form. Many methods have been advocated for the relief of this troublesome symptom. L. H. Prince (22) of Chicago, from an observation of 1,000 consecutive cases of anesthesia concludes that "Threatened vomiting may be checked in most cases by phrenic compression." Certainly so simple a remedy deserves a thorough trial.

Paul Rosenberg (23) believes that by
Paul Rosenberg(23) believes that by

cocainizing the mucous membrane of the nose, these reflexes could be lessened or abolished. He claims that by this method vomiting during narcosis is rarer and sickness following anesthesia does not occur. Gerster (24) of New York, tried this method carefully in 100 cases, and concludes that "there was less nausea and vomiting, but in about ten cases there were symptoms of cocaine poison

ing, one of which was so severe as to require indefinite postponement of the operation. Preliminary injections of atropin have been used for the purpose of preventing vomiting. J. B. Blake (25) gives definite figures on this point. From 100 recorded cases he found seventy-one per cent free from vomiting. And in another series of cases without preliminary atropin injections, he found but forty-three per cent free from vomiting. The method that has met with most success in allaying the vomiting

and nausea after ether is the inhalation of oxygen gas after the ether inhalation is stopped. I understand that this has been used to some extent in Washington hospitals and would be pleased to hear the opinions of those who have employed it.

On the nervous system the action of the two agents is nearly the same. "The order of events is the same for both. The cerebral centers are influenced before the sensory fibres of the cord and these before the motor fibres,

while last of all the medulla is paralyzed" (28).

Having gone cursorily over the effects of the two agents on the respective organs most affected, and giving due weight to the concensus of opinion and to statistics it would appear that in general, ether is the anesthetic of choice. Yet there are cases where chloroform

might better be substituted for ether. From the preceeding this would seem to

be the case, first, where there is extensive disease of the lungs, or acute disease of the air passages. Second, in marked disease of the kidneys, and particularly in chronic interstitial nephritis with atheromatous arteries and a hypertrophied left ventricle. Third, in operations about the mouth or upper air passages, especially if the thermo-cautery is to be

used near the face. With a view of diminishing the dangers in anesthesia many rules have been laid down for their administration, choice of mechanical devices and various mixtures have been advocated. The oldest of these and one still largely in use is the A. C. E. mixture. Alcohol, chloroform and ether in the proportion of one, two and three. Its administration is the same as that of chloroform, and its action is due to the two agents discussed. The statistical death rate for this mixture is one in 5,550. The latest of the mixtures is that of oxygen gas with chloroform, ether or A. C. E. Its chief advocates so far are its originators, Drs. Markoe and C. S. Cole (29, 30) of New York, and Dr. De Hart (27) of Brooklyn, who has devised a mask for its convenient administration. From their experience they claim besides additional safety, that it allays nausea and vomiting and shortens the period of recovery to consciousness. The time required to produce anesthesia by this method is considerably lengthened. For example, Dr. DeHart (27) says that

"pure oxygen should not be used with ether on account of its tendency to counteract etherization and make it a very slow process." Therefore, he dilutes his oxygen with thirty-three per cent of nitrous oxide gas or air, and with this mixture passed through the ether he produced anesthesia in from seven to fourteen minutes. With ether alone Dudley Buxton (28), a prominent London anesthetist, says it takes him from ninety seconds to two-and-a-half minutes to produce anesthesia using Clover's inhaler.

The length of time necessary to produce complete anesthesia is sometimes of considerable moment, and to cut this as short as possible the English anesthetists have devised means for first giving nitrous oxide gas, and following this by ether. In the hands of experts this has been satisfactory. The English anesthetists do not think that chloroform acts quicker than ether, and with a less stage of excitement. The reason for this is doubtless due to the fact that they largely use Clover's inhaler, which allows them to so graduate the dose as to give very little ether at first, but as soon as the fifth nerve filiments are obtunded to give a more concentrated vapor than is possible by an open method.

The danger signals during inhalation are variously valued by different men. Diametrically opposite views have been given as to the deductions to be drawn from the size of the pupil during inhalation, but there seems to be a common belief that any sudden change in size is significent. All authorities are of the opinion that the breathing is to be closely watched as an index to the patient's condition, as well as giving an idea of the amount of anesthetic being taken into the system. The advocates of chloroform lay particular stress on this point.

Most writers agree that the condition

of the pulse is a symptom to be considered. Dr. J. B. Roberts(31), however, says, from a study of ether deaths and a personal experience with three cases: "I believe that as a rule danger from ether is shown by the respiration and I always in etherizing have watched the respiration with more care than the pulse, but this custom which is general among surgeons, I now feel is founded upon error." That ether, which stimulates the heart and vaso-motor center, requires more attention to the circulation; and chloroform, which depresses the circulation, requires attention to the breathing seems contradictory. But when we remember that an over-stimulated heart becomes more rapid and its force less, and that when stimulated till it stops from exhaustion there is little hope of its again starting, then we see good reason for noting the pulse during etherization. And when we recall the intimate connection between circulation and respiration, we know that a weakened or dilated heart causes disturbance of breathing, and that this in turn embarrasses the right side of the heart by giving it more work. Hence in chloroform anesthesia the breathing acts as one index to the force of the heart's action.

But there are signals of danger other than those of cardiac failure, or of overdosage. The anesthetizer must see that his patient does not aspirate mucus from nose, mouth and pharynx. That the tongue does not fall back and close the glottis. If the patient vomits he must see that there is free escape of vomited matter. For an oedema of the lung, due to a toxic action of ether, there is perhaps no relief. Yet proper measures should be taken; such as-immediate venesection, inversion of the patient to allow escape of the profuse secretion, and stimulation by hypodermics of nitro

glycerine, strychnine and cocaine. If the cedema is due to overwork of the right heart these effects may be of benefit.

Evidences of over-dosage, short of cardiac failure, are cyanosis, rapid and shallow, or irregular breathing, fast and feeble pulse, and relaxation of muscles shown by dropping back of the tongue. For the lesser degrees of over-dosage, stopping the anesthetic, admitting fresh air and drawing forward the tongue, or raising the angles of the jaw and at the same time extending the head, usually suffice. But where symptoms of heart failure occur, the one remedy is artificial respiration. Dr. Fell (32) of Buffalo, has advocated forced respiration as being more certain in its results than artificial respiration. Dr. Wright (33) has added bleeding from an artery before artificial respiration is begun. The object being to quickly rid the blood of its excess of the anesthetic. The passage of duly areated blood into the arterial system is blocked by the venous and chloroform charged blood, which passed through the pulmonary capillaries before artificial respiration was resorted to. By opening an artery we provide an outlet for the greater part of the vitiated blood, and we reduce the resistance in the arterial system. From chloroform there is an enfeebled heart to tide over its burden, and hence stimulants are to be administered. Hypodermics of strychnia, cocaine, camphor, nitro-glycerine and digitalin are all good stimulants.

For paralysis of the respiratory center due to chloroform, Prof. Hobday(34), a veterinarian, has had success in animals by medicinal doses of hydrocyanic acid, either dropped on the tongue or given hypodermetically undiluted. But in these cases artificial respiration was also resorted to.

With a heart over-dosed with ether,

amyl nitrite inhalation, by dilating the contracted arterioles, may reduce the load on the heart. H. C. Wood lauds the virtues of strychnine in ether poisoning and in regard to whiskey he says, "It seems to me an unalterable rule of practice that no alcohol should ever be given to the patient suffering from anesthetic cardiac failure." In cardiac failure from ether then, artificial respiration, alone or aided by bleeding to diminish the work of the heart and oxygen gas, to hasten proper ventilation of the blood, hold out the main hope of 1eestablishing the From the preceeding we

circulation. circulation.

may conclude that:

I.

No anesthetic now known is free from danger. But the danger is lessened according to the skill and experience of the anesthetizer, though it is never entirely eliminated.

2. For safety, ether is the anesthetic of choice, unless it is specially contra-indicated.

3. In anesthetizing both pulse and respiration are to be noted.

4. Artificial respiration or forced respiration are to be at once instituted in cardiac failure.

5. Oxygen should be at hand in case of accident, and to be given after anesthesia to allay its unpleasant effects. References:

1. Der Aertz. Prackticker, Sept. 1895. 2. London Lancet, April 18, 1896. 3. A report of a committee appointed: by the Royal Med. and Chirurg. Society, 1864.

4. London Lancet, 1894, I. 5. Brit. Gyn. Jour., May, 1896. 6. Arch. fur Klin. Chirurg., 1895. 7. Chicago Clin. Rev., Nov., 1895. 8. Brit. Med. Jour., Oct. 20, 1894. 9. Clin. Jour. Lond,, 1893-'94. 10. London Lancet, April 28, 1894. II. Deutsch Med. Woch., Sept. 13, 1894. 12. Berlin Klin. Woch., 1894, No. 51. 13. Deutsch Med. Woch., 1895, No. 8. 14. Deutsch Med. Woch., July 18, 1895.

15. Trans. Col. of Phys. Phila., April 5, '93. 16. Trans. Am. Surg. Ass. Phila., 1895. 17. Boston M. and S. Jour., June 6, 1895. 18. Jour. Am. Med. Ass., Jan. 4, 1896. 19. Deutsch Med. Woch., Sept. 20, 1094. 20. Wiener Med. Woch., Jan. 18, 1896. 21. Med. and Surg. Reporter Phila., April 18, 1896.

22. Railway Surg., April 7, 1896.

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23. Berlin Klin. Woch., 1895, No. 1 and 2. 24. Annals of Surg. Phila., 1896, XXIII. 25. Boston M. and S. J., Sept. 27, 1894. 26. Med. and Surg. Report, April 4, 1896. 27. Boston M. and S. J., April 16, 1896. 28. Anesthetics-Dudley Buxton, 2d ed. 29. Med. Record N. Y., Oct. 12, 1895. 30. Therap. Woch. Vienna, Feb. 2, 1896. 31. Phila. Med. Times, June, 1881. 32. Med. Record N. Y., May 30, 1895. 33. Brit. Med. Jour., Jan. 25, 1896. 34. Jour. of Compar. Path. and Therap. June, 1896.

Some years ago the late Dr. Howland, made some experiments before this Society, going to show the utility of an admixture of the nitrous oxide and oxygen gases in the production of anesthesia. It is true that all the experiments that he made before the Society were upon chickens, but he gave his reasons for using these, and those who were present will remember that the chickens went under the influence of the mixed gases very promptly, without struggle, laid upon their sides without any movement whatever, breathing regularly, and were, to all appearances, as in natural sleep. We all know that nitrous oxide itself is a very prompt anesthetic, but unfortunately its use cannot be indulged in for any

prolonged operation, but if by the admixture of oxygen gas, as Dr. Howland claimed, we may secure safety to our patients, quickness of the action of the anesthetic, and entire obliteration of sensation during surgical operations, we will have obtained something which for we have been reaching out for a long time.

Dr. I. S. Stone said: There is one question, referred to by Dr. Johnson, that I think needs a little elaboration, that is, in reference to giving any anesthetic during the existence of nephritis. The prevailing idea is that it is better to give chloroform in all cases in which albuminuria is present. I have used chloroform extensively, and in regard to my personal position relating to giving anesthetics in albuminuria it seems to me the proper way to consider that question is this: If a patient needs an operation to save his life, and the extent of nephritis is not great, either one of the anesthetics should be administered. Of course, if the heart is weak we prefer ether.

For my part I should not hesitate, if the operation is necessary to save life, to proceed with the anesthetic, either ether or chloroform. I have given ether often when albuminuria was present, and I have often seen albuminuria follow the administration of chloroform and ether

At first I thought it followed ether more often, but there is no question about it that the trouble may follow chloroform as well. At the Columbia Hospital they claim that albuminuria. follows both anesthetics. When the patient has albuminuria and the operation can be postponed, I think it very unwise to give any sort of anesthetic. Of course all of us have to do more or less experimenting. A patient of mine. died from chloroform administration. She had had septicemia for perhaps a month or six weeks, and as she had albuminuria it was thought best not to give ether, and in order to get her anesthetized as quickly as possible to do a short operation, (open a pelvic abscess I think) chloroform was used, and the patient died before she was taken to the operating room, and therefore before the incision was made: we should have an anesthetic, as Dr. Smith says, which could be given without danger.

Not over a month ago I saw one of our best assistants continue the administration of the anesthetic after the glottis was closed and without real respiration, yet there was motion of the abdominal muscles. In regard to what Surgeon General Laurie has said about patients and animals dying by failure of heart and respiration, those of you who are familiar with this report will know that he claims in a very large majority of instances the patient's respiration ceases first. Now it is very strange that there should be no greater unanimity about this. It has been shown in a vast number of instances, and I believe in nearly every instance, that the patient is getting carbon dioxide poisoning with the over-dose of chloroform, and the respiration has ceased before the doctor notices it, and consequently the double poisoning is going on before the heart ceases.

at

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Dr. Reyburn said: My experience was very extensive with anesthetics during the war. Chloroform only was given, and we never had a single death from it. Two cases of death from ether have come under my observation. One case was that of the late Father Boyle, whom many here will remember, and the other a woman that I operated on Providence Hospital two years ago. believe that in the use of anesthetics, the administration is really the most important factor. For myself, I have returned to the use of chloroform. Ether is more troublesome to give, much more irritative, and is often followed by distressing after effects, while chloroform is much more simple, and I believe if properly given the danger is about the same; but I do think, as Dr. Stone says, that in every hospital anesthetics should be given only by persons selected and educated for that purpose.

Dr. J. Taber Johnson said: I have not had great experience in giving ether, but I have had considerable in operating where other people gave it, and I must testify to the very great amount of comfort enjoyed by the operator when some one is giving it in whom he has confidence. We have all seen a great deal of inefficient work in administering anesthetics. The anesthetizers duties are

for

just about as important as those of the operator. Anesthetics have sometimes caused the death of the patient when an operation was going on which had no special danger attached to it. I remember sometime ago a case in which chloroform was given for the operation for piles, and the patient was dead before the ligature was applied, before anything was really done by the surgeon. It seems to me that we should-it is our honest duty to develop our technique in this as well as in all other directions, and if we could have in the hospitals in our city a trained man who would be known as an expert in giving anesthetics, we would be doing more our patients than by letting this important part be performed by inexperienced persons. I cannot say which is the safer of the anesthetics. We have, as Dr. Stone said, an increase of albumen in the urine after giving chloroform, as well as after giving ether, but so far as my knowledge goes from personal experience and from what I know of the experience of others, ether seems to be safer than chloroform, that is if we take statistics of 1,000 or 10,000 cases, but our hospital records are defective. They are keeping statistics in other directions, but they are defective in reference to anesthetics. If we could have this point more thoroughly developed I am sure it would be greatly to the advantage of all. If we take patients by the 1,000, 10,000 or 100,000, data collected from many hospitals in a certain. year or ten years, we will find that out of 10,000 cases where anesthetics are given there are more deaths from chloroform than from ether. But it is true, as Dr. Reyburn says, that a number of cases in which patients have lost their lives from the bad administration of ether are not set down against ether, for the reason that the patients die several days after with pneumonia or nephritis or bronchitis, which was caused by the ether. These late deaths help to equalize the matter to some extent. Ether, then so far as I can see, is safer than chloroform, it is safer in the hands of an inexperienced man, who could kill a patient a great deal easier with chloroform than with ether.