Dr.

one's patient was not being suffocated with one agent, while the suggestion was constantly before one's eyes that either that or something else was threatening to suspend his animation or destroy his life. Brush's assertion that they always looked badly under its influence is somewhat reassuring, but his suggestion that the appearances were due to some chemical changes in the blood itself, only leads one to dread the possibility of there being some ultimate, if not immediate, danger resulting from its administration. Chemical combinations

which could produce such changes in the circulating medium, even temporarily, are not be disregarded.

With this case yet fresh in my mind, I sought some explanation for this somewhat anomalous state of apparently threatened death and yet assured safety. In the course of my inquiries I found some observations by Ulbrich referred to. This observer, I found, had used the spectroscope for the purpose of determining the relation which nitrous oxide bore to the blood during its administration. As a result of his researches, Ulbrich declared that there was a chemical union between nitrous oxide and the hæmoglobin. These observations, unless it could be shown that this union was not of a character to destroy or even abrogate temporarily the function of the hæmoglobin, would still leave the question an unsettled one, provided they were confirmed.

Spectroscopic analyses of the blood were not new, for in 1871, Preyer, of Jena, made similar researches. Buxton directed his spectroscopic researches particularly toward the physiological effects of nitrous oxide. Later, MacMunn made spectroscopic experiments. upon the blood. But the most carefully conducted experiments upon the relation which nitrous oxide bore to the blood seem to have been those of Rothmann," and these may be looked upon as being the most reliable studies upon the subject up to the present time."

In the first place Rothmann, with true German instinct, set out to criticize the methods of the only one of these observers who drew any definite conclusions from his studies, namely, Ulbrich. He declares the experiments of the latter to be utterly unreliable, for the reason that he made use of concentrated solutions of the blood elements. In following Ulbrich's methods, it was found that as a result of this concentration the spectroscopic absorption bands are shown broader, darker, or quite unrecognizable. Rothmann's first step was to estab

3 Korresponder zblatt f. Zahnärzte, Berlin, 1887.

4 Internat. klin. Rundschau, Vienna, 1884, No. 4. › Vierteljahrschrift f. Zahnheilkunde, 1888, Hft. 3. 6 August, 1889.

He

lish beyond a doubt the exact spectrum of the hæmoglobin when in the full performance of its function, i. e., combined with oxygen. then established the fact that the spectrum of blood, loaded or saturated with nitrous oxide, possessed precisely the same spectrum as oxyhemoglobinic blood. This is a point of incalculable importance, for inasmuch as the hæmoglobin is enabled to continue its function, in spite of the presence of the gas in the circulating medium, no harm. can come from the continued administration of the latter during long operations. Upon suspending the inhalation of the gas, the processes of oxydation are at once resumed as the atmospheric air is breathed.

The favorable experiences of the dental branch of the profession, extending over many years, in the administration of nitrous oxide for the performance of short operations, will always warrant its use for such purposes. The results of Rothmann's operations, which, if they do not explain the condition of apparent cyanosis, at least demonstrate that the essential blood elements, far from being in the condition which characterizes a suspension of their function (carbo-hæmoglobinic blood), are in precisely the opposite state (oxy-hæmoglobinic blood), and that, hence, the administration of the gas may be kept up for a length of time sufficient for almost any operation with perfect safety.

I should not fail, in this connection, to call attention to what may be a source of inconvenience in the use of this agent in general surgical operations. I refer to the altered color of the blood as it flows from the cut vessels, and the difficulty in some localities of distinguishing by its color arterial flow from simple venous or capillary oozing. An arterial twig may, for several reasons, not always give off a per saltum stream, and yet furnish sufficient blood to embarrass the operation and require the clamp, and perhaps a ligature as well. While slight pressure will suffice for simple capillary oozing, it is a waste of time to resort to this in the case of a flow from an arterial branch. If these two are combined (arterial flow and capillary oozing) and the location of the artery is not marked by its usual interrupted stream, one can readily see how the operation may be delayed pending an effort to identify the latter.

Another point occurs to me. In the cases in which the gas was administered for me, not all gave me such a favorable experience as the one above related. In at least one, a case in which I designed to remove a portion of the lower jaw for necrosis, it was found impossible to bring the patient under its influence. Ether was then used, but, whether from the previous efforts with the nitrous oxide or from some peculiar idiosyncrasy on the part of the patient, it was found impossible to control her powerful efforts at resistance without exerting undue force. I was finally compelled to order the substitution of chloroform.

Under this agent the operation was brought to a satisfactory conclusion. This inability to anesthetize the patient is a rare one, according to dental operators.

Finally, a peculiar condition of muscular rigidity, which is not abolished by pushing the anaesthetic, as in the case of other agents, but which rather increases as the narcosis deepens until it finally extends to the muscles of respiration, is sometimes noticed. When this latter circumstance is observed, it is an imperative demand for a suspension of the anaesthetic. This very seldom troubles our dental friends, for it is just at this stage that, by a dexterous twist, they accomplish the purpose for which the anaesthetic was administered. But in an operation which is to be a prolonged one, even if the rigidity does not extend to the respiratory muscles, it may become a source of serious embarrassment to the operator, particularly under circumstances where a relaxed condition is absolutely necessary, such as operations about the anus, rectum, perinæum, etc. This complication has likewise occurred to me.

Neither clinical experience nor experimental observation has yet demonstrated to the entire satisfaction of surgeons the exact conditions under which each of these anæsthetics may be most advantageously employed. My advice is to attempt no operation requiring anæsthesia with but one of these agents only at hand; and if it be decided beforehand to use nitrous oxide, it would be but a wise precaution to have both of the others within reach.

FATTY HEART, WITH DILATATION; PULMONARY CONGESTION, PERICARDITIS, PERITONITIS.

BY W. H THAYER, M. D.

Read before the Brooklyn Pathological Society. November 14, 1889.

The subject of this paper was a man in his sixty-fourth year, a widower three years, with three children between twenty and thirty years of age. For thirty years he had been a shipping merchant in New York, residing in Brooklyn. Before that time he was a seaman and captain of an East India clipper ship. He was compactly built, of good figure, medium height, of regular habits, easy life, and apparently good health. He was taken ill on the 24th of June, and died July 4th, ten days later. The next day Dr. G. R. Westbrook made an autopsy for me, at which Dr. Mosher and I were present, which is

here reported before giving the record of the illness, because some of the lesions were not accounted for by any symptoms.

Autopsy. At 11 A. M., July 5th, twenty-two hours after death: Rigor mortis well marked. Two inches of fat in abdominal wall. The peritoneal cavity contains many ounces of serum, slightly turbid, and with some flocculi of lymph floating in it. The peritoneum of the left side of the abdomen covering the ileum, and in the pelvis covering the bladder, has a slight exudate of recent lymph upon its surface, and in the pelvis there are recent adhesions between the bladder and the opposite peritoneum. The remainder of the peritoneal cavity is normal. The ileum is considerably contracted, owing to old thickening of its peritoneum, looking like cicatrices. But internally it is normal, there being no ulcers nor other changes of the mucous membrane. The stomach contains some thick stringy mucus. Its mucous membrane is normal; strips more than an inch long can be raised.

The peritoneal surface of the liver is rough like a file, but has no recent exudation. Its substance is somewhat soft, but otherwise normal. The gall bladder contains about two ounces of bile.

The kidneys are of normal size and consistency, and give no evidence of disease. The bladder is normal, and contains about six ounces of clear urine.

The right lung is almost universally and closely adherent by old adhesions. Its substance is full of serumn; crepitates everywhere; no hepatization. The pleural space, not adherent, contains several ounces. of serum. The left lung is normal, without adhesions, and its pleural cavity has several ounces of clear serum. There is no lymph in either cavity, nor any evidence of pleuritis.

The heart is large, nearly empty and very soft, tearing with the slightest effort. The pericardium is rough with a reddish exudate, especially on the posterior surface of the heart. There is no serum in the pericardium, and there are no adhesions. The heart is not hypertrophied; the endocardium and all the valves are normal, and the ascending aorta has no atheroma or other abnormity. The blood is everywhere remarkably dark.

Dr. Shaw, who was unable to attend the autopsy, examined microscopically a portion of the wall of the left ventricle, and found much. interstitial fat, but no degeneration of the muscular fibres, nor any other morbid condition.

I learn from the son of my patient that the father has had no serious illness within the recollection of the son, except a violent diarrhoea lasting a day or two about three years ago. He is not known to have had any fainting fits. A slight catarrh with occasional hoarseness is

all the trouble that he reported himself liable to when I was summoned to him. He had never previously been under my care, but I have seen him familiarly as a neighbor for ten years, and always had the impression that he was a vigorous, healthy man.

On the night of June 24th, 1889, between 12 and 1 o'clock, I was called to him, and found him complaining of pain under the upper part of the sternum. There was no fever nor dyspnoea. He had been at his business as usual the day before, and apparently well when he went to bed. Suspecting indigestion, a mustard emetic was administered, which made him vomit a quantity of partly digested food-eight hours after his latest meal. When his stomach had been evidently emptied, the pain continuing, I gave him ether by inhalation, with temporary relief. But the pain returning, I made a hypodermic injection of Magendie's solution of morphia, in viij, with sulphate of atropia, gr. ; after which the pain was removed and he slept till morning.

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At 9 A. M, June 25th, his temperature was 98%; he had no appetite; he was ordered a seidlitz powder at noon. Got ten grains of of sulphonal in the afternoon and again in the evening.

June 26th. The pain has left its original seat, and appears in the region below left nipple over a surface covered by the hand; is not acute, nor is there any tenderness. Pulse 120, very feeble. Tongue covered with moist, whitish coat. No dejection yet. Got seidlitz powder again this morning.

R Pil. Rhei, No. ij, now.

7 P. M.-Is very weak, with thready pulse. No dejection. Has had no desire for food, and taken none; but occasionally two teaspoonfuls of whiskey.

Gave gr. 1/2 of sulphate of strychnia, and directed milk punch at 9 P. M.

Was called to him at midnight. Find he has had repeated convulsions for the last hour. Wakes from sleep suddenly with blowing respiration, cheeks puffed out, eyes turning upward, then pupils dilating, flexors of legs and arms beginning to contract and go into tonic spasm. Then suddenly sits up, as by a spasm of the pelvic and abdominal muscles, and immediately comes into full consciousness and intelligence, the entire paroxysm not occupying more than one minute. These paroxysms are repeated every five or ten minutes the intervals he is quiet, makes no complaint, and does not know that anything has occurred. Once I had my fingers on his radial artery, and found the pulsation ceased entirely for several seconds, just as the paroxysm began.

In