforations for the admission of air, and brings the opening A over B, affording a free flow of gas to the mouth-piece through the inhaling valve. The sliding tube is prevented from rotating by the screw-pin, D, which works in a slot, C. The inhaling and exhaling valves — the former in- * The S. S. White Co. Plate 6. ternal, the latter external— consist of two thin disks of mica, F F, which are inclosed in circular open cages. The inhaling valve is open- ed in respiration by being drawn against the front of the cage, the exhaling valve being closed by the pressure of the outside air. In expiration both disks are thrown against the further ends of the cages, opening the exhaling and closing the inhaling. The entire inhaler, except the mouth-piece and the two valve-disks, is of metal, smoothly finished, the outside polished and nickel-plated. It is readily taken apart for clean- ing. The illustrations are half-size. Flexible Face-Pieee tor Inhalers. Plate 7. 50 ARTIFICIAL ANESTHESIA. In this form of face-piece the oval shape is maintained by the peculiar metal fittings, as shown in detail. It can be applied to the JNo. 1 or No. 3 inhaler. The inhalers which cover the entire face are sometimes objec- tionable to delicate patients. It must be remembered that the color of the blood, as shown through the mucous membrane of the lips is one of the principal guides to the condition of the pa- tient during the inhalation of gas, and if they are covered too closely from view by the hood or otherwise, we have lost that means of diagnosis. In instances of hare-lip, or where, from swelling or other causes, the muscles of the jaw become so con- tracted as to render it impossible to pass the mouth-piece be- tween the teeth, a rubber covering is recommended. Inflatable Face -Piece for Inhaler. The inflatable face-piece consists of a soft rubber hood with an inflatable edge-cushion attached to a metal frame, which is screwed into the inhaler. The frame, which preserves the shape of the hood, may be readily detached for cleansing by un- screwing the nut which holds it to the neck of the inhaler. The cushion is inflated through the little tube. The best adaptation to the face is obtained when it is only partially distended. The inflatable face-piece* consists of a soft rubber hood with an inflatable edge-cushion attached to a metal frame, which is screwed into the inhaler. This frame, which preserves the shape of the hood, may be readily detached for cleansing by un- screwing the nut which holds it to the neck of the inhaler. The cushion is inflated through the little tube. The best adaptation to the face is obtained when it is only partially distended. This is an improvement on a face-piece which has been in use in England for several years. In adapting it to the No. 3 in- haler we have found it desirable to place the exhaling-valve on the frame of the face-piece. * The S. S. White Co. Inflatable Fay Anaesthetic Ag-ents— Conclusions. In conclusion, there are various practical considerations which the writer thinks may well be taken into review while studying the physiology of nitrous oxide narcosis. If nitrous oxide acts as a sedative in virtue of its own inherent properties, and does not owe its value as an anaesthetic to asphyxial processes called into play by concurrent privation of oxygen, it should be our aim to push the gas and give free vent to expired gas. We should see that our patient changes as freely as possible his residual air during inspiration, and expires as freely as possible the refuse-laden nitrous oxide, which has been stationary within the air-spaces during the last respiration. We cannot but think that, whatever may be the saving of gas brought about by employing supplemental bags wherein the nitrous oxide is collected and reinspired a.gain and again, the patient suffers thereby from the double evil of breathing diluted and impure nitrons oxide, and, further, is not favorably placed BLOOD ALTERATIONS BY ANESTHETIC AGENTS. 93 for exhaling the refuse of the lungs. We should incline to attribute to this method the cases one occasionally meets with of severe headache, vertigo, dizziness and other untoward symptoms consecutive upon nitrous oxide inhalation. It is a very im- portant point to induce very free inspirations of pure nitrous oxide, and to avoid anything like inducing partial asphj^xia, and in practice this gives the best and most satisfactory re- sults. The behavior of the heart under nitrous oxide should encour- age us to use this agent freely, and during its administration to icatch rather the respiration than the pulse, since it would ap- pear that syncope, if it occur, occurs secondaril}" through the luUing to sleep of the respiratoi^ centres. The cases in which nitrous oxide has been said to kill by heart failure are few, and even in these we are not at all sure that the fatal faint was not due to fear or shock incurred by a nervous system already shaken by suffering, and rendered still more obnoxious to shock by an imperfect narcosis. When we remember the period of heightened sensibility which precedes complete restitution of consciousness, we can easily comprehend the terrible jars a de- bilitated nervous system must sustain if operative procedure be carried on into this stage. Clover long ago pointed out from his vast clinical experience that patients may be allowed to cease breathing, and yet no fear need be entertained, as a few vigorous pressures upon the thoracic parietes will reinitiate respirations. Now we accept his statement, and explain it under physiological laws. There are other practical points that are suggested by knowl- edge of the action of nitrous oxide. Of these, not the least important is that the erotism called into existence in a fairly large proportion of patients, and controlled only in a few by the restraints of habitual thought and judgment, should render all persons most careful to avoid possible incrimination through hallucination. For the sake alike of patient and operator, a witness should always be within earshot, or within sight, when- ever nitrous oxide is administered. Again, the decided action this anaesthetic has upon the nerve centres, and its tendency to call forth irregular explosions of 94 ARTIFICIAL ANESTHESIA. nervous energy, might by some be taken as contra-indicatory to its employment for patients who are the subjects of epileptiform seizures. We do not, however, think we can with justice say that the giving the gas renders a fit more likely to occur than the operation. We are aware any strong excitant will call forth a seizure, whereas the sedative action of the nitrous oxide will, by lessening stimulation from without, be less inclined to pro- voke the attack. Nitrous Oxide in General Surgery. Dr. L. Macdonald, of Washington, D. C, has found, while not discarding ether and chloroform, nitrous oxide gas capable of producing anaesthesia of a degree that was quite satisfactory for the performance of such prolonged operations as breast ex- tirpation, laparotomies, hysterectomies, amputations — indeed, almost all operations in surgery, except those within the oral respiratory tract, whether the operation required two minutes or two hours. It cannot always be relied upon to produce thorough and complete muscular relaxation. It is therefore not the best an- aesthesia for use in the examination of joints, displacements, fractures, etc. From the point of economy and convenience he has found it is far inferior to other anaesthetics, as each pro- tracted operation costs about two dollars. We have published in our third edition, p. 136, that as early as March, 1874, Dr. D. H. Goodwillie published a paper, which had been read before the Medical Library and Journal Associa- tion of New York, of his success in a prolonged surgical opera- tion by the administration of nitrous oxide gas.* On April 20, 1875, C. A. Brackett, D.M.D., of Newport, administered the gas (about thirty minutes) for Dr. Squire of that city for the removal of a cancer of the breast (second operation), as he did not dare to give ether, the patient being so debilitated, f It is Dr. Brackett's impression that the late Dr. J. Marion Sims was among the earlier, if he was not the earliest, to use ■•'■ Johnson's Dental Miscellany in March, 1874. t Private letters of Dr. Brackett. NITROUS OXIDE AND OXYGEN AS AN ANAESTHETIC. 95 nitrons oxide in long operations, and notably in uterine andi abdominal surgery. His knowledge of anaesthetic agents was, comprehensive and intimate, and the nature of the operation which he specially performed gave him strong reasons for wish- ing to avoid the vomiting and retching following the use of' ether. There probably are records accessible to determine, at least approximately, the time of his beginning to use nitrous, oxide in his practice. However, in the article above named,, page 224, Dr. Sims says : "Nitrous oxide has been used in general surgery by many- eminent surgeons in New York, Philadelphia, Baltimore, and elsewhere. It has been used successfully in New York by James R. Wood, Carnochan, and others. The late Marion Sims has used it in difficult and prolonged operations (ovariotomy) re- quiring thirty, forty, fifty-seven and sixty minutes, and in one case one hour and fifty minutes, and always with most satisfac- tory results. ' ' The reference on page 136 to Dr. Goodwillie's article should be to "Johnson's Dental Miscellany, Vol. I., No. 3, p. 85." "Dr. Brackett appreciated many years ago the fact, that owing to the necessity of suspension of administration before operations in the mouth began, nitrous oxide was, in a sense» less well adapted to such operations than it is to almost all other minor surgery. Some years ago he was permitted to address the Newport Medical Society on the subject at a regular meet- ing, urging then, as he had done many times privately before and since, the great aid and comfort that nitrous oxide may and should be to general practitioners and specialists, other than dentists, in multitudes of cases occurring every day in which such help would be acceptable. It is most gratifying to him that the agent is gradually winning its way to a larger useful- ness." Nitrous Oxide and Oxyg^en as an Anaesthetic. The great advantages of nitrous oxide, as an anaesthetic, have induced various observers to endeavor to find a method of administering gas continuously, so as to keep up the anaesthetic 96 ARTIFICIAL ANAESTHESIA. influence for a sufficient length of time for the performance of surgical operations. Paul Bert, some years ago, made experiments with animals in a chamber of compressed air, a mixture of nitrous oxide and oxj^gen being inhaled. He found that anaesthesia could be kept up for a long period, and he urged the construction of such chambers for operating upon the human subject. Some few- experiments were made in minor surgery, but nothing was attempted on a large scale on account of the bulk and ex- pense, etc. In 1881, Dr. Si Klikovich, in St. Petersburg, made some ex- periments on himself with a mixture of nitrous oxide and oxygen in the proportion of 80 to 20, without any increase of atmos- pheric pressure, with a satisfactory result. Zweifel soon fol- lowed, and later Hillischer. Hewitt's Apparatus. In 1892 I received from my friend, Frederick Hewitt, M.D., of London, Lecturer on Anaesthetics at the London Hospital, a pamphlet in which he gives the report of a series of cases, with a description of his apparatus and mode of using the same. I have had also the opportunity of testing his instrument, as ex- aminer of anaesthetics, in conjunction with Professors Dorr and Cryer, at the Philadelphia Dental College. The following is an illustration of the instrument, with a de- scription : Hewitt's New Simplified Portable Apparatus for Administering- Nitrous Oxide and Oxygen.* Directions for Use. — All air or gas should first be pressed out of the double bag,t the indicator turned to "air" (see *See Dr. Hewitt's paper on "Further Observations on the Use of Oxygen with Nitrous Oxide," in The Joicrnal of the British Dental Association for June 15th, 1894. fit is not advisable to press the bags too tightly, as the suction caused by the sides adhering together has a tendency to draw the valves in the delivery tilbes through to the wrong side. APPARATUS FOR ADMINISTERINa NITROUS OXIDE. 97 Plate 20), and the two divisions of the bag nearly, but not quite, filled with their respective gases, by rotating the foot keys. No further addition of oxygen will be needed. The Plate 19. Apparatus complete. face-piece should then be very accurately applied. Air will be breathed freely through the apparatus. The valves should be heard to act, otherwise the face-piece is not fitting, or the patient is not breathing as freely as he should. The indicator 98 ARTIFICIAL ANESTHESIA. is now turned to "1," which means that nitrous oxide with a small quantity, possibly 1 or 2 per cent., of oxygen will be inhaled. It is most important that the two divisions of the double bag should be kept equally and partly distended, as shown in Plate 19. The anaesthetist must therefore keep his foot almost constantly turning the nitrous oxide foot key in order that the two parts of the bag may remain equal in size throughout. After two or three breaths at " 1 " the indicator should be turned to "2," and progressively, after every two or three breaths, to " 3," "4," "5," "6," "7," "8," "9," or "10," according to the type of patient. In children and very anaemic persons the indicator maybe placed at "2," "3," or even "4," to start with, and turned to a fresh number every breath or two. But in adults in good health less oxygen must be given. Important. — As it is essential to the proper working of the apparatus that all the four valves act well, and the ten oxygen inlets be kept entirely clear, it is recommended that the appa- ratus be taken apart from time to time and the condition of these ascertained. To Examine Oxygen Inlets. — Take out the three milled head screws, remove the indicator handle with detent spring, replace the centre screw in dial side of stop-cock, and pull out the inner drum. If any of the openings appear to be clogged pass a piece of metal wire of suitable size through each one until quite clear. Lubricating Inner Brum. — It is very important that no grease or oil be put on that part of the drum which revolves immediately over the oxygen inlets. Any neglect of this will cause them to get choked, and render it necessary to take the apparatus to pieces again. To Examine Valves in Delivery Tubes. —Slip off the necks of gas bag one after the other, the valves can then be drawn out of the tubes by the finger. In replacing them always have the inlets to mixing chamber open, to avoid the rubber dies being forced through to the wrong side. The centre screw, which keeps in position and regulates the tension of the detent spring, will in time get somewhat slack ; APPARATUS FOR ADMINISTERING NITROUS OXIDE. 99 it should then be screwed up again to the necessary' degree of tightness. The experience of many observers, but especially that of Professor Hillischer, of Vienna, and Dr. Hewitt, of London, demonstrates the fact that a mixture of oxygen with nitrous ^ggw4 may be practically utilized as an anaesthetic, and that such \ Plate 20. Indicator, etc. a mixture is in all respects the safest and most satisfactory agent at our command for minor surgical operations. It en- ables us to utilize the anaesthetic feature of nitrous oxide with- out its one element of danger, viz, its tendency to produce asphyxia. While the records show that the asphyxial factor of nitrous oxide narcosis is but a slight element of danger in its use — for no anaesthetic has been so largely and indiscrimi- nately used — it is still important that we should take advantage 100 ARTIFICIAL ANAESTHESIA. of any means which will successfully eliminate this one danger- ous feature. The method and apparatus devised by Dr. Hewitt fully meet all practical requirements, and though somewhat more complicated than the ordinary nitrous oxide apparatus, is sufficiently simple and convenient, as is seen in the drawing he has sent us. In our own experiments we have found that it takes a little longer time to induce ansesthesia in the human subject by the mixture of nitrous oxide with ox3"gen than when pure nitrous oxide is used. There is to be noted in this connection that while it takes longer to induce anaesthesia with the oxygen and nitrous oxide mixture than with nitrous oxide alone, the result- ing anaesthesia is of longer duration where the mixed gases are used. Dr. Hewitt's figures relative to average period for inhalation for dental operations are as follows : Average Period of Inhalation for Dental Operation. Average Period of Resulting Ansesthesia. NgO per se, . . . . NgO -h in sufficient quantity to prevent all asphyxial symp- toms, About 51 seconds. About 110 seconds. 30 seconds. 44 seconds. In typical cases of ansesthesia by mixed oxygen and nitrous oxide, there is almost an entire absence of cyanosis, stertor or jactitation, which are the characteristic symptoms of asphyxia. It is this fact which proves our theory that nitrous oxide pos- sesses anaesthetic properties apart from those which it induces by virtue of its shutting off of oxygen. According to Jol3'et and Blanche, coma is not produced until the amount of oxygen in the blood is reduced to between three and four per cent. When so reduced, we have cyanosis as a concomitant. The absence of duskiness of the features may be relied upon as an indication that there is certainly a greater amount of oxy- DR. Hewitt's method of using nitrous oxide. 101 gen than four per cent, present. M. Claude Martin, of Lj'on-s, administered to a dog a mixture of nitrous oxide with fifteen per cent, of oxygen for three consecutive da3's, with apparently no ill eflfects upon the animal. " It must be evident, then, that we have to deal, in the case of the mixed gases, with an anaes- thetic which does not induce asphyxia ; or, if so, the condition is modified to an extent which obliterates its ordinary character- istic symptoms. It is also evident, for this reason, that it pos- sesses greater freedom from danger. If it can be demonstrated that the anesthesia induced by the mixture of nitrous oxide and oxj'^gen, is nevertheless caused by the action of insufficiently oxygenated blood upon the nerve centres, notwithstanding the entire absence of all of the usual symptoms of oxj-gen-starva- tion, we may strongly suspect that other well-known anaesthetics act in an analogous way, by interfering with proper oxygenation of the blood." ' On Dr. Hewitt's 3Ietliod of Using- Xitrous Oxide and Oxj'gen as an An^estlietie. The views which have been published in this country have been, in the main, favorable to the employment of Dr. Hewitt's method in dental operations and minor surgery. The following was the time consumed by this method in the case of two pa- tients, Dr. J. D. Thomas performing the operation for the re- moval of carious teeth. In the first case, one hundred and ten seconds were consumed before the corneal reflexes were fully abolished, and, as nearly as could be determined, there re- mained forty seconds of available anaesthesia after removal of the face-piece. In the second case, one hundred and sixty seconds were con- sumed in the administration, resulting in thirty seconds of avail- able anaesthesia. In the pulse, as reported, at the close of the administration there was found but slight variation either in fulness or frequency. There were none of the usual sjTnptoms of asphyxia manifested, there being an entire absence of blue- ness, stertor or jactitation. Dr. Thomas objects to the face- piece of Dr. Hewitt, as he desires at all times to see the patient's lips. 102 ARTIFICIAL ANESTHESIA. Dr. Kirk,* who read a valuable pai)er on the subject of Dr. Hewitt's method from personal observation, made the following remarks at the conclusion of the discussion : "I want to correct one idea of Dr. Thomas that is erro- neous, namely, that the time of administering the mixed gases is in any sense a guide to the condition. We were simply timing the administration as a matter of record, and not as a guide for the anaesthetic condition produced. "There is another point to be borne in mind in relation to the face-piece as used in this method. By Dr. Hewitt's method you are giving oxygen in connection with the nitrous oxide almost from the start, and the patient is getting a certain amount of oxj^gen immediately. There is no time when the patient is not taking some oxygen. Consequently, the chances of oxygen-starvation are very much lessened, the asphyxial condition to which Dr. Thomas alludes being constantly pre- vented, and we thus eliminate what is a very potent element of danger in giving nitrous oxide alone. "I quite agree with him as to the danger of proceeding with the administration where the patient so quickly succumbs and becomes cyanotic under pure gas. There the face-piece, I ad- mit, is a serious objection, but in the method of Dr. Hewitt the fact that we are giving oxygen continuously with the nitrous oxide is a safeguard against any accident which may occur from the inability to see the lips." Conclusions of Dr. Hewitt. "So far as my experience has gone, I am inclined to regard the use of oxygen with nitrous oxide as of distinct advantage in the large majority of cases in dental practice. But we cannot shut our eyes to the fact that the administration of the mixed gases involves more time, more attention to detail, and more skill than are essential for the employment of nitrous oxide in the ordinary manner, whilst the risks of unpleasant after-effects * Dental Cosmos, Dec, 1894, op. cit. Experiments made with Prof. Dow and Dr. M. H. Cryer. Dr. Kirk, editor of the Dental Cosmos, meeting of Academy of Stomatology. CONCLUSIONS OF DR. HEWITT. 103 are a trifle greater. It hence follows, that unless we can show that the gain is considerable we are hardly justified in advocat- ing an}' departure from the usual lines of practice, I have attempted to point out that in many instances this gain is con- siderable, and for my own part I shall certainly continue to use the mixture in preference to ordinary nitrous oxide for such cases. But when a very short operation has to be performed upon a patient who has taken nitrous oxide itself on a pre- vious occasion with the best results, I would continue to use it." When any additional preparation might alarm a nervous sub- ject, or when time is a matter of great consideration, the use of nitrous oxide per se is possibly preferable to that of the mixture. I need hardly remind, you that it is not always an easy matter to prophesy the duration of an operation. A tooth which is looked upon as easy of removal often gives trouble, and under these circumstances an additional fifteen or twenty seconds in the anaesthesia may make all the difference in the result of the case. By the use of the apparatus brought before your notice, an attempt may be made in every case to secure the satisfactory form of anaesthesia which has been described. Should the case turn out to be an exceptional one, nitrous oxide alone can at once be substituted with the best results. In this way every case may be brought to a successful issue. The extra trouble incurred by having a bag full of oxygen in communication with the ordinary nitrous oxide apparatus is very small, whilst the benefits that will result in the majority of cases from the addi- tion of a proper proportion of this gas are very great. The mixture is to be chiefly recommended as preferable to nitrous oxide itself — (1) In children ; (2) In anaemic and debilitated patients ; (3) In any one who has previously exhibited great unsuscep- tibility to nitrous oxide, and has remained a very short time under the influence of the gas ; (4) In patients who, under nitrous oxide itself, have experi- enced unpleasant sensations ; (5) In patients very advanced in j^ears, and in those suffering 104 ARTIFICIAL ANESTHESIA. from such serious visceral disease that ordinary nitrous oxide seems unadvisable.* Observations on the Stateiiieiits and Abstracts from Monograph of Dr. H. C. Wood.f Experimental Study of Nitrous Oxide. The length of time which Drs. Wood and D. Cerna found to elapse between the commencement of inhalation and anaesthe- sia, varied from fifty-one seconds to three minutes and fifty seconds. The average period, two minutes and eight seconds. This is the same as given in our manual, p. 92, one minute fifty-five seconds ; never less than one minute forty-nine sec- onds. Pulse experiment, 1. The inhalation of nitrous oxide was immediately followed by an enormous rise of arterial pres- sure, associated with great disturbance of the pulse ; the heart beats very irregular, with long pauses, followed by a number of very rapid pulse beats. Compare these with the tracings at p. 91, on man in our work. This increase of the pulse in man is sometimes due to excitement resulting from fear. As soon as the inhalation is free and full, respiration becomes slow, the tension of the pulse falls, the number of beats per minute is in- creased, the tidal or predicrotic wave is slightly better marked, and the dicrotic wave becomes well marked. When the mouth- piece is removed, and any operation is to be performed, the pulse undergoes a marked change. This is probably due to re- flex action through the vagus to the heart. Immediately after the operation the pulse gradually assumes its normal condition (in the reverse order) through the stages it had undergone when the nitrous oxide gas was applied. Experiment 4 shows the pulse so characteristic of the action of nitrous oxide gas. When the pneumogastric had been pre- viously divided it is absent, and it is therefore due to stimula- tion of the inhibitory cardiac apparatus. This is the same idea, * Pamphlet received from Dr. Hewitt. t Presented to the Interoational Congress, Berlin, August 6, 1890, with the experiments with Dr. D. Cerna (The Therapeutic Gazette, August, 1890). EXPERIMENTS OF DR. WOOD. 105 only in different language, as is our work. The extraordinary rise in arterial pressure which took place in some of Dr. Wood's experiments during the inhalation of nitrous oxide gas, has, as he observes, an important bearing upon practical medi- cine. Some time since a death from apoplexy occurred in Philadel- phia* directly after the inhalation of nitrous oxide, and it is well known that Dr. Lafont, of France, has asserted that occa- sionally diabetes mellitus and albuminuria, have been produced by the anaesthetic use of nitrous oxide. It is entirely conceiv- able that in a man with atheromatous or otherwise diseased ar- teries the inhalation of the gas might cause a rise in the arte- rial pressure, which should produce rupture of smaller or larger vessels, and cause serious sj^mptoms. Chloroform directly depresses the heart, and even ether has a similar influence when it is in excess, but nitrous oxide would appear directly or indirectly, to stimulate the heart and to keep up this stimulation, at a time when the respiratory function is almost completely obliterated. Expeilinents with Nitrous Oxide Gas and Mtrogen Gas. "A lost respiratory function can be temporarily replaced by artificial respiration, but no substitute has been found at all for an arrested heart. It is easy to see why death has so very rarely occurred during anaesthesia from nitrous oxide. Dr. Wood comes to the conclusion by experiment ' that the fall of arterial pressure which occurs in the advanced stage of nitrous oxide anaesthesia, is due to vaso-motor paralysis.' The same danger, according to the Hyderabad Commission, is to be found in chloroform, viz., paralj^sis of the vaso-motor centre. Nitro- gen gas also received the attention of Drs. Wood and Cerna. The experiments were three in number, f In the first, uncon- sciousness was complete in one minute and ten seconds. Death * See details of case, Manual of Ansesthetics, p. 115 ; also influence of Nitrous Oxide on Brain and Spinal Cord, p. 18 ; and also a recent report of deaths. t Therap. Gaz., 1890. 8 106 ARTIFICIAL ANAESTHESIA. occurred three minutes after the beginning of the inhalation of the gas; the arterial pressure was raised in forty seconds twelve millimetres ; during the next ten seconds it went up ten millimetres more, and then fell abruptly eighty to ninety milli- metres in the next ten seconds, and continued to fall until death took place. The other two were similar, as may be seen by the table. The experiments, according to the doctor, indicate a parity of action between nitrogen and nitrous oxide, that the two agents act in a similar manner, that is, by shutting off oxygen. ' ' Oxygen and Carbonic Acid. "In the second series of these experiments was determined the action of oxygen and carbonic acid. In the first of these ex- periments, after the inhalation of pure oxygen for two minutes, the pulse was four beats per minute below its starting-point, and the arterial pressure three millimetres below its level. Ex- periment 13, the pulse at the end of four minutes of inhalation had been reduced eight beats, while the blood pressure had fallen four millimetres ; in the third experiment about the same. "These experiments certainly show that the inhalation of pure oxygen gas has no influence upon the circulation — a simple pumping out of the blood of carbonic acid. Then followed a direct experimental study of the effects of carbonic acid, pure and dilute with air, upon arterial pressure. "As a result of the experiments, Dr. Wood thinks that the following proposition is established : carbonic acid, when breathed into the lungs alone, sometimes causes a slight and temporary rise in the arterial pressure, but usually after a short time a very decided fall, having the most power when mixed with oxygen in the proportion of two to one. It also acts as a powerful pulse depressor. After section of the vagi, the inhalation of carbonic acid does not produce slowing of the pulse. ' ' The observations and experiments on oxygen of Dr. Wood differ from our own and many others, as we will be able to show under oxygen. THE AFTER-EFFECTS OF NITROUS OXIDE GAS. 107 The After-Eifects of Nitrous Oxide Gas. Many persons will remember that both Dr. Barker and the late Dr. Webb, while living, declared that thej' felt some ill effects in their own persons ^rom nitrous oxide gas. No one can read the full account which we liave given of the ph^'siological action of this gas upon the nervous sj'Stem, more especially the brain and spinal cord, without perceiving the powerful impressions which it makes upon these important organs, and how near unto death it may bring the patient. In our own experiments and those of Dr. Buxton on the brain and spinal cord, we have met with dilatation and laceration of the vessels, with of course an increased impulse in the blood supply to the nerve centres and vessels. Such a state would indicate a condition favorable to nervous energy, but this is soon followed by interference with the due regularity of the cerebral and cerebellum circulation, if carried too far, producing irregular muscular action, rigidity and ner- vous exhaustion ; also disturbance producing marked reflex action and even ankle clonus. Amongst the occasional phe- nomena which occur are opisthotonus, paralysis of the bladder and involuntary action of the urinary and rectal secretions. Another distressing class of symptoms are the excitation of the sexual centres and abolition of the normal checks imposed upon the production of orgasm. In some cases there is a quiet prolongation of nitrous oxide narcosis, unaccompanied by the wild convulsions of asphyxia, when the breathing absolutely stops while the heart beats on. Fortunatel}', in these cases, artificial respiration, conducted for one or two admissions of air, restores the patient to anima- tion, and all goes well. No danger is, in fact incurred, unless the anaesthetist is in- competent or negligent of his solemn charge. The following observations expressed in a recent discussion on the subject are of value : "Dr. J. D. Thomas recognized ten or twelve 5"ears ago the dangerous element of asphyxia in giving nitrous oxide, and it came in this way. In operations requiring considerable time it was considered dangerous to continue the inhalation long, but 108 ARTIFICIAL ANESTHESIA. by alternating a breath of air with a breath of gas it seemed to overcome all dangerous symptoms which accompany the asphyxiated condition from the use of pure nitrous oxide. Even in that class of persons who asphyxiate very easily, show- ing oxygen-starvation which begins as soon as the jSrst or second breath is taken, the admission of a little atmospheric oxygen will relieve it, so that has been the method which I have fol- lowed for ten or twelve years in certain cases, but not in all. "In giving nitrous oxide, the only danger accompanying it, in my mind, is the want of oxygen. That is exhibited in numer- ous ways. All the deaths that have occurred, when not by accident, and which have resulted from the physiological action of nitrous oxide, have been, to my mind, from the want of oxygen. "As to accidents, many things might occur. Among others, the one where there is considerable jactitation producing con- striction of the glottis. This is the result of asphyxiation, and one breath of air will relieve it entirely. Yet the glottis may be so constricted as to produce actual suffocation ; one or two have died in that way. That is, in my judgment, an accident, for as soon as the patient gets a breath of air he is safe. If the trachea had been opened below the larynx it would have been obviated. "Another phase of the want of oxygen is that shown in the respiration of people who breathe very slowly and who never oxygenate the blood to the proper degree in normal respiration, and who thus never get a full supply of oxygen. The moment it is reduced or cut off they immediately show an asphyxiated condition, and sometimes very quickly a suspension of breath- ing, which is perhaps the first exhibition of danger. Most of the deaths have been shown to have been by suspended respi- ration, the heart's action continuing some time afterward, some- times ten or eleven minutes. " Now there is the other extreme, the class of anaemic people ; their blood is lacking in red corpuscles to such an extent that the lips show no color at all. I have seen cases of this anaemic character which will often succumb, after taking the second breath of nitrous oxide, before any effect could possibly have ACCIDENTS IN EXTRACTING TEETH. 109 been made on the nerve centres directly by the gas. It is not the effect of the an 0. CAJ This body, commonly called ' ' ether, ' ' is manufactured on a large scale by heating a mixture of strong alcohol and concen- trated sulphuric acid to 140°. The reaction takes place in two stages : in the first, ethyl, sulphuric acid, and water are formed : CA] H) aH5] H] ^ + yso,= ^ so, 4- ^0. H J HJ H ) h] The ethyl, sulphuric acid acts at 140° upon another molecule of alcohol ; hydrogen and ether change places, and ether and sulphuric acid are formed : H J H H CsHJ CHEMICAL AND PHYSICAL PROPERTIES OF ETHER. 149 The ether and the water produced are distilled off, whilst the sulphuric acid remains behind, ready to convert another quan- tity of alcohol into ether. The Chemical and Physical Properties of Ether, Ether is colorless, very volatile, inflammable, both it and its vapor, which latter is twice as heavy as ordinary air, and sinks therefore to the floor, which is important to remember ; the vapor becomes ignited when a light has to be used, or a heated metal. It is soluble in alcohol ; its odor is garlic-like, strong and pungent. Its taste is hot, slightly soluble in water. Ether must be kept in the dark and in well and carefully prepared tins. When in ordinary use, keep in an opaque glass bottle ; for if kept in a hot place, or in the tropics, it is apt to change by absorption of water, undergoing decomposition and developing acetic acid, making it unfit for inhalation. A tin form of bottle has been found very useful in ordinary cases. The following are some of the methods of determining if the ether is pure for inhalation : 1. Ether, if pure, forms a clear mixture with oil ; but if it contains much water or alcohol, an emulsion will result, 2. Water is also detected by adding tannin ; for when water is present the mixture 'becomes syrupy, while, if absent, the powdered tannin remains unchanged. 3. Alcohol, if present, gives a red stain, with crystals of fuchsine ; it also increases the specific gravity. 4. Acids, sulphuric and sulphurous, when found in it, are detected by the precipitates they give with barium chloride ; also an acid which produces a deep red color upon the addition of an iron salt. 5. Fusel oil may be detected by leaving a greasy stain on paper, and, when inhaled, produces a burning and choking sensation — in some cases almost suffocation. The Inhalation of Ether— Etherization, Anaesthesia. Where ether is inhaled freely, mixed with too much air, it produces intoxication, with roaring and buzzing in the ears, 150 AKTIFICIAL ANAESTHESIA. varying in its effects upon different individuals. In some per- sons it causes depression, with weeping ; others, elevation of spirits, indicated bj^ shouting, laughing, singing; others dis- posed to fight or strut about declaiming, imagining themselves upon the stage. When still semi conscious, there is a feeling as if one's immediate surroundings were afar off, with visions and illusions. In this first stage the patients will open their eyes, and a slight noise or loud talking will arouse them. If now almost all air is withdrawn, and the patient breathes deeply and long, it brings about sooner or later the second stage of complete unconsciousness or ether narcosis ; but still there is muscular rigidity. As soon as this passes off, complete anaes- thesia takes place, when the patient lies quiet, with slow and regular automatic respiration, and the arm, when elevated, will fall as if paralyzed, and the eye, if touched, will not wink. Now and then we have a slight stertor in the breathing. This is the time for operation and the partial withdrawal of ether, giving the patient sufiicient ether to keep him fully under its influence. Very deep, stertorous respiration, due to paresis of the mus- cles of the palate, should be the signal for allowing air to mix with ether vapor or for the entire withdrawal of the anaesthetic. The usual appearance of the face of the patient during ether- ization is reddish, lips especially ; if very marked pallor and lividity show themselves, indicating failure of heart action, the ether is to be stopped at once, and the feet of the patient elevated and the head depressed until the color returns. An- other important sign of danger is what is termed shallow breathing ; the respiration, from being slow and regular, be- comes very much quickened, and then becomes slower and slower, until it gradually ceases or intermits for long intervals. In such case, stop the inhaler and admit cold air, or apply the vapor of aqua ammonia to the nose ; or to strike the chest with the corner of a wet towel, wrung out of ice-cold water, applied to the uncovered chest with some little force, or drop a little of the ether on the open chest, will generally cause the patient to make a sudden gasp, and rouse the respiratory function to action. If these measures fail, then resort must be had to artificial PRECAUTIONS TO BE EMPLOYED. 151 respiration, and the prevention of great reduction of heat, as the lungs are the cliief eliminators, the kidneys only doing a part, and j^et, if they are diseased, it is apt to produce great distress, and may be the cause of death. Precautious to be Euiployed Before aud After Usiug- Ether as au Ausesthetic. Ether should not be inhaled immediately after a full meal ; indeed, it is better to take only a biscuit or cracker, or a glass of wine or a teaspoonful of brandy and water, or a«scruple of bromide of potassium in water, half an hour before, always avoiding for several hours previous the risk and annoj'ance of a full stomach. Nothing like solid food should ever be allowed a feeble patient before inhalation for twenty-four hours. If nourishment is necessary, let it be of liquid character, like beef tea, as solid food, not digested, has been the cause of death in more than one person. Perfect quiet should be enjoined on all around the patient, as noise, or even loud talking, interferes with the perfect and rapid action of the anaesthetic. Nothing like a tight band or gar- ment should prevent the free action of the throat or chest, or interfere with the muscles of respiration. False teeth should always be laid aside until after the inhalation is over. An examination of the kidneys should always be made before using ether, as they are the active agents in eliminating ether from the blood, and if they are unaWe to perform this office, and if the skin is cold, moist, and inactive, death will super- vene by accumulation of mucus in the lungs, or congestion of the brain, as in true Bright's disease of the kidneys. Avoid all excitement to the patient from fear, sight of instru- ments, too many spectators, noise of any kind, etc., all of which tend to induce shock. Have appliances for resuscitation at hand, and plenty of fresh air during the administration of the anaesthetic. In ether the respirations and heart need to be watched during and after ansesthesia, and also prevent the reduction of temperature by hot bottles of water, etc. , in the later stages of narcosis from ether. 152 ARTIFICIAL ANAESTHESIA. luflaiiiinability of Ether, Treatment of Dangerous Symptoms.— 1. Nekton's plan suggests immediate inversion of the patient in case of heart failure, and artificial respiration^ keeping it up for some time. 2. Inhalation of gtt. v.-x. of nitrite of amyl may be given early, the tongue being drawn out to lift the epiglottis, by elevating the jaw (Nancrede). 3. Stimulation, in case respi- ration is affected, but not entirely suspended, should be em- ployed by means of either atropine, ammonia to the nostril, cold towel, or injection of ammonia into the veins, or ice in the rectum. 4. Galvanism, if employed, may be administered by the following methods : Herapath's method (Lancet, 1852). The positive pole is placed to the nostril and the negative pole over the diaphragm. A reflex action is thus excited between the fifth pair and the pneumogastric. This is used chiefly in case of respiratory failure or general galvanic action. Numerous accidents have come to our knowledge in which the ether was ignited, and, although causing no actual injur}'', produced much fear and confusion. Dr. Squibb has seen ether take fire at a measured distance of fifteen feet between the source of escaping vapor and the source of fire. This ignition of ether vapor is apt to occur while applying the actual cautery. All agents that produce inebriation, like alcohol, only increase the collapse, and the patient must be kept warm while under its influence, or the tempm-ature will sink below the normal, the skin become cold and clammy, with symptoms of collapse. The pulse-rate falls, the breathing becomes embarrassed, and an increase of secretion takes place in the lungs, and death occurs from pulmonary oedema and respiratory paralysis, just as in drunkards who are exposed to cold. On account of the simi- larity of their action, alcoholic stimulants should not be given where a patient appears to be sinking from ether administra- tion. Alcohol and ether, the more closely their effects on the lower animals are studied, the more closely are they seen to corre- spond. Atropia and digitalis, on the other hand, are of some value, but their effects have been greatly magnified ; they could PHYSIOLOGICAL ACTION OF ETHER. 153 be given in much larger doses than we are accustomed to and without harm. In considering the causes of death from ether we must not forget that patients sometimes die of heart failure, collapse, or shock. The following means have been found valuable in such cases : A hj^podermic of strychnine administered half an hour before the anaesthesia. Cases in which Ether Should Not be Employed as an Anaesthetic, Except by an Expert or with the Greatest Care. — The conditions rendering anaesthetics dangerous are : Fatt}'' degeneration of the heart, a prominent contra-indication where there is pain in heart. Physiological Action of Etiier. The following experiment was made, allowing an animal fully to recover from the mixed anaesthetic, and placing it under the full effects of Squibb' s ether fortior (in the University of Penn- sylvania laborator}", in the presence of Prof. Reichert, Dr. Thomas and the writer). Ether was crowded on it until the respiration ceased and the heart almost stopped beating ; then a solution of 100th of a grain of sulphate of atropia was introduced, to determine if it had any power to stimulate the heart or restore respiration in this stage ; but it produced no such results, and the animal was dead. If the same amount of caution is employed in the use of this powerful agent, as in the use of chloroform, the number of deaths would be less. It must always be borne in mind that in full anaesthesia, no matter what agent is employed, there is a suspension of life forces, and but a step to death. The administration of atropine may be resorted to, but mor- phia, subcutaneousl}'^ injected, will increase the risk with ether, not so much with chloroform. There are many individuals who have idiosyncrasies, and cannot bear even what is known as a small dose of morphia without great disturbance of the stomach or faintness. It has been suggested to add atropine to the morphia, but the experiment just related will demonstrate that it will not re- lieve the heart when fullj" under the influence of the stronger 11 154 ARTIFICIAL ANESTHESIA. ether. There are no agents which relieve the irritation of the broncho-pulmonary mucous membrane so well as keeping the Plate 21. Ether, First Stage. Plate 22. Ether, Second Stage. Plate 23. Chloroform. Plate 24. Bromide of Ethyl. skin warm, and free from moisture or draughts. Above all, no one should give the ether who has not some practical experi- ACTION ON BRAIN, HEART AND CIRCULATION. 155 ence and is not desirous of witnessing the operation. Let his whole attention be given to the patient, and never crowd the ether after the patient has become fully anaesthetized, but keep it off at a distance, so that the patient may get a small portion of it. The foregoing is a more recent series of sphygmographic tracings. There will be found a decided difference in the pulse and heart in these tracings : ether in Plates 21 and 22, chloro- form in Plate 23, and bromide of ethyl in Plate 24. It will be noticed how much freer from influence upon the heart ether is, and how distinct and free from dangerous di- crotic impressions compared with chloroform, which depresses the action of the heart. Hydrobromic ether is not considered quite so dangerous as chloroform. The Action on the Brain, Heart and Circulation by Ether. The functions of the cerebrum or brain are first affected before those of other portions of the nervous system. After a more prolonged inhalation the anterior or motor centres soon fail to respond to mechanical irritation, yet the functions of the medulla oblongata are performed. If the inhalation of ether is still further carried on, the sen- sory and finally the motor functions of the medulla oblongata are involved, and death occurs from a paralj^sis of the respira- tory centres of the heart. Louget states that he found the sensory functions abolished very early, but he has never failed, in any stage of the narcosis from ether, to get a response from the anterior part of the cord by employing powerful galvanic currents. The elevation of the pulse line shows the stimulating property of the ethereal influence. Plate 25 represents the excited pulse writing of a small and nervous female previous to etherization and operation. Plate 26 represents the pulse writing of the same patient when steadied by etherization. The contrast is remarkably favorable. Plate 27 represents the pulse writing of a healthy young man 156 ARTIFICIAL ANESTHESIA. of 22 previous to operation for artificial pupil, an affection which had not interfered with his general health. Plate 28 represents the same when taken under full etheriza- tion, and after the completion of the operation. A comparison Plate 2.". Plate 26. Plate 27, Plate 28. of this pulse writing with that of the natural soft pulse, will;be ample evidence of the safety of etherization in its action on the heart. The Action of Ether upon the Circulation. According to Dr. Wood, " It is firml}^ established by the co- inciding results of very many experiments performed by various observers, that during etherization there is usually a pronounced ALLIS' ETHER INHALER. 157 rise in the arterial pressure, which is commonly maintained even through a prolonged narcosis, and may continue after manifest failure of respiration. Sooner or later, if the inhalation be con- tinued, the rise of arterial i)ressure is followed by a fall, which may progressively increase until the manometrical needle reaches almost zero. There have been very fev^ careful studies of the details of the action of ether upon the circulation, but such facts as we have go to show that the primary influence of the drug is to stimulate both vaso-motor centres and heart, and that during the stage of low pressure there is depression of the vaso- motor centres and also of the heart. This belief in the primary stimulation of the vaso-motor centres, rests almost entirely upon the research of Professors Bowditch and Minot, made in 1874, and the subject is well worthy of a careful restudy. There is much reason for the belief that in advanced and profound ether-narcosis, the bloodvessels are affected by the direct action of the substance upon their coats.'" Most American surgeons give ether as an anaesthetic by a closed cone, in such a manner that the patient breathes the same air over and over again. This is a very unsafe mode, and to it is due, in a large measure, the alarming prostration of the patients while undergoing operations. Some cases present such profound symptoms of shock that the operation has to be suspended until hypodermic injections of brandy, ether and strychnine are given. Indeed, in some cases, it is with great difficulty that the patients are kept from dying on the table, while some die from oedema of the lungs. Fully impressed with this idea, I advise them using Dr. Allis' improved inhaler, and have thus far found it to act promptly, safely and eco- nomically. Allis' Ether Inhaler. We present plates of the apparatus of Dr. Allis for the ad- ministration of ether. This instrument has been in use in the United States and Europe for several j^ears, and may be said to have won the foremost place among the standard instruments. This and the following plates are two-thirds the size of the manufactured instrument. 158 ARTIFICIAL ANESTHESIA. It is now made simpler and stronger than the first that were offered to the profession. Plate 29. Instrument complete. Description of the Inhaler.— Plate 30 consists of a metallic frame sufficiently large to cover the lower part of the face. The bars are nearly a quarter of an inch broad, leav- ALLIS' ETHER INHALER. 159 ing a quarter of an inch between each and its fellow. The spaces are made by a punch, which removes a section from a solid sheet of metal. It will thus be seen that there can be no danger of the bars giving way, as they would were they soldered upon a band. In Plate 31 there is a bandage partly laced between the bars. It has been passed from side to side, dividing the instrument Plate 30. into parallel sections. On the right, a part of the bandage may be seen rolled up. When the bandage has been passed between all the bars, and the hood or cover put on (Plate 29), one can look through the instrument from end to end, and there is a space of nearly a quarter of an inch between the several sections of the bandage. 160 ARTIFICIAL ANESTHESIA. The advantages of this mode of construction are as follows : 1. It gives the patient (Plate 32) the freest access of the air. It is necessary that the air should be saturated with the vapor of ether, by dropping from the bottle. Plate 31. 2. It affords a series of thin surfaces, upon which the ether can be dropped and from which it will almost instantly evapo- rate. In this respect it differs from the sponge, which retains the ether in a fluid state much longer. Should the bandage become soiled a new one can be inserted in a few minutes. ALLIS' ETHER INHALER. 161 3. By leaving the instrument open at the top, the supply can be kept up constantly if desired; and as ether va-por is heavier than air, there is [no loss by not covering it. The top should never he covered. Plate 32. SNOWDEN 4. It is kept clean by removing the strips of white muslin each time that it is employed. Mode of using the inhaler : 1. Place a towel beneath the chin of the patient, as experience has taught that a towel should always be within reach in admin- istering anaesthetics. 2. Place the instrument over the face, covering the nose and chin, and let the patient breathe through it before any ether is 162 ARTIFICIAL ANAESTHESIA. applied. This will convince him that he is not to be deprived of air. 3. Begin with, literall}^, a few drops of ether; this will not irritate the lar^^nx. Add, in a few seconds, a few drops more, and, as soon as the patient is tolerant of the vapor, increase it gradually to its fullest eflfect. When the effect of the anaes- thetic is apparent, a single layer of a coarse towel may be laid over the nose and mouth, and the instrument replaced. This is a wise precaution against vomiting or spitting. 4. When the patient is fully influenced, it is well to add a few drops at short intervals, and thus keep up a gradual anaes- thetic eifect. It was found with Allis' inhaler that the shortest time required to produce complete angesthesia in a young female patient was three minutes, and the amount of ether employed was only one fluid ounce. The longest period required in an adult female was seven minutes, and the amount of ether used two ounces and a half. In a few instances there was hysterical tendency among the females. If solid food had been taken, vomiting would follow, but after liquid, or light forms of nour- ishment, vomiting was very rare ; not more than one in fifty cases. In temperate males the time for full anaesthesia was from five and a half to eight minutes. Ether consumed : min- imum quantity, two ounces; maximum, three ounces. Chloro- form cannot be inhaled in this apparatus, as too much is wasted. Now, in Allis' apparatus there is no chance for the ether to remain in its fluid state, which is the case when a strip of mus- lin is used, but exposed as it is, on a thin stratum of muslin, it yields its anaesthetic principle promptly. To close this apparatus at the top would necessitate ingress of air at the part surrounding the mouth, for air must be admitted. If it be excluded at the bottom and left open at the top, the advantage of having a constant supply of ether dropping upon the folds is very great. A FOLDING ALLIS' ETHER INHALER. 163 A Folding Allis' Ether Inhaler. This inhaler is open to the objection, though to a less extent than other instruments of its class, of being somewhat cumber- some when carried about, and of occupying, therefore, consid- erable space in the operating satchel. This has been overcome by slightly altering the shape of the inhaler, in such a manner, as to allow of its being folded flatwise. The accompanying plates will show how this is accomplished. Plate 33 represents the inhaler folded, ready for placing in the pocket or satchel, in which shape it occupies about as much room in the pocket or Plate 33. SNOWDEN satchel as an ordinary visiting list. By a very simple move- ment, provided for by bringing together the corners of the metal sides, the two long sides are made to separate from each other, until the shape shown by Plate 34 is formed, in which position it is securely held, by a little bar, which swings over from one corner, to the one diagonally opposite, and fastened, by its bent extremity, into a socket provided for the purpose. The only covering needed for an Allis' Inhaler, is a simple towel folded lengthwise, in which the instrument is inclosed, just prior to its use. This can be procured at the patient's house, and, after the operation, unpinned and thrown aside. 164 ARTIFICIAL ANESTHESIA. Experiments with Allis' inhaler by Dr. G. H. Coburn, a resi- dent phj^sician of Howard Hospital, carefullj^ recorded all the cases, at our request, occurring during two years, in which this form of Allis' inhaler was employed in the various surgical operations .performed in the institution with most satisfactory results. The objections to this form of apparatus are : 1. That the exhaled vapor is not convej^ed to the floor, but is diffused in the air, to be breathed by the operator and his Plate 34. SNOWDEN assistants. For a single operation this is not of much import- ance, but where there are a number of cases the arrangement is not conducive to the comfort of the operator. 2. The bandage of muslin across the bottom becomes clogged with moisture and saliva, and at times by discharges from the stomach, and cannot be so readily removed. 3. Owing to the peculiar arrangement of the muslin strips it is tedious, when it is required for a number of patients, to remove or replace them. In a conversation with Dr. Allis he stated that he considered the chief merit of his instrument was that it thoroughly and A FOLDING ALLIS ETHER INHALER. 165 instantaneously liberated the ether, and that while there was not the least impediment to respiration, yet all the air was impregnated with the anesthetic. Neither ether nor chloroform can be inhaled in the pure state. It is always atmospheric air, impregnated with the anaes- thetic, that sustains life and produces anaesthesia. The expression ' ' give him nothing but ether, exclude the air," are only relative terms; they simplj^ mean saturate the air as much as possible with the ether. Permit the patient to have no fresh air, but compel him to breathe air charged with ether. When he first employed his instrument bystanders would suggest that it be closed at the top, so as to permit no escape of ether. This will show that the true laws of ether were overlooked ; ether vapor, while it will diffuse itself throughout an entire room, is of greater specific gravity than atmospheric air, and tends to the floor. As germain to this subject, we would direct attention to the following experience recorded by the late Dr. Wm. Goodell, of Philadelphia, in the course of a recent paper, giving a year's experience in ovariotomy : "One of the chief lessons I have learned from my experi- ence during the past year is to administer ether. Hitherto I have, in common with most American surgeons, given this anesthetic by a closed cone, in such a manner that the patient breathed her own air over and over again. I am now disposed to think that this is a very unsafe mode, and that to it is due, in a large measure, the alarming prostration of the patient while undergoing the operation. For instance, among the twenty-five cases of last year, cases 70, 71, and 82 presented such profound symptoms of shock that the operation had to be suspended until hypodermic injections of brandy and of ether were made, and some degree of reaction had set in. In cases 70 and 71 it was indeed with great difficulty that the women were kept from dying on the table, while case 85 clearly died 166 ARTIFICIAL ANAESTHESIA. from oedema of the lungs. Now I do not find such alarming symptoms referred to in any reports of cases by British opera- tors. I am therefore forced to the conclusion that either under the strain of rivalry they do not operate in very desperate cases or their mode of administering anaesthetics is a safer one than ours. Fully impressed with, this idea, I have lately been using Dr. Allis' improved inhaler, and have thus far found it to act promptly, safely, and economically. " Clover's Small Portable Ether Apparatus. Is a very good inhaler (see Plate 35). The face-piece is edged with an air cushion. The ether ves- sel and warm water chamber which surround it and maintain it at the desired temperature for evaporation rotate upon the mouth of the face-piece. When the instrument is first applied the stopper should be opposite the patient's forehead, and the indicator, which travels round the lower end of the water chamber, pointing to the figure 0. The bag should not be placed in position until the patient has taken two or three inspirations-, it must then be inflated by blowing air into it, and be fitted to the upper end of the water chamber, as shown in the figure. As the ether vessel is turned round the indicator traveling from to 1, 2, 3, and F successively, the air has to traverse the ether vessel before reaching the bag, and so the patient gets gradually a more and more highly saturated ether atmosphere. Two ounces of ether are poured into the project- ing arm before the operation, and these usually sufl&ce for the case. The opening is so arranged as to prevent an excessive quantity being used, and to guard against the possibility of a few drops escaping through the inner openings. The ether vessel and surrounding water chamber are so ar- ranged that, although the vapor freely escapes, no fluid over- flows in whatever position the inhaler may be held. The water chamber is centred by a shaft which communicates with the interior of the ether receptacle, and the vapor escapes into this shaft. From below a hollow metal c^-linder fitting to the face- clover's small portable ether inhaler. 167 piece, and above shaped like a clarionet mouth-piece, enters the sliaft and closes it, being able at the same time to rotate with the face-piece. To this is fixed the long metal indicator turned at right angles at its extremity. From above a similar- shaped piece of metal is fixed, so that the two "clarionet" pieces are adjacent, the lower one capable of rotation, the upper one fixed. Finall}^ the shaft is completely closed above by the air bag, which is attached to a metal cj^inder, closing but freely movable in the shaft. Ether can only reach the Plate 35. Fig. 0. Figs. 0, 1, 2, 3, and F Ether patient when the two "clarionet" pieces wholly or partially coincide. When the lower piece moves, the indicator travels with it, and should it point to the ether way is blocked, and then the patient breathes simply air through the shaft in and out of the bag. As soon as the indicator is moved from the ' ' clarionet ' ' pieces cease to shut off ether, and the air enters the chamber and becomes impregnated with its vapor. When F is reached the patient is inhaling ether vapor diluted only by the amount of air exhaled from his lungs. The following is the method of using this inhaler : The appropriate sized face- 168 ARTIFICIAL ANAESTHESIA. piece being selected and two ounces of ether placed in the receiver, the air-bag is removed and the indicator turned to 0. The patient is then directed to inspire deeplj', and the face- piece applied firmly but gently. Uniform pressure is well borne, while hard pressure, if unequally distributed, will not be tolerated. When the patient has taken two or three deep breaths, the air-bag is filled by the administrator blowing in air, and is placed into an aperture at the top of the dome, so that the patient now breathes in and out of this bag. The indicator is now moved to 1, so that the patient is breathing one-fourth ether and three-fourths air, A few breaths of such a dilution of ether will accustom the larynx to the irritating vapor, and so obviate coughing, spasm, and the wretched feeling of suffo- cation which ensues upon presenting a strong ether atmosphere to the patient at the commencement of an inhalation. This tolerance achieved, the indicator is pushed to 2, and the patient then inhales half ether and half air. If this strength of vapor do not distress him, the indicator can be, after a few seconds, carried to 3 (one-fourth part air, three parts ether) and then to F (all ether). The patient will, in from ninety seconds to two minutes and a half, be completely unconscious and ready for operation. Some persons require more ether to afi"ect them, and those who persistently resist taking the anaesthetic by hold- ing iheir breath, or by taking the shallowest breaths consistent with life, will delay the onset of unconsciousness much longer. These persons also, since they voluntarily semi-asphyxiate themselves by repressing respiratory movements, suffer great additional discomfort from the feeling of suffocation they induce. As soon as complete anaesthesia is thoroughly established, the indicator may be brought back to 2, and there kept until the operation is over. It may be necessary in warm weather, and in the case of prolonged operations, to renew ether in the receiver. This is easily done by removing the inhaler from the patient's face, loosening the cork, and pouring in a further supply. The patient will, during a prolonged operation, require the THE CONE AND ITS MODIFICATIONS. 169 inhaler taken off his face every sixth breath or so, in order that he may take a few inspirations of air. The necessity for this will be readily recognized by the degree of cyanosis apparent in the face, and by the character of the respirations and the pulse. It should be carefully borne in mind that the amount of an an- aesthetic required to produce narcosis is much greater than is needed to maintain that condition. Also the degree of narcosis must be varied in correspondence with the region of the body upon which operative measures are being pursued. The Cone and its Modifications. The cone is the chief form in which ether is administered as an anaesthetic in the United States. It is made by folding a starched towel, inside of which is a newspaper, into a cone large enough to go over the mouth and nostrils. The edges are rounded, and the sides pinned together with catch-pins. In the apex of this cone is placed a carefully washed sponge dipped in hot water and squeezed out from time to time so as to prevent freezing of the watery portions of the ether. Ether is poured on the sponge, half an ounce at a time, and repeated, as found necessary, by removing the cone from the patient's mouth. A very convenient cone has been found in the ordi- nary straw cuff, in which is fixed a sponge, devised by a dentist of Hartford. Advantages of the Cone for the Inhalation of Ether. — The advantages are : first, the ease with which they are made and removed from the patient's mouth when there are signs of danger ; second, the simple cone is never employed with a second patient, which is a great advantage in the way of cleanliness. All heavy or complicated inhaling apparatus are objectionable, as they are apt to become unclean, the valves get out of order, and the patient interfered with in his movements by the weight of them. The chief objections to the cone and its modifications are that they allow the undiluted ether vapor to impinge upon the larynx, or the sponge to become frozen with wastefulness of the ether. 12 170 ARTIFICIAL ANESTHESIA. Plate 36. Dr. Lente's Ether Inhaler. As early as 1866, Dr. Lente invented a form of inhaler, which has recently been modified. (See Plate 36.) The present im- proved instrument resembles very much the face-piece of " Wal- denburg's apparatus" for the inhalation of condensed and rari- fied air. The idea of using sheet brass and the india-rubber air- cushion was taken from it. The air-cushion, however, proved a failure, and the inventor sub- stituted hair for stuffing the cushion, which he states retains sufficient of its rotundity to fit the face air-tight. Mode of Employing this Form of Inhaler. — A piece of sheet lint is stuff'ed into the cone, a piece of wire or whalebone is slipped in so as to keep the lint in place and prevent its touching the face. The lint is satu- rated with ether and placed over the face. There is an open- ing, fitted with a cork stopper at the apex, large enough to ad- mit air. This is usually closed, but if it is found necessary, the stopper can be removed. The ether can be poured in at this opening without removing the apparatus from the patient's face. Its cleanliness is perfect, as a different piece of lint should be employed each time. Lente's Ether Inhaler. Ether Inhalers— Modifications of the Cone. One of the same kind as the above is that called after its de- signer, Dr. Ormsby, of Dublin (Plate 37). It consists of a leather face-piece with cushioned rim, provided with a valve, which can be opened at the pleasure of the administrator ; at the top of the face-piece is a cone-shaped wire cage, covered externally with leather, and leading into a soft leather bag, covered by a loose net, which prevents its undue expansion. In ETHER INHALERS MODIFICATIONS OF THE CONE. 171 Plate 37. the wire cage a sponge is placed, and upon this an ounce of ether is poured. The apparatus is applied to the patient's face, and he is desired to take a full breath. Even when the valve is kept widelj" open, the sense of suffocation is so great (the rush of ether vapor producing more or less spasm) that the patient struggles fiercely to escape what appears like im- pending asphyxia. Should it be necessary to add fresh anaesthetic during the operation, it is done by pouring ether down a tube which enters the centre of the sponge. Ormsby's inhaler is open to several objections, e.g., it pro- duces great discomfort by al- lowing undiluted ether vapor to impinge upon the larynx ; Ormsby's Ether Inhaler. the sponge is very liable to freeze hard, and so no evaporation of ether takes place ; it occasions great struggling ; it is wasteful of the ether. This apparatus is used quite extensively both in England and Ireland. Hearn's Ether Inlialer. It is named after its inventor, Dr. Joseph W. Hearn, of Philadelphia, who has had an extended experience in the ad- ministration of anaesthetics. The inhaler (Plate 38) has its outer case, A, made of thin sheet metal, having the lower edge, which comes in contact with the face, covered with rubber. Inside of this case a screen of wire gauze, B, is fitted, which comes opposite the lower joint, as at A. The lint or Canton flannel upon which the ether is poured is 172 ARTIFICIAL ANESTHESIA. shown at C, and is held in place between the wire gauzelscreen, B, and the funnel-shaped top, D. The object of this inhaler is to furnish an undiluted ether Plate 38. SNOWOEN. Hearn's Ether Inhaler. vapor, and prevent, as it should when ether is used, the patient's inhaling the surrounding atmosphere. The time re- quired to produce complete anaesthesia, in ordinary cases, is from five to eight minutes. CHEATHAM S ETHER INHALER. 173 Clieathain's Ether Iiilialer. This operates by replenishing the evaporating surface with- out removing it from the face. A patient cannot be etherized as quickly with it as with the common cone, but with much less ether, and by it you avoid the disagreeable effects of having the ether permeating every part of the office or house in which it is used. Its convenience of application is, also, quite obvious. The ease with which the face-piece (being paper) can be re- moved immediately after use and thrown away is, we think, a strong recommendation in its favor, The apparatus consists of a tin cup (Plate 39, A), holding in the inside a sponge as an evaporating surface, and connected from the top by rubber tubing with the bottle that contains the anaesthetic. This tube has attached to its distal end a cap, D, that will fit over the neck of almost any bottle, thus doing away with Lente's graduated bottle. Plate 39. Cheatham's Ether Inhaler. Mode of Using the Inhaler. — Make a cone of paper, cut the top off, so when the tin cup, A, is slipped inside the top of the cup it will protrude a line or two from the top of the cone. Place tin cup, B, over both cup and cone, screw it down tightly by means of nut, C, and you have the cone held tightly. At- tach tube to top of cup and the apparatus is complete. The smaller the cone the more quickly you can get the patient under the influence of the anaesthetic. We would suggest, after the 174 ARTIFICIAL ANESTHESIA. cone is in position, the bottom should be trimmed, leaving a part of it (we shall call it the back part) that is intended to go over the chin three inches longer than the cup, and sloping for- wards and upwards, leaving the front part, intended to go over the nose, about an inch longer than the cup. E gives an inside view of cup A* Parkinson Ether Inhaler. " In presenting this apparatus to the notice of the profession, I wish at the outset to disclaim any idea of misappropriation. The instrument is in principle identical with Ormsby's inhaler, the best points of which have been utilized. A practical experience of some nine years with the original apparatus has Parkinson Ether Inhaler. A. Inhaler ready for use. B. Ether reservoir. C. Ether measure, showing sponge inside. 1. Air cushion, inflated. 2. Air cap. 3. Wire net basket to contain sponge. 4. Rubber bag collapsed. induced me to modify it, so that a compact, efficient and inex- pensive inhaler could be obtained by any practitioner. The improvements are the substitution of rigid, instead of flexible * These various forms of inhalers can be had from the S. S. White Co., Snowden, Gemrig or Kolbe, instrument makers, of Philadel- phia; also Geo. Tieman & Co., of New York, and from Codman & ShurtleflF, of Boston. PARKINSON ETHER INHALER. 175 metal in the face-piece, the omission of the ether supply tubes, and the modification of minor details throughout. "The apparatus consists of a metallic face-piece, the base of which corresponds to the usual facial lines. To the upper part of this is fastened a wire net basket, around the mouth of which, and projecting into the face- piece, is a small gutter, which pre- vents ether or moisture from dropping on the patient. On one side of the face-piece is an air cap, which exposes or covers a slot, on rotation. A collapsible rubber bag, shaped somewhat like a cranial ice cap, is attached to the face-piece, its elastic neck grasping the apex of the latter, where a groove has been made for its reception. A rubber air cushion fits over the base of the face-piece, maintaining its position by a lip which forms part of the cushion. "To prepare the inhaler for use, when the temperature of the room is below 65, place a small napkin or towel, wrung out of very hot water, in the face-piece for a few minutes. The sponge, which should have an absorption capacity of two ounces, is soaked, squeezed dry, and placed in the wire net cone, so that every part is above the gutter. The air cushion is then fitted and partially inflated. Pour one ounce, by measure, of ether on the sponge, and place the inhaler on the face, with the air slot wide open. This should be closed after three or four inspirations. During the progress of an operation, fresh air is added, as required, in quantities of four drachms. If used for half an hour, it is advisable to remove the sponge and squeeze out the moisture which has formed by condensation. "The points of superiority claimed for this inhaler are, that it is compact, portable and inexpensive. It is simple in con- struction, and the rubber portions, when worn out, are easily duplicated. It is most economical in the use of ether, and the unpleasant odor of the drug, by diffusion, is absent. With it the production of anaesthesia is a certainty. The rapidity of its action will equal any apparatus, and there is no method of ether administration which surpasses it in safety. "Amongst the objections raised are those common to all per- manent apparatus : that it is dirty, and that infective matter will adhere to it, or may lotige in the sponge. The simplicity of its 176 ARTIFICIAL ANESTHESIA. construction admits of a ready and perfect cleansing ; and no part will be injured by hot water or antiseptic solutions which are familiar to most practitioners. Against the inhaler per se it is urged that the anaesthesia partakes largely of carbonic di- oxide poisoning — that this is a source of danger, and an insep- arable defect." Inhaler of Nitrous Oxide Gas or Etlier of Codnian & Sliurtleff, of Boston. The points for which they claim superiority are : 1. Durability; being made of metal, they are not liable to be easily broken, as so frequently happens to the hard-rubber inhalers, and as they are nickel-plated they retain their brilliant polish without change. 2. For convenience both to the patient and operator. With one hand, the latter can apply the inhaler, and open or close the two-way stopcock, leaving the other hand at liberty to con- trol the patient, or for such exigencies as may occur. As the elastic hood covers both nose and mouth, the patient is saved the necessity of having the nostrils closed either by clamps or the fingers — a part of the operation always very disagreeable, and to very sensitive patients positively frightful, as it produces a feeling of suffocation. 3. Cleanliness. The rubber hood, which alone comes in contact with the face, is easily removed and replaced ; and as all the other parts are either metal or hard rubber, the whole instrument can be kept perfectly pure by washing, which is a point of great importance to the comfort of the patient. 4. Durability and accurate working of the valves. Upon this, perhaps, more than anything else, depends the successful administration of anaesthetics. If the exhaling valve does not quickly and perfectly close while the gas is being inhaled, air is taken in with it, and the gas is so much diluted that it very much delays, or wholly prevents, the desired effect. If, on the other hand, the inhaling valve does not work prop- erly, the patient breathes back into the reservoir a mixture of nitrous oxide and air. CODMAN ^ still retains his faith in the use of a pure bromide of ethyl, which he has now used for six years with the due care and caution with which every anaesthetic should be thus employed : "Philadelphia, February 11, 1896. " Laurence TuRNBULL, M.D., "255 South Seventeenth Street. " My Dear Doctor: Your letter of February 10th is at hand. I find no reason to lose faith in the value of bromide of ethyl 238 ARTIFICIAL ANAESTHESIA. as an anaesthetic for short operations and examinations. I am using it constantly. " Very sincerely yours, "E. E. Montgomery, ''''Professor of Clinical Gynaecology^ '"^Jefferson Medical College^ Philadelphia.'" Anaesthesia by tlie Bromide of Ethyl.* The bromide of ethyl has been extensively employed of late by the dentists of Germany and in the minor operations in surgery of short duration. It should be administered in the following manner: While the patient is becoming accustomed to the odor of the anaesthetic, no external impression must be given, nor noise made by those around him. Skinner's apparatus should be used, lined with rubber and covered with a piece of flannel, upon which is poured a few drops of the anaesthetic, so as to exclude all air. The anaesthetic requires from fifty to sixty seconds, and lasts three minutes. The requisite amount is from five to ten grammes for an in- fant and ten to fifteen grammes for an adult, with no unpleasant results. This anaesthesia has been found very convenient for incisions in abscesses, etc., tenotomies of tendons, the applica- tion of the thermo-cautery, extirpation of small tumors, and for quickly emptying a tubercular deposit. Bromide of ethyl is a nervous sedative, and is employed in epilepsy, hysteria, etc. Dose, for internal use, five to thirty drops in sugar, or, better, in capsules ; must be kept from light, heat and air ; and, to obtain pure, ordered in sealed tubes. Be sure not to order bromide of ethylene, which is poisonous if employed in spray or by inhalation, Dose, 150-300 M. * By Dr. Kolliker (Centralblatt fiir Chirurgie. No. 20. p. 385, 1891). PART FOURTH. CHAPTER VIII. ChloToform— Dichlorinated Chloride of Methyl— Terchloride of Formyl (CHClsj. Cbloroform. The ordinary method of preparing chloroform is by the distil- lation of alcohol and chloride of lime ; but owing to the heavy duty upon alcohol the following methods will show that it can be manufactured at less cost. One of these new processes con- sists in the substitution of wood alcohol (this is one-third less in price than grain alcohol). When wood is subjected to destructive distillation, the result is pyroligneous acid and pyroxylic spirit, commonly called wood alcohol. The latter is separated in a very impure state, redis- tilled with lime, and then manufactured into chloroform, and is purified in the ordinary way with chloride of Hrae and sulphuric acid. The manufacture of chloroform from pure wood alcohol is not entirely new, but the value of the patent consists in the fact of being able to use the alcohol in a crude or intermediate state before it is separated from the pyroligneous acid and the other liquid constituents of wood, thus reducing the cost to a minimum. Chloroform prepared from wood spirit is specifically lighter, and has at times an empyreumatic odor from acids or chlorinated 240 ARTIFICIAL ANESTHESIA. oils, and gives rise, when inhaled, to unpleasant sensations, with prostration and headache. Many chloroform accidents are doubtless due to impurities in the drug. Sleep is obtained with difficulty, and is disturbed in character. In some cases, to in- duce sleep, the attempt has had to be given up, as the impure chloroform only produced irritation of the lungs and stomach, inducing vomiting, etc. Ad Improved Chloroform. The new process for the manufacture of chloroform we quote from no less an authority than Sadler : * "The raw material from which chloroform is made is the gray acetate of lime. While this is distinctly purer than brown ace- tate, it still contains both moisture and tarry matter. To free it from these and to raise the percentage of actual acetate of lime, it is carefully roasted before being submitted to dry distil- lation. This roasting forms the subject of patent No. 393.079, issued to Grustav Rumpf, of Frankfort, Germany, and assigned to Roessler and Hasslacher, of New York. It is done in a series of three slightly inclined cylindrical retorts, in which the material is continually pushed forward by revolving blades. The gray crude acetate is dropped in and passes along the length of the upper retort, until it drops upon the blades which revolve in the second retort, and, passing along this, is dropped into the third or lowest retort, from which it issues and is collected in suitable vessels. By this continuous rotating process the crude material can be purified without notable decomposition of the true acetate. "The patentee claims that 'in the process of subjecting ace- tates in a closed vessel to heat applied externally to the vessel for distilling acetone from the acetates, the desired slowness and uniformity of temperature may be secured by stirring the ace- tate, so that all portions of the mass will be subjected to the heat resulting from direct contact with the bottom of the vessel, and by admitting free steam from time to time into direct con- * Pharmaceutical Record, August 19, 1889, Samuel P. Sadler. ' AN IMPROVED CHLOROFORM. 241 tact with the acetates in case of any undesirable rise in temper- ature within the vessel. ' ' ' This is effected by mechanical agitation provided for by the paddles which rotate around the vertical central axis. Steam is admitted by one of the openings above, while the products of distillation pass off by another opening in the top of the retort. The crude acetone distillate so obtained, while richer than be- fore in real acetone, still contains oily distillation products and much water from condensed steam. In this dilute state it is treated with milk of lime to remove the higher ketones and other compounds. It is then distilled from a large plain still, and the fractions rich in acetone passed to a column still, where it is rectified until it becomes almost if not quite anhydrous. In practice, two column-still rectifications are carried out, one after the other, so that the pure acetone shows 99° or 100° by the alcoholometer. It is now fitted for use in the direct manu- facture of chloroform. The process and form of apparatus for most successfully carrying out this chloroform manufacture, con- stitute the subject of United States patent No. 383,992, also issued to Gr. Rumpf and assigned to Roessler and Hasslacher. The patentee first states, that in order to get the full yield of chloroform, it is necessary to take a much larger proportion of bleaching powder than that given in "Watts' Dictionary of Chemistry," Yol. 1, page 918, and states that for 58 pounds of acetone at least 600 pounds of chloride of lime of thirty-five per cent, available chlorine are necessary. The yield will then be from one hundred and fifty to one hundred and eighty per cent, of the weight of acetone employed instead of about thirty-three per cent. The still having been filled to a proper height with water, the charge of bleaching powder is introduced, and the man-hole closed with cement. The agitators having been started by means of the revolving shaft, the acetone, previously diluted, is pumped in gradually. As it enters, it rises and reacts with the bleaching-powder solution, and the chloroform produced, distilled spontaneously from the delivery tube, passes through the condenser, and is collected under water. The introduction 242 ARTIFICIAL ANAESTHESIA. * of diluted acetone is to be effected at intervals only, otherwise some will distill over unchanged, or the reaction will become too violent, and much frothing ensue. When the delivery of chloroform begins to slacken, steam is gradually introduced to heat up the mixture and drive over the last portion of chloro- form which remains. The contents of the still are then dis- charged into a drain. They consist of very dilute calcium acetate solution mixed with calcium hydrate and calcium chlo- ride. The reaction for this production of chloroform from acetone seems to be simply 2C3Heo + GCaOCl, = 2COI3H + CalC^HsOOa + 2Ca(OH)2 4- 3CaCl2. This would demand one equivalent of chloroform for one of acetone used, or 206 parts of chloroform by weight reckoned on the weight of the acetone. In practice, 180 parts are usually obtained, although 200 parts have actually been ob- tained at times. The chloroform obtained is quite free from the chlorinated side products w^hich often accompany the chloroform made from impure alcohol. It is, nevertheless, thoroughly purified by treatment with sulphuric acid and careful washing, and is then brought exactly to the United States Pharmacopoeia standard. Commercial chloroform when obtained is a transparent, heavy liquid containing ninety-eight per cent, of chloroform, frequently containing hydrochloric acid, chlorine, and foreign chlorine compounds, with traces of arsenic as impurities. It is therefore unfitted to use as a medicine, or as an anaesthetic agent, until purified. Chloroformum Purificatuni— Purified Chloroform. (CHCI3; 119.2— CH2CI3; 119.2.) After careful purification, by means of redistillation, in con- tact with sulphuric acid, carbonate of sodium, lime, potash, alcohol and water, it is then ready for use. Chloroform, in its pure state, is a heavy, clear liquid, having a specific gravity of PURIFIED CHLOROFORM. 243 1.49°. It has a characteristic, pleasant, and ethereal odor, a burning sweet taste, and a neutral reaction. It dissolves in alcohol and ether in all proportions, but only mixes with water in small proportions, and will, after a time, sink to the bottom of such mixtures in clear globules, owing to its being so much heavier. It communicates its sweetish taste to water. Dose, 3 to 10 min. given in capsules, or mixed with alcohol as the spiritus chloroform, 1 volume in 20. Dose, 20 to 60 min., or in the mistura chloroform i — chloroform 8, camphor 2, fresh yolk of egg 10, water 80. Dose, tablespoonful. If a few drops be permitted to evaporate from blotting paper, no stain, or no foreign odor should be perceptible after the odor of chloroform ceases to be recognized. When applied to the skin, chloroform evaporates rapidly, and produces a feeling of cold. When the evaporation is prevented, it passes through the epidermis, and acts as an irritant to the inner skin, producing rubefaction and local anaesthesia. (See article on Local Anaesthetics. ) No chloroform should be used for anaesthetic purposes which does not comply with the following requirements : 1st test. When dropped in distilled water, there should be transparent globules with no milky appearance. 2d. Chloroform should have an agreeable odor. 3d. It should not redden blue litmus paper. 4th. When added to a solution of nitrate of silver, it should not form a precipitate, nor even cause cloudiness. 5th. Test with a solution of iodide of potassium (for free chlorine). 6th. When brought to the boiling-point with a concentrated solution of caustic potash it should not become colored. (Ab- sence of aldehyde and arsenic.) 7th. Sulphuric acid should not blacken it when brought in contact with chloroform. 8th. Mixed with concentrated sulphuric acid and shaken, it should separate in half an hour into two colorless layers. Chloroform is liable to sudden changes, and exposure to light, an imperfect stopper, or partially filled bottle frequently affect its purity ; hence, it should be tested before using. The com- 244 ARTIFICIAL ANAESTHESIA. bined action of permanganate of potash and a caustic alkali has been recommended as an exceedingly delicate test and re- agent. Mode of Administering- Chloroform. To inhale (inhalo) is to inspire or draw air, either alone or charged with vapors of various volatile agents, into the lungs. When chloroform was first discovered as an anaesthetic the apparatus employed was that designed for etherization, but of a more reduced size. It was found that the less volatile nature of chloroform permitted even the abandonment of all compli- cated apparatus, and most physicians and surgeons preferred to use a handkerchief or a compress of linen folded to several thicknesses (some even preferring to have it starched so as to retain its shape). After having arranged the folds (using a safety-pin to hold them together) in a cup shape, on this linen drop several drops of chloroform from a graduated bottle (so as to be able to measure the quantity employed). Apply over the mouth and nostrils of the patient, allowing however at the beginning enough free space for the atmospheric air to enter with the chloroform. If the subject be nervous, irritable and mani- fest a feeling of sufi'ocation, remove the compress still further, and even mix a small portion of cologne water until the patient becomes accustomed to the odor. The chief objection to this mode of employing the chloroform is the waste and the tendency of the moist cloth to adhere to the parts and irritate the skin. Eflforts were then made to overcome or diminish these objections by the use of a more complicated apparatus. It was necessary to fulfil two requirements : to have an ab- sorbent surface on which to drop the chloroform, and to permit the access of air which must be mingled with the anaesthetic vapors, and to prevent waste of the chloroform. In England, where chloroform was first employed, several apparatus were devised by "Snow," " Sansom & Clover," etc. They all had disadvantages which prevented their general adoption. One of the more simple inhalers much used in Eng- MODE OF ADMINISTERING CHLOROFORM. 245 Plate 45. land consisted of a metallic box, with the margin hollowed out in the parts which correspond to the nose and chin of the pa- tient, and of which the bottom and lower wall are pierced by a hole, permitting the entrance of the air. An attachment in the shape of a horse-shoe, fastened to the upper wall in the interior of the apparatus, permits the firm adjustment of several rolls of linen, or two bundles of lint, on which the chloroform is dropped. The linen or lint is renewed each time the box is used, and by this means the apparatus is always in a state of perfect cleanliness. Then they had " Skinner's " apparatus, a mask or wire frame over which was attached a piece of woollen stuff. The wire frame is placed over the nose and mouth of the patient, and on he exterior, or the woollen cover, is dropped a certain quantity of chloroform. The apparatus of Raynard (of Toulon), Plate 45, is employed in France, especially in the navj?-. It is composed of a conical horn of pasteboard (A), pierced by a large opening at the top, and ter- minating in a mouth -piece which fits over the mouth and nose of the patient. The apparatus is lined on the inside with wool, at a certain distance from the top of the cone is a diaphragm (B), formed by several folds of wool, presenting in the centre a large aperture for the entrance of at- mospheric air. It is upon this diaphragm that the chloroform is dropped or poured. The "an- aesthetic horn" of Raynard has the disadvantage of leaving much to be desired in the way of cleanliness. Patients very often expectorate into the interior of the apparatus in that stage of anaesthesia which the French call "sputation," and it is difficult to cleanse it without destroying it. 246 ARTIFICIAL ANAESTHESIA. At Plate 46 is seen the inhaler which is made by Charriere, of Paris. It is a wire frame, a, B, B and c, on which is fitted a covering of muslin which is held in place by wires a and c. There is a hook at the top which is held by the left hand, while in the right is the chloroform in a graduated bottle, and the chloroform is carefully dropped on the exterior of the flannel, not too rapidly, else there is produced a choking sensation. In neither of these inhalers should the chloroform be poured, else sudden stoppage of the respiration and suffocation of the pa- Plate 46. Modification Inhaler of Skinner and Charriere, of Paris. tient take place, or the liquid chloroform may pass into the larynx and cause death. Clover's apparatus, which we have described in its original form under ether, was subsequently modified by Dr. Buxton. Junker's apparatus is composed of a bottle having two tubes ; it is enveloped in plated steel, but this envelope is pierced by a longitudinal opening, showing what is inside the bottle ; this opening has marked upon it a graduated scale, which designates the quantity of the anaesthetic employed. A hook allows the operator to suspend the apparatus from his clothing. One tube conveys to the bottom of the bottle the MODE OF ADMINISTERING CHLOROFORM. 247 air, which is forced there by a Richardson bellows. This air, after having mingled with the chloroform, passes out by an at- tachment and through the other tube to the mouth-piece, which is placed before the mouth and nose of the patient. This mouth-piece, of hard rubber, has a valve of soft rubber which opens with expiration and closes with inspiration. A movable ring, placed at the point where the vapors arise, and pierced by two slits, corresponding to two openings of the same calibre in the attachment which prolongs the mouthpiece on this side, allows a greater or less quantity of pure air to reach the patient ; this being mingled with the anaesthetic vapors, is propelled through the tube into the mouth-piece. Half an ounce of chloroform is poured into the bottle through a funnel-shaped opening fixed in a screw top ; air is then pumped through the chloroform, and in its passage it takes up the vapor. The foot bellows are fixed by straps, one of which slips over the toe, while the other receives the heel in the longer loop. When the foot presses lightly, the air in the bel- lows is forced through the tube into the bottle, thence through the other tube to the face-piece. The net-enclosed ball is for equalizing the stream of air and the avoidance of splashing. It is important not to put more than half an ounce of chloro- form into the bottle at once, and not to pump the air spasmodi- cally or too forcibly ; otherwise pure chloroform may be drawn through the system of tubes into the face-piece. Even if this should not happen, a strong blast of chloroform -impregnated air is very unpleasant and deleterious if allowed to impinge upon the face. When the bottle has become nearly empty, the mill-headed stopper which closes the -funnel is removed and more chloroform is added ; thus the apparatus need never be unhooked from the administrator's coat and the top never un- screwed until the administration is over, when the bottle should be emptied and cleaned. Dr. Buxton remarks: "A practical acquaintance with the imperfections of this inhaler has led to modifications of value, though it must not be supposed that by its use the patient is placed outside the range of possible danger." 248 AKTIFICIAL ANESTHESIA. The Scotch Method of Adiniiiistering- Chloroform,^ In July, 1892, the author was invited as one of the Commit- tee on Anaesthetics of the British Medical Association, prior to the meeting at Nottingham, to be present at the clinics of Prof. Chiene and witness his method of administration of chloroform. The following are his teachings in his syllabus of Lectures on Surgery — Chloroform : A. Action of chloroform is (first) stimulant ; (second) seda- tive. (a) Abolishes sensation. (b) Abolishes power of motion and reflex action. (c) Stops respiration. (d) Stops hearts action, (e) Kills patient. B. Method of Administration — Towel versus Engine — Brains versus Valves. 1. Give all your attention. 2. Have your artery forceps ready. 3. Watch the breathing. 4. Watch patient's appearance. How do you know when the patient has had enough ? (a) Insensibility of conjunctiva. (b) Muscular relaxation. (c) Local insensibility of part to be operated on. C. Dangers. (a) Tongue falling back. (b) Glottis closing. (c) Fainting. (d) Vomiting. (e) Respiration and heart's action stopped. D. Signs and treatment of these dangers. (a) Use the artery forceps to draw the tongue forward. (b) Lower the head, dash cold water on the face and chest, open windows and doors. * Prof. Jolin Chiene, University of Edinburgh, Scotland. SCOTCH METHOD OF ADMINISTERING CHLOROFORM. 249 (c) Small doses of solution of cocaine, mustard plaster to the epigastrium, with lime-water and milk ; ice in small pieces. (d) Artificial respiration ; elevate the upper part of the body.* Drs. Wallace, Musselman, and his chief assistant, Dr. Emer- son, all ready to assist or answer any questions. Number of students and medical men in attendance from 25 to 30. The chloroform was given to the care of one medical man, who had been at least one month under careful instruction in its use. The professor stated that the latter was simply to attend to that duty and nothing else; he was not even to restrain the patient. We noticed he had a woman as an assistant who, in the first case, attended to the pulse. We found that the operator watched the patient, so as to be sure everything was going on all right, as he considered this all important when performing the most difficult operation. He stated that, as a rule, it was most important only to watch the respiration. He also stated that there was no preparation of the patient (this was incor- rectly reported in the British Med. Joimi.), only the giving of a cup of beef-tea at 8 a.m. No special examination of the habits of the patient, his heart, lungs or kidneys. The chloro- form was administered on a towel. He performed four operations, none of them capital ones. Three of the cases did well under the chloroform, but in the fourth, for removal of anterior and posterior tibial nerve for pain in stump, the patient, who was a sailor, resisted the ac- tion of the chloroform, and it had to be removed twice, as he had an epileptiform convulsion with rigid chest, so that the younger assistants became alarmed, but not the Professor, who inquired of us what we did in such cases. We stated that we withdrew the chloroform entirely or gave ether. Ultimately he was able to perform the operation with considerable difficulty, as the man struggled violently, and required several assistants to control him. Prof. Chiene stated that such cases were termed * Clinic of Professor John Chiene, University of Edinburgh, July 11, 1893. 17 250 ARTIFICIAL ANESTHESIA. by him alcoholists, sailors, as a rule, being verj^ intemperate men. Such cases die in the hands of an ordinary practitioner who attempts to give chloroform alone without the required number of assistants (see case reported in Philadelphia Med. News, September 24, 1893). The conclusion arrived at by the Hyderabad Commission on Anaesthetics, that chloroform kills by interference with respira- tion, is, no doubt, correct in the large majority of fatalities with this drug. When the commission^ however, goes on to lay it down as a law in the administration of chloroform that the pulse need not be noted ; that, indeed, noting it is actually harmful because it takes the anaesthetist's attention off the only thing worth watching, i.e., the respiration, it goes too far. A large number of cases have of course been published in which chloroform, properly administered, has caused death by paralyz- ing the heart before it interfered with the process of respira- tion ; but the teaching of the commission is so positive, and as many surgeons and anaesthetists think so dangerous, that all cases in which the heart was first affected should be made known. Two such cases occurred at the Royal Victoria Hospital, Netley, lately {London Lancet, March 18, 1893). A skilled anaesthetist gave the chloroform from a " Krohne's" inhaler, than which there is no better apparatus for the purpose, and no struggling took place in either case. One was the case of a child aged three years, on whom the operation of needling was being performed for a congenital cataract ; but as the operation was completed, the boy's face suddenly became pale, and the pulse was found to be imperceptible at the wrist and artery in the neck. At this time no cessation of the movements of the chest and abdominal walls took place, and air was heard to pass in and out of the lungs freely. Under the use of the interrupted current, friction and ether subcutaneously, the attack of syn- cope passed off. The second case was that of a man on whom the radical cure was being performed for an inguinal hernia. The patient took the chloroform freely until the sack of the hernia was twisted. When this was done, the man's face im- mediately blanched and the pulse became imperceptible, whilst CHLOROFORM. 251 the movements of respiration continued vigorous and effective. Ether was injected, the head lowered, sponges wrung out of very hot water were applied over the heart and electricity to the neck. In about five minutes the pulse was again felt, and the man recovered. Had the rules laid down by the Hyderabad Commission for the administration of chloroform been carried out in these two cases ; had the indications afforded by the ob- servation of the pulse been disregarded, and the condition of the respiration alone noted, the chances are that the deaths of these patients would have had to be added to the already too long list of " deaths under chloroform." Facts collected from the published statements of " The Lan- cet's Commission on Anaesthetics," March 15 and April 15, 1893, were to supplement the work of the second "Hyderabad Commission, who made all of its experiments on living animals." This last commission of the Lancet was a consideration of the re- sults arrived at by clinical observations from all the larger hospi- tals of the Continent, as well as India, America and the Colonies. Dr. Dudley Buxton gave the directions to the inquiry without any reference to his own views, in order to arrive at a con- tinuous series of cases from 1847 (the date of the first employ- ment of chloroform as an anaesthetic). Not only were the above sources of information used, but the records of Snow (1858) and those collected by the committee of the Royal Medical and Chirurgical Society, published in their transactions in 1864. (The report deals with all the anaesthetics, but chiefly chloro- form.) Classification of Cases. The reports of the cases have been divided into the following classes : (1) Deaths under and apparently due to an anaesthetic ; (2) Deaths under and remotely due to an anaesthetic; and (3) untoward cases, 7.e., cases in which some mishap occurred which was not followed by fatal results, but which was directly or re- motely due to the anesthetics employed. Cliloroforin. No age possesses immunity from death from anesthetics. The greatest number of deaths in males appears to take place 252 ARTIFICIAL ANESTHESIA. between the ages of twenty-five and fifty. The fatalities of women are most frequent between the ages of twenty-one and forty-five. GrEOGRAPHicAL DISTRIBUTIONS OF FATALITIES. — Deaths are reported from all quarters of the globe. It was noticed that in Scotland, where chloroform is so widely and extensively em- ployed, few reliable sources of information exist of the deaths which result from its exhibition. Deaths do occur from chloroform in Scotland, notwithstand- ing a contrary belief has been assiduously promulgated. Such cases are not, however, often brought to light, since Coroners' inquests are almost unknown, and there is not the opportunity for newspaper publicity that occurs in England and America. A casual search of medical journals reveals the following chlo- roform casualties : Edinburgh Royal Infirmary (1878 to 1880), 3 deaths ; Western Infirmary, Glasgow (1883 to 1886), 3 deaths ; Royal Infirmary, Glasgow (1883 to 1885), 2 deaths; other parts of Scotland (1881 to 1883), 6 deaths. England, 110 deaths to 14 in Scotland during the same period. Population of England in 1880, 28,247,151 ; Scotland, 3,991,490. Ratio of deaths in England, 1 to 256,792 ; in Scotland, 1 to approximately 285,107; vide Dr. Alex. Wilson. Methods Employed for Administering- Chloroform* 1. Those in which no special form of inhaler was employed : Chloroform poured on a handkerchief, Chloroform poured on a towel. Chloroform poured on a napkin, Chloroform poured on a sponge, Chloroform poured on lint, Chloroform poured into an extemporized cone. In fewer instances the process is described as having been conducted by the "open method," or chloroform given from a "cone of paper," "cloth," "compress" and so on. The re- corded deaths resulting from chloroform being administered without an inhaler are rather more than double those occurring when an inhaler is used. CAUSES ASSIGNED FOR DEATH. 253 2. Deaths under chloroform when a specified apparatus (in- haler) was emploj^ed : the order of deaths during their use. The following are the methods employed : Inhalers (kind unspecified). Skinner's inhaler (flannel mask stretched on a wire frame). Snow's inhaler. Junker's inhaler. Clover's inhaler. Esmarch's inhaler. Metallic inhaler. Grey's Hospital inhaler. Morton's ether inhaler. Weiss' s apparatus. Open method, chloroform " poured " on lint after the man- ner of "Syme." who taught that plenty of the drug should be used. Open method, chloroform "dropped" on lint after the manner advocated by the dosmetric school, who teach that by dropping on lint almost safety is insured. Causes Assigned for Death. Of predisposing causes intemperance and wasting disease, the existence of emphysema, pathological conditions of the heart and bloodvessels are the most noted. ■■ Immediate Causes of Death — Heart Failure and Re- spiratory Cessation. —Of the 506 cases recorded and which have come under the "Lancet Commission " the pulse is stated by the person who reports the death to have failed in first 143 instances, while in 59 records the respiration is described as being primarily stopped ; in 46 it is mentioned that the respira- tion and circulation (as judged by the pulse) ceased simultane- ously; whilst in 36 the pulse probably, it is asserted, failed first, in 4 the respiration probably failed first, and in 12 they probably failed simultaneously; in 211 cases no record was given as to which failed first. Of the cases collected by the committee of the Royal Medi- cal and Chirurgical Society, out of 83 cases, 26 are given in which the pulse failed first, 4 in which respiration failed first, 254 ARTIFICIAL ANAESTHESIA. 11 in which respiration and circulation failed simultaneously, 9 in which the pulse, probably, failed first, 2 in which the respi- ration, probably, failed first, and 7 in which they, probably, failed simultaneously, while 24 cases had no records of these points. A very careful consideration of all the records which have been brought under the notice of the commission would seem to favor the conclusion that in the lar^e majority of cases, the symptoms and phenomena detailed bear out the view that death was due to syncope in so far as the clinical evidence would decide^ one way or the other. In drawing up this summary the greatest difficulty has arisen in many cases from the looseness and inadequacy of the pub- lished records. It has been necessary in some instances to place apparently similar cases under different headings, when the causes assigned for death have been diiferent, although the lessons have been similar. Thus in one case death is attributed by the narrator to syncope, although it is stated that food was found in the wind-pipe, which, it may be presumed, caused respiratory trouble, leading, it may be, to syncope as an ulti- mate result. No attempt has been made to tabulate information as to the quantity of chloroform used or its quality. Repeated Inhalation. Of the cases examined 11 males who had died under chloro- form had taken it safely once before, 11 females and 13 males more than once. Purified Chloroform — Anaesthetic and Physiolog-ical Action. When one per cent, of chloroform is mixed with three to five per cent, of atmospheric air, it becomes charged with it, and in this form it is usually employed as an anaesthetic. The amount of vapor which can be taken up (held in solution) by the air of the atmosphere, varies with the elastic tension of the chloroform vapor at different temperatures. Thus, at 40° R, a small quantity of chloroform would evaporate into air ; at PURIFIED CHLOROFORM. 255 130° F., so much would volatilize as to give rise to an almost pure chloroform vapor. In the following table, taken from Snow's "Anaesthetics," the amount of chloroform in vapor is shown in 100 cubic inches of saturated mixture of air and chloroform at different temperatures : jgrees F. 40 Air per cent. 94 . Vapor per cent 6 45 . . 93 . • > 7 50 92 . 8 55 90 . . 10 60 88 . . 12 65 85 . 15 70 81 . . 19 75 78 . 22 80 74 . . 26 85 70 . 30 90 £> _i 1 £> 65 . 1 n 35 One grain of chloroform in 100 cubic inches of air produces the second degree of narcosis, but never carries chloroformiza- tion further. This corresponds to a proportion of 1 part by measure of chloroform in 16,285 parts blood, or 0.0000614, the proportion by weight. Two grains in each 100 cubic inches of air, or 2V saturation (uniiy being saturation), produces the fourth stage of narcosis, or 0.0001228 the proportion by weight. Any proportion above two grains in the hundred causes in- terference with respiration ; three grains in the hundred seems about the ratio which renders respiration impossible. Three grains represent 2.3 cubic inches vapor, and as air ,at 100° F. can take up 43.3 per cent, of its volume, the blood must contain from -^ to xV of the proportion it is capable of absorbing when the respiratory centres are poisoned. Snow found further, that calcuhiting the weight of the blood as thirty pounds, twelve minims of chloroform in the circulation produce narcosis of the second degree ; eighteen minims, the third degree (surgical anaesthesia) ; twenty-four deep narcosis (fourth stage), and thirty-six should paralyze the medullary centres. In practice more is needed, because a certain propor- 266 ARTIFICIAL ANAESTHESIA. tion evaporates from the tracheal and bronchial surfaces, and is carried out in expiration. If twelve minims be evaporated into a bladder, and inhaled to and fro, no more air being allowed than can be blown from the lungs, narcosis of the sec- ond degree actually results. Now, taking thirty-six minims as a lethal dose, the following considerations, upon which Snow strongly insisted, explain how easily this quantity may enter the circulation if the administrator be not perpetually upon his guard against over dosage ; eighteen minims represent the amount absorbed to produce surgical narcosis ; this amount might be absorbed by the use of thirty-six minims, the remain- ing eighteen minims being exhaled as above mentioned. These thirty-six minims represent 37.5 cubic inches of vapor, which, at 60° F. , would require 257 cubic inches of air. The 300 cubic inches thus formed would be inspired in twelve respiratory acts (25 cubic inches being the amount of tidal air). Now, if a vapor of this strength were continuously inhaled, the residual and complemental air would become saturated, and as about 250 cubic inches represent the air in the lungs, this amount would at 60° F. contain the vapor of thirty minims. Assuming only half this quantity to be absorbed, that is fifteen minims, we should then have 18 + 15, or thirty-three minims in the blood, an amount almost, if not quite, enough to paralyze the respiratory centre. These points being held in remembrance will explain many cases of chloroform death ascribed to "idio- syncrasy," or the " fatty heart, " which stand inexpert chloro- formists in such good stead. Death from chloroform does not, however, always result from respiratory paralysis. Death occurs from heart-failure, cardiac syncope or asphyxia, from too large a quantity of chloroform being employed ; also , owing to the closure of the glottis, or paralysis of laryngeal muscles ; also, respiratory failure, or absorption into the blood and nerve structures, producing entire alteration of them. What has experimentation determined definitely in regard to the action of chloroform? The action of chloroform on the brain is, first, congestion ; but when there is complete anaes- thesia, it produces decided anaemia in man and animals. The muscular excitement of the second stage is, according to experi- PURIFIED CHLOROFORM. 257 ments, purely physical ; and there is, during the production of anaesthesia, a steady lowering of reflex action. Chloroform at first induces contraction, and afterwards much the same pupillary phenomena are seen during the action of drugs which affect the cerebro-spinal system, even in those, which, in the first instance, produce myosis. In such, if the action of the drug be pushed, a stage is arrived at when the function of the respiratory and cardiac centres is so seriously compromised that the pupils become widely dilated and fixed. This may be illustrated by the action of three drugs — opium, chloroform and alcohol. In opium coma, the pupil is always firmly contracted, while in alcohol coma, we can distinguish it from opium, if we pull the beard or hair, as this act will cause temporary dilatation. In chloroform narcosis, the same pupillary phenomena are observed during the extreme stages. From personal observa- tions, extending over several hundred carefully recorded cases, it is seen that the pupils are in a very variable state during the preliminary periods, much too variable to permit any rule being formulated regarding them. When, however, reflex action is abolished, except in the cardiac and respiratory centres, the pupils become contracted and fixed. (Dr. MacEwen, of Grlas- gow, stated to us, that young operators frequently make the serious mistake of judging that the patient is ready for an operation merely from the test of touching the cornea with impunity, when an examination of the opposite eye will con- vince him that he has produced by the close application of the chloroform of the cloth, nothing more than a local anaesthesia, confined to one eye.) Anaesthesia from chloroform is divided into five stages, as follows : In the first stage — from commencement of inhalation to im- pairment of consciousness — fulness of the head, ringing, buzz- ing in the ear, palpitation of the heart are sometimes felt ; there is also some diminution of common sensation. In the second stage the mental powers are impaired, although not suspended. The patient remains passive, as if sleeping, or occasionally makes a voluntary movement. Sometimes laugh- 258 ARTIFICIAL ANESTHESIA. ing, singing, talking are indulged in during this stage. Snow believed that dreaming occurs at this time, and then only. Towards the close the patient becomes restive ; he attempts to remove the face-piece or towel, for he is conscious of being in- convenienced by the vapor, but not of the necessity for remain- ing passive. Common sensation is much blunted, so that patients submit without expostulation to painful manipulation. This degree of narcotism is sufficient for obstetric practice and the after-stage of prolonged operations. As a rule, struggles or expressions of pain which show themselves at the time are not subsequently remembered. hi the third stage all voluntary movements are lost. The conjunctival vessels become full, the muscles rigid, and struggles, even epileptiform convulsions, may supervene. As the stage advances the muscles relax." Inarticulate jabbering and mouth- ing occur. Although really insensitive to pain, the patient may flinch or even cry out. Later in this stage, all reflex acts are abolished, the conjunctival and nasal receding last. The patella jerk also persists late, while under deep anaesthesia the ankle-joint phenomenon appears. In the fourth stage breathing is stertorous, the pupils dilated, and the muscles completely relaxed and flaccid. In this stage the patient is profourtdly unconscious, and is drifting into dan- ger. Such deep narcosis is seldom needed, save for the reduc- tion of old-standing dislocations, etc. The fifth stage is the interval which, following the fourth degree of narcosis, intervenes between the respiratory embar- rassment and total cessation of breathing. Even after dyspnoea has passed into apnoea, the heart continues to beat for a brief while. This stage marks the period when chloroform tension in the blood is great enough to paralyze the respiratory centres in the medulla oblongata. The third stage may be regarded as the safety zone of com- plete chloroform narcosis. But if anaesthesia be pushed beyond this stage, wide dilatation of the pupils ensues, indicating a sus- pension of function in the cardiac and respiratory centres. This is a most critical condition, though one by no means neces- sarily fatal, as by lowering the head and raising the floor of the THE PUPIL AS A GUIDE IN GIVING CHLOROFORM. 259 table, and by promptly carrying out artificial respiration, even while feeble respiratory eiForts are being made by the patient, the danger may be, and frequently has been, averted. Given a person free from organic lesion of the nerve centres, heart or lungs, in whom, during chloroform narcosis, stable mydriasis suddenly occurs as a result of the action of chloroform on the respiratory centres, the patient ought to recover if artificial respiration, coupled with the lowering of the head, be promptly resorted to, and the former efficiently carried out. It is inter- esting to note, in such cases, the marked efiect produced by ele- vating the foot of the table, so as suddenly to place the patient's head and thorax at a very low level, the pupils becoming quickly contracted. In this connection, however, it ought to be borne in mind that one of the earliest indications of a return of reflex action is vomiting, which, as a rule, is accompanied by dilated pupils, the result of cerebral ansemia. In cases where the functions of the cerebro- spinal system, especially of the cardiac and respiratory centres, have already been enfeebled (by organic lesion or otherwise), chloroform acts more powerfully, a few whififs sufficing to induce complete insensibilitj", and the administration of an ordinary dose giving rise to an alarming state, which only prompt measures can prevent from becoming fatal. In such cases the pupils very readily pass into wide dilatation, with a very small amount of chloroform. When the function of the brain is suspended by want of oxygenated blood, the pupils are widely dilated and fixed. This may be seen in cases of asphyxia, either by poisonous gases or arising from mechanical causes. It was once observed by Dr. MacEwen in two men, who had all but succumbed by inhaling coal-gas, emanating from a broken gas-pipe in their bed-room, and it is also seen in cases of hanging. The Pupil as a Gviide in Giving- Cliloroforni. Neilson considers the pupil a reliable indication of a patient's condition, under chloroform anaesthesia, and concludes from hig experiments as follows : "1. The effect produced by chloroform on the pupil is, at first, 260 ARTIFICIAL ANESTHESIA. dilatation, varying in degree and duration, then contraction as the narcosis becomes profound, and dilatation again when the sensibilitj' is returning. If the administration be still con- tinued, with the pupil strongl}^ contracted and motionless, the pupil will also dilate, but in this case more suddenly and com- pletely, and will be coincident with a state from which it will be difficult or impossible to resuscitate the patient. This latter is the dilatation of asphyxia. "2. So long as the pupil dilates in response to excitation by pinching, etc. , the patient is not sufficiently narcotized for the operation to be proceeded with unless the latter is slight and does not require complete anaesthesia. ' ' 3. When the pupil becomes strongly contracted and immobile, no more chloroform should be given until it begins to dilate again. If, then, further anaesthesia be required, a little more chloroform should be given until the pupil again contracts. ' ' 4. The occurrence of sickness causes dilatation similar to, but more sudden than, that which happens when sensibility is re- turning, and the efforts of vomiting have the effect of arousing the patient." During the first half-minute of the inhalation of chloroform, there is a progressive lowering of the arterial pressure. Chloro- form, if injected into the jugular vein, instantly arrests the heart's action. Chloroform produces contraction of the red blood disks ; if, however, air be admitted to blood containing chloroform, the red corpuscles rapidly disappear, dissolving in the serum, out of which, after a time, haematin crystallizes. One authority states that after anaesthesia bile-acids appear in the blood ; and it has been found that the oxygen of the blood undergoes an increase during anaesthesia. During the action of chloroform the temperature falls, the circulation is retarded, and the skin gives off less insensible perspiration. According to the recent experiments of Ranke, which we have before referred to and repeated on several small animals (and this is also the view of the late Claude Bernard), the nature of the action of chloroform upon the nerve cells is slight coagulation ; but if the animal was killed with the chloroform, TOXICOLOGICAL EFFECTS. 261 there was hardening of the nerve trunks and entire change, in which evident coagulation of the albuminoid tissues took place. If chloroform was mixed with blood not exposed to the air, there is no change except contraction, either shown under the microscope or by spectrum analj'sis ; this we have repeatedly determined in the frog, rabbit, pigeon, etc. Toxicological Effects. Chloroform is the most potent and agreeable anaesthetic, but the most dangerous, and is the one in which death may occur at any and every stage by inhalation. Chloroform kills so sud- denly that neither skill nor care can always guard against a fatal result. Another disadvantage of chloroform is its high boiling-point, requiring a great amount of heat and vital force to exterminate it from the body, so that it is probably never eliminated entirely by the lungs, but only with the aid of all excreting organs. Any deficiency or derangement of the body which may consequently lead to such suppression or elimination, causes the nervous system to be overwhelmed with consequent inactivity. Almost all anaesthetics may kill during the first stage by asphyxia ; the air may be very highly charged — even saturated — with the agents ; so much so, that owing to its pun- gency it cannot be breathed, and if forced upon the patient, stifles and suffocates him in exactly the same manner as would sulphur burned under his nostrils ; death would thus occur without much having entered the body. Owing to the danger which accompanies its use, chloroform should onlj^ be administered when other anaesthetics are not available ; or under the especial circumstance that without it the shock of the operation might kill the patient. In railroad accidents, and military surgery, it becomes at times absolutely necessary ; and in the holds of ships, especially those of iron, where the temperature is very high, it is resorted to on account of its rapidity of action, smallness of quantity required, cheap- ness, small bulk in transportation, and the less risk of explo- sion and ignition. In obstetrics, chloroform is used with com- parative safety to the mother, although a few deaths have been reported ; but from our observations taken, in carefully- 262 ARTIFICIAL ANESTHESIA. watched cases, it is apt to be fatal to the infant. Conclusions have been drawn, that in long and instrumental labors, ether, or bromide of ethj^l, although not so pleasant, are much safer to the child. The s\'mptoms which usually occur as precursors of death from chloroform are a sudden paleness or lividity of the coun- tenance, shallow breathing, stertor, loss of, or a quick and weak pulse, tossing about of the patient, delirium, convulsions, or coma. Chloroform should never be administered in a sitting posture, nor should a patient rise suddenly when under its influence. JVliat is the chief danger to be apprehended when chloroform has been used, and how do we prevent fatal symptoms, as closure of the glottis, fainting, failure of the pulse, or respira- tory syncope? Stop the administration of the chloroform, lower the head to an angle of forty degrees, and elevate the feet above the level of the body, and remove the mucus or blood that may collect in the mouth during the operation. Draw out the tongue, and retain it out by a hgature, Ketch forceps, or dry towel, and elevate the jaw, and above all use artificial respiration, keeping it up for at least one hour if necessary. Administer from ten to twenty drops of nitrite of amjd, if the face is pale, but not, if flushed; drop from a bottle on a piece of cloth and hold it to the nose and mouth. If the patient make no efi'ort to breathe, force it up the nostrils by means of a small hand-spray compressing apparatus, and expand the chest by manipulation with the elbows to the side, and compress the chest. This should be continued until the heart acts. Flagellation with towel wrung out of ice water is very useful, but do not chill the patient. If there is still increased narcosis, employ hypodermic injections of water of ammonia (containing five per cent, of ammonia gas) to the quantity of a drachm or two, or solution of sulphate of atropia. But depend chiefly on lowering the head, and artifi- cial respiration long continued. Grive the patient plenty of fresh air b}'^ opening the windows ; if cold, cover with blankets. Apply a galvanic or Faradaic current during the artificial res- piration, one electrode to the base of the neck and the other to A NEW WAY OF RAISIXO THE EPIGLOTTIS. 263 the epigastric region, on a line with the diaphragm, but not in the region of the heart or solar i)lexus. Let the assistants or nurses rub the extremities briskly, and use even slight blows, on the neck, and side of the chest, but not on the stomach. It is not safe to continue an operation immediately on a pa- tient's recovery from the excessive action of anaesthetics, but to wait until respiration has been energetically restored ; otherwise, a new and generally fatal asphyxia may be produced. It is well to remember that angemia of the brain is secondary to the ces- sation of the heart's action, and that to restore vitality to the brain requires that the heart's action be restored. For this purpose, as we have stated before, there is nothing better than lowering the head and artificial respiration, and the use of it is to be continued, not onlj' for a few moments, but for hours; indeed, recoveries have occurred after the use of the Faradaic current and artificial respiration for one hour. It has been clearly proven that in cardiac and respiratory failure, the pneumogastric nerve retains its excitability in chlo- roform poisoning, and it is, therefore, extremely dangerous to apply electricity to the neck in this condition. (See the experi- ments and observations of Doctors Hare and Martin on the phrenic nerve. ) A J^ew Way of Raising- tlie Epiglottis. Dr. Howard, of London, has endeavored to prove that trac- tion of the tongue cannot, as is supposed, raise the glottis, but that the only way by which it can be certainly raised is by ex- tension of the head and neck, whereby its elevation is instant and complete. The patient is brought to the edge of the bed, or the chest is elevated, so that the head may swing free, and with one hand under the chin, and the other on the vertex, steadily, but firmly, carry the head backward and downward, until the most possible extension of the head and neck is ob- tained. In reference to the above paragraph, we addressed a letter to Dr. H. A. Hare, knowing that he, in conjunction with Dr. Martin, had made experiments on the subject. He sent us the 264 ARTIFICIAL ANESTHESIA. following article, which is of so much importance that we have published it entire for the benefit of those who may have an urgent respiratory crisis in anaesthetization. The Treatment of Arrested Respiration in Anaesthesia.* " In a paper read before the Medical Society of London, Dr. Benjamin Howard maintains the following propositions : "1. The epiglottis falls backward in apnoea, and closes the glottis ; the first thing in order and importance is the elevation of the epiglottis. "2. Traction upon the tongue, however, and whatever the force employed, does not and cannot raise the epiglottis, as sup- posed. " 3. The epiglottis can only be raised by extension of the head and neck. ' ' 4. The full effect of extension can only be secured, with certainty, by making the extension complete, as directed. " 5. The method of making extension is as follows : ' Having, by bringing the patient to the edge of the table or bed, or by elevation of the chest, provided that the head may swing quite free, with one hand under the chin and the other on the vertex, steadily but firmly carry the head backward and downward; the neck will share the motion, which must be continued till the utmost possible extension of both head and neck are ob- tained. Sometimes a slight elevation and extension of the chin will at once check stertor, or irregularity of breathing; but understand, the extension, which can in no case do harm, should always be rather more than appears necessary. It should never be forgotten, however, that the full effect of extension, as above described, can be secured with certainty only by mak- ing the extension complete, as directed.' * By Edward Martin, M.D., Instructor in Surgery, University of Pennsylvania; Surgeon to the Philadelphia Hospital and to the Howard Hospital ; and H. A. Hare, M.D , Demonstrator of Thera- peutics, and Instructor in Physical Diagnosis, in the Medical Depart- ment, and in Physiology, in the Biological Department, University of Pennsylvania. THE TREATMENT OF ARRESTED RESPIRATION. 265 "These propositions are, in some respects, so contrary to the daily experience of surgeons and anaesthetizers, and, if well founded, are of such supreme importance in cases of suspended animation, that we have conducted a series of experiments de- signed to test, in so far as this is possible, by working upon the dead body, the validity of Howard's conclusions. "Limiting our inquiry to those cases of threatened death which occur from respiratory obstruction, during the adminis- tration of an ansesthetic, we must first endeavor to discover the mechanical cause which is principally operative in producing such obstructions. We presume that by apnoea, Howard means, not a condition of suspended respiratory efforts through hyper- oxidation of the blood, which is the true significance of the term, but cessation of respiratory movement. We cannot be- lieve the epiglottis is chiefly at fault as an obstructive agent, because, in the vast majority of cases, the air-passage is at once made free by drawing the tongue forward ; since tip-traction has no effect upon the epiglottis, as stated by Howard and con- .firmed by our own observations, this manipulation could not relieve the breathing were the epiglottis the cause of the diffi- culty. The effect of traction upon the tip of the tongue is to draw this organ free from the soft palate and the post-pharyn- geal wall ; it is the tongue, then, fallen back upon the posterior wall of the pharynx, which is the most common obstructing cause; consequently, the tongue should receive the most im- mediate consideration. We do not for a moment deny the possibility of respiratory difficulty being caused by the epiglot- tis alone, though experimentally the inward passage of air was very little influenced by any position of the epiglottis, provided the tongue was carried well forward : we would insist, how- ever, upon the position of the tongue as a matter of prime im- portance. Considering next the effect of tongue-traction upon this epiglottis, we are not prepared fully to indorse Howard's statement. Tip-traction moves the epiglottis not at all ; this we have confirmed by many trials, both in the living and in the dead subject ; but if a tenaculum is fixed in the dorsum of the tongue two and a half inches back from the tip, traction at once draws the base of the tongue, and the epiglottis with it, 18 266 ARTIFICIAL ANESTHESIA. far forward, so that the air-passage is absolutely free from the larynx to the mouth. Traction can then be so applied to the tongue that the epiglottis is raised and the air-way made ab- solutely free, and we have devised an instrument by which this may be accomplished without the laceration attendant on the use of hooks or forceps. " Is extension of the head and neck the only method of rais- ing the epiglottis? Again we are compelled to take exception to Howard's statement. As detailed in our experiments, the epiglottis can be raised by traction upon the dorsum of the tongue by pressing the greater cornua of the hyoid bone forward by the action of gravity in the abdominal decubitus, and most thoroughly by flexing the neck and extending the head upon the neck. That Howard's position accomplishes mechanically all that he claims for it, we freely grant. The way in which the soft, collapsed structures straighten under his manipulation, the tongue riding forward and the epiglottis springing erect, is most striking ; and we are convinced that the admirable me- chanical explanation he gives for this effect is correct. Howard states : "'.... by extension of the head and neck, carried to the utmost completeness, the backward-fallen tongue, the velum palati and uvula, are all simultaneously shifted from the air- way, and the entire pharynx is enlarged throughout as fol- lows : a. The tongue, the dorsum of which before fell by gravi- tation upon the then horizontal posterior wall of the pharynx, falls upon the now horizontal arch of the palate, b. The velum palati, by means of the great tension of the palato-pharyngeal muscles, is pulled away from the posterior wall of the pharynx, the entire membrane being stretched tightly forward and downward, behind part of the dorsum of the tongue, forming a partition which helps to shut the tongue out of the pharynx and into the mouth, where it belongs, and with part of the dorsum forms the anterior wall of a new post-oral air-way, thus created and maintained, c. The pharynx, anteriorly, is stretched far forward by the extremely tense sterno-thyroidei muscles acting through the thyroid cartilage, by the genio-hy- oidei and mylo-hyoidei muscles, acting through the os hyoidei. THE TREATMENT OF ARRESTED RESPIRATION. 267 The base of the tongue and the velum palati are shifted forward in the manner alread}^ described, the posterior nares being shifted, by the extension of the head, by its oecipito-vertebra^ articulation, about sixty degrees. Posteriorly, the wall of the pharynx is shifted back its whole length by the extension of the cervical vertebrae upon each other, in all about thirty degrees, extension being particularly great just opposite the glottis. Thus the upper air-way, which before was a tortuous, angular, flaccid canal — barely, and if at all uncertainly permeable — is made an enlarged, firm, but slightly curved tube, free through- out from the glottis to the nares. ' "With all this, except the backward shifting of the posterior wall of the pharjmx by extension, we are fully in accord. We cannot, however, concede that his practical deduction from these facts is a step in the right direction. With the head and neck in extreme extension, the soft palate is strapped over the dor- sum of the tongue, the mouth is closed from the pharynx and the entrance of air to the lungs depends absolutely upon the condition of the nostrils. Can it be considered an additional safeguard — an improved method — to substitute for the roomy mouth an air- way, but just sufficient at the best, subject to an infinite variety of obstructions, varjdng in size from hour to hour, in many persons absolutely, and permanently occluded? Certainly no American rhinologist would answer in the affirma- tive. Hypertrophies, polypoid growths and vegetations are not the rare exception. The slightest congestion is frequently suffi- cient to block patulous nares. A nostril which will admit the little finger of the surgeon, when the patient is standing, may become completely closed when the head is placed on a level with the body. The recumbent or dependent position, the irritating effect of ether upon the mucous membranes, cephalic congestion due to insufficient oxidation, all combine to render the nostrils unsafe — in fact, absolutely impracticable — as the sole passage of communication between the lungs and the ex- ternal air. We cannot believe that recourse to this method, in cases of suspended animation under anaesthetics, could be fol- lowed by favorable results ; if the tongue were drawn forward it would certainly provide ample air-way, the passage from the 268 ARTIFICIAL ANESTHESIA. pharynx to the mouth being opened by this manipulation. One of the great advantages of this method, however, as claimed by Howard, is that the necessity for traction upon the tongue is entirely done away with. If the necessity for drawing for- ward the tongue is not done away with we cannot see that Howard's method offers any material advantage over that ordi- narily practiced in this city. "Our experiments show that extension of the head carried so far that the base-line (Reid's) makes an angle of somewhat more than fifty degrees to the plane of the bed, or table, raises the tongue and epiglottis so entirely clear of the posterior pharynx that there is ample air-way ; the soft palate, too, lies free of the post-pharyngeal wall, but is not drawn closely across the dorsum of the tongue, thus allowing respiration to take place through the mouth. If, in the course of an anaesthetiza- tion, there is respiratory difficulty, the method which obtains here is as follows : The chin is immediately pressed forward by the fingers placed behind the rami of the lower jaw ; at the same time, and by the same manipulation, the head is extended, the pillow, if any has been used, being removed ; if there is still apparent obstruction the tongue is now drawn forward. With this manipulation, except in case of foreign body or abnormality of structure, the air-passage from the mouth to the larynx is absolutely free. Hereafter we may modify this method, so placing the pillow that the neck is flexed as far forward as pos- sible, then extending the head upon the neck, as we find that this gives us wide dilatation, the posterior pharyngeal wall rep- resenting the arc of a circle, from the concavity of which exten- sion of the head draws forward the tongue, epiglottis and larynx. In the method as detailed above it rarely occurs that the tongue has to be drawn forward. "Finally, we cannot grant that Howard is justified in believ- ing, of the hundred cases of death due to the administration of an anaesthetic, that in each case the epiglottis was in all prob- ability unraised, and continued unraised until death was com- plete. The appearance of the parts after death cannot be taken as indicative of their relative position during life — when inspi- ratory efibrts are still taking place, when the rigor mortis has not THE TREATMENT OF ARRESTED RESPIRATION. 269 made the surrounding muscles more rigid than the epiglottis. Again, the very traction upon the tongue, as usually exerted, extends the head sufficiently to carry the epiglottis free of the post-pharyngeal wall. Finally, where inspiratory efforts are being made, there is no difficulty in determining whether or not air is entering the chest ; the noise of its passage through the mouth and throat, the respiratory sounds, are sufficiently char- acteristic of its free entrance ; while sinking in of the inter- costal spaces, epigastrium, and suprasternal region, during an inspiratory effort, are absolutely diagnostic of obstruction. These signs, though not so patent, are still sufficiently clear in artificial respiration, and if the cause of death were even in the majority of cases simply obstructive, this condition of obstruc- tion would unquestionably have been recognized and remedied, if not by position certainly by tracheotomy or intubation. "The results of our examinations, made upon several cada- vers, are as follows : " By chipping away the basilar process of the occipital bone the naso-pharjmx is exposed. "Subject in the dorsal decubitus, head midway between flexion and extension, eyes looking directlj^ upward, Reid's base-line (from the lower border of the orbit through the bony meatus) at right angles to the plane of the table. " The tongue lies in close contact with the posterior wall of the pharynx, only the tip of the epiglottis being visible. The soft palate and the dorsum of the tongue shut the mouth from the pharynx. The air-passage is completely obstructed by the tongue and epiglottis, "By means of a tenaculum passed through its tip, the tongue is seized and drawn forward as far as possible. The body of the tongue is drawn clear of the post-pharyngeal wall and the soft palate ; the hyoid bone, the base of the tongue and the epiglot- tis are not at all influenced. " The tenaculum is now fixed two and a half inches from the tip ; traction draws both the base of the tongue and the epi- glottis well forward. "The fingers are passed behind the angles of the lower jaw, and the latter is pressed forward ; this elevates the epiglottis 270 ARTIFICIAL ANESTHESIA. and the base of the tongue about a quarter of an inch from the post-pharyngeal wall. Extending the head so that the base- line makes an angle of forty-five degrees with the plane of the table, draws the base of the tongue and the hyoid bone far for- ward, this motion being at the same time imparted to the epi- glottis, so that the latter stands upright, and is separated from the posterior wall of the pharynx by an interval of about an inch. By tightly closing the jaw, the antero-posterior space is still further increased. "The body is drawn to the end of the table, so that the head hangs free ; the latter is now extended until the base-line is par- allel to the plane of the table ; the antero-posterior space be- tween epiglottis and pharynx is slightly greater than that which obtains from moderate extension. At the same time the tongue drops toward the roof of the mouth, the soft palate is put upon the stretch, and the mouth cavity is shut out from that of the pharynx. " Placing the head so that the base-line is perpendicular to the plane of the table again produces complete closure of the pharynx, owing to the tongue and epiglottis falling directly backward. "Placing the fingers upon the posterior cornua of the hyoid bone, and pressing the latter directly forward, carries the epi- glottis and tongue about one-half inch forward and entirely free of the post-pharyngeal wall. "With the head moderately extended, and the jaw pushed forward, an effort is made to crowd the tongue and epiglottis against the post-pharyngeal wall ; this is found to be impos- sible. "Flexing the neck by lifting the head forward (keeping the base-line perpendicular to the plane of the table) separates the post-pharynx from the epiglottis and the base of the tongue by about one-half an inch. Extending the head upon the neck, the neck being still flexed, produces a yet wider separation, the antero-posterior diameter of the breathing space being some- what more than one inch. "Placing the body in the position of abdominal decubitus, the base-line being perpendicular to the plane of the table, the THE TREATMENT OF ARRESTED RESPIRATION. 271 hyoid bone, base of the tongue and epiglottis all fall forward, leaving an interval of about half an inch between the epiglottis and post-pharyngeal wall. "On elevating the shoulders, by seizing them and lifting them directly upward, this space is increased to fully an inch ; at the same time the arytenoid cartilages are drawn backward, exposing the glottis throughout its whole extent. " Bringing the body to the end of the table and letting the head droop forward (still in abdominal decubitus), thus flexing the neck to its full capacit3% then extending the head at the occipitoatloid articulation, exposes the larynx more completely than any of the previous postures or manipulations. "Conclusions. — The epiglottis may prevent free entrance of air to the lungs, even though the tongue is pulled forward. Any means which accomplishes the anterior projection of the hyoid bone, immediately and infallibly raises the epiglottis and the base of the tongue. " The hyoid bone may be made to project anteriorly by direct pressure upon its cornua, by direct pressure or traction applied to the dorsum of the tongue, behind the anterior half-arches of the palate, by the action of gravity in the abdominal decubitus, or by extension of the head upon the neck. "Extension of the head upon the neck, carried as far as forty- five degrees, produces practically as patulous a condition of the air-way as forced and extreme extension. At the same time this moderate extension usually leaves sufficient room between the palate and the dorsum of the tongue for breathing to con- tinue through the mouth. " In forced extension of the head and neck, the entrance of air into the lungs depends upon the sufficiency of the nasal pas- sages. " Flexion of the neck, with extension of the head upon the neck, does away with the epiglottis as an obstructing factor as completely as any other posture. This is best accomplished by supporting the head upon a high pillow, then pulling it di- rectly backward by the hand placed under the chin, so that the weight of the head falls upon the occiput rather than upon the back of the neck. 272 ARTIFICIAL ANESTHESIA. ''Therefore, in case of an urgent respiratory crisis in anaes- thetization, we would direct that the index fingers placed behind the greater cornua of the hyoid bone, and the middle fingers resting upon the angles of the lower jaw, both these structures be pressed directly forward, the same force also serving to ex- tend the head upon the neck. If obstruction to breathing still persists, the tongue should be at' once drawn or pushed forward by force, exerted upon its dorsum posterior, to the anterior half-arches. "No force, unless directly applied to the tongue itself, is sufficient to infallibly prevent this organ from acting as an ob- structing factor. No manipulation yet devised can, in every case, take the place of direct action. "The tongue may act either in conjunction with the pharyn- geal walls or with the palate, in preventing free entrance of air. If the position of moderate extension and direct traction or pressure upon the tongue fail to remove the obstruction to breathing, intubation or bronchotomy remains as the last re- sort. Apparatus of Martin and Hare for the Treatment of Cases of Arrested Respiration, and their Conclusions in Injury or Destruction of the Phrenic Nerve. " The apparatus which we devised for use in a case where the body is too large to permit of the operator swinging it, as in the man and dog, under similar circumstances to those named, was constructed as follows, and consisted of a board supported on an upright of equal width and rounded edge, the horizontal plank resting by means of a groove on its under sur- face upon the convexity of the vertical support. To this hori- zontal board is then bound the subject, and by a see-sawing movement the body is rapidly changed, so that at one moment the head is down at an angle of forty-five degrees, and at the next moment is correspondingly raised, while the feet fall. In this way the weight of the abdominal contents is thrown against the diaphragm as the head is lowered, and the air in the thorax is thereby driven out. On the other hand, if the head is rap- CONCLUSIONS. 273 idly raised and the feet ftill, the abdominal contents drop into the pelvic space, dragging the diaphragm after them, and thereby producing inspiration. "In order at the same time to extend the chest, as the ab- dominal contents sagged downwards, we were forced to invent a simple apparatus which, by means of cords, raised the arms above the head at the moment that the feet approached the floor." Cunclusions. " 1st. Injury or destruction of the phrenic nerves is not fol- lowed by death, as has heretofore been taught. ' ' 2d. That in injuries involving the diaphragmatic movements it is important that the patient shall not be anaesthetized, as under those circumstances the absence of voluntary aid in respi- ration may be attended by fatal results. "3d. The seriousness of phrenic injury is in direct ratio to the dependence of the respirations of the normal animal on the diaphragm, and to the ability of the chest walls to make com- pensatory movement. "4th. The symptoms resulting from interference with the functions of the phrenic nerves are as definite and character- istic as those following interference with any other motor nerve. There will always be well-marked increase in the scope of the thoracic excursions, and distinct reversal of the move- ments of the belly, i.e., the belly will retract on inspiration. " 5th. Fear of injury to one or both phrenic nerves need not prevent operations about the neck and upper portion of the chest, provided that due caution be exercised, that the patient is but shghtly under the influence of the anaesthetic at the time, that danger of injury to these nerves is most imminent. Infancy, however, constitutes an exception to this rule ; only absolute and pressing necessity for operation would afford justi- fication for such a procedure in early life. "6th. The real effects of section of the phrenic nerves being known, it follows that the nerve is subject to the same opera- tion in case of injury as are other nerves of the body, such as suture. 274 ARTIFICIAL ANESTHESIA. "7th. The presence of the abdominal viscera are necessary for the normal movements of the diaphragm. "8th. The abdominal contents may alone be used for the pro- duction of artificial respiration, but while they are always to be employed to this end their use should never be allowed to dis- place those movements which are directed to the chest. Both should be used together if possible. " 9th. In cases of injury to the phrenic nerves support should be given to the belly walls, to prevent movement of the same, and to brace and steady the paralyzed diaphragm, care being taken that the floating ribs are free. " 10th. The method of Sylvester drives more air through the lungs than any other single method, but its best results are not gained unless the feet be drawn down as the arms are extended. " 11th. The volume of respired air after section of the phre- nic nerves is temporarily decreased until the thorax compensates for the loss of the diaphragm. " 12th. Oxygen gas is a valuable agent in the treatment of persons sufiering from coal-gas poisoning. " 13th. Oxygen gas aids very materially in bridging over the respiratory crisis occurring after injury to the phrenic nerves. " 14th. In life-saving stations, mines, police stations, or other points to which asphyxiated persons may be brought for resus- citation, in hospital clinics, or in private houses, where ether or chloroform is given, oxygen in appropriate form for immediate administration should be provided. The accoucheur also will find in this gas a valuable adjunct in the treatment of cases of suspended animation in the newly born. Very small cylinders, containing forty gallons of the compressed gas, are easily car- ried and require a small amount of space. " 15th. The electrical methods now employed for the resusci- tation of persons who have ceased breathing are dangerous and unjustifiable." On the Influence of Climate and Heat on the Use of Chloroform. — The following extracts from letters of distin- guished surgeons in the South will show the influence of climate on the use of chloroform : Dr. Langdon B. Edwards, editor of the Virginia Medical DANGERS AND TREATMENT OF FATAL SYMPTOMS. 275 Monthly, October 21, 1878, states that it is one of the most pe- culiar facts he has ever known in medical practice— the diifer- ence of experience in Europe and in the North with chloroform and ether as compared with that of the South— the high rate of mortality in the North and the low rate in the South. Anaesthetics are used for more trivial affections and surgical operations in the South than in the North, and, of course, for obstetrical cases, etc. Even during the war, when the South- erners were not using Squibb' s ether, or a chloroform having the reputation of such purity, their preference was for chloro- form, although of home manufacture. Had a case that was fatal occurred from its use in any of the small cities or towns it would have become wide-spread news. The operation of insertion of a needle into the heart might excite the quiescent organ to action, while again it might cause a feebly beating heart, that would perhaps recover if given a chance, to become hopelessly inco-ordinated. Abstract as to the Dangers and Treatment of Fatal Symptoms from tlie Use of Chlo- roform as an Anaesthetic. 1st. Failure of the heart, which may o.ccur at all stages. 2d. From reflex inhibition by terror. 3d. By the irritation of the vapor. 4th. From chloroform idiosyncrasy. Symptoms. —Feeble, fluttering pulse; pallor; grayness or blueness of the face, ears and fingers, or a sudden interruption or complete stoppage of the heart action. Treatment.— Careful examination of the heart, lungs and kidneys, and forbidding chloroform in cases of atheromatous disease of the vessels, which can be felt ; fatty degeneration of the heart, with great pallor of skin and feebleness of action ; aortic or advanced mitral disease, which must be determined by the history and stethoscope. If the symptoms given in the first part are present, the chloroform must at once be removed, the head and body inverted, first removing all foreign bodies from the mouth ; let limbs be elevated in women and blankets 276 ARTIFICIAL ANESTHESIA. well wrapped around them, or the body inverted over the knee of an assistant. When, as occasionally happens, the anaesthe- tizer is single-handed, the raising of a patient by the feet is practically out of the question, except to one of unusual strength. Any one of good physique is able, however, to ac- complish the same thing quite readily by placing his hands be- neath the patient's hips, and raising them until the leg can be slipped beneath, and the patient then rests upon his knee, the foot being upon the bed. The head and shoulders can now be Plate 4'/ Sylvester's Method of Artificial Eespiration. swung off the bed, and at need the patient, from the head to knees, brought into a vertical position. If the tongue has fallen back, draw it forward, and keep it held firmly out of the mouth. If the breathing is not relieved, an assistant employs Sylves- ter's method of artificial respiration as follows : The operator stands behind the patient and grasps the arms near the axillae ; he first presses the arms into the sides, so as to compress the thorax and expel air, whilst an assistant makes gentle pressure upon the abdomen. Next, he firmly draws the arms away from the sides, everting them, and lifting the patient as the arms be- THE EPIGLOTTIS IN CHLOROFORM ACCIDENTS. 277 come about 45° 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 is repeated twelve or sixteen times in a minute. Forced respiration is stated to be an advance upon artificial respiration, and will save human life where the latter will fail. According to Dr. Geo. E. Fell, of Buffalo, N. Y. {Journal Amencan Medical Association^ October, 1889), the apparatus consists of a bellows to supply a steady stream of air, which passes through an air-heating apparatus-; an air-valve which controls the ingress of air to the lungs, and is connected by an elastic tube and tracheotomy tube in the neck and trachea of the patient. The Epiglottis in Chloroform Accidents. Dr. A. E. Prince, in N. Y. Med. Jour. , says : " As an illus- tration of the uncertain knowledge which exists upon the sub- ject, may be cited the belief that drawing out the tongue will raise the epiglottis, and thus open the air-way to the lungs. This belief exists in the minds of a large proportion of the pro- fession, and the procedure is employed and recommended by many leading surgeons. By way of correcting the error, refer- ence is here made to a demonstration, by Benjamin Howard, before the Roj^al College of Surgeons, England, the conclusions drawn from which are : First, contrary to the universal belief, traction of the tongue cannot raise the epiglottis ; second, by sufficient extension of the head and neck, whether bj'^ volition, instinct, reflex action or by effort of another, whether in the healthy, in the djang or in the dead, the epiglottis is instantly and beyond prevention made completely erect ; third, by a com- plete extension of the head and neck the tongue and velum, as respiratory obstructions, are removed simultaneously with the epiglottis, and without a moment's delaj^ the entire air-way may be straightened and made free throughout by the nearest person." We copy this article because it differs from the well received idea. 278 ARTIFICIAL ANESTHESIA. Resuscitation by Anal Dilatation. Dr. L. C. Grosvenor, of Chicago, in the Journal of Orifickd Surgery, August, 1893, gives an unique as well as amusing ac- count of three cases of resuscitation by means of forcible dila- tation of the anal orifice. The first case was a man dying from an over-dose of morphine. The second was the arousing of an infant born asphj'xiated, while the third was that of infantile eclampsia. His modus operandi is to grease the thumbs of either hand and proceed to dilate the sphincter. He thinks this process acts as a direct stimulant through the sympathetic, and believes it might be successfully applied in resuscitating the drowned where the spark of life is not quite extinct. Brunton on Chloroform. After the reading of Dr. Wood's paper on Anaesthesia, Dr. T. Lauder Brunton,* in introducing the discussion of the subject of chloroform narcosis to the Berlin Congress, spoke as follows : "Does danger to life during chloroform narcosis arise from failure of the heart or failure of the respiration, and how is such danger to be averted?" After tracing the nature of the early investigations for the discovery of the toxic effects of chloroform, he concluded : "I grant at once that chloroform is a protoplastic poison. I have rendered the muscles of an ani- mal as stiff as a piece of wood by injecting it into the artery of a lamb. I have stopped the pulsations of an animal's heart by blowing chloroform vapor directly into the lungs. But what I wish to maintain is, that notwithstanding all this, when chloro- form vapor is inhaled in the usual way by inspiratory efforts of the patient himself, it does not stop the heart, but first acts upon the respiratory centre, and, by stopping the breathing, prevents a quantity of chloroform, sufficient to stop the heart, from reaching that organ." This we consider false reasoning on the part of this distin- guished experimenter, and is the old doctrine of Syme and the * Abridged from his paper, The Lancet, August 16, 1890, p. 351. BRUNTON ON CHLOROFORM. 279 Edinburgh School. Listen to him when he informs us of the time between the respiration and its action on the heart : "We may saj', then, that the time of grace is only half a minute^ and if the administrator's attention should be so distracted as to allow this half a minute to elapse after the respiration has ceased, the patient will probablj'' die." It is evident, then, that constant attention to the respiration is required ; and, indeed, this was the great lesson taught us by our experiments. When chloroform was inhaled with free admixture of air, it usually produced a fall of blood-pressure to some extent, but the administration of chloroform may be con- tinued for a long time without much further fall, provided, always, that plenty of air be given with it. If, however, chlo- roform vapor be given with a deficient quantity of air, the fall of blood-pressure is very rapid, the cardiac pulsations become slow and irregular, and shortlj'' cease altogether. This irregularity is well shown in the tracing of the Glasgow committee, from which thej^ draw these conclusions, that chloroform depresses the heart, and does so irregularly, and in an unforeseen manner. The tracing is evidently one of slow pulse due to irritation of the vagus. In numerous experimental attempts to irritate the vagus. Dr. Brunton did not succeed in reproducing the tracings, but on simpl^'' closing the animal's mouth and nostrils, or closing the opening of the tracheal canula when one had been introduced, he was able at once to reproduce the tracing. He was able to produce such curves both when the animal was thoroughly under chloroform and when it was completel^^ out of chloroform. He found, that with pressure upon the chest, death occurred very rapidly from the administration of chloroform. This is a very important hint, both to the assistants and the operator also, to avoid tight clothing or the corset in the care of ladies ; and this is applicable in the use of all angesthetics. Examina- tion of both heart and the urine is of vital importance. The question, he states, is still unsettled, and cannot be finally settled either from a purely clinical or the purely experi- mental side. Both must be worked up together, and to this 280 ARTIFICIAL ANESTHESIA. end the London Lancet has sent out a circular asking for infor- mation regarding all cases of death from chloroform. When all the deaths from chloroform have been completely tabulated, their causes may be interpreted by the light of experiments. An abstract of the first of these we produce, and this from a Scotch surgeon of eminence : " Statistics show that the fatalities attributed to chloroform cannot be explained by the condition of the patient's previous health, the severity of the operation, or the result of the autopsy." More Recent Views in Keg-ard to the Action of Anaesthetics. Conclusions of a report of the action of chloroform, with a criticism of the second Hyderabad Commission, by W. H. Gas- kill, M.D., F.R.S., Lecturer on Physiology in the University of Cambridge, andL. E. Shore, M.D., Demonstrator of Physiology in the University of Cambridge.* The principle upon which Lawrie administers chloroform may be summed up in a single sentence : "Never, at any moment of the administration of chloroform, administer it in so concen- trated a form as to cause irregularity of respiration, and cease the administration as soon as complete anaesthesia has been in- duced. " The danger, then, of chloroform administration con- sists (1) of causing a serious fall of blood-pressure, owing to weakening the heart from too great a percentage of chloroform in the air, which, in its turn, causes failure of respiration ; and (2) cessation of respiration after long administration, although given with plenty of air, after anaesthesia has been established. A more recent criticism by Dr. Brunton, of London, states, as a result of his physiological experiments, that respiration is affected, causing asphyxial condition of the blood, the com- bined action of chloroform and asphyxia affecting the heart. The Action of Chloroform. — Dr. Lauder Brunton, after going over the experiments of Drs. Gaskell, Shore and others, reaches "••■ British Medical Journal, February 4, 1893. ACTION OF ANAESTHETICS RECENT VIEWS. 281 the following conclusions : (1) That Drs. Gaskell and Shore are mistaken in regard to the fall in blood-pressure produced by chlo- roform as the most important question connected with its action. (2) That the conclusions of the Hyderabad Commission are en- tirely unaffected by their criticism, which is directed to two things : (a) the effect of chloroform injected into the jugular vein and (b) the pulse tracings obtained during chloroform narcosis. In regard to (a), the error into which "Gaskell and Shore " sup- pose the commission to have fallen was suspected by the com- mission, and, as they believe, was avoided. In regard to (b), the criticism of Drs. Gaskell and Shore, it is not directed against the conclusions of the commission, but against the comments made in the course of describing individual experiments. The tracings thus criticised were not considered as satisfactory evi- dence by the commission, and were consequently not emplo3^ed by them as a basis for their conclusions. (3) That they have devised a most ingenious plan of experiment by cross circula- tion and have obtained many interesting results. While these experiments may afford much valuable information, they are not entirely free from fallacy, as they were not performed on ani- mals under chloroform influence alone, but with either morphine or chloral. (4) That they entirely confirm the conclusions of the Hyderabad Commission, that the chief danger from chloroform is the concurrence of asphj^xia, and that the most important practical point is attention to respiration, as maintained by Syme and Lister. We feel, like Dr. Wood,^ that Dr. Brunton has in his recent publication given away the whole case of the Hyderabad Com- mission, as follows : " As every one knows, the Hyderabad Commission, the great supporter of the exclusiveness of respiratory death, derived most of its authority from the presence on the Board of Lauder Brun- ton, of London, who in a recent publication says : 'If we drive chloroform into the trachea, or air very heavily loaded with chloroform vapor into the lungs by artificial respiration, it will be absorbed in sufficient quantities to paralyze the heart. ' This * Anaesthesia, by Dr. H. C. Wood. 19 282 ARTIFICIAL ANESTHESIA. is a practical giving away of the whole case of the Hyderabad Commission, at least as I have understood it, and as I believe it to have been understood by the general profession. However this may be, it is a confession that the chloroform death is not of necessity due to asphyxia, so that it must be admitted, first, that both ether and chloroform may kill the man or the lower mammal either by arrest of respiration or by syncope ; second, that syncopal death from chloroform is not common, though it does occur in the lower animals, but is not rare in man ; third, that the difference between ether and chloroform, so far as the mode of death is concerned, is that that form of death (synco- pal) which is common under the influence of chloroform is rare under the influence of ether. ' ' Resuscitations by Lingual Tractions.* Members of the Royal Navy having frequently, when at sea, to consider the best means to resuscitate the drowning, and our coast guards having to rescue people by means of the Board of Trade's rocket apparatus and coast ladder appliance, it struck me that a few observations might be of use to the readers of the United Service Gazette^ with the view of dispelling the hitherto erroneous views which have been too commonly accepted anent resuscitation. Dr. J. Y. Laborde, Professor of Physiology at the Paris Faculty of Medicine, according to his own accounts, has founded a French school of enthusiastic inquirers and experimenters who, in extraordinary and apparently hopeless cases — cases where it was alleged that all other methods of artificial respira- tion and the like had failed — nevertheless resuscitated many still-born infants and adults apparently dead. In his recently published treatise, he and his followers declare that already, up to March 20, 1894, they had saved sixty-three lives, which, ac- cording to their own statements, were all rescued by Laborde's methods of repeated, long-continued, persistent lingual trac- tions, or pulling the tongue outwards, downwards and forwards * By J. Lawrence Hamilton, M.E.C.S. Reprinted from tlie United Service Gazette, August 11, 1894. RESUSCITATIONS BY LINGUAL TRACTIONS. 283 at the rate of from fifteen to twenty or more tractions to the minute, movements that are accredited with having special powers to excite contractions of the diaphragm, to promote the suspended powers of the respirator}^ reflex. Laborde suggests that death is absolute where repeated lingual tractions fail to restore animation. In the accidental asphyxia or syncope noticed in experiment- ing upon animals, especially on dogs, above all where anaesthe- tics had been administered, in French laboratories presided over by Dr. Laborde, the first operation was to seize the tip of the tongue. Thereby not only were the laryngeal-pharyngeal tracts opened, but repeated rhythmical retractions as a rule resulted in the return of respiration, which followed close upon a series of loud hiccoughs. At first these noisy hiccoughs responded, as it were, passively to the artificial lingual tractions, but later the respiration became automatic and spontaneous. In the Royal Medico-Chirurgical Transactions, vol. Ixxii., Dr. Bowles has shown that, in apparent death from drown- ing, in the supine or horizontal position, the paralyzed tongue, by letting its base drop backwards, thereby blocks up the pharynx. Although it hooks up the dropped base of the tongue, nevertheless Laborde's method fails to remove the frothy water, often nmco-sanguineous — with or without mud, sand and the like — from the water-logged lungs, and perhaps also the abnormal contents of the stomach and oesophagus, which may also be more or less filled with somewhat similar foreign materials. In every case, first put the patient in a suitable position to allow of the immediate escape of these fluids from his chest, in which procedure pulling the dropped base of the tongue for- wards is pressingly urgent. In a much condensed form. Dr. Laborde's Tractions Rhyth- mees de la Langue might be worth translating into and publish- ing in English ; but then only if the well-known up-to-date work of others, including that of Dr. Alexander Morison, were added to Dr. Laborde's investigations. 284 ARTIFICIAL ANESTHESIA. John Hunter's 1776 historical paper on resuscitation, by means of his specially constructed bellows inflated with air or with oxygen, is not even mentioned by Dr. Laborde ! His book ignores references or even allusions to the best liter- ature and past experimental research on the resuscitation of men and animals, which greatly detracts from the value of Dr. Laborde' s far too one-sided observations and vague conclu- sions. Some of Dr. Laborde's cases of alleged resuscitations of still- born children would doubtless have spontaneously recovered without medical assistance. Dr. Champney's elaborate experiments, published in 1887, on the artificial respirations of still-born children, could be advan- tageously studied by Professor Laborde, as well as Taylor and Stevenson's (1894) Deaths from Secondary Causes after Suc- cessful Resuscitations. In all cases of attempted resuscitation and of first aid in ambulance drills to restore suspended animation, added to the usual methods of resuscitation, Laborde's method should be tried, though to rely on it solely, as advocated and implied by Dr. Laborde, would be indeed foolish and frequently fatal. Rhythmic Traction of the Tong-ue in Accidents. The Asphyxia from Chloroformization.* We come now to speak of chloroformic intoxication, to which belongs the primitive accident of cardiac syncope or that of respiration, or both occurring at the same time, which so often mark the beginning of the administration of chloro- form in surgical ansesthetization, or which constitute one of the episodes during the anaesthesia. It is precisely, as we can doubtless recall, in these conditions, that we have experimentally determined the application of this procedure of rhythmic traction of the tongue in treating chlo- roformic accidents, and these are, really, its point of departure *Les Tractions Eythmees de la Langue. Par I. V. Laborde^ Directeur des Travaux Physiologiques a la Faculte, Membre de I'Academie de Medecine. Paris, 1894. Translation. RHYTHMIC TRACTION OF THE TONGUE. 285 and its origin. It is by the aid of systematic lingual traction that we have conquered, in our laboratory, all conditions of snycope or accidental asphyxia following chloroformic or chlo- ral anaesthesia. No doubt the same results would have fol- lowed the same treatment in surgical operations. We have received in this connection another fact (of which there will soon be mention) from Dr. Filiget, hospital surgeon —the account of a case in his own practice which, in regard to the procedure of which it treats, presents a real interest. (See on this subject an interesting observation of Dr. Gigard, of the Cote St. Andre, Isere, published in the Med. Tribune, No. 12, 1894.) In August, 1883, M. Filiget, substituting for M. Lariboisur^, had occasion to operate on a patient— Jules Broe— for cancer of the superior left maxillary. He practiced preparatory trache- otomy and administered ether by the trachea. In the^ course of the operation a respiratory syncope supervened, with ap- parent death. Traction of the tongue was immediately resorted to and recalled the patient to life. I am convinced, in fact, and have already remarked in former communications, that simple traction of the tongue beyond the mouth, such as has been resorted to by surgeons for a long time, with the end in view of freeing the back part of the throat, as one might say the speaking tongue, from being drawn back by the excitation and contraction caused by chloroform— that this traction can, I say— and has in certain cases done so— restore respiration. This is demonstrated in the preceding case of Dr. Filiget' s, but it would not suffice in advanced cases of asphyxia following chloroformization with apparent death. It is neces- sary to add, reiterated and persistent rhythmic tractions consti- tute the true and systemic procedure in question. The majority of surgeons who are acquainted with this method do not fail now to use this treatment at the first evi- dence of danger from chloroformization, and we know that m a certain number of cases, of which it is to be wished that the operators themselves might publish them, the gravest accidents and probably more or less imminent death habitually occurring in such conditions have been averted. 286 ARTIFICIAL ANESTHESIA. We give below two cases of this nature, of which one has been published in a medical journal and the other comes from one of OUT colleagues. "An operation was performed two days since at the Hospital of St. Andrew of Bordeaux, by Dr. Dennea, upon a patient suffering from neoplasm of the larynx, the anaesthetic used being chloroform, with a centigramme of morphia, where this procedure of Dr. Laborde's succeeded, although all respiration was suspended, and the patient blue, almost black, from as- phyxia. Although the canula had been placed in the trachea, respiration did not return. Rhythmic tractions of the tongue were made persistently, respiration returning at first irregularly but later perfectly. ' ' Professor E. Masse added to his account of the case the fol- lowing remarks : "Dr. Laborde has certainly given us here a most beautifu result. It cannot be contested that he was successful in restor- ing respiration in this subject in a state of asphyxia from the combined action of chloroform and of stenosis of the larynx. This method, while not excluding all others, gives us another arm upon which to lean, and which seems to give naturally the best results in accidents from the use of chloroform. "Dr. Laborde has often used this treatment during opera- tions upon animals. Every one knows that complete asphyxia frequently occurs in dogs under chloroformic inhalation. After ten minutes' traction of the tongue he has often restored ani- mals when they were in a state of complete asphyxiation. He gives the following observations of his friend and colleague, Dr. Meniere, of the National Institute of Deaf Mutes : "'Apparent Death Following Chloroformization. — Recalled to life of rhythmic traction of the tongue. Your remarkable work upon rhythmic traction of the tongue in the case of apparent death has interested me greatly. Since your presentation to the Academy of your observations upon this subject are multiplying, permit me to offer one of which I know personally. "'Observation XIII. — Last month one of my little pa- tients of the Dispensary Furtado-Hine presented an external RHYTHMIC TRACTION OF THE TONGUE. 287 caries of the mastoid, caused by an osteo-periostitis following an old chronic otorrhoea. Operation was plainl}' indicated. It was necessary to make a complete curettage of the region. One of my residents, who was quite aufait in anaesthetic prac- tice, gave the chloroform. The child slept easily, nothing par- ticular occurring to note. " 'The operation, of eight minutes, was finished, and I was about to pass a drain when I noticed that the patient was not breathing. No beating of the heart, no pulse, no respiration. The face was cadaverous in color. "' Immediately the child was put upon the table with his head hanging over, and one of my internes resorted at once to artificial respiration. At the same time I seized the tongue with pincers, and made in continued fashion rhythmic traction of the tongue, as you have described. It was six minutes be- fore the first physiological inspiration was evident. We con- tinued the tractions and artificial respiration during a moment longer, and the child was saved. "'I am convinced that the tractions rendered me here a veritable service. " 'I can only repeat, apropos of this, what I said in one of my first communications to the Academy on this subject. (No- vember 22, 1892.) "'In the case of chloroformic accidents by respiratory or cardiac syncope, or of both together, the procedure of the tongue can be, as in experimental chloroformization, the most powerful means and the quickest of resuscitation, not only by putting the tongue out to free the back part of the mouth, but of making with it repeated and rhythmic tractions until the appear" ance of a hiccough, the precursor of returning respiration.' " NoTE.^As we go to press, we received from one of our colleagues in Algeria, Dr. Mosiman, Ex-Medicia Major in the Army and Chief of Clinics of Val-de-Grace, one of the most remarkable cases of recalling to life by lingual traction made upon a young man operated for haemorrhoids, he being in a state of apparent death from chloroformization. ''I am per- suaded," he declares, "that had I not known this procedure, I should have lost my patient." 288 ARTIFICIAL ANiESTHESIA. Dr. Perrier, Surgeon to the Lariboisiere Hospital, also gives a case in his practice equall^^ successful under like circum- stances. On the Iiija^uence of Cliloroforin in Producing- Tis- sue Chang-es, Such as Fatty Degeneration of the Heart, of the Diaphragm and Other Striated Muscles, and also of the Parenchyma of the Liver and Kidneys. As early as 1850, Casper stated that chloroform produced chronic poisoning, and later Liman afl&rmed that after prolonged chloroformization patients pass into an abnormal condition which continues for days, even for weeks, and finally ends in death. These views were confirmed by R. Unger,* who reports as the result of his investigations, pursued since 1883, that the inhalation of chloroform produces fatty degeneration of the heart, of the diaghragm and other striated muscles, and also of the parenchyma of the liver and kidneys. He was also of the opinion that protracted inhalation of chlo- roform vapor, during tedious operations, may thus produce a state of weakness, in which a second inhalation may prove fatal, though the patient apparently tolerates the first inhalation without dangerous symptoms. For this reason he opposes the use of chloroform in normal child-birth. These results were confirmed by Dr. Strassman,t in his experi- ment on dogs, who found that the first organ to be affected was the liver, then the heart, and after that the other viscera. He states that the nature of the morbid change was not fatty de- generation, but fatty infiltration. The actual cause of death in fatal cases appeared to be the cardiac affection, as in all such a very marked degree of change was found in the heart. In non-fatal cases the morbid change was found to have disappeared in a few weeks' time. When morphine was given previously to chloroform less of the latter * E, Unger (5 Cent, fiir Chir., Artificial Anaesthesia, Turnbull, 3d Edit., p. 462, 1890). t Turnbull, Manual of Anaesthetics, 3d Edit., p. 490. PERILS OF CHLOROFORM ADMINISTRATIONS. 289 was required, and consequently the changes produced were not so considerable as when the ordinary amount was given. Animals suffering from hunger, loss of blood, etc. , were espe- cially predisposed to the morbid changes due to the chloroform. These researches were further confirmed by experiments on animals by Ostertag, Kast and Mester. A more important de- parture was made by Dr. Eugene Fraenkil, by a careful study upon four human subjects, dying after prolonged chloroformiza- tion, who found a wide-spread necrotic degeneration, associated with a disposition of much pigment in all parts of the body, but especially affecting the hearty muscle and the epithelmm of the kidney. In summing up these various experiments. Prof. H. C. Wood and Dr. W. S. Carter* state, in further confirmation of the powerful influence of chloroform on nutrition — there are also the observations of Salkowski — that marked increase in the output of nitrogenous waste is caused by the administration of the drug to dogs ; of Kast and Mester, that there is a marked increase in the elimination of chlorine and nitrogen produced by the anaesthetic ; and of Petruschcy, that after death from chloroform the intercellular juices become rapidly acid. Ostertag in his conclusions differs somewhat from Unger in believing that the fatty degeneration is, in part, due to the de- struction of the red -corpuscles by the chloroform. As, however, he also believes that the destruction of the protoplasm is, in part, affected by the direct influence of the chloroform, the difference between his views and those of Unger is not vital. Moreover, whatever of scientific interest may attach to the method in which chloroform produces its ravages to the sur- geon, the method is of little practical importance, the vital fact being that chloroform itself directly or indirectly destroys the living protoplasm in almost all proportions of the human body. Perils of Cliloroforiii Administrations in Dental Operations. If a patient is not thoroughly under the influence of chloro- form any irritation of the fifth nerve would produce slowing of * Copied from original Essay. MSS., 1896. 290 ARTIFICIAL ANAESTHESIA. the heart's action, and finally stoppage through the pneunio- gastric nerve. This has been clearly shown by experiments on rabbits. This may account for the deaths in the dental chair from operations on teeth. Chloroform is the most powerful of the anaesthetics ; too much caution cannot be written and taught, that the heart power is most seriously reduced by its action, and that it is incapable of supplying the brain properly unless the patient is in the recumbent posture. The researches of Richardson, Rabuteau, and others, have shown that the physiological action of chloroform increases in intensity and danger as the number of carbon atoms increase, so that while wood spirit (methyl alcohol), with but a single atom of carbon, is transient and slight in its eiFects, those of fusel oil (pentyl alcohol), which has five atoms of carbon, are prolonged and severe. Chloroform Given Improperly. The fact that teeth have been extracted under chloroform, and without injury to the patient, does not justify its use for this purpose. The surgeon that would seat a patient in a chair and give chloroform to amputate a finger, or even open an ab- scess, would be guilty of negligence short of criminality ; but much more culpable is he who performs so simple an operation as the extracting a tooth in this position. We are too much inclined to excuse blunders, hoping that the blunderers have been taught a salutary lesson, which, however, is of no benefit to the person who has come to an untimely death. There should be more care in dealing with the ills which flesh is heir to, so that the patient survives the treatment. It is a well- recognized rule, that a patient should never immediately assume the upright posture, especially after the use of chloroform, whose chief depressing influence is upon the heart, as by plac- ing the head low, the blood returns to the brain and heart, and the patient is safe. This well-known method of Nelaton has had to be employed in several instances in the same case, and thus saved the life of the patient. The heart of every patient should be examined before a systemic anaesthetic is employed, and to a patient with fatty heart, chloroform should never be given. THE EMPLOYMENT OF NITRITE OF AMYL. 291 It is now beginning to be observed by the profession generally that there is something of very material importance in the manner in which anaesthetics are administered ; that there is an anaesthetic art deserving careful study and application in practice. It is not an uncommon observation to see the admin- istration of the anaesthetic intrusted without discrimination to an assistant who holds the paper cone carelessly over the pa- tient's face, and watches, in the meantime, the various steps of the operation. Can it be wondered that, in a process involving such essential physiological functions, dangerous and alarming symptoms arise and escape notice under these circumstances? Unquestionably, the administration of the anaesthetic should receive the undivided attention, during an operation, of one who has, by study and training, acquired a knowledge of the proper method of administering the agent, and who, in danger, will be prepared to act promptly and intelligently in his efforts at restoration. The Employment of Nitrite of Aniyl. Being desirous of knowing some of the more obscure points in regard to the way in which the nitrite had been used in a case of death from chloroform, we wrote to Dr. Taylor, address- ing the following questions : Did the nitrite of amyl produce a flushing of the face, action of the heart, and diflficult breathing when you employed it yourself? Did you use a tube to force it up the nostrils when the breathing had ceased? How many drops were employed ? Was it in capsules or dropped from a bottle? The doctor kindly replied as follows : Richmond, May 31, 1878. Doctor Turnbull : Dear Sir : Your letter dated May 20th found me out of the city for a few days. I am very glad to answer your inquiries. You say that " Professor Nekton's method will sometimes fail, especially when morphia has been used with the chloroform." No morphia was given at the time with the chloroform. It 292 ARTIFICIAL ANESTHESIA. was during the sickness that large quantities had been adminis- tered. In regard to the amyl used, it was made by Squibb, and was, I think, pure. I am sorry I cannot find a sample of it to send you for examination. It was dropped from a bottle upon a handkerchief. The number of drops was not ascer- tained. No tube was introduced into the nose. Very respectfully, etc. , Hugh M. Taylor. *" The number of deaths from chloroform which have occurred up to date will be seen in our tables. It will be seen by a glance how and why deaths from chloroform have occurred, and how unsatisfactorily, in most of the cases, the facts con- nected with the circumstances have been reported. In our last edition we have entered into detail concerning such deaths (with table) from chloroform. In this later edition we have detailed but a few. * We do not think the doctor quite justified in the use of so power- ful an anaesthetic in so trifling an operation as external perineal urethrotomy. The nitrite of amyl was not employed until the patient- had become unable to inhale it. His conclusionsf are not the most recent, as a careful reading of our table of deaths from it will show. It gives but little warning before it kills the patient. t See full account of case, p. 426, 3d edition of Manual. DEATHS FROM CHLOROFORM AND ETHER. 293 CHAPTER IX. Table of Deaths from Chloroform, and Ether, since the Hyderabad Ck)minissions, with Conclusions— From 1888 to 1895 inclusive. We live in an age of wonderful progress ; in nothing is this better proven than in the multiplication of new and valuable books. The works of even one 5'ear becoming almost obsolete, new editions and new works taking their place. This is also the case with original experiments and investigations, crowding out the old. Nothing is lacking in either men or money. Two of the most munificent works of this kind have recently been undertaken in even far-ofi" India, the sum of ten thousand dol- lars having been spent by the Nizam of Hyderabad in experi- ments on anaesthetics alone. This large sum was given owing to the devoted efforts of Surgeon-Major Lawrie, of the Army of India, who is a great admirer and believer in the opinions held by the late Professors Sj^me and Simpson, of the Edin- burgh School, in regard to chloroform. There were two Commissions, one held in 1888, in which 141 dogs were killed by chloroform inhalation, and the symptoms and results of careful post-mortems were made. The chief conclusions which were arrived at were "that it is impossible for chloroform vapor to kill dogs by acting primarily on the heart, and this holds good, no matter in what doses or in what manner the poisoning is induced. " These conclusions having been received with doubt by many physiologists, and more especially by the editors of the London Lancet, led to a Second Commission, and Dr. Lauder Brunton, a well-known author and physiologist, was added to the Commission. The conclusions of the Second Commission were published January 19, 1890. About six hundred animals, chiefly dogs, were employed in the investigations. The experiments of the committee were designed to show the effect upon the blood-pressure, heart and respiration of the 294 ARTIFICIAL ANESTHESIA. inhalation of chloroform, ether and the A. C. E. mixture, ad- ministered in various ways and under varying conditions. The subjects of the Commission were five in number: 1. To test the suitability and safety of chloroform as an anaesthetic. The experiments with ether and the A. C. E. mixture were instituted principally for the sake of comparison with chloroform on certain points, and it is not pretended that they afford a complete exposition of the action of those agents on the system. 2. The effect of pushing the above-named anaesthetics (a) to a dangerous degree, and more especially until the respiration ceases ; (b) until death results. 3. The modifications in the effects of these anaesthetics which result from (a) asphyxia in varying degrees and produced by various means (b) from the use of drugs, such as morphine, atropine, physostigmine and others. 4. The reality or otherwise of the alleged liability during ordinary chloroform administration to the occurrence of pri- mary or secondary syncope or stoppage of the heart, brought about either by shock or through fatty or weak heart, or by haemorrhage, or by changes in the position of the body. To investigate these points, in the first place a large number of operations, which are reported to be especially dangerous in reference to shock, were performed in every stage of anaes- thesia, and numerous experiments were also made to show the effect of direct irritation of the vagus. Secondly, a number of animals were dosed with phosphorus before they were experi- mented on. This caused the weakening of the heart by fatty degeneration of its fibres, but at the same time other compli- cated changes in the whole of the organs of the body, not met with in the condition known as fatty heart in human beings. On the other hand, there are conditions often found in the fatty heart, such as changes of the coronary vessels, which were not produced by the phosphorus. 5. The effects of the anaesthetics above mentioned upon different animals, more especially upon monkeys, as the nearest approach to human beings. In brief, the practical conclusions arrived at as to the effects DEATHS FROM CHLOROFORM AND ETHER. 295 of chloroform, "that in every instance the respiration stopped before the heart," and all that was necessary for safety was to attend to that alone. Soon after the publication of the views thus expressed, several practical chloroform ists gave their opinion, founded on professional experience, that chloroform was by no means to be considered safe by simply attending to the respiration, and that the heart still played a most import- ant part in the deaths, as may be seen from the numerous deaths from syncope given in our tables. With this view I have made a most careful collection of all the deaths both from chloroform and ether, from every avail- able source, assisted by several friends. These deaths have been arranged in a tabular form, giving the name, age, history, nature of operation, anaesthesia used, amount used, apparatus employed, posture, how long under influence, whether heart or respiration stopped first, means to resuscitate, how long con- tinued, post-mortem, cause of death and references, except in a few instances. The result of examinations and analysis of the table will be found on pages following. The exceedingly small number of deaths from ether demon- strates its great safety ; still, as it will and does kill (and we notice that the feeble and persons suffering from malignant dis- ease are more apt to be its victims, see IS'os. 10, 11 and 18), we would advise its use as an anaesthetic and a full study and knowl- edge of the best modes of using it, which we judge is not the case in Europe. It is true that "chloroform acts more rapidlj' than ether, is pleasanter to take, causes less congestion of blood in the veins, is much more portable and handy." The last two qualities render it preferable in certain classes of operations, e.g.^ in those on the eye and in military or travelling establishments. On a campaign it would be impossible to find room to carry ether or time to use it. Again, ether cannot be used in hot climates or in close prox- imity to artificial light ; nor is it suitable in certain conditions of the lungs, because ether is more apt to cause suffocation than chloroform, which is given with a much greater admixture of 296 ARTIFICIAL ANESTHESIA. air. Against these advantages on the side of chloroform ether has only one, which, however, is sufficient to outweigh them all — it is safer. With regard to occasional unexplained deaths under chloro- form, it must be remembered that they occur also under ether, though not so frequently, and used to occur in a similar way be- fore the use of anaesthetics at all. Dr. Brunton also had several accidental deaths, but in every case "the usual chloroformist was absent, and no one was attending to the chloroform" — a most significant statement. How often might the same be said (with a stress on the word "attending") in our hospital practice. The Hyderabad conclusions really imply a tremendous indictment against the administrators of chloroform — nothing less than that of causing death by carelessness. Unhappily, no one familiar with the administration of anaesthetics can doubt that there is some ground for this. How else account for the widely differing records of different administrators ? Every surgeon knows that with good chloroformists he is perfectly con- fident and easy, with others the reverse. The last word has by no means been said upon this controversy ; but if we may ven- ture a prophecy, it is that the answer to the question, "Is chloroform safe?" will eventually be, "That depends on who gives it. ' ' We have proofs in opposition to the experiments and state- ments of the Commission, that chloroform may arrest the heart before arrest of respiration. In one experiment breath- ing continued two minutes after the heart had ceased to act. The Pulse During Chloroform Anesthesia. —A case in point, in which chloroform so depressed the pulse that ether had to be resorted to. The British Medical Committee (1890) on anaesthetics, after examining the kymographic tracings taken by the Hyderabad Commission, cannot agree with the Hydera- bad Commission in holding that there is no danger to the heart during the administration of chloroform. Both committees have found that death occurs by failure of respiration in the great majority of cases, and that chloroform causes a gradual fall of blood pressure, which in itself is a source of danger. Both have also observed that in addition to this gradual fall DEATHS FROM CHLOROFORM AND ETHER. 297 there may be sudden and unexpected falls, with slowing of the heart ; but as to the explanation of these falls they differ. The Hyderabad Commission holds that these falls, during which life is in jeopardy, are caused by asphyxia, while the British Medi- cal Association Committee affirm that they are due to failure of the heart, due to a specific action of the chloroform upon the organs (from which ether is free). The general conclusion of the British Medical Association Committee is, that while recog- nizing the great value of the work done by the Hyderabad Commission, and more especially as aided by Dr. Lauder Brun- ton, they consider that the commission attach too much import- ance to the most common mode of death from chloroform — failure of respiration — and fail to recognize the danger to the heart that may arise in certain physiological conditions. They consider it unwise and unsafe in practice to pay no attention to the state of the circulation, and to observe respiration alone. Further, they consider it unwise to convey to the public, even through the profession, the notion that there is practically no danger in the administration of chloroform."^ In the Man- chester Medical Chronicle, January 7, 1891 (page 276), Dr. Law- rie, President of the Hyderabad Chloroform Commission, makes the following statement in answer to Alexander Wilson and others in their reviews of the Hyderabad Commission, pub- lished in the Chronicle of February 9, 1890. Wilson concludes his review as follows : " Increased knowledge has added nothing new to the direction for its (chloroform) administration." Law- rie states : "The Hyderabad Commission was appointed to con- firm or disprove Syme's and Simpson's principles that we should be guided as to the effect of chloroform entirely by the respira- tion. The commission has not only proved that these princi- ples are sound, but has also proved that the art of administering chloroform with safety consists in keeping the breathing abso- lutely regular throughout the inhalation." This proof is new, and has never been established before. After criticising the teachings of Wilson, he states that the commission has shown, 1, that the lowering of the blood-pressure, which chloroform and all anaesthetics cause when efficiently administered, is in * British Medical Journal, Editorial, June, 1890. 20 298 ARTIFICIAL ANESTHESIA. itself a harmless event if the respiration alone be attended to and taken as a guide, and if the administration be stopped when the patient is fully anaesthetized ; and 2, that the sudden falls of pressure, which the Glasgow Committee asserted are dan- gerous and attributed to chloroform, are due to stimulation of the vagus, and, by slowing the circulation, are a safeguard against overdoing. The commission further proved that all irregularities in the fall of the blood-pressure and in the circulation under chloro- form, including such an irregularity as dilatation of the heart, which occurs when chloroform is administered properly, are due to improper administration with irregular breathing and insufficient air (page 277). Again (page 278), every medical man ought to be able to give a dose of chloroform with as much precision, as certainly as a dose of morphine or of any other poison. The practical outcome of the disastrous teachings of the (rlasgow Committee, backed up by Professors Wood and MacWilliam, is, that the relief of pain by chloroform is to be handed over to the specialists, who alone are to administer it, though their own declarations and statistics show that they can- not give it with safety. Exactly in proportion as this teaching gains ground, the profession suffers loss in credit and in pocket, and the advantages which chloroform confers are most seriously restricted and curtailed. The extensive experiments of the Commission have left the chloroform question in the following condition : It was not found possible to directly paralyze the heart (of dogs) by chloroform in some 600 administrations. Death from chloroform is due apparently from paralysis of the vaso-motor and respiratory centres — probably one or both of these may be affected. When death occurs, it is the result of an overdose of the drug. The most conclusive statements and experiments are given in the paper of Dr. MacWilliam in answer to the strictures and conclusions published by Dr. Lawrie. "In the Medical C/iromc?e,* January, 1891, Surgeon-Major * Medical Chronicle, Manchester, 1891, xiii., 352-355. DEATHS FROM CHLOROFORM AND ETHER. 299 Lawrie, in an article on the Hyderabad Chloroform Commis- sion, makes some comments on certain results obtained by me in a recent investigation on the action of chloroform and ether published in the British Medical Journal, October 11, 18 and 25, 1890. " In my paper I described the frequent occurrence of dilata- tion of the whole heart under the influence of anaesthetic doses of chloroform. Such dilatation was not due to changes in the pulmonary circuit, or to fall of arterial pressure." Dr. Lawrie urges that the cardiac dilatation was due to ob- struction of the circulation of the lungs, or to this along with a fall in the blood-pressure. He saj's : "The irregularities in the tracings of the Griasgow Committee, and Professor Mac- William's recent bogie of dilatation of the heart, are due to obstruction of circulation in the lungs through interference with, or irregularity of, the respiration." And later: "Ob- structed circulation in the lungs, and a rapidly falling blood- pressure, are more than enough to account for the dilatation of the whole heart, which occurred in his experiments, and which he wrongly attributed to the direct action of chloroform. "Nor can this hypothesis of Surgeon-Major Lawrie's be briefly and conclusively disposed of There is an abundance of decisive evidence available. First, as regards the alleged influ- ence of obstruction of the circulation in the lungs, in causing dilatation of the heart. In my paper, in the Bntish Medical Journal, I stated the fact that such an explanation was incom- petent to explain the cardiac condition, since the whole organ was dilated in my experiments. Dilatation of the right side of the heart might conceivably (if there were no evidence to the contrary) be accounted for by the pressure of pulmonary ob- struction, but dilatation of the left side {e.g. the left auricle) could clearly not be accounted for in the same way, since pul- monary obstruction necessarilj^ diminishes in a large measure the flow of the blood into the left auricle, and this part becomes small and collapsed. This seemed so obvious to me that I did not discuss the matter at any great length." I shall now state, briefly, some facts in regard to Surgeon- Major Lawrie's hypothesis of obstructed circulation in the lungs : 300 ARTIFICIAL ANAESTHESIA. "1. There is no proof whatever of the occurrence of pulmo- nary obstruction from the administration in mammals of anaes- thetic doses of chloroform, sufficiently diluted with air, as was the case in mj' experiments, the amount of chloroform vapor in the air never exceeding four per cent. "2. On the other hand, there is decisive proof that pulmonary obstruction was not present in my experiments. Obstruction of the circulation would necessarily cause distension of the pulmonary artery as well as, and indeed earlier than, distension of the right heart. The pulmonary artery would become large and tense in consequence of the increased peripheral resistance to the outflow of blood from that vessel. Then the increased tension would react upon the right heart and cause distension there also. But in my experiments there was no distension of the pulmonary artery during the administration of chloroform. The vessel did not become distended ; it was soft and compres- sible, and the tension within it was low. It is quite certain, then, that pulmonary obstruction could not have been the cause of the dilatation, even on the right side of the heart. "3. Even if pulmonary obstruction had been present — as was not the case — such obstruction could not have produced the condition which I described, or anything similar to it. "I have on various occasions purposely brought about a con- dition of pulmonary obstruction by mechanical means with a view to studying the features cf this condition. This I did by injecting into one of the great systemic veins some particular substance, e.g. lycopodium powder, which would cause embol- ism of the pulmonary vessels and so obstruct the circulation in the lungs. When such a substance is injected into the vein, it rapidly passes through the right heart into the pulmonary ves- sels, speedily causing more or less extensive and sudden ob- struction of the pulmonary circulation, according to the amount and suddenness of the injection." The effects resulting from the plugging of the minute pul- monar3^ vessels induced in this way are very noteworthy, and illustrate clearly the consequence of obstruction of the circula- tion of the lungs. The pulmonary artery swells up and be- comes largely distended, while at the same time the vessel feels DEATHS FROM CHLOROFORM AND ETHER. 301 hard and tense to tlie touch ; the pressure within the vessel is greatly elevated. The right ventricle, and the right auricle also, partake in the condition of distension, being unable to discharge their contents in the normal fashion in face of the greatlj' augmented resistance in front. The lungs become pale and anaemic. Meanwhile it is important to observe that the left auricle becomes smaller and collapsed-looking, in conse- quence of the obstacle offered to the passage of the blood through the lungs. Strong respiratory efforts, with convul- sions of the asphyxial type (accompanied by spasmodic contrac- tion of the systemic arteries) supervene in consequence of the stoppage of the respiratory purification of the blood; the medullary centres become violently stimulated by the venous character of the blood. Death speedily follows. " It is unnecessary to enter closely into a comparison, or rather contrast, of the typical illustration of pulmonary obstruction here afforded, and the condition of cardiac dilatation which I have described as occurring under the influence of chloroform. It is obvious that obstruction of the circulation in the lungs produces changes strikingly different from those that result from the action of chloroform ; and that the hypothesis of pul- monary obstruction may at once be dismissed as entirely insuffi- cient and inapplicable, so far as explanation of the cardiac dila- tation occurring under chloroform is concerned. "Seeing that it is easy to dispose of the question of pulmo- nary obstruction in regard to the effects of chloroform upon the heart, I shall now advert briefly to the possibility of cardiac dilatation being dependent on a rapidly falling blood-pressure, as alleged by Dr. Lawrie. "This is a matter which I carefully considered in my paper, and in regard to which I was able to state definitely that the cardiac dilatation is not due to a fall of blood-pressure. This is conclusively proved by the following facts : 1. Dilatation of the heart does not by any means always run parallel to the fall of pressure which ordinarily results from the administration of chloroform. Sometimes there is a very marked fall of pressure, with little or no dilatation of the heart, while at other times the heart begins to dilate before the pressure begins to fall. 302 ARTIFICIAL ANESTHESIA. 2. Moreover, the heart in some instances begins to dilate during the temporary rise of pressure which at times precedes the fall. 3. Further, there may be distinct dilatation of the heart with- out any change of pressure at all. 4. Lastly, it can easily be shown that a simple fall of pressure, equal in amount to that which ordinarily occurs under chloroform, induced by means which do not directly affect the heart — e.g.^ section of a vaso- motor nerve, haemorrhage, etc. — does not cause dilatation of the organ as chloroform does. " It is clear, then, that the dilatation of the heart brought about by chloroform cannot be due to obstruction of the circula- tion in the lungs, or to a fall of systemic blood-pressure ; it must result from a depressing influence exerted by the anaes- thetic on the organ, 1, directly ; or 2, through the vagus nerves. "Finally, as this depressing influence, leading to dilatation, is readily manipulated after section of both vagi, it is obvious that chloroform must act upon the heart directly. I cannot help feeling that even a comparatively slight amount of actual observation of the features and results of a simple lowering of the blood-pressure and of real pulmonary obstruction would have prevented Surgeon-Major Lawrie from putting forward and adhering to such a hypothesis as I have here discussed — a hypothesis at once insufficient, absolutely untenable, and in conflict with large and somewhat elementary facts in the phys- iology of the circulation." Respiration After Cliloroforni Asphyxia. There is no doubt that in India deaths do occur (see case No. 43) from the administration of chloroform, yet we know from the facts staged in our work that the climate of that region, like our Southern States, is favorable to its use as an anaes- thetic. Recently there has come to our notice, while in search for facts on the subject of prevention of deaths from chloro- form, the following cases and opinions of practical surgeons, which we consider worthy of most serious attention. Two cases of chloroform asphyxia were reported by Surgeon- Major Bartholomew and Civil Surgeon Ahmedabad. a. A pa- tient aged 31, thin and emaciated, had sufi'ered eight years from RESPIRATION AFTER CHLOROFORM ASPHYXIA. 303 vesical calculus. He was operated on and the stone, weighing 50ozs. , extracted, when it was observed that respiration had ceased. Ether hj^poderniicall}' and the usual remedies were used without effect, and artificial respiration (Sylvester method) con- tinued for three hours before the patient took a long breath (the heart action, though feeble, had not ceased). Six drachms of chloroform had been given. A patient aged 18 had had 5 drachms of chloroform given prior to enucleation. After the operation the breathing was observed to have ceased, and the patient could not be roused. Artificial respiration was carried on for one hour, and on giving a galvanic shock the patient recovered consciousness. Drs. Peche}^ Phipson, Banks, Maconachie, Mej'er and Collee, all of the Army of India, cited instances in their experience of pro- longed chloroform asphyxia, and ultimate recovery by artificial respiration and the galvanic shock. Dr. Meyer stated that there was a danger of inducing delirium of the heart by the prolonged use of electricity (this is the case when applied too near the heart), and thereby superadding a serious complication which might in itself prove fatal. Frequently patients did not breathe for some time after artificial respiration, because the lungs had had such a large quantity of air thrown in as to do away with the physiological reflex stimulus to the respiratory centre. We do not in our work advise the use of hypodermics of mor- phine or atropine before the use of chloroform as an anaesthetic, and would call attention to this case, also, as the surgeon did not employ the galvanic shock, and did not keep up the artifi- cial respiration long enough. In a discussion which took place in the Paris Society of Sur- gery, upon a paper* treating of the use of hypodermics of mor- phine and atropine before the inhalation of chloroform, the author of the paper, M. Regnier, was led to try this method in his practice by the recommendation of M. Dastre, who reported favorable results from its use in animals, and of M. Aubert, a surgeon, who stated that narcosis and awaking were facilitated * L'Union Medicale, August 5, 1890. 304 ARTIFICIAL ANESTHESIA. by the injection of } gr. morphine muriate and -g^ gr. atro])ine sulphate fifteen or twenty minutes before the operation, and that inconvenient results were observed but rarelJ^ M. Reg- nier used this method with a number of patients, until, unfor- tunately, a fatal accident occurred. A feeble girl, aged 16, was aifected with tubercular disease of the bones of the foot, and, as the lungs presented but a few rales in the apex of one side, he decided to chisel out the cuboid bone. Half an hour before the operation he gave a hypodermic injection of 3% gr. of morphine and ^^5 gr. of atropine. Anaes- thesia was easily induced, and not more than from five to seven fluid drachms of chloroform were required for the whole opera- tion, which lasted only a few minutes. About ten minutes after the chloroform had been removed, and while the dressings were being applied, she opened her eyes without speaking, and was then carried to her ward. Three minutes later news was brought that she had ceased breathing. Upon reaching her bed he found the respirations very infrequent. They ceased suddenly as the pulse disappeared, although feeble heart-beats were still heard. The pupil then quickly dilated. Protracted artificial respiration seemed, at the end of half an hour, to excite spontaneous respiration , but this soon failed, although supple- mented by ether injection and other methods. Post-mortem examination showed anaemia of the cerebral hemispheres and medulla oblongata. Death in this case came on very slowly from chloroform in- toxication. It was quite remarkable that life could be pro- longed for more than twenty minutes by artificial respiration. It was claimed that the chloroform must have been eliminated slowly, and that the elimination was rendered more slow than it would otherwise have been by the influence of the morphine and atropine. Two members of the Society reported that they had observed in experiments on dogs, that morphine and atropine given be- fore chloroform, produced no reflex phenomena at the begin- ning, but rendered much more grave such complications as ap- peared at the end. In some cases there was quite protracted and severe dyspnoea. In dogs thus treated very little chloro- CONCLUSIONS. 305 form was needed ; in men more was required. It appeared to be conceded that the method was useful in the laboratorj^ but not in the cUnic, as the chances of intoxication were increased. Another member who had tried the method, stated, that in male patients nothing worthy of note was usuallj' observed, while in female patients the awaking was much more slow than'" with chloroform alone. He thought women were more sensitive than men to the influence of atropine. Out of five cases he had lost one patient. The operation was for nephrectomy, and lasted an hour, fifteen fluid drachms of chloroform being used. After a short awakening the respiration began to fail, cyanosis appeared, and in spite of all measures, death occurred in an hour and ten minutes. Conclusions. 1. During the protracted use of chloroform as an anaesthetic, the blood is changed in character, lowered in pressure, with weakening of the action of the heart and changes in its struc- ture. 2. Dilatation of the heart occurs under the use of chloroform at all stages on both sides of the heart, while the heart muscle is weakened. 3. Cardiac failure occurred before respiration in thirteen in- stances out of forty-three cases of death from chloroform. 4. The depressing influence of chloroform on the heart me- chanism is not exerted through the vagus nerves, and section of both vagi does not obviate the weakening and dilating influ- ence of chloroform on the heart. 5. Too many trifling operations are performed under chloro- form ; its use should be reserved for those cases in which ether, nitrous oxide, or cocaine will not produce the anaesthesia desired. 6. Ether deaths, as a rule, occur in patients of a certain class, usually from obstructed respiration, and occasionally the heart will stop first, as in two of the four cases in our tables. 7. Watch both pulse and respiration, both in chloroform and ether ; when the breathing becomes very rapid, danger is near. These changes are apt to follow the first act of respiration. Chloroform vapor should not be employed over four per cent. 306 ARTIFICIAL ANESTHESIA. NOTES REFERRED TO IN THE TABLE. Note 1. Paralj'sis of pneumogastric nerve, the direct effect of the chloroform, superinduced by effort at vomiting. Note 2. Respiration failed gradually, at one time stopping, and com- menced again after artificial respiration. Note 3. Anaesthesia not complete when operation commenced, and heart and respiration ceased. Note 4. Four Deaths from the Inhalation of Chloroform in Reading and Vicinity During the Past Three Years.* On April 8, 1890, at a meeting of the Berks County Medical Society, a paper was read, entitled " Chloroform Anaesthesia," by Dr. John T. Carpenter, of Pottsville, Pa., which was published in the University Medical Magazine, June, 1890. The drift of this paper and the discussion which followed was that chloroform, if skilfully administered, was a safe anaesthetic, and was prefer- able to ether on account of its safety, speediness of action, and general absence of any unpleasant sequelae. This discussion dis- closed almost a unanimous opinion favorable to the use of chloro- form as an anaesthetic. One distinguished medical officer of the United States Navy and two representative physicians of Phil- adelphia were present, and they all displayed a strong prefer- ence for the use of chloroform. Only one physician besides myself, Dr. W. Murray Weidman, a gentleman of large sur- * By John W. Keiser, M.D., Reading, Pa., University Medical Magazine, Aiagust 6, 1895. TABULAE STATEMENT SHOWIN& THE "DEATHS FROM OHLOEOFORM AND ETHER SINCE THE HYDERABAD COMMISSION.' """"'"■' VK..::=::::: SJlo™°"'°°' -zs- nil,., I 1 bl B«io,e ¥ NOTES REFERRED TO I>' THE TABLE. 307 gical experience, declared himself favorable to the use of ether. He in substance said that he never had any experience with chloroform ; that he always used ether, and that the exigencies of railway surgery were such that he frequently operated while an ordinary workman administered it, arid that he never had any disastrous results from its employment. In this discussion I opposed the use of chloroform with all the ability that I could command, and made the prophecy that if the opinions I had just heard would be put into actual practice they surely would result in an occasional death from the use of chloroform, which could have been avoided by the use of a safer anaesthetic ; and it was not necessary for me to wait many j^ears before the truth of this prophecy was realized. I give the particulars of this meeting as it reveals the attitude of the local profession towards the use of chloroform. In this community a large number of ph.ysicians are very favorably disposed to the use of chloroform ; I am, neverthe- less, absolutely certain that it is not as frequently used as ether ; and if these two anaesthetics were of equal safety the deaths resulting from the use of ether would exceed those from chloro- form. In a paper published by me August, 1890, in the Mag- azine, which was designed as a reply to 3Ir. Carpenter's paper, I stated, after investigation, that I had learned of two deaths from chloroform in this locality, and was unable to discover any from ether. Since then two more deaths from chloroform have happened in this vicinity, making a total of four. With a view of impressing upon the profession the unavoid- able dangers attending the use of this dangerous angesthetic, I will briefly relate the circumstances of these last two deaths. About three years ago a competent physician of this city, now deceased, went to a neighboring village to operate on a multiple stricture of the urethra in a middle-aged gentleman. After the chloroform was inhaled a few moments the patient, without a moment's warning, suddenly died. The physician who gave the anaesthetic admitted to me in private conversation that the only cause of death in this case was chloroform, and expressed regret that he had not used a safer anaesthetic. 308 ARTIFICIAL ANAESTHESIA. About one month ago a girl of 16 applied to the Reading dispensaiy for the removal of a small but disfiguring growth upon one of her eyelids. The two competent phj^sicians en- deavored to persuade her to submit to the operation without an anaesthetic, but she insisted upon having it. According to a newspaper report, made by the attending physicians, about fifteen drops of chloroform were placed on a towel, and after taking several inhalations she sprang from the table. She was again persuaded to get on the table, and the instant the inhala- tions were recommenced she died. The coroner's jury rendered the following verdict: "Death was caused by heart-failure while being put under the use of chloroform We agree that the chloroform was administered in the usual professional manner. ' ' The physicians in this case contended that the girl died from fright, and not from the anaesthetic; but I think that the verdict was a just one, and that fright was insufl&cient to account for death. If it was a factor in the death of this unfortunate girl it was only possible in conjunction with the paralyzing influence of chloroform. I believe that if all deaths from chloroform were published in the medical journals the number would be enormous, and the publicity would compel the abandonment of chloroform as an anaesthetic, save in a few cases in which it would be specially indicated. Note 5. ' ' In the case given there is little doubt that a valuable life might have been spared. A youth, aged 15, required eleven teeth to be taken out to qualify him for admission into the Royal Navy. An appointment was made by a dentist with the youth's own medical man to give chloroform. We do not wish to pillory this gentleman, with whom we deeply sympathize for the terrible disaster with which he is associated ; we are aware that very many practitioners adopt the plan he resorted to and recognize it as a routine procedure in dental operations. We must, however, most emphatically denounce it as a dangerous and undesirable one. Chloroform was administered with a towel — a method which easily induces an overdose of the anaes- NOTES REFERRED TO IN THE TABLE. 309 thetic — and the pulse was kept under observation. We read nothing of the respiration or the pupil, though doubtless they, too, were kept under observation. The dentist removed one tooth, and finding the second somewhat difficult some delay arose, during which the boy partly came round. The chloro- form was readministered and the remaining teeth were re- moved. Then the patient died. In a report which is before us we read that the medical man in his evidence said: 'Turn- ing round again, he noticed a change in the patient's condition.' It is significant how often ' going wrong ' occurs when the back is turned. The necropsy — performed by an independent med- ical man — revealed, we are informed, the startling fact that on examination of this boy, who is described as being in ' perfect health ' and as having been passed for the Royal Navy at head- quarters except as regarded his teeth, that his lungs were in such a condition that ' the boy could not have lived above two years.' Surely no lesion so serious could have escaped the examination at headquarters, and that of the medical man who expressly states he scrutinized the lad before giving him the chloroform. The posture of the patient is not mentioned ; probably the boy was in the dentist's chair — a position unsuited for the administration of chloroform." — London Lancet, March 12, 1893. Note 6. Deaths from Ether. Our friends think we have in our previous editions not given so much prominence to the deaths from ether as to those from chloroform, still we can state truthfully that our work will be found to contain the whole number of deaths from all anaes- thetics as far as we have been able to collect them, sparing no time nor money in the effort to do so, and these deaths were reported in full not only before the meeting of the British Medical Association in 1893-4, but also published to the med- ical world, and in this edition we publish some additional deaths. 310 ARTIFICIAL ANESTHESIA. Official Statement from the Paris Edition of the New York Herald, March 27, 1893, by His Physicians, AS TO the Death of Colonel E. F. Shepard FROM Ether. At the request of Mr. Chauncey M, Depew and the members of the Shepard family, Drs. McBurney and McLane have pub- lished the following statement : "We met at Colonel Shepard' s house for the purpose of making an exploration, under ether, on the bladder, and pro- posed, if practicable, to remove the stone which it contained. The presence of the stone was determined by two careful exam- inations on February 24th and March 9th. These examinations, which were made without the use of an anaesthetic, gave the pa- tient some pain. Between Feburary 24th and March 24th several examinations of the urine were made, but no evidence of any organic disease of the kidneys was found. The heart and lungs were healthy, and, after a careful examination, no disease, such as might interfere with the proper performance of the opera- tion, was discovered. The operation was postponed at Colonel Shepard's request until March 24th. We especially instructed him to eat very lightly on the day of the operation and to take no food afterwards. . Before the Operation. "We found Colonel Shepard in his study, apparently in good spirits, but he felt a little nervous about the operation. He removed his clothes, wrapped himself in a dressing-gown, looked about the room and at the seemingly elaborate prepara- tions and expressed surprise at their detail. He was told that they related chiefly to surgical cleanliness and were no greater than would be made at a good hospital, "At a quarter to one o'clock the administration of ether was commenced, it having first been explained to him that he was to take full inspirations and not to offer any resistance, in order to come more rapidly under the influence of the anaesthetic. For a few minutes he inhaled the ether uncommonly well, breathing full and freely. His color then changed somewhat, NOTES REFERRED TO IN THE TABLE. 311 he was apparent!}' nauseated and in another moment vomited. After that his color was better, but his respiration was not sat- isfactorj' nor was his pulse. The further administration of the anaesthetic was therefore discontinued, but as yet not enough ether had been given to continue the proposed operation. "All our efforts were now directed to securing proper respira- tory action. As usual in cases where the respiration is not perfectly satisfactory, the breathing continuing very labored, an examination was made of the larnyx to discover whether possibly a particle of food had lodged in it, but this was proved not to be the case. " Extreme Measures Resorted to. — The patient's condi- tion was now so alarming as to call for extreme measures, and, in the hope that the symptoms were due to the presence in the windpipe of vomit material, accidentally inhaled, the operation of tracheotomy was performed. No foreign material was found. We even passed a rubber tube down the windpipe into the bronchial tubes, making use of a powerful aspirating syringe, without discovering the presence of anything but bloody mucus. "In the meantime several careful examinations were made of the lungs, and sounds heard indicated oedema of these organs. Oxygen had been previously sent for, and under its influence the patient slightly revived. Artificial respiration and every other means that might possibly give relief were resorted to. From this time onwards the patient's breathing was even more embarrassed, but still artificial respiration was continuously kept up, although the pulse became steadily more feeble. Colonel Shepard sank rapidly into unconsciousness in spite of all our efforts, and died at ten minutes past four. "The Cause of Death. — Our opinion is that Colonel Shepard died from sudden oedema (congestion of the lungs) following upon the administration of ether, but primarily due to some cause unknown to us. ' ' James W. McLane, M. D. , (Signed) ' ' Charles McBurney, M. D. ' ' Ed, Note. — The unfortunate part of this case is that no post-mortem verified the cause of death. 312 ARTIFICIAL ANAESTHESIA. The Relative Mortality of Ether and Chloroform as Anaesthetics.* " In preparing statistics upon the subject of ether and chlo- roform as anaesthetics we have endeavored to adhere closely to certain principles of criticism which we reluctantly adopted as absolutely necessary in order to reduce the evidence before us to coherence. Data of varying degrees of merit, and obtained under such different conditions that it is the greatest careless- ness to range them together as facts of equal weight, are never- theless commonly found side by side. From such statistics we could not draw any definite conclusions. Nay, the conditions are ignored which we proposed to ourselves as the ultimate test of the value of any series of data. Are there, we asked our- selves, any observations recorded that show that ether and chlo- roform have been fairly tried together upon that common ground on which both may enter as anaesthetics and display their peculiar powers upon cases regularly selected with care and judgment? Pursuing this subject, we have been on our guard against any bias in ourselves and have carefully searched for it in the writings of others. "The number of papers to be examined is astonishingly great. Most of them, we are sorry to say, are liable to the suspicion of partiality. Among those of doubtful authority, from our own point of view, which, it must be remembered, is purely critical, are the following : The experimental ; those recounting individual experiences with ether alone or with chloroform alone ; those that assume that the use of chloroform ought to be entirely abandoned ; the controversial and polemic, of which unfortunately there are some. Secondly, we have noted as instances of that frame of mind which is unsuitable for fair judgment such statements as Surgeon-Major Lawrie's, that ' the most important result of the labors of the Hyderabad Commission has undoubtedly been to establish the proof that chloroform has never, under any circumstances whatever, a direct action upon the human heart ;' or M, Julliard's confes- •-•■ Editorial from The Medical News, Philadelphia, October 1, 1892, by Dr. George M. Gould. RELATIVE MORTALITY OF ETHER AND CHLOROFORM. 313 sion that for ether he has long been ' tin partisan convaincu ;' or again, his saying, too loosely we feel, that 'Prof Tripier has administered ether without accident 6500 times, while on the other hand he had a case of death snr un nombre infiniment mohulre ch chhroformisation.' "It is enough to observe here that by following any party or school we cannot arrive at the truth. In our own j udgment, it is assuredly unfortunate that men will use one anaesthetic exclu- sively, for some cases are fit for chloroform, others for ether, others again for nitrous oxide gas, still others, perhaps, for the A. C. E. mixture. "Naturally, we have not found many statistics that are free from the faults that we have either pointed out or hinted at. Indeed, we know but one that is accurate, and has besides the merits we required. Such statistics, we felt bound, must show observation of scientific accuracy, taken during a considerable time, under uniform conditions, by men of approved ability and knowledge entirely interested in a fair trial of ether and chloro- form, using neither one nor the other exclusively, but both alike and as nearly as possible an equal number of times ; with registrations made at the time of the operation, of the number of cases, with the deaths and accompanying circumstances. By means of these statistics, and these alone, may we hope to arrive at a final judgment on the controverted claims of ether and chloroform. We append a table of these desirable data. It is compiled immediately from the St. Bartholomew's Hos- pital Reports. It includes all the observations made. "It must be admitted that these results are by no means favorable to chloroform, yet we do not go so far as to say, with M. Julliard, that we must show these statistics to be inexact, or renounce chloroform. We see that the use of chloroform has increased with moderate fluctuations, reaching a maximum in 1890, and a preponderance over ether in that year of 727 cases, with one death for each anaesthetic. It is evident, then, that the surgeons had sufficient confidence in chloroform to continue its use— a fact in its favor. Whether this- confidence is deserved we may judge by an examination of the circum- stances attending the deaths. In the table we have noted the 21 314 ARTIFICIAL ANESTHESIA. cases of syncope ; these may be left to speak for themselves. Of the remaining deaths, we maj^ ascribe two to asphyxia. The others, we think, were highly probable with any anaes- Number of Cases. Deaths. vA -o « V.'x Remarks on the Cases ^ o^ g ciO Pertaining to Chlo- =2 o JU 02 roform. ^' o o o o o3 ^ ^ 5!^ 5 a^zi !>H W •^ H 187o 617 120 764 None None None 1876 670 28 1004 " " SS 15 21 London. P-l bO m CD g ^Ch § o c- O) 2 S- all- mechanical asphyxia, principally due to a cancerous growth of the mouth, and possibly also to the entrance of blood into the larynx. In the fourth place, I would remark, in connection with the nitrous oxide fatalities, that one of them occurred from the entrance of an extracted tooth into the larynx. But, as in the ether case, I have added this, so that it may be said that every possible case has been included. "We next pass to a fuller consideration of the chloroform GENERAL CONDITION. 333 fatalities themselves. These, 27 in number, I have arranged in two groups, viz. : " Group 1. — Cases reported with sufl&cient fulness to admit of ■comparisons and analj-ses being made of them ; and " Group 2. — Cases with sufficient data to admit of any such classification or analysis. ' ' (We have had to omit the table for want of space.) " I may say, however, that no case has been included in this group unless it is to be found reported in one of the leading medical or dental journals, or unless I have been able to thor- oughly satisfy myself, through the medium of correspondents, that it actually took place. Should any doubt exist in any one's mind as to these cases I shall be much pleased to place my ref- erences at his disposal. ' ' Sex. "Of the 19 cases 5 were males and 14 females. This pre- ponderance of female over male patients is to be explained by the fact, with which all dental practitioners must be familiar, that the great majority of those who require anaesthetics for dental operations are women "Women and children are the best subjects for chloroform, and I have no hesitation in saying that if men of vigorous build constituted the majority of patients requiring angesthetics for dental operations, the number of accidents under chloroform would be even greater than at present. ' ' Age. " Most of the patients were young, the highest recorded age being 37, the lowest 8 to 10 years. This is again to be explained by the reasons which I have just given." General Condition. "Taken collectively, there was no case with any condition which precluded the use of an anaesthetic or which rendered anaesthesia perilous. Experience has now convinced most thoughtful observers that the presence of a 'weak heart,' or, in fact, the existence of cardiac disease, in no way contra-indi- cates the employment of an appropriate anaesthetic." 334 ARTIFICIAL ANESTHESIA. Preparation. '* Nothing is said as to the regulation of the diet or looseness of the attire in nine of the nineteen cases. Of the remaining ten there is evidence of the diet having been regulated in six cases, and of the attire having been loosened before the admin- istration in five. In onlj?^ two cases is there a note of both of these precautions having been adopted. In one case there is evidence that no precautions were taken at all ; in fact, the pa- tient was attired in a tight-fitting new dress." Posture. " . . . . Thus we find that in one case the patient was in the sitting posture ; in three cases in the sitting or semi-recumbent posture ; in three cases in the semi-recumbent posture ; in one in the semi-recumbent or dorsal posture ; and in four cases in the dorsal posture. In other words, there is evidence that the patient was either sitting or semi-recumbent in seven of the twelve cases in which any details as to posture are given. "The posture of a patient during the administration of chlo- roform for a dental operation is a matter to which attention should be carefully directed. Most medical and dental practi- tioners are aware of the influence which a more or less vertical position of the body may exert upon the circulation — effects which are directly dependent upon the force of gravity. But there would appear to be comparatively few who fully realize the fact that in dental operations generally, and more particu- larly in dental operations under chloroform, the circumstances which usually attend the administration of the anaesthetic are very favorable to the occurrence of arrested breathing. It will be well to say something as to the effects of posture upon the circulation. " A very complete research by Dr. Leonard Hill, communi- cated not long ago to the Royal Society, is of importance in this connection. Dr. Hill finds the circulation in the lower animals to be directly influenced by the force of gravity, the arterial tension in the carotid arteries rising in the feet-up and falling in the feet-down posture. He further finds that the splanchnic vaso-motor mechanism, which regulates the quantity POSTURE. 335 of blood in the splanchnic area, compensates for these changes in the tension of the carotids, and that, when the mechanism is intact, and the heart is acting efficiently, raising the trunk and lowering the feet has no dangerous effect upon the circulation, for by the constricting action of the splanchnic mechanism, blood is prevented from accumulating in the splanchnic area and the heart, and therefore the carotids and the brain are kept properly supplied. But if the splanchnic vaso-motor mechanism be damaged, as, for example, by the use of large quantities of chloroform, by asphyxia, or by other causes, an alarming and perhaps fatal attack of syncope may attend eleva- tion of the trunk, for the splanchnic area is full of blood, and the arterial system is comparatively empty. Dr. Hill laj^s stress, too, on the fact that if the heart's action has become de- pressed from an overdose of chloroform or other causes, this elevation of the trunk will be even more liable to end disas- trously. But should the patient's circulation be extremely feeble (from nervous apprehension, functional or organic dis- ease, ansemia, etc.), before the administration, or should it become greatly depressed (from the use of too small or of too large quantities of the anaesthetic, from vomiting, from as- phyxial complications, or from surgical shock) during the ad- ministration, any elevation of the trunk from the horizontal plane may certainly be fraught with considerable danger. "Extension of the Head and Neck.— It is a common practice in dental surgery for the head to be thrown well back- wards upon the trunk in order to allow of the extraction of upper teeth. This procedure, however, has the effect of bring- ing the base of the tongue and epiglottis away from the pharynx and larynx respectively, so that the act of swallowing is ren- dered difficult or impossible. Any one may satisfy himself with regard to this point by making the experiment upon his own person. " When extension of the head and neck is practiced during deep anaesthesia, another danger comes into operation, viz., that of foreign substances actually entering the now insensitive, open, and unprotected larynx." Flexion of the Head upon the Sternum. Opening the 336 ARTIFICIAL ANESTHESIA. Mouth Very Widely by Means of Props or Gags. — By placing one or more pillows under the head, without raising the shoulders, the tongue will tend to touch the pharyngeal wall, and the breathing may thus become impeded, stertor passing into complete obstruction. This was pointed out by Bowles. A similar state of things may arise during the extraction of lower teeth, respiration completely ceasing so long as the lower jaw is driven down towards the sternum. Again, if the mouth be opened very widely by a prop or a gag, respiration will be liable to become arrested when the patient is ansesthetized, the depression of the lower jaw having the same effect in approxi- mating the tongue to the pharynx as when the whole head is flexed by means of pillows. In the semi-recumbent and dorsal postures the tongue maj% during properly established anaesthesia, gravitate towards the pharyngeal wall and obstruct breathing. I have frequently demonstrated at the Dental Hospital the great difference, in regard to the occurrence of obstructive stertor, between a nearly vertical posture and a position approaching the semi- recumbent — the latter being a very favorite one for dental ope- rations. I am now speaking of nitrous oxide cases, but the remarks apply to chloroform. When the body and head are nearly vertical the tongue rests on the floor of the mouth, and obstructive stertor is not likely to arise. When the body and head are thrown more backwards, as they almost invariably are when chloroform is about to be given, tongue-stertor is far more likely to arise, and respiration to become embarrassed from this cause. Metliocl of Adininistration and Quantity of Cliloroforin Used. In 5 of the 19 cases no particulars are obtainable concerning the method adopted or the quantity of chloroform used. The method is referred to in 13 cases. In 3 of these a Skinner's mask was employed ; in 2 a folded napkin ; in 2 a piece of lint; in 2 a " napkin " (? folded or not); in 1 a towel ; in 1 an "open inhaler;" in 1 a Junker's apparatus; and in 1 it is stated that the chloroform was administered "in the usual way." The PHENOMENA DURING ADMINISTRATION. 337 quantit}^ of chloroform used is given in 6 of the cases. The smallest quantitj^ was half a drachm ; the largest was a little over 2 drachms. If we take "a little over" — an expression used in 2 of the cases — to mean 20 minims, and if we reckon 45 minims to have been employed in the case in which "40 to 50 minims" is mentioned, the average quantity of chloroform used in these 6 fatal cases works out at about 2h drachms. Special reference will subsequently be made to the 2 remark- able cases in which only 30 minims and 40 to 50 minims respec- tively were employed. Natiu'e of Operation. The proposed operation is not stated in 5 of the 19 cases ; in 1 it is said that a "large number of roots " had to be removed ; in 4 cases ' ' several teeth ' ' are referred to ; in 1 case eighteen roots had to be extracted ; in 2 cases nine teeth ; in 2 cases six teeth ; in 1 case the roots of one tooth and then two entire teeth ; in 1 case three teeth ; in 1 case one tooth and one stump ; and in 1 case one tooth only. Relation of Dangerous Symptoms to Operation. In 3 cases the dangerous symptoms arose before the opera- tion ; in 8 during ; in 2 during or after ; in 5 after ; and in 1 it is impossible to say at what juncture they occurred. Phenomena During Administration and Operation. Fatal Phenomena. "The occurrence of dauirerous sj'mptoms during the admin- istration of an anaesthetic for the comparatively minor opera- tion of tooth extraction is usually so disturbing that a cleai' and systematic statement is next to impossible. "For example, breathing may so noiselessly and insidiously cease that the cessation may readily escape detection, the more so as thoracic and abdominal movements may continue even when there is complete obstruction to the entry and exit of air to and from the chest. "Amongst the 19 fatal cases there are no less than 6 (viz., Nos. 2, 9, 10, 15, 16 and 18) in which chloroform was readmin- 338 ARTIFICIAL ANESTHESIA. istered during the operation — a fact which corroborates the opinion that this rcadministration in dental surgery is hazard- ous unless skilfully conducted. "Chloroform is administered in very small quantities at a time, as I have often seen it administered, and a highly unsat- isfactory state of affairs results. I believe Syme's dictum was that 'drachms may save whilst drops may kill,' and there is a good deal of truth in this remark. When chloroform is given in too small quantities at a time, and delay arises in producing surgical anaesthesia, the circulation will often show signs of running down. Pallor, feeble pulse, shallow and almost imper- ceptible breathing will arise. An experienced administrator, taking in hand such a case at such a time, would add half a drachm, a drachm or even more of the ansesthetic to the lint, and apply the latter more closely to the face, with the result that respiration would quickly increase in force." Post-Morteiii. "Nothing is said as to any iwst-mortem having been per- formed in 8 of the cases. In 4 it is stated that no autopsy was made. In the remaining 7 cases the particulars obtainable are so imperfect and meagre that no useful purpose would be served in classifying them. ' ' We regret we cannot give the whole of this pamphlet (32 pages), but have endeavored to give a full abstract and the latter portion. CHAPTER XI. Anaesthesia by Chloroform and Oxygen. In our third edition (p. 474) it is there stated and published, in 1887,* that Dr. Kreutzmann, of San Francisco, emplo3^ed not the pure chloroform, but Billroth's mixture (three parts of ether to one of chloroform) in conjunction with oxj^gen. The "•■• Pacific Medical and Surgical Journal, August, 1887. OXYGEN WAS AN ANTIDOTE TO CHLOROFORM. 339 discoverer of this method was Dr. Neudorfer, of Vienna, who claims on theoretical grounds that its emploj^ment is entirely without danger. We also published in the same edition (p. 210), 1890, the following case, illustrating the fact that Oxyg-eii Was an Antidote to Chloroform. "A young man attached to the laboratory of the New York Medical College became asphxiated from the inhalation of the vapor of chloroform ; and so far had its effects been carried that he became pulseless, and all hopes of his resuscitation aban- doned ; and as all the usually recommended remedies had been tried without success, nothing but the death of the j^oung man was looked for, when I proposed, as a dernier resort, the appli- cation of pure oxygen gas, as the only chance by which resusci- tation could be brought about ; but at the time the proposal met with opposition from the medical men present, who were anxiously watching what seemed to be the expiring efforts of the poor bo}^, expecting each moment to be his last. Having, how- ever, consented, the gas had not been more than a few seconds applied to his nostrils, when he who was apparently beyond the help of human skill, and absolutel}'' in articido mortis, arose and placed himself upon a chair, proving most conclusively how correct I was in proposing the application of oxj^gen gas as a remedy against the deleterious effects of chloroform as an anaes- thetic. " — Dr. Simeon AhroJurms. I also published the following facts in corroboration of the great value of oxygen gas : ' ' Dr. Loyssel has experimented with pure oxygen and from it has obtained very good results. He concludes : ' ' 1st. That in certain poisonings, such as those by chloroforms^ ether, opium, sulphuretted hydrogen, carbon dioxide, cyanhy- dric acid, oxygen constitutes the only means of recalling the patient to life, when all else has failed. " 2d. That its presence in the operating room is certain pro- tection against fatal accidents from the use of anaesthetics. "3d. That it succeeds equally well in asphyxia caused by strangulation, by immersion, by toxic gases, etc., as well as with the new-born, in condition of apparent death. 340 ARTIFICIAL ANESTHESIA. "4th. Life can almost, with certainty, be maintained in all cases where respiration has not entirely ceased, even if there are long intervals between the inspiratory efforts. " 5th, If the respiratory and circulatory functions have been completely arrested for a short time, they may be re-established by means of oxygen, which it is necessary to administer with perseverance, even when it is believed that all efforts will be useless. There are reported many cases of drowned persons, and of children apparently dead, who have been saved, thanks to persistence in administering oxygen. "6th. Oxygen may be inhaled in notable quantity without the least danger." On page 202 were given a number of careful experiments to determine if it were an anaesthetic, and concluded that pure oxygen was not a true anaesthetic, but could be inhaled with safety even in large quantities. In February, 1895, was published a valuable communication by Dr. H. L. Northrop, giving his reasons for the administration of oxygen with chloroform when the latter is used as an anaes- thetic, and he premised by stating that he had administered it in one hundred operations, from the most minor to laparotomy, for haematoma, amputation of breast, celiotomy for ruptured liver, herniotomy, amputation of leg, and several cases of ap- pendicitis : " The idea of combining oxj^gen with chloroform for anaes- thetic purposes occurred to me a year and a half ago, while considering the physiological effects of chloroform. Since then I have demonstrated its practical utility. "A search was made for me in the Patent Office at Wash- ington ; I have examined the Index Medicus for the past five years for articles bearing upon the subject, and I wrote to Lon- don hospitals and received a reply.* From none of these sources could I learn of anything in regard to this combination. Thus it would appear that this is the first instance in which oxygenated chloroform has ever been used. * This is the old idea to go abroad for what can be found at home. OXYGEN WAS AN ANTIDOTE TO CHLOROFORM. 341 "Function must go on even during the anaesthetic state, though, of course, it is depressed and limited — in the first place by the presence in the blood of a virulent poison, and in the second place because both the cerebro-spinal and sympathetic nervous systems are partially overpowered and cannot continue their work. I say partially overpowered, because it is the cen- sory and motor nerves of the cerebro-spinal system which, so far as we know, are most deeply and prominently poisoned. To prove this statement, the nerve-centres of the cerebro-spinal system governing the respiratory and circulatory functions are not involved in the poisoning unless a lethal dose be adminis- tered, while at the same time we have a more or less complete paralysis (if you please) of all the other motor and sensory nerves. Again, to aid in maintaining the circulation, we must have a continuance of vaso-motor influence, and this must be, and is, supplied by the sympathetic nervous system, "This satisfactorily proves that certain functions are carried on to some extent even during the anaesthetic state. To just what extent function is carried on it is impossible to say, and, in fact, it is not at all necessari^- for us to know. Function de- pends upon the oxidation of tissue ; oxygen is the oxidizing agent of the body. Anything that lessens the supply of oxy- gen to the animal body will interfere with its functions. The extent to which function is interfered with depends, of course, upon how much the supply of oxygen is lessened. It is cer- tain, therefore, that we must have oxygen in sufficient amount if function — and, therefore, existence, life, vitality — is to be maintained. " Why is chloroform such a deadly anaesthetic? Why have thousands of dollars been expended and thousands of animals been sacrificed, and Hyderabad and Glasgow Commissions been appointed ? Why have medical men argued and debated with one another, vainly trying to solve this momentous question ? Is it not all for the purpose of trying to determine why chloro- form kills, and to find a safer method for its administration ? ' ' The vapor of chloroform is very heavy — more than four times as heavy as atmospheric air. Because of its weight, when administered by the open method, atmospheric air is 342 ARTIFICIAL ANESTHESIA. partiallj'^ excluded, and therefore the amount of oxj'^gen ab- sorbed is diminished. If the air is mixed with chloroform mechanicallj', as bj" the Junker inhaler, we even then have the amount of oxygen absorbed reduced one-half, and, of course, this is replaced bj' the absorption of an equal weight of chlo- roform. If the chloroform be given in a more concentrated vapor, its weight is sufficient to prevent the absorption of oxy- gen altogether, and death follows, in great part, from complete deprivation of oxygen. "We have seen that oxj^gen is necessary for the maintenance of function ; function is necessary if life exists ; chloroform, by the weight of its vapor and by the physical laws governing the arrangement and absorption of gases, displaces the oxj'gen and reduces the quantity absorbed one-half, even if the atmos- pheric air be freely mixed with it. " Chloroform, by its weight, falls into the deepest and ultimate air-vesicles ; hence it is brought into close contact with the blood, and rapid absorption is favored. This, of necessity, potently tends to surcharge the blood with chloroform and to displace or decrease the normal amount of oxygen, and inter- feres with oxidation, upon which function depends. For this reason our patient's life is endangered, and that is why, also, pure oxygen should be mechanically mixed with the vapor of chloroform." Mr. President: Your Anaesthetic Commission* begs leave to make its final report upon the experiments with chloroform and oxj^gen, presenting to you the data of 100 cases, with a few observations and practical conclusions as the outcome of our work. We preface our tabulated list of cases by stating that all of our patients underwent a careful preliminarj^ physical examina- tion as regards heart, lungs and kidnej^s, the result of the same being noted on anaesthetic blanks. Squibb' s chloroform was used, and the oxygen was contained, under pressure, in iron cylinders, each of which held forty gal- * Formal report of the Ansesthetic Commission, of which Dr. H. S. Northrop was chairman. OXYGEN WAS AN ANTIDOTE TO CHLOROFORM. 343 Ions. The oxj-gen was passed througla the chloroform, the vapor thus formed conveyed to a mask or inhaler, which was made to fit closely around the patient's mouth and nose. The inhaler was provided with a valve for admitting or excluding atmospheric air, and a rubber bag, into which the patient ex- haled when the valve was closed. This simple form of appa- ratus was found convenient, portable and easily managed and controlled. Complete augesthesia was produced, as a rule, in a shorter time than can be done by ether or chloroform. The shortest time required to bring about complete anaesthesia with ox5^gen- ated chloroform was one-half minute, in one case, and the long- est time 10 minutes. (The latter case was an alcoholic, and one of our earlier cases, when we were not well acquainted with our anaesthetic. ) The average time consumed in anesthetizing each case was 4i5(j minutes, which average is probably lower than any yet published for ether or chloroform administered by the open method, and possibly lower than any for the closed in- halers (Clover and Junker). The quantity of chloroform used in many of the cases was certainl}' insignificant, and. of course, the amount of oxj^gen consumed must have been in direct proportion to the quantity of chloroform vaporized. We could not ascertain the quantity of oxj'gen used in each case ; one cylinder, however, lasted for about six hours of anaesthetizing. One of the most prominent (and, we must say, pleasing and satisfactory) conditions attending the use of oxygenated chloro- form was a rosy color and healthful blush of the lips and cheeks, and a bright red oxygenated state of the blood flowing from a wound. These apparent expressions of good aeration were noticed by many by-standers, and are worthy of note because of the contrast presented to the well-known, death-like pallor at- tending the use of chloroform alone. Vomiting occurred in about 30 per cent, (or less) of the cases. It has usually been of short duration, consisting of a watery, greenish fluid (bile and mucus), and only an ounce or two to each case so afi'ected. Some of our patients had slight, tem- porary nausea, others merely retching without vomiting, and, as 344 ARTIFICIAL ANiESTHESIA. above stated, about 30 per cent, vomited. Frequently retching occurred while the patient was on the operating table. This was immediately and successfully controlled in all cases by turning on the current of oxygenated chloroform. In the matter of vomiting our anaesthetic was put to a pretty good test. More than a year ago Dr. I. G. Smedley removed the ovaries of a woman who was anaesthetized with ether. She vom- ited persistently for one week and her general condition became seriously imperiled. Previously to this her cervix and perinaeum were restored by the late Dr. Groodell, of this city. Ether was given this time also, and she vomited for 9 days after the opera- tion. She was a case on our list, nephroraphy having been performed by Dr. W. B. Van Lennep. Our notes say: "Con- scious in 10 minutes after placed in bed at 3 p.m. No vomiting until after 9 P.M., when cracked ice was given. Vomiting of a thin, greenish fluid in mouthful quantities at intervals all night." The next morning the patient's stomach and liver were quiet^ and remained so, an uneventful recoveiy following. Oxygenated chloroform usually slows the pulse, and the more deeply the patient is anaesthetized the more slowly the heart beats, but the pulse is full and strong. The respirations are apparently not affected. The respiratory movements are cer- tainly not labored or excited, though in one or two cases the respirations were irregular, at one time fast, at another slow. Recovery takes place very quickly, our patients often being wide awake in 10 or 15 minutes after they are placed in bed, and almost invariably without any delirium or sign of intoxica- tion. As an exception to the statement just made, Case 10, a minister, required four people to hold him in bed for the first 10 or 15 minutes following his operation. I have received, February 20, 1896, a more recent and care- ful description of the arrangement for the administration of chloroform and oxj^gen. Dr. Northrop states : "It gives me pleasure to make known the favor with which chloroform and oxygen, as an anaesthetic, has been received, to lay down a few exphcit rules for its ad- ministration and to now describe a new apparatus. "I wish to publicly thank Dr. J. H. McClelland, of Pittsburg, OXYGEN WAS AN ANTIDOTE TO CHLOROFORM. 345 for the unreserved and valuable endorsement he has given this anaesthetic, after the most thorough tests. "This article is prompted by a feeling of its necessity at the present time, in view of the fact that frequent inquiries are made of me in regard to ' C. & 0.' apparatus. The apparatus can now be bought of Charles Lentz & Sons, 18 North Eleventh Street, Philadelphia, and has received my final approval." The following, Plate 48, is an illustration of oxygenated chloroform apparatus. Plate 48. "It is arranged in a nicely polished wooden box, 18 inches long, 7 inches wide, 7 inches deep, contains a steel cjdinder holding 40 gallons of pure oxygen, a graduated 2-ounce bottle, the requisite length of rubber tubing and the inhaler. The latter has an inflatable face-shield attached to a metallic hood, with which is also connected a rubber respiratory bag. This, with the small wheel to be attached to the cjdinder, the perfor- ated rubber cork and nickel-plated brass tubes, is all the appa- ratus necessary for the proper administration of chloroform and oxygen. One may (and should) also keep in his C. & 0. box 23 346 ARTIFICIAL ANESTHESIA. one (or two) quarter-pound cans of ether, a folding Allis ether inhaler, a hj^podermic sj^ringe, proper stimulants, a pair of vul- sella forceps and an infusion apparatus. A mouth-gag will be added to the above list by those who desire it. The apparatus weighs 19| pounds. "In order to use the apparatus put two ounces of pure chloro- form into the bottle, attach the tubes to the cylinder and per- forated cork, and place the bottle in the corner near the open end of the box, passing the tube leading to the inhaler through this opening. Pull out the cylinder until it touches the bottle and fix it in position by tightening the screw in the top of the iron ring supporting the cylinder. Put the wheel on the cylin- der valve, close and fasten the lid of the box, and the apparatus is ready. "It is my custom to place the box on the left side of the patient, upon the bed or operating table, or upon a high stool or small table, if its position beside the patient would interfere with the operation. "In administering the anaesthetic turn the wheel carefully until a gentle but continuous current of oxygen bubbles up through the chloroform, and apply the mask directly to the patient's face, making it fit tightly. The oxygenated chloro- form vapor at this stage is not (should not be) concentrated enough to disturb the equilibrium of the patient's respirations. All anaesthetists know that the deeper and fuller the subject breathes the more easily and rapidly will a state of narcosis be produced. The same holds good when employing chloroform and oxygen. As the patient approaches the unconscious state turn on a slightly stronger current of oxygen, and if the stage of rigidity ensue (it is very frequently absent) a still stronger current should be used. " It is sometimes possible to begin anaesthesia with a moder- ately strong current, to continue the same until complete relax- ation is produced, and this without causing a ripple of disturb- ance in the patient's respiratory or cardiac functions. Several times it has been my surprise (and pleasure) to find my patient completely relaxed and ready for operation while I was waiting for a stage of rigidity. OXYGEN WAS AN ANTIDOTE TO CHLOROFORM. 347 " I have found that complete relaxation and puffing breath- ing, which are characteristic of deep anaesthesia, prevail at first, even though the cornea be not insensitive. The latter indica- tion of the full anaesthetic state will come later; but do not wait for it before notifying the operator to begin. Continue the inhalation, and, as a rule, the cornea will shortly become ansesthetic. I say as a rule, for sometimes it seems impossible to bring about its in-sensitiveness. Here the patient is usually a male, probably an alcoholic, large, muscular, ' bull-necked. ' But simply having a sensitive cornea dees not mean that he is not ready for operation. Experience has proved that he is and that he will not resist surgical interference. "Further demands for 0. & 0. are made in the same way as for any anaesthetic. Eesistance upon the part of the patient, recurring sensitiveness of the cornea, attempts to vomit, etc., all indicate a renewal of the inhalations. It is my habit to leave the inhaler in position, even though the current be turned off. And as long as the mixture is being inhaled I watch the cornea and pupil particularly and feel the pulse at the wrist oc- casionally. The wrist is, in my opinion, the only place to satis- factorily test the heart's action. If the cornea is totally insen- sitive, and especially if the pupil is enlarging, turn off the oxygen. Watch for the return of the sensitiveness of the cor- nea, and in a few minutes it will be found. Inhalations need not be renewed immediately, however. The anaesthetist must use his own judgment here, and at all times, as to the quantity of the anaesthetic to be employed. " Should retching occur and vomiting threaten, administer a fairly concentrated vapor, at the same time encouraging the patient to breathe, which can be done by keeping the jaw well raised. This will be found effectual in bringing about relaxation of the diaphragm and abdominal muscles. " In case of collapse it may be thought advisable to remove the long rubber tube from the chloroform bottle and attach it to the cylinder in order to administer pure oxygen to the col- lapsed subject. It will perhaps be necessary to pull out the tongue and perform artificial respiration at the same time. "I advise each possessor of a C. & 0. apparatus to carry a 348 ARTIFICIAL ANESTHESIA. piece of paper in the box, and to regularly note the date and length of operation, thus keeping a record of the duration of time the cylinder is used. Let him also number each cylinder upon the label near the end, and so be able to determine ap- proximately the amount of oxygen it contains, and accordingly the length of time it should last, I have found a cylinder to furnish oxygen enough for from four to six hours of operating. •' Let me again caution the anaesthetist not to waste the oxy- gen. When not desiring to make the patient inhale the vapor, turn off the current completely, even though the inhaler be left in position. It requires but the slightest turn of the wheel to furnish a current of the proper strength." Cliloroforin and Oxygen. The most recent observations in regard to the efl&ciency of the anaesthetics, chloroform and oxygen, Dr. Northrop reported a few months ago, and Dr. Hassler* has had the same good re- sults since that report. The number of cases during the year, 254 having vomited following its use is but 9.5 per cent., occur- ring mostly in alcoholic and intestinal operations. The shortest time to complete anaesthesia was 48 seconds, and the longest 12 minutes, in a hysterical woman. The smallest amount used was three drachms in seventy minutes for the operation of colo- totomy, for removal of both ovaries. Ether has been given more frequently than any other anaesthetic. The same authority states that "chloroform has been re- stricted to children, alcoholics and short operations." In this year's report they only employed nitrous oxide in one case. Upon inquiry among the surgeons of all the schools in Phil- adelphia I find but only one or two who have employed chloro- form and oxygen to any extent ; indeed, only one. Professor Montgomery has used it extensively in his operations. But I find they all have it at hand for use after extensive operations in case of any indication of very weak pulse and respiration. -;•;- "^ Year's Work of Ausestlietizing 370 Cases in Dr. Northrop's Hospital," March, 1896. OXYGEN-INHALING APPARATUS. 349 Oxygen-Tnlialing^ Apparatus. A very useful apparatus is that devised bj" the S. S. White Co. ; the administration is absolutely under the control of any intelligent individual. Plate 49. The inhalation apparatus will be seen in Plate 49, and is a modification of the nitrous oxide apparatus. A represents the cylinder filled with compressed oxygen gas into a liquid ; B, the gas valve ; C, a rubber bag holding three pints ; D, a wash-bottle half filled with water. The wash- 350 ARTIFICIAL ANAESTHESIA. bottle serves several important purposes : it indicates how fast the gas is flowing ; it also calls attention if the valve of the cj'linder be not closed tightl}-; arrests an}^ dust that might be carried from the C3'linder, or from the interior of the tubing or bag ; and moistens the gas, thus preventing its absorbing moisture from the throat and air passages. At E is a mouth- piece attached by a rubber tube to the bottle ; F, a rubber tube connecting rubber bag to B ; and G, a rubber tube connecting the bag with the wash-bottle by means of a glass tube which extends nearly to the bottom of the bottle. In using the appa- ratus arrange the parts as shown in the Plate, being careful to place the leather wagher properly at the outlet of the valve (B), and half fill the bottle (D) with water. Open the valve (B) very slowly and cautiously ; the oxygen will then flow through the tube (F) to the gas bag (C). When the bag is fllled the valve (B) may be closed and the apparatus is ready for use. If the valve (B) is open too much a portion of the gas may rush by the bag, and forcing its way through the water be lost ; to correct this it is only necessary to partially close valve (B). In adminis- tering oxygen by the lungs the usual practice is to cause the patient to inhale very slowly from three to four gallons, say twice a day, taking it into the mouth through the glass tube, breathing at the same time through the nostrils. The gas should be retained in the lungs as long as possible, as more than this quantity may do harm. In severe cases of dyspnoea, asthma, croup, diphtheria or pneumonia much larger quantities may be required, as in a case of the latter disease, reported by Dr. Albert X. Blodgett (Boston Medical and Surgical Journal, November 20, 1890), which gives a record from his note book, as follows : The patient was "in articulo mortis." Oxygen inhalations had been employed at intervals during the progress of the case, always with relief to the patient. He now directed that the administration of the gas be made continuous, not with any hope of curing, for he states that he was under the positive conviction that the patient was irrevocably doomed : the best result he looked for being simply relief to the sensation of suflfo- cation. The gas was conveyed from the tank in which it was MIXED ANAESTHETICS. 351 supplied through a wash-bottle directly to the mouth of the patient, and a constant stream of gas was flowing through the tube all the time, so that with each of the rapid inspirations the patient was obtaining a constantly increased amount of oxygen. This was continued for lOG hours, the quantity of gas emploj-ed being not far from two hundred gallons in twentj^-four hours. The patient having then progressed far enough toward convalescence to warrant it, the oxygen inhalations were discon- tinued. The patient was eventually restored to her previous condition of health. Commenting on the case, Dr. Blodgett said: " I feel that in extreme dyspnoea or in threatened asphj^xia we have in this agent the means of obtaining in many cases a distinct relief of the suffering, and a painless, if inevitable, death." CHAPTER XII. Mixed Anaesthetics. The various mixtures of ansesthetics first received their im- pulse from the report of the Chloroform Committee of the Medical Chirurgical Society of London, who declared their su- periority in point of safety. M. Perrin gives an account of the first death, known at that time to have taken place under a given mixture of ether and chloroform, and gives the credit to the chloroform as being improperly administered, and Snow says the patient died of haemorrhage ; but our reading of the case, carefully reported by Dr. R. Crockett,* leaves the decided impression that chloroform arrested the heart's action, inducing vomiting, and caused a stoppage of the respiration. The fol- lowing is an abstract of the important facts in the case, and is interesting as the first death from the mixture: "A sprightly * Am. Jour. Med. Sci., July, 1857, pp. 284-5. 352 ARTIFICIAL ANESTHESIA. little bo3% five years of age, was brought to the doctor to have a fattj'- tumor removed from his back. The tumor, commencing at a point at its inferior termination, opposite the last rib, about two and a half inches to the right of the spinous processes, and extending obliquely upwards, crossing the spine seven inches, required two elliptical incisions, nine inches long, for its re- moval." The operation was commenced at 9.30 A.M., April 4th, and the dissection was rapidly executed, stopping to ligate a large artery that was earlj^ divided ; the remaining arteries were compressed as they were divided. The tumor was quickly removed and a ligature applied to the last artery, being the sixth in number. While sponging the wound the boy began to vomit, and on examining the wrist he was found to be pulseless. Dr. K., who had charge of the anaesthetic and pulse, replied that "the pulse had never given way until he began to vomit." He ejected a small portion of the contents of the stomach. He was immediately placed in the "prone position," as recom- mended by Dr. Marshall Hall. The finger was introduced into the mouth to be certain that the tongue had not fallen back so as to obstruct the glottis, or the entrance of air into the wind- pipe, and the extremities were rubbed with aqua ammonia. The patient died three or four minutes from the commencement of the vomiting. "He lost probably four ounces of blood; certainly not exceeding six." There was no post-mortem ex- amination. The anaesthetic used was a mixture of washed ether, four parts, and one of chloroform, obtained from the late Frederick Brown, of Philadelphia, w^hose character is a sufiicient guaran- tee that they were pure. Everj^ preparation for the operation having been made, the administration of the ana3sthetic was commenced by Dr. Crockett, observing all the precautions so fully recommended by Erichsen, p. 78, of his " Operative Sur- gery." As soon as anaesthesia was induced, the sponge was confided to Dr. Kincannon, who held his finger all the while on the patient's pulse. The doctor concludes, " I have lately em- ployed this anaesthetic freely, formerly having used ether alone. As yet I have not seen a case of death reported fro'ni ether ^ or this mixture of it with chloroform, that I can now recollect. MIXED ANAESTHETICS. 353 Are there any such reported ? I fear all the deaths from anaes- thesia are not reported." Five deaths from the use of this mixture have been published. The chief object of these anaesthetic mixtures is the avoid- ance of the danger from sJwch, or from the depressing influence upon the heart-action, which chloroform most certainly exerts, and which ether and alcohol prevent. The committee before referred to proposed the following mixtures : Parts. A. Alcohol, 1 Chloroform, 2 Ether, 3 B. Chloroform, 1 Ether, 4 C. Chloroform, 1 Ether, 2 Dr. Sansom's mixture* is equal parts by measure of chloro- form and absolute alcohol. The introduction of alcohol, which plays an important part in the mixture, was, according to the doctor, due to Dr. Harley. The committee says it is by " the uniform blending of the ether and chloroform, when combined with alcohol, and probably the more equable escape of the con- stituents in vapor." The chloroform is the potent agent, and the others chiefly coadjutors, vehicles and diluents of the chlo- roform. Dr. Sansom gives the following testimony as to the stimu- lating eff"ects of alcohol in counteracting the depressing influ- ence of chloroform : " In my own experiments I have found that alcohol has had the greatest eff"ect in sustaining the heart- action during the influence of the chloroform. I can particu- larly recollect one instance, in which alcohol was administered in vapor to a frog, after it was impossible to cause death by any strength of chloroform vapor." In recommending this mix- ture before the Obstetrical Society of London, Dr. Sansom went one step farther, and stated that this mixture gives off" a pro- portion of chloroform vapor in a given time almost exactly * Chloroform : Its Action and Administratiou. By Arthur Sansom, M.B., London. 354 ARTIFICIAL ANESTHESIA. half of that which is given off by chloroform pure and sim- ple. The result is not confirmed by any experiment of his published . What are the ohjections to ancesthetic "mixtures 9 1. The length of time required for the production of complete anaesthesia. 2. The probability of entire sensibility not being abolished. 3. The unequal rate of evaporation or vaporization of the fluids. There is not any doubt but that the process is slower and at- tended with more excitement by the mixed fluids than by chlo- roform alone. The second objection cannot be sustained. The third is the "element of danger." It was flrst advanced by Snow. He says: "When ether is combined with chloroform, the result is a combination of the undesirable qualities of both agents, without any compensating advantage," and the danger is because the operator, toward the end of the process, may be giving a pure chloroform when he thinks he is giving the weaker mixture of vapors. Dr. Ellis endeavored to prove this, and states : ' ' Out of the six or seven minutes occupied by the evaporation of the half-drachm of fluid, the first was occupied chiefly by the ether, the next three by the chloroform with a little alcohol, and the last by the alcohol alone. In an inhaler, the patient would have breathed, for one-fifth of the time, chiefly the vapor of ether ; for the next three-fifths, that of chloroform, with a little alcohol; and at last, only the vapor of a minute quantity of alcohol." These results are not stated as obtained by actual experiments, and they depend, first, upon the purity of the agents employed ; second, upon the boiling- point, which has a great influence upon the results, for the more volatile the fluid, the greater will be the variation. We here give the boiling-point of the most important anaes- thetics. The temperature which is constant for the same substance, under the same atmospheric pressure, is called the hoiling- point The following are the agents employed as anaesthetics in the form of vapor, the boiling-points being given for the mean pressure of 760 millimeters : MIXED ANAESTHETICS. 355 Protoxide of nitrogen, 88° Carbonic acid, 78° Chloride of etlij'l v. pure ether, .... 11° Ether, 35° Chloroform 63° Alcohol, 78° Oil of turpentine, 157° A difference of pressure of 0.25 centimeter will cause a dif- ference in the boiling of water one-tenth of a degree. The boiling-point is also influenced by dissolving in a fluid a sub- stance more volatile than itself (as ether and chloroform) ; it increases the boiling-point in proportion to the amount dis- solved. The temperature of the atmosphere has a powerful influence on these volatile agents, as it is a well-known chemical fact that the saturation of the air increases vastl}^ with the in- crease of temperature, and the capacity of the air for aqueous vapor is doubled with each 27° of temperature, Fahrenheit. Sulphuric ether at 60° F. and thirty inches of the barometer expands two parts of the air into three, and forms, therefore, at that temperature and pressure, one-third of the air inhaled into the lungs of a patient. Under the same circumstances, chloroform expands fourteen parts of air into fifteen, and con- sequently the vapor of chloroform constitutes one-fifteenth part of the air inhaled. The following experiments were made October 30, 1878, so as to determine the time required for each of the agents to evaporate on a given surface of tissue-paper, suspended in the air at a temperature of 70° F. , one drop of each being carefully measured by the same dropping machine. The time was accu- rately kept by Dr. C. S. Turnbull, son of the writer, and the results served to confirm the rough experiments made before the Dental Convention at Washington, D. C, on October 10, 1878, and proved the facts stated in the author's first edition of this work. We have always found that when such a mixture was poured upon the inhaler, the most volatile spirit would rise first, then the next, and so on, leaving the least easily evapo- rated upon the inhaler. Another important fact was proven, and which was before referred to, that the alcohol employed in 356 ARTIFICIAL ANESTHESIA. the mixtures with chloroform in England, also the ethers made from such alcohols, are much inferior to those made in this country from grain, not from wood, potatoes or other agents. I regret to state this is no longer the case. These latter are slow in evaporation, and are mixtures themselves, containing a large amount of carbonaceous products. The following are the results obtained, after numerous ex- periments, by the author, with as many of the agents employed in the various mixtures, and obtained from the reliable estab- lishments of Powers & Weightman, Bullock Wyeth & Bro. , and J. P. Remington : Alcoliol, absolute 95 (W. & Bro.), Alcohol, common (W. & Bro.), Chloroform (P. & W.), . Ether (Squibb's), . Ether, common, 0.750 (P. & W.), Ether, Hydrobromic (R), Methylic alcohol (B. & C), . Potato spirit,*- (B. & C), Temperature, 70 F. Barometer, 30.08. Time, 2 p.m. Danger from the Water Produced from Ether. Besides the danger from inhaling the ether pure and simple, there is another to be prevented ; that is, to get rid of the watery vapor from the mixture and also from the lungs of the patient, which collects on the sponge. If the napkin or inhaler is too close to the patient's mouth and nose, it will most effectu- ally prevent air from reaching the lungs. How is this to be prevented? By squeezing out the sponge, napkin, lint, or if an inhaler is employed that cannot thus be treated, casting it aside, and taking a clean napkin, with as much starch in it as possible, so as to keep it in shape. It has been well observed by Perrin : "We believe we shall render a veritable service if we popularize the idea that anaes- & Crenshaw, Min. Sec. 1 24 10 00 00 24 00 12 00 24 00 12 . 1 00 . 12 00 Passed through charcoal by W. & Bro. BRIEF EXTRACT OF EXPERIMENTS. 357 thesia should be observed and studied at the hospital with as much care as every other subject of practical medicine." Sansom also says: " The administrator should be experienced. Several hospital committees have acted wisely in appointing a chloroformist, a measure which is not of less value to the oper- ating surgeon than it is to the benefit of the patient. One who administers chloroform in any case should confine himself exclu- sively to the task he has undertaken, and should constantly mark the symptoms." What are the sj^mptoms of danger? The failure of the pulse, irregularity of the respiration, and the blanched countenance, and, as beautifully expressed by an old writer in reference to successful administration of anaesthetics : " Proceed steadily but cautiously to the end in view. He who makes haste slowly, and with a boldness tempered by wisdom,, carries his patient down into the dark valley which borders on death, drowns human agonies in the waters of Lethe, and tri- umphs in the crowning glory of his art. The Inlialation of Cliloroform and Ether a Cause of Aural Disease. Cases of deafness are reported by Dr. Charles E. Hackey, of New York, as having followed the inhalation of chloroform for complete narcosis for surgical operations. Dr. D. B. St. John Roosa, of New York, has also published that several cases of tinnitus aurium and loss of hearing have come under his observation, which were said to have been caused by the inhalation of ether for the purposes of anaesthesia. No such results have followed in our use of anaesthetics. Brief Extract of Experiments with a Mixtiu'e of Ether and Bromide of Ethyl and Chloroform Performed hy Drs. Reichert, Turnhull and Thomas, May 6, 1885. Experiments were performed first upon a rabbit, then upon a dog. In the first instance a mixture of ether and bromide of ethyl (.lij to Oj) was applied, and the animal prepared by in- serting a tube, to which a pulse indicator was attached, into the 358 ARTIFICIAL ANESTHESIA. carotid artery, thereby showing the regular action of the heart. The trachea was opened and a tube appKed. The nasal branch of the fifth pair of nerves was irritated, and inhibition of the heart's action was immediately shown, and when repeated cessation was almost produced. The animal was allowed to recover, after which it was proposed to apply chloro- form and repeat the test ; but almost simultaneously with the application of the chloroform the heart's action ceased entirely, showing the dangerous character of that agent as an anaesthetic. The post-mortem showed the lungs to be in a normal condi- tion, as were also all the organs except the liver, which was badly tuberculous, a condition frequently found in the rabbit. A perceptible heart-motion continued for some time after death, but with insufficient force to propel the blood, the indicator remaining perfectly quiet. In the second instance ether was applied to the dog with sim- ilar preparation as the rabbit, and with like result, after which he was injected with chloral, and a current of electricity was applied to the laryngeal branch of the pneumogastric nerve. The effect upon the heart was instantaneous to such an extent as to cause complete suspension of the pulsation. The result was the same when the current was applied to the pneumogastric, the continuance of which must have produced death. Mixed Ansestlietics. According to Dr. Wood it is probable that many of the diffi- culties which attend the use of ether can be overcome by put- ting in the inhaler, or the sponge, ethyl bromide and then ether, the patient passing insensibly from the bromide narcosis into that of the ether. We prefer much better the plan to commence anaesthetization with nitrous oxide to be followed with ether, and which is em- ployed by a few surgeons of this country. If the statistics which we give from St. Bartholomew's Hospital for this com- bination can be depended upon, in which 12,941 anaesthetiza- tions were given, there being but one death, this is one of the most conclusive proofs to our mind of narcotic anaesthetic prop- DR. w. atlee's mixture. 359 erties of nitrous oxide as not simply' an asph3^xiant that we have a record of. A second death was reported in the London Lancet^ 1896, of an individual under nitrous oxide and ether. Dr. W. Atlee's Mixture. It maj" again be inquired which is the best mixture to employ in ordinar}^ surgical operations when it is absolutel}^ necessary to employ such mixtures. The mixture C in midwifery. Mix- ture A, or, as it is familiarly known, A.-C.-E. or " ace-of-spades mixture," the most agreeable of all. In the operation for ovari- otomy we prefer the C mixture, as also advised by the late Dr. Washington Atlee ; the volumes of the two agents are so dif- ferent that they ought to be mixed b.y weight, not by measure, else chloroform will be much in excess, as it is a little over twice the weight of ether. In employing alcohol it should be as near to absolute as possible, and free from any color, smell or taste. The ether should be almost anhydrous, pure, full strength, and well washed. The late Dr. Atlee was of the opinion (which has been con- firmed) that there is a chemical union of the ether and chloro- form, for it has been found that, if this mixture was exposed to the light, a change took place which rendered the mixture not fit for the purposes of inhalation ; it, therefore, should be kept from the light, and mixed just before being emploj^ed. Perfectly dry chloroform decomposes but slowly, even in direct sunlight ; but the presence of water, which always exists in alcohol and ether, and the action of light at the same time, causes chloroform to decompose into formic and hydrochloric acids. CHCI3 4- 2H,0 = CH2O2 + 3HCL. We have had charge of the anaesthetic mixture (one part by measure of chloroform and two of washed ether) in an opera- tion by the late Dr. Washington Atlee, during the successful removal of an ovarian tumor weighing forty pounds, and have also assisted him in three cases, in which others gave this same mixture, with good results, and with no apparent risk to the safety of the patient. Dr. Atlee always administered the anassthetic after the patient was upon the operatirig table, and one individual had charge of 360 ARTIFICIAL ANyESTHESIA. and was responsible for it. In his three hundred ovariotomies, he informed me he had never lost a patient by the anaesthetic. The mixture is given, in almost ever}^ instance, by means of the starched towel. The following experiments were made to determine the ac- tion of ether and chloroform when mixed : When ether and chloroform are mixed there is an elevation of temperature, and the greatest heat is produced when the mixture is made in equivalent parts ; that is, by weight, about nine and one-quar- ter parts of ether to thirteen and one-quarter parts of chloro- form. As the chloroform is more than twice as heavy as ether, the volumes would be about one and four-tenths chloroform to two of ether. But little contraction in volume takes place, and it may be considered that molecular combination takes place between the chloroform and ether. The mixture begins to boil at 50° to 51° C, and may be separated into its constituents by fractional distillation ; but when allowed to evaporate sponta- neously, as when used as an anaesthetic, both liquids pass into vapor simultaneously. Whatever mixture is employed, nothing will obviate the necessity of care in the administration, and, above all, do not give more of the agent than is absolutely necessary to keep the patient free from pain ; not one drop more ; for, like all patent medicines which we employ, an excessive dose is sure to kill, and unless we have before gauged the patient's powers, let caution be our guide in the administration of so powerful an anaesthetic. In our anxiety to see the various steps of an ope- ration, we must not saturate the sponge or lean over the patient, and by accident suffocate him. It is, unfortunately, too much the practice to entrust the inhaling apparatus to some inexperi- enced hand, who, perhaps, never before administered an anaes- thetic, and even in some hospitals to the youngest assistant surgeon or dresser. An Albstract of the Reports of Kecent Deaths from a Mixture of Ether and Chloroform. The death of a lady had occurred in the practice of Dr. Eastham, a dentist of Boston, causing much excitement in professional circles. The death had taken place about noon, REPORTS OF RECENT DEATHS. 361 but very few, except those particularly interested, were aware of it till the next day. The coroner, Dr. Ainsworth, who was called in directly after the accident, formed a jury of physicians and apothecaries, and ordered an autopsy. This was made the next morning by Dr. R. H. Fitz, pathologist to the Massachu- setts General Hospital, and on the same day the jury met and, having viewed the body, adjourned until the 14th. The anaes- thetic was either chloroform or a mixture of chloroform and ether. The latter proved to be the one used. The jury met again on the 14th, and, having heard a part of the evidence, readjourned till the evening of Wednesday the 19th. Instead of death resulting from ether, it was, as proved by the analysis, due to chloroform^ and the coroner's jury presented the follow- ing verdict: "Death was caused by the inhalation of chloro- form, administered in a mixture of chloroform and ether." Dr. Henry Buren, of Chicago,^ gives the following version of a death which took place in that city from the inhalation of a mixture of ether and chloroform : "3Irs. B. , aged 32, American, had suffered from fistulse in ano for six months. On the 22d of November last I operated on her, finding at this time two artificial openings into the rec- tum, one on either side of the anus. Dr. A. Groesbeck admin- istered the anaesthetic, which consisted of equal parts of sul- phuric ether and chloroform. The operation was performed in a few seconds. The patient exhibited no alarming symptoms while under the influence of the anaesthetic, and revived in the usual time. " On the morning of the 30th of November, eight days after the operation, I desired to make a thorough examination of the wounds and renew the dressing, and in this, as in some of the previous dressings, the patient insisted upon partial immu- nity from pain. To this end I commenced to administer upon a napkin two parts of sulphuric ether and one of chloroform. After a few inhalations the patient became violently intoxi- cated, and resisted, with great force, all efforts to quiet her, de- manding, in the language of one in delirium, to be let alone. * Chicago Medical Journal, February, 1878. 24 362 ARTIFICIAL ANESTHESIA. I immediately ceased to administer the anaesthetic, and with great effort prevented her from jumping from the bed. The face became at first turgid, the whole body convulsive, and in a few seconds the patient was dead. "All of the means usually resorted to were employed to re- store action of the vital functions ; artificial respiration, ele- vating the lower extremities, dashing cold water in the face, drawing forward the tongue, spirits of ammonia applied to the nostrils, and finally a galvanic battery, which was conveniently at hand, but to no avail. "I have to say, in justice to the record of this case, that the patient had for many years habitually partaken of opium. At the time of her unfortunate death she could take at each dose from two to three grains of morphia. During the time she was under my care one-half grain doses of morphia were prescribed at proper intervals, but she asserted that this quantity did not sufficiently support her, and through her nurse, and by stealth, she secured additional quantities from the neighboring drug stores, and took the same daily without my knowledge or con- sent. " I am now of the opinion that the patient had taken an un- usually large dose of morphia on the morning of her death, and that the combined influence of this overdose and the additional paralyzing effects of the anaesthetic caused cardiac syncope, and that this was the cause of death. "A woman, aged 46, extremely fat, and of slow intelligence, although having complained of shortness of breath, was not known to be the subject of organic heart disease. She was to be operated upon for senile cataract. A mixture of chloroform and ether, in a modified Clover's apparatus, was being admin- istered by the house surgeon. From the commencement of the administration respiration was noticed to be shallow, but there was struggling. The pulse was feeble, but not intermittent. There was some slight lividity of cheeks and forehead. Chlo- roform was at once removed and a few whiffs of pure ether administered as a stimulant. Other means for circulation were tried, but in vain ; the patient died. At the post-mortem ex- amination the heart was found flaccid and empty, the mitral REPORTS OF RECENT DEATHS. 363 valve was contracted, the aortic valves were incompetent, kid- neys fatt}" and granular.* "In the spring of 1865, while stationed at the U. S. A. ' Summit ' House General Hospital, Philadelphia, the staff were performing an amputation of the leg. At the suggestion of Surgeon Joseph Taj'lor, in charge, the A. C. E. mixture was used.f The anaesthetic was administered b}" Surgeon A. A. Leavitt, executive officer of the hospital. During the opera- tion the patient's respiration failed. The condition became so alarming that the operation was temporarily discontinued, and all present turned their attention to restoring the patient. Artificial respiration, cutaneous excitation and inhalation of fumes of ammonia, fortunatelj', were successful. The opera- tion was then finished, with the patient only partially uncon- scious. For many years I had not used this mixture, using either ether alone, or the mixture of ether two parts, chloro- form one part, by weight ; or, rarely, chloroform alone. "During the past two years I have, on several occasions, used the A. C. E. mixture with gratifying results, being led to use it again by the favorable reports given by various authorities. During the summer of 1886 I was removing cancerous mam- mary and axillary glands, assisted by Drs. Martin and Chesney, of Cairo, West Virginia. To Dr. Chesney was intrusted the administration of the anassthetic, which was the A. C. E. mix- ture. During the operation I had requested him to discontinue the anaesthetic, as the patient was sufficiently under the influ- ence. This he did ; he had his finger on the pulse, and devoted his entire attention to the patient's condition. The mammary gland had been removed, care being taken by Dr. Martin to prevent entrance of air into the veins. I noticed the extreme pallor of the patient's face, and simultaneously Dr. Chesney said the pulse had failed, so as to be inappreciable. I imme- diately placed a bottle of nitrite of amyl to her nostrils ; respi- ration was good. Asking Dr. Martin to hold it there, I prepared a hypodermatic syringe with 20 m. of tr. digitalis, and injected it into the prsecordial region. Dr. Martin meantime * Med. Times and Gazette, August 18, 1876. t W. H. Sharpe, M.D., Medical News, March 5, 1887, p. 257. 364 ARTIFICIAL ANiESTHESIA. announced a slight recovery of pulse. I next administered several sj^ingefuls (hypodermatically) of whiskey, and we had the pleasure of seeing the patient rally from this heart-failure, due, I think, to the depressing influence of the chloroform. It was carefully administered — with a sponge in a cone — i.e., a towel stiffened with a sheet of paper in its folds ; the sponge was held in its place in the apex by transfixing with long pins to prevent it falling down on the patient's face. The chloro- form and ether were of reliable manufacture. It afterward developed that at this time the liver was involved in secondary cancerous inflammation, to which the patient succumbed a few weeks after recovery from the operation. "A more recent case of death from a mixture of etJiefr and chloroform is reported in the Philadelphia Medical Times, March 15, 1879, by I. A. Cleary, Assistant Surgeon U. S. A. Private H. D. B., Co. 19, U. S. Infantry, aged 33, large, robust ; addicted to liquor. Injury of middle finger, right hand, resulting in gangrene ; decided to amputate. A mixture of equal parts of ether and chloroform {weight or measure not stated). Two ounces of whiskey were given ten minutes prior to inhalation. The anaesthetic was administered on a piece of lint covered with a small towel held square. He personally ad- ministered the mixture, while the steward observed the pulse ; air was freely admitted ; he inhaled freely. About two drachms were first poured on the cloth, but with no apparent eflFect Qie^ evidently^ receiving nothing hut ether). Shortly after about the same quantity was poured on ; he observed that ' he did not feel it. ' After a time about the same quantity was again poured on. A further quantity was poured on the cloth (say, in all, ^viij), when he began to laugh, followed by attempts to articu- late, and made strong gesticulations with his arms. He now passed to a state of unconsciousness, when the pulse was not perceived. This was followed by relaxation and death. At once the anaesthetic was removed ; cold water dashed in the face. He adds, ' Everything I ever heard of, saw or read, appropriate for such a case, was done, but to no efi"ect. ' He states as the cause of death paralysis of the heart (I think it was syncope from the chloroform)." ADMINISTRATION OF NITROUS OXIDE AND ETHER. 365 How Shall Nitrous Oxide and Ether be Adminis- tered? Dr. Frederick W. Silk, of London, an anesthetist of wide experience, has invented a useful apparatus for the production of anaesthesia by the combined method. In placing his inven- tion before the profession, Dr. Silk himself comments on the striking similarity in the principle applied by him and that of Dr. Hewitt, who had pursued an independent line of work. The only difference between the apparatus of Dr. Silk and that of Dr. Hewitt is, that the valve arrangement between the face- piece and the ether-chamber in Dr. Hewitt's apparatus has been transferred by Dr. Silk to the face-piece itself, where it is con- trolled by the fingers of the hand holding the face-piece in position. Dr. Silk and Dr. Hewitt have both attained a method greatly superior to the usual one of an ether chamber suspended around the neck, and connected with a face-piece by means of the bag inclosing the tube. Dr. Silk, however, considers the new method still defective, because of the difficulty of adminis- tering nitrous oxide with a mere " whiff" of ether, as in dental work. The ether-chamber, when charged so that the indicator stands at 0, is so constructed that it is almost impossible, in warm weather especially, to prevent a very distinct and disa- greeable odor of ether from pervading the face-piece at all times. Dr. Silk saj's that this apparently trifling objection becomes a serious one in the treatment of nervous and excitable patients. Another difficulty is the total exclusion of air, which is so important a feature in the administration of nitrous oxide. Complicated mechanism— valves, stopcocks, chamber and pipe adjustments render this total exclusion difficult just so soon as the effects of wear and changes of temperature are manifest in the apparatus, and notably toward the close of the administra- tion, when the bag is becoming empty, and the inspiratory effort is greater. Dr. Silk says that the gas reservoir should be brought as near the mouth as possible in all cases, and espe- cially when it is narrow, with various divisions made by joints, valves, etc. There is always the possibility of leakage, and gas is moreover but feebly mobile. 366 ARTIFICIAL ANESTHESIA. In cases where nitrous oxide and ether are administered in succession Dr. Silk finds his apparatus often useful in abolish- ing the pulmonary spasm, and the struggling which is manifest in the later stages of narcosis ; but he expresses disappoint- ment that these phases have not been entirely abolished, and that in some instances they have seemed to be intensified. This he attributes largely to the greater rapidity with which nitrous oxide narcosis is produced, as compared with that following • ether, the former growing quite profound before the latter has reached the first stage. The consequent necessity for admitting air at that period retards the development of the final stages of ether narcosis, and prolongs or even intensifies the stage of struggling and excitement. In commenting on Dr. Hewitt's and his own apparatus, Dr, Silk saj^s : "I am bound to con- fess, however, that it is a very distinct improvement on old methods, and that I still continue its use." — Medical Register^ October, 298. Mixtures of Nitrous Oxide, Etliers, CWoroforni aud Alcohol for Inhalation. In our numerous experiments with the various angesthetic agents we have always found it difl&cult to make any true chem- ical combination. Most of the vapors diifer very much in density, and are given off at different temperatures, the vapor of chloroform being four times heavier than air ; and unless some means are employed to keep them in motion the denser vapor will gravitate to the bottom. Such is also the case with the liquid anaesthetics. They will, when shaken up, look, for the time, a perfect mixture ; but if allowed to stand, the heavier liquid, like chloroform, will sink to the bottom, and if the bot- tle is not well shaken each time when used the patient is apt, during the conclusion of a tedious operation, to receive the chloroform almost pure. The combination of nitrous oxide with ether had been carried out in England for many years, and we have given a description of Clover's apparatus, with his careful directions for use. Then we have the useful inhaling apparatus of Dr. Buxton, of London, with a reference to that of Drs. Silk and Hewitt ; also that of Drs. Codman and Shurt- MIXTURES FOR INHALATION. 367 leff, of Boston. Another convenient attachment has been arranged by Dr. A. M. Long, by which the nitrous oxide gas is condensed into a liquid, and then mixed with ether, drop by drop, in a combining chamber. This apparatus has been em- ployed, to a limited extent, at the Philadelphia Dental College, combining from twenty to thirty drops of ether to five gallons of the gas. It is well known that both nitrous oxide gas and ether are stimulants, and this combination should never be given to persons of full habit or flushed face, for fear of overaction of the vessels of the brain, producing convulsion or apoplexy. Mixtures of chloroform and nitrous oxide, or chloroform, alco- hol and nitrous oxide, in the proportions of from five to six drops to five gallons of the gas, have been employed ; but the fear is that unscrupulous persons would not limit themselves to this quantity, but would use a larger proportion, running the risk of destroying their patient. We have already given our opinion of preparatory anaes- thetic combinations of various agents to disguise the taste and smell of the anaesthetic, under bromide of ethyl, and would advise all persons administering anaesthetics to be sure of the agent they employ, so as to be able to counteract any dangerous element. A mixture of nitrous oxide and ether vapor would explode on contact with flame or even a spark. It would not be spon- taneously explosive, and would not be more dangerous than a mixture of ether vapor and air. 368 ARTIFICIAL ANESTHESIA, Junker's Iiilialer. Plate 50, There should have been inserted at page 246 this plate of Junker's Inhaler for Chloroform, a full description of which will be found on that page. SOUCHON S IMPROVED AN^STHETIZER. 369 Soiiclion's Improved Anaestlietizer. [The cuts in this article were not received in time to be in- serted in the paper on page 178. "We therefore repeat a portion of the description which had to be omitted at that time.] Plate 51. Fr^n "Description of Apparatus.— The present improved appa- ratus is considered perfect in all particulars. It is composed of 370 ARTIFICIAL ANAESTHESIA. a glass cylindrical receptacle, with a frame supporting a ring, A, for the thumb and a rubber bulb, B, so that it can be worked with one hand. From the bulb originates a rubber tube, C, wrapped with coiled wire to prevent it from bending ; it ends in the inlet-tube, J) ; just at the point of junction, at E, is a ball-valve which prevents the liquid from entering the bulb when the pressure upon the latter is released. The inlet-tube extends through the liquid anaesthetic to the very bottom ; its lower end is bevelled to prevent the orifice from being stopped by coming in contact with the bottom of the receptacle. "This inlet-tube slides up and down through another shorter tube, D\ so that it can be drawn well up above the level of the liquid anaesthetic, thereby diminishing the strength of the vapors injected through the outlet-tube into the pharynx. This feature makes the apparatus thus set an ansesthetizer of the first model. ' ' The receptacle is closed by a metallic lid that screws around its neck ; a washer makes it air-tight. "From this lid springs the metallic portion of the outlet-tube, F ; it originates directly from the under surface of the lid ; it is i inch in diameter inside and 1 i inches in height ; after a very sharp curve of 90°, it terminates by an orifice of not loss than 3^ inch." PART FIFTH. CHAPTER XII I. Local Anaesthesia and Aneesthetics, Electrical Osmosis aocl Cataplioresis. Local anaesthesia has for its object to abolish the sensibility of the skin and other parts of the body. This is accomplished by certain local anaesthetics or substances which diminish the sensibility of the part by their contracting influence upon the peripheral or surface nerves or filaments of the deeper-seated nerves. The use of cold was one of the earliest and most effi- cient means of producing local anaesthesia, either in the form of snow or ice, with or without the chloride of sodium, or common salt, which was mixed with the broken ice and applied in a bag of linen, or now in a better form by the use of a rubber bag, which is arranged both for the convenience and comfort of the patient. The injection of ice-water is also used as a local anaesthetic. Then followed soon after their discovery, and to obviate the dangers of a general anesthesia, the use of chloroform, ether, bromide of ethj^l, rhigolene, carbon bi- sulphide, absolute alcohol, carbonic and carboHc acids, hydro- chlorate of ammonia, also the bromide and sulphate of am- monia. The iron salts, particularly the sesquioxide, have an anaesthetic action without producing coagulation at the point of introduction. Acetate of lead is also an anaesthetic, and among organic substances, hydroquinine, resorcin, antipyrin, substances belonging to the digitalis group, and serpent venom, in small doses. Essential oils, such as oil of turpentine, hydrate of ter- ebene, eucalyptol, oil of chamomile flowers, and a number of others, have a remarkable effect, according to Dr. Liebreich, who states that these substances act by destroying the nerve ends and by irritating the neighboring parts, causing what has been called "'painful anaesthesia." Many of these agents act 372 ARTIFICIAL ANESTHESIA. by entering the circulation, and others by their direct effect upon the tissues. With regard to the cornea, there are two kinds of anassthesia by subcutaneous injection of the dorsal re- gion in rabbits and guinea pigs ; for the eye^ by allowing a few drops of the substance in solution to fall on the cornea. In preparing solutions, even of distilled waters, we must remember that the water acts as a caustic, and must be sterilized. The most important and valuable of all these local anaesthetics is cocaine, which causes no pain. It is, however, followed by contraction of the vessels. Electricity as a Local Ansestlietic Alone or witli Cocaine. The pain felt during the extraction of a tooth is lessened by the emploj^ment of rapid respiration (Bonwell's method), vio- lent muscular effort, or vibration. A still more powerful ad- junct is electricity applied along the course of the nerves. The Faradaic, or interrupted galvanic current, was at one time em- ployed in this city to produce a local anaesthesia. This employ- ment of electricity has been revived by Dr. I. Corning, of New York, by first perforating the skin with needles with the instru- ment of "Baunschiedt," and then applying over the surface a sponge electrode saturated with a two per cent, solution of hy- drochlorate of cocaine. This should be kept connected with the battery from three to four minutes, and be of sufficient intensity to cause a slight sensation of heat. It has been found safer, and that the method can be made more efficient, if the surface be blanched by the pressure of Esmarch's rubber bandage, as by this means strong solutions of cocaine can be employed with more safety. Electrical Osmosis for tlie Treatment of Living- Dentine.* Electrical osmosis, electrical diffusion, anodal diffusion, and cataphoresis are terms used by different authorities to express nearly the same phenomena. * Eead before the New York Institute of Stomatology, November 26, 1895, by Henry W. Gillett, D. M.D. Reprint, Newport, February, 1896 ; also International Dental Journal, February, 1896, OSMOSIS FOR TREATMENT OF LIVING DENTINE. 373 The first three terms will be recognized as entirely synony- mous, and need no defining to make them intelligible. Electrical osmosis, the one chosen for my title, is probably the one having the widest acceptation among electricians. Cataphoresis is a medical term which has come into use among electrotherapeutists, and is recognized by few electrical experts outside of those interested in medicine. The definition of the term given by Dr. "William J. Morton* seems to cover the ground fully. It is this : ' ' The movements of fluids, together with the substances they hold in solution, from the positive pole of electrodes conveying a continuous current in tissue towards the negative pole." "When we consider this definition in connection with the human tooth, which generations of our profession have been striving to penetrate with some drug which should modify its sensitiveness, or with applications which should modify morbid conditions of the tooth-pulp, it becomes at once important, and, indeed, imperative that we make use of this principle, if we find it possible to do so. It is not necessary for me to mention before this audience the many advantages to accrue, for both patient and operator, from any feasible and harmless method of subduing the sensitiveness of the dentine of the human tooth. " It is equally unnecessary for me to enumerate the many dif- ferent means that have been tried to attain this end. It has not always happened that the means which have been tried and found helpful have proved harmless. The ill results from the use of arsenic and the strong mineral acids are examples of this fact. I have been amazed, within a year or two, to find a set of these so-called obtundents indorsed by members of our pro- fession of recognized standing, which are of a most pernicious character. Upon applying to them simple tests within the reach of every intelligent operator, they reveal the fact that their efficiency is due to the most corrosive mineral acids. ' ' Of course, every progressive operator has certain applications which he uses with success in some percentage of cases, but I * Cataphoresis and solution of H2O2 for bleaching teeth, etc., Den- tal Cosmos, June, 1895. Note also the terms electric diffusion and electric medicamental diffusion, proposed by Dr. W. J. Morton. 374 ARTIFICIAL ANAESTHESIA. think it is the universal experience to find that, in many of the cases where we need help most, none of these applications are of much assistance. "For several years I have been taking a keen interest in a method of applying drugs to sensitive dentine, which seemed to promise a more universal usefulness than anything which we have before had at our command."* Dr. Gillett sums up the results of his experiments as fol- lows : Ten per cent, aqueous solution of cocaine applied on the positive electrode with a weak electric current for a few minutes will anaesthetize the skin. (Experiment No. 1.) A similar cocaine solution applied for the same time without the current has no angesthetic effect. (Experiment No. 2. ) The same electric current without the cocaine has no anaes- thetic effect. (Experiment No. 3.) Cocaine solutions of from fifteen to twenty-five per cent, ap- plied in sensitive cavities for ten or twenty minutes do not modify their sensitiveness. (Experiments Nos. 4, 5, 6. ) The electric current alone applied to sensitive dentine, sodium-chloride solutions of varying strengths being added to insure good electrical connections, does not perceptibly modify the sensitiveness. (Experiments Nos. 8, 9, 11.) Cocaine solutions and the electric current applied to sensitive dentine, together, do completely anaesthetize it ; consequently the cocaine is the active agent. (Experiments Nos. 7, 10, 12.) This treatment renders it possible to do for these nervous and hypersensitive organizations desirable operations, which, without some such means, are utterly impossible. It also en- ables the operator to perform much more satisfactory opera- tions for sensitive children from twelve to sixteen years of age, and to do these operations (which would otherwise be entirely too formidable to contemplate) with no objection from the little patient and with no danger of exhaustion afterwards. The effect of the cocaine in these applications does not seem to reach deeply into the dentine in most cases. By prolonging * Dr. Gillett gives a full resume of wliat had been done prior to his own experiments, which we have not space to give, but would recom- mend our readers to the original paper. OSMOSIS FOR TREATMENT OF LIVING DENTINE. 375 the application, however, the pulp itself may, in favorable cases, be anaesthetized, even through a layer of dentine. It is quite often the case that a ten- or twelve-minute appli- cation will anaesthetize the dentine deeply enough to allow the greater portion or all of the cutting to be done painlessly, but for deep grooves it may be necessary to repeat the application. In cases where there is much sensitiveness, and consequently much time will be required to prepare the cavity at all, I find the time required for applying the cocaine is fully made up by the increased speed possible after the sensitiveness is under control. " As to the time the cocaine effect persists, I find it difficult to get accurate knowledge. I am not always able to be certain whether renewed sensitiveness is due to penetration through the anaesthetized layer or to returning sensation. I had ex- pected that the effect would be more lasting than cocaine effects in tissues, where the circulation is more rapid. I have, how- ever, seen- one or two cases where there had been a profound effect produced and where there was a return of the sensitive- ness in fifteen or twenty minutes. " As to the effect upon the pulp or the tooth, I have examined some of the teeth where the first applications were made, and I am unable to find any trace whatever of a permanent change in their condition. " Some of my first work with cocaine and electrical osmosis was done in my own mouth. Stronger currents were used than I dare to apply in the mouths of my patients, and deep anaes- thetic effects were obtained. No ill results have followed, and the tooth is normal in its sensitiveness after nearly a year's test. As to the applicability of the method, I find that it is almost universal. The exceptions are in the cases of the com- paratively rare subjects who are not readily affected by cocaine, and the occasional case where the difficulties of insulating the tooth or cavity are too great. "This latter class of cases will be much smaller in the hands of the expert operator, and this added necessity for the rubber dam will stimulate the operator's ingenuity in applying it in difficult cases. I very seldom find a case where I am unable to use the method with success, if I desire to do so. 376 ARTIFICIAL ANAESTHESIA. " In my use of electrical osmosis I have found a single patient who is so sensitive to the current as to be only able to take a seven-volt current as a maximum. For her I readily anaesthet- ized a bicuspid so as to remove a portion of the pulp, but a large molar cavity required a long application, and was only a partial success. " As to deep anaesthetic effects about the roots of teeth, I have not met with success in the limited trials I have made. I have received numerous queries as to the use of the inethod for ex^- tracting, but I see no probability of its replacing the present methods for that purpose. I have made one or two attempts to reach the nerve branches entering the tooth by applying the electrodes on opposite sides of the gums. The results were not encouraging, and in the case where my most determined efforts were made I produced a decidedly objectionable result in the breaking down of the gum tissue under the positive electrode. I have, however, obtained satisfactory results from cocaine cataphoresis on the sensitive gum about roots undergoing prep- aration from crowning. "It would seem to me feasible to treat by electrical osmosis that very troublesome condition resulting from undue wear or erosion of the grinding surfaces of molar teeth, where the sen- sitiveness is almost a menace to health, by reason of its pre- venting proper mastication, and where it defies the action of the most violent caustics. ' ' For doing this work I have had made the instrument you see before you, technically an adapter or fractional volt selecter, the working of which I will explain. ' ' A milliampere metre is also almost essential. This selecter is intended for use with the Edison one hundred and ten volt continuous current. I have the Electro -Therapeutic Company at work devising a battery apparatus for use instead of the Edison current. I have not used batteries because I did not want to have the care of them, but when the incandescent current is not accessible, battery systems with a capacity of thirty or more volts may be successfully used with suitable modifying apparatus. " First, let me enumerate the precautions necessary in using the one hundred and ten volt current." OSMOSIS FOR TREATMENT OF LIVING DENTINE. 377 Have the selecter connected according to the instructions provided with it. An absolute safeguard, but one not necessary if connections are properly made, is to insulate the chair by placing linoleum or rubber under its feet, and also to see that gas pipes, water pipes, and any other wires are out of the reach or protected from contact. " I always apply the rubber dam, as it is difficult, and often impossible, to prevent leakage of current through other tissues if this is not done. "Any metal fillings which will be in contact with the wet cotton in the cavity or with the electrode must be covered. The current from a metallic surface into dentine is irritating and painful. I find Gilbert's temporary stopping a very useful mate- rial for this purpose. Wax will also do. In caises where I am working on an approximal cavity in one tooth, and a filling in the next tooth is too close to allow of its satisfactory insulation, I apply the rubber at first onl}'^ over the tooth to be worked upon, thus insulating it completely ; or, if the rubber is already in place, a second rubber may be applied over the tooth to be worked upon. The positive electrode should be of platinum, as most other metals are affected by the current and are liable to stain the tooth. " These conditions being provided, see that j^our current is turned on. I always test this by touching the metal parts of the electrodes together, and watch the milliampere meter to ob- serve the result. ' ' "This selecter is so arranged that when the needle is at zero, and contact of electrodes is made as described, about one mill will be recorded. Getting this result insures the operator that all connections have been made and that the apparatus is ready. If, however, a larger quantity of current is indicated by the milliampere meter, it shows that the rheostat contact is not at the right place. This same proceeding would also serve to de- tect any break-down in the rheostat if it had occurred. Twenty seconds serve to assure the operator on these points if his appa- ratus is conveniently placed. I then wet the negative sponge electrode with water or dilute salt solution. I place in the 25 378 ARTIFICIAL ANESTHESIA. cavity a pellet of absorbent cotton saturated with a twenty to thirty per cent, cocaine solution. I prefer not to have this cotton extend outside of the cavity, and to keep the solution confined to the cavity as much as possible. This concentrates the current in the part I desire to affect. "The negative wet sponge electrode I usually allow the patient to hold most of the time. It is preferable to be applied about the face or neck, as near the tooth as is convenient. Having placed this and allowed the patient to take it, I apply the posi- tive electrode to the cotton in the cavity and begin slowly to increase the current by turning the large fibre knob of the rheostat head in the direction indicated by the needle which records voltage. The first consciousness of the current some- times comes to the patient as the typical little * kick ' or ' kink ' of the -galvanic current, but it is a very small one with this selecter. More often the patient is only conscious of an indefinite, gradually increasing pressure, and if the current is pushed too rapidly this may increase to pain. It is therefore necessary to watch the patient carefully, and to pause in the turning-on process as soon as the change in the eye of the pa- tient indicates that he is beginning to feel the current to an uncomfortable degree. "After the first experience, if cautiously managed, a patient will usually give the operator all necessary indications for his guidance, and allow him to keep the current up to a point just short of pain. "After one experience with it the sensation is readily borne, even by sensitive children of twelve or fourteen. In fact, they are often the most enthusiastic about its use. "As the operator pauses at the point where the patient indi- cates that he is getting enough, or even turns back a little if there is too much current, it is well to assure the patient that any disagreeable sensation will subside promptly. It usually does this in from one-half minute to two minutes, and then the voltage may be increased slowly and gradually, with pauses long enough for any disagreable sensation to disappear. " Subjects differ very much in the amount of current they will -bear without discomfort. It is usually found, however, that by OSMOSIS FOR TREATMENT OF LIVING DENTINE. 379 very gradual increase, and by taking more time to reach the maximum in these sensitive cases, a sufficient amount may be applied to any case to attain the result of anaesthetizing the dentine. "It is my customary habit, as soon as I have opened into a sensitive cavity, to make an application lasting from eight to twelve minutes. If I have reason to expect difficulty with the case I make the application longer. If the first application is not sufficient for all I wish to do I repeat it later. " I have some ten or twelve cases on record where twenty to thirty minutes have been needed to get sufficient effect. These were all cases where both patient and operator felt compensated for the time spent. Most of them were either extremely sen- sitive teeth or subjects who could bear but little current, and several of these cases would have been all but impossible with- out the aid of this method. "On the other hand, I have numerous cases where ten or even eight minutes have been ample time for successful results. ." Having reached a voltage likely to be sufficient, I allow it to stand at that point till the end of the application. "Fifteen to twenty volts will usually be attained in seven or eight minutes. In many cases, with small cavities and little sensitiveness to the current, twenty-five or thirty volts may be marked in the same time. "The higher voltage works more rapidly. "At the end of the application I usually break connection at the negative electrode, as there is less often any shock in so doing. If the subject is very sensitive to the current, I turn the voltage down low before breaking connection. "Having concluded the application, I turn off the current in the selector by means of the switch. This lever may also be used for concluding the application of current if you find no objectionable shock resulting. "Then I test the cavity, and finding it all right proceed as usual, bearing in mind that the effect may not have gone as deeply as I wish to go with my instruments, so it is still neces- sary to watch for signs of returning sensitiveness. "The expert electrical knowledge required for this process is 380 ARTIFICIAL ANESTHESIA. not such as to be a formidable obstacle to any skilful prac- titioner. The instructions provided will serve to arm him with sufficient knowledge for his first cases, and the other needed knowledge will come to him quickly as he goes on with his work. "In connecting this selecter, it is only necessary to screw the plug provided into a lamp socket, and place the cords in the binding posts. Carry the wire from the positive binding post to the binding post of the milliampere metre, which is marked + (positive). Connect the cord attached to the positive plati- num electrode to the other post of the milliampere metre, then lead the cord of the negative electrode from the unused post of the selecter. "The electrodes may be readily detected by passing a current through a small piece of wet litmus paper. The positive pole will be found to redden the litmus, while the negative turns it blue." The author reports a number of interesting and successful cases. After a year's employment of electrical osmosis or cataphore- sis by the method proposed and kindly explained in the pres- ence of several well-known physicians and dental doctors by its author, Henry W. Grillett, D.M.D., it has been found by a good number of practitioners to be an efficient aid, particularly applicable to the cases of most extremely sensitive dentine. Guaiacol-Cocaine Cataplioresis. In a recent address before a New York dental society, Dr. James Morton described a method of producing local anaesthe- sia"^ more rapidly and more profoundly than by any means before known to him. This was by the use of guaiacol as a solvent for hydrochlorate of cocaine, and caused to penetrate tissue by the aid of the electric current, upon the principle of electro-physics cataphoresis which we have before referred to. The writer states that electro-guaiacol cocaine anassthesia re- * The Dental Cosmos, January, 1896, No. 1, page 48. CONCLUSIONS. 381 quires two-thirds less time and two-thirds less current than aqueous solution of cocaine used by the cataphoric method. The formula for the mixture is : ^ Guaiacol, 5j. Cocaine hydrochlorate, gr. M. These quantities constitute a strong solution, containing from eight per cent, of cocaine to thirty-two per cent., and can, if desired (but we trust will not), be used without a great amount of care on the part of the operator. Having already experimented with this new preparation on the skin and mucous membrane, he then employed it in produc- ing anaesthesia of sensitive dentine, and he states with perfect success in cases reported. He employed a new " fractional volt selecter " of the Electro- Therapeutic Co., which he states worked perfectlj^, controlling device of the current from the street mains. x\lso a new cata- phoric electrode, b}^ which the application is made to both sides of the gum. Conclusions.* "1. Electric medicamental diffusion (' cataphoresis ') is not only a possible but a practical procedure ; since, "2. Sensitive dentine may, with the greatest ease, be so thoroughly anaesthetized that operations upon it and in it cause no pain. '* 3. The dental pulp, even though not fully exposed, may be anaesthetized so that instruments may enter the pulp cavity without causing pain. "4. By emploj^ing a properly constructed electrode, soft tis- sues like the gums may be completely anaesthetized. "5. Soft tissues, like large areas (three inches by one and one-half inches by one-half inch deep) of the derma and sub- jacent tissues, may be completely anaesthetized for surgery." This can be done without any current, by the Schleich method. * Dental Cosmos, January, 1896. 382 ARTIFICIAL ANAESTHESIA. " 6. Gruaiacol alone and other similar substances and deriva- tives in themselves non-conductors of electricity, by the addition of a very minute quantity of some innocent substance of an elec- trolytic nature, may be caused to penetrate tissue by the aid of electricity, and thus exhibit anaesthetic effects unobtainable without the aid of the added electrolyte. " 7. Guaiacol restrains the action of cocaine to local territory ; increases the rate of its cataphoric penetration through the epi- dermis and other tissues ; shows the rate of its absorption into the system ; prevents consequent toxic effects ; and adds its own anaesthetic qualities to those of cocaine. ' ' After considerable use of guaiacol (see page on guaiacol) by the dental profession, it was found at times, either from impurities or its own nature being a creasote, a form of carbolic acid, to act as an irritant and caustic, so that it is no longer employed alone, but with fifteen per cent, of anhydrous hydrochlorate of cocaine, and termed guaiacocaine."^ Dr. E. C. Kirk, of Philadelphia, and W. J. Younger, of San Francisco, report excellent results from the use of guaia- cocaine. I)r. Kirk says that complete anaesthesia was produced in six and a half minutes, using a current varying from one-tenth to four and a half milliamperes. At the Post-Grraduate School and Hospital, New York, Dr. F. N, Wilson removed a large pigmented naevus from a patient. The naevus was three inches long by one and a half inches broad, and complete anaesthesia was obtained in five minutes, using the electric current as an adjunct. No pain was felt during the operation, nor whilst ten deep stitches were being inserted to close the wound. Regarding this operation, Dr. Morton says : " It is noteworthy in this case that the anaesthetic effects extended at least one-half an inch deep, and that there were no toxic effects of cocaine (a sixteen per cent, solution in guaiacol was used). The absence of toxic effects seems to me to be due to the fact that the guaiacol holds the cocaine in solu- tion, thus localizing its action and preventing its diffusion into * McKesson & Eobbius, New York. CONCLUSIONS. 383 the circulation. This, if a fact, and it seems to be one, is of the highest importance, since the onl}' objection which could be raised to the use of cocaine so extensively, and of such strength as described in the above instance, would be the danger of the absorption of a poisonous dose, especially in a highly vascular tissue, such as the naevus operated upon." Prof Michaux, in speaking of local anaesthesia, recommended the trial of the new combination of guaiacol and cocaine : " Guaiacol is one of the best solvents of cocaine, and being itself a slight local anaesthetic and non-conductor, it intensifies the action of the cocaine. It is also more profound in its action and is deeply penetrating. Its cataphoric application is also said to consume two-thirds less time and current than the sim- ple cocaine solution. The sixteen per cent, solution appears to be the strength most commonly preferred. " Besides producing an anaesthetic condition of the skin and mucous membrane, it has been used with perfect success for inducing anaesthesia of sensitive dentine." — University College Bulletin. These powerful preparations of cocaine are not free from danger when used on soft tissues, or even on sensitive dentine where leakage through the rubber dam may occur, and a poison- ous dose be swallowed which might prove very serious, especially in the case of a delicate person. PART SIXTH. LOCAL. ANESTHETICS. CHAPTER XIV. Coca Plant, Leaves — Preparations, More Especially the Wine Made from the Leaves, also the Active Principle — Cocaine : Its Action as a Stimulant of the Nervous System and Eetarder of Meta- morphosis — Cocaine and its Salts, Solutions, Tests of Purity — Cocaine Inebriety and Habit, Treatment — Death from Cocaine. Erytliroxyhn Coca ; Folia Coca^. The Leaves. Nat. Order : Eirythroxylacece. Lamark. U. S. P. The coca is a small tree four to six feet high, indigenous to the mountains of Peru and Bolivia, and cultivated in both these countries on the eastern slope of the Andes,' in damp, warm vallej^s. The leaves are chewed by the natives to satisfy hunger, to strengthen the weak, to stimulate the nerves and to remove depression or melan- choly. The extract obtained by alcohol of 21° and 56° has all the gummy and resinous principles of the coca leaf, as well as the fatty, nitrogenous principles, the tannin, the chlorophjd and the alkaloid. It is this extract which represents best, and in exact proportion, the constituent principles of coca. Like tea and coffee, coca is used in nervous headache, and as a substitute for opium in opium habit. A similar use has sug- gested itself in the treatment of alcoholism, spermatorrhoea, generative debility, granular pharyngitis and relaxation of the muscles of the larynx, pharynx and middle ear. There is a wine of coca made from the fresh and dry leaves with sherry or claret wine. WINE OF COCA, FROM COCAINE. Plate 52— (Figs. 1-13) * 385 Wine of Coca, from Cocaine. We have been disappointed in the results of the administra- tion of the ordinary wine of coca in the market, and it has been suggested the preparing of this wine so that it will contain a fixed proportion of cocaine, and at the same time be free from the tannin, resin and other inert or deleterious substances pres- ent in the leaves. To a good-bodied wine— claret— add two and a half grains of -*The entire illustration is that of branch with young foliage and flowers. No. 2, entire flower ; between 2 and 3, petal ; 4, flower with petals removed; 5, calyx and pistil ; 6, vertical section ovary; 7 and 8, transverse sections ovary ; 9 and 10, fruit ; 11, transverse section of fruit ; 12, section of stem with leaves removed ; 13, apex of leaf 386 ARTIFICIAL ANESTHESIA. the hj^drochlorate of cocaine to the pint, the dose being half a wine-glassful, which will contain about a twenty-fourth of a grain, repeated at each meal. We have found this wine of special value as a tonic to the vocal apparatus, or in cerebral hyperae- mia, the result of excessive mental or phj^sical disturbance. It has also been found useful in hysteria, and as a tonic and stimulant in weakened and exhausted nervous system. Therapeutical Uses of Coca Leaves. We have employed the coca and found it useful, first, in our own case, and also in that of several of our patients. The first efi"ect of our experiments with the wine elixir and fluid extract of coca in full doses was a somewhat irregular muscular action or co-ordination, and if given in large doses walking becomes irregular. Soon after the moderate dose there comes a feeling of comfort, and as the effects pass off there is a slight irregu- larity of the rhythm of the heart. This is followed after a cer- tain time, if taken at night, by a pleasant sleep. If taken through the day and not immediately before meals by a person with no desire for food, or if taken after meals, it passes off before the next regular meal and the appetite is not affected. The wine was the first preparation recommended to us, but after using that made in this city with sherry wine, we found it objectionable to certain of our patients, causing headache and dyspeptic symptoms ; so that in Jefferson Medical College Hos- pital we resorted to a preparation of claret wine or the fluid ex- tract in doses of sixty drops, three times a day. One week after, a patient with tinnitus reported that the noises were much less, throat less irritable, and it was possible to obtain a view of the vocal cords, which were found white, but still somewhat relaxed in the act of phonation. The only objection to its continued use in this form was the constipation. This constipation, it is stated by our patients, does not follow the use of the extract made with glycerine, or the lime-water infusion. Still the peculiar tannin which it contains is one of its important agents, and should not be omitted, as it unites with the active principle ; therefore it is best to use the active preparation, for the constipation can be readily obviated by adding a mild laxative, like elixir of cascara. COCAINE AND ITS SALTS. 387 In man the coca diminishes the appetite for food for some hours, and at the same time greatly increases the muscular strength and endurance. The celebrated traveler, " Tschudi," found, when coca leaves were taken in infusion, it conferred a singular immunity from suifering, and prevented the haemor- rhages which were apt to occur in the elevated passes of the Andes, some of which are 17,000 feet high. If used to excess, coca deranges the digestion and causes habitual constipation. Cocaine and Its Salts. In 1855 Graedeke discovered in coca an alkaloid to which he gave the name erythroxyline ; but this principle was first thor- oughly studied by Dr. Albert Niemann, from whom it received the name cocaine, as an anaesthetic, but first used in the eye by Dr. Karl Koller, of Vienna. The hydrated alkaloid cocaine is in light, white, spongy frag- ments, or in light amorphous powder, very much like magnesia. It is not perfectly white, but very nearly so. It is nearly insoluble in water, but very soluble in acids, giving solutions that are not quite colorless. When a very small particle is laid upon the tongue, and the tongue then held against the roof of the mouth, a moderately bitter taste is perceived. In a few seconds more the bitterness gives place to numbness and insensibility of the surfaces, as though scalded by hot liquid, except that there is no pain. This numbness increases for a few minutes and then diminishes slowlv, and disappears in from ten to twenty min- utes in proportion to the quantity applied. The hydrochlorate of cocaine is an almost white crystalline powder, though the fragments of crystals are so small that it appears to be an amorphous powder, even under a glass of low power. The powder when dry is loose and mobile, but when exposed to air becomes a little damp and clammy, although it does not ap- pear to be deliquescent. It is soluble in all proportions in hot water, in alcohol, and in somewhat less than half its weight of water at ordinary temperatures. Its solutions are not always colorless, but appear to be nearly so when seen in small vials, even up to the strength of 20 per cent. Solutions of 50 or 60 per cent, strength are, however, of a greenish-yellow tint. The 388 ARTIFICIAL ANESTHESIA. solutions are neutral to test-paper. When tested with solution of chloride of barium thej'' give, after a moment or two, the faint- est cloud (limit of sulphates). With test solution of oxalate of ammonium the result is negative (absence of lime). When the salt is burnt on a platinum surface there is merely a trace of residue (limit of inorganic matter), and the spot moistened with water scarcelj^ affects the color of neutral litmus paper (limit of inorganic alkalies). According to Dr. Niemann, the discoverer of cocaine, the alkaloid, when heated in a tube, decomposes, with the evolution of a dense sublimate of benzoic acid. Wohler and Losson found, upon heating cocaine several hours in a sealed glass tube with concentrated hydrochloric acid, that the cocaine resolved itself into benzoic acid, methyl alcohol and ecognine. Cocaine and Its Impiu'ities. The presence of hygrine and ecognine in the hydrochlorate of cocaine may be detected by treating the salt with cold concen- trated sulphuric acid. If the salt is pure the result is a com- pletely colorless solution. The impurities will stain the solution. The Instability of Cocaine. The great instability of cocaine is now well known, the simple contact of the free alkaloid with water being sufficient to decom- pose it. The hydrochlorate, which is much more stable, should be absolutely neutral ; volatilized completely, forms a colorless or slightly turbid solution in water, gives a colorless solution with strong sulphuric acid, and should not reduce permanganate of potassium immediately. Cocaine has the composition CnHsiNOi. It is slightly soluble in water, more so in alcohol and freely in ether. In addition to it coca leaves contain cocatannic acid, wax, and a pale, yellow, oily, volatile alkaloid, hygrine. Ecognine., which is obtained by the action of hydrochloric acid on cocaine, has the composition CgHisNOs, and is insoluble in ether. We had found it valuable in affections of the nose and ear, and had used it both before and after operation in a 5 to 10 per cent, solution, applied with a brush. ACTION OF COCAINE UPON THE ANIMAL SYSTEM. 389 The test for cocaine is potassium permanganate, producing a permanganate salt, and when heated there is a distinct odor of bitter almonds. Chloride of gold produces a distinct precipitate of small fern frond-shaped crystals arranged in stellate groups. A solution of iodide of potassium and picric acid produces precipitates of color, etc., which are peculiar to cocaine. The physiological tests are its anaesthetic influence on the eye, dilatation of the pupil and benumbing sensation on the tongue. The test for pure cocaine (Stockman's), or pure hydrochlo- rate of pure cocaine, is that when heated with strong hydro- chloric acid in a sealed glass tube, in the water bath, it splits up into its components without any change of color, except a very light yellow tint (from the HCI). When isatropylococine is so treated it splits up into ecognine and a brown, oily-looking body, which is decomposed isatropic acid. The anaesthetic pro- perties of cocaine are destroyed by boiling. Cocaine salts are now made synthetically on a large scale. CHAPTER XV. Experiments with Cocaine on Animals. The Physiological Action of Cocaine Upon the Ani- mal System, More Especially Upon Dogs. Through the courtesy of Professor Reichert, of the Univer- sity of Pennsylvania, the following experiments were performed in his laboratory, May 14, 1889 : A dog, weighing 8 pounds, was injected with 1^^ grains of Merck's cocaine. Pulse 172, temperature R. 38.9, being at the rate of 2 centigrammes per kilo. Soon after he became rest- less, moving his tongue in and out of his mouth, showing an extra secretion of saliva. Then followed jerking movements of the muscles, more especially of the neck and head, being unable to stand on his feet, as though intoxicated. The pupils became 890 ARTIFICIAL ANESTHESIA. dilated, balls very prominent and hard from increased intraocu- lar pressure. In the course of ten minutes or more convulsions supervened. Temperature increased to 39.4°, pulse to 124. After 15 minutes there were both clonic and tonic convulsions. His bodily movements were in a circle, swaying his head from side to side. This motion of the head continued for several hours — even after the movement of the limbs, which had been lost, had been regained. A pinch was felt, showing no want of reflex excitability. When fully under the influence of the cocaine sight and hearing seemed unimpaired until convulsions set in. At times there was great diSiculty in co-ordination, but there was no up and down motion of the head, and the convul- sive motions were almost always rotary and to and fro. Second Experiment. — Weight 16J pounds, pulse 120, tem- perature 38.9°. Dose for his weight, 10 centigrammes. A much more timid animal than the first, and after 15 minutes became very restless, with his head at times between his feet, having a weaving motion, his mouth making a snapping move- ment. The grain and a half of cocaine which he received by injection did not appear to produce the desired intense physio- logical efi"ects, so that one and a half grains extra was intro- duced over the spine. Now his brain became evidently very much affected, and his delirium overcame his timidity. When under great excitement he began by running around the labo- ratory, battering himself at intervals against anything that was in his way. Respiration increased, causing him to pant. Ears were thrown back, eyes protruding, balls hard, pupils dilated, but not to the same degree as the first animal. It was early noticed that heat is increased in the human body by the use of cocaine. In 1887, Mosso, of Turin, demonstrated by experiment that this drug possessed a remarkable power over the bodily temperature, raising it independently of convul- sions or section of the spinal column^ and this is owing, accord- ing to Mosso, to direct changes in the tissue, or the action of cocaine on the heat centres supposed to exist in the spinal cord. These facts in regard to the section of the spinal cord have not been confirmed by Professor Reichert (see p. 53). In the ex- periments of Dr. Hare upon dogs only, one is noted as having ACTION OF COCAINE UPON THE ANIMAL SYSTEM. 391 violent convulsions. A portion of cocaine emplo5'ed bj' him varied from half a grain in a dog weighing nine pounds to three- quarters of a grain to a dog weighing seventeen pounds. In every instance the cocaine was injected into the jugular vein. Animals, like human beings, are affected differentl}". The following are the most recent conclusions of Professor Reichert on the action of cocaine on animal heat functions : " There are comparatively few drugs known to therapeutists that are capable of causing a notable increase of bodily temper- ature, and even of these a large percentage is supposed to owe this activity largely or wholly to accompanying motor disturbances. It is at least a curious circumstance that all poisons which ap- preciablj" increase temperature are pronounced convulsants. Among the most decided of the phj'siological actions of cocaine is that of producing a rise of temperature which, even in mod- erate doses, may be quite remarkable. Yon Anrep* states that the temperature of the skin was always decidedly increased from the first, while the rectal temperature at the same time remained unaltered, or was decreased from 0.5° to 1° C. , the latter rising, however, during the convulsions, to a similar ex- tent. Danini (quoted bj^ Anrep) notes that a rise amounting to 1° C. occurs during, and is dependent upon, the convulsions. Mossof always observed a rise, amounting to as much at times as 3. 1° C. , and, contrary to Danini, being independent of con- vulsions, since it occurred in animals rendered motionless by curare. Hare,+ in ten experiments in which the drug was in- jected intravenously, records a rise varying from 2° to 7.5° F. (1.11° to 4.17° C), the average being 4.14° F. (2.3° C). Dose for dose the action is more powerful and prompt when intra- venously injected than when hypodermatically." In Reichert's studies, comprising about twentj^ experiments on dogs, a marked increase was always noted. " In all, Merck's hydrochlorate of cocaine was used and injected hypodermati- cally. The fatal dose in dogs is about 0.03 gram per kilo. * Pfluger's Archiv., Bd. XXI. s. 68. t Archiv. f. Exp. Path. u. Phar., Bd. XXIII. s. 153. j University Medical Magazine, Vol. I., p. 358. 392 ARTIFICIAL ANAESTHESIA. Doses of 0.0025 gram per kilo elicit fairly well-defined symptoms of cocaine poisoning, dilatation of the pupils, restlessness, saliva- tion, increased frequency of respiration, more frequent and for- cible pulse, increased temperature, etc. With such doses the temperature is increased about from 0.2° to 0.5° C. Doses of 0.01 gram per kilo cause a rise of from 1° to 2° C. Doses of 0.02 gram per kilo, a rise of from 2° to 4° C. The increase is, however, not always in proportion to the dose, relatively small doses sometimes causing a considerable rise, and vice versa. The potency of cocaine in this respect is altogether remarkable, and places the drug in the foremost rank of pyrogenic agents ; indeed, so powerful is it at times that animals suffer from heat dyspnoea. Moreover, the action is one of notable permanency, the temperature, after large but sublethal doses, remaining above normal for six or eight hours or more. "Following the rise of temperature and subsequent return to the normal, a fall ensues, which, even after moderate doses, lasts for some hours. ' ' The results of my experiments are not in accord with Von Anrep's statements above referred to, since in every instance a marked rise of temperature occurred, from the first simultane- ously in the rectum and axilla (skin), the thermometers at both points of observation in our experiments being placed in posi- tion before giving the drugs, being allowed to settle, and not being removed during the entire time of observation. The alterations in temperature progressed paH passu in both cases. The rectal temperature rises more rapidly than that of the skin, this being due, to a large extent, if not wholly, to the quicker reaction of the thermometer in the former position. The ther- mometers used, when placed in the rectum, settle in from three to five minutes, but from ten to fifteen minutes are required in the axilla, although the thermometers were identical in make and sensitiveness." We cannot give the full details of Dr. Reichert's experiments, but he showed that a rise in tempera- ture does not occur after section of the spinal cord. We have shown by the above experiments on dogs the action of cocaine. FATAL DOSE OF HYDROCHLORATE OF COCAINE. 393 On the Actiou of Cocaine on the Eye. When introduced into the eye, it causes local anassthesia, with dilatation of the pupil, paralysis of accommodation, slight lachrymation, and enlargement of the palpebral fissure. When injected into the back of the orbit, it causes protrusion of the eyeball. Its effects appear to be due to stimulation of the peripheral ends of the sympathetic. Subcutaneous injec- tions also produce local anaesthesia at the point of application, so that subsequent irritation at that spot produces no sensation in man and no reflex action in animals. When taken internally, it appears to have in small doses a stimulating, and in large doses a paralyzing action on the nerve centres. It affects first the cerebral hemisphere, next the medulla, and afterwards the spinal cord. The writer has performed numerous experiments on himself and others to determine the action of the alkaloid cocaine and its chief salt, the hydrochlorate. In moderate doses of the hydrochlorate it can be adminis- tered in from one-fifth to even one-quarter of a grain every hour, until the patient is relieved, or the peculiar constitutional symptoms show themselves, these doses acting as a stimulant on the peripheral ends of the sympathetic. In larger doses it has an action on the nerve centres, affecting first the cerebrum, next the medulla, afterwards the spinal cord. If employed in still larger doses there is intense exhilaration, or intoxication, more or less loss of consciousness, followed by palpitation and even death, although this is rare. I have seen no deaths from cocaine for the last six years in Philadelphia. Fatal Dose of Hydrochlorate of Cocaine. Peculiar effects : A nervous thrill or tingling sensation, in- crease of pulse, dryness of the tongue, relief of pain or gastric disturbance, sensation of fulness in the head or heat of the face, at times producing wakefulness, followed by frontal head- ache ; in other cases there is dilatation of the pupil, with a tendency to sleep, the patient awaking in his ordinary condi- tion of mind. If larger doses are required, the symptoms are 26 394 ARTIFICIAL ANAESTHESIA. similar in character, only increased in intensity, great mental excitement, increased irregularity in rhythm or force of the heart, insomnia, or being unable to sleep, and invariably head- ache the following morning. The fatal dose is usually from six to ten grains, but from idiosyncrasy or peculiarity of constitution a much smaller dose may prove fatal. Dr. Hammond, of New York, took very much larger doses. Before the last injection the pulsations of the heart were 140 to the minute, and characteristically irregu- lar. He found his mind passing beyond his control, and he was becoming an irresponsible agent. He lost all conscious- ness half an hour after administering the last dose, remaining so until nine o'clock next morning, when he awoke with an in- tense headache with a great deal of cardiac and respiratory dis- turbance. No marked influence appeared to be exercised upon his spinal cord or upon the ganglia at the base of the brain. There were no disturbances of sensibility (no anaesthesia, no hyperaesthesia), and no interference with mobility except that some of the muscles, especially those of the face, were subjected to slight twitchings. In regard to sight and hearing he noticed that both were affected ; but that while the sharpness of vision was decidedly lessened, the hearing was increased in acuteness. At no time were there any hallucinations. The exciting action of cocaine on the brain is extremely prominent among its physiological peculiarities — much more so than its anaesthetic influence. 1. The first noticeable effect on the lower animals is restless- ness, gradually increasing to more or less intense excitement. 2. In animals the cerebellum is more or less affected. 3. Chloral is certainly antagonistic — so with chloroform, also ether — during anaesthetic stage, but not during its primary stage of excitement. 4. There is some evidence to indicate that the semi-circular canals are affected, as shown by the vertiginous movements. 5. In poisonous doses the convulsions seem to be both of cerebral and spinal origin, but chiefly cerebral. COCAINE INEBRIATION AND HABIT. ^ 395 6. The motor or sensory nerves do not seem to be affected until late in the poisoning. 7. The action on circulation is complex ; pneumogastric nerves primarily stimulated, secondarily depressed. Blood pressure similarly affected. Therapeutic doses probably act as circula- tory stimulant. 8. The pupils in all of the experiments were dilated and intra-ocular pressure increased. We have never noticed any, injurious effects on animals in any way after using non-lethal doses. The}' naturally suffer some after-depression because of the intense mental and muscular excitement during the action of the poison, 9. Bodil}' temperature is increased. 10. Tissue metamorphosis, as is indicated by Dr. Reichert's experiments, is probably increased. 11. The fatal dose for animals is about 0.03 grammes per kilo of bod}'^ weight. The fatal dose for man varies within very wide limits. 12. It is claimed that it at times interferes with the healing of the wound after operations, and to be less efficient on other membranes than the conjunctiva. CHAPTER XVI. Cocaine Inebriation and Habit — Treatment — Deaths from Cocaine — Morbid Changes in Poisoning by Cocaine. In the cases under Dr. Crother's care a correct history was obtained; in the five cases who sought advice by person and letter their own personal statements were the chief sources of information. In two cases statements were confirmed by others, and where such statements corresponded with the facts in other cases, they were accepted as probably true. The following are some of the facts which appeared from the history of these cases : 396 ARTIFICIAL ANJ3STHESIA. Alcohol, opium, chloral, bromides and other narcotics had been used more or less to excess in all these cases before co- caine was taken. In four of these cases coca had been used for months before cocaine was tried. Hence they were all literally drug maniacs, or inebriates, whose special symptom of disease is a morbid impulse for narcotic drugs, which will bring rest and relief to the organism. He is also persuaded to be- lieve that cocaine inebriety, or coca mania, will never become prominent, and will be confined to a class of neurotics who, by the use of other drugs, have prepared the soil for this new drug-mania. It will never take the place of alcohol or opium in common use. Its action is too uncertain and transient. The present novelty and glamour about its effects will die away when its real value is ascertained. The element of contagion in these cases presents a curious psychological phase ; thus some extravagant newspaper statement of the terrible effects of this drug will rouse curiosity to test it, or the printed history of a case appearing as daily news draws the attention of neu- rotics, and it is safe to say that a large per cent, not only pur- chase, but test this drug on themselves. Cocaine should not be used as a substitute in breaking away from the use of other narcotics. It should not be used in large or long-continued doses. It cannot be used indiscriminately. However valuable it may be, there is a cer.tain limit to its power and practical use. The treatment of cocaine inebriety is the same as that of alco- hol or opium cases. Forced abstinence from the di^g, rest and building up the system are the general methods pursued. More profound degeneration and debility exist than in other forms of inebriety, requiring a longer time for successful treatment. Clouston {Edinh. Med. Jour., 1891) advises stopping the drug, careful watching, nursing, the use of every sort of food that will keep up the strength, and of the bromide of ammonium, brandy or wine, tea and coffee, and possibly a hypnotic, like paraldehyde or sulphonal, for at least two or three nights. States of mania and melancholy often continue for some time after the use of the drug is given up, and disappear very slowly. It is for these states that special surroundings and TREATMENT OF NERVOUS SYMPTOMS. 397 care are essential. The prognosis is alwaj^s uncertain. The craving for drugs that their effects may be broken up and res- toration follow ; but such cases generally are unable to bear much exposure, and not unfrequently relapse on the slightest temptation. On making inquiry of Dr. Osier, now of Baltimore, one of the attending physicians of the largest hospital in Philadelphia, as to how many cases he had ever seen of cocaine habit, he stated but one or two, and of opium or morphia habit, during his term of service of four months, there were but four cases. In what dose did he give cocaine ? As a rule, one-quarter of a grain was the usual dose, and the strength of the solution for hypodermic application was two per cent. If this rule is fol- lowed, we think that it is as safe as morphine, atropine and agents of a like character. Treatment of Nervous Symptoms from Cocaine. Should nervous symptoms occur, such as temporary deafness, blindness, loss of taste or smell, place the patient on a lounge or sofa, open the windows and admit plenty of pure air, then employ from five to ten drops of the nitrate of amjl in capsules, broken on a handkerchief, to be inhaled by the nostrils. Should the patient become covered with cold perspiration, livid in color, apply dry friction to the skin, with twenty drops of aromatic spirits of ammonia, in water, repeated at intervals. Should the patient suffer from gastric cramps, give a teaspoonful of compound spirits of lavender, or, if not relieved, brandy. Use morphine, hypodermically, one-eighth of a grain. If the pulse be irregular or intermittent, with shallow, gasping, irregular, convulsive or suspended breathing, artificial respiration should be resorted to, with hypodermic injections of ether or chlo- roform, and even the galvanic battery, to prevent a fatal result. In cases of poisoning, the nitrate of amyl is considered the best antidote. Claude Bernard has demonstrated by his experi- ments that cocaine, in its action on the cerebral circulation, was exactly the antagonist of nitrate of amyl. Under the effects of amyl, the cerebral arteries contract, anaemia of the brain de- 398 ARTIFICIAL ANAESTHESIA. velops, the arterial pressure is increased and the face looks pale. Cocaine causes a dilatation of the vessels of the heart, hyperaemia, with diminished arterial pressure, sets in, in the encephalon, and the face appears flushed and in a general state of venous congestion. Cocaine is antagonistic in its action to ether and chloroform. The convulsive seizures induced by the action of poisonous doses of cocaine can be at once allayed by the inhalation of either of these agents. In cases of cocaine poisoning in man, we therefore recommend that ether or chlo- roform should be administered to allay the first and severer symptoms, chloral being afterward given in small doses to keep up the effect. We were highly delighted to find, from a pamphlet of Prof. Viau,* that he had been able to modify the hydrochlorate of cocaine in solution with pure phenol, gr. ij., to cocaine, gr. iv. , to 100 grs. distilled water, so as to prevent, in 87 cases, any un- pleasant results from its use in the extraction of teeth. This solution was prepared as directed by the Paris dental surgeon : ^> Crystallized xjlienic acid, . . . gr. j. Cocaine, pure, grs. ij. Distilled water, grs. 100. M. Sol. aad filter. Make each time that it is employed. And before a class of about 200 students the mixture was in- jected into the jaw in a case of diseased antrum in a young lady. She was then operated upon by Dr. Garretson, who removed the diseased bone with the dental engine. She bore the opera- tion with great equanimity, and with so little pain as to be un- noticed by the students ; and when asked, at the completion of the operation, she stated that she experienced some slight pain. The case was an interesting one in its freedom from excitement and haste, and the quiet way in which she would rise, expec- torate the blood and be cleansed from the horrible disfigure- ment, avoiding the great risk produced by profound anaesthesia, which is so nigh unto death, required in such an important operation. '-■• Monograph, by Prof. George Viau, Paris, 1892. schleich's infiltration method. 399 Sclileich's Infiltration Method of Local Angestliesia by Cocaine.* Dr. H. y. Wiirdemann was the first to use the method of "Schleich" in the United States, and gives the following im- portant testimony in favor of this metliod : "He has personally done half a hundred operations upon the eyelids, etc., by this form of anaesthesia, as well as various operations upon other parts of the body while prosecuting his original investigations. He also assisted at a number of operations, as ovarian tumors, amputations, hernias — to all the minor operations." Schleich, in an extensive use of his method for at least one year, makes the following statement, that local anaesthesia with cocaine can be employed successfully in ninety per cent, in all operations. Another advantage he claims is the rapidity of its application and the short time in the preparation of the patient, and the safety, if his rules are carried out. Again, the after-, effects, as vomiting and depression, are much more rare. As we have already stated, he employs various strengths of the solution. He seems to prefer the medium strength of solution, which has but one part, with two parts of sterilized chloride of sodium to one thousand. If the skin is very sensitive to the puncture of the needle, the part is sprayed by ethyl chloride ; or, if it is in a mucous surface, by the five per cent, solution of carbolic acid. A free application of glycerine over all surround- ing parts is also highly recommended. It must be particularly remarked that the infiltration on one spot lasts from fifteen to twenty minutes, and should it be found necessary to return to such a spot at the expiration of this time, a fresh infiltration would be necessary. In this way we may operate for hours on the same spot. It must also be remembered, that after the period above mentioned, the parts of skin which have been held back during the operation, must be anaesthetized over again, and care should be taken to make the wheals large enough to allow space for the thread and knots, one method being to produce one on * The Infiltration Method of Anaesthesia. Eeprint Am. Med. Asso.. November 16. 1895. 400 ARTIFICIAL AN.57.STHESIA. each side of the separated cuticle, and draw the needle and thread through the centre of these. Inflamed Parts. There is a great difference of sensibility in the anaesthetizing of a normal part, or of a highly sensitive one, such as inflamed parts by abscess, tumors, etc. In these cases it is absolutely necessary to start the anaesthesia in the healthy parts. Begin the infiltration far back from the seat of inflammation, and in- sert the needle through the first-formed wheal gradually, while pressing steadily on the piston, deep into the part toward the seat, emptying the syringe all outside of the inflamed zone. In this way the infiltration is carried on from the four oppo- site points at first, and then only gradually the upper cuticle is treated, and this also beginning first in the healthy region. In this way wheal after wheal is formed until the whole of the inflamed part is saturated, which can be readily observed by the disappearance of the red inflamed color and its substitu- tion by the white zone of the infiltration. The best action of this form of anaesthesia has been found on parts like the fingers or toes or penis. The return circulation can be interrupted by circular constriction, and the entire quantity can be retained. Corning has used hard rings pressed upon flat skin-areas in order to similarly interrupt the circulation of the fluids that tend to carry away the anaesthetizing substance. Under this practice there are three zones of sensory nerve-activity — a zone of com- plete anaesthesia corresponding to the area in which the cocaine is in sufficient concentration to completelj'^ overcome the sensi- bility of the nerve-endings and filaments, a zone in which sensa- tion is partially inhibited, and an area in which the anaesthesia gradually fades away. It was easily seen that if by osmosis or by the mechanical movement of fluids the cocaine was brought into contact with all the nerve-structures in approximately one degree of concen- tration, and if this contraction were exactly that required to inhibit nerve-action, the desired result would be accomplished with a minimum quantity of the drug. INFLAMED PARTS. 401 Liebericli ami Wiirdemaiin have shown, however, that the in- jection of simple water into the tissues in such a way as to pro- duce an artificial oedema will induce, with some discomfort, a transitory anaesthesia. C. L. Schleich found that by combining a small quantity of cocaine with a weak salt-solution, the dis- comfort was removed and the anaesthesia prolonged ; and it only remained to add a little morphine to the solution to prolong the beneficent action sufficiently to give opportunity for the perform- ance of surgical operations. Some surgeons add a minute quan- tity of atropine. Complete anaesthesia depends, in this method, upon the artificial ischaemia established, and upon the high pressure to which the tissues are subjected ; also upon the low- ered temperature brought about b^^ the introduction of the cool water; and finally upon the direct action of the anaesthetizing drugs. Leaving aside alleged personal disinclination on the part of European clinicians to adopt the method of Dr. Schleich, it seems to me that the failure of the infiltration-method up to the present time to become popular, depends upon the fact that a special technic is required. This technic is, however, so simple and easy that x^merican physicians, I am sure, need only read an account of it to understand and practice it. And, as local anaesthesia can be induced by it in a few moments for the opening of abscesses, furuncles, or carbuncles, for the removal of a prepuce, or for the amputation of fingers, or even of the forearm, with the use of a solution of one part of cocaine in a thousand of water^ every intelligent worker must grant its ad- vantages and apply it in practice. The hypodermic syringe which he employs is larger and the needles longer, and of vari- ous lengths, being straight and curved. It has been suggested to have an asbestos packing. These needles are always kept ready for use in an antiseptic solution of carbolic acid. The parts before operation should be shaved, and all hair removed, except in the eyelashes or eyebrows, and should be well washed with Castile soap and hot water, followed by alcohol, and last — but not least in importance — a solution of one to five thousand of bichloride of mercury. The following formulas are advocated by Schleich :* ""■■ Translation by Dr. H. V. Wiirdemann. Pamphlet, p. 3. 402 ARTIFICIAL ANJ3STHESIA. Cocaine mur., Morph. mur., . Natr. chlor., . Aqu. dest. ad., M. Sterilisat. adde. sol, ac carbol. 5 per cent .20 .025 .20 100. gtt. ij. S. Solution No. 1, strong. For operating upon highly inflamed or hyperesthetic areas. ^ Cocaine mur., .10 Morph. mur., .025 Natr. chlor., . .20 Aqu. dest. ad., . . . . . . 100. M. Sterilisat. adde. ac. carbol. 5 per cent. gtt. ij. S. Solution No. 2, medium. For most operations. ^ Cocaine mur., .01 Morph. mur., .005 Natr. chlor., .20 Aqu. dest. ad., 100. M. Sterilisat. adde. sol. ac. carbol. 5 per cent. gtt. ij. S. Solution No. 3, weak. For superficial operations upon nearly normal tissues. All are to be kept strictl}^ sterile ; glass stoppers or scorched cotton, such as are used in bacteriologic experiments for the bottles ; small quantities to be poured out in smaller vessels for each operation. Just before operation the solution should be cooled by laying the bottle containing it on ice. The common form of hypodermatic syringe with the finest of needles is all that is usually needed. Dr. Chas. Denison, of Denver, Colo. , has given us an aseptible syringe of larger capacity, with piston packing of asbestos, which is particularly applicable for aseptic injection. The syringe is kept in good order by being fre- quently soaked in a five per cent, carbolic solution and the needle sterilized after each operation. The discovery of these truths, so valuable for the question of local anaesthesia, is due simply to a slight change of method — the application of the solution within and not under the skin. The anaesthesia is caused by the replacement of the normal fluids of the tissues by a fluid of less specific gravity (the water), THE TECHNIQUE OF LOCAL ANAESTHESIA. 403 which causes anaemia, compression and cooling, producing thereby a temporary paralysis of the nerve filaments. The pain of the infiltration of indifferent solutions is abolished by the minute doses of narcotic drugs (morph., cocaine, carb. ac). " It is perhaps well to here go into the technique of the pro- duction of local anaesthesia by this method. The field of oper- ation is made aseptic in the usual manner. Having the re- quired formula, the solution aseptic and cold, we fill the sterilized hypodermic syringe, pinching the skin slightly be- tween the thumb and forefinger of the left hand ; the needle is then passed obliquely under the epidermis to the papillae, intra- Plate 53. Diagram of a section of the skin, showing formation of the first wheal. cutaneously, until the lumen is fully inserted. A few drops are then injected, thereby producing a white elevated wheal, the infiltration extending throughout the whole thickness of the skin. (See Plate 53.) There is immediate and complete anaes- thesia throughout the extent of the infiltration, which lasts from ten to twenty minutes, according to the density of the tissue so oedematized. The needle is then re-inserted at the periphery of the wheal, and the area infiltrated to the required extent and depth. No tissue offers any deviation from the dictum ; every structure is made anaesthetic that can be arti- ficially oedematized : this holds good for skin, mucous and synovial membrane, periosteum, fascia, muscle, lymph glands, nerves, viscera, and even bone." 404 ARTIFICIAL ANESTHESIA. Anaesthesia exists only within the area infiltrated by the solu- tion, and outside of that normal sensation remains. In opera- tions on or through the skin and mucous membranes, the first wheal is increased to the size of a dime by increased pressure on the piston ; the needle is moved and re-inserted at the periphery of the wheal, but still within it, and a new wheal Plate 54, Formation of the cutaneous wheals. raised. In this way the line of incision is marked out to any desired length or breadth. (See Plate 54.) In general surgical operations we would then infiltrate the underlying tissues by slowly pushing in the needle and injecting a few drops at a time until the deeper tissue is oedematized. By cooling the spot selected for the formation of the first wheal by ether or rhigolene spray, or, on mucous membranes, by touching the spot with a strong solution of carbolic acid or NOTES ON THE DANGER OF SEPSIS. 405 applying cocaine, the first injection may be made, if so desired, without even feeling the prick of the needle. This is seldom necessary, as a very fine needle may be inserted without pain even in very tender tissues, such as the eyelids. The succeeding injections may now be made without causing sensation. There is no sensation to the infiltration proper. Where the tissues are inflamed, the sensibility is pathologi- cally increased. Here it is indispensable that the infiltration be begun in sound tissue and carried over into the part to be oper- ated upon. The dilated blood and lymph channels of the inflamed skin allow us to anaesthetize quite a large spot from one puncture. The injection should be done slowly at first, and when the in- filtration is only felt by its tension we may rapidly flood the part to the required extent. Under no circumstances must the fluid be primarily injected into an abscess, an exudation or a patho- logic focus. The only result is increased tension and pain. We must not lose sight of the cardinal fact that the anaesthesia exists only within the area infiltrated by these solutions, and that outside of that there is normal sensation. The method rests principally on the production of a complete artificial cedema of the tissues. Wherever we wish to operate with exact anaesthe- sia, the field of operation must be tensely filled with the solu- tion, so that it exudes from the cut surface. The following important caution Dr. Wiirdemann has pub- lished as late as February, 1896, and has kindly placed it at our disposal : Notes on the Danger of Sepsis in Endermatic Injection (Infiltration Anaesthesia).* "The growing popularity of infiltration anaesthesia since its discovery, in 1891, by Schleich, of Berlin, and subsequent in- troduction into Germany and America one and a half years ago, leads me to sound a note of warning regarding its indiscriminate use without proper care as to the technique. The only substan- tial objection to this form of local anaesthesia that has been * See editorial in Medical News, February, 1896. 406 ARTIFICIAL ANAESTHESIA. heretofore raised is that of the possibility of infection from septic fluids, unclean hands or instruments. "There are certainly many physicians who either do not clean their hypodermatic syringes or simply wipe them off, and then go to the next patient. It is not customary to make special preparation of the skin, or of the hypodermatic needle, for ordi- nary hypodermatic injection. Even the fluid used in which to dissolve the morphine, etc. , tablet is not always drawn from an aseptic source. The small amount of serum which clings to the needle on withdrawal is certainly a culture medium for the streptococcus. " It is remarkable that we see or hear but little of hypoder- matic abscess, which, despite septic injection, must be an un- common occurrence. We can only ascribe this to the fact that in the hypodermatic injection the fluid is deposited in a com- paratively compact depot under the skin, and does not come intimately in contact with the cells of the tissue, and thus per- mits of rapid phagocytosis, as the blood is not driven out of the surrounding tissue and the fluid is rapidly absorbed. Quite different is endermatic injection, for when fluid is slowly infil- trated into the tissues it distends the meshes, replacing the fluids and the blood entirely for a length of time (10 to 20 minutes). The infiltrating fluid is brought intimately into rela- tion with the cellular elements, and phagocytosis does not obtain in time to counteract the effect of implantation of septic germs which could thus gain a foothold, and more certainly cause sup- puration than in ordinary hypodermatic injection. ' ' A case of sloughing has been brought to my notice in which the Schleich method was used for anaesthesia in operation for mammary abscess. The infiltration fluid was prepared by a local druggist ; the infiltration was made by the physician with a hypodermatic syringe and needle used for ordinary medicinal injection. 'Anaesthesia was complete, but operation was fol- lowed by sloughing of the whole surface of the skin injected. ' "Schleich does not report any such cases at his hands. In several hundred injections that I have made, I have had no trouble. Reports coming to me from other surgeons do not chronicle such an event, which can only be the fault of the NOTES ON THE DANGER OF SEPSIS. 407 operator Sclileioh lias pointed out in his brochure and in his other writings that absolute sterilization of everything m connec- tion with the procedure should obtain. I have referred to this in my own articles. I would emphasize the following points : " I The ingredients of the solution should be made absolutely sterile This mav only be obtained by hoiUng aU the solutions for Jive minutes before each operation (afterwards cooling the same) The factor is especially pertinent, as leading manufac- turing chemists in the United States and Germany have infil- tration tablets on the market for extemporaneous preparation for the several fluids. The tablets themselves are presumably aseptic, but if fingered ever so slightly cannot remain pure. BoiUng the solutiom after mixing does not interfere with their ancpsthetic qualities. * i i • "II. The bottles, corks and stoppers containing the solutions, the dishes used in which to pour out small quantities of the solution, should all be previously boiled (or sterilized by heat), and not suffered to remain exposed to contaminating influences, not even the air, but should be covered after coohng. " It is even more necessary for instruments, etc., to be aseptic than for ordinary operations. Any good hypodermatic syringe and needle may be used, but should be previously prepared by immersion for at least one-half hour in a five per cent, carbolic solution, which may be removed before operation by washing in sterilized water. The finest and sharpest of needles are advisa- ble. These may be sterilized by boiling in soda solution or by carbolic immersion. "The person preparing the solution should prepare his hands, as well as the surgeon, as carefully as if for an abdominal opera- tion. The part to be operated upon should be made aseptic in the usual manner. Attention to detail is absolutely necessary for the success of heaUng as well as for anaesthesia. "It is the fault of the operator if he does not secure perfect anaesthesia and aseptic infiltration, followed by good healing." Messrs. John Wyeth & Brother have prepared from the formulge of Dr. Schleich a series of soluble compressed tablets, which can be obtained from any regular pharmacist. « It is a well recognized fact that boiling destroys the cocaine, so it is to be added when cool. 408 ARTIFICIAL ANESTHESIA. The advantages of these soluble compressed tablets are mani- fold. They are at once soluble, are made of the several desired strengths, are permanent and stable, the solutions can be pre- pared in a moment, the fear of septic infection from stale solu- tions is entirely removed, the operator can always be supplied with more than sufficient for any emergency, and the combined ingredients do not deteriorate or change by age or climatic influences. We feel there is a wide field for the use of this method, not only in the hands of surgeons, but with the general practitioner, for the relief of local pain, and to the dentist they will prove an invaluable aid. The following are the sizes of these soluble compressed tab- lets: Tablets to Make 100 Minims of Solution. No. 1. — Strong. Cocaine hydrochlor., 1-5 grain. Morph. hydrochlor., 1-40 grain. Sodium chloride, C. P., 1-5 grain. One tablet dissolved in 100 minims of water yields the Strong Solution, representing : 1-500 part of cocaine hydrochlor. 1-4000 part of morph. hydrochlor. 1-500 part of sodium chloride, or each 1000 minims contain 2 grains cocaine hydrochlor. 1-4 grain morph. hydrochlor. 2 grains sodium chloride. No. 2. — Normal. Cocaine hydrochlor., . . . . . 1-10 grain. Morph. hydrochlor., 1-40 grain. Sodium chloride, C. P., 1-5 grain. One tablet dissolved in 100 minims of water yields the Normal Solution, representing; 1-1000 part of cocaine hydrochlor. 1-4000 part of morph. hydrochlor. 1-500 part of sodium chloride, or, in other words, each 1000 minims of this Solution equal : 1 grain cocaine hydrochlor. 1-4 grain morph. hydrochlor. 2 grains sodium chloride. NOTES ON THE DANGER OF SEPSIS. 409 No. 3.~Weah Cocaine hydrocblor., 1-100 grain. Morph. hydrocblor., 1-40 grain. Sodium chloride, C. P., 1-5 grain. One tablet dissolved in 100 minims of water yields the Weak Solu- tion, representing: 1-10,000 part of cocaine hydrocblor. 1-4000 part of morph. hydrocblor. 1-500 part of sodium chloride, or each 1000 minims of Solution contain 1-10 grain cocaine hydrocblor. 1-4 grain morph. hydrocblor. 2 grains sodium chloride. Should more than 100 minims be required, use one tablet for every 100 minims of water used. Tablets to Make 500 Minims of Solution. No. 4. — Strong. Cocaine hydrocblor., 1 grain. Morph. hydrocblor., 1-8 grain. Sodium chloride, C.P., 1 grain. One tablet dissolved in 500 minims of water yields the Strong Solu- tion. No. 5. — Normal. . Cocaine hydrocblor., 1-2 grain. Morph. hydrocblor., 1-8 grain. Sodium chloride, C.P., 1 grain. One tablet dissolved in 500 minims of water yields the Normal Solution. No. 6.— Weak. Cocaine hydrocblor,, 1-20 grain. Morph. hydrocblor., ..... 1-8 grain. Sodium chloride, C.P 1 grain. One tablet dissolved in 500 minims of water yields the Weak Solu- tion. Should more than 500 minims of solution be required, use one tab- let to every 500 minims of water. In cases where the Solution is desired to be stronger or weaker 27 410 ARTIFICIAL ANAESTHESIA. than the Normal Solution, but being of the same relative pro- portions of Cocaine, Morphine and Sodium Chloride as in the Normal Solution, all that is necessary is to either increase or decrease the quantity of water to be used to each tablet of the Normal Recipes No. 2 and No. 5. Special attention is called to the fact that in the Normal (No. 2), Strong (No. 1) and Weak (No. 3) tablets only the Cocaine Hydrochlorate varies, while the Morphine Hydrochloride and the Sodium Chloride are the same amounts in all three recipes. This also applies to Nos. 4, 5 and 6. The Tablets are put up in tubes of 20 tablets each, in cases holding 10 tubes, and also in larger packages, such as lOO's, 500's and lOOO's. Dr. Bransford Lewis, of St. Louis, in an article in the Med- ical Standard* giving his experience in the use of this method, cites the following practical points : "Every tissue of the body, without exception (skin, muscle, gland, mucous membrane, nerves, etc.), becomes insensible to pain when infiltrated in the manner described. This obtains for bone and the hard structures as well as the soft ones. Bone is reached either through infiltrating its periosteum or by in- jecting into the medulla. Nerve trunks are anaesthetized sepa- rately, first by applying 5 per cent, carbolic acid solution, and then through this inserting the needle and fluid. " Only the infiltrated, artificially oedematous tissue is anaes- thetic, the tissues just outside retain normal acuteness or insen- sibility. Consequently in the course of an operation, with absorption of the infiltrated fluid, it is necessary to renew the injections or extend their area coincidently with the operative fluid. "With the proper fluid anaesthesia ensues immediately on its being introduced into the tissues, and lapse of time is not requisite for developing insensibility. This again is in marked contrast to the efl"ect of the older methods of producing anaes- thesia. Its advantage is great. "Anaemia resulting from the method, there will be less * Medical World, p. 41, February, 1896. USE OF COCAINE UPON NASAL MUCOUS MEMBRANE. 411 bleeding (oozing) than under ordinary circumstances. Distor- tion of the tissue from the infiltrated fluid does not cause any especially increased diflficulty in securing and tying or twisting bleeding vessels. Nevertheless, in operating in deeper struc- tures, care must be taken to avoid risk of piercing blood-vessels, nerves, etc. "Strong solution of cocaine (10 to 20 per cent.) will quickly constringe the vessels and hence will not be absorbed ; while a weak solution (1 to 5 per cent.) will be absorbed and produce S3^stemic poisoning. ' ' The Use of Cocaine Upon the Xasal Mucous Mem- brane Prior to and During- Anaesthesia. Kosenberg, in an article published in the Berliner KUnische WocJienschreft, Nos. 1 and 2, 1895, advocates the use of cocaine upon the nasal mucous membrane prior to and during anaes- thesia, claiming three-fold advantages : 1. As the patient's perception of the odor of the anaesthetic is much diminished, the feeling of suffocation is entirely absent. 2. The stage of excitement is either shorter or entirely absent. 3. Vomiting during narcosis is rarer than usual. 4. Sickness following anagsthesia does not occur. G-erster reports the results in 100 cases where this method was employed in the operating room of the G-erman Hospital, New York. A 5 per cent, solution of cocaine was used. The patient freed his nose from mucus, and 2 minims of the solution were sprayed into each nostril. Two minutes later the process was repeated, one-half of the quantity being employed. Every half-hour dur- ing the operation the nose is again sprayed and, for the last time, just before the patient leaves the table. In 52 cases chloroform was given ; ether in 24 cases ; and the A. C. E. mixture in 13 cases. In the other cases more than one of these anaesthetics were employed. It was found that the cocaine diminished considerably the distress and oppres- sion felt by the patient at the beginning of the anaesthetic, and that the reflex irritation, as manifested by struggling, coughing and nausea, is diminished. 412 ARTIFICIAL ANESTHESIA. In from 10 to 20 of the cases there were sj'mptoms such a& marked pallor and acceleration of the pulse rate, followed by profuse sweating, which were considered directly due to cocaine. There was less nausea, vomiting and malaise than usually fol- lows anaesthesia. Vomiting is recorded as following 25 per cent, of the cases. In alcoholic cases Rosenberg's method affords little advantage over the usual anaesthetization. {Ame?-- ican Medico- Surgical Bulletin^ February 8, 1896, p. 192.) Another method has been proposed by Dr. David H. Loud- Ion, of Denver. A preliminary spray of the pharynx and naso- pharynx with a mixture of ether one part, and liquid petrolatum two parts, with a solution of cocaine if desired. ( The Phila- delphia Polyclinic, February 8, 1896, p. 55.) CHAPTER XVII. On the Use of Cocaine in the Teeth, Nose, Throat and Eye. Every now and then there are reported in the medical jour- nals the most absurd statements of poisoning by cocaine. The following is an example, no name nor journal given : '' Suffered from toothache, the tooth being ' dead ' and the nerve canal having been drilled out (acted as his own dentist), and con- cluded to extract, and the tooth broke. Injected the gums with a two per cent, solution of cocaine. (Not stated if freshly made or what the cocaine was dissolved in, alcohol or water, hot or cold. Or if he had the right kind of syringe, which should be longer than ordinary hypodermic, with handles so that sufl&cient control over the force can be made to penetrate down to the tooth.) Waited half an hour and again injected about the same amount of cocaine, and still failed to secure the offending root. It still paining, concluded to inject the nerve canal, and inserted needle and making considerable pressure (irregu- lar), when suddenly the plunger went home, and about twenty drops (more or less) of the solution passed into the alveolar WAS IT COCAINE POISONING? , 413 process. Instantly all pain ceased. (Cocaine is not instantane- ous in its action.) "In thirt}' minutes, however, I liad a decided rigor, followed by profuse sweating and vomiting, cold extremities and a ter- rific headache. These symptoms continued for some forty-eight hours. Not over a drachm (or hi gr. of cocaine) of the two per oent. solution was used." All of these sj^mptoms might well have followed such a bungling operation, and not one particle of cocaine need have been employed. Here is just such another case: Was it Cocaine Poisoning? On November 27th I was hastily called to the ofl&ce of our den- tist, and found there a case as follows : Female, about 28 years old, married, and the mother of three children, the youngest about four months old. She had had three teeth extracted (the last one broke), and for a local anaesthetic about forty minims of the following solution had been used : ^> Cocaine hydrochlor., gr. vj Pheuacetiue, gr. xxiv Menthol, gr. v Ether, m. xxx Glycerine, dr. j Water, • . oz. j. M. " As the last one was being drawn she became unconscious and respiration ceased. It was on the opposite side of the village from my office, and when I got there I found her much in the same condition as above described, though the heart's action was good, considering the length of time she had been in this condition. I immediately gave -^ gr. strych. nitrat. hypoder- matically, followed with whiskey, and used artificial respiration, and in a few seconds she began to breathe, and after about three-fourths of an hour began to try to talk. After a short time I had her removed to her home, but on reaching there she had relapsed into the same condition as at first, and this time the pulse was so weak that it was scarcely perceptible. I immediately gave 3^ gr. strych. nit. hypodermatically and more 414 « ARTIFICIAL ANESTHESIA. whiskey, and in a few minutes she had rallied sufl&ciently, so I gave her aromatic spirit of ammonia by the mouth, and in an- other half-hour she began to call for her baby. Did not let baby nurse until next morning, and then not until the breasts had been emptied twice with the breast-pump. On the follow- ing day, i.e., on the 28th, I found her sitting up, but she com- plained of feeling so very tired. She has made a good recovery. " Now, was it the effect of the fluid used, or did it come from the shock produced by breaking the last tooth ? I know it was not all hysterical, and besides, she has never had hysteria in the past. Did the fact that she was a ' nursing woman ' have any- thing to do with the case? The dentist told me he thought she swallowed some of the fluid which leaked out of the syringe and fell into her mouth, and that the gums did not bleed very much. " I have used cocaine (four per cent, solution), being careful to not exceed ten minims at a time, since I have been practicing medicine, and have used it regardless of the color of the hair and eyes, and have never had any bad results from it."* In both of these cases there were large doses employed, and the cocaine also swallowed. The hysterical element had also an important influence in these so-called cases of cocaine poisoning. It is well known to all surgeons of any long experience that the most simple operation in minor surgery will be followed by syn- cope, difficulty of breathing, fainting and prostration, and indeed all the symptoms described as poisoning, as in the above case, all of which can be promptly relieved with aromatic spirits of am- monia and whiskey. Cocaine is not necessarily a dangerous anassthetic if carefully prepared with distilled, sterilized water, and used in an absolutely clean hypodermic syringe, for in the last six years there has not been one death due to its use, in the city of Philadelphia. If it is to be kept a short time, add a small amount of phenol, say five per cent. If the patient is feeble, add a minute quan- tity of morphia and atropia, 150th of a grain, as it sustains the heart action ; careful compression by the fingers each side of the tooth, by an assistant, in extraction. * C. H. Herrick, M.D., Gilbertsville, N. Y., Medical World, Jan- uary, 1896. USE OF COCAINE IN THE NOSE AND THROAT. 415 The Use of Cocaine in the Nose and Throat. There are certainly but few individuals who are so susceptible to the influence of cocaine, that it cannot be carefull}^ applied to the nose or throat by means of a pledget of absorbent cotton charged and applied to the part to be operated upon. By this we are able to determine whether the apparent hypertrophy of the tissues is real or only temporary. We very rarely spray the part, but apply solutions varying from four to ten per cent. If it is simply to diminish secretions, we use the four per cent. ; but when a polypus, tonsil, or part of the turbinated bone is to be removed, we increase the solution to ten per cent. In this manner we can apply, without pain, a small ball of chromic acid, chloroacetic acid, or crystals of nitrate of silver. After the production of local anaesthesia, with shrinking of the erec- tile tissue, in the course of a shorter or longer period there occurs a decided reaction, and the blood returns with great force. To prevent this we spray the part with an alkaline solu- tion, and then with a four per cent, solution of antipyrin. If there is acute or chronic rhinitis, it is treated by spraying the nasal fossae every other day with liquid vaseline or alboline, in which are dissolved in each ounce five grains of menthol with two of extract of eucalyptus. This local treatment with cocaine we have kept up for the last six years with satisfaction, and with the exception of once in a while as in the case of an hysteri- cal woman, who, after the application of a solution of cocaine to her nasal mucous membrane, will suddenly feel faint, with di- lated pupils, extremities cold, and heart action rapid and feeble ; but this is soon relieved by placing her flat on the ground, and applying a few whiff's of ether with ammonia to the nostrils, and administering from thirty to sixty drops of aromatic spirits of ammonia internally with water. Cocaine in Diseases of the Ear. — In our third edition, on pages 86 to 90, will be not^d that we have used cocaine very freely in diseases of the ear, and found it of great value in re- lieving pain within the middle ear when removing diseased structure, bone tissue, and especially in ulcerations, in which we use the curette with the application of powerful agents to the parts with the same precaution as in the throat or nose. We 416 ARTIFICIAL ANAESTHESIA. now but seldom use the general annestlietic except in deep-seated operations, when the ossicles are remov^ed, or diseased mastoid, or large masses of dead bone. In every instance in which we use cocaine to the ear, especially when the drum-membrane is removed, we apply it by absorbent cotton to the part to be treated, and always after five minutes follow it by the four per cent, of antipyrin sprayed over the part. When we employ it in the Eustachian tube or in the pharynx, in its vicinity we tip the Eustachian forceps or delicate appli- cator with absorbent cotton, and then charge it with cocaine solution, avoiding all excess which may pass into the interior. Even when it passes into the oesophagus, we maj' find a small portion produce only dryness with a loss of taste for a few hours. Cocaine in Diseases of the Eye. — The proper method of preventing any injurious influence upon the eye is, in all cases of operation, to use the solution of two to four per cent., which should be made fresh each time it is required. The packing of the hypodermic syringe is also to be cleansed by passing through the same antiseptic solution, as it is apt to become foul. When it is given to a patient as an ordinary eye-wash, a solution of boric acid is made with a minute portion of cocaine added, and this solution is to be employed with a dropper kept in an air- tight bottle and case. The dropper is to be carefully washed out with a hot antiseptic solution of bicarbonate of sodium in boiling water after using it. Deaths from Cocaine. In a recent article"^ by a medical gentleman of experience in the use of this valuable anaesthetic, cocaine, he stated there had been a very large number of deaths from this agent. Fearing that I might not have an account of all the deaths, I wrote to him, desiring him to be so good as to give me a list from the numerous researches he had made, of. any cases of death since my enumeration up to 1890. The following was his kind reply : *• Med. and Surg. Eeporter, February 15, 1896. DEATHS FROM COCAINE. 417 " FEBRirARY 20, 1896. ''^ My Dear Doctor : "The following cases of death, due to the injection of co- caine, have come to notice since 1890. There have been, of course, many more during the past five years, but one finds, on looking up the literature of the subject, that many writers have reported numbers of cases at a time, and do not specify the dates, so I cannot state how many cases occurred before and since 1890. "The Lyons Medical, Lyons, published in August, 1891, a report of a death in a dentist's ofiice. " Delbose reported five deaths in the Journal de Medicine et de Chirurgie, of Paris, February, 1891. "In 1892 and '93 Dufournier reported nine deaths in the Archives G-enerales de Medicine." This we found to be a mistake, as his last case was Septem- ber, 1888, and published in October, 1889. In my third edition (p. 49-55), 1890, there was reported every case of death from cocaine in full up to December, 1889 ; in all, eight cases, when we went to press, from the time of its intro- duction in 1855. Most of the cases of death were obtained from a monograph by Dr. Mattison, of New York, and my own examination of every journal published, both of this country and of Europe. The following were my conclusions after a care- ful study of every case reported. There has been as far as I am informed but one death reported as having occurred in this city^ In a careful reading of Dr. Mattison's before-referred- to mon- ograph we found a few points on which we wanted a little more definite information, and wrote to him for that purpose, but re- ceived no reply. The name of the journal in which were given the details of the Russian surgeon's case is not reported. Might not the operation of scraping and cauterizing a tuberculous ulcer have caused the death of the young woman ? Was not three-quarters of an hour a long time before the cocaine had developed its toxic efi'ects? We find, as a rule, they are decided in five to eight minutes. We cannot find the number of the American Lancet in which the case is reported by Dr. Long. What was the disease of the larynx ? The case of Dr. F. M. 418 ARTIFICIAL ANAESTHESIA. Thomas was not reported in any medical journal. Judging from the symptoms, the woman died from paralysis, and had been under treatment for the same. We were unable to find where Dr. Knabe's case was published. Such cases frequently die from cardiac degeneration followed by dropsy, the result of scarlatina ; the dose was so small, only four to twelve drops — the exact amount not determined — of a four per cent, solu- tion. Now we come to the case of Dr. Simes, of Philadelphia. In reading this case over carefully we are of the opinion, from the symptoms and post-mortem record, that the man had been an epileptic; and again a twenty per cent, solution is too strong, and should never be employed in the urethra or rectum,* as it enters the veins by endosmosis, and it also acts upon the spinal nerve, and has been found a true cerebro-spinal ex- citant in large doses. The dose internally is one-sixth, one- fourth, one-third of a grain. We find that with a two per cent, solution, with acid carbolic gr. x. to the oz., we obtain all the results we desire if repeated, and if possible controlled by posi- tion, or a ligature, as suggested by Corning, of a rubber tube. The case reported by Abadie is very imperfect in its details and cannot be received until further information is obtained, still we consider it our duty to publish all the cases of alleged deaths, so as to induce a proper caution in persons who have never employed the drug, just as we do in prescribing morphia and other powerful alkaloids. In the two cases reported by "Lanianchi and Montalli " the first was an epileptic and the second one afflicted with phthisis. In one case Montalli gave in mistake twenty-two grains of the drug. Reclus reported to the Societe de Chirurgie, 21 Mars, a case of death from cocaine. It occurred in the hands of another doctor. The patient was a man, aged 72 years, affected with enlarged prostate and retention of urine. Aspiration was per- formed, and the next day, it having been found again impossi- ble to enter the bladder through the urethra, he injected twenty * Six grains has produced poisonous symptoms when employed, in the rectum. DEATHS FROM COCAINE. 419 cubic centimetres of a five per cent, solution of cocaine. The man was at once seized with tremors, became pale, and succumbed in a few minutes. Reclus states that, as a general rule, a two per cent, solution only should be injected, and not more than fifteen to twenty centigrammes of it at a time. If these two rules had been observed the accident would not have taken place. — La Tribune Medlcale, March 29, 1894. Being desirous of obtaining the record of deaths from cocaine and verifying those cases of deaths which I had obtained up to the time of my edition of 1890, I wrote to my friend, Dr. Marcel Natier, of Paris, who most kindly sent me the Arch. General de Medicine, October, 1889, which I found contained three extra cases, making in all eleven deaths, which were as follows : Case 9. An interne of the University College Hospital had ordered 1 gram. 25 cent. gram, of cocaine with the intention of injecting it into the bladder of a man, 30 years of age, troubled with acute cystitis. Unfortunately he had neglected to state the use of the drug on his prescription and the druggist delivered it, telling the nurse it was probably a potion. It was given as such, and the patient succumbed. It was not at first pronounced an accident, but at the end of a half-hour convulsions set in, and from those he died. — Bull. Med., 24Fevrier, 1889. This was a case of direct poisoning by the use of over 15 grains, and no means employed to prevent its fatal effects. Case 10. A woman swallowed by mistake 5 grammes of a solution of chlorohydrate of cocaine, 30 per cent. A quarter of an hour after the ingestion the patient was taken with a spasm of the throat, nauseated without vomiting. The lips became cyanosed, the pupils dilated, the pulse almost imperceptible, and the patient succumbed amidst convulsions. At the post-mortem a small cavity was found in the right lung, with a slight fatty degeneration of the heart. The brain, 420 ARTIFICIAL ANAESTHESIA. the meninges and the abdominal viscera were congested. (Mon- talli, Lo Sperimentate^ Sept., 1888.) A more recent case of recovery was reported by Dr. M. V. Ball, of Philadelphia, where a patient of his, with a suicidal intent, swallowed a solution of cocaine (6 drachms), of a five per cent, solution of cocaine, equal to about 1 82" grains. Reco- very took place under the use of black coffee ; strychnine, ^V grain, was administered by the mouth, and some champagne was given. The early administration of ^ of a grain of morphia did probably influence the course of the case. I am also indebted to Dr. Natier'^ for the following death which have occurred since 1890, only three cases in six years, and which confirm my observations that in the proper selected cases and the exact dose, not to exceed J grain, it will be found the most valuable local anaesthetic that we can employ, especially when associated with small quantities of morphia and chloride of sodium in solution. Dr. Bergu relates the history of a man who, in October, 1891, was operated upon at the Hospital Lariboisiere for a sim- ple hydrocele, of medium size, of two months' duration. He used an injection of iodine after anaesthesia of the vaginal tunic, by means of a soupspoonful (probably a tablespoon — about 250 M. — 5 grains) of solution of hydrochlorate of cocaine, fifty per cent. After twenty minutes' rest, the patient left the hall, but returned ten minutes later, feeling indisposed ; went into a state of syncope, followed by convulsions and pupillary phenomena. Injections of ether, artificial respiration, tracheotomy, inha- lations of oxygen, all were useless, and death followed rapidly. The well-known and usual clinical and experimental symptoms of cocaine poisoning were well manifested. The autopsy made by Dr. M. Richardson (who had already reported medico-legally 11 cases of death from cocaine, all that he could collect since its introduction) revealed no mortal lesion. There was only * Dr. Marcel Natter, Chef du Service des Maladies dii Nez, des Oreilles et da Larynx a la Polyclinique de Paris; Editor Eevue Inter- national, Rhinologie, Otologic and Laryngologie. COCAINE IN GASTRITIS. 421 congestion of the brain and lungs. There was a slight mitral insufficiency in the heart, which, perhaps, favored the acci- dent, but could not have had an important effect. The dose of cocaine, however, was not extraordinarj'— usually one puts in the tunica vaginalis o. g. So. of cocaine for 30 grammes of water. Perhaps the thin coating of this acute hydrocele ab- sorbed the drug with unusual rapidity. In any case, M. Bergu, who, after numerous operations, would have affirmed, some weeks ago, the absolute harmlessness of this procedure, de- clares, without denouncing cocaine, that at his next hydrocele he will hesitate. M. Eeclus believes that the maximum dose employed by Hcenel is dangerous ; that even gr. 0.3 cent.— which was the quantity used with M. Bergu' s patient— is also dangerous. In Dr. Keclus' first experiments he uses the doses of 0.3 cent.,* and has had now and then serious enough accidents. He does not exceed gr. 20 cent., and he usually injects into the hydro- cele— not evacuated— a gr., .05 cent., on gr., .075 cent., a syringeful, and has never had the slightest alarming symptoms, while angesthesia has been very well produced. To exceed this dose is both useless and dangerous. It is absolutely necessary to recognize the possibility of danger from rapid absorption through the thin coating of an acute hydrocele. * The French use the abbreviation gr. to signify gramme and c. for centigramme. 422 ARTIFICIAL ANESTHESIA. CHAPTER XVIII. Therapeutics of Cocaine — Gastritis produced by Poisoning treated by Cocaine, and Aflfections of the Stomach, Tetanus. Skin Disease. Cocaine in Gastritis Produced by Poisoning-. In a recent case published by a physician* in Scranton, Pa., a young girl, after an unsuccessful attempt at suicide by lauda- num, took "Rough on Rats." She was given ipecac and sulphate of zinc ; also large quantities of dialized iron and lime- water. Two grains of morphine were administered hypoder- matically in divided doses during the night, and the woman was kept anaesthetized by means of chloroform and ether for twelve hours. Whenever the anaesthetic was withdrawn, the patient would rebel, and was with diflBculty held by three persons when not profoundly under the influence of ether. Twelve hours after the poison had been taken, the girl was still in terrible agony, and showed signs of collapse. It was suggested by an- other physician that over half an ounce of a four per cent, solution of cocaine hydrochlorate (about ten grains) should be administered, it being supposed that all the arsenic had been vomited or neutralized, and that gastritis had set in. In a few minutes the patient ceased to complain of her stomach, the mania subsided and the anaesthesia was discontinued. The pulse grew stronger, and the woman was soon able to walk with assistance. Cocaine in Affections of tlie Stomacli. Cocaine has been found most useful in certain affections of the stomach. From the researches and clinical observations we arrive at the following conclusions : 1. That cocaine exerts on * Dr. J. Emmet O'Brien. COCAINE IN BOULIMIE OR INSATIABLE HUNGER. 423 the mucous membrane of the stomach, and that of the diges- tive tube, an action as certain as on the external mucous mem- branes. 2. That for this action to be as complete as possible, one must facilitate the impregnation of the gastric and intesti- nal mucous membranes by promoting their secretions. Hence the advantage of associating cocaine with alkalies.* For the action to attain its maximum duration, one must add to this mixture very small doses of morphine. Cocaine in Persistent or Uncontrollable Vomiting. From the peculiar action of cocaine upon mucous membranes and vascular tissue, it was supposed, theoretically, to be capable of diminishing the sickness of pregnancy and other severe irri- tation of the stomach of a reflex character. It has been tested in a number of cases with more or less success. Cocaine in Lavage or Gavage. In the act of inserting the stomach pump or tube there is almost always pain and spasm, due to the contractions which take place on the isthmus of the fauces, which may be obviated by painting with a two per cent, solution of cocaine. It has been found very valuable in certain spasmodic and even per- manent stricture of the oesophagus; where dilatation is re- quired, a two per cent, ointment is applied to the tube. Cocaine in Boiiliinie or Insatiable Hunger. This peculiar intense and insatiable hunger or canine appe- tite is peculiar to pregnancy, and can in some cases be relieved by small doses of hydrochlorate of cocaine, ^ to t^^ or even k of a grain taken at intervals, in pill form, while in the recum- bent posture. * It must be remembered tbat caustic alkalies decompose the cocaine. 424 ARTIFICIAL ANESTHESIA. Tetanus Treated by Morphia and Cocaine. Lopez is quoted by the Journal of Nervous and Mental Dis- eases, for December, 1887 (Medical News, January 28, 1888), as reporting in an Italian journal the following case : M. Gr., fifty years old, having worked in the cold and wet, complained of rheumatic pains in the back and extremities. Three days after he had an attack of opisthotonus, painful spasms and all the symptoms of idiopathic tetanus. Morphine and chloral hy- drate were prescribed. For three days the patient, under the influence of these medicines, had little pain ; but there was in- creased muscular rigidity and spasms. At last he was unable to swallow, and death was believed imminent. Injections of morphine were without efi"ect. Then the writer injected three syringefuls of a mixture of morphia and cocaine, five per cent, of each. The eff'ect was immediate. After two hours he could move the extremities, open his mouth and turn himself in bed. The next day he continued to improve. There remained a slight trismus and a little rigidity of the neck. A quarter of a syringeful of the same solution was injected in each side of the neck, and the day after all the symptoms had disappeared. Cocaine in Skin Diseases. Lustgarten ( Wiener Med. Wochenschrift, November 12, 1887) states, what we demonstrated soon after cocaine was discovered, that where the epidermis is in contact, cocaine ajiplied to the skin is not absorbed ; but where the horny layer is thin or absent (removed by alkalies, alcohol or chloroform), it acts. A two per cent, solution used several times daily allays the itching in acute and subacute eczema, being especially valuable in eczema of the anus and genital regions of both sexes. In the form of ointment he employs oleate of cocaine, from 6 to 15 grains; lanolin, 4 J drachms; followed by the use of a dusting powder (two of the best are finely-powdered talc or lycopodium). In pruritus ani, suppositories may be made containing three- fourths of a grain of oleate of cocaine. The author cautions against the toxic effects of cocaine, three cases of this kind having been encountered when only three-fourths of a grain had been used. COCAINE IN CRACKED NIPPLES. 426 Treatment of Chilblain. Apply with cotton or wool a four per cent, solution of co- caine for ten minutes ; then remove the cotton and cover the parts with compound tincture of benzoin. This repeated a few times will entirely relieve the pain and irritation. A valuable ointment for the same disease is equal parts of oil of turpentine and compound rosin ointment. Apply by rubbing in the ointment near a hot fire at bedtime. Another salve is recommended by Dr. Lassar : ^^ Acid carbolic cry St., ..... gr, xv. Ung, plumbi, 5v. Lanolin, 5iiss, Oil amygdal., Oil lavend. aa . . . gr. xx. M. Cocaine in Intense Itching- of the Skin. In the various forms of pruriginous affections of the skin, cocaine with vaseline or a two per cent, solution in alcohol will allay the distressing itching of the skin. Cocaine in Biu*ns. Either the solution, or ointment of cocaine, has the great advaritage of dissipating the intense pain of severe burns when in a two per cent, solution. Cocaine in Anal or Vulval Priu'iency or Painful Herpes. ^ Cocaine oleat., . . 40 to i gramme (gr. viiss. to xvss.). Lanolin, . , . 18 grammes (3v.). 01. oliv., . , .2 grammes (gr. xxxi.). To be used several times a day. — Gaz. Hebe, des Sci. Mede., Montpelier, Jani 14, 1888. Cocaine in Cracked Xipples. A two per cent, powder of hydrochlorate of cocaine and starch, applied to the fissure in the nipple of nursing women, 28 426 ARTIFICIAL ANESTHESIA. covered with collodion, will relieve the distressing pain. The same good results follow fissures of the skin of the hands during very cold weather. A few inveterate cases require first to touch the fissures with a fine pencil of nitrate of silver very gently. Cocaiue in Acute Catarrh, Coryza, or Cold in the Head. In acute catarrh, or cold in the head, we have a condition of engorgement of the blood-vessels in the nasal mucous mem- brane, and the secretion, which at first is thin and water}^ through hyperstimulation of the glands, soon becomes more charged with broken-down epithelial cells, lymph corpuscles, pus globules, etc., until it assumes the character of thick, tena- cious mucus, or muco-pus. If cocaine be applied early to the membrane in a case of acute coryza, its constringing influence on the membrane must diminish the blood supply, and thus prevent the engorgement and transudation. We have person- ally tested its abortive action in an attack of coryza. As soon as the initial stage has passed over, and secretion commenced, a four per cent, solution should be applied freely over the interior turbinated bones of each side. As is well known, the coryza of nursing infants and young children may, by preventing suckling, prove a very serious afl*ection. It can be cured, however, by the introduction into the nasal cavity, six times daily, of a one per cent, solution of the hydrochlorate of cocaine, on cotton, for five minutes. Ac- cording to the author, children who previously had obstinately refused to nurse will commence to suckle a few minutes after the first application of the cocaine, and the coryza is ordinarily cured after about four days of this treatment.^ ^t Hydrochlorate of cocaine, . . . i gr. Very finely powdered starch, . . .49 grs. Mix intimately. SiG. — Use at intervals of about an hour until relieved. *' This treatment is made more successful by the spray of the anti- septic tablets of Dr. Seller ; also useful in hay fever to cleanse the parts. COCAINE IN WHOOPING-COUGH. 427 Cocaine in Hay Fever. Sir Andrew Clark prefers to use a solution of five per cent., applj^ing it to the interior of the nose and back of the soft palate, by means of a large camel's-hair pencil attached to an aluminium shank, and bent at an appropriate angle. For use in the form of nasal bougies a quarter of a grain or more of the hydrochlorate of cocaine is dissolved in a mixture of gelatine and glycerine, and made of different weights and shapes, according to the peculiarities of the case on which they are to be employed. Cocaine and Phosphate of Lime in LarjTigeal Tuberculosis. Professor John Schnetzler used phosphoric acid in different degrees of concentration, even in full strength, applied by means of a brush or the S3Tinge to the larynx, producing pain in some cases, which he obviates by the use of the following powder : ^ Cocaine mur., 0.1 (gram.). Calci. phosphor., 100 01. menth. pip., . . . . . gtt. v. M. Use by insufflations. Though the remedy has no specific influence on the tubercular process, relief (and under favorable conditions also recovery) has been obtained in several cases ; it is also an excellent rem- edy in all catarrhal affections of the upper air passages. — Jour. Am. Med. Association, January 21, 1888. Cocaine in Whooping- Coug-h. Dr. Weintraub, of Eydknhuen, prescribes the following formula, with good results : ^ Cocaine muriat., . , . . gr. j. ^ to 1 gr. Aqu.-amygd. amar., . . . 5iiss. M. Si«. — Ten to fifteen drops several times a day. —Alg. Med. Central Ztg., 91, 1887. 428 ARTIFICIAL ANESTHESIA. Cocaine and Resorcin in Wliooping--Cough. Resorcin has been found one of the most available remedies in pertussis, reUeving the bacterial origin of the disease. Since 1885 cocaine has been used as a preliminary to the resor- cin, as we found that it lessened the intensity and frequency of the cough before the resorcin had time to destroy the morbific germs. We use a four per cent, solution and an eight per cent, solution of resorcin ; and this combination constitutes the best treatment for whooping-cough now at our command. Cocaine Mixtiu*e for Relief of Coug^h and of Chronic PliarjTigitis. The following formula has been recommended for the relief of the cough in chronic pharyngitis : ^ Cocaine, gr. iss. Glycerine, fSj. Aquse dest., f 3x 5ij. Acid carbol., gr. i- SiG. — Apply morning and evening with a suitable brush. — Medical News, April 11, 1885 . ^ ^ Cocaine by Insitfflation and Inhalation. A. Inhalation. ' Cocaine hydrochlor., . • gr. iij. Potassii chlorat., .... . 5ij. Aquse laurocerasi, . fSxij. B. Insuffiation. * Cocaine hydrochlorat, . . gr. j. Morphise hydrochlorat, • gr.j. Bismuth sub-nitrate, Sacch. alb., . . . aa . . 5j. ij. M. Cocaine in Paroxysmal Sneezing. ^ Sol. of hydrochlorate of cocaine (4 per cent.), 5j, Acid carbolic, 5j. Tinct. camphora, 5iss. Aquee, 5ij. M. Lotion. Syringe or spray the nostrils each morning with posterior nasal syringe or spray apparatus. COCAINE IN DISEASES OF EYE AND EAR. 429 Dr. Da Costa [Med. and Surg. Reporter, Nov. 7, 1885), hav- ing found solutions of cocaine favorable in rose cold or hay fever, concludes as follows : That the remed}" is not radical, and, strictly speaking, curative. He has found that it gives great comfort, converts severe into light cases, enables to remain in their homes those who otherwise are obliged to flee to hay fever resorts, and relieves much suffering and distress. After the suffering and distress are relieved by the cocaine we have found permanent relief from the spray of a solution of peroxide of hydrogen, one-half ounce to half a pint of pure water. The spray apparatus must be of glass or rubber, as all metallic contact destroys the peroxide of hydrogen. Cocaine in Astlima. Mosler, of Grreefswald {Birin. 3Ied. Review, p. 2.36, Nov., 1886), points out that cocaine has a central as well as a periph- eric local action on the sensory nerve endings, and this central action is at first stimulating, but afterward sedative or narcotic. By both these reactions cocaine ought to be of use in asthma. Beschorner has published two cases in which it was of service, and Mosler in three cases has obtained excellent results. All these were uncomplicated, and occurred in young people of twenty-three to twenty-five years of age. The drug was given subcutaneously in two per cent, solution. CHAPTER XIX. •Cocaine in Diseases of the Eye and Ear — Eucaine Hydrochlorate, a Kew Local Anaesthetic. The best antiseptic solution of cocaine contains gr. -^u^ of bichloride of mercury, and may be employed after keeping a few days, if made with pure distilled water. I have found that a strong solution will cause a feeling of roughening, and will detach the epithelium of the eye. This will require an infusion of pith of sassafras, with camphorated tincture of 430 ARTIFICIAL ANAESTHESIA. opium (a teaspoonful in a coffee cup of the tea), to relieve the disagreeable symptoms. The cocaine should be a two per cent, solution, and freshly made when required. The question of using a freshly-prepared solution is of the utmost importance. Cases of irritation and inflammation often occur after using solutions too strong or containing mould. Like- wise the syringe must be kept scrupulously clean, and after wash- ing and wiping, draw a few drops of equal parts of olive oil and liquid carbolic acid up and down the needle, then wipe it dry. Cocaine in Diseases of the Eye. Five cases of ordinary catarrhal conjunctivitis were treated successfully, but not worthy of being reported in detail. Case Sixth. — Case of cyclitis in a young lady of sixteen, C. G. , at school, with extreme pericorneal congestion. The pain in the eye was very much relieved by dropping in a two per cent, solution of the hydrochlorate of cocaine, and congestion disappeared as if by magic. She was directed colored glasses, and not to use her eyes ; when the pain returned, to drop in one or two drops of the same solution. Case Seventh. — A gentleman, T. L., aged sixty years, with catarrhal conjunctivitis, which attacks him during autumn and remains most of the winter, increased by cold winds and read- ing by gaslight. He was suffering from a discharge in the morning and burning through the daj^ I applied a two per cent, solution to the eye with a brush, when he complained of a slight smarting for a few seconds. After the smarting had disappeared, he bore without flinching a solution of boro-glyce- ride to get rid of the excessive secretions which blurred his vision at night. It also removed the red and irritable appearance of the edges of the eyelid. Case Eighth. — This case is similar to No. 6, only in a lady of thirty-nine, who has a great deal of writing to do, and is em- ployed in a book-bindery ; but a few applications of the two per cent, solution relieved her. In two of the eye cases, dilatation of the pupil took place ; but not for some time after full application ; it caused slight dryness, but did not interfere with the vision. TREATMENT OF OONORRH(EAL OPHTHALMIA. 431 Case Nintli. — Case of acute coryza without pain, but sneezing, complained that when the solution was applied by means of a dropper it caused her pain, but there was no return of painful sneezing, which is in certain families the forerunner of the swelling of the mucous membrane with cold in the head. Case Tenth. — A gentleman, aged thirty-seven, who has a broken nose and a hypertrophic catarrh on very slight exposure, was attacked on the evening of the 23d of January with great oppression. Having to ride in the countrj' in an open carriage and stand in mud and ice for some hours, he returned in the evening with a feeling of great distress and pain in his head, and mucous membrane of the nasal passages much swollen. Two applications of a two per cent, solution of the hydrochlorate to the whole surface of the posterior nares at intervals of five minutes, followed with a five per cent, solution of the alkaloid in oleic acid, gave him great relief, so that he could breathe with comfort and satisfaction. He was then directed one-eighth grain of morphia sulphas, and one-hundredth of atropine, to be taken at bed-time. 24th. — Still sufi'ering somewhat from the difficulty of the breathing through the nostrils, but a repetition of the applica- tion of the oleate relieved him entirely. January 26. — Discharged the patient, cured. Case Eleventh. — Catarrhal inflammation of the eyelids, known as blepharitis marginalis, with defective vision, in a school girl, aged ten years. The crusts around the eyelids were removed twice with a warm two percent, solution of cocaine, after resting for a time ; then the eyelids were painted with a solution of boro-glyceride ; these two preparations used together entirely removed the redness and gave great relief to the little patient. She was directed to continue the use of the solution of boro- glyceride for some time, not to use her eyes, and wear smoked glasses when in the sun. Cocaine in the Treatment of Gonorrlioeal Oph- thalmia. Mr. x\. Leahy reports (in the Indian Med. Gazette., July, 1886) two cases of gonorrhoeal ophthalmia, in both of which 432 ARTIFICIAL ANESTHESIA. the greatest benefit was derived from application of cocaine. As it is well known, in gonorrhoeal ophthalmia it is of primary importance to lessen the inflammation rapidly, to relieve the intense congestion of the conjunctival vessels and reduce che- mosis, and by so doing prevent ulceration and sloughing of the cornea. Last, but not least, is the relief of the ocular and cir- cum-orbital pain, which, by its persistence, greatly depresses the patient and prevents sleep. Mr. Leahy employed a mix- ture composed of one-half grain of sulphate of atropine and two grains of sulphate of cocaine incorporated with one hundred grains of vaseline. This mixture was introduced beneath the upper ej'^elids, and after three days' treatment the chemosis rapidly became less, the discharge diminished in quantity, the pain completely disappeared, and the cornea, which had been hidden by the chemosis, became visible. Cocaine and Atropia for Iritis. Guaiaila gives the following as used by many ophthalmolo- gists : ^ Cocaine hydrochlor., . . . . gr. i. Atrop. sulphat., . . . . . gr. 1. Acid boric, gr. iv. Aquse destillat., . . . - . Siiss. M. SiG. — One or two drops in the eye every half hour until the pupil dilates. — jL' Union Medicale, June 25, 1887. On the Use of the SoUition of Cocaine Hydrochlo- rate in Ear Disease. Nov. 20, Gr. B. M., M.D., applied for deafness in both ears, but especially the right. On examination found the sides of meatus and lumen filled with separated masses of scales several millimeters in length, firmly attached to the parts, which, on removal by the forceps, gave him great pain. He also found the pressure of the ear speculum painful. This was explained after the removal of a portion of these diseased scales by find- ing the under surface inflamed, reddened, and ready to bleed at the sHghtest touch of the instrument. To obviate this pain and COCAINE HYDROCHLORATE IN EAR DISEASES. 433 allow the entire removal of this desquamated material, a four per cent, solution of hydrochlorate of cocaine was instilled into the ear every five minutes for fifteen minutes. At the end of this period, again began removing the offending material without so much pain ; still it was not a true anaesthesia, and if we made strong pressure with the speculum in introducing it, it also gave him slight pain ; still he was able to bear it much better with the solution, until all was removed from the right ear. He was then directed a sol. zinci sulpho-carbolate, grs. iv. ; morphia sulphas, grs. i.; iv. oz. of aqua destillata. For the left ear, after the use of the forceps, gave an alkaline solu- tion to drop in ten drops three or four times a day and rest for fifteen minutes so as to remove what scales were on the m. tympani. November 23, washed out the remaining scales, and inflated the middle ear, with great improvement of hearing in both ears. November 25th, H. F. M., aged 29, bank clerk, suffering from deafness and constant " ratthng or buzzing," from congestion and hypertrophy of the pharyngeal tonsils and mucous mem- brane of the post-nasal spaces, which required cutting freely with a tenotomy knife. Before doing so I applied a four per cent, solution of the cocaine, and although I made five differ- ent incisions into the enlargement, he was not aware that it was accomplished until he found a few drops of blood passing into his oesophagus. One week after he reported by letter of improvement in hearing. In this operation not one-fourth the amount of blood was lost as in such cases without the cocaine, the parts remaining quite rigid for some time after the opera- tion. November 29th. — Applied the four per cent, solution to a lady suffering from excessive secretions of glands of the throat, and passing into the Eustachian tube causing noises of a variable character. She suffered also from swelling and hypertrophic conditions of the posterior portion of the nasal mucous mem- brane and turbinated bodies. The parts were cleansed with spray of Dobell's solution, and a strong current of dry con- densed air was employed to free them from moisture, a flexible silver catheter was introduced first into the right side of the 434 ARTIFICIAL ANESTHESIA. nose and a nozzle was fitted to it, and then the elastic tube of the condensed air chamber, and a few drops of the solution of hydrochlorate of cocaine were introduced into the catheter, and the parts spra3'ed by forcing the air through it. In the same operation performed upon the opposite ear, there being a devi- ation of the septum, there was more pain, but very much less than when we introduced the instrument before. The spray- ing was repeated at three different times, when in about ten minutes she felt the peculiar apparent swelling and drying effects, and great relief from the noises, by the freedom with which air passed through the Eustachian tubes. The lady reported, a week after, improvement of hearing and more free- dom from the noises. Eucaine Hydrochlorate. This is a more recently discovered local anaesthetic, which acts physiologically like cocaine, but is less poisonous. The pulse with eucaine is always decreased in frequency; with cocaine there is primary acceleration. Eucaine causes no ischagmia, but vascular dilatation. Another difference is that the pupils are not affected ; midriasis does not occur, and the reaction to light remains normal. The convenient name of eucaine has been adopted in the place of its chemical one of methylester of a benzoylated oxypiperidin carbonic acid. See formula, p. 39. Like cocaine, its free base is with difficulty soluble in water and forms large shining crystals, melting at 104° to 105° G. (220° to 222° F.). With acids it forms neutral salts having the same action as the base itself. The hydro- chlorate, the salt which we have employed, cr^^stallizes from a watery solution in permanent shiny plates or scales, which con- tain one molecule of water of crystallization, and having a formula of 0i9H2,NO,HCl.H2O. " Local Action. — A two to five per cent, solution of eucaine instilled into the eye of an animal, as a dog or rabbit, caused complete local anaesthesia in from one to three minutes. It began in the cornea, and spread from thence to the conjunc- tiva, and lasted on an average from ten to twenty minutes. It was readily prolonged by repeating the dose. It was always EUCAINE HYDROCHLORATE. 435 accompanied by a slight hyperaemia and slight irritation of the palpebral conjunctiva. This was only the case with the methyl alcohol form ; the watery solution caused at most a very slight hyperaemia. The pupil was not dilated, and reacted well to light. Injected under the skin, eucaine caused complete anaes- thesia of the part, so that the reflex could not be evoked even with a needle. A similar complete local anaesthesia of the mucosa was affected when a eucaine solution was painted over it. " The general action of the drug^ both in cold and warm blooded animals, consisted in a marked excitation of the entire central nervous system, followed by paralysis in toxic doses- going on to death. Even 0.002 cent. gram. (-^ grain) caused irritability, heightened reflexes, inco-ordination, and finally general paralysis in the animals experimented with. Small doses administered to mice and rabbits caused increased reflex excitability and increased but weakened respiratory movements. Medium doses of 0.02 to 0.03 cent. gram. {^ to J grain) per kilo- gram (35 ounces) caused repeated tonic and clonic convulsions. The animals lay senseless on their sides, with dyspnoea, opistho- tonos, and finally paresis of the posterior limbs. These phe- nomena were most marked when large toxic doses of 0.10 to 0.15 cent. gram. (IJ to 2\ grains) per kilogram (35 ounces) were administered ; the convulsions returned continuously, and af- fected all the muscles of the body. The animals finally died when the paralysis reached the respiratory muscles. "When the dose was not a fatal one, the convulsions gradually ceased, the increased reflex excitability disappeared, and the paresis of the hind limbs slowly improved. "The effect of eucaine on the central nervous system is there- fore at first excitant, and later, in toxic doses, paralyzing. The paralysis is a central one, for if the sciatic nerve of a frog^ poisoned with eucaine is exposed, and its peripheral end irri- tated with the induced current, the limb reacts in a normal manner. "As regards its action on the heart and the bloodvessels, the subcutaneous and intravenous injection of small and medium doses slows it on the average from twenty to thirty 436 ARTIFICIAL ANiESTHBSIA. beats per minute, but without otherwise modifying the beats, or increasing the blood-pressure. This effect on the pulse is caused by the excitation of the central vagus ; for section of the vagi causes an immediate increase of the pulse to the nor- mal and above it, together with an increase of the blood -pres- sure. Death occurs from paralysis of the respiratory centres, for the heart continues to beat for some time thereafter."* Eucaine as a Local Ansestlietic.f "Dr. G. A'^inci, of Messina, described eucaine as possessing the properties of cocaine as a local anaesthetic, but as being less toxic and as having no effect upon the pupil. The last state- ment seemed to me to be of practical importance, because a dilated pupil is an impediment to the performance of many operations upon the eye. It has long been my practice to neu- tralize the dilating effect of cocaine by a preliminary application of eserine, but this course is not entirely satisfactory. It is difficult to secure the precise degree of effect w^hich is desired, while the eserine dilates the vessels of the iris and occasions free bleeding when they are incised. It also renders the iris tissue comparatively rigid, so that it is less easily drawn out of the anterior chamber. I obtained a supply of a five per cent, watery solution of eucaine hydrochlorate from Mr. Rodgers, of 327 Oxford Street, and used it last week for a cataract extrac- tion, the patient being a woman. Before my arrival the nurse had applied a drop of the solution within the lower lid every five minutes for six times, and I found the eye perfectly insen- sitive. The pupil was unaffected and acted readily to light. There was scarcely any bleeding from the cut iris ; there was perfect quiescence of the muscles and there was no pain. I asked the patient whether she had felt anything, and she re- plied : ' I felt something moving about my eye, but it did not hurt me.' There was no pain afterwards, and healing was un- interrupted. I have since successfully used a single application * Pamphlet from Schering and Glaze. t By Eobert Brudenell Carter, F.R.C.S., England, Consulting Oph- thalmic Surgeon to St. George's Hospital. From The Lancet, July 11, 1896. EUCAINE HYDROCHLORATE IN THE EYE. 437 of the same solution as a preliminary to the removal of a for- eign body imbedded in the cornea. "In the original paper it is said that eucaine has been suc- cessfully used in dentistry and laryngology, and that solutions may be injected hypodermically without injury. My first experi- ments will certainly induce me to use it again, and for tenoto- mies as well as for iridectomy or extraction. It is said that the solution, above mentioned, may be sterilized by boiling again and again, if necessary, without undergoing decomposition or suffering any deterioration of quality. Eucaine Hydrochlorate in the Eye. Having had made a careful solution of hydrochlorate of eucaine, two per cent., in distilled water (a second supply ob- tained from the regular agents. Sobering & Glaze), in July, 1896, it was applied to the eye of a patient, and it created both pain and lachrymation, with no soothing an aesthetic after-effects such as is produced by such a solution of hydrochlorate of cocaine. The following abstract from a letter, addressed to my son, ex- plains this peculiarity : "Dr. George Merling, the discoverer of eucaine, and likewise a director of the Sobering Chemical Works in Berlin, is of the opinion that the irritation was caused by some methyl alcohol contained in the preparation supplied heretofore." "Eucaine AND Cocaine. — In the Therajpeutische Moiiatshefte Blatter for July 23d, the suggestion is made, in consequence of the burning occasionally caused by instilling a two per cent, solution into the eye, that Berger's plan is followed, that of in- stilhng first a drop of a one per cent, solution, and then, after two or three minutes, a drop of a two per cent, solution. Ber- ger, it is added, uses eucaine and cocaine together, in the fol- lowing solution : ^ Eucaine hydrocliloride, Cocaine hydrochloride, . . aa . . 3 grs. Distilled water, 300 grs. M. "The exsanguinating action of the cocaine, often undesirable. 438 ARTIFICIAL ANESTHESIA. is thus avoided, and its action on the pupil and the accommo- dation is diminished one-half." — NewYork Med. Jour., August 18, 1896. Directions for the Use of Eucaine Hydrochlorate in Dentistry. " 1. Dissolve 1 gramme (15 grains) of eucaine in 10 grammes (150 minims or 2J fluidrachms) of distilled water and boil the solution. The solution should be perfectly clear, and is best preserved in a glass- stoppered bottle containing about 10 grammes (2J fluidrachms). ' ' 2. Thoroughly disinfect the mucous membrane before the extraction by cleansing it vigorously with tampons of absorbent cotton soaked in peroxide of hydrogen or other antiseptic solution. " 3. Insert the needle of the sj^ringe close to the edge of the gum, and never any higher than half-way the alveolar process. Enough fluid must be injected to whiten the mucosa in the im- mediate neighborhood of the puncture and cause a slight eleva- tion, and no more. Both a buccal and a lingual injection must be made. It is very important that the injection he not made at the point of junction of the alveolar and buccal mucous mem- branes. "4. Extraction is to be done as soon as the patient himself feels the anaesthesia, which is in about one minute, and not im- mediately after the injection. It should be done carefully and without the excessive application of force. "5. After the bleeding has ceased, the remaining eucaine solution must be removed by puncturing the swelling with the needle and maldng digital pressure upon the gum. " 6. Every extraction with resection is followed by some little swelling. When a good deal of eucaine has been employed, and when some of it has gotten under the mucous membrane lining of the bucco-alveolar furrow, we must warn the patient that there will be some swelling, which, however, will be entirely painless, and will retrogress spontaneously in one or two days. The oedema thus set up is entirely harmless; it disappears quickly and without pain, and is never accompanied by any by-effects. EUCAINE IN MINOR SURGERY. 439 "7. Before making an injection, care should be taken to ex- clude any air contained in the syringe. That is accomplished by holding the syringe needle upwards, and allowing a drop or two of the solution to ooze out." Report on Eiicaine in Dentistry.* "Dr. Laurence Turnbull: ^^ Dear Doctor : As requested, I have tested the ' eucaine ' which you furnished me in such cases as came under my care in the clinic. I also gave some to a gentleman who has a large extracting practice (using cocaine, one per cent.). The solution used in all cases was a two per cent, eucaine in distilled water, and about fifteen or twenty drops injected. It has proven very satisfactory, quite as much so as cocaine, in its local effects, and so far no ugly symptoms have shown themselves. About fifteen persons have had it injected, some for a number of teeth at one time. I did not note the pulse effects." Dr. A. A. Shaw, dentist, 615 Massachusetts Avenue, Cam- bridgeport, Mass., states, under date of June IT, 1896: "I have used eucaine hydrochlorate in a number of patients with gratifying results : so much so that I intend to continue its use. I am keeping the records of cases, and expect to make a report of the same for one of the dental journals. One thing I notice particularly is its prompt action and no after-effects." Dr. Walter Fleming, Hotel Imperial , Broadway and Thirty- Second Street, New York, states, under date of June 1, 1896 : " I have used it but once, but that very satisfactory, and I shaU continue it in preference to cocaine." Eucaine in Minor Surg-ery— Report of a Case.f " While cocaine has been of undoubted value in minor sur- gery, its use having enabled the surgeon to dispense with gene- ral anaesthetics in lesser operations, many cases have been re- ported in which its exhibition, even in very small quantities, has been attended with serious and even fatal results. If these * By Otto E. Inglis, Philadelphia Dental College, t By Arthur L. Fuller, M.D., Houston, Texas. 440 ARTIFICIAL ANAESTHESIA. accidents were due to the use of excessive quantities of the drug they could be guarded against ; but the^' seem to have occurred quite independently of the amount used, and this un- certainty of action has undoubtedly caused many surgeons to employ it less than they otherwise would have done. " It is claimed that in eucaine we have a drug which is prac- tically innocuous and which produces a local anaesthesia fully as effective as that of cocaine. While the reports of its use in ophthalmic and dental practice show that it has a very strong claim on our attention, very few reports of its use in general surgery have so far come to hand, and this emboldens me to report a case which is interesting solely from its employment as an anaesthetic. "Miss J, L. , aged 18, came to me with a large mole on her neck. The mole was so situated as to show above the back of her dress, and caused her much distress on account of its un- sightliness. After injecting endermically twenty minims of a ten per cent, solution of eucaine, I made an elliptical incision through the skin and removed the mole, together with a little surrounding skin. The piece removed was somewhat larger than a quarter dollar. The edges were then brought together with two sutures and a simple dressing applied. On the third day the sutures were removed and the wound covered with col- lodion. The place is now, eight days after removal, quite healed, only a thin red line marking the site of the operation. " In this case the anaesthesia, which covered an area as large as a half-dollar, was rapidly induced and absolutely perfect, the patient not even knowing when the incisions were being made or the sutures introduced, though the tissues were so hardened by the eucaine that it was only with difficulty the needles could be made to pierce it. Such perfect anaesthesia I have never seen induced by endermic injections of cocaine. I observed no bad effects on the circulation, though from the position of the mole there was no means of preventing the whole amount of eucaine entering the circulation in a very short time, and there were no bad after-effects, the wound healing well and quickly. "This case has given me a very favorable impression of eucaine, and I shall in future almost entirely substitute it for CHLORIDE OF ETHYL. 441 cocaine in my practice, reserving the latter for those cases in which sutures are required, for while eucaine seems to be the superior in the thoroughness of the anaesthesia induced, it so hardens the tissue that it is only with the greatest difficulty that sutures can be introduced, a drawback which may possibly be overcome by the use of weaker solutions, if such are found to act as well as the one used in this case. " Since writing the above, my friend, Dr. E. N. Gray, of this city, has described to me a case in which he used eucaine. The patient was suffering from a tubercular ulcer, and he wished to scrape away the diseased tissues. He tried painting the sur- face of the ulcer with a four per cent, solution of cocaine, but it had so little effect that the patient could not bear the scrap- ing. Some days later he tried an eight per cent, solution of eucaine and was able to curette the nicer freely with no discom- fort to the patient. He states that the anaesthesia was perfect, that it was induced more rapidly, extended more deeply and lasted longer than that of cocaine. His experience coincides with mine as regards the hardening of the tissues, and he in- forms me that the eucaine coagulated the pus, so that it came away like lumps of cheese."* CHAPTER XX. Chloride of Ethyl, or Ether Chlorhydric— Characters. Mode of Prep- aration, Discovery. Experiments of Clover— Mono-Chlorethane— Wigger's Anaesthetic Ether— Chloride of Ethyl as a Local Anses- thetic— Objections to Powerful Eefrigerative Agents— Experi- ments with Chloride of Ethyl and Pental by Dr. H. C. Wood and David Cerna, M.D.— Compounds, Phenol, Camphor, Menthol, and Eesorcin — Antipyrine as a Local Anaesthetic. The chloride of ethyl (C4H5CI) is a neutral liquid, very mo- bile; has an agreeable and penetrating odor. Its density at zero — 0.921, boils 12° C. Little soluble in water; very solu- ble in alcohol. It does not precipitate the salts of silver even * International Journal of Surgery vol. ix., September, 1896, No. 9. 29 442 ARTIFICIAL ANESTHESIA. in alcoholic solutions. Its vapor burns with a blue flame, pro- ducing chlorohydric acid preparation. It is prepared as follows : We introduce it into a receiver, with two parts of marine salt, pouring equal parts of alcohol and sulphuric acid. It is then slightl}^ heated. Shortly, the chloride of ethyl is disengaged in a gaseous form. It is then washed in a vase containing tepid watei', and dried by causing it to pass through tubes containing chloride of calcium, and is finally condensed in a vase sur- rounded by a refrigerative mixture. The product is very easily altered, and should be preserved in a long narrow-necked bottle, and sealed by the heat of the lamp hermetically. It is also prepared by the method of M. P. Mounet, of Lyons. "^ "In a boiler of iron or steel, with a perforated lid of 200 litres of capacity, there is introduced alcohol pure 92° — 55 kilos; acid chlorhydrique. of commerce at 22° Baume — 110 kilos. The boiler is furnished with a menometer and a ther- mometer, and a spigot to disengage or flow ofl". The boiler is hermetically closed, and the mixture is heated for two hours to 125° C. The pressure on the boiler amounts to 25 atmospheres. Having allowed it to cool to about 60°, they open the spigot, which, by a tube of copper, is put in communication with the boiler and the refrigerant of ice and broken salt, which sur- rounds the worm of the still. Chloride of ethyl is rapidly dis- tilled. To have it completely pure, it is rectified by passing through water slightly alkaline, and it is then placed in closed glass, ready for use as a local anaesthetic in the proportion of ten grammes each." — Marcel Baiideuii, Progress Medicale. Chloride of ethyl was discovered in 1795 by the Dutch chemists Deimann, Troostwyk, Bondt and Lawernburg. Snow employed it as an anaesthetic first in England in 1851, then Simpson, Clover and Nunnelej'^ in England, followed by Lieb- reich, Langenbach and Steff"en in Grermany, who subsequently availed themselves of it and published their observations. After this then followed researches made by a committee of the British Medical Association, and the following were their conclusions which were reported on the properties of this anaes- * Anaesthesia. Par A. Auvard aud E. Caubet, Paris, EueffetCo., 106 Boulevard St. Germaiu. CHLORIDE OF ETHYL. 443 thetic. The following effects were observed on frogs : Anaes- thesia was produced in four minutes, the heart beating natur- &\\y for thirty-six minutes ; on hot-blooded animals the move- ment of the heart experienced no modification. A compara- tive trial was then made between the chloride of ethyl and chloroform on a dog, which demonstrated in the anaesthesia of the chloride of ethj-l that the rhythm of the heart was not disturbed, but when the chloroform was substituted the heart became rapidly dilated and beat immoderately, and the cardiac force diminished rapidly. The committee concluded that the dog could live for a longer time under the anaesthetic effects of the chloride of ethyl, while it would soon die under the influ- ence of the chloroform. On man we observe the following effects after inhalation : We notice an agreeable heat which ex- tends over the body. In one or two minutes the sensation be- comes confused, with tinnitus aurium and whistling and buzz- ing. Then a certain muscular rigidity appears and then anaes- thesia commences. The patient is longer in becoming conscious than in chloroform, but the after-effects are less. Vomiting is frequent, but is less painful and lasts a shorter time than with chloroform. Clover has made extensive use of it, and has had but one death in 1877 anassthesias. He prefers to com- mence the inhalation by the use of the nitrous oxide, and con- tinue by the chloride of ethj^l. When you give it alone it is better to continue it alone until the period of agitation is passed, and administer it with prudence, withdrawing it every three or four inhalations. Anaesthesia is induced in between three to five minutes. Dilatation of the pupil will indicate the moment when we should cease the inhalations. See more recent experi- ments with this agent by Prof H. C. Wood, on page 445. Mono-Chlorethane. — It is made by the action of alcohol and hydrochl. acid and C2H5CI. It is a gas at ordinarj" tempera- ture, and is compressed into a liquid ; burns with a green flame ; specific gravity, 0.918 at 8° C; boils at 122° C. To be held from six to ten inches away from surface to be sprayed ; spray b}' the heat of the hand. It is highly inflammable. Another chloride is known as the polychlorate or Wigger's anaesthetic ether, which is a mixture of chlorinated ethyl ; chlorides chiefly 444 * ARTIFICIAL ANESTHESIA. trihedra and penta. Chlorethane, clear liquid, ethereal ; sweet, aromatic taste ; local anaesthetic ; non-irritant uses ; chiefly employed externally in rheumatism and sciatica. Chloride of Etbyl as a Local Ansestlietic. The chloride of ethyl is a local anaesthetic, and can be em- ployed without danger sprayed on the skin. It produces a rapid lowering of the temperature of the skin, and a complete anaesthesia of the region touched and its adjacent parts. The surgeon must first cover the skin with a greasy body like glycerine or collodion, to avoid the direct irritating action of the chloride of ethyl, as it sometimes causes a sharp pain in the parts, especially if they have been irritated before. Objections to PoAverful Refrig-erative Agents. The most serious objection to all powerful refrigerative agents is, that they reduce the temperature of the skin and adjoining tissue, and if carried to the condition of an appearance of pork- like nature, when circulation is restored sloughing is very apt to take place, and with it the death of the skin. Our object in employing these agents is to give confidence to the patient that the pain will not be severe, and as small a quantity as possible should be employed. Chloride of Ethyl and Pental.* ' ' The editor of the Dental Cosmos has submitted to us the two agents whose names head this article, with the request that we should investigate their physiological properties sufficiently to determine the question whether they can be of service as prac- tical anaesthetics. The present paper, therefore, is not an ex- haustive scientific study of the physiological action of these two drugs. Chemists are so multipljdng compounds, that if each compound is to be thoroughly studied by the physiologist the result would hardly be contained in the world's literature, * By Horatio C. Wood, M.D., and David Cerna, M.D. Eead June 22, 1892. Eeprinted from the Transactions of the Philadelphia County Medical Society. CHLORIDE OF ETHYL. 445 and it is only worth while in the first place to carry these inves- tigations far enough to determine the practical importance of new agents. This much excuse for what may seem, to the pure physiologist, the lack of completeness of the present study. " In such an investigation as the present, the first point to be determined is whether the substance has anaesthetic properties ; the second question is whether the anaesthesia produced is fuga- cious or permanent ; the third question is whether the anaes- thesia is accompanied by danger to life. Chloride of Ethyl. " Chloride of ethyl is at present largely used as a local anaes- thetic agent, which acts not by virtue of any inherent anaesthetic properties, but on account of the intense cold produced by its extraordinarily rapid volatilization. The extreme volatility of the chloride almost proves, a priori, that any effect which it may have upon the human system will be of correspondingly brief duration, since very volatile substances are thrown off from the lungs with rapidity. This a priori reasoning is en- tirely confirmed by our direct experiments. " We have found it difficult, with out the construction of special inhalers for the use of large quantities of chloride, to produce anaesthesia in the dog by the ordinary method of administra- tion. The chloride disappears from an inhaler which allows free access of air, almost as fast as it can be poured on. We have used it in two ways. In the one method we connected a large rubber tube with a cannula placed in the trachea of the dog, and then squirted the ansesthetic into the tube in such a manner that it would diffuse itself over the walls of the tube for a considerable distance. The administration in this way of ten grammes of the chloride of ethjd failed to produce distinct anaesthesia in the dog, although the respiration was affected and some fall of the arterial pressure occurred. We append details of two experiments. '"''Experiment I, — Dog, weight twelve kilogrammes. Griven ten grammes by inhalation, thrown into the tracheal tube in about three minutes. During this time the circulation varied at dif- 446 ARTIFICIAL ANAESTHESIA. ferent periods considerably. No anaesthesia was produced.. The arterial pressure was at first reduced. ''"Experiment II. — Dog. Normal pressure, 190 mm.; pulse rate, 120. Ten grammes chloride of ethyl introduced in tra- cheal tube as rapidly as possible. After an inhalation of twenty seconds: pressure, 185; pulse rate, 144, Seventeen seconds later the pulse began to grow slow and the pressure to fall. Eleven seconds later : mean pressure, 155; pulse rate, 72; the individual waves varying from one to two cm. in height. This condition, with gradual rise of pressure, continued for a minute, when the pressure rose to 190 and the pulse rate to 140. No anaesthesia was produced. " This experiment shows that the chloride of ethyl is capable of acting as an anaesthetic, provided that its vapor be given in concentrated form. Why anaesthesia was not produced by the second inhalation of ten grammes is not clear, but we believe that it was because air was taken m more freely, owing to the cone not having been placed tightly over the nose of the animal. The results of this experiment indicate, first, that the efi'ect of the drug is exceedingly fugacious, since ten grammes failed to produce a complete anaesthesia of more than two minutes' du- ration — this, further, in spite of the fact that air was not fur- nished with sufficient freedom to yield the full supply of oxygen to the blood ; second, that the anaesthesia is accompanied with a marked fall in the rate of the pulse and the force of the arterial pressure, the pressure having fallen forty-eight millimetres and the pulse forty-five per minute at the coming of the first anaes- thesia, whilst in the third inhalation, shortly after the loss of the reflexes, the pressure stood at ninety, instead of the normal, one hundred and sixty. " Owing to the comparatively small amount of the chloride of ethyl put at our disposal, in the further study of the chloride of ethyl we confined ourselves to administering the drug by in- jecting it into the jugular vein. This method of experimenta- tion has the advantage of greater exactness in dosage, and the results are entirely parallel with those which follow the admin- istration of the remedy through the lungs. " It is plain, that whether a drug be injected directly into the CHLORIDE OF 'eTHYL. 447 jugular vein, or whether it enter the system Ijy absorption into the pulmonic capillaries, it must first reach the heart before being diffused throughout the general circulation. In the one case the drug passes first into the right side of the heart, whilst in the other case it goes into the left side of the heart. The anaesthesia which follows the injection of the chloride of ethyl into the jugular vein is very fugacious, as is shown in the fol- lowing tracing, which demonstrates the effects of the injection of two-tenths of a gramme into the jugular vein. The liquid was injected between the two crosses ; the anaesthesia, as de- monstrated by the loss of the cornea reflexes, appeared at the first 'o' and disappeared at ^ox,^ having therefore lasted less than half a minute. It will be seen that the amount of the anaesthetic was sufficient to reduce the circulation to a very dangerous degree. "The effect of chloride of ethyl upon the respiration is very marked. If the dose has been sufficient to produce anaesthesia, the respiration at first is often stimulated in the extent of the movements as well as in the number per minute. Thus, in one experiment, the normal respiration being 50, the rate became 60; in another, the rate increased from 70 to 80, without, how- ever, any increase in the extent of the movements ; a little later in this experiment, the animal still being anaesthetized, the num- ber of the respirations fell to 40 per minute, but became nearly quadrupled in size. In still another experiment the respiration before the injection was 60 per minute, and after the injection, during the early anesthesia, was still 60 per minute, but the excursions of the needle connected with Marey's tambour were three times the size of what they had been before the admin- istration of the drug. In a fourth experiment the respira- tions before ansesthesia were 70 per minute ; during the early anaesthesia, 120 per minute; a few seconds later, 100 per minute ; the movements of the needle being at the same time enormously increased. ' ' In all our cases the fall of blood-pressure, after the injection of chloride of ethyl, has been immediate and excessive ; the blood-pressure has continued low without rise during the whole period of anaesthesia, but has returned rapidly to the normal as 448 ARTIFICIAL ANESTHESIA. anaesthesia wore off. The cardiac beats have always at first been arrested, but subsequently have become of enormous size, and continued so almost to the end, as is shown in the accom- panying reproduction of a tracing. The pulse-waves were also at this time absolutely consonant with and proportionate to the respiratory movements. " We believe that our research has demonstrated, first, that the chloride of ethyl is capable of acting as an anassthetic, but that it is eliminated with extraordinary rapidity, and that its action is extremely fugacious ; second, that the anaesthesia which it produces is always accompanied by a fall of the blood-pressure, which is probably at least in part due to the direct depressing effect of the drug upon the heart ; third, that the action of the drug upon the circulation is in no way dependent upon its influ- ence upon respiration, although it is not certain that the pro- nounced depression of the blood-pressure is not a factor in influ- encing respiratory movement ; fourth, that at least in the dog, chloride of ethyl produces at first an increase of the respiratory movement either in rate or amount, or more commonly in each respect, but that finally respiration becomes slow, and at last stops almost abruptly; fifth, that usually, if not always, the cessation of heart-beat and the arrest of respiratory movement occur as nearly simultaneously as may be. ' 'As the result of the various experiments which we have made with chloride of ethyl, we believe that the fugaciousness of the action of the drug must interfere with its use as a general anaes- thetic, and that its depressing effect upon the circulation is too pronounced for it to be a safe anaesthetic. It is most probable that if it should come to be employed in practical medicine as an anaesthetic, there would be a record of sudden deaths through cardiac failure proportionately even more numerous than those caused by chloroform . On the other hand, our research indi- cates very strongly that the small amount of chloride of ethyl which is used in producing local anaesthesia for dental purposes has practically no effect upon the human system, any of the drug that is absorbed into the system being eliminated in the course of a few minutes. ' ' PENTAL. 449 Pental, "With pental we have made a few experiments, both by in- halation and injection into the veins. Though the number of these experiments is not great, they seem to us sufficient to show that pental as an anassthetic acts quickly and fugaciously, but that it will probably be found more dangerous than the chloride of ethyl, and much more dangerous than chloroform. We append a tabular statement of one of the experiments made by inhalation. Experiment VII. — Dog, weight 12.345 kilogrammes. 1 Time. ATin Clan Pres- sure, Pulse per Respira- tion Remarks. Mm. mm. per min. 154 138 30 20 Inhalation of contents of bottle (10 grammes of drug). 1 20 130 96 63 9 00 140 96 51 Reflexes weak. 3 10 150 150 60 Inhalation of contents of second bot- tle. 4 10 100 135 54 Complete ansesthesia. 6 40 150 60 57 Reflexes returned. Great excite- ment of animal. 11 40 160 Inhalation of contents of third bot- tle. 12 10 90 102 72 13 ]0 90 188 75 Complete anaesthesia, but respiration somewhat shallow. 14 10 116 192 69 Reflexes returned. In four min- j utes later animal had regained ■ complete consciousness, and showed great excitement. Was afterward killed. "An examination of the record of the experiment just given will show that the production of anaesthesia with pental was each time accompanied by a marked fall of the arterial pressure. Thus, in the first inhalation, the pressure had fallen from 154 to 100 mm., when anaesthesia was complete ; whilst during the second anaesthesia the pressure fell from 160 to 90. In each anaesthetization the respiratory rate was increased, although the extent of the respiratory movements most of the time were not distinctly above the normal. 450 ARTIFICIAL ANAESTHESIA. "In no case have we caused death by the inhalation of pental, but the accompanying tracing records the pulse-wave and the respiratory movements under the influence of a lethal dose of pental (two grammes) injected into the jugular vein." "In our experiments in demonstrating the great effect of pental upon the heart, it is shown that the heart was at once affected much more severely than the respiratory centres, that they failed to recover themselves, and stopped beating before the arrest of respiration; indeed, full, deep inspiration occurred a half-minute after complete arrest of the circulation. " In conclusion, we are led by our experiments to believe that pental will probably prove to be a dangerous anaesthetic, and if extensively used, will produce death by cardiac arrest. It is probable, also, that the after-effects of pental, in the human being, would be disagreeable ; at least we repeatedly noticed in the dog a peculiar wild excitement directly after the anaesthesia from pental had gone off." "Phenol and Camphor. — By various combinations of phe- nol and camphor. Dr. Shaffer has formed a number of local an- aesthetics, which have been found very useful in minor surgery of the ear, throat, nose and teeth. " The first one is the 'Phenol Camphor,' ' Carbolated Cam- phor,' 'Phenolated Camphor,' and 'Campho-Phenique. ' When common or Japanese camphor and crystallized carbolic acid were mixed together and heated, a colorless liquid resulted, possessing antiseptic and local anaesthetic properties. " We have employed this agent, on the suggestion of Dr. S. MacCuen Smith, on a dossei of antiseptic cotton, introduced in the auditory meatus, in the second stage of the troublesome form of furunculous inflammation, or when the furuncle has pointed and has discharged, or been opened by a bistoury under careful anaesthetic precautions. By this agent we get rid of the hypertrophy of the canal and relieve pain. "There are many other forms of these combinations also, When menthol is acted upon by chloral, trichloric-acetic acid and thymol, when heated with camphoi", it forms a transparent oily fluid ; also menthol with camphor, first described by Dr. S. Scott Bishop, and employed by him in ear and throat dis- MENTHO-PHENOL. 451 eases. The last of these forms, described by Dr. Shaifer, is as follows : Meiitlio-Plienol. " Mentho-phenol, as its name indicates, is obtained by adding one part of phenol to three parts of menthol, and then melting the mixture. A transparent liquid is obtained, having an aro- matic odor and taste. Applied to the tongue, it produces a temporary anaesthesia similar to that of cocaine, although not so lasting as the latter. It is, of course, lighter than water, having a specific gravity of 0.973. It is nearly insoluble in water and glycerine, but it readily dissolves in alcohol, ether, chloroform and most of the light and heavy oils. It dissolves- iodine, iodoform and aristol. Water of ammonia, mixed with mentho-phenol, changes it to a dark vinous color in a few days. It is antiseptic, with strong analgesic properties. It may be used preparatory to cauterizing chancroidal sores and curetting necrotic surfaces. As a mouth-wash, it may be used with advantage, two drops being mixed with an ounce of the aqueous menstruum. ' ' The most admirable results have been obtained by Dr. Edward H. Shaffer, in minor surgery, such as abscesses, using a mentho- phenol mixture (five per cent.) warm, and when the lancet was plunged deeply under the nail, to his surprise the patient uttered no cry nor manifested any demonstrative indications of pain. The patient assured him that the pain had ceased like magic when the finger was immersed in the warm mentho- phenol mixture. The finger was dressed with gauze, rendered antiseptic with two per cent, of mentho-phenol, and healed in a few days. " In a case of suppurative otitis media et interna, accompanied with great pain and throbbing, an offensive purulent discharge created an eczematous eruption in the vicinity of the outer ear. The frequent syringing of the auditory canal with very warm water, mixed with mentho-phenol, soon checked the suppura- tive inflammatory process, and resulted in the disappearance of the eczema. In another case, in which a small insect had crawled into the ear of a lady, a warm mixture of two per cent. 452 ARTIFICIAL ANESTHESIA. of mentho- phenol produced the insect, to the great satisfaction of the patient. Wounds — incised, punctured, lacerated, etc. — will heal kindly when cleansed with warm water, mixed with two per cent, of mentho-phenol. In dental practice, mentho- phenol finds its indications as an anodyne anaesthetic in odontalgia, obtunding the sensitiveness of dentine, and as an antiseptic in alveolar abscess, suppurating pulps of teeth, periodontitis, etc. ' ' He has used the medicament in pustular acne. The pustules may be opened without causing much pain, after having been first touched with vaseline containing five per cent, of meniho- phenol. Mixed with almond oil or alcohol, in the proportion of two per cent, of the medicament, I have used it as an external application in itching of the skin. I have never used it sub- cutaneously nor by the mouth. Mentho-phenol, like every other remedy, has its natural limitations of employment. It cannot, for instance, be used in ophthalmological practice on account of the unpleasant burning which follows its use when applied to the conjunctiva." Resorcin-Caniplior. "This liquid is obtained by heating equal parts of resorcin and camphor. Its indications are the same as those of thymol- camphor. It is superior to the mercurial ointment in the removal of pediculi. My chief object in writing this article was for the purpose of directing the attention of those interested in medical chemistry to the large number of chemical compounds which can be produced when the difi'erent camphors are united with the phenols and their congeners. The close chemical relationship of these substances naturally leads one to infer a -correspondingly intimate physiological affinity." Antipyrine as a Local Ansestlietic. In Vienna it has already been found necessary to forbid the sale of antipyrine except under doctors' prescriptions, as no less than seventeen deaths were attributed to stoppage of the heart's action, owing to overdoses. The freedom with which the prescription of this remedy (antipyrine) has been assumed by ANTIPYRINE AS A LOCAL ANESTHETIC. 453 the public has long since been viewed with anxiety bj^ the medical profession, and frequent warnings have alreadj^ fallen upon deaf ears ; and j'et it is to be feared that if the epidemic of influenza should spread, manj^ more examples of recklessness will have to be recorded. Hypodermic injection of antipyrine has been strongly recom- mended for the relief of pain by See and others. See considers that it rivals morphine in the extent of its action, that it has not the unpleasant after-effects of that drug, and that it does not interfere with nutrition or lead to a " craving. ' ' Berdach has lately been experimenting with the drug in this way at Prof. Bamberger's clinic at Vienna. He uses a fifty per cent, solution in distilled water, and has experienced nothing but favorable results. All kinds of painful conditions were so treated, the injection being made at the most painful spot. For a few seconds after administration there is a local pain and burning •, but this soon passes off, and is followed by analgesia over an area of more than a centimetre round the point of injection. Frankel and others had previously noted this. The most important point inBerdach's observations is, that the pain is relieved in a few seconds after the injection, the relief lasting for at least six hours. No disagreeable effects, such as vomiting, sweating, rash on the skin, or depression of the heart or pulse were noticed, and in those patients who were febrile the tem- perature remained uninfluenced. This is too favorable an account, and we cannot indorse these statements, and would advise caution in its use. It is also valuable in chronic catarrh in the form of spray, dissolved in hot water, from 10 to 40 grains to the ounce. At times we commence with solution of cocaine, then followed by antipyrine, or the two combined — 2J parts of cocaine and 8 parte of antipyrine to 100 parts of water — and last, by pure vaseline in pharyngeal irritation involving the nose and Eustachian tubes, with deafness. 454 ARTIFICIAL ANESTHESIA. CHAPTER XXL Local Ansesthetics — Oil of Eucalyptus, Ether, Ehigolene, Methyl and its Chloride, Hydrastine, Homatropine and Ephedrine, Brucine, Apomorphiue, Erythrophleine, Caffeine, Helleboriue, Canadol, Menthol, Iodoform, lodol, Bromide of Ethyl, Bromide of Potas- sium, Carbolic Acid, Quinine, Antifibrin, Tymol, Urethane, Tri- onal and Tritronal, Naphthalene, Sulphoual, Pyoktauin and Trichloracetic, Aristol, Euphorine, Hypnal, Exalgen. Having given briefly the most important results of the recent observations and experiments -with cocaine and eucaine, I now pass to the second part of our subject, the older local anaes- thetics. Oil of Eucalyptus. This agent is recommended as a local anaesthetic in dental operations and toothache. Apply one drop or more on cotton to the sensitive dentine just before excavating for filling. The vinegar and oil in the form of emulsion is a powerful and useful liniment for neuralgia, etc. The oil has also decided antiperiodic powers, as well as being one of the best stimulat- ing expectorants in acute and chronic bronchitis. From one- half to one drachm a day may be given in divided doses in capsules or mucilage. Etlier as a Local Anaesthetic. This apparatus, Plate 55, and the various modifications, are employed for local anaesthesia, and j)roduces so much cold by atomizing the ether and other volatile agents that it freezes the skin and even the deeper tissues. It was first used by Dr. B. W. Richardson, of London. It consists of the elastic bulb D, which, with its valves, serves to force air into the elastic cham- ber C, which, alternately expanding and contracting, supplies a steady stream of air to the atomizing tubes A, which are of metal, one branch of which dips into the bottle B, containing LOCAL ANAESTHETICS RHTGOLENE IN SPRAY. 455 the ether, and the inner tube for deHverinif? tlie ether runs up- wards to the extremity of the outer tube. The ether must be directed on the surface, and must be the strongest, therefore free from alcohol and water. When the parts are properly frozen, they become pale, shrunken and tallowy-looking, and, when cut, like frozen fat. When the rubber bag D is compressed by the hand, the reser- voir bulb is filled, and a double current of air is produced ; one Plate 55. current descending and pressing upon the ether, forcing it along the inner tube, and the other ascending through the outer tube, and playing upon the column of ether as it passes from the inner tube. The ether which is used in England for producing local anaesthesia is a mixture of amyl hydrate and anhydrous ether; it has a low boiling-point and specific gravity, and is dangerous when inhaled. The best form of ether to employ for local anaesthesia is the anhydrous, which is almost free from alcohol and water, and gives the best results. liocal Angesthetics.— Rhig'olene in Spray. Khigolene. — This is one of the most volatile of liquids, and is obtained by the distillation of petroleum. Its specific gravity 466 ARTIFICIAL ANESTHESIA. is 0.625, and it will boil in the hand. It was first introduced by Dr. Bigelow, of Boston. A superficial layer of the skin has been successfully frozen by rhigolene. Not only on the skin, but Dr. Jarvis and others have used it in inter-nasal surgery by means of an atomizing apparatus, which will freeze the tissues in less than one minute. Cartilage and mucous membrane can, when thus frozen, be deeply and freely divided without much pain or haemorrhage. Drs. Edes, Dana and Jacobi had used rhigolene spray with benefit in the treatment of neuralgia ; but it has been found objectionable, because of the intense degree of cold produced, and also because it could not be applied to a sufficiently large space.* In cases requiring extensive operative interference, cocaine has been partially utilized in conjunction with the rhigolene. At one time rhigolene was considered very explosive ; this is not the case unless mixed with air, and brought near to an open light, or the incandescent cautery. Dr. Richardson, of London, has found rhigolene to dissolve camphor and spermaceti, which solution, applied with cotton and wool, he found an excellent dressing to burns. This same fluid would also dissolve iodine, and was valuable in diseases of the respiratory tract by inhalation. The strength of the iodine solution which he uses is five grains to a fluid ounce of rhigo- lene. Methyl. This is another new local anaesthetic, so stated, but obtained from an old agent, namely, methyl alcohol. This is the alcohol obtained from wood spirit, and much employed in England, but not in this country. The new agent is stated to be neutral, volatile, with an ethereal odor and pungent taste. The subcutaneous injection of methyl induces more or less anaesthesia, but it is of short duration. ( Vrafch, No. X., 1887, Bull Gen. de Therap., July 15, 1887, and Amer. Jour. Med. Sci, October, 1887, p. 527.) *- New York Medical Journal, July 31, 1887. HYDRASTIS CANADENSIS AND HYDRASTINE. 457 Chloride of Methyl. Dr. Jacobi has found the chloride of methyl an analgesic or local anaesthetic, which did not aifect the general condition of the patient, and that it was invaluable in the treatment of neu- ralgia, for the immediate relief of severe pain. It was used in the form of spray under high pressure. The objection was the expense of the apparatus and the difficulties of getting the drug (pure). (See Med. and Surg. Reporter, vol. Ivii., July 2, 1878, our observations on this drug, and its analogy to chloroform as usually obtained ; see also p. 207. ) From his experience in the use of condensed carbolic acid, his conclusions were that, in the absence of chloride of methyl, it was able to take the place of that remedy in sciatica. Hydrastis Canadensis (Golden Seal) and Hydrastine. The white alkaloid contained in Hydrastis canadensis (Grolden Seal). Experiment shows that it is to this alkaloid, rather than its more obtrusive neighbor, berberine (j^ellow alkaloid), that the valuable properties of Golden Seal are due. Its phys- iological action, as determined by experiment on the lower animals, is briefly as follows : ' ' In small doses it elevates and in large doses it depresses the blood-pressure ; that in small doses it produces contraction, and in large doses dilatation of the vascular walls ; that in the period of elevated blood-pressure it inhibits cardiac action ; that in small doses it produces anaemia and in large doses hypersemia of the alimentary surface ; that it induces uterine contractions ; that it enhances the irritability of the motor and depresses that of the sensory nerves ; and that it exercises its control over all these organs through a central, and not through a peripheral influence." Experiments on man confirm the preceding. It dilates slightly the pupil of the eye, and as a local anaesthetic has value, though its action is not so marked as that of cocaine or brucine applied locally, or theine injected hypodermically. Hydrastine is most applicable in catarrhal states of the stomach, 30 458 ARTIFICIAL ANESTHESIA. bowels, eye, ear, nose and throat, though it is indicated in many other diseased conditions. Amongst the diseases for which it has been found a valuable topical application may be mentioned hyperidosis, seborrhoea, acne, eczema, ulcers, gonor- rhoea, certain forms of gleet, various forms of conjunctivitis, and in the ear to arrest or modify irritating catarrhal and puru- lent discharges. Its effects of contracting the uterus so power- fully may be of special value in obstetrics, and its marked action on the spinal nervous system indicates it as a valuable tonic to this portion of the body. Probably hydrastine possesses much of the therapy internally, as well as externally, of the drug from which it is obtained, such as being indicated in dyspepsia, con- stipation, haemorrhoids, jaundice and other functional disorders of the liver, etc. Dose, xV to i grain. Mr. 1. N. Bredin found the following formula, used as an injection four times daily, gives beneficial results in gonorrhoea and leucorrhoea, when every other treatment, local and internal, failed : IJ» Hydrastin, . . . . ; . • 5j. Sol. morphise (B. P.), 5ij. Mucil. acacise, ad, . . , . , f Siv. M. SiG. — Use as au injection four times daily. Care should be taken to distinguish the resinoid of the eclec- tics, hydrastin, which consists chiefly of hydrochlorate of ber- berine, from the crystalline alkaloid hydrastine (hydrastina). Honiatropine. Discovered by Landenburg. It is a derivative of tropeine, which latter is produced by heating tropine gently, in contact with organic acids, and dilute hydrochloric acid. Tropine is a derivative of hyoscyamine, also of atropine. Merck has suc- ceeded in crystallizing it in transparent colorless prisms. The most useful salt has been shown to be the hydrobromate, which is crystallizable and not hygroscopic. Its action is similar to that of atropine, being mydriatic, narcotic, sedative and anaes- BRUCINE. 459 thetic. The dilatation of the \m\n\ takes place verj' energetic- ally with honiatropine, the action beginning in from fifteen to twenty minutes, and reaching its height after from sixty to seventy minutes ; while the recovery takes place in a compara- tively short time, usually from six to ten hours. It is generally indicated in the same complications as atropine and other alka- loids of this class. Chlorohydrate of Ephedi'iiie. Tweedy and Ringer have proved by experimentation that horn atropine acts upon the heart in the same way as atropia, but is much milder and safer. Dr. Frommuler prefers homa- tropine to atropine for checking the night sweats of phthisis. He also found it an immediate and certain antidote to pilocar- pin. Dose, -J to ^ of a grain. Homatropine has been employed in a large number of cases in this city, of the strength of eight grains to the ounce of dis- tilled water, with the Tuio^ of bichloride of mercury. The instillations have been made every hour until full dilatation takes place, and with satisfactory results, passing away soon, unless, as will sometimes happen, the druggist substitutes atro- pine, not having the homatropine on hand. The chlorohydrate of ephedrine is a new mydriatic alkaloid obtained from Ephedra vulgaris by M. Kinnossuke Menra. It should be employed in a solution ten times more concentrated than homatropine, but it is much less costly. It does not para- l^^ze the accommodation for near vision. Hydrobroinate of Homatropine. (C16H21NO3HB. Soluble in ten parts of water.) A careful study of the action of hydrobromate of homatro- pine by Eisley and Jackson has proved to them that this drug is entirely satisfactory for the correction of anomalies of refrac- tion, and is an efficient and reliable mydriatic. Bruclne. Dr. Mays, of this city, introduced pure brucine as a local anaesthetic, and kindly furnished us with a solution in oleic 460 ARTIFICIAL ANESTHESIA. acid. We made a number of careful experiments with it, and found it had some slight anaesthetic properties, but with the objection that when used freely on a mucous membrane or abraded surface it produced some of the symptoms of strychnia poisoning. It is true, it is less powerful, and eliminated more rapidly than strychnia, but it has this one serious objection. The old idea was that the effect of brucine, in producing convulsions, was said to depend on admixture with strychnia, but Dr. L. Brunton found that pure brucine would produce convulsions and death in rabbits when injected subcutaneously. Aponiorpliiae Hydrocliloras. The objection to apomorphia is that it causes very profuse secretions from the mucous membranes. It also acts as a poison on the muscular fibre of the ventricle of the heart, like an acid, when employed internally. Yet there are ophthalmic surgeons of this city who use it with success, applying it every ten or fif- teen minutes to the eye, one drop at a time. Erytliroplileine, or Haya. (The Active Principle of Erythrophlceum Guineense.) From a most interesting paper, read a month ago (January 11, 1888), before the Medical Society of Berlin, by Dr. Lewein, we extract the following concerning a drug that promises much : "The hydrochloride of erythrophleine (made by E. Merck, of Darmstadt) is readily soluble in water. A two per cent, solu- tion in a dog's eye renders it insensible for from ten to twenty- four hours. This solution is much stronger than need he for anaesthetic uses, as will be seen as we proceed, for Dr. Lewein states that ' solutions of the strength of one-fourth or one-tenth or one-twentieth of one per cent, produce anaesthesia of the cornea and conjunctiva, continuing for from several hours up to two days, and gradually increasing in intensity during that time.' The action is altogether local, and if a solution of it be injected into the eyelid of an animal, it becomes so insensible that touch does not induce motion, while the eye itself retains perfectly its sensibility. IIELLEBORINE. 461 "To give an idea of the powerful action of this substance: If we make a solution of the proportion of ^ gramme to 100 grammes of water, i.e., ^V gramme to 2000 drops of water (ap- proximately f of a grain to one fluid ounce or a solution of about yf^ of one per cent.), and of this inject three full drops into the eye, full anesthesia is produced (by 0.00015 grammes erythrophleine hydrochloride) (or twenty-three ten-thousandths of a grain). If from 0.0005 grammes to 0.0015 grammes of this solution be injected into a guinea-pig, such an insensibility is produced in the injected part, that one can cut these otherwise so sensitive animals deeply, down to the muscles, without ob- serving any symptom of pain." According to " Karewski," Medical Press, March 4, 1888, complete anaesthesia was never obtained, but its action was much heightened by the local production of anaemia. Its action was not uniform in all cases. Subcutaneous injection of at least ^3- of a grain was necessary to produce analgesia. The after-effects were very disagreeable, amongst them violent pain at the point of insertion, coming on in a few minutes afterwards, and becoming intolerable, lasting several days. Caflfeina — Caffeine . A crystalline principle occurring in tea and coffee. Various trials of caffeine have not been satisfactory as a powerful local anaesthetic. It is valuable in slight operations, but much infe- rior to cocaine. Theine, which chemically is the same as caffeine, has also slight anaesthetic properties. They are both most valuable diuretics. The citrate of caffeine in five-grain doses, alone or in conjunction with antipjTine, is a useful remedy in congestive headaches. HeUeborine. The helleborus niger contains two active principles, hellebo- rine and helleborin. Both of the substances are glucosides. The first has been employed as a local anaesthetic. Internally they are both narcotics and active cardiac poisons. 462 ARTIFICIAL ANESTHESIA. Canadol. This is a volatile product obtained from naptha. Liquid^ limpid, very volatile, easily inflammable, benzoine odor. It has been used as a substitute for ether as a local anaesthetic^ and is employed by means of Richardson's spray apparatus. Meutliol. Has been found very useful as a rubefacient, and combined with some hypnotic, it has anaesthetic properties. It is useful combined with cocaine. Menthol is an oil of peppermint camphor; is employed in diseases of the throat and ear, dissolved in ether or olive oil from ten to fifty per cent. It is a great pain reliever when the crystals are sprinkled on an aconite plaster and slightly incor- porated by the aid of heat. Iodoform. (CHI2, 392-8. ) Iodoform is employed as a local anaesthetic and antiseptic, as a dressing after operations. Preparation : Mix an alcoholic solution of potash with tincture of iodine, and evaporate it. Character: Small, lemon-yellow, lustrous crystals of the hexag- onal system, having a saffron-like and disagreeable odor, very difficult to overcome, and unpleasant iodine-like taste. Not perceptibly soluble in water, soluble in eighty parts of alcohol at 59° F. , in five parts of ether, and in chloroform, benzol, ben- zine, and in the fixed and volatile oils, lard, lanolin or vaseline. Dose, 1-3 grains. It is given in the form of a pill or in a capsule, or mixed with tragacanth, sugar of milk and glycerine, or better, sugar-coated ;. by the rectum in the form of a suppository or vaginal capsule. The disagreeable smell may be in part covered by Tonquin bean, coumarin , or roasted coffee in powder. As an inhalation in phthisis a solution may be used contain- ing 20 grains of iodoform, 20 minims of oil of eucalyptus, or 10 of creasote, i fl. oz. rectified spirit, and } fl. oz. ether. This is used with an inhaler of horse-hair matting, lined with cotton wool, on the interior of which the solution is droDped . (Dresch- feld.) DEODORIZED IODOFORM AND OINTMENT. 463 As an external application it is dusted over the abraded skin, ulcer, or mucous membrane. An old favorite preparation for topical application is the ethereal solution of iodoform (.^i. 5v.) applied with absorbent cotton to the affected parts in the nares, post-pharjmgeal space, mouth, fauces, larynx and trachea. The nozzle of the spray-producer is apt to become choked, and must be washed out frequently with pure ether. It may also be applied to the nose in the form of a bougie, containing i to ^ grain made with gelatine and glycerine. Actions: Iodoform destroys bacilli, and is an antiseptic deo- dorizer and local anaesthetic. It also destroys leucocytes. If given in large doses it weakens the circulation, or if long con- tinued in moderate doses, it has the same action. If absorbed from a large raw surface or employed too freely, it produces muscular rigidity, anaesthesia, sleep followed by sleeplessness, headache, irritability, hallucinations, loss of memory, melan- cholia, and even death. These disagreeable effects are dimin- ished by bicarbonate of potash, 10-grain doses every hour or two, in water. It has a most extraordinary power to prevent the develop- ment of giant cells, and may thus prevent the growth of mor- bid tissue, as cancer, etc. After death from iodoform, the heart, liver, kidnej^s and muscles exhibit fatty degeneration. Iodoform. (Cotton Wick.) Gersung. of Vienna, has found cotton wick impregnated with iodoform an excellent material for tampons in the drainage of wounds whose secretion is moderate ; Bellroth's clinic wick, saturated with tannin and iodoform, is used with excellent re- sults. Its removal is much less painful and inconvenient than thsit of g'duze.—Centralblattfilr Chirurgie, July 30, 1887. Deodorized Iodoform and Ointmeiit. Mr. Louis G-enois has advocated the use of the purified naphthaline to mask the odor of the iodoform, as follows : 464 ARTIFICIAL ANAESTHESIA. Purified naphthaline, 7i grains. Powdered turmeric, li grains. Iodoform, 91 grains. Rub together until thoroughly mixed. Oiiitineiit Iodoform. Deodorized iodoform (as above), . . . Sij. Oil of almond, Siss. Lanolin, 5vss. M. We have tried this preparation, but the strong odor of the naphthaline is one objection. Iodoform in Variola. Colleville has had excellent results in preventing severe scar- ring, and lessening pain in variola by the local use of: Iodoform, 1 part. Vaseline, 20 parts. Although used freely in cases of confluent variola, no ill effects were observed. — Bevue de Therapeutic, November 5, 1889. Iodoform Deodorized. Cantrella, pharmacist, Paris, has found of all the ways devised for hiding the odor of iodoform, the following combi- nation is the best : Iodoform, gr. xv. Menthol, gr. I. Essence of lavender (of best quality), . . gtt. 1. In addition, the hands may be washed in water containing a little lavender brandy or essence. Cocaine may be added to the mixture when instant anaesthesia is required, as follows : Iodoform, gr. xv. Cocaine, gr. f • — Bulletin General de Therapeutic, Nov. 15, 1887. TREATMENT OF DIARRHCEA. 465 For deodorization of hands or any other part of the body impregnated with iodoform, Doux, in the Bulletin of the Phar- maceutical Society of Bordeaux, advises, first, vigorous soap- ing of the hands, then washing them in water to which is added tincture of iris (blue or white flag), when the odor disappears completely. Increasing- the Antiseptic Powers of Chloroform. Gr. de Ruyter {Arch. f. Kl. Chirurg. , Bd. xxxy. , Hft. 1) states that solutions of iodoform in ether, chloroform and alcohol have greater antiseptic properties than the powdered drug, owing to the production of free iodine. The following solution was found an excellent antiseptic, and much superior to the ethereal one : Iodoform, 1 part. Ether, 2 parts. Alcohol, . . . ' 8 parts. The author confesses that outside of the body iodoform has little power over the greater number of disease germs. It has, however, been shown that when in contact with the fluids of the body the iodoform is decomposed, and is then capable of acting on bacteria. An Antidote for Iodoform. The Rep. de Farms states that Dr. Behring recently gave a twenty per cent, solution of bicarbonate of potassium in a case of severe iodoform poisoning. The best results followed its use, it seeming to act as a direct antidote to iodoform. Fortu- nately, cases of iodoform poisoning are rare ; so much so, indeed, that they are termed "idiosyncrasies." Treatment of Diarrhoea by Iodoform and Charcoal. ^ Iodoform, . grs. ix. Ether, 5iiiss. Vegetable charcoal, finely powdered, . . Siiiss, Glycerin, Sxii. M. SiG. — A teaspoonful after each evacuation. 466 ARTIFICIAL ANAESTHESIA. The iodoform must be dissolved in the ether, and the pow- dered charcoal thoroughly mixed. After the ether has evapo- rated, the glycerine should be added. On the Local Use of Iodoform in Ear Diseases and Dental Operations. The following were the conclusions of our friend, the late Dr. Cassell, after using this agent in the treatment of ear diseases for some years : " Iodoform is of service alone in cases of ear disease in which there is a lesion of tissue (ulceration), and notably in those of caries of the mastoid, complicated with polypus granulations. After these are removed the local application of iodoform, as a fine, dry powder generally acts capitally, and, I may add, suc- cessfully. It is worthy of trial as an internal remedy in those cases of deafness following eye disease, where there are keratitis and scooped (Hutchinson's) teeth, and other outward signs of hereditary syphilis or tuberculosis. "Nerve Paste. — A preparation for devitalizing dental pulps, composed as follows : R . Iodoform pulv. , cocaine hydro- chlorat. , aa gr. xx.; menthol crust., gr. v.; glycerina, q.s. to make a stiff paste. "Iodoform has not been much used by the dental practi- tioner, but I think in it we have a remedy that exactly meets the requirements of some cases. It possesses the alterative properties of iodine, without its caustic qualities; indeed, it is a very soothing application to inflamed and irritated parts. It has been used with the happiest result in the treatment of old abscesses, its alterative and anodyne qualities rendering it just the thing for those cases in which, from the ravages of calculus or from abscess, the socket cells are involved, and that peculiarly annoying neuralgia results, from which the patient finds slow relief. In these cases even the extraction of the tooth does not always bring the immunity sought for some time. "To apply the paste, take a ])robe armed with cotton, and take up some of the compound paste, introduce it into the cavity, or under the gum and around the roots. " It can be introduced into the crown and roots, to relieve THE ANTI-BACTERIAL ACTION OF IODOFORM. 467 neuralgia, or to cure persistent abscess. In the treatment of antral disease it is regarded as one of the very best remedies. Used as above directed, its effect is ver^^ soothing, and it will speedil}" diffuse itself, and its influence, over the seat of irrita- tion. If some persons should object to the odor, the iodol may be substituted in the place of the iodoform." locloforni Gauze TainpoDS. Iodoform gauze tampons have been found useful in rectal disease. They are stated to be painless and antiseptic. The mode of preparation of the iodoform gauze is given by Dr. Weir, as follows ("Antiseptics: How Used and How Made," Med. News, December 17, 1887) : Pour over five yards of absorbent gauze a mixture of Iodoform, Siiiss. Eesiu, . . Siss. Alcohol, foiv. Glycerine, f5vi. M. The Ajiti-Bactei*ial Action of locloforni. In an article by I. Amory Jeffries, M.D. , of Boston {Amer. Jour. Med. Sci., January, 1887), he states that iodol and salol gave prompt results of anti-bacterial action, but iodoform, he concludes, from numerous experiments, has no direct action as a germicide, a result agreeing with Heyn and Roosing. Looked at from the clinical side, the ultimate object of all medi- cal research, he gives the following rules: 1. Iodoform, not being a germicide, is not a fit substance to use to procure asepsis of instruments, materials or wounds. 2. Iodoform is allowable, in the present state of our pharma- copoeia, in inflicted wounds where the true germicides are contra- indicated, as by danger of poisoning or impracticability, 3. As has long been known, iodoform has a decided tendency to stop serous oozing, and therefore may be indicated in wounds where the moisture threatens the integrity of the aseptic or antiseptic dressing. Laboratory tests are not . always what occurs in the body, and different observers produce different 468 ARTIFICIAL ANAESTHESIA. results. Dr. Robert T. Weir, of New York, with his friend, Dr. Weeks, has published in Med. News., December 17, 1887, the following observations on antiseptics : Iodoform in powder only retarded development of germs after twelve hours' exposure, lodol in powder exerted no effect. Whoever has kept abreast with the current literature will not be surprised at two things : First, that the fact taught us several years ago by Koch has been confirmed by Dr. Weeks, that only solutions or mixtures of the various antiseptics have no value other than is slowly exerted by the fatty matters themselves; and, second, that iodoform — concerning the power of which in germs much has lately been written — exerts its germicide action but slowly. On this point of the value of iodoform in controlling inflammation — ordinary and tuberculous — Dr. Weir says that the clinical experience of surgeons is in favor of its usefulness, and is decidedly opposed to the laboratory deductions. The discus- sion of this subject, however, has developed the fact that this substance, in dry powder, often contains germs, and that it works best when acted upon and changed by wound secretions. Practically, it is nearly always used in a dampened condition, by him, in the New York Hospital, in conjunction with the moist sublimate gauze. In this combination it is depended upon as a supporter of antiseptics. lodol. "lodol (CINH) is produced by the action of iodine on pyrol in the presence of caustic potash. It has an acid reaction, is free from the disagreeable odor of iodoform, and contains 88.9 per cent, of iodine. It is a yellowish-brown powder, insoluble in water, slightly soluble in cold alcohol, and readily soluble in oil. According to Mazzoni, it is a more powerful antiseptic than iodoform ; it acts as a local anaesthetic and favors granu- lation ; administered internally in doses of two grains, it pro- duces no intestinal disturbance. It may be used in the same way as iodoform. " I have been using this agent in the place of iodoform. Very many of my patients object to the odor of iodoform ; iodol, being odorless, has this great advantage, though its cost at present is lODOL. 469 much greater than that of the iodoform. I have found it as useful as iodoform in ear and throat aifections. It has been stated that it is not so valuable in intra-uterine affections as iodoform. "Dr. Assaky, of Bucharest, Roumania, said that wounds unite under iodol by first intention. This union, however, being the result of various and complex conditions attending operation, it is not possible to attribute to iodol alone the ab- sence of suppuration and inflammatory conditions. In wounds which gape and suppurate, iodol is an excellent antiseptic. It rapidly retards suppuration, renders it inodorous, reduces the frequency of dressing and considerably hastens cicatrization. In ulcerating or gangrenous wounds, iodol aids to resist the de- structive process, and changes the wound, after a variable time, to a healthy granulating condition. This action of iodol ex- tends itself to hard chancres. In case of soft chancres the result is variable. Sometimes it transforms them into a simple wound with brief delay ; at others it is insufficient for this pur- pose, and it becomes necessary to employ in addition, locally, antiseptic lotions. The same is true with reference to open venereal buboes of the groin. The powdered iodol has this advantage over iodoform, that it is free from odor and is not toxic in its effect. "Doses of iodol, of from one-sixteenth of a grain to three grains daily produce no functional trouble, even if continued a long time. These doses give marvellous results in tertiary syphilis and in scrofulous affections. In the secondary stage of syphilis, taken internally, it rapidly destroys the syphilitic mani- festations. Iodol seems to aid the general nutrition and increase strength and flesh. It is indicated in all cases of specific malnu- trition. Iodol is an antipyretic. In acute infectious diseases, such as erysipelas, etc., it causes a rapid fall of temperature. " (1) Powder of Iodol. — The pure powder maybe used ; it is readily dusted over a raw surface or insufflated into the throat. Possessing no toxic power, it is of more importance to cover the diseased surface than to measure the dose. For all laryngeal, pharyngeal, post-nasal and oral conditions, this is, perhaps, the most generally useful application. 470 ARTIFICIAL ANESTHESIA. " (2) A Solution in Alcohol and G-lycerine. — This was Mazzoni's original application : lodol, one part ; alcohol, six- teen parts ; glycerine, thirt3^-four parts. This forms a good ap- plication by means of the brush, or may be used as a very coarse spray. "(3) loDOL, One Drachm; Ether, One Ounce.— This forms a clear brown solution, useful for application either by the spray or brush. The ether, quickly evaporating, leaves the pow- der in situ. It is useful for naso-pharyngeal atrophic conditions. " (4) Iodol,One Drachm ; Glycerine, One Drachm ; Vas- eline, Seven Drachms. — This is a modification of one of Rumbold's sprays. It is a very soothing application for pharyn- geal conditions. It requires to be warm before using. "(5) loDOL Pastilles. — lodol, one grain; glycerine, one minim ; glycogelatine, eighteen grains. These are very useful for chronic pharyngeal conditions, and are much preferable to iodoform pastilles. "(6) loDOL Bougies, containing half-grain of iodol in each. These are made for me, for use in diseased nasal conditions. " (7) Iodol Wool, ten per cent., for tampons, etc. " (8) Iodol Gauze for dressings. " I have used iodol in a number of cases of laryngeal phthisis with very beneficial results. Adopting Lublinski's method, I have applied it as an insufflation of the pure powder in some cases once daily, in others three times a week. "Ulcerations in the inter-arytenoid region have cleansed and healed up completely, and the characteristic arytenoid oedema has diminished under its influence. Tuberculous ulcerations of the epiglottis and pharynx have been benefited by it and been arrested, and the distressing pains on deglutition which accom- pany this condition are much relieved by iodol. In some patients, to whom solid food was entirely interdicted by reason of the pain on swallowing, deglutition has become compara- tively easy under daily laryngeal insufflations of iodol. If the iodol is carefully and accurately applied over the ulcerations, it will completely heal them. I have cases under treatment where there was originally extensive laryngeal ulceration, but at pres- ent all active mischief is arrested. Iodol remarkably diminishes IODOFORM AND lODOL. 471 the cougli of this cundition. It is not to be supposed, of course, that insufflations of iodol, or of an}- other substance, will cure extensive phthisical disease of the larj^nx, but they will certainly arrest ulceration, relieve pain and cough, and allow the patient comparative comfort. The iodol remains for a long time in contact with an ulcerated surface. Sprays of chloride of zinc (gr. XXX. ad 5j.) have, in some cases, been combined with the iodol treatment. For ozaena, I find that iodol tampons are effective in arresting the foul smell of nasal caries, or for the true ozaenic conditions independent of carious bone. "As a spray or brush application, it is very beneficial for naso-pharyngeal atrophic catarrhs. For the ordinary forms of pharyngitis, accompanied or not with follicular disease, I find it a very serviceable insufflation, and one which, moreover, is not unpleasant to the patient. The pastilles are also grateful in these conditions. It is important that the application of iodol, as of any other medicament, to the nasal, pharyngeal or laryn- geal mucous membrane should be preceded by thorough cleans- ing of these parts with the alkaline lotion, so as to insure the bringing of the powder into direct contact with the diseased tissue, and not merely to lay it on the surface of the mucus. I have found it produce excellent effect in extensive ulcerations of the inside of the cheek, dusted over the exposed surface twice daily. In cases where there is great pain the addition of one-eighth to one-quarter grain morphine to the iodol insufflated will be found very advantageous. "To summarize: iodol is odorless or nearly so, tasteless, pro- duces no constitutional effects, contains nearly as much iodine as iodoform, and parts with it more readily; it is antiseptic, anaesthetic, a promoter of granulation and healing; arrests suppuration and deodorizes foul secretions. Possessing thus all the virtues of iodoform, it is surely preferable on account of its pleasant and slight odor and the absence of taste. It does not disturb the stomach as iodoform does." — E. Norris Wolfen- den, M.D., in the Practitioner. locloforni and Iodol. Is iodol perfectly safe given internally and employed locally? The experiments of Marcus and Pahl [Maug. Dess. Berlin^ 472 ARTIFICIAL ANESTHESIA. Ther. Gazette, January 16, 1888) show that when iodol was given in sufficient doses to animals it caused emaciation, albuminous urine, fall of temperature, general loss of muscular power, and finally death from fatty degeneration of the liver, kidney and other tissues. In a case published in the Ther. Gazette (see vol. xi., p. 768), iodol caused, when used as a surgical dressing, symptoms of poisoning. Still, it is less poisonous than iodo- form , but the post-mortem appearances are the same. It has been found valuable in a number of cases of tubercular laryn- gitis, throwing the pure powder into the larynx once a week ; also in ozaena with good results, alone or combined with creosote and gl3^cerine and boracic acid. Iodol in Diplitheria. In order to test the statements of Dr. Mazzoni, Dr. L. L. Stembo, of Yilna, tried ( ' ' Proceedings of the Vilna Medical Society," No. V., 1887, p. 114) the local use of iodol in seven cases of diphtheria, two of which were severe. The drug was applied either alone, in powder, or in the form of a solution. (R. lodoli., 9ss. ; liq. vini, 5ss. ; glj^cerine, ^iiiss.) All the patients recovered after treatment lasting from four to six days. The advantages claimed by Dr. Stembo for iodol are its com- plete harmlessness, its freedom from unpleasant smell or taste, the painlessness of its application, and the absence of any untoward or secondary effects, such as loss of appetite, nausea, vomiting, etc. — British MedicalJournal, April 9, 1888. Trousseau has found the following formula useful : For an ointment : Vaseline, Sijss. Iodol, gr. 30 to 60. In solution : Iodol, 3 parts. Alcohol, 35 parts. Glycerine, 62 parts. In disease of the ducts, as the lachrymal, etc., the following was found useful : BROMIDE OF POTASSIUM AS A LOCAL ANESTHETIC. 473 Liquid vaseline, Sviiss. lodol, gr. xlv. {Revue Gen. de Clin, et Ther., December 29, 1887; Med. News, January 28, 1888.) Mazzoni, who first proposed the use of iodol in practical medicine, employed a solution composed of iodol, one part; alcohol, sixteen parts ; and glycerine, thirty-four parts. The dose of iodol is from two to three grains a day, but both Pick and xlssaky have given as high as thirty grains a day without injury. Pick asserts that iodol is absorbed much less freely than iodoform, requiring from twelve to eighteen hours for the full elimination of the iodine in the urine when tested by a solution of starch. Dr. Harlan, of Chicago, uses iodol in combination with pure terebene, as a topical application to lacerated edges of the gums after the removal of necrosed bone. It has been also found beneficial in the treatment of pyorrhoea alveolus. Combined with oleum gaultheriae, it forms an excellent antiseptic in de- strojnng the odors in the cavities of diseased teeth, and control- ling pain. Iodol and the other substitutes for iodoform have not, as yet, taken its place; it is still employed most exten- sively both in surgery and general medicine with success. Bromide of Ethyl as a Local Anaestlietlc. The bromide of ethyl has advantages as a local anaesthetic, a pleasant odor, not inflammable, and has been used in France and this country with good results (see pp. 227 to 238). The ordinary atomizer produces a satisfactory spray with the bro- mide of ethyl, ether and rhigolene. Bromide of Potassium as a Local Anaesthetic for the Geuito-L^i-inary Apparatus. Bromide of potassium has long been used as a local applica- tion to the throat and larynx to diminish sensibility. Acting upon this suggestion, J. Kijanizyer (St. Petersburg Med. Wochenschr., No. 51, IS79— Medical Record) applies it in a similar manner and with similar eflPects to the gen i to -urinary 31 474 ARTIFICIAL ANAESTHESIA. apparatus. He injects a solution of salt into the urethra, when the latter is the seat of painful, acute or chronic inflammation in strictures, and in cases of frequent pollutions. In urethritis, he says, that the pain, redness and tumefaction of the mucous membrane decreased rapidly, the discharge diminished, and soon disappeared entirely with the aid of mild astringents. In a case of stricture, with chronic urethritis and painful micturi- tion, where the urethra was extremely sensitive, and the severe pain prevented the introduction of bougies, in spite of the use oP cannabis indica and belladonna salve, a bougie was introduced with scarcely any pain after the use of bromide of potassium injections for seven days. Kijanizyer uses eight grammes of potassium bromide dissolved in 180 grammes of water. Four grammes of the fluid are injected two or three times a day, and the fluid retained in the urethra a few minutes. From his ob- servations he concludes that the injections are of decided use, in all cases where the indication is to diminish sensibifity in the urethra and neck of the bladder; in the treatment of strictures with bougies, in inflammations of the urethra and their compli- cations; in chordee, dysuria, neurosis, etc., and for pollutions depending upon peripheral causes. He also recommends the local use of the salt, as indicated in catarrh of the bladder and of its neck, in increased sensibility of the latter, and for cystic calculi and the like. He considers the eff"ects to be due to the diminished irritation and lessened quantity of blood in the in- flamed tissue. Ethyl Iodide. This agent has been found useful as a local anaesthetic, and anti-spasmodic in hay-fever and cold in the head. It is most effectively applied by means of glass capsules broken in a hand- kerchief, and then inhaled from it, covering the face. Another method is by means of a half-filled glass bottle, which is inclosed in the hand, the heat vaporizing the liquid. Chloral and Camphor as a Local Angesthetic. Equal parts of chloral and camj^hor were recommended years ago by Dr. Fordyce Barker to stop the secretion of milk, and PIPER METHYSTICUM AND THE COCAINE MOLECULE. 475 now we note from the Canada Med. and Surg. Jour., March, 1885, that before the Medico-Chirurgical Society of Montreal, Dr. Lapthorn Smith read a paper on the use of a mixture of about equal parts of chloral hydrate and camphor as a local an- icsthetic. He stated that when placed in the solid form to- gether in a bottle they soon produced a clear, thick liquid, which, when applied on a piece of lint, covered with oil-silk, to a painful surface, complete analgesia resulted. He reported three cases in which he tried it with good success. The first was a whitlow of the finger, which the patient refused to have opened. Shortly after applying it the pain disappeared, and three days later it was lanced, and the pus let out without the patient, a young lady, experiencing any pain whatever. The second case was a very painful bubo, which completely disabled the patient, a gentleman, from doing his work. The mixture of chloral hydrate and camphor was applied frequently on a piece of lint, with the result that a few hours after the first ap- plication he was so much relieved that he returned to his duties next day, and fluctuation becoming evident a few days later, it was opened, the operation causing only about a quarter of the usual amount of pain. The third case was an operation for the removal of a large sebaceous cyst of the face, which was accom- pHshed after the frequent application of the local anaesthetic for several hours previously by means of a brush. The incision in the skin was almost painless, but it produced no efi'ect upon the deeper structures to which the cyst was firmly adherent. The action of the anaesthetic is much less marked on healthy than on inflamed and painful skin. Piper Methysticum and tlie Cocaine Molecule. Filehn remarks {Berl Klin. Woch., vii., 1887), that for a time cocaine seemed to stand alone in its local anesthetic action. Then a similar property was found to belong to the resin from piper methysticum (Kava). All the ordinary alkaloids have been tested in reference to this point by Bergmeester and E. Ludwig, with negative results. Searching after a substitute, Filehn directed his attention to the chemical constitution of the cocaine molecule. Just as atropine can be split up into and re- 476 ARTIFICIAL ANESTHESIA. constituted from tropic and acid tropin, so cocaine can be re- solved by heat into benzoic acid, methyl alcohol and ecgonine. Carbolic Acid. * Carbolic Acid {carbo and oZewwi " oil "). — Carbolic acid, impure [acidum carhoUcum)^ a liquid obtained from coal-tar oil hy treatinoj it first with an alkali, then with an acid, and finally distilling it. It is of a brownish shade, becoming reddish brown on exposure. It consists of carbolic acid and cresylic acid, with impurities derived from the coal-tar. This form is only used externally, or for disinfecting pur- poses, and, at the iron works, mixed with oil for relieving burns. Pure Carbolic Acid {acidum carboJicum purificatum). — When pure, and while it is in crystals or liquid, it is also termed phenic acid, or phenol. Its odor and taste is like creosote, fusible at from 93 to 104, forming an oily liquid, soluble in from 20 to 33 parts of water, and in alcohol, ether, glycerine, and the essential oils. Carbolic acid, if ap- plied to the skin, produces pain and local anaesthesia, so that the actual cautery and other irritating substances can be applied, or incision made with comparative impunity. In the form of sHghtly carbolized oil, it is most valuable in burns over a large area of skin, yet care must be observed for fear of absorption, if there is much loss of the skin. It is also used in treating surgical diseases by hypodermic injections, as hydro- cele and haemorrhoids. Carbohc acid prevents or corrects putre- faction in cases of purulent infection, dissecting wounds, hos- pital gangrene, and parasitical diseases of the skin, as scabies, prurigo, thrush. Internally it may be given in doses of from J grain to 2 grains, in a tablespoonful of some bland liquid, every hour, in cases of yeasty vomiting, flatulence, dependent on fermentation in undigested food. Its salts, as the carbolate of soda, of potash, zinc, have been used externally for local application and for disinfecting purposes ; also in various aque- ous, alcoholic and ethereal solutions, and in the form of liniment and ointments. It has been ascertained that if animals, to whom carbolic acid had been previously administered, are treated by soda sul- CARBOLIC ACID. 477 phate. a harmless compound of phenol and sulphuric acid is formed. Thus it has been found that the symptoms of carbolic acid i)oisoning are relieved by the free use of this agent. If this, or even the common Grlauber salt, is given when the urine becomes dark-colored, it will arrest the toxic phenomena from slow poisoning. In these sudden cases, when the carbolic acid is swallowed in such large quantities, it has been advised to resort to zinc sulphate, sulphate of magnesia, Epsom salts, or any sulphate. After the evacuation of the stomach, the free use of lime-water and olive or linseed oil is useful to soothe the burnt mucous membrane, and when this is not at hand resort to flour starch, eggs or milk with warm water. While a resident physician at the Philadelphia Hospital a fatal case of poisoning took place from swallowing the ordinary liquid acid, which is of a brown color, resembling brandy ; the individual mistaking it for that agent, swallowed it. Collapse followed, and death was almost immediate. Several similar cases have occurred since. The seventh case occurred at Liverpool quite recently, the acid being mistaken for spirits, as reported in a Glasgow newspaper while we were on a visit to that city. In the first case which we had the opportunity of seeing a post-mortem was made, and the tissues, from the throat to the rectum, were of a brown color, and changed to a leather-like consistency, while the urine and other secretions were black. Carbolic acid has produced poisoning both by its local appli- cation and by being swallowed. Children and delicate women have been the sufferers from its free local application. It pro- duces a species of intoxication. The symptoms are, in the case of adults, nausea, vomiting and headache ; but in children the symptoms are more severe, the temperature falling below nor- mal, the pulse being extremely weak, and the body covered with a cold sweat. Fatality in a Belfast Hospital.— A patient in Belfast Hospital, named James Jeffers, was accidentally poisoned in that institution, through taking a draught of carbolic acid, which the nurse in the ward in which he was located gave him in mistake for a black draught. x\fter drinking a portion of the stuff, Jeffers remarked, "You have given me the wrong 478 ARTIFICIAL ANESTHESIA. medicine," and fell back insensible. The nurse having discov- ered the mistake, by testing the liquid, rushed wildly for the house physician, who was promptly in attendance. Antidotes were administered, but the man died an hour afterwards. Miss Torrens, who was taken seriously ill shortly after tasting the poison, was placed under arrest. She was not aware of the death of the patient, and the doctors considered it would be injudicious to inform her of the fact. The affair created quite a sensation in Belfast, where Miss Torrens' friends move in the best society. Another. — Another death from carbolic acid poisoning — the eighth in a few weeks — occurred at Liverpool, a woman drinking the poison in mistake, as usual, for spirits. Quinine an Antipyretic and Anaesthetic. The first and best known of the agents is the active principle of cinchona, or quinia, and its various salts, but chiefly the sul- phate, which is now so extensively employed. This valuable medical agent, some twenty years ago, was most employed by Fenner, of New Orleans, and in enormous doses as a sedative in all kinds of fever ; but it was found that in many instances it depressed the nervous system and acted most injuriously upon the patient — so that at the present day it is no longer emploj^ed in such poisonous doses. Soon after the Grermans took up this same drug and described it as an antipyretic, and with it endeavored to reduce the temperature of all fevers, especially that of typhoid. In thus endeavoring to cure the disease by the simple reduction of temperature, the}^ did not eff"ect a cure, but frequently the immense doses of quinine acted upon the nervous system and as an anaesthetic, and caused the death of the patient. At the present day it is resorted to chiefly as an antiseptic to combat or destroy the various forms of bacteria, or micrococci, and diseases of a remittent or intermittent type. To obviate its injurious effects upon the nervous system it should be combined with the bromides or hydrobromic acid, or extract of ergot. LOCAL ANAESTHETICS, ANALGESICS AND HYPNOTICS. 479 JLocal Aiiji^sthetics, Analgesics and Hypnotics. ^'Thymol, the product of the fractional distillation of the vol- atile oil of thyme, obtained from the plant thj'mus vulgaris, has long been used as a substitute for carbolic acid, in its varied applications, with the great advantage of having a less disagree- able odor, and causing no pain, as it is not irritating. " It has recently found a new use in the treatment of chyluria dependent upon filaria in the blood. As a remedy for this affection has long been sought, the favorable report of Surgeon- Major E. Lawrie, of Hyderabad, of a cure of two cases is worth noting. The important practical point noticed was that thymol destroyed the organisms present in the system. Reason- ing a priori, Dr. Lawrie tried it extensively in diseases such as leprosy, phthisis and gonorrhoea, but without success. His conclusions then are that either thymol, acting evidently as a fatal poison to the filaria, is not a poison to the bacillus, whicli seemed to him very unlikely, or else the bacilli are not the cause of the diseases above mentioned. Other cases are now necessary to corroborate Dr. Lawrie' s good results." (Dr. Squibb's Epliemeri,<<, vol. iii., No. 6, p. L311.) Dr. Hartmann [Deutsche Med. Wochenschrift) has employed thymol in toothache from cavities, in place of arsenious acid. He fills the cavity of the tooth with a tuft of cotton on which thymol has been sprinkled. It does not irritate the mucous membrane of the mouth much, and it is easily removed by rins- ing the mouth with water. If a rapid action is desired let the patient rinse the mouth often with warm water, in order to facilitate the solution of the drug. It never increases the pain at first, as arsenic does, and is not poisonous. — Lancet- Clinic. "SuLPHONAL is one of the usually safe (but uncertain) hyp- notics which has had very wide use, and has largely increased during the past year. Two of its properties of great merit are its odorlessness and almost tastelessness. (The usual dose is from ten to fifteen grains suspended in hot water.) Its effect has been noticed to last over to a second and third night ; and if this peculiarity is noted, it has its evident advantages as well as disadvantaees. Italian observers have mentioned favorable 480 ARTIFICIAL ANAESTHESIA. results in diabetes. It diminishes the quantity of sugar, the polyuria, and the thirst. They also have noticed its good effects in either greatly diminishing, or entirely suppressing, the night- sweats in phthisis. Dr. D. D. Stewart, of Philadelphia, recom- mends it to be taken thoroughly dissolved in as hot an aque- ous solution as agreeable. Sleep is then induced very soon after taking, and thus is avoided the usual delay of an hour or more before the effect is ordinarily produced. Dr. AY. H. Gilbert, of Baden-Baden, reports danger from its popular and steady use. It is surely bad practice to leave the matter in the patient's hands to the extent of directing him to take a certain dose whenever he cannot sleep, as is apparently the practice with some. There are evidences now on record of the habit being established approaching that of the morphine habit. Fatal cases also have been reported during the past year. For such an effective and widely used hypnotic, then, the conclusion should be to use caution." — Ephemeris. vol. iii.. No. 6, p. 1310. Sulphonal (Di-Ethyl-Sulphon-Di-Methyl-Methane) continues to be a very prominent agent in the practitioner's hands, although caution is urged and generally exercised. "Occasionally an eruption over the body follows its use. After a time the urine is found to be of a dark color, which a microscopical and clinical examination proves to be caused by the presence of haematoporphyrin, and in some cases large quantities of indican. Experience with this hypnotic teaches us to be very cautious in its administration, to watch closely the effects of the first doses in a patient who has not previously taken it, and always to discontinue its use when the urine gets dark." Dr. Edmund Andrews, of Chicago, 111., Professor of Clini- cal Surgery in the Northwestern Medical School, writes as follows : " I found, some years ago, that it had a singular antispas- modic quality, and, in consequence of my brief writings and personal statements on that point, it is considerably used in Illinois for that effect. ' ' In the painful muscular spasms after fractures of the thigh and of some other bones, its effects are surprising in LOCAL ANAESTHETICS, ANALGESICS AND HYPNOTICS. 481 eflfectually suppressing the spasms without necessarily inducing sleep. Opiates will do as long as the patient keeps awake, but the moment he drops asleep he is liable to be aroused by the spasms. Sulphonal suppresses them totally by night or day, without any reference to whether the patient is asleep or awake. "Some healthy men are troubled by cramps in the limbs at night. Sulphonal taken occasionally — sometimes only once a week — prevents them. The effect seems to be very pro- longed. '* Some cases of persistent hiccough are stopped by it. " Some surgeons use it to arrest nocturnal emission of semen with striking effect, the action seeming to be by arresting the nocturnal spasms of the ejaculatory muscular fibres that expel the semen. "I do not know that any one has tried it in epilepsy or tetanus. "Its hypnotic and anodyne powers are feeble. "I have not seen it produce any of the alarming symptoms often described when given in 10- or 15-grain doses for cramps once in a day or two, or in 8- grain doses for nocturnal emissions given two or three times a day," Mr. J. A. Shaw-Mackenzie, M.R.C.S., of London, England, recommends this agent in railway and sea sickness. He reports as follows :* "Inquiry elicits the fact that there are many who suffer from railwa}^ sickness. I am not aware that direct attention has been given to this special cause of megrim ; I am satisfied, however, that the inconvenience is real, and that there are many who are more or less affected by a long journey, and in whom a rail- way journey of two hours produces as much dread and misery as a sea passage. I venture to draw attention to the value of sulphonal in these cases, and to suggest its further and more extended trial in both railway and sea journeys. In children, train sickness is common, while in adults railway megrim varies * London Lancet, vol. i., 1395, p. 1434; Ephemeris, voL iv., No. 1306, p. 1728. 482 ARTIFICIAL ANESTHESIA. from undue fatigue and inability to sleep the same night to in- tense headache, sickness and prostration coming on after some two hours in the train. The dose of sulphonal would vary, o^ course, according to the severity of the symptoms and the length of the journe.y. In my own case I find that 10 to 15 grains are sujfficient for the day journey to Edinburgh, while 20 to 30 grains in divided doses are necessary for the night and day journey to the north of Scotland." ^^ Sulphonal — This is a hypnotic, valuable in insanity when sleep is required, but there is danger from it in doses of 3 to 4 grammes, and it then becomes a poison. From the deep sleep which it produces, if weak from loss of blood, the patient is apt not to recover. At other times it causes alarming symptoms in the intellectual functions, disorder of the motor system and digestive tract. The dose is from 5 to 1 5 grains one to three hours before going to bed ; better taken with hot fluid." ''Pyoktanin (methyl- violet) is the newly adopted trade name given to one of the anihne dyes long used for staining bacilli and micro-organisms ; it is now believed to have a de- structive action on these organisms, and it has been put forth as a new antiseptic and bactericide. There is another form called the yellow. Each is used for special purposes. The former seems now to be preferred in surgical operations gene- rally, and the latter in ophthalmological in particular. Its pus- destroying property, from which it derives its name, is appa- rently well established at this time, but it has not shown uniformly good results otherwise. However, there are observers now who claim that it has little effect, if any, on suppuration, and the staining of the hands and clothes which accompany its use is strongly against it. This latter objection, however, has been met somewhat by the suggestion that these stains may be removed by soap-lather well rubbed in, and washing or brush- ing off with alcohol. It has been employed in the treatment of cystitis with some favorable results ; but in general urethral injections, where much good may follow, Mr. F. F. Burghard, of King's College hospital, claims that too strong solutions are recommended. He advises beginning with a solution not stronger than 1 to 3000, and gradually increasing up to 1 to LOCAL ANESTHETICS, ANALGESICS AND HYPNOTICS. 48S 1500, otherwise irritation and scalding on micturition occur. On open wounds and ulcers the powder is simply dusted on with good effect, and where thej' have become septic this agent is more efficacious than any other antiseptic. Remarkable suc- cess is reported from abroad from its use on malignant growths ; and even cancer has been experimented upon, both here and abroad, with the result of ameliorating the sufferings and of acting as an effective deodorizer. In the various affec- tions of the eye very diverse reports are on record, both in this country and abroad. In general, the majority acknowledge- that some good effects follow its use, but it has not yet arrived at that surpassing value at which its introducer would figure it." — Ephemeris^ vol. iii., No. 6, p. 1306. "Acid Trichloracetic offers us another great agent for detecting albumin in urine. It is one of the newer tests, which bids fair to remain with us. It has been used considerably since it was first brought forward, and with success. Insurance examiners are the loudest in praising it. It may be used in the form of a saturated solution, or a crystal of the acid may be dropped in the suspected urine. The turbid line, which form& immediately at the junction of the liquids, is to be distinguished from that formed by urates by the rapidity of formation of the former. "This acid has also been found effectual as a caustic and astringent. In throat and nose affections its effect is much more local than some of the other caustics. It is readily solu- ble in water, and deliquesces easily. Out of 140 cases treated by one practitioner, 87 needed but one application. Dr. J. W. Gleitzmann, of tliis association, has met with very favorable results, and summarizes as follows: '1. Trichloracetic acid compares favorably with other caustics in hypertrophic condi- tions of the throat and nose, and is a valuable addition to the remedies now in use. 2. In the greatest majority of cases it i& sufficient to produce the desired reduction of tissue, although it does not supersede the galvano-cautery. 3. It can be applied with safety to the larynx w^ithout any evil consequences. 4. Its chief advantage in nasal affections is the drjniess of its- eschar, which prevents unpleasant sequelae, and makes after- treatment unnecessary.' " — Epheineris, vol. iii., No. 6, p. 1285. 484 ARTIFICIAL ANESTHESIA. "Aristol is one of the new antiseptics brought forth as a substitute for iodoform. It is a reddish -brown powder made by treating a strongly alkaline solution of thymol with iodine. It gradually becomes paler in color, due to the iodine given ofif from exposure to sunlight and to heat. It therefore should be kept from an undue amount of light or heat. It has the dis- advantage in some respects of being insoluble in water. Owing to its unstable nature, the excipients which may be employed are limited. It is used mostly in the powdered form, but its use "with olive oil, collodion and the ointments in general is rapidly on the increase. For the two previous years it has been mostly known by the name of 'annidalin,' but recently, and since the inauguration of new modes of preparation, it has been urged forward with renewed vigor under its present name. "From recent investigation it appears that its efficiency is largely due to its instability, and anj" attempt to render it free from its property of slowly giving off iodine renders it compar- atively inert. It has been suggested that this very fact may account for some of the failures which have been reported by some investigators. "Aristol at the present time has universal testimony as to its usefulness in medicine. Some go so far as to claim that it is one of the most important additions to our materia medica in recent years. Its antiseptic power is very pronounced. It has a slight, but not unpleasant, odor. When dusted on open wounds or ulcers it is not irritant, and promotes rapid cicatriza- tion. It has no toxic effects, as iodine cannot be found in the urine after using in any of its forms of application: It is, therefore, a safe remedy to leave in the hands of a patient, as experience has now proved. None of the iodoform substitutes have as large a proportion of iodine as iodoform itself, aristol having less than one." "Recent Hypnotics and Analgesics. — Urethane— ethyl carbonate. A decided antagonist to strychnine. Also a hyp- notic in doses of 30 to 60 grains ; but it was noticed that a rapid tolerance of the drug took place, and is therefore unreliable. iyhloral Hydrate. — This is not a certain hypnotic, yet in doses NAPHTHALINE. 485 of 30 to 45 grains it has been found useful. Occasionally, headache, giddiness and nausea follow its administration, with diminished tension and frequency of pulse. "Trional and Tetronal. — Trional and tetronal contain three and four ethyl groups, and sulphonal only contains two. As a hypnotic, tetronal was, in fourteen cases, superior to sul- phonal, in six cases equal, and in four inferior. The dose is the same. In a more recent report tetronal is said to have all the disadvantages of sulphonal without its power, its action being more sedative than hypnotic. Euphomie. — Euphorine is phenyl urethan, derived from aniline — white crystalline powder. It is an antiseptic. Dose, from 15 to 20 grains in twenty-four hours ; can be taken without bad results. In a few cases euphorine acted well as an analgesic, but, on the whole, the success must be considered small. According to ' Sanso- ric,' in chronic ulcers and ophthalmia, the powder proved itself a better antiseptic than any other which the author had tried. '"''Hypnal. — By heating antipyrine with chloral hydrate a crys- talline compound is produced which is termed hypnal, and par- takes in a marked degree of the properties of both. Dose, 15 grains. It was found to produce sleep with anodyne effect. ^'' Exalgin. — Methj^lacetanilid ; a benzine derivative allied to phenacetin. Dose, J grain in facial neuralgia, given in rectified spirits. It was found unsuitable as an antipyretic because, in full doses, it is apt to produce untoward symptoms." — Ephe- meris, vol. iii., pp. 1283-1288. Kaphtlialine . Naphthaline (CH) is the product of the distillation of coal- tar, of which it posseses the disagreeable odor. It should be carefully used on account of its irritant effects on the renal tissues, and the peculiar modifications in the nutrition of the eye. Naphthaline has been found useful in flatulent dyspepsia in combination with a small portion of morphia. Naphthaline has been found one of the best agents for ex- pelling taenia and ascarides. The dose for an adult is 15 grains 486 ARTIFICIAL ANESTHESIA. when the stomach is empty (in capsules), followed immediately by two tablespoonfuis of castor oil. Children may take 4 to 8 grains, and at the same time a tablespoonful of castor oil. Prior to taking the dose the patient should eat freely of salad and green food. Guaiacol (Mononietliyl-Catecliol ; Liquid Methyl Ether of Protocatechin). Obtained from beech-wood creosote by fractional distillation — CHgOa = C6H,(OH)OCH3— colorless, limpid, oily liquid ; aromatic odor. Specific gravity, 1.33 at 15° C. Boils, 201- 207° C. Antiseptic, antipyretic, analgesic. Tasteless, insolu- ble in water, slightly soluble in alcohol and ether, sparingly soluble in glycerine and fixed oils. It may be given in capsules, wine or oil. Dose, five drops daily. Valuable local remedy in lupus and other forms of external surgical tuberculoses. It has been found by Dr. William James Morton that guaiacol re- strains the action of cocaine to local territory and prevents its toxic action. (See his article, p. 380, on Gruaiacol-Cocaine Oataphoresis. ) Tropacocaine. — This alkaloid was obtained from the narrow- leaved coca plant of Java. It is in the form of an oily liquid, which solidifies in radiating crystals, and is soluble in chloro- form, ether and benzine. Dr. Arthur P. Chadbourne has found its action similar to cocaine, and only half as toxic as cocaine. In lower animals, in full doses (dose not stated), loss of co- ordination, followed by violent convulsions, disturbance of respiration, coma and death by centric asphyxia. Tropacocaine has been used as a local anassthetic in the eye, it is asserted, with good results. This has not been confirmed. It acts more quickly than cocaine. It is not a good mydriatic. Benzol (benzoin) CeHg. A hydrocarbon formed by the dry distillation of organic substances, but chiefiy derived from coal- tar. It is inflammable and very volatile, and is an excellent solvent for grease. It acts as a local anaesthetic on epizoa. Its vapor is used in whooping-cough. " Chloralamid (chloral-formamide) is the new hypnotic ob- tained by the combination of chloral and the colorless, oily, GUAIACOL. 487 liquid formamide — an organic compound allied to urea. Our foreign brethren are very enthusiastic over their results with it as a decided rival to chloral and sulphonal. Its best effects are produced in cases of idiopathic insomnia, cases where the in- somnia is not due to either extreme pain or excitement. Al- though it may succeed in some cases in overcoming slight pains, it cannot be classed as an anodyne. It induces a natural and refreshing sleep, and, as a rule, is not followed by headache on waking the following morning. A sense of well-being is the result of the rest it affords. It is thought by some to be a deeper sleep than that produced by chloral. There have been some failures to^produce sleep with it, but the per cent, of such cases is small. Some Parisian and Grerman observers claim that its action is exactly the same as chloral hydrate, if allowance be made for the smaller proportion of chloral anhydride in the chloralamid. It was supposed that it acted by decomposing in the circulation, liberating chloral ; but there does not occur with it the marked depression so characteristic of chloral. In the majority of cases it works well, but in a small proportion there are unusual effects, not, however, in greater proportion than with morphia or chloral. There are no apparent cumulative effects, and no craving for it is noticed, although it may be given nearly every twenty-four hours for several weeks. Of late some success has been met in cases of epilepsy; but the most satis- factory results have been obtained in senile insomnia, pulmo- nary diseases and hysteria. It appears to possess the very happy property of counteracting the desire to micturate at night in senile cases. It occurs in colorless crystals, with a mild, slightly bitter taste, and without odor. It is soluble in about ten parts of cold water, and one should be cautious not to dissolve it in warm water,- nor to heat the solution after it is made, as it very rapidly decomposes. Its use in this country is rapidly spreading. " — Epliemeris, vol. iii., p. 1292. PAKT SEVENTH. CHAPTER XXII. Anaesthesia and Ansestlietics. A Supplement for the Student to Commit to Memory. Ansesthesia — the word is derived from the Greek avaiaew^a, want of feeling, or condition of insensibihty, or loss of feeling due to a variety of pathological conditions of the brain centres. The origin of the phrase "artificial anaesthesia " is due to Oliver Wendell Holmes. Anaesthetic, not to feel a substance that produces insensibility to feeling of pain, and causes muscular relaxation. Anaesthetics act in various ways, as general, partial and local. The first systemic anaesthetic is alcohol. It is a cardiac stimu- lant and anaesthetic. It is obtained by the distillation of fer- mented grain, as " Spiritus Frumenti," or whiskey, but, to be pure, alcohol must test not less than forty per cent. Absolute alcohol is purified by redistillation and bone-black filtration. The symbol of alcohol is (C2H5HO4), and contains but nine per cent. , by weight, of water. JEther (made by the action of sulphuric acid on alcohol) is the first and most important; it is a stimulating anaesthetic. Anaesthesia by ether is divisible into two stages. The first is one of excitement, and the second stage is evinced when the conjunctiva is insensible to the touch of the finger, and muscular relaxation is complete, with slightly stertorous breathing. During the second stage there is complete loss of consciousness, with perfect relaxation, and when the arm is lifted it falls at ANAESTHESIA AND ANAESTHETICS. 489 once. The respiration is slow and regular. If this anaesthetic stage is forced, the stertorous breathing is increased, and there is partial paralysis of the muscles of the palate, in which event it is a good rule to temporaril}' withdraw the anaesthetic agent. Ether, one of the most important of stimulating anaesthetics (U. S. P.). Specific gravity, 0.725-0.728 = 64°. Boils at 37° C. Ethyl oxide; ethylic or sulphuric ether, should contain ninety-six per cent, ether, four per cent, alcohol, traces of water, CiHioO. Discovered in 1540 by Valerius Cordus, who gave it the name of oleum vitrioli dulce. Frobenus changed the name to ether in the year 1730. Its anaesthetic properties were first suggested by Dr. Jackson, of Boston, to W. T. Gr. Morton, a dentist, who employed it under the name of ' ' Lethion ' ' for extracting teeth ; and the first successful de- monstration in general surgery was made by him in the Massa- chusetts General Hospital, October 16, 1846, when Dr. John C. Warren removed a tumor without any indication of pain. Ether is produced by acting upon strong alcohol* with sul- phuric acid, and heating the mixture to 280°-300° F. This compound undergoes double decomposition, ethjd sulphuric acid and water being first liberated, the ethyl sulphuric acid after- wards combining with a molecule of alcohol to form ethyl ether and sulphuric acid, thus : Beaction, C2H5OH + H^SO, = SO2OHOC2H5 -f H^O. Then, C2H5OH + SO2OHOC2H5- (C2H5)20 + H^SO,. Formula, (02115)20 or C4H10O. The ether is purified by passing over fused chloride of cal- cium, which removes the alcohol, and is then rectified by distil- lation. The vapor is very inflammable and sinks, by its density, to the floor. There are sold three kinds of ether — commercial ether, unfitted for anaesthesia, purified ether, and absolute ether. AD]\nNiSTRATiON. — Ether as an ansesthetic should be given cautiously with great gentleness by dropping from a bottle upon a folded napkin or by means of Allis' inhaler. * Ethyl hydrate, absolute alcohol (C20H5OH) of good quality should not contain more than one per cent, of water. 32 490 ARTIFICIAL ANESTHESIA. Cliloroforni. Chloroform was discovered as chloric ether by Guthrie, in America, and by Soubeiran, in France, in 1831, who made it by the action of chloride of lime on alcohol. In 1832 chloroform was rediscovered (chemical process) by Liebig. By him it was produced as follows : Methyl chloride and chlorine in vapor CH3CH + 2CI2 = 2HC1 X CHCI3. By this method it was very impure. Its impurities, methodic compounds, were very com- mon, and can be detected by the addition of a few drops of sulphuric acid. If impure, this acid will blacken the liquid (chloroform). The ordinary process of manufacture is bj' the action of bleaching powder upon alcohol, and the chief impurities are free chlorine gas and hydrochloric acid. The cheaper process for the manufacture of chloroform is termed the acetone process ; but this "acetone," which is ob- tained from various sources, is not always pure. The proper agent to be employed is alcohol. Many of the fatalities are, no doubt, due to the use of this cheap variety of chloroform. A very pure Chloroform is now made from Chloral Hydrate. Added Impurities. — Alcohol or ether. Chloroform boils at 60° C; sp. gr. 1. A temperature of 96° vaporizes chloro- form if held in the hand. It is not inflammable, but near a flame of gas decomposes, separating into poisonous vapors. Chloroform should be kept in tin or dark amber-colored bottles, and in the dark. Specific gravity 149° at 15° C. Boils at 60° C. Comp. HCI3. A form of stimulating anaesthetic mixture is composed of alcohol, ether and chloroform, or nitrous oxide and oxygen. Chloroform is a depressing angesthetic. The principal general or systemic anaesthetics emploj^ed are alcohol, nitrogen monox- ide or nitrous oxide, ether or ethjd oxide (C4H5O) (C2H5)0, chloroform, methyl chloride, terchloride of formjd, bromide of ethyl or hydrobromic ether. Bromide of Ethyl, Hydrobromic or Bromic Ether. — CaHjBr. Specific gravity 1.4733 ; boils at 40.7° C. It is pre- pared by distilling alcohol (ethj^lic) with either bromine, hydro- bromic acid, or bromide of phosphorus ; it is a colorless, trans- THE MOST PROMINENT LOCAL ANESTHETICS. 491 lucent liquid, of ethereal smell and sweet taste. Its action upon human beings is to produce unconsciousness and anaesthesia in one minute and partial relaxation {occasioncdly complete) in two to three minutes. When given to excess it kills b}^ direct action upon the respiratorj' centres. For prolonged operation it is not advisable — the limit of time is fortj^ minutes. Impu- rities, free bromine, carbon, bromide phosphorus and bromo- form. Should be kept in sealed tubes and from both light and air. It should not be emploj-ed except for examinations and in minor surgery and for an occasional obstetric case. Nitrous Oxide G-as. — NgO, obtained from nitrate of am- monia hj distillation. Kt 226° F. the salt melts ; at 460° F. it gives oif gas. Purified by passing through solution of sul- phate of iron and caustic potash and water. It is now to be had condensed, at a temperature of 44.60° F. (7° C), into a liquid at a pressure of fifty atmospheres, and can be carried about in steel cylinders for convenient use. If not properly prepared the liquid gas may contain air. The Most Proininent Local Anaesthetics. Cocaine hydrochlorate. Cocaine cataphoresis by electricity. Cocaine benzoate. Cocaine borate. Cocaine carbolate (cocaine phenate). Camphor phenique. Carbolic acid. Chloral hydrate. Ether absolute. Ethyl bromide. Ethyl chloride. Eucaine hydrochlorate. Guaiacol, with cocaine cataphoresis. Ice (with chloride of sodium). Menthol (peppermint camphor). Methj'l chloride. Salicj'iate of sodium. 492 ARTIFICIAL ANESTHESIA. The most important of these local anaesthetics is cocaine, active principle of the erythroxylon coca. The leaves of the plant from which it is obtained are employed as a stimulant and sustaining agent, when mixed with a little lime, and are chewed like tobacco by the Indians of Peru and South xlmerica. When making long journeys over the mountains of South America the Indians can, by its use, go for a long period of time without food. The alkaloid is prepared by maceration with lime, and distillation, and is then dissolved in alcohol for purification. Its composition is C1TH21N1O4. Its action is first stimulant, then narcotic. It is a powerful local anaesthetic on the mucous memhrane. When applied to the eye it causes dryness of tis- sues, dilatation of the pupil and partial paralysis of accommo- dation. Dose, i" to -I of a grain. Contra-indkation. — Fatty degeneration of the heart and atheromatous disease of the arteries. Must be employed with caution in hysterical individuals and epileptics. Antidotes. — Amyl nitrate, free use of black cofi'ee, aromatic spirits of ammonia, and for the depression following, minute doses of nitrate or sulphate of strychnia, -i^ to i^ of a grain. Amount of cocaine used must be in proportion to the extent of surface it is desired to anaesthetize. In no case should the quantity exceed one grain and three-quarters. Cocaine should never be used in cases of heart disease, or in persons of highly nervous temperament. In injecting cocaine the intradermic method is preferable to hypodermic. By injecting into, not under, mucous membrane or skin, the risk of entering a blood-vessel is avoided. It has been found valuable to dissolve it in a boiled solution of chlo- ride of sodium. During injection the patient should always be in a recumbent or semi-recumbent position ; in operations upon the nose and throat, or teeth, the head should not be raised until anaesthesia is complete. It is of great importance that cocaine should be pure, since its combinations with certain other alkalies result in poisonous compounds. Liebermann discovered among the amorphous accessory PRECAUTIONS TO BE TAKEX. 493 bases of coca leaves an exceedingly toxic substance : Isatropyl- cocaine, which, accordinor to Liebreich, acts as a direct heart- poison. The last-named investigator speaks hereof as follows : "I deem it quite probable that the hydrochlorate of cocaine, unless it be very perfectly made, also contains th^ afore-men- tioned heart-poison, even though it be found but in traces." Following cocaine, the next important local anaesthetic is eucaine. Its advantages are. that it is less poisonous than co- caine, but is apt to produce more burning in the eye than cocaine; but by combining the two this is obviated. Precautlon.s to Be Taken in Administration of Cliloroforni, Ether and Xitrou.s Oxide. Chloroform. — In employing chloroform as an anassthetic note that there is no organic disease of the heart or kidneys ; see that the bowels have been moved ; but little food must be given the day before : commence with gentleness and care, and, drop by drop, pour the liquid upon a towel or a wire frame covered with a flannel. After a minute or two the strength is increased so as to get over the stage of excitement, but do not keep the towel too near the face of the patient. "Watch the respiration with great care, and note the pulse for fear of heart depression in weak subjects. As a rule the head should be low. Judge of the fitness for the operation by loss of conjunctival reflex by gently touching with the finger. Xote the size of pupil for sudden dilatation, or as an indication of heart depres- sion. If the patient vomits, turn him to one side, and with the fingers remove any solid food, and prevent its being drawn back into the larynx by a strong inspiration. It is a well-recognized maxim that chloroform should not be administered in a dental chair, nor for the removal of a tooth. The color of the patient's face, lips and ears is important, as great Hvidity, cyanosis, and pallor are all indications of danger. "Watch for dropping back of the tongue, dropping of the jaw. If chloroform must be employed as the anaesthetic, it is well to have it mixed with oxj'gen gas, as it is thereby made more safe. 494 ARTIFICIAL ANAESTHESIA. Etlier, What are the Precautions in the Use of Ether ? Commence just as you would with chloroform ; give it in small quantities, and do not place patients on their backs and pour it down into the mouth, and in this way choke them in the beginning, but use it first by dropping, and then add a few drops of cologne water. After the first stage the towel or inhaler can be placed almost in contact with the mouth, having previously anointed the lips and nose with vaseline, in which there is a small quantity of cocaine. Be careful not to give an excess of ether. The etherizer must give his whole attention to the patient both before, during, and after the operation. Anaesthetics are rapidly absorbed, and almost as rapidly eliminated by the skin. They are taken into the blood and reach every portion of the system. The action of anaesthetics is secondly upon the nerve centres controlling sensation and muscular motion. The symptoms of asphyxia are developed in the use of all anaesthetics, and are analogous but not identical with true an- aesthesia asphyxia, which is quite common with nitrous oxide, less with ether, and still less with chloroform. They all pro- duce temporary changes in the blood, but do not become per- manent, unless administered in poisonous doses. It has been found that when an animal or man is killed by ether or nitrous oxide, the arterial blood gives only spectrum lines of reduced haemoglobin, while after death from chloroform, the lines of oxyhaemoglobin are very apparent. Dr. Chalmers Da Costa endeavored to show that deaths under ether were the same as in chloroform, but his observa- tions have not been confirmed. Watch the respiration. Remember that the nervous cen- tres regulating the act of respiration are situated on the floor of the fourth ventricle. If instead of normal respiration it is stertorous, as when breathing through the nose and mouth at the same time, irregular respiration is apt to follow, in which case the lips are partially closed, the cheeks distended, and the BEFORE GIVING AX ANAESTHETIC. 495 nostrils dilate with each expiration, which is attended with a puffing sound. When the respiration becomes irregular, look out ; for there is danger with the use of the anaesthetic. The cerebrum presides over the functions of intelligence and volition, while co-ordination and emotional impressions depend upon the medulla oblongata and cerebellum. Resuscitation is the act of raising up again, or the bringing to life from suffocation or asphyxiation. Asphyxia is the effect upon the body of non-oxygenated blood, in turn causing obstruction of the larynx, which is also produced by food, blood or other foreign substances. It is characterized by extreme lividity of countenance, prominence of eyeball, and all symptoms of obstructed respiration. In artificial respiration the aeration of the blood is produced by artificial means, by the muscles of the chest which are moved ; the arms also act as levers by compressing the chest, and the elevation of them expands it. Place the patient on one side at intervals, so as to give exit to mucus, blood or water, as in drowning ; employ rhythmic movement of the chest, and keep the tongue drawn out. There are some ten different methods of artificial respiration practiced, but all depend upon the principles we have announced. The jaw must always be forced forwards, as it is apt to fall back : so also the tongue must be drawn out. Before Giving- an Aneestlietic. "Inquiry should be made before giving the anaesthetic, if the patient has any foreign body in the mouth. Also, if the patient has ever taken an ansesthetic before. The consent of the patient should in all cases be obtained, except in that of a child or in a case of great emergency. When ether is first inhaled, even when mixed with air, it is apt to cause a feeling of oppression or suffo- cation, which can be overcome by encouraging the patient to take a deep breath, and increasing the strength of the vapor. Then there is an interval of rest when the patient almost ceases to breathe, followed by a degree of excitement, when the 496 ARTIFICIAL ANESTHESIA. patient is apt to shout, sing or crj', swear, or even ready, when the stage is passed, to fight. Then the patient becomes quiet, and passes into the true ansesthetic state or sleep. For vomiting after ether, apply mustard plaster over the epigastrium, with the use of a grain of aeetanilide every hour or by rectal in- jections of bromide of sodium and laudanum in starch-water. For persistent singultus, drachm-doses of HoiFman's anodyne are very effective. For vomiting after the use of ether Dr. Hare recommends the following formula : 1 grain of aeetanilide, 1 grain monobromated camphor, and 1 grain of citrated caffeine, given every hour for six or eight doses. "Oxygen and Ether. — The mixture of ether vapor and oxygen gas forms a highly explosive compound. If ozonized ether is conducted into anhj'drous ether, it forms a thick liquid which explodes if heated. Chloroform when mixed with oxy- gen undergoes no change." (Hare.) Specific Gravity of Ether. Specific gravity is the measured weight of a substance com- pared with that of an equal volume of another taken as a standard. For liquids, distilled water is the standard at its maximum density. It is found that the specific gravity of ether differs very much as given by different authorities. On p. 148, the writer has given it as 0.750 at 59° F., from U. S. P. In a recent work by Dr. Hare it is stated: "at 77° F. the specific gravity of ether should be 0.714 to 0.717. The ether which is chiefly employed in private practice and also in most of our hospitals is that of Dr. Squibb." The writer requested the well-known pharmaceutical chemist, Mr. Frank E. Morgan, of Philadelphia, to determine for him the specific gravity of this form of ether, which he has kindly done as follows : " Squibb' s Ether for Ancesthesia has a specific gravity of .725 at 59° F. Absolute Ether has a specific gravity of about .718 at the same temperature. ' ' ELECTRICITY IN RESUSCITATION. 497 Electricity in Resuscitation. In applj'ing this agent in resuscitation it must always be borne in mind that the dr^'^ skin offers an enormous resistance to the passage of the current, but if the skin is well wet with salt water the current will pass through it with facilit3\ For gen- eral galvanization, so as to bring the whole nervous system under the influence of the galvanic current, one pole (usually the negative) is placed at the epigastrium, while the other, or positive, is passed over the forehead, or by the inner border of the stero-cleido-mastoid muscle, from the mastoid fossa to the sternum ; again, along the nape of the neck to the spine. The seance should not be longer than one to two minutes, from ten to fifteen cells. If a galvanic batter}^ is not at hand, a faradic current can be employed. The efforts at resuscitation should not cease for less than half an hour, and requires the efforts of several assistants. In some instances, in India, they have kept it up with ultimate success after three hours. The efforts should not be rough, but gentle, rhythmal and continuous, using all the rational means that are known to have given success. Never employ excessive doses of alcohol, brandy, digitalis, atropia, or strychnia. In certain diseased conditions, severe and rough treatment at resuscitation cause certain death, as in aortic and mitral regurgitation with fatty heart, hgemop- tysis, and tuberculosis. In the selection of an anaesthetic we must choose the one that is the most safe under the particular conditions of the individual case. A few important words which are to be fully comprehended by the student : Asphyxia is the suspension of vital phenomena, a darkening of the lips and skin, and no pulse. When complete there is paralysis of the respiratory centre. Its cause may be (a) the anaesthetic alone, (h) the anaesthetic, plus venous blood, (c) venous blood alone, id) irrespirable gases. Blood-pressure is regulated in one of the following ways : 1 . By the heart directly in the force and frequency of its beat. 2. By the heart directly, by sending impulses along the depres- 498 AETinCIAL ANAESTHESIA. sor nerve to tlie vaso-constrictor centre, inhibiting its cause of this fall of pressure. Cardiac failure^ primar}^ cardiac arrest, lowering of blood- pressure and form of heart, the incomplete mechanism as a force in the circulation. Snycope, to faint, a temporary or permanent suspension of the functions, both of respiration and circulation, from a sud- den lowering of blood-pressure, sufficient to induce stasis of the cerebral circulation and unconsciousness. Shock may be partial, complete or reflex, the inhibition of a number of nerve centres. The vaso-constrictor centre is always more or less involved. Reflex surgical shock is a result of the reception of painful impression on the central nervous system. Additional Means of Resuscitation During" the Ad- ministering- of Anaesthetics. In "Konig's" method, the operator stands upon the pa- tient's left side and faces him, and laj^s the open hand upon the patient's chest, with the ball of the thumb between the apex- beat of .the heart and the edge of the sternum, and presses the chest-wall quickly and strongly thirty times every minute. This plan owes its efficacy to direct action upon the suddenly failing heart. Dr. Kelly, of Johns Hopkins Hospital, Baltimore, pursues the following plan in chloroform-asphj^xia : "The anaesthetic is at once suspended, the wound is pro- tected, and, if abdominal, a broad piece of gauze is laid over the intestines under the incision. An assistant steps upon the table and takes one of the patient's knees under each arm, and thus raises the body from the table until it rests upon the shoulders. The anaesthetizer at once brings the patient's head to the edge of the table, where it hangs extended, with the trachea and nasal cavity in line. The operator stands at the head and institutes respiratory movements as follows : mspii'a- tion, by placing the open hands at each side of the chest poste- riorly over the lower true ribs and drawing the chest forward and outward, holding it thus for two seconds ; expiration, by reversing the movement, by placing the hands on the front of ADDITIONAL MEANS OF RESUSCITATION. 499' •the chest over the lower ribs and pushing them backwards and inward, at the same time compressing the chest. The success of the manoeuvre will be demonstrated b}' the rush of air in and out of the chest. The heart and pulse should be carefully watched. As the respirator}' movements are continued, a little flickering pulse-wave will be observed at the wrist, which shortly becomes faint and regular, and gradually increases in strength. From 10 to 30 of these respiratory movements will be sufficient to excite voluntary breathing. Movements must be timed to suit the natural efforts. This method is not available in cases of patients with constricted fusiform chests (tight lacers) ; in such cases direct antero-postenor (?) compression must be prac- ticed over the lower third of the sternum with one hand there and the other placed on the back at a point opposite the one in front." It is stated that Dr. Kelly^ has had fifteen cases, up to 1894, of resuscitations by following this method. It is to be remembered that the doctor lives in the southern portion of our country, Maryland, and we have already stated that in warm latitudes like our southern country, Africa and India, chloro- form can be administered with much more safety. Again, Dr. Kelly has a large corps of both male and female assistants to carry out the various steps of artificial respiration, just as they have in India. Dr. Kelly's assistant is a most competent medical man, on whom he depends to give the anaesthetic ; he has nothing else to do but to attend to this one object, and Dr. Kelly is a most rapid and brilliant operator, as we have had the opportunity to note ; he is ever watchful of his patient, and ready on the instant the heart shows any indication to weaken, to direct that anaesthetics should at once be stopped, and resus- citative measures instituted. Again, he is most careful not only of the pulse but also the respiration in every case, showing he is no believer in the Sims and Lawrie doctrine of only atten- tion to the respiration. * Johns Hopkins Hospital Eeports, vol. iii., Nos. 7, 8, 9, 1894, and illustrations kindly sent by Dr. Cullen. 500 ARTIFICIAL ANiESTHESIA. CHAPTER XXIII. Experimeuts of Dr. H. C. Wood and Dr. Hobart A. Hare in Reply to the Hyderabad Commissions, February, 1890, and of Dr. Hare and Dr. Thornton in 1893. After a careful series of parallel experiments, especially in reference to the result of the influence of chloroform on dogs, were noted the following conclusions :'^ "As we use between us, in the laborator}^ of the University of Pennsjdvania, many dogs yearly, a very large proportion of which are finally killed by chloroform, we may be excused for our positive statement that chloroform is a cardiac jparalyzant^ and does kill dogs by a direct action upon the heart, or its contained ganglia, espe- cially since we have been strengthened in our opinion by the fact that Dr. E. T. Reichert, Professor of Physiology at the University of Pennsjdvania, has reached results confirming our own, and has frequently demonstrated the same to the Univer- sity classes. . . , . . It has been the custom of one of the authors of these experiments in his lectures before the University class to demonstrate , by means of the respiratory tembour, the mer- curial manometer and the kymography, a continuation of respi- ratory movements after cardiac arrest through chloroform. Further than this, we have at various times taken tracings proving the same facts. "The statements that have recently been made in the Indian journals and in the London Lancet have led us to re-examine the subject, and to make a series of experiments upon it with great care. We have also varied and extended these experi- ments in order to determine whether chloroform paralyzes the heart by indirect action through the vagus. "The experiments show that chloroform acts as a powerful depressant poison upon respiration and circulation ; that some- times the influence is most felt at the heart, and death results * Medical News, February 22, 1890. EXPERIMENTS OF DR. WOOD AND DR. HARE. 501 from cardiac arrest, and that in other cases the drug paralyzes primarily the respiratory centres, while in other instances it seems to act with equal force upon the medulla and heart. "So far as practical medicine is concerned it makes little diflference whether the heart stops just before or just after respiration, so that these cases in which cardiac arrest and respiration arrest are almost simultaneous, are, for the purpose of the clinician, the same as these in which heart arrest pre- cedes respiratory paralysis. " Finally, the results also coincide with our previous experi- ence in the laboratory, and with what we believe to be the gen- eral belief of physiologists — that cardiac arrest is specially prone to occur when chloroform is administered rapidly and in concentrated form. ' ' These two sets of experiments may be in part accounted for, and are given by Dr. Wood.* He stated "that he did not desire to express any doubt whatever as to the correctness of the experimental data of the Hyderabad Chloroform Commission, but simply claimed that both his and their set of experiments, although they had yielded different results, had been properly performed. He suggested that high heat or other climatic conditions surround- ing the pariah dog of India might make its heart less sensitive to the action of chloroform than the heart of the dog bred in our northern climates. "In March, 1892, Surgeon Lawrie found that the original propositions of the Hyderabad Chloroform Commission were not received with that degree of confidence which he expected, especially the final conclusions, in which the Commission states that chloroform may he given in any case requiring an operation with perfect ease and absolute safety^ so as to do good loithout the risk of evil. Dr. Lawrie wrote to Dr. Hare, asking him if another chloroform research could be instituted for the govern- ment of His Highness the Nizam of Hyderabad, who agreed to pay the entire expenses. It was stated that the express ob- * Dr. H. C. Wood's Address on Anaesthesia read before International Medical Congress, Berlin, August 6, 1890. 502 ARTIFICIAL ANESTHESIA. ject of the research was the reconcihation of at least some of the contradictory conclusions reached by various experimenters during the past few years." Dr. Hare* assented, and associated with him Dr. E. Q. Thornton, his demonstrator, not inviting Dr. Wood to take any part in it. The title of their paper was "A Study of the Influence of Chloroform upon the Respiration and Circula- tion, "f We have only space to quote a brief summary of this very elaborate paper : Suniiiiary. ' ' From the immense number of observations , in regard to the action of chloroform, in the laboratory and in the operating- room, it is evident that sufficient data are at hand to give us material to reach positive conclusions, and that the contradic- tory results hitherto obtained must have been reached by misin- terpretation and error in experimental method, tinctured per- haps by opinions formed previous to the completion of a line of study. There are certain facts in regard to chloroform which few will deny, the chief of which are that it has the advantage of rapid action without disagreeable preliminary or subsequent symptoms ; its bulk is small and its odor agreeable, but, more important than all, it is much more dangerous than ether. "Though the Hyderabad Commission, in their preliminary conclusions (page 30, paragraph 43) assert that ether is as dan- gerous as chloroform if given sufficiently to produce true anaes- thesia, we believe that the safety of ether is so universally recognized that this conclusion of the commission can only be excused by the remembrance that ether has probably been used as little by those who wrote this paragraph as chloroform is used in many parts of America. This possibility is made a probability when we read that ' if surgeons choose to be content with a condition of semi- anaesthesia, it can no doubt be pro- duced with perfect safety, though with discomfort to the patient, by ether held rather closely over the mouth. Such a * Now Professor of Therapeutics, Jefferson Medical College; for- raerly connected with the University of Pennsylvania. t Pamphlet published by G. S. Davis, Detroit, Mich., 1893. SUMMARY. 503 condition of imperfect ana3sthesia would never be accepted by any surgeon accustomed to operate under chloroform. ' That this statement shows, to put it mildly, that the writer knows not whereof he speaks, is proved by the universal employment of ether by hundreds of the best surgeons the world over in preference to chloroform. Further than this, medical literature contains so many statistical papers showing the small percentage of deaths from ether as compared with chloroform that this point need not be debated. "The truth about the fatty heart appears to be that chloro- form per se in no way endangers such a heart, but, on the con- trary, by lowering the blood-pressure, lessens the work that the heart has to perform, which is a positive advantage. But the mere inhalation of chloroform is only a part of the process of the administration in practice. A patient with an extremely fatty heart may die from the mere exertion of getting upon the operating-table, just as he may die in mounting the steps in front of his own hall door, or from fright at the mere idea of having chloroform or of undergoing an operation, or during his involuntary struggles. Such patients must inevitably die occa- sionally during chloroform administration, and would do so even were attar of roses or any other harmless vapor substituted for chloroform. " [We agree entirely with this statement; but as chloroform has confessedly some cardiac action and a very positive vaso- motor and respiratory eifect, the fatal result might be more direct. ] " Having given the evidence we have accumulated, let us see what practical deductions may be drawn. "From a careful stud}" of the experiments so far reported, from studies made by one of us some two years ago with H. C. Wood, and, finally, from the careful series of experiments, we believe that the question can be settled by the acceptance of both views in a modified form, or, in other words, that there is no real antagonism in the beliefs that chloroform kills by de- pression of the heart or depression of the respiration. "We very positively assert that chloroform practically always kills by failure of respiration when administered by inhalation, 504 ARTIFICIAL ANAESTHESIA. provided — and this provision is most important — that the heart of the anaesthetized is healthy, and has not been rendered func- tionally incompetent by fright or violent struggles, or, again, by marked asphyxia. By a healthy heart we mean one which has not undergone true fatty degeneration, or has not so severe a valvular lesion as to make the slightest variation in the even tenor of the circulation fatal. "That the circulatory depression may be dangerous is not only evident, but it is stated to be so by the second Hyderabad Commission itself at the end of paragraph 8. This circulatory depression may be so profound that recovery is impossible even with the most thorough artificial respiration, a fact stated by the second Hyderabad Commission in paragraph 25, which we quote in this paper. This emphasizes the fact that we cannot afford to totally ignore the effect of chloroform on the circula- tion, and we cannot consider the patient in danger of circulatory failure only when the respiration ceases, but as soon as it BECOMES ABNORMAL. "1. Is chloroform a safe anaesthetic? "2. Are we to watch the pulse or respiration during the use of the drug, and what are the signs in the respiratory function indicative of danger to the patient? " 3. What is the true cause of death from chloroform? "4. Is death from chloroform possible when it is properly administered ? ' ' 5. Under what circumstances is the surgeon to use chloro- form in preference to the less dangerous anaesthetic ether ? ' ' 6. What is the best way of administering chloroform ? "To the first question the answer is, Yes, for the majority of cases, jDrovided it is given by one who is skilled in its use and not only knows how to give it, but to detect signs of danger. It is not so safe as ether at any time, other things being equal, and never so safe in the hands of a tyro. "To the second question the answer is, Watch the respiration, because as soon as enough chloroform is used to endanger the circulation, the respiration will show some signs of abnormality either in depth, shallowness or irregularity. In other words, the very effect of the drug may be to cause such deep and rapid SUMMARY. 505 respirations that an excessive quantit\' of the drug is taken into the kings, and continues to be absorbed even after the inhaler is "withdrawn. "The answer to question 3 is, That death is always due, in the healthy animal, to respiratory failure, accompanied by cir- culatory depression, which latter may be severe enough to cause death, even if artificial respiration is used skilfully. Death only occurs in the healthy animal when chloroform is given in exces- sive quantities. " Question 4 is impossible to answer for man from the basis of experimentation, as we cannot produce identical diseased states in animals with those developed under various conditions in man. The physician, having a case of heart disease, should always advise the patient of the danger of any anaes- thetic, and he should remember, whether it is wise to tell the patient or not, that anaesthesia always means a step towards death even in the healthiest of men. In the event of a death under chloroform, the physician is not to blame if he has taken proper preliminary precautions and given the chloroform properly. " In answer to Question 5 we have several points to offer : "1. Hot climates (where ether is inapplicable), where a free circulation of air increases the safety of the patient. "2. Chloroform may be used whenever a large number of persons are to be rapidly anaesthetized, so that the surgeon may pass on to others and save a majority of lives, even if the drug endangers a few, as on the battle-field, where only a small bulk of anaesthetics can be carried. " 3. Its employment is indicated in cases of Bright' s disease requiring the surgeon's attention, owing to the fact that anaes- thesia may be obtained with so little chloroform that the kid- neys are not irritated, whereas ether, because of the large quan- tity necessarily used, would irritate these organs. Quantity for quantity, ether is, of course, the less irritant of the two. "4. In cases of aneurism, or great atheroma of the blood- vessels, where the shock of an operation without anaesthesia would be a greater danger than the use of an anaesthetic, chloro- form is to be employed, since the greater struggles caused by 33 506 ARTIFICIAL ANAESTHESIA. ether and the stimulating effect which it has on the oirculation and blood-pressure might cause vascular rupture. "5. In children or adults who already have bronchitis, or who are known to bear ether badly, or, in other words, have an idiosyncrasy to that drug, chloroform may be employed. "6. Persons who struggle violently, and who are robust and strong, are in greater danger from the use of chloroform than the sickly and weak, probably because the struggles strain the heart and tend to dilate its walls. "The safest method of administration is by Lawrie's or Esmarch's inhaler, because these provide free circulation of air and do not distract the attention of the anaesthetizer from the respiratory movement by complicated apparatus. Apparatus imuch like these, in allowing a free amount of air, are the Hy- K^erabad chloroform inhaler or open-ended cone, with Krohne's .and Seseman's respiration indicator attachment. "The Junker inhaler, even with its modifications, is too com- ;plicated and cumbersome, and while less chloroform is wasted in administering the drug, it must all be thrown out of the bottle ■afterwards. If used at all, it should be used with the increased ; air-supply and respiration indicator of Krohne and Seseman. "1. The chloroform should be given on absorbent cotton, •stitched in an open cone or cap. (A depression made through ithe opening in the inside flannel bag will answer as well.) "2. To insure regular breathing, the patient, lying down, with everything loose about the neck, heart and abdomen, , should be made to blow into the cone, held at a little distance , from the face. The right distance throughout the inhalation is the nearest which does not cause struggling, or choking, or hold- ■ ing of the breath. Provided no choking or holding of the breath occurs, the cap should gradually be brought nearer to, : and eventually may be held close over, the mouth and nose as ; insensibility deepens. "3. The administrator's sole object while producing anaes- ^ thesia is to keep the breathing regular. As long as the breath- ing-is regular, and the patient is not compelled to gasp in chlo- roform at an abnormal rate, there is absolutely no danger what- ever in pushing the.an^sthetic till full anaesthesia is produced. SUMMARY. 507 " 4. Irregularity of the breathing is generall}- caused by in- sufficient air, which makes the patient struggle or choke or hold his breath. There is little or no tendency to either of these untoward events if sufficient air is given with the chloro- form. If they do occur, the cap must be removed and the patient must be allowed to take a breath of fresh air before the administration is proceeded with. " 5. Full anaesthesia is estimated by insensitiveness of the cornea. It is also indicated by stertorous breathing or by com- plete relaxation of the muscles. Directly the cornea becomes insensitive or the breathing becomes stertorous, the inhalation should be stopped. The breathing may become stertorous while the cornea is still sensitive. The rule to stop inhalation should, notwithstanding, be rigidly enforced, and it will be found that the cornea always becomes insensitive within a few seconds afterwards. " It is only necessary to add that the patient should be so dressed for an operation that his respiratory movements can be easily seen by the chloroformist. In the climate of India this is not difficult to manage, but it is rather more so in the climate of Europe ; so that in this respect, and in this respect alone, the chloroformist in England iS placed at a distinct disadvantage compared with the chloroformist in India. "Note. — Since writing this report two important papers upon this subject have appeared in the London Lancet — the one by Graskell and Shore, in which they carried out a complete line of ingenious cross-circulation experiments, and from which they conclude that the fall in blood-pressure seen under chloro- form is due to cardiac rather than vaso-motor depression ; and another paper, published by Lawrie, in the London Lancet for February 11, 1893, in which he refutes the statements made by Gaskell and Shore, and details experiments which he believes combat those of the two investigators just named." An abstract of both of these papers will be found on pp. 280-299. According to Dr. Hobart A. Hare,* Larwie's inhaler consists of four bamboo sticks supporting unbleached muslin, which * Park's Treatise on Surgery, vol. i., p. 295. 508 ARTIFICIAL ANESTHESIA. provides a free circulation of air, and do not distract the atten- tion of the anaesthetizer from the respiratory movement by complicated apparatus. Apparatus much like these, in allow- ing a free amount of air, as the Hyderabad chloroform in- haler, or open-ended cone, with Krohne and Seseman's respi- ration indicator attachment, the inner lining is of white felt, the outer cone is leather. It can be used directly, or by the air- pump attached to the top. Krohne and Seseman have also made a modification ol" Junker's inhaler, with a respirator indicator, but even with this indicator it is considered too com- plicated. To Prevent tlie Action of Chloroform on the Heart.* (We give also the opinion of Dr. Guerin, which is quite adverse to the theory upheld by Dr. Souchon, pp. 178, 269.) M. A. Guerin, of Paris, stated that death from arrest of the heart might be prevented in chloroform anaesthesia, simply by having the patient inhale the chloroform only by the mouth. In death from arrest of the heart the cardiac muscular fibres cease to contract under the influence of a nasal-nerve reflex, which causes inhibition of the heart through the medium of the pneumogastric. If a rabbit be made to inhale chloroform directly through the trachea after tracheotomy, the heart is in no waj'^ afi"ected ; if, however, the animal be made to inhale it through the nose, the heart is arrested. Now, as the trachea has been cut transversely, the chloroform inhaled by the nose cannot pass the bronchi. It is, therefore, plain that the anaes- thetic acts upon the heart movements only through the nasal nerves, and the cardiac nerves of the pneumogastric, the for- mer acting reflexly upon the latter. In administering chloro- form, therefore, its action upon the nasal nerves should be pre- vented by pressing the nose of the patients between the fingers of the hand, holding the compress until anaesthesia be pro- duced, when the nasal fossae, being also anaesthetized, will have no reflex action. * France. Huitieme Congres Franpais de Chirurgie. Meeting at Lyons, October 9 to 13, 1894. ANAESTHETICS. 509 Dr. W. I. Fleming, in a discussion on anaesthetics, stated that he found house surgeons, as a rule, who came to Glasgow hospitals, had no knowledge whatever of the mode of using ether, and he was obliged to train them to it. He also stated the proneness of dogs to succumb to chloroform, and he had been compelled as a matter of economy to use ether for that purpose. In regard to cats the case was exactly the reverse, and to kill a cat with chloroform was a difficult thing. This important matter of idiosyncrasy did not appear to have been commented upon by the Commission."^ "I think we have not to look far to find the reason of the greater safety of ether. The full bounding pulse of ether anaes- thesia shows how much the circulatory system is stimulated by it, and the rapid and deep character of the breathing proves the same influence on the respiratory organs. So if instead of using an anaesthetic which has a tendency to depress both the respi- ration and the circulation (as chloroform has), we employ one that has a direct!}' stimulating effect, we are much more likely to tide these ' morituri ' over their operations."! CHAPTER XXIV. AnsBsthetics. Tlieii' Talue in Disease— Wliicli to Avoid and Those to Employ. First, as a rule in diseases of the hrain, either acute or chronic, cocaine is to be avoided. Ether has been found one of the most valuable in brain affections not organic, when given with great care, premised with a few inhalations of nitrous oxide gas, and followed by the inhalation of oxygen gas. ^- G. A. Stockwell, M.D., Detroit, !Micli., Therapeutic Gazette, August 15, 1890. t John Freemau, F.E.C.S., in Bristol Medico-Chirurgieal Journal, July, 1896. 510 ARTIFICIAL ANESTHESIA. In Diseases of the Heart. — In a fatty heart there is a degene- ration of the muscular fibres, or an increase in the quantity of subpericardial fat, or fatty infiltration. The former is the most serious condition, and is due to a deficiency in the supply of oxygenated blood to the heart. It gives rise to asthma, an- gina pectoris, and tends to syncope and sudden death. In fatty hearts cocaine and chloroform are to be avoided, while ether and oxygen gas have been found to be the remedies. In cardiac dyspnoea these two agents can be employed as anaesthetics in the horizontal posture, avoiding all hurried movements. In aortic stenosis or valvular disease., ether is not to be em- ployed, but a mixture of chloroform, ether and alcohol. Ether is to be avoided in all pulmonary diseases of an acute character. In neuralgia, valuable results have been obtained from cocaine as a local anaesthetic, with morphia and the anode of the elec- trical current, or camphor with equal parts of chloroform ; also chloride of ethyl has been found useful in local neuralgic pains as a local application. In neuralgia over various parts of the body, nitrous oxide can be employed with advantage in the middle of the day. In nervous aphonia, not organic, with intermittent loss of voice, the inhalation of nitrous oxide gas followed by vapor of ether, will restore the voice ; also hot water in tin inhaler, with compound tincture of benzoin or guaiacum, a teaspoonful in a pint of water, which must be kept hot. Diseases of the Lungs. — Pure nitrous oxide gas can be admin- istered with air, but do not cover the face, as it has to be care- fully watched to see that no asphyxia be the result (it is also useful in aphonial bronchial asthma). In pulmonary phthisis, as a rule, use the inhalation of the spray or vapor of menthol or eucalyptus in alboline, with a portion of bromide of ethj4, only sufficient to tide over pain if the operation is short. When there is a tumor or foreign body to be removed from the larynx, chloroform is to be preferred to ether, but in post- nasal operations for the removal of adenoid growths ether is to be employed. When it is absolutely necessary to give ether in case of slight ANESTHETICS. 511 pulmonary disease, on account of a prolonged operation, the patient's skin, feet and body are to be kept warm, and after the operation must be watched until reaction has taken place. Watch also that the pulse and respiration are normal. It is well to use the inhalation of oxygen gas if the skin become dark. In all diseases of the Iddneij, especially in Bright'' s disease^ or diabetes, ether must not be employed, nor should chloroform. Nitrous oxide gas with oxj-gen is one of the best anaesthetics in this form of disease. Epilepsy and chorea, when not of an organic character, have been benefited by the inhalation of nitrous oxide gas. Spraying of the spine by ether vapor, and the internal administration of fluid extract of cimicifuga racemosa, have been found very useful. Nitrous oxide gas has been found useful in certain hysterical conditions when not dependent on organic disease of the brain. Ether has been found a valuable remedy in hysteria, by inha- lation or administered internally in capsules, or associated with emulsion of gum arabic with valerian, asafoetida, musk or camphor. In insomnia, nitrous oxide gas has been found, at times, use- ful, but not proper if there is vascular excitement, marked arterial tension or associated with diseases of the arteries or hypertrophy of the heart. In these latter cases the bromides are found to be the most useful. At times a small dose of the atropia sulphate, j^q of a grain, with |^ of a grain of morphia sulphate, will relieve pain of head, from loss of sleep, only to be given at long intervals. Sciatica can be treated successfully by the subcutaneous in- jections of ether or chloroform, or given internally in doses of from ten to fifteen drops, repeated morning and evening for three days, or until the patient is relieved. No local injurj^ results by this method, as the injections are made by the ordi- nary method, superficially, not deep. The objections to deep freezing the skin bj^ ether, rhigolene or ethyl chloride are that the skin becomes destroyed and ulceration and great pain follow. In cerebral surgery, neither opium nor morphia should be employed prior to the operation. 512 ARTIFICIAL ANESTHESIA. Ether can be employed in abdominal sur^ejery in conjunction with oxj'^^en gas, to prevent the belching or vomiting. A small dose of hydrochlorate of cocaine has been found very useful. The more rapid the etherization is produced without air, the greater the danger of asphyxia. Average time to produce complete unconsciousness by ether is from seven to eight minutes. Appearance of the face when fully under ether, chloroform or nitrous oxide should be natural ; anj^ deep cyanotic appearance denotes approaching asphyxia. The pulse at the wrist and the temporal artery should be care- fully noted by the angesthetizer or assistant. What to do first in case of danger : " See that there is no obstruction to the respirator}^ passage by the throwing back of the paralyzed parts upon the larynx. Use the method of Hare and Martin (see p. 272). Place the index finger of each hand upon the corresponding cornua of the hj^oid bone, while the middle fingers rest upon the angle of the jaw, and then press forward and upward, the same force serving to extend the head upon the neck ; if this fails to open the glottis, then by means of a towel grasp the tongue and make rhythmic traction. If the tongue cannot be held by this means, use a tenaculum or for- ceps, thrust far back into the base of the tongue, and draw it forward." " According to Dr. Wood, inversion of the body at an angle of forty degrees does not resuscitate in the manner which Dr. Holmes believed when the circulation has practi- cally ceased in anaesthesia ; inverting the body must cause the blood which has collected in the extremely relaxed vessels of the abdomen to flow into the right side of the heart and dis- tend it, and this distension, this increase of intra-cardiac pres- sure, may at a critical moment have an influence upon the failing organ sufficient to recall it into functional activity. The drug to be employed in cases of weak heart is full doses of digitalis given hypodermically, either before the administration of an anaesthetic or when cardiac collapse occurs." The use of amyl nitrite will in some cases cause an increase of the pulse- wave when passed by a hand spray into the nostrils. Strychnine has been found, both by experiment and experience, CHLOROFORM EMPLOYED WITH SAFETY. 513 a most valuable drug in raising the arterial pressure and the rate and depth of the respiration. It should be given in full doses for a robust adult ; as large a dose as xV grain has been given with good results. But, as we have stated before, the most wonderful results have been obtained b\' the use of artificial res- piration, Sylvester's or other methods. Then we have the forced respiration by the foot-bellows of Dr. George E. Fell, by "which air is 'forced' into a receiving chamber, which in turn is connected with an apparatus for warming the air, and a valve which can be opened and shut by a movement of the finger. This valve in turn leads to the tracheal tube. When the valve is opened the air rushes through the chamber into the lungs and expands them ; when the finger is lifted the valve shuts, the lungs con- tract, and so respiration goes on. Dr. Wood* has suggested a much cheaper, simpler, and probably equally efficient, appa- ratus, which may consist simply of a pair of bellows of proper size, a few feet of india-rubber tubing, a face mask and two sizes of inhalation-tubes. There should also be set in the rub- ber tubing a metal tube, similar to the tracheal canula of the physiological laboratory, so that it is in the power of the operator to allow for the escape of any excess of air thrown by the bellows. ' ' In Wliat Class of Cases can Cliloroform be Employed with Safetj? Chloroform, in certain conditions, is a direct cardiac depres- sant, while, as expressed by the late Dr. Fordyce Barker, in obstetrics he had found that " chloroform had a very different effect from that which it had when given as an anaesthetic in •surgical practice. The reason that he assigned for this was, that in surgical practice the anaesthetic was given to anticipate suffering, while in the case of the parturient woman, it was used for the relief of pain already existing. Under the latter circumstances he believed the system would tolerate the de- pressing influence of the drug, which it might not in ordinary conditions." In our own experience, and after numerous experiments, we * "Anaesthesia," by H. C. Wood, Pamphlet, p. 33. 514 ARTIFICIAL ANiESTHESIA. would limit the use of this most potent of all the anaesthetics to very young children, or to those who are weak, strumous, or overgrown ; to puerperal eclampsia, in very violent convulsions in male adults, or in females during delivery where rapidity of dilatation of the os uteri is absolutely necessary to save the mother's life. In some rare cases of painful operation, where, after contin- ued efforts, no complete insensibility can be produced by ether, we would feel justified in the use of chloroform on a clean sponge or inhaler. "There are certain bodily conditions, hardly to be spoken of as disease, which would exert some influence in the selection of the anaesthetic. In his recent book Dr. Frederic W. Hewitt states that old persons whose chests have become rigid, seem not to be able to respond sufficiently to the demand made upon them by ether, and that very old persons bear chloroform prac- tically well. In applying such a principle as this, it must be remembered that it is not the years of the person, but the ex- tent of senile changes in his tissues, which should influence the ansesthetizer. Dr. Hewitt recommends in such cases the A. C, E. mixture ; if such mixture be employed, it should always be freshly made at the time of its administration. "Extreme obesity is another bodily condition in which it is affirmed that ether is often not well borne, producing so much excitement and respiratory irritation, as to forbid its use. Under these circumstances again, Hewitt recommends the A. C. E. mixture, but states that there are certain cases in which chloro- form is necessary in order to secure sufficient tranquillity of breathing. I have not had practical experience with such pa- tients of sufficient amount to be weighty, but my feeling is that in such cases ether should be first tried, and then, if it be not well borne, chloroform substituted, ether being again employed when quiet anaesthesia has been thoroughly established." In this connection we feel as if it would be well to give the admirable views of an expert. Dr. John N. Upshur, Richmond, Va. ,'^ on "The Therapeutic Application of Chloroform in * Professor of Materia Medica and Therapeutics, Medical College of Virginia. Trans. Pan-American Medical Congress, vol. i., p. 922. CHLOROFORM EMPLOYED WITH SAFETY. 515 Labor." In the south of our country it is stated chloroform can be emplo.yed with perfect safety, although we have our doubts, and have expressed them freely in this edition. "Since the primeval curse fell upon our race, and pain and anguish have been the invariable and dreaded accompaniment of man's entry into the world, to soothe woman's sorrows and conduct her safely through the crisis is an object worthy our highest effort, and one to be sought for with commendable de- votion. " To accomplish this end the administration of chloroform has become a routine practice, and the consensus of opinion from a very large number of obstetricians is in favor of its safety when thus exhibited. Careful observations for many years has tended to make me question its utility in many cases ; nay, to convince me that oftentimes it adds to the peril and prolongs the trial. "In the light of the foregoing facts I most earnestly avow my belief that we, as physicians, should place chloroform upon the same platform as other drugs, and not be influenced by our sympathies aroused by the pleadings of patients or the fash- ionable routine practice of the day, but initiate and sustain a much needed reform in our obstetric work, chloroform being administered, as other agents, when the indications in the case imperatively demand it — not unless. He is a bold man who, invading the domain of nature, interferes with her physiologic processes and places the wife and mother in a position of in- creased peril, and perchance in the shadow of a fatal issue, or at least of a life of invalidism and suffering, where before the home was irradiated with the effulgent rays of the sunlight of true and unalloyed happiness. ' ' 516 ARTIFICIAL ANESTHESIA. CHAPTER XXV. The Legal Eesponsibility of Physicians in the Administration of An- esthetics — Medico-legal Relations of Ansesthetics — Experiments of M. Dolbeau — Case in Philadelphia of a Surgeon Dentist — The Important Question whether Chloroform can be Administered for Criminal Purposes? — Cases in France, England and the United States — Dr. N. L. Folsom, R. M. Denig — Chloroform as a Poison — The Chloroform Habit — Hypnotic Ansesthesia and its Analogous States in their Various Aspects. On tlie Leg-al Responsibility of Physicians in the Administration of Anaesthetics. It is a noted fact, that when anaesthetics are trusted in the hands of an educated and careful surgeon, the mortality from their use is reduced to the minimum. The individual who ad- ministers the anaesthetic should have nothing else to do ; his hands, eyes and mind should be on this alone. In our hospitals, ■clinical assistants should be instructed for at least six months in the chemical, physiological and toxicological nature of anaes- thetic agents, and after being thoroughly trained in their use, and in the means of resuscitation, receive a certificate of com- petency. This is done in the Philadelphia Dental College after a careful examination by the professors and an expert. It is too often the case that valuable lives are placed, as it were, in the hands of young men who have no proper knowledge of their use, and who do not appreciate the great responsibility under which they are laboring. Such powerful agents as chloroform and ether, or their compounds, should be handled with skill, judgment and discretion, fully realizing that on the exercise of these depends the life of the patient. There is no doubt that many deaths have been caused through the want of this proper knowledge and experience. Who is at fault in this ? It is, as a rule, the fault of the medical schools and of the operating surgeon, who, in a general way, considers this as a secondary matter, and trusts the anaesthetic to any person who may be LEGAL RESPONSIBILITY OF PHYSICIANS. 517 with him. To the experienced ej^e signs of danger are almost always evident — the disturbed, stertorous, or shallow respira- tion, the pulse, the pallid or leaden hue of the skin, the flutter- ing heart ; but on the novice or recent graduate these make little or no impression. We repeat it, that a physician or a surgeon, in administering ether and chloroform, or their compounds, is responsible for the life of the patient, and it would be well for some of them if laws were enacted compelling them to employ the least fatal anaesthetic, unless some idiosyncrasy on the part of the patient did not allow of the use of such an agent, or one less dangerous. Again, in our navy, especially on board steamers, and in coun- tries where the average temperature is 80° F. or over, chloro- form might be allowed, but in the army, in the field, as well as in the navy, only in capital, very painful or extensive opera- tions, this exception being enforced by a rule. Daniel S. Riddle, Esq., New York, said, as regards the enact- ment of further laws on this subject, it was not necessary. There are sufficient laws already. The difficulty is in enforcing them. If there is carelessness on the part of the doctor, he should be held responsible. It is the same with lawyers. It belongs to the profession of medicine to say whether these agents have been carelessly used; and if they have been care- lessly used, it is their duty to produce, as well as indicate, the person who uses these great powers carelessly. "If we law- yers," he remarked facetiously, "find out that you are carelessly using these things, it is our duty to pitch in." Coroner Ellinger thought it would be a hard matter to hold doctors responsible, because it is difficult to state scientifi- cally where the responsibility can rest. It ought at least to be shown that there was conscious negligence in the performance of duty. The condition of the patient should be taken into account, and that must be left to the discretion and knowledge of the attending surgeon. He thought that the medical stu- dent ought to be taught the danger of the agent he employs, how and when to use it judiciously, and should be required to secure a certificate to the efi'ect that he has been so instructed before being let loose upon the public. The public would then 518 ARTIFICIAL ANiESTHESIA. know that he possesses a knowledge of the agent which he em- ploys. Beside, the phj^sician would be conscious of a certain moral responsibility, for he held that the moral responsibility which every medical gentleman must feel, is greater than the responsibilities placed upon him by the laws of the land. Jacob F. Miller, Esq. , agreed with those who advocated care in the use of these agents. Man is living in the midst of dan- gerous forces, and will continue to use them, though of neces- sity many deaths occur. But in order to rest a case against the user, it is necessary to show negligence. Negligence is the gist of the action. The physician, surgeon or lawyer contracts for the ordinary skill and care of his profession. He does not contract for any extraordinary skill. The law does not hold him any more responsible than that. It would be unreason- able to do so, because few persons could safely practice their profession ; and if any person should use anaesthetics, and the patient should die, that is not sufficient to charge him with the responsibility. He thought that all would admit that if a man not having the ordinary skill of his profession should, by unskilful administration of anaesthetics, cause the death of the patient, he should be prevented from doing further damage by a suit for malpractice. Would it not be better to stop him by such procedure ? Shall a man be allowed to use such danger- ous forces just as he pleases — let the consequences be what they may? People consult phj^sicians because they say they have the requisite skill to use these things. They hold them- selves out to the community as having this skill, and they ought to possess it ; if they do not, and harm results from it, they ought to be held responsible. The coroner says that" physicians are actuated by moral responsibility, which is no responsibility at all. The quack will go on with his practices until he is stopped by the law. Where is his moral responsi- bility ? What does he care ? His practice only goes to show that he has no moral responsibility. That lawyers should check such practices is due to the profession^ to the public, and to God. But before they take a case of malpractice they ought to be con- vinced that there is malpractice. It may be all very well to say that negligence is the gist of an action. If it cannot be shown LEGAL RESPONSIBILITY OF PHYSICIANS. 519 that there is negligence, the case should not be takeji, for when the case arrives at the courts you must show that the defendant is guilty of neglect, and that is done by calling upon a i)hysician who is able to say where negligence has been committed, and that he is guilty of it. This evidence is necessary ; lawyers cannot get along without it. Mr. Max F. Eller spoke of the fact that, for any action, as many "experts" could be obtained by one as the other, pro- vided enough money is paid for such expert testimony. Some will say the patient should have been notified of the danger ; others that he ought not. Some will say the chloroform killed him ; others not. For that reason he thought that before making any more laws regarding the proper administration of anaesthetics, those which already exist should be administered in a better manner, and physicians should be a little more care- ful how they administer anaesthetics. Mr. Eller referred to the popular fallacy that chloroform could be used successfully for the purpose of effecting robbery. He thought that that delusion ought to be dispelled, for the time between the actual administrstion of chloroform and the period of annihilation of sensation, is sufficiently long to render the accomplishment of the object impossible. Such a plea is used by criminals to shield themselves from the consequences of their own crimes. In this we differ from Mr. Eller, and have collected some important evidence in its favor. A correspondent of the Societe d^ Hygiene et de Medicine Legal, Paris, having been interrogated as a judicial expert as to "whether the emploj^ment of narcotics, in the liquid or gas- eous state, can produce an anaesthesia so profound that viola- tion of the persons to whom it has been given may be perpe- trated without awakening them," gave an affirmative answer. M. Dolbeau, apropos to his judgment, made a series of re- searches, the results of which were laid before the society. He limits the question to the employment of chloroform, and starts with the following proposition : ' ' Can chloroform in vapor he administered to a person who is sleeping naturally, to the production of ancesfhesia , without awak- ening him?^^ 520 ARTIFICIAL ANAESTHESIA. In M. Dolbeaivs experiments the chloroform was given id the usual manner, on a cone held an inch or so above tlie nos- trils, so as to enable a constant view of the countenance. In the first series of experiments three patients out of four were awakened bj' the chloroform inhalations ; in the second series, four out of six ; in the third, only three out of nine. It is not without interest to observe the increasing proportion of subjects anaesthetized ; the manual dexterity' acquired by the experiments is not without influence upon the results ob- tained. Accordingly, as a result of his experiments, M. Dol- beau believes himself authorized to formulate the following conclusions : " Scientifically, it is difficult, but often possible, to cause in- sensibility by means of chloroform in persons who are sleeping a natural sleep. Certain precautions — the employment of a perfectly pure agent and experience — are also conditions which favor the attempt at anaesthesia. "It is probable that certain subjects are absolutely refractory — that is to say that it is impossible to anaesthetize them with- out taking every precaution. Others, on the contrary, particu- larly young children, submit easily to anaesthesia without having been awakened by the irritation produced by the anaesthetic agent in the air-passages. "From a criminal point of view it is certain that chloroform, administered to sleeping individuals, may facilitate the perpe- tration of certain crimes. It is, however, probable that the conditions favorable to anaesthesia are rarely found on the oc- casion of criminal attempts. In justice, the expert should declare that it is possible, but not easy, to render a person who sleeps, so insensible by chloroform that the said person might become the victim of any violence. " The responsibility attending the use of anaesthetics is of great importance to medical men, as frequently their personal and professional reputation is at stake ; it is therefore always better, in the administration of an anaesthetic to a female^ to have some reliable person present. This is especially necessary when ether or chloroform is employed." During the early period of the author's medical career, soon LEGAL RESPOXSIBILITY OF PHYSICIANS. 521 after graduating, we had in our Quiz class a young, ambitious dental surgeon, one of the most gentle and amiable of men, who was desirous of obtaining the medical degree, which he ultimately attained. Soon after this the man was married, settled in this city, and acquired a large business. At that time it was common for the dentist to administer angesthetics in their office without an attendant in the extracting of teeth, etc. He had a young female patient to whom he admin- istered chloroform alone, and who afterwards stated that he had taken improper liberties with her person during this state. This case caused great excitement in our city, and the public sympathy was with the young female, and a suit was insti- tuted in which damages were claimed. The case was argued by distinguished lawyers on both sides, and voluminous testi- mony taken. The judge charged the jury, and the sentence was ten years' imprisonment. Subsequently the sentiment of the community changed, and it believed it was all the result of her vivid imagination, and that she was laboring under a delusion. The majority of physicians and dentists signed a petition, and the sentence was remitted. "It is stated by Taylor 'that the vapors of ether and chlo- roform have been criminally used in attempt at rape. In a case which occurred in France, a dentist was convicted of this crime upon a woman to whom he had administered the vapor of ether.' Xow this may be just such a case as the one in our own city. Ether, from its disagreeable taste and irri- tating vapor, is much more difficult to administer forcibly and against the will of a patient. The numerous stories of anes- thesia b}^ simply placing a few drops on a handkerchief under a patient" s nose or mouth are in the majority of cases perfectly absurd, as the shortest time required to bring a patient fully under the influence of either of these drugs— even when forci- bly held in contact— is from two to ten minutes, and if subse- quent rough handling takes place the patient is at once roused to make resistance by struggling. ^Ve were once called to a woman^ who had been in the habit of employing chloroform by inhalation from a small bottle to cause sleep ; she accidentally, when in a drowsy state, let the open bottle drop on the pillow' 34 522 ARTIFICIAL ANAESTHESIA. and its contents saturating the covering, she laj'' with her face in it. But instead of making her sleep soundl}^, it pro- duced most distressing nausea, and her family were awakened by her efforts at vomiting, and so her life was saved, she not being able to arouse suflSciently to get rid of the offending mat- ter, which would have lodged in her trachea, or the contents of the stomach might have been brought into the bronchial tubes by deep inspiration, and thus have caused suffocation. But it is not always the result, as persons have emploj^ed this means to produce death and have been successful." The former case in Philadelphia settled the important point in the minds of medical men of this city that this incomplete unconsciousness does not coexist with complete motor and sen- sory anaesthesia, and, therefore, anaesthetics are employed with- out any fear in all important operations. These observations are, in part, corroborated by two learned authors in a recent and most admirable work on medical jurisprudence, in which they state : "A question of some importance to the medical jurist natu- rally occurs here, namely : ' Wliether cldoroform can he adminis- tered for improper jyurposes f^ We know, however, that insen- sibility from chloroform (and more slowly from ether) vapor is only slowly induced. It would be difficult, therefore, to admin- ister chloroform forcibly and against the will, while, of course, the stories of immediate anaesthesia produced bj^ it are but idle fables. Still, it might be administered to persons asleep with- out much difficulty, and this seems the only possible condition under which it could be convenientlj^ used for improper pur- poses unless considerable force were employed to prevent the person struggling, which, under ordinary circumstances, would be an almost insurmountable difficulty to its use." The following case,* which occurred in England, more com- pletely confirms our case of the condition of semi-angesthesia : "A case of the utmost importance to the whole profession, not in G-reat Britain only, but everywhere, was tried before Mr. Justice Hawkins, at the assizes, at Northampton, on the 9th ■-'• Philadelphia Medical Times, December 22, 1877. LEGAL RESPONSIBILITY OF PHYSICIANS. 523 of November. It was a charge against a surgeon's assistant of criminal assault — of rape upon a patient when under the influence of chloroform. If there is a dastardly crime, it is to take advantage of a woman's helpless unconsciousness to vio- late her person. And so the magistrate thought who sent the accused to jail, on the 14th of September, declining to hear anything in his favor, and resolutely refusing to accept bail. The charge was that a married woman, named Child, went to the surgery of her family medical attendant to have her teeth operated upon. She had been there a day or two before, but the attempt to put her under chloroform then failed. A second attempt was rather more successful. She evidently had some peculiarities or idiosyncrasies in relation to chloroform, for he gave it for an hour, and yet she was never sufficiently under its influence to admit of the operation being performed. She was accompanied by a ' friend — a Miss Fellows. At the end of the hour, Miss Fellows went out of the room. In a quarter of an hour Miss Fellows returned. The prosecutor main- tained that, on Miss Fellows' s return, she was quite con- scious, but unable to speak. Finding it impossible to perform the operation, the accused accompanied the prosecutrix and her friend home. So far, Mrs. Child had been unable to speak, but shortlj'' after the accused left the house she complained to her husband that he had taken advantage of the absence of Miss Fellows to assault her criminally'. Next day, when the accused called, he was told about what she had said, and he re- plied that she was laboring under a delusion. Under cross- examination, Mrs. Child said that she told the accused that if he would admit the off"ence and quit the town (Birmingham) she would forgive him. This the accused declined to do, denying that he had committed any ofi"ence. He was then given in cus- tody. The prosecutrix stated that the ofl"ence was perj)etrated immediately after Miss Fellows left the room ; that the prisoner went upon his knees, and then assaulted her. Miss Fellows stated that on her return she found 3Irs. Child in precisely the same position in the chair which she occupied when she went out of the room. Such were the facts of the case. It was quite clear that there had been either an assault committed, or that 524 ARTIFICIAL ANESTHESIA. the woman was under the influence of a very pronounced delu- sion. The whole of the accused's conduct was in favor of the latter h3^pothesis. But in such a matter, where no third person was present, the statement of one of the two parties concerned must be taken. When a woman whose character was apparently without blemish (for in cross-examination no attempt was made to call her reputation in question) makes a definite charge against a man of assaulting her under circumstances which permitted of such an assault, the law could only send the case to a jury. In the meantime, the unfortunate surgeon's assistant was sent to prison. "When the case came to be tried, a large number of medical men of repute came forward voluntarily to aid the accused's defence, and did this quite gratuitously. The chief witness for the defence was Dr. B. W. Richardson, F.R.S., whose celebrity is world-wide. As is well known. Dr. Richardson has studied anaesthetics very carefully and for many years. He stated that there were four stages or degrees in which chloroform operated. The first stage was that in which consciousness was not lost ; there was resistance and a desire for air. In the second, con- sciousness is lost, but the operation is impossible, the patient screaming, often without provocation. The third stage is that of complete unconsciousness, and where all rigidity is lost. This is the stage which permits of operation. In his opinion, the patient was in the second stage, the third never having been reached. He stated that, in his own experience, he had known persons in this second stage to have delusions as to what had taken place during that time. He related a number of cases, and stated that the fact of such delusions being induced by chloroform was one of the earliest objections raised to its adoption. He related one case, where the patient, a female, was being operated upon by a dentist, and alleged that the dentist criminally assaulted her. And this she persisted in, though her father, her mother, Dr. Richardson and the den- tist's assistant were all present throughout the whole time. She persisted in her conviction long after the effects of the chloroform had passed away, and Dr. Richardson said she was probably of that belief still. This evidence of Dr. Richard- LEGAL RESPOXSIBILITY OF PHYSICIAXS. 525 son's was corroborated by the experience of Dr. Hawk^by of London, and by Dr. Saundby and Mr. J. R West, of Birmino-. ham The judge asked the jury if it was necessary to sum up, and they rephed it was unnecessary-they were already agreed upon a verdict of acquittal. Mr. Justice Hawkins pointed out that such a verdict would not be the slightest imputation upon the absolute sincerity of the prosecutrix, who. no doubt, firmly believed every word of what she had said. He then congratu- lated the accused upon having had an opportunitv of fully vindicating himself from the charge preferred, and 'said that the verdict of acquittal did not mean that there was insufficient evidence, but that the accused was entirely cleared of any rmputation in respect to the charge preferred against him. Ihere could be no doubt the prosecutrix labored under a delu- sion. The accused was then discharged from custodv, havino- been in prison two months for no offence. It is not merely that this unfortunate man was imprisoned for two months for an imaginary offence, but that any man who is present when a woman is being put under chloroform is liable to have the same charge brought against him that gives this case its gravity and importance. "Such being the case, it becomes necessarv that a little more should be known amidst the profession, as well as the laity, as to the occurrence of erotic sensations in women Ihe subject is not a pleasant one, but that is no reason why it should not be investigated. If it is a fact, and there IS no doubt about this, that women, when bein- put under chloroform, are liable to those erotic sensations^hich they experience from sexual intercourse, the sooner the fact is generally known the better. It is just the mysterv which surrounds such facts that permits such a monstrous hard- ship as that mentioned above to be a possibility at all. Of course, it is obvious enough to any one that it^is a delicate matter to inquire into the subjective sensations of women iiut if these subjective sensations take the practical form of a charge of rape, two months in jail and a trial bv jurv, they pass from the domain of sentiment and enter that of stern reality. Few, comparatively few. of the profession seem to 526 ARTIFICIAL ANESTHESIA. be aware that women are subject to conditions and sensations identical with those associated with the sexual act, which arise quite subjectively and without any extrinsic stimulus. The delusion of St, Catharine, that the devil visited her every night, and enjoyed her person when she was asleep, and could offer no resistance, is no unique experience, but one common enough to women. Every one familiar with asylum work knows that a certain percentage of women patients have this delusion, among others, that the medical superintendent comes nightly to their bed, and violates their person during sleep. Of course there is no foundation of any kind for such delusions, except the subjective sensations of the woman herself How strongly such a delusion, however, may be fixed in a woman's mind is evidenced by the case related by Dr. Richardson, where a woman persisted in her belief, though her own father and mother, as well as others, were present, and where such an assault was physically impossible. Such being the case, it behooves every man who is to be present with a woman when she is to be placed under chloroform to see that there is at least one other person present, and that, too, the whole time, without intermission, dur- ing which the woman is under the influence of chloroform, and that such other precautions be taken as will preclude the pos- sibility of such a charge being raised. That Mrs. Child charged this unlucky man in good faith need not be questioned for a moment. She was far from being hostile to him, for she offered if he would avow his guilt and leave the town she would forgive him. The charge was not pressed from any rancorous spite ; that is abundantly clear. But it is equally clear that something had occurred to that woman which she interpreted into the sexual act, and that this was so firmly fixed in her con- sciousness that it could not be dislodged. It becomes necessary, then, that the subjective sensations of women should be inves- tigated, and made the subject of scientific observations ; and seeing that they exist, they must have a scientific value ; and that no prudishness should prevent attempts being made to ascertain what the actual facts are, and what is their interpreta- tion." The following is the experience of Dr. N. L. Folsom, of Portsmouth, New Hampshire, in the same line : LEGAL RESPONSIBILITY OF PHYSICIANS. 527 " In J 854 a clergyman's sister came to my office for the pur- pose of taking ether and having a tooth extracted, and brought her brother's wife with her. I began to administer the ether to the patient, and whilst renewing it she got away from me, and seemed alarmed and offended. I did not attempt to com- pel her to breathe any more ether, but urged her to take it, and so also did her brother's wife, but she would take no more. She had the impression, so her brother told me, that I attempted to violate her, and that his wife assisted me. It was a long time afterward before she would fully give up that she was mistaken in the matter." We are almost certain, after a number of careful experiments, that chloroform and ether can be administered in sleep, so as to produce the first stage of anaesthesia, and can be carried to full completion or total unconsciousness. Still, this is rare without disturbing the patient's stomach, causing nausea, or irritation of the lungs, with risk of sudden death, by its dense vapor, and thus rousing him or her to consciousness, or a condition in which the patient can resist its influence if the party is willing to make the effort. Another important point is that loud talk- ing or handling, even in some cases the slightest touch or pain in any way, will cause the patient to start and rouse him to resist. In the case of ether, the patient can almost always see distinctly, and in some instances is able to talk during the anaes- thetic state. Attention has been directed by Dr. J. M. Quimby, of Jersey City, N. J. , to certain facts connected with the use and abuse of chloroform, and from these facts inferences have been derived which may be interesting and instructive to the profession, con- firming the power of the physician to place his patient under an anaesthetic while asleep. He states, " that in consequence of the recent murder of Po- liceman Smith, in Jersey City, while he and his wife were sup- posed to be asleep in bed, his wife was arrested as a.particeps criminis. She denied the charge, and asserted that she had been chloroformed during sleep, and therefore was innocent of the crime. "The State denied this, and contended that it was impossible 528 ARTIFICIAL ANESTHESIA. for her to have been chloroformed in that way ; that the fumes of the chloroform would have certainl^^ awakened her from her natural sleep, and therefore she must have known who the mur- derer or murderers ivere. " Here, then, as will be seen, arose a verj^ nice and important medico-legal question, viz. : whether a person could be chloro- formed whilst in natural slumber without first being awakened, or, in other words, whether the application of chloroform, properly given, would awaken the person to whom it was applied ; or, could such person pass from the natural to an artificial sleep (or chloroform sleep) without being aroused by its application ? Mrs. Smith asserted most positively that she was chloro- formed while she was asleep in bed with her husband, and knew nothing about the murder until she awoke in a bewil- dered condition, feeling the cold elbow of her husband pressing against her side. It may be stated here that there was found in the room of the murdered man a bottle partly filled with chloroform and a folded towel with bloody finger-prints, which Mrs. Smith asserted was upon her face when she awoke. She also described quite accurately the taste, smell and pungency of chloroform. "Without going into further details, the counsel for Mrs. Smith applied to me to know if it were possible to transfer a person from a natural to an artificial sleep by the use of chlo- roform without first arousing the sleeper from his natural slum- ber. I replied that I had never attempted the application of chloroform to a person while in a natural sleep, and that books, as far as I knew, were silent on that point ; although I thought there would be no difficulty, if proper care were taken in admin- istering the chloroform, in transferring a person from the natural to an artificial sleep. "I was strongly urged on the part of Mrs. Smith's counsel, and in behalf of humanity and justice, to settle by experiment this disputed question. To accomplish this result I made the following experiments : I made arrangements with Mr. A. to enter his room in an hour or two after he had retired, and when he was asleep apply the chloroform, which I did with entire LEGAL RESPONSIBILITY OF PHYSICIANS. 529 success, transferring him from the natural to the chloroform sleep without arousing him from his natural slumber. I used about three drachms of Squibb' s chloroform, and occupied about seven minutes in putting him to sleep. The second case was a boy, aged 13, who was suffering from an ingrowing toe- nail. He refused to allow me to touch him with knife or for- ceps without etherizing him, and when I attempted to apply the ether he screamed and struggled so desperately that his mother became frightened, and asked me to desist from giving him ether. In this dilemma I advised the mother to take the boy home and put him to bed with a light supper, and I would call at the house between nine and ten o'clock that evening, give him a little chloroform, and remove the nail without the boy knowing anything about it. "I called at the time agreed upon, with my friend, Dr. Cahill, and found the boy quietly sleeping. I applied the chlo- roform, divided the nail in the centre, and removed the two segments by the application of forceps without awakening the patient or his having any knowledge of the operation until next morning, when he awoke, and, discovering the condition of his foot, remarked that had he known ' it would not hurt any more than that he would have had it taken out at the office, and was ashamed that he had made such a fuss about it.' " "Case No. 3 was a boy, aged 10, who was brought to my office suffering from a swelling over the lower jaw, which proved to be an abscess due to decayed teeth ; but the boy would not let me come near him with either lancet or forceps ; so, as in previous cases, I advised his mother to take him home and send him to bed with a light supper, and that I would call at the house after he got asleep, administer the chloroform, open the abscess, extract the teeth, and he would know nothing about it ; all of which I did without arousing the boy. "I remained with the patient about one hour after the ope- ration, to attend to any haemorrhage that might occur, and to observe if any change would take place when he would pass from his artificial to his natural slumber again. "Finding there was no change in that time I left, requesting the parents to watch him and let me know exactly at what hour he awoke. 530 ARTIFICIAL ANAESTHESIA. " When I called next morning, they reported that he awoke at six o'clock, exclaiming, ' I must have swallowed my teeth, for they are both gone ! ' " "Beware of Chloroforming Women without an At- tendant I — At Oakland, Cal. , during July, 1880, a bank teller, named E. F. Schroeder, killed Dr. Albert Lefevre, a prominent dentist of that place. It appears that Mrs. Schroeder went to the train on the day of the shooting to meet her husband. Mrs. Schroeder told him, that on the Saturday previous, while under the influence of chloroform in Dr. Lefevre' s office, the dentist made a felonious assault upon her. Schroeder at once proceeded to Dr. Lefevre' s office and committed the tragedy. It is believed that Mrs. Schroeder' s charge against the dentist is purely illusory. Such hallucinations are not uncommon after chloroform administrations. Some remarkable cases exist where hallucinations of this nature have taken the form of absolute conviction in the minds of persons laboring under them, al- though there exists abundant evidence to prove that this con- viction was utterly unfounded. The coroner's jury rendered a verdict charging Schroeder with murder. We know of an in- stance in which the presence of a third party saved a like im- putation against the character of an innocent practitioner. The lady herself beyond reproach still had such an illusion after recovering from the administration of the chloroform." " Prosecution of a Dentist. — At the Manchester Assizes, before Mr. Justice Day, an action was brought against Mr. James Jackson, a dentist, of Burnley, in which the plaintiff, Mr. Robert Jackson, farmer, sought to recover damages for the alleged seduction of his daughter while under the influence of nitrous oxide. There was also a cross-action for slander brought against the plaintiff. The trial occupied nearly three days. "His Lordship, in summing up, said the one substantial issue for the jury was, did James Jackson, the dentist, or did he not, administer gas or some narcotic to the young woman, Margaret Ann Jackson, and did he, while she was under the influence of some anaesthetic, criminally assault her? That was the question they had to determine, and it was a question of the very gravest moment. The consequences to the one side CHLOROFORM ITS ACTION AS A POISON. 531. or the other must necessarily be of the most serious character. The charge which was made against the dentist was one of assault under circumstances of the most aggravated and nefa- rious nature. The charge, on the other hand, of which the woman would be guilty, if she had made a false accusation, was one of the most wicked, odious and vile that could be brought by one human being against another. The case was one of a most extraordinary character, and one which, he was happy to think, was very rarely raised in a court of justice. It was one which demanded at the hands of the jury, as he knew it would most assuredly receive, their deepest and most anxious atten- tion, so that to the utmost of their ability they might do justice between the parties. He did not hesitate to say that the ques- tion was of an extremely difficult character, but it was one which he was confident the jury would, using their own good sense, solve to their thorough satisfaction ; and if they did solve it to their satisfaction, it should be satisfactory to all well-minded people. He would say nothing about damages, because it was unnecessary. The parties probably were none of them in a po- sition to pay damages. That, however, was utterly unimpor- tant, and should not affect the amount of damages. It was unnecessary for him to say a word about damages, because he should not venture to put any limit upon the damages which they might award to the one side or the other. " The jurj^ retired to consult on the case, and after deliberat- ing for three hours returned to court and stated that there was no possibility of their coming to an agreement. The judge thereupon discharged them. ' ' Chloroform — Its Action as a Poison. Chloroform is an irritating poison. In a case quoted by Taylor, an individual swallowed four ounces. He was able to walk a considerable distance after taking this large dose, but subsequently fell into a state of coma. The pupils were dilated, the breathing was stertorous, the skin cold, pulse imper- ceptible, and there were general convulsions. He recovered in five dsija. A second case reported, swallowed nearly two ounces and recovered, and a third swallowed two ounces, but he died 532 ARTIFICIAL ANESTHESIA. in six hours afterwards. In this case the pupils were fully dilated, the breathing was stertorous, and the skin covered with a cold perspiration. On inspection, the lungs were found much ■engorged with blood, and there were some apoplectic effusions in these organs. The stomach was slight]}^ inflamed in patches and the mucous membrane was softened. * A physician, aet. 57, swallowed three ounces of chloroform. He immediately began to stagger, as if intoxicated, vomited, sank into a deep stupor, and was in a state of complete anaesthesia. His skin was pale and tolerably warm ; the muscles were relaxed, the breathing short, and the action of the heart weak and intermittent. In about fourteen hours sen- sibihty returned. Acute gastritis ensued, with rapid collapse, and proved fatal in twenty-nine hours from the time the chloro- form was taken. t Treatment. — In poisoning from liquid chloroform, the stomach-pump and emetic should be resorted to. If evidence of suspension of the action of the heart (syncope) exists, there should be a free exposure of the face to a current of air, compression of the chest and artificial respiration, warm appHcations to the chest, with an inversion of the body, ac- tive friction and stimuli externally and by the rectum. The poles of a galvanic battery, applied to the chest and side of the neck, with sponges dipped in hot water, should be used. Solution of ammonia in water has been found useful when in- jected hypodermically, and strychnia, in the same way, to act upon the respiration. Aromatic spirits of ammonia must be given with water, and great care taken of gastritis and disturb- ance of the liver, which are apt to follow in the convalescence of the patient. The Chloroform Habit, or Chloroform by the Mouth. I have received the following letter from a friend on the chloroform habit, and sent him my reply : * American Journal Medical Sciences, October, 1866, page 571. t American Journal Medical Sciences, January, 1870, page 276. THE CHLOROFORM HABIT. 533 " Shelbourne, Mass., May 29, 1890. "My pear Doctor : " What I wish to know is whether chloroform, given by the mouth, is good and sa/e practice. I have given it several times that way, and always had good results. There is a doctor in this town who is a chloroform inebriate, and I have known him to take thirty -four ounces (34 o) of chloroform in twenty-three hours. He always gave his patients chloroform for everything,, and usually gave it by the mouth. For a small operation he gave a teaspoonful in a glass of wine, and told them to breathe rapidly through the mouth. It acts quickly and very nicely. I have never seen any authority for administering it hj the mouth, and have wondered lately if it were safe practice. If you should find a leisure moment some day, should be pleased to know your views on the subject. If safe, I prefer giving it that way in many cases. Yours, "H. H. Flagg." The writer's answer was, that he considered chloroform given by the mouth neither a safe nor judicious practice, as death may follow by paralysis of the heart. The fatal dose is given in recent works in the table of poisons as 5j (see GoidcVs Dic- tionary)^ the treatment of which is as follows : Draw the tongue forward for air, use artificial respiration, faradic current, hot and cold douche, amyl nitrite. The chloroform habit is usually the result of its secret use, and is considered most degrading to both body and mind (see Chloroform as a Poison, page 531). Transitory mental and muscular excitement, similar to that referred to when dealing with the after-effects of ether, may occur in hysterical and neurotic subjects. Delirium lasting three days has been recorded.* Loss of speechf (attributed to cerebral haemorrhage) has also been supervened after chloro- formization. Persons who have had maniacal attacks before the * See an interesting pamphlet, " Ether as an Anaesthetic," by Josiah de Zouche, M.D., of Otago. in which delirium lasting three days in a boy of 14 was met with after chloroform-inhalation. t Lancet, vol. i., 1870, p. 553. Chloroform was given for a tooth extraction. The aphasia lasted five weeks. 534 ARTIFICIAL ANESTHESIA. administration of chloroform, have been known to suffer from a recurrence of their mental disorder after the use of this anaes- thetic* Hypnotic Anaesthesia and its Analogous States in their Various Aspects. While spending the winter in France (1893) there was placed in my hands, by a scientific layman, the work of " La Tourette " on Hypnotism. It was shortly after the time that there had occurred a newspaper controversy between a distinguished medi- cal editor of London and an ancient physician of Paris, the latter of whom had given unusual prominence in his practice to the agency of hypnotism, while the former, after experiment- ing with a number of his cases, believed the doctor had been de- ceived in them. Having, in my previous edition, brought forward this agency as a means of producing a certain form of anaesthesia, which can be employed in certain rare surgical operations, I have en- deavored to improve the opportunity to study the subject more in detail, especially in its anaesthetic and medico-legal aspect, so as to make my work more useful to my medical, dental, and scientific confreres. Hypnotism is still being tried in the alembic of the medical and scientific mind, its friends still hold- ing to certain results, obtained by the most carefully conducted experiments, while others give it a very high estimate far beyond what it deserves as a nerve agent. Yet, from what has been seen, we must not be too skeptical. The late Prof. Charcot answers the skeptics as follows: "In presence of the evidence of facts presented, scientific skepticism is only an arbitrary skepticism." No one with average intelligence can help being impressed with the fact that certain hysterical individuals can be placed in a so-called hypnotic condition or state by individuals, or by con- stant gazing intently, for a given time, at a bright object, like metal, brought near to the eyes of those susceptible. While the individual is in this condition, certain phenomena can be pro- duced. ■« See Savage, Brit. Med. Journ., Dec. 3, 1887, p. 1199. THERAPEUTIC HYPNOTISM. 535 The following is an abstract of the histon- of the hj^pnotic state. Propositions of ]Mesmer (Animal Magnetism) 1779. The theoiy of universal magnetic attraction. The report of the secret Royal Commission demanded of Mcsmer, by Louis XTl. , describing the various symptoms produced and some important medico-legal facts. In 1784 Pa\'seger discovered how to pro- duce artificial somnambulism, and described successful magnet- ism, ls2]. Discussions of the Academies of Paris by Du Potet Foessa and the Report of Husson, 1825-1834. The prize of Beerdin, 1837-1840. The discussion in the Academie of Medicine of its medico- legal importance and the institution of the Penal Code. Then follows the Xeuryphologie of "Braid ;" but no great scientific progress was made until 1878, when " Charcot " and " Brouar- del " took up the subject and made long, careful, and elaborate experiments, and came to the following conclusions as to its medical application and therapeutic uses. Hypnotism as an Antestlietie. Hypnotism (from hypnos) is the production of sleep by what was generally known as animal magnetism. Only certain in- dividuals are susceptible to its influence. The person who operates has, in our opinion, great will power over the indi- vidual operated upon. The patient hj-pnotized is not absolutely insensible, but operations of a trifling nature can be performed without apparent pain. It is stated by La Tourette that excellent effects have resulted in the treatment of accidents and complications, from the use of hypnotism, in certain forms of contractions of muscles and paralysis ; also in mental alienation and manifestations of hysterical delirium. Therapeutic Hj^pnotisni. It is quite well known, according to "La Tourette," that a course of action suggested to a hypnotized person is followed irresistibly and unconsciously^ by that person after, as well as during, the hypiiotic state. Upon this is based the medical ap- plication of hypnotism. If a subject can be made to carry out useless, eccentric, or, in some cases that have become known, 536 ARTIFICIAL ANESTHESIA. even criminal suggestions, without his own knowledge of the character of the cause of his action, why, ask the scientific ex- perimenters, may not the same cerebral mechanism be brought into play to influence the physical state of persons suffering from certain kinds of disorders? The influence of the mind and the imaginative faculties on the body in such cases has long been known ; and it is maintained that this kind of suggestion does not differ, in reality, from that of the hypnotic state. What- ever may be the cause which excites the nervous centres of the brain to intervene in order usefully to modify the organic function of the body, the process, say these investigators, is the same. Reports submitted at the late congress in Paris, the treatment of invalids in this manner already shows some remarkable re- sults. Two physicians of Amsterdam told of 414 cases they had treated by hypnotism. Of these 100 were fully cured, in 98 there was a noticeable improvement, in 92 a slight one, and in only 71 were there no results ; 58 cases were not followed. These cases included organic maladies of the nervous system, mental diseases, and neuralgia, besides others not directly con- nected with the nervous system. The treatment of the insane was especially discussed by others, and here, too, success has been obtained in some cases, though the difficulties are far greater than in physical maladies. A curious and interesting report was presented by one of the physicians in regard to his experiments with children, whom he found easier to influence by suggestion than their elders. In this he submitted as a proven conclusion the value of hj^pnotic suggestion as "an excellent auxiliary in the education of vicious or degenerate children," it being " especially efl&cient in reacting against vicious instincts, habitual lying, cruelty, theft, and inveterate idleness. " This is, perhaps, one of the most startling assurances we are given of the powers of hypnotism in the hands of competent men ; and such results, already attained, seem to point to possibilities of great importance in the further development of this study. There is another side to all this, however, which the congress in Paris did not fail to consider. That is the danger of the abuse and the irresponsible use of the hypnotic phenomena. THERAPEUTIC HYPNOTISM. 537 Trick performances of travelling quacks are common, even in this couiitr}'. and the.y are to be considered not onlj-as a vulgari- zation of the science, but a danger to health and morals. Equal danger rests in opportunities that hypnotism affords the crimi- nally inclined, which can easily be seen are numerous. A hyp- notized subject is really made the instrument of vengeance or cupidity, quite unconsciousl}'' to himself, after emerging from the hypnotic state ; and not only that, but may be made to take upon himself the sole blame. All these perils, it may be, will some time have to be guarded against, though knowledge of the subject is j^et too restricted to make them alarming. But if this be so, it will be only one more instance, so many of which modern times can show, in which things of yalue to humanity are perverted to damaging uses. Of course, this unfortunate fact will not put an end to the investigations which promise so much of value ; the advances made in this curious and, in its scientific application, so recent branch of scientific studj" will be watched with great interest. Report of the Coniniittee Appointed hj the British 31edical Association to Investigate the Xatiu'e of the Phenomena of Hypnotism — Its Value as a Therapeutic Agent, and the Propriety of Using' It. The Committee, having completed such investigation of hyp- notism as time has permitted, have to report that they have satisfied themselves of the genuineness of the hypnotic state. No phenomena which have come under their observation, how- ever, lend support to the theorj'' of " animal magnetism." Test experiments, which have been carried out by members of the Committee, have shown that this condition is attended by mental and physical phenomena, and that these difi"er widely in different cases. Among the mental phenomena are altered consciousness, temporary limitation of will power, increased receptivity of suggestion from without, sometimes to the extent of pro- ducing passing delusions, illusions and hallucinations, an ex- 35 538 ARTIFICIAL ANESTHESIA. alted condition of the attention and post-hypnotic sugges- tions. Among the physical phenomena are vascular changes (such as flushing of the face and altered pulse rate), deepening of the respirations, increased frequency of deglutition, slight muscular tremors, inability to control suggested movements, altered mus- cular sense, anaesthesia, modified power of muscular contrac- tion, catalepsy and rigidity, often intense. It must, however, be understood that all these mental and physical phenomena are rarely present in any one case. The Committee takes this op- portunity of pointing out that the term hypnotism is somewhat misleading, inasmuch as sleep, as ordinarily understood, is not necessarily present. The Committee is of the opinion that, as a therapeutic agent, hypnotism is frequently effective in relieving pain, pro- curing sleep and alleviating many functional ailments. As to its permanent efiicacy in the treatment of drunkenness, the evidence before the Committee is encouraging, but not conclu- sive. Dangers in the use of hypnotism may arise from want of knowledge, carelessness or intentional abuse, or from the too continuous repetition of suggestions in unsuitable cases. The Committee is of opinion that, when used for therapeu- tic purposes, its employment should be confined to qualified medical men, and that under no circumstances should female patients be hypnotized except in the presence of a relative or a person of their own sex. In conclusion, the Committee desires to express its strong disapprobation of public exhibitions of hypnotic phenomena, and hopes that some legal restriction will be placed upon them. F. Needham, Chairman. T. OuTTERSON Wood, Hon. Sec. July, 1892. INDEX. ACETIC Ether, aneesthetic prop- erties, by Dr. H. C. Wood. 200. A. C. E. Mixture, 353; accideuts with, 351 ; use of in old per- sons with rigid chest, 514; iu extreme obesity, 514; E. C. Mixture, 352. Acetauilide, use of, in vomiting, i 496; in extreme obesity, 514. Acid, carbolic, 476 ; trichloracetic, new test for albumen, 483. Action of chloroform, 35, 254,261, 275, 313; cocaine, 387; ether, 31, 149. Acupuncture with cocaine by Baunschiedt's method, 372.^ Administration of cocaine, 37, 386 : chloroform, 243 ; ether, 149. After-effects of anasthetic chlo- roform, 288; nitrous oxide, 107, 108, 109. After-treatment of alcohol, 147; cocaine. 393; chloroform, 261- 273 ; ether, 152 ; nitrous ox- ide, physiological action, 78, 84, 93, 107. Albumen, examination for, 317, 151 ; new test, 483. Alcobolists, the danger of giving an ansesthetic to, 250. Alcohols, absolute, 135; alcohol- ism, 147 ; different kinds of, 135 : medico-legal aspect, 146 ; physiological action, 136-141 ; influences on kidney and liver, 141; strychnine and solution of a salt of gold in chronic alcoholism, 147; tox- icology of, 147; use in dis- eases and as food, 136. Aldehyde, 207, 208. Allis. Dr. O. H., 157; inhaler, 158, 159. Amvlene, its vapor, 206; death 'from, 207. Amory, Dr. Boston, experiments on animals with nitrous ox- ide, 79. Amyl nitrite, 291, 397, 514. Anaemia, danger from in anaes- thesia from nitrous oxide, 79. Analgesics. 479. AnEesthetics. geographical distri- bution of fatalities, 2.52 ; value in disease— which to avoid and those to employ 509. Aphonia, nervous, treatment of, 508. Aristol, 484. BEDDOES, Thomas. Pneumatic Medical Institution, 27. Beer drinkers, hypertrophied kidneys, liver, etc., 144, 145. Benzol, 486. Bernard, Claude, experiments on angesthesia produced by in- troducing the tube through the nose into the lower pharynx, 184; on the action of cocaine on cerebral circu- lation, 397; the action of chloroform upon nerve cells, 260. Bert, M. Paul, use of nitrous ox- ide and oxygen, 96. Bichloride of methylene, 201; discovery and. introduction, 202 ; deaths from, 203. Bigelow, Dr. H. T., use of rhigo- lene, 456. Blood, actual changes produced by anaesthetics, 36; after death by nitrous oxide, 70; appearance of frogs in direct contact by chloroform, 73; anaesthetics in contact, 74, 540 INDEX. 75; arterial, becoming deoxi- dized. 78; examinatiou of by Drs. McQuillen, Eichard- son, Thomas, C. S. Turubull and author, 79, 80 ; pressure under nitrous oxide, 87, 88, 496; on alteration by anes- thetic agents, especially nitrous oxide, etc., 92. Bonwill's method of producing an?3sthesia, 372. Boston monument to commemo- rate the discovery of anaes- thesia by ether, 37. Bowditch and Minot, researches, 157. Brackett, Dr. C. A., of Dental Medicine (D.M.D.), prolonged anaesthesia from nitrous ox- ide in major operations in surgery, 94. Brandy, improper use of, in opera- tions, 139 ; in diphtheria, 127. British Medical Association, 1892, reports of aneesthetics, 537 ; hypnotism, 538. Bright's disease, cases of injury from anaesthetics in chronic, 225; nitrous oxide, effects on, 80; ether, action on, 155. Bradford, John Eoss, B. Sc, Uni- versity physiological labora- tory, experiments upon the brain and spinal cord, 82. Bromide ethylene (not ethylbro- mide), 204. Bromide ethel, hydrobromic ether or bromide of ethyl, 227; history of, 227; impuri- ties, 235: mode of employ- ment, 230 ; mode of prepara- tion, 227; mixtures of and their dangers, 233-235; use of in Germany, 238 ; value of in obstetrics, 236, 237. Bromoform as an anaesthetic, 205 ; use in treatment of whooping-cough, 205 ; heart depressant, physiological ef- fects, by Prof. Eeichert and Dr. Kriger, 205, Bruntou, criticism of Drs. Gas- kill and Shore, 280, 281. Buren, Dr. Henry, Chicago, case of death from mixture of ether and chloroform by, 361. Burnet, James B., A.M., M.D., Newark, N. J., use of Jiitrous oxide in old pleuritic adhe- sions, acute irritation, pain- ful catarrhal bronchitis, etc., 125. Butyl chloride, cardiac pulsation becoming weaker and finally extinguished, caused by, 206. Buxton, Dr. Dudley, experiments on physical changes in the condition of the brain and spinal cord with Prof. Hors- ley, 80 ; action of nitrous oxide on the heart, 86; re- viewing nitrous oxide exper- iments, 88; on the kidneys, 89 ; respiratory rhythm, 89 ;' administration of nitrous oxide to children, by. 111. CAFFEINE, 461. Canadol, 462. Carbon, dichlorine or chloric ether, 204. Cardiac failure, definition of treatment, 494-498. Catarrh, the use of cocaine in acute, 426. Carter, Dr. Wm. S., experiments with Prof. Wood on tissue changes after death from ether, 186, 187. Cerna, Dr. D., and Dr. Wood, ex- periments with nitrous oxide, 105. Changes of tissue found in cases of death after ether, 186. Chiene, Prof. John, clinic in University, Edinburgh, me- thod of administering chlo- roform, 248, 249. Children, use of nitrous oxide and oxygen by Dr. Hewitt for, 103. Chilblain, use of cocaine in treat- ment of, 425. Chloric ether. 35, Chloralamid, 486. Cholera, treatment by ether and camphor, 195. INDEX. 541 Circulation, action of ether upon, 155; action of chloroform, 531. Chloroform, administration of, •243. 247, 252. 253 : to alcohol- ists, 250; antidotes for poison- ing by. 532. 533; action of, 248; deaths from, 293; and deaths from after-eftects. 318; dan- gers. 248 ; deaths from in Reading, Pa.. 306; deaths from in dental operations, 329; dangers in dental sur- gery, 275 ; dangers in treat- ment of. and signs of. duty of assistants in, 248, 249 ; dis- covery of, 35: inhalers for. 183, 244-247. 253, 506 ; mode of administration, 248 ; mode of preparation. 239 : or ether, which (?), 211 ; the pupil as a guide, 259; signs and treat- ment of dangers. 261 ; the pulse during, 296; Eauke's experiments, 260 ; Scotch method, 248; stimulation, 248: toxicological effects of, 261. Clover small portable inhaler, 167 ; patients ceasing to breathe and how to start them again. 168. Coca plant leaves, preparations, etc., use in treatment of dis- ease, 384; use of wine of, made from the fresh dried leaves, also cocaine. 385. Coca leaves, active principle of, 386; therapeutic uses of. 336. Cocaine, experiments with, 390, 391 ; action on nerve centres, 393; action on the animal system, 289; antagonism to ether and chloroform, 398; chemical tests. 388, 389; in diseases of the ear, 415 : in diseases of the eye, 412, 416; in diseases of the nose, teeth, throat, 412. 415; inebria- tion and habit, treatment of, 395-396 ; inebriety, treat- ment of, 396; its impurities and instability, 388; maxi- mum dose of, 421 ; number of deaths from, 416 ; no mor- bid changes in. 420 ; on sight, hearing and brain, 394; poi- soning from, 420: prior to and during aufesthesia, 411; in circumorbital pain, treat- ment by. 432 ; spray of petro- latum ether with, 412 ; use on nasal mucous membrane prior to and during anaesthesia, 411 ; was it poisoning by (?), 413. Chorea, use of nitrous oxide in treatment of. 121, 511. Cold in the head, treatment of by cocaine. 426. 429. Collapse from ether, and treat- ment of, 153. Cone and its modifications, cone, 244. 508 ; ether, 169, 171. Coltou. Dr., safety in diseases of nitrous oxide, 119. Conclusions of experiments upon the brain and spinal cord with nitrous oxide, 83. Corning, Dr. J., early introduc- tion of the use of cocaine by electricity, 372. Coryza, treatment by ether, 196. DA COSTA, Dr. J. C, blood alter- ations by ether, 219. Dangers, chloroform, ether, 132; treatment of. 152. David, Dr. Th., director of L'Ecole Dentaire of Paris, conclu- sions on extraction of teeth under anesthesia, 112. Davy, Sir Humphrey, experi- ments with nitrous oxide, 27. Deaths from alcohol, 137, 140, 142, 145, 146 ; amvlene, 207 ; cocaine, 416 ; ether. 153-293 ; chloral hvdrate. 208: chloro- form. 214^ 252, 253. 308 ; ethyl bromide. 232. 235; nitrous oxide. 112. 113. 114, 115; ether, a death. 309; ethyl bromide, 227 : after cessation of anaesthetic and return to consciousness. 189. Degeneration of vessels from dis- ease, anaesthetics to be 542 INDEX. avoided in such cases, 127; death from, 115, 116. Dental operations, accidents in extracting teeth, Buxton on, 109 ; in children, 111 ; chloro- form in, 329; paper read by Dr. Hewitt before British Dental Association on, 329 ; table of deaths and general condition, 332. Denison, Dr. Chas., on importance of aseptible syringe for solu- tion of cocaine, 402. Delirium, from use of nitrous oxide in a chronic drinker, 127 ; from chloroform, 533 ; ether, 197. Diarrhoea, use of camphor and ether in, 195. Dioscorides on the use of mandra- gora, 25. Diphtheria, treatment by ether iodol, 197, 472. Dogs, experiments by H. C. Wood on, 127 ; oxygen and nitrous oxide on, 188; ether and chloroform, 188; vivisection by Prof. Schaffer's bromo- form, 205 ; bromide of ethyl, 229-230 ; chloroform, by Dr. Strassman, 288 ; cocaine, 389 ; experiments by Drs. Eeichert and Turnbull, 390-392. Dysmenorrhcea, treatment of by ether, camphor, etc., 195. E. C. MIXTUEE, 351. Emmet, the late Dr., danger of nephritis from ether, 213. Ephedrine chlorohydrate, 459. Epiglottis, Howard's new way of raising, 263 ; new way of ex- amining, 264. Epilepsy, treatment by ether and camphor, 195 ; nitrous oxide in, 116-122. Ether, ethyl, action on circula- tion, 156-157 ; action on brain, head and circulation, 155 ; after-effects of, 318, 533 ; apparatus for administra- tion per rectum, 191-192; as angesthetic, 149 ; chemical composition, 148 ; chemical properties, 149; chemical re- action, 148; chief dangers from administration by rec- tum, 191-192 ; cone, use and modificatious of, 169-171 ; danger from the cold and watery vapor, 356; dangerous symptoms and treatment of, 152, 494 ; ethyl oxide, ether of commerce, 148; experiments on deaths from ether fortior, 155; how manufactured, 148 ; inflammability of, 152; in- halation of, 149-150 ; inhalers for, 157-186; the Allis, 157- 166; Cheatham's, 173; Clover's small, 166-167 ; Codman and Shurtleflf's, 176 ; Hearn's, 171 ; Lente's, 170 ; Ormsby's, 171 ; Parkinson's, 174; Souchon's, 178 ; inhalation of to pro- duce ansesthesia, 149-150 ; internal administration of, 193-195 ; intoxication by, 197-199 ; is it possible to have death produced by an anaes- thetic some time after cessa- tion of administration by rectum ? 191 ; mode of deter- mining its purity for inhala- tion, 149; or chloroform, which (?), 211 ; physiological action of, 153; precautions before and after use as an anaes- thetic, 151, 490 ; specific grav- ity, 489 ; sphygmographic tracings from, 155 ; tissue changes found in cases of secondary death after, 186. Ethyl chloride, 441 ; and pental, 444. Ethylene bromide, 204. Ethylene chlorhydrin, 204. Eucalyptus, 454. Eucaine, hydrochlorate, 434 ; chemical composition, 39-40 ; general action of, 435 ; and cocaine, 437 ; local action on the eye of, 436-437 ; in dent- istry "^ and minor surgery, 438-441. Evans, Dr., of Paris, reintroduc- tion of nitrous oxide, 29. Exalgin, 485. INDEX. 543 Experimeuts, abstract of the deadly after-eflects of chlo- roform, by Drs. C. Thiem aud P. Fischer, of Berlin, 318- 320; bromide of ethyl on auimals, 229; bromoform, by Dr. Krei^er, 205 ; by the late Dr. Washington Atlee with bichloride of methylene, 203; by Dr. H. Northrop with oxygen and chloroform, 340: by" Dr. Buxton, on the physiological action of ni- trous oxide. SO-Sl: carbonic acid and oxygen. Dr. Wood, 106 ; conclusions by Dr. Bux- ton on the brain and spinal cord, S3: on arrested respi- ration, by Drs. Martin and Hare, 264 ; first, second and third series, by McQuillen, 73 : on blood alterations by ether, by JohnC.DaCosta, 219; on the kidney, S9 ; of Paul Bert, on compressed oxygen, 96 ; on the physiological ac- tion of ether, by Drs. Eeich- ert, Thomas and Turnbull, on use and abuse of atropine and morphia. 153; on the reflexes under nitrous oxide gas, 84 ; on the action of nitrous ox- ide, and of the mixture of ni- trous oxide and oxygen, by Dr. Wood, 127; on the phy- siological action of alcohol, by David Cerna, M.D.. of Texas, 140 ; on tissue changes found in cases of secondary death after ether, bv Drs. H. C. Wood and William S. Carter, 186 ; on the value of oxygen gas in prolonged operations where ether has been used, 209-210; on the physiological action of bro- mide of ethyl, by Schneider, Aboneje. Thornton and Max- well, 229 : on local anaesthe- tics, by Dr. Leibreich, 371; on osmosis in treatment of living dentine, by Henrv W. C4illett, M.D., 372; on "bro- mide of ethyl, by Dr. Koel- licker, 231 ; proportions of anaesthetic vapor and air at each compression of the bulb of Souchou's auxiliary injec- tor, 183 ; to determine the time required for evaporation on a given surface of paper, by the author and Dr. C. S. Turnbull, 35.5-356; with a mixture of ether and bro- mide of ethyl and chloro- form, by Drs. Reichert, Thomas and Turnbull, 357; with Allis's inhaler with ether, bv Dr. G. H. Coburn, 164. FISCHER, Dr. P., experiments with Dr. C. Thiem on the after-efi"ects of chloroform, 318. Flatulent dyspepsia, carbolic acid in, 476. Formad, Dr., influence of alcohol on the kidnevs and liver, 141-146. Formic ether, 201. GAEDEKE, discovery of ery- throxyline, 38. Galvanism in chloroform nar- cosis, 495 ; in ether, 1.52 ; in treatment of living dentine, 375 : by Herapath's method, 152. Gaskell and Shore, Drs., new views of anaesthetics, 280, 281 : answer by Hare, 507. Garretson, the late Dr., use of phenic acid and cocaine in solution, 393. Gastritis produced by " Rough on Rats,"' treatment by co- caine, 422. Geographical distribution of fa- talities from chloroform, 252. Gillett, Henry W., M.D., electrical osmosis for treatment of liv- ing dentine, 370-376. Glottis, spasm of, from cocaine, chloroform, 262-264; ether, 150-1.52 ; nitrous oxide, 108- 110; treatment of, 262-264. 544 INDEX. / Goodell, Dr. Wm., experience with ether. 165. Goodwillie, Dr. H., surgical oper- ations under nitrous oxide, 94-95. Gonorrhceal ophthalmia, treat- ment by cocaine, 431. Gout, treatment by ether, 194. Gray, Dr., use of eucaine as an ansesthetic, 441, Guaiacol, with cocaine, 486. Guthrie, Mr. Samuel, discovery of chloroform by, 35. HABIT, chloroform, 532. Halliburton, Prof., University College, London, examina- tion of the blood in nitrous oxide anaesthesia by, SO. Hammond, Dr., experiments with cocaine by, 394-395. Hamilton, Dr. A. McLane, use of nitrous oxide in insomnia, epilepsy, neuralgia by, 117 ; functional heart disorders, 118. Hare, Dr. Hobart A., treatment of arrested respiration by, 264; conclusions with Dr. Martin, 273; experiments with H. C. Wood, M.D., 500 ; reply to the Hyderabad Com- missions, 500. Harley, Dr., introduction of alco- hol in mixed ansesthetics, 353. Hay fever, the late Sir Andrew Clark's treatment of, 427 ; treatment by cocaine, by J. M. DaCosta, 429. Heart, action of ether upon, 155-157 ; causes of death from ether, treatment with strychnine, 153 ; which an- sesthetic to employ for dis- eases of, 510. Heat produced by cocaine, 392. Hegar and Kaltenbach, experi- ments by, 319 ; unchanged chloroform found in urine by, 319. Helleborine, 461. Haemorrhage in use of bromide of ethyl, no increase of, 229. Hewitt, Dr. F.. apparatus for ad- ministering nitrous oxide and oxygen, portable and simplified, 96-97; Dr. J. D. Thomas, use of this method in extracting teeth. 101; his objection to the face-piece of, 102; conclusions of, 102-103. Hillischer, Prof., of Vienna, use of mixture of oxygen with nitrous oxide as an anaes- thetic, 99. Hirsch, Dr. A. B., value of oxy- gen gas after prolonged oper- ations with ether, 209-210. Hoarseness, 426-428. Homatropine. 458. Horsley, Prof., on patellar tendon phenomena under profound anaesthesia, 84. Hospital records of cases of anaesthesia, 317-318. House surgeons, the need of pro- per instruction, 507, 516, 517, Howard, Dr., method of raising the epiglottis, 263. Hunger, insatiable, relieved by cocaine, 423. Hyderabad Commission, answers to cause of death, 299; cause of death stated by, 298 ; history of, 293; table of deaths from chloroform and ether from the first, 306 (notes on 306-309) ; tests of the suit- ability and safety of it, 294 ; Dr. Brunton's giving away the whole case, 281 . Hydrastis canadensis and Hydras- tine, 457. Hydrate, chloral, 208. Hydriodic ether, 201. Hydrobromate of homatropine, 459. Hydrobromic ether (see Bromide of Ethyl). Hydrocele, deaths from injection of cocaine, 420-421. Hypnal, 485. Hypnotics, 479. Hypnotism, 534-536. INFILTEATION 399-411. anaesthesia, INDEX. 545 Inhalation of chloroform hy the nose, objections to, by Dr. M. A. Gueriu, of Paris, 508; Souchou, use of inhalation by the nose. 178-1S6. Inhalers, the Allis. shut and open, 157-165 ; Buxton's, Dr., modification of Clover's, for nitrous oxide and ether, 67- 68; of Junker's, 246, 368; Codmau and Shurtleff's, ni- trous oxide, etc., 177; cone, modifications of 169, 171 ; Esmarch's, chloroform, mod- ified by Charriere, Paris, 246 ; French navy, employed in, 245 ; Hewitt's, for nitrous oxygen and oxygen, 97; in- jector of Souchou's for use in operations on face and mouth, 178; Lawrie's, modi- fied by Krohne, 507, 508, and Lewis and Long, nitrous ox- ide, 69 ; Seseman. 506 ; Lente (ether), 170 ; Ormsby, im- proved, 171 ; Skinner's, for chloroform, 245 ; Thomas (nitrous oxide), 46; S. S. White Co., 47-5.3. Insanity from prolonged use of anaesthetics, 127. Insomnia, use of nitrous oxide in, 117 ; use of ethylene bro- mide in, 204. Instability of cocaine, 388; use of quinia in intermittent fever, 478. Intoxication from alcohol, 139 ; ether, 197; in Ireland, 198; in Eussia, 198. Iodide of ethyl. 474. Iodide of methyl, 206, 456. lodol, 468. Iodoform, 462-468. Irregular action of anEesthetics in bromide of ethyl, 233; chloroform. 2.58. Irritation of skin, treatment of, 425. JACKSON, Dr., part in the dis- covery of anaesthetics (ether), 32. Jolyet and Blanch's experiments, and references to them, 77, 100, 128. Junker's inhaler, 246, 368. KAST, doubts whether or not chloroform is changed in the urine, 319. Kiduevs, action of alcohol on, 142, 143, 187, 224; disease of, which ansesthetic to employ, whicii to avoid, 511; action of chloroform on, 224-226; action of ether on, 186, 187; experiments with nitrous ox- ide, 89; the influence of aneesthetics on, bv the late Dr. Emmet and Prof. W. F. Xorris, 225. Kirk, Dr., on Dr. Hewitt's me- thod of using nitrous oxide and oxygen as an ausesthetic, its safetv. etc., 102. Klikovich, Dr. Si, of St. Peters- burg, experiments with a mixture of nitrous oxide and oxygen, 96. Koellicker recommends bromide of ethyl, 231. Koller, Dr. Karl, of Vienna, dis- coverer of anaesthetic power of cocaine on the eve, etc., 38. Krohne's and Seseman's respira- tion indicator attachment, 505, 508. LABOE, use of nitrous oxide and oxygen in. by Klikovich and Zweifel, 123. Laryngeal tuberculosis, treat- ment of, 427 Larynx, spasm of, chloroform, ether and cocaine in disease of, 384; nitrous oxide, 108, 110. Laughing gas (see Nitrous Ox- ide), 27. Lawrie, Dr., arrangement of Hy- derabad Commissions, 293 ; strictures and conclusions, answer to. 299 ; unfair state- ments, 325, 328. Lavage or gavage, painful treat- ment by cocaine, 423. 546 INDEX. / Levis, Dr., cases of death from impure bromide of ethyl, 235. Lewis, Dr. Bransford, of St. Louis, use of Schleich's me- thod, 410. Liebreich, Dr. M. Oscar, sub- stances which produce local ansesthesia, 371, .372. Liniments for relief of neuralgia, etc., 554. Link, Dr. John E., on the use of whiskey as an anaesthetic, 137, 138. Local anaesthesia and anes- thetics, 371 ; absolute alco- hol, acetate of lead, antipy- rine, carbolic and carbonic acid, bromide of ethyl, car- bon bisulphide, chloroform, cold, ice and snow, ether, hy- drochlorate of ammonia, hy- droquinine, rhigolene, resor- cin, sulphate and bromide of ammonia, the iron salts, how they act, 371. Local ansesthetics and analgesics, antipyrine, antifebrin, apo- morphine, bromide of ethyl, bromide of potassium, bru- cine, electricity, 371, 372. Long, Dr., experiments with ether, 32. Longet, on narcosis from ether, 155. Loyssel, Dr., experiments with oxygen as an antidote to chloroform, 339. McDonald, Dr. L., nitrous ox- ide in general surgery, 94. MacEwen, of Glasgow, the pupil in suspended function of brain from want of oxygen- ated blood, 259. Mandragora wine, 26. Martin, M. Claude, of Lyons, ex- periments with a mixture of nitrous oxide and oxygen administered to dogs, 101. Martin, Dr. Edward, on treat- ment of arrested respiration, 264. Mays, Dr., of this city, successful use of brucine by, 459, 460, Maximum dose of cocaine, 397. Mattison, Dr. J. B., of Brooklyn, deaths from cocaine toxsemia, 417. McQuillen, the late Dr., experi- ments on the action of chlo- roform on the blood, 71-74. McWilliams, experiments and ob- servations to Dr. Lawrie, 298. Medico-legal relations of anaes- thetics in France, 112 ; in Ireland and Eussia, 198. Mental disturbance and insanity, 127 ; from chloroform, 533. Menthol, 462. Mesmerism (see Hypnotism). Methyl-violet, 482. Methyl, 456. Methyl, chloride of, local anaes- thetic, danger from too free use, 457 ; iodide of, 206. Methylic ether, 201. Methylene, bichloride of, 202; Dr. Richardson's mixture of, 202, 203 ; the late Sir Spencer Wells's use of, 202, 203. Miller, Dr. John S., form of ap- paratus for use of ether by the rectum, 193. Miller, Jacob F., Esq., advocated care in the use of anes- thetics, 518. Miles, Dr. A. B., ether or chlo- roform — which ? 211. Mixed anaesthetics, 232, 233, 351- 356 ; report on, by chloroform committee, Med. Chir. Soc. of London, first death bj- M. Perrin, .351 ; second, by Dr. E. Crockett, 351. Montgomery, Dr. E. E., bromide of ethyl as an anaesthetic in labor, 236-238. Morphine and atropine before chloroform, experiments of the Paris Society of Surgery, 303, 304 ; and ether and chlo- roform, 1.53. Morgan, the late Dr., of Dublin, substitution of ether for whiskey, 198. Morton, results obtained with ether in Mass. Gen. Hospital by, 31, 32. INDEX. 547 Hosier, treatment of asthma by cocaiue, 429. Mosso, of Turin, experiments showing an increase of bodily temperature by the use of cocaine, 390, 391. Mott, the late Valentine, objec- tions to the use of brandy in surgical operations, 139. Mowat. Sphygmographic tracings from pulse under nitrous oxide, 90, 91. XAXCEEDE, Dr., directs tongue to be drawn out to lift up the epiglottis. 1.52. Xaphthaline, 4S5. Nelaton, treatment of dangerous symptoms after using ether as an anaesthetic by, 152. Nephritis, danger of. by action of blood saturated with ether, 213. Nervous symptoms, treatment of by ether and camphor. 195. Neuralgia, which aneesthetic to employ. 510. Niemanns. Dr. Albert, 33. Nipples, treatment of cracked, by cocaine, 425. Nitrite of amyl, the employment of. 291 : non-success with. 291. Nitrogen gas. action when in- haled solely without oxygen, 70 ; after-effects of, 107 ; deaths under, 112-115 ; ex- periments with nitrous oxide gas and nitrogen, 105. Nitrous oxide, administration to children, 111; after-effects of accidents in extracting teeth under, 112 ; after-effects of, 107; as an anesthetic in labor, ]23; and oxygen, 95; blood alterations, conclu- sions, 92, 93 ; chemical com- position and mode of prepa- ration, 41-43 ; conclusions of experiments on the brain and spinal cord, 53, S4 ; dan- ger of, bv Dr. J. D. Thomas, 107; deaths under, 112-116; experiments with, 73; ex- periments with on kidneys, 89 ; experiments with the spectroscope, 74, 75; experi- ments on respiratory rhythm, 69 ; on men, pigeons, rabbits, by Dr. C. S. Turn- bull and associates, 75 ; gaso- meter, 53 ; heart disease, 120; Hewitt's apparatus for ad- ministration with oxygen, 97-99; in general surgery, 94, 95 ; in chorea, epilepsy, hysteria. 121 ; inhaler. 46-51 ; its safety as a therapeutic agent in diseases of the lungs, 119 ; nervous diar- rhoea, sluggish circulation and nervous prostration, 126; on insanity or mental disturbance following an operation with prolonged use of, 127' original experi- ments on the action of. and oxvgeu with, by H. C. Wood, M.D., 127-134: physical properties and physiological action, 69-71 ; proper method of administration. 65; re- flexes under, S4-55 ; thera- peutic application of, 116- 116 ; wall bracket for office and surgeon's cases, for use of, 63-65. Northrop, Dr. H. L., reasons for the administration of oxy- gen with chloroform, 340, 341 ; report on experiments, 342 : use of apparatus, 345^ 348.' 0D0NT0L0C4ICAL Society of Great Britain, committee found averages in administra- tions of nitrous oxide, 91, 92. Officiers de Sante of France, den- tists who hold no diploma have no right to extract teeth except under supervi- sion of doctor. 111. Olefiant gas 'see Ethylene;. Ophthalmic surgery, cocaine as a local angesthetic, its import- ance in operations on the eye, 38, / 548 INDEX. Opium as a narcotic, aud use as an ansesthetic, 26. Ovariotomy, use of nitrous oxide in, 95 ; in general sui-gery, 94. Oxide, ethyl, as an aufesthetic, 148. Oxygen gas. apparatus for the administration of, with chlo- roform, 345, 346 ; average period of inhalation of the combined gases, 100 ; in pro- longed operations, in which ether has been administered, 209, 210 ; inhaling apparatus for, 349; nitrous oxide aud, with experiments by Dr. H. C. Wood, 127-132, 134 ; thera- peutic use, with nitrous ox- ide, 124-126; Drs. Wood and Cerna on the combined gases, 104; when the gas is to be preferred, conclusions by Dr. Hewitt, 102. PARALYSIS from nitrous oxide, 127; treated by nitrous ox- ide, 122. Pental, original experiments on dogs, by Dr. H. C. Wood, 449. Pereira's use of ether to relieve the effects caused by chlo- rine gas, 31 ; before its intro- duction as an ansesthetic, 31. Perrin, M., first death from mixed anaesthetics, 351. Pharynx and naso-pharynx treated by compound spray of cocaine, 415. Pharyngitis, granular use of co- caine in, 384, 428. Phenic acid in solution for ex- traction of teeth. 398 ; use of, by the late Dr. Garretson, 398. Phenol and camphor, 450. Phenol, mentho, 451 ; properties and uses, 451. Phthisis, which anaesthetic to use, 510. Physicians, their legal responsi- bility in the administering of anaesthetics, 516. Pneumonia following careless use of ether treated by ni- trous oxide, 119. Poisoning by cocaine, use of ether aud chloroform in, 398. Post-partum haemorrhage, ether, 195. Priestly and Scheele, study and application of "different kinds of airs and gases," and their discovery of oxygen, 27. Precautious to be taken in ad- ministration of chloroform, ether aud nitrous oxide, 494. Prevention of death from ether, 210 ; chloroform, 339. Prop of wood or rubber to keep the mouth open, 66. Proper use of morphia and chloroform, 303. Pruritus vulva, treatment by cocaine of, 425. Pulse, during chloroform anaes- thesia, 296. Pyoktanin, 482. QUININE, 478. Quimby, Dr. J. M., experiments on the use of chloroform while the patient is asleep, 527-529. EECOEDS, hospital, examination of urine, 317: before opera- tion, 321 ; of autopsy, 318. Eectum, use of ether by, 191 ; chief dangers from, 191-192 ; chief dangers from apparatus, 192-193. Eeicherts. Prof., studies with co- caine on animals, 389-392; chloroform, 500. Eegnier, M., use of hypodermic of morphia and atropine be- fore inhalation of chloro- form, 303. Eesearches of Bowditch and Minot, 157. Eesorcin and cocaine in whoop- ing-cough, 428. Eespiration, artificial, Sylvester's method, 276 ; arrested respi- ration in anaesthesia, 280; the feet should be well drawn up, 276 ; irregularity in use of chloroform, 290-291; im- portance of prolonged, 303. IXDEX. 549 Eesuscitatiou. electricity iu, 496; Kouik's. 497; Kelly's, 497; by lingual traction, 2S2 ; by rhythmic traction of the tougue iu accidents and from chloroformizatiou. 264. Eichardsou, Dr. B. W., of Lon- don, experiments with me- thylic ether, bichloride of methvl. 201 ; with iodide of methyl. 206.' Eichardsou, Dr. M., report of ele- ven deaths from cocaine, 420. Eiddle, Daniel S., Esq., of Xew York, opinion in regard to the enactment of further law on responsibility of physi- cians, .517. SAXSOM, Dr.. testimony as to the stimulating effects of alcohol in counteracting the depressing influence of chlo- roform, .35.3. Schiff, Prof., of Geneva, on vivi- sections, the safety of ether, deaths from chloroform. 200. Schleich's infiltration method of local anfesthesia by cocaine. 399. Sciatica, treatment of, 511. Scotch method of administering chloroform, 248. Sepsis after use of cocaine, danger of, 405 : Schleich's method, 405-406. Sexual excitement, 525 ; ether and camphor in, 195. Shepard, Col. J., death from ether, 310-311. Shock, 1.53, 353. Sims, Dr. Marion, use of nitrous oxide in difficult and pro- longed operations, 95. Skin disease, the use of cocaine in its treatment, 424. Sneezing, paroxysmal, treatment of, by cocaine, 428. Snow's table showing the amount of chloroform vapor which can be held in solution by air, 255-256. Souchon's improvedansesthetizer, 369. Spasm of stomach, intestines or heart, use of ether in, 194. Squibb, Dr. Edward, on the in- flammability of ether. 152. Stenosis or vulvular disease, which ansesthetic to employ, 510. Stomach affections treated by cocaine, 422. Students, facts for, 488, 517. Struggling, violent, the dangers of. under chloroform, 506. Strychnine in chronic alcohol- ism, 147 ; in heart failure in chloroform, 153. Sulphonal, 480. Supplement of facts in anaesthe- sia for the student to commit to memory, 488. Surgery, cerebral, what anes- thetic to give and which not to give, 509. Surgeons, their responsibility for the life of the patient, 516. Syncope, primary, from chloro- form, Dr. Eobert Kirk, of Edinburgh, 3.32, 49S. TABLE of deaths from chloro- form and ether since the Hyderabad Commission, by the writer, 307. Tables of deaths from various aneesthetics, by George M. Gould. 314. Tables of Committee of the Odontological Society of Great Britain on average of administration of nitrous oxide, 92. Tape-worm, use of ether, etc.. in, 194. Tetanus treated by morphia and cocaine. 424. Tissue changes found in cases of secondary death after ether, 156; from chloroform, 318. Therapeutics of cocaine, 422. Therapeutic application of ni- trous oxide in nervous aphonia, neuralgia, asthma, 116 : insomnia, by A. McLane Hamilton, 117. / 550 INDEX. Thompson, Elihu, experiments with nitrogen, 128. Thornton, Dr. E. Q., experiments with Dr. Hare, 502. Thymol, 479. Trional and tetronal, 485. Tropacocaine, 486. Turnbull, Dr. C. S., experiments of, 75-79, 357. UEETHANE, 484. VALUE of anaesthetics in dis- ease, 509. Vapor of anaesthetics, boiling points, 353. Vernuil, experiments with bro- mide of ethyl, 230. Viau, Prof., use of phenic acid, and cocaine, 398. Vomiting, uncontrollable, treated by cocaine, 423 ; how to pre- vent it, 151, 489, 496. WATEE produced from the evap- oration of ether, danger from, 356; as a local anaesthetic, 402. Wells, Horace, discoverer of an- aesthesia with nitrous oxide, 28 ; monument to, 29. Whether chloroform may be ad- ministered for improper pur- poses, Dr. J. M. Quimby, 527 ; case at ISTorthamptou, Eng- land, 522; case reported by Dr. K L. Folsom, 526. Which anaesthetic to avoid, whose to employ, 509. Whooping-cough, treatment by bromoform, 205 ; by cocaine, 427 ; by ether, 197. Women without attendants, be- ware of chloroforming them, 5.30. Wood. G. B., M.D.. the influence of anaesthetics on the kid- neys, more especially ether and chloroform, 224. Wood, Dr, H. C, action of ether on the circulation, 156 ; ex- periments on nitrous oxide by, 127 ; abstract from a mon- ograph on experimental study of nitrous oxide with Dr. D. Cerua, 105 ; on carbonic acid and oxygen, 106; that ni- trous oxide should not be employed where there is de- generation of vessels, 127. Wooden prop to keep the mouth open when employing nitrous oxide gas, 66. Wiirdemann, Dr. H. V., first to use the Schleich's infiltration method in the United States, 399. ZWEIFEL proved chloroform to be present in the urine of the new-born infant whose mother had been given chlo- roform, 319. HD81 Turnbull T84 1896 A-.-t -: x>i _ ^ _ T COLUMBIA UNIVERSITY LIBRARIES (hsi.stx) RD 81 T84 1896 C.I Artificial anaesthesia, a manual of anae 2002315467