some instances, impossible operations. But more recently there has been a movement among American surgeons to replace it, in most cases, by chloroform, following the English and German line of thought and practice in this particular. On the other hand, some of our European confrères, attracted by the quite noticeable absence of reported accidents occurring during ether anesthesia, and attributed to the latter, have turned their attention to the uses and advantages of this anesthetic agent. In the Geneva clinic, Julliard seems to have led the way among European surgeons in the abandonment of chloroform, and the substitution therefor of ether. His results were of so highly satisfactory a character as to arrest the attention of Dumont.' This surgeon has now used sulphuric ether for over two years, to the exclusion of chloroform, and his experiences are entirely corroborative of those of Julliard. He expresses himself as being entirely in favor of this agent, and that, too, in very decided terms, claiming for it all that American surgeons have claimed for it in regard to its superiority over chloroform. With increasing use and familiarity with this means of producing surgical narcosis, Julliard and Dumont became quite as expert in its use as their colleagues upon this side of the Atlantic, frequently succeeding in producing complete surgical narcosis in from one to two minutes. The freedom from dangerous and threatening symptoms occurring in the course of the administration, in the hands of Dumont, is also a striking feature of this surgeon's experience. For instance, he reports that in 182 administrations in but a single instance was there any necessity for anxiety regarding the patient's condition. In this patient, an old subject suffering from chronic bronchitis, collapse occurred. The conclusions of Dumont in regard to the propriety of administering sulphuric ether to persons suffering from pulmonary affections are entirely in accord with those to which surgeons of extensive experience in the use of this agent have arrived, viz., that such must always be a source of more or less anxiety on the part of the administrator. In addition it may be noted, that it is also a rather universally acknowledged fact that the more acute the lesion of the air passages or pulmonary structure itself, the greater the danger. There can be no gainsaying the fact that ether produces far greater irritation of the air passages than chloroform; and further, that the resistance to its administration, owing to the involuntary repugnance almost invariably shown to its vapor, on the part of patients, is somewhat difficult to overcome, and often stands in the way of an easy and comfortable transition from a state of consciousness to that of insensi 1 Korrespondenzblatt £. Schweizer Aertzte, 1889. No. 23. bility as compared with its rival. The assertion, however, I know, will be echoed by thousands who have used ether for many years, that these disadvantages are far more than counterbalanced by the decidedly greater safety of this agent. It is a noticeable fact, yet one not easily accounted for, unless one may imagine a national determination to disparage anything which Germans have a decided leaning toward, that in those portions of Switzerland where the French element prevails, there is a growing interest in ether, and this agent has been steadily growing in favor as an anæsthetic in these districts. Be that as it may, our German colleagues seem to have taken alarm at the increasingly large mortality attending chloroform administrations, and with their proverbially philosophical and inquiring turn of mind, have set out to settle the truth about this question, in their usual exact manner, by instituting a series of experiment upon the lower animals. It is now nearly two years ago since Ungar, discoursing upon this theme, claimed that animals, chloroformed for several hours at a time, and upon successive days, showed upon dissection indubitable evidences of fatty degeneration of, first, the heart and liver; second, of the kidneys and striped muscular structures; and third, of the gastric and mucous membranes generally. These were attributed by Ungar to the direct poisonous effects of chloroform. More recently Strassman has published some very interesting experiments bearing upon the question of the fatal after-effects of chloroform, in which he essentially corroborates the observations of Ungar, and sums up the results of his researches as follows: 1. After prolonged chloroformization, in dogs, there can be demonstrated a fatty metamorphosis of the liver; the heart may partake of the same changes as a secondary result. Other organs are seldom affected. These changes consist of true fatty degeneration and not of fatty infiltration. 2. Subsequent to the usual chloroform narcosis, and when recovery therefrom has apparently taken place, a fatal result is occasionally observed to occur. 3. Inasmuch as in the fatal cases the heart changes were found to be particularly well marked, these latter may reasonably be assumed to have been the cause of death. 4. In non-fatal cases the evidences of degenerative changes are not found after several weeks. 5. These changes are particularly prone to occur in those in whom debilitating influences, such as hunger, loss of blood, etc., can reason 2 Virchow's Archiv., Bd. 115. ably account for the susceptibility to this undue action of the anaesthetic. In young and vigorous animals a greater power of resistance counteracts the tendency to these changes. These researches and published observations of both Ungar and Strassman, agreeing as they do in all essential particulars, point to but one conclusion. The charges brought against chloroform by its earlier opponents are more than sustained; for whereas it was supposed that the accidents during its administration were due to influences of a more or less functional character, it now transpires that, in addition to what has been looked upon either as a paralysis of the heart muscle through interrupted nerve force, or over-stimulation of the inhibitory apparatus, or both, we are to expect, in addition, true organic changes in the structure of the heart itself, as a result of the use of chloroform. The deductions to be drawn from this presentation of facts would seem to be obvious, and yet, notwithstanding the apparently logical inferences which one would at the first glance draw, after careful study of the question, there are still some practical difficulties in the way of laying down any hard and fast rule, regarding the choice as between chloroform and ether as an anæsthetic agent. It would seem, however, as if the following conclusions, as far as they go, might be justified. 1. As an anæsthetic for surgical purposes, ether will be found to be less dangerous and more generally applicable.. 2. If chloroform is to be used at all, it should be only for short operations or dressings otherwise painful. If necessity exists in any given case for the frequent exhibition of an anesthetic, chloroform should give place to ether. Young and vigorous persons, and even those in advanced years who have not been subjected to debilitating influences, or not the subjects of degenerative disease, may take chloroform with comparative safety; yet there is no reason why this same class may not take the safer anæsthetic, ether, as well. 3. In aged persons suffering from pulmonary affections, the administration may be commenced with chloroform; but, if it is found that the operation is to be a long one, ether should be substituted. 4. If degenerative disease of the kidneys and heart exist, and no pulmonary complication, ether should be used. If all of these conditions co-exist, judgment must be exercised as to which has a predominating influence, and the choice made accordingly. In any event, the anaesthetic chosen under these circumstances should be used with great care. I desire to refer to the pernicious habit of producing a mixed narcosis (chloroform and ether given simultaneously) simply to condemn it most unqualifiedly. Whatever good or evil resides in either agent should be kept apart, and the habit of uniting the one and at the same time attempting to prevent the undue influence of the other, must always remain a matter of uncertainty and doubt; the practice is, beyond doubt, unscientific, and should always be discouraged to the last degree. The habit of administering atropia hypodermically prior to the administration of the anesthetic has received the sanction of authority, and I know of no valid objection to urge against it. In ether narcosis it certainly lessens the tendency to profuse secretion from the mucous membrane of the air passages, and Barthelow's assertion that it acts as a stimulant to the respiratory centres seems to be borne out by experience. There are some advantages in combining morphia with this agent, particularly where it is deemed best to use chloroform as the anæsthetic agent. Without doubt it seems to lessen the amount of chloroform necessary to produce and maintain anæsthesia, and correspondingly lessens the danger to be apprehended from the use of the latter. There have been some attempts made during the past four years to popularize in the profession the use of nitrous oxide as an anesthetic for general surgical use. The name of Paul Bert, of France is prominently associated with these attempts, but his published observations tended to discourage, rather than encourage, surgeons in the use of this agent. The reason for this resides in the fact that Bert sought to prove that for the purposes of its proper and safe administration for a protracted time, it is necessary that a specially prepared chamber be used, and that a fixed and certain atmospheric pressure be maintained during the administration. With ether and chloroform always at command, no surgeon would submit to such elaborate preparations, involving as they do an outlay of money, time and energy not warranted by the advantages to be obtained by the use of the gas. I have always entertained some doubt as to the necessity, in the use of this agent, for such extraordinary precautions, and I therefore hailed with delight the assertion of Dr. Geo. W. Brush, of Brooklyn, who has had many years' experience in the use of nitrous oxide, administered for dental operations, that it could in most cases be utilized for prolonged operations, with the patient in the recumbent position. The wide-spread belief in the innocuousness of the gas, the utter absence of depression arising from its use, the absence of any irritating qualities, as well as taste and smell, together with the ease of its administration and rapidity with which patients recover from its anæsthetic effects have always been attractive qualities to me; but I confess that the appearances of ghastly cyanosis and impending suffocation which the patient presents while under its influence, and which to my mind could only be explained by an accumulation of carbonic dioxide in the blood, deterred me from giving the agent that fair and unprejudiced trial wh ch it would seem to deserve. Yielding, however, to the assurances of Dr. Brush that, whatever the cyanosis might be due to, it certainly was not a sign of impending dissolution, I consented to allow of its trial in a very important operation, the pioneer of its kind, that of modified laryngectomy after Cohen's proposition. Dr. T. R. French, our esteemed laryngologist, had seen the case, one of typical epithelioma of the left ventricular band and vocal cord, with me, and it was upon his suggestion that I entertained Dr. Brush's proposition, with whose experience in nitrous oxide administration I was not at that time familiar, to allow him to demonstrate the feasibility, (even under the adverse circumstances of being compelled to administer the gas through a tracheotomy tube, and keeping the nostrils plugged and mouth covered), of keeping the patient in a condition of safe anesthesia for a length of time sufficient for the purposes of this operation. The result was a perfect revelation. to me. The operation, together with the elaborate packing of the wound, securing of the stump of the trachea and fixation of a feeding tube in the opened œsophagus, occupied just one hour and forty minutes; during the whole of this time anesthesia was maintained, and at its close the patient, whose pulse had never wavered, but on the contrary, preserved its force and rate the same as before she came upon the table, became fully conscious within two minutes after the administration of the gas ceased. Had she not been prevented from doing so, she would have insisted upon her ability to walk from the operating-room to her own bed. No elaborate preparation was needed, and the only departure from the apparatus ordinarily employed by the dentists consisted of a screw coupling by means of which the tubing which conveyed the gas could be attached to the tracheotomy tube. But the cyanosis, the ghastly appearance, even worse than that presented when the grim monster himself has taken possession of the patient, was present all the time; and I am not ashamed to say that, in the absence of any rational explanation of the condition, it was all that I could do to preserve my equanimity during this trying period. In spite of Dr. Brush's assurances, I felt far from comfortable, and whatever credit my colleagues who witnessed that operation may be inclined. to give me for its successful completion, they will never know how much I was handicapped by that ashen gray, death-like upturned face within a few inches of my own during the whole time. But why this peculiar condition, than which nothing can be more horrible? If it was not the result of the accumulation of carbonic dioxide in the blood, what was it? It was small comfort to know that |