heavy breakfast of solid food. There was no nausea in either of those cases.

In a recent case of cataract extraction, the patient went beautifully under the influence of the anesthetic, extraction was accomplished, and the patient recovered so as to be able to count fingers; but, owing to some strong coffee which she drank, from dyspeptic symptoms, or the swallowing of water soon after the operation, she became very sick at her stomach, and vomited for nearly twenty-four hours, and yet the case did well. In a case of operation for torticollis in a woman, she swallowed so much air with the ether that, as a consequence, she complained of pain, of a hysterical character, in lower part of the abdomen-the same which is often the result of nitrous oxide gas inhaled, and too much air admitted.

A few days ago we received a letter from Dr. J. Patterson Cassels, of Glasgow, a distinguished aurist, and a surgeon to the celebrated Glasgow Infirmary; he writes that he has used a specimen of the hydrobromic ether, which I gave him at Cork, as vapour, in diseases of the middle ear, and has also employed it as an anæsthetic with success.

THE ADMINISTRATION OF ANESTHETICS.

By ROBERT SAUNDBY, M.D. Edin., M.R.C.P.,

Assistant Physician, late Pathologist and Chloroformist, to the General Hospital, Birmingham.

Ir may be assumed that the anesthetic agents usually employed in practice are ether and chloroform. Moreover, it may be affirmed that they are so safe and satisfactory that, while we all shall welcome any better, it is not wise to abandon these well-tried means for every new compound. possessing anæsthetic properties, with nothing else to recommend it but its novelty.

But these agents are neither satisfactory nor safe unless properly administered with due discrimination of the cases suitable to each. The reports of deaths from both chloroform and ether which appear nearly every week point to the urgent need for those who have larger practical experience than ordinary to formulate their opinions. Even at the risk of being considered dogmatic I shall try to state accurately what are the methods I use, the precautions I have found necessary, and the errors I have learnt to avoid in the

administration of anaesthetics; and I hope by clearly enunciating my own views to raise certain questions in a definite manner, which shall be capable of being affirmed or denied, but at any rate must be answered.

The agent to be preferred.-As a general rule I prefer ether, because I believe it to be safer and the public believes it to be safer; it is a perfectly satisfactory anæsthetic, and its after-effects are less depressing than those of chloroform. The kind of ether I use is Macfarlane's methylated ether, as made for Dr. Keith, because it is cheaper, and in every way as good as the more expensive kinds. The apparatus I employ is a towel folded lengthwise, with three or four thicknesses of paper between the folds, made into a cone by twisting it on one hand, and fixing it with a few safety pins.

Preliminary arrangements.-No solid food should have been taken for at least three hours before the time fixed for the administration. I can recommend the plan proposed and practised by my friend Mr. Priestley Smith of administering a dose of chloral hydrate an hour before. Do not give brandy or any other stimulant just before administering ether; it is unnecessary, will probably be vomited, and introduces another factor into the conditions which we should try to keep as simple as possible. Examine the chest, and make inquiries as to cough in all cases. Inflammation of the lungs or air-passages forbids the use of ether. The vapour of ether irritates healthy lungs, often to an excessive degree, and sometimes causes a slight bronchitis for a day or two, while occasionally it gives rise to fatal oedema of the lungs, even where no previous disease existed in these organs. It is therefore plain that all inflammatory conditions of the lungs are likely to be made worse by ether, Chloroform is to be preferred in all such cases. Cardiac disease per se does not contra-indicate ether, as the drug aids a weak heart. In aortic incompetence with badly filled arteries the circulation becomes better during the administration of ether. In mitral disease the case is somewhat different. It must be remembered that ether frequently causes spasmodic dyspnoea, which ordinarily need cause no alarm, and calls for nothing but temporary suspension of the administration, but during which there is great venous turgescence, and the right side of the heart is necessarily overloaded with blood. So that wherever I have reason to believe that the right side of the heart is weak and dilated I should prefer chloroform to ether. The same would hold good of dilatation of the right ventricle apart from mitral disease.

Fractures, herniæ, and other conditions in which complete

muscular relaxation is required are cases in which, cæteris paribus, I should use chloroform.

Operations about the face can sometimes be performed only with difficulty, or not at all, while ether is being administered; in these chloroform must be employed.

Young children take chloroform with such ease and safety that it is to be preferred for them.

Method of administration.—The orifice of the cone should be large enough to cover the lower two thirds of the patient's face, and take in the chin and lower jaw. It is always preferable to have the patient lying down with his shoulders a little raised, and his head not much higher than his shoulders; the pillow should be firm and flat; unfasten anything that is round the patient's neck; ask him to turn his head with the right cheek on the pillow, to shut his eyes and mouth, to breathe through his nose; tell him to try to go to sleep, and assure him that the ether will be given him cautiously. Pour about an ounce of ether into the cone, and approach it slowly towards the patient's face; with a little encouragement he will soon submit to having it brought quite close, for partial anaesthesia is rapidly induced. When once it is close to his face it should not be removed for some minutes, in spite of any struggles or protests. Fortunately, patients rarely recollect what occurs at that time if the cone has been approached gradually. The ether should be given liberally, as atmospheric air is being excluded, and the patient is respiring nothing but ether vapour. Stertorous breathing is a sign that the patient is "over," and that the operation may begin. If there is much lividity stop giving ether for a short time, and the natural colour will soon return. The ether must be given almost continuously throughout the operation. Stertorous breathing is not a warning of danger. On the contrary, I like to hear this noisy breathing, as I feel sure my patient is going on all right.

Cautions. It is absolutely necessary that one person should do nothing else but administer the anæsthetic. He should never leave his post to assist or perform other duties. His business is to give the anaesthetic and to watch the breathing. He should let his own breath, as it were, hang on the breathing of his patient, so that he cannot breathe himself till his patient breathes. In this way he will be able to detect the slightest irregularity. With ether there is often some spasm, and respiration stops for a time, but a tap on the chest or rotating the head starts it again, as a rule. If inspiration seems difficult, remove any mucus from the fauces with the finger, draw out the tongue with a pair of

artery forceps, and pull it well forward, so as to open the glottis. If this does not succeed artificial respiration must be resorted to while the tongue is still drawn forward, but it is satisfactory to say that I have never yet needed to have recourse to it.

The colour of the skin of the ears is a good index to the state of the circulation. If these are livid the administration should be stopped temporarily.

After the operation. It is prudent not to leave the patient,. or at least except in the care of a properly qualified medical attendant, until he has shown signs of returning consciousness. This may be hastened by sponging his face with cold water, or slapping it gently with a wet towel, not so roughly as to cause marks. Sometimes holding the nose provokes a long inspiration through the mouth, followed by the sudden return of consciousness. This manoeuvre is of no use when ruder measures fail, but it may precede them, and is often successful.

Where chloroform, for any of the reasons given above, is to be preferred, I administer it on a towel folded square.. The preliminary arrangements and precautions are much the same as in the case of ether; but the patient requires, if possible, more careful watchihg. The reflex sensibility of the eye must be tested frequently; when it is abolished the operation may commence, and the chloroform should be administered with caution. Stertorous breathing is a warning to suspend the administration. Should respiration stop the tongue must be drawn out, and artificial respiration commenced at once. The respiration must be watched continuously. The pulse may be disregarded, as it gives no timely warning of approaching danger. Although chloroform does not require to be administered continuously, it is not less necessary to continue to watch the respiration, even though no chloroform is being given. Accidents often happen from disregard of this precaution. The chloroform may be safely poured freely on the towel, but this should be cautiously approached to the face, until finally the fingers of both hands press its lower edge against the margin of the jaw, while the surface of the towel forms an angle of fortyfive degrees with the face. The experience of the Edinburgh school affords the widest basis for affirming the practical value and safety of this method of administering chloroform.

I have had two deaths from anæsthetics - one from chloroform and one from ether. The former was a case of gummatous disease of the larynx, for which tracheotomy was performed when the patient was nearly moribund from asphyxia. It was in my early days, and at the present

time I should decline to administer any anæsthetic in such a case. The other was from acute oedema of the lungs supervening some hours after the administration of the ether, and which I fully reported at the time. Both were hospital cases. In the numerous administrations I have had in private I have never met with a case which has given me any cause for alarm, though many have given me much anxiety. Indeed, I may say that I never administer anæsthetics without anxiety; for it appears to me no slight thing to hold a fellow-creature suspended between life and death for an hour or more, during which each respiration is watched for anxiously, and all our attention is strained to notice the first indication of impending danger.

In conclusion, I will recapitulate the points which I desire especially to insist upon :-1. Ether is to be generally preferred as an anæsthetic. 2. Inflammatory affections of the lungs and air-passages absolutely contra-indicate its employment. 3. It should be the sole business of one person to administer the anaesthetic during an operation. 4. The breathing must be watched so long as the patient is under the influence of the anesthetic, whether it is still being administered or not.-Lancet.

THE ACTION OF ANÆSTHETICS.

THE Report of the Committee appointed to investigate the action of anæsthetics is to-day laid before our readers. The results of this inquiry are so important and so far-reaching as to demand the most serious consideration from every one whose lot it is to administer anæsthetics. The Committee, which included Professor McKendrick, Dr. Coats, Dr. Ramsay, and Mr. Newman, has already submitted three preliminary reports, which have appeared in former numbers of this journal. In conducting these investigations, two lines were followed: first, to discover wherein the special dangers of chloroform consist; and second, to attempt to find some safer anæsthetic. Observations made on rabbits showed that chloroform had a most disastrous action on the heart, as well as upon the respiratory centre; that, while ether might be administered for an indefinite period without affecting the heart, no sooner was the inhalation of chloroform commenced, than the right ventricle began to distend, and, in course of time, the cardiac contractions ceased. In every respect but one ether was superior to chloroform. It had, however,