BROOKLYN VITAL STATISTICS FOR FEBRUARY, 1890. By J. S. YOUNG, M.D., Dep. Commissioner of Health. 243 291 759 ΠΟ 25 2 45 The mortality by classes and by certain of the more important diseases were as Causes: Diphtheria 94 Bright's Diseases. 31 Deaths by sex, color, and social condit on, were as follows: 84 32 Still-births, excluded from list of deaths, were as follows: Certain foreign and American cities show the following death-rate for the month THE BROOKLYN MEDICAL JOURNAL PUBLISHED MONTHLY BY THE MEDICAL SOCIETY OF THE COUNTY OF KINGS. In the month of December, 1876, I read a paper before the Kings County Medical Society, entitled "Nitrous Oxide in Minor Surgery," which was published in the "Proceedings" of the society for that month. I therein predicted for this anæsthetic a wider field in the future than the one to which it was chiefly assigned at that time, and expressed my belief that some day it would take its place in general surgery as one of the important anæsthetics. The reasons for this were that investigation had shown it to be a safe and pleasant agent, quickly administered, from which the patient rapidly recovered without shock and, usually, without nausea or other disagreeable symptoms connected with the administration of ether and chloroform. Statistics at that time were overwhelmingly in its favor for all the shorter operations in general and dental surgery, and this continues. The record shows seven deaths from nitrous oxide (three of these, however, are indirectly attributed to it) in over one million administrations, and this probably does not include half the cases that have been anæsthetized with it, if we include those for dental operations. Comparative statistics show a ratio of one death in about two hundred administrations of chloroform, one in about five hundred of ether, and of nitrous oxide one in ten thousand. If it can be shown that the safer agent can be used in most of the operations where an anesthetic is required, we shall have little excuse for resorting to the more dangerous ones, even though a slight additional expense is involved in the use of the safer anæsthetic. My apology for presenting a paper on the subject of anaesthetics, when so much has been written about them before, is that I hope to show that nitrous oxide is the safest and best anæsthetic for most of the operations in surgery, and also to offer my conclusions as to its physiological action, amendatory to those offered in my former paper. At the time of the writing of that paper my experience in its use, in the more important operations of surgery, had been limited to a few cases. Since then it has been quite extensive, the cases including almost all the operations in general surgery, many of them oft repeated; and I append the details of a few of these cases confirmatory of my position. I pass by the more simple cases, such as operations for the dilatation of the sphincter ani, lancing of felons, etc., and take some of those more serious in character. A few days after presenting my paper, in 1876, the late Dr. W. H. Giberson called upon me and asked me to go with him to the City Hospital, of which he was visiting surgeon, and make a test of nitrous oxide in some of his cases there : CASE NO. 1.-An operation for injecting a hydrocele. Anæsthesia maintained about eight minutes. CASE NO. 2.-An operation for phimosis. ten minutes. Anæsthesia maintained CASE NO. 3.-Dr. Giberson then said there was a sailor in the hospital with a compound, comminuted fracture of the arm, the result of a fall on shipboard. The physical condition of the man was such that he feared the shock of the administration of ether or chloroform, and asked if I would be willing to give him nitrous oxide, I consented, and the patient was successfully anæsthetized, the arm removed, and stump dressed; the time occupied being about thirty-five minutes. The patient was removed to his bed, recovered consciousness promptly, and asked for something to eat. He made a rapid recovery, without an unfavorable symptom. CASE NO 4.-That of a prominent professional gentleman of this city, who had a cancerous tumor removed from the lower lip. Anæsthesia maintained for one hour and twenty minutes, the patient manifesting no sign of shock, recovering promptly on the removal of the inhaler. In this case there was difficulty in accommodating myself to the operator (the late Dr. J. C. Hutchison), but by plugging the mouth and pharynx with cotton, the patient breathing through the nose, I was enabled to adjust my inhaler so as to uncover the lower lip and administer the anæsthetic. CASE NO. 5.-Another of Dr. Hutchison's cases. Lithotrity was performed, and the débris removed by Bigelow's apparatus. Anæsthesia was maintained for one hour. This was not quite as satisfactory a case as the others, the patient being more or less rigid at times, but no more inconvenience was encountered than is often met with in ether narcosis. A few months afterward lithotomy was performed for the same patient, nitrous oxide being again used, as the patient and operator both preferred it. The same tendency to rigidity was encountered as on the former occasion, and, at my suggestion, ether was substituted for a few minutes, when relaxation ensued, and nitrous-oxide anæsthesia was resumed, and continued satisfactorily to the end of the operation—over a half hour. CASE NO. 6. This was also a case of lithotomy, operated upon by Prof. J. C. Gouley, of New York city. Anesthesia was easily maintained for over half an hour, the patient recovering within three minutes after removal of the inhaler, making a joking remark. None of these cases manifested any symptoms of nausea. Anæsthesia maintained for twenty-five minutes. No unfavorable symptoms; neither nausea nor depression. Recovery prompt. CASE NO. 8.-Amputation of breast. Anæsthesia maintained for over half an hour. There was a marked bronchitis existing, which was at first somewhat troublesome, but did not materially interfere with the maintenance of anesthesia satisfactorily. Many other cases could be cited, but these are sufficient to show the feasibility of nitrous-oxide anæsthesia for prolonged operations, by the method adopted by the writer, details of which will be given later in this paper, when considering the physiological action of the anæsthetic. I will cite only one other case, a recent one, referred to by the operator, Dr. Geo. R. Fowler, in his paper, published in the March number of THE BROOKLYN MEDICAL JOURNAL. The details are mainly given by Dr. Fowler. Low tracheotomy had been performed some days before, and when I saw the patient it was to determine how the anesthetic could best be administered through the tracheotomy-tube, there being no other way. I decided to have a special apparatus made connecting with my inhaler, and, with the consent of Dr. Fowler, the inner cannula was removed and taken to G. Tiemann & Co., of New York city, and, a thread being cut in this, a connection was made by means of flexible rubber tubing attached to a graduated ring, upon which at thread was also cut so as to admit of its being screwed into the cannula. When all was completed, the aperture was so small that it seemed doubtful whether the patient could get enough air through it to sustain life. I therefore practised breathing with it until satisfied that the patient would be safe from asphyxia. When the patient came into the room her pulse was 112, but dropped to go as soon as anæsthesia was established, and remained so throughout the operation, which was that of laryngectomy, and lasted for one hour and forty-five minutes. The anesthesia was uniform during the whole time and the recovery prompt, as Dr. Fowler has stated, without shock or any unpleasant symptom that could be attributed to the anesthetic. Perhaps the writer has not done his whole duty in not publishing his former experiences with this agent, as many of the profession have expressed surprise that it could be used for prolonged operations; but, while investigating the question of its physiological action, it seemed as well to wait until something satisfactory along this line could be determined, and it is only recently that he has been able to do this, none of the views of other writers according with experience. My early investigations with nitrous oxide were connected with its administration for dental operations, but after entering upon the practice of medicine and surgery I pursued them carefully, as time would permit, along the lines of general surgery and the prolonged operations therein, and in the last fourteen years have administered it in hundreds of cases, the cases enumerated being a few culled from this experience. There has been, here and there, an unsatisfactory case, and in these ether or chloroform has been resorted to. The apparatus which one is obliged to use is somewhat cumbersome, but the advantages gained compensate for this. Nausea sometimes occurs, but it is rare, and when it does manifest itself is not as persistent as with the other anæsthetics. Its successful administration for prolonged operations requires some skill and experience, or the patient may speedily recover from its effects in the midst of the operation, or, as happened in one of my first cases, too little atmospheric air was admitted, and when the operation was completed I had for a moment some concern for his safety; but happily he recovered rapidly. There has been so much written upon the subject of the physiological action of this anæsthetic, and the views of the writers are so widely divergent, that it is with some hesitation that I approach this part of the subject with a theory of my own, and my conclusions will be subject to any modifications which the completion of a series of experiments, which were begun over a year ago, may demand. A few preliminary experiments were made at the Johns Hopkins University, |