ANESTHESIA THE MACMILLAN COMPANY 
NEW YORK • BOSTON • CHICAGO • DALLAS 
ATLANTA • SAN FRANCISCO 
MACMILLAN & CO., Limited/ 
LONDON • BOMBAY • CALCUTTA 
MELBOURNE 
THE MACMILLAN CO. OF CANADA, Ltd. 
TORONTO ANESTHESIA 
BY 
JAMES TAYLOE GWATHMEY/M.D. 
FIRST PRESIDENT OF AMERICAN ASSOCIATION OF ANESTHETISTS, ANESTHETIST TO THE NEW YORK SKIN 
AND CANCER, COLUMBIA, AND PEOPLES HOSPITALS, FELLOW AMERICAN MEDICAL 
ASSOCIATION AND THE NEW YORK ACADEMY OF MEDICINE 
WITH COLLABORATORS ON SPECIAL SUBJECTS 
ILLUSTRATED 
SECOND REVISED EDITION 
NEW YORK AND LONDON 
THE MACMILLAN COMPANY 
1924 PRINTED IN THE UNITED STATES OF AMERICA 
Copyright, 1914 and 1924, 
By THE MACMILLAN COMPANY. 
Set up and electrotyped. Published June, 1924. This Book is Dedicated to the 
Memory of 
CHARLES BASKERVILLE, Ph.D., F.C.S. 
Formerly director of the Chemical laboratories of the College of the 
City of New York. Born in Mississippi 1870, died in New York City 
January 28, 1922. He was known internationally for his investiga- 
tions and discoveries in chemistry and was the author of numerous 
standard works in chemistry. He was also the discoverer of the 
chemical elements carolinium and berzelium, the collaborator and co- 
editor of the First Edition of "Anesthesia," -who proved (a) beyond all 
cavil that, "Ether can be heated easily and economically and that it can 
be delivered to the patient at any desired temperature within limits," 
and that, "while ether boils at 34.6° C., it does not escape violently from 
an oil-ether mixture when the mixture is heated higher, namely, to body 
temperature of 37° C.; (b) "The rate of separation of ether from the 
oil quickly acquires a definite and fairly fixed speed. The significance of 
this conduct cannot fail to be of great importance, for by this means the 
proper content of ether may be maintained in the blood to produce any 
desired physiological effect that has a quantitative relation thereto, for 
example the third or surgical stage of anesthesia." This was one of the 
principal factors that placed colonic anesthesia upon a scientific basis, 
(c) He was instrumental in assisting manufacturers in the purification 
of all anesthetics, (d) Under his direction and supervision for the first 
time in the history of Medicine a "List of Anesthetics" (t.e., all sub- 
stances known to- have any qualities whatever of this nature, regardless 
of whether or not they were ever used as such) was compiled. This list 
is invaluable to the research worker, although it may be considered more 
suggestive than helpful by the practical anesthetist. 
Above all, he was ever ready with helpful advice to aid anyone seeking 
to improve anesthesia by rendering the substances used as chemically 
pure and as efficient as science could make them. "Even as a surgeon minding oft to cut 
Some careless limb, before in use he puts 
His violent engines in the victim's member, 
Bringeth his patient in a senseless slumber; 
And griefless then, guided by use and art, 
To save the whole, saws off the infested part." 
-Dubartas, 1592 A. D. 
ORIGIN OF THE WORD "ANESTHESIA" 1 
Boston, Nov. 21, 1846. 
My Dear Sir: 
Everybody wants to have a hand in a great discovery. All I will do 
is to give you a hint or two as to names, or the name to be applied to 
the state produced and the agent. 
The state I think should be called "Anaesthesia." This signifies in- 
sensibility, more particularly (as used by Linnaeus and Cullen) to objects 
of touch. (See Good-Nosology, p. 259.) The adjective will be "anaes- 
thetic." Thus we might say the state of anaesthesia, or the anaesthetic 
state. I would have a name pretty soon, and consult some accomplished 
scholar such as President Everett or Dr. Bigelow, Sr., before fixing upon 
the terms which will be repeated by the tongues of every civilized race 
of mankind. 
You could mention these words which I suggest for their considera- 
tion, but there may be others more appropriate and agreeable. 
Yours respectfully, 
0. W. Holmes.2 
1 Copy of Dr. Holmes ' letter to Dr. Morton. Morton, W. J.: Memoranda Re- 
lating to the Discovery of Surgical Anesthesia. Post Grad. 20: 333, 1905. 
2 Oliver Wendell Holmes, American Poet, Essayist and Novelist, Professor of 
Anatomy and Physiology in the Medical School of Harvard University, 1847-1882. PREFACE TO THE SECOND EDITION 
Certain subjects in connection with anesthesia, which were empha- 
sized in the first edition, and which were considered radical at that time, 
have now become commonplace. Among others may be mentioned heat 
(98° F.) oxygen, rebreathing, and oil-ether colonic anesthesia. 
The value of heating ether vapor was recognized by the British 
Government during the World War in officially endorsing the Shipway 
Apparatus. Oxygen has not been so highly endorsed for routine admin- 
istration, but as research and clinical results become more generally 
known, it will be increasingly used instead of air, as a vehicle for the 
anesthetic, especially ether. Oil-ether colonic anesthesia is now used the 
world over, and will continue to gain adherents in the exact ratio as its 
physiology is understood. 
Spinal analgesia and intravenous anesthesia are being used for more 
definite indications, and less as a novelty or for demonstration purposes. 
Local and paravertebral anesthesia have made tremendous strides, 
one of the leading surgeons of the United States performing 55 to 65 
per cent of all major operations under peripheral anesthesia. 
The chapters on Electrical and Sequestration Anesthesia and mental 
influence and hypnosis have been entirely omitted, the former not having 
been developed beyond the experimental stage and the latter chapters 
being more suggestive than practical. 
The chapter on Statistics has been omitted. No agent or method is 
without mortality. Nevertheless, with increasing knowledge as to their 
limitations, all agents and methods are being placed upon a higher plane 
of safety. 
The "List of Anesthetics" has been omitted as the space was regarded 
more important for text setting forth new matter. PREFACE TO THE FIRST EDITION 
The administration of anesthetics, along with practically every other 
phase of medicine and surgery, is undergoing a steady evolution. The 
development in the application of anesthetics has been most marked 
within recent years, so that any given anesthetic or method which is 
considered the best to-day may be entirely replaced by a safer and a bet- 
ter to-morrow. Even to-day there is not a little divergence of opinion as 
to which is the best method. No longer are the leaders in medicine and 
surgery satisfied with a form of anesthesia which simply renders the 
afflicted one insensible to pain during an operation, and which allows 
the surgeon to work with great freedom and confidence, but they insist 
further, and rightly, upon maintaining the patient's vitality, reducing 
the effect of shock as much as possible, and having the patient as com- 
fortable as may be during recovery and convalescence. 
"Every hospital, certainly every large hospital, should have as a regu- 
lar member of its staff an attending anesthetist, as is the case in some, 
whose authority in his special department should be as complete as is 
that of the attending physician or surgeon in their fields. This arrange- 
ment will be particularly important during the next few years when the 
older methods of anesthesia-chloroform, ether, cocain, etc.,-will be com- 
peting with, and greatly modified by, newer procedures, e. g., nitrous 
oxid, intratracheal insufflation, spinal anesthesia, intravenous anesthesia, 
intra-arterial injection of novocain by the methods of Bier and Ramshoff, 
measures for the prevention and relief of acapnia, the prevention of pain 
associations, etc." * 
The dignity of this special field in medicine can be greatly enhanced 
and its progress equally advanced by such organizations as the New York 
Society of Anesthetists and American Association of Anesthetists, wherein 
the theories and practice are fully presented and discussed with the 
liveliest interest and general profit. 
* From the Report of the Committee on Anesthesia, American Medical Associa- 
tion, June, 1912. 
xi PREFACE 
xii 
The main purposes of this book are: 
(1) To give in a practical and utilizable form the essentials of the 
subject of the administration of anesthetics; 
(2) To save the busy medical practitioner or student the labor of 
weeding out from the voluminous literature upon the subject the facts 
which he must constantly bear in mind in the successful practice of this 
important branch of medicine; 
(3) To emphasize, wherever possible, the thought that "to bring a 
living being to that borderland in which life in many respects so simu- 
lates death should at no time be a fool's occupation"; and 
(4) While primarily intended as a work for the active practitioner 
and student, to suggest many lines for further research. 
The authors will be grateful for suggestions, and especially for ac- 
counts of unusual experiences met with in practice. 
Due consideration has been given to the historical development of 
anesthesia, but emphasis has been laid upon modern American practice 
without neglecting European procedures. This has been accomplished by 
happily securing the cooperation of successful investigators-to whom sin- 
cere thanks are here extended, and whose names appear at the heads of 
those chapters prepared by them-within the various fields of the sub- 
ject. Ample space has, therefore, been given to methods of administra- 
tion which are as yet in the experimental stage, although dominant prom- 
inence has gone to those methods whose utility has become established. 
A list of anesthetics with valuable data and references (Chapter XX) 
is presented complete, as far as we are aware, for the first time. It is 
hoped that the contents of this chapter may prove of value not only to 
the profession of medicine, but to the professions of dentistry, pharmacy, 
and chemistry as well, for there the investigator may possibly find a drug 
more nearly ideal for his purposes than any now in general use for ob- 
tunding sensation or inducing unconsciousness. 
As modern medicine now more generally recognizes the importance 
of a knowledge of chemistry in all its branches, that phase of the sub- 
ject has been quite fully developed, not only along the lines of original 
purity of the drug used, the conditions favorable to its preservation in its 
highest purity, but its course within the body, resulting either in the 
destruction of the drug or its elimination from the body. 
To some it might have been desirable to indicate from whom certain 
instruments could be obtained and to specify the quality of drugs sup- PREFACE 
xiii 
plied by the different manufacturers, but for obvious reasons that could 
not be. As for the latter, the absolute purity of the drug administered 
cannot be too strongly emphasized. The standards of purity given in 
the text are those determined after prolonged and most painstaking in- 
vestigations. These standards of purity should be insisted upon by the 
physician. It is quite out of the question to have every sample to be used 
examined by an expert chemist-and only an expert chemist should pass 
upon the quality of an anesthetic-but occasional chemical examinations 
may be made, and, knowing the quality of the drug as supplied on the 
market, one must then place reliance upon the reputation of the firm 
supplying the drug. We have found the reputable houses anxious to pro- 
vide drugs of the highest purity, but unfortunately close chemical super- 
vision does not always obtain, and impure products do get upon the mar- 
ket through carelessness of workmen or failure to provide against de- 
terioration of the drug, even though it leave the manufacturer of a proper 
grade. 
James Tayloe Gwathmey. 
Charles Baskerville. 
New York City. CONTENTS 
CHAPTER I 
THE HISTORY OF ANESTHESIA 
PAGB 
Introductory Remarks : Ancient History; Beginning of the Christian 
Era; Asiatic Sources; Middle Ages; Hypnotism; Real Beginnings 
of Surgical Anesthesia; Discovery of Ether Anesthesia; The Dis- 
covery of Nitrous Oxid for Surgical Anesthesia .... 1-11 
Ether: Morton; First Public Demonstration; Letheon; Anesthesia 
in England11-19 
Chloroform : Theological Opposition to the Use of Anesthetics; The 
Early Use of Chloroform in Midwifery; Some Physicians Believe 
in Pain; Prejudice Developed against Chloroform; Scientific Ad- 
ministration of Ether and Chloroform; Efforts to Overcome Ob- 
jections to Chloroform by Use of Substitutes and Improved In- 
halers; A.C.E. Mixture; Substitutes; First Vapor Inhaler; 
Nitrous Oxid More Generally Appreciated; Nitrous Oxid and 
Oxygen; Discarding Chloroform for Ether; Improved Methods 
for Administering Ether; Warmed Ether Vapor; Chloroform 
Condemned; Medication before Anesthesia; The Use of Chloro- 
form Accompanied with Danger; Chloroform and Oxygen; Com- 
binations and Sequences in Anesthesia; Ethyl Chlorid; Im- 
portance of Trained Anesthetists20-27 
Bibliography27-29 
CHAPTER II 
GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
Introductory Remarks : Definition of Terms; Chief Anesthetic Agents 30-32 
Theories of the Action of General Anesthetics : Spencer's 
Theory; Binz's Theory; Bernard's Theory; Dubois' Theory; 
Schleich's Theory; Muller's Theory; Meyer-Overton Theory; 
Wright's Theory; Traube's Theory; Mathews-Brown Theory; 
Moore-Roaf Theory; Gill's Theory; Hober's Theory; Baglioni's 
Theory; Reicher's Theory; Gros's Conclusions; Biirker's Theory; 
Verworn's Theory; Conclusions of Lillie; Conclusions . . 32-56 
xv xvi 
PAGE 
Effects of General Anesthetics upon Various Parts of the 
Organism : The Respiratory System; The Circulatory System; 
The Muscular System; The Glandular System; The Nervous 
System56-62 
Factors Which May Be Said to Modify the Physiology of 
Anesthesia as Ordinarily Induced: Warming the Agent; 
Experiments on Warming Ether; Effects of Moisture; Combining 
Oxygen with the Agent; The Influence upon Anesthesia of Oxy- 
gen Intra-abdominally Administered; Preceding the Administra- 
tion with Oil of Bitter Orange Peel; Utilizing Carbon Dioxid 62-99 
CHAPTER III 
the use of rebreathing in the administration of anesthetics 
W. B. Gatch, M.D. 
Ether: Effect of Ether Vapor on Respiratory Passages; Compari- 
son of Toxic Effects Following Use of Open and Closed Methods; 
Effects of Over-Concentration of Ether Vapor . . . 100-103 
Nitrous Oxid, Alone and Combined with Ether: Method of 
Administration; Basis of Technique; Practical Advice; Main- 
tenance of Ether Balance; Elimination of Ether from the Sys- 
tem; Effect of Morphin on Ether Elimination; Clinical Results; 
Long Operations; Fatalities; Cardiac Cases; Hypercapnia; 
Acapnia; Ether and Acapnia; Other Advantages of Rebreathing; 
Post-Anesthetic Nausea; Post-Anesthetic Abdominal Distention; 
Post-Anesthetic Lung Complications; Method Demands Experi- 
ence 103-115 
Chloroform and Ethyl Chlorid: Suggested Investigations; Dan- 
gers; Advantages115-116 
CHAPTER IV 
nitrous oxid 
History: Early Use in Dentistry; Nitrous Oxid Administered with 
Oxygen; Physical Properties; Chemical Properties; Impurities 
of Nitrous Oxid; Standard of Purity118-123 
Special Physiology: The Hyper-Oxygenation Theory; The Deoxy- 
genation or Asphyxiation Theory; The Theory of the Specific 
Action of Nitrous Oxid upon the Brain Cells; Effects upon the 
Respiratory System; Effects upon the Circulatory System; Effects 
upon the Nervous System; Effects upon the Muscular System; 
Effects upon the Glandular System and Other Structures; Causes 
of Death; Stages of Anesthesia; Elimination; After-effects 123-135 
CONTENTS PAGE 
Comparison with Other Agents135 
Indications and Contraindications135 
Administration: Heating the Gas; Essential Features of Any 
Satisfactory Apparatus; Apparatus for Administering Nitrous 
Oxid Alone or With Air; Dangers of Administration of Nitrous 
Oxid Alone; Recognition of Asphyxial Symptoms; Administra- 
tion of Nitrous Oxid Alone; Administration to Asphyxiation With 
and Without Valves; Use of Expiratory Valve Alone; Adminis- 
tration Without Valves; Precautions When Administered Alone; 
Administration of Nitrous Oxid With Air in Unknown Quanti- 
ties; Administration of Nitrous Oxid With Definite Amounts 
of Air; Nitrous Oxid as a Sequence to Ether; Nitrous Oxid With 
Air; Technique of Ether-Nitrous Oxid (Air) Sequences; Tech- 
nique With A.C.E.; Advantages of Ether (or Chlorof orm-Ether) - 
Nitrous Oxid Sequence; The Advantages of Administration of 
Nitrous Oxid With Oxygen; Superiority of Oxygen Over Air; 
The Administration of Nitrous Oxid With Indefinite Quantities 
of Oxygen; Gatch's Method of Administration; Davis's Method; 
Methods of Administration with Definite Quantities of Nitrous 
Oxid and Oxygen; Gwathmey's Method; Teter's Method; Tech- 
nique to be Followed in Administering Nitrous Oxid and Oxygen 
With the Teter Apparatus and the Teter Nasal Inhaler; Nitrous 
Oxid Oxygen Endopharyngeally; Boothby and Cotton Apparatus; 
The Gwathmey-Woolsey Nitrous Oxid-Oxygen Apparatus . 136-175 
CHAPTER V 
ETHER 
History of the Use of Ether as Anesthetic .... 176-178 
Chemistry: The Term Ether; Properties of Ether; Anesthetic 
Ether; Precautions in Handling Ether; Sources of Impurities in 
Ether; Standards of Purity With Which Anesthetic Ether Should 
Comply; Role of Alcohol in Ether; Peroxids; Aldehyd; Physio- 
logical Action of the Impurities and Administration Means to 
Avoid Them178-184 
Special Physiology: Effects Upon Respiratory System; Effects 
Upon Circulatory System; Effects Upon Nervous System; Effects 
Upon Muscular System; Effects Upon Glandular System and 
Other Structures; Causes of Death from the Administration of 
Ether; Stages of Ether Anesthesia; Elimination; After- 
effects 184-199 
Administration of Ether: The Open or Drop Methods; The 
Mask; Ethyl Chlorid-Ether Sequence by the Drop Method; The 
Ethyl Chlorid-Ether-Chloroform Sequence; The Ethyl Chlorid- 
Ether Sequence by the Closed Method; Chloroform-Ether Se- 
quence; Anesthol-Ether Sequence by the Drop Method; The 
CONTENTS 
xvii xviii 
FAGB 
Ether Rausch; The Semi-Closed Method; Towel and Paper Cones; 
The Handkerchief Method; The Closed Method; The Nitrous 
Oxid-Ether Sequence; Technique of the Nitrous Oxid-Ether Se- 
quence; Nitrous Oxid-Ether-Chloroform Sequence; The Vapor 
Method of Anesthesia; Warmed Ether Vapor . . . 199-231 
Vapor: The Open Method; Endopharyngeal Anesthesia; Oxygen- 
Ether Administration; Concentration of Ether Vapor; The Closed 
Method; Amount of the Anesthetic Used; Care of the Apparatus; 
Hints; Advantages; Treatment of Accidents .... 231-247 
Indications and Contraindications of Ether: Indications; Con- 
traindications 247-249 
CHAPTER VI 
ethyl chlorid 
Chemistry : Chemical History; History of Its Use as an Anesthetic; 
Uses; Preparation; Properties; Storage and Containers; Impur- 
ities Which May Develop in Ethyl Chlorid; Detection of Im- 
purities in Ethyl Chlorid. 250-258 
Physiology : Effects upon Respiratory System; Effects upon Circula- 
tory System; Effects Upon the Nervous System; Effects Upon the 
Muscular System; Effects Upon the Glandular System; Causes 
of Death Under Ethyl Chlorid Anesthesia; Stages of Anesthesia; 
Elimination; After-Effects; Comparison With Other Anesthetic 
Agents 258-267 
Indications and Contraindications 267-269 
Administration: Experimental Data; Methods of Administration; 
Open Method; Semi-Closed Method; Closed Method; Combi- 
nations and Sequences 269-279 
Bibliography 279-280 
CHAPTER VII 
chloroform 
Chemistry: History; History of Its Use as an Anesthetic; Prop- 
erties; Uses; Preparation of Chloroform; Impurities Liable to 
Be Present in Chloroform; Stability of Chloroform; Decomposi- 
tion of Pure Chloroform; Role of Alcohol in Anesthetic Chloro- 
form; Character of Containers; Stoppers for the Containers; 
The Changes Which Anesthetic Chloroform Undergoes When a 
Current of Oxygen is Conducted Through It; The Decomposition 
of Chloroform Vapor Upon Exposure to Gas Light, Etc., Dur- 
ing Administration; Effect of Agitation Upon Anesthetic Chloro- 
form'; Standards of Purity for Anesthetic Chloroform . 281-296 
CONTENTS PAGE 
Special Physiology : Effects Upon the Respiratory System; Effects 
Upon the Circulatory System; Effects Upon the Nervous System; 
Effects Upon the Muscular System; Effects Upon the Glandular 
System and Other Structures; Causes of Death from the Ad- 
ministration of Chloroform; Stages of Anesthesia; Elimina- 
tion 297-310 
Indications and Contraindications: Indications; Contraindica- 
tions; After-Effects; Comparison with Other Agents . . 310-311 
Administration of Chloroform : Drop Method; Other Methods of 
Administration; The Roth-Drager Oxygen and Chloroform Ap- 
paratus; Vernon Harcourt's Inhaler; Junker Apparatus; 
Braun's Inhaler; Gwathmey Three-Bottle Vapor Inhaler . 311-324 
CHAPTER VIII 
THE SELECTION OF THE ANESTHETIC 
AND 
TECHNIQUE FOR SPECIAL OPERATIONS 
Conditions Affecting Selection: Inhalation Anesthetics; Safest 
Anesthetic; Chloroform with Oxygen; Value of Combinations 
and Sequence in Anesthetics; Safest Sequences . . 324-326 
Rules to Be Obeyed in Selecting the Anesthetic: Age; Heart 
Disease; Pulmonary Tuberculosis; Obese Patients; Thin Sub- 
jects; Athletes; Alcoholics, and Other Drug Habitues; Diseases 
of the Lungs; Kidney Diseases; Cancer; Nervous Patients; Epi- 
leptics; Insane Patients; Status Lymphaticus . . . 326-337 
Special Operations : Short Operations; Nitrous Oxid; Ethyl 
Chlorid; Chloroform and Ether; The Mastoid; The Upper Res- 
piratory Tract; Excision of the Tongue; Cleft Palate; Sub- 
mucous Operations; Adenoid and Tonsil Cases; Tracheotomy; 
Goiter (Angina, Ludovici, Exophthalmos-Graves' Disease); 
Amputations; Operations Upon Fingers and Toes; Circumcision; 
Rectal Cases; Obstetric Cases; Curettage; Genito-urinary Opera- 
tions; Laparotomy; Gastro-enterostomy and Similar Operations; 
Peritonitis or Intestinal Obstruction357 
Conclusions 357 
Bibliography 357-358 
CHAPTER IX 
TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
Duties of the Anesthetist in Addition to Giving the Anes- 
thetic 361-362 
The Anesthetist's Kit: Anesthetist's Motto; Mouth Gag; Con- 
tents of Kit; Emergency Treatment to Insure Breathing 362-363 
CONTENTS 
xix xx 
PAGE 
The Management of Ordinary Cases: Preliminary Treatment; 
Treatment During Anesthesia; After-treatment . . . 364-379 
Management of Difficult and Unusual Cases: Respiratory; 
Muscular; Nervous; Idiosyncratic; Shock; Post-Anesthetic 
Toxemia 379-415 
CHAPTER X 
ANESTHESIA by intratracheal insufflation 
Definition416 
History416 
The Apparatus for Intratracheal Anesthesia in the Human 
Being: Apparatus No. I; Apparatus No. II; The Catheter or 
Tube to Be Used; The Introduction of the Tube . . 419-429 
The Course of the Anesthesia 429-430 
Errors Wihch May Occur in Technique: Accidents and How 
They May Be Avoided430 
Indications for Intratracheal Anesthesia 431 
Bibliography 432 
CHAPTER XI 
ANESTHESIA BY COLONIC ABSORPTION OF ETHER VAPOR 
History 433-434 
Development of the Method 435 
Technique of Method : Preparation of Patient; The Administra- 
tion; After-treatment 436-437 
Discussion of Cases 437 
Conclusions : Indications, Contra-indications; Advantages; Disad- 
vantages 438 
OIL-ETHER, COLONIC 
History 438-439 
Laboratory Investigation 439-442 
Technique 442-448 
Physio-Pathological Aspects 448-455 
Clinical Results 455-460 
Indications 460-461 
Contra-indications 461 
Advantages 461-463 
Oil-ether Colonic Anesthesia in Obstetrics . . . 463-464 
CONTENTS CONTENTS 
xxi 
CHAPTER XII 
Part I 
LOCAL ANESTHESIA 
PAGE 
History: Explanation of Poisonous Action; Novocain, Butyn; 
Urea and Quinin Hydrochlorid; Preparation of Solutions; 
Sterilization of Solutions; Syringes; Indications and Scope of 
Local Anesthesia; Local vs. General Anesthesia; General Prep- 
aration and Technique; Details as to Comfort of Patient; After- 
treatment; Healing; Combination of Local and General An- 
esthesia 465-477 
Methods : Surface Application; Infiltration; The Regional Method; 
Paravertebral Anesthesia; Parasacral Anesthesia; Sacral Anes- 
thesia; Trans-sacral Anesthesia; Splanchnic Anesthesia; Ve- 
nous Anesthesia; Arterial Anesthesia 478-493 
Special Application: Skin; Head and Neck; Ear; Nose and Ac- 
cessory Sinuses; Tonsils; Tracheotomy; Larynx; Thyroid; 
Thorax and Breast; Laminectomy; The Extremities; Genito- 
urinary System; Rectum; Gynecology; Abdomen; Inguinal 
Hernia; Recurrent Hernia; Femoral Hernia; Umbilical 
Hernia 493-527 
CHAPTER XIII 
THIRD STAGE ANESTHESIA 
Ether 528-531 
Nitrous Oxid 532-534 
CHAPTER XIV 
local anesthesia as applied in dentistry 
Herrmann Prinz, M.D., D.D.S. 
History 535-536 
The Hypodermic Method536 
Cold 537 
Mode of Application of Ethyl Chlorid537 
Cocain : Preparation of Cocain Solutions; Sterilization of Solu- 
tions; Substitutes Proposed for Cocain; The Hypodermic Ar- 
mamentarium . . 538-543 
Technique of Injection: The Subperiosteal Injection; Peridental 
Anesthesia; Intra-osseus Injection; Perineural Injection; The 
Injection into the Pulp; Methods of Anesthetizing the Pulp 543-553 xxii 
CONTENTS 
CHAPTER XV 
SPINAL ANALGESIA AND SPINAL ANESTHESIA 
PAGE 
Introduction 554-555 
History : Discovery of and Experimentation with Cocain; Experi- 
mentation with Cocain from the Neurological Point of View 
with Regard to Its Analgesic Effects upon the Sensory Nerves, 
Including the Spinal Cord; Application of the Analgesic Effects 
of Cocain upon the Cord to Surgical Operations Below the Dia- 
phragm; Extension of the Surgical Application of Spinal An- 
algesia to Parts of the Body Above the Diaphragm; Experi- 
mentation with Other Agents 555-563 
Anatomical and Physiological Considerations: Origin; Vol- 
ume; Specific Gravity; Movements; Pressure; Diffusion . 563-572 
Course, Extent, and Duration of Analgesia: Course; Extent; 
Duration 572-577 
Accompanying Phenomena: Subjective; Objective . . . 577-582 
Post-operative Phenomena 582-586 
Indications and Contra-indications 586-594 
Advantages and Disadvantages : Advantages; Disadvantages . 594-596 
Deaths 596-599 
Analgesic Agents : Cocain; Tropococain; Stovain; Novocain 599-604 
Sterilization of the Analgesic Agent 604-605 
Sites of Injection 605-612 
The Patient: Preliminary Preparation of Patient; Position of 
Patient 612-614 
Apparatus and Materials 614-617 
Technique of Injection617-623 
Additional Illustrative Case Reports 623-626 
Conclusions 627 
CHAPTER XVI 
INTRAVENOUS ANESTHESIA 
William F. Honan, M.D. and J. Wyllis Hassler, M.D. 
Physiology 629 
Technique 629-637 
Mixed Forms of Anesthesia 637-638 
Blood Changes 638-639 
Urinary 'Examination 639 CONTENTS 
xxiii 
CHAPTER XVII 
SYNERGISTIC ANALGESIA AND ANESTHESIA WITH SPECIAL REFER- 
ENCE TO MAGNESIUM SULPHATE 
PAGE 
Definition of Terms 640 
Development of Theory of Inhibition as Applied to Anesthesia: 
Laboratory Experiments; Physiological Consideration;. Effects 
of Magnesium Sulphate; Action on Nerve Trunks; Subcuta- 
neous Injection; Subarachnoid Injection .... 640-648 
Animal Experiments : Preparation of Magnesium Sulphate Solu- 
tions; Prolonged Effect of Morphin; Technique of Administra- 
tion: Hypodermoclysis with Nitrous Oxid and Oxygen by 
Inhalation; Modified or Simple Technique with Nitrous Oxid 
and Oxygen; Ether by Inhalation; Alkaline Synergistic 
Method; Technique with Ether and Oil by Colonic Instillation. 
Rector's Technique: Formulae for Instillation; Magnesium Con- 
tent of Blood; Summary of Results; Technique with Local 
Agents: Lathrop's Technique; Technique for Dental Surgery 648-659 
Advantages of Method 659-661 
Dangers 661-663 
Mortality 663-665 
Indications and Contra-indications 665 
Conclusions 665 
CHAPTER XVIII 
THERAPEUTIC USES OF INHALATION ANESTHETICS 
Anesthetic Treatment for Special Conditions: In Renal and 
Biliary Colic; In Cases of Acute Pain or Shock; In the Pas- 
sage of Renal or Biliary Calculi; Extreme Irritability of the 
Central Nervous System; Convulsions of Infancy and Child- 
hood; Puerperal Eclampsia; In Anemic Convulsions; Convul- 
sions and Seizures Depending upon Poisoning, and Cerebral 
Diseases; Use in Diagnosis; Insomnia or Extreme Restlessness; 
Acute Mania; Some Miscellaneous Applications of Ethyl 
Chlorid 666-611 
Other Uses of Agents Employed in the Administration of An- 
esthetics: Ether in the Treatment of Infections; Ether Irri- 
gation of the Abdomen 671-674 xxiv 
CONTENTS 
CHAPTER XIX 
THE MEDICO-LEGAL STATUS OF THE ANESTHETIST 
PAGE 
Introduction: Police Power; The Medical Profession Established; 
Contest Between the Schools of Medicine; The Status of the 
Physician 675-680 
The Physician's Liability: Ethical Liability of the Physician; 
The Civil Liability of the Physician; Malpractice; Liability of 
the Specialist; The Criminal Liability of the Physician; Gross 
Ignorance or Negligence; Statutory Liability . . . 680-687 
CHAPTER XX 
ANESTHESIA DURING THE WORLD WAR 
The Military Surgical Operating Room : The Efficiency Prob- 
lem; Operative Technic 688-692 
The Problem of Anesthesia in Thoracic Surgery : Bunnell Appa- 
ratus; General Analgesia by Oral Administration . . 692-710 
CHAPTER XXI 
ETHYLENE ANESTHESIA 
Arno B. Luckhart, Ph.D., M.D. 
History and Early Literature711-720 
Comments by the Author 721-723 
Preliminary Medication 723-726 
Additional Facts 726-728 
Ethylene and Oxygen in Oral Surgery .... 728-729 
Technique for General Surgery 729-730 
Dangers and Mortality of Ethylene 730-731 
CHAPTER XXII 
PAINLESS CHILDBIRTH BY SYNERGISTIC METHODS 
Development 732-734 
Method : 
Cowan's Technique; Results 734-737 
Case Reports: 
Administration; General Impression of Results; Oral Admin- 
istration of Ether; Normal Saline Instillation; Magnesium Sul- 
phate Infection . . . . . . . . . 737-748 
Summary 748-750 CONTENTS 
xxv 
APPENDIX I 
OXYGEN 
PAGE 
History of Oxygen751 
Methods of Manufacturing Medicinal Oxygen . . . 751-752 
Impurities That May Be Present in Oxygen . . . . 752 
Purity of Commercial Medicinal Oxygen752 
Standards of Purity That Should Be Required for Oxygen to 
Be Used in Medicine753 
APPENDIX II 
Doses for Animals 753-756 
Index of Authors 897-903 
Index of Subjects 924-939 SPECIAL subjects and authors 
Rebreathing in Anesthesia. 
Willis D. Gatch, A.B., M.D. 
Professor of Surgery, Indiana University School of Medicine, 
Indianapolis, Ind. 
Anesthesia by Endotracheal Insufflation. 
Charles A. Elsberg, A.B., M.D. 
Professor of Clinical Surgery, University of Bellevue Hospital 
Medical College, New York; Attending Surgeon, Mount Sinai Hos- 
pital, and New York Neurological Institute. 
Anesthesia by Colonic Absorption of Ether and Oil. 
Introduction, History and Remarks on Physiology. 
Walter S. Sutton, A.B., A.M., M.D., F.A.C.S. (deceased). 
Late Associate Professor of Surgery, University of Kansas School 
of Medicine, Attending Surgeon Bell Memorial Hospital, Kansas 
City, Mo. 
Local Anesthesia. 
James F. Mitchell, A.B., M.D. 
Surgeon to Providence Hospital, Washington, D. C. 
Intravenous Anesthesia. 
William Francis Honan, M.D., F.A.C.S. 
Attending Surgeon to the Fifth Avenue, Flower and Metropolitan 
Hospitals, Department of Public Welfare, New York City. 
Local Anesthesia as Applied in Dentistry. 
Herrmann Prinz, M.D., D.D.S. 
Professor of Dental Materia Medica, Pharmacology and Thera- 
peutics, Thomas W. Evans Museum and Dental Institute, School of 
Dentistry, University of Pennsylvania, Philadelphia, Pa. 
Spinal Analgesia and Anesthesia. 
William Seaman Bainbridge, A.M., Sc.D., M.D. 
Attending Surgeon, N. Y. City Children's Hospitals and Schools, 
Consulting Surgeon, Manhattan State Hospital, Ward's Island. 
xxvii xxviii 
SPECIAL SUBJECTS AND AUTHORS 
Medico-Legal Status of the Anesthetist. 
John W. Crim, L.I., LL.B. 
Former Assistant United States Attorney, Former Special Assistant 
Attorney-General of the United States. 
Ethylene. 
Arno B. Luckhardt, B.S., M.S., Ph.D., M.D. 
Associate Professor of Physiology, University of Chicago. ANESTHESIA 
CHAPTER I 
THE HISTORY OF ANESTHESIA 
Introductory Remarks : Ancient History; Beginning of the 
Christian Era; Asiatic Sources; Middle Ages; Hypnotism; Real Be- 
ginnings of Surgical Anesthesia; Discovery of Ether Anesthesia; The 
Discovery of Nitrous Oxid for Surgical Anesthesia. 
Ether: Morton; First Public Demonstration; Letheon; Anes- 
thesia in England. 
Chloroform : Theological Opposition to the Use of Anesthetics; 
The Early Use of Chloroform in Midwifery; Some Physicians Believe 
in Pain; Prejudice Developed against Chloroform; Scientific Adminis- 
tration of Ether and Chloroform; Efforts to Overcome Objections to 
Chloroform by Use of Substitutes and Improved Inhalers; A.C.E. Mix- 
ture; Substitutes; First Vapor Inhaler; Nitrous Oxid More Generally 
Appreciated; Nitrous Oxid and Oxygen; Discarding Chloroform for 
Ether; Improved Methods for Administering Ether; Warmed Ether 
Vapor; Chloroform Condemned; Medication before Anesthesia; The 
Use of Chloroform Accompanied with Danger; Chloroform and Oxygen; 
Combinations and Sequences in Anesthetics; Ethyl Chlorid; Impor- 
tance of Trained Anesthetists. 
Bibliography. 
INTRODUCTORY REMARKS 
Sacred,1 profane, and mythological literature abound in incident, 
fact and fancy, showing that from the earliest times man has sought 
to assuage grief and pain by some means of dulling consciousness. In 
these attempts many methods and diverse agents have been employed. 
The inhalation of fumes from various substances, weird incantations, 
the external and internal application of drugs and many strange con- 
1 The Bible and Talmud contain references to the ancient practice of induc- 
ing sleep by artificial means. 
1 2 
ANESTHESIA 
coctions, pressure upon important nerves and blood vessels, the "laying 
on of hands" or animal magnetism, mesmerism, hypnotism, and the many 
methods which come within the pale of modern science, as well as 
pseudo-science, have played their part in the evolution of anesthesia. 
It is intended in this section to give a brief review of what is now 
known as general, or inhalation, anesthesia. The various other measures 
for the dulling of consciousness and for the induction of partial or com- 
plete insensibility to pain are fully discussed under their respective 
heads, and will be given only scant attention in this connection. 
Ancient History.-During the classic era of Grecian literature, 
Homer in his "Odyssey" 1 caused Helen of Troy to put some drug into 
wine to "lull all pain and anger, and bring forgetfulness of every sor- 
row." It is not known what constituted Helen's nepenthe, some believ- 
ing it to have been mandragora, while others maintain it was opium. 
Five hundred years after Homer, Herodotus, the great historian of 
Greece, tells of a custom among Scythians of inhaling the fumes of a vari- 
ety of hemp, which produced an exalted mental state, followed by sleep. 
The chronicles of ancient Rome furnish similar evidence. For in- 
stance, these record the utterances of the renowned mythological oracle 
of Apollo at Delphi, which were probably nothing more nor less than the 
exaggerated ravings of the priestess Pythea. Her seemingly inspired 
sayings are attributed to the inhalation of carbon dioxid,2 which is sup- 
posed to have been generated in the cavern. Having been removed to the 
altar before the convulsive stage set in, her mumblings were interpreted 
by the faithful as the voice of Apollo. The famous Grotta del Cane, near 
Naples, at the present time furnishes an example of conditions which 
may have been utilized for just such purposes.3 
Beginning of the Christian Era.-That the use of mandragora was 
well known at the beginning of the Christian era is absolutely certain, 
for many references to it are made by the writers of that period. Dios- 
corides, a Greek physician, who lived about the middle of the first cen- 
tury, and who was for seventeen hundred years an authority on the 
science of healing, makes what is probably the earliest allusion to its 
use.4 Galen,5 another Greek and a contemporary of Dioscorides, makes 
mention of the power of mandr agora to paralyze sensation and motion. 
Lucian, in speaking of Demosthenes, says he aroused his fellow citizens, 
1 Homer's ' ' Odyssey "; 4, 220. 
2 Memphis marble and vinegar were used as a local anesthetic by the Romans! 
2 From the sides of the cavern, steam and carbon dioxid emanate in suffi- 
cient quantities to form a stratum in which dogs are first convulsed and then 
asphyxiated, while persons who are in a standing position above the stratum 
are unaffected. 
4De Med. Mat., Lib. 4, 76. The root of "atropa mandragora" was boiled 
in wine and administered prior to surgical operations. 
6 Ibid., Lib. 7, 207. THE HISTORY OF ANESTHESIA 
3 
who were as if put to sleep by mandragora. Roman historians, among 
them Pliny,1 also described the use of mandragora from earliest times. 
The people of their country employed it extensively to relieve the suffer- 
ing of victims of crucifixion. 
Asiatic Sources.-Preparations of different drugs were made by the 
Jews and Chinese, and given to criminals to produce such a mental state 
that they would confess their crimes, or to make less agonizing the hor- 
rible tortures inflicted. 
In view of the fact that it is indigenous to China, undoubtedly the 
Chinese were the first to use Indian hemp as a means of dulling the con- 
sciousness of pain. The Egyptians used this herb under the name of 
"hashish" The fumes of this, when inhaled, induced intoxication and 
mental exaltation. 
A Chinese practitioner of the third century, .Hoa-tho, gave to a 
patient a preparation of hemp, whereby he shortly became insensible "as 
if he had been drunk or deprived of life." We are told that after a cer- 
tain number of days the patient found himself "reestablished" without 
having experienced the slightest pain during the operation. 
The ancients early noted that volatile substances acted more promptly 
and effectually when inhaled than other substances taken by the mouth, 
and inhalation was employed by the Greeks, Romans, Arabians and 
Chinese. 
Middle Ages.-In the thirteenth century, an oil which put patients 
to sleep on occasions of painful operations was prepared and successfully 
■used by Hugo de Lucca. It consisted "of opium, of the juice of the 
unripe mulberry, of hyoscyamus, of the juice of hemlock, of the juice of 
the leaves of mandragora, of the juice of the leaves of wood ivy, of lettuce 
seeds, of dock seeds, and water hemlock boiled with a sponge, which, for 
use, was soaked in hot water and applied to the nostril." To awaken the 
patient, another sponge, soaked in vinegar, was applied to the nose. 
As late as 1534 this "spongia somnifera" was still in use. Shortly 
after this, Pare referred to it as a practice "used formerly by operators." 
The uncertain action of this concoction arising from necessary differ- 
ences in preparation, from the method of application of the vapor, and 
from the ignorance of the strength of the various ingredients, led to its 
temporary abandonment. It is difficult to imagine why the preparation 
of anesthetics was neglected, when medicine was making the rapid 
progress which marked its development during the sixteenth century. 
Hewitt2 states: "In 1589 Giambattista Porta, a surgeon who prac- 
ticed in Naples, used an essence made from hyoscyamus, solanum, poppy, 
and belladonna, enclosed in a leaden vessel, and, the lid being opened, the 
patient would draw in by breathing the most subtle strength of the 
1 De Med. Mat., Lib. 35, 94. 
2 Hewitt, Frederick D.: " Anaesthetics, ' ' 4th ed., 3. 4 
ANESTHESIA 
vapor, so that thereby he would be buried in a most profound sleep, nor 
be aware of what had been done to him." 
Shakespeare makes several references to the soporific effects of vari- 
ous drugs, showing that a knowledge of this quality obtained in his day. 
Early in the seventeenth century, he makes Cornelius, the court physi- 
cian, prescribe a drug which 
"Will stupefy and dull the sense awhile; but there is 
No danger in what show of death it makes, 
More than the locking up the spirits a time, 
To be more fresh, reviving. " 
It is thus seen that ancient, medieval and modern history furnish 
numerous examples of the use of drugs and other media which brought 
about partial or complete unconsciousness. Moreover, it is well estab- 
lished that the Assyrians accomplished the same end by the compression 
of blood vessels before circumcision; and in the early part of the seven- 
teenth century this custom was revived by Valverdi, who compressed the 
nerves and blood vessels of the parts to be operated upon. 
Hypnotism.-The foregoing resume of historical references to 
methods employed in former times needs but the addition of a brief men- 
tion of the hypnotic effects induced by weird incantations, as practiced 
by the Egyptians, Persians, Indians, and others. This leads up to the 
time of Greatrakes, the noted "Irish stroker," who produced sleep as a 
result of his magnetic touch, or "the laying on of hands." He was prob- 
ably the most noted advocate of this method prior to Mesmer, the Swiss 
physician, who, about the middle of the eighteenth century, investigated 
the phenomena of animal magnetism along scientific lines, applying his 
researches to curative ends and enunciating a doctrine which became 
known as "mesmerism," after the founder. 
Real Beginnings of Surgical Anesthesia.-It was at the close of the 
-eighteenth century that modern surgical anesthesia was foreshadowed, 
with the discovery of hydrogen in 1766, nitrogen in 1772, and oxygen 
and nitrous oxid in 1774. "Pneumatic chemistry," as it were, opened 
up a field of experimentation which made possible surgical operations 
under conditions which Humphrey Davy described as "uneasiness being 
swallowed for a few minutes by pleasure." 
Soon after the discovery of these gases, attempts were made to put 
them to practical use. In 1785 Pierson, of Birmingham, England, used 
ether inhalation for asthma, and in 1789 the Medical Pneumatic Insti- 
tute was organized under Dr. Beddoes, where huge reservoirs of gases 
were installed for the treatment of phthisis and other diseases by inhala- 
tion. This Institute, which was superintended by Humphrey Davy, 
while not successful in itself, was important in that it led to Davy's 
experiments with nitrous oxid. By 1799 and 1800 Davy had become THE HISTORY OF ANESTHESIA 
5 
sufficiently well acquainted with this gas to use it for the alleviation of 
headache and also for the extraction of one of his own wisdom teeth. 
This latter event led him to make the historic prediction, "Since nitrous 
oxid seems capable of destroying physical pain, it may be used in surgical 
operations, where there is no great effusion of blood." The value of this 
suggestion was not recognized for nearly half a century. 
Warren, of Boston, used "sulphuric ether" in 1805 on a patient suffer- 
ing with phthisis, and in 1806 it was used in attacks of asthma. Faraday 
seems to have been the first to recognize the value of "sulphuric ether" 
as an anesthetic. In 1818, there appeared a paragraph attributed to 
Faraday in the Quarterly Journal of Science and Arts, in which it was 
pointed out that "when the vapor of ether is mixed with common air 
and inhaled, it produces effects very similar to those occasioned by 
nitrous oxid." 
An incident occurred on November 6, 1821, which, had it been cor- 
rectly interpreted, might have led to an earlier discovery of general 
anesthesia. On that day, Stockman, of Utica, gave an exhibition in 
Rome, N. Y., of the effects of nitrous oxid. After the demonstration, the 
lecturer, on adjourning to a back room, found there a young man com- 
pletely anesthetized with his mouth to the faucet of the gas tank. He 
had been stealing the gas for its exhilarating effect and had been over- 
come by it. 
The first successful experiments upon lower animals, for the purpose 
of rendering them insensible to pain by means of the inhalation of gases, 
were made by Henry Hill Hickman 1 between the years of 1820 and 1828. 
Hickman was twenty years of age when he became a member of the 
Royal College of Surgeons and began his career as a country practitioner 
in the little town of Ludlow, Shropshire, England. 
"Impressed by the agonizing sufferings of those on whom he was 
called to operate, he resolved to seek some method of alleviating their 
pain by rendering them unconscious before the operation. With this 
object, he commenced a series of experiments on animals, first, by pro- 
ducing semi-asphyxiation by the exclusion of atmospheric air; then by 
causing them to inhale small quantities of carbon dioxid, and later 
nitrous oxid gas. After rendering the animals unconscious, he excised 
the ears, amputated their legs, made incisions, then dressed the wounds, 
noted the time they took to heal, and the period of their complete recov- 
ery. He carried on these experiments for some time, and at last met 
with considerable success. This convinced him that, could he but carry 
out his experiments on the human subject, his methods would become of 
the greatest value to mankind in making painless the performance of 
major surgical operations." 
1 Henry Hill Hickman: "A Forgotten Pioneer of Anesthesia,'' Brit. Med. 
J., April 13, 1912, 843. 6 
ANESTHESIA 
His notes on some of these interesting experiments are still extant 
in his own handwriting, of which the following is an extract: 
"Experiment 1, March 20th.-I took a puppy a month old and 
placed it on a piece of wood surrounded by water, over which I put a 
glass cover so as to prevent the access of atmospheric air; in ten minutes 
he showed great marks of uneasiness, in twelve minutes respiration be- 
came difficult, and in seventeen minutes ceased altogether; at eighteen 
minutes I took off one of the 
ears, which was not followed by 
hemorrhage; respiration soon 
returned, and the animal did 
not appear to be the least sensi- 
ble of pain; in three days the 
ear was perfectly healed. 
"Experiment 2.-Four days 
after, the same puppy was ex- 
posed to a decomposition of the 
carbonate of lime by sulphuric 
acid. In one minute respira- 
tion ceased; I cut off the other 
ear, which was followed by very 
trifling hemorrhage, and, as be- 
fore, the puppy did not appear 
to suffer any pain; in four days 
the wound healed. The day 
after the operation he seemed 
to require an additional quan- 
tity of food, which induced me 
to weigh him, and I found he gained 9 oz., 1 drachm and 24 grains in 
nine days." 
While Hickman was successful, he was unable to demonstrate "the 
results of his experiments before his professional brethren, and every- 
where he was met with the greatest scepticism and his system was gen- 
erally derided and condemned as dangerous and useless. . . . Dis- 
heartened by his failure to secure a hearing from the profession in his 
own country, he at length resolved to lay the matter before the Royal 
Academy of Medicine in Paris, and drew up a memorial to King Charles 
X. praying for permission to perform his experiments before the leading 
medical men of that city." The king sent the letter to the Royal Acad- 
emy of Medicine and notified Hickman. The Academy appointed 
Gerardin 1 to investigate the matter and report to them. He reported as 
follows on October 21, 1828: 
"Painless Operations.-M. Gerardin reported on a letter written to 
Fig. 1.-Henry Hill Hickman. 
1Gerardin: Archives generales, Paris, 18, 453. THE HISTORY OF ANESTHESIA 
7 
His Majesty Charles X. by Mr. Hickman, a London surgeon, in which 
that gentleman asserted he had discovered a means of performing the 
most troublesome and dangerous operations without pain. The method 
consisted in producing temporary insensibility by the methodical intro- 
duction of certain vapors into the lungs. Mr. Hickman had made 
numerous experiments on animals, and was desirous of obtaining the 
cooperation of the leading physicians and surgeons of Paris, in order to 
make the same experiments on the human subject." 
French surgeons proved to be no more liberal in their attitude than 
had been their British colleagues. When Gerardin's report was presented 
only one member (Larry) championed Hickman's cause, offering himself 
as a subject for experimentation. The other members sneered at the 
idea proposed by Hickman, and so the young surgeon, disappointed and 
hopeless, returned to England, where he died a few months later (1829) 
at the age of twenty-nine. 
"In this tragic manner the curtain fell upon the life of Henry Hill 
Hickman, who practically sacrificed his career and gave his life in his 
attempts to gain recognition for his discovery of a method of producing 
anesthesia by inhalation and rendering patients unconscious to pain dur- 
ing severe surgical operations." 
While the suggestion of painless surgery seemed to be in the air, 
no one laid definite, hold upon it. In 1830, two deaths from nitrous 
oxid attracted much attention. Each was caused by the breaking 
of a jar containing the gas in the room where the victim was 
sleeping. 
Discovery of Ether Anesthesia.-The efforts of the past culminated 
in the discovery of inhalation anesthesia, with ethyl ether as the agent, 
in 1842. The public had gradually become familiar with the inhaling 
of vapors. It is reported in the American Journal of Science for Janu- 
ary, 1832, that Ives, of New Haven, used chloroform (see page 281) in 
medicine. Humphrey's book on "Medicated Vapors" appeared in 1831. 
At about this time scientific lecturers were in the habit of demonstrating 
the intoxicating properties of ether on young men; and many young peo- 
ple, especially medical students, held wild frolics under its influence, after 
inhaling it to the point of intoxication. It so happened that these lec- 
tures and ether parties were directly responsible for the discovery of 
surgical anesthesia. 
In 1839, some young people held a quilting party near Athens, Ga., 
after which they finished the evening by inhaling ether. At the height 
of the frolic, a negro boy appeared at the door and was invited to partake 
of the ether, but he refused. Some of the boys dragged him in 
and forced a handkerchief, covered with ether, to his mouth and nose. 
After a long struggle he became quiet and the boys desisted. Instead 
of getting up, the negro lay as if asleep and, much to the terror of 8 
ANESTHESIA 
the culprits, did not awaken until medical attention was given an hour 
later. 
The inhalation of ether and also nitrous oxid to the stage of excite- 
ment was a common occurrence in different parts of the country at this 
time. 
It remained for Crawford W. Long,1 of Georgia, to intelligently 
1 CraWford Williamson Long was born in Daniellsville, Madison County, 
Georgia, November 1, 1815. His family was prominent socially and in public 
affairs. Long graduated second in his class from Franklin College at the age 
of nineteen, and from the medical department of the University of Pennsyl- 
vania in 1839, after which time he spent one year "walking" the hospitals of 
New York City. As a student in the University of Pennsylvania he was under 
the immediate tutorship of George B. Wood. Da Costa ("Crawford W. Long," 
"Old Penn Weekly Review, April 6, 1912) states: "Wood's condemna- 
tion of the premature reporting of cases and drug actions may have decided 
Long a few years later to delay in publishing the report of the action of ether. 
He insisted that observers must never be content with a single experiment." 
Woods Hutchinson stated at the unveiling of the monument to Long at Jeffer- 
son, Georgia, that ' ' His discovery was no accident. His real genius and the 
proof of his greatness lay in his wisdom to see the possibilities. His courage 
to attempt experiments, the confidence in his own opinions, and the heartfelt 
love and sympathy for his suffering patients led him to employ the anesthetic 
he had discovered not once but many times. He was great in his courage, brav- 
ing the possibility of the fearful consequences which would have followed failure 
in those early days of experiment. In many matters he was ahead of his day 
and generation. He was one of the first to hold that tuberculosis is curable, 
and that fresh air and diet will effect cures in this dread malady. He added 
to the sum of human immunity from horror and suffering long before Sir J. Y. 
Simpson used chloroform for the purpose." 
Jackson, in a letter to the Bost. Med. and Surg. J., April 11, 1861, states, 
among other things, that, "I then called on Profs. Joseph and John Le 
Conte, then of the University of Georgia, at Athens, and inquired if they knew 
Dr. Long, and what his character was for truth and veracity. They both as- 
sured me that they knew him well, and that no one who knew him in that town 
would doubt his word, and that he was an honorable man in all respects. . . . 
He is a very modest, retiring man and not disposed to bring his claims before 
any but a medical or scientific tribunal. ' ' 
The University of Pennsylvania, on March 30, 1912, unveiled a medallion to 
Long. The state of Georgia has sent his name to Washington, D. C., as one of 
her two most celebrated sons. Hewitt, Foy, and Buxton, of England, as well as 
Young, of Johns Hopkins Hospital, all give the credit to Long as the dis- 
coverer of surgical anesthesia. 
J. F. Groves, in a letter to Hugh H. Young, of Johns Hopkins Hospital, 
under date of January 15, 1897, in giving an account of an operation, states the 
following: "The patient was placed in a recumbent position on a bed, with 
the hand to be operated on in front for convenience of the surgeon. Dr. Long 
poured ether on a towel, and held it to the patient's nose and mouth, too, to 
get the benefit of inhalation from both sources. Dr. Long determined when the 
patient was sufficiently etherized to begin the operation by pinching or pricking 
him with a pin. Believing that no harm would come of its use for a con- 
siderable length of time, he profoundly anesthetized the patient, then gave me THE HISTORY OF ANESTHESIA 
9 
make use of facts which were common knowledge to all. Long and his 
pupils indulged frequently in "ether frolics," during which he was badly 
bruised, yet he noticed, upon recovery, that he had not been conscious of 
pain. Frequent observations of this fact, in connection with himself 
and his students, led Long to conceive the idea of using ether to prevent 
the pain of surgical operations. 
When twenty-six years of age, and in the first year of his practice, 
Long determined to try the ex- 
periment with ether as soon as 
possible, and so, on March 30, 
1842, he administered ether to 
Mr. James Venable and re- 
moved a small tumor from the 
neck. At the close of the oper- 
ation the patient assured Long 
that he had not experienced 
even the slightest degree of 
pain. 
This experiment was so 
highly successful that Long 
continued to administer ether 
in surgical cases, recording 
about eight such cases between 
1842 and 1845. But since his 
was the narrow sphere of a lo- 
cal country doctor, his surgical 
cases were few and his fame did 
not get beyond the restricted 
world in which he lived. He 
made no secret of his discovery, 
but did not advertise the fact until others had laid claim to the honor.1 
Fig. 2.-Crawford W. Long. 
the towel, and I kept up the influence by holding it still to the patient's nose. 
The patient was entirely unconscious-no struggling-patient passive in the 
hands of the operator. ' ' 
1 The original bill for services of Long to Mr. Venable is still in existence, and 
is as follows: 
James Venable 
to Dr. C. W. Long, Dr. 
1842. 
Jan. 28 
Sulphuric Ether 
$ .25 
Meh. 30 
Sulphuric Ether and Exsecting tumor 
2.00 
May 13 
Sul. Ether 
25 
June 6 
Exsecting tumor 
2.00 
$4.50 10 
ANESTHESIA 
Long not only used ether upon patients, but behind closed doors he 
administered it io a medical student, and had the student adminis- 
ter the anesthetic to him, in order to discover the physiological ac- 
tion of the drug. Owing to the prejudice and ignorance of the popu- 
lace, Long was prevented from using ether in as many cases as he might 
have. In a very scientific spirit he administered ether to a negro boy 
having two fingers to be amputated, removing one finger under the in- 
fluence of ether and the second without ether. He did this to prove 
that insensibility to pain was due to the agent used. 
"Dr. Long is necessarily deprived of the larger honor which would 
have been his due had he not delayed years after the universal acceptance 
of surgical anesthesia. It is also to be regretted that his published details 
of the mode of administering the ether and the depth of the anesthesia 
are so meager and unsatisfactory. While the accepted rule that scientific 
discovery dates from publication is a wise one, we need not in this in- 
stance withhold from Dr. Long the credit of independent and prior 
experiment and discovery, but we cannot assign to him any influence 
upon the historical development of our knowledge of surgical anesthesia, 
or any share in the introduction to the world at large of the blessings of 
this matchless discovery." 1 
In regard to this point, DaCosta 2 remarks: "Long has been criti- 
cised for not publishing his discovery at once. Jenner waited twenty 
years to publish his and after twenty years had only made twenty-three 
observations. Suppose someone had published about vaccination after 
Jenner had worked nineteen years, would Jenner any the less have been 
the discoverer?" 
But being far removed from the turmoil and strife that environed the 
lives of the then three other claimants, Long was not embittered as were 
the others. He continued to practice medicine in Jackson County, 
Georgia, and died June 16, 1878, in the sixty-second year of his age. 
The Discovery of Nitrous Oxid for Surgical Anesthesia.-In 1844, 
two years and eight months after Long anesthetized the first patient with 
ether, Horace Wells,3 a dentist of Hartford, Conn., attended a lecture on 
"Laughing Gas" by G. Q. Colton, a chemist. He noticed (as had Long 
with ether) that a young man under the influence of nitrous oxid 
bruised himself very severely, yet was apparently unconscious of pain. 
Wells had long been studying the question of the painless extraction of 
teeth, and had previously reasoned that, if excitement from ordinary 
causes could make one indifferent to pain, the same would probably be 
true of artificial excitement. 
1 Welch, William H.: "A. Consideration of the Introduction of Surgical 
Anesthesia," 9. 
2 Loc. cit. 
s Horace Wells was born in Hartford, Windsor Co., Vt., Jan. 21, 1815. THE HISTORY OF ANESTHESIA 
11 
This incident impressed upon him the belief that the administration of 
nitrous oxid would bring about the result for which he had been looking. 
He planned to test his conclusions on himself. The next day, December 
11, 1844, Colton was called in to administer the gas, and, while Wells was 
under its influence, Riggs extracted one of his teeth. On recovering 
consciousness, Wells was so en- 
thusiastic over the success of the 
operation that he made plans 
for its immediate use, and there- 
after daily extracted teeth under 
its influence. Early in 1845, he 
went to Boston in order to lay 
the matter before the medical 
profession. He gave a public 
demonstration before the Har- 
vard Medical College, but be- 
cause he did not understand 
the proper administration of 
the gas-probably because he 
did not use a sufficient volume 
- the demonstration failed. 
Wells was a sensitive man, and 
this public failure overwhelmed 
him and he felt himself dis- 
graced. He continued to ad- 
minister gas in private practice 
for some time, but eventually 
gave up dentistry altogether. 
In 1847 his reason gave way and, early in 1848, he died by his own hand. 
Fig. 3.-Horace Wells. 
ETHER 
On witnessing one of Wells' operations, H. 0. Marcy remarked that 
as a student he had found that nitrous oxid and the vapor of "sulphuric 
ether," when inhaled, produced exactly the same effects. Wells had tried 
ether, but, owing to the choking sensations produced, resolved to adhere 
to nitrous oxid. 
Morton.-It was left, however, to William T. 0. Morton, a former 
pupil of Wells, to place the use of ether as an anesthetic upon a sound 
basis. His discovery was entirely independent of that of Long, who had 
preceded him four years.1 
'"William Thomas Greene Morton (Patton, J. M.: "Anesthesia and Anes- 
thetics," 17) was born in Massachusetts, studied dentistry in Baltimore, and 12 
ANESTHESIA 
First Public Demonstration.-The first public demonstration of 
surgery without pain was given in the Massachusetts General Hospital, 
was a successful practitioner in Boston. He experimented with drugs and with 
hypnotism in connection with the painless extraction of teeth, and, as we have 
seen, was associated with Wells in his investigations of nitrous oxid. After 
the public failure of the experiment of Wells, he abandoned gas and tried 
' chloric ether ' with unsatisfactory results. At the suggestion of his preceptor, 
Charles Jackson (Morton being at 
that time a student of medicine), 
a physician of Boston, but best 
known as a geologist and chemist, 
he experimented with sulphuric 
ether, beginning his experiments 
on animals. ' ' In connection with 
his experiments upon animals Mor- 
ton 's wife writes: ' ' Every spare 
hour he could get was spent in ex- 
periment. He used to make experi- 
ments nearly every day on 'Nig,' a 
black water spaniel, a good-sized 
dog that had belonged to his fa- 
ther. His clothes seemed always 
saturated with the smell of ether. 
One day he came running into the 
house in great distress (for he 
was always tender-hearted), lead- 
ing the dog, which walked rather 
queerly, and said, 'Poor Nig, I 
have had him asleep a long time; 
I was afraid I had killed him. ' ' ' 
Morton stated to his wife, ' ' The 
time will come, my dear, when I 
will banish pain from the world. ' ' 
"At this time he used to bottle up 
all sorts of queer bugs and insects until the house was full of crawling things. He 
would administer ether to all of these little creatures and especially to the big 
green worms he found on grapevines. ' ' His friends laughed at these experiments, 
but Morton replied, "I shall succeed. There must be some way of deadening 
pain. ' ' It was after this that he began experimenting upon himself. 
' ' His success in this direction encouraged him to make a personal experiment, 
and, in September, 1846, he inhaled ether from a handkerchief while sitting in 
his operating chair. He was unconscious for several minutes, and, on regain- 
ing consciousness, he was so elated by his success that he decided to again in- 
hale the drug and submit to an extraction while under its influence. At this 
moment the door bell rang and he admitted a man named Eben Frost, whose 
face was bandaged and who was in that state of mingled hope and consterna- 
tion so familiar to all dental surgeons. He asked if it were not possible to 
mesmerize him, and readily consented to inhale ether when assured that it was 
superior to mesmerism. To the joy of the operator and the astonishment of the 
patient, the attempt was perfectly successful.'' Elizabeth Morton: "The Dis- 
covery of Anesthesia,'' McClure's Magazine, Sept., 1896. 
Fig. 4.-William T. G. Morton. THE HISTORY OF ANESTHESIA 
13 
in the presence of the surgical and medical staff in the crowded 
amphitheater, on October 16, 1846. "Sulphuric ether'' was used on this 
occasion, though Warren used "chloric ether"1 thereafter, and pre- 
ferred it. 
"It was a trying moment to this medical student when he determined 
to exhibit his discovery of practical ether anesthesia before his class- 
mates, professors, and the public. But so convinced was he, by reason 
of his experience gained in private practice, of success, that he was will- 
Fig. 5.-The Original Morton Inhaler. 
ing to face this ordeal. Morton came into the amphitheater late, delayed 
by waiting for the completion of a new inhaler. Just a few minutes 
before, Dr. Warren had remarked, 'As Dr. Morton has not arrived, I 
presume he is otherwise engaged,' apparently conveying the idea that 
Dr. Morton was not likely to appear. As he was about to proceed with 
his operation Morton entered. Amidst that sea of faces he saw not one 
which was sympathizing. Blank incredulity, or, at the best, curiosity, 
alone was to be seen. Warren, turning to him, remarked: 'Well, sir, 
your patient is ready.' Adjusting his apparatus, Morton calmly admin- 
istered the anesthetic and, turning to Dr. Warren, said: 'Dr. Warren, 
your patient is ready.' The silence of the tomb reigned in the large 
amphitheater while Dr. Warren made his first incision through the skin 
and dissected out a large tumor, while the patient made no sign nor 
moved a muscle of his body. When the operation was completed, Dr. 
Warren turned to the audience and said slowly and emphatically: 'Gen- 
1See Baskerville and Hamor: J. Ind. Eng. Chem., 4, No. 3. 14 
ANESTHESIA 
tiemen, this is no humbug,' and Bigelow remarked, 'I have seen some- 
thing to-day that will go around the world.' " 1 
Operations under ether followed quickly, and from that time its use 
as an anesthetic spread rapidly throughout the world. 
It is almost inconceivable to 
those who now witness operations 
daily under anesthesia to appreciate 
what it really means to the patient 
and to those who are compelled to 
be present. No one has brought this 
out more forcibly than Hayden,2 in 
an article in which he gives a 
description of an operation previous 
1 In July, 1868, Morton left his home 
for New York to reply to an article that 
had recently appeared in one of the 
monthlies advocating Jackson's claim to 
be the discoverer of ether anesthesia. 
His wife states that this article "agi- 
tated him to an extent she had never 
seen before. ' ' It was extremely hot, and 
after reaching New York he telegraphed 
his wife that he was ill and for her to 
come. Under the treatment of the dis- 
tinguished Sayre, Morton rapidly im- 
proved and he attempted to drive his 
wife to a hotel on Washington Heights 
as a change from the hot city. On the 
way through Central Park he complained 
of feeling sleepy, but refused to give 
his wife the reins or to turn back. Sud- 
denly he sprang from the carriage and 
stood on the ground, apparently in great 
distress. He quickly lost consciousness, 
and his wife called upon a policeman 
and Swann, a druggist, who assisted in 
placing Morton upon the grass, but he 
was past hope of recovery. He was 
taken at once to St. Luke's Hospital, but 
was dead by the time he reached there. 
At the time of his death he was forty- 
eight years of age. He was buried in Mount Auburn Cemetery in Boston in the 
presence of many noted physicians. Over his tomb an inscription written by 
Jacob Bigelow is placed, which states: 
"William T. G. Morton, Inventor and Revealer of anesthetic inhala- 
tion, by whom pain in surgery was averted and annulled; before whom, 
in all times, surgery was agony; since whom, science has control of 
pain. ' ' 
2 Hayden, William R.: Inter. J. Surg., 1896. 
Fig. 6.-The Original Morton Inhaler. 15 
THE HISTORY OF ANESTHESIA 
to the introduction of anesthesia, and of operations as they are conducted 
at this time. 
Then 
"With a meek, imploring look, and the startled air of a fawn, as her 
modest gaze meets the bold eyes fixed upon her, she is brought into the 
amphitheater crowded with men, anxious to see the shedding of her 
blood, and laid upon the table. With a knowledge and merciful regard 
Fig. 7.-One of the Earliest Operations under Ether at the Massachusetts 
General Hospital. 
as to the intensity of the agony which she is to suffer, opiates and stimu- 
lants have been freely given her, which, perhaps, at this last stage, are 
again repeated. She is cheered by kind words and the information that 
it will soon be over, and she freed forever from what now afflicts her; 
she is enjoined to be calm, and to keep quiet and still, and, with assis- 
tance at hand to hold her struggling form, the operation is commenced. 
"But of what avail are all her attempts at fortitude? At the first 
clear, crisp cut of the scalpel, agonizing screams burst from her, and, 
with convulsive struggles, she endeavors to leap from the table. But 
force is nigh. Strong men throw themselves upon her and pinion her 
limbs. Shrieks upon shrieks make their horrible way into the stillness 
of the room, until the heart of the boldest sinks in his bosom, like a lump 
of lead. 16 
ANESTHESIA 
"At length it is finished, and, prostrate with pain, weak from her 
exertions, and bruised by the violence used, she is borne from the amphi- 
theater to her bed in the wards, to recover from the shock by slow 
degrees." 
"How would the same case be now? With a sweet, calm smile play- 
ing around her mouth,-an evidence of pleasant dreams,-her eyes fast 
closed as in a gentle sleep; her body extended languidly and listlessly 
as in the repose of childhood, surrounded by no ill-favored men whose 
powerful aid will be needed; with no crowd of medical men to guard 
against unforeseen accidents. The surgeon, and his two assistants to 
pass the necessary implements, or to assist in stanching the blood, are 
all who are required. At his leisure-not hurried by the demands of 
pain to complete as soon as possible-he can coolly prosecute his work, 
varying it to suit any exigency of the occasion, and ready to profit by 
any favorable contingency which its course may present. 
"When finished, and all is in that proper condition which will demand 
no fresh interference for some time, the patient is awakened from her 
slumber, and receives the glad information that it is all over, and she is 
to be tortured no more. The one grateful look which answers this news 
can have no value placed upon it. Alone, it is worth a lifetime of exer- 
tion and trouble?' 
The formal announcement to the medical profession of this discovery 
was made by H. J. Bigelow 1 in a paper read before the Academy of 
Arts and Sciences, on November 3rd, and before the Boston Society of 
Medical Improvement, on November 9th, and published in the Boston 
Medical and Surgical Journal, November 18, 1846.2 
Letheon.-On October 27, 1846, Morton and Jackson sought to 
patent their anesthetic under the name of "Letheon." From its odor 
it was soon recognized as "sulphuric ether." 3 Not long afterwards Jack- 
Now 
1 Bigelow (Boston Med. and Surg. J., Nov. 18, 1846) called attention to the 
experiments which he conducted for the purpose of ascertaining the nature of 
' ' Letheon. ' ' His first experiment was with sulphuric ether, the odor of which 
was easily detected in Morton's preparation. 
2Patton, Joseph M.: "Anesthesia and Anesthetics," 18. 
s J. F. B. Flagg, M.D., D.D.S., one-time Professor of Anatomy and Physi- 
ology in the Philadelphia College of Dentistry, "was particularly prominent as 
having announced to the dental and medical world that the so-called 'Letheon' 
of Mr. Morton, of Boston, was simply washed sulphuric ether, thus securing to 
them an unpatentable material." Med. and Surg. Reporter, Phil., Dec. 7, 1872. 
Flagg (Flagg, J. F. B.: "Ether and Chloroform," Phila., 1851), in re- 
viewing briefly the history of the inhalation of ether, says: ' ' The surgeons of 
Massachusetts General Hospital, together with a few initiated, become aston- 
ishingly fervent in their praises of an 'Invention,' which required the com- 
bined efforts of scientific attainments and mechanical skill to develop. Clas- THE HISTORY OF ANESTHESIA 
17 
son resigned his interest in the "invention" and attempted to show that 
he alone was the discoverer of anesthesia by ether. While he was writing 
his contentions to the French 
Institute, Horace Wells went in 
person to claim the honor of be- 
ing the real discoverer of anes- 
thesia, and thus a three-sided 
controversy was begun. 
"Partly with a view of keep- 
ing his discovery out of the 
hands of persons who might use 
it unwisely, and acting upon the 
advice of Rufus Choate and Ca- 
leb Cushing, lawyers of national 
reputation, Dr. Morton patent- 
ed his application of sulphuric 
ether." 1 
While Morton probably had 
the right to patent his discov- 
ery, the fact that he did so was 
most regrettable, for the patent 
right caused much dissatisfac- 
tion and adverse comment. 
Many refused to accept it on the 
grounds of quackery. One year 
after its discovery, 1847, one of the largest hospitals in North America 
had not tried it at all. When Europe confirmed the efficacy of ether, the 
opposition subsided. 
Fig. 8.-Charles T. Jackson. 
sical erudition came to their aid, and, for a season, good, old ' sulphuric ether ' 
was made to succumb to the name of 'letheon. ' 
"A circular is broadly cast through the length and breadth of the country, 
announcing that a compound has been discovered, which, by breathing into the 
lungs, induces so deep a slumber as to enable us to perform the most painful 
surgical operations with entire unconsciousness on the part of the patient. In 
connection with this announcement are the names of Dr. Jackson and Dr. Mor- 
ton, as its combined (?) discoverers. 
"A patent is sought, and, under the protection of a caveat, agents are ap- 
pointed to traverse the country, selling to all, who will buy, the right to use 
the compound. Thus qualifying everybody and anybody in the use of this 
powerful agent that would pay the sum of 
'1 In cities over 150,000 inhabitants, $200 for seven years. 
"In cities over 50,000 and less than 150,000, $150 for seven years. 
"And so on, down to 
"In cities under 5,000, $37 for seven years." 
1 Morton, Mrs. Elizabeth Whitman: ' ' The Discovery of Anesthesia, ' ' Mc- 
Clure's Magazine, Sept., 1896. 18 
ANESTHESIA 
In 1849 Morton petitioned Congress for a reward for his discovery. 
He was at once opposed by Jackson and the friends of Wells, who was 
then dead. The celebrated ether controversy thus begun occupied 
the attention of Congress for many years, and was characterized 
by the greatest animosity between these former bosom friends and com- 
panions. 
Jackson's name is most closely associated with his claim to priority 
in the discovery of the anesthetic properties of ether, which was the sub- 
ject of a long controversy, that was very painful to him. His claim 
was supported by the testimony of Francis Alger, J. B. S. Jackson, 
Martin Gray, and T. T. Bouve, to whose eulogy before the Boston Society 
of Natural History we are indebted for most of the facts given here- 
with. These gentlemen were his chosen friends, and were for a long 
time closely associated with him. J. B. S. Jackson was one of the signers 
of a remonstrance addressed to Congress against its making a grant of 
money to W. G. Morton, Jackson's rival in the claim of discovery, based 
upon the ground that the signers believed that the reward, so far as the 
question of discovery was concerned, ought to go to Jackson. Martin 
Gray published a pamphlet under his own name, maintaining that J ack- 
son was the sole discoverer of anesthesia, and that Morton could only be 
considered to have performed a secondary part by proving that the ad- 
ministration of ether is safe in surgical operations. Bouve, who was for 
a considerable time a student in Jackson's laboratory, and afterward met 
him frequently in social intercourse, accorded to him the honor of having 
been the discoverer of the anesthetic properties- of ether, but "never 
thought him entitled to the credit of its introduction into use, or even 
to that of having thoroughly verified what he claimed to be true respect- 
ing the safety of administering it. He had experimented upon himself, 
and had afterward demonstrated respecting it, even going so far as to 
recommend its use by others, and this constituted discovery; but he did 
not prove to others what he was himself convinced of, and allowed 
precious time to pass-yes, much time-without making any application 
of the discovery. Indeed, had it not been that Mr. Morton sought from 
him means to prevent pain when extracting teeth, it is doubtful if the 
world would have had the advantage of the discovery for years, if ever. 
The truth is, Dr. Jackson was a great genius and had remarkable intui- 
tive perceptions of scientific truths, but, from some peculiarities hard to 
comprehend, he often contented himself with enunciating what he recog- 
nized as fact, without striving to substantiate it. He himself admitted 
his shortcomings in this respect. When Dr. Gray had written his essay 
upon the discovery of ether, claiming for Dr. Jackson all the merits of 
its introduction, I objected to his view of the matter, and took the 
ground that the world was indebted to both Jackson and Morton for the 
great boon; to one as the scientific discoverer and suggester of its use in THE HISTORY OF ANESTHESIA 
19 
surgical operations, to the other for his application of it and its practical 
introduction. 
"Dr. Jackson, learning of this, upon meeting me remarked that I was 
thought not to be friendly to him in the matter. I then said: 'Doctor, 
you have known for a long period what Mr. Morton is now demonstrating 
to be true, but have allowed it to remain a dormant fact in your mind. 
If he had not sought information from you, might it not have remained 
so for some years longer ?' He answered that possibly it might. I think 
it may fairly be said that without both Jackson and Morton the world 
might have been none the happier for what either would have done; one 
supplemented the other. To them together belongs the great honor of 
having served humanity beyond what language can express." 1 
"For five years Long refused to take part in the conflict, but finally, 
in 1854, persuaded by his friends that in that way alone could he obtain 
recognition of his claims, he wrote to Senator Dawson giving an account 
of his work. It seems that Dawson was a friend of Jackson, for he wrote 
to him of this new claimant and requested him to investigate his case. 
This Jackson did, calling upon Long at his home in Athens on March 8, 
1854. 
"Dr. Jackson finally acknowledged the justice of Dr. Long's claims 
and wrote to Senator Dawson to that effect. 
"On April 15, 1854, the appropriation bill2 was up before the Senate 
for its final reading. The friends of Wells and Morton, relying on the 
volumes of manuscript they had presented, were confidently awaiting the 
result, when Senator Dawson arose and said that he had a letter from 
Jackson which acknowledged that a Dr. Long in Georgia had undoubt- 
edly used ether before any of the claimants for the appropriation. 
"Coming as it did from so prominent a contestant, this announce- 
ment fell like a thunderbolt on the rival claimants, and from that time 
they seem to have lost all hope of gaining the reward, and passively 
allowed the bill to die. 
"Desirous only of preventing another from being recognized by Con- 
gress as the discoverer, and not wishing any pecuniary reward himself, 
Long never pushed the matter farther, and his documents of proof were 
never even brought up before Congress." 3 
Anesthesia in England.-Bigelow took some ether with him to Lon- 
don and the first operation (extraction of a tooth) was performed on 
December 19, 1846, at the home of Bott, of Gower Street.4 Two days 
1 Pop. Sei. Mon., 1881, 19, 405. 
2 The bill proposed to appropriate $100,000 as a recompense to the real dis- 
coverer. 
3 Young, Hugh H.: "Long, the Discoverer of Anesthesia," read before the 
Johns Hopkins Hospital Historical Society, Nov. 8, 1896. 
4 A very interesting account of the first major operation under ether in Eu- 
rope is given by Dr. F. W. Cock in the University College Hospital Magazine, 20 
ANESTHESIA 
later, ether was administered to patients at the University College Hos- 
pital by Squires, Liston operating. In 1847, J. Y. Simpson, a Scottish 
physician, first used ether in midwifery, and, finding that the pains of 
labor might be wholly abolished without interfering with uterine con- 
tractions, adopted it in his obstetric practice. 
CHLOROFORM 
On March 8, 1847, Flourens pointed out the anesthetic qualities of 
chloroform and ethyl chlorid, but his observations did not attract gen- 
eral attention. During the same year Simpson,1 who had not been 
entirely satisfied with ether on account of its irritating qualities, incon- 
venience of administration and odor, consulted Waldie, a chemist of 
Liverpool. The latter suggested the use of chloroform, of which "chloric 
ether" was an alcoholic solution. The vapor of "chloric ether" had been 
previously used as an anesthetic with little success, but when Simpson 
had obtained the chloroform from Edinburgh and experimented with it, 
on November 4, 1847, he was more than satisfied with its anesthetic 
qualities. Thereafter he tried it in obstetric practice with success.2 
as follows: ''Dr. Bott, a general practitioner of Gower Street, W. C., informed 
Robert Liston, the surgeon of University College Hospital, or rather North Lon- 
don Hospital, as it was then called, that he had used ether successfully on a 
dental case in his own house. Liston sought the aid of Peter Squire, the well- 
known chemist of Oxford Street, in order to fashion an apparatus for adminis- 
tering ether, and the inhaler was first tried on his nephew, William Squire. 
The latter, profiting by the experience on himself, gave the anesthetic to Liston's 
patient. The patient was a man of thirty-six years suffering from disorganized 
knee-joint, and it was decided to amputate. The mouthpiece was applied by 
Squire and the patient soon sank into insensibility. William Cadge, Liston's 
junior, compressed the femoral artery, and Ransome, the house surgeon, held the 
limb. Liston rapidly completed the operation in twenty-five seconds, accord- 
ing to Palmer, the dresser. The inhalation had been stopped as the operation 
was begun. On coming round, the patient tried to lift himself, and asked when 
the operation was going to begin. On being shown the stump he fell back and 
wept. Liston acknowledged the success of the new anesthetic by the remark, 
'The Yankee dodge, gentlemen, beats mesmerism hollow.' This was a sarcastic 
hit at Dr. EHiotson, a physician of the same hospital, who practiced the occult 
art in connection with medicine. The notes of this case are still extant. The 
dresser, who wrote them, remarks that not the slightest groan was heard from 
the patient, nor was his countenance at all expressive of pain." 
1 J. Y. Simpson was born at Bathgate, Linlithgowshire, Scotland, June 7, 1811. 
In 1832 he received the degree of Doctor of Medicine. On Nov. 4, 1847, he dis- 
covered the anesthetic properties of chloroform, and made known the fact in a 
paper on Nov. 10, 1847. He received the highest honors from the British Gov- 
ernment for this discovery. He died at Edinburgh, Scotland, May 6, 1870, in the 
fifty-ninth year of his life. 
2Simpson, Sir James: ''New Anaesthetic," 1847, 7; Illustrated London 
News, Dec. 4, 1847, 370-2. Simpson, E. B., Century, 25, 412; Liv. Age, 66, 720; THE HISTORY OF ANESTHESIA 
21 
On November 10, 1847, the slow but steady progress of the use of 
ether received an effectual setback by the publication of Simpson's 
famous pamphlet on a "New Anaesthetic Agent as a Substitute for Sul- 
phuric Ether in Surgery and Midwifery." 
Because of Simpson's writing and his efforts in behalf of chloroform, 
the use of this new anesthetic spread with remarkable activity, and soon 
had almost entirely supplanted 
ether in general surgery. Its prog- 
ress was hastened also by its ease of 
management and speedy action, and 
because its vapor was much pleas- 
anter to take than that of ether. 
Theological Opposition to the 
Use of Anesthetics.-One of the 
most singular struggles of medical 
science during modern times oc- 
curred in our own days and in a 
Protestant country. Just as there 
resulted a theological and sectarian 
condemnation of and opposition to 
inoculation, vaccination, and the use 
of coca and quinin, so did the ad- 
vocacy of the use of anesthetics in 
obstetrical cases by James Young 
Simpson meet with a vigorous storm 
of protest. The hostility of the 
Scotch ecclesiastical authorities to 
the alleviation of pain in childbirth 
had its source in an old belief in Scotland. In 1591, for example, a lady 
of rank, one Eufame Macalyane, was charged with seeking the assistance 
of Agnes Sampson for the relief of pain at the time of the birth of her 
two sons, and was accordingly burned alive on the Castle Hill of Edin- 
burgh;1 and this view, which stood for nothing kind, merciful, or hu- 
mane, persisted even to the middle of the nineteenth century. Simpson's 
use of chloroform was denounced from the pulpit as impious and contrary 
to Holy Writ; and Biblical texts were numerously cited, the general 
declaration being that to use chloroform was "to avoid one part of the 
primeval curse on women." As in the time of witchcraft, so strong was 
the power of the church, so universal the belief in the guilt of all women, 
that, notwithstanding the fact that Simpson wrote pamphlet after pam- 
Fig. 9.-Sir James Y. Simpson. "To 
whose genius and benevolence the 
world owes the blessings derived from 
the use of chloroform for the relief of 
suffering." 
Mon. J. Med. Sci., Sept., 1847; Ednb. Medico-Chir. Soc., Nov. 11, 1848. J. Y. 
Simpson's "Anaesthesia," 1849, 93, 145, 182, 193, 203. Chloroform of the 
density 1.48 was used by Simpson in 1847. 
1Dalyell's "Darker Superstitions of Scotland," 130, 133. 22 
ANESTHESIA 
phlet to defend the blessing he had introduced, he seemed about to be 
overcome, when he seized a new weapon, which was, according to White,1 
probably the most absurd by which a great cause was ever won: "My 
opponents forget," he said, "the twenty-first verse of the second chapter 
of Genesis; it is the record of the first surgical operation ever per- 
formed, and that text proves that 
the Maker of the universe, before 
He took the rib from Adam's side 
for the creation of Eve, caused a 
deep sleep to fall upon Adam." We 
are told that this was a stunning 
blow, but that it did not entirely 
kill the sectarian opposition, for the 
leaders of the resistance had 
strength left to maintain that the 
"deep sleep of Adam took place be- 
fore the introduction of pain into 
the world-in a state of innocence." 
However, Thomas Chalmers, a new 
champion, now intervened, and, 
with a few pungent remarks, dis- 
persed the enemy, forever, and the 
greatest victory of science against 
suffering was gained.2 
When anesthetics were first used 
in obstetrics in the United States, 
prominent New England clergymen also assailed their administrators as 
having sacrilegiously thwarted "the curse," but such "impious frustra- 
tion of the curse of the Almighty upon woman" 3 began to be regarded 
as the greatest boon ever conferred by science upon mankind, shortly 
after the vigorous support of Chalmers in Scotland. 
The Early Use of Chloroform in Midwifery.-The records of the 
Dublin Lying-in Hospital show that the mortality with anesthesia was 
one in three hundred and twenty, and that the women were delivered 
within two hours from the commencement of labor. Without anesthesia, 
the average labor case was twenty hours with a mortality of one in eleven. 
Some Physicians Believe in Pain.-In spite of these statistics, we 
find some doctors pleading earnestly against anesthesia in those days. 
"Pain during operations is in a majority of cases even desirable, and its 
prevention or annihilation is, for the most part, hazardous to the 
Fig. 10.-Bust of Sir James Y. Simpson. 
(In the National Gallery, Edinburgh, 
Scotland.) 
3"A History of the Warfare of Science with Theology," 1908, 63. 
2 Duns' "Life of Sir J. Y. Simpson," 1873, 215-222; 256-260. 
3 For the views of an enlightened woman on this question, see Matilda Joslyn 
Gage's "Woman, Church and State," 241, 242, 244 and 433. THE HISTORY OF ANESTHESIA 
23 
patient." A French physiologist stated that it was a trivial matter to 
suffer, and a discovery whose object was to prevent pain was of a slight 
interest only. 
Prejudice Developed against Chloroform.-Until January 28, 1848, 
chloroform was believed to be a safe anesthetic, but the death of a young 
woman on that day, while under the influence of chloroform, and several 
ether deaths not long after, gave good cause for the suspicion that the 
drug might be more dangerous than at first supposed. 
Scientific Administration of Ether and Chloroform.-John Snow, 
believing that in a too concentrated vapor of chloroform lay the danger, 
invented an inhaler in 1847 which was designed to regulate the per- 
centage of vapor. After several years of experience with anesthetics, he 
published, in 1858, as the result of his experiments, the first attempt to 
place the administration of ether and chloroform upon a scientific basis. 
He was the first to describe the effect of inhaling definite percentages 
of chloroform vapor and air, and experimented to discover the manner 
in which death occurred under chloroform, ether, and other anesthetics. 
He came to the conclusion that chloroform caused death by primary 
cardiac paralysis, due to the inhalation of a too concentrated vapor. 
Efforts to Overcome Objections to Chloroform by Use of Substitutes 
and Improved Inhalers.-Because of his belief in the dangers of chloro- 
form, Snow investigated amylene as an anesthetic and was the first to 
administer it. His death checked considerably the advance in-the scien- 
tific investigation of anesthetic agents. 
J. T. Clover, a worthy successor of Snow, was the first to improve the 
principle of chloroform administration. He published, in 1862, an 
account of his chloroform inhaler, by means of which the percentages 
of chloroform and air could be more accurately regulated than 
hitherto. 
"A.C.E. Mixture."-The agitation of the question of the physiologi- 
cal effects of anesthetics caused an investigation to be made by a Com- 
mittee of the Royal Medical and Chirurgical Society of Great Britain. 
This Committee, appointed "to inquire into the uses and the physiologi- 
cal, therapeutical, and toxicological effects of chloroform," reported in 
1864. They agreed with Snow that the concentrated vapor of chloro- 
form was dangerous, and, because of the inconvenience of the adminis- 
tration of ether, recommended the "A.C.E. mixture" as a substitute. 
This was originally used by George Harley and was composed of alcohol/ 
one part, chloroform, two parts, and ether, three parts. The com- 
mittee also urged the free admixture of air as of first importance. A 
detailed account of this and other mixtures will be found on page 
142. 
Substitutes.-Two or three new anesthetics were introduced about 
this time, but while they may have been favorably received in certain 24 
ANESTHESIA 
circles, and for a limited period of time, they never gained general favor. 
In 1861, "Kerosolene" was introduced in Boston by Dickinson, Bow- 
ditch, and Merrill. In 1867, Benjamin Bichardson introduced "bichlorid 
of methylene." For a time many surgeons were very enthusiastic over 
the drug, claiming that it had fewer drawbacks than any other. Amer- 
ican surgeons were not so enthusiastic, believing that its dangers differed 
only in degree from those of chloroform. 
First Vapor Inhaler.-On November 30, 1867, in an article in the 
Medical Times and Gazette, Junker described a very ingenious appar- 
atus for the administration of chloroform, especially valuable in opera- 
tions on the nose, throat, or mouth. 
Nitrous Oxid More Generally Appreciated.-For nearly twenty 
years little was heard of nitrous oxid, but in 1863, because of the efforts 
of Jhe same Colton from whom Wells had received his first inspiration, 
nitrous oxid began to regain the ground it had lost. 
In that year, Colton formed an association of dentists to perform 
operations with the use of nitrous oxid, and by 1867 had recorded 
20,000 administrations without an accident. These results strongly 
attracted the dental profession. Rymer, of London, administered the 
gas successfully there in 1864, and in 1867 Colton demonstrated in 
Paris before Evans, an American dentist. This led to its general intro- 
duction into England, for, during the following year, Colton had his 
own apparatus taken to that country by Evans, who administered the 
gas before the Dental Hospital of London. On Dec. 7, 1868, a joint 
committee of the Odontological Society and the Dental Hospital issued 
a report which favored nitrous oxid so highly that it has since held 
the highest position among the anesthetics of modern dentistry. The 
analgesic properties of nitrous oxid in dentistry are of recent develop- 
ment. 
Nitrous Oxid and Oxygen.-In 1870, Colton published a pamphlet 
showing the result of the physiological action of the gas in its practical 
application to the original discoveries of Davy, Wells, and others. A 
long step toward making nitrous oxid more practicable was taken in 
1868, when E. Andrews, of Chicago, reported for the first time the use 
of a mixture of nitrous oxid and oxygen with most satisfactory results. 
He published accounts of several cases, in which, by mixing oxygen with 
nitrous oxid, he had obtained a more satisfactory form of anesthesia 
than with nitrous oxid alone. But since the medical profession had 
always insisted on the exclusion of air, Andrews failed to get the notice 
he deserved. The late Paul Bert, ten years afterwards, again drew 
attention to the same procedure. 
In order to overcome its too feeble action, the large amount of gas 
necessary, and the limited time during which anesthesia could be pro- 
duced, Bert gave a mixture of nitrous oxid and oxygen (85: 15) under THE HISTORY OF ANESTHESIA 
25 
increased atmospheric pressure. He argued that the pressure was 
necessary in order to have a uniform mixture of the gases, but 
Hewitt and others believed that pressure was not essential. Bert's 
apparatus for positive pressure was tried with only partial success, it 
being too cumbersome and expensive. Hewitt states that the most 
recent and best development in modern anesthetics is the combination of 
oxygen with nitrous oxid, producing a non-asphyxial and absolutely 
safe form of anesthesia. 
Discarding Chloroform for Ether.-During the year 1870 Simpson 
wrote to Bigelow in Boston: "Chloroform is the greatest triumph of 
all, for it has, if not entirely, yet nearly entirely, superseded the use of 
'sulphuric ether.' " In spite of this statement, the use of ether had, in 
the main, held its position against chloroform in the United States. In 
1890, after twenty years filled with records of accidents from the use of 
chloroform, surgeons all over the world began to discard it for ether. 
Improved Methods for Administering Ether.-Pollack, Warrington, 
and Hayward warned against the use of chloroform, and Clover's experi- 
ments did not lead him to the belief that chloroform could be made as 
safe as ether. He became less and less inclined to use it, substituting 
nitrous oxid in minor operations. He improved the methods for ad- 
ministering the latter gas and introduced its use as a preliminary to 
ether. Clover also discovered the proper principles of ether adminis- 
tration, and pointed out the advantages of air limitation during the 
etherization. In 1876, he published an account of his apparatus for 
the administration of nitrous oxid and ether, either separately or in 
succession. 
Warmed Ether Vapor.-The introduction of Clover's portable regu- 
lating ether inhaler in 1877 went a long way toward solving the question 
of the rapid and safe administration of ether. This inhaler has gained 
a wider reputation than any other apparatus of its kind. Its use has 
shown the value of warmed ether vapor with regard to after-effects. 
Chloroform Condemned.-During this year, 1877, Clover adopted 
"bichlorid of ethidene" (ethylidene chlorid), which Snow had used 
in 1851; but, since a death resulted from it, it did not gain favor. The 
report of the "Glasgow Committee" of the British Medical Association, 
issued in 1879, agreed with Snow and his followers in stating that blood 
pressure and heart action under chloroform were distinctly reduced; 
and while, where fatalities occurred, respiration usually ceased first, 
the heart might be primarily paralyzed. The report of the First Medical 
Association Committee, issued in 1880, stated that many deaths from 
chloroform were clearly proven to be the result of carelessness or igno- 
rance. Chloroform was condemned and ether also, though in a less 
marked degree. The committee recommended "bichlorid of ethidene," 
but this drug is now practically unknown. 26 
ANESTHESIA 
The dispute reached such proportions that, in order to settle it, the 
Hyderabad Chloroform Commission was appointed in 1889. This was 
financed by the Nizam of Hyderabad at the suggestion of Surgeon- 
Major Lawrie, whose views had long been with the Edinburgh School. 
After numerous experiments, the commission filed a report agreeing 
entirely with Syme and the supporters of chloroform. The conclusions 
thus stated were not accepted by the medical profession generally, and 
so a second Hyderabad Commission was appointed, the Nizam again 
supplying the funds. This time experiments were carried on upon a 
larger scale, and observations were made on many of the lower animals; 
but the report, issued in 1891, was a corroboration of the conclusions 
reached by the First Commission. 
Medication before Anesthesia.-In 1881, Alexander Crombil, Sur- 
geon at the Calcutta Medical College Hospital, strongly advocated a 
combination of the use of morphin and chloroform. He said that he 
had never seen a death from chloroform, and ascribed his success to the 
use of a hypodermic of morphin before the administration of the chloro- 
form. This idea came from Claude Bernard, who reported experiments 
on dogs along similar lines in 1869. Another attempt to show the 
cause of death under chloroform was made by Lauder Brunton in 1887. 
He stated his theory to show that incomplete anesthesia with chloro- 
form was the most frequent cause of fatal results. George Foy, in 1889, 
supported these views. 
The Use of Chloroform Accompanied with Danger.-The Second 
Committee of the British Medical Association appointed to investigate 
the effects of anesthetics, their safety, and methods of administration, 
after studying reports of 26,000 cases in hospital and private practice, 
concluded that no method of using chloroform was free from danger. 
They found ether singularly safe in healthy individuals, though minor 
troubles more commonly resulted from its use. Their final conclusion 
was that the most important factor in the administration of anesthetics 
was the experience already acquired by the administrator. 
The Third Committee of the British Medical Association was ap- 
pointed in 1901, to put the determination of chloroform quantitatively 
upon a sound basis. They endeavored to discover the smallest possible 
dose, by volume in the atmosphere breathed, necessary to produce an- 
esthesia; and also the smallest possible dose necessary to maintain 
anesthesia after loss of consciousness. They recommended an inhaler 
devised by Vernon Harcourt, which permitted a maximum of 2 per 
cent of chloroform vapor with gradations downward. 
Chloroform and Oxygen.-In an attempt to make chloroform safer 
for anesthetic purposes, Neudorfer, of Vienna, introduced the use of 
chloroform and oxygen in 1886.1 Bertel advocated it before the St- 
1His method was described in the Lon. Med. Record. THE HISTORY OF ANESTHESIA 
27 
Petersburg Medical Society, as also did von Idelson. It did not gain 
favor because of the lack of a device for regulating proportions. Kreutz- 
mann, of San Francisco, in 1887, wrote a description of a simple ar- 
rangement for administering chloroform and oxygen. He used the 
Junker Inhaler and spoke very highly of the results. He commented 
on its greater rapidity, lack of marked excitement, quicker return to 
consciousness and fewer unpleasant after-effects. On January 25, 1896, 
the British Medical Journal stated that the number of cases of the use 
of chloroform and oxygen were then too few for any general conclusions 
to be drawn. Oxygen was used with chloroform by Schall, of Brooklyn, 
in 1895, and Northrop, of Philadelphia, and this combination has been 
the routine anesthetic in a hospital of Pittsburgh for nine years. 
Combinations and Sequences in Anesthetics.-Among other recent 
advances, it may be noted that anesthetics are used more in combination 
and sequence than ever before. In pulmonary anesthetics, the placing 
of rebreathing upon a scientific basis by Gatch, and the combination of 
general and local anesthetics by Crile, are noteworthy advances. For 
spinal and regional anesthesia, electrical, rectal, intratracheal insufflation, 
morphin, and intravenous anesthesia, and hypnotism, the reader is re- 
ferred to the chapters dealing especially with the different forms of 
anesthesia. 
Ethyl Chlorid.-Ethyl chlorid is being used more and more where 
it is impossible to use nitrous oxid, on account of the difficulty of pro- 
curing the gas in tanks, etc., in certain localities. 
Its general properties were discovered by Carlson in 1896; in 1902, 
it was introduced in England as a general anesthetic, and in the latter 
country it has recently almost displaced nitrous oxid. 
Importance of Trained Anesthetists.-The tendency of the present 
day is toward absolute accuracy in the choice of anesthetics and in the 
amount administered. This, together with a competent anesthetist who 
has been thoroughly trained for that particular work, insures to the 
patient of the twentieth century complete oblivion from pain during 
surgical operations, with a minimum of discomfort and risk. 
BIBLIOGRAPHY 
"Anaesthetics Ancient and Modern; an Historical Sketch of Anaesthesia." 
Burroughs, Wellcome & Co., London, 1907. 
Bigelow, Henry J.: "Surgical Anaesthesia, Addresses and Other Pa- 
pers." Boston, 1900. 
Buxton, Dudley W.: "Crawford Williamson Long (1815-1879), the 
Pioneer of Anaesthesia, and the First to Suggest and Employ Ether 28 
ANESTHESIA 
Inhalation during Surgical Operations." Reprinted from the Pro- 
ceedings of the Royal Society of Medicine, 1912, 5, 19-45. 
Colton, J. Q.: "Anaesthesia: Who Made and Developed This Great Dis- 
covery?" A. G. Sherwood & Co., New York, 1886. 
"A True History of the Discovery of Anesthesia," A. G. Sher- 
wood & Co., New York, 1896. 
Emerson, E. W.: "A History of the Gift of Painless Surgery." Hough- 
ton, Mifflin & Co., Boston and New York, 1896. 
Foster, Burnside: "The History of the Discovery of Anesthesia." St. 
Paul, Minn., 1896. 
Foy, G.: "Anaesthetics, Ancient and Modern." London, 1889. 
Hayden, William R.: "History of Anesthesia, or Painless Surgery." 
Inter. J. Surg., New York, 1896. 
Hodges, Richard Manning: "The Introduction of Sulphuric Ether," 
1891. 
Lyman, Henry M.: "The Discovery of Anesthesia." Va. Med. Mon., 
Sept., 1886. 
McManus, James: "Notes on tlie History of Anesthesia." Hartford, 
Clark & Smith, 1894. 
Maduro: "The Status of General Anesthesia, in 1900." Med. News, 
Sept., 1900. 
Morton, William James: "Memoranda Relating to the Discovery of 
Surgical Anesthesia," and Wm. T. G. Morton: "Relation to This 
Event." New York, 1905. 
Nevius, Laird W.: "The Discovery of Modern Anesthesia. By Whom 
Was It Made? A Brief Statement of Facts." New York, 1894. 
Old Penn, April 6, 1912, 10, No. 19, 587. 
Patton, J. M.: "Anesthesia and Anesthetics." 
"Report to the House of Representatives of the United States of Amer- 
ica, Vindicating the Rights of Charles T. Jackson to the Discovery 
of the Anaesthetic Effects of Ether Vapor, and Disproving the Claims 
of W. T. G. Morton, to That Discovery. Testimony in Relation to 
the Claims of Dr. Horace Wells, with Evidence Explanatory 
Thereto." Washington, 1853. 
Rice, Nathan P.: "Trials of a Public Benefactor." New York, 1859. 
Shaw, S. Parsons: "Who Discovered Anesthesia ?" Palmer & Howe, 
Manchester, 1868. 
Sims, Janies Marion: "The Discovery of Anesthesia." J. W. Ferguson 
& Son, Richmond, 1877. 
Simpson, Sir James Young: "Anesthesia, etc." D. Appleton & Co., 
New York, 1872. 
"Answer to Religious Objections Advanced Against the Em- 
ployment of Anaesthetic Agents in Midwifery and Surgery." Lon- 
don, 1847. THE HISTORY OF ANESTHESIA 
29 
Smith, Truman: "An Inquiry into the Origin of Modern Anesthesia." 
Hartford, Brown & Gross, 1867. 
"Testimony Establishing the Claim of William T. G. Morton, M.D., on 
the Ether Discovery." 
"The Semi-Centennial of Anesthesia, October 16, 1896," Mass. Gen. 
Hospital, Boston, 1897. 
United States Congress. Senate Report from Select Committee, etc., 
32nd Congress, 2nd Session, Rep. Com. No. 421, Feb. 19, 1853. 
Warren, Edward: "Some Account of the Letheon, or Who Was the 
Discoverer?" Dutton & Wentworth, Boston, 1847. 
Warren, J. Collins: "The Influence of Anesthesia on the Surgery of 
the Nineteenth Century," 1896. 
Warren, J. M.: "The History of Anesthetics from an American Point 
of View." 
Welch, William H.: "A Consideration of the Introduction of Surgi- 
cal Anesthesia." 
Young, Hugh H.: "Long, the Discoverer of Anesthesia." Johns Hop- 
kins Hist. Bull., Nos. 77-78, Aug.-Sept., 1897. CHAPTER II 
GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
Introductory Remarks: Definition of Terms; Chief Anesthetic 
Agents. 
Theories of the Action of General Anesthetics: Spencer's 
Theory; Binz's Theory; Bernard's Theory; Dubois' Theory; Schleich's 
Theory; Miiller's Theory; Meyer-Overton Theory; Wright's Theory; 
Traube's Theory; Mathews-Brown Theory; Moore-Roaf Theory; Gill's 
Theory; Hober's Theory; Baglioni's Theory; Reicher's Theory; Gros's 
Conclusions; Burker's Theory; Verworn's Theory; Conclusions of Lillie; 
Conclusions. 
Effects of Inhalation Anesthetics upon Various Parts of the 
Organism : The Respiratory System; The Circulatory System; The 
Muscular System; The Glandular System; The Nervous System. 
Factors Which May Be Said to Modify the Physiology of 
Anesthesia as Ordinarily Induced: Warming the Agent; Experi- 
ments on Warming Ether; Effects of Moisture; Combining Oxygen with 
the Agent; The Influence upon Anesthesia of Oxygen Intra-abdominally 
Administered; Preceding the Administration with Oil of Bitter Orange 
Peel; Utilizing Carbon Dioxid. 
INTRODUCTORY REMARKS 
All attempts to give a detailed account of the action of anesthetic 
agents in general upon the organism reveal the practical impossibility 
of proceeding very far without employing a modifying phrase, "this 
varies with the agent employed," "according to conditions," "with chlo- 
roform," "with ether," etc. Therefore relatively little space is given 
here to the general physiology, special attention being directed to the 
particular physiology of each agent in the individual chapters where 
the several drugs are discussed in detail. In fact, the special physiology 
of ether, chloroform, or other inhalation anesthetic agent, is of far more 
value to the practical anesthetist than is the physiology which is applica- 
ble alike to all, the former having been evolved largely from clinical ob- 
servation, whereas the latter is the outcome chiefly of laboratory ex- 
perimentation, many points concerning which have not been definitely 
determined. 
30 GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
31 
Definition of Terms.-The term "general anesthetic" is employed in 
contradistinction to local or spinal analgesic. The state of general an- 
esthesia, or unconsciousness concurrent with insensibility to pain, is 
usually brought about by inhalation, but may be induced by various 
agencies introduced into the organism by other channels than the 
respiratory system. It may perhaps also be induced by hypnotism and 
electrical influences. 
The various narcotic and analgesic drugs which are administered by 
mouth or otherwise are excluded from discussion in this chapter. 
The state induced by the administration of inhalation anesthetics 
is designated, by the usually accepted phraseology, general anesthesia, 
anesthesia, and narcosis, all signifying unconsciousness with general 
loss of sensation, including, of course, loss of pain sense. 
Analgesia, loss of sensibility to pain, is not to be confounded with the 
above terms. The terms "light anesthesia" and "heavy anesthesia," 
whose use has been challenged by some writers1 are not in- 
correct, if considered to apply merely to degrees or stages of anes- 
thesia. 
Certain factors are generally accepted as entering into the physico- 
chemical relations of the anesthetic agent to the organism, giving rise 
to results which may be noted and controlled clinically. These factors 
are as follows: 
(1) It should be of such nature or combination, or must be capable 
of such methods of administration, as will reduce the danger to life to 
a minimum. 
(2) The anesthetic agent should possess such physical properties 
that it is easily taken into the system. 
(3) It should produce the general, complete, or temporary inhibi- 
tion of action of the nervous mechanism presiding over cerebration, 
sensation, and motion. 
(4) It should be capable of administration with the least inter- 
ference with respiration, circulation, or other vital processes. 
(5) It should act in such manner that its immediate effects are 
at all times under the control of the administrator. 
(6) It should reduce general shock to a minimum. 
(7) It should not cause serious or lasting after-effects, the organism 
promptly resuming the physiological functions existent immediately 
before the administration of the anesthetic. 
In the light of recent laboratory and clinical experiments, a further 
requirement may be added to those heretofore generally accepted as 
applying to the satisfactory inhalation anesthetic; this is: 
(8) The agent should be of such a nature or combination as to render 
possible the practically complete elimination of the second stage of an- 
'"Review of Blumf eld's Treatise,'' Lancet, Sept. 21, 1912. 32 
ANESTHESIA 
esthesia-the stage of excitement-during which the dangerous phe- 
nomena of anesthesia are often noted. 
Chief Anesthetic Agents.-The chief agents and combinations of 
agents which fulfil the above requirements are: (1) nitrous oxid; (2) 
ether; (3) ethyl chlorid; (4) chloroform; (5) combinations and se- 
quences of the above with each other and with oxygen. 
THEORIES OF THE ACTION OF GENERAL ANESTHETICS 
Inasmuch as there are still "mysteries of anesthesia," many points of 
physiology upon which expert opinions differ, we present a brief review 
of the theories concerning the mode of action of anesthetics, as ad- 
vanced by the earlier investigators as well as by more recent writers. 
No attempt has been made to catalogue all the theories proposed, or to 
follow strict chronological sequence. 
Spencer's Theory.1-Narcotic and anesthetic agents are commonly 
supposed to have special relations to the nervous tissue, rather than to 
other tissues. Because of the different effects produced, it is even sup- 
posed that some of them have elective affinities for the matter composing 
certain nervous centers rather than for that composing others. As the 
same anesthetic does not act in the same way on all persons, but here 
affects one center more, and there another, it must be assumed that 
the chemical compositions of these centers are in such cases interchanged. 
Since, in the same individual, the same quantity of the same anesthetic 
will produce quite different effects in different states of the circulation, 
the hypothesis requires the supposition that these contrasts of chemical 
composition among the nervous centers interchange from hour to hour. 
The various substances that affect the nervous system-the narcotic 
and anesthetic agents-are substances that produce changes in albumi- 
nous matters, their respective effects being modified by the various con- 
ditions under which they act. "Agents having powerful affinities for 
components of the tissues and fluids," according to Spencer, "given in 
small quantities to avoid destruction of the membranes, can scarcely 
reach the nervous system in uncombined states; and may be expected to 
work their respective effects through the instrumentalities of the com- 
pounds they have formed. The most conspicuous effects will be wrought 
by those agents which, while they can produce molecular changes in 
albuminous substances, have not such powerful affinities for them, or 
for their elements, as to be arrested on their way to the nervous system. 
The anesthetics and narcotics may fairly be regarded as fulfilling this 
requirement." It need not be supposed that the anesthetic or narcotic 
has more affinity for protein-substance of nerve corpuscle or nerve fiber 
'Spencer, Herbert: "Synthetic Philosophy," Vol. I; "Principles of Psychol- 
ogy," Appendix; "On the Actions of Anaesthetics and Narcotics," 631. GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
33 
than for the other forms of protein-substance with which it comes in 
contact. Its effect is comprehensible, however, as resulting from the 
structural relations of nerve corpuscle and nerve fiber. 
In order to understand why excitement precedes narcosis, one must 
observe the different relations of nerve corpuscle and nerve fiber to the 
blood. The vesicular tissue of the nervous system is far more vascular 
than its fibrous tissue. While the matter of the nerve vesicles is so 
arranged as to offer the least possible obstacle to the reception of the 
fluid from the adjacent capillaries, the matter of nerve fibers is shielded 
by a medullary sheath. When any agent, therefore, which is capable of 
so changing the molecular state of nerve matter as to arrest its function 
is carried into the blood, the first action is upon the nerve corpuscles. 
"Each change produced in one of these," according to Spencer, "implies 
a disengagement of molecular motion that is immediately propagated 
along the connected nerve fibers, and excites the parts to which they 
run. Every nerve corpuscle being thus quickly acted upon, and emitting 
successive discharges as the successive molecular transformations are 
wrought in it, there results a general exaltation of state, physically in 
the invigorated pulse and contractions of the muscles, and as shown 
psychically in the rush of vivid ideas and intensified feelings." While 
this is going on, while some molecules of the anesthetic agent have thus 
quickly passed from the closely adjacent capillaries into the almost 
naked matter of the nerve corpuscles, other such molecules are elsewhere 
on their way through the outer coats of the nerve tubes and the medul- 
lary sheaths within these, reaching, in time, the bundles of fibrillae 
forming the axis-cylinders. The isomeric changes which they immedi- 
ately begin to produce in these at first add to the general excitement. 
As the anesthetic invades a nerve fiber more and more, a greater and 
greater number of its molecules are rendered unable to transfer a wave 
of the peculiar isomeric change which constitutes a nervous discharge, 
and finally the fiber becomes impermeable. 
The impermeability, other things being equal, takes place sooner 
in the longer nerve fibers than in the shorter, the probability being 
that, after a given interval, a long fiber is more likely than a short 
fiber to be invaded at some parts of its course. This presumably ex- 
plains why, in an animal, anesthesia occurs first in the hinder extremi- 
ties, the parts of the surface nearer to the nervous centers losing their 
sensibility later. 
Numerous factors (point of absorption; rapidity of absorption; 
quantity absorbed; relative molecular mobility of the agent; its chemical 
relation to the blood and other substances; general state of circulation 
and of circulation in each nervous center; and character of nerve fibers 
acted upon) cooperate to cause variation in the effects produced by the 
various agents, by different doses and by the same dose under different 34 
ANESTHESIA 
conditions. It is not necessary, therefore, to assign elective affinities for 
special centers as the only possible causes of the special effects. 
Binz's Theory.1-The ganglion cell, according to Binz, is the point 
of attack of the anesthetic agent. In his experiments, fresh sections of 
the brain cortex of rabbits were placed in a one per cent solution of 
morphin hydrochlorid, or exposed to chlorin vapors. The effect of 
coagulation-necrosis was produced, as is seen when protoplasmic poisons 
of neutral reaction are allowed to act upon large transparent infusoria. 
The protoplasm is at first darkened, and the movements become slug- 
gish; later on the protoplasm becomes granulated, and the movements 
cease. Recuperation may take place from the first stage, by washing 
away the poisons, but not from the last stage. The first stage is likened 
by Binz to the sleep of the cell; the last to death. The first trace of 
coagulation may redissolve but coagulation itself does not. 
Bernard's Theory.2-Bernard regarded the ganglion cell as the point 
of attack of the narcotic agent. In his opinion, the mechanism of an- 
esthesia is always the same, in spite of the difference of the narcotic 
agent; for they all produce one identical modification in the ganglion 
cell. This modification of the ganglion cell consists in a semi-coagula- 
tion of the protoplasm of the nerve-cell, this semi-coagulation being 
merely transitory, the protoplasm resuming its previous state after the 
removal of the narcotic agent from the cell. This view was derived 
from the rigidity of muscle fibers after their exposure to chlorin vapors. 
Miiller 3 points out that the same mechanism cannot be assumed to 
underlie all narcoses, the mechanism of indifferent narcotics differing 
from the mechanism of narcosis caused by many basic narcotics. He 
believes, however, that a semi-coagulation of the protoplasm is pro- 
duced by the majority of the basic narcotics. 
Dubois' Theory.4-Dubois proposed a modification of Bernard's 
theory, holding that narcotics act by producing a dehydration of the 
protoplasm, or by decreasing the dissociation of the inhibition-water 
of the tissues. Organisms which are exposed to the action of these 
dehydrating substances are transformed into a state of latent vitality. 
Muller 5 points out that this theory is entirely erroneous, the water 
that is withdrawn being derived from the "cell juice," but not from the 
protoplasm. Bichet states that a compound becomes a more efficient 
'Binz, C.: "Ueber Anaesthetika, " Deutsche Klinik, 1860, No. 29, 277; 
'1 Ozonisierte Luft, ein schlafmachendes Gas," Bert. klin. Wochnschr., 1882, 
No. 1, 6; "Die Wirkung ozonisierter Luft auf das Gehirn," Berl. klin. 
Wochnschr., 1884, No. 40, 633. 
2 Bernard, C.: " L'anesthesie, " Union med., Paris, 1869, 8, 109. 
'Miiller, B.: " Narkologie, " I. 
'Dubois, R.: "Contribution a 1'etude de la physiologie generale des anes- 
thesiques, " Seances et Mem. Soc. de Biol., Oet. 24, 1885, 625. 
0 Muller: Loc. tit. GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
35 
narcotic, or a stronger poison, the slighter its solubility in water. This 
assertion applies to a definite number of narcotics, up to a certain de- 
gree. All indifferent narcotics, of difficult solubility in water, have the 
property of penetrating quickly to the entire protoplasm and require 
only a few seconds to get into the cell juice. Overton's statement holds 
good, that the strongest narcotics are those compounds which at the 
same time combine a very slight solubility in water with a very great 
solubility in ether, olive oil, or the lecithin mixtures. 
Schleich's Theory.1-According to Schleich, the first influence of the 
anesthetic agent is manifested by the stimulation of peripheral organs, 
followed by local stimulation at the end apparatus of the sense-organs. 
The effects upon the central apparatus are as follows: 
The blood circulates in the neuroglia in very fine vessels, and the 
first effect of the narcotic is felt as a heavy, dull sensation over the 
entire head; the result of the neuroglia irritation would be sleep, if 
the ganglion cells were not themselves stimulated at about the same 
time. As a matter of fact, this sleep can be produced in the early stage 
in certain individuals, for example in children, by very gradual an- 
esthetization. The small quantities of the anesthetic which at first cir- 
culate in the blood may cause a stimulation of the vasomotors, and 
thereby a narrowing of the vessels, on account of the close connection 
of the neuroglia protoplasm cells with the vessels. The function of the 
protoplasm cells is thereby diminished, due to limited fluid; the inhi- 
bition is lessened; ideas and thoughts travel about unchecked. It is 
not until the onset of vasomotor paralysis that the vessels become larger, 
so that the narcotic agent can stimulate the protoplasm cells directly. 
The roaming ideas are now restricted. The inhibitory function of the 
neuroglia advances- and penetrates between the individual sensory asso- 
ciations. The situation becomes blurred; momentary consciousness is 
lost; only individual ideas reach consciousness; the condition takes on 
more and more similarity to sleep, at first restless and full of dreams, 
later on deep and quiet. The pupils are still sensitive to light stimuli, 
but no longer reach their full width on closure of the lids; the contrac- 
tion increases as the narcosis advances. The pupils are contracted also 
in sleep. There probably exists a reflex arc between neuroglia irrita- 
tion and oculomotor function, or sympathetic paralysis, respectively. 
Poisons such as chloroform are relatively mild, because they are 
first accompanied by neuroglia irritation, whereas the true cell poisons 
penetrate at once into the ganglion cells, exerting their relative influence 
beyond the protective action of the neuroglia, and acting upon the gan- 
glion cells by way of the lymph spaces and blood vessels. Narcoses with 
chloroform, ether, alcohol, etc., are increased physiological mechanisms, 
namely, changes in repletion with blood and irritations of the neuroglia. 
1 Schleich: ' ' Zur Infiltrations Anaesthesie, ' ' Therap. Monatsh., 1894, 429. 36 
ANESTHESIA 
When these substances are administered in definite quantities which 
create a state of equilibrium between the action of the narcotic and the 
power of resistance of the neuroglia, their effect becomes narcotic, and 
this effect increases the more the scale of equilibrium tips toward the 
narcotic, until finally the neuroglia is overcome, and the effect is then 
the same as that of the cell poisons which directly attack the ganglion 
cell, omitting the neuroglia. 
Schleich considers the narcotic agents as primary neuroglia poisons, 
and their antagonists (the cell poisons) as primary cell poisons. He 
also assumes a variable sensitiveness of the neuroglia in the different 
developmental stages. The effect of chloroform, and the majority of 
narcotics, upon the individual centers of the human brain, pursues a 
course in inverse ratio to the phylogenetic development of the centers. 
The extraordinarily poisonous effect of chloroform and of morphin 
upon certain individuals is explained by him as due to the fact that, in 
these cases, the neuroglia does not react to the ordinary toxic dose by a 
stimulation, but directly by paralysis. 
Muller's Theory.1-After considering various theories of narcosis, 
Muller formulated his own view concerning the mechanism of 
anesthesia. 
After the narcotic agent has reached the ganglion cells of the cere- 
bral cortex, it exerts its action upon the lecithin-cholesterin mixture of 
the ganglion cell, causing it to undergo a physical transformation. Ac- 
cording to Schleich's theory, the plasma cells of the neuroglia are also 
important and possess inhibitory properties; they surround each func- 
tionating ganglion cell and communicate directly with a vessel. As 
the plasma cells are directly connected with the perivascular lymph 
spaces of the vessels, and are themselves surrounded by lymph spaces, 
the narcotic agent which is contained in a definite concentration in 
the blood plasm must be taken up by the lymph of the lymph spaces, 
and an equilibrium in the concentration of the two fluids in the narcotic 
must become established. It depends upon the composition of the proto- 
plasm of the plasma cells, how much narcotic they will take up before 
this reaches the ganglion cell. The paralysis of the plasma cell rep- 
resents that instant at which the quantity of the narcotic in the plasma 
cell is such that no additional amount can be taken up. The narcotic, 
at this moment, gets also into the ganglion cell. The plasma cell is now 
passed without its protoplasm taking up anything of the narcotic, and 
the ganglion cell takes up the narcotic from the intercellular lymph. 
The function of the neuroglia explains the different effects of the nar- 
cotic upon the individual centers. By assuming the presence of lecithin- 
cholesterin mixtures also in the plasma cells, it becomes intelligible that 
they possess the capacity of dissolving the narcotic agents. Possibly, 
1 Muller, B.: Loc. cit. GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
37 
these plasma cells contain still another similar substance, which does 
not exist in the ganglion cells, and thereby invests the plasma cells 
with the capacity of fixing still larger quantities of the narcotic. This 
other body may be contained in larger amounts in the phylogenetically 
older plasma cells than in the younger cells, thus accounting for the 
prolonged resistance in still another way. The significance of the 
solubility of the narcotic in the cells of the neuroglia is at once evident, 
when the function of the neuroglia is interpreted as something more 
than connective tissue function. The different effect upon the ganglion 
cells is explained by the different number of existing plasma cells. The 
action of the neuroglia consists in modifying the solubility of the nar- 
cotic agent and thereby controlling the rate of its penetration into the 
ganglion cells. 
Meyer-Overton Theory.-In 1899 Hans Meyer announced his theory 
of narcosis;1 the following year E. Overton described his theory of anes- 
thesia;2 and in 1905 Meyer restated his theory.3 Since these two 
theories were formulated independently and without conference,4 and 
in general agree, this explanation of anesthesia is usually referred to as 
the Meyer-Overton theory. 
According to Meyer, the narcotizing substance enters into a loose 
physico-chemical combination with the vitally important lipoids of the 
cell, perhaps with lecithin, and in so doing changes their normal rela- 
tionship to the other cell constituents, through which an inhibition of 
the entire cell chemism results. The narcosis disappears as soon as the 
loose, reversible combination, dependent upon the solution tension, 
breaks up. 
In accordance with these views Meyer formulated the following 
statements: 
"(1) All primarily indifferent chemical substances which are solvents 
for fat and substances resembling fat must exert a narcotic action upon 
living protoplasm, in so far as they can diffuse therein. 
"(2) The effect must manifest itself first, and most strongly, in those 
cells in whose chemical structure these fatty or lipoid substances pre- 
dominate and presumably are the essential carriers of the cell function, 
-namely, in the first place, in the nerve cells. 
"(3) The relative efficiency of such narcotic agents must be de- 
pendent upon their mechanical affinity for lipoid substances, on the 
one hand, and for the remaining body constituents, i. e., principally 
1 Archiv f. exper. Pathol, u. Pharmakol., May 16, 1899, 110, 119. 
2"Studien uber die Narkose, zugleich ein Beitrag zur allgemeinen Phar- 
makologie, " Jena, 1901. 
""The Theory of Narcosis," Harvey Lectures, 1905, 7; J. Am. Med. Assn., 
Jan. 20, 1906, 167. 
* J. Am. Med. Assn., Jan. 29, 1906, 169. 38 
ANESTHESIA 
water, on the other hand. It is dependent, therefore, upon the division 
coefficient which determines their distribution in a mixture of water 
and lipoid substances." 
Overton carried out extensive observations and investigations con- 
cerning the osmotic properties of living plant cells and animal cells, 
followed by experimentation with general anesthesia. He was firmly 
convinced of the fact that the mode of action of anesthetic agents can 
in no way be explained on the basis of chemical reaction; for the reason 
that many of the strongest indifferent narcotics belong chemically to 
the most stable and sluggish compounds. The effect of narcotic agents 
is essentially a function of their lipoid solubility. 
Overton showed that substances may be divided into different groups 
according to the rapidity with which they diffuse into protoplasm, the 
rate of diffusion, as a general rule, depending upon the solubility of 
the substances in fat, lecithin, and lipoid substances of that type. If 
S represents the solubility of the substance in fat, and Sw that of 
Q 
the same substance in water, then the ratio -1 is termed the distri- 
Sw 
bution coefficient of the substance. According to Overton, the value of 
this coefficient determines the velocity of diffusion into cell protoplasm. 
It has been indicated by Meyer and Overton1 that anesthetics and 
narcotics are usually substances which diffuse rapidly, and that, there- 
fore, these substances should have a high distribution coefficient. Meyer 
accordingly compared the aliphatic narcotics, and found that the nar- 
cotic power of these was roughly proportional to the magnitude of the 
distribution coefficient. This finding has been expressed as follows: 
The strength of the narcotic action of a compound is dependent upon 
its solubility in lipoid substance.2 But, as has been pointed out by May,3 
this is not exactly correct, since it depends not so much on its actual 
solubility in lipoid substances as upon the ratio of its solubility in lipoids 
to that of its solubility in water. 
Meyer compared the narcotic power of the aliphatic narcotics by 
ascertaining the smallest concentration which would produce a definite 
physiological effect, and he expressed the values as fractions of a normal 
solution, calling these the "liminal values." He and Baum4 discussed 
the work of Dubois 5 in reference to which they advanced the theory that 
the relative strengths of anesthetics are dependent upon their mechan- 
ical affinity for fatty substances, like lecithin in the protoplasm, on the 
one hand, and to the other constituents in the protoplasm, especially 
1 Arch. f. exp. Path. u. Pharm., 1901, 42, 109 and 119. 
2 See Hober's Theory, p. 46. 
8 Loc. tit. 
4 Arch. f. exp. Path. u. Pharm. 42, 109. 
5 See Dubois ' Theory, p. 34. GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
39 
water, on the other hand. In support of these views, they showed that 
the proportion between solubility in fat and solubility in water of a 
number of narcotics runs parallel with their anesthetizing activity. 
The theory of Overton and Meyer is well supported by the paral- 
lelism of narcotic effect and distribution coefficient. Then, too, a num- 
ber of subsidiary facts appear to lend it additional support; for example, 
the observation of Mansfield,1 that some narcotics have a more powerful 
action when administered to starved animals, the explanation suggested 
being that in these there is less tissue fat to absorb some of the narcotic 
and that a greater portion of the latter is in consequence absorbed by 
the central nervous system; and the observation of Tunnicliffe and 
Rosenheim2 that the addition of lecithin protracts the effect of chloro- 
form on the heart.3 
However, other facts seem to show that the theory is, to say the 
least, incomplete. For instance, the peripheral nerves contain a large 
amount of lipoid substance, yet they are much less affected by the ali- 
phatic narcotics. It has also been pointed out by Cushny 4 that many 
aromatic compounds have a high distribution coefficient, but are never- 
theless devoid of narcotic action. There is, however, a possible expla- 
nation of these facts in Traube's theory (see p. 42) of surface tension. 
It appears reasonable to conclude from these facts: 
(1) That the rapid penetration of the cells should be the most 
essential condition of enabling a substance to exert its effect on the 
interior of the cells. 
(2) That, after the substance has gained entrance, its solubility in 
the cell lipoids may be the important factor in determining narcotic 
action. 
The Meyer-Overton theory is more than merely interesting. It 
ostensibly gives a simple explanation of narcosis and seems to afford a 
means of elucidating other processes, as phagocytosis.5 In support of 
the combination of, say, chloroform with lecithin, we have the analogous 
conduct of this compound with salicylid,6 leprarin,7 and even water;8 
and further support is given to the Meyer-Overton theory by the finding 
1 Centr. Physiol., 20, 664. 
2 Proc. Physiol. Soc., 1903, 15. 
8 Tunnicliffe and Rosenheim studied the action of chloroform and ether on 
the heart by adding them to saline fluid perfused through the heart by Locke's 
method. The depressing action on the heart produced by chloroform was found 
to be very marked, but if lecithin was also added the effect was found to be 
delayed. 
4Cushny: "Text-book of Pharmacology,'' 1904, 128. 
5 See Graham: J. Am. Med. Assn., March 26, 1910, 1044. 
8 Anschutz: Ann., 273, 94. 
'Kassner: Arch. Pharm., 237, 44. 
8 See Z. anal. Chem., 25, 118. 40 
ANESTHESIA 
of Nerking,1 that, in the case of animals to which a solution of lecithin 
has been administered, the anesthesia lasted for "a much shorter time" 
than in the case of the control animals, and the work of Graham,2 
who found that lecithin and olive oil added to etherized blood restored 
phagocytosis. Although the theory is well supported by certain evidence, 
it is too specific to be altogether satisfactory. 
There is much uncertainty as to the mode of action of anesthetics 
and particularly as to their effect upon permeability. While some writers 
hold that anesthetics increase permeability, others take the opposite 
view.3 As pointed out by Osterhout,4 to clear up this confusion appears 
to be a necessary step toward a theory of anesthesia. He seems to have 
attained a definite solution of the problem in the cases he describes-a 
result due to the employment of quantitative methods. 
The experiments of Osterhout were made by measuring the con- 
ductance of living tissues of a marine plant, laminaria. Under the con- 
ditions of the experiment, an increase or decrease of conductance 
signified a corresponding increase or decrease of permeability.5 The 
anesthetics (ethyl ether, chloroform, chloral hydrate, and alcohol) were 
mixed with sea water and sufficient concentrated sea water was then 
added to make the conductivity equal to that of sea water. The material 
was then placed in the mixture and its conductance was measured at 
frequent intervals. 
Two distinct effects were observable in the experiments conducted 
by Osterhout. One was a toxic effect evidenced by an increase in 
permeability, while the other involved a decrease in permeability. He 
was forced to the conclusion, from the results obtained, that it was 
the reversible change, involving a decrease of permeability, which was 
associated with the anesthetic action. This is indeed reasonable.6 Os- 
terhout pointed out that the fact that typical anesthetics decrease the 
permeability of the tissue to ions is significant in view of the fact that 
the transmission of nervous and other stimuli is believed to depend on 
the movement of ions within the tissues. 
Wright's Theory.7-Wright undertook an investigation to determine 
1 Munch, med. Woch., 1908, 1733. 
2 J. Am. Med. Assn., March 20, 1910, 1043. 
3 Cf. Hober: " Physikalische Chemie der Zelle und der Gewebe, " 1911, 219, 
223, 489; Lillie: Am. J. Physiol., 1912, 29, 372; 30, 1; and Lepeschkin: Ber. d. 
bot. Ges., 1911, 29, 349. 
4 Science, n. s., 37, No. 942, 111. 
5 The method is described in Science, n. s., 35, 112 (1912). 
8 The distinctive mark of an anesthetic is the reversibility of its action; 
hence it can hardly be concluded that this action is associated with an irre- 
versible change in permeability. Such a change is not peculiar to anesthetics, 
although common to all toxic substances. 
'Wright, Hamilton: "The Action of Ether and Chloroform on the Neurons 
of Rabbits and Dogs,'' J. Physiol., 1900-1, 26, 30, 362. GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
41 
whether chloroform and ether produce any transient or permanent 
changes in the cortical or spinal neurons. 
In rabbits he found that these agents produced changes in the nerve 
cells of both the brain and spinal cord. These changes were slight at first, 
but became more marked as the anesthesia continued. The principal 
change was described by him as "rarefaction." In the advanced cases 
he employed the term "skeleton cell," and, in the most marked cases, 
he found that a "pseudo-degenerative" change had set in. 
In dogs there were practically no changes up to two hours, but, 
between that time and four hours, changes occurred in the nerve cells 
similar in kind to those observed in rabbits, although less in degree. 
These changes became more marked as the anesthetic was continued. 
Wright regarded the changes observed in the cells and their pro- 
cesses as due directly to the influence of the anesthetic, and not due indi- 
rectly to the capillary anemia which is produced. 
Inasmuch as it is generally conceded that ether and chloroform cir- 
culate in the blood as such, producing no biochemical changes in the 
blood, Wright concluded that the neuronal changes are biochemical 
in nature, and are produced by the anesthetic that reaches them via the 
blood stream. 
There is nothing, he holds, to suggest that chloroform or ether could 
cause these changes mechanically; the supposition that they act chem- 
ically is extremely probable. 
It is obviously impossible to say that these changes occur in human 
beings. Wright did not consider, however, that there is any analogy 
between the changes described and those biochemical anabolic and 
katabolic changes that occur in daily life, and mark sleeping and waking 
hours. He regarded the action of narcotics, such as ether and chloro- 
form, as pathological, not very intensely so, yet as something which is 
remote from physiological processes. In sleep there is probably an 
opportunity, he says, for the constituents of the nerve cells to undergo 
anabolic changes, whereas in the unconsciousness produced by anes- 
thetics the process appears to be associated with an exhaustion of them. 
A subsequent series of experiments1 was undertaken (1) to determine 
whether a still more prolonged period of anesthesia renders the changes 
more intense, and (2) to ascertain whether the pseudo-degenerative 
change is permanent: the answer to the first question was affirmative; 
to the second, negative. 
In the cases in which the anesthesia was kept up longest it was 
found that even the nuclei and the nucleoli were affected, the latter 
being the last part of the cell to show the effect of the drugs. The 
slow return of the conjunctival reflex in these cases, he thought, indi- 
cated that after a certain period of anesthesia (six hours in the dog) 
'Wright: Ibid., page 363. 42 
ANESTHESIA 
the depression of neuronal function becomes more rapidly profound, 
and that there is a limit to the time of safe anesthesia. The histological 
changes observed induced this view. A greater alteration occurred in 
the cells during the three hours between the sixth and the ninth hours 
of anesthesia than during the five hours between the first and the sixth 
hours. 
The changes observed in the cells were transitory, disappearing with 
the disappearance of the drugs from the circulation and tissues, or soon 
thereafter. Forty-eight hours after nine hours of ether narcosis the cells 
were found to be practically normal. 
The rarefaction of the cell substance and the formation of monili- 
form (necklace-like) swelling noted in the dendrons, according to 
Wright, may modify nervous function. "To such changes," he says, 
"may perhaps be attributed those losses of memory, slight manias and 
melancholias that are now and then reported to follow prolonged anes- 
thesia in the human subject." 
Traube's Theory.1-In his theory of the production of general anes- 
thesia, Traube contradicts the lipoid solubility, claimed by Overton, 
as the primary cause of the penetration of the anesthetic agent into 
the cell. This cause, according to Traube, consists in the surface ten- 
sion. When two fluids of different surface tension are separated through 
a membrane, the fluid having the lower tension can find its way to that 
with the higher tension; so that the difference between the surface 
tensions explains the entrance of the anesthetizing fluid into the cells.2 
He also claims the existence of a close conformity between the narcotic 
efficiency and the surface tension in the case of pure anesthetic agents 
which are free from toxic side-effects. 
Mathews-Brown Theory.-Mathews3 made Nef's bivalent carbon 
hypothesis 4 the basis of a hypothesis for protoplasmic respiration which 
'Traube: " Theorie der Osmose und Narkose," Arch. ges. Physiol., 1904, 
105, 451; Phil. Mag. (6), 8, 704; Z. physiol. Chem., 105, 541. 
2 When the drug has thus gained entrance to the cell, it may exercise its 
narcotic power in proportion to its solubility in the cell lipoids. 
3 Mathews, A. P.: Biol. Bull., 1905, 8, 331. 
4 The bivalent carbon hypothesis of Nef (J. Am. Chem. Soc., 26, 1549) ap- 
proaches the action of narcotic agents to the fundamental reactions of organic 
chemistry. According to his investigations of the chemistry of the element car- 
bon, protoplasmic respiration can be explained as a vital reaction through the 
decomposition of water, on the basis of a change in valence of the carbon atom 
from four to two. The quadrivalence of carbon is not constant, the existence 
of carbon compounds containing bivalent carbon having been definitely estab- 
lished. The bivalent carbon compound of cells, or their respiratory elements, 
are the point of attack of the entering anesthetic agent. The action is assisted 
by a rise in temperature. Substances which are perfectly indifferent chemi- 
cally, such as the volatile saturated hydrocarbons, may produce anesthesia by 
entering into a loose chemico-physical combination with certain cell constituents, GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
43 
Brown 1 considers plausible. The bivalent carbon compound of the pro- 
toplasm, which, according to Mathews, may be either simple or complex, 
decomposes the water of the tissues into its elements. The oxygen, com- 
bining with the compounds constituting protoplasm, oxidizes them. The 
hydrogen, uniting with free oxygen or other substance in the tissues, 
passes off as gas. 
Mathews holds that anesthetics inhibit the action of the bivalent 
carbon, thereby decreasing the respiration of the cell protoplasm, result- 
ing in the stage known as anesthesia. 
Brown, referring to this theory, thought it more likely that the sub- 
stances producing a narcosis do so, "not by an action on any one of the 
essential processes of the protoplasm, but from the combined influence 
of all of them. The role that the lipoids of the cell play in narcosis may 
be only that of a solvent or gatherer for the narcotic, or more, depending 
upon whether or not the lipoid is concerned with the essential living 
processes of the cell." 
Mathews had previously called Brown's attention to the fact that 
starfish eggs were greatly affected by chloroform, ether, etc. The effect 
appeared to be a partial liquefaction of the protoplasm. Mathews sug- 
gested that possibly the power of each member of this group of com- 
pounds to liquefy the starfish eggs might be proportional to its narcotic 
power. Mathews had made some experiments along this line, a report 
of which was published. This work was repeated and extended by 
Brown, who made a comparative study of a number of the compounds in 
common use as anesthetics, narcotics and hypnotics. 
The change produced in the eggs was found to be a profound one. 
The eggs enlarged and became lighter in color; the protoplasm became 
less granular, and finally there was a rupture of the envelope at some 
spot, the contents flowing out. 
Brown called attention, in this connection, to Hermann's 2 observa- 
tion of a similar change in red blood corpuscles when treated with an- 
esthetics. The process indicated that the contents of the cell had been 
increased, in amount and fluidity. The explanation, according to 
Brown, seems to be that the narcotics are taken up by the fat-like bodies 
of the egg. 
From his comparative studies Brown concluded, in part, as follows: 
"(1) That anesthetics and narcotics, at certain concentrations, cause 
a profound change in the eggs of starfish. This change appears to be a 
the effect disappearing as soon as this loose reversible combination ceases. 
From this point of view, narcosis represents an inhibition of the entire chemism 
of the nerve cell, through changes in the normal mutual relations of the cell 
constituents. 
'Brown, Orville Harry: "A Pharmacological Study of Anesthetics and 
Narcotics," Am. J. Physiol., 1905-6, 15, 85. 
"Hermann: Arch. Anat. Physiol., Wes. Med., 1866, 27. 44 
ANESTHESIA 
partial liquefaction. The power of the compounds in bringing this about 
is indicative of their power as narcotics; i. e., the narcotic substance 
which produces liquefaction of the eggs in a dilute solution will also, 
in small amounts, produce narcosis. 
"(2) That anesthetics and narcotics do not cause the liquefaction if 
they are sufficiently concentrated or sufficiently diluted. The concen- 
trated solution causes a change which has the appearance of a coagu- 
lation. 
"(3) The most important role of the lipoids in bringing about anes- 
thesia probably is one of accumulation. If they are concerned with the 
essential process of the cell, then their part is most likely a broader one. 
"(4) Anesthesia is very possibly the result of an inhibition, by the 
compounds, of the enzymotic processes of the cell, as suggested by 
Neilson and Terry.1 
"(5) Mathews' idea that the anesthetics produce their results by their 
influence upon the respiratory elements-the bivalent carbon compound 
-of the cell is a tenable one. 
"(6) Nef's bivalent carbon hypothesis may help to explain the more 
rapid narcosis when the temperature is slightly raised." 
Moore-Roaf Theory.2-Moore and Roaf have found that the action of 
the numerous substances used as anesthetics probably depends on the 
general type of interaction between it and the cell protoplasm. In 
regard to chloroform, they pointed out that attention was not restricted 
to the action on nervous structures, since all cells (bacteria, amebae, 
ciliated cells, etc.) are equally affected. It was therefore concluded 
that the action must take place with some chemical constituent present 
in all varieties of protoplasm, and that theories based on the high con- 
tent of nerve cells in lecithin and fatty constituents may be disregarded. 
Proteid is the substance of all others universally present in all cells, 
and Moore and Roaf found that chloroform formed loose compounds 
with many proteids; in fact, that it would precipitate them if in excess.3 
This, they thought, explains the greater solubility of chloroform in the 
blood, or in serum and hemoglobin solutions, than in water or in saline 
solutions. 
Their theory of narcosis may thus be expressed: The loose com- 
pound of proteid-chloroform is similar to oxyhemoglobin. When anes- 
thesia occurs, the proteid-chloroform compound of the blood has parted 
with its chloroform to the cell proteids; the compound here formed 
undergoes dissociation when the chloroform pressure is reduced on 
'Neilson and Terry: Am. J. Physiol., 1905, 14, 248. 
2 Moore and Roaf: Proc. Roy. Soc., 73, 382. 
3 Formanek (Z. physiol, Chem., 29, 416) has also found that both chloroform 
and chloral hydrate are good precipitants of the blood pigment, particularly at 
56° C. He recognized that chloroform is a precipitant for proteids. GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
45 
cessation of administering the anesthetic, and anesthesia thus 
ceases. 
Later, Moore and Boat1 supplied confirmation to the theory that 
chloroform and other anesthetics form unstable compounds with pro- 
teids, and that they produce their effects by thus interfering with the 
chemical activities of protoplasm. They learned that the solubility of 
the anesthetic was greater in serum than in water, and that beyond a 
certain concentration, which was definite for each anesthetic, precipi- 
tation of the compound with proteid occurred. It was found that the 
vapor pressure was always higher in an aqueous solution than in solu- 
tions which contained proteid, and determinations of freezing points 
and electrical conductivity supported the main contention of the inves- 
tigators.2 
Edie3 investigated the proteids of serum and hemoglobin in ref- 
erence to the work of Moore and Boaf. It was found that the compound 
of chloroform and hemoglobin was less stable than carboxy-hemoglobin, 
and that when sufficient chloroform was added to produce precipitation 
the amount of chloroform found in the precipitate was constant. In 
the case of the serum proteids, also, the amount of chloroform was found 
to be fairly constant. 
The action of chloroform and hemoglobin has also been studied by 
Kruger,4 whose experiments showed that chloroform was not an indif- 
ferent reagent toward hemoglobin, but that it changed it into a more 
insoluble modification without apparently producing any profound 
chemical alteration. 
The following determined facts seem to lend the theory of Moore 
and Boaf additional support: 
(1) It has been shown by Carlson and Luckhardt5 that during 
chloroform or ether anesthesia the osmotic concentration of the blood 
rises. This varies with the depth, and not with the duration, of the 
anesthesia. The main factor in this observation appears to be that the 
ether or chloroform itself is dissolved in the blood, although there are 
other factors which cannot be altogether excluded. 
(2) Camus and Nicloux6 have found that ethyl chlorid is taken up 
by the blood with great rapidity and is also eliminated with rapidity. 
(3) Li von 7 found that during anesthesia produced in dogs by amy- 
1 Moore and Roaf: Proc. Roy. Soc., B., 77, 86. 
2 Thompson, Yates, and Johnston, Lab. Report, Liverpool, 1905-6, 151-94; and 
cf. the investigations of Buglia and Simon: Arch. ital. biol., 48, 1. 
" Thompson, Yates, and Johnston, Lab. Report, Liverpool, 1905, 6, 195. 
' Beitr. chem. Physiol. Path., 3, 67. Cf. Gianasso: Riforma Medica, 32 No. 19, 
who is of the opinion that chloroform destroys the red corpuscles of the blood. 
5 Compt. rend. Soc. biol., 55, 143. 
' Ibid., 145, 1437. 
' Ibid., 55, 143. 46 
ANESTHESIA 
lene there is no arrest of internal combustion; but, on extracting the 
blood gases, amylene was found as a constituent. 
Gill's Theory.1-Gill's observations concerned chloroform, which, ac- 
cording to his theory, abstracts oxygen from the blood, being itself 
destroyed in the process. "The deoxygenation factor," according to 
Gill, "which is their proximate cause, thus intermediates between the 
indirect phenomena and their ultimate cause, which is chloroform." 
The relation between chloroform and the blood is held by him to be 
twofold. It causes deoxygenation by the diminishment of the normal 
supply of air to the alveoli of the lungs, and by its physiologico-chem- 
ical action it is indirectly the cause of the suspension of the functions 
of the cerebral centers. 
Hbber's Theory.2-In his studies on the physical chemistry of excita- 
tion (of muscle) and of narcosis, Hober found that isotonic solutions 
of normal salts of the alkali metals produce currents of rest of varying 
intensity and direction when applied locally to the non-injured sartorius 
muscle of the frog. When arranged according to their power of pro- 
ducing this current, the various anions and cations form two series, 
which coincide with those which have been deduced from their action on 
the solubility of egg-white and of lecithin.3 This coincidence is one 
of the reasons for Hober's conclusion that excitation and the electrical 
reaction accompanying it are closely connected with the consistency of 
the muscle colloids. 
According to Hober, narcotics inhibit the change in the colloids (of 
the axis cylinder), which change accompanies the normal current of 
action, and, in accordance with the current theory of narcosis, due to 
Meyer and Overton, this colloidal change is supposed to occur in the 
lecithin. Narcosis would therefore consist, first, in the accumulation 
of the lipoid-soluble narcotic in the lipoid substance (lecithin), and, 
second, in the inhibition of the colloidal changes which excitation nor- 
mally produces in this substance. 
Baglioni's Theory.4-Baglioni maintains that narcotic effect depends 
1 Gill, Richard: ' ' The CHC13 Problems, ' ' 1906, 2, Physiological Action. 
2Pfluger's Archiv, 1907, 120, 492; J. Chem. Soc., 94, ii, 121. 
8 An examination of the effect of normal salts on the precipitation of egg- 
albumen, serum-albumin, and lecithin, and on the catalysis of methyl and ethyl 
acetates by acid and by alkali, was made by Hober (Beitr. chem. Physiol. Path., 
11, 35). The results obtained by catalysis were quite regular; for instance, the 
chlorids of the alkali metals accelerated the acid catalysis in the order of their 
atomic weights, lithium chlorid being most, and caesium chlorid least, active. 
In neutral solutions, the order of efficiency as precipitants became irregular, and 
depended simultaneously on both ions. 
On the efficiency of various salts of the alkali metals as lecithin precipitants, 
see also Porges and Neubauer: Biochem, Z., 7, 152. 
4 Francis and Fortescue-Brickdale: ' ' The Chemical Basis of Pharmacology, ' ' 
1908, 86. GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
47 
on the deprivation of oxygen from the "inogen" compounds in the 
central nervous system; narcosis is a reducing process. This theory is 
based on the fact that, in the case of various groups of benzenephenol 
derivatives, the paralyzing action of the substance is inversely propor- 
tional to the amount of oxygen already in the side-chain, and that 
deprivation of oxygen by breathing inert gases, as carbon dioxid or 
hydrogen, produces symptoms similar to those of chloroform. Support 
to the view is had from the work of Herter,1 who showed that chloro- 
form, ether, and chloral hydrate diminish the oxidizing capacity of 
tissues. The theory of Baglioni indicates a possible mode of the action 
of narcotics after they have entered the cell. The other theories mainly 
pertain to the conditions which determine entrance into the cell 
substance. 
Reicher's Theory.2-Reicher carried out a series of experimental 
studies on anesthetized dogs, in which he invariably found a considera- 
ble increase of the fat, or the lipoids, in the circulating blood. From 
this he drew the conclusion that the narcotic effect is not due to the 
fixation of the anesthetic in the lipoids of the brain, but rather to the 
washing out of the lipoids from the brain. The Meyer-Overton theory 
should accordingly be revised. Through the lipemia there occurs a 
profound impairment of the fat metabolism, which, in its turn, leads 
to acetone intoxication.3 Again, the acetone intoxication explains a 
part of the fundamental disturbances of the nervous system produced 
by the general anesthesia. 
The modification of the Meyer-Overton theory, as proposed by 
Reicher on the basis of his findings, is as follows: The decisive factor 
for the efficiency of an anesthetic consists in its relative solubility 
in the lipoids. There takes place not simply a change of the normal 
physical condition, not merely a fixation in a sort of rigid solution, 
without the extrusion of lipoids from the cell; there occurs also an 
expulsion of vital lipoids and fats, in an as yet unknown mutual 
action between the anesthetic agent and the cell lipoids, this inter- 
action perhaps playing a part in the occurrence of the general anes- 
thesia; the lipoid remains for a long time chemically and microscopically 
demonstrable in the blood, as well as histologically demonstrable in the 
organs. 
Kramer's4 experiments do not bear out Reicher's assumption as 
to the cause of the lipemia. The explanation of this phenomenon, 
1 Herter and Richards: Am. J. Physiol., 12, 207. See also Wright: J. 
Physiol., 26, 362. 
2 Reicher, K.: " Chemisch-experimentelle Studien zur Kenntniss der Nark- 
ose, " Zeitschr. Idin. Med., 1908, 65, 235. 
s These results refer to aliphatic derivatives. 
4 ' ' The Role of the Lipoids and Particularly Lecithin in Narcosis, ' ' J. Exper. 
Med., 1913, 17, No. 2. 48 
ANESTHESIA 
according to Kramer, is still an open question, for from his observations 
he concluded: 
"1. The intravenous injection of five to thirty cubic centimeters of 
a 5 or 10 per cent emulsion of lecithin, depending upon the size of the 
animal used, does not interfere with the induction of anesthesia, and 
this can be accomplished as readily in animals thus injected as in 
controls. 
"2. In six out of nine experiments lecithin had no effect upon the 
rapidity with which the various phenomena which indicate the animal's 
recovery from the effects of the anesthetic appeared/' 
Gros's Conclusions.1-Gros's experimental investigations of the rela- 
tionship of general and local anesthetics, on the basis of physical chem- 
istry, show that the latter have, in many respects, the same properties 
and effects as the former. General anesthetics possess the following 
three properties:2 
(1) A general action on protoplasm. 
(2) An elective action upon the nervous system, especially the 
central nervous system. 
(3) The possibility of restitution of the functions which have been 
disturbed by the anesthetic agent. 
Biirker's Theory.3-According to Biirker, anesthesia is produced in 
such a way that, in the first place, the anesthetic agent accumulates 
especially in the nervous system, on account of its marked lipoid solu- 
bility. This accumulation, as such, does not suffice, but a chemical 
reaction results, the anesthetic agent appropriating the active oxygen. 
In consequence, this substance is withdrawn from the nervous tissue 
which is so arid of oxygen, and this oxygen deprivation leads to tem- 
porary asphyxiation, with paralysis of the physiological function. The 
products which originate in the oxidation of the anesthetic agent may 
be considered as partially responsible for the untoward after-effects of 
general anesthesia. 
This theory is based upon the following observation, as well as upon 
'Gros, O.: "Ueber Narkotika und Lokalanesthetika," Arch. exp. Path. u. 
Pharm., 1910, 63, 80. 
2 These three properties are likewise found in the local anesthetics, cocain, 
eucain, stovain, alypin and novocain, which are protoplasmic poisons. The 
more strongly a general anesthetic acts upon the central nervous system, the 
stronger is its action also as a local anesthetic. 
The theory of Meyer and Overton is also applicable to local anesthetics. As 
compared to general anesthetics, the local agents show the important difference 
that the sensory nervous system is more sensitive toward them, in a general way, 
than the motor nervous system. 
The anesthetic potential of the local anesthetic salt depends on that of the 
base and the degree of hydrolytic dissociation. 
3Biirker: "Eine neue Theorie der Narkose, " Centralbl. Physiol., 1911, 24, 
103; Miinch. med. Woch., 1910, 27, 1445. GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
49 
certain other well-known facts: When an electric current is passed 
through acidulated water, saturated with ether or some other anesthetic 
agent, only a very small amount of oxygen is liberated at the anode, the 
remaining oxygen being utilized for the oxidation of the ether, with 
the production of carbon monoxid, carbonic acid, acetaldehyd, etc. 
Biirker's experiments, in his opinion, are promising in regard to the 
rational selection of the anesthetic agents by means of electrolysis; and, 
at the same time, they elucidate the character of the oxidation processes 
in the living substance. It is also noteworthy, in this connection, that a 
~ solution of grape-sugar (1.8 per cent) has practically no influ- 
ence upon the course of the electrolysis, in acid and neutral solutions, 
showing that the active oxygen alone is evidently insufficient for its com- 
plete combustion. 
The chemical indifference of the anesthetic agents, or a purely 
mechanical change in the condition of the plasma colloids, in the sense 
of Meyer and Overton, can hardly be admitted, according to Biirker, 
whose experiments indicate a temporary asphyxiation of the nervous 
system, in general anesthesia in the sense of Verworn and his school. 
The mechanism of this asphyxiation is suggested by the results of the 
electrolytic experiments. The bad after-effects of general anesthesia 
are accounted for by the changed metabolism in general, which would 
be entirely inexplicable in the case of a chemical indifference of the anes- 
thetic agent. The metabolism is altered in a similar way as in diabetes, 
a disturbance of the normal oxidation processes being probably respon- 
sible. 
Verworn's Theory.1-Verworn, in his recent monograph, contributes 
the result of his investigations, after ten years' work on the elucidation 
of the mechanism of anesthetics by means of experiments. On the basis 
of his findings, he groups anesthesia under the headings of the manifold 
paralyses which originate through a disturbance of the oxygen metabol- 
ism. General anesthesia is equivalent to asphyxiation of the tissues. 
This asphyctic state does not occur in consequence of the deficiency in 
oxygen as such, but it arises through the inhibition of the oxidation 
processes by the anesthetic agents. Accordingly, asphyxiation may also 
occur in the presence of abundant oxygen contents of the medium in the 
surroundings of the tissue or of the tissues themselves. In asphyxiation 
through the anesthetic the paralysis is acute; in asphyxiation in a 
medium free from oxygen the paralysis is more gradual in onset. 
In discussing the potential fashions in which the anesthetic, by pene- 
trating into the cell, suppresses its capacity for the production of oxida- 
tions, Verworn inclines to the explanation that the anesthetic agent pre- 
vents the transmission of oxygen from the medium and the reserve stores 
'Verworn, M.: "Narkose" (Monograph), Jena, 1912. 50 
ANESTHESIA 
in the cell to the oxidizing materials. This explanation is most readily 
compatible with the laws of lipoid solubility and anesthetic action, for- 
mulated by Meyer and Overton; in this connection, Verworn assumes 
that the lipoids are in some way closely related to the oxygen carriers. 
In conclusion, the author explains the difference between sleep and 
general anesthesia: In sleep, a reaction takes place, with the assistance 
of the oxygen; whereas, in general anesthesia, the restitution is inhibited 
through the prevention of the oxygen of the oxidation processes. Hence, 
these processes are radically different. 
Commenting on the view of Verworn, Lillie 1 points out that "cell- 
division-e. g., in developing egg-cells-usually ceases if the oxygen sup- 
ply is insufficient. Contractile activities are decreased or abolished. 
Many organisms, however, show only slight immediate effects; this is 
true of many Protozoa; Vorticellae, for instance, remain contractile for 
some time after simple removal of oxygen from the medium, although 
they are at once paralyzed by anesthetics. "Such facts oppose the view 
held by Verworn and others, that the anesthetic acts primarily on the 
oxidative mechanism of the cell. It is true that the rate of oxidation 
in active tissues is lowered during anesthesia, but this effect is rather a 
consequence than a cause of the lessened activity. Obviously wherever 
free oxygen is necessary to the normal activities of a tissue its withdrawal 
will arrest those activities. But the effects produced by lack of oxygen 
are not to be identified with anesthesia because of such incidental resem- 
blances." 
The Conclusions of Lillie.2-Lillie has indicated that under certain 
well-defined artificial conditions, as well as under some that are normal, 
"the living system-organism, tissue or cell-becomes temporarily in- 
active and irresponsive to stimuli. When such an artificially induced 
state of inhibition is well marked and lasting it is called anesthesia, or, 
in a somewhat more restricted sense, narcosis. This condition may last 
for hours or even days, but apparently not indefinitely; and, when it 
passes off, the normal vital activities and properties return unimpaired. 
This apparently complete reversibility is one of the most remarkable 
features of anesthesia, and distinguishes it from death-a perhaps re- 
lated but characteristically irreversible change. The terms 'anesthesia' 
and 'narcosis' are somewhat differently applied, although they have 
the same essential significance; the former relates to any temporarily 
insensitive condition, however produced, while 'narcosis' usually means 
an anesthesia produced by chemical substances." 
Lillie used the term anesthesia to designate "any temporary or rever- 
sible lowering or loss of the normal vital responsiveness, or of the normal 
automatic vital activity, under the influence of certain artificial sub- 
1 Science, n. s., 37, 959. 
2 Ibid., Nos. 965, 959-972. GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
51 
stances or conditions. Anesthesia, as thus defined, may be exhibited by 
the most various organisms and cells, if not by all. It is fully as charac- 
teristic of plant cells as of animal cells, although its manifestations may 
be less obvious and striking in the former group of organisms. In its 
most familiar aspect the complete organism, e. g., a man, or an isolated 
living tissue, as a nerve or muscle, fails during anesthesia to show any 
response to a stimulus which normally excites it strongly. In other 
words, the capability of responding to stimuli-what we call 'irritabil- 
ity'-is in anesthesia diminished or lost. When the condition passes off 
the normal responsiveness returns unimpaired." 1 
However, such decrease of the vital activity or responsiveness is not 
a solely artificial phenomenon. Conditions physiologically resembling 
anesthesia occur normally in the life of many organisms; sleep is, for 
example, a variety of physiological, regularly recurring narcosis, and all 
irritable tissues lose their responsiveness for a brief period following 
excitation. The last-mentioned state, the so-called "refractory period," 
has been compared with narcosis by some physiologists. There are also 
noteworthy resemblances between narcosis and fatigue. Thus the degree 
of irritability of a tissue may vary within a wide range under normal as 
well as artificial conditions. 
Lillie calls attention to a number of physical conditions which may 
deprive a cell temporarily of irritability; for example, mechanical shock 
and electrical currents may have this effect.2 
1 ' ' Thus a muscle exposed to ether vapor soon ceases to contract on stimula- 
tion; under the same conditions a nerve ceases to conduct; in motile plants like 
sensitive plants the characteristic osmotic motor mechanisms cease to act. Auto- 
matic activities like ameboid movement, ciliary movement, protoplasmic flowing, 
cell division, and growth may also be brought temporarily to a rest by anes- 
thetics. Claude Bernard showed that seedlings ceased growth in an ether-im- 
pregnated atmosphere, and resumed it when the ether was removed. Fertilized 
egg-cells cease to divide in the presence of an anesthetic in appropriate concen- 
tration, although they remain living and proceed with cell-division and develop- 
ment when the anesthetic is removed. Other less evident cell-processes, includ- 
ing metabolism, are similarly affected; the rate of oxidation is usually dimin- 
ished during anesthesia though there are exceptions to this rule." 
3 * ' Under certain conditions the electric current may produce effects closely 
resembling typical anesthesia. This occurs when a weak constant current 
is passed through an irritable tissue like muscle or nerve; during the flow 
of the current the irritability of the tissue is modified in the neighborhood of 
the two electrodes, being heightened at the cathode and lowered at the anode; 
and in this latter region the nerve may become completely insensitive to 
stimuli that ordinarily cause strong excitation. The inexcitable state thus 
produced is called " anelectrotonus "; it is in reality a form of local anes- 
thesia, and as such has been employed for the alleviation of pain in sciatica 
and similar conditions. Muscle is affected in a similar manner; the frog's 
heart may thus be rendered locally incapable of contraction, as in the sim- 
ple class experiment familiar to all physiologists. This action of the cur- 
rent probably depends on its altering the electrical polarization normal to the 52 
ANESTHESIA 
"Irritability may, however, be more readily modified by the use of 
chemical substances than by any other means, and, as is well known, 
many such substances are in daily use in medical and surgical practice 
for procuring local or general insensibility to pain-hence the applica- 
tion of the name 'anesthetic' to the large class of substances possessing 
this property." 
Before considering the mechanism of stimulation and of its modifi- 
cation by anesthetics, Lillie reviewed the most recent conceptions of the 
nature of the physico-chemical constitution of the living cell. He re- 
gards it as clear that the living protoplasm is a "polyphasic system," 
that is, a mixture consisting of various substances and solutions which 
are only partly miscible with one another, and are thus interrelated like 
the different phases of an emulsion or similar system. "These several 
phases, which are partly solid, partly liquid, appear in each living cell 
to have a constant and definite arrangement, whose exact nature varies 
characteristically from cell to cell. There appears typically to be a solid 
or semi-solid structural substratum consisting of colloidal material, most 
of which is in a water-swollen or hydrated state; in addition to this 
more fixed and permanent part of the cell organization, numerous sim- 
pler substances are present-sugars, salts, ami no-acids and others- 
largely in a state of simple aqueous solution, but probably partly ab- 
sorbed at the surfaces of the colloidal phases. There is evidence that it 
is by the oxidation of certain of these substances, especially sugar, rather 
than of the colloidal material, that most of the energy manifested in the 
cell-processes is set free. The colloidal substratum furnishes the condi- 
tions under which the energy-yielding oxidations and other metabolic 
changes take place, and apparently determines their course, character, 
and velocity. The solid colloidal material of the cell may in one sense be 
considered as a by-product of the metabolic activities of the protoplasm; 
it appears, once formed, to undergo itself relatively slight change, but to 
influence profoundly, by its presence and arrangement, the character of 
cell-metabolism. The colloids are of varied chemical nature; they are 
chiefly proteins and lipoids, and it is to be noted that they are built up 
by various forms of molecular union and polymerization from relatively 
simple substances furnished by the environment. This is true not only 
of plants, but also of the individual cells of higher animals, where the 
material which goes to form proteins reaches the cell in the form of 
amino-acids, or of simple polypeptides." 
membranes of the irritable elements-only in a direction the inverse of that 
causing stimulation. There is much evidence that the state of polarization of 
the semipermeable membranes bounding the irritable elements is an important 
factor in determining the degree of responsiveness to stimulation; the facts of 
electrotonus indicate that by altering the polarization by an external current 
the irritability of the tissue may be changed in the direction either of increase 
or of decrease." GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
53 
"However simply organized a cell may seem, there are certain ele- 
ments of structure which appear always to be present, and to play a 
fundamentally important role in stimulation and in other life-processes. 
These are the membranes. Most, if not all, living cells are delimited 
from the medium in which they live by thin, semi-permeable colloidal 
surface-films, the so-called plasma-membranes. Similar semi-permeable 
partitions are often found in the cell-interior, e. g., about nuclei, 
vacuoles, chromatophores, and other structures. They appear to be 
formed of the same colloids as the other protoplasmic structures, namely, 
proteins and lipoids. These colloids, like many other organic substances, 
have, when dissolved in water, a marked influence in lowering the sur- 
face-tension of the solvent. Any substance thus acting tends, by the 
operation of Gibbs' principle, to collect or condense on the free surfaces; 
if the substance is colloidal in nature it may there pass out of solution 
and form a solid surface-film or membrane; and it is probably under 
conditions essentially like these that the cell-membranes are formed. 
Artificial membranes similar in many of their properties to the plasma 
or nuclear membranes of cells may be formed in protein solutions about 
droplets of chloroform, mercury or other water-immiscible substances. 
Now the plasma-membranes of irritable cells undoubtedly play a funda- 
mentally important part in stimulation, as will be seen below, so that it 
will be necessary to consider first some of the essential properties of these 
membranes before passing to the consideration of the stimulation-process 
itself and its modification by anesthetics. 
"The plasma-membranes are typically semi-permeable structures-so 
much so that living cells form in many cases the most convenient and 
rapidly acting osmometers that we possess. Two provisos are necessary 
in making use of living cells as osmometers: first, the dissolved sub- 
stance must not by its own action impair the semi-permeability of the 
membrane, and, second, it must not appreciably penetrate the membrane 
during the time occupied by the experiment. The plasma-membranes 
are, in fact, semi-permeable only in relation to certain classes of sub- 
stances; toward others they show themselves freely permeable, and the 
character of these substances is important, because indication is thus 
afforded of the chemical nature of the materials composing the mem- 
branes." This, in Lillie's opinion, is a matter of fundamental impor- 
tance in the theory of anesthesia. 
"The plasma-membrane is characteristically and intimately con- 
cerned in the stimulation process. During stimulation it appears to 
undergo a sudden and quickly reversible increase of permeability. The 
electrical variation is one expression of this change, but there are others 
as well. Thus the movements of sensitive plants, which occur under the 
same conditions of stimulation as those of irritable animal tissues, are 
due to a collapse of turgid cells, consequent upon a sudden loss of the 54 
ANESTHESIA 
semi-permeable properties of the plasma-membranes enclosing the osmot- 
ically active solution or cell-sap. Here at least is one irritable tissue 
where the connection between permeability increase and stimulation 
seems unmistakable." 
With regard to why anesthetics interfere with the stimulation- 
process, Lillie pointed out that in the first place they can be shown 
experimentally to interfere with both of the characteristic manifestations 
of stimulation, (1) the action-current and (2) the change of permeabil- 
ity. If these are the critical or primary events on which the other 
effects following stimulation depend, it is evident that suppression of 
these must involve a suppression of the entire series of processes result- 
ing from stimulation, including the oxidations, the contraction-changes 
and the other special features of the response. 
That the action-current as well as the mechanical response of a 
muscle is suppressed by anesthetization has long been known. In nerves 
also, anesthesia abolishes the action-current. On the foregoing hypothe- 
sis, the electrical variation is the expression of some alteration in the 
plasma-membrane, involving a temporary increase of permeability. 
Hbber 1 has found that potassium salts, which deprive nerves of irritabil- 
ity and render them locally negative, cause at the same time a visible 
alteration in the axis-cylinders; these structures swell and stain more 
diffusely; he found further that these effects are checked or prevented 
if the nerves are first anesthetized with ethyl urethan. Experiments on 
voluntary muscle gave analogous results. If a frog's muscle is partly 
dipped into an isotonic solution of a potassium or rubidium salt the 
tissue contracts somewhat and becomes locally negative; this effect is 
also inhibited or retarded in the presence of an anesthetic. If the local 
negativity is the expression of a change produced by the salt in the col- 
loids of the plasma-membrane, rendering the latter more permeable than 
before, Hbber's results indicate that the anesthetic decreases the sus- 
ceptibility to such changes of permeability. If this is the case we 
can partly understand why the anesthetized tissue becomes less sus- 
ceptible to stimulation, since stimulation involves an increase of per- 
meability. 
Lillie concluded that, if an anesthetic acts by so modifying the 
plasma-membrane of the irritable cell as to render difficult or impossible 
the rapid variations of permeability which are essential to stimulation, 
"it ought to act similarly on other cells, i. e., it should protect these cells 
also against the action of permeability-increasing substances or agencies. 
If an organism can be found whose cells undergo immediate .and obvious 
increase of permeability under conditions which at the same time cause 
stimulation, it should become possible to determine whether suppressing 
the stimulating action of a given agency is equivalent to a suppression 
1 See page 46. GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
55 
of its permeability-increasing action. The two effects ought to show a 
definite parallelism if the above hypothesis is well based." 
Lillie investigated the antagonism between salts and anesthetics,1 
and his results may be summarized as follows: 
1. In the action of pure isotonic sodium chlorid solutions on Areni- 
cola larvae the most evident effects are: (1) strong stimulation of the 
musculature, causing intense and prolonged contraction; (2) increase 
in the permeability of the pigment-cell membranes sufficient to allow 
visible exit of pigment; (3) immediate arrest of ciliary movement, fol- 
lowed by disintegration of the cilia; and (4) a general toxic action. 
2. In the presence of a large number of anesthetics, in concentra- 
tions corresponding to those producing typical neuromuscular anes- 
thesia in sea water, all of these characteristic immediate effects of the 
pure salt solution are diminished or prevented. 
3. In general, the permeability-increasing action and the stimulat- 
ing action of the salt solution undergo closely parallel decrease or pre- 
vention in the presence of the anesthetic. Prevention of sudden per- 
meability increase thus seems equivalent to prevention of stimulation; 
it is also equivalent to prevention of the immediate toxic .action of the 
solution. The anti-stimulating and the anti-cytolytic effects of the anes- 
thetic thus show a definite parallelism. 
4. In anesthesia the essential effect is a temporary alteration in the 
condition of the surface films or plasma membranes of the irritable ele- 
ments, of such a kind that these membranes no longer undergo, under 
the usual conditions of stimulation, the rapid increase of permeability 
essential to this process. 
5. The membranes thus become during anesthesia increasingly re- 
sistant to permeability-increasing agencies: this involves increased resis- 
tance to those forms of toxic action which depend on destruction of the 
normal semi-permeability of the membranes. Hence the association of 
an anti-cytolytic or antitoxic action with the anti-stimulating action of 
the anesthetic. The observations made by Lillie also indicate that the 
degree of resistance of the membranes, and of other colloidal structures 
like cilia, is intimately dependent on the state of their component 
lipoids. 
Conclusions.-It appears to be established beyond doubt that the 
anesthetic is in solution in the blood during narcosis,2 and the thorough 
1 Am. J. Physiol., 1913, 31, No. 5, 255. See also Science, n. s. 37, Nos. 959, 
764. 
2 The investigations of Tissot (Compt. rend., 143, 234) show that in animals 
rapidly anesthetized by chloroform the amount present in the blood may exceed 
50 mg., more than 70 mg. per 100 c.c., and may even reach 70 to 80 mg. If, 
however, the anesthesia is slowly induced, it sinks to 45 or even 35 mg. More 
than 70 mg. per 100 c.c. of arterial blood often causes death. Tissot found 
that the amount in venous blood is always less than in arterial blood. His ANESTHESIA 
56 
investigations of Moore and Roaf strongly point to the fact that an 
unstable compound is formed with hemoglobin, just as occurs in the case 
of proteid. It is probable that, in every case, anesthesia occurs when the 
unstable compound parts with the anesthetic to the cell proteids, and 
that penetration of the cells by virtue of the anesthetic to the cell lipoid 
occurs simultaneously. In this way, the relative power of the various 
anesthetics may be explained, for narcotic action is here dependent upon 
solubility in blood, stability of the compound, if any, formed with hemo- 
globin, rapidity of penetration of the cells, and nature of the solution 
in the cell lipoids. 
EFFECTS OF INHALATION ANESTHETICS UPON VARIOUS PARTS 
OF THE ORGANISM 
When a volatile agent such as chloroform, ether, ethyl chlorid or 
nitrous oxid is inhaled, the first action, naturally, is upon the respira- 
tory system. Passing from the air vesicles of the lungs into the pul- 
monary blood stream, the general anesthetic now acts upon the nervous 
mechanism, and, through this, upon the muscular and glandular struc- 
tures, the entire organism thus becoming more or less profoundly influ- 
enced. It is readily conceivable that the effects upon these interdepen- 
dent vital functions cannot be considered as isolated phenomena, but 
must be dealt with as correlated features of the complete mechanism of 
anesthesia. 
It is easily understood that it is impossible to trace the effects of the 
agent in successive steps and in a manner that is applicable to all cases. 
The phenomena may vary more or less with the agent employed, with 
the subject anesthetized, with the method of administration, and with 
various conditions. For these reasons, the discussion of the physiological 
action of general anesthesia upon the human subject must of necessity 
be general. The more specific action of the individual agents is given 
further consideration under the respective subjects. It is to be under- 
stood, furthermore, that the phenomena observed are those of a clinical 
character, rather than those noted by the experimental physiologist. 
Effects upon the Respiratory System.-The effect of anesthetic 
agents upon the respiratory system may be considered under two heads: 
(1) The primary or local action of the agent upon the upper respira- 
tory passages. 
(2) The secondary or general action upon the respiratory system, 
resulting from the stimulation of the respiratory center, and from the 
effect upon the muscular system, produced by the circulating anesthetic. 
Local Effect.-The direct action of the inhaled anesthetic upon the 
work seems to explain satisfactorily the cause of chloroform poisoning, espe- 
cially when considered in conjunction with the work of Moore and Eoaf. GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
57 
respiratory passages may cause coughing, a sense of suffocation, and 
temporary suspension of respiration ("holding the breath"). 
General Effect.-This varies with the agent employed, the method 
used, the subject anesthetized, and other factors; it also varies with the 
stage of anesthesia. 
Ordinarily, particularly where the local effects are inconsequent, nor- 
mal respiration becomes deeper as the respiratory center is more and 
more profoundly influenced by the circulating anesthetic, and more 
rapid if an asphyxial element enters. During the earlier stages of 
anesthesia breathing may be interfered with by psychic impulses. This 
is particularly apt to be the case with nervous, excitable subjects, and 
those who, through fear, resist the action of the anesthetic. With 
nitrous oxid or other agents so administered as to cause a pronounced 
exclusion of oxygen from the respiratory apparatus, there is apt to be 
exaggerated or stertorous breathing, and the muscles of respiration are 
prone to assume a condition of tonic or clonic spasm. (See Effects upon 
the Muscular System.) There may be temporary suspension of respira- 
tion (apnea), due, according to recent researches,1 to a fall of carbon 
dioxid pressure in the respiratory center, while the oxygen pressure is 
still sufficiently high not to give rise to excitement of the respiratory 
center. This condition, sometimes called "physiological apnea," may 
merge into true asphyxia in the event of "pushing" the anesthetic or of 
allowing undue physical constriction in any part of the respiratory tract. 
It is to be borne in mind by the anesthetist that the rate, rhythm, 
and amplitude of respiration are subject to various modifications by 
traumatic, thermal, and electrical stimuli. 
The interpretation by the administrator of the various respiratory 
sounds is discussed under administration. 
Effects upon the Circulatory System.-The effects of the anesthetic 
agent upon the blood itself, upon the heart, and upon blood pressure 
vary with the drug employed. The circulatory changes which are more 
or less characteristic in the different anesthetics will be considered more 
in detail under the special physiology of each agent. 
Experimental physiologists are not agreed concerning the various 
factors which influence the circulatory mechanism during inhalation 
anesthesia, nor are they agreed with reference to the effects of the anes- 
thetic agent upon the blood itself. Certain data are sufficiently well 
established, however, to be of practical value, and to these attention will 
be confined. 
The only changes produced in the chemical composition of the blood 
by the circulating anesthetic, according to many physiologists, are those 
arising from a diminished supply of oxygen. It has been claimed, how- 
ever, by other investigators, that the hemoglobin content of the red 
1 J. Physiol., 32, 225. 58 
ANESTHESIA 
corpuscles is markedly decreased; that there is destruction of the red 
corpuscles (DaCosta), and that the urobilinuria which may occur two or 
three days after anesthesia is probably the result of this destruction. It 
is also claimed that lecithin and cholesterin are increased, fat, according 
to Reicher, being increased up to two or three times the normal amount. 
Disintegration of the fat and albuminoid bodies is sufficient to lead to 
the increased secretion of acetone. The specific gravity of the blood 
commences to rise shortly after the beginning of the operation, the in- 
crease continuing for several days thereafter, according to observations 
made by Sherrington and Copeman 1 on healthy animals. 
Poggiolini2 investigated the morphological changes of the blood, in 
ether and chloroform narcosis, in a series of experiments on healthy 
rabbits. The different results which have so far been obtained in the 
examination of the influence of ether or chloroform narcosis upon the 
blood are referred by him to the fact that the influence of existing dis- 
eases, of the operation itself, and of the binding of the animal have not 
been sufficiently considered. His experimental findings led him to the 
following conclusions: 
The changes of the blood constituents, noted after ether or chloro- 
form narcosis, are independent of the duration of the narcosis, of the 
quantity of the narcotic, of the frequency of the narcosis, and of the 
time-interval between the individual narcoses. Deep narcosis, with ether 
or chloroform, induces leukocytosis, of variable duration and degree. At 
the same time, the relative composition of the leukocytes is changed, 
either the lymphocytes or the neutrophile polynuclear cells undergoing 
an increase. The change of the leukocyte picture persists for a longer 
time in chloroform narcosis than after ether narcosis. The red blood 
corpuscles and the hemoglobin present rather variable changes, inde- 
pendent of each other, after the two narcoses. However, after chloro- 
form narcosis there are regular destructive and retrogressive changes of 
the red blood corpuscles, which are absent after ether narcosis. Accord- 
ingly, inhaled chloroform appears to be more toxic, and of a more pro- 
longed action, than ether, in the opinion of Poggiolini. 
The psychic state influences the circulation in the initial stage of 
anesthesia, as manifested by pallor, lividity, syncope, and even death. 
The cardiac and vasomotor centers are more or less frequently influenced 
in such cases, these exigencies being more apt to occur in nervous and 
excitable patients, particularly those who are frightened before begin- 
ning the inhalation. 
Just as the efficient function of the respiratory system during anes- 
1 Sherrington and Copeman: "Variations Experimentally Produced in the 
Specific Gravity of the Blood," J. Physiol., 1893, 14, 52. See section on "Shock." 
2 Poggiolini: "Le modificationi morphologiche del sangue nella narcosi 
eterea e nella cloro-narcosi, " Il Policlinico, 1911, Sez. Chir. 18, 3-5. GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
59 
thesia is dependent, in part, upon the circulatory system, so is the proper 
condition of the circulation dependent upon respiration. Obstruction of 
the respiratory passages, however slight, has its concomitant circulatory 
disturbance. A slight degree of obstruction gives rise to a corresponding 
degree of venous congestion, manifested by freer bleeding at the site of 
operation, and perhaps by the swelling of the tongue and adjacent parts, 
these changes being greater in some subjects than in others. 
The action of the anesthetic upon the heart may be primary, but, as 
a rule, it is secondary. The muscles of the heart, as well as those of the 
arterioles, are directly affected by the anesthetic, the effect varying 
according to the particular agent, the method of administration, and the 
extent to which it is carried. The effect may be that of direct stimula- 
tion (as with ether) or of direct sedation (as with chloroform). 
Changes in the blood pressure are dependent upon the anesthetic 
employed and the body position. With nitrous oxid there is a marked 
rise in blood pressure; with ethyl chlorid there is, according to some 
observers, a slight rise, according to others none; with ether there is 
first a rise and then, with deep narcosis, a slight fall; with chloroform 
there is, according to universal agreement, a fall in blood pressure. The 
mechanism of the rise or fall is a disputed point. Some physiologists 
have maintained that the fall is the result of direct vascular dilatation; 
others hold that it is due to dilatation of nervous origin. Recent experi- 
ments tend to establish the correctness of the former view. 
Various other factors influence the circulation during anesthesia, 
such as hemorrhage resulting from the operative procedure, the position 
of the patient, deep breathing, and positive pressure. According to 
Eppinger and Hofbauer,1 "the pulse in patients whose diaphragm was 
unusually high or low showed that the circulation in the legs was better 
when the diaphragm was high, as the quadrate foramen was thus left 
open. When the diaphragm is low, this foramen is more squeezed 
together and the flow of blood up from the lower part of the body is thus 
impeded. At the same time, deep breathing pushes the diaphragm low 
down and it thus presses on the liver and liver veins and thus promotes 
the circulation in the region." 
Effects upon the Muscular System.-The effects of inhalation anes- 
thetics upon the muscular system may be considered under two head- 
ings : 
(1) Direct, which are of interest to the experimental physiologist 
rather than to the practical anesthetist, inasmuch as they involve the 
direct contact of the muscle with the anesthetic agent, a contingency 
which does not normally arise in clinical work. 
(2) Indirect, which are of nervous origin. 
The indirect muscular phenomena of general anesthesia are almost 
'"Kreislauf und Zwerchfell," Zeitsch. f. Iclin. Med., 72, No. 1. 60 
ANESTHESIA 
entirely controllable by certain methods of administration, to which 
reference will be made in detail later. Under these circumstances, 
namely, the administration of oil of bitter orange peel as a preliminary 
to the anesthetic agent, the conscious voluntary movements of the pre- 
liminary stages of narcosis are practically held in abeyance. The un- 
controllable muscular movements in the stage of excitement are absent 
because there is no such stage. Subconscious purposive movements and 
simple tonic spasm, local or general, are not noted. The coordinated 
movements sometimes noted in deep anesthesia as ordinarily induced are 
absent, as are likewise the tremors of moderate narcosis. 
The usual conscious, subconscious, and unconscious movements, the 
tremors and clonic spasms noted during the administration of any of the 
inhalation anesthetic agents, or the ordinary combination of these, are 
more or less completely held in abeyance by the action of oil of orange, 
administered as a preliminary to these agents. (See Preceding the Ad- 
ministration with Oil of Bitter-Orange Peel, p. 91.) For further details 
concerning effects upon muscular system, see Special Physiology of each 
agent. 
Effects upon the Glandular System.-The effects of general anes- 
thetics upon the glandular system may be considered under two heads: 
(1) The immediate effects, or those noted during the administra- 
tion. 
(2) The secondary, or after-effects, or those observed after the sub- 
sidence of anesthesia, when the anesthetic agent is no longer circulating 
in the blood. 
Both the immediate and the after-effects vary with the anesthetic 
agent, with the method of administration, with the degree to which nar- 
cosis is carried, and with various other factors to be discussed more in 
detail under the special physiology of each anesthetic. 
The immediate effects involve particularly the mucous, salivary, 
sweat, and lachrymal glands. The secretion of mucus and saliva is 
greater during light and moderate narcosis, whereas it is decreased dur- 
ing the deeper stages. The same holds true with lachrymation with all 
the general anesthetic agents. The sweat glands are more or less affected 
in the various stages of narcosis by the different anesthetics. In the 
presence of cyanosis or severe shock with any agent, the sweat glands 
become hyperactive, as evidenced by the "cold perspiration" which sub- 
sides with the restoration of proper respiration and circulation. 
Renal function Is interfered with during the administration, accord- 
ing to some observers, being increased up to the point at which the 
corneal reflex disappears and completely arrested during profound anes- 
thesia. This decreased secretion of urine during the administration may 
continue to the point of complete suppression, resulting in death. Vari- 
ous intermediate degrees of suppression and concentration, with in- GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
61 
creased chlorids, phosphates, urea, casts, and albumin in greater or less 
quantity, have been noted, the urine gradually returning to normal 
within a week after the anesthesia. 
These observations apply to chloroform and ether. The occurrence 
of albuminuria during the administration of inhalation anesthetics is 
said to occur with some of the agents and not with others. 
Fatty degeneration of the liver, kidneys, heart, and other organs may 
occur, particularly after repeated administrations of chloroform, unless 
safeguarded by heat, moisture, oxygen, and rebreathing, together with 
enemas of normal saline, olive oil, and glucose.1 
Effects upon the Nervous System.-The sequence in which the parts 
of the nervous system are involved in the production of general anesthe- 
sia is still the subject of discussion among experimental physiologists as 
well as practical anesthetists. English and American investigators hold 
that the cerebral cortex is first involved; the basic ganglia and cere- 
bellum,2 second; the sensory centers of the cord which connect the brain 
with the periphery, third; the cerebro-spinal motor tracts and centers, 
fourth; and the respiratory, vasomotor, and cardiac centers of the 
medulla, fifth. Inhibition of all functions, and death, follow. Accord- 
ing to Dastre and other French observers, the sensory nuclei of the cord 
or the cerebral ganglia are affected before the cortical centers are 
involved. 
The order in which the special senses are affected by the general anes- 
thetic cannot be definitely stated. The majority of observers seem to be 
agreed that sight is lost before hearing, and that taste persists longer 
than either of these. With nitrous oxid, hearing is the last sense to 
disappear and the first to reappear. The sense of smell is very easily 
lost, as is witnessed in the effect of oil of bitter orange peel, to which 
reference has been made. 
The reflex phenomena of general anesthesia may occur during any 
stage of narcosis, from the beginning of the induction period to the 
period immediately preceding inhibition of respiration. They vary con- 
siderably with different patients. 
The reflex circulatory phenomena are of special importance from a 
practical point of view. They may arise during all stages of anesthesia, 
and they may vary in intensity from slight reflex vasomotor stimulation 
1 See Chapter on Treatment, Preliminary, During, and After Anesthesia. 
'Francis and Fortescue-Brickdale ("The Chemical Basis of Pharmacology,'' 
1908, 81) state that the physiological action of the entire group of aliphatic nar- 
cotics is first on the higher centers of the cerebrum, then on the lower centers 
of the medulla and cord. Eventually, continue these authors, the reflexes are 
completely abolished, and this constitutes an important distinction between this 
group and the alkaloidal narcotics, of which the principal representative is mor- 
phin. In large doses morphin increases reflex irritability, and in small doses 
does not depress it. 62 
ANESTHESIA 
or inhibition, with consequent rise or fall of blood pressure during the 
earlier stages, to profound circulatory shock during the stage of deep 
narcosis. They vary with the anesthetid eiiiployed, being more com- 
monly manifested with chloroform than with ether; with the method of 
administration, being largely eliminated by the modern methods (see 
Chapter VIII) ; with the degree to which the anesthesia is carried; and 
with the state of the nerve centers (vasomotor, cardio-inhibitory, cardio- 
accelerator) acted upon by the anesthetic agent. 
Reflex circulatory disturbances of a serious nature, occurring during 
the earlier stages of anesthesia, before consciousness is entirely lost, are 
often of psychic origin. It is important, for this reason, that the sur- 
gical procedure be not commenced until anesthesia is complete. 
The occurrence of circulatory shock after the induction of general 
anesthesia has been the subject of much serious investigation, the work 
of Crile 1 being particularly noteworthy.2 
Reflex respiratory phenomena are more frequently present during 
the lighter than during deeper degrees of narcosis. It is to be borne in 
mind, however, that the psychic stimuli of the conscious stages of anes- 
thesia may give place to the traumatic stimuli of the stage of surgical 
anesthesia. These stimuli, applied in any part of the body, may cause 
reflex spasmodic movement of the tongue, whereby this organ is drawn 
over the laryngeal orifice, giving rise to laryngeal spasm, respiratory 
and expiratory spasm, coughing, retching, and stertorous breathing. 
When these phenomena assume a serious and menacing character, 
the condition is described as "respiratory shock." This is most apt to 
supervene during moderate anesthesia. 
FACTORS WHICH MAY BE SAID TO MODIFY THE PHYSIOLOGY 
OF ANESTHESIA AS ORDINARILY INDUCED 
It has been suggested 3 that the phenomena resulting from the ad- 
ministration of inhalation anesthetic agents more properly come under 
the head of pathology than of physiology. However this may be, certain 
it is, as elsewhere stated, that practically every phenomenon varies with 
the particular anesthetic agent administered, with the general condition 
of the patient, with the condition of the blood, and with various other 
factors. 
For these reasons, it has been deemed advisable to consider here cer- 
tain factors which, introduced into the administration of inhalation 
anesthetics, may be said to modify, to a more or less pronounced degree, 
1 Crile, G. W.: ' ' Surgical Shock. ' ' 
1903. 
Also, Boston Med. and Surg. J., March, 
2 Chapter on Treatment, p. 41. 
3Wright, Hamilton: Loc. cit. GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
63 
some of the phenomena ordinarily observed, and commonly considered 
under the head of physiology. These factors are: 
1, Warming the agent; 2, utilizing moisture; 3, combining oxygen 
with the agent; 4, preceding the administration with oil of bitter 
orange peel; 5, utilizing carbon dioxid; 6, rebreathing.1 
The consideration of these factors, particularly the first, necessarily 
involves the introduction of a certain amount of technique, which, of 
itself, would no doubt more properly come within the chapter on Ad- 
ministration, or perhaps Special Physiology. The following discussion 
may be considered, therefore, as an addendum to General Physiology. 
Warming the Agent.-The value of warmed anesthetics has been 
recognized by many anesthetists since Clover2 devised his double- 
current apparatus, by means of which the expired air warmed the anes- 
thetic agent. Since that time various attempts have been made to 
deliver to the patient warmed ether or other agent,3 but in each instance 
the apparatus was found to be inadequate, too complicated for practical 
use, or otherwise unsatisfactory. 
It was not until 1905, however, that systematic laboratory experi- 
ments and clinical observations were begun,4 with a view to determining 
the relative value of the various inhalation anesthetics when these are 
administered cold and when they are warmed to the temperature of the 
blood (98.6° F.). These observations were made by Gwathmey par- 
ticularly with reference to: (1) safety as regards life; (2) the main- 
tenance of body temperature, and the consequent lessening of the danger 
of shock; (3) recovery from the anesthetic; and (4) after-effects. 
Other phenomena were also noted. 
Safety to Life.-First, with chloroform: In order to determine 
the value of chloroform as regards life when heated to 100° F. and at 
room temperature, Gwathmey 5 made a number of experiments, using 
compressed air and passing this air through chloroform at room tem- 
perature and then to a special animal mask, using a Junker inhaler for 
the chloroform. He found that it took 6.57 minutes on the average to 
kill sixteen animals. Employing the same technique with the addition 
of another Junker inhaler, filled with warm water and placed in a warm 
receptacle between the chloroform and animal mask, he found that the 
average time required to kill seventeen animals was 20.35 minutes,6 thus 
1 Chapter on Rebreathing. 
2Clover: Brit. Med. J., March 15, 1873, 282; July 15, 1876, 74; Jan. 20, 1877. 
3 (1) Hawksley: Brit. Med. J., Aug. 2, 1873, 177. (2) Foy: "Anesthetics, 
Ancient and Modern," 141. 
4 Gwathmey: Med. Bee., Oct. 14, 1905; N. Y. Med. J., Feb., 1908; J. Am. 
Med. Assn., Oct. 27, 1906; Am. J. Surg., July, 1908. See also Coburn: Med. 
Bee., March 1, 1913. 
B For technique, see p. 317. 
6 See table, p. 64. 64 
ANESTHESIA 
showing that chloroform at blood temperature is three times as safe as 
chloroform at room temperature. 
TIME REQUIRED TO KILL ANIMALS WITH CHLOROFORM AND AIR 
No. of experiment 
1 
No. of minutes required 
to kill at 100° F. 
18 
No. of minutes required 
to kill at normal 
temperature 
4.5 
2 
57 
3 
3 
26.5 
7 5 
4 
24.5 
7 
5 
15 
4 
6 
16 
4 
7.... 
15 
3.5 
8 
8 
• 7.5 
9 
13 
9 
10 
22 
5.5 
11 
12 
7 
12 
17 
10 
13 
21 
6 
14 
25 
9 
15 
27 
10 
16 
17 
7.5 
17 
12 
.... 
17)346 
16)105 
20.35 
6.57 
Second, with nitrous oxid and oxygen instead of chloroform, and 
passing the mixed gases through a tube, first at room temperature, and 
then surrounding the tube with hot water, and, last, surrounding the 
tube with ice, and in all instances measuring the temperature accurately 
by a thermometer placed in a bent tube, using the same animal mask 
and giving all animals first six per cent of oxygen with nitrous oxid 
for five minutes, and then reducing the amount of oxygen to three per 
cent, the following results were obtained: Twelve animals were anes- 
thetized and killed by nitrous oxid and oxygen at room temperature. 
The average time for the eye and extremity reflexes to be abolished was 
4 minutes. The average time required to kill was 9 minutes and 20 
seconds. The shortest time was 4 minutes and the longest 12 minutes. 
Nine of these animals struggled violently until anesthetized; two were 
quickly asphyxiated; one weakling remained quiet after two minutes. 
In all cases, heart action, rapid at the start, ran from 150 up to 200 
during the frightened struggles; as anesthesia progressed, it again 
became irregular, with marked second sound accentuation, and very 
rapid and weak just before death. The respiration in all cases was 
irregular, and gasping to variable degrees. In all cases tonic convul- 
sions occurred just before death. In 25 per cent of the cases convulsions 
occurred during the first three to five minutes (probably anoxemic); GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
65 
continuation of heart action after respiration ceased: average time, 2 
minutes; longest, 3 minutes; shortest, 1 minute. 
Twelve animals were anesthetized with warm nitrous oxid and oxy- 
gen by having the tube containing the mixture of gases passed through a 
hot water bath kept at a temperature of 98° C. The same proportions 
were used as in the administration of the cold gases. In all other re- 
spects the technique was the same as far as the experimenter could 
possibly make it. 
Abolition of Reflexes.-Two animals (weaklings), anesthetized 
with 6 per cent oxygen mixture, lost their reflexes at the end of 5 
minutes; 6 animals had reflexes abolished with the 3 per cent oxygen 
mixture in 12 to 25 minutes, the average time being 18 minutes. Four 
were not anesthetized at the end of 30 minutes. After the removal of 
the inhaler, 2 were able to walk in from one to two minutes. The other 
2 were killed. Eight animals were killed by the anesthetic; the average 
time was 18 minutes. Four were in good condition at the end of 30 
minutes; two were disposed of as noted above; and two were put away 
for future work. The shortest time was 12 minutes; the longest time, 
28 minutes. Eight struggled from 1 to 3 minutes because held, and 
the remainder did not struggle after the first few breaths. 
Heart Action.-After preliminary excitement, action was regular 
in force and frequency until death approached, when it became rapid 
and weak. 
Respiration.-In all cases respiration was quiet and regular after 
the first few minutes, becoming gasping just before death. 
Convulsions.-No early convulsions occurred. Mild tonic convul- 
sions occurred just before death. Continuation of heart action after 
cessation of respiration: average, minutes; shortest, 2 minutes; 
longest, 5 minutes. 
The third series of experiments was conducted in precisely the same 
manner as the first two, as regards technique, percentage of oxygen, etc., 
with this difference: the tube containing the mixture of gases passed 
through a vessel packed in ice. The U-shaped tube containing the ther- 
mometer was also packed in ice. The thermometer did not vary from 
33° to 34° F. during the administration. Ten animals were killed. The 
results were as follows: After eight to ten breaths of this cold mix- 
ture, violent struggling ensued and breathing ceased almost immedi- 
ately. Fibrillary twitchings greatly resembling a chill occurred in all 
animals after the first minute of inhaling the mixture. The average 
time required to kill was 5 minutes and 34 seconds, or about 4 minutes 
less than at the normal temperature, and 13 minutes less than the 8 
animals killed by the warmed gases. The shortest time was 3 minutes 
and 55 seconds; the longest time, 7 minutes. 
From the above, it will be seen that warmed nitrous oxid and oxy- 66 
ANESTHESIA 
gen is much safer than using this mixture of gases at the room tempera- 
ture, and very much safer than the cold gases. 
The following case history illustrates very clearly the difference be- 
tween cold and warm nitrous oxid and oxygen as observed in the human 
subject. A large number of similar histories could be cited. 
Female. Age, about 45 years. April 19, 1907. Patient was given 
grain of morphin and 1/150 grain of atropin thirty minutes before 
the operation. Operation (laparotomy) lasted two hours, during the 
whole of which time the patient was kept under the influence of nitrous 
oxid and oxygen, without the aid of any other anesthetic. A fibroid 
tumor weighing thirty-five pounds was removed. At the end of one hour 
the anesthetist's (J. T. G.) gas tanks became exhausted, and he was 
compelled to use the hospital tanks, which unfortunately were of such 
size and condition that he could not use his hot-water attachments. As 
soon as he began using the cold gases, the respirations showed a marked 
decrease in number and were slightly labored, but, with this exception, 
the narcosis was entirely satisfactory, the patient making an uneventful 
recovery and without nausea or vomiting. 
Third, with ether: Only a few experiments were conducted with 
ether, but the number was sufficient to fully convince one that warm 
ether acts similarly to warm chloroform and warm nitrous oxid; that 
is, it is twice as safe, as shown by the fact that it took over twice as 
long to kill the animals with warm ether vapor as with cold. 
Fourth, with ethyl chlorid: We have made no experiments with 
warm ethyl chlorid, but by analogy we may conclude that, as chloro- 
form, ether, and nitrous oxid are increased in value by heat, the value 
of ethyl chlorid would likewise increase. 
From the animal experiments with the different anesthetics, i. e., 
chloroform, ether, and nitrous oxid and oxygen, first at the room tem- 
perature, and then heated to the temperature of the blood, and finally 
with nitrous oxid and oxygen at -f- 33° to -|- 34° F., we conclude that all 
anesthetics heated to the temperature of the blood are increased in value 
as regards life, without decreasing their anesthetic effect. From these 
experiments it is also evident that to these highly sensitive creatures 
the warm gases were much pleasanter to inhale. From clinical experi- 
ence it can be stated positively that the facts learned in the laboratory 
are beyond all question true also in practice. 
The Maintenance of Body Temperature.-A large number of 
observations have been made with reference to the effect of narcosis upon 
the body temperature.1 The loss of body temperature observed in all 
1 Kapeler: ' ' Anaesthetica, ' ' Deut. Chir., 1880, 33, 168; Hare: ' ' Experi- 
ments to Determine the Influence of Etherization on the Normal Bodily Tem- 
perature, etc.," Therap. Gaz., 1888, 12, 317; Dastre: "Les anesthetiques: 
physiologic et applications chirurgicales," Paris, 1890; Allen: "Effect of GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
67 
instances, both in the experiments upon animals and in clinical observa- 
tions upon the human subject, has been variously explained as being due 
to diminution of oxidation, to radiation of heat from uncovered portions 
of the body, to the effect of the anesthetic agent upon the regulatory 
centers, to the increased output of heat in consequence of dilatation of 
the cutaneous vessels, etc. 
Whatever the cause of this loss of body temperature, it is interesting 
to note that even a fraction of a degree of elevation of temperature of 
the anesthetic agent above that of the room will have a marked effect in 
maintaining the body temperature of the patient. The author's observa- 
tions in this regard have been amply verified by those of Davis,1 both 
upon animals and upon human subjects. 
In twenty-six patients anesthetized with warm ether vapor, there 
was a loss of body temperature averaging .29° F. as against the loss of 
1.02° F. in one hundred and forty cases anesthetized under similar con- 
ditions with the open drop method. The shortest period of anesthesia 
in which the temperature was noted was forty minutes, the longest four 
and three-quarter hours. The temperature was taken by rectum imme- 
diately before starting and immediately after the removal of the anes- 
thetic. 
These experiments of Davis upon human beings undergoing surgical 
operations are most conclusive. The practical application of this lies 
in the fact that in the majority of instances the patient's temperature is 
necessarily lowered by the surgical operation, and also by the anesthetic 
as usually administered. 
In this connection it may be well to emphasize the fact, mentioned 
by Davis,2 that an undue elevation of the body temperature, as a conse- 
quence of employing a warmed anesthetic agent or as a result of other 
measures, may prove injurious. In one of his animal experiments the 
body temperature of the subject was elevated by means of an electro- 
thermal pad and blankets. There was a rise of 4.14° F. in one and 
three-quarter hours, at which point death suddenly occurred. An over- 
dose of ether was a presumptive factor, but the chief factor was thought 
to be this great increase in temperature. 
The following are the charts of two human subjects, in which death 
was supposed by Davis to have been caused by giving a warmed anes- 
thetic for too long a time. In the second case, that of a child five 
months old, it would seem that the shock from too long an anesthetic 
Anesthesia upon the Body Temperature and Blood Pressure," Trans. Am. Surg. 
Assn., 1896, 14, 367; Morley: "The Effect of Anesthesia upon the Body Tem- 
perature," Am. Gynecology, 1903, No. 3, 300. 
1 Davis: "On the Effect of Narcosis upon the Body Temperature," Johns 
Hopkins Hosp. Bull., April, 1909, 118. 
2 Loc. tit. 68 
ANESTHESIA 
and not the warmed ether vapor was the immediate cause of death. The 
following are the records:1 
CASE 1 
Date-October 7, 1908. 
Name-H. G. 
Address-Johns Hopkins Hospital. 
Age-35. 
Surgeon-Cushing. 
Operation-Cerebellar Exploration. 
Anesthetic-Ether Vapor Warmed. 
Amount-225 gm. 
Temp, before anesth.-38. 
Temp, after anesth.-40.44. 
Temp, operating room-31.1 
Sex-NT 
Method-Open. 
Duration-3 hours. 
Narcotics-N one. 
Stimulants-N one. 
Complications. 
Temperature two hours after the anesthetic, 41.3°. Patient died one hour 
later. 
CASE 2 
Name-C. C. 
Address-Johns Hopkins Hospital. 
Age-5 M. 
Surgeon-Cushing. 
Operation-Spina Bifida. 
Anesthetic-Ether Vapor Warmed. 
Amount-50 gm. 
Temp, before anesth.-38. 
Temp, after anesth.-39.8 
Temperature operation room-29.5. 
Date-May 29, 1908. 
Sex-M. 
Weight-■ 
Method-Open. 
Duration-2| hours. 
Narcotics-None. 
Stimulants-N one. 
Complications 
Anesthesia ended 5.00 p. m., Temperature, 39.8. 
5.30 p. m., Temperature, 40.5. 
6.00 p. m., Temperature, 40.1. 
6.30 p. m., Temperature, 40.2. 
7.00 p. m., Temperature, 40.5. 
7.30 p. m., Temperature, 40.8. 
8.00 p. m., Temperature, 41.4. 
Died, 8.25 p. m. 
It may be interesting in this connection, before considering the ques- 
tion further, to note some observations concerning the temperature stim- 
ulus as applied to certain agents. 
1 Private communication from Dr. Davis. GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
69 
Hoffmann,1 in his discussion of the cooling-off of the inspired air 
and its causative connection with post-operative pulmonary affections, 
says that, in the ether-drop-anesthesia according to Witzel, there occurs 
an automatic regulation of the ether contents of the inspired air. This 
self-regulation is brought about through a considerable refrigeration of 
the temperature of the inspired air. This cooling can be avoided with- 
out disturbance of the automatic regulation, by the utilization of a 
suitable mask. 
Stursberg 2 discussed the behavior of blood pressure under the action 
of temperature-stimuli in ether and chloroform anesthesia, as well as its 
bearing upon the occurrence of subsequent complications. In ether nar- 
cosis it will be found that a cold stimulus is followed by vascular con- 
traction, possibly without a later reactive dilatation, thus supplying the 
conditions for "catching cold." 
The action of chloroform, Stursberg found, is not generally followed 
by extensive vascular contraction on the refrigeration of the skin; con- 
sequently, the distribution of the blood is not altered in the sense of an 
induced hyperemia of the internal organs, which does away with a condi- 
tion favoring the origin of "colds." 
Recovery from the Anesthetic.-With the idea of testing the 
influence of heat upon the recovery of the subject from the anesthetic, 
Gwathmey anesthetized three animals at the same time, under glass 
receptacles, for ten minutes, afterward placing them in receptacles, one 
at 0° F., another at 100° F., the third being allowed, as a control, to 
come out in the room temperature. The animals were changed in posi- 
tion on three successive days. In each instance, the animal in the warm 
chamber made a slightly more rapid recovery than the others. The ani- 
mal in the cold box came out in chills, while the one in the room tem- 
perature came out a close second to the one in the warm box. 
With reference to human beings, it may be stated that, by applying 
hot towels to the patient's face, or by aerating the lungs with hot air 
toward the close of any anesthesia, the patient recovers quickly from the 
anesthetic. 
It will thus be seen that recovery from the anesthetic is facilitated 
by the natural inhalation of warmed atmospheric air, or by the artificial 
introduction into the lungs of a current of warmed air. Experimental 
and clinical observations have abundantly verified these findings with 
reference to the use of warmed anesthetics. 
1 Hoffmann, M.: " Heber die Abkiihlung der Inspirationsluft bei der 
Aethertropfnarkose, ihre Bedeutung und ihre Verhiitung, " Mittlg. a. d. Grenzgeb. 
d. Med. u. Chir., 1910, 21, 869. 
2 Stursberg, H.: "Ueber das Verhalten des Blutdrnckes unter des Einwirkung 
von Temperaturreizen in Aether und Chloroform Narkose, " Mittlg. a. d. Grenz- 
geb. d. Med. u. Chir., 1911, 22, 1. 70 
ANESTHESIA 
After-Effects.-A great deal has been written, by many investi- 
gators, concerning the immediate and delayed after-effects associated 
with inhalation anesthesia. Observations made by Clover and others of 
the earliest workers in this field tended to prove that the after-effects are 
lessened when a warmed vapor is used. Subsequent laboratory experi- 
ments and clinical observations have amply verified these findings. 
A warmed vapor (provided it is not too warm) gives rise to less irri- 
tation to the air passages, and thus decreases the danger of post-anes- 
thetic bronchitis and pneumonia. 
The warmed vapor, being less irritating to the buccal mucous mem- 
branes, causes less stimulation of the salivary and mucous glands, and 
consequently there is a less profuse secretion of saliva and mucus than 
is apt to occur when cold vapor is administered. The anesthesia, there- 
fore, is accompanied and followed by less nausea and vomiting than 
occur as a consequence of the hypersecretion of these nauseating fluids 
when a cold vapor is employed. This observation is particularly striking 
with ether. 
The late after-effects, such as acid intoxication and its consequences, 
have received voluminous attention from many observers, among whom 
there is no unanimity regarding the cause of these manifestations. 
Doubt has been expressed by some concerning the existence of such 
sequels. Idiosyncrasy, gastro-intestinal disturbances, preexisting met- 
abolic fault, nervous influence, and failure of complete elimination of 
the agent from the blood, with consequent degenerative changes in the 
vascular elements and other tissues, are some of the explanations offered. 
Whatever the cause, it seems to be fairly well agreed that acidosis, 
and other late after-effects, occur in a certain proportion of cases. 
With the administration of warmed anesthetics, according to the 
method described in the section on Administration (p. 63), both the 
immediate and the delayed after-effects are reduced to a minimum.1 
Experiments on Warming Ether.-It is maintained by some investi- 
1 It has been known for a long time that during chloroform and ether anes- 
thesia the temperature of the body is lowered, and the opinion has been ad- 
vanced that the great fall of temperature may be partially responsible for the 
development of pneumonia. 
A. Lawen (Munch. med. Woch., 1911, 2097) has studied the question as to 
whether post-operative pneumonia can be avoided by warming the anesthetic 
prior to its inhalation. He therefore experimented with an apparatus by means 
of which the chloroform and ether vapors could be warmed. His results show 
that pneumonia cannot be thus avoided, though he does not doubt that a small 
proportion of cases of post-operative pneumonia may be prevented by the pro- 
posed modification of the method of inhalation anesthesia. He considers that 
the warmed anesthetics are only suitable for prolonged abdominal operations, 
and for operations in which the wounds are extensive, such as in amputation of 
the breast. He also considers the warmed anesthetic to be indicated for patients 
who have lost much blood or who are suffering from shock. GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
71 
gators that ether vapor cannot be heated. Seelig 1 conducted a series of 
experiments for the purpose of establishing the correctness of this view. 
The authors of this book, wishing to settle the disputed point with 
reference to the possibility of heating anesrhetic vapors, undertook a 
series of experiments to determine whether the vapor is really warmed by 
being passed through a coil ten feet long placed in a heater, according to a 
method in actual practice. 
A rubber tube, of the same length as that used in actual practice, 
with a thermometer placed at one end and also a thermometer for room 
Fig. 11.-Gwathmey's Vapor Apparatus with the Tube Leading from the Heater 
as in Actual Practice, a. Compressed air; b. Gwathmey anesthetic apparatus; 
b1. ether container; b11. water; b. ether vapor exit; c. vapor heating apparatus; c1. elec- 
tric hot plate; c11. asbestos mat insulator; cin. water bath; civ. thermolite heater; 
cv. inlet to heater; d. exit for heated vapor; e. asbestos insulator; f. 60 cm. rubber 
tube; G. glass T-tube; h. 200° C. thermometer; i. drain; k. thermometer for room 
temperature. (From S. G. Davis.) 
temperature, was employed (see Fig. 11). Compressed air was passed 
through for one hour. 
(Joss 2 has found that ether cools the air inhaled 33° to 44° F. below 
the temperature of the room. The cooled air undoubtedly lowers the 
resisting powers of the cilia of the ciliated epithelium lining the upper 
air passages when these passages become chilled. Infection is more 
likely to find its way into the finer air passages as salivation increases 
under the chilled anesthetic.) 
These experiments gave the following data: 
From Table 1 it will be seen that the temperature of the ether 
vapor can be raised to any degree desired and maintained at that point. 
The vapor may be heated by different methods, but this is probably one 
of the easiest, as with this simple apparatus one is not dependent upon 
electricity as the heat source. 
1Seelig, M. G.: "The Fallacy of Warmed Ether Vapor," Inter. Med. J., 
Sept., 1911; see also, Cotton and Boothby: "The Uselessness of Warming 
Anaesthetic Vapor," Surg., Gyn. and Obst., Dec., 1912. 
2 Mitteil. a. d. Grenzgeb. d. Med. u. Chir., 22, No. 40. 72 
ANESTHESIA 
TABLE 1-Using Rubber Tube with Continuous Flow 
Amount of ether taken, 4 ounces. 
Amount of ether used, 3.5 ounces in one hour. 
Compressed air flow, continuously through ether. 
Room temperature, 24° C., Nov. 4, 1911. 
After 5 minutes.... 29.25° C. 
After 10 minutes.... 29° 
After 15 minutes.... 31° 
After 20 minutes.... 31° 
After 25 minutes.... 30° 
After 30 minutes.... 30.25° 
After 35 minutes.... 32.25° 
After 40 minutes.... 32° 
After 45 minutes.... 32° 
After 50 minutes.... 30° 
After 55 minutes.... 30° 
Temperature, 
65 cm. from heater 
(usual distance) 
Ether container 
warmed as is 
necessary. 
Heated ether 
container. 
In order to determine the temperature of ether at different distances 
from Davis' heater, which was attached to the Gwathmey three-bottle 
vapor inhaler, a series of experiments were conducted in the chemical 
Fig. 12.-Gwathmey's Vapor Inhaler with Heating Apparatus, f. Glass tube di- 
vided into six parts of 10 cm. each; f.' thermometers; i. drain; k. thermometer for 
room temperature; e. asbestos insulator. 
laboratories of the College of the City of New York by the authors. The 
experiments were carried out by Mr. W. A. Hamor. 
A special glass tube was constructed with uniform side tube openings 
10 cm. apart, into which thermometers were inserted (see Fig. 12). 
At the side-tube exits and over the thermometers, a tightly fitting rubber 
collar was placed to prevent leakage. The glass tube was attached to a 
thermolite coil-heater, immersed in a water bath, which was kept at the GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
73 
boiling point by an electric hot-plate. The Gwathmey vapor apparatus 
was attached to this heater; compressed air was passed through the 
ether bottle, the resulting ether-vapor-air stream then passing through 
the water-bottle of the vapor-apparatus, and finally through the heater 
and the tube into which were inserted thermometers. Readings were 
made every five minutes for one hour and the room temperature was 
noted at the same time. The following table shows the results: 
TABLE 2-Using Glass Air Condenser Attached to Heater 
Amount of ether taken, 4 ounces. 
Amount of ether used, 3 ounces. 
Compressed air flow, continuously through ether. 
Room temperature, 23.5° C. 
Temperature in Degrees Centigrade at Various Distances 
November 4, 1911 
Time in minutes 
5 
10 
15 
20 
251 
30 
35 
40 
45 
50 
55 
60 
From heater: 
At 10 cm.... 
36 
40.5 
42 
38.5 
40 
41 
40 
44 
44.5 
45 
46 
47 
At 20 cm.... 
27 
33.5 
34 
32 
33.5 
33.5 
33 
35 
35 
34.5 
34.5 
35 
At 30 cm.... 
25 
30.5 
30 
29 
30.5 
30 
29 
31 
30.5 
30.5 
30 
30 
At 40 cm.... 
24 
28 
28 
28 
28 
28 
27 
29 
29 
29 
29 
29 
At 50 cm.... 
24 
26.5 
26 
26 
26.5 
26 
26 
28 
28 
28 
27.5 
27.5 
At 60 cm.... 
24 
26 
25.5 
25 
26 
25.5 
25.5 
26.5 
26.5 
26.5 
26.5 
26.5 
1 Rearrangement of flow. 
Boothby 1 has maintained that "warmed ether per se" possesses no 
merits over "cold ether," that is, not warmed. According to him, the 
concentration of the ether vapor in the air passing over or through the 
ether varies with the temperature of the liquid ether itself, that is, as 
the ether evaporates more or less rapidly the temperature of the liquid 
is lowered with a decrease in concentration of ether vapor in the effluent 
mixture from the vaporizer, hence the patient does not get enough ether. 
The specific heat of ether vapor is very small, consequently the mixture 
quickly acquires room temperature. Air, the volume of which per 
minute was determined by a Bohr meter, was passed over the surface of 
ether placed in a Wolff bottle, wherein the ether presented a surface 
area of about 50 sq. cm. The temperature of the liquid ether was noted 
with a thermometer immersed about 1.5 cm. in the ether. The tempera- 
1 Discussion before the New York Society of Anesthetists, 1913. Copies of the 
curves were courteously provided by Dr. Boothby. Fig. 13c.-Boothby Curve. 
Fig. 13b.-Boothby Curve. 
Liters of Air per Min, 
Temp, of Ether 
Per cent of Ether 
Minutes 
Exp, Stopped as Ether is Exhausted 
Fig. 13a.-Boothby Curve. GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
75 
ture of the air-ether mixture coming from the apparatus was noted in a 
Waller gas balance, which served to indicate the composition of the mix- 
Liters of Air per Min. 
Temp, of Ether 
Per cent of Ether 
Minutes 
Fig. 13d.-Boothby Curve. 
ture. The curves obtained by Boothby are given herewith, sufficiently 
labeled to be self-explanatory. In connection with Boothby's con- 
clusions the following facts demand con- 
sideration : 
(1) Ether given by the "vapor 
method" does not go, mixed with air or 
oxygen, first into a ballon or reservoir 
subsequently to be breathed by the pa- 
tient, but directly to the patient, hence 
it enters the air passages before it has 
had time to acquire room temperature. 
(See Authors' Experiments, p. 63.) 
(2) Ether administered in any way 
by inhalation eventually reaches body 
temperature in the lungs. The total 
shortage of heat is not taken from the 
entire surface of the lungs, but is local- 
ized in the bronchial passages, that is, 
there is local chilling or heating if the 
vapor be too hot. 
(3) Davis has shown clinically that 
very beneficial results are had even if the 
vapor be produced from cold ether, pro- 
vided it is subsequently warmed. (See 
Chapter on Administration, p. 67.) 
Fig. 13e.-Boothby Curve. 76 
ANESTHESIA 
From the preceding table it will be seen that ether vapor may be 
heated, and the heating maintained for any length of time and delivered 
to a patient as predetermined by the anesthetist. For instance, we see 
that at 60 cm. from the heater at the end of sixty minutes the tem- 
perature was three degrees C. higher than the room temperature. About 
the same amounts of ether and air were used in this experiment as are 
usual in practice. 
Air was passed through the ether and water-bottle of the vapor- 
apparatus without the heater and readings kept up for forty-five min- 
utes. The following table gives the result: 
TABLE 3-Non-Warmed-Room Temperature 
After 5 minutes 
27.5° C. 
Room 
temperature 
28° C. 
After 10 minutes 
27° 
28° 
After 15 minutes 
27.5° 
28° 
After 20 minutes 
27.5° 
28° 
After 25 minutes 
27.5° 
28° 
After 30 minutes 
27.5° 
28° 
After 35 minutes 
27° 
27° 
After 40 minutes 
27° 
27° 
After 45 minutes 
27° 
27° 
From this table it will be seen that at the end of forty-five minutes 
the vapor was approximately sixteen degrees F. below blood temperature. 
The results show that ether vapor can be heated easily and inexpen- 
sively, and that it can be delivered to the patient at any desired tem- 
perature, within limits, by placing the heater or warming device at 
different distances from the patient's face. 
Effects of Moisture.-Since 1909, Gwathmey has employed warmed 
moist vapors for pulmonary anesthetics. Baskerville 1 has called atten- 
tion to the importance of moisture, among other factors which influence 
the course of anesthesia. "It has been shown," he says, "that the admin- 
istration of moist ether, free from aldehyd, at body temperature, is 
rarely followed by nausea (less than ten per cent), and the usual strain 
upon the kidneys is not observed." 
"Nitrous oxid, ether, and chloroform," he continues, "each exerts its 
specific physiological effect in producing anesthesia without asphyxia- 
tion, provided the respiratory and cardiac functions are approximately 
normal. This may be and is being accomplished by administering these 
gasified drugs with sufficient oxygen not to interfere seriously with the 
1 Baskerville: ''The Chemistry of Anesthetics," Science, n. s., Aug. 11, 1911. GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
77 
normal function of the hemoglobin of carrying oxygen to the capillaries, 
and sustaining cardiac stimulation, and by maintaining the usual con- 
centration of carbon dioxid in, and providing its regular elimination 
from, the blood; for it is the respiratory stimulant (Yandall Hender- 
son). Other factors involved are temperature and moisture. The anes- 
thetics are carried into the system at body temperature. This may be 
and is being accomplished by warming, and, in the case of ether and 
anesthetic chloroform, by passing the vapor through heated water, which, 
at body temperature, not only removes the oxidation products, but sat- 
urates the gas with moisture (Gwathmey method). The osmotic action 
of the alveolar cells is thus affected only to the extent of the density 
of the gases introduced into the lungs, and not, as normally is the case, 
by temperature (always lower) and desiccation as well." 
Bruning,1 finding compressed air relatively much more harmful to 
the lungs than pure oxygen, or air in the Geppert apparatus, instituted 
experiments to determine the factors which cause the difference in effect. 
Differences in the temperature could not, in his opinion, be responsible, 
as repeated measurements always showed 25° to 30° in all the gases, 
uniformly. For the same reason, the strength of the air current could 
not be responsible. The remaining factor was the content in moisture 
of the different gases. 
The oxygen and the air from the steel cylinders had only a relative 
humidity of 10-15 per cent. These values are so low that the sojourn in 
such dry air would normally be harmful for man and might lead to 
pneumonia. We feel most comfortable in air which contains between 40- 
60 per cent moisture. 
Inspiration of Compressed Air With Water Vapor.-In a 
series of experiments upon mice, different degrees of moisture were 
obtained by allowing water to drip into the air stream. The desired 
humidity was produced in such a way that water was poured into 
the ether-flask of the Roth-Drager apparatus, with a regulated outflow 
of the water, so that, after some practice, the gas-mixture would be 
maintained fairly constant at the desired humidity. (See Table 4, 
page 78.) 
The table shows that the lungs presented nothing pathological, with 
moisture contents of the air from 50-70 per cent. Even after three 
breathing periods no changes were found. But when the moisture con- 
tents were diminished below 40 per cent, or increased to 100 per cent, 
hemorrhages at once made their appearance. As the air in Geppert's 
apparatus contains approximately 95 per cent relative moisture, the 
occurrence of slight pulmonary lesions is readily understood. The entire 
'Bruning, A.: "Studien zur Narkosenfrage, ins besondere uber die An- 
wendung von Sauerstoff und komprimierter Luft," Deut. Z. Chir., 1911-12, 113, 
532. 78 
ANESTHESIA 
TABLE 4-Inspiration of Compressed Air With Water Vapor 
Mouse 
No. 
Duration 
of exp. 
Time to 
sacrifice 
or second 
exp. 
Second 
exp. 
Time to 
sacrifice 
Macroscopical 
lung findings 
Moisture 
contents 
of 
air 
36 
1M 
hours 
at 
once 
Nothing 
pathological 
70% 
45 
IM 
hours 
at 
once 
Some hyperemia, 
otherwise normal 
35% 
41 
2 
hours 
at 
once 
Normal 
appearance 
55% 
42 
2 
hours 
7 
hours 
Some hyperemia, 
otherwise normal 
55% 
37 
1M 
hours 
19M 
hours 
2 
hours 
at 
once 
Nothing 
pathological 
70.65% 
38 
1M 
hours 
19M 
hours 
2 
hours 
22 
hours 
free 
3d experiment, 
M hour, 
killed at once. 
Lungs normal 
70.65 + % 
46 
1M 
hours 
at 
once 
Marked hyperemia, 
some hemorrhages 
100% 
experimental series justifies the conclusion that too much dryness and 
too much moisture are injurious for the lungs; but when these extremes 
are avoided, oxygen, compressed air, and the Geppert apparatus can be 
equally recommended. 
A later series of experiments showed similar pulmonary changes from 
artificially dried air, as after the breathing of air that had been com- 
pressed; therefore, the cause of the hemorrhages cannot be referable to 
any abnormal composition of the air in the steel cylinders. 
It still remains to be shown why the lungs are less injured by oxygen, 
although it has only a relative moisture content of 10-15 per cent, than 
by the equally dry air; and also why the dryness as such can act harm- 
fully. Injuries through very dry air are explained by Bruning as 
follows: 
The alveolar epithelia are lined with a thin layer of water, which is 
derived from the blood, and by its constant evaporation invests the GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
79 
expired air with its high content of moisture. In this thin layer, oxy- 
gen is dissolved and is carried from here by diffusion to the blood 
corpuscles. When the moisture contents of the inspired air are abnor- 
mally low, the water evaporates very rapidly, the capillaries-which are 
exposed for a large part of their circumference-dry out, and permit 
the blood corpuscles to pass between them. In addition, the secretion- 
pressure for oxygen drops, through the lesion of the endothelia, and the 
organism reacts by an increased blood supply-hyperemia-in order to 
take up the same quantity of oxygen through an increased surface. In 
the further course, inflammatory manifestations on the bronchi make 
their appearance. The slight bloody extravasates, on breathing of pure 
oxygen, are interpreted by Bruning as a chemical injury. The passage 
through a dried-out cell being necessarily hindered, the oxygen remains 
for a longer time in contact with the protoplasm; or the cell must exert 
an increased activity, in order to accomplish the same functional results. 
Consequently, there are over-stimulation and over-taxation of the cell. 
On breathing an air saturated with water-vapor, the evaporation of 
the alveolar moisture proceeds more slowly, the water-layer at the walls 
is likely to be thicker and to stimulate the cells by its constant oxygen- 
contents. The secretion-pressure of the endothelia is normally subject 
to constant fluctuations, in the opinion of Bruning, corresponding to 
inspiration and expiration, so that the cellular protoplasm regularly 
enjoys a brief rest. 
The slightness of the pulmonary changes, on the breathing of pure 
oxygen, is attributed by Bruning to the increased oxygen partial pres- 
sure, which facilitates diffusion and secretion. 
Bruning concluded, from his experiments, that, in the brief time of 
a general anesthesia, injury to the lungs is to be feared only under em- 
ployment of compressed air from the steel cylinders, and that this can 
be avoided by moistening the air to about 50 per cent. 
The examination of the lungs, after the inhalation of the different 
gases, showed very considerable difference. After the inspiration of 
compressed air, the lungs of mice invariably showed extensive hemor- 
rhages and bronchitic symptoms, which were especially evident after 
long duration of the experiment, or several repetitions. The air in Gep- 
pert's apparatus and oxygen have a similar effect, but to a much less 
degree. The lesions are dependent upon the relative moisture of the air, 
and can be avoided by moistening the inspiration air with water vapor, 
up to 50-80 per cent. Too high a vapor-saturation acts in the same 
sense as too much dryness. The absence of grave lesions in oxygen- 
breathing, in spite of low moisture, is referable to specific properties of 
the oxygen. 
Bruning's experiments led to the following practical conclusions: 
(1) General anesthesia by means of the Roth-Drager apparatus, 80 
ANESTHESIA 
under utilization of oxygen, is preferable to general anesthesia under 
employment of compressed air, unless the moisture of the air is artifi- 
cially increased to 50 per cent. 
(2) General anesthesia with oxygen is equivalent to general anes- 
thesia by means of the Geppert apparatus. 
(3) In the accidents of general anesthesia, artificial respiration alone 
is always efficient for the introduction of enough oxygen into the body; 
the breathing of pure oxygen offers no advantages. 
(4) The majority of the advantages, claimed for oxygen, are only 
due to the more accurate dosage by means of the modern anesthetic 
apparatus. 
Combining Oxygen with the Agent.-In 1904, experiments were 
conducted (J. T. G.)1 to determine the value of oxygen, as compared 
with atmospheric air, in combination with different anesthetic agents, 
attention having been particularly directed to the subject by certain 
statements made by Hewitt. 
With reference to nitrous oxid Hewitt says: "It is now established 
beyond all doubt that, by employing certain percentages of atmospheric 
air with nitrous oxid, a better form of anesthesia can be obtained than 
with the undiluted gas, and that, by using oxygen instead of atmospheric 
air, a still better form of anesthesia is obtainable." 
Concerning chloroform, however, Hewitt's views are not so favorable: 
"It is doubtful whether there is any great advantage in the addition of 
oxygen to atmospheric air during the administration of chloroform, save 
perhaps in cases in which much respiratory difficulty is present, and in 
these cases the use of any tightly fitting inhaling apparatus would almost 
certainly neutralize the theoretical advantages of using oxygen." 
Reasons for Using Oxygen.-The advocacy of the combination of 
oxygen with inhalation anesthetics is based largely upon the experiments 
of Priestley, Demarquay, Bichet, Paul Bert, and others, and upon the 
clinical observations of Andrews, of Chicago, with nitrous oxid, and of 
Neudorf er, of Vienna, with chloroform. 
The reason for giving oxygen with nitrous oxid is explained by 
Hewitt2 in the following manner: "A mixture of 40 per cent of air 
and 60 per cent of nitrous oxid would contain about 8 per cent of 
oxygen and 32 per cent of nitrogen; and although the 8 per cent of 
oxygen would be sufficient to nearly or completely preserve the natural 
color of the patient's face, and to suppress clonic muscular spasm, the 
60 per cent of nitrous oxid would be insufficient to produce tranquil 
anesthesia. If, however, instead of using air for oxygenating purposes, 
we employ oxygen, we shall be able to replace the 32 per cent of useless 
1 Gwathmey, J. T.: "Experiments to Determine the Value of Oxygen in 
Combination with the Different General Anesthetics," Med. Rec., Nov. 19, 1904. 
2 Hewitt: "Anaesthetics," 4th ed., 311. GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
81 
nitrogen by a corresponding quantity of useful nitrous oxid, and the 
proportion of the latter will now rise to 92 per cent." 
From this it will be seen that there is a physiological basis for the 
combination of oxygen with nitrous oxid. Clinical experience bears out 
the theoretical calculations. 
The ground for using oxygen with chloroform or the "C.E. mix- 
ture," ether, or ethyl chlorid, is as well founded, theoretically and clin- 
ically, as is that of its combination with nitrous oxid. 
Normally for every volume of inspired air, 4.8 per cent of oxygen is 
abstracted, 4.3 per cent of carbon dioxid being substituted. During 
anesthesia the blood becomes more and more venous from an obstruction 
to the entrance of air into the lungs, and from the blood failing to take 
from the air its usual supply of oxygen. Asphyxia is produced more by 
the diminution of oxygen than by the increased amount of carbon 
dioxid. According to Patton,1 Rumph found a decrease of 40 per cent 
of carbon dioxid eliminated in the respiratory exchanges, and Bichet 
found a decrease of 50 per cent in the elimination of carbon dioxid in 
chloralized dogs. 
Bert's experiments with chloroform show a progressive diminution in 
oxygen absorbed, and of carbon dioxid given off. Lorrain Smith has 
shown that dyspnea, from changes in the gaseous composition of the 
blood may be due to a deficiency of oxygen. 
Richet states that blood which contains an anesthetic in solution 
preserves, when shaken with ether, its full ability for fixing oxygen. 
Irregular forms of breathing may also occur from too little oxygen, as 
in the closed administration of volatile agents; or, from carbon dioxid 
dyspnea, as in rebreathing during the administration. 
The experiments of Priestley and others, of placing small animals 
under two different receivers, one filled with oxygen and the other with 
air, showed that those under the oxygen receiver survived twice as long 
as the others; also, that the death of birds in the oxygen was not accom- 
panied by convulsions as was that of birds that died in the air; further- 
more, that the heart retained its irritability for several hours when death 
took place in oxygen. 
Demarquay 2 immersed two kittens in water and kept them there 
until they had lost consciousness. One had previously been confined for 
twenty minutes in a glass case, containing two parts of oxygen and one 
of air, and the other had breathed only atmospheric air. On removing 
them from the water there was only a slight movement of the lower 
jaw. At the end of five minutes and a half, the superoxygenated kitten 
1 Patton, Joseph M.: "Anesthesia and Anesthetics,'' 1903. 
2 Demarquay, J. N.: " Essay on Medical Pneumatology: Physiological, 
Clinical, and Therapeutic Investigation of the Gases,'' Translated by Samuel S. 
Wallian, A.M., M.D., 1889. 82 
ANESTHESIA 
arose, totteringly walked around, and made an uneventful recovery. The 
other partially recovered at the end of fifteen minutes, but died the next 
day. These experiments were repeated a number of times, and always 
with the same result. 
The above experiments, illustrating the value of oxygen as compared 
to air, have been practically paralleled by Gwathmey. Regardless of the 
anesthetic used, animals have lived twice as long with oxygen as with 
air. With oxygen the heart continued to beat long after respiration 
ceased. 
It may be added here that the heart always continued to beat a 
variable length of time after respiration ceased, whether air or oxygen 
was used, and with all anesthetics. Greater success in reviving them 
after cessation of respiratory and cardiac activity has come with the use 
of oxygen than with air. 
The after-effects produced upon animals have been carefully studied. 
Inasmuch as oxygen is constantly employed clinically, with both chloro- 
form and ether, it may be stated positively that the after-effects are 
reduced to a minimum. 
Experiments with Animals.-In the experiments conducted by 
Gwathmey a closed mask with an expiratory valve, with the light 
rubber bag just behind the mask, was used. This animal mask 
was a cone-shaped brass cylinder inches in diameter at the base and 
11/2 inches at the apex. Over the base, or open end, were stretched two 
thicknesses of thin rubber, fastened around the margin of the cone by a 
rubber band. A small opening inches in diameter was cut in the 
center, into which the animal's nose was placed. The technique in each 
instance was as nearly as possible the same, the same amount of anes- 
thetic being used in each experiment, and the flow of air and oxygen 
being regulated. 
To make these experiments as accurate as possible, over one hundred 
animals were killed, and the average time recorded. It has not been 
deemed necessary to enter into details of the exact weight, age, size, and 
physical condition of each animal. It may be said, however, that ani- 
mals as nearly alike as possible in all essential respects were selected for 
each comparison. The results, in detail, as will be seen from the 
tables on pages 84 and 85, varied in accordance with the individual 
characteristics and conditions; as a whole, they confirmed the claim that 
the use of oxygen in connection with any form of anesthetic practically 
eliminates the percentage of danger which has hitherto been recognized 
as inseparable from the practice of anesthesia. 
In order to determine the difference in toxicity of the drugs used, 
the time was taken from the application of the mask to the stoppage of 
the heart. As the toxic effects came on so rapidly, observations on the 
pulse, respiration, and blood pressure were of little value. GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
83 
Twenty-six animals were killed with chloroform and air, the average 
time being nine minutes; the shortest time, three minutes; the longest, 
seventeen minutes. Thirty-eight animals were killed with chloroform 
and oxygen, the average time being twenty-one minutes; the shortest 
time, five minutes; and the longest, one hour and a half. (See p. 84.) 
With ether and air twelve were killed, the average time being nine- 
teen minutes, the shortest fifteen, and the longest thirty-three minutes. 
Seven were killed with the same anesthetic and oxygen, the average time 
being thirty-five minutes, the shortest twenty-five minutes, and the long- 
est one hour. (See p. 85.) 
With one part of chloroform and two parts of ether, thirteen animals 
were killed, six with air and seven with oxygen. The average time with 
air was nineteen minutes; with oxygen, thirty-five minutes. The short- 
est time with this mixture and air was fifteen minutes; the longest time, 
thirty minutes. The shortest time with oxygen was sixteen minutes; 
the longest, one hour and ten minutes. (See p. 85.) 
From the above it will be seen that chloroform with oxygen is safer 
than chloroform with air, and is also safer than any of the other general 
anesthetics with air. This means that, instead of giving a very high 
mortality, chloroform with oxygen is as safe as ether with air. 
From the above experiments and clinical observations it may be 
deduced that oxygen increases the value of all anesthetics in rendering 
their administration safer to the patient without decreasing the anes- 
thetic quality. 
In a recent paper Bruning 1 discusses the value of oxygen employed 
in connection with narcotics. He states that oxygen alone will not 
account for the improved narcosis witnessed in the administration of 
anesthetics with perfected apparatus. He attributes this to the exact 
and equal dosage, and maintains that compressed air is equally useful 
if the moisture of the lungs is artificially increased to 50 per cent. (See 
p. 86.) 
In accidents in narcosis, according to Bruning, artificial respiration 
alone is always sufficient to introduce oxygen into the body. Pure oxy- 
gen inhalation offers no advantage. The smaller proportion of anesthetic 
needed when oxygen is employed he attributes solely to the improved 
dosage facilities with the Roth-Drager apparatus. The minimizing of 
the after-effects, such as headache, vomiting, etc., he attributes to the 
diminished amount of chloroform employed. The employment of oxygen 
inhalation after narcosis is of no special value, as deep breathing and a 
thorough ventilation of the lungs promote the more rapid elimination 
of the anesthetic. 
Bruning states that a patient with rosy lips and a pink appearance 
might suddenly become asphyxiated, as saturation with chloroform 
1 Bruning: Loc. cit. 84 
ANESTHESIA 
TABLE 5. 
The figures in the first column indicate the number of the experiment; the 
second column, the number of minutes required to kill. 
1 
With 
Air 
Chloroform 
1 
With 
Oxygen 
26 
2 
3 
cc 
2 
5 
3 
iy2 
cc 
3 
10 
4 
7 
cc 
4 
5U 
5 
4 
cc 
5 
30 
6 
4 
cc 
6 
40 
7 
314 
cc 
7 
28 
8 
7J4 
8 
13 
9 
9 
9 
5 
10 
cc 
10 
8 
11 
7 
cc 
11 
15 
12 
10 
cc 
12 
17 
13 
6 
cc 
13 
30 
14 
9 
cc 
14 
30 
15 
10 
cc 
15 
13 
16 
cc 
16 
18 
17 
cc 
17 
14 
18 
10 
cc 
18 
30 
19 
10 
CC 
19 
20 
17 
cc 
20 
37 
21 
16 
cc 
21 
22 
13 
cc 
22 
33 
23 
16 
cc 
23 
8 
24 
11 
CC 
24 
25 
12 
cc 
25 
10 
26 
12 
CC 
26 
io>4 
cc 
27 
18 " 
cc 
28 
7 
cc 
29 
18>4 
cc 
30 
cc 
31 
13 
tt 
32 
26 
CC 
33 
cc 
34 
90 
Ct 
35 
14 
cc 
36 
26 
Ct 
37 
23 
CC 
38 
33>4 
232total; 
total; 
8.94 average. 
21.3 average GENERAL PSYCHOLOGY OF INHALATION ANESTHESIA 
85 
With 
With 
Air 
Oxygen 
1 15 
Ether 
1 25 
2 18 
ll 
2 
3 27 
Cl 
3 
4 15 
Cl 
4 34 
5 33 
ll 
5 27 
6 16 
Cl 
6 40 
7 18 
ll 
7 
8 21 
ll 
9 16 
ll 
10 9 
Cl 
11 
li 
12 
Cl 
235 total; 
total; 
19 average. 
35 average. 
With 
With 
Air 
Oxygen 
Mixed Chloroform and Ether (1:2) 
1 15 .... 
U 
CC 
CC 
.. 1 40 
2 30 .... 
U 
U 
CC 
CC 
. 2 16 
3 .... 
CC 
CC 
CC 
cc 
.. 3 70 
4 15 .... 
CC 
CC 
CC 
cc 
.. 4 37 
5 17 .... 
CC 
CC 
CC 
fi 
. 5 42 
6 30 .... 
CC 
CC 
CC 
cc 
. 6 22 
CC 
CC 
CC 
cc 
.. 7 
total; 
total; 
19 average. 
36 average, 
With 
Air 
1 21 
2 26 
Anesthol 
(( 
With 
Oxygen 
1 38 
2 14H 
3 10 
(C 
3 74 
57 total; 
19 average. 
126 total; 
42 average, 
With 
Summary 
With 
Air 
Oxygen 
1 
9 
Chloroform 
.... 1 21 
2 
19 
.... Chloroform and Ether 
.... 2 35 
3 
12 
..., Ether 
.... 3 35 
4 
19 
Anesthol 
.... 4 42 86 
ANESTHESIA 
would not change the color of the blood. He claims that more oxygen is 
set free in the plasma of the blood, and that the color depends only upon 
its richness in oxygen and not upon its carbon dioxid. Zuntz 1 holds 
that animals die as soon under oxygen-chloroform as under air-chloro- 
form. In chloroform poisoning, according to Bruning, the first thing to 
do is to reduce the concentration of poison in the blood and to eliminate 
it from the body. To do this, the circulation must be maintained so that 
the hypersaturated blood may go through the lungs and be purified. 
This is best accomplished by radical, artificial breathing, thus securing 
a thorough expansion of the lungs. In this way, so much oxygen is 
introduced into the lungs that the inhalation of concentrated oxygen is 
unnecessary. Vidal2 asserts that in primary disturbances of the respira- 
tion only artificial breathing is necessary, as, owing to the blood becom- 
ing rich in oxygen, eupnea, which delays the excretion of chloroform, 
occurs. 
In treating accidents in narcosis a suggestion is made that oxygen 
might exercise a directly injurious chemical action on the body cells. 
Bruning quotes Paul Bert as stating that animals die when exposed 
to a hyper-pressure of 3-4 atmospheres of pure oxygen. As animals, on 
inhalation of ordinary air, died only on a hyper-pressure of 15 to 20 
atmospheres, he thought the danger lay not in the pressure, but in the 
oxygen. 
Bruning makes the peculiar statement that, from his experimenta- 
tion, the administration of oxygen after the narcosis only delays the 
awakening, inasmuch as it never hastens the elimination of chloroform. 
Furthermore, in his opinion, it is no antidote to chloroform in narcosis 
accidents. Deep, free breathing is always sufficient to eliminate the 
chloroform from the system. 
The difference in the results of Bruning's experiments and those of 
Gwathmey can be explained only by the employment of an entirely dif- 
ferent technique and different apparatus under different conditions of 
climate. In Gwathmey's experiments, results were obtained by elim- 
inating as far as possible every factor that might tend to confuse. 
Rebreathing, as advocated by Gatch, was used constantly, both with 
oxygen and compressed air. There is not the slightest question but that, 
under proper conditions, oxygen, in a very great measure, prevents 
poisoning, especially in chloroform or ether narcosis. 
Muller's3 experimental findings are divided into three groups, 
namely chloroform-oxygen narcosis; ether-oxygen narcosis; and com- 
bined narcosis, the latter being subdivided according to sequence, 
3Zuntz: Berl. Iclin. Woch., 1901, No. 20. 
2Vidal: Zentr. Chir., 1911, No. 11. 
3 Miiller, B.: " Ueber den Einfluss der Gange misehnarkosen auf die inneren 
Organe, " Arch. f. Idin. Chir., 1905, 71, 420. GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
87 
namely, chloroform-ether-oxygen narcosis and ether-chloroform-oxygen 
narcosis. 
Chloroform-oxygen narcosis diminishes the blood pressure, which 
drops constantly from the beginning of tolerance to the end, rising again 
when the patient awakens. The diminution of the blood pressure is 
considerably less in chloroform-oxygen narcosis than in simple chloro- 
form narcosis. The height of the blood pressure never drops so low 
below the normal blood pressure as in simple chloroform narcosis, and 
the course of the oxygen-mixture narcosis is of uniform appearance. But 
remissions are not altogether absent, and the chloroform effect can there- 
fore not be entirely overcome. The number of respirations undergoes a 
greater diminution with chloroform alone than with the oxygen-mixture 
narcosis, in which it approximates the normal standard. 
Concerning the effect of the oxygen narcosis upon the internal 
organs, the advantage of the addition of oxygen to chloroform consists 
in the removal of the carbon dioxid and in its substitution by oxygen, 
which induces a greater power of resistance on the part of the individual 
cells. The fatty changes of the cells, as well as the effect upon the heart, 
are not so severe in mixed as in simple chloroform narcosis. The mixed 
narcosis also involves a considerable saving of chloroform. 
In the oxygen-ether narcosis no depressive effect upon the blood 
pressure was demonstrable. The level of the blood pressure was always 
above normal, so that the blood pressure was invariably increased, exactly 
the opposite to chloroform-oxygen narcosis. Ether-oxygen acts upon 
the internal organs in an analogous fashion to ether, but the changes are 
less considerable, especially the salivation and fatty metamorphosis. 
The difference is due to similar factors to those in chloroform-oxygen 
inhalation, namely, the lessened consumption of ether, the supply of 
oxygen, and the prevention of carbon dioxid intoxication. Ether-oxygen 
narcosis possesses less narcotic power as compared to simple ether 
narcosis, especially in resistant individuals, habitual users of al- 
cohol, etc. 
Combined oxygen inhalation, with ether and chloroform, is utilized 
for the avoidance of the disadvantages of these two methods of narcosis; 
it diminishes the toxic effects of ether as well as of chloroform, but 
requires accurate dosage, careful observation of the patient, and a knowl- 
edge of the indications and contraindications for the individual anes- 
thetic agents. The effects of ether, for example, are merely diminished, 
but still present, so that certain dangers are involved in the narcosis if 
the patient is predisposed. Therefore, definite indications must always 
be present for this narcosis, for there are patients who are predisposed to 
a toxic effect of ether and unable to tolerate this narcosis. Ether-oxygen 
narcosis furthermore possesses less narcotic power than simple ether nar- 
cosis, and this is especially important in resistant individuals, such as 88 
ANESTHESIA 
neurasthenics and habitual users of alcohol, who in many cases cannot be 
brought under the influence of ether-oxygen narcosis. A reduced nar- 
cotic power is also frequently noted in chloroform-oxygen narcosis, so 
that it is difficult or impossible to narcotize alcoholic individuals. In 
order to avoid the disadvantages of chloroform-oxygen narcosis as well 
as of ether-oxygen narcosis, a combination of the two narcoses has been 
created in the form of combined oxygen narcosis, which is subdivided 
into chloroform-ether-oxygen narcosis and ether-chloroform-oxygen nar- 
cosis. By means of these combined narcoses the dangers and disadvan- 
tages of inhalation narcosis are much reduced. The favorable effects of 
these narcoses are due to diminution of the toxic action of ether as well 
as chloroform. 
Muller 1 investigated the fatty changes of the vital parenchymatous 
internal organs in animals after simple and mixed narcoses. It was 
found that any narcosis gives rise to a more or less well-marked incipient 
fatty metamorphosis in the internal organs. The change in the kidney 
is frequently not marked enough for albuminuria to appear, but some 
alteration of the epithelia is present after all narcoses. This incipient 
fatty metamorphosis, which does not attack all cells at once, promptly 
subsides again. An existing fatty metamorphosis, such as is caused, for 
example, by a preceding narcosis, becomes seriously aggravated by a re- 
peated inhalation of narcotic agents. It makes no difference what anes- 
thetic is used; chloroform, chloral hydrate, and ethyl bromid have the 
most energetic action in this respect; the last named agent being alto- 
gether useless for prolonged narcosis. Ether acts in a general way less 
strongly upon the heart and brain, but, after several narcoses with ether, 
fatty changes are likewise found in these organs. Each prolonged ether 
narcosis is followed by small pneumonic foci in the lungs, with mucus in 
the alveoli, collection of blood corpuscles in the alveoli, and round cell in- 
filtration in the surrounding tissue. These lung changes are of slight 
degree with chloroform. On the other hand, the liver and the kidney 
are affected less by ether than by chloroform. In a general way, there 
is a certain uniformity about the injurious effects of the various nar- 
cotics, except graded differences in the intensity of the action. Mixtures 
of chloroform and ether were found to be by no means better anesthetics, 
but rather possessed worse properties. The experiments showed that any 
mixture which contained chloroform did not act very differently from 
a pure chloroform narcosis. Mixed ether narcoses were followed, like the 
pure ether narcoses, by pneumonias of the above-described type. 
The practical application of these findings consists in the best possi- 
ble abbreviation of the narcosis; the avoidance of repeated narcosis 
1 Muller, B.: " Ueber Fettmetamorphose in den inneren parenchymatosen 
lebenswichtigen Organen nach einfachen und Misch-Narkosen. " Arch. f. klin. 
Chir., 1905, 75, 896. Fig. 14.-Oxygen Passing through Rubber Coil Immersed in Hot Water (Service 
of Dr. Bainbridge). 
Fig. 15. -Intra-abdominal Administration of Oxygen in Case of Intestinal 
Adhesions. 90 
ANESTHESIA 
within three to six days; and the examination of the organs before each 
narcosis, as to a preexisting fatty metamorphosis. Certain affections 
are a strict contra-indication against any narcosis, especially fatty meta- 
morphosis in the heart, kidneys, and liver. 
The Influence upon Anesthesia of Oxygen Intra-abdominally Ad- 
ministered.-It is not proposed in the present volume to consider surgical 
subjects such as may re- 
late to or modify the ad- 
ministration of a n e s - 
thetics. However, it is of 
importance to note the 
effect upon anesthesia of 
oxygen administered in- 
tra-abdominally, accord- 
ing to the method of Bain- 
bridge,1 who instituted, for 
purposes not connected 
with anesthesia, a series 
of animal experiments 
with oxygen and air, 
which verified, in a re- 
markable manner, our ex- 
periments with oxygen 
and the different anes- 
thetics. 
In a series of experi- 
ments to determine the 
difference between oxygen 
and air, oxygen was intro- 
duced into the abdomen 
following the technique 
as described upon human beings. It was found that oxygen was 
completely absorbed in all cases left undisturbed for seventy-two hours. 
There was a slight increase in pulse rate and respiration, also a slight 
rise in blood pressure. The effect upon the degree of anesthesia 
was marked, the animal showing a tendency to recover almost immedi- 
ately from the influence of the anesthetic. In cases where the anesthesia 
was profound, reflexes quickly became active. Animals into which the 
oxygen had been introduced were able to stand up from two to ten 
minutes after the discontinuance of the anesthetic. All reactions were 
more prompt when warmed oxygen was used instead of oxygen at 
normal temperature. The dark blood was changed to scarlet. In no 
Fig. 16.-Suturing of the Peritoneum. Continu- 
ous stitch to inserted tube; purse-string stitch 
(1) encircling tube. 
1 Bainbridge, W. S.: Annals of Surgery, March, 1909; N. Y. J. Med., June, 
1908; N. Y. Med. J., Apr., 1909. GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
91 
case was there macroscopic evidence that oxygen was an irritant to the 
peritoneum or any of the abdominal viscera. It was also found that 
oxygen stimulated intestinal peristalsis. 
When air was introduced instead of oxygen, the pulse, respiration, 
and blood pressure were particularly influenced, and the degree of anes- 
Fig. 17.-Aponeurosis United with Interrupted Sutures, the Muscle Having Been 
Previously Sutured. (1) Untied ends of peritoneal purse-string; (2) Untied suture 
through aponeurosis, passing halfway around tube. 
thesia was not affected. The time required for recovery after the anes- 
thetic agent had been discontinued was from fifteen to twenty-five 
minutes. 
In the abdominal administration of oxygen Bainbridge employs a 
gas containing 94-97 per cent oxygen. The gas is warmed to a tem- 
perature of 90°-100° F., by passing it through a rubber tube from the 
tank in which it is compressed into a wash bottle filled with hot water. 
From this bottle the partially warmed gas passes through the exit tube. 
This long exit tube is again connected to a piece of glass tubing, and 
to this, in turn, is attached a piece of sterile rubber tube, through 
which the gas is introduced into the abdominal cavity. (Figs 14 and 
15.) 
Animal experiments and clinical experience in a large number of 92 
ANESTHESIA 
cases have proven that oxygen can be safely administered intra-abdom- 
inally, that it lessens shock, controls hemorrhage from small vessels, 
lessens the degree of cyanosis, nausea, and vomiting, prevents the for- 
mation of adhesions, and stimulates to such a degree that more anes- 
thetic is necessary in order to keep the patient anesthetized until the 
completion of the operation. The technique of closing the wound 
and withdrawing the rubber tube, so as to prevent the leakage of 
oxygen, either into the tissues or into the surrounding atmosphere, 
is shown in Figures 16, 17, 18, and 19. 
Preceding the Administration 
with Oil of Bitter Orange Peel.- 
A procedure which exerts a striking 
influence upon the course of anes- 
thesia is the preliminary adminis- 
tration by inhalation of oil of orange 
(25 per cent oil of bitter orange 
peel, U. S. P., with 75 per cent of 
alcohol, U. S. P.). 
Gwathmey,1 who first employed 
this method, had long been in the 
habit of preceding the anesthesia by 
the administration of a one per cent 
vapor of cologne or whiskey, the 
agent being placed in one of the 
bottles of his three-bottle vapor ap- 
paratus (see illustration, p. 225). 
Later he adopted oil of bergamot or 
terpineol 2 for the purpose of mask- 
ing the odor of ether vapor. (See 
Chapter VIII.) 
Finding the induction period of 
anesthesia thus deprived of its ter- 
rors for many patients, particularly 
for nervous women and frightened 
children, the subject lapsing quietly into unconsciousness when the anes- 
thetic vapor was turned on, a search was instituted for a substance with 
a more penetrating yet none the less agreeable odor, which could be 
vaporized and utilized as a preliminary to ether or other inhalation 
anesthetic agent. 
With this object in view, the authors experimented with a number of 
Fig. 18.-Superficial Fascia United. 
(1) Untied peritoneal purse-string; (2) 
Untied aponeurosis suture. 
1Gwathmey: "The Vapor Method of Anesthesia," Med. Sec., Oct. 14, 1905. 
2Gwathmey: Terpineol ("lilacine") serves to mask the odor of ether vapor, 
and is a respiratory antiseptic, but, like oil of sweet orange, is less satisfactory 
than oil of bitter orange peel, because of its very sweet odor. GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
93 
odoriferous substances.1 From the table (page 94), by Passy,2 quoted 
by Tigerstedt,3 and rearranged here in the sequence of penetrating 
power, it will be seen that other odorifer- 
ous substances .exceed oil of orange in 
penetrative power. To these, however, 
some patients might find objection, 
whereas to the delightfid odor of oil of 
bitter orange peel it is hardly likely that 
anyone would object.4 
The table shows how many milli- 
grams of odorous substances, respective- 
ly, must be contained in one liter of air 
in order to produce a barely perceptible 
olfactory sensation. The list illustrates 
the functional capacity of the human ol- 
factory organ in regard to quantity. 
Zwaademaker,5 using the olfactom- 
eter, noticed that in the case of certain 
odoriferous substances the threshold, or 
very first beginning, of perception takes 
on a high value, under increasing con- 
centration, after a certain optimum has 
been reached. 
With the above facts in mind, 
Gwathmey employed oil of bitter orange 
peel in alcoholic solution, first using it 
by the drop method with ether. He 
found that in this way the odor of ether 
was completely masked, not only for the 
patient but for the occupants of the 
operating room as well. The patient passed into the stage of surgical 
anesthesia as one dropping into a profound sleep. There was no stage 
of excitement, the nausea and vomiting being materially reduced. The 
Fig. 19.-Tube Withdrawn; Peri- 
toneal Purse-string Tied; 
Knot Beneath Aponeurosis. 
(3) Aponeurosis suture. FiguA 
illustrates practicability of plac- 
ing skin-stitches while tube re- 
mains in the abdomen. 
1 Nussbaum (.Rundschau, 1888, 759) found that the odor of chloroform vapor 
might be masked by means of oil of cloves. In the experiments of the authors, 
the masking agents tried (terpineol, oil of bergamot, oil of patchouli, oil of 
lemon, orange, etc.) were superimposed upon water at 37° C., and the anesthetic 
vapor was then passed through. 
2 Passy: ' ' Forme periodique du pouvoir odorant dans la serie grasse, ' ' Compt. 
rend. Acad. d. Sciences, 1893, 116, 1007. 
' Tigerstedt: "Lehrbuch der Physiologic des Menschen," 1902, 2, 132. 
4 Eulimen, a pure limonene (density, 0.850 at 15° C.; boiling point, 175° C.), 
prepared according to a patented process (D. R.-P. 204, 163), has been proposed 
as an addition to narcotic mixtures ("Riedel's Mentor," 1911, 152). 
8 Zwaademaker, H.: "Die Physiologic des Geruches," Leipsic, 1895. 94 
ANESTHESIA 
TABLE 6. 
Milligrams per liter of air 
Mint leaves (Folia Menthoe) 
0.0000005 
- 0.00001 
Essence of Wintergreen 
0.000005 
- 0.0004 
Orange essence 
0.00005 
- 0.001 
Ether 
0.0005 
- 0.004 
Camphor 
0.005 
- 
Natural musk 
0.01 
- 0.1 
entire administration progressed smoothly, and the patient recovered 
from the anesthetic with none of the after-effects so frequently noted 
with ether.1 
Woolsey, of Brooklyn, developed and perfected the method of employ- 
ing the oil of orange-ether sequence by the closed method with the three- 
bottle vapor inhaler. He has a record of over 200 cases. He uses it 
wherever the nitrous oxid-ether sequence is indicated and prefers it to 
the latter method. It is unquestionably of inestimable value, especially 
where the transportation back and forth of the nitrous oxid cylinders 
is a matter of consideration. The technique is as follows:2 
The water bottle is filled with the usual amount of water, namely, 2% 
to 3 ounces. A solution of oil of orange, of the composition described, 
in one- to two-dram quantity, is placed in the water. Ether (four to six 
drams) is placed in the chloroform bottle, which receptacle is sur- 
rounded by lukewarm water. The usual quantity of ether (4 ounces) 
1 French has used the drop method of oil of orange-ether in over 50 cases; he 
states: "One of the most important and valuable recent contributions to anes- 
thesia methods is the ability to omit, or bridge, the second stage, or stage of 
excitement, and, judging by the results obtained, we are deeply impressed with 
the desirability of attaining narcosis without struggle. This can, without doubt, 
be accomplished, in the period of induction, with nitrous oxid; but, in our 
judgment, it can be done with greater ease and certainty with the essence of 
orange. It unquestionably requires a large experience with the administration 
of nitrous oxid to enable one to dovetail it so accurately with the ether which 
follows that the stage of excitement will be eliminated. It can, however, be done, 
and when done successfully, if all other things are equal, we can safely predict 
the best prospect for the operation and the best condition during recovery. The 
remarkable effects of the oil of orange as a preliminary to ether have been dem- 
onstrated in our clinic, and have proved to our satisfaction that, with it, the ad- 
ministration of ether is made far less disagreeable and that it greatly assists in 
the reduction of shock by bridging the stage of excitement. We have used it 
repeatedly with perfect success, the patients sinking into complete anesthesia as 
a child falls to sleep. Our observations thus far have brought the belief that an 
anesthesia conducted in this way is a contributive factor in reducing hemorrhage, 
also in reducing the quantity of the anesthetic and in shortening and modify- 
ing the anesthetic after-effects." French, Thomas R.: "Nitrous Oxid, Es- 
sence of Orange, Ether, and Sequestration in General Anesthesia," N. Y. Med. 
J., May 24, 1913. 
2See also "Vapor Method of Anesthesia." GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
95 
is placed in the ether bottle. The index is turned to "Air," and the 
bag is filled with the air pumped through the water bottle, which con- 
tains the oil of orange. The mask is placed upon the patient's face, and 
the patient breathes back and forth in the bag. The air is pumped 
vigorously so as to keep the bag two-thirds full at all times. The index 
is turned gradually toward "Chloroform," the receptacle in which the 
four to six drams of ether are placed. The patient is now getting a very 
small amount of ether, which is apparently imperceptible. The index is 
gradually turned to full "Chloroform," the patient getting more and 
more of the mild attenuated ether vapor. If, at this time, the patient 
coughs, sneezes, or swallows, or shows in any way that he perceives the 
ether, the index is immediately turned back to "Air." The same pro- 
cedure is repeated until the index reaches full "Chloroform." When 
this is accomplished the index is turned back to air again and gradually 
turned toward "Ether." The expiratory valve is, at all times, only 
slightly open. The bag remains moderately distended, a slight positive 
pressure being a decided advantage in some cases, the expiratory valve 
permitting a continuous but small escape of air. The patient will now 
be found to be in a state of full surgical anesthesia, the average time 
required to reach this stage being four and one-half minutes. Anes- 
thesia is maintained with the index turned for one-eighth to one-quarter 
of an inch from air, but between "air" and "ether," constant pumping 
being continued at all times. The breathing, as a rule, is quiet and 
regular, approximating the breathing in chloroform anesthesia more 
nearly than that usually seen with ether. The lid reflex is absent, the 
eyeballs are rolling, but the patient is sufficiently relaxed for all surgical 
operations. The usual amount of ether used with this method is two or 
three ounces for the first hour and one ounce for the second. The after- 
effects are usually conspicuous by their absence. The patient goes under 
in practically the same way as with a good nitrous oxid-ether sequence. 
There is no struggling or other indication of the second stage. The pulse 
is normal, the color reflex good, and there is no disturbing mucous rale. 
The physiological basis for the beneficial effect of oil of orange 
in the administration of inhalation anesthetics may be found in the pre- 
vention of reflex stimulation, by the anesthetic agent, of certain sensory 
nerves. Dastre 1 attributed early syncope to reflex stimulation of the 
pneumogastric and trigeminal nerves, particularly the sensory branches 
supplying the nasal mucous membrane and the larynx. Embley 2 has 
also emphasized the part played by the increased excitability of the 
vagus mechanism, particularly during the early part of the administra- 
tion. In his inhalation experiments Embley found that failure of 
respiration is mainly due to fall in blood pressure. With good blood 
'"Les anesthetiques,'' Paris, 1901, 104-109. 
2 Embley: Brit. Med. J., April 5, 12, 19, 1902. 96 
ANESTHESIA 
pressure, failure of respiration (his experiments concerned chloroform) 
is practically impossible. Restoration of respiration is dependent upon 
restoration of blood pressure. The chances of dangerous vagus inhibi- 
tion are greatly increased by imperfect respiration. 
From these findings it would seem fair to assume that any factor 
which prevents undue reflex inhibition of the nervous mechanism of 
respiration and which, by its stimulation of the respiratory center, pre- 
vents fall in blood pressure, will have a beneficial influence upon the 
course of the anesthesia. The oil of orange seems to exert this bene- 
ficial influence by dulling the sense of smell to such an extent that the 
odor of the anesthetic agent is not noticeable during the administration. 
It has been determined by our laboratory experiments upon guinea-pigs 
that the oil of orange exhibits no pronounced anesthetic effect upon these 
animals. The exact nature of its physiological action is, therefore, yet 
to be determined. 
The smoothness of the anesthesia seems to the authors to be depend- 
ent upon the power of oil of orange to obtund the olfactory nerve to such 
an extent that the odor of the ether vapor is not noticeable. This view 
has not been verified by laboratory experimentation, however. 
Concerning this "Mystery of Ether Anesthesia," 1 as this action of 
oil of orange has been called, the following comment is made: 
"We are confronted here with a problem that has so far eluded solu- 
tion. The problem of noci and anoci associations finds instant solution, 
at least as far as its practical aspect is concerned. With a few drops of 
oil of orange (in alcoholic solution) we accomplish all that formerly 
demanded much preliminary psychic care, gas-oxygen inhalations, and 
injections of novocain, and quinin and urea hydrochlorid before and 
after anesthesia. Are pleasant odors narcotic to the olfactory nerve? 
Is that some explanation of their widespread and age-long use ? Certain 
unpleasant odors are undoubtedly terrifying to animals, those of their 
enemies, for example. If pleasant odors are indeed sedative to the olfac- 
tory nerve, does that suffice to explain their extraordinary influence, at 
least when followed by ether, over the entire nervous system? Is there 
merely an association of ideas? The smell of ether is associated with 
the surgical knife in the minds of adults, and is terrifying to children 
from its irritating qualities. Perhaps the very familiarity and the harm- 
lessness associated with the odors of flowers and fruit are sufficient to 
suggest powerfully to the subject that what he is about to undergo can- 
not be dangerous, or even unfamiliar." 
Utilizing Carbon Dioxid.-The physiological importance of the car- 
bon dioxid content of the blood has only recently come to be fully recog- 
nized. Of still more recent origin is the demonstration of its relation 
to the administration of inhalation anesthetics. 
1"A Mystery of Ether Anesthesia," Editorial, N. Y. Med. J., Sept. 14, J912. GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
97 
Extensive investigations by physiologists in America and Europe 
have established the fact that carbon dioxid is not merely a waste- 
product, but performs a distinct role as a "harmone," or chemical-regu- 
lator of various functions. The carbon dioxid content of the blood, 
according to Henderson,1 exercises regulative influences upon the heart- 
rate, upon the vascular tonus, upon the peristalsis of the alimentary 
canal, upon the mental condition, and upon a number of other functions 
of the body. From the data presented by him it appears that even a 
slight reduction in the carbon dioxid content of the arterial blood 
causes a marked quickening of the heart-rate. "Further reduction," he 
says, "induces an extreme tachycardia, complete cessation of peristalsis, 
failure of many reflexes, and coma. If an extreme reduction of the CO2 
content of the blood is effected very rapidly, the heart comes into a state 
bordering on tetanus. This cardiac tetanus practically abolishes the 
pumping action of the heart. Arterial pressure falls and death results. 
"If the reduction in the arterial CO2 is less extreme, but is main- 
tained for a considerable time (an hour or more, according to the extent 
of the reduction), so that the tension of CO2 in the venous blood and in 
the tissues is reduced, symptoms and conditions result which are sim- 
ilar, in many respects, to those occurring in mountain sickness and are 
apparently identical with those of surgical shock. Arterial pressure falls 
to a very low level, and, if the condition is continued, the circulation 
fails. The fall is not due merely to tachycardia, for the heart-rate in 
the later stages is not always extremely rapid, but is caused by a loss of 
tonus in the peripheral veins and capillaries, and by the consequent stag- 
nation of the blood in these vessels. The mental condition of the subject 
is comatose. The reflexes are greatly reduced in responsiveness. Vigor- 
ous stimulation of afferent nerves causes no rise of arterial pressure. 
The condition of the nervous system and the stage of excitement through 
which it develops are not due primarily to the fall .of arterial pressure. 
They precede the fall. Although the coma is, of course, intensified by a 
low pressure, it may occur to a considerable extent coincidently with the 
high pressure of the earlier stages. 
"The respiration, when the subject is left to breathe naturally, be- 
comes very shallow. It is liable to pass into apnea. This condition is 
the direct effect of the reduced CO2 tension in the respiratory center." 
The reduction of carbon dioxid leading to the conditions described 
can be effected by various means detailed by Henderson, among which 
may be mentioned as having a practical bearing upon anesthesia: (1) 
artificial respiration; (2) the hyperpnea incident to the stage of excite- 
ment of incomplete anesthesia; (3) the hyperpnea produced by vigor- 
1 Henderson, Yandell: "Acapnia and Shock," Am. J. Physiol., Feb. 1, 
1908; Feb. 1, 1909; April 1, 1909; Feb. 1, 1910; June 1, 1910; Nov. 1, 1910; 
Aug. 1, 1911. 98 
ANESTHESIA 
ous and prolonged stimulation of the afferent nerves; (4) exposure of 
the abdominal viscera to the air so as to allow a free exhalation of carbon 
dioxid from the surface of these organs. Variations in the oxygen con- 
tent of the blood, according to Henderson, play little part, if any, in the 
production of these conditions. The regulation of the carbon dioxid 
tension of the air in the pulmonary alveoli, and the extent to which 
carbon dioxid is eliminated from the blood in its passage through the 
lungs, appeared to him to be the most important factors in the preven- 
tion of shock. In experiments in which he had induced shock, Hender- 
son found that restoration of carbon dioxid to the tissues and blood (or 
rather the maintenance of a condition which permits the tissues rapidly 
to restore their C02) proved effective in inducing rapid recovery. 
"Under all conditions, except during hyperpnea, in which condition the 
cardiac activity is increased sympathetically with the respiratory excite- 
ment, and, to a certain extent, even in this condition, the heart-rate can 
be kept down and the development of shock prevented." 1 
It is important to note that in the absence of respiratory excitement 
the heart-rate is an index which varies inversely as the carbon dioxid 
content of the arterial blood. The investigations which led Henderson to 
make his extensive experiments and observations, and his own work, are 
briefly reviewed in the section on Shock (see p. 383). 
The experiments of Henderson and the observations of Mosso 2 led 
Levi,3 in 1910, to consider the practicability of utilizing mixtures of 
carbon dioxid with oxygen for the purpose of stimulating the bulbar 
centers in surgical cases in which the automatic activity of these centers 
is temporarily paralyzed in consequence of the effects of chloroform or 
ether, or operative trauma, or of a combination of these causes. He first 
experimented on animals. Failure of respiration was induced by means 
of the single or combined action of nitrites, chloroform, and morphin. 
The animals were then made to inhale a mixture of oxygen with carbon 
dioxid in percentages from 10 to 30. In every case he noted an almost 
immediate return of the breathing and the effects of the inhalation were 
1 Henderson's method for regulating the heart rate in his early experiments 
' ' depended upon the manipulation of the hand bellows with which artificial 
respiration was administered, and on the adjustment of the escape vent in the 
side of the cannula tied into the trachea. As the pulmonary ventilation was in- 
creased or diminished, the heart rate was correspondingly accelerated or retarded. ' ' 
2 Mosso: Arch. exp. Path. u. Pharm., 1906, 54, 285. 
3 Levi, Ettore: "The Clinical Use of Carbon Dioxid with Oxygen," J. Am. 
Med. Assn., March 16, 1912. 
Also: "Nota preventia sulle applicazioni terapeutiche, nella pratica chirur- 
gica e medica di mischele li ossigeno e di anidriole carbonica," Acad. med. fis., 
Frienze, March 16, 1910; "Studi sull'azione fisiopatologica dell'anidriole car- 
bonica, e sulle applicazioni terapeutiche, nella pratica chirurgica e medica, di 
mescele di ossigeno ed'anidriole carbonica," Bev. Crit. di Clin. Med., 1910, Nos. 
30 and 31. GENERAL PHYSIOLOGY OF INHALATION ANESTHESIA 
99 
found to last for some time after the mixture had been discontinued. 
He then administered these gas mixtures to patients who were in a 
state of partial or complete coma as a consequence of trauma or extensive 
and prolonged operation. With mixtures of from 5 to 20 per cent of 
carbon dioxid in oxygen, the depth of breathing and the regularity of 
the rhythm were notably improved. His most satisfactory results were 
obtained with a mixture containing 15 per cent of carbon dioxid. In 
cases which exhibited Cheyne-Stokes respiration, normal breathing was 
restored, continuing so for some time after the inhalation of the gas 
mixture ceased. Marked improvement in circulation was also noted, the 
disappearance of cyanosis being one of the most striking features. 
In routine practice Levi employs the mixture of carbon dioxid and 
oxygen as soon as the slightest tendency to failure of respiratory or car- 
diac function appears. The almost invariable result, during nearly two 
years of experience with the method in hundreds of cases, has been a 
rapid return of normal heart action and breathing. The best results were 
noted where the condition of shock had not progressed too far, although 
striking beneficial results were obtained even in the latter cases. 
It is interesting to note that Levi's observations with this method 
seemed to him to afford an explanation, to some extent, of the good 
effects obtained with the method employed in connection with artificially 
reduced circulation. "It seems probable," he says, "that the remark- 
able rapidity with which patients subjected to narcosis under this con- 
dition recover consciousness, as observed by many authors, is due to the 
sudden return to the general circulation of a large amount of blood 
rich in carbon dioxid, when the lower limbs are unbandaged. Follow- 
ing up this suggestion, we have found that the use of a gas mixture 
containing from 10 per cent to 15 per cent of carbon dioxid after the 
completion of an operation is very effective in causing a prompt awaken- 
ing of the patient. It seems also to tend to decrease the post-chloro- 
formal vomiting. This is doubtless referable to the rapid elimination 
of chloroform from the blood and tissues under the influence of the 
increased respiration induced by the carbon dioxid." 
Levi does not give the technique by which he obtains the definite per- 
centages of carbon dioxid. Henderson has perfected an apparatus for 
definitely controlling the percentages of carbon dioxid. The requisite 
carbon dioxid percentage may be maintained by means of rebreathing as 
follows: When too much carbon dioxid is lost, as judged by the symptoms 
detailed (p. 97), the amount may be increased by allowing the subject to 
rebreathe for from three to six minutes, according to requirements, the 
anesthetic agent being discontinued meanwhile. When the breathing be- 
comes forced and other signs of distress appear, suggesting too much car- 
bon dioxid, rebreathing is discontinued and the administration of the an- 
esthetic is resumed. Four per cent has been found to be the limit of safety. CHAPTER III 
THE USE OF REBREATHING IN THE ADMINISTRATION OF 
ANESTHETICS i 
W. D. Gatch, M.D. 
Ether : Effect of Ether Vapor on Respiratory Passages; Compari- 
son of Toxic Effects Following Use of Open and Closed Methods; Ef- 
fect of Over-Concentration of Ether Vapor. 
Nitrous Oxid Alone and Combined with Ether: Method of 
Administration; Basis of Technique; Practical Advice; Maintenance of 
Ether Balance; Elimination of Ether from the System; Effect of Mor- 
phin on Ether Elimination; Clinical Results; Long Operations; Fatali- 
ties ; Cardiac Cases; Hypercapnia; Acapnia; Ether and Acapnia; Other 
Advantages of Rebreathing; Post-Anesthetic Nausea; Post-Anesthetic 
Abdominal Distention; Post-Anesthetic Lung Complications; Method 
Demands Experience. 
Chloroform and Ethyl Chlorid: Suggested Investigations; 
Dangers; Advantages. 
Rebreathing in the administration of ether and chloroform has been 
under discussion ever since the introduction of these agents as anes- 
thetics. With the introduction of etherization by the open method, 
rebreathing has fallen into disfavor, and many writers condemn it.2 
When properly regulated, and when the oxygen supply is ample, 
rebreathing can be put to a valuable use. The evidence in favor of this 
is derived partly from a series of 2,500 nitrous oxid-oxygen and nitrous 
oxid-oxygen-ether anesthesias given by a closed method at Halsted's 
clinic, and partly from the recent and very important work of the 
1 Taken from a paper read before the Section on Pathology and Physiology 
of the American Medical Association, at the Sixty-second Annual Session, Los 
Angeles, June, 1911. Reprinted, with modifications, by courtesy of J. Am. Med. 
Assn. 
2 Cunningham and Anderson: "Methods of Administering Ether," J. Am. 
Med. Assn., Nov. 7, 1908, 1574. 
100 REBREATHING IN ADMINISTRATION OF ANESTHETICS 
101 
physiologists, Henderson,1 Hill,2 Haldane,3 and others, on the carbon 
dioxid metabolism of the body. 
ETHER 
The subject can be approached most simply by considering the harm- 
ful results supposed to follow the administration of ether by the use of 
closed masks. Ether only will be considered for the present, because 
most of the investigations bearing on the subject of rebreathing have 
dealt with this anesthetic. The ill effects in question may be grouped 
under two heads: 
(1) Injury to the lungs; (2) general toxic effects. 
Effect of Ether Vapor on Respiratory Passages.-Dreser,4 Offergeld,5 
Poppert,6 and Holscher,7 have studied very carefully the effects of ether 
vapor on the respiratory passages. Dreser regards any concentration of 
vapor which cannot be inhaled by the patient while in the conscious state 
without discomfort and coughing as harmful to the lungs. Applying 
this test he fixed on 6 to 7 per cent as the highest concentration which 
should be used. Offergeld, experimenting on animals, found that the 
lungs, after etherization by a closed method, showed much graver in- 
juries than after etherization by an open method. With the closed 
method he found extensive fatty degeneration and desquamation of the 
epithelium of the air-passages, also many minute hemorrhages into the 
alveoli; many of the animals died of bronchopneumonia. With the 
open method the pulmonary lesions were of a comparatively unimportant 
character, unless the administration was frequently repeated at short 
intervals. Poppert, whose experiments were similar to Offergeld's, con- 
cluded that ether vapor .was more irritating to the lungs the greater its 
'Henderson: "Acapnia and Shock'' (a series of papers), Am. J. Physiol., 
1908, fl, 126; 1909, 23, 345; 1909, 24, 66; 1910, 25, 310; 1910, 26, 385; 1910, 
26, 260; 1910, 27, 152. 
2 Hill and Flack: "The Effect of Excess of Carbon Dioxide and of Want 
of Oxygen on the Respiration and the Circulation,'' J. Physiol., June 30, 1908; 
"The Influence of Oxygen Inhalations on Muscular Work,'' J. Physiol., July 
I, 1910. 
3 Haldane and Poulton: "The Effects of Want of Oxygen on Respiration,'' 
J. Physiol., 1908, 390. 
4 Dreser: "A Contribution to the Study of Anesthesia by Ether, ' ' Johns 
Hopkins Hosp. Bull., Jan., 1895. 
6 Offergeld: ' ' Lungenkomplicationen nach Aethernarkosen, ' ' Arch. f. klin. 
Chir., 1907, 83, 505. 
8 Poppert: ' ' Experimented und klinische Beitrage zur Aethernarkose und 
zur Aether-Chloroform-Mischnarkose, ' ' Deutsch. Z. Chir., 67, 505. 
' Holscher: ' ' Experimented Untersuchungen uber die Entstehung der 
Erkrankungen der Luftwege nach Aethernarkose,'' Arch. f. klin. Chir., 1898, 55, 
175. 102 
ANESTHESIA 
concentration. Holscher studied the distribution of secretion in the air- 
passages during ether narcosis. He found that there was only a very 
slight secretion from the epithelium situated below the level of the 
larynx. By putting coloring materials into the mouths of anesthetized 
animals he proved that mucus and saliva might be aspirated into the 
deepest air-passages. His conclusion was that "affections of the air- 
passages occurring after ether are, for the most part, due to the aspira- 
tion of infectious mouth contents." 
The experimental results dealing with the effects of ether vapor on 
the lungs may be summarized as follows: 
(1) The irritant action of the vapor varies according to its concen- 
tration. 
(2) Post-operative lung complications are frequently caused by the 
aspiration of mouth contents. 
(3) The greater severity of the pulmonary lesions found after 
experimental etherizations by the closed method can be satisfactorily 
accounted for by the great concentration of ether vapor in the closed 
masks and by the greater liability to aspirate mouth contents when these 
are used. 
Comparison of Toxic Effects Following the Use of Open and Closed 
Methods.-We now have to consider why the general toxic effects which 
follow ether anesthesia are more severe after the closed method than 
after the open method. Writers are almost unanimous in asserting that 
this is the case. The work of Ladd and Osgood 1 is very important in 
this connection. These authors studied the frequency of post-anesthetic 
vomiting in patients after etherization with the Blake cone, and in those 
etherized by the "gauze ether" method. Vomiting was much more fre- 
quent and severe among the former patients than among the latter. 
With the Blake cone cases they found acetone in the urine after opera- 
tion in 88 per cent of the cases, while with the "gauze ether" cases they 
found it in only 26 per cent. The technique and advantages of the open 
method are discussed by Miss Magaw,2 who reports 1-4,000 cases with 
most satisfactory results. In short, there is no doubt that this method 
of etherization is better than the rather crude closed methods that it 
has replaced. Its disadvantages and dangers will be referred to later. 
The causes commonly held responsible for the ill effects which follow 
the closed method are the following: (1) anoxemia; (2) overconcen- 
tration of ether vapor; (3) toxic organic substances in the expired air; 
and (4) excess of carbon dioxid in the expired air. 
There is reason to believe that the first and second of these possible 
causes are the real ones. From our present knowledge, the third is not 
xLadd and Osgood: "Gauze Ether," Ann. Surg., Sept., 1907. 
2 Magaw, Alice: "A Review of Over 14,000 Cases of Surgical Anesthesia," 
Surg., Gynec. and Obstet., 1906, 3, 795. REBREATHING IN ADMINISTRATION OF ANESTHETICS 
103 
important, since physiologists have demonstrated that there are no 
organic poisons in the expired air, or at least for practical purposes of 
anesthesia our clinical results indicate that such substances, even if they 
exist, need not be seriously considered.1 The excess of carbon dioxid is 
harmless and can be utilized to good advantage. 
Effect of Overconcentration of Ether Vapor.-It is evident that 
anoxemia and overdosage of ether-evils almost unavoidable when this 
anesthetic is given in a tightly closed mask-must do harm. It is known 
that a deficiency of oxygen quickly causes the gravest injuries to the 
tissues. Dreser found that the gas within a closed etherizing mask 
would, at times, put out a burning candle. He also found that the ether 
vapor within the closed mask sometimes reached a concentration as high 
as 34 per cent, while 6 to 7 per cent is the greatest concentration which 
can be inhaled without irritation to the air-passages. With such an 
overdosage of ether as this, it is true that the excess of carbon dioxid 
within the closed mask is injurious, for it stimulates the respiration 
powerfully, and leads quickly to an overabsorption of ether by the blood. 
If the truth of what has just been stated be admitted, it follows that, 
if we can prevent anoxemia, overconcentration of vapor, and too great a 
depth of anesthesia, we can obviate most of the serious objections to the 
closed method of giving ether. 
NITROUS OXID, ALONE AND COMBINED WITH ETHER 
The principles laid down in the foregoing paragraphs have been used 
in developing a method of anesthesia, the technique and advantages of 
which will now be described. Nitrous oxid and, if necessary, ether are 
the anesthetics used. The apparatus employed 1 consists essentially of a 
mask connected by a piece of flexible tubing to a rubber bag. This 
forms a closed space into which the patient breathes. On the mask is a 
valve-box by means of which the patient can be made to breathe to and 
1 Crowder, Thomas R.: "A. Study of the Ventilation of Sleeping-Cars," 
Arch. Int. Med., Jan. 15, 1911, 85; Haldane and Smith: "The Physiologic 
Effects of Air Vitiated by Respiration," J. Path, and Bad., 1892 and 1893, 
1, 168, 318; Erclents Fliigge: "Report of Experiments at the Institute of Hy- 
giene at Breslau," Z. f. Hyg., 1905, 363, 388, 405 and 433; Hill and Walker: 
"The Relative Influence of the Heat and Chemical Impurity of Close Air," J. 
Physiol., Nov. 9, 1910. 
Rosenau and Amos (J. Med. Bes., 1911, 25, 35) claim to have found in the 
expired air minute quantities of organic matter. They expressly state, how- 
ever, that their work does not necessarily indicate that this material is poison- 
ous. Their results await confirmation. 
1 The apparatus is described elsewhere in detail. It will be noted that the 
arrangement for giving ether has been changed so as to permit of a more ac- 
curate dosage. The method of administration is practically unchanged, except 
that Gatch now allows rebreathing for somewhat longer intervals. 104 
ANESTHESIA 
fro into the bag, or to inspire from the bag and expire into the air, thus 
emptying the bag. The bag is attached to a small box, through which 
the current of gas must pass back and forth from the bag to mask. Into 
this box nitrous oxid and oxygen are admitted, and ether, drop by drop, 
from a receptacle above. The ether is vaporized in the box from a series 
Fig. 20.-Gatch Nitrous Oxid-Oxygen Apparatus. 
of drip-plates and any excess of liquid ether can be drained off at once 
by a stopcock. 
Method of Administration.-The mask is adjusted carefully to the 
patient's face and the bag filled with nitrous oxid containing a very 
small amount of oxygen. The patient is made to breathe this mixture 
in and out through valves, thus replacing all the air in his lungs with 
nitrous oxid and oxygen. The bag is next refilled with the same mix- 
ture of gases, which the patient is made to rebreathe for from five REBREATHING IN ADMINISTRATION OF ANESTHETICS 
105 
to eight minutes. At the end of this time he is allowed to empty the 
bag, breath by breath, into the air, after which it is refilled, and the 
same procedure is repeated. Oxygen is given, without any attempt to 
estimate its exact percentage to the nitrous oxid, in quantities just suffi- 
cient to prevent cyanosis. If desired, nitrous oxid can easily be given 
under positive pressure, by keeping the bag slightly overdistended. 
This is sometimes a useful procedure in managing difficult cases. Anes- 
thesia is usually established in less than two minutes. If the anesthesia 
is unsatisfactory with nitrous oxid alone, ether is added. This com- 
Fig. 21.-Chart Showing Pulse and Respiration with Rebreathing. 
bined nitrous oxid-ether anesthesia has many points of practical and 
scientific interest. 
Ether is not given till the patient's respiration has been stimulated 
by the accumulation of carbon dioxid which results from the rebreath- 
ing. It is then added drop by drop. The heated gases quickly evaporate 
it from the drip plates, and it is rapidly absorbed by the blood because 
of the increased pulmonary ventilation. The most difficult subjects can 
thus be deeply anesthetized. 
Basis of the Technique.-Reference has already been made to 
DresePs experiments, in which he proved that from 6 to 7 per cent of 
ether vapor is the greatest concentration which can be inhaled by a 
patient in the conscious state without irritation and coughing. Precau- 
tions must be taken to keep the concentration of ether vapor in the mix- 
ture of gases below this level in order to eliminate the possibility of 
injuring the lungs. This is quite easily accomplished, as the following 
simple calculation will show. The gas-bag, moderately distended, holds 
about 10 liters of gas, the mask and tubing hold about 1 liter, and the 
entire respiratory system of the patient holds about 3 liters. When the 106 
ANESTHESIA 
patient is rebreathing these all form one closed space, with a total 
capacity of about 15 liters. The problem therefore is simply to deter- 
mine how much ether must be added to 15 liters of gas in order to make 
the concentration of ether vapor 7 per cent. Abel has calculated the 
amount of ether to be 4.2 c.c. However, the conditions of the problem 
are so variable that the amount of ether required cannot be determined 
with absolute accuracy. The varying temperature in the apparatus, the 
loss of ether through leaks and by absorption in the lungs, are factors 
for which no accurate data can be furnished, as they are variable. But 
absolute accuracy is not necessary, because the constant loss of ether 
Fig. 22.-Chart of the Pulse, Respiration and Blood-Pressure During Anesthesia 
of Two Hours and Fifteen Minutes' Duration. Pulse: line with crosses. Res- 
piration: line with circles. Blood-pressure: line with heavy dots. The patient was a 
woman of 65 with carcinoma of the sigmoid. The operation was closure of a fecal 
fistula by double lateral anastomosis, repair of an old wound in the abdominal wall, 
and colostomy. Note the constant level of the pulse and the maintained rise of blood- 
pressure. The temperature rose from 98.6° to 99.9.° The recovery was excellent. 
gives us a wide margin of safety, so that ether can probably be added 
much faster than the calculation allows, without exceeding the danger 
limit. 
Practical Advice.-With the drops of ether falling at the rate of 120 
to the minute, it has been found that it takes two and one-quarter min- 
utes to add the 4.2 c.c. Therefore, if we give ether at this rate and take 
precautions not to keep it dropping for more than two minutes at any 
one time, and to keep the bag constantly full of gas, we can be sure that 
the ether vapor will not reach a concentration greater than 7 per cent. 
The anesthetist can estimate the approximate strength of ether vapor 
by its odor as it escapes from the valve-box. 
Maintenance of Ether Balance.-It has been found unnecessary to 
give ether constantly during the administration. When enough has been 
given to produce satisfactory anesthesia, even in cases requiring a deep 
narcosis, the anesthesia can be maintained with nitrous oxid alone. 
This is to be explained by the fact that the rebreathing prevents the 
ether, once dissolved by the blood, from being thrown off as rapidly as REBREATHING IN ADMINISTRATION OF ANESTHETICS 
107 
it would otherwise be by the lungs, which are 
the organs by which it is practically all elim- 
inated.1 Suppose, for example, that a patient 
having a certain amount of ether dissolved in 
his blood is given some fresh nitrous oxid and 
oxygen to rebreathe. The ether will be thrown 
off from his lungs till the tension of its vapor 
in the gases being breathed will equal that in 
the blood. When this occurs no more ether 
will be eliminated until a new supply of gas is 
furnished. 
Elimination of Ether from the System.- 
Not only can we prevent the elimination of 
ether by rebreathing, but we can also hasten 
the elimination by a rapid ventilation of the 
lungs with fresh gas. During the process of 
rebreathing, carbon dioxid accumulates in the 
body and stimulates the respiratory center so 
that the breathing becomes deep and rapid- 
often fifty or sixty respirations to the minute. 
When a patient, anesthetized in the manner 
described, and breathing at such a rate, is 
given a fresh supply of gas and allowed to dis- 
charge each breath into the air, he apparently 
rapidly rids himself of the small dose of ether 
he has been given. Thus it is possible to 
anesthetize a patient so deeply that he will not 
stir during a Whitehead or other operation re- 
quiring deep narcosis, and yet have him con- 
scious before leaving the operating room. By 
careful administration we can, in most cases, 
keep the patient from knowing that he has 
been given any ether at all, so complete and 
rapid is its elimination. 
It is recommended that this method of re- 
moving a volatile anesthetic by rapid ventila- 
tion of the lungs be used at the close of every 
administration of chloroform or ether. The 
increased pulmonary ventilation can be easily 
Fig. 23.-Chart Showing 
Value of Rebreathing 
During Operation. 
1 Hewitt: ' ' Anaesthetics and Their Administration, ' ' 3rd ed., 50; Cushny: 
"Pharmacology and Therapeutics," 4th ed., 166; Cushny: "The Exhalation of 
Drugs by the Lungs," J. Physiol., 40, 17; Nicloux: "Elimination de 1'ether 
contenu dans le sang apres 1'anesthesie pendant la periode de retour," Compt. 
rend. Soc. biol., 1907, 1, 8. 108 
ANESTHESIA 
brought about by making the patient breathe in and out, through valves, 
air or oxygen containing a small percentage of carbon dioxid. 
Effect of Morphin on Ether Elimination.-In this connection, it is 
interesting to consider the effect which morphin has on the elimination 
of ether or chloroform from the body. Morphin decreases markedly the 
rate of pulmonary ventilation.1 Large doses of this drug must therefore 
retard the elimination of the anesthetic and thus increase its toxic action. 
It is often possible to detect the odor of ether or chloroform on the 
patient's breath for several hours after operation. This slow excretion 
may be due, in part at least, to the morphin, a hypodermic of which is 
desirable before or after almost every anesthesia. Perhaps this effect of 
morphin can be alleviated by means of the method just described for 
the quick elimination of the anesthetic. 
During the stay of ether in the system its toxic action cannot be 
prevented. It has been found that the dose of ether, and its consequent 
ill effects, may be reduced to the minimum by employing a combination 
of this agent with nitrous oxid. and morphin, the major part of the 
anesthesia in this case being produced by the nitrous oxid and mor- 
phin. The effect of ether, when thus administered, is relatively much 
greater than when given alone, for, as is well known, narcotic drugs, 
given in combination, reinforce the action of one another.2 Thus the 
powerful joint effect of morph in and scopalamin has been explained. 
Clinical Results.-The form of anesthesia herein described has been 
in use in the surgical clinic of the Johns Hopkins Hospital for two 
years, over 2,500 patients having been anesthetized by this method. 
It is there the routine form of anesthesia for all operations, except 
those on the face, upper air-passages, or cranium. In these it has been 
found inconvenient on account of the difficulty of keeping the mask in 
place. 
Before the operation, the patient is given an enema and deprived of 
food for several hours, but is allowed to take small quantities of water. 
About thirty minutes before the anesthesia is begun a hypodermic of 
morphin and atropin is given, the dose for an adult being morphin 
1/6 grain, atropin 1/100 grain. The anesthesia is started after the 
patient has been placed on the table and while the field of operation is 
being surrounded by sterile towels. It is established so quickly that the 
incision can usually be made in two minutes after the mask has been 
put on. Any depth of anesthesia which the condition of the patient and 
the nature of the operation may require can be easily obtained, because 
of the control of the patient's respiration which is given by the rebreath- 
xCushny: "Pharmacology and Therapeutics," 4th ed., 211. 
2 Fuhner: ' ' Pharmakologische Untersuehungen uber die Mischnarkose, '' 
Munch, med. Woch., 1911, No. 4; Burge: "Die Wirkung von Narkotikakom- 
binationen, " Deutsch, med. Woch., 1910, No. 1, 20; No. 2, 62. REBREATHING IN ADMINISTRATION OF ANESTHETICS 
109 
ing. In abdominal operations, if the increased activity of the respiration 
is inconvenient, it can be prevented by giving a fresh supply of gas at 
frequent intervals. The bleeding during nitrous oxid-oxygen or nitrous 
oxid-ether anesthesia is about the same as during open ether anesthesia. 
The patient's temperature, provided he is kept dry and covered, will be 
found elevated from 0.5° to 2° after an hour's operation. Thus any 
special device for heating the gases is unnecessary, since the patient him- 
self attends to this.1 With light narcosis, under nitrous oxid and oxygen 
alone, the pulse may be rapid (from 140 to 160 to the minute), but this 
is of no significance, provided it is regular and of good quality, and 
there is no hemorrhage. The rapid heart-rate decreases when ether is 
given. 
Long Operations.-This form of anesthesia is especially well suited 
for long operations. In fact, the anesthesia does the patient so little harm 
that, within reasonable limits, the duration of the narcosis need not be 
considered. This is often advantageous to the surgeon, when deliberation 
and minute attention to detail are necessary. The following typical 
cases illustrate the method: 
Case 1.-The patient was a negro man, aged 27, in good physical 
condition. Operation: Excision of a sarcoma from the right popliteal 
space, and blood-vessel transplantation. Duration of anesthesia, five 
hours. The pulse-rate per minute varied from 72 to 100. The blood- 
pressure at the end of four hours of anesthesia was 130 mm. of mercury. 
The patient regained consciousness before leaving the table. He had no 
headache, nausea, or vomiting though he was given water at once. His 
urine after operation contained no albumin or acetone. He was allowed 
to rebreathe at two and one-half and three-minute intervals. The nar- 
cosis was deep and quiet. Ether was given with the gas for the first 
half hour. 
Case 2.-The patient was a white woman, aged 30, in rather poor 
condition. Operation: Resection of the ascending and transverse colon. 
Duration of anesthesia, two hours and five minutes. No ether was used. 
The narcosis was light, the patient at times moving her limbs. Recovery 
was immediate and unattended with headache or vomiting. 
Case 3.-The patient was a colored woman, aged 30, in good con- 
dition. Operation: Excision of the right breast, pectoral muscles and 
axillary glands for advanced cancer of the breast, Thiersch skin graft- 
ing of the raw surface of the breast. Duration of anesthesia, three 
hours and fifty-five minutes; ounces of ether, 130 gallons of gas 
and 30 of oxygen were used. The anesthesia was quiet and satisfac- 
tory, the recovery immediate and without headache, nausea, or vom- 
iting. 
l0n the subject of "Warmed Anesthetic Vapor," see Gwathmey, N. Y. J. 
of Med., Feb., 1905. 110 
ANESTHESIA 
Cautions.-A word of caution is, however, necessary. During any 
administration, and especially during a long administration, the 
patient's breathing must be kept free and unobstructed, and his color 
good. If a patient has to work hard for every breath he soon wears 
himself out. The color of the blood in the wound, the hue of the 
patient's face, and the character of his breathing, as shown by the 
movements of the rubber bag, are the best indicators of his condition. 
The surgeon himself can hardly fail to notice these. If the patient's 
breathing cannot be kept unobstructed, the use of the apparatus should 
be abandoned at once and some other method for the production of 
anesthesia employed. 
Fatalities.-Three fatalities, during or immediately after operation, 
in the series of 2,500 cases have been recorded. How much the an- 
esthesia was to blame for these may be judged from the following 
reports: 
Fatality 1.-The patient was a colored woman, aged 44, with ex- 
ophthalmic goiter of four years' standing. She had an irregular inter- 
mittent pulse, the rate of which had been between 120 and 140. Her 
heart was enlarged, and she had ascites and edema of the ankles. Dur- 
ing the last week of her life she had several severe attacks of dyspnea, 
associated with extreme rapidity and irregularity of the pulse. For 
these she was given a course of digitalis, which improved her condition 
so much that it was thought she could withstand a partial thyroidectomy. 
When the mask was placed over her face, she made a very slight struggle 
and took several shallow breaths. The operator then saw the superficial 
veins of her neck suddenly dilate. This apparently marked the time 
of death, and occurred within half a minute of the time the anesthetic 
was started. 
Fatality 2.-The patient was a man with aortic and mitral insuf- 
ficiency, on whom it was proposed to do a perineal prostatectomy. He 
was given ether with the gas and oxygen. The anesthesia went very 
well till the patient was placed on the perineal table with his buttocks 
elevated; then he became cyanotic and died. An immediate autopsy 
revealed the presence of a large pericardial effusion, the presence of 
which had not been recognized before the operation. 
Fatality 3.-The patient was a girl of 16, with multiple infectious 
arthritis; general condition poor. Operation: Injection of both knees 
with oil and manipulation of knees, ankles, and elbows. Duration of 
anesthesia, fifteen minutes. The anesthesia was uneventful, except for 
a marked increase in pulse-rate while each joint was being manipu- 
lated. At no time was the breathing obstructed. At the close the pulse- 
rate went up very rapidly; the color became cyanotic and could not be 
cleared up with oxygen. The breathing became weaker and weaker, 
and finally ceased. An autopsy showed a very large thymus and hyper- REBREATHING IN ADMINISTRATION OF ANESTHETICS 
111 
trophy of all the lymphatic tissues. The pathologists gave status lym- 
phaticus as the cause of death. 
The first and second of these patients had circulatory disease of 
such gravity that the anesthesia is not to be seriously blamed for the 
deaths. How the third fatality was brought about it is hard to under- 
stand. The toxicity of nitrous oxid is certainly too low to have 
caused it. 
Cardiac Cases.-Notwithstanding these fatalities, it is believed that 
this form of anesthesia, properly employed, is well suited for cardiac 
cases. Two cases of Cesarean section performed by J. W. Williams on 
women with serious valvular lesions will show the grounds for this belief. 
Both women were in about the seventh month of pregnancy, and in 
both delivery was necessary in order to save the life of the patient. 
One patient was in extremis and her death on the table was regarded 
by the operator as probable. Both women had such urgent dyspnea 
that the anesthetic had to be started with the patient sitting upright. 
The same method of administration was employed in each case. Each 
patient was given a hypodermic of morphin large enough to quiet 
her. In inducing anesthesia great care was exercised to avoid the least 
excitement or struggling on the part of the patient. Both were allowed 
to rebreathe oxygen till the respiration was stimulated before any nitrous 
oxid was given. Enough ether was used to give a quiet anesthesia. 
The operations were performed with the patients' bodies elevated at an 
angle of 20° to 30°. The pulse of both patients was much better during 
anesthesia than before, and the operator was able to proceed without 
undue haste. Both patients made an excellent recovery. 
Hypercapnia.-Clinical experience has certainly shown that an excess 
of carbon dioxid in the blood-a hypercapnia during anesthesia to the 
degree allowed-is harmless. Hill and Flack state that "the effects of 
carbon dioxid on the heart can always be quickly recovered from, even 
if the blood-pressure has sunk to zero." These authors found that car- 
bon dioxid up to a percentage of 35 in the air breathed stimulates 
the respiration, while above 35 it depresses it; also that percentages up 
to 22 produce a rise in blood pressure, while higher percentages cause 
a fall. Of course it is impracticable to determine exactly what per- 
centage of carbon dioxid a patient is breathing. The anesthetist must 
regulate the time of rebreathing so that the patient's respiration is 
moderately stimulated. The periods of rebreathing for 10 liters of 
gas range from three to five minutes, any leakage from the apparatus 
being meanwhile made up by the addition of fresh gas.1 
1 After rebreathing 10 liters of oxygen for three minutes, it was found to con- 
tain 8.9 per cent CCK Allowing for the decreased COo formation during anes- 
thesia, it is probable that the percentage breathed by the patient is seldom 
above this. 112 
ANESTHESIA 
Acapnia.-Does a deficiency of carbon dioxid in the blood-acapnia 
-do serious harm? Henderson has been able to reduce animals to a 
state of extreme shock by overventilation of their lungs. He asserts 
that acapnia causes complex osmotic changes in the tissues, which result 
in a passage of water from the blood into the lymph and into the tissue- 
cells, and a dilatation of the finer veins. Interference with the normal 
filling of the right side of the heart by this process is the essential phe- 
nomenon in surgical shock. In extreme cases of acapnia the blood- 
stream is so scant and the respiration so feeble that the tissues do not 
receive the necessary amount of oxygen. An asphyxial acidosis results 
which does the body-cells irreparable injury. Whether Henderson's 
theory be accepted or not it must be admitted that the accumulation of 
carbon dioxid by the process of rebreathing is an efficient stimulus to 
the respiration and circulation. In fact, it is used as a purely thera- 
peutic measure in cases of morphin poisoning, in cases of so-called 
traumatic or toxemic shock, and wherever the respiration is feeble.1 
Oxygen can be given much more effectually and cheaply by the use of 
rebreathing than in the ordinary way. Thus, with anesthetics of low 
toxicity and the use of rebreathing, a very ill patient may be benefited 
by an anesthetic. 
Ether and Acapnia.-On the other hand, when ether is given by the 
open method, we take a very efficient means of producing acapnia, 
because ether diminishes the formation of carbon dioxid by the tissues, 
and, by stimulating the respiration, hastens its elimination. Symptoms 
of a mild grade of acapnia under open ether anesthesia are com- 
mon. Thus a patient who has perhaps been difficult to anesthetize, 
or who has been lightly under ether for some time and is breathing 
at a rapid rate, will gradually stop breathing. After an interval of 
perhaps two or three minutes, his respiration will start again but will 
not be normal for a long time. This occurrence, though alarming, is 
seldom followed by harmful results. 
Hundreds of patients are etherized daily by the open method without 
developing symptoms of shock. What prevents a serious grade of 
acapnia in the great majority of cases? Several factors are concerned.2 
(1) Many anesthesias are of too brief duration for acapnia to 
develop. 
(2) There is frequently more or less obstruction to the breathing 
during narcosis, and this prevents acapnia. 
1 Patients with feeble pulse and respiration-so-called shock cases-should 
be made to rebreathe air in oxygen till their respiration is normal, before breath- 
ing the anesthetic. 
2Levi, Ettore: "Studies on the Pathophysiologic Action of CO2 and on 
the Therapeutic Applications in Surgery and Medicine of Mixture of O2 and 
COa, " Estr. d. rev. crit. di din. med., 1910, 11, 30, 31. REBREATHING IN ADMINISTRATION OF ANESTHETICS 
113 
(3) The slowing of the respiration which results from a prelim- 
inary hypodermic of morphin may protect from the same danger.1 
(4) The so-called "open" method is usually not "open" at all, for 
the mask is so covered with towels or gauze that the patient does con- 
siderable rebreathing. 
Other Advantages of Rebreathing.-Apart from the prevention of 
acapnia, rebreathing presents several other advantages over open ether 
anesthesia. The chief of these are: 
(1) Lessened post-anesthetic vomiting. 
(2) Decrease in number of cases of abdominal distention after 
operation. 
(3) Practical abolition of post-anesthetic lung complications.2 
Post-Anesthetic Nausea.-Vomiting after operation depends on 
many things besides the anesthetic. About 35 per cent of our patients 
vomit, but the vomiting is usually very slight. Of 200 patients only four 
had more than very transient vomiting. Of these cases one was a case 
of exophthalmic goiter, one a case of stone in the common bile-duct, one 
a case of spreading peritonitis from an appendix abscess, and one a 
case of intestinal reaction. The nausea alone seldom prevents a patient 
from taking water and nourishment at once after operation. 
Post-Anesthetic Abdominal Distention.-Very little experimental 
work has been done regarding the question of abdominal distention 
following ether anesthesia. Cannon and Murphy 3 observed a great delay 
in the emptying of the stomach contents into the duodenum, and a 
slowing of the passage of food along the intestines after etherization. 
Figure 24, which is a tracing obtained from D. R. Hooker,4 demonstrates 
1Crile: "The Blood-pressure in Surgery," 281. 
3 Homans: "Post-Anesthetic Pulmonary Complications," Bull. Johns Hop- 
kins Hosp., April, 1909. 
3 Cannon and Murphy: ' ' The Movements of the Stomach and Intestines in 
Some Surgical Conditions," Ann. Surg., 1906, 13, 513. 
* Thanks are due Dr. Hooker for permission to publish this tracing and for 
the following note: 
' ' Dr. Gatch has asked to have added a note covering some unpublished experi- 
ments done in the physiologic laboratory of the Johns Hopkins University, which 
appear to have a direct bearing on his own work. 
"Cross-sections of blood vessels or intestine, to which a recording lever was 
attached, were hung in a moist chamber. In the use of tissue from warm- 
blooded animals the temperature of the chamber was maintained constant at 35° 
C. Through the chamber were passed alternately streams of oxygen and carbon 
dioxid gas. By this method the tissue studied was exposed to practically pure 
atmospheres of the gases. The experimental conditions, therefore, did not fall 
within physiologic limits, so far as the percentage of gas is concerned. Work 
is now in progress to investigate the effect of different percentages of oxygen 
and carbon dioxid. Aside from the result of this future work, however, the 
interesting fact has been demonstrated that the musculature of the blood vessels 
responds in atmospheres of the gases studied in an exactly opposite manner 114 
ANESTHESIA 
the paralyzing effect of a weak ether vapor on the pyloric ring of the 
frog. It also shows that carbon dioxid acts as a powerful stimulant to the 
muscle of the ring. Of course the conditions to which the bowel was 
subjected when this tracing was obtained were abnormal, yet the paraly- 
sis by ether is exactly what any clinician would expect. It is well recog- 
nized that an excess of carbon dioxid in the blood promotes peristalsis, 
Fig. 24.-Tracing Obtained from the Pyloric Ring of a Frog Suspended in a Moist 
Chamber into Which Ether Vapor and Carbon Dioxid Could Be Passed. At c, 
carbon dioxid was passed over the muscle, causing a sharp contraction; at ei very dilute 
ether vapor was turned on with the carbon dioxid, causing immediate relaxation; at ez 
the ether was turned off. 
to the musculature of the intestines. Carbon dioxid causes a marked improve- 
ment in the tone of the intestines and a marked relaxation of tone in the veins 
and arteries. On the other hand, oxygen causes a relaxation of tone in the 
intestines and an improvement of tone in the veins and arteries. These results 
were obtained in the case of both warm-blooded and cold-blooded animals and 
demonstrated with graphic records. 
"If it be true that Henderson reasoned by analogy from the behavior of 
the smooth muscle in the intestine to that in the blood vessel (especially the 
veins) in developing the acapnia theory of surgical shock, it is obvious from 
these results that his reasoning was not entirely justifiable. 
"The correlation of the difference in action of these gases in physiologic 
economy tempts speculation. The body seeks to rid itself of any excess of car- 
bon dioxid. Jerusalem and Starling (J. Physiol., 1910, 40, 279) have shown 
that carbon dioxid (0.625 of an atmosphere) increases the efficiency of the 
isolated mammalian heart chiefly by improving its diastolic relaxation. Bayliss 
(J. Physiol., 1901, 26, 32) has shown that this gas relaxes vascular tone. It 
has long been known that in the intestine the same gas increases peristalsis, and 
Mall {Johns Hopkins Hosp. Bep., 1896, 1, 37) has suggested that rhythmic move- 
ments of the intestines may help to empty the venous plexuses in the walls and 
thus aid in driving the blood into the portal system. We have, therefore, a 
coordination of activity which greatly facilitates the circulation of blood and 
the consequent rapid elimination of the carbon dioxid. Oxygen in excess, on 
the contrary, would tend to bring about opposite effects with a resultant retarda- 
tion of the circulation. 
"In conclusion, it should be clear to the reader that this is a chemical regu- 
lation of the circulation entirely peripheral in its action. The action of the 
gases on the medullary' centers is a wholly different question. ' ' REBREATHING IN ADMINISTRATION OF ANESTHETICS 
115 
and Henderson 1 has shown that the normal intestinal movements which 
cease after a laparotomy can be restored by passing a stream of carbon 
dioxid over the exposed bowel. These experimental results are con- 
firmed by clinical experience. It will be recalled that we use the smallest 
possible amount of ether, and produce a hypercapnia by making a patient 
rebreathe. In the 200 cases referred to above there was not a case of 
abdominal distention except after laparotomy, and among the laparoto- 
mies, seventy-five in number, it occurred in but three cases, these being 
the same patients who had considerable vomiting. 
Post-Anesthetic Lung Complications.-In 2,500 cases of nitrous 
oxid-oxygen or nitrous oxid-oxygen-ether anesthesia there was but 
one case of post-anesthetic pneumonia; this was in a girl with general 
peritonitis, who recovered. This absence of pneumonia may have been 
partly accidental, since pneumonia after operation may be due to causes 
other than the anesthetic. The record is striking, however, and all the 
more so because patients with pulmonary tuberculosis, bronchitis, and 
empyema were anesthetized without hesitation. It contrasts markedly 
with the record after open ether. Here in a series of 400 cases there was 
one death from ether pneumonia, and two deaths, one with autopsy, from 
acute pulmonary tuberculosis.2 The latter patients were both operated 
on for tuberculous glands of the neck. Both patients died rather late- 
in from two to three weeks-after operation, but they ran a high tem- 
perature from the first. It was the opinion of L. V. Hammond, who 
had charge of the work on tuberculosis at the Johns Hopkins Hospital, 
that the etherization had lighted up small apical foci of disease un- 
detected before operation. 
Method Demands Experience.-The impression must not be gained 
that this form of anesthesia is free from danger. It is without danger 
so far as post-operative effects are concerned. During the administra- 
tion, however, there are dangers. These arise from causes which can 
generally be foreseen and which can always be prevented by careful and 
skillful administration. The method should not be used except by those 
who have made a special study of its problems. 
CHLOROFORM AND ETHYL CHLORID 
Suggested Investigations.-The foregoing discussion of the use of 
rebreathing in the administration of ether and nitrous oxid will apply, 
in part at least, to the administration of all anesthetics given by inhala- 
tion. It would seem that rebreathing in the administration of chloro- 
1 Henderson: ' ' Shock after Laparotomy: Its Prevention, Production, and 
Relief," Am. J. Physiol., 1909, 21, 60. 
2Walsh: "Chloroform Rather Than Ether Anesthesia in Tuberculosis,' 
J. Am. Med. Assn., Aug. 28, 1909. 116 
ANESTHESIA 
form and ethyl chlorid would be attended by the same advantages that 
exist in the giving of ether and nitrous oxid. The general principles 
which govern the administration of these agents by a closed method are: 
First: The problem of dosage, which must be taken into account 
because of the high toxicity of chloroform and ethyl chlorid. A definite 
measured quantity of the anesthetic should be added to each measured 
volume of the gas which serves as a vehicle for administering it. The 
narcosis should be begun with a very dilute anesthetic vapor. 
Second: When once anesthesia is established, it should be main- 
tained in the same way as with an ether anesthesia, namely, by pre- 
venting the elimination of the drug from the patient's blood by making 
him rebreathe oxygen or air. The elimination of the anesthetic at the 
close of the narcosis could be hastened by overventilation of the patient's 
lungs. 
Dangers.-The chief dangers of this method are: 
(1) Anoxemia due to a failure to give sufficient oxygen or to an 
obstructed airway. 
(2) Impediments to the respiration, which, in a long anesthesia, may 
exhaust the patient. 
(3) With cardiac cases, excitement during the period of induction. 
Advantages.-The chief advantages of this method are: 
(1) The rapidity and pleasantness with which anesthesia is estab- 
lished. 
(2) The ease with which any depth of anesthesia can be secured. 
(3) The prevention, to a very large extent, of post-anesthetic vom- 
iting, pulmonary complications, and abdominal distention. 
Fig. 24A.-Henderson-Coburn.- Carbon dioxid outfit for post-operative inhalation in 
adjustable proportions. (See p. 96.) CHAPTER IV 
NITROUS OXID 
History: Early Use in Dentistry; Nitrous Oxid Administered with 
Oxygen; Physical Properties; Chemical Properties; Impurities of 
Nitrous Oxid; Standard of Purity. 
Special Physiology: The Hyperoxygenation Theory; The De- 
oxygenation or Asphyxiation Theory; The Theory of the Specific Action 
of Nitrous Oxid upon the Brain Cells; Effects upon the Respiratory 
System; Effects upon the Circulatory System; Effects upon the Nervous 
System; Effects upon the Muscular System; Effects upon the Glandular 
System and Other Structures; Causes of Death; Stages of Anesthesia; 
Elimination; After-effects. 
Comparison with Other Agents. 
Indications and Contraindications. 
Administration: Heating the Gas; Essential Features of Any 
Satisfactory Apparatus; Apparatus for Administering Nitrous Oxid 
Alone or With Air; Dangers of Administration of Nitrous Oxid Alone; 
Recognition of Asphyxial Symptoms; Administration of Nitrous Oxid 
Alone; Administration to Asphyxiation With and Without Valves; Use 
of Expiratory Valve Alone; Administration Without Valves; Precau- 
tions When Administered Alone; Administration of Nitrous Oxid With 
Air in Unknown Quantities; Administration of Nitrous Oxid With Defi- 
nite Amounts of Air; Nitrous Oxid as a Sequence to Ether; Nitrous 
Oxid With Air; Technique of Ether-Nitrous Oxid (Air) Sequences; 
Technique With A.C.E.; Advantages of Ether (or Chloroform-Ether)- 
Nitrous Oxid Sequence; The Advantages of Administration of Nitrous 
Oxid With Oxygen; Superiority of Oxygen Over Air; The Administra- 
tion of Nitrous Oxid With Indefinite Quantities of Oxygen; Gatch's 
Method of Administration; Davis' Method; Methods of Administration 
With Definite Quantities of Nitrous Oxid and Oxygen; Gwathmey's 
Method; Teter's Method; Technique to be Followed in Administering 
Nitrous Oxid and Oxygen With the Teter Apparatus and the Teter Nasal 
Inhaler; Nitrous Oxid Oxygen Endopharyngeally; Boothby and Cotton 
Apparatus; The Gwathmey-Woolsey Nitrous Oxid-Oxygen Apparatus. 
117 118 
ANESTHESIA 
HISTORY 
In 1772, Priestley 1 discovered nitrous oxid, called by him "dephlo- 
gisticated nitrous air," by reducing nitrogen dioxid (NO2), "gaseous 
oxide of azot," with moist iron filings. In 1793, Deimann and others 
prepared the gas by heating ammonium nitrate (NH4N03), essentially 
the commercial process for its manufacture to-day. 
In 1798, the "Pneumatic Institute" was founded for the purpose 
of investigating the "medical powers of factitious airs or gases" and was 
set up at Clifton by Dr. Beddoes. The immediate idea to be followed 
out was the treatment of phthisis and other lung troubles by inhalation 
of various gases. Humphrey Davy was assigned the office of superin- 
tending the experiments. One of the first outcomes of his researches, 
the result of his experimentation with nitrous oxid upon animals, is 
given in the following historical and often quoted sentence :2 "As nitrous 
oxid in its extensive operation appears capable of destroying physical 
pain, it may probably be used to advantage during surgical operations in 
which no great effusion of blood takes place." Then Davy actually 
inhaled the gas and recorded his own sensations and the behavior of 
others after they had inhaled it. 
Early Use in Dentistry.-In December, 1844, Colton delivered a lec- 
ture on nitrous oxid and other gases in Hartford, Connecticut. Horace 
Wells, a dentist of that place, was present. He noticed that a person 
under the influence of the gas was capable of sustaining a severe injury 
without apparently feeling any pain. This fact so impressed him that 
he requested Colton to administer the gas to him, and, while under its 
influence, had a tooth extracted without feeling the least pain. Upon 
regaining consciousness, he exclaimed, "A new era in tooth-pulling." 
From that time on he administered the gas to his patients with more or 
less success.3 With the death of Wells, which occurred in 1848, and 
the introduction of ether, nitrous oxid was not thought of again as an 
anesthetic until Colton revived its use in 1863. Rymer in England and 
Hermann in Germany also undertook (1864-1866) some experiments 
with nitrous oxid. 
1 ' ' Experiments and Observations on Different Kinds of Air, " 1, 3; " Mem- 
oirs of Joseph Priestley to the Year 1795," 1803, 1. 
2Davy: "Researches, Chemical and Philosophical, Chiefly Concerning Nitrous 
Oxide," London, 1800. 
3 Upon attempting to make a public exhibition at the Massachusetts General 
Hospital the inhaler was removed, possibly too soon, and the patient gave a 
piercing cry. Wells was immediately looked upon as an imposter. He, a 
modest, retiring man, felt the imputation deeply, and, while continuing to ad- 
minister the gas in private, never summoned sufficient courage to attempt an- 
other public exhibition. Later he gave up the practice of dentistry, became 
more or less unsettled in his mind, and died by his own hand. NITROUS OXID 
119 
In 1867, Colton was able to give a record of twenty thousand suc- 
cessful cases; and in 1868 an auspicious demonstration took place at 
the Dental Hospital in London, mainly through the financial assistance 
and patronage of the well-known American dentist, Evans, of Paris. 
At this period it was considered safe for short operations. Some sur- 
geons, however, declaimed 
against nitrous oxid as unsatis- 
factory and dangerous. Never- 
theless, a Joint Committee of 
the Odontological Society and 
of the Dental Hospital reported 
so favorably upon the value of 
the gas that it has since occu- 
pied the foremost place as an 
anesthetic in modern dentistry 
Nitrous Oxid Administered 
with Oxygen.-In 1868, An- 
drews published accounts of a 
number of cases in which he 
had obtained a non-asphyxial 
form of anesthesia by using oxy- 
gen with nitrous oxid. 
It is now well established 
that an efficient anesthesia can 
be maintained by administering 
definite percentages of air with 
the gas. Also, by combining 
nitrous oxid with oxygen we 
may obtain a deeper, more satisfactory and safer anesthesia. Further- 
more, by warming a mixture of the gas and oxygen, and by the addition 
of small amounts of ether and chloroform, a satisfactory form of anes- 
thesia can be maintained for over 80 per cent of all surgical cases. 
Brown, of Cleveland, Ohio, was the first to use a warmed mixture of 
nitrous oxid and oxygen.1 Clover and Coleman first attempted the con- 
tinuous administration of nitrous oxid through the nose. Patterson, in 
1899, improved upon this, and Kilpatrick,2 in 1902, still further im- 
proved this method by placing a regulation expiratory valve upon the nose- 
piece. Teter improved the technique of nasal anesthesia by using oxygen 
and warm nitrous oxid with a perfected nosepiece. Karl Connell, of 
Roosevelt Hospital, has only recently improved the technique of admin- 
istering nitrous oxid and oxygen by using nasal catheters and a pharyn- 
Fig. 25.-Gardner Q. Colton. 
1 The first recorded experimentation with these gases at different tempera- 
tures on lower animals was by Gwathmey in 1906. 
2 Medical Press, July 18, 1902. 120 
ANESTHESIA 
geal breathing tube to maintain a clear airway and also by rebreathing 
to decrease the amount of gases used. 
Physical Properties.-Nitrous oxid, "laughing gas," nitrogen prot- 
oxid, nitrogen monoxid, N2O, is a colorless gas at ordinary tempera- 
tures; it possesses a specific gravity of 1.527. One liter of the gas 
weighs 1.97 gm.; 100 cubic inches weigh 47.29 gm. Under a pressure of 
50 atmospheres at -J- 7° C. (-(- 44.6° F.) or 30 atmospheres at 0° C., 
it is converted into a colorless mobile liquid having a density of 0.937 
(at 0° C.);1 the liquid has the lowest refractive index of all liquids. 
The ease with which it may be liquefied is taken advantage of and liquid 
nitrous oxid is supplied on the market in steel cylinders of various 
capacities. A convenient size for short operations, or for preliminary 
administration to produce unconsciousness before the use of ether or 
chloroform, is a small tube weighing about 39 ounces gross, which holds 
6 ounces of the gas. For hospital work vanadium-steel cylinders holding 
200 to 250 gallons of the gas are serviceable.2 Fifteen ounces of the 
liquid on evaporation yield about fifty gallons of the gas. The cylinders 
usually, and should always, have a statement upon an attached label 
indicating the weight of liquid within. By remembering that an ounce 
of the liquid yields about three and one-third gallons of the gas, at 
ordinary, room temperature and pressure, the operator can readily know 
the amount of gas at his disposal. By weighing before and after use 
each time, and entering the difference upon the label, the anesthetist 
always knows what his supply is. This information is of vital impor- 
tance in some cases. 
Nitrous oxid, like other gases, expands when heated. The gas and 
liquid within the cylinder are under a theoretical pressure of at least 
750 pounds per square inch even below room temperature. Often the 
pressure is over 1,000 pounds per square inch. If the cylinders are sub- 
jected to undue heat, the pressure may become so great as to burst the 
cylinder, producing serious consequences; therefore, any unnecessary 
heating of the cylinder should be avoided. Such accidental explosions 
have occurred. 
The boiling point of nitrous oxid at 760 mm. pressure is -90° C.; 
the freezing point is -102° C. If the liquid is allowed to escape under 
atmospheric pressure through a small orifice, part of it is converted into 
a compact snow,3 which has a temperature of -100° C. This snow, 
along with some ice produced from the moisture of the air by the low 
1 Faraday, 1823. 
2 According to the best modern practice, vanadium-steel cylinders are the 
safest, for, even if they burst, they are not shattered, but simply split along 
the seam. 
'Wills: "A Modification of Thilorier's Method for Preparing Solid Carbon 
Dioxide," J. Chem. Soc., IS, ii, 21. NITROUS OXID 
121 
temperature, may sometimes choke the outlet and interfere with the 
regular flow of the gas. This difficulty will never be encountered when 
small amounts of the gas are used, if the simple precaution be taken to 
keep the outlet well above the level of the liquid within-in short, if the 
gas is drawn off with the cylinder in a vertical position, outlet upward.1 
When, however, the gas is to be used in prolonged cases it is desirable 
to heat the outlet. 
Liquid nitrous oxid may be preserved with perfect safety for an 
indefinite time in steel cylinders provided with good valves. Some 
administrators 2 have noted differences between nitrous oxid which had 
and had not been liquefied. These differences undoubtedly were due to 
the admission of undetermined and variable amounts of air in prepara- 
tion for or during administration, or to temperature conditions brought 
about by administering the gas from the liquid without the warming 
referred to above.3 
Nitrous oxid is soluble in water, volume for volume, at 0° C.; the 
solubility diminishes greatly on elevation of the temperature of the 
water. The solution seems to be mainly physical, as we have no evidence 
of chemical union between the nitrous oxid and water as in the case of 
carbon dioxid and water, beyond the formation of an unstable hydroxid, 
N2O6H2O, at 0° C. The gas may be collected over warm water. It 
is quite soluble in absolute alcohol at zero. 
Chemical Properties.-Nitrous oxid is quite stable, not being decom- 
posed into its elementary constituents by heat, unless the temperature is 
very high. It supports combustion, if the combustion has been actively 
started; that is, a strongly burning taper is not extinguished when 
plunged into the gas, but continues to burn, utilizing the oxygen and 
liberating the nitrogen. Nitrous oxid has a pleasant odor and a slightly 
sweet taste. It may be respired without discomfort, with suitable ap- 
paratus. When pure it exhibits no irritant properties. 
Impurities of Nitrous Oxid.-The manufacture of nitrous oxid de- 
pends upon heating ammonium nitrate, 
NH4NO3=N2O4-2H2O; or 
some combination of salts which produces ammonium nitrate, as, for 
example, KNO3 + NH4C1; 3NaNO3 + (NH4)3P04; or 2NaN0,+ 
1 In connection with the devices for using cylinders in the horizontal position, 
see Sheppard: Lancet, 1891, 424; Hewitt, "Anaesthetics," 3rd ed., 268. 
'Roberts: Brit. J. Bent. Sci., Dec. 15, 1884. 
"Smith and Leman: J. Am. Chem. Soc., 1911, 33, 1116, give analytical 
results indicating a difference in the gas when drawn from cylinders with the 
outlet upward or reversed. They state that there is less nitrous oxid and more 
air (than that originally in the cylinder) in the gas when first drawn from 
the upright cylinders. Cylinders should have all the air removed before filling. 
If this has not been the case and the cylinder is thoroughly shaken just before 
the use, the gas is of uniform composition, as has been shown by Baskerville. 122 
ANESTHESIA 
(NH4)2SO4.1 The impurities liable to be present depend upon the 
materials used, proportions present, heat treatment, and conditions of 
the pumps and containers.2 
Compressed nitrous oxid obtained in the American market from 
different manufacturers gave on analysis the following values: 
ANALYSIS* 
Sample 
No. 
N2O 
H2O 
CO2 
nh3 
o2 
N2,etc. 
bydiff. 
N2Oby 
explo- 
sion 
N2O by 
Cu + 
co2+h2 
N2Oby 
Cu + 
h2 
1 
99.7 
0.13 
0 
0.006 
Presept 
0.16 
97.5 
99.4 
99.7 
2 
96.6 
0.15 
0 
0.001 
Present 
3.25 
95.0 
96.2 
96.6 
3 
99.5 
0.15 
0 
0 
Present 
0.35 
97.3 
99.3 
99.5 
4 
95.9 
0.16 
Present 
0 
Present 
3.94 
94.1 
95.6 
95.9 
* Baskerville and Stevenson, loc cit. The last column gives the figures con- 
tained by the new method devised by them. 
Smith and Leman analyzed four cylinders of liquid nitrous oxid 
from different manufacturers, with the results shown on page 123.3 
Standard of Purity.-Nitrous oxid which is to be used for anesthetic 
purposes should contain at least 95 per cent of N2O and no solids, 
1 One of the authors (C. B.), in conjunction with Stevenson, has made an 
investigation of this subject and devised methods of analysis, for the details of 
which see J. Ind. and Eng. Chem., Aug., 1911. Erdman and Stolzenberg, Berlin, 
43, 1708, Willard, Compt. rend. (1894) 118, 646, found that a hydrate of 
nitrous oxid (N2O.6H2O) may be obtained by keeping at 0°, in a sealed tube, 
a mixture of liquid nitrous oxid and water. Ice does not appear to react with 
nitrous oxid. Willard (ibid., 118, 1096) found that nitrous oxid may be freed 
from air and nitrogen, the commonest contaminants, according to him, by the 
preparation of this hydrate, which, although scarcely decomposed below 0° under 
ordinary pressure, furnishes about 200 times its volume of gas when warmed 
above this temperature. He devised an apparatus for the purification of nitrous 
oxid by this means. [Ann. Chim. Phys. (7), 11, 289.] 
2 Commercial nitrous oxid is apt to contain these impurities: Cl2, No, 
NO2, HNO3, NH2, HC1, CO2, O2, N2, rare gases of the air, and organic matter 
(from lubricants). Of these the first six only produce any irritation of the 
respiratory mucous membrane, and they are usually removed in its manufacture, 
if present, by washing the gas in turn with solutions of sodium hydroxid, fer- 
rous sulphate, and sulphuric acid. Further purification may be accomplished 
by the formation of a hydrate below 0° C., by fractional condensation and 
subsequent fractional distillation. 
3 J. Am. Med. Assn., 57, No. 7. NITROUS OXID 
123 
Percentage of 
No. 1 
No. 2 
No. 3 
No. 4 
Nitrous oxid 
95 4 
93 4 
95 8 
96 1 
Oxygen . 
0.0 
1.4 
1.1 
0.1 
Nitrogen 
4.6 
5.2 
3.1 
3.5 
Carbon dioxid 
0.0 
0.0 
0.0 
0.3 
liquids, combustible organic matter, chlorin, or other oxids of nitrogen.1 
The last two impurities may be tested for by slowly passing 10 liters 
through silver nitrate and ferrous sulphate solutions. No precipitate 
should be produced in the former, and no brown or black coloration in 
the latter. 
SPECIAL PHYSIOLOGY 
The evolution of knowledge concerning the physiological action of 
nitrous oxid administered by inhalation is striking and the changes of 
opinion are radical. The conceptions of the physiological action of this 
agent have, in a large measure, been controlled by the clinical methods 
of administration employed at various times. Three distinct steps in 
this process.of elimination and up-building, based upon experimental 
and clinical data, may be traced. 
The Hyperoxygenation Theory.-Sir Humphrey Davy believed that 
nitrous oxid was decomposed into its constituents, nitrogen and oxy- 
gen, during its passage through the circulation. It was thought that 
this produced superoxygenation of the blood, and that this overproduc- 
tion of oxygen led to the formation of unusual amounts of carbon dioxid, 
which, in turn, produced a form of "internal asphyxia." 
Oliver and Garrett2 examined the gases of the blood of a dog while 
under nitrous oxid, with the results shown on page 124. 
From these figures it will be seen that there is undoubtedly a large 
increase in nitrogen in the blood after nitrous oxid inhalation. There 
seems, however, to be no conclusive evidence that nitrous oxid splits up 
in the organism, the gas being too stable to be decomposed at the tem- 
perature of the blood. The increase in nitrogen, as shown by the fore- 
1 Lack of knowledge of the content of real N2O may seriously interfere with 
the satisfactory use of this, the safest, anesthetic, especially when it is admin- 
istered by the proper method, namely, mixed with oxygen. If the preparation 
contains more than 95 per cent N2O, the variation in the proportion of the two 
gases will depend then, in fact, upon the amount of oxygen actually mixed, and 
the percentage is not seriously altered. 
2 Lancet, 1893, 683. (The analytical methods and technique employed in 
these determinations are not known.) 124 
ANESTHESIA 
Normal 
Dog 
Before 
Inhalation 
After 
Inhalation 
co2 
34.3 
15.66 
o2 
22.0 
3.49 
N, 
1.8 
11.23 
N2O 
22.49 
going figures, remains unexplained. Frankland 1 analyzed the expira- 
tory products of several administrations and failed to find any distinct 
evidence of decomposition. The theory, therefore, that the brain cells 
are overpowered, so to speak, by an excess of oxygen, with the resulting 
phenomenon of anesthesia, was abandoned as being untenable. 
The Deoxygenation or Asphyxiation Theory.-When it became fairly 
well established that nitrous oxid is too stable a gas to be decomposed 
upon its entrance into the circulation, as formerly supposed, opinion 
swayed in the opposite direction, and the theory proposed was that, the 
hemoglobin of the blood having a greater affinity for nitrous oxid than 
for oxygen the oxygen becomes displaced from the lungs and other tis- 
sues by the nitrous oxid, the brain cells and nervous centers being thus 
starved, so far as oxygen is concerned, are smothered, as it were, by 
nitrous oxid. To this condition the term asphyxiation is applied, and 
unconsciousness, or anesthesia, is the inevitable result. This mechanical 
displacement of oxygen by nitrous oxid, leading to "tissue asphyxia," 
has been characterized as a more dangerous view, from a practical stand- 
point, than the hyperoxygenation theory. 
Hermann 2 concluded that nitrous oxid was simply absorbed by the 
blood plasma, and that its action was only that of asphyxiation, the con- 
ditions being accounted for by the exclusion of the oxygen normally 
breathed. He found that one hundred volumes of blood at body tem- 
perature would absorb sixty volumes of nitrous oxid. This ratio was 
later fixed by Bert as one hundred to forty-five. 
This theory of so-called deoxygenation has been supported by Jolyet, 
Blance, Duret, Johnson, Heid, Amory, Wood, Cerna, and many others, 
and lately by Crile. 
This theory held sway, as did the short-lived preceding hyperoxy- 
genation theory, during the period when nitrous oxid was used almost 
exclusively for dental and very short surgical operations. During this 
time nitrous oxid was rarely inhaled pure. It was not only difficult to 
obtain a pure gas, but, when obtained, it was administered in such a way 
that it was variably diluted with air, the effects produced being, as a 
1 St. Bartholomeiv's Hospital Record V. 
2 Brit. Med. J., 1868, 378. NITROUS OXID 
125 
rule, those of intoxication rather than anesthesia. Inasmuch as air 
exclusion, or oxygen exclusion, was considered the prime factor, the 
apparatus devised during that period aimed at this object. The appara- 
tus devised by Colton was fitted with inspiratory and expiratory valves 
for the purpose of accomplishing the rigid exclusion of air. 
The Theory of the Specific Action of Nitrous Oxid upon the Brain 
Cells.-Despite the fact that air-exclusion was aimed at, it was soon 
found that the alternate inhalation of nitrous oxid and air served to 
maintain a more or less complete anesthesia for protracted surgical 
operations. The asphyxiation theory was generally accepted until An- 
drews,1 in 1868 (see History, p. 24), showed that anesthesia could be 
maintained over a longer or shorter time at will, by mixing oxygen with 
nitrous oxid. This, quite naturally, upset the deoxygenation theory, 
and led to the conclusion that the nitrous oxid must exercise some 
specific action upon the brain cells. The observations of Bert2 and the 
early experiments of Buxton 3 verified the hypothesis that nitrous oxid 
produced narcosis by virtue of other than asphyxiating qualities. 
This theory has held its own up to the present time, the variation of 
opinion bearing reference to what constitutes the specific action of 
nitrous oxid upon the nervous centers. 
Kemp,4 following a series of experiments begun in 1890, fbr the pur- 
pose of determining the validity or invalidity of the deoxygenation 
theory of nitrous oxid anesthesia, as the result of fourteen experiments, 
took a position intermediate between those who hold that the action of 
nitrous oxid and of nitrogen is the same, and those who hold that 
nitrous oxid is simply an indifferent gas, acting like nitrogen. He 
found that the difference in the action of the two gases, when given pure, 
was so masked by the rapid onset of asphyxia that any wide-reaching 
generalizations were unsatisfactory. Two points, however, he considered 
worthy of especial notice: (1) That anesthesia was induced more 
quickly with nitrous oxid than with nitrogen; (2) that the muscular 
movements which always supervene upon deprivation of oxygen were 
milder with nitrous oxid than with nitrogen. 
A second set of experiments was conducted by Kemp, in which 
enough oxygen was given to sustain the life of the animal while the 
action of nitrous oxid and of nitrogen was being studied. 
These experiments lead up to the present-day methods of administer- 
ing nitrous oxid, and to the modification of the physiological action of 
1 Andrews: J. Brit. Dent. Sci., 1869, 22. 
2 Bert: ' ' Pression barom6trique. ' ' 
'Buxton, Dudley W.: (1) "On the Physiological Action of Nitrous Oxide," 
Trans, Odontological Soc. of Great Brit., 1886, n. s., 18, 133; (2) Ibid., 1887, 
n. s., 19, 90. 
4 Kemp, G. T.: "Nitrous Oxide Anaesthesia," Brit Med. J., Nov. 20, 1897, 
1480. 126 
ANESTHESIA 
this and other inhalation anesthetic agents by oxygen, as detailed in the 
chapter on General Physiology, p. 30. 
In the following discussion of the action of nitrous oxid upon the 
organism it is to be borne in mind that the gas, given alone, is under 
consideration. It is especially to be remembered, however, that the 
administration of nitrous oxid alone belongs to the past and not to the 
present period of the science of the administration of anesthetics. 
Brunn,1 who discusses the mode of action of nitrous oxid, recalls the 
demonstration by Bert of a specific narcotic efficiency on the part of 
nitrous oxid. Bert successfully avoided the onset of asphyxia by means 
of the inhalation of the nitrous oxid-oxygen mixture under pressure, 
proving at the same time that the narcosis could be arbitrarily length- 
ened. In this way he demonstrated the accuracy of his theoretical reflec- 
tion, that it is the over-low partial pressure of the nitrous oxid-in the 
nitrous oxid and oxygen mixture as inhaled under ordinary atmospheric 
pressure-which prevents a sufficient absorption of nitrous oxid in the 
blood for the onset of narcosis. This deficit was successfully remedied 
by Bert through raising this partial pressure to the level of the atmos- 
pheric pressure. 
Brunn emphasizes the fact that in order to understand the mode of 
action of nitrous oxid it is necessary to keep carefully apart the experi- 
ments with the inhalation of pure nitrous oxid-which always involves 
two factors, namely, the nitrous oxid action and the asphyxiation- 
and the experiments with the inhalation of nitrous oxid under a simul- 
taneous supply of a sufficient quantity of oxygen. 
Brunn refers to a series of fundamental experiments which were made 
by Goldstein,2 who showed the narcotic effect of nitrous oxid on frogs. 
In comparative experiments, a frog ceased to react after five and a half 
minutes to strong external stimuli, in a nitrous oxid atmosphere, 
whereas the same frog had not yet lost its power of reaction after an 
hour and a quarter in a pure hydrogen atmosphere. However, the 
nitrous oxid narcosis was made to disappear again by the admixture of 
a small quantity of air. 
For the explanation of this phenomenon, Goldstein regarded the 
assumption of diminished partial pressure as insufficient, and he 
believed, in contradistinction to Bert's views, that a rapid and complete 
narcosis was produced and maintained only when the effect of the 
nitrous oxid was combined with that of a deficiency in oxygen. This 
statement certainly holds good for "ordinary" nitrous oxid anesthesia, 
but he admitted himself that in a greater density of the nitrous oxid 
this was alone sufficient for the production of a complete narcosis. 
1 Brunn, M. v.: "Die Stiekoxydulnarkose, " "Die allgemein Narkose," 
1913, 325. 
2Brunn: Die allgemein Narkose," 1913, 325 et seq. NITROUS OXID 
127 
The study of the respiration of warm-blooded animals, under the 
effect of nitrous oxid, first led Goldstein to recognize the fact that in 
rabbits the respiration gradually becomes slower and more superficial, 
in an inclosed space with air as well as in a mixture of nitrous oxid 
and oxygen, until the respiration finally ceases, at 3-4 per cent oxygen 
contents of the gas mixture, without preceding signs of dyspnea. In 
sudden asphyxiation Goldstein distinguished three stages. The first is 
characterized by inspiratory efforts, to which are added, in the second 
stage, violent expiratory muscular efforts, combined with clonic convul- 
sions; in the third stage there are infrequent inspiratory movements, 
the expiratory muscles remaining entirely inactive. Comparative experi- 
ments, with inhalation of nitrogen on the one hand and nitrous oxid 
on the other, yielded considerable differences. In the case of nitrous 
oxid, narcotic effects are almost instantaneously manifested, so that the 
dyspneic efforts do not reach nearly the same degree as in breathing 
nitrogen. The clonic convulsions are altogether absent. The second 
stage of the asphyxiation is more rapidly terminated. The most impor- 
tant difference, however, as compared to ordinary asphyxiation, accord- 
ing to Goldstein, is the appearance of loss of reflexes only just before 
the respiratory paralysis, namely, in the second half of the third stage 
of asphyxiation in ordinary asphyxiation; whereas, in nitrous oxid 
inhalation, the loss of reflexes is already present in the second stage, 
namely, long before the respiratory center is endangered. 
In Goldstein's experience the inhalation of a mixture of 73 per cent 
nitrous oxid and 27 per cent oxygen, in dogs, was followed by a diminu- 
tion in the number of respirations, while the depth was increased. The 
anesthesia, according to Goldstein, appears the more rapidly, and with a 
proportionately less degree of asphyxia, the higher the organization of 
the brain-namely, earlier in man than in the laboratory animals. 
Effects upon the Respiratory System.-Experimental observations 
have established the fact that nitrous oxid, given pure, or alone, rapidly 
induces asphyxia by gradual paralysis of the respiratory center in con- 
sequence of the prolonged action of the increasingly deoxygenated, or 
venous, blood. The respirations, which at first become more rapid and 
deep, become convulsive as the deoxygenation process is continued, then 
slow and shallow, finally ceasing altogether. When the asphyxial ele- 
ment is absent, the convulsive character of the respirations is not noted. 
Numerous experiments with animals have established the fact that 
when death is caused by pure nitrous oxid the usual post mortem signs 
of asphyxia are present. It has been emphasized by Hewitt1 that the 
character of the pulse is greatly dependent upon the fullness and effi- 
ciency of the respiration. Whatever differences there may be between 
the phenomena produced by nitrous oxid, by nitrogen, and by mechan- 
1 Hewitt: "Anaesthetics," 1912, 90. ANESTHESIA 
128 
ical closure of the trachea, one and all, according to Hewitt, lead to 
fatal asphyxia. 
Because of the lessened amount of tissue change which takes place 
in nitrous ox id anesthesia, the quantity of carbon dioxid given off by 
the lungs is decreased. The significance of this, with reference to the 
practical question of shock, is considered in the Chapter on Treatment 
Before, During, and After Anesthesia. 
Nitrous oxid is not injurious to the lungs, being a non-irritating 
gas. The bronchial irritation of which some have complained is par- 
tially eliminated by warming the agent (see Chapter on General Phys- 
iology, p. 64). It is still further eliminated by passing the gases 
through water, as described on page 323. 
For men, Goldstein1 emphasizes the point that anesthesia sufficing 
for the performance of brief operations is already present prior to the 
extinction of the reflexes, at a time when the respiration is regular, 
deep, and of almost normal frequency. The pulse at this time is also 
approximately normal and of increased volume. 
Effects upon the Circulatory System.-There is a divergence of opin- 
ion concerning the actual role played by nitrous oxid in the blood. 
According to Buxton's 2 view, nitrous oxid, when administered pure, 
enters the blood by diffusing through the thin walls of the air-cells in 
the lungs. A small quantity is dissolved in the blood, but the bulk of 
the gas is connected in some loose way with the constituents of the 
blood. Buxton's view is that it is probably associated moiie or less 
closely with the albumins and albuminoids of the liquor sanguinis and 
corpuscles. He does not think that there is any destruction of red blood 
corpuscles. He reports having carefully watched the corpuscles in the 
web of a frog's foot while the frog was in a bell-jar of nitrous oxid, and 
was able to observe not only the phenomena of the circulation under 
these conditions, but also to satisfy himself that no breaking up of 
corpuscles was evident. The loose association which nitrous oxid is 
assumed to form with hemoglobin, as proved by the darkened color taken 
on by arterial blood when it is shaken with the gas, seems to indicate 
'■•hat nitrous oxid is able to displace oxygen in its chemical union in the 
Mood. This combination of nitrous oxid with the constituents of the 
blood, if such actually occurs, is very unstable and very different from 
that produced by carbon monoxid, which is cumulative. Blood which 
has been saturated with nitrous oxid gives it up at once when left in free 
contact with oxygen or the air, and this has been used as a strong argu- 
ment against the acceptance of the formation of a compound, however 
loose it might be. This does not necessarily follow, for such conduct 
may readily be due to mass action, that is to say, both oxygen and 
1 Brunn: Loc. cit. 
2 Buxton: "Anaesthetics," 1907, 60. NITROUS OXID 
129 
nitrous oxid may form weak compounds with hemoglobin, the former 
being the stronger. Fresh hemoglobin will form compounds with the 
respective gases in proportion, not only in accord with the stability of 
the compounds, but in proportion to the relative quantities brought in 
contact with the hemoglobin. When the percentage of nitrogen mon- 
oxid in inspired air is very small it forms practically no appreciable 
amount of its loose compound, at least not a sufficient quantity to circu- 
late in the system to produce its physiological effects beyond those of 
exhilaration, i. e., intoxication. When the inspired gas contains only 
nitrous oxid the percentage will be rapidly diminished; in fact, almost 
as fast as the oxyhemoglobin in the blood is brought in contact with 
it. By regulating the proportions of the two gases brought into con- 
tact with the blood, it is theoretically possible to keep the oxygenation 
of the tissues going on as in normal life and at the same time secure the 
true physiological effect of the nitrous oxid. In maintaining these con- 
ditions another important factor enters in, namely, carbon dioxid. 
Yandell Henderson 1 has demonstrated that the carbon dioxid in the 
blood is a respiratory stimulant. Therefore, overventilation with oxygen 
is to be avoided. In advocating rebreathing of nitrous oxid-oxygen 
mixture, Gatch 2 claims that the beneficial effects are due to the carbon 
dioxid which comes from the expired air. His practice is to allow 
rebreathing until the percentage of carbon dioxid in the gas in the bag 
reaches four per cent; that is to say, the composition of ordinary expired 
air as far as carbon dioxid is concerned. For a more detailed treatment 
of this the reader is referred to the Chapter on Rebreathing. 
If the absorption is a phenomenon of simple solution-and that 
nitrous oxid displaces a certain amount of oxygen in the blood is gen- 
erally accepted by all observers-then the amount actually absorbed by 
the blood will depend upon the percentage composition of the mixed 
gases inhaled; that is, the partial pressure exerted by the gas in ques- 
tion. When nitrous oxid containing practically no free oxygen is 
inhaled the normal oxygen content of the blood is quickly diminished. 
If the percentage of nitrous oxid in the inspired gases is reduced to 
the minimum by discontinuing its administration, that which was ab- 
sorbed is quickly thrown out of the circulation by virtue of its vapor 
tension and oxygen takes its place, reproducing the normal conditions 
of the gaseous contents of the blood, as far as oxygen is concerned. 
In the blood, according to the investigations of Klikowisch,3 nitrous 
oxid causes no chemical or morphological changes of any kind, but it is 
'"Acapnia and Shock," "Carbon Dioxide as a Factor in the Regulation of 
the Heart Rate," Am. J. Physiol., Feb. 1, 1908, SI, No. 1. 
a"Nitrous Oxide-Oxygen Anesthesia by the Method of Rebreathing," J. Am. 
Med. Assn., March 5, 1910. 
8 Brunn: Loe. cit. 130 
ANESTHESIA 
in the blood merely in the form of a physical solution. It is pro- 
portionately rapidly reexcreted on diminution of the partial pressure. 
Decomposition of the nitrous oxid in the blood into oxygen and nitrogen 
does not seem to occur. In the spectral analysis the behavior of blood 
that has been saturated with nitrous oxid is the same as that of blood 
containing oxyhemoglobin (Klikowisch, Rothmann). This also goes 
to show that nitrous oxid does not enter into any stable chemical com- 
bination with oxyhemoglobin. Besides the short duration of the nar- 
cosis, the absence of after-effects likewise points in the same direction. 
The opposite view of Ulbrich is declined by Rothmann, who explains the 
divergent findings of Ulbrich as due to the employment of too highly 
concentrated blood solutions, causing the absorption bands to become 
wider and less distinct. 
Recently (1908) Hamburger and Ewing have expressed themselves 
in favor of the harmlessness of nitrous oxid for the blood. They found 
it to produce no permanent diminution of the hemoglobin, and no 
anemia, as well as no increased hemolysis. Although differences in the 
quantity of the hemoglobin and the red blood corpuscles may occur, they 
are of transitory character and devoid of surgical importance. The 
formation of reduced hemoglobin is not referable to the anesthetic, but 
to the associated asphyxia. An increase of the time of coagulation is 
common, but not invariably present. 
The experiments of Buxton 1 and later of Wood and Cerna 2 indicate 
that nitrous oxid exerts a direct action upon the heart itself, having 
little or no direct influence upon the vasomotor centers of the brain 
cortex. Kemp,3 on the other hand, holds that nitrous oxid can hardly 
be said to exert a direct action upon the heart, the cardiac effects being 
much more apt to depend upon the amount of oxygen admitted than 
upon the nitrous oxid. For further data concerning the modification 
of the anesthetic by oxygen or by atmospheric air, see Chapter II, 
General Physiology. 
Blood pressure is always increased with nitrous oxid given alone. 
With a judicious use of air or oxygen nitrous oxid anesthesia may be 
continued for a sufficient time to permit of any ordinary surgical inter- 
vention with very little variation in blood pressure. 
Concerning the blood pressure, Goldstein's4 findings showed a 
marked increase to be exceptional, in contradistinction to the usual belief 
that blood pressure rapidly undergoes an enormous increase in the first 
stages of the asphyxiation. His first experiments concerned asphyxia- 
tions with nitrogen and hydrogen, but a considerable rise of the blood 
1 " Anaesthetics, " 1907, 57 et seq. 
2 Therap. Gas., Aug., 1890. 
s Brit. Med. J., Nov. 20, 1897, 1482. 
4 Brunn: Loc. cit. NITROUS OXID 
131 
pressure was likewise absent with nitrous oxid, although some increase 
was present. The blood pressure underwent no essential changes when 
dogs and rabbits were given, in addition to the nitrous oxid, a quantity 
of air sufficient for the avoidance of dyspnea. 
Effects Upon the Nervous System.-It has already been noted that 
the third distinct step in the evolution of knowledge concerning the 
physiological action of nitrous oxid had for its foundation the specific 
action of the agent upon the nervous system. The earlier experiments 
of Buxton, Wood and Cerna, and others, to which reference has already 
been made, confirmed the theory of the direct action of the gas upon the 
nervous system. Buxton,1 in observations upon this subject, found that, 
while asphyxia caused diminution of the bulk of the brain and cord, 
nitrous oxid produced so great an enlargement as to force out the 
cerebrospinal fluid. He referred these changes to a vasomotor origin, 
and held that they explained many of the nervous phenomena elicited in 
persons narcotized with nitrous oxid. The most natural inference, from 
the study of the reflexes and other effects upon the nervous system, is, 
according to Kemp,2 that nitrous oxid acts most powerfully upon the 
central nervous system, especially upon the brain cortex. 
The effect of nitrous oxid, when first inhaled, is a pleasurable exhil- 
aration, which varies with the individual, with the degree of dilution of 
the gas with oxygen or air, and with the method of administration 
employed. During this time the senses of the individual are rendered 
more acute; this is followed by analgesia; and then by anesthesia, during 
which last the patient is profoundly unconscious and insensitive to 
pain. 
Hallucinations, frequently of an erotic nature, often mark the hyper- 
esthetic stage which precedes anesthesia. These not infrequently persist 
after the complete return of consciousness. The practical and medico- 
legal significance of this phase of nitrous oxid anesthesia is easily 
apparent. 
Effects Upon the Muscular System.-It is a well-established fact that 
nitrous oxid does not usually induce muscular relaxation when adminis- 
tered alone. WThen oxygen deprivation is complete, and the administra- 
tion of nitrous oxid is continued, the limbs become rigid, the body some- 
times assuming the position of opisthotonos. Sometimes rhythmic 
tremors of the upper extremities are noted. The muscular manifesta- 
tions, other than general rigidity, are now seldom seen in nitrous oxid 
anesthesia, for the reason that it is practically never given alone, even 
for very short operations. For a further discussion of the muscular 
phenomena see Stages of Anesthesia, p. 59. 
Effects Upon the Glandular System and Other Structures.-Nitrous 
i Buxton: ' ' Anaesthetics, ' ' 1907, 62. 
2Kemp: Loc. tit. 132 
ANESTHESIA 
oxid causes, according to Kemp,1 a contraction of the renal vessels, so 
that urinary secretion is rapidly diminished. Inasmuch as nitrous oxid 
is not eliminated through the kidneys (see Chapter on Physiology, page 
60), it would seem fair to assume that the gas exerts no unfavorable 
effect upon these organs, and that the albuminuria sometimes reported 
is due to other causes. Involuntary micturition may occur during 
nitrous oxid anesthesia. 
The alimentary tract is not unfavorably affected by nitrous oxid 
unless its administration is pushed to an unnecessary degree. In such 
case there may be some nausea, vomiting, and even involuntary defeca- 
tion. 
The untoward symptoms which accompany nitrous oxid anesthesia 
are generally ascribed to unnecessary deoxygenation rather than to any 
irritant or other quality of the gas itself. 
Causes of Death.-When nitrous oxid is given pure, or alone, death 
is always due to oxygen deprivation or asphyxia. The heart continues 
to beat after respiration has ceased, which proves that death is not due 
to failure of circulation. (For further data concerning the effects of 
overdose, which may lead to shock or to death, see Stages of Anesthesia, 
p. 59, and General Physiology, Chapter II.) 
Stages of Anesthesia.-The stages of anesthesia when nitrous oxid is 
used alone are rarely seen. Attempts have been made to separate the 
phenomena and to classify them under distinct stages, but this is impos- 
sible for the reason that it takes only from thirty seconds to one minute 
to reach full surgical anesthesia, the time elapsing between consciousness 
and surgical anesthesia being so short that these different degrees cannot 
be noted. 
Inasmuch as nitrous oxid is now so seldom given alone, but rather 
with air, with oxygen, or with the utilization of rebreathing, so that the 
duration of the anesthetic period can be prolonged at will, it is possible 
to note definite stages just as is the case with other inhalation anes- 
thetics. The course of the anesthesia is smooth and practically feature- 
less, as is the case with the other agents, unless there is faulty technique 
somewhere. A leak in the apparatus, a mask that does not fit snugly, 
too much oxygen, not enough nitrous oxid, neglect of preliminary med- 
ication-any one or a combination of these errors of technique may 
convert a featureless narcosis into one marked by more or less disagree- 
able complications. From experiments upon lower animals it is known 
that too much oxygen or too little nitrous oxid may act as an overdose, 
with the same phenomena noted with an overdose of ether or chloroform. 
The first stage is marked by a subjective feeling of warmth in the 
lips, and a sort of numbness in the limbs and other parts of the body, 
quickly followed by a feeling of exhilaration, sometimes described as a 
1Kemp: N. Y. Med. J., Non., 1899. NITROUS OXID 
133 
"thrilling." This may be, and generally is, accompanied by the impulse 
to breathe more rapidly and more deeply. Tinnitus, a feeling of fullness 
in the head, and a "smothering" sensation, if the nitrous oxid is 
"pushed" too rapidly, precede the loss of consciousness. Objectively, it is 
noted that the respirations are quickened and deepened, the pulse grows 
fuller, and blood pressure is raised. Twenty to thirty seconds is the 
average duration of this stage, which may be said to end with the dis- 
appearance of coordination and consciousness. 
The second stage, or stage of excitement, is initiated with the loss of 
consciousness. Incoherent thoughts and words and purposeless muscular 
movements, particularly of the arms and legs, are now apt to occur. 
The laughing, crying, muttering, and incoordinate movements vary with 
the patient. As may be imagined from the name, "laughing gas," ex- 
hilaration rather than depression is apt to mark the psychic phenomena 
of this stage. It is during this period that fanciful, sometimes erotic, 
dreams, which may persist after the return of consciousness, occur. The 
pulse is still full, and somewhat more rapid than during the first stage. 
The respirations are more rapid and deeper than normal, or than during 
the first stage in cases where the right proportion of air or oxygen is not 
given. Swallowing movements, and sometimes stertor, are noted. The 
pupils become dilated, and a twitching of the eyelids is often followed 
by their separation. The skin now assumes the duskiness or lividity 
which is generally a feature of nitrous oxid anesthesia, and which is 
more or less marked according to the normal complexion of the indi- 
vidual and according to the care with which the administration is con- 
ducted. Hearing continues during this stage. While the patient is 
unconscious, any undue roughness or careless treatment may markedly 
increase the excitement, aggravating all the phenomena noted. No 
surgical intervention should be attempted during this stage. 
The third stage, or the stage of surgical anesth esia, with perfect tech- 
nique, is induced in about sixty seconds to four minutes, the time vary- 
ing, of course, with the patient, with the purity of the nitrous oxid, and 
with the technique as regards the regulation of oxygen and other details. 
The stertorous, snoring breathing, with loss of rhythm, mentioned by 
many writers as marking the onset of the surgical stage of anesthesia, 
depends upon the method of administration, and especially upon the pre- 
liminary medication. Breathing should be automatic, regular, and with- 
out noise. The pulse is full and regular, and slightly increased in rapid- 
ity, from 80 to 90, though it may be normal. The lividity previously 
noted should not be increased in degree as anesthesia advances. The lid 
and other reflexes are abolished, and muscular relaxation is more or less 
complete, according to the purpose of the anesthesia and the technique 
employed. 
In order to maintain this stage of surgical anesthesia, it is important 134 
ANESTHESIA 
not to give too much oxygen or too much nitrous oxid, with a corre- 
sponding increase or decrease of the other gas. The time required to 
reach this stage is so short that an inexperienced administrator may 
allow the patient to "come out" or to go on to the stage of overdose. In 
this connection it is to be borne in mind that nitrous oxid is stimulat- 
ing, and that the patient must not be allowed to return to the second 
stage, or the stage of hypersensitiveness. 
The automatic breathing, with or without stertor, the widely dilated 
or contracted pupils (varying with the preliminary medication), full and 
regular pulse, with a slight degree of cyanosis, indicate the third stage. 
Two or three stertorous respirations indicate complete anesthesia. 
The fourth stage, or stage of overdose, supervenes through some error 
of technique by which asphyxia becomes the predominant feature of the 
narcosis. Breathing becomes embarrassed, usually through convulsive 
muscular spasm. The interference with respiration is first marked by 
hyperpnea (excessive breathing), then by dyspnea (difficult breathing). 
Violent or convulsive expiratory efforts, sometimes accompanied by gen- 
eral muscular spasms, mark the second stage of asphyxia. Following 
this there is a stage of exhaustion in which muscular spasm is super- 
seded by muscular flaccidity. The pupils become more widely dilated, 
the lids are widely open, the conjunctivae are insensitive, the pulse be- 
comes imperceptible, respiration is marked by prolonged sighing inspira- 
tions, which gradually cease. Paralysis of the respiratory center is com- 
plete, and death supervenes. Marked cyanosis accompanies this condi- 
tion of affairs. Interference with the passage of the blood through the 
pulmonary and systemic vessels, and accumulation, in consequence, of 
blood in the right side of the heart and in the systemic veins, with the 
circulation, in all parts of the body, of deoxygenated blood, explain the 
eventuation of the stage of overdose in nitrous oxid anesthesia. 
This stage of anesthesia may be rendered more liable by certain 
preexisting conditions, which are discussed under Contraindications. 
The length of time before it eventuates in death varies with the sub- 
ject. 
It may be noted that the time required to reach full surgical narcosis 
is from thirty seconds to four minutes, varying with the patient; that 
the available period for operation depends entirely upon the technique 
employed, ranging from thirty seconds to hours; and that the recovery 
period, when asphyxial symptoms do not occur, is completed in five min- 
utes or less from the time the mask is removed. 
Elimination.-The rapidity with which the blood will rid itself of 
nitrous oxid has been made the subject of study by Kemp,1 who found, 
in animal experiments, that in less than two minutes the quantity of 
nitrous oxid in the blood fell from over twenty per cent to six and nine- 
xKemp: Brit. Med. J., Nov. 20, 1897, 1480. NITROUS OXID 
135 
tenths per cent. The normal rapid recovery of patients, he holds, is 
quite in accord with these findings. 
It has already been noted that nitrous oxid is not eliminated by the 
kidneys. The lungs furnish the channel of elimination of nitrous oxid. 
After-Effects.-As already stated, there are less after-effects with this 
anesthetic than with any other. The only possibility of after-effects is 
when the subject is unsuited for this particular form of anesthesia; or 
when an irregular narcosis has been given; or when the nervous system 
is so upset for any reason that the least excitement is cause for anxiety. 
The Lancet of March, 1902, mentions a case in which, after a few min- 
utes' inhalation, the patient remained practically asleep for four days. 
The undesirable patients so often referred to, that is, men with powerful 
build, are sometimes temporarily unbalanced after a short administra- 
tion. Again, those with weak hearts may have slight pallor, feebleness 
of pulse, and faintness; as a general rule, however, all of these things 
are conspicuous by their absence. 
COMPARISON WITH OTHER AGENTS 
In the earlier period of nitrous oxid history this agent was hardly 
comparable with other inhalation anesthetics, inasmuch as it was not 
considered a true anesthetic. With modern methods, however, this no 
longer holds. Nitrous oxid is considered as truly an anesthetic as is 
ether or chloroform. Given with oxygen it ranks above either so far as 
safety to life is concerned. In point of after-effects it takes precedence 
over all other agents, since it is practically free from sequelae if admin- 
istered with a fair degree of care. Nitrous oxid and ether, with enough 
oxygen to prevent cyanosis, is the safest inhalation anesthetic, both as to 
life and after-effects. 
INDICATIONS AND CONTRAINDICATIONS 
Nitrous oxid alone is very limited in its indications. In fact, at this 
stage of development of methods of administration it is never indicated. 
It is distinctly contraindicated, even for very short operations, in young 
children (under four years), because of their immature musculature, 
which makes breathing in the bag difficult for them. It is also distinctly 
contraindicated with old persons, or persons with a generally weakened 
musculature, and in adults of whatever age whose arteries are sclerosed. 
Advanced phthisis, valvular disease, and women during any of the physi- 
ological epochs, when nervous and mental phenomena are apt to be easily 
exaggerated, present contraindications to the use of nitrous oxid alone. 
When this gas is judiciously employed, with the careful admission of 136 
ANESTHESIA 
oxygen, the contraindications are modified. It is still contraindicated 
for children, because these patients take any anesthetic poorly with a 
closed method. (See Chapter VIII, Selection of Anesthetic.) 
For strong, muscular, athletic, alcoholic and obese subjects, or per- 
sons with any obstruction to the air passages, such as enlarged tonsils, 
adenoids, etc., and for ophthalmic surgery, nitrous oxid is contraindi- 
cated, unless employed with the utmost skill. 
ADMINISTRATION 
Before discussing the different methods of administration it might 
be well to pause and consider a few necessary details. 
Heating the Gas.-This is accomplished in several ways: (1) by an 
alcohol lamp, with a coil for the gas going through the upper portion of 
the heater, as in the Teter apparatus (see p. 152); (2) by a coil from 
the tank being placed in a hot water cup, as in the Gwathmey anesthetizer 
(p. 150); (3) by passing the gas through a coil contained in a metal 
cylinder filled with thermal salts, as used by Griffith Davis (see 
p. 148) ; (4) by passing the gas over water electrically heated (see 
p. 424). 
The gas should be heated to the temperature of the body. Heating 
the gas admits of its uniform diffusion through the alveolar walls and 
usually enables the administrator to secure surgical anesthesia before the 
asphyxial signs occur. 
Essential Features of Any Satisfactory Method or Apparatus.-All 
apparatus should embody the four fundamental principles underlying 
the successful administration of nitrous oxid and oxygen, that is to say, 
valvular and rebreathing, warmed vapors, moisture regulation of the 
pressure, and addition of other anesthetics when needed. 
Apparatus for Administering Nitrous Oxid Alone or with Air.-All 
that is necessary for the administration of the gas alone is a tightly fit- 
ting mask, with valves which may be thrown out of use when rebreathing 
is to be utilized. To this mask a rubber bag is attached. Rubber tubing 
connects the bag with the gas cylinder. When air is added to the nitrous 
oxid an extra valve may be used to allow definite proportions of air. 
Dangers of Administration of Nitrous Oxid Alone.-The majority 
of fatalities have occurred with the administration of nitrous oxid 
alone, and given through valves. Of these fatalities the greater number 
were men in robust health or alcoholics. Nitrous oxid has no toxic 
effect as have chloroform and ether. Death occurs as a result of asphyx- 
iation. 
The only possibility of a death by asphyxiation is the inability of the 
administrator to differentiate between asphyxial and anesthetic signs. 
Whether it is administered alone, with air or with oxygen, the anes- NITROUS OXID 
137 
thetist should be careful to keep a clear airway and see that no asphyxial 
symptoms occur at any time. 
Recognition of Asphyxial Symptoms.-Embarrassed respiration, ir- 
regular, shallow, and jerky, is an asphyxial symptom. This may or may 
not be accompanied by stertor. The fingers and muscles of the arms and 
legs are thrown into clonic spasms, which quickly develop into tonic 
spasms with rigidity and muscular contraction of the muscles of the 
neck and chest. There is marked cyanosis. Eyelids may or may not be 
closed, but are usually open with lid reflex present. The respiration 
ceases. If at this point the mask is removed, in the vast majority of 
cases the patient comes out of this state apparently none the worse for 
the experience. The heart will always be found beating slowly and regu- 
larly, even after cessation of respiration. If, however, the mask is held 
rigidly in place at this point, so that the next long, deep breath is gas 
instead of air, a cessation of all the vital functions is apt to cease 
immediately. No administration of nitrous oxid should be attempted 
unless the anesthetist is prepared for a tracheotomy. 
Administration of Nitrous Oxid Alone.-If given in this way, with- 
out mixture of air or oxygen, and without heating, it must necessarily 
be for short operations, and it must be given to the point of asphyxia- 
tion, then discontinued and administered again. This is the most dan- 
gerous way in which to administer the gas, and should never be 
attempted except in emergency cases or as a sequence. It is true that 
patients have been anesthetized in this way for short operations with a 
resulting fatality that is almost negligible; nevertheless, 90 per cent of 
all fatalities have occurred when the gas was thus administered. 
Administration to Asphyxiation with and without Valves.-A crude 
method, practiced by many dentists, is to administer the gas to the point 
of asphyxiation, remove the mask, and make the extraction. 
Use of Expiratory Valve Alone.-Another method is to use the ex- 
piratory valve alone, thus allowing to-and-fro breathing from the first, 
and increasing the pressure until full anesthesia ensues. This requires 
more gas and a little longer time, but it is almost as valuable as washing 
out the lungs by the valvular method, and then switching to to-and-fro 
breathing. It is preferable to using valves alone. 
Administration without Valves.-The third method of giving the 
gas is without any valves, by allowing the gas to flow in the mask and 
simply increasing the pressure in the bag and allowing the surplus to 
escape under the margin of the mask, and continuing to increase the 
pressure until ingress of air between the face and the mask is impossible, 
and full anesthesia is secured. This is a makeshift, and a wasteful 
method, but it may be well to know that anesthesia can be satisfactorily 
induced in an emergency in this way. 
Precautions When Administered Alone.-Whenever the gas is ad- 138 
ANESTHESIA 
ministered alone, as for the extraction of a tooth or the opening of an 
abscess, it is always best to have some method of switching from the 
valves to to-and-fro breathing. With some patients the asphyxial point 
Fig. 26.-Guedel's Apparatus for the Self-administration of Nitrous Oxid and 
Air. Apparatus attached to cylinder. (1) Stopcock controlling flow of gas from 
supply bag. (2) Respiratory valve. (For detail see Fig. 27.) (3) Flexible rubber nose 
mask without valves. Valves are removed to body of apparatus so that mixture of 
gas and air can be regulated without disturbing the patient. (4) Metal band with 
hook for hanging apparatus to operating chair or table. In obstetrical work the ap- 
paratus is placed on its side on the bed. (5) Hollow metal handle for nose mask. 
Patient holds mask. 
will be reached before true anesthesia occurs. This is the principal 
objection to the administration of nitrous oxid alone. When adminis- 
tered only part of the time through valves, the anesthetist should make 
the change before the asphyxial signs occur, and deepen the anesthesia NITROUS OXID 
139 
by simply holding the mask in position and allowing the patient to 
breathe back and forth in the bag. The advantages gained by this 
method are that it is safer and also gives a deeper and longer period 
of available anesthesia with a smaller amount of gas; the after-effect 
will also be less. In fact, by closing either the mouth or nares, thus 
compelling the patient to breathe through the one open airway, and 
using this airway for the administration, a satisfactory anesthesia has 
been induced by inserting the rubber tube from the gas tank and grad- 
Fig. 27.-Guedel's Apparatus, Showing Detail Construction of Respiratory 
Valve. (1) Expiratory openings. A disc prevents the entrance of air during in- 
spiration and permits the escape of part of the expired gases during expiration. (2) In- 
spiratory openings for admitting air which is mixed with the inspired gas. (3) Screw 
for regulating percentages of inspired air. (4) Screw limiting movements of disc for 
regulating amount of gas rebreathed. (5) Graduated dial showing percentages of air 
inspired. 
ually increasing the pressure. This is a wasteful method and is not 
advocated. In all cases there should be some means of heating the gas 
before it reaches the patient. 
Guedel has perfected an apparatus for the administration of nitrous 
oxid alone, and especially for the use of the analgesic stage of nitrous 
oxid. He recommends it specially for confinement cases. His cylinder 
of nitrous oxid is placed within convenient reach of the patient. The 
patient takes the apparatus and places it over the nose or mouth and 
inhales until the anesthetic stage is reached, when the hands drop to the 
side. It is also used by dentists for the analgesic stage of anesthesia. 140 
ANESTHESIA 
The apparatus is commendable in that it is very simple and inexpensive. 
(See Figs. 26 and 27.) 
Administration of Nitrous Oxid with Air in Unknown Quantities.- 
The continuous administration of nitrous oxid with enough air to pre- 
vent asphyxial symptoms places a severe tax upon the anesthetist's 
resources. With selected subjects and under proper conditions a safe 
and even plane of anesthesia can be maintained. 
Directions.- (a) With valves alone: Place the mask in position 
and induce anesthesia as stated above. When stertor, irregular breathing, 
or automatic breathing announces surgical anesthesia, raise the mask for 
one respiration, then reapply and hold in position for from three to ten 
respirations, according to the patient, when another breath of air is 
given, and so continued. 
(b) With valves and to-and-fro breathing: This method is better 
for the patient, keeping the pulse nearly normal, respirations deep and 
full, with better muscular relaxation, and is an easier anesthetic to 
maintain. In getting the patient under, the following procedure is 
usual: 
(1) If the apparatus will allow, have the patient breathe air through 
the valves before turning on the gas. 
(2) Turn on the nitrous oxid and allow the patient to breathe 
through valves from three to seven times. 
(3) Now have to-and-fro breathing for as many times. 
(4) Return to valves for three to seven breaths. 
(5) Now have to-and-fro breathing as before. 
This alternating from valves to to-and-fro breathing will occupy from 
forty seconds to a minute and a half, when the patient will be found to 
be deeply under the anesthetic. 
If, now, the operation is to last for one hour or more, either the 
above or the following method can be used after surgical anesthesia has 
been established. 
Use the expiratory valve alone, allowing a small but regular flow of 
the gas at all times, thus keeping the bag fairly distended by having 
rebreathing constantly and removing the mask whenever the stertor or 
other asphyxial signs become too marked. This method is especially 
useful for alcoholics and athletes, and all other patients in which a posi- 
tive pressure is indicated. The above method has also been successfully 
employed in nose and throat work, using the nosepiece with expiratory 
valve and having a stopcock between the nosepiece and bag for an occa- 
sional breath of air. By regulating the expiratory valve any amount of 
pressure can be maintained in the lungs. This method of anesthesia can 
be kept up indefinitely, and is especially useful in adenoid and tonsil 
cases. 
This rebreathing, together with the expiratory valves, can be more NITROUS OXID 
141 
readily maintained when used as a sequence to the drop method of ether 
(p. 204), when the patient has been under the influence of the ether 
for ten to fifteen minutes, or toward the close of any operation lasting 
one hour or more. 
The Administration of Nitrous Oxid with Definite Amounts of Air. 
-Hewitt has made a number of experiments to determine the exact per- 
centage of nitrous oxid suitable to be administered with air. The fol- 
lowing are the net results of these experiments: The best definite mix- 
ture for men is from 14 to 18 per cent of air; for women and children, 
18 to 22 per cent of air. 
If, during an administration of nitrous oxid with air, the supply 
of oxygen gives out, anesthesia can be continued by pushing back the 
bag containing the oxygen so that air can be admitted through the 
valve and allowing a continuous flow of from 14 to 22 per cent of air 
with the nitrous oxid. The best method of administration is for the 
anesthetist to be able to use the valves, and also switch to to-and-fro 
breathing at any time during the administration. Whenever, for any 
reason, no oxygen is at hand, it is necessary, if a continuous flow of air 
through the valves is to be allowed, that the apparatus is so arranged 
that the air supply is independent of the nitrous oxid. 
Directions.-Anesthesia is instituted as follows: Place the index 
to the air valve so as to allow an intake of 25 per cent of air. Allow 
the full intake of nitrous oxid through that valve. After two or three 
inspirations, cut down the air intake to between 14 and 22 per cent. 
Turn the nitrous oxid valve so as to allow rebreathing continuously. 
From this time on the index to the air valve must be changed to suit 
the requirements of the case. If positive pressure is indicated, this can 
be accomplished by tightening the screw on the expiratory valve so that 
very little air escapes, at the same time increasing slightly the flow of 
nitrous oxid. In order to determine approximately the percentage of 
air being used, the flow of nitrous oxid must be an even one. Occa- 
sionally it will be necessary to cut off the air entirely and have to-and-fro 
breathing until the anesthesia is satisfactory; then return to the valve 
and continue. This form of anesthesia is especially useful as a sequence 
after surgical anesthesia has been maintained for thirty minutes or more, 
when, for any reason, the chloroform and ether should be reduced to a 
minimum. 
Nitrous Oxid as a Sequence to Ether.-When nitrous oxid is used 
as a sequence to ether the reflexes should be allowed to become active 
before instituting the change. With the chloroform-ether-nitrous oxid 
sequence the reflexes should be very active and the change be made grad- 
ually; that is to say, allow rebreathing in the bag before turning on the 
nitrous oxid. Even in laparotomies, where absolute relaxation is 
required, after anesthesia has been maintained for thirty minutes or 142 
ANESTHESIA 
more, this method can be successfully substituted. This reduces the 
amount of ether or chloroform to a minimum, and, there being less 
strain upon the kidneys and lungs, the after-effects are reduced to a 
minimum. 
Nitrous Oxid with Air.-As previously stated, when nitrous oxid 
and air are used as a sequence, the maintenance of an even plane of 
anesthesia is so easy and, at the same time, satisfactory that the descrip- 
tion of the technique of this sequence is worthy of a place by itself. 
Technique of Ether-Nitrous Oxid (Air) Sequence.-If ether by the 
drop method has been used and a change to nitrous oxid is desired, 
allow the reflexes to become slightly active; place the mask upon the 
face and turn to to-and-fro breathing, the bag being two-thirds full of 
the nitrous oxid. Note the results, and increase the pressure in the 
bag to intensify the anesthesia, or, if the anesthesia is satisfactory, main- 
tain it by either of the methods already outlined. When the reflexes are 
abolished slight cyanosis sets in, and the anesthesia is now changed to 
one of nitrous oxid and air. When this occurs remove the mask when- 
ever necessary for one inhalation or more, and then repeat, allowing the 
gas to flow in the bag slowly but regularly. If, however, the patient is 
very lightly under, allow breathing through valves for three to eight 
respirations, turn to to-and-fro breathing, then allow one to two breaths 
of air, and then return to the gas. Allow air whenever the reflexes are 
entirely abolished and cyanosis is marked and breathing stertorous. 
Technique with A.C.E.-The technique with chloroform-ether, or 
the A.C.E. mixture is as follows: 
Allow the eyelids and other reflexes to become somewhat active; place 
the mask upon the face as the patient exhales, the mask being arranged 
for to-and-fro breathing, but the bag empty. Remove the mask from 
face, allow patient one breath of pure air, and replace mask so that the 
exhalation enters the bag. Continue thus, alternately raising and 
replacing the mask until the bag is filled. When this occurs hold the 
mask in place. If reflexes are now abolished raise the mask and allow 
one breath of air and thus continue until reflexes begin to get quite active 
again. When this occurs turn on gas slowly, allowing rebreathing until 
they are lulled or abolished. 
Advantages of Ether- (or Chloroform-Ether) Nitrous Oxid Se- 
quence.-By instituting nitrous oxid anesthesia after any operation 
that has lasted at least one hour, the following results are accomplished: 
A non-poisonous 1 anesthesia replaces a poisonous one at a time when 
a stronger anesthetic is capable of doing the greatest damage. The 
resisting powers of any individual at this time being reduced to a mini- 
1 The term non-poisonous is here used in a restricted sense as compared with 
chloroform and ether, which are active poisons to both the nerve and muscle 
fibers. NITROUS OXID 
143 
mum, the kidneys, lungs, and other parenchyma are thus possibly 
saved the coup de grace. Nitrous oxid and air fulfil all demands at 
this time, the relaxation required being easily maintained. 
The Advantages of Administration of Oxygen with Nitrous Oxid.- 
When oxygen is used with nitrous oxid, a safer, deeper, and more satis- 
factory anesthesia is obtained than is possible with air. When the 
nitrous oxid is heated and supplemented by warmed moist ether, when 
necessary, we have the best form of anesthesia, considered from every 
standpoint, available to-day. Those who have never used oxygen with 
nitrous oxid, and who have acquired the technique of administering it 
alone, will be surprised by the ease and latitude given by this combina- 
tion. One of us (J. T. G.) has given several anesthesias lasting for two 
hours and more with nitrous oxid and oxygen without the aid of ether, 
chloroform, or ethyl chlorid, and in one instance the anesthetic was not 
preceded by any preliminary medication. With adults the preliminary 
medication gives a wider latitude to the anesthetist than if this were not 
used. When the subject is well selected, and the administration properly 
conducted, a slight increase in the percentage of oxygen being allowed 
from time to time as the operation proceeds, the mechanical breathing, 
color, and reflexes, together with the relaxation required, are sufficient 
guides for our use. The pulse and respiration will usually be normal, 
except when stimulated by the operation. If loud stertor commences or 
increases it is a sign for more oxygen. If muscular twitches are observed 
at any time this also is an indication for more oxygen. 
In anesthetizing children under ten years of age, after surgical anes- 
thesia is reached, it is best to raise the mask slightly from the face, about 
one-eighth of an inch, and allow the little patient to breathe the com- 
bined gases by having a plus pressure in the bag at all times, or by 
keeping the expiratory valve open and allowing rebreathing constantly. 
Weak, anemic men and middle-aged women can be successfully anes- 
thetized with nitrous oxid and oxygen alone, provided the valves and 
rebreathing are used discriminately. With a vast majority of patients 
it is safer to supplement the nitrous oxid and oxygen with small 
amounts of ether. 
Superiority of Oxygen Over Air.-The objection to using air is that 
it contains a large percentage of nitrogen which is useless for anesthetic 
purposes. Hewitt has illustrated this in the following manner: When 
air is given the equation could read like this: 
Air (by volume), 40 per cent = 
8 per cent oxygen 
32 per cent nitrogen 
Nitrous oxid 60 per cent = 
60 per cent nitrous oxid 
This mixture, containing eight per cent of oxygen by volume, would 
be the proper amount as far as the oxygen is concerned. Sixty per cent 144 
ANESTHESIA 
of nitrous oxid would be insufficient to produce tranquil anesthesia. By 
using oxygen instead of air in the above equation we are able to replace 
the thirty-two parts of useless nitrogen by a corresponding quantity of 
useful nitrous oxid, the percentage of oxygen remaining the same. The 
equation would now read like this: 
Oxygen = 8 per cent (by volume) 
Nitrous oxid = 92 per cent (by volume) 
This is about the average used with adult patients, and is perfectly 
satisfactory. 
Administration of Nitrous Oxid with Indefinite Quantities of Oxy- 
gen.-Willis D. Gatch, formerly of Johns Hopkins Hospital, Baltimore, 
deserves the credit of emphasizing and placing upon a scientific basis 
the value of rebreathing. His apparatus consists-besides the cylinders 
Fig. 28.-Diagrammatic Sketch Showing Simple Method of Administering Nitrous 
Oxid and Oxygen with Indefinite Quantities of the Agents Used. 
oi gas and oxygen, and connections-of one rubber bag, face-piece, and a 
two and a half-inch pipe connecting face-piece and bag. His mask con- 
sists principally of a rubber cuff, which is turned down over the ordinary 
mask so as to grasp the chin, cheeks, and nose of the patient. The patient 
may be made to breathe air or gas through valves or to-and-fro breathing 
into the bag. The main features of his apparatus are as follows: 
(1) It is simple, light, and easily portable. 
(2) It may be quickly sterilized by boiling. 
(3) There is economy in the use of gas. 
Gatch's Method of Administration.-"With the air-vent open, the cuff 
of the mask is fitted to the patient's face, care being taken to prevent NITROUS OXID 
145 
the admission of air at the sides of the nose. In some cases it may be 
necessary to lay a piece of gauze across the bridge of the nose and draw 
the cuff over it, or to hold the cuff there with the finger. The inner tube 
of the valve-box is pushed to its mid-position and nitrous oxid admitted 
to the bag. The patient now inhales this gas and expires into the outer 
air, thus washing out, as it were, all the air from his lungs. This process 
is continued until he becomes very slightly cyanotic. Then the inner 
tube is pushed to its final position and the patient breathes to-and-fro 
into the bag. At this moment a small puff of oxygen is admitted to the 
bag, just enough to restore the natural color of the face. The patient 
now rebreathes a mixture of nitrous oxid and oxygen until the inner 
tube of the valve box is moved back 
to its mid-position. He then ex- 
hales each breath into the air until 
the bag is empty. The anesthetizer 
then fills it with a fresh mixture of 
gases, which the patient again re- 
breathes. No attempt is made to 
measure the exact percentage of 
oxygen given. This we regard as 
unnecessary. It is perfectly easy 
to add directly from the oxygen 
cylinder exactly the right amount 
of this gas to each bag of nitrous 
oxid. The patient's color is an ex- 
tremely delicate indicator of the 
amount of oxygen he is getting. 
Our rule is to give just enough 
oxygen to keep the patient's color 
free of the least tint of cyanosis. 
The most elaborate device for reg- 
ulating the percentages of the two 
gases can do nothing more than 
this." 
All that is needed to success- 
fully maintain surgical anesthesia 
with nitrous oxid and oxygen by 
the above method is any ordinary 
accurately fitting face-piece, and a 
mask with valves that will also allow rebreathing when indicated, and a 
rubber bag. Any inhaler used for the gas-ether sequence can be utilized 
to give gas and oxygen by the Gatch method. The stopcock at the end 
of the bag may be replaced by a Y-shaped connection having tubes lead- 
ing respectively to the nitrous oxid and oxygen tanks. The bag is to 
Fig. 29.-Davis Nitrous Oxid-Oxygen 
Apparatus. Fig. 30.-Nasal Inhaler. 
Fig. 31.-Connell Gas-Oxygen Apparatus.-The best apparatus for scientific work. Fig. 32.-Large Tanks of Nitrous Oxid and Oxygen upon Portable Stand.-Sight 
feed apparatus attached. 
Fig. 33.-Miller Modification of Lumbard Airway. Fig. 34.-The Heidbrink Anesthetizer. 
Fig. 35.-Large Gwathmey.-Vapor mask for nitrous oxid or ethylene and oxygen. Fig. 36.-Hospital Model of Gwathmey Sight Feed Apparatis. 
Fig. 37.-Modified Flagg Inhaler. Fig. 38.-McKesson Apparatus. 
Fig. 39.-McKesson Apparatus.-Junior Special. NITROUS OXID 
151 
be kept filled with nitrous oxid, and a puff of oxygen is given whenever 
indicated by cyanosis or active reflexes. 
While this apparatus has been used in thousands of cases with satis- 
factory results, from the description of the apparatus and the method 
of administration given above it can be readily perceived that, unless the 
strictest attention is given to the administration, flaws will occasionally 
occur to mar the fixed plane of anesthesia that is to be aimed for. A 
possible objection outside of this consideration is the fact that the gases 
are not warmed except by the rebreathing of the patient, although they 
are thus properly moistened. 
Davis' Method.-Griffith 
Davis' apparatus embodies all 
the good features of the 
Gatch apparatus, and, in ad- 
dition, all the nitrous oxid is 
passed through a warming 
apparatus before it enters the 
mixing chamber. 
Coburn has devised an ap- 
paratus for the administra- 
tion of nitrous oxid and oxy- 
gen, according to the princi- 
ples enunciated by Gatch, but 
with the addition of an elec- 
trical heating apparatus for 
warming the gases. Coburn's 
hospital stand is very neat 
and compact. 
Methods of Administra- 
tion with Definite Quantities 
of Nitrous Oxid and Oxygen.-Hewitt's Method.-Hewitt's apparatus 
consists of two bags, one of which is used for nitrous oxid and the other 
for oxygen; and a mask with valves, cylinders, and connections. 
Hewitt's technique consists in administering the gases in the following 
manner: 
"The bags are half filled with their respective gases. When the 
gas is turned on, nitrous oxid and a small percentage of oxygen gain 
admission to the lungs. The bags are kept as nearly equal as possible 
in size, and partially distended throughout. The percentage of oxygen 
is gradually increased as the operation proceeds, but also occasionally 
admit a breath of fresh air." Hewitt limits the class of patients suit- 
Fig. 40.- Gwathmey Oxygen 
Y-Piece Adaptedf or Bennett's, 
Furniss', or Gwathmey's In- 
haler. Fig. 41.-Teter Nitrous Oxid-Oxygen Apparatus. 153 
NITROUS OXID 
able for this apparatus to weak, anemic men and middle-aged women. 
His experience with this apparatus has not been such as to recommend 
its general adoption. 
Gwathmey's Method.-The Gwathmey apparatus is a modi- 
fication of Hewitt's with the valve on the nitrous oxid bag so ar- 
ranged that rebreathing can be instituted at any time. Ether can 
also be added when necessary, and the nitrous 
oxid is heated by Brown's hot-water coil and 
cups. Ethyl chlorid can be given with the 
nitrous oxid and oxygen, if needed. The ex- 
piratory valve is regulated by a screw. Free 
expirations or forced expirations can thus be 
instituted at will by the anesthetizer. The 
technique is about the same as with the Teter 
apparatus. 
Teter's Method.-One of the best ap- 
paratus yet devised for the administration of 
nitrous oxid and oxygen for all purposes 
is the apparatus invented by Charles K. 
Teter, of Cleveland, Ohio. All the vapors 
inhaled by the, patient are warmed and 
can be given through valves, or by the 
method of rebreathing, or a combination 
ot these two methods, and at normal or 
positive pressure. The bags for the gas 
and oxygen are separate, and a definite amount 
of oxygen is constantly being mixed with the 
nitrous oxid. A certain amount of the expired gases is also constantly 
escaping through the expiratory valve. Warmed ether or chloroform can 
be added when needed. A more even plane of anesthesia is possible with 
this apparatus than with any other. A valve is placed upon the oxygen 
bag, but not upon the nitrous oxid, which allows continuous to-and- 
fro breathing. The following is the technique as given by Dr. Teter 
for the usual administration, and also for the administration through the 
nose. 
Technique.-"Fill the nitrous oxid bag about two-thirds full; fill 
the oxygen bag so that it is pretty well distended and is under a 
little pressure. Just before placing inhaler over the patient's face, 
open the valve from the nitrous oxid bag. Now place inhaler in posi- 
tion, being sure that you have perfect coaptation to exclude all air. 
Start the nitrous oxid flowing from the cylinder into the bag; this 
should be so regulated as to keep this bag full all the time. After the 
patient has been breathing the pure gas for about ten to fifteen sec- 
onds, the oxygen valve should be opened to the second notch (which 
Fig. 42.-The Teter Vapor 
Warmer. 154 
ANESTHESIA 
will be shown on the side of the valve cap and indicated by the ratchet), 
then keep increasing this one notch at a time, after three or four in- 
Fig. 43.-Teter's Face-Mask. 
halations, until you have reached the fifth or sixth notch; do not turn 
this any further unless there are symptoms of asphyxia manifested. 
(The first manifestation 
of asphyxia would be blue- 
ness of the features, which 
would be noticed first in 
the mucous membrane of 
the lips, in the ears and 
eyelids). If there are 
asphyxial symptoms, pres- 
ent, you should advance 
the oxygen valve still far- 
ther forward. It will be 
necessary to start the oxy- 
gen flowing from the oxy- 
gen cylinder into the bag 
after the patient has been 
breathing the mixture 
about forty seconds, in or- 
der to keep this bag well 
distended at all times, 
otherwise you would not 
be receiving the amount of 
oxygen indicated or desired. In order to keep the oxygen bag well dis- 
tended the oxygen is allowed to flow very slowly from the cylinder, so 
Fig. 44.-Teter Ether Attachment. NITROUS OXID 
155 
slowly that one will not be able to hear it, but enough to keep the bag 
well distended all the time. Practice is the only sure teacher, but one 
is soon able to adjust this properly. 
"If your patient is not going under the effects of this mixture after 
Fig. 45.-Teter Nasal Inhaler. 
he has been breathing it for about forty seconds or less, he is inhaling 
too much oxygen, or there is an admixture of air. If the latter is the 
case, correct it; if the former, turn the oxygen valve back a notch or 
two for a few seconds, and, if he still does not respond, it may be that 
the oxygen is flowing too fast from the cylinder; if so, correct this, 
and your patient should pass into a sound and peaceful sleep. Of 
course, you will find some few patients that are exceptionally hard to 
Fig. 46.-Teter's Auxiliary Tube for Administering Nitrous Oxid and Oxygen 
Through the Mouth. Used in connection with the nasal inhaler. 
anesthetize, but by persistence all patients can be anesthetized with 
nitrous oxid and oxygen. 
"By close observation on your part and being able to diagnose symp- 
toms properly in order to know when to increase or decrease the amount 
of oxygen, you are enabled not only to induce any desired depth of 
narcosis, but are able to maintain it for any reasonable length of time Fig. 47.-Teter Nitrous Oxid-Oxygen Apparatus with Nasal Inhaler in Use. 
Fig. 48.-Teter Nitrous Oxid-Oxygen Apparatus with Nasal Inhaler in Use, 
with Surgeon Operating. NITROUS OXID 
157 
without ever admitting one breath of atmospheric air. In fact, you will 
be able to obtain and maintain better anesthesia without the admit- 
tance of air. You should not cause any jactitation of the muscles, or 
much if any cyanosis in producing anesthesia. ... Do not be in too 
much of a hurry in bringing your patient under the influence of any 
anesthetic agent, but take some little time and give the system time 
to accustom itself to the new order of things. You will not only get 
much better results, but you will cause the anesthetic to be much safer 
by so doing." 
Technique to be Followed in Administering Nitrous Oxid and Oxy- 
gen with the Teter Apparatus and the Teter Nasal Inhaler.-"Fill the 
respective bags as stated under the 
heading, 'Technique for the proper 
administration of nitrous oxid and 
oxygen when the face inhaler is to be 
employed.' Open the valve from the 
nitrous oxid bag. then adjust inhaler, 
taking the thumbs and spreading the 
lower part of rubber cap so that this 
will not press upon the alae of the 
nose, tending to close the nostril. 
This inhaler is so constructed that by 
proper adj ustment it will fit any nose. 
In small children the top may be up 
as high as the forehead, but this will 
not matter so long as all air is ex- 
cluded. 
"After adjusting inhaler, instruct 
the patient to breathe through the 
nose. If he will not do so, hold a 
piece of rubber over the mouth. (A 
quarter of a rubber ball the size of a 
large orange makes the best thing pos- 
sible for this purpose.) Now allow 
the nitrous oxid to flow continually so 
as to keep the nitrous oxid bag full. 
After the first few inhalations turn 
the valve from the oxygen bag to 
the second notch and gradually in- 
crease this to the fifth or sixth notch, as the symptoms will indicate. 
After about one-half minute you should start the oxygen to flowing 
from the cylinder into the bag very slowly, so slowly that you will 
not be able to hear it, but enough to keep this bag well filled all the 
time. 
Fig. 49. - Teter's Nasopharyn- 
geal Tubes for Nitrous Oxid 
and Oxygen. 158 
ANESTHESIA 
"After inducing the desired depth of anesthesia, which should be 
accomplished in about two minutes, remove the rubber from the mouth. 
If the patient breathes through the mouth release the plunger in the 
inhaler, and it will descend upon the exhalation disk. This is done by 
loosening a set screw, which normally holds this plunger up and away 
from the exhalation disk. The inhaler is to be held firmly in position. 
Fig. 50.-The Ohio Monovalve, Including Ether Cup. 
Now the nitrous oxid is turned on more strongly from the cylinder, 
and the pressure thus formed in the bag will force the nitrous oxid 
through the nose, and, although the patient is inhaling and exhaling 
through the mouth, he is compelled to breathe the nitrous oxid, as 
it is under pressure greater by far than the atmospheric pressure. 
The oxygen bag is also allowed to fill with oxygen, and this is 
forced along with the nitrous oxid, according to symptoms indicating 
its need. 
"It is out of the question to expect to maintain as tranquil an 
anesthesia by this method as is possible where we can exclude all at- NITROUS OXID 
159 
mospheric air and are not hampered in applying our agent, but we 
can keep our patient under the anesthetic for any length of time and free 
from all physical pain. 
"If the patient continues to breathe through the nose, all that is 
necessary is to regulate the oxygen in accordance with symptoms dis- 
played and continue to the completion of the operation." 
Nitrous Oxid-Oxygen Endopharyngeally.-Connell has developed a 
very satisfactory method of administering 
nitrous oxid and oxygen, the technique of 
which is as follows: 
After the patient is surgically saturated 
with the anesthetic, the delivery is shifted to 
the pharyngeal method by the nasal route. 
Each nostril is plugged by a collar of thick 
rubber tubing slipped over the nasal cathe- 
ters. The pharyngeal rebreathing tube is 
then inserted, to which is attached a re- 
breathing bag. The quantity found most 
useful with this method is eight liters per 
minute, beginning with a five per cent oxy- 
gen mixture and increasing gradually up to 
a nine or ten per cent mixture by the end of 
the first hour. Where surgical relaxation is 
desired and protection against subconscious 
suffering is indicated, this is to be obtained 
not by dangerously increasing the oxygen 
starvation, but by adding ether as indicated. 
The rebreathing is used solely for economy. 
If the pharyngeal delivery is 22 liters, or five 
and one-half gallons, a minute, rebreathing 
may be dispensed with if the mouth be kept 
closed. (See Connell's Anesthetometer, p. 
160.) 
The Ohio Monovalve.-The gas pressure 
as it leaves the cylinders is automatically reduced and controlled here. 
In preparing to give the anesthetic, a cylinder of nitrous oxid and 
oxygen are both opened as far as the valves will permit. The gas 
passes through regulators which reduce the pressure to about two 
pounds, then through automatic valves, where it is further reduced to 
breathing pressure. The bags fill automatically, but when they are 
full the gas stops flowing. The bags are refilled as fast as the gas is con- 
sumed. 
There is only one valve to handle. With it, pure nitrous oxid is 
given, and when it is turned beyond a certain point oxygen is mixed 
Fig. 51.-Ohio Small Ni- 
trous Oxid Inhaler. May 
be easily carried to bedside 
or hospital ward; very 
satisfactory for short an- 
esthesia. 160 
ANESTHESIA 
in fixed percentage. If turned still farther, the nitrous oxid is closed 
off and pure oxygen is administered. 
If the patient is a deep breather, the gas can be given with in- 
creased force by simply turning a regulating device on top of the 
nitrous oxid and oxygen automatic valves. These are close to the one 
valve referred to, and are so easy to operate that there is no danger of 
confusion. 
The monovalve is made in two designs, one especially for offices 
and hospitals, where it is easily moved about on castors, and another 
design, which can be packed up and carried around from place to place. 
Boothby and Cotton Apparatus.-The apparatus of Boothby and 
Cotton seems to mark a distinct step in advance. The apparatus 
is not portable, but is especially applicable for hospital use. 
Fig. 52.- Connell's Anesthetometer. NITROUS OXID 
161 
A PERFECTED APPARATUS1 WITH NOTES ON ADMINISTRATION' 
"Desirability of Constant Mixture and Necessity of Ether 
Addition.-All experimental and clinical work has emphasized the 
fact that a constant mixture (rightly proportioned for the particular 
case in hand) produces a smoother anesthesia than a mixture of vary- 
ing composition; in other words, it has been shown that an intermit- 
tent and irregular supply of either gas 
does not conduce to a smooth surgical an- 
esthesia. 
"Hewitt was the first to develop an ap- 
paratus at all applicable for general surgi- 
cal use. His methods of overcoming the 
pressures of the nitrous oxid and oxygen 
in the tanks is to use semi-elastic bags 
which are kept more or less full from the 
tanks by means of an intermittent flow of 
the gases controlled directly by hand 
valves. From these bags the flow of gas 
to the patient is regulated by a specially 
constructed and graduated valve that al- 
lows definite proportions of gas to pass 
from each bag, providing the pressures 
within the same are equal. 
"In practice it has been found very 
difficult to keep the two bags evenly and 
equally distended, even if great pains and 
constant attention are being given by the 
operator to the manipulation of the hand 
valves; therefore, the pressure in the two 
bags varies and, consequently, the mix- 
ture actually received by the patient must 
of necessity be very varied. 
■ "Fundamental Principles. In- 
volved in Securing Constant Mix- 
tures.-As a result of the inadequacy of any apparatus built on the 
principle of the Hewitt, we took up, now over a year ago, the study 
of the problem. We laid down four fundamental principles which 
were to be met, namely: 
Fig. 53.-Pressure Gauges for 
Large Tanks of Nitrous 
Oxid and Oxygen. 
* See Figs. 54-55. 
'Written by Frederic J. Cotton, First Assistant Surgeon, Boston City Hos- 
pital, and Walter M. Boothby, Assistant in Anatomy, Harvard Medical School, 
Assistant Surgeon, Mount Sinai Hospital (Boston, Mass.), Anesthetist to the 
Boston City Hospital. 162 
ANESTHESIA 
"(1) There must be an absolutely regular flow of each gas at any 
rate desired, without the necessity of frequent valve manipulation. 
"(2) The flow of the gases must be rendered visible so that their 
proportions can be approximately estimated at a glance. 
"(3) An efficient method of adding ether vapor gradually yet rap- 
Fig. 54.-Boothby and Cotton Apparatus Set Up. (See page 169.) 
idly up to any amount that even an extreme case may require must be 
available. 
"(4) The face-piece must be so modified as to be absolutely air- 
tight and also practically self-retaining. 
"Maintaining Regular Flow of Gases.-The first point, the 
crucial one, is to obtain an even flow of nitrous oxid gas from its 
liquefied form. This necessitates the use of an automatic reducing 
valve. The same is true of oxygen, although not in liquid form, in simi- 
lar tanks under a pressure of 1,500 to 1,800 pounds to the square inch. 
The province of such a valve is to reduce these pressures to a working 
basis of 20 pounds to the square inch; a good valve should act auto- NITROUS OXID 
163 
matically, and require no attention on the part of the anesthetist; 
furthermore, it does not freeze or become otherwise obstructed. 
"This principle of the automatic reduction of high tank pressures 
is so fundamental that we consider it essential that this feature be 
actually an integral part of the apparatus and not secondarily attached 
Fig. 55.-Boothby and Cotton Apparatus Folded. (See page 170.) 
to tanks which are then connected to an apparatus designed on the 
Hewitt type. For general use a tank of moderate size (containing 75 
gallons of oxygen and 250 gallons of nitrous oxid) is the most prac- 
tical and convenient; accordingly we have designed our apparatus for 
that size of tank (the smaller sizes can of course be used and are pref- 
erable for transportation in house operating). 
"Visible Control of Flow of Gases.-The second desideratum, 
namely, rendering the rate of flow of gases visible, so that the relative 
proportion of each gas may be estimated at a glance (also assuring the 
administrator of the fact that the desired flow is actually taking place) 
has been solved by having each gas bubble separately through water 
into a glass mixing chamber. 
"The volume of gas delivered to the patient is controlled by means 164 
ANESTHESIA 
of a hand valve of fine adjustment acting against the low pressure de- 
livered by the reducing valve. This is entirely independent of the 
automatic reducing valve. The hand-valves can be set to give any 
desired volume, which will continue unaltered for hours; a change in 
the rate of flow is obtained by simply turning the valve-handle a trifle 
till such volume per minute as is desired is seen to bubble through the 
water of the mixing chamber. 
"The aim of the anesthetist is to determine, as early in the anes- 
thesia as possible, the proportion of nitrous oxid and oxygen suited to 
the patient under his care. The greater his experience the earlier will 
he be able to do this with certainty. After this proportion is once 
ascertained the apparatus will deliver the same mixture as long as de- 
sired. After a brief experience one is enabled to approximate the de- 
sired proportion solely by the eye, thus rendering it easier to quickly 
obtain the constant mixture needed for the particular patient in hand. 
In difficult cases it greatly helps the anesthetist to determine whether 
the patient becomes rapidly cyanotic (and this is not a rare occurrence 
with beginners) ; the anesthetist can see at a glance that the cause of 
the difficulty is obstruction of the respiratory passages and not due to 
an insufficient proportion of oxygen in the mixture being administered 
to the patient. 
"Addition of Ether Vapor.-The third essential point, which 
consists of being able, gradually yet rapidly, to add to the respired 
mixture ether vapor (as much as an extreme case may need), has 
been met by providing a second chamber, containing ether. The gases, 
after leaving the mixing chamber, pass to a three-way valve by which 
they are allowed to pass by the ether chamber entirely, or are made to 
pass either partly or wholly over the surface of the ether, or they may 
be forced (if desired) to bubble through the ether. 
"Thus any amount of ether vapor required, from the minutest trace 
to a relatively high percentage, can he almost instantly obtained. 
"The possibility of gradually and yet rapidly increasing the strength 
of the ether vapor is a material advantage, for it allows the anesthetist 
to just 'catch' the patient within a few seconds after he gives a sudden 
warning of being 'light' by moving the legs, contracting the abdominal 
wall, or showing symptoms of impending vomiting. At such moments 
one may gradually but rapidly increase the ether percentage to that 
obtained by bubbling through the ether; after a few respirations the 
patient is seen to relax or the symptoms of impending vomiting dis- 
appear, at which time the ether should be entirely shut off. It is best, 
as a rule, at the beginning of trouble indicating a 'light' condition, to 
make no change in the rate of flow of the gas or oxygen, for when ether 
is administered a slight excess of oxygen is desirable-; but, as soon as 
the impending trouble is overcome, the rate of oxygen may be slightly NITROUS OXID 
165 
decreased, or that of nitrous oxid increased, depending on the amount 
of rebreathing desired. In all probability the new mixture will main- 
tain a perfect condition of anesthesia for the rest of the operation, 
possibly without the necessity of again touching the valves. 
"Because we have emphasized the necessity of having available an 
appliance by which strong ether vapor can be administered we must 
not be misunderstood; in at least one quarter of the cases no ether at 
all will be required; in perhaps another quarter about two minutes' 
inhalation of ether will be needed during the last stages of the prepa- 
ration of the patient; in another small proportion an occasional addi- 
tion of ether vapor for one or two minutes through the course of the 
administration will be found advisable; only very rarely and in re- 
bellious alcoholic cases will more than a total of ten minutes' respira- 
tion of ether in addition to the gas mixture be needed for an hour's 
operation; and, even in these difficult cases, practically no more ether 
is needed after the first hour, no matter how long the operation is pro- 
longed. Accordingly little or no nausea and vomiting follows a prop- 
erly conducted nitrous oxid-oxygen-ether anesthesia in a great ma- 
jority of cases. 
"Pre-medication.-The cases run somewhat more smoothly, and 
perhaps with an average decrease in the amount of ether vapor needed, 
resulting in a more nearly ideal recovery, if moderate doses of mor- 
phin (gr. y8 to y±) and of atropin (gr. 1-120 to 1-100) are given 
hypodermically one-half hour before the beginning of the anesthesia.1 
At the Boston City Hospital this is a standing order, but if it is omitted 
for any reason we are not concerned except in the case of bad alcoholics. 
In other words, the preliminary injection of morphin is by no means 
essential, though it is desirable unless contradicted by some known 
peculiarity of the patient. 
"Non-leaking Face-piece.-The fourth point necessary for a 
nitrous oxid-oxygen anesthesia is to exclude even traces of air from 
leaking in between the mask and the face. This necessity holds true 
for every case and must be accomplished in spite of peculiarities of the 
facial contour or the presence of beard and whiskers. Boothby 2 recently 
described a collar that is not only air-tight but practically self-retain- 
ing. To those using this collar we call attention, elsewhere more fully 
dealt with, of the dangers of positive pressure; the expiratory valve 
must be so set that an outflow of the gases may occur whenever the 
pressure inside the masks exceeds 2 mm. of mercury, which is a pres- 
1 In the beginning, following the lead of Crile, we used scopolamin with the 
morphin. Often an efficient hypnotic, scopolamin has seemed to us too uncer- 
tain in its action to be worthy of routine use, and we have come to use atropin, 
which does at least reliably insure us against trouble from excess of mucus. 
3 Boston Med. and Surg. J., 1912, 166, 9, 328. 166 
ANESTHESIA 
sure that is just sufficient to maintain the rebreathing bag full but 
not distended. 
"Rebreathing Regulated.-For an even anesthesia, and as an aid 
to the avoidance of surgical 
shock, a certain constant 
amount of rebreathing is of 
benefit; approximately the 
rate of flow of the gases 
should be such that from a 
quarter to a half of the vol- 
ume of each respiration is 
of freshly added gas mix- 
ture. Such a proportion re- 
duces to within reasonable 
limits the expense of gas- 
oxygen anesthesia; too 
much rebreathing is apt to 
be followed by post-opera- 
tive discomfort, usually in 
the form of headache, and 
it may cause an increase of 
post-operative nausea and 
vomiting. Vomiting dur- 
ing the progress of the an- 
esthesia is often an indica- 
tion of excessive rebreathing 
for that particular patient, 
although in comparison 
with other patients it may 
not appear excessive; at all 
events increasing the vol- 
ume per minute of the gas 
mixture frequently clears 
up the symptoms. Our ob- 
servations on the effect of 
rebreathing, so far as they 
go, agree clinically with the 
laboratory findings of Hen- 
derson. Our observation of 
the blood pressure under nitrous oxid-oxygen (ether) anesthesia is that 
there is a distinct rise not only at the commencement but also through- 
out the operation. After the removal of the mask with its accompany- 
ing necessity for rebreathing, there is a distinct and rapid fall in the 
blood pressure. In two instances, both on very sick and debilitated 
Fig. 56.-Boothby and Cotton Face Mask. NITROUS OXID 
167 
patients, this fall was sufficient to abolish the radial pulse; the appear- 
ance of the patients and their mental attitude remained good; recovery 
was prompt and within one-half hour they were in fine condition and 
remained so. 
"Avoidance of Cyanosis.-Surgical anesthesia is never obtained 
when the patient appears in the least degree cyanotic on account of 
asphyxial spasm and rigidity. On the contrary the patient must al- 
ways be pink. Any anesthesia accompanied by cyanosis is dangerous. 
Deaths under nitrous oxid-oxygen are doubtless due to conducting 
the anesthesia according to the erroneous idea of the necessity and 
safety of cyanosis; no deaths have been reported in which the patient's 
color was maintained pink. 
"We have suggested that, in some cases, even when respiring a mix- 
ture of gas and oxygen in which the proportion of the latter is sufficient 
to maintain a pink color, the patient might be brought under too pro- 
found an influence of nitrous oxid, and the anesthesia be made danger- 
ously deep. Our use of an absolutely air-tight face-piece has enabled us 
to demonstrate that such a condition occurs not infrequently. In fact, 
toward the end of a long operation it is often necessary to use equal parts 
of oxygen and nitrous oxid. 
"The symptoms of an overdose of nitrous oxid in the presence of 
sufficient oxygen to keep the patient pink is, first, stertorous respiration, 
and second, the onset of an excessive secretion of mucus; unless the 
percentage of nitrous oxid is then decreased, the patient's face and hands 
take on a death-like pallor (not cyanotic) ; there is an absolute loss of all 
the facial reflexes; the respirations become shallow; and probably the 
blood pressure falls (that is, the temporal cannot be found so readily 
although the rate is not excessive). This condition, if pushed, would 
probably lead to death from paralysis of the respiratory center, though 
we know of no experimental evidence to support the hypothesis. 
"The point we wish to make is that an excess of nitrous oxid may 
be given even with a proportion of oxygen sufficient to maintain the 
patient pink and the respirations normal; if a death-like pallor with 
the other symptoms noted should now supervene while respiring such 
a mixture, the patient is rapidly approaching the danger point of ex- 
cessive anesthetization. In such a condition no time should be lost, 
for as yet we do not know how soon actual respiratory failure and death 
may occur. In brief, the mask should be removed, and, if necessary, 
artificial respiration instituted together with the administration of oxy- 
gen. 
"The use of nitrous oxid for prolonged anesthesia is still in its in- 
fancy and its danger limits are not well understood; in consequence, 
for several years yet its effects must be carefully watched. 
"When Ether Should Be Added to the Mixture.-Although the 168 
ANESTHESIA 
patient is rapidly rendered unconscious (two minutes) by nitrous oxid- 
oxygen, yet it is nearly ten minutes before the body is sufficiently satu- 
rated with the nitrous oxid to permit the beginning of an abdominal 
operation. During this period, which may be occupied by the prepa- 
ration and draping of the patient, we allow the anesthetist to depart 
somewhat from our rule in regard to avoidance of cyanosis; but even 
here we permit only the slightest degree of duskiness and never enter- 
tain the possibility of deep cyanosis. By the time the incision is made 
the patient must be actually pink and remain so throughout the oper- 
ation. If then a mixture of nitrous oxid and oxygen with a propor- 
tion of the latter sufficient to keep the patient pink will not produce 
sufficient relaxation to meet the demands of the surgeon, the anesthetist 
must add ether vapor till relaxation is complete. 
"For the best results close cooperation on the part of the surgeon 
and the anesthetist is essential. During the greater part of the ma- 
jority of operations complete relaxation is not needed; when such re- 
laxation is required by the surgeon he should so inform his anesthetist, 
who will be able within two minutes, by the proper administration of 
ether, to provide the same; as soon as such need is over the ether may 
be discontinued. 
"Obstruction of the Air Passages.-A cyanotic condition of the 
patient, however, sometimes quickly develops even with an evidently 
liberal supply of oxygen as shown by the flow through the mixing 
chamber. In such cases the trouble is without question an obstruction 
of the air passages and must be quickly remedied. Contrary to the 
generally accepted opinion, cheek and tongue obstruction of the air pas- 
sages is extremely common under nitrous oxid-oxygen anesthesia, and 
its prevention is absolutely essential. The most frequent cause is an 
obstruction of the nares together with a valve-like action of the lips 
or cheeks against the teeth that occurs in mouth breathing when there 
is muscular relaxation. A ready means of overcoming such a condi- 
tion is to slip up under the face-piece or collar a piece of gauze or a thin 
ribbon retractor into the angle of the mouth to keep the lips apart and 
the cheek away from the teeth; or pieces of rubber tubing about six 
inches long, guarded by safety pins, may be introduced into the nares 
through the oro-pharynx. In rare cases the tongue may drop back and 
cause obstruction in spite of every effort to prevent the same by hold- 
ing the jaw forward; in such cases a silkworm-gut stitch should be 
passed through the tongue and brought out under the collar, with a 
dental mouth prop placed between the teeth to prevent biting of the 
tongue. An absolutely free air passage for the gases must always be 
maintained; any slight obstruction, most commonly on inspiration, 
causes a labored respiration under which conditions a smooth anes- 
thesia is impossible; besides it throws an extra exertion onto the patient. NITROUS OXID 
169 
"The theoretical benefit to be obtained from an increase of pressure 
is less than one per cent in efficiency; accordingly, a procedure embody- 
ing the dangers of collapse and of sudden death, with such a meager 
beneficent return, should not be used. 
"In practice, therefore, the rebreathing bag should just become 
taut at the end of an expiration; this corresponds to a pressure of one 
or two mm. of mercury, which is sufficient to open the respiratory 
valve at the end of the expiration, and thus to allow the last part of 
the expired gases, that part which (as McKessen points out) contains 
the largest percentage of CO2 to escape into the air. 
"The experimental apparatus recently described by us, built on the 
principles enunciated above without regard to lightness and portability, 
has been most satisfactory and has met all expectations. We have re- 
versed our former opinion as to the desirability of having an attach- 
ment for warming the gases and this attachment has been discarded. 
"An apparatus to meet all requirements described above must have 
some size and weight. These items, however, have been reduced to 
their lowest terms by great care in the design and arrangement of the 
various parts. For the purpose of transportation the apparatus can be 
collapsed to a reasonable carrying size (height, 17 inches; length, 22 
inches; width, 17)4 inches) by the simple removal of four lag bolts, 
set up with thumb screws, which allows the top half of the machine to 
swing down into the lower half; th. center bar or axis acts then as a 
convenient handle and the framework forms a protecting cage for the 
valves and the glass chambers. To reduce the weight, the patterns have 
been made as small as is consistent with the strength requisite for hard 
hospital use and transportation for house operating, and the castings 
(except the valves) are made of aluminum alloy. The carrying weight 
is just under fifty pounds. 
"Fig. I.1 (1) Hand valve to regulate the volume supply of oxy- 
gen; it works against a low pressure of about 25 pounds to the square 
inch, therefore it can be set for, and will continue to deliver, any con- 
stant amount, and this can be estimated by seeing the rate of flow as 
the gas bubbles through the water in the glass mixing chamber (7). 
"(2) Ether valve; when pushed over to the left the mixed gases 
from 7 go directly to the patient; when in the center (as illustrated) 
the mixed gases pass over the surface of the ether in chamber 8; when 
pushed over to the right the gases must bubble through the ether. 
"(3) Hand valve; to control the volume of nitrous oxid in same 
manner as (1) regulates oxygen. 
"(4) Low pressure gauge; the one on the left indicates the pressure 
of oxygen, and that on the right nitrous oxid, after being automatically 
reduced by the reducing valve. 
1 See Fig. 54, page 162. 170 
ANESTHESIA 
"(5) Regulating handle on the reducing valve; this, after being set 
for the desired low pressure (20 lb.), does not need to be again touched. 
"(6) High pressure gauge; to show the pressure in the supply tank. 
"(7) Glass mixing chamber; contains water through which each 
gas bubbles separately, thus giving a ready means of estimating at a 
glance the rate of flow of both the oxygen and the nitrous oxid. 
"(8) The ether chamber; by valve 2 the gases, after being mixed 
in 7, are allowed to pass around the ether chamber or made to pass 
partly or wholly over the surface of the ether, or forced to bubble 
through the ether, thus adding any desired amount of ether vapor toi 
the respired mixture. 
"(9) One of four valves; introduced so that any one of the tanks 
may be removed and replaced by a full one without interrupting the 
use of the apparatus. 
"(10) Cups to fill the chambers with water and ether. 
"(a) Valve on tank. 
"(b) Screw by which each tank is clamped into its yoke. 
"(c) One of the two nitrous oxid tanks on right side. 
"(d) One of the two oxygen tanks on left side. 
"(e) Rebreathing bag. 
"(f) Mask with celluloid face-piece and the Boothby air-tight 
self-retaining collar. 
"(h) Two of the four lag bolts which may be removed by un- 
screwing the thumb nuts on the inside to allow the 
top of the table to invert into the lower half. 
"(i) Center axis on which the top half swings. 
"Fig. II.1 (1) Center axis on which the top half swings; the middle 
portion serves as a handle. 
"(2) One of the four thumb nuts which are removed to invert the 
table. 
"(3) Mixing and ether chamber protected by the frame when top 
is inverted for transporting. 
"(4) Pet cocks for drawing off the water and ether from the cham- 
ber before inverting. 
"(5) The under side of one of the automatic reducing valves. 
"(6) The metal nipple to which the rubber tube is attached that 
leads to the rebreathing bag. 
"Size: Height, 17 inches; length, 22 inches; width, 1714 inches; 
weight, 50 pounds (aluminum castings)." 
The Gwathmey-Woolsey Nitrous Oxid-Oxygen Apparatus.-The 
Gwathmey-Woolsey apparatus has been developed in accordance with 
the principles recognized as essential in the evolution of nitrous oxid and 
oxygen anesthesia, especially those utilized by Gatch and by Boothby 
1 See Fig. 55, page 163. NITROUS OXID 
171 
and Cotton. The gas supply is conveniently and efficiently furnished 
when equipped for portable use, first, by two one hundred gallon tanks 
of nitrous oxid which are in direct connection with the reducer at all 
times; second, by one forty gallon tank of oxygen, easily and quickly 
replaced when necessary. 
The pressure of the nitrous oxid is reduced by an efficient reducer 
of small dimensions and 
light weight; that of the 
oxygen, by a very small 
valve. The gases are deliv- 
ered under low pressure 
into a combination sight 
feed and warm water bath, 
where the administrator 
can see, on one side of a 
nickel partition, the nitrous 
oxid flowing, and on the 
other the oxygen. This 
sight feed enables the anes- 
thetist to regulate the pro- 
portions of the gases very 
carefully. 
This water sight feed is 
warmed by an alcohol lamp 
adjustable to its under sur- 
face, thus supplying heat 
and moisture, which are 
valuable assets in the ad- 
ministration of any anes- 
thetic. From the sight 
feed, the mixed gases pass 
at the top through an exit 
tube to which is attached 
the rubber tube running to 
the rubber bag and mask. 
The gas cylinders are 
opened wide into the re- 
ducing valves, the flow 
from these valves being controlled by very sensitive wheels. 
When the two nitrous oxid tanks and one oxygen tank are in 
place (enough for a two-hour administration), the total weight is under 
forty pounds. In hospitals where the supply is obtained from large 
tanks or from a generator in the cellar, the delivery hose from these 
sources may be attached to the apparatus. 
Fig. 57.-Gwathmey-Woolsey Nitrous Oxid- 
Oxygen Apparatus. R, reducing valve of ni- 
trous oxid; R1, regulating valve of nitrous oxid; 
O, regulating valve for oxygen; F, sight feed; 
S, supports. 172 
ANESTHESIA 
The Gwathmey-Woolsey Mask.-The Gwathmey-Woolsey mask 
is an anatomical one made to fit the bones of the face. A rubber collar, 
devised first by Gatch and later used by Boothby and Cotton, is retained 
as an essential feature of the mask. The adjustment of this collar, to the 
absolute exclusion of all air, is considered one of the important features 
of the technique. 
Ether.-In the small number of cases in which it is necessary to 
Fig. 58.-Gwathmey-Woolsey Nitrous Oxid-Oxygen Apparatus with Cylinders 
Attached. O, regulating valve for oxygen; O2, oxygen tank; N2O, nitrous-oxid tank. 
give ether in combination with gas and oxygen it may be introduced 
by placing an ether chamber directly on the mask and between the 
mask and bag, as is usual with all gas-ether apparatus. The chimney 
piece of the Gwathmey gas-ether apparatus, to which the gas bag is 
attached, has been retained. This contains the inspiratory and ex- 
piratory valves upon a sliding cuff. With this cuff, the anesthetist can 
regulate the patient's breathing, through valves, partly through valves, 
rebreathing entirely, or, as is generally the case, rebreathing with the 
expiratory valve slightly open. 
Positive Pressure.-Five mm. of mercury pressure in the re- 
breathing bag have been found a very great help in those subjects 
usually considered unsuitable for nitrous oxid and oxygen. NITROUS OXID 
173 
Endotracheal Insufflation.-The apparatus was especially de- 
vised for endotracheal work. It has been found most acceptable wher- 
ever endotracheal work is needed, the constant flow of the gases insur- 
ing an even anesthesia without danger. When used in this way, no bag 
is necessary, the connection being made directly with the tube in the 
trachea. The cases in which it has been used have been entirely satis- 
factory. The patient is anesthetized in the usual way, the catheter is 
inserted in the trachea, and a glass connecting tube is placed in the 
catheter, joining it with the rubber tube from the apparatus. 
A mercurial manometer which automatically "blows off" at twenty- 
five mm. of mercury pressure is attached for endotracheal work. For 
the usual anesthesia, a safety valve set for a pressure of ten pounds 
protects the glass "sight feed." 
Nasal Anesthesia for Oral Surgery.-For such operative pro- 
cedure the bag can be dispensed with and the general principles outlined 
by Teter allowed to govern the technique. The Teter auxiliary tube 
for the mouth, to prevent spattering when the volume of gas is too 
great through the nasal passages, is also used. This method is entirely 
satisfactory in cases of adenoids and tonsils. 
Analgetic Work.-With the nose-piece in position, a great many 
surgical operations, especially dental work, may be done with ease dur- 
ing the analgetic stage of nitrous oxid-oxygen anesthesia. The ab- 
sence of the bag, or any impediment around the patient's head, is a 
very great advantage. The automatic action of the apparatus after 
once the flow of gases is started is a great help. It is now an acknowl- 
edged fact that dentists can do their work more acceptably to the pa- 
tient and with greater satisfaction to themselves when using nitrous 
oxid and oxygen for painful dental work than without this help, or 
with only a local anesthetic. 
Obstetrical Cases.-Guedel1 reports a number of cases with ap- 
paratus for the self-administration of nitrous oxid and air in obstet- 
rical cases. The analgetic properties of nitrous oxid and oxygen have 
not been tested in this field. It would seem, however, to be preferable 
to nitrous oxid and air by virtue of the absence of the slightest asphyxi- 
ation and the presence of a more prolonged stage of analgesia, the idea 
being to suppress all pain without completely subduing muscular effort. 
The nasal administration, although more wasteful than the usual method 
of mask with bag, is the most agreeable and most satisfactory method 
for these cases, inasmuch as it leaves the face entirely uncovered. The 
patient can thus answer questions, which is sometimes necessary in 
order to avoid passing from analgesia to anesthesia. 
Technique of Administration for General Work.-The mask, 
with the cuff turned up, is placed upon the patient's face and held in 
1 Indianapolis Med. J., Oct., 1911. Fig. 59.-Portable Gwathmey Apparatus, St. Louis Model. 
Fig. 60.-Obstetrical Inhaler for Self-Administration. NITROUS OXID 
175 
position until unconsciousness ensues. The cuff is then turned down 
and fastened around the neck; it now becomes self-retaining. If the 
patient is a vigorous alcoholic or a nervous individual, the bag should 
be partly filled with nitrous oxid alone. When the gas is turned on, 
from two to six breaths, according to the patient, should be allowed 
through valves; the sliding cuff is then pulled out, and rebreathing 
instituted, the expiratory valve being left very slightly open, say one- 
sixteenth of an inch. As signs of anesthesia appear, oxygen should be 
allowed to bubble through in about the proportion that will be main- 
tained throughout the operation. For the first five minutes the bag 
should be slightly overdistended, thus insuring a deeper anesthesia. 
After that, seven-eighths distention will meet all conditions. It is 
unnecessary to manipulate the valves after the patient has been anes- 
thetized five minutes, a slight increase or decrease in the oxygen, or a 
slight increase or decrease in the nitrous oxid, according to the re- 
quirements of the patient, being all that is necessary. Quite often the 
patient will continue to be satisfactorily narcotized for ten or twenty 
minutes without the supply valves being touched. Five mm. pressure 
will relax resistant patients sufficiently for all surgical operations. 
There is thus a continuous flow of nitrous oxid and oxygen, with 
continuous rebreathing. There is slight escape of the exhalations at 
all times. The patient's color reflex should be maintained, and duski- 
ness should not be allowed. Stertor should be avoided whenever possi- 
ble by the anesthetist sustaining the lower jaw with the hand or lessen- 
ing the amount of nitrous oxid. 
To summarize, the advantages of the Gwathmey-Woolsey apparatus 
are: 
(1) Absolute and perfect control of the gases flowing at a low 
pressure. 
(2) The gases are easily warmed whenever the patient's condition 
demands it. 
(3) It is especially adaptable for endotracheal anesthesia, solving 
the problem of the administration of nitrous oxid and oxygen by this 
method. 
(4) Small amounts of ether can be added whenever necessary. 
(5) An even, automatic flow of gases, opening up a new field espe- 
cially for using the analgetic properties of the gases. 
(6) Small size and portability of the apparatus. 
(7) The irritating impurities of the gases themselves, as well as 
small particles of rust from the inside of the cylinder, are washed out 
in the water filter sight-feed. CHAPTER V 
ETHER 
History of the Use of Ether as an Anesthetic. 
Chemistry: The Term Ether; Properties of Ether; Anesthetic 
Ether; Precautions in Handling Ether; Sources of Impurities in Ether; 
Standards of Purity with Which Anesthetic Ether Should Comply; 
Role of Alcohol in Ether; Peroxids; Aldehyd; Physiological Action of 
the Impurities and Administration Means to Avoid Them. 
Special Physiology: Effects Upon the Respiratory System; Ef- 
fects Upon the Circulatory System; Effects Upon the Nervous System; 
Effects Upon the Muscular System; Effects Upon the Glandular System 
and Other Structures; Causes of Death from the Administration of 
Ether; Stages of Ether Anesthesia; Elimination; After-Effects. 
Administration of Ether: The Open or Drop Method; The 
Mask; Ethyl Chlorid-Ether Sequence by the Drop Method; The Ethyl 
Chlorid Ether-Chloroform Sequence; The Ethyl Chlorid-Ether Sequence 
by the Closed Method; Chloroform-Ether Sequence; Anesthol; Anesthol- 
Ether Sequence by the Drop Method; The Ether Rausch; The Semi- 
Closed Method; Towel and Paper Cones; The Handkerchief Method; 
The Closed Method; The Nitrous Oxid-Ether Sequence; Technique of 
the Nitrous Oxid-Ether Sequence; Nitrous Oxid-Ether-Chloroform Se- 
quence; The Vapor Method of Anesthesia; Warmed Ether Vapor. 
Vapor: The Open Method; Endopharyngeal Anesthesia; Oxygen- 
Ether Administration; Concentration of Ether Vapor; The Closed 
Method; Amount of the Anesthetic Used; Care of the Apparatus; Hints; 
Advantages; Treatment of Accidents. 
Indications and Contraindications of Ether: Indications; 
Contraindications. 
HISTORY OF THE USE OF ETHER AS AN ANESTHETIC 
In 1795, ether was employed medicinally for the relief of asthma. 
About this time inhalation therapeutics seems to have been a medical fad 
for a short period, and ether and nitrous oxid were used to the exhilarat- 
ing stage only. Although injuries received while under the influence 
176 ETHER 
177 
were not felt, no one seemed to think of carrying the physiological effect 
of the drug beyond what is generally termed the second or excitement 
stage. 
Twenty-three years later, in the English Quarterly Journal of Sci- 
ence and Arts, Faraday is stated to have said: "When the vapor 
of ether mixed with common air is inhaled it produces effects very 
similar to those occasioned by nitrous oxid. By the imprudent in- 
spiration of ether a gentleman was thrown into a very lethargic state, 
which continued with occasional periods of intermission for more than 
thirty hours." Teachers, lecturers, and medical students had a gen- 
eral idea of the physiological action of ether when thus administered, 
and were in the habit of illustrating lectures by allowing inhalations 
to continue until the exhilarating effects were produced. This con- 
tinued for the next thirty-four years, and ether frolics by students and 
others were indulged in. Occasionally, but accidentally, of course, the 
third, or surgical stage, was reached. Those who sustained injuries 
in these ether frolics did not complain, and, further, those who en- 
tered the third or surgical stage of anesthesia seemed, upon recovery, 
to have enjoyed the experience rather than otherwise. 
These two facts were coupled together by Crawford W. Long, of 
Jackson County, Georgia, who in 1842 (302 years after its discovery 
and 47 years after it was first used medicinally) administered ether 
with the intention of prolonging surgical anesthesia while performing 
an operation. The anesthesia and operation were successful, and this 
procedure was practiced upon several different occasions by him and 
his assistants. Unfortunately he took no pains to acquaint the world 
at large of his discovery until Morton had successfully administered sur- 
gical anesthesia with ether in the General Hospital of Massachusetts, in 
Boston, four years later, October 17, 1846. 
The first operation with ether in England occurred two months 
later, on Dec. 19, 1846, at the house of Dr. Boot, in Gower Street, 
London. J. Y. Simpson, in January, 1847, first employed ether in 
midwifery practice; he discovered that the labor pains were wholly 
abolished, the contraction of the uterus continuing. Thus painless child- 
birth was produced for the first time in the world's history. 
The physiological effects of different percentages of ether and other 
narcotics, as determined by experiments on the lower animals, were 
first pointed out by John Snow in 1858, and later by J. T. Clover. 
Clover was also the first to demonstrate the very great advantages of 
the closed method of air limitation and to introduce the nitrous oxid- 
ether sequence. 
The first committee to attempt definite scientific work was ap- 
pointed in 1864, twenty-two years after ether was first used as an anes- 
thetic. 178 
ANESTHESIA 
Braun, a German physician, was the first to modify the Junker 
inhaler into one for giving ether as well as chloroform, either sepa- 
rately or in combination, and one of the authors of this book carried 
this vaporizing a step further by passing the vapors through hot water, 
thereby bringing them up to the temperature of the blood, and at the 
same time washing out various impurities. Gwathmey made experi- 
ments upon animals to discover the difference between the normal, 
warm and cold vapors of ether, and also between air and oxygen as 
the vapor carrier. 
Contemporaneously with the writing of this book experiments were 
made by the authors, who succeeded in masking the odor. (See Chap- 
ter II, p. 91.) 
CHEMISTRY 
The Term Ether.-Ethers are organic chemical compounds of the 
general formula R. 0. R', where R, R' represent alkyl or aryl groups. 
Ethers are therefore the oxids of the alcohol radicals, and may be re- 
garded as anhydrids of the alcohols, being formed by the elimination 
of one molecule of water from two molecules of the alcohols. They are 
related to the alcohols in the same way as the metallic oxids are related 
to the metallic hydroxids. 
Ethers may be simple or mixed.1 Simple ethers are the oxids of 
monovalent alkyls; that is, they contain two similar alcohol radicals. 
Mixed ethers are those with different radicals attached to the oxygen 
atom. 
The term ether, as ordinarily used, signifies diethyl ether, ethyl 
ether, oxid of ethyl, "ethane-oxy-ethane," "hydrate of ethylene," ethylic 
ether, "hydrate of ether," "hydric ether," "vinous ether," or "sulphuric 
ether," the last two terms being survivals of an earlier nomenclature. 
The term must not be confounded with "compound anesthetic ether."2 
Properties of Ether.-Pure ethyl ether is a colorless, very mobile, 
strongly refractive, neutral, inflammable liquid, possessing a penetrat- 
ing but exhilarating odor and a sharp, burning taste. It has a specific 
gravity of 0.718 - 0.719 at 15/4°, and boils at 34.6° under 760 mm. 
pressure of mercury. By intense cooling, ether forms an ice-like solid 
which melts at -117° C. (Olszewsky). It is very volatile, and, if 
1 Compound ethers, or more properly esters, are hydrogen salts in which the 
typical acid hydrogen has been replaced by an alkyl, and may therefore be looked 
upon as alkyl salts of organic acids, since an alcohol and an acid radical are 
present. 
2 ' ' Compound anesthetic ether " is a mixture of absolute ethyl ether and amyl 
hydrid (rhigolene), proposed by Richardson for the production of local anes- 
thesia by means of cold. Accidents have occurred as the result of using this mix- 
ture as an inhalation anesthetic. ETHER 
179 
placed on the skin, it evaporates rapidly, producing cold and numbness. 
Ether is only slightly soluble in water (1 in 12 at -|- 22° C.), and it 
dissolves little water (about 1 in 34 at -|- 22° C.). It dissolves alcohol, 
benzin, and chloroform in all proportions. It is a good solvent for 
fats and some resins. 
Anesthetic Ether.-This may contain ethyl alcohol (up to four per 
cent) and traces of acetaldehyd, acids, and water, although, for reasons 
given in the text, the last three mentioned should be entirely absent. 
Precautions in Handling Ether.-Ether has a high vapor tension. 
When a vessel containing ether is left open to the air, the vapor rises 
sufficiently to displace the air or other gas overlying it, and then flows 
over the edge of the containing vessel. As the vapor is very heavy, 
being 2.6 times as heavy as the air, it falls to the table, shelf, or floor 
upon which the vessel rests. The vapor is very inflammable, and, when 
mixed with air, forms an explosive mixture, which is readily ignited 
by a flame. Great care should be taken to avoid using ether near an 
open flame, as a lighted gas jet, burning candle, or stove, or in the 
neighborhood of a hot cautery. A cautery should never be used about 
the mouth or nose when ether is used as the anesthetic. Several cases 
of severe burning have been recorded where these precautions were not 
taken. 
It is important also to take the same precautions when pouring 
ether from one vessel to another. The heavy vapor will travel some 
distance along a floor, for example, before being sufficiently dissipated 
to be free from danger. Where ether is used with electric lights care 
should be taken that these are not arc lights, and, if they are incan- 
descent bulbs, that there are no short circuits or sparks, as the vapor 
may be thus ignited. 
Sources of Impurities in Ether.-All ether of anesthetic grade is now 
prepared from ethyl alcohol and sulphuric acid. The impurities to be 
suspected are therefore: (a) Those present in the two materials used; 
(b) those produced in the process; (c) those developed during storage.1 
It is almost needless to call attention to the necessity of having ethyl 
ether as pure as human ingenuity can provide it. The methods used 
for purification and some of the means of detecting impurities are 
comparatively modern. Many of the impurities are rarely found in 
anesthetic ether, as they are removed in the process of purification; 
and, when some of them are found, the trouble may usually be traced 
to substitution, accidental or otherwise, of commercial ether for that 
of anesthetic grade. Some manufacturers make anesthetic ether only, 
thus removing one source of possible human error. As in the case of 
1 The elimination of all the possible contaminants of ethyl ether, particularly 
those usually present in small amounts, has been discussed by Baskerville and 
Hamor in detail; see J. Ind. Eng. Chem., 3, 302, 307, 309, 316, 380, 391 and 395. 180 
ANESTHESIA 
other chemicals, there are cases of sophistication, but these are com- 
paratively rare. 
Impurities from Materials Used in Manufacture.-The sul- 
phuric acid used is of high grade, and usually contains no impurities 
which volatilize with the ether.1 Rectified ethyl alcohol, 95 per cent, 
with 5 per cent water, is used. The process of rectification of the alco- 
hol does not always remove amyl, propyl, or butyl compounds, or "fusel 
oil," and the essential oils characteristic of the source of the ethyl alco- 
hol, which is commercially never free from aldehyds and traces of 
acetic acid. The source of the alcohol-that is, whether it is made 
from grain, molasses, sawdust, or what not-is immaterial, provided 
it has been properly rectified. Acetal, extractive matter (from barrels), 
and tannic acid are often present in the alcohol. Acetone and formalde- 
hyd may also be present, but are to be suspected only when methylated 
alcohol is employed.2 In the United States, alcohol denatured with 
ether is now allowed in the manufacture of ether, so there is little or no 
likelihood of the last mentioned contaminants. 
Contaminating By-products Introduced by the Process.-The 
crude ether distillate resulting in the manufacture of ether by the con- 
tinuous process contains, together with water, alcohol and sulphur di- 
oxid 3 as the principal contaminants, although small amounts of other 
impurities (as fusel oil, empyreumatic oily matter, ethyl acetate, alde- 
hyd, acetic acid, acetal, acetone alone, or with furfurol) are generally 
present, these varying with the purity'of the materials used in the manu- 
facture and with the care with which the etherification is conducted.4 
These can be and are largely removed in the subsequent purification. 
Impurities Developed in Storage of Ether.-The standards laid 
down by the various pharmacopoeias of the world are not uniform. This 
is especially true for ethyl ether and chloroform. Some pharmacopoeias 
call for an admixture of alcohol. This may come from its retention 
in the process of manufacture, or, as has been recommended, it may be 
added to the rectified ether up to 4 per cent. Other pharmacopoeias 
call for an almost absolute ether (sp. gr., 0.720, 15/15° C.). The role 
1 Purchasers of ether have in the past complained of ether which contained 
sulphuric acid. Such contamination can be due solely to substitution of "com- 
mercial" ether. 
'Guerin (J. Phar. Chem., [7], 4, 492) reported that he had detected acetone 
and formaldehyd in certain samples of anesthetic ether on the market in France 
(Dec., 1911); and this ether had evidently been prepared from alcohol denatured 
with methyl alcohol. 
* It should be mentioned that the greatest yield of ether is obtained at 140- 
145° C., and that above this temperature much sulphur dioxid is evolved. 
'Patch (Proc. Am. Pharm. Assn., 54, 337) found that a sample of ether sold 
as 90 per cent contained only 74 per cent; that two samples of U. S. P. strength 
possessed an acid reaction and yielded a residue; and one sample answering all 
other tests gave a brown residue. 181 
ETHER 
of the alcohol will be discussed in another paragraph. If alcohol is 
added, then the impurities present in the alcohol are to be found in the 
ether supplied, but, of course, in correspondingly smaller amounts. As- 
suming that the ether is prepared pure with the exception of the vicari- 
ously allowable percentage of alcohol and its usual five per cent of 
water, there are changes which take place on keeping under certain 
conditions, namely, peroxidation, with the subsequent formation of 
acetaldehyd and acetic acid. 
Experiences of expert anesthetists, not accounted for by idiosyncrasy, 
obtained in the use of ethyl ethers supplied by various manufacturers 
in numerous surgical cases, caused Baskerville to carry out a series of 
elaborate investigations on the quality of the anesthetics supplied by 
various makers, and to determine what changes, if any, occurred in the 
drugs when kept under the conditions obtaining in everyday life. 
Standards of Purity with Which Anesthetic Ether Should Comply.- 
All tests which have been reported in the literature were tried out. 
Many were found to be of no value and some to be misleading. Some 
pharmacopoeial tests are unnecessarily rigid; some are open to im- 
provements; others should be replaced entirely by improved methods 
of detection; and several new tests should be incorporated for de- 
tecting impurities not considered. Exhaustive investigation into modes 
of manufacture, validity of applicable chemical tests, as given in 
the pharmacopoeias of every civilized nation, methods of administra- 
tion, and clinical experience warrant the assertion that ethyl ether 
complying with the tests given by authorities for specific gravity, 
boiling point, odor, residue, activity, aldehyd, and peroxids will give 
the best results by whatever method the ether anesthesia may be 
induced. 
It must be recognized that the demand for a good ether for anes- 
thesia involves difficulties inherent in the practical application of chem- 
ical methods by hospitals and physicians. As already stated, anesthetic 
ether should be provided in small containers, and it is impracticable, 
and should be unnecessary, to test the contents of each container 
before use; hence, reliance must be placed on the experience and 
integrity of the manufacturer and on the uniformity of his product. 
We have found that some ethers of the market vary from time to time, 
not only in specific gravity and absolute ether content, but also in im- 
purities. It is incumbent upon him who uses ether to take proper pre- 
cautions to prevent the development of storage impurities of which the 
manufacturer may have been innocent. 
Role of Alcohol in Ether.-For various reasons a pure ether may be 
mixed with ethyl alcohol when it is to be used for anesthesia. Impuri- 
ties then observed may be due in part to the alcohol used in dilution. 
Practically all ethyl alcohol contains some acetaldehyd. 182 
ANESTHESIA 
Ethyl alcohol serves, it is asserted, as a preservative for ether when 
the latter is properly stored. This, we believe, is without foundation 
in fact. Small amounts of ethyl alcohol interfere in no way with the 
application of ether in anesthesia. However, the presence of alcohol is 
unnecessary except when ether is administered by the "drop method." 
In this method the presence of alcohol prevents too rapid volatilization 
and consequent chilling of the mask with which the ether is adminis- 
tered and the freezing of the moisture of the breath or of the air 
therein, or the alcohol lowers the freezing point of the condensed water, 
thus preventing solidification of that water. Some administrators state 
that this freezing prevents the patient getting a full free flow of the 
vapor. A serious factor also is the chilling of the lungs by the cold 
vapor. Davis, of the Johns Hopkins Hospital, has made observations 
on the temperatures of a number of patients anesthetized with ethyl 
ether by the drop method and by warm vapors of ether.1 In the former, 
the body temperature dropped 1° to 2° F., and in the latter, not more 
than 0.3° F. in any case. Alcohol occurring in ether is subject to oxida- 
tion, producing bodies in the following order: alcohol, aldehyd (alde- 
hyd peroxid), acetic acid. 
Some have maintained that pure ethyl ether free from alcohol is 
unsuitable for anesthesia, but it is a fact that the vapor from ether 
containing alcohol, when passed through water at 40° C., whereby the 
alcohol is removed, may be, and is being, used with great success for 
anesthesia. 
Peroxids.-Ethyl ether of anesthetic grade contains peroxidized 
compounds after exposure to atmospheric oxygen for considerable 
periods of time, especially when it is stored in colorless glass vessels 
or in badly-stoppered tin containers. The latter is an unfortunately com- 
mon practice in some hospitals. The extent of the oxidation is de- 
pendent upon the purity of the sample, the amount of air present, the 
nature of the container, the temperature conditions, and, in the case 
of glass vessels, the intensity of the light, which accelerates the oxida- 
tion.2 
1 Discussed on pp. 60-80. 
2 Baskerville and Hamor made the following experiments: 
Ether was allowed to stand for 200 days in 150-c.c. tin containers, partly 
filled, stoppered as well as the mouth of the containers would permit, and ex- 
posed to varying temperature conditions inside of a window with southern ex- 
posure. The conditions of storage were similar to those which obtain in many 
laboratories and hospitals. None of the samples so exposed exhibited a peroxid 
reaction originally, but all contained small amounts of water and alcohol. The 
following results were obtained, using the vanadic acid and cadmium potassium 
iodid tests: 
No. 1A (container one-fifth full) : strong peroxid reaction; strongly acid. 
No. IB (container one-half full) : marked peroxid reaction, but less pro- 
nounced than in No. 1A; strongly acid. (Continued on p. 183.) ETHER 
183 
Aldehyd.-Acetaldehyd is undoubtedly the commonest and most 
objectionable contaminant of anesthetic ethers, and its presence may 
account for some of the observations made in practice.1 Several have 
found occasion to emphasize the objectionable presence of aldehyd in 
many ethers on the market.2 It is one of the impurities most likely to 
be generated by exposing partially filled containers to varying at- 
mospheric conditions for long periods of time. Ether should not be 
stored in glass vessels for any length of time without being tested for 
oxidation products before use, and the tin containers should be of such 
capacity that they need not be opened without being soon emptied. 
Any remnants in these containers, especially if they have been kept 
for some time, should not be used for anesthesia without purification. 
The careless practice observed in some large hospitals where the operat- 
ing rooms are in more or less continuous service is to be looked upon 
with disapproval. The using of large containers of ether or chloroform, 
and placing them on a shelf where the drug is subjected to the condi- 
tions referred to, should not be countenanced by those in authority. It 
can scarcely be defended on the score of expense, as the cost of the 
anesthetic of this nature used in an operation is trifling in comparison 
with the other costs involved, and should not be counted when not only 
the comfort but the safety of the patient is taken into consideration. 
Physiological Action of the Impurities and Administration Means 
to Avoid Them.-Since it is highly important that ether intended for 
(Continued from p. 188.) 
No. 1C (container four-fifths full) : very faint peroxid reaction. 
No. 2A (container two-thirds full) : no peroxids present. This container 
was provided with a tightly fitting stopper. The neck of the can was cylindrical, 
whereas those holding the preceding were provided with a conical neck, and it 
was thus possible to cork the can more securely. 
No. 2B (one-half full) : no peroxids present. This sample was stoppered 
similarly to No. 2A. 
No. 3A (one-tenth full) : strong peroxid reaction. 
No. 3B (one-third full) : no peroxids present. This container was properly 
stoppered. 
No. 3C (three-fourths full) : no peroxids present. Container was well stop- 
pered. 
No. 3D (four-fifths full) : no peroxids present. Container was properly 
stoppered. 
Walton (Can. Drug., 23, 584) has reported that one out of eight samples 
of commercial ether examined contained hydrogen dioxid. 
1 Acetaldehyd vapor, when inhaled, produces asphyxia. Prolonged exposure 
to light and air gives rise to aldehyd in ether, and such treatment greatly 
affects the results of etherization. In one case of which we have record, a sam- 
ple of ether which induced irritation of the respiratory tract during etherization 
was examined, and the only impurity found was acetaldehyd. 
2 Thoms: Pharm. Ztg., 1894, 777; Warden: Pharm. J. and Trans., 1885, 
521; Am. J. Pharm., 57, 148; and Graham: Proc. Penn. Pharm. Assn., 1906, 
153. 184 
ANESTHESIA 
anesthetic purposes should be carefully manufactured and properly 
stored, as prolonged exposure to light and air produces aldehyd and 
acetic acid, which greatly affect the results of etherization, causing cough- 
ing, suffocation, and even dangerous after-effects, such ether should al- 
ways be tested for peroxids and aldehyd, and the presence of the latter 
should be rigorously guarded against, especially if the ether is to be 
administered by the drop method; or the ether, if so contaminated, 
should be administered by a method which eliminates these impurities 
before it is introduced into the animal system. This is accomplished by 
the Gwathmey method, as experimentally determined by Baskerville. 
Anesthetic ethers known to contain minimum amounts of aldehyd, 
ether known to contain excessive amounts (both offered on the market), 
and ether to which still larger amounts of aldehyd were added, were 
placed in the Gwathmey apparatus and severally operated as in prac- 
tice, except that the vaporized ether, which the patient would have got, 
was condensed and examined. The aldehyd, acetic acid, and alcohol 
accumulated in the water, and the condensed ether (which the patient 
breathed) was free from the aldehyd and acetic acid, as shown by the 
most rigorous application of the tests recommended for their detection. 
SPECIAL PHYSIOLOGY 
The various factors which have been mentioned as exercising a modi- 
fying influence upon the physiological action of inhalation anesthetics 
in general are notably potent with reference to ether. Inasmuch as this 
agent is more commonly employed for general surgical purposes than 
any of the others, the effects of these modifying factors have been given 
most attention in the administration of ether. In the present stage of 
the development of this branch of surgery it is the exception rather 
than the rule to find an anesthetist giving ether alone, without the 
utilization of one or all of the modifying factors discussed under Gen- 
eral Physiology. (See p. 30.) It is to be borne in mind, however, 
that the following consideration of the physiological effects of ether 
involves the administration of this agent without reference to sequence 
with other agents or to adjuvant medication, and without the utilization 
of other factors previously mentioned. 
With ether, no less than with chloroform and the other inhalation 
anesthetics, the discussion of its effects upon specific parts of the 
organism is purely arbitrary, and is resorted to for purposes of con- 
venience. It is to be borne in mind that this agent presents no excep- 
tion to the general rule of the correlation of effects. 
For a discussion of the course of ether anesthesia when all the modi- ETHER 
185 
fying factors are considered, according to the most advanced technique, 
the reader is referred to Chapter VIII. 
Effects Upon the Respiratory System.-It is unequivocably agreed 
that ether has a powerful stimulating effect upon the respiratory sys- 
tem during the earlier stages of its administration, as evidenced by the 
increased rate of respiration. As the administration proceeds, how- 
ever, the direct action of the agent upon the respiratory center causes 
a slowing of the respiratory movements and a decrease in their depth, 
with final complete cessation of respiration, in consequence of paralysis 
of the center, as the administration is carried beyond the limits of 
safety. The rate, depth, and stertor of respiration thus become the 
safest guides as to the degree of anesthesia, as will be seen when the 
stages are discussed. 
The respiratory system is affected before the circulatory, and for 
this reason it is possible to resuscitate the subject when respiration 
temporarily ceases from other causes than paralysis of the respiratory 
center. 
Ether exercises a pronounced irritating effect upon the air passages, 
which gives rise to a free secretion of mucus. 
For further details of the effects of ether upon the respiratory sys- 
tem the reader is referred to Anesthesia, p. 247. 
Effects Upon the Circulatory System.-The effect of ether upon the 
blood has been made the subject of a large part of the experimental 
investigation of the physiological action of this agent. 
Engelhardt,1 in his experimental study of ether narcosis, was ena- 
bled to establish strictly definite relations between the concentration of 
the narcotic agent and the temperature of the vehicle in the effect of 
disintegration on human and animal red blood corpuscles. In these 
experiments 9.4 per cent sucrose solutions and salt solutions, such as 
0.9 per cent sodium chlorid and 5.5 per cent magnesium sulphate solu- 
tions, were mixed with known quantities of ether. The higher the con- 
centration of the narcotic agent, the lower the temperature at which 
the red blood cells were dissolved; vice versa, the weaker the concentra- 
tion, the higher the temperature limit at which hemolysis took place. 
In animals, as well as in man, the disintegration-point corpuscles-i. e., 
the temperature at which the fluid changed its color through the break- 
ing down of the theoretical corpuscular sheath and the escape of hemo- 
globin-was lowered by several degrees, after prolonged narcosis, with 
indifferent salt solutions. In the case of salt solutions containing ether, 
on the other hand, the red blood corpuscles which had been removed 
from the animal body during or after the narcosis were dissolved only 
at a higher temperature. In other words, the resistance of the red 
1 Engelhardt: "Neue Gesichtspunkte in der Beurteilung der Aethernarkose," 
Aftti. a. d. Grenzgeb. d. Med. u. Chir., 13, 1903-1904. 186 
ANESTHESIA 
blood corpuscles against the narcotic agent was increased. Briefly, 
the red blood corpuscles of etherized animals, according to Engelhardt, 
have a lower "melting point" in indifferent salt solutions, whereas the 
"melting point" of the narcotized erythrocytes is increased in salt solu- 
tions which contain ether. The explanation for this increased resist- 
ance has not yet been discovered. 
In his experimental investigations on the appearance of intravital 
coagulation and thrombosis in the vessels of internal organs after ether 
narcosis, Mulzer1 was enabled to demonstrate a disintegrating effect 
of the ether vapors upon the cells. The primary factor consists in an 
injury of the red blood corpuscles through the anesthetic agent, which 
leads secondarily to agglutination and coagulation, with formation, or 
excretion, of fibrin. 
With special reference to ether, twenty-five healthy animals, mostly 
rabbits, were anesthetized so deeply with ether such as is used for nar- 
cosis that the corneal reflexes were lost during the entire duration of 
the experiment. Some animals died during the narcosis, while 
others were subjected to vivisection, under deep narcosis, at the end of 
a definite period, and fresh specimens of their organs were prepared. 
In seven animals, which survived at most half an hour in the narcosis, 
nothing pathological was found, and the vessels contained only normal, 
undeformed, well-stained blood corpuscles. When the narcosis even 
slightly exceeded half an hour, more or less numerous blue-stained 
granules were found within the vascular lumina, especially in the sub- 
pleural small vessels of the lung, attached to the vascular walls. The 
red cells in the vascular lumen were, for the most part, perfectly 
normal only in the center, but deformed, granular, and disintegrated 
toward the vascular wall. In case the narcosis could be continued for 
three-quarters of an hour to one hour, there appeared fine blue threads, 
radiating from the blue granules or passing between them into the 
layer of the deformed red blood corpuscles. After a still longer dura- 
tion of the narcosis the contents of certain vessels were seen to be dis- 
tinctly arranged after the fashion of typical thrombi, granular-fibrillar 
masses alternating with layers of deformed or normal erythrocytes. In- 
dividual lumina of small vessels were entirely filled with granular and 
fibrillar masses, between which lay only some masses of reddish detritus, 
but no normal blood corpuscles. Occasionally distinct granules and very 
delicate threads could also be demonstrated in the capillaries of the 
pulmonary alveoli. Although these processes occurred chiefly in the 
finer vessels of the lung, they were also observed, although to a less 
marked extent, in the vessels of the liver and the kidneys. 
1 Mulzer: ' ' Das Auf treten intravitaler Gerinunungen und Thrombose in den 
Gefassen innerer Organe nach Aether und Chloroform Narkosen, " Munch, med. 
Woch., 1907, No. 9, 408. ETHER 
187 
These blue-stained granular and fibrillar masses are regarded by 
Mulzer as granular and fibrillar fibrin. As the primary factor, he as- 
sumes a lesion of the red blood corpuscles through the circulating ether, 
which acts as a blood poison. This leads secondarily, favored by a 
variety of other causes, to agglutination and coagulation, with forma- 
tion, or excretion, respectively, of fibrin. The number of the red blood 
corpuscles is very considerably diminished, after the narcosis, and the 
changes in the configuration of the erythrocytes plainly indicate the 
destructive influence of the narcotic agent. 
Bloch,1 who investigated the effects of ether upon the hemoglobin 
and the red blood corpuscles during ether narcosis in man and in rab- 
bits, considers it as certain that any narcosis causes an organic change 
of a certain number of red blood cells in consequence of the chemical 
absorption of the anesthetic agent into the blood. Provided the operative 
intervention is not too long and is conducted under proper concentra- 
tion of the ether vapor, without too great a difference in temperature 
at the surface of the lung, the lesion does not exceed the degree of a 
"physiological" injury of the erythrocytes. Otherwise the hemoglobin 
escapes entirely from the red cells under disintegration of the cellular 
lecithin sheath, only the stroma remaining behind; or the hemoglobin 
may escape in part, rendering hemoglobin debris of various forms visible. 
These erythrocyte ruins are retained in the liver, spleen, and other 
organs, and are in part utilized again. The lost blood corpuscles are 
replaced by compensatory function of the bone marrow, from which 
new erythrocytes pass into the blood, according to Bloch, whose state- 
ments are based- upon the counting of the blood corpuscles and the de- 
termination of the hemoglobin. 
In an experiment upon a rabbit blood corpuscles with polychroma- 
tophile degeneration, microcytes, macrocytes, masses of stellate figures, 
etc., were found by means of Jenner's blood stain, so that Bloch does 
not regard it as altogether impossible that ether narcosis may ultimately 
produce the blood picture of pernicious anemia. 
As the most tangible evidence of the destructive power of ether upon 
the blood, hemorrhagic transudates into the body cavities were found 
in animals which had been killed by the narcosis. Individual differences, 
as emphasized by Bloch, must be assumed to exist in different animal 
species, and even in different animals of the same species. 
Stursberg 2 studied the behavior of the blood pressure, under the 
1 Bloch: "Neuere Untersuchungen uber die Einwirkung von Aether auf 
Haemoglobin und rote Blutkorperchen wahrend der Narkose an Menschen und an 
Kaninchen, " Deut. Ztschr. f. Chir., 1909, 97, 132. 
'Stursberg: " Ueber das Verhalten des Bhitdrucks unter der Einwirksung 
von Temperatureizen in Aether und Chloroform Narkose und seine Bedeutung fur 
Entstehung der Nachkrankheiten. " Mitt. a. d. Grenzgeb. d. Med. u. Chir., 1911, 
£2, 1. 188 
ANESTHESIA 
action of temperature stimuli, in ether narcosis, as well as its bearing 
on the origin of post-anesthetic diseases. He found that the action of 
cold upon the skin is followed by a contraction of the peripheral arteries, 
and hence a rise of blood pressure with increased blood supply to the 
internal organs. This behavior of the vascular reflexes, in his opinion, 
certainly plays an important part in the origin of diseases due to catch- 
ing cold. He investigated the behavior of dogs in ether narcosis under 
the action of cold produced by plunging the animal into a cold bath. It 
was found that in ether narcosis this vascular reflex behaved as in un- 
narcotized animals. In chloroform narcosis, on the other hand, the 
refrigeration of the skin is not followed by extensive vascular contrac- 
tion with hyperemia of internal organs. Ether narcosis, therefore, in- 
volves certain conditions for after-diseases due to cold which do not 
exist in chloroform narcosis. Accordingly any chilling of the skin is 
to be carefully avoided in ether anesthesia. 
Ether acts as a direct heart stimulant during the early stages of its 
administration, and when, during the course of deeper narcosis, the 
subject is allowed to return to a lighter degree, the pulse is accelerated, 
and blood pressure is slightly raised or remains constant. Ether be- 
comes a cardiac depressant only in the later stages of anesthesia, or 
when a toxic amount is employed. Because of its depressing effect, 
under these circumstances, upon the vasomotor center, there is general 
arterial dilatation, with slowing of the pulse and a slight fall of blood 
pressure. In fatal cases of ether toxemia cardiac failure follows failure 
of respiration. 
While the circulation may be stimulated or depressed by surgical 
shock or other means, in the vast majority of cases of ether anesthesia 
it is dependent upon the respiration. Blood pressure is maintained at 
the highest level during full surgical anesthesia by giving the smallest 
dose possible to obtain this state. An overdose of the anesthetic, or an 
obstruction in the airway, rapidly increases shock, with consequent fall 
of blood pressure and with rapid and feeble pulse. While the heart may 
be arrested in diastole by ether, a fatal case of reflex inhibitory arrest 
has never been reported. The circulation is immediately affected by the 
handling of important nerves and blood vessels, but the heart usually 
resumes the normal rhythm as soon as this ceases. The auricles, as a 
rule, are more affected than are the ventricles, as indicated by a weak- 
ened auricular contraction and increased ventricular relaxation. 
Effects Upon the Nervous System.-The first effect of ether upon the 
nervous system is one of stimulation. Like chloroform, however, with 
increasing dosage, it produces progressive paralysis of the central nerv- 
ous system, the phenomena affecting the centers in the following order: 
(1) The higher cerebral centers, involving the intellectual faculties; 
(2) The lower cerebral centers, involving sensation and motion; ETHER 
189 
(3) The spinal cord, involving sensation and motion; 
(4) The medullary centers, involving vital function. 
Sensation is not lost with equal rapidity throughout the body, the 
back and the extremities being involved first, the genital organs and 
rectum next, and the parts supplied by the trigeminus last. 
The effects of ether upon the nervous system, as observed clinically, 
are given under the Stages of Anesthesia. 
Effects Upon the Muscular System.-During the early administration 
of ether, when the stimulating action of the agent is generally mani- 
fest, the muscular system is affected no less than other parts of the 
organism. The entire muscular system may be thrown into a state of 
tonic contraction, or, as pointed out by Hewitt,1 there may occur a 
fine tremor, designated as the "ether tremor." As the administration 
proceeds, general muscular relaxation ensues. It is to be borne in mind, 
however, that spasm of various parts of the muscular system, particu- 
larly of the masseter, the tongue, the laryngeal muscles, the muscles of 
the neck, chest, and abdomen, may occur during the course of ether 
anesthesia, giving rise to respiratory embarrassment and other compli- 
cations. 
The clinical significance of the effects of ether upon the muscular 
system is considered under Stages of Anesthesia. 
Effects Upon the Glandular System and Other Structures.-The ac- 
tion of ether upon the glandular system is of clinical importance with 
reference to the course of the administration, but particularly with 
regard to the influence upon the after-effects. Because of the stimulat- 
ing and irritating effects of ether upon the mucous membranes of the 
upper air passages, trachea and bronchi, there is always a hypersecretion 
of mucus, which, in some instances, amounts to what has been called 
mucus-inundation. This may give rise to fatal asphyxia, and is pre- 
sumably one of the causes of post-anesthetic bronchitis and pneu- 
monia. 
The irritating effect of ether affects the salivary glands, giving rise 
to an excessive secretion of the fluid. When this is swallowed, post-anes- 
thetic vomiting is apt to occur. Coincidentally with hyperactivity of the 
mucous glands of the respiratory tract and of the salivary glands, there 
is apt to be overactivity of the mucous glands of the stomach and intes- 
tines, causing retching and vomiting during and after the administra- 
tion. 
The action of ether upon the liver and kidneys has called forth con- 
siderable investigation, both clinical and experimental. 
Grondahl,2 studying the effects upon the kidneys, found, in 75 ether 
1 Hewitt: "Anaesthetics," 363 (1912). 
2Grondahl: "Wirkung der Aethernarkose auf die Nieren, " Norsk Mag azin 
for Laegevidenskaben, 1905, No. 5; Deut. med. Woch., 1905, No. 25, 1005. 190 
ANESTHESIA 
narcoses, where the urine had been examined before the narcosis, albu- 
min present in 27 cases (36 per cent), always associated with cylin- 
ders, excepting in three instances. The albumin frequently did not 
appear until the second day, and promptly subsided in the major- 
ity of the cases. The high percentage of albuminuria is referred by 
Grondahl to the fact that, in general, these patients had undergone 
severe and prolonged operations. Albuminuria appeared at the end of 
the first day in 20 per cent of the cases, and, at the end of the second 
day, in 16 per cent. The average duration of the albuminuria was from 
seven to nine days. It was influenced by the age of the patients, the time 
of the operation, and the amount of ether used. In case of repeated nar- 
cosis the albuminuria appeared after each narcosis, but with diminishing 
severity. Ether accordingly, in Grbndahl's opinion, does not cause an 
intoxication-nephritis. 
According to Rathery and Saison,1 ether inhalation, single or 
repeated, is capable of producing certain lesions of the liver and the 
kidneys in rabbits, although by no means invariably. The renal lesions 
are less frequent and less severe than in the corresponding experiments 
with chloroform. The liver, on the other hand, seems to be even more 
sensitive toward ether than toward chloroform, for it is often changed 
more seriously after ether inhalation. 
Thompson 2 summarizes his observations upon the effects of ether 
upon renal activity as follows: 
"(1) During ether narcosis the volume of urine secreted is affected in 
two ways. In the majority of experiments there is a decrease, in a few 
an increase. The latter is probably an early or light effect, the former 
a pronounced effect. The depressing effect is, however, more marked 
than with chloroform, and complete arrest occurs more readily. 
"(2) The after-effect is less marked but similar to that of chloro- 
form. The maximum outflow of urine occurs about three hours after 
removal of the anesthetic. 
"(3) The output of nitrogen with ether corresponds more closely 
with its influence on the outflow of urine than is the case with chloro- 
form. In the later stages of the anesthesia, where the urine volume is 
decreased, the excretion of nitrogen is diminished almost exactly to the 
same degree as the urine volume. In the group of catheter experiments 
the excretion of nitrogen fell to 26.03 per cent, the quality of urine to 
25.4 per cent of the normal amount. 
"(4) The effect of ether narcosis on the circulation of the urine dif- 
1 Rathery, F., and Saison, M.: " Lesions experimentales du foie et du rein 
a la suite d'inhalation d'ether au lapin," Compt. rend. Soc. de. biol., L. 18, 5, 
211 (1910). 
2 Thompson, W. H.; ' ' Anaesthetics and Renal Activity, ' ' Brit. Med. J., 
March 17, 1906. ETHER 
191 
fers also from that of chloroform. With the former the urine, when 
diminished in volume is, as a rule, more concentrated (contains more 
nitrogen). The converse was the case with chloroform. The effect of 
ether is therefore primarily vascular. 
"(5) In ether narcosis, when the curves of urine outflow, kidney vol- 
ume, and blood pressure are compared, although there is not complete 
parallelism, there is, on the whole, a closer correspondence than is the 
case with chloroform. This statement does not apply to the arrest of 
urinary secretion, which occurs more readily, and with a relatively higher 
blood pressure, in ether than in chloroform narcosis. 
"(6) The escape of leucocytes into the urine, after full ether nar- 
cosis, is more marked than with chloroform, probably indicating a higher 
degree of stasis in the glandular capillaries. Dilatation of capillaries 
and escape of leucocytes have been noted by previous investigators, after 
ether inhibition, in the case of other vascular areas than renal. 
"(7) An increased excretion of chlorids is seen after ether inhala- 
tion, but is much less, and of shorter duration, than in the case of 
chloroform. 
"(8) Temporary albuminuria appears in dogs in a much larger pro- 
portion of experiments with ether than with chloroform. 
"(9) Reducing substances, not sugar, which were not present in the 
normal urine, appeared in a small number of the experiments after ether 
narcosis." 
From experiments upon dogs, Grube 1 attributes the glycosuria ob- 
served during ether narcosis to a disturbance of the heat regulation of 
the organism. He is of the opinion that the reduction in temperature 
is produced by the radiation from the skin, as a result of the vasodilata- 
tion caused by the ether. 
Nicloux 2 conducted an interesting series of experiments upon guinea 
pigs with reference to the passage of ether from the mother to the fetus. 
The following conclusions were arrived at: The ether passes from the 
mother to the fetus; the fetal liver contains more ether than the mater- 
nal liver, presumably due to the relative richness of the former in leci- 
thin. Chloroform shows exactly the same behavior. This transition is 
in every way comparable to the behavior of alcoholic substances, which 
involve the blood corpuscles and the plasm in the same proportion. 
Nicloux 3 was also able to demonstrate the passage of considerable quan- 
tities of ether into the milk in ether narcosis. The animal serving for 
these experiments was a goat. The cause is referred by Nicloux to the 
1 Grube: Arch. ges. Physiol., 138, 601. 
3 Nicloux, M.: "Passage de 1'ether de la mere au foetus," Compt. rend. 
Soc. de biol., 1908, 64. 
3Nicloux: "Passage de 1'ether dans le lait," Compt. rend. Soc. de biol., 1908, 
64. 192 
ANESTHESIA 
affinity of ether for fats. Analogous investigations have shown the 
passage of chloroform into the milk. 
Fabre and Verrier1 report, as contributions to the knowledge of 
the influence of ether narcosis upon the lactation, two observations upon 
nursing mothers, who were put under ether for the performance of minor 
operations (ruptured perineum and anal fissure). The secretion of milk 
was in no way modified in these two cases, and the infants were put to 
the breast on the day of the operation without untoward results. 
In the discussion of these observations Rancher stated that in his 
experience with several cases the action of the anesthetic on the secretion 
of milk was always negative. There is, accordingly, no reason to put off 
a necessary operation on a nursing mother. The child is not usually put 
to the breast on the day of the operation, but more to let the patient rest 
than for fear of a secretion of inferior milk. On the following day the 
nursing may be resumed. 
Causes of Death from the Administration of Ether.-Because of the 
relative safety of ether, the causes of death from its administration have 
not been made the subject of such extensive experimental and clinical 
investigation as has chloroform. 
It is generally conceded that, in fatal ether toxemia, respiration fails 
before circulation. Respiratory failure may result from paralysis of the 
respiratory center, or as the result of an overdose, or it may occur quite 
independently of this, from obstruction of the air passages from any 
cause. Fatal reflex respiratory shock may supervene as the result of the 
surgical procedure, and is more apt to occur, in consequence of reflex 
muscular spasm, during the lighter stages of anesthesia than during full 
surgical narcosis. 
According to Hewitt,2 "The all-important point concerning respira- 
tory failure in moderately healthy patients under ether is that, however 
such failure may arise, the circulation at the moment when breathing 
ceases is sufficiently satisfactory for remedial measures to be almost 
invariably successful. The heart is not likely to fail unless restorative 
measures be too long delayed." 
According to Henderson,3 primary cardiac death may occur under 
ether. Primary cardiac failure can be induced, easily and with cer- 
tainty, simply with ether. Failure to recognize this in the past has been 
due, he asserts, mainly to the fact that dogs have hitherto been the 
principal experimental animals, and dogs rarely exhibit the phenomena. 
Cats, on the other hand, and many human subjects, after being rendered 
1 Fabre and Verrier: "Influence sur la lactation de I'anesthesie par 1'ether," 
Bull, de la Soo. d. Obstet. et de Gynecol., May, 1912, 552. 
2 Hewitt: " Anassthetics, " 367 (1912). 
8 Henderson, Yandell: "Primary Heart Failure in Normal Subjects under 
Ether," Surg., Gynecol., and Obstet., Aug., 1911, 161. ETHER 
193 
acapnic, are liable to die of primary cardiac failure under ether. They 
are hypersusceptible to ether in the same manner that acapnic dogs and 
acapnic persons are hypersusceptible to chloroform. Henderson believes 
that these forms of death, and, in fact, by far the greater number of 
all deaths under anesthesia, are fundamentally due to acapnia resulting 
from the excessive pulmonary ventilation of the stage of excitement. 
Stages of Ether Anesthesia.-When ether is administered according 
to the most modern technique (see Administration, p. 199), the sub- 
ject, as a rule, quietly passes into the stage of surgical anesthesia, as if 
falling into a profound sleep, from which the recovery is so uneventful 
that it may be likened to the awakening from normal slumber. 
It is always to be borne in mind, however, that there may be indi- 
vidual variations from the usual course of events, even with the most 
careful technique. When the anesthetist, for any reason, fails to employ 
the various auxiliary measures now in use, the stages of anesthesia are 
quite well marked. Four stages may be observed, which are as follows: 
First Stage, or Stage of Light Anesthesia.-In the last edition of his 
"Anaesthetics" (1912, pp. 362-363) Hewitt states that, in consequence of 
the pungent and rather disagreeable odor of ether, "it is impossible to 
avoid completely all unpleasant sensations at the commencement of the 
inhalation." This is so easily and so completely accomplished by the 
preliminary administration of an alcoholic solution of oil of bitter 
orange peel (see p. 91), that it seems almost unnecessary to give in 
detail the phenomena otherwise noted during the first stage. 
This stage usually occupies the first two minutes of the inhalation. 
Respiration is accelerated. Blood pressure is slightly increased, the 
pulse is full and bounding, and the color reflex is heightened. If the 
vapor is administered in too great concentration, there may be holding 
of the breath, swallowing, closure of the glottis, a feeling of suffocation, 
muscular rigidity, coughing, and turning of the head from side to side. 
The pupils are dilated. The special senses are disturbed, though the 
order in which they are affected has not been definitely determined. 
Second Stage, or Stage of Excitement.-With ether, as with chloro- 
form, this stage, so far as the excitement is concerned, should not occur. 
It is obviated in part or in full by the utilization of modern technique, 
which calls for the adaptation of the method to the individual case. In 
any event, this stage is marked by the more or less abrupt loss of con- 
sciousness, with the consequent interference with memory, volition, and 
intelligence. The subject, however, responds to stimuli, and may give 
evidence of apparent consciousness. Words and sentences become more 
and more incoherent, and crying, singing, or laughing, shouting, and 
struggling may initiate a typical stage of excitement. As the anesthesia 
deepens, marked rigidity of the muscles, clonic or tonic contractions, 
partially of certain muscles, notably the muscles of the jaw and larynx, 194 
ANESTHESIA 
appear. The pupils continue to be dilated and mobile. Mucus and 
saliva are now freely secreted. The face is flushed, and, unless care is 
exercised in keeping the airway clear, cyanosis may occur. Perspiration 
now appears over the face and other parts of the body. The pulse is still 
accelerated, full and bounding. Respiration may now become irregular, 
and apnea may occur, the cessation of breathing lasting for variable 
lengths of time. The "ether-tremor," to which reference has been made, 
sometimes occurs during this stage, the patient shaking with quite 
noticeable violence. This is more apt to occur as the subject is emerging 
from than when going under the influence of the anesthetic. In either 
event this phenomenon disappears with the deepening of the anesthesia. 
Vomiting occurs, if at all, during the transition from the second to the 
third stage. The muscles particularly concerned in respiration are now 
no longer subject to reflex stimulation, and, as the subject passes into 
the third stage, they become so flaccid that there is no longer danger of 
serious interference with respiration from this cause. 
Third Stage, or Stage of Surgical Anesthesia.-The recognition of 
this stage of anesthesia is important, inasmuch as the subject is not in 
condition for operative interference until this time. The indications of 
normal surgical anesthesia may be briefly stated as follows: 
(1) Respirations regular, deep, and softly stertorous. 
(2) Muscles of extremities lax. 
(3) Color of face, ears, and lips about normal. 
(4) Pupils reactive to light. 
(5) Lid reft.ex weakly present. 
(6) Coughing reflex absent. 
(7) Phonation absent. 
It is to be borne in mind that there may be greater or less variation 
from the indications of what may be called normal surgical anesthesia, 
but this is not sufficient to obscure the recognition of this stage. 
The respirations are now regular, full, and generally audible. A 
soft stertor may be considered normal, but if breathing becomes strongly 
stertorous it is an indication of some obstruction in the airway. The 
respirations are the principal guide as to the depth of narcosis. When 
the regular, automatic, respiratory action is obtained, this should be 
maintained, bearing in mind slight variation in different individuals. 
A decrease in the depth and amplitude of respiration indicates a return 
to consciousness, and calls for an increased amount of the anesthetic. 
An increase in stertor should be modified by changing the position of 
the lower jaw or head. 
Cyanosis is not present in normal anesthesia. 
The heart action is accelerated, compared with the normal, during 
this stage, and the pulse is full, bounding, and regular, usually varying 
from 80 to 110 per minute. As the anesthesia progresses the face may ETHER 
195 
become more flushed than normal. Blood pressure, as a rule, remains 
constant. 
The pupils, when no preliminary medication is used, may be slightly 
dilated (from 3)/o to 4% mm.),1 or they may contract to normal, re- 
maining so throughout this stage. The eyeballs are generally fixed, 
though they may be rolling. 
Relaxation of all the muscles now occurs, the continuance of this 
stage depending upon the further conduct of the administration. (See 
Administration, p. 199.) 
Fig. 61.-The Pupillometer. 
The third stage of anesthesia may change in the direction of (1) 
return to consciousness, or (2) deepening narcosis, or the beginning of 
the fourth stage. 
The indications of returning consciousness may be summarized as 
follows: 
(1) Respiration weak. 
(2) Pallor of face. 
(3) Swallowing movements. 
(4) Pupils dilated. 
(5) Lid reflex return. 
(6) Lachrymation excessive. 
(7) Phonation returns. 
These phenomena call for an increased amount of the anesthetic. 
Fourth Stage, Stage of Deepening Narcosis, or Stage of Overdose.- 
The indications of the onset of this stage may be summarized as follows: 
(1) Respirations weak. 
(2) Dusky appearance of face (cyanosis). 
(3) Pulse soft, feeble, irregular. 
(4) Pupils dilated; no reaction to light. 
(5) Eyeballs fixed and dry. 
(6) Eyelids separated. 
The first indications of impending overdose, ordinarily noted by the 
administrator, are the irregular pulse and the quiet feeble respirations. 
The muscles become flaccid. Blood pressure is markedly decreased. 
1 It may be noted here that the average ether pupil, as measured by the 
pupillometer, is larger than the average chloroform pupil (see p. 308). 196 
ANESTHESIA 
When ether is given in an overwhelming dose, the heart may be paralyzed 
immediately after paralysis of respiration. 
Elimination.-Nicloux 1 investigated the elimination of ether, after 
the narcosis, and found that the quantity of ether amounts to about 150 
mg. per 100 c.c. of blood, immediately after the cessation of the inhala- 
tion; then the amount of ether in the blood rapidly diminishes, so that 
only one-half of the above quantity is demonstrable at the end of five 
minutes. Only traces of ether can be detected after two hours, and none 
is left after four hours. 
As compared to the elimination of chloroform, the elimination of 
ether must be designated as very rapid. 
These findings are in keeping with the observations of other investi- 
gators. 
After-Effects.-The after-effects of ether narcosis may be considered 
under two heads, viz.: (1) Immediate, and (2) Remote. 
Immediate After-Effects.-It has been stated that if ether is admin- 
istered according to modern methods, with the utilization of preliminary 
and accompanying factors, the subject emerges, as a rule, from the anes- 
thetic state as if from normal sleep, feeling no ill effects so far as the 
anesthesia is concerned. Under other circumstances, however, even with 
the most careful technique, the recovery period may be marked by retch- 
ing, nausea, and vomiting. Hematemesis sometimes occurs, and very 
rarely hemoptysis is encountered.2 Transient mental disturbances, 
amounting in some instances to mania and dementia, have been reported. 
Muscular excitement may be noted for a brief period, and in rare in- 
stances choreiform movements have been known to last for two or three 
weeks. Cerebral hemorrhage, with resulting hemoplegia, has been noted 
in persons with arteriosclerosis. Pulmonary complications ("ether- 
bronchitis" and "ether-pneumonia") are among the most frequent early 
after-effects. 
Remote After-Effects.-The remote after-effects of ether narcosis are 
not of such frequent occurrence and severity as follow the use of chloro- 
form. Many interesting observations have been made, however, particu- 
larly with reference to the results of the action of ether upon the various 
organs. 
The studies of Ross and Hawk 3 consisted primarily of an inquiry 
into the influence of diet and of a subnormal body temperature upon 
post-anesthetic glycosuria. The subjects used were dogs, and the anes- 
1 Loc. cit. 
2 Hewitt: Loc. cit., 375. 
3 Ross and Hawk: ' ' Further Studies on the Metabolic Influence of Ether 
Anaesthesia," from the Laboratory of Physiological Chemistry of the University 
of Illinois, Dec., 1911. ETHER 
197 
thesia was brought about either by means of specially prepared, so-called 
"dehydrated," ether,1 or by ether U. S. P. Two methods of administra- 
tion were employed: one a compressed air method in which the appara- 
tus concerned was similar to that of Gwathmey; whereas, in the other 
instance, the ordinary cone method was utilized. In a portion of the 
experiments a specially devised apparatus was employed to maintain the 
normal temperature of the animal during the anesthesia period. In each 
instance this period was two hours in duration. 
When fed diets, principally meat, containing from 3.3-4.1 grams of 
carbohydrate per kilogram body weight, the dogs gave no evidence of 
post-anesthetic glycosuria under any conditions, i. e., with either type 
of anesthetic, either method of administration, or after a pronounced 
lowering of the body temperature. When the carbohydrate portion of 
the diet was entirely replaced by meat, post-anesthetic glycosuria was 
observed in every instance, irrespective of the character of the anesthetic, 
the mode of its administration, or the course of the body temperature. 
All urines were examined qualitatively by means of copper and bismuth 
reduction tests, and quantitatively by means of fermentation and polar- 
ization. 
Grube 2 investigated the influence of ether narcosis upon the body 
temperature and the carbohydrate metabolism. According to his obser- 
vations, the glycosuria which follows upon the ether narcosis in dogs, 
often also in man, can be prevented by counteracting the simultaneous 
lowering of the body temperature, which is produced by the vasodilator 
effect of the ether, combined with the arrest of muscular activity. 
The conclusions of Hawk,3 after careful animal experimentation with 
reference to the effects of ether upon the urine, are as follows: 
(1) An initial diuresis proportional to the length of anesthesia fol- 
lows ether narcosis, varying from thirty minutes to four and one-half 
hours. 
(2) Ether anesthesia invariably caused the animal to lose weight 
upon the day of the narcosis. 
(3) The fractions of urine first voided after ether anesthesia pos- 
sessed specific gravities ranging from 1.024 to 1.042, as compared with 
the normal specific gravity of 1.015 to 1.019. 
1 This ether was later found by Baskerville to contain even more acetaldehyd 
than the ether U. S. P. used. Consequently, it may be concluded that the usual 
or even excessive amounts of acetaldehyd present in anesthetic ether play little 
or no part in the production of post-anesthetic glycosuria. 
2 Grube: ' ' Ueber den Einfluss der Aethernarkose auf die Korpertemperatur 
und den Kohlehydratestoffwechsel," Pfliiger's Arch. f. d. ges. Physiol., 1911, 
138, 601. 
'Hawk, P. B.: "On the Diuresis Hollowing Ether Narcosis," J. Med. Res., 
1908-1913, 203. 198 
ANESTHESIA 
Seelig 1 summarizes the result of his investigations concerning ether 
as follows: 
(1) Ether inhalation always produces a more or less marked glyco- 
suria in dogs which are fed on meat. 
(2) The glycosuria is always demonstrable during the narcosis, but 
lasts only a short time beyond it. 
(3) Persistent carbohydrate-feeding prevents the occurrence of 
glycosuria in dogs. 
(4) Suppression of an existing ether glycosuria, through subsequent 
intravenous oxygen infusion, is not feasible. 
(5) The glycosuria is associated with hyperglycemia. 
(6) The glycogen contents of the liver are greatly diminished after 
ether narcosis. 
(7) No glycosuria occurs when the ether inhalation is combined with 
a simultaneous intravenous infusion of oxygen, provided that correct 
dosage of oxygen is administered. 
(8) Intravenous introduction of CO2 does not give rise to glycosuria. 
Rohricht2 examined the urine of 100 patients who had been operated 
upon under ether narcosis, as to the appearance of glycosuria, with 
positive findings in twelve cases. He arrived at the conclusion that 
neither the operative traumatism nor the quantity of the ether admin- 
istered and the duration of the narcosis stand in a direct causative rela- 
tion to the resultant glycosuria; but that this must be interpreted as a 
consequence of an injury to the organism through the inhaled ether. 
The exact nature of this injury is problematical, Rohricht finding no 
sufficient explanation in the fat-infiltration of the liver, or in the chem- 
ical and mechanical action of ether on the blood, or in an influence upon 
the nervous organs. In his opinion, several partly unknown effects of 
the ether must coincide in order to produce the glycosuria. A glyco- 
suria-producing property of the ether can hardly be imagined in the 
absence of an individual predisposition. In his opinion, advanced age 
has a certain bearing upon the occurrence of post-narcotic glycosuria. 
Undoubtedly, however, the ether narcosis may be the cause of an abnor- 
mal composition of the urine. 
In a study of acetonuria following ether anesthesia Hamblen 3 found, 
in 120 cases etherized by the cone method, acetonuria developed in 88.5 
per cent. In the same number anesthetized by the drop method only 26 
per cent showed acetonuria. (For further discussion of this subject, see 
1Seelig: "Heber Aetherglykosurie und ihre Beeinflussung durch intravenose 
Sauerstoffinfusionen, " Arch. exp. Pathol, 1905, 52, 481. 
2 Rohricht, R.: " Klinische Beobachtungen uber Glykosurie nach Aethernar- 
kosen, " Beitr. zur Idin. Chir., 1906, 48, 535. 
3 Hamblen: ' ' The Occurrence of Acetonuria Following Ether Anesthesia, '5 
Univ. Penn., Med. Bull., June, 1909. ETHER 
199 
Chapter IX, Treatment Before, During, and After Anesthesia, p. 365, 
section on "Post-Anesthetic Toxemia.") 
Engelhardt1 affirms a specific toxic action of the narcotic agent, more 
particularly ether, and the affections of the lungs are referred by him to 
cytolytic or hemolytic processes (aside from pulmonary edema through 
overdosage, and coarse aspiration-pneumonia). The onset of pulmonary 
changes, after ether narcosis, depends, in his opinion, upon the "melting 
point" of the red blood corpuscles and the quantity of ether absorbed by 
the erythrocytes and the blood-plasm on the one hand, and upon the 
temperature of the body on the other hand. As the small quantity of 
anesthetic which has passed into the blood can rarely be ascertained, he 
emphasizes that this cell-dissolving action represents the highest de- 
gree-the only one that can be tested experimentally, however-of the 
injurious influence of the narcotic agent upon the body cells. In support 
of his argument, he mentions the fact that a decrease in the number of 
post-operative pneumonias is noted in narcosis with morphin-scopola- 
min as well as in spinal anesthesia. 
In discussing post-operative pulmonary complications and throm- 
boses after ether narcosis, Otte 2 says that excellent results were obtained 
in regard to pneumonia, bronchitis, secretion of mucus, and thrombosis. 
The narcotic was repeatedly administered in the presence of pulmonary 
complications, such as tuberculosis, asthma, or bronchitis, without any 
essential aggravation of the bronchitis, or rise of temperature. As a 
very important and useful aid in ether narcosis, as well as in all other 
inhalation narcoses, he recommends systematic inhalations of warm 
water-vapor, before and after the narcosis, preferably with an admixture 
of thymol and salicylic acid. 
ADMINISTRATION OF ETHER 
The Open or Drop Method.-The administration of ether alone by 
the drop method, and continuously on an open mask, is not as desirable 
as certain other methods. Many surgeons and anesthetists, however, 
prefer this method to any other, and for this reason the best procedure 
of administration will be fully described, but not until the necessary pre- 
liminaries have been considered. 
The Dropper.-It is better to drop the ether from the original con- 
tainer than to pour the contents into some patented or other dropper. 
No container holding over 100 grams, or, at the most, a quarter of a 
1 Engelhardt: ' ' Ziir Entstehungsursache postoperativer Pneumomen, ' ' Centr. 
Chir., 1907, No. 4, 89. 
2 Otte, A.: " Ueber die postoperativen Lungenkomplikationen und Throm- 
bosen nach Aethernarkosen, " Munch, med. Woch., 1907, No. 50, 2473. 200 
ANESTHESIA 
pound, should be used. Internes and others using original tin contain- 
ers as droppers often neglect to cut out the top and replace the same 
Fig. 62.-Dropper From Original Can, Old Form. 
with a cork after perforating this top to admit of its use as a dropper. 
In this way quite as much ether may be wasted as is used. It is more 
important to maintain the original purity of the ether used. Four good 
methods for making a dropper out of an original tin container are as 
follows: 
First: Bend a safety pin as shown in the illustration, then pass it 
through the cap on the neck of the ether can, when the free end may 
be again straight- 
ened. Then clasp 
safety pin and drop 
from either end. 
Second: A num- 
ber of pin holes are 
made in the top of 
the neck of the can. 
A small piece of sur- 
gical gauze is now 
placed over these 
holes and twisted so 
as to come to a 
point. This gauze 
prevents the ether 
from squirting out 
of the can. When 
the can is not in use a small piece of surgeon's plaster may be placed over 
the pinholes to prevent excessive evaporation; or, preferably, the top may 
be cut out and a clean velvet cork inserted. It is inadvisable to use the 
Fig. 63a.-Chloroform and Ether Containers 
for the Drop Method. ETHER 
201 
remainder of this ether, even with these precautions, if it has 
to be kept for any length of time, say, a week or more. However, 
there are occasions when only small amounts of ether are used 
Fig. 63b.-Chloroform and Ether Containers for the Drop Method. 
in an operation, and many short operations may quickly follow each other. 
In such event the container may be used until the ether is consumed. 
Third: When a new can is to be used, or the cans above described 
are to be used again, a safety pin, one inch long or more, bent in the 
middle at right angles, is placed by the side 
of the cork, and pin and cork are inserted 
into the can. (Fig. 63b.) The rate of 
flow of ether may be regulated perfectly by 
pressing the thumb against the protruding 
part of the bent pin. The cork should be 
firmly inserted to avoid its being pushed 
out by this pressure. The cork may often- 
times be used again. This, of course, de- 
pends upon its condition. 
Fourth: Notch the cork very slightly, 
place a small piece of gauze in the notch 
and insert in the neck of the can, after 
cutting out the top. Mechanical obstruc- 
tions, such as pieces of cork, may, how- 
ever, interfere with the flow of ether. The 
cork should not be used again. 
An excellent tin container, so arranged for dropping ether, has re- 
cently appeared upon the market. 
Fig. 64.-Coburn Airway 
Tube. 202 
ANESTHESIA 
Ether is also now obtainable in glass ampules, so constructed that, 
by snipping the tip thereof, they may be used as droppers; or the neck 
Fig. 65.-Glass Container for Holding Ether. 
may be cut off and the contents poured into a vaporizer. The ampules 
are made by one company of actinic and by another of anactinic glass; 
the latter protects the ether from decomposition by light (Fig. 65). 
Fig. 66.-Lumbard's Rubber Ether Blanket and Elastic Mask Holder. 
The Mask.-The usual mask consists of a wire frame and metal hoop 
for holding the gauze in place. When an ordinary ether mask is 
used without towels, gauze, or something else around the mask, much 
of the vapor is blown into the air by the patient's breath, the 
surgeons, anesthetist, and nurses getting the full benefit of it, and, in 
a private house, the disagreeable, penetrating odor will linger almost as ETHER 
203 
long as if the cone had been used. The patient gets the cold vapor that 
sinks through the mask. Everyone suffers in consequence of this crude 
and antiquated method. 
The prevention of waste and the administration of the ether in the 
most acceptable way by this method are accomplished as follows: 
The mask is covered with as many thicknesses of gauze as possible 
without interference with free respiration (from 1/16 to % of an inch in 
thickness). The patient thus receives a more perfect vapor than if only 
one or two layers of 
gauze are used, 
consequently there 
is much less irrita- 
tion to the respira- 
tory passages. 
The Yankauer 
Mask.-The Yan- 
kauer mask, of 
closely woven wire 
over which are 
stretched several 
layers of gauze, is one of the best masks for the drop method of ether or 
chloroform. 
The Ferguson Mask.-The best mask yet devised for the drop 
method for ether alone is that devised by Ferguson. It consists of a 
wire frame, so flexible that it can easily be adjusted to the face by bend- 
ing the wire between the fingers. It is covered with several thicknesses 
of gauze, which are held in place by a wire band. The unusual feature 
consists of a wire frame surrounding this gauze mask, over which is 
stretched a canton flannel bag, with a small hole either in the middle or 
on the side, depending upon whether the patient is in the dorsal or 
lateral position. This outer covering of canton flannel prevents the 
blowing of the ether vapor all over the room. The best feature of this 
mask is that it gives the patient a warmer vapor. It is really semi- 
closed, a certain amount of rebreathing taking place, but not as much as 
is usual with a rubber bag. As the mask is not air-tight, it is in a 
measure automatic, and does not require so intimate a knowledge of the 
physiological action of ether to maintain the surgical level called for by 
the operation. The patient is not subjected to cold ether vapor, as with 
the cone or ordinary mask, and consequently comes out of the anesthetic 
in a better condition. 
The Mayo brothers, of Bochester, Minn., have probably used the drop 
method of ether for a longer period of time and had a larger number of 
administrations than any other surgeons. They report between 14,000 
and 20,000 administrations. The following is their method: 
Fig. 67.-Yankauer-Gwathmey Dbop and Vapor Mask. 204 
ANESTHESIA 
"All patients are anes- 
thetized on the operating table 
in the operating room, while 
preparation of the patient is 
going on at the same time. 
This is one of the important 
factors in producing a rapid 
surgical narcosis. 
"An acute cold is a contra- 
indication to any anesthetic, 
but as soon as the cold be- 
comes chronic there is not 
much danger from etheriza- 
tion, and, instead of operating 
during an acute cold and giv- 
ing chloroform (unless in an 
emergency), we wait a few 
days until the acute attack has 
passed, and then they are as 
good subjects for ether as for 
any other anesthetic. Chronic 
bronchitis is often improved 
by an anesthetic. 
"Use a four-ounce ether 
can and fit an ordinary cork 
with a groove on either side 
into its mouth, fill one groove 
with absorbent cotton and let 
it extend out of the can about 
one inch. One can regulate 
the drop easily by the manner 
in which the point is clipped. 
We usually fix two cans, one 
with a large dropper, and use 
it until the patient is fully 
under the anesthetic, and then 
change to the other can with 
the small dropper, and con- 
tinue its use during the opera- 
tion. The inhaler used is the 
improved Esmarch, with two thicknesses of stockinet (frame boiled and 
stockinet changed after each patient). We drop as slowly and carefully 
in giving the ether as though it were chloroform, until the patient's face 
is flushed, and then a few layers of surgeon's gauze are added, and the 
Fig. 68.-The Ferguson Mask. A, B, C, E, 
wire frame; E, retaining wire; D, gauze; 
F, canton flannel hood; G, opening in hood 
for air; also used to drop anesthetic on to D; 
K, open chamber; M, under surface of the 
mask next to patient's face. ETHER 
205 
ether is given a trifle faster until the patient is surgically etherized; then 
return is made to the same covering as at the start, and the regular drop 
continued throughout the operation. A patient can be brought under 
ether in this way in from three to five minutes, and, when ready, patients 
do better if the operation is started at once. 
"As it requires very little ether to keep a patient surgically etherized, 
one can change to the small dropper during the operation. A much 
deeper narcosis is required to start an operation or to make the incision 
than later on when the operation is in progress. Patients should be 
prepared for each stage of the anesthesia with an explanation of just 
how the anesthetic is expected to affect him; 'talk him to sleep,' with 
the addition of as little ether as possible. We have one rule: patients 
are not allowed to talk, as by talking or counting patients are more apt 
to become noisy and boisterous. Never bid a patient to 'breathe deep,' 
for in so doing a feeling of suffocation is sure to follow, and the patient 
is also apt to struggle." 1 
Davis gives the following as his method of administration of ether 
by the drop method: 2 
"Place a piece of rubber protector over the patient's eyes to shield 
them from the ether vapor. Protect the face with a moist towel or gauze 
which extends over the rubber tissue and around the chin. Use a wire 
frame mask similar to the Esmarch chloroform inhaler, only larger, in 
order to give more space under the inhaler for the mixture of air and 
ether. Cover the wire frame with one or two layers of stockinet or 
several layers of gauze. The gauze should be thrown away and the wire 
frame boiled after each administration. 
"Apply the mask to the patient's face and administer the ether drop 
by drop, very slowly at first, then gradually increasing as the patient is 
able to take the stronger vapor. When the patient cannot respond to 
questions, a moist towel or gauze is wrapped snugly around the mask, 
leaving a small area in the center for the free passage of air through the 
gauze. By this method the air is prevented from escaping around the 
edges of the mask, and is made to pass through the ether-laden gauze. 
The ether should not be dropped down faster than the patient can com- 
fortably breathe it in. Never be in a hurry to put the patient to sleep. 
Do not let an impatient operator worry or hurry you on, as the welfare 
of the patient depends upon the slow and gradual ratio of the increasing 
concentration of the ether-vapor. The patient will become unconscious 
in two or three minutes, and should be ready for the operator in ten 
minutes. After the patient has become completely anesthetized very 
1 Magaw, Alice: "A Review of ' Over Fourteen Thousand Surgical Anesthe- 
sias, ' " Surg. Gyn. and Obst., Dec., 1906, 795-799. 
2 Davis, S. Griffith: ' ' The Administration of Ether by the Drop Method, '' 
Md. Med. J., May, 1907. ANESTHESIA 
206 
little ether, dropped slowly, but continuously will suffice to maintain the 
proper condition. Having reached surgical anesthesia, the further efforts 
of the anesthetist should be devoted to observing the respiration, pulse, 
pupils, and the patient's general condition, and to prevent him from 
passing into that dread stage of respiratory paralysis. The respiration 
should be quiet, with perhaps a very slight snore. Panting and rapid 
breathing, or irregular stertorous breathing, indicate that the patient 
needs more air." 
Ethyl Chlorid Ether Sequence by the Drop Method.-Using an 
ordinary Esmarch inhaler, with a lozenge-shaped aperture cut in the 
Fig. 69.-Davis Dropper for Insertion in Original Container. 
rubber tissue which is placed over the gauze covering the mask, encircle 
the mask with a towel so as to have more or less rebreathing. Com- 
mence dropping the ethyl chlorid upon the mask until the patient 
reaches unconsciousness. Now begin dropping ether. If the patient 
swallows, or shows any signs of returning consciousness, continue drop- 
ping the ethyl chlorid until this disappears, then recommence with 
the ether. Continue in this way until full surgical narcosis is reached, 
when the ethyl chlorid may be discontinued. The ether may now be 
continued by the drop method, as already outlined, or ethyl chlorid 
may be sprayed intermittently for five to ten seconds on the mask until 
the second stage is reached, when a switch may be made to ether. If 
signs of consciousness ensue, ethyl chlorid must be continued to be inter- 
mittently sprayed, the ether at the same time being dropped upon the 
mask. 
The Ethyl Chlorid-Ether-Chloroform Sequence.-The change to 
chloroform should not be made until the patient is in full ether anes- 
thesia. The anesthetist should then allow the reflexes to become slightly 
active and the chloroform should be commenced very gradually. The ETHER 
207 
change to chloroform should be made if there is profuse secretion of 
mucus and saliva following the ethyl chlorid and ether. 
The Ethyl Chlorid-Ether Sequence by the Closed Method.-The 
ethyl chlorid anesthesia may be induced, as fully given in the chapter 
upon Ethyl Chlorid, and a switch can then be made to ether by 
revolving the ether chamber. It is safer and better from every stand- 
point to admit the ethyl chlorid from the bottom of the bag instead of 
near the patient's face. Two to five c.c. of ethyl chlorid are usually suffi- 
cient to obtain the anesthesia desired before turning on the ether. 
The advantages of the ethyl chlorid-ether sequence are, principally, 
the rapidity of induction and freedom from the second, or struggling, 
stage of anesthesia. This sequence is usually much quicker than the 
nitrous oxid-ether sequence. 
Whenever the open or closed method of ethyl chlorid-ether is used, 
ether can be either dropped or turned on very gradually much earlier 
than in the nitrous oxid-ether sequence. 
Warning! With the ethyl chlorid-ether sequence it is unnecessary 
to carry the patient to full surgical narcosis. The anesthesia induced 
by ethyl chlorid is usually quiet and without either cyanosis or stertor. 
There is, however, a possibility of danger in the initial stages from sink- 
ing the patient too deep. Whenever the lid reflex is entirely abolished a 
change should be made. It is unnecessary to wait for the cornea to 
become insensitive. Ethyl chlorid-ether sequence is especially indicated 
for children, and for nervous individuals, who might be frightened by 
a mask or bag being placed over the face. 
Chloroform-Ether Sequence.-When morphin has been given as a 
preliminary, and the induction is preceded by the use of a few drops of 
farina cologne or an alcoholic solution of oil of bitter orange peel, a 
remarkable difference in all the reflexes may be noted as the patient goes 
under the anesthetic. The induction will, under these circumstances, 
proceed to the second stage with chloroform. When this stage is reached, 
give one drop of ether every thirty seconds for one or two minutes, then 
alternate the drops of ether with the chloroform, and, finally, as the 
third stage is reached, continue with ether unless the reflexes become 
active, when a few drops (3-8) of chloroform can be given and the ether 
continued. This is the safest way to induce anesthesia when ether is the 
terminal anesthetic, for the simple reason that the struggling stage will 
not occur if careful attention is given to the small details. Ether thus 
replaces chloroform at what is known as the dangerous stage of anes- 
thesia. During the last few minutes of the anesthesia chloroform may 
again replace the ether. In this way the patient comes out of the anes- 
thetic without noticing the odor of ether. 
The change from ether to chloroform must take place when the 
reflexes are slightly active, and in the following manner: Commence 208 
ANESTHESIA 
with one drop of chloroform every ten seconds and note whether the 
reflexes are deepened or not, then change to two drops, and then to three 
drops every ten seconds. It will be found that the patient can be kept 
lightly under in this way, and between the second and third stages with- 
out causing any nausea or vomiting, provided some preliminary medica- 
tion has been given. 
Anesthol.-Neef's 1 definition of anesthol is "chloroform modified to 
increase its safety without impairing its anesthetic usefulness." For a 
full discussion of anesthol see pages 276-278. 
The Anesthol-Ether Sequence by the Drop Method.-In the anesthol- 
ether sequence, as well as in the ethyl chlorid-ether sequence, a factor of 
safety is preliminary medication with morphin. The New York Ger- 
man Hospital's system is to give about *4 of a grain of morphin one- 
half hour before narcosis. Hellman,2 anesthetist to the German Hos- 
pital, prefers pantopon, % of a grain three-quarters of an hour before the 
operation, and repeats this just before the operation. In certain selected 
cases he gives grain of hyoscin with the first dose. Hellman states 
that, while he thoroughly dislikes morphin before anesthesia, in panto- 
pon he has a safe and reliable aid. 
Neef states:3 "The odor of the anesthetic may become markedly 
repugnant to those who have previously been under its influence, and 
assurance on this point may help to bring about a prompt decision. A 
few drops of a 10 per cent emulsion of Persian oil of rose in deodorized 
alcohol on the mask is an efficient way of eliminating this disagreeable 
element in the induction of anesthesia." 
Using an ordinary chloroform or some similar mask, the anesthesia 
is commenced with one to three drops of the oil of orange, which is then 
followed by the anesthol and continued with ether. This is, in the 
authors' opinion, safer than the chloroform or ethyl chlorid-ether se- 
quence, and much safer than the continuous use of ether by the drop 
method for the following reasons: 
First: Anesthol is less "smelly" than chloroform or ether, and for 
this reason no doubt is less irritating to the upper air passages. 
Second: The anesthesia is induced a little quicker than by chloro- 
form. 
Third: Both experimental and clinical experience justify the state- 
ment that next to nitrous oxid it is probably the safest induction anes- 
thetic. 
The administration is conducted as follows: With the mask encir- 
1 Neef, F. E.: "Surgical Essentials," Am. J. Surg., April, 1912. 
2 Hellman, A. M.; "The Use of a New Opium Preparation Before Anes- 
thesia-A Preliminary Note with a Report of 50 Cases," J. Am. Med. Assn., Jan., 
1912, n. s. 7, No. 1, 39-45. 
3 Loc. cit. ETHER 
209 
cled by a towel, the anesthol is administered drop by drop, say one drop 
the first ten seconds, two drops the next ten seconds, etc. As soon as 
the patient becomes accustomed to the anesthetic vapor the drops may be 
rapidly increased. If the patient's breathing is shallow a few drops of 
ether from time to time will stimulate and keep up the respiratory func- 
tion. As the stage of primary anesthesia or unconsciousness is reached, 
the ether must be pushed as rapidly as the condition of the upper air 
passages of the patient permits. If ether is given at this time, drop by 
drop, and there is no swallowing reflex, it should be continued; other- 
wise, if there are swallowing reflexes, anesthol may be continued for ten 
or twenty seconds and then the ether recommenced. 
If there is objection made by the patient to the vapor strength, as 
indicated by the turning of the head or holding of the breath, the mask 
may be slightly lifted from the face and then replaced. If there is 
marked pallor of the face, and the pulse is weak during the induction 
stage, the anesthol should be immediately replaced by ether. Cyanosis 
should not be allowed during the induction period. If this occurs a 
rearrangement of the air passages by moving the head to right or left, 
or by supporting the chin, or raising slightly the lower j aw, or, in elderly 
people, supporting the aloe of the nose, will correct this trouble. The 
usual amount of anesthol necessary to induce anesthesia when morphin 
has been given is 15 to 25 c.c. 
The average time, when morphin or some preliminary medication 
has been given, is five minutes; without this preliminary, it is eight 
minutes. When properly given the morphin-anesthol-ether sequence is 
induced in over 90 per cent of cases with no stage of excitement what- 
ever. The induction stage must not be prolonged too long, as vomiting 
is apt to occur. 
After the change has been made to ether, if it is desirable to deepen 
the anesthesia for any reason, instead of crowding the ether and thereby 
producing unnecessary salivation, a few drops of anesthol will quickly 
and safely deepen the anesthesia, without the salivary gland activity 
that would be produced by an amount of ether sufficient to obtain the 
relaxation called for. 
A glance at the statistics for the anesthol-ether sequence will fully 
convince anyone of the safety and desirability of this sequence. At the 
German Hospital, in the year 1905, 149 cases were given anesthesia by 
this method, increasing in number each year until the year 1911, when 
there were 919. 
The Ether Rausch.-Coughlin1 recently described the "ether 
rausch." We quote voluminously from Coughlin's article. 
The ether rausch, according to Coughlin, was used in this country 
twenty-five years ago. Lindner, of Dresden, has used it more than five 
'Coughlin, William T.: J. Am. Med. Assn., July 1, 1911, 17, 18. 210 
ANESTHESIA 
thousand times. Coughlin is using it at the College Clinic, St. Louis 
University Medical School. He reports two hundred cases, in some of 
which he acted both as the anesthetist and operator. The only fail- 
A. Wire Frame of the Mask. 
B. The Pad of Gauze in Position. 
C. The Frame Covered with Oiled Silk 
Fig. 70.-The Ether Rausch. 
ures were in patients who refused to proceed beyond the first two or 
three inhalations. He recommends it for all minor surgical operations 
that can be better done if the patient feels no pain, such as opening 
abscesses, setting fractures, reducing dislocations, and removing ingrow- 
ing toe-nails. From his experience he states that it is contraindicated 
in any operation which requires more than five minutes' time, or in 
those in which general relaxation is necessary. Pale, flabby children, 211 
ETHER 
chronic bronchitis, emphysema, marked arteriosclerosis, or diseases of 
the pulmonary or cardiovascular system also contraindicate its use. 
Coughlin thinks it is preferable to any local anesthetic for the special 
cases outlined. In many cases of great local inflammation the injection 
of a hypodermic needle gives almost as much pain as the relief it affords 
during the actual incision. The ordinary Esmarch inhaler is not satis- 
factory, as it does not allow enough ether to be introduced at one time 
to produce general anesthesia without very great irritation of the upper 
air passages. The mask, therefore, must be a large one; large enough 
to fit the outside of the face. Air must be rigidly excluded as far as 
possible. An ordinary Derby hat has been frequently used by Coughlin 
for this purpose. It is placed over the patient's face with the saturated 
ether gauze attached to the crown by a safety pin. Wet towels are placed 
around the undersides of the hat, thus excluding all air. The mask 
generally used, however, is a very large wire frame, the margin of which 
fits closely the outer margin of the face. A pad of gauze is placed at 
the top of this mask, which is then saturated with ether and then the 
wire frame is covered with oiled silk, the points of contact with the mask 
and face being filled in with the wet towels. The patient is told that 
the only unpleasant feature is the smell of the ether. He is now re- 
quested to raise his arm and to keep it raised as long as possible. 
After placing the mask over the face the patient is told to breathe 
deeply. At about the twelfth inhalation the arm wavers and begins to 
fall. The mask is removed and at once the operation is begun and 
quickly finished. The patient may be cyanosed at first, but this quickly 
disappears, and he comes out of the anesthetic quietly. In the particular 
case related by Coughlin the patient was eating dinner twenty minutes 
after the operation was concluded.1 
The Semi-Closed Method.-The drop method of ether just described 
can be changed quickly into the semi-closed method in the following 
manner: 
Have the mask with towels arranged according to Davis's method for 
administering drop by drop. 
Place another towel around the mask and face and then place an 
additional towel over the opening in which the ether is dropped. This 
will insure, more or less, to-and-fro breathing. The upper towel can be 
removed from time to time, when half a dram to one dram of ether 
may be poured upon additional pieces of gauze placed upon the top of 
the mask. The upper towel is now to be quickly replaced. 
The rebreathing will continue for two to four minutes, when ether 
may be again added and the towel replaced as before. This procedure is 
1 As ethyl chlorid has a longer stage of analgesia than any other inhalation 
anesthetic theoretically, at least, it should be preferable to ether for the 
' ' rausch. ' ' 212 
ANESTHESIA 
indicated when, for any reason, it is hard to maintain a proper degree 
of anesthesia by the ordinary drop method. 
Towel and Paper Cones.-These cones are still used in a great many 
hospitals, and one of the best methods of making them is described 
by Miller (Providence, R. I.) as the Handkerchief Method, and is fully 
illustrated. 
The Handkerchief Method of Administering Ether.-"This is the 
result of a search for a simple, clean, and otherwise practical appliance 
for the administration of ether by the internes of hospitals. It has been 
used with satisfaction in over 20,000 cases. 
"The appliance consists of: (1) an open cone; (2) a ring of sheet 
metal; (3) a handkerchief and diaphragm of gauze. 
"The cone is made from three sheets of newspaper folded to form a 
strip six inches wide. (Fig. 71 A.) This strip is folded upon itself 
to form a funnel which, when flattened out, has a breadth of six inches. 
(Fig. 71 B.) The funnel is covered with a clean towel which meas- 
ures about eighteen by twenty inches. The towel is placed on a flat 
surface. The newspaper funnel is placed upon the towel with one end 
of the funnel at the middle of the towel. The towel is folded about the 
outside of the funnel. (Fig. 71 C.) The long end of the towel is 
pushed through the funnel (Fig. 71 D) and folded over the end of 
the funnel. (Fig. 71 E.) The short end of the towel is folded inside 
the funnel. (Fig. 71 F.) 
"A strip of sheet brass, silver plated, two inches wide and fif- 
teen inches long, is formed into a ring which is adjustable in size. (Fig. 
71 G.) The ring is sterilized by boiling. 
"A diaphragm composed of eight layers of No. 1 sterile surgical gauze 
is placed over one end of the cone. (Fig. 71 H.) The metal ring is 
adjusted to a size a little smaller than the inside of the cone. It is 
placed over the diaphragm and pushed inside the cone, carrying the 
diaphragm to the full depth of the ring. (Fig. 71 I.) The ring is 
pulled open as far as possible, fixing the diaphragm in the cone. (Fig. 
71 J.) There is thus formed a chamber, its sides formed of the thin 
sheet of metal, its floor formed of eight layers of gauze, and its roof free. 
The roof of this chamber is the distal end of the cone. A handkerchief 
of No. 1 sterile surgical gauze is well shaken out and placed in the 
chamber. (Fig. 71 K.) The two sides of the chamber are drawn 
together and held by a safety pin passing through the two sides of the 
cone close to the metal ring. (Fig. 71 L.) At the proximal end of 
the cone is an air space four inches deep. The temperature in this space 
during an ordinary administration of ether is about 88° F. (Fig. 71 M.) 
"Before beginning the administration of ether with this cone, the 
gauze handkerchief is drawn partially out from the chamber, leaving a 
clear airway at one end of the chamber. (Fig. 71 L.) On the gauze A 
B 
C 
D 
E 
F 
Fig. 71a-f.-The Handkerchief Method. G 
H 
I 
J 
K 
L 
Fig. 71g-l.-The Handkerchief Method-Continued. M 
N 
o 
Fig. 71m-o.-The Handkerchief Method-Continued. 216 
ANESTHESIA 
diaphragm are placed a few drops of the oil of orange. The proximal 
end of the cone is fitted to the patient's face, and he is allowed to take 
several breaths through the cone. 
Ether is then added to the gauze 
handkerchief, drop by drop, until 
the patient has become accustomed 
to the vapor. (Fig. 71 N.) Then 
the gauze handkerchief is pushed 
into the chamber, so as to completely 
fill it, and ether is added gradually 
until anesthesia is complete. (Fig. 
71 0.) 
"If this proceeding is carried out 
slowly there is no coughing, choking, 
or feeling of suffocation. The sup- 
ply of air necessary for respiration 
is not interfered with, and the 
amount of ether vapor inspired is 
imperceptibly increased. 
"During the operation ether is 
added constantly, drop by drop, or 
poured on the handkerchief fre- 
quently in small quantities, at the 
distal end of the cone, or through 
the proximal end, on removing the 
cone momentarily from the patient's face. The handkerchief is frequently 
taken from its chamber and shaken out. In this way the evaporating 
Fig. 72.-Cone Adjusted to the Face. 
There is ample air space above, and 
nose space below the frame. Right 
hand supports the chin, to prevent 
relaxation of the jaw and prolapse of 
the tongue. Left hand folds the top 
of cone to increase the amount in- 
spired. (Gallant: Med. Record, Dec., 
1899.) 
Fig. 73.-Allis Inhaler with Soft 
Rubber Cover for Semi - open 
Method. 
Fig. 74.-Allis Inhaler, Metal with 
Rubber Cushion for Face and 
Gauze Diaphragm. ETHER 
217 
surface is kept free and the amount of ether remaining on the handker- 
chief is frequently noted. The eyes are not covered. 
"The handkerchief method has the following theoretical advantages: 
(1) simplicity; (2) cleanliness; (3) continuous administration of 
ether; (4) evaporating surface at some distance 
from the patient's face; (5) no interference with 
free air supply; (6) warmed ether vapor; (7) 
steady, constant control over the amount of 
ether vapor inspired; (8) economy; no ether is 
wasted by soaking into the cone, or by running 
down the neck of the patient. 
"This method has also the following practical 
advantages: 
"(1) Inexperienced anesthetizers have been 
quickly taught to use the method satisfactorily. 
"(2) Anesthetizers who have been accustomed 
to the use of other methods have all preferred the 
handkerchief method after a short trial. 
"(3) Patients who have taken ether badly in 
other ways have been smoothly anesthetized by the 
handkerchief method." 
When using these cones, or any other semi-closed or closed method 
of ether, it is always best to begin the administration with an open mask 
by pouring one or two drops of the oil of orange and then proceed- 
ing to the drop method as described by Dr. Davis. As the patient 
reaches surgical anesthesia, change to the cone mask, upon which has 
been placed one or two drams of ether; continue adding the ether from 
time to time as the condition of the patient demands. 
The Closed Method.- 
The closed method of ad- 
ministering ether was the 
immediate precursor of the 
gas-ether sequence. It was 
developed in England in 
1872, and has been em- 
ployed successfully in thou- 
sands of cases since that 
time. Dr. Clover was the 
first to develop an appara- 
tus that received extensive recognition. As the method of administration 
is the same with any mask and bag, regardless of the name of the in- 
haler, directions will be given suitable for any apparatus that may be 
used. 
Any inhaler for the administration of the nitrous oxid-ether se- 
Fig. 75.-The Esmarch 
Inhaler. 
Fig. 76.-Comparative Size of Bores of 
Inhalers (Luke) . 218 
ANESTHESIA 
quence should have a large 
bore. The two illustra- 
tions taken from Luke 
make further comment 
unnecessary. 
The Nitrous Oxid- 
Ether Sequence.-The ni- 
trous oxid-ether sequence, 
which consists in giving 
one or two bags full of 
gas and, while the patient 
is unconscious, gradually 
turning on the ether, was 
probably introduced into 
this country by Thomas 
Bennett, of New York 
City. 
The Bennett In- 
haler. - This apparatus 
consists of a face-piece 
with a rubber cushion, a 
gas cylinder and a cylin- 
der for holding the valves 
used in administering gas, 
and two bags. The ap- 
paratus can be taken apart 
and used for the closed 
administration of ether 
alone, or for gas and air, 
or for the gas-ether se- 
quence. Nearly all of the 
gas - ether apparatus in 
America are probably 
modifications of this in- 
haler. 
The Gwathmey In- 
haler. - The Gwathmey 
inhaler, for the adminis- 
tration of the nitrous 
oxid-ether sequence, is a 
modification of the Ben- 
nett inhaler. It consists 
of a face-piece with expiratory valves, one cylinder for the passage of 
gas alone or through ether, or the continuance of the administration 
Fig. 77.-Bennett's Nitrous Oxid-Ether Ap- 
paratus: Ether Inhaler. 
Fig. 78.-Bennett's Nitrous Oxid-Ether Appa- 
ratus: Gas Inhaler. 
Fig. 79.-Bennett's Nitrous Oxid-Ether Appa- 
ratus: Gas and Ether Inhaler. ETHER 
219 
with ether alone by the closed method, and a chimneypiece contain- 
ing an inspiratory and expiratory valve. These valves can be easily 
pulled out of the way by a sliding collar, so that to-and-fro breathing 
Fig. 80.-The Gwathmey Inhaler Open. 
can be instituted at any time. A rubber bag is attached to this chim- 
neypiece. At the other end of the bag a rubber tube with a stop- 
cock connects the bag to the gas cylinder. If the Gatch method 
of administration of gas and oxygen is to be used, a Y-piece con- 
nects the nitrous oxid and oxygen cylinders to the bag. The appara- 
tus is reduced in weight 
and bulk to nearly one- 
half that of the Bennett 
apparatus, having one 
cylinder and one bag. The 
object of the nitrous oxid- 
ether sequence is to avoid 
the first and second stages 
of ether narcosis with its 
preliminary excitement, 
struggling, coughing, hold- 
ing the breath, swallowing, 
and all other disagreeable 
and disgusting effects that 
were formerly connected 
with this stage of etheriza- 
tion, and to enter imme- 
diately into the third stage for surgical anesthesia. The patient is 
thus enabled to take advantage of one of the safest general anesthetics 
Fig. 81.-The Gwathmey Inhaler Closed 220 
ANESTHESIA 
in the most agreeable manner possible, and with the least physical and 
nervous strain. It is the exception for the patient to show any excite- 
ment whatever, and deep anesthesia is generally reached in about three 
minutes. 
The Furniss Gas-Ether Inhaler.-This inhaler consists of exactly 
the same number of pieces as the Gwathmey inhaler, and differs only in 
Fig. 82.-Gwathmey Nitrous Oxid-Ether Apparatus. 
minor details. In purchasing any apparatus for the administration of 
nitrous oxid and ether in sequence, the purchaser should bear in mind 
one general rule governing the safety of the method of administration, 
and that is the size of the aperture through which the patient breathes. 
(See Fig. 76.) 
As the technique for the administration of the gas-ether sequence is 
practically the same for all three inhalers, general directions applicable 
to all three inhalers follow. 
The distinctive feature of the Gwathmey gas-ether inhaler is that, 
as the ether chamber is turned on, the ether can escape into the bag only 
-the opening toward the patient's face being still closed. This con- ETHER 
221 
tinues until the ether chamber is one-half on, at which time it begins to 
show at the opening toward the patient's face. The patient thus gets a 
more uniform and diluted ether vapor than if both openings of the 
ether chamber appeared at the same time. This makes it possible to 
make the change to ether without the patient swallowing or showing 
other recognition of the change. 
The Davis Inhaler.-This inhaler is for the gas-ether sequence or 
the ethyl chlorid-ether sequence; the ether in every instance is given by 
the drop method. The 
apparatus is a perfect 
one for the purposes 
for which it is used. 
Davis was probably 
the first in America 
to get out an appara- 
tus for the adminis- 
tration of ether by the 
closed drop method. 
Technique of the 
Nitrous Oxid-Ether 
Sequence.-First: Fill 
the rubber bag with 
gas. It is well to 
have the gas bag at- 
tached to the nitrous 
oxid cylinder through- 
out the operation, so 
that a change can be 
made in the gas mix- 
ture or additional nitrous oxid added to the bag at any time. 
Second: Place two to four drams of ether in the ether chamber. 
Be careful to have the ether chamber so arranged that the odor will not 
penetrate the face-piece or other chambers of the inhaler. 
Third: See that the air cushion on the face-piece is partly inflated. 
If this cushion is too tightly inflated it will not be as effective in exclud- 
ing the air as when it is only partly inflated. 
Fourth: Place the mask gently upon the patient's face, having first 
removed all pillows. Have the patient breathe through the valves or 
airway once or twice before turning on the gas. When the gas is 
turned on, it should enter the inhaler quietly. (It will not do this if 
the bag is overdistended.) Have the patient breathe one bag of gas 
through valves. Then turn to to-and-fro breathing, and, if necessary, 
refill the bag again with gas. The patient will now be unconscious, 
provided no air has been allowed to enter the inhaler between the face 
Fig. 83.-The Fubniss Nitrous Oxid-Ether Apparatus. 222 
ANESTHESIA 
and mask or any other part of the apparatus. Now begin turning on 
the ether very, very slowly. If the patient coughs, swallows, or holds 
the breath, turn off the ether and allow a little rebreathing, and then 
begin with the ether again. If the patient still rebels, more nitrous 
oxid should be added in the bag. When the ether chamber is on full 
the patient should be in deep sur- 
gical anesthesia, which should be in 
from two to three minutes, depend- 
Figs. 84 and 85.-The Davis Apparatus, Showing Inhaler for Ethyl Chlorid- 
Ether Sequence by the Closed Drop Method. 
ing upon the patient. Surgical anesthesia is usually indicated by a slight 
snore. A breath of air may now be admitted by raising the mask from 
the face on inspiration and replacing again so as to catch the expiration 
of the patient in the bag. The expired air thus passes through the ether 
chamber and keeps the bag full of warm ether vapor. A breath of fresh 
air may be admitted every two to six breaths, according to the condition 
of the patient. One or two drams of ether poured from the container into 
a minim glass should be added every two and one-half minutes. This may 
be necessary for the first five or ten minutes; after that, a dram every 
three minutes will be all that is necessary with the majority of patients. 
In very cold weather it is always best to place the inhaler upon a ETHER 
223 
radiator or stove or in 
front of a register, or to 
dip it in hot water before 
commencing the a n e s - 
thesia. 
Caution! With any 
closed inhaler never allow 
the bag to become deflated, 
otherwise the patient at- 
tempts to breathe from the 
vacuum, and a tremendous 
strain is immediately 
thrown upon the respira- 
tory and circulatory sys- 
tems, resulting in shock 
and collapse, if unnoticed. 
Nitrous Oxid - Ether - 
Chloroform Sequence.- 
For all operations lasting 
over one hour it is well to 
change to chloroform or 
ether on an open mask for 
the last ten or fifteen min- 
utes. The change to chlo- 
roform should be made 
when the reflexes are 
slightly active. Very small 
amounts of chloroform 
will be necessary to main- 
tain the narcosis. If at 
any time the patient be- 
comes pale or shows signs 
of shock from any cause, 
ether by the drop method 
should be immediately 
substituted for the chloro- 
form. The indications for 
a change from the closed 
method to the open would 
be rapid respirations or 
marked cyanosis. Deep 
anesthesia is easily and 
safely maintained with 
ether by the closed method. 
Fig. 86.-Davis Apparatus for Gas-Ether or 
Ethyl Chlorid-Ether by Drop Method. 
Fig. 87.-Oden-Foshee Adjustable 
Ether Drop Cup 224 
ANESTHESIA 
The pulse is usually full and bounding, the respirations are deep, and 
the face is flushed. Unless the change to chloroform is made toward 
the close of the operation, the patient does not usually come out of 
Fig. 88.-Davis Heater with the Gwathmey Three-Bottle Vapor Inhaler. 
this method of anesthesia as quietly as if this change had not been 
made. There does not seem to be the danger attached to the adminis- 
tration of chloroform in this way after the circulatory and respiratory 
Fig. 89.-Vapor Mask. A. The mask, one-third size. B. Rubber covering for the mask, 
which helps to prevent cooling and waste of the anesthetic. 
A. 
B. 
centers have been stimulated by the nitrous oxid and ether. The 
change to chloroform may be made immediately after reaching full 
ether anesthesia if for any reason it is desired to give the smallest 
amount of ether and at the same time avoid the dangers of the initial 
stages of chloroformization. ETHER 
225 
The Vapor Method of Anesthesia.1-The vapor method is one in 
which air, oxygenated air, oxygen, or other gas passes either over or 
Fig. 90.-Top of Three-Bottle Vapor Inhaleb. 
through the anesthetic agent, or the anesthetic is allowed to drip into the 
current of air and is thus vaporized before being delivered to the pa- 
tient. The term distin- 
guishes it immediately from 
the drop method, where the 
anesthetic is placed upon 
gauze or other material and 
is vaporized by the patient. 
When the vapor is car- 
ried by tube to the pharynx 
or trachea it is called endo- 
pharyngeal or endotracheal 
insufflation, the word insuf- 
flation meaning "the blow- 
ing of powder (or gas) into 
a cavity." 2 
Endopharyngeal, endo- 
tracheal, and rectal anes- 
thesia are modified forms of 
the vapor method of admin- 
Fig. 91.-Diagram of Top of Three- 
Bottle Inhaler. 
1 For a discussion of the vapor method by chloroform, see Chapter VII. 
' Gould: ' ' Medical Dictionary. ' ' ANESTHESIA 
226 
istration. Junker's small chloroform bottle, operated by a hand atomizer, 
was probably the first vapor apparatus. The reasons for the evolution of 
the administration of ether from the drop and cone to the vapor method 
have been aptly described as follows: "Until within a very few years ether 
has suffered from an evil reputation with patients despite its indescriba- 
ble beneficence. This reputation has been due in no small degree to the 
Fig. 92.-Combination Machine.-Where the air pressure (which is here attached to 
mouth gag) may also be used for anesthesia, and the suction for the blood and 
secretions. It is especially valuable for adenoid and tonsil operations. 
manner of its administration. The liquid ether has been poured or 
dropped on a sponge or other absorbent material, and the sponge placed 
in a glass, metal, or rubber container called a cone. This in turn was 
placed more or less insistently and abruptly over the mouth and nose, 
and inhalation of the suffocating fumes forced until unconsciousness 
ensued. Such a proceeding had everything to make it intolerable to 
the sufferer, and was endured only to afford escape from a greater 
horror-the pain of operation." 
Warmed Ether Vapor.1-Ether vapor may be delivered to the patient 
warmed to room or body temperature, as conditions demand, by so 
many different methods that there is no longer a question of the pa- 
1 For detailed discussion of warming the anesthetic vapor, see p. 71. ETHER 
227 
tient's inhaling a warmed vapor. The value of employing warmed 
ether vapor is, however, still doubted by some practitioners. 
When the closed vapor method is used the temperature of the ether 
vapor is increased to from ten to twenty degrees, so that, when inhaled, 
Fig. 93.-Endopharyngeal Tubes for Maintaining Insufflation Anesthesia. 
(Lumbard.) 
the vapor is practically at room temperature. With the open method 
the ether vapor is usually warmed by being passed over or through hot 
water. The condition of the patient, the season, and the locality de- 
termine whether or not the vapor should be warmed. A patient whose 
vitality is exhausted, and who may be already in a state of shock, needs 
artificial heat from every source to prevent a further decrease in body 
Fig. 94.-Glass Nasal Tubes for General Anesthesia. (Lumbard.) 
temperature. On the other hand, it would be entirely unnecessary to 
heat the vapor for any ordinary operation during very hot weather. 
Between these two extremes there is a mean of temperature (usu- 
ally room temperature), at which experience has taught that all re- 
quirements of safe anesthesia are met. 228 
ANESTHESIA 
It may be of interest in this connection to note the experience of 
other observers. 
Lawen 1 is convinced that chilling is one of the essential contributing 
Fig. 95.-Junker Inhaler. (1) Uncovered mask and hand pump attached. (2) Vapor 
mask covered. (3) Tubes for mouth work. (4) Sponge holder. 
factors to post-operative complications. In twenty-seven reported cases 
with an apparatus for warming the fumes, the results were excellent. 
Joss 2 finds that ether cools the air inhaled 33° to 44° below the 
temperature of the room. The cooled air undoubtedly lowers the re- 
1 Miinch. med. Woch., Oct. 3, 1911, 58, No. 40, 2097. 
3 Mitteil. Grenz. Med. und Chir., Jena, 1911, SS, 528. ETHER 
229 
sisting powers of the cilia of the ciliated epithelium lining the upper 
air passages, when these passages become chilled. Infection is more 
liable to find its way into the finer air passages, as salivation increases 
under the chilled anesthetic. 
Fig. 96.-Lumbard's Glass Nasal Tubes (A and B). Same Attached to Drum 
for Drop Method of Ether-Chloroform (C). 
Hervey,1 after demonstrating that ether is warmed when inhaled 
by the patient, sums up his experience with warmed ether as follows: 
"(1) The administration of ether vaporized at a distance from the 
patient, the so-called closed method, is a distinct advance, 
whether warmed or not. 
"(2) The vapor acts with increased rapidity proportional to its 
warmth. 
"(3) Placid breathing, resembling natural sleep during anesthesia, is 
often an index of nerve competence, and this efficiency is 
weakened and disturbed by algid anesthetic irritations. 
lN. Y. Med. J., Feb. 15, 1913. Fig. 97.-Three-Bottle Vapor Apparatus Connected with Electric Heateb and 
Vapor Mask. 
Fig. 98.-Foot Pump Attached to Three-Bottle Vapor Inhaler The vapor passes 
through hollow tubes welded to mouth-gag. ETHER 
231 
"(4) Ether amounts will average less than by other methods, as 
shown by statistics of hospital expense. 
"(5) Patients awaken with less distress and with a marked favorable 
difference in appearance. 
"(6) It is suitable for extreme infancy and old age. 
"(7) Dryness of the throat is never complained of unless oxygen 
has been added. 
Fig. 99.-Gwathmey Method of Administering Warmed Vapor Through the Nose. 
"(8) Cold produces the so-called irritation of ether, contributing to 
nausea, vomiting, and shock, delays the return to nutrition,- 
disturbing the stomach by ingestion of ether-laden secre- 
tions,-and annoys the patient by leaving a lingering after- 
taste on the breath, due to impairment of the eliminative 
functions of the mucous membranes. 
"(9) The vapor warmed in some way loses a portion of its odorifer- 
ous strength and persistence, to the relief alike of anesthetist, 
surgeon, and patient." 
He also states that "it requires no expert observer favorably to con- 
trast the natural and placid breathing of a patient anesthetized by 
warm vapor with that of one whose membranes are swollen and awash 
from the irritation of algid inhalations." 
VAPOR 
The Open Method.-When the open method is indicated the vapor 
mask is used. The latest model consists of a close-fitting mask, the 
base of which is a hollow tube with perforations inside so that, as the 
vapor is pumped either by foot or by an electric motor, or passed from an 
oxygen or air tank through the apparatus, the patient inhales a certain 232 
ANESTHESIA 
known percentage of the anesthetic and gets only this percentage, re- 
gardless of the depth or rate of respiration. The upper part of the mask 
is modeled after the Yankauer, and is made of wire gauze. The mask is 
Fig. 100.-Ether Vapor Mask Encircled by a Towel Held in place by a Safety Pin. 
Fig. 101.-Same.as Figure 100 with Outer Fold of Towel Dropped as Patient 
Reaches Surgical Anesthesia. 
usually surrounded by a towel, the object of which is to decrease the 
amount of ether vapor blown away, to reduce the quantity, and to in- 
crease the safety, by warming the vapor by the slight amount of re- 
breathing thus obtained. Fig. 102a 
Figs. 102a and 102b.-Methods of Holding Jaw Forward so as to Maintain an 
Open Airway. 
Fig. 102b. 234 
ANESTHESIA 
Where the mouth is necessarily open during long operations upon 
the nose or mouth, the mouth gag with hollow tubes attached or a hol- 
low tube may be substituted for the vapor mask just referred to. or 
pharyngeal tubes may be used. 
Small children and weak anemic men or women can be easily anes- 
thetized by the open method of vapor alone. Ordinarily it is best to 
commence by the drop method and switch to the vapor as the patient 
reaches surgical anesthesia. If, however, the vapor alone is to be relied 
upon, the anesthetist proceeds as follows: Air is pumped vigorously 
Fig. 103.-Pinneo's Ether Vapor Apparatus, Disconnected. 
through the bottle marked air or water. The index should now be grad- 
ually turned toward chloroform. If the patient coughs, sneezes, or 
holds his breath, the index should be turned back again and a fresh 
start made. Continue in this way until the patient is well under the 
anesthetic, when ether may be substituted for the chloroform in the same 
manner. If the patient is a child, and if there is a suggestion of status 
lymphaticus or other contraindication to chloroform, ether may be 
placed in the small chloroform bottle, and the gradual change to ether, as 
just described for chloroform, made. As the patient becomes accus- 
tomed to this mild vapor the stopcock may be very gradually turned 
to the larger ether bottle. 
For strong, vigorous adults or alcoholics ether from the small bottle 
may not be sufficient to get the patient under quietly and easily. In 
this instance the vapor may be supplemented by drops of chloroform 
or ether upon the vapor mask. After the patient is well under surgical 
anesthesia it will be easy to hold him with the vapor alone. 
Most elderly patients do better with the combination of ether and 
chloroform than with any other anesthetic. When this is so, the index 
must be turned to a place between ether and chloroform and such a com- ETHER 
235 
bination of these drugs maintained as will satisfy all given require- 
ments.1 
Pinneo has devised a very useful apparatus for vapor anesthesia, the 
vapor being heated by an ordinary electric bulb. 
Endopharyngeal Anesthesia.-Karl Connell was the first to report 
a large number 
of cases by this 
method. We 
quote voluminous- 
ly from his paper 
on automatic 
pharyngeal anes- 
thesia : 
"In view of 
the objections to 
the endotracheal 
delivery, I have 
been led to seek 
a method which 
would overcome 
the necessity of 
intubation and 
the dangers of a 
badly supervised 
delivery, yet pre- 
serve the feature 
most desired for 
routine anes- 
thesia, to wit, an 
automatic, even, 
accurate, and 
effective delivery of the anesthetic agent. In the pharyngeal insufflation 
method of large volumes of dilute anesthetic agent deep into the pharynx, 
I believe we have such a method. The delivery is established after full 
surgical relaxation has appeared by face-mask methods. Speaking now of 
ether vapor in air delivery, the essential feature of this pharyngeal method 
is that a volume of air is insufflated by positive pressure into the lower 
pharynx, a volume sufficient to provide entirely for each inspiration, with- 
out any air being inhaled by nose or mouth, and a volume bearing a 
known percentage of ether vapor in the greatest dilution which will hold 
that patient evenly and safely anesthetized for the operation in hand. 
Fig. 104.-Pinneo's Ether Vapor Apparatus in Use. 
1 For additional literature relating to the subject of vapor anesthesia, see 
Cullom: J. Am. Med. Assn., Sept. 21, 1912, 1114; Hervey: N. Y. Med. J., 
Nov. 9, 1912; and Pinneo: J. Am. Med. Assn., Nov. 23, 1912, 1862. 236 
ANESTHESIA 
"The delivery is accomplished by preference through two catheters 
inserted one through each nostril a distance, on the average, of 12 cm. 
"The proper distance to insert each catheter is the distance measured 
Fig. 105.-Pinneo's Mouth Tube for Continuous Vapor Anesthesia. 
Fig. 106.-Endopharyngeal Insufflation and Mouth Tube Combined. 
off on the tube from its eyelet, from the auditory meatus to the ala nasi 
on that side. This carries the tube well into the lower pharynx, but not 
into the esophagus. 
"The catheters selected for the adult are size 18, F, soft rubber, ETHER 
237 
velvet eye, with accessory eyelet. These are attached to a Y metal de- 
livery tube with bent prongs for convenience of placement and to pre- 
vent angulation and to hold the catheters in place. This Y tube accu- 
rately fits the nose and forehead, and is held in place by adhesive 
plaster strapped across the brow. 
"The volume insufflated is such as to entirely supply the needs of 
inspiration without extraneous dilution. This requires 18 liters of air 
per minute for the average adult, into which is vaporized the ether." 
The essentials of endopharyngeal anesthesia, according to Connell, 
are as follows: 
"First: The ether tension in the arterial blood to the sensorium is 
the determining factor of anesthetization. 
"Second: This tension is established by maintaining in the alveolar 
air during preliminary narcosis an ether content of from 30 to 45 per 
cent by weight to air under conditions at sea level, an equivalent in 
pressure of from 119 to 182 mm. of mercury. During the early stage of 
anesthesia, say for the first twenty to forty minutes, this tension must 
be maintained by percentages scaling from 26 down to 15 per cent. 
After the establishment of anesthetic saturation of the body, it is main- 
tained at about the latter percentage, the equivalent of an ether pressure 
of 48 mm. in the alveolar air. 
"Third: These figures probably hold for the entire animal kingdom, 
the variable factors seen in ordinary etherization being these: Firstly, 
the rapidity with which the body is brought to complete anesthetic 
saturation, as determined by the efficiency with which the ether tension 
in the alveolar air is maintained by fresh delivery, by diffusion, and by 
tidal movement; secondly, the rapidity of blood circulation; thirdly, 
the bulk of the particular body to be saturated and the capacity of that 
body for storage and destruction of the ethyl radical. 
"Fourth: The zones of anesthesia above and below this saturation or 
anesthetic tension point are already well established for man. With 
absolute certainty as to the outcome, man may be placed in an ether 
atmosphere of the percentage of ether or vapor pressure required to pro- 
duce deep, medium, or light anesthesia. 
"Fifth: The zone of surgical relaxation, i. e., an ether pressure of 
45 to 50 mm., is a zone for many hours devoid of danger by ether intoxi- 
cation. 
"When one links these evident advantages of a full and continuing 
knowledge of the dose delivered, with the advantage of an even, auto- 
matic, unwearying, impersonal machine delivery of the anesthetic agent 
and its menstruum, the combination works for ideal anesthesia. 
"For anesthesia to be maintained automatically, at the same time 
safely, with uniform success, requires that three factors be under the 
control of the operator or anesthetist: Firstly, that complete prelim- 238 
ANESTHESIA 
inary relaxation of the individual be secured; secondly, that the anes- 
thetic agent and its menstruum be so delivered as to be freely available 
for respiration; thirdly, that the delivery be of such volume as to en- 
tirely supply the needs for respiration, as well as of such accurately 
measured and known percentage or tension of anesthetic as to hold a 
given individual safely and evenly anesthetized. 
"For delivery to become automatic the anesthetic agent and its 
menstruum must be made freely available for inspiration by the delivery 
passing the chief obstruction, namely, the base of the tongue. Full 
preliminary anesthesia is best accomplished by face-mask methods, since 
man will not tolerate the introduction of pharyngeal or endotracheal 
tubes when conscious, nor breathe quietly in the subconscious stage of 
preliminary anesthesia the irritating vapors, i. e., 30 to 45 per cent of 
ether by weight, needed for establishment of complete anesthesia. These 
vapors to be inhaled quietly must be inhaled by the subconscious patient 
in such a way as to arouse no unusual impressions. Attempting to blow 
vapors of the strength needed for the induction of anesthesia into the 
pharynx or trachea results in straining, coughing, gagging, and the 
swallowing of air. Only when the patient is completely relaxed can 
insufflation methods be instituted. This period of face-mask delivery 
occupies six to twelve minutes for the most advantageous relaxation. 
If the operative procedure is now to occupy more than five or ten min- 
utes, automatic insufflation may be established with decided advantage. 
"Of course, it is to be distinctly understood that in the administra- 
tion of anesthetics by the aid or means of automatic contrivances intelli- 
gent supervision is at all times necessary." 
Connell1 compares endotracheal and endopharyngeal anesthesia in 
the following manner: 
"The ideal place to deliver ether vapor in air is, without question, 
directly into the trachea by insufflation through a loose endotracheal 
catheter after the method of Meltzer. For effective delivery, for com- 
plete and certain aeration, for even and controllable anesthetization, for 
freedom from shock and from the sequels of ether anesthesia, this 
method is not surpassed. 
"Time does not permit me to elaborate on these nor on the various 
accessory advantages of this method, namely: the ability to maintain, 
when desired, positive pressure on the interior of the lung, to exclude 
mucous and other foreign material from the bronchial system, and to 
maintain an ideal artificial respiration if accident arises. 
"The one and only hindrance to the establishment of the endo- 
tracheal delivery as a routine method of anesthesia is the act of intuba- 
tion. 
1 Extracts from paper read by invitation before the first annual meeting of 
the American Association of Anesthetists, Minn., June 18, 1913. ETHER 
239 
"This alone, with its possible dangers, its ever-present delays, and 
occasional difficulty of intubation will, no doubt, effectively block the 
general adoption of this very useful and effective mode of delivery as 
a routine method of anesthesia." 
Endopharyngeal anesthesia is not so thoroughly effective in control 
over aeration or over positive pressure, nor so effective in excluding for- 
eign material from the larynx as the endotracheal delivery. 
Oxygen-Ether Administration.-According to the investigations of 
some authorities, the apparent advantage by the administration of oxy- 
gen is in the exact and equal dosage at all times. 
Hewitt states:1 "There is little if any advantage to be gained by 
this system of anesthetizing, except in certain special cases. We have 
seen that in vigorous subjects some degree of air limitation is actually 
advantageous in conducting etherization. When we pass, however, 
from the vigorous subject, at one end of the scale, to the exhausted and 
feeble individual at the other, we have not only to be careful to provide 
a sufficient supply of air with the anesthetic, but we may even find it 
necessary to replace air by oxygen in our administration. Generally 
speaking, when respiratory embarrassment is present to such a degree 
that there is duskiness or actual cyanosis, ether is, as we have seen, 
contraindicated. In certain exceptional and desperate cases, however, 
in which defective blood oxygenation coexists with such a degree of 
cardiac derangement that the risk in giving a general anesthetic is that 
sudden syncope may arise from a very slight degree of respiratory em- 
barrassment, ether may be the only permissible anesthetic, and under 
such exceptional circumstances as these the administration is best ef- 
fected in conjunction with oxygen." 
Others do not agree with Hewitt that little or no advantage is to be 
gained by the administration of oxygen with ether. On the other 
hand, we have every reason to believe that the after-effects of ether are 
considerably diminished by the combination with oxygen instead of 
air. Sufficient data are not at hand for us to speak authoritatively upon 
this subject. The administration of oxygen with ether is one of 
the simplest and at the same time safest procedures possible. At- 
tach any vapor inhaler to the ordinary large hospital oxygen tank and 
allow the oxygen to pass through the ether, and this vapor to then pass 
through the water bottle and thence to the patient. A very simple 
apparatus for the administration of ether and oxygen can be quickly 
made as follows: 
Procure two wash bottles holding about six ounces. Have the rub- 
ber stoppers perforated to hold small glass tubes, as in the ordinary 
wash bottle that accompanies any oxygen tank used in hospitals. The 
first bottle should be filled with four ounces of ether, the second bottle 
1 Hewitt: ' ' Anaesthetics, ' ' 340. 240 
ANESTHESIA 
with four ounces of water. Allow the oxygen-ether vapor to pass 
through the water bottle by a rubber tube connecting the two bottles. 
The efferent tube should then pass on to the patient. This vapor may 
be administered through the apex of an ordinary cone, the cone to be 
made more or less air-tight by towels wrung out in hot water placed 
around the margin of the 
cone and on the patient's 
face. We again refer to chart 
(page 668) of a patient 
anesthetized with oxygen and 
ether, showing the even pulse, 
temperature, respiration, and 
blood pressure. The only ob- 
jection to the impromptu ap- 
paratus is the fact that the 
oxygen or ether cannot be in- 
creased or decreased separate- 
ly, as in the Gwathmey or 
some similar apparatus espe- 
cially made for that purpose. 
When using this method the 
patient should be anesthetized 
by the nitrous oxid-ether or 
oil of orange-ether sequence 
or the chloroform-ether se- 
quence, and after reaching 
the surgical stage a switch 
should be made to the oxy- 
gen-ether combination. The 
pulse will be found to be full 
and bounding, the respira- 
tions deep and regular, and 
the color index marked. Suf- 
ficient air will be let in by 
such a mask to slightly dilute 
the oxygen. The oxygen-ether combination has not been tried out by 
the closed method except in very short cases, and is not recommended. 
Few complications will arise to give the anesthetist uneasiness when the 
oxygen-ether combination is administered with a suitable apparatus and 
by the open method, already described. 
Concentration of Ether Vapor.1-Dreser has made laboratory ex- 
periments regarding the percentages of respirable ether vapor. Differ- 
ent accurate mixtures, placed in rubber bags, were inhaled by a number 
Fig. 107.-Gwathmey's Ether-Oxygen Vapor 
Apparatus with Electric Heater on Low 
Pressure Oxygen Tank. 
1 Johns Hopkins Hosp. Bull., Jan., 1895, No. 6. ETHER 
241 
of men. All agreed that 8 per cent ether vapor was irrespirable, that 
9 per cent caused contraction of the glottis, that 7 per cent caused irri- 
tation and cough, that 6 per cent was slightly irritating but not irre- 
spirable, and that 5 per cent was usually respirable. Dreser concluded 
that: "A person in a conscious state should not inhale ether vapor ex- 
ceeding 7 per cent. Now when a patient by inhaling a weaker concen- 
tration of ether vapor has been made insensible, to such a degree at least 
as to show no more reflex action, this very state will favor the injuri- 
ous effect of the stronger concentration upon the lungs. As long as the 
Fig. 108.-Chart I, Showing the Necessary Percentage of Ether Vapor for the 
Endopharyngeal or Endotracheal Administration. 
patient is conscious, the reflex contraction of the glottis prevents the 
irrespirable gas or vapors from entering the finest air passages." The 
anesthetist should take care that the lungs of the narcotized patient 
are not injured. In a closed inhaler the percentage of carbonic acid 
met with in these experiments, even with healthy persons, was never 
high enough to produce the slightest narcosis, "therefore the percentage 
of carbonic acid met with in the air of the masks could not be looked 
upon as having a paralyzing or narcotizing effect." 
Karl Connell1 was the first to develop the accurate percentages of 
ether necessary for surgical anesthesia when given by the vapor method 
either endopharyngeally or endotracheally. These charts represent a 
composite of three hundred cases of surgical anesthesia at the Roose- 
velt Hospital charted after a working experience had been gained on a 
previous series of about six hundred cases. 
Chart I indicates the zones of ether anesthesia in terms of weight 
1 Extracts from a paper read by invitation before the first annual meeting 
of the American Association of Anesthetists, Minn., June 18, 1913. 242 
ANESTHESIA 
of ether to air delivered under working conditions. The volumetric 
equivalent and ether vapor pressure equivalent are tabulated in parallel 
columns, as is the absolute weight of ether per liter in the air at de- 
livery and at body temperature. 
These zones are for practical working guidance in surgical etheriza- 
tion, and are not absolute. The zones above the 15 per cent level gradu- 
ally lower toward that level as the anesthetic tension of about 48 milli- 
Fig. 109.-Chart II, Showing the Most Advantageous Ether Pressure. 
meters of the entire body is attained. At the end of an hour of full 
anesthesia even the zone of deep anesthesia for a considerable length of 
time might result lethally. For example, when a dog, after anesthetic 
saturation, is carried in the zone of profound anesthesia by endotracheal 
delivery, respiratory effort ceases in about an hour, only to begin again 
when the ether tension is lowered. Such dosage would result fatally if 
provision is not made for artificial respiration. These zones are the same 
whether the delivery be by face-mask or by insufflation. 
Chart II shows the most advantageous ether pressure to maintain 
in the pulmonary air, charted in terms of weight of ether in air under 
usual working conditions at sea level. 
The percentages above 15 per cent during the preliminary and early 
stage of full surgical anesthesia are needed to establish the proper 
anesthetic tension in the arterial blood to the sensorium pending such ETHER 
243 
time as the entire circulating and fixed tissues of the body are brought 
to uniform tension. As seen on the chart, there is a difference of 20 
to 30 minutes between the length of time such saturation takes in 
a man of the young, robust, or alcoholic type to the much shorter time 
taken to saturate the small, relaxed woman or child. All types, how- 
ever, when the general tension is once established, run on the same 
base line. This, for complete anesthesia, is between 14 per cent and 15 
per cent by weight of ether, yielding a tension between 45 and 51 milli- 
meters. The absolute point is not as yet fully established, but is proba- 
bly about 48 millimeters. In fact, it would seem from preliminary ob- 
servation that this tension is basic not alone for all types of man, but 
also for the entire animal kingdom. Below this level the operative 
case may be carried where only light anesthesia is desired, or when the 
operation reaches such a stage that protection against shock influence 
is no longer needed (i. e., that very effective protection conferred by 
full ether anesthesia), or where the anesthetist desires the patient to 
enter the zone of slow ether desaturation and recovering consciousness. 
This recovery zone may be so gauged that in short operations the patient 
leaves the table practically conscious and, even after long operations, in 
full possession of all pharyngeal reflexes. 
Saturation of the arterial blood and sensorium is complete in the 
curve shown, to the extent of full surgical anesthesia, in about two min- 
utes for each liter of circulating blood, being complete in medium- 
sized children in six minutes, and in the adult in twelve minutes. 
Operations, even major procedures, may be begun before full relaxation 
is established or at the peak of the preliminary curve, say at the end 
of six minutes in a docile adult. Yet where it is desired to fully pro- 
tect the patient against shock-producing and inhibitory influences, it is 
desirable to wait for full surgical relaxation, i. e., about ten to twelve 
minutes. 
While the arterial blood to the sensorium may be fully charged by 
high percentages within ten minutes, yet the general body of an adult 
is not brought to full tension, approximating 48 millimeters, by the 
delivery curve shown, for from forty to sixty minutes. Desaturation 
proceeds even more slowly, although marked changes of deadened or 
awakened sensibility may be seen within three minutes by increase or 
decrease of ten millimeters of ether vapor pressure in the air deliv- 
ered. This sensitiveness is more pronounced before the anesthetic ten- 
sion of the entire body is established. Partial recovery is more rapid 
than deepening anesthesia by changes of equal degree before saturation 
is complete. After the anesthetic tension is established, anesthesia may 
be more rapidly deepened than diminished, an observation readily ex- 
plicable on physical and chemical grounds. 
The patient may be carried in the zone of profound anesthesia or 244 
ANESTHESIA 
deep, medium, or light anesthesia at will. With the data at present in 
hand, the most advantageous anesthetization by ether can be plotted in 
advance for the type of individual and for the nature and stage of the 
operation, and maintained after the initial stage entirely automatically, 
and, were it desirable, without the presence of any anesthetist. The 
ether intoxication may be reduced to a small factor and shock influence 
effectively blocked. 
Conclusions.-The percentages of ether needed by man are well 
established, and the most advantageous anesthesia may be plotted in 
advance. These percentages are probably basic for the animal kingdom. 
Fig. 110.-Administration of Warmed Ether Vapor by the Closed Method. 
A curve plotted for man for advantageous etherization rapidly ascends 
in the preliminary stage to 30 to 45 per cent by weight of ether in air, 
after five minutes it falls, reaching 26 per cent by the tenth minute, 
when surgical relaxation is well established. Through the next half 
hour it scales downward, reaching 15 per cent in 30 or 40 minutes. 
It runs on or about this base line for some hours, descending when the 
zone of recovery is desired to be entered. 
The Closed Method.-When the closed method is decided upon, any 
mask and bag used in the gas-ether sequence may be employed. A 
rubber tube from the three-bottle vapor inhaler in this instance will 
be attached to the stopcock of the bag. The expiratory valve will be 
left slightly open so as to have the escape of a small amount of air at 
all times, while at the same time constant rebreathing is maintained. 
The inspiratory valve of the inhaler should be out of commission. Air 
should be constantly forced in, and the bag kept about nine-tenths 
full so that no effort either to inhale or exhale is exacted of the patient. 
With vigorous pumping a bead of 1/8 to of an inch in height 
will be maintained in the ether bottle. Continuous pumping must be ETHER 
245 
maintained throughout the administration of the anesthetic. Toward the 
close of the anesthesia the tubes from the pumping apparatus and of the 
mask should be detached from the three-bottle vapor inhaler and at- 
tached to the warming apparatus, and the patient's lungs thus thoroughly 
aerated before the mask is removed from the face, the bag to be 2/3 
inflated as before. This should be done from five to ten minutes before 
the completion of the operation so that by the time the operation is 
Fig. 111.-Three Bottle Ether (Anesthol) and Oxygen Vaporizer-Munkittricks. 
-To be attached to the operating table. With yoke for attachment of high pres- 
sure oxygen cylinder or connection with low pressure oxygen tank. 
finished the patient's reflexes will all be present and he will be practically 
from under the influence of the anesthetic. 
Amount of the Anesthetic Used.-With the closed vapor method 
usually two (rarely three) ounces of ether per hour are required; if three 
ounces are used the first hour, one ounce will suffice the second hour. 
With the open method, three to four ounces of ether are necessary to 
maintain complete relaxation. 
Care of the Apparatus.-All the ether and chloroform remaining in 
the apparatus should be thrown away. The water bottle should be 
emptied and the bottles detached from the apparatus (this last pro- 
cedure in order to save the rubber washers). The mask and bag should 
be thrown into the sterilizer and boiled as are other surgical apparatuses, 
or they should be thoroughly rinsed in carbolic 1-40 or bichlorid solu- 
tion and then rinsed in cold water. If a tube or mouth gag is used, 
it should also be thoroughly boiled after each operation. 
Hints.-The principal care of the anesthetist with any vapor appa- 246 
ANESTHESIA 
ratus is to see that there is no leakage either at the bottles or face- 
piece or bag, also that no kinks occur in the rubber tubing or that pres- 
sure is not made on the tube by assistants or nurses. 
Advantages.-The following are the advantages of the vapor method: 
First: The small amount of the anesthetic used, two to four drams 
for a thirty-minute operation, or two or three ounces of ether per hour. 
Second: The technique is easily acquired. 
Third: Objectionable mucous rale is usually entirely absent. 
Fourth: In over ninety per cent of cases there are no unpleasant 
after-effects. 
Fifth: A continuous plane of narcosis is easily maintained. 
Sixth: An intermitting narcosis which is wrong in principle is 
avoided. 
Seventh: The passage back and forth over the dangerous vomiting 
center is usually made easily. 
Treatment of Accidents.-When respiration ceases the first thing to 
do is to give the patient a quick, hard slap upon the chest. If this does 
not start the respiration, the next movement is to place the hands upon 
the side walls of the chest and press very hard several times in succes- 
sion. If the patient does not begin to breathe immediately the follow- 
ing procedures must be followed and in much quicker time than it takes 
to give the directions: 
First: Insert a mouth gag and pull the tongue well forward. 
Second: Lower the head, and while this is being done pressure 
upon the side walls of the chest must be continued. As soon as the 
patient is lowered to the Trendelenburg position, grasp the arms just 
above the elbows, and press them vigorously to the sides and then draw 
the arms backward and sideways over the head, at the end of this move- 
ment making considerable traction. Repeat this movement about 15 
times to the minute. At the same time have an assistant dilate the 
sphincter ani. Another assistant can be vigorously massaging the pre- 
cordial region while artificial respiration is being kept up. If there are 
a sufficient number of nurses or assistants standing around, bandages 
starting at the feet and continued to the thighs with the idea of ex- 
pressing the blood in the extremities to the body is sometimes beneficial. 
If these procedures do not give some definite result within two minutes, 
the Lewis pendulum swing should be attempted. 
If respiratory arrest is due to mucus or saliva, the anesthetic must 
be discontinued, a mouth gag inserted, and the upper air passages 
swabbed out with a sponge placed upon a long sponge holder. 
If the fourth stage is brought on by hemorrhage or shock from 
handling important nerves or blood vessels, and the respiration is still 
good and a dilute ether vapor has been given, a Trendelenburg position 
with bandaging of the lower limbs and intravenous saline infusion will ETHER 
247 
usually rectify this condition. If the fourth stage is anticipated from 
certain events, it may be sometimes prevented by a hot rectal saline 
infusion. It is not unusual where the patient is in an extreme condi- 
tion to start a hypodermoclysis at the time the operation is commenced. 
According to American statistics, one death occurs in 5,623 adminis- 
trations of ether by the drop or vapor method. This means that death 
is due to gross carelessness or ignorance. 
In extremely rare and unusual cases of status lymphaticus, in 
which the organs may be diseased and anomalous, such as a very small 
heart with a large aorta and enlargement of the tongue, it is quite con- 
ceivable that the heart may be paralyzed before the respiration ceases. 
When paralysis occurs from this condition it is usually during primary 
anesthesia. If the anesthesia is continued for 15 minutes or over, 
compensation occurs and a death after that time could hardly be at- 
tributed to this cause. 
INDICATIONS AND CONTRAINDICATIONS OF ETHER 
Indications.-Hewitt states that in "healthy and moderately healthy 
subjects the risk connected with the administration of ether is very 
slight, the reported fatalities having almost invariably taken place in 
exhausted or markedly diseased individuals." 
The senior author agrees with Hewitt as to the risk connected with 
the administration of ether. 
With the modern methods of administration, and with the combina- 
tions and sequences which make it possible to adapt the anesthetic to the 
patient, the indications for ether almost parallel the indications for 
operation, except, of course, for very short surgical interventions. 
Ethev is especially indicated to continue the narcosis in operations 
about the mouth or nose, such as excision of the tongue or lower jaw, 
where there is considerable shock. 
Ether by the vapor or drop method is indicated for adenoid and 
tonsil cases, and wherever the status lymphaticus is suspected. Wher- 
ever a deep anesthesia is desired, ether by the closed method is indi- 
cated, as for amputations, dislocations, genito-urinary operations, lapa- 
rotomies, excision of the breast, amputation of the cervix, vaginal and 
supravaginal hysterectomy, and in all conditions of shock and collapse. 
Contraindications.-The first objection to any method of adminis- 
tration of ether is where the patient has suffered intensely from a pre- 
vious administration of this drug, and expresses a decided dislike for 
the odor and after-effects. Such idiosyncrasies must be respected. The 
senior author knows of one death caused by disregarding this rule. The 
history of this case is appended. 248 
ANESTHESIA 
Patient, female, aged 35 years. Operation, removal of ovarian 
tumor. The anesthetist was warned not to use ether, as nausea and 
vomiting of an exaggerated type had followed a previous administra- 
tion of this agent. The anesthesia was begun with chloroform, but as 
surgical anesthesia was reached pulse, respiration, and color seemed to 
indicate a change. A few drops of ether were placed upon the mask 
to stimulate the patient. Almost immediately vomiting ensued. Upon 
deepening the anesthesia vomiting ceased, and a smooth narcosis en- 
sued to the end of the operation. Ether was used from time to time 
as needed. As the patient came out of the anesthetic vomiting started 
again, and continued, with intermissions, for forty-eight hours. The 
character of this vomiting was so violent that a retention stitch was 
broken and a small piece of intestine was caught in the wound. When 
the dressings were removed the tissues along the line of incision ap- 
peared tense and swollen. Upon reopening the wound, the gut was 
found to be gangrenous, and this portion was removed under an anes- 
thetic. In spite of good nursing, peritonitis and death followed. 
Nitrous oxid and oxygen would probably have saved the life of this 
patient. 
Kocher1 states that respiratory disturbances and pathological 
changes in the respiratory organs, with dyspnea, are contraindications 
of prime importance. Ether, he holds, causes more suffering and more 
lasting damage to the respiratory organs than can b.3 attributed to 
chloroform. 
In lung and kidney disease, bronchitis, phthisis, dyspnea, and em- 
physema, and in ophthalmic operations, patients do better with some 
other anesthetic than ether. 
In aneurism and atheroma ether is contraindicated. It is also 
contraindicated in acute attacks of asthma or bronchitis. In chronic 
bronchitis or asthma ether introduced cautiously and given by modern 
methods is perfectly safe. In any condition with high blood pressure 
ether is contraindicated. 
Mortimer 2 states that ether should not, as a rule, be given to in- 
fants and young children, in whom it excites much mucous secretion 
which may embarrass breathing or lead to bronchitis. 
Elderly people do not usually take ether well, because of the de- 
generate state of the respiratory and circulatory systems. Heavy smok- 
ers and people whose mouths and throats are in an unhealthy state, 
who are likely to cough and secrete much mucus and to have enlarge- 
ment of the tongue and upper air passages, are considered by Mortimer 3 
as unfavorable subjects for ether. 
'"Text-Book of Operative Surgery," 50. 
* ' ' Anesthesia and Analgesia, ' ' 55. 
* Loc. cit. ETHER 
249 
Ether is contraindicated if an actual cautery, a lamp, or any kind of 
electrical spark is to be employed. 
Most writers state that ether is contraindicated in operations upon 
the brain, because of the desirability of having the field of operation as 
free from blood as possible. Many surgeons, however, prefer the drop, 
or vapor, method of ether in all operations upon the brain. Similarly, 
exophthalmic goiter is stated as contraindicated, but many surgeons pre- 
fer ether by the open method for this operation. CHAPTER VI 
ETHYL CHLORID 
Chemistry : Chemical History; History of Its Use as an Anesthetic; 
Uses; Preparation; Properties; Storage and Containers; Impurities 
Which May Develop in Ethyl Chlorid; Detection of Impurities in Ethyl 
Chlorid. 
Physiology : Effects upon Respiratory System; Effects upon the 
Circulatory System; Effects upon the Nervous System; Effects upon the 
Muscular System; Effects upon the Glandular System; Causes of Death 
under Ethyl Chlorid Anesthesia; Stages of Anesthesia; Elimination; 
After-Effects; Comparison with Other Anesthetic Agents. 
Indications and Contraindications. 
Administration : Experimental Data; Methods of Administration; 
Open Method; Semi-closed Method; Closed Method; Combinations and 
Sequences. 
Bibliography. 
CHEMISTRY 
Chemical History.-Ethyl chlorid ("sweet spirit of salt"; cethylum 
chloratum; aether chloratus; aether hydrochloricus seu muriaticus; hydro- 
chloric ether; chloro-ethane; monochlorethane; chloroethyl; leichter 
salzather; ether chlorhydrique; chelen or chelene; kelen or kelene; ano- 
dynone; antidolorin; ethylol; loco-dolor, etc.) was first obtained in alco- 
holic solution by Basil Valentine (pseudo-).1 Sweet' spirit of salt was 
1He described its preparation thus (Diederholung des grossen Steins der 
uralten Weisen, ed. Petreeus, p. 72): "This I also say that when the spirit 
of common salt unites with spirit of wine, and is distilled three times, it be- 
comes sweet and loses its sharpness." In his "Last Testament" (Basilius Val- 
entinus, ed. Petraeus, p. 786) he also says: "Take of good spirit of salt which 
has been well dephlegmated and contains no watery particles one part; pour to 
this half a part of the best and most concentrated spiritus vini, which also con- 
tains no phlegma or vegetable mercury." Valentinus goes on to state that this 
mixture must be repeatedly distilled, and then "placed in a well-closed bottle and 
allowed to stand for a month or until it has all become quite sweet and has lost 
its acid taste. Thus is the spiritus salis et vini prepared, and may be readily 
extracted. ' ' 
In 1739 Johann Pott demonstrated that sweet spirit of salt could be ob- 
250 ETHYL CHLORID 
251 
well known to the later chemists. Glauber, for example, referred to it in 
1648. 
In 1749 1 Ludolff stated that, on heating alcohol with sulphuric acid 
and sodium chlo-rid, a distillate was obtained which, when treated 
with lime, yielded an ether, but he endeavored in vain to obtain a sim- 
ilar compound by the action of hydrogen chlorid (muriatic gas) on 
alcohol. Baume was also unsuccessful in this direction, but Woulfe 2 
obtained the preparation in this way, and it was afterwards prepared 
and sold by an apothecary in Germany under the name of "Basse's 
hydrochloric ether" (1801). 
History of Its Use as an Anesthetic.-Flourens 3 drew attention to 
the anesthetic properties of ethyl chlorid in 1847, and Heyfelder, in 
the following year, first administered the vapor for surgical purposes. 
Unsatisfactory symptoms often accompanied its administration at that 
time, these effects being attributed to imperfection in the manufacture 
and the consequent presence of impurities. The use of the agent as a 
general anesthetic was abandoned until 1895, since which time it has 
rapidly gained in favor. This is principally attributable to the improved 
methods of administration and to an increase in the knowledge of its 
properties and physiological action; and last, but not least, to improve- 
ments in its manufacture. 
Ethyl chlorid may be regarded as ethyl alcohol (CH3CH20H), in 
which the OH has been replaced by Cl; hence the formula CH3CH2C1, 
which was established by Colin and Robiquet.4 
Alcoholic muriatic ether is a solution of ethyl chlorid in an equal 
amount of alcohol by volume. It has been used as an internal stimulant 
in doses of 0.6 to 1.8 c.c. 
Uses.-So far ethyl chlorid has not been used technically, although 
Palmer 5 called attention to its advantages (and disadvantages) as an 
industrial refrigerating agent. In medicine it is used for (a) general 
anesthesia (by inhalation); (b) local anesthesia (by external applica- 
tion, in effect, refrigeration) ; (c) diagnostic and therapeutic purposes. 
Its physiological action will be referred to later. 
Preparation.-As noted, ethyl chlorid may be regarded as ethyl 
alcohol (C2H50H) in which the hydroxyl has been replaced by chlorin. 
tained by the action of butter of arsenic or butter of antimony (arsenic or 
antimony trichlorid) on spirit of wine, and other chemists found that other 
metallic chlorids might be employed for the same purpose. Rouelle, in 1759, 
found that ethyl chlorid results from the action of sulphur chlorid, phosphorus 
pentachlorid, aluminum chlorid, ferric chlorid, stannic chlorid, etc., on alcohol. 
1 Die in der Medicin siegende Chemie ■ • • , Erfurt, 1746-9. 
2 Phil. Trans., 1767, 520. 
3 Hewitt: "Anaesthetics," 1907, 11. 
* Ann. chim. phys. (2), 1, 343. 
5 Eng. Digest, 5, 262. 252 
ANESTHESIA 
Ethyl alcohol is the raw product from which it is usually made, although 
ethyl chlorid results in the regulated chlorination of ethane,1 and on 
treating acetic and other ethers with hydrogen chlorid by the action of 
hydrochloric acid on ether in sealed tubes,2 and by the action of chlorin 
on ethyl iodid. In actual practice ethyl alcohol is mixed with hydrogen 
chlorid, which acts as a desiccating agent itself,3 or dehydrating agents, 
as zinc chlorid4 or phosphorus pentoxid5 are added to remove the 
water produced. If these agents were not added the reversible reaction 
would reach an equilibrium. This equilibrium may be avoided by 
increase of pressure.6 
Impurities from Materials Used.-If pure hydrogen chlorid be 
used there is little danger of impurities being introduced from that 
source. The quality of the alcohol used, however, is very important. If 
denatured alcohol, especially if wood alcohol be the denaturant, or one 
of the denaturing substances, then methyl chlorid will likely be pro- 
1 Darling: Ann., 150, 216; Sehorlemmer: Compt. rend., 58, 703. 
2 Berthelot. 
8 Ethyl chlorid may be prepared by distilling ethyl alcohol (5 parts), sul- 
phuric acid (2 parts), and sodium chlorid (12 parts) together, or by passing 
dry hydrogen chlorid into absolute alcohol; but it is said that the action of 
hydrochloric acid upon alcohol gives a poor yield of chlorid unless zinc chlo- 
rid is added to the alcohol before passing in hydrochloric acid (Groves: J. Chem. 
Soc., 1874, 27, 637). Groves found that when hydrochloric acid gas was passed 
into a boiling solution of zinc chlorid (2 parts) in 95 per cent ethyl alcohol 
(3 parts), the yield was nearly theoretical. He purified the product by wash- 
ing with water. 
'Kruger [J. prakt. Chem. (2) 14, 193] recommended that a mixture of one 
part of zinc chlorid in 82 parts of ethyl alcohol should be saturated with hydro- 
chloric acid gas in the cold, and then heated to the boiling point. Hydrochloric 
acid gas being conducted into the mixture during distillation, as the process is 
carried out, a reflux condenser prevents the alcohol vapor from coming over, and 
the zinc chlorid is said to act by abstracting water from the alcohol, the nascent 
ethylene combining with hydrogen chlorid to form ethyl chlorid, according to 
Sehorlemmer (J. Chem. Soc., 1876, 308). On the action of hydrochloric acid 
on alcohol, alone and in the presence of zinc chlorid, see also Robiquet and 
Colin: Ann. chirn. phys. (2), 1, 343; Regnault, ibid. (2) 71, 355; Kuhlmann: 
Ann., 33, 108; and Lowig, Pogg: Ann., 45, 346. On velocity of the reaction, 
see Kailan: Monatsh., 1907, 28, 559. The formation of ethyl chlorid in this 
process is partly due to the action of hydrogen chlorid upon alcohol, and partly 
to the union of this nascent ethylene with hydrogen chlorid. 
6 The practice of some American manufacturers is to use phosphorus pen- 
toxid as the dehydrating agent. 
8 The process of Mennet and Cartier (French Patent, 206, 574, June 23, 
1890) relates to the production of ethyl chlorid. An autoclave of 150 liters 
capacity is used, into which a mixture of 95 kg. of hydrochloric acid (21° Be.) 
and 34 kg. of 93-95 per cent ethyl alcohol is maintained at 50 atmospheres 
pressure and at 130° C. for about 28 hours. The pressure is then diminished to 
42 atmospheres, and finally the autoclave is cooled. See also Hager's Handbuch 
d. pharm. Praxis, 1910, 1, 189. ETHYL CHLORID 
253 
duced. This gas (b.p., -24° C.), while very soluble in ethyl chlorid, 
may easily be removed by rectification. Aldehyds form compounds 
with hydrogen chlorid. Any acetic acid present is liable to form acetyl 
chlorid, and the higher alcohols, as propyl, butyl and amyl, produce 
their corresponding halogen derivatives. It is desirable, therefore, to use 
only absolute alcohol of the highest degree of rectification. 
An examination of seven different makes of ethyl chlorid obtainable 
in London in 1905 showed that all the branded samples were pure, as 
was also one unbranded sample. The report of this investigation1 
states that ethyl chlorid should be free from water, foreign chlorids, 
acids, aldehyds, ether, alcohol, and organo-metallic substances. 
Purification.-Ethyl chlorid is purified2 by passing the vapor 
through water, dilute caustic solution, and then concentrated sulphuric 
acid. This treatment is intended to free it from alcohol,3 hydrogen 
chlorid,4 and water. Redistillation is sometimes practiced. This rec- 
tification serves to remove other alkyl chlorids, the methyl going off in 
the first fractions of the distillate, and the higher compounds remain- 
ing in the residue. 
Properties.-Ethyl chlorid is a colorless mobile liquid at low tem- 
peratures and is exceedingly volatile. It possesses a sweetish taste and a 
pungent, yet fragrant, "ethereal" odor. It is inflammable, burning, 
when ignited, with a smoky green-edged flame, producing fumes of 
hydrogen chlorid; hence care must be exercised in using it near an 
open flame or a hot cautery. It even decomposes when very close to a 
hot bulb or an incandescent electric light. 
Ethyl chlorid does not freeze at -29° C.; it possesses a boiling 
point of 4-12.5° C.5; and its specific gravity is 0.92138 at 0° 6, 0.9176 
at 4-8° 7, 0.9510 at 4"12° 8, and at 4-25° 9 the vapor has a specific 
gravity of 0.91708. Its vapor density is 2.22. 
Water dissolves about one-fiftieth of its weight of ethyl chlorid and 
acquires a sweetish, ethereal taste. Ethyl chlorid is readily soluble in 
ethyl alcohol and ethyl ether, and neither solution should give a reaction 
with silver nitrate solution, as ethyl chlorid itself does not react with 
silver nitrate at ordinary temperatures. Ethyl chlorid dissolves phos- 
phorus, sulphur, fats, oils, and many resins. It combines with many 
1 Lancet, 1905, ii, 1631. 
3 Pharm. J. (4), 15, 694. 
'Acetyl chlorid decomposes to acetic and hydrochloric acids with water. 
* And other bodies forming acids with water. 
'Regnault: Jahresber., 1863, 67. 
'Pierre: Compt. rend., 27, 213. Darling (Jahresber., 21, 328) found a 
density of 0.9252 at this temperature. 
'Linnemann: Ann., 160, 195. 
'Ramsay: J. Chem. Soc., 35, 470. 
'Perkin: J. prakt. Chem. (2), 31, 481. 254 
ANESTHESIA 
metallic chlorids-for example, antimony pentachlorid and ferric chlorid 
-to form crystalline compounds. 
Storage and Containers.-Owing to its extreme volatility, ethyl 
chlorid cannot be kept in ordinary bottles, except at a temperature be- 
Fig. 112.-Sealed Tubes of Ethyl Chlorid. These contain 3 and 5 c.c. for use in 
various inhalers for general anesthesia. 
Fig. 113.-Double-End Ethyl Chlorid Tube. This possesses the advantage of 
enabling the operator to utilize the spray whose emerging angle will be most conven- 
ient. They are put up in 10 and 30 gm sizes. 
Fig. 114.-Automatic Closing Tube for Ethyl Chlorid. These are made to hold 
10, 30, and 60 gm of ethyl chlorid and are used for local and general anesthesia. 
They may be graduated. The tube is glass, but the automatic cap is made of a non- 
corroding metal. 
Fig. 115.-Automatic Closing Tube for Ethyl Chlorid. It is graduated in cubic 
centimeters for discharging any desired amount and containing 60 c.c. 
Fig. 116.-Flexible Spraying Nozzle. This is detachable, made of soft German silver 
tubing, and enables the operator to reach any tooth and to enter the nose, throat or 
external auditory canal to apply ethyl chlorid as a local anesthetic. 
low 4-10° C., and even then the stopper must be tight-fitting and very- 
well secured, and the bottles should preferably be stored in an inverted 
position. Ethyl chlorid is now supplied on the market in sealed or 
mechanically capped glass or metal tubes of convenient forms, wherein 
the ethyl chlorid is held under pressure. Automatic closing tubes are ETHYL CHLORID 
255 
preferable for local anesthesia, and there are at least five different types 
of these on the American market, each manufacturer using his special 
form of container, some of which are described here. Ethyl chlorid is 
also furnished by certain manufacturers in plain capped tubes. 
Containers of ethyl chlorid should be kept in a dark, cool place, re- 
mote from lights or fire; and no empty tubes should be refilled with a 
A 
B 
C 
Fig. 117.-Ferguson's Ethyl Chlorid Tubes eor General and Local Anesthesia. 
A. -50 c.c. tube of ethyl chlorid intended for general anesthesia only. The capillary 
is gauged so as to deliver the proper amount of ethyl chlorid in the right time to produce 
a satisfactory narcosis. It is graduated and has a large capillary bore. It is not adapted 
for producing local anesthesia. 
B. -50 c.c. tube open, showing the graduations. 
C. -Tubes containing respectively 30 c.c. or 60 c.c. of ethyl chlorid are made for 
local anesthesia only. The capillary on each is of the same size, and is gauged so as 
to deliver the minimum amount of ethyl chlorid compatible with a good local anesthesia, 
thereby preventing waste. These tubes differ from the 50 c.c. tube in capacity and 
size of capillary bore, and are not adapted for producing general anesthesia except in 
the case of infants or young children, and very susceptible subjects. 
Open the tube by pushing the thumb button forward as far as it will go in a direction 
parallel with the long axis of the tube. Do not press down on the button, as by doing 
so the capillary tube may be broken. When through using, remove the thumb from 
the button and allow the spring to bring the cap back in place; the tube is thus closed 
instantaneously and tightly. If any foreign matter becomes lodged on the end of the 
capillary tube, interfering with its free working, gently wipe it off with the finger, at 
the same time grasping the tube in the hand to cause pressure by body heat and to drive 
the obstructing particles out. Never try to free it with a needle, pin or other instrument. 
fresh lot of the compound, since such an economy may result in spread- 
ing infection. 
Glass as Compared with Metal Containers.-It is maintained by some 
that ethyl chlorid decomposes when exposed to air and sunlight; hence 
that the drug should be kept in metal containers. It is further claimed 
that, inasmuch as ethyl chlorid is inflammable, there is less danger of 
breaking in accidentally dropping the metal container. In opposition to 
this, it may be said that, in filling any container, no air remains in it on 
account of the great volatility of ethyl chlorid. Furthermore, in draw- 
ing off a portion of the contents of a tube, pressure is produced within 
the tube which is constant for each temperature, it matters not how 
much liquid ethyl chlorid is present, so long as there is some liquid 256 
ANESTHESIA 
there; hence no backward pressure is created, whereby air may be sucked 
into the tube. Undoubtedly light facilitates the decomposition of ethyl 
Fig. 118.-The Gebauer Container for Ethyl Chlorid. 
chlorid by oxygen, but it has not been shown that light produces any 
change in ethyl chlorid when oxygen is absent. Assuming that the 
ethyl chlorid is pure, there is another objection to the use of a metal 
Fig. 119.-Technic of Ethyl Chlorid Measure-Dropper. Attach the measure-drop- 
per to an ethyl chlorid tube; holding the tube in a horizontal position with the apex of 
the dropper pointing down, open the valve in the tube by gradually turning the screw 
to the right, allowing the ethyl chlorid to fill the chamber in the dropper, at the 
same time holding the thumb over the opening in the apex of the dropper as shown in 
cut. When the graduated chamber in the dropper is filled to the desired amount, 
close valve again. 
Now hold the tube with the apex of the dropper pointing downward about two or three 
inches directly above the gauze in the inhaler and remove the thumb. The ethyl 
chlorid will now issue from the dropper in forms of drops, which are directed upon the 
gauze in the inhaler. As a general rule 3 to 5 c.c. will suffice to anesthetize a person 
for a short operation, but there is no fixed rule as to the quantity of ethyl chlorid required, 
since some will take more than others. The anesthetist must be guided entirely by the 
symptoms of his patient as to the duration and quantity of the ethyl chlorid required. 
If it is observed that 3 c.c. will not suffice to anesthetize the patient, one simply opens 
the valve again in the tube and lets 1 or 2 c.c. more of ethyl chlorid flow into the gradu- 
ated chamber of the dropper and proceeds as before. If the ethyl chlorid does not 
drop fast enough from the apex of the dropper, it can be made to drop faster by placing 
the thumb or finger over the opening in the neck of the dropper marked "A". With a 
little practice the dropping may be regulated. 
container, namely, inability to tell how much of the preparation is within 
the tube and how much has been or is being used in the anesthesia.. This 
has been met by having a graduated (3 c.c. capacity) dropper made of 
glass, which may be attached to the metal container. The design of such 
a dropper is shown in Figure 119. ETHYL CHLORID 
257 
Impurities Which May Develop in Ethyl Chlorid.-Uncertain re- 
sults have been encountered by several who have used ethyl chlorid for 
general anesthesia and these have been attributed in some cases to im- 
purities that were present and were later detected chemically.1 
The original product must not have been properly purified, for the 
conditions essential for the decomposition of ethyl chlorid itself in- 
volve oxygen, and, as animadverted, oxygen has no opportunity to enter 
the receptacle in which ethyl chlorid is dispensed. The presence of small 
amounts of water may bring about a reverse change in ethyl chlorid, 
with the formation of ethyl alcohol and hydrogen chlorid. The latter 
may readily be detected by spraying some of the drug into a clear silver 
nitrate solution. The appearance of a turbidity indicates free hydrogen 
chlorid, as pure ethyl chlorid does not thus react with silver nitrate. 
Detection of Impurities in Ethyl Chlorid.-The impurities likely to 
occur in ethyl chlorid are (a) those which it brings with it from the 
manufacturer and (b) those resulting through careless storage. While 
the exact nature of all of these is unknown, yet ethyl chlorid, complying 
with the requirements of the pharmacopoeias as given below, is entirely 
suitable for the purposes for which it is intended. On account of its 
volatility, the examination of ethyl chlorid presents more difficulties 
than are encountered in the cases of ethyl ether and chloroform; and it 
is indeed fortunate that it may be easily prepared in a state of com- 
parative chemical purity. 
The Pharmacopoeia of the United States 2 prescribes the following 
tests for purity: 
1. "If 10 c.c. of ethyl chlorid, while cold, be dissolved in alcohol, 
and a few drops of silver nitrate T. S. be added, no turbidity should be 
produced (absence of hydrochloric acid). 
2. "If 10 c.c. of ethyl chlorid be agitated with 10 c.c. of cold water 
and the supernatant stratum of ethyl chlorid be evaporated spontane- 
ously, and if a few drops of potassium dichromate T. S. be added to the 
remaining aqueous liquid, followed by some diluted.sulphuric acid, and 
the mixture be boiled, no odor of aldehyd should be developed, and a 
greenish or purplish color should not be produced in the liquid (absence 
of alcohol). 
3. "On allowing ethyl chlorid to evaporate from clean, odorless 
blotting paper, which has been saturated with it, no unpleasant odor 
should remain upon the paper (absence of sulphur compounds, etc.)." 
The British Pharmacopoeia requires that it should leave no residue on 
evaporation and that an aqueous or alcohol extract should have no acid 
reaction with blue litmus paper. The Deutsches Arzneibuch 3 requires 
1 Hawley: J. Am. Med. Assn., 1906, 47, 502. 
'8th decennial revision, 32 
'1910, 37. 258 
ANESTHESIA 
also that "during evaporation, and, thereafter, no garlic odor should be 
apparent (phosphorus compounds)." The French Codex,1 while giving 
the incorrect specific gravity, states it should be free from ethyl bromid 
and iodid. The Pharmacopoeia Helvetica 2 requires that, when its vapors 
are led through water, the water must not give an acid reaction with 
litmus nor a reaction with silver nitrate. 
All the tests seek to eliminate acids. 
PHYSIOLOGY 
One of us (J. T. G.) has not employed ethyl chlorid, either in the 
laboratory or in the operating room, to such an extent as to warrant the 
consideration of this agent from the point of view of personal experience. 
In the pages which follow, therefore, the reported work of other investi- 
gators is freely and almost exclusively utilized. 
Effects Upon the Respiratory System.-The effect of ethyl chlorid 
upon the lungs, according to Muller,3 is pathological rather than physio- 
logical. Cole 4 found that, when given in the form commercially known 
as somnoform (see p. 276), ethyl chlorid markedly increased the size 
and rate of contraction and the tone of the diaphragm, which remained 
in a state of strong tonic contraction, the heart still beating strongly. 
Embley5 found, from his experiments upon animals, that, as the 
blood pressure fell, respiration ceased, and, as the blood pressure rose, 
the respiration returned. He does not, therefore, agree with other in- 
vestigators in the view that respiration may be paralyzed by ethyl 
chlorid independently of fall of blood pressure, in ordinary administra- 
*1908, 249. 
2 1907, 27. 
3 Muller, B.: "Narkologie, " 1, 454. 
4 Cole: Proc. Physiol. Soc., June 15, 1903; J. Physiol., 29, 25. 
6 Embley: Proc. Roy. Soc., 78, 31 (1906); Pharm. J. (4), 24, 650; Lancet, 
April 20, 1907. The solubility of ethyl chlorid vapor in water at normal pres- 
sure and +21° C. is 253.36 per cent by volume (0.678 per cent by weight) ; and 
the solubility in blood is approximately 500 per cent of vapor by volume at 38° C. 
The heart muscle is paralyzed by ethyl chlorid just as it is by chloroform and 
in contrast with ethyl ether, but the quantity of ethyl chlorid vapor in air 
required is nineteen times as great as that of chloroform to produce similar 
results. On the vascular system the net result is dilatation, but the degree of 
paralysis is strikingly less than that produced by chloroform, even when the 
latter is present in less than one-tenth of the quantity of air inspired. A 
strength of 5 to 7 per cent of ethyl chlorid vapor in the air required appears 
to be the limit of safety from danger of syncope in dogs for prolonged and 
continuous administration, and the conclusions arrived at by Embley are con- 
sidered to apply to man. For the administration of ethyl chlorid he advises 
employing a gasometer containing the proper mixture of air and ethyl chlorid 
vapor. ETHYL CHLORID 
259 
tions. Respiratory arrest is preceded by a remarkable prolongation of 
the respiratory pause. In none of Embley's experiments was the heart 
arrested before respiration. The integrity of the respiratory mechanism 
in ethyl chlorid narcosis, he holds, is dependent upon the maintenance 
of blood pressure. 
Respiratory frequency is not affected as a rule; but McCardie 1 states 
that ethyl chlorid quickens and deepens respiration. 
Effects Upon the Circulatory System.-According to Muller,2 the 
solubility of ethyl chlorid in water is slight and the solution very loose, 
for which reasons the blood-serum takes up only a slight amount. It is 
not much more soluble in blood-serum than in pure water. A small 
amount is, however, taken up by the blood corpuscles. On account of its 
slight solubility in blood-serum, very highly concentrated mixtures of 
air and ethyl chlorid must be carried to the lungs, for, in consequence 
of the loose solution, the vapor is at once given off from the blood, the 
patient awakening promptly unless such highly concentrated mixtures 
are administered. 
Embley,3 who investigated the pharmacology of ethyl chlorid, found 
that the solubility of the vapor in water at normal pressure and 21° C. 
is 253°, 36 per cent by volume (0.678 per cent by weight) ; and the solu- 
bility in blood is approximately 500 per cent of vapor by volume at 
38° C. 
Camus and Nicloux 4 found that ethyl chlorid is taken up by the 
blood with great rapidity, and that it is also eliminated very rapidly. 
All authorities are agreed that in full surgical narcosis with ethyl 
chlorid a very great fall in blood pressure is noted. Even when given 
for a short time, according to McCardie,5 a fall of blood pressure takes 
place. 
Embley 6 says: "The effect of ethyl chlorid upon the heart muscle, 
as is the case with chloroform, is paralytic, but the quantity of ethyl 
chlorid vapor required in the air is nineteen times as great as that of 
chloroform to produce comparable results." He further states that the 
effect of ethyl chlorid upon the arterioles isolated from the central ner- 
vous system is relaxation. (In this respect also it is similar to chloro- 
form, but the amount required is vastly greater.) The effects upon the 
vasomotor mechanism also are parallel with the action of chloroform. 
From his experimental work Embley found that the action of ethyl 
1 McCardie: 1 ' The Position of and Mortality from Ethyl Chloride as a 
General Anesthetic," Brit. Med. J., March 17, 1906, 616. 
2 Muller: Loc. cit. 
'Embley: Proc. Boy. Soc., 78, 31 (1906); Lancet, April 20, 1907; Pharm. J., 
24, 650. 
4 Camus and Nicloux: Compt. rend., 145, 1437. 
"McCardie: Lancet, Oct. 7, 1905; Brit. Med. J., March 17, 1906. 
6 Embley: Loc. cit. 260 
ANESTHESIA 
chlorid on the vascular system caused dilatation. The degree of paraly- 
sis, however, is strikingly less than that produced by chloroform, "even 
when the latter is present in less than 1/10 of the quantity of the air 
inspired." 
Embley concludes: (1) That vagus inhibition of the heart occurs 
very readily in ethyl chlorid vapor of a strength of ten per cent and 
upward when administered in the air inspired; (2) that sudden fall of 
blood pressure occurred during the administration of ethyl chlorid vapor 
in a strength ranging from ten to twenty per cent, owing to vagus in- 
hibition of the heart. If thirty per cent is administered, fall of blood 
pressure is due to weakening of the cardiac arterial musculature; (3) 
that cardiac inhibition is not so serious from ethyl chlorid as it is from 
chloroform. It requires nineteen times more ethyl chlorid to produce 
a given degree of cardiac depression than is required of chloroform, 
while it requires only four times as much to produce cardiac arrest by 
vagus stimulation; hence, inhibition sets in relatively more rapidly. 
Herein rests the relative safety of ethyl chlorid. 
Webster,1 who experimented upon animals with ethyl chlorid, ethyl 
bromid, and ethyl iodid, says: "The difference of any action between 
the chlorid, bromid, iodid and somnoform is one of degree only and 
this degree seems to depend upon the volatility of the drugs." With 
small doses he found that there was a slight rise in blood pressure, fol- 
lowed by a return to normal, whereas, with larger doses, the pressure 
rapidly fell. 
Buxton2 states that flushing of the face, due to dilatation of the 
peripheral vessels, is always associated with ethyl chlorid inhalation, 
and may account, in part, for any fall of blood pressure that takes 
place. When large doses of ethyl chlorid are employed the circulatory 
changes are secondary to the respiratory changes. 
Effects Upon the Nervous System.-Muller holds that the blood car- 
ries the gas into the cerebrum and to the ganglion cells, into the fluids 
of which the ethyl chlorid passes, and is taken up by the cholesterin- 
lecithin mixtures. This results in paralysis of the cells. But, as the 
solubility in the cell-juice is slight, only a small amount of ethyl chlorid 
enters into the cell, insufficient, in short narcosis, to paralyze all the 
cells. Although the centers of pain-sensation may be paralyzed, the 
quantities do not always suffice to paralyze the more resistant centers 
against narcotic agents; as a result, the reflexes, the muscles, and so forth 
are not completely paralyzed, inhibited, or relaxed in the anesthesia. It 
is only after the ethyl chlorid vapors have been inhaled for some time 
that larger amounts of these vapors collect in the central elements of the 
ganglion-cells, in the cholesterin-lecithin mixtures (which dissolve larger 
1 Webster: Bio-Chem. J., 1, 328 (1906). 
'Buxton: "Anaesthetics," 256. ETHYL CHLORID 
261 
quantities of ethyl chlorid than water or blood-serum), inducing a total 
paralysis of the centers. 
The action upon the nerve tissue was studied by Cantelupe, who 
found that ethyl chlorid exerted a double action; on the one hand a 
direct chemical action, and on the other an indirect action, due to cere- 
bral anemia through paralysis of the vasomotor center. The fibers of 
the white substance, in the cerebrum as well as the cerebellum, are found 
to present slight degenerative changes, which are interpreted as the ex- 
pression of the nutritive changes of the nerve-cell, and therefore also of 
its nervous process, and which still persist at the period of awakening. 
Such changes may be purely functional, and therefore curable. 
Effects Upon the Muscular System.-Muscular rigidity may be pres- 
ent during the stage of excitement. In some cases, according to Hewitt,1 
muscular relaxation accompanies stertor, but there is more often some 
rigidity. This rigidity in some subjects may be so general as to cul- 
minate in opisthotonos. The strong tendency to contraction of the 
masseter muscles has been noted by all administrators of this ethyl 
chlorid. 
Effects Upon the Glandular System.-It is held by various observers 
that the gastric and intestinal functions are slightly influenced; the secre- 
tions of the liver and the kidneys are diminished. 
Causes of Death Under Ethyl Chlorid Anesthesia.-From the fore- 
going discussion of the effects of ethyl chlorid upon the organism we 
may agree with the statement of Hewitt 2 that ethyl chlorid may prove 
fatal in two distinct ways, viz.: (1) by simple overdose, ethyl chlorid 
toxemia, or ethyl chlorid syncope; (2) by intercurrent respiratory em- 
barrassment (asphyxia). 
The prominent features of simple overdose, as noted by Hewitt, are: 
pallor, pulselessness, arrest of breathing, wide dilatation of the pupils, 
general muscular flaccidity and separation of the lids. Cardiac arrest 
quickly follows. 
In death from asphyxia with ethyl chlorid the intercurrent respira- 
tory embarrassment, according to Hewitt, may depress a circulation al- 
ready depressed by the agent. The prominent features in this instance 
are: spasm about the jaws, mouth, tongue, larynx, or respiratory mus- 
cles. Respiratory arrest, with some cyanosis, supervenes, followed by 
cardiac arrest. 
Stages of Anesthesia.-The stages of ethyl chlorid anesthesia are a 
little different from those of the other pulmonary anesthetics. 
The 'first stage is an analgesic stage which commences after two or 
three breaths of the anesthetic, and which lasts over thirty seconds. 
1 Hewitt: ' ' Anaesthetics, ' ' 439. 
2 Ibid., 455. 262 
ANESTHESIA 
This is the stage before stertor and other signs of anesthesia appear. It 
is sufficient for opening an abscess, but the operator is taking the risk of 
causing pain unless he works rapidly. 
The second stage is a true anesthetic stage which lasts from one to 
three minutes after removing the mask from the face.' In fact, the 
anesthetic stage is sometimes deepened after the removal of the mask, 
owing to the absorption of the ethyl chlorid from the lower air passages. 
On account of the spasm of the masseter, as frequently happens during 
this stage, it is necessary that a dental prop be inserted between the 
teeth in all cases, and not only when intra-oral operation is contem- 
plated. 1 
The third stage is again one of analgesia. It lasts from 30 to 40 
seconds, during which no sensation is felt, but the patient may talk or 
move slightly. Just before the patient becomes conscious, swallowing 
occurs for some little time. The first sense to return is hearing, and 
the next is sight. 
The fourth stage, when the administration is continued too far, 
corresponds to that of other inhalation anesthetics under the same cir- 
cumstances, viz., the bulb is affected, causing cessation of respiration, 
arrest of the heart, and death. 
In prolonged ethyl chlorid narcosis, Muller distinguishes four stages, 
as in all narcoses. The first and second stages are very brief. The re- 
flexes, however, are lost, and the pupils present exactly the same be- 
havior as in other narcoses. In the brief narcosis, on the other hand, 
the pupils continue to react, nor are the other reflexes lost. 
Herrenknecht,2 whose experience with ethyl chlorid as a narcotic 
agent was so entirely satisfactory that he earnestly endorsed its employ- 
ment, distinguished four stages of narcosis, as follows: (1) The pre- 
narcotic analgesic stage; (2) the stage of excitement; (3) the stage of 
deep sleep; (4) the post-narcotic analgesic stage. 
The first stage, according to Herrenknecht, is chiefly characterized 
by the diminishing frequency of the pulse and respiration, the deepen- 
ing of the respiration and the onset of moderate muscular tension. The 
eyeballs are almost invariably turned upward. The patient is still con- 
scious, however, and aware of the fact that he is being operated upon, 
although there is not the least sensation of pain. The hearing is still 
completely preserved in this stage. 
The second stage, or stage of excitement, occurred only rarely in the 
experience of Herrenknecht, and was limited to habitual abusers of al- 
cohol and to very nervous and excitable patients. As a prophylactic 
measure, he always administered morphin, or preferably morphin- 
1 Boyle: "Practical Anesthetics," 126. 
2 Herrenknecht: "3000 Aethylchloridnarkosen, " Miinch. med. Woch., 1907, 
No. 49, 2421. ETHYL CHLORID 
263 
scopolamin, to patients of this type, prior to the narcosis; and more 
ethyl chlorid was injected into the mask, in order to hasten the third 
stage. 
The third stage is characterized by muscular relaxation, and com- 
plete loss of reaction to external stimuli; the conjunctival and corneal 
reflexes have disappeared; the patient appears as if quietly asleep. 
The fourth stage resembles the first, except that the patient con- 
veys the impression of being wide awake; there is no noteworthy pain. 
The fourth stage is hardly ever absent, not even when the third stage 
has not been reached and the supply of ethyl chlorid has been stopped 
after the onset of the first stage. The end of the fourth stage is recog- 
nized by the movements of defense on the part of the patient, and the 
manifestation of pain on operative interference. 
The signs of complete anesthesia under ethyl chlorid are: (1) A 
quick, deep, and regular respiration; (2) eyeballs fixed or rolling; (3) 
face usually slightly flushed; (4) muscular relaxation or rigidity; (5) 
pupils widely dilated; (6) absence of conjunctival and corneal reflexes. 
A continuous, safe narcosis is not easily maintained with the present 
methods. Much cyanosis is a signal for the admission of air or the 
temporary discontinuance of the anesthetic. Respiratory embarrassment 
and spasm of the jaw are common in muscular subjects. Increasing 
stertor is a signal for more air. 
The best guide is probably the respiration. If the anesthesia is very 
deep, cessation of the administration is indicated. It is to be borne in 
mind that anesthesia is deepened after the administration is discon- 
tinued, owing to the absorption of the agent from the lower air-passages. 
The pulse is usually slow. 
The signs of an overdose are: (1) Unusually widely dilated and 
fixed pupils; (2) very great pallor; (3) intermittent respirations or 
gasping for breath. 
Elimination.-Experiments were performed by Lotheissen,1 to deter- 
mine if ethyl chlorid was still demonstrable in the expired air some 
time after the narcosis. For this purpose, the expired air was passed 
through a pure concentrated alcoholic solution of potassium hydroxid 
into water, which was then heated and mixed with a solution of silver 
nitrate, in order to test for the presence of chlorin. The reaction never 
occurred when the inspired ethyl chlorid was expired through this appa- 
ratus; whereas it appeared at once after the direct introduction of even 
small traces of ethyl chlorid vapor. Upon the basis of these observa- 
tions, Lotheissen concluded that ethyl chlorid was not breathed out 
again in the undecomposed state, the chlorin, at least, disappearing 
from the expired air. But as this air did not possess the odor of mus- 
1 Lotheissen: ' ' Aethylchlorid Sauerstoff Narkose," Arch. Idin. Chir., 1910, 
91, 65. 264 
ANESTHESIA 
tard-oil, Lotheissen was of the opinion that a chemical change occurred; 
perhaps the formation of ethyl thiocarbimide (C3H5NS), for the lungs 
have a strong reducing power. At any rate, the ethyl chlorid does not 
remain fixed for any length of time, so that it cannot exert a prolonged 
narcotizing effect, which means a great advantage in case of threatened 
asphyxia. 
The excretion of ethyl chlorid1 takes place mostly through the 
lungs; especially in brief narcosis nearly all the vapors are again elimi- 
nated by the lungs relatively rapidly on account of the looseness of the 
solution in the blood. The kidneys and other glands enter only very 
slightly into consideration in brief narcosis, essential amounts of ethyl 
chlorid being eliminated by those organs only in prolonged narcosis. 
The very slight solubility in the blood-serum also induces the complete 
absence of gastric affections, nausea, vomiting, etc., after brief narcosis, 
for the small quantities in the blood are at once eliminated and do not 
pass into the gastric juice, or do so only in very minute amounts, devoid 
of any effect. In prolonged narcoses, larger amounts enter the blood and 
are also secreted into the gastric juice, giving rise to nausea or even 
vomiting after awakening. The solubility in the cholesterin-lecithin 
mixtures, which are formed in the protoplasm of the cells, is also less 
than with chloroform or ether, for example, so that no such quantities 
can accumulate in the cells. When the inhalation of new vapors in the 
narcosis ceases, no new quantities are taken to the cells, but the quanti- 
ties contained in the cells are reeliminated. However, this elimination 
can take place only in the quantities which the blood-serum is capable of 
dissolving. As the cholesterin-lecithin mixtures of the ganglion cells 
dissolve ethyl chlorid, and therefore accumulate the same during the 
narcosis, in considerably larger quantity than the blood-serum is capable 
of dissolving, the narcosis will naturally continue until the last quanti- 
ties of ethyl chlorid have been eliminated from the ganglion cells. In 
a brief narcosis, these accumulated quantities are very trifling in 
amount; after a prolonged anesthesia, however, they reach a certain 
amount beyond which one must not pass or the patient will die. As 
ethyl chlorid is only slightly soluble in cholesterin-lecithin mixtures- 
less than chloroform, for example-this quantity is smaller than what is 
stored up in the ganglion cells. Nevertheless, after prolonged narcosis, 
this quantity of ethyl chlorid will suffice to produce after-effects, in the 
form of vertigo, headache, etc. 
After-Effects.-Concerning the after-effects of ethyl chlorid upon 
the animal organism, Konig 2 states that the result of the examination of 
the urine of the animals for albumin proved negative in all his experi- 
ments. Examinations were made a few hours after the narcosis, and on 
1 Muller: Loc. cit. 
'Konig, R.: "Die Chloraethylnarkose,'' Arch. Iclin. Chir. 1912, 99, 147. ETHYL CHLORID 
265 
the next day. This serves to show that the ethyl chlorid exerts no in- 
jurious action upon the blood corpuscles and the kidneys, leaving no 
noteworthy after-effects in this respect. 
The after-effects occurred in so far, however, as all the animals were 
found to undergo a more or less considerable loss of body weight, usually 
about 100 gm., within 8 to 10 days. Several animals suffered from diar- 
rhea. Rabbits which were narcotized repeatedly, on successive days, or 
every other day, recovered very slowly from the narcosis; they were ex- 
tremely drowsy and weak, a considerable time elapsing before the normal 
condition was reestablished. This observation, as well as the loss in 
body weight, combined with severe diarrhea, permits the conclusion that 
ethyl chlorid hardly leaves the organism so rapidly as is generally as- 
sumed to be the case. Perhaps there occurs a chemical change, namely, 
a decomposition of the ethyl chlorid in the lung, which organ is said to 
possess a strong reducing power. It is probable that this was suggested 
by Lotheissen, who asserted after his experiments that at least the 
chlorin must disappear from the expired air, as it is no longer de- 
monstrable in the same. Konig points out that Lotheissen's experiments 
and conclusions are not tenable, and that these investigations in no way 
prove a retention of chlorin in the organism. 
Clinically, the after-effects vary according to the preparation of the 
patient, the length of the administration, and the method employed. It 
is conceded by all unbiassed observers that vomiting is one of the com- 
monest after-effects, occurring in from 15 to 20 per cent of cases. Nau- 
sea associated with headache occurs in even a greater percentage. The 
nausea is the same as in ether narcosis, but of shorter duration. It 
seldom lasts over 15 minutes; in exceptional cases, however, it has lasted 
30 hours.1 Hysterical symptoms may appear in young girls and erotic 
patients. Erotic thoughts and dreams may occur with this anesthetic as 
with nitrous oxid and oxygen. (It is for this reason that the anesthetic 
should never be administered except in the presence of a third person.) 
Fainting and collapse are sometimes observed. Jaundice has been re- 
ported in a few cases, showing the effect upon the liver. Albuminuria is 
absent except in prolonged cases. Fatty degeneration of the kidneys and 
liver has been noted after repeated administrations. These symptoms 
may come on in from one to six hours after the administration and 
may continue for several hours. Collapse is more liable to follow ethyl 
chlorid than any other anesthetic.2 This is the principal reason why 
attempts have never been made at a prolonged anesthesia with this drug. 
Symptoms of asphyxia appear only with too highly concentrated vapors, 
or when the inhalation is continued after the onset of prolonged slum- 
ber; i. e., when the so-called narhosenbreite (extent of narcosis) is ex- 
ceeded. 
1 Hewitt: Loc. cit., 446, 
' Ibid. 266 
ANESTHESIA 
Comparison with Other Anesthetic Agents.-The narcotic power of 
ethyl chlorid, when administered by inhalation, mixed with air, is simi- 
lar to that of ether, and weaker than that of chloroform. Because of 
the rapidity with which it abolishes consciousness, and the evanescent 
effects (fugaciousness) of the agent, unless these are forestalled, it is 
more comparable to nitrous oxid than to either chloroform or ether. 
Maass,1 who is an opponent of ethyl chlorid narcosis, maintains that, 
in regard to its absolute danger, ethyl chlorid should be ranked as at 
least equal to chloroform, for like the latter it may cause heart-death. 
Relatively, ethyl chlorid is more dangerous than chloroform, in so far 
as its desirable as well as undesirable effects are characterized by the 
rapidity of the onset and the almost instantaneous development to a 
climax; while the risk of a fatal overdosage is rendered imminent by the 
smallness of the permissible dose, as well as the impossibility of working 
in great dilution with air. For this reason, the successive use of ethyl 
chlorid and chloroform is by no means advisable, as the prepared or 
suggested injury through the brief ethyl chlorid anesthesia will develop 
to such an extent in the following chloroform-narcosis, by the summa- 
tion of the stimuli, as it were, as to endanger the patient's life to an 
alarming degree, especially as the disturbances concerned in the summa- 
tion all affect the circulatory system. In a similar way, Maass also 
considers the beginning of ether narcosis with ethyl chlorid as an added 
danger. Ethyl chlorid cannot even remotely concur with nitrous oxid, 
where the effect of the latter suffices, for this gas is very much less dan- 
gerous than ethyl chlorid. It is better to employ ether, he holds, when 
nitrous oxid or local anesthesia is not sufficient. The respiration and 
the heart action are apt to be overwhelmed very suddenly, the ethyl 
chlorid attacking the body so vehemently that it succumbs before the 
system can accommodate itself to its action. 
Ethyl chlorid is appropriate for use in the act of parturition, be- 
cause the patient's exhaustion permits the production of a relaxed state 
approaching analgesia with small doses of an anesthetic sufficient for the 
application of forceps. Another special indication for ethyl chlorid is 
in war surgery, because soldiers who have been anesthetized with ethyl 
chlorid awaken sooner and more completely, and thus become fit for 
transportation, than those who have received ether or chloroform. 
Furthermore, ethyl chlorid involves less danger of shock than chloro- 
form, for wounded soldiers suffering from both physical and mental ex- 
haustion. 
The advantages of ethyl chlorid as compared with other liquid in- 
halation, or aliphatic anesthetics, consist in the rapidity with which it 
produces anesthesia, and the usually complete absence of after-effects, 
1 Maass: ' ' Chloraethyl als Inhalationsanaesthetikum, ' ' Therap. Monatsh., 
1907, 303. ETHYL CHLORID 
267 
when properly employed. On the other hand, ethyl chlorid can in no 
way replace either chloroform or ether, where prolonged loss of sensa- 
tion is required, its great toxicity strictly forbidding the exceeding of a 
maximum dose of 5 c.c. 
Upon the basis of his experience, Herrenkneeht1 concludes that ethyl 
chlorid is the least dangerous narcotic which we possess at present, not 
even excepting nitrous oxid. However, it is not applicable for prolonged 
narcoses, because the scope of the narcosis is evidently not a wide one 
in the case of ethyl chlorid, and is therefore easily surpassed. It is 
naturally dangerous when too much is given in a short time of such a 
highly efficient agent, capable of so rapidly inducing narcosis. The in- 
halation should be interrupted with the onset of muscular relaxation and 
disappearance of reflexes. According to animal experiments, and the ex- 
perience of other observers with patients, respiration usually stops first 
with ethyl chlorid, followed by failure of the heart action. Hence, im- 
mediate artificial respiration, perhaps combined with cardiac massage, 
will probably always prevent a threatened death, as the very volatile com- 
pound promptly escapes from the body. In spite of the large number of 
his ethyl chlorid narcoses (3,000) Herrenkneeht has never yet been 
obliged to resort to artificial respiration or stimulation with camphor. 
Hewitt2 thinks that ethyl chlorid is far more dangerous than nitrous 
oxid and distinctly more dangerous than ether, the reason for this being 
stated as the considerable fall of blood pressure which takes place. Re- 
garding its safety, Boyle 3 says ethyl chlorid cannot be compared with 
nitrous oxid and oxygen, and rates its dangers as equal to those of chloro- 
form. Luke and Ross 4 state that this drug is safer as an anesthetic 
agent than ether, chloroform, or ethyl bromid, but that it must not be 
considered as safe as nitrous oxid. 
Behr 5 indicates, as special advantages of ethyl chlorid, the relative 
harmlessness of the drug when used in suitable doses, its pleasant odor, 
which facilitates its employment, more especially for children, also the 
absence of a feeling of suffocation and the diminution of the stage of 
excitement, the rapid induction of anesthesia, the speedy return to con- 
sciousness, and, finally, the total absence of after-effects. 
INDICATIONS AND CONTRAINDICATIONS 
Indications.-In this discussion of the indications for the use of 
ethyl chlorid no reference will be made to the administration of this 
1 Herrenkneeht: Loc. cit. 
* Hewitt: ' ' Anaesthetics, ' ' 1907, 135, 444. 
'Boyle: Practical Anaesthetics," 1907, 141. 
'Luke and Ross: 'Anaesthesia in Dental Surgery." 
Behr: Berl. klin. Woch., 1911, No. 2, 67. 268 
ANESTHESIA 
agent as a preliminary to ether or chloroform, this phase of the subject 
being considered under each respective combination or sequence. 
Children, according to all the writers consulted in this connection, 
are the best subjects for the administration of ethyl chlorid. It has 
been used as a routine anesthetic for children five days old and up- 
ward,1 being especially well borne by infants from a few weeks to a few 
months old. Children of any age, up to about eight years, take this 
anesthetic, as a rule, without difficulty, losing consciousness and becom- 
ing quiet in about ten seconds, and giving a satisfactory anesthesia of a 
minute or a minute and a half. It is preferred by some 2 to any other 
agent for circumcisions, for example, and for the majority of short 
operations in children under eight years of age.3 In dental operations 
upon children, where not more than two teeth are to be extracted, and 
for removal of tonsils and adenoids, it is advocated.4 
Luke and Ross,5 Cantlie,6 Mortimer,7 and many others, consider ethyl 
chlorid preferable to nitrous oxid for short operations upon very young 
subjects. 
Adults present no special indications for ethyl chlorid anesthesia. 
This agent may be given satisfactorily, however, to very aged and anemic 
subjects,8 but great care is advocated 9 in such cases, the recumbent posi- 
tion being insisted upon. In patients whose general condition is satisfac- 
tory, and when the administration is skilfully conducted, ethyl chlorid 
may safely be employed.10 
For short operations, where greater muscular relaxation is required 
than is obtainable by nitrous oxid, or where a deeper narcosis is desired, 
for short examinations or operations in gynecological work, and in brief 
operations in obstetrical practice, ethyl chlorid may be satisfactorily 
employed.11 
Contraindications.-The earlier advocates of ethyl chlorid acknowl- 
edged practically no contraindications to its use. Girard, for example, 
according to McCardie,12 held that circulatory troubles and respiratory 
affections did not contraindicate its use; neither age nor sex, nor alcohol- 
1 Mortimer: ' ' Anesthesia and Analgesia, ' ' 50. 
2 Knight, H. Astley: "Notes on Ethyl Chloride,'' Brit. Med. J., March 17, 
1906, 618. 
3 McCardie: Loc. tit. 
* Cantlie, James: "Anesthetics and Surgical Technique.'' 
s Luke and Ross: ' ' Anesthesia in Dental Surgery, ' ' 92. 
'Cantlie: Loc. tit., 171. 
' Mortimer: Loc. tit., 50. 
8 Luke and Ross: Loc. tit., 92. 
9 Buxton. 
19 Hewitt: Loc. tit., 441 (1907). 
"McCardie: Brit. Med. J., March 17, 1906, 617. 
12 Ibid. ETHYL CHLORID 
269 
ism, nor other intoxications forbade its administration. The only doubt- 
ful factor was the state of the urinary organs. 
In a general way it may be stated that robust, athletic, and alcoholic 
subjects and confirmed smokers present contraindications to the use of 
ethyl chlorid, as do likewise persons suffering from chronic or acute 
diseases. Any obstruction to swallowing renders ethyl chlorid danger- 
ous. Respiratory affections, whether due to contracted or small air 
passages, to marked pharyngeal catarrh, or to diseases of the lungs in- 
volving marked respiratory embarrassment, particularly in the presence 
of bronchorrhea, are contraindications to the administration of this 
agent. Feeble heart action, with a probability of fatty degeneration, is 
given as a contraindication. 
It is generally conceded that ethyl chlorid is not suitable for oper- 
ations, long or short, during which absolute muscular relaxation is de- 
sired. 
ADMINISTRATION 
Experimental Data.-According to Konig,1 a careful examination of 
the available literature concerning the dosage of ethyl chlorid shows 
the remarkable fact that, up to the present time, no exact dosage has 
been stated. Very imperfect methods have been employed, which by no 
means permitted an accurate dosage of the ethyl chlorid in the inspired 
air. The quantity of the liquid narcotic used is not decisive for the 
course of the narcosis, but the decisive factor consists in the amount of 
narcotic vapor which is mixed with the air breathed by the patient, or 
the laboratory animal; in other words, the vapor tension of the inspired 
air. The quantity of narcotic taken up by the blood and the tissue juices, 
Konig asserts, is dependent upon the ethyl chlorid contents of the in- 
spired air; the higher the latter (up to a certain degree), the more is 
taken up by the blood from the inspired air. When constantly new air 
saturated to the same degree with ethyl chlorid is supplied to the in- 
dividual, just as much as has already been excreted from the blood will 
be taken up again. The contents of the blood in ethyl chlorid, there- 
fore, will be adjusted to a certain standard which is dependent upon the 
contents of the inspired air in these vapors. 
In view of the fact that the dose of ethyl chlorid required for nar- 
cosis (meaning the smallest dose at which narcosis just begins) is not 
known, Konig endeavored, in a series of experiments, to establish the 
amount of the smallest narcotizing dose, by the use of accurately meas- 
ured quantities. It was also important to obtain in all cases a complete 
narcosis, that is, a narcosis with less of the corneal reflex and relaxation 
of the muscles. Furthermore, the longest possible duration of the nar- 
1 Konig: Loc. cit., 147. 270 
ANESTHESIA 
cosis was aimed at, in order to study the effects of ethyl chlorid in ex- 
tensive narcoses, such as are absolutely necessary for operative purposes. 
The animals serving for these experiments were frogs and rabbits. 
The latter were selected for the reason that they are best adapted to 
experimental investigations, and also because all the experiments for the 
determination of the narcotizing dose of an anesthetic agent have been 
almost exclusively performed upon rabbits. The ethyl chlorid of Hen- 
ning (Berlin) and the preparation of Kahlbaum (Berlin) were used 
for these experiments. In order to grade the dose with accuracy, it was, 
of course, necessary for the preparations to be absolutely pure. The 
purity was determined by passing the ethyl chlorid vapors into water, 
and ascertaining that this water neither reddened blue litmus paper nor 
became at once opaque upon acidulation with nitric acid and addition of 
silver nitrate. 
A number of experiments were performed on rabbits, using a mask, 
in order to employ the customary method of narcosis in the human sub- 
ject. The idea was to obtain a short but deep narcosis, with muscular 
relaxation and disappearance of the corneal reflex. The customary pro- 
cedure was therefore exactly followed, meaning that doses of 2 to 5 c.c., 
averaging 4 c.c., of ethyl chlorid, were administered at the beginning 
of the narcosis, which was then continued with smaller quantities, 1 
to 2 c.c. These narcoses were invariably associated with extreme restless- 
ness on the part of the rabbits. The most violent tonic-clonic spasms 
appeared constantly, and were usually increased to an enormous in- 
tensity. The extremely rapid onset of the narcosis was characteristic of 
the experiments with the mask; the corneal reflex was usually lost as 
soon as one minute later, and deep narcosis with complete muscular re- 
laxation set in. But there again at once appeared the rhythmic twitch- 
ing, typical for rabbits, independent of the respiration, frequently lim- 
ited to the extremities, but often involving the entire body of the animal. 
Chewing spasms, and, in consequence, salivation, as well as opisthotonos 
and exophthalmos, were almost invariably demonstrable. Respiration 
was always extremely irritated. There was severe dyspnea, rapidly in- 
creasing to such a degree, with concentrated vapors, as to terminate at 
last in arrest of breathing. On immediate removal of the mask, and in- 
stitution of artificial respiration, the breathing promptly returned spon- 
taneously (with the exception of one case), and the animal soon awoke. 
The awakening always took place very rapidly, after one or two minutes, 
as a rule, as soon as the animals were supplied with fresh air. Other- 
wise the narcosis took the usual course of prenarcotic excitement and 
increased muscular tonus; muscular relaxation in the stage of deep nar- 
cosis; and another postnarcotic increase of the muscular tonus, with a 
certain analgesia. The pupils were usually dilated, and the eyeballs 
were prominent, causing marked exophthalmos. Frequently distinct ETHYL CHLORID 
271 
cyanosis was demonstrable. These. symptoms were due to vasomotor 
paralysis. Arrest of respiration invariably preceded the stoppage of the 
heart action, showing that ethyl chlorid, on account of its first stimu- 
lating and then paralyzing action upon the respiratory center, is not an 
indifferent narcotic, although the dangerous asphyxia can usually be 
prevented, or removed, by suitable precautionary measures. 
The most important results of Kenig's experiments, from the stand- 
point of the therapeutic employment of ethyl chlorid, are as follows: 
The smallest narcotizing dose of ethyl chlorid, for cold-blooded animals, 
is about 2 volume per cent (1.85 vol.) ; for warm-blooded animals, about 
4 or 9 volume per cent, respectively. The fatal dose cannot be accurately 
stated. In cold-blooded animals death was caused with a dose of about 
15 volume per cent. The narcotization-zone of ethyl chlorid is ex- 
tremely wide. Although the facts established upon rabbits cannot all be 
unconditionally referred to man, the efficient doses for man must be 
nearly the same as that for rabbits. 
Methods of Administration.-The authors of this volume are con- 
vinced, from a review of the literature of ethyl chlorid employed as an 
inhalation anesthetic, that the best possible method for the administra- 
tion of this agent has not yet been evolved. Theoretically, the best and 
safest method of administration is with warmed, moistened, and oxygen- 
ated vapor of ethyl chlorid. So far as we are aware, this method has 
not been employed in full, no one having experimented with warmed 
ethyl chlorid vapor. Under Combinations and Sequences (p. 276) it 
will be seen that this agent has been employed with oxygen. An appa- 
ratus could easily be devised for administering the vapor warmed, moist- 
ened and oxygenated, and in definite amounts, in known percentages of 
the combined vapors. With these modifications of technique, and with 
the preliminary use of an alcoholic solution of oil of bitter orange peel, 
as indicated, doubtless many of the objections to ethyl chlorid as a gen- 
eral anesthetic might be overcome. Its field of usefulness might like- 
wise be widened. 
Hewitt1 calls attention to two important points in connection with 
the administration of ethyl chlorid which help to explain the incidence 
of dangerous symptoms. "In the first place," he says, "ethyl chlorid 
narcosis is, by the method now in use, so rapidly induced that it is 
usually difficult or impossible to recognize any stages or degrees in the 
administration. In the second place, the appearance of the patient dur- 
ing full narcosis is unattended either by cyanosis or pallor-symptoms 
which with nitrous oxid and with chloroform respectively indicate that 
a sufficiently large quantity of the drug has been given. When these 
two points are borne in mind it will readily be seen that, unless proper 
care is taken, the limits of safety may readily be overstepped, and that 
1 Hewitt: Loc. cit., 1907, 442. 272 
ANESTHESIA 
the patient may be plunged, with few if any intervening symptoms, from 
a safe to a dangerous degree of narcosis. If cyanosis is present it is 
due to 'overcrowding.' " 
Open Method.-The open method of administration has nothing to 
commend it save its seeming safety, which, to the superficial observer, 
lies in a large intake of an unlimited supply of air together with un- 
known quantities of ethyl chlorid. 
An ordinary chloroform mask is placed over the patient's face and 
ethyl chlorid is administered drop by drop, or a small stream of ethyl 
chlorid is intermittently sprayed upon the mask until anesthesia ensues. 
The anesthesia produced in this way seems to be perfectly safe, but cer- 
tainly no more so than the anesthesia produced by Ware's mask. 
Anesthesia produced by the open method has been kept up from 
thirty to forty minutes. Care must be taken to stop its administration 
immediately upon rigidity or spasm. As long as the respirations are 
free and clear, there is seemingly no danger from this method. 
Collapse is less liable to occur after prolonged anesthesia with the 
open method than with the closed. 
Milne,1 who reports 600 cases of ethyl chlorid anesthesia, 300 by the 
open method and 300 by the closed method, from his experience, advo- 
cates the open method. 
Malherbe's 2 method of administration is as follows: A handkerchief 
is held in the palm of the right hand, which is hollowed out to receive it. 
Into this hollow a jet of chlorid of ethyl is sprayed, 2 to 4 c.c. The 
"compress" is then firmly applied over the mouth and nose of the patient, 
who is instructed to breathe deeply. The head and lower jaw are sup- 
ported with the left hand. "It is absolutely necessary," he says, "not to 
allow any air to be breathed." Anesthesia is complete in 30 to 40 sec- 
onds. If the operation is protracted, he renews the dose, claiming that 
15 c.c. is sufficient for 15- or 20-minute operations. He also reports, from 
a colleague, 93 operations, lasting from 8 to 48 minutes, the patients 
varying from very young infants to two patients over 80 years of age. 
Semi-Closed Method.-Martin Ware3 has reported one or two thou- 
sand cases without a fatality. The apparatus which he used consists of 
a rubber face-piece, into which a tube three to five inches long is in- 
serted; a few layers of gauze are placed between the tube and mask. A 
stream of ethyl chlorid is directed on the gauze intermittently, thus ap- 
1 Milne: ' ' The Administration of Ethyl Chloride by an Open Method, ' ' 
Brit. Med. J., 1911, 1051. 
2 Malherbe: ' ' Chloride of Ethyl as a General Anesthetic, ' ' Med. Press and 
Circ., 1911, 91, 461. 
'Ware, Martin: Med. News, Aug. 3, 1901; Med. Bee., April 6, 1901. 
On ethyl chlorid in general anesthesia, see A. M. Bodge: Boston Med. and 
Surg. J., Feb. 25, 1909, 234. Leighton (St. Louis Med. Bev., Feb. 16, 1907) 
considers the combination ethyl chlorid-ether an ideal one. ETHYL CHLORID 
273 
proximating the drop method of chloroform; a layer of hoarfrost quickly 
forms, due to the freezing of the watery vapor of the expired air. As 
this frost covers the gauze, a hissing noise is heard as the patient goes 
into the third stage of anesthesia. If the gauze is entirely covered with 
ice, the mask should be immediately removed upon inspiration and re- 
placed again upon expiration. 
Ware stated that relaxation can be readily secured in children, and 
also in alcoholics, when a preliminary injection of morphin is given. 
With neurotics, relaxation is very difficult to secure. He estimated the 
Fig. 120.-Martin Ware's Apparatus for Administering Ethyl Chlorid. 
failures at five per cent. By failure was meant a prolonged period of 
excitation, and, while the patient was seemingly narcotized, the possi- 
bility of causing muscular rigidity by painful manipulations. 
Closed Method.-In order to obtain the best results from ethyl 
chlorid, it is necessary to employ a rubber bag large enough to receive 
three or four full expirations, and some arrangement for allowing the 
ethyl chlorid to enter the bag below so that there may be a very gradual 
mixture of the ethyl chlorid with the expired air. The connections be- 
tween the mask and the bag must be large enough not to interfere with 
respiration in the slightest way. This being so, the small tubes contain- 
ing 3 to 5 c.c. of ethyl chlorid may be easily attached to a stopcock of 
any gas-ether apparatus. A rubber tube large enough to hold the glass 
ethyl chlorid tube securely (admitting the small glass apex of the ethyl 
chlorid container well into the caliber of the tube) may be attached to 
the bag as shown in the illustration (Fig. 121). A piece of cotton or 
gauze must be placed between the end of the glass tube and the bag so 
as to prevent any glass entering the bag. After the bag has been in- 
flated by the respirations of the patient, this tube may be broken be- 
tween the thumb and first two fingers of the anesthetist's hand and the 
ethyl chlorid allowed to go into the bag. When the closed method is 
followed, one or two cubic centimeters of ethyl chlorid is sufficient for 
children, and for feeble and anemic adults. Five cubic centimeters will 
be found sufficient, as a rule, for adults, alcoholics, and athletes. 274 
ANESTHESIA 
Whether the patient is in the recumbent or sitting position, the head 
must be on a line with the body, thus insuring an absolutely free air- 
way. No pillows should be allowed under the head unless some de- 
formity, such as accompanies rheumatism, will not permit of the head 
going back. If the operation is one in which the mouth is to be opened, 
such as extraction of teeth, adenoids, and tonsils, and excision of the 
tongue, a mouth gag must be inserted before the administration com- 
mences, otherwise difficulty may be experienced in opening the mouth. 
It sometimes happens that, even with full surgical narcosis, the masseter 
muscle may be firmly contracted, making it almost impossible to 
Fig. 121.-Ethyl Chlorid by the Closed Method, 
pry the teeth apart. The duration of an administration given by the 
closed bag and inhaler can be expected to be from one to three minutes. 
The administration is conducted as follows: 
Upon expiration, the mask is firmly applied to the face; upon inspira- 
tion it is raised slightly, say from % to 14 of an inch from the face, and 
reapplied immediately, so as to catch the full expiration. In from 
three to five respirations the bag will be full, when it must be held firmly 
in place upon the face. The ethyl chlorid tube is now broken and, if 
at the end of a minute the patient is not completely under the influence 
of the anesthetic, the end of the bag can be tilted up slightly, when the 
ethyl chlorid will mix more intimately with the inclosed air. In full 
surgical anesthesia the muscles are relaxed, with the exception of the 
masseter, as stated before. The pulse is full and bounding and increased 
in rapidity. The respirations in an ideal anesthesia are also full and 
regular but not as full as with nitrous oxid and oxygen, or with ether 
by the closed method. Usually there is some stertor, the eyes may be 
fixed and turned downward, the pupils dilated and the lid reflex abol- 
ished. There is no cyanosis or jactitation. If too large a dose is given 
or the inhaler is held on the face too long, there may be a rigidity or ETHYL CHLORID 
275 
opisthotonos. The color should be pink; if cyanosis or spasm is present 
the mask must be taken off the face and again reapplied. 
The average time required to induce anesthesia is one minute. If an 
anesthesia of from five to fifteen minutes is required, a breath of air 
should be given and the inhaler reapplied about every four to six respira- 
tions, with the occasional spraying of a little ethyl chlorid into the inhaler. 
The method last described, of introducing ethyl chlorid at the bot- 
tom of a closed bag through a stopcock, was first proposed by Hewitt. 
Hewitt,1 from the experi- 
mental work of Kdnig, and from 
his own clinical observations, con- 
cluded that, "as with other anes- 
thetics, the effects produced by 
ethyl chlorid primarily depended 
upon its vapour tension in the at- 
mosphere presented to the patient. 
But the last-named observations 
tend to show that there is no defi- 
nite percentage mixture the con- 
tinuous inhalation of which will 
produce satisfactory results. With 
percentage mixtures sufficiently 
weak to be respirable without dis- 
comfort an unsatisfactory type of 
anesthesia results; while with 
mixtures sufficiently concentrated 
to produce narcosis satisfactorily 
the initial sensations are so un- 
pleasant as to prescribe such 
initial vapour concentration. So 
far as our present knowledge ex- 
tends," he continues, "it would 
seem that, with this anesthetic, 
the best results are to be obtained 
by a rational and cautious use of 
the close system of anesthetization, the vapour being gradually but in- 
creasingly added to the to-and-fro respiratory current till anesthesia takes 
place. We have yet to ascertain whether any special concentration of 
vapour should be aimed at, after consciousness has been destroyed, and, 
if so, how such concentration may be secured. We have also to deter- 
mine by future research the relative influences of the oxygen limitation 
and the carbonic acid retention which are involved in close methods of 
administering ethyl chlorid." 
Fig. 122.-Davis Ethyl Chlorid-Ether 
Inhaler: Closed Drop Method. 
'Hewitt: Loc. cit., 431. 276 
ANESTHESIA 
From his experience Hewitt found that if ethyl chlorid is admin- 
istered to adults from an open or semi-open inhaler large quantities of 
the drug will be needed to bring about even partial anesthesia, the third 
stage not being attained in many cases. He found that unsatisfactory 
anesthesia was obtained when attempts were made to administer, by the 
valveless method, percentage mixtures of ethyl chlorid and air, that is, 
without rebreathing. When half the amount was given by the valve- 
less system and the other half by rebreathing, the results were still un- 
satisfactory. He next tried a definite ethyl chlorid and air mixture 
diluted with a further unknown quantity of air by the valvular system,- 
the pure mixture, of known composition, being breathed by the same 
system, the remainder of the mixture being breathed by the close system. 
The results were again unsatisfactory, swallowing and shallow breathing 
characterizing the administration. A measured quantity (5 c.c.) of 
ethyl chlorid was next given by means of a Clover inhaler, to which was 
attached a bag containing 10,000 c.c. of air. The expirations were at 
first allowed to escape but were retained during the second half of the 
administration. This method proved more satisfactory than any of the 
preceding. His final experiments were with the following procedure: 
"(1) Placing 3,000 c.c. of atmospheric air in a bag; (2) allowing the pa- 
tient to commence rebreathing this air; and (3) gradually diffusing 
therein a measured amount of ethyl chlorid contained in a small glass 
tube connected with the bottom of the bag." With this method the re- 
sults were satisfactory in thirteen cases in which he first tried it, but sub- 
sequently it was found to be somewhat less satisfactory than when the 
patient's own expired air, as opposed to fresh air, was used to partially 
fill the inhaling bag before the introduction of the ethyl chlorid." 
For further information relative to the administration of ethyl 
chlorid, see additional bibliography at end of chapter. 
Combinations and Sequences.-Somnoform.-Somnoform is a mix- 
ture of 5 per cent ethyl bromid, 60 per cent methyl chlorid, and 35 
per cent ethyl chlorid. It is not so stable as ethyl chlorid, having a 
greater tendency to decompose, and, like the latter drug, causing head- 
ache and vomiting. It is very seldom used in this country, pure ethyl 
chlorid being preferred by the majority of those who advocate ethyl 
chlorid for any purpose. 
Anesthol.-Anesthol, which was first employed by Willy Meyer,1 
in 1898, is a clear, transparent fluid of a very agreeable odor. It is a 
1 Meyer, Willy: ' ' The Improvement of General Anesthesia on the Basis of 
Schleich's Principles. With Special Reference to Anesthol," J. Am. Med. Assn., 
Feb. 28, 1903; ibid., March 7, 1903. Also "The Improvement of General Anes- 
thesia on Basis of the Principle of Adapting the Boiling Point of the Anes- 
thetic to the Temperature of the Body (Schleich)--Ten Years' Experience at 
the German Hospital," Med. Rec., Aug. 15, 1908. ETHYL CHLORID 
277 
combination 1 of 17 per cent of ethyl chlorid, 35.89 per cent of chloro- 
form, and 47.19 per cent of ether. It has a specific gravity of 1.045, 
which, as Meyer points out, is very close to that of blood (1.056-1.059). 
Its boiling point is 104° F (40° C.). For a further exposition of the 
principles involved in the making and use of this preparation see 
page 208. 
Meyer's observations with this anesthetic, administered by means of 
the drop method and an Esmarch inhaler,2 are as follows: 
"1. Surgical anesthesia is established in the majority of cases in 
about eight minutes. If morphin is previously administered, even this 
time is very frequently reduced by a few minutes. 
"2. The stage of excitation, if it sets in at all, is of very short 
duration. 
"3. Complete anesthesia having been gradually induced, the pulse 
is full and slow-of the chloroform-anesthesia type-and respiration 
regular, not stertorous. 
"4. In no instance has there been an increase in salivation or 
bronchial mucus during narcosis. 
u5. The face presents a healthy color. There is no pallor nor 
cyanosis. 
"6. If too little of the anesthetic is given, the patient will begin to 
gag or vomit, as with chloroform; if too much is administered, respira- 
tion will become shallow, and eventually, if still more is poured on the 
mask, stop altogether, but the pulse will not be interfered with. In other 
words, the respiratory and not the circulatory center is first affected by 
an overdose. . . . The tendency throughout the narcosis is toward re- 
covery from the effect of the anesthetic, not toward a profound anes- 
thesia. . . . 
"7. After the anesthetic has been stopped, the patient soon comes 
to, sometimes even while still on the operating table. If he sleeps 
1Sollman: "Pharmacology," 437. "The claim that anesthol is a chemical 
compound, and that its composition does not alter on evaporation, seems to be 
unfounded." 
2 Neef ("Practical Points in Anesthesia") states that at the German Hos- 
pital it is the practice to employ a Schimmelbusch mask, covered with flannel, 
over which impermeable cloth, with a lozenge-shaped fenestrum the size of a ten- 
cent piece, is placed. He also states that it requires 15-20 c.c. for induction, 
and 40-60 c.c. for narcosis. It is now the routine custom at this institution to 
administer a hypodermic of morphin, 1 /12 to % gr., one-half to three-quarters of 
an hour before anesthesia. Cardiac collapse occurs during induction, if at 
all. This is indicated by weak pulse and pallid face. A change to ether by the 
drop method will quickly remedy this. When stimulants are needed at any 
other time, a few drops of ether may be added. With anesthol the volume of the 
pulse may be expected to decrease about one-third in the course of an hour, and as 
much as one-half in a two-hour anesthesia. "Crowding" is the cause of sali- 
vation or cyanosis during anesthesia, and of excessive vomiting afterward. 278 
ANESTHESIA 
longer, it is usually on account of the previously administered morphin. 
"8. Vomiting occurs in a small percentage of cases after return to 
consciousness. It is, however, not of a prolonged or distressing type. 
"9. Untoward after-effects,1 such as bronchitis, pneumonia, ne- 
phritis, are not seen as a result of anesthesia with this mixture. A pre- 
existing catarrh of the bronchi or inflammation of the kidneys may, of 
course, become somewhat aggravated for a few days, but never to the ex- 
tent that may happen after the inhalation of other gaseous substances. 
These complications certainly are never produced by this anesthetic. 
"10. Patients afflicted with serious valvular cardiac lesions, chronic 
pulmonary affections, atheromatosis, diabetes, profound anemia, or other 
complications of serious character have stood this preparation most 
satisfactorily; contrary to what one would be justified in expecting in 
such cases, a better circulatory and respiratory condition was induced 
during anesthesia. 
"11. The total quantity used is generally small. Our narcotizers 
very often carry a patient through an anesthesia lasting from one to two 
hours, with two to three ounces." 
For further information, especially in reference to the chemistry of 
anesthol, see page 208. 
Ethyl Chlorid and Oxygen.-Lotheissen 2 proposes an improve- 
ment of ethyl chlorid narcosis by means of the simultaneous inhalation 
of ethyl chlorid and pure oxygen. For this purpose, he constructed an 
apparatus which is a modification of the Roth-Drager apparatus, for hos- 
pital practice; also a smaller, cheaper apparatus which can be easily 
transported to the patient's dwelling. This new method of ethyl chlorid 
narcosis has been used by him for five years past, without unfavorable ex- 
periences, in about five hundred anesthesias. The usual duration of an- 
esthesia was ten minutes, only a small number being longer than twenty 
minutes. The average quantity of ethyl chlorid administered per min- 
ute amounted to 1 to 2 c.c. with liters oxygen. In cases concerning 
habitual users of alcohol, in whom anesthesia could not be obtained 
within two or three minutes, a few drops of ether were added, resulting in 
a mixed narcosis of ethyl chlorid and ether with oxygen. In Lotheis- 
sen's experience, it is not advisable to pass to chloroform or its mixtures 
after the beginning of the narcosis with ethyl chlorid. In order to avoid 
asphyxia, in consequence of concentrated vapors, the oxygen is allowed 
to escape before the ethyl chlorid is inhaled. The pulse-rate and res- 
piratory frequency are not affected, as a rule. Vomiting is less common 
than with other narcotics. After-effects are always trifling and transi- 
tory. Although Lotheissen admits hardly any contraindications, he does 
1 Torek, F.: "Anesthol Poisoning Causing Acute Yellow Atrophy of Liver 
After Operation for Ileo colic Intussusception," Am. Surg. J., 1910, 52, 489-492. 
3 Lotheissen: Loc. cit. ETHYL CHLORID 
279 
not employ the ethyl chlorid-oxygen narcosis in those cases where it is 
advisable to avoid general anesthesia. 
Rosenthal and Berthelot1 have found that a mixture of oxygen and 
ethyl chlorid, instead of ethyl chlorid alone, produces very satisfactory 
anesthesia, even to one hour's duration. In 1906 they stated that all the 
experiments had been conducted upon animals. 
Ethyl Chlorid and Nitrous Oxid.-Ethyl chlorid has been given 
by one of the authors (J. T. G.) with nitrous oxid and oxygen in 
a number of cases, thus securing complete relaxation, otherwise unobtain- 
able with the latter combination. Ethyl chlorid may be sprayed into 
the inhaler or through an inspiratory valve. The only objection to using 
ethyl chlorid in this way is the fact that considerable vomiting occurs 
immediately after the removal of the mask. 
Ethyl Chlorid with Ether.-The ethyl chlorid-ether sequence 
is given in the same way as the nitrous oxid-ether sequence, that is, 
with any of the closed inhalers. As the patient gets well under the 
ethyl chlorid, the ether is turned on gradually. The technique of the 
administration is as follows: 
Attach a tube containing 3 to 5 c.c. of ethyl chlorid to the stop- 
cock of the bag by a rubber tube. As the patient fills the bag three- 
fourths full, break the neck of the tube of ethyl chlorid and thus allow 
the ethyl chlorid to enter the bag. As the patient sinks under the ethyl 
chlorid, turn on the ether very gradually. 
Ethyl Chlorid with Chloroform.-Ethyl chlorid should not be 
administered preliminary to chloroform, inasmuch as both of these 
agents are respiratory depressants, both are cardiac poisons, and both 
act quickly. They have been used in this way, but this sequence should 
be avoided because it is dangerous. 
BIBLIOGRAPHY 
Blumfield: "Recent Work in the Field of Anaesthetics." The Prac- 
titioner, 1903, 420. 
Braine, Carter: "The Administration of Anaesthetics in Dental 
Surgery." Brit. Dent. J., Oct., 1904, 717. 
Buxton, Dudley: "Operations on the Upper Passages from the 
Anaesthetists Point of View." The Practitioner, Jan., 1905, 77. 
Chaldecott, J. H., and Stephenson: "Ethyl Chloride as a General 
Anaesthetic in Eye Work." The Ophthalmoscope, April, 1904, 129. 
Daniells, G. W. B.: "The Administration of Ethyl Chloride." Brit. 
Med. J., 1904, 949. 
De Prenderville: "Advantages of Ethyl Chloride Anaesthesia." 
The Lancet, 1904, 978. 
1Eosenthal and Berthelot: Compt. rend., 146, 43. 280 
ANESTHESIA 
Flemming, A. L.: "Ethyl Chloride: A Few Practical Remarks." 
Bristol Med. Chir. J., Sept., 1904, 228. 
Hatch, R. M.: "Chloride of Ethyl as a Dental and General Anaes- 
thetic." Brit. Dent. J., Oct., 1903, 638. 
Hewitt, F. W.: "Anaesthetic Effects of Ethyl Chloride." The Lan- 
cet, 1904, 1408 and 1486. 
Hilliard, Harvey: "Ethyl Chloride as an Anaesthetic in General 
Practice." The Practitioner, Feb., 1905, 203. 
Luke, T. D.: "The Use of Ethyl Chloride as a General Anaesthetic." 
Edinburgh Med. J., 1903, 425. 
Lynch, Jerome M.: "The Choice of an Anaesthetic in Anal Sur- 
gery." Va. Med. Semi-Monthly, July 24, 1908. 
McCardie, W. J.: "Ethyl Chloride as a General Anaesthetic." The 
Lancet, 1903, 952 and 1198. 
Seelig, M. G.: "Combined Ethyl-Chloride and Ether Anaesthesia." 
St. Louis Courier of Med., Feb., 1905. 
Ware, Martin W.: "One Thousand Personally Conducted Cases of 
Ethyl Chloride Narcosis." J. Am. Med. Assn., Nov. 8, 1902. CHAPTER VII 
CHLOROFORM 
Chemistry: History; History of Its Use as an Anesthetic; Proper- 
ties; Uses; Preparation of Chloroform; Impurities Liable to Be Present 
in Chloroform; Stability of Chloroform; Decomposition of Pure Chloro- 
form; Role of Alcohol in Anesthetic Chloroform; Character of Contain- 
ers ; Stoppers for the Containers; The Changes Which Anesthetic Chloro- 
form Undergoes When a Current of Oxygen Is Conducted Through It; 
The Decomposition of Chloroform Vapor Upon Exposure to Gas Light, 
etc., During Administration; Effect of Agitation Upon Anesthetic Chlo- 
roform; Standards of Purity for Anesthetic Chloroform. 
Special Physiology : Effects Upon the Respiratory System; Effects 
Upon the Circulatory System; Effects Upon the Nervous System; Ef- 
fects Upon the Muscular System; Effects Upon the Glandular System 
and Other Structures; Causes of Death from the Administration of Chlo- 
roform ; Stages of Anesthesia; Elimination. 
Indications and Contraindications: Indications; Contraindi- 
cations; After-Effects; Comparison with Other Agents. 
Administration of Chloroform : Drop Method; Other Methods of 
Administration; The Roth-Drager Oxygen and Chloroform Apparatus; 
Vernon Harcourt's Inhaler; Junker Apparatus; Braun's Inhaler; 
Gwathmey Three-Bottle Vapor Inhaler. 
CHEMISTRY 
History.-Chloroform, CHCL (trichlormethane, methenyl trichlorid, 
dichlorinated chlorid of methyl, perchlorid of formyl, formyl trichlorid), 
was independently discovered in 1831 by Guthrie, Soubeiran, and 
Liebig,1 yet it has been asserted that there are indications of an ear- 
lier acquaintance with the compound. For example, we are told by 
Hutman,2 on the authority of Johannes Porta 3 and Sir Walter Scott,4 
1 A fuller historical account may be had in pp. 20-22. 
2 J. Chim. med. (3), 4, 476. 
3 " Magna Naturalis, " 1619. It should be mentioned here that in 1589 Giau- 
battista Porta used an essence made from hyoscyamus, solanum, poppy and 
belladonna, enclosed in a lead vessel, for producing sleep by inhalation of the 
vapor. 
4 "Letters on Demonology and Witchcraft," 1830. 
281 282 
ANESTHESIA 
that chloroform was known in former times and was then employed as a 
means of producing insensibility. Investigation shows that this state- 
ment is based upon misinterpretation.1 
History of Its Use as an Anesthetic.-In March, 1847, Flourens 
announced to the Academy of Sciences of Paris that chloroform exer- 
cised on the lower animals an anesthetic action analogous to that of 
ether. In the same year Doctor (afterwards Sir) J. Y. Simpson, 
looking for a more convenient and less objectionable anesthetic than 
ether, consulted Mr. Waldie, a chemist of Liverpool, who suggested that 
he use chloroform. In November, 1847, he read a paper entitled "No- 
tice of a New Anaesthetic Agent as a Substitute for Ether in Surgery 
and Midwifery." From this time on its use spread rapidly. 
In January, 1848, Hannah Greener, the first victim to chloroform, 
died at Winlaton near Newcastle, Dr. Meggison being the chloroformist. 
It may be appropriate to relate exactly under what circumstances she 
died. The operation was for an ingrown toe-nail. The girl was seated 
in a chair and only a,few whiffs of chloroform were administered, and 
she died. She was only eighteen or twenty years of age. The history 
of this first case is given in detail for the reason that so many of the 
physiological principles relating to chloroform, as we know them to-day, 
were violated on that occasion, namely: 
First: It was administered with the patient in an upright posture. 
Second: It was administered for a minor operation. 
1 Most ancient authors who pretend to treat of the wonders of natural magic 
give recipes for calling up phantoms by the inhalation of certain gases from 
burning medicated mixtures, generally of oils, and by the use of suffumigations 
of strong herbs (Hibbert's "Apparitions," 120). The ancient Egyptians, As- 
syrians, and Chinese were familiar with many vegetable substances (e. g., can- 
nabis indica') capable of producing ecstatic, sedative, and anodyne effects (Snow's 
"Chloroform and Other Anaesthetics," 1858; Bernard's "Legons sur les anes- 
thesiques et sur 1'asphyxie," 1875; Lyman's "Artificial Anesthesia and Anes- 
thetics," 1883; and Dastre's "Les anesthesiques," 1890). From the "Odys- 
sey" (iv., 220) we learn that Helen "cast a drug into the wine whereof they 
drank, a drug to lull all pain and anger and bring forgetfulness of every sor- 
row." Herodotus refers to the custom of the Scythians of inhaling the fumes of 
a kind of hemp; Disscorides (De Med. Mat., iv., 76) makes mention of the prac- 
tice of boiling in wine the root of the Atropa Mandragora and of administer- 
ing some of the decoction prior to surgical operations; and Pliny (xxxv., 94) 
refers similarly to the powers of the mandrake. Mandragora appears to have 
been used to some considerable extent (Galen, lib. vii., 207; Lucian, "Demos- 
thenes Ecomium, " 36); it was employed in compounding the "spongia som- 
nifera" of Theodoric. The Bible and the Talmud also contain references to 
ancient practices of inducing sleep by artificial means. However, excepting the 
use of Memphis marble and vinegar as a local anesthetic by the Romans, carotid 
compression and (later) mesmerism, vegetable narcotics only were used to as- 
suage suffering and for the induction of unconsciousness until the foreshadowing 
of the modern system of anesthesia by the discovery of nitrous oxid. CHLOROFORM 
283 
Third: It was administered to a patient with high nervous tension. 
Fourth: It was probably administered in a concentrated dose. 
Fifth: To a young, vigorous woman. There would be no justifica- 
tion for such a fatality with our present knowledge. 
Ten years after its introduction as an anesthetic, Dr. John Snow 
published his classical work on "Chloroform and Ether Anaesthesia," 
giving among other things an exact percentage of chloroform and appa- 
ratus for administration of the same. 
In 1879 the first committee on the British Medical Association met 
and condemned the use of chloroform. In 1890, the second Hyderabad 
committee met and concluded that chloroform was a comparatively safe 
drug when properly used. In 1901 the British Medical Association 
committee published a second report condemning the indiscriminate use 
of chloroform. In the same year Dr. Frederick Hewitt issued a second 
edition of his work on anesthetics, stating (page 497) that with a com- 
pound sequence (N2O-Ether-CHCl3) it is possible to proceed to deep 
chloroform anesthesia with safety and smoothness. 
In 1904 one of us (J. T. G.) read a paper at a meeting of the Sur- 
gical Section of the New York Academy of Medicine, showing that the 
value of chloroform was more than doubled when used with oxygen in- 
stead of air, and also stating that this combination was, theoretically at 
least, safer than ether and air. 
In 1906 1 one of the authors of this book (J. T. G.) read another 
paper before the American Medical Association, drawing attention to the 
remarkable difference between warm and cold chloroform vapor, and 
giving reasons why chloroform should be preferred in the Southern 
States, Cuba, Philippines, and in any of the tropical countries. 
Properties.-Chloroform is a colorless, limpid liquid, possessing a 
sweet but somewhat burning taste and an agreeable "ethereal" odor. 
When absolutely pure, it possesses a density of 1.49887 at 15/4° and 
boils at 4-61.2° C. Pure chloroform decomposes under certain condi- 
tions, which will be referred to later, and should never be used for anes- 
thesia. Anesthetic chloroform does and should contain 0.25 to 1.00 per 
cent of ethyl alcohol, which acts as a preservative. Therefore anesthetic 
chloroform may have a specific gravity of not less than 1.476 at 25/25°.2 
1 " A Plea for the Scientific Administration of Anesthetics, ' ' J. Am. Med. 
Assn., Oct. 27, 1906, 47, 1361-1364. 
2 The anesthetic chloroform on the American market varies in specific gravity 
from 1.4730 to 1.4827 at 25/25°, usually in close proximity to 1.476, the mini- 
mum density permitted by the Pharmacopoeia. 
The samples of chloroform of German manufacture examined by Baskerville 
and Hamor (Joe. cit.) varied in specific gravity from 1.487 to 1.492 at 15/15°, 
although one sample possessed a density of 1.497 at this temperature. 
The specific gravities of the chloroforms recognized as official by the pharmaco- 
poeias of various countries are given in the following table: (Continued on p. 284) ANESTHESIA 
284 
When pure, chloroform is not combustible; but when mixed with 
alcohol, it burns with a smoky flame edged with green. Chloroform is 
slightly soluble in water (0.822 gm. per 100 gm. water at 20° C.) and it 
imparts to it a sweet taste. It is miscible in all proportions with abso- 
lute alcohol, ether, benzene, and petroleum spirit. It is soluble to a lim- 
ited extent in aqueous alcohol. It may be made into an emulsion with 
water by means of saponin. Chloroform is an important technical sol- 
vent; it dissolves fats, certain components of india-rubber, resins, sul- 
phur, phosphorus, iodin, various alkaloids, many alkaloidal salts, as well 
as many other organic compounds.1 
Uses.-Chloroform is used in medicine as an anesthetic,2 stimulant, 
antispasmodic, counterirritant, antiseptic;3 as an antidote in cases of 
(Continued from p. 283) 
1.480 
1.489 
1.490 
1.497 
1.498 
1.500 
1.485- 
1.489 
1.485- 
1.490 
Spain 
Portugal 
Mexico 
Switzerland 
Greece 
Chili 
France 
Roumania 
Germany 
Denmark 
Hungary 
Norway 
Sweden 
Finland 
Belgium 
1.485-1.495 
1.490-1.500 
1.490-1.493 
1.490-1.495 
1.498-1.500 
1.499-1.500 
Not below 
1.476 
at 25° 
Japan 
Austria 
Italy 
Great Britain 
Holland 
Russia 
United States 
DENSITIES AT 15° ACCORDING TO VARIOUS PHARMACOPCEIAS 
The chloroform constants according to various editions of the United States 
Pharmacopoeia are as follows: 
Date Density at 15° Boiling Point 
1851 1.49 142° F. 
1869 1.490-1.494 140° F. 
1873 1.480 142° F. 
1882 1.485-1.490 60-61° C. 
1893 Not below 1.490 60-61° C. 
'See, in this connection, Pettenkofer: Jahresber., 1858, 363; Schlimpert: 
Ibid., 1859, 405; Nowak: Archie Pharm. (3), 3, 281; Hesse: Pharm. J. (3)4,649. 
2Sir James Simpson: "New Anesthetic," 1847, 7; Illust. London News, 
Dec. 4, 1847, 370-2; E. B. Simpson: Century, 25, 412; Liv. Age, 66, 720; 
J. Med. Sei., Sept., 1847; Ednb. Medico-Chir. Soo., Nov. 11, 1848; J. Y. Simp- 
son's "Anesthesia," 1849, 93, 145, 182, 193, 203. 
3 As an antiseptic, chloroform prevents the growth of micro-organisms, but it 
does not affect the action of soluble ferments (J. Soc. Chem. Ind., 1886, 331). On 
the antiseptic applications of chloroform, see Robin: Compt. rend., 30, 52; Au- 
gendre: Ibid., 31, 679; Barnes: Pharm. J. (3), 5, 441; Salkowski: Chem. 
Report., 1888, 166; and Pharm. J. (3), 18, 315, 356, 855. CHLOROFORM 
285 
strychnin poisoning, and as an analgesic; technically in electrotechnics, 
rubber industry, and photography; and in dentistry as a solvent. 
Preparation of Chloroform.-Chloroform is made from alcohol, ace- 
tone, or "methylated spirit," by treatment with chlorid of lime 
("bleach"), other hypochlorites, or electrolysis of a halogen salt in the 
presence of the first mentioned substances. It is also made from carbon 
tetrachlorid by reduction, the tetrachlorid, as a rule, being previously 
made from carbon disulphid. 
Impurities Liable to Be Present in Chloroform.-The impurities 
liable to be present may be from the variety of materials used in the 
manufacture of chloroform just noted, and changes the product is liable 
to undergo on keeping, which will be considered later from chemical and 
physiological standpoints. 
Impurities from the Manufacturer.-These are usually the so- 
called "organic impurities," which are found in considerable amounts in 
a chloroform which has been made from poorly rectified spirit, acetone, 
or carbon tetrachlorid (the sources), if impure chemicals have been 
employed in the manufacture or subsequent rectification and purifica- 
tion, or if the chloroform has not been properly purified. These im- 
purities, even though some may not be of much importance from a 
physiological standpoint, must still be given attention, since an im- 
pure chloroform is likely to become altered through oxidation during 
storage, notwithstanding the fact that pure ethyl alcohol has been 
added. 
The possible impurities of this class are as follows: Excess water; 
excess alcohol; acetone; methyl alcohol; carbon tetrachlorid; tetra- 
chlorethylene, hexachlorethane, etc.; aldehyds; amyl, propyl, and butyl 
alcohols, and compounds; ether1; acids (sulphuric, hydrochloric, formic, 
acetic); metallic chlorids; ethyl chlorid; ethylene chlorid; ethylidene 
chlorid2; ethyl acetate; oils ("empyreumatic," "pyrogenous," "chlori- 
nated") ; fixed and extractive matter. 
Purification in Manufacture.-Some of the impurities are 
washed out with water, others are removed by treatment alternately with 
concentrated sulphuric acid and sodium carbonate. This product is then 
further purified by fractional distillation. The details of treatment 
would be out of place here, however. 
Impurities Liable from Improper Storage.-Although the ra- 
tionale of their development will be discussed in later paragraphs, the 
1 From 1865 to 1875, ether was considered as one of the general contaminants 
of chloroform. 
2 About 1880, ethylidene chlorid was regarded as a general impurity of chloro- 
form. 286 
ANESTHESIA 
possible impurities of this class may be conveniently enumerated here. 
They are: Acetaldehyd; acetic acid; formic- acid; carbonyl chlorid; 
hydrochloric acid; hydrogen dioxid; chlorin; chlorinated derivatives 
of alcohol oxidation products. 
These impurities are dealt with specifically in Appendix II on page 
871. 
Physiological Considerations in Respect to Impurities.- 
Huchard 1 has said, "Pure chloroform, well given to a patient prepared 
for it, almost never kills." Serious results have occurred from the use 
of anesthetic chloroform containing foreign substances, and although the 
grades at present sold as chloroform for anesthesia hardly contain suffi- 
cient impurities which can be held responsible per se for deaths which 
have occurred during narcosis, yet the presence of these products may 
account for some, at least, of the disagreeable after-effects so often no- 
ticeable following the administration of some chloroform.2 Conse- 
quently, anesthetic chloroform should comply with the most rigid tests,3 
and the preparation which conforms with these requirements, and at the 
same time is comparatively less likely to decomposition than others also 
answering the same tests, should at all times be preferred to a cheaper 
but less stable grade. According to the investigations of Feigl and 
Meier,4 the customary chemical examination of a sample of anesthetic 
chloroform is not conclusive, but requires confirmation by biological 
tests. Most important, however, is clinical experience. 
In regard to the fatal results which have been obtained in practice 
following the use of chloroform vapor for the induction of anesthesia, a 
considerable percentage of cases, especially those where death has ensued 
immediately upon first inspiration, may not be due to the action of 
chloroform at all.5 However, Simpson 6 enumerates a number of cases 
1 J. des. Pract., May 31, 1902. 
2 We have private information as to ill effects from chloroform supplied by 
certain dealers. 
3 The pharmacopoeial tests are, in general, insufficient, and samples of chloro- 
form may comply with the tests prescribed by various pharmacopoeias, and yet 
important differences may be shown to exist among them by means of other 
tests. These facts have been brought out by Langaard (Therap. Monatsh., May, 
1902). Our opinions will be found in this book. 
* Biochem. Z., 1906, 316. Feigl and Meier marked out the blood-pressure 
curves on a drum by means of a kymograph; healthy dogs were made to inhale 
equal quantities of chloroform of different makes through a tracheal canula. 
The results obtained showed that the different brands of chloroform, although 
they appeared almost identical by the chemical tests, differed considerably in 
their liability to cause a diminution in blood pressure and to cause arhythmia 
of the pulse beat. 
5 See, in this connection, Nussbaum: Handb. d. allg. p. spec. Chir., 1867, 
612; Lawrie: Lancet, 1890, i, 149. 
e Brit. Med. J., 1870, i, 199. CHLOROFORM 
287 
antedating the general introduction of anesthesia which may be classed 
as "chloroform deaths."1 
In all indubitable cases the nature of the chloroform administered 
certainly plays an essential role; this fact is supported by convincing 
evidence, even though the percentage of deaths caused by chloroform 
administered during operations is unaccountably different in different 
years, times, and places. We can only attribute the existing diversity of 
opinion on the subject to the degrees of purity of the anesthetic used, 
the different modes of administration, the varying lengths of the time 
of anesthesia, the varying severity of the operation, and the state of the 
patient. 
According to almost all authorities, the first danger from the use 
of chloroform consists in an interruption of respiration,2 and it has 
been said that only after the observation of the pulse had superseded 
that of respiration did chloroform deaths become more frequent.3 Ex- 
perience has therefore clearly shown that every obstacle to respiration 
must be removed; the presence of irritating contaminants in the anes- 
thetic must, as a consequence, be guarded against.4 In France Sedil- 
lot,5 who laid the greatest stress on the purest chloroform, did not have 
to record a single death; but in nine-tenths of all the chloroform deaths 
on record not a word is said in regard to the article employed, and 
consequently an important factor for forming an opinion is entirely 
excluded.6 
1 Sansom ("Chloroform," London, 1865) put the average mortality at 0.75 
per 10,000; Richardson {Med. Times and Gas., 1870) at 2.8; and Morgan {Med. 
Soc. Va., 1872), at 3.4. 
2 Metcalfe {Trans. N. Y. Acad. Med., 1, 145) stated in 1850 that his experi- 
ence, extending then to 800 administrations, went to substantiate the fact that 
the use of impure chloroform causes headache, nausea, and bronchial irritation. 
3 Hewitt: Proc. Roy. Med. and Chir. Soc., 890. 
* Occhini [Pharm. J. (3), 8, 988] came to the conclusion that the tolerance 
of chloroform can be assured by the preventive use of ammoniacal inhalations. 
Although chloroform and ammonia have a mutually antagonistic action on the 
heart, according to Ringer {Practitioner, 1881, 19), such a method is unneces- 
sary if pure chloroform of anesthetic grade is properly administered to a pa 
tient prepared for it. 
5 Bull. Soc. Chir., 7, 1881. 
6 Some exceptions may be noted here. Dr. Hunter McGuire, surgeon in the 
Confederate Army during the Civil War, at one time remarked that chloroform 
had been administered 40,000 times in his corps alone without a single death, 
and he attributed the result largely to the splendid grade of chloroform which 
the Union Army had supplied him (almost all the chloroform used by the Con- 
federate Army was captured from the Federals, although some of English manu- 
facture came through a blockade.) 
In 1882 Preston [Pharm. J. (3), 12, 982] recorded that there had occurred 
53 deaths in 152,260 administrations, and that in these 53 cases the impure 
chloroform had something to do with the fatal results. Atthill {Brit. Med. J., 288 
ANESTHESIA 
DuBois-Reymond1 appeared to have experimentally demonstrated 
that impure chloroform is dangerous. Therefore, to the rules for ad- 
ministering chloroform so often given, he considered that one omitted 
by all but Sedillot and his school should be added, namely, that the 
quality of the chloroform be carefully determined and only the very best 
chloroform procurable be employed for anesthesia. 
There can be no question but that DuBois-Reymond obtained re- 
sults which indicated rather a difference of degree than of kind be- 
tween the action of pure and impure anesthetic chloroform. He insisted 
that the impurities act as cardiac depressants;2 but, as was noted at 
1892, i, 110) stated that he had administered chloroform in over two thousand 
cases, and considered that it is essential for its safe use that the chloroform be 
pure; he mentioned that the chloroform in general use at that time was often 
impure. 
Chisholm (Sci. Am. Suppl., No. 642, 10,259), who had in 1888 a record of 
10,000 cases of general anesthesia with chloroform and no deaths, recorded his 
experiences, but made no mention whatsoever of the purity of the chloroform 
used. 
1 Brit. Med. J., 1892, 1, 209. 
2 The report of the Hyderabad Commission shows that deaths from chloro- 
form are more frequently due to its checking the power of respiration than to 
arrest of the heart's action; see, in this connection, Lancet, 1890, 1, 149, 421, 
486, 1140, 1369; 1890, 2, 356. Indeed, Lawrie states (Chloroform, 1901, 15) 
the doctrine that chloroform has no direct action on the heart must be con- 
sidered as finally established. This is supported by the results of the bio- 
chemical observations of Feigl and Meier (Biochem. Z., 1906, 316), who con- 
cluded that narcotic doses of pure chloroform have little or no action on blood 
pressure, the heart, or the circulatory system in general; and that these effects, 
when observed, are usually due to accompanying impurities in commercial alco- 
hol. Some observations, however, seem to indicate that chloroform has an action 
on the circulatory system, although in these cases the purity of the anesthetic 
was not always considered. Cf., for example, Filehne and Biberfeld: Z. f. 
exper. Path. u. Therap., 1906, 3, 171; these investigators discuss the advisability 
of adding volatile analeptics to chloroform to prevent the reduction of blood 
pressure. Also, Busquet and Pachon (Compt. rend. Soc. biol., 66, 90) reported 
fibrillation of guinea-pig's heart under the influence of chloroform; Schaeffer 
and Scharlieb (Proc. Physiol. Soc., 1903, 17) have insisted on the specific nature 
of the action of chloroform on cardiac muscles; and Embley and Martin (J. 
Physiol., 32, 147) have found that the action of chloroform in the blood in such 
quantities as may occur with inhalation of 1 to 3 per cent of vapor in air para- 
lyzes the neuromuscular mechanism of the blood vessels. Tissot (Compt. rend., 
142, 234) reported that more than 70 mg. of chloroform per 100 c.c. of arterial 
blood often causes death. It appears that chloroform forms a loose combination 
with hemoglobin; for a discussion of the physical chemistry of anesthesia, 
wherein this is discussed, see Moore and Roaf: Thompson, Yates and Johnston 
Lab. Bept. Liverpool, 1905-6, 151-94. 
Waller (Nature, 76, 403) "tested purified chloroform against the concen- 
trated residue of its impurities, and found the former to be more powerful 
than the latter"; he did not, however, lay any stress upon the fact that anes- CHLOROFORM 
289 
the time,1 it does not appear that by their removal pure anesthetic 
chloroform2 ceases to hamper circulation? That the impurities are 
ordinarily very slight DuBois-Reymond admitted, but he contended that, 
although really infinitesimal in quantity, they act strongly in chloro- 
form solution. From his experimental investigations and deductions, 
we learn that there are undoubted impurities which are able to intensify 
and hasten the lethal properties of chloroform, but we cannot definitely 
assert just what these are. We know, however, what the general likely 
impurities of anesthetic chloroform are; and, if proper precautions are 
taken to guard against their presence, untoward symptoms should not 
follow the proper administration of anesthetic chloroform. 
Stability of Chloroform.-There has been not a little variety of 
opinion among chemists as to the nature and products of the decom- 
position of chloroform, especially the changes which chloroform under- 
goes upon exposure to air; in fact, this discordance dates from the intro- 
duction of chloroform as an anesthetic and prevails to-day. This con- 
dition is ascribable to the many influencing factors occasioned by the 
degree of purity of the chloroform which may have been under ex- 
amination, the extent and nature of its exposure; but it is principally 
due to the failure to consider, and therefrom to correctly interpret, the 
role of the general variable, alcohol, and with it the accompanying 
moisture. 
Decomposition of Pure Chloroform.-The products of the decomposi- 
tion of "pure" chloroform, according to various investigators, may be 
thus summarized: 
thetic chloroform can be of variable quality. Tunnicliffe (Pharm. J., (4), 18, 
515) subjected samples of anesthetic chloroform to mechanical shaking for sev- 
eral days, then exposed them for a considerable time to direct July sunlight, and 
finally allowed them to evaporate in the laboratory to one-half bulk; the residual 
portion did not differ at all from pure chloroform in its toxic action on cardiac 
muscle. 
1 Brit. Med. J., 1892, 1, 236. 
2 ' ' Chloroform Pictet ' ' was taken as the example. 
3 See (1) supra, and also Charteris and MacLennan: Brit. Med. J., 1892, 1, 
679, who believed that differently manufactured chloroform, although conform- 
ing to the tests specified by the British Pharmacopoeia, might have different ac- 
tions, and that possibly some of the dangers were due to the employment of 
impure chloroform-not by any means an original idea, yet one unique, coming 
as it did as the expression from a therapeutic standpoint. Therefore, they 
tested this assumption by administering six different makes of chloroform to 
guinea-pigs and found that there was a very evident difference in action ex- 
hibited by the different chloroforms, five of which were of standard British manu- 
facture. Thus, with ' ' chloroform Pictet ' ' and one chloroform prepared from 
pure ethyl alcohol, recovery was quicker than with chloroform from rectified 
spirit, and three other makes from ethyl alcohol, and, further, during recovery 
no rhythmic tremors were observed. 290 
ANESTHESIA 
Chlorin; Hydrogen chlorid Morson; Maisch; Hager. 
Carbonyl chlorid Rump; Regnault. 
Carbonyl chlorid; Hydrogen chlorid.... Schoorl and Van den Berg; Dott. 
Carbonyl chlorid; Chlorin Brown; Schacht and Biltz; Adrian. 
The formation of carbonyl chlorid alone has been definitely agreed 
upon. Free chlorin 1 can only result from the photochemical decom- 
position of carbonyl chlorid: C0CL,"< 
The decomposition of chloroform has been universally conceded to 
be an oxidation process. The extent of the oxidation is dependent upon 
the nature of the container, the amount of air present, the purity of 
the sample, and the intensity of the light to which it is exposed.2 
It is likely that, in the cases where chlorin has been identified as 
an indication of incipient alteration of chloroform, hydrogen dioxid 
was the real cause of the reactions observed. 
Role of Alcohol in Anesthetic Chloroform.-With regard to the 
changes which occur in anesthetic chloroform, that is, chloroform con- 
taining alcohol, during exposure to air and light, there also existed a 
decided diversity of opinion,3 principally owing to the fact that no 
examinations were made during the course of the various investiga- 
tions, so far as we are aware, for the presence of the oxidation products 
of alcohol in such chloroform. Some have even regarded the presence 
of absolute alcohol in chloroform as deleterious.4 The whole subject 
1 Vide Baskerville and Hamor: J. Ind. Eng. Chem., 4, No. 4. 
2 It is generally accepted that chloroform is unaffected by light alone, and 
that light, although it accelerates oxidation, is not a necessary factor in the 
process. However, several investigators appear to have inclined to the view that 
light favors decomposition. In this connection, see Coehn and Decker: Ber. 43, 
130; and Weigert: Ann. Physik, 1907 (4), 24, 55. The influence of light on 
the reversible reaction, CO+CL, < COC12, seems to be purely catalytic. The 
role of any water is that of a true chemical catalyst. The decomposition of pure 
chloroform is accelerated by light, and carbonyl chlorid is formed with in- 
creased readiness in the presence of acids. Lowry and Magson (Trans. Chem. 
Soc., 93, 121) observed that the formation of carbonyl chlorid is evidently 
accelerated by the presence of acids. 
3 DuBois-Reymond (Sci. Am. Suppl., No. 839, 13, 413) considered that alcohol 
was of no use when impurities were present and was not necessary when the chloro- 
form was pure; and Helbing and Passmore . (Helbing's Pharm. Record, 
March, 1892) concluded from the few experiments which they made on the de- 
composing influence of sunlight on chloroform in the presence of concentrated 
sulphuric acid that the value of the addition of absolute alcohol to pure chlo- 
roform was questionable. These investigators assumed that the chloroform which 
they termed pure contained no alcohol. 
4 Pharm. J., 7, 345. Mialhe found that chloroform acquired "caustic proper- 
ties" when mixed with a small quantity of absolute alcohol, and concluded that 
chloroform used in medical practice which caused vesication of the lips and nos- 
trils contained a certain quantity of anhydrous alcohol, the presence of which 
was suspected by Soubeiran and Gerdy. Mialhe thought that the alcohol might 
act by combining with and coagulating the albuminous fluids of the body. CHLOROFORM 
291 
was therefore carefully investigated by one of us (C. B.)1 It was also 
hoped to throw light on, if not fully explain, the role of alcohol2 and 
other substances in the so-called preservation of chloroform, a satisfac- 
tory explanation of which had been wanting. 
Those who have investigated the part played by alcohol in preserv- 
ing chloroform, up to the present time have held that either chloroform 
decomposes in the presence of alcohol and that alcohol takes care of 
the decomposition products, or that the alcohol acts as a "catalytic re- 
tarding agent" (Stadlmayr). 
We have definitely shown that the products of the oxidation of anes- 
thetic chloroform are primarily the oxidation products of alcohol, and 
that no decomposition of chloroform itself occurs while the oxidation 
of alcohol proceeds. When the oxidation of alcohol reaches a maximum, 
decomposition of the chloroform goes on, as in the case of pure chloro- 
form, with the exception that chlorinated derivatives of the oxidation 
products of alcohol may result. The decomposition of the chloroform 
itself is retarded, even prevented, so long as oxidation of the alcohol 
proceeds, and the retardation is consequently dependent upon the 
amount of alcohol present. The preservative action of alcohol, first sug- 
gested by Squibb in 1857 and later (1863) by Brown, independently, is 
essentially that of a "shunt," and any substance soluble in chloroform 
and readily oxidizable will exert an inhibitory effect on the oxidation of 
chloroform itself; for example, sulphur and many other substances.3 
1 Loc. cit. 
2 The amounts of alcohol stated as permissible in the various official chloro- 
forms intended for anesthetic purposes are as follows: 
Belgium 1.0 per cent. 
Denmark 1.0 per cent. 
Sweden .0.5-1.0 per cent. 
United States .0.6-1.0 per cent. 
France 0.005 part by weight. 
Italy 0.5 per cent. 
Switzerland 1.0 per cent absolute. 
3 "Inorganic Preservatives.'' Boettger (Bull. de therap., May 15, 1864) 
found that chloroform which had undergone decomposition by exposure to sun- 
light might be purified by agitation with sodium hydroxid, and stated that when 
chloroform was placed in contact with sodium hydroxid it might be preserved 
indefinitely. Newman and Ramsay (Lancet, Jan. 23, 1897) recommended a simi- 
lar treatment, namely, the use of lime, both for purification of decomposed 
chloroform and as a preservative. Brown (Pharm. J., 61, 669; Mon. Set., 53, 
423), however, found that the method of Newman and Ramsay was unsatisfac- 
tory. These compounds act by combining with the decomposition products of 
chloroform. They do not prevent decomposition. 
Allain (Chem. Ztg., 19, 310) learned that sulphur, purified by digesting for 
24 hours with ammonia, and then carefully washed and dried, would effectually 
prevent the decomposition of chloroform. (In a sample saturated with sulphur, 
after exposure to sunlight for four months, no impurities could be detected and 292 
ANESTHESIA 
All compounds which have been found to serve as preservatives of chlo- 
roform are reducing agents, and the effect is only due to their capacity 
for oxidation. 
Character of Containers.-Anesthetic chloroform should preferably 
be furnished in vials, ampules, or bottles of high-grade anactinic 
the sample produced a "normal anesthesia''). Temoin (Pharm. central., 45, 
872; Chem. and Drug., 64, 973) reported that chloroform to which 0.4 per cent 
of sulphur had been added underwent no alteration on keeping, even when ex- 
posed to light. This was verified by Dott [Pharm. J., (4), 2, 249], -who also 
experimented successfully with morphin, gallotannic acid, and hypophosphorus 
acid. 
"Organic Preservatives.'' Masson [J. pharm. chim., (6) 9, 568] found that 
poppy-seed oil exerted a marked preservative action on chloroform. A specimen 
containing 0.1 per cent was exposed to direct sunlight for 21 days, at the end 
of which time there was no decomposition; and one with 0.2 per cent of the 
oil, kept in ordinary light, showed no decomposition in three years. From 
Masson's own observations on the preservative powers of alcohol (Masson con- 
sidered that the preservative action of alcohol on chloroform was demonstrated 
by the condition of the samples at the Pharmacie Central, in 1899, where speci- 
mens containing only 0.1 per cent and exposed in yellow glass bottles in a win- 
dow to diffused light were found to have kept perfectly after standing for ten 
years), one would conclude that he considered it perfectly satisfactory. 
Breteau ("French Patent," 1905, 353, 858) devised a method for the pre- 
vention of the alteration of chloroform in the air and light, and of indicating 
finally the decomposition, which consisted in adding to the chloroform from 5 to 
10 thousandths parts of one of the following bodies: pith of elder, cork of 
coniferae; and 3 to 5 thousandths parts of guaiacol, ionone, spermaceti, choles- 
terol, terpineol, citronellic acid, geranic acid, etc. He stated that the elder pith 
might be impregnated with a solution of a material colorless in chloroform, and 
dry, this material, as Congo red, undergoing a change of tint under the influence 
of the decomposition products of chloroform. Congo red was stated to be very 
desirable, since it turned blue, and gradually decomposed, when the alteration 
was decided. Later Breteau mentioned the following substances as preservatives 
of chloroform in addition to those previously mentioned: ethyl alcohol and ethyl 
ether, nitrobenzene, methyl and amyl salicylates, thymol, and coniferin. As 
indicators, he stated that cellulin and gelatin might be used in addition to 
dyestuffs and that the indicator might also consist of a dyestuff which changed 
color in the presence of the decomposition products of chloroform ("First Addi- 
tion to French Patent," 353, 858, 1905, dated June 30, 1905). Still later he 
stated that the indicator might be interposed between the chloroform and the 
stopper of the container, or might be fixed to the stopper, or might even form 
the stopper. Cinnamic acid and inosite-mono-methyl ether were added to the 
list of preservative agents ("Second Addition to French Patent," dated Nov. 
18, 1905, 358, 858). 
Breteau and Woog (Compt. rend., 143, 1193) found that, by the use of 2 to 
4 parts per 1,000 of oil of turpentine, purified spermaceti, menthol, terpineol, 
citronellol, geraniol, amyl and methyl salicylates, guaiacol, thymol, safrol, ionone, 
or methyl-protocatechuic aldehyd, chloroform could be preserved in white glass 
bottles in diffused light. A number of indicators show the acidity of chloroform 
undergoing incipient decomposition before it is sufficiently developed to affect 
silver nitrate. CHLOROFORM 
293 
glass,1 containing about the quantity sufficient for one narcosis, and at 
the most not more than can be used within several days. If, for any 
particular reason, chloroform is ordered in a large container, it is ad- 
visable, immediately after opening it, to subdivide the entire remain- 
ing contents into two-ounce bottles, taking care to fill the small bottles 
completely. In no case should chloroform be gradually withdrawn in 
small quantities from large bottles or carboys. When it is found neces- 
sary to store anesthetic chloroform it should always be kept in a cool, 
dark place, in well-filled, or, better still, completely filled, tightly stop- 
pered bottles of anactinic glass. 
The keeping qualities of anesthetic chloroform may be seriously 
affected by the character of containers. The question of keeping anes- 
thetic chloroform in tin containers has been much agitated in 
the United States War Department, and within the last ten years this 
department has decided in favor of the tin container. We (C. B.) be- 
lieve that glass containers are more conducive to the maintenance of 
purity for several reasons. First, in cleaning the vessels before filling, 
any foreign matters present may be readily observed and the bottles 
properly cleaned. Second, in the case of tins, some of the flux used in 
soldering may be introduced and thus impart an acid reaction to the 
chloroform. Hydrochloric acid accelerates the decomposition of chloro- 
form. The introduction of this flux is also a problem in ether manu- 
facture which requires the utmost care. Third, we have been informed 2 
that "moist chloroform in the presence of a metal will slowly form 
traces of CH2C12 and probably . . . that it is possible to distill pure, 
dry chloroform in a metal container and produce a decomposition, as 
shown by the following formula: 
4CHC13 4- Cu2 = C2C16 + 2CH2C12 + Cu2Cl2. 
This reaction, however, takes place so slowly that it would never be 
noticed except in the handling of a material on which superlative efforts 
have been expended for years in order to get the last extreme of purity." 
Moreover, "all chloroform contains traces of CH2C12." 
Stoppers for the Containers.-The Pharmacopoeia of the United 
States formerly required the use of glass-stoppered bottles,3 but subse- 
1 The glass should show no alkaline reaction when the bottle is filled with dis- 
tilled water containing several drops of phenolphthalein solution and heated at 
100° C. for six hours. On the action of alkalies on chloroform, see Berthelot, 
Bull. Soc. chim., (2), 29, 4; Andre, Compt. rend., 102, 553; de St. Martin, ibid., 
106, 492; and Mossier, Monatsh., 29, 573. It appears to be well established that 
potassium hydroxid in alcoholic solution will slowly decompose chloroform. 
2 By a prominent manufacturer in a private communication. 
3 All of the manufacturers of chloroform in this country use brown glass 
(" anactinic ") bottles. Of the eight different makes of German chloroform that 
have come into our hands, only two were contained in colorless bottles. 294 
ANESTHESIA 
quently changed this to well-stoppered bottles, thus allowing the use of 
cork stoppers, a practice which has become general in this country.1 
Two objections have been urged against the employment of cork 
stoppers: 
First, the chloroform penetrates the cork after some time, especially 
during the agitation incidental to shipment, causing shrinkage and per- 
haps leakage.2 The second objection is that organic matter is ex- 
tracted from the cork, and the chloroform fails when the sulphuric 
acid test, a test used for the detection of fusel oil, chlorinated decom- 
position products, etc., is applied. To obviate these difficulties cer- 
tain manufacturers of chloroform have adopted the plan of covering 
the bottom of corks with tin foil, a procedure which so far has been 
found to be satisfactory, but which may be open to some of the objec- 
tions to tin containers. Other manufacturers use a paper or parchment 
covering, and still others select only the best corks and extract them 
thoroughly with chloroform before use. 
The Changes Which Anesthetic Chloroform Undergoes When a Cur- 
rent of Oxygen Is Conducted Through It.-Among the anesthetic mix- 
tures the combination of chloroform vapor with oxygen was used shortly 
after the introduction of chloroform as an anesthetic, and it has re- 
cently been reintroduced into practice by Neudorf er, Kreutzmann, and 
others. It is stated by anesthetists that oxygen does not antagonize the 
action of chloroform on the heart or nerve centers, but that it protects 
the patient from the dangers which result when chloroform is admin- 
istered while his blood is in a condition of undue venosity 3 and that it 
prevents any intercurrent asphyxial condition. Gwathmey has stated 
positively 4 that oxygen increases the value of all inhalation anesthetics 
as regards life.5 
1 In Germany, however, glass-stoppered bottles are used by prominent pro- 
ducers of anesthetic chloroform. 
2 Allain [J. pharm. chim. (3), 9, 571] and Masson [ibid., (6), 9, 568] have 
recommended that, when chloroform is kept in cork-stoppered bottles, a lute of 
"bichromate gelatin" should be used to prevent leakage. This is unnecessary 
when a proper stopper is used, and the employment of lutings on the stoppers 
has led to differences between the manufacturer and consumer in the past. 
3 Buxton: ' ' Anaesthetics, ' ' 4th ed., 299. 
4 Med. Hee., Oct. 8, 1910, 616. On chloroform-oxygen narcosis, see also Zieg- 
ner: Munch, med. Woch., 57, 2585. 
5 It has been maintained, however, that chloroform undergoes alteration in 
this procedure. Falk (Deut. med. Woch., 1902, 862) attempted to demonstrate 
that the passage of oxygen through chloroform (the purity of this was not de- 
scribed, but it was evidently of the grade specified by the German Pharma- 
copoeia) produces chemical changes in the anesthetic. He reported that, after 
the passage of oxygen for 20 minutes, changes could be recognized in the resi- 
dual chloroform, in some cases hydrochloric acid and in others an acid having re- 
ducing properties (acetic acid, resulting from the oxidation of the alcohol in 
the chloroform used?) having been recognized. The quantities produced were CHLOROFORM 
295 
We have investigated the changes which anesthetic chloroform under- 
goes when a current of oxygen is conducted through it. We have found 
that no serious oxidation occurs during the period of anesthesia, and 
that the oxidation which does occur has to do only with the alcohol pres- 
ent. Furthermore, it was determined that the oxidation products were 
entirely removed when the chloroform vapor was swept by the oxygen cur- 
rent through water.1 
The Decomposition of Chloroform Vapor Upon Exposure to Gas 
Light, Etc., During Administration.-The occurrence of untoward symp- 
toms during the administration of chloroform in rooms in which gas is 
burning,2 or where there are other varieties of naked flames,3 or strong 
electric light 4 has been reported; consequently authorities have warned 
found to be greater the higher the temperature and degree of illumination. 
This work is partially contradicted by the clinical results obtained by anesthetists, 
and by the observations of Willcox and Collingwood (Brit. Med. J., Nov. 5, 1910) 
on the administration of oxygen bubbled through absolute alcohol. They stated 
that the administration of oxygen bubbled through absolute alcohol is a marked 
cardiac stimulant. It is especially important to note that they found the admin- 
istration pleasant and non-irritating to the patient-that it caused no ill-effects to 
the lungs or bodily system. 
1 Baskerville and Hamor, loc. cit. Anesthetic chloroforms containing 0.56 to 
1.00 per cent of alcohol and 0.03 to 0.05 per cent of water were used. Oxygen 
was allowed to flow through 3% to 4 ounces of chloroform in the Gwathmey 
apparatus at such rates that about half remained in the vaporizer after 3% to 
10% hours. The vapors were cooled by a suitable condenser and collected. The 
examination of the residue and condensed chloroform showed the following: 
Acidity (acetic acid) : 
Chloroform used None. 
Residue in container0.00015 gm. in 100 c.c. 
Condensed chloroform None. 
Sulphuric acid test: 
Chloroform used Negative. 
Residue in containerMarked reaction. 
Condensed chloroform Negative. 
2 One of the earliest references to the decomposition of chloroform by exposed 
flames is in the China Med. Missionary J., Dec., 1888, 160. Iterson, Fischer, 
and Zweifel drew attention to this decomposition in 1889, and in that year Pat- 
terson narrated personal experiences (Practitioner, 42, 418). See also Lancet, 
March 12, 1898; Birmingham Med. Bev., Aug., 1892; but especially, Schumburg, 
Apoth, Ztg., 13, 758; Gerlinger, ibid., 17, 314; and Eisenlohr and Fermi, Ber., 
1892, 585. Soubeiran and Liebig had observed that a mixture of chloroform and 
alcohol in equal measures burns with a smoky flame and pungent odor. 
According to Ramsay and Young (Jahresber., 1886, 628), the vapor of chloro- 
form, when passed through a red-hot tube, yields hexachlor-benzene, perchlor- 
ethane, and some perchlorethylene. 
3 Oil lamps and candles. Waddelow, Pharm. J. (4), 6, 324. 
4 Buxton (" Anaesthetics, " 1907, 180) states that he observed that chloroform 
decomposes when a powerful electric lamp is held over the inhaler. Cf. Schoorl 
and Van den Berg (Pharm. Weekblad, 43, 47), who show that air is necessary 
for such decomposition. 296 
ANESTHESIA 
against the performance of surgical operations by gas light.1 As to just 
what products are formed there is a difference of opinion. Iterson 2 
considered that there occurred a combination of the chloroform vapor 
with the combustion gases, whereas Hartman3 and Waddelow4 ob- 
served an odor of chlorin. Von Langenbeck considered that chloro- 
carbonic acid was formed, and Breaudat found hydrochloric acid and 
an acrid oil. 
At all events, when a mixture of chloroform vapor and air is decom- 
posed by a flame, irritating compounds are formed.5 
Effect of Agitation Upon Anesthetic Chloroform.-Tunnicliffe con- 
cluded that when chloroform is initially pure, except for added alcohol, 
it remains free from pharmacological deterioration under the ordinary 
conditions of military transport, providing that the bottles are kept 
closely stoppered and protected from strong light. Baskerville sub- 
jected several samples of chloroform to intermittent agitation for over 
two hundred hours in a Spiegelberg shaking apparatus and learned 
that: 
(1) When anesthetic chloroform is subjected to agitation accom- 
panied by shock, the alcohol present undergoes oxidation, the extent of 
this being dependent upon the amount of air present, the nature of the 
agitation, especially its violence and length, and the light exposure. 
The experiments were all made in daylight at about 20° C. 
(2) Impurities decomposable by sulphuric acid are formed under 
such conditions, these resulting both from oxidation of the alcohol and, 
when unprotected cork stoppers are used, from the extraction of or- 
ganic matter from the stopper or luting. "Chlorinated decomposition 
compounds" may form, although we are inclined to attribute the re- 
sponse had for their presence to oxidation products of alcohol in this 
case. 
Since these conclusions apply to anesthetic chloroform of the present 
United States Pharmacopoeia degree of purity and strength, care should 
be exercised to see, when such chloroform is shipped for considerable dis- 
tances, or is to be kept in stock on shipboard, that a minimum amount 
of air is present. 
Standards of Purity for Anesthetic Chloroform.-There have been 
instances of sophistication of anesthetic chloroform,6 and these, while 
1 E. g. Von Langenbeck: Pharm. Ztg., April 6, 1889, 221. 
2 Ibid. 
3 Ibid. 
4 Loc. cit. See also Wardleworth, Pharm. J. (4), 14, 376. 
5 Lancet, 1899, 1, 1728; Therap. Gas., 1899, 601; Breaudat's "Diet, de physi- 
ologic." Cf. Ragsky, J. prakt. Chem., 46, 170. 
6 Baird (Proc. Mass. Pharm. Assn., 1906, 59) examined six samples of chloro- 
form in 1904 and found one adulterated. CHLOROFORM 
297 
rare, have been cases mainly of substitution of commercial chloroform.1 
The purity of the drug may be endangered through lack of chemical 
control in the manufacture or from careless storage. It is quite evident 
that every sample cannot be tested. Reliance must be placed upon the 
integrity of the manufacturers. Confidence in the product, however, 
may be enhanced by chemical examinations of shipments from time 
to time. Manufacturers and users will find that compliance with the 
tests given in Appendix II will insure a drug suitable for anesthesia. 
SPECIAL PHYSIOLOGY 
The difficulties encountered in the study of the effects of chloroform 
upon the organism have been attributed by Gill2 to the isolation of the 
phenomena of the physiological action of this agent-in other words, 
to "the arbitrary separation of prominent phenomena from their inti- 
mate surroundings." Conclusions should not be drawn from an indi- 
vidual phenomenon, but from a set of phenomena, or a "state." Gill 
cites, as an illustration, the phenomenon of pallor, which is a direct 
manifestation of reflex stimulation of the vasomotor center. It is 
also a direct result of primary cardiac syncope, and, again, it is a 
secondary result of stomachic inhibition of the respiratory center. The 
fallacy of drawing conclusions from pallor alone, without the aid of the 
accompanying phenomena, is obvious. 
In considering the special physiology of chloroform, as well as of 
the other inhalation agents, for purposes of convenience the phenomena 
have been grouped according to the part of the organism chiefly in- 
volved. It is to be borne in mind, however, that the effects of chloro- 
form upon one system of organs cannot be entirely dissociated from 
its effects upon other systems, and that a given result may be produced 
by different causes, or by a combination of causes. 
Inasmuch as the physiological action of inhalation anesthetics in 
general is based largely upon observations made concerning the effects 
1 This appears to have been practiced as late as 1885 in this country, since 
Davenport [Am. J. Pharm., (4), 16, 111] reported that fourteen out of fifteen 
samples of chloroform examined by him in that year were the crude article. 
Chloroform of inferior grade, frequently encountered about 1880 [see Perrin: 
Pharm. J., (3), 9, 614; and Championniere, ibid., (3), 12, 623], especially in 
France, is now rarely represented as being of anesthetic grade. This is largely 
due to the stringency of many of the pharmacopoeias, but is in part to be ascribed 
to the experience and integrity of the manufacturers. It sometimes happens, 
however, that chloroform is declared to be impure by surgeons, following a fa- 
tality from its use in particular, when this is not the case. For an example, see 
the experiences of Blum: Pharm. J., (4), 19, 103. 
2 Gill, Richard: "CHOI, Problem," 1906, 2. ANESTHESIA 
298 
of chloroform, the discussion of the special physiology of this agent may 
entail a certain amount of repetition. 
Effects Upon the Respiratory System.-The effects of chloroform 
upon the respiratory system are secondary to, and largely dependent 
upon, the effects of this agent upon the circulation, low arterial tension 
being a very important factor. The respiratory system, even to the 
extent of complete cessation of breathing, is also affected through the 
action of chloroform upon the nervous mechanism of respiration. 
When concentrated chloroform vapor is administered, asphyxial 
symptoms immediately appear, free breathing being suspended from 
reflex closure of the larynx. With a low percentage of chloroform, 
according to the experiments of Collingswood and Buswell,1 chloroform 
quickly produces apnea of a pronounced character. This is not due 
to diminution of carbon dioxid in the blood, for it can be produced 
by chloroform mixed with expired air. Chloroform diminishes the ex- 
citability of the respiratory center to the carbon dioxid stimulus. 
Buckmaster and Gardner 2 have given a number of plethysmographic 
tracings to show the lung ventilation during chloroform anesthesia with 
different percentages of chloroform and ether, and also analyses of the 
blood gases. They show that with unimpeded respiration under anes- 
thesia by chloroform given at a slight positive pressure, the ventilation 
of the lung takes place at a lowered level. During a narcosis in which 
respiration continues, the lung ventilation is diminished in the first 
three minutes by about sixty per cent of its original value, and by a 
similar amount after prolonged anesthesia. They consider that the 
carbon dioxid content of the blood is reduced below a threshold value 
by any state of hyperpnea prior to administration of the drug, and this 
diminution in carbon dioxid content plus the diminished excitability 
of the respiratory center would suffice to retard or abolish the activity of 
the center. Gas analyses actually show that with a deep and rapid 
respiration there is a marked fall in the carbon dioxid content of the 
blood. They also bring forward evidence to show that the diminution 
in oxygen content of the blood during chloroform narcosis is not due 
entirely to diminished alveolar ventilation, but to the action of the drug 
on the red corpuscles. For further effects of chloroform upon the 
respiratory system see Stages of Anesthesia, p. 306. 
Effects Upon the Circulatory System.-The effects of chloroform 
upon the circulatory system have been made the subject of extensive 
investigation, from both the experimental and the clinical points of 
view. 
The action of chloroform upon the blood, when administered by in- 
halation, has engaged the attention of a number of investigators. It is 
1 Collingswood and Buswell, Proc. Physiol. Soc., 1907, '34. 
2 Buckmaster and Gardner, London Loy. Soc., Nov. 16, 1911; Nature, 88, 131. CHLOROFORM 
299 
conceded to have a practical bearing upon the administration of this 
agent. 
Gill,1 in discussing the relation between chloroform and the blood, 
emphasizes the point that this relationship is twofold. The negative 
action of the chloroform causes deoxygenation by diminishing the nor- 
mal supply of air to the alveoli; its physiological, or physicochemical, 
action is indirectly the cause of the suspension of the functions of the 
cerebral centers. The quantity of chloroform vapor that is absorbed 
may, therefore, be limited to the amount of oxygen requisite to be 
abstracted from the blood. Inasmuch, however, as the blood, which is 
directly affected by the physiological action of chloroform, is a variant, 
and as its actual condition necessarily influences the result that appears 
in it, it follows, as Gill contends, that each individual example re- 
quires its own anesthetic degree of chloroform action. Any undue inter- 
ference with the proper function of the respiratory apparatus tends, 
by increasing the deoxygenation of the blood, to intensify the action of 
chloroform. 
According to Carlson,2 the osmotic concentration of the blood is in- 
creased during chloroform anesthesia in proportion to the depth and 
duration of the anesthesia. This is probably due chiefly to the amount 
of the anesthetic dissolved in the serum. 
The action of chloroform on the reducing power of the blood has 
been studied by Lambert and Garneier.3 When defibrinated blood is 
treated with a current of air containing chloroform vapor, the reducing 
power of the blood is sometimes increased at once, always after an 
hour, and this increased reducing power is not due to the dissolution of 
chloroform in the blood. When, however, defibrinated blood and similar 
blood containing chloroform are made to circulate respectively through 
the two lobes of a fresh liver, the glycogen disappears more rapidly in 
the lobe through which the blood containing chloroform circulates, and 
at the same time the reducing power of this blood increases more rap- 
idly than that of pure blood, and in a higher degree than corresponds 
with the glycogen that disappears. It follows, therefore, that the in- 
creased reducing power is not due simply to a more active formation 
of sugar or to a diminution in its rate of consumption. 
Tunnicliffe and Rosenheim4 studied the action of chloroform on 
the heart by adding saline fluid perfused through the heart by Locke's 
method. The depressing action on the heart produced by chloroform 
was found to be very marked. It was delayed, however, when, in addi- 
tion to the saline fluid, lecithin was added. The quantity of chloroform 
1 Gill: Loc. cit., 254. 
2 Carlson: Am. J. Physiol., 21, 161. 
3 Lambert and Garneier: Compt. rend., 132, 493. 
4 Tunnicliffe and Rosenheim: Proc. Physiol. Soc., 1903, 15. 300 
ANESTHESIA 
which seriously affected the heart was practically identical with that 
in the blood in fully narcotized animals. 
Schaefer and Scharlieb 1 have insisted on the specific nature of the 
action of chloroform on cardiac muscles. The state of the heart called 
paralytic dilatation is regarded by them as one of excitatory inhibition; 
excitation of the terminal inhibitory mechanism is, however, distin- 
guished from excitation of the vagus and its endings, and can be 
brought about by chloroform when the vagus endings are thrown out of 
action by atropin. The high development of the inhibitory mechan- 
ism in the heart explains why it, of all muscular tissues, should be 
most profoundly affected. 
It is of special interest to note that in the frog chloroform produces 
contraction of the blood vessels, and not dilatation, as most observers 
have stated. In the frog used, the central nervous system was destroyed, 
either entirely or with the exception of the cerebrum. 
The action of chloroform on the blood vessels has been studied by 
Embley and Martin 2 with reference to the kidneys and bowels. They 
found that chloroform, in the blood in such quantities as may occur 
with the inhalation of one to three per cent of the vapor in the air, 
paralyzes the neuromuscular mechanism of the blood vessels. This 
partly, at least, accounts for the fall of blood pressure which results. 
These findings are not contradictory to those of Schaefer and Scharlieb, 
but rather supplement them.3 Vessels in different parts may react in dif- 
ferent ways to the same poison in different doses. The dilatation is 
mainly confined to the splanchnic area. 
It is now generally conceded by clinical observers that a dilatation 
of the entire cardiovascular system follows the inhalation of chloro- 
form. The fall of blood pressure is thus accounted for. 
Tissot4 has studied the proportion of chloroform in the organism 
during anesthesia. In animals rapidly anesthetized by chloroform 
the amount present in the blood may exceed 50 mg. per 100 c.c., and 
may reach 70-80 mg. If the anesthesia is slowly induced, it sinks to 
45 or even 35 mg. More than 70 mg. per 100 c.c. of arterial blood often 
causes death. In the brain the chloroform is in equilibrium with that in 
the blood. If a fatal result ensues, at the moment of the heart's arrest 
the amount in the venous blood is more than in the brain, but afterward 
the amount in the brain is often higher than in the venous blood. The 
amount in the venous blood is always less than in arterial blood. The 
length of the period of anesthesia, proportion of chloroform in the 
brain, and the rapidity of blood circulation are important factors. 
1 Schaefer and Scharlieb: Proc. Physiol. Soc., 1903, 17. 
2 Embley and Martin: J. Physiol., 32, 147. 
3 Schaefer and Scharlieb: Loc. cit. 
4Tissot: Compt. rend., 142, 234. CHLOROFORM 
301 
Meyer and Gottlieb 1 have directed attention to the narrow margin 
between a therapeutic dose and an overdose of chloroform. They found 
that in deep narcosis, with compensated heart action, the blood content 
of chloroform is 0.035 per cent, whereas in the blood of a dog anes- 
thetized to the point of cardiac failure, the chloroform content was 
0.058 per cent. The reason for this narrow margin, they hold, is that, 
in spite of the fact that respiration ceases first, the heart is the organ 
primarily affected. This explains why artificial respiration often fails 
unless the pressure upon the chest is sufficiently forcible to expel the 
chloroform-laden vapor from the left ventricle. Otherwise the heart 
continues to be poisoned. The left ventricle, which is principally af- 
fected in heart failure, was found by Pohl, according to Meyer and 
Gottlieb, to contain 0.22 per cent of chloroform, whereas the right heart 
contained only 0.02 per cent. These investigators found, in some of 
their experiments, that chloroform could be detected in the blood seven 
hours after cessation of the anesthesia. The danger comes, not from 
the amount of chloroform contained in the blood, but from its hyper- 
saturation with the vapor at some one time. 
Abel2 found that in the stage of complete anesthesia the brain con- 
tains three times more chloroform than an equal weight of blood; blood 
containing 0.015 per cent, and brain substance 0.0418 per cent. The 
serum of the blood contains very little chloroform during anesthesia, 
the greater part that is taken up and carried by the blood being bound 
to the red and white corpuscles. 
The effect of chloroform upon the heart itself has been the subject 
of much investigation and wide diversity of opinion. By some 3 it has 
been maintained that primary cardiac paralysis occurs only with high 
percentages of vapor; by others 4 it has been claimed that permanent 
stoppage of the heart is no more likely to occur with high percentages 
than with low ones. These views have been challenged by those 5 who 
hold that the heart is never primarily affected, its action being maintained 
until respiration has ceased. Despite these diverse findings, it is now 
almost unanimously agreed that chloroform, administered to the degree 
of surgical narcosis, acts as a direct heart sedative or depressant, and 
that death occurs as a result of this action. 
The indirect action of chloroform upon the heart has also given rise 
to diversity of opinion, particularly with reference to the question of 
fatality. Whether this action is the indirect result of the irritation by 
the vapor upon the sensory nerve-endings within the upper air and pul- 
1 Meyer and Gottlieb: ' ' Experimentelle Pharmakologie. ' ' 
'Abel: Bull. Johns Hopkins Hosp., Jan., 1895. 
3 Snow: "On Chloroform and Other Anaesthetics," 1858. 
* Comm. Royal Med. and Chir. Soc.; also, Glasgow Comm. (1879-1880). 
5 First Hyderabad Commission, 1891. 302 
ANESTHESIA 
monary passages, giving rise to stimulation of the cardio-inhibitory 
center, or whether it is a direct result of the effects upon this center of 
the anesthetic circulating in the blood, has not been determined. 
The entire subject of cardiac inhibition has been studied experi- 
mentally by Embley.1 He found that cardio-inhibitory effects are com- 
mon with atmospheres containing more than two per cent of chloroform 
vapor. The degree of inhibition increased with increasing percentages 
of the vapor. His findings with reference to fatal cardiac inhibition 
are not in keeping with those of the Hyderabad Commission.2 Embley 
held that slowing or complete inhibition of the heart's action did not 
occur in animals in which he divided the vagi, and that in order to 
bring about complete and permanent cardiac inhibition more injury to 
the heart is necessary than occurs in slight chloroform anesthesia. The 
Hyderabad Commission, on the other hand, held that animals may be 
killed by vagus excitation. As Hewitt has pointed out, the possibility 
and extent of the application of these and similar observations to human 
subjects are yet to be determined. 
The vasomotor center is primarily stimulated by chloroform, and 
does not become paralyzed by the direct action of the agent until the 
stage of deepening narcosis, when death is imminent. 
The cause of death from the administration of chloroform has been 
made the subject of so much experimental and clinical investigation 
that it has been thought advisable to consider this phase of the action 
of this agent upon the organism under a special heading. 
Effects Upon the Nervous System.-According to the consensus of 
opinion, based upon clinical observation, chloroform produces a pro- 
gressive paralysis of the central nervous system, the order in which this 
results being as follows: (1) The higher cerebral centers, involving 
the intellectual faculties; (2) the lower cerebral centers, involving 
sensation and motion; (3) the spinal cord, involving reflex action; 
(4) the medullary centers, involving vital function. 
For purposes of convenience the above order will be followed in the 
ensuing brief discussion of the effects of chloroform upon the nervous 
system. For further data on this subject see the Stages of Anesthesia, 
p. 306. 
Effects Upon the Muscular System.-The effects of chloroform upon 
the muscles of the heart and blood vessels have been discussed under 
Effects upon the Circulatory System. 
Muscular spasms are prone to characterize the ordinary administra- 
tion of chloroform, this tendency being the greater the more vigorous is 
the muscular development of the subject. The muscles of the extrem- 
1 Embley: '' The Causation of Death During the Administration of Choloro- 
form, " Brit. Med. J., Apr. 5, 12, 19, 1902. 
2 Loc. cit. CHLOROFORM 
303 
ities, abdomen, chest, larynx, neck, and jaws are particularly apt to be 
involved in tonic spasms during the earlier stages of chloroform anes- 
thesia. As anesthesia progresses to the deeper stages, muscular relax- 
ation follows spasm, as a rule. Sometimes, however, clonic spasms of 
certain muscles, particularly of the fingers (piano-playing movements), 
may be noted, the extremities may be involved in slow, coordinated 
movements, or jerky adductor movements of the arms may occur, pre- 
sumably as the result of clonic contractions of the muscles of the chest. 
Spasmodic tongue retraction may occur, giving rise to stertor and 
stridor. 
(For the important significance of the muscular phenomena of 
chloroform anesthesia see Stages of Anesthesia, p. 306.) 
Effects Upon the Glandular System and Other Structures.-The 
mucous, salivary, and sweat glands are stimulated to hypersecretion dur- 
ing light chloroform anesthesia. 
Nicloux and Fourquier demonstrated that chloroform has a special 
affinity for fat, for liver, kidney, spleen, and nerve tissue, and for striped 
muscle. According to these investigators the liver of the fetus is even 
more materially affected than is that of the mother. 
Thompson 1 conducted a large number of animal experiments, which 
led to the following conclusions with reference to the kidneys: 
(1) The volume of urine secreted by the kidneys is affected, as a 
rule, during chloroform narcosis, in two ways. In the early stages, when 
the anesthesia is light, the quantity is frequently increased, whereas, 
during full anesthesia, the secretion is always diminished, and may be 
suppressed. 
(2) The after-effect is invariably a great increase, which may reach 
to four times the normal volume for the same period of time. The 
maximum outflow may occur about three hours after removal of the 
anesthetic. 
(3) The total excretion of nitrogen is, as a rule, greatly increased. 
The averages taken from experiments with diminished urine volume 
show that during the anesthetic period the excretion of nitrogen fell to 
eighteen per cent of the normal, whereas the quantity of urine in the 
same series fell only to thirty-five per cent of the normal. In a minor- 
ity of the experiments with increased urine volume, the total nitrogen 
per period was also increased, but to a much less extent than the volume 
of urine in the same experiments. 
(4) The urine secreted during chloroform anesthesia is almost in- 
variably more dilute (contains a lower percentage of nitrogen) than the 
normal urine. This holds good even when the volume of urine is dimin- 
ished. Hence it is inferred that chloroform affects not only the blood 
1 Thompson: '1 Anaesthetics and Renal Activities, ' ' Brit. Med. J., Mar. 17, 
1906. 304 
ANESTHESIA 
flow through the glomerules, hut also the secretion of nitrogenous solids 
in the tubules, the latter being even more marked than the former. 
(5) There is a general but not accurate correspondence between 
urine outflow, kidney volume, and blood pressure. The relationship be- 
tween the first and second is closer than that between the first and 
third. 
(6) In prolonged narcosis, with marked diminution of urine volume, 
there is a considerable exudation of leucocytes in the renal tubules, 
which subsequently escape with the urine. The condition is probably 
produced by more or less vascular stasis in the glomerular vessels. 
(7) The excretion of chlorids is much increased both during and 
after chloroform narcosis. Tn the fourth period, after the removal of 
the anesthetic, the amount in the urine of the dog may be ten times the 
normal quantity. 
(8) Albumin appears in a small proportion of experiments after 
chloroform inhalation. 
(9) Reducing substances other than glucose are almost invariably 
increased. The nature of the reducing substance has not been definitely 
determined. 
Chloroform, according to Apperly's 1 observations, affects the cells of 
the liver, interfering with the metabolism of fats. The poisonous fatty 
acids, which cause an acid intoxication, are thus thrown out into the 
blood. The cells lining the tubules of the kidneys are so damaged that 
their excretory function is interfered with. As acute infections, espe- 
cially of the peritoneum, cause changes in the same organs, chloroform 
should not be given in these cases. 
According to Delbet2 and his co-workers, chloroform has a special 
affinity for the adrenals and checks their functioning. These effects are 
responsible, they hold, for operative shock and for sudden quiet death 
in coma after an operation. Delbet injects 0.0004 or 0.0006 gm. epine- 
phrin subcutaneously at the beginning of the operation, thus rendering 
anesthesia more regular, diminishing operative shock, and lessening the 
frequency of sudden post-operative fatalities. If prostration continues, 
another dose of epinephrin is given the next day. 
Levy's 3 investigations seem to prove that epinephrin may be safely 
injected just before induction, or during deep anesthesia, but that a 
certain definite risk is taken when injection is made during light chloro- 
form anesthesia. 
For further discussion of the effects of chloroform upon the glandu- 
1 Apperly, R. E.: " Effect of Chloroform and Ether on Liver and Kidneys 
in Health and Its Significance in Certain Infective Conditions," Brit. Med. J., 
Sept. 14, 1912, 2, 2698. 
'Delbet: lierue de Chirurgie, 1912, No. 4, 32. 
'Levy: Brit. Med. J., Sept. 14, 1912. CHLOROFORM 
305 
lar system, see sections on Elimination, p. 309, and After-Effects, p. 
310. 
Causes of Death from the Administration of Chloroform.-In sum- 
ming up the action of chloroform upon the organism, Hewitt says 1: 
"So far as we have gone, then, it would seem that we have in chloroform 
a drug which is a powerful protoplasmic poison; which, when given in 
toxic quantities, leads to death of the organism, not because it paralyzes 
respiration-for, were it merely a respiratory depressant, artificial respi- 
ration would be invariably successful in averting death-but because, as 
recent researches have shown, it markedly depresses the circulation. It 
is this circulatory depression which renders it difficult to resuscitate 
patients. The fact that an overdose of chloroform generally paralyzes 
respiration before the heart's action finally ceases must not be allowed to 
overshadow the more important fact that, prior to and during the res- 
piratory failure, the heart has, in many cases, ceased to circulate blood 
through the organism. Whether in true chloroform toxemia the fatal 
circulatory failure is principally (a) a failure of cardiovascular origin 
due to chloroform directly affecting the musculature of the vascular 
system as a whole; whether it is principally (b) a failure of cardiac 
origin, the chloroform directly affecting the cardiac muscle relatively 
more than the walls of the arteries and arterioles; whether it is prin- 
cipally (c) a failure due to the action upon the nervous mechanism which 
controls cardiac action; or whether it is principally (d) due to a paraly- 
sis of the vasomotor mechanism-we cannot at present positively say." 
According to Gill:2 "In narcosis which runs its course uncompli- 
cated by vasomotor, stomachic, or (primary) cardiac disturbance the 
ultimate cause of death is oxygen-starvation. The respiratory muscles 
tend to become exhausted, and their failure to act forms a proximate 
cause: the action of the heart also tends to fail, and cardiac syncope, 
indirectly induced by the negative action of the agent when in the form 
of vapor, becomes the intermediary means of the causation of death. 
The question which fails first, the heart or the action of the respiratory 
machine, will be decided by the initial condition of the former. If the 
heart be abnormal, and, in consequence, less able than normally to with- 
stand increased pressure in its right ventricle, it will fail before the 
respiration. But if the heart be normal, the action of the respiratory 
machine will cease before the pulse disappears, because the power of 
resistance possessed by the respiratory muscles is known to be less than 
that of the heart." 
Luke and Ross 3 attribute chloroform deaths to cardiac syncope aris- 
ing from the following: 
1 Loc. cit., 1912, 126. 
2 Gill, Richard: "The CHC1 Problem,'' 2, Physiological Action, 284. 
3 Luke and Ross: ' ' Anaesthetics, ' ' 3rd ed., 192, 306 
ANESTHESIA 
(1) Beflex stimulation of the vagus, causing inhibition of the cardiac 
pulsations (during light anesthesia). 
(2) The depressant action of the chloroform on the medullary cen- 
ter of the heart, the vasomotor center, the intrinsic ganglia, and the 
myocardium itself (in deep anesthesia from overdose). 
(3) Cessation of respiration by: (a) Direct obstruction from laryn- 
geal stertor, or from the falling back of the tongue; (b) Direct retarda- 
tion and arrest of the pulmonary circulation, first in the capillaries and 
later in the larger vessels, due to the direct local action of chloroform; 
(c) Interference with the respiratory center in the medulla, and the 
subordinate centers in the spinal cord. 
Stages of Anesthesia.-Under the caption, Factors Which May Be 
Said to Modify the Physiology of Anesthesia as Ordinarily Induced 
(p. 62), attention is directed to the fact that, in the experience of one 
of us (J. T. G.), the phenomena observed during the administration 
of inhalation anesthetics are modified, to a more or less pronounced 
degree, by certain procedures now employed by a number of anesthetists. 
This modification is particularly to be noted in the sequence of events 
commonly described as stages of anesthesia. It is to be borne in mind, 
however, that in the present discussion of the physiology of chloroform, 
as manifested in these stages, reference is made to the administration as 
ordinarily given, and not with the utilization of the various factors 
mentioned. 
Four stages of chloroform anesthesia are usually described. It 
should be noted, however, that the division of chloroform narcosis into 
these four stages is more or less arbitrary. Administered by modern 
methods, with proper care, the induction period is so gradually merged 
into that of surgical anesthesia that only the keenest observer is able to 
detect the successive steps. On the other hand, when improperly admin- 
istered, the induction period passes so quickly into the fourth stage, or 
stage of overdose, that the anesthetist is unable to detect the danger 
signals until it is too late. For this reason, it is often stated that death 
from chloroform most frequently occurs during the initial stage. 
The First Stage, or Stage of Light Anesthesia.-The first few 
drops of chloroform may have no appreciable effect upon the subject, 
except to stimulate respiration and circulation. If a light vapor (two 
per cent of chloroform in the air inhaled) is administered, practically 
no subjective phenomena are noted during this stage, which is of longer 
duration under these circumstances than when a more concentrated 
vapor is employed. With the heavier vapor, breath-holding, coughing, 
resistance to the anesthetic, and other disturbances, such as retching, 
vomiting, or cyanosis, may occur. The pupil may enlarge, all the senses 
may become slightly more active, and incoherency of ideas and speech 
may become apparent. CHLOROFORM 
307 
Analgesia appears at this stage, but operation should not be under- 
taken at this time, as the reflexes are often exaggerated, and death may 
result from reflex cardiac inhibition. An increase in the heart's action 
and a rise of blood pressure are invariably present. 
The cerebral centers are affected in this stage. Different subjective 
sensations, such as ringing and roaring sounds, may be present, usually 
varying with the vapor concentration, but sometimes occurring despite 
the careful administration of the vapor. 
The breathing is usually deep and regular, and the pulse quick and 
full. 
The order of disappearance of reflexes during this stage is: (1) 
superficial skin; (2) vomiting; (3) swallowing; and (4) coughing. 
The Second Stage, or Stage of Excitement.-This stage should 
never occur when chloroform is properly administered. (See Adminis- 
tration, p. 311.) Carelessly employed, however, chloroform anesthesia 
may be marked by a definite stage of excitement, during which the 
respiration becomes irregular, the pulse becomes more rapid, there may 
be struggling, shouting, disconnected talking, crying, and laughing. The 
face is flushed, and the pupils continue dilated. Muscular spasms, par- 
ticularly spasm of the muscles of the jaw and neck, chest, and abdomen 
may occur, indicating the need of air. 
When the chloroform vapor is too dilute the patient, if a child, may 
pass into a "chloroform sleep"; if an adult, vomiting may be induced. 
"False anesthesia" is known to be present when a patient consciously or 
unconsciously begins breathing automatically, when the anesthetist 
knows that not enough chloroform has been given to induce full surgical 
anesthesia. It is best to ignore the pupil and corneal reflexes at this 
time. If respiration is slow, or if it interferes with the quiet induction 
of full surgical anesthesia, a few drops of ether upon the mask will 
usually remedy this trouble. The eyes are poor guides at this time. The 
pupils are usually widely dilated, the eyeballs may move from side to 
side, or may be stationary. As the anesthetic is increased in strength, 
the movements of the eyes become less marked, the muscles relax, and 
the subject passes into the third stage. 
Stertor may occur, but is not necessarily indicative of anesthesia. 
Vomiting will take place if the stage of excitement is unnecessarily pro- 
longed, its imminence being indicated by feeble, small pulse. 
The cerebellar centers are now progressively affected. Sensibility to 
pain is greatly diminished. The patient may answer questions, of which 
there is no recollection afterwards. There may be unintelligent mutter- 
ings. 
With alcoholic and athletic patients it is difficult to induce anesthesia 
without a conspicuous stage of excitement. 
By the maintenance of an open airway, by the manipulation of the. 308 
ANESTHESIA 
lower jaw in such a way that the presence of an open airway is always 
apparent, and by the insistence upon absolute silence in the room, the 
anesthetist may successfully carry a patient from the induction period 
into full surgical narcosis without any signs of the stage of excitement. 
The Third Stage, or Stage of Surgical Anesthesia.-In this 
stage the muscles are relaxed, the pupils contract to normal size, the 
respiration (this is the principal guide) becomes regular and automatic. 
Phonation and the conjunctival and corneal reflexes disappear. The 
pulse rate is lessened, and the face becomes pale. When the pulse rate 
falls below fifty, and extreme pallor is present, shock is imminent. The 
pulse should be normal, or a little below normal. 
When the stage of surgical anesthesia is established, which usually 
requires from four to eight minutes, it must be maintained. A lighten- 
ing of the anesthesia may affect the vomiting center. 
The eyes are usually fixed during this stage, with the pupils con- 
tracted but responding to light. Hewitt found, by taking measurements 
with the pupillometer (see illustration, p. 195), that in most cases the 
pupil, in this stage, measures from two to three millimeters in diameter, 
usually about two and a half millimeters. Occasionally it remains widely 
dilated. "A very small pupil (1 to l-fA mm.)," Hewitt says, "in most 
cases indicates a light anesthesia; while a somewhat dilated pupil (3)/2 
to 4)/2 mm.) usually means either that the anesthesia is very profound, 
or more probably that the dilatation is of reflex origin and is associated 
with a light anesthesia." 
The muscular phenomena of the stage of surgical anesthesia are 
important danger signals. As previously stated, complete muscular 
relaxation should accompany this stage. Under the caption, Effects 
upon the Muscular System, attention is directed to the fact that surgical 
anesthesia may be accompanied by certain clonic muscular movements, 
as well as by slow, coordinated movements of certain muscles, and by 
jerky adductor movements of the arms following spasm of the pectoral 
muscles. The significance of these phenomena is that they may be taken 
by the anesthetist or by the surgeon to indicate a lightening of the anes- 
thesia; in other words, a return to the second stage. If, under this 
misapprehension, the anesthetic is pushed with a view to obtaining more 
perfect relaxation and quietude, the subject may be at once plunged into 
a condition of apnea, which may eventuate in respiratory paralysis and 
death. 
The third stage is always marked by a lowering of body temperature. 
The order of disappearance of reflexes in the third stage is as follows: 
(1) phonation; (2) conjunctival; (3) corneal; (4) pupil to light; 
(5) bladder and rectal. The last two disappear with deepening narcosis. 
The Fourth Stage, Stage of Deepening Narcosis, or Stage of 
Overdose.-It has been previously stated that the subject may pass so CHLOROFORM 
309 
quickly from the first stage, or the induction, period, into the stage of 
overdose, that the intervening phenomena, the danger signals, cannot be 
noted, and that death supervenes, therefore, during the first few minutes 
of the administration. The present discussion of the stage of overdose, 
however, refers not to this state of affairs, but to the more gradual 
sequence of events, with culmination, through misapprehension of condi- 
tions, or other exigencies of administration, in what has come to be 
known as the fourth stage. 
The ushering in of this stage is indicated by extreme pallor, abolition 
of all reflexes, and very great relaxation of the muscles. The breathing 
becomes more and more shallow; the pulse becomes weaker, irregular, 
and thready. Blood pressure continues to fall. Vasomotor paralysis, 
sudden or gradual respiratory failure, and complete cardiac inhibition 
are the final phenomena of the stage of overdose, which thus culminates 
in death. 
Elimination.-From studies upon the influence of chloroform on 
intravital staining with methylene-blue it has been found 1 that, although 
the results in rabbits were not uniform, evidence was obtained of dimin- 
ished reduction on the part of chloroformed brains. The increased cir- 
culation of the dye in the blood is due to the impaired excretory activ- 
ities of the kidneys and liver. This explains a more abundant passage 
of the dye into the digestive tract, and the tint of the blood in part 
accounts for the appearance of the brain. The muscles, however, are less 
deeply stained than in control animals. 
The amount of chloroform in the urine of dogs, subjected for pro- 
longed periods to the anesthetic, has been found 2 to be extremely small, 
namely, from 6 to 8 mg. per 100 c.c. of urine. The urine after anes- 
thesia, it has been noted, has a high specific gravity, a strongly acid 
reaction, and, in 70 per cent of the cases examined by Baldwin 3 (40 in 
number), there was a marked acetone reaction, due to a disturbance of 
metabolism, probably in the liver cells. Tests made by Vitali 4 with 
urine of four patients, during and after the administration of chloro- 
form, revealed the fact that chloroform did not pass into the urine, and 
that the presence in the urine of other organic chlorin compounds could 
not be detected. This observation is not in harmony with the findings 
of others,5 who state that the urine may show traces of chloroform, the 
drug existing in an unchanged state for as long as twelve days after 
administration. 
1 Herter and Richards: Am. J. Physiol., 12, 297. 
2Nicloux: J. pharm. chim., 1906, 24, 64. 
3 Baldwin: J. Biol. Chem., 1, 239. 
' Vitali: L 'Oroso, 22. 
5 Thien and Fischer: Deutsch, med. Ztg., Dec. 2, 1889. See also Demeraux 
and Minet: L'Echo med., June, 1904. 310 
ANESTHESIA 
Chloroform is largely excreted through the expired air, according to 
Meyer and Gottlieb.1 A small part is broken down in the organism, 
increasing the chlorid content of the urine. 
INDICATIONS AND CONTRAINDICATIONS 
The indications and contraindications for chloroform may be cate- 
gorically stated. For further discussion of the subject see Chapter VIII, 
Selection of Anesthetic. 
Indications.- (1) Obstetrical cases, in which the heart is usually 
hypertrophied and only primary anesthesia is required; (2) young chil- 
dren, particularly as an introduction to ether; (3) old people, as a pre- 
liminary to ether; (4) persons afflicted with epilepsy, convulsive seizures 
of any kind, tetanus; (5) affections of the respiratory system-pul- 
monary tuberculosis, asthma, emphysema; (6) aneurysm; (7) pleurisy; 
(8) operations involving the upper respiratory tract-excision of tongue, 
inferior or superior maxillae, enlarged glands, or tumors that encroach 
upon the airway; (9) operations in which the Trendelenburg position 
is indicated; (10) obese and flabby patients, particularly as an intro- 
ductory anesthetic; (11) insane patients; (12) operations upon the 
brain; (13) operations in which the actual cautery is to be used close 
to the face. 
Contraindications.- (1) Weak, anemic children, with enlarged 
glands in different parts of the body; (2) status lymphaticus (see Chap- 
ter VIII, Selection of Anesthetic); (3) very prolonged operations; 
(4) minor surgery, when a safer anesthetic is available; (5) all opera- 
tions where, for any reason, the patient is in the sitting posture, or when 
the body must be raised to this position during the operation; (6) ath- 
letes and alcoholics who have had no preliminary medication. (7) 
patients whose general condition is poor, as indicated by a weak, anemic 
appearance; (8) general septic conditions, especially when due to long- 
standing tuberculous glands; (9) diabetic patients; (10) very thin per- 
sons, not otherwise diseased;2 (11) cyanosis already present; (12) low 
blood pressure from any cause; (13) the presence of an open flame. 
After-Effects.-The after-effects of chloroform narcosis may be con- 
sidered under two heads, viz.: (1) immediate, and (2) remote. 
1 Meyer and Gottlieb: Loe. cit. 
2 ' ' How strong a factor the fat plays is shown by the experiment on hungry 
animals where the brain takes up much more anesthetic than on well-fed animals 
in whom the fatty tissues absorb part of such narcotic. From these experiments 
we can readily imagine the absorption of narcotics by the lipoids of the nervous 
system during the narcosis and the return of function with their excretion back 
to the blood and the still further excretion of the anesthetic through the lungs." 
Meyer and Gottlieb: "Experimentelle Pharmakologie." CHLOROFORM 
311 
Immediate After-Effects.-If chloroform is scientifically admin- 
istered to a patient carefully prepared, and under proper climatic condi- 
tions, the subject passes into a profound sleep, awakening as from nat- 
ural slumber. Under other circumstances, however, the awakening may 
be accompanied by nausea, retching, and vomiting, with pallor and 
almost imperceptible pulse. Hiccough sometimes proves an annoying 
after-effect. As a rule, with chloroform, bronchial and pulmonary 
sequelae are absent. In neurotic and hysterical individuals mental dis- 
turbances, sometimes amounting to maniacal seizures, may follow. De- 
lirium of three days' duration has been reported. Aphasia has also been 
reported as following chloroform. 
Remote After-Effects.-Fatty infiltration of all the organs, ac- 
cording to some observers, follows the prolonged or repeated administra- 
tion of chloroform. Fatty degeneration of the liver, the heart, and the 
kidneys is particularly apt to occur under these circumstances, this being 
the outcome of a direct poisoning of these organs by the drug. Even 
when given in repeated, very small amounts, chloroform will lead to 
atrophic cirrhosis of the liver. 
Albuminuria, acetonuria, urobilinuria, acetonemia, acidosis, which 
have been noted by various observers as following chloroform anesthesia, 
are discussed under the special head, Post-Anesthetic Toxemia, in Chap- 
ter IX, Treatment Before, During, and After Anesthesia. 
Comparison With Other Agents.-It is important for the anesthetist 
to bear in mind the relative anesthetic value of the agent. The strength 
of chloroform as an anesthetic, as compared to ether, is calculated by 
Hewitt as 6 to 1, by Cushny as 8 to 1. Its anesthetic power is greater 
than that of ethyl chlorid. 
ADMINISTRATION OF CHLOROFORM 
Drop Method.-When chloroform was first introduced by Simpson, 
the method employed consisted in putting an unmeasured quantity of 
chloroform on a handkerchief, placing the handkerchief thus treated 
over the nose and mouth of the patient, and continuing the administra- 
tion in a somewhat similar manner. Not many years elapsed before the 
necessity for a different method suggested itself. Simpson then advised 
that a single layer, of a towel or a handkerchief, should be placed over 
the patient's nose and mouth, and that the anesthetic be added, drop by 
drop. This proved to be so much safer than the first way of administer- 
ing chloroform that the method has been advocated by every writer 
since that time. Inasmuch as the drop method will unquestionably con- 
tinue to be employed, and inasmuch as many will continue to use chloro- 312 
ANESTHESIA 
form alone, it is important that the safest method of administration in 
this way be considered. 
The Patient.1-It is more important with chloroform than with 
any other anesthetic that the head be on a line with the body. If a pillow 
is placed under the head it should be pushed under the shoulders, in 
order to prevent asphyxial symptoms during the second stage. This 
pillow should be removed as the third stage is reached. If in the dorsal 
position, the head should be turned slightly to one side, the anesthetist 
holding the symphysis of the jaw with the index finger, the little finger 
resting upon the carotid artery; the left hand should hold the chloro- 
form dropper. The clothing should be perfectly loose, shoes and stock- 
Fig. 123.-The Pilling Chloroform Dropper. 
ings being removed; a tight waist or neckband will materially interfere 
with what might otherwise be a featureless narcosis. If bandages are 
on the neck or around the waist, these should be cut but not necessarily 
removed before the operation begins. 
The Dropper.-It is even more important that chloroform should 
be dropped from the original container than ether or other inhalation 
anesthetics; therefore, containers arranged for dropping should be used. 
If not so arranged 2 the dropper recommended under ether will serve 
satisfactorily. 
Induction.-As the vast majority of chloroform fatalities reported 
have occurred in the first few minutes of administration, it is most 
important that the psychical element be controlled as much as possible, 
both by preliminary medication and by the conversation of the nurses, 
physicians, or friends who may be near. In addition the anesthetic will 
go much more smoothly if some Farina cologne is dropped upon the 
1 For general preparation of patient see Chapter IX, Medication, Prelim- 
inary, During, and Post-anesthesia. 
2 Tracings on a smoked drum indicate that the blood pressure is maintained at 
a much higher level when the anesthetic is induced slowly, as here outlined. CHLOROFORM 
313 
mask. This should be supplemented in one-half minute by one or two 
drops of aromatic spirits of ammonia, or, preferably, of an alcoholic 
solution of the oil of bitter orange peel.1 The first drop of chloroform 
can now be administered, and in 30 seconds the second drop, that is, 
two drops the first minute. This can be increased to six drops the 
second minute. The third minute, two drops may be given every ten 
seconds; the fourth minute, three to four drops every ten seconds; the 
fifth minute, five to ten drops every ten seconds. If the patient is not 
in full surgical anesthesia at this time, the administration may be con- 
tinued as follows: eight or ten drops every ten 
seconds for one or two minutes longer. No time 
is wasted by beginning the administration of 
chloroform very slowly. The mucous membranes 
are, in a measure, blunted, and, if conducted 
methodically in this way, the surgical stage will 
be ushered in by the automatic respirations of the 
patient, the first and second stages not being ob- 
served ordinarily. 
Maintaining Surgical Anesthesia.-When 
the surgical stage is reached the amount necessary 
to continue the anesthesia will be found to be one- 
half of the amount necessary to induce anesthesia; 
that is to say, if seven drops every ten seconds 
induce surgical anesthesia in six minutes, three or 
four drops every ten seconds will easily maintain 
an even plane of anesthesia. When the third stage is reached, however, it 
is well for the anesthetist to continue dropping the maximum amount 
for one or two minutes and then to go back to three drops every ten 
seconds for the next minute or so, and then to decrease this amount to 
two, or increase to three or four drops every ten seconds continuously, 
after that depending upon the patient's reflexes. 
In surgical anesthesia the muscles are relaxed, the pupil contracts 
to normal, the respirations (and this is the principal guide) become 
regular and automatic. The reflexes disappear; the pulse slows down, 
and, with chloroform alone, the face is usually pale. "A pulse below 50 
and extreme pallor are danger signals for the circulation." 2 
The respiration is slow, regular, and deep; all motor senses except 
those of respiration and circulation are completely depressed. 
It usually requires from four to eight minutes to reach full surgical 
anesthesia. 
When surgical anesthesia is finally obtained the patient must be kept 
in this stage. A lightening of the anesthesia may touch the vomiting 
Fig. 124.-A Chloro- 
form Dropper which 
Should Never be 
Used. 
1 See Chapter II, General Physiology. 
2 Meyer and Gottlieb: Loc. cit. 314 
ANESTHESIA 
center and trouble will immediately follow. The pulse should be norma], 
or a little below normal; if oxygen or ether is given, and the anesthetic 
warmed, it will be normal, or just a little above. The eyes are usually 
fixed during this stage, with pupils contracted but responding to light 
unless morphin has been previously given. When morphin has been 
given the pupils are contracted throughout. In abdominal operations it 
is usually necessary to abolish the lid reflex; where muscular relaxation 
is not required this reflex may be allowed to remain. In either case the 
reflex should not be consulted oftener than once every two or three 
minutes. It must be remembered that patients differ in all of these 
things. It is best, therefore, to be guided by all available signs, viz.: 
respiration, circulation, lid and color reflex, and amount of anesthetic 
given. 
In the third stage the spinal nerves are affected. With the drop 
method the face is usually pale, but when administered with oxygen the 
cheeks are usually flushed and the patient presents a very natural appear- 
ance. There is usually a reduction of body temperature when given by 
the drop method, but with warmed oxygen the normal temperature is 
usually maintained, or slightly raised. 
Warmed Chloroform.-The chloroform container should be dipped 
into a pan of hot water, from time to time, to facilitate the vaporization 
of the liquid. It is much safer to use the drug in this manner. Occa- 
sionally the mask should be entirely removed from the face for one or 
two respirations. The anesthetist must anticipate stages by careful 
observation of his patient. Surgical anesthesia may be maintained as 
follows: If three drops are given for ten seconds the patient will grad- 
ually come out of the anesthetic stage. As the pulse goes up and becomes 
full and bounding, the color improves and the reflexes become slightly 
active; this dosage can be increased to five or seven drops every ten sec- 
onds for a minute or so. As the reflexes become blunted again the anes- 
thetist should go back to three drops every ten seconds and continue as 
before. This method of ' administration by a watch relieves the anes- 
thetist of a tremendous nerve strain and enables him to produce a con- 
tinuous and safe narcosis. 
In order to determine the comparative value of chloroform as regards 
life when heated to 100° F., and at normal temperature, a number of 
experiments were made, using compressed air, and passing this air 
through chloroform at room temperature, and then to a special animal 
mask, using a Junker inhaler for the chloroform. Gwathmey 1 found 
that it took 8.92 -|- minutes on the average to kill (26 animals being 
used). Employing the same technique, with the addition of another 
Junker inhaler filled with warm water and placed in a warm receptacle 
between the chloroform and animal mask, it was found that the average 
1J. Am. Med. Assn., 47, 1361-64. CHLOROFORM 
315 
time required to kill (using 17 animals) was 20.35 minutes, thus show- 
ing that chloroform at blood temperature is three times as safe as chloro- 
form at room temperature. 
Intermittent Narcosis.-Chloroform should never be administered 
in the manner sometimes employed, unfortunately, with ether, namely, a 
small quantity, then a pause, and again a small quantity* The objection 
urged against the drop method outlined above is that the anesthetist is 
occupied every second of the time the patient is under the anesthetic. 
This is, in reality, one of the strongest arguments in its favor, as any 
untoward signs or symptoms are immediately recognized, and avoidable 
accidents are not encountered. 
Color Reflex.-If the anesthesia has been induced as outlined 
above, the patient's color will vary according to the individual. If, at 
any time, a sudden pallor appears about the nose and mouth, it indi- 
cates shock from some cause, or is a premonitory symptom of vomiting. 
If the latter, this condition can be immediately rectified by an increased 
dosage. The anesthetist should touch the forehead or ear of the patient 
occasionally and note the reflex; i. e., the quickness with which the color 
returns. This reflex, taken in consideration with other signs to be given 
below, is a good indication of the heart's action. If the color returns 
immediately after removing the pressure of the finger, the heart is in 
good condition. If this reflex is very slow it may not necessarily indi- 
cate danger; but it would indicate a weak heart, and possibly dangerous 
ground. 
The Pupil.-If morphin has been given as a preliminary medica- 
ment, the pupil will contract as soon as surgical anesthesia is reached, 
and usually remain so throughout the operation (this, of course, will 
depend somewhat upon the action of the morphin in that particular 
subject). It is unnecessary to attempt any observation of the eye as 
long as the reflexes are active and the patient is in the second stage of 
anesthesia. If no preliminary medicament has been given the pupil will 
be contracted a little below normal. If surgical shock intervenes from 
loss of blood, or handling important nerves and vessels, or if too light 
an anesthesia is being maintained, the pupil may dilate. If an overdose 
of the anesthetic has been given the pupil will also dilate, but will remain 
in this condition. The difference between the dilated pupil of a light 
anesthesia and one of an overdose must be determined immediately by 
the anesthetist. This can be done by recalling the amount of anesthetic 
that has been given within the last two or three minutes. 
Conjunctival Reflex.-In order to obtain the conjunctival reflex, 
place the index finger upon the upper eyelid and gently separate it from 
the lower lid. Now press down slightly upon the upper lid and bring 
the ball of the second finger in contact with the conjunctiva of the upper 
lid thus exposed. All of this should be done quickly. If the lid closes, 316 
ANESTHESIA 
or if it remains insensitive when considered with the other signs, it will 
indicate whether or not the necessary plane of anesthesia is being main- 
tained. 
Lower Lid Reflex.-This reflex is relied upon by some anesthetists. 
As the upper lid is separated from the lower, a movement of the lower 
lid, active, slight, or dulled, would indicate the degree of narcosis. 
Eyelash Reflex.-This is obtained by passing the index and second 
finger quickly over the eyelash of either eye. 
Lid Reflex.-Many anesthetists merely open the eye, and only 
deepen the narcosis when closure ensues. This is not quite so sensitive 
a sign as the lower lid reflex. 
Regardless of the eye reflex used, it should not be resorted to oftener 
than twice in five minutes, or, better still, once in five minutes. One 
eye should be held in reserve, for if this sign is resorted to by the anes- 
thetist too often, the reflex becomes either too deadened or too active to 
be of value. 
Pulse.-The pulse is most important in chloroform anesthesia. If 
cold chloroform is administered, a drop of five beats a minute is easily 
noted. If given warmed, as suggested in this chapter, the pulse will be 
maintained at a normal rate (see page 314). If anesthesia is induced 
as indicated, a rise in the second stage need not necessarily be expected. 
In full surgical anesthesia the pulse should be full and regular; any 
change in rhythm or fullness should be a warning to the anesthetist. 
Color reflex must always be considered in connection with the pulse. If 
no unusual loss of blood or handling of important nerves has taken 
place, an increase in the volume and rhythm indicates that the patient is 
regaining consciousness, and is a call for an increase in the amount of 
anesthetic. A running pulse would indicate shock from some source; an 
irregular pulse is always an indication of danger. 
Respiration.-The respiration is to be more closely watched than 
any other sign. The respirations should be maintained as full and regu- 
lar as possible; shallow respiration indicates vasomotor depression, or it 
may occur just before vomiting, or as one of the signs of shock. Irreg- 
ular and shallow breathing may be caused by too small an amount of 
anesthetic. It should be the anesthetist's aim to keep the respirations 
full and regular. Even when ether is contraindicated as the anesthetic, 
one, two, or three drops upon the mask for one or two minutes (at the 
same time continuing the chloroform administration) is a good pro- 
cedure. If there is an objection to this, Farina cologne, or an occasional 
drop of aromatic spirits of ammonia, or an alcoholic solution of the oil 
of bitter orange peel (as in the beginning) may be tried. The gentle 
rubbing of the lips with a towel, or piece of gauze, will usually stimulate 
the respiration. The anesthetist must not rely upon any one of the 
above signs, but must consider each in its relation to the other, and their CHLOROFORM 
317 
relation to the surgical procedure as a whole. In this way only can the 
proper level of anesthesia be maintained. 
From laboratory and clinical experience, the senior author has been 
fully convinced for a number of years that the dangers from chloroform 
are reduced to a minimum so long as the respirations arc full and regu- 
lar, and the concentration does not exceed 2 per cent. In the intentional 
killing of hundreds of animals in the laboratory we have failed to see a 
death from chloroform in which the respirations did not cease before the 
heart. The only exception to this rule was when the chloroform was 
given in a very concentrated vapor. This view is confirmed by Hare,1 
who states that 'The dominant action of chloroform is certainly upon the 
respiratory centers in the medulla, and that this effect is the cause of 
death in most cases of chloroform accident. Not only does nearly all ex- 
perimental work teach us this, but in a collective investigation as to the 
cause of death under chloroform nearly every case reported was found to 
have suffered primarily from respiratory arrest." These findings were in- 
dependently confirmed by Randall and Cerna in Texas. The only excep- 
tion to this would be in cardiac disease of any kind, when it can be easily 
understood that this organ would be the first affected. When we take 
into consideration that chloroform affects the respiratory centers and, in 
addition, has direct action upon the heart itself, and that there is also a 
lowering of the temperature during the administration, it is easily under- 
stood that, in a long operation, all three of these factors acting together 
would readily produce shock of a serious nature. 
Other Methods of Administration.-The best results have been ob- 
tained with the Roth-Drager, or the Gwathmey three-bottle vapor 
inhaler, or some similar apparatus, in which the percentage of chloro- 
form is approximately known, oxygen being administered conjointly with 
the chloroform, and the vapors being warmed through rebreathing. The 
patients come out of this form of anesthesia in as quiet a state as with 
nitrous oxid and oxygen. 
The Roth-Drager Oxygen and Chloroform Apparatus.-The Roth- 
Drager apparatus is designed to supply a mixed anesthestic of chloroform 
or ether vapor, separately or combined, in an atmosphere of oxygen. The 
face-piece (which is rigid and is suitable for all faces except the edentu- 
lous) forms an additional mixing chamber, as it admits air which dilutes 
the oxygen and thus presents an atmosphere richly supplied with oxygen 
and easily respirable. The percentage of anesthetic vapor is always 
known, as is also the pressure. The patient merely breathes to and fro 
into the face-piece, which is kept filled with the mixed gases. By 
gradually increased doses the administrator controls the amount of anes- 
thetic required at different stages of the operation; if he desires only 
chloroform, he turns that indicator. If ether is to be added he can easily 
1 Bull. Johns Hopkins Hosp., Jan., 1895. 318 
ANESTHESIA 
do so, and regulate the amount of each as the patient requires. The 
average induction period is six to eight minutes for adults. It is seldom 
marked by excitement or struggling, and respiration seems free and un- 
embarrassed. The narcosis is sufficiently profound for all surgical opera- 
tions requiring relaxation. 
The apparatus is extremely simple to work, in spite of its somewhat 
formidable appearance. It produces a satisfactory narcosis without any 
period of struggling or respiratory distress. 
Fig. 125.-The Roth-Drager Apparatus. Simple hand apparatus. 
The after-effects are usually slight, if the anesthetist is careful to 
limit the amount of anesthetic given. It is clear that the anesthetist is 
enabled to obtain and maintain an anesthesia which would be either dan- 
gerous or impossible without the use of oxygen combined with the anes- 
thetic. Vomiting may occur if too feeble a vapor is given during the 
induction period. 
The apparatus delivers three liters of oxygen mixed with five liters 
of air, which is the volume of gas necessary for the breathing of an adult, 
that is, eight liters per minute. The falling of the drops of chloroform 
or ether is both visible and audible. In this way a constant control of 
the working of the apparatus is possible. The principal points of advan- 
tage claimed for the apparatus are: 
(1) The color of the face does not alter; (2) the awakening is 
infinitely more easy; (3) irritation of the bronchia is reduced to a 
minimum; (4) the breathing is quiet and regular; (5) depression of CHLOROFORM 
319 
the pulse does not occur; (6) the pupils remain contracted; (7) re- 
covery takes place quickly and completely. 
Chemical investigations show that even in a long narcosis a decom- 
position of the chloroform does not occur. The anesthetist has both 
hands free at all times. 
Statistics of the General Hospital at Lubeck show that the usual 
amount of chloroform consumed is grams for a narcosis lasting 
At her 
Chloroform 
DRAGERWERK 
LUBECK 
Fig. 126.-The Roth-Drager Apparatus. Hand double apparatus. 
about 40 minutes. The amount of chloroform used with the Roth- 
Drager apparatus for the same length of time is 20 grams. The con- 
sumption of oxygen for 40 minutes amounts to 129 liters. 
In Figures 125, 126, and 127 the parts of the apparatus are let- 
tered as follows: M, the main valve of the oxygen cylinder; N, the 
finimeter, showing the quantity of oxygen contained in the cylinder 
at all times, and thus rendering a constant control of its contents pos- 
sible ; 0, a small, easily manipulated valve by means of which the stream 
of oxygen can be quickly turned on and off; P, an instrument which 
indicates the number of liters of oxygen used per minute; Q, the thumb- 
screw which is turned to perform the dosing of oxygen (P operates in 
response to Q) ; R, the cock which controls the dose of chloroform ad- 
ministered per minute; T, the chloroform in a removable glass which is 
graduated so as to provide a further means for ascertaining the quantity 
of chloroform used during each narcosis; V, the gasifier with observa- 320 
ANESTHESIA 
tion glass; L, the economizing apparatus with bag I. L is connected 
with the face-mask by a metal hose. 
The scale of the chloroform cock R is graduated, the graduations 
representing drops per minute and grams per minute, so that the 
strength of the dose being administered can be ascertained by merely 
looking at the position of the scale. By turning the pointer in another 
position any change in the strength of the dose can be instantaneously 
effected. The chloroform reservoir G is kept in position by the arm B. 
To remove the glass the lever B is 
pressed downward. The stream- 
ing of the oxygen causes suction 
in the glass S. By this means the 
chloroform is drawn up through 
the pipe H and is caused to fall 
from the drop-former T drop by 
drop. The drops fall into the 
stream of oxygen, burst into frag- 
ments and vaporize. By turning 
the chloroform the strength of 
suction can be adjusted at will, 
and, if desired, can be stopped al- 
together. 
Vernon Harcourt's Inhaler.- 
The improved Harcourt inhaler 
provides a definite mixture of air 
or oxygen with chloroform. A 
maximum two per cent vapor is 
provided. This is supposed to be 
the most accurate inhaler ever de- 
vised for the administration of chloroform. Two colored glass beads are 
dropped in the chloroform bottle to indicate the temperature ranges 
between 13° and 15° C. If the temperature of the chloroform is below 
13° 0., both the colored beads will float. If it is above 15° 0., both will 
sink. The correct temperature is indicated by the blue bead sinking and 
the red bead beginning to sink. A two per cent chloroform vapor can 
be continuously administered, or only air may be inhaled. The valves 
are of delicate mechanism, and easily moved by the inspiration and 
expiration of the patient. It has been found that with this apparatus 
a one per cent vapor, or less, is sufficient to maintain an even narcosis 
in the average run of cases. 
Hewitt's criticism of this inhaler is as follows I1 
First: That the current through it depends upon the respiratory 
action of the patient. 
Fig. 127.-The Roth-Drager Apparatus. 
1 Hewitt: "Anaesthetics," 1912, 492. CHLOROFORM 
321 
Second: That the face-piece pressure, which is often necessary in 
order to obtain proper chloroform percentages, will seriously interfere 
with the respiration. 
Third: That its management be- 
comes irksome to the administrator, 
particularly in long cases. 
Fourth: That it cannot be used 
for many operations. 
Fifth: It cannot be readily ster- 
ilized. 
Sixth: The disadvantage of mak- 
ing the respiratory pump of the pa- 
tient act as the pump of the ap- 
paratus. 
From the fact that several fatal- 
ities have been reported while using 
this apparatus, it would seem that 
accidents cannot be entirely pre- 
vented by accurate chloroform per- 
centages. A comparison of this 
inhaler with the Roth-Drager ap- 
paratus, taking into consideration the 
appearance of the patient immedi- 
ately after the discontinuance of the 
narcosis, would compel us to prefer 
the Roth-Drager apparatus. 
There is no provision in the Ver- 
non Harcourt inhaler for rebreathing. In addition, no effort is placed 
upon the respiratory pump by the Roth-Drager apparatus, as the oxygen 
Fig. 128.-Vernon Harcourt's In- 
haler, Complete with Face Piece, 
Bottle and Beads. 
Fig. 129.-Junker's Apparatus. 
or air with chloroform is forced into the bag under certain, definite 
pressure. 322 
ANESTHESIA 
Junker Apparatus.-This was the first vapor 1 apparatus devised, and 
it is especially applicable for adenoid and tonsil work, or any opera- 
tions about the head where the anesthetist must constantly change his 
position. The apparatus is so arranged that an approximate maximum 
of two per cent is reached. The percentage will vary according to the 
amount and temperature of ether in the bottle and pressure upon the 
hand bulb. The great advantage of this and all other similar inhalers 
is that a continuous narcosis can be maintained with the mouth open. 
(Fig. 129.) The vapor can also be given through nasal tubes directly 
into the nares, without interfering with the operator. 
Fig. 130.-Hewitt-Mason's Mouth-Gag with Anesthetic Tubes. 
Junker's original inhaler consisted of a bottle holding about two 
ounces of chloroform; this bottle was suspended from the coat of the 
anesthetist by a hook. A hand-bellows forced air through a tube run- 
ning through the top of the bottle to the bottom; air was forced through 
this tube, and, as it bubbled up through the chloroform, was conveyed 
to the patient by another tube that merely penetrated the cork; this 
latter tube was fastened either to a mask or a hollow tube or a nose- 
piece. It was entirely satisfactory, provided the bottle was not tilted, 
and that no mistake was made in attaching the rubber tubes from the 
face-piece and hand-bulb to the tubes entering the top of the bottle. 
In either event, liquid chloroform would be forced into the upper air 
passages. Hewitt made a decided improvement upon the Junker inhaler 
by making it impossible for such an accident to occur. He also de- 
vised a metal mouth-tube and mouth-gag, after which other mouth- 
gags, including one of the author's (J. T. G.), have been modeled. 
(Fig. 130.) 
Oxygen may be passed through the chloroform by merely attaching 
the tube from the oxygen tank to the afferent tube leading to the bottle. 
1 The vapor method is one in which air, oxygenated air, oxygen, or other gas 
passes either over or through the drug, thus vaporizing and delivering the an- 
esthetic in predetermined percentages. For a discussion of ether vapor anesthesia, 
see Chapter V. CHLOROFORM 
323 
Most of the bottles now have compartments for both chloroform and 
ether, so that the anesthetist can combine the vapors at will. The ap- 
paratus was designed especially for operations about the head, neck, 
and upper air passages, especially operations where the mouth must re- 
main open for some length of time. 
Braun's Inhaler.-Braun, of Leipzig, modified Junker's inhaler so 
that either chloroform or ether alone, or any combination of the two 
drugs, might be given. A metal mask, without valves, but with a small 
opening in the top to insure the supply of air, comes with the ap- 
paratus. Braun's apparatus originated with the idea of giving a con- 
tinuous anesthesia with highly attenuated ether vapor to which, from 
time to time, chloroform is added, according to requirements; he thus 
secures the advantages of both agents and discards their disadvantages. 
He adds only small amounts of chloroform when the ether vapor is in- 
sufficient to produce the desired effects. The Braun apparatus is sim- 
ple and easy to operate, and has decided advantages over the Harcourt 
inhaler. 
Gwathmey Three-Bottle Vapor Inhaler.-The apparatus is a modifi- 
cation of Braun's, with the addition of a water bottle, through which 
all the vapors of chloroform and ether must pass before getting to the 
patient. In addition, in cold weather, a heater is used to warm the 
anesthetic to the temperature of the blood. With this apparatus air or 
oxygen can be increased or decreased without, at the same time, de- 
creasing or increasing the anesthetic vapor. The apparatus consists of 
three six-ounce bottles. In the ether and water bottles the end of the 
tube is flattened out so as to get the maximum amount of vaporization; 
the smaller bottle, containing a little over one ounce, is placed within 
the large six-ounce bottle marked "chloroform." The tube in the chlo- 
roform bottle is perfectly straight. It is estimated that with the mask 
used a two per cent maximum vapor is obtained. Pure ether, chloro- 
form, or a mixture of these anesthetics, may be given by simply turn- 
ing one stopcock on the top of the metal holder. (See p. 334.) 
A drop of chloroform from an average pipette weighs 20 mg. and 
from a stoppered bottle 25 mg. (Waller and Wells1), and its vapor in- 
haled with average inspiration (400-500 c.c. air) provides a one per cent 
mixture. 
1 Lancet, July 9, 1904, p. 76. CHAPTER VIII 
THE SELECTION OF THE ANESTHETIC AND TECHNIQUE FOR 
SPECIAL OPERATIONS 
Conditions Affecting Selection : Inhalation Anesthetics; Safest 
Anesthetic; Chloroform with Oxygen; Value of Combinations and 
Sequence in Anesthetics; Safest Sequence. 
Rules to Be Observed in Selecting the Anesthetics: Age; 
Heart Disease; Pulmonary Tuberculosis; Obese Patients; Thin Subjects; 
Athletes, Alcoholics, and Other Drug Habitues; Diseases of the Lungs; 
Kidney Diseases; Cancer; Nervous Patients; Epileptics; Insane Pa- 
tients; Status Lymphaticus. 
Special Operations: Short Operations; Nitrous Oxid; Ethyl 
Chlorid; Chloroform and Ether; The Mastoid; The Upper Respiratory 
Tract; Excision of the Tongue; Cleft Palate; Submucous Operations; 
Adenoid and Tonsil Cases; Tracheotomy; Goiter (Angina Ludovici, Ex- 
ophthalmos-Graves' Disease) ; Amputations; Operations Upon Fingers 
and Toes; Circumcision; Rectal Cases; Obstetric Cases; Curettage; 
Genito-urinary Operations; Laparatomy; Gastro-enterostomy and Simi- 
lar Operations; Peritonitis or Intestinal Obstruction. 
Conclusions. 
Bibliography. 
CONDITIONS AFFECTING SELECTION 
In selecting an anesthetic for a given operation many things must be 
considered. First of all, the safety to life. Then the applicability of 
other anesthetics to the patient, whose size, age, habits of life, and con- 
dition at the time of operation must all be considered. The surgeon's 
likes and dislikes also demand attention. If he is accustomed to using 
chloroform, with its quiet breathing and subdued pulse, he will not 
be satisfied with ether, with its quick, bounding pulse and rapid respira- 
tion. Some surgeons object seriously to a patient moving, although this 
movement may not interfere with the operation. The very fact of the 
patient's moving may cause him to become nervous and thus prevent 
him from doing his best work. Again, other surgeons like a light anes- 
324 ANESTHETIC AND TECHNIQUE FOR SPECIAL OPERATIONS 
325 
thetic, and those who have adapted themselves to nitrous oxid and 
oxygen may not be pleased with chloroform with its absolute quiet and 
relaxation. 
Inhalation Anesthetics.-A list of anesthetics, their combinations 
and sequences, is therefore desirable. The following list, as regards 
safety to life, is based upon original experiments made, in 1904, by 
one of the authors (J. T. G.) : 1, Nitrous oxid with oxygen; 2, 
nitrous oxid with air; 3, ethyl chlorid with oxygen; 4, ethyl chlorid 
with air; 5, anesthol with oxygen; 6, ether with oxygen; 7, chloroform 
with oxygen; 8, ether with air; 9, C. E. mixture (chloroform two parts, 
ether three parts, and oxygen); 10, C. E. mixture with air; 11, chloro- 
form with air. 
Safest Anesthetic.-Nitrous oxid with oxygen is easily the safest 
anesthetic known. It is almost impossible to kill normal animals with 
this combination. If they are asphyxiated, and the mask is removed, 
the heart will continue to beat for several minutes. This gives suffi- 
cient time for the gas to escape as it reaches the lungs, and for breath- 
ing to commence again automatically. Such is the case in the labora- 
tory and in the operating room. The only likelihood of a mistake is 
when the physiological signs of asphyxiation are not known. 
Chloroform with Oxygen.-While chloroform is classed as the most 
dangerous anesthetic, generally speaking, the purity of the chemical, 
the mode of administration, and the environment may considerably 
alter its place in the list. If used with oxygen, and in definite per- 
centages, it is safer for certain cases (i. e., patients with abnormally 
narrowed air passages) than is nitrous oxid with oxygen. Again it is 
safer in tropical countries and in the summer time than in a colder cli- 
mate or during the winter. The patient's physique may be such that 
it would be very difficult, if not impossible, to administer nitrous oxid 
with oxygen alone. 
Value of Combinations and Sequence in Anesthetics.-Again, the 
relative safety of these anesthetics is enhanced by using them in proper 
combination and sequence. The following is a list of the usual com- 
binations and sequences: 
(1) Nitrous oxid with oxygen, combined with warm ether. 
(2) Nitrous oxid with oxygen, combined with ethyl chlorid (either 
closed or open). 
(3) Nitrous oxid-ether sequence. 
(4) Nitrous oxid-ether sequence (closed method), followed by ether. 
(5) Nitrous oxid-oxygen-ether sequence (vapor or drop). 
(6) Nitrous oxid-ether sequence, followed by ether and chloroform. 
(7) Nitrous oxid-ethyl chlorid-ether sequence (closed method). 
(8) Ethyl chlorid-ether sequence. 
(9) Ethyl chlorid, ether-chloroform sequence. 326 
ANESTHESIA 
(10) C. E. mixture-ether sequence. 
(11) C. E. mixture-ether-chloroform sequence. 
(12) Chloroform with ether sequence (vapor or drop). 
(13) Chloroform ether-chloroform sequence (vapor or drop). 
(14) Chloroform-ether (vapor or drop), followed by ether (closed 
method). 
(15) Ether-chloroform sequence. 
(16) Ether-chloroform-ether sequence. 
Safest Sequence.-The latest and best development in anesthetics 
is the use of ether and chloroform in combination with nitrous oxid 
with oxygen, making nitrous oxid and oxygen the basis of the anes- 
thesia. It has also been found by clinical experience that what is com- 
monly known as the gas-ether sequence,-that is, giving first gas from 
one to two minutes, and then switching to ether,-is the best method of 
administering ether in suitable cases. (See page 218.) The gas-ether- 
chloroform sequence is a still further modification of the above, and 
for certain cases it is probably the best sequence. No hard-and-fast 
rules are to be laid down, however, for the selection of the anesthetic, 
for the method of its administration, or for the time of changing from 
one anesthetic to another. This must be learned by experience, and the 
anesthetist must know the physiological effect and the dosage of each 
drug that he uses. 
The fact that these anesthetics are used in combination and se- 
quence by the most expert anesthetists of to-day is good evidence that 
in many cases no one agent is suitable throughout the anesthesia. It 
is unwise to suggest or recommend this or that special anesthetic or 
method, as, for example, ether by the drop method, for this seems like an 
attempt to fit the anesthetic to the anesthetist rather than to the pa- 
tient. 
RULES TO BE OBSERVED IN SELECTING THE ANESTHETIC 
Some definite rules serve to guide us in the selection of a suitable 
anesthetic. 
Age.-Infants.-Children under one year of age should never be 
kept under the anesthetic longer than one hour. Many children have 
been successfully anesthetized for one or two hours at a delicate age, but 
a certain definite risk is incurred when the anesthesia lasts one hour or 
more for a child under one year old. 
Until within recent years it has been the custom to administer chloro- 
form to children. A number of deaths have been reported of children 
dying two or three days after the administration of chloroform, and post- 
mortem examination has revealed the fact that these children had what 
is known as status lymphaticus. (See page 331.) "The clinical evi- ANESTHETIC AND TECHNIQUE FOR SPECIAL OPERATIONS 
327 
deuces of this condition do not allow its certain detection beforehand, 
but the anesthetist will be wise to be particularly on his guard when the 
patient is a child or young adult of slight physique, though good 
height, pale complexion, timorous disposition, or with large tonsils and 
adenoids. If the spleen is palpable and there are palpably enlarged cervi- 
cal or abdominal glands, apprehension is still better founded. Lymphoid 
follicles visible on the epiglottis and much enlarged papillae at the back 
of the tongue are also evidences suggestive of the condition." 1 On 
this account it is now customary to administer ether alone or the C. E. 
mixture. 
If chloroform is given at all to very young children, it should be ad- 
ministered warm, and preferably with oxygen instead of air. 
Chloroform should not be entirely abandoned for children or other 
subjects because it has been misused in the past. It is unquestionably 
safer and better to induce the anesthesia with chloroform in the majority 
of instances and to maintain the anesthesia with ether than to shock the 
child by attempting to commence the anesthesia with ether. It is always 
best to begin the anesthesia with one or two drops of the essence of bitter 
orange peel (25 per cent U. S. P.), or any cologne, provided it is not 
sweet smelling. Any sweet perfume or scent tends to produce vomiting 
at this time. There are a very few conditions in which the anesthesia 
should be maintained with chloroform. Some anesthetists have used 
nitrous oxid from the start by simply allowing it to flow from a tube 
to the patient's nose and mouth, without any mask, and diminishing the 
quantity as cyanosis appeared. Crying children are easily and quickly 
anesthetized, and for this reason should not be given chloroform at all. 
Nitrous oxid, unless given by some open method, is a very poor anes- 
thetic for young children, as they do not seem to be equal to the task of 
breathing through valves. 
Ethyl chlorid is preferred by many anesthetists for young children. 
They usually succumb rapidly and without struggling or cyanosis. 
Infants should preferably be anesthetized in the mother's or nurse's 
arms. The method should be the same as for sleeping children.2 Care 
should be taken in anesthetizing children to make the operation as in- 
formal as possible. Mental suggestion here plays a great part, as well as 
gentleness in voice and movement. Questions such as "How old are 
you ?" or "What is your name ?" and immediately calling the child by the 
first name, put them at their ease at once. Avoidance of all appearance 
of restraint is necessary. Where a child is obstinate or terrified it is 
best to induce unconsciousness as rapidly as possible. Such children 
must be firmly restrained until this is accomplished. 
1 Latham A., and English, T. Crisp: "A System of Treatment," 3, 25. 
2 See article on Alexander's and Gwathmey's ' ' Technique in Adenoid and 
Tonsil Operations. ' ' 328 
ANESTHESIA 
Children Five to Eight or Ten Years oe Age.-The anesthesia 
should be commenced with some perfume and continued by the drop 
method of chloroform or anesthol until the third stage is reached; then 
the second mask should take the place of the first and the anesthesia 
should be deepened and maintained by ether. This is the best method to 
use. English authorities recommend the C. E. mixture. The poison- 
ous effects of chloroform in connection with status lymphaticus need not 
be feared when chloroform is used in this way. Children under five years 
of age should not be kept under full surgical anesthesia more than two 
hours. 
Ten to Nineteen Years of Age.-The best anesthetic for young 
people is a judicious combination of chloroform and ether given by the 
vapor or drop method. No preliminary medication is usually necessary. 
In some cases, however, morphin and atropin, in small quantities, can be 
used to advantage to prevent excessive flow of mucus. One-twentieth to 
one-twelfth of a grain of sulphate of morphin, with 1/300 of a grain of 
atropin, is the usual dose. 
Nineteen to Fifty Years of Age.-Nitrous oxid and oxygen, the 
gas-ether, chloroform or anesthol-ether, or ethyl chlorid-ether sequences 
are probably the best agents for patients from 19 to 50 years of age. 
Preliminary medication for this class of patients must be considered as a 
part of the general anesthetic. It should be varied according to the size 
and condition of the patient. One-eighth to one-quarter of a grain of 
morphin, with 1/150 grain of atropin, can usually be given with very 
great advantage. 
Fifty and Over.-Elderly people yield more readily than do younger 
subjects to the combination of chloroform and ether by the vapor or 
drop method. The closed method or the gas-ether sequence is usually 
contraindicated. When atheromatous conditions are present, or cerebral 
hemorrhage from any cause is feared, ether is contraindicated, as is also 
nitrous oxid with oxygen. Chloroform with oxygen should be used in 
these cases. Weak, anemic men and middle-aged women yield better to 
nitrous oxid with oxygen, either alone or supplemented by small amounts 
of ether and chloroform. 
Many of these patients have some respiratory trouble, as chronic 
bronchitis or asthma, or arteriosclerosis. There is very little fear of 
chloroform poisoning in the aged, and yet it is always best to supplement 
chloroform by ether in sufficient quantity at least to maintain a good 
type of respiration throughout the anesthesia. Care should be taken to 
avoid the slightest cyanosis. Elderly patients are, as a rule, good sub- 
jects for anesthetization, not only in inducing and maintaining the anes- 
thesia, but also as regards after-effects. 
Heart Disease.-Unless some definite signs, such as swollen ankles, 
pulmonary edema, or dyspnea, are present, it is unnecessary to pay atten- ANESTHETIC AND TECHNIQUE FOR SPECIAL OPERATIONS 
329 
tion to any heart lesion. An open method is usually best in these cases, 
anesthesia being induced with chloroform, the chloroform-ether mixture 
or anesthol, and continued with ether and oxygen. If loss of compensa- 
tion is present, as indicated by any of the above signs, pulmonary anes- 
thesia should be avoided and local or spinal anesthesia used. A prelimi- 
nary dose of morphin may be used to advantage in these cases. A deep 
anesthesia is preferable to a light one. For paracentesis of the peri- 
cardium, nitrous oxid with oxygen is preferable. 
Pulmonary Tuberculosis.-Patients with tuberculosis should have 
nitrous oxid and oxygen whenever possible. Ether is contraindicated, 
as it is liable to light up a diseased lung that may have been in a quies- 
cent stage for some time. Warmed chloroform and oxygen is the second 
choice. 
Obese Patients.-As a general rule a healthy obese patient seems to 
be immune to any poisonous after-effects from chloroform. Obese pa- 
tients and those with obstructed or narrowed passages are best anes- 
thetized by warm chloroform and oxygen. Any closed method should 
be avoided with these patients. 
Thin Subjects.-With thin, anemic individuals all other anesthetics 
should be considered before using chloroform, anesthol, or ethyl chlorid. 
Athletes, Alcoholics, and Other Drug Habitues.-Athletes and per- 
sons addicted to the excessive use of alcoholic stimulants should always 
receive preliminary medication, regardless of the anesthetic selected. 
Morphin, with atropin or some other appropriate drugs, may be employed. 
For alcoholics, especially, if one to two ounces of whiskey in eight ounces 
of saline solution is administered per rectum, in combination with mor- 
phin given hypodermically, the anesthetic acts more satisfactorily than 
when alcohol is withheld. Persons addicted to the use of drugs, such as 
morphin, etc., should not be restricted before the anesthetic in the use 
of the particular drug concerned, but should be given the dose to which 
they are accustomed. The immediate ill results of withholding drugs at 
this time are easily recognizable, but the opportunity for its final dis- 
continuance is apparent. 
The requisite preliminary medication having been given, the vapor 
and drop method of anesthesia is preferable to any closed method, as 
these patients suffer especially from deprivation of oxygen. 
According to Mahoney,1 alcoholic subjects do better with treatment 
for a week or ten days with bromids, with the gradual withdrawal of 
alcohol. Treatment for even a few days is better than none. 
Diseases of the Lungs.-In pleurisy, empyema, abscess of the lung, 
and in all operations in which one lung is involved, the patient should 
lie with the diseased lung lower, in order to assist drainage and reduce 
1 Mahoney, Daniel F.: " Some Considerations of Ether Anesthesia. ' ' Boston 
Med. and Surg. J., Oct. 19, 1911. 330 
ANESTHESIA 
the chance of infecting the healthy lung, and also to allow the healthy 
lung perfectly free respiratory action. 
If pneumonia is present and an operation is absolutely necessary, lo- 
cal, spinal, or rectal should be preferred before pulmonary anesthesia. 
In dyspnea a local, spinal, or rectal anesthesia is preferable to a pul- 
monary anesthetic. If, however, a pulmonary anesthetic is used, chloro- 
form with oxygen is the first choice, the patient being allowed to assume 
the attitude in which it is easiest for him to breathe. 
In acute or chronic bronchitis or phthisis, asthma, pneumonia or any 
diseases of the respiratory passages, ether is, if possible, to be avoided, 
even with the most improved methods of administration. Oxygen and 
chloroform or nitrous oxid and oxygen are the anesthetics to be chosen. 
Morphin or some similar medication should always be used in these 
cases. 
Kidney Diseases.-In all kidney diseases ether and chloroform are 
usually contraindicated. Nitrous oxid with oxygen is the anesthetic to 
be preferred. 
In cases of diabetes in which sugar is either absent from the urine 
or present only to a slight degree, chloroform with oxygen anesthesia is 
unattended by risk, but when the quantity is abnormally large there is 
danger of diabetic coma. Chloroform should be avoided in these cases, 
and nitrous oxid and oxygen chosen as the anesthetic. These patients 
should be carefully dieted in order to reduce the amount of sugar to the 
minimum. Before regaining consciousness they may relapse into a coma- 
tose condition and die from acetonemia. (For a discussion of aceto- 
nemia, see Chapter IX.) 
Cancer.-Wherever the cachectic condition that is usually associated 
with advanced cancer exists, the patient takes kindly to the anesthetic 
and requires very little of it to maintain surgical anesthesia. These pa- 
tients should always be given a preliminary dose of morphin before 
going to the operating table, as many of them have been accustomed to 
this medication. For removal of a cancerous breast, nitrous oxid and 
oxygen for elderly people, and ether and oxygen by the vapor method 
in younger subjects, are preferable, as the anesthetist is out of the way 
and shock is less liable to occur than with other procedures. Chloroform 
may be sparingly used in connection with the ether. It is best to antici- 
pate shock in these cases by giving one pint of saline with one ounce of 
glucose per rectum two hours before the operation. Fifteen to twenty 
minutes before any operation is concluded a pint of saline with three or 
four ounces of glucose should be given per rectum. 
Nervous Patients.-Nervous patients should be gotten under the 
anesthetic as quickly as possible. The gas-ether sequence or nitrous oxid 
should be used. This prevents hysterical symptoms from appearing. 
Epileptics.-A preliminary of morphin is indicated for this special ANESTHETIC AND TECHNIQUE FOR SPECIAL OPERATIONS 
331 
class of patients and the anesthetic induced with chloroform, with a 
switch to ether in the second stage. The anesthetist must be ready to 
prop a mouth gag between the teeth if a seizure should occur as the 
patient is going under the anesthetic. The prop should be inserted be- 
tween the teeth as the patient is recovering. It is usually well to give a 
small hypodermic toward the close of the operation, as this will prevent 
a later seizure occurring. 
Insane Patients.-Insane patients should always have a preliminary 
medication of morphin % of a grain one hour before the operation, to 
be repeated, with 1/150 grain of atropin, one-half hour before the anes- 
thetic is commenced. The anesthesia should be induced with chloroform 
and maintained with ether and oxygen by the vapor method. Mental 
aberrations have been known to occur after the inhalation of any or all 
pulmonary anesthetics. This is probably caused by irregular or inter- 
mittent narcosis. 
Status Lymphaticus.-Definition.-Status lymphaticus or thymi- 
cus, or lymphatism, is a condition of infancy and childhood, marked by 
hyperplasia of the lymphatic structures, spleen and bone marrow, and 
persistence of the thymus gland (Stedman). It has also been defined as 
a condition of unstable equilibrium, coma, convulsions, and vomiting 
accompanying hyperplasia of the persisting thymus (Gould); and as a 
morbid state due to excessive production or growth of lymphoid tissues, 
such as the thymus and thyroid glands, resulting in impaired develop- 
ment, lowered vitality, and sometimes death (Dorland). 
History.-As early as 1614 attention was called by Felix Plater to 
the fact that the thymus was enlarged in three cases of sudden death 
from dyspnea in one family. In 1823, and again in 1829, Kopp men- 
tioned the association of the enlargement of the thymus gland with sud- 
den death. Paltauf, in 1889 and 1890, collected, for the first time, a 
large number of cases of sudden death in adults, in which there was 
enlargement of the tonsils, lymphatic gland system, the follicles at the 
base of the tongue, the spleen, and the thymus gland, with narrowing 
of the aorta. Kundrat, in 1895, published ten cases of death immediately 
after anesthesia by chloroform or some mixture containing it, also one 
case in which ether was the anesthetic. Sudden deaths were noted after 
this time in many cases in which no anesthetics had been administered. 
Lymphatic hyperplasia has been found to occur in every chloroform 
fatality for the past twenty years in the children's clinic at Gratz. The 
first case recorded in England was reported by Wolff in 1905. Two 
deaths under local anesthesia have been recorded by Horoszkiewicz. 
Anatomy.1-"The thymus gland is a temporary organ attaining its 
full size at the end of the second year, when it ceases to grow and re- 
mains practically stationary until puberty, at which period it rapidly 
1 Gray: ' ' Anatomy, ' ' 1442. 332 
ANESTHESIA 
degenerates. It does not entirely disappear, for the shrunken and de- 
generate mass even in later life maintains a likeness to the original form 
and retains within its substance small portions of thymus tissue (Wal- 
deyer). If examined when its growth is most active, it will be found to 
consist of two lateral lobes placed in close contact along the middle line, 
situated partly in the superior mediastinum, partly in the neck, and ex- 
tending from the level of the fourth costal cartilage upward as high as 
the lower border of the thyroid gland. It is covered by the sternum 
and by the origins of the sternohyoid and sternothyroid muscles. Below, 
it rests upon the pericardium, being separated from the arch of the aorta 
and great vessels by a layer of fascia. In the neck, it lies on the front 
and sides of the trachea, behind the sternohyoid and sternothyroid 
muscles. The two lobes generally differ in size; they are usually con- 
nected so as to form a single mass but are sometimes separated by an 
immediate lobe. The thymus is of a pinkish gray color and is lobulated 
on its surfaces." 
Diagnosis.-The majority of writers are agreed that a positive diag- 
nosis of this condition during life is very difficult. The fact is that en- 
larged tonsils and the conditions termed status lymphaticus by most 
writers call for the extirpation of the tonsils with the idea of increasing 
oxygen in the tissues and the blood, and stimulating the growth of 
the individual. Connor1 says: "The plainest sign of congenital 
hyperplasia of the vascular system is the noticeably small size and thin 
walls of all arteries." 
Pasty complexion, a large amount of subcutaneous fat, and, in 
adults, a scant amount of axillary or pubic hair are usual; also the hair 
of the head has a peculiar dry, brittle character. Enlargement of the 
faucial, pharyngeal, and laryngeal tonsils is frequently present. The 
diagnosis of a tumor running under the sternum would be almost pathog- 
nomonic of this condition. Cocks 2 considers the X-ray examination sec- 
ond only to the general condition of the patient in making a diagnosis. 
Most patients dying during or immediately after anesthesia have 
been young people or children, of flabby type, with enlarged adenoids, 
tonsils, thyroid (usually), and thymus; with narrow, high-arched palate, 
small mouth and throat, and weak heart sounds. During anesthesia a 
grayness of complexion or pallor is witnessed, with weak heart action and 
shallow breathing. Enlargement of the thyroid is said to exist in more 
than 50 per cent of cases. Enlargement of the tongue is an important 
factor in diagnosis. The spleen has been found to be greatly enlarged in 
many cases, also the mesenteric, popliteal, axillary, and inguinal glands. 
Exophthalmic goiter may also be present, in which event heart failure 
1 Connor: N. Y. State J. Med., 1906, 282-284. 
2 Cocks: "A Contribution to the Pathology and Clinical Diagnosis of Status 
Lymphaticus," read before the Am. Laryn., Ehinol., and Otol. Soc., May, 1912. ANESTHETIC AND TECHNIQUE FOR SPECIAL OPERATIONS 
333 
under the anesthetic is probable. Congenital defects such as cleft palate 
and cleft kidney are sometimes associated with status lymphaticus. All 
patients have a pale, thin skin, pasty complexion, and usually subcu- 
taneous fat. The glands of the neck are also sometimes enlarged. The 
above complex symptoms are noted when, given chloroform for any 
length of time, much of the anesthetic is absorbed and less secreted than 
is usual, with a consequent continual poisoning of the system until death 
occurs several days after the anesthetic. Sometimes delayed chloroform 
poisoning is mistaken for status lymphaticus. In status lymphaticus, 
especially in children, patients seem to dread the anesthetic more than 
is usually the case. This fear would certainly add to the shock and 
decrease the normal resisting force of all the organs to the effects 
of the anesthetic. Two cases of death, noted by Wheelock,1 at 
Fort Wayne, were due to cardiac failure and asphyxiation. In cardiac 
failure no premonitory symptoms are present, but in asphyxiation there 
is a disturbance of breathing at various times. An enlarged thymus has 
sometimes produced pressure from which asphyxial symptoms have de- 
veloped. In some of the reported cases, death occurring during anes- 
thesia always came suddenly, with pallor and dilated pupils. In some 
there were superficial respiration and intermittent pulse just before the 
last signs mentioned, together with cyanosis and dyspnea. Ohlmacher 2 
states that deaths from status lymphaticus are due to increased intra- 
cranial pressure, with sudden edema. Halstead 3 points out the great 
danger of operating for adenoids and tonsils upon children with status 
lymphaticus, on account of the great shock which the added fright and 
violent struggling would bring on-in some cases enough to produce 
death. 
Choice of the Anesthetic for Suspected Cases.-From the study 
of a large number of statistics, the fact that chloroform is contraindi- 
cated cannot be questioned. Roberts 4 concludes that ether is the safest 
anesthetic for all of these cases. Unquestionably chloroform should be 
avoided in all suspected cases. Ether by the vapor or drop method 
should be the anesthetic of choice. No closed method should be used 
on account of the possibility of pressure symptoms. Children who sink 
into deep anesthesia quickly from small doses of the drug should at once 
be considered questionable cases for the anesthetist. 
Preparation for Operation.-Great precaution should be taken 
that the preparation and preliminary medication be complete, so that 
whatever is given, when the time for operation arrives, the patient 
will be in a more or less drowsy condition and indifferent to the anes- 
1 Toledo Med. and Surg. Rep., 1909, 35, 395-399. 
2 J. Am. Med. Assn., Feb., 1904, 42, No. 7. 
3 Phila. Med. J., Nov. 3, 1900. 
4 Trans. Am. Laryn., Rhinol. and Otol. Soc., St. Louis, 1908, 507-524. 334 
ANESTHESIA 
thetic. (See Chapter IX, Treatment, Preliminary, During, and After 
Anesthesia, p. 365; also Acetonemia. 
Treatment During Anesthesia.-If sudden syncope occurs, mas- 
sage of the heart, in connection with artificial respiration, should be insti- 
tuted immediately. Hilliard1 thinks that the hypodermic injection 
of morphin and atropin before the administration of the anesthetic 
is of great value, and that, with this addition, general anesthesia is 
safer than local anesthesia. 
Fig. 131.-The Gwathmey Three-Bottle Vapor Inhaler, Mouth Gag, with Hollow 
Tubes Attached. (See page 323.) 
Mortality.-Harvey Hilliard 2 gives a very complete history of a 
fatal case of status lymphaticus in a young man aged twenty-one, six feet 
two inches in height, very thin, and of a highly neurotic temperament. 
Operation: circumcision. 
The patient was a great smoker of cigarettes and subject to attacks 
of faintness. The patient had the usual preparation, but was allowed to 
smoke during the morning, the operation being at twelve o'clock. Hil- 
liard found on examination a rapid pulse, poor chest expansion, and con- 
siderable enlargement of the thyroid gland. Chloroform-ether mixture 
was the anesthetic. During the induction period, the heart beat very vio- 
lently. A light anesthesia was maintained. When the prepuce was 
severed, the patient turned an ashen color and stopped breathing. Rhyth- 
mic tongue traction was employed and amyl nitrite vapor, the adminis- 
trator pressing the lower ribs to restore respiration. This brought the 
patient round. The anesthetic was discontinued with the idea of dis- 
continuing the operation, when the patient immediately stopped breath- 
ing. The usual restorative methods were resorted to, but proved unavail- 
ing. Artificial respiration was kept up for forty-five minutes, but the 
patient did not again come around. 
1 Hilliard, Harvey: "A Fatal Case of Status Lymphaticus,'' Brit. Med. J., 
Jan. 25, 1908, 202. 
2 Idem: Loc. cit. ANESTHETIC AND TECHNIQUE FOR SPECIAL OPERATIONS 
335 
Post-mortem examination showed the thyroid gland enlarged, with 
degenerated changes. The thymus gland was persistent and weighed 
24 grams. The heart was dilated, with thin, flabby walls. 
In thirty-five cases reported by McCardie the average age was six- 
teen years, the youngest patient being six months; seven were under ten 
years of age, fourteen between the ages of ten and twenty, eight from 
twenty to thirty, and two from thirty-one to thirty-two, the oldest being 
fifty-five years. There was no distinction as regards sex. 
Cocks 1 reports forty-six cases of status lymphaticus in approximately 
sixteen hundred autopsies at the Bellevue Hospital Pathological Depart- 
ment. 
In thirty cases examined by McCardie for status lymphaticus the 
deaths during or after anesthesia were: seventeen from chloroform, six 
from ether, five from a mixture of chloroform and ether, and two doubt- 
ful eases, in which the anesthetic was nitrous oxid. There is also re- 
corded the death of an infant, one year old, after an injection of 1/12 
of a grain of morphin, in whom post-mortem examination revealed the 
signs of status lymphaticus. Two deaths are reported under local anes- 
thesia, both patients being women, aged thirty and thirty-one years, 
respectively. 
Death from any cause, and especially during the anesthesia, is always 
very sudden. In rare instances the enlarged thymus gland may com- 
press the trachea sufficiently to cause death by suffocation. Toxemia in- 
duced by the thymus may reduce the subject to such a degree that sud- 
den shock may cause death, toxemia being primarily responsible. Pa- 
tients have also been known to die from such a trivial shock as bathing. 
Post-Mortem Examination.-Autopsy usually showed adenoids and 
tonsils enlarged, thymus gland very large, and spleen also enlarged; 
heart and liver healthy. The aorta and small arteries were smaller and 
thinner than normal, with signs of cardiac dilatation, evidence of recent 
rickets, and sometimes incomplete development of the sexual organs. In 
some cases fatty degeneration of liver (principally), kidneys, heart and 
other muscles was noted. Hyperplasia of the lymphatic glands is usually 
noted, also evidence of infantilism, such as, for example, scanty pubic or 
axillary hair. Exophthalmic goiter is frequently associated with status 
lymphaticus. Cocks reports over fifteen deaths occurring in connection 
with cerebrospinal meningitis. 
Observation Upon Animals.-Offergeld and Muller 2 have made 
a number of interesting experimental narcoses upon animals with the 
following results (presumably with chloroform at room temperature in 
all cases and without oxygen except as stated) : 
'Cocks: Loc. cit. 
2 Offergeld and Muller: ' ' Experimenteller Beitrag z. toxiscrien Wirkung dea 
Chloroforms auf die Nieren, " Arch. f. Iclin. Chir., 1905, 75, 758. 336 
ANESTHESIA 
Animals chloroformed for two hours, after recovery from the immedi- 
ate effects of the anesthetic, usually died from 48 to 60 hours afterward; 
post-mortem examination showing parenchymatous degeneration of the 
heart, liver, and kidneys. When artificial nephritis was produced, exten- 
sive injury occurred even with a fifteen-minute anesthesia. When injured 
by mineral acid, pus, germs, or the injection of diphtheria toxins, it was 
found that the kidneys were usually affected by chloroform narcosis. 
When pregnant animals were used, this fact in itself did not favor fatty 
degeneration unless complicated with kidney lesions. A second chloro- 
formization favored greatly the degenerated changes in the kidneys. Fat 
seemed to disappear in the tissues and to accumulate in the liver. Offer- 
geld concluded that anemic and cachectic conditions of the patient fa- 
vored the poisonous action of chloroform, and he warned against the 
danger of repeated chloroform anesthesias. He also believed that the 
prevention of the ill effects of chloroform might be accomplished by a 
mixture of chloroform and oxygen. 
Muller concluded that the changes in the internal organs always 
appeared first as fatty changes, depending upon the time and number of 
the anesthesias; that these changes were in direct proportion ro the anes- 
thetic power of the agent used; that they usually disappeared after anes- 
thesia ; that a second anesthesia was always very dangerous; that the 
fatty changes following the second anesthesia were twice as severe as 
from the first, regardless of the time given; that the second anesthesia 
should never be given for at least three days after the first; that pneu- 
monias occurred frequently with ether; that chloroform should be the 
second anesthetic; that mixed anesthesias did not prevent these fatty 
changes; and that these changes took place in the vessel walls of the 
brain as well as of the other internal organs. 
Bandler's 1 experiments seem to show that ether does not produce the 
changes in the liver cells caused by chloroform. 
Strassmann 2 chloroformed animals previously weakened by loss of 
blood, with a greater resulting fatty degeneration than upon normal ani- 
mals. 
The senior author (J. T. G.) agrees with Henderson 3 that unskillful 
anesthesia is more often the cause of death, and especially in adenoid and 
tonsil cases, than the status lymphaticus or heart disease. Henderson 
states that "writers assume that status lymphaticus was the cause of 
death, although there may have been no autopsy. Even in those cases 
in which an autopsy was performed, the pathologist's report sometimes 
1 ' ' Ueber den Einfluss der Chloroform und Aethernarkose auf die Lieber, ' ' 
Mittlg. aus den Grenzgebeit. der Med., 1896, 1, 303. 
2 Virchow's Arch., 1899, 115, 1. 
3Henderson, Yandell: "Primary Heart Failure in Normal Subjects Under 
Ether," Surg. Gyn. and Obstet., Aug., 1911. ANESTHETIC AND TECHNIQUE FOR SPECIAL OPERATIONS 
337 
indicates that if he had not been told what to find he would scarcely 
have found it. 
"On looking up the general subject of status lymphaticus, I find that 
this mysterious (I might almost say mystical) condition was only a few 
years ago used in precisely the same way, and with the same confidence, to 
explain another class of fatalities. It is less than a decade since the 
time when, if a patient died suddenly after an injection of antitoxic 
serum, an unsuspected condition of status lymphaticus was invoked as 
the explanation. In many of the very best text-books of pharmacology 
(written, by the way, by laboratory men), the practice of occasionally 
interrupting the administration of ether, and of allowing the patient to 
come for a few moments pretty well out of anesthesia, is expressly recom- 
mended. If anesthetists will only realize that this is a procedure which, 
above all others, should be shunned, the number. of cases of so-called 
status lymphaticus fatalities, under anesthesia, will, I believe, show a 
sudden and marked decrease." 
Henderson concludes his article by stating that "unsuspected cases 
of status lymphaticus are often invoked after tonsil operations, which are 
due entirely to the ether being administered intermittently and the sub- 
ject rapidly coming part way out of the anesthesia rather than to any 
connection of the tonsils with the thymus." 
SPECIAL OPERATIONS 
Short Operations.-Precautions.-As many fatalities have been re- 
ported from all anesthetics for short operations, it is well to state the 
means of avoiding them or reducing them to the minimum in the fu- 
ture. 
First: With the exception of emergency cases, all patients should 
be as well prepared for a minor operation as for a major one. 
Second: Rules regarding diet, cleansing of the gastro-intestinal 
tract, and also preliminary medication, if the psychic element is in evi- 
dence or much suffering is anticipated after the operation, must not be 
neglected. 
Third: Constrictions around the neck and waist, such as a tight 
collar band, corsets, or belts, should be removed. 
Fourth: The head and trunk should be in one straight line and the 
anesthetic given as speedily as consistent with safety. 
Regardless of the anesthetic used, all bandages around the abdomen 
or neck should be cut, but not necessarily removed. It is impossible to 
induce a smooth anesthesia with bandages in place. In all operations 
upon, the head, neck, or upper air passages the anesthesia must be con- 
siderably lessened before the bandages are reapplied, otherwise cyanosis 338 
ANESTHESIA 
may appear and the patient will remain under the anesthetic an unneces- 
sarily long time. When the sitting or semi-sitting position is used, 
chloroform must not be given. 
Nitrous Oxid.-For all short operations nitrous oxid, first through 
valves and then with to-and-fro breathing until deep anesthesia ensues, 
is the best method. Hasbrouck,1 of New York City, who has given 
nitrous oxid for the extraction of teeth over 100,000 times, prefers 
nitrous oxid alone, and administers oxygen only as indicated. From his 
large experience he declares that while patients suffer little nausea or 
vomiting from the combination of oxygen with nitrous oxid, a still 
smaller percentage have any after-effects with the nitrous oxid alone. 
No one is justified in giving nitrous oxid without having tanks of 
oxygen in place and available for immediate use. 
Nitrous oxid is the recognized anesthetic for the extraction of teeth. 
It should also be used for dislocations, opening abscesses, breaking up 
adhesions, examinations, removing or reapplying painful dressings, etc. 
For prolonged dental work the nasal inhaler should be used and a 
combination of nitrous oxid and oxygen under pressure given. 
Nitrous oxid and oxygen may be used for its analgesic quality, the 
patient never reaching the anesthetic stage. 
Exceptions to the above rule for selecting nitrous oxid or nitrous 
oxid and oxygen for short operations is where there is any great swelling 
or engorgement of the neck. The administration of gas in this condi- 
tion may quickly induce dangerous symptoms. The author knows of one 
case in which a fatality occurred when nitrous oxid and oxygen were 
given for the extraction of a tooth. An undetected abscess at the base of 
the tongue burst at the height of anesthesia and immediately filled the 
patient's lungs with pus, the patient dying within three minutes. 
Ethyl Chlorid.-Ethyl chlorid is contraindicated for extraction of 
teeth unless oxygen is used with it or nitrous oxid is not available, not 
only on account of the possibility of a fatality, but also because of the 
nausea and dizziness that so often follow a short application of this anes- 
thetic, the percentage of cases nauseated being much greater than when 
nitrous oxid or nitrous oxid and oxygen are used. 
Chloroform and Ether.-Chloroform is contraindicated, as there is 
a very great possibility of a fatality unless a deep anesthesia is main- 
tained. There is no contraindication to ether except for the after-effects. 
In ophthalmic cases, in which quiet is absolutely essential, chloroform 
by the vapor method, and with oxygen, is preferable to any other com- 
bination. This applies especially to such operations as iridectomies. 
Nitrous oxid with air or oxygen is contraindicated in these cases on 
account of increased congestion of the blood vessels, as is also any closed 
method. For enucleations a preliminary medication is indicated, and 
1 Personal communication. ANESTHETIC AND TECHNIQUE FOR SPECIAL OPERATIONS 
339 
some closed method preferably should be used to initiate the anesthetic. 
The narcosis should be continued with some form of vapor anesthesia. 
Chloroform should be avoided if possible at this time. It is unnecessary 
now, as formerly, to anesthetize deeply with ether and depend upon the 
resulting anesthesia for the operation. 
Paracentesis of the membrana tympani should only be done under 
nitrous oxid with oxygen (preferably) or nitrous oxid alone. Ethyl 
chlorid would be the third choice. 
The Mastoid.-Of all serious surgical cases the easiest, from the 
anesthetic standpoint, is a mastoid operation. A deep anesthesia is re- 
quired only in the initial stages. The hammering and chiseling seem 
to have some anesthetic effect, as the vapors can be almost withdrawn 
and the reflexes allowed to become quite active without the patient evin- 
cing any conscious movement. If nausea follows a mastoid operation, 
the anesthetist has not measured up to his opportunities. 
Generally speaking, the best procedure for mastoid cases is to begin 
the anesthetic by the drop method of chloroform, gradually switching to 
the drop method of ether and then changing to the oxygen-ether vapor 
method. This gets the anesthetist completely out of the way and the 
patient comes out of this anesthetic, as a rule, without any nausea, vomit- 
ing, or shock. 
The nitrous oxid-ether sequence or any closed method is contra- 
indicated, as the bag and mask are more or less in the surgeon's and 
assistant's way. Preliminary medication of morphin or something simi- 
lar is most helpful in these cases. 
The Upper Respiratory Tract.-In all operations upon this part of 
the body a preliminary douching with some antiseptic (in some in- 
stances to clear the parts of the blood and pus) is absolutely essential. 
As a general rule, any closed method should be avoided with this 
special class of operations. Chloroform for the induction, and chloro- 
form and oxygen, or ether and air, for the maintenance, is the best 
procedure. 
Excision of the Tongue.-The majority of surgeons seem to prefer 
the dorsal position for excision of the tongue, with a sandbag under the 
shoulders, or with the headpiece slightly dropped. In this position, when 
the head is well flexed and the anesthetist supports the lower jaw with 
one hand, a clear airway is easily maintained, the blood and other secre- 
tions being more easily removed than by any other method, and, conse- 
quently, with less discomfort to the patient afterward. Some surgeons 
prefer the upright position. The anesthesia can be easily maintained by 
means of this vapor method, with the tube ending in the mouth or 
nose, or pharyngeal or intratracheal insufflation. Pharyngeal anes- 
thesia (see p. 235) is, as a rule, all-sufficient. 
For excision of the glands of the neck or operations upon the lips 340 
ANESTHESIA 
and cheeks some form of vapor anesthesia should be employed. In all 
of these cases a deep anesthesia is best, unless facilities for removing 
blood are not adequate when the patient's cough reflex is allowed to re- 
main. 
Cleft Palate.-It is well to avoid gas as the initiatory anesthetic for 
these operations, anesthol or chloroform being the best. The anesthesia 
can be maintained by ether with oxygen or air and by the vapor method. 
In intranasal and antrum of Highmore operations the anesthesia 
should be maintained by the vapor method. 
Submucous Operations.-While the majority of physicians do these 
operations in their offices under some local anesthetic, lately it has been 
urged that these can be better operated upon under a general anesthetic. 
Closed methods should be avoided, and the anesthetic should usually be 
induced with chloroform and maintained with chloroform and ether by a 
tube in the mouth. The patient should always have some preliminary 
medication. 
Adenoid and Tonsil Cases.-In adenoid and tonsil cases, to-and-fro 
breathing of nitrous oxid followed immediately by ether, and supple- 
mented later by the vapor of ether passed through a tube placed either 
in the mouth or nostrils, is the best. In all operations upon adults, 
where the mouth must be open, as the excision of the tongue, jaw, etc., 
the vapor method should be used, preceded by the drop method of chlo- 
roform and ether, or the nitrous oxid-ether sequence, according to the 
patient. The exception to this rule will be where the patient has some 
lung trouble. In that instance, rectal or morphin anesthesia, or spinal 
analgesia, should be used. 
Alexander's and Gwathmey's technique 1 in adenoid and tonsil opera- 
tions covers the ground for the operations in the recumbent position. 
We quote voluminously from this paper. The ideals for which one 
should strive may be divided as follows: 1, preparation of patient; 2, 
good anesthesia; 3, good technique; and, 4, after-treatment. 
Preparation of Patient.-The night previous to the operation the 
patient is given a cathartic; to adults, some cathartic pill; to children, 
castor oil or calomel. The next morning, if the result is not satisfac- 
tory, a simple enema should be given, at least two hours before the opera- 
tion. The temperature is then taken. No food is allowed for six hours 
before the time of operation. If the operation is early in the morning, 
no food whatever should be given. The last meal should consist of a 
plate of clear soup or bouillon with two crackers. Cases are on record 
of children vomiting a bolus of food or a small piece of undigested meat, 
which, getting into the trachea, caused serious disturbances, even septic 
pneumonia. Milk is especially prohibited. From nervousness or other 
lt<Technique in Adenoid and Tonsil Operations," N. Y. Med. J., March 11, 
1911. ANESTHETIC AND TECHNIQUE FOR SPECIAL OPERATIONS 
341 
causes this coagulates, and the vomited curds are as much of a menace 
as particles of any other article of food. 
For nervous children over six years of age, chloretone, five grains, 
given one hour before operation, is valuable. From fifteen years up- 
ward, one-eighth or one-sixteenth grain of morphin, and one one-hun- 
dredth-and-fiftieth grain of atropin should be given, or ten grains of 
chloretone one hour before operation. 
Immediately before the operation, the upper air passages should be 
sprayed with some antiseptic solution. Liquid petrolatum with men- 
thol is especially recommended, as it lubricates the passages, facilitating 
the passing of the catheters. This procedure has quite a psychic effect, 
in addition to the physical, that is most beneficial. 
In addition to the preliminary treatment, mental suggestion is here of 
the utmost importance, and varies with the characteristics of different 
patients. . 
On the table, the patient wears a loose, warm gown or robe, thick 
woolen socks, and is covered by a blanket, over which is placed a rubber 
sheet, fitting closely around the neck. Care should be taken to prevent 
any constriction at the neck or waist. The hair is covered with a sterile 
towel, as is also the rubber sheet. 
Anesthesia.-The ideal anesthetic for this particular operation 
must be safe; deep enough to abolish all reflexes, including the cough, 
swallowing, and tongue reflexes; and continuous, so that there will be 
no necessity for the reapplication of the anesthetic or for the delay caused 
by the removal of blood from the operative field. Furthermore, the pa- 
tient should come out of the anesthetic within fifteen minutes, in a natu- 
ral way, without delirium or nausea. Vomiting is reduced to a mini- 
mum if no blood is allowed to enter the stomach during the operation. 
For a very nervous child, or one having experienced previous fright 
from any cause, the time of operation should be in the early morning, 
say, one hour before the usual time for the child to awaken, or during 
the noonday nap. 
The patient should be anesthetized while asleep. This has been done 
many hundreds of times, and with children is much safer than any other 
method. To successfully anesthetize a sleeping child, the mask or gauze 
should never touch the face. The anesthetic is begun with chloroform, 
a few drops at a time, and gradually increased until rhythmical and 
automatic respiration indicates the commencement of surgical anes- 
thesia. A change to ether by the vapor or drop method is then made. 
On account of the undeveloped muscles of children under six years of 
age, these patients should be anesthetized by the vapor or drop method 
of ether or chloroform. Any closed method puts too severe a strain upon 
the chest walls. The usual procedure is as follows: 
In all cases in which the drop or vapor method is used, a few drops ANESTHESIA 
342 
of cologne upon the mask, just before the anesthetic is started, will allay 
fear, and increase confidence in the anesthetist. From three to six drops 
of chloroform are then given, followed by as many of ether, then alternat- 
ing, and changing entirely to ether as surgical anesthesia is reached. 
This procedure gets the patient under the anesthetic in from three to five 
minutes, and without any struggling. 
One should always bear in mind that many of these little patients 
have the lymphatic temperament, in which chloroform is absolutely 
contraindicated. Whenever this is suspected, the drop method of ether, 
given carefully and slowly at first, and increased rapidly as the stage of 
surgical anesthesia approaches, will bridge over the disagreeable features 
which sometimes occur with this method of anesthesia. 
From six years of age upward, decidedly the best technique is the 
gas-ether sequence, followed by the vapor method. The ether or chloro- 
form is passed through a tube attached to the mouth gag. 
If a patient has bronchitis or a catarrhal condition of the upper air 
passages, ether is absolutely contraindicated. Warm chloroform and 
oxygen is the safest anesthetic for this condition. 
The tube on the suction apparatus in the mouth, as employed in a 
large number of cases, has been found to be more or less in the way, and, 
to obviate this, we have adopted the plan of placing the catheters at- 
tached to the suction apparatus in the nares, so that the ends are just 
visible when the tongue is depressed. This compels the patient to breathe 
through the mouth, and the anesthesia is more easily maintained in this 
way than by any other method. (Fig. 93.) The patient thus receives 
all the vapor, and the blood is not in the way of the operator. Surgical 
anesthesia is as easily maintained in this way with ether as with 
chloroform. 
Hewitt uses the gas-ether-chloroform sequence for this operation, as 
do also others who make a specialty of anesthetizing for nose and throat 
operations. 
With the bent tube in the ether chamber we are enabled to get a more 
nearly saturated ether vapor than ever before, thereby rendering the use 
of the chloroform unnecessary in a large majority of cases. This method 
seemed to work well in one or two cases, but was not a complete success, 
so we finally abandoned it and developed the present method. 
So far, the nasal tubes have acted perfectly in taking up the blood, 
and no trouble is experienced in keeping a clear field for the operator. 
A tube was formerly attached to the tongue depressor, but it was found 
that the tongue depressor had to be removed occasionally, during which 
time the patient might regain the lost reflexes and thus cause the sur- 
geon embarrassment. With the vapor apparatus as now perfected, we are 
able to give a continuous anesthesia after the mouth gag has been placed ANESTHETIC AND TECHNIQUE FOR SPECIAL OPERATIONS 
343 
in position, and the patient is in any posture desired by the surgeon. 
If the operator prefers the patient in a dorsal position, it is unneces- 
sary to turn the head to either the right or left, to stop the operation for 
the reapplication of the 
anesthetic mask, or to re- 
move the blood from the 
oral or nasal cavities. 
By means of this con- 
tinuous narcosis, together 
with the use of the blood 
suction apparatus, the 
time of operation is re- 
duced from one-third to 
one-half. The surgeon is 
also enabled to do more 
thorough work, without 
the feeling of the neces- 
sity of hurrying lest the 
patient come out of the 
anesthetic, since as even a 
plane of anesthesia can 
thus be maintained as for 
any other surgical pro- 
cedure. 
Deep chloroform nar- 
cosis, with great profusion 
of blood in this position, is 
more or less dangerous. 
For this reason the gas- 
ether sequence to get the 
patient deeply under the 
influence, followed by 
ether vapor anesthesia, is 
nearly ideal for this par- 
ticular operation. 
When ether is contraindicated, a tube from the oxygen tank replaces 
the foot pump. Warm oxygen alone, or oxygen with chloroform, may 
thus be given as indicated (Fig. 107). 
Suction Apparatus.-This consists of a vacuum water pump (Fig. 
133), which is attached to any spigot or tap by an adjustable connec- 
tion (Fig. 133). The rush of water through this brass cylinder creates 
a diminished pressure which is transmitted to a Wolff bottle by connect- 
ing rubber hose. Another rubber hose leads from the Wolff bottle to 
Fig. 132.-The Water Suction Apparatus for 
Adenoid and Tonsil Operations. 344 
ANESTHESIA 
the patient; to the free end of this hose are attached two rubber cathe- 
ters, which, when placed in position, utilize the vacuum and complete 
the apparatus. 
Good Technique.-The desiderata in the matter of good technique 
are: 1, Good light; 2, bloodless field; and, 3, maximum speed. 
Good Light.-After experimenting with various forms of reflected 
light, we find direct illumination of the operative field to be the most 
Fig. 133.-Pump Attached to Spigot With Water Turned On. 
desirable. This is obtained by using an electric headlight and condenser, 
supplied by a dry cell battery, or, better, by a current controller. Shielded 
lights on instrument and anesthetic tables prevent interference with the 
operator's light. 
By means of the brilliantly illuminated field so provided, anomalies 
of formation are noted, and bleeding vessels may be seen and clamped, 
thereby avoiding much tissue laceration and bleeding. 
Bloodless Field.-Our attempts at reaching this ideal are still in the 
formative period; so much has already been gained, however, that we 
feel justified in reporting the method. Our efforts were addressed to, 
firstly, the reducing of the blood lost; and, secondly, to the removal of ANESTHETIC AND TECHNIQUE FOR SPECIAL OPERATIONS 
345 
that which was lost. We attempted, as detailed under anesthesia, to de- 
crease by sequestration the amount of blood volume in the operative area. 
Our experiments to date have convinced us that this procedure, when 
perfected, may be of positive value. Immediately after the enucleation, 
a pad of gauze, firmly pressed into the bleeding area, helps to reduce the 
hemorrhage; however, the sum total of blood lost was not much affected, 
until, after much experimenting, we evolved the present method of blood 
removal. This consists of a graduated Wolff bottle, suction pump, and 
attachments. 
Rubber catheters, with several additional holes made near their tips, 
are introduced through the nares as soon as surgical anesthesia is pres- 
ent. They are allowed to lie alongside of each other in the pharynx, 
their ends about an inch above the epiglottis. The enlarged ends of the 
catheters are joined by a Y connection with the rest of the apparatus, 
the tube passing over the patient's head. With the patient's head thrown 
back, this region becomes a natural reservoir, which is thus readily 
drained. 
As soon as we began using this method, we noticed a marked reduc- 
tion in the amount of blood and mucus collected. Previous to using the 
catheters, our average of many cases was four ounces; now it is seldom 
over two. A study of the blood supply of the tonsillar area throws no 
light on the reason for the diminished hemorrhage, yet it has occurred in 
too many cases to be a coincidence. 
After complete removal of adenoids and tonsils, the patient is turned 
on one side, the catheters are withdrawn, and the vault is explored with 
the finger for shreds. 
The vault is now wiped over with alcohol on gauze, and the nares are 
douched with cold saline solution. This latter procedure washes out all 
clotted blood, and hastens the patient's return to consciousness. 
Maximum Speed.-Maximum speed is obtained by simplicity of 
method in operating. A skilled anesthetist and an assistant physician 
or nurse are essential. An occasional swab is employed to remove clotted 
blood not sucked up by the catheters. The adenoids are then removed 
in the usual way. The average time of operation is eight minutes. 
After-treatment.-The patients are kept in bed for twenty-four 
hours, and given liquid food. The throat is sprayed every two hours 
with mild liquid antiseptics and a hydrogen peroxid solution, used alter- 
nately. When cervical stiffness is present, massage and hot applications 
are employed. Complications are met with appropriate remedies. 
The Upright Position.-Many operators prefer the upright posi- 
tion for adenoid and tonsil operations. French,1 of Brooklyn, has de- 
vised a chair table, and has worked out a technique that approaches the 
ideal for operations in this position. "The method consists in placing 
1 French, Thomas E.: N. Y. Med. J., June 1, 1912, 1125. 346 
ANESTHESIA 
the patient upon a table for anesthetization in the recumbent position, 
and, when the stage of excitement has passed, in converting the table into 
Fig. 134a.-Dr. French's Chair Table. 
a chair and bringing the body to the sitting posture; or, for that matter, 
placing it in almost any position except one with the face downward. 
(See Figs. 134a to 134j.) 
Fig. 134b.-Dr. French's Chair Table. 
"Before the patient is wrapped in a blanket, a stout, four-inch 
bandage is made to encircle the upper part of the back, the ends being ANESTHETIC AND TECHNIQUE FOR SPECIAL OPERATIONS 
347 
drawn up under the axillae and over the front of the shoulders, and for 
the moment allowed to hang in the recesses on either side of the head 
Fig. 134c.-Dr. French's Chair Table. 
rest (Fig. 134 B). After the patient has been wrapped in a blanket, 
the leather straps attached to the seat are fastened rather loosely around 
the hips, and the legs, below the knees, are strapped to the footrest 
(also shown in Fig. 134 C). When the patient is nearly anesthetized 
Fig. 134d.-Dr. French's Chair Table. 
the anesthetist turns the wheel at the junction of the back of the chair 
with the seat, and the body is thus raised slowly forward (Fig. 134 D) to 348 
ANESTHESIA 
the upright position, the mechanism being so constructed that as the 
back ascends the footrest descends. The seat, which is a trifle higher in 
front than at the back, is covered with a mat of corrugated rubber, 
which checks largely, if not entirely, the tendency of the body to slide 
toward the foot of the table or chair. Whjle the upward movement is 
taking place, the headrest is adjusted to the patient's head by means of 
Fig. 134e.-Dr. French's Chair Table. 
the smaller wheel on the side of the back section (Fig. 134 E), and this 
is accomplished with such ease and accuracy that the position of the 
head for the proper administration of the anesthetic and the desired dis- 
play of the field of operation can be readily maintained. At the same 
time the shoulder bandage is adjusted by drawing the ends around the 
headrest, when they are caught under, and tied to a hook on the back of 
the chair. The patient has now reached the upright position and is ready 
for operation. If the surgeon desires to operate while standing, the 
chair part of the mechanism can be raised (by means of the large wheel ANESTHETIC AND TECHNIQUE FOR SPECIAL OPERATIONS 
349 
in the frame of the base) sufficiently to bring the head of the patient 
opposite his own (Fig. 134 F). If, however, he desires to operate while 
sitting, the chair can be lowered, if necessary, as far as the base (Fig. 
134 G), and these movements can be made with surprising ease, even if 
the patient's body is of great weight. Figure 134 G also shows the 
anesthetist standing inside the rear part of the frame of the base, in 
Fig. 134f.-Dr. French's Chair Table. 
which position he can administer the anesthetic and control the mechan- 
ism of the chair. If respiratory troubles arise, and it is desired to lower 
the patient's head, this can be quickly done by tilting the chair backward 
(Fig. 134 H), and then by wheel action converting the chair into a table 
top in the Trendelenburg position (Figs. 134 I and 134 J). 
"With an ordinary chair, or even with the special chair as previously 
constructed, it has been, at times, very difficult to place and keep the 
head of the patient in the required position for the proper administra- 
tion of the anesthetic and for easy access to the field of operation. With 
the new method, the inexperienced interne or newly graduated medical Fig. 134g.-Dr. French's Chair Table. 
Fig. 134h.-Dr. French's Chair Table. ANESTHETIC AND TECHNIQUE FOR SPECIAL OPERATIONS 
351 
Fig. 134i.-Dr. French's Chair Table. 
man can, under instruction, bring the patient to, and maintain him in, 
the upright position, with perfect ease and safety. This is accomplished 
partly by means of wheel devices, the slightest turn of which either raises 
or lowers the upper portion or the whole of the body, or elevates or de- 
Fig. 134j.-Dr. French's Chair Table. 352 
ANESTHESIA 
presses the headrest, and that, too, without further need of attention 
than is required in turning them. 
"The secret of a safe and an uninterrupted administration of an 
anesthetic in the upright position is in keeping the neck somewhat 
stretched and the head moderately extended over the headrest." 
French states that "a sudden change from the horizontal to the up- 
right position, while the patient is under ether narcosis, is apt to occa- 
sion a too rapid development of cerebral anemia and a consequent loss 
of cardiac balance. 
"Experience would seem to show that the danger of blood flowing into 
the trachea is no greater during the routine operations which we are wont 
to perform in the nose and throat when the body is upright than when 
in the Rose position. 
"The blood thus flowing into the gastro-intestinal tract has never, 
in our experience, made its presence manifest by untoward disturbances 
in that canal. Our results, in the considerable number of patients upon 
whom we have operated in the upright position, have led us to the con- 
viction that the fear of blood flowing into the air passages is based upon 
theory and not upon fact. 
"There is less shock, and less disturbance in other ways, to the pa- 
tient after operation because less ether is required to maintain narcosis 
when the sitting posture has been attained. This is, no doubt, due to the 
diminished blood pressure in the vessels of the head when the body is 
in the upright position and under the influence of a general anesthetic. 
The difference between the flushed face in the recumbent position and 
its relatively pale appearance in the upright position is at times very 
marked. The difference in the quantity of the anesthetic required is, 
we believe, due to the difference in the amount of blood in the brain in 
the two positions, which, in French's opinion, is another reason for this 
special technique. 
"The abstraction of a considerable quantity of blood from an anemic 
child adds to the cachexia, diminishes its rallying powers, and reduces 
the body resistance in the event of the onset of any special disorder. 
Shock is felt more by the child than the adult, and although the child 
recovers from the shock more rapidly the ultimate recovery will be re- 
tarded if a considerable amount of blood has been lost. As a rule, chil- 
dren in a fair state of health before operation sustain the loss of a rela- 
tively large quantity of blood in a very remarkable way, and in time 
recover their usual, if not better, health, but they do not always do so 
without concurrent disturbances; and how often such disturbances are 
due directly or indirectly to the loss of blood it may be difficult to say." 
For operations upon the tonsils and adenoids under nitrous oxid and 
oxygen, see page 156. 
Tracheotomy.-It is sometimes safer to perform this operation under ANESTHETIC AND TECHNIQUE FOR SPECIAL OPERATIONS 
353 
a local anesthetic on account of the congestion produced or difficulty in 
breathing if a general anesthetic is used. When there is no obstruction 
in any part of the air passages, there is no objection to doing a trache- 
otomy under general anesthesia. After the tracheal tube is inserted, 
anesthesia is easily maintained by chloroform or ether vapor. If no 
vapor apparatus is convenient, an ordinary mask is held over the trachea, 
and the anesthetic carefully given. For thyroidectomies careful pre- 
liminary medication is essential, and the anesthetic should be instituted 
very slowly and carefully. • Chloroform and oxygen is probably the best 
anesthetic to use. Any closed method is contraindicated, as there is 
always the possibility of the thyroid lessening the diameters of the air 
passages by pressure. 
Goiter (Angina Ludovici, Exophthalmos-Graves' Disease).-If a 
general anesthetic is determined upon, ether and chloroform with oxygen 
by a tube is probably the best method of administration. Closed methods 
should be avoided with these cases, as deaths have been reported under 
nitrous oxid and ethyl chlorid. Many surgeons prefer a local anesthetic. 
(See page XIV.) 
Crile's method of "stealing upon the thyroid" has been widely 
adopted. He states: 
"In cases of Graves' disease the mere proposal to perform an opera- 
tion becomes also a pathological excitation; this excitation may so much 
increase the disease that the patient is even less able than before to bring 
herself to submit to adequate treatment. On all sides this disease is 
beset by vicious circles; by pathological interactions. The ideal plan of 
approach, at least in my experience, is to assure the patient that hers 
is a curable malady, that it can be treated in a hospital, and that non- 
operative measures will first be tried; then if they prove inadequate a 
simple operation will be done; that it will be best to leave this decision 
to the judgment of her medical adviser, and that, since even the discus- 
sion of operation is both unpleasant and injurious, it would be best not 
to open this subject again. The patient usually gladly consents to leave 
the whole matter to the judgment of the physician, and the way is then 
opened for the most effective treatment which in my judgment has ever 
been proposed-namely, ligation or excision on the new principle of 
anoci-a£sociation." 
The technique is as follows: "For about five days before the opera- 
tion the patient is treated every morning. A hypodermic injection of 
sterile water and inhalation of fresh air with a little nitrous oxid 
through the same inhaler that will be used on the day of operation is 
what constitutes the treatment. The entire treatment lasts five minutes 
each day. The tachycardia and other nervous symptoms that usually 
occur with each treatment become less marked as the day of operation 
approaches. On the morning of the operation, which is performed in 354 
ANESTHESIA 
one of the favorable phases of the numerous cycles of the disease, the 
patient receives the treatment as usual. One-eighth to one-sixth of a 
grain of morphin and scopolamin (atropin should be omitted in these 
cases) is substituted for the sterile water, and the nitrous oxid is carried 
to the stage of surgical anesthesia. The patient falls asleep in her bed 
without realizing that the first step of an operation has already begun. 
The patient is then transported anesthetized to the operating room, 
where the operative field is prepared. The anticipation of the operation 
and excitement usually attendant upon the induction of anesthesia, 
sometimes producing fatal shock, are by this method eliminated. 
"Up to this point the patient's brain, hence the remainder of the 
body, is in a negative state, and this is half of the innovation of the 
specialized operation; the other half is this: any injury of any sensitive 
part of the body, though the patient is under inhalation anesthesia, ex- 
cites the brain, and hence, through the brain, all of the motor mechan- 
ism, especially the thyroid. Inhalation anesthesia is but a thin veneer, 
and, although the patient is unconscious, the afferent impulses set up by 
the operation reach the brain apparently as readily as if no anesthetic 
was given. 
"This is the source of the hyperthyroidism, so called, that constitutes 
the greatest danger of the operation. Operation under inhalation anes- 
thesia on any sensitive part of the body produces precisely the same ex- 
acerbation of the disease (hyperthyroidism) as operations upon the thy- 
roid gland itself. How may this be avoided ? It may be wholly avoided 
by the use of complete local anesthesia in addition to general anesthesia, 
by the use of novocain throughout the entire operation, just as com- 
pletely as if the patient had received no general anesthesia." 
"By this technique," Crile states, "the scope of the operation is 
greatly increased and the gland can be safely removed from any patient 
whose condition will endure the metabolic influence of the sudden with- 
drawal of so much active gland tissue." 
With operations upon the brain, it is better to use chloroform and 
oxygen. Nitrous oxid and oxygen are contraindicated, as they raise ar- 
terial tension with unnecessary bleeding. For the same reason ether 
should be avoided as a preliminary, as any struggling will immediately 
induce congestion with increased bleeding. In an emergency case, or if 
the patient is unconscious, preliminary medication should be avoided. 
Amputations.-For amputations, dislocations, setting fractures, and 
similar operations, preliminary medication is essential, and a fairly deep 
anesthesia should be used. Gas and oxygen by some closed method is 
preferable for work of this character. 
Operations Upon Fingers and Toes.-Operations upon fingers and 
toes require a deep anesthesia in order to avoid reflex movements, on 
account of the unusually large nerve supply in these parts. ANESTHETIC AND TECHNIQUE FOR SPECIAL OPERATIONS 
355 
Circumcision.-For circumcision of a child the best plan is to start 
with one or two drops of the essence of bitter orange peel and supplement 
this with chloroform drop by drop until the second stage is reached, 
when a switch to ether by the drop method is instituted. A change to 
the closed method may then be advantageously made. The anesthesia 
should be considerably lessened before the final dressings are applied. 
Rectal Cases.-All rectal cases should have full physiological doses 
of morphin with some other drug. The anesthesia can be induced and 
maintained with nitrous oxid and oxygen or ether by the closed method. 
Chloroform should be avoided in these cases. 
Obstetric Cases.-In obstetrical practice, on account of the enlarge- 
ment of the heart at that period, and the patient always welcoming the 
anesthetic, chloroform with oxygen is preferred, and is unattended with 
the immediate risk that might be inseparable from chloroform at an- 
other time. An additional reason for chloroform being safe at this time 
is the continuous dilatation of the sphincters of the uterus and vagina, 
compelling the patient to take deep breaths, and thereby get rid of the 
anesthetic almost as soon as administered. A deep anesthesia is not 
indicated at any time, both on account of the child and the mother. The 
anesthesia should be maintained between the second and third stages if 
possible. The reported fatalities from chloroform in this connection are 
exceedingly rare, and are usually due to gross carelessness, ignorance, or 
attempting to maintain too deep an anesthesia. If ether is used it can 
easily be deodorized by the vapor method. Nitrous oxid and oxygen 
given to the stage of analgesia is becoming more and more popular. 
Anesthesia should be avoided during the menstrual period, as there is 
a greater possibility of hysterical or maniacal excitement afterward. If, 
however, an operation is imperative, a warm oxygenated chloroform 
vapor is indicated. 
Curettage.-For curettage or similar operations, nitrous oxid and 
oxygen, or warm chloroform vapor with oxygen or air, if the type of 
patient permits, is best. 
Genito-urinary Operations.-In genito-urinary operations, where 
deep anesthesia is always required, the nitrous oxid-ether sequence is in- 
dicated. 
Laparotomy.-In laparotomies, where absolute relaxation is required, 
the nitrous oxid-ether sequence, to. be followed by chloroform when the 
patient is in the Trendelenburg position, is the combination preferred by 
such men as Hewitt1 and Boyle.2 Boyle's routine procedure is to change 
to chloroform or the chloroform-ether mixture after fifteen or twenty 
minutes. 
Chloroform is administered with less danger when the patient is in 
1 Hewitt: 1 ' Anaesthetics. ' ' 
a Boyle: ' ' Practical Anaesthetics, ' ' 142. 356 
ANESTHESIA 
the Trendelenburg position, on account of the large amount of blood in 
the brain at that time. Relaxation of the abdominal muscles is assisted 
by placing a sandbag under the knees and slightly raising the shoulders. 
Gastro-enterostomy and Similar Operations.-In addition to the 
usual preliminary preparation, Crile's method is as follows: 
"Starved and Anemic Patients.-A preliminary transfusion of 
blood brings back the vitality of patients exsanguinated by hemorrhages 
and makes them good risks; thus the surgeon may reclaim the bad risks 
in hemorrhage from ulcer of the stomach or duodenum. 
"In starvation cases the risk cannot be so successfully reclaimed, 
though the patient may be much improved by transfusion. The risk in 
these cases is not shock and depression, but a broken metabolism ex- 
pressing itself as acidosis. 
"Since employing transfusion I have had the opportunity of seeing 
more clearly the dangers of acidosis, for I have operated on cases all but 
moribund, and have seen them pass through the operation unchanged, 
and have seen metabolic death follow. Heretofore such cases would not 
have been operated, and if operated would not have survived long enough 
for study. There is a stage of acidosis rather easily recognizable which 
proves fatal as a metabolic process in spite of complete control of the 
blood volume, and measurably of the blood pressure. This does not in 
the least apply to acute or chronic hemorrhage. Here transfusion gives 
an absolute control." 
Crile states, further, that "the combination of nitrous ox id, general 
anesthesia, and novocain, local anesthesia and quinin, and urea hydro- 
chlorid as a post-operative anesthesia combined with ample incision and 
gentle handling establishes ano ci-association-or shockless operation." 
Other surgeons get excellent results by starting a hypodermoclysis 
as soon as the patient is in surgical anesthesia and continuing this 
throughout the operation. As much as two quarts of normal saline can 
be taken by a patient in this way with splendid results. With the vapor 
method of ether anesthesia, the patient's pulse can be easily maintained 
at normal, provided the surgeon is gentle in his manipulation. 
Peritonitis or Intestinal Obstruction.-If morphin has been used to 
quiet pain the anesthetist should be informed of this fact. Otherwise 
too deep an anesthesia may be instituted at the commencement of the 
operation. Surgeons here should not insist upon absolute relaxation, as 
in many cases it is almost impossible to maintain this condition. If 
regurgitation of fecal matter is present, the stomach should be well 
washed out before the induction of the anesthetic and the stomach tube 
left in place during the operation. The open method of administration 
should be used, initiated preferably with chloroform and continued with 
ether. If vomiting occurs, the anesthetist must immediately insert a 
mouth gag (but must not pull the tongue forward) and with his finger ANESTHETIC AND TECHNIQUE FOR SPECIAL OPERATIONS 
357 
or a sponge on a sponge holder keep the throat absolutely clear. Death 
by suffocation is always imminent in these cases. 
CONCLUSIONS 
With these general indications as a guide, it can readily be seen how 
Impossible it is to say that some one anesthetic should be used at a cer- 
tain age, or for a given disease, or for some specific operation. The con- 
ditions blend in such a way that the anesthetic must be selected for each 
case; the safety of the patient, and the successful termination of the 
operation, being the results sought. If the surgeon is so situated that 
he must work without a trained assistant and without the refinements of 
anesthesia customary in the larger cities, ether should be the anesthetic 
of choice. Finally, when thus handicapped, the surgeon should always 
remember that it is possible with morphin and whiskey, plus a very 
small amount of general anesthetic, to complete successfully nearly any 
operation. Fatalities have unquestionably occurred from the use of 
some one anesthetic or method. No hospital or clinic can be considered 
to rank among the first when a routine procedure is countenanced. When 
for any reason, after careful choice and deliberation, the anesthetic is 
taken badly a change should be made immediately. 
BIBLIOGRAPHY 
Abelin: Jdhrb. f. Kinderkr., 1870, 55, 116. 
Adami & Nicholls: "Principles of Pathology," 2, 697. 
Albwot: "System of Medicine." 
Bagensky: Cent. Zeit. f. Kinderh. 
Bartel, J.: "Ueber die hypoplastische Konstitution und ihre Bedeu- 
tung," Wien. klin. W chnschr., 1908, 21, 783-790. 
Barten & Stein: "Ueber abnormale Lymphdrusenbefunde und deren 
Beziehung zum Status thymicolymphaticus," Arch. f. Anat. u. 
Entwicklung sgesch., Leipz., 1906, 231-249, 2 pl. 
Von Bardeleben: Arch. f. klin. Chir., 46, 149. 
Beneke: Berl. klin. Woch., 1894, 31, 216. 
Biechele, R. A.: "Status Lymphaticus with a Report of Cases," Arch. 
Pediat., New York, 1904, 21, 500-508. 
Biedert: Ibidem, 1896, 33, 581. 
Blake: Ann. of Surg., 1902, 35. 
Blumer: Johns Hopkins Hosp. Bull., Oct., 1903, 14. 
Bonnet: Gaz. des Hopitaux, Dec. 9, 1899. 
Bovaird, D., Jr.: Arch, of Pediat., 1906, 23. 
Bradley, E. B.: "Death Under Anesthesia Due to Status Lymphaticus," 
Jour. Am. Med. Assn., Chicago, 1910, 59, 1785. ANESTHESIA 
358 
Brickner: Foster's "Therapeutics, Ether." 
Carlyll, H. B.: "The Thymus Gland and the Status Lymphaticus," 
Guy's Hosp. Bep., Lond., 1910, 64, 1-37, 1 pl. 
Clessin: Munch, med. Woch., 55, 330-1898. 
Cocks, G. H.: "Status Thymo-Lymphaticus and Its Relation to Sud- 
den Death," Man. Eye, Ear & Throat Hosp. Rep., N. Y., 1911, 12, 
199-216. 
Conner, L. E.: "The Clinical Diagnosis of Status Lymphaticus," N. Y. 
Med. J., New York, 1906, 6, 282-284. 
Coolidge, E. L.: "Status Lymphaticus, Report of a Case." Bull. Ly- 
ing-in Hosp., N. Y., 1908, 4, 149-151. 
Daut: Jahrb. f. Kinderkr., 1898, 47, 14. 
Day: "Another Case of Status Lymphaticus," Pediat., N. Y., 1910, 22, 
428-433. 
Ehrhardt: Arch. f. klin. Chir., 78, 598. 
Epstein: Munch, med. Woch., 1902, 49, 1728. 
Escherich: Bert. klin. Woch., 1896. 33, 645. 
Ewing: "The Lymphatic Constitution." N. Y. Med. J., July 10, 1897, 
37. 
Farret: These de Paris, 1896. Quoted by Hotz. 
Fer: Corr. f. schzvei. Aertze, 1904, 34, 2. 
Fischl: Munch, med. Woch., 1902, 49, 1728. 
Fliigge: Vrtljschr. f. gerichtl. Med., 1899, 17, 20. 
Friedjung: Centralbl. f. d. Grenzgeb. d. Med. u. Chir., 1900, 111, 465. 
Friedlander: Arch, of Ped., 1907, 24, 490. 
Friedleben : Die Physiologic der Thymusdruse, 1858. 
Ganghofer: Munch, med. Woch., 1902, 49, 1728. 
Gardner: "Lymphatism," Proc. Roy. Soc. Med., Lond., 1909-10, 111, 
Sect. Anaesthesia., 19-44. 
Gluck: Bert. klin. Woch., 1894, 31, 670. 
Grawitz: Deut. med. Woch., 1888, 12, 429. 
Griffith: Trans. Ass. Am. Phys., 1903, 18. 
Halsted: Phila. Med. J., 1900, 859. 
Harris: "The Laryngoscope," Feb., 1910, 199. 
Hart: Centralbl. f. d. Grenzgeb. d. Med. u. Chir., May to August, 1909. 
Hedinger: "Ueber die Kombination von Morbus Addisonii mit Status 
Lymphaticus." Frankf. Z. f. Path., Wiesb., 1907, 1, 527-543, 1 pl. 
"Ueber Beziehung zwischen Status Lymphaticus und Morbus Ad- 
disonii." V erhandl. d. deut. path. Gesell., 1907; Jena, 1908, 11, 
29-32. 
Henderson, Yandell: "Primary Heart Failure in Normal Subjects Un- 
der Ether," Surg. Gynec. & Obstet., Aug., 1911, 161-165. 
Heussler: Deut. med. Woch., 1894, 38. 
Hinrichs: Bert. klin. Woch., 1908, 45, 825. ANESTHETIC AND TECHNIQUE FOR SPECIAL OPERATIONS 
359 
Hotz: Beit. z. klin. Chir., 1907, 55, 525. 
Howland: "The Symptoms of Status Lymphaticus in Infants and 
Young Children." Tr. Am. Pediat. Soc., Phila., 1907-08, 19, 51-59; 
also, Proc. Path. Soc., Phila., 1909, /£, 267-276. 
Humphry: "Clinical and Post-mortem Observations on the Status 
Lymphaticus with Deductions and a Plea Against the Alaligning oi 
Ethyl Chlorid as a General Anesthetic." Lancet, Lond., 1908, 11, 
1870-1874; also, J. Al ent. Sc., Lond., 1909, 55, 473-481; "Status 
Lymphaticus," Lancet, Lond., 1909, 11, 1703-1705. 
Jackson: J.Am. Aled. Assn., May 25, 1907. 
Jessen: Aerz. sachverstand. Zeit., 1898. 
Kassowitz: Munch, med. Woch., 1902, 49, 1728. 
Kauffmann: "On Two Cases Suggesting Relationship to Status Lym- 
phaticus." Bep. Soc. Study Dis. Child., Lond., 1907-08, 8, 435-438; 
also, Birmingh. Med. Bev., 1908, 64, 182-184; also, Brit. J. Child. 
Dis., Lond., 1908, 5, 430-432. 
Kern: "Status Lymphaticus." J. Indiana Med. Assn., Fort Wayne, 
1909, 2, 480-482. 
Koch: "Status Lymphaticus mit Persistierendem Thymus." Deut. 
med. AVoch., Leipz. u. Berl., 1911, 37, 1102. "Mechanische Thy- 
mus-Erstickungstod mit Status Lymphaticus." 
Konig: Central, f. Chir., 1897, 24, 605. Verhandl. d. deut. Gesell. f. 
Chir., 1898, 35, 119. 
Kopp: Denkwurdigkeiten, 1830, 1. 
Krause & Cohen: Deutsche med. AVoch., 1890, 450. 
Kundrat: Wien. klin. AVoch., Jan. 3, 10, 17 and 24, 1895. 
Lange: Jahrb. f. Kinderkr., 1898, 48, 119. 
Marfan: Bull. Soc. Hopit., 1894, 11, 361. 
Mau: "Enlarged Thymus and Sudden Death." Med. Chron., Man- 
chester, 1910-11, 53, 216-223. 1 pl. 
McCardie: "Status Lymphaticus in Relation to General Anaesthesia." 
Brit. Med. J., Lond., 1908, 202, 196. 
Munro: "The Status Lymphaticus." Lancet, Lond., 1909, 2, 1468. 
Musser & Ullom: "A Case of Status Lymphaticus." Med., Detroit, 
1904, 10, 351-359. Also reprint. 
Nettel: "Ueber einen Fall von Thymustod." Arch. f. klin. Chir., 1904, 
73, 636. 
Nordmann: Correspond, f. schweiz. Aerzte, 1889, 202. 
Norton: Phila. Med. J., 1898, 249. 
Oehme: "Lymphfollikel im kindlichen Knochenmarke." Munch, med. 
AVoch., 1909, 56, 446-449. 
Ohlmacher: J. Am. Med. Assn., Feb. 13, 1904. 
Paltauf: Wiener klin. Woch., 1889. 
Park: "The Status Lymphaticus." Tr. Am. Surg. Assn., Phila, 1905, 360 
ANESTHESIA 
23, 241-250. Also, Surg. Gynec. J Obstet., Chicago, 1905, 1, 140- 
145. Also, St. Louis Med. Bev., 1906, 53, 394. 
Penkert: Deut. med. Woch., 1902, 28, 810. 
Plater: "Observatorium in Hominis Affectibus Plurisque, etc." libri 
tres, 1614, 111, 172. 
Purrocker: Munch, med. Woch., 1899, 46, 943. 
Rachford: Tr. Assn., Am. Phys., Phila., 1910, 25, 570-579; also, Am. J. 
Med. Sci., Phila. and N. Y., 1910, 140, 550-557. 
Ranke: Ibidem, 1902, 40, 1728. 
Rehn: Verhand. d. deut. Gesell. f. Chir., 1906, 35, 2, 364. 
Richter: Munch, med. Woch., 1902, 49, 1728. 
Roberts: "The Status Lymphaticus with Particular Reference to Anaes- 
thesia in Tonsil and Adenoid Operations," Tr. Am. Laryngol. 
Rhinol. and Otol. Soc., St. Louis, 1908, 507-524. 
Rubra & Brown: "Note on a Case of Status Lymphaticus with Refer- 
ence to the Administration of Anaesthetics." Lancet, Lond., 1907, 
11, 1759. 
Satterlee: "A Case of Status Lymphaticus." Arch, pediat., N. Y., 
1909, 25, 689-692. Discussion, 702. "Status Lymphaticus." Brit. 
Med. J., Lond., 1909, 1, 1042. 
Schultz: Beit. z. klin. Chir., 1901, 638. 
Schwinn: J. Am. Med. Assn., 1908, 2059. 
Siegel: Bert. klin. Woch., 1896, 33, 887. 
Simon & d'CElsnitz: Bull. Soc. Pediat., 1902, 26. 
Sbderland & Backman: "Studien bfver Thymusinvolutionen." Upsala 
Lbkarefbr Forh., 1908, 13. 
Sorgo: Central, f. Grenzgeb. Med. u. Chir., 1898, 6-10. 
Starr: N. Y. Med. News, 1896, 421. 
Targhetta: These de Paris, Jan., 1902. 
Thremich: Vrtljschr. f. gerichtl. Med., 1901, 21, 300. 
Todd & Emery: "Specimensfrom a Case of StatusLymphaticus." Bep. 
Soc. Study Dis. Child., Lond., 1903, 1904, 4, 293-296. 
Vintras: "Status Lymphaticus." Lancet, Lond., 1907, 1, 295. 
Von Werdt. "Zur Frage der Beziehung swischen Status Lymphaticus 
bzw. Thymolymphaticus und Morbus Addisonii." Berl. klin. Woch., 
1910, J7, 2383-2386. 
Warthin: "The Pathology of the Status Lymphaticus with Lantern 
Demonstration." Am. J. Obst., N. Y., 1909, 60, 348-356. 
Weigert: Berl. klin. Woch., 1906, 887. 
Wheelock: "Anesthesia in Lymphaticus." Toledo M. and S. Rep., 
1909, 35, 395-399. 
Wiesner: "Gefiissanomalien bei sog. Status Thymicolymphaticus." 
Verhandl. d. deutsch. path. Gesellsch. Jena, 1909, 217-219. 
Witmer: Beitr. z. klin. Chir., 29, 189. CHAPTER IX 
treatment before, during, and after anesthesia 
Duties of the Anesthetist in Addition to Giving Anesthetic. 
The Anesthetist's Kit: Anesthetist's Motto; Mouth Gag; Con- 
tents of Kit; Emergency Treatment to Insure Breathing. 
The Management of Ordinary Cases: Preliminary Treatment; 
Treatment During Anesthesia; After-Treatment. 
Management of Difficult or Unusual Cases: Respiratory; 
Muscular; Nervous; Idiosyncratic; Shock; Post-Anesthetic Toxemia. 
DUTIES OF THE ANESTHETIST IN ADDITION TO GIVING THE 
ANESTHETIC 
The anesthetist who thinks his duties comprise getting the patient 
under, maintaining narcosis until the surgeon gives the signal to let up, 
Fig. 135.-Supporting Jaw to Maintain Free Airway with Two Fingers on the 
Carotid Artery. 
and seeing to it that the patient is safely removed from the operating 
table to the bed is doomed to failure. Much more than this devolves 
upon him. He must be assured that the proper preliminary hygienic, 
361 362 
ANESTHESIA 
psychic, and medicinal preparation is attended to; he must find out 
whether the breathing is oral or nasal, and direct his anesthetic vapor ac- 
cordingly ; he must keep a clear airway either by manipulating the lower 
jaw or by a suction pump or sponging; he must maintain an even nar- 
cosis; he must keep the mouth gag (if used) in position; he must pro- 
tect the patient from too much pressure upon the throat and chest either 
from artery forceps, or from an assistant or anyone leaning too heavily 
upon the chest; he must assist the surgeon in any way that may be de- 
sirable, according to the exigencies of the case. He must be equipped 
for the management of all manner of emergencies which may concern 
his part of the surgical procedure or the after-treatment of the case. 
In order to meet the exigencies, whatever their nature, as they arise, 
the following equipment will be found invaluable: 
THE ANESTHETIST'S KIT 
Anesthetist's Motto.-The difficulty with all inhalation methods of 
administration, as before mentioned, is respiratory. While the motto of 
the anesthetist should be Anticipation, yet there sometimes occur cases 
in which asphyxial symptoms take such a course that interference is 
necessary in order to retain a clear air passage. 
Mouth Gag.-The skilled anesthetist seldom uses a mouth gag and 
tongue forceps. In thousands of cases it should not be necessary. (This 
does not apply to cases in which the mouth is to be operated upon.) 
Nevertheless, the anesthetist should always be prepared to use both. 
Contents of Kit.-The following is a list of the apparatus that should 
be convenient whenever an anesthetic is given, regardless of the method: 
(1) A wooden gag or screw with which to open the mouth. 
(2) Mouth gag, so patterned that the blades will fall one behind the 
other when closed, this being the easiest to place between the teeth. 
(3) Tongue forceps. The best tongue forceps have a small projec- 
tion to clasp the tongue directly in the middle. If this is placed in the 
median line, there will be little or no bleeding, as there are very few 
blood vessels and nerves in this part of the tongue. The tongue is really 
composed of two parts joined in the median line. The tongue forceps 
with two projections will invariably cause a flow of blood. 
(4) A tracheotomy set. This should be in a case, every part steri- 
lized, and ready for use. It should not be open unless an emergency 
calls for its use. 
(5) A curved needle threaded with silk, sterilized, and wrapped up. 
(6) A hypodermic syringe. 
Emergency Treatment to Insure Breathing.-Whenever the anesthet- 
ist anticipates trouble of any kind, he should examine the mouth of the TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
363 
patient, and, if this is not done before the administration, it requires 
but a second to open the lips and determine immediately which side of 
the mouth will be the best in which to place the wooden wedge or 
screw. Before placing the wedge or gag in the mouth, however, the 
anesthetist should exhaust every plan to have the patient breathe natu- 
rally. If unsuccessful in this, while every second counts in an emer- 
gency, it is unnecessary to destroy or injure the patient's teeth. After 
the mouth has been opened sufficiently with the wooden screw, place the 
mouth gag in position, insert the tongue forceps in the median line, 
one-half to one inch from the tip of the tongue, and pull the tongue 
forward. If an airway is thus secured, and the patient recommences 
breathing, it is always best to then remove the tongue forceps and gag. 
Nevertheless it must be borne in mind that, if such a procedure has be- 
come necessary once, it is likely to recur at any time. Very little trac- 
tion is necessary to pull the tongue forward. In addition to moving the 
jaw and head in different directions, one of the best means of overcom- 
ing asphyxial symptoms is by placing a tube from the oxygen tank in 
the nose or the mouth. If a stream of oxygen has to be kept up in this 
way during the remainder of the operation, the patient will be no worse 
for it. 
Again, the anesthetist must bear in mind that, if in the midst of an 
operation asphyxial symptoms continue to assert themselves, it is always 
possible to considerably diminish the amount of pulmonary anesthetic 
by administering a hypodermic of morphin. 
For excision of the tongue, or any operation in which it is necessary 
to hold it forward for any length of time, a thread would be less in the 
way than the tongue forceps. The needle should be inserted in about 
the same place as the tongue forceps, the thread pulled through and tied 
in a convenient loop, and the needle cut off. The thread may then be 
caught with an artery forceps. 
It is the purpose of this chapter to give, in condensed form, certain 
practical suggestions concerning the management of surgical cases, from 
the anesthetist's point of view. It is now well known that the success 
of the anesthesia as regards the ultimate recovery of the patient is largely 
dependent upon the preliminary preparation, the treatment during the 
course of the narcosis, and the care after the anesthesia is discontinued. 
In order to render this part of the present volume as available as pos- 
sible for practical purposes, the subject is divided into: (1) The man- 
agement of ordinary cases before, during, and after anesthesia; (2) the 
management of difficult and exceptional cases before, during, and after 
anesthesia. 364 
ANESTHESIA 
THE MANAGEMENT OF ORDINARY CASES 
Under this category come the ordinary run of surgical cases-pa- 
tients who need, perhaps, a certain amount of suggestive therapy along 
with the requisite medicinal treatment, regardless of the anesthetic 
agent to be employed. 
Preliminary Treatment 
The preliminary preparation of a patient about to be anesthetized 
may be: (1) Hygienic; (2) psychic; (3) medical. Some patients re- 
quire one or the other; others require all the preliminary adjuvants 
that may be brought into requisition. 
Hygienic.-Grooming of Patient.-The patient should be as thor- 
oughly prepared (as far as his or her condition permits) as if for an ath- 
letic event. A warm bath with thorough cleansing of the skin and a 
shampoo for the hair, followed by an alcohol rub, should precede all 
other treatment. Removal of hair over and adjoining site of operation 
with scissors and razor should be done the night previous to a morning 
operation, or in the morning for an afternoon operation. "One of the 
most essential points in preparing the patient for operation is to make 
sure that the preceding night is a restful one. If the patient is in 
pain, or is particularly nervous, a hypnotic should always be admin- 
istered." 1 
The Mouth and Nose.-If possible, a dentist should cleanse the 
teeth thoroughly, removing loose and hopelessly decayed teeth, and then 
giving the patient a suitable antiseptic mouth wash to be used every four 
or five hours until time for the operation. This wash should be used 
to cleanse the nasal passages as well. 
"The disinfection of the mouth is a matter of so much importance 
in the prevention of pneumonia from aspiration during anesthesia that 
it should never be neglected." Hydrogen dioxid, one part to three of 
water, or potassium permanganate in a weak solution, may be used for 
this purpose. 
The Bladder.-"Patients should either empty the bladder or be 
catheterized immediately before the operation. 
"If urine is scanty, bicarbonate of potash or citrate of potash 
in small quantities, not more than 20 or 30 grains within twenty- 
four hours, added to pure water should be given freely to flush the 
kidneys. 
"Should a more active diuretic be desired, small doses of sweet spirit 
of niter may be added to the draft, since this simple remedy acts as 
1 ' ' American Practice of Surgery, ' ' 4, 132. TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
365 
an efficient diuretic, in many cases overcoming any tendency to spasm 
of the renal vessels and flooding these organs with blood."1 
Intestinal Tract.-No athlete is ever given a purge on the night 
immediately preceding a contest, and the time should be past when a 
patient is thus debilitated before entering the operating room. 
All are agreed on the advisability of emptying the intestinal tract, 
the method and time of doing this varying with different hospitals and 
surgeons. 
"Two days before the operation the patient is given one or two table- 
spoonfuls of castor oil or a dessertspoonful of natural Carlsbad salts 
in a glass of warm water, or at noon on the day before the operation 
a purgative should be given, followed in eight or nine hours by an enema, 
the amount of purging being increased or diminished according to the 
patient's strength. 
"In intestinal obstruction, with frequent vomiting or regurgitation, 
a careful insertion of the stomach tube, which may be left in place, is 
necessary before commencing the anesthesia. 
"The bowels should not act more than twice in the twenty-four hours 
previous to the operation. Many surgeons dispense entirely with purga- 
tion, as the worst condition of all is when the patient is suffering from 
an artificial diarrhea at the time of operation. The number of bacteria 
increases as the intestinal contents become more liquid, and diminishes 
with the abatement of the diarrhea. 
"The intestinal tract should be cleansed and practically emptied be- 
fore the time of operation. Two ounces of castor oil are administered 
12 to 16 hours before operation, and the large bowel is emptied by a 
soapsuds enema on the morning of the operation. The cleansing of the 
entire intestinal tract, together with the withholding of nourishment, 
renders the canal practically sterile in its upper portions, facilitates 
intra-abdominal manipulation, and lessens the possibility of gaseous dis- 
tention after the operation. The administration of sterilized foods is 
also a good procedure." 2 
Diet.-"While advantageous to have the stomach empty, it is not 
essential to starve the patient for twelve or eighteen hours. Easily di- 
gested gruels of barley or rice can be given in small quantities up to 
within two or three hours of the operation with distinct advantage. 
Starchy gruels permit the liver to store up glycogen and thereby place 
it in a favorable position for maintaining its function. Animal broths 
throw an undue strain upon the kidneys in the elimination of extrac- 
tives. Hunter believes that the absence of glycogen from the liver, by 
diminishing the combustion processes in that organ, diminishes the anti- 
toxic power of the liver cells, so that the starved individual is more 
1 Keen's '1 Surgery, ' ' 5, 1008. 
2 Am. J. Surg., 4, 131. 366 
ANESTHESIA 
easily affected by poisons than the glycogen-rich person. So, too, an 
absence of carbohydrate material results in extensive changes in fat 
metabolism, which results in an increased formation of acid, and so 
tends to the development of acidosis." 1 
"The patient should be kept in bed and given liquid diet for eighteen 
hours prior to the operation. Water is freely given by mouth up to 
within three hours of the time of operation. The practice of withhold- 
ing water involves unnecessary hardship and discomfort, while its free 
administration aids materially in the subsequent elimination of ether, 
and is undoubtedly a factor in preventing the possibility of shock. When 
inadvisable to give water by mouth, one-half pint of normal saline may 
be administered per rectum two hours before the patient goes on the 
table." 2 
Psychic.-Some patients, as we have stated, require one or all forms 
of preliminary preparation in order to insure a smooth, safe, and alto- 
gether satisfactory anesthesia. The expert anesthetist must be able to 
judge of the particular requirements of the individual case. Over 
seventy per cent of cases, according to conservative estimates, require 
both mental and medical treatment in order to insure the best results. 
Children and nervous and irritable adults require psychic preparation 
for the coming ordeal, and the anesthetist who ignores this factor runs 
the risk of having to deal with more or less serious difficulties during 
some portion of the time when the patient is under his care. In this con- 
nection the Chapter on Hypnotism will be found helpful. 
Idiots and insane persons, as a rule, require only medical prepara- 
tion. In many cases, however, in which the mental defect is of a mild 
degree of severity, the patient is susceptible to the reassuring influence 
of a calm and forceful personality. Those who have had occasion to wit- 
ness operations in homes or hospitals for defectives or the insane have 
observed this. The senior author (J. T. G.) recalls the case of a feeble- 
minded boy who, when about to be operated upon for the removal of 
adenoids and tonsils, flew into an uncontrollable rage at the sight of one 
anesthetist, who made no pretense of giving the patient the benefit of 
suggestive therapy, whereas another anesthetist, availing himself of this 
aid, experienced no difficulty in getting the child to take the anesthetic 
quietly. 
Patients already in a state of coma require no preliminary treat- 
ment. 
Necessity for Preliminary Mental Preparation.-"There can 
be little doubt that the mental condition of the patient does not receive 
enough attention from the average anesthetizer. It is remarkable that 
patients, whose thoughts are made to run in pleasant channels as the an- 
1 Keen's "Surgery," 5, 1000. 
2 "American Practice of Surgery," 4, 131. TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
367 
esthetic is first given, usually take the drug more quietly than those who 
inhale it in a condition of mental distress. This is particularly true of 
nervous women and children. When the fears of a patient who is con- 
scious are developed into the terrors of semiconsciousness, in which the 
patient imagines the most frightful accidents are taking place, it can be 
readily understood that profound nervous shock is produced." 1 
"Where but little is required to turn the scales toward the side of 
death, unquestionably fear may sometimes lead to fatal results through 
psychical shock, through the lack of cooperation of the patient in declin- 
ing proper nourishment, through loss of sleep, and finally through im- 
paired resistance, which results from the combination of these factors. 
Such extreme dread as is referred to here should be carefully considered, 
so that every effort may be made to soothe the fears of the sufferer, as 
the successful outcome of an operation sometimes materially depends on 
the tranquilized state of the patient's mind. It is often not the most 
formidable and dangerous operations which thus terrify patients, and it 
is not always the hysterical or simple-minded who are the victims of this 
dread. Psychical shock, although rarely fatal of itself, may readily 
prove a determining lethal factor in a patient with unsound organs, who 
is also subjected to the physical shock and loss of blood of an operation." 2 
Crile states that: "Although there is not convincing proof, still there 
is strong evidence that the effect of the stimulus of fear upon the body 
without physical activity is more injurious than the effect of fear with 
physical activity. It is well known that the soldier lying under fire 
waiting in vain for orders to charge suffers more than the soldier that 
flings himself into the fray; that a wild animal in an open chase against 
capture suffers less than when cowering in captivity." 
If this is true, exactly the same state exists when a patient lies in 
bed awaiting an operation. Crile goes even further, and states: "That 
the brain is definitely influenced, even damaged, by fear has been proved 
by the following experiments: 
"Rabbits were frightened but not injured, and not chased, by a dog. 
After various periods of time the animals were killed and their brain 
cells compared with the normal. Widespread changes were seen. The 
principal gross phenomena expressed by the rabbit were rapid heart, 
accelerated respiration, prostration, tremors, and a rise in temperature. 
"The dog showed similar phenomena, excepting, instead of muscular 
relaxation, as in the rabbit, it showed aggressive muscular action. Both 
the dog and the rabbit were exhausted and, although the dog exerted 
himself actively and the rabbit remained physically passive, the rabbit 
was much more exhausted than the dog. 
"Other observations were made upon the brains of foxes chased for 
1 Keen's ' ' Surgery, " 5, p. 12. 
"Am. J. Surg., 4, 120. 368 
ANESTHESIA 
various distances by members of a hunt club, then finally overtaken by 
the hounds and killed. The brain cells of these foxes as compared with 
those of a normal fox showed extensive physical changes." 
Illustrations Showing Necessity for Mental Treatment.- 
There is recorded the history of a patient in whom the psychic element 
predominated to such an extent that the patient suddenly expired dur- 
ing the shaving of the groin, preparatory to an operation for hernia.1 
There is a record of another patient whose dread of the anesthetic 
was such that the narcotiser dropped water upon the mask for a few min- 
utes with the idea of assuaging his anxiety and distress of mind, but 
even this procedure did not prevail, and the patient died before a single 
drop of chloroform touched the mask.2 
A patient at Bellevue Hospital, in New York City, cut his throat in 
anticipation of an operation which was to be performed upon him the 
following day. 
A patient (in private practice), who had been given only a few 
breaths of nitrous oxid, jumped from the table, fled from the room, and 
was never afterward located, so far as operation was concerned, by the 
surgeon.3 
We see the other extreme in obstetric practice. The patient always 
welcomes the chloroform, as she is in such a state of mind that she is 
willing to do anything to relieve her suffering. The vast majority of 
surgical cases come between these two extremes. 
Mental Depression.-It is interesting to note that the majority of 
fatal cases reported, in which the psychic element predominated to such 
an extent that a fatality resulted, were men, and these are the patients 
who have this mental depression. Not only so, but they are men in ro- 
bust health, requiring possibly but a slight operation. 
In the light of these statistics, it is wrong to place an alcoholic or 
an athlete upon the table without endeavoring to eliminate this psychic 
element. 
Diagnostic Evidences of Fear.-In spite of the fact that most 
patients claim not to be fearful of the ordeal through which they are 
to pass, and possibly present no outward manifestation of fear, the anes- 
thetist, listening to the heart of the patient just before the administra- 
tion, discovers that things are not what they appear to be on the surface. 
In a great many instances the palpitation of the heart is alarming, and 
seems to be absolutely out of the control of the patient. In a great many 
others the heart is beating faster and with more force than normal. 
This state of affairs means that, when the anesthetic is finally adminis- 
tered, the patient is in an attitude to resist the effects of the anesthetic. 
1 Sir James Y. Simpson's work, 2, 144. 
2 Kappeler: ' ' Anaesthetics, " 118. 
3 This case was reported to the senior author by the surgeon. TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
369 
On the other hand, even though the patient may say that she is afraid 
(men never admit it), if this patient has had the proper preliminary 
medication, the heart will be found normal. In other words, the nerv- 
ous mechanism has been taken out of the patient's control temporarily; 
not only so, but the mind is now in a condition where a few suggestions 
in the proper spirit and manner are readily grasped by the patient. When 
the patient, thus doubly prepared, has the anesthetic administered, the 
chances are all in favor of a sleep approaching that of nature. "The 
transition from partial sleep to complete anesthesia is not so sudden as 
from complete wakefulness, and is more easily accomplished." (Crile.) 
Influence of Omission of All Preliminary Medication in Pos- 
sible Subsequent Operations.-When this preliminary medication is 
omitted, even if everything goes on, to all appearances, smoothly, the 
patient's condition of mind as he approaches the operating table may 
come back to him at some future time when a second operation is needed, 
and so act upon his nerves as to make him defer the operation until, 
possibly, too late for anything but palliative surgery. 
Importance of Preliminary Medication.-Not only is a patient 
in a proper frame of mind to receive suggestions when preliminary medi- 
cation is used, but the whole nervous system is obtunded, especially the 
olfactory nerve and the vomiting center. The patient, therefore, takes 
more kindly to the anesthetic, passing quietly and quickly into full sur- 
gical anesthesia. If, during the operation, it is possible to lighten the 
anesthesia without disturbing the surgeon, the patient can be held be- 
tween a light and deep narcosis without once disturbing the dangerous 
vomiting center. The patient comes out, as a usual thing, without either 
conscious or unconscious vomiting. The kidneys and lungs have also 
been saved unnecessary irritation by thus reducing the amount of pul- 
monary anesthetic one-third to one-half. 
Even when this element of fear is seemingly entirely absent, the pa- 
tient, disregarding preliminary treatment of all kinds, incurs a certain 
definite and needless risk, often out of all proportion to the operation 
to be performed. A gentle laxative, rest in bed at the place of opera- 
tion, and a small physiological dose of morphin or some other sedative 
should be insisted upon for even slight operations. 
Two illustrative cases from the writer's and one from a noted sur- 
geon's practice in New York City will suffice. 
(1) Adenoid and tonsil case of a young girl twenty-two years of 
age. She refused to stay in a private sanitarium over night, and conse- 
quently did not have any morphin preliminarily. Patient walked in 
from the street, and, while the surgeon and myself retired to another 
room, disrobed and laid herself upon the table, and was draped by the 
nurse for operation. Heart sounds normal and no outward appearance 
of nervousness. Induction of anesthesia uneventful. About two min- 370 
ANESTHESIA 
utes after beginning the operation patient stopped breathing, and after 
the usual procedure was revived and the operation completed. Patient 
was compelled to stay in hospital for two days on account of laxity of 
the sphincter ani, and the surgeon was put to his wits' end to explain 
the relation of this condition and subsequent diarrhea to the adenoid and 
tonsil operation. 
(2) Patient, male, sixty-five years of age. Carcinomatous gland 
of neck. Patient walked into hospital on the morning of the operation, 
and had no preliminary medication before coming to the operating room. 
Heart slightly hypertrophied and sometimes failed to compensate. After 
operation had progressed about fifteen minutes, respiration ceased for 
no apparent reason except lack of preliminary treatment of all kinds. A 
quick slap on chest wall over precordial region failed to start the respira- 
tory pump. The head of the table was quickly lowered; sphincter ani 
stretched, traction on tongue and artificial respiration with massage of 
precordial region were immediately instituted. All of these factors acting 
together resulted finally in the patient's respiratory center reasserting 
itself, and the operation was successfully completed. 
(3) Patient, male, age thirty-five; vigorous health, slight operation 
under cocain. No preliminary medication of any kind was attempted 
beyond cleansing the immediate field of operation. A few drops of co- 
cain were injected into the urethra, when the patient immediately 
stopped breathing, and all efforts at resuscitation failed. 
The above fatal case and the two nearly fatal cases illustrate most 
forcibly the imperative necessity of safeguarding patients by preliminary 
medication in so-called minor operations. 
In order to completely eliminate the element of fear, Crile has elabo- 
rated a method which he calls anoci-association. This consists of block- 
ing off the nerve supply to the field of operation (in external operations) 
by the local or intraneural infiltration of novocain. The brain is thus 
completely isolated from operative influence, and, according to Crile, "is 
not more affected than if the operation were performed on clothing." 
This is of importance aside from the comfort of the patient, because, 
as Crile has shown, the element of fear has a definite effect on the cells 
of the brain. These changes, to whatever due, are always proportional to 
the extent of the loss of vital force. 
Medical.-The medical treatment consists of: 
(1) The treatment necessary to prepare the patient for the opera- 
tion, which is in part included under hygienic treatment. 
(2) The narcotics and hypnotics preliminarily given as a desirable 
part of the anesthetic. 
There is a complete unanimity among surgeons as to the preliminary 
use of morphin in local, spinal, intravenous, and rectal anesthesia. (See 
remarks in each of these chapters.) On the other hand, there is a wide TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
371 
diversity of opinion as to prescribing morphin and other narcotics before 
pulmonary anesthetics, most surgeons believing thoroughly in their use, 
while others never employ them before an operation, but inconsistently 
prescribe some of them immediately afterward. As all pulmonary anes- 
thetics are improved by use of these drugs more than are the four spe- 
cial classes of anesthesia mentioned above, there should be a greater 
unanimity of opinion concerning their value than exists at present. 
Rules Governing Preliminary Medical Preparation.-Prelimi- 
nary medication consists usually of morphin, hyoscin, chloretone, bro- 
mids, and whiskey, either alone or in combination. The following rules 
will assist in determining whether or not preliminary medication, and es- 
pecially morphin, should be used.1 
(1) Whenever morphin (or other narcotic) is to be given at all, it 
should always be given before, instead of after, the operation, in order to 
obtain the benefits of it in the induction and maintenance of anesthesia. 
(2) After taking it, the patient must be kept in bed absolutely 
quiet, and at the proper time carried to the operating room. 
(3) All athletes, alcoholics, neurotic and plethoric patients should 
have preliminary medication in order to take away, as far as possible, 
the physical control which might enable them, when the second stage of 
narcosis is reached, to take a deep breath, hold it, and thus force upon 
the heart all the anesthetic vapor in the lungs, creating an overdose. 
(4) In the extremes of life, the very young, the very old, under 
seven and over seventy, if morphin is given at all, it should be with very 
great caution. 
(5) Whenever morphin is given a lighter narcosis should be main- 
tained than when this drug is not employed. 
(6) Care must be taken in administering the usual doses of mor- 
phin when chloroform is the terminal anesthetic. It is best to use some 
other drug, as both morphin and chloroform have a depressing effect on 
the respiratory centers. Atropin is the best drug to employ as a pre- 
liminary to chloroform (or any combintion of drugs with chloroform), 
rendering inhibito-respiratory reflexes less liable to occur. If used alone, 
atropin, 1/100 to 1/150 of a grain, 30 minutes to 1 hour before the 
operation, is the proper dose. One-eighth of a grain of morphin with 
1/150 grain of atropin is a good combination when chloroform is used 
alone. 
Preliminary narcotic medication increases the confidence of nervous 
patients, lessens the amount of anesthetic required, prevents the exces- 
sive accumulation of mucus in the throat, reduces the liability to shock, 
and eases the immediate post-operative pain, while often giving to the 
patient a happier exit from the influence of the anesthetic." 2 
1 Collins, C. IT.: J. Am. Med. Assn., Mar. 26, 1911. 
2 Am. J. Surg., 4, 132. 372 
ANESTHESIA 
"Through countless experiments it has been found that narcoses are 
possible with far smaller amounts if preceded a few hours before by a 
hypnotic, even though these hypnotics act on entirely different organs." 1 
Time for Giving the Preliminary Medication.-Whenever medi- 
cation is used, it should be given for its full physiological effect to be 
apparent just before the time scheduled for the operation. It is just as 
important not to give the preliminary medication too long as too short 
a time before the operation. 
For morph in or any of its combinations, at least 30 minutes should 
be allowed. The physiological effect of morphin and atropin is indicated 
by dryness of the mouth and slight slowing of the heart and respiration. 
Doses of Preliminary Medicaments.-When chloretone is used 
alone, it is best to start at least 1 hour or an hour and a half ahead 
of time. Probably the best way to give this drug is 5 grains with % 
glass of water every 15 minutes until 15 grains have been taken. The 
last dose is to be given at least 30 minutes before the operation. When 
chloretone and morphin are used in combination, only small doses of 
both drugs are necessary, in order to have the desired effect. Ten grains 
of chloretone with glass of water, 1 hour before the time, and % to 
1/6 grain of morphin 30 minutes before, is usually sufficient. 
Some experimental laboratories report that *4 grain of morphin with 
15 grains of chloretone would be absolutely safe for an athlete or an alco- 
holic. 
The average dose is 1/8 to 1/6 grain morphin with 1/150 grain atro- 
pin, for women; and 1/6 to grain morphin with 1/100 grain atropin 
for men. One-eighth to grain of morphin, with 1/100 grain sco- 
polamin iy2 hours before the operation has been used by some surgeons 
with very great success. 
Collins'2 perfected technique is probably the best ever published, and 
for this reason is given in full. His "final choice resulted only after 
using hyoscin-morphin-cactin combination in 70 cases and morphin and 
atropin in a few cases. He first used chloroform, but in the majority of 
his cases ether was the anesthetic used. Lately he has been using nitrous 
oxid, and finds this acts equally well. This preliminary medication is 
given to all patients over seven years old. 
In exophthalmic goiter cases, on account of the nervous element, it 
is given the night before and repeated one and a half hours before the 
operation. 
All relatives and friends are excluded from the room, and every 
necessary manipulation and handling of the patient is now completed. 
The hypodermic is administered iy2 hours before the operation, and 
consists of a solution containing scopolamin, 1/100 grain, and morphin, 
1 Meyer and Gottlieb: 1' Experimentelle Pharmakologie. ' ' 
2 Loo cit., 15. TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
373 
1/6 grain. The room is now darkened and quiet maintained. In about 
30 minutes the patient becomes drowsy and in a tranquil condition of 
mind. 
Twenty minutes before the operation a layer of gauze or cotton is 
placed over the eyes, and the patient is now carried and placed upon the 
operating table. 
The anesthetic is administered while the final cleansing of the opera- 
tive field is concluded. 
After the operation the patient usually sleeps from two to five hours 
before becoming completely awrake. The smarting pain of a recent opera- 
tion is thus entirely eliminated. 
In over 1,000 cases there were no deaths and only 1 case presented 
unpleasant symptoms, and there was practically no post-operative vomit- 
ing (about 1 in 10). 
Indications and Contraindications of Preliminary Medica- 
tion.-The contraindications of morphin are the extremes of life; acute 
or subacute nephritis; a state of coma; where, for any reason, the re- 
flexes are not to be abolished; in those extremely rare cases in which 
morphin is taken with distress, with accompanying disagreeable after- 
effects, and especially in cases of idiosyncrasy; also very weak and feeble 
patients, and those with any respiratory affection. 
If for any reason morphin in any of its various combinations is 
contraindicated, an ounce of whiskey and 7 ounces of saline solution per 
rectum, i/G hour before the operation, usually has the desired effect of 
quieting the patient. 
When ether is contraindicated and chloroform or ethyl chlorid is the 
anesthetic of choice, atropin is especially indicated as the preliminary 
medicament to be used. It maintains the respiration, and with ethyl 
chlorid prevents profuse salivation with consequent nausea and vom- 
iting. 
The experimental and clinical experiences of Herrenschmidt and 
Beauvy 1 have made them come to the following conclusion: 
"That adrenal extracts should be administered to chloroformed sub- 
jects, whether the suprarenal capsule shows evidence of weakness or 
whether it gives evidence of struggle and consequent reaction. The ef- 
fect of prolonged chloroform administration on the medullary portion 
of the adrenal is diminution and even disappearance of both chromaffin 
and adrenalin. 
"Delbet has administered adrenalin to more than 1,000 chloroformed 
patients. The results have been splendid. He believes that adrenalin 
unquestionably regularizes the narcosis and diminishes (in most cases 
eliminates) post-operative shock." 
*P. Delbet, A. Herrenschmidt, and A. Beauvy: Revue de chirurgie, Apr. 10, 
1912. 374 
ANESTHESIA 
Treatment During Anesthesia 
The object of treatment during anesthesia is the maintenance of the 
patient's vitality on as nearly normal a plane as possible. 
The anesthetist should at all times anticipate the needs of the sur- 
geon, and also give necessary directions for any treatment the patient's 
condition demands during the operation, for instance, during a lapa- 
rotomy, if a Trendelenburg posture is called for and a light anesthesia 
is being maintained at the time, the anesthesia should be immediately 
deepened, otherwise the muscles will stiffen up with the changed posi- 
tion and cause trouble. 
Again, if there is shock from handling important vessels and nerves 
or inflamed tissues or breaking up an adhesion, the anesthetic must be 
lessened and the oxygen increased, and a rectal saline or hypodermo- 
clysis given, thus keeping the pulse and respiration as nearly normal as 
possible. 
Hydrant Water or Saline Enema to Relieve Thirst, Prevent Nausea, 
and Assist Kidneys.-Furthermore, to mitigate the thirst which may 
arise from the morphin, to give strength and volume to the pulse and 
also to assist the kidneys and prevent the formation of gas in the intes- 
tine, two pints of normal saline solution, 105° to 115° F., per rectum 
materially assists in this direction, and brings the patient out in a far 
better condition than when this has not been included. This should be 
given as a routine measure, and for the special purposes here mentioned, 
while the patient is still in full surgical anesthesia, a slight Trendelen- 
burg position assisting greatly in the retention of the fluid. 
If the saline enema is quickly absorbed or has been given continu- 
ously during the operation, it may be discontinued 10 to 15 minutes be- 
fore the conclusion. Instead of the normal saline, ordinary hydrant 
water may be used with advantage, according to Trout.1 
He 2 compared over 400 alternate cases. Actual experiments proved 
that tap water could be continued over a longer period with less rectal 
irritation than with any saline solution. He cites the fact that "thera- 
peutists sometimes obtain wonderful results in the treatment of acute 
and chronic nephritis by substituting a salt-free diet." He also refers 
to deaths that "showed experimentally that they were due to the sodium 
chlorid and not to the amount of water or to hemolysis." Reference is 
also made to experimenters who have "actually produced not only an 
acute, but a chronic, nephritis in rabbits by the continual administration 
of this drug." He refers to Vincent, who "was able to control to a large 
extent a number of cases of hysteria by employing a salt-free diet with- 
'On the abuse of normal salt solution, see G. H. Evans: J. Am. Med. Assn., 
Dec. 30, 1911, 2126. 
2 Trout: "Proctoclysis," J. Am. Med. Assn., May 4, 1912, 1352. TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
375 
out their knowledge, and accentuated the symptoms by a corresponding 
increase in salt." 
Trout mentions specifically one of his own cases, an interval appen- 
dix, in which "there followed a transient albuminuria which remained 
for two days." Water was then substituted for the salt solution per 
rectum, and at the end of twenty-four hours the albumin had disap- 
peared. At the end of the next twenty-four hours, salt solution was 
again used and albumin appeared within the next twenty-four hours. 
Salt solution was then discontinued and water started, and the patient 
did not show any more albumin up to the time of his discharge from 
the hospital. In this case there was never any edema. 
"When a poison is introduced into the system it unites to form new 
compounds with the cell protoplasm, and this molecular union must be 
broken up before the poison can be eliminated. Salt solution has no spe- 
cific action in either bacterial or vegetable poisoning. 
"If absorption is a process of osmosis it is certainly reasonable to pre- 
sume that a solution which is not isotonic with blood will be more readily 
absorbed from the rectum, and our series of cases tends to confirm this 
view." 
"Conclusions.- (1) All patients show less rectal irritation from 
proctoclysis if given a soapsuds enema before the operation. 
"(2) The patients given water by rectum absorbed nearly 400 c. c. 
more to the 24 hours than did the patients given salt solution, the aver- 
age for the water series being 2,444 c. c. per 24 hours and the average for 
the salt series being 2,041 c. c. per 24 hours. 
"(3) The patients given salt solution by rectum required nearly 
twice as much water by mouth to relieve thirst, or, to give exact figures, 
in the water cases only 332 c. c. were taken in the first 24 hours; in the 
salt cases 696 were required in the first 24 hours. 
"(4) The amount of urine was practically the same in both cases. 
"(5) In 17 cases the patients complained of tasting salt without 
having any idea that normal salt solution was being given by rectum. 
None of the water series made any such complaint. 
"(6) In drainage cases more fluid may be taken by rectum than in 
those laparotomies closed without drainage. 
"(7) Proctoclysis should be employed more frequently than it has 
been in the past and in all classes of cases in which it is possible. Care 
should be exercised to prevent "water logging" of the entire system, and 
this applies to both salt and water. 
"(8) In peritonitis cases with drainage it is possible to have the pa- 
tients take four or five times as much fluid by rectum as in the cases on 
which this paper is based." 
Lawson 1 corroborated Trout's findings. "Theoretically, at least," he 
'Lawson, George B.: J. Am. Med. Assn., Apr. 18, 1908, 1267. ANESTHESIA 
376 
says, "it seems better in the toxemias to use plain water in place of 
normal saline so that the osmotic pressure would increase the absorption; 
also by increasing the fluids of the body without increasing the sodium 
chlorid one better facilitates urinary secretion." 
Olive Oil to Restore the Opsonic Index.-The administration of five 
ounces of warm olive oil is strongly recommended by Ferguson.1 He 
states that "anesthesia by ether or chloroform lowers the opsonic index, 
that is to say, reduces the patient's power to resist an infection which 
was existing at the time of the operation or which may be a post-opera- 
tive acquirement; second, the bacteria are not materially affected either 
in respect to number or activity; third, this impaired resistance is 
brought about through the medium of both phagocytes and serum." 
Ferguson cites a number of experiments to prove this theory, upon 
both animals and human beings: "In the human experiments 5 ounces 
(150 c. c.) of warm olive oil were passed slowly into the rectum through 
a tube immediately after the patient had returned from the operating 
room. This was followed after three to six hours by a restoration of 
phagocytic power, while, on the contrary, the injection of the same 
amount of physiologic salt solution had no appreciable effect in shorten- 
ing the period of phagocytic depression." 
It is suggested that a certain amount of the oil is absorbed and en- 
ters the blood stream; and, furthermore, "in all probability a certain 
amount of ether is present in the intestinal tract which may be held by 
the oil, and thus prevented from becoming reabsorbed." 
Where long exposure of intestines is unavoidable, as in gastro-en- 
terostomy and similar operations, hypodermoclysis should be begun as 
soon as the patient is in surgical anesthesia, thus anticipating and in a 
great measure preventing surgical shock. 
When sudden hemorrhage occurs rectal saline, with the patient in a 
slight Trendelenburg position, will more quickly restore the volume of 
blood lost, and in this way reestablish circulatory equilibrium, than any 
other procedure. This, of course, is in addition to whatever measures 
the surgeon may institute for the control of hemorrhage. 
As a further preventive of post-operative shock, filling the abdominal 
cavity with oxygen at the close of the operation is a useful procedure. 
Aeration of Lungs.-As the operation is drawing to a close, if the 
anesthetic has been other than nitrous oxid, a system of aeration of the 
lungs should be initiated as follows: 
Place any mask with rubber bag over the face of a patient and com- 
mence pumping in warm air, the bag to be kept slightly distended or 
overdistended for two or three minutes and then emptied, and this 
1 Ferguson, Robert H.: " The Opsonic Index in Relation to Surgical An- 
esthesia. " E. R. Squibb & Sons. TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
377 
process is repeated (unless the patient is entirely conscious) until he is 
ready to be removed from the operating table. 
Removal of Patient.-The patient should be moved with as little 
jolting as possible, and should be well covered over with hot blankets 
while on the stretcher, special care being taken to protect the head as 
well as the feet. 
Technique of Removal to the Bed.-Unless straps are under the 
Fig. 136.-Preparing to Lift Patient. Head of patient to foot of bed. 
patient or there is an abundance of help, instead of lifting the patient 
directly over the stretcher into the bed, place the head of the patient at 
the foot of the bed, the stretcher and bed thus forming a right angle, 
with anesthetist and nurse standing within the angle thus formed. In 
this position a very heavy patient can be easily lifted by one, or, at most, 
two, people and placed in bed without jarring or jolting and without 
straining the backs of those lifting. The patient should always be lifted 
as high as the head, in order that the principal weight of the body be 
carried in a vertical position. The strain upon the muscles of the back 
is thus materially lessened. 
If a sedative is indicated after the operation, it is best to use some 
other drug than morphin, if this has been used as a preliminary, as a 
repetition of morphin may induce nausea. If, however, it is repeated, 378 
ANESTHESIA 
the atropin should be omitted, as the dryness of the throat caused by 
this drug is usually a source of very great discomfort to the patient. 
The whiskey and saline enema is one of the best medicaments to use 
after an operation. Chloretone, in 5-grain doses, and hyoscin, either 
alone or combined with morphin, is also good. 
Finally, with proper preliminary medication, the anesthetic may be 
discontinued much earlier. Patients usually continue to sleep or doze 
Fig. 137.-Carrying Patient Head High. This patient weighed over two hundred 
pounds and was easily lifted. 
from the morphin given for from to 1 hour after the effects of the pul- 
monary anesthetic have worn off. The acute pain of the operation is 
thus minimized and the necessity for any further medication is not so 
great. 
After-treatment 
If the anesthetic has been properly administered, all reflexes should 
be present as the patient is being placed in bed. 
Two pillows should be immediately placed under the head and shoul- 
ders of the patient, unless indications of shock are evident. A towel 
should be placed over the eyes to keep out the light, and the room dark- 
ened but well ventilated, the patient being protected from draughts by 
a screen. TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
379 
The saline or water enema should be repeated every few hours, unless 
olive oil has been given. 
Permit no loud talking or moving around, thus allowing the patient 
to sleep partly from the preliminary medication and partly from the 
nerve exhaustion usually accompanying any surgical operation, until he 
awakens from this twilight slumber in a quiet and natural manner. 
Water.-As soon as he is awake, free administration of either cold 
or hot water will make the patient comfortable. If nausea is present, 
and vomiting ensues, the stomach is washed out and the nausea will 
subside much more quickly than if the water had not been taken. This 
should be "further supplemented by small quantities of salt solution, 200 
or 300 c. c., per rectum every 4 hours. The free administration of water 
not only hastens the elimination of ether, but also supplies fluid for 
active kidney work and militates against the occurrence of shock. After 
36 to 48 hours, a liquid diet may be begun, and buttermilk, fresh milk, 
or lager beer, albumin water flavored with fruit juice or sherry, or tea or 
coffee, may be acceptable." 1 
For post-anesthetic vomiting it is a routine custom among many 
British surgeons to give tincture of iodin, % minim (i/2 minim of 
U. S. P. tincture) in a teaspoonful of water, every half hour for 3 or 4 
doses.2 
If vomiting occurs in spite of preliminary medication and anestheti- 
zation by proper methods, one of the oldest and simplest methods of re- 
lief is the inhalation of vinegar fumes. 
Sometimes it may be necessary to give a rectal injection of 30 to 40 
drops of deodorized tincture of opium with 60 grains of sodium bromid, 
to quiet the vomiting center. 
MANAGEMENT OF DIFFICULT OR UNUSUAL CASES 
In the foregoing pages we have considered the adjuvant manage- 
ment of ordinary cases-cases in which the course of anesthesia conforms 
to what, from experience, one may safely predict; cases in which, in 
other words, the expected happens. 
The anesthetist, however, who settles himself comfortably at the head 
of the patient, believing that no dangers need be anticipated so long as 
he has observed the rules for preliminary medication and so long as he is 
careful in his technique of administration, is apt at any moment to have 
a rude awakening, for anesthesia is no exception to the general rule of 
life, and the unexpected must always be anticipated. This is true (1) 
1 Am. J. Surg., 4, 152. 
2 The post-anesthetic treatment varies, of course, with the nature of the oper- 
ation. ANESTHESIA 
380 
particularly, because of the fact that individual susceptibility, or insus- 
ceptibility, to the given agent or method of administration may upset all 
calculations; (2) because a slight error in technique may convert minor 
difficulties into those of major proportions; (3) because the exigencies 
of the surgical procedure itself may create unexpected emergencies for 
the anesthetist; because latent or undiscovered pathological conditions 
may become complicating factors. 
The minor difficulties which may be encountered may be grouped un- 
der the following heads: 
(1) Respiratory; (2) muscular; (3) nervous; (4) idiosyncratic. 
Respiratory 
Dyspnea, hyperpnea, apnea) and stertor are among the respiratory 
difficulties most commonly encountered. Some patients, particularly 
young children and nervous women, persist, despite suggestive therapy, 
in an irregular or hesitating manner of breathing, while others "hold 
their breath." If allowed to go under the anesthetic in this way, the 
manner of breathing may characterize the stage of surgical narcosis. In 
some cases more serious respiratory disturbances, even temporary respira- 
tory arrest (apnea), may supervene, calling for the more heroic manage- 
ment discussed hereafter (see p. 393). 
A too strong vapor (chloroform or ether) may give rise to hesitant 
breathing after loss of consciousness. As a rule, safe, rhythmical respira- 
tion can be induced reflexly by the manipulation of the lips (brisk rub- 
bing, with towel or sponge), or fauces (swabbing out with rough gauze), 
or other form of peripheral stimulation. 
The convulsive inspiratory effort (sobbing) with contraction of the 
diaphragm and spasmodic closure of the glottis, particularly noted in 
children, may lead to unpleasant complications because of the liability 
to the sudden inhalation of too large quantities of the anesthetic, with 
consequent asphyxia, or overdose symptoms, varying according to the 
anesthetic employed. 
If the anesthesia is begun while the patient is still breathing in this 
manner, the administrator must be on guard and the anesthetic dose 
regulated accordingly. If the graver respiratory manifestations present 
themselves, they must be dealt with as hereinafter indicated. 
In chloroform narcosis one must always be on guard for so-called 
false chloroform anesthesia-early shallow breathing instead of aug- 
mented breathing, which marks the second stage in the uneventful cases. 
If this be mistaken for a quickly induced surgical narcosis, with com- 
plete loss of sensation, etc., and the anesthetic be continued and the 
operation begun as if this were so, the patient may be plunged into pro- 
found shock, calling for the treatment outlined in this chapter, TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
381 
or the error may be recognized and corrected by peripheral stimulation, 
friction applied to lips, or face, or hypochondriac region, vigorous rub- 
bing, slapping, or pinching. 
Sometimes in intranasa] surgery, sneezing, of reflex origin, may oc- 
cur and persist, becoming so violent as to cause a distinct complication. 
This can usually be controlled by spraying the nasal passages with co- 
cain. Sneezing, according to Hewitt, may be so violent as to constitute 
a distinct difficulty, especially in delicate operations about the face.1 
In operations upon the intestines, hiccough, due to some reflex irrita- 
tion, may become a disturbing factor. If the anesthesia is initiated 
properly, and care is taken to prevent an accumulation of mucus in the 
fauces, and hence the swallowing of an undue quantity thereof, this 
phenomenon is easily controlled. 
The coughing, retching, and vomiting, minor difficulties arising early 
in the administration from improper preparation of the patient or from 
imperfect technique, may become annoying features in the stage of surgi- 
cal narcosis. Deepening the narcosis will generally obviate these phe- 
nomena. 
Muscular 
Various muscular phenomena have been noted by different observers, 
aside from the struggling and other manifestations of muscular reflexes 
which accompany the stage of excitement as ordinarily observed. Tris- 
mus, or jaw spasm, spasm of the abdominal muscles, general persistent 
muscular rigidity, fine muscular tremors, such as the "piano playing" 
movements of chloroform anesthesia, the spasmodic contractions of the 
pectoral muscles indicating slight asphyxia, are all to be met with in ex- 
ceptional cases. The various clonic muscular phenomena may become a 
serious menace to life if mistaken for a return to the second stage of 
anesthesia (particularly with chloroform). If the narcosis is deepened 
under this misapprehension, the patient may be quickly and unexpect- 
edly plunged into the stage of overdose, which may call for vigorous 
measures of resuscitation. 
Nervous 
In exceptional cases, particularly among neurotic subjects, and when 
preliminary medication has been neglected, the administration of any 
inhalation anesthetic may be followed by the immediate onset of vio- 
lent insanity. If operation is imperative in such cases, it is best to delay 
the further administration until narcotic medication has had time to 
take full effect. The anesthetic should then be given very gradually, 
1 Hewitt: "Anaesthetics," 1912, 912, 543; see, also, Lancet, Dec. 2 and 16, 
1893. 382 
ANESTHESIA 
beginning with the essence of orange, if an open method is indicated. 
If a closed method, essence of orange or nitrous oxid. 
Idiosyncratic 
It is a well-known fact that some individuals cannot be operated upon 
under local or spinal analgesia. (See case reported by Bainbridge, p. 
623.) So, with inhalation anesthetics, very rare cases of insuscepti- 
bility, apparent or real, are encountered. Hewitt1 reports two cases in 
which there was insusceptibility to nitrous oxid, probably traceable to 
alcoholism. He directs attention to the point that an acquired suscepti- 
bility may be manifested in persons infected with malarial parasites. The 
same author reports two other cases in which there was marked insus- 
ceptibility. In one the induction was begun with nitrous oxid and ether, 
with a change to chloroform, then to ether, the C. E. mixture finally 
proving successful. Tn the other case the anesthetic was begun with 
ether by the open method, without preliminary medication. After wait- 
ing for morphin and atropin to take effect, another effort was made, be- 
ginning with chloroform and switching to ether. Loud crowing breath- 
ing lasted throughout, but the operation was completed successfully. 
Hypersensitiveness, rather than insusceptibility, it would seem, is the 
difficulty to be guarded against. 
There are practically no minor difficulties of any unusual character 
encountered after anesthesia. 
Among the major difficulties which may be encountered in the course 
of inhalation anesthesia, or the after-management of the case, and which 
directly concern the anesthetist, are (1) shock, and (2) post-anesthetic 
toxemia. 
These difficulties undoubtedly vary with the anesthetic, with the gen- 
eral preliminary and concurrent management of the case, with the 
method of administration, with the physical peculiarities of the patient, 
with the technique and skill employed by the surgeon, and with preexist- 
ent pathological conditions. 
Whatever the cause or causes, and however these complications may 
be precipitated, the anesthetist must know how best and most expedi- 
tiously to deal with them. They are, therefore, directly concerned with 
the prognosis and treatment of the individual case, and it behooves the 
anesthetist to be familiar with them from the theoretical, as well as 
from the practical, point of view. In the pages which follow, an attempt 
is made to set forth, as briefly as possible, the theories, and the views 
with regard to management, of those who, by virtue of their original 
observations, are best qualified to speak with authority. Whatever per- 
'Hewitt: '1 Anaesthetics," 1912, 332, 333; 548, 549. TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
383 
sonal experience the authors have had is merely corroborative; we there- 
fore take the liberty of drawing freely from those who have concentrated 
effort in these given directions. 
Shock 
By far the most important complication which may arise in the 
clinical experience of the anesthetist is shock. When, for any reason, 
the patient emerges from the even plane of a safe and satisfactory anes- 
thesia into that alarming composite condition which is designated as 
shock, the anesthetist must be able quickly to marshal all his resources 
toward the restoration of the normal anesthetic condition. 
Shock may be considered under the four heads, according to the chief 
factors which induce it, of: (1) surgical shock, that for which the sur- 
geon is responsible; (2) psychic shock, shock produced in a patient by 
inability to control the nervous system; (3) dietetic shock; (4) anes- 
thetic shock, that for which the anesthetist is responsible. 
Surgical Shock.-Shock has been described 1 as "a condition of gen- 
eral depression produced by various causes." With shock we have: (1) 
a fall in blood pressure; (2) nerve centers react feebly to afferent stim- 
uli; (3) pulse rapid and feeble; (4) respiration shallow; (5) all cu- 
taneous reflexes lessened; (6) increased perspiration, with skin cold and 
moist; (7) temperature lowered; (8) mental condition one of quiet 
depression, patient may be conscious [this, of course, does not apply to 
shock during anesthesia]; (9) no pain or discomfort, but a feeling of 
weakness. 
Various factors are concerned in the production of shock, and may 
pertain as much to the shock produced by surgical procedure, during 
narcosis, as when shock is the result of accident or any cause operative 
under ordinary circumstances. 
Keen 2 gives these factors as follows: 
"Age.-In the new-born, before the physiological connections be- 
tween the great divisions of the central nervous system have been estab- 
lished, it is quite probable that at least certain operations are very much 
more nearly shock-free than they will ever be again. (There is a short 
period of immunity that disappears with the establishment of the 
through paths of the nervous system). They are not only shock-free, 
but free from any appreciation of pain: In the new-born extensive 
operations for cleft palate are endured without anesthesia, pain, or shock, 
the only immediate risk being hemorrhage. Within a week or more 
these physiological connections become established, after which the infant 
becomes even more susceptible to shock than the adult. 
1 ' ' American Practice of Surgery, " 1, 4 33. 
2 Keen's "Surgery," 1, 922. 384 
ANESTHESIA 
"Adult Life.-This is the period of greatest resistance to shock. 
"Old Age.-The senile heart has an uncertain and limited range of 
action. The arteries are hard and the blood pressure is high. The aged 
only apparently endure operations well. The risk is determined not by 
the age of the patient, but the age of the circulatory apparatus. Toward 
the completion of life's cycle the resistance to shock is at a minimum. 
"Time of Day.-The vital powers are highest in the morning, and 
the psychic factor at a minimum. The most unfavorable time 12 to 2 
A. M. Autumn and early winter the best. Summer the worst. 
"Occupation.-Professional and business men are more susceptible 
than the farmer, laborer, and mechanic. The industrious are better sub- 
jects than the idle. The resistance of criminals is remarkable. Soldiers 
and sailors are good risks; athletes, not so good; worst risk, overworked 
surgeon over 50 years of age. Cachectic patients bear operations poorly. 
In pernicious anemia the operator's risk is great. In chronic anemia the 
risk is better, but still great. In chronic anemia from loss of blood the 
risk is better; in acute anemia from hemorrhage the risk is still better." 
Psychic Shock.-Psychic shock is "due to the powerful impulses from 
the highly specialized centers of the cerebrum acting upon the vital cen- 
ters of the medulla." 
It is hard to differentiate between prostration by fear and prostration 
by injury. In most injuries the psychic and mechanical factors are 
mixed. 
"The deep impression left upon the brain by a powerful nervous 
shock often endures for months and years." 
Irritating Chemicals.-Those which cause marked irritation at the 
point of contact may produce shock. 
(According to Mummery, "Burns of the first and second degree with 
extreme irritation only are apt to cause more shock than burns of the 
third and fourth degree causing destruction of tissue." Burns extend- 
ing over half of the body frequently cause death from shock.) 
Toxic Causes.-Abscess breaking into the peritoneal cavity, and 
pouring out intensely irritating chemical compounds, causes shock by 
intense local irritation and constitutional disturbance. 
Mechanical Causes.-By mechanical stimulation of nerve centers 
or trauma afferent impulses are sent toward the centers. 
"An abnormally low blood pressure is the essential phenomenon of 
the state commonly designated surgical shock." 
"Shock is the problem of the various kinds of stimulation of the 
nervous system." 
Susceptibility of the various tissues depends upon the quality and 
quantity of their nerve supply. 
"A fall in blood pressure usually occurs while incising the skin over 
the abdomen." TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
385 
"Asphyxia is always attended by a retarded pulse and slow and pow- 
erful respiratory efforts. A fall in temperature is the result of low blood 
pressure." 
Circulation.-The entire arterial system bleeds into the dilated 
venous system, and the bulk of the blood is not freely circulated. 
Respiration.-It is accelerated. Sighing and irregular or increased 
action may appear. The respiration wave is shortened. Inspiratory and 
expiratory efforts are quickened, and the pause is lengthened. Later, 
the gasping type of respiration with tracheal and chin tug indicates im- 
pending dissolution. 
Muscular System.-The voluntary and involuntary muscular sys- 
tems are relaxed; kidney and digestive tract diminished in function; 
skin relaxes; pallor with consequent outflow of water or perspiration. 
Face is shrunken, pinched, and elongated; eyes lusterless and sunken, 
with lids only half closed; lips parted, thin, and pale, but may be cy- 
anotic; drooping jaw, partly open mouth, falling in of cheeks. 
Crile,1 in his epoch-making experimental researches concerning shock, 
made the following observations concerning its production and the re- 
sultant effects. These observations were made upon animals in the 
laboratory. 
"Skin.-Cutting and tearing caused in the greater number of 
instances a rise of blood pressure, though sometimes no effect was ob- 
served. 
"Negative Results.-Kidney, Spleen, Bladder, Eyes.-Mechanical 
injury caused usually no appreciable change in either the circulation or 
the respiration. 
"Ears.-As skin usually. 
"Mouth.-Crushing, tearing, cutting, and puncturing the tongue 
produced no effect on either the circulation or respiration. 
"Heart.-The slightest direct contact with the heart caused marked 
changes in its beat and in the blood pressure,-a fall in blood pressure, 
with short, irregular strokes. 
"Diaphragm.-Contact, however slight, with the abdominal side of 
the diaphragm caused in every instance markedly arhythmic respiration. 
"Abdomen.-In making the incision through the skin in the abdom- 
inal sections there was frequently noted a fall in the blood pressure; this, 
in fact, was the rule. 
"Cutting muscles or fascia produced little or no effect. On opening 
the peritoneum a fall was noted. 
"Liver.-Manipulation of the gall-bladder caused a marked tem- 
porary fall. 
"Uterus.-A rise in blood pressure. 
"Testicles.-A fall in blood pressure. 
1 Crile, George W.: ' ' An Experimental Research into Surgical Shock. ' ' 386 
ANESTHESIA 
"Penis.-A fall in blood pressure. 
"Vagina.-A rise in blood pressure, and increase in depth and fre- 
quency of the respirations. 
"Anus.-Same. 
"Peritoneum.-Contact, however slight, with the peritoneum or vis- 
ceral peritoneum caused marked arhythmic respiratory action. The 
diaphragmatic peritoneum produced the most marked respiratory 
changes. Continuation of the manipulation does not secure tolerance un- 
less confined to the same area?' 
The duration of an operation was found to be an important factor in 
the production of shock. Animals may be killed by the effect of con- 
tinuous anesthesia alone, though the anesthetic is carefully administered, 
so that a percentage-calculated upon the ratio between the actual dura- 
tion of anesthesia and the average length of time a dog may survive 
continuous anesthesia,-is allowed for the pure anesthetic factor in any 
given case; that is to say, if ten hours be allowed as the average length of 
time a dog may live under continuous anesthesia and the given experi- 
ment lasted two hours, then twenty per cent of the cause of death was cal- 
culated to represent the anesthetic factor. This calculation applies to 
ether. There is strong evidence tending to show that chloroform, even 
barring accidents, is a more potent factor in destroying the animal than 
is ether. 
Contact with air is a very great irritant to local tissues, owing to the 
lowering of local temperature and to the drying. Exposure of the 
thoracic cavity causes great disturbance of respiration, and the time of 
exposure should be as short as possible. "The element of time in ab- 
dominal operations in every experiment was unmistakable." 
Temperature.-The effect on the intestines of cold water and of the 
intravenous cold saline solution showed more directly the depressing in- 
fluences of the cold. The direct effect of warm towels applied to the ex- 
posed intestines, of warm saline in the abdomen, improved the respira- 
tion immediately, and as nearly as could be estimated caused at least 
a check in the declining blood pressure. 
Anesthesia.-The respirations in over-anesthesia became generally 
more shallow and slower, and if the anesthetic was continued would fail 
suddenly. The blood pressure pari passu gradually fell. Upon removing 
the ether both would rise, much as they fell. The respiratory indica- 
tions were usually in advance of any other symptom in foretelling the 
tendency of the anesthesia. The effect upon respiration was so constantly 
in advance of other effects, for example, that upon the circulation, 
that the latter was habitually neglected. Ether in no instance caused 
sudden cardiac arrest; chloroform, three times, each time early in the in- 
halation and before surgical anesthesia had been induced. Chloroform 
proved to be more toxic than ether. Over-anesthesia rendered the ani- TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
387 
mals subject to early collapse and decidedly less capable of withstanding 
a protracted experiment. 
Hemorrhage.-Loss of blood always predisposes to shock. Respira- 
tions are always accelerated and deepened in profuse hemorrhage. 
Hemorrhage from the large venous trunks caused the most pro- 
found effect upon the blood pressure, because the quantity of blood 
supplied to the heart was immediately diminished, while if the 
hemorrhage was arterial the income of blood was not so suddenly 
diminished.1 
Dietetic Shock.-Chauvin and CEconomos 2 state that disturbances of 
metabolism are observed regardless of the anesthetic, or method of ad- 
ministration, whether local, spinal, or general. This "dietetic shock" is 
due to fasting immediately preliminary to and following anesthesia. This 
shock can be avoided by the use of glucose, 150 gm., tincture of cinna- 
mon, 6 gm., and tincture of nux vomica, 0.59 gm. and water to make 300 
gm., or some other easily digested carbohydrate diet. When this mixture 
was taken the day before and the three days following the operation, the 
urine showed no pathologic changes such as occurred when this regime 
was not followed. 
Anesthetic Shock.-In the preceding pages we have discussed shock 
from the surgical and theoretical points of view. We come now to the 
consideration of shock caused by the anesthetist,3 independently of the 
1 According to J. Am. Med. Assn., June 14, 1913, in post-partum hemorrhage 
the patient may survive a loss of about half of the total amount of the blood in 
the body. Whether or not this conclusion is applicable to other forms of acute 
loss of blood is not definitely determined, but it is probably not far out of the 
way. 
2 Chauvin, E., and CEconomos, S. N.: "Necessity for Avoiding Dietetic Shock 
in Operative Cases," Revue de Chir., Paris, Mar., 33, No. 3. 
3 Shock, hemorrhage, and the anesthetic are closely related, according to 
French: "In the testing work in anesthesia the writer has had foremost in 
mind the great need of reducing shock. It is generally conceded that the child 
is more susceptible to shock than the adult, due, in some way, no doubt, to the 
fact that the child is anatomically and physiologically different from the adult. 
The tests have, therefore, been applied especially to children in the controlling 
of hemorrhage and in the administration of anesthetics. We find no variance 
from the belief among surgeons who have given careful thought to their work 
upon infants and children, that the losing of blood is a matter of the greatest 
import to them and that all means should be used to prevent hemorrhage in 
operating upon them. And we are now convinced that shock from the loss of 
blood and from the anesthetic can be materially reduced by the manner of admin- 
istering the anesthetic. 
"According to the observations of the writer of this paper there is, irrespec- 
tive of all other conditions, a well defined and never failing relationship between 
the degree of skill in which a patient is anesthetized in the upright position and 
the amount of hemorrhage which occurs during the anesthesia, for there seems to 
be no question but that hemorrhage is reduced if the anesthetic, from the be- 
ginning, is smoothly administered, the second stage omitted, and the patient ANESTHESIA 
388 
surgical procedure The subject is partly covered in the discussion of the 
fourth stage, or the stage of overdose, of each of the inhalation anesthetic 
agents. Other factors, however, besides overdose, may enter into the 
production of anesthetic shock. These, together with the treatment of 
the condition, however it may be produced, are considered in the fol- 
lowing pages. 
Anesthetic shock may be produced in three ways: (1) By giving 
an overdose of the anesthetic; (2) by maintaining too light an anes- 
thesia; (3) by failing to keep an open airway. We will discuss these 
briefly, seriatim. 
Shock Caused by Giving an Overdose of the Anesthetic.-It 
has been stated that the liability of shock from an overdose of the anes- 
thetic varies with the subject, with the method of administration, with 
the agent employed, and with various other factors. The signs of over- 
dose have been given under each inhalation anesthetic, respectively, and 
need not be reiterated here. 
With nitrous oxid, if a slight degree of asphyxia, by delimiting the 
supply of air or oxygen, is maintained throughout a long operation, this, 
in itself, is apt to produce a state of shock. This is all the more apt to 
occur if a certain amount of shock has been caused through the manipu- 
lation of the surgeon, or through hemorrhage. This combination of 
circumstances may lead to complete shock, calling for the measures 
of resuscitation described under Surgical Shock, provided the im- 
mediate withdrawal of the anesthetic and the restoration of carbon 
dioxid balance, in accordance with the theory of Henderson, are 
not sufficient to restore respiration and circulation to a plane of 
safety. 
With ether the chief danger of shock from an overdose is caused by 
the maintenance of too deep an anesthesia during a long and difficult 
operation. Such a state of affairs always calls, primarily, for lightening 
the anesthesia. If this is not sufficient, other methods described else- 
where should be employed. 
With ethyl chlorid it is to be remembered that shock from overdose 
is especially liable to occur with a careless or inexperienced adminis- 
trator, for the reason that anesthesia is so rapidly induced that the 
brought into full surgical anesthesia without jarring or body disturbance of 
any kind. The uniform employment of helpful mental suggestion by every in- 
dividual in contact with the patient up to the time of the induction of anesthesia, 
to assist in preventing an excessive discharge of nervous energy through fear- 
which is one of the elements in the 'anoci-association' of Crile; the administra- 
tion of morphin to patients who display a marked degree of apprehension; an 
anesthetizing room free from an atmosphere of excitement and from unneces- 
sary noise; the preliminary use of nitrous oxid or the essence of orange." 
French, Thomas R.: ''Nitrous Oxid, Essence of Orange, Ether and Sequestra- 
tion in General Anesthesia." jV. Y. Med. J., May 24, 1913. TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
389 
border line between safety and danger may be quite easily passed. This 
is particularly true because of the fall in blood pressure which always 
accompanies anesthesia by this agent. In the presence of the signs of 
shock already stated, if immediate withdrawal of the anesthetic does 
not revive the patient, the more active measures must be quickly insti- 
tuted. 
With chloroform it is more dangerous to keep the patient under deep 
surgical anesthesia than with any other agent, except, perhaps, ethyl 
chlorid. The shallow respiration, weak, thready pulse, sudden and com- 
plete dilatation of the pupil, and extreme pallor of the face are the 
danger signals which, separately or combined, should put the anes- 
thetist on his guard. At times the anesthetic, in conjunction with 
the surgical procedure, brings about a condition of shock with start- 
ling suddenness. Withdrawal of the anesthetic may answer the pur- 
pose, but it is more than probable that more heroic measures will be 
necessary. 
Shock During Light Anesthesia.-This form of shock is espe- 
cially seen during laparotomies in which the patient has been too hastily 
or improperly anesthetized and the surgeon begins the operation before 
full surgical anesthesia is reached. 
We will suppose the patient just beyond the second stage, but not in 
full surgical anesthesia. In this condition, if the operation is a lapa- 
rotomy, every tug upon the viscera will increase the respiratory effort. 
If this hyperpnea is kept up during the entire period and the operation 
is a lengthy one, it will result in acapnia, and thus finally affect the circu- 
lation. 
If the patient is already in a reduced condition there is a possibility 
of this condition being a serious one. 
If the operation is upon an extremity, where no important vessels or 
nerves are involved, the chances for a dangerous degree of shock are ma- 
terially lessened. 
Shock from an Obstructed Airway.-The space between the ex- 
ternal respiratory orifices and the epiglottis has been very properly called 
by Meltzer the "death space," inasmuch as this part of the respiratory 
tract causes more trouble to the anesthetist than everything else com- 
bined. 
Shock may be caused from allowing a slight degree of cyanosis 
throughout a long operation, this being caused by allowing a more or 
less continuous interruption to the breathing. Shock is more often 
caused in this way than is commonly supposed. 
Obstruction by Closure of the Alee of the Nose.-In elderly people 
especially, or in very weak or nervous individuals, obstruction of the air 
passages by closure of the alae is not an unusual thing. It is easily pre- 
vented by placing rubber tubing of convenient size, about an inch and n 390 
ANESTHESIA 
half long, in each nostril, allowing the ends to project a quarter to half 
an inch outside. This condition may also be remedied by manipulating 
the lower jaw in such a way that the patient is compelled to breathe 
through the mouth instead of the nose. 
Shock from Labial Stertor.-A dangerous degree of shock from this 
source is not apt to occur because this form of stertor is so objectionably 
apparent to all present that it is usually quickly remedied if the open 
method is in use. It may cause serious trouble if the closed method is 
being used and the anesthetist is unable to observe the lips of the pa- 
tient. This condition is modified by pressing the jaw upward and at the 
same time slightly forward. Also by placing the end of a towel or a piece 
of gauze between the lips. 
Closure of the Glottis by the Tongue Dropping Back.-This is the 
most common form of stertor met with, and is fortunately remedied 
very easily. It is caused by the relaxation of the muscles supporting the 
tongue as the patient reaches the third stage of anesthesia. The tongue 
drops back, thus closing or partially closing the glottis. Tongue stertor 
may be caused in the beginning of the anesthesia by failure of the anes- 
thetist to remove the pillow, or anything that may be under the patient's 
head, or by allowing the head to remain in a straight line with the body, 
instead of having it turned either to the right or left side. There are a 
small number of patients who breathe better when the head is propped 
up and the chin pressed in, but these are the exceptions. The vast ma- 
jority of patients breathe much better in full surgical anesthesia with 
the head on the same horizontal plane with the body, and also turned 
slightly to one side. This does not apply to obese patients with a short 
neck. These patients' heads should be supported in such a way that no 
effort is thrown upon the neck muscles. 
Respirations.-If a patient's respirations are perceptibly increased or 
interfered with by a closed method, and it is impossible to maintain an 
even anesthesia in this way, a change to the open method should imme- 
diately be made. 
Many anesthetists use an artificial airway during surgical anesthesia. 
Ferguson's description of the original Hewitt's airway and his own fol- 
lows : 
"Hewitt's airway (Fig. 138) consists of a somewhat rigid rubber 
tube, C, curved so that, when it is in position in the patient's mouth, 
it will conform to the upper aspect of the base of the tongue. It has 
its laryngeal end beveled to correspond with the opening into the 
larynx. At the proximal end a metal funnel-shaped mouthpiece is 
attached, Figure 138 B. This has a deep groove so as to enable it 
to be clutched by the teeth in order to hold it in position. The 
tube is introduced into the pharynx and respiration takes place through 
it. TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
391 
"Ferguson's modification of Sir Frederick Hewitt's airway, Figure 
139, differs from its predecessor in having the proximal end of the 
funnel closed (Fig. 139, D) and two openings (one on each side of the 
truncated cone) for the ingress and egress of air, Figure 139, E. Thus 
there can be no danger of dropping ether into the top of the funnel, 
because it is not open, and since the orifices are in the sides which 
slope toward the lumen of the 
tube, and therefore away from 
the source of dropping, it is 
almost impossible to get any 
ether into the tube. Should 
the patient's cheek be resting 
on the table, any ether that 
might enter the upper fenestra 
would pass across the funnel 
and out of the lower fenestra, 
so that it is almost impossible 
for any liquid ether to enter 
the airway, no matter what 
the position of the patient 
may be. 
"Ferguson lengthened and 
otherwise changed the metal thimble (Fig. 138, F) so that it extends 
well into the rubber tube C without enlarging the middle of the tube 
(Fig. 139, G). Consequently a patient's teeth may clutch the rubber 
tube C anywhere between G and the groove near E (Fig. 139) and 
the inside metal tube will re- 
sist the pressure and the lu- 
men of the airway remain 
open. 
"This airway should be in- 
troduced after surgical anes- 
thesia has been reached. If 
the patient is not well under 
the anesthetic, the contact of 
the tube with the pharyngeal 
wall may incite gagging. To 
adjust the airway the jaws 
should be separated, the 
tongue brought gently for- 
ward, and the airway passed 
back into the pharynx with 
the convex portion of the curved rubber tube nearest the roof of the 
mouth. The instrument of itself will then assume a proper position. 
B 
0 
'A 
B 
F, 
c 
Fig. 138.-Hewitt's Artificial Airway. 
Fig. 139.-Ferguson's Modification of 
Hewitt's Artificial Airway. 392 
ANESTHESIA 
The pharyngeal tube is useful to do away with respiratory embarrass- 
ment due to any form of occlusion of the extrapharyngeal respiratory 
tract." 1 
Connell's Breathing Tube.-Connell's breathing tube (Fig. 140) is 
a flattened copper tube curved to fit the roof of the mouth, easy of in- 
troduction. It provides for the minimum displacement of oral struc- 
tures and abundant free gas channel from the outer world to the lower 
pharynx. This tube is used in ordinary anesthesia with any face mask. 
An attachment at the end of this tube permits the placing of a re- 
breathing bag fitted with a stopcock at the distal end. Rebreathing may 
be regulated by this stopcock. A rubber dam is placed on this pharyn- 
geal tube and so adjusted between the gums and lips as to make an air- 
tight joint. 
Fig. 140.-Connell's Breathing Tube. A flattened metallic tube curved to fit 
the palate and pharynx. Provides a free non-collapsible airway without dis- 
placement of oral structures. 
With the placing of any breathing tubes, or the maintenance of 
a free airway by other methods, the stertor due to the anesthetic is 
eliminated. 
Treatment of Anesthetic Shock.2-When the pulse disappears 
and the respirations become very shallow or cease, in the absence of 
cause for suspecting surgical shock, the anesthetist may know that he is 
to blame for the condition. He must be able to quickly judge the par- 
ticular error of technique which has brought about the state of shock, and 
to correct this error accordingly. If withdrawing the anesthetic, deepen- 
ing the narcosis, or restoring openness of airway fail to revive the pa- 
tient, certain other measures must be resorted to, according to the sever- 
ity of the shock. (1) A quick, vigorous slap on the chest; (2) imme- 
diate lowering of the head. If the subject is an infant, it should be 
suspended by the heels; (3) dilatation of the sphincter ani; (4) 
1 J. Am. Med. Assn., June 14, 1913. 
2 For Resuscitation by Electricity, see Chapter XVI. TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
393 
the application of hot or cold cloths to the face. If these simpler 
measures do not suffice, one must resort to (5) artificial respiration. 
This is accomplished by various methods, some of which are given 
below. 
Artificial Respiration by Manual Means.- (1) The anesthetist 
grasps the arms of the patient near the elbows, and presses them firmly 
against the sides, thus expelling any chloroform vapor that may be in 
the air passages. The arms should be held tightly against the patient's 
sides for at least fifteen seconds. (2) They should then be drawn laterally 
below the head and held in this position for ten or fifteen seconds. This 
procedure should be repeated fifteen times a minute. Massage of the 
precordial region by an assistant is most helpful, as is also intermittent 
dilatation of the sphincter. Hypodermics do little, if any, good at this 
time. It is the anesthetist's duty to see that an open airway is maintained 
during this procedure. The mouth gag should be inserted and the 
tongue forceps applied, and 
the tongue pulled well for- 
ward, if there is any occlu- 
sion of the air passages. 
Traction of the tongue 
sometimes stimulates the 
respiration. (3) If none 
of these efforts is successful 
and the patient is in a state 
of collapse, the following 
method of Lewis1 should 
be tried: 
Lewis ''Pendulum 
Swing."-"The patient 
should be suspended by the 
fully flexed knees and swung 
forcibly from side to side 
for a period of from one to 
two minutes. Suspension is 
best accomplished by the 
operator's forearms so 
grasping the patient's knees as to hold the anterior surface of both legs 
against operator's chest, allowing dependence of thighs, trunk, arms, and 
head of patient, facing away from operator. Except in children it is 
necessary for the operator to stand upon a dais, box, or chair of sufficient 
height to permit full pendulum swing of the patient from side to side 
without contact of patient's arms or head with the floor. Swinging 
should be done as vigorously as possible to secure by centrifugation a 
Fig. 141.-The Lewis Pendulum Swing. 
1 Lewis, Eugene Richards: In a private communication. 394 
ANESTHESIA 
forcible distention of heart and intracranial vessels. The suffusion of 
neck and face which is brought on by this swinging is the index by 
which to judge the effect of centrifugation. Notes on several cases 
follow. 
"September 1, 1899, male, 15 years, brought to Wilkes-Barre City 
Hospital with dislocation of right femur, 20 hours' standing. Physical 
examination negative; chloroform was administered; patient resisted con- 
siderably and suddenly ceased breathing. Usual measures and artificial 
respiration continuously for over ten minutes, during which time strych- 
nin and atropin were administered hypodermically, but failed to re- 
establish respiration. We then attempted to restore the patient by in- 
creasing the volume of blood in head, neck, and chest, using forcible 
centrifugation to accomplish this. Accordingly the patient was grasped 
by the knees, and was swung to and fro, sideways with all possible force, 
until there was manifest a deep suffusion upon neck and head. The 
patient was then placed upon the table, and was found to be breathing 
spontaneously. Chloroform was continued cautiously, and reduction of 
the dislocation was effected. 
"In July, 1901, at Wills Eye Hospital, Philadelphia, service of Dr. 
Radcliffe, case for squint operation. Chloroform was given, with early 
collapse and cessation of respiration. Slapping chest, cold douching, 
atropin, and strychnin hypodermically and artificial respiration all failed 
to restore breathing. After about four minutes, patient was swung as 
above described, until marked suffusion of face and neck occurred; spon- 
taneous respiration was reestablished. 
"Trinity Hospital, Milwaukee, service of H. V. Wurdemann, Jan- 
uary 28, 1902, Patterson, medical student, 22 years, for brossage of 
lids and canthoplasty. Physical examination negative. Chloroform 
anesthesia, collapse and cessation of respiration before beginning of 
operation. After three minutes of ineffectual attempts to revive the 
patient, he was swung vigorously till face and neck were well suffused, 
resulting in establishing spontaneous respiration. Operation was 
thereupon completed under chloroform anesthesia without further 
trouble. 
"In 1903 or 1904 chloroform was given in a case of tonsillect- 
omy. Collapse occurred and respiration ceased. Douching, slapping 
chest, stretching sphincter ani and artificial respiration for four 
or five minutes failed to revive patient. Swinging for about 45 sec- 
onds succeeded in establishing spontaneous respiration without further 
trouble. 
"March 29, 1911, Max L., 8 years, brought to Mercy Hospital from 
Wisconsin. Hypertrophic tonsils and adenoids. Physical examination 
negative. Chloroform was given, patient somewhat nervous, but resisted 
very little. Early in narcosis, before loss of all reflexes, patient's respira- TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
395 
tion suddenly became superficial and then stopped entirely. Very slight 
grade of cyanosis followed by a sudden marked pallor with radial and 
Fig. 142 a.-Artificial Respiration. First Movement. 
temporal pulse not palpable; widely dilated pupils. Artifical respira- 
tion with lowered head was ineffective. Dilating sphincter gave no re- 
Fig. 142 b.-Artificial Respiration. Second Movement. 
sponse whatever. Amyl nitrite was useless because patient's respiration 
had ceased. The patient was now grasped under flexed knees and swung 396 
ANESTHESIA 
from side to side with considerable force, much the same as one might 
swing an asphyxia livida at birth. A pale cyanosis soon appeared about 
the mouth; respiratory movements, at first shallow and irregular, could 
be made out, and soon spontaneous respiration was established. The 
force of the heart beats remained irregular for at least an hour, and a 
circumoral pallor was present for at least two hours. The operation was 
performed the following day, ether as anesthetic, with no return of symp- 
toms of day before. 
"April 19, 1911. Well-built girl of 24 years, weight about 150 
pounds. Chloroform as anesthetic. Did not struggle, but refused to 
breathe anesthetic quietly and regularly. Had reached a deeper stage 
of narcosis than preceding patient. Failure of respiration came on sud- 
denly, but pulse remained fair. Cyanosis became marked. Artificial 
respiration, camphorated oil, ammonia hypodermically, with stretching 
of sphincter ani failed. Resuscitation was now attempted by swinging the 
150-pound patient as above described. Since this was primarily and 
entirely respiratory failure, the reaction following suspension and swing- 
ing was all the more marked. The operation was sucessfully completed 
with ether, after resuscitation." 
Apparatus for the Induction of Artificial Respiration.-It cannot be 
too strongly emphasized that, no matter how efficient may be a given 
apparatus for the maintenance of artificial respiration, when the exi- 
gency arises no time must be lost while the apparatus is being put in 
place. It is necessary, therefore, to resort to one or more of the meas- 
ures for the induction of artificial respiration described in the foregoing 
pages, while the mask is being placed upon the face, or the tubes into 
the pharynx or trachea, as the case may be. Nor should such measures 
be discontinued until the apparatus is working-in other words, until air 
is being forced into the lungs. 
Draegers Pulmotor.-The Draeger pulmotor is being used with 
great success. It will not overdistend a small lung, and will fully dis- 
tend the adult lung. It works automatically, adapting itself to the ca- 
pacity of the 
lung. The dif- 
ferent parts, and 
the manner of 
application, are 
illustrated and 
explained in the 
a c c o mpanying 
figures. 
Preliminaries.- 
1. Remove the 
clothing from 
Fig. 143a. TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
397 
the upper part of the patient's body. In cases of 
drowning, lay the patient face downward, on a 
support that raises the abdomen, and apply pres- 
sure to the back so as to make the water rush out 
of the lungs and stomach. 
2. Free the mouth and throat from mucus, 
preferably by means of a cloth wrapped round 
the forefinger. 
3. The unconscious patient should be laid on his back, and the 
shoulders raised by means of a folded garment, leaving the head well 
thrown back. 
4. To enable the 
air to gain free ac- 
cess to the lungs, 
the tongue should 
be gripped with the 
forceps provided 
for that purpose, and then drawn forward as far as it will come, and 
held in that position. 
Placing the Pulmotor in Position.-5. The pul- 
motor mask must be buckled firmly to the head, 
leaving the tongue projecting between the lower 
jaw and the edge of the mask. The flexible tubes 
should rest on the forehead, not over the mouth. 
Take care that the mask fits airtight. This can be 
accomplished by bending the edge of the mask and 
tightening its tw'o straps. 
The lower jaw must not be forced back (down- 
ward). If necessary, it should be pushed forward, 
by means of the manipulation illustrated in Figure 143D, to such an 
extent that the teeth in the 
lower jaw project beyond those 
of the upper jaw, not forget- 
ting to keep the tongue firmly 
drawn out. 
6. The lever U of the ap- 
paratus should be moved into 
the position marked "Pul- 
motor," and the valve of the 
oxygen cylinder V opened. If 
the passage to the lungs is 
open, and the mask fits air- 
tight, respiration will com- 
mence. 
Fig. 143b. 
Fig. 143c. 
Fig. 143d. 
Fig. 143e. 398 
ANESTHESIA 
If this does not occur, and the apparatus is 
found to reverse too quickly, and to continue doing 
so, it is a sign that the passage to the lungs is not 
free. In such event, remove the mucus, draw the 
tongue further out and push the lower jaw for- 
ward. 
If the apparatus does not reverse at all, then the mask is not fitting 
tight. (See 5.) 
If necessary, the pulmotor can be made to pulsate (delivery and suc- 
tion strokes) by hand. (See 8.) 
The Pulmotor in Operatio n.-7. The air forced 
in and out of the body by • the pulmotor should pass only into 
Fig. 143f. 
Fig. 143g. 
the lungs, and not into the stomach. In order to insure this 
and to close the esophagus, the manipulation devised by Dr. Roth 
Fig. 143h. 
Fig. 143i. TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
399 
of Lubeck, consisting in the application of finger pressure to the Adam's 
apple of the throat, is practiced. Two fingers are gently pressed on the 
middle of the throat against the windpipe, which, being firm, closes the 
underlying esophagus, and thus completely prevents access to the 
stomach. 
Fig. 143j. 
8. If, from any cause, respiration should not go on automatically, 
the pulmotor may be reversed by hand, by moving the small lever H 
to and fro, the lever being firmly held all the time. 
The Lungmotor.-T h e 
lungmotor is a device operated 
by hand, with notched grada- 
tions for different ages, as 
shown in Fig. 144. It does not 
depend upon back pressure in 
the lungs, but exhausts the air 
upon expiration. The advan- 
tages claimed for it are that it 
requires less physical labor 
than manual methods, and de- 
livers a positive volume of air 
with each movement. It is 
available for persons of all 
ages and correspondingly vary- 
ing lung capacities. 
Meltzer s Devices for Arti- 
ficial Respiration.1 - Meltzer 
has evolved two methods for the induction of artificial respiration: (1) 
Pharyngeal tube; (2) mask, as in other devices. In either case the 
Fig. 144.-The Lungmotor. 
1 J. Am. Med. Assn., May 10, 1913, 1407. RT. 
R.V 
S.T. 
S.V. 
B 
Fig. 145.-Meltzer's Apparatus for Artificial Respiration with Pharyngeal 
Tube and Foot Bellows. P. T., pharyngeal tube; R. V., respiratory valve. The 
ring turns the valve; turning to the right (facing the pharyngeal tube) brings an in- 
spiration and to the left brings an expiration. B., foot-bellows; S. V., safety-valve. 
The bottle of the safety-valve should be shorter and have a wider diameter than the 
one in the figure; it is less likely to turn over. S. T., stomach-tube introduced through 
the opening in the pharyngeal tube. 
R.V. 
Jnfl.' 
s.v. 
OXYGEN 
Fig. 146.-Meltzer's Apparatus for Artificial Respiration with Mask Attached 
to Oxygen Tank. M., mask; Infl., tube for inflating the rubber ring around the 
rim of the mask; R. V., respiratory valve; S. V., safety-valve. An oxygen cylinder 
provides here the insufflation pressure. The figure shows also the weight on the abdo- 
men and the belt around it. TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
401 
apparatus is operated by means of foot bellows, compressed air or oxygen 
from a tank, or a motor. Figs. 145 and 146 illustrate clearly the 
mechanism and application of these devices. 
Meltzer demonstrated that the blood pressure is considerably raised 
by placing weights upon the abdomen, thus greatly increasing the proba- 
bility of a successful termination of the efforts at resuscitation. 
"The weight of the abdomen prevents the entrance of air in any con- 
siderable quantity into the stomach, and the little which gets there es- 
capes again when the insufflation is cut off; it never gets into the intes- 
Fig. 147.-Blood-Pressure Tracing from an Etherized Dog Which Received an 
Intravenous Injection of Sodium Nitrite. Blood-pressure low, 44 millimeters; 
pressure on the abdomen brings up the blood pressure to 70 millimeters mercury, and 
the pulse pressure is nearly doubled in size. 
tines. The pressure on the abdomen has still another significance. In 
patients with completely abolished respiration usually the blood pressure 
is also very low, and most of the blood may be accumulated in the ab- 
dominal viscera. The heart is then scantily filled, and not enough ar- 
terial blood is sent to peripheral organs. Under such circumstances a 
good pressure on the abdomen may raise the blood pressure by even as 
much as 30 millimeters of mercury; the heart is filled more efficiently, 
and sends more blood to the medulla oblongata, arousing there the activi- 
ties of the respiratory and vasomotor centers." 
Figure 147 shows the effect of abdominal pressure on the blood 
pressure. 
Theories Concerning the Cause of Shock.-The theories concerning 
the cause of shock, however produced, whether by the anesthetic or by 
the surgical procedure, have come to be accepted as falling under two 
heads: 
(1) Crile's theory of deoxygenation, or paralysis of the vasomotor 
centers, with a "manifest transference of the blood from the arteries 
into the veins." 
(2) Henderson's acapnia theory, or the hyperactivity of the vaso- 402 
ANESTHESIA 
motor centers through loss of carbon dioxid from the tissues and the cir- 
culating blood. 
Vasomotor Paralysis (Deoxygenation)-Crile.-The phe- 
nomena of shock, according to this theory, are due to the exhaustion of 
the vasomotor centers in the medulla and spinal cord, with the resultant 
loss of control of the pressure of the blood in the arterial system and 
the consequent collection of the blood in the great splanchnic reservoir 
in the abdomen. The fall in blood pressure which follows this loss of 
control is accompanied by a fall in the general body temperature; the 
respirations become weak from secondary exhaustion of the respiratory 
centers, the blood and tissues are not properly oxygenated, and the oxy- 
gen starvation described heretofore (see p. 97), if not checked, leads to 
loss of consciousness and eventual paralysis of all vital functions and 
death. 
This theory of shock is accepted by Mummery, Latham, and English, 
and a number of others. 
Prevention of Shock (Crile).-Prevent as far as possible the loss of 
blood. Atropin, hypodermically administered, was an efficient protec- 
tion against cardiac inhibition in operations in the "inhibition area" in 
the larynx, and in such operations as might cause mechanical stimula- 
tion of the vagi. Cocain, hypodermically injected, guards the heart 
against cardiac inhibition almost as efficiently as does atropin. "For 
morphin and alcohol, our observations were negative." Tearing, manip- 
ulating, stretching, forced dissection, all tend to produce shock, more 
than the use of sharp instruments and gentle manipulation. 
"Animals to which, while inducing anesthesia, an overdose had been 
given did not endure a prolonged experiment, and not only was it more 
difficult to maintain an even anesthesia afterward, but the animal also 
showed a marked tendency to recurring respiratory failures." 
So far as could be judged, less shock was produced when warm so- 
lutions were used than when cold; when the laboratory was warm, than 
when near the freezing point. 
Moist heat1 protecting the tissues lessened the amount of local irri- 
tation, and hence the shock. 
Posture.-Posture is of considerable importance. The blood pressure 
always rose when the head was tilted downward, and fell when the board 
was tilted in the opposite direction. 
Operations upon the extremities, if performed bloodlessly, and if the 
nerve trunks had been subjected to a cocain "block," produced no shock. 
Amputation of a leg caused no more effect than did cutting the hair. In 
rough axillary and chest dissections there was a marked tendency to 
respiratory failure. In abdominal procedure, if the omentum was made 
1 See Chapter on General Physiology (Warming the Anesthetic; The Utili- 
zation of Moisture). TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
403 
to cover the viscera, thereby preventing direct contact with them, there 
was very much less shock. Handling the omentum did not produce 
vasomotor and respiratory disturbance. Dragging in the mesentery was 
followed by a decline in blood pressure. In operations upon the gall- 
bladder and liver it was necessary to be cautious as to traction on account 
of the great fluctuation in blood pressure likely to be caused by mechani- 
cal interference with the larger venous trunks. The most dangerous area 
is in the region of the duodenum, pylorus, and gall-bladder. The least 
dangerous area is the pelvic peritoneum and its viscera. The uterus, 
tubes, and ovaries contribute but little to shock, even when they are se- 
verely crushed and torn. The severity of shock induced in abdominal 
operations is in direct ratio to the distance from the pelvis. Injuries of 
the large intestines produce much less depression of the blood pressure 
than those of the small intestines; injuries of the stomach about the same 
as the small intestines. 
Intravenous infusion of normal saline solution causes all the blood 
pressures to rise. Quantities up to twice the amount of blood calculated 
to be in the animal have been given before the pressure was sustained. 
The value of these injections is apparently wholly mechanical. The 
combination of small and frequently repeated hypodermic injections of 
strychnin, together with saline infusion, produces a sustained effect. 
Overstimulation was followed later by a greater depression. The appli- 
cation of heat was of benefit. 
Treatment of Shock in Accordance with the Vasomotor Paralysis or 
Deoxygenation Theory.-Naturally, if one accepts the theory of shock 
proposed by Crile, the treatment must be carried out accordingly. Crile 
recommends the use of strychnin sulphate and artificial respiration; in 
other words, an increase in the supply of oxygen. 
Latham and English 1 advocate the following measures: "The prin- 
cipal factor in treating shock is to maintain an efficient circulation until 
such time as the vasomotor centers have recovered, and at the same time 
to secure rest to the brain during that period. The use of stimulants is 
therefore contraindicated, especially strychnin. Inject morphin and 
raise the foot of the bed three feet so as to place the abdomen on a higher 
level than the head and thorax (chairs are better than blocks for this 
purpose), this position to be maintained until all symptoms of shock 
have worn off. Bandaging the abdomen tightly assists in raising the 
blood pressure. This bandage must not embarrass the movements of the 
chest; for the same reason heavy bedclothes must be supported on a 
cradle. Bandaging the extremities is also useful in some cases. 
"Increasing the total quantity of fluid in the circulation by infusion 
of normal saline tends to raise the blood pressure, and aids in recovery 
of vasomotor centers. Adrenin in suitable quantities added to the 
1 Latham and Crisp English: "A System of Treatment,'' 93. 404 
ANESTHESIA 
saline materially assists. Adrenin, they hold, acts directly upon the 
peripheral arteries, and causes a great increase in the blood pressure 
without acting upon the nerve centers. Its action is transitory, and it 
must be put directly into the vein. It should only be added to solutions 
which are introduced directly into the veins. It is useless to add to 
solutions which are introduced per rectum or subcutaneously. Rectal 
infusion is useful in cases of slight or early shock (or to prevent shock), 
as is also subcutaneous infusion." 
Intravenous Infusion in Serious Cases of Shock.-Infusion, to be 
effective, must be carried out continuously until the patient is well on the 
way to recovery and is out of danger. 
Transfusion of human blood is far more effective than any form of 
saline infusion. 
Pituitary Extract.-This is similar in action to adrenin, although 
as used at present the drug is not so powerful. It has the advantage 
over adrenin that its effects last from a half hour to one hour. It must 
also be injected into a vein. It can be administered in fairly large 
doses with safety, but subsequent doses have less effect than the original 
dose. 
Keen 1 recommends the following measures: " (1) The prevention of 
further shock; (2) the support of the circulation; (3) the securing of 
physiologic rest." 
Support of the Circulation.-Head-down posture increases blood in 
brain, heart, and lungs. Extremities and abdomen may be bandaged. 
Use heavy layers of cotton and broad flannel bandages. Crile's pneu- 
matic rubber suit is the best, as the pressure is under control, and the 
air placed in the suit may be warmed and the pressure increased or 
diminished without disturbing the patient. The blood pressure may be 
raised in this way from 15 to 40 mm. mercury. Saline infusions may be 
given. 
Physiologic rest is the most important consideration in the treatment 
of shock. "When the motor activity takes the form of obvious work per- 
formed, such as running, the depletion of the vital force, expressed by 
various phenomena, is termed physical exhaustion. When the expendi- 
ture of the vital force is due to stimuli which lead to no obvious work 
performed, especially if the stimuli are strong and the expenditure of 
energy rapid, it is designated as shock." 
Under nitrous oxid anesthesia the physiologic changes and the brain 
cell changes, following an equal trauma, were approximately one-third 
those following ether. 
Traumatized animals whose blood pressures were maintained by di- 
rect transfusion of blood, thereby eliminating the factor of anemia, still 
showed physical changes in their brain cells; animals similarly anes- 
1 Loc. cit. TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
405 
thetized and transfused, but not traumatized, showed no change. 
"Shock is an overstimulation of the whole motor mechanism." 
Anoci-association.-"If the patient be kept free from any emotional 
excitations by special management and by narcotics, or be not permit- 
ted to know that the operation is to be performed at a special time, 
and if such patient be anesthetized in such a manner that no adap- 
TEMPERATURE 
PULSE 
Fig. 148.-Chile's Abdominal Hysterectomy Chart. Temperature: each heavy line 
represents the average 5:00 P. M. temperature of ten patients during the first four 
days after operation. Pulse: each heavy line represents the average 5:00 P. M. pulse 
rate of ten patients during the first four days after operation. 
tive response is excited by such an anesthetic as the pleasant nitrous 
oxid, and if the field of operation be so completely blocked by local anes- 
thesia that no traumatic impulse reaches the brain, and if in closing 
the wound another local anesthetic is employed that will block nerve im- 
pulses for, say, twenty-four hours, thus preventing the after-pains, such a 
patient will then have been operated upon in such a manner that the 
motor mechanism has received no adequate stimulus." Hence there is no 
surgical shock, nor interference with digestion, nor nervous impairment 
afterward, i. e., no change in the circulation, the respiration, the digestive 
functions, nor the mentality of the patient. 
"Although ether anesthesia produces unconsciousness it apparently 
protects none of the brain cells against exhaustion from the trauma of 
surgical operations." 
Under nitrous oxid anesthesia there is approximately only one- 
fourth as much exhaustion, after equal trauma, as under ether. "Either 
nitrous oxid protects or ether predisposes to exhaustion under trauma." 
Causes and Prevention of Post-operative Gas Pains.-"The 
patient is anesthetized as usual, but the entire line of incisions is care- 406 
ANESTHESIA 
fully blocked with novocain, including the peritoneum. If then, at the 
end of the operation and before the peritoneum is closed, there is applied 
TEMPERATURE 
PULSE 
Fig. 149.-Chile's Thyroidectomy Chart. Temperature: each heavy line represents 
the average 5:00 P. M. temperature of ten patients during the first four days after 
operation. Pulse: each heavy line represents the average 5:00 P. M. pulse rate of ten 
patients during the first four days after operation. 
around the entire line of stitches a complete anesthetic block that will 
last a number of days (as 50 per cent alcohol or quinin and urea hydro- 
chlorid), and if in stitching the peritoneum every stitch is placed within 
this blocked zone, then the afferent impulses caused by stitch irritation 
are blocked, and hence cannot excite the protective mechanism of intes- 
Fig. 150.-Chile's Chart of Mortality Rate per Thousand of Operative Cases 
from Lakeside Hospital. The last thousand were under anoci. 
tinal inhibition. It has been found that such blocking does minimize or 
even prevent post-operative gas pains in all sorts of abdominal opera- 
tions." 
Vasomotor Hyperactivity (Acapnia)-Henderson.-The chief 
opponent of the vasomotor paralysis or deoxygenation theory of shock 
is Yandell Henderson, the originator of the theory that shock is due to 
the hyperactivity of the vasomotor centers, as a consequence of the loss, TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
407 
for some reason, of carbon dioxid, and the effort on the part of the organ- 
ism to compensate for this loss. 
We cannot, perhaps, better explain Henderson's theory than by quot- 
ing from one of his papers 1 an illustrative case: 
"A man in the prime of life was setting off fireworks when a giant 
Fig. 151.-Operations Under Anoci-association. A. Appendectomy. B. Herniot- 
omy. C. Hysterectomy. D. Cholecystotomy. (Crile.) 
A. 
B. 
C. 
D. 
firecracker exploded in his hand and shattered it. There was no con- 
siderable loss of blood. For two hours he suffered intensely, although 
he received a quarter of a grain of morphin. Then anesthesia with 
ether was attempted, and his breathing immediately began to fail. The 
anesthetic was withdrawn, and respiration improved. Three hours after 
the accident he stopped breathing quite suddenly. Artificial respiration 
and stimulants were ineffective, and he died. Yet his pulse was fairly 
A. 
B. 
C. 
Fig. 152.-Technique of Abdominal Operation Under Anoci-association. A. Infil- 
tration of skin and subcutaneous tissue with 1-400 novocain. B. Infiltration of fascia 
and muscle. C. Infiltration of posterior sheath and peritoneum. D. Peritoneum 
inverted; infiltration with % per cent, of quinin and urea hydrochlorid. (Crile.) 
good before and even for some minutes after respiration ceased. Why 
did that man die? In order to make the further discussion of my topic 
clear, I will present immediately the explanation to which, as it seems 
to me, all the data point. During the period after the accident his 
breathing was of the type which insupportable pain always excites. This 
hyperpnea involved a far greater ventilation of the lungs than normal 
breathing affords. Consequently the CO2 content of the blood, and 
finally also of the body as a whole, was greatly diminished. When the 
1 Henderson, Yandell: "Fatal Apnea and the Shock Problem," Johns Hop- 
kins Hosp. Bull., Aug., 1910, 21, No. 233. 408 
ANESTHESIA 
anesthesia was attempted it was almost inevitable that respiration should 
show signs of failure. CO2 is the normal stimulant of respiration; there- 
fore, after this normal chemical stimulant to breathing had been re- 
duced, pain alone maintained the breathing. Anesthesia removed the 
pain. Finally breathing stopped for the very simple reason that there 
was not enough C02 left in the blood to excite the respiratory center to 
activity. To this condition of diminished CO2 content in the blood 
Mosso has given the name "acapnia," from the Greek "kapnos," smoke. 
Literally, acapnia means smokelessness. Perhaps I should remind you 
that the arterial blood normally contains 20 volumes per cent of oxygen, 
and 40 of CO2, and that the body as a whole has an enormously greater 
store of C02 than of oxygen." 
Henderson instituted a long series of experiments which are now 
too well known to need repetition here. His observations led him to the 
conclusion that the condition of low arterial pressure, noted in shock, 
is not due to fatigue or inhibition or failure of any sort in the vaso- 
motor center. On the contrary, in his opinion, this center does its full 
duty almost to the last. The failure of circulation appears, in his ex- 
perience, to be due to diminution in the volume of the blood by transu- 
dation of its fluids out of the vessels into the tissues, a process resem- 
bling edema. "It is a complex peripheral process," he says, "induced 
initially by the influence of acapnia upon the veins and capillaries and 
upon the tissues. Thus when death (or shock) follows intense physical 
suffering, not complicated by hemorrhage, there are two principal stages. 
At first the excessive breathing diminishes the CO2 content of the blood. 
If, at any time after this condition of acapnia has been induced, the pain 
is greatly diminished, and the respiratory center is thus allowed to re- 
lapse into standstill, fatal apnea vera may occur. If, on the other hand, 
the pain is sufficiently continuous to keep the respiratory center con- 
tinually excited, then apnea is prevented, and the condition of acapnia 
becomes more and more acute and general until the circulation fails, 
and the subject sinks into surgical shock." Both fatal apnea and the 
more slowly developing failure of circulation, he holds, are due ini- 
tially to acapnia induced by the excessive breathing occurring under 
torture.' 
He does not agree to the importance of the role ascribed by others to 
oxygen in maintenance of the function of the respiratory center. On the 
contrary, he considers that Mischer expressed the essential truth regard- 
ing the regulation of normal breathing: "Over the oxygen supply of the 
blood CO2 spreads its protecting wings." 
Henderson considers that death from respiratory failure is explained 
as due to these "protecting wings." 
"Those cases of fatal apnea," according to Henderson, "which more 
than any other interest the clinician, are, I suppose, the failures of TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
409 
respiration under anesthesia. If the patient ceases to breathe in his 
bed, it is his own fault, but if he does so on the operating table the 
anesthetist has to bear the responsibility. For such cases of apnea 
the acapnia hypothesis affords a simple explanation. Anesthesia di- 
minishes the strength of inflowing afferent irritations. Furthermore 
profound anesthesia raises the threshold of the respiratory center for 
C02. In other words, the respiratory center of a man or animal in pro- 
found anesthesia automatically maintains more than the normal CO2 
content in the blood. Thus, when a man or a woman or a child has suf- 
fered prolonged pain, and thereby has been brought into a condition of 
more or less acapnia, the production of anesthesia by removing the affer- 
ent pain stimuli, and also by raising the threshold, that is, by dimin- 
ishing the sensitiveness, of the respiratory center for C02, inevitably 
leads to apnea." 
Prevention of Acapnia.-The prevention of acapnia for the 
prevention of excessive pulmonary ventilation. According to Hender- 
son, the administration of morphin and full anesthesia diminishes the 
activity of respiration under pain, and thus prevents acapnia. If, how- 
ever, morphin and chloroform be administered to an animal which has 
suffered pain for some time, apnea is hastened unless carbon dioxid is 
also administered. 
In moderate degrees of shock, induced by irritation of afferent 
nerves or by exposure of the viscera, Henderson has found it possible 
to induce rapid recovery by the infusion into a vein of normal saline or 
Ringer's solution saturated with carbon dioxid, and then making the sub- 
ject breathe an atmosphere of oxygen and carbon dioxid or oxygen alone. 
In profound shock he has found that these measures fail to effect an 
ultimate recovery. 
Treatment.-Henderson outlines two methods of treating acapneal 
respiration under anesthesia. One method involves the intratracheal 
insufflation of a gentle stream of oxygen gas, according to the method 
devised by Volhard. For man the quantity of oxygen should be not less 
than 400 c. c. per minute. 
The other method of restoration of breathing to which Henderson 
refers has been found by him to be remarkably successful in restoring 
dogs during apnea. It consists in the administration of air or oxygen 
containing 5 or 6 per cent of carbon dioxid, the breathing being started 
by one or two artificial respirations. As soon as the normal tension of 
carbon dioxid in the lungs is restored, spontaneous breathing imme- 
diately recommences and continues as long as the inspired air contains 
a sufficient quantity of carbon dioxid to stimulate the respiratory center. 
McKeson for the past five years has used an apparatus for measuring 
the blood pressure in connection with all anesthetics, for the special pur- 
pose of anticipating shock. His remarks follow: 410 
ANESTHESIA 
THE INTERPRETATION OF PULSE, RESPIRATION, AND BLOOD 
PRESSURES WITH SPECIAL REFERENCE TO 
SURGICAL SHOCK 
"What is the purpose of taking blood pressures during opera- 
tions ? 
" 'Feeling the pulse' has proved to be an unreliable method in de- 
termining the pressure values of the pulse. And, if the anesthetist is 
to be acquainted with the condition of his patient, he must be able to 
determine quite accurately these pressures for comparison as the opera- 
tion proceeds. To anticipate shock and to apply remedial measures be- 
fore the process has become well advanced requires an earlier recogni- 
tion than is possible without the sphygmomanometer. 
"Before shock (excluding shock from hemorrhage) becomes so well 
established that it may be positively diagnosed clinically, the patient 
passes through certain circulatory disturbances which are indicative of 
the condition to follow as certainly as certain weather conditions fore- 
cast rain. 
"What are the important factors in making this interpretation ? 
"Let us first state briefly a few facts concerning the physiology in- 
volved in the maintenance of blood pressure. The heart is the pump; 
the great arteries are more or less elastic and admit more blood from 
the heart by distention; the arterioles are the 'shut-off' valves control- 
ling peripheral resistance and determining the volume of blood to pass 
through a certain group of capillaries; the capillaries and veins act in 
this connection as return tubes to the heart and lungs, which return the 
blood through the pressure of various muscles, gravity, and suction by 
the heart and lungs. 
"The pressure in the arteries before systole represents the conditions 
of resistance and elasticity of the vessels. Other things being equal, an 
increase in the diastolic pressure means more resistance; a decrease, less 
resistance in the arterioles. At the next ventricular contraction the heart 
must produce enough pressure to equal the diastolic pressure before the 
valves will open; from this point the remaining portion of the contrac- 
tion will produce the discharge of blood into the aorta, and is called 
pulse pressure-the discharge power of the heart. 
"The pulse pressure is the working pressure in moving the blood, 
and concerns the heart only. So that it represents the most important 
single guide to the power of the heart. 
"The systolic pressure represents the pressure developed during sys- 
tole, and is the sum of the diastolic and pulse pressures. It is evident 
that the systolic pressure will be more variable than the diastolic, for it 
must accommodate itself to variations in the heart rate and pulse pres- TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
411 
sures, and is therefore not as valuable a sign as was formerly supposed 
in determining oncoming shock. 
"The heart must maintain a certain pressure in the aorta that its 
own tissues may be properly bathed in blood through the coronaries. 
This may be accomplished in falling pressures by increasing the output 
of the heart and, to some extent, by increased peripheral resistance, 
although, clinically, after arterioles once dilate, the heart must usually 
compensate by increasing its output, as they seldom regain their tone 
during operation. 
"Respiration aids the heart in producing blood pressure in the hu- 
Fig. 153.-Blood Pressure Apparatus as Used by McKeson. 
man subject. Intrapulmonary pressure is increased during exhalation, 
aiding the heart to force the blood out of the chest. This force under 
anesthesia normally increases the blood pressure from 5 to 10 mm. of 
mercury above the reading obtained during inhalation. During inhala- 
tion the blood is drawn out of the great veins leading into the thorax, 
so readily seen during extensive neck or breast operations; at the same 
time the capillary resistance,in the lungs is greatly reduced, so the right 
heart can more easily force a large volume of blood over to the left side. 
And when exhalation begins again the lungs squeeze out the excess blood 
into the left heart, increase intrapulmonary pressure, and again blood 
pressure is elevated. 
"It should be remembered that with the abdomen open the diaphragm 
cannot increase intra-abdominal pressure, and the return of blood from 
the abdomen at the time of chest aspiration (inhalation) will not be as 
perfect as usual, which may be an important element in venous stasis 
here. 412 
ANESTHESIA 
"A respiratory rate of more than 30 per minute is too rapid to assist 
in moving the blood, throwing the whole burden on the heart. Also, a 
constant intrapulmonary pressure interferes with venous supply to the 
heart. 
"An obstructed airway of any considerable degree, on the other hand, 
increases the respiratory variation of blood pressure, but if the respira- 
tions are too long and powerful it has the same effect as a continued 
positive pressure-interfering with the venous return and increasing 
the danger of a dilated right heart. 
RECOVERY OF CONSCIOUSNESS--MINUTES 5 
POST OPERATIVE VOMITIRQ WW 
REMARKS 
OXYGEN REBREATHINQ NITROUS OXIDE 
RE8P. PULSE AN0 BLOOD PRESSURE 
Percent 
FIRST HQUB 
SECOND HOUR 
Fig. 154.-McKesoh's Blood Pressure Chart No. 3908. 
"In order to clarify our previous statements and to apply them to a 
concrete case, let us examine a copy of our chart No. 3908; a woman 
aged 64, weight 120, in good physical condition, was operated on for ob- 
struction of the colon with adhesions, and the appendix was removed. 
An H. M. C. tablet containing 1/6 grain morphin was given hypodermi- 
cally about 1 hour before. The anesthetic was N2O and O2 without novo- 
cain infiltration in the line of the incision. Just before anesthetization, 
the (S) systolic pressure was 135, the (D) diastolic pressure 90, making 
a pulse pressure of 45, pulse 82, respiration 20. 
"During the first 15 minutes of the anesthesia nothing happened ex- 
cept a very slight increase in respiration frequency. During the latter 
portion of this time abdominal manipulations and traction on the intes- 
tines was followed by a slight fall at (A) in the pulse rate, a 25 mm. 
fall of systolic, and a 10 mm. fall of the diastolic pressures. In the be- 
ginning we had a pulse pressure of 45 mm., which was probably nearly 
normal for this patient, while at the end of 25 minutes it was 35 mm. 
What had happened? 
"When the intestines were exposed, handled, and dragged up, and 
rough gauze pads introduced into the belly to pack certain loops away TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
413 
from the desired field, the arterioles relaxed and the diastolic pressure 
fell. With an easier outlet for the blood and a comparatively slow pulse, 
the pulse pressure weakened slightly and the systolic fell markedly. 
"This is not shock, but if it should continue as started it would re- 
sult in shock in about 30 minutes or when the pulse pressure is but 10 
to 15 mm. and the diastolic is 70 mm. or less. There was no reason for 
apprehension in this case, for, between (B) and (C), when less trauma 
was inflicted while doing the appendectomy, there was a compensatory 
increase of the heart rate, bringing the pressures to their former posi- 
tions. Of course, this cost the heart 25 beats more each minute, but the 
reserve power in a heart not already complicated with disease is usually 
sufficient to keep up a rapid rate for several hours, provided that pres- 
sure is maintained. It shows here that the arterioles are still open, and 
even in the last 10 minutes, when more 0 is used in the mixture, as 
the pulse falls the diastolic falls; but 10 minutes after the anesthesia 
and operation are completed the pulse, respiration, and blood pressure re- 
lations are practically reestablished as before the anesthesia was begun. 
"So it is possible by an intelligent interpretation of the pulse, respira- 
tion, and blood pressure to anticipate the occurrence of surgical shock 
at least 20 minutes and usually much longer. 
"Anesthetic overdosage, however, must not be confused with surgical 
shock, although many of the signs are similar in the relative overdosage 
cases, and the respiration and heart may be brought to a standstill in a 
very few minutes." 
Post-Anesthetic Toxemia 
The second of the major difficulties which may arise as a conse- 
quence of the administration of an inhalation anesthetic is post-anes- 
thetic toxemia. Acetonuria, acetonemia, acidosis, acid intoxication are 
terms applied to delayed chloroform poisoning, concerning which a 
voluminous literature has been compiled within recent years. Ether 
also is now believed to give rise to acid intoxication. 
It is the opinion of some observers, the senior author among this 
number, that so-called post-anesthetic toxemia exists only in cases in 
which there is already a tendency to acidosis, or in which this condi- 
tion is precipitated by careless technique on the part of the anesthetist. 
In every case the presence of acetonuria or other acid conditions 
should be ascertained beforehand, and treatment instituted to correct the 
trouble as nearly as is possible before the anesthetic is administered. 
Elimination, by bowels, kidneys, and skin, should be stimulated for sev- 
eral days previous to the anesthesia, and the tendency to hyperacidity 
should be counteracted by the administration of suitable alkaline medica- 
tion. An important part of this preparation is careful attention to the 
diet. ANESTHESIA 
414 
Four or five days before the operation the patient should be given 
sodium bicarbonate, fifteen grains daily, until the urine is alkaline in 
reaction. Meats should be restricted or excluded, and the patient placed 
upon a strictly vegetable diet for this length of time. Two hours before 
the operation a saline enema, one pint or more, with one ounce of olive 
oil and one ounce of glucose, should be given. One hour before the 
operation small amounts of morphin should be administered, according 
to the patient's condition. (See Preliminary Medication, p. 70.) If 
chloroform is used at all, it should be used only in the beginning of the 
anesthesia, and a change should be made to ether at the second stage. 
The rule of Mortimer 1 in connection with these cases is a good one: 
"Never give chloroform alone except for rare and special reasons." Small 
amounts of chloroform may be used until the second stage is reached; 
this excludes the element of fear, and is a desirable procedure if the 
psychic element is very much in evidence. This method is preferable 
to inducing the anesthetic with ether, which might give rise to very great 
fright and necessitate holding the patient. 
Beven and Favill2 collected over twenty-nine scattered cases, seem- 
ingly identical, in regard to acid intoxication and late poisoning effects 
from chloroform and ether anesthetics. The first case reported is so 
typical of the poisonous after-effects of chloroform that all the facts in 
connection with it are worthy of being recorded. 
An unusually long time and a large amount of the anesthetic were 
required to establish surgical narcosis. The time of narcosis and opera- 
tion is not stated, but the patient was thoroughly conscious a short while 
afterward with a pulse of 102 and a temperature of 101°. About two 
days later the first symptoms of poisoning were marked, the mother of 
the child noticing that she was not quite natural in her remarks. The 
physicians were called, and found the child talking incoherently and 
exhibiting evidences of great fright. This mental condition appeared 
without warning, as all symptoms had pointed to an uneventful recov- 
ery up to this time (44 hours after the operation). There was a rising 
pulse, with unremitting delirium and a curious shrieking outcry. The 
delirium was partly controlled by small amounts of morphin. At regu- 
lar intervals a period of excitement-practically a convulsion-would 
occur, lasting for one minute or perhaps longer. Death occurred 110 
hours after the operation, with a gradually rising temperature, irregu- 
lar and rapid pulse. Cheyne-Stokes respiration was present. During the 
last two days before the child's death a sweetish, acetone odor was noted 
on her breath. 
Other Cases.-Several clinicians have noted symptoms appearing 
from two to six days after chloroform narcosis. Violent and persistent 
1 Mortimer: 1 ' Anesthesia and Analgesia, ' ' 65. 
2 Bevan, Arthur D., and Favill, Henry B.: J. Am. Med. Assn., Sept. 2, 1905. TREATMENT BEFORE, DURING, AND AFTER ANESTHESIA 
415 
vomiting, icterus, sometimes piercing shrieks, profuse sweating, and a 
picture of terror on the face seemed to be the clinical symptoms, also 
air hunger, as evidenced by deep breathing and cyanosis. Fatty changes 
have been noted in liver, heart, or kidneys, or all of these organs, on 
autopsy; acute yellow atrophy, fatty denegeration, or fatty infiltration 
of the liver have also been noted. Death usually occurs from exhaus- 
tion, the patient sinking into a state of coma from the third to fifth day. 
The urine contains albumin in all cases, and is usually scanty. Probyn- 
Williams1 states that, while deaths have followed the inhalation of 
chloroform more frequently than any other anesthetic, cases have been 
reported with both ether and ethyl chlorid. Brewer 2 reports a case fol- 
lowing an operation for acute appendicitis. 
When death occurs from acidosis,3 it seems to be due to lack of oxy- 
gen, as there is struggling for breath and cyanosis. The symptoms are 
vomiting, sweetish odor of breath, face flushed, lips dry, weak, rapid 
pulse, restlessness, unconsciousness. In children the acetone is given 
off through the lungs. In adults it is excreted by the kidneys. Pathol- 
ogy of acidosis is fatty degeneration of liver, kidneys, and muscles. Con- 
ditions under which acidosis may occur: Diabetes, carcinoma, digestive 
disturbances, starvation, gastric ulcer, excessive fat ingestion, infec- 
tious fevers, chronic morphinism, fatty liver, starvation (lack of carbo- 
hydrates), and following ether or chloroform anesthesia, in 120 cases 
etherized by the "cone method," acetonemia developed in 88.5 per cent. 
Of the same number with the drop method only 26 per cent showed 
acetonuria. 
xProbyn-Williams: "A Practical Guide to the Administration of Anesthet- 
ics," 166. 
2 Brewer: Ann. of Surg. (1902), 36, 48: , 
3 Hamblen: Univ, of Penn. Med. Bull., June, 1909. CHAPTER X 
ANESTHESIA BY INTRATRACHEAL INSUFFLATION 
Charles A. Elsberg, M.D. 
Definition. 
History. 
The Apparatus for Intratracheal Anesthesia in the Human 
Being: Apparatus No. I; Apparatus No. II; The Catheter or Tube 
to Be Used; The Introduction of the Tube. 
The Course of the Anesthesia. 
Errors Which May Occur in Technique: Accidents and How 
They May Be Avoided. 
The Indications for Intratracheal Anesthesia. 
The Value of Insufflation of Pure Air or Air and Oxygen 
as a Method of Artificial Respiration. 
Bibliography. 
Definition.-Intratracheal insufflation is the name given by Meltzer 
and Auer to a method by means of which a mixture of air and ether 
is driven deep into the trachea by means of external pressure through a 
tube which has been introduced into the trachea through the larynx. 
History.-Physiological Basis.-Animal Experiments.-In 1909 
Meltzer and Auer 1 first published an account of their experiments, which 
culminated in the method of anesthesia to which they gave the name 
"intratracheal insufflation." Physiologists had long known that animals 
could be kept alive by blowing air into the lungs, but this method had 
never been satisfactorily applied to the human being. Fell, O'Dwyer, 
Kuhn, Volhard, and others attempted to apply methods of this kind to 
man. Hirsh, Robinson, and others showed that the blood could be well 
oxygenated by passing a stream of oxygen intermittently through a tube 
to the bifurcation of the trachea. 
It is well known that breathing is kept up by alternating respiratory 
movements and that the proper ventilation of the lungs depends upon 
the normal activity of the muscles of respiration and the intact condi- 
tion of the walls of the thorax. Meltzer and Auer discovered that the 
proper exchange of the air in the lungs can be accomplished by an 
1 Meltzer and Auer: J. Exper. Med., 1909, 11, 622. 
416 ANESTHESIA BY INTRATRACHEAL INSUFFLATION 
417 
almost continuous stream of air passing in one direction. They found 
that if they passed a tube through the larynx of a dog almost to the 
bifurcation, and blew air through this tube in a continuous stream, the 
animal could be kept alive for many hours, even after all voluntary 
respiratory movement had been abolished by curare. By allowing the 
stream of air to pass over the surface of ether in a bottle, they found that 
animals could be very satisfactorily anesthetized. In these animals it 
was possible to open both pleural cavities widely and to have the animals 
remain alive for many hours. 
The apparatus used by Meltzer and Auer 1 was a very simple one. 
Fig. 155.-Meltzer's Simple Apparatus for Intratracheal Insufflation. B, foot- 
bellows; S. T, stopcocks; E, ether bottle with S. C, stopcock and F, funnel; M, 
manometer; S. V, mercury safety valve; IN-T, intratracheal tube. 
It consisted of a foot bellows connected by tubes with a bottle containing 
ether and with a mercury manometer. The tubes were so arranged that 
more or less of the air from the bellows passed over the surface of the 
ether, and thus became more or less saturated with ether vapor. The 
air and ether mixture was blown in at a pressure of 15 to 20 mm. of 
mercury. The only condition essential to success was that the tube be of 
a size less than one-half of the diameter of the trachea, so that the air 
and ether which passed up the trachea and out through the larynx and 
mouth in a continuous stream had free escape. Later it was found of 
advantage to interrupt the stream three to six times a minute, so as to 
allow the lungs to partially collapse for a moment at times, and thus 
to get rid of small quantities of carbon dioxid which are apt to remain 
in the pulmonary alveoli. 
With this simple apparatus, Meltzer and Auer 2 made many investi- 
1 Meltzer and Auer: J. Exper. Med., 1909, 11, 622. 
2 Med. Rec., 1910, 77, 487. 418 
ANESTHESIA 
gations upon animals, and they recommended the method as an emi- 
nently safe one for anesthesia. They pointed out that it might have 
great value for intrathoracic operations, and that it was an ideal method 
for artificial respiration. Elsberg 1 made a large number of experiments 
on animals, and performed numerous operations upon the lungs of dogs, 
and Carrel2 used the method with great satisfaction in his operative 
work upon the heart and thoracic blood vessels of dogs. In all of these 
experiments one or both pleural cavities were widely opened, the heart 
action remained good and regular, superficial respiratory movements per- 
sisted. In other words, the method of intratracheal insufflation was effec- 
tive in preventing collapse of the lungs when the thorax was opened. 
Later, Nordman,3 Schlesinger,4 Boothby and Ehrenfried,5 Fischer,6 and 
others investigated upon animals the value and advantages of the method 
from the standpoint of the anesthesia and with regard to its efficiency 
in the presence of a single or double pneumothorax. The reports of all 
these authors have been uniformly in favor of the method. 
From an extensive and thorough experimental investigation of anes- 
thesia by intratracheal insufflation of air and ether, Meltzer 7 concludes 
as follows: "The essentials of the method of intratracheal insufflation 
consist8 in the introduction deep into the trachea of a flexible elastic 
tube, the diameter of which has to be much smaller than the lumen of 
the trachea, and 9 the driving through this tube of a nearly continuous 
stream of air which returns through the space between the tube and the 
walls of the trachea. The distinguishing features of this method consist 
in the following two new principles: 1. By bringing the pure air di- 
rectly to the larger bronchi, and by driving out the vitiated air from 
these bronchi through the force of the returning air stream, that part 
of the Meath space' is eliminated which is represented by the mouth, 
pharynx, larynx, and trachea. The chief aim of the complicated nervous 
and muscular mechanisms of respiration is to establish an efficient venti- 
lation, capable of overcoming the obstacles offered by the mentioned 
Meath space.' A well-arranged intratracheal insufflation is fully capable 
of relieving and replacing the normal respiratory mechanism. 2. The 
practically continuous recurrent air stream prevents the invasion of in- 
different or infectious foreign matter from the pharynx into the trachea. 
1 Elsberg: Med. Sec., 1910, 77, 493. 
2Carrel: Med. Bee., 1910, 77, 491; J. Am. Med. Assn., 1910, 54, 28. 
"Nordman: Archiv f. Idin. Chir., 1910, 92. 
"Schlesinger: Archiv f. Idin. Chir., 1911, 95. 
'Ehrenfried: Boston Med. and Surg. J., 164, 532. 
"Fischer: Surg. Gyn. and Obstet., 1911, 13, 566. 
'Meltzer: J. Am. Med. Assn., Aug. 12, 1911. 
"Meltzer and Auer: J. Exper. Med., 1909, 11, 622. 
9 Meltzer: J. Am. Med. Assn., Aug. 12, 1911. ANESTHESIA BY INTRATRACHEAL INSUFFLATION 
419 
"The usefulness of the method is at least threefold. 1. It is capable 
of keeping up an efficient respiration in cases in which the normal mech- 
anism of external respiration fails. 2. It overcomes efficiently and con- 
veniently the difficulties pre- 
sented by double pneumothorax. 
3. It offers a safe and reliable 
method for anesthesia, especial- 
ly for the administration of 
ether." 
Meltzer and Auer and the 
investigators who took up their 
work thus demonstrated that in 
animals the method of intra- 
tracheal insufflation is very effi- 
cient both for anesthesia in gen- 
eral and for thoracic operations 
in particular. Its first applica- 
tions in the human being were 
made by Elsberg,1 who was soon 
followed by other surgeons in 
the United States and else- 
where. 
The Apparatus for Intra- 
tracheal Anesthesia in the Hu- 
man Being.-A very simple ap- 
paratus constructed upon the 
plan of the one used in the lab- 
oratory can easily be put to- 
gether by anyone. Such an ap- 
paratus would suffice in an 
emergency. The construction 
and working of the one sug- 
gested by Meltzer can be easily 
understood from the diagram 
(see Fig. 155). For general use 
in the human being, a more 
complete apparatus is necessary, one that cannot get out of order, and 
which is surrounded by every possible safeguard in case of trouble with 
any of its parts. 
The essentials for such an apparatus are: (1) A source of air (elec- 
tric blower, foot bellows, hand pump); (2) a system of tubes connected 
with an ether reservoir and a mercury manometer; (3) a regulator or 
automatic blow-off that should prevent too great pressure in the tubes; 
Fig. 156.-Elsberg's Apparatus, for Hos- 
pital Use. 
1 Elsberg: Am. Surg., Feb., 1911; June, 1911; Dec., 1911. 420 
ANESTHESIA 
(4) a warm water tank, by means of which the air stream can be 
warmed and moistened. 
For hospital use, it is advisable to have an apparatus which works 
automatically, and to reserve the foot bellows as an addition which can 
be used if the motor and blower are out of order, or if there is no elec- 
tric current. Elsberg devised two 
forms of apparatus, viz.: (1) an ap- 
paratus meant for hospital use; (2) 
a smaller and more easily portable ap- 
paratus. A description of these fol- 
lows. 
Apparatus No. 1 (see Figs. 156 
and 157).-The entire apparatus is 
contained in a wooden box 381/2 
inches long, 11 inches deep, and 18 
inches wide. It is easily transport- 
able. The box is placed on the floor 
near the head end of the operating 
table, and the front is turned down1 
in order to expose the interior, 
which contains the following (Fig. 
157). By means of the switch A and 
the rheostat B the electric current is 
carried to the 1/6 horsepower motor 
C, which drives the blower D. The 
air passes through the tube E and the 
oil filter F and the tube G into the 
bottle H. This bottle contains hot 
water, so that the air, as it bubbles 
through the water, is warmed, washed, 
and moistened. The current of air 
then passes through the tube I to the 
rubber tube, which is connected to the intratracheal catheter. To this 
tube, No. 1, is connected the ether reservoir J. 
The ether reservoir consists of a glass jar, which is held air-tight 
against its cover by a spring clamp below. The cover contains the open- 
ings of two tubes (X, X'), which are connected with the main tube I. 
The hand wheel K, which moves an indicator on a scale above it, is ar- 
ranged to control the air passing through the tube I. When the indi- 
cator stands at zero at the scale, pure air is passing through the tube I. 
As the indicator is turned, more and more of the air is diverted into the 
one tube (X), which leads into the ether reservoir. When full ether is 
turned on, all of the air has to pass into the ether reservoir and over the 
Fig. 157.-Diagram to Explain the 
Parts of Elsberg's Apparatus 
No. 1. The letters refer to the 
letters in the text. 
1 The box is now arranged so that the front can be entirely removed. ANESTHESIA BY INTRATRACHEAL INSUFFLATION 
421 
surface of the ether, so that it becomes saturated with ether vapor. 
When the indicator shows that pure air is passing through the tube I, 
the tubes which lead into the ether reservoir are closed, and the ether 
reservoir can be removed if necessary and refilled. 
The manometer L is connected with the tube I, and records the 
pressure of the air current which is flowing through it. The ends of the 
Fig. 158.-Elsberg's Simplified Portable Apparatus for Intratracheal Insuffla- 
tion. To show the motor and blower. 
manometer tube have hard rubber stopcocks, which can be closed when 
the apparatus is to be transported-a possible spilling of the mercury in 
the manometer being thus prevented. 
The tube M leads into the main tube G and has also a stopcock, and 
to its tip the tube from an oxygen tank can be connected so that oxygen 
can be added to the air if desired. The tube P leads to a foot bellows, 
which has been added to the apparatus as a safety device if anything 
should happen to the motor or blower, or to be used where no electric 
current is available. When the stopcock N is closed and 0 is opened, 
and the foot bellows used, the air passes into the tube G' and into the 
water bottle. When the stopcock N is open and 0 is closed, no air can 422 
ANESTHESIA 
enter the main tube from the bellows, and air passes to the water bottle 
from the blower. It takes only a moment to turn the two stopcocks 
so that one can instantly switch from air from the blower to air from the 
foot bellows and vice versa. 
The water bottle II is held firmly in place by a clamp. The tubes 
from it are connected to the main tube by bayonet points, so that the 
Fig. 159.-Jackson's Speculum in Position for the Introduction of the Endo- 
tracheal Catheter. Note the position of the patient's hoad. 
bottle can be easily removed when it is to be filled or emptied. The per- 
forated cork is held firmly and air-tight by a clamp. 
The apparatus and its handling are simple. When it is to be used, 
the water bottle is first one-third filled with hot water, the stopcocks 
on the manometer opened, the stopcock N opened and 0 closed, the 
switch turned on, the rheostat turned on full, and the motor and blower 
thus set in motion. The stopcock M is left wide open. As soon as the 
apparatus has been connected with the intratracheal tube the stopcock 
M is slowly turned until the manometer shows that the pressure of the 
air is 20 mm. 
The percentage of ether is regulated according to the depth of the 
anesthesia; usually the indicator has to be turned until it show's that half 
or full ether is being used. 
By means of the stopcock at I (below the manometer), the air and ANESTHESIA BY INTRATRACHEAL INSUFFLATION 
423 
ether current can be diverted from the intratracheal tube so that no air 
enters the intratracheal tube, but all of it escapes through the open stop- 
cock. 
The management of this apparatus is extremely easy. From the mo- 
ment the power is turned on and the pressure regulated, the anes- 
thetist's principal duties consist in watching the pressure gauge and 
occasionally interrupting the current of air so as to momentarily collapse 
the lungs. He can be seated near the table so as to observe the pulse of 
the patient. 
Apparatus No. 2.-This apparatus is much smaller than No. 1. It 
can be easily carried around like a handbag. It is 21 inches high, 20 
inches broad, and 9y2 inches wide (Figs. 158 and 159). The apparatus 
is similar to No. 1, but is much lighter and much more compact. The 
motor and blower are underneath in a closed compartment. At A the 
foot bellow's, which lies in a compartment above, is to be attached. B is 
the stopcock for regulating the pressure, C is a simple lever by which the 
anesthetizer can switch from air from blower to air from bellows. The 
tube D leads into the metal water tank in the inside of the box. E is 
the ether reservoir held by the eccentric below. Above this is the ether 
regulator. F is the manometer, G the safety valve allowing regulation of 
pressure. H is the stopcock for making interruptions of the current.1 
The apparatus of Janeway is very complete, but very complicated 
(Figs. 160A and B). The following description will serve to explain the 
various parts of the machine. No. 1 is a motor which turns the wing 
blower 2. From the blower the air passes through the air filter and 
muffler 3. By the valve 4 the current of air may be divided into two 
reciprocally varying quantities; one portion passes directly over the 
heated water (heated by electricity) in jar 5, while the other portion 
passes through jar 5, after first passing over the surface of ether in jar 6. 
Thus the whole current of air or any desired proportion may be mixed 
with ether, and in this manner varying quantities of ether supplied to 
the patient. Provision is also afforded for still further saturating the air 
with ether by valve 7, which is so arranged that a small quantity of the 
air passing through jar 6 may be made to bubble through only the 
top layers of the ether irrespective of the level of the ether in the jar. 
The blow-off valve 8 prevents any injurious excess of pressure, and valve 
9, operated by worm wheel 10, mechanically interrupts the current of 
air passing to the patient at any desired intervals. 
In Fischer's apparatus (Fig. 161) the air pressure is obtained by 
means of a hand pump. Fischer published a complete description of his 
apparatus,2 but a study of Figure 161 will allow the reader to gain a fair 
idea of it. 
1A full description of this apparatus will be found in the Ann. Surg., 1912. 
2 Surg. Gynec. and Obstet., Nov., 1911. Fig. 160a. 
Fig. 160b. 
Fig. 160a and b.-Janeway's Apparatus. ANESTHESIA BY INTRATRACHEAL INSUFFLATION 
425 
Ehrenfried's apparatus (Fig. 162) has the merits of simplicity, but, 
like Fischer's apparatus, has no safety device by means of which the 
method can be continued if any part of the main apparatus is broken 
or out of order. 
The Catheter or Tube to Be Used.-The tube which is to be in- 
troduced into the trachea must be fairly rigid, so that it cannot be 
coughed out of the trachea when it is once in place. A soft rubber tube 
should never be used. Not only is the introduction of a soft rubber tube 
more difficult, but it is not rigid enough, as it might be compressed if a 
spasm of the larynx should occur. The ordinary silk-woven urethral 
catheter with a side opening near its end fulfills all requirements. It has 
Fig. 161.-Fischer's Apparatus. The handle of the hand pump is not shown in the 
photograph. 
the additional advantage that it can be obtained everywhere. The cathe- 
ter should have two marks upon it-one 13 centimeters and a second 26 
centimeters from the tip. The average length of the adult trachea is 12 
to 13 centimeters; of the thyroid cartilage, 5 centimeters; of the distance 
from the incisor teeth to the glottis, 14 centimeters. Therefore, if the 
tip of the intratracheal tube is 26 to 27 centimeters from the incisor 
teeth, it will lie about 5 centimeters or less above the bifurcation of the 
trachea. 
The size of the catheter must, of course, vary with the diameter of 
the trachea and the size of the larynx. For the adult, it is advisable to 
use a tube of the size 24 of the French scale. The diameter of this size 
of tube corresponds to about one-half of the length of the glottis, as seen 
through the direct laryngoscope. Sometimes a somewhat larger cathe- 
ter must be used, but it is always better to use a tube that is too small 
than one that is too large. 
In children the catheter must be correspondingly smaller. The 426 
ANESTHESIA 
length of the catheter in the trachea will vary with the size of the child, 
but it has been found that in general the length of the catheter that 
should be below the glottis measures about the same as the length of 
the tube from the glottis to the incisor teeth. In other words, if the 
Fig. 162.-Ehrenfried's Apparatus for Intratracheal Etherization. (Driven by 
foot pump which is not shown in the photograph.) It consists essentially of a copper 
hot-water jacket, holding a Wolffe bottle containing ether. There are cocks by which 
the air from the bellows may be sent in any proportion through a coil in the hot water, 
over the surface of the ether, or made to bubble through ether. Attached to the 
outside of the jacket is a mercury bottle safety-valve. On the delivery tube is a con- 
trivance to filter the air and to prevent droplets of condensed ether from being car- 
ried over into the lungs. 
catheter has been introduced as far as the glottis, it will have to be 
pushed again as far downward as to have the tip in the proper part of 
the trachea. 
The Introduction of the Tube.-In many patients it is possible to 
Fig. 163.-Cotton-Boothby Introducing Cannula, Ehrenfried's Modification, 
for Soft-Rubber Tubes. 
introduce the catheter after the epiglottis has been pulled forward by 
means of the index finger, which acts also as a guide. In children the 
intubation is always easy by this means. In many adults the epiglottis ANESTHESIA BY INTRATRACHEAL INSUFFLATION 
427 
cannot be reached by the finger; in these patients the intubation is im- 
possible by touch alone, and a special instrument must be used. Vari- 
ous guides with a laryngeal curve and variously shaped laryngeal forceps 
have been tried. None of these has been uniformly satisfactory, but 
Boothby and Cotton recommend their introducer (see Fig. 163), and 
Ehrenfried has one of his own (Fig. 164). I have found that the tube 
can always be quickly and easily introduced when the larynx is in plain 
view, which can be easily accomplished by means of the Jackson direct 
laryngoscope (see Figs. 92 and 165). With a very little practice, one 
can learn to use this instrument and obtain an admirable view of the 
glottis, so that the catheter can be readily introduced between the vocal 
cords. Anyone who is to use the method of intratracheal anesthesia 
Fig. 164.-Ehrenfried's Introducing Forceps for Stiff or Soft-Rubber Tubes. 
should practice the method of the exposure of the larynx with the Jack- 
son instrument. 
If the larynx is well cocainized it is possible to introduce the cathe- 
ter and anesthetize the patient by means of intratracheal insufflation of 
the anesthetic. The introduction of the tube is unpleasant, however, and 
the beginning of the insufflation may cause the patient much discomfort 
because of the reflexes at the bifurcation of the trachea. In the cases 
where a preliminary anesthesia by inhalation is inadvisable (where there 
is danger of collapse of the trachea, etc.), the best plan to follow is to 
introduce the catheter after the larynx has been well cocainized; then 
to anesthetize the patient by means of ether given through a mask or 
cone held over the end of the catheter and the mouth. 
In general, it is best to give the patient a dose of morphin and 
atropin and then to anesthetize him in the usual manner with ether. 
When the patient is well under anesthesia, he is brought into the operat- 
ing room and placed upon the operating table, with the head hanging well 
downward over the end of the table and the mouth held open with an or- 
dinary mouth gag.1 The direct laryngoscope is then introduced and 
1 Preliminary cocainization of the larynx is unnecessary. 428 
ANESTHESIA 
pushed along the posterior wall of the pharynx until the epiglottis is in 
plain view. The epiglottis is pulled well forward by the beak of the 
instrument and the glottis well exposed. One usually obtains a fine 
view of the larynx, can clearly see the opening between the cords, and can 
B 
A 
c 
Fig. 165.-Jackson's Direct Laryngoscope. (See p. 226.) 
estimate its size and length. If there is any difficulty in exposing the 
vocal cords, the head and neck are pulled forward as a whole, the head 
being kept bent backward as before. A catheter whose outside diameter 
measures about one-half of the length of the glottis (in general No. 
Fig. 166.-Elsberg's Clip to Hold the Intratracheal Tube in Place. The rubber 
covered arms B B' lie between the teeth and hold the tube between them. The wires 
W W' fit over the ears like the wires of spectacles. 
24 F can be used) is then selected. This is introduced through the laryn- 
goscope and into and through the larynx. The tube is then pushed for- 
ward until the second mark on it shows that the tip is 3 to 5 centimeters 
above the bifurcation of the trachea. Air will now be heard rushing 
in and out through the catheter. The patient is very apt at this time to ANESTHESIA BY INTRATRACHEAL INSUFFLATION 
429 
have an attack of spasmodic coughing and to hold his breath. This need 
not cause concern, as respiration will soon begin again. One must be 
sure that the tube is in the trachea and not in the esophagus. If one is 
in doubt, the catheter must be withdrawn and reinserted. One soon 
learns, however, to recognize the sound of the air rushing in and out 
through the tube. 
The tube is now held in place and the laryngoscope withdrawn, the 
entire manipidations thus far having occupied only a minute or two. 
The patient is then pulled back upon the operating table. 
A small clip serves to hold the catheter in place (see Fig. 166). It 
consists of a clip bent at right angles, the branches covered by rubber 
tubing. This fits between the teeth so that the patient cannot bite the 
catheter, which is held firmly in place. The clip is held in position by 
elastic wires, which fit over the ears like a pair of spectacles. After the 
clip is in place the mouth gag is removed, the catheter is connected with 
the connecting tip of the tube which leads from the insufflation appa- 
ratus, and from which the mixture of air and ether is flowing, and the 
insufflation is begun. 
The Course of the Anesthesia.-Ether is the safest anesthetic to use 
for intratracheal insufflation. The dosage of chloroform has not yet 
been sufficiently well worked out. Nitrous oxid and air or oxygen can 
also be given by insufflation. The ether anesthesia is usually very sat- 
isfactory. The patients are quiet, their musculature is relaxed, they 
breathe quietly and superficially. Some respiratory movements should 
always persist, and the anesthetizer should never keep the pressure, 
as shown by the manometer, so high that active breathing ceases alto- 
gether. 
If the catheter that has been introduced into the trachea is of cor- 
rect size and in the proper position, the face of the anesthetized patient 
will be of a pink, rosy color, with the veins of the forehead slightly prom- 
inent. The pulse is full, bounding, and regular. If the patient is cya- 
nosed, it means that the tube is not deep enough in the trachea or that 
too large a tube has been used. 
When the insufflation is begun, the patient may have a short attack 
of spasmodic coughing. This need cause no concern, and the insuffla- 
tion can be continued. The cough will sometimes persist if the end of 
the intratracheal tube is too near the bifurcation; it must then be with- 
drawn one or two centimeters. 
There is a complete absence of mucus rattling in the throat during 
the entire period of the insufflation. 
It is advisable to insufflate pure air for a few minutes at the end of 
the anesthesia in order to blow out the anesthetic from the lungs and 
trachea. Then the patients will awaken very quickly; they will often 
answer questions before the dressings have been applied. When the in- 430 
ANESTHESIA 
tratracheal tube is withdrawn, there is often a short period of apnea, 
then regular deep breathing again begins. 
Cough and expectoration do not occur after anesthesia by intra- 
tracheal insufflation unless the patient had a pulmonary lesion before 
the operation, or an operation was performed upon the lungs. No pul- 
monary complications, of even the mildest kind, have been observed in 
more than 500 anesthesias. As soon as the patients are awake, they 
speak freely, are not hoarse, and do not complain of pain or. discomfort 
in the throat. The larynx and trachea have a remarkable tolerance for 
the tube, which can remain in place for hours without danger. 
Post-operative vomiting is certainly quite unusual after intratracheal 
insufflation. This is probably due to the fact that no ether vapor can 
be swallowed. 
The patients seem to be less apt to show symptoms of shock than 
those anesthetized for long operations by ether inhalation. They are 
never too deeply under the anesthetic; in no instance has dilatation of 
the pupils as an evidence of too deep an anesthesia been observed. 
Occasionally, with patients upon whom an abdominal operation is 
to be performed, complete relaxation of the abdominal muscles is not 
obtained. These patients will also be found to be refractory to ether 
anesthesia by inhalation. 
Errors Which May Occur in Technique.-When the technique of 
intratracheal insufflation is once learned and the apparatus used by the 
anesthetizer is understood, errors or accidents should never occur. Spe- 
cial attention must be paid to the following features of the method. 
The catheter that is used should be too small rather than too large, 
so that there is never an interference with the free escape of the air and 
ether by the side of the tube and out through the larynx and mouth. If 
the proper size of intratracheal tube is used, there should be no danger 
of the overdistention of the lungs. The Elsberg apparatus is arranged 
so that no excess of pressure in the lungs can occur. Every apparatus 
should have an automatic safety valve or blow-off, to act as a safeguard 
against a temporary or prolonged over-pressure, which might be injuri- 
ous to the lung tissue. 
Accidents, and How They May Be Avoided.-The accidents that 
have occurred so far have been due to errors in technique. In the case of 
Fischer,1 one of the tubes which led into the ether reservoir was under 
the surface of the ether, and, by turning the wrong stopcock, pure ether 
was blown into the lungs. The tubes which lead into the ether bottle 
should never be below the surface of the ether; in fact it is only neces- 
sary that they reach into the cover of the ether reservoir. 
In three other cases, two of which resulted fatally, the pressure was 
too high, so that injury to the lung tissue and emphysema in the sub- 
iLoc. cit. ANESTHESIA BY INTRATRACHEAL INSUFFLATION 
431 
cutaneous tissue resulted. This could not have occurred if the appa- 
ratus had been provided with a safety valve for the prevention of excess 
of pressure. In one of the cases an intratracheal soft rubber tube 
was pushed down until it completely filled one of the branches of 
a bronchus, allowing no air to escape. With a proper apparatus and 
the proper technique, all these accidents could have been avoided. In 
Mt. Sinai Hospital almost 500 patients have been anesthetized without 
accident. 
Another advantage of the method of intubation, in which the vocal 
cords are brought into view, is that the catheter can be introduced when 
the glottis is open, no force being necessary in pushing it dowm into the 
trachea. 
It need hardly be mentioned that one must be sure that the tube is 
in the trachea and not in the esophagus, otherwise overdistention of the 
stomach could easily occur. It is probable, however, that in such a case 
the air would be regurgitated as fast as it entered the stomach. 
The anesthetizer should never give an anesthetic by insufflation un- 
less he thoroughly understands the working of the apparatus he is using, 
nor should he forget to interrupt the entering stream of air and ether 
2 to 4 times a minute. 
To sum up particular points to w'hich attention must be paid, the 
anesthetizer must be certain: (1) That the catheter is in the trachea; 
(2) that it is not too far down-too near to or beyond the bifurcation; 
(3) that there is a safety valve on his apparatus; (4) that the interrup- 
tions in the air stream are made; (5) that respiratory movements per- 
sist. 
The Indications for Intratracheal Anesthesia.-Anesthesia by intra- 
tracheal insufflation is of value: 
(1) In thoracic surgery (whenever the thoracic cavity has to be in- 
vaded, to prevent the collapse of the lungs). 
(2) In operations upon the head and neck, where the anesthetizer 
can be out of the way or where the giving of the anesthetic is ordinarily 
difficult, as in bilateral suboccipital craniotomy or laminectomy, where 
the patient has to lie flat on the abdomen. 
(3) It is almost indispensable in those operations in the mouth where 
the pharynx and larynx must be kept free of fluid or blood. The stream 
of air and ether which is continually escaping from the larynx and 
mouth blows out any blood that might run down the throat, so that the 
operator need have no fear of any passing into the trachea. In such 
operations as complete removal of the tongue, removal of the upper or 
lower jaw, excision of malignant disease of the tonsil, the intranasal or 
intrabuccal approach to the hypophysis, etc., packing the pharynx is 
unnecessary. These operations are made much easier when the patient 
is anesthetized by the intratracheal method. The tube is kept in one cor- 432 
ANESTHESIA 
ner of the mouth, and is never in the way of the operator. In the opera- 
tion of laryngectomy, intratracheal anesthesia is advisable. 
(4) Operations around the trachea, especially removal of the thy- 
roid gland, can be made much easier when the patient is anesthetized by 
intratracheal insufflation. The interference with the smoothness of the 
anesthesia when the trachea is pressed or pulled upon is avoided, and 
there is no danger of collapse of the trachea. 
(5) In operations in which there is danger of vomiting and aspira- 
tion of vomited material. Thus in operations for intestinal obstruction 
done under intratracheal anesthesia, the danger of the patients "drown- 
ing" in their own vomitus is avoided. 
(6) In prolonged operations, and with cachectic individuals. Shock 
seems particularly rare in patients anesthetized by this method. 
The future may show that intratracheal anesthesia will have a still 
larger field of usefulness than that here outlined. 
The Value of Insufflation of Pure Air or Air and Oxygen as a Method 
of Artificial Respiration.-This is a feature upon which too little stress 
has thus far been laid. Whenever there is need for prolonged artificial 
respiration, such as in opium poisoning, drowning, etc., the method will 
surely be very useful. In several instances we have kept patients alive 
in good condition for three, four, six, or seven hours although during 
that time not a single respiratory movement was made. The color of 
the patient remained pink, and the blood was well aerated. It is a 
valuable characteristic of this method that the patients need not breathe 
in order to have oxygenation of the blood occur, the apparatus doing 
the breathing for them. In this respect the method differs from all 
others for this purpose. It may be added that it has the same advantage 
over both the positive and negative pressure methods for thoracic surgery. 
In the latter the respiratory movements of the patient are absolutely 
necessary, aeration of the blood being impossible without them. With 
intratracheal insufflation oxygenation of the blood will occur just as well 
whether or not the patient makes respiratory movements. 
A large number of apparatus are now on the market, and many 
surgeons have devised intratracheal anesthesia machines for their own 
use. Perhaps the best known apparatus is that of Connell (1) in which 
the rate of ether vapor used can be exactly regulated and in which the 
interruptions to the flow of the air and ether mixture are made auto- 
matically. Equally good and serviceable apparatus have been described 
by Adson and Little (2), Mueller, Williams (3), Pratt (4), and others. CHAPTER XI 
ANESTHESIA BY COLONIC ABSORPTION OF ETHER AND OIL- 
ETHER COLONIC ANESTHESIA 
PART I 
ANESTHESIA BY COLONIC ABSORPTION OF ETHER 
Walter S. Sutton, A.B., A.M., M.D., F.A.C.S.1 
History. 
Development of the Method. 
Technique of Method: Preparation of the Patient; The Admin- 
istration ; After-treatment. 
Discussion of Cases. 
Conclusions: Indications; Contra-indications; Advantages; Dis- 
advantage. 
History.-The high efficiency of the intestinal mucous membrane of 
vertebrates in general as a transmitter of gases to and from the blood 
stream has long been recognized. As early as 1808 Erman 2 opened the 
abdomen of cobitus fossilis, and observed that when air was swallowed 
the liver and the intestinal veins of the fish became bright red; while 
when hydrogen or nitrogen was substituted the color of the organs 
changed to dark purple. Baumert,3 in 1855 analyzed the gas passed 
per rectum by the same kind of fish, and found a marked decrease in the 
oxygen content and corresponding increase in nitrogen when swallowing 
of air had been prevented for several hours. Jobert,4 in 1877, discov- 
ered that in callichihys asper, a Brazilian fish, air-swallowing is essential 
to life, the fish dying in about two hours if prevented from the exercise 
of this form of accessory respiration. In mammals, also, similar 
phenomena have long been known. Thus, Paul Bert,5 in 1870, found 
that if the trachea of a kitten be clamped the animal will die of asphyxia 
1 Deceased. The history and much of the physiology of colonic anesthesia was 
originally formulated by Dr. Sutton, upon whose work the author's experience, 
in great measure, has been based and developed. 
'Erman: Ann. d. Phys, und Chem., 1808, 30, 113. 
3 Baumert: ' ' Chemische Untersuchungen u. d. Respiration d. Schlemmpeit- 
gers, " Breslau, 1885, 24. 
* Jobert: Ann. d. Soc. Nat., 1877, 5, No. 8. 
"Bert: Physiol, compt. de la respir., Paris, 1870, 173. 
433 434 
ANESTHESIA 
in about thirteen minutes, but, if the intestine be inflated with air, life 
may be prolonged for twenty-one minutes. A similar absorption of 
oxygen by the intestinal circulation in man is indicated by the results of 
Tappeiner,1 who, in 1886, by analysis of gases from various portions of 
the alimentary canal of an executed criminal, found 9.19 per cent of 
oxygen in the stomach, only a trace in the ileum, and none in the colon 
and rectum, whereas the percentage of carbon dioxid showed a regular 
increase from stomach to colon. 
Recognizing this activity of the intestinal mucosa, the early experi- 
menters with ether as an anesthetic attempted its administration by this 
route. The method is first mentioned in Pirogoff's 2 work on etheriza- 
tion, published in 1847. The original idea of Pirogoff was the introduc- 
tion of liquid ether into the rectum. Being warned by Magendie that 
this could not be done with impunity, he devised the method of vaporiz- 
ing the ether by means of heat and administering the drug in this form. 
He reported 81 cases with two deaths, but unfortunately failed to give a 
detailed report of the latter. In the same year, Roux,3 y'Yhedo,4 and 
Duprey 5 employed injections of liquid ether, pure or in aqueous mix- 
ture, with the result of producing complete anesthesia. Pirogoff, in par- 
ticular, wrote enthusiastically of the advantage of the rectal method, 
even expressing the belief that it might supplant the inhalation pro- 
cedure. The method, however, disappeared from current literature, not 
to reappear until 1884. In this year Molliere 6 revived interest in the 
subject, introducing a new technique, in which he employed a Richardson 
hand bellows for forcing the ether vapor into the intestine. This method 
he later abandoned in favor of the earlier process of placing the ether 
container in a water bath (for which he recommended a temperature 
of 120° F.) and employing the pressure incident to the generation of 
vapor to force the latter into the gut. 
Before the close of the year 1884, Yversen, Hunter, Bull,7 Weir,8 
Wancher,9 and Post10 had recorded their experience with the method 
Among the cases reported by these observers a number showed more or 
less marked diarrhea and melena, and one death was directly traceable 
to the procedure. 
1Tappeiner: Arbeit en a. d. path. Institut zu Miinchen, 1886. 
2Pirogoff: "Reeherches pratiques et physiologiques sur 1'etherization, " St. 
Petersburg, 1847. 
3 Roux: J. d. I'Academic d. sciences, 1847, 18. 
4Y'Yhedo: Gazette med. d. Paris, 1847. 
"Duprey: Academie royale de medecine, March 16, 1847. 
"Molliere: Lyon medical, 45, 1884. 
7 Bull: N. Y. Med. J., March 3, 1884. 
8 Weir: Med. Bee., 1884. 
* Wancher: Cong, internal, d. sciences med., 1884. 
"Post: Boston Med. and Burg. J., 1884. ANESTHESIA BY COLONIC ABSORPTION OF ETHER 
435 
Development of Method.-The method again fell into disuse, not 
to be revived until 1903, when Cunningham added to the technique of 
administration a new feature in the employment of air as a vehicle for 
carrying the ether vapor into the intestine. The first publication of 
Cunningham (written jointly with Leahy1) appeared in 1905, being 
preceded by articles by Dumont2 and Krugeline, the latter reporting 43 
cases without untoward symptoms. 
Stimulated by the records of improved results following the use of 
the Cunningham technique, many surgeons and anesthetists hastened to 
give the method a new trial, with the result that the subject has now 
acquired a considerable literature. 
In 1910, Sutton published the results of a series of about 140 per- 
sonally conducted cases, together with a description of the apparatus 
developed in the course of the work and the technique used in the 
application of the method at Roosevelt Hospital. 
About the same time, J. H. Cunningham, Jr.,3 published his third 
article on the subject, giving the best review of the literature up to that 
time. 
Cunningham made the first great advance by using a water bath of 
a temperature below the boiling point of ether, and by carrying the 
ether vapor into the intestine in a vehicle of air. (Molliere had pre- 
viously used a hand bellows to force the ether vapor into the intestine, 
but without admixture of the air.) In the Cunningham apparatus no 
provision was made for emptying the distended intestine, this being 
accomplished when necessary by inserting the finger of the anesthetist 
through the sphincter and alongside the rectal tube. 
Vidal added to the apparatus a provision for a continuous return 
flow of gas from the rectum, and a year later Leggett added to 
the Cunningham apparatus an exhaust tube which could be opened 
when it was desired to empty the intestine, but which remained 
closed in the interval. In July, 1909, Ligueu, Morel, and Verliac 
first reported the use of oxygen as a vehicle for ether vapor in rectal 
anesthesia. The work of these writers was confined to animal experi- 
mentation. 
Sutton improved upon all of these methods by developing an ap- 
paratus that may be regarded as consisting of three parts: (1) A gen- 
erator in which the mixture of oxygen and ether is produced; (2) an 
afferent tube system which carries this product into the intestine; and 
(3) an efferent tube system for the purpose of exhausting the contents 
of the gut. 
1 Cunningham, J. H., and Lahey, F. H.: Boston M. S. J., 152: 450, 1905. 
2 Dumont: Cor.-Bl. f. schweiz. Aerzte, 33: 455, 1903; ibid., 34: 447, 1904; 
38: 785, 1908. 
3 Cunningham, J. H.: N. Y. M. J., 91: 904, 1910. 436 
ANESTHESIA 
Technique of Method.-Preparation of the Patient.-One of the 
most important considerations, observed by all workers with intestinal 
anesthesia, is the thorough cleansing of the colon. This is accomplished 
by a cathartic (castor oil) given the night preceding the operation and 
followed in the morning by high soapsuds enemata repeated until the 
return is clear. In Sutton's cases, three enemata, one and one-half to 
two hours apart, were regarded as the minimum number. In alcoholic 
and very muscular subjects, and in operations on the mouth or upper 
respiratory tract, it has been found useful to give % to *4 grain of 
morphin, and %2o to %oo grain of scopolamin hypodermically one 
hour before operation. 
The Administration.-Sutton recommended, whenever possible, the 
use of oxygen instead of air as a vehicle. The reasons for this are: (1) 
It reduces the dangers of anesthesia; (2) it greatly diminishes the 
rapidity and depth of respiration, in some cases even causing the phe- 
nomenon of apnea or hyperoxygenation, thus greatly reducing the loss 
of ether through the lungs; and (3) it obviates the necessity of the fre- 
quent use of the exhaust, and hence contributes to the smoothness of 
the anesthesia and the comfort of the anesthetist.1 
The depth of narcosis is determined by the pupils, which are usually 
at maximum contraction in complete anesthesia by this method (unless 
morphin and scopolamin have been administered), when the pupillary 
signs have little value; by the degree of muscular relaxation, and by 
the color which may be noted from the lips and face, but better from 
the color of the blood in the wound. The character of the respiration 
is of less value, as the patient may have excellent color, though breathing 
very infrequently. Short, shallow, jerky respiration, especially when 
associated with a dusky color, is a danger sign, just as it is in the 
pulmonary method. 
The writer rarely takes the pulse except in cases which are manifestly 
doing badly, or where cardiac complications are known or suspected. 
Muscular tone is best determined from the tension of the jaw muscles 
and from the presence of voluntary movement of the tongue. It is the 
writer's habit to keep one finger in the patient's mouth in order to 
detect the first active tightening of the jaw or voluntary movement of 
the tongue. Sufficient ether need not be given to make the lower jaw 
entirely relax, but merely enough to prevent actual biting of the finger. 
Difficulty in breathing is readily overcome by extending the head on 
the neck by simply pulling with the finger upon the upper incisors. This 
has always been sufficient, so that in the entire series of cases here re- 
ported neither mouth gag nor tongue forceps was used to improve the 
respiration of the patient. 
1 The same reasons, with the exception of the third, apply to oxygen with 
ether by inhalation. ANESTHESIA BY COLONIC ABSORPTION OF ETHER 
437 
After-treatment.-As soon as the patient is returned to bed, a high 
soapsuds enema is given, the fluid, if necessary, being siphoned off after a 
few minutes. This treatment is repeated a half hour later. Vomiting 
is usually absent; when present it is very rarely severe, the patients, 
curiously enough, disclaiming any feeling of nausea. Recovery is rapid. 
The possibility of the transmission of typhoid, amebic colitis, or 
other intestinal infection, from one patient to another is prevented by 
keeping the rectal tube and the Y-tube in a one per cent solution of 
formalin between operations. The glass tip of the accessory mouth tube, 
when not in use, is kept in the same solution. 
Discussion of Cases.-Sutton administered ether by this method to 
about 140 cases in the surgical service of Roosevelt Hospital. Of this 
number careful records were taken of the first 100 cases. It may be 
said, however, that all were satisfactory, and that untoward results 
occurred in none. In only one case-the second of the series-was an 
attempt made to administer the anesthetic per rectum from the be- 
ginning. This proved so slow, and was so uncomfortable and distasteful 
to the patient, that after about twenty minutes a cone was used to com- 
plete the initial establishment of the anesthesia. Inasmuch as there is 
no real indication for beginning the administration by rectum, a second 
attempt to do so has not been made. The longest operation of the series 
consumed two hours and twenty minutes; the shortest, five minutes; the 
average time being fifty-three minutes. The average consumption of 
ether was 87 grams per hour in the 64 consecutive cases in which a 
record of this point was kept. 
Sutton stated that this method, safeguarded by improved apparatus, 
and by the use of oxygen as a vehicle for the ether vapor, is one of 
extreme safety in the absence of definite intestinal lesions. 
Conclusions.-In general, the colonic method of administration of 
ether is more complex than the pulmonary method, and requires of the 
anesthetist a broader appreciation of the physiological factors involved. 
For these reasons alone its field of usefulness is limited to cases in which 
it presents distinct advantage over the pulmonary method. It is not a 
method, therefore, which is adapted to the experimental use of the tyro, 
but is a valuable addition to the armamentarium of the trained anes- 
thetist. The indications and contra-indications may be summarized as 
follows: 
Indications.- (1) Operations upon the respiratory tract (head, 
neck and chest), especially such as lay open the mouth, larynx, pharynx, 
and trachea. (2) Operations upon patients in whom absorption must be 
minimized on account of lung, heart, or kidney lesions. (3) Operations 
upon patients already suffering from respiratory embarrassment. 
Contra-indications.- (1) Operations upon patients presenting 
lesions of the alimentary tract, especially such as might cause weakness 438 
ANESTHESIA 
of the wall of the colon. (2) Laparotomies in general, except such as do 
not open the general peritoneal cavity, e.g., suprapubic cystotomy. This 
is because of the interference of the inflated colon with the work of the 
surgeon.1 (3) Operations upon patients with markedly incompetent 
sphincter ani or with large fistula in ano. A patient with an open 
appendicostomy would offer the same difficulty of leakage. (4) Opera- 
tions upon patients suffering with orthopnea. In these cases it may be 
impossible to inflate the colon because of the obstruction caused by the 
weight of the other viscera resting upon it. (5) Emergency cases in 
general, because of the lack of preparation of the colon. 
Advantages.-The points in favor of the method in cases in which 
its use is indicated may be summed up as follows: (1) Freedom of opera- 
tive field from contamination by the anesthetist. (2) Ability to main- 
tain a smooth and continuous anesthesia in operations involving the 
respiratory tract, thus shortening the time and reducing the shock of 
the operation. (3) Uniform depth of anesthesia, causing light narcosis 
and marked saving in ether. This saving is much greater when oxygen 
is used as the vehicle. (4) Lessening of pharyngeal and bronchial se- 
cretion, and of tonic contraction or troublesome relaxation of jaw 
muscles. (5) Ability to administer oxygen without interruption of 
anesthesia. (6) Minimized loss of heat during operation because of 
diminished sweating and ether refrigeration. (7) Reduction of post- 
operative vomiting and nausea. (8) More normal respiration and pulse 
than with any other method of general anesthesia. (9) Less hemorrhage 
in head operations. (10) Less tax on the heart, lungs, and kidneys. 
Disadvantage.-One point against the method in cases where its 
employment is indicated is the occasional difficulty in maintaining pro- 
found anesthesia without the use of the supplementary mouth tube. 
OIL-ETHER, COLONIC 
History. 
Laboratory Investigation. 
Technique. 
Physio-pathological Aspects. 
Clinical Results. 
Indications. 
Contra-indications. 
Advantages. 
History.-The original work of Cunningham,, and Sutton's careful 
record of cases, were prominent factors in the development of oil-ether 
colonic anesthesia. In 1913, at the Seventeenth International Medical 
1 This depends upon the surgeon and his assistant more than upon the in- 
flated colon.-J. T. G. ANESTHESIA BY COLONIC ABSORPTION OF ETHER 
439 
Congress, in London, the author read a paper on Oil-ether Anesthesia.1 
The experimental animal work was completed just previous to this 
date. 
Laboratory Investigation.-Animal Experiments.-All of the ex- 
perimental laboratory work was conducted under the immediate super- 
vision of Professor Wallace, of the pharmacological department of the 
University and Bellevue Medical College. 
Rate of Evaporation of Ether.-Experiments in the laboratory 
of the College of the City of New York, under the supervision of the 
late Professor Charles Baskerville, were then made to secure the follow- 
ing information that might be of service clinically. 
(1) A comparison of the rate of evaporation of ether from different 
mixtures of ether and the same oil. 
(2) A comparison of the rate of evaporation of ether from the same 
per cent mixtures of different oils and ether. 
The oils used were of three types, vegetable, animal, and mineral, 
being, respectively, olive, cotton-seed, corn, peanut and soya-bean; cod- 
liver and lanolin (anhydrous), and Russian mineral oil. All the 
vegetable oils, except olive, were refined by a process devised by Profes- 
sor Baskerville, and were neutral. The other oils were purchased in the 
open market. The experimental work was carried out by Mr. Hyman 
Storch, under Professor Baskerville's direction. The data obtained for 
the 25, 50, and 75 per cent mixtures of vegetables and animal oils are 
shown graphically in Figs. 189-191. In the curves the abscissae show the 
percentage of ether evaporated (based on volume measurements) and 
the ordinates the time of the evaporation. 
Thus, it was demonstrated that, regardless of whether the oil was 
animal, vegetable, or mineral, that is, corn, cotton-seed, peanut, cod-liver, 
lanolin, soya-bean or olive oil, or whether a 20, 50 or 75 per cent mixture 
was used, the rate of evaporation remained constant. Furthermore, if 
the mixture was placed in a vessel with greater surface area than that 
of a test tube, the evaporation was still constant, although the rate was 
increased. 
These charts, showing the percentage of ether evaporation during a 
period of two and one-half hours, should convince the most skeptical 
that, in so far as this factor is concerned, giving ether-oil colonically is 
a safe procedure, admitting of an absolutely even plane of anesthesia, 
which would not be the case if the ether evaporated irregularly either in 
point of time or quantity. The charts show, furthermore, that the 
patient does not absorb a tremendous amount of ether immediately upon 
injection, which would result in anesthetic shock, but that he becomes 
anesthetized gradually in accordance with the constancy in evaporation 
of the ether from the mixture in the colon. 
1 Lancet, December 20, 1913. Rates of Evaporation from 25, 50 and 75 Per Cent Mixtures of Oils and Ether (Baskerville). 
Fig. 169 
Fig. 168 
Fig. 167 ANESTHESIA BY COLONIC ABSORPTION OF ETHER 
441 
The Bactericidal Action of Oil-ether Mixtures.-In the lab- 
oratories of the Department of Health of New York City, experiments 
Fig. 170.-Comparison of Rates of Evaporation of Different Mixtures of Olive 
Oil and Ether (Baskerville). 
were conducted under the supervision of the Director of the Bureau, 
William H. Park, Dr. Cary W. Noble doing the detail work, on the 
Fig. 171.-Effect of Increased Surface on the Rate of Evaporation of Ether 
from a 75 Per Cent Mixture of Corn Oil and Ether (Baskerville). 
bactericidal action of ether-oil mixtures, using 5, 10, 20 and 30 per cent 
mixtures against the Bacillus coll. These tests showed that 10, 15 and 442 
ANESTHESIA 
20 per cent oil-ether mixtures killed practically all B. coli with two and 
one-half minutes' exposure, in tubes of broth. 
Since infection from the colon bacillus is a factor to be reckoned 
with in many surgical operations, it may be inferred from these tests 
that the bactericidal action of the oil-ether mixtures affords an added 
element of safety with this method of rectal anesthesia. 
It is interesting to note that oil-ether mixtures have a very great 
bactericidal power. This would refer especially to surgical cases in the 
first stage of typhoid fever, although it would be contra-indicated in 
the later stages. It would also have a theoretical bearing upon the use 
of oil-ether mixtures in other diseases and for other purposes than surgi- 
cal. Tests were made using 5, 10, 20 and 30 per cent oil-ether mixtures 
against a standard typhoid culture. These tests show that the 5 per cent 
oil-ether mixtures have an inhibiting effect on typhoid fever bacilli after 
fifteen minutes' exposure, and that 10, 20 and 30 per cent mixtures 
inhibit the growth after five minutes' exposure. 
The Technique.-It is most important that the administration of 
the oil-ether mixture be delegated to one who can use it in all cases, and 
not to a different doctor or nurse each time it is employed in a given 
hospital or clinic. 
Apparatus.-The simplicity of the equipment required for this 
method is a decided point in its favor. The only apparatus used is a 
special rectal tube or catheter one-quarter of an inch in diameter and 
about 28 inches in length; a clamp for this tube; a three-inch glass 
funnel with which to introduce the oil-ether solution; a Gwathmey tube 
about 30 inches long and % of an inch in diameter with which to flush or 
remove fluid from the rectum; and a towel which is placed over the 
face of the patient when administration is begun, to prevent dilution of 
the anesthetic in the air-passages until narcosis is complete. A pharyn- 
geal airway tube should be convenient, to lighten the anesthesia if neces- 
sary. Of course, the tubes should be sterilized before use. 
Dosage.-In using the oil-ether method, the anesthetist must bear in 
mind the peculiar physiological effects of the oil-ether mixture in order 
to prevent errors in administration. From observation of a large number 
of cases the rule of one ounce of a 65 per cent solution of ether in oil for 
every 20 pounds of body weight in the normal adult has been found 
satisfactory, and this amount and this percentage should never be ex- 
ceeded. This amount compares favorably with that employed in all 
other methods of administering ether. Age, weight, fever, anemia, and 
general weakness modify the dosage as in other methods of general 
anesthesia, and, by diminishing the amount of the mixture administered 
in accordance with these factors, over-dosage may be readily controlled. 
For Patients under Six Years.-A 50 per cent solution should be 
employed. This mixture is non-irritating, is easily retained without ANESTHESIA BY COLONIC ABSORPTION OF ETHER 
443 
preliminary medication, and is followed by satisfactory anesthesia in ten 
to twenty minutes. A child four to six years of age would probably 
require just a little more than one ounce for every twenty pounds of body 
weight. No risk should be incurred with children because the rate of 
evaporation is much more rapid than in the case of adults. The mixture 
may be administered very slowly and from one-half to one ounce may be 
added later, if necessary. 
For Patients from Six to Twelve Years.-A 55 to 65 per cent solu- 
tion is used without preliminary medication. One ounce is administered 
for every twenty pounds of body weight, and twenty to thirty minutes 
should be allowed for the anesthetic to have full effect. 
For Patients from Twelve to Fifteen Years.-One ounce of a 65 per 
cent solution to every twenty pounds of body weight should be adminis- 
tered, with the addition, if required, of %2 grain of morphin and %oo 
grain of atropin given hypodermatically, or a 5 grain chloretone sup- 
pository, as a preliminary. 
For patients of Fifteen Years and Upward.-A 65 per cent mixture is 
injected, the amount and preliminary medication varying with the size 
and general condition of the patient, the same rule being followed as to 
quantity, that is, one ounce for every twenty pounds of body weight, 
except for the obese patient. Six ounces of a 65 per cent solution, 
that is, the usual dosage for the average case, will maintain anes- 
thesia from two and one-half to three hours, provided a clear airway 
is maintained. No more than 8 ounces of this solution should ever be 
given. 
For Weak, Anemic Patients.-The mixture should consist of olive 
oil, 35 to 45 per cent, and ether, 55 to 65 per cent. 
For Alcoholics.-Two hours before operation %oo grain of hyoscin 
hypodermically should be given; one hour before operation, repeat, with 
14 grain of morphin, after which the oil-ether is given. 
Preliminary Treatment.-A cathartic of castor oil should be 
given, preferably two nights preceding the operation, and repeated the 
following night, and purging should be avoided. This should be followed 
the morning of the operation by warm water enemas, one hour apart, 
until the return is clear, when the patient should be permitted to rest for 
two or three hours. 
The quantity of the preliminary medication depends largely on the 
opinion of the surgeon or anesthetist, and will vary with this method as 
with other methods of administration. In order to obtain the most 
satisfactory results with adults, preliminary medication is essential, with 
a rest in bed of two or more hours before injection. As the preliminary, 
chloretone and paraldehyd may be used, since both have been found to 
diminish the amount of the anesthetic required and to assist materially 
in gauging the susceptibility of the patient to this form of anesthesia. 444 
ANESTHESIA 
Other hypnotics of equal value may be substituted for them if preferred. 
Isopral has also a slight local analgesic, as well as a general hypnotic, 
effect, and may prove satisfactory. 
Technique with Chloretone.-Two hours before operation visitors 
should be excluded, the room darkened, and quiet maintained. With the 
patient in the Sims position, give per rectum 5 to 30 grains of chloretone 
in a suppository, or dissolved in 2 to 4 drams of ether mixed with an 
equal amount of olive oil. Thirty minutes after the chloretone has been 
given, inject hypodermatically % to % grain of morphin, with %00 to 
%oo °f a grain of atropin; the larger doses are given only to athletes 
and alcoholics, for whom the method of medication differs as follows: 
Two hours before the operation give %Oo grain of hyoscin hydrobromid 
hypodermatically, and one hour before operation repeat the hyoscin with 
% grain of morphin, omitting the rectal preliminary. 
Technique with Paraldehyd.-When paraldehyd is used in connection 
with ether it intensifies the action of the drug and insures more com- 
plete relaxation without in any way affecting the pulse or respiration, 
and by employing it as a preliminary with this method the usual amount 
of oil-ether solution may be reduced. 
One hour before operation administer by rectum a solution of % 
grain of morphia, 5 grains of chloretone, one to 4 drams of paraldehyd, 
and 31/2 drams of ether and olive oil in equal parts. This one-ounce 
solution takes the place of the chloretone suppository, in the technique 
previously described. In other respects that technique should be fol- 
lowed except with athletes, alcoholics, and patients weighing over 160 
pounds. For these patients, instead of administering morphin and 
atropin hypodermatically, the paraldehyd solution should be repeated. 
For the average patient the dose should not be repeated. 
The Use of Local Anesthetics.-The question of whether or not 
a local anesthetic should be used at the site of the operation is a matter 
for the surgeon himself to determine. Where the opinion of the writer 
is asked, he advises its use unless it is contra-indicated by special 
conditions. 
Administration of Oil-ether.-The Patient.-A convenient lifter 
should be placed under the patient before beginning the injection. The 
administration of oil-ether colonic mixture is best accomplished with 
the patient in his own bed, lying on the left side, in the Sims' position. 
If the bed is in a ward, it should be screened and the exposure of the 
patient avoided by introducing the rectal catheter between two suitably 
adjusted sheets. A pillow under the hips is sometimes helpful. It is 
not always necessary that the patient should know that an anesthetic is 
being administered, but, in any event, he should be kept perfectly quiet 
and should never be left alone at any time after having received the 
injection. ANESTHESIA BY COLONIC ABSORPTION OF ETHER 
445 
Induction.-It is most important to mix the solution thoroughly by 
stirring or by shaking it in a bottle for one minute. Forty to sixty 
minutes before operation, place a towel over the patient's face; the oil- 
ether mixture is poured very slowly, allowing about one minute for the 
introduction of each ounce, through the funnel, which should not be held 
over a foot above the rectum, attached to the rectal tube which has been 
well lubricated, and filled partly with oil, inserted four inches within 
the rectum. At the very least, five minutes should be consumed in ad- 
ministering six ounces, the usual amount required. The catheter shouk\ 
now be clamped. Pressure over the peritoneum with a towel or bandage 
for five minutes will prevent any feeling of expulsion. Unconsciousness 
Fig. 172.-Showing Patidnt in Position for Oil-Ether Administration. 
generally follows in from five to ten minutes after the completion of the 
injection, when* the patient may be carried to the operating room, and, 
except in rarer cases, full surgical narcosis is reached in from thirty to 
forty minutes. 
If the patient goes to sleep before the required amount has been given, 
STOP! If unconsciousness is delayed over ten minutes, a few whiffs 
of ether or nitrous oxid may be used. It is advisable not to withdraw 
the catheter until* the completion of the operation, ar withdrawal of the 
solution. 
Maintaining Anesthesia.-After the patient has received the mix- 
ture a clear airway must be maintained by placing a finger beneath the 
symphysis of the lower jaw. Care must be exercised to prevent the air 
supply from being cut off, either by the head falling forward or sidewise, 446 
ANESTHESIA 
or by the tongue falling backward. If the breathing is easy and regular, 
with the reflexes active, the patient will be found to be completely re- 
laxed and in surgical narcosis as long as the operation lasts. Six ounces 
of the 65 per cent mixture will last from two and one-half to three hours. 
If the operation is completed before this time, the catheter should be 
unclamped and as much of the mixture drawn off as possible. 
The physiological changes incident to this method will be found to 
result in the automatic maintenance of surgical narcosis. The anesthetist 
has complete control of the anesthesia at all times, and any error in judg- 
ment as to the proper amount of the solution in the first place may be 
quickly rectified by either the addition or withdrawal of the mixture. If 
the patient shows undue susceptibility to the ether, part or all of the 
mixture may be withdrawn immediately, if necessary. On the other 
hand, if the patient seems too lightly narcotized with the regulation dose, 
anesthesia may be deepened by the addition of a few drops of ether or 
chloroform on the towel, which is preferable to increasing the amount 
of the solution; or it may prove sufficient to prevent the dilution of the 
anesthetic with the outside air by placing over the face a towel slightly 
puckered just above the nose and mouth, but held securely to the face 
around the edges, so as to inhibit the escape of the ether vapor and 
induce a certain amount of rebreathing. Anesthesia may be concluded 
at any time by placing a Gwathmey tube in position and massaging over 
the colon from right to left to expel the remaining mixture. When 
anesthesia is so terminated, the anesthetic stage merges into one of deep 
sleep. 
Danger Signs.-If a mistake in judgment as to the amount of the 
anesthetic is made, it is manifested in about fifteen minutes by the fol- 
lowing symptoms: (1) There is slight cyanosis. (2) There is a diminu- 
tion in the activity of the reflexes. (3) There may be stertor, or em- 
barrassed respiration, and except in the obese, even though slight, is a 
danger signal. If any of the above symptoms are present, narcosis is 
becoming too profound, and 2 or 3 ounces of the mixture remaining 
in the colon should be withdrawn immediately through the Gwathmey 
tube placed 4 to 6 inches up the rectum beside the catheter, and if the 
symptoms persist, the rectum, should be irrigated with cold water and 
the sphincter stretched. If this does not give relief immediately, a 
Lumbard breathing tube should be introduced and 1,000 to 2,000 c.c. of 
normal saline given intravenously. 
If respiratory arrest occurs, a bag filled one-third full with carbon- 
dioxid gas is placed over the face, and the condition remedied by artificial 
respiration. The chief danger of this method lies in respiratory arrest. 
Even though conditions seem ideal under oil-ether colonic anesthesia 
-that is, the color of the patient is good, the skin is warm to the touch, 
the reflexes active and the pulse normal, with complete absence of stertor ANESTHESIA BY COLONIC ABSORPTION OF ETHER 
447 
and even of the puffing so frequently observed under inhalation anes- 
thesia-watchfulness m.ust be exercised at all times. The very simplicity 
of the method may lead the inexperienced to attempt its use without 
adopting the precautions which must be observed*in order to make this or 
any other method of general anesthesia safe. When the oil-ether solution 
is injected in accordance with the fixed rules outlined herein, it is 
physically impossible to shock the patient either at the time of introduc- 
tion or during anesthesia. 
If a third stage inhalation anesthesia is superimposed upon a light 
colonic anesthesia, the patient would be plunged into the fourth or deeper 
zone immediately. If, on the other hand, the colonic is too deep, in 
addition to whatever else is done, oxygen should be administered. When 
an unsatisfactory or too light colonic anesthesia needs supplementing, it 
is usually only necessary to produce unconsciousness. 
Post-operative Treatment.-Immediately upon conclusion of the 
operation the clamp on the catheter is released, and the end lowered so 
that the residual mixture is syphoned off. The Gwathmey tube is in- 
serted into the rectum to a depth of about 6 inches, or as high up the 
Fig. 173.-Gwathmey Rectal Irrigation Tube. 
colon as is convenient without traumatism, alongside the catheter. 
About one gallon of soapy water is now poured through the funnel at- 
tached to the catheter, and is syphoned off by the Gwathmey tube. At 
the same time in order to expel any liquid that may remain, the colon is 
massaged gently from right to left. The Gwathmey or large rectal tube 
should now be withdrawn. Two to 4 ounces of olive oil should then be 
introduced into the rectum, followed by one pint to one quart of water, 
or 4 to 8 ounces of black coffee, and the catheter withdrawn. 
The reflexes should now be quite active and the patient breathing 
quietly. Further after-treatment is the same as in other forms of 
anesthesia. The patient should be returned to bed with as little jolting 
or handling as possible, the room should be darkened, and free ventilation 
established. The patient usually recovers consciousness in from thirty 
to fifty minutes after this procedure, quietly, without nausea, vomiting 
or pain, and analgesia continues for some time after consciousness is 
restored. 
Technique for General Practitioners.-It would be safer for a 
practitioner, who must work unassisted, to use a 55 to a 65 per cent 
solution of ether and oil, to allow thirty to sixty minutes for the mixture 448 
ANESTHESIA 
to have its full physiological effect, and then to supplement this dosage, 
if necessary, with a few drops of ether on a mask. This procedure would 
be better than inducing profound anesthesia with a 75 per cent solution, 
with the possibility of having to withdraw some of the mixture if the 
patient were too deeply narcotized. This combined method would also 
be a safer one for hospital internes and others who have not had extensive 
experience in the administration of anesthetics. 
Lathrop's Technique for Thyroid Cases.-Lathrop 1 reports hav- 
ing used oil-ether colonic anesthesia in 1,002 cases. He recommends the 
method especially for goiter cases, for neurotics, for patients with 
asthma, for hernia operations, and for all operations on the head and 
neck. He especially emphasizes its usefulness in thyroidectomy, where 
the absence of the ether cone gives freedom of movement to the surgeon, 
and when the patient may be anesthetized with little conception of what 
is taking place. 
Technique for Hyperthyroid Cases.-An injection of 4 ounces of 
plain water is given every second day for a week preceding operation, 
with instruction to the patient to retain it for its tonic effect. The morn- 
ing of operation she is given the regular dose of ether-oil and paraldehyd 
followed by hypodermic, and the full mixture, all given while she is in 
bed. She usually goes to sleep very quietly, though at times requiring a 
few drops of chloroform; is taken to the operation room, the gland re- 
moved, or ligation performed, and when she awakens, she is in her bed, 
with little knowledge of what has taken place, aside from knowing some- 
thing has happened to her throat; but the fear is greatly diminished. 
Dickinson sums up the argument for oil-ether anesthesia as follows: 
"To any one who has witnessed anesthesia by the inhalation method, 
and then watches the most delightful, childlike slumber of the person 
under rectal anesthesia, there will be a great and comforting surprise. 
The cone to the face, even with gas-oxygen, is an affront. Those who 
prefer local anesthesia also give affront by their presence and manipula- 
tion; but the surgeon who quietly steals up behind and induces anesthesia 
per anum does not in any way disturb the psyche, and the chain of reac- 
tions so detrimental are not instituted." 
Physio-pathological Aspects of Oil-ether Colonic Anesthesia.-Many 
surgeons have commented on the analgesic state of oil-ether colonic 
anesthesia. One (in a personal communication) states that: "In two 
cases analgesia was produced, but complete anesthesia was not. One case 
was a recurrent carcinoma of the face and the other an adenofibroma of 
the breast. The patients were semiconscious but felt no pain. In the 
operation for carcinoma of the face the Percy cautery was used for one 
1 Read before the Section on Surgery, General and Abdominal, at the Seventy- 
first Annual Session of the American Medical Association, New Orleans, April, 
1920. ANESTHESIA BY COLONIC ABSORPTION OF ETHER 
449 
hour and ten minutes. In the case of tumor of the breast the growth 
was removed, a frozen section made and examined-all of which con- 
sumed about thirty-five minutes. The patient would answer any ques- 
tions asked, but suffered no pain, nor did she remember anything about 
the operation." It is entirely possible that a method of rectal analgesia 
may be developed from the perfecting of the technique of oil-ether colonic 
anesthesia. 
In order to induce and conduct an effective administration of oil- 
ether colonic anesthesia, the anesthetist must have a thorough under- 
standing of the physio-pathological action peculiar to ether dissolved in 
oil. It is evident from the character of the few adverse criticisms of this 
method that failures have been due to the fact that certain important 
physiological factors have received but superficial attention. 
Theoretically, the administration of any anesthetic should presuppose 
a full knowledge on the part of the anesthetist of the physiological action 
of the drug. Practically, however, in case of pulmonary anesthesia, this 
knowledge may be, and, in the vast majority of cases, is dispensed with 
in favor of an accurate knowledge of the symptoms of incomplete and of 
excessive narcosis, and of the practical means of correcting each. This 
knowledge, gained by extensive observation and supervised experience in 
the pulmonary method of administration, is not sufficient basis for the 
undertaking of the administration by the colonic method. 
The course of the circulation of ether in the blood following rectal 
injection differs markedly from that produced by ether inhalation. A 
very short time, within two to five minutes, after the mixture enters 
the rectum it is heated from room to body temperature; a portion of the 
ether, at the same time, leaves the oil in the form of gas, which is 
absorbed by the blood circulating in the small capillaries surrounding the 
colon. From the colon through the liver, the ether is carried by the 
greater circulation to the heart, and from the heart it is pumped into 
the lungs where part is excreted through the air passages and lost, the 
remainder being immediately re-absorbed and carried on to the brain 
and the central nervous system. The odor of ether is perceptible in 
the patient's breath in from three to four minutes. By the time the 
anesthetic has reached the lungs it is thoroughly warmed to hody 
temperature. 
Effects of Ether upon the Organism.-There is no irritation to 
the lungs, and accumulations of mucus and saliva are usually absent, or 
so small in amount that they are negligible factors in anesthesia. With 
rectal administration only the ether necessary for narcosis, which is 
excreted by the lungs, goes through the respiratory tract. Therefore, 
local irritation to the upper air-passages, which takes place with pul- 
monary methods, causing a great increase in bronchial secretions, is not 
present in oil-ether anesthesia. 450 
ANESTHESIA 
Breathing with this form of anesthesia is perfectly normal. The 
patient breathes as in natural sleep, so quietly that not even the alse of 
the nose move, and there is consequently less danger of respiratory arrest 
than with any inhalation method. In two or three experimental cases, 
before the exact dosage had been determined, respiratory paralysis oc- 
curred, but was promptly relieved. The reflexes are quite active, espe- 
cially the lid reflex; at the same time a very great degree of relaxation 
exists throughout the whole muscular system. The pulse rate depends 
upon preliminary medication. When preliminary medication has been 
given, the pulse is about normal; otherwise, very full and bounding. 
Usually the face is not flushed, but there is no cyanosis as in inhalation 
anesthesia. Blood pressure remains constant. 
On account of the large quantity of vapor which is lost by exhalation, 
the brain is never so deeply narcotized as when the anesthetic is ad- 
ministered by pulmonary methods, in which the higher centers of the 
brain are first affected. In the colonic method the first symptom of 
anesthesia is sensory paralysis of the extremities, while the higher brain 
centers are the last to be affected, an observation which is verified by the 
manner in which the patient emerges from anesthesia. Consciousnss is 
regained long before sensations of pain are manifested. This, no doubt, 
is a strong factor in the wide latitude of safety afforded by this method. 
With no other anesthetic or method of administration would it be pos- 
sible to have a patient's respiration cease for eight minutes and recom- 
mence as in one of the cases cited in which an overdose was given. 
Automatic Maintenance of Anesthesia.-When an oil-ether 
anesthesia is established, its depth has been found to be automatically 
and evenly maintained by four factors acting in harmony: (1) the con- 
stant rate of ether evaporation from the oil; (2) the distention of the 
colon, which permits less ether to be absorbed than when the colon is 
only partially distended; (3) the cooling of both the mixture and the 
gut during evaporation, which retards elimination and absorption, and 
(4), the difference between the ether absorptive power of the colon and 
the eliminative capacity of the lungs. 
In the first place, the rate of evaporation of the ether from the oil in 
accordance with certain inflexible physical laws, conclusively demon- 
strated experimentally, is always constant in normal individuals. The 
ether may always be separated from the oil by warming, but unless the 
temperature of the mixture is suddenly raised to an excessively high 
point, the ether passes off deliberately. After administering the oil- 
ether mixture it is impossible at any time to withdraw the oil and leave 
the ether, or to withdraw the ether and leave the oil. Every molecule of 
ether is bound to a molecule of oil, and this union is broken only when 
evaporation occurs. In no other way can their separation be effected. 
During anesthesia the amount of this vaporization per minute never ANESTHESIA BY COLONIC ABSORPTION OF ETHER 
451 
varies. Therefore, it is impossible to have a deep anesthesia at one time 
and a light anesthesia at another, unless the anesthesia is deepened by 
rebreathing or lightened by an airway tube. 
With regard to the second factor, Sutton found that when the colon 
was fully distended not so much ether was absorbed as when it was only 
partially distended. However, the absorbing area of the colon is so much 
smaller than the excretory area of the lungs that a moderate distention of 
the entire colon is essential to increase its absorbing surface, and a 
sufficient degree of pressure must be employed to obtain this distention. 
Sutton reports that his attention was first directed to the necessity for 
the use of a moderate pressure by the repeated observation that reduction 
of pressure often resulted in deepening narcosis and checking absorption, 
and that the optimum pressure to be maintained in the colon was de- 
termined experimentally to be about twenty millimeters of mercury. 
That unusual or over-pressure does not occur during oil-ether anesthesia 
is proved by the degree of distention of the colon and by the absence of 
distressing after-effects, such as diarrhea, and bloody stools, which at- 
tended previous methods of rectal etherization. 
In the third place, as the ether leaves the oil in gaseous form, heat is 
extracted from the surrounding parts, and the mixture, as well as the 
gut, is cooled off in the process. This retards both elimination and ab- 
sorption and aids in regulating the dose. Pharmacologists, physiologists, 
and surgeons are agreed in stating that etherization produces a general 
lowering of body-temperature. As loss of heat is a prominent factor in 
surgical shock, and as surgeons have noted that during oil-ether anes- 
thesia the colon is cold even through a rubber glove, it has been suggested 
that the possible temperature loss might prove an element of danger. 
This frigid condition noted in the colon is the direct result of the 
evaporation of the ether from the oil. As the oil-ether solution ap- 
proaches body temperature, ether vapor is given off, which cools the 
mixture and retards evaporation. This process recurs automatically 
until all the ether has parted from the oil. In the meantime, the tem- 
perature of the patient remains normal, as determined by a thermometer 
placed in the mouth or axilla. The skin is warm to the touch; the color 
of the face suggests thorough oxidation. The cold, elammy sweat, some- 
times noticed with ether given by other methods, is absent. Further- 
more, the question has been raised as to whether this method is not 
directly opposed to the theory of the administration of warmed anes- 
thetics. Paradoxical as it may seem, the patient under oil-ether colonic 
anesthesia always inhales a warm, moist vapor. In the course of its 
circulation from the small blood vessels of the colon through the liver 
to the heart on its way to the lungs, the ether is moistened and thor- 
oughly warmed to body temperature, a fact which is verified by the ab- 
sence of lung irritation and bronchial secretions. 452 
ANESTHESIA 
The fourth consideration, the difference between the gradual and 
equal absorption of the ether from the colon and its freedom of excretion 
from the lungs, obviously acts as a powerful factor in insuring the 
patient's safety. 
That these four factors, acting harmoniously, produce as even a plane 
of anesthesia as can possibly be maintained by any other method is well 
illustrated by the sphygmographic tracing of a dog under oil-ether 
anesthesia for one hour, during which the pulse and respiratory tracings 
never varied. This fact has been further demonstrated in many thou- 
sands of cases surgically anesthetized by this method in which, without 
any supplementary anesthetic, the pulse, respiration, temperature, re- 
flexes, and blood pressure remained constant. 
The Amount of Ether Employed.-In the induction of an oil- 
ether anesthesia the total amount of the anesthetic dose, as estimated by 
the age, weight and general condition of the patient, must be injected at 
one time in order to establish the ether tension in the blood essential to 
surgical narcosis. Objections have been raised to this procedure on the 
ground that loss of control might ensue. 
In the pulmonary method the drug is taken in by the automatic 
respiratory efforts of the patient, and is eliminated in the same way if 
pure air be substituted for the anesthetic mixture. No anesthetic- 
containing reservoir remains to continue imparting the drug to the blood 
plasma. Further, as the only means of elimination of the anesthetic is 
the same as the means of absorbing it, only so great an amount of the 
drug need be absorbed as is necessary to produce in the general circula- 
tion the required one-fourth of one per cent for the narcotization of the 
central nervous system. The absorbing surface of the lungs is so great 
and so well adapted to the purpose that a comparatively low concentra- 
tion of anesthetic vapor in the respired air is sufficient to produce the 
required percentage in the circulating blood. 
In the colonic method of administration all these conditions are 
changed. The drug cannot be taken in by the muscular action of the 
patient, nor can any unabsorbed excess be directly eliminated in that 
way. In the event of too deep narcosis the active intervention of the 
operator is necessary. However, it is a fallacy to presume that the total 
amount is utilized immediately by the patient. If this were so, every 
oil-ether anesthesia would be accompanied by clinical signs of shock, 
whereas anesthetization by this method is not only singularly free from 
such complications, but it is more even in depth than any other form of 
anesthesia on account of the invariable physiological adaptations which 
control the evaporation of the ether from the oil. In operations lasting 
one hour or less, by filling the lower bowel with water and massaging 
from right to left immediately over the colon, all of the remaining mix- 
ture is recovered and the patient regains consciousness in fifteen to thirty ANESTHESIA BY COLONIC ABSORPTION OF ETHER 
453 
minutes. These facts prove beyond all question that only the amount 
required to maintain surgical anesthesia is absorbed. 
Brinkley states that he has never failed to get back less than 
ounces of an 8-ounce injection, even in cases which were under the 
anesthetic for an hour and a half. An analysis of the difference between 
51/2 ounces withdrawn and the 8 ounces introduced amounts to about 
the same, or less than V/2 ounces per hour. A small allowance must also 
be made for the amount of fluid in the rectum which cannot be with- 
drawn at the time of administration, but, at the same time, allowance 
must be made for the amount washed out by the soapsuds solution, 
these amounts probably being about equal. Each of these differences 
requires the intelligent attention of the anesthetist. 
Furthermore, most anesthetists and physiologists of to-day maintain 
that the amount of ether utilized by the patient in the maintenance of 
anesthesia must always be the same, regardless of the method of intro- 
duction. "The ether tension in the arterial blood to the sensorium is 
the determining factor of anesthetization" (Connell). In order to 
maintain the same level of anesthesia, this factor must be the same, 
whether the ether be introduced intravenously, by inhalation, or per 
rectum. 
The amount of the anesthetic employed in this method bears favor- 
able comparison with that employed in all other methods of administer- 
ing ether. Six ounces of ether with 2 ounces of oil, given to a patient 
weighing 160 pounds or more, will last nearly three hours with even 
respiration and blood pressure and constant reflexes. Since the plane 
of anesthesia is constant, the patient is absorbing about two ounces of 
ether per hour. In two instances in which the operation lasted about 
three hours, the patient recovered full consciousness, without delirium, 
within fifteen minutes after being returned to bed, which shows that the 
six ounces of ether were automatically utilized by the patient at the rate 
of approximately two ounces per hour. Only one other form of narcosis 
requires so small an amount, that is, intravenous anesthesia, which aver- 
ages 1% ounces of ether per hour. The drop method is variously re- 
ported as requiring from 4 to 6 ounces per hour, and the endotracheal 
from 6 to 8 ounces per hour, that is, more than any other method. 
Effect of Olive Oil on the Opsonic Index.-Olive oil is now 
used almost exclusively in this method, as less nausea and vomiting 
occurred when olive oil was used than with other oils. The verification 
of this statement by other observers would confirm the work of Graham 1 
on the restoration of the opsonic index by the absorption of olive oil into 
the system after the operation. 
It is an established fact that ether anesthesia lowers the opsonic index 
of the blood, that is to say, reduces the power of the patient to resist 
1 Graham, E. A.: J. A. M. A., 54, 1043, 1910. 454 
ANESTHESIA 
infection whether of pre-anesthetic, operative, or postoperative origin. 
Graham, experimenting with fats and other ether-soluble substances in 
the large intestine of etherized individuals, has shown beyond question 
that olive oil is capable of restoring to the blood certain properties which 
are inhibited by the action of the ether, that is, those concerned with 
phagocytosis. The injection of certain amounts of the oil into the rectum 
is followed after three to six hours by a restoration of phagocytic power, 
although ordinarily depression lasts for several days, while the injec- 
tion of the same amount of physiological salt solution has no appreciable 
effect in shortening the period of phagocytic depression. The oil absorbs 
any ether vapor that may still remain in the intestine, and, therefore, 
not only prevents the protraction of undesirable after-effects but insures 
speedier restoration of the opsonic index and more satisfactory recovery. 
The theoretical objection has been made that the oil might interfere 
with the anesthetic action of the ether, but the author has repeatedly 
injected olive oil into patients under inhalation anesthesia and can state 
positively that oil has no effect whatever upon the depth or the course of 
anesthesia. It certainly does not lessen anesthetic action. 
Toxicity.-Apart from other considerations, the absolutely quiet 
respiration, the normal pulse rate, the even maintenance of blood pres- 
sure and the presence of good color, all of which are characteristic of an 
oil-ether anesthesia, would indicate the absence of toxic conditions. 
Upon withdrawal of the mixture and termination of anesthesia, the 
anesthetic stage merges into one of deep sleep from which the patient 
awakens gradually and as easily as from natural slumber. The absence 
of nausea and vomiting in the majority of cases, with no change in the 
urine, the blood, or the mucous membrane, as determined by the procto- 
scope, and the fact that ether vapor colonic anesthesia was used by Sutton 
and Brewer for patients with impaired organs, as well as the fact that 
oil-ether anesthesia is now being successfully used in one hospital only in 
desperate cases in which inhalation anesthesia might prove dangerous, 
are further indications that there is less toxicity during oil-ether anes- 
thesia than with the usual inhalation methods. 
Death.-Theoretically, fatality is less likely to result from this 
method, since the lungs are free to eliminate ether as fast as it is 
absorbed from the rectum, but undoubtedly, deaths have and will occur 
with oil-ether, as with other anesthetics, if administered when contra- 
indicated or with faulty technique. Certainly it should never be 
administered in borderline cases, unless the physiology is thoroughly un- 
derstood. One patient among the early cases did succumb within twenty- 
four hours after the administration of the anesthetic. This patient had 
regained consciousness and had fully recovered from narcosis. The 
coroner's inquest revealed the fact that every organ in the body was 
diseased, and that a vegetating growth completely obstructed one of the ANESTHESIA BY COLONIC ABSORPTION OF ETHER 
455 
coronary arteries. In the opinion of the surgeon and the coroner, these 
conditions fully accounted for death. 
The theoretical objections to oil-ether based upon faulty technique 
are misleading, and are of little importance in comparison with the 
clinical results in many thousands of successfully conducted oil-ether 
anesthesias. 
After-effects.-In oil-ether colonic anesthesia undesirable after- 
effects are reduced to a minimum and compare most favorably with the 
post-anesthetic sequelae of routine methods of ether and chloroform ad- 
ministration. In fact, it has been demonstrated, in over 1,000 cases, that 
the dangers and discomforts which usually attend inhalation anesthesia, 
including nausea, post-ether pneumonia, and renal injuries, are practi- 
cally absent. 
The complications incident to intravenous anesthesia, such as throm- 
bosis, embolus, and infection, are also eliminated by this method of 
induction, and the difficulties encountered in other methods of rectal 
etherization, such as diarrhea, bloody stools or blood-streaked returns, 
do not follow oil-ether colonic anesthesia. This procedure has been used 
in anesthetizing consumptives, asthmatics, and patients with bronchitis, 
and in no instance has the condition of the patient been aggravated. 
Clinical Results.-The first successful public clinical demonstration 
of oil-ether colonic anesthesia was made on September 27, 1913, at 
The People's Hospital, New York City, on one of Dr. I. M. Rothenberg's 
patients, Dr. Solomon Rothenberg operating. This work was continued 
with success at Columbus Hospital, at other hospitals in New York City, 
and in neighboring cities, and thence throughout the United States and 
other countries, with its ultimate recognition and introduction into mod- 
ern surgery as a thoroughly satisfactory method of producing ether 
narcosis through the rectum. 
Case Reports.-The ages of patients ranged from four to seventy- 
one years. Careful blood and urine analyses were made before and after 
operation, and the blood pressure was taken during operation. Some of 
the patients were also examined with a proctoscope for possible inflam- 
matory after-effects. None of these examinations showed any contra- 
indications, and patients who had been previously anesthetized by other 
methods, and who were capable of making an intelligent comparison, 
expressed themselves most enthusiastically in favor of oil-ether. The 
cases noted are a few of those which are most illustrative of various 
physiological elements which must be taken into consideration in the 
colonic administration of oil-ether. They show that judgment must be 
exercised with regard to the preliminary medication and the amount and 
percentage of the anesthetic used. 
Cases I to III indicate the dangers to be avoided and the dosage to be 
employed, 456 
ANESTHESIA 
Case i.-Boy; age, 10 years. Hydrocele and circumcision. Sulphate 
of morphin, M2 grain, was given hypodermically 30 minutes before opera- 
tion, and also a five-grain chloretone suppository at the same time; between 
75 and 100 c.c. of a 75 per cent solution were introduced very slowly, the 
patient falling asleep before the full amount was introduced, sleeping 
quietly through the operation, and making an uneventful recovery. 
Case ii.-Girl; age, 9 years. Adenoids and enlarged tonsils. Dosage, 
100 c.c. of a 75 per cent solution without preliminary medication. The 
child complained slightly as the mixture was injected. The relaxation 
was perfect, and she left the hospital five hours after operation. 
Case in.-Woman; age, 38 years; weight, 125 pounds. Carcinoma of 
the breast. The patient was given % grain of morphin, and Moo grain of 
atropin hypodermically; 5 grains of chloretone, dissolved in 2 drams of 
ether, and mixed with 2 drams of olive oil, were introduced into the 
rectum, 30 minutes before operation. Eight ounces of a 75 per cent mix- 
ture were introduced into the rectum in 6 minutes' time. The patient was 
in surgical anesthesia 4 minutes after the total mixture had been intro- 
duced. Three ounces were drawn off during the operation as the patient 
seemed to be too deeply narcotized. The resultant anesthesia was perfect 
in every respect, the patient breathing quietly as in natural sleep during 
the entire time of the operation. An uneventful recovery without nausea 
or vomiting followed. Blood and urine analyses proved negative. 
Cases IV and V show that the simplicity of this method does not 
preclude watchfulness. The chief danger lies in the possibility of 
respiratory arrest. 
Case iv.-Woman; age, 30 years; weight, less than 100 pounds. Pelvic 
cellulitis. The patient was given 14 grain morphin and %oo grain atropin 
hypodermically, and a suppository containing 20 grains of chloretone as 
preliminary medication. Eight ounces of a 75 per cent solution of ether 
in oil were administered. The patient evidently received an overdose of 
both preliminary medication and anesthetic. Respiratory arrest occurred 
a few minutes after she was placed upon the operating-table. Artificial 
respiration, stretching of the sphincter, and the intravenous introduction 
of 1,000 c.c. of normal saline were employed. A bag containing a small 
amount of carbon dioxid was then placed over her face, whereupon respira- 
tion recommenced immediately. 
During the time of this respiratory arrest, which, according to the 
operating nurse, lasted 8 minutes, the pulse was full, regular, and approxi- 
mately normal. The color of the lips and tongue was good. The operation 
was satisfactorily performed, and the patient was returned to bed. An 
uneventful recovery is recorded in this instance, with no nausea, vomiting 
or other ill effects. 
Case v.-Man; age, 47 years; weight, 160 pounds. Private patient. 
Excision of the tongue, floor of the mouth, and glands of the neck. Dura- 
tion of operation, nearly 3 hours on account of the adhesions and abnor- 
malities resulting from a cancerous growth. The patient was given 
grain of morphin with Idso grain of atropin hypodermically, half an 
hour before operation, and 10 grains of chloretone in a suppository at the 
same time. Eight ounces of a 75 per cent mixture of oil and ether were 
administered. The patient dropped to sleep almost immediately. At the 
end of one hour the pulse was full and regular, but there was stertor 
which perceptibly increased until respiration ceased for three minutes. 
The rectum was washed out with cold water, and as much as possible 
of the mixture was withdrawn. Respiration recommenced without other ANESTHESIA BY COLONIC ABSORPTION OF ETHER 
457 
measures being employed, and the operation was continued and completed 
without further interruption. When the patient was returned to bed 
the pulse was 72 and the respiration normal. This patient also made an 
uneventful recovery with no nausea or diarrhea following. 
Note.-An inhalation anesthetic would have undoubtedly increased the 
engorgement and congestion usually following such cases. This case is 
illustrative of the action to be taken in event of overdosage. The rectum 
should be immediately washed out and one or two ounces of oil injected. 
Only 6 ounces of a 65 per cent solution should have been used in this case. 
With this dosage, however, it would have taken the patient fifteen to 
twenty minutes longer for the anesthetic to become effective. 
Cases VI and VII illustrate the value of this method for insane 
patients, neurotics and greatly agitated patients. 
Case vi.-Woman; age, 38 years; weight, 105 pounds. Tumor of 
the breast. At 9:00 a.m. was given 5 grains of chloretone dissolved in 
ether and oil; at 9 :30 a hypodermic of Vs grain of morphin and Moo grain 
of atropin. The patient was insane, and it was necessary that quiet should 
be maintained and none but the nurse allowed in the room. A 75 per cent 
mixture of ether and oil was prepared in an adjoining room, and the 
nurse was told exactly how to administer the 5 ounces of the mixture 
required for this case. The nurse carried out the instructions, with no 
protest whatever from the patient. In 15 minutes the patient was uncon- 
scious; she was picked up, and placed upon the operating-table in an 
adjoining room. The operation was performed with no movement what- 
ever by the patient; lower bowel was siphoned off and thoroughly irrigated; 
one ounce of olive oil and one pint of cold tap water were left in the 
bowel. This patient had no nausea or vomiting whatever. She was suf- 
ficiently sensible to appreciate that everything possible had been done 
for her comfort. 
Note.-The possibility of trouble in this case was very great, if the 
patient learned of the operation. The anesthetic was administered, the 
operation performed, and the patient returned to bed without ever seeing 
a doctor. 
Case vii.-Boy; age, 8 years. Broken arm. Patient greatly agitated. 
The anesthetic was administered by the child's mother, while he was lying 
on a sofa, the surgeon being in the next room. There was no preliminary 
medication nor preparation. Patient dropped to sleep quietly, the anes- 
thesia being entirely successful. 
Cases VIII to X are representative of many which confirm the asser- 
tion that the oil-ether method of colonic anesthesia is especially indicated 
for operation on the obese. 
Case viii.-Weight of patient, 250 pounds. Umbilical hernia. Relaxa- 
tion perfect, and anesthesia all that could be desired. 
Case ix.-Weight of patient, 240 pounds. Umbilical hernia. Relaxa- 
tion perfect, and anesthesia all that could be desired. 
Case x.-Private patient; weight, between 200 and 300 pounds. As in 
all private cases, a nurse preceded the anesthetist, following his directions 
in regard to administration, his duty being to supplement, withdraw, 
deepen, or lighten the anesthetic according to the indications. The result 
was ideal. 458 
ANESTHESIA 
Cases XI to XIII were borderline cases in which the anesthesia was 
a problem and required careful judgment as to the amount administered. 
They illustrate the range of the anesthetist's control in making oil-ether 
colonic anesthesia a safe procedure. 
Case xi.-Woman; weight, less than 100 pounds. Incomplete abor- 
tion of three weeks' duration; pulse, 150. As a preliminary y8 grain 
morphin, Fiso grain atropin, and 10 grains chloretone were employed. 
Four ounces of a 75 per cent oil-ether solution were administered. Patient 
completely anesthetized in 10 minutes, did not vomit, and 3 hours after 
the operation asked when the doctor was coming to operate. Left hospital 
four days later. 
Case xii.-Woman; weight, 165 pounds. Gallstones. Almost imper- 
ceptible pulse. Patient was given a preliminary administration of grain 
morphin, ¥150 grain atropin, and 10 grains chloretone. Eight ounces of 
a 75 per cent oil-ether solution were administered. Pulse improved imme- 
diately. After establishing ether tension, the patient seemed a little too 
deeply narcotized, and 3 ounces of the solution were siphoned off before 
the operation was begun. The anesthesia was supplemented with chloro- 
form when operating on the gall-bladder. Operation lasted 1 hour and 
30 minutes. Patient reacted immediately upon irrigation, and made an 
uneventful recovery, without vomiting. 
Case xiii.-Child; age, years; weight, 40 pounds. Septic tonsils; 
swollen and inflamed glands. Patient an only child; born a blue baby. 
Lips very blue. Operation imperative. Foramen ovale patient; also systolic 
murmur. Dosage, 2 ounces of a 60 per cent oil-ether solution, given 20 min- 
utes before operation. It was necessary to complete anesthesia with a few 
drops of ether on the mask. Duration of operation, 15 minutes. Patient 
was quite cyanosed during operation. Colon massaged immediately. 
Residue was drawn off and 2 ounces of olive oil injected per rectum. Con- 
sciousness returned in 15 minutes after patient was returned to bed. In 
this case the solution was given by the nurse. The child did not see the 
doctors. He went under anesthesia quietly and easily, and came out 
without nausea or vomiting. He told his mother that he had a nose-bleed 
while asleep. He left the hospital in three days, and five months later 
had gained 10 pounds and seemed to be improving. 
Note.-Any inhalation method would have been contra-indicated in 
this case, especially nitrous oxid and oxygen. 
Careful laboratory examinations were made in three cases, with the 
following results: 
Case Reports of Dr. A. S. Brinkley-'With Complete Urinalyses.- 
The comparative clinical and microscopical appearance of the urine fol- 
lowing the anesthetic, I have found to be about the same in both the 
inhalation and rectal methods of administration. I will give a short 
report of three cases: 
Case i.-Mr. P. C., white, male, aged 28 years, Italian. Operated 
upon March 19, 1914. Operation, enucleation of glands. The patient was 
given 8 ounces of a 75 per cent mixture of ether in olive oil. This was 
one of our first cases and no suppository of chloretone was given, and the 
patient complained of cramp-like pains in the rectum but not enough 
to expel the mixture. The mixture was allowed to run in slowly, about 
eight minutes being consumed. Two minutes later the patient was under ANESTHESIA BY COLONIC ABSORPTION OF ETHER 
459 
full anesthesia. A radical dissection was done, lasting one hour and ten 
minutes with perfect anesthesia throughout. The patient returned to his 
room with pulse 100, and three hours later the pulse was 72. He vomited 
once, three hours after the operation. He had slight nausea that after- 
noon, but no nausea or vomiting afterwards. Highest pulse rate next day 
was 88 and temperature 99. Fourth day, the highest pulse rate was 80 
and temperature 98. He had a very comfortable day and was given 
calomel on the third day. On the sixth day, the highest pulse rate was 
78 and temperature 98; had a very good day. He has never complained 
of discomfort in the rectum. Patient left for home in good condition on 
the tenth day. 
Urinalysis day before operation: color, amber; transparency, cloudy; 
reaction, acid; sugar, negative; albumin, negative; specific gravity, 1.020; 
microscopic examination, negative. First day after operation: color, 
amber; transparency, cloudy; reaction, acid; sugar, negative; albumin, 
negative; specific gravity, 1.025; and microscopic examination, negative. 
Third day after operation: color, amber; transparency, slight cloudiness; 
reaction, acid; sugar, negative; albumin, negative; specific gravity, 1.035; 
and microscopic examination, negative. Sixth day after operation: color, 
amber; transparency, slight cloudiness; reaction, acid; sugar, negative; 
albumin, negative; specific gravity, 1.025, and microscopic examination, 
negative. A chloretone suppository was given to everyone after this, and 
no further trouble with rectal cramps has been experienced. 
Case ii.-Mr. H. T., white, male, aged 19 years. Operated upon 
November 23, 1914. Operation, subtemporal decompression. Patient was 
given 7x/2 ounces of a 66% per cent mixture of ether and olive oil preceded 
by a suppository of 10 grains chloretone. The mixture was allowed to 
run in slowly, eight minutes being consumed, and no discomfort was 
experienced. The patient was quite a long time becoming relaxed, so 
after thirty minutes had passed ether by inhalation was administered for 
one minute only. The mask was removed and the patient remained under 
perfect anesthesia for the entire length of operation, which was forty-five 
minutes. The patient returned to his room with pulse 78 and respirations 
18. Three hours later the pulse was 78 and temperature 98.4 and respira- 
tions 20. He vomited once nine hours after operation. There was no 
more nausea or vomiting. Highest pulse rate next day was 100. Patient 
was very restless and semi-delirious. He had been in this condition since 
entering the hospital. On the sixth day, pulse was 86 and temperature 
98.4, and he was much quieter than usual. He left for home on the four- 
teenth day apparently much improved. He never complained of discomfort 
in the rectum. 
Urinalysis day before operation: color, straw; transparency, cloudy; 
reaction, acid; sugar, negative; albumin, negative; specific gravity, 1.022; 
diacetic acid, negative; microscopic examination, few pus and blood cells. 
The first day after operation: color, straw; transparency, cloudy; reaction, 
acid; sugar, negative; albumin, negative; specific gravity, 1.012; diacetic 
acid, negative; and microscopic examination, few pus and blood cells and 
calcium oxalate crystals. Third day after operation: color, straw; trans- 
parency, cloudy; reaction, acid; sugar, negative; albumin, negative; specific 
gravity, 1.014; diacetic acid, negative; and microscopic examination, few 
pus and blood cells. Sixth day after operation: color, straw; transparency, 
cloudy; reaction, acid; sugar, negative; albumin, negative; specific gravity, 
1.018; diacetic acid, negative; and microscopic examination, occasional 
pus and blood cells. 
Case in.-Mrs. H. A. R., white, female, age 42 years, housewife. Oper- 
ated upon October 11, 1915. Operation, amputation of the left breast. 460 
ANESTHESIA 
This patient had taken anesthetic by open method before, and she had a 
great deal of apprehension and fear about taking it again. Sixty-six and 
two-thirds per cent ether and olive oil was given, preceded by chloretone 
suppository grains 10. Mixture was introduced slowly, ten minutes being 
consumed. The patient was under surgical anesthesia in eighteen min- 
utes. A tumor-like mass was removed and frozen section made confirmed 
diagnosis of fibro-cyst adenoma. The operation was completed, including 
examination of frozen section, in forty minutes with perfect anesthesia 
throughout. The patient returned to her room with pulse 84 and respira- 
tions 20. Three hours later her pulse was 72 and respirations 20. She 
was slightly nauseated and vomited three times during the first six hours, 
but had no nausea or vomiting afterwards. Highest pulse rate next day 
was 90, temperature 99, and she had a very comfortable day. Fourth day 
she was given calomel. Her pulse was 74 and temperature 98.6. 
Indications.-It has now been demonstrated conclusively that the 
lives of certain types of patients are better safeguarded by the employ- 
ment of oil-ether colonic anesthesia than by any other method. For 
certain subjects and operations it has proved to be the least hazardous 
and the best method from every point of view. It is especially indicated 
in the very obese, regardless of the nature of the operation, both on 
account of the difficulties encountered with inhalation methods in indi- 
viduals having narrowed air passages, and on account of the affinity of 
fats for oil. For the obese any inhalation method is fraught with risk; 
spinal and local anesthesia are difficult; intravenous anesthesia is less 
objectionable but is also attended with difficulty in this type of patient. 
With oil-ether administration, however, these patients enter surgical 
narcosis easily and awaken as from natural sleep. In every instance of 
this kind the nausea is negligible. For neurotics, the insane, and those 
in whom the psychic element predominates, this method is also especially 
adapted. 
It has been found ideal where the element of fear is as potent a factor 
as it is in goiter patients, especially in hyperthyroidism, and in all opera- 
tions upon the respiratory tract, head, neck and chest, where the presence 
of an ether cone is a hindrance to the surgeon as well as a source of 
possible infection. It is the best of all methods in surgery of the 
upper air-passages and in cases where the patients are already suffer- 
ing from respiratory embarrassment. In such cases the anesthetist 
is free to assist the surgeon by using a suction apparatus for blood, 
without at the same time lightening narcosis by withdrawing the ether 
vapor, as would occur in all inhalation anesthesias, except endotracheal 
anesthesia. 
It is especially indicated in esophagoscopy, and in suspension laryn- 
goscopy, bronchoscopy, and gastroscopy, where the absence of excessive 
mucous secretions in the air-passages is a valuable factor. In these cases 
the patient is further safeguarded by having a clear passage for the exit 
of ether vapor. This airway lightens the anesthesia very little and the ANESTHESIA BY COLONIC ABSORPTION OF ETHER 
461 
introduction of the instrument prevents the possibility of its growing too 
profound. Furthermore, with this method, the patient does not crawl 
as the instrument is introduced, nor is the focus liable to disarrangement 
at any time. 
It has been demonstrated in practice also that the method may be 
used, with perfect results and no inconvenience to the surgeon, in many 
abdominal operations, including hernial reductions and laparotomies. 
Since ether proves less irritating when given in this way, it may be 
administered with confidence to those patients who have suffered nausea 
and vomiting from previous inhalation etherization. 
Its field of usefulness is further extended by its value in cases where 
absorption must be minimized on account of lung, heart or kidney 
lesions. It may be given without deleterious effects to patients suffering 
from tuberculosis, pulmonary abscesses, pneumonia, empyema, and medi- 
astinal abscesses. 
Contra-indications.-Oil-ether colonic anesthesia should never be 
employed in diseased conditions of the intestines. Pathological condi- 
tions of the lower bowel, such as colitis, hemorrhoids, ulcer, and fistula 
in ano, are positive contra-indications to the method, and it is important 
to ascertain whether such conditions are present. The introduction of 
the oil-ether solution is aggravating to intestinal lesions, especially in 
cases where the intestinal walls have been weakened by disease, and 
there is a possibility of resulting perforation of the gut. Even where 
no lesion is known to be present, if there is considerable rectal pain 
upon the introduction of the solution, rectal anesthesia should be 
discontinued. 
Finally, owing to the necessity for preliminary preparation of the 
colon, this method is contra-indicated, as a rule, in emergency cases. 
Advantages.-From an extended personal experience, as well as that 
of a large number of surgeons and anesthetists, and from a critical review 
of all the available data on oil-ether colonic anesthesia, the writer feels 
certain that the following advantages may be justly attributed to the 
method. 
Safety.- (1) In oil-ether colonic anesthesia the limits of safety are 
wider than with any other known method, as shown by the difference 
between the dosage required for surgical narcosis and that which precipi- 
tates toxemia. The fact that it requires from ten to twenty minutes for 
the anesthesia to fully assert itself would also indicate that an equal time 
would be given if any undesirable symptoms should present themselves, 
and that is exactly what occurs. This is well illustrated in the case in 
which a near-fatality resulted. The patient received four times the re- 
quired preliminary medication and two-thirds more of the mixture than 
is necessary, with a resulting respiratory arrest of eight minutes. Upon 
instituting the usual restorative measure, she made an uneventful re- 462 
ANESTHESIA 
covery. (2) The safety of this method is further assured by the fact 
that the lungs are free to eliminate ether as fast as it is absorbed from 
the rectum and that, owing to the large quantity of vapor which is lost 
by exhalation, the brain is never deeply narcotized. (3) When the 
technique outlined by the author is adhered to, both pre-anesthetic and 
surgical shock, so far as the anesthetic is concerned, are almost impos- 
sible. (4) Post-operatively, the oil-ether solution acts as a prophylactic 
against colon bacillus infection. (5) In head and neck surgery, the 
operative field is free from contamination by the anesthetist. (6) While 
the total amount of the mixture is in the body, the patient is as safe from 
an overdose as if it were in a container outside the body. (7) No deaths 
may be attributed directly to this method, when properly given, and in- 
telligently supervised. 
Comfort.- (1) With the oil-ether method patients are anesthetized 
in bed with little or no conception on their part of what is taking place. 
The administration is conducted without the slightest exposure of the 
patient. (2) The patient lies on the left side in perfect comfort, in 
marked contrast to the disagreeable supine position required for anes- 
thesia by inhalation. (3) The apprehension of impending danger 
usually caused by placing a mask over the face is avoided and the patient 
enters surgical narcosis easily and rapidly with no sense of suffocation. 
(4) In operations where the element of fear is a dominant factor, in the 
presence of insanity or of nervous tension, the pre-operative control of 
mental distress and excitement by this method has proved invaluable. 
(5) The comfort of the patient is further enhanced by the fact that he 
awakes in an analgesic state and post-operative pain is eliminated for 
five to twenty hours. 
Control.-Owing to certain physiological factors which have been 
defined, narcosis is automatically maintained at a more even plane than is 
possible with any inhalation anesthetic, unless administered by a skilled 
anesthetist using a perfect apparatus. The anesthetist always has com- 
plete control of the anesthesia. Any error in judgment may be quickly 
rectified by the addition or withdrawal of some of the mixture, or 
anesthesia may be terminated at any time by withdrawal of the mix- 
ture. 
Efficiency.- (1) This method insures prevention of shock. (2) 
Narcosis is smooth and of uniform depth. (3) Pulse and respiration 
remain near normal, without mucous rales. (4) There is little or no 
change in blood pressure. (5) The reflexes are not disturbed. (6) A 
more complete relaxation of the general muscular system is secured than 
with any other known method. (7) The stage of excitement so often 
characteristic of inhalation anesthesia is eliminated. (8) The patient 
always inhales a warm, moist vapor, and the direct irritation of a con- 
centrated vapor is overcome. (9) Loss of heat is minimized during ANESTHESIA BY COLONIC ABSORPTION OF ETHER 
463 
operation because of the diminished sweating and ether refrigeration 
with this method. (10) In over 95 per cent of cases there is no eructa- 
tion of gas during or after anesthesia. (11) Hypersecretion of mucus 
and saliva is absent, for the oil-ether is less irritating to the colonic 
mucous membrane than ether vapor is to that of the respiratory tract. 
(12) The absence of the ether cone in surgery of the head and neck not 
only lessens the technical difficulties of the operation by giving con- 
tinuous access to the field of operation, but also considerably lessens the 
duration of the operation. (13) There is also less hemorrhage in head 
operations. (14) The patient's stomach, lungs, and kidneys are spared. 
(15) As a partial analgesic, oil-ether injection is the best preparation 
for local analgesia. (16) Furthermore, this method not only does 
away with many of the dangers of inhalation anesthetics, but avoids 
thrombus, embolus, and infection, the chief dangers of intravenous 
anesthesia. 
Simplicity.-The apparatus required is inexpensive and the sim- 
plicity of the technique enables the anesthetist to devote his entire time 
to the patient. (2) It is the safest and simplest method for use by the 
practitioner who must work alone. 
After-effects.--(1) With normal patients such complications as 
colitis, bloody stools, or blood-streaked returns do not occur. (2) There 
are no toxemic complications. Blood and urine analyses, as well as 
clinical symptoms, fail to reveal any toxicity due to this method. (3) 
The distressing after-effects of inhalation ether anesthesia are absent; 
this is especially true of vomiting. (4) Post-operative nausea, as well 
as gas pains, is reduced to a negligible quantity, and there is no post- 
operative pneumonia. 
These conclusions have been based upon the actual demonstration of 
the advantages claimed for the method in cases estimated at over 10,000, 
in patients of all ages, under the care of various surgeons, who are en- 
thusiastic in expressing their unqualified approval of oil-ether colonic 
anesthesia. 
Oil-ether Colonic Anesthesia in Obstetrics.-Ten years after its in- 
troduction for general surgery, oil-ether was first systematically tested in 
100 obstetrical cases by Thaler and Hubei.1 
The mixture was 90 grams (3 ounces) of ether and 120 grams (4 
ounces) of olive oil. The amount used at one injection was 100 c.c. 
(3y2 ounces) introduced very slowly. In a typical case, a few minutes 
after injection, the eyelids close and a general relaxation sets in. The 
condition is suggestive of twilight sleep, but if there is no marked effect 
after ten minutes, a second injection of 50 c.c. is given. In only one 
case was the method entirely impractical. With this one exception there 
was no complaint of pain or irritation of intestine. 
1 Centralblatt fur Gyndkologie, Leipsic, 47, 337-384 (March 3, 1923). 464 
ANESTHESIA 
In 16 cases this injection (50 c.c.) was repeated once. 
" 25 " " " " " " twice. 
" 20 " " " " " " three times. 
" 15 " " " " " " four times. 
" 12 " " " " " " five times. 
" 4 " " " " " " six times. 
" 2 " " " " " " seven times. 
" 1 " " " " " " eight times. 
In one case the maximum total amounted to 767 c.c., of which 270 c.c. 
were lost. No rectal irritation. 
In 88 cases the results were satisfactory. 
" 4 " there was absolute failure. 
(( 80 " normal or very strong labor contractions. 
" 20 " labor was reduced or retarded. In these cases quinin or 
pituitary extract was added. 
In some cases the labor seemed to be improved by the oil-ether 
mixture. 
In 73 primiparas average duration of birth 20% hours. 
" 27 multiparas " " " " 10% " 
No anomalies of the after-birth period were observed. No change in 
fetal heart beat. Usually born pink. 
In 84 children condition normal-cried immediately. 
" 14 " " apneic-breathed normally in five minutes with- 
out resuscitation. 
In 2 cases typical asphyxia-1 revived and second-forceps-was not 
resuscitated. 
In the majority of cases during the intervals between labor contrac- 
tions, the patients lay as if asleep, during labor contractions slightly 
restless and groaned occasionally. 
The time of rectal instillation: 
In 24 cases the os was dilated 2-4 fingers. 
a 27 a a a a u 3 u 
a g a a a a a a 
" 3 " " " " " more than 4 fingers. 
No morphin or alkaloids were used. In no case was there excitement. 
Vomiting in five cases. Strong thirst in seven cases. After delivery a 
deep sleep. Upon awakening do not recall any incidents. Of 99 born 
alive, 1 child died on fifth day, after third day intestinal inflammation 
and subsequently pneumonia. Some children were sleepy during the first 
one or two days. Ether by inhalation by comparison -with this method 
affects the brain too much. 
The disadvantage might be the impossibility of exact dosage on ac- 
count of loss, but according to the writers, the difference of individual 
reactions makes exact dosage irrelevant. The method is impractical in 
private homes. CHAPTER XII 
PART I 
LOCAL ANESTHESIA 
James F. Mitchell, M.D. 
History: Explanation of Poisonous Action of Cocain; Novocain; 
Butyn; Urea and Quinin Hydrochlorid; Preparation of Solutions; Ster- 
ilization of Solutions; Syringes; Indications and Scope of Local Anes- 
thesia; Local vs. General Anesthesia; General Preparation and Tech- 
nique; Details as to Comfort of Patients; After-treatment; Healing; 
Combination of Local and General Anesthesia. 
Methods : Surface Application; Infiltration; The Regional Method; 
Paravertebral Anesthesia; Parasacral Anesthesia; Sacral Anesthesia; 
Transsacral Anesthesia; Splanchnic Anesthesia; Venous Anesthesia; 
Arterial Anesthesia. 
Special Application: Skin; Head and Neck; Ear; Nose and Ac- 
cessory Sinuses; Tonsils; Tracheotomy; Larynx; Thyroid; Thorax and 
Breast; Laminectomy; The Extremities; Genito-urinary System; Rec- 
tum ; Gynecology; Abdomen; Inguinal Hernia; Recurrent Hernia; 
Femoral Hernia; Umbilical Hernia. 
HISTORY 
The desire to alleviate pain is as old as man; its fulfillment has 
had to wait long (Braun). Previous to the introduction of cocain, 
but little had been accomplished in attempting to produce local anes- 
thesia for surgical operations. The Egyptians were said to have pos- 
sessed certain applications for this purpose, but investigation has shown 
them to have been more superstition than actual fact. 
Compression of nerve trunks was probably the earliest method to be 
of any real service. Originating in antiquity, it was practiced by the 
Arabs, revived by Pare in the seventeenth century, and throughout suc- 
ceeding ages one sees it cropping out anew in some special tourniquet or 
pressure pad, only to be again abandoned. It survives now in the form of 
the Esmarch elastic bandage, which, it is true, will produce anesthesia 
of the distal part of a limb. The uncertainty of the anesthesia and the 
465 466 
ANESTHESIA 
length of time necessary to produce it, the actual pain of the pressure 
itself, and the danger of gangrene and motor paralysis render it unsafe 
and impracticable. In slight operations on the fingers and toes, it is 
often bearable and quite satisfactory; and, in lessening the pain of the 
first introduction of a hypodermic needle, firm digital compression of the 
skin is of material assistance. 
An Italian surgeon, Severino, through his pupil, Thomas Bartholinus, 
in the sixteenth century, first called attention to the application of cold 
locally as a means of reducing sensibility. Three centuries later it was 
again brought into practice by the animal experiments of John Hunter, 
and in 1807 Larrey, Napoleon's surgeon, reported that in amputations 
done on the field of battle at very low temperatures (-19° C.) the sensi- 
bility of the extremities was completely abolished. In 1886 Sir Benjamin 
Ward Richardson, an enthusiastic worker for the attainment of local 
anesthesia, placed this method on a practical basis by the invention of 
the ether spray. This survives to-day as the ethyl chlorid spray, which is 
more or less widely used for the performance of many minor procedures. 
Ethyl chlorid, as a freezing agent, was described by Rothenstein in 1867 
and reintroduced by Redard in 1891 as a local anesthetic. It is an in- 
flammable gas, but is dispensed commercially compressed into a colorless 
fluid contained in a cylinder, the nozzle of which is provided with a stop- 
cock. Boiling at 13° C., it evaporates at once at ordinary room tempera- 
ture. The stopcock is opened and the tube held at a distance of several 
inches, allowing the spray to play upon the part to be anesthetized until 
it is white and frozen. The freezing process acts as a terminal anes- 
thetic, and is complete in a few seconds. Applied to nerve trunks, freez- 
ing will completely block their conduction of sensation; but this is ac- 
complished only at the expense of great pain. Prolonged or extensive 
freezing is apt to cause sloughing, and even in limited areas the return 
of tissues to their normal state is very painful. Its field of usefulness is 
therefore narrow, and in nearly all cases the injection of some anesthetiz- 
ing drug is much to be preferred. Both pressure and cold, however, act 
as aids in intensifying and prolonging the action of injected drugs. 
Besides these physical means-pressure and cold-ancient medical 
literature is replete with instances of drugs claimed to produce local loss 
of sensation. Mandragora, aconite, and a host of others have been ex- 
ploited as applications to mucous membrane or unbroken skin. All have 
been discarded as practically worthless. 
Electricity came in for its trial as a local anesthetic, and as a means 
of carrying in drugs was at one time extensively employed. The effect 
was probably more that of suggestion than of actual medication. 
Local anesthesia through the physiological action of special drugs was 
made possible in 1853 by Alexander Wood, who introduced the hypo- 
dermic syringe, and thus offered a new means of applying solutions to LOCAL ANESTHESIA 
467 
sensitive parts. Wood began at once with the injection of morphin in 
the neighborhood of nerve trunks for the relief of neuralgia. Many cases 
were reported in which local anesthesia was thus produced. The results 
obtained were due to the general rather than to the local action of the 
morphin. Many other substances were tried, but none was found satis- 
factory until in 1884 the anesthetic action of cocain was demonstrated 
by Koller. With it begin the developments of modern local anes- 
thesia. 
The earliest clinical demonstrations of the value of cocain were made 
by Halsted (1884) and Corning (1885). Even at this early stage, 
Halsted pointed out many of the essential points, and emphasized the 
importance of intradermal injection and the efficacy of very dilute solu- 
tions. Hall and Halsted also showed that injection of a nerve trunk in 
any part of its course is followed by a sensory paralysis in its entire 
peripheral distribution, thus paving the way for the • neuroregional 
method, which later was developed by Crile, Cushing, and Matas. To 
Reclus and Schleich is due the credit of lessening the danger of poisoning 
by reducing the strength of solutions. It had long been observed that 
the danger of poisoning could be eliminated by controlling the circula- 
tion of the injected area and for this purpose a tourniquet served well in 
the distal portion of a limb or cold was applied in other regions for its 
vasoconstrictor action. 
The demonstration of the value of adrenalin as an addition to solu- 
tions of cocain and other anesthetics, as brought out by Elsberg, Barker, 
and Braun, wras an enormous step forward. Adrenalin was first prepared 
in 1901 in pure form. It is a powerful vasoconstrictor, and in a dilution 
of 1: 1,000,000 will produce local ischemia. It takes the place of the 
physical aids, cold and pressure, and by hindering absorption acts as a 
valuable safeguard against poisoning. It can be added to solutions drop 
by drop in the commercial strength (1:1,000), or may be prepared with 
the anesthetizing drug in tablet form. 
Many substitutes for cocain have been introduced chiefly because of 
their lesser Few of these have become popular, novocain being 
the chief survivor. 
In 1908 Bier suggested a new method of producing local anesthesia 
in the limbs by the injection of novocain into a vein, and in 1909 Goyanes 
modified this method by making the injection directly into an exposed 
artery instead of a vein. These methods have not been generally adopted 
because they offer very little more than the simpler procedure of nerve 
blocking. The present success of local anesthesia is due largely to de- 
velopment of nerve blocking which was originally demonstrated by 
Halsted. Some forms of this procedure are of sufficient importance to 
be known as distinct methods. Paravertebral and splanchic anesthesia 
thus represent the greatest development in technique. 468 
ANESTHESIA 
Anesthetizing Drugs-Explanation of Poisonous Action.-Co azin, 
the first drug to make local anesthesia a practical possibility, has been 
strongly criticized because of the danger of poisoning. This was due at 
first to the strong solution used and later to faulty technique, too rapid 
injection, or imperfect control of the circulation. Cocain, like all other 
anesthetizing drugs is a protoplasmic poison, forming with protoplasm 
an unstable combination which breaks dowm slowly, after which the 
tissues return to their normal condition and resume their normal func- 
tion. That part which has entered into this combination and has exerted 
its anesthetizing power cannot be absorbed; therefore poisoning can be 
due only to absorption of the excess, which the tissues are unable to take 
up. The toxic dose varies with the concentration of the solution and its 
method of application. Subcutaneously it is stated for cocain to be 50 
mg., intravenously 2 mg., and intra-arterially ten times this amount. 
In weak solutions slowly injected, much larger amounts can be used than 
in concentrated solutions, or with rapid injection. The brain and central 
nervous system are most susceptible. Sensory nerves are more rapidly 
affected than motor. The mildest symptom of poisoning is slight dizzi- 
ness, and from this there are all grades leading to collapse, convulsions, 
and death. The inhalation of amyl nitrite is the best antidote for the 
early symptoms. Epigastric discomfort, transient pallor, and sweating, 
often seen at the beginning of an operation, are purely psychic and not 
toxic, and disappear quickly with the administration of a few whiffs of 
aromatic spirits of ammonia or lowering of the head. Cocain is ordi- 
narily used in two strengths, viz., one per cent solution for direct injec- 
tion into nerve trunks or for local application to mucous membranes, and 
one-tenth of one per cent for skin injection and general infiltration. 
Strong solutions act more quickly than weak ones. Adrenalin is always 
combined with cocain in the solution to control absorption. The toxicity 
of cocain and the difficulty of obtaining it due to legal restrictions on 
account of its habit forming propensity have practically banished it from 
general use. 
Novocain, discovered by Einhorn, was first clinically tested by Braun 
in 1905. It has been extolled by him in several papers,1 and has been 
quite generally adopted. It is now recognized as the best and safest 
substance for the production of local anesthesia. It is from seven to- 
ten times less toxic than cocain. Its solutions stand boiling and keep for 
a long time without deteriorating. Its action is increased and prolonged 
by the addition of adrenalin. It is conveniently supplied in tablet form. 
The ordinary strength for infiltration purposes is 0.5 per cent, and for 
the injection of nerve trunks or for rapid results in a small field 1 or 2 
per cent. Braun states that as much as 250 c.c. of a 0.5 per cent solu- 
1 Braun: Deutsch, med. Woch., 1905, 31, 1667; Deutsche Ztschr. f. Chir., 
1911, 3, 321; Lokalancesthesie, Ed. 3, 1913. LOCAL ANESTHESIA 
469 
tion, or 125 c.c. of a 1 per cent solution, can be injected without fear of 
intoxication, but cautions that in spite of this we should ever bear in 
mind that novocain is a poison. For ordinary purposes a 4 per cent stock 
solution of novocain in distilled water may be sterilized, sealed, and kept 
on hand. This is diluted just before using with sterile normal salt solu- 
tion and adrenalin added in the proportion of 0.001 gm. to 25 c.c. of the 
stock solution. The most convenient method is to make up fresh solu- 
tions from novocain-suprarenin tablets. The best, of these prepared 
according to Braun's directions contains novocain hydrochlorid (0.125 
gm.) and synthetic suprarenin (0.000125 gm.). These tablets are sup- 
posed to be sterile; but it is safer to insure sterilization by boiling, which 
does not destroy the activity of the synthetic suprarenin. One tablet 
dissolved in 25 c.c. of normal salt solution gives a 0.5 per cent solution, 
and two tablets in the same amount a 1 per cent solution. The tablets 
for the required amount of solution are best dissolved in a small amount 
of normal salt solution and boiled in a porcelain dish over a flame, and 
then the necessary amount of normal salt solution is added. It should 
be borne in mind that one can use with safety a much larger amount of 
novocain injected slowly in weak solution than in a strong solution 
rapidly injected. Novocain is somewhat slower than cocain in its 
action, and it is therefore wise to wait a few minutes after injecting it 
before beginning an operation. It has practically no action when applied 
to mucous membranes and therefore cannot replace cocain for this pur- 
pose. Novocain or procain of domestic manufacture is quite as reliable 
as the original foreign product. It is dispensed in powder form, and in 
sterile solution in ampoules for small operations; but most convenient 
are the tablets either with or without suprarenin. The A tablet corre- 
sponds to the original formula of Braun cited above. Butyn,1 a new 
synthetic local anesthetic has been given extensive trial as a result of 
which it is claimed to be superior to cocain for operations on the eye, 
nose and throat. It acts more rapidly than cocain when applied to 
mucous membranes and is more powerful, a smaller amount being re- 
quired. Its action is more prolonged and no toxic effects have been 
noted. It does not affect the pupil, has no ischemic effect and does not 
dry or shrink the tissues. It may be combined with epinephrin to pro- 
long its action. Its solutions do not deteriorate rapidly even when ex- 
posed to air and light, nor is the anesthetic efficiency impaired by boiling. 
For infiltration purposes 0.5 per cent solution is sufficient and for in- 
stillation into the eye or application to mucous membranes one to five 
per cent. It would seem that butyn may prove an excellent cocain substi- 
tute in this particular field when novocain fails. 
Urea and Quinin Hydrochlorid was suggested in 1907 by Thibault 
as a substitute for cocain. It can be obtained as powdered crystals in 
JBulson, A. E., Jr.: J. A. M. A., 1922, 78, 343. 470 
ANESTHESIA 
tablet form or in solution in sealed tubes. It is claimed for it that 
anesthesia appears quickly and lasts for several hours or days, thus 
eliminating post-operative pain; that its toxicity is practically nothing; 
and that it causes a deposition of fibrin which serves to prevent post- 
operative hemorrhage. It has therefore been especially recommended in 
the removal of tonsils and in operations about the anus and rectum, and 
as an injection in operations under local or general anesthesia for the 
prevention of post-operative pain. For application to mucous membranes 
10 to 20 per cent solutions are used, while for injection purposes the 
ordinary strength is 0.5 to 1 per cent. Where prolonged action is de- 
sired it is advised to wait from 5 to 30 minutes or longer before begin- 
ning the operation. It has some strong advocates, notably Hertzler.1 
Numerous other drugs have for one reason or another been exploited; 
but, with the exception of novocain, none is very popular at the present 
time. It would seem that with cocain, novocain, and butyn all the re- 
quirements of local anesthesia of to-day can be fulfilled. 
Preparation of Solutions.-In the preparation of any solution for 
the production of local anesthesia, certain facts should be borne in mind. 
Water, forcibly injected into the skin, will produce a transient anesthesia 
of the edematized area. It is accomplished at the expense of pain, hence 
the term "anesthesia dolorosa," applied by Liebreich. Chemically in- 
different fluids of the same specific gravity and the same freezing point 
as the tissue fluids, when injected slowly, do not cause pain or anesthesia. 
Such fluids are called isotonic. Normal physiologic salt solution is an 
example. Fluids of greater or less osmotic tension cause pain by drawing 
water from the tissues or by causing them to swell. By the use of 
isotonic physiologic salt solution as a vehicle for analgesic drugs, the 
tissues are not injured and recover promptly. The salt solution has no 
physical effect itself, but allows the drug to act alone. Schleich believed 
that the edematization of the tissues was the essential factor, and laid 
little stress on the analgesic drug. This idea has been disproved and 
more and more dependence has been placed on the analgesic action of 
the drug. A satisfactory solution should therefore be isotonic with the 
tissue fluid, and should be capable of control as to absorption. The 
first condition is attained by the addition of sodium chlorid and the 
second by adrenalin. 
Sterilization of Solutions.-Freshly prepared solutions are essential 
in order to insure constant and definite results. A single boiling just 
before use does not lessen the efficiency of the anesthetic or of the 
adrenalin, but repeated boiling, age or exposure to air will render both 
inactive. Both cocain and novocain solutions stand sterilization in the 
autoclave very well (20 minutes at 115°-120° C.) and if corked imme- 
1Hertzler: J. Am. Med. Assn., 1909, 53, 1393; also "Surgical Operations 
with Local Anesthesia," 1912. LOCAL ANESTHESIA 
471 
diately afterward will retain their activity for a long time. A convenient 
method of preparation is to place the solution in small bottles of one to 
four ounce capacity, that is, enough in a bottle for one operation. The 
bottle is filled with a wooden cork over which is placed a loose hood of 
cotton covered with gauze secured by a rubber band around the neck of 
the bottle. Before placing it in the sterilizer the cork is loosened without 
lifting the hood, and when sterilization is completed the cork is driven 
in by grasping it through the hood. This method has the advantage of 
safety in storing and transporting the solution and when the cork and 
A. 
G 
F 
H 
C 
B 
D 
E 
Fig. 174.-Syringes and Solution Bottles for Local Anesthesia. 
A, Set of glass syringes of assorted sizes ; B, Ordinary hypodermic syringe-glass with 
asbestos packing; C, Larger syringe of same type; D, All metal syringe ; E, Cannula for 
intravenous anesthesia ; F', Porcelain cups for holding sterilized solutions ; G, Bottles of 
sterilized salt solution ; H, Vial containing tablets. 
hood are removed leaves a sterile surface over which to pour out the 
solution. It is also an excellent method of preparing salt solution. The 
only instances of sloughing of tissues from the injection of a local 
anesthetic which we have had the misfortune to encounter, were due to 
a nurse furnishing a concentrated stock salt solution for the preparation 
of the anesthetic, and we feel therefore that too much care cannot be 
taken in providing proper and convenient material. 
By far the most convenient method is to use the tablets in which 
the drug is combined with suprarenin. The tablets placed between 
layers of cotton in small vials are sterilized by dry heat at 80° C. for 
.an hour on three successive days. They can then be dissolved in the 472 
ANESTHESIA 
proper amount of sterile salt solution immediately before operation. 
This will be found very useful when operations are to be done away from 
hospital surroundings. 
For routine work novocain solution is prepared daily. Just before 
operation a sufficient number of A tablets are boiled in a small amount 
of salt solution in a porcelain crucible and then the proper amount of 
sterile salt solution added. One tablet in 25 c.c. of salt solution gives 
the 0.5 per cent solution used for ordinary infiltration. 
Syringes.-Syringes for injection purposes may be of any type which 
can be boiled. For ordinary work the usual hypodermic syringes are 
satisfactory, and for minor operations the all-metal one has proved most 
economical, and will last for years without need of repair. In more ex- 
tensive operations and for the intravenous method larger glass syringes 
are suitable. Sets of them can be obtained with needles of assorted 
sizes; the syringe barrels being graduated in order to note the amount 
of anesthetic used. The syringes should be boiled in plain water, and 
after operation should be carefully dried and a drop of castor oil run into 
them. This keeps the packing from drying out, and in the case of 
all-metal or all-glass syringes prevents sticking of the piston. Steel 
needles are quite satisfactory, and a variety of sizes should be kept on 
hand, varying from short hypodermic needles to those 8 to 12 cm. in 
length, for deep injections. These should be thoroughly dried after 
use and a wire inserted in each to perserve the patency of its lumen. 
Needles of platinum or nickel possess the very distinct advantage of free- 
dom from occlusion by rust, and though expensive are probably more 
economical because of their longer life. There is no necessity for a 
syringe larger than one of 20 c.c. capacity. In the days when Schleich's 
method prevailed and edematization of tissues rather than drug action 
was depended upon, there was more need of such an apparatus as 
that of Matas. This consists of a graduated bottle containing the 
anesthetizing fluid under compressed air. The tube to which the 
injecting needle is attached is controlled by a stopcock, and the fluid 
can be forced into the tissues in any amount and under any desired 
pressure. 
This principle has been developed in the elaborate pressure apparatus 
of Farr, with which an extensive infiltration can be accomplished with 
great ease and rapidity. For general purposes a Record syringe of 10 to 
20 c.c. capacity preferably with side supports for the fingers is all that 
is needed. There are also several types of self-filling syringes with two- 
way valves which are time-saving and avoid the necessity of withdrawing 
or detaching the needle. 
Indications and Scope of Local Anesthesia.-The last few years have 
shown a steady increasing interest in the whole subject of anesthesia. 
New methods of administering general anesthetics have been developed LOCAL ANESTHESIA 
473 
and the dangers of general anesthesia lessened. The administration of 
anesthetics has been taken from the hands of the green interne in hos- 
pitals, and specialists in this particular branch have developed. Condi- 
tions have greatly improved in this respect. Nevertheless there still 
remains a large field of usefulness for local anesthesia, and in many in- 
stances an absolute necessity exists. America, the birthplace of local 
anesthesia, has left its development to European surgeons, and only 
lately has shown a revival of interest. One still sees a great deal of 
skepticism and distrust, which can mostly be attributed to ignorance of 
the technique and its possibilities. One sees men attempting operations 
under local anesthesia wrho show from the first needle prick their 
absolute unfamiliarity with its general principles, and hears them later 
express their opinions as to the unsatisfactoriness of the method. 
American hurry, too, is in a large part responsible. In spite of skill, 
these operations usually require more time. From the patient's stand- 
point, the question is different. One rarely hears a patient w7ho has been 
through an operation in skilled hands condemn the method or select a 
general anesthetic for a second experience. In our clinic there is a 
distinctly growing class of patients w7ho demand a local anesthetic. This 
applies especially to hernia cases, where a general anesthetic is never 
given. 
Again, there are those patients of greatly lowered vitality, in 
whom general anesthesia of itself might be enough to turn the scale 
downward, who may be safely carried through a serious surgical pro- 
cedure under local anesthesia. Haste is unnecessary; operations may be 
much more thoroughly and carefully done than where every effort is 
bent on shortening the period of anesthesia. Thus in strangulated her- 
nias, especially where the strangulation has lasted some time, I believe 
local anesthesia imperative, an opinion shared by Lund,1 Labat2 and 
many others. An important and large class includes a host of minor 
procedures often considered too trivial for general anesthesia and usually 
done without any anesthetic-exploratory punctures, opening of 
furuncles, etc. These can be accomplished more thoroughly and with 
vastly more comfort to the patient with the aid of a little novocain. 
Many persons who would rather bear such ills as disfiguring scars, benign 
tumors, small anal fissures or hemorrhoids than submit to a general 
anesthetic, will gladly welcome their removal under local anesthesia. 
When hospital conveniences are wanting or assistants not at hand, as in 
country practice, a knowledge of the principles of the various local 
methods will make the apparently impossible an easy possibility. 
Local versus General Anesthesia.-Where general narcosis is abso- 
lutely contra-indicated, as by extensive pulmonary involvement, many 
1Lund: Ann. of Surg., 1911, 54, 420. 
2Labat: Surg., Gyn. and Obstet., 1922, 34, 398. 474 
ANESTHESIA 
operations may be performed by local means without any change in the 
patient's general condition. In many instances where there are no con- 
tra-indications whatever to a general anesthetic, the comfort of the pa- 
tient after operation, the absence of nausea and vomiting, and the addi- 
tional element of safety are enough to decide in favor of the local pro- 
cedure. There is no doubt that the blocking of the transmission of nerve 
impulses from the field of operation is a valuable factor in the prevention 
of shock. This has been thoroughly demonstrated by Kocher and Crile, 
who in bad operative risks, when operating under general anesthesia, at 
the same time shut off the field of operation from the brain by a thor- 
ough infiltration with cocain or novocain. Crile 1 states that, "if one 
combines a complete local anesthesia with a general anesthesia and avoids 
fear, then it matters not how poor the risk, nor how extensive the opera- 
tion, the nervous system is wholly protected and the immediate opera- 
tive risk wholly eliminated." There is no absolute rule; but it is safe 
to say that, when the field of operation can be made painless and the 
operative procedure as well carried out under local anesthesia as with 
general narcosis, local anesthesia may be the method of choice. The 
question of time may figure largely in this choice, and one of the greatest 
factors against the local method is the amount of time consumed and 
the greater strain on the surgeon himself. In children and very nerv- 
ous individuals it is often unsatisfactory. The very nervous individual 
is rare, who cannot be brought to a neutral state by establishing a con- 
dition of mutual confidence which should exist between surgeon and 
patient, or by a preliminary dose of morphin and scopolamin. I have 
been able to circumcise a boy of five and operate for hernia in another 
of ten years under local anesthesia, and in many cases one is surprised 
at the ease with which children can be controlled during operations under 
local anesthesia once their confidence has been gained. Farr reports 
wonderful success in an extensive series of operations on young children. 
With the exception of some children and very nervous patients, there 
are no contra-indications. In careful hands the danger of poisoning 
should be entirely eliminated. The danger of post-operative pulmonary 
and renal disturbances is greatly lessened, a most desirable fact. There 
is no question that pneumonia does occur after operations under local 
anesthesia, especially in old or very obese persons, just as it might occur 
in the same type on being put to bed on account of a fractured limb, but 
that the probability is lessened by the avoidance of a general anesthetic 
cannot be denied. 
General Preparation and Technique.-The general preparation of the 
patient is the same as for general narcosis; except that, unless especially 
contra-indicated by the nature of the operation, a cup of coffee or a very 
1 Crile: Surg., Gyn. and Obstet., 1911, 13, 170. LOCAL ANESTHESIA 
475 
light breakfast may be taken. It is really better when possible to have 
something in the stomach. An hour before operation a hypodermic 
injection of morphin sulphate (gr. 1/6) is given, and to this may be 
added a small dose, of scopolamin (gr. 1/200 to 1/150). Crile 1 says that 
"under the influence of morphin and scopolamin no one is a coward, no 
one is brave, everyone is in a neutral state." The patient should be re- 
assured as to the nature of the operation and its probable outcome, and 
the surgeon should have the confidence of the patient. When brought 
into the operating room, instruments and preparations should as far as 
possible be kept out of sight, and a quiet though cheerful atmosphere 
should prevail. The recumbent position is the unbroken rule even for 
the most trivial procedure. The table should be made comfortable by 
means of a rubber-covered soft mattress and a pad to support the spine. 
Too much stress cannot be laid on the importance of this pad under the 
spine, whether the anesthesia, be general or local. There is no doubt 
that nearly all the backache following operations can be avoided by atten- 
tion to this slight detail. 
Details as to Comfort of Patient.-Sensibility to pain undoubtedly 
differs in individuals, and varies with race, age, culture, intelligence, and 
mental condition. The importance of psychic pain should not be under- 
estimated, and the "moral anesthetist" is a most useful factor. His 
duty is to record the pulse and to talk with the patient, to divert his 
attention from the operation or to encourage him as to its progress. 
An occasional sip of water, a whiff of aromatic ammonia, or a reassuring 
remark may tide over an important step in the operation or may ward 
off impending nausea and other psychic phenomena. I frequently allow 
patients to smoke, and often the anticipation of a promised drink or some 
delicacy will keep their thoughts far from the field of operation. On the 
part of the surgeon himself, there are certain essentials to success, first 
of which is plenty of time. He should be able to converse without inter- 
fering with his work, an accomplishment readily attained with practice. 
He must often change his whole style of operating, avoiding the desire 
for rapid and brilliant work and cultivating tact, patience, self-control, 
and attention to details. Care must be taken in sponging and in the 
placing of retractors and their handling by assistants. Haste is always 
to be avoided, and gentle handling of the tissues is imperative. The 
accidental clamping of a nerve trunk or traction on some sensitive area 
in the early stages of an operation is apt to shake the patient's confi- 
dence and interfere materially with success. There is demanded then 
of the surgeon not only familiarity with the course and distribution of 
sensory nerve trunks, but an accurate knowledge of the sensibility of the 
various tissues and organs to pain. Much of our knowledge in this re- 
1Crile: Surg., Gynec. and Obstet., 1911, 13, 170. 476 
ANESTHESIA 
spect we owe to the painstaking observations of Lennander.1 The skin 
is everywhere sensitive, but varies somewhat in different locations. Once 
through the skin, fat, muscle, tendon and fascia are insensitive, if nerve 
trunks and large vessels are avoided; likewise bone and cartilage, while 
periosteum and synovial membranes are exquisitely sensitive. Abdominal 
organs, with some restrictions to be explained later, are not sensitive to 
pain, but the parietal peritoneum, on the other hand, is acutely so. 
Fig. 175.-Showing Triangular Pad Supporting Back and Sandbag as Support 
for Feet. 
Bearing these facts in mind, having proper solutions and instruments, 
the surgeon selecting the appropriate technique for each case will find 
little difficulty in accomplishing extensive operative procedures under 
local anesthesia, and his success will increase steadily with experience. 
After-treatment.-The after-treatment does not differ greatly from 
that after general narcosis, except that liquid nourishment may be begun 
1Lennander: Centralbl. f. Chir., 1901, 8; Mitt. a. d. Grenzgeb. d. Med. u 
Chir., 1902, 10, 38; 1906, 15, 465; 16, 19; 16, 24; also "Tr. Sect, on Surg.," 
Am. Med. Assn., 1907, 211. LOCAL ANESTHESIA 
477 
immediately, as nausea does not interfere. After abdominal operations 
it is better during the first twenty-four hours to limit the diet to liquids 
to prevent distention. 
Healing'.-Healing is in no way hindered. I have never seen slough- 
ing from the anesthetic except twice, when a nurse made up the cocain 
solution with saturated instead of normal physiologic salt solution. A 
similar experience is reported by Strobe.1 If anything, healing is 
better as a rule than with general anesthesia, a fact which can be 
attributed to the gentler handling of tissues enforced by the use of local 
methods. 
Combination of Local and General Anesthesia.-While any one of 
the methods about to be described may suffice for the successful anes- 
thetization of the operative field in individual cases, it often happens 
that it is necessary to use a combination of methods. It should be 
remembered also that there are useful combinations of local and general 
anesthesia. An operation may be started under local anesthesia, and 
when a procedure is reached which must of necessity be painful some 
general anesthetic is administered. Under such conditions a few whiffs 
will often suffice to tide over the painful step, or if it be desired to obtain 
narcosis this can be done with less anesthetic than would be required 
ordinarily. 
Too much credit cannot be given to Crile 2 for his work on anoci- 
association, the principle of which is to exclude all stimuli from the 
brain, and so protect the patient from shock. "By blocking nerve con- 
duction, local anesthetics protect the brain from the effects of local 
operative injury, but they do not protect the brain against destructive 
psychic strain. Inhalation anesthetics exclude the psychic stimulation 
of the brain cells, but do not eocclude the operative stimulation. Each 
anesthetic covers a part of the field, but there is no single agent that 
alone can produce anociation, which is the goal of operative surgery." 
The combination recommended is that of nitrous oxid-oxygen inhalation 
with thorough local infiltration with novocain. "By its use not only 
the immediate operative results but the post-operative morbidity and 
mortality as well are lessened or eliminated." Crile has not only estab- 
lished a most important and useful technique of anesthesia, but has 
rendered inestimable service in calling the attention of surgeons to the 
shock-producing effect of the rough handling of tissues during the course 
of operations under general anesthesia. The surgeon to apply the method 
properly must be trained in the application of local anesthesia and the 
careful handling of tissues which is such an important part of its 
technique. 
1 Strobe: Deut. Ztsch. /. Chir., 1909, 99, 201. 
a Crile and Lower: "Surgical Shock," etc., Philadelphia, Saunders, 1920, 
p. 125. 478 
ANESTHESIA 
METHODS 
The methods practiced in local anesthesia will be considered under 
the following heads: (1) surface applications; (2) infiltration; (3) the 
regional method, including (a) paravertebral anesthesia, (6) parasacral 
anesthesia, (c) sacral or caudal anesthesia, (d) trans-sacral anesthesia, 
(e) splanchnic anesthesia; (4) venous anesthesia; (5) arterial 
anesthesia. 
Surface Application.-Cocain applied to mucous membranes by 
means of the spray or swab will produce loss of sensibility. Its use in 
this way is confined for the most part to special work, as laryngology or 
ophthalmology. Very strong solutions were formerly used (10 per cent 
cocain), but the tendency now is to reduce the strength. As a matter 
of fact, 0.5 per cent to 1 per cent is quite sufficient. With these weaker 
solutions anesthesia appears more slowly, but in time is just as thorough. 
Here, as elsewhere in local work, one must not hurry, but should wait 
for 10 to 30 minutes before beginning any step likely to cause pain. 
Cocain applied in this way may produce far-reaching effects, as when 
anesthesia of the teeth is brought about by the placing of a cocain tampon 
in the nose. Many specialists still use cocain in strong solutions for 
application to mucous membranes, and a great many of the reported cases 
of poisoning and death are from these fields.1 Novocain, unfortunately, 
has very little action upon mucous membranes and cannot be used as a 
substitute for cocain. Butyn is recommended as the best and in some 
ways has advantages over cocain beyond its lesser toxicity. It is used in 
1 to 5 per cent solutions and may be combined with epinephrin to prolong 
its action and produce ischemia. No instance of poisoning has been 
reported. 
Infiltration.-By this was originally meant an artificial edema pro- 
duced by injecting fluid into the tissues. Anesthesia may be thus 
brought about physically with plain water or salt solution. The older 
method of Schleich 2 depended upon the pressure rather than the drug 
action for its effect, an error which was corrected by the later work of 
1 In a report by a special committee of the American Medical Association, in 
1921 (J. A. M. A., 1921, 77, 1336), there are recorded 27 deaths from local 
anesthesia in nose and throat work, during the years 1919-1921. Of 22 of 
these in which the details are given, cocain alone (11), or in combination with 
another drug (7), figured in 18. Solutions of 10 to 20 per cent, or even cocain 
crystals were applied to mucous membranes. Three deaths were attributed to 
novocain. In practically all cases the rule that the reclining position must be 
insisted upon had been violated. In a region where absorption can be so rapid 
the greatest care must be exercised as to the drug used, the strength of the 
solution, the length of time of its application to mucous membrane or the 
rapidity of its injection. 
2Schleich: ' ' Schmerzlose Operationen, " Berlin, 1894. LOCAL ANESTHESIA 
479 
Reclus 1 and others, in which the tissues are injected layer by layer as 
encountered. Braun 2 accomplishes the same thing by a circumscribing 
Fig. 176.-Circumscribing Injection for Benign Tumor. 
injection through one or more punctures, and aims to anesthetize the 
nerves before they reach the skin or the field of operation, thus making it 
Fig. 177.-Circumscribing Injection for Benign Tumor. 
unnecessary to separately anesthetize the skin. This naturally requires 
waiting for from 15 to 30 minutes before beginning the operation. It is 
'Reclus: ' ' L 'Anesthesie localises," etc., Paris, 1903. 
'Braun: ' ' Lokalanaesthesie, " Leipzig, 1913. 480 
ANESTHESIA 
much more satisfactory to produce a skin wheal in all cases so that the 
operation may be started almost immediately after the injection, and 
while the skin is being reflected the deeper injection is taking effect. 
Braun's method is the preferred technique of to-day and novocain (0.5 
per cent -j- adrenalin) the best drug. The secret of success in extensive 
operations lies not only in using the anesthetizing solution freely, but in 
waiting long enough for it to take effect, i. e., the operation should not 
be started for at least 15 minutes after the injection. For a circum- 
scribed tumor, for instance, this method is ideal. The line of incision 
is marked by one or more skin wheals, and through them the 
whole region about the tumor is freely injected. Then, after waiting 
a sufficient time, the extirpation can be painlessly done. In many 
instances, though, the procedure of Reclus-injecting layer by layer as 
the tissues are encountered-will be satisfactory. Here the sensitive 
tissues only are injected, and special attention is paid to blood vessels 
and regions likely to carry sensory nerves. Weak solutions (0.1 per cent 
cocain or 0.5 per cent novocain) are used for all such infiltrations. Sim- 
ple infiltration is useful in a host of minor procedures, and may even 
be all that is necessary in many major operations. Where the field of 
operation is extensive and the pre-operative estimation of its extent is 
not definite, better results can be obtained by employing some form of 
nerve blocking. Infiltration, however, is the keystone of local anesthesia. 
The Regional Method.-This aims to reach the nerves which supply 
the field of operation, often at a distance. The anesthetizing fluid is dis- 
tributed about a nerve trunk so that it is bathed in it (perineural) or 
is injected directly into its substance (endoneural). This method was 
first demonstrated by Halsted1 on the inferior dental nerve for the 
painless extraction of teeth. It is capable of very wide application, and 
was at first especially developed by Braun, Crile,2 Matas,3 Cushing,4 and 
others. In perineural injection the time required to produce anesthesia* 
and the thoroughness of the anesthesia, naturally depend upon the size, 
of the nerve trunk and the strength of the solution. Strong solutions 
(1 to 2 per cent novocain) are used about larger trunks, as the ulnar 
at the elbow. In blocking off a large number of smaller fibers, as the 
ascending branches in the scalp or the radial nerve about the wrist, 
the ordinary infiltration solution will suffice (0.5 per cent novocain). In 
endoneural injection the needle is thrust directly into the nerve and 
the fluid injected until the nerve appears edematous and swollen. The 
needle should point centrally, as this prevents traction and causes less 
3Ha]sted: N. Y. Med. J., Dec. 6, 1884. 
2 Crile: J. Am. Med. Assn., 1902, 38, No. 8. 
3Matas: Trans. Louisiana State Med. Soc., 1900, 329; see also, Phil. Med. J., 
1900, 6. 
'Cushing: Johns Hopkins Hosp. Bull., 1900. LOCAL ANESTHESIA 
481 
pain. There is ordinarily no complaint of pain when the needle is 
introduced. The conductivity of the nerve to all impulses is immediately 
blocked. Usually the nerve must first be exposed by dissection, but oc- 
casionally a superficial nerve, as the ulnar, may be reached through the 
skin. Here also the strong solutions give the most rapid anesthesia. 
Endoneural and perineural injections have had their greatest field of 
application in the surgery of the extremities for resections, amputations, 
etc. Hughson 1 has recently developed 
a method of locating peripheral nerves 
at their exit through the deep fascia by 
electrical stimulation with an extremely 
simple apparatus. By means of an at- 
tachment to the needle of the injecting 
syringe, deeper sensory nerves may be 
very accurately located, so that the 
injection may be made into or directly 
at the nerve. 
Experience has shown that it is not 
necessary to strike absolutely the nerve 
with the needle, but that if a large 
amount of novocain solution is depos- 
ited in the neighborhood of a nerve, it 
will in a short time (ten to twenty 
minutes) be as thoroughly blocked as 
though the solution were injected into 
its substance. By taking advantage of 
this fact, it has been possible to extend 
the field of regional anesthesia to prac- 
tically all parts of the body. In certain 
regions there has been developed such 
special technique as to justify certain 
distinctive names as (a) paravertebral, 
(&) parasacral, (c) sacral or caudal, 
(c?) trans-sacral, and (e) splanchnic anesthesia. 
(a) Paravertebral Anesthesia.-The thoracic nerves after leaving the 
intervertebral foramina immediately give off each one an anastomotic 
branch to the sympathetic and then divide into an anterior and posterior 
branch. The posterior branches supply the muscles and skin of the 
back. The anterior branches constitute the intercostal nerves. These 
and the lumbar nerves supply with sensation the whole of the chest wall 
and abdominal wall, the parietal pleura and parietal peritoneum. 
Through their anastomotic branches to the sympathetic they also inner- 
Fig. 178.-Hughson's Device for 
Localization of Nerves by 
Electrical Stimulation. 
(Localization of cutaneous 
nerves by electrical stimulation 
applied to nerve block anes- 
thesia. ) 
1 Hughson: Johns Hopkins Hosp. Bull., 1922, 33, 338. 482 
ANESTHESIA 
vate the organs within the chest and abdomen and they are the only 
sensory supply to these regions. If, then, we can reach them with an 
anesthetic before the branches to the sympathetic are given off, we will 
obtain complete insensibility of the chest and abdomen and the organs 
Fig. 179.-Technique of Paravertebral Injection. (From Regional Anesthesia, 
Labat.) 
within. This is known as paravertebral anesthesia, and was first sug- 
gested by Sellheim 1 (1905), and later developed by Laewen 2 (1911), 
Kappis 3 and others. The injections are made through an anesthetic 
1Sellheim: Verhandl. d. denitsch. Gesellsch. f. Chir., 1906, p. 176. 
2Laewen: Miinchen. med. Wchnschr., 1911, No. 26, p. 1390. 
8Kappis: Miinchen. med. Wchnschr., 1912, No. 15, p. 794. LOCAL ANESTHESIA 
483 
strip of skin 5 cm. from the midline, as in intercostal anesthesia. The 
needle locates the lower border of a rib. It is then slightly withdrawn 
and turned at an angle of 30° toward the midline and passed along the 
lower border of the rib to the angle between the rib and the transverse 
process. Meanwhile the solution is injected in order to displace the 
pleura. From 15 to 20 c.c. of solution are injected. It amounts really 
to a subpleural infiltration. The upper thoracic nerves are concerned 
with the innervation of the chest and axilla, the 6th to the 12th dorsal 
and the 1st and 2nd lumbar nerves with that of the abdomen, and 
the sacral nerves with the pelvic organs. It must be remembered, 
however, that in the skin especially there is marked overlapping of the 
regions supplied by the respective nerves and therefore it is always neces- 
sary to block above and below the nerves directly supplying the field of 
operation. It may be said of paravertebral anesthesia that, when the 
technique is fully carried out, absolute anesthesia is obtained. The 
technique, however, is by no means simple or easy, especially in stout 
individuals; nor is the method entirely without danger. It is quite 
an undertaking to block from 5 to 12 nerves on either side and a large 
amount of anesthetic is required, often approaching the limit of toxicity. 
Severe collapse has been reported from spread of the fluid along the 
nerves into the spinal canal. For routine abdominal operations, at least, 
it cannot be lauded as a safe, simple or entirely practical method. On 
the other hand, it is highly praised by some experienced in its use as 
by Siegel1 who, in 1917, reported 1,000 abdominal operations performed 
under this technique. Paravertebral anesthesia may be applied more 
readily when only one side need be injected, as in operations upon the 
neck or breast. However, in many instances it is simpler to block the 
nerves farther along in their course. 
(5) Parasacral Anesthesia.-In operations upon the pelvic organs, 
after anesthetization of the abdominal wall, we have to consider the 
blocking of the sacral nerves with their anastomoses with the sympathetic. 
This is accomplished by what is known as parasacral anesthesia-simpler 
and safer than the lumbar intraspinal method and giving anesthesia of 
longer duration. A dermal wheal is made 1.5 to 2' cm. to either side 
of the tip of the coccyx. Through one of these a needle 12 cm. long is 
introduced and the lower border of the sacrum at the side of the coccyx 
is located. The point of the needle is passed by this anteriorly and 
always in contact with bone is pushed upward parallel to the midline 
until it stops against bone. This will be at the upper border of the 
second sacral foramen. While the needle is being slowly withdrawn 
40 to 50 c.c. of 0.5-1 per cent novocain are injected infiltrating the 
region of the 2nd to the 5th sacral nerves. The first sacral foramen is 
reached by directing the needle a little outward and pushing it up until 
1 Siegel: Ztschr. f. Geburtsh. u. Gynak., 79, No. 1, p. 76. 484 
ANESTHESIA 
it impinges on bone and stops, when an injection of 30 c.c. is made. 
The same injections are repeated on the opposite side. In addition an 
injection is made anterior and posterior to the coccyx. Excellent anes- 
thesia is obtained by this method for pelvic, vaginal, genital and rectal 
operations. The sphincter ani is paralyzed. The rectum and prostate 
Fig. 180.-Parasacral or Presacral Anesthesia. Median Section shows pelvic vis- 
cera displaced far forward. Normally the rectum, even when empty, rests against 
the sacrum. (Meeker & Frazer, Surg. Gyn. & Obst. 1922.) 
and neck of the bladder are anesthetized. The peritoneum of the floor of 
the pelvis only is controlled, so that the anesthesia is not sufficient for 
hysterectomy. The method is safe and no mishaps have been reported. 
It was first suggested by Braun, who considers it more reliable than 
caudal anesthesia. Tolken has reported a series of 43 successful 
applications. LOCAL ANESTHESIA 
485 
(c) Sacral Anesthesia: Caudal Anesthesia.-In parasacral anesthesia 
the sacral nerves are blocked after leaving the vertebral canal. They may 
be reached within the canal after they leave the dura by the technique 
of sacral anesthesia which was introduced in 1903 by Cathelin.1 This 
is to be carefully distinguished from spinal anesthesia, for the injecting 
needle does not penetrate the dura. The patient is placed on his side 
and the sacro-coccygeal junction determined. The sacral hiatus is just 
above this and is usually palpable, or, if not, can be located by feeling 
the lowest sacral spine. A skin wheal is made in the midline and a fine 
trocar with stilet is introduced down to the dense membrane which closes 
the sacral canal. This can be felt as it offers some resistance to the 
trocar. After penetrating this membrane (Fig. 181), the trocar enters a 
Fig. 181.-Longitudinal Median Section of the Lower Sacrum and Surrounding 
Tissues Showing Technique of Epidural Injection. (After Cathelin. Meeker 
& Frazer, Surg. Gyn. & Obst. 1922.) 
free space when it is pushed along in the direction of the canal, for three 
or four centimeters. The stilet is withdrawn and, after waiting to see 
that neither blood nor spinal fluid escapes, about 30 c.c. of one per cent 
novocain suprarenin solution are injected. Anesthesia appears in a few 
minutes, is complete in twenty minutes, and lasts for two hours. It 
involves the area of distribution of the sacral and coccygeal nerves and, 
1Cathelin: Ann. d. mol. d. org. genito-urin., 1903, 21, 606. 486 
ANESTHESIA 
while not as extensive as parasacral anesthesia, is most satisfactory for 
operations about the perineum, anus, and rectum, and when aided by 
infiltration suffices for extensive pelvic work. Thompson 1 finds that 
the anesthesia varies in extent, and that this is accounted for by the 
fact that the solution diffuses along the space outside the dura and 
ascends to different levels, in some instances as high as the upper lumbar 
and lower dorsal nerves. He states that in his clinic it is used as a 
routine procedure in all operations on the anal canal and lower rectum, 
in perineal operations, in external uretherotomies, and in operations on 
the body of the penis. The method is highly praised by Harris,2 who 
has done much to popularize it. No accidents nor untoward results 
have been recorded. 
(d) Trans-sacrdl Anesthesia, was proposed by Davis in 1913 as a 
substitute for sacral or parasacral anesthesia. It is claimed to be more 
certain in its results than sacral and less difficult than parasacral. It 
is highly praised by Meeker and Frazer 3 in a report of 225 consecutive 
operations at the Mayo Clinic. They give the details of the technique 
with excellent illustrations. The method consists in short of blocking 
the sacral nerves through the posterior sacral foramina. The solution is 
0.5 novocain with epinephrin, and from 75 to 140 cubic centimeters the 
ordinary amount required. There may be some tenderness over the 
sacrum, but complications and after-effects are rare and never serious. 
There were no cases of vomiting, rigors, syncope, convulsions or col- 
lapse in the Mayo series. The extent of anesthesia covers the entire 
pelvic floor and all structures lying below the pelvic peritoneum. 
The only contra-indications are deformities of the sacrum and in- 
fection of the skin and subcutaneous tissue of the sacral region, or 
malignant disease of the same parts. It may thus be employed for 
all gynecologic, genito-urinary, or rectal operations in the area of its 
anesthesia. 
(e) Splanchnic Anesthesia.-The findings of Lennander that the 
abdominal organs are insensitive to cutting, crushing or burning have in 
general held good. But it is a matter of common knowledge that, even 
with anesthetization of the parietal peritoneum, operative procedures 
within the abdomen cause severe unpleasant sensations. Neuman in 
1911 was the first to shed light on this question. He found that in 
frogs and dogs irritation of the stomach, intestines, and mesentery pro- 
duced characteristic defensive movements, but after section of the 
splanchnic nerves these reactions did not appear. Kappis repeated these 
experiments with the same results, and found the stomach and intestinal 
wall insensitive: but on the contrary the great and lesser omentum, 
1 Thompson: Tr. Am. Surg. A., 1917. 
2Harris: "Keen's Surgery,'' Vol. VIII, p. 858. 
3 Meeker and Frazer: Surg. Gyn. and Obst., 1922, 35, 801. LOCAL ANESTHESIA 
487 
Fig. 182.-Transsacral Anesthesia. On the right side note relation of cutaneous 
points to posterior superior spines and sacral cornu. Soft tissues have been 
removed on the left exposing the sacral foramina. (Modified from Pauchet. 
Meeker & Frazer, Surg. Gyn. & Obst. 1922.) 
biliary passages, and the vessels of the mesentery and hilus of the liver 
highly sensitive. It is now accepted that the parietal peritoneum is 
Fig. 183.-Oblique Cross Section Through the First Sacral Foramina (semi- 
diagrammatic). Note slight median inclination of needles which are in proper 
position for injections into the foramina. (Meeker & Frazer, Surg. Gyn. & Obst., 
1922.) 
supplied by the intercostal and upper lumbar nerves; the stomach, small 
intestine, omentum, liver and hilus of the spleen by the major and minor 488 
ANESTHESIA 
splanchnic nerves; and the large intestine and pelvic organs by the 
lumbar and sacral nerves. Therefore, by exclusion of the spinal nerves 
and anesthetization of the splanchnics, the upper abdomen is rendered 
insensitive. 
The great splanchnic nerve arises by a series of roots from the 
gangliated cord from the fifth to the ninth ganglia, inclusive. Descend- 
ing along the antero-lateral aspect of the vertebral column it gains the 
abdominal cavity by piercing the crus of the diaphragm. The small 
splanchnic nerve arises from the ninth and tenth, or tenth and eleventh 
ganglia and pierces the diaphragm usually just lateral to the splanchnic 
major. After entering the abdomen the nerves pass medially and distally 
into the celiac plexus, at first lying on the antero-lateral surface of the 
vertebral bodies and then approaching the midline. From the celiac 
ganglion nerves pass out along the vessels of the mesentery. 
The splanchnics may be blocked by injecting an anesthetic solution 
near their point of exit from the diaphragm. The solution when injected 
in this vicinity rapidly spreads through the loose retroperitoneal tissues 
and coming in contact with the splanchnic nerves is sufficient to block 
them for one to two hours. As the splanchnics supply only the viscera 
splanchnic anesthesia must always be combined with thorough anes- 
thetization of the abdominal wall. 
There are three methods of anesthetizing the splanchnics. The first 
described by Kappis 1 in 1914 consists of injecting the nerves from the 
back. A skin wheal is made just below the twelfth rib 7 cm. from the 
midline. Then a long needle (12 cm.) is inserted and passed deeply 
into the tissues at an angle of 45 degrees with the sagittal plane of the 
body. After a few centimeters the body of the vertebra is reached; then 
the point of the needle is passed around the body of the vertebra to the 
front until the point of transition of the lateral into the anterior surface 
of the vertebral body is reached. This is the vicinity of the splanchnics. 
Here about 25-50 c.c. of 0.5 per cent novocain-adrenalin solution are 
injected. Then the patient is turned over and the procedure repeated 
on the other side. It is better to make the injection 0.25 to 0.5 cm. 
lateral to the vertebra instead of right against it. If the needle introduced 
at 7 cm. from the midline comes in contact with bone at a depth of less 
than 8, 9, or 10 cm. according to the obesity of the patient, it is not on 
the side of the vertebral body and it is necessary to change its direction 
and introduce it more deeply. 
The second method described by Braun 2 in 1911 is carried out from 
in front after opening the abdomen in the midline. The left lobe of the 
liver is raised from the underlying organs, the stomach pushed slightly 
to the left and the forefinger placed on the anterior surface of the first 
'Kappis: Zentralb. f. Chir., 1918, 45, 709. 
3 Braun: "Oertliche Betaeubung, " 5th ed., 1919. LOCAL ANESTHESIA 
489 
lumbar vertebra. This lies at about the level of the ensiform cartilage 
and just above the pancreas. Then a 12 cm. hollow needle is carefully 
passed along the forefinger, the pulsating aorta pushed slightly to the 
left and the needle inserted at the middle of the vertebral column and 
about 100 c.c. of 0.5 per cent novocain-adrenalin solution injected. The 
needle is correctly placed only when it encounters bone immediately 
after insertion. 
In 1917 Wendling1 suggested a method of reaching the splanchnics 
from in front through the unopened abdomen by inserting a fine needle 
just to the left of the midline one centimeter below the tip of the xyphoid 
cartilage. It is passed deeply through the tissues perpendicular to the 
plane of the table, transfixing the abdominal wall, the left lobe of the 
liver, and the lesser omentum,-and 50 to 80 c.c. of 0.5 per cent novocain- 
adrenalin solution injected in the vicinity of the splanchnics. The re- 
sistance to the passage of the needle gives information as to the location 
of its point, but even Wendling advises preliminary trials on the cadaver. 
In all the methods it is important to make sure the needle is not in a 
vessel before any solution is injected. Theoretically it is conceivable that 
interruption of the splanchnics might cause a reduction of tone of the 
abdominal vessels, with resulting plethora of the abdominal viscera and 
anemia of the brain. Theoretically the heart action could also be im- 
paired by a sudden change in blood pressure. But practically this does 
not seem to be the case. Marked changes in the pulse and unconscious- 
ness do not occur, and blood pressure taken during the course of opera- 
tion has shown no greater variations than occur in any abdominal 
operation. Injection of the splanchnics from the rear has been the 
method most used. Against Wendling's method is its uncertainty, and in 
Braun's method the handling of the viscera, which is necessary in order 
to inject the splanchnics, is painful. Some modification of this latter 
method, however, is often of great service in obtaining a partial or local- 
ized splanchnic anesthesia, as in Allen's technique 2 for kidney surgery, 
or in other procedures where the abdomen has already been opened. 
Kappis 3 reported in 1918 that he had performed almost 200 operations, 
mostly on the stomach and gall-bladder, under splanchnic anesthesia by 
his own method, and with increasing practice was obtaining better and 
better results, so that at the time of his publication he was having 
scarcely a failure. This posterior method of injection has been popular- 
ized in America by Labat.4 That it does offer a distinct aid in upper 
abdominal operations in patients who would be bad surgical risks if 
operated upon under general anesthesia is evidenced by a steadily in- 
1 Wendling: "Bruns' Beitung,'' Vol. 110, 1918. 
'Allen: Tr. South. Surg. and Gyn. A., 1920, 32, 180. 
'Kappis: Zentralbl. f. Chir., 1918, 45, 709. 
'-Labat: Brit. J. Surg., 1921, 8, 278. 490 
ANESTHESIA 
creasing number of favorable reports, as for example, a splenectomy 
done on a greatly debilitated man by Kanavel.1 
Venous Anesthesia.-In April, 1908, Bier2 presented this method 
of local anesthesia for the limbs by injecting novocain into the super- 
ficial veins. It is applicable to all operations on the extremities, such 
Fig. 184.-Technique of Injection of Splanchnic Nerve According to Labat 
(Kanavel, Surg. Clin. N. Am., 1921, vol. 1). 
as tendon transplantations, joint resections, or amputations. It is 
contra-indicated in cases of diabetic or senile gangrene. The most im- 
portant point is the production of complete ischemia by means of rubber 
bandages. The limb is elevated, and a thin rubber bandage tightly ap- 
plied from the fingers or toes up to a point a short distance above which 
the vein is exposed. Immediately above this a second Esmarch bandage 
1 Kanavel: Surg. Clinics of N. A., 1921, Vol. 1. 
2Bier: Archiv f. klin. Chir., 1908, 86, 1007. LOCAL ANESTHESIA 
491 
is applied as tightly as possible, being sure to cover a broad surface, as a 
narrow bandage soon becomes painful. Beginning centrally, the first 
bandage is removed to a point distal to the field of 
operation, where a third bandage is tightly placed. 
The field of operation is then shut off on either side 
from the circulation. The space between the two 
bandages should not be less than 10 cm. nor more 
than 25 cm. In the case of peripheral operations a 
single central bandage only is applied, but this should 
not be placed higher than the middle of the forearm 
or lower leg, except for amputations. The next step 
is to fill the segment between the two bandages with 
novocain solution, bringing all the nerve terminals in 
contact with this solution by means of a reversed 
venous supply, thus producing a direct anesthesia of 
the parts lying deeper and beyond the distal bandage. 
A large superficial vein should be selected, and may 
be conveniently marked out before applying the band- 
ages-the internal saphenous in the leg or the ba- 
silic or cephalic in the arm. A small transverse in- 
cision is made under infiltration with novocain, and 
the vein dissected free and ligated as high as possible. 
Using this ligature as a retractor, the vein is lifted 
up and an oblique incision made into it with scissors. An ordinary 
cannula is introduced, pointing peripherally into its lumen, and tied 
Fig. 185.-Method 
of Applying Rub- 
ber Bandages for 
Bier's Venous 
Anesthesia. (Pro- 
gressive Medicine, 
Dec., 1909.) 
Fig. 186.-Syringe and Cannula for Bier's Venous Anesthesia. 
tightly in place. The novocain is slowly injected through the cannula, 
sometimes under considerable force. The cannula may be connected 492 
ANESTHESIA 
to the syringe by a piece of heavy rubber tubing, but it is easier, as a 
rule, to fit the syringe directly to the cannula. The superficial veins 
between the bandages fill out and later collapse, showing that the fluid 
has passed on. Sometimes a valve offers opposition, but readily yields to 
the pressure of the syringe. As much as 40 to 50 c.c. of 0.5 per cent 
novocain without adrenalin may be used in the arm and 70 to 80 or 100 
c.c. in the leg. The fluid is prevented from escaping by clamping the 
connecting tube or the vein itself. In small limbs the segment between 
the bandages is almost immediately completely anesthetized-direct 
anesthesia; in larger ones the operation should not be started for a few 
minutes. In from 5 to 10 minutes there is complete sensory and motor 
paralysis of the limb peripheral to the distal bandage-indirect anes- 
thesia. Sensory paralysis appears a minute or so earlier than motor. 
The muscles are flaccid and relaxed. The anesthesia persists as long as 
the proximal Esmarch bandage is left in place, and disappears soon after 
its removal. It is necessary therefore to complete the operation before 
removing this bandage. The bandage in time becomes painful. Bier's 
longest operation was one and three-quarter hours. The bandage being 
removed, the cannula is taken out, the vein ligated, and the wound 
closed. It is unnecessary to attempt to wash out the novocain; for it 
enters into combination with the tissues, and is returned to the circula- 
tion in an altered form. No cases of poisoning have been reported. Ad- 
renalin is, according to Bier, not only unnecessary, but may interfere 
with the distribution of the anesthetic. Intravenous anesthesia has been 
given a fairly extensive trial, and has proven most satisfactory for all 
operations on the extremities. In traumatic surgery it should find a 
most useful field. Hayward 1 reports from Bier's clinic, 375 operations 
including amputations and fixation of fractures. Anesthesia was com- 
plete in 93 per cent. Kaerger 2 from the same clinic reports another 
group of 150 cases, and describes the application of this method to minor 
operations on the hands and feet, a most useful procedure in office or 
dispensary work. The method does not seem to be much used, as it 
has no particular advantages over nerve blocking supplemented by 
infiltration. 
Arterial Anesthesia.-Goyanes 3 in 1908 first obtained anesthesia of 
a limb by the injection of an anesthetic into an artery. He later reported 
a series of operations. The technique is quite similar to that of venous 
anesthesia, except that, instead of a superficial vein, an important artery 
is exposed between the two bandages. The artery is not opened, but 
through a very fine needle thrust into its lumen one injects 50 to 100 c.c. 
of a 0.5 per cent novocain solution. Anesthesia is complete in from 5 to 
1 Hayward: Arch. f. klin. Chir., 1912, 99, 993. 
3 Kaerger: Arch. f. klin. Chir., 1912, 99, 983. 
•Goyanes: Centralbl. f. Chir., 1909, 36, 791; Rev. din. de Madrid, 1909, 1, 12. LOCAL ANESTHESIA 
493 
15 minutes, and lasts as long as the proximal bandage is in place, with 
partial anesthesia continuing several hours, thus minimizing post-opera- 
tive pain. The novocain enters into combination with the tissues, and is 
not returned into the general circulation as such. As has been shown 
experimentally by Oppel,1 the toxic dose of cocain is much larger intra- 
arterially than intravenously, so this method should really be safer than 
the intravenous. There is no apparent effect on the wall of the artery 
itself. 
Ransohoff2 has reported a somewhat similar method, injecting 1 
c.c. of 2 per cent cocain into an artery without exsanguinating the limb. 
This technique would not seem as satisfactory as the injecting of a larger 
amount of a weaker solution into an empty vessel. The intra-arterial 
method seems to show no advantages over the intravenous, and has the 
disadvantage that arteries are more difficult of access than superficial 
veins. That the method still has some adherents is shown by a recent 
report of a series of operations by Calcagno.3 
SPECIAL APPLICATION 
As to the application of one or the other of these various procedures 
to individual operations, the discretion of the operator must decide. In 
certain instances experience has shown the fitness of some particular 
method, as in Cushing's operation for inguinal hernia; in others, where 
there is no particular choice, suggestions only can be given. The first 
thought should be given to the nerve supply of the field of operation and 
how it can best be reached by the anesthetizing solution. To give the de- 
tails of the technique in each individual operative procedure would re- 
quire space far beyond the scope of this work. For the minute working 
details of special operations references will be given from time to time, 
while for the more extensive applications one may consult the works 
of Crile, Matas, Schleich, Bier, Braun, Allen, Pauchet, Labat, and 
others. 
Skin.-As has been stated, the skin may be anesthetized for small 
incisions by freezing, by pressure, or by infiltration. By far the most 
satisfactory method is the production of a wheal by the injection of 
any of the weak solutions which have been discussed. The line of 
incision should be accurately determined and the injection begun at 
one end. The skin is picked up between the thumb and finger and firmly 
compressed. The needle is then quickly thrust in obliquely just beneath 
the surface, and the fluid slowly injected until the skin turns white. The 
10ppel: Munch. med. Woch., Aug. 31, 1909. 
'Ransohoff: Ann. of Surg., 1910, 51, 453; Lancet Clinic, Aug. 7, 1909. 
' Calcagno: S emana med., 1922, 29, 661. 494 
ANESTHESIA 
needle is then pushed along, injecting as it goes, until a wheal has been 
raised the full length of the needle. The needle is withdrawn and re- 
inserted within the forward edge of the wheal, and this procedure re- 
peated until the whole line of incision is marked by a continuous wheal. 
In this way the first needle prick is the only painful one. This line is 
immediately anesthetized, and the incision may be made at once. Careful 
Fig. 187.-Production of Skin Wheal. 
anesthetization of the skin is very necessary; for if there is pain at the 
first incision the patient loses confidence. Anesthesia thus produced 
with 1: 1000 cocain plus adrenalin or with 0.5-1 per cent novocain and 
adrenalin will last for two or three hours. If the method of Braun is 
used and the incision not made for some minutes, a separate injection 
of the skin is not necessary. One or more small wheals are raised, and 
through these anesthetic areas the subcutaneous and deeper tissues are 
injected, thus affecting the nerves before they reach the skin. All in- LOCAL ANESTHESIA 
495 
jections should be made slowly, as rapid distention of sensitive tissue is 
always painful. 
Fig. 188.-Congestion of Wheal and Beginning of Deep Injection. 
The subcutaneous fat is sensitive only in the vessels and nerve trunks 
which traverse it. Therefore, after the skin incision is made, these 
structures may be sepa- 
rately injected and di- 
vided. Before a clamp is 
applied to any such vessel 
or nerve an injection 
should be made about it, 
for pinching is more pain- 
ful than cutting. With 
this technique absolutely 
painless removal of such 
benign skin lesions as se- 
baceous cysts, warts, moles, 
scars, lipomata, etc., can 
be accomplished. With 
Braun's circumscribing 
method it is necessary to 
wait for some time, while 
the layer method permits 
immediate incision, an ad- 
vantage in minor work. Where a tumor is to be shelled out by blunt 
dissection, and retraction of the surrounding tissues is required, Braun's 1 
Fig. 189.--Anesthetization of Skin by Subcu- 
taneous Injection, Showing the Wide Area of 
Distribution Through Two Injection Points. 
("The American Practice of Surgery," Vol. IV.) 
1 See illustrations, p. 479. 496 
ANESTHESIA 
method is most useful. Here again it must be urged that the essentials 
for painless work are abundance of the anesthetizing solution and a suffi- 
cient interval between its injection and the commencement of the opera- 
tion. Immediate injection into inflamed skin is extremely painful. In 
anesthetizing such areas it is important to make the first injection at 
some distance in normal skin and slowly approach the tender region, 
or to completely surround the inflamed part with the injection with- 
out touching it, thus blocking the nerves at a distance. In this way 
localized infections may be completely excised, or abscesses opened and 
drained. 
Fig. 190.-Injection of the Deeper Structures Through the Same Points as in 
Figure 189. The arrows represent the needle passing in various directions through 
skin, subcutaneous tissue, and muscle, to the periosteum. (After Braun. "The 
American Practice of Surgery," Vol. IV.) 
Head and Neck.-In the surgery of the head, face and neck, with 
special applications for the throat, nose, eye, ear and teeth, local anes- 
thesia has a very wide field of usefulness. Attention to the nerve supply 
will make possible the performance of many extensive operations in 
which general narcosis is ordinarily required. 
The scalp with its underlying fascia and periosteum receives its whole 
nerve supply from below, hence it is possible to render insensitive con- 
siderable areas by injecting subcutaneous cross strips below the proposed 
seat of operation. Ordinary scalp wounds may be repaired by infiltrat- 
ing about them, and sebaceous cysts and other benign growths removed 
by infiltration or circumscribing injection. If the periosteum is sepa- 
rately injected and reflected, the skull may be painlessly opened and the 
surface of the brain examined or even its depths explored. The jarring 
of the chisel and mallet is unpleasant, but not painful, as I have dem- 
onstrated many times in removing osteophytes; but the bone-drill, Gigli 
saw, or rongeur forceps do not cause any complaint. The brain sub- 
stance and the dura show no evidence of sensibility to operative manipu- 
lation. The treatment of the ordinary compound, depressed fracture, 
without loss of consciousness, is easy and satisfactory by anesthetizing LOCAL ANESTHESIA 
497 
simply the scalp and periosteum. Osteoplastic flaps may be raised and 
tumors removed or epidural and subdural hemorrhages and abscesses 
evacuated. 
Cushing1 has reported the painless removal of a large sub- 
cortical cyst without any anesthetic, the bone flap having been freed at 
a previous sitting. The Gasserian ganglion may be moved without any 
Fig. 191.-Cross Strip Infiltration Blocking Area of Compound Fracture in 
Occipital Region. 
particular difficulty by simple infiltration.2 Extensive use of cocain in 
the scalp was formerly feared because of the danger of absorption, but 
with the modern pneumatic tourniquet or with adrenalin added to the 
solution there is practically no risk in using large amounts of novocain 
in weak solution. In cases of delirium or great irritability, head in- 
juries had best be treated with a general anesthetic. 
1 Cushing: J. Am. Med. Assn., 1908, 50, 847. 
'Taylor: Ann. of Surg., 1921, 73, 779. 498 
ANESTHESIA 
The face offers many possibilities for the local methods. The definite 
supply of the fifth nerve, with access to its branches at their exit from 
the skull, makes the anesthetization of its distribution an attractive field 
for nerve blocking. The supra-orbital, infra-orbital, and inferior dental 
are readily attacked at their respective foramina. Plastic operations 
about the outer ear, the mouth, nose, and eyelids are easily executed with 
the aid of simple infiltra- 
tion, and we now do in 
office practice the major- 
ity of such operations 
formerly requiring gen- 
eral narcosis. Post-oper- 
ative pain is delayed long 
enough to enable the pa- 
tient to return to his 
home and get comfort- 
ably settled. A knowl- 
edge of anatomy and 
attention to nerve supply 
will make possible most 
extensive procedures, as 
has been so ably demon- 
strated by Matas in the 
painless partial excision 
of both superior maxillae 
by blocking the nerves. 
Partial removal of the 
tongue, the cheeks, or 
gums can be done under 
infiltration or by blocking 
the lingual and inferior 
dental nerves. The tech- 
nique of blocking the individual branches of the fifth nerve will be found 
in the works of Offerhous,1, Braun,2 and Haertel3 who describe the 
anatomic approach to the Gasserian ganglion by needle puncture. The 
ganglion is reached through the foramen ovale, and injected with 1 c.c. 
of 2 per cent novocain-suprarenin solution, obtaining almost immediately 
anesthesia which lasts about an hour and a half. Haertel reports 16 
operations by this method, including six resections of the upper jaw, 
three of the lower jaw, and two of the tongue. Braun states that under 
Fig. 192.-Nerve Supply of Face and Scalp from 
the Cervical Plexus and Trigeminal Nerve. 
I, N. frontalis; 2, n. supraorbitalis; 3, n. zygo- 
matico-temporalis (trigeminus II) ; 4, n. auriculo- 
temporalis (trigeminus III) ; 5, n. aurieularis mag- 
nus; 6, n. occipitalis minor ; 7, n. occipitalis major ; 
8, n. supra- and intratrochlearis; 9, n. infra- 
orbitalis; 10, ramus nasalis ext. nervi ethmoidalis; 
II, n. metalis. (After Braun. "The American 
Practice of Surgery," Vol. IV.) 
1Offerhaus: Arch. f. Tclin. Chir., 1910, 92, 1. 
2 Braun: ' ' Lokalansesthesie, " Leipzig, 1913. 
aHaertel: Verhandl. d. deutsch. Gesellscht. f. Chir., 1911, 1, 243; also Arch, 
f. Iclin. Chir., 1912, 100, 193. LOCAL ANESTHESIA 
499 
local anesthesia resection of the upper jaw has quite lost its danger. 
Of ten patients he has lost none, and had no pulmonary complica- 
tions. 
Haertel reports nine with equal success. The application in dentistry 
is given in detail in another section. The lower jaw can be reached, for 
wiring of fractures, by infiltration with a separate injection of the 
periosteum, and great as- 
sistance may be had from 
the blocking of the inferior 
dental nerve. Perineural 
injection at the mental for- 
amina with submental in- 
filtration will enable one to 
remove a growth on the 
lower lip with its area of 
lymphatic drainage. In 
elderly persons it is a dis- 
tinct advantage to carry out 
this procedure without a 
general anesthetic. The 
cervical lymph nodes can 
thus always be removed. 
The best routine technique 
is to first distribute in the 
submental and submaxil- 
lary regions a liberal infil- 
tration of 0.5 per cent novocain-suprarenin solution, and then proceed 
with the excision of the lip. By the time this is completed and the 
gloves are changed, anesthesia in the neck is so well established that the 
dissection can be carried out at will. By substituting a block of the 
cervical plexus at the posterior border of the sternomastoid or by para- 
vertebral blocking the most elaborate dissection of the neck is possible. 
With the latter method there is some danger from blocking at the same 
time the vagus and phrenic nerves. 
Ear.-The ear, as far as its external part is concerned, can be anes- 
thetized by injections through two points, one close to the superior at- 
tachment of the auricle and one below the lobule in the furrow between 
the mastoid process and the articulation. From these two points the 
fluid is injected subcutaneously and along the wall of the external audi- 
tory canal. This often produces anesthesia of the drumhead as well. A 
solution of cocain (1 per cent) and adrenalin applied on a piece of cotton 
to the drumhead for ten or fifteen minutes will give a sufficient anesthesia 
for paracentesis. 
The mastoid process can be operated upon by periosteal injection, 
Fig. 193.-Showing the Area of Anesthesia 
Produced by a Cross Strip of Subcutaneous 
Injection Above the Supra-Orbital Ridge, 
Blocking the Nerve Supply from Below. 
(After Braun. "The American Practice of 
Surgery," Vol. IV.) 500 
ANESTHESIA 
and in 1908 forty cases were reported for Politzer's clinic, in which 
the radical operation was thus done.1 Unless there is some contra- 
indication, operations upon the mastoid should be left to general 
anesthesia. 
Fig. 194.-Sensory Innervation of the Mucous Membranes of the Head. The 
areas supplied by the various cranial nerves are indicated by the numbers of the 
nerves. (After Hasse. Haertel in Arch. f. klin. Chir., 1912.) 
Nose and Accessory Sinuses, Tonsils.-In the treatment of affections 
of the nose and accessory sinuses cocain has occupied a unique position, 
producing not only satisfactory anesthesia, but, by contracting the mu- 
cous membranes, permitting thorough examination and local treatment. 
It is applied on cotton soaked with the solution and left in place for from 
five to fifteen minutes. The solution ordinarily used was 5 per cent cocain 
plus adrenalin; but the same results can be obtained with 1 per cent co- 
cain, except that a longer period of waiting is required. Many instances 
1Haymann: Zentralbl. /. Ohrenheilk., 1908, 6, 203. LOCAL ANESTHESIA 
501 
of cocain poisoning and deaths have been reported from this particular 
field, and it is hoped that butyn with adrenalin may supplant cocain 
1 
5 
2 
if 
6 
4 
Fig. 195.-Sagittal Section through the Foramen Ovale. The section represents 
a somewhat obliquely placed vertical plane corresponding to the cannula Inserted 
in the Gasserian ganglion. (1) Gasserian ganglion fossa; (2) Porous portion 
of temporal bone; (3) Carotid canal; (4) Occipital bone; (5) Anal wing of 
sphenoid; (6) Infratemporal plane; (7) Cannula in foramen ovale. (Haertel in 
Arch. f. klin. Chir., 1912.) 
7 
entirely. Unfortunately, novocain has no action when applied to mucous 
membranes and can be used only where infiltration or nerve blocking is 
possible. Enucleation of 
the tonsils is in most cases 
readily accomplished by a 
thorough infiltration of 
the peritonsillar area. It 
has been claimed that 
there is greater tendency 
to bleeding after tonsillec- 
tomy under local anes- 
thesia, and the method 
has therefore met with 
some opposition. Hertz- 
ler 1 makes a strong plea 
for the use of quinin and 
urea hydrochlorid, claim- 
ing that it lessens the dan- 
ger of post-operative hem- 
orrhage. Experience has 
shown that this danger is 
no greater after tonsillectomy under local anesthesia, and in most clinics 
1Hertzler: Am. J. of Surg., 1911, 24, 351. 
Fig. 196.-Position and Size of Skin Wheal, for 
Puncture of Gasserian Ganglion. (Haertel 
in Arch. f. kiln. Chir., 1912.) 502 
ANESTHESIA 
the local method is a matter of routine in adults. One per cent novocain 
with adrenalin is the anesthetic of choice and gives rapid and thorough 
anesthesia. 
Eye .-The eye was the site of the first practical use of cocain. In 
many operations upon this organ narcosis has distinct disadvantages, and 
must be very deep in order to destroy sensation. Again the active co- 
operation of the patient is often desirable. The greater number of all 
operations are therefore done under local anesthesia. Two to five per 
cent solutions of cocain have been used, and are applied by dropping into 
the eye-instillation. Adrenalin increases and prolongs the action of 
the cocain. Subconjunctival injections are used in extensive operations, 
and enucleation of the eye can be painlessly done.1 For this one-half per 
Fig. 197.-Front and Side Views Showing the Direction of the Cannula to 
Reach the Gaserian Ganglion According to Haertel's Method. From the 
front the cannula points toward the eye; from the side toward the auricular 
process of the malar bone. (Haertel in Arch. j. klin. Chir., 1912.) 
cent novocain is satisfactory, but for instillation novocain cannot be used. 
Butyn 2 has been recommended as an efficient substitute for cocain in one 
to five per cent solution for instillation; or one-half per cent for infiltra- 
tion. As it has no ischemic action, and does not affect the pupil, 
adrenalin must be added where these effects are desired. 
Neck.-The greater part of the sensation of the skin and subcuta- 
neous tissue, with the fascia and muscles of the anterior part of the neck, 
is supplied by the branches of the cervical plexus, which can readily be 
reached along the posterior border of the sternomastoid muscle. The 
cervical nerves can also be anesthetized by the paravertebral method at 
their exit from the spinal canal, but one must bear in mind the danger 
of blocking at the same time the pneumogastric and phrenic nerves. 
Simpler methods may therefore be employed in the majority of neck 
xVail: J. Ophthal. <$• Oto-Laryngol., Aug., 1911. 
2Bulson, A. E., Jr.: J. A. M. A., 1922, 78, 343. LOCAL ANESTHESIA 
503 
operations. The infiltration method finds here a most extensive field 
of usefulness. Ligation of any of the great vessels can be done with the 
greatest ease. Benign tumors can be removed and individual glands or 
groups of glands excised. Com- 
plete excision of all the glands is 
difficult but possible. I have 
done this by blocking of the cer- 
vical plexus aided by infiltration, 
the dissection being carried along 
the jugular vein from the clavicle 
to the skull. Such dissections, 
however, are tedious, and unless 
there is some absolute contra- 
indication, general narcosis is to 
be preferred. In extensive malig- 
nant disease, as for Crile's block 
dissection, local anesthesia should 
not be considered. 
Tracheotomy. -In adults 
tracheotomy is by choice an oper- 
ation for local anesthesia by infil- 
tration. The trachea being opened and its mucous membrane sprayed 
with cocain, it is possible to explore its lower portion and even the 
bronchi. The cooperation of the patient may in this way be of great 
assistance in the expulsion of foreign bodies, so that they may be re- 
moved through the tracheal incision. 
Larynx.-In operative procedures upon the larynx general narcosis 
has particular disadvantages which may be avoided by the use of cocain. 
Crile 1 has demonstrated that the reflex-carrying power of the superior 
laryngeal nerve may be abolished by spraying the mucous membrane 
with cocain; or the nerve may be reached by infiltration about the tip 
of the posterior cornu of the hyoid bone. The larynx is readily exposed 
by infiltration, and may be partially or totally extirpated. 
Thyroid.-In many European clinics it has long been the custom to 
complete the majority of operations upon the thyroid gland under local 
anesthesia, and Kocher assigned his low mortality in great part to this 
fact. Mayo, on the other hand, wTith his wonderfid results, has used the 
method but little. One sees now, however, a gradually increasing ten- 
dency of American surgeons to employ local anesthesia. Thus, Ochsner,2 
for example, reports 107 thyroidectomies and describes the technique of 
injecting the anesthetizing solution as employed in his clinic. With the 
recent improvement in the administration of general anesthetics the 
Fig. 198.-Area of Anesthesia Produced 
by Blocking the Cervical Plexus at 
the Posterior Border of the Sterno- 
mastoid Muscle. (After Braun. 
"The American Practice of Surgery.") 
1 Crile, Geo. W.: The Laryngoscope (St. Louis), Dec., 1912. 
2Ochsner: Surg. Clinics of N. A., 1921, 1, 981. 504 
ANESTHESIA 
choice is not so important as it was a few years ago, when deaths under 
general anesthesia in goiter operations were not uncommon. If one 
will have the patience to work out the details of operations under the 
local methods in a few of these cases, he will be impressed with the ease 
with which seemingly difficult ones can be handled, and many a poor 
operative risk may thus be brought within the lines of safety. In 
hyperthyroidism this is especially applicable. These very nervous pa- 
tients seem to be particularly amenable to the application of the local 
methods, and it is surprising to see how well they stand even ex- 
tensive operations when aided by a preliminary dose of morphin or 
scopolamin. 
Fig. 199.-Blocking the Cervical Plexus at Posterior Border of Sternomastoid 
Muscle. 
The ligation of the thyroid arteries in such cases should always be 
done under local anesthesia. Crile often performs these operations with- 
out removing the patients from bed. For the ligation of the superior 
thyroid arteries, or, rather, of the superior poles, on both sides, a single 
transverse line of skin incision about two and a half inches in length 
crossing the central part of the thyroid cartilage is infiltrated. Through 
this a deep injection is made on either side. The incision is carried 
through skin and platysma muscle. The inner border of the sterno- 
mastoid is retracted outward, the omohyoid inward and upward, thus 
exposing the superior pole of the gland. A linen thread is passed 
around the pole, including all its vessels. Before this is tied it is well 
to inject a few drops of 1 per cent novocain about the pole, as the tighten- 
ing of the ligature is often painful. The inferior arteries can best be LOCAL ANESTHESIA 
505 
approached at the posterior border of the sternomastoid muscle just 
above the clavicle, as recommended by Rogers, the artery thus being 
secured before it passes behind the carotid. This method will be found 
much more satisfactory than exposing the artery anterior to the car- 
otid, which necessitates greater retraction and more or less delivery of the 
thyroid gland. A separate transverse incision is made for each artery, 
and the ligation is done with practically no pain. 
Fig. 200.-Injection of Neck for Thyroidectomy. Note Needles Passing along 
Sternomastoid Muscles to Block the Cervical Plexus. 
In operations upon the gland itself for the partial or complete re- 
section of a lobe or for the removal of cysts or other tumors, the trans- 
verse collar incision is ordinarily used. In this operation one may 
either anesthetize by Braun's method or by layer infiltration. Bier 1 de- 
scribes his procedure as follows: "Through anesthetic skin-wheals a 
subcutaneous injection of the field of operation is made in the form 
of a quadrant. Then the needle is carried obliquely under the fascia 
along the border of the sternomastoid, constantly injecting in the direc- 
1Bier: Ar chi v f. klin. Chir., 1909, 40, 349. 506 
ANESTHESIA 
tion of the great vessels without reaching them. The needle is intro- 
duced upward and downward under the fascia, and in deeply situated 
goiters the injection is carried behind the sternum. Finally the isthmus 
is injected. Naturally the needle cannot be passed all the way behind 
the goiter, but with sufficiently generous use of the fluid (60 to 80 c.c. 
of 0.5 per cent novocain plus adrenalin) it diffuses everywhere. At 
times even the recurrent laryngeal may be paralyzed by the novocain. 
The important point now is to wait a sufficient time before beginning 
the operation, when the goiter can usually be removed without any com- 
plaint of pain." 
Fig. 201.-Incision Through Skin and Platysma Muscle Showing Almost Blood- 
less Field. 
Another method which has proven quite satisfactory is the following. 
The line of incision is infiltrated with one-half per cent novocain. 
Through this a subcutaneous injection is carried well above and below, 
into and under the platysma. An injection of 1 per cent novocain is 
now made along the posterior border of the sternomastoid to surround 
the branches of the cervical plexus. The incision through the skin and 
platysma is made and the skin flaps reflected. The ribbon muscles are 
then retracted or divided and the goiter exposed. An injection of the 
weaker solution is now made all about the gland, especially about its 
upper pole. As a rule, no further application of the anesthetic is re- 
quired. It must be borne in mind that the chief sensitive areas encoun- 
tered in the actual cutting part of the operation are the skin and the 
vessels, and that the procedure most likely to cause pain is retraction. 
The gland itself is not sensitive, and, once exposed, tumors may be pain- LOCAL ANESTHESIA 
507 
lessly enucleated from it or portions of it excised at will. In all thyroid 
operations novocain has proved to be the best anesthetic. In cases of 
hyperthyroidism the adrenalin should be omitted because of the reaction 
which has been demonstrated by Goetsch. 
The possibilities of extensive operative work in the neck have been 
greatly increased by the introduction of the novocain-suprarenin solution, 
because of the enormous amount of the solution which can be used with 
safety. The special importance of the combination of local and general 
anesthesia in surgery of the neck has been emphasized by Crile.1 
Thorax and Breast.-There are two operations in the region of the 
thorax which in our clinic are always done under local anesthesia, ex- 
cept in very young children: open reduction of a fractured clavicle and 
resection of a rib for empyema or the drainage of abscess of the lung. 
Other minor procedures, as tapping the pericardium or aspiration of the 
pleura, so often accomplished at the expense of great pain, may be ren- 
dered perfectly painless by the judicious injection of a local anesthetic. 
Where an aspirating needle is introduced in an intercostal space through 
a frozen point on the skin there may be intense pain if it happens to 
strike the periosteum or an intercostal nerve or vessel, and there is al- 
ways pain when the parietal pleura is reached. The course of the needle 
may be completely anesthetized by first injecting the skin and then dis- 
tributing a liberal amount of a weak solution in the intercostal space 
and about the ribs or in the periosteum and finally in the pleura. A 
fairly long needle is used and the injection kept up continuously as the 
needle is pushed in until the pleura is reached. It does not matter if the 
pleura is penetrated by the needle. 
In the excision of a rib the injection may be made in the same way 
or the tissues may be injected layer by layer as encountered. When the 
periosteum is reached, it is given a separate thorough injection, then in- 
cised and reflected. The division of the rib denuded of periosteum is 
absolutely painless. The parietal pleura is quite sensitive, and requires 
a separate injection, but the lung and visceral pleura are not sensitive 
and may be painlessly incised or punctured. When several ribs are to 
be excised, it is easier to break the intercostal nerves at a distance nearer 
their exit from the spinal canal. By means of this multiple intercostal 
block the application of regional anesthesia to thoracic surgery is ex- 
tended to any limit. 
A fractured clavicle may be exposed for reduction and fixation in just 
the same way. Its periosteum being thoroughly anesthetized, no pain is 
caused by the adjustment, drilling, and fixation of the fragments. As 
immediate anesthetization is desirable and the amount used is small, 1 
per cent novocain is advised, or a liberal injection of the whole neighbor- 
hood of the fracture with 0.5 per cent novocain-suprarenin after a few 
1Crile: Jour. Am. Med. Assn., 1912, 59, 114. 508 
ANESTHESIA 
minutes will yield a painless operative field. In complicated fractures 
with several fragments, perfect reduction can be obtained, and a much 
simpler and more comfortable dressing may be applied. As there is no 
need of forced restraint to overcome displacement, the forearm may be 
left free and the period of disability is materially lessened. The results 
of this procedure have been most gratifying, and its ease and simplicity 
are strong recommendations. With careful suturing of skin and sub- 
cutaneous tissue the resulting scar is almost unnoticeable. 
The breast is a poor field for local anesthesia. Its nerve supply is 
diffuse and abundant. Small benign tumors can be removed by a diffuse 
circumscribing injection, and exploratory incisions may be made or ab- 
scesses opened in the same way. The whole breast can be excised by an 
extensive infiltration beneath and around it; but large amounts of fluid 
are necessary, and absorption is rapid. Malignant growths should always 
be operated under general anesthesia. By intercostal blocking with the 
aid of subcutaneous injection along the clavicle and a circumscribing 
injection about the operative field, it is possible to do the radical opera- 
tion for malignancy. This, however, should be attempted only under the 
most absolute contra-indications to general anesthesia, for the operator 
should in no way be hampered in any detail where thoroughness is so 
essential. A combination of nitrous oxid analgesia combined with the 
local anesthesia is here most useful. 
In the axilla, individual glands and small tumors or abscesses may 
be treated as in the other parts of the body; but in extensive dissec- 
tions, because of the rich and diffuse nerve supply and the necessarily 
painful traction on unanesthetized tissues, general anesthesia is indi- 
cated. 
Laminectomy is possible through paravertebral injection of the nerves 
corresponding to the operative field with the two above and two below. 
Frazier1 has worked out the technique and gives anatomical details. 
For the control of pain in manipulation of the cord and nerve roots he 
uses stovain applied on pledgets of cotton. 
The Extremities.-The arms and legs have been fruitful fields for 
the application of neuro-regional anesthesia, and in the development of 
methods have played an important part. The very definite nerve supply 
offers suitable opportunity for perineural and endoneural injection, and 
by a combination of these with subcutaneous blocking or local infiltration, 
almost any operation upon the extremities is possible. Intravenous and 
intra-arterial2 injection also have their field of usefulness and still retain 
some advocates, although neither method has become popular. 
The brachial plexus may be exposed at the scalini and blocked by 
direct injection, thus making possible amputations or other operations 
1 Frazier: Ann. Surg., 1918, 68, 12. 
* Calcagno: Semana med., 1922, 29, 661. 509 
LOCAL ANESTHESIA 
in any part of the arm. Crile 1 has thus done a shoulder-girdle amputa- 
tion. Kulenkampff2 has described a method by which he reaches the 
Fig. 202.-Cross-section of Forearm, 5 cm. above the Wrist. The arrows indicate 
the direction of the needle in reaching the median and ulnar nerves for perineural 
injection. (After Braun. "The American Practice of Surgery," Vol. IV.) 
plexus above the clavicle without incising the skin. He gives anatomic 
details, and reports 25 cases, in only three of which was a little ether 
necessary. This method has been extensively employed, but is not 
Fig. 203.-Sensory Nerves of One Side of Finger. Showing Method of Reaching 
Both Nerves Through One Puncture. 
altogether free from danger. Injury of the phrenic nerve and pneu- 
mothorax have been reported.3 The plexus may also be reached below 
1 Crile: J. Am. Med. Assn., 1902, 38, 491. 
2 Kulenkampff: Zentralbl. f. Chir., 1911, 38, 1337. 
'Vischer: Cor.-Bl. f. schweiz. Aerzte, 1918, 48, 772. 510 
ANESTHESIA 
the clavicle by palpating the axillary artery beneath the pectoralis major, 
and injecting above and below it. In the arm the large nerve trunks 
may be exposed and injected, obtaining anesthesia in the areas of their 
Fig. 204.-Method of Injecting to Obtain Anesthesia of the Finger or Meta- 
carpal Region. 
distribution. This can be done most readily at the elbow. The nerves 
of the arm are accessible also for perineural injection at various points. 
The median nerve may be reached at the wrist by introducing the needle 
on the ulnar side of the tendon of the palmaris longus and passing 
obliquely beneath this tendon toward the radius, a distance of 1 or 2 cm. LOCAL ANESTHESIA 
511 
The radial nerve may be blocked by subcutaneous injection. The ulnar 
nerve may be approached a couple of inches above the wrist by the needle 
passing between the ulna and the tendon of the flexor carpi ulnaris., 
Minute details of the anesthesia obtained by injection at various points 
are given by Braun. 
Fig. 205.-Distribution of the Nerves of the Upper Extremity to the Skin 
Anteriorly and Posteriorly. 1, Supraclaviculares; 2, cutaneus brachii medialis; 
3, cutaneus brachii anterior; 4, cutaneus antebr. med.; 5, cutaneus antebr. 
lateralis; 6, cutaneus antebr. dorsalis; 7, radialis superflcialis ; 8, ramus palmaris 
n. mediani; 9, ramus palmaris n. ulnaris; 10, ramus dorsalis n. ulnaris; 11, n. 
ulnaris; 12, n. medianus; 13, cutaneus brachii lateralis. (After Braun. "The 
American Practice of Surgery," Vol. IV.) 
One of the most common applications of the perineural method is in 
the anesthetization of an individual finger or toe. Each finger is sup- 
plied by four sensory nerves, two anterior and two posterior. These can 
be surrounded by the solution through two punctures at the base of the 
finger on the dorsal aspect, the needle being carried close to the bone. 
The strong solution (1 per cent) is used, and in a few minutes the whole 
finger can be rendered insensitive. Injections between the metacarpals 
will produce anesthesia of the fingers and metacarpal region as well. 
Many operations on the extremities can be done by infiltration alone. 512 
ANESTHESIA 
Lerda 1 reports a method for the painless reduction of fractures by in- 
jecting the region of the fracture freely with a weak solution by means 
of a long needle. Anesthesia is com- 
plete in 8 to 10 minutes, and in 30 
cases there was no pain during the 
reduction of the fragments. Where 
wiring or plating is indicated the 
bone may in many instances be ex- 
posed by infiltration and the perios- 
teum freely injected, when reduc- 
tion can be painlessly done. This is 
especially true of the olecranon 
and patella, which we attack as 
a matter of routine under local 
anesthesia. The tibia also lends 
itself readily to such treatment, 
and the radius and ulna often 
without much difficulty. With 
the addition of nitrous oxid at the 
moment of reducing the fragments, very extensive fractures may be fixed. 
Fig. 206.-Cross-section through Base 
of Finger. Showing the direction 
of the needle in anesthetizing the 
whole finger, a, Flexor tendons ; b, 
bone; c, extensor tendons. The 
nerves are indicated by black dots 
according to the size of the in- 
dividual trunks. (After Braun. 
"The American Practice of Surgery," 
Vol. IV.) 
Extensor hall. 
N. peronaeus 
N. peronaeus superf 
Tibialis ant, 
Extensor dig 
Tibialis post 
M. peronaei 
Flexor dig. 
Flexor hall 
M. suralis 
Fig. 207.-Cross-section through Leg Just Above Ankle, Showing Direction of 
Needle for Perineural Injection of Posterior Tibial Nerve. (After Braun. 
. "The American System of Surgery," Vol. IV.) 
'Lerda: Zentralbl. f. Chir., 1908, 34, 1417. Fig. 208.-Circumscribing Subcutaneous Block for Cutting Skin Grafts from 
Anterior Surface of the Thigh. 514 
ANESTHESIA 
In an old lady of 85 years with an oblique fracture of the shaft of the 
femur, I was able to expose the seat of fracture painlessly by infiltra- 
tion. She was then given a few whiffs of nitrous oxid while the 
greatly displaced fragments were brought into line and secured with a 
clamp. During the drilling and application of a Lane plate and screws 
she was conscious and talking, but felt no pain. She was gotten up in a 
chair on the following day, and left the hospital in six weeks, walking 
without crutches or cane. 
Small osteomyelitic cavities can be painlessly gouged out after thor- 
ough injection of the periosteum. While the bone substance is insensitive, 
the medullary cavity of the long bones is sometimes quite the opposite. 
In the buttocks and upper part of the thigh, local methods are un- 
satisfactory because of the diffuse nerve supply. The groin, however, is 
readily invaded by means of diffuse infiltration, and a complete dissec- 
tion of the glands of this region is not difficult. The sciatic and other 
nerves of the leg can be utilized for blocking when exposed by dissection. 
Skin grafts may be cut from the antero-lateral surface of the thigh by 
blocking the external cutaneous nerves. The posterior tibial nerve can 
be reached for perineural injection at the internal malleolus by inserting 
the needle 1 cm. from the median border of the tendo Achillis, passing 
it directly forward to the posterior surface of the tibia and then with- 
drawing it slightly and injecting the solution. The various operations 
for ingrowing toe nails can always be done by anesthetizing the toe, as 
already described. The operation for hallux valgus can be painlessly 
accomplished by an injection between the metatarsals. Small varices can 
be excised by infiltration, and by the intravenous method one can do a 
complete excision of varicose veins of the legs by the open method or by 
Mayo's stripping procedure. By this method also all resections of joints 
and tendon transplantation are possible. It must be remembered when 
approaching a joint by layer infiltration that synovial membranes are ex- 
quisitely sensitive, and a separate anesthetization is necessary. The joint 
is emptied of what fluid it contains by aspiration, and is refilled through 
the same needle with 0.5 per cent novocain. In a few minutes it is quite 
insensitive for exploration or removal of foreign bodies, etc. Laewen 1 
in 1911 presented the technique of reaching by puncture the various 
nerves of the leg. Keppler 2 in 1912 gave further details with the report 
of cases. Babitzki3 has described a method of reaching the sciatic nerve 
at its foramen, controlling the course of the needle by a finger in the 
rectum. 
Genitourinary System.-In this field of surgery, as in other special- 
ties, it has been the custom in the past to use unnecessarily strong solu- 
1 Laewen: Deutsch. Ztschr. f. Chir., 1911, 3, 252. 
3 Keppler: Arch. f. Chir., 1912, 100, 501. 
3Babitzki: Zentralbl. f. Chir., 1913, 40, 227. Fig. 209.-Blocking the Nerves in the Metatarsal Region in Operation for 
Hallux Valgus. 516 
ANESTHESIA 
tions. The urethra can be anesthetized by applying 1 per cent cocain 
plus adrenalin and the bladder by running into it 1: 1000 cocain and 
adrenalin, or 0.5 per cent novocain-suprarenin. It is necessary to wait 
a few minutes to obtain anesthesia. The introduction of instruments for 
exploration or treatment is then free from pain. Internal urethrotomy 
is much more painful than gradual dilatation. External urethrotomy by 
infiltration is quite satisfactory. In suprapubic cystotomy the bladder 
should first be anesthetized and the suprapubic opening made by means 
of infiltration or local field block. Tinker 1 has been able to accomplish 
perineal prostatectomy by means of infiltration and blocking of the peri- 
neal nerves, and Lanz 2 reports similar work. Franke and Posner 3 pre- 
sent a study of the sensory nerves of the pelvis and perineum with the 
technique of reaching them by puncture. They report ten prostatecto- 
mies by their method, all accomplished under absolute anesthesia. The 
more recent introduction of the sacral method-epidural, parasacral 
and trans-sacral render possible the accomplishment of perineal or 
suprapubic prostatectomy and other operations upon the bladder, 
urethra and perineum by a safe and comparatively simple technique.4 
The scrotal contents can be satisfactorily anesthetized by a thorough 
injection of the cord at or below the external ring. All operations 
for hydrocele or varicocele thus belong to the routine local anesthesia 
group. 
Fig. 210.-Anesthetization of Prepuce in Circumcision. (After Reclus. "The 
American Practice of Surgery," Vol. IV.) 
Circumcision in adults, likewise, belongs to the same class, and may 
be considered an office operation. In children it is more difficult, the 
youngest in my experience being a boy 5 years of age. The line of skin 
1 Tinker: Jour. Am. Med. Assn., 1905, 44, 471. 
2 Lanz: Deut. med. Woch., 1905, 34, 953. 
3 Franke and Posner: Arch. f. klin. Chir., 1912, 49, 139. 
4Pauchet: Urol, and Cut. Rev., 1917, 21, 486. LOCAL ANESTHESIA 
517 
incision is injected with the weak solution, the incision made, and the 
skin reflected. The mucous membrane is now injected with the same 
solution, the needle being introduced from the skin side. The mucous 
membrane is slit up the dorsum to the corona and the foreskin rolled 
back. The circular line of incision in the mucous membrane is now 
infiltrated, and when the frenum is reached it is given a special injection 
of a few drops of the strong solution. The mucous membrane is cut away 
and the sutures inserted. This method is most satisfactory and abso- 
lutely painless. Krogius applies the blocking method by injecting sub- 
Fig. 211.-Anesthetization of Base of Prepuce in Circumcision. (After Reclus, 
"The American Practice of Surgery," Vol. IV.) 
cutaneously a ring about the base of the penis, while Braun injects 0.5« 
per cent novocain about the coronary sulcus. 
Kidney.-The kidney may be very easily exposed and explored by 
simple infiltration, but when it must be delivered or when nephrectomy 
is contemplated, further anesthesia is necessary. Allen 1 describes in 
detail a technique which has proved satisfactory. It consists in exposing 
the kidney under infiltration and then blocking the splanchnic nerves 
through the wound, thus eliminating the pain caused by traction on the 
pedicle. 
Paravertebral blocking can also be used and was first applied by 
Kappis 2 in 1912. It is necessary to block the last five dorsal and the 
first three lumbar nerves. 
Rectum.-All operations about the anus which do not require dilata- 
tion of the sphincter fall readily within the domain of local anesthesia, 
and with proper technique those requiring dilatation may all be in- 
cluded. As to the anesthetic, many specialists in this line recommend 
nothing more than sterile water or salt solution, while Hertzler 3 and 
others are enthusiastic in their claims for quinin and urea hydrochlorid 
on account of the abolition of post-operative pain, the anesthesia lasting 
sometimes for several days. The ordinary 0.5 per cent solution of 
1 Allen: Trans. South. Surg. Assoc., 1920, 32, 180. 
2Kappis: Zentralb. f. Chir., 1912, 39, 249. 
'Hertzler: Am. J. of Surg., 1911, 24, 351. 518 
ANESTHESIA 
novocain and adrenalin is not satisfactory. The anal margin is particu- 
larly sensitive, and it is well in attacking it for any operative procedure 
to begin the skin injection at some little distance in less sensitive skin 
and gradually work up to the anus by injecting ahead of the needle. 
In this way external hemorrhoids and superficial fistulas may be pain- 
lessly excised, and even the extensive operation of Ball for pruritus 
offers no difficulty. 
Fig. 212.-Anesthetization of Anal and Rectal Region Showing Needles In- 
serted at Four Cardinal Points to Pass up along the Rectum. 
The whole anal region and lower part of the rectum can be anes- 
thetized by a circumscribing injection, so that the sphincter may be pain- 
lessly and thoroughly dilated for the excision or cauterization of 
hemorrhoids, the excision of fissures, etc. The skin is anesthetized 
about the anus, and through it at four cardinal points one or two centi- 
meters from the anus a long needle is introduced and the weak solution 
injected. With a finger in the rectum as a guide, the needle is thrust 
into the substance of the sphincter and along the bowel close to the 
mucous membrane, injecting always ahead of it. In this way the 
sphincter is thoroughly infiltrated and the lower part of the bowel en- 
circled by a wall of anesthetizing fluid. In a few minutes dilatation may LOCAL ANESTHESIA 
519 
be slowly proceeded with. It is very easy even in poor subjects to com- 
plete such an extensive procedure as the modified Whitehead operation 
for the complete excision of the hemorrhoidal area. The rectum is 
sensitive only in its lower few inches, so that for the treatment of the 
valves or high ulcers and polyps no further anesthetization is required. 
For extensive dissection in the ischio-rectal region and in malignant 
conditions trans-sacral or parascral anesthesia is better than the local 
circumscribing block. In combination with local block of the abdominal 
wall complete resection of any type may be done. Labat1 reports 33 such 
operations from the 
Mayo Clinic performed 
upon patients who were 
poor risks because of 
chronic heart or kidney 
lesions, pulmonary tu- 
berculosis or diabetes. 
He cites cases showing 
the satisfactory anes- 
thesia obtained and the 
innocuousness of the 
method. 
G-ynecology.-Lo cal 
anesthesia has not been 
popular in gynecologic 
work, nevertheless its 
possibilities are great, 
and reports of extensive 
operations have been 
made. Most of the classi- 
cal perineal operations 
might be done under in- 
filtration. Henrich 2 reports favorable experiences in dilating and oper- 
ating upon the cervix after thoroughly injecting its substance. Sell- 
heim 3 describes a considerable experience in blocking the pubic nerve 
for the suture of perineal tears, application of forceps, and various 
gynecologic operations. Huge 4 cites numerous vaginal operations and 
two complete vaginal hysterectomies accomplished painlessly under a 
simple infiltration with novocain. Krantz 5 gives an account of 13 cases 
in which he did the Alexander-Adams operation under local anesthesia. 
Fig. 213.-Showing Separate Injection of Fr.enum 
in Circumcision. (After Reclus. "The Ameri- 
can Practice of Surgery," Vol. IV.) 
*Labat: Johns Hop. Hosp. Bull., 1922, 33, 134. 
2 Henrich: Zentralb. f. Gyn., 1909, 33, 505. 
'Sellheim: Zentralb. f. Gyn., 1910, 34, 897. 
4Ruge: Zentralb. f. Gyn., 1912, 36, 561. 
6Kraatz: Zentralb. f. Gyn., 1910, 34, 1129. 520 
ANESTHESIA 
Sampson1 and Broese2 have also reported major gynecologic work 
under local methods, and Trout,3 describes 18 cases of Caesarean section 
painlessly and successfully accomplished under infiltration with novo- 
cain. All of these surgeons support Lennander's views as to the lack 
of sensation in the pelvic viscera themselves and emphasize the im- 
portance of avoiding traction. These reports all represent work done 
under the old infiltration methods. As in rectal surgery, the newer 
methods of sacral blocking have broadened the field so that practically 
all pelvic and perineal work may be readily placed in the field of regional 
anesthesia. Meeker and Frazer4 from the Mayo Clinic report 225 
Fig. 214.-Sagittal Section of Rectum, Showing the Direction of the Needle in 
Anesthetizing the Rectum. A, cross-section, in a vertical plane, of the anus and 
rectum; in diagram B are shown the four points (1, 2, 3, 4) where the needle 
should be inserted. (After Braun. "The American Practice of Surgery," Vol. IV.) 
operations on the pelvic floor and its viscera done under trans-sacral 
nerve block anesthesia between November, 1920, and May, 1922. 
Abdomen.-In operations involving only the abdominal parietes 
without invasion of the peritoneal cavity, little need be said, as the ordi- 
nary technique of the infiltration method applies. All the usual incisions 
for intraperitoneal work may be conducted in this way until the peri- 
toneum is reached, when new principles enter, viz.: the difference in the 
sensitiveness of the parietal and visceral peritoneum and the sensibility 
of the abdominal viscera themselves.5 
1 Sampson: Ann. of Surg., 1905, 41, 216. 
2Broese: ZentraTb. f. Gyn., 1910, 34, 1523. 
3 Trout: Surg. Gyn. and Obst., 1918, 37, 95. 
4 Meeker and Frazer: Surg. Gyn. and Obst., 1922, 35, 801. 
5 For a discussion of this question see Mitchell: J. Am. Med. Assn., 1911, 
57, 709, where a review of the subject is given with reference to the views of 
physiologists and surgeons. 215 A 
Fig. 215.-Series of Illustrations showing Progressive Steps in Operations for 
Radical Cure of Inguinal Hernia.--(a) Formation of Skin Wheal.- (b) Skin 
Wheal Complete.- (c) Injection through External Oblique Aponeurosis.- (d) 
Aponeurosis Opened in Line of Canal Showing Relation of Needle to Nerves.- 
(e) Injection of Nerves-Note Needle Pointing Centrally.- (f) Nerves Retracted- 
Sac and Cord Elevated.- (g) Sac Opened-Omentum Presenting. Insert Showing 
Omentum Reduced.- (h) Infiltration of Neck of Sac from Within.- (i) Purse- 
string Suture being Placed Around Neck of Sac.- (j) Ends of Purse-String 
Suture being Carried Behind Internal Oblique and Through Its Substance. Insert 
Shows Suture Ready to Tie Anchoring Neck of Sac High Up Behind Internal 
Oblique.- (k) Lowest Suture in Place, Including Poupart's Ligament. Periosteum 
Over Pubic Spine Conjoined Tendon and Rectus Sheath. Insert Showing Re- 
lation of Needle to Nerves.- (1) Row of Deep Sutures Complete Approximating 
Muscles to Poupart's Ligament.- (m) External Oblique Overlapped in Front of 
Cord, Ready for Skin Closure. 215 B 215 C 215 E 
215 D 215 G 
215 F 215 I 
215 H 215 K 
215 J 215 M 
215 L LOCAL ANESTHESIA 
We owe to Lennander1 the determination of the following facts, 
which, though changed in part by the more recent researches of Neuman, 
Kappis and others, still form the best working basis for the guidance of 
the surgeon in intra-abdominal work under local anesthesia. The parietal 
peritoneum is intensely sensitive to pain, but not to pressure, heat, or 
cold. The abdominal viscera, on the other hand, possess no sense of pain. 
In other words, the visceral peritoneum and the abdominal organs, inner- 
vated only by the vagus or sympathetic nerves, are not sensitive to pain, 
and painful abdominal sensations are transmitted only by the phrenic, 
the lower six intercostals, and the lumbar and sacral nerves, which supply 
the parietal peritoneum. For the mesentery, his findings are not abso- 
lute, though he considers it also insensitive. We now know that the 
splanchnics through their branches from the spinal nerves do carry 
sensory fibres to the abdominal viscera, but the sensation transmitted by 
them is rather that of discomfort than of actual pain. The splanchnics 
reach the viscera through the mesentery and are influenced therefore by 
pulling or dragging. 
No one should invade the abdomen without having in mind these 
points. It can be readily seen that an especially careful technique is 
necessary and that the parietal peritoneum is to be treated with the 
greatest respect. Before incising the parietal peritoneum, it, or its sub- 
serous connective tissue, should be widely infiltrated to allow retraction, 
and dragging on it should as far as possible be avoided. The placing of 
retractors and the force' with which they are drawn upon should be care- 
fully regulated. In introducing or removing gauze pads, care should be 
taken not to rub them over unanesthetized parietal peritoneum. By de- 
pressing the viscera in introducing the pads, and then allowing them 
to come up against the parietes, they may be painlessly placed. In han- 
dling the viscera, avoid dragging on the mesenteries or parietal attach- 
ments. Incising, suturing, burning, or crushing any part of the gastro- 
intestinal tract does not cause pain so long as there is no dragging on 
the parietal peritoneum directly or through the mesentery. 
It is evident, then, that in organs lying in apposition to the anterior 
abdominal wall operations under local anesthesia offer little difficulty. 
The liver may be painlessly incised with a knife or cautery and the gall- 
bladder opened for the removal of stones or for drainage. The region of 
the common duct, however, is most sensitive and difficult of approach. 
Gastrostomy is practically always possible, and gastro-enterostomy, in the 
absence of adhesions, is not difficult. Adhesions between viscera can be 
painlessly separated, while the separation of organs adherent to the 
parietal peritoneum is very painful. The intestines are available for 
521 
1Lennander: Centralbl. f. Chir., 1901, 8; also Mitt. a. d. Grensgeb. d. Med. 
u. Chir., 1902, 10, 38; 1906, 15, 465; 1906, 16, 19; 1906, 16, 24; see also, " Tr. 
Sect, on Surg.," J. Am. Med. Assn., 1907, 211. 522 
ANESTHESIA 
suture, anastomoses, resections, etc. In suspected perforation of the 
intestine in typhoid fever, an exploratory laparotomy under local anes- 
thesia is accomplished with no risk and should always be done rather 
than subject the patient to the dangers of delay while awaiting a definite 
diagnosis. Typhoid patients make ideal subjects as a rule, and the whole 
operation, including suture of the perforation, can ordinarily be com- 
pleted without any further anesthetic. The appendix in interval cases, 
when free, can be readily removed, as we have demonstrated in many 
cases. The only pain experienced is in clamping or pulling on its mesen- 
tery, when it is referred to the region of the umbilicus. I have been 
able also by very careful technique to remove some acutely inflamed 
appendices and even drain deeply situated abscesses after packing off the 
rest of the abdomen. Inflammation does not alter the sensitiveness of 
the viscera to operative procedures, but greatly increases that of the 
parietal peritoneum. In abdominal surgery the combination of local and 
general anesthesia is often a most valuable one. A little nitrous oxid 
may be given while those procedures involving the parietal peritoneum 
or necessitating mesenteric traction are carried out and the rest of the 
operation done under local anesthesia. 
We have found this especially useful for various anastomoses for the 
relief of ineradicable malignant disease in greatly exhausted patients. 
In gastro-enterostomy for such a condition of the pylorus, the explora- 
tion and demonstration of the condition are made under local anes- 
thesia. Whiffs of nitrous oxid are given while the anastomosis clamps 
are applied and the stomach and intestines brought into position for 
suture. The suture itself is painless, and the local anesthesia induced 
for the incision is sufficient for the closure of the abdomen. Lennander's 
article is replete with brilliant abdominal work under local anesthesia, 
and Schley 1 cites some interesting cases, showing what extensive opera- 
tions may be done in this way. Thus, under the simplest form of local 
infiltration a great deal can be accomplished by exercising care and 
bearing in mind Lennander's teaching. That regional anesthesia will 
entirely supplant general inhalation anesthesia in abdominal surgery no 
one will claim. That with the application of one or more of the newer 
methods it offers unlimited possibilities cannot be denied. Practically 
any abdominal operation which is possible under general narcosis can 
be accomplished under regional anesthesia and its employment may be 
the factor of safety in bad surgical risks. It behooves the modern sur- 
geon then to familiarize himself with the technique of the various 
methods and to become skilled in their application, that he may give 
to his patients every possible chance for a successful termination of opera- 
tive procedures entrusted to his care. In making the ordinary abdominal 
incisions for intra-abdominal work it is usually better to employ some 
1 Schley: Med. Rec., Dec. 19, 1908. LOCAL ANESTHESIA 
523 
method of nerve block rather than direct infiltration of the line of 
incision. In many instances the circumscribing block of Braun is suffi- 
cient. In other cases, it may be better to block the nerves at a distance. 
The whole anterior and lateral abdominal work, with the parietal peri- 
toneum, is supplied by the last six dorsal and the first two lumbar nerves. 
Paravertebral blocking will give complete anesthesia and absolute relaxa- 
tion, but this means the blocking of sixteen nerves at their exit from the 
spinal canal, an extensive procedure. A much simpler and more practi- 
cal method is to reach the nerves further along in this course. This can 
be done by infiltrating along the costal margin, obtaining a block of the 
upper abdomen; and by extending the infiltration downward to the iliac 
spine rendering the whole half of the abdominal wall anesthetic. Such 
a block permits the use of retractors, thus allowing good exposure. By 
adding to the abdominal wall block the appropriate block, paravertebral, 
sacral, or splanchnic anesthesia can be obtained in that part of the 
abdomen embracing the contemplated operative procedure. The possi- 
bilities of the different methods have been mentioned. Attention is again 
called to the importance of avoiding traction and rough handling and 
to the value of the judicious combination of whiffs of nitrous oxid with 
regional anesthesia to tide over some necessarily painful step. 
Hernia.-Hernia in all its external forms belongs by choice to local 
anesthesia. When strangulation is present local anesthesia is imperative, 
for the question of hurry is eliminated, as well as the shock of general 
narcosis and the danger of drowning from fecal vomitus. Local anes- 
thesia is the rule in our clinic. It is usually demanded by patients, and 
the knowledge of the method is passed on from one to another. For 
anatomical reasons simple inguinal hernias are best adapted to the 
method, for femoral and umbilical are easily maneuvered. Recurrent 
hernias are often difficult, but with experience comes ease in their man- 
agement. Age is no bar except for early childhood, my youngest case 
being a boy of ten. I have recently had a successful and painless opera- 
tion with uneventful recovery and cure in a man of 96 with a strangu- 
lated inguinal hernia. The greatest obstacles are fat and adhesions, 
because of technical difficulties in the first instance and pain in the latter. 
As to the thoroughness of the operation, there is no necessity for the 
altering of any step under the local method, and any particular type of 
operation can be utilized. The post-operative period is much more com- 
fortable, from the absence of nausea and vomiting. Healing is if any- 
thing better. Nerves are respected, thus leaving stronger muscles, and 
recurrences are no more frequent. Why, then, should a patient be sub- 
jected to the added risk and discomfort of an unnecessary general anes- 
thesia? The only reason could be to save time and trouble for the 
surgeon. In our clinic for many years all external hernias have been 
done under total anesthesia. 524 
ANESTHESIA 
Inguinal Hernia.-The radical cure of inguinal hernia as described 
by Cushing 1 is one of the most practical demonstrations of the neuro- 
regional method. With some slight modifications we use this in all in- 
guinal hernias. The skin in the line of proposed incision is infiltrated 
with novocain (0.5 per cent) and adrenalin, producing a wheal. Through 
this an injection of the same solution is made along its whole length 
into the subcutaneous tissues. Gentle massage is administered over this 
injected region for a few minutes-usually while the operator is putting 
Fig. 216.-Relations of the Inguino-Scrotal Nerves to the Hernia Incision. I, 
Iliohypogastric; II, ilio-inguinal; III, genito-crural; IV, genital branch ; V, crural 
branch. (After Cushing. "The American Practice of Surgery," Vol. IV. ) 
on his gown and the towels are being arranged. The incision at its 
upper angle is carried through skin and subcutaneous tissue to the 
aponeurosis of the external oblique. If the incision is completed 
throughout its whole length at this period, unanesthetized nerve fibers 
with one or two large vessels will be encountered in the fat, division of 
which is painful. When the external oblique is exposed, the line of 
the inguinal canal can be seen as a thinned-out area or weak line, which 
leads to the external ring. An incision is made in this in the line of 
the fibers of the external oblique, which exposes immediately the ilio- 
1 Cushing: Ann. of Surg., 1900, 31, 1. LOCAL ANESTHESIA 
525 
inguinal and ilio-hypogastric nerves. Into each of these, at as high a 
point as possible, the needle is thrust, pointing centrally, and a few drops 
of novocain plus adrenalin injected. From this point on we usually 
abandon the knife for blunt-pointed dissecting scissors. The skin 
incision can now be completed as desired, with no discomfort. The di- 
vision of the external oblique is completed according to the operator's 
method. We carry it directly through the external ring. The flaps of 
external oblique are cleared by dissection with scissors and retracted by 
clamps. The nerves are freed and held aside by one of the clamps on 
the edge of the external oblique to preserve them from injury. The 
cremaster is divided in the same line and retracted, thus exposing the 
sac and cord. An injection is made about the exposed front and sides 
of the neck of the sac; and between the elements of the cord a few drops 
are diffused. In small hernias the neck of the sac may be completely 
injected at this point, but in larger ones it is impossible to reach the 
deeper part. The sac is now opened in front, its edges held apart with 
clamps, and the contents inspected and reduced or excised as occasion 
demands. We have frequently excised large portions of omentum or 
removed the appendix, and in cases of strangulation have resected the 
intestine. The posterior line of the neck of the sac can now be seen as 
a thickened white band. This is injected with the weak solution, com- 
pleting the injection of the neck. The injection is carried well up above 
the neck of the sac. The sac is now divided at its neck, the neck is freed 
and closed with a purse-string suture. Traction on the neck of the sac 
is to be carefully avoided; for being parietal peritoneum it is exquisitely 
sensitive, and its disturbance causes not only pain, but often nausea and 
vomiting. The removal of the lower part of the sac after this division 
is not painful. The subsequent steps of the operation, depending on the 
surgeon's choice of method, may be carried out as under general narcosis, 
once the sac is disposed of. Bier 1 and Braun 2 hold that injection of 
nerves at all is superfluous and unnecessary, and prefer to make an 
injection of the whole area through the skin and to wait fifteen minutes 
or more to obtain anesthesia by diffusion of the fluid about the nerves 
and sac. I have not found this method as satisfactory as that of Cushing. 
The injection of the individual nerves adds little trouble. The nerves 
are subject to variation in their course, but not enough to materially in- 
terfere, and can usually be located with little difficulty. Cushing's sketch 
shows their usual distribution. An advantage in Cushing's method is 
that the operation can be begun almost immediately after the skin in- 
jection is completed. 
Recurrent hernias were formerly considered as necessitating general 
narcosis. For years we have been doing them all under local anesthesia, 
1Bier: Archiv f. klin. Chir., 1909, 90, 349. 
2 Braun: "Die Lokalansesthesie," Leipzig, 1913. 526 
ANESTHESIA 
and find them little more troublesome, although, in most cases the 
method of the original operator being unknown, the anatomical relations 
may be at first a little confused. In such cases it is best to carry the 
incision higher and block the nerves well above the former field of opera- 
tion. The region is then anesthetized, and the dissection of scar tissue 
made easy and painless. 
Femoral hernias, if small, can be readily treated by simple layer in- 
filtration. In larger hernias, or where strangulation is present, the in- 
cision is carried up above the external ring, a small incision made in the 
Fig. 217.-Scheme of Injection in Large Umbilical Hernia. The figures indicate 
the injection points; the arrows and dotted lines show the direction of the needle, 
and the solid lines the incision. This represents a characteristic example of the 
circumscribing blocking method of Braun. ("The American Practice of Surgery," 
Vol. IV.) 
external oblique, and the ilio-inguinal nerve blocked. With the anes- 
thesia produced in this way and a generous infiltration with the weak 
solution above the sac, no difficulty is experienced. 
Umbilical hernias can practically always be repaired under local 
anesthesia, and the large ones in very fat women demand it. For ordi- 
nary ones the circumscribing injection of Braun with separate injection 
of the skin is satisfactory. I prefer local anesthesia in all cases, and 
use the layer method of infiltration with the overlapping closure of 
Mayo. Even the largest are adapted to this form of treatment. Occur- 
ring as they do in very fat individuals-bad risks under general narcosis 
-they make a striking tribute to the value of local anesthesia. In such 
an operation on a woman weighing over three hundred pounds, two skin 
incisions over 30 cm. long, including between them a large area of skin 218 A 
Fig. 218.-Series of Illustrations Giving Progressive Steps in Operation for 
Radical Cure of Femoral Hernia :-(a) Anatomy of Femoral Region Showing 
on Left Side a Femoral Hernia and on Right Side the Skin and Fascia Removed.- 
(b) Cross Section Through Poupart's Ligament Showing Relation of Structures 
in the Femoral Arch.-(c) Sac Freed Showing Injection of its Neck and Blocking 
of the Ileo-inguinal Nerve Through External Oblique Aponeurosis; Sac Opened, 
Omentum Presenting.- (d) Sac Excised, Closed with Purse-String Sutures, Ends 
of Suture Carried Through Femoral Canal and Brought Out on Surface of 
External Oblique to Anchor Neck of Sac.- (e) Mattress Suture Through Poupart's 
Ligament and Pectineus Muscle to Close Femoral Canal. 218 P> 218 C 218 E 
218 D LOCAL ANESTHESIA 
527 
and fat to be excised, were made transversely. The sac was opened 
without attempting to free it from the overlying skin. It was filled with 
many feet of adherent large and small intestine and omentum. The neck 
of the sac, about 15 cm. in diameter, was thoroughly infiltrated with the 
cocain solution. The contents were freed and reduced. The sac was 
then divided near its neck, and after being dissected from the skin was 
removed. The opening was repaired by the Mayo overlapping method, 
the peritoneal site of each suture being injected before introducing the 
needle. Although this operation consumed over three hours, the patient 
suffered no shock, had no nausea, made a good recovery, and has re- 
mained cured of this condition. 
In the same way post-operative ventral hernias can be handled under 
local anesthesia. They consume a great deal of time, and are a source 
of wear and tear on the surgeon, but the results are ample reward. The 
repair of hernias is one of the most satisfactory applications of local 
anesthesia if the surgeon will have ever in mind the cardinal principles: 
the differences in the sensation of tissues, a sufficient and suitable applica- 
tion of properly prepared anesthetizing solution, and, above all, patience 
and plenty of time. CHAPTER XIII 
THIRD STAGE ANESTHESIA1 
ETHER 
A Subclassification Showing the Significance of the Position and 
Movements of the Eyeball.-Heretofore four stages of anesthesia have 
been recognized: the first stage, during which the patient experiences 
analgesia but retains consciousness; second, the stage of excitement; 
third, the surgical stage; fourth, the stage beginning with respiratory 
failure and ending with death. 
The latitude of the third stage of anesthesia with ether is great,-so 
great that the patient may easily be given an overdose of ether without 
being in any immediate danger. Post-operative toxemia is in direct 
proportion to the amount of ether given. The patient may be carried 
lightly, with good relaxation and quietude, and suffer but slight post- 
operative toxemia from the ether; or he may be carried for an hour in 
the deeper strata of the third stage with immediate safety so far as 
concerns the anesthetic, but with a resulting heavy post-operative 
toxemia. Light anesthesia, if the surgeon can operate to good advantage, 
is infinitely better than deep anesthesia. With ether, there is a light 
stage of surgical anesthesia which affords the surgeon as much ease 
and comfort in operating as a state of deepest anesthesia. 
The eyeball with its varying positions and movements affords an 
anesthetic sign which, in proper classification when considered in its 
association with other signs, is a reliable guide to the stage of anesthesia 
present. After the first ten or fifteen minutes of anesthesia have elapsed, 
oscillation or excentricity of the eyeball marks the ideal stage of operative 
anesthesia with ether. 
The third stage of ether anesthesia may be divided into four parts 
or strata. Correlation of the signs found in the various strata of the 
third stage are shown in Chart A. 
Column A, Fig. 220, shows respiration with anesthesia deepening. 
There is no rhythm to the respiration of the second or excitement 
stage. Transition from the second to the third stage is recognized 
by the inauguration of rhythmical and exaggerated respiration; the 
exaggeration is marked, and continues so almost without change, through- 
out the first, second and third strata of the third stage, provided there 
1 By Arthur E. Guedel. 
528 219 A 
Fig. 219.-Series of Illustrations Giving Progressive Steps in Operation for 
Radical Cure of Ventral Hernia :-(a) Post Operative Ventral Hernia Following 
Drainage Through Gridiron Incision.- (b) Circumscribing Injection.- (c) Incision 
Through Skin and Fascia Removing Scar.- (d) Sac Projecting Through External 
Oblique; Injection of Neck of Sac and Infiltration Beneath External Oblique.- 
(e) Completion of Layer Dissection ; Sac Excised and Neck Closed.- (f) Deep Layer 
of Sutures Placed Overlapping Internal Oblique and Edge of Rectus Muscle.- 
(g) Sutures in External Oblique Showing Overlapping. Insert Showing Cross Sec- 
tion of Closure:-(a) Petitoneum.- (b) Rectus.- (c) Internal Oblique.- (d) Ex- 
ternal Oblique.-(e) Fat.- (f) Skin. 219 C 
219 B 219 E 
219 D 219 G 
219 F THIRD STAGE ANESTHESIA 
529 
is a continuance of sufficient ether to carry the anesthesia progressively 
downward. As the fourth or lowest stratum of the third stage is reached 
there begins a true respiratory depression. This depression grows pro- 
gressively greater until it becomes a respiratory paralysis, which marks 
the transition from the fourth stratum of the third stage into the fourth 
stage. 
SCHEMATIC CHART SHOWING THE SIGNIFICANCE OF 
CERTAIN REFLEXES UNDER VARIOUS STAGES 
OF ETHER ANESTHESIA. 
Stages of 
Anesthesla 
Respiration [• Eyeball 
Anesthesia going ■ 
Down °Up ! 
Pupil 
Without With 
Morphin 
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Up and Down 
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Third-Stage Bther Anesthesia 
Fig. 220.-Chart A. 
Column. B shows respiration with anesthesia lightening. After the 
fourth stage is entered and respiration has ceased, if the ether be re- 
moved and respiration started by artificial means, it will begin as it 
left off. There is a shallow effort or two, then shallow but more or less 
rhythmical respiration which increases in depth, the rhythm being main- 
tained, progressively, as the excess ether is unloaded and the fourth 
stratum of the third stage is traversed upward. The progressive increase 
reaches its maximum as the third stratum is entered when there is an 
exaggeration corresponding to that of the same stratum in Column A. 
With the continued lightening of anesthesia, the respiration maintains 
this exaggeration more or less definitely throughout the third and the 530 
ANESTHESIA 
second strata. As the lower border of the first stratum is reached there 
occurs a beginning quieter respiration, which grows progressively quieter 
as the first stratum is traversed upward, reaching its greatest quietude 
just before the anesthesia emerges from the surgical stage into the 
second stage, which now becomes the stage of vomiting, retching, or 
coughing. 
Column C shows the eyeball, its movements, and position. As long 
as the eyeball is oscillating, or in an excentric position even though sta- 
tionary there is no danger that too much ether has been given. The 
upper stratum of the third stage is a stage wherein the motor oculi 
muscles are partially paralyzed. Either there is an intermittent con- 
traction and relaxation of the various muscles causing a rhythmical 
oscillation of the eyeball, or there is an unequal tonic contraction of 
one set of muscles over another, causing a stationary but excentric globe. 
Occasionally, in the alcoholic or extremely nervous type instead of the 
above, there is a slight twitching movement of the globe, usually in the 
lateral direction. It is sometimes necessary to observe the open eye as 
long as twenty seconds before this movement is seen. Therefore, the 
inspection should always be more than momentary in order to exclude 
the movement. 
As seen in the chart the motion of the eyeball on its excentricity in 
the third stage of anesthesia is greatest at the extreme upper border of 
the upper stratum. With anesthesia lightening, the phenomena continue 
well into the second stage. With anesthesia deepening, from the be- 
ginning of the third stage (the upper border of the upper stratum), 
there is a progressive decrease of the movements of the eyeball, or degree 
of excentric position, until the second stratum of the third stage is 
reached. This point is marked by the return of the eyeballs to a 
stationary and centric position with the significance that all of the 
motor oculi muscles are wholly paralyzed. If the anesthesia be pro- 
gressively deepened there does not occur any further movement of the 
eyeballs. 
In cases of rapid induction with ether in sequence to ethyl chlorid 
or nitrous oxid, if it is necessary in order to secure early relaxation, 
to put the patient into the second stratum of the third stage, it is the 
duty of the anesthetist to allow the anesthesia to become lighter after the 
operation is commenced until the motor oculi muscles recommence their 
activity. It should be maintained at this stage throughout the operation, 
the activity being permitted to increase as the time reaches the half 
hour, three quarters, and the hour. In other words, great activity of 
the motor oculi muscles is permissible with good anesthesia, progressively, 
as the operation is prolonged. 
If it were possible in all cases to take ample time for straight ether 
induction (fifteen to twenty minutes) the anesthesia could be carried THIRD STAGE ANESTHESIA 
531 
down gradually to the first stratum of the third stage and maintained 
there from the beginning with no necessity of entering the lower strata 
for relaxation. 
In finishing the discussion of Column C, it is important to state 
that whenever the respiration is found to be unusually quiet or seemingly 
depressed, the eye must be inspected. If the eyeball is oscillating or 
excentric, the stage of anesthesia is right and ether is to be continued. 
If the eyeball is stationary and centric, with the pupil dilated, anesthesia 
is too deep and ether is to be discontinued at once. 
Column D1 shows the pupil without morphin. Morphin either 
alone or in combination with other drugs is so universally used as 
a pre-anesthetic narcotic that this column is only of relative impor- 
tance. Even without morphin the pupil in the average case does not 
bring dilatation until the lower part of the second or upper part of 
the third stratum is reached. Therefore, the dilatation of the pupil is 
to be considered an indication of a too deep anesthia. 
Column E 1 shows the pupil with morphin. It is sometimes stated 
that when morphin is given in combination with atropin in the usual 
proportions of *4 to %50 grains, the pupillary reflex will be the same 
as if no morphin were given. This is not true. With this combination, 
the pupil will not dilate as early in anesthesia as when no morphin has 
been given. 
It is safe to assume that when morphin has been given any dilatation 
of the pupil is a manifestation of too deep an anesthesia. 
Column F shows the laryngeal movements. The movement of the 
larynx (swallowing) becomes doubly important in this classification. 
With the eyeball moving or excentric, the danger lies not so much in 
the possibility of the patient "going out" as in "coming out." There 
is usually in all cases a rhythmical movement of the larynx up and 
down with respiration, and always an exaggerated movement of this 
organ up and down with swallowing. The movement of the larynx with 
swallowing is of importance because it assists in guarding against the 
patient vomiting during the course of operation. 
With anesthesia lightening, at the extreme upper border of the upper 
stratum of the third stage, just before the patient comes out to the 
second or the vomiting stage, there will usually occur an exaggerated 
up-and-down movement of the larynx, half a minute or thereabouts 
before vomiting takes place. If the little finger of mask holding hand 
be allowed to rest over the larynx, this exaggerated movement may be 
1 Columns D and E can be considered only relatively accurate for all cases. 
This discussion considers only the toxic dilatation of the surgical stage of anes- 
thesia, and does not attempt to classify the early dilatation of the pupil which 
appears with the stage of analgesia, and disappears during the excitement stage. 
There is no significance attached to this. 532 
ANESTHESIA 
detected immediately it begins, and there is time, by the judicious in- 
crease of ether, to carry the course of anesthesia deeper and avoid 
vomiting, retching, or coughing. 
The patient cannot be safely relaxed and quiet regardless of the 
amount of ether given, if the respiratory passage be not kept freely 
open, or if he be allowed to suffer any degree of mechanical asphyxia. 
Where the respiratory passages cannot be kept freely open, pure oxygen 
should be administered, through the ether or separately. Only in this 
way can the patient be relaxed. 
The Eyeball under Other Anesthetic Agents.-Although this discus- 
sion is intended to cover primarily the third stage or ether anesthesia, 
the significance of the eyeball classification is not limited to ether alone. 
These signs hold good with any of the general inhalation anesthetics 
regardless of pre-anesthetic narcotics. Morphin in any combination 
does not influence them; neither does chlorid nor its allied drugs. The 
eyeball signs are 98 per cent constant. 
Conclusions.- (1) As long as any movement or excentric position of 
the eyeball is noted, the patient has not had too much anesthetic. 
(2) The upper stratum of the third stage of anesthesia is entirely 
satisfactory to the surgeon, and much post-operative discomfort and 
depression will be avoided by not exceeding the depth of this stratum. 
(3) An overdose of ether is any amount of that drug given over 
and above that which is actually necessary to produce the first stratum 
of the third stage. 
NITROUS OXID 
Interpretation of Chart B.-For induction, administer one hun- 
dred per cent N2O until narcosis is obtained, preventing deeper anes- 
thesia by the admixture of oxygen. In normal individuals, anesthesia 
may be maintained by approximately 90 per cent N2O and 10 per cent 
oxygen. Higher percentages of oxygen should be used for anemic 
patients, and for plethorics a lower percentage than for normal 
individuals. 
Another method of induction is the administration of 7 or 8 per 
cent of oxygen with 93 or 92 per cent of N2O for one minute, followed 
by one hundred per cent N2O for forty seconds. A large number of 
patients are well anesthetized by this time, after which the proper 
proportions should be found to maintain this stage of anesthesia; this 
is usually 90 per cent N2O and 10 per cent oxygen, slight deviations 
from these figures being made to meet the individual needs of the 
patient. When there is any doubt about the safety of the depth of 
narcosis, higher percentages of oxygen should be given. 
The rhythm of respiration shown on the chart is similar to that THIRD STAGE ANESTHESIA 
533 
PEEBLES GRAPHIC ANESTHESIA CHART 
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Fig. 220.-Chart B. 534 
ANESTHESIA 
exhibited by the patient. When the respiration is as shown, in the 
third stratum of the third stage, a high percentage of oxygen will lighten 
the anesthesia and bring the patient back through each successive stage. 
Color must not be depended upon at the expense of other signs, for 
it may vary considerably with different types of patients. Anemics 
sometimes do not take on any color when they are actually in the danger 
stage. 
The pupil is a definite sign in determining the depth of narcosis. 
There is less response, however, where morphin is used. In the ideal 
operative stage, the pupil will appear small and there will be no reaction 
to light. When a dilatation without reaction to light is present, it 
should always be regarded as a danger sign and an increased amount of 
oxygen should be administered. 
The eyeball may be either oscillating or excentrically fixed in normal 
or plethoric individuals. These movements or positions are much more 
marked in the earlier stages of anesthesia. In nervous or alcoholic 
patients, jerky movements are often present. 
The resistant lid indicates a lack of relaxation or very light anesthesia. 
While muscular tonus is not readily eliminated under gas-oxygen anes- 
thesia, if a greater degree of relaxation than usual is required, the state 
of narcosis may be carried beyond the operative stage for a few seconds 
and higher percentages of oxygen immediately added to the mixture. 
When there are unusual movements of the larynx, caused by an effort 
to swallow, the patient is suffering from nausea. This may be overcome 
in many cases by carrying the anesthesia nearer to the second stratum 
of the third stage, which is the ideal operative stage. 
The patient's head should be sufficiently elevated, at all times, to 
prevent closing of the air passages by dropping of the chin upon the 
neck. 
In dental operations better results may be obtained by inserting a 
dental proper or mouth gag before induction, and by packing the mouth 
well with gauze or cotton as soon as unconsciousness is present, thus 
preventing the dilution of the gases by the inflow of air. This packing 
also has the added advantage of preventing particles of teeth from en- 
tering the bronchi or blood being precipitated into the stomach. 
The percentages of the two gases and their rates of flow should be 
under perfect control at all times. CHAPTER XIV 
LOCAL ANESTHESIA AS APPLIED IN DENTISTRY 
History. 
The Hypodermic Method. 
Cold. 
Mode of Application of Ethyl Chlorid. 
Cocain : Preparation of Cocain Solutions; Sterilization of Solu- 
tions; Substitutes Proposed for Cocain; The Hypodermic Armamen- 
tarium. 
Technique of Injection : The Subperiosteal Injection; Peridental 
Anesthesia; Intra-osseus Injection; Perineural Injection; The Injection 
Into the Pulp; Methods of Anesthetizing the Pulp. 
Herrmann Prinz, M.D., D.D.S. 
History.-Probably the oldest known dental prescription that was 
used for the purpose of abolishing pain arising from an aching tooth is 
recorded upon a clay tablet that was found in Nippur. Its age may be 
approximately placed at 2250 b. c. Recent excavations that have been 
made near Nippur and Babylon have brought to light valuable informa- 
tion regarding the practice of medicine under Hammurabi, King of 
Babylon, a contemporary of Abraham. The clay tablet is written in 
the Babylonian tongue, which was the official language of diplomatic 
intercourse from the Euphrates to the Nile. The contents of this tablet 
refer to the "worm" theory of dental caries, and the treatment consists 
in filling the painful cavity of the tooth with a cement prepared by 
mixing powdered henbane seed with gum mastic. In Egypt lhe suet of 
the crocodile, locally applied, was believed to relieve pain, and Pliny 
refers casually to the mystic lapis memphitis, the stone of Memphis, 
which, when rubbed on the surface of the skin in conjunction with sour 
wine, was said to produce local anesthetic effects. In an early Cymric 
manuscript, which was probably written about the end of the fifteenth 
century, among a large number of conjectures we find the following: 
"How to extract a tooth without pain: Take some newts, by some called 
lizards, and those nasty beetles which are found in ferns in the summer- 
time. Calcine them in an iron pot, and make a powder thereof. Wet 
the forefinger of the right hand, and insert it in the powder, and apply 
535 536 
ANESTHESIA 
it to the tooth frequently, refraining from spitting it off, when the tooth 
will fall away without pain. It is proven." 
In the early days of modern dentistry we meet with many feeble 
efforts to alleviate pain during trying operations. The search for new 
methods and means pressed the mysticism of the electric current into 
service, opening to the charlatan a prolific field, which, even to this day, 
has not lost its charm. Richardson's voltaic narcotism for a time at- 
tracted the attention of the medical profession; and Francis, in 1858, 
recommended the attachment of the electric current to the forceps for 
the painless extraction of the teeth. As dental depots still offer appli- 
ances of this nature for sale, it seems that the method is still in vogue 
with some operators. 
Various drugs were employed, chloroform, alcohol, ether, opium, and 
the essential oils, either simply or as compounds, usually under fanci- 
ful names. Snape's "calorific" fluid, composed of chloroform, tincture 
of lemon balm, and oil of cloves; "nabolis," consisting of glycerite of 
tannic acid and a small quantity of chloral hydrate; Morton's "letheon," 
which was ether mixed with aromatic oils, are examples of proprietary 
preparations which enjoyed quite a reputation in their time. 
In 1853 Alexander Wood introduced a method of general medica- 
tion by means of hypodermic injections. It was at once suggested to em- 
ploy such drugs as morphin or tincture of opium for the purpose of pro- 
ducing local anesthesia. The results were not encouraging, however, 
until Koller, in 1884, advocated cocain. With the introduction of this 
drug into therapeutics, local anesthesia achieved results which were be- 
yond expectations, and its adoption created a new era in local anes- 
thesia. 
Local anesthesia may be obtained in two definite ways: (1) By in- 
hibiting the function of the peripheral nerves in a circumscribed area 
of tissue, this process being called "terminal anesthesia"; (2) by block- 
ing the conductivity of a sensory nerve trunk somewhere between the 
brain and the periphery, termed "conductive anesthesia." Conductive 
anesthesia may be produced by injecting into the nerve trunk proper- 
endoneural injection-or by injecting into the tissues surrounding a 
nerve trunk-perineural injection. The latter form is the usual method 
pursued when conductive anesthesia for dental purposes is indicated. 
The Hypodermic Method.-The successful practice of local anesthesia 
in dental surgery involves the careful correlation of a number of impor- 
tant details, each one constituting a definite factor in itself, the neglect 
of which must necessarily result in failure. As a whole, the practice of 
local anesthesia by the hypodermic method represents the composite of 
the following factors: (1) A solution of active ingredients correspond- 
ing to the physical and physiological laws which govern certain func- 
tions of the living cell; (2) a carefully selected hypodermic armamen- LOCAL ANESTHESIA AS APPLIED IN DENTISTRY 
537 
tarium; (3) a complete mastery of the technique; (4) a proper selec- 
tion of the method suitable for the case on hand; (5) good judgment 
of prevailing conditions. 
Cold.-Physically reducing the temperature of the body by the appli- 
cation of cold (ice-pack, ice and salt mixture, cold metals, etc.) was 
practiced by the older surgeons. Arnott, in 1849, and Blumdell, in 1855, 
advocated ice-packs for the painless extraction of teeth. 
Through the efforts of Sir B. W. Richardson, in 1866, this method 
was placed on a rational basis by the introduction of his ether spray. 
To obtain good results, an ethyl ether free from water is necessary. 
Certain other carbon compounds possess similar properties in vary- 
ing degrees, depending on their individual boiling points. In 1867 
Rottenstein called attention to the use of ethyl chlorid as a refrigerat- 
ing agent, and Rhein, in 1889, introduced methyl chlorid for the same 
purpose. In 1891 Redard reintroduced ethyl chlorid as a local anes- 
thetic. It has since been marketed under various trade names, as anti- 
dolorin, kelene, locodolor, etc. Mixtures of methyl and ethyl chlorids, 
in various proportions known as anesthyl, anestile, coryl, meth-ethyl, 
etc., have been extensively used in minor oral and general surgery. A 
pure ethyl chlorid is best suited for this purpose, as it lowers the tem- 
perature of the tissues sufficiently to produce a short superficial anes- 
thesia in a few minutes. Too rapid cooling or prolonged freezing by 
methyl chlorid or the various mixtures thereof produce deeper anesthesia, 
but such procedures are dangerous. They frequently cut off circulation 
in the affected part so completely as to produce sloughing (necrosis). 
Liquid nitrous oxid, liquid or solid carbon dioxid (known as carbon 
dioxid snow), and liquid air have been recommended for similar pur- 
poses. However, they require cumbersome apparatus, and are extremely 
dangerous. 
Mode of Application of Ethyl Chlorid.-For the extraction of teeth, 
immediate removal of the pulp, opening of abscesses, and other minor 
operations about the oral cavity, the ethyl chlorid tube should be warmed 
to body temperature by placing it in heated water, and its capillary end 
should be held about six to ten inches from the field of operation. The 
distance depends upon the size of the orifice of the nozzle, and com- 
plete vaporization should always be produced. The Gebauer tube1 is 
fitted with a spray nozzle, which shortens the distance to one or two 
inches, and is especially well adapted for dental purposes. The stream 
is directed upon the tissues until the latter are covered with ice crys- 
tals and have turned white. For the extraction of teeth, the liquid 
should be projected directly upon the surface of the gum, as near to 
the apex of the root as possible, but care should be taken to protect the 
crown of the tooth on account of the painful action of cold on this part. 
i See Figure 221, page 538. 538 
ANESTHESIA 
The tissues to be anesthetized should first be dried and well surrounded 
by a film of vaselin or glycerin, and protected by cotton rolls and nap- 
kins, to prevent the liquid from running into the throat (Fig. 221). The 
patient should breathe through the nose. Occasionally light forms of 
general anesthesia are introduced by inhaling the vapor. 
Precautions.-On account of the difficulty of directing the stream of 
ethyl chlorid upon the tissue in the posterior part of the mouth, it is 
not successfully applied to those regions. The intense pain produced 
Fig. 221.-Application of the Ethyl Chlorid Spray. 
by the extreme cold prohibits its use in pulpitis and acute pericementitis. 
To anesthetize the second and third branches of the fifth nerve, it is rec- 
ommended to direct the stream of ethyl chlorid upon the cheek in front 
of the tragus of the ear, but the author has not seen any good results 
from such a procedure. 
Caution should be exercised in using ethyl chlorid near an open 
-flame or in conjunction with the thermo-cautery, as severe burns have 
resulted by setting the inflammable vapor on fire. 
COCAIN 
Cocain, when injected into the tissues, produces typical local and 
general effects. Locally, it possesses a definite affinity for the peripheral 
nerves; it causes constriction of the smaller arteries, producing light 
anemia in the injected area, with diminished action of the leukocytes. 
However, different parts of the organism require different doses to bring 
about the same reaction. Upon mucous surfaces, paralysis of the sensory 
nerves is produced; the senses of touch and smell are temporarily in- LOCAL ANESTHESIA AS APPLIED IN DENTISTRY 
539 
hibited. The blood, as such, and the circulation suffer little. If cocain 
in sufficient quantities is absorbed by the circulation, general manifesta- 
tions are produced from bringing other tissues in close contact with the 
poison. The principal disturbances of the central nervous system make 
themselves known by vertigo, a very slight pulse, enlarged and staring 
pupils, and difficult respiration. Vomiting may occur; the throat feels 
dry. Intense excitement is followed by epileptiform spasms; finally, 
complete loss of sensation and mobility results, which terminates in 
death from cessation of respiration. 
Precautions.-With our increased knowledge of the action of cocain 
upon the tissues, and with proper technique of injection, dangerous re- 
sults are comparatively rare at present. No direct chemical antidotes 
are known, and the treatment of general intoxication is purely symp- 
tomatic. Anemia of the brain, which is of little consequence, may be 
readily overcome by placing the patient in a recumbent position or by 
complete inversion if necessary. As a powerful dilator of the peripheral 
vessels, the vapors of amyl nitrite are exceedingly useful; it is best ad- 
ministered by placing three to five drops of the fluid upon a napkin 
and holding it before the nostrils for inhalation. The flushing of the 
face and an increase in the frequency of the pulse follow almost momen- 
tarily. For convenience, amyl nitrite may be procured in small glass 
capsules, holding the quantity necessary for one inhalation. Nausea 
may be remedied by administering small doses of spirit of peppermint, 
aromatic spirit of ammonia, or validol. To overcome the disturbances 
of respiration, quickly instituted artificial respiration is the alpha and 
omega of all methods of resuscitation. The only drug that has proved 
to be of value in this connection is strychnin in the form of sulphate, or 
the nitrate in full doses by means of hypodermic injections. 
Preparation of Cocain Solutions.-The relative toxicity of a given 
quantity of cocain solution depends upon the concentration of the solu- 
tion. Reclus and others have clearly demonstrated that a fixed quantity 
of cocain in a 5 per cent solution is almost as poisonous as five times the 
same quantity in a 0.5 per cent solution. From the extensive literature 
on the subject, we are safe in fixing the strength of the solution for 
dental purposes at 1 per cent. This quantity of cocain lowers the freez- 
ing point of distilled water just a little above 0.1° C. To obtain an iso- 
tonic solution, corresponding to the freezing point of the blood, 0.8 per 
cent of sodium chlorid must be added. 
Having thus prepared a cocain solution which is equal to the blood 
in its osmotic pressure upon the cell wall, it is now necessary to aid 
the slightly vasoconstrictor power of the drug by the addition of a mod- 
erate quantity of adrenalin, thus increasing the confinement of the solu- 
tion to the injected area by producing a deeper anemia. The purpose of 
this is twofold: (1) To act as a means of increasing the anesthetic 540 
ANESTHESIA 
effect of cocain; (2) to lessen its toxicity upon the general system by 
slower absorption. As stated above, one drop of adrenalin solution 
added to 1 c. c. of the isotonic cocain solution is sufficient to produce 
the desired effect. 
A suitable solution for dental purposes may be prepared as follows: 
B Cocain hydrochlorid 5 grains ( 0.3 gm.) 
Sodium chlorid 4 grains ( 0.25 gm.) 
Sterile water 1 fluid ounce (30.0 c. c.) 
To each syringeful (2 c. c.) add two drops of adrenalin chlorid solution when 
used. 
Sterilization of Solutions.-Ready-made cocain solutions may be 
sterilized only with difficulty; they will not keep when frequently ex- 
posed to the air. The ready-made anesthetic solutions found in the 
market usually contain preservatives such as phenol, naphthol, boric 
acid, iodin, essential oils, alcohol, etc., in variable quantities. Some 
of these solutions have a distinct acid reaction. While they may 
produce a serviceable degree of anesthesia, they usually damage the 
injected tissues sufficiently to retard the normal process of wound 
healing. 
Substitutes Proposed for Cocain.-Since the introduction of cocain 
into the materia medica for the purpose of producing local anesthesia, 
various substitutes have been placed before the profession, superiority in 
one respect or another being claimed for each over the original cocain. 
The more prominent members of this group are tropacocain, eucain B, 
acoin, nirvanin, alypin, stovain, novocain, and, very recently, quinin 
and urea hydrochlorid. None of these compounds, with the exception 
of novocain, has, in the opinion of the author, proved satisfactory for 
the purpose in view. 
Novocain is about two to six times less toxic than cocain. It does 
not irritate in the slightest degree when injected; consequently no pain 
is felt from its injection per se. It is soluble in its own weight of 
water; it combines with adrenalin in any proportion, without interfering 
with the physiological action of the latter, and it is readily absorbed by 
the mucous membrane. The studies of Biberfield and Braun brought 
to light another extremely interesting factor concerning the novocain- 
adrenalin combination. Both experimenters, working independently of 
each other, observed that the adrenalin anemia on the one hand, and the 
novocain anesthesia on the other, were markedly increased in their 
total effects upon the tissues. Consequently a smaller quantity of this 
combination is required to produce a given therapeutic effect than is re- 
quired of each individual drug. Very recently it has been shown by 
Esch that adrenalin possesses a specific action upon nerve tissue, viz.: 
it affects the latter tissue in a peculiar manner so that it will take up the LOCAL ANESTHESIA AS APPLIED IN DENTISTRY 
541 
anesthetic more readily. Its action may be compared to a mordant or 
fixing agent such as is used in tissue staining. The effects of the injec- 
tion of such solutions of the combined drugs are usually confined to the 
injected area; general effects are therefore rarely produced. 
A suitable solution of novocain for dental purposes may be prepared 
as follows: 
Novocain 10 grains (0.6 gm.) 
Sodium chlorid 4 grains (0.25 gm.) 
Distilled water1 fluid ounce (30 c. c.) 
Boil 
To each syringeful (2 c. c.) add two drops of adrenalin chlorid solu- 
tion when used. Fischer strongly advocates the following so-called 
"normal anesthetic solution," which, when prepared under strict aseptic 
precautions and when preserved in amber-colored bottles, will keep: 
Novocain 23 grains (1.5 gm.) 
Sodium chlorid 14 grains (0.92 gm.) 
Thymol 1/3 grain (0.02 gm.) 
Distilled water3 fluid ounces, 1% fluid drams (100 c. c.) 
To each cubic centimeter add one drop of synthetic suprarenin solu- 
tion when used. A sterile solution may be made extemporaneously by 
dissolving the necessary amount of novocain-adrenalin in tablet form in 
a given quantity of boiled distilled water. A suitable tablet may be pre- 
pared as follows: 
Novocain 1/3 grain (0.022 gm.) 
Suprarenin hydrochlorid 1/1200 grain (0.000054 gm.) 
Sodium chlorid 1/8 grain (0.008 gm.) 
One tablet dissolved in 20 minims of sterile water makes a 2 per cent 
solution of novocain ready for immediate use. 
Solutions for hypodermic purposes should preferably be made fresh 
when needed. A small glass dish and a dropping bottle constitute the 
simple outfit for such work. The dropping bottle should hold from one 
to two ounces, and should be provided with a dust cap. On one suitable 
bottle on the market, "a groove on one side of the neck of the bottle 
and a vent on the other connected with two grooves in the back of the 
stopper allow the contents to flow out drop by drop. A quarter turn 
of the stopper closes the bottle tightly." The water used for making 
the solution should be boiled and filtered distilled water. 
Directions.-The hypodermic solution can be made extemporaneously 
in a few seconds, as follows: Place a tablet in a sterile glass dish, add 542 
ANESTHESIA 
20 minims (1 c. c.) of 
water, and to facilitate 
the solution mash the tab- 
let. The solution is now 
ready for immediate use. 
The Hypodermic Ar- 
mamentarium.-The Syr- 
inge.-A hypodermic syr- 
inge that answers all den- 
tal purposes equally well is 
an important factor in 
carrying out the correct 
technique of the injection. 
The injection into the 
dense gum tissue requires 
from 15 to 50, or even 
more, pounds of pressure 
as registered by an inter- 
posed dynamometer, while in pressure anesthesia 100 or more pounds 
are frequently applied. 
The selection of a suitable hypodermic 
syringe is largely a matter of choice. 
All-glass syringes, glass-barrel syringes, 
and all-metal syringes are the usual types 
found in the dental depots. After testing 
most of the dental hypodermic syringes 
offered to the profession within the last 
five years by means of the pressure gauge, 
and in clinical work subjecting the 
syringes to routine wear and tear, the 
author has found that an all-metal syringe 
of the Imperial type is to be preferred to 
other makes. They are usually made of 
nickel-plated brass, which, however, is a 
disadvantage, as the nickel readily wears 
off from the piston, and exposes the easily 
corroded brass. The Manhattan all-metal 
platinoid syringe gives the best general 
service, and the author can conscientiously 
recommend it to his confreres. The 
syringe holds 40 minims (2 c. c.), is pro- 
vided with a strong finger cross-bar, and 
is extremely simple in construction. The piston consists of a plain 
metal rod, without a thickened or ground piston end or packing. The 
Fig. 222.-Outfit for Preparing the Hypoder- 
mic Solution. 
Fig. 223Dental Hypodermic 
Syringe. LOCAL ANESTHESIA AS APPLIED IN DENTISTRY 
543 
piston rod is sufficiently long to allow about two inches of space between 
the cross bar and the piston top. This space is of importance, as it 
allows the last drop of the fluid to be expelled under heavy pressure 
without tiring the fingers. 
Needles.-Dental hypodermic needles should be made preferably of 
seamless steel, or, better still, of nickel-steel, 26 to 28 B. & S. gauge, and 
provided with a short razor-edge point. Thicker needles cause unneces- 
sary pain, and thinner needles are liable to break. Iridio-platinum 
needles are preferred by some operators, as they may be readily sterilized 
in an open flame. The needle should measure from a quarter to a half 
inch. For infiltration anesthesia one-inch needles are necessary, and 
curved needles of various shapes are essential in reaching the posterior 
parts of the mouth. For pressure anesthesia special needles are required, 
and may be bought at the depots, or they may be quickly prepared by 
grinding off the steel needle at its point of reinforcement. The sterile 
needle should be kept in well-protected glass containers. The needles 
are sterilized after each use by boiling in plain water, dried with the 
hot-air syringe, and immediately transferred to a covered sterile glass 
dish. The sterile needles should not be again touched with the fingers, 
and the customary wire insertion is unnecessary. 
TECHNIQUE OF INJECTION 
Various methods of injecting the anesthetic solution about the teeth 
are in vogue. For the sake of convenience they may be divided as fol- 
lows: (1) The subperiosteal injection; (2) the peridental injection; 
(3) the intra-osseous injection; (4) the perineural injection; (5) the 
injection into the pulp. 
Preliminary Steps.-Before starting any surgical interference in the 
mouth, the field of operation should be thoroughly cleansed with an 
antiseptic solution. A thin coat of the official tincture of iodin painted 
over the surface is very useful for this purpose. After the diagnosis is 
made, the method of injection best suited for the case on hand is then 
decided upon. 
The Subperiosteal Injection.-The subperiosteal injection about the 
root of an anterior tooth is best started by inserting the needle midway be- 
tween the gingival margin and the approximate location of the apex. The 
pain of the first puncture may be obviated by using a fine, very sharp- 
pointed needle, by the simple compression of the gum tissue with the 
finger tip, by holding a pledget of cotton saturated with the prepared 
anesthetic solution on the gum tissue for a few moments, or by applying 
a very small drop of liquid phenol on the point of puncture. The needle 
opening faces the bone, the syringe is held in the right hand at an acute 
angle with the long axis of the tooth, while the left hand holds the lip 544 
ANESTHESIA 
and cheek out of the way. After puncturing the mucosa, a drop of the 
liquid is at once deposited in the tissue, and the further injection is 
painless. Slowly and steadily the needle is forced through the gum tis- 
sue and periosteum (Fig. 224) along the alveolar bone toward the apex 
of the tooth, depositing the fluid under pressure close to the bone on its 
upward and return trip. The continuous slow moving of the needle pre- 
Fig. 224.-Method of Injection into the Labial Subperiosteal Gum Tissue. 
vents injecting into a vein. A second injection may be made by par- 
tially withdrawing the needle from the puncture and swinging the 
syringe anteriorly or posteriorly, as the case may be, from the first route 
of the injection. This latter method is especially indicated in injecting 
around the upper molars. After removing the needle, place the finger 
tip over the puncture and slightly massage the injected area. A circular 
elevation outlines the injected field. The naturally pink color of the 
gum will shortly (Fig. 225) change to a white anemic hue, indicating the 
physiological action of the adrenalin on the circulation. No wheal 
should be raised by the fluid, as that would indicate superficial infil- 
tration and, consequently, failure of the anesthetic. 
Extraction.-As the liquid requires a definite length of time to pass 
through the bone lamina and to reach the nerves of the peridental mem- 
brane and the pulp, from 5 to 10 minutes should be allowed before the LOCAL ANESTHESIA AS APPLIED IN DENTISTRY 
545 
extraction is started. The length of time depends on the density of the 
surrounding structure of the tooth. The progress of the anesthesia may 
be tested with a fine-pointed probe, and its completeness indicates the 
time when the extraction should be started. 
Technique for Different Teeth.-The upper eight anterior teeth 
usually require a labial injection only, while the molars require both a 
buccal and a palatine injection, using a slightly curved needle for this 
Fig. 225.-Method of Injecting into the Palatine Subperiosteal Gum Tissue. 
purpose. Buccally the injection is made midway between the mesial 
and distal root, and on the palatine side over the palatine root. 
The lower eight anterior teeth are comparatively easily reached by 
the injection. The straight needle is inserted near the apex of the tooth, 
the syringe is held in a more horizontal position, and the injection pro- 
ceeds as outlined above. 
The lower molars require a buccal and lingual injection. The 
curved needle is inserted midway between the roots, the gum margin, 
and the apices. The external and internal oblique lines materially hin- 
der the ready penetration of the injected fluid, and therefore ample time 
should be allowed for its absorption. 
If two or more adjacent teeth are to be removed, the injection by 
means of infiltrating the area near the gum fold directly over the apices 
of the teeth is to be preferred. It is advisable to use a one-inch needle 546 
ANESTHESIA 
for this purpose, holding the syringe in a horizontal position, so as to 
reach a larger field with a single injection. 
Fig. 226.-Subperiosteal Injection about an Upper Cuspid. 
Abscesses.-Injection into inflamed tissues, into an abscess, and 
into phlegmonous infiltration about the teeth is to be avoided. Injec- 
Fig. 227.-Subperiosteal Injection about an Upper Molar. 
tion into engorged tissue is very painful; the dilated vessels quickly 
absorb cocain without producing a complete anesthesia, and general poi- LOCAL ANESTHESIA AS APPLIED IN DENTISTRY 
547 
soiling may be the result. In purulent conditions injection is decid- 
edly dangerous, as it forces the infection beyond the line of demarca- 
tion. If the abscess presents a definite outline, the injection has to be 
made into the sound tissue surrounding the focus of infiltration. If a 
tooth is affected with acute diffuse or purulent pericementitis, a distal 
and a mesial injection usually produce successful anesthesia by blocking 
the sensory nerve fibers in all directions. 
Peridental Anesthesia.-Teeth or roots standing singly, or teeth 
affected by pyor- 
rhea, or similar 
chronic peridental 
disturbances, are 
frequently quickly 
and satisfactorily 
anesthetized by in- 
jecting the fluid di- 
rectly into the peri- 
dental membrane. 
This method is 
known as periden- 
tal anesthesia, and 
its technique i s 
very simple. In 
single-rooted teeth 
a fine and short hypodermic needle is inserted under the free 
margin of the gum, or through the interdental papilla, into the peri- 
dental membrane between the tooth and the alveolar wall. Sometimes 
the needle may be forced through the thin alveolar bone so as to reach 
the peridental membrane direct. To gain access to this membrane in 
teeth set close together, slight separation with an orange-wood stick or 
other suitable means is often found to be of advantage. Two, some- 
times three, injections are necessary. To force the liquid into the mem- 
brane usually requires a higher pressure than that which is necessary 
for injecting into the periosteum covering the alveolar process, but the 
quantity of the anesthetic liquid is less than that which is required for 
the former injection. Acute inflammatory conditions of the peridental 
membrane and its sequelae prohibit the use of this method. Peridental 
anesthesia is one of the most satisfactory forms of local anesthesia, since 
the seat of the nerve supply of the tooth is very quickly reached, and, as a 
consequence, the results obtained are in the majority of cases extremely 
satisfactory, provided that general conditions justify its application. 
Intra-osseous Injection.-The gum tissue is thoroughly cleansed with 
an antiseptic solution, and is then anesthetized about the neck of the 
tooth in the usual manner. After waiting 2 or 3 minutes, an opening 
Fig. 228.-Peridental Injection about an Upper Bi- 
cuspid. 548 
ANESTHESIA 
is made into the gum tissue and the bone on the buccal side with a fine 
spear drill or a Gates-Glidden drill. The opening should be made more 
or less at a right angle with the long axis of the tooth, a little below 
the apical foramen in single-rooted teeth or between the bifurcation in 
the molars. The right-angle hand piece is preferably employed for this 
purpose. The drill should be of the same diameter as the hypodermic 
needle. The gum fold is tightly stretched to avoid laceration from the 
rapidly revolving drill. As soon as the alveolar process is penetrated, a 
peculiar sensation conveyed to the guiding hand indicates that the 
alveolus proper is reached, and the sensation felt by the hand is about 
the same as that experienced when a burr enters into the pulp chamber. 
In this artificial canal the close-fitting curved needle of the hypodermic 
syringe is now inserted, and the injection is made in the ordinary way. 
The quantity of fluid used is much less than is usually needed for a 
subperiosteal injection. The roots of the teeth are imbedded in a sieve- 
like mass of bone tissue (diploe), which allows a ready penetration of 
fluid when injected under pressure. 
Perineural Injection.-For the anesthetization of a number of teeth 
in the upper or the lower jaw, conductive anesthesia by means of peri- 
Fig. 229.-Perineural Injection upon the Buccal Side of the Upper Jaw. A, B, 
injection below the infra-orbital foramen; A1 B1, injection over the region of the 
tuberosity. 
neural injection is preferably employed. The perineural injection is 
made near the point of exit or entrance of the various nerves about their 
respective foramina. To anesthetize all the teeth of one-half of the upper 
jaw, 4 injections are necessary, i. e., 2 buccally and 2 on the palatine 
side of the bone. A 1-inch needle is required for such work. To reach LOCAL ANESTHESIA AS APPLIED IN DENTISTRY 
549 
the many small branches of the posterior dental nerves at the alveolar 
foramina, the injection is macle buccally over the region of the tuberosity 
about inch above the gingival line between the first and second molar 
teeth. The second injection is made below the intra-orbital foramen, 
so as to reach the middle and anterior dental nerves. With the index 
finger of the left hand the foramen is approximately located by exerting 
pressure upon the nerve exit. The lip is lifted up with the middle 
finger of the same hand, and the needle is now inserted between the 
apices of the cuspid and first bicuspid teeth. The needle is slowly 
pushed forward until its point is felt beneath the finger tip. To reach 
the nerve supply of the hard palate, one injection is made near the pos- 
terior palatine canal, and the other near the foramina of Scarpa. The 
great palatine nerves pass through the posterior palatine canals on both 
sides of the hard palate. The canals lie about % of an inch above the 
edge of the alveolar process and the last molar tooth. They move pos- 
teriorly with the eruption of the successive teeth. The nasopalatine 
nerves pass through the foramina of Scarpa (incisive foramen), which 
are situated in the line of the suture of the maxillary bones. If an 
imaginary line is drawn from the distal borders of the two cuspids, pass- 
ing over the hard palate, it will ordinarily pass through the foramina. 
The needle should be inserted directly back of the papilla, which lies pos- 
teriorly between the central incisor teeth. 
To anesthetize one-half of the mandible, three injections for the 
deposition of the anesthetic solution are necessary. The first injection 
is applied near the mandibular foramen, the second near the mental 
foramen, and the third into the incisive fossa. To locate the mandibu- 
lar foramen in the mouth the lingual surface of the ramus is palpated 
with the finger, the anterior sharp border of the coronoid process is 
easily felt about % of an inch posterior to the third molar. The process 
passes downward and backward from the third molar, and enters into 
the external oblique line. Mesially from this ridge is to be found a small 
triangular concave plateau, which is facing downward and outward, 
being bound mesially by a distant bony ridge and covered with mucous 
membrane. As. there is no anatomical name attached to this space, 
Braun has called it the retromolar triangle (trigonum retromolare). In 
the closed mouth it is located at the side of the upper third molar, and 
in the open mouth it is found midway between the upper and lower 
teeth. Immediately back of the mesial border of this triangle, directly 
beneath the mucous membrane, lies the lingual nerve, and about three- 
eighths of an inch further back the mandibular nerve is to be found. 
This last nerve lies close to the bone, and enters into the mandibular 
foramen, which is partially covered by the mandibular spine. 
Before starting the injection, the patient should be cautioned to rest 
his head quietly on the headrest of the chair, as any sudden movement 550 
ANESTHESIA 
or interference with the hand of the operator may be the cause of break- 
ing the needle in the tissues. The syringe, provided with a 1-inch 
needle, is held in a horizontal position, resting on the occluding surfaces 
of the teeth from the cuspid backward and slightly toward the median 
line. The needle is to be inserted three-eighths of an inch above and the 
same distance back of the occluding surface of the third lower molar, 
Fig. 230.-Perineural Injection upon the Hard Palate. A, B, injection near the 
foramina of Scarpa; C, D, injection near the posterior palatine canals. 
the needle opening facing the bone. This position will insure the cor- 
rect direction of the needle point, so as to reach the tissues immediately 
surrounding the nerves, and not lose the injection in the adjacent thick 
muscle tissue. The needle must always be in close touch with the bone, 
and is now slowly pushed forward, depositing a few drops of fluid on its 
way until the ridge is reached. About five drops of fluid are injected 
in this immediate neighborhood for the purpose of anesthetizing the 
lingual nerve. The needle is now pushed very slowly forward, always 
keeping in close touch with the bone and depositing fluid on its way, 
until it is pushed in about five-eighths of an inch. It is important to 
carefully feel the way along the bony wall of the ramus, as the needle 
may have to pass over the roughened and bony elevations which afford LOCAL ANESTHESIA AS APPLIED IN DENTISTRY 
551 
attachment to the internal pterygoid muscle. During the injection the 
syringe should remain in the same horizontal position as heretofore out- 
lined. Soon after the injection, paresthesia of one-half of the tongue on 
the side of the injection occurs, which is soon followed by anesthesia of 
the mandibular nerve. Paresthesia of the mucous membrane and half 
of the lower lip is also established. The pulps of the lower teeth, in- 
cluding the cuspid and lateral incisor, the gum tissue on both sides of 
the jaw, and a part of the anterior floor of the mouth are anesthetized. 
The complete anesthesia of the two nerves also anesthetizes the whole 
alveolar process in this region. About five minutes are required for the 
complete anesthetization of the lingual nerve, and at least fifteen min- 
Fig. 231.-Perineural Injection Near the Mandibular 
Foramen. 
utes for the mandibular nerve. Braun claims that the injection is abso- 
lutely free from danger, while Roemer states that danger may arise if 
the whole quantity of the solution should accidentally be injected into a 
vein. 
The mental foramen lies midway between the superior and inferior 
border of the body of the mandible on its external surface, usually below 
the second bicuspid teeth. Its opening always faces posteriorly. An 
injection near this point increases the anesthesia in the cuspid region. 
The incisive fossa is a shallow depression on the external surface of the 
mandible between the cuspid teeth. It may be located by the palpating 
finger immediately above the chin. A number of small foramina are 
found in this region for the passage of nerves and nutrient vessels. The 
lower incisors may be anesthetized by making injections anteriorly into 
the incisive fossa, and one posteriorly in the region corresponding to 
the fossa. Usually peridental anesthesia is to be preferred for these 
teeth. 
Precautions.-Conductive anesthesia is serviceable if a number of 
teeth have to be removed at one visit. It should be borne in mind, how- 
ever, that in the average case only one-half of either jaw should be anes- 552 
ANESTHESIA 
thetized at one sitting, so as to keep the quantity of the injected anes- 
thesia solution within the limits of ordinary dosage. 
The Injection into the Pulp.-By pressure anesthesia, pressure cata- 
phoresis, or contact anesthesia, as the process is variously termed, we 
understand the introduction of a local anesthetizing agent in solution 
by mechanical means through the dentine into the pulp for the purpose 
of rendering it insensible to pain. Simple hand pressure with a suitable 
instrument, the hypodermic syringe, or the so-called high-pressure 
syringe, is recommended for such purposes. 
Methods of Anesthetizing the Pulp.- (1) The pulp is wholly or 
partially exposed. The tooth is isolated with rubber dam, and cleaned 
with water and alcohol. The cavity is excavated as much as possible, 
and, if the pulp is not exposed, it is dehydrated with alcohol and hot air. 
A pledget of cotton or a piece of spunk is saturated with a concentrated 
cocain or novocain solution, placed into the prepared cavity, and covered 
with a piece of vulcanizable rubber. With a suitable burnisher, slowly 
increasing, continuous pressure is applied for from 1 to 3 minutes. The 
pulp may now be exposed and tested. If it is still sensitive, the process 
is repeated. Loeffler states that "this pressure may be applied by taking 
a short piece of orange wood, fitting it into the cavity as prepared, and 
directing the patient to bite down upon this with increasing force. In 
this way we can obtain a well-directed regulated force or pressure with 
less discomfort to the patient and operator." Miller describes this 
process as follows: "After excavating the cavity as far as convenient, 
and smoothing the borders of it, take an impression in modeling com- 
pound, endeavoring to get the margins of the cavity fairly well brought 
out; put a few threads of cotton into the cavity and saturate them thor- 
oughly with a five to ten per cent solution of cocain; cover this with a 
small bit of rubber dam, and then press the compound impression down 
upon it. We obtain thereby a perfect closure of the margin, so that the 
liquid cannot escape, and one can then exert pressure with the thumb 
sufficient to press the solution into the dentin." 
(2) The pulp is covered with a thick layer of healthy dentin. With 
a very small spade drill, one bores through the enamel or direct into the 
dentin at the most convenient place, guiding the drill in the direction of 
the pulp chamber. The chips are blown out, the cavity dehydrated with 
alcohol and hot air, and the syringe, provided with a special needle,- 
making as nearly as possible a water-tight joint,-is applied. Slow, con- 
tinuous pressure is applied for from two to three minutes. With a 
round burr the pulp should not be exposed, and, if still found sensitive, 
the process is repeated. 
Recently a method has come into vogue which allows successful anes- 
thetization of the pulp by injecting the anesthetic solution around the 
apex of the tooth. The spongy alveolar process, which contains lymph LOCAL ANESTHESIA AS APPLIED IN DENTISTRY 
553 
channels, allows the ready penetration of the fluid. The injection 
should be made close to the bone, the needle being pushed slowly toward 
the apex, while the fluid is deposited drop by drop. No wheal should be 
raised by the injection, otherwise the benefit of the pressure from the 
dense gum tissue is lost. CHAPTER XV 
SPINAL ANALGESIA AND SPINAL ANESTHESIA 
William Seaman Bainbridge, Sc.D., M.D. 
Introduction. 
History: Discovery of and Experimentation with Cocain; Experi- 
mentation with Cocain from the Neurological Point of View with Re- 
gard to Its Analgesic Effects Upon the Sensory Nerves, Including the 
Spinal Cord; Application of the Analgesic Effects of Cocain Upon the 
Cord to Surgical Operations Below the Diaphragm; Extension of the 
Surgical Application of Spinal Analgesia to Parts of the Body Above the 
Diaphragm; Experimentation with Other Agents. 
Anatomical and Physiological Considerations: Origin; Vol- 
ume; Specific Gravity; Movements; Pressure; Diffusion. 
Course, Extent, and Duration of Analgesia : Course ; Extent ; 
Duration. 
Accompanying Phenomena: Subjective; Objective. 
Postoperative Phenomena. 
Indications and Contraindications. 
Advantages and Disadvantages : Advantages; Disadvantages. 
Deaths. 
Analgesic Agents : Cocain; Tropacocain; Stovain; Novocain. 
Sterilization of the Analgesic Agent. 
Sites of Injection. 
The Patient : Preliminary Preparation of Patient; Position of Pa- 
tient. 
Apparatus and Materials. 
Technique of Injection. 
Additional Illustrative Case Reports. 
Conclusion. 
INTRODUCTION 
In the pages which follow the term analgesia (av + aXyos) is em- 
ployed with its strict etymological significance-absence of sensibility to 
pain. The broader term, anesthesia (av + aiaflycns)-without sensation 
-is purposely avoided, except when quoting from authors who make no 
554 SPINAL ANALGESIA AND SPINAL ANESTHESIA 
555 
differentiation, and when referring to the exceptional cases in which 
analgesia merges into anesthesia. 
Complete loss of sensation comes only with narcosis - 
a state of profound unconsciousness. In some instances, with heavy 
dosage, an analgesic agent injected into the subarachnoid space may 
produce a state of mental lethargy bordering upon that which follows 
the inhalation of an anesthetic agent, with the loss of all forms of sensa- 
tion-a real anesthesia. As a rule, however, with moderate dosage, the 
analgesic agent introduced into the spinal canal gives rise only to anal- 
gesia-loss of sensibility to pain. Tactile sense, the sense of heat and 
cold, of pressure and of traction, are not completely destroyed in the 
latter case. 
The operator who fails to bear in mind the above differentiation is 
apt to experience more or less difficulty at times, and to feel that he has 
a right to chronicle dissatisfaction or failure with the method under dis- 
cussion. 
It has been our purpose to give, as briefly as possible, in the pages 
which follow, a cursory review of the work of others, rather than to con- 
fine ourselves strictly to the limits of personal experience. With spinal 
analgesia, as with every other form of analgesia or anesthesia, the method 
has its enthusiastic adherents and its uncompromising opponents. We 
have endeavored, in the light of personal experience, to examine the evi- 
dence pro and con, and to give a fair and impartial statement of our 
findings. 
HISTORY 
The history of spinal analgesia may be divided, for purposes of con- 
venience, into four periods, which are more or less overlapping in time 
and achievement: (1) Discovery of and experimentation with cocain; 
(2) experimentation with cocain from the neurological point of view, 
with regard to its analgesic effects upon sensory nerves, including the 
spinal cord; (3) application of the analgesic effects of cocain upon the 
cord to surgical operations below the diaphragm; (4) extension of the 
application of spinal analgesia to parts of the body above the diaphragm. 
Experimentation with other agents. 
Discovery of and Experimentation with Cocain.-The discovery 
by Niemann, in 1859, of the alkaloid of coca leaves, to which the name 
cocain was given, may be said to mark the first event in the history of 
spinal analgesia. 
The discovery by Schraff, in 1862, of the local analgesic properties of 
this substance when placed upon the tongue was the second step forward 
in the history of this method. 
With the application of the latter discovery to surgical purposes, sug- 556 
ANESTHESIA 
gested by Koller,1 in 1884, the history of spinal analgesia was fairly in- 
itiated. 
Following immediately upon these discoveries and their announce- 
ment,2 many experiments were undertaken by investigators throughout 
Europe and America, all having for their motive the production of local 
analgesia for surgical purposes. This particular phase of the general 
subject of anesthesia falls within the scope of the chapter on local anal- 
gesia. It concerns the history of spinal analgesia only in so far as the 
discovery and application of cocain by others led to the sequence of de- 
ductive reasoning by Corning, and furnished the means for the applica- 
tion of the theories by which he gave to the world the discovery of spinal 
analgesia. 
Experimentation with Cocain from the Neurological Point of 
View with Regard to Its Analgesic Effects Upon the Sensory Nerves, 
Including the Spinal Cord.-Corning's brilliant work 3 on the prolonga- 
tion of the analgesic effects of cocain subcutaneously administered was 
the logical antecedent to his equally brilliant experiments with the local 
medication of the cord.4 
In his first paper on spinal analgesia Corning was influenced in his 
deductions by the work of Harley,5 who showed that a poison such as 
strychnin, injected under the membrane covering the cord, "can act 
only through the intermediation of the blood vessels, since, when the 
latter are separated from the cord, the solution remains entirely inert." 
Corning concluded from this that, "in order to obtain the most im- 
mediate, direct, and powerful effects upon the cord with a minimum 
quantity of a medicinal substance, it is by no means necessary to bring 
the substance into direct contact with the cord; it is not necessary to 
inject the same beneath the membranes, as in the case of the frogs, since 
the effects are entirely due to the absorption of the fluid by the minute 
vessels. On the other hand, in order to obtain these local effects, it is 
first necessary to inject the solution in the vicinity of the cord; sec- 
1 Koller, Karl: '1 On the Use of Cocaine to Anesthetize the Eye, ' ' Wiener 
med. Woch., Oct. 25, Nov. 1, 1884. Translated by H. Knapp: "Cocaine and Its 
Uses in Ophthalmic and General Surgery." Putnam's Sons, N. Y., 1885. 
2Noyes, Henry D.: "A Few Cursory Notes on the Proceedings of the Meet- 
ing of the German Ophthalmological Society, Held at Heidelberg in the Middle 
of September of This Year." Med. Rec., Oct. 11, 1884. 
'Corning: (1) "On the Prolongation of the Anaesthetic Effects of the 
Hydrochlorate of Cocaine When Subcutaneously Injected. An Experimental 
Study." N. Y. Med. J., Sept. 19, 1885; (2) "The Author's Method of Local 
Anesthetization by Incarceration of the Anaesthetic in the Field of Operation, ' ' 
Part II, ' ' Local Anaesthesia, ' ' 34. 
4 Corning: ' ' Spinal Anaesthesia and Local Medication of the Cord, " N. Y. 
Med J., Oct. 31, 1885, Reprinted, 1909, 72, 790. Also in "Local Anaesthesia," 85. 
5See Ringer, «Sidney: "A Handbook of Therapeutics," 1870, 387. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
557 
ondly, to select such a spot as will insure the most direct possible entry 
of the fluid into the circulation about the cord." 
He reasoned that, if placed between the spinous processes of the 
vertebrae, "the anesthetic would be rapidly absorbed by the minute 
ramifications of the veins referred to, and, being carried by the blood 
to the substance of the cord, would give rise to anesthesia of its sensory 
and perhaps also of its motor tracts." 
It was with this conception of the matter that Corning carried out 
his early experiments, first upon a dog and then upon a man. 
In the case of the man, who was suffering from spinal weakness and 
seminal incontinence, 30 minims of a 3 per cent solution of cocain were 
injected between the spinous processes of the eleventh and twelfth 
dorsal vertebras. 
These experiments encouraged Corning to proceed with his investi- 
gations, and in 1888 he published a report1 of his injection of cocain 
hydrochlorate in the immediate neighborhood of the cord. 
The injections were made in the lumbar and dorsal regions, and thus 
Corning, antedated by three years the work of Quincke 2 with lumbar 
puncture. 
Quincke found, independently, being unaware of Corning's work, 
that it was possible to remove the cerebrospinal fluid after lumbar punc- 
ture apparently without danger to the subject. He also demonstrat- 
ed that a considerable amount of the cerebrospinal fluid may be with- 
drawn. 
Quincke's experiments were made with a partly different object in 
view from that which actuated Corning, but the former's discovery un- 
doubtedly had its effect in stimulating interest in the subject of spinal 
puncture, as it concerned the induction of spinal analgesia. 
Following the work of Corning and Quincke, various experiments 
were made with reference to the effect of medicinal fluids upon the 
spinal nerves and cord. 
Ziemssen 3 proposed the injection of such substances through lumbar 
puncture. 
Sicard,4 in 1898, published the report of a series of experiments in 
which he injected into the subarachnoid space normal salt solution, 
1 Corning: ' ' Further Contribution on Local Medication of the Spinal Cord, 
with Cases." Med. Rec., March 17, 1888; also "Headache and Neuralgia," 1888, 
157. 
3 Quincke: "Die Lumbalpunktur des Hydrocephalis." Berl. Iclin. Woch., 
1891, No. 38. 
3Ziemssen: Wiesbaden Kongr., 1893. 
4Sicard: "Essais d'injections microbiennes, toxiques et therapeutiques, 
par voie cephalo-rachidienne. ' ' Compt. rend. Soc. de Biol., Paris, April 30, 1898; 
also "Toxine et antitoxine tetanique par injections sous-arachnoidiennes, " ibid., 
Nov. 12, 1898. 558 
ANESTHESIA 
tetanus toxin, morphin, and other substances, and later he reported 1 
the results of his investigations concerning the toxic effects of cocain 
when introduced into the subarachnoid space through the intracranial 
or spinal route. 
From his first series of experiments Sicard concluded that the 
subarachnoid space could receive relatively large quantities of fluid, and 
that the effects of such fluid injected in this manner varied in propor- 
tion to the amount of dilution and to the rapidity with which the solu- 
tion was injected. 
Independent investigations by Jaboulay 2 confirmed Sicard's conclu- 
sions. 
Corning, meanwhile, was still pursuing his experimental studies, and 
in 1894 he published the details of his method of irrigating the cauda 
equina with medicinal fluids.3 
While he was engaged in testing his method of medicating the spinal 
cord, Corning became impressed with the desirability of introducing the 
remedies directly into the spinal canal, "with a view to producing still 
more powerful impressions upon the cord, and more especially upon its 
lower segment." 
"There can be no doubt," he states, "especially if the injection be 
made between the second and third lumbar vertebrae, that the functions 
of the lower segments of the cord itself may be powerfully affected in 
this manner. We have only to conceive of the cerebrospinal fluid being 
at this point thoroughly impregnated with the medicinal fluid and 
lying in direct contact with the pia ... to be convinced of the potency 
of such a procedure." 
The dangers involved in such an operation were made a matter of 
consideration by Corning, and his own observations were in accord with 
the work of Mitchell 4 and Thoburn.5 
Mitchell showed that a simple puncture of a nerve of an animal with 
a sharp needle causes little bleeding, which passes away without grave 
results. 
Thoburn called attention to the harmlessness of such slight trauma- 
tism as the pricking of the cauda equina. 
This work was later verified by Crile's investigations.6 He found, 
1 Sicard: ' ' Inoculations sous-arachnoidiennes chez le chien; voie cranienne, 
voie rachidienne," Compt. rend. Soc. de Biol., Paris, Oct. 29, 1898; also ''In- 
jection sous-arachnoidienne de cocaine chez le chien," ibid., May 20, 1899. 
2 Jaboulay. ''Drainage de 1'espace sous-arachnoidienne et injection de 
liquides medicamenteux dans les meninges, ' ' Lyon med., May 15, 1898. 
'Corning: "Pain," 1894, 247 et seq. 
* Mitchell, S. Weir: ''Injuries of Nerves and Their Consequences," 1872. 
'Thoburn, William: "Injuries of the Cauda Equina," Brain, 10, 381 et seq. 
' Crile: ' ' An Experimental and Clinical Research into Certain Problems Re- 
lating to Surgical Operations," 1901. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
559 
from a series of recovery experiments, that it was difficult to locate the 
point of injection, and that it was only in cases where no aseptic pre- 
cautions had been taken at the time of the injection that the track of 
the needle could be traced by the unaided eye, careful inspection failing 
to reveal the point of injection in cases where such precautions had been 
taken. 
Corning 1 emphasized the fact that serious disturbances of sensation 
and mobility, having their origin in the cauda equina, are always due to 
gross lesions, and not to insignificant circumscribed causes. 
Application of the Analgesic Effects of Cocain Upon the Cord to 
Surgical Operations Below the Diaphragm.-The studies of Corning 
seem to have made little or no impression upon the minds of the various 
investigators to whose experiments reference has been made. Despite 
the fact that he had suggested, in his original contribution, the surgical 
application of the method,2 no such application had been made until 
Bier, of Kiel, demonstrated its entire feasibility and published the re- 
sults of his work.3 Odier,4 who injected cocain into the spinal cord of 
rabbits, noting the resulting protoplasmic changes in the nerve cells and 
the analgesia of the body below the point of the injection, failed to make 
any clinical application of the latter finding. 
With the publication of Bier's paper the surgical application of spinal 
analgesia was definitely established. 
Bier observed the effects of analgesia induced by this method upon 
himself, his assistants, and six patients. Lumbar puncture, after the 
method of Quincke, was employed. The passage of the needle was ren- 
dered painless by means of Schleich's infiltration. He used two cubic 
centimeters of a one per cent solution of cocain. 
The appearance of Bier's paper led to the immediate adoption of the 
method by many surgeons throughout the civilized world, but especially 
in France and America. His findings were verified by Seklowitch,5 
experimenting upon dogs. 
Tait and Caglieri6 are credited with having performed the first sur- 
1 Corning: "Pain," 1894. 
'Corning: Op. cit. (N. Y. Med. J., Sept. 19, 1885)-"Whether the method 
will ever find an application as a substitute for etherization in genito-urinary or 
other branches of surgery, further experience alone can show. ' ' 
3 Bier: "Versuche fiber Cocainisirung des Riickenmarkes, " Deut. Zeit. f. 
Chir., Leipzig, 1899, 361. 
* Odier: ' ' Recherches sur les mouvements de la cellule ner- 
veuse de la moelle epiniere, " Rev. Med. de I. Suisse Romande, 1898, 18, 59. 
'Seldowitch: "Ueber Cocainisirung des Riickenmarkes naeh Bier," Centralbl. 
f. Chir., 1899, 41, 1110. 
8 Tait and Caglieri: "Experimental and Clinical Notes on the Subarach- 
noid Space," Trans. Med. Soc. State of Cal., April, 1900, 266. Also, J. Am. 
Med. Assn., July 7, 1900. 560 
ANESTHESIA 
gical operation under spinal analgesia in America, on October 26, 1899. 
Osteectomy of the tibia, in a patient fifty-four years of age, was per- 
formed without pain or discomfort, and with no unpleasant after-effects. 
One c. c. of a per cent solution of cocain was employed. 
The procedure was "popularized" by Tuffier,1 who extended the appli- 
cation of the method from its original domain of the lower extremities, 
as practiced by Bier, to the genito-urinary organs and abdomen. He 
subsequently performed hysterectomy, salpingectomy, nephrectomy, 
pylorectomy, cholecystectomy, etc., under subarachnoid analgesia. 
The position of spinal analgesia in the surgical world was established 
upon a firm basis by the work of Bier, Tait and Caglieri, Tuffier, and 
others of the early investigators, and the literature of the subject at 
once began to assume extensive proportions. The scope of the applica- 
tion of the procedure was quickly extended, and the method came to be 
employed in old and young, for divers conditions, and with varying de- 
grees of skill and success. 
It was not long until Bier felt called upon to protest2 against the 
recklessness with which the method was being employed, regardless of 
the fact that no noteworthy improvement in technique had been evolved. 
He protested especially against the dangerously large doses of cocain 
which some operators used. New methods, he said, should be devised in 
an attempt to reduce the toxicity of the drug and to prevent the un- 
pleasant by-effects so often noted. He suggested the application of the 
procedure to operations upon the entire trunk and arms, and made a 
plea for an effort to find less harmful drugs which would produce anal- 
gesia by this method. 
In obstetrical practice subarachnoid analgesia was employed early in 
its history, Kreis 3 being credited with having first made this application 
of the method. Doleris,4 Marx,5 Dupaigne,6 and others utilized the pro- 
'Tuffier: (1) "Analgesie chirurgicale par 1'injection sous-arachnoidienne 
lombaire de cocaine," Soc. de Biol., Nov. 11, 1899, in Semaine med., 1899, 389; 
also, La Bresse med., Nov. 15, 1899, 294; (2) "L'Analgesie chirurgicale par voie 
rachidienne," 1900. In L'CEuvre medico-chirurgical, Critzman, 1901-02, 24-30. 
2 Bier: ' ' Bemerkungen zur Cocainisirung des Riickenmarkes, ' ' Munch, med. 
Woch., Sept. 4, 1900, 1226. 
'Kreis: "Ueber Medullarnarkose bei Gebarenden, " Centrlbl. f. Gyn., July 14, 
1900, 724. 
4Doleris: "Analgesie par injection de cocaine dans 1'arachnoide lom- 
baire, " Compt. rend. d. I. Soc. d'Obst., de Gyn., et d. Pediat. d. Paris, 1900, 
S, 328. 
'Marx: (1) " Medullary Narcosis During Labor, a Preliminary Report," 
Med. News., Aug. 25, 1900, 293; (2) "Medullary Narcosis During Labor," Med. 
Bee., Oct. 6, 1900, 521; (3) "Analgesia in Obstetrics Produced by Medullary 
Injections of Cocain," Phila. Med. J., Nov. 3, 1900, 857. 
"Dupaigne: "Anesthesie rachidienne par le cocaine," Ann. de Gyn. et Obst., 
Paris, 1901, 55, 44. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
561 
cedure for the same purpose. My own experience with spinal analgesia 
in obstetrical practice is limited to one case, but this was an excellent 
one in which to test the method in this class of cases. (See case descrip- 
tion on page 593.) 
In the early stage of the surgical application of spinal analgesia the 
author of this section began to employ the method, being particularly 
interested at that time in its use in young children. Seven cases oper- 
ated upon under spinal analgesia were reported,1 the youngest being 2y2 
and the oldest 11 years of age. The former case was apparently the 
youngest in which the method had been employed at that time. The 
youngest cases on record at that time were: One, 8 years, operated by 
Murphy; one each at 11 years, by Bier, Lugueu, and Kinderjy, and one, 
12 years, by Tuffier. 
An additional series of forty cases 2 was reported during the follow- 
ing year, the youngest of this series being and the oldest 19 years 
of age. Twenty-four of these cases were reported in detail. 
Report3 was published of twelve operations upon infants and young 
children ranging in age from 3 months to 5 years. Of this series the 
history of that case, No. XII, is detailed on page 588. 
Tuffier 4 reported a case in an infant 3 months old. 
Extension of the Surgical Application of Spinal Analgesia to Parts 
of the Body Above the Diaphragm. Experimentation with Other 
Agents.-It is impossible, within the limited space, to follow the work 
of the very large number of surgeons who have devoted attention to the 
subject of spinal analgesia during the years which have intervened since 
the appearance of Bier's original communication.5 The historical con- 
tributions, other than those mentioned, have been largely in the nature 
of modifications of technique, and the verification of the earlier results 
by a large number of clinical cases. 
With certain notable exceptions, both the experimental and the clini- 
cal investigations were concerned with the production of analgesia below 
the diaphragm and its application to the surgery of those regions. 
Tait and Caglieri,8 in 1900, reported 3 cases in which cocain was 
injected into the sixth cervical space without untoward effects. The 
'Bainbridge: "Analgesia in Children by Spinal Injection, with a Report of 
a New Method of Sterilization of the Injection Fluid," Med. Hee., Dec. 15, 
1900. 
2Bainbridge: "A Report of Twenty-four Operations Performed During 
Spinal Analgesia," Med. News, May 4, 1901. 
•Bainbridge: "Report of Twelve Operations on Infants and Young Children 
During Spinal Analgesia," Archives of Pediat., July, 1901. 
'Tuffier: "Sur la rachicocainisation, " La Presse med., Paris, June 8, 1901, 
265. 
'Bier: Op. cit., Deut. Zeit. f. Chir., Leipzig, 1899, 51, 361. 
'Tait and Caglieri: Op. cit., Trans. Med. Soc. State Cal., April, 1900, 266. 562 
ANESTHESIA 
patients were examined weeks after the injection and found to be frew 
from any complication. 
Morton/ in 1900, also presaged the recent extension of spinal anal- 
gesia to surgical operations upon all parts of the body. "I think," he 
said, "we will soon find that, by injecting higher into the dorsal region, 
anesthesia can be extended all over the body with perfect safety. It has 
been demonstrated in the dog by making an injection in the upper part 
of the dorsal region. It does not interfere with motion, consciousness, or 
sense of touch." 
In a later communication 2 Morton said: "I think we have a safe 
and reliable analgesic in the subarachnoid injection of cocain for the 
performance of any surgical operation on any portion of the body, re- 
gardless of age, sex, or disease, and one which has no contraindications." 
In this report Morton tabulated 253 cases operated upon by him, 24 in 
females, 229 in males, 8 of the operations being above the diaphragm. 
An additional series of 61 cases was added to the above report, 15 of 
which were upon the upper extremities or head. The analgesia was com- 
plete in all cases. One case in which the operation was above the dia- 
phragm was reported in detail.3 
Chaput and others performed operations on parts of the body above 
the diaphragm under spinal analgesia. 
It appears that the work of Tait and Caglieri, Morton, and others, 
with high injection, has not been followed up with further published 
clinical application, for which reason, perhaps, originality in this regard 
has been generally accorded to Jonnesco. 
In September, 1908, before the Congress of the International Society 
of Surgery, in Brussels, Jonnesco,4 of Bucharest, described his new 
method of general spinal anesthesia, and reported 14 cases operated 
upon by this method. The method is detailed, and selected cases cited, 
103 of which were high dorsal analgesias, and 295 dorso-lumbar anal- 
gesias. 
In a later article 5 Jonnesco says: "It is an error to confuse lumbar 
rachianesthesia, conceived by Corning and popularized by Bier, with my 
method. As I have many times emphasized, my method is a new one 
and altogether distinctive, because I have generalized spinal anesthesia, 
adapting it to all operations on any part of the body. This has not yet 
'Morton: "Is the Subarachnoidean Injection of Coeain the Preferable Anes- 
thesia Below the Diaphragm?" Pac. Med. J., Nov., 1900. 
2Morton: "The Subarachnoid Injection of Cocain for Operations on All 
Parts of the Body," Am. Med., Aug. 3, 1901. 
3 Morton: ' ' Report of a Lipoma Removed from the Cheek under Medullary 
Narcosis," Phila. Med. J., July 6, 1901. 
'Jonnesco: "Remarks on General Analgesia," Brit. Med. J., Nov. 13, 1909. 
5Jonnesco: "Concerning General Rachianesthesia," Am. J. of Surg., 1910, 
29, 33. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
563 
been done by others, although it is now a year and a half since I read a 
paper on this subject at the International Surgical Congress in Brussels. 
I secured this anesthesia by piercing the spinal column at all levels, and 
by adding strychnin to the anesthetic stovain, novocain, tropococain, 
etc." 
Jonnesco holds that the fact that the respiratory nerves are not in- 
volved in the high injections, although all the other nerves of that spinal 
region are paralyzed, is due to the influence of the strychnin. To this 
latter statement reference will be made under the head of physiological 
action. 
In the addition of the strychnin to the analgesic solution Jonnesco is 
evidently original. As early as 1903, however, the author of this sec- 
tion used strychnin hypodermatically in conjunction with spinal anal- 
gesia, with the same ends in view, of supporting the patient and pre- 
venting respiratory depression. 
Following the suggestion of Bier concerning the desirability of dis- 
covering some more suitable drug than cocain for spinal analgesia 
(see page 560), a large amount of experimental work has been done 
with a view to accomplishing this end. Tropacocain, stovain, novocain, 
beta-eucain, beta-eucain lactate, alypin, nirvanin, holocain hydrochlorid, 
acoin, orthoform (new), and anesthesine are some of the drugs which 
from time to time have been made the subject of experimental or clinical 
investigation. (See page 599.) 
ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS 
With the discovery by Cotugno (Dominions Cotunnius), in 1764, of 
the "collection of water about the brain and in the spine," a new interest 
was given to the cerebrospinal column. The observations of Cotugno 
upon the bodies of animals were confirmed by him upon human sub- 
jects, and his declaration that the nervous centers were bathed by this 
cephalo-spinal fluid called forth a brief but very good description by 
Haller, in 1766, and a complete study by Magendie, in 1825. Follow- 
ing these early investigators, a number of others continued the study 
of the anatomy and physiology of the cerebrospinal canal. Corning's 
experiments with reference to the local medication of the cord, and the 
discovery by Quincke that it is possible to remove the cerebrospinal 
fluid by lumbar puncture without danger to the subject, gave a still more 
definite interest to this region. The surgical application, made by Bier, 
of the discoveries of Corning and Quincke called forth an extensive 
series of investigations concerning the anatomical and physiological rela- 
tions of the vertebral canal. 564 
ANESTHESIA 
The extent of the experimental and clinical study devoted to this 
subject may be imagined when one realizes, as stated by Mott,1 that in 
the ten years preceding 1910 there appeared in the Revue Neurologique 
abstracts of 187 papers on the physiology of the cerebrospinal fluid. 
Despite the many contributions to the subject, there is a notable 
diversity of opinion with reference to certain practical points relating 
to the physiology of the cerebrospinal canal and its contents, as will be 
seen. 
Among the more recent investigators of the anatomical relations of 
the canal, Gerstenberg and Hein 2 and Lusk 3 have given valuable practi- 
cal contributions. Michelson 4 and others have emphasized the impor- 
tance of bearing in mind that the spinal fluid bathes a number of cranial 
nerves, as well as the spinal roots, so that those nerves may also become 
exposed to the toxic action of the analgesic agent when it passes to a 
sufficient height in the dural sac. The abducens, trochlear, motoroculi, 
and optic are the cranial nerves primarily, and most frequently, involved 
in spinal analgesia. 
It is to be taken for granted that the general anatomy of the parts 
involved is a matter of accurate knowledge on the part of the surgeon 
who undertakes spinal puncture, for which reason no space is given to 
this subject. Certain practical points which are directly concerned in 
the matter of the selection of the site for puncture, and in controversy 
relating to lateral or median puncture, are reserved for the section on 
Sites of Injection. (See p. 605.) 
Physiological investigation has established certain facts with refer- 
ence to the cerebrospinal fluid which have a practical bearing upon 
spinal puncture and spinal analgesia. The composition, origin, density, 
volume, pressure, drainage, and motion of the fluid have been made the 
subject of exhaustive research, formerly by physiologists and neurolo- 
gists, and latterly by those especially interested in its utilization for 
therapeutic purposes, particularly with reference to spinal analgesia. 
Origin.-Faivre, in 1854, suggested the intimate relationship between 
the choroid plexus of the central nervous system and the cerebrospinal 
fluid. Subsequent investigation has tended to support the view that the 
cerebrospinal fluid is a secretory product of the epithelial cells of the 
choroid plexus and of the ependyma membrane. 
1 Mott, F. W.: "The Cerebro-spinal Fluid," Lancet, July 2 and 9, pp. 1 and 
79, 1910. 
2 Gerstenberg and Hein: ' ' Anatomische Beitrage zur Riickenmarkesanasthesia, ' ' 
Z. f. Geburtsch. u. Gyn., 1907-08, 61, 524; also, Verhandlungen der Gesellschaft f. 
Geburtsh. u. Gyn., zu Berlin, 1907-08. 
3 Lusk, William C.: " The Anatomy of Spinal Puncture with Some Con- 
siderations on Technic and Paralytic Sequels," Ann. of Surg., Oct., 1911, 449. , 
* Michelson: 1 ' Der gegenwartige Stand der Lumbal-anaesthesie, ' ' Ergebnisse 
der Chir. und Ortho., 1912, 4. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
565 
Volume.-There is abundant evidence of the fact that the cerebro- 
spinal fluid is continually being secreted. The quantity in the subarach- 
noid space, the ventricles of the brain, and the central canal of the spinal 
cord is said to vary from 50 to 150 c. c., the average being from 100 to 
130 c. c. (See pp. 619 and 624 Dry Spine.) 
Specific Gravity.-According to Gray, who studied the cerebro- 
spinal fluid in a series of normal children, from whom it was obtained 
on the operating table, the specific gravity varied from 1.0054 to 1.0071. 
In cases of extreme shock the specific gravity rose to 1.0076, 1.0080, and 
1.0083. The fluid of older children tended to be of a higher density 
than that of infants and younger children. 
The specific gravity of the fluid in adults is stated by Nogue 2 to vary 
from an average of 1.003 to as high as 1.020. By the majority of the 
writers consulted it is stated to vary from 1.004 to 1.007. 
Movements.-The cerebrospinal fluid is in constant motion. Being 
constantly secreted, it is likewise continuously drained through the 
arachnoid sheaths of the nerves, the perivascular lymphatic sheaths, and, 
according to some observers, the Pacchionian bodies. This subject has 
been studied by Schwalbe, Key and Betzius, Tait and Caglieri, Klose 
and Vogt, and a number of others, and recently reviewed by Chambard.3 
When sepia, India ink, or other colored fluid is injected into the 
canal, the colored corpuscles accumulate around the nerve roots and the 
cranial nerves near their exit orifices. The elimination in this manner of 
soluble substances injected into the fluid illustrates the meningeal per- 
meability from within outward. 
In addition to the constant drainage of the cerebrospinal fluid there 
are also pulsation, a systolic flux and reflux, and a transportation, under 
certain circumstances, of the entire bulk of the fluid, as when, in the 
horizontal position, the fluid is transported on to the medulla and the 
brain. 
Pressure.-The pressure under which the fluid exists is dependent 
upon the cerebral circulation, and varies under certain circumstances and 
in different positions of the body. The actual pressure is taken by lum- 
bar puncture in the sitting posture. This has been found by Quincke to 
vary from 50 to 150 millimeters of water. 
Diffusion.-Tait and Caglieri,4 in their valuable experimental and 
clinical work on the subarachnoid space, employed a large number of 
1 Gray, H. Tyrrell: "A Study of Spinal Anaesthesia in Children and In- 
fants," Lancet, Sept. 25 and Oct. 2, 1909. 
2Nogue: "Anesthesie," Traite de Stomatologie, 1912, 6, Paris. 
* Chambard: " L 'Anesthesie Lombaire, ' ' These de Paris, 1911. 
4 Tait and Caglieri: Op. cit., Trans. Med. Soc. State of Cal., April, 1900, 266. 
See, also, J. Am. Med. Assn., July 7, 1900. 566 
ANESTHESIA 
animals and a series of cadavers, and several patients were subjected 
by them to lumbar puncture for therapeutic purposes, with the hope of 
clearing up certain doubtful points relating to the physiology of the 
subarachnoid space. 
By means of their experimental work on animals and their clinical 
studies on man, these investigators confirmed the theory that absorption 
and elimination occur when chemical substances are injected directly 
into the subarachnoid space, and that the osmotic current exists in only 
one direction; in other words, as shown by Sicard, that there is exos- 
mosis, but no endosmosis. 
The mode of diffusion of the cerebrospinal fluid was studied by 
means of colored mixtures, which enabled the workers to note with ac- 
curacy and facility both the miscroscopic and the macroscopic results. 
When injected without pressure, the colored fluid stained the space at 
the point of injection, then diffused in all directions, ascending and de- 
scending, following the meningeal prolongations along the spinal nerves, 
to the intervertebral foramina, where it stopped abruptly. The extent 
and the rapidity of the diffusion were influenced by the amount, the 
composition, and the specific gravity of the liquid injected, and chiefly 
by the pressure under which it was injected. 
It was found that a slow injection of 1 c. c. of the colored mixture, 
in a rabbit weighing 900 gm., ascended rapidly, the fluid being found 
around the medulla oblongata and at the base of the brain when the 
animal was killed 10 hours after the injection. 
The same amount of fluid injected under pressure was found 26 
hours later to have diffused from the spinal subarachnoid through the 
foramen of Magendie to the fourth ventricle, through the iter a tertio, 
or aqueduct of Sylvius, to the third ventricle, and finally to the cortex of 
the brain. If 5 c. c. of the colored fluid were injected under great 
pressure in the lumbar space, the diffusion occurred instantaneously. 
Experiments were instituted to determine the course followed by the 
fluid from the lumbar space to the cortex of the brain. It was found 
that the pia-arachnoid was colored in its entire course along the 
cord and brain, continuing along the sheath of the auditory, facial, and 
optic nerves, and following the prolongations through the cribriform 
plate of the ethmoid. The stain followed the meningeal sheath on the 
optic nerve, generally stopping at the junction with the sclerotic. In 
several of their specimens Tait and Caglieri found that the stain in- 
volved the sclerotic, choroid, papilla, and retina. 
Halbreich,1 from a series of experiments on dogs and frogs, con- 
cluded that the solution, when injected in the lumbar region, is the 
more liable to reach the medulla oblongata the larger the quantity of 
fluid injected and the more the head of the subject is lowered. The 
1Halbreich: Med. Obos., Russia. Abst. in J. Am. Med. Assn., 1902, 603. SPINAL ANALGESIA AND SPINAD ANESTHESIA 
567 
gray matter is penetrated, according to this investigator, by diffusion 
and osmosis, and by the lymphatics. 
Crile,1 in his studies upon the cord, injected a solution of cocain, 
which was colored with methylene blue. He found that an injection of 
r/z dram of this solution, made in the lumbar region, stained the entire 
cord and the under surface of the brain in 30 seconds. The various 
localized functions of the cord and medulla were rapidly anesthetized, 
the respiratory center in the medulla, for example, being anesthetized 
within a few seconds by lumbar arachnoid injection. A forcible injec- 
tion wras followed within a few seconds by a direct fall in blood pressure 
and by cessation of respiration. Crile found that the fluid ascended 
about as rapidly with the subject in a vertical position as in the hori- 
zontal, and he concluded that the effect of the anesthetic was due to 
local contact with the nerve structure, and not to absorption. This view, 
he held, is in full accord with the general action of cocain on other 
nerve structure. Crile purposely employed large doses in these experi- 
ments in order to determine the control, or, as he expresses it, the want 
of control, the operator can have over the extent of the analgesia. 
The attempt to ascertain to just what physiological action of the 
analgesic agent the analgesic state may be attributed in the case of 
subarachnoid injection has led to various theories of more or less con- 
tradictory character. 
Bier 2 held that the sequence of symptoms following the injection is 
the result of changes in the circulation caused by the introduction of a 
heterogeneous substance into the spinal canal, and that it is not due to 
any toxic action of the cocain. 
Nicoletti3 attributed it to the vasomotor constrictive action of the 
injected agent. 
Goldan 4 held that the circulation is no factor in the production of 
analgesia when cocain is injected into the subarachnoid space, the effects 
being due, in all probability, to the passage of the cocai-n from the 
subarachnoid space along the perivascular spaces in the tunica adven- 
titia of the blood vessels to the sensory columns of the cord, also directly 
into the lymph spaces of the nerves themselves. 
The investigations of Donitz and Barker seem to have led to different 
conclusions with respect to the manner of extension of the analgesia. 
1 Crile, George W.: ' ' An Experimental and Clinical Research into Certain 
Problems Relating to Surgical Operations." Phila., 1901, 145 et seq. 
2 Bier: ' ' Bemerkungen zur Cocainisirung der Riickenmarkes, ' ' Miinch. med. 
Woch., Sept. 4, 1900. 
3 Nicoletti: " L 'analgesia cocainica del midollo spinale nella chirurgia gine- 
cologica, " Treizieme Congres International de Med., Paris, Sec. de Chir. Gen., 
1900; see, also, Archiv. Ital. di Ginicol., Aug. 1900, 512. 
4Goldan: ' ' Intraspinal Cocainization for Surgical Anesthesia," Med. News, 
Nov. 3, 1900. 568 
ANESTHESIA 
Donitz 1 maintains that it is not a question of diffusion, but simply 
one of shifting the balance in the liquor spinalis, which takes place at 
the moment of the change of posture; that "it is not a question of the 
action of gravity on the analgesic compound at all, nor is it one of 
hypothetic currents." 
Barker,2 on the other hand, in his interesting series of clinical ex- 
periments, makes use of gravity by employing an injection compound 
of much greater specific weight than that of the liquor spinalis. As- 
suming that there are only three ways in which an analgesic fluid in- 
jected in the second lumbar interspace can make its direct effects felt 
in the mid-dorsal region or higher, Barker says with reference to these, 
in sequence: 
"(1) Diffusion alone of one fluid in another is a slow process, and, 
as we shall see, is unlikely to be the mode of spread of the injected fluid 
in this procedure. 
"(2) Bier and his followers have aimed at shifting the whole in- 
jected compound upward or downward with the whole mass of the liquor 
spinalis by raising or depressing the pelvis. That the cerebrospinal 
fluid does recede somewhat toward the head on elevation of the pelvis 
is undoubted, but it is hard to imagine its doing so to such an extent as 
to carry with it a cloud of fluid lighter than itself from the second lum- 
bar to the fifth dorsal vertebra, some 8 to 10 inches. I venture to think 
that with such a fluid as he has used, whose specific gravity is 1.0058, 
suspended in the liquor spinalis, whose specific gravity is 1.0070, what 
he has achieved by elevation of the pelvis has rather been a more rapid 
diffusion of the injected drug, due to the consequent oscillation of the 
spinal fluid, aided, perhaps, by vascular pulsation. But this rapid diffu- 
sion would, of course, dilute the injection, and perhaps carry it further 
than desirable. 
"(3) There remains, then, the third possibility, namely, that an 
injected compound heavier than the liquor spinalis may be affected by 
gravity, and sink through the latter in a way quite different to the be- 
havior of a fluid of less specific gravity, such as that referred to." 
Other investigators, notably Babcock,3 by using an injection fluid 
lighter than the cerebrospinal fluid, seek to affect the sensory nerves 
without involving the motor nerves. The regulation of the position of 
the patient's body, with such a fluid, controls the area affected by the 
1Dbnitz: "Die Hohenausdehung der spinal Analgesie," Munch. med. Woch., 
Nov. 27, 1906. 
2 Barker: "A Report on Clinical Experiences with Spinal Analgesia, ' ' Brit. 
Med. J., March 23, 1907. 
3 Babcock, W. Wayne: (1) "Spinal Anesthesia. A Clinical Study of 658 
Administrations," Penn. Univ. Med. J., Aug., 1909; (2) "The Range of Activity 
and the Untoward Effects of Certain Spinal Analgesics; Based on Two Thousand 
Administrations," Trans. Am. Ther. Soc., 1910, 57. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
569 
analgesia. The rate of diffusion of the lighter fluid is controlled by the 
addition of a larger or smaller percentage of alcohol. Babcock holds that 
the analgesic drug is decomposed by the cerebrospinal fluid, which still 
further limits its field of activity. The less the alcohol used, the more 
rapid is this decomposition; hence, as the fluid diffuses, it decomposes, 
and the anesthetic effect can be limited very largely to any desired por- 
tion of the spinal canal. 
Tuffier,1 considered the analgesic action of the agent to be local, 
whether it be exerted upon the cord, the nerve roots, or the spinal 
ganglion, being not determined. He inclined to the belief, however, 
that it is confined exclusively to the nerve roots. The early symptoms, 
such as malaise and trembling, he attributed to the direct action of the 
anesthetic agent upon the spinal axis. 
Spiller and Leopold 2 experimented with stovain in an effort to de- 
termine certain points with reference to the action of this agent upon the 
nervous system. They thought that perhaps stovain, which produces 
temporary anesthesia, might, by repeated injections, produce anesthesia 
of gradually increasing duration until a finally persisting loss of sensa- 
tion, resulting from organic change, might ensue. They desired to 
ascertain whether a systemic degeneration of the posterior roots and 
their continuation in the posterior columns of the cord is the common 
result of the repeated use of stovain. They also desired to determine 
whether the paralysis that occurs in stovain anesthesia is of a motor 
or sensory type, i. e., whether it is produced by changes in the peripheral 
motor neurons, or is the result of ablation of all afferent impulses which 
normally pass over the posterior roots. They called attention to the fact 
that reflex action and all recognition of toxicity of the limbs, and neces- 
sarily of the position of the limbs, are lost if all peripheral afferent im- 
pulses are cut off. 
In order to satisfy themselves upon these points with reference to 
stovain, Spiller and Leopold experimented upon dogs, 5 subjects being 
employed. They performed lumbar puncture, using stovain in doses of 
0.05 gm. to 2 gm., the injections being usually at intervals of 2 or 3 days. 
They divided the symptoms into temporary and permanent. The 
temporary symptoms consisted of flaccid paralysis and complete or par- 
tial sensory loss. The permanent symptoms consisted of ataxia, de- 
creased sensation, and, in one case, loss of patellar reflex. The symp- 
toms became permanent after the third injection, remaining until the 
end of the experiment. 
These investigators considered that their experiments clearly demon- 
strated that stovain affects especially the anterior and posterior roots of 
'Tuffier: Op. cit., La Presse medicale, June 8, 1901. 
2Spiller and Leopold: "The Effects of Stovain on the Nervous System," 
J. Am. Med. Assn., June 4, 1910, 1840. 570 
ANESTHESIA 
the cord. The degeneration of the posterior root fibers was intense, as 
was likewise that of the intramedullary portion of the lumbar and sacral 
posterior root fibers in the thoracic region. The posterior thoracic roots 
were unaffected. Stovain evidently causes slight degeneration in the 
periphery of the anterolateral columns, but has less effect here than on 
the nerve roots. 
The lesions obtained by them could not have been produced, they 
hold, by the trauma of the needle, as the sections of the lumbar region 
examined were 1/2 to 2 inches above the point of injection, and yet the 
posterior and anterior roots were greatly degenerated. 
"It would be unwarranted/' they conclude, "to apply these findings 
too strictly to man, as no grave changes have been found as yet in the 
human cord. At most, our findings would show that repeated injec- 
tions of stovain might be injurious, and would make one cautious in em- 
ploying several injections within a short time in the same subject." 
Spielmeyer 1 examined human spinal cords in his study of the patho' 
logico-anatomical considerations involved in spinal analgesia. He ex- 
amined the central nervous system of 13 patients who had died from 
various causes within from 2 to 8 days after spinal analgesia with sto- 
vain. In all except 1 case death was in no way related to the spinal 
analgesia. In 1 case death was due to respiratory paralysis 40 hours 
after the operation. 
Upon examination of the woman who died from respiratory paraly- 
sis advanced changes in the cells of the spinal cord were found. Spiel- 
meyer did not regard these as a direct effect of the analgesic agent, simi- 
lar changes having been found in other cases in which death was due to 
respiratory paralysis of different origin. In three other cases Spiel- 
meyer was enabled to demonstrate characteristic changes in the 
polygonal motor cells of the cord. The cells of the posterior horn and 
the spinal ganglia presented no changes. Spielmeyer was able to pro- 
duce, experimentally, similar changes in the motor ganglion cells of 
dogs and monkeys. 
Michelsson holds the view that, as this histological picture exactly 
corresponds to the phenomena which usually follow upon the destruction 
of the axis cylinder, it must be left undecided whether a primary or 
secondary effect of stovain upon the ganglia is responsible, although 
animal experiments rather favor the first assumption. It is certainly 
remarkable, he says, that these changes can be observed only on the mo- 
tor ganglion cells, high up in the cervical cord, and that there is always 
a predominating number of normal polygonal cells, besides the affected 
cells. This probably accounts for the fact that motor disturbances were 
1 Spielmeyer: ' ' Pseudosystemer-krankungen des Riickenmarkes naeh sto- 
vainanasthesie, " Neurol. Centrlbl., Jan. 16, 1909, 69; see, also, Munch, med. 
Woch., Aug. 4, 1908, 1629. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
571 
not noted in any of Spielmeyer's cases in man or in animals. In the 
13 cases Spielmeyer employed stovain in doses of 0.12 gm. Patients 
who had received the customary dose of 0.05 gm. to 0.07 gm. presented 
no changes in the central nervous system, so that the assumption would 
seem to be justified that this stovain dose as a rule does not produce 
any lesions of the ganglion cells. 
Klose and Vogt1 employed tropococain and novocain in a series of 
experiments, which led them to the same results as those obtained by 
Spielmeyer with stovain. 
These investigators found that the inj'ected agents are distributed 
over the entire space occupied by the cerebrospinal fluid within half 
an hour at the latest. The specific gravity of the solution, and the posi- 
tion of the animal, are of subordinate importance. The alkaloids re- 
main for a disproportionately long time in the cerebrospinal fluid. 
Among the agents examined by them, tropococain persisted for relatively 
the shortest time, stovain for the longest, novocain ranking midway 
between. In this scale of excretion the duration of the absorption, the so- 
journ in the blood, and the duration of the analgesia stand in direct 
proportion to the time after which absorption begins. 
Following the work of Klose and Vogt, Barker 2 conducted a series 
of experiments to determine how long stovain remains in the dural sac 
after injection, unabsorbed, fixed, or destroyed; what effects, apart from 
analgesia, the agent produces; what immediate and remote effects, if 
any, the drug has upon the structures with which it comes in contact; 
and how the agent is eliminated from the system generally. Attention 
is directed by him to the importance of determining these points with 
reference to the various analgesic compounds or agents before this 
method of inducing analgesia can be put in its proper place among sur- 
gical procedures. 
In nine of his cases previously injected with stovain Barker with- 
drew the cerebrospinal fluid, for various reasons, at periods varying 
from half an hour to forty-six hours after injection. Stovain was found 
to be present in six cases, the time after injection ranging from one-hal,f 
hour to twenty-four hours; negative in one case at forty-four hours; 
and doubtful in two at forty-five and forty-six hours respectively. 
The question whether any immediate effect is produced upon the 
structures within the dura by the stovain injection was answered, in 
Barker's experience, in the affirmative. In all the cases in which he 
withdrew cerebrospinal fluid within 46 hours of the injection of stovain 
1 Klose and Vogt: ''Physiologische nnd anatomische Untersuchungen zur 
Lumbalanasthesie und zur Frage ihrer klinischen Verwertharkeit, " AfuncTt. med. 
Woch., March 9, 1909. 
2 Barker: ' ' Elimination of Stovain After Spinal Analgesia, ' ' Brit. Med. J., 
Sept. 18, 1909, 789. 572 
ANESTHESIA 
into it the fluid was distinctly turbid. The turbidity was found on 
microscopical examination to be due to the presence of leukocytes of 
various forms. The theory that the headache which sometimes follows 
spinal analgesia is due to aseptic irritation and hypersecretion within 
the dura did not seem to Barker quite satisfactory. 
Barker found from the study of his cases that, long after the anal- 
gesic effect of the drug has passed off, stovain or its base can be shown 
to be unmistakably present in the cerebrospinal fluid. No satisfactory 
answer could be given to the question, Why does the analgesia last for 
only a couple of hours? He suggested that only perfect stovain is 
analgesic, and that its base split off by the alkaline cerebrospinal fluid 
is not, and that this base is what is recovered in subsequent tappings. 
From his clinical studies he thought it clear that no permanent 
structural change in the nervous structures leading to definite symp- 
toms has been proved to be due to the injections. 
From the foregoing references to the experimental work of various 
investigators it will be noted that the physiological action of cocain and 
other analgesic agents when injected into the subarachnoid space was 
not clearly understood in the earlier stages of the development of spinal 
analgesia, and that the studies of later investigators have not served 
to fully settle these problems. 
COURSE, EXTENT, AND DURATION OF ANALGESIA 
Course.-The course of the analgesia, or the sequence in which the 
various parts of the body are affected, varies with the individual, the 
point of injection, the agent employed, and the technique. 
As a rule, in lumbar analgesia, after a minute or so, sensibility to 
pain is lessened in the perineum, external genital organs, and the inner 
side of the thigh. The first reflex to disappear is the patellar, which is 
quickly followed by the disappearance of ankle clonus. Loss of sensi- 
bility to pain follows, in the order named, in the posterior surface of the 
thighs and legs, the soles of the feet, and the anterior surface of the 
legs, and the thighs up to Poupart's ligament. The analgesia then 
gradually extends to the umbilical region, and from that zone on, in 
some instances, higher and higher, until universal analgesia, as this 
may be determined from superficial tests, supervenes. In some in- 
stances this includes the mucous membranes of the mouth, nose, and 
larynx. 
The course of the disappearance of sensibility to pain is segmental, 
proceeding from the fourth or fifth sacral, segment by segment, to what- 
ever limit it reaches in the individual case. 
Extent.-Analgesia may be partial or complete, with reference to Fig. 232. -Operation Under Way for Removal of Tumor of Abdominal Wall Under 
Spinal Analgesia. Ten minutes after puncture. Face screen in position. 
Fig. 233.-Second Operation, Same Analgesia, Same Patient as in Figure 232. 
Exsection of varicose veins, both legs; patient reading, resting paper against face 
screen. 574 
ANESTHESIA 
the extent of the body involved, as well as to the degree to which sensa- 
tion is abolished. T.he term complete is generally employed to signify 
the degree of loss of sensation, particularly pain sense, though the 
word is not infrequently used with reference to the extension of the 
analgesia over the entire body. For the latter purpose the word 
universal is perhaps preferable. When the cerebral cortex becomes 
involved, the analgesia merges into true anesthesia, during which 
the patient loses consciousness, or lapses into a deep sleep with 
snoring. 
In the majority of instances in which the analgesic agent is injected 
Fig. 234.-Same Patient as in Figures 232. and 233. At End of Operation. While the 
wounds are being sutured, She drinks a cup of tea; facial expression shows absence of 
pain or discomfort. 
into the lumbar or lower dorsal region the analgesia extends to the um- 
bilical region. Under different circumstances the height to which this 
goes varies, as previously noted. 
It not infrequently happens that complete analgesia to a very high 
level, or even universal analgesia, follows the introduction of moderate 
doses of the analgesic agent into the lumbar region. 
Morton,1 in 1903, published a record of 929 cases operated upon be- 
low the diaphragm and 76 above it. In one case he removed the entire 
superior maxilla for carcinoma, the analgesia being complete. He intro- 
duced in this case half a grain of cocain between the third and fourth 
lumbar vertebrae. 
1 Morton: 11 Excision of the Superior Maxillary Under Medullary Narcosis," 
Am. Med., March 21, 1903, 451. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
575 
Chaput1 noted that in 53 of 102 cases the analgesia extended above 
the diaphragm, the arms being involved in 31, the face in 13; while 
in 9 cases the analgesia of the head was complete. This high analgesia 
was obtained by the rapid and forcible injection of large doses of cocain. 
Pedeprade 2 noted 5 cases in which analgesia was complete through- 
out the body. 
Tuffier 3 reported the removal of a cyst of the lung under medullary 
analgesia. 
In 4 of the writer's early cases the analgesia extended over the entire 
body, even the mucous membrane of the mouth and larynx being com- 
Fig. 235.-Enlarged Picture of Patient's Face Showing Facial Expression. 
pletely analgesic, as recorded in a personal letter to Patterson and in- 
corporated by the latter in his admirable resume of the literature of 
spinal analgesia.4 In 27 other cases, operated upon under lumbar anal- 
gesia, with moderate doses, the analgesia was sufficiently extensive to 
have rendered painless operation upon the upper part of the body. 
A typical instance of universal analgesia 5 was that of a female pa- 
tient, aged years, who was suffering from tuberculous abscesses of 
the foot, with tarsal necrosis. On February 7, 1901, she was operated 
upon under cocain spinal analgesia. The injection was made between 
1 Chaput: ' ' Sur la Cocaine Lombaire, ' ' Butt, et Mem. d. I. Soc. d. Chir. de 
Paris, 1901, 883. 
2Pedeprade: "L'Analgesie par injection de cocaine sous 1'arachnoide lom- 
baire en chirurgie. " Paris, 1901. 
sTuffier: Op. cit., La Presse med., June 8, 1901. 
4Patterson: "Spinal Analgesia. The Present Status of the Method Based on 
a Review of the Literature,'' Archiv Internat. d. Chir., 1, 502; 2, 53. 
'Bainbridge: "A Report of Tyventy-four Operations Performed During 
Spinal Analgesia,'' Med. News, May 4, 1901, Case IX. 576 
ANESTHESIA 
the third and fourth lumbar vertebrae, the amount of cocain being 15 
minims of a two per cent solution. Analgesia extended to the level of 
the diaphragm in 2 minutes. The operation lasted 20 minutes, and in- 
cluded the opening of the abscesses and the removing of carious bone 
and tuberculous tissue. At the close of the operation, 25 minutes after 
the injection, there was absolute absence of pain sense over the entire 
body. Tests proved that the analgesia was present in the conjunctiva, 
the mouth, on the tongue, and over the posterior pharyngeal wall. 
A similar instance of complete analgesia.occurred in a child five years 
of age,1 upon whom circumcision was performed. Other cases of anal- 
gesia extending practically over the entire body are cited.2 In one case 
(No. XXII) a tuberculous sinus extending into the external condyle 
of left humerus was enlarged and dead bone removed. In another (No. 
XXIV) the left thumb was amputated at the lower third of the meta- 
carpal bone. In the former case 8 minims of a two per cent solution of 
cocain were injected between the third and fourth lumbar vertebrae; in 
the latter 32 minims of a two per cent solution were injected between 
the second and third lumbar. 
In a number of recorded instances the analgesia was unilateral, pre- 
sumably, according to Dbnitz,3 because the injection was made at the 
beginning of the cauda equina, in the right or left group of nerve fibers, 
instead of the cisterna terminalis. Diffusion is thus incomplete, the so- 
lution reaching only the contiguous nerve roots, hence producing only 
partial analgesia, or analgesia of a given side. 
Duration.-The duration of analgesia induced by subarachnoid in- 
jection is generally from % of an hour to hours, with cocain, sto- 
vain, and tropococain, the last named being'shorter than the other two, 
and from to 3 hours, with novocain and adrenalin. Instances have 
been recorded where the analgesia lasted from 17 minutes to 8 hours. 
Jonnesco states that with his method analgesia lasts from to 2 
hours. 
The writer has found the analgesia to vary in duration from 45 
minutes to 3 hours and 20 minutes. This has reference to the complete 
return of pain sense. During the early days, when the dosage was so 
uncertain, when cocain was used exclusively, and when so much was 
being said concerning the dangers of this agent, very conservative doses 
were employed, and the analgesia was often of shorter duration than 
obtains at the present time, when the method is more thoroughly under- 
stood in all its phases. It may be said, however, that, with all the added 
knowledge gained from experience, the duration of analgesia is still 
1 Bainbridge: "Report of Twelve Operations on Infants and Young Chil- 
dren During Spinal Analgesia," Archives of Pediat., July, 1901, Case I. 
2 Bainbridge: Op. tit., Med. News, May 4, 1901, Cases XV, XXII and XXIV. 
sDbnitz: Verh. d. deutsch. Gesell. f. Chir., 1905, 536. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
577 
problematical, and will doubtless continue to be so until some definite 
scientific basis for dosage is formulated. 
ACCOMPANYING PHENOMENA 
Subjective.-The manifestation of subjective symptoms begins 
within from two to eight minutes after the injection is made, varying 
with different patients. As a rule, the first subjective symptom noted is 
a tingling sensation and numbness in the feet and sometimes in the legs. 
During the first ten minutes or so there is a sense of malaise, charac- 
terized by a feeling of epigastric heaviness, thirst, and air-hunger. A 
sensation of cold, or of heat, with sweating, and sometimes salivation, 
follow the vasomotor reaction to the analgesic agent. In a certain pro- 
portion of cases there is a trembling of the legs amounting to clonic 
contractions. There may be cramps in the muscles of the legs. 
Nausea occurs in about thirty per cent of cases, as culled from the 
literature by Patterson.1 It seems to bear no relation to the preceding 
meal. The size of the dose of the analgesic agent injected bears a rela- 
tion to the nausea, the larger the dose the more certain the nausea. 
The bulk or volume, rather than the strength, of the injected fluid is 
held by Gray and others to be the main factor in the production of 
nausea. 
Vomiting, which occurs in about forty per cent of cases, begins, as 
a rule, in from five to ten minutes after the injection, sometimes earlier. 
It occurs in women more frequently than in men. It is seldom re- 
peated more than 3 or 4 times. There may be late vomiting, coming on 
in from 2 to 3 hours after operation, and continuing for 2 or 3 days, 
according to some writers. Personal experience, and that of all but a 
few operators, is at variance with this observation. 
An interesting study of the subjective symptoms has been furnished 
by Fraicou,2 who operated upon himself for hernia under spinal anal- 
gesia with strychninized stovain. 
The injection was made by an assistant, between the twelfth dorsal 
and first lumbar vertebrae, 1 c. c. of water, containing 5 centigrams of 
stovain and 1 milligram of strychnin, being employed. In addition to 
this, 2 centigrams of stovain were employed locally in the iliac fossa 
and external portion of the inguinal region. 
During the entire operation, which was performed without assist- 
ance, the analgesia was complete below the anterior superior iliac spines. 
The body above this level remained unaffected throughout. The anal- 
'Patterson: Op. cit. 
2Fraicou: "Auto-observation d'une auto-operation de hernie sous la rachi- 
strychno-stovainization, " La Presse med., Feb. 11, 1911, 105. 578 
ANESTHESIA 
gesia disappeared as the work was drawing to a close, and the suture 
of the skin was slightly painful. 
The conclusions formulated from this experience are in part as fol- 
lows: (1) The pain produced by the spinal puncture is greater than 
that caused by a simple subcutaneous injection with the Pravaz syringe. 
The pain, however, is less disagreeable than the sensations experienced 
by the majority of patients at the beginning of chloroform anesthesia. 
(2) The anesthesia became established with pleasant sensations, and 
disappeared imperceptibly. 
Fig. 236.-Amputation of Foot Just Above Ankle Joint Under Spinal Analgesia. 
Operator with clamp grasping sensory nerve and cutting it short; note absence of 
pain in expression. 
(3) The mild excitement at the beginning of the anesthesia, and 
the vertigo which was felt on making sudden movements, are proof of 
the anesthetic fluid having slightly spread toward the cerebral 
hemispheres. The intellectual faculties remained absolutely intact, and 
consciousness was entirely preserved. This is conclusively proven by the 
fact that the surgeon also conducted a delicate operation upon himself 
to a successful outcome. 
(4) The technique of the anesthetic method and the patient's 
position after the injection are the essential factors on which depend 
the degree and intensity of the anesthesia. 
(5) The anesthesia has a great tendency to remain segmental. 
(6) The harmlessness of the method of rachi-strychno-stovainiza- Fig. 237.-Inguinal Hernia, Inherent Intestine, Adhesions Being Pulled Apart 
Under Spinal Analgesia. Babcock's diffusible solution. Head lowered. 
Fig. 238.-Same as Figure 240, Head Elevated. Patient reads to surgeons during 
operation. 580 
ANESTHESIA 
tion is illustrated by the fact that during the entire anesthesia no un- 
pleasant incident or phenomenon occurred, aside from vertigo caused 
by all sudden movements, despite the sitting position which it was 
necessary for the operator to maintain throughout. 
(7) The contrast between the absence of any accident during the 
anesthesia and the onset of transitory postoperative and postanesthetic 
symptoms is accounted for by the fashion in which the operation was 
performed. Although in the upright position, and although the move- 
Fig. 239.-Same Patient at End of Operation. Patient drinking water. 
ments during the operation had no influence upon the onset of imme- 
diate symptoms, they gave rise at least to secondary disturbances. 
Another instance of auto-observation of the symptoms caused by 
spinal analgesia was the operation for appendicitis recently performed 
upon himself by Dr. Bertram F. Alden, chief surgeon to the French 
Hospital, San Francisco. 
The following history embraces the auto-observations of a patient 
operated upon by the author: 
Miss E. F., 47 years of age, trained nurse. According to her own 
statement, she had had chronic nephritis for a number of years, with 
albumin as high as 25 per cent by volume at times, with hyaline, 
granular and blood casts, crystals of triple phosphate, and kidney and 
bladder epithelia. This statement was verified by urinalysis previous to 
operation. For 35 years she had had goiter, which was found to be of 
the cystic variety. The goiter developed with puberty, since which time SPINAL ANALGESIA AND SPINAL ANESTHESIA 
581 
she had always been extremely nervous, with more or less functional 
irregularity of the heart. Referred to me, January 5, 1911, by Dr. E. M. 
Mosher, of Brooklyn, for multiple uterine fibroids which filled the entire 
pelvis. On January 14 panhysterectomy and appendectomy were per- 
formed under spinal analgesia, one-half dram of a 3 per cent solution of 
stovain being injected between the second and third lumbar vertebrae. 
The patient's description of her experience follows: "In a few min- 
utes (5) after the injection the lower extremities became lifeless. Just 
as the incision was made into the skin of the abdomen my head was 
raised in order to put a pillow under it. I saw the incision, and felt the 
doctors working, but experienced absolutely no pain until the last 3 
stitches were applied. These caused slight pain. By this time the anal- 
gesia was gradually disappearing. I slept at short intervals during the 
operation. I was given during the operation by hypodermic injection 
1/100 gr. nitroglycerin and 1/6 gr. morphin, and at intervals small 
quantities of brandy and water by mouth. After the operation I drank 
lemonade to the health of the doctors. I was removed to my room per- 
fectly conscious and free from pain. I had no unpleasant after-effects 
from the analgesia. The wound healed by primary union." 
On February 11, 1911, half of the cystic thyroid gland was removed 
under local cocain analgesia. Since that time the patient has been per- 
fectly well, resuming her work as a professional nurse. 
Objective.-Tests elicit the fact that the sense of pain is the first to 
disappear, while the senses of touch and posture are gradually lost to a 
greater or less extent, according to dosage. Motor pareses manifest 
themselves first in the muscles of the feet, gradually extending upward. 
The extensors are more pronouncedly involved than are the flexors. 
From Patterson's 1 investigation of the subject, it appears that in 
about 30 per cent of the cases there is incontinence of feces, due to the 
direct insensibility of the rectum. In about 10 per cent of the cases 
there are urethrovesical symptoms. In all cases the sense of distention, 
as well as of contact, with reference to the bladder is lost. 
Pallor of the face and profuse perspiration are sometimes noted. 
The general observation seems to be that there is a fall of blood 
pressure following immediately upon the injection, and that this varies 
with the completeness of the analgesia and with the parts affected. The 
pulse rate varies from 80 to 129 beats per minute, but the cardiac 
rhythm is regular. 
Babcock 2 holds that surgical shock is less apt to occur with spinal 
analgesia than with general anesthesia, because of the blocking off of the 
nerves of sensation in the former. "The shock of the later stages of 
1 Patterson: Op. cit. 
2 Babcock: "Spinal Anesthesia, a Clinical Study of 658 Administrations," 
Penn. Med. J., Aug., 1909. 582 
ANESTHESIA 
the operation/' he says, "is negatived by the emergence of the spinal 
centers from the depression of the anesthetic. For this reason, under 
spinal anesthesia it is not unusual to find the pulse stronger and fuller 
and the patient in better general condition at the end of an operation 
than at the beginning." 
In low analgesia the effect upon the respiration is shown in a greater 
or less increase in rapidity, while the rhythm is practically unchanged. 
The greatest danger of so-called high analgesia is paralysis of the mus- 
cles concerned in respiration. This may vary from slight and temporary 
respiratory embarrassment to complete and lasting respiratory paralysis. 
Jonnesco 1 holds that such phenomena as pallor, nausea, and sweating 
rarely occur when the stovain-strychnin solution recommended by him is 
used. The face, in such cases, retains its normal aspect; nausea occurs 
in 2.25 per cent, vomiting in 1.25 per cent, and sweating in 2 per cent. 
He has noticed fecal incontinence in 4 per cent of cases in cachectic, 
feeble individuals. The pulse, which is slowed by stovain alone, is usu- 
ally normal in rapidity and strength when the stovain-strychnin solution 
is employed. Sometimes, according to Jonnesco, it rises to 80 or 90, 
but always remains strong. The 5 cases in which he noted temporary 
stoppage of respiration were cases in which he departed from his usual 
method in some detail. The addition of the strychnin is claimed by him 
to obviate this difficulty. 
POSTOPERATIVE PHENOMENA 
Alessandri 2 contributes a compilation, from the Neuro-pathological 
Institute in Rome, of the unfavorable accidents and complications fol- 
lowing spinal analgesia with stovain injections. 
The nervous system, according to this observer, which has a great 
affinity for stovain, presents chromatolysis of the nerve cells, which may 
affect all parts, inclusive of the bulb. In this way paresis of all descrip- 
tions may follow. Nausea and vomiting are not uncommon, as the im- 
mediate result of the effect upon the bulb. Syncope and severe respira- 
tory disturbance are equally frequent. 
Among the remote results of stovain analgesia mentioned by Ales- 
sandri are: Hyperthermia, up to 40° C., lasting several days, referred 
by some observers to shock due to operation; disturbance of the sensory 
nerves, represented by headache, and pains of the spinal nerves; trophic 
disturbances in the form of bed sores; psychic disturbances in the form 
of delirium and persistent insomnia. 
1Jonnfesco: Op. cit., Brit. Med. J., Nov. 13, 1909, 1396. 
2 Alessandri: ' ' Gli accidenti nervosi rachianestesia, ' ' Il Morgagni, Aug. 24, 
1909. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
583 
Attention is called to the fact that certain disturbances which have 
been attributed to the stovain may also be referable to faulty puncture of 
the medullary canal or puncture at an unsuitable spot. 
Intense headache, dizziness, nausea, vomiting, rigidity of the neck, 
tenderness to pressure over the cervical vertebras, and pain in the small 
of the back constitute a symptom-complex known as meningism-due 
to irritation of the meninges. 
Sleeplessness, lasting sometimes for as long as 7 nights, has been re- 
ported as following subarachnoid analgesia. 
Postoperative fever, with or without chills, the temperature some- 
times running as high as 102° F., in some instances follows the injec- 
tion of tropococain, the fever being a manifestation of irritation of the 
heat center of the brain. 
Headache, retention of urine, and rise of temperature are seldom 
noted, according to Jonnesco, when his method is employed, and when 
they do occur they are of short duration. He has observed headache in 
6.25 per cent of cases, but it is not severe, and disappears in a few hours 
after operation. Transitory retention of urine was observed in 4.5 per 
cent of cases. In no case did the temperature reach 104° F. Post- 
operative vomiting has rarely been observed by him, and he has never 
seen postoperative analgesia paralysis. 
Hoseman,1 in discussing the after-effects of lumbar analgesia and 
their control, calls attention to the importance of measuring lumbar 
pressure. This serves to show that headache as a sequel to lumbar anal- 
gesia is always associated with changes of pressure, which is rarely in- 
creased, but frequently diminished. Where the pressure is increased the 
headache is favorably affected by the withdrawal of spinal fluid; when 
it is decreased, the introduction of fluid in the form of subcutaneous salt 
infusion and enemata is serviceable. The introduction of these meas- 
ures in the Rostock Surgical Clinic obviated the severe after-effects of 
lumbar analgesia. 
It has been claimed by a number of writers that albuminuria is one 
of the after-effects of spinal analgesia. Babcock 2 failed to corroborate 
this statement, never having observed any clinical evidence of irritation 
of the kidneys. 
My own experience is in keeping with that of Babcock. As a routine 
practice the urine is examined on the day following the injection, and 
the findings, with regard to albuminuria, are uniformly negative. 
Various motor manifestations have been noted. Among these may be 
mentioned paralysis of one or both abducens, the trochlearis, and some- 
times the oculomotor muscles, coming on from 4 to 18 days after the 
1Hoseman: Verhandl. d. deutsch. Ges. f. Chir., 38 Kongress 1909, 17. 
2 Babcock: ' ' Spinal Anesthesia, a Clinioal Study of 658 Administrations, ' ' 
Penn. Med. J., Aug., 1909. 584 
ANESTHESIA 
analgesia, and disappearing spontaneously in from 21 to 36 days. Par- 
eses of the legs sometimes remain for a number of hours, as may also 
those of the rectum and bladder. 
Lusk 1 correlated the reported cases of paralytic sequels of the lum- 
bar injection of spinal analgesic agents, finding quite a number of in- 
stances. "These paralyses," he says, "became apparent either closely 
consecutive to the recovery of the patient from the effects of the anes- 
thetic, or else later after an interval of complete restoration of function 
to the patient. They are regarded as due either to trauma inflicted 
on the nerve structures by the puncturing needle, or to some irritative 
action of the solution injected. It can be seen that paralyses attributable 
to the former cause must be limited to the lower half of the body, and 
that their onset, as in the case of any severe nerve injury, ought to be 
immediate. The late occurrence of a paralysis would seem to be at total 
variance with a traumatic origin, and might consequently be regarded as 
characteristic of an irritation by the anesthetizing drug. In support of 
the latter proposition is the fact that paralysis of the upper extremity 
and more frequently of the eye muscles, following the lumbar injection 
of a spinal anesthetic, which could by no possible logic be attributable to 
the traumatism of a lumbar needle puncture, are characterized by a late 
onset. These late occurring paralyses are sometimes permanent." 
Persistent paralyses are very rare, according to Fisher.2 When they 
do occur, according to this writer, they are referable to imperfect asepsis 
(spinal meningitis), or to the injection of a too highly concentrated, irri- 
tative solution. 
In my first paper,3 under the head of after-effects, the statement is 
made that in all cases whatever after-effects were noted were of a tem- 
porary nature. In only one case (cited by Lusk) were there any seri- 
ous symptoms following operation. 
In the case referred to the patient, a male child 7 years of age, was 
in a very poor general condition, with a marked lumbar kyphosis, and 
a large psoas sinus with small inguinal opening. Operation consisted in 
the enlargement of the sinus, curettage of the bodies of the third and 
fourth lumbar vertebrae. The cocain solution, 9 minims of a one per 
cent solution, was injected to the right, between the twelfth dorsal and 
first lumbar vertebrae, thus avoiding the site of the spinal curvature. In 
9 minutes after the injection, analgesia was present over the entire body, 
with the exception of a space bounded behind by the posterior fontanelle, 
in front by the point of the chin, and laterally on each side by the angle 
of the jaw, the malar bone, the temporal ridge, and the parietal boss. 
1 Lusk, William C.: " The Anatomy of Spinal Puncture, with Some Con- 
siderations on Technique and Paralytic Sequels," Ann. of Surg., Oct., 1911. 
2 Fisher: "L'Anesthesie rachidienne, " These de Paris, 1911. 
3 Bainbridge: Op. cit., Med. Rec., Dec. 15, 1900. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
585 
Some nausea and vomiting occurred for a few minutes after the injec- 
tion. During the operation the patient was free from pain, and showed 
no sign of nervousness. He answered questions and manifested a full 
command of his faculties. Analgesia disappeared in 1% hours. Before 
operation, the temperature was 98.4°; pulse, 126; respiration, 34. 
One hour after operation, temperature, 100.6°; pulse, 108; respiration, 
36. The patient vomited twice during the night. The pulse was good. 
The day following the operation the child was restless at intervals, 
and cried out. An ice cap was applied, sodium bromid given in small 
doses, and the bowels thoroughly opened. The second day after opera- 
tion the patient seemed stupid, and was apparently unable to express his 
desires in words. He did not move the right arm and hand, and the legs 
were drawn up. There was a slight elevation of temperature, with weak 
and rapid pulse. The third day was marked by a continuation of the 
stupidity, failure to talk, and slight movement of the right arm. Strych- 
nin and digitalin in small doses were administered hypodermatically. 
Improvement then began to be noted, ability to move the right arm 
slowly returned, the legs could be extended, and the patient began to 
talk. One month after operation he was in excellent condition, and bet- 
ter than before operation. 
In a later paper 1 the following statement occurs: "Of the many 
scores of cases upon which I have operated in this way, the ages have 
varied from 4 months to 67 years. With cocain as an agent, and with 
my present technique, I have had no failures and no serious after-effects. 
Many of the patients have been under my observation for several years 
after the operation without any deleterious effects being noted. The 
prophesied evil to the cord-which the needle should never touch-has 
not been seen in any cases coming under my observation." 
This early experience, which was almost exclusively with cocain, has 
been corroborated, in the main, during the years which have elapsed since 
the introduction of the method. In 1,065 cases, in hospital and private 
practice, and with other agents as well as with cocain, I have had only 
1 death (with the diffusible stovain solution, probably due to status 
lymphaticus; one case of temporary partial paralysis (see p. 584); one 
case of failure to induce analgesia, due to idiosyncrasy (see p. 623); one 
case of failure due to so-called "dry spine" (see p. 624); and two cases, 
with alypin, in which there was considerable respiratory depression. In 
all the other cases there were no accompanying or postoperative symp- 
toms of permanent or serious moment. 
1 Bainbridge: "Further Remarks on Spinal Analgesia." Read before the 
Med. Soc. of the Co. of Westchester, Yonkers, March 15, 1904. 586 
ANESTHESIA 
INDICATIONS AND CONTRAINDICATIONS 
The extremes of opinion with reference to the safety of spinal anal- 
gesia have been expressed by Murphy 1 and Jonnesco.2 The former 
said: "The mortality of spinal analgesia is such as to cause it to be 
abolished as an analgesic of choice, if not sufficient to cause statutory 
enactments against its use." The latter holds that there are no contra- 
indications for "general spinal anesthesia," which, according to his be- 
lief, is absolutely safe, has never caused a death nor produced any im- 
portant complications, early or late, is infinitely superior to inhalation 
anesthesia, is within the reach of all, and may be employed with any 
patient. 
Between these two extremes of opinion may be found various degrees 
of conservatism and radicalism. Reference to the views of a few who 
have written upon the subject will serve to show how widely divergent 
they are concerning the indications and contraindications for spinal 
analgesia. 
Bier, speaking before the German Medical Congress in April, 1909, 
cautioned against indiscriminate resort to spinal analgesia, and ad- 
vised its restriction to pelvic operations and operations upon the lower 
extremities. 
According to Buxton,3 the consensus of opinion narrows the limits 
of the employment of this method, excluding from its use the following 
individuals: "The wounded in war, children, persons over 65, syphi- 
litics, those who have some infective or septic disease, sufferers from 
serious heart or nerve lesions, arteriosclerosis, the nervous and the alco- 
holic, those who have albuminuria, and diabetics." "This list," he con- 
tinues, "comprises the opinions of various experts and narrows the field 
very considerably, but it is only fair to say that many able surgeons 
who adopt the spinal puncture are prepared to risk the dangers of the 
conditions named and do not select their cases." 
Matas4 limited the indications: (1) To adults, and to reasonable 
persons who have good self-control, thereby excluding children, hysteri- 
cal patients, and the insane; (2) to patients in whom the methods of 
local or regional anesthesia are inapplicable; (3) to patients suffering 
from emphysema, advanced asthma, chronic bronchitis, and other res- 
1 Murphy, John B.: "The Practical Medicine Series," 2, Editorial note, 28; 
' ' General Surgery, ' ' 1909. 
2 Jonnesco: Op. cit., Brit. Med. J., Nov. 13, 1909. 
3 Buxton, Dudley W.: ' ' Discussion on Spinal Analgesia, ' ' Section on Phar- 
macology and Therapeutics, Brit. Med. Assn., Brit. Med. J., Sept. 18, 1909, 786. 
4 Matas, Rudolph: 1' Local and Regional Anesthesia with Cocain and Other 
Analgesic Drugs, Including the Subarachnoid Method, as Applied in General 
Surgical Practice," Phila. Med. J., Nov. 3, 1900. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
587 
piratory affections in whom a general inhalation anesthetic is absolutely 
contraindicated; in advanced cardiac cases with degenerative lesions 
(on account of the possible depressing effects of the injection and ex- 
citement of the circulation); (4) in the majority of cases in which the 
painful part of the operation is not likely to be prolonged beyond one 
hour and a half. Matas also acknowledges its indication in labor, espe- 
cially in nephritic patients. 
Babcock 1 employed spinal analgesia "in the most serious types of dis- 
ease requiring operation below the level of the diaphragm where the pa- 
tient suffered from severe shock, hemorrhage, marked sepsis or toxemia, 
or in conditions of extreme debility." 
Gray2 has found the method to be particularly indicated in many 
cases of abdominal surgery, preventing shock and reducing mortality 
25 or 30 per cent. 
Leedham-Green,3 after an exhaustive experience with the method, 
found it to be indicated in dealing with gravely debilitated patients, such 
as those suffering from chronic intestinal obstruction, extravasation of 
urine, senile gangrene, and the like, where the disturbance occasioned 
by a general anesthetic often robs the patient of his chance of recov- 
ery. He also found it to be of great value for catheterization of the 
ureters in patients with highly sensitive bladders, as in cases of tubercu- 
losis. 
Canny Ryall4 uses the method for operations on all parts of the 
body. Craniotomy, excision of the sympathetic ganglia, extirpation of 
the larynx, and excision of one-half of the tongue, with removal of the 
glands from both sides of the neck, are some of the operations performed 
by him under spinal analgesia. 
Summing up the findings of many surgeons, it would seem that the 
method is generally conceded to be contraindicated in persons suffering 
from concomitant affections of the heait, lungs, and kidneys; from defi- 
nite lesions of the nervous system, especially of the spinal cord; from 
sepsis or pyemia; from recent lues, and, according to some, from the 
later manifestations of this disease. Persons already in shock, or col- 
lapse, are not suitable subjects for this method, and for this reason it is 
considered by some to be unsuitable for war surgery. 
It may be generally conceded, also, that, as a rule, the method should 
be employed for operations below the costal border, being especially indi- 
cated for operations upon the genital organs, perineum and rectum, and 
1 Babcock: Op. cit., Penn. Med. J., Aug., 1909. 
3 Gray: ' ' Indications for the Employment of Spinal Anesthesia in Ab- 
dominal Surgery," Brit. Med. J., Sept. 2, 1911. 
'Leedham-Green: "Discussion on Spinal Analgesia," Section on Pharma- 
cology and Therapeutics, Brit. Med. Assn., Brit. Med. J., Sept. 18, 1909, 789. 
4 Ryall: Brit. Med. J., June 19, 1909. 588 
ANESTHESIA 
upon the lower extremities. As is well known, many surgeons do not 
subscribe to these limitations. 
The method has been found uniformly satisfactory in a considerable 
number of infants and young children in whom I have employed it. The 
youngest child operated upon by me under spinal analgesia 1 was a male 
3 months old, in very poor general condition, suffering from double 
inguinal hernia, with danger of incarceration. Incarceration finally oc- 
curred, and the patient was operated upon under chloroform anesthesia. 
Active stimulation was necessary during the narcosis. The patient re- 
covered from this operation, but the other side became strangulated some 
days later. The patient was in such poor general condition, in addition 
to having developed bronchitis and having undergone an operation so 
shortly before, that it was deemed unwise to resort to a second general 
anesthesia. Spinal cocain analgesia was employed March 19, 1901. 
Point of puncture, between third and fourth lumbar vertebraj; amount 
of cocain, 6 minims of a one per cent solution. Injection, 11:32 a. m. 
Analgesia to the level of the diaphragm at 11:40. Operation begun at 
11 Infant began to cry before the needle was inserted in the back, 
and continued to cry until the feeding bottle with a small quantity of 
milk was allowed. Vomited once. There was no pain, and the patient 
remained quiet the greater part of the time. The sac was separated 
and opened, exposing intestines, the appearance of which confirmed the 
necessity for operation. When the constricted neck of the sac was en- 
larged a coil of intestine came down. Difficulty was experienced in re- 
ducing the intestine, and a few breaths of chloroform were given for the 
purpose of still further relaxing the muscles and quieting the child, who, 
by this time, had become frightened at the efforts to place the loop of 
intestine back in the abdominal cavity. The suturing of the abdominal 
wall and the completion of the operation were accomplished under the 
analgesia from the cocain. 
At the end of the operation, at 12:15, the loss of the pain sense was 
complete to the level of the diaphragm. There was no vomiting from 
the time of the initial emesis until the chloroform was administered. 
To those present at the operation, it was apparent that a general anes- 
thetic would have proved fatal to the child. Perfect recovery resulted. 
The most striking report of the application of spinal analgesia in 
children comes from Gray,2 who published an interesting series of ob- 
servations in 300 cases in infants and young children, the youngest be- 
ing 12 hours old, the oldest 13 years. Of the operations performed, 190 
1 Bainbridge: Op. cit., Archives of Pediat., July, 1901, Case XII. 
2 Gray, H. Tyrrell: (1) "A. Study of Spinal Anaesthesia in Children and In- 
fants, from a Series of 200 Cases," Lancet, Sept. 25, Oct. 2, 1909; (2) "A Fur- 
ther Study of Spinal Anaesthesia in Children and Infants," Lancet, June 11, 
1910. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
589 
were upon the trunk, and 104 upon the extremities. Failure to obtain 
anesthesia resulted in 10 out of the 300 cases. 
Of the first 100 cases, 9 children died subsequently from diseases for 
which they were operated upon. Necropsy showed no abnormality in the 
nerve roots, the cord, or its membranes. 
In the second series of 100 cases there were no deaths from the spinal 
analgesia. 
In the third series of 100 cases the author reports one death under 
analgesia. The patient was in such condition that operative relief 
seemed imperative, and death was practically certain under general anes- 
thesia. Necropsy in this case showed that both lungs were completely 
collapsed; that there was pneumothorax on both sides; that the left side 
of the diaphragm was extensively infiltrated, with malignant new growth 
extending into the left pleura; that there were several nodules on the 
under surface of the right side of the diaphragm and metastatic de- 
posits in various other regions; and that the growth from which the pa- 
tient was suffering was a retroperitoneal sarcoma, involving kidney, 
pancreas, etc. The outcome in such a case cannot be considered as cor- 
roborative evidence of the alleged contraindication of infancy and child- 
hood. 
In concluding his last report, Gray says: "Such disadvantages as 
are consequent on the use of this method are very greatly overshadowed 
by the advantages to the patient and surgeon in certain cases. I believe 
that spinal analgesia is urgently called for on all occasions where the 
after-progress of a case is likely to be influenced by shock during opera- 
tion, and often in cases when its employment is of definite assistance to 
the surgeon in doing his work as perfectly as possible." 
Waugh,1 of the Great Ormond Street Hospital for Sick Children, 
says concerning spinal analgesia in children: "So striking is the imme- 
diate result, as witnessed by the surgeon, that for my own part all opera- 
tions on children below the level of the fifth thoracic nerve involving 
considerable shock are unhesitatingly performed under spinal anesthesia 
as the anesthesia par excellence for such cases." "That I have been 
able," he continues, "to resect six inches of intestine for acute obstruc- 
tion in a baby eighteen hours old, perform a lateral anastomosis by suture 
in the ordinary way, and send the child out of the hospital in a fort- 
night's time is a striking testimony to its value." He adds that he has 
completely abandoned the use of general anesthesia for children in all 
cases of acute appendicitis, intussusception, and acute intestinal obstruc- 
tion, which cases form no small share of the operative work in a large 
children's hospital. 
Preleitner,2 in Escherich's clinic, had an experience of 40 cases in 
1 Waugh, George E.: Personal communication, 1911. 
2Preleitner: Miinch. med. Woch., 1905, 52. ANESTHESIA 
590 
children, with discouraging results. Fraenkel,1 discussing Preleitner's 
paper, held that spinal analgesia does not eliminate the psychical factors, 
for which reason the method had not obtained a foothold in the surgery 
of children. 
Barker 2 excluded children from his list of patients, along with "ob- 
viously nervous and excitable people.'"' 
Gray,3 commenting upon such experiences, stated that they are en- 
tirely contradicted by his own experience. "From the psychical aspect," 
he says, "no more suitable patients for spinal anesthesia could be found, 
since ignorance is their safeguard against panic, and it may be stated 
generally that the younger the children the more satisfactory are they 
in this respect." The most troublesome age, in his experience, is between 
2 and 5 years, children of this age being with greater difficulty kept 
quiet. 
Personal experience is in accord with that of Gray. As Attending 
Surgeon, New York City Children's Hospitals and Schools, ample oppor- 
tunity has been afforded me to test the utility of spinal analgesia, not 
only in infants and young children, but in the highly neurotic, epileptic, 
and idiotic. 
In one instance,4 the patient, female, aged 4 years and 10 months, 
of very nervous temperament, being operated upon for umbilical entero- 
epiplocele, gave some hysterical manifestations during the operation, and 
cried as if in pain. Careful tests proved, however, that the analgesia 
was complete with reference to pain sense. No serious accompanying or 
post-operative symptoms occurred in this case. 
In another case 5 of the same series, the patient, male, aged 9 years, 
was an epileptic, operated upon for congenital malformation of the glans 
and prepuce, with hypospadias. No pain or nervousness was noted in 
this instance. 
Of the cases reported in another paper,6 the following features 
were noted: epileptic; highly neurotic; nervous temperament; feeble- 
minded, deaf and dumb, hydrocephalic; marked idiocy, with epilepsy; 
highly neurotic; marked idiocy, with epilepsy; highly neurotic; 
idiocy. 
Among the conclusions formulated in the last-named paper is the fol- 
lowing: "In neurotic patients there are often hysterical symptoms di- 
rectly following the completion of the injection, but, as a rule, in a few 
1 Fraenkel: Munch, med. Woch., 1905, 52. 
2 Barker: Op. cit., Brit. Med. J., March 23, 1907. 
3Gray: Op. cit., Lancet, Sept. 25, 1909. 
4 Bainbridge: Med. Bee., Dec. 15, 1900, Case II. 
5 Ibid., Case V. 
6Bainbridge: Med. News, May 4, 1901, Cases I, II, VIII, XIII, XV, XVI, 
XIX, XXI, XXIV. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
591 
moments a calm follows and the patient lies perfectly still." Subse- 
quent experience bears out this statement. 
It has been claimed that convulsions are apt to follow spinal punc- 
ture in epileptics. In personal experience with 16 epileptic patients 
operated upon under spinal analgesia, not one instance of convulsion on 
the table has been witnessed. No increase in nervous symptoms was 
noted in any case, and several patients were distinctly better for days 
after the injection. Many of these children have lived for years after- 
ward, and have died of other diseases, nothing being found abnormal 
with the cord or the nerve roots. 
The contraindication of age beyond 65 years does not hold in all 
cases. Weber 1 reported a case in which he operated upon a man of 84 
years. Jonnesco's oldest recorded case in 1909 was 75. Barker oper- 
ated upon one patient 71 years of age. Many other instances are on 
record of operations under spinal analgesia in patients far past middle 
life. 
An early personal case 2 was that of a woman 67 years of age, who 
was suffering from complete procidentia, with beginning gangrenous 
changes in the lower part of the uterus, fatty heart, edema of the lower 
extremities and marked edema of the local parts, and suppression of 
the urine for twenty-four hours previous to operation. Ether was 
thought to be contraindicated because of the absence of urine; chloro- 
form had been tried, but the patient collapsed under it. Cocain spinal 
analgesia was resorted to, 35 minims of a two per cent solution being 
injected between the second and third lumbar vertebrae. Analgesia was 
complete below the clavicles in 15 minutes, and lasted 2 hours and 50 
minutes. The operation lasted only 30 minutes, as, after scarification 
of the cervix and curetting, it was found possible to reduce the uterus 
inside the pelvis and to retain it there without further operative pro- 
cedure. 
The only unpleasant symptoms in this case were nausea a few min- 
utes following puncture, retching once or twice, and slight headache, 
with 2 degrees elevation of temperature the night after the operation. 
Recovery was uneventful. 
Another patient, male, 66 years of age, was operated upon for in- 
flamed, irreducible right inguinal hernia, January 24, 1911. The hernia 
could not be held by truss, and gave repeated symptoms of impending 
strangulation. In addition to this the patient was suffering from ad- 
vanced arteriosclerosis, enlarged prostate, cystitis, and a double car- 
diac lesion, and gave evidence of an old healed process in the right lung. 
The operation was successfully performed under spinal analgesia, with 
1 Weber: J. Am. Med. Assn., Feb. 9, 1900. 
2 Case IV, of paper read before the Med. Soe. of the County of Westchester,, 
Yonkers, March 15, 1904. 592 
ANESTHESIA 
2 c. c. of a three per cent stovain-dextrin solution, injected between the 
third and fourth lumbar vertebrae. There was no nausea, no vomiting, 
or other untoward symptom, the patient read throughout the operation, 
and recovery was uneventful. 
A man 70 years old was operated upon by me August 4, 1911, under 
cocain spinal analgesia, with 18 minims of a two per cent solution, in- 
jected between the third and fourth lumbar vertebrae. The patient for 
years had suffered from hypertrophy of the prostate, with the usual 
symptoms. He had had electrical treatment for 5 years, with temporary 
benefit. For a year he had been in a pitiable condition, passing urine 
almost constantly, in dribbles, with retention in the bladder of from 
24 to 36 ounces of urine, and having to wear a urinary receptacle night 
and day. The urine was about 25 per cent by volume of pus and detri- 
tus, with blood casts and albumin. He was running several degrees of 
temperature when first seen, early in July, and was in very poor general 
condition. Arteriosclerosis of moderate degree added to the complica- 
tions. 
The patient was put to bed, the bladder washed out for a time, and 
the alimentary canal cleared. With preliminary medication of gr- 
morphin and 1/200 gr. nitroglycerin, Young's operation for prostatec- 
tomy was performed without difficulty. Analgesia was complete to the 
clavicles in 3 minutes, and remained so during the entire operation, 
which lasted an hour. There was slight nausea for a moment at the be- 
ginning of the operation, but this quickly subsided. There were no 
other unpleasant symptoms. The operation was at 12 :30 p. m. At 7 
p. M. the temperature was 102.8°; pulse, 112; respiration, 24. At 10 
p. m. the temperature was 101°; pulse, 114; respiration, 30. At 2 p. M. 
the following day, temperature, 100.6°; pulse, 110; respiration, 28. At 
6 a. m., temperature, 99°; pulse, 100; respiration, 22. At 3 p. m., tem- 
perature, pulse, and respiration were normal. Recovery uneventful. 
Spinal analgesia has been employed in the most elaborate gynecologi- 
cal and general surgery, the variety of operation, in suitable subjects, be- 
ing no contraindication. 
Wertheim,1 in a paper read before the joint session of the Chicago 
Medical and Gynecological Societies, October 10, 1906, said: "For over 
a year we used, with exceptionally good results, lumbar anesthesia. We 
use for this purpose stovain with the addition of adrenalin. Even very 
old cachectic women with badly degenerated hearts bear this operation 
well by this procedure." 
Barker,2 in his third series of 100 cases, a number of which were very 
'Wertheim: "The Radical Abdominal Operation in Carcinoma of the Cervix 
Uteri," Surg., Gyn. and Obst., Jan., 1907. 
2Barker: "A Third Report on Clinical Experiences with Spinal Analgesia,'' 
Brit. Med. J., Aug. 22, 1908. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
593 
grave conditions, cited, as the worst general condition to be contended 
against, the case of a woman 48 years of age, operated on in the country 
for gangrene of nearly 5 feet of the small intestine strangulated by 
bands. The patient was pulseless, and cyanosed in face and hand, with 
pulse between 120 and 130. About 6 eg. (0.92 gr.) of stovain placed 
her in comfort in 5 minutes, 4 feet and 9 inches of black gangrenous 
bowel were excised, and the healthy gut anastomosed above and below, 
with perfect recovery. 
In obstetric practice the method is not infrequently indicated, and 
has been successfully employed by a number of European and American 
obstetricians, as stated in the section on history. 
Doleris and Malartic1 conclude that the uterine contractions be- 
come painless in from 5 to 10 minutes after the injection of from 1 
to 2 centigrams of cocain, remaining practically painless, though per- 
ceptible, for a period of about 27 minutes after an injection of milli- 
grams. Complete analgesia, according to these authors, has a duration 
of from 1 hour and 23 minutes to hours, with a dose of from 
1 to 2 centigrams. The uterine contractions become energetic, more 
frequent, and of longer duration after the injection than before it, and 
in the interval between the contractions the uterus remains in a condi- 
tion of tension during a variable period. 
They found the bleeding to be much less than usual, and in a case 
of placenta prasvia the hemorrhage spontaneously ceased before the rup- 
ture of the membranes. The action of the cocain on the fetus, in their 
experience, was nil. 
Cesarian section has been successfully performed under spinal anal- 
gesia by Sinclair,2 Hopkins,3 and Doleris.4 
Marx5 recommended spinal analgesia in all cases in which the first 
stage of labor is prolonged. By the use of small doses, used as required, 
he has been able to carry a patient painlessly through labor of 8 hours' 
duration. 
The only case 6 in which I have employed spinal analgesia in ob- 
stetrics was for the delivery of a full-term child by means of high for- 
ceps operation. The patient, Mrs. H., 26 years of age, lived in a tene- 
1 Doleris and Malartic: "Analgesic obstetricale par injection sous-arach- 
noidienne de cocaine," La Semaine med., 1900, 243. 
2 Sinclair: ' ' Caesarian Section under Cocaine Anaesthesia, " J. of Obst. and 
Gyn. of Brit. Bmp., Sept., 1902, 221. 
3 Hopkins: "Case of Caesarian Section under Spinal Anaesthesia," J. Am. 
Med. Assn., May 24, 1902, 1355. 
* Doleris and Malartic: Op. cit., Compt. rend. d. I. Soc. d'Obst., Gyn. et Ped. 
d. Paris, 1900, 328. 
3 Marx: Med. Rec., Oct. 6, 1900, 521. 
6 Bainbridge: Reported before the Surgical Section, Am. Med. Assn., Atlantic 
City, June 4-7, 1912. 594 
ANESTHESIA 
ment house, and this was her fifth confinement. Labor began at 6 :30 
on the evening of February 23, 1901, the weak and ineffectual pains 
continuing until 2 :30 a. m. of February 24. The membrane then rup- 
tured, and the infant's heart beat became very weak, then practically 
inaudible. It was determined to deliver the child by forceps, under 
spinal analgesia. The injection was made at 3 :35 a. M., 20 minims of a 
two per cent solution of cocain being introduced between the third and 
fourth lumbar vertebrae. At 3 :48 analgesia was complete to the level 
of the chin, and at 4:20 the child was born. By 6:55 analgesia had 
fully disappeared. The analgesia was so perfect that the mother went 
to sleep during the delivery, being unconscious of the birth of the child 
until she was awakened by its cry. 
Ehrenfest1 calls attention to the following objections which may be 
urged against spinal analgesia for general obstetrical use: (1) It is not 
a harmless procedure. (2) Disagreeable symptoms inevitably follow the 
injection. (3) It may have a toxic effect on the child, such cases having 
been reported. (4) The analgesic effect may disappear just at the mo- 
ment when it is necessary and only the unpleasant sequelae, such as 
vomiting and extreme nervousness, remain. (5) The loss of the active 
help of the abdominal muscles is a very decided disadvantage. 
From the weight of conflicting testimony with reference to the indi- 
cations and contraindications for spinal analgesia, it may be deduced, in 
a general way, that, granting the need of operation, and the impractica- 
bility of local or regional analgesia, the indications for spinal analgesia 
are the contraindications for general inhalation anesthesia. So far as 
the character of the operative procedure is concerned, there are practi- 
cally no contraindications to the employment of spinal analgesia. With 
the modifications of injection fluid now in use, it may be said that no 
part of the body is under the ban of contraindication. Despite the im- 
provements of technique and the extension of domain, the method is 
employed more often as one of expediency than as one of choice. 
ADVANTAGES AND DISADVANTAGES 
Advantages.-The advantages of spinal analgesia may be stated cate- 
gorically and briefly as follows: 
(1) Very little apparatus is required. 
(2) The operative technique presents few difficulties, hence the 
method is easy of application. 
(3) The injection may be made by the surgeon himself, thus obvi- 
lEhrenfest: "A Few Remarks on the Use of Medullary Narcosis in Ob- 
stetrical Cases," Med. Bee., Dec. 22, 1900, 967. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
595 
ating the necessity of an assistant. For emergency, military, and naval 
surgery this is a distinct advantage. 
(4) Analgesia is quickly induced, from 4 to 10 minutes being suffi- 
cient, as a rule, for the induction of analgesia as far as the diaphragm. 
(5) The relative safety, as regards life, with good technique, skil- 
fully executed, is high. 
(6) Does not depress the heart, like chloroform, or cause pulmo- 
nary and renal complications, like ether, as these anesthetics are ordi- 
narily administered. 
(7) Insures physical quietude during operation, which is of dis- 
tinct advantage to the surgeon. 
(8) Insures the patient's aid, which may be desirable, as in cough- 
ing mucus or blood from the throat. 
(9) May save the life of patients who, because of contraindications 
to inhalation anesthesia, would be consigned to their fate without opera- 
tive relief. 
(10) Controls surgical shock by blocking off reflexes. 
(11) Obviates persistent postoperative retching and vomiting, 
which is of especial advantage in abdominal work. 
(12) Lessens postoperative pain. 
(13) Lessens postoperative restlessness which results from post- 
operative pain. 
(14) Diminishes the danger of postoperative pulmonary compli- 
cations. 
(15) Gives "abdominal stillness," emphasized by Jonnesco, Gray, 
and others, in connection with laparotomies. 
(16) Decreases mortality. 
Busse,1 upon the basis of experience with 1,232 cases of lumbar anal- 
gesia, points out the following advantages of this method as compared 
with inhalation anesthesia: 
(1) The blood pressure is not seriously affected. 
(2) Asphyxia is considerably less frequent. 
(3) Vomiting during the operation is less common and less pro- 
fuse. 
(4) Vomiting after operation occurs less frequently. 
(5) Vesical disturbances are reduced to about one-third to one- 
half. 
(6) Deaths from pulmonary embolism seem to become less com- 
mon. 
Babcock 2 emphasizes the following advantages of this method over 
general anesthesia: 
1 Busse: Prakt. Ergebnisse der Geburts. u. Gyn., 1909, 1; also, CentraTbl. f. 
Gyn., 1910, No. 42, 1363. 
. 2 Babcock: Penn. Med. J., Aug., 1909. 596 
ANESTHESIA 
(1) It reduces the mortality and morbidity of operations. 
(2) It insures physical quietude before, during, and after the opera- 
tion. 
(3) It secures complete muscular relaxation and a desirable peri- 
staltic stimulation. 
(4) It increases the patient's comfort and resistance. 
Disadvantages.-The disadvantages of spinal analgesia have been 
variously estimated, from none at all to an overwhelming number, by 
the enthusiastic advocates of the method on the one hand, and its un- 
qualified opponents on the other. By conservative opinion they may be 
summed up categorically and briefly as follows: 
(1) Unpleasant accompanying and postoperative phenomena, 
which, despite all precautions, may occur. 
(2) Possible dangers from the analgesic agent per se, which, though 
not so frequent as formerly, do nevertheless occur, and have always to 
be borne in mind. 
(3) Uncertainty as to the length of the analgesia, which may wear 
off before the operation is completed. 
(4) Uncertainty as to the exact amount necessary to produce the 
desired effect in a given case. 
(5) Absolute commitment of the surgeon to the consequences of the 
dose injected, the effects of which, if untoward, cannot be controlled, as 
in the case of a general anesthetic, the dose of which may be regulated 
to suit the exigencies of the individual case. 
(6) Consciousness on the part of the patient, and the consequent 
possibility of psychic pain, nausea, and other disturbances, especially on 
the part of nervous individuals. 
(7) Incomplete muscular relaxation, which may occur when relaxa- 
tion is desirable. 
(8) Failure to obtain sufficient cerebrospinal fluid to warrant mak- 
ing the injection, sometimes attributed to so-called "dry spine," and 
occurring at times in the experience of skillful operators. 
(9) Possible injury to and irritation of the spinal cord and nerve 
roots. 
DEATHS 
It has been repeatedly stated that death statistics are of no practical 
value in determining the direct toxic working of the drugs employed 
for the induction of spinal analgesia, the question being mainly one of 
dosage. Deaths have been reported in connection with each of the 
drugs in common use, whether justly attributable directly to the action 
of the drug in any case being a debatable point. It is fair to assume 
that other factors are to be considered in connection with fatalities re- SPINAL ANALGESIA AND SPINAL ANESTHESIA 
597 
suiting from spinal analgesia. For all surgeons, except, possibly, the 
few peculiarly expert operators who recognize no limitations to the 
method, the selection of the subject for spinal analgesia must exert con- 
siderable influence over the mortality record. The entire management 
of the case, including the surgical interference, bears a direct relation- 
ship to the safety of the method. Despite every possible safeguard, how- 
ever, deaths have occurred, and will doubtless continue to occur, with 
this as with every other method. 
Chiene 1 collected the reports of over 12,000 cases, with 22 deaths, 
or, roughly, 1 death in 570. He holds that, if the cases be analyzed in 
which death occurred, it will be found that very few can be attributed 
solely, or even partially, to the anesthetic. In analyzing the table of 
statistics given by Strauss,2 in which the latter collated 22,717 cases, 
with 46 deaths, Chiene found that 25 of the 45 deaths reported oc- 
curred when cocain was used, which works out at 21 deaths in 15,842 
cases where other drugs were employed, or 1 in 754. Only 3 of these 
were stated to be clearly due to the analgesic agent, or 1 in 5,282, 
and 9 more seemingly in connection with the agent; in all, 1 in 
1,320. 
Compared with results obtained in a similar number of cases by gen- 
eral anesthesia, Chiene considered the above figures not so unfavorable 
as some writers have claimed. 
Jonnesco 3 gives the following statistics: From July 5, 1908, to Nov. 
8, 1909, 758 cases were operated upon by Jonnesco or his assistants. 
Two cases in London and 23 in America bring the total to 783, of which 
195 were superior dorsal and 588 dorsolumbar injections. If to this 
number be added 603 earlier lumbar analgesias, he has a record of 1,386 
rachianesthesias, without mortality. 
In a later communication Jonnesco 4 gives the following personal sta- 
tistics : One thousand and five cases, from July 8, 1908, to September 29, 
1910, including 238 high analgesias (operations on the head, neck, su- 
perior extremities, and thorax), and 267 low analgesias (operations on 
the abdomen, pelvis, perineum, and inferior extremities). These statis- 
tics include 2 cases operated upon by Jonnesco in London and 23 in 
America. The ages of the patients varied from 1 month to 82 years. 
He had no deaths, he avers, due to the method, in the 2 years. Two fatal 
cases among high analgesias occurred among his Roumanian colleagues, 
but these were referable to overdoses of stovain or strychnin. 
'Chiene: Op. cit., Brit. Hied. J., Sept. 18, 1909, 785. 
2Strauss: "Der Gegenwartige Stand der Spinalanalgesie," Deutsch. Zeit. f. 
Chir., July, 1907, 275. 
3Jonnesco: Am. J. of Surg., op. cit., 1910, 29, 33. 
'Jonnesco: "La rachi-anesthesie generate," Bev. de Therapeut. med.-chir., 
Dee. 1, 1910, 798. 598 
ANESTHESIA 
Kohler1 collected 7,780 cases, with 12 deaths. Chaput2 knew of 
no deaths among 7,000 cases. Tuffier 3 reported one death (not posi- 
tively attributable to the analgesia) in 11 years. Gray 4 reported one 
death in his series of 300 cases in children. Barker 5 formulated a table 
of the results at 5 British hospitals working on exactly the same princi- 
ples and technique, and with the same instruments and solutions care- 
fully prepared. This table represents 2,354 cases, including 775 cases 
under his own observation, in which there were only 3 deaths, or 0.1 per 
cent. 
Michelsson,6 discussing the various attempts to calculate the mortality 
of spinal analgesia on the basis of statistical compilations, gives the fol- 
lowing divergent results: Tomachewski calculates the mortality of spinal 
analgesia as 1:17847; Strauss, 1:2524; Chiene, 1:570; Hohmeier, 
1: 200. The figures of Strauss are held by Michelsson to be nearest the 
truth of the matter, although the mortality percentage is stated a little 
too high, omitting cocain analgesia, the mortality amounting to about 
1:3500. 
In a personal experience of 1,065 cases, covering an extensive variety 
of operations upon patients ranging in age from 3 months to 70 years, 
there has been one fatality.7 This might easily be attributed to other 
causes (see pp. 585, 625). 
It is worthy of note, in connection with the subject of mortality due 
to the subarachnoid injection of anesthetic agents, that Engsted8 has 
reported the successful use of ether as an antidote to cocain and other 
drugs employed as local or spinal analgesics. He has been able, by this 
means, to revive patients who were practically in extremis. The best 
results are obtained, he holds, when ether is administered to the degree 
of mild surgical narcosis, or even less. A mask is employed, and the 
vapor given by the drop method, thus preventing adding to the danger 
by excluding air from the lungs already engorged with venous blood. 
1 Kohler: Deutsch. Zeit. f. Chir., 1909, 16. 
3 Chaput: Brit. Med. J., May 30, 1908, 1330. 
3 Tuffier: Personal communication, March, 1911. 
4Gray: Op. cit., Lancet, June 11, 1910. 
"Barker: Brit. Med. J., March 16, 1912, 597. 
"Michelson: Op. cit., Ergebnisse d. Chir. und Ortho., 4, 1912. 
' Bainbridge: ' ' Spinal Analgesia-Development and Present Status of the 
Method, with Brief Summary of Personal Experience in 1,065 Cases, ' ' J. Am. 
Med. Assn. Read before the Section on Pharmacology and Therapeutics, in joint 
session with the Section on Pathology and Physiology, American Medical Associa- 
tion, Atlantic City, June 6, 1912. 
8 Engsted, J. E.: "Ether: An Antidote of Cocain and Stovain Poisoning," 
J. Am. Med. Assn., March 19, 1910, 964. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
599 
ANALGESIC AGENTS 
The Therapeutic Committee of the British Medical Association 1 in- 
vestigated the following local analgesic agents: stovain, novocain, tropa- 
cocain, beta-eucain, alypin, beta-eucain lactate, nirvanin, holocain hy- 
drochlorid, acoin, orthoform (new), and anesthesine. 
Among the points to which especial attention was directed in this 
investigation was the suitability of the agent for medullary narcosis. 
Preliminary experiments reduced the list to 4, viz.: stovain, novocain, 
tropacocain, and beta-eucain lactate, which were subjected to further 
investigation. After comparing these drugs one with the other, the 
conclusion was reached that novocain is the most satisfactory for 
general use. "Its anesthetic action is equal to that of cocain, and 
its toxicity and general destructive power on the tissues are very much 
less." 
Of the four drugs mentioned in the above report, stovain, novocain, 
and tropacocain are most generally used, though some operators, myself 
among the number, still find, at times, a place for cocain. Various modi- 
fications of the analgesic solution and its preparation have been adopted. 
A few are mentioned here. 
Cocain, tropacocain, stovain, and novocain are considered in the or- 
der of their introduction for purposes of spinal analgesia, and not with 
reference to their relative merits. Personal experience with other agents, 
eucain and alypin, for example, does not warrant devoting to them fur- 
ther consideration. Eucain was discarded because it gives a "patchy" 
analgesia, and alypin because it depresses respiration. 
The analgesic agents most commonly employed are variously modi- 
fied, the purpose being to produce a fluid of the same, heavier or lighter 
specific gravity, as compared with the cerebrospinal fluid. The injec- 
tion fluid, thus modified, is more or less diffusible, according to its rela- 
tive specific weight, and, as a consequence of the relative diffusibility, 
the analgesia produced is more or less controllable as regards its extent. 
The various analgesic solutions may be classed, according to their 
relative specific gravity, as follows: (1) Analgesic agent, plus water, 
plus alcohol; (2) analgesic agent, plus water; (3) analgesic agent, plus 
water, plus cerebrospinal fluid; (4) analgesic agent, plus cerebrospinal 
fluid alone; (5) analgesic agent, plus water, plus normal salt solution; 
(6) analgesic agent, plus water, plus dextrin, glucose, or gum arabic. 
To any of the above may be added, if desired, adrenalin or some sim- 
ilar product, as employed by Bier, Gray, and many others, or strychnin, 
as suggested by Jonnesco. 
1 Le Brocq: 1 ' Report on the Local Anaesthetics Recommended as Substi- 
tutes for Cocaine," Brit. Med. J., March 27, 1909. 600 
ANESTHESIA 
Solutions of lighter specific gravity than the cerebrospinal fluid are 
generally called diffusible, whereas those of heavier specific gravity are 
called non-diffusible solutions. To the former class belongs No. 1; to 
the latter, No. 6. 
Cocain.-During the early days of spinal analgesia cocain was the 
agent most commonly employed, but because of the various fatalities and 
the many unpleasant accompanying and postoperative phenomena which 
marked the experimental stage it has been pretty generally abandoned. 
Allen 1 says: "Since 1899, when Bier's first work appeared, cocain 
has gradually given way to the less toxic and equally effective stovain, 
novocain, or tropacocain, and it is now never used." He considers that 
it has no place in spinal analgesia. With this view probably the ma- 
jority of surgeons are in accord. 
A more favorable opinion of cocain is expressed by Filliatre,2 who 
declares that this agent, employed by his method, is absolutely devoid 
of danger. His method, which he has employed in 1,500 cases, consists 
in first withdrawing 30 c. c. of cerebrospinal fluid, then injecting from 
0.5 to 2 c. c. of a 2 per cent solution of cocain. This gives a dosage of 
from 1 to 4 eg. (0.15 + to 0.6 gr.) of cocain. 
J. Garland Sherrill, of Louisville, Kentucky, has always found a 
two per cent solution of cocain quite satisfactory, never using over 15 
minims as a dose. 
Charles Chassaignac (private communication), of New Orleans, has 
used cocain in doses ranging from 1/5 to 14 gr. 
E. Denegre Martin (idem), New Orleans, gives cocain the prefer- 
ence, employed in doses of 5 minims of a 4 per cent solution. 
Simon Marx (idem), New York City, mentions cocain as his second 
choice, stovain being first. He uses cocain in doses of 14 gr- 
In a rather extensive experience with cocain the results of Bain- 
bridge with this agent have been uniformly successful when the solution 
has been prepared according to his method. The dose employed ranges 
from 5 to 20 minims of a two per cent, and from 5 to 30 minims of a 
one per cent, solution. 
Cocain has been largely employed as a standard by which to gauge 
the toxicity of other analgesic agents. It is considered twice as toxic as 
tropacocain, about 7 times more toxic than novocain, and 6 times more 
toxic than stovain. 
While cocain is more toxic than other agents, needing, in conse- 
quence, more safeguarding, the resulting analgesia is more profound, 
and lasts longer, with correspondingly moderate dosage. 
The toxicity of cocain has been attributed by many writers to harm- 
1 Boston Med. and Surg. J., 163, No. 19. 
2 Ann. d. mol. d. org. genito-urin., 1909, No. 13. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
601 
ful by-products resulting from its decomposition by the heat used in 
sterilizing this agent. Others contend that cocain is not decomposed 
by heat, and that the unpleasant phenomena which accompany its use in 
some cases result not from the cocain or its decomposition products, but 
from the water used in making the solution. 
Tropacocain.-It is claimed by some that analgesia occurs sooner 
with tropacocain than with cocain, and that it is of longer duration. 
Personal experience is that there is very little difference in these regards. 
The solution recommended by Willy Meyer 1 is as follows: 
Tropacocain hydrochlorate 0.15 gm. (2V2 grs.) 
Sodium chlorid 0.06 gm. (1 gr.) 
Distilled water 10.00 gm. drs.) 
Fifty minims of this solution contain 5 centigrams (5/6 gr.) of 
tropacocain, which is the dose usually required. This dose gives an anal- 
gesia sufficient for an operation lasting 1 hour or longer. 
The Bier solution of tropacocain, so largely used, is put up in am- 
pules containing 1.3 c. c. of a 5 per cent solution of tropacocain, with 
adrenalin hydrochlorid, 0.00013 per c. c. The dose of tropacocain usu- 
ally given is 5 cgm. (5/6 gr.). 
Slajiner2 employed spinal analgesia in 2,700 cases, during the years 
1901-1909, in his capacity as chief physician to the Surgical Depart- 
ment of the Laibach General Hospital. In all these cases tropacocain 
was used (Merck's sterilized flasks), the usual dose being 0.07 gm. 
(1 + gr-)- 
Colombani,3 on the basis of 1,100 operations performed under tropa- 
cocain analgesia, advocates as the usual dose 0.08 gm. (1% + gr.). 
Erhardt4 recommends the addition of gum arabic to the tropacocain 
solution used for spinal analgesia, in a dosage of three per cent gum to 
a one per cent tropacocain solution. The advantages of the addition are 
unmistakable, consisting in the diminution of the general toxic manifes- 
tations, and the prolongation of the anesthetic effect. The essential 
cause for the lessened toxic action is referable to the delayed absorption 
and the less immediate contact with the central nervous structures. 
Hertel,5 after having performed lumbar analgesia with watery solu- 
tions of tropacocain, recommends the addition of gum arabic, which he 
has already employed in 82 cases. Apparently the danger is diminished, 
1 Meyer, Willy: Med. News, April 13, 1901. 
"Slajiner: Beit. z. Iclin. Chir., 1910, 67. 
"Colombani: Wiener klin. Woch., 1909, No. 39. 
"Erhardt: Munch, med. Woch., 1908, No. 19, 1005. 
"Hertel: Miinch. med. Woch., 1910, No. 16, 844. 602 
ANESTHESIA 
although not entirely excluded; the analgesia seems to reach higher, and 
the number of failures is also apparently diminished. 
Stovain.-The Bier compound of stovain is as follows: 
Stovain 4 per cent 
Sodium chlorid 0.11 per cent 
Epirenin borate 0.01 per cent 
Tuffier recommends a 10 per cent solution of stovain in normal salt 
solution. 
Chaput uses the following: 
Stovain 10 per cent 
Sodium chlorid 10 per cent 
Distilled water 80 per cent 
The Stovain-Billon solution so largely employed is marketed in am- 
pules of 2 c. c., each cubic centimeter containing: 
Stovain 0.04 gm. (6/10 gr.) 
Adrenalin borate 0.00013 gm. 
Sodium chlorid 0.0011 gm. 
Each ampule contains 8 cgm. of stovain (1 1/5 gr.), so that a mini- 
mum or a maximum dose may be given. 
Barker's compound (stovain-glucose) is: 
Stovain 10 per cent 
Glucose 5 per cent 
Distilled water 85 per cent 
The glucose was added by Barker for the purpose of obtaining a fluid 
of heavier specific gravity than the cerebrospinal fluid. By this means 
he believed it would be possible to localize the analgesia. 
Houghton 1 has contributed a report of 400 cases operated upon un- 
der spinal analgesia induced with the Barker stovain-glucose solution. 
From his previous experience2 with other drugs, followed by the series 
of cases in which he confined himself to the use of the Barker solution, he 
concludes that the 5 per cent solution of stovain and glucose has given 
the most consistent and reliable results. In this series there was no 
case of failure to enter and to inject the spinal sac, no case in which the 
injection failed to induce adequate analgesia, and no case which gave 
cause for any anxiety as to the safety of the method. In life-saving 
operations, such as amputation of the leg for diabetic gangrene, or 
1 Houghton, J. W. H.: " Spinal Analgesia. Report of 400 Operations at 
the Military Hospital, Aidershot," Lancet, Oct. 12, 1912, 1008. 
2 Royal Army Med. Corps. J., Aug., 1908, and Oct., 1909. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
603 
operation upon a patient with advanced cardiac disease, in which neither 
chloroform nor ether is admissible, stovain can be used. In Houghton's 
experience there was absence of shock during operation, and the muscular 
relaxation was so complete that much less time was required for the com- 
pletion of the operation than with chloroform. 
The dextrin-stovain solution employed by Gray consists of stovain, 
3 per cent, with dextrin and suprarenin in saline solution. This solu- 
tion is placed upon the market in ampules of 2 c. c. each, one ampule 
being sufficient for the induction of analgesia to the diaphragm, and 
often above. 
The dose is 0.015 to 0.04 gm. (1/5 to % gr.) of stovain. 
The stovain-strychnin solution suggested and so extensively used by 
Jonnesco in the so-called high analgesia must be prepared in advance 
of the time of operation, inasmuch as the strychnin sulphate takes some 
time to dissolve. 
The amount of strychnin and stovain in the solution varies with the 
site of injection, the patient's age, and general condition. Jonnesco uses 
from 1 to 10 cgm. of stovain. 
Babcock, who advocates a solution of lighter specific gravity than 
the cerebrospinal fluid, uses the following combination, made by Mor- 
gan, of Philadelphia: 
Stovain 08 p. c. 
Ac. Lactic 02 
Abs. Alcohol 20 
Aq. dest q. s. 2.00 
The alcohol content of this solution is reduced in strength about one- 
half by the admixture of the solution with the cerebrospinal fluid before 
it is thrown into the spinal canal. 
Lambotte, of Antwerp, and his assistants have employed stovain in 
over 1,800 cases, with uniformly satisfactory results. 
It may be of interest to note that at Sing Sing, the New York State 
prison at Ossining, stovain has been used exclusively since August, 1908, 
for operations below the level of the umbilicus.1 The results have been 
uniformly successful, with no deaths due to the anesthetic, in approxi- 
mately 400 operations performed by H. E. Mereness, Jr., and F. E. Lat- 
tice. The Billon preparation is employed. 
Novocain,2-The novocain-suprarenalin solution advocated by 
Braun,2 who first suggested the addition of adrenalin to analgesic 
agents, is put up in ampules of 3 c. c. each, containing: 
1 Personal communication from Mereness, Feb. 23, 1913. 
aBraun: Deutsch. Monatsh. Jahnheilk., June, 1906. 604 
ANESTHESIA 
Novocain 0.15 gm (1 to 1| gr.) 
Suprarenalin0.000325 gm. (1-250 gr.) 
This is equal to five minims of suprarenalin solution, 1-1000, to 3 
c. c. of sterilized distilled water. Of this solution 2 to 3 c. c. may be 
used. 
Meissner 1 reports 600 lumbar analgesias from the Tubingen Surgical 
Clinic, in all but 40 of which novocain was employed, first in 5 per cent 
solution (2 to 3 c. c.), later in 1 per cent solution (6 to 7 c. c.). 
Byall2 reports having used novocain with the addition of strychnin, 
according to the Jonnesco method. 
Chaput3 reports 405 cases treated with novocain, a 4 per cent solu- 
tion being used, without addition. The dose was from 0.06 to 0.08 gm. 
Hypodermic tablets, novocain, 1/3 grain, are on the market. Each 
tablet contains novocain 0.020 gm. 
In 988 of my 1,065 cases simple solutions of the analgesic agent- 
cocain, stovain, tropaeocain, etc.-with water, were employed. In the 
remaining cases I have used various modified solutions, heavier and 
lighter, with and without the addition of adrenalin or other similar 
product. With no intention of condemning any of these modified solu- 
tions, I must confess that my preference is decidedly in favor of the sim- 
ple solution, with the analgesic agent sterilized according to the method 
herein detailed. With such a solution, prepared under personal super- 
vision, I am sure of the fluid injected into the subarachnoid space. If 
it were possible, as with Waugh, Gray, Barker, Babcock, and those who 
employ the ready-made solutions, to obtain the modified solutions fresh 
and dependable, the matter would be different. The fact remains, how- 
ever, that all of the solutions prepared and dispensed in ampules deteri- 
orate with time, and unless one is convenient to the source of supply 
there is always a doubt concerning the potency of the agent. 
STERILIZATION OF THE ANALGESIC AGENT4 
Many of the unfortunate results obtained in the early history of 
spinal analgesia were presumably due to improper methods of sterilizing 
the analgesic agent. This was certainly true of cocain. In order to 
overcome this difficulty various methods of sterilization have been de- 
vised, of which those of Tuffier, Roux, Murphy, and Bainbridge are ex- 
amples. 
1 Meissner: Beit. klin. Chir., 64, No. 1. 
2Ryall: Brit. Med. J., June 19, 1909. 
3Chaput: Gas. des Hopitaux, 1910, No. 48. 
4 See Chapter V. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
605 
The numerous special compounds have each a special method of 
preparation, wThich need not be detailed here. 
In 1899 the following method 1 for the sterilization of cocain was 
first employed by me, and since that time it has been found equally satis- 
factory for the other analgesic agents in general use. The simplicity of 
the procedure renders it valuable for emergency work, as well as for 
other surgical cases in which spinal analgesia is indicated. 
The method is as follows: Five grains of fresh cocain hydrochlorid 
crystals, carefully weighed, are placed in a sterilized measuring glass. 
Two drams of strong ether are added, and mixed thoroughly with the 
cocain crystals by means of a sterilized glass rod. The mixing process is 
continued until all the ether is evaporated. One-half to 1 ounce of warm 
boiled or filtered water or normal salt solution is then added. One-half 
ounce makes practically a 2 per cent solution, and 1 ounce a 1 per cent 
solution. Of the former solution 10 to 20 minims may be employed; 
of the latter, 10 to 30 minims. 
The drug is practically sterilized in its manufacture, and all that 
infects it is apt to be on the outside of the crystals. Careful bacteriologi- 
cal tests were made by me to determine the extent to which this process 
sterilized the cocain, and it was found that practically all ordinary organ- 
isms are destroyed. (See Fig. 253, p. 616.) 
The crystals do not deteriorate, as do the cocain and other solutions. 
It is advisable, however, if possible, to employ only fresh crystals, or to be 
sure that the crystals employed have been kept perfectly dry. 
In the preparation of the diffusible solution employed by Babcock 
pasteurization is resorted to instead of sterilization. 
SITES OF INJECTION 
The routes commonly adopted for spinal puncture are the lumbar 
and the sacrolumbar, the former being preferable in human beings and 
the latter in animals. For purposes of spinal analgesia the points of 
election are generally conceded to be between the spinous processes of 
the third and fourth or fourth and fifth lumbar vertebrae. It is easier 
to enter the canal at these sites, and the danger of injury to the cord is 
minimized. 
Lusk 2 emphasizes the conclusion, drawn from a series of anatomical 
studies, that "the only vertebral interspaces through which puncture of 
the subarachnoid space can be made with practical assurance that nerve 
structure will not be penetrated are the fourth lumbar and the lumbo- 
sacral, preferably the former." 
1 Bainbridge: Op. cit., Med. Rec., Dec. 15, 1900. 
2Lusk: Op. cit., Ann. of Surg., Oct., 1911. 606 
ANESTHESIA 
According to this author, "The anatomical findings in eleven dissec- 
tions of the arachnoid membrane, from the conus medullaris up into the 
cervical region, were condemnatory of the procedure of puncture within 
Fig. 240.-Diagram of Cross-section Opposite the Fourth Lumbar Interspace. 
Below the lower border of the fifth lumbar vertebra nerve-roots were adherent to the 
arachnoid. Above this level the arachnoid was firmly adherent over the posterior 
surfaces of the laterally situated nerve-roots of the cauda equina, while mesially it lay 
loosely over the posterior surface of the nerve structures, to which it was connected by 
delicate trabeculae from about one-eighth to one-quarter inch in length, the shorter 
trabeculae occupying the more lateral position. (Lusk.) 
this area, as one attended with the greatest liability of penetrating the 
cord." 
Fig. 241.-Diagram of a Cross-section Through the Dorsal Spine. Showing how 
the arachnoid membrane may be adherent to the posterior surface of the cord, which 
was the predominating anatomical arrangement in this and the lower cervical regions 
in six out of ten dissections. The close contact between the arachnoid and dura is 
here illustrated. (Lusk.) 
In fifteen dissections the conus medullaris was found by Lusk to 
terminate in 11 cases at the level of the first lumbar vertebra, 3 times SPINAL ANALGESIA AND SPINAL ANESTHESIA 
607 
at the level of the junction between the twelfth dorsal and the first lum- 
bar vertebra, and once it reached to the lower border of the second 
lumbar vertebra. The normal or usual termination is shown in Figs. 
245 and 248. 
Of 11 dissections of the arachnoid membrane above the conus, in only- 
three was there a complete posterior arachnoid space present all the way 
up into the cervical region, the channel being interrupted at intervals 
by transverse septa. In three dissections the arachnoid membrane was 
adherent to the posterior surface of the cord all the way from the conus 
up to the cervical region; in one it was completely adherent above the 
level of two inches above the conus, and in two above the levels of the 
fifth and seventh dorsal vertebrae respectively. (See Figs. 240 and 241.) 
From these findings Lusk concludes that, if the cerebrospinal fluid 
be constantly withdrawn as a result of mesial puncture at or above the 
level of the conus, in many instances the substance of the cord must be 
traversed by the needle and the fluid taken from the anterior portion of 
the arachnoid space. 
In all the 15 dissections Lusk found that the one site at which lum- 
bar puncture of the arachnoid space coidd have been made without lia- 
bility of injury to the nerve roots was mesially in the interval between 
the fourth and fifth lumbar vertebrae. The great tendency of the nerve 
roots to become adherent to the posterior wall of the arachnoid sac in the 
lumbosacral interspace, as well as for the subarachnoid space to become 
shallower in this region, rendered this the site of second choice. 
Despite the anatomical findings of Lusk and others who have studied 
the subject from this point of view, injections have been successfully 
made at higher levels than those above indicated. 
Morton,1 in two cases, injected between the last dorsal and first lum- 
bar, but abandoned this site as being unnecessary. 
Tait and Caglieri2 (see p. 561) reported having injected cocain into 
the sixth cervical space, without untoward effects. 
Jonnesco,3 who at first advocated piercing the column "at all levels," 
later abandoned this procedure and confined himself to two sites: (1) 
superior-dorsal, between the first and second dorsal vertebrae, and (2) 
dorsolumbar, between the twelfth dorsal and first lumbar vertebrae. "I 
had already been convinced by experience," he said, "that spinal anes- 
thesia was not so regional as I had believed, and that mediocervical punc- 
ture was as useless as it was dangerous. It favors the appearance of 
bulbar phenomena-nausea, vomiting, pallor of the face, momentary 
1 Morton: Am. Med., Aug. 3, 1901. 
2 Tait and Caglieri: Op. tit., Trans, of the Med. Soc. of the State of Cal., 
April, 1900; also, J. Am. Med. Assn., July 7, 1900. 
aJonnesco: Brit. Med. J., Nov. 13, 1909; also, Revue' de therap. med.-chir., 
Dec. 1, 1910, 798. Fig. 242.-Spinal Cord Enclosed in 
Unopened Dural Sheath Lying 
Within Vertebral Canal. Neu- 
ral arches completely removed on right 
side, and partially, on left, in order 
to expose dorsal aspect of dura. 
(Piersol.) 
Fig. 243.-Posterior Wall of Verte- 
bral Canal Has Been Removed and 
Dural Sheath Opened to Expose 
Spinal Cord and Dorsal Roots 
of Attached Nerves. (Piersol.) SPINAL ANALGESIA AND SPINAL ANESTHESIA 
609 
stoppage of respiration, and so on-phenomena due to a too direct 
action of the anesthetic fluid upon the bulb. Their occurrence may be 
avoided by making the puncture lower down between the first and sec- 
ond dorsal vertebrse, which produces as perfect and deep analgesia for 
Pons 
Arachnoid 
Vertebral Artery 
Medulla 
Ligamenta 
denticulata 
Anterior roots of 
spinal nerves 
Dura, reflected 
Spinal cord covered 
with arachnoid and 
pia 
Pig. 244.-Upper Part of Spinal Cord Within Dural Sheath, Which Has Been 
Opened and Turned Aside. Ligamenta denticulata and nerve-roots are shown 
as they pass outward to dura. (Piersol.) 610 
ANESTHESIA 
the segment of the body comprising the head, neck, and upper limbs as 
is produced by the mediocervical puncture. I have therefore reduced 
sites of election for puncture or 
two." These are stated above. 
Canny Byall,1 one of the 
most enthusiastic advocates of 
the Jonnesco method for opera- 
tions- upon the upper part of the 
body, makes the injection into 
the first dorsal space, and for 
operations upon the lower part 
into either the eleventh or 
twelfth dorsal spaces. He rarely 
uses lumbar puncture, since, in 
his experience, better results are 
obtained by making the injec- 
tion into the dorsal region. He 
finds no advantage in making 
a cervical puncture, for perfect 
analgesia lasting an hour or two 
can be obtained by injecting be- 
tween the first and second dor- 
sal spines. 
Gray 2 considers it unneces- 
sary to make the puncture 
higher than the interspace be- 
tween the first and second lum- 
bar vertebras, the space between 
the third and fourth being best 
for routine work. 
Avamresco3 varies the site 
of puncture according to the op- 
eration, as follows: (1) For 
operations on the perineum, ex- 
ternal genitals, and anus, be- 
tween the third and fourth lum- 
bar vertebrae; (2) for operations 
on the inguinal region and lower 
1 Ryall: Op. cit., Brit. Med. J., 
June 19, 1909. 
2 Gray: Op. cit., Lancet, Sept. 
25 and Oct. 2, 1909. 
3Avamesco: Lancet, 1901, 1, 637. 
Fig. 245.-End of Spinal Cord With Roots 
of Lower Nerves Descending in 
Cauda Equina to Gain Their Respec- 
tive Foramina. (Piersol.) Fig. 246.-Schematic Picture Showing Landmarks Used In Locating Space Between 
Third and Fourth Lumbar Vertebrae. 
Fig. 247.-Schematic Picture Showing Needle Inserted Between Third and 
Fourth Lumbar Vertebrae of the Spinal Canal, but below the Cord. 612 
ANESTHESIA 
extremities, between the first and second lumbar spines; (3) for opera- 
tions on the abdomen below the umbilicus, between the ninth and tenth 
dorsal spines; (4) for operations on the abdomen above the umbilicus, 
between the sixth and seventh dorsal spines. 
Babcock 1 injects in the second lumbar interspace for operations not 
involving tissues above the level of Poupart's ligament, or the first lum- 
bar or twelfth dorsal interspace, if intra-abdominal manipulations are 
required. 
Personally, I recognize no advantage by going into the subarachnoid 
space at a higher point than between the third and fourth lumbar verte- 
brae, though on several occasions, because of deformity of the spine, or 
for other reasons, the spaces between the first and second, and be- 
tween the second and third lumbar vertebrae, have been successfully en- 
tered. In cases where there is to be much pulling and tearing of the 
tissues of the abdomen, particularly in the upper part, I sometimes in- 
ject between the twelfth dorsal and the first lumbar. Analgesia of any 
part of the body, however, may be obtained by lumbar injection, plus the 
use of an analgesic agent of equal or lighter specific weight than the 
cerebrospinal fluid, or by employing a fluid of greater specific weight, 
plus the lowering of the patient's head. 
THE PATIENT 
Preliminary Preparation of Patient.-The operator who is to make 
the injection should apply the principles of psychotherapy to the patient 
some time before the operation, if this is possible. The indications for 
the method in the given case should be explained, and emphasis laid upon 
the advantages of this method over inhalation anesthesia. A clear un- 
derstanding of what is to be expected on the part of the patient is quite 
conducive to the successful application of the method. At any rate, the 
patient's confidence should be gained by the operator. This is particu- 
larly true of nervous and excitable persons. Even with children much 
can be accomplished in this way. Not infrequently a doll or other toy 
put into the hands of the child patient will divert attention and gain 
confidence, sometimes rendering an otherwise intractable patient quite 
docile. 
A hypodermic injection of morphin (% to 14 gr.), combined in some 
cases with atropin or hyoscin, may be given half an hour or an hour be- 
fore injection. It serves to tranquilize the patient and to make him less 
susceptible to any possible pain or discomfort contingent upon the initial 
procedure. Bromids instead of morphin may be given the day before,, 
or nitroglycerin (1/200-1/100 gr.), given coincidentally with the spinal 
injection, may be advantageous. Strychnin (1/60 gr.) given at the time 
1 Babcock: Op. cit., Penn. Med. J.. Aug., 1909. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
613 
of the injection is supportive. Combined with nitroglycerin, it lessens 
the danger of headache, shock, and other disagreeable symptoms. 
No preliminary medication is given with children. 
Preliminary prepara- 
tion of the patient as re- 
gards diet, catharsis, etc., 
which is of so great im- 
portance in inhalation 
anesthesia, is not essen- 
tial in spinal analgesia. 
Patients coming into the 
hospital from the street, 
with no preliminary 
preparation in these re- 
gards, have been operated 
upon as successfully, and 
with as few accompany- 
ing and postoperative 
phenomena, as have those 
who have been subjected 
to the most careful pre- 
paratory care. Generally 
speaking, however, atten- 
tion to no details which 
conserve the patient's vi- 
tality and comfort should 
be neglected. 
Position of Patient. 
-The position of the pa- 
tient while the injection 
is being made is impor- 
tant. One should sit 
evenly on the edge of the 
table, the feet hanging 
down. The arms are 
folded against the abdo- 
men. At the moment of 
the puncture the patient 
should bend the head 
down, as in Figure 256, 
and push against the abdomen with the arms in such way as to arch the 
back and separate the vertebrae as much as possible. In the case of chil- 
dren and infants, it is necessary for the attendant to see that this position 
is maintained. 
Fig. 248.-Patient in Sitting Posture Ready for 
Spinal Puncture. 1 and 2, Highest points of 
crests of ilia; 3, spinous processes of third, fourth 
and fifth lumbar vertebrae. 614 
ANESTHESIA 
The patient must be warned beforehand, and reminded at the time, 
to maintain this position, and not to straighten up or otherwise move 
until told to do so. 
Fig. 249.-Injection Being Made With Patient in Recumbent Position. 
If for any reason it is impossible to make the puncture with the pa- 
tient in the above position, it may be done in the recumbent posture, as 
shown in Figure 249. 
APPARATUS AND MATERIALS 
The apparatus and materials employed in the induction of spinal 
analgesia are shown in Figures 250 and 251. 
The apparatus for giving the injection of the analgesic agent con- 
sists of a syringe and two cannulas. 
The syringe, which is made by Ford & Co., of New York, is entirely 
of metal, including the piston, so that it expands uniformly upon boil- 
ing. It has a capacity of 5 c. c., the corresponding quantities in the two 
systems being graduated upon the piston. 
The cannulae are made in two sizes, of three lengths; the points are 
ground short and beveled, with a cutting edge all round. The shank is 
of flexible metal, so that it will bend without breaking. 
The cannula slips on a ground joint, fitting accurately the handle, 
without washers or screws. The proximal end of the cannula is fitted 
with a handle which can be firmly grasped. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
615 
Through the cannula runs a stylet, the proximal end of which is 
rounded, knob-like, so that it can be pressed against the base of the index 
finger, adding firmness of grip. 
Fig. 250.-Table Containing Instruments and Materials Used in Giving Spinal 
Analgesia, (a) Glass with sterilized water; (b) empty glass in which to collect cerebro- 
spinal fluid (c) bottle of iodin for sterilizing the skin; (d) graduate for preparing solu- 
tion; (e) bottle of collodion; (f) bottle of ethyl chlorid wrapped in sterilized gauze; (g) 
sterilized gauze and sterilized cotton; (h) small can of strong ether wrapped in sterilized 
gauze; (i) dish of bichlorid solution; (j) two powders, 5 grains each, one of cocain and 
one of tropacocain; (k) two ampules containing stovain (suprarenin-glucose solu- 
tion) ; (1) two needles and syringe (Bainbridge); (m) small scalpel for making punc- 
ture; (n) clamp with piece of sterilized gauze for painting the skin with iodin; (o) glass 
rod for mixing. 
The instrument can be taken apart and thoroughly sterilized. 
Figure 252. shows the fine needle employed by Babcock. The syringe 
is a Luer syringe of 2 c. c. capacity, graduated in cubic centimeters and 
Fig. 251.-Bainbridge's Syringe and Needle. 
Fig. 252-Babcock's Needle for Spinal Analgesia. 
millimeters. The obturator which conies with this needle fits perfectly 
around the opening at the end of the needle, thereby closing it entirely 
during the time it is being injected and until the obturator is withdrawn, B 
A 
C 
D 
E 
Fig. 253.-Sterilizing the Apparatus. A, placing the drug in the graduate; B, adding ether 
to sterilize; C, mixing ether with powder into a paste; D, adding required amount of water 
to make given solution; E, testing syringe with sterile water; F, testing syringe; G, filling 
syringe with injection material. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
617 
before the syringe is slipped into the hub for the injection of the analgesic 
agent. This needle is made by Charles Lentz & Sons, Philadelphia. 
In sterilizing the apparatus no soda or other alkalies should be em- 
ployed, nor should the analgesic agents be in any way allowed to come 
in contact with these substances, which destroy their analgesic properties. 
The sterile implements and materials are placed upon a table covered 
with a sterile sheet until ready for use. 
Various needles, syringes, etc., have been devised and advocated, and 
are readily obtainable. The apparatus described above will answer all re- 
quirements of spinal analgesia. 
TECHNIQUE OF INJECTION 
The operator's hands are made aseptic in the nsual manner. 
The site of puncture may be cleansed in the ordinary way, by scrub- 
bing, etc., or, if desired, it may be rendered aseptic, after the patient has 
been placed upon the table, by painting the skin with tincture of iodin. 
If preferred, the area may be painted an hour or so before operation, and 
again after the patient is placed upon the table. 
If the iodin method is employed, no preliminary washing should be 
resorted to unless it is done a sufficiently long time before the painting 
for the tissues to become thoroughly dry. If desired, the skin may be 
sponged with ether, which quickly evaporates, leaving a perfectly dry 
surface for the action of the iodin. This is not necessary, however, as 
the iodin is sufficient for purposes of antisepsis. 
The patient, in the position shown in Figure 248, with the puncture 
site painted with iodin, as shown in Figure 254, is draped with the 
sterilized sheet, as shown in Figure 255. 
This sheet has cut in it a hole or window (Fig. 255) large enough for 
purposes of injection. The operator, in making his examination and 
identification of landmarks, runs no risk of contaminating his hands 
by contact with skin surfaces which have not been rendered aseptic. 
The site of puncture is now located in the following manner, as indi- 
cated in Figures 256, 257, and 258: 
(1) The highest points on the crests of the ilia are located by the 
hands, as shown in the figures. 
(2) The sites of the second, third, fourth, and fifth lumbar verte- 
brae are marked. 
(3) The thumb of each hand is placed in the space between the sec- 
ond and third, third and fourth, or fourth and fifth lumbar vertebrae, 618 
ANESTHESIA 
according to the selection of site, at the mid-point between the two. One- 
half inch to either side of this point is the site for the puncture. 
The puncture point being located, the assistant plays ethyl chlorid on 
the area, or, if preferred, 
a preliminary injection 
of cocain or other local 
analgesic agent may be 
made. (See Fig. 257.) 
A small incision is 
now made through the 
true skin, which is ren- 
dered hemostatic as well 
as analgesic by the ethyl 
chlorid. 
The needle is passed 
through the incised skin 
and subcutaneous tissue, 
straight forward, as in 
Figures 250 and 261. It 
is then depressed, the 
point being made to go 
upward, forward, and in- 
ward, toward the median 
line. It is inserted from 
iy2 to 2 inches, accord- 
ing to the thickness of 
the patient's flesh. 
When the needle is 
felt to impinge upon the 
bone surrounding the 
foramen, it is depressed 
a little more, and pushed 
forward, when it comes 
upon the ligamentum 
subflavum, then the dura 
mater. In piercing the 
ligament and dura there 
is a peculiar sensation 
like the popping of a membrane. This signifies the entrance to the sub- 
arachnoid space. 
The cerebrospinal fluid escapes, as shown in Figure 259, under ordi- 
nary circumstances. If it does not flow freely, something is wrong. The 
needle may not have entered the right place, or it may be clogged. A 
stylet should not be inserted into the needle. Another syringe should be 
Fig. 254.-Puncture Site Area Painted with Iodin. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
619 
ready, and with this, if one cannot draw out blood or fluid, the needle 
should be withdrawn, and, after being rendered patent, be reinserted. 
It should be noted that there is considerable difference in spines with 
reference to the amount of 
cerebrospinal fluid, some 
being what is called "dry," 
with little fluid escaping 
upon puncture; others, 
"wet," with an abundance 
of fluid under high tension. 
The quantity withdrawn de- 
pends upon the tension. If 
the fluid comes out with 
force more is withdrawn 
than when it is not under 
much pressure. 
I prefer not to proceed 
with the injection unless 
the fluid issues with at 
least an approximate quan- 
tity and tension. Gray1 
does not hold to this point. 
Discussing the general 
opinion that satisfactory 
analgesia will not result un- 
less there is a free flow of 
fluid, he says: 
"This is true enough in 
the main, but if, after pa- 
tience and perseverance, a 
free flow of fluid cannot be 
obtained, but only slow 
drops (or if slightly blood- 
stained fluid only appears), 
I consider that the injec- 
tion should be attempted before making another puncture, provided 
cerebrospinal fluid has been seen. I have encountered this class of case 
on two or three occasions, when, in spite of failure to obtain a free jet, a 
perfectly satisfactory anesthesia has resulted from the injection." 
Dbnitz 2 and Dean 3 suggest that when the fluid flows scantily this is 
an indication for a larger quantity of the analgesic solution. 
Fig. 255.-Sterilized Sheet, Patient Draped, 
and Window Made at Site of Puncture. 
xGray: Op. cit., Lancet, Sept. 25, Oct. 2, 1909. 
a Verhandl. d. deutsch. Gesellsch. f. Chir., 1905, 525-548. 
* Brit. Med. Jour., 1907, 2, 869. Fig. 256.-Locating the Site for Puncture. 
Fig. 257.-Applying Ethyl Chlorid and Incising the Skin. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
621 
In some cases, despite careful technique and repeated attempts, at 
different sites, no cerebrospinal fluid is obtainable. Such cases have 
doubtless led to the expression "dry spine," but it is rather to be in- 
ferred that they come under the category mentioned by Gerstenberg and 
Hein, Lusk, and others. (See pp. 564 and 605 et seq.) A personal ex- 
perience with such a case is cited on page 624. 
The first few drops of fluid may be bloody, which may signify merely 
that a small quantity of blood has been carried in with the needle. If it 
Fig. 258.--Showing Direction of Needle About to Enter Spinal Canal. 
continues bloody, however, something more serious is to be considered. 
This rarely happens, but when it does the operation should be discon- 
tinued. 
Sometimes, when the fluid does not flow freely, it will do so if the 
patient will cough, thus causing more tension upon it. 
An uncontrollable patient, who will not remain still and quiet, should 
be held steadily while the puncture is being made, or the needle should be 
withdrawn at once. The injection of the analgesic agent should not be 
made unless the patient is perfectly quiet. 
The fluid is injected slowly, as shown in Figure 260. The obliquity of 
the passage of the needle has the advantage that no tract is formed for 
the fluid to follow as the needle is withdrawn. 
The body of the vertebra in front should not be touched with the 
needle, because of the presence there of a large plexus of blood vessels. 622 
ANESTHESIA 
When the needle is withdrawn a cotton and collodion dressing is ap- 
plied, as shown in Figure 261. 
If low analgesia 
is desired, for op- 
eration upon the 
lower part of the 
body, the patient 
may be allowed to 
sit up for a few 
minutes after the 
injection, or the 
head may be ele- 
vated. 
If high anal- 
gesia through lum- 
bar puncture is 
desired, for opera- 
tions upon the up- 
per part of the 
body, the head is 
lowered, or a fluid 
with lower specific gravity than the cerebrospinal fluid is employed. 
Having had no personal experience with the Jonnesco method of induc- 
ing high analgesia, no 
statement can be 
made with reference 
to the relative merits 
of the so-called high 
analgesia for this pur- 
pose, as compared 
with lumbar injection 
plus modified agent or 
position of patient. 
Babcock1 prefers 
to use a small needle 
(Fig. 252), and to go 
in without the pre- 
liminary nicking of 
the skin. If the pa- 
tient has received no 
preliminary medica- 
tion the area marked 
off on the back is frozen by a spray of ethyl chlorid. The needle is intro- 
Fig. 259.-Cerebrospinal Fluid Escaping. 
Fig. 260.-Injecting Solution. 
1 Babcock: Op. cit., Penn. Med. J., Aug., 1909. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
623 
duced through the line marking the injection point, at right angles to 
the skin, and about 2 millimeters to one side of the median line. The 
needle is carried steadily forward until the resistance of the ligamentum 
subflavum is felt, when the mandrin is withdrawn from the needle, which 
is then carried on through the dura. 
If high analgesia is desired, Babcock considers it advisable, before the 
injection is given, to so reduce the cerebrospinal fluid that it issues only in 
drops from the needle. The needle is cautiously rotated to make sure that 
the bevel point is en- 
tirely through the mem- 
brane. The syringe is 
then attached, and about 
1 c. c. of cerebrospinal 
fluid is cautiously with- 
drawn to mix with and 
dilute the analgesic so- 
lution. The mixture is 
now steadily and rather 
rapidly injected, the 
needle with the attached 
syringe quickly with- 
drawn, and the patient 
immediately placed in 
the recumbent posture 
with the head slightly 
raised. This last point 
is of the utmost im- 
portance. 
In testing for analgesia, which begins in from three to ten minutes 
after the injection, one should bear in mind the difference between anal- 
gesia and anesthesia. (See Introduction, p. 554.) 
Fig. 261-Cotton and Collodion Dressing on 
Puncture Point. 
ADDITIONAL ILLUSTRATIVE CASE REPORTS 
With the preliminary preparation, the necessary adjuvant medica- 
tion, and the careful technique, as outlined in the foregoing pages, there 
should be no difficulty with spinal analgesia, unless some anatomical 
anomaly or an idiosyncrasy be encountered. Occasionally,-very rarely, 
-one encounters a patient who possesses an idiosyncrasy with refer- 
ence to one or another, or perhaps all, of the spinal analgesic agents. 
Such a case was encountered by me recently, as was also one of so-called 
"dry spine.' 
Case of Idiosyncrasy.-H. C., female, aged 24. Consulted me in Feb- 
ruary, 1911, with reference to hernia and displacement of the uterus. Pa- 624 
ANESTHESIA 
tient was anemic and nervous, and had an old healed tuberculous lesion 
of the lung. Otherwise in fair general condition. She requested that 
operation be performed under spinal analgesia. This was undertaken on 
February 14, 1911, no preliminary medication being employed. 
Spinal puncture was made, between the third and fourth lumbar 
vertebrae, and 30 minims of fluid withdrawn. An injection was made of 
15 minims of a 3 per cent solution of novocain. After an interval of 15 
minutes there was no analgesia, even in the feet. A second injection 
was made, this time with stovain, 12 minims of a 3 per cent solution 
being used. After waiting 20 minutes the site of operation was still 
sensitive. During all this time (40 minutes from the time of the first in- 
jection), the patient was in good condition, with only slight nausea and 
no vomiting. The pulse was 120, full and strong. 
The operation was abandoned for the day, it being thought unwise to 
subject the patient to a third injection. During the next three days 
she suffered from slight headache, but was otherwise in good condition. 
On February 17 another attempt was made to induce spinal anal- 
gesia. Oocain was used on this occasion, 15 minims of a 2 per cent solu- 
tion being employed. After 25 minutes there was no evidence of anal- 
gesia so far as pain sense was concerned. The patient was nervous to 
begin with, and became nauseated after the injection, but the pulse (120) 
was fairly strong. A second attempt was made, but, as there was no es- 
cape of fluid, no injection was made. 
On the assumption that the patient had an idiosyncrasy, it was de- 
cided to test the matter with local injections. Accordingly, 1 c. c. of a 
2 per cent solution of cocain was injected at the site of operation, but 
without success. The patient became quite hysterical, and the entire mat- 
ter was abandoned. Patient was subsequently operated upon under gen- 
eral anesthesia. 
Upon further questioning, it was learned from the patient that in 
1900 an attempt was made by Dr. Frederick Kammerer, of New York, 
to operate upon her for appendicitis under spinal analgesia, cocain being 
employed. No analgesia was obtained, and the operation was performed 
under general anesthesia. 
Case of So-called "Dry Spine."-B. M., female, negro, aged 17. Oper- 
ation, Woman's Hospital, Philadelphia, January 25, 1912, appendectomy. 
Gangrenous appendix found to be walled off by adhesions. Recovery un- 
eventful. 
This patient had Bright's disease and an old consolidation at the apex 
of one lung. For these reasons it was thought advisable to operate under 
spinal analgesia. 
An attempt was made to operate in this case under spinal analgesia, 
but without success. Puncture was made between the fourth and fifth 
lumbar vertebrae, but, only a tiny drop of fluid being obtained, injection SPINAL ANALGESIA AND SPINAL ANESTHESIA 
625 
was not made. A second attempt with another needle proving futile, 
puncture was made successively in the spaces between the third and 
fourth and second and third lumbar vertebrae. No fluid being obtained, 
the effort at spinal analgesia was abandoned, and the operation was per- 
formed under inhalation anesthesia. 
Case of a Typical "Satisfactory" Analgesia.1-L. L., female, aged 58, 
admitted to the New York Skin and Cancer Hospital, March 18, 1911, 
for operation for lipomata of the abdominal wall, papilloma of neck, 
angiomata of abdominal wall, and varicose ulcers of the legs. Opera- 
tion, March 20, 1911. The various growths were removed, and the ul- 
cers of the legs excised. 
Adjuvant medication: Strychnin sulphate, 1/60 gr.; nitroglycerin, 
1/200 gr. 
Analgesic agent: Glucose-adrenalin-stovain, one ampule, 2 c. c.; 
stovain, 3 per cent. 
Analgesia extended to neck, and lasted for 1 hour and 55 minutes. 
There was no nausea, no vomiting, no headache, or other unfavorable 
symptom, and recovery was uninterrupted. 
Case of Typical Analgesia, Injection in Recumbent Position.-Fig- 
ure 262 represents the injection being given with the patient in the 
recumbent position. This patient was a male, B. N., aged 38 years. 
Operated upon for gangrene of the foot February 7, 1911, the foot being 
partially amputated. 
No preliminary medication. Stovain, 8 minims of a 3 per cent solu- 
tion, injected between the third and fourth lumbar vertebrae. Analgesia 
complete to the umbilicus in 8 minutes. No unfavorable symptoms. 
On February 24, 1911, amputation of foot, leaving os calcis. Sixteen 
minims of a 3 per cent solution of stovain in water employed. Within 
2 minutes after the injection the patient was analgesic to the nipple line, 
and 5 minutes after the injection the operation was begun. No unfavora- 
ble symptoms. Patient manifested an interest in the entire procedure. 
An Additional Case (No. 1069), of Special Interest.2-During the 
Clinical Congress of Surgeons of North America, held in New York City 
in November, 1912, a patient at the New York Polyclinic Hospital died 
after a lumbar subarachnoid injection of stovain, preparatory to the per- 
formance of an operation for hernia. 
P. H., Irish, male, age given as 50 years, probably 60 or more; chronic 
alcoholic. Came to my clinic at the New York Polyclinic Medical School 
and Hospital, October 18, 1912, seeking relief for a condition which 
1 This is the case with which the technique is illustrated, Figs. 248 and 254 
to 261. 
'Bainbridge: "Spinal Analgesia-Development and Present Status of the 
Method, with a Brief Summary of Personal Experience in 1,065 Cases." J. 
Am. Med. Assn., Nov. 23, 1912, 59, 1855-1859. 626 
ANESTHESIA 
proved,'upon examination, to be right inguinal hernia, at times irreduci- 
ble, and causing great suffering. The man gave a history of having felt a 
sharp, tearing pain in the right groin, while operating a taxicab, about 
three months previous to coming to the clinic. Since that time he had 
been to several dispensaries in a vain search for relief. He had used a 
truss without success. Failing to obtain relief by other measures, he 
wished to be operated upon at once. 
From the general physical examination the patient was found to be 
in a very bad condition, as the result of the prolonged excessive use of 
alcoholic stimulants. The following conditions were present: general 
atheroma of the arteries; renal insufficiency, due to chronic Bright's dis- 
ease; marked enlargement of the liver; myocarditis, with systolic mur- 
mur at the base; emphysema; rales over the bases of both lungs. A his- 
tory of chronic gastritis was also elicited. 
The patient's general condition was such that immediate operation 
was not deemed advisable. He was told, accordingly, to abstain from the 
use of intoxicants, and to refrain from lifting or straining; he was put 
upon a diet, tonics, etc., and was kept under observation for about three 
weeks. Despite the fact that only slight improvement followed this 
regime, he insisted upon operation. He was then admitted to the hos- 
pital on November 14, and prepared for operation the next day. 
Because of the man's general condition, inhalation anesthesia was con- 
sidered contraindicated. He was prepared, accordingly, for operation 
under spinal analgesia. Before the members of the Congress of Surgeons 
present, I injected into the cauda equina twenty-six minims of a one per 
cent solution of stovain. The patient, who presented no symptoms differ- 
ing from those of the average subject during the spinal injection, was 
then sent to another room to be operated upon by E. M. Foote and Claude 
A. Frink, of my staff, while I concluded my lecture before the Congress. 
The man's mind was perfectly clear, his pulse was good, there was no 
nausea, no cyanosis, no respiratory embarrassment-in fact, none of the 
symptoms of stovain poisoning. He suddenly turned pale, said, "I am 
dying," and instantly died. 
The case was made a coroner's case, and an autopsy was performed 
the next day, with the following findings: 
Marked edema of the brain, so-called "wet brain"; myocarditis; 
atheroma of aorta; aortic insufficiency; emphysema of lungs; chronic 
interstitial splenitis; chronic gastritis; chronic enteritis; chronic intersti- 
tal nephritis. Spinal cord showed no gross lesion. 
The coroner's inquest was held on December 4, 1912. The jury, after 
listening to the testimony of the above facts and a number of experts as 
to the indications of death by stovain poisoning, did not find that the 
man died of stovain poisoning, but that death was caused "by pathological 
conditions" as described, and all concerned were exonerated from blame. SPINAL ANALGESIA AND SPINAL ANESTHESIA 
627 
CONCLUSION 
In summing up the entire subject of spinal analgesia, the author of 
this section wishes to reiterate that this method is not to be considered as 
replacing inhalation anesthesia. It has, however, a distinct place in sur- 
gery, and as the indications and contraindications are more clearly un- 
derstood and the technique of the method improved, its field of useful- 
ness has widened, and will doubtless continue to widen. It must never- 
theless still occupy a limited sphere until further accurate and scientific 
experimentation has led to more certain conclusions with reference to the 
physiological action of the agents employed and the dosage in which they 
may be used to obtain a given result. CHAPTER XVI 
INTRAVENOUS ANESTHESIA 
William F. Honan, M. D. and J. Wyllis Hassler, M. D.1 
Physiology. 
Technique. 
Mixed Forms of Anesthesia. 
Blood Changes. 
Urinary Examination. 
Fig. 262.-Patient under Anesthesia by the Intravenous Method. Note globular 
indicator with control stopcock; also method of maintaining arm in proper position. 
General anesthesia by the intravenous route was demonstrated as a 
possibility by Ore of Lyons in 1872, chloral hydrate in solution being the 
1 Surgeons to the Metropolitan Hospital, N. Y. City. Abstract from a paper 
read before The American Association of Anesthetists, June, 1913; published in 
Ann. of Surg., Dec., 1913, J. B. Lippincott Co., N. Y. With permission of 
Dr. Honan. 
628 INTRAVENOUS ANESTHESIA 
629 
hypnotic agent employed. The method seemed very successful in 51 
cases, but subsequent fatalities, due, perhaps, both to the drug used and 
the method employed, led to its discontinuance. 
At the Berlin Surgical Congress, in 1910, six surgeons of prominence 
corroborated the success of Burckhardt, who led in perfecting the tech- 
nique of this method. Kiimmel reported 90 cases in his own experi- 
ence. Later, Fedorow, of St. Petersburg, collected 530 cases from three 
Russian clinics, in which hedonal was used with no deaths attributable to 
the anesthetic. Fedorow and his colleagues used a 0.75 per cent solution 
of hedonal in normal saline solution. 
Physiology.-The correct interpretation by the anesthetist of the 
physiological effect is that, when once a level of narcosis sufficient for the 
purposes of the surgeon is reached, very little anesthetic is necessary to 
maintain the anesthetic tension, and that so long as the tissues are not 
overnarcotized the cells will part with the anesthetic and regain their 
normal physiological status when the administration of the drug is with- 
drawn. 
In the employment of intravenous anesthesia, the agent is directly 
introduced into the blood, and is maintained there at the desired anes- 
thetic tension. In this method, the production of anesthesia is very 
rapid, the preliminary state of excitement is nearly always absent, the 
patient breathes almost naturally, the color of the skin remains good, 
and the relaxation and flexibilty of the muscles are absolutely satisfac- 
tory to the operator. The degree of narcosis can be maintained to a 
nicety, and at the completion of the operation the patient often answers 
questions rationally before leaving the operating table. 
For the safe and satisfactory induction of anesthesia by the intra- 
venous route, it is highly essential that the details of the technique, 
which is remarkably simple, be carefully and systematically observed. 
Honan's own work has embraced about all of the operations usually 
employed in a large general surgical service, males, females, and children, 
and, at the present time, we can recall only one death in about 350 ad- 
ministrations that could be justly attributed to the method of anesthe- 
sia, and in that single instance the regrettable fatality was due to the 
unfortunate misunderstanding of a verbal order as to anodynes after the 
operation. 
Technique.-For the intravenous use of ether, the patient, having 
been prepared for operation, is taken to the anesthetizing room about 
thirty minutes before the time for operation, and placed preferably upon 
the operating table which is to be used during the operation. A sub- 
cutaneous injection of morphin sulphate, gr. 1/6; atropin sulphate, gr. 
1/100; and scopolamin, gr. 1/1000, is given at one dose-preferably in 
the loose tissues of the chest, abdomen, or thigh. From this time until 
the actual anesthesia is accomplished, it is extremely advisable to keep 630 
ANESTHESIA 
the patient as quiet as possible, so that when the administration begins 
the patient is in a condition of reposeful relaxation of mind and body. 
No matter how anxious or fearful of the result of the operation, the pa- 
tient in thirty minutes is sustained and supported by the hypodermic 
medication, and the injurious effects of acute fear, which Crile has dem- 
onstrated are identical with those of acute shock, are successfully com- 
bated. A five to seven and one-half per cent solution of ether with fil- 
tered sterile Ringer's solution (normal saline solution may be used if the 
other is not available) at a temperature of 85° F. is poured into a reser- 
voir which has a capacity of 2000 c.c. The solution is thoroughly 
mixed, and care should be taken to see that the ether is dissolved; for 
even after violent succussion there may be some stratification, the lighter 
ether floating upon the surface of the solution. 
The solution having been prepared, the reservoir is adjusted on a 
stand eight feet above the floor level, at which point it remains during 
the administration. The fluid flows through an indicator which con- 
Fig. 263.-Holder for Arm. 
tains a pipette, then through a rubber tubing into a blunt cannula, and 
so into the vein. The indicator consists of a cylindrical or globular bulb 
of a capacity of from two to four ounces with an inside pipette very 
similar to that used in the Murphy apparatus for protoclysis. When the 
apparatus is working properly, the lower half of the indicator is filled 
with solution, while the upper half contains air. The solution flows 
from the tank through the pipette, and drops on the surface of the fluid 
in the lower half of the indicator. By means of a compression top, placed 
below the indicator, the rate of flow can be accurately controlled, and, if 
the fluid in the bulb is kept at a proper level, a satisfactory index is fur- 
nished as to the rate the solution enters the vein. Usually the arm 
furthest from the operator is selected and the median basilic or cephalic 
vein exposed, but should the operative field be the skull, face, neck, or 
chest, where the infusion apparatus would inconvenience the surgeon INTRAVENOUS ANESTHESIA 
631 
or his assistant, the internal saphenous at the internal malleolus is se- 
lected. As a matter of fact, any vein, in any locality remote from the 
operator, may be utilized, the simple precaution being that it is super- 
ficial, free from varicosities, and sufficiently large to be readily exposed 
and to admit the small cannula through which the anesthetic solution is 
to be introduced into the system. If the elbow is selected, a padded 
splint, large at one end and tapering to a size somewhat wider than the 
forearm, is placed beneath the patient, extending from beyond the tips 
Fig. 264.-Vein Exposed and Ligated Distally. This ligature not shown in illus- 
tration. Vein is being opened with scissors. (Annals of Surgery.) 
of the fingers to the opposite side of the body; a few turns of a three- 
inch rubber bandage just above the wrist will maintain extension of the 
forearm and prevent involuntary movements which might occur in the 
first stage of anesthesia and dislodge the cannula from the vein, an em- 
barrassing but easily preventable accident. A space of about four to six 
inches over the bend of the elbow is now firmly wiped once over with 
a 5 per cent solution of thymol in carbon tetrachlorid on a piece of 
gauze. This is sufficient to thoroughly sterilize the skin, which has not 
received any previous preparation. It has an advantage over iodin, which 
is usually employed, in that it is more efficacious and, as an antiseptic, 
does not discolor the skin, a great advantage when superficial veins are 
to be dissected. It is not advisable to bandage the distal extremity of a 
limb to render the veins more prominent, as the compressor must be very 
quickly removed when the cannula is introduced, and that often adds to 632 
ANESTHESIA 
the difficulty. If the veins are not particularly prominent, an assistant 
may make some pressure with the hand on the upper and inner aspect 
of the arm while the vein is being exposed. There should be no blunder- 
ing at this point, since nothing so disturbs the morale of the patient, de- 
stroys confidence, and adds fear and anxiety, when composure should be 
supreme, as the futile, clumsy attempts to find the vein by anesthetists 
not accustomed to doing surgical work. 
We make it very emphatic that the exposure of the vein and the in- 
troduction of the cannula should be done with scrupulous regard to asep- 
sis, since septic thrombosis at this point might lead to unpleasant after 
Fig. 265.-Cannula Introduced and Tied in the Vein. (Annals of Surgery.) 
results. The skin Qver the vein selected is infiltrated with a few drops of 
one-half of one per cent solution of cocain, sufficient to make a blot one- 
half inch in diameter. The skin containing the blot is drawn aside from 
the vein with the thumb of the left hand so as not to be directly over the 
vein, and a small incision one-third to one-half an inch is made through 
into subcutaneous fat. The vein is now exposed by wiping with a bit of 
gauze for two or three firm strokes. A small hemostat, with a double 
ligature of No. 1 catgut, is now carefully thrust beneath the vein, and, 
by gently moving it horizontally in and out, the vessel is lifted from its 
bed and the exposure is complete. The ligature is cut, the lower half is 
tied tightly and attached to a hemostat, the upper half being tied loosely 
with half a knot and also clamped with a hemostat. The operator now 
takes the proximal ligature in his left hand, the assistant making slight 
tension on the one distal; the vein is lifted and put somewhat on the 
stretch. With a small rather blunt scissors an incision is made, em- 
bracing about two-thirds the caliber of the vessel. The operator now INTRAVENOUS ANESTHESIA 
633 
takes the cannula in his right hand, and, slightly relaxing tension on the 
proximal ligature which he holds, he is able usually to quickly insinuate 
Fig. 266a. 
Fig. 266b. 
Figs. 221a and b.-Salvarsan Method of Introducing the Needle. 
it into the cavity of the vein. By manipulating the proximal ligature as 
to tension, he is able to facilitate this movement, though it is often ad- 
visable to have the assistant pick up the flap of the incised vein with a 634 
ANESTHESIA 
small pair of anatomical forceps which exposes the lumen, steadies the 
vessel, and very considerably facilitates the introduction of the cannula. 
The half loose knot in the proximal ligature is now drawn snugly down 
on the cannula, which is sufficient to hold it in place. A piece of ad- 
hesive plaster about 3 inches wide is placed about the rubber tubing con- 
nected with the cannula, which relieves all tension and tends more than 
anything else to prevent the accidental slipping of the tube from the 
vein. A large gauze pack is now placed over the incision, and the sur- 
geon and assistant take their respective places to begin the contemplated 
operation. We have found that actual exposure of the vein and tying on 
of the cannula is the most satisfactory and safe procedure, many sugges- 
tions having been made as to the use of a technique similar to that em- 
ployed in the salvarsan treatment; special needles have been made and 
tried only to return to the very satisfactory procedure described above. 
The solution should be administered at a full flow at the beginning, 
the anesthetist reducing the stream at the appearance of the usual signs 
of surgical anesthesia. It is quite as incumbent upon the anesthetist td 
take the usual precautions to secure and maintain an unobstructed air- 
way and efficient respiratory act, as in the usual method of anesthesia. 
Ether is rapidly eliminated by the lungs in this method, and, as is true 
of all methods, efficient respiration prevents accumulation and tension 
on the tissues, increases its output, and lessens its toxicity. In from one 
to five minutes anesthesia will be complete, and the operation may pro- 
ceed. 
It is highly important, as was noted above, to be economical in the 
use of the anesthetic solution; the patient should be placed in the appro- 
priate position for the intended operation, the operative field draped, 
the skin disinfection completed, and the surgeon absolutely ready to make 
the initial incision when the cannula is inserted into the vein. There is 
a limit to the patient's tolerance for even salt solution, and it is very 
desirable that any portion of the period of anesthesia be not wasted upon 
preparation, but reserved solely for the actual operative technique. When 
the degree of narcosis is obtained, which varies somewhat with the nature 
of the operation, the flow into the vein is reduced by the control cock 
just below the indicator. It may be allowed to drip in a very fine stream 
or at the rate of 40 to 60 drops per minute, the corneal reflex affording a 
reliable guide for administration. The anesthetist readily becomes ac- 
quainted with the effects of the drug by this method, and, as narcosis 
can be absolutely and beautifully controlled, there is no need for any 
embarrassment to the operator from involuntary muscular contractions. 
Again, let it be urged that careful attention be directed to the main- 
tenance of an open airway, and, as the muscles of the jaws and neck are 
very much relaxed, the tongue should not be allowed to drop back into 
the pharynx. It is more important to attend to these respiratory pre- INTRAVENOUS ANESTHESIA 
635 
cautions than if the patient were being anesthetized by the inhalation 
method. The Hewitt breathing tube is very useful in assisting to main- 
tain a proper airway and also as an aid to holding the tongue forward. 
Our usual practice is to fix the tongue with a pair of fine tenaculum for- 
ceps and let them hang by their own weight. We advocate a continuous 
flow in intravenous anesthesia, no matter what agent is employed as the 
hypnotic, though a few times we have interrupted the stream for a few 
Fig. 267.-Cornell Noiseless Suction Apparatus for Use in General Surgery. 
moments without any appreciably harmful effect at the conclusion of the 
operation, unless it has been quite prolonged; particularly if ether alone 
has been used, the dressings should be applied before the flow is actually 
stopped, as the return to consciousness often comes very promptly and 
the patient may resist efforts to finish the toilet of the incision properly. 
The blood pressure rises slightly with the use of ether in this way. We 
use it preferably in the old and cachectic patients, avoiding its use in 
young, full-blooded, or alcoholic subjects. 
Oozing is more noticeable, perhaps, in the operative field, and, if the 
cavity of the abdomen is the seat of the operation, fluid quickly accumu- 636 
ANESTHESIA 
lates there. If extensive adhesions are to be dealt with, the fluid rap- 
idly becomes blood-stained, and there might be instances where this 
might embarrass and delay the operator, but we have not been so trou- 
bled. The patient may be 
brought from one degree of 
anesthesia to another very 
rapidly by the judicious use of 
the control indicator, and it is 
well that the operation be en- 
tirely finished and dressings 
applied before the administra- 
tion is stopped. If the admin- 
istration has been skillfully 
performed, the patient will 
quietly drop to sleep without 
any appreciable indication of 
a stage of excitement. The 
face will flush, eyes roll, and 
some of the voluntary muscles 
stiffen for perhaps a few sec- 
onds, when suddenly the pa- 
tient seems to have fallen into 
a quiet but deep sleep without 
the noisy stertorous respiration 
usually associated with nar- 
cosis. The usual signs, corneal 
reflex, pupillary indication, 
etc., are about as noted in the 
same degree of anesthesia by 
the inhalation method. At the 
conclusion of the operation, 
which may last from two to 
three hours, at the expenditure 
of about 1000 e. c. of solution 
per hour, the cannula is with- 
drawn by a quick jerk from 
the vein, the loose half knot of 
catgut is tied, which ligates 
the proximal portion of the 
vein. The wound is closed with a few fine silk sutures of 000 silk on 
No. 10 straight needles, wiped once with carbon tetrachlorid and 
thymol, 50 per cent solution, and an aseptic dressing applied. The 
patient is returned to bed, and, if much solution has been used and 
the operation prolonged, a semi-Fowler position is employed, and the 
Fig. 268.-Another Model Apparatus for 
Intravenous Anesthesia. The reservoir 
and tube for preliminary narcosis are in one 
piece, and the solutions are controlled by 
an ingeniously perforated glass stopcock. 
(Annals of Surgery.) INTRAVENOUS ANESTHESIA 
637 
nurse instructed to turn the patient every one or two hours. This is 
a necessary precaution; for, if a very great quantity of fluid is used, 
there are naturally some possibilities of pulmonary edema, and 
curiously enough, certain spots on the back and buttocks often 
develop, looking like bruises. This is due to the anesthetic fluid 
settling in the loose fatty tissue of the most dependent portion of 
the body. Occasionally the patient will have a chill such as may occur 
when saline infusion is given to combat shock. This condition quickly 
subsides, particularly if hot-water bags are placed about the patient. It 
is a curious fact that this phenomenon will occur when solutions ten de- 
grees higher than the body temperature are introduced into the circu- 
lation. The employment of ether in this way seems almost devoid of 
danger from either immediate or remote complications, and represents 
the basic type of intravenous anesthesia, from which have grown many 
modifications. 
Mixed Forms of Anesthesia.-Experience has shown that in intra- 
venous anesthesia better results are obtained, both as to the production 
of the narcosis and a state of anoci-association, if hypnotic agents are em- 
ployed at the same time, which are of very widely different character, 
both as to chemistry and physiological action and which may be said to 
act synergetically. If the narcosis is first established by the use of a 
hypnotic, like hedonal or isopra], and the subsequent course conducted 
with the ether solution, the anesthesia is more satisfactory in every way. 
The method seems safer and more efficient; less solution is required to 
maintain the narcosis and the post-anesthetic history is free from inci- 
dents. Of the many substances employed in the preliminary narcosis, 
isopral seems to best fulfill the requirements. Into the smaller reservoir 
is placed 250 c. c. of a one and one-half per cent solution of isopral in 
Ringer's solution, which has been boiled, filtered, and maintained at a 
temperature, approximately, of 85° F.; into the larger, 2,000 c. c. of a 
five per cent solution of ether. Artery clips or compression tops are 
placed on the tubes leading from each reservoir to control the outlets. The 
apparatus, particularly rubber connections, is now carefully examined to 
see that all parts are secure, since the slipping of a rubber tube from its 
glass connection during anesthesia makes a very embarrassing situation, 
which may be easily prevented by a careful inspection before the ap- 
paratus is used. Everything being in readiness now, the vein examined, 
the solution from the smaller reservoir, which will be used first, is al- 
lowed to flow through the tubing to force out the air and to fill the in- 
dicator a trifle below the free end of the pipette. The cannula being 
introduced into the vein, the isopral solution is allowed to flow slowly into 
the vein, allowing four to five minutes for the entire 250 c.c. to enter the 
circulation. Usually, before that amount has been used, the patient has 
passed from a condition of consciousness to what is apparently a normal 638 
ANESTHESIA 
sleep, without a stage of excitement, and, if this preliminary narcosis has 
been skillfully conducted, there is nothing in the entire realm of anes- 
thesia which so approximates normal sleep. The patient breathes quietly 
and naturally, there is no noisy respiration, the color remains good, and 
the transition from wakefulness to deep sleep has been so quietly accom- 
plished that one is scarcely prepared to believe that narcosis is complete 
until examination shows complete muscular relaxation and absence of 
corneal reflex. This stage may be reached before the entire 250 c.c. of 
isopral solution has been used; often 100 c.c. is sufficient. However, in 
the very robust, and particularly in those addicted to the use of drugs or 
alcohol, this preliminary stage may be prolonged. Before the isopral 
solution is entirely exhausted, the clip is placed upon the tubing leading 
from the smaller reservoir and, simultaneously, the one from the larger 
reservoir is removed, allowing the ether solution to enter the circulation. 
Narcosis having been wholly or partially accomplished, the flow in this 
instance is just sufficient to maintain the degree already established, or 
such as may meet the demands of the operation. Hedonal may be used 
in the same way except that it is used in a 0.75 per cent solution. It is 
a more powerful respiratory sedative than isopral, and the precaution 
should be observed that it should enter the circulation slowly and espe- 
cial attention be paid to its proper elimination by the maintenance of an 
adequate airway. It is possible to deeply narcotize a patient with 
hedonal in ten seconds after the cannula is introduced into the vein by 
allowing the flow full headway, but such effects are sensational in their 
rapidity, serve no useful purpose, and are not always devoid of danger. 
Blood Changes.-In every case it was found that ether raised the 
blood pressure from 2 to 24 mm., this rise being followed by a fall of 2 to 
20 mm. in from one to three hours and then gradually returned approxi- 
mately to the point observed before operation. 
Hedonal invariably lowered the blood pressure from 6 to 25 mm. of 
mercury, paraldehyd in about the same proportion, so also isopral. When 
mixtures were used, such as hedonal and ether, paraldehyd, or isopral and 
ether, the blood pressure was influenced to the extent of being about 
the same as before the operation, as only a small quantity of the hyp- 
notics was used in the anesthetic mixtures. They, however, in every in- 
stance prevented the increased pressure noted when ether-scopolamin- 
morphin combination was used. It was singularly noted that female pa- 
tients showed little or no changes in the blood pictures, neither did males 
in operations of short duration. Alcoholic habitues naturally required 
more anesthetic and, in one case, in which anesthesia was accomplished 
with a five per cent solution of paraldehyd in normal saline, there was 
decided crenation of red cells with some clumping crenation, and some 
crenation was noted when a mixture of ether 3 per cent and paraldehyd 
25 per cent was employed. Some crenation was also noticed in one case INTRAVENOUS ANESTHESIA 
639 
where a large quantity (3,500 c.c.) of 7 per cent ether in normal saline 
was used. In every case the blood picture returned to normal in about 
four hours. 
Hemoglobin, estimated by Tallquist scale, showed an average diminu- 
tion of 5 per cent. There seemed to be no changes either in appearance 
or number of the leucocytes, and where an actual leucocytosis was ob- 
served before the infusion was given the blood picture was practically un- 
changed. The erythrocytes were not materially affected, except in three 
cases in which narcosis had been produced by paraldehyd. 
Urinary Examination.-The urinary analyses made before the opera- 
tion and for three or four days afterward showed no marked differences 
in the specimens. The total amount was increased and specific gravity 
lowered during the first twenty-four hours; often the specific gravity and 
solid content of the urine remained unchanged. In no case, even after 
employing 7.5 per cent ether solution, did blood, albumin or casts appear 
in the urine, though German observers have reported occasional cases of 
transient hemoglobinuria after the use of the stronger ether mixtures. 
It was quite surprising that there was not a large urinary output after 
the infusion of large quantities of fluid, so much so that the patients 
were regularly catheterized, thinking perhaps there might be some vesical 
paresis from overdistention, but we failed to find at any time a urinary 
output in proportion to the amount of fluid introduced into the circula- 
tion. CHAPTER XVII 
SYNERGISTIC ANALGESIA AND ANESTHESIA: WITH SPECIAL 
REFERENCE TO MAGNESIUM SULPHATE 
Definition of Terms. 
Development of Theory of Inhibition as Applied to Anes- 
thesia: Laboratory experiments. Physiological considerations: Effects 
of magnesium sulphate; Action on nerve trunks; Subcutaneous injec- 
tion; Subarachnoid injection. 
Animal Experiments: Preparation of magnesium sulphate solu- 
tions. Prolonged effect of morphin. Technique of Administration: 
Hypodermoclysis with nitrous oxid and oxygen by inhalation; Modified 
or simple technic with nitrous oxid and oxygen; Ether by inhalation; 
Alkaline synergistic method. Technic with ether and oil by colonic 
instillation. Rector's technic: Formulas for instillation; magnesium 
content of the blood; summary of results. Technic with Local Agents: 
Lathrop's technic; technic for dental surgery. 
Advantages of Method. 
Dangers. 
Mortality. 
Indications and Contra-indications. 
Conclusions. 
DEFINITION 
By synergism is meant the reciprocal augmentation of the action of 
one drug by that of another. This reciprocal augmentation of the action 
of one anesthetic agent by that of another induces the state which has 
come to be known as synergistic anesthesia, when accompanied by un- 
consciousness, and synergistic analgesia when the subject is conscious. 
The effect of the synergistic action of drugs is not due to a simple 
summation of similar pharmacological actions; indeed, this action of 
drugs is much greater than the summation of their pharmacological 
actions. No satisfactory explanation of synergism can be gjven.1 
DEVELOPMENT OF THEORY OF INHIBITION AS APPLIED TO 
ANESTHESIA 
The discovery of the anesthetic properties of magnesium sulphate 
was due to the observations of Meltzer, who, while experimenting for 
1 Meyer, H. H., and Gottlieb, R.: ' ' Pharmacology. ' ' Philadelphia: J. B. 
Lippincott Company, 1914, pp. 510, 575. 
640 SYNERGISTIC ANALGESIA 
641 
other purposes, noted that two drops of a 5 per cent solution of mag- 
nesium sulphate, injected intracerebrally into a rabbit, produced com- 
plete anesthesia and relaxation lasting several hours. From that time 
on Meltzer and his co-workers undertook, on a purely theoretical basis, 
experiments with magnesium salts, with a view of testing a far-reaching 
biological hypothesis-the question of inhibition. It was found from 
these experiments,1 performed on dogs, cats, rabbits, and monkeys, that 
intravenous injections of very small doses of magnesium salts inhibit the 
respiration and cause paralysis of the entire body; that local applications 
to nerve trunks block the conductivity and abolish the excitability of the 
nerves; that subcutaneous injection produces deep narcosis with complete 
muscular relaxation; and that subarachnoid injection produces nearly 
immediate anesthesia and paralysis of the extremities. 
To Meltzer and his associates, therefore, belongs the credit of the 
discovery of the anesthetic properties of magnesium salts, magnesium 
sulphate being the chief of these. 
Laboratory Experiments. -De Neen's 2 experiments with Magnesium 
sulphate anesthesia were limited to the lower animals. Three cats and 
thirteen dogs were used; some of them were used for more than one 
experiment. Nineteen experiments were performed. Magnesium sul- 
phate was used in sterile solutions of y and 25 per cent strengths. They 
were injected subcutaneously, subcutaneously and intramuscularly, intra- 
muscularly, intra spinally, and intravenously. 
From the results of these experiments, DeNeen concluded that mag- 
nesium sulphate is toxic in large doses, and will cause respiratory 
paralysis; that it will produce general analgesia, although the animal is 
conscious; that it will cause sloughing and gangrene in some cases, when 
introduced subcutaneously or intramuscularly, or when it escapes into 
the muscles or connective tissue. He further states that respira- 
tory paralysis or death may result when the dose is given in too short 
a time and that the intravenous method of administration is to be 
preferred. 
In these early experiments on animals, and in the early clinical use 
of magnesium sulphate, this agent was used as the single factor in the 
induction of anesthesia.3 
While Meltzer and his associates were at work on this problem, as 
1 Meltzer, S. F.: " Inhibitory and Anesthetic Properties of Magnesium 
Salts." Medical Record, 1905, 48, December 16, 965. 
a Read during the Organization Meeting of the Interstate Association of 
Anesthetists in Cincinnati, May 4, 5, 1915. 
3 Haubold, H. A., and Meltzer, S. J.: " Spinal Anesthesia by Magnesium 
Sulphate." A Report of Seven Operations Performed Under Its Influence. 
Jour. Am. Med. Assoc., March 3, 1906. 642 
ANESTHESIA 
subsequently related,1 Schutz,2 in a preliminary report, expressed the 
view that the susceptibility to magnesium injections could be increased 
occasionally, but not constantly, by sodium oxalate. Starkenstein 3 found, 
"like Schutz, that the addition of oxalates constantly gave a visible 
increase of the magnesium narcosis." 
Gates and Meltzer published their first observations along this line 
shortly after the appearance of these reports.4 Their experiments, as 
afterwards related, had established the fact, among others, that sub- 
cutaneous or intramuscular injections of sodium oxalate in subtoxic 
doses, when administered to an animal which received a subminimal 
dose of magnesium sulphate, produced profound anesthesia and paralysis 
of long duration, although the usual effects of sodium oxalate alone are 
of a stimulating character." Joseph and Meltzer 5 from experiments on 
animals with respect to the life-saving action of physostigmin in poison- 
ing by magnesium salts, reach the following conclusions: 
Physostigmin is capable of efficiently antagonizing some of the toxic 
actions of magnesium salts. It may directly serve as a life-saving agent 
against a fatal poisoning by magnesium salts, if the dose of the latter em- 
ployed be not too large. 
Physostigmin overcomes the toxic effects of magnesium essentially by 
the aid it renders to the depressed function of respiration. This aid is of 
threefold origin. It stimulates the respiratory center; it antagonizes the 
"curare-like" action of the magnesium-ion upon the nerve endings of the 
respiratory muscles; and it stimulates the nerve endings of the pneumo- 
gastric nerves within the lungs. 
Physostigmin antagonizes also the magnesium action upon the periph- 
eral nerve endings and probably also the action upon muscle tissue. The 
extent of this antagonism, however, seems to be not very significant. 
A combination of subminimal doses of magnesium sulphate intra- 
muscularly and ether by intratracheal insufflation was found by Meltzer 
and Auer6 to be effective in animals, and by Peck and Meltzer 7 and 
Elsberg and Meltzer in human beings. 
1 Gates, F. L., and Meltzer, S. J.: " An Experimental Study of the Additive 
and Antagonistic Actions of Sodium Oxalate, and Salts of Magnesium and Cal- 
cium in the Rabbit." Jour, of Exp. Med., 1916, 23, 655. 
2 Schutz, J.: Wien. klin. Wchnschra., 1913, 24, 745. 
3 Starkenstein, E.: Wien. klin. Wchnschr., 1913, 26, 1235. 
* Gates, F. L., and Meltzer, S. J.: Zentralbl. f. Physiol., 1913-14, 27, 1169. 
"Joseph, Don R., and Meltzer, S. J.: "The Life-Saving Action of Physostig- 
min in Poisoning by Magnesium Salts. ' ' Jour, of Pharmacol, and Exper. Therap., 
1909, 1, No. 3, 369-387. 
• Proc. Soc. Exper. Biol, and Med., 1912-13, 10, 159; Zentralbl. f. Physiol., 
1913-14, 27, 632. 
T Peck, Charles H., and Meltzer, S. J.: " Anesthesia in Human Beings by 
Intravenous Injection of Magiiesium Sulphate." Jour. Am. Med. Assoc., Octo- 
ber 14, 1916, 67, 1131. SYNERGISTIC ANALGESIA 
643 
The further development of magnesium sulphate anesthesia was 
interrupted by the World War, no reference to the subject in the litera- 
ture of the period covered by our participation in the war being found. 
In 1921, the theory and development of synergetic anesthesia and 
analgesia with magnesium sulphate and other agents was taken up by the 
author and his associates. 
The first observation on the subject published by the author concerned 
the application of the principle of synergism and colonic analgesia (see 
infra). 
PHYSIOLOGICAL CONSIDERATIONS 
According to Meyer and Gottlieb, "if the weakening or the prevention 
of the action of one drug by that of another be called antagonism, the 
one-sided or reciprocal augmentation of such action may be called 
synergism." 1 
Meltzer2 defined the synergistic action of magnesium sulphate as 
follows: "When after the administration of a very small amount of ether, 
insufficient to cause anesthesia, an inefficient amount of magnesium is 
injected intramuscularly, a profound anesthesia follows, which can be 
maintained for several hours." Many examples of this synergistic 
action, notably, of morphin and scopolamin, and morphin and nitrous 
oxid or ether, are now well known, and the physiological principle is 
utilized to advantage in anesthetic practice. 
The theory of synergism seems to confirm Burg's law.3 
The sum of the combined action of two or more narcotics administered 
simultaneously or shortly after each other, produces a much more powerful 
effect than when a total equivalent quantity of either one narcotic had 
been administered alone. This increased action is particularly marked 
when the two narcotics have different cell receptors or belong to different 
chemical series, in which case the two drugs seem to potentiate each other, 
and that a dose of any one drug acts much more markedly when given in 
frequent small doses than when administered at once in a single dose. 
In line with this theory is the fact, well known to anesthetists, that 
nitrous oxid, the least harmful of the general anesthetics in its effects 
upon the tissues and organs of the body, is dangerous when used alone. 
If, however, the patient is first rendered analgesic by means of magnesium 
sulphate and morphin, the anesthesia being completed with nitrous oxid 
and oxygen, the patient sinks into unconsciousness without struggling, is 
fully relaxed during operation, and is free from after-effects such as 
nausea, vomiting, and pain. 
1 Meyer and Gottlieb: "Pharmacology Clinical and Experimental" (Halsey), 
p. 575. 
'Meltzer, S. J., and Auer, J.: Proc. Soc. Exper. Biol, and Med., 1912-13, 
10, 159. 
3 Allen: ' ' Local Anesthesia ' '; 2nd ed.; p. 194. 644 
ANESTHESIA 
While magnesium sulphate, used alone, in proper dosage, is not a 
safe agent in producing anesthesia, neither is it as valuable for this 
purpose as some others. When used for its synergistic properties, it is 
not only absolutely harmless, but is one of the most effective of the known 
anesthetic agents. 
The combination of magnesium sulphate with morphin, in anesthesia, 
was first suggested by Pellini1 but the physiological effects of the com- 
bination were not known until demonstrated clinically. Not only does 
magnesium sulphate with morphin synergize nitrous oxid and oxygen, 
but, when used with ether, it reduces the amount required by from one- 
third to one-half, with no decrease in efficiency. Magnesium sulphate, 
when used as a synergist, exerts no deleterious effect on any of the tissues 
or organs of the body, including the respiratory center. It seems to 
act mechanically with morphin, holding it in contact with the tissues 
longer than the morphin alone is able to maintain such contact. With 
ether, and with nitrous oxid and oxygen, it acts by deepening or in- 
creasing the effect, rather than by prolonging it. Hence, the same 
amount of morphin may be used with magnesium sulphate as with 
sterile water. For instance, % grain of morphin in 2 to 4 c.c. of a 
25 per cent solution of chemically pure magnesium sulphate is increased 
in value from 50 to 100 per cent, as compared to the same amount 
of morphin used in sterile water. One hypodermic of the mixture 
will relieve pain for from ten to thirty hours, as compared with 
two to four hours with sterile water. When magnesium sulphate is 
used with ether, the latter may be cut one-third to one-half in 
amount. When magnesium sulphate is used with nitrous oxid and 
oxygen, the oxygen may be considerably increased and the nitrous oxid 
decreased. 
The difficulties experienced with the usual inhalation anesthesia are 
the lack of relaxation essential for many surgical procedures, and the 
after-effects of nausea, vomiting, and gas pains, induced by morphin 
when used alone. By the addition of magnesium sulphate to the pre- 
liminary morphin medication, a better relaxation is obtained and the 
nausea, vomiting, and gas pains are much reduced, if not entirely 
eliminated. If, on the other hand, no allowance is made by the anes- 
thetist, and if a state of anesthesia is superimposed upon the state induced 
by preliminary medication, the patient is immediately plunged into the 
danger zone and possibly into a condition of shock from inhalation 
anesthetic. The same degree of relaxation can be obtained with perfect 
safety by transferring the patient to the first stage of inhalation anes- 
thesia, thus removing him from the danger zone by two stages, accom- 
plishing analgesia with unconsciousness. This condition is approximated 
1 Gwathmey, James T.: "Synergistic Colonic Analgesia.'' J. A. M. A., 1921, 
76, 222-225. SYNERGISTIC ANALGESIA 
645 
by using morphin with magnesium sulphate as the analgesic, and induc- 
ing unconsciousness with nitrous oxid and oxygen. 
Cushny 1 holds that the injection of morphin is occasionally followed 
by some nausea, which is much more frequently present during recovery 
from the drug. Evidently the effect of the magnesium salts abolishes 
this delayed untoward effect of morphin. It is well known that the 
preliminary administration of morphin abolishes the stage of excitement 
and is a potent factor of safety, since over 90 per cent of all deaths occur 
in the first five minutes of any inhalation anesthesia. This preliminary 
medication renders the anesthesia easier, smoother, and safer. The 
nausea and vomiting come on later as the effect is wearing off, and are 
sometimes most disastrous. In favor of morphin, Cushny states: "It 
has little direct action on the circulation in man; the blood pressure 
remains high. It is not contraindicated in Bright's disease of the kidney, 
as it is not excreted in the urine." Meyer and Gottlieb state: "Percep- 
tion of pain is diminished by doses which scarcely affect the motor 
centers, and which have no appreciable influence on the perception of 
ordinary sensations." These observers hold that "scopolamin is not an 
analgesic, and yet the combined administration of small doses of morphin 
and small doses of scopolamin, which by themselves produce hardly any 
effect, results essentially in an exaggeration of the effects of morphin." 
The synergism of morphin and scopolamin, morphin and atropin, and 
morphin with all the general anesthetics, is well known. The synergism 
of morphin and magnesium sulphate is now partly understood. The 
prolonged analgesic effect, with absence of untoward effects, such as 
abdominal distention, headache, and post-anesthetic vomiting, consti- 
tutes a distinct advance in the technique of anesthesia. 
EFFECTS OF MAGNESIUM SULPHATE 
The question of the possible harmful effects of magnesium sulphate 
on the tissues has been raised since this drug has been used synergisti- 
cally in anesthetic practice. It may be well, therefore, to review briefly 
the findings of those who have made the most extensive study of the 
physiological action of magnesium salts, particularly magnesium sul- 
phate, when administered for anesthetic purposes by different methods. 
Action of Magnesium Sulphate by Intravenous Injection.-Recapitu- 
lating their studies on the toxicity of magnesium salts in intravenous 
injection, the effects of which are most striking as affecting the respira- 
tions, Meltzer and Auer2 state that, "dilute solutions injected would 
1Cushny: "Pharmacology," 1915, p. 242. 
'Meltzer, 8. J., and Auer, John: "Physiological and Pharmacological Studies 
of Magnesium Salts. II. The Toxicity of Intravenous Injections; in particular 
the effects upon the Centres of the Medulla Oblongata." Am. Jour, of Physiol., 
1906, 15, No. 4, 387-405. 646 
ANESTHESIA 
produce a gradual decrease of the inspirations, and, if continued, would 
lead up gradually to an inhibition of respiration which after a very brief 
slight struggle would terminate in complete rest. Concentrated solutions 
rapidly injected would terminate the respiration at once, and very fre- 
quently without the sequence of the struggles of asphyxia. Under no 
circumstances did the injections ever cause an increase of the inspirations 
in depth or frequency. In other words: Magnesium salts do not excite 
the respiratory function; on the contrary, if present in the blood in 
sufficient quantity are capable of rapidly and completely inhibiting all 
respirations, and at the same time inhibiting all the excitation phe- 
nomena of asphyxia." 
In a later communication, Auer and Meltzer1 showed that the 
paralysis of the respiratory function caused by the prolonged intravenous 
injection of magnesium sulphate is readily met by intrapharyngeal or 
intratracheal insufflation of ether and other paralytic effects by the intra- 
venous injection of calcium chlorid solution. Clinical application was 
made of these findings.2 
Action of Magnesium Salts Applied to Nerve Trunks.-Meltzer and 
Auer 3 conducted a series of experiments to determine whether solutions 
of magnesium salts have a local anesthetic effect when applied to nerve 
trunks, from which they reached the following conclusions: 
Solutions of magnesium salts, even in strong concentrations, when 
directly applied to the nerve trunks of animals, never seemed to produce 
irritation. 
By applications of solutions of magnesium salts to nerve trunks the 
conductivity can be interrupted, a more or less complete block for afferent 
and efferent, for normal or artificial, impulses, can be established. This 
can be accomplished by hypertonic, isotonic, and hypotonic solution. The 
more concentrated the solution the sooner the effect is established. In 
general it takes more time for the magnesium solutions to cause a nerve 
block than for other known local or general anesthetics. The block pro- 
duced in the nerves by the magnesium solutions disappears some time 
after removal of the solutions; the recovery of the nerve is greatly assisted 
by washing with Ringer's solution. 
The solutions of magnesium salts affect the cardiac fibres more readily 
than the efferent fibres for the oesophagus and the afferent respiratory and 
vasoconstrictor fibres within the vagus; also the sensory fibres within the 
1 Auer, John, and Meltzer, S. J.: " The Intravenous Injection of Magnesium 
Sulphate for Anesthesia in Animals." Jour. Exper. Med., 1916, 23, No. 5, 641-653. 
a Peck, Charles H., and Meltzer, S. J.: " Anesthesia in Human Beings by 
Intravenous Injection of Magnesium Sulphate." Jour. Am. Med. Assoc., 1916, 
67, Oct. 14, 1131-1133. 
3 " Physiological and Pharmacological Studies of Magnesium Salts.-III. The 
Narcotizing Effect of Magnesium Salts upon Nerve Fibres." Am. Jour. Physiol., 
1906, 16, No. 2, June 1, 233-251. SYNERGISTIC ANALGESIA 
647 
sciatic nerve are more readily affected than the motor nerve fibres. It is 
believed that the difference is not due to a selective action of the magnesium 
solutions upon the different nerve fibres but to a difference in the irritability 
of the nerve endings of these nerve fibres. 
Action of Magnesium Sulphate in Subcutaneous Injection.-Accord- 
ing to Meltzer and Auer 1 magnesium sulphate exerts a profound effect 
upon the nervous system. The hypodermic injection is painless; the 
effect seems to be exclusively of an inhibitory character. Complete anes- 
thesia, including relaxation of all voluntary muscles, with subsequent full 
recovery in animals, may be obtained by employing magnesium sulphate 
in 25 per cent solution, subcutaneously. The subcutaneous injection of 
magnesium sulphate, in their experience, never led to an immediate or 
late appearance of diarrhea or to more frequent stools. The salts are 
eliminated to a great extent through the kidneys. Absence of pain 
sensation and complete muscular relaxation can be fully developed before 
the stage of complete abolition of the conjunctival reflex is reached. Not 
a single instance was observed in which magnesium sulphate produced 
an increase of excitation. These observers stated, however, that sub- 
cutaneous injections of this drug can be fatal to animals, if given in large 
doses. The salts, under these circumstances, appear to affect mainly 
the respiration, which gradually becomes more and more shallow 
until it ceases. This takes place invariably before the heart stops 
beating. 
Meltzer and Auer 2 learned, from a series of experiments on rabbits, 
that the intravenous injection of any calcium salt is capable of neutraliz- 
ing, almost instantaneously, all the symptoms produced by the sub- 
cutaneous injection of any magnesium salt. Their conclusions from 
these experiments follow: 
Intravenous infusion of various calcium salts is capable of completely 
reversing the pronounced inhibitory effects brought on by various mag- 
nesium salts. The respiratory paralysis, the lost lid reflex, the motor 
paralysis, the lost general reflexes, the general anesthesia, the loss of con- 
sciousness, the depression of the cardio-inhibitory action of the vagus, the 
lowering of the blood pressure,-all are reversed and completely restored 
in a very short time by the injection of a comparatively small quantity 
of a calcium salt. This statement does not hold good for conditions 
brought about by large doses of magnesium. 
Calcium efficiently antagonizes the abnormal activity of its three 
1 Meltzer, S. J., and Auer, John: "Physiological and Pharmacological 
Studies of Magnesium Salts. I. General Anesthesia by Subcutaneous Injec- 
tions." Am. Jour. Physiol., 1905, 14, 366. 
2 Meltzer, S. J., and Auer, John: "The Antagonistic Action of Calcium upon 
the Inhibitory Effect of Magnesium." Am. Jour, of Physiol., 1908, 21, No. 15, 
May 1, 400-419. 648 
ANESTHESIA 
inorganic associates in the animal body, Mg, K, and Na, be the activity an 
over-inhibition or an over-excitation. 
The facts, as known at present, are still in harmony with the theory 
that magnesium favors essentially inhibitory processes in the animal body. 
The antagonism of calcium to magnesium is a phenomenon common 
to animals and plants. 
Action of Magnesium Sulphate in Subarachnoid Injection.-Haubold 
and Meltzer,1 following the experiments on animals, involving the appli- 
cation of solutions of magnesium sulphate to the spinal cord, employed 
intraspinal injections of this agent in human surgery. From their 
experience in seven cases, they concluded that magnesium sulphate in 
intraspinal injection proved to be as efficient an anesthetic in human 
beings as it was found to be in animals. 
All of the above methods, intravenous, local, subcutaneous, sub- 
arachnoid together with the antidotes, physostigmin and calcium chlorid 
have been discarded for use in clinical practice. The margin between 
the safe and toxic doses was insufficient to justify its use alone in human 
beings. 
If an idiosyncrasy should exist, and the patient show signs of poison- 
ing from any method in which magnesium sulphate is used, i.e. lowered 
respiration, with loss of lid reflex, large quantities of normal salt solu- 
tion, intravenously, should be given. At the same time administer 
oxygen by inhalation. 
ANIMAL EXPERIMENTS TO DETERMINE THE SYNERGISTIC 
EFFECTS OF MAGNESIUM SULPHATE 
As stated above, Meltzer and his associates, while recognizing the 
"additive and antagonistic" actions of magnesium salts, failed to make 
use, in clinical anesthesia, of their synergistic properties. This phase of 
the subject was practically dormant when the author and his associates, 
in 1920, began a series of animal experiments for the purpose of deter- 
mining the possibilities in this direction. 
The author and Greenough 2 conducted the following experiments, 
giving magnesium sulphate and ether in water, subcutaneously: 
A male guinea pig, weighing 290 grams, was given 6 c.c. of an aqueous 
solution containing 4 grams of magnesium sulphate and 5 c.c. of ether 
in each 100 c.c. at fifteen minute intervals. The pig was completely 
anesthetized for twenty-seven minutes, beginning forty minutes after 
1 Haubold, H. A., and Meltzer, S. J.: " Spinal Anesthesia by Magnesium 
Sulphate. A Report of Seven Operations Performed under its Influence." Jour. 
Am. Med. Assoc., March 3, 1906. 
3 Gwathmey, James T., and Greenough, James: "Experiences with Syner- 
gistic Anesthesia. ' ' Am. J. Surg., 1921, 36, 22. SYNERGISTIC ANALGESIA 
649 
the first injection. To another pig, weighing 310 grams, 12 c.c. of the 
same solution were given in the same manner. This animal was anes- 
thetized for one hour and forty-five minutes, beginning thirty-eight 
minutes after the first injection. 
The test used for anesthesia was a high-tension spark passed through 
the animal from one of the extremities to the back. This always pro- 
duced an involuntary contraction of the muscles but unless some motion 
with a muscle not on the path of the current was made, it was considered 
anesthetized. Both of the animals recovered and were kept over a month. 
They showed no ill effects, either locally, by sloughing, or by suppurat- 
ing, or generally. 
The first animal received a total of 0.83 gm. of magnesium sulphate 
and 1.04 c.c. of ether per kilo of body weight and was anesthetized for 
one-half hour. The second received 1.55 gm. of magnesium sulphate 
and 1.93 c.c. of ether per kilo of body weight and was anesthetized for 
one hour and forty-five minutes. It was found that for one hour's 
anesthesia, 3 c.c. of this solution per 100 gm. of body weight, or 1.2 gm. 
of magnesium sulphate and 1.5 c.c. of ether per kilo of body weight was 
the best dosage. 
As a control, water and ether were given to one animal and water and 
magnesium sulphate to another in the same dosage as with the second 
animal mentioned above, but anesthesia was not obtained in either case. 
The whole dose was administered at one time, or was divided into as 
many as six equal doses; the best results were obtained by giving it in 
three equal doses at fifteen minute intervals. The probable explanation 
of the effectiveness of the latter dosage is that if both drugs are given 
in one dose, at the same time, the ether is more quickly absorbed, and 
its action is over before that of the magnesium sulphate reaches its 
maximum; and the result is a succession of effects rather than a summa- 
tion. On the other hand, if the administration covers too long a period 
both drugs are being eliminated as they are being absorbed, and sufficient 
concentration for anesthesia is never reached. 
A female fox terrier weighing 4.5 kilos was given, intravenously, 
75 c.c. of an aqueous solution containing 4 grams of magnesium sulphate 
and 5 c.c. of ether, over a period of fifty minutes. The dog was anes- 
thetized for one hour and nephrectomy was performed. 
The total dose in this case was 0.6G gm. of magnesium sulphate and 
0.83 c.c. of ether per kilo. This was about one-half of the dose given the 
guinea-pigs but was given intravenously instead of subcutaneously. 
PREPARATION OF MAGNESIUM SULPHATE SOLUTION 
Auer 1 gives the following instructions for the making of a 25 per cent 
solution of magnesium sulphate: 
1 Personal communication. 650 
ANESTHESIA 
M 
- means a solution made by dissolving the molecular weight of the 
salt in grams, always including the water of crystallization, in enough 
water to make one liter. 
Example: MgS04 + 7H2O. 
Mg = 24.4 atoms weight 
S = 31.98 
04= 64. (4 16) 
= 14. (7 IL) 
07=112. (7 16) 
246.38 
Instead of weighing out 246.38 grams of the crystalline salt of mag- 
nesium sulphate, weigh out 250 grams and add enough water to make 
1000 c.c., thus making a 25 per cent solution. The difference is so slight 
that it can be neglected with safety. 
M 
MgS04 -f- 7H2 - = 25 per cent solution. 
M 
- solution = % of the molecular weight of the salt dissolved in 
enough water to make one liter. In practice the various dilutions 
M M M M M 
(- ■ -4 etc.) are made up from an - stock solution: Example - : 
2, 4, 8. 1 4 
M 
Take any amount of - solution and add enough distilled water to make 
M 
four times the bulk of the - solution originally taken. 
M . M 
(25 c.c. - solution, add enough H2O to make 100 c.c. = - solution.) 
M . M 
(50 c.c. -7- solution add enough H2O to make 400 c.c. = - solution.) 
1 o 
M 
An - solution of any salt is considered roughly equimolecular with 
8 
an 0.8 per cent sodium chlorid solution. 
It will be noted that if the water of crystallization is neglected, an 
M 
- solution made with crystalline salt is only about 12 per cent in 
strength. On the other hand, if one calculated the strength of solution 
by weight per cent., a 4 per cent solution made with exsiccated 
(anhydrous) magnesium sulphate is about 2 times as strong (8 per cent) 
as a 4 per cent solution made with the crystalline magnesium sulphate. 
This is due to the fact that the crystalline salt contains about 50 per cent 
of its weight as water of crystallization; therefore all percentage solu- SYNERGISTIC ANALGESIA 
651 
tions made up with the anhydrous salt are about twice as strong as 
the same percentage solution made with the crystalline salt. 
THE PROLONGED EFFECT OF MORPHIN 
To Adrian V. S. Lambert of the Presbyterian Hospital, New York 
City, more than to any one else, is due the credit for observing the 
prolonged analgesic effect of morphin when used with magnesium sul- 
phate, and also for the technique of administering magnesium sulphate 
by hypodermoclysis, when supplemented by nitrous oxid and oxygen. 
The following case from Dr. Lambert's service illustrates the differ- 
ence between magnesium sulphate and plain water when used with 
morphin: 
No. F.-Badly lacerated wound of leg, gas infection, opened wide 
December first, gastrocnemius severed. 
December. Duration, hours. 
2nd. 1.15 a.m. Morphia 1/5 MgSCh, 2 c.c. 25%, quiet until 5 5% 
6.15 a.m. Morphia 1/12 MgSO<, 2 c.c. 25%, no pain all day. ... 18 
The magnesium was now discontinued. Morphin alone use. 
3rd. 1.30 p.m. Morphia 1/6, pain in two hours 2 
3.25 p.m. Morphia 1/6, pain at 6.40 3*4 
The magnesium was again added to the morphin. 
6.55 p.m. Morphia 1/6, MgSCh 25%, 2 c.c. no pain till next day 23 
4th. 5.00 p.m. Morphia 1/10 MgSO<, 2 c.c. 25%, no pain till next a.m. 17 
5th. 10.15 a.m. Morphia 1/10 MgSO«, 3 c.c. 25%, quiet all day 10 
8.15 p.m. MgSOi, 3 c.c., very good night 19 
6th. 3.50 p.m. MgSCh, 3 c.c. 25%, severe pain after 3 hours 3 
6.15 p.m. Morphia 1/8 MgSCh, 2 c.c. 25%, jerking of leg in 2 
hours 2 
9.15 p.m. Morphia 1/8 MgSCh, 2 c.c. 25%, quiet night 19 
The patient required one hypodermic of morphia 1/10 to 1/6 and MgSCh, 
2 c.c., 25 % each day after this until December 13th. Codein and morphia 
alone did not give relief. 
From the above table it may be concluded that when the magnesium 
sulphate (2 to 4 c.c. of a 25 per cent chemically pure solution) is used 
with morphin the value of the morphin is increased 50 to 100 per cent. 
By either increasing or repeating the dose of morphin with sterile water, 
its action is intensified but not prolonged, as when used with magnesium 
salts. 
TECHNIQUE OF ADMINISTRATION 
Hypodermoclysis.-Two soap-suds enemata one hour apart, or one 
soap-suds enema followed by a thorough irrigation until the return is 
clear, are given the night before the operation. A low tap-water enema 
may be given early the next morning. If not already in place, a folded 
sheet is placed under the patient to serve as a lifter at the proper time. 
The bed is now screened, if in a ward, or the room darkened and quiet 652 
ANESTHESIA 
demanded. Two hours before the operation a chloretone suppository, 
grs. xv, is given, after which the patient is not allowed to leave the bed. 
A half-hour later a subpeetoral hypodermoclysis is given of 300 or 
400 c.c. of a sterile and chemically pure 4 per cent solution of crystalline 
magnesium sulphate at a temperature of 110° F., or the same amount 
may be given as a retention enema at this time. One tablet of "A" novo- 
cain suprarenin dissolved in the solution allays the small amount of pain 
caused by the distention of the tissues. The whole procedure should be 
carried out aseptically and the solution should run in by gravity in not 
less than thirty minutes. 
A towel is now placed over the face, and every inducement is offered 
for sleep. The first hypodermic of morphin, one-eighth of a grain, is 
given one and a half hours before the time set for the operation. It may 
be given in plain water or preferably in a solution of magnesium sulphate. 
This is repeated at intervals of fifteen or twenty minutes, until the full 
amount is given, the average adult receiving three-eighths of a grain. If 
an idiosyncrasy is present, it will develop before the time for the third 
dose. Quite often one-quarter of a grain is sufficient, especially for 
women. 
At the proper time the patient should be lifted as gently and quietly 
as possible and placed upon the stretcher. Under no circumstances should 
he be allowed to help himself. When these precautions are taken, he will 
arrive in the operating room in a quiet and comfortable mood and quite 
often asleep. If the patient is asleep he is probably in an analgesic 
state. 
Nitrous Oxid and Oxygen by Inhalation.-The mask should be 
applied before the usual preparation for the operation begins, as the gases 
themselves add considerably to the analgesia. With the mask in place, 
the oxygen is started at the same time as the nitrous oxid, and at no 
time should the patient be cyanosed or any attempt made to induce the 
usual signs of anesthesia. The patient, even before the inhalation of 
the gases, is in a state of almost complete analgesia, and the gases are 
used only to render the patient unconscious and to complete the analgesia. 
After the skin and peritoneum are incised, the oxygen may be rapidly 
increased up to 35 per cent, as the patient will be found fully relaxed, 
and stertor and cyanosis merely add to the danger without increasing 
efficiency. The second or excitement stage is absent, unless too low a 
percentage of oxygen is used and the patient becomes cyanosed. In 
certain cases, the gas and oxygen may be discontinued after the peri- 
toneum is opened; if rigidity is present, it should be immediately re- 
applied, and again during closure. A continuous administration with a 
high percentage of oxygen is the most satisfactory. 
Modified or Simple Tebhnic with Nitrous Oxid and Oxygen.-Where 
no great relaxation is required, for minor operations, or where, for any SYNERGISTIC ANALGESIA 
653 
reason, it is impracticable to carry out the technique described, the 
following modified technique has proved its value: One and a half hours 
before the operation, give by hypodermic % grain of morphin (or the 
H.M.C. tablet) in 2 to 4 c.c. of a chemically pure 25 per cent solution 
of magnesium sulphate, and repeat in twenty minutes for a patient below 
par, and a third time for robust patients-making the maximum dose 
% of a grain of morphin (with possibly %oo grain of atropin) and 
12 c.c. of magnesium sulphate. This is to be supplemented by gas and 
oxygen (the oxygen to be started at the same time as the gas). The 
patient should never be cyanosed at any time, and the percentage of 
oxygen should be slightly increased over the usual amount after the 
operation has begun. If-with the medication-the patient is asleep 
when placed upon the operating table in the majority of cases-he will 
also be analgesic-even for the skin-and will require no inhalation. 
Smythe states: Continued use of the twenty-five per cent solution, in a 
large number of cases enables me to report that the analgesic effect of 
the morphin is prolonged with equal certainty and success, as it is when 
supplemented by the subcutaneous use of the four hundred c.c. of a 
four per cent solution. 
Ether by Inhalation.-The Alkaline Synergistic Method.-The 
technique employed by Glass and Wallace 1 consists of a preliminary 
alkaline treatment of sodium bicarbonate and lactose for several days 
before operation, in order that the patient may be thoroughly saturated 
with the carbonate. Immediate pre-operative treatment is essentially 
that of Gwathmey and Greenough, w'hich consists of a hypodermoclysis 
of a 4 per cent chemically pure and sterile solution of crystalline mag- 
nesium sulphate, 200 c.c. given one and one-half hours before operation, 
and morphin sulphate, from %0 to % grain in 1.5 c.c. of a 25 per cent 
chemically pure and sterile solution of the magnesium sulphate, given at 
fifteen minute intervals, for two or three doses, starting one and a quarter 
hours before operation. The patient is then kept in a darkened place, 
and very gently removed to the anesthetizing room, where the general 
anesthetic of ether by the drop method is commenced. The patient is 
practically in a state of analgesia and the excitement stage is nil. The 
pulse usually is slow at first, rising somewhat in the second stage, but 
returning to a lower rate during the operation. There is very little 
paresis of the intestine, and there are less acidosis and nausea, with 
vomiting practically eliminated except when the gall-bladder has been 
emptied or removed. The synergistic analgesia is prolonged. The 
amount of ether used is lessened, thus reducing bronchial and renal 
irritation to a minimum and causing less acidosis. There is no disten- 
1 Glass, S. J., and Wallace, H. 8.: ' ' Pre-operative Treatment for Post-opera- 
tive Comfort." Report of Synergistic Anesthesia, Jour. A.M.A., Feb. 18, 1922. 654 
ANESTHESIA 
tion and no gas pain. There have been no deleterious results, such as 
abscess, necrosis of tissue, or laxative effect. With the alkaline syner- 
gistic method, the post-operative condition is entirely altered; there is 
an absence of gas and wound pains and no distention, which, with 
subsequent improved appetite and lessened mental depression, makes 
convalescence shorter and more agreeable. 
Technique with Ether and Oil by Colonic Instillation.-In 1921, 
Gwathmey1 employed the principle of synergism in the induction 
of analgesia and anesthesia by colonic instillation. In other words, 
he directed his efforts toward obtaining a complete brain block by 
using much smaller amounts of ether than heretofore employed and 
adding to this effect of ether the synergistic effects of the combined 
morphin and magnesium sulphate. It was found that % grain of 
morphin by hypodermic injection in 2 c.c. of magnesium sulphate solu- 
tion, given two hours before operation and twice repeated at half-hour 
intervals, is sufficient to reduce the amount of ether heretofore used in 
oil-ether colonic anesthesia. With this hypodermic dosage, perfect anal- 
gesia with unconsciousness has been obtained by the addition, colonically 
administered, of 3 to 4 ounces of ether and 2 drams of paraldehyd 
in 2 ounces of oil. This amount is amply sufficient for a two-hour 
operation. 
It depends entirely on the operation and the patient's mental attitude 
whether unconsciousness is necessary and shall or shall not be induced. 
A patient under synergistic colonic anesthesia is not in a third-stage 
anesthesia, but is analgized and unconscious, as represented in the 
accompanying chart. 
Synergistic 
Analgesia 
Danger 
Zone 
Analgesia 
A 
1st Stage 
B 
C 
2d Stage 
D 
3d Stage 
E 
F 
G 
Stages of anesthesia: A, commencement of anesthesia; A B, analgesia; 
B C, first, or excitement, stage; C D, second stage; D E, third, or surgical, 
stage-the usual stage in which operations are performed with inhalation 
anesthesia; E F, danger zone; F, respiratory arrest; G, death. 
The danger of the relaxed tongue, obstructing the airway, will be 
eliminated, and as the patient will be separated from the danger zone 
by the second and third stages of anesthesia, expert supervision will be 
unnecessary. 
1Gwathmey, James T.: "Synergistic Colonic Analgesia.'' J.A.M.A., 1921, 
76, 222-225. SYNERGISTIC ANALGESIA 
655 
RECTOR'S TECHNIQUE AND RESULTS 
In abdominal and pelvic surgery Rector 1 found that the simple use 
of magnesium sulphate, morphin sulphate and ether in combination is 
not sufficient to produce deep analgesia, and that even with the addition 
of paraldehyde, per rectum, in doses of 5i, the technique often fails in 
relieving the muscular spasm or rigidity of abdominal parietes. The 
addition of chloretone and cannabis indica given by mouth or in sup- 
positories, followed by the sigmoid instillation, give excellent results. 
After much experimental work, Rector adopted the following pro- 
cedure which has been used in over 2000 cases. 
The preliminary preparation in all cases is the same. The night 
before the operation, two soap suds cleansing colonic enemas into the 
sigmoid are given, one hour apart, i.e., 8: 00 P.M. and 9: 00 P.M.; the 
rectal tube being inserted into the bowel ten to twelve inches. The 
morning of operation the patient is given two very slow, clear water 
enemas, one hour apart, i.e., 5: 00 A.M. and 6: 00 A.M., the patient 
going to the toilet after each enema. No food or liquid is permitted 
after the supper of the night previous to operation. Two and one-half 
hours before the patient is taken to the operating room, a hypodermic 
of morphin sulphate gr. and atropin gr. Yisq is administered. Fifteen 
minutes before the giving of the instillation, a rectal tube is inserted, 
sixteen to eighteen inches, for the purpose of carrying away any fluid 
that may have collected or flatus that may be present. The patient is 
then placed upon the ward carriage and two hours before time specified 
for operation is placed upon the left side with buttocks elevated and 
lower extremities well flexed. The instillation is then thrown very 
slowly into the sigmoid bowel, the time required being about fifteen 
minutes, the tube is clamped and left in situ, to be removed only when 
the patient is placed upon the operating table. 
After the giving of the sigmoid instillation the patient, if in ward, is 
removed to an adjacent room which has been previously darkened; if in 
private room, the shades are drawn and door closed. Light is excluded 
from the eyes by covering the face with a dark colored mask, and the 
ears stuffed with cotton. Occasional attention is given to the patient 
until removed to the operating room. As much noise as possible is 
avoided at all times. Orders and necessary conversation are given in a 
low tone of voice. There may be some nausea but seldom is vomitus 
present. Before being taken to operating room, the patient is catheter- 
ized. In most instances the loss of sensation begins at the feet and 
extends upward, the patient reporting that the limbs feel heavy, and 
1 Rector, Joseph M.: 11 Synergistic Analgesia, Clinical Observations." Am. 
Jour. Surgery, Oct., 1922. 656 
ANESTHESIA 
while movement is possible, the pressure of mattress or bed clothing is 
not felt. Analgesia will increase until the patient does not feel the 
prick of a pin or the pinching of the skin. 
Formula for Instillation 
2 drains magnesium sulphate, C.P 8 gm. 
ounces glucose, pure, Merck 45 gm. 
1 ounce olive oil 30 mils 
5*4 drams acacia, granulated 22 gm. 
2 ounces ether 60 mils 
4 drams paraldehyd 15 mils 
V* gr. morphin sulphate 016 gm. 
12 ounces water, sufficient to make 360 mils 
Rub the acacia with the olive oil in a dry mortar until uniformly 
mixed. Dissolve the magnesium sulphate and glucose in 200 mils of 
water, then add at once 30 mils of this solution to the olive oil and 
acacia mixture contained in the mortar and triturate lightly and rapidly 
until a thick, homogeneous emulsion is produced. Add remainder of 
magnesium sulphate and glucose solution, in several portions, triturating 
after each addition. Transfer emulsion into a bottle of 500 mils capacity 
and successively add the morphin sulphate previously dissolved in a 
small amount of water, the paraldehyde and the ether, shaking well after 
each addition; lastly, add sufficient water to make the product measure 
360 mils. Close the bottle immediately with a well fitting cork, make 
secure with twine, and keep in a cool place.1 
The foregoing formula for instillation has been reduced by the author 
to the following, which has been found to be equally efficacious: 
8 gm. -Magnesium Sulphate 2 drams 
60 mils-Ether 2 ounces 
30 mils-Oil 1 ounce 
15 gm. -Glucose 4 drams 
22 gm. -Pulverized Acacia 6 drams 
.016 gm. -Morphin Sulphate 14 grain 
15 mils-Paraldehyd 4 drams 
210 mils-Water-sufficient to make 7 ounces 
This mixture is to be prepared in the same way as Rector's only 
using smaller amounts throughout. The only change in technique is as 
follows: Two hours before operation insert rectal tube four inches into 
the rectum and let it remain in situ for 15 to 20 minutes until all fluid 
that may have collected or flatus that may be present is expelled. Take 
15 to 30 minutes to give the instillation. 
Magnesium Content of the Blood.-St. George determined the mag- 
nesium content of the blood, following Rector's technique. The blood 
1Kinon: Jersey City Hospital Reports, 1921. SYNERGISTIC ANALGESIA 
657 
of five patients was used according to the method of Kremer and Tisdal 
(Journ. Biol. Chem., Aug., 1921, Vol. 47) at hourly intervals for a 
period of four hours. It was found that the magnesium reached its 
maximum concentration in the blood within one hour after its admin- 
istration, and thence gradually diminished, returning to normal at the 
end of four to five hours. In the five cases the normal magnesium content 
of the blood was found to average between three and four milligrams 
per 100 c.c. of serum. At the conclusion of one hour the maximum 
concentration averaged 9.5 to 10 mg. of magnesium. Two hours later 
the average was 8.5 mg.; three hours later 5.5 mg.; and four hours later 
3.9 mg. per 100 c.c. were found. 
Summary of Results.- "The pre-operative emotional factors do not 
appear, as the patient is convinced that the disagreeable effects and 
after-effects of the inhalation anesthetic will not occur. The fear, dread 
and anxiety of the operation are not present, as the patient does not 
know when he is to be taken from his bed. The exhaustive effect of 
surgical trauma is almost completely abolished, as analgesia begins one 
hour previous to operative measures, and continues for one-half to one 
hour following the return to bed. Vomiting is seldom, following return 
to consciousness; at this time cracked ice is given with no ill effects. The 
return to bed is followed by quiet, restful sleep, interrupted only by 
individual desires, or obeyance to instructions. The changes in pulse, 
respiration and blood pressure, in their respective phases are most con- 
stant in proportional difference. In 14 cases, the pulse rate at end of 
operation was lower than at the beginning. The lowest rate at beginning 
was 66; at end 60. The highest rate at beginning was 140; at end 126. 
Average rate at beginning was 96; at end 85. These cases included 
4 vaginal and 10 abdominal-vaginal, one of which was an abdominal 
hysterectomy with pulse rate at beginning 108; at end 100. In 150 
cases, three gave no change and 147 cases a variation from 2 to 20 beats. 
In the respiratory phase, 32 cases gave no change and 118 cases a 
variation of 2 to 10. 
The blood pressure was taken in 70 cases: 
Beginning of operation, recumbent, systolic lowest 100, highest 216 
" " " " diastolic " 40, " 130 
End " " " systolic " 90, " 140 
" " " " diastolic " 40, " 100 
At no time was there a drop in systolic pressure beyond 15 points, while 
the average was 10. (Rector.) 
Greenough (personal communication) studying the magnesium con- 
tent of the blood in patients receiving 16 gm. of crystalline magnesium 
sulphate subcutaneously found a curve corresponding to that of St. 
George. At the end of one and one-half hours it averaged 9 milligrams, 658 
ANESTHESIA 
two hours 9.5 mg., hours 9.1 mg., 3 hours 7 mg., 31/2 hours 
6.2 mg., 4 hours 4.6 mg., and thereafter reached the normal level of 
3 mg. 
It was also found that the analgesic and anesthetic effort was in direct 
proportion to the increase in magnesium content and that patients rising 
to 9 mg. or over required very little supplemental inhalation anesthetic. 
The most conspicuous result in using synergistic analgesia with and 
without inhalation anesthesia is the total absence of shock or exhaustion. 
TECHNIQUE WITH LOCAL AGENTS 
Lathrop 1 uses synergistic methods combined with local agents for 
the skin chiefly in cases of hernia and goiter. The following technique, 
with little variation, has now been used in over 300 cases: 
Two or three hours before operation a simple cleansing enema is 
given, then rest in bed. The type of patient determines the success of 
the method; highstrung, nervous individuals may require a few whiffs 
of ether. The stolid go through without a complaint. It is most essen- 
tial to tell the patient that the preliminary preparation he will now 
receive will not put him to sleep. One hour before operation: Hypo- 
dermic, deep in deltoid region, of morphin sulphate gr. % in 25 minims 
of a 25 per cent solution of MgS04; 45 minutes before operation: repeat 
hypodermic; 30 minutes before operation: repeat hypodermic with 
hyoscine grains %Oo added. 
Rectal instillation: ether, ounces 1 to 2, olive oil, drams 4 to 6. This 
technique is varied as follows: Only the very nervous goiter patients 
receive hyoscine, and the ether instillation. In male patients with goiter, 
or in simple goiter in women with no pronounced nervous symptoms, or 
who are not apprehensive of danger, the rectal ether instillation is 
omitted. Cover the face with a damp towel or gauze, remove to operating 
room as quietly as possible. Patient is now analgesic except the skin. 
On the table the skin is injected with apothesine or novocain solution. 
During the operation the patient may converse when asked questions. 
Ecker,2 with the idea of obtaining a safer, deeper, and more satis- 
factory anesthesia for dental surgery than had hitherto been possible 
with nitrous oxid and oxygen alone, finally adopted synergistic methods. 
A 50 per cent solution of paraldehyd and anesthol was placed in the 
ether container. Three to eight drops of anesthol was the average amount 
used with each patient. The sprinkler from the ether container of a 
TECHNIQUE FOR DENTAL SURGERY 
'Jour. A.M.A., July 10, 1920, 75, pp. 82-85. 
3 Ecker, M.: " Synergistic Anesthesia for Dental Surgery. ' ' Am. Jour, of 
Surg., April, 1921. Also personal communication. SYNERGISTIC ANALGESIA 
659 
Gwathmey apparatus was removed and a straight rod inserted. The 
gases were then passed through the tube and over the surface of the 
mixture. Over 20,000 administrations with no unfavorable results, were 
given with this technique. A theoretical objection obtains against using 
anesthol or any mixture containing chloroform. 
In carrying further the idea of synergistic anesthesia, Ecker has 
made use of ethyl carbamate (urethane). This, according to the U. S. 
Dispensatory, is one of the safest of the somnifacient drugs, but it is 
considered to be too weak and inconstant in its action on man to be of 
practical use. It occurs in crystalline form, is non-volatile, and readily 
soluble in water or alcohol. Ecker uses this drug as a synergist instead 
of anesthol. A small amount (not over half a teaspoonful) is placed in 
the container and moistened with a few drops of paraldehyd. The gases 
are now passed over the urethane in the same manner as with anesthol. 
According to Ecker, when the face mask is used, 20 to 40 seconds more 
leeway is obtained than with the gases alone, while with the nasal 
inhaler, anesthesia may be continued indefinitely. Since the urethane is 
non-volatile, and only a small quantity at most could be blown over by 
the gas current, it is difficult to understand how any appreciable syner- 
gistic effect could be obtained. But Ecker, who has used this method 
for over 20,000 administrations, is convinced that such an effect does 
occur, and in this he is corroborated by other oral surgeons. 
ADVANTAGES OF METHOD 
Table I, compiled from charts of the Presbyterian Hospital, shows 
the comparative lengths of time during which patients were comfortable 
without post-operative sedatives. 
From Table I it is proved that the patient is comfortable four times 
as long with the synergists as without them, and receives less morphin. 
With the synergists, the appetite is better on account of the absence of 
wound pain and of gas; this means a marked shortening of the con- 
valescence as well as a much more agreeable one. Without the synergists, 
there were 8 cases requiring supplementary sedatives, not including the 
first sedative, one of the cases having three repetitions. With the syner- 
gists, there were no repetitions within twenty-four hours after the 
administration of the first sedative. 
Smythe 1 employed magnesium sulphate combined with morphin and 
nitrous-oxid-oxygen (Gwathmey technique), as shown in Table No. II, 
and in another series of cases, Table No. Ill, magnesium sulphate was 
not used. When magnesium sulphate was used, a smaller quantity of 
1 Smythe, Frank D.: "Clinical Experience with Synergistic Analgesia in a 
series of Major Operations," Memphis Med. Monthly, 42:237, 1921. Also "Syn- 
ergistic Analgesia," Am. Jour. Surg., July, 1923. 660 
ANESTHESIA 
TABLE I 
Patients Receiving 25 Per Cent MgSO< (5 to 30 c.c.) 
No. 
Operation 
Sex 
Time of Post-operative 
Sedative 
1 
Direct hernia 
Male 
None 
2 
Double inguinal hernia 
Male 
32 hours 
3 
Carcinoma of rectum 
Male 
29 
4 
Carcinoma of rectum 
F emale 
28 
5 
Acute appendicitis-gen. peri- 
tonitis 
F emale 
30 
6 
Incarcerated hernia 
Male 
24 
7 
Chronic appendicitis 
F emale 
17 
8 
Acute appendicitis 
Male 
13 
9 
Carcinoma of stomach 
Male 
13 
10 
Ischiorectal abscess 
F emale 
12 
11 
Chronic appendicitis 
Male 
12 
12 
Chronic appendicitis 
Male 
12 
13 
Chronic appendicitis 
h'emale 
10 
14 
Chronic appendicitis 
Male 
5 
15 
Inguinal hernia 
Male 
4 
16 
Lacerated wound of leg 
F emale 
3 
Total elapsed time 
Average time 
244 hours 
16 hours, 16 min. 
Parallel Series of Cases without the Synergists 
No. 
Operation 
Sex 
Time of Post-operative 
Sedative 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
Ischio-rectal abscess 
Carcinoma of rectum 
Hernia 
Incarcerated hernia 
Chronic appendicitis 
Acute appendicitis 
Chronic appendicitis 
Double hernia 
Left inguinal hernia 
Chronic appendicitis 
Carcinoma of rectum 
Chronic appendicitis 
Carcinoma of stomach 
Acute appendicitis 
None 
None 
15 hours 
10 hours 
3 hours 
2 hours 
6 hours and 12 
hours 
hours and 12 
hours 
3 hours and 10 
hours 
2 hours and 14 
hours 
2 hours and 9 
hours 
hours and 8 
hours 
1 hour and 18 
hours 
V2 hour, 2, 6 and 
12 hours 
Total elapsed time 
Average time 
49%: hours 
4 hours, 6 minutes SYNERGISTIC ANALGESIA 
661 
nitrous oxid was required to maintain satisfactory unconsciousness with 
relaxation. Novocain (one-half of one per cent solution) was used in 
all cases for anesthetizing the field of operation. 
From the tables it is noted that the patients who received mag- 
nesium sulphate were comfortable more than twice as long after 
operation as those who did not receive it. Smythe further states that 
20 per cent of the patients operated upon with the aid of synergistic 
analgesia did not require a post-operative sedative; all those who did not 
receive the synergists required morphin and some of them several doses. 
There were no untoward local or systemic effects. Nausea and vomiting, 
gas pains, and gastric dilatation, were completely eliminated in some of 
the cases, and much reduced in the others. 
Weston and Howard 1 have injected 2 c.c. or more of a 50 per cent 
solution of magnesium sulphate subcutaneously or intramuscularly more 
than a thousand times with no local pain or sloughing. They state the 
sedative action occurs in fifteen to thirty minutes and lasts from five to 
seven hours, and is found to be a very good substitute for morphin and 
hyoscin. In a few instances the patient became quiet but did not sleep. 
In 82.7 per cent it was effective. In 6 per cent the dose was repeated 
before sedation occurred. In 11 per cent no effect was noted even after 
three or more doses. 
Further illustrating the value of magnesium sulphate, compared 
with other anesthetics, Burge,2 in attempting to determine how anes- 
thetics decrease oxidation, found that "Narcotics of widely different 
constitution, such as chloroform, ether, nitrous oxid, and magnesium 
sulphate, decrease the catalase of the blood parallel with the increase in 
the depth of narcosis. A very powerful anesthetic, such as chloroform, 
decreases the catalase more quickly and more extensively than does a less 
powerful anesthetic, such as ether. Slowly acting anesthetics, such as 
magnesium sulphate, decrease accordingly the catalase of the blood more 
slowly than a quickly acting anesthetic, such as nitrous oxid." 
DANGERS 
Meltzer 3 found that the heart and pulse remain normal during anes- 
thesia by magnesium sulphate, and that the danger of this agent is its 
effect on respiration; death was due in all cases to inhibition of the 
respiratory center. In saturating a patient sufficiently to produce anes- 
thesia, inhibition of the respiration is approached very closely, and the 
margin of safety is slight. But when used as a synergist with morphin, 
'Weston and Howard: "Magnesium Sulphate as a Sedative," Am. Jour. Med. 
Sciences, March, 1923, p. 431. 
a Burge, W. E.: American Year Boole of Anesthesia and Analgesia, 1917- 
1918, p. 87. 
3Meltzer, S. J.: Med. Bee., 1905, 68, 965. 662 
ANESTHESIA 
TABLE II 
Patients Receiving Magnesium Sulphate with Morphin as per 
Technique Described 
No. 
Operation 
Sex 
Time of Post-operative 
Sedative 
1 
Acute appendicitis with 
pregnancy. Ap. 
Female 
4 hours 
2 
Acute appendicitis with 
pregnancy. Ap. 
Female 
None 
3 
Appendiceal abscesses, retro- 
cecal, oophorosalpingitis 
with perforation of gut 
F emale 
13 hours 
4 
Cholecystitis with stones 
Male 
hours 
5 
6 
Carcinoma of cervix and bi- 
lateral and salpingoophor- 
itis. Panhysterectomy 
Chronic appendicitis. Bi- 
lateral laceration of cervix 
Female 
11 hours 
7 
Acute appendicitis, right- 
oophorosalpingitis, abscess 
Female 
None 
8 
Hernia, bilateral 
Male 
None 
9 
Cholecystitis 
Female 
15 hours 
10 
Fibroid tumors of uterus. 
Salpingo-oophoritis, double 
panhysterectomy 
Female 
16 hours 
Total lapse of time before sedative required after operation, 86 hours. 
Average time, 10 hours, 36 minutes. 
Parallel Series of Cases without Magnesium Sulphate 
TABLE III 
No. 
Operation 
Sex 
Time of Post-operative 
Sedative 
1 
Chronic appendicitis, retro- 
version, laceration of cer- 
vix 
F emale 
4 hours 
2 
Salpingo-oophoritis, left ret- 
roversion 
F emale 
1 hour 
3 
Chronic appendicitis 
F emale 
7 hours 
4 
Cesarean section 
Female 
7 hours 
5 
Chronic appendicitis with 
cholecystitis 
Male 
714 hours 
6 
Acute appendicitis 
Male 
4 hours 
7 
8 
Chronic appendicitis with 
adhesions to gall bladder 
Acute appendicitis 
Female 
I2V2 hours 
9 
Appendicitis 
Male 
3y2 hours 
10 
Chronic appendicitis 
Female 
3 hours 
Total lapse of time before sedative required after operation, 52 "hours 
and 30 minutes. 
Average time, 5 hours and 30 minutes. SYNERGISTIC ANALGESIA 
663 
and nitrous oxid and oxygen, or ether, the respiration is actually in- 
creased. When 200 to 400 c.c. of 4 per cent solution by hypodermoclysis 
is used, the respirations average 20. (The normal adult's respirations 
average 16 to 19 per minute.) In only exceptional instances have the 
respirations been lowered, while with all methods the pulse remains 
normal. 
The danger with the synergists lies, not in the possibility of imme- 
diate death, but in the probable masking of all symptoms of shock. 
MORTALITY 
Curtis 1 reports a death with symptoms of acute poisoning, following 
the use of 310 c.c. of a 4 per cent solution of magnesium sulphate as a 
synergist. He states that post-mortem examination showed profound 
changes in the liver, and that the changes were such as have been ob- 
served in liver tissues when death has resulted from an anesthetic. 
There were persistent nausea and repeated vomiting, increase in the 
pulse rate, jaundice and moderate elevation of temperature and breathing 
"labored." 
We do not agree with Curtis as to the cause of death in his case. In 
support of this contention we refer to Meltzer's observations cited above. 
Also laboratory animals, when given a lethal dose of magnesium sulphate, 
are never distressed by persistent nausea and vomiting, nor is the breath- 
ing, in man or animals, ever "labored." In magnesium sulphate intoxica- 
tion, after subcutaneous injection, the respiration gradually slows, 
becomes shallow, and finally ceases while the heart still beats. Anderson 2 
observed in two cases of poisoning by magnesium sulphate that the 
breathing was slow and deep and scarcely perceptible. There was no 
jaundice in these cases. 
Hyperglycemia and sometimes glycosuria are caused by all of the 
anesthetics, nitrous oxid, chloroform, ethyl chlorid, and ether, by the 
intravenous injection of fairly concentrated salts, and by anything tend- 
ing to produce tissue asphyxia. 
"Intravenous injections of magnesium salts cause a considerable 
hyperglycemia with only a mild glycosuria (Kleiner and Meltzer); it is, 
however, a merely temporary phenomenon and is no contraindication to 
the use of magnesium salts." 3 
Profound changes in the liver do not occur in laboratory animals even 
when given in sufficient volume to kill the animal. 
1 Curtis, Arthur T: " Magnesium Sulphate Solution as an Acid in An- 
esthesia," J.A.M.A., 1921, 77, 1492. 
2 Anderson, W. W.: " Magnesium Sulphate Poisoning in Children, ' ' Georgia 
M.A.J., 1921, 10, 826. 
3 Jour. A.M.A., March 25, 1916, 66, 931-934. 664 
ANESTHESIA 
This last statement is based on Meltzer, Auer and their associates' 
work with magnesium sulphate for over thirteen years, during which 
time no liver changes were noted. Also Boos 1 reports a number of cases 
in which magnesium sulphate was given in large dosage as a laxative 
but for various reasons failed to "come through," consequently was 
absorbed and produced magnesium sulphate poisoning. Autopsies were 
held, evidently with negative results, except in one case that received a 
total of seven ounces of the salt. In this case, "the kidneys suggested a 
toxic substance." The finding by Curtis (if correct) of any amount of 
magnesium sulphate in the liver would by no means indicate death as a 
consequence. 
Probably the first fatal case with the synergists was my own. This 
patient was anesthetized three different times; age 50 years with a 
history of soft chancre 25 years previously, and a four plus Wassermann, 
but in good condition with the exception of carcinoma of the tongue for 
which he came for operation. 
May 26, 1921-the first operation, glands of neck. 
1 p.m. Chloretone supposity grs. xx 
Morphin sulphate grs. 3/8), , 
Atropin sulphate gr. 1/100 J 
1:20 MgSCh 4% -400 c.c. hypodermoclysis. 
1:30 Paraldehyde 3 drams I 
Ether 2 ounces/ by rectum 
Oil 1 ounce | 
2 :30 Operation-had to supplement with anesthol throughout, 
but satisfactory otherwise. Irrigation and hot coffee per 
rectum afterwards. 
5 :30 Returned to bed in good condition. 
10:00 Complained of pain 10 p.m.- hours after operation. 
Uneventful recovery. 
June 1, 1921-second operation. 
Medication same as before except increase in morphin* gr. 
V2 (instead of %) and ether 3 ounces (instead of 2). 
Two hour operation. Complained of pain seven hours 
later. Convalescence as usual. 
June 18, 1921-third operation. 
Medication same as last operation, except increase in ether 
to four ounces. 
2 hours and 45 minutes operation. Pulse 116. Respiration 
24. Died four hours later. No autopsy. 
Comment.-This patient evidently died from the increase of ether to 
four ounces, as no untoward effects occurred after the two previous 
operations, the magnesium sulphate remaining the same in each opera- 
tion. The lid re-flex was absent after the third operation. In my opinion 
this patient could have been saved at any time within the four hours by 
a normal saline given intravenously, and oxygen by inhalation. Four 
hundred c.c. of a 4 per cent solution of magnesium sulphate sub- 
'Boos: Journal A.M.A., Dec. 10, 1910, 55, No. 24, 2039. SYNERGISTIC ANALGESIA 
665 
cutaneously, and four ounces of ether by rectum is a dangerous dose. 
Four hundred c.c. of a 4 per cent solution of magnesium sulphate and 
three ounces of ether is the maximum safe dose. Four hundred c.c. of 
a 4 per cent solution of magnesium sulphate and two ounces of ether per 
rectum is a safe preliminary for the average adult. 
INDICATIONS 
Synergistic analgesia and anesthesia are especially indicated for the 
insane, the neurotic, and in plastic and orthopedic surgery. 
CONTRA-INDICATIONS 
Theoretically, any kidney disease would contraindicate the use of 
magnesium sulphate.1 
CONCLUSIONS 
(1) Magnesium sulphate when combined with nitrous oxid and 
oxygen (or ether), by its synergistic action, decreases the amount of 
anesthetic agents necessary to produce anesthesia. 
(2) When morphin in sterile water is given as a preliminary to 
any inhalation anesthetic, the analgesic effects obtained during induction 
almost entirely abolish the stage of excitement; by using magnesium 
sulphate with morphin, the morphin effect is retained during the time 
the patient is emerging from the inhalation anesthesia, and nausea and 
vomiting are eliminated, as a state of analgesia still exists. Wound and 
gas pains are likewise reduced to a minimum, and quite often are entirely 
eliminated; post-operative shock is reduced, and relaxation is as satis- 
factory as with the administration of ether. 
(3) If magnesium sulphate were used for no other purpose than 
the prolongation of the effects of morphin, its revival would be fully 
justified. 
1Note: The maximum amount routinely used for synergistic anesthesia is six- 
teen grams (two drams). The smallest amount as related by Boos, in which death 
occurred was over thirty-one grams (one ounce), over twice the amount given 
for synergistic anesthesia. One and a half ounces were given a child three and 
a half years old, with poisoning and recovery. A child of 15 was poisoned with 
one ounce of the salts, but recovered. CHAPTER XVIII 
THERAPEUTIC USES OF INHALATION ANESTHETICS 
Anesthetic Treatment for Special Conditions : In Renal and 
Biliary Colic; In Acute Pain or Shock; In the Passage of Renal or 
Biliary Calculi; In Extreme Irritability of the Central Nervous System; 
Convulsions of Infancy and Childhood; Puerperal Eclampsia; In 
Anemic Convulsions; Convulsions and Seizures Depending Upon Poi- 
soning, and Cerebral Diseases; Use in Diagnosis; Insomnia or Extreme 
Restlessness; Acute Mania; Nitrous Oxid and Oxygen; Some Miscel- 
laneous Applications of Ethyl Chlorid. 
Other Uses of Agents Employed in the Administration of An- 
esthetics: Ether in the Treatment of Infections; Ether Irrigation of 
the Abdomen. 
ANESTHETIC TREATMENT FOR SPECIAL CONDITIONS 
Anesthesia has been used sporadically and, in some few instances and 
localities, regularly for special conditions or for diseases not yielding to 
surgical operations. 
In Renal and Biliary Colic.-In renal and biliary colic and for 
similar acutely painful seizures it has been used with great success. 
Now that the analgesic stage of all anesthetics, especially of nitrous 
oxid and oxygen, is more clearly recognized, it is probable that anes- 
thesia will be used more frequently than ever before for conditions just 
stated and for similar conditions. A patient in an acute seizure of 
renal colic, who might seriously object to being anesthetized to the sur- 
gical stage, would embrace the opportunity of the analgesic stage of any 
anesthetic. 
In Acute Pain or Shock.-In cases of acute pain or shock it is used 
for temporary relief, not with the idea of curing, but simply to afford 
time for recovery to take place without pain. When anesthetics are 
given for the analgesic qualities alone they should be employed only 
under the direct supervision of a physician. If cyanosis or unconscious- 
ness appear, the agent should be withdrawn, to be reapplied again solely 
for the relief of pain. 
666 THERAPEUTIC USES OF INHALATION ANESTHETICS 
667 
In the Passage of Renal or Biliary Calculi.-In the passage of renal 
or biliary calculi, chloroform or ether by the drop method on gauze or 
a handkerchief affords speedy relief; also in the crises of locomotor 
ataxia. 
In Extreme Irritability of the Central Nervous System.-Wher- 
ever extreme irritability of the central nervous system exists, as in 
tetanus, strychnin poisoning, or convulsive affections, chloroform to the 
second stage will easily relieve suffering without affecting the conscious- 
ness. Hewitt records one case of a child kept more or less under the in- 
fluence of chloroform for thirteen days, one hundred ounces being used. 
It is necessary to administer the anesthetic only to the point where mus- 
cular spasm subsides, when it is discontinued. The anesthetic is to be 
reapplied only when tetanic spasm is imminent. If the rigidity is con- 
tinuous the administration must be maintained until signs of the rigid- 
ity disappear. 
It is unnecessary to state that, except in the presence of urgent indi- 
cations, these agents should not take the place of morphin or opium. 
When, despite the use of morphin or opium, acute pain persists, chlo- 
roform or ether may be administered for short periods to supplement the 
action of these drugs. 
Convulsions of Infancy and Childhood.-Convulsions of infancy 
and childhood are easily and safely treated with pulmonary anesthetics, 
administered to the analgesic stage. Ethyl chlorid is preferred, because 
its analgesic stage is longer than that of any other inhalation anes- 
thetic, and because it is the preferable anesthetic for children, in the 
opinion of many anesthetists. 
Puerperal Eclampsia.-Chloroform has been used for a number of 
years for puerperal eclampsia. Care must be taken, however, if the pa- 
tient is cyanosed. In these cases ether is the safest drug. 
In Anemic Convulsions, Convulsions and Seizures Depending Upon 
Poisoning, and Cerebral Diseases.-In anemic convulsions, convulsions 
and seizures depending upon poisoning, and cerebral diseases it is better 
to use nitrous oxid and oxygen, with a nasal inhaler, for the analgesic 
effect than to use chloroform or ether, especially chloroform, inasmuch 
as these latter drugs in themselves sometimes, under certain conditions, 
induce serious after-effects. 
Use in Diagnosis.-General anesthesia is frequently employed to 
produce muscular relaxation where diagnosis of certain conditions is 
doubtful. The selection of the anesthetic in these instances would de- 
pend upon the conditions already stated. Unless contraindicated, 
nitrous oxid and oxygen is the best agent for such conditions as "hys- 
terical contractions," phantom tumors, and malingering. 
Insomnia or Extreme Restlessness.-In insomnia or extreme rest- 
lessness morphin and similar drugs are often ineffectual. The patient 668 
ANESTHESIA 
may be in such a condition that the usual measures necessary to pro- 
duce a quiet state, such as warm baths, massage, etc., cannot be used 
except to very great disadvantage. Under these circumstances it is per- 
fectly justifiable to produce anesthesia and to inaugurate the necessary 
remedial procedures. Mortimer 1 treated a vigorous man who had had 
no sleep for many days and nights in spite of various hypnotics. The 
anesthetic was administered, and the patient remained asleep for four 
hours. By giving a little more anesthetic at longer intervals the patient 
remained asleep for two hours longer. The rest of the night he re- 
mained quiet instead of wandering about. The next morning he was 
rational, had a bath, and ate a good breakfast. He slept most of the 
day and the following night, awakening quite recovered on the second 
morning. 
Acute Mania.-In cases of acute mania, either temporary or recur- 
rent, if the condition is apparently dependent upon no perceptible or 
CODE! RESP.-o- B. P. ++•++TEMP.-PULSE--o-- 
Fig. 279.-Anesthesia in a Case of Acute Mania. 
organic lesion, it would seem, theoretically at least, that general anes- 
thesia would,-in connection with other remedies before, during, and 
after,-tend to lessen or shorten the usual period in which the patient 
may have to be confined. 
Anesthetics may be given with less danger for therapeutical pur- 
poses than when surgical interference is necessary. 
The first case, as far as we are aware, in which an anesthetic was 
given for the definite purpose of attempting to affect favorably the 
brain cells without injuring the body occurred at the instigation of one 
of us (J. T. G.) in March, 1912, Dr. Swepson J. Brooks and Dr. T. 
Drysdale Buchanan associated. The case was one of mania of ten or 
twelve years' standing. It is given in full to show that a patient may be 
'Mortimer, J. D.: Brit. Med. J., Jan. 7, 1899. THERAPEUTIC USES OF INHALATION ANESTHETICS 
669 
successfully and easily anesthetized for a number of hours without com- 
plications or shock resulting therefrom. The case is suggestive of great 
possibilities in psychiatry, and is given here primarily for that reason. 
The patient was in full surgical anesthesia at 10 o'clock, and the 
anesthetic was discontinued at 4:30 p. m., the patient being practically 
under the anesthetic for six and one-half hours. The result was entirely 
negative, as far as affecting the patient's condition favorably. It was 
satisfactory from an anesthetic standpoint. The patient came out of 
the anesthesia, and was entirely rational, with absolutely no unpleasant 
symptoms of any kind. The temperature, pulse, respiration, and blood 
pressure were taken at regular intervals, and the chart (Fig. 279) 
shows the result. The narcosis was started with one-quarter of a grain 
of morphin with l/150th grain of atropin at 9 o'clock. The pulmonary 
anesthesia was commenced with chloroform at 9 :55 by the drop method, 
Hour 
Temp. 
Pulse 
R.esp.1 
B.P. 1 
Sleep! 
Stim. 
Medicine 
Nourish- 
ment 
Remarks 
A.M. 
8 - 
(Enema): 
Saline Glucose " i 
M. 1 
(per Hypo): 
Morph. Sulph. gr. | 
Atrop. gr. jja 
9.30 
Heart normal on ex- 
amination. 
9.55 
99.2 
108 
150 
Chloroform administer- 
ed (drop). 
10.05 
76 
10.15 
Ether administered 
10.20 
90 
(drop). 
Oxygen & Ether ad- 
ministered (vapor). 
10.25 
120 
10.30 
96 
24 
10.34 
96 
24 
11.- 
11.08 
96 
24 
110 
11.20 
Slight snore--lid reflex 
-pupil slightly dil. 
11.30 
-eyeballs rolling. 
96 
24 
110 
Slight perspiration- 
breathing easy. 
11.45 
99.8 
96 
24 
98 
Pt. warm but not per- 
12.15 
100 
spiring. 
..... 
96 
24 
Slight perspiration- 
eyeballs rolling. 
12.30 
102 
24 
100 
12.45 
102 
24 
loot 
do. 
P.M. 
100 
do. 
1.- 
102 
24 
1.15 
96 
24 
100 
do 
1.30 
96 
24 
115 
do. 
1.45 
96 
24 
112 
2.10 
. • • . . 
102 
30 
114 
2.20 
96 
30 
114 
2.40 
. • • . • 
112 
24 
112 
(Enema): 
Olive Oil 
3.10 
96 
116 
Massage-Alcohol rub. 
3.40 
3.45 
108 
30 
Catheterized- 5 >x 
4.00 
99.8 
108 
30 
114 
Slight perspiration. 
4.15 
108 
30 
120 
4.30 
100 
102 
24 
118 
Ether discontinued. 
4.45 
120 
30 
120 
1 
Amt. Ether used 5 ix 670 
ANESTHESIA 
and was gradually changed to ether by the drop method. At 10 o'clock 
the patient was in full surgical anesthesia, and at 10:25 oxygen and ether 
by the vapor method were substituted. This was continued to the end. 
In acute mania or other mental condition the alimentary canal 
should be thoroughly evacuated, and when the patient is under the 
anesthetic lecithin, olive oil, and saline should be continuously admin- 
istered with the idea of having enough lecithin absorbed to affect the 
brain cells favorably. The patient should be given enough morphin 
toward the close of the pulmonary anesthetic to continue sleep, so that 
he will awake in as nearly a natural manner as possible. The table on the 
preceding page and chart (Fig. 279) show the result of this anesthesia. 
Nitrous Oxid and Oxygen.-Under the influence of nitrous oxid 
with 20 per cent oxygen, Klikowitsch 1 found in the majority of healthy 
individuals accelerated cardiac contractions, diminished pulse waves, 
rarer and deeper inspirations. In cases of weakened heart action an 
unfavorable influence upon the heart not only failed to occur, but a 
favorable effect was actually demonstrable. The cardiac contractions, 
while somewhat diminished in number, were increased in efficiency. 
For these reasons, as well as on account of the beneficial influence on 
attacks of angina pectoris, on vomiting and cough of reflex origin, Kli- 
kowitsch employed nitrous oxid for therapeutic purposes. 
Some Miscellaneous Applications of Ethyl Chlorid.2-To Differ- 
entiate Between a Neuralgia of Central and One of Periph- 
eral Origin.-The theory is that if the lesion be central no inter- 
ference along the course of a centripetal nerve will alter its manifesta- 
tion; while if the trouble is with terminal nerves, when communication 
between the periphery and the centers is cut off, all pain will disappear. 
The method is to freeze the tissues between the apparent lesion and 
the spinal canal or cranium either by freezing, as done for local anes- 
thesia, or by "reinforced freezing," i. e., by injecting a quantity of dis- 
tilled water beneath the skin over the part to be frozen or directly into 
the tissue until an appreciable bulging is produced, and then directing 
the spray of ethyl chlorid on this spot. The water will become ice, 
and the deeper tissues will be frozen or thoroughly chilled. "Coin" 
freezing is accomplished by placing a coin of suitable size and wet with 
water on the skin and spraying ethyl chlorid on it, when "a congelation" 
less severe than reinforced freezing, more severe than ordinary cutaneous 
congelation and one more accurately localized is obtained. 
To Differentiate Neuritis from Neuralgia.-"Neuralgia of an 
accessible nerve treated by freezing near its point of exit and failing to 
yield to repeated applications of the spray is not a veritable neuralgia, 
but a neuritis or a complicated neuralgia." 
1 Quoted by Brunn: "Die Allgemeine Narkose, " 1913, 325. 
'Abrams: Am. Med. Surg. Bull., Dec. 15, 1895, 1487-1490. THERAPEUTIC USES OF INHALATION ANESTHETICS 
671 
As a Means of Localizing Pain.-If the area of pain is large, or 
there are many painful points, the pain will not cease until the exact 
spot of origin is frozen. In this way Abrams has discovered out of 
many cicatrices the one causing pain, a small neuroma, and a carious 
tooth not otherwise suspected. 
To Diffeeentiate Many Neuralgic Affections of the Head 
and Thoracic and Abdominal Parietes from Visceral Diseases.- 
For this freezing is usually necessary along the intercostal nerves at 
their exit from the vertebrae. In this way symptoms that have been or 
could be interpreted as disease of some viscus have been referred to their 
true origin. 
OTHER USES OF AGENTS EMPLOYED IN THE ADMINISTRATION 
OF ANESTHETICS 
Reference (Chapter II, p. 91) has been made to the use of vari- 
ous agents which have been found, from laboratory experimentation 
and clinical experience, to modify the action of inhalation anesthetics. 
Reference will be found in Chapter XV, p. 598, to the use of ether 
as an antidote to the various agents employed for purposes of spinal 
analgesia. 
Ether in the Treatment of Infections.-We come now to the con- 
sideration of ether in the treatment of various infections. While this 
may be said to be apart from the subject of anesthesia, it has a practi- 
cal bearing with which the anesthetist should be familiar. 
Souligoux1 has habitually and successfully employed ether in the 
treatment of peritoneal infections. He was led to this in 1891 by the 
following observation: In his service as an interne, with Leport, he was 
in charge of a man, both of whose legs had been crushed by a heavily 
loaded truck. The legs were reduced to a mass with crushed bones, which 
protruded from the midst of the large wounds, and there seemed nothing 
left but a double amputation at the thigh, to which the patient refused 
to submit. Souligoux carefully cleansed the wounds and poured in a 
liberal supply of ether, after which the two legs were put up in plaster. 
To his extreme astonishment, no infection occurred, and the patient's 
legs were preserved. He believed this to be due to the ether, which is 
very volatile and which had penetrated into all the corners and irregu- 
larities of the wounds, thus permitting their disinfection. Since that 
time he has washed all wounds with ether, and employs ether also for all 
superficial infections, lymphangitis, erysipelas, etc. 
Mode of Application.-The mode of application is as follows: In 
i Souligoux: "Sur 1'emploi de 1'ether dans les infections," Bull, et Mem. 
Soc. de Chir. de Paris, Feb. 25, 1913, No. 7, 293. 672 
ANESTHESIA 
a case of lymphangitis of the arm, for example, the limb is carefully 
washed with water and soap, as if to prepare for operation. After the 
skin has been wiped dry the entire affected region is wrapped in 
bandages, on which a liberal supply of ether is poured. The part is 
then wrapped in oiled silk, which is held in place with straps, which are 
tightened at the two extremities of the dressing, so that the ether can 
only evaporate slowly, and, to guard still further against evaporation, 
the limb is surrounded with a thick layer of non-absorbent cotton. 
Results Obtained.-The results obtained with this treatment are 
excellent, according to Souligoux, who has been able to obtain many 
cures in eases of grave infections. Ether has been employed by him in 
this manner in several hundreds of cases, always with commendable re- 
sults. 
Ether Irrigation of the Abdomen.-Since 1891 he has introduced 
ether into the peritoneal cavity of guinea-pigs without harm. He did 
not venture to experiment in this way upon man, however, until 1912. 
This was done under the following conditions: In July he was called 
to see a patient who for eight days had suffered from intestinal obstruc- 
tion, with entire arrest of feces and gas, and stercoral vomiting. On 
the sixth day a laparotomy was performed for making an artificial anus. 
The iliac incisions were followed by the escape of gas and fecal matter 
from the abdomen, showing the existence of a perforation of the intes- 
tine, which required closure. Median laparotomy was performed. The 
abdomen was filled with fecal matter and gas; the bloated coils were 
covered with false membranes, and, after a prolonged search, a perfora- 
tion was found on the cecum, the size of a quarter. This was closed. 
Regarding the patient as doomed, remembering his experience with ether 
in 1891, and being aware of Morestin's frequent employment of ether 
in abdominal operations, Souligoux poured ether into the abdomen, 
upon the coils, into the small pelvis,-in other words, applying a thor- 
ough irrigation of the abdomen with ether. After careful wiping two 
drains were placed, one toward the small pelvis, the other toward the 
upper portion of the abdomen. 
To the great surprise of Souligoux, the patient made a good recov- 
ery, and he has since made free use of ether, with excellent results, in all 
abdominal interventions associated with pus. 
Marcille, according to Souligoux, followed the same procedure in sur- 
gical cases, as a routine method. The following is a summary of his ob- 
servations. 
Clinic Cases.- (1) Six patients, operated upon, with peritoneal 
infection, through ruptured tubal pregnancies. In each instance the 
peritoneum of the small pelvis and the affected coils of intestine were 
wiped off with ether-soaked bandages. He obtained six cures. 
(2) Seventeen patients, operated upon, with strangulated hernia. THERAPEUTIC USES OF INHALATION ANESTHETICS 
673 
In each instance the coil was washed with ether. All the patients heard 
from were cured. 
(3) Three patients, operated upon, with abdominal wounds and 
contusions, (a) Contusion, at 9 a. m. Operation, at 10 p. m. A per- 
forated coil, turbid fluid in peritoneal cavity, found. Copious ether irri- 
gation. Drainage. Cure. (b) Knife wound of abdomen, operated 
upon in third hour. A divided coil, a small perforation of another coil, 
two wounds of mesentery, found. Copious ether irrigation. Drainage. 
Cure, (c) Case of frightful abdominal traumatism, the individual be- 
ing practically cut in two, the wound extending from Scarpa's triangle 
on the right side to the left iliac fossa. Repair of the numerous vascu- 
lar and visceral wounds. Irrigation with ether. Death during the 
night. 
(4) Three cases of general peritonitis, operated upon. Ether; free 
drainage. Two cures; one death. 
(5) Infarct of entire large intestine and two meters of small gut, 
all contained in an enormous eventration. Operation. Part of these coils 
were gangrenous; stercoral abscesses had formed. Resection of the en- 
tire mass contained in the eventration, involving the entire large intes- 
tine as far as the iliac flexure, and two meters of the small intestine. 
Free ether irrigation. Reestablishment of intestinal functions; gas and 
stools. Good pulse next morning. Death from syncope after thirty-six 
hours. 
(6) Rupture of stomach, through ulcer. General peritonitis, with 
large amount of purulent fluid, false membranes in intestine found 
upon operation. Suture of the perforation. Free ether irrigation. 
Drainage. Cure. 
(7) Compound fracture of forearm bones. Badly soiled wound. 
Washed with ether, and sutured without drainage. Healed by primary 
union. 
Observations.-It appears, from the sum-total of these observa- 
tions: (1) That irrigation of the peritoneal cavity with ether is in no 
way injurious. In all the cases where Souligoux employed it he noted 
that the coils of intestine became pink, and contracted under the action 
of the ether; (2) that this irrigation seemed to have a powerful action 
as a disinfectant of the peritoneum. 
In the discussion of Souligoux's paper Cuneo stated that ether dress- 
ings, according to the technique of Souligoux, had been employed by 
him in cases of lesion of the extremities, usually lesions of an inflamma- 
tory character, such as panaris, phlegmons, etc. Excellent results were 
obtained by this method. On the other hand, the idea of pouring ether 
into the peritoneum did not appeal to him. The observations of Souli- 
goux did not seem to him to be demonstrative, and the cures appeared 
to be especially referable to the timeliness of the intervention. The sup- 674 
ANESTHESIA 
pression of the cause of complications was a factor in the success. The 
question of drainage he regarded as secondary in itself. He had be- 
come convinced of this by obtaining a considerable proportion of cures 
in general peritonitis of appendicular origin, through the simple abla- 
tion of the appendix, and closure, without drainage. There is nothing, 
in his opinion, to permit the claim that in the observations of Souligoux 
the cure was due to the irrigation of the peritoneum with ether. 
Souligoux, in replying to the remarks of Cuneo, said the latter had 
not well understood the observations described. He reiterated some of 
the details of the case of obstruction of eight days' standing. The per- 
foration, he said, may be assumed to have coincided with the severe pain 
which was felt at this time. There was an inundation of fecal matter 
and gas in the abdomen. He had had so little confidence himself in 
the recovery of the patient that when he saw her in the evening he be- 
lieved he had made a mistake in the room, and left without speaking to 
her. On learning of his mistake he returned, finding the woman in fairly 
good condition. He was unable to believe that her recovery was en- 
tirely independent of the ether. He was convinced, from his observa- 
tions, that ether is not only harmless, but may be very useful in the 
treatment of peritoneal infections. 
Treatment of Pertussis with Oil-ether Injections.1-Four cases were 
treated by the high rectal injections of 6 c. c. of a 40 per cent ether 
solution in olive oil. The injections were repeated every six hours. Two 
of these patients stopped coughing quite promptly, and two failed to 
respond. This method was employed in order that the treatment might 
be carried out at home; and, if a larger series proves its efficacy, it will 
make it much simpler of use. 
It is quite obvious that the earlier the treatment is instituted, the 
greater the possibility of good results. 
1 Mason, Cleon C., J. A. M. A., 81: 2115, 1923. CHAPTER XIX 
THE MEDICO-LEGAL STATUS OF THE ANESTHETIST 
John W. H. Crim 
Introduction : Police Power; The Medical Profession Established; 
Contest Between the Schools of Medicine; The Status of the Physician. 
The Physician's Liability: Ethical Liability of the Physician; 
The Civil Liability of the Physician; Malpractice; Liability of the Spe- 
cialist; The Criminal Liability of the Physician; Gross Ignorance or 
Negligence; Statutory Liability. 
INTRODUCTION 
An examination of the vast number of decisions of the higher courts 
of the several States of the United States discloses the fact that the 
discovery and use of anesthetics 1 by the medical profession have had 
little or no effect upon the well-established principles of medical juris- 
prudence, and the profession of the anesthetist, of inestimable im- 
portance to the medical profession, and consequently to society in gen- 
eral, has found no place either in our courts or legislatures. At the 
outset it may be said that only those having qualifications of a physi- 
cian 2 or dentist should be permitted to administer anesthetics; that 
it should be made a penal offense in every State for any person other 
than a legally qualified medical or dental practitioner to administer 
either a general or local anesthetic or a drug for the purpose of produc- 
1 That which produces insensibility to pain: State v. Baldwin, 36 Kan., 1. 
2 The term ' ' physician ' ' is here used in a broad sense, including all who are 
lawfully engaged in the practice of medicine: Harrison v. State, 102 Ala., 170. 
At one time the term "physician" was employed in contradistinction to that 
of ' ' surgeon, ' ' but the modern use of the term includes those who perform surgery 
as well: Alison v. Haydon, 4 Bing., 619; Wetherel v. Marion County, 28 Iowa, 
22; Little v. Sliker, 33 N. J. L., 507; Matter of Hunter, 60 N. C., 447. 
The term "Physician and Surgeon" is not limited to any one school of prac- 
titioners: Raynor v. State, 62 Wis., 289. 
Osteopaths hardly come within this classification, unless they have pursued suc- 
cessfully an accepted course of study in medicine. For statutory definitions of 
above terms, see Public Health Law New York, 1909. 
675 676 
ANESTHESIA 
ing a state of unconsciousness during any medical, surgical, or dental 
operation. Dentists should be permitted to administer such anesthetics, 
general and local, as are necessary in the practice of dental or oral 
surgery and medicine, and should not be permitted to give either a local 
or general anesthetic in other medical or surgical operations or during 
childbirth. To determine the fundamental responsibility of an anes- 
thetist, one must look to the general principles of law which apply 
to the physician in the ordinary practice of his profession, with this ex- 
ception: the practitioner holding himself out to the public as an anes- 
thetist is properly considered a specialist, and is therefore held to a 
commensurately higher degree of skill and learning, in so far as the 
administration of anesthetics is concerned, than the ordinary practi- 
tioner.1 It will therefore suffice, for the purposes of this chapter, to 
indicate the general principles which define the duties of the physician 
with regard to his ethical, civil, and criminal responsibility, and to dis- 
1 In this place it is appropriate to insert a summary of views relative to the 
training and status of the anesthetist. 
Hellman (N. Y. Med. J., 95, No. 22, 1146) considers that no one without a 
medical training can ever become an expert anesthetist, and that nurses, sisters 
of mercy, and others should be excluded from general anesthetic work. The ad- 
ministration of anesthetics is legally medical practice, and as such may be han- 
dled only by graduate physicians in New York. 
However, we may point out that instruction in the practical administration of 
anesthetics should be a requisite part of the regular medical and dental courses. 
On the training required by the anesthetist, see the discussion in J. Am. Med. Assn., 
52, No. 20, 1614-5; and on the teaching of anesthetics, see an earlier paper, 
ibid., 51, No. 14, 1167. 
Chipman (Ya. Med. Semi-Mon., 15, No. 12, 278) discusses the general signifi- 
cance of the term "anesthetist." In the "paid anesthetist system," the anes- 
thetist gives all anesthetics, in private cases receiving remuneration from the pa- 
tient, directly or indirectly, while with ward cases he either administers himself 
or has an interne give the anesthetic under his direction, and for these cases he 
receives no compensation. This system, Chipman maintains, is a long-delayed 
need. He considers that the trained anesthetist should play a very large part in 
reducing the death rate to a minimum. 
"The Trained Anesthetist" has been discussed by Porter. (Lancet-Clinic, 
103, No. 25, 641.) He thinks that the administration of anesthetics should only 
be done by the trained man and that he should be an expert. He goes on to say: 
"Surgeons should insist upon having a trained anesthetist for all operations. 
. , . The anesthetist's work is the equal of any other special line of work." 
Abernethy (Southern Med. J., 3, No. 8, 489) has treated of the anesthetist 
as a specialist. In the administration of a general anesthetic the exercise of 
judgment and skill is necessary, and this can only be obtained through special study 
and experience. As much care should be exercised in the administration as in the 
performance of an operation; and the anesthetist should have, and does have in 
properly regulated cases, as much responsibility as the surgeon. 
On the general practitioner as an anesthetist, see Moriarta: J. Am. Med. 
Assn., 53, No. 10, 768; and, on the professional anesthetist, consult Metzenbaum: 
Ohio State Med. J., 6, No. 3, 124. THE MEDICO-LEGAL STATUS OF THE ANESTHETIST 
677 
cuss, in appropriate places, the legislation and decisions pertaining to 
the administration of anesthetics by physicians, surgeons, anesthetists, 
and dentists. 
Police Power.-The application of the principles of law to the 
relations between physician and patient has its source in the right of 
society to prescribe rules of human conduct which conduce to the gen- 
eral welfare, that is, the police power inherent in sovereignty; accord- 
ingly, it is to the police power of a State 1 that society looks for protec- 
tion from ignorance, superstititon, and quackery in the medical profes- 
sion. The limitation upon legislatures in enacting statutes for the pur- 
pose of regulating the practice of medicine is measured by the extent of 
the police power; and, conceding that the protection of public health is 
of vital importance in modern government, a most casual examination 
of the early legislation, or the want thereof, reveals the inadequacy, as it 
were, of the ancient forms of government in this respect. For example, 
we are told that, under the Roman civil law and the English common 
law, the right to practice medicine and surgery was free to all persons.2 
It is therefore not surprising to learn that the barber 3 and the priest 4 
were relied upon to "heal the ill." Speculation upon the inadequacy 
of a government which permitted such a condition receives additional 
interest in the fact that the barber and priest could not sue and recover 
for their services-a cardinal privilege of the twentieth century practi- 
tioner, not only from the standpoint of sustenance, but because a judg- 
ment in his favor for services rendered is an estoppel to a civil action 
against him for malpractice; conversely, proof of malpractice is a de- 
fense to an action for professional services.5 Custom precluded the prac- 
titioner from making a specific charge for his services, and required him 
to accept whatever compensation, or honorarium, as it was then called, 
his patient chose to pay. The inevitable result of the conditions fostered 
by these customs prompted Parliament to pass a statute during the reign 
of Henry V. (1422), which, under a penalty of both fine and imprison- 
ment, prohibited anyone "using the mysterie of physyck unless he hath 
studied in some university and is at least a bachelor of science." 
The Medical Profession. Established.-Following this legislation by 
1 See Com. v. Gibson, 7 Pa. Dist. Rep., 386; Com. v. Finn, 11 Pa. Sup. Ct., 620; 
Matter of Campbell's Registration, 197 Pa., 581; Dent v. W. Va., 129 U. S., 114; 
Reetz v. Mich., 188 U. S., 505. 
2 Denton v. State, 21 Neb., 445; State v. Morrill, 7 Ohio Dec., 52; State v. 
Carey, 4 Wash., 424. 
3 Allison v. Haydon, 4 Bing., 619. On the low state of surgery in the Middle 
Ages, see Kottelmann: " Gesundheitspflege in Mittelalter, " 1890, 216. 
4 Baas: ' ' Gesehichte der Mediein, ' ' 204; von Raumer: ' ' Hohenstaufen, ' ' 6, 
438; Fort: "History of Medical Economy During the Middle Ages," 1883, 
chaps, xiii and xviii. 
s Abbott v. Mayfield, 8 Kan. App., 387. 678 
ANESTHESIA 
Parliament, the practice of medicine savored of a profession; but it was 
not until Parliament enacted the well-known act of Henry VIII.,1 
which denounced the medical profession as "ignorant persons who could 
tell no letters on the book, common artificers, smiths, weavers, and 
women, who took upon themselves great cures, partly using sorcery and 
witchcraft, and partly applying very noxious medicines to the disease," 
that it became a well-defined and established profession. With this cloak 
of legislative protection thrown around it, the profession at once at- 
tained a higher standard; medical schools were organized and various 
systems of medicine came into existence. 
Contest Between the Schools of Medicine.-The greater amount of 
subsequent legislation in both England and America, between 1550 and 
1890, grew out of the jealousy existing between the followers of such 
schools as Allopathy and Homeopathy. It is indeed a curious com- 
mentary on the history of the medical profession that the enmity be- 
tween the several schools and systems, growing out of the efforts of one 
to fortify itself by legislation at the expense of loss of privilege to the 
other, was reflected in the legislature of the State of New York during 
the latter half of the nineteenth century, when, in its efforts to appease 
the warring schools, it enacted laws so liberal that the doors of the medi- 
cal profession were opened to ignorant, and even fraudulent, empirics- 
a condition which happily has been remedied by more recent legisla- 
tion. 
The Status of the Physician.-The legal status of a physician is 
frequently compared to that of the lawyer, but there is one important 
element which differentiates the two professions and should be con- 
stantly borne in mind in any comparison; the lawyer is an officer of 
the Court, and, because of this relation, the Court has summary power 
to inquire into his professional conduct in connection with any case; 
whereas the physician is under no such restraint, and the medical so- 
cieties, which have been organized for the purpose of protecting the 
public against imposters, frequently find this power so limited that it 
often becomes necessary for the public to resort to the legislature for 
protection. The status of a physician in this country was ably de- 
scribed by the late Justice Field, in delivering the opinion of the Su- 
preme Court of the United States affirming the constitutionality of 
the legislation prescribing the qualifications of one to practice medi- 
cine:2 "Few professions require more careful preparation by one who 
seeks to enter it than that of medicine. It has to deal with all those 
subtle and mysterious influences upon which health and life depend, 
and requires not only a knowledge of the properties of vegetable and 
*3 Henry VIII., c. 11; 14 and 15 Henry VIII. 5; 5 Car., 1. 
2 Dent v. West Virginia, 139 U. S., 114, affirming 35 W. Va., 1. For the med- 
ical practice laws of all States, see "American Medical Directory," 3rd ed., 1912. THE MEDICO-LEGAL STATUS OF THE ANESTHETIST 
679 
mineral substances, but of the human body in all its complicated parts, 
and their relation to each other, as well as their influence upon the 
mind. The physician must be able to detect readily the presence of 
disease, and prescribe appropriate remedies for its recovery. Everyone 
may have occasion to consult him, but comparatively few can judge of 
the qualifications of learning and skill which he possesses. Reliance 
must be placed upon the assurance given by his license, issued by an 
authority competent to judge in that respect, that he possesses the 
requisite qualifications. Due consideration, therefore, for the protec- 
tion of society may well induce the State to exclude from practice those 
who have not such a license or who are found upon examination not to 
be fully qualified. The same reasons which control in imposing con- 
ditions, upon compliance with which the physician is allowed to prac- 
tice in the first instance, may call for further conditions as new modes 
of treating disease are discovered, or more thorough acquaintance is 
obtained of the remedial properties of vegetable and mineral substances, 
or a more accurate knowledge is acquired of the human system and of 
the agencies by which it is affected. It would not be deemed a matter 
for serious discussion that a knowledge of the new acquisitions of the 
profession, as it, from time to time, advances in its attainments for the 
relief of the sick and suffering, should be required for continuance in 
its practice, but for the earnestness with which the plaintiff in error 
insists that, by being compelled to obtain the certificate required, and 
prevented from continuing in his practice without it, he is deprived of 
his right and estate in his profession without due process of law. We 
perceive nothing in the statute which indicates an intention of the 
legislature to deprive one of any of his rights." 
The wisdom underlying the statutes requiring a general education 
as a prerequisite, supplemented by special study at accredited medical 
schools, as qualifications precedent to the application for the license to 
practice medicine, cannot be questioned. The legislation of the sev- 
eral States of the United States in this respect has been approved by 
the courts in holding those statutes constitutional which prohibit the 
practice of medicine and surgery by unlicensed persons.1 On the other 
hand, when the licentiate has conformed to these reasonable require- 
ments, it follows that it is the better part of wisdom to rely on his 
integrity2 and desire to succeed in the application of his knowledge, 
skill, and judgment, thereby characterizing his profession with little 
restraint in the fields of experiment and investigation; for to limit the 
1 Blalock v. State, 112 Ga., 338; O'Conner v. State, 46 Neb., 157; State v. 
Mylod, 20 R. I., 632; State v. Van Doran, 109 N. C., 864; Hale v. State, 58 Ohio 
St., 676; State v. Carey, 4 Wash., 424. 
2 That a State may require good character on the part of the licentiate: 
Hawker v. New York, 170 U. S., 189. 680 
ANESTHESIA 
latitude, as it were, of his independence of thought, obviously would 
be tantamount to impeding progress in both the art and science of 
medicine. By the same token, it is impossible to prescribe a fixed rule 
of responsibility on the part of the practitioner, inasmuch as the cir- 
cumstances and conditions surrounding cases vary, and accordingly all 
conclusions with respect to a physician's liability must be drawn from 
the facts underlying each particular case. It is upon this theory that 
the courts have held that the defendant cannot successfully meet the 
charge of malpractice by showing his methods were successful in simi- 
lar cases.1 
THE PHYSICIAN'S LIABILITY 
Ethical Liability of the Physician.-While the privilege which 
permits the lips of the physician to remain sealed and to hold inviolate 
the relations between physician and patient has its foundation in the 
civil responsibility of the physician to inform himself of the habits, 
tendencies, circumstances, and history of the patient,2 it is to that higher 
law, the ethics of the medical profession, that society must ultimately 
* Baker v. Hancock, 63 N. E., 323; 64 N. E., 38; but see Stern v. Laning, 106 
La., 738. 
2 Communications from a patient to his physician were not privileged at com- 
mon law: Bex v. Gibbons, L. C. and P., 97; Broad v. Pitt, 3 C. and P., 518; God- 
dard v. Gardner, 28 Conn., 172; Barnes v. Harris, 7 Cush. Mass., 577; People v. 
Stout, 3 Park. Crim. N. Y., 670; Kendall v. Grey, 2 Hilt. N. Y., 300; but on con- 
siderations of public policy: Lissak v. Crocker, 119 Cal., 442; Kling v. Kansas 
City, 27 Mo. App., 231; Hoyt v. Hoyt, 112 N. Y., 493. 
Statutes have been enacted in most jurisdictions prohibiting the disclosure, 
against the will of the patient, of information acquired by physicians in their 
professional capacity: Conn. Mut. L. Ins. Co. v. Union Trust Co., 112 U. S., 250; 
Dreier v. Cont. L. Ins. Co., 24 Fed. Rep., 670; Shafer v. Eau Claire, 105 Wis., 
239; Wells v. N. E. Mut. L. Ins. Co., 187 Pa St., 166; Davis v. Supreme Lodge, 
etc., 165 N. Y., 159; Territory v. Corbett, 3 Mont., 50; Blair v. Chicago, etc., 
89 Mo., 334, 383; Cooley v. Foltz, 85 Mich., 47; Nelson v. Niederland Co., 110 Iowa, 
600; Bower v. Bower, 142 Ind., 194; and Colo. Fuel Co. v. Cummings, 8 Colo. 
App., 541. In the case of Eobinson v. Supreme Commandery, U. C. G. C. of W., 
79 N. Y. S., 13, it was stated that Code Civ. Proc., 834, provides that physicians 
shall not be allowed to disclose information acquired in attending a patient in a 
professional capacity. An Indiana statute provides that a physician .shall be 
incompetent to testify, over his patient's objections, as to any knowledge acquired 
by him in treating such patient: Aspy v. Botkin, 66 N. E., 462. Utah Rev. St., 
3414, provides that a physician cannot, without the consent of his patient, be ex- 
amined in a civil action as to any information acquired in attending the patient 
which was necessary to enable him to prescribe for the patient. In order that 
such statutes may apply, it is necessary that the relation of physician and patient 
should exist or at least that conditions are such that the patient is impresse I 
with the belief that it does: People v. Koerner, 154 N. Y., 355; Clarke v. State, 
8 Kan. App., 782. THE MEDICO-LEGAL STATUS OF THE ANESTHETIST 
681 
look for protection rather than to legislatures and courts. The sanc- 
tity of the relations between physician and patient has ever been held 
with a most profound appreciation throughout the history of the medi- 
cal profession; and in this respect the comprehensive ethical code at- 
tributed to Hippocrates admits of no amendment. 
The Civil Liability of the Physician.-In defining the necessary 
qualifications on the part of the practitioner, the courts have held, with- 
out exception, that one holding himself out to the public as a general 
practitioner of medicine and surgery must possess and exercise the 
average degree of skill and learning possessed by members of the pro- 
fession practicing in similar localities,1 in the light of the present state 
of medical science.2 The physician is not infallible, and, except by ex- 
press agreement, in accepting a case, does not guarantee a cure.3 The 
reasonable and ordinary care, skill, and diligence demanded by this rule, 
are those which are commonly practiced by physicians and surgeons in 
the same, or similar, localities and in the same general line of practice in 
similar cases. The degree of care, skill, and diligence varies in differ- 
ent communities 4 and in different cases. The opportunity for observ- 
ing the latest approved methods of treatment, and the facilities for 
obtaining drugs and appliances, are material in determining the re- 
sponsibility on the part of the practitioner; hence, it will be seen that 
the above rule exacts higher degrees of care, skill, and diligence on the 
part of the city practitioner, than is demanded of the practitioner in 
the more remote communities. 
1 Pike v. Honsinger, 155 N. Y., 201; Eislein v. Palmer, 7 Ohio Dec., 365; 
Lawson v. Comnaway, 37 W. Va., 159; Nelson v. Harrington, 72 Wis., 591; Mullin 
v. Flanders, 73 Vt., 95; Jackson v. Burnham, 20 Colo., 532; and Force v. Gregory, 
63 Conn., 167. 
Not in "his locality": Whitesell v. Hill, 101 Iowa, 629; Burk v. Foster, 24 
Ky. Law Bep., 791; 114 Ky., 20. Cf. 53 Neb., 28; 92 N. Y. S., 1063; and 37 
W. Va., 159, wherein "his community" is specified. In Wohlert v. Seibert, 23 Pa. 
Super. Ct., 213, the comparative distinction is "the skill . . . ordinarily pos- 
sessed by the average of members of the profession in good standing. ' ' 
2 Baker v. Hancock, 63 N. E., 323; 29 Ind. App., 456; 64 N. E., 38; Thomas 
v. Dabblemont, 67 N. E., 463; 31 Ind. App., 146; Dunbauld v. Thompson, 80 
N. W., 324; 109 Iowa, 199; Forrell v. Ellis, 105 N. W., 993; 129 Iowa, 614; Gil- 
lette v. Tucker, 65 N. E., 865; 67 Ohio St., 106; 93 Am. St. Rep., 639; Bigney v. 
Fischer, 59 A., 72; 26 R. I., 402; and Eislein v. Palmer, 7 Ohio, Dec., 365. On 
the implied undertaking of a physician, see also Bich v. Pierpont, 3 F. and F., 35; 
Pettigrew v. Lewis, 46 Kan., 78; Small v. Howard, 128 Mass., 131; Pike v. Hon- 
singer, 155 N. Y., 203; McCandless v. McWha, 22 Pa. St., 261. In the last case 
it was stated that the care, skill, and diligence exercised must be that of "thor- 
oughly educated" physicians, but it was evidently not intended to impose a 
higher standard of care than that usually required. See Smothers v. Hanks, 34 
Iowa, 286. 
3 Ewing v. Goode, 78 F., 442; Dye v. Corbin, 59 W. Va., 266. 
4 Whitesell v. Hill, 70 N. W., 750. 682 
ANESTHESIA 
Malpractice.-The failure on the part of the practitioner to exer- 
cise "the average degree of skill and learning possessed by members of 
the profession practicing in similar localities, in the light of the present 
state of medical science," resulting in injury to the patient, is malprac- 
tice, and renders the practitioner liable for the injuries resulting there- 
from.1 However, a mere error in judgment does not constitute mal- 
practice, unless such error is inconsistent with the degree of skill which 
it is the duty of a physician to possess. In a leading case the Court 
has said:2 "The law relating to malpractice is simple and well settled, 
although not always easy of application. A physician and surgeon, by 
taking charge of a case, impliedly represents that he possesses, and the 
law places upon him the duty of possessing, that reasonable degree of 
learning and skill that is ordinarily possessed by physicians and sur- 
geons in the same or similar locality where he practices, and which is 
ordinarily regarded by those conversant with the employment as necessary 
to qualify him to engage in the business of practicing medicine and 
surgery. Upon consenting to treat a patient, it becomes his duty to use 
reasonable care and diligence in the exercise of his skill and the applica- 
tion of his learning to accomplish the purpose for which he was employed. 
He is under the further obligation to use his best judgment in exercising 
his skill and applying his knowledge. The law holds him liable for an in- 
jury to his patient resulting from want of the requisite knowledge and 
skill, or the omission to exercise reasonable care, or the failure to use his 
best judgment. The rule in relation to learning and skill does not require 
the surgeon to possess that extraordinary learning and skill which be- 
long only to few men of rare endowments, but such as are possessed 
by the average number of the medical profession in good standing. 
Still he is bound to keep abreast with the times, and a departure from 
approved methods in general use, if it injures the patient, will render 
him liable, however good his intentions may have been." 
The failure on the part of the patient to follow the reasonable and 
necessary instructions of the physician relieves him of responsibility.3 
Similarly, a physician is under no legal obligation to accept a case 
against his will; but, having accepted, he cannot withdraw without 
1 But a mere want of due care and skill gives no right of action when no injury 
has resulted: Ewing v. Goode, 78 Fed. Rep., 442; Cay ford v. Wilbur, 86 Me., 414; 
Eowe v. Lent, 42 N. Y., 483; Fowler v. Sergeant, 1 Gant. Cas. Pa., 355. 
2Pike v. Honsinger, 155 N. Y., 201. On a physician's liability for errors of 
judgment, see also Carpenter v. Blaker, 50 N. Y., 696; Heath v. Glisan, 3 Or., 64; 
McKee v. Allen, 94 Ill., App., 147. As to what constitutes negligence or malprac- 
tice, see Sullivan v. McGraw, 118 Mich., 39; Keller v. Lewis, 65 Ark., 578. 
3 Geiselman v. Scott, 25 Ohio St., 86; Becker v. Janinski, 27 Abb. Cas. N. Y., 
45; Haire v. Eeese, 7 Phila., 138; Haering v. Spicer, 92 Ill. App., 449; DuBois v. 
Becker, 130 N. Y., 325. For contributory negligence on the part of patient: 
Haering v. Spicer, 92 Ill. App., 449. THE MEDICO-LEGAL STATUS OF THE ANESTHETIST 
683 
giving reasonable notice,1 and the fact that his services are gratuitous 
does not relieve him of the responsibility to exercise reasonable and 
ordinary care, skill, and diligence. He is civilly responsible for the 
want of skill and negligence on the part of his partners, agents, ap- 
prentices, and assistants,2 and, while he incurs no liability in the failure 
to effect a cure,3 in case he doubts his competency in a particular case 
it is both his legal and moral duty to recommend the employment of 
another physician.4 The physician is under an implied obligation, 
when he undertakes a case, to bring to his assistance such obtainable 
remedies and appliances as discovery and experience have found to be 
most proper and beneficial, and -which are therefore sanctioned by use 
in such cases;5 but the mere fact that the instrument used is unusual 
is not sufficient to show a want of care and skill.6 The practitioner is 
chargeable with a knowledge of the probable consequences of an injury 
or of negligence or unskilfulness;7 he is bound also to know the natural 
and probable results of the remedy he uses; ? and, in order to be relieved 
from liability on the ground that his course was pursued through an 
error of judgment, he must keep within recognized and approved meth- 
ods, and cannot depart from the known rule and usage of the profes- 
sion to ramble in the fields of investigation and experiment.9 Finally, 
it should not be overlooked that it is the duty of the physician to in- 
form himself of those habits, tendencies, and circumstances of the pa- 
1 On the liability of a physician for failure to attend a patient, see Dale v. 
Lumber Co., 48 Ark., 188; Mucci v. Houghton, 89 Iowa, 608; Barbour v. Martin, 
62 Me., 536; Gerken v. Plimpton, 70 N. Y. S., 793; 62 App. Div., 35; Lathrope 
v. Flood, 63 Pae., 1007. 
On the physician's right to determine the frequency of his visits to a patient, 
see 51 L. R. A., 298. 
2 Tish v. Welker, 5 Ohio Dec., 725; Wilkins v. Ferrell, 10 Texas Giv. App., 231. 
3 Physicians are not insurers of successful or beneficial results: Ewing v. 
Goode, 78 Fed. Rep., 442; Styles v. Tyler, 64 Conn., 432; Tish v. Welker, 7 
Ohio N. P., 472; McKee v. Allen, 94 Ill. App., 147; English v. Free, 205 Pa., 624. 
4 See M alien v. Boynton, 132 Mass., 443. 
5 Stevenson v. Gelsthorpe, 10 Mont., 563; McCandless v. McWha, 22 Pa., 261. 
6 Alder v. Buckley, 1 Swan Tenn,, 69; Prichard v. Moore, 75 Ill. App., 553. 
It has been ruled in Missouri (Fanhooser v. Berghoof, 90 Mo., 487) that 
whether or not the practitioner in substituting other appliances for those which had 
been properly tested and were commonly used was guilty of a want of the 
requisite degree of care and skill is a question for the jury. This decision is of 
particular interest to the anesthetist, since the development of anesthetic apparatus 
is progressive, and the introduction of novel appliances is largely due to indi- 
vidual effort and experience. 
' Gerken v. Plimpton, 62 N. Y. App. Div., 35; Dubois v. Decker, 130 N. Y., 325. 
8 Bogle v. Winslow, 5 Phila., 136; 20 Leg. Int., 46. 
• Slater v. Baker, 2 Wils. C. Pl., 359; Jackson v. Burnham, 20 Colo., 532; Tefft 
v. Wilcox, 6 Kan., 46; Branner v. Stormont, 9 Kan., 51; Patten v. Wiggin, 51 
Me., 594; Hesse v. Knippel, 1 Mich. N. P., 109; Pike v. Honsinger, 155 N. Y., 203. 684 
ANESTHESIA 
tient which are necessary and relevant in the prudent management of 
the case. 
Liability of the Specialist.-If the specialist professes to belong to 
a particular school of practitioners,1 he must measure up to the stand- 
ard of that school,2 for "the law implies that surgeons and physicians, 
in the treatment of all cases they undertake, should exercise reasonable 
care and diligence, and should give attention proportionate to the deli- 
cacy of the operation and case." 
It is upon this theory that if a physician holds himself out as hav- 
ing special knowledge and skill, "he is bound to bring to the discharge 
of his duty to a patient employing him as such specialist not merely 
the average degree of skill possessed by general practitioners, but that 
special degree of skill and knowledge possessed by physicians who are 
specialists in such cases, in the light of the present state of scientific 
knowledge,3 for, obviously, to measure the liability of a specialist by 
the standard appliable to the ordinary family physician, would open 
the door of the medical profession to quackery and permit consequent 
fraud upon the public. 
In defining the responsibilities of a specialist, a Court4 has well 
said: "The question when a physician becomes a specialist is not one 
of law, but one of fact primarily for his own determination; but, when 
he holds himself out as a specialist, it becomes his duty to use that de- 
gree of skill which such a practitioner of necessity should possess." 
The reasoning in this opinion is not predicated upon any new 
theory, nor in its application is it peculiar to the relations between 
physician and patient, for it is a well-established principle of law that, 
"in all those employments where peculiar skill is requisite, the one who 
offers his services is understood as holding himself out to the public as 
possessing the degree of skill commonly possessed by others in the same 
employment." 
With respect to the degree of skill required by anesthetists, the de- 
cisions pertaining to specialists5 fortify the conclusion that the anes- 
thetist should be held to that degree of care, skill, and knowledge ordi- 
narily possessed by practitioners in good standing devoting special at- 
tention and study to the administration of anesthetics. As a rule, the 
surgeon is responsible to the family, while the anesthetist is responsible 
to the surgeon; but if the anesthetist has been specially called in by 
1 Force v. Gregory, 63 Conn., 167; Bowman v. Woods, 1 Greene Iowa, 441; 
Corsi v. Maretzek, 4 E. D. Smith, N. Y., 1; Williams v. Poppleton, 3 Or., 131; 
Hesse v. Knippel, 1 Mich. N. P., 109. 
2 Martin v. Courtney, 77 N. W., 813. 
3 Baker v. Hancock, 63 N. E., 323; 64 N. E., 38; 29 Ind. App., 456. 
4 Baker v. Hancock, 63 N. E., 323. 
5Feeney v. Spalding, 89 Me., Ill; McMurdock v. Kimberlin, 23 Mo. App. 523; 
Stern v. Lanng, 106 La., 738. THE MEDICO-LEGAL STATUS OF THE ANESTHETIST 
685 
the patient or the practitioner, he is on the same footing as the 
surgeon. 
The Criminal Liability of the Physician.-The criminal liability 
on the part of a physician, for the purposes of this discussion, may be 
summarized in the following propositions: 
(1) Where the practitioner wilfully adopts procedure liable to 
jeopardize the life or health of the patient.1 
(2) Where the practitioner wilfully omits to adopt the procedure 
necessary in safeguarding the life or health of the patient.2 
(3) Where injury to the patient results from gross ignorance or 
negligence on the part of the physician. 
(4) Where the practitioner is guilty of conduct prohibited by 
statute. 
No application of the above propositions to procedure on the part 
of the practitioner can be made without due regard to the principle of 
law that one is presumed to intend the natural, necessary, and probable 
consequence of his acts. 
Gross Ignorance or Negligence.-The liability on the part of the 
practitioner growing out of gross ignorance or negligence is of serious 
concern to the anesthetist in view of the occasional deaths which occur 
during and immediately subsequent to an anesthetization. 
It is a monument to the honor of the American medical profession 
that so few cases have grown out of the liability of the practitioner 
for death resulting from gross ignorance or negligence in the adminis- 
tration of anesthetics that the law in this country cannot be said to 
be clearly defined. 
In general it may be said that the law presumes that the practitioner 
has used due care and skill, and accordingly the burden of proof is on 
him who alleges gross ignorance or negligence.3 This presumption re- 
quires the plaintiff in civil actions to prove his case by a preponderance 
of evidence and in criminal cases beyond a reasonable doubt. 
The few American decisions read in the light of the English law 
1 For a discussion of the question, ' ' Has the Physician Ever the Right to Ter- 
minate Life?" see 55 Albany Law J., 136; and Haeckel: "Wonders of Life,'' 
1905, 116. 
2 Where the death of a person results from the criminal negligence of the prac- 
titioner in the treatment of a case, the latter is guilty of manslaughter: State v. 
Reynolds, 42 Kan., 320; Hyatt v. Adams, 16 Mich., 198; State v. Gile, 8 Wash., 
12. The real question upon which criminal liability depends is whether there 
was criminal negligence, which is hardly a matter of degree. On the facts con- 
stituting criminal negligence, sec State v. Hardister, 38 Ark., 605; Com. v. Pierce, 
138 Mass., 165; Rex v. Long, 4 C. and P., 398; Webb's case, 2 Lewin C. C., 196; 
and Reg. v. Chamberlain, 10 Cox C. C., 486. 
' Pettigrew v. Lewis, 25 Pac. R., 458; Feeney v. Spalding, 80 Me., Ill.; Peck v. 
Hutchinson, 55 N. W., 511; Wohlert v. Siebert, 23 Pa. Super., 214; Georgia North- 
ern Ry Co. v. Ingram, 40 S. E., 708. 686 
ANESTHESIA 
indicate that the courts, in ascertaining the responsibility of the prac- 
titioner when death has resulted from the administration of anesthetics, 
consider three classes of facts, viz.: (1) the necessity of the operation; 
(2) the competency of the operator; (3) whether the wound or injury 
would have proved mortal without the operation. 
Among the pertinent inquiries which arise in determining gross 
ignorance or negligence under this classification of facts are the kind 
and fitness 1 and quality of the anesthetic administered, the method of 
administration followed, the consent 2 of the patient to its administra- 
tion, the peculiar condition or temperament of the patient, if necessary 
and relevant, and the circumstances permitting of their acquirement,3 
skill in the use of instruments, and proper qualifications 4 of and in- 
structions to those in immediate charge of the patient as to the use of 
medicines,5 a disregard of which by the practitioner, if found gross, 
renders him criminally responsible. Hence, it will be seen that criminal 
malpractice in this respect differs from civil malpractice only in degree. 
In defining criminal malpractice in a leading case, the Court said:6 
"Criminal negligence exists where the physician or surgeon, or per- 
son assuming to act as such, exhibits gross lack of competency, or gross 
inattention, or criminal indifference to the patient's safety, and this 
may arise from his gross ignorance of the science of medicine or 
surgery and of the effects of the remedies employed, through his gross 
negligence in the application and selection of remedies and his lack of 
proper skill in the use of instruments, or through his failure to give 
proper instructions to the patient as to the use of the medicines." 
It is important to mention here that it has been held by the Supreme 
Court of Vermont that a physician administering an anesthetic is not 
liable for not protesting against an operation not favored.7 
Statutory Liability.-To determine the statutory liability on the 
part of the practitioner, it is necessary to examine the statutes of the 
several States. As indicated above, they have their origin in the police 
power of the State. Other than those statutes which prohibit the per- 
1 Bogle v. Winslow, 5 Phila. Reports, 136. 
2 Mohr v. Williams, 95 Minn., 261. Actions have been brought in England for- 
alleged anesthetization without consent. In these cases, the patient and anesthet- 
ist, who was also the operator, were alone together; but they failed on the grounds 
that anesthetization by force was impossible and that there was collateral evi- 
dence of consent. 
For discussion of consent from an English anesthetist 's point of view, see 
J. D. Mortimer: "Anesthesia and Analgesia,'' 1911, 255. 
3 Lewis v. Dwinel, 84, Me., 497; Logan v. Field, 75 Mo. App., 594. 
4 For qualifications of a trained nurse, see Art. 12, Public Health Law, State 
of New York, 1909. 
5 Hampton v. State, 50 Fla., 55. 
* Hampton v. State, 39 Southern R., 424. 
1 75 Atl. Rept., 641. THE MEDICO-LEGAL STATUS OF THE ANESTHETIST 
687 
formance of illegal operations 1 and the treatment of a patient by a 
physician under the influence of intoxicants, with the exception of 
Ohio, which prohibits the administration of anesthetics except in the 
presence of a third party who must be a competent witness,2 none of 
the States has passed statutes directly affecting the anesthetist. An 
anesthetic should not be administered without the presence of an as- 
sistant or a third person, except in cases of emergency; and, in the ab- 
sence of a professional assistant, the operator must assume the entire 
responsibility. If, however, the assistant is duly licensed, the responsi- 
bility is assumed by both. 
Finally, it may be said that, in the administration of anesthetics, 
whether by physician, surgeon, dentist, anesthetist, or other professional 
assistant, the practitioner should at all times exercise the highest de- 
gree of caution, for it is not only difficult to determine the proximate 
cause of death in cases where an anesthetic has been used, but women, 
particularly young women, are likely to have erotic sensations while 
under its influence, and thus an added responsibility may be brought to 
the practitioner in defending his good character and fidelity of pur- 
pose.3 
1 No one may give an anesthetic for an illegal operation. 
2 '1 Whoever uses upon another an anesthetic, unless at its administration, and 
during the whole time the person is wholly or partly under the direct influence of 
it, there is present a third person competent to be a witness, shall be fined not 
more than Twenty-five Dollars nor less than Dive Dollars" (Laning's "Rev. 
Stat.," 10685). 
3 Sexual intercourse with a woman while she is unconscious has been held to 
be against the will of the woman and without her consent so as to constitute rape: 
Com. v. Burke, 105 Mass., 377; Com. v. Childs, 2 Pgh., 398; Lewis v. State, 30 
Ala., 54; Shirwin v. People, 69 Ill., 55. An attempt to administer chloroform to 
a woman for the purpose of having sexual intercourse with her while she is under 
its influence is an attempt to rape: Milton v. State, 34 Texas App., 284. 
As to chloroform as a means of facilitating crime, see Proc. N. Y. Med. Leg. 
Soc., 1872, 298-317; cf. also Bogers v. State, 33 Ind., 543. 
However, in an interesting pamphlet by Stephen Rogers on chloroform (Har- 
per and Bros., New York, 1877), it is argued with much force that for the pur- 
poses of attack chloroform cannot be effectively used. See also: 3 Whart. and 
St. Med. J., 245, 594; and Wharton's "Criminal Law," 1896, 1, 527. But cf. 
Ford v. State, 41 Tex. Crim., 270; State v. Greene, 2 Ohio Dec., 255; 3 West. L. 
Month., 185. 
For cases of conviction for rape committed on a woman under the influence 
of ether, see State v. Green, 3 Whart. and St. Med. J., 597; and Com. v. Beale, 
ibid., 245, 596, 612. 
On alleged murder by inhalation of chloroform to sleeping unconscious victim, 
see Fairchild: Medico-Legal J., 24, 19, 34. 
For a discussion of the question, "Can Chloroform Be Used by Inhalation to 
Commit Murder, Robbery or other Crime on an Unconscious Victim," Bell: 
Medico-Legal J., 24, 28. 
On "The Medico-Legal Questions Arising in the Case of Patrick," Bell: 
Medico-Legal J., 22, 494, 529. CHAPTER XX 
ANESTHESIA DURING THE WORLD WAR 
The Military Surgical Operating Room: The Efficiency Prob- 
lem; Operative Technique. 
The Problem of Anesthesia in Thoracic Surgery: Bunnell 
Apparatus. 
General Analgesia by Oral Administration. 
In the main, anesthesia in war surgery differs from that in civil 
practice only in the magnitude of the number of administrations and 
the circumstances under which these are given. Certain problems, how- 
ever, were encountered in the World War which seem worthy of note 
here, particularly since they are not wanting in application to surgery in 
civil life. The first of these deals with the military surgical operating 
room; the second, with anesthesia in thoracic surgery; and the third, 
with the oral administration of anesthetic agents for short operations 
and painful dressings. 
THE MILITARY SURGICAL OPERATING ROOM 
The following observations and suggestions are based on the prem- 
ises 1: (1) That, by fully utilizing the surgeon's time, the output of any 
surgical team is more than doubled. (2) That the possibility of infec- 
tion in advanced hospitals is reduced to a minimum. (3) That the 
number of surgeons in any hospital is reduced by one-half. (4) That 
the plan, with modifications, in accordance with circumstances, may be 
utilized in civil as well as military hospitals. 
At the beginning of the World War, and throughout its course, in 
some places, each surgical team had only one operating room. In civil 
hospitals, it is almost the universal custom to provide one table for each 
operating room. Under war conditions speed is a necessity; in civil 
practice, it is often a necessity, and always an advantage. The utilization 
of the surgeon's entire time in surgical work is the determining factor in. 
the efficiency of any military hospital. The same may be said to apply, 
to a less marked degree, perhaps, to civil hospitals. The plan outlined 
makes it possible for the surgeon to devote his entire time and effort 
to actual surgical work; it doubles, and in some instances, even trebles, 
1 Gwathmey, James T.: The Three Table Military Operating Rooms, Annals 
of Surgery, October, 1919. 
688 ANESTHESIA DURING THE WORLD WAR 
689 
the amount of work he can do, regardless of whether he be a rapid or a 
slow operator. 
With only one operating table for each surgical team, or in each 
operating room, surgical dressings must be applied after the operation i§ 
completed, stretcher bearers called, and another patient brought in, 
anesthetized and sterilized, before the surgeon can begin the next opera- 
tion. Usually this takes from ten to fifty minutes, fifteen minutes being 
a fair average. A surgeon using one operating table will therefore lose 
fifteen minutes or more between operations, or one hour's valuable time 
in operating on five patients. If these five patients represent a morning's 
work, in a day's work, at least two hours of the surgeon's time will be 
needlessly lost. This time may be entirely recovered by making certain 
changes in operating-room equipment and technique. 
Many British surgical staffs, in the war zone, adopted the plan of 
having two tables for each operating team. As the dressings were being 
applied to the first patient, the patient on the second table was anes- 
thetized and then removed-for convenience of sterilization, etc.,-to the 
first table. Five to ten minutes is saved in this way and it is an improve- 
ment over the one-table plan. However, if the second operation proves 
to be a very short one, this time may be lost again before a third patient 
can be brought in, anesthetized, and sterilized, and the operation begun. 
The advantage of two tables, with the addition of nitrous oxid, oxygen 
and ether as the anesthetic, is shown in the following record of a week's 
work of one anesthetist at a Base Hospital, working with a number of 
surgeons and where speed was not an essential: 
September 25 11 cases 
" 26 17 " 
" 27 16 " 
" 28 16 " 
" 29 12 " 
" 30 10 " 
This shows an average of 13% cases per day of seven to eight hours. 
The best day, under the same conditions, when speed was essential, was 
34 cases. 
The average for this anesthetist, working under similar conditions, 
with chloroform and ether, was eight to nine cases per day. In fact, with 
chloroform and ether, the work was so much delayed that other anes- 
thetists had to be called in. Environmental technique and not the 
anesthetist, is a contributory factor in the successful dispatch of surgical 
cases. 
The efficiency problem, therefore, involves changes in the operating- 
room technique, in the anesthetic, and in the surgical team, which have 
already proved entirely practical for one unit, and which, therefore, can 
be applied to an entire operating theater. The changes are as follows: 690 
ANESTHESIA 
(1) Each surgical team to consist of a surgeon, one anesthetist, two 
sterile nurses, and two surgical assistants or orderlies. 
(2) Two sets of surgical instruments such as are commonly used 
in all operations, viz., knives, scissors, retractors, artery forceps, etc. 
(3) Nitrous oxid, oxygen and ether as the anesthetic. 
(4) The surgeon to wash and then sterilize his rubber gloves, without 
changing. 
(5) Three operating tables, so arranged that the anesthetic mask can 
be changed from one patient to the other, without having to move the 
nitrous oxid and oxygen tanks? and without having to move the tables. 
The plan on opposite page, in collaboration with Mrs. Mae Noe Daly, 
of Auto-Chir No. 7, of the French Army, is drawn to scale, and shows 
the position of the tables and anesthetic outfit, by which the surgeon's 
time can be utilized to the utmost, and full advantage taken of the rapid 
induction of anesthesia and the elimination of the anesthetic. 
No special arrangement of hut, tent, or operating room is essential 
in order to utilize the three-table plan. Three tables can be placed any- 
where. In the light of our experience, a mobile hospital, with elaborate 
sterilizing outfits on wheels, and with only one operating table for each 
surgeon, is an unwise expedient. The author has witnessed eight full 
teams, each team having only one table, occupied all night with one hun- 
dred patients, alternately working and loafing (of necessity, loafing) as 
each patient was carried out and another brought back, placed on the 
table, prepared and anesthetized. The same one hundred patients could 
have been operated on more satisfactorily in the same length of time by 
four teams with three tables each, and the efficiency of four full teams 
would have been saved for the next day's work. 
Soldiers from the battle line, as a rule, show no antipathy toward 
being placed upon an operating table next to one in active use. If any 
interest whatever is shown, it is only a mild degree of curiosity. Usually, 
they have had an unknown quantity, one-half grain or more of morphia, 
before leaving the front line. No preliminary medication, therefore, 
is ever advisable in an evacuation hospital. 
Operative Technique.-The patient on the first table is anesthetized 
and operated upon. Instruments and sterilization for this table are on 
two shelves running the length of the hut, immediately to either side 
of the anesthetic tanks, and within easy reach of the nurses. While the 
first patient is being operated upon, the second patient is being prepared 
(as far as his injuries permit) by the second nurse. As the dressings are 
needed for the first patient, the anesthesia ceases. The dressing and 
bandaging is done by the nurse. 
While the next patient is being anesthetized, the surgeon is rinsing 
'Only the largest size nitrous oxid (3,200 gal.) and oxygen (1,200 gal.) tanks 
are recommended. Fig. 270.-Field hospital operating barrack, American Red Cross, 4 Place de la Concorde, Paris, Bureau de Construction, February 9, 1918. 692 
ANESTHESIA 
and sterilizing his rubber gloves, without removing them; a sterile towel 
is pinned over his gown, and sterile armlets are pulled up and pinned in 
place. The operation upon the second patient now begins (three minutes 
or less). Instruments for this second patient are placed on a sterile 
towel, on a part of the patient's body not to be operated upon. The 
second operation may, and sometimes does, begin before the first patient 
is removed from the table. 
The first nurse now prepares and sterilizes the third patient. Steril- 
ization and instruments for the third patient are upon a shelf within 
convenient reach of the nurse. At the proper time this patient is 
anesthetized, as was the second, the surgeon sterilizing as before and then 
operating. By this time another patient has been brought in and placed 
on the first table. This patient is prepared for operation by the nurse 
from table two, and the above sequence is followed continuously. 
The immense advantage of this plan, plus team work, is shown in the 
record of a certain team, consisting of one surgeon, one anesthetist, and 
one orderly. Starting at 2 p.m., and continuing until 8 p.m., with 
one hour out for tea, 24 cases were operated upon. It is fair to assume 
that with two sterile nurses and two orderlies, and utilizing the entire 
time of the surgeon, each team should average 10 to 50 cases per day. 
Four teams should average 75 to 100 cases per day. 
While this plan is intended primarily for a casualty clearing or evacu- 
ation hospital, it is entirely practical for a base hospital, and in civil 
practice, where time for the patient is not such a vital element. But 
here some preliminary medication should be given to insure the even 
working of the plan. 
THE PROBLEM OF ANESTHESIA IN THORACIC SURGERY 
The following observations are based upon between 80 and 100 animal 
experiments conducted in the Central Medical Department Laboratories, 
A. E. F., Dijon, France, and a large clinical experience with surgical 
teams working in the advanced zone of the American Army and confining 
themselves almost exclusively to chest surgery.1 Both the anesthetic 
agent and the method to be employed were thoroughly tried out, and were 
finally decided upon sometime before entering upon the surgical duties at 
the front. 
The Agent.-Patients who require thoracic surgery usually have other 
injuries, are more or less shocked, and suffer from lowered blood pressure. 
Inasmuch as one of the clinical features of chloroform anesthesia is 
lowered blood pressure, and for other reasons, chloroform was not con- 
sidered. In the author's opinion it should not be used in war surgery, 
except, possibly, in a 50 per cent solution with ether, and then only as a 
1 Gwathmey, James T.: Medical Record, June 12, 1920. ANESTHESIA DURING THE WORLD WAR 
693 
preliminary to ether, or for very short operations, and never as a 
terminal anesthetic. The final choice was between ether and nitrous oxid 
and oxygen; both were used in our animal experiments. 
Anesthetic of Choice.-Other things being equal, the agent selected 
should sustain the blood at the highest possible level consistent with good 
surgical anesthesia during the operation, and with a minimum of reaction 
after operation. In general narcosis with ether or nitrous oxid and 
oxygen, the blood pressure depends more upon the depth of anesthesia 
than upon the agent, and if the same technique is used it is sustained as 
well with the one as with the other. Crile,1 unfortunately, published a 
misleading chart that seems to show that "an animal under nitrous 
oxid anesthesia endured shock-producing trauma better than an animal 
under ether anesthesia," using the irregular and unscientific drop method 
of ether for the comparison of the two agents. (See chart.) Every 
surgeon knows that the blood pressure does not fall in this way under 
ether during operations requiring extensive trauma. 
Dr. Carl Connell and the author 2 paralleled the experiments of Crile, 
following his technique absolutely, traumatizing the animal and con- 
tinuing the experiment for the same length of time, but giving the ether 
by the vapor method pharyngeally, so that the quantity of ether and the 
volume of air were so regulated that an even anesthesia was maintained 
at all times. The chart made from these experiments seemed to prove 
that animals under ether, properly given, stand shock as well as those 
under nitrous oxid anesthesia. But neither Crile nor Connell and the 
author carried their observations beyond the immediate experiment. 
Marshall3 of the British Army verified the work of Connell and the 
author, and disproved the work of Crile, by showing clinically that the 
blood pressure is sustained equally well under ether vapor and with 
nitrous oxid and oxygen, the ether in Marshall's cases being given in 
probably the safest and best possible way, that is, warmed and oxygenated, 
and by the vapor method. He carried his investigations further, how- 
ever, and, following his patients through the shock ward, found that in 
a few hours a lowered blood pressure, that did not obtain when nitrous 
oxid and oxygen were administered, succeeded the administration of 
ether. 
Cannon 4 states that ether in a shocked animal caused a fall of blood 
pressure which might be as great as 30 or 40 mm. of mercury, even though 
only a sufficient degree of anesthesia was induced barely to abolish 
1 Crile, George W.: Southern Med. Jour., January, 1910. 
3 Gwathmey, J. T., and Connell, Carl: New York Med. Jour., October 28 and 
November 4, 1916. 
3 Marshall, Geoffrey: ' ' Anesthetics at a Casualty Clearing Station. ' ' Proc. 
Boy. Soc. of Med., 1917, 10 (section of anesthetics),. 17-36. 
4 Cannon: ' ' Historical Record of the Services of the Laboratory of Surgical 
Research, American Army, at Dijon," 1918. 694 
ANESTHESIA 
simple reflexes. He holds that if the same degree of anesthesia be 
maintained with nitrous oxid and oxygen, the reflexes could be abolished 
with no fall of blood pressure whatever. Since Cannon does not use heat 
and oxygen with the ether, but uses air at room temperature, the 
comparison, in the author's opinion, is not a fair one. 
Marshall's work and charts, in connection with collateral data, caused 
us to decide upon using nitrous oxid and oxygen. 
Fig. 271.-'Composite Tracings (Crile) : A, Nitrous oxid (plus oxygen) ; B, ether 
(by the open drop method) Connell and Gwathmey; C, ether by the endo- 
pharyngeal method. 
The Method.-The endotracheal and endopharyngeal methods are 
used successfully in lung surgery, so far as the immediate operation is 
concerned. Each method requires an initiatory anesthesia sufficiently 
deep to abolish all reflexes before the insertion of the tubes. This 
initiatory anesthetic favors lowered blood pressure and lowered tempera- 
ture, and would be a serious handicap to a patient previously exsan- 
guinated or in a state of shock from other causes, and might possibly 
prove fatal. The endotracheal method is an operation in itself, requiring 
additional time, and accidents occasionally occur. For these reasons both 
methods were discarded for a safer and simpler one. 
Positive-pressure, Face-mask Method.-The method finally se- 
lected, by process of elimination, calls for the use of an air-tight face 
mask, with a rubber-bag reservoir for the gases close to the mask. As 
a result of animal experiments, a pressure of from 5 to 12 mm. of 
mercury was decided upon. This pressure was first determined by means 
of a mercurial manometer placed in the circuit, but this was discarded as 
unnecessary when it was found that the required pressure could be esti- 
mated easily by the following observation: When the rubber bag is ANESTHESIA DURING THE WORLD WAR 
695 
slightly overdistended with the gases, to such an extent that upon full 
inspiration the seams of the bag are still slightly distended, there is a 
pressure of from 5 to 7 mm. of mercury. 
The positive-pressure method used involves: (1) A constant supply 
of fresh gases; (2) a constant escape of some of the gas; (3) a slight 
amount of rebreathing. 
The escape of the gases may be through an expiratory valve, although 
a valve is not absolutely essential, since the mask may be held in such a 
way that a constant leakage occurs. No air can possibly enter the 
apparatus at any time when positive pressure is sustained. A slight 
positive pressure in addition to the gases is unquestionably an important 
factor in maintaining anesthesia. The value of positive pressure as a 
factor in maintaining anesthesia was recognized by the earliest observers. 
Paul Bert was full convinced that anesthesia with nitrous oxid could 
not be maintained without positive pressure, and he had constructed for 
this purpose an apparatus weighing many hundreds of pounds. In 
addition to being an aid in maintaining anesthesia, positive pressure in 
lung surgery is a very great aid to the surgeon. Willy Meyer wras among 
the first to recognize the great advantage of positive pressure, and he had 
constructed an apparatus costing thousands of dollars for the regulation 
of the pressure as needed. Yates holds that "Positive pressure control 
made examination of the lung and operation much easier and eliminated 
the necessity for dangerous traction. It offered a simple test of the air 
tightness of the closure and of satisfactory hemostasis; the necessity for 
undue haste was eliminated." 
Apparatus.-The army apparatus for administering nitrous oxid and 
oxygen is so simplified and so inexpensive (the whole apparatus weighs 
not over five pounds) that it may be universally used, not only for lung 
surgery but for other operations as well. 
Oxygen Percentage Used.-This positive-pressure method, in addition 
to enabling the surgeon to accomplish the best work in lung sur- 
gery, allows the anesthetist to give a higher percentage of oxygen, 
while still maintaining the same degree of anesthesia. With positive 
pressure not less than one part of oxygen to three of nitrous oxid is 
given. 
Experiments by Cannon and Cattell with the army apparatus show 
that when three holes of nitrous oxid and one of oxygen is given, both 
anesthesia and blood pressure are fully maintained; but when the pro- 
portion is four to one, the blood pressure gradually falls. This simply 
means that it is important to give the maximum amount of oxygen at 
all times with any apparatus that may be used. Usually two holes of 
oxygen and six of nitrous oxid is the minimum amount, the percentage 
of oxygen being rapidly increased, as circumstances allow. Both per- 
centage and quantity are important. For the best results it is also 
important to have the largest sized cylinders, 3,500 gallon nitrous oxid 696 
ANESTHESIA 
and 1,200 gallon oxygen containers. This relieves the anesthetist of all 
worry with regard to the supply of gases, and permits their unstinted use 
as needed. 
Depth of Anesthesia-.-In the laboratory one or two dogs succumbed 
from maintaining too deep an anesthesia. Full surgical anesthesia that is 
safe without preliminary medication was found to be unsafe with this 
medication. For these reasons, the technique gradually evolved from 
deep to light anesthesia, and finally to analgesia with unconsciousness. 
This evolution depended in a very large measure upon the observations 
and the work of Captain Middleton as medical consultant and pathologist, 
and upon his observations in the shock ward; upon the radiographic 
work of Dr. Drane, and most especially upon the experiments of Lieut.- 
Colonel Cannon. As the morphin was gradually increased, it was found 
that more oxygen could be given and that the patients were more 
comfortable and quiet after the operation than when inhalation anesthesia 
alone was depended upon. The high percentage of oxygen used, in 
connection with other obvious symptoms, would seem to prove that 
analgesia and not anesthesia is present.1 In the system outlined here 
from 15 to 35 per cent of oxygen is used. 
It happened occasionally in our earlier work that when too much 
oxygen was given all physiological requirements were met and breathing 
ceased temporarily, for a half or three-quarters of a minute, the pulse 
continuing as before and the patient having a pink color. This temporary 
cessation can be obviated by : (1) decreasing the positive pressure 
momentarily; (2) allowing air to enter the mask; or (3) slightly increas- 
ing the amount of nitrous oxid. By using any one of these methods the 
breathing may be caused to continue normally. 
T echnique.-Preliminary Medication.-In all chest cases the patient 
is given one-quarter, three-eighths or one-half grain of morphin, usually 
three-eighths, hypodermatically, forty to sixty minutes before operation. 
Rapid or labored breathing, sometimes an important harmful factor in 
thoracic surgery, is eliminated by giving morphin, and the patient comes 
to the table in the best possible condition. In only the very young soldier 
was the respiration so reduced as to be noticeable, but even in his case it 
was not dangerous. Age seemed to be a more important factor in this 
particular than the seriousness of the wound. Lieut. Cattell investigated 
the influence of morphin in shocked animals and found, "that it de- 
creased the degree of acidosis which otherwise developed, or prevented its 
onset, an effect probably due to the influence of morphin in reducing 
tissue activity." 
Narcosis.-The narcosis is started with an amount just sufficient to 
1 It may be stated in this connection that Hewitt proved, very conclusively, that 
from 5 to 7 per cent of oxygen with nitrous oxid is sufficient to maintain surgical 
narcosis. This is the amount now universally used. ANESTHESIA DURING THE WORLD WAR 
697 
maintain anesthesia with the Army apparatus, two holes of oxygen and 
six of nitrous oxid. The mask is held tightly on the face, and the first 
three or four exhalations are allowed to escape through the expiratory 
valve, after which the expiratory valve is turned off, and part of each 
exhalation is allowed to escape between face mask and face. The rubber 
bag is filled to plus pressure, as already described. When the skin 
incision is made, if there is no movement or indication of pain, the oxygen 
is increased to three holes, the nitrous oxid remaining the same. The 
patient has a pink color, the lid reflex is active, the eye rolling, yet the 
muscles are well relaxed. From this time on any further increase in 
oxygen is determined by the condition of the patient. If the patient has 
been gassed, or is still bleeding, equal proportions of the gases may be 
used, or, in some instances, 75 per cent oxygen and 25 per cent nitrous 
oxid positive pressure being maintained in all instances. In every case 
full oxygen is given as the last stitches are put in. The patient now has 
a very pink color, with pulse and respiration so nearly normal that his 
true condition may be almost entirely masked. He should be treated in 
every instance as a shocked patient. 
Analgesia:-During the operation the patient is in a state of analgesia 
induced by the morphin, and in first stage anesthesia from the nitrous 
oxid and oxygen. He is safer than if full surgical narcosis were main- 
tained with gases alone, or if a state of analgesia were maintained with 
morphin alone. Either agent used alone would result in cyanosis, slowed 
pulse and respiration, and lowered blood pressure. Analgesia or first- 
stage anesthesia (with morphin, nitrous oxid and oxygen) may be 
graphically expressed as follows: 
Danger 
Zone. 
Analgesia. 
1st Stage. 
2d Stage. 
3d Stage. 
A 
B 
C 
D 
E 
F 
G 
A = Commencement of anesthesia. 
A B = Analgesia. 
B C = First or excitement stage. 
C D = Second stage. 
D E = Third or surgical stage-the usual stage in which operations are 
performed with inhalation anesthesia. 
E F = Danger zone. 
F = Respiratory arrest. 
G = Death. 
The safest and best narcosis available to-day for lung surgery is 
obtained by the combination of the highest possible safe physiological 
dose of morphin (in our experience three-eights of a grain, given one- 
quarter grain forty minutes before operation and one-eighth grain ten 
minutes later), reinforced by nitrous oxid given with the highest possible 698 
ANESTHESIA 
percentage of oxygen, fifteen to thirty-five per cent, with positive pressure 
-given in the easiest and simplest way. 
It is safest because it is separated from the danger zone by the second 
and third stages of anesthesia (C to E). The anesthetist, therefore, 
has twice the leeway or double the time in which to correct or modify the 
anesthesia if untoward events suddenly occur. In gassed cases, oxygen, 
75 per cent, and nitrous oxid, 25 per cent, with positive pressure (5 to 10 
mm. of mercury), with morphin as indicated, will induce and maintain 
satisfactory analgesia in a badly wounded soldier. It is best because 
the blood pressure is maintained at the highest level possible with the 
given patient. 
In no instance were patients strapped to the table or held by orderlies, 
the preliminary medication rendering this unnecessary. Only once in 
thirteen instances was it necessary to give a small amount of ether (1 to 
4 drams), two drams usually being sufficient for the entire operation. 
We never hesitated to give ether when indicated. Since surgical anes- 
thesia with positive pressure is easily maintained with nitrous oxid and 
oxygen, plus one or two drams of ether, if as much as two ounces of ether 
per hour is used, the anesthesia becomes an ether anesthesia, the nitrous 
oxid being wasted. 
Possible Danger in Method.-If the same degree of nitrous oxid and 
oxygen anesthesia is maintained when morphin is given as is usual with- 
out it (i.e., third stage or full surgical anesthesia), shock with labored 
breathing results. When the proper amount of morphin is given (one- 
quarter, three-eighths, or one-half grain), and when nitrous oxid and 
oxygen are used, the morphin eliminates the stage of excitement and 
analgesia and first-stage anesthesia become synonymous terms.1 When 
given as a preliminary to any method of anesthesia, the light anesthesia 
produced by morphin must not be ignored. In other words, both the 
amount and the depth of the inhalation anesthesia must be lessened. If 
the same depth of anesthesia is maintained with morphin as would obtain 
without it, this depth of superimposed anesthesia in itself will produce 
shock. This constitutes the only danger of this method. 
When three-eighths of a grain of morphin is given hypodermatically, 
the patient's lid reflex under gas and oxygen should be quite active, the 
breathing quiet and natural, the pulse about normal. Stertor, abolition 
of lid reflexes, or cyanosis should not be permitted at any time. At the 
conclusion of an anesthesia conducted along the lines suggested, the 
patient comes out from the influence of the gases almost as soon as the 
mask is removed, the analgesia from the morphin continuing for quite a 
1 Marshall (loc. cit.') states that "shocked patients do not bear morphin well." 
This conclusion was unquestionably the result of observing men come to the 
Casualty Clearing Station already heavily morphinized and receiving an addi- 
tional hypodermic at the station. ANESTHESIA DURING THE WORLD WAR 
699 
while. The patient can answer questions intelligently, but should be 
allowed to remain quietly dozing as long as possible.1 
Variations in Technique.-The face-mask method with positive pres- 
sure may be used without preliminary medication. However, narcosis 
comes on sooner and with less forcing of the inhalation anesthetic, and, 
the margin between complete anesthesia and respiratory failure is 
lengthened, thus making it a safer procedure, when some form of pre- 
liminary medication is used. The next most powerful analgesic to mor- 
phin is ether, drams four, liquid paraffin, drams six, mixed and given 
by mouth with salt, pepper and lime juice on the bottom of the wine 
glass and also on top of the mixture. This should be given thirty minutes 
before the operation, and may be repeated in ten minutes, if necessary. 
Other preliminaries possessing a powerful synergistic effect with nitrous 
oxid or ether are bromid of potash and paraldehyd, two drams of each, 
given in four ounces of water at about 115° F., by rectum. 
It sometimes happens that, through untoward circumstances, one 
must resort to ether by the drop or some other method for lung surgery. 
When this occurs the same general principles apply, i.e., the use of 
morphin as indicated as a preliminary, and the maintenance of a very 
light (first stage) anesthesia, just beyond the grunting stage. When 
narcosis is thus maintained, the patient's lungs are inflated to a greater 
extent, the patient responding in a measure to the stimulus of the 
operation and breathing deeply, and the blood pressure is higher than 
when third degree or full surgical anesthesia obtains. The respirations 
are always deeper and more regular with a light anesthesia, especially 
when morphin is used. 
The consensus of opinion among surgeons who have used both 
methods, i.e., with and without positive pressure, is against the drop 
method or any other in which the anesthetist has not complete control 
of the lungs, inflating or collapsing them as required by the surgeon. 
Artificial respiration, when necessary, is more easily maintained with the 
face-mask method than with endotracheal or endopharyngeal anesthesia. 
The author wishes it explicitly understood that he does not consider 
the technique here outlined to be the best for all patients and all opera- 
tions. Nitrous oxid and oxygen, given by an open method (i.e., with an 
extra large face mask), and with one-half to two ounces of ether per 
hour, is a decidedly better method for abdominal cases where full surgical 
relaxation is demanded. 
1 It is customary in certain clinics to give nitrous oxid and oxygen for 
painful dressings, but the gases are given in such small quantities that the patient 
groans and complains throughout, the anesthetist assuring him the while that 
he is not suffering. When the mask is removed the patient remembers nothing 
that has occurred. This is amnesia, and is not the analgesia referred to in 
this paper. 700 
ANESTHESIA 
Summary of Technique.-(1) Hypodermic of morphin sulphate, one- 
quarter, three-eighths, or one-half grain, with three-eighths as the average 
dose, forty to sixty minutes before operation. 
(2) The face-mask method of anesthesia with, preferably, (a) nitrous 
oxid and oxygen, or (b) ether, air and oxygen. 
(3) Positive pressure, slight at first, but from commencement of 
anesthesia, increasing to from five to ten mm. of mercury during opera- 
tion ; then gradual withdrawal as operation is completed. 
(4) The highest percentage and largest amount of oxygen permis- 
sible with regular breathing. 
(5) First-stage anesthesia, with morphin analgesia throughout. 
(6) Constant increase of oxygen as operation proceeds (but never to 
the point of fulfilling all physiological needs, and so temporarily arrest- 
ing respiration). 
Clinical Conclusions.-The value of the method herein detailed has 
been summarized, from the clinical point of view, by Cannon 1 as follows: 
(1) Three months' active experience in the clinical application of 
these experimental data proved specifically, reduction of the incidence, 
degree and extent of pleurisy. 
(2) Prevention of contralateral collapse. 
(3) Practical elimination of pneumonia as a complicating factor. 
(4) Operations performed under analgesia rather than anesthesia, 
permitting successful surgical intervention in otherwise hopeless chest 
wounds, and eliminating to a large degree the anesthetic factor in shock. 
Bunnell Apparatus.2-This apparatus is useful for the purpose under 
discussion, but was not used as far as the author knows, during the 
World War. 
In this method the differential pressure apparatus is the size of a 
jack-knife and there is no more difficulty in applying it than in giving 
the ordinary gas and oxygen anesthesia. Nitrogen oxid with oxygen has 
the following advantages over ether as an anesthetic in thoracic surgery. 
(1) It is the only general anesthetic which will allow the continuous 
application of a mask to the face throughout the operation. Ether 
causes the collection of mucus in the throat, coughing, vomiting, and 
such relaxation that the tongue falls back into the pharynx. These 
emergencies, which are practically not encountered when nitrous oxid 
and oxygen are used, make the face-mask impracticable with ether, and 
necessitate either a catheterization of the trachea, or the enclosing of the 
head or body of patient in a cabinet. 
(2) No pump of any kind is needed. 
1 Loc. cit. 
2 Bunnell, Sterling: Personal communication to author, March 20, 1922. Also: 
Calif. State Jour, of Med., January, 1910; Jour. Am. Med. Assoc., 1912, 58, 
March 23, 835. ANESTHESIA DURING THE WORLD WAR 
701 
(3) Nitrous oxid and oxygen is the safest anesthetic; compared with 
ether, there is little or no shock from gas, and shock and lowering of 
resistance are important factors in causing death following operations 
within the chest. 
Fig. 272.-An Attachment to Anesthetic Mask Which Raises the Pressure so 
as to Prevent Collapse of the Lungs in Intrathoracic Operations. The 
spring device (A) is shown fastened by snap clamp (B) to valve of mask. 
Slider (C) presses a spring on lever (D), which applies the desired pressure to 
the exit valve of the mask through the short piece of rubber tubing (E). 
(4) Actual cautery may be used on ends of bronchial tubes as nitrous 
oxid is not inflammable. 
The Apparatus.-The only special apparatus needed is a small spring 
device. This is made to snap on to the valve stem of the mask of any 702 
ANESTHESIA 
standard nitrous oxid and oxygen apparatus. As can be seen in Fig. 
291, the slider is set at any desired point and presses the spring 
that pushes the lever which presses the valve of the mask. Thus, the 
position of the slider controls directly the degree of inflation of the 
lungs. 
Principle.-The expansion of the nitrous oxid and oxygen, as they 
are allowed to escape from their storage cylinders, furnishes the positive 
pressure. The mixed gases are delivered into a mask and can escape 
only when they are under sufficient pressure to force open an exit valve, 
which is closed by a spring set at the desired pressure. As the patient 
inhales, the valve closes, and he inhales nitrous oxid and oxygen. As he 
exhales, this exit-valve opens and the expired gases escape. This takes 
place with ordinary anesthesia with any standard gas and oxygen ap- 
paratus without differential pressure. The pressure on the valve, which 
is the only open part of this respiratory system, is then atmospheric 
pressure. When the spring device is applied physiologic conditions are 
not altered, but a little additional pressure is added to atmospheric pres- 
sure on the valve. It is the same as if the head of the patient were in 
a cabinet with pressure at a little more than atmospheric (say at 768 
instead of 760). 
The pressure in the mask can never exceed this amount because the 
valve will open, and it can never fall below this amount because of the 
flow of gases into the mask. The result is that the pressure in the 
respiratory system remains practically constant, so long as there is 
sufficient flow of gases into the mask. It will be seen that the lungs will 
remain inflated to any desired degree, and if an extra large gush of gas 
should rush from the tank, the impulse is not visibly transmitted to the 
lungs, but merely spends itself through the exit-valve. 
Directions for Use.-The patient should receive preliminary medica- 
tion of morphin gr. % and atropin gr. %go ; less nitrous oxid will then 
be required. One person should give the anesthetic and another should 
manage the mask and pressure. When the chest is about to be opened, 
the spring device should be snapped on to the valve on the mask and the 
slider moved down to the mark corresponding to 8 mm. Hg. This extra 
pressure is not noticeable in the breathing, and when the chest is opened 
the lungs do not collapse. The mask should be kept snugly on the face 
with the pneumatic brim well inflated. If it does not quite fit, a towel 
permeated with petrolatum should be looped around it. This will make 
it air-tight. In adjusting the position of the slider, one should be gov- 
erned entirely by the degree of inflation of the lungs. They should be 
kept almost flush with the chest-wall. Great care should be taken to 
move the slider slowly. It will be found that at all times one can cause 
a great inspiration by suddenly moving up the slider, thus removing the 
pressure. A sudden collapse of the lung is the greatest stimulus to an ANESTHESIA DURING THE WORLD WAR 
703 
inspiration and is a terrific shock to the patient, as such collapse never 
occurs during life. Sudden releasing of slider should be carefully 
avoided and used only to relieve apnea. The lungs should never be 
allowed to bulge into the wound but should be brought up to it as the 
chest is closed. 
Before the operation the nitrous oxid and oxygen apparatus and mask 
should be gone over while it is under water and all leaks should be re- 
paired with adhesive plaster. Much gas may be saved by so doing. It 
is important to ascertain before starting that the cylinders of nitrous 
oxid and oxygen are full. 
Clinically, the degree of inflation of the lungs is not visibly altered 
by the irregularities in the flow of gases, but remains constant and under 
perfect control by the position of the slider. The elastic contracting 
force of the lungs themselves is exactly counterbalanced by the slight 
increase of pressure within them; and the size of the lungs, even with 
both pleural cavities open, is then easily influenced by the expansion 
and contraction of the chest walls which closely surround them. In 
inspiration it is as easy for the gases to pass down the trachea and push 
the lung periphery ahead of it, to follow the receding chest wall, as it 
is for air to enter the chest through the wound. Therefore, it will be 
seen that the inflated lungs expand and contract during the thorax 
operation to the same extent that they do in ordinary quiet breathing. 
The chest wall excursions are slightly greater than in quiet breathing, 
though with much reserve ability and not in the least labored. The 
valve opens and closes rhythmically with respiration, and the quiet 
hissing of the gases escaping through it can be heard at each expiration. 
With a greater flow of gases a slight hissing is heard in inspiration 
also. 
The spring device may be used for artificial respiration, for by mov- 
ing the slider up and down the lung can be rhythmically filled with 
oxygen and allowed to collapse. In case the chest is not open, the slider 
may be moved down without danger of overdistention, but with the 
chest open it should be moved not more than to the one-half inch mark, 
which corresponds to a pressure of 8 mm. Hg. The degree of inflation 
of the lungs is always under perfect control. They move to and fro 
about an inch following the excursions of the chest w'all. 
It is possible in some cases to perform an intrathoracic operation 
without differential pressure. However, it is not justifiable to do so, 
unless from necessity, without the use of some pressure method. The 
great labored respirations that occur when the chest is open cause the 
mediastinum to flap violently from side to side, thus causing shock. 
This, together with the lessened ventilation and consequent strain on 
the circulatory apparatus, adds very materially to the hazard of an 
operation within the chest. 704 
ANESTHESIA 
GENERAL ANALGESIA BY ORAL ADMINISTRATION 
Gwathmey and Karsner,1 in a preliminary communication based on 
animal experiments and a sufficient number of clinical cases to support 
the conclusions drawn from the experimental work, discussed the feasi- 
bility of employing general analgesia, with loss of sensation, and with 
or without loss of consciousness, for otherwise painful dressings and for 
short operations. The desirability of such a procedure becomes apparent 
immediately on entering a military hospital; it likewise has a definite 
place in civil surgery. The experimental work on which these observa- 
tions were based was aided, in France, during the World War, by grants 
from the American Red Cross. 
Many war wounds are accompanied by fractures of bones, and the 
importance of keeping such patients quiet is universally recognized. If 
the dressing of such a wound is accompanied by severe pain, it was cus- 
tomary to produce nitrous oxid-oxygen or light ether anesthesia for at 
least the first few dressings, necessitating in most cases, because of limi- 
tation of apparatus, removal of the patient to the operating room. This 
usually means pain and the danger of misplacing the bone fragments 
before and after dressings, as well as loss of time to surgeons, nurses, and 
orderlies. General analgesia, produced simply and quietly without tak- 
ing the patient from his bed, was the logical solution of this difficulty, 
and the technique evolved as the result of this study made it possible to 
administer the analgesic by mouth with perfect safety. It is, of course, 
applicable to practically all forms of painful dressings; it may be neces- 
sary to supplement the analgesia with novocain for the skin incisions, a 
hypodermic injection of morphin, or even by light inhalation anes- 
thesia. 
Local conditions made it seem advisable to select rabbits as 
the animals for the preliminary work. The animals were tied to a 
board and the various substances given by stomach tube, after 
which the animals were immediately released and placed under 
observation. 
Quinin and Urea Hydrochlorid (Nikalgin) : 
Weight of 
Animal 
Amount 
Result 
2200 gm 4 c.cm. 
2105 " .... 8 c.cm 
2250 " .... 16 c.cm. 
1795 " .... 30 c.cm 
2215 " .... 60 c.cm. 
No systemic effect. 
Unable to stand after 10 minutes and 
died in 8 to 17 hours. 
1 Gwathmey, James T., and Karsner, Howard T.: Brit. Med. Jour., March 
2, 1918. ANESTHESIA DURING THE WORLD WAR 
705 
Trional (dissolves in alcohol, 1 grain to 1.5 c.cm.) : 
Weight of 
Animal 
Amount 
Result 
2230 gm 1 grainReflexes active. 
2470 " .... 3 grainsReflexes abolished in 1 hour; still on 
feet. 
2175 " .... 6 grainsReflexes abolished in 45 minutes, re- 
maining so for 5y2 hours; full re- 
covery in 8 hours. 
2460 " .... 9 c.cm. alcohol Reflexes partly abolished. 
(control) 
Morphin Tartrate (in water) : 
1810 gm V2 grain . .. 
2560 11 . .. . 2 grains... 
2000 " .... 3 grains... 
2050 " .... 4 grains... 
No appreciable effect. 
Paraldehyd: 
1710 gm 2 c.cm Dropped in 15 minutes, slept 4 hours; 
not analgesic. 
2220 " ... . 4 c.cm Dropped in 15 minutes; analgesic 6 
hours; complete recovery. 
6 c.cm Died in 15 hours. 
Ether in Olive Oil, 50 per cent: 
2430 gm 5 c.cm Reflexes only partially inhibited; never 
off feet. 
2170 " .... 15 c.cm Reflexes partially inhibited. 
2420 " .... 30 c.cm Reflexes completely abolished; appar- 
ently full recovery. On repeating 
dose next day, animal died in 30 
minutes. Necropsy showed dilated 
stomach, with congestion, erosion, 
and submucous petechise. 
2060 gm 20 c.cm Reflexes abolished in 6 minutes; ap- 
parently complete recovery in 1 hour 
16 minutes. Killed after 24 hours, 
and necropsy showed same findings 
as in preceding animal. 
2095 gm 25 c.cm Reflexes abolished in 5 minutes; ap- 
parently complete recovery in two 
hours. Killed after 24 hours, with 
same result as in preceding animal. 
- 30 c.cm. olive oil No effect. Killed after 24 hours, and 
without ether showed same condition in stomach 
as preceding animals. 
Ether in Olive Oil, 25 per cent: 
Animal 
No. 1 .. 30 c.cm Down in 12 minutes; reflexes not abol- 
ished. 
No. 2 20 c.cm Incoordinate. 
No. 3 10 c.cm No apparent effect. 
Amount 
Result 
All three animals were killed after twenty-four hours; stomach not 
dilated, fundus much congested and covered with much adherent mucus. 706 
ANESTHESIA 
Paraldehyd plus 25 per cent Ether in Olive Oil: 
Weight of 
Animal 
2100 gm 1 c.cm. paralde- 
hyd No effect. 
1880 " .... 10 c.cm. ether in 
olive oil Down in 5 minutes; reflexes partially 
inhibited; practically restored in 10 
minutes. Recovery in 25 minutes. 
2170 " .... Combination of 
above Down in 5 minutes. Reflexes practi- 
cally abolished in 10 minutes. Re- 
covery in 30 minutes. 
1950 " .... Paraldehyd 2 
c.cm. and 25% 
ether in olive 
oil 20 c.cm.. .Down in 5 minutes; slept for nearly 
2 hours. 
2060 " .... 25% ether in 
olive oil 20 
c.cm Down in 5 minutes; slept for 1 hour. 
Amount 
Result 
Other Combinations: 
Weight of 
Animal 
Amount 
Result 
2000 gm... 
'Morphin tartrate .... 1 grain 
Ether 2.5 c.cm. 
-Albolen 7.5 c.cm. 
'Morphin tartrate .... 1 grain 
Paraldehyd 1 c.cm. 
Albolen 2 c.cm. 
Paraldehyd 1 c.cm. 
Ether 3.75 c.cm. 
-Albolen 11.25 c.cm.. 
All incoordinate but 
no other effect. 
1965 gm.. 
2110 gm... 
These experiments were not conducted as experiments on the detailed 
physiology of analgesia, but simply for the purpose of demonstrating 
that analgesia could be produced by oral administration of proper agents. 
As will be seen, various combinations of drugs were not especially suc- 
cessful, and in rabbits the best results were obtained by the use of ether 
in oil. It was found, however, that this mixture produced acute gastritis 
in the animals, but further investigation showed that olive oil alone 
produced quite as severe a gastritis as when combined with ether. Know- 
ing that olive oil is practically non-irritant to the human stomach, it was 
considered safe to proceed with the investigation on man. It was 
thought, however, that some mineral oils might be even less irritant in 
man, and accordingly the menstruum was changed to either liquid 
paraffin (albolen) or Russian mineral oil. The fact that there are said 
to be ether drinkers in Ireland and France who apparently suffer no 
more than alcoholics, made it seem additionally safe to try the mixture 
of the two for clinical work. Additional support was drawn from the ANESTHESIA DURING THE WORLD WAR 
707 
fact that in many hospitals ether was being applied as a local dressing 
without deleterious results. Finally, a 65 per cent solution of ether in 
oil has been used in many thousands of cases of oil ether colonic anes- 
thesia without any sign of local irritation to rectum or colon. 
The following combinations were tested clinically: 
Clinical Data 
I. Ether \ -- 
Liquid paramn J 
Aq. menth. pip fl v 
II. Paraldehyd fl3j to iij 
50 per cent ether in albolen q.s. ad 
Aq. menth. pip fl v 
III. Ether fl5-iijss 
Albolene A3 iv 
Aq. menth. pip ft v 
The mixtures containing paraldehyd were disagreeable to the taste 
and smell, the ether oil very much less so, but the difficulty was soon 
overcome by following a suggestion by Major W. E. Lower. One ounce 
of port wine is placed in a glass and the analgesic in another glass. The 
patient takes a mouthful of wine, holds it for about thirty seconds, 
rinsing the mouth so as to get the aroma in the upper air passages and 
the taste well established, and then swallows the wine. The ether mixture 
is then taken and is followed immediately by the remainder of the wine. 
Several wines and liqueurs were tried but port wine was found to be 
the most satisfactory. It was given to numerous patients with excellent 
results; only one patient was nauseated, a man who was violently op- 
posed to taking the wine. As opposed to that case it was given to an- 
other man, who had repeated attacks of vomiting. His dressing was 
done without pain, and his vomiting ceased permanently. All patients 
were able to take food and wTater shortly afterward, and even in those 
much exhausted by infection, there were no deleterious after-effects. It 
wasi soon found that the paraldehyd served no useful purpose, and most 
of the dressings were done with Formula I. While it is well not to give 
the analgesic immediately after a meal, no especial preparation of the 
stomach is necessary. 
Under the general direction of Major W. E. Lower, the following 
cases w'ere dressed in No. - (Lakeside, U.S.A.) General Hospital, 
American and British Expeditionary Forces, by Lieutenants B. I. Har- 
rison and W. R. Barney. All the dressings were done without removing 
the patient from the ward. 
Case i 
Soldier, aged 36. Gunshot wound of right thigh, and infected com- 
pound comminuted fracture of femur. Previous dressings had been very 708 
ANESTHESIA 
painful, and the splint could not be changed without general inhalation, 
anesthesia. Given: Paraldehyd fl3 j, ether AS iij, liquid paraffin q.s. ad j). 
In fifteen minutes fell into a light sleep. The wound was dressed, splint 
removed, through-and-through wound irrigated with ether, gauze drain 
inserted down to femur, and Thomas splint applied with extension. The 
patient talked during the dressing, felt practically no pain, and suffered 
no nausea or other ill after-effects. The dressing was repeated in a similar 
manner every other day for four dressings, and in none of them was there 
pain or any alteration of pulse or respiration. 
Case ii 
Soldier, aged 28. Gunshot wound of left thigh, with compound com- 
minuted fracture of femur. He was given same mixture as Case I, and 
fell asleep after twelve minutes. The Thomas splint was removed and 
replaced, gauze packing removed, wound irrigated with ether, and another 
gauze pack reinserted. The patient groaned when the pack was reinserted, 
but after regaining complete consciousness said that he had felt no pain 
during the dressing. Three subsequent dressings were done on alternate 
days with no nausea or other after-effects, nor alteration of pulse or 
respiration. The patient complained of the taste of the mixture, but said 
it was far to be preferred to the extreme pain of the dressings. 
Case hi 
Soldier, aged 23. Gunshot wound of left leg-compound comminuted 
fracture tibia and fibula; through-and-through infected wound. He was 
given the same mixture as Case I, fell asleep after fifteen minutes and slept 
for thirty minutes, during which the dressings were done. Thomas splint 
repadded, packing removed and reinserted; ether irrigation. Two dress- 
ings were done without ill after-effects. 
Case iv 
Soldier, aged 39. Gunshot wound of left thigh, through-and-through, 
with compound comminuted fracture of head of femur. All previous 
dressings extremely painful. Given paraldehyd fl5 ij, ether, albolene, aa 
fl3 iij. Wound cleansed, packing removed and reinserted. The patient 
groaned at one time, but had no later recollection of having had pain. 
The pulse increased from 108 to 110 and respirations from 26 to 28. No 
nausea. Three subsequent dressings on alternate days were equally pain- 
less and without ill after-effect. 
Case v 
Soldier, aged 23. Gunshot wound of right leg, infected; compound 
comminuted fracture of tibia. Dressings very painful. He was given 
same mixture as Case l; dressing done with much less pain than before; 
the pulse rose from 100 to 116, and respiration from 24 to 26. A few days 
later the dose was repeated, and the patient slept through the dressing. No 
ill after-effects. ANESTHESIA DURING THE WORLD WAR 
709 
Case vi 
Soldier, aged 27. Gunshot wound of thigh; streptococcus infection. 
No fracture. Given morphin tartrate gr. %, ether iij, albolene AS iij, 
paraldehyd fl3 ij. Multiple superficial incisions were made for drainage 
with very slight pain, probably because of dressing following too soon after 
administration of mixture. The pulse rose from 110 to 120. The patient 
was vomiting before the mixture was given, but retained it and did not 
vomit afterwards. 
Several other dressings are briefly summarized in the accompanying 
table. The following cases from the service of Captain D. C. Taylor, 
R.A.M.C., illustrate some of the possibilities of the method: 
Two almost parallel cases of penetrating wounds of the knee occurred 
on November 15th. Case I was given the usual inhalation ether anesthesia 
with the Shipway apparatus; Case n was given 1 oz. of 50 per cent ether 
in liquid paraffin. Thirty minutes later a supplementary 2 drachms of 
chloroform were given by inhalation during the operation. The knee-joint 
was opened, pieces of comminuted patella removed, the joint irrigated with 
saline and closed. Both cases rested quietly for one hour after operation. 
Case I then complained, and required a hypodermic injection of morphin 
for the control of restlessness and pain. About the same time Case n 
awakened, drank some milk, and fell asleep again. Both patients slept 
until breakfast time. Case I drank some tea, but refused other food. 
Case n had tea, porridge, and bread-and-butter. Neither vomited after- 
wards, and both were evacuated to a base hospital in about four hours. 
Two other cases of Captain Taylor's were given each a double dose 
of the mixture (2 oz. 50 per cent ether in liquid paraffin). Each re- 
quired only a few additional drops of inhalation anesthesia. The re- 
sultant analgesia after operation was a little more prolonged than with 
inhalation anesthesia. One of these patients was ready for operation in 
ninety seconds, and required 1 dram of chloroform, given drop by drop, 
to "carry on" an operation lasting thirty minutes. 
The substitution of chloroform for paraldeyhd has been found to 
make even a more satisfactory mixture than the preceding. The follow- 
ing formula has been used in approximately thirty cases: 
Chloroform fl5 ss to j 
Ether 1 
Liquid paraffin J aa flSnjas 
It is not recommended at the present time to exceed this. It is our 
opinion that the toxic effect of this small amount of choloroform can be 
disregarded in military surgery. 710 
ANESTHESIA 
Discussion 
The physiology of "general analgesia" by oral administration has not 
been subjected to an exhaustive investigation, but certain important facts 
should be borne in mind by those who contemplate using the method 
outlined. The oil and ether mix perfectly, and do not separate into 
layers. Baskerville has shown the rate of evaporation from minute to 
minute to be constant, so as to form a straight oblique line when plotted 
out. This holds true with different percentages of ether in the oil, in all 
cases assuming a constant temperature and exposed surface. It is there- 
fore impossible for the patient to get an overdose at one time and an 
insufficient amount at another time. The total amount is not absorbed 
at one time; if it were, the administration of 2 ounces of 50 per cent 
ether in oil would produce complete anesthesia, as there would be lib- 
erated 1 ounce of ether. Only a light analgesia is obtained which, for 
operative procedures, must usually be supplemented in some way. Nat- 
urally, the surface for evaporation is greater in the stomach than is the 
case in the colonic method, and the absorption of ether more rapid. The 
total amount that may be given with safety by this method has not yet 
been determined. It is considered advisable for the present to supplement 
the method either by local anesthesia or the administration of small 
amounts of anesthetic by inhalation. But it is important to remember 
that the patient is as safe by this method as if the ether were in a con- 
tainer outside the body. All anesthetics are analgesics, and before the 
danger zone is reached the patient must become anesthetized; hence the 
patient in the analgesic stage is separated from the danger zone by the 
period of anesthesia. We consider analgesia by this method as safer than 
any method of anesthesia. If the anesthetist carries his patient to the 
"blear-eyed" snoring stage, he defeats the object for which this special 
method was devised, the object being to take advantage of the analgesic 
stage of any and all anesthetics used. If adopted it would release from 
the routine of administration of anesthetics a certain number of physi- 
cians who now, in military hospitals, devote their entire time to that 
work. CHAPTER XXI 
ETHYLENE ANESTHESIA 
Arno B. Luckhardt, Ph.D., M.D. 
History and Early Literature.-In the early years following the dis- 
covery of the general anesthetics (ether, chloroform and nitrous oxide, 
1842-1847), physicians, physiologists and pharmacologists tested out 
on laboratory animals, and on themselves, a great variety of more or 
less volatile liquids, as well as several gases, hoping to discover not only 
some new anesthetic but perhaps an anesthetic agent superior to those 
but recently introduced. 
Thomas Nunneley, surgeon at Leeds, was most actively engaged in 
such research. In 1849 he published data based on the examination 
of some 37 compounds. Olefiant gas or ethylene was one of those 
examined. But his results were so unsatisfactory that he deemed it 
unworthy of further trial and serious consideration. In fact, he con- 
sidered common coal gas not only "cheap and easily manageable" but 
a decidedly better anesthetic agent. Nunneley did, however, use 
ethylene dichlorid (Dutch oil, oil of the Dutch chemists) quite ex- 
tensively in his surgical practice and with results more satisfactory 
than those reported by Simpson. Careless bibliographers and authors 
credit both with having used ethylene gas itself when both state spe- 
cifically that they used the "chlorid of hydrocarbon," a colorless oily 
liquid of peculiar sweetish taste and ethereal odor" produced by the 
interaction of "equal parts of olefiant gas and chlorin." 1 
The physiologist, L. Herman, made some preliminary experiments 
with ethylene (1864) in which he noted on himself a mild intoxicating 
action (schwach berauschend). He never redeemed his promise to give 
a detailed account of the gas on himself probably because he nearly 
killed himself by inhaling a product containing carbon monoxid (1874). 
Davy and Muller experimented with the gas; the latter described chiefly 
toxic effects which point strongly to the probability that he was using 
an impure product. Eulenberg (1876) denied these toxic properties 
*See article by Luckhardt & Lewis: J. A. M. A., December 1, 1923, p. 1851, 
for further details. A more detailed account of the available bibliography will be 
found in this article. 
711 712 
ANESTHESIA 
and induced a slight anesthesia in one rabbit and one pigeon but killed 
the pigeon by a 30 per cent ethylene-air mixture. 
In 1885, Luessem reported several fatalities using a 75 per cent 
ethylene-oxygen mixture on frogs, rabbits, and one canary, due pre- 
sumably to the presence of CO. Using a purer product he anesthetized 
two dogs and on£ guinea pig with an 80 per cent ethylene-oxygen 
mixture. The same mixture had very little effect on himself; for only 
after eighteen minutes of inhalation did he notice weakening of arms 
and legs, vertigo, and an uncertainty of gait. He described neither 
analgesia nor suggested the possible use of ethylene as an anesthetic. 
In the ensuing thirty-three years no further reference to ethylene 
is found in the literature. In 1918, Luckhardt and Thompson, without 
knowledge of the previous work just reported, established on frogs, rats, 
and one dog the analgesic and anesthetic properties of ethylene gas when 
administered in a mixture of 80 per cent ethylene and 20 per cent 
oxygen. They took up the study of this gas at the time because of its 
great toxicity on carnations, castor oil plants, and sweet pea seedlings. 
Since ethylene was found by Crocker and Knight1 to be more toxic than 
carbon monoxid for carnations it was thought possible that ethylene 
might be extremely toxic for animals and that the toxic properties of 
ordinary illuminating gas for animals and man might be due quite 
as much to the ethylene as to its carbon monoxid content. The Great 
War interrupted the research temporarily. Luckhardt and Carter re- 
sumed the work in 1922, and the preliminary and unpublished experi- 
ments of the investigators were confirmed and greatly extended. The 
work involved not only a. greater number of experiments on frogs, 
white rats, mice, guinea-pigs, rabbits, and kittens, but included also 
a study of other gases administered simultaneously to a given species 
of animal. The apparatus was so devised that it was possible to ad- 
minister ethylene, nitrogen, hydrogen, and nitrous oxid to a given 
species at the same time, at the same rate, and in the same concentration; 
partly in order to evaluate the possible asphyxial effects of ethylene 
in producing anesthesia, partly to compare the effects of ethylene at 
a given concentration with the same concentration of the well known 
anesthetic, nitrous oxid.2 
The work was next extended to the dog. No deleterious results 
having been observed in the dog after relatively prolonged and oft 
repeated administrations of the gas, Luckhardt and Carter studied its 
effects first on themselves and other volunteers. At a private demon- 
tration given in the Physiology Building of the University of Chicago to 
a group of surgeons, internists, and professional anesthetists, Luckhardt 
1 Crocker & Knight: Botanical Gazette, 1908, pp. 259-276. 
2 Luckhardt & Carter: Jour. Amer. Med. Assoc., March 17, 1923, vol. 80, p. 765. ETHYLENE ANESTHESIA 
713 
and Carter again served as subjects. So well satisfied were the physicians 
with the rapid action of, complete relaxation by, and rapid recovery 
from the gas that ethylene was used within several days (March 14, 
1923) in the Presbyterian Hospital, Chicago, as a general anesthetic. 
Brown 1 reported confirmatory results on mice, rabbits, cats and dogs. 
On April 27, 1923, Luckhardt and Carter 2 reported the first 106 cases 
operated on under ethylene at the Presbyterian Hospital, Chicago. 
Preparation of Ethylene (C2H4) or Olefiajit Ga^.-Ethylene, or ole- 
fiant gas as it was known years ago, was apparently prepared by one 
Becker even before Ingenhouss, whom Priestley (in 1779) credits with 
first having generated it. Following Ingenhouss, a great many Dutch 
chemists prepared it (Deimann, Paets, van Troostwayk, Bondt, Lauwer- 
enbusch), who studied its chemical and physical properties. The early 
investigators found that it combined readily with chlorin gas to form 
an oily colorless liquid. The compound so formed was given a variety 
of names, such as "chlorid of olefiant gas," "hydrochlorate of chlorid 
of acetyle," "chlorid of hydrocarbon," "Dutch oil," or "oil of the Dutch 
chemists" (1849). It was this compound and not ethylene itself which 
Simpson experimented with and which Nunneley used as an anesthetic 
agent in a number of cases.3 
Ethylene is quite readily prepared by allowing very small quantities 
of absolute ethyl alcohol to interact slowly with very hot sulphuric acid, 
orthophosphoric acid, or even with kaolin. As a result of this interaction 
ethyl alcohol loses a molecule of water: 
' h2so4 
or 
H3P04 
or 
„ Kaolin 
C2H5OH + heated 
= C2Ht + H20. 
Luckhardt and Carter used the orthophosphoric method which con- 
sists of slowly introducing absolute alcohol from a separatory funnel 
led to the bottom of a 500 c.c. flask, containing between 100 and 150 c.c. 
of orthophosphoric acid, held at a temperature of 210 to 230 C., the 
ethylene being allowed to pass first through an empty wash bottle 
(which took care of the water distilling over), thence through a series 
of four wash bottles containing 33 per cent potassium hydroxid (to 
remove any carbon dioxid present), being finally collected, into 17 liter 
demijohns for storing. 
1 Brown: Canadian M. A. J., March, 1923. 
2 Luckhardt & Carter: Jour. Am. Med. Asso., Vol. 80, May 19, 1923, p. 1440. 
3 The author could find a record of only four cases although Nunneley states 
that he used it extensively in his practice (Nunneley: Prov. Med. Surg. Jour., 
Leeds, March, 1849, p. 166. Also Nunneley: Trans. Proc. Med. fy Surg. Assoc., 
London, 1849, pp. 167-381). 714 
ANESTHESIA 
Hempel advises passing the gas also through concentrated sulphuric 
acid (specific gravity, 1.84, to remove the aldehyd) and in addition 
through copper sulphate (for the absorption of phosphin, if any should 
be present), but the two latter precautions were found to be unnecessary. 
Anhydrous aluminum sulphate was used as a catalyst in somd of the 
preparations, but with questionable results. 
This method was chosen after the concentrated sulphuric acid- 
absolute alcohol method of Ehrlenmeyer and Bunte had been tried, 
partly because much less potassium hydroxid was necessary to take 
care of the carbon dioxid, since no sulphur dioxid was formed, and 
partly because of the fact that a single portion of phosphoric acid could 
be used repeatedly, since the water removed from the alcohol was 
distilled over immediately at this temperature, the acid remaining 
undecomposed. 
The purity of the ethylene thus prepared was determined by analysis 
of samples, bromin absorbing 98 per cent plus, the unabsorbed portion 
proving to be air coming from the generator chamber. Since bromin 
water will also absorb acetylene, this test is not specific. 
A great many methods (described in modern text-boo'ks on organic 
chemistry) have been devised for the preparation of ethylene. The 
one described is rapid and cheap. 
Physical and Ch'emical Properties of Ethylene,-The molecular 
weight of ethylene is 28.04. When prepared as described it is a colorless 
gas having a sweet smell. Many state that the gas smells like molasses 
or sorghum. A few find the odor quite unpleasant. 
Solubility.-It dissolves to some extent in water (0.149 c.c. at 
20° C.). Alcohol and ether are much better solvents. In fuming 
sulphuric acid it is quite soluble (1 c.c. absorbs 8 c.c. C2H4). Ethylene 
forms with bromin, ethylene bromid (C2H4Br2). In fact its solu- 
bility in bromin water is so rapid and complete that the method 
is used quantitatively for the determination of ethylene in the presence 
of benzol. 
Ethylene liquefies at 10° C. under a pressure of 60 atmospheres. 
It not only burns in air with a luminous flame but forms with air 
or oxygen a highly explosive mixture. 
C2 H4 '+ 3O2 = 2CO2 + 2H2O 
\|z Jz 1 
(2 vols. 4- 6 vols. - 4 vols. -|- 4 vols.) 
Impurities.-No standards of purity have as yet been elaborated. 
Assuming the storage tanks to be perfectly clean, the generation of 
ethylene by the dehydrating action of hot phosphoric acid on ethyl 
alcohol might lead to the production of carbon monoxid and phosphin 
-both extremely toxic in their action. The variability in the odor of ETHYLENE ANESTHESIA 
715 
different tanks of commercially prepared ethylene and the accumulation 
of an oily material in the gauges at the tank connection are objectionable 
features which the manufacturers are doing their best to eliminate by 
a more careful method of production and compression. At present, 
also, the high moisture content of the gas predisposes to freezing with 
consequent interference to a free flow of ethylene from the tank to the 
gas bags. In our experience the use of gas from highly odoriferous tanks 
of ethylene was followed by an unusual amount of postanesthetic 
vomiting. 
Distribution.-Ethylene is said to escape in large quantities from 
crude oil coming from oil wells and is distilled off during the purification 
of the crude oil. It is formed during the distillation of many organic 
substances. It is present in illuminating gas in variable percentage 
(4% to 22%). Its concentration in the fumes coming from the exhaust 
of a gasoline engine (e.g., automobile) depends greatly on the adjust- 
ment of the carburetor. 
Uses.-Stored in tanks in a more or less pure form under a pressure 
of 800 to 1200 pounds it has been used for some time for light, heat, 
and (with oxygen) as a welding agent. In a dilution with air (1: 5000) 
it has been found to ripen green oranges and lemons with amazing 
rapidity (Denny). During the last war it was used in the preparation 
of mustard gas. 
The Physiological Effects of Ethylene.-Respiration.-In the ab- 
sence of asphyxia, the respiratory center is not markedly affected. If 
care is taken not to force the concentrated gas (100 per cent ethylene) 
in inducing the anesthetic state, the respiration rate remains normal 
for the individual, no period of hyperpnea or dyspnea being in evidence. 
With the proper mixture anesthesia is maintained with respirations 
which are slow, regular and somewhat shallow. The rate and depth 
of respirations are more nearly like normal sleep than is the case with 
other general anesthetics. If the anesthetic is pushed to the limit in 
the dog, the respiratory center fails first (asphyxial stimulation) fol- 
lowing a period of marked activity and at a time when the heart beats 
more slowly perhaps but quite regularly and forcefully. A short period 
of artificial respiration (with air or oxygen) suffices Completely to re- 
suscitate the animal. 
Cardio-inhibitory Center.-Under the usual conditions of anes- 
thesia the rate of the heart is not appreciably affected. In some indi- 
viduals who are deeply anesthetized a slight decrease in the pulse rate 
of central vagal origin is noted. 
Vasomotor Center.-A slight depression of the blood pressure may 
occur (10 to 15 mm. Hg) in the course of a prolonged and deep ethylene- 
oxygen anesthesia. No exact data are as yet available as to the cause 
of this depression. The unusually pink coloration of the skin, mucous 716 
ANESTHESIA 
membranes, and viscera suggests a generalized vasodilatation as the pos- 
sible cause of this slight lowering of blood pressure. This factor coupled 
with the slight cardiac inhibition might account for the phenomenon, 
especially if it were shown that the cardiac systole was less forceful. 
Hemoglobin.-The almost florid condition of the patient noted at 
times, not only during the operation, but for a short time after the 
cessation of the anesthesia, suggested, however, that ethylene might 
form with hemoglobin a specific but easily dissociable hemoglobin deriva- 
tive of cherry red appearance. The persistence of the characteristic 
red color on the sponges furthermore suggests such a compound. 
Manchor 1 has in fact described such a compound as occurring in vitro. 
This investigator found that the absorbability of ethylene by blood 
decreases from 0° C. to 36.2° C. At the last mentioned temperature 
100 c.c. blood absorbs only 2.6 c.c. (760 mm. pressure); at 0° C., 27.0 c.c. 
(736 mm. pressure). So far, however, no characteristic spectrum of 
ethylenated blood has been detected. From this discussion, it is clear 
that the pink coloration of the skin and mucous membranes may be 
due not to vasodilatation but to a peculiar light red ethylene-hemo- 
globin. 
Nervous System.-The rapid action on nervous tissue after a few 
inhalations of 80 per cent C2H4 O2 mixture is striking. This is 
most noticeable with respect to the olfactory sense. The peculiar odor 
of the gas rarely persists after the fourth full inhalation and reflex 
swallowing induced by this or a slightly higher concentration of the 
gas ceases about the same time. Consciousness is then quite promptly 
lost (certainly in the author) with a sense of well being and a quiet 
and supreme contentment. The anesthetic state promptly supervenes 
following the inability of the subject to maintain the arm in an extended 
position or to repeat any word previously agreed upon. The analgesic 
state is present for some appreciable time before the deep tendon reflexes 
are abolished. In fact, analgesia may be present within thirty seconds 
after administration. 
Musculature.-In most individuals a complete flaccidity of the 
skeletal muscles is present on disappearance of the tendon reflexes. 
Tone, rhythmicity and the irritability of the smooth musculature (e.g., 
of the gastro-intestinal tract and uterus) are lost late. 
Glandular System.- (a) The sweat glands are not stimulated, the 
patient remaining warm and dry even after a prolonged administration. 
(b) Neither do the salivary glands pour out large quantities of 
mucus as is common with ether. 
(c) Since ethylene has no irritating action on the mucous membrane 
1Manchot: Untersuchungen ueber die Sauerstoffbindung in Blut. Annalen, 
370:241, 1909. Luekhardt & Carter, J. A. M. A., 80, 1923, p. 765; also Luckhardt 
& Lewis, J. A. M. A., 1923. ETHYLENE ANESTHESIA 
717 
of the respiratory passages, there occurs no increased secretion of tracheal 
or bronchial mucus. 
It has been used during acute coryza, active sinusitis, acute and 
chronic bronchitis, emphysema and active pulmonary tuberculosis with- 
out any evidence of untoward effects. 
(d) Kidneys.-Ethylene anesthesia whether of short duration or 
otherwise has not been followed so far by an interference with or de- 
rangement of kidney function in normal man or healthy dogs (albu- 
minuria, glycosuria, excretion of phenolsulphonephthalein, ratg of 
elimination of intravenously injected Ringer's solution), nor have any 
alarming symptoms appeared in patients who had at the time of opera- 
tion definite evidences of nephritis and retention.1 A detailed investi- 
gation of the blood chemistry, alkali reserve, kidney function, etc., 
before and after ethylene anesthesia is well under way at the 
Presbyterian Hospital, Chicago (Oberhelman). 
Post-anesthetic Effects.-Vomiting.-About 16 per cent of patients 
vomit on awakening just prior to regaining consciousness. Some 30.2 
per cent of all patients vomit either on awakening or several times 
within the first three hours following the anesthesia. The cause of 
vomiting is not quite clear and has been discussed in the recent article 
by Luckhardt and Lewis.2 Impurities in the ethylene may have a great 
deal to do with the emesis, or may be entirely responsible for it. 
Gas Pains.-The low incidence of gas pains (4.2 per cent) as com- 
pared with ether (36.6 per cent) is an advantage well worth mentioning. 
Delayed After-Effects.-The author has been more or less deeply 
anesthetized for from 1 to 5 minutes some 20 times during the past 
eleven months without noticing any effects immediately on recovery 
(save for slight sense of exhilaration) or at any time afterwards. Further 
work on this aspect ought to be done at an early date on the usual 
laboratory mammals to determine whether or not prolonged or oft 
repeated anesthesia is followed by delayed necrosis or other changes in 
various viscera. 
Causes of Death.-When ethylene is pushed to the limit in dogs the 
respiratory center fails first and at a time when the heart beats more 
slowly perhaps, but quite forcefully. Artificial respiration, as noted 
above, quickly restores the animal. 
In a series of over 1100 patients operated under ethylene anesthesia 
at the Presbyterian Hospital, Chicago, there has been no fatality nor 
any condition of the patient which threatened to be serious. 
Elimination.-In the absence of accurate data, it can be said without 
serious error that the major portion of ethylene is promptly eliminated 
by the lungs. In an early publication a suggestion was made (and 
1 Kretschmer & Luckhardt: " Ethylene Anesthesia in Urology." (In press.) 
'Luckhardt & Lewis: J. A. M. A., Vol. 81, 1923, p. 1851. 718 
ANESTHESIA 
one worthy of further research) that ethylene was in part oxidized by 
the body. Some ethylene is probably eliminated by the stomach; for 
the author has on several occasions had an eructation of ethylene gas 
two to four hours after an anesthesia. 
Technique of Administration and Stages of Anesthesia.-No special 
instructions are necessary for administering ethylene-oxygen anesthesia. 
Anyone capable of administering nitrous oxid can, with a little ex- 
perience, give ethylene with good results. It should be remembered, 
however, that ethylene is a more powerful anesthetic than nitrous oxid. 
Luckhardt and Carter 2 found that mice, rats, rabbits, guinea-pigs, and 
kittens could be anesthetized with a 90 per cent ethylene and 10 per cent 
oxygen mixture in one-half of the time necessary to anesthetize the 
same animals with the same percentage of nitrous oxid. Even in lower 
concentrations ethylene was found to be more rapid in its action. Be- 
cause of its more rapid and potent action the administration really 
requires less skill, experience, and watchfulness. 
A 90 to 95 per cent mixture is directed towards the patient's nose. 
After breathing this mixture of air, ethylene and oxygen of uncertain 
composition for some ten seconds with loss of the olfactory sense and 
often of the pharyngeal reflex, the mask is tightly applied (open 
method) and the patient supplied with an 80 to 85 per cent mixture. 
The exact percentage of ethylene varies with the individual and nature 
of the operation. On the basis of some 800 operations the average 
mixture used was 87.6 per cent (with about 13 per cent oxygen). 
The stages of anesthesia can be judged by the same criteria, on the 
whole, as described for nitrous oxid. If a short (5 to 10 minutes) 
period of administration is allowed before operative procedures are 
begun, muscular relaxation is more pronounced than immediately after 
the induction of the anesthetic state. The anesthetic should never be 
forced. As with nitrous oxid (Gwathmey) this latter procedure simply 
invites danger 1 and may be followed by jactitations. 
Our observations on ethylene were made on patients, on the whole, 
who have not been premedicated with morphin, scopolamin, codein, or 
atropin. As a result, we have been able to properly appraise the potency 
of ethylene as an anesthetic agent. Alone it is more powerful than 
nitrous oxid for animals and man but not quite as effective as ether. 
When given from one-half to three-quarters of an hour following the 
administration of a suitable dose of morphin (in adults) or codein (in 
children) with or without atropin, ethylene-oxygen produced an anes- 
thetic state as profound as ether and without the prolonged uncomfortable 
after effects to the patient (vomiting, gas pains) and anxiety to the 
surgeon (post-operative pneumonia) noted after this latter anesthetic. 
There certainly is no known special contra-indication to the use of 
1Gwathmey: J.A.M.A., 81, 1923, p. 1133. ETHYLENE ANESTHESIA 
719 
morphin or atropin. For upper abdominal work particularly, pre- 
medication is a decided aid in attaining a smoother anesthesia. In 
this class of patients premedication eliminates the tendency of the 
anesthetist to push the anesthetic in order to obtain more complete 
relaxation with possible failure of the respiratory center.1 Of the two 
evils, morphin is certainly the lesser when given prior to anesthesia. 
If this has not been done, the administration of a small amount of 
ether is from any point of view more physiological than repeated and 
dangerous attempts at saturation of such patients who appear to be 
especially refractory. 
The statement just made implies that ethylene-oxygen can be ad- 
ministered with ether. As a matter of fact, the induction to ether is 
smoother than it is with nitrous oxid. 
Contra-indications.-At no time, perhaps, is the choice of an anes- 
thetic a matter of greater concern to the surgeon than it is in elderly 
men who consult the urologist for surgical aid. The existing pulmonary, 
cardiac, vascular and renal pathology and, of course, functional im- 
pairment, requires an anesthetic which will neither predispose to 
pneumonia, cripple the action of the heart, effect a dangerous elevation 
of blood pressure, or suppress still further the urinary excretion. In 
such conditions, ethylene is the anesthetic of choice as well as in 
diabetics who require surgical interference. Whether used in children 
of six or men of eighty-eight, with extensive pathology, no deleterious 
effects were noted. Even after its continuous administration for three 
hours and ten minutes, one patient (leg operation) recovered conscious- 
ness in less than five minutes, got off the operating table with some 
aid, and ate his usual meal two hours later. There exists at present 
no contra-indication to its use. It has been used in the young and 
old with extensive pathology other than that for which operated on. It 
has been used in general surgery, genito-urinary surgery,2 gynecology 
and obstetrics,3 in oral surgery and dentistry (Dodge, Christiansen). 
Advantages.-The advantages of ethylene-oxygen as a general anes- 
thetic have been fully discussed in an article,4 to which we refer the 
reader. These advantages are as follows: 
(1) Ease of induction and rapidity of recovery. 
(2) Relaxation without cyanosis. 
(3) Absence of sweating. 
(4) Absence of respiratory irritation. 
(5) Narrow anesthetic margin. 
1Gwathmey: J.A.M.A., 81, 1923, p. 1133. 
2 Kretschmer & Luckhardt: Article in press. 
3 N. Sproat Heaney: An article on its use in Gynecology & Obstetrics is now 
in press. 
4 Luckhardt & Lewis, vide supra. 720 
ANESTHESIA 
The low incidence of gas pains and relative freedom from severe 
and prolonged vomiting are advantages chiefly emphasized by patients 
previously operated on under ether. At that we are certain that the 
incidence of post-anesthetic vomiting will be greatly reduced with the 
production of a purer commercial product. Pure ethylene has a distinct 
odor. No one, perhaps, not even surgeons or anesthetists, will complain 
of the gas on this score once it is tanked as a chemically pure product. 
As previously pointed out the sense of smell is soon lost after but a 
few inhalations of ethylene. So far it has not been found neces- 
sary to disguise its odor with perfume or essential oils (oil of pine, 
lemon). 
Disadvantages.-Aside from the odor just discussed ethylene has two 
disadvantages, one insignificant, the other more serious. Oozing at the 
time of operation is more marked with ethylene than with the other 
anesthetics. It was never serious nor did the oozing persist after dis- 
continuance of the anesthetic. 
The inflammability of the gas and its explosibility in proper con- 
centration with air or oxygen is a property of the gas which precludes 
its use in the presence of a free flame, electric cautery, or in the imme- 
diate proximity of any source of electrical discharges. In this respect 
it resembles ether. The possible development of static electricity as 
the result of the long continued flow of ethylene-oxygen mixture through 
the rubber tubing leading to the mask and the sudden ignition of this 
mixture by a jump spark suggests that there should be an uninterrupted 
metallic connection from the tank to the face mask and that the tank 
be itself grounded. Ether-oxygen mixtures administered through insu- 
lated rubber tubing have been known to explode with serious violence 
as the result of a jump spark. Although the instances are very rare, 
every precaution should be taken to avoid their occurrence by the method 
suggested above. The same precautions apply for ethylene-oxygen and 
should be taken before some serious accident occurs. These potential 
dangers of ethylene-oxygen anesthesia have been exaggerated, unfortu- 
nately, by some, and minimized by others. Generated by students of 
elementary organic chemistry for purposes of subsequent study, ethylene 
has been put in tanks, shipped and used for purposes of lighting, heating 
and welding under conditions less carefully supervised to avoid serious 
explosions than in the operating room. 
Case Reports.-The inclusion of case reports with a short discussion 
would unduly lengthen this article. A short series illustrative of ethylene 
anesthesia are incorporated in a recent article.1 The forthcoming articles 
of Kretschmer & Luckhardt and N. Sprout-Heaney likewise contain 
several cases of interest. 
1 Luckhardt & Lewis, vide supra. ETHYLENE ANESTHESIA 
721 
COMMENTS BY THE AUTHOR 
Confirmatory and independent opinion seems necessary in order to 
establish firmly so new an anesthetic as ethylene. Therefore the follow- 
ing notes, even in a text-book, do not seem out of place. 
It would seem that Brown's independent observations and priority 
of notification of animal experiments should receive recognition, although 
Luckhardt certainly commenced laboratory work on ethylene before 
Brown. To Arno B. Luckhardt, more than to any one individual, goes 
the credit for painstaking laboratory work of the highest order, indis- 
putably establishing ethylene as an anesthetic and analgesic agent, both 
safer and better than nitrous oxid. 
Experimental Data.-There are fourteen hydrocarbon gases: 
Acetylene C2H2; Ethylene C2H4; Propylene C3H6; 
Butylene C4H8; Allylene C3H4; Crotonylene C4H6; Terene C5H8 
and the vapors: 
Benzene C6H6; Styrolene C6H8; Naphthalene C10H8; 
Pentane C5H12; Hexane C6H14; Heptane C7H16; Octane C8H18. 
All of these have anesthetic value, and should be carefully investi- 
gated. Acetylene may be of greater anesthetic and analgesic value, 
but the possibility of explosion would be ever present. The author has 
used propylene (C3H6) in the laboratory; it has anesthetic and analgesic 
qualities, and if its odor could be modified, and no pathological lesions 
followed, it could be used. Unless it was equal to or superior to ethylene 
it would be useless to develop it. 
The laboratory work for this paper was done in the Pharmacological 
Department of the University and Bellevue Hospital Medical College 
under the supervision of Dr. George Barclay Wallace, using white mice 
and dogs. Ethylene (C2H4) is an unsaturated hydrocarbon, is not a 
highly reactive gas, and is not likely to form compounds in the body. 
Explosibility.-"With the conditions under which it is used as an 
anesthetic, it is non-explosive." (Brown.) In order to obtain an 
authoritative opinion on this important subject, G. 0. Curme, Jr., Chief 
Chemist of the Carbide & Carbon Chemical Corporation, was consulted. 
He sent the following report made by John K. Mabbs, Research Engineer 
of the Linde Air Products Company, who, after exhaustive work over 
an extended period, states: "In view of the evidence presented, it 
appears that the relative explosion hazards of ethylene, ether and 
propylene, when mixed either with air or oxygen, are practically equal." 
Action in the Blood.-Brown states that ethylene apparently does 
not enter into chemical combination with the hemoglobin of the blood, 
and that it probably exists in the blood during anesthesia in a state of 
physical solution. Both Brown and Luckhardt agree that 80 per cent 
ethylene and 20 per cent oxygen is the proper proportion for anesthetiza- 722 
ANESTHESIA 
tion. "Blood pressure remains good even at the end of an hour's 
anesthesia." (Brown.) 
Comparative Value.-To determine the comparative value of 
ethylene, ether and nitrous oxid were used as a control. The experiments 
throughout were conducted from a comparative and practical standpoint 
and not to decide any detailed physiological or pathological questions. 
The smaller animals were placed in a glass vessel in the stopper of 
which was a short tube reaching from the anesthetic. A glass overflow 
tube passed through the same stopper and extended to within half an 
inch of the bottom of the jar. In Rilling a number of animals with 
either ethylene or nitrous oxid, there was always sufficient warning to 
resuscitate the animal if necessary. If the animals were taken out 
before the auxiliary respiratory muscles were brought into play (as 
indicated by the interrupted and gasping respiration) they could easily 
and always be revived. If a small amount of oxygen was used, the 
period in which respiration could be counted upon was considerably 
lengthened. Ethylene seemed to affect the brain to a greater degree 
than nitrous oxid, as indicated by the bulging of the eyes with death 
from ethylene. If respiration ceased entirely before the attempt at 
resuscitation, the result was always in doubt and rarely successful. 
When oxygen was used, the induction was smoother, the maintenance 
easier, and the relaxation better with ethylene than with nitrous oxid. 
If a small amount of ether is used with either gas, induction, mainte- 
nance and relaxation are all improved. 
Double Saturation Condemned.-We did not saturate or double 
saturate the animals, and then continue the anesthetic, as this is 
considered an unphysiological and dangerous process. This method is 
mentioned only to be condemned, as it is contrary to the rules of 
ordinary prudence observed by all persons in their wakeful moments, 
and in a normal condition. No patient would submit to asphyxiation 
and resuscitation if told in advance that they would be subjected to this 
experiment, yet this is exactly what occurs. When a patient receives 
100 per cent nitrous oxid long enough to be thoroughly saturated, all 
the tissues of the brain are distended; and if this state is held for any 
length of time or pushed further, there is a possibility of the brain being 
permanently injured, resulting in insanity or some other disorder. The 
author has been personally informed of one case of insanity resulting 
directly from secondary saturation. 
One or two drams of ether added to nitrous oxid and oxygen results 
in a smoother narcosis, and the nausea is increased but little, if at all. 
As ethylene has a much stronger action than nitrous oxid upon the 
brain (as is indicated by the bulging eyes), secondary saturation would 
be especially hazardous with ethylene. It is unnecessary because prac- 
tical results can be obtained without this risk to life. ETHYLENE ANESTHESIA 
723 
The following is the technique of secondary saturation: 
Technic of Secondary Saturation (McKesson).-"Anesthesia is in- 
duced by administering 100 per cent nitrous oxid until the first muscular 
phenomenon of oxygen hunger is observed, as indicated by a change in 
the character or rate of respiration, accompanied by a little snort, a twitch 
of the eyelid, jerk of the hand or foot, or some similar anoxemic muscular 
contraction, clonic in character. Oxygen should now be added to tfte 
nitrous oxid in sufficient proportion to prevent temporarily the further 
development of anoxemia. If relaxation is indicated but has not occurred, 
then proceed to secondary saturation. 
"Secondary Saturation.-Reduce the proportion of oxygen or admin- 
ister 100 per cent, nitrous oxid until the pupil dilates and tonic muscular 
spasm or rigidity develops, and respiration becomes slow or stops. Now 
administer one breath of 75 to 100 per cent oxygen, if he inhales; if he 
does not, partly fill the lungs by inflation with pure oxygen once or twice 
-usually once is sufficient. The cyanotic color now begins to lighten, 
the pupils retract, the pulse is normal or slower than before, the muscles 
become perfectly relaxed and presently respirations resume." 
McKesson further states: "I believe this is safer for the patient than 
an ether sequence or combined gas oxygen-ether mixture, and convalescence 
is decidedly better when even the small amount of combined ether is avoided 
in the narcosis." Fortunately preliminary medication and ethylene make 
"secondary saturation" of very minor importance.1 
Methods Used.-With ether and air (or oxygen), induction is 
slower but maintenance is easier and relaxation is better than with either 
ethylene or nitrous oxid. With ethylene and oxygen, there seemed to 
be a tendency to accumulation, or a tendency to sink deeper when the 
gauges were set at a given place. However, a satisfactory anesthesia 
could always be maintained by a slight increase in oxygen after the first 
few minutes. 
Comparatively, nitrous oxid seemed more of an asphyxiant than 
ethylene and the margin of safety was narrower. In order to maintain 
a smooth anesthesia, a certain amount of cyanosis seemed indispensable 
with nitrous oxid; with ethylene, the same degree of anesthesia could 
be easily maintained with the animal's paws and nose pink at all times. 
The comparative analgesia was not attemped at this time, but was 
later determined in the human subject very definitely. 
A sufficient number of dogs were used to determine that: With 
ethylene or any of the agents used, (1) anesthesia was safer with morphin 
than without the preliminary; and (2) an even plane of anesthesia was 
easier to maintain with ethylene and oxygen than with nitrous oxid 
and oxygen. 
PRELIMINARY MEDICATION 
Up to recent times, the value of preliminary medication has been 
more a matter of opinion than of fact. This refers especially to 
'McKesson, E. I.: " Advances in Pure Nitrous Oxid-Oxygen Anesthesia," 
Am. J. Surg. 34: 10, 1920. 724 
ANESTHESIA 
morphin. In order to determine whether preliminary medication in- 
creases the margin of safety of ether anesthesia, experiments were made 
in the laboratory of the New York University and Bellevue Hospital 
Medical College, under the supervision of Professor George Barclay 
Wallace, the detail work being carried out by his associate, E. J. Pellini, 
and the author. A number of animals received each an injection of 
morphin sulphate for the purpose of rendering them more tractable. 
Ten minutes later 0.5 c.c. of paraldehyd and one c.c. of potassium bromid 
per kgm. weight of aminal in enough water to make a complete solution, 
were given by stomach tube. This was allowed to act for about forty-five 
minutes, after which the animal was placed on the table and anesthetized 
by the intravenous injection of seven per cent ether in saline. The 
time and the quantity of ether solution used was noted when complete 
anesthesia had taken place, and again when respiratory paralysis oc- 
curred. The animal was then resuscitated by artificial respiration. A 
period varying from four to seven days or over was allowed for recovery. 
After this rest the experiment was repeated with and without the pre- 
liminary medication, except for the morphin. 
The following is a protocol showing especially the "margin of safety": 
DOG NO. 20-WEIGHT, 13 KILO. 
Without Preliminary Medication 
June 15,1915. 
10 :30 a. m. 0.5 c.c. of 2 per cent morphin solution. 
11:34 Started intravenous ether administration. 
11:381/2 Complete anesthesia, using 13k c.c. ether solution. 
11:42 Respiratory failure; required only 99 c.c. more ether 
solution. 
With Preliminary Medication 
Sept. 7, 1915. 
2 :50 p. m. 0.5 c.c. of 2 per cent morphin solution. 
3 :10 6.05 c.c. paraldehyd and 13.0 grams potassium bromid. 
3 :59 Started intravenous ether administration. 
4:01% Complete anesthesia, using 87 c.c. ether solution. 
4:09% Respiratory failure required c.c. more ether solution. 
The following conclusions may be drawn from these investigations: 
(1) Anesthesia comes on sooner and less ether solution is used after 
the administration of preliminary medication. 
(2) The margin between complete anesthesia and respiratory failure 
is lengthened with preliminary medication, making anesthesia a safer 
procedure; in other words, "the margin of safety" is increased. 
In every instance the animal was anesthetized more easily and with 
less excitement when preliminary medication was employed. ETHYLENE ANESTHESIA 
725 
Preliminary to surgical operation, or as a hypnotic to replace or to 
assist morphin, this combination can be used with confidence; it has 
been most satisfactorily used in over 200 cases. When for any reason 
ether is contraindicated, it can be used as a preliminary to ethylene or 
nitrous oxid and oxygen. 
With the patient in the Sims position, give per rectum: 
B Paraldehyd 1 
Potassii bromidi, Jaa i ve ij, 
Aquae q. s. ad §iv. 
M. Sig. Give thirty to fifty minutes before operation. 
Crile has demonstrated that when the administration of morphin 
precedes the induction of anesthesia, the acidity of the blood is less than 
in anesthetized animals which have not received this preliminary dose. 
Neither did the morphin when thus given interfere with the return of 
the blood to its normal alkalinity. If, however, morphin was given after 
acidity had been produced by the anesthetic, it delayed the time of 
neutralization; and if given in large doses it prevented the animal from 
overcoming the acidosis. It seems, therefore, that morphin, as a regu- 
lator of acidosis, should always be given before, instead of after operation. 
Cattell1 seems to confirm this. 
Experiments were made to determine the effect of morphin on the 
reduction of the alkali reserve which occurs in shock and low blood 
pressure. A cannula was placed in the pericardium to control the 
arterial pressure, which was reduced to 60 mm. Hg. A mercury 
manometer was connected with one carotid artery and in the other a 
cannula was inserted to obtain blood for the tests. Morphin was given 
in doses of from 10 to 20 mgm. per kilogram of body weight. 
Under the influence of the morphin there was recovery of the alkali 
reserve. This was most marked when the morphin was used before the 
blood pressure was lowered. In several cases the alkali reserve was 
higher at the end of three hours than it was at the beginning of the 
experiment. 
Cattell carried out a series of experiments, principally upon 
cats in which the blood pressure was artificially depressed to 60 mm. Hg. 
A number of the animals were given large doses of morphin and others 
were used for controls. In the former there was at first a slight de- 
pression of the blood pressure, but practically complete recovery within 
two hours. In the control animals the rise in blood pressure was slower 
and less marked. 
1 Cattell, M: " Studies in Experimental Traumatic Shock, VIII, The Influence 
of Morphin on the Blood Pressure and Alkali Reserve in Traumatic 'Shock." 
Arch. Surg., 1923, vii, 96. 726 
ANESTHESIA 
Those who have given preliminary medication a thorough clinical 
test are firmly convinced of its value from both a psychic and a practical 
standpoint. The new preliminary, paraldehyd, and bromid of potassium, 
admits of many variations, and should have a thorough trial. For 
instance, bromid of potassium, one to two drams, may be given in a 
quart of water, per rectum, the night before the operation or two hours 
before the operation. The paraldehyd may be given alone or in com- 
bination with morphin, one half to three quarters of an hour before the 
operation. Either drug may be given alone or in combination with 
the other. Paraldehyd and potassium bromid are among the safe drugs 
of the pharmacopeia. 
ADDITIONAL FACTS 
The following data were collected by T. Drysdale Buchanan, the detail 
work being carried out by Patterson, assistant superintendent of the 
Metropolitan Hospital, New York City. Two hundred and ninety-one 
(291) patients were anesthetized by the open drop ether method. Of 
these, 241 received morphin and atropin as a preliminary; 52, or about 
20 per cent, had nausea or vomiting on the first day, and in only 5 cases 
did it last longer than the second day. The operations lasted from 
fifteen to one hundred thirty-five minutes. The remaining 50 pa- 
tients had no preliminary medication. Twenty-eight of these, or over 
50 per cent, had nausea and vomiting. In none did it last beyond the 
first day. The operation lasted from fifteen minutes to one hour. All 
cases were followed up to the fifth day. The gas pains were the same 
in each series. From the foregoing data it will be seen that morphin 
and atropin decrease nausea and vomiting with the open drop ether 
method over 50 per cent. Cattell states: "There is no evidence that 
morphin has any deleterious action on the circulation or that its use 
is contra-indicated in shock." 
The best method of administering the morph in is to dissolve it in 
two c.c. of a 25 per cent solution of magnesium sulphate,1 bacteria free 
in sterile salt solution.2 
The administration is three small doses of morphin y8 grain each; 
add to the second dose or %50 of a grain of atropin. The first 
dose is given one hour and a half before the time set for the operation 
and is repeated at twenty-minute intervals. "Continued use of the 
twenty-five per cent solution in a large number of cases enables me to 
report that the analgesic effect of the morphin is prolonged with as 
much certainty and success as when supplemented by the subcutaneous 
1 Magnesium sulphate is now put up in ampoules of 2 c.e. sterile solution 
25 to 50 per cent strength Unless the magnesium sulphate is used in large 
quantities, the ampoule is the preferable metnod. 
2 Smythe, Frank D., Am. J. Surg., July, 1923. ETHYLENE ANESTHESIA 
727 
use of the 400 c.c. of a 4 per cent solution." Smythe further states that 
with this preliminary medication 
(1) "The patient is neither frightened nor apprehensive concerning 
the operation or its outcome. 
(2) "The stage of induction is greatly shortened and there is rarely 
a period of excitement. 
(3) "Forty per cent of the patients thus prepared do not require 
an analgesic after operation. 
(4) "The appetite returned earlier in patients operated upon when 
magnesium sulphate had been employed, because of the absence of pain 
and restlessness incident to the trauma inflicted at operation. 
(5) "The patient remained pink throughout the operation, the pulse 
rate rarely exceeded 90, generally varying form 80 to 84. 
(6) "The record of the nurse and bedside notes show that synergized 
patients go on an average four times as long after an operation before 
an analgesic is required than patients who were given morphin dissolved 
in sterile water alone. 
(7) "A general analgesic state obtains and synergized patients go 
for an average of fifteen hours without calling for something to relieve 
pain, as compared with free pain interval of only four hours with patients 
operated upon without the synergists. 
Smythe uses novocain along the line of incision and has his anes- 
thetist use nitrous oxid and oxygen for a light inhalation anesthesia. 
If ethylene and oxygen were used instead of nitrous oxid and oxygen, 
both the analgesia and relaxation would be increased, and more oxygen 
could be given; the only question then would be whether or not the 
vomiting is increased during or immediately after operation with the 
ethylene. 
Another preliminary medication of value is 10 to 15 grains of 
chloretone by mouth or as a suppository, and of a grain of morphin 
by hypodermic. 
When ether is given with oil colonically, nausea, gas pains and other 
untoward effects are absent. One or two ounces of ether with the same 
amount of oil, with or without of a grain of morphin added, given 
one hour before operation, is an effective preliminary medication. With 
two ounces of ether and oil given colonically, plus % of a grain of 
morphin and 6 c.c. of a 25 per cent solution of magnesium sulphate 
given hypodermically, many operations can be performed without any 
inhalation, such as perineorraphy, dilatation and curettage, etc. The 
absence of after-effects, such as pain, nausea and vomiting will compare 
favorably with either nitrous oxid or ethylene and oxygen. (For technic 
of administration see Chapter on Oil-Ether Anesthesia.) 
For shock prophylaxis, Wells 1 recommends morphin hypodermically 
1 Wells, Charles J., Am. J. Surg., July, 1923. 728 
ANESTHESIA 
one hour before the operation. Twenty minutes later, a retention enema 
of one to two quarts of a 5 per cent sodium bicarbonate and 5 per cent 
glucose solution is administered, allowing about twenty minutes for the 
instillation. In diabetics, the glucose is omitted, and the sodium 
bicarbonate increased to 10 per cent. In other cases the glucose may 
be increased to 20 per cent. The author suggests a combination of 
Smythe's and Wells' techniques, and ethylene nitrous oxid and oxygen 
by inhalation. 
ETHYLENE AND OXYGEN IN ORAL SURGERY 
Before proceeding with the clinical administration, the animal ex- 
periments were repeated in the offices of M. Ecker, dentist and oral 
surgeon, in order to convince him that his patients would be quite as 
safe under ethylene and oxygen as under nitrous oxid and oxygen. In 
association with Ecker,1 over one hundred administrations with ethylene 
and oxygen were given, and while this is a comparatively small number 
they were sufficient to confirm the results of the animal work; and by 
way of comparison with over 50,000 administrations of nitrous oxid 
and oxygen, and 20,000 administrations with the same gases passed 
over a mixture of urethan and paraldehyd in Ecker's previous work, 
we were able to reach very definite conclusions. 
The administrations were given with ethylene and oxygen alone, and 
also with nitrous oxid in sequence and combination. When nitrous 
oxid and oxygen were used for induction and ethylene added, the 
induction was smoother but the analgesia was not so great. When the 
ethylene and oxygen were passed over paraldehyd or essence of orange, 
the odor seemed less objectionable than when used alone. In only two 
cases out of the hundred was there nausea and vomiting. The admin- 
istrations averaged from 40 seconds to three minutes, the longest in this 
series being seventeen minutes. Each patient Was questioned as to 
nausea, headache, or unpleasant odor, and with only three exceptions 
the replies were negative. Recovery seemed just a little slower than 
with nitrous oxid and oxygen, but all patients were able to walk un- 
assisted from the chair to the adjoining room. 
The most important result of this series of cases was the determina- 
tion of the amount of analgesia. The best results were obtained with an 
induction of two parts of ethylene and two of oxygen, changing in forty 
seconds to four parts of ethylene. With this proportion, the patient was 
always pink, and when the operation began there was no movement 
whatever. If the face mask was used, analgesia was present almost 
twice as long as when nitrous oxid and oxygen was used. 
1 Ecker has now administered Ethylene with Nitrous Oxid and Oxygen over 
400 times. ETHYLENE ANESTHESIA 
729 
It is a well known fact that of the four anesthetics, ether, chloroform, 
ethyl chlorid, and nitrous oxid, ethyl chlorid possesses, by far, greater 
analgesic properties than the others; yet ethylene possesses as great, or 
even greater, analgesic properties than ethyl chlorid. For instance, with 
ethylene an extraction can be made either before consciousness is en- 
tirely lost or after the return of consciousness without the manifestation 
of any pain reflexes. Using the nasal inhaler, the analgesia may be 
continued indefinitely with an active lid reflex and pink color. With 
nitrous oxid, the patient may be snoring and slightly cyanosed, yet 
almost invariably there would be a slight reflex or movement, although 
the patient may have no remembrance of pain afterward. In this series 
not a single patient had to be strapped or restrained in any way. In 
every instance the brain block was more complete than the control case 
when given nitrous oxid and oxygen, the analgesia appearing earlier 
and lasting much longer. The finger could be swept around the pharynx 
without eliciting any reflex whatever, thus suggesting this agent as 
possibly the ideal one for adenoid and tonsil operations. In other short 
cases, the analgesic properties of ethylene have been fully demonstrated. 
About one-third less ethylene and one-half more oxygen were used in this 
series than with the usual technique of nitrous oxid and oxygen. 
TECHNIQUE FOR GENERAL SURGERY 
Closed Method (Face Mask and Bag}.-In clinical work the 
author prefers to use ethylene and nitrous oxid and oxygen, combining 
and alternating the two gases according to the requirements: if more 
relaxation is needed, ethylene is added; if the anesthesia is too deep, 
or the pulse rate slow, a change to nitrous oxid is made; ethylene may 
be added or substituted again as indicated. The proportion is two 
parts of oxygen to four parts of ethylene or 6 parts of nitrous oxid, or 
two parts of ethylene and three parts of nitrous oxid when given 
together. This method gives an elasticity to the administration never 
before feasible. As the skin incision is being closed, the bag is emptied 
and the lungs are thoroughly flushed out with oxygen. When the 
patient has had preliminary medication, he usually awakens on the 
table in a pain-free state, but will probably fall into a quiet slumber 
upon his return to bed. 
The Open Method.-Where for any reason the closed method is con- 
traindicated, the best procedure is to use a very large mask, about 
four times the size of the ordinary chloroform mask. Starting the 
anesthetic with two parts of oxygen and four of nitrous oxid, the author 
passes this over the surface of anesthol for about two minutes, or until 
the patient is semi-conscious, and then begins adding ether. A change 
is then made to ethylene, the anesthol and nitrous oxid being turned 730 
ANESTHESIA 
off; the anesthol is used no more during the operation, the nitrous oxid 
occasionally. The anesthesia is continued with one or two parts of 
oxygen and one or two parts of ethylene passed through the ether. 
Surgical anesthesia is present in five minutes. A type of anesthesia 
ensues that is characterized by extreme relaxation, good color, pulse and 
respiration. Advantage is thus taken of the full analgesic qualities of 
both ethylene and ether without pushing the patient near the danger 
zone. I employ this method in gall-bladder and other cases requiring 
complete relaxation, using ethylene throughout, neither surgeons nor 
nurses being aware of the fact unless told. With this technique, the 
ether completely masks the odor. A greater and safer relaxation obtains 
with this method than is possible using the drop ether, and with patient 
in the third strata of the third zone. It is the logical procedure to add 
ethylene to ether in this way, this agent being theoretically the element 
that gives analgesic and anesthetic value to ether, and the result seems 
to prove the theory, since only half the usual amount of ether is used. 
Oxygen is given in equal proportion to the ethylene, so that the patient 
is pink at all times. The emergence from the anesthetic is slower than 
by the closed method, but is a vast improvement over any open method. 
The open ethylene-oxygen-ether method is safe, simple, and efficient. 
In ethylene we have a most valuable agent and one that is destined 
to remain with us, provided we can obtain a purer and more reliable 
gas than is now supplied. The administration of ethylene and oxygen 
to 1000 consecutive surgical cases of all kinds, using neither preliminary 
medication nor ether, has fully proved its analgesic and anesthetic 
qualities and speaks well for Dr. Isabella Herb as an anesthetist. It 
is unnecessary, therefore, for others to repeat this procedure. No further 
attempt should be made to use it in this or any other extreme way. Dr. 
Herb occasionally discarded this method for the open drop ether method, 
which fact is very greatly to her credit. 
DANGERS AND MORTALITY OF ETHYLENE 
A death from ethylene might occur in the same way as from nitrous 
oxid, i.e., by exclusion of oxygen or asphyxiation. The record before 
me of one death from ethylene illustrates how all deaths from either 
ethylene or nitrous oxid occur. "I was forcing the anesthesia somewhat, 
to close the abdomen." If you force ethylene (i.e., cut down your 
oxygen and increase your ethylene), or saturate with ethylene or nitrous 
oxid, you change from a safe third degree anesthesia to the first strata 
of the fourth stage, or danger zone. Death may then occur at any time. 
When respiration ceases, the case is usually beyond recall. 
Avoidance of Dangers.-There are two ways to avoid this tragedy: 
(1) Change to open drop ether method instead of forcing. ETHYLENE ANESTHESIA 
731 
(2) By proper preliminary medication (Combination of Wells' and 
Smythe's technic) have your patient analgized. Use ethylene only to 
complete the analgesia and produce unconsciousness. With this method 
you are separated by two stages from the danger zone. Your patient is 
as safe and free from danger as if you were using local analgesia. 
For reasons just stated, a combination or sequence of anesthesia is, 
generally speaking, far safer than any single agent. 
A. 
B. 
Fig. 273.-A. Apparatus for Ad- 
ministering Ethylene, Nitrous 
Oxid, Oxygen and Ether in 
Sequence or Combination, Open 
or Closed Method. 
Fig. 273.-B. Top View. CHAPTER XXII 
PAINLESS CHILDBIRTH BY SYNERGISTIC METHODS 
The development of painless labor by synergistic methods was un- 
dertaken from a purely scientific and altruistic viewpoint. It was 
decided that the method should be so simple that it could be used 
either in the home or hospital, and by any physician, in an entirely 
empirical manner. The ideal sought was a state of relaxation and 
analgesia, with consciousness but little if at all impaired, so that 
full cooperation might be had at all times. The methods by which 
this condition was to be obtained were outlined to the chief and at- 
tending obstetricians of the Lying-in Hospital, Asa B. Davis and 
George W. Kosmak, and were as follows: 
(1) To start with a minimum dose at which time no definite results 
were expected and gradually to increase the dose until definite results 
were obtained. 
(2) To stop at any time in the development of the technic, if 
either mother or child appeared to be in danger. 
(3) To publish the results whether favorable or unfavorable. 
With this understanding, work was commenced on the 10th of Feb- 
ruary, 1923. The first 4 cases showed practically 75 per cent failure. 
Later (9 months later) we secured over 75 per cent success. By "suc- 
cess" is meant the amelioration of pain to such an extent that patients 
state that they were "helped,"-only a few of the 75 per cent had a 
comparatively painless labor. By "failure" is meant whenever the 
patient obtained no relief from the method. At no time was the 
mother's condition imperiled in the slightest degree. Only in one in- 
stance did the infant seem to be affected. Whether or not this was 
from the medication cannot be stated positively, but seemingly it was. 
In the first series of drugs used, there was not only failure but delay. 
This delay was in a measure corrected by placing 10 grains of quinin 
hydrochlorid in the mixture. Sollmann states that "satisfactory results 
have been reported from its use in all stages of labor. This drug 
stimulates the contractions and increases the tone of the uterus." 
Since this addition, in only one or two cases has there been any delay, 
and in these exceptional cases, exhausted nature was more powerful 
than the drug. 
There also seemed at one time to be an increase in the nausea and 
vomiting. This was corrected in a very great measure by eliminating 
732 PAINLESS CHILDBIRTH 
733 
urethan and paraldehyd, thus also making the final mixture simpler. 
The other drugs considered fundamental to the scheme are magnesium 
sulphate, urea, ether, and morphin. Two to four drams of the mag- 
nesium salts is the maximum dose used in our investigations of painless 
labor, although the author has used two ounces of the salts per rectum 
in other cases without deleterious effect. The magnesium sulphate 
must be chemically pure (the usual commercial product may cost 10 
cents per pound-the chemically pure $1.00 per pound). 
Weston and Howard have injected 2 c.c. or more of a 50 per cent 
solution of magnesium sulphate subcutaneously or intramuscularly more 
than a thousand times with no local pain or sloughing. They state the 
sedative action occurs in fifteen to thirty minutes and lasts from five to 
seven hours, and is found to be a very good substitute for morphin and 
hyoscin. In a few instances the patient became quiet but did not sleep. 
In 82.7 per cent it was effective. In 6 per cent the dose was repeated 
before sedation occurred. In 11 per cent no effect was noted even after 
three or more doses (mental cases). 
Rector has used magnesium sulphate colonically in doses of two drams 
in over 1,000 cases. The Presbyterian Hospital used the salts over 200 
times by hypodermoclysis in four dram doses 4% solution with good 
results. In both instances other drugs or agents were added to complete 
the analgesia or anesthesia. 
Magnesium sulphate used in two to four dram doses by rectum 
leaves a margin of safety amply sufficient to satisfy the most critical 
and is, next to urea, probably the safest drug in the combination. In 
the final series this drug is given hypodermatically, 25% to 50% solution 
in ampoules. 
In a personal communication, Alma J. Neill, Professor of Physiology, 
University of Oklahoma, states: "I have found that the rate of diffusion 
of the magnesium sulphate with urea was rather constant; that is, the 
range was between 30.9 and 32.1 per cent with the exception of a 6 per cent 
solution of the magnesium sulphate and a 1 per cent solution of the urea 
which diffused very much faster, it having diffused 48.1 per cent in the 
same time. The whole range of percentages was used both with the 
magnesium sulphate and the urea. Each time the 6 per cent solution 
of the magnesium sulphate and the 1 per cent solution of the urea diffused 
practically 50 per cent faster than any other combination or any other 
substance which 1 tried." This idea has not been worked out satisfactorily 
as yet, but is now being investigated. 
Hewlatt has given 25 grams of urea every hour until 12 M. (100 grams 
in all) with no untoward results. Cushney states: "It is rapidly absorbed 
from the intestine and is practically devoid of action in the tissues even 
in the larger doses." The amount used, 1 per cent of a 4 ounce mixture, 
is therefore negligible as far as danger is concerned. It is used with the 
idea that it increases the absorbability of the magnesium sulphate. The 
exact relation between "diffusion" and "absorbability" is not definitely 
known, nor can we state at this time how much the efficiency of the method 
is due to the urea. Urea is not used in the last series. 
"Ether is the anesthetic of choice if the patient is suffering from any 
form of toxemia or requires stimulation or is suffering from shock." The 
amount used in our mixture, two to four drams to a maximum of not over 734 
ANESTHESIA 
three ounces needs no extended comment. (Four to six ounces of ether 
is the amount used in colonic anesthesia.) 
The next drug to consider is alcohol. The ounce of alcohol was 
used principally as a vehicle for the ether; it also increases the absorb- 
ability of the mixture. Alcohol is below ether in analgesic qualities. 
This has now been reduced to two drams, in order to decrease the 
excitement which occurs in a certain percentage of cases. Three-eighths 
of a grain of morphin per rectum (in our opinion) is the limit for this 
drug. The hyoscin is used to accentuate the value or to synergize the 
morphin. The alcohol was later reduced to two drams. The morphin 
and hyoscin are not given colonically in the last series-if at all by 
hypodermic, dissolved in magnesium sulphate, and then only in the 
early stages. 
"The exaggeration of the effects of small doses of morphin which results 
from its combination with scopolamin are of great practical importance. 
This synergism may be experimentally demonstrated in various species 
of animals, especially in those species in which scopolamin alone, even 
when given in large amounts, produces no narcotic effects. The combined 
administration of small doses of morphin and small doses of scopolamin, 
which by themselves produce hardly any effects, results essentially in an 
exaggeration of the effects of morphin." (Burgi, Madelung.) Morphin 
and the hypnotics of the alcohol group when administered simultaneously 
also act synergistically, with a resulting exaggeration of each other's 
pharmacological actions." (Burgi, Fuhner.) 
THE METHOD 
It is the exceptional patient who is so unfortunate as not to have 
received instructions, among other things, to keep the lower bowel 
clean, especially in the last stages of labor. The rule at the Lying-In 
Hospital is to examine and give a cleansing enema when admitted to 
the hospital. The patient is then sent to the floor where delivery 
takes place. The patient is therefore already prepared for the colonic 
administration of the drugs used, and this is the method adopted. A 
six ounce mixture seemed preferable, but was too frequently expelled, 
therefore a four ounce mixture is the final choice. 
Time.-In selecting the time for the rectal instillation, we seemed to 
follow naturally the Freiburg method which is as follows: After labor 
is well on its way, when the pains are four or five minutes apart and 
lasting thirty or more seconds, the first hypodermic is given. The 
rectal instillation is given whether in a four ounce mixture or in divided 
dosage of two ounces. Analgesia is present in from fifteen minutes to 
one hour after the administration, even in those cases in which a delayed 
action occurs. The time factor is subject to change. 
Selection of Cases.-In the development of this method great care is 
being taken in rejecting cases that would in any way obscure the issue. PAINLESS CHILDBIRTH 
735 
For instance, if the uterus is dilating evenly and the contractions occur 
regularly, but with little pain, no medication is given; an even and 
sometimes painless delivery is then assured; or, when the cervix is fully 
dilated (four fingers or more) medication is withheld. Again, if the 
fetal heart sounds are irregular or bad, or malpositions occur, or if 
there is any question about the condition of the child, medication is 
withheld. After starting this method, a patient with indistinct fetal 
heart sounds was admitted to the hospital. Medication was withheld 
and the child was delivered, but died within forty-eight hours. If the 
method had been tried in this case it would have properly come 
under suspicion. The cases selected were those not too far advanced 
and where there was a possibility of helping them. The selection or 
rejection of these cases necessarily fell upon the House Surgeons 1 of 
the Lying-In Hospital to whom full credit is herewith given in exercising 
unusually good judgment. 
Results.-The results have varied, but in the majority of cases, the 
patients have been "helped," the "pains were lessened" and, in a few, 
a comparatively painless delivery has occurred. Others were not helped 
in the slightest, while one or two stated that the pains were "intensified." 
This last statement can only be accounted for by taking into considera- 
tion the mentality of the patient who possibly expected very great help 
and received but little. 
Formulae.-After using over fifteen different formulae the procedure 
was changed entirely as follows: The magnesium sulphate is now given 
by hypodermic and the rest of the medication by rectal instillation. 
Formula number 16 is 2 c.c. of a twenty-five per cent solution of 
magnesium sulphate (chemically pure) and morphin is added to the 
first hypodermic when indicated. Hypodermic is repeated once or twice 
but without the morphin. The rectal instillation used is: 
$ 
Quin. H. Br Grains 10 
Alcohol '. Drams 2 
Ether Ounces 
Olive Oil, q. s Ounces 4 
Reliance is placed upon the synergism of ether and magnesium sulphate 
for the major effect. 
Cowan states that, "in nearly all cases the cervix has dilated with 
or without the addition of morphin but dilatation has progressed faster 
with the thick tough cervix when morphin has been given with the 
magnesium sulphate. In excitable patients and where you expect a 
long labor dissolve % or 14 grain of morphin in the first hypodermic 
1 Edward J. Donovan, John O'Reagan, Leland R. Cowan, Robert Abbe Me- 
Kensie, F. J. Hudson. The Pharmacist of the Hospital, T. A. Crolly, was most 
helpful in working out the various formulae. 736 
ANESTHESIA 
of magnesium sulphate. The ether, dissolved in olive oil is given by 
rectum but not to the extent as used by Thaler and Hubei. The ether 
is not repeated as it is retained in over 98 per cent of the cases. The 
following is the usual procedure: Hypodermic magnesium sulphate 
(chemically pure) 2 c.c. of a 25 per cent solution (with or without 
morphin) is given when the cervix is dilated about two fingers, and 
repeated when necessary-one to three times. Fifteen minutes to one 
hour later the instillation is given, when the pains are four or five 
minutes apart and lasting 30 or more seconds, and when the cervix 
is dilated two and one-half to three and one-half fingers. 
This present technique is far superior to anything we have heretofore 
used, and with the last forty patients in the first 100 cases has been 
changed only in minor details. 
Normal cases, not too far advanced, are selected as otherwise the 
issue would be obscured. The usual method is as follows: Place patient 
in Sims position with hips slightly elevated and insert small catheter 
filled with olive oil (to exclude air) three or four inches in rectum. 
A small glass funnel is attached to free end of catheter and is held just 
above the hips; the mixture is now poured in slowly. Pressure is made 
during pains with a crumpled towel held in the hand pressed firmly 
against the perineum to prevent expulsion. 
Cowan improvised a technic for parturient women, for which he 
cannot be given too much credit, and which is vastly superior in some 
cases to the funnel gravity method just described, inasmuch as it takes 
less time, is less likely to be expelled and by forcing the mixture into 
the upper portion of the rectum it is more quickly absorbed. In ad- 
vanced cases it converts an uncertain procedure into a certainty and is 
as follows: 
Cowan's Technic.-Connect catheter with large syringe holding the 
mixture, instil slowly, and with gentle pressure force the fluid between 
pains, the whole amount to be instilled between two and three pains. 
During pains pressure upon the perineum as heretofore. 
This procedure should not take over five minutes, but pressure on 
the perineum should continue for fifteen minutes more. The advantages 
of this technic are obvious. The descending head tends to occlude the 
rectum and make instillation by gravity long and difficult, but with a 
syringe we can force a considerable part of the fluid beyond the head 
into the upper portion of the rectum. With this method the whole 
amount of fluid is retained in over 95 per cent of the cases. Relief of 
pain is noticed in from fifteen to forty-five minutes, the pain-free 
period lasting from four to five hours. "Some hours after the initial 
hypodermic when the drowsiness begins to wear off, and patient becomes 
restless with pains-a hypodermic of magnesium sulphate serves to 
prolong the sedative effect. As many as six 2 c.c. doses of the 25% PAINLESS CHILDBIRTH 
737 
solution alone at hourly intervals have been given with the not infrequent 
addition of Vs or % of morphin when indicated." (MacKenzie.) 
In a small series of cases the rectal instillation was given without 
the preliminary hypodermic, with a view to using morphin and mag. 
sulph. only as required. In these cases, however, the patients were more 
disturbed by the treatment and the sedative effect was impaired, so 
that the method described above was employed again as a standard. 
Results.-The effect of the synergists upon the nervous system is 
exciting in 3 per cent of the cases, unchanged in 3 per cent and sedative 
in 94 per cent. 
It was thought this excitement was due to the alcohol, which is now 
reduced from four to two drams. There has not been a sufficient 
number of cases since to determine the effect of this reduction. 
The deliveries are 4 per cent with forceps and 96 per cent normal. 
Occipito-posterior positions rotate in about the same proportion with 
as without synergists. 
Comparatively, postpartum hemorrhage is unchanged. 
Labor is increased in time in 4 per cent, and progresses uneventfully 
in 96 per cent of the cases. 
Nausea occurs in 2 per cent, thirst in 4 per cent, vomiting 8 per 
cent and normal and uneventful in 86 per cent of the cases. 
Pain is increased in 1 per cent, unchanged in 3 per cent and modi- 
fied or painless in 96 per cent of all cases. 
Condition of Baby.-Asphyxia (not fatal) 1 per cent, apneic 2 per 
cent and crying 97 per cent. 
CASE REPORTS 
From service on Fifth Floor {O'Reagan}. 
With the present technic pain is materially decreased in all cases, 
and in a few entirely eliminated: and labor is not, as a rule, delayed or 
prolonged, any more than it would be if the drugs were not used. 
From service on the Sixth Floor {Cowan}. 
July 13, 1923. Mrs. R. W., Multipara. All previous labors normal. 
When admitted severe pain every two or three minutes and lasting for 
one minute. Cervix 2 fingers dilated, thick and soft. Ampoule of 
magnesium sulphate (2 c.c. 25 per cent solution) given at time of 
instillation. Distinct sedative effect lasting four and one-half hours. 
Patient stated she felt very little pain but was conscious that contractions 
were continuing. Second ampoule of magnesium sulphate given but no 
decided effect. Patient had fairly strong pains for two and one-half 
hours before delivery. Baby crying when delivered. 
Conclusion.-Morphin should have been given with first ampoule of 
magnesium sulphate, but instillation should have been delayed until 
cervix was dilated to about three fingers. 738 
ANESTHESIA 
July 31, 1923. Para I, Mrs. I. V. Colored. Moderate sized woman 
who cooperated well when admitted, was having strong pains every 
two minutes, lasting fifteen seconds. Cervix three fingers dilated, soft, 
thin. Hypodermic 2 c.c. magnesium sulphate 25 per cent solution and 
at same time instillation was given, syringe method. Whole amount 
retained. Distinct sedative effect. Pains practically subsided, but 
patient felt contractions continuing. Patient dilated fully with the 
synergists. No nausea, or vomiting. Patient delivered one and one-half 
hours after instillation. As head was passing over perineum patient 
had considerable pain for five minutes. Excited. First degree lacera- 
tion. No chloroform given except for repair. Baby crying when 
delivered. 
Conclusion.-This patient should have had morphin with first hypo- 
dermic and also chloroform during last five minutes of delivery. 
July 14, 1923. Mrs. L. S. Para I. Medium size, pains every five 
minutes, fairly strong and lasting fifteen to thirty seconds. Cervix 
three and one-half fingers dilated, soft, but not obliterated. Hypodermic 
and instillation given at same time. Sedative effect lasted three hours 
and twenty-five minutes when hypodermic was repeated with good 
synergistic effect. Thirst and vomiting present. Cervix dilated from 
three and one-half fingers to full dilation. Delivery was spontaneous, 
four hours and thirty-seven minutes after instillation, and with only 
one hard pain while head was passing over perineum. No laceration. 
No chloroform used. Patient drowsy for one hour following delivery. 
Child crying and normal. 
July 22, 1923. Mrs. C. C. Para I. Moderate sized woman, having 
pains every five minutes and lasting fifteen seconds. One ampoule of 
magnesium sulphate 2 cc. 25 per cent solution with % grain of morphin 
was given when cervix was dilated two to two and one-half fingers. 
Instillation given by syringe method when cervix was three fingers 
dilated, soft, but not obliterated. Whole amount retained. Two and 
a half hours afterwards hypodermic magnesium sulphate 25 per cent 
solution. Patient cooperated well. Sedative effect marked, as evidenced 
by sleepy appearance and little pain, but patient stated she felt con- 
tractions continuing. 
Some nausea and slight vomiting. Cervix dilated fully. L. 0. P. 
position rotated to L. 0. A. and was delivered spontaneously about four 
and a half hours after instillation. Patient had severe pains during 
last five or ten minutes. First degree laceration. 
Conclusion.-A very good result but this patient should have had 
chloroform the last five or ten minutes while head was passing over 
perineum. 
From service on the Sixth Floor (Cowan). 
July 18, 1923, Mrs. V. H., primipara, large, heavy type of patient, PAINLESS CHILDBIRTH 
739 
having hard pains every minute, very noisy and complaining especially 
of backache which was almost unbearable. Cervix dilated two fingers. 
A hypodermic of morphin sulph. gr. %, dissolved in 2 c.c. of a 25 per 
cent solution of. magnesium sulphate, given. The second ampoule of 
magnesium sulphate without morphin was given one hour later. (Some 
relief but patient still complains of pain.) 
Rectal instillation given one and a half hours after first hypodermic, 
cervix thin and dilated 3 fingers. At first slight irritating effect, sedative 
effect beginning fifteen minutes after instillation. Backache ceased 
immediately, pains less severe, but patient was conscious that contrac- 
tions were still going on. Cervix dilated fully in forty-five minutes and 
delivery in one hour and forty-five minutes after instillation. Baby crying 
and normal in every way. No anesthetic used while head was passing 
over perineum, and delivery was accomplished practically with no pain- 
no laceration. The analgesic effect was still present after delivery, as 
evidenced by piercing perineum with towel clip without causing pain. 
No postpartum hemorrhage. 
Conclusion.-Such ideal results cannot be expected in all cases. 
September 1st, 1923, to January 1st, 1924, Robert Abbe MacKenzie 
was house surgeon on the fifth floor, and F. J. Hudson was house surgeon 
on the sixth floor of the Lying-In Hospital. As their predecessors, 
they gave 100 per cent cooperation in the development of this technic. 
Living in the Hospital-each case at all times under their direct super- 
vision-their observations and notes are most valuable. We quote from 
their notes as we proceed. 
September 1st a change was made in the formula, just as the House 
Staff changed. A series of mishaps occurred; patients became boisterous, 
had to be restrained, but no accidents to mother or child. 
Key to Tabulation.-A favorable result is listed in the tables as "A". 
Sedative effect less complete or not so prolonged is classed "B". Those 
cases in which patients fail to lose themselves in sleep but feel senses 
clouded and know pain less acutely are grouped as "C". The poor results, 
i.e., where effect is negligible or where complications ensue have been 
designated "D." MacKenzie's notes follow tabulation. 
Formula No. 1 
Quinin Hydrobromid gr. 15 
Alcohol 5 3 
Ether 3 3 
Oil q. s. 3 5 
Total 9 cases, formula No. 1 
Note: The results with this mixture were so uniformly unfortunate 
that its use was discontinued after trial in nine cases. In seven of these 
cases marked excitement followed the injection. Cerebral stimulation 
and extreme bodily restlessness proved quite alarming and altogether 
unsatisfactory. Memory for events during this period was wiped out, 740 
ANESTHESIA 
however. The patients recalled nothing of their labor pains although 
reminiscent in some cases of the shouting and singing to which they 
gave themselves. Two of the cases in this group gave excellent results- 
prolonged sedative effect and complete loss of memory. 
Case No. 1+ 851+63 
Results "D" 
Formula No. 1 
3:00 Initial hypo (Morph, gr. %-Mag. Sulph. 25%) 
3:1+5 Rectal Instillation 
4:30 Hypo Mag. Sulph. 
5:30 Hypo Mag. Sulph. and Morph, gr. % 
11:00 Delivery 
Administration 
Slight sedative effect with marked excitement and vomiting. Ad- 
ministration 0. K. Discarded formula. 
Large muscular young woman-Para 1. Hard dry labor, great 
apprehension. No appreciable effect from preliminary hypodermic of 
morphin and mag. sulph. Instillation well retained-patient becoming 
almost immediately talkative and disoriented. For three hours periods 
of quiet alternated with restlessness and mental stimulation (singing 
and talking). Vomiting occurred several times. Normal second stage 
patient not difficult to control. Chloroform given during last half hour. 
Baby 0. K. 
In order to correct the excitement stage, the formula was weakened 
in every way: formula and MacKenzie's notes follow: 
Formula No. 2 
Quinin hydrobromid gr. 5 
Alcohol 3 2 
Ether 5 2 
Oil, q. s. 5 4 
Note: This mixture employed in sixteen cases gave unsatisfactory 
results in the majority of instances. Very slight sedative effect in many 
cases with increased annoyance to the patient, and a tendency to undue 
excitation caused this formula to be discarded. 
A 
B 
C 
D 
Primip 
3 
2 
4 
2 
Multip 
1 
1 
2 
1 
Total 
4 
3 
6 
3 
16 cases, formula No. 2 
Factors having a tendency to cause excitement would be a too rapid 
injection of the instillation, air forced into the colon, inability of the 
patient to understand English or to appreciate the objective desired. PAINLESS CHILDBIRTH 
741 
A third change was now made also, a return to the gravity method of 
instillation-the syringe only used when indicated, i.e., when the gravity 
method was impractical. 
Formula No. 3 (now in use regularly in w?rd cases) 
Quinin hydrobromid gr. .10 
Alcohol 3 2 
Ether 5 2% 
Oil, q. s. 5 4 
A 
B 
C 
D 
Primip 
26 
8 
1 
1 
Multip 
4 
4 
1 
- 
Total 
30 
12 
2 
1 
45 cases, formula No. 3 
Case No. 3 85923 
Result "B" 
Formula No. 3 
A dministration 
Initial hypo (Morph, gr. J and Mag. Sulph) at 7:15 
Rectal Instillation 7:30 
Hypos of Mag. Sulph. at 8, 9, 10, and 11 
Patient an intelligent Danish girl-Para I. Instructions and later 
questioning conducted through interpreter. Pains frequent and severe- 
cervix 3 F. thick, soft. Morphin given 15 m. before instillation. Pa- 
tient complained of burning in rectum but retained the injection. 
Sleep did not follow as in most cases. Patient tossed restlessly in bed 
with pain and vomited a number of times. Behavior in second stage 
good. Spontaneous delivery six hours after instillation. 
Upon questioning on day after labor patient states that she felt 
contractions but knew little pain. Felt as if in a daze, impressions 
indistinct, remembers vomiting and hypodermic injection vaguely. Was 
conscious even during labor of relief afforded by treatment and remains 
very grateful. 
Case No. 1 8391$ 
Result "A" 
Formula No. 3 
5:00 P.M. Hypo Morph, gr. %-Mag. Sulph. 50% 2 c.c. 
7:00 P.M. Rectal Instillation 
7.'30 P.M. Hypo Morph, gr. Vs-Mag. Sulph. 2 c.c. 
11:00 P.M. Hypo Mag. Sulph. 2 c.c. 
12:00 M. Delivery 
A dministration 
Young colored woman-Para I, dry labor. Strong frequent pains 
through afternoon, cervix only 2 F. and thick at 7 p. m. when instilla- 
tion given. Immediate sedative effect, patient sleeping quietly then for 742 
ANESTHESIA 
four hours. At this time began to stir and groan with pain until in a 
short while caput appeared at perineum. Spontaneous delivery 5 hours 
12 m. after instillation. Small amount of ether given. 
Patient very grateful for analgesia afforded. Remembers indistinctly 
strong bearing down pains just before ether given. States that early 
pains of dilatation before injection were most trying part of whole labor. 
Case No. 2 85560 
Result "A" 
Formula No. 3 
A dministration 
A.M. Rectal Instillation 
4:10 A.M. Hypo Morph, gr. Vs-Mag. Sulph. 50% 2 c.c. 
9:00 A.M. Delivery 
Turkish woman speaking no English. Instillation given as soon as 
patient admitted and examined. Patient obviously suffering great pain 
particularly in the back. Cervix 2-3 F. Hypodermic given immediately 
after instillation. Patient went to sleep, remained very quiet for three 
hours, although at one time when disturbed for examination was well 
oriented. After three hours hard bearing down pains began, patient 
made no outcry, pushed very well, and drowsed between contractions. 
A little chloroform given to retard progress while head delivered. 
Delivery five hours after instillation. 
Administration.-Selection of cases is of utmost importance as well 
as time of treatment. The ideal case, a primipara with cervix rigid, 
(firm, 2-3 F.) having strong frequent contractions and distressed with 
pain and fear can, of course, be only approximated in most instances. 
Adequate cooperation on the part of the woman in labor involving first, 
proper comprehension of purposes of treatment and second, the measure 
of control to insure its success frequently cannot be obtained. In fact 
the results tabulated as noted have been obtained in a remarkably diverse 
collection of patients, often incapable of receiving any instruction, and 
with the instillation analgesia employed at such varied stages in the 
course of labor as circumstances and individual peculiarity made possible. 
The synergistic principle previously stressed has not been neglected 
and further reliance is placed on subcutaneous injection of magnesium 
sulphate in concentrated solution as experience demonstrates its value. 
It might be mentioned at this point that 50 per cent magnesium 
SULPHATE EMPLOYED IN THE LAST 25 CASES HAS SHOWN ITS DESIRABILITY 
OVER THE LESS CONCENTRATED SOLUTION. 
A preliminary hypodermic of morphin sulphate grains % or % 
dissolved in 2 c.c. of 25% or 50% mag. sulph. is almost invariably 
employed, and serves well to lessen patients' discomfort and dull sensi- 
bilities otherwise somewhat aroused by the rectal injection. The instilla- 
tion is given one-half to one hour later with the patient in bed removed 
whenever possible from distracting sights and sounds. The attitude PAINLESS CHILDBIRTH 
743 
assumed by patient lying on left side with hips somewhat elevated is 
conducive to comfort as well as favoring absorption of injection. Utmost 
importance is attached to elimination of fecal material from the rectum, 
a cleansing enema being frequently necessitated before the instillation 
is given. Care is taken to introduce the ether and oil slowly without 
inclusion of bubbles of air. The gravity method is used where the 
fluid runs in easily, although some pressure with barrel of syringe is 
often necessary. Patients complain only of slight burning in rectum, an 
unpleasantness brief in duration. In only three cases-not included in 
series here reported-has the mixture been expelled in whole or in part. 
Where good effect follows instillation no further medication need be 
given. 
General Impression of Results (MacKenzie).-"To all observers, an 
impression of real benefit to patients is apparent. The contrast between 
a restless, apprehensive woman suffering acutely with continual ache 
in back and sharp recurring pains of contraction, tired out also by her 
early efforts at dilatation of the cervix; and the quiet, sleeping, or 
drowsy, unworried patient stirring only when contractions occur is 
striking. There are no offensive dreams, rarely any untoward cerebral 
excitement to mark the period of stupor immediately following instilla- 
tion. In the ideal case the patient remains sleeping or quiet for about 
four hours, proceeding then to pick up the task of labor with renewed 
strength and uncomplaining vigor. She appears refreshed, no longer 
apprehensive, and oftentimes retains her drowsiness through a severe 
second stage and delivery. In a number of instances labor has progressed 
so rapidly that the head descends to perineum without appreciation by 
patient. In the larger number of cases a fairly normal sensation in 
second stage of labor is anticipated. 
"Progress in labor is not retarded.-The cervix softens more rapidly 
under influence of analgesic injection, and pains succeeding upon period 
of apparent inactivity are stronger and more effective by reason of the 
rest afforded patient. 
"No danger to the fetus has been recognized?' 
This method must not be confused with oil-ether colonic anesthesia, 
as a comparison between the synergistic method and the colonic, as 
used by Thaler and Hiiber for the same purpose, that is painless child- 
birth, will readily show. In Thaler and Huber's series, using only the 
oil-ether, the dose was repeated twice in 25 cases, three times in 20 cases, 
4 times in 15 cases and 5 times in 12 cases; 88 cases received an average 
of 3% ounces of ether, and one case received as much as ounces 
of ether. With the synergists, the injection is never repeated. The 
total amount, 2y2 ounces, is never exceeded. The reduced amount of 
ether is explained by the synergizing of the magnesium sulphate with 
the ether. 744 
ANESTHESIA 
Oral Administration of Ether.-The ether was given to 22 cases by 
oral administration; the magnesium sulphate, by hypodermic. 
No. 2. Ether, drams iv 
Paraffin oil, drams vi 
Aqua menth. pip. M v 
1 & 3. Port wine, oz. i 
The two doses are poured into separate medicine glasses; the patient 
is allowed to take approximately one-third of the wine slowly, hold in 
mouth so as to establish aroma and taste; this is immediately followed 
by mixture No. 2, patient first inhaling deeply, all of it being quickly 
swallowed, the remainder of the wine then being given to clear away 
the taste and odor of the ether. The patient is urged to keep quiet for 
ten or fifteen minutes, to prevent nausea. 
The magnesium sulphate injections are given thirty minutes before 
or at the time of the oral administration of the ether mixture. Only 
those cases were chosen where no disproportion existed between the size 
of the pelvis and fetus, and which promised to make normal progress. 
The doses were given when the patient was well into labor and when the 
cervix was from two to four fingers dilated. In about one-third of the 
cases the injection of MgS04 was repeated after one hour. 
The mixture was not retained in three cases. 
Three cases received morphin sulphate, gr. % in the solution of 
MgS04. 
Fourteen showed a definite sedative effect from the magnesium 
sulphate-ether combination. 
Excitement, or symptoms of mild intoxication, was noted after fifteen 
to twenty minutes in three cases. 
Uterine contractions seemed unaffected in nineteen cases; increased 
in none; and decreased in two. 
Sensation of pain was decreased in eleven; increased in none; not 
affected in eleven. 
There was slight cyanosis of the child in four cases; delayed respira- 
tion (one to three minutes) in two. 
In the series, no variation from the usual amount of postpartum 
bleeding was noted. 
From this limited number of cases, we believe there is shown a 
definite analgesic and moderate sedative effect from the combined action 
of ether and magnesium sulphate, with a tendency to shorten the first 
stage of labor by allowing more rapid dilatation of the cervix,-and this 
without detrimental effects to child or mother. 
Some means of prolonging the effect would be advantageous 
(Hudson). PAINLESS CHILDBIRTH 
745 
The fact that there was slight cyanosis in four cases and delayed 
respiration (one to three minutes) in two, out of a total of twenty-two 
cases, would seem to indicate that ether by mouth is more dangerous to 
the fetus than when given colonically. Compared to this, MacKenzie 
states that "no danger to the fetus has been recognized" in a series of 
73 cases. Ether by inhalations is probably also more dangerous to the 
fetus, since it affects the higher cerebral centers to a much greater 
extent than when given colonically. For example, under colonic anes- 
thesia it is not unusual to communicate with a patient undergoing an 
operation for excision of upper or lower jaw, complete excision of breast, 
or any other radical and painful operation. The brain is never as free 
to coordinate under inhalation ether as with colonic. In using this 
method for painless childbirth, we utilize to the fullest extent the 
analgesic properties of ether. We can get the cooperation of the patient 
if desired. In private practice, where the practitioner has the full 
confidence of his patient and the cooperation would be 100 per cent, the 
synergistic method would be much more satisfactory and efficient than 
in any hospital ward service. 
Normal Saline Instillation.-The technic used in the next series is 
based upon the fact that one quart of normal saline given by rectum 
one hour before operation as a good prophylactic measure where shock, 
especially from hemorrhage, is expected. Also, all authorities are agreed 
that the parturient woman accumulates a certain amount of blood over 
and above that normally in the body, exclusive of the weight of the 
hypertrophied uterus and its contents. The thought occurs that, when 
a woman comes to term and labor ceases for a more or less indefinite 
time, nature has failed to provide this extra amount of blood in anticipa- 
tion of a great loss, and so labor automatically ceases. If this theory 
is correct, by supplying a patient with the necessary amount of blood 
in the form of normal saline, and at the same time administering anal- 
getics to abolish the element of fear, the woman should come to term. 
Certainly, neither mother nor child would be injured by the procedure, 
and both should be helped. 
Hudson's notes follow: 
Report of 6 cases in which a 6 per cent solution of ether in saline 
was given by Murphy drip with the intention of causing stimulation of 
uterine contractions or, where no pains were present, of inducing labor. 
The Murphy drip was begun after the lower bowel had been thoroughly 
cleansed by an S.S. enema. The average time required for administra- 
tion of the one quart mixture was two hours, twenty-five minutes. 
Class B. CASE I.-Para I., having pains every ten to twelve minutes; 
cervix one finger dilated, and then, one hour after the start of in- 
stillation, said she "felt dopey." Pains began to increase after one 
and one-half hours. Morphin, grs. % in MgSO4 by hypodermic, forty- 746 
ANESTHESIA 
five minutes after starting drip. Delivery normal, seven and three- 
quarters hours after starting drip. Baby's condition good. No undue 
hemorrhage. Uterus well contracted. 
Class A. CASE II.-Para II., had pains before admission to hos- 
pital, but no pains after coming in. Started Murphy drip one hour and 
twenty minutes later; cervix hard, one and one-half fingers dilated. 
Given MgSO4, 25 per cent solution, 2 c.c. Patient becoming restless, 
with pains in the back, two hours and forty-five minutes after starting; 
repeated MgS04, and added morphin, gr. 8 p. m. (three hours, five 
minutes after starting), gave oral mixture of oil, ether, and port wine,- 
this was not retained. At 9 p. M. (four hours, five minutes), cervix 
five fingers dilated and soft. Delivery at 9 :45 (four hours, fifty minutes 
after starting). Normal delivery. Child showed slight cyanosis and 
respirations were delayed a short time (50 seconds). Moderate amount 
of bleeding. Uterus contracted well. Labor progressed well; uterine 
contractions strong and regular. The mixture was poorly absorbed, 
so patient really took only about one pint of the ether saline 
mixture. 
Class A. CASE III.-Para I., had labor pains early in the morning, 
BUT THESE SUBSIDED ABOUT 11 :00 A. M. 
11:50 A.M., gave morphin, gr. y8, in MgS04, 25 per cent. Cervix 
at this time was thick, two fingers dilated. 
12 :15, started Murphy drip. Patient restless after two hours. Ex- 
pelled much of solution, but went on with labor. 
8:00 p. m., pains strong and regular, but cervix dilating poorly 
(three and a half fingers). 
10:50 P. M., given morphin, gr. y8 (H.) 
Delivery normal at 1:00 a.m., twelve hours and forty-five minutes 
after starting rectal instillation. Baby's condition good. 
Class B. CASE IV.-Para II., having occasional slight pain. 
Cervix one and one-half fingers dilated, soft. 
12:10 p.m., started Murphy drip. No immediate result noted. Small 
portion expelled. 
3:40 p. m., Mag. Sulph. 25 per cent solution. No sedative effect 
seen, but uterine contractions became regular and strong by 8 :00 p.m. 
Patient very noisy and difficult to control; results were difficult to 
determine. 
Normal delivery at 10:50 p. m.,-about eleven hours. Condition 
good; normal amount of third stage bleeding. 
Class B. CASE V.-Para I. Pains regular and fairly strong when 
rectal instillation was begun (4:55 p. m.). Cervix two fingers and thin. 
After thirty minutes, tube was removed and a small amount of the 
mixture expelled. For two hours, a slight sedative effect was noted, 
the patient remaining stuporous; after this period the contractions PAINLESS CHILDBIRTH 
747 
became normally severe, with the usual amount of pain. Delivery nor- 
mal at 11:30 (seven hours). Baby crying. 
Case VI. Para V. No pains nor uterine contractions; cervix soft, 
one and a half fingers dilated. Murphy drip given, requiring one hour 
and fifteen minutes, at the end of which period patient was drowsy. 
Slept at intervals and had no uterine contractions or pains. This 
condition lasted for two hours. Was up about the ward the following 
day, and discharged from hospital until labor pains might begin. Sup- 
posedly full term patient. This case is important-if any conclusions 
may be drawn from one case-inasmuch as it is not an abortifacient- 
and unless full term has been reached-the technic is unimportant. 
A sufficient number of cases has not been given this last mixture 
to enable us to draw any definite conclusions. Theoretically, it is the 
most logically correct of the three methods here outlined. Mackenzie 
and Hudson have tabulated 100 cases, making in all a total of 200 cases. 
In not a single instance has the method come under suspicion, neither 
has the life of the mother or child been jeopardized. It is now being 
used (formula No. 3) in the Out-Patient Department. If successful 
here, it will prove our hypothesis that the method is so simple that it 
can be used anywhere, by any physician, and in an empirical manner. 
Magnesium Sulphate Injections.-Five cases were given injections 
of magnesium sulphate only. At times pains were strong and the cervix 
three fingers dilated. Two c.c. of 25 per cent solution in three cases, 
and 2 c.c. of a 50 per cent solution in two cases. Some analgesic effect 
was noted in all, being slight in two cases and sedative in three. No 
effect seen on the uterine contractions; no detrimental effects noted on 
babies. Morphin sulphate, grs. %, was included in one of the injections 
of 25 per cent solution. 
Whenever morphin has been given to cases in labor during the past 
three months it has been given in 2 c.c. of 25 per cent solution of 
magnesium sulphate, since the action seems definitely prolonged by this 
combination. 
"In Twilight sleep,' fetal asphyxia occurs in 9.6 per cent of cases 
but fetal mortality is not above the average." In our series the per- 
centage is less than 1 per cent and this case was not fatal. The usual 
objections against twilight sleep (a) prolonged labor for hours and 
days, use of forceps more often necessary, the percentage of ruptured 
perineums higher, failure of occipito-posterior positions to rotate nor- 
mally (b) restless delirium and violence, disturbance of heart and lungs, 
postpartum hemorrhage and uncertain results, do not seem to obtain 
with the present standardized method, using technic and formula No. 3. 
In our series only in one case in 64 did asphyxia occur which gives 
a percentage of 0.64. As a general proposition "synergistic analgesia" 
is a safer condition than either oil-ether analgesia or "Twilight Sleep." 748 
ANESTHESIA 
In Twilight Sleep too much dependence is placed upon morphin and its 
action is too greatly stressed-hence the high percentage of asphyxia. 
With the statistics here presented it is equally as safe as nitrous oxid 
and oxygen-or ethylene and oxygen. With the synergistic method, wre 
attempt to secure relaxation with the magnesium sulphate as well as 
using it for its power of prolonging the effect of the morphin. Ether 
is a powerful stimulant and analgesic as well as anesthetic. The attempt 
is made here to use it only for its stimulating and analgesic properties 
and we believe we obtain this by using it in the minimum dosage 
as given. 
SUMMARY 
(1) Labor is not delayed, for while the pain is relieved the contrac- 
tions continue in over 98 per cent of the cases. 
(2) The condition of the baby is not affected by the medication. 
(3) Ether administered colonically to the mother is safer from the 
offspring's standpoint than is sufficient morphin to produce the same 
effect. 
We feel that in this small series of a little over 200 cases we have 
established the fundamental principles upon which painless labor may 
be safely worked out, i.e., by using the minimum dose of a number of 
drugs, compatible and synergizing, using each drug for a definite and 
specific purpose. Furthermore, by judiciously modifying and combining 
the three methods outlined-oral, colonic, Murphy drip-we hope not 
only to have normal labor painless from commencement to the com- 
pletion of whatever repairs may be necessary but also to be able within 
certain limits to control the time of delivery. PAINLESS CHILDBIRTH 
749 
Chart used in evolving this method. 
LYING-IN HOSPITAL 
ANALGESIC CHART 
A.P. Number 
Date 
Formula Number 
NAME OF PATIENT 
Para 
TIME 
DilatedFingers 
Thick 
Soft 
Hard 
.Obliteration 
ACTUAL 
TOTAL 
1. Hypodermic 
with gr... 
without 
morphin 
Cervix 
2. " effect 
runchanged 
sedative 
. exciting 
3. Rectal Instillation: Retained-. Gravity.... 
Oral administration Irritated.... 
Murphy Drip Expelled.... Syringe.... 
■method 
Cervix: Dilated.... Angers 
Thick 
Soft 
Hard 
Obliteration 
'unchanged 
sedative 
.exciting 
4. Effect of enema and hypodermic: 
5. Hypodermic repeated without morphin 
6. " repeated without morphin 
Not affected 
increased 
decreased 
7. Contractions of uterus- 
Does labor progress? 
8. Sensation of pain 
decreased 
increased 
not affected 
9. Delivery 
with forceps 
without forceps 
10. Do occipito-posterior positions rotate normally? 
crying 
apnoeic 
asphyxia 
11. Condition of baby 
12. Postpartum 
Remarks on any of above numbers on reverse side. 
hemorrhage 
contraction of uterus 
Directions for Giving Hypodermic and Colonic Instillation.-The 
hypodermic should be given when the cervix is approximately two fingers 
dilated. If a 25% solution of magnesium sulphate is used, 1/6 or 1/4 grain 
of morphin may be given with the first hypodermic only; if a 50% solution, 
give 1/8 or 1/6 grain of morphin. The hypodermic should not be repeated 
unless the sedative effect is wearing off or is insufficient. State to patient 
object of hypodermic is to relieve pain. From now on the patient should 
be kept as quiet as possible. If in a ward the bed should be screened, if 
in a room lower shade and exclude light and close the door. Loud talking 
and noise of all kinds is avoided as far as possible. Just before giving 
instillation repeat object is to relieve pain. When cervix is about three 
fingers dilated accompanied by good contractions place patient on left side 
-Sims' position. Hips slightly elevated. Fill catheter and funnel with olive 
oil in order to exclude air and insert about four inches into rectum. Place 
whole amount of instillation in a funnel or syringe and give slowly, care 
being taken not to admit air between olive oil in catheter and mixture in 750 
ANESTHESIA 
funnel or syringe. Under gentle pressure pass the fluid between contrac- 
tions giving the whole amount between two to four contractions-tell the 
patient to "squeeze up" in order to induce reverse peristalsis. State that if 
contents are retained there will be no pain and thus secure her co- 
operation. Make pressure on perineum with a towel during pains for 10 
to 15 minutes, but withdraw tube gently in 5 or 10 minutes. From now 
on patient can be on back or in whatever position is most comfortable for 
her. Place cotton in ears and cover head with preferably some dark colored 
material or with a towel. Give only necessary attention to patient, talking 
in a low voice and making all manipulations as gently as possible. Note 
time of hypodermic and instillation on special chart and fill out chart as 
labor progresses. If oral method, or Murphy drip is used, change chart 
accordingly. 
REFERENCES 
Anesthesia-Gwathmey, pages 12 and 21. DeLee: Principles and Prac- 
tice of Obstetrics. Soilman: A Manual of Pharmacology, p. 548. Amer. 
eTour. Med. Sciences, clxv, (March) 1923, p. 431. Amer. Jour. Surgery, 
Oct., 1922. Monographic Medicine, Vol. 1, page 423. Cushny: Pharma- 
cology. Manual of Midwifery: Jellett and Mandill. Zentralbl. f. Gyn., 
1923, xlvii, 337-384. Meyer and Gottlieb: Pharmacology, p. 42. Mid- 
wifery: Berkley, Andrews-Fairbarn. APPENDIX I 
OXYGEN 
History of Oxygen. 
Methods of Manufacturing Medicinal Oxygen. 
Impurities That May Be Present in Oxygen. 
Purity of Commercial Medicinal Oxygen. 
Standards of Purity That Should Be Required for Oxygen to 
Be Used in Medicine. 
History of Oxygen.-The alchemists1 were probably acquainted 
with oxygen, perhaps also the Greeks 2 in the fourth century, and the 
Chinese,3 long before Priestley's experiments. In 1630 Jean Rey4 
knew that certain metals, when heated, fix a portion of the air, and in 
1674 Mayow 5 prepared oxygen from niter. In 1771 Scheele 6 prepared 
a gas by heating several oxids, including the black oxid of manganese, 
and, at about the same time, Cavendish 7 studied oxygen. To Priestley,8 
however, has been given the honor of discovering oxygen as a constitu- 
ent of the air. Davy 9 and Lavoisier 10 later studied the preparation and 
nature of this gas. 
Methods of Manufacturing Medicinal Oxygen.-At the present 
time there are the following methods of preparation and manufacture of 
oxygen :1X 
1 Bolton: Am. Chem., 4, 170. 
2 Hoefer: "Histoire de la Chimie, " 2, 271. 
'Duckwood: Chem. News, 53, 250. 
4 Jean Rey: "Essai sur la recherche de la cause pour laquelle 1'airain et le 
plomb augmentent de poids quand on les calcine," Bazas, 1630. 
5 Mayow, Rodwell: Chem. News, 8, 113. 
6 Scheele: ' ' Chemische Abhandlung von der Luft und dem Feuer, ' ' Upsala u. 
Leipzig, 1777. 
? Cavendish: Trans. Hoy. Soc., 56, 432; 74, 119, 170; 75, 372. 
'Priestley: Ibid., 62, 147; 65, 384; 73, 398; 75, 279; 78, 147, 313; 79, 7, 289; 
"Experiments and Observations on Different Kinds of Air," London, 1775-1777, 
2, 29; 3, 1; "Experiments and Observations Relating to Various Branches of 
Natural Philosophy," London, 1779, 1, 192. 
9 Trans. Loy. Soc., 101, 1. 
10Crell: Chem. Journ., 4, 440; 5, 125; Chem. Ann., 1786, 1, 33, 136; 
1778, 1, 354, 441, 528, 552; 1788, 2, 55, 262, 431, 433; 1789, 1, 145, 162, 260, 323; 
2, 68, 145, 433; 1790, 1, 69, 518; 1791, 1, 71; 1803, 1, 29. 
11 Baskerville and Stevenson (J. Ind. Eng. Chem., 1911, 3, No. 7) made an 
elaborate investigation on this subject. For details of procedure and methods 
used, this paper should be consulted. 
751 752 
ANESTHESIA 
(1) Heating chlorates; (2) heating chlorates with various sub- 
stances; (3) from hypochlorites, and reaction of chlorin and water; (4) 
heating sulphuric acid or sulphates; (5) heating various solids and mix- 
tures (Mn02, CuB407, etc.); (6) combustion of solid mixtures (chlo- 
rates with combustible material, alkaline peroxids with hydrated salts, 
etc.); (7) reaction of peroxids ("oxone") with water and aqueous solu- 
tions; (8) by electrolysis of water; (9) from the air by means of mer- 
cury, cuprous chlorid, barium dioxid; manganates, plumbates, or living 
matter; dialysis or absorption; (10) from liquid air. 
For medicinal purposes oxygen is manufactured according to methods 
2, 7, 8, and 10. 
Impurities That May Be Present in Oxygen.-The following sorts 
of matter may be suspected to exist in a cylinder of oxygen gas: 
(1) Solids; (2) liquids; (3) gases and vapors: H2O; halogen acids, 
HN03, organic acids; O3, NO2, N2O3, SO2; NH3, organic bases; C02, 
halogens, oxids of chlorin; HCN, (CN)2; PH3, SbH3, AsH3, H2S; H2; 
C01CH4, organic matter; N2, N2O, rare gases of the atmosphere. 
If the method by which the oxygen has been prepared is known, a 
consideration of many of these impurities is unnecessary. For example, 
impurities which exert a distinctly injurious physiological action are not 
to be suspected in oxygen prepared by electrolysis, liquid air, or the de- 
composition of alkaline peroxids (Na202) by water. It is only neces- 
sary to know the percentage of actual oxygen present in the gas. This 
may be determined most conveniently, and with sufficient accuracy, by 
absorption in alkaline pyrogallate solution. Care should be taken to use 
an alkali produced electrolytically or Hempel's1 precaution to prevent 
the production of carbon monoxid. Nitrogen and the inert noble gases 
of the air are determined by difference. 
Purity of Commercial Medicinal Oxygen.-One of us (C. B.)2 has 
devised elaborate methods for the examination of oxygen and determined 
the purity of "C. P." oxygen offered on the market for medicinal use. 
Below is given a tabulation of the results of analyses, according to these 
methods, of seven makes of oxygen. 
No. 
Source of oxygen 
o2 
H2O 
CO2 
h2 
Organic 
Matter 
n2 
etc. 
All other 
impurities. 
1 
KClOs + MnO2 
93.20 
0.30 
0.11 
0 
0 
6.39 
0 
2 
KCICh + MnO2 
98.31 
0.14 
present 
0 
0 
1.54 
0 
3 
KCIO3 + MnO2 
92.82 
0.26 
trace 
0 
0 
6.92 
0 
4 
KCIO3 + MnO2 
97.13 
0.23 
present 
0 
trace 
2.63 
0 
5 
Liquid air 
96.10 
0.15 
0.01 
0 
0 
3.74 
0 
6 
Electrolysis 
99.23 
0.35 
9.03 
0.14 0 
0.25 
0 
7 
NaaCh + H2O 
99.20 
0.50 
trace 
0 
0 
0.30 
0 
These were all medicinally pure. 
'"Gas Analysis," English translation by Dennis, 1906, 149. 
2 In conjunction with Stevenson, loc. cit. APPENDIX III 
753 
Standards of Purity That Should Be Required for Oxygen to Be 
Used in Medicine.-The gas should he neutral toward moist, delicate 
litmus paper (showing absence of irritating acid or alkaline gases) ; and, 
when passed through an aqueous solution of silver nitrate, it should pro- 
duce no turbidity (absence of chlorin or chlorin oxids). Not more than 
an opalescence should be produced when 2 liters of the gas are passed 
slowly through an aqueous solution of barium hydroxid (showing mini- 
mum of carbon dioxid). This condition is to be modified when a mix- 
ture of oxygen and carbon dioxid (4 per cent of the latter) is deliber- 
ately used. See Chapter II. When 5 liters of the gas are passed slowly 
through an aqueous solution of sodium hydroxid, then over heated cop- 
per oxid, and finally through an aqueous solution of barium hydroxid, no 
turbidity should be produced (showing absence of organic impurities, as 
hydrocarbons). The gas should contain at least 95 per cent oxygen upon 
the dry basis. As supplied for use, the gas should contain no liquids and 
no solids. APPENDIX II 
DOSES FOR ANIMALS1 
The drugs are arranged alphabetically; in the case of salts, by the 
more important ion. In the case of crude drugs the dose refers to fluid 
preparations. The "just fatal" doses have generally been worked out 
with considerable accuracy, but may vary somewhat with different sam- 
ples of the poison and with each lot of animals. The doses marked with 
an asterisk (*) have been confirmed by the author; the others were com- 
piled from pharmacologic literature. 
Doses of drugs not contained in this list may be ascertained by con- 
sulting the original papers cited in the Manual of Pharmacology. 
M.F.D.-minimum fatal dose (average). 
It is convenient to remember that a dose of 1 mg. per kg. corresponds 
to about 0.05 gm. or 1 grain for an adult man. 
Alcohol, amyl 
Fall Blood pressure: Dog. vein, per kg., 5 c.c. of 2 per cent (Salant, 
1909). 
M.F.D.: Rabbit, stomach, per kg., 1.7 to 2.0 gm. 
Narcotic: Rabbit, stomach, per kg., 0.8-1.25 gm. 
Alcohol, butyl 
M.F.D.: Rabbit, stomach, per kg., 2.1-2.5 gm. 
Narcotic: Rabbit, stomach, per kg., 1.0-1.5 gm. 
Alcohol, ethyl 
Ergograph: Man, 20 to 40 c.c. of 20 per cent (Chap. 33, V). 
M.F.D.: Rabbit, stomach, per kg., 6.25-7.25 gm. Cat, peritoneum, 
per kg., 8 c.c. 
Narcotic: Dose, Frogs, lymph-sac, 2 c.c. of 25 per cent. 
Alcohol, methyl 
M.F.D.: Rabbit, stomach, per kg., 7-9 gm. 
Narcotic: Rabbit, stomach, per kg., 3.2-5.5 gm. Dog, stomach, per 
kg., 4 c.c. (sleep lasting several days). 
Atropin sulphate 
M.F.D.: Rabbit, stomach, per kg., 1.4-1.5 gm.; hypodermic, 0.5-0.75 
gm.; vein, 0.07-0.075 gm. Dog, per kg., hypodermic, 0.14-0.4 
gm.; vein, 0.06-0.07 gm. Cat, per kg., hypodermic, 0.03 gm. 
1 This appendix is taken from Soilman's book on ' ' A Laboratory Guide in 
Pharmacology." For a complete list of all drugs, the reader is referred to that 
book. 
754 APPENDIX 
755 
Guinea-pig, per kg., hypodermic, 0.6 gm; vein, 0.085 gm. Rat, 
per kg., hypodermic, 2.5 gm. 
Cannabis 
Narcosis: Gog, stomach, per kg., 0.05 gm. of Extract. 
Chloral 
Ordinary Dose (anesthetic, narcotic, temperature, antidote, etc.) : 
Cat, stomach, per kg., 0.25 gm. (2.5 c.c. of 10 per cent). Dog. 
stomach, per kg., 0.25 to 0.3 gm.; vein, per kg., 0.1 to 0.15 gm. 
Rabbit, stomach, per kilogram, 0.6 gm.; rectum, per kilogram, 
0.3 gm. 
Narcotic: Frog, lymph-sac, 0.02 gm. (1 c.c. of 2 per cent). 
Chloretone 
Anesthetic (after morphin) : Dog, stomach, per kg., 0.2 to 0.25 gm. 
(in alcohol). Cat, stomach, per kg., 0.3 gm. (in alcohol). Rab- 
bit, stomach, per kg., 0.15 to 0.2 gm. (in alcohol). 
Chloroform 
Anesthetic: Mammals, vein, per kg., 1 c.c. of 0.5 per cent. 
Narcotic: Frogs, lymph-sac, 0.2 gm. (1 c.c. of 20 per cent in oil). 
Ether 
Anesthetic : Mammals, vein, per kg., 14 to % c.c. of saturated solution 
(Derouaux, 1909). 
H edonal 
Rabbit: stomach, per kg., sleep, 0.1 to 0.2 gm., anesthetic, 0.25 gm. 
Isopral 
Effects: Cat, stomach, per kg. (Sollmann and Hatcher, 1908). Sound 
natural sleep, to 0.1 gm.; light coma, 0.11 to 0.18 gm.; deep coma, 
above 0.18 gm.; mean M.F.D., 0.25 to 0.30 gm. 
Magnesium chlorid 
M.F.D.: Dog, vein, per kg. 0.223 gm. (2.35 c.c. of M/8), Joseph 
and Meltzer, 1909). 
Magnesium sulphate 
Anesthetic: All animals, hypodermic, per kg., 1.5 to 1.75 gm. (6 to 
7 c.c. of 25 per cent). 
Fatal: All animals, hypodermic per kg. 2 gm. 
Morphin hydrochlorid or sulphate 
Narcotic and Preliminary Anesthetic: Dog, hypodermic, per kg., 10 
to 20 mg. (Vi f° % c.c. °f 4 Per cent). Cat, hypodermic, per kg., 
20 to 60 m. ()/2 to c-C- of 4 per cent). Rabbit, hypodermic, 
per kg., 5 to 20 mg. (% to % c.c. of 4 per cent). 
M.F.D.: Dog, vein or hypodermic, per kg., 0.4 gm. (Lentharz). 
Cat, hypodermic, per kg., morphin, 20 mg. (14 c.c. of 4 per cent) 
Rabbit, hypodermic, per kg., 0.2 to 0.32 gm. (Stockman, 1891; 
Joffroy and Lervaux); stomach, per kg., 0.7 to 1 gm. Guinea-pig, 
hypodermic, per kg., 0.7 gm. White rat, hypodermic, per gm., 756 
ANESTHESIA 
0.42 mg. (Hunt, 1907). White mouse, hypodermic, per gm., 
0.6 mg. (Hale, 1910). 
21/orphin-atropin-urethan anesthesia 
Cat, hypodermic, per kg., morphin, 20 mg. c.c. of 4 per cent) 
with atropin, 1 mg. (1 c.c. of 1: 1000). 
M orphin-atropin-urethan anesthesia 
Cat, rectal or stomach, per kg., 3 c.c. of the M.A.U. Mixture (1 c.c. 
= 10 mg. of morphin, 0.2 mg. of atropin, and 0.2 gm. of urethan). 
Morphin-scopolamin anesthesia 
Dog or rabbit, hypodermic, per kg., morphin, 10 mg. (14 c.c. of 
4 per cent) with scopolamin, 0.67 mg. (% c.c. of 1:1000). De- 
tails, Boytcheff, 1907). 
Narcotin 
Light narcosis: Dog, hypodermic, per kg., 50 mg. Mouse, hypo- 
dermic per 15 to 20 gm., 10 mg., not fatal. Frog, lymph-sac, 
50 to 70 mg. 
Papaverin hydrochlorid 
M.F.D.: Cat, hypodermic, per kg., 128 mg. (G. H. Mueller, 1908). 
Paraldehyd 
Anesthesia: Rabbit, stomach, per kg., 1 gm. 
Anesthesia: Fowl, rectum, per kg., 2 c.c. 
Phenol, 
M.F.D.: Cat, hypodermic, per kg., 0.09 gm. (as 2.5 per cent). Rabbit, 
hypodermic or stomach, per kg., 0.6 gm. Guinea-pig, hypodermic 
or peritoneum, per kg., lymph-sac, per gm., 0.1 to 0.6 mg. (as 
5 per cent). 
Urethan 
Anesthetic: Rabbit, per kg.: stomach, 1 gm.; rectum, 0.75 gm.; after 
morphin, stomach, 0.75 gm.; rectum, 0.5 gm. Cat, stomach, 0.75 
gm. per kg. Dog, ditto, 1.5 gm. per kg. Frog, lymph-sac, 0.2 
gm. (2 c.c. of 10 per cent). 
Yohimbin 
M.F.D.: Mammals, hypodermic, per kg., 6.5 mg. INDEX OF AUTHORS 
Abel, 301 
Abelin, 357 
Abernethy, 676 
Abrams, 670 
Adami and Nicholls, 357 
Alessandri, 582 
Alexander and Gwathmey, 327, 340 
Allain, 291, 294 
Allbutt, 357 
Allen, 66, 489, 517, 600, 643 
Amos and Rosenau, 103 
Anderson, 663 
Anderson and Cunningham, 100 
Andre, 293 
Andrews, 125 
Andrews, Berkley, and Fairbarn, 750 
Anschutz, 39 
Apperley, 304 
Atthill, 287 
Auer, 649 
Auer and Meltzer, 416, 417, 418, 642, 
643, 645, 646, 647 
Augendre, 284 
Avamresco, 610 
Babcock, 568, 581, 583, 587, 595, 612, 
622 
Babitzki, 514 
Backman and Soderland, 360 
Bagensky, 357 
Bainbridge, 90, 554, 561, 575, 576, 584, 
585, 588, 590, 593, 598, 605, 625 
Baird, 296 
Baldwin, 309 
Bandler, 336 
von Bardeleben, 357 
Barker, 467, 568, 571, 590, 592, 598 
Barnes, 284 
Bartel, 357 
Barten and Stein, 357 
Baskerville, 76, 291 
Baskerville and Hamor, 13, 179, 182, 
283, 290, 295 
Baskerville and Stevenson, 122, 751, 
752 
Baum and Meyer, 38 
Baumert, 433 
Bayliss, 114 
Beauvy, Delbert, and Herrenschmidt, 
373 
Behr, 267 
Bell, 687 
Beneke, 357 
Berkley, Andrews, and Fairbarn, 750 
Bernard, 34, 282 
Bert, 125, 433 
Berthelot, 293 
Berthelot and Rosenthal, 279 
Bevan and Favill, 414 
Biberfeld and Filehne, 288 
Biechele, 357 
Biedert, 357 
Bier, 467, 490, 505, 525, 559, 560, 
561, 567 
Bigelow, 16, 27 
Blake, 357 
Bloch, 187 
Blum, 297 
Blumer, 357 
Blumfield, 279 
Boettger, 291 
Bolton, 751 
Bonnet, 357 
Boos, 664 
Boothby, 73, 165 
Boothby and Cotton, 71, 161, 432 
Bovaird, 357 
Boyle, 262, 267, 355 
Bradley, 357 
Braine, 279 
Braun, 466, 467, 468, 479, 480, 488, 
498, 525, 603 
Breteau, 292 
Breteau and Woog, 292 
Brewer, 415 
Brickner, 358 
Brinkley, 453, 458 
Broese, 520 
Brown, 43, 291, 713 
Brown and Rubra, 360 
Bruning, 77, 83 
Brunn, 126, 128, 129, 130 
Buchanan, 726 
Buckmaster and Gardner, 298 
Buglia and Simon, 45 
Bull, 434 
Bulson, 469, 502 
Bunnell, 700 
Burge, 661 
Burge, 108 
Burgi, 734 
Biirker, 48 
Burroughs, Welcome and Co., 27 
Busquet and Pachon, 288 
Busse, 595 
Buswell and Collingswood, 298 
Buxton, 27, 125, 128, 130, 131, 260, 
268, 279, 294, 295, 586 
Caglieri and Tait, 559, 561, 565, 607 
Calcagno, 493, 508 
Camus and Nicloux, 45, 259 
757 758 
INDEX OF AUTHORS 
Canon, 693 
Canon and Murphy, 113 
Cantlie, 268 
Carlson, 299 
Carlson and Luckhardt, 45 
Carlyll, 358 
Carrel, 418 
Carter and Luckhardt, 712, 713, 716 
Cathelin, 485 
Cattell, 725 
Cavendish, 751 
Cerna and Wood, 130 
Chaldecott and Stephenson, 279 
Chambard, 565 
Championniere, 297 
Chaput, 575, 598, 604 
Charteris and MacLennan, 289 
Chauvin and (Economus, 387 
Chiene, 597 
Chipman, 676 
Chisholm, 288 
Clessin, 358 
Clover, 63 
Coburn, 63 
Cock, 19 
Cocks, 332, 335, 358 
Coehn and Decker, 290 
Cohen and Krause, 359 
Cole, 258 
Colin and Robiquet, 251, 252 
Collingswood and Buswell, 298 
Collingwood and Wilcox, 295 
Collins, 371, 372 
Colombani, 601 
Colton, 28 
Connell, 159, 235, 241 
Connell and Gwathmey, 693 
Conner, 358 
Connor, 332 
Coolidge, 358 
Copeman and Sherrington, 58 
Corning, 467, 556, 557, 558, 559 
Cotton and Boothby, 71, 161, 432 
Coughlin, 209 
Crell, 751 
Crile, 62, 113, 353, 356, 367, 385, 467, 
474, 475, 480, 503, 507, 509, 
558, 567, 693 
Crile and Lower, 477 
Crim, 675 
Crocker and Knight, 712 
Crowder, 103 
Cullom, 235 
Cunningham and Anderson, 100 
Cunningham and Lahey, 435 
Curtis, 663 
Cushing, 467, 480, 497, 524 
Cushny, 39, 107, 108, 645, 750 
DaCosta, 8, 10 
Dalyell, 21 
Daniells, 279 
Darling, 252, 253 
Dastre, 66, 95, 282 
Daut, 358 
Davenport, 297 
Davis, 67, 205 
Davy, 118, 751 
Day, 358 
Dean, 619 
Decker and Coehn, 290 
Delbet, 304 
Delbet, Herrenschmidt, and Beauvy, 
373 
DeLee, 750 
Demeraux and Minet, 309 
Demarquay, 81 
DeNeen, 641 
DePrenderville, 279 
De St. Martin, 293 
Dickinson, 448 
Dioscorides, 2, 282 
Dodge, 272 
d'CElsnitz and Simon, 360 
Doleris, 560 
Dohsris and Malartic, 593 
Donitz, 568, 576, 619 
Dott, 292 
Dreser, 101, 240, 241 
Dubois, 34 
DuBois-Reymond, 288, 290 
Duckwood, 751 
Dumont, 435 
Duns, 22 
Dupaigne, 560 
Duprey, 434 
Ecker, 658, 728 
Ehrenfest, 594 
Ehrenfried, 418 
Ehrhardt, 358 
Einhorn, 468 
Eisenlohr and Fermi, 295 
Elsberg, 418, 419, 432, 467 
Embley, 95, 258, 259, 302 
Embley and Martin, 288, 300 
Emerson, 28 
Emery and Todd, 360 
Engelhardt, 185, 199 
English and Latham, 327, 403 
Engsted, 598 
Eppinger and Hofbauer, 59 
Epstein, 358 
Erdman and Stolzenberg, 122 
Erhardt, 601 
Erman, 433 
Escherich, 358 
Evans, 374 
Ewing, 358 
Fabre and Verrier, 192 
Fairbarn, Berkley, and Andrews, 750 
Fairchild, 687 
Falk, 294 
Faraday, 177 
Farret, 358 
Favill and Bevan, 414 
Feigl and Meier, 286, 288 
Fer, 358 
Ferguson, 376, 390 INDEX OF AUTHORS 
759 
Fermi and Eisenlohr, 295 
Filehne and Biberfeld, 288 
Filliatre, 600 
Fischer, 418, 423, 430 
Fischer, Iterson, and Zweifel, 295 
Fischer and Thien, 309 
Fischl, 358 
Fisher, 584 
Flack and Hill, 101 
Flagg, 16 
Flemming, 280 
Flourens, 251 
Fliigge, 103, 358 
Formanek, 44 
Fortescue-Brickdale and Francis, 46, 
61 
Foster, 28 
Foy, 28, 63 
Fraenkel, 590 
Fraicou, 577 
Francis and Fortescue-Brickdale, 46, 61 
Franke and Posner, 516 
Frankland, 124 
Frazer and Meeker, 486, 520 
Frazier, 508 
French, 94, 345, 387 
Friedjung, 358 
Friedlander, 358 
Friedleben, 358 
Fiihner, 108, 734 
Gage, 22 
Galen, 2, 282 
Ganghofer, 358 
Gardner, 358 
Gardner and Buckmaster, 298 
Garneier and Lambert, 299 
Garrett and Oliver, 123 
Gatch, 100, 129 
Gates and Meltzer, 642 
Gerardin, 6 
Gerlinger, 295 
Gerstenberg and Hein, 564 
Gianasso, 45 
Gill, 46, 297, 299, 305 
Glass and Wallace, 653 
Gluck, 358 
Goldan, 567 
Gottlieb and Meyer, 301, 310, 313, 
372, 640, 643, 750 
Gould, 225 
Goyanes, 492 
Graham, 39, 40, 183, 454 
Grawitz, 358 
Gray, 331, 565, 587, 588, 590, 598, 
610, 619 
Greenough and Gwathmey, 648 
Griffith, 358 
Grondahl, 189 
Gros, 48 
Groves, 8, 252 
Grube, 191, 197 
Guedel, 173, 528 
Guerin, 180 
Gwathmey, 63, 80, 92, 109, 283, 294, 
314, 644, 654, 688, 692, 718, 719, 
750 
Gwathmey and Alexander, 327, 340 
Gwathmey and Connell, 693 
Gwathmey and Greenough, 648 
Gwathmey and Karsner, 704 
Haertel, 498 
Hager, 252 
Halbreich, 566 
Haldane and Poulton, 101 
Haldane and Smith, 103 
Halsted, 333, 358, 467, 480 
Hamblen, 198, 415 
Hamor and Baskerville, 13, 179, 182, 
283, 290, 295 
Hare, 66, 317 
Harley, 556 
Harris, 358, 486 
Hart, 358 
Hartman, 286 
Hasbrouck, 338 
Hassler and Honan, 628 
Hatch, 280 
Haubold and Meltzer, 641, 648 
Hawk, 197 
Hawk and Ross, 196 
Hawksley, 63 
Hawley, 257 
Hayden, 14, 28 
Hayman, 500 
Hayward, 492 
Heaney, 719 
Hedinger, 358 
Hein and Gerstenberg, 564 
Heinrich, 519 
Helbing and Passmore, 290 
Hellman, 208, 676 
Hempel, 751 
Henderson, 97, 101, 115, 129, 192, 336, 
358, 407 
Hermann, 43, 124 
Herodotus, 282 
Herrenknecht, 262, 267 
Herrenschmidt, Delbert, and Beauvy, 
373 
Hertel, 601 
Herter and Richards, 47, 309 
Hertzler, 470, 501, 517 
Hervey, 229, 235 
Hesse, 284 
Heussler, 358 
Hewitt, 3, 80, 107, 121, 127, 189, 192, 
193, 196, 239, 251, 261, 265, 
267, 268, 271, 275, 280, 283, 
287, 305, 320, 355, 381, 382 
Hibbert, 282 
Hickman, 5 
Hill and Flack, 101 
Hill and Walker, 103 
Hilliard, 280, 334 
Hinrichs, 358 
Hober, 40, 46 760 
INDEX OF AUTHORS 
Kreis, 560 
Kretschner and Luckhardt, 717, 719 
Krugeline, 435 
Kruger, 45, 252 
Kuhlmann, 252 
Kulenkampff, 509 
Kundrat, 359 
Labat, 473, 489, 519 
Ladd and Osgood, 102 
Laewen, 70, 228, 482, 514 
Lambert, 651 
Lambert and Garneier, 299 
Langaard, 286 
Lange, 359 
von Langenbeck, 296 
Lanz, 516 
Latham and English, 327, 403 
Lathrop, 448 
Lavoisier, 751 
Lawrie, 288 
Lawson, 375 
LeBrocq, 599 
Leedham-Green, 587 
Leighton, 272 
Leman and Smith, 121, 122 
Lennander, 476, 521 
Leopold and Spiller, 569 
Lepeschkin, 40 
Lerda, 512 
Levi, 98, 112 
Levy, 304 
Lewis, 393 
Lewis and Luckhardt, 711, 716, 717, 
719, 720 
Lillie, 40, 50, 51, 55 
Linnemann, 253 
Livon, 45 
Lotheissen, 263, 278 
Lower and Crile, 477 
Lowig, 252 
Lowry and Magson, 290 
Lucian, 282 
Luckhardt, 711 
Luckhardt and Carlson, 45 
Luckhardt and Carter, 712, 713, 716 
Luckhardt and Kretschner, 717, 719 
Luckhardt and Lewis, 711, 716, 717, 
719, 720 
Ludolff, 251 
Luke, 280 
Luke and Eoss, 267, 268, 305 
Lund, 473 
Lusk, 564, 584, 605 
Lyman, 28, 282 
Lynch, 280 
Maass, 266 
MacLennan and Charteris, 289 
Madelung, 734 
Maduro, 28 
Magaw, 102, 205 
Magendie, 434 
Magson and Lowry, 290 
Mahoney, 329 
Hodges, 28 
Hoefer, 751 
Holscher, 101 
Hofbauer and Eppinger, 59 
Hoffmann, 69 
Homans, 113 
Homer, 2, 282 
Honan and Hassler, 628 
Hooker, 113 
Hopkins, 593 
Hoseman, 583 
Hotz, 359 
Houghton, 602 
Howard and Weston, 661 
Howland, 359 
Hubei and Thaler, 463 
Huchard, 286 
Hughson, 481 
Humphry, 359 
Hutman, 281 
Iterson, 295 
Iterson, Fischer, and Zweifel, 295 
Jaboulay, 558 
Jackson, 8, 359 
Jellett and Mandill, 750 
Jerusalem and Starling, 114 
Jessen, 359 
Jobert, 433 
Johnston, Thompson, and Yates, 45 
Jonnesco, 562, 582, 586, 597, 607 
Joseph and Meltzer, 642 
Joss, 71, 228 
Kaerger, 492 
Kailan, 252 
Kanavel, 490 
Kapeler, 66 
Kappeler, 368 
Kappis, 482, 488, 489, 517 
Karsner and Gwathmey, 704 
Kassner, 39 
Kassowitz, 359 
Kauffmann, 359 
Keen, 365, 366, 367, 383, 404 
Kemp, 125, 130, 131, 132, 134 
Keppler, 514 
Kern, 359 
Kilpatrick, 119 
Kinon, 656 
Kleiner and Meltzer, 663 
Klikowitsch, 670 
Klose and Vogt, 571 
Knight, 268 
Knight and Crocker, 712 
Koch, 359 
Kocher, 248 
Kohler, 598 
Koller, 467, 556 
Konig, 264, 269, 359 
Kopp, 359 
Kraatz, 519 
Kramer, 47 
Krause and Cohen, 359 INDEX OF AUTHORS 
761 
Malartic and Doleris, 593 
Malherbe, 272 
Mall, 114 
Manchot, 716 
Mandill and Jellett, 750 
Mansfield, 39 
Marfan, 359 
Marshall, 693, 698 
Martin and Embley, 288, 300 
Marx, 560, 593 
Masson, 292, 294 
Matas, 467, 480, 586 
Mathews, 42 
Mau, 359 
May, 38 
Mayow, 751 
McCardie, 259, 268, 280, 359 
McGuire, 287 
McKeson, 409 
McKesson, 723 
McManus, 28 
Meeker and Frazer, 486, 520 
Meier and Feigl, 286, 288 
Meissner, 604 
Meltzer, 418, 641, 661 
Meltzer and Auer, 416, 417, 418, 642, 
643, 645, 646, 647 
Meltzer and Gates, 642 
Meltzer and Haubold, 641, 648 
Meltzer and Joseph, 642 
Meltzer and Kleiner, 663 
Meltzer and Peck, 642, 646 
Metcalfe, 287 
Meyer, 37, 276, 601 
Meyer and Baum, 38 
Meyer and Gottlieb, 301, 310, 313, 372, 
640, 643, 750 
Meyer and Overton, 38 
Miahle, 290 
Michelson, 564, 598 
Milne, 272 
Minet and Demeraux, 309 
Mitchell, 465, 520, 558 
Molliere, 434 
Moore and Roaf, 44, 45, 288 
Morgan, 287 
Moriarta, 676 
Morley, 67 
Mortimer, 248, 268, 414, 668, 686 
Morton, 12, 17, 562, 574, 607 
Mossier, 293 
Mosso, 98 
Mott, 564 
Muller, 34, 36, 86, 88, 258, 259, 264 
Muller and Offergeld, 335 
Mulzer, 186 
Munro, 359 
Murphy, 586 
Murphy and Cannon, 113 
Musser and Ullom, 359 
Neef, 208, 277 
Nef, 42 
Neill, 733 
Neilson and Terry, 44 
Nerking, 40 
Nettel, 359 
Neubauer and Porges, 46 
Neuman, 521 
Nevius, 28 
Newman and Ramsay, 291 
Nicholls and Adami, 357 
Nicloux, 107, 191, 196, 309 
Nicloux and Camus, 45, 259 
Nicoletti, 567 
Nogu6, 565 
Nordmann, 359, 418 
Norton, 359 
Nowak, 284 
Noyes, 556 
Nussbaum, 93, 286 
Occhim, 287 
Ochsner, 503 
Odier, 559 
(Economos and Chauvin, 387 
Oehme, 359 
Offergeld, 101 
Offergeld and Muller, 335 
Offerhaus, 498 
Ohlmacher, 333, 359 
Oliver and Garrett, 123 
Oppel, 493 
Osgood and Ladd, 102 
Osterhout, 40 
Otte, 199 
Overton, 37 
Overton and Meyer, 38 
Pachon and Busquet, 288 
Palmer, 251 
Paltauf, 359 
Park, 359 
Passmore and Helbing, 290 
Passy, 93 
Patch, 180 
Patterson, 575, 577, 581 
Patton, 11, 16, 28, 81 
Pauchet, 516 
Peck and Meltzer, 642, 646 
Pedeprade, 575 
Penkert, 360 
Perkin, 253 
Perrin, 297 
Pettenkofer, 284 
Pierre, 253 
Pinneo, 235 
Pirogoff, 434 
Plater, 360 
Pliny, 3, 282 
Pogg, 252 
Poggiolini, 58 
Poppert, 101 
Porges and Neubauer, 46 
Porta, 281 
Porter, 676 
Posner and Franke, 516 
Post, 434 
Poulton and Haldane, 101 
Preleitner, 589 762 
INDEX OF AUTHORS 
Preston, 287 
Priestly, 118, 751 
Prinz, 535 
Probyn-Williams, 415 
Purrocker, 360 
Quincke, 557 
Rachford, 360 
Rag sky, 296 
Ramsay, 253 
Ramsay and Newman, 291 
Ramsay and Young, 295 
Ranke, 360 
Ransohoff, 493 
Rathery and Saison, 190 
Raucher, 192 
Reclus, 467, 479 
Rector, 655 
Regnault, 252, 253 
Rehn, 360 
Reicher, 47 
Rey, 751 
Rice, 28 
Richards and Herter, 47, 309 
Richardson, 287, 466 
Richter, 360 
Ringer, 287, 556 
R'oaf and Moore, 44, 45, 288 
Roberts, 121, 333, 360 
Robin, 284 
Robiquet and Colin, 251, 252 
Rohricht, 198 
Rosenau and Amos, 103 
Rosenheim and Tunnicliffe, 39, 299 
Rosenthal and Berthelot, 279 
Ross and Luke, 267, 268, 305 
Roux, 434 
Rubra and Brown, 360 
Ruge, 519 
Ryall, 587, 604, 610 
Saison and Rathery, 190 
Salkowski, 284 
Sampson, 520 
Sansom, 287 
Satterlee, 360 
Schaeffer and Scharlieb, 288, 300 
Scharlieb and Schaeffer, 288, 300 
Scheele, 751 
Schleich, 35, 467, 478 
Schlesinger, 418 
Schley, 522 
Schlimpert, 284 
Schoorl and Van den Berg, 295 
Schorlemmer, 252 
Schultz, 360 
Schumburg, 295 
Schutz, 642 
Schwinn, 360 
Scott, 281 
Sedillot, 287 
Seelig, 71, 198, 280 
Seldowitch, 559 
Sellheim, 482, 519 
Shakespeare, 4 
Shaw, 28 
Sheppard, 121 
Sherrington and Copeman, 58 
Sicard, 557, 558 
Siegel, 360, 483 
Simon and Buglia, 45 
Simon and d'CElsnitz, 360 
Simpson, 286 
Simpson, E. B., 20, 284 
Simpson, J., 20, 284 
Simpson, J. Y., 28, 284, 368 
Sims, 28 
Sinclair, 593 
Slajiner, 601 
Smith, 29 
Smith and Haldane, 103 
Smith and Leman, 121, 122 
Smythe, 659, 726 
Snow, 282, 301 
Soderland and Backman, 360 
Soilman, 277, 750, 754 
Sorgo, 360 
Souligoux, 671 
Spencer, 32 
Spielmeyer, 570 
Spiller and Leopold, 569 
Starkenstein, 642 
Starling and Jerusalem, 114 
Starr, 360 
Stein and Barten, 357 
Stephenson and Chaldecott, 279 
Stevenson and Baskerville, 122, 751, 
752 
Stolzenberg and Erdman, 122 
Strauss, 597 
Straussman, 336 
Strobe, 477 
Stursberg, 69, 187 
Sutton, 433, 435 
Tait and Caglieri, 559, 561, 565, 607 
Tappeiner, 434 
Targhetta, 360 
Taylor, 497 
Temoin, 292 
Terry and Neilson, 44 
Teter, 153 
Thaler and Hubei, 463 
Thibault, 470 
Thien and Fischer, 309 
Thoburn, 558 
Thompson, 190, 303, 486 
Thompson, Yates, and Johnston, 45 
Thoms, 183 
Thremich, 360 
Tigerstedt, 93 
Tinker, 516 
Tissot, 55, 288, 300 
Todd and Emery, 360 
Torek, 278 
Traube, 42 
Trout, 374, 520 
Tuffier, 560, 561, 569, 575, 598 INDEX OF AUTHORS 
763 
Tunnicliffe, 289 
Tunnicliffe and Rosenheim, 39, 299 
Ullom and Musser, 359 
Unger, 432 
Vail, 502 
Valentine, 250 
Van den Berg and Schoorl, 295 
Verrier and Fabre, 192 
Verworn, 49 
Vidal, 86 
Vintras, 360 
Vischer, 509 
Vitali, 309 
Vogt and Klose, 571 
Waddelow, 295, 296 
Walker and Hill, 103 
Wallace and Glass, 653 
Waller, 288 
Walsh, 115 
Walton, 183 
Wancher, 434 
Warden, 183 
Wardleworth, 296 
Ware, 272, 280 
Warren, E., 29 
Warren, J. C., 29 
Warren, J. M., 29 
Warthin, 360 
Waugh, 589 
Weber, 591 
Webster, 260 
Weigert, 290, 360 
Weir, 434 
Welch, 29 
Wells, 10, 727 
Wendling, 489 
von Werdt, 360 
Wertheim, 592 
Weston and Howard, 661 
Wheelock, 333, 360 
White, 22 
Wiesner, 360 
Wilcox and Collingwood, 295 
Willard, 122 
Wills, 120 
Witmer, 360 
Wood and Cerna, 130 
Woog and Breteau, 292 
Woolsey, 432 
Woulfe, 251 
Wright, 40, 41, 47, 62 
Yates and Johnston, 45 
Y'Yhedo, 434 
Young, 19, 29 
Young and Ramsay, 295 
Ziemsen, 557 
Zuntz, 86 
Zwaademaker, 93 
Zweifel, Iterson, and Fischer, 295 INDEX OF SUBJECTS 
Abdomen, effect of shock on, 385 
ether irrigation of, 672 
local anesthesia of, 520 
Abdominal distention, effect of re- 
breath'ing on, 113 
post-anesthetic, 113 
Abdominal operations, shock in, 403 
under anoci-association, 407 
under chloroform, 314 
under local anesthesia, 520 
under oil-ether colonic anesthesia, 
461 
under spinal analgesia, 559, 587 
site of injection for, 612 
Abdominal spasm during anesthesia, 
381 
Abscess of the lung, anesthesia in, 329 
oral injection into, contra-indicated, 
546 
Acapnia, 406 
as cause of death under ether anes- 
thesia, 193 
as cause of shock, 401. See also 
Vasomotor activity 
prevention of, 112, 409 
Accessory sinuses, local anesthesia in 
surgery of, 500 
A. C. E. mixture, administration of, 
142 
early use of, 23 
Acetaldehyd, in chloroform, 286 
in ether, 183 
Acetic acid, impurities in ethyl chlorid 
due to, 253 
in chloroform, 285, 286 
Acetone, preparation of chloroform 
from, 285 
Acetone-chloroform, 724, 772. See also 
Chloretone 
Acetonuria, after ether anesthesia, 198 
See also Chloroform poisoning 
Acetyl chlorid, presence of, in ethyl 
chlorid, 253 
Acid intoxication due to ether, 413 
post-anesthetic, 70 
symptoms of, 415 
treatment for, 414 
See also Chloroform poisoning 
Acoin, 540 
in spinal analgesia, 563, 599 
Adenoid and tonsil cases, 340 
after-treatment of, 345 
anesthesia in, 341 
death due to unskilful anesthesia in, 
336 
Adenoid and tonsil cases, nasal nitrous 
oxid-oxygen anesthesia in, 
173 
preparation of patient, 340 
results in, due to lack of preliminary 
medication, 369 
technique of, 344 
upright position for, 345 
use of ethyl chlorid in, 268 
use of nitrous oxid in, 140 
Adenoid operations, ether in, 247 
use of Junker apparatus in, 322 
Adrenalin, combined with novocain, in 
dental anesthesia, 540 
in local anesthesia, 467 
in preparation of cocain solutions, 
539 
in spinal analgesic solutions, 576, 
599 
with chloroform, 373 
with cocain, 467 
Adrenalin, hydrochlorid in spinal anal- 
gesia, 601 
Adrenals, effects of chloroform on, 304 
Adrenin with saline in shock preven- 
tion, 403 
Aeration of lungs during anesthesia, 
376 
/Ether hydro chlor icus seu muriaticus, 
250. See also Ethyl chlorid 
2Ethylum chloratum, 250. See also 
Ethyl chlorid 
After-treatment for adenoid and tonsil 
cases, 345 
in intravenous anesthesia, 636 
in ordinary cases, 378 
Age in relation to spinal analgesia, 591 
in resistance to surgical shock, 383 
selection of anesthetic with regard 
to, 326 
Aged, ethyl chlorid anesthesia in, 268 
nitrous oxid anesthesia contra-indi- 
cated in, 135 
Air, administration of nitrous oxid 
with, 142 
in definite amounts, 141 
in unknown quantities, 140 
comparative value of oxygen and, 81 
effect of, on chloroform, 290 
ethyl chlorid and, 276 
insufflation of, as a method of arti- 
ficial respiration, 432 
following intratracheal anesthesia, 
429 
preparation of oxygen from, 752 
764 INDEX OF SUBJECTS 
765 
Air passages, obstruction of, in nitrous 
oxid-oxygen anesthesia, 168 
Airway, artificial, in surgical anes- 
thesia, 390 
Airway, free, method of maintaining, 
361 
maintenance of, by artificial respira- 
tion, 393 
in intravenous anesthesia, 634 
with breathing tubes, 390, 392 
obstruction in, due to shock, 389 
open, maintenance of, in ether anes- 
thesia, 233 
Albuminuria, absence of, in ethyl 
chlorid anesthesia, 265 
in anesthesia, 61 . 
in ether narcosis, 190 
Alcohol as preservative of chloroform, 
283, 285, 290, 295 
in anesthetic block for shock preven- 
tion, 406 
in ether, oxidation of, 182 
in painless childbirth, 734 
in preparation of ethyl chlorid, 252 
in spinal analgesic solutions, 599, 
603 
test for, in ethyl chlorid, 257 
Alcohol oxidation in chloroform agita- 
tion, 296 
Alcoholic muriatic ether, 251 
Alcoholics, administration of nitrous 
oxid in, 140 
choice of anesthetic in, 329 
colonic ether anesthesia in, 443 
ethyl chlorid anesthesia in, 262, 269 
oil-ether colonic anesthesia for, 443 
preliminary medication in anesthetiz- 
ing, 371, 372 
under spinal analgesia, 626 
use of ethyl chlorid, ether, and oxy- 
gen in, 278 
Alcohols, dosage of, for animals, 754 
Aldehyd in anesthetic ether, 183 
in chloroform, 285 
Aldehyds, compounds of, with hydro- 
gen chlorid, 253 
Alden's auto-operation under spinal 
analgesia, 580 
Alexander and Gwathmey on adenoid 
and tonsil cases, 340 
Alimentary tract, effect of nitrous oxid 
on, 132 
Alkaline synergistic method, 653 
Allis ether inhaler, 216 
Allopathy and homeopathy, 678 
Alypin, 540 
in spinal analgesia, 563, 585, 599 
Ammonia administration in respiratory 
failure, 396 
with chloroform, 287 
Amputation of arm under local anes- 
thesia, 508 
of foot under spinal analgesia, 625 
Amputations, anesthesia in, 354 
Amyl in chloroform, 285 
Amyl alcohol, dosage of, for animals, 
754 
impurities in ethyl chlorid due to, 
253 
Amyl nitrite, as an antidote to cocain 
poisoning, 479 
in respiratory failure, 395 
use of, in anemia of the brain due 
to cocain, 539 
Amyl salicylates as preservative of 
chloroform, 292 
Amylene, Snow's first administration 
of, 23 
Analgesia, definition of, 31 
in positive pressure anesthesia, 697 
oral administration, 704, 710 
Analgesic chart, 529, 749 
Andrews, E., nitrous oxid and oxygen 
mixture by, 24 
Aneleetrotonus, 51 
Anemia, choice of anesthetic in, 328 
of the brain, due to cocain, 539 
surgical shock and, 384 
Anemic convulsions, anesthetic treat- 
ment of, 667 
Anemic subjects, ethyl chlorid anes- 
thesia in, 268 
gastro-enterostomy in, 356 
Anesthesia, arterial, 492 
during the World War, 688 
graphic chart, 533 
in England, 19 
origin of name, vii 
"Anesthesia dolorosa," 470 
Anesthesine in spinal analgesia, 563, 
599 
Anesthetic, agents, 32 
chloroform, 283 
origin of name, vii 
safest, 325 
selection of, 324 and See Selection 
of anesthetics 
Anesthetics, antagonism between salts 
and, 55 
combination of oxygen with, 80 
effect of moisture on, 76 
effect of, on circulatory system, 57 
on glandular system, 60 
on muscular system, 59 
on nervous system, 61 
on respiratory system, 56 
inhalation, See Inhalation anesthesia 
intra-abdominal administration of 
oxygen in connection with, 89 
rebreathing in administration of, 
100 
selection of, 324, and See Selection 
of anesthetics. 
use of carbon dioxid with, 96 
use of oil of bitter orange peel pre- 
ceding administration of, 91 
warming, 63 
Anesthetist, duties of, 361 
kit of, 362 
laws relating to, 686 766 
INDEX OF SUBJECTS 
Anesthetist, liability of, 684 
medico-legal status of, 675 
Anesthetist, qualifications of, 675 
Anesthetizing drugs, poisonous action 
of, 468 
Anesthol, 208, 276 
in operations for cleft palate, 340 
use of, in children, 328 
in heart disease, 329 
Anesthol-ether sequence by the drop 
method, 208 
for adult patients, 328 
Anesthol-oxygen, safety of, 325 
Anesthyl, 537 
Anestile, 537 
Aneurysm, chloroform indicated for, 
310 
ether contra-indicated in, 248 
Angina Ludovici, anesthesia in, 353 
Angina pectoris, nitrous oxid and oxy- 
gen in treatment of, 670 
Angiomata of abdominal wall, opera- 
tion on, under spinal analgesia, 
625 
Animals, doses for, 754 
Anoci-association, 370, 388, 405 
operations under, 406 
Anociation, 477 
Anedyne. See Ethyl Chlorid 
Anodynone, 250. See also Ethyl 
chlorid 
Anterior teeth, technique of sub- 
periosteal injection of anes- 
thetic solution about, 545 
Antidolorin, 250, 537. See also Ethyl 
chlorid 
Antrum of Highmore operations, an- 
esthesia in, 340 
Anus, anesthetization of, 517 
effect of shock on, 386 
site of spinal puncture for, 610 
Apnea in anesthesia, 57, 298, 308, 380, 
408 
Appendectomy, shock in, 412 
under local anesthesia, 522 
under spinal analgesia, 580, 589 
Arm amputations under local anes- 
thesia, 508 
Arnott, ice packs advocated by, 537 
Aromatic spirits of ammonia in chloro- 
form administration, 313, 316 
Arterial anesthesia, 492 
Arterioles, effect of ethyl chlorid on, 
259 
Artificial respiration, 83, 86, 463 
apparatus for induction of, 396 
by insufflation of pure air or air and 
oxygen, 432 
following use of cocain, 539 
in ethyl chlorid anesthesia, 267 
in status lymphaticus, 334 
in treatment of acapnia, 409 
in treatment of shock, 393 
by Draeger's pulmotor, 396 
by Lewis "pendulum swing," 393 
Artificial respiration, in treatment of 
shock, by lung motor, 399 
by manual means, 393 
by Meltzer's apparatus, 399 
Asphyxia and shock, 388 
death due to, in ethyl chlorid anes- 
thesia, 261 
in status lymphaticus, 333 
due to nitrous oxid, 127, 132, 134, 
136, 154 
symptoms of, 137 
in ether anesthesia, 189 
prevention of, in ethyl chlorid-oxy- 
gen anesthesia, 278 
Asphyxiation of tissues in anesthesia, 
49 
Asphyxiation theory of nitrous oxid 
action, 124 
Asthma, anesthesia in, 330 
chloroform indicated for, 310 
ether contra-indicated in, 248 
ether treatment for, 4, 176 
spinal analgesia in, cases of, 586 
Atheroma, ether contra-indicated in, 
248 
Atheromatous conditions, choice of 
anesthetic in, 328 
Athletes, administration of nitrous 
oxid in, 140 
choice of anesthetic in, 329 
ethyl chlorid anesthesia contra-indi- 
cated in, 269 
preliminary medication in anesthe- 
tizing, 371 
Atropin, administration of, during an- 
esthesia in status lymphaticus, 
334 
as preventive of cardiac inhibition, 
402 A 
in acute mania, 669 
in preliminary medication, 371, 373, 
612 
in respiratory failure, 394 
in shock prevention, 402 
omission of, in post-operative treat- 
ment, 378 
preceding adenoid and tonsil opera- 
tions, 341 
preceding anesthesia, 328, 331 
preceding intratracheal anesthesia, 
427 
preceding nitrous oxid-oxygen anes- 
thesia, 165 
with ethyl chlorid, 373 
Atropin sulphate, dose of, for animals, 
754 
in intravenous anesthesia, 629 
Automatic closing tubes for ethyl 
chlorid, 254 
Auto-observations under spinal anal- 
gesia, 577, 580 
Avamresco's sites for spinal puncture, 
610 
Axillary glands, enlargement of, in 
status lymphaticus, 332 INDEX OF SUBJECTS 
767 
Babcock's needle for spinal analgesia, 
615 
solution, 603 
Baglioni's theory of anesthesia, 46 
Bainbridge, W. S., on spinal analgesia 
and spinal anesthesia, 554 
Bainbridge's method of cocain steri- 
lization, 605 
of intra-abdominal administration of 
oxygen, 89 
of spinal analgesia, 600, 604 
Bandages, cutting of, preceding anes- 
thesia, 337 
Bandaging in arterial anesthesia, 492 
in shock prevention, 403 
in venous anesthesia, 490 
Barium hydroxid in testing purity of 
oxygen, 753 
Barker's experiments on cerebrospinal 
fluid diffusion, 568 
with stovain injection in spinal anal- 
gesia, 571 
Barker's solution for spinal injection, 
568, 579 
Barker's stovain-glucose solution for 
spinal analgesia, 602 
Baskerville, experiments of, on effect 
of moisture on anesthetics, 76 
Baskerville and Gwathmey, experi- 
ments of, on warming ether 
vapor, 71 
Behr on ethyl chlorid anesthesia, 267 
Bennett's nitrous oxid-ether apparatus, 
218 
Bernard, Claude, on chloroform, 26 
theory of anesthesia advanced by, 
34 
Bert on nitrous oxid anesthesia, 126 
Bert's apparatus for nitrous oxid and 
oxygen, 24 
Bertel on chloroform and oxygen, 26 
Beta-eucain, 540 
in spinal analgesia, 563, 599 
Beta-eucain lactate in spinal analgesia, 
563, 599 
Betacain, 540 
Biberfield, experiments of, with novo- 
cain-adrenalin, 540 
Bichlorid of ethidene introduced by 
Clover, 25 
' ' Bichlorid of methylene, ' ' introduc- 
tion of, 24 
Bier on spinal analgesia, 559, 562, 567, 
602 
Bier's method of local anesthesia, 490 
in hernia, 525 
limitations in use of, 586 
stovain solution for, 602 
tropacocain solution for, 601 
of thyroid surgery, 505 
of venous anesthesia, 490 
Bigelow, Jacob, on Morton, 14 
Binz's theory of anesthesia, 34 
Bitter orange peel, 240 
Bivalent carbon hypothesis, 42 
Bladder, care of, preliminary to anes- 
thesia, 364 
local anesthesia of, 516 
Blake cone 102 
Bloch on the effects of ether upon the 
blood, 187 
Blocking the cervical plexus in goiter 
operation, 506 
in surgery of neck, 502 
line of stitches, dosage for, 406 
Blood, action of chloroform upon, 298 
effect of anesthetics on, 57 
effect of ether upon, 185 
effect of nitrous oxid on, 128 
in stools under colonic ether anes- 
thesia, 455 
Blood changes in intravenous anes- 
thesia, 638 
Blood pressure and shock, 383, 410 
effect of abdominal pressure on, 401 
effect of anesthetics on, 59 
effect of ethyl chlorid on, 259 
effect of nitrous oxid on, 130 
in chloroform-oxygen narcosis, 87 
in ether-oxygen narcosis, 87 
in intravenous anesthesia, 638 
in nitrous oxid-oxygen anesthesia, 
166 
in operations under Crile's method, 
402 
in spinal analgesia, 581, 595 
increase of, in shock prevention, 402 
relation of, to respiration in ethyl 
chlorid anesthesia, 259 
Blood-pressure apparatus of McKeson, 
409, 411 
Bloodless field for adenoid and tonsil 
operations, 344 
Blumdell, ice packs advocated by, 
537 
Body weight, loss of, following ethyl 
chlorid anesthesia, 265 
Boothby, on warmed ether vapor, 73 
Boothby and Cotton apparatus for ni- 
trous oxid-oxygen anesthesia, 
160 
Boothby and Cotton face mask for 
nitrous oxid-oxygen anesthesia 
166 
Boyle on ethyl chlorid anesthesia, 
267 
Brachial plexus, anesthetization of, 
508 
Brain, effect of anoci-association on, 
370 
effect of chloroform on, 301 
effect of shock on, 384 
examination of, under local anes- 
thesia, 496 
Brain cell changes under nitrous oxid 
anesthesia, 404 
Brain cell exhaustion under ether anes- 
thesia, 404 
Brain surgery, anesthesia in, 354 
chloroform indicated for, 310 768 
INDEX OF SUBJECTS 
Braun, experiments of, with novocain- 
adrenalin, 540 
on layer infiltration, 505 
on local anesthesia in hernia, 525 
Braun's inhaler for chloroform-ether 
administration, 323 
Braun's method for circumcision, 514 
for thyroid operations, 505 
in local anesthesia of skin, 495 
Braun's novocain-suprarenalin solution 
for spinal analgesia, 603 
Breast surgery under local anesthesia, 
507 
Breathing. See Respiration 
British Pharmacopoeia, ethyl chlorid 
tests prescribed by, 257 
Bromids in preliminary medication, 
329, 371 
for spinal analgesia, 612 
Bronchi, effect of nitrous oxid on, 128 
Bronchitis, anesthesia in, 330 
chronic, spinal analgesia in, 586 
ether contra-indicated in, 342 
post-anesthetic, caused by ether, 
189 
Bronchoscopy, oil-ether colonic anes- 
thesia in, 460 
Bruning on effect of moisture contents 
of air on lungs, 78 
on value of oxygen with narcotics, 
83, 86 
Brunn on mode of action of nitrous 
oxid, 126 
Brunton, Lauder, on chloroform, 26 
Bunnell's apparatus for positive pres- 
sure face-mask anesthesia, 700 
Burckhardt on intravenous anesthesia, 
629 
Biirker's theory of anesthesia, 48 
Busse on spinal analgesia, 595 
Butyl alcohol, dosage of, for animals, 
754 
impurities in ethyl chlorid due to, 
253 
in chloroform, 285 
Butyn, local anesthetic, 469 
poisonous action of, 469 
Buxton on effect of nitrous oxid on the 
blood, 128 
on ethyl chlorid anesthesia, 260 
on limitations in use of spinal anal- 
gesia, 586 
Cachexia, intratracheal insufflation in, 
432 
Caglieri on spinal analgesia, 559, 561, 
565 
Calcium salts, reverse action of mag- 
nesium salts, 647 
Calculi, renal or biliary, passage of, 
anesthetic treatment for, 667 
Camphorated oil administration in re- 
spiratory failure, 396 
Cancer, anesthesia in, 330 
Cannabis, dose of, for animals, 755 
Cannula for Bier's venous anesthesia, 
491 
for spinal analgesia, 614 
introduction of, in intravenous anes- 
thesia, 632 
Cantelupe, on action of ethyl chlorid, 
261 
Carbon dioxid, early use of, 2 
effect of, in rebreathing, 111 
on arteries and veins, 114 
on intestines, 114 
for restoration of respiration, 446 
in dental anesthesia, 537 
in oil-ether colonic anesthesia, 446 
loss of, in shock causation, 406 
physiological role of, 96 
reduction of, in the blood by chloro- 
form, 298 
causes of, 97 • 
effects following, 97 
use of, with anesthetics, 96 
Carbon dioxid snow, 537 
Carbon tetrachlorid, preparation of 
chloroform from, 285 
Carbonyl chlorid as product of pure 
chloroform decomposition, 290 
in chloroform, 286 
Carcinoma, acidosis in, 415 
of superior maxilla, operation for, 
under spinal analgesia, 574 
Carcinomatous gland case, results in, 
due to lack of preliminary medi- 
cation, 370 
Cardiac arrest due to chloroform, 386 
Cardiac cases, use of rebreathing in 
anesthetizing, 111 
Cardiac massage in ethyl chlorid anes- 
thesia, 267 
in status lymphaticus, 334 
Cardiac syncope due to chloroform, 
305 
Carlson and ethyl chlorid, 27 
on chloroform, 299 
Carotid arteries, compression of, 467 
Castor oil in preliminary treatment, 
365, 436 
Catarrh, of upper passages, ether 
contra-indicated in, 342 
Cathartics, use of, preceding adenoid 
and tonsil operations, 340 
Catheters, rubber, for removal of 
blood, in adenoid and tonsil op- 
erations, 345 
Catheters, tracheal, for intratracheal 
insufflation, 425, 426, 430 
introduction of, 426 
Caudal anesthesia, 485 
"C. E. " mixture, 81 
safety of, 325 
use of, in children, 327 
in heart disease, 329 
with air, safety of, 325 
C. E. mixture-ether-chloroform se- 
quence, 326 
C. E. mixture-ether sequence, 326 INDEX OF SUBJECTS 
769 
Cerebral diseases, convulsions from, ni- 
trous oxid-oxygen in, 667 
Cerebrospinal fluid, diffiusion of, 565 
escape of, on puncture, 618, 621 
in spinal analgesic solutions, 599 
movement of, 565 
origin of, 564 
physiology of, 563 
pressure of, 565 
specific gravity of, 565 
volume of, 565 
Cerebrospinal meningitis, death due to 
status lymphaticus in, 335 
Cesarian section under spinal anal- 
gesia, 593 
Chaput on spinal analgesia, 562, 575, 
598 
stovain solution for, 602 
Chart, analgesic, 749 
anesthesia, graphic, 529 
Cheeks, operations on, under local an- 
esthesia, 498 
Chelen, 250. See also Ethyl chlorid 
and Kelene 
Chemicals and psychic shock, 384 
Chest dissections, shock in, 402 
Chiene on death due to spinal anal- 
gesia, 597 
Children, administration of nitrous 
oxid-oxygen in, 143 
anesthetic treatment for convulsions 
in, 667 
and shock, 387 
choice of anesthetic for, 326 
ether contra-indicated for, 248 
nitrous oxid anesthesia contra-indi- 
cated in, 135 
oil-ether anesthesia for, 442 
use of ethyl chlorid anesthesia in, 
268 
use of spinal analgesia for, 561, 588 
Chloral, dose of, for animals, 755 
Chlorethyl. See Ethyl Chlorid 
Chlorethylene chlorid. See Ethylene 
Chlorethylidene. See Ethylidene chlorid 
Chloretone, dose of, for animals, 755 
in postoperative treatment, 378 
in preliminary medication, 371, 727 
for oil-ether anesthesia, 444 
use of, preceding adenoid and tonsil 
operation, 341 
Chloretone and morphin, doses of, in 
preliminary medication, 372 
Chlorid of lime in preparation of 
chloroform, 285 • 
Chloriden. See Ethylidene chlorid 
Chlorin, action of, on ethyl iodid, 252 
as product of pure chloroform de- 
composition, 290 
in chloroform, 286 
"Chlorinated" oils in chloroform, 285 
Chloroaethyl, 250. See also Ethyl 
chlorid 
Chloro-ethane, 250. See also Ethyl 
chlorid 
Chloroform, administration of, 311 
ammonia in, 287 
apnea in, 298, 308 
by drop method, 311 
in case of acute mania, 669 
in locomotor ataxia, 667 
in passage of renal or biliary cal- 
culi, 667 
Snow's scientific, 23 
with Braun's inhaler, 323 
with Gwathmey three-bottle vapor 
inhaler, 323 
with Harcourt's inhaler, 320, 321 
with Junker's apparatus, 322 
with Roth-Drager oxygen and 
chloroform apparatus, 317 
with the Yankauer mask, 203 
alcohol as preservative of, 283, 285, 
290, 295 
amount of, used with Roth-Drager 
apparatus, 319 
and shock, 389 
anesthetic, 283 
as a solvent, 284 
as preliminary to ether, 310 
atropin as preliminary medicament 
to, 373 
changes in, due to combination with 
oxygen, 294 
chemistry of, 281 
Clover's inhaler for, 23 
combined with ethyl chlorid and 
ether (anesthol), 276 
combining oxygen with, 80 
containers for, 292, 293 
the drop method, 200 
decomposition of, 289, 290 
due to strong light, 295 
density of, 283 
dose of, for animals, 755 
early prejudice against, 23, 25 
early use of, 20 
effect of agitation on, 296 
effect of temperature on, 283 
effect of warming on, 63 
effect of, upon blood pressure, 59 
upon the circulatory system, 298 
upon the glandular system, 303- 
305 
upon the kidneys, 303, 309 
upon the liver, 304 
upon the muscular system, 302 
upon the nervous system, 302 
upon the respiratory system, 298 
elimination of, 309 
ethyl chlorid and, 279 
ethyl chlorid compared to, 258, 266 
experimental use of, in animals, 335 
fatty metamorphoses, following use 
of, 88 
Harcourt's inhaler for, 26, 320 
history of, as an anesthetic, 282 
impurities in, 285 
fatal after-effects due to, 286 
in spinal analgesia, 588 770 
INDEX OF SUBJECTS 
Chloroform, Moore-Roaf theory of 
action of, 44 
overdose of, 308 
Pilling dropper for, 312 
preparation of, 285 
preservatives of, 291 
properties of, 283 
pure, decomposition of, 289 
purification of, 285 
relative anesthetic value of, 311 
safety of, 83 
as affected by temperature, 314 
shipping of, 296 
Simpson's early use of, 20 
Snow's inhaler for, 23 
solubility of, 284 
special physiology of, 297 
specific gravity of, 283 
stability of, 289 
standards of purity for, 296 
substitutes for, 23, 24 
temperature stimulus and, 69 
uses of, in medicine, 284 
warmed, 314 
with air, safety of, 325 
with alcohol, 295 
with atropin, 371, 373 
with ether, in elderly persons, 328 
in submucous operations, 340 
nitrous oxid-ether sequence fol- 
lowed by, 325 
with ethyl chlorid, 115 
dosage for, 116 
rebreathing in the administration 
of, 115 
with morphin, 26, 371 
with nitrous oxid and ether, 223 
Chloroform and oxygen, 26, 87, 294 
in adenoid and tonsil cases, 342 
in brain operations, 354 
in diabetes, 330 
in dyspnea, 330 
in elderly people, 328 
in goiter, 353 
in obese patients, 329 
in obstetric cases, 355 
in respiratory diseases, 330 
in thyroidectomy, 353 
in tuberculosis, 329 
safety of, 325 
Chloroform anesthesia, after-effects of, 
310, 415 
due to impurities, 286 
blood changes due to, 58 
by intratracheal insufflation, 429 
contra-indications for, 310 
kidney diseases, 330 
rectal cases, 355 
short operations, 338 
status lymphaticus, 333 
death due to, 305 
excitement during, 307 
false, 380 
for adult patients, 328 
in adenoid and tonsil cases, 341 
Chloroform anesthesia, in cancer, 330 
in children, 326 
in circumcision, 355 
in curettage, 355 
in epileptics, 331 
in heart diseases, 329 
in insane patients, 331 
in laparotomy, 355 
in mastoid operations, 339 
in obstetrics, 368 
in operations for cleft palate, 340 
in operations on the respiratory 
tract, 339 
in peritonitis or intestinal obstruc- 
tion, 356 
in submucous operations, 340 
in tracheotomy, 353 
indications for, 310 
respiratory difficulties in, 380 
stages of, 306 
status lymphaticus associated with, 
331 
use of Lewis pendulum swing in, 
394 
Chloroform Pictet, 289 
Chloroform poisoning, 413 
cases of, 414 
symptoms of, 415 
use of oxygen and, 86 
Chloroform treatment for acute pain 
in tetanus, 667 
in cases of puerperal eclampsia, 
667 
in convulsive affections, 667 
in nervous irritability, 667 
in strychnin poisoning, 667 
Chloroform-ether-chloroform sequence, 
326 
Chloroform-ether-nitrous oxid sequence, 
141 
Chloroform-ether-oxygen narcosis, 87 
Chloroform-ether sequence, 207, 240, 
326 
Cholecystectomy under spinal anal- 
gesia, 560 
Cinnamic acid as preservative of 
chloroform, 292 
Circulatory system, effect of anes- 
thetics on, 57 
effect of ether upon, 185 
effect of ethyl chlorid on, 259 
effect of nitrous oxid on, 128, 131 
reflex changes in, in anesthesia, 61 
Circumcision, anesthesia in, 355 
ethyl chlorid anesthesia for, 268 
under complete spinal analgesia, 
576 
under local anesthesia, 516 
Citronellol, as preservative of chloro- 
form, 292 
Civil liability of physician, 681 
Clavicle, fractured, wiring of, under 
local anesthesia, 507 
Cleft kidney, associated with status 
lymphaticus, -333 INDEX OF SUBJECTS 
771 
Cleft palate, anesthesia in, 340 
associated with status lymphaticus, 
333 
Closed method of administering ethyl 
chlorid, 273 
of anesthesia, contra-indicated in 
elderly people, 328 
in obese patients, 329 
in status lymphaticus, 333 
of etherization, Clover's, 177 
ill effects of, on the lungs, 101 
Clover, on nitrous oxid and ether, 25 
Clover chloroform inhaler, 23 
Coburn, apparatus for nitrous oxid- 
oxygen anesthesia, 149, 150, 151 
Cocain, 467 
as preventive of cardiac inhibition, 
402 
discovery of, 555 
experimentation with, 555 
in anesthesia of scalp, 496 
in spinal analgesia, 576, 585, 600, 
604, 624 
in tonsillectomy, 501 
in treatment for sneezing, 387 
in treatment of nose, 500 
injection of, preliminary to puncture 
in spinal analgesia, 618 
poisonous action of, 468 
sterilization of, Bainbridge's method 
of, 605 
substitutes for, in local anesthesia, 
468, 540 
toxicity of, 600 
use of, in dentistry, 538 
precautions in, 539 
preparation of solutions of, 539 
sterilization of solutions of, 540 
substitutes for, 540 
Cocain ' ' block ' ' in operations upon 
extremities, 402 
Cocain infiltration, in general anes- 
thesia, 474, 478 
in venous anesthesia, 491 
Cocain solutions, for surface anes- 
thesia, 478 
preparation of, 470 
sterilization of, 470 
Cocain-adrenalin solution in anesthe- 
tization of urethra and bladder, 
516 
in circumcision, 516 
Cocainization of larynx for intra- 
tracheal insufflation, 427 
' ' Coin ' ' freezing with ethyl chlorid, 
670 
Cold as local anesthetic, 466, 537 
Cold perspiration in anesthesia, 60 
Colic, biliary, anesthetic treatment in, 
666 
renal, anesthetic treatment in, 666 
Collapse during anesthol administra- 
tion, 277 
following ethyl chlorid anesthesia, 
265, 272 
Collins ' technique in preliminary medi- 
cation, 372 
Cologne, use of, in adenoid and tonsil 
operations, 342 
Colombani on tropacocain in spinal 
analgesia, 601 
Colonic absorption of ether, anesthesia 
by, 433 
Colonic analgesia, synergistic, 654 
Colonic instillation, in painless child- 
birth, 749 
Colonic instillation of ether and oil, 654 
Color reflex in administration of 
chloroform, 315, 316 
Colton, J. Q., 10, 24 
use of nitrous oxid in dentistry by, 
118 
Combinations and sequence in anes- 
thetics, list of, 325 
Combined oxygen narcosis, 87 
Comfort of patient during operation 
under local anesthesia, 475 
' ' Compound anesthetic ether, ' ' de- 
fined, 178 
Compression of nerve trunks in local 
anesthesia, 465 
Conductive anesthesia, 536 
by perineural injection, 548 
Coniferin as preservative of chloro- 
form, 292 
Conjunctival reflexes, absence of, in 
ethyl chlorid anesthesia, 263 
in chloroform administration, 316 
Connell on endopharyngeal anesthesia, 
235, 238 
on ether vapor concentration, 241 
Connell method of nitrous oxid-oxygen 
anesthesia, endopharyngeally, 159 
Connell's anesthetometer, 160 
Connell's breathing tube, 392 
Consciousness during spinal analgesia, 
578 
Contact anesthesia. See Pressure anes- 
thesia 
Containers for chloroform, 292 
for ethyl chlorid, 254 
glass vs. metal, 255 
Convulsions, effect of warming the an- 
esthetic on, 65 
Convulsive affections, anesthetic treat- 
ment for, 667 
Copper oxid in testing purity of oxy- 
gen, 753 
Cork stoppers for chloroform contain- 
ers, objections to, 294 
Corneal reflexes, absence of, in ethyl 
chlorid anesthesia, 263 
Corning, discovery of spinal analgesia 
by, 556, 562 
on cocain, 467 
Cortical neurons, effect of anesthesia 
on, 41 
Coughing, during anesthesia, 381 
during intratracheal anesthesia, 429 
Coughlin's ether rausch, 209 772 
INDEX OF SUBJECTS 
Cotton-Boothby apparatus for nitrous 
oxid-oxygen anesthesia, 160 
Cotton-Boothby introducing cannula, 
Ehrenf ried's modification of, 
for soft rubber tubes, 426 
Cowan's technic, in painless childbirth, 
736 
Craniotomy, bilateral suboccipital, in- 
tratracheal insufflation indicated 
in, 431 
under spinal analgesia, 587 
Crile on anoci-association, 367, 388, 
405 
on cerebrospinal fluid diffusion, 567 
on combination of general with local 
anesthesia, 27, 475 
on lumbar puncture, 558 
on necessity of preliminary mental 
preparation, 366, 369 
on prevention of shock, 385, 402 
Crile method for gastro-enterostomy, 
356 
in goiter, 353, 354 
Crile's abdominal hysterectomy chart, 
405 
Crile's chart of mortality rate of op- 
erations under anoci-association, 
406 
Crile's pneumatic rubber suit, 404 
Crile's theory of de-oxygenation, as 
cause of shock, 401 
Crile's thyroidectomy chart, 406 
Crim on medico-legal status of anes- 
thetist, 675 
Criminal liability of physician, 685 
Criminal negligence, 686 
Criminals and resistance to surgical 
shock, 384 
Crombil on medication before anesthe- 
sia, 26 
on morphin and chloroform, 26 
Cuneo on ether disinfection, 673 
Cunningham apparatus for colonic 
ether anesthesia, 435 
Curettage, anesthesia for, 355 
Cushing on local anesthesia, 524 
Cushing's anesthetization for inguinal 
hernia, 524 
Cushing's sketch of nerves in inguinal 
hernia operations, 524 
Cyanosis, avoidance of, in nitrous ox- 
id-oxygen anesthesia, 167 
during intratracheal insufflation, 429 
in asphyxia with ethyl chlorid, 261 
in ethyl chlorid anesthesia, 263, 272, 
275 
in nitrous oxid anesthesia, 133, 168 
Cyst, subcortical, removal of, under 
local anesthesia, 497 
Cystotomy, suprapubic, under local 
anesthesia, 516 
Da Costa on Long, 8, 10 
Davis apparatus for ethyl chlorid- 
ether by drop method, 223 
Davis apparatus for gas-ether by the 
drop method, 223 
for nitrous oxid, 151 
Davis dropper for insertion in original 
container, 205, 206 
Davis heater for gas or oxygen, 223 
with the Gwathmey three-bottle 
vapor inhaler, 224 
Davis inhaler for ethyl chlorid-ether 
sequence by the closed drop 
method, 222, 275 
for gas-ether sequence, 221 
Davis method of ether administration, 
205 
of nitrous oxid anesthesia, 151 
Davis nitrous oxid-oxygen apparatus, 
145 
Davy, Sir Humphry, on nitrous oxid, 
4, 118, 123 
Death due to acidosis, 415 
due to ether, 415 
due to lack of preliminary medica- 
tion, 370 
due to shock, 384 
in cases under anoci-association, 406 
under chloroform anesthesia, 282, 
287, 305, 414 
under colonic ether anesthesia, 437, 
455 
under ethyl chlorid anesthesia, 415 
causes of, 261 
under intravenous anesthesia, 629 
under spinal analgesia, 589, 596, 625 
Debility, extreme, spinal analgesia in, 
587 
Decomposition of chloroform, due to 
tin containers, 293 
upon exposure to gas light or naked 
flames, 295 
Decomposition of pure chloroform, 289 
products of, 290 
Defecation, involuntary, following use 
of nitrous oxid, 132 
Definitions, 31 
"Dehydrated ether," 197 
Dehydration of protoplasm by anes- 
thetics, 34 
Deimann, preparation of nitrous oxid 
gas by, 118 
Denatured alcohol, methyl chlorid pro- 
duced from, 252 
Dental hypodermic needles, 543 
Dental hypodermic syringe, 542 
Dental prop, use of, in ethyl chlorid 
anesthesia, 262 
Dentistry, chloroform contra-indicated 
in, 338 
ethyl chlorid anesthesia in, 268, 338 
local anesthesia in, by cocain, 538 
by cold, 537 
by ethyl chlorid, 537 
by hypodermic method, 536 
history of, 535 
technique »of injection, 543 
nitrous oxid in, 118, 338 INDEX OF SUBJECTS 
773 
Dentistry, nitrous oxid-oxygen anes- 
thesia in, 173 
Dentists as anesthetists, 676 
Deoxygenation as cause of shock, 401 
of blood, an effect of chloroform, 
299 
Deoxygenation theory of anesthesia, 46 
of nitrous oxid action, 124 
Deutsches Arzneibuch, ethyl chlorid 
tests prescribed by, 257 
Dextrin in spinal analgesic solutions, 
599 
Dextrin-stovain solution for spinal • 
analgesia, 603 
Diabetes, acidosis in, 415 
anesthesia in, 330 
Diagnosis, use of anesthetics in, 667 
Diaphragm, effect of ethyl chlorid on, 
258 
effect of shock on, 385 
position of, as it affects anesthesia, 
59 
Diarrhea following ethyl chlorid anes- 
thesia, 265 
Dichlorinated chlorid of methyl, 281. 
See also Chloroform 
Diet in acid intoxication, 413 
post-operative, 379 
preliminary to anesthesia, 365 
Dietetic shock, 387 
Diethyl ether, 178 
Diffusion of cerebrospinal fluid, experi- 
ments on, 565 
Digestive tract, effect of shock on, 385 
Digitalin in spinal analgesia, 585 
Dilatation of cardiac muscles due to 
chloroform, 300 
of pupils in ethyl chlorid anesthesia, 
261, 263, 264 
Distribution coefficient and narcotic 
effect, 38 
Dizziness following use of ethyl 
chlorid, 338 
Dol6ris on spinal analgesia, 560, 593 
Donitz on spinal analgesia, 567, 576 
Doses, for animals, 754 
Double-end ethyl chlorid tube, 254 
Double saturation, 722 
Draeger's pulmotor for artificial res- 
piration, 396 
Drainage cases, care of, during anes- 
thesia, 375 
Dreser on effect of ether vapor on the 
lungs, 101, 103, 105 
on ether vapor concentration, 240 
Drop method of chloroform administra- 
tion, 311 
dropper for use in, 312 
induction of anesthesia by, 312 
preparation of patient for, 312 
reflexes in, 315 
warmed chloroform in, 314 
of ether administration, as antidote 
to drugs used in spinal anal- 
gesia, 598 
Drop method of ether administration 
in case of acute mania, 669 
in locomotor ataxia, 667 
in passage of renal or biliary cal- 
culi, 667 
Dropper, ethyl chlorid, 256 
Pilling chloroform, 312 
Droppers for open method of ether 
administration, 199 
Drowning, insufflation of pure air or 
air and oxygen in, 432 
Drug habitues, choice of anesthetic in, 
329 
Drugs, anesthetizing, poisonous action 
of, 468 
"Dry spine," effect of, on spinal an- 
algesia, 585, 596, 621, 625 
DuBois Reymond, on impure chloro- 
form, 288, 290 
Dubois' theory of anesthesia, 34 
Duration of operation and shock, 
386 
Dyspnea, anesthesia in, 330, 380 
following overdose of nitrous oxid, 
134 
Ear operations, under local anesthesia, 
499 
Eclampsia, puerperal, anesthetic treat- 
ment of, 667 
Ehrenfest's objections to spinal anal- 
gesia in obstetrics, 594 
Ehrenfried's apparatus for intra- 
tracheal insufflation, 425, 426 
Ehrenfried's introducing forceps for 
stiff or soft rubber tubes, 427 
Elayl chlorid. See Ethylene chlorid 
Electric current for dental anesthesia, 
536 
Electricity, anesthetic effect of, 51 
in local anesthesia, 466 
Electrolysis, preparation of oxygen by, 
752 
Elimination of chloroform, 309 
of ether, 107 
of ethyl chlorid, 263 
Elsberg, on anesthesia by intratracheal 
insufflation, 416 
Elsberg's apparatus for intratracheal 
insufflation, 419 
Elsberg's clip to hold intratracheal 
tube in place, 428 
Embley, on ethyl chlorid, 258, 259, 260 
on chloroform, 300, 302 
Emergency cases, colonic ether anes- 
thesia contra-indicated for, 461 
Emergency treatment, to insure breath- 
ing, 362 
Emphysema, case of, following intra- 
tracheal insufflation, 430 
chloroform indicated for, 310 
spinal analgesia in, 586 
Empyema, anesthesia in, 329 
under oil-ether colonic anesthesia, 
461 774 
INDEX OF SUBJECTS 
' ' Empyreumatic " oils in chloroform, 
285 
Endoneural injection in local anesthe- 
sia, 480 
of the extremities, 508 
Endopharyngeal administration of 
nitrous oxid and oxygen, 159 
Endopharyngeal anesthesia, 235 
catheters for, 236 
compared with endotracheal, 238 
essentials of, 237 
in thoracic surgery, 694 
percentage of ether vapor for, 241 
Endopharyngeal insufflation and mouth 
tube combined, 236 
Endopharyngeal tubes for insufflation 
anesthesia, 227 
Endotracheal anesthesia, compared 
with endopharyngeal, 238 
in thoracic surgery, 694 
percentage of ether vapor for, 241 
Endotracheal insufflation, in nitrous 
oxid-oxygen anesthesia, 173 
See also Intratracheal insufflation 
Enema during anesthesia, 374 
in preliminary treatment of intes- 
tinal tract, 365 
Engelhardt on after-effects of ether, 
199 
on effect of ether upon circulatory 
system, 185 
English's measures for shock preven- 
tion, 403 
Engsted's method of spinal analgesia, 
598 
Enteroepiplocele, umbilical, operation 
for, under spinal analgesia, 
590 
Enucleation, anesthesia in, 338 
Epileptics, anesthesia in, 330 
chloroform indicated for, 310 
under spinal analgesia, 590 
Epinephrin, injection of, preliminary 
to chloroform anesthesia, 304 
Epirenin borate in spinal analgesia, 
602 
Erhardt's solution for spinal analge- 
sia, 601 
Erotic dreams in ethyl chlorid anes- 
thesia, 265 
Erotic sensations during anesthesia, 
687 
Esch, on action of adrenalin, 540 
Esmarch bandage in local anesthesia, 
465 
in venous anesthesia, 490, 492 
Esmarch inhaler, 204, 206, 217 
Esophagoscopy, oil-ether colonic anti- 
thetic for, 460 
Essence of orange, preliminary use of, 
388 
See also Oil of bitter orange peel 
Esters, defined, 178 
Ethane, chlorination of, 252 
' ' Ethane-oxy-ethane, " 178 
Ether, action, of hydrochloric acid on, 
252 
addition of, to ethyl chlorid and oxy- 
gen in alcoholics, 278 
administration of. See Ether ad- 
ministration 
after-effects of, 199 
aldehyd in, 183 
amount employed in oil-ether colonic 
anesthesia, 452 
and acapnia, 112 
and chloroform in submucous opera- 
tions, 340 
nitrous oxid-ether sequence fol- 
lowed by, 325 
use of, in elderly people, 328 
and nitrous oxid, 141 
and oil, by colonic instillation, 654 
and oxygen, 87 
in cancer, 330 
in heart disease, 329 
in insane patients, 331 
anesthetic, alcohol in, 181 
aldehyd in, 183 
composition of, 179 
compound, defined, 178 
peroxids in, 182 
standards of purity to be main- 
tained in, 181 
chemistry of, 178 
chloroform-ether followed by, 326 
colonic absorption of, 433. See also 
Ether administration 
combined with ethyl chlorid and 
chloroform (anesthol), 276 
compound, 178 
containers for, 182 
defined, 178 
dose for animals, 755 
early experimenters with, 11, 434 
effect of, on blood pressure, 59 
on organism, 449 
on the circulatory system, 185 
on the glandular system, 189 
on the muscular system, 189 
on the nervous system, 188 
on the respiratory system, 185 
effect of warming on, 66 
elimination of, 196 
ethyl chlorid and, 279 
ethyl chlorid compared to, 266 
Faraday's use of, 5 
fatty metamorphoses following use 
'of, 88 
first use of, in midwifery, 20, 177 
history of use of, as an anesthetic, 
176 
impurities in, administration means 
to avoid, 183 
sources of, 179 
in acid intoxication, 414 
in cases of puerperal eclampsia, 
667 
in chloroform, 284, 307 
in cocain sterilization, 605 INDEX OF SUBJECTS 
775 
Ether, in intravenous anesthesia, 630, 
635, 637 
in sterilization of apparatus for 
spinal analgesia, 616 
in strychnin poisoning, 667 
in treatment of acute pain in 
tetanus, 667 
in treatment of infections, 671 
cases of, 672 
Long's use of, 8 
manufacture of, 180 
mixed, 178 
Morton's experiments with, 11 
nitrous oxid-ether sequence followed 
by, 325 
olive oil in, 705 
peroxids in, experiments of Basker- 
ville and Ham or on, 182 
Pierson's use of, 4 
precautions in handling, 179 
respiratory failure due to, 192 
role of alcohol in, 181 
simple, 178 
special physiology of, 184 
synergistic, by inhalation, 653 
temperature stimulus and, 69 
use of oil of bitter orange peel with, 93 
warm, nitrous oxid and oxygen com- 
bined with, 325 
with air, safety of, 325 
with nitrous oxid and chloroform, 223 
with nitrous oxid and morphin, 108 
with oxygen, safety of, 325 
See also Ethylether 
Ether administration, 100, 199 
Allis inhaler for, 216 
Bennett inhaler for, 218 
by colonic absorption, 433 
administration of, 436 
advantages of, 438 
after-treatment, 437 
cases of, 437 
conclusions, 437 
death under, 454 
development of, 435 
disadvantages of, 438 
history of, 433 
indications and contra-indications 
for, 437 
method for, 436 
Sutton's method of, 436 
technique, 436 
by intratracheal insufflation, 416 
causes of death from, 192 
closed method of, 177, 217 
Esmarch inhaler for, 217 
Gwathmey inhaler for, 218, 219 
handkerchief method of, 212 
open or drop method of, 198 
as antidote to drugs used in 
spinal analgesia, 598 
Davis's, 205, 206 
droppers for, 199 
in case of acute mania, 669 
in locomotor ataxia, 667 
Ether administration, open or drop 
method of, in passage of renal 
or biliary calculi, 667 
masks for, 202 
Mayo's, 203 
oral, for painless childbirth, 744 
percentages of vapor for, 241 
rebreathing in, 100 
semi-closed method of, 211 
Snow's inhaler for, 23 
with closed masks, ill effects of, 
101 
with nitrous oxid, 218 
with oxygen, 239 
with the ether rausch, 209 
with warm water-vapor inhalations, 
199 
Ether anesthesia, after-effects of, 
196 
blood changes due to, 58 
cone method of, 198 
contra-indications to, 247 
in brain operations, 354 
in diseases of respiratory pas- 
sages, 330 
in kidney diseases, 330 
in short operations 338 
in tuberculosis, 329 
danger of shock with, 388 
discovery of, 7 
excitement stage of, 193 
exhaustion under, 405 
first operation in England under, 
19, 177 
in adenoid and tonsil cases, 340 
in children, 327 
in England, 19 
in epileptics, 331 
in Graves' disease, 353 
in mastoid operations, 339 
in obstetrical cases, 355 
in operations for cleft palate, 340 
in operations on the respiratory 
tract, 339 
in peritonitis or intestinal obstruc- 
tion, 356 
in status lymphaticus, 333 
indications and contra-indications of, 
247 
indications of returning conscious- 
ness under, 195 
light stage of, 193 
normal surgical stage of, 194 
overdose stage of, 195 
stages of, 193 
synergistic, 653 
third stage, 528 
Ether balance, maintenance of, in re- 
breathing, 106 
Ether-chloroform-ether sequence, 326 
Ether-chloroform-oxygen narcosis, 87 
Ether-chloroform sequence, 326 
drop method of, Lumbards nasal 
tubes for, 229 
for elderly patients, 234 776 
INDEX OF SUBJECTS 
Ether chlorohydrique, 2*50. See also 
Ethyl chlorid 
Ether controversy between Morton, 
Jackson and Wells, 17 
Ether elimination, 107, 196, 379 
effect of morphin on, 108 
Ether frolics, 7, 9, 177 
Ether irrigation of the abdomen, 672 
Ether pressure, 242 
Ether rausch, Coughlin on, 209 
Ether spray in dentistry, 537 
invention of, as local anesthetic, 466 
Ether storage, impurities developed in, 
180 
' ' Ether-tremor, " 194 
Ether vapor, administration of, by 
Meltzer's method, 238 
advantages of, 246 
by open method, 231 
concentration of, 240 
effect of, on respiratory passages, 
101 
in adenoid and tonsil cases, 340, 343 
in tracheotomy, 353 
mask for, 232 
maximum concentration of, without 
irritation, 103, 105, 106 
percentages of, for anesthesia, 241 
Pinneo's apparatus for, 234, 236 
treatment of accidents under, 246 
use of, with nitrous oxid and oxy- 
gen, 164, 167, 172 
warmed, 25, 225 
experiments with, 70 
Gwathmey's administration of, 
231 
temperature required for, 227 
Etherization, open and closed methods 
of, compared as to toxic effects, 
102 
Ethical liability of physician, 680 
Ethyl acetate, in chloroform, 285 
Ethyl alcohol, dose of, for animals, 754 
in chloroform, 283, 289 
in drop method of ether administra- 
tion, 182 
in manufacture of ether, 180 
preparation of ethyl chlorid from, 
252 
Ethyl bromid, combined with methyl 
chlorid and ethyl chlorid (som- 
noform), 276 
Ethyl chlorid, 20, 27 
administration of, 269 
after-effects of, 264 
and air, 276, 325 
and chloroform, 115, 279; 285 
rebreathing in administration of, 
115 
and ether, 279 
and nitrous oxid, 279 
and oxygen, 278, 325 
atropin as preliminary medicament 
to, 373 
causes of death under, 261 
Ethyl chlorid, chemical history of, 250 
chemistry of, 250 
combinations and sequences with, 
276 
comparison of, with other anesthet- 
ics, 266 
containers for, 254 
contra-indications to, 268, 338 
danger of shock with, 388 
dosage of, 269 
effect of, on blood pressure, 259 
on circulatory system, 259 
on glandular system, 261 
on muscular system, 261 
on nervous system, 260 
on respiratory system, 258 
effect of warming on, 66 
elimination of, 263 
experimental data on administration 
of, 269 
flexible spraying nozzle for, 254 
for anesthetizing children, 327 
for local anesthesia in dentistry, 537 
history of use of, as an anesthetic, 
251 
impurities in, 252, 257 
detection of, 257 
in convulsions of infancy and child- 
hood, 667 
indications for, 267 
introduction of, into England, 27 
methods of administration of, 271 
closed, 273 
open, 272 
semi-closed, 272, 273 
nitrous oxid with oxygen combined 
with, 325 
physiology of, 258 
preliminary to puncture in spinal 
analgesia, 618, 620 
preparation of, 251 
properties of, 253 
purification of, 253 
sealed tubes of, 254 
solubility of, in water and in blood 
serum, 259 
stages of anesthesia with, 261 
storage of, 254 
therapeutic uses of, 670 
uses of, 251 
Ethyl chlorid-ether-chloroform se- 
quence, 206, 325 
Ethyl chlorid-ether sequence, 325 
by closed method, 207 
by drop method, 206 
for adult patients, 328 
Ethyl chlorid measure dropper, 256 
Ethyl chlorid spray in local anesthesia, 
466 
Ethyl chlorid syncope, 261 
Ethyl chlorid toxemia, 261 
Ethyl chlorid tubes, 254 
Ethyl ether, 178 
as preservative of chloroform, 292 
discovery of, as an anesthetic, 7 INDEX OF SUBJECTS 
777 
Ethyl iodid, action of chlorin on, 252 
Ethylene, action of, on blood, 721 
administration of, 718, and See 
Ethylene anesthesia 
avoidance of dangers of, 730 
causes of death from, 717 
comparative value of, 722 
dangers of, 730 
distribution of, 715 
elimination of, 717 
experimental data, 721 
explosiveness of, 721 
impurities of, 714 
mortality of, 730 
physiological effects of, 715 
on cardio-inhibitory center, 715 
on glandular system, 716 
on hemoglobin, 716 
on kidneys, 717 
on musculature, 716 
on nervous system, 716 
on respiratory system, 715 
on vasomotor centers, 715 
post-anesthetic effects of, 717 
preparation of, 713 
properties of, 714 
solubility of, 714 
uses of, 715 
Ethylene and nitrous oxid and oxygen, 
729 
Ethylene and oxygen, in oral surgery, 
728 
Ethylene anesthesia, 711 
administration of, 718 
advantages of, 719 
case reports on, 720 
contra-indications to, 719 
double saturation, 722 
early literature of, 711 
disadvantages of, 720 
history of, 711 
preliminary medication, 723 
secondary saturation, 723 
stages of, 718 
Ethylene chlorid in chloroform, 285 
Ethylic ether, 178 
Ethylidene chlorid, in chloroform, 285 
introduced by Clover, 25 
Ethylol, 250. See also Ethyl chlorid 
Eucain in spinal analgesia, 599 
Eucain-B, 540 
Evans, and nitrous oxid, 24 
Excitement preceding narcosis, 33 
Excitement stage, effect of oil of bitter 
orange peel on, 93 
in ethyl chlorid anesthesia, 262 
in nitrous oxid anesthesia, 133 
Exophthalmic goiter, in status lym- 
phaticus, 332, 335 
preliminary medication in, 372 
Exophthalmos, anesthesia in, 353 
Experimentation, animal, with oil- 
ether colonic anesthesia, 439 
Extraction of teeth, local anesthesia 
for, 544 
Extremities, operations on, cocain 
' ' block ' ' in, 402 
intravenous anesthesia for, 490 
under local anesthesia, 508 
Extremities, lower, operations on, 
under spinal analgesia, 586, 588, 
597, 610 
upper, operations on, under spinal 
analgesia, 597 
Eye, enucleation of, anesthesia in, 338 
use of nervocidin in, 781 
Eye surgery, under local anesthesia, 
502 
Eyeballs, in ethyl chlorid anesthesia, 
263, 274 
significance of position and move- 
ments of, 528, 532 
Eyelid, operations on, under local an- 
esthesia, 498 
separation of, in overdose of ethyl 
chlorid, 261 
Fabre on the effect of ether on lacta- 
tion, 192 
Face, changes in, due to shock, 385 
nerve supply of, 498 
Face mask, Teter, for nitrous oxid-oxy- 
gen anesthesia, 154 
Face-mask method of anesthesia, 694 
Bunnell's apparatus for, 700 
Facial operations, chloroform indicated 
for, 310 
under local anesthesia, 498 
Fainting, following ethyl chlorid anes- 
thesia, 265 
False chloroform anesthesia, 380 
Faraday on ether, 5, 177 
Farina cologne in chloroform adminis- 
tration, 312, 316 
Fatty degeneration of kidneys and 
liver, following repeated admin- 
istrations of ethyl chlorid, 265 
Fatty metamorphosis and anesthesia, 
88, 90 
Fear, diagnostic evidences of, 368 
prevention of, 388 
prior to anesthesia, effect of, 366, 
369 
Fedorow on intravenous anesthesia, 629 
Ferguson's artificial airway, 391 
Ferguson's ethyl chlorid tubes for gen- 
eral and local anesthesia, 255 
Ferguson's mask for ether administra- 
tion, 203, 204 
Fetus, effect of ether upon the, 191 
Fever after spinal analgesia with 
tropo-cocain, 583 
Fevers, infectious, acidosis in, 415 
Filliatre on cocain in spinal analgesia, 
600 
Finger anesthetization, 511 
Finger operations, 354 
Esmarch elastic bandage in, 466 
Fischer's apparatus for intratracheal 
insufflation, 423, 425 778 
INDEX OF SUBJECTS 
Fischer's ' ' normal anesthetic solu- 
tion, " 541 
Fisher on paralyses after spinal anal- 
gesia, 584 
Fistula in ano, colonic ether anesthesia 
contra-indicated in case of, 461 
Flexible spraying nozzle for ethyl 
chlorid, 254 
Flushing of face associated with ethyl 
chlorid anesthesia, 260 
Foot, removal of tuberculous abscesses 
of, under spinal analgesia, 575 
Formic acid, in chloroform, 285 
Formyl trichlorid, 281. See also 
Chloroform 
Foy, on chloroform, 26 
Fractures, treatment of, under infil- 
tration of cocain and adrenalin, 
512 
under intravenous anesthesia, 492 
Fraicou's auto-operation under spinal 
analgesia, 577 
Fraicou's solution for spinal analgesia, 
577 
Freezing as a means of local anesthe- 
sia, 537 
in anesthetization of skin, 493 
with ethyl chlorid as local anesthetic, 
466, 670 
French on use of oil of bitter orange 
peel, 94 
French chair table, 346 
French Codex, ethyl chlorid tests pre- 
scribed by, 258 
French method of adenoid and tonsil 
operations in upright position, 
345 
Freiburg method of painless childbirth, 
734 
Furniss gas-ether inhaler, 220 
Gall-bladder operations, shock in, 403 
under local anesthesia, 521 
Gallotannic acid as preservative of 
chloroform, 292 
Ganglia, sympathetic, excision of, 
under spinal analgesia, 587 
Ganglion cells, effect of ethyl chlorid 
on, 260 
in anesthesia, 34, 36 
role of, in ethyl chlorid anesthesia, 
264 
Gangrene from Esniarch elastic band- 
age, 466 
of intestine, operation for, under 
spinal analgesia, 593 
senile, spinal analgesia in, 587 
Gas-ether-chloroform sequence, 326 
in adenoid and tonsil cases, 342 
Gas-ether sequence, 326 
contra-indicated in elderly people, 
328 
for adult patients, 328 
in adenoid and tonsil cases, 342 
in nervous patients, 330 
Gasserian ganglion, injection of, in 
local anesthesia, 498 
Gasserian ganglion puncture according 
to Haertel, 498 
Gastric ulcer, acidosis in, 415 
Gastro-enterostomy, anesthesia in, 356 
hypodermoclysis in, 376 
under local anesthesia, 522 
Gastroscopy, oil-ether colonic anesthe- 
sia for, 460 
Gatch, W. D., on rebreathing in ad- 
ministration of anesthetics, 27, 
100 
Gatch's method of administering ni- 
trous oxid and oxygen, 144 
Gatch's nitrous oxid-oxygen apparatus, 
104 
"Gauze ether" method, 102 
Gebauer container for ethyl chlorid, 
256 
Gebauer tube for administration of 
ethyl chlorid in dental anesthe- 
sia, 537 
General anesthesia, combined with 
local anesthesia, 477 
definition of, 31 
theories of, 
Baglioni's, 46 
Bernard's, 34 
Binz's, 34 
Biirker's, 48 
Dubois', 34 
Gill's, 46 
Gros's, 48 
Hbber's, 46 
Lillie's, 50 
Mathews-Brown, 42 
Meyer-Overton, 37 
Moore-Roaf, 44 
Muller's, 36 
Reicher's, 47 
Schleich's, 35 
Spencer's, 32 
Traube's, 42 
Verworn's, 49 
Wright's, 40 
versus local anesthesia, 473 
General anesthetics, chief, 32 
definition of, 31 
requirements of, 31, 32 
Genitals, external, site of spinal 
puncture for operations on, 
610 
Genito-urinary operations, anesthesia 
in, 355 
under local anesthesia, 514 
under spinal analgesia, 560, 587 
Geraniol, as preservative of chloroform, 
292 
Gerstenberg on spinal analgesia, 564, 
621 
Gill on chloroform, 297, 299, 305 
Gill's theory of anesthesia, 46 
Gland removal from neck under spinal 
analgesia, 587 INDEX OF SUBJECTS 
779 
Gwathmey nitrous oxid-oxygen appar- 
atus, 150 
Gwathmey oxygen Y-piece, 151 
Gwathmey rectal irrigating tube, 447 
Gwathmey three-bottle vapor inhaler, 
317, 323, 334 
Gwathmey vapor apparatus, 71 
Gwathmey vapor inhaler, 147 
Gwathmey and Alexander on adenoid 
and tonsil cases, 340 
Gwathmey and Baskerville, experiments 
of, on warming ether vapor, 71 
Gwathmey-Woolsey mask for nitrous 
oxid-oxygen anesthesia, 172 
Gw'athmey-Woolsey nitrous oxid-oxygen 
apparatus, 170 
Gynecology, ethyl chlorid anesthesia in, 
268 
local anesthesia in, 519 
Haertel's method of nerve blocking, 
498 
Halbreich's experiments on cerebro- 
spinal fluid diffusion, 566 
Hallucinations, due to nitrous oxid, 
131 
Hallux valgus, injection of skin inci- 
sion for, 514 
Hamblen on acetonuria after ether, 198 
Handkerchief method of ether adminis- 
tration, 212 
Harcourt's inhaler, 26, 320 
Harley, " A. C. E. mixture ' ' by, 23 
on spinal analgesia, 556 
' ' Hashish, ' ' 3 
Hassler and Honan, on intravenous 
anesthesia, 628 
Hawk on effects of ether on the urine, 
197 
on glycosuria after ether, 196 
Hayden on surgery under anesthesia, 
14 
Hayward on Bier, 492 
on chloroform, 25 
Head, intratracheal insufflation indi- 
cated in, 431 
under local anesthesia, 496 
under spinal analgesia, 597 
Headache after spinal analgesia, 583 
following ethyl chlorid anesthesia, 
264 
Healing after local anesthesia, 477 
Heart, action of chloroform upon, 299, 
301, 317 
concomitant affections of, spinal 
analgesia contra-indicated in, 
587 
effect of anesthetics on, 59 
effect of ethyl chlorid on, 258 
effect of nitrous oxid on, 130 
effect of nitrous oxid and oxygen 
on, 670 
effect of shock on, 385 
effect of warming the anesthetic on, 
65 
Glands, enlarged, chloroform indicated 
for, 310 
Glands of neck, choice of anesthetic in 
removal of, 339 
Glandular system, effect of anesthetics 
on, 60 
effect of chloroform on, 303 
effect of ether on, 189 
effect of ethyl chlorid on, 261 
effect of nitrous oxid on, 131 
Glass containers for ethyl chlorid, 255 
Glottis, closure of, by the tongue, 390 
Glucose in dietetic shock, 387 
in spinal analgesic solutions, 599, 
602* 
use of, preceding anesthesia in can- 
cer, 330 
Glucose-adrenalin-stovain solution in 
spinal analgesia, 625 
Glycogen, importance of, in liver, dur- 
ing anesthesia, 365 
Glycosuria in ether narcosis, 191, 196 
Goiter, anesthesia in, 353 
operations for, under local anesthe- 
sia, 503 
under spinal analgesia, 580 
Goldan on spinal analgesia, 567 
Goldstein, experiments of, with nitrous 
oxid, 126 
Goyanes on arterial injection, 492 
Graphic anesthetic chart, 533 
Graves' disease, anesthesia in, 353 
Gray on spinal analgesia, 587, 588, 
589, 590, 598 
dextrin-stovain solution by, 603 
site for spinal puncture by, 610 
Groin, diffuse infiltration in, 514 
Grbndahl on effect of ether on the kid- 
neys, 189 
Gros, conclusions of, on relation of 
general and local anesthetics, 
48 
Gross ignorance or negligence, on part 
of physician, 685 
Groves, J. F., on Long, 8 
Grube on effect of ether upon body 
temperature and carbohydrate 
metabolism, 197 
on glycosuria in ether narcosis, 191 
Guaiacol, as preservative of chloro- 
form, 292 
Gum arabic in spinal analgesic solu- 
tions, 599, 601 
Gwathmey, anesthetization of a case of 
acute mania by, 668 
experiments of, on warming anes- 
thetic agents, 63, 69 
with oxygen combined with anes- 
thetic agent, 82 
use of oil of bitter orange peel by, 
92 
Gw'athmey inhaler, for nitrous oxid- 
ether sequence, 218, 219, 220 
Gw'athmey method of nitrous oxid-oxy- 
gen anesthesia, 153 780 
INDEX OF SUBJECTS 
Heart disease, choice of anesthetic in, 
328 
Heart failure, death due to, in status 
lymphaticus, 333 
Heart lesions, colonic ether anesthesia 
indicated in, 437 
oil-ether colonic anesthesia for, 461 
Heat during colonic ether anesthesia, 438 
effect of, on ethyl chlorid, 253 
moist, as preventive of shock, 402 
Heat. See also Warming the anes- 
thetic agent 
Heavy anesthesia, defined, 31 
Hedonal, dose of, for animals, 755 
in intravenous anesthesia, 637 
Hein on spinal analgesia, 564, 621 
Hellman, on training of anesthetists, 
676 
Hemoglobin, role of, in anesthesia, 44 
Hemorrhage, during anesthesia, saline 
enema for, 376 
post-operative, in local anesthesia, 470 
Hemorrhoids, operations for, under 
local anesthesia, 485, 518 
Henderson, 101, 388, 407 
on acapnia as cause of shock, 401 
on acapnia in rebreathing, 112 
on arterial pressure due to shock, 408 
on death due to ether, 192 
on physiological role of carbon di- 
oxid, 97 
on vasomotor hyperactivity as cause 
of shock, 406 
Hernia, operation for, ether disinfec- 
tion in, 672 
under local anesthesia, 523 
under oil-ether colonic anesthesia, 460 
Hernia, femoral, operation for, under 
local anesthesia, 526 
Hernia, inguinal, cure of, under local 
anesthesia, 524 
operation for, under spinal anal- 
gesia, 579, 580, 588, 591, 625 
Hernia, post-operative ventral, opera- 
tion for, under local anesthesia, 
527 
Hernia, recurrent, operation for, under 
local anesthesia, 525 
Hernia, umbilical, operation for, under 
local anesthesia, 526 
Hernia, ventral, under local anesthesia, 
527 
Herrenknecht, on ethyl chlorid anes- 
thesia, 267 
Hertel's solution for spinal analgesia, 
601 
Hertzler on urea and quinin hydro- 
chlorid as local anesthetic, 470, 
500, 515 
Hervey on warmed ether vapor, 229 
Hewitt, Frederick D., 3, 8 
on administration of nitrous oxid 
with air, 141 
on causes of death under ethyl 
chlorid anesthesia, 261 
Hewitt, Frederick D., on combining 
oxygen with anesthetic agent, 80 
on effects of chloroform, 285, 305, 
667 
on ethyl chlorid anesthesia, 267, 
271 
on nitrous oxid and oxygen, 25 
on oxygen-ether administration, 239 
on respiratory failure due to ether, 
192 
Hewitt's artificial airway, 390 
Hewitt's breathing tube in intravenous 
anesthesia, 635 
Hewitt's method, of administering 
ethyl chlorid, 275 • 
of nitrous oxid-oxygen anesthesia, 
151, 161 
Hewitt-Mason's mouth-gag with anes- 
thetic tubes, 322 
Hexachlorbenzene in chlqroform de- 
composition, 295 
Hexachlorethane in chloroform, 285 
Hiccough during anesthesia, 381 
Hickman, 5 
History of anesthesia, 1 
libber's theory of anesthesia, 46 
Hoffmann, on temperature in ether- 
drop-anesthesia, 69 
Hohmeier, on death due to spinal anal- 
gesia, 598 
Holocain hydrochlorid, in spinal anal- 
gesia, 563, 599 
Hblscher on effect of ether vapor on 
the lungs, 102 
Homeopathy and allopathy, 678 
Honan and Hassler, on intravenous 
anesthesia, 628 
Hooker's tracing showing effect of 
weak ether vapor on pyloric ring 
of frog, 114 
Hoseman on lumbar pressure, 583 
Houghton on spinal analgesia with 
Barker solution, 602 
Hughson's device for localization of 
nerves, 481 
Humphrey's 11 Medicated Vapors," 7 
Hyderabad Chloroform Commissions, 
26 
Hyderabad Commission, on cardiac in- 
hibition, 302 
"Hydrate of ether," 178 
"Hydrate of ethylene," 178 
Hydrocarbon gases, 721 
Hydrochloric acid in chloroform, 285, 
293 
in chloroform decomposition, 296, 
in preparation of ethyl chlorid, 
252 
test for, in ethyl chlorid, 257 
Hydrochloric ether, 250. See also 
Ethyl chlorid 
Hydrogen, discovery of, 4 
Hydrogen chlorid as product of pure 
chloroform decomposition, 290 
in preparation of ethyl chlorid, 252 INDEX OF SUBJECTS 
781 
Hydrogen dioxid, 364 
in chloroform, 286 
in disinfection of mouth, 364 
Hygienic treatment preliminary to 
anesthesia, 364 
Hyoscin in post-operative treatment, 
378 
in preliminary medication, 371 
for spinal analgesia, 612 
Hyoscin-morphin-cactin combination, 
372 
Hypercapnia in rebreathing, 111 
Hyperoxyg>enation theory of nitrous 
oxid action, 123 
Hyperpnea following overdose of ni- 
trous oxid, 134 
in anesthesia, 380, 389 
Hyperthermia after spinal analgesia, 
582 
Hyperthyroid cases, ioil-ether colonic 
anesthesia in, 448 
Hyperthyroidism, 354 
Hypnotism, 4 
Hypochlorites, preparation of oxygen 
from, 752 
Hypodermic apparatus, 472 
for dental use, 542 
Hypodermic injection in shock preven- 
tion, 403 
prior to local anesthesia, 475 
Hypodermic instillation, in painless 
childbirth, 749 
Hypodermic method of local anesthesia 
in dentistry, requirements for, 
536 
Hypodermic syringe, invention of, 466 
Hypodermoclysis, 651 
in gastro-enterostomy, 356, 376 
in treatment for shock, 374 
Hysterectomy, abdominal, under anoci- 
association, 405 
under spinal analgesia, 560 
Hysteria, control of, 374 
Hysterical symptoms following ethyl 
chlorid anesthesia, 265 
Ice packs for painless dentistry, 537 
von Idelson on chloroform and oxygen, 
27 
Idiosyncrasy and failure to produce 
spinal analgesia, 585, 623 
Idiosyncratic difficulties during anes- 
thesia, 382 
Idiots, psychic treatment for, prelim- 
inary to anesthesia, 366 
Illegal operations, law relating to 
anesthesia in, 687 
Incisive fossa, location of, 551 
Infancy, convulsions of, treated by an- 
esthesia, 667 
Infants, selection of anesthetic for, 326 
Infections, ether treatment of, 671 
Infiltration in abdominal operations, 
520 
in anesthesia of the extremities, 508 
Infiltration in anesthetization of skin, 
493 
in eye operations, 502 
in eyelid operations, 498 
in facial operations, 498 
in genito-urinary surgery, 514 
in gynecology, 519 
in hernia, 523 
in larynx surgery, 503 
in local anesthesia, 478 
in local jaw operations, 498 
in mouth operations, 498 
in nasal operations, 498, 500 
in neck surgery, 496, 502 
in operations on accessory sinuses, 500 
in operations on breast, 507 
in operations on buttocks, 514 
in operations on cheeks, 498 
in operations on gums, 498 
in operations on tonsils, 500, 501 
in operations on thorax, 507 
in outer ear operations, 498, 499 
in rectal surgery, 517 
in scalp wounds, 496 
in thyroid operations, 503 
in tongue excision, 498 
in tracheotomy, 503 
Schleich's, in spinal analgesia, 559 
submental, in lower lip operation, 
499 
Infiltration layer of Braun, 505 
Infusion in shock prevention, 403 
Ingrowing nails, local anesthesia in, 
514 
Inguinal glands, enlargement of, in 
status lymphaticus, 332 
Inguinal hernia operation under local 
anesthesia, 524 
under spinal analgesia, 579, 580, 588, 
591, 625 
Inguinal region, operations in, site of 
spinal puncture for, 610 
Inhalation anesthesia, discovery of, 3, 
7 
physiology of, 30 
Inhalation anesthetics, list of, based 
on safety to life, 325 
therapeutic uses of, 666 
Inhaler, Allis, 216 
Bennet, 218 
Esmarch, 217 
Furniss gas-ether, 220 
Gwathmey, 218, 219, 220 
Harcourt's, 320, 321 
Junker, 228 
Inhibition, cardiac, due to chloroform, 
302 
Inhibition, theory of, 640 
Injection in spinal analgesia, technique 
of, 617 
Injection into pulp, 552 
"Inogen" compounds in nervous sys- 
tem, effect of anesthesia on, 47 
Inosit-mono-methyl ether as preserva- 
tive of chloroform, 292 782 
INDEX OF SUBJECTS 
Insane patients, anesthesia in, 331 
chloroform indicated for, 310 
psychic treatment for, preliminary 
to anesthesia, 366 
Insomnia after subarachnoid anal- 
gesia, 583 
anesthetic treatment for, 667 
Instillation, colonic, in painless child- 
birth, 749 
hypodermic, in painless childbirth, 
749 
saline, in painless childbirth, 745 
Instillation of cocain in eye surgery, 
502 
Insufflation, endopharyngeal. See En- 
dopharyngeal anesthesia 
endotracheal. See Intratracheal in- 
sufflation 
Insusceptibility to anesthetics, 382 
Intestinal obstruction, anesthesia in, 
356 
in children, spinal analgesia in, 589 
intratracheal insufflation in, 432 
Intestinal operations under local anes- 
thesia, 522 
Intestinal tract, care of, preliminary to 
anesthesia, 365 
Intestines, effect of temperature on, 
during anesthesia, 386 
Intra-abdominal administration of oxy- 
gen, 89, 90 
Intra-arterial anesthesia, 492, 493 
Intranasal operations, anesthesia in, 
340 
Intra-osseous injection of anesthetic 
solutions in dentistry, 547 
Intratracheal insufflation, apparatus 
for, 419 
bibliography on, 432 
course of anesthesia by, 429 
definition of, 416 
history of, 416 
in prevention of acapneal respiration, 
409 
indications for, 431 
physiological basis of, 416 
technique of, 426 
errors in, 430 
value of, as a method of artificial 
respiration, 432 
Intravenous anesthesia, 628 
administration of anesthetic in, 634 
after-treatment in, 636 
apparatus for, 630, 635, 636 
blood changes in, 638 
history of, 628 
mixed forms of, 637 
of extremities, 506, 509, 511 
patient under, 635 
physiology of, 629 
preliminary narcosis in, 370, 629, 637 
selection of vein for, 630 
solutions for, 630, 634 
technique of, 629 
urinary examination in, 639 
Intravenous infusion in serious cases of 
shock, 404 
Intussusception in children, spinal 
analgesia in, 589 
lodin, preliminary use of, in oral sur- 
gery, 543 
in post-operative vomiting, 379 
in spinal injection, 617 
in sterilization of skin, 615 
Ionone, as preservative of chloroform, 
292 
Iridectomy, use of chloroform in-, 338 
Ischemia in venous anesthesia, 490 
Isoamyl nitrite. See Amyl Nitrite 
Isopral, dose of, for animals, 755 
in intravenous anesthesia, 637 
in preliminary medication for oil- 
ether colonic anesthesia, 444 
Jaboulay on spinal analgesia, 558 
Jackson, 8, 12, 14, 16 
Jackson's direct laryngoscope, 428 
Jackson's speculum, 226 
Janeway's apparatus for intratracheal 
insufflation, 423 
Jaundice following ethyl chlorid anes- 
thesia, 265 
Jaw excision under local anesthesia, 498 
Joint, resection of, under local anes- 
thesia, 514 
Jonneseo's method of spinal analgesia, 
562, 576, 582, 586, 591, 595, 597, 
603, 610, 622 
mortality record in cases under, 597 
site of spinal puncture in, 607 
Jonneseo's stovain-strychnin solution 
for, 582, 603 
Joss on warmed ether vapor, 228 
Junker apparatus for chloroform ad- 
ministration, 321 
Junker chloroform bottle, 226 
Junker inhaler, 24, 27, 228, 314 
modification of, for ether by Braun, 
178 
Keen's prevention of shock, 383, 404 
Kelen, 250. See also Ethyl chlorid 
Kelene, 250, 537 
Kemp, experiments of, with nitrogen 
and nitrous oxid, 125 
Keroselene, introduction of, 24 
Kidney lesions, oil-ether colonic ether 
anesthesia indicated for, 461 
Kidney operation under local anes- 
thesia, 517 
Kidneys, care of, during anesthesia, 
374 
concomitant affections of, spinal 
analgesia contra-indicated in, 
587 
diseases of, anesthesia in, 330 
ether contra-indicated in, 248 
effect of chloroform on, 303, 309 
effect of ether on, 189, 248 
effect of nitrous oxid on, 132 INDEX OF SUBJECTS 
783 
Kidneys, effect of shock on, 385 
effect of spinal analgesia on, 583 
elimination of ethyl chlorid through, 
264 
fatty degeneration of, following re- 
peated administration of ethyl 
chlorid, 265 
preliminary treatment of, dosage for, 
364 
Kidnerjy on spinal analgesia, 561 
Kit of anesthetist, 362 
Klikowitsch on nitrous oxid and oxy- 
gen, 670 
Klose on spinal analgesia, 565, 571 
Kocher on contra-indications to ether, 
248 
on local versus general anesthesia, 
474 
on thyroid operation under local an- 
esthesia, 503 
Kohler on death due to spinal anal- 
gesia, 598 
Koller, cocain advocated by, 536 
Koller's use of cocain in surgery, 467, 
556 
Konig on administration of ethyl 
chlorid, 269 
Konig on after-effects of ethyl chlorid 
anesthesia, 264 
Kreis's use of spinal analgesia in ob- 
stetrics, 560 
Kreutzman on chloroform-oxygen, 27 
Krogius's method of local anesthesia 
in circumcision, 517 
Lachrymation, effect of anesthesia on, 
60 
Lactation, effect of ether, on, 191 
Ladd on toxic effects of etherization 
by the closed method, 102 
Laewen on nerve-blocking, 514 
Lambotte on stovain in spinal anal- 
gesia, 603 
Laminectomy, intratracheal insufflation 
indicated in, 431 
under local anesthesia, 508 
Laparotomy, anesthesia during, 355, 
374 
oil-ether colonic anesthesia in, 461 
post-anesthetic abdominal distention 
after, 115 
shock in, 389 
under local anesthesia, 519, 520 
under spinal analgesia, 595 
Laryngectomy, intratracheal anesthesia 
indicated in, 432 
Laryngology, local anesthesia in, 503 
Laryngoscope, Jackson's direct, 428 
Laryngoscopy, under oil-ether colonic 
anesthesia, 460 
Larynx, cocainization of, for intra- 
tracheal insufflation, 427 
Larynx operations under colonic ether 
anesthesia, 454, 457 
under local anesthesia, 503 
Larynx operations under spinal anal 
gesia, 587 
Latham's measures for shock preven- 
tion, 403 
Lathrop's technique of oil-ether colonic 
anesthesia, 448 
Laughing gas. See Nitrous oxid 
Lavosier, oxygen studied by, 751 
Lawen on post-operative pneumonia, 70 
on warmed ether vapor, 228 
Lecithin in case of acute mania, 
669 
Leedham-Green's use of spinal anal- 
gesia, 587 
Leg, amputation of, shock in, 403 
Legal status of physician, 678 
Legislation, medical, early, 677 
Lennander on lack of sensation in pel- 
vic viscera, 476, 521 
Leopold on spinal analgesia, 569 
Lerda on local anesthesia in reduction 
of fractures, 512 
Letheon, 16, 536 
Levi on use of carbon dioxid with anes- 
thetics, 99 
Lewis pendulum swing, 246, 393 
Liability of physician, 680 
of specialist, 684 
Light, effect of, on chloroform, 290, 
295 
on ethyl chlorid, 256 
in adenoid and tonsil operations, 344 
Light anesthesia, definition of, 31 
shock during, 389 
Light chloroform anesthesia, 306 
Lillie's theory of anesthesia, 50 
Lime as preservative of chloroform, 291 
Lingual nerve, anesthetization of, 550, 
Lip excision under local anesthesia, 
499 
Lips, operations on, anesthesia in, 339 
Lipoid solubility theory of anesthesia, 
37, 46 
Lipoidemia, 47 
Lipoids, role of, in anesthesia, 43 
Lipomata, removal of, under local anes- 
thesia, 495 
under spinal analgesia, 625 
Liquid air, in dental anesthesia, 537 
Liver, effect of chloroform on, 304 
effect of ether on, 189, 198 
effect of shock on, 385 
fatty, acidosis in, 415 
fatty degeneration of, following re- 
peated administrations of ethyl 
chlorid, 265 
incision of, 521 
Liver operations, shock in, 403 
Local anesthesia, 465 
after-treatment in, 476 
as applied in dentistry, 535 
cocain, 538 
cold, 537 
ethyl chlorid, 537 
hypodermic method, 536 784 
INDEX OF SUBJECTS 
Local anesthesia as applied in dentistry, 
history, 535 
technique of injection, 543 
caudal, 485 
circumcision under, 513, 516 
combined with general anesthesia, 
477 
details as to comfort of patient, 475 
general preparation and technique in, 
474 
healing after, 477 
history of, 465 
in diseases of the lungs, 330 
in eye surgery, 502 
in gastro-enterostomy, 356 
in Graves' disease, 353 
in gynecology, 519 
in heart disease, 329 
in hernia, 523 
in kidney surgery, 517 
in larynx surgery, 503 
in neck surgery, 502 
in rectum surgery, 517 
in surgery of genito-urinary system, 
514 
in surgery of head and neck, 496 
in thyroid operations, 503 
in tracheotomy, 503 
in treatment of nose and tonsils, 500 
indications and scope of, 472 
infiltration method of, 478 
methods of, 478 
mortality in, 468, 474 
of abdomen, 520 
of accessory sinuses, 500 
of axilla, 508 
of brachial plexus, 508 
of buttocks, 514 
of ear, 499 
of extremities, 508 
of face, 498 
of fingers, 511 
of mastoid, 499 
of skin, 493 
of thorax and breast, 507 
parasacral, 483 
paravertebral, 481 
preliminary use of morphin in, 370 
presacral, 484 
regional method of, 480 
sacral, 485 
solutions in, 470 
special application of, 493 
splanchnic, 486 
surface application method of, 478 
syringes and solution bottles for, 
471, 472 
through physiological action of spe- 
cial drugs, 466 
trans-sacral, 486 
versus general anesthesia, 473 
Local anesthetics; relation of general 
anesthetics to, 48 
Loco-dolor, 250, 537. See also Ethyl 
chlorid 
Locomotor ataxia, anesthetic treatment 
for, 667 
Loeffler on method of anesthetizing 
dental pulp, 552 
Long, Crawford W., 8, 19, 177 
Lotheissen, experiments of, on elimina- 
tion of ethyl chlorid, 263 
Lotheissen's method of administering 
ethyl chlorid and oxygen, 278 
Lues, spinal analgesia contra-indicated 
in, 587 
Lumbar pressure, measurement of, 583 
Lumbar puncture, early experiments in, 
557, 563 
Lumbard's elastic mask holder, 202 
Lumbard's glass nasal tubes, 229 
Lumbard's rubber ether blanket, 202 
Lungs, aeration of, during anesthesia, 
376 
concomitant affections of, spinal 
analgesia contra-indicated in, 
587 
diseases of, anesthesia in, 329 
ether contra-indicated in, 248 
effect of ethyl chlorid on, 258 
effect of moisture contents of air on, 
77 
effect of nitrous oxid on, 128 
excretion of ethyl chlorid through, 
264 
Lung abscess, drainage of, under local 
anesthesia, 507 
Lung complications, post-anesthetic, 
abolition of, by rebreathing, 113, 
115 
Lung cyst removal under medullary 
analgesia, 575 
Lung lesions, oil-ether colonic anes- 
thesia indicated in case of, 461 
Lung surgery, anesthetics in, 694 
Lungmotor for induction of artificial 
respiration, 399 
Lusk, 564, 621 
on paralyses due to spinal analgesic 
agents, 584 
on spinal puncture, 605 
Lymphatism, 331. See also Status 
lymphaticus 
Lymph-nodes, cervical, removal of, un- 
der local anesthesia, 503 
Magnesium chlorid, dose of, for animals, 
755 
Magnesium content of blood, 656 
Magnesium salts, reverse action of cal- 
cium salts, 647 
Magnesium sulphate, 
action of, by intravenous injection, 
645 
in subarachnoid injection, 648 
in subcutaneous injection, 647 
on nerve trunks, 645 
and morphin, 644 
anesthesia, 641 INDEX OF SUBJECTS 
785 
Magnesium sulphate, anesthetic prop- 
erties of, 640 
antagonism of physostigmin to, 642 
dosage of, for animals, 755 
effects of, 645 
in painless childbirth, 733, 747 
laboratory experiments on, 641 
preparation of solutions, 649 
synergistic effects of, 640, 643, 648 
Malartic on spinal analgesia in obstet- 
rics, 593 
Malherbe's method of administering 
ethyl chlorid, 272 
Malpractice, 682 
criminal, 686 
Management of ordinary cases, after- 
treatment in, 378 
preliminary treatment in, 364 
treatment during anesthesia in, 374. 
See also Treatment 
Management of unusual cases, 379, 
415 
idiosyncratic difficulties in, 382 
muscular difficulties in, 381 
nervous difficulties in, 381 
post-anesthetic toxemia in, 382, 413 
respiratory difficulties in, 380 
shock in, 383. See also Treatment 
Mandibular foramen, location of, 549 
Mandibular nerve, anesthetization of, 
551 
Mandragora, 2, 282, 466 
Mania, acute, anesthetic treatment for, 
668 
Manual means of artificial respiration, 
393 
Marcille on ether irrigation of abdo- 
men, 672 
Martin, on cocain in spinal analgesia, 
600 
Marx on spinal analgesia, 560, 593, 
600 
Mask, attachment to, for intrathoracic 
surgery, 701 
Boothby and Cotton, for nitrous oxid- 
oxygen anesthesia, 166 
Ferguson, 203 
Gwathmey-Woolsey, for nitrous oxid- 
oxygen anesthesia, 172 
Meltzer's, for artificial respiration, 
400 
usual ether, 202 
Yankauer-Gwathmey, 203 
Massage, cardiac. See Cardiac Mas- 
sage 
Masseter muscles, contraction of, under 
ethyl chlorid, 261 
Mastoid operation, anesthesia in, 339 
local, 499 
Matas, on cocain, 467, 480 
on limitations in use of spinal anal- 
gesia, 586 
Mathews-Brown theory of anesthesia, 
42 
Mayos' administration of ether, 203 
Mayos' stripping procedure under local 
anesthesia, 514 
Maxillae, operations on, chloroform in- 
dicated for, 310 
McKesson, blood-pressure apparatus of, 
409, 411 
blood-pressure chart of, 412 
method of, for anticipating shock, 
410 
Measure dropper for ethyl chlorid, 256 
Mechanical causes of psychic shock, 
410 
Median nerve, anesthetization of, 510 
Mediastinal abscess, treated under oil- 
ether colonic anesthesia, 461 
Medical Pneumatic Institute, organiza- 
tion of, 4 
Medical treatment preliminary to anes- 
thesia, 26, 370 
" Medicated Vapors," by Humphrey, 7 
Medication, preliminary, 723, 726 
Medico-legal status of the anesthetist, 
675 
Meissner on novocain in spinal anal- 
gesia, 604 
Meltzer, devices of, for artificial res- 
piration, 399 
experiments of, with magnesium salts, 
640 et seq. 
method of, for ether vapor adminis- 
tration, 238 
Meltzer apparatus for intratracheal in- 
sufflation, 417 
Meltzer pharyngeal tube, 400 
Meltzer and Auer, experiments of, 
with intratracheal insufflation, 
416 
Meningism after stovain anesthesia, 
583 
Menstrual period, anesthesia during, 
355 
Mental depression, fatal effects of, 368 
Mental foramen, location of, 551 
Mental preparation for anesthesia, 366 
Mental suggestion in adenoid and ton- 
sil operations, 341 
in anesthetizing children, 327 
Menthol as preservative of chloroform, 
292 
petrolatum and, as a spray, preceding 
adenoid and tonsil operations, 
341 
Mesenteric glands, enlargement of, in 
status lymphaticus, 332 
Mesmerism, 2, 4 
Metal containers for ethyl chlorid, 255 
Metallic chlorids in chloroform, 285 
Methenyl trichlorid, 281. See also 
Chloroform 
Methethyl, 537 
Methyl alcohol, dosage of, for animals, 
754 
in chloroform, 285, 692 
Methyl chlorid, combined with ethyl 
bromid and ethyl chlorid, 276 786 
INDEX OF SUBJECTS 
Methyl chlorid for local anesthesia in 
dentistry, 537 
presence of, in ethyl chlorid, 252 
Methylated spirit, preparation of 
chloroform from, 285 
Meyer on anesthol, 276 
Meyer's tropacocain solution for spinal 
analgesia, 601 
Meyer-Overton theory of anesthesia, 37 
Michelson on spinal analgesia, 564, 570, 
598 
Micturition, involuntary, in nitrous oxid 
anesthesia, 132 
Military surgical operating room, 688 
one table, 689 
operative technique, 690 
surgical teams, 690 
three tables, 690 
two tables, 689 
Milk, prohibited preceding adenoid and 
tonsil operations, 340 
Miller on method of anesthetizing den- 
tal pulp, 552 
Milne, open method of administering 
ethyl chlorid advocated by, 272 
Minor surgery, intravenous anesthesia 
in, 492 
Mitchell on local anesthesia 465 
on nerve injuries 558 
Mixtures, anesthetic, 707 
Moisture, effects of, on anesthetics, 76 
Molars, technique of periosteal injec- 
tion of anesthetic solution about, 
545 
Moles, removal of, under local anes- 
thesia, 495 
Moore-Roaf theory of anesthesia, 44 
Moral anesthetist, 475 
Morphin, administration of, during 
anesthesia in status lymphaticus, 
334 
as preservative of chloroform, 292 
contra-indications to, 373 
doses of, 372 
for acid intoxication, 414 
for adenoid and tonsil operations, 
341 
for anesthol administration, 277 
for colonic ether anesthesia, 436. 
440 
for ether anesthesia, 207, 208 
for ethyl chlorid anesthesia, 262, 
277 
for intratracheal anesthesia, 427 
for local anesthesia, 475 
for nitrous oxid-oxygen anesthesia, 
165 
for oil-ether colonic anesthesia, 436, 
445 
for spinal analgesia, 558, 581, 592, 
612 
effect of, on ether elimination, 108 
in administration of chloroform, 314 
in case of acute mania, 669 
in emergency treatment 363 
Morphin, in goiter, 354 
in intravenous anesthesia, 629, 638 
in post-operative treatment, 377 
in preliminary medication, 328, 339, 
369, 412, 696, 726 
in prevention of acapnia, 409 
in rectal cases, 355 
prolonged effects of, 651 
with chloroform, 26 
Morphin and magnesium sulphate, 644, 
651 
Morphin-anesthol-ether sequence, 209 
Morphin-atropin-urethan, dosage of, for 
animals, 756 
Morphin hydrochlorid, dosage of, for 
animals, 755 
Morphin injection in neuralgia, 467 
in shock prevention, 403 
Morphin-scopolamin, 108 
decrease in post-opeyative pneumonias 
under, 199 
dosage of, for animals, 756 
in painless childbirth, 734 
prophylactic use of, with ethyl chlorid 
anesthesia, 262 
Morphin sulphate, dosage of, for ani- 
mals, 755 
Morphin tartrate, 705 
Morphinism, chronic, acidosis in, 415 
Mortimer on chloroform, 414 
on contra-indications to ether, 248 
Morton, 11, 16, 177 
first demonstration of surgical anes- 
thesia by, 13 
on spinal analgesia, 562 
cases of, 574 
Morton inhaler, 13 
Morton's "letheon," 536 
Motor paralysis from Esmarch elastic 
bandage, 466 
in venous anesthesia, 492 
Mouth, disinfection of, preliminary to 
anesthesia, 364 
effect of shock on, 385 
operations on, colonic ether indicated 
in, 460 
ether for, 247 
intratracheal insufflation for, 431 
local anesthesia for, 498 
Mouth-gag, 362 
Hewitt-Mason's with anesthetic 
tubes, 322 
in artificial respiration, 393 
in epileptics, 331 
in ethyl chlorid anesthesia, 274 
in intratracheal anesthesia, 427 
Mucous glands, effect of anesthesia on, 
60 
effect of warming the anesthetic on, 
70 
Mucus, secretion of, after ether, 189, 
199 
Muller, on use of oxygen with anes- 
thetics, 86 
theory of anesthesia, 36 INDEX OF SUBJECTS 
787 
Miller, theory of ethyl chlorid anes- 
thesia, 260 
Mulzer, experiments of with ether 
upon the blood, 186 
Murphy on spinal analgesia, 561, 586, 
604 
Muscular changes due to psychic shock, 
385 
Muscular flaccidity in overdose of ethyl 
chlorid, 261 
Muscular phenomena during anesthesia, 
381, 385 
Muscular relaxation or rigidity in ethyl 
chlorid anesthesia, 263 
Muscular system, effects of anesthetics 
on, 59 
effects of chloroform on, 302 
effects of ether on, 189 
effects of ethyl chlorid on, 261 
effects of nitrous oxid on, 131 
"Nabobs," 536 
Nails, ingrowing, local anesthesia in, 514 
Narcosis defined, 31 
distinguished from anesthesia, 50 
in positive pressure anesthesia 696 
Narcotin, dose of, for animals, 756 
Nasal anesthesia with nitrous oxid-oxy- 
gen, in aural surgery, 173 
in obstetrics, 173 
Nasal inhaler, Teter, 155 
Nasopharyngeal tubes for nitrous oxid 
and oxygen, Teter's, 157 
Nausea after ethyl chlorid anesthesia, 
264, 338 
after use of nitrous oxid, 132 
due to cocain, 539 
in spinal analgesia, 577, 582, 595 
post-anesthetic, 113 
effect of oil of bitter orange peel 
on, 94 
effect of warming the agent on, 70 
treatment for, 379 
preliminary medication in, 373 
prevention of, during anesthesia, 374 
Neck, operations on, colonic ether anes- 
thesia indicated in, 460 
intratracheal insufflation indicated 
in, 431 
under local anesthesia, 502 
under spinal analgesia, 597 
swelling or engorgement of, nitrous 
oxid contra-indicated in, 338 
Necrosis, due to prolonged freezing in 
dental anesthesia, 537 
Nef's bivalent carbon hypothesis, 42 
Nepenthe, 2 
Nephritis, anesthesia in, 374 
preliminary medication by mor- 
phin, contra-indicated in, 373 
spinal analgesia in 580, 587 
Nephropectomy under spinal analgesia, 
560 
Nerve block in local anesthesia, 515 
of arm, 508 
Nerve block in local anesthesia of face, 
498 
Nerve centers, specific action of ni- 
trous oxid on, 125 
Nerve corpuscles in anesthesia, 33 
Nerve fibers in anesthesia, 33 
Nerve tissue, effect of ethyl chlorid on, 
261 
Nervous patients, choice of anesthetic 
in, 330 
Nervous phenomena during anesthesia, 
381 
Nervous system, anesthetic treatment 
for extreme irritability of, 667 
effect of anesthesia on, 61 
effect of chloroform on, 302 
effect of ether on, 188 
effect of ethyl chlorid on, 260 
effect of nitrous oxid on, 131 
post-operative effects of spinal anal- 
gesia on, 582 
Neudorfer on chloroform and oxygen, 
26 
Neuralgia, differentiation of, from neu- 
ritis, by ethyl chlorid, 670 
from visceral diseases, by ethyl 
chlorid, 671 
ethyl chlorid in diagnosis of, 670 
injection of morphin in, 467 
Neuroglia, in anesthesia, 35 
Neuroregional anesthesia in inguinal 
hernia, 524 
local method of, 467 
of extremities, 508 
Neurotic patients, preliminary medica- 
tion in anesthetizing, 371 
under spinal analgesia, 591 
Nicloux on ether elimination, 196 
on the passage of ether from mother 
to fetus, 191 
Niemann's discovery of cocain, 555 
Nikalgin 704 
Nirvanin, 540 
in spinal analgesia, 563, 599 
Niter in preliminary treatment of kid- 
neys, 364 
Nitrogen monoxid. See Nitrous oxid 
Nitrogen protoxid. See Nitrous oxid 
Nitroglycerin injection in spinal anal- 
gesia, 581', 592, 612, 625 
Nitrous oxid, administration of, 136 
alone, 137 
apparatus for, 136 
dangers of, 136 
guedel apparatus for, 138 
precautions in, 137 
as a sequence to ether, 141 
by intratracheal insufflation, 429 
rebreathing in, 103 
with air 136, 140, 142 
advantages of oxygen over, 143 
in unknowm quantities, 140 
in definite amounts, 141 
safety of, 325 
with chloroform-ether, 142 788 
INDEX OF SUBJECTS 
Nitrous oxid, administration of, with 
oxygen. See Nitrous oxid and 
oxygen 
after-effects of, 135 
analysis of, 122 
asphyxiation theory of action, 124 
causes of death from, 132 
chemical properties of, 121 
comparison of, with other agents, 135 
contra-indications to, 135 
contra-indicated in ophthalmic cases, 
338 
danger of shock with, 388 
deoxygenation or asphyxiation theory 
of action of, 124 
discovery of, 4, 10 
early use of by Humphrey Davy, 5 
in dentistry, 118 
effect of, on blood pressure, 59 
on circulatory system, 128 
on glandular system and other 
structures, 131 
on muscular system, 131 
on nervous system, 131 
on respiratory system, 127 
elimination of, from the blood, 134 
ethyl chlorid and, 279 
ethyl chlorid compared to, 266 
for anesthetizing children, 327 
for short operations, 338 
history of use of, 118 
hyperoxygenation theory of action 
of,'123 
impurities of, 121 
in adenoid and tonsil cases, 340 
in convulsions from poisoning 667 
in dentistry, 11, 24, 118, 537 
in fracture reduction under local 
anesthesia, 512 
in gastro-enterostomy, 356 
in goiter, 353 
in insanity cases, 381 
in local anesthesia of abdomen, 522 
in nervous patients, 330 
in paracentesis of membrana tym- 
pani, 339 
in tonsil cases, 140 
indications and contra-indications 
for, 135 
introduction of, into England, 24 
liquid, 120 
in dental anesthesia, 537 
manufacture of, 121 
method of heating, 136 
overdose of, symptoms of, 167 
physical properties of, 120 
preliminary use of, 388 
significance of eyeball in, 532 
special physiology of, 123 
specific action of, on brain cells, 125 
stages of anesthesia with, 132 
standard of purity of, 122 
Stockman and, 5 
third stage anesthesia in, 532 
with ether, 25 
Nitrous oxid, administration of, with 
ethylene chlorid, 749 
Nitrous oxid and oxygen, 24, 80, 119, 
143 
administration of, Davis' method of, 
151 
endopharyngeally, 159 
Gatch's method of, 144 
Gwathmey's method, 153 
Gwathmey-Woolsey method of, 171 
Hewitt's method of, 151 
Teter's method of, 153 
with oxygen, in definite quantities, 
Boothby and Cotton method of, 
160 
with oxygen in indefinite quanti- 
ties, 144 
with rebreathing, 103 
advantages of, 143 
combined with ether, 103„ 164,167,172 
combined with ethyl chlorid, 325 
combined with warm ether, 325 
contra-indications to, 328 
brain operations, 354 
effect of warming on, 64 
effect of, on heart action, 670 
for endotracheal work, 173 
for adult patients, 328 
in anemic convulsions, 667 
in cancer, 330 
in curettage, 355 
in diabetes, 330 
in diagnosis, 667 
in kidney diseases, 330 
in obstetrical cases, 355 
in paracentesis of the pericardium, 329 
in rectal cases, 355 
in respiratory diseases, 330 
in short operations, 338 
in synergistic analgesia, 652 
in tuberculosis, 329 
premedication in, 165 
safety of, 325 
therapeutic uses of, 670 
use of, in Gatch's apparatus, 104, 
107 
Nitrotis oxid anesthesia, 404 
exhaustion under, 405 
Gatch's method of, 103 
acapnia in, 112 
basis of technique of, 105 
clinical results of, 108 
fatalities from, 110 
hypercapnia in, 111 
in cardiac cases, 111 
in long operations, illustrative cases 
of, 109 
maintenance of ether balance in, 106 
Nitrous oxid-ether sequence, 218, 240, 
325 
followed by ether, 325 
followed by ether and chloroform, 
325 
in genito-urinary operations, 355 
in laparotomy, 355 INDEX OF SUBJECTS 
789 
Nitrous oxid-ether sequence in mastoid 
operations, 339 
inhalers for, 218 
introduced by Clover, 177 
technique of, 221 
Nitrous oxid-ether-chloroform sequence, 
223 
Nitrous oxid-ether vapor sequence, 
diagrammatic sketch of, 245 
Nitrous oxid-ethyl chlorid-ether se- 
quence, 325 
Nitrous oxid-oxygen-ether sequence, 
325 
Northrop on oxygen and chloroform, 
27 
Nose, care of, preliminary to anesthesia, 
364 
closure of alae of, during anesthesia, 
389 
operations on, ether for, 247 
under local anesthesia, 498 
treatment of, under local anesthesia, 
500 
Novocain, 467 
historical, 467, 468 
in anoci-association, 370 
in anesthesia of scalp, 497 
in gastro enterostomy, 356 
in goiter operations, 354 
in hypodermic tablets, 604 
in local anesthesia, 468 
in dentistry, 540, 541 
in spinal analgesia, 563 571, 576, 
599, 603 
in venous anesthesia, 490 
poisonous action of, 468 
Novocain infiltration in general anes- 
thesia, 474 
in venous anesthesia, 491 
Novocain injection along line of in- 
cision in shock prevention, 406 
Novocain solutions, 468 
for arterial anesthesia, 492 
Novocain-adrenalin for dental anes- 
thesia, 540 
Novocain-suprerenin injection of Gas- 
'serian ganglion, 498 
Novocain-suprarenin solution, in anes- 
thesia for fractured clavicle, 507 
of urethra and bladder, 516 
in removal of cervical lymph-nodes, 
499 
in thyroid operations, 507 
-Obese patients, chloroform indicated 
for, 310 
choice of anesthetic in, 329 
oil-ether colonic anesthesia in, 460 
Obstetrics, anesthesia in, 355 
chloroform anesthesia in, 20, 310, 368 
ethyl chlorid anesthesia in, 266, 268 
nitrous oxid-oxygen anesthesia in, 
173 
oil-ether colonic anesthesia in, 463 
spinal analgesia in, 560, 587, 593 
Obstetrics, synergistic methods in, 732, 
and see Painless childbirth 
Occupation and surgical shock, 384 
Odor, anesthetic, elimination of, 93, 
207 
Offergeld on effect of ether vapor on 
the lungs, 101 
Offergeld and Muller experiments of, 
with animals, 335 
Ohio monovalve, 158 
Ohio small nitrous oxid inhaler, 159 
Oil of bitter orange peel, use of, pre- 
ceding anesthesia, 60, 92 
in children, 327 
in chloroform administration, 313, 
316 
in chloroform-ether sequence, 207 
in circumcision, 355 
physiological basis of, 95 
Oil of bitter orange peel-ether se- 
quence, 240 
Oil-ether colonic anesthesia, 438 
administration of, 444 
advantages of, 461 
after-effects of, 455 463 
amount of ether employed in, 452 
apparatus for, 442 
automatic maintenance of, 450 
cases of, 455 
clinical results, 455 
contraindications, 461 
danger sign, 446 
dosage of, 442 
effects of, 449 
efficiency of, 462 
history of, 438 
in obstetrics, 463 
indications for, 460 
induction of, 445 
laboratory investigation, 439 
Lathrop's technique, in thyroid cases, 
448 
local anesthetics used in 444 
maintaining anesthesia, 445 
oil-ether mixture for, 443 
physio-pathological aspects of, 448 
post-operative treatment, 447 
preliminary preparation for, 443 
technique of, 442, 447, 448 
toxicity of, 454 
Olefiant-gas, preparation of, 713 
Olive oil, administration of, during 
anesthesia, 376, 379 
and opsonic index, 376, 453 
in case of acute mania, 670 
Oliver and Garrett, on hyperoxygena- 
tion theory of nitrous oxid, 123 
Ophthalmology chloroform in, 338 
Opisthotonos, due to ethyl chlorid, 261 
Opium, deodorized tincture of, in post- 
operative vomiting, 379 
Opium poisoning, insufflation of pure 
air or air and oxygen in, 432 
Opposition to anesthesia, theological, 
21 790 
INDEX OF SUBJECTS 
Opsonic index, and olive oil 376, 453 
Orange peel. See Oil of bitter orange 
peel 
Orthoform, in spinal analgesia, 563 
Orthoform-new, in spinal analgesia, 599 
Osgood on toxic effects of etherization 
by the closed method, 102 
Osmotic concentration of the blood in 
anesthesia, 45 
Osteopaths, 675 
Osterhout, experiments of, 40 
Otte on after-effects of ether, 199 
Ovary operations, shock in, 403 
Over-anesthesia, 371, 386, 413 
Overdose, 402 
in anesthetic shock, 388 
in anesthol anesthesia, 277 
in ether narcosis, 195 
in ethyl chlorid anesthesia, 263 
in nitrous oxid anesthesia, 134 
in spinal analgesia, 597 
of chloroform, 305, 308 
Overdose stage in anesthesia, 381 
Overton. See Meyer-Overton 
Oxalates, antagonistic action of physo- 
stigmin to, 642 
in synergistic analgesia, 642 
Oxygen, 751 
air and, insufflation of, as a method 
of artificial respiration, 432 
as preventive of post-anesthetic 
shock, 376 
as vehicle for ether vapor in colonic 
anesthesia, 436 
combination of, with anesthetic, 
agent, 80 
experiments on, 82 
discovery of, 4 
effect of, on intestines, 114 
on veins and arteries, 114 
ethyl chlorid and, 278 
history of, 751 
impurities in, 752 
in adenoid and tonsil operations, 
343 
in chloroform administration, 294, 
314, 317 
increase of, in shock prevention, 403 
intestinal absorption of, 434 
intra-abdominal administration of, in 
connection with anesthesia, 89 
methods of manufacturing medicinal, 
751 
nitrous oxid and. See Nitrous oxid 
and oxygen 
purity of commercial medicinal, 752 
standards of purity for, 753 
supply of, essential in all nitrous 
oxid operations, 338 
with carbon dioxid in treatment of 
acapnia, 409 
with chloroform by Harcourt's in- 
haler, 321 
Oxygen-ether vapor, administration of, 
239 
Oxygen-ether vapor in mastoid opera- 
tion, 339 
"Paid anesthetist system," 676 
Pain, acute, anesthetic treatment for, 
666 
in spinal analgesia, 578 
localization of, with ethyl chlorid, 
671 
post-operative, effect of preliminary 
medication on, 371 
gas, prevention of, 405 
in local anesthesia, 470 
Painless childbirth by synergistic meth- 
ods, 732 
administration, 742 
case reports, 737 
chart, 749 
Cowan's technique, 736 
directions for colonic instillation, 
749 
directions for hypodermic instilla- 
tion, 749 
formulae, 735 
magnesium sulphate injections in, 
747 
method, 734 
normal saline instillation, 745 
oral administration of ether, 744 
results 735, 737, 743 
selection of cases, 734 
synergistic analgesia in, 747 
summary, 748 
tabulation, 739 
time, 734 
Painless surgery, first demonstration 
of, by Morton, 12 
Pallor due to shock, 385 
in administration of chloroform, 308, 
313, 315 
in chloroform anesthesia, 389 
in overdose of ethyl chlorid, 261 
in spinal analgesia, 581 
Panhysterectomy under spinal anal- 
gesia, 581 
Pantopon, preliminary medication with, 
in ether narcosis, 208 
Papaverin hydrochlorid, dose of, for 
animals, 756 
Papilloma of neck, operation on, under 
spinal analgesia 625 
Paracentesis of membrana tympani 
anesthesia in, 339 
under local anesthesia, 499 
of pericardium, choice of anesthetic 
in, 329 
Paraldehyd, 705, 706 
dose of, for animals, 756 
in intravenous anesthesia, 639 
in preliminary medication in oil- 
ether anesthesia, 444 
Paralysis, due to spinal analgesic 
agents, 584 
Parasacral anesthesia, 483 
Paravertebral anesthesia, 481 
Pareses, motor, in spinal analgesia, 582 INDEX OF SUBJECTS 
791 
Parturition, use of ethyl chlorid in, 
266. See also Obstetrics and 
Painless Childbirth 
Passy on odorous power of various sub- 
stances, 93, 94 
Pasteurization in Babcock's diffusible 
solution for spinal analgesia, 
605 
Patterson on spinal analgesia, 577, 581 
Patton's ' ' Anesthesia and Anes- 
thetics, " 11, 16 
Peebles graphic anesthesia chart, 
529 
Pelvic operations under spinal anal- 
gesia, 586, 597 
Penis, effect of shock on, 386 
Pericardium, tapping of, under local 
anesthesia, 507 
Pericementitis, injection of anesthetic 
solution in, 547 
use of ethyl chlorid contra-indi- 
cated in, 538 
Peridental anesthesia, 547 
Perineum operations, under spinal 
analgesia, 587, 597 
site of spinal puncture for, 610 
Perineural injection of anesthetic so- 
lutions in dentistry, 548 
in extremities, 506, 507 
in local anesthesia, 480 
in lower lip operation 499 
of posterior tibial nerve, direction of 
needle in, 512 
Periosteal injection in local anesthesia 
of mastoid process, 499 
Periosteum, anesthetization of, 514 
Peritoneal infections, ether treatment 
in, 671, 674 
Peritoneum, effect of shock on, 386 
parietal, local anesthesia of, 521 
visceral, lack of pain sense in, 521 
Peritonitis, administration of fluid per 
rectum in, 375 
anesthesia in, 356 
with drainage, 375 
Permeability of cell membranes, anes- 
thesia and, 53 
Petrolatum w'ith menthol, as a spray, 
preceding adenoid and tonsil op- 
erations, 341 
Pharmacopoeia Helvetica, ethyl chlorid 
tests prescribed by, 258 
Pharyngeal tube, 390 
Connell's, 392 
Ferguson's, 391 
Hewitt's, 390 
in nose and mouth operations, 234 
Meltzer's for artificial respiration, 
400 
Pharynx operations, colonic ether indi- 
cated in, 460 
Phenol, dose of, for animals, 756 
Phosphorus pentoxid, in preparation 
of ethyl chlorid 252 
Phthisis, anesthesia in, 330 
Phthisis, nitrous oxid anesthesia contra- 
indicated in, 136 
Physician, civil liability of, 681 
criminal liability of, 685 
ethical liability of, 680 
liability of, growing out of gross ig- 
norance or negligence, 685 
qualifications of, 679 
status of, 678 
statutory liability of, 686 
Physiologic rest in treatment of shock, 
404 
Physiology of cerebrospinal fluid, 563 
of chloroform, 297 
of inhalation anesthetics, in general: 
effects of inhalation anesthetics 
upon various parts of the organ- 
ism, 56 
introductory remarks, 30 
modifying factors, 62 
theories of the action of general 
anesthetics, 32 
of intravenous anesthesia, 628 
Physostigmin, antagonist of oxalates 
and magnesium sulphate, 642 
Pilling chloroform dropper, 312 
Pinneo's ether vapor apparatus, 234, 
235 
Pinneo's mouth tube for continuous 
vapor anesthesia, 236 
Pituitary extract injection in cases of 
shock, 404 
Plasma cells of the neuroglia, in anes- 
thesia, 36 
Plasma-membranes, role of, in anes- 
thesia, 53 
Plethoric patients, preliminary medi- 
cation in anesthetizing, 371 
Pleura, aspiration of, under local an- 
esthesia, 507 
Pleurisy, anesthesia in, 329 
chloroform indicated for, 310 
Pneumonia after ether, 189 
anesthesia in, 329, 330 
from aspiration during anesthesia, 
prevention of, 364 
oil-ether colonic anesthesia in, 461 
Pneumothorax, intratracheal insuffla- 
tion in, 418 
Poggiolini on blood changes in anes- 
thesia, 58 
Poisoning, chloroform. See Chloroform 
poisoning 
due to cocain cause of, 468 
nitrous oxid-oxygen in seizures from, 
667 
opium, 432 
Pollack, on chloroform, 25 
Popliteal glands, enlargement of, in 
status lymphaticus, 332 
Poppert on effect of ether vapor on 
the lungs, 101 
Porter on the trained anesthetist, 676 
Positive pressure method of anesthesia, 
694, 695, 696 INDEX OF SUBJECTS 
792 
Positive pressure method of anesthesia, 
dangers in, 698 
mask for, 700 
Post-anesthetic pneumonia, effect of 
warming the agent on, 70 
Post-anesthetic toxemia, 413 
Post-mortem examination in status 
lymphaticus, 335 
Post-operative gas pains, causes and 
prevention of, 405 
Posture during local anesthesia 475 
during oil-ether colonic anesthesia, 
444 
during spinal analgesia, 613, 625 
for adenoid and tonsil operations, 
345 
Potassium permanganate in disinfec- 
tion of mouth, 364 
Preliminary medication, dosage for, 
372 
importance of, 369 
in ethylene anesthesia, 723 
in intravenous anesthesia, 629, 
637 
in oil-ether colonic anesthesia, 436, 
444 
in thyroid operations under local 
anesthesia, 504 
indications and contra-indications 
of, 373 
lack of, ill effects of, 381 
rules for, 371 
time for giving, 372 
See also Morphin and Atropin 
Preliminary treatment in ordinary 
cases, 364 
Preliminary treatment, hygienic 364 
medical, 370 
psychic, 366 
preparation of patient for colonic 
ether anesthesia, 436 
for oil-ether colonic anesthesia, 
444 
for spinal analgesia, 612 
Presacral anesthesia, 484 
Preservatives in ready-made anesthesia 
solutions, 540 
Pressure anesthesia, 552, 694 
Priestley, discovery of nitrous oxid by, 
118 
Prinz, Herrmann, on local anesthesia 
as applied in dentistry, 535 
Procain, local anesthetic, 469 
Proctoclysis in anesthesia, 375 
Propyl in chloroform, 285 
Propyl alcohol, impurities in ethyl 
chlorid due to 253 
Prostatectomy under local anesthesia, 
516 
under spinal analgesia, Young's op- 
eration for, 592 
Proteid compound theory of anesthesia, 
44 
Protoplasm, physicochemical constitu- 
tion of, 52 
Protoplasmic respiration and anes- 
thesia, 42 
Psoas sinus enlargement in child under 
spinal analgesia, case of, 584 
Psychic preparation for anesthesia, 
366 
Psychic shock, 384 
Psychic treatment preliminary to anes- 
thesia, 366 
Puerperal eclampsia, anesthetic treat- 
ment for, 667 
Pulmonary abscess, oil-ether colonic 
anesthesia in, 461 
Pulmonary anesthetics, preliminary 
use of morphin in, 370 
Pulmonary complications after ether, 
Otte on, 199 
Pulmonary tuberculosis, chloroform in- 
dicated for, 310. See also 
Phthisis 
Pulmotor, 396, 398 
Pulp, dental, method of anesthetizing, 
552 
Pulpitis, use of ethyl chlorid contra- 
indicated in, 538 
Pulse and shock, 383, 410 
in anesthol anesthesia, 277 
in chloroform anesthesia, 307, 316 
in ethyl chlorid anesthesia, 274 
in ethyl-chlorid-oxygen anesthesia, 
278 
in intratracheal anesthesia, 429 
in nitrous oxid anesthesia, 133 
in operations under anoci-association, 
405 
in spinal analgesia, 582 
Pulselessness in overdose of ethyl 
chlorid, 261 
Puncture site, cotton and collodion 
dressing on, 622 
location of, in spinal analgesia, 620 
painted with iodin in spinal anal- 
gesia, 618 
Pupillometer, 195, 308 
Pupils in chloroform administration, 
306, 308, 315 
in ethyl chlorid anesthesia, 262 
Pyemia, spinal analgesia contra-indi- 
cated in, 587 
Pylorectomy under spinal analgesia, 
560 
Quincke's experiments with lumbar 
puncture, 557, 559, 563 
Quinin, 540 
and urea hydroehlorid, 469, 704 
in anesthetic block for shock preven- 
tion, 406 
in gastro-enterostomy, 356 
solutions of, in local anesthesia, 469 
Radial nerve, anesthetization of, 511 
Rape, anesthesia and, 687 
Rathery on effects of ether on kidneys 
and liver, 190 INDEX OF SUBJECTS 
793 
Raucher on effect of ether on lactation, 
192 
Rebreathing, advantages of, 113 
charts showing effect of, on pulse, 
respiration, and blood pressure, 
105, 106, 107 
in administration of anesthetics, 100 
in chloroform administration, 317 
in chloroform-ether-nitrous oxid se- 
quence, 141, 142 
in nitrous oxid anesthesia, 137, 140 
in nitrous oxid-oxygen anesthesia, 
129, 144, 159, 166 
in shock cases, 112 
Reclus, 478, 489, 539 
Rectal anesthesia, 225 
by colonic absorption of ether, 433 
in diseases of the lungs, 330 
preliminary use of morphin in, 370 
Rectal cases, anesthesia in, 355 
Rectal infusion in shock prevention, 
404 
Rectification of ethyl chlorid, 253 
Rector's technique in synergistic anal- 
gesia, 655 
Rectum, surgery of, under local anes- 
thesia, 517 
under spinal analgesia, 587 
Reflexes, after anesthesia, 378 
cutaneous, and surgical shock, 383 
in chloroform anesthesia, 307, 315 
in ethyl chlorid anesthesia, 260, 262 
in nitrous oxid anesthesia, 133 
Regional method of local anesthesia, 
480 
Reicher's theory of anesthesia, 47 
Removal of patient after operation, 
technique of, 377 
Renal calculi, anesthesia for, 667 
function, effect of anesthesia on, 60 
Resection of joint, under local anes- 
thesia, 514 
Resistance to surgical shock, 383 
Respiration and shock, 383, 385, 410 
effect of warming the agent on, 65 
emergency treatment to ensure, 362 
in anesthesia, 57 
in anesthol anesthesia, 277 
in chloroform' administration, 287, 
298, 313, 316 
in ethyl chlorid anesthesia, 258, 263, 
274 
in ethyl chlorid-oxygen anesthesia, 
278 
in nitrous oxid anesthesia, 127, 133 
in stage of overdose of nitrous oxid, 
134 
Respiratory conditions under spinal 
analgesia, 582 
Respiratory difficulties during anesthe- 
sia, 380 
Respiratory failure due to loss of car- 
bon dioxid In blood, 406 
Respiratory system, anesthesia in op- 
erations on, 330, 339 
Respiratory system, effect of anesthetics 
on, 56 
effect of ether upon, 185, 192, 248, 
330 
effect of ethyl chlorid on, 258, 269 
effect of nitrous oxid on, 127 
reflex changes in, in anesthesia, 62 
See also Lungs 
Restlessness, extreme, anesthesia for, 667 
Retching during anesthesia, 381 
Rhein, methyl chlorid as a refrigerat- 
ing agent introduced by, 537 
Rib resection for empyema under local 
anesthesia, 507 
Richardson's voltaic narcotism, 536 
Rigidity, muscular, during anesthesia, 
381 
Ringer's solution in intravenous anes- 
thesia, 630, 637 
with carbon dioxid in prevention of 
shock, 409 
Roaf theory of anesthesia, 44 
Rohricht on glycosuria after ether, 198 
Roth-Drager oxygen and chloroform 
apparatus, 317 
Rottenstein, on ethyl chlorid as a re- 
frigerating agent, 537 
Roux, on spinal analgesia, 604 
Ryall on spinal analgesia, 587, 604, 610 
Rymer and nitrous oxid, 24 
Sacral anesthesia, 485 
Saison on effects of ether on the liver 
and kidneys, 190 
Saline enema during anesthesia, 374 
in acid intoxication, 414 
in post-operative treatment, 378 
in preliminary medication, 373 
in treatment of shock, 374 
Saline infusion in shock prevention, 
403, 409 
intravenous infusion of, effect of, 
on blood pressure, 403 
instillation, in painless childbirth, 
745 
normal physiologic, as vehicle for 
analgesic drugs in local anesthe- 
sia, 470 
use of, following adenoid and tonsil 
operations, 345 
in acute mania, 669 
in cocain solutions, 469, 470 
in cocain sterilization, 605 
in intravenous anesthesia, 629 
in spinal analgesic solutions, 599, 
603 
Saline solution and glucose, use of, 
preceding anesthesia in cancer, 
330 
Saline solution infiltration in local an- 
esthesia, 478 
Saline solution injection into sub- 
arachnoid space, 557 
Salivary glands, effect of anesthesia 
on, 60 794 
INDEX OF SUBJECTS 
Salivary glands, effect of warming the 
anesthetic on, 70 
Salpingectomy under spinal analgesia, 
560 
Salts, antagonism between anesthetics 
and, 55 
Salvarsan method of introducing 
needle in intravenous anesthesia, 
632 
Saturation, double, 722 
secondary, 722, 723 
Scalp, anesthetization of, 496 
cocain solution for local, 497 
nerve supply of, 496 
Scar removal under local anesthesia, 
495 
Schall on oxygen and chloroform, 27 
Schleich's infiltration anesthesia, in 
spinal analgesia, 559 
Schleich's method of anesthesia, 478 
Schleich's theory of anesthesia, 35 
Schraff's discovery of local analgesia 
with cocain, 555 
Sclerosis of arteries, nitrous oxid 
anesthesia contra-indicated in, 
135 
Scopolamin, in goiter, 354 
in intravenous anesthesia, 629, 639 
in preliminary medication, doses for, 
372 
for nitrous-oxid-oxygen anesthesia, 
165 
Scopolamin-morphin injection in local 
anesthesia, 475 
Sebaceous cyst removal under local an- 
esthesia, 495, 496 
Secondary saturation, 722, 723 
Seelig on ether inhalation, 198 
Selection of anesthetic, conditions af- 
fecting, 324 
for special operations, 337 
rules to be observed in, 326 
Semi-closed method of administering 
ethyl chlorid, 272 
Sensory innervation of mucous mem- 
branes of head, 500 
Sensory nerves, cocain experimentation 
on, 556 
Sensory paralysis in venous anesthesia, 
492 
Sepsis, spinal analgesia contra-indi- 
cated in, 587 
Sequence and combinations in anes- 
thetics, 325 
safest, 326 
value of, 325 
Shock, 382, 383 
anesthetic, 387 
treatment of, 392, 666 
anticipation of, 410 
causes of, 401, 405 
dietetic, 387 
diminution of, in upright position 
for adenoid and tonsil opera- 
tions, 352 
Shock, due to obstructed airway, 389 
due to overdose of anesthetic, 388 
duration of operation and, 386 
during anesthesia, 374, 389 
effect of hemorrhage on, 387 
effect of, on cerebrospinal fluid, 565 
effect of pituitary extract on, 404 
effect of posture on, 402, 404 
effect of preliminary medication on, 
371 
from labial stertor, 390 
in operation on appendix, 413 
in spinal analgesia, 581, 587, 595 
intravenous infusion and, 404 
physiologic rest in treatment of, 
404 
post-operative adrenalin in preven- 
tion of, 373 
prevention of, 376, 379, 382 
by Crile, 402 
by support of circulation, 404 
Henderson on, 409 
Keen's measures for, 404 
measures for, by Latham and Eng- 
lish, 403 
saline infusions in, 404 
water in, 366 
psychic, 384 
surgical, 383, 410 
and time of day, 384 
susceptibility of organs to, 402 
theories of cause of, 401 
Crile's vasomotor paralysis, 402 
Henderson's vasomotor activity, 
406 
treatment of, 392, 666 
treatment of, in accordance with 
Crile's theory, 403 
Short operations, anesthesia in, 337 
Shoulder amputation under local anes- 
thesia, 509 
Sicard on spinal analgesia, 558, 566 
Sicard's experiments on injections into 
subarachnoid space, 557 
Simpson, Sir James Y., 8, 20, 25, 177, 
282, 286, 311 
Simpson's ' ' Anaesthesia, ' ' 21 
Simpson's "New Anaesthetic," 20 
Sims' position in oil-ether colonic an- 
esthesia, 445 
Skin, appearance of, in nitrous oxid 
anesthesia, 133 
local anesthetization of, 493 
production of wheal in, 494 
solution for, 494 
Skin and surgical shock, 383 
Skin grafting under local anesthesia, 
514 
Skin injection, solution for, in local 
anesthesia, 470 
Skin reflexes due to shock, 385 
Sleep, 51 
difference between anesthesia and, 
50 
twilight, 747 INDEX OF SUBJECTS 
795 
Sleeping child, method of anesthetiz- 
ing, 341 
Skull examination under local anesthe- 
sia, 496 
Smokers, ethyl chlorid anesthesia con- 
tra-indicated in, 269 
Snape's "calorific fluid," 536 
Sneezing during anesthesia, cocain for, 
381 
Snow, John, 25, 177, 283, 
Snow' 's inhaler, 23 
Soapsuds enema in after-treatment for 
colonic ether anesthesia, 437 
in preliminary treatment, 375 
for colonic ether anesthesia, 436 
Sobbing in anesthesia, 380 
Sodium bromid in post-operative vom- 
iting, 379 
Sodium chlorid, in preparation of co- 
cain solutions, 539 
in spinal analgesic solution, 601 
with cocain in local anesthesia, 470 
Sodium nitrite, 401 
Solubility of chloroform, 284 
Somnoform, 276 
effect of, on diaphragm, 258 
Souligoux on ether in the treatment of 
infections, 671 
Spasm, muscular, in asphyxia, with 
ethyl chlorid, 261 
Spasms, muscular, due to chloroform, 
303 
Specialist, liability of, 684 
Spencer's theory of anesthesia, 32 
Sphincter ani, dilatation of, in treat- 
ment of shock, 393 
Spielmeyer's experiments in spinal 
analgesia, 570 
Spiller and Leopold's experiments, 
with stovain in spinal analgesia, 
569 
Spinal analgesia, 554 
abdominal operation under, 559, 587 
advantages and disadvantages of, 594 
analgesic agents for, 599 
sterilization of, 604 
anatomical and physiological consid- 
erations in, 563 
apparatus and materials for, 614 
sterilization of, 616 
auto-operations under, 577, 580 
Babcock's solution for, 603 
Barker's stovain-glucose. solution 
for, 602 
Bier's stovain solution for, 602 
Bier's tropacocain solution for, 601 
Braun's novocain-suprarenalin solu- 
tion for, 603 
by tropacocain, 601 
case reports on, 623 
cases of complete, 574 
in children, 588-590 
Chaput's stovain solution for, 602 
course of, 572 
deaths due to, 596 
Spinal analgesia, decrease of post- 
operative pneumonias under, 199 
discovery of, 555 
duration of, 576 
early application of, to surgery, 559 
Erhardt's solution for, 601 
extent of, 572 
facial expression of patient under, 
575 
first surgical operation under, 559 
Gray's dextrin-stovain solution for, 
603 
history of, 555 
in diseases of the lungs, 330 
in heart disease, 329 
in obstetrics, 593 
indications and contra-indications 
for, 586 
opinions of surgeons on, 586 
injection with patient in recumbent 
position, 614 
Jonnesco's stovain-strychnin solu- 
tion for, 603 
Meyer's solution for, 601 
operations on the aged under, 591 
phenomena accompanying, 577 
objective, 581 
subjective, 577 
post-operative phenomena of 582, 
595 
preliminary use of morphin in, 370 
preparation of patient for, 612 
sites of injection in, 564, 605 
technique of injection in, 617 
typical satisfactory case of, 625 
Spinal cord, cocain experimentation 
on, 556 
illustrations of, 608 
lesions of, spinal analgesia contra- 
indicated in, 587 
Spinal neurons, effects of anesthesia 
on, 41 
Spinal puncture, early experiments in, 
557 
Lusk on, 605 
patient in sitting posture for, 613 
routes for, 605 
Byall's method of, 610 
schematic pictures showing location 
of space between third and 
fourth lumbar vertebrae, 611 
Spinal puncture site, location of, 618 
Avamresco's, 610 
Gray's, 610 
Jonnesco's, 607, 608 
Spine, diagrammatic cross-sections 
through, 606 
Splanchnic anesthesia, 486 
Splanchnics, anesthetizing of, 488 
Spleen, enlargement of, in status 
lymphaticus, 332 
Spongia somnifera, 3 
Spraying nozzle for ethyl chlorid, 254 
Starfish eggs, effect of anesthetics on, 
43, 44 796 
INDEX OF SUBJECTS 
Starvation, acidosis in, 415 
Starvation cases, gastro-enterostomy 
in, 356 
Status lymphatieus, 326 
anatomy of, 331 
chloroform contra-indicated in, 310 
choice of anesthetic in suspected 
cases of, 333 
definition of, 331 
diagnosis of, 332 
ether for, 247 
history of, 331 
mortality from, 334 
observations on, in animals, 335 
post-mortem examination in, 335 
preparation for operation in, 333 
treatment of, during anesthesia, 334 
Statutory liability of physician, 686 
Sterilization of analgesic agents, 604 
of apparatus for spinal analgesia, 
616 
Stertor in anesthesia, 380, 464 
in chloroform administration, 307 
in ethyl chlorid anesthesia, 274 
labial, shock from, 390 
prevention of, during anesthesia, 
392 
Stimulation, peripheral, during anes- 
thesia, 380 
Stitch irritation, prevention of, by an- 
esthetic block, 406 
Stockman and nitrous oxid, 5 
Stomach operations, shock in, 403 
Stovain, 540 
in spinal analgesia, 563, 576, 582, 
599, 603, 624 
with adrenalin, 592 
Stovain injection by lumbar puncture, 
effect of, on nervous system, 
569 
Stovain solutions in spinal analgesia, 
602 
diffusible, 585 
Stovain-Billon, in spinal analgesia, 602 
Stovain-dextrin solution in spinal anal- 
gesia, 592 
Stovain-glucose solution in spinal anal- 
gesia, 602 
Stovain-strychnin solution in spinal 
analgesia, 582 
Strychnin, use of, in respiratory dis- 
turbances, 539 
in respiratory failure, 394 
in spinal analgesia, 563, 582, 585, 
599, 603, 612 
Strychnin injection in shock preven- 
tion, 403 
Strychnin poisoning anesthetic treat- 
ment for, 667 
chloroform in, 285 
Strychnin sulphate in shock preven- 
tion, 403 
in spinal analgesia, 625 
Stursberg, on effects of ether narcosis 
on the blood, 188 
Stursberg, on temperature stimulus in 
ether and chloroform anesthesia, 
69 
Submucous operations, anesthesia in, 
340 
Subperiosteal injection of anesthetic 
solutions in dentistry, 543 
Suffocation, due to enlarged thymus, 
335 
Sulphate of morphin, use of, preceding 
anesthesia, 328 
Sulphur compounds, test for, in ethyl 
chlorid, 257 
Sulphuric acid in chloroform, 285 
in preparation of ether, 180 
in preparation of ethyl chlorid, 252 
preparation of oxygen from, 755 
Sulphuric ether, 178 
Suprarenalin in spinal analgesic solu- 
tions, 603 
Surface anesthesia, 478 
Surface tension theory of anesthesia, 
42 
Sutton's apparatus for colonic absorp- 
tion of ether, 435 
Sweat glands, effect of anesthesia on, 
60 
Sweating in spinal analgesia, 582 
Synergism, 640, 643 
Synergistic analgesia, 640, 654, 656, 
657, and See Magnesium 
advantages of, 659 
administration of, 651 
colonic, 654, 656, 657 
conclusion, 665 
contra-indications, 665 
dangers of, 661 
definition of, 640 
development of, 640 
ether and oil, by colonic instillation, 
654 
ether, by inhalation, 653 
history of, 640 
in painless childbirth, 747 
indications, 665 
mortality of, 663 
nitrous acid in, 652 
oxalates in, 642 
physiological considerations, 643 
Rector's technique in, 655, 657 
results, 657 
technique of administration, 651, 
655, 658 
Synergistic anesthesia, 640 
Synergistic methods, in obstetrics, 732, 
and See Painless childbirth 
Synthetic suprarenin with novocain in 
local anesthesia, 469 
Syringe for Bier's venous anesthesia, 
491 
for injections in local anesthesia, 
471, 472 
for spinal analgesia, 614 
Tait on spinal analgesia, 560, 565, 607 INDEX OF SUBJECTS 
797 
Tait and Caglieri's experiments on 
the subarachnoid space, 565 
Teeth, operations on, under local anes- 
thesia, 496, 544 
See also Dentistry 
Temperature (body), effect of anes- 
thesia on, 66, 67 
effect of warming the agent on, 67 
in operations under anoci-associa- 
tion, 405, 406 
shock and, 383, 385, 402 
Tendon transplantation under local 
anesthesia, 514 
" Terminal anesthesia," 536 
Terpineol, use of, preceding anesthesia, 
92 
Testicles, effect of shock on, 385 
Tetanus, anesthetic treatment for, 667 
chloroform indicated for, 310 
Tetanus toxin injection into subarach- 
noid space, 558 
Teter auxiliary tube, 155, 173 
Teter ether attachment, 154 
Teter face mask, 154 
Teter method of nitrous oxid-oxygen 
anesthesia, 153 
Teter nasal inhaler, 155 
Teter nasopharyngeal tubes for nitrous 
oxid and oxygen, 157 
Teter nitrous oxid-oxygen apparatus, 
152, 156 
Teter vapor warmer, 153 
Tetrachlorethylene in chloroform, 285 
Theories of general anesthesia. See 
General anesthesia, theories of 
Thibault, use of quinin and urea hy- 
drochlorid by, 469 
Thin subjects, choice of anesthetic for, 
329 
Third stage anesthesia, 528 
Thirst, relief of, during anesthesia, 
374, 375 
Thompson on effects of ether upon 
renal activity, 190 
Thoracic surgery, anesthesia in, 692, 
694 
intratracheal insufflation indicated 
in, 431 
under local anesthesia, 507 
under spinal analgesia, 597 
Three-bottle vapor inhaler, 225, 230 
attached to oxygen tank, 240 
Thrombosis after ether, 186, 199 
Thymicus, 331. See also Status 
lymphaticus 
Thymol, as preservative of chloro- 
form, 292 
in carbon tetrachlorid for steriliza- 
tion in intravenous anesthesia, 
631, 636 
Thymus gland, 331 
enlargement of, 333, 335 
See also Status lymphaticus 
Thyroid, enlargement of, in status 
lymphaticus, 332 
Thyroid, operations on, methods of, 503 
under local anesthesia, 503 
under oil-ether colonic anesthesia, 
448 
Se.e also Thyroidectomy- 
Thyroid arteries, ligation of, under 
local anesthesia, 503 
Thyroidectomy, anesthesia in, 353 
intratracheal insufflation in, 432 
under anoci-association, 406 
under local cocain anesthesia, 581 
Tibia, ostectomy of, under spinal anal- 
gesia, 560 
Tin containers for chloroform, 293 
Tissue asphyxia, 124 
Toe anesthetization, 510, 514, 515 
Tongue, enlargement of, in status 
lymphaticus, 332 
excision of, anesthesia in, 339 
chloroform indicated for, 310 
under local anesthesia, 498 
under spinal analgesia, 587 
Tongue forceps, use of, in anesthesia, 
362 
in artificial respiration, 393 
Tonsil cases, 340 
use of ether for, 247 
use of Junker apparatus in, 322 
use of nitrous oxid in, 140 
See also Adenoid and tonsil cases 
Tonsillectomy, ethyl chlorid anesthesia 
for, 268 
local anesthesia for, 501 
Tonsils, enlargement of, in status 
lymphaticus, 332 
treatment of, under local anesthesia, 
501 
Toxemia, induced by thymus, 335 
post-anesthetic, 413 
use of water during anesthesia in, 
376 
Toxic causes of psychic shock, 384 
Trachea, operations around, intra- 
tracheal insufflation indicated 
in, 432 
operations on, colonic ether indicated 
in, 437 
Tracheotomy, anesthesia in, 352 
under local anesthesia, 503 
Transfusion of blood in serious cases 
of shock, 404 
preceding gastro-enterostomy, 356 
Trans-sacral anesthesia, 468 
Traube's theory of anesthesia, 42 
Traumatic surgery, intravenous anes- 
thesia in, 492 
Treatment after anesthesia, 361, 378, 
379 
by colonic absorption of ether, 
437 
local, 476 
anesthetic, for special conditions, 
666 
before anesthesia, 361 
during anesthesia, 361, 374 798 
INDEX OF SUBJECTS 
Treatment emergency, to insure breath- 
ing, 362 
for acapnia, 409 
of ordinary cases during anesthesia, 
364. See also Management 
of unusual cases, 379. See also 
Management 
preliminary, in ordinary cases, 364 
Tremors, muscular, during anesthesia, 
381 
Trional, 705 
Trismus during anesthesia, 381 
Tropacocain, 540 
in spinal analgesia, 563, 571, 576, 
583, 599 
Tubes for ethyl chlorid, 254 
glass nasal, for general anesthesia, 
227 
Tuberculosis, choice of anesthetic in, 
329 
use of oil-ether colonic anesthesia 
in, 461 
Tuffier's use of spinal analgesia, 560, 
569, 575, 598, 602, 604 
Tumor, benign, removal of, under 
local anesthesia, 479 
circumscribed, operation for, under 
local anesthesia, 479 
in airway, chloroform indicated for, 
310 
of abdominal wall, operation for, 
under spinal analgesia, 573 
removal of, by blunt dissection under 
local anesthesia, 495 
under the sternum in status lym- 
phaticus, 332 
Twilight sleep, 747 
Ulnar nerve, anesthetization of, 511 
United States Pharmocopoeia, ethyl 
chlorid tests prescribed by, 
257 
Upright position for adenoid and ton- 
sil operations, 345 
Urea and quinin hydrochlorid in local 
anesthesia, 469, 704 
Urea hydrochlorid, 540 
in anesthetic block for shock pre- 
vention, 406 
in gastro-enterostomy, 356 
See also Quinin and urea hydro- 
chlorid 
Urethan, dose of, for animals, 756 
Urethra, solution for local anesthesia 
of, 516 
Urethotomy, infiltration in, 516 
Urinary examination in intravenous 
anesthesia, 639 
Urine, effect of anesthesia on, 60 
effect of chloroform upon, 191, 303, 
309 
effect of ether upon, 190, 197 
effect of nitrous oxid on, 132 
extravasation of, spinal analgesia 
in, 587 
Urine, negative findings in, after ethyl 
chlorid anesthesia, 264 
Urobilinuria following anesthesia, 58 
Uterus, effect of shock on, 385 
operations on, shock in, 403 
Vagina, effect of shock on, 386 
Valentine, Basil, discovery of ethyl 
chlorid by, 250 
Valverdi, 4 
Valvular disease, nitrous oxid contra- 
indicated in, 135 
Vanadium steel cylinders for nitrous 
oxid, 120 
Vapor, strength of, effect of, on 
breathing, 380 
Vapor anesthesia by open method, 231 
Vapor inhaler, first, 24 
Vapor mask, 224, 232 
Varicose ulcers of legs, operation on, 
under spinal analgesia, 625 
Varicose vein excision under intrave- 
nous anesthesia, 514 
under spinal analgesia, 573 
Vascular system, effect of ethyl chlorid 
on, 258, 260 
Vasomotor depression, 316 . 
Vasomotor paralysis as cause of shock, 
402 
Vein exposed and ligated distally for 
intravenous anesthesia, 631 
Venous anesthesia, Bier's method of, 
490 
Ventilation, pulmonary, after ether or 
chloroform, 107 
effect of morphin on, 108 
Ventral hernia, local anesthesia in, 527 
Verrier on effect of ether on lactation, 
192 
Vertigo following ethyl chlorid anes- 
thesia, 264 
Verworn's theory of anesthesia, 49 
Vinegar fumes, inhalation of, in post- 
operative vomiting, 379 
Vogt on spinal analgesia, 565, 571 
Voltaic narcotism, 536 
Vomiting, absence of, following intra- 
tracheal insufflation, 430 
after anesthol administration, 278 
after ethyl chlorid anesthesia, 264 
after use of ethyl chlorid and ni- 
trous oxid, 279 
after use of nitrous oxid, 132 
during anesthesia, 381 
during chloroform anesthesia, 306 
in ether anesthesia, 189 
in ethyl-chlorid oxygen anesthesia, 
278 
in peritonitis or intestinal obstruc- 
tion, 355 
in spinal analgesia, 577, 582, 595 
post-anesthetic, 102, 379 
effect of carbon dioxid on, 99 
effect of oil of bitter orange peel 
on, 94 INDEX OF SUBJECTS 
799 
Vomiting, post-anesthetic, effect of 
warming the agent on, 70 
lessened by rebreathing, 113 
post-operative dosage for, 379 
prevention of, by preliminary medi- 
cation, 373 
with Roth-Drager oxygen and chloro- 
form apparatus, 318 
War surgery, anesthesia in, 688 
ethyl chlorid anesthesia in, 266 
Ware apparatus for administering 
ethyl chlorid, 273 
Ware's method of administering ethyl 
chlorid, 272. 
Warmed chloroform, 314 
Warmed ether vapor administration, 
by closed method, 244 
amount of anesthetic for, 245 
care of apparatus for, 245 
Warmed ethyl chlorid vapor, 271 
Warming anesthetic agent, 63 
death following, 67 
effect of, on after-effects of anes- 
thesia, 70 
on body temperature, 66 
on convulsions, 65 
on heart action, 65 
on recovery from anesthetic, 69 
on reflexes, 65 
on respiration, 65 
experiments in, with ether vapor, 70 
safety to life and, 63 
Warming nitrous oxid, 136 
Warren and "sulphuric ether," 5 
Warrington on chloroform, 25 
Wart removal under local anesthesia, 
495 
Water enema during anesthesia, 374 
in post-operative treatment, 379 
Water infiltration in local anesthesia, 
470, 478 
"Water logging," prevention of, 375 
Water suction apparatus for adenoid 
and tonsil operations, 343 
Water vapor, inspiration of compressed 
air with, 77 
Waugh on spinal analgesia for chil- 
dren, 589 
Webster on ethyl chlorid, 260 
Wells, Horace, 10, 17, 24 
use of nitrous oxid in dentistry by, 
118 
Wheal, production of, in skin anes- 
thetization, 493 
Whiskey, administration of, preceding 
anesthesia in alcoholics, 329 
in post-operative treatment, 378 
in preliminary medication, 371, 373 
with saline enema, 378 
Wood, Alexander, hypodermic injec- 
tion for dental anesthesia intro- 
duced by, 536 
invention of hypodermic syringe by, 
466 
Woolsey. See Gwathmey-Woolsey 
Woolsey method of employing oil of 
orange-ether sequence, 94 
World War, anesthesia during, 688 
Wright's theory of anesthesia, 40 
Yankauer mask for ether, 203, 232 
Yohimbin, dose of, for animals, 756 
Ziemssen's experiments with lumbar 
puncture, 557