SUBJECTS FOR PAPERS AND DISCUSSION. First Day. I. Measures by which to prevent the diffusion of different communicable diseases from country to country, or within the limits of any single country,-e.g. : 1. Yellow Fever, Cholera, Plague. 2. Enteric Fever, Scarlet Fever, Measles, Hooping Cough, Diphtheria. 3. Syphilis. 4. Glanders, Hydrophobia, Anthrax. Second Day. II. Influence of various articles of Food (not including Water) in spreading Parasitic, Zymotic, Tubercular, and other Diseases. Third Day. III. Conditions to be imposed on the legally-qualified practitioners of one country who may seek authority to practise in another country. IV. Precautions to be taken in Medical Nomenclature and Classification to guard against False Statistical Conclusions. ON THE COMBINED USE OF MORPHIA AND CHLOROFORM IN PRODUCING AND MAINTAINING SURGICAL ANESTHESIA. BY ALEXANDER CROMBIE, M.D. EDIN. Superintendent of the Medical School and Mitford Hospital, Dacca, Bengal. CLAUDE BERNARD's remarkable observations on the effect of morphia in reproducing and prolonging the anesthetic action of chloroform do not seem to have attracted the attention of English surgeons. Even on the Continent, notwithstanding their obvious great practical value, the experiments that were made, and which were entirely successful, as a corroboration of those which had been made on the lower animals, do not appear to have led to any general adoption of the combination in practical surgery. Shortly after the publication of Bernard's lectures before the College of France in 1869, M. Uterhart reported that he had employed the two drugs conjointly in five cases with excellent results; and in 1872 MM. Labbé and Guyon communicated a note to the Académie des Sciences, in which they alluded to the observations of Nussbaum of Munich, and MM. 1 Practitioner, vol. iii. p. 255. NO. CL. D D Regault and Sarazin of Strasburg on the same subject, and detailed four operations in which the combination of the subcutaneous injection of morphia and the inhalation of chloroform was adopted.1 Beyond these two notices I have not been able to discover any allusion to the practice, and as I believe it to be one the importance of which cannot be overstated, and which, in my hands, has robbed chloroform almost entirely of its inconveniences and risks, I think it my duty to communicate my experience of it to the profession in a wider sphere than that which I have yet been able to influence in the course of my duties as an Indian surgeon. The observations of Claude Bernard to which I allude first came to my notice in 1873, in the Journal of Anatomy and Physiology for November, 1869, page 166. They were to the effect that when a dog has been previously narcotised by morphia it can be quietly and completely anæsthetised by a much smaller quantity of chloroform than usual; that, under such circumstances, anæsthesia is induced without any initiatory stage of excitement; and that morphia reproduces the anaesthetic effect of a previous dose of chloroform. At that time, 1873, I was resident surgeon at the Calcutta Medical College Hospital, where it was part of my duty to administer chloroform to every case requiring it, and I was abundantly familiar with the risks which accompany its use, and I determined to put Bernard's observations to practical proof on the operating-table. I was not then aware of the Continental reports on the beneficial effects of the combination, the references to which I have given above. The first case that came up for operation was a strong young European sailor, a patient of the late Dr. Cutcliff. I administered twenty-five minims of the ordinary solution of the hydrochlorate of morphia by the mouth five minutes before he left the ward, and in two minutes more commenced the inhalation of chloroform. Nothing could have been more disappointing than the result. The stage of excitement was violent and prolonged; the patient resisted, shouted, and struggled, requiring four or five assistants 1 Practitioner, vol. ix. p. 58. to keep him on the table. I had never had greater difficulty in getting a patient under chloroform, and the operation was finally performed while the excitement had been only partially overcome. This result, so little in accordance with what I had been led to anticipate, I attributed, rightly or wrongly, to the morphia having acted as a cerebral stimulant instead of as a narcotic, which it is liable to do under circumstances of mental excitement, such as those under which this patient was labouring during the time when it was beginning to act upon him; that is to say when he was in a state of apprehension and agitation previous to the operation. I imagined that the usual excitement produced on the inhalation of chloroform had been intensified and prolonged in consequence of its coinciding with the stimulating action of a small dose of morphia. I therefore determined to adopt a different procedure in the next case. I had not long to wait. An old native woman had been run over by a carriage in the street, and was brought into hospital with a compound fracture of both bones of the leg above the ankle. She was under the care of Dr. Cutcliff, who decided to amputate below the knee. There She was placed on the table, and immediately after the commencement of the inhalation of chloroform I injected twenty minims of the same solution of morphia (one-sixth of a grain) under the skin of the front of the abdomen. The stage of excitement was only faintly expressed, and on the cornea becoming insensitive to touch I removed the chloroformed towel from her face, and intimated to the surgeon that she was ready. was some delay in securing one of the branches of the posterior tibial artery, which had been cut short, high in the apex of the wound, and the operation lasted exactly half an hour, from the time when she was "ready" till she was lifted on to a stretcher and carried off to the ward. During the whole of that time she lay in a calm, peaceful sleep, and I, as administrator of chloroform, had nothing to do but test the sensitiveness of the cornea from time to time. Twice only did she show signs of returning to consciousness, when the re-application of the towel to the face for a few seconds sufficed to restore complete anæsthesia. The result in this case left nothing to be desired. The anæsthesia, once established under the co-operation of morphia and chloroform, was kept up for the space of half an hour by the inhalation, on two occasions only, of a few additional drops of chloroform, probably not amounting to half a drachm altogether. I have adopted the same procedure in every operation of any magnitude which I have performed during the past seven years, without any material variation, and invariably with a similar happy result. When Dr. Cutcliff's. lamentable death occurred in October, 1873, I succeeded him as lecturer on surgery, and as second surgeon to the Calcutta Medical College Hospital, and afterwards as Professor of Materia Medica, and more recently as Superintendent of the Vernacular Medical School and Mitford Hospital at Dacca, where nearly two hundred operations are performed under chloroform annually; I have continued to advocate, both by precept and example, the combined use of morphia and chloroform in the production and maintenance of surgical anesthesia. Dr. S. B. Partridge, who was my colleague in the Calcutta Medical College Hospital, seeing my results, adopted and practised my procedure till he left India in January, 1879, and I believe that, till quite recently at least, it had also become a part of the routine practice of the other surgeons who have been connected with that hospital. The advantages derived from the combination are first, the prolongation of the anesthetic effect of the chloroform, once it has been established; and secondly, the small quantity of chloroform required to keep it up afterwards. The first advantage is most conspicuous in operations about the mouth and face. The prolongation of the anæsthesia originally induced in this way is often so great as to enable me to perform operations of the first magnitude without being interrupted by the necessity of recommencing the inhalation of chloroform on account of the patient returning to consciousness in the middle of it. The benefit, both to the patient and surgeon, in these cases is too obvious to require mention. I will give two examples from my more recent experience. In March, 1878, I removed the right superior maxilla from a native woman, aged forty-five, with the assistance of Surgeon |