I. GENERAL CONSIDERATIONS UPON 
MAJOR ANESTHESIA. 
II. THREATENED DEATH DURING 
MAJOR ANESTHESIA. 
III. A BRIEF DIGRESSION UPON SHOCK.* 
BY 
ROBERT H. M. DAWBARN, M. D., 
PROFESSOR OF SURGERY AND OF SURGICAL ANATOMY, NEW YORK 
POLYCLINIC COLLEGE AND HOSPITAL. 
* A number of papers published in t’he April and June New York 
Polyclinic and the August, September and October Atlanta Medi- 
cal and Surgical Journal. 
DANBURY, CONN. 
DANBURY MEDICAL PRINTING COMPANY 
1897. I. GENERAL CONSIDERATIONS UPON 
MAJOR ANESTHESIA. 
II. THREATENED DEATH DURING 
MAJOR ANESTHESIA. 
III. A BRIEF DIGRESSION UPON SHOCK.* 
BY 
ROBERT H. M. DAWBARN, M. I)., 
PROFESSOR OF SURGERY AND OF SURGICAL ANATOMY, NEW YORK 
POLYCLINIC COLLEGE AND HOSPITAL. 
* A number of papers published in the April and June New York 
Polyclinic and the August, September and October Atlanta Medi- 
cal and Surgical Journal. 
DANBURY, CONN. 
DANBURY MEDICAL PRINTING COMPANY 
1897. I. GENERAL CONSIDERATIONS UPON 
HAJOR ANESTHESIA. 
II. THREATENED DEATH DURING MAJOR 
ANESTHESIA. 
III. A BRIEF DIGRESSION UPON SHOCK.* 
By Robert H. M. Dawbarn, H. D., 
Professor of Surgery and of Surgical Anatomy, New York 
Polyclinic College and Hospital. 
Which shall we use—ether or chloroform? 
There is no study less profitable than that of the 
relative death-percentages all over the world 
from chloroform vs. ether. It is absolutely wast- 
ed time. That von Nussbaum saw chloroform 
used forty thousand times without a death,f 
and that chloroform has been exhibited thirty- 
six thousand five hundred times in the Edin- 
burgh Infirmary with but one fatal result,\ would 
seem evidence that such danger from the use of 
this anesthetic as exists is largely due to the per- 
sonal equation; that is to inexperience on the 
part of the anesthetist, or to improper meth- 
ods of meeting the emergency. Whereas, in 
studying 12,000 cases operated upon in New 
* A number of papers published in the April and June New York 
Polyclinic and the August, September and October Atlanta 
Medical and Surgical Journal. 
+ \Vood’s Reference Handbook, Vol. I, p. i8q. 
\American Journal of Medical Sciences, November, 1888. 4 
York Hospital, Dr. Weir found ether-deaths in 
the proportion of one to each two thousand.* 
In New York, Philadelphia and Boston there 
is a curious distrust of chloroform not apparent 
in the rest of the world of surgery to the same 
degree, either abroad or in this country. 
The writer was one of a hundred or more 
auditors when that famous surgeon, Dr. Henry 
B. Sands, once told a story which it required a 
man of his eminence and his truthfulness to 
relate, concerning an experience of his in Ger- 
many. He was present during an operation by 
Dr. Schede in the Allgemeines Krankenhaus in 
Hamburg-Eppendorf, when Schede happened 
to remark that he had never in his life seen 
ether given; that he and all the famous men 
of his country relied solely upon chloroform. 
Dr. Sands thereupon agreed to enlighten his 
inexperience, and taking the anesthetist’s place 
gave ether to the next patient. It is painful 
to relate that this patient had the bad taste 
to die from the ether, thus casting discredit 
upon a most valuable drug. Dr. Sands said 
that he and Dr. Schede worked over the man 
with artificial respiration and other means for 
a long while, but failed to revive him. And 
I venture to say that Dr. Schede now has the 
same distrust and fear of ether as an anesthetic 
* Trans. Am. Siirg. AssnVol. VI, p. 544. 5 
which seems to prevail regarding- chloroform 
in the trinity of cities just named. 
If it be admitted that, taking averages the 
world over, more deaths on the table occur from 
chloroform than from ether, nevertheless were 
we to add those happening weeks and months 
later, due to ether-irritation of lungs or kidneys 
in persons already enfeebled in these organs, 
perhaps the percentages would be different. 
It is unquestionably true that more skill is 
needed to give chloroform safely than ether. 
Were the writer to need an operation upon 
himself he would choose ether, if subjected to 
an “emergency” anesthetist, but chloroform 
if that assistant were skilled and experienced. 
Even in the three cities just mentioned to- 
gether, however, certain conditions are recog- 
nized as justifying the use of chloroform as 
against ether. These are: 
1. The presence of severe pain. Chloroform 
is relatively safe in childbirth, even in the 
hands of inexperience.* The reason is, per- 
haps, that the suffering causes cerebral conges- 
tion to some degree, and with plenty of blood 
*H. C. Wood says (Therapeutics, 7th. edition, p. 150): “So far as 
I know, no death has yet occurred from chloroform during par- 
turition.” 
Wood’s Reference Handbook, Vol. 1, p. 195: “Chloroform has 
been used in natural labor many hundreds of thousands of times, 
yet but a single case of death is on record where it was administ- 
ered by a competent medical man, and in this instance there is 
lack of post-mortem confirmation.” 6 
in the brain chloroform is safer than otherwise. 
2. In childhood; at least, this is the teaching 
of Dr. Jacobi and numerous other children’s 
specialists. 
3. To control convulsions—uremic, epileptic, 
strychnic et al. Here ether would be too slow 
in taking effect. 
4. In cases where actual cautery must be 
used about the mouth, ether being inflammable. 
5. In certain diseases of the lungs, kidneys, 
stomach, brain. 
6. In military surgery, being less bulky, 
more rapid in action and cheaper. 
7. In hot climates (ether boils at 950 F., 
chloroform at 1420 F.) 
8. At night, if flame must be held near the 
patient. (But chloroform is not free from disad- 
vantage at night, being decomposed by the 
flame, and chlorine and other gaseous irritants 
set free. All surgeons have noticed the ten- 
dency to cough under such circumstances.) 
The Question of Mixtures.—This is one that 
remains unsettled, the widest divergence of 
views continuing. Dr. J. C. Reeve, already 
quoted as to relative mortality, says: “The 
chloroform committee of the Medico-Chirurgi- 
cal Society of London in 186.4 recommended, 
among others, a mixture of one part alcohol, 
two parts chloroform and three parts ether, by 7 
measure, known as the ‘A. C. E. mixture,’ which 
has probably been used more than any other. 
At Vienna a mixture of six parts of ether to 
one of chloroform has been used so much as to 
be known as the ‘Vienna mixture.’ It is stated 
that there have been eight thousand adminis- 
trations of it without a death. Billroth, of the 
same city, used a mixture of three parts of 
chloroform, one of ether, and one of alcohol.” 
Against such mixtures the argument has 
always been urged that a new chemical is not 
thus made, with a single rate of diffusion; and 
that while the rate of relative evaporation is 
doubtless in part modified by the mixture, the 
patient substantially gets first ether, then chlo- 
roform, then alcohol, in order of volatility. 
The writer agrees with the majority of surgeons 
in feeling that a gain in security is not made 
thereby. Straight drinks are safest—to speak 
after the manner of the world. 
Chloride of Methylene. (CH2 Cl2).—This is 
mentioned simply as standing as a type of 
drugs belonging more or less to the chloroform 
class—the halogen anesthetics. This short 
essay does not permit of a careful discussion 
of them. This particular one enjoys the in- 
dorsement of Sir Spencer Wells, who after 
considerable use of it, regards it as the best 
anesthetic. 8 
Nitrous Oxide. — The writer believes that 
laughing-gas will be considerably more used in 
the future, in general surgery, than in the 
past. Now that it is obtainable in liquid form 
in small steel canisters* of such a size that one 
may be slipped within a small handbag, an 
objection to its use has disappeared. A special 
closely fitting mask and a large thin rubber 
bag to hold the gas generated from the liquid, 
complete the outfit. 
Heretofore its exhibition has remained almost 
solely in the hands of dentists; but it would 
seem that there is a field here for young physi- 
cians to fill. The writer has many times em- 
ployed a certain dentist to give gas at the 
patient’s house, and on more than one occasion 
the operation has lasted, with satisfactory anes- 
thesia, fully three-quarters of an hour.f 
As every one knows, the color of the patient 
meanwhile is always ghastly in its lividity; but 
this seems not dangerous in realty. Differing 
* It is liquefied by about forty atmospheres. Since i860, or 
thereabouts, N2 O has been liquefied and shipped in large canis- 
ters all over the'world. But in general surgery at the patient’s 
residence, there has, as yet, been comparatively little use of the 
small, easily portable steel cylinders of the liq'uid. 
t Prof. R. Ogden Doremus informs the writer that many years 
ago at a lecture at Stein way Hall, N. Y., for the benefit of the 
widow of Dr. Horace Wells, Dr. J. Marion Sims stated that he 
(Sims) had performed an operation an hour and twenty minutes 
long under laughing-gas anesthesia. 9 
from ether or chloroform, should alarming- 
symptoms appear, removal of the inhaler is 
followed by prompt improvement—almost with 
the first breath of pure air inhaled. Of course 
some little skill is needed to keep the patient 
from waking repeatedly during an operation 
of some length, but it is certain that the ex- 
perience and the care need not be more than 
for the safe use of chloroform. It is a pleasure 
to see the absence of the initial choking and 
struggling and of subsequent anorexia and 
nausea with these patients; and certain ones 
who would refuse a needed operation, because 
of the ether or chloroform, will agree readily to 
take laughing-gas. 
Due largely to the investigations of Dr. Paul 
Bert, of Paris, as to exhibition of nitrous oxide 
with oxygen, we know that it has anesthetic 
qualities aside from merely depriving the 
patient of oxygen. And the addition of oxy- 
gen, by removing the lividity alluded to, seems 
desirable. Dr. W. W. Van Arsdale has recently 
shown that the best proportion would seem to 
be io per cent, of oxygen to 90 per cent, of the 
Ns O—with a tight face-mask, and pressure, as 
from a heavy book, upon the gas-bag. He also 
noted that with this addition of oxygen, men, 
and alcoholics of both sexes, do not so readily 10 
succumb to the anesthesia as do women, and 
non alcoholic subjects.* 
The kind of inhaler to be used for ether and 
for chloroform is a matter of no little import- 
ance. With chloroform the safest proportion 
is estimated at from 3 to 4 per cent, of it min- 
gled with the inspired air. Clover’s apparatus, 
permits of such accuracy, but is very expensive. 
In practice we find that Esmarch’s inhaler is safe 
and it is the one most used everywhere. (See 
figure ) This device permits of abundant ad- 
mixture of air. The chloroformshouldforsafety, 
be poured on from a drop-bottle, a few minims at 
a time. The improved Esmarch inhaler shown 
in the illustration allows instant change of the 
flannel or gauze or cotton- wadding cover, for each 
new patient—a decided gain in cleanliness. The 
cover is sure to be soiled to some extent whenever 
used, because (if for no other reason) of the oil or 
vaseline with which the patient’s face should be. 
smeared, to prevent a dermatitis due to the 
irritant chloroform-vapor. In use, the cover- 
ing material is laid upon the frame, over this 
* It would seem an obvious advantage and great convenience 
if the laughing-gas mingled with io per cent, of oxygen could be 
liquefied together and supplied from the same canister to the pa- 
tient. This is not feasible, however. Oxygen requires 3ooatmos- 
pheres (more than two tons to the square inch) plus the most 
intense cold to make it liquid, and would hardly be safe in a port- 
able canister. Laughing-gas needs but 40 atmospheres for lique- 
faction, as stated heretofore. 11 
the wire rim is snapped into place, and any 
excess of the covering" is trimmed away with 
scissors. 
As to ether-inhalers upon the market, their 
number is considerable. Perhaps, however, the 
Improved Chloroform Inhaler. 12 
familiar towel-and-newspaper cone of home 
manufacture is still the favorite with the bulk 
of the profession. It has at least the merit of 
cleanliness, for the same cone is seldom used 
twice. Still, with ether quoted at upwards of 
a dollar a pound, and the ordinary estimate 
being a pound for each hour of anesthesia, it is 
plain that the device is an expensive one. 
Allis’s inhaler has been used to an enormous 
extent, and need not be described. It also is 
wasteful of ether, and as it is rather bothersome 
to remove the old and replace by new the num- 
erous folds of bandage on which the ether is 
poured, too often we see these inhalers, though 
soiled by sputum and other ejecta, continued 
for some time in use upon successive patients. 
Chloroform drop-bottle. It is always safest to give the drug drop 
by drop in this way. The author’s ether inhaler. The upper'figure shows the cage removed and filled with gauze. 14 
The ether-inhaler figured herein (see figure) 
was devised by the writer some ten years ago, 
and has since been continually used at his clinic 
and in private practice. A few years ago Dr. 
F. H. Wiggin, gynecologist to the New York 
City Hospital, wrote a commendatory article 
upon it after using it for some time. It is made 
by F. A. Reichardt & Co. of 27 Barclay street, 
this city, to whom the author feels indebted for 
the ingenuity and painstaking care which have 
so improved upon the original suggestion. 
Its advantages are (a) economy, and (b) ease 
of cleansing, as well as (c) those benefits and 
added safety to the patient resulting from 
avoidance of saturation of all his tissues by a 
great excess of ether. The apparatus is upon 
the same principle as the well-known one of 
Clover, but is less complicated and less expen- 
sive. 
(a) As to economy, the thing will pay for 
itself, in saving of ether, after a very few long 
operations. It is literally true that only one- 
fourth to one-fifth as much ether is needed as 
with a home-made cone; indeed, hardly more 
of ether than one uses of chloroform in an 
equally long operation, provided a skilled anes- 
thetist is in charge. Also, it is simple and 
durable, and should last for years. 15 
(,b) The stout open cage of aluminum fitting 
within the solid outer frame receives a lit tie 
gauze, or absorbent cotton, or a handkerchief. 
On this the ether is poured. At the end of the 
operation the cage is removed, emptied, and held 
beneath the hot water faucet for a moment, 
when it is clean and ready for the next case. 
The face-piece of stout rubber of course is 
removable for washing, as is the air-bag. This 
latter is a light, thin rubber bag, of a capacity 
considerably greater than that of the lungs. 
The solid rubber face-piece is more durable and 
simpler than are the pneumatic ones seen on 
certain other inhalers, and fits the face quite 
closely enough. To avoid one more contrivance 
demanding cleansing, no device is used (as with 
the Clover and the Ormsby, for instance) for 
pouring in ether without removal from the 
face. In this inhaler, just as with the home- 
made cone, when more ether is needed the cone 
is removed long enough—a few seconds only— 
to receive it. 
(c) Under this heading the reader will 
observe that because of the air-bag attachment 
the ether is rebreathed again and again. This, 
of course, economizes ether, but what is more 
important, it saves surcharging the blood, and 
the lungs, kidneys and other viscera. The 
ether thus warmed is also, because of that 16 
warming-, less apt to cause an ether-pneumonia; 
continued evaporation of ether being very chill- 
ing, as everyone knows. Since much less ether 
is given, it follows that the danger of death 
from ether-narcosis is lessened. It is surprising 
to one accustomed to the home-made cone to 
see how quickly the patient recovers entire 
consciousness; and whereas by the former 
device the breath remains redolent of ether 
for nearly twenty-four hours, and for the same 
reason the anorexia is long continued, by the 
use of the inhaler we are discussing the elimina- 
tion is completed and the patient’s appetite has 
returned in much less time. 
Because of rebreathing the same air a COg 
anesthesia is superadded to that from the ether, 
and consequently the patient is almost as 
quickly anesthetized and with as little strug- 
gling as if from chloroform. To the writer 
this seems one of the distinct advantages of 
the Clover air-bag principle, and he would differ 
from those who consider the CO 2 an objection.* 
It is, of course, easy to observe the colour of 
the skin or mucous membranes, and if more 
oxygen is desired, to hold the cone less tightly 
to the face, permitting at any time an admix- 
ture of air. 
♦See in corroboration of this view several experiments quoted 
in Wood’s Therapeutics, 7th edition, p. 135, showing that a car- 
bonic acid anesthesia is a safe one. 17 
THREATENED DEATH DURING MAJOR 
ANESTHESIA. 
There are two surgical emergencies so appal- 
ling in their character, and so quickly fatal if 
not promptly met, that they may be said to 
transcend in importance all others. These are, 
anesthesia-narcosis threatening death, and un- 
expected haemorrhage upon the operating table. 
In each of these the safety of the patient 
demands that the surgeon shall have his knowl- 
edge at his finger-tips, and be ready instantly 
and almost automatically to do the right thing. 
The first of these is the topic under discussion 
in this paper; and no one will demur to the 
statement that it is the duty of every doctor to 
memorize the measures to meet this indication 
until they are as familiar to him — as much a 
part of himself—as is the alphabet. For no 
time will be left to him for debate when con- 
fronted by the actual fact. Every moment is 
then golden, and indecision equally with unwise 
choice may cost a life. 
Prevention is half the battle. If the sugges- 
tions under this heading are heeded, few indeed 
will be the actual cases encountered. 
The writer makes it an invariable rule, and 
has done so for many years, to precede every 
exhibition of either chloroform or ether by a 
PREVENTION. 18 
hypodermic injection of morphine sulphate 
guarded by atropine sulphate; in the adult from 
gr. y to gr. y, of the former, and from gr. 
to gr. of the latter; allowing, say, a quarter 
of an hour for it to take effect. Also as a rule, 
an ounce or more of whisky or brandy is given 
at the same time. 
There are several reasons for this course, bur 
one alone should suffice; namely, that all of 
these drugs are analgesics, and that consequent- 
ly much less of the anesthetic need be inhaled, 
and the danger of death is to just that extent 
lessened. 
Indeed,if any reason exists why neither chloro- 
form nor ether nor laughing-gas should be 
taken, a fairly comfortable operation is possible 
by free use of these means alone, as all surgeons 
know. 
Again; nearly 50# of all deaths from CH Cl3 
have occurred before complete anesthesia was 
accomplished; commonly within the first min- 
ute or two of its exhibition, and when only a 
very little had as yet been used.* Had the stage 
of excitement and of fright been prevented by a 
little morphine, atropine and whisky, with their 
calmative and steadying influence on the reflexes, 
this mortality would probably have been avoided. 
It will be noted that all three of the aids 
♦Wood’s Ref. Handbook, Anesthetics, Vol. I, p. 190. 19 
mentioned (morphine, atropine, alcohol) are 
heart-tonics when used in moderation, and tend 
also to diminish the likelihood of operative 
shock; and further, that atropine is one of our 
best vaso-motor stimulants. 
(For all the reasons mentioned in the last sen- 
tence the writer approves of the use of strych- 
nine sulphate, in small doses, for a few days 
prior to any severe operation. Perhaps, when 
shock is actually present, it is of more value 
than any one other drug; and if this be true, its 
use in prevention of shock would seem sensible.) 
Dr. H. C. Wood has demonstrated the value of 
strychnine when used by needle in treating anes- 
thesia-narcosis; and here again its use in preven- 
tion seems occasionally indicated. 
Although we approve of the use of alcohol 
prior to anesthesia, as just stated, because then 
less of the anesthetic will be needed, a clear 
distinction must here be drawn between this 
fact and its exhibition as a remedy where death 
is actually threatening from an excess of ether 
or chloroform. This distinction must not be 
forgotten. 
The writer has witnessed again and again 
instances of the accident under discussion, in 
which the operator and his assistants endea- 
voured by numerous hypodermic injections of 
whisky or brandy—narcotics—to revive a pa- 20 
tient suffering from an excess of another nar- 
cotic. Dr. H. C. Wood has used the strong lan- 
guage to characterize this procedure, that “it is 
little better than murder! ” To be sure, alco- 
hol is a heart-tonic, but we have other equaly 
swift heart-tonics which do not tend to deepen 
the deadly narcosis. 
Rather recently the cocainization of the nares 
and larynx by spray, just prior to anesthe a, 
has been considerably used. It certainly rend- 
ers the inhalation less unpleasant, and in the 
case of chloroform, may quite conceivably pre- 
vent danger. We know that very early in a 
chloroform-anesthesia a certain danger some- 
times exists that this irritant drug may cause a 
reflex action whereby the pneumogastric nerve 
stops the heart—and it may not wake up again.* 
Quite a little work has lately been done by 
various surgeons regarding anesthesia by ether 
mixed with oxygen. It would seem that the 
idea may be of value in helping to avoid nar- 
cosis in excess. It has not, however, come into 
general use. It is a revival, in principle at leas', 
of the “ozonic ether” of Dr. Richardson, who 
advised this for anesthesia before the Brit. 
Med. Association in 1865. He produced this 
compound by agitating a 30 volume solution of 
* The suggestions in the opening paragraphs under prevention 
form an effective safeguard against this danger. 21 
peroxide of hydrogen with anhydrous ether, 
and adding 5% of alcohol. 
Under the heading of Prevention we must 
remember not to begin cutting until the patient 
is “under to the surgical degree.” Buxton, Reeve 
and other writers upon anesthetics have pointed 
out the surprisingly large proportion of cases in 
which incomplete anesthesia, by lowering vital 
functions, has permitted fatal shock to result 
from trivial though painful operations, such 
as strabismus, tooth-extracting, circumcision, 
etc. Indeed, it is estimated that 40% of chloro- 
form deaths have been in cases of such a trifl- 
ing nature, and there seems no other adequate 
explanation of so large a proportion in com- 
parison with deaths during major operations. 
Again, in reference to chloroform, it is prob- 
ably safer to tip the table so as to have the 
head a trifle lower than the feet; this as a meas- 
ure of precaution, and for reasons to be more 
fully discussed later, under the heading of treat- 
ment. But the patient may be permitted to 
choose whether to lie upon the back or the side 
during the inhalation. 
Many are the recorded cases of death from 
chloroform exhibited in the sitting or the half- 
reclining postures; which invite anaemia of the 
vital centres. Dr. H. A. Hare has recently 
pointed out the fact that chloroform kills really 22 
by vaso-motor paralysis, whereby “the man is 
suddenly bled into his own veins and capilla- 
ries, as effectively as if into a bowl;” and in- 
stant anaemia of brain and heart results.* 
It is the part of wisdom to insist upon twenty- 
four hours, at least, in hospital (preferably) and 
in bed, before anesthesia. Bodily rest, and time 
in which the mind may grow accustomed to the 
new environment, are of obvious value. 
A rule, which should be inflexible, requires 
the cautious surgeon to make a physical exami- 
nation of his patient’s various organs shortly 
before operating. Notably, the kidneys must 
not be neglected. Presence of albumen should 
interdict the use of ether. It is believed that 
those with impaired renal function are more 
apt than others to succumb to the narcosis. 
Certain surgeons, and especially Dr.. R. F. 
Weir, consider chloroform at least equally an 
irritant to the kidneys. Here we surely have 
an indication for the employment of nitrous 
oxide anesthesia. 
If any faintness be noted due to the prepara- 
tory fasting which we must enforce, nothing 
♦Under prevention Dr. R. C. Kemp’s recent ingenious suggestion 
deserves mention: this is to use rectal flushing by hot salt-water, 
with his double current tube, during the whole operation; there- 
by maintaining filled blood-vessels, and inducing a stronger 
heart-action. 
This would also help to prevent shock. 23 
but benefit can result from a nutrient enema 
an hour or so before the operation. This may 
also contain whisky or brandy if desired, and is 
a good way in which to exhibit the alcohol 
which we have advised for routine use, in prep- 
aration for anesthesia. 
Perhaps it is a waste of words to mention 
that the bowels and bladder must have been re- 
cently evacuated; and that it is a duty of the 
anesthetist to see that corsets and all tight cloth- 
ing are removed, also artificial teeth. Let 
the inhalation be most gradually commenced; 
it is always a mistake to force a sudden uncon- 
sciousness. With a nervous patient grant 
permission, if desired, to hold the inhaler him- 
self for a time; and meanwhile a few cheery 
words will often allay fright, which is dan- 
gerous. 
(The beginner should be taught that the pal- 
pebral reflex is practically as good a guide as 
the conjunctival. There is no justification for 
the subsequent sore eyes due to frequent rub- 
bing of the cornea or conjunctiva, so often to 
be noted.) 
The writer considers stertorous respiration 
—which is due to paralysis of the velum pendu- 
lum palati, from deep anesthesia—a sufficient 
indication, as a rule though not invariably, for 
permitting inhalation of a larger proportion of 24 
air. To keep the patient snoring heavily through 
a long operation, is to subject him to a nearer 
approach to a lethal dose than the writer deems 
wise, and also to invite shock. 
The colour of the blood is to be noted by the 
surgeon, and if it seems a shade too dark the 
anesthetist should be warned. The pupils too 
are a fair though not quite reliable guide. 
Should they suddenly dilate it means instant 
peril. 
In using a tampon-canula after tracheotomy, 
for exhibition of the anesthetic, let it be re- 
membered that here especial care is needed, as 
it is unpleasantly easy to exclude all oxygen, 
and to have an asphyxiated patient in conse- 
quence. 
Perhaps a word may not be amiss regarding 
anesthesia by the rectum. This is practicable by 
ether-vapour, the bottle being placed in hot 
water and the vapour conveyed by a rubber tube 
upwards into the rectum.* The advantage is, 
avoidance of the excitement, coughing and semi- 
strangling sometimes observed while begin- 
ning the ordinary method; also it is of use 
where actual cautery about the mouth or nose 
is contemplated. Disadvantages are, occasional 
causation of a severe proctitis; and also in 
* Upwards, to avoid possibility of pouring fluid ether into the 
bowel. 25 
event of excessive narcosis, the patient, al- 
though the supply be stopped, must absorb the 
large amount of ether-vapour filling his rectum 
and colon before he can begin to revive. 
When a child is to be anesthetized, chloro- 
form being the intended means, it is an excel- 
lent plan to avoid all excitement and fright by 
giving it during sleep. With a moderate 
amount of skill this is not a difficult feat, the 
child gently sliding from the natural into the 
artificial slumber. With adult patients, how- 
ever, while possible of accomplishment in occa- 
sional instances, this is not generally practic- 
able. 
And finally, under prevention still, we should 
allude to a plan, little advocated in print, but 
which has only to be witnessed once in order to 
commend itself. Namely, as a measure of pre- 
caution (in a patient of feeble vitality about to 
be subjected to operation), maintaining a re- 
serve-guard of pure blood, by accumulating it in 
one or more of the extremities; to be released, 
in event of need, during narcosis. 
For other purposes this temporary seques- 
tration of blood has been employed by a num- 
ber of physicians; but Dr. David Webster was 
first to suggest it for this indication, in 1887, in 
a letter to the N. V. Med. Journal; and shortly 26 
thereafter the writer was the first actually so 
to «use it. 
The technique is simple. The thigh, for ex- 
ample, is corded at the groin; at first slightly, 
for a few minutes, permitting it to swell visibly 
from accumulated blood, and then tightly 
enough to obstruct all flow in either direction. 
This is done with a rubber bandage. The limb 
is now kept wrapped in a blanket, with warm 
bottles or bricks about it. In case of dangerous 
narcosis, release the band, elevate the limb, 
and you pour great quantities of pure blood 
into the body surcharged with ether or chloro- 
form. The good results are striking and super- 
vene promptly, the patient quickly becoming 
conscious. 
It is obvious that in an operation which will 
probably occupy much time this plan might not 
be wise; but for half an hoyr or less the blood 
can be so retained without danger to the limb.* 
Last, under the heading of prevention, but 
not least, we should mention the advisability of 
placing on guard at the head of the operating 
table only an experienced man. In almost 
every hospital this wotk is relegated to the 
*For fuller details, and a study of the other purposes for 
which, prior to an operation, this plan may be employed, the 
reader is referred to the writer’s article upon Anesthesia Nar- 
cosis, in Vol. IX of Wood’s Reference Handbook, and in which is 
quoted in full an essay by Dr. Charles McBurney upon this point. 27 
junior assistant—in the opinion of the writer, a 
grave mistake. If that junior has had instead 
some months during which opportunity is given 
him to observe the proper methods and learn 
to avoid the perils of anesthesia, then as senior 
assistant he becomes a comparatively safe man 
to trust. 
TREATMENT. 
Dr. H. C. Wood in his study of this subject 
for the Berlin Congress teaches that the treat- 
ment should be practically identical whether 
for ether- or for chloroform-narcosis; and this 
is the doctrine we will follow. 
Under this heading, in order to be systema- 
tic and orderly, the better to aid memorizing, 
let us discuss: 
1. Respiratory trouble, (a) Obstruction to the 
entrance of air. (b) Failure of the respiratory 
center. 
2. Heart trouble. 
Of course, too, we may have to treat both i 
and 2 at the same time. 
Under (a) of the first head we have to deal 
with dropping- of the tongue back upon the 
larynx, causing asphyxia; and also with obstruc- 
tion from thick, ropy mucus, or blood, or pus, 
or vomited food inhaled. 
I. RESPIRATORY TROUBLE. 28 
Trouble with the tongue is best met by Ben- 
jamin Howard’s method of raising the epiglot- 
tis. This can rarely be done effectively by use 
of tongue-forceps (though these may of course 
be tried), and if such traction fail to relieve the 
dyspnoea, the Howard position should be 
adopted, by over-extending the head. Turn it as 
sharply backward as possible, at the same time 
closing his mouth. You have now an almost 
straight passage from the nostrils to the lar- 
ynx; and the tense genio- and mylo-hyoid and 
digastric muscles, and in turn the hyo-epiglottic 
ligaments, force the epiglottis to stand upright 
and to ward off the tongue from falling back 
upon the laryngeal entrance. 
Instead of this plan, and somewhat less effect- 
ual, is the method of forcing the lower jaw 
forward by the thumbs of the anesthetizer 
placed behind the rami. Thereby again the 
above-named muscles and ligaments are made 
somewhat tense, also the genio-hyo-glossi mus- 
cles, and in turn the glossi-epiglottic attach- 
ments; and the epiglottis is thus lifted. 
Should our difficulty be with foreign matter 
in the pharynx and mouth, here we use sponges 
on long holders. Often the gag meanwhile is 
necessary. Vomiting implies insufficient anes- 
thesia, and a tendency to vomit should be met 29 
promptly and prevented by pushing the anes- 
thetic, until this reflex is subdued. 
One need hardly remark that the operator 
imperils his patient’s life who does not insist 
upon five or six hours’ prior abstinence from 
food. But occasionally a patient disobeys the 
injunction and does not confess. Then too, we 
occasionally, if rarely, meet a case where from 
previous muscular atony of the stomach, or 
from obstruction at the pylorus, or from ner- 
vous gastric inactivity due to fear of the com- 
ing event, food eaten even twelve and twenty- 
four hours earlier is vomited during the opera- 
tion. # 
Should a portion of this be inhaled, it will 
probably catch in the rima glottidis. In that 
case, inverting and shaking the patient must 
promptly be tried; and if imminent suffocation 
compels, the operation of laryngotomy must be 
done, which takes less time than the reading 
of this sentence. It is a single, transverse 
thrust through skin and crico thyroid mem- 
brane, entering the air-space well below the 
chink of the glottis. 
Under (b) we may try: 
i. Laborde’s method of rhythmic traction 
upon the tongue, quite vigorously, and about 
as frequently as the normal respiratory act. 30 
2. Dr. W. Gill Wylie’s plan, which is to 
seize a handful of the belly-wall, about the 
region of the navel, and to lift it sharply for- 
ward, away from the spinal column. At once 
the patient gasps, from reflex stimulation. This 
is repeated again and again until normal respi- 
ration is established. 
3. Stretching the sphincter ani vigourously 
with the thumbs. 
4. Ice slipped into the rectum, or placed 
against the nape of the neck. 
5. Slapping the chest and abdomen with 
towels wet in ice-water. 
If the patient be “under to the surgical de- 
gree” it is plain that such methods as the fore- 
going, dependent as they are for success upon 
reflex stimulation, cannot be really effective 
until a portion of the anesthetic is eliminated 
from the blood and the reflexes return. Hence 
the use of: 
6 Large hot saline injections, by rectum or 
a vein; acting more by direct effect of hotter 
blood upon the respiratory center than by reflex 
action. 
7. Various methods of artificial respiration, 
such as Sylvester’s, Hall’s, Schultze’s (with lit- 
tle children); and several more. Those just 
named are too well known to need description. 
We may say a word, however, as to the tech- 31 
nique of certain others. Koenig’s plan is inter- 
mittent pressure with both hands about the 
chest, one of the thumbs being placed in a 
space over the heart (differing simply in this 
latter respect from von Nussbaum’s method) 
between the apex-beat and the sternum. And 
Maas’ modification of Koenig’s, is one whereby 
the pressure aforesaid is made very rapidly— 
one hundred and twenty times a minute—in- 
stead of at the ordinary respiratory rate of speed. 
All of these methods would seem to act 
mainly by frequent expulsion of narcotized air, 
and admission of fresh; though Koenig and 
Maas claim for the thumb in one of the prse- 
cordial spaces a mechanical stimulant or irri- 
tant effect upon the heart, as well. 
8. Insertion of a soft catheter down the 
larynx and trachea, and use of the operator’s 
lungs to replace narcotized air by fresh. 
9. The bellows-method: A special and in- 
genious mechanism for removing exhausted or 
poisoned air, and replacing it at each stroke by 
an equal bulk of pure atmospheric air. 
10. Inhalation of oxygen, while efforts at 
respiration are being artificially maintained. 
Every well-equipped operating-room should be 
supplied with a canister of oxygen, against such 
an emergency. 
11. Electricity. (See p. 46 of this pamphlet.) 32 
12. Drugs. Of these, atropine and strych- 
nine, both by needle, are our chief reliance. 
Both have the value, beside being active res- 
piratory stimulants, of being also vaso-motor 
tonics. 
We now come to the study of the cases in 
which the leading- or the sole factor is heart 
failure; the respiration meanwhile continuing 
with a fair degree of regularity and effective- 
ness. Such instances are more often seen in 
chloroform- than in ether-narcosis. Sundry 
chloroform commissions have agreed in report- 
ing that dogs die as a rule by respiratory fail- 
ure, under chloroform. But while this is pos- 
sible also in the case of human beings, surgeons 
know that, with the latter, more frequently the 
heart fails first. Therefore, a good anesthetist, 
though watching the breathing, never removes his 
finger from the patient's pulse while exhibiting 
chloroform. With ether this is hardly so neces- 
sary, the respiration being then the danger- 
signal. 
i. Inversion of the Patient.—This, the plan of 
Nelaton, * should be regarded as our first 
II. HEART TROUBLE. 
* The story so current, of Nelaton and the mice, is incorrect. It 
has this basis of fact, however, that Nelaton Junior, when a child, 
having as he supposed killed some mice with chloroform, was 
directed by his famous father to suspend one by the tail; where- 
upon it recovered. Thus Nelaton applied for his boy’s instruc- 
tion, a lesson from his own experience in surgery. It will be 33 
choice when the heart is mainly at fault. No 
one could read without conviction upon this 
point the graphic account* of a patient upon 
whom, when threatened with death from chloro- 
form, Nelaton practiced inversion three several 
times with final success. The first time she 
remained inanimate during fifteen to twenty 
minutes, and at length Dr. Sims believed her 
dead. When the pulse finally began to be 
noticeable and she was deemed safe, she was 
changed from the vertical to the horizontal 
posture. Instantly all signs of life ceased. 
Again was the patient promptly inverted, and 
after an apparently even more hopeless fight 
than before the heart resumed work. Once 
more the recumbent posture; again, seemingly, 
dpath; again immediate inversion. This third 
time Sims thought her case to be surely hopeless. 
But not so! And when the heart-beats were at 
length felt, no one dared to let her lie down 
until she was both wide awake and kicking 
vigourously. 
Dr Sims remarks that recovery after one in- 
version might not be conclusive proof; but 
that the three collapses successfully met by 
seen that this reverses the story as usually told. It is here given 
upon authority of the Junior Dr. Nelaton. who says that he subse- 
quently tried this experiment upon mice ‘'forty or fifty timts or 
more, and always with the same unvarying result.” (Dr. J. 
Marion Sims, "The Story of My Life,” pp. 324-325.) 
* Dr. J. Marion Sims, ibid, pp. 321-324. 34 
three inversions, in this lady’s case, were to him 
utterly convincing as to the extreme value of 
Nelaton’s plan—to whose coolness in this emer- 
gency he also pays high compliment. 
(It is to be regretted that the lack of knowl- 
edge in those early days as to the proper tech- 
nique of chloroform-exhibition, and especially 
as to the modes of prevention of such peril as 
that described above, should have induced Sims 
to throw the weight of his influence in America 
against this anesthetic.) 
It would be hard to exaggerate the practical 
value of this plan, although the accuracy of the 
physiological explanation usually given by way 
of accounting for its effectiveness may be ques- 
tioned. Thus, we commonly read that the inver- 
sion causes blood to be poured by gravity from 
the lowermost parts of the person into the 
anaemic brain, which is thus stimulated to send 
forth more vigourous nerve-power to the failing 
heart. To the writer it seems plain that this is 
only in part the true explanation, and that, in 
fact, it can only apply to such blood as may be 
found in the neck and upper part of the chest. 
In only one way can blood from any point be- 
tween the heart and the feet reach the brain, if 
the patient is inverted; i. e., by being pumped 
through the heart. Certainly it can not by 
gravity alone. And since we know that me- 35 
chanical distention of the chambers of the heart 
by the circulating fluid is a most important 
factor in exciting cardiac contraction, the proper 
explanation is not far to seek. 
Probably no other operator has relied more 
fully upon this one method than has Dr. Chisolm 
of Baltimore; and yet although his extensive 
record of operations under chloroform (more 
than ten thousand without a death) makes his 
opinion deserving of respect, we think there 
are few who will, with him, stick to inver- 
sion alone, and refuse to use artificial respira- 
tion—in order to hasten the exit of the narco- 
tized air—and other valuable aids to resuscita- 
tion, in addition to Nelaton’s plan. Nelaton 
himself used artificial respiration plus inversion. 
The writer would here urge the general use 
of thefollowingmethod, which has several times 
been used successfully in his clinic, and in the 
employment of which his assistants are trained: 
BEST METHOD. 
Upon the appearance of heart-failure dur- 
ing the anesthesia, the patient is slid down the 
table until his legs drop beyond its lower end, 
thus making a right-angle with the thighs. The 
table isnow inverted;it is turned head downward. 
Consequently the patient is instantly in N£la- 
ton’s position,and his arms drop loosely on either 
side of his head. One assistant, only, is needed 36 
to hold the patient in place, and this is done by 
clasping the ankles, the legs giving an abun- 
dantly long leverage for the maintenance of 
the right-angle just mentioned. 
Now, the operator, facing his inverted pa- 
tient, seizes the lower part of the chest with 
both hands and compresses and relaxes alter- 
nately (method of von Nussbaum); his left 
thumb is in the intercostal space which seems 
most nearly over the heart (Koenig); and the 
acts of compression aforesaid are very rapidly 
repeated—as much so as possible (Maas); 
thereby the more quickly pumping out poisoned 
air and pumping in pure air. In addition, it 
will be noted that following each such empty- 
ing of the lungs by the surgeon, the Ndlaton 
posture (by dragging on the pectoral muscles, 
through the weight of the arms hanging by the 
sides of the patient’s head) causes a mechanical 
inspiratory act after Sylvester’s principle. So 
that at one and the same time, by the writer’s 
simple suggestion, we can carry into effect the 
various treatments recommended by all five 
surgeons named. 
This fact need not of course preclude the use 
of yet additional plans, if thought best, at the 
hands of assistants. 
The method of Hill (abdominal compression, 
the patient lying horizontally upon the table 37 
meanwhile) which forces blood toward the 
heart, while obviously of some value in heart- 
failure is certainly less e fficient for such purpose 
than gravity, by Nelaton’s position. The same 
is true of tightly bandaging the lower extrem- 
ities. 
2. Heat.—It cannot be questioned that among 
methods of exciting a narcotized heart to resume 
work one of the most efficient is heat.* A quart 
or more of water (normal salt-solution preferred) 
as hot as the hand can bear, poured through a 
funnel, or by irrigator, into the rectum while the 
patient is inverted as just advised, is standard 
treatment. (The average capacity of the large 
gut, colon and rectum together, is nine pints). 
Of course, if coffee is at hand, this, or other 
non-alcoholic stimulants, may be added to such 
enema. 
The patient’s body and limbs should not be 
left uncovered to be chilled, but should be 
wrapped in warm blankets. This po nt s im- 
portant, and too often neglected. 
Moist heat applied over the heart is of much 
value. The late Dr. Sands, of New York, used 
it repeatedly, to the writer’s knowledge, who 
has seen not only this gentleman but several 
♦The writer places it only second in value to posture, 
and thinks it should always be used as soon as the patient is in- 
verted. 38 
others of thebestknown surgeons of New York 
cause a blister several inches square on the 
prsecordium by application of steaming hot 
cloths during dangerous anesthesia-narcosis. 
Dr. Charles McBurney said some years ago 
in a letter to the writer: “When the heart 
flags seriously in ether and chloroform-narcosis 
I regard very hot applications directly over the 
heart as of decided value as a means of stimu- 
lating that organ to renewed activity. * * * 
I like the idea of your intravascular hot saline 
injections very much, and shall use it at the 
first opportunity.” 
The latter sentence has reference to a plan 
devised by the writer, whereby heat may with 
infinitely more directness and efficiency be 
brought to bear on the heart. This is to introduce 
hot salt-zvater directly into the blood-currcnt, and 
thereby to stimulate both the heart and the 
respiratory centre in the medulla.* 
This is so self-evidently a useful proposition 
as hardly to need argument in its defence. (See 
article upon “Anesthesia Narcosis” in Vol. ix, 
Wood's Reference Handbook, in which tne writer 
first suggested it). 
If, as is generally admitted, heat applied over 
the heart can stimulate that viscus—whether 
* The hot enema, advised on a previous page, acts similarly, of 
course; being in part absorbed from the bowels by the vessels; 
but in an ugly case, more speedy heart-stimulation than this is 
called for, additionally. 39 
directly, by extension through the chest-wall 
until felt by the apex-beat, or reflexly—how 
much more efficient must be that stimulation 
when that heat is brought directly into the heart- 
chambers, in the blood! The method has addi- 
tional value as a heart-stimulant by increasing 
the bulk of circulating fluid, and thus accom- 
plishing in a different way what N61aton’s pos- 
ture does. 
Four points have here to be considered: (a) 
the place of entrance, (b) the solution for injec- 
tion, (c) the proper temperature of that solution, 
(d) the proper amount. 
{a). In most cases, perhaps, a vein or an 
artery in the operation-wound will offer almost 
instant entrance to the canula; if not, it is the 
work of but a few moments to expose any 
superficial vein, for instance, the median basilic. 
(b). The fluid used should be the “normal* 
salt-solution,” which is six-tenths of a part of 
common table-salt per hundred; roughly, a 
heaped teaspoonful to the quart, boiled and 
filtered. At the present writing this is always 
kept at hand during severe operations by 
* Normal in the sense of corresponding with the proportion of Na 
Cl in the blood; and not with the chemical use of the term normal. 
Let it not be forgotten that plain water (devoid of Na Cl) thrown 
into the blood in any considerable amount is promptly fatal by 
disintegrating the red discs. The writer has witnessed this re- 
sult, upon the dog. 40 
most surgeons, for another purpose; namely, 
to prevent shock when this is feared, by using 
intravenous saline infusion while the patient is 
still on the operating table. 
DIGRESSION UPON SHOCK. 
As a brief digression, the writer begs to re- 
mark that since the autumn of 1891, this plan of 
prevention of shock has been in use at his 
clinic, as a consequence of some months of 
experimental work upon dogs, with hot saline 
vascular infusion after bleeding; testing intra- 
arterial pressures, at differing temperatures of 
the injected fluid, with the kymog'raph and the 
mercurial manometer, in the Columbia College 
physiological laboratory during the winter and 
spring of ’90—’91. So far as known, other sur- 
geons did not until later adopt this plan against 
shock.* In evidence is submitted a brief quota- 
tion from the writer’s article in the N. Y. Med. 
Record, Jan. 2nd, 1892. “Whoever has seen cases 
of cardiac failure upon the operating table, 
whether from anesthetics or from other causes, 
knows that surgeons rely much for resuscitation 
* A careful stf*dy of the Index Medicus and the N. Y. Acad, of 
Med. library justify this statement. 
Dr. F. Lange did, however, in 1888, advocate water by rectum to 
prevent shock, where a very bloody operation was anticipated; 
and Drs. Weir, Tiffany and others approved.—(Trans. Am. Surg. 
4ss’n., Vol. VI, p. 540 et seq.) 41 
upon the application of almost (or quite) scalding 
hot, wet cloths over the heart. As in many such 
instances the patient is devoid of reflexes, being 
completely anesthetized, I must believe that 
the undoubted stimulating effect of these appli- 
cations is in such instances due to the direct ex- 
tension of heat until felt by the cardiac ganglia. 
“Whoever has noted the vigour with which 
unstriped muscle, everywhere, reacts to the use 
of heat—-for example, the much stronger and 
decidedly more permanent uterine contractions 
which result from hot post-partal injections, as 
opposed to cold ones—must believe it probable 
that such unstriped muscle, forming as it does 
a most important tunic of the blood-vessels, 
would be greatly aided by hot saline infusion 
in regaining its lost tone. Perhaps, too, the 
central sympathetic centres would feel and 
respond to this stimulus. 
“Now, since a more vigourous cardiac action, 
accompanied by a somewhat restored vascular 
tone, would go far toward recovery, both from 
haemorrhage and its attendant shock, I have 
felt that the experiment was well worth trying.” 
Again, a quotation from the writer’s article in 
the Med. Record of Nov. 12th, 1892: “And why 
would it not be well, at the end of any and every 
operation grave enough to make shock a prob- 
able result (though, because of the ether, not yet 42 
at hand) to inject subcutaneously a quart or two 
of hot salt-water? It would be painless, the 
patient not yet being out of anesthesia. It 
would certainly be harmless. And I believe 
it would do much to prevent, by maintaining 
filled blood-vessels, otherwise fatal shock from 
developing. It seems not improbable that we shall 
ultimately see this done as a matter of routine, 
after all severe operations." At that date the 
writer had tried the method in but very few 
instances to prevent shock, using a pint or more 
within the vessel, and a pint or more in the cellu- 
lar tissues; and of course could not speak, as all 
can to-day, with absolute certainty as to its value. 
Where the gravity of the operation, or severe 
loss of blood, make shock a probability, let the 
surgeon use the “ounce of prevention” by 
striking first. If he waits to treat shock until 
it has already struck its deadly blow at his 
patient’s vitality, experience teaches that very 
likely no means at his command can then save 
the victim. 
The writer discusses the matter here and now, 
both by way of further explanation as to why the 
hot saline infusion is of such value (against both 
shock and narcosis), and because it explains why 
the operator should always have hot salt-water 
at hand, for either indication. 43 
ANESTHESIA HEART-FAILURE: CONTINUED. 
(e). The proper temperature for the injec- 
tion fluid is as hot as tJie hand can bear (both 
for treating narcosis and for prevention of shock; 
upon which point see the writer’s experiments, 
Record, Jan. 2d, ’92, quoted). This will be about 
118° to 1200 Fahr.* Of course the temperature at 
the heart, when the great bulk of blood has diluted 
the slowly entering fluid, will be much lower 
than this. There need be no fear of injuring 
the blood or other tissue by such heat. Very 
many times, (against shock mostly, of course), 
the writer has now used it, as hot as the hand 
could tolerate, and never with cause for subse- 
quent regret. 
• (d). The proper amount to be injected 
against heart-failure from anesthesia may be set 
down as at least one pint; a quart if the gravity 
of the symptoms does not abate. It must for 
this indication be started promptly—the pa- 
tient being in Ndlaton’s position meanwhile— 
but we must avoid excessive speed of flow. 
Take five minutes at least, for a pint; and 
stop as soon as distinct improvement in the pulse 
can be noted. (But to prevent shock where there 
has been severe bleeding, the writer never, in the 
* This fact has very recently been re-verified by Dr. R. C. Kemp, 
also in the Columbia laboratory; showing- that 118-120° F. best 
stimulates the heart. 44 
adult, uses less than a quart, intravenously, and 
often three pints or more, according to effect; and 
occasionally has to repeat this within a few 
hours; and in ugly cases, perhaps yet again. 
But almost equally efficient in prevention and 
treatment of shock is the long-continued hot 
salt-water enema * post operationenv, the foot of 
the bed being elevated meanwhile.) 
3. Cold.—Although not so efficient as heat, 
the application of a piece of ice over the heart, 
or slapping the praecordium with a towel wet in 
ice-water, will sometimes reflexly excite more 
vigourous contractions. It will be useless if the 
patient is under anesthesia “to the surgical de- 
gree,” for most of the reflexes are then abol- 
ished. 
4. Use of Drugs.—Our fountain syringe and 
canula are still in place—the latter tied within 
a vein. Either mingled with the hot salt- 
water, or preceding it, or following it, we may 
use properly diluted aqua ammonice, a remedy 
of unquestionable value. The latter with 
strychnine and digitalis comprise all the drugs 
recommended as of real use in this condition 
by Dr. H. C. Wood,in his Berlin report in 1890; 
who, however, did not experiment with stro- 
* This is best maintained at an even temperature, and without 
soiling the bed, by use of Dr. Kemp’s double-current rectal tube. 
(Reynders & Co., N. Y.) 45 
phanthus and many other heart-tonics. He 
says: “From fifteen to twenty-five minims of 
the aqua ammonise fortior, diluted with four 
times its bulk of water,should be thrown directly 
into a vein of the arm, and repeated in fifteen 
minutes if necessary.” 
The only hypodermic abscess for which the 
writer has ever been personally responsible was 
caused by an injection of aqua ammonise—and 
not the fortior—in a case of extreme opium 
narcosis with a failing heart; not injected within 
a vein, as it should have been, but into the sub- 
cutaneous connective tissue of the thigh. A 
slough more than an inch across resulted. The 
same drug may be exhibited by inhalation, with 
distinct caiition,as it is capable of causing violent 
local inflammation when used in excess. 
Regarding amyl nitrite, recommended by Bur- 
rall and others, Wood found it inefficient on 
dogs. Paralyzing as it does unstriped muscle 
everywhere, and consequently completely dilat- 
ing the blood-vessels, it must inevitably dimin- 
ish the resistance, caused by vascular tone, 
against which the heart has to work in pump- 
ing blood; and is hence an indirect heart-stimu- 
lant. If that tone be lost from complete 
narcosis, then it is plain that in such cases, at 
such time, this drug would be almost useless, 
since its direct stimulant effect on the heart is 46 
but slight. Now, as Dr. Hare points out,* para- 
lyzingand dilating the blood-vessels is just how 
chloroform kills. So that.amyl nitrite may be 
said to do more harm than good. 
Strychnine has already been discussed. Both 
as a heart and vascular tonic and as a respiratory 
stimulant it is of great value. 
Regarding digitalis, the testimony is equally 
strong so far as the heart and vessels are con- 
cerned. The writer carries regularly to his op- 
erations a solution of strychnine sulphate in 
equal parts of the tinctures of digitalis and stro- 
phanthus, and has repeatedly used this combi- 
nation by hypodermic needle with benefit. 
Strophanthus alone he has not employed. 
However, since it is more rapid in action than 
is digitalis, and stimulates the heart vigor- 
ously and very much like digitalis, it would 
seem obviously indicated. 
5. Electricity in the treatment of anesthesia- 
narcosis is mentioned rather with disapproval 
by most recent writers. Although the poles 
are applied to neck and epigastrium, to stimu- 
late the phrenics, the current would seem as 
likely to stimulate the pneumogastrics and thus 
help to stop the heart. The writer has not per- 
sonally been convinced that it does any good in 
these cases. 
* See pp. 21-22 of this pamphlet. 47 
Two remaining devices the writer has never 
seen used; but cannot doubt that they may be 
of value in absolutely desperate cases. This 
has been repeatedly demonstrated on the lower 
animals. One of these is— 
[ echanical stimulation of the heart by 
a long, slender needle passed through the 
anterior chest-wall (D. W. Buxton).* 
7. The other, introduction of a finger 
through a cut in the praecordium, thus permit- 
ting intermittent pressure on the heart through 
its uncut pericardium; to be repeated some 
twenty times, at the rate of seventy or eighty 
times per minute. It is not necessary to empty 
the heart thereby; a slight pressure will drive 
on some blood. (G. Rowell).f 
In conclusion, it is perhaps needless to say 
that surgeons employ not one alone but as many 
as are deemed wise, at once, from this list of 
weapons against an enemy that comes unex- 
pectedly, and kills quickly if at all. The writer 
has endeavoured to indicate which methods 
among all of these are most to be relied upon, 
so far as his personal experience enables him to 
judge. 
* Anesthetics, 2nd edition, 1892, p. 122. 
+ Brit. Med. Jotir.. Oct. 29th, 1892.