bronchial tubes. While she was in this unconscious státe she was quickly transferred to the operating table and with very little preliminary preparation, an incision was made directly in the pleural cavity. A stream of pus was quickly ejected a distance of at least six or eight feet. Further use of ether was quickly attended by cyanosis in varying degree.

Without taking too much time, another instance might be cited quite in contrast where as the result of observations and with the permission of the surgeon in charge, chloroform was administered to a similar case, an adult who had previously suffered from a rupture of the lung tissue in an attack of empyema to such an extent that the purulent fluid worked into the bronchi on that side and also the bronchi of the other lung, and where at one time life was thought to be extinct, since she was practically drowning in her own purulent fluid. Persistent efforts led to her gradual rallying and in two or three days chloroform was administered with the maximum allowance of air. The anesthesia and operation were conducted without the slightest trace of cyanosis or respiratory embarrassment or any other complication, and in due time she returned to her home a happy, grateful patient.

Another instance was where a metacarpal bone was undergoing tubercular ostitis and needed to be exposed and curetted. The patient had a bad family history and at the age of eighteen was not only showing these osseous tubercular manifestations but had occasional attacks of so-called bronchitis. Ether was administered,

as was customary, and the writer well recalls the copious outpouring of mucous from the entire respiratory tract early in the anesthesia and this persisted throughout with a variable degree or cyanosis, despite all measures. The entire duration of the anesthesia and operation was about twenty minutes, but it required twice as many days to get the young lady over the after effects of the anesthesia, since she had a very persistent subsequent bronchitis. Some weeks later, owing to her poor reparative powers, it seemed necessary to again expose and curette the diseased bone. This time chloroform and not ether was administered allowing the maximum of air. Anesthesia and operation were conducted without special incident. and the after effects were trifling compared with those in the first incident.

As illustrating a still different phase of this subject, an experience on Dec. 16 may serve a good purpose. The patient, a woman of mature years, had suffered a fall with fracture of some of the bones of the leg about the ankle. Anesthesia was invoked for the purpose of a thorough examination preparatory to adjusting suitable splints. The one who gave the anesthetic commenced with nitrous oxide and ether, as is frequently done in this clinic. After some minutes, when the writer entered the room, the patient was still in a semi-anesthetized condition and further efforts resulted in but little progress. I removed the inhaler for a full glance at the patient's face. It became apparent that she was very likely somewhat accustomed to the influence of alcoholic stimulants and hence the ether vapor operated in a familiar way. Immediate change to chloroform, which drug, by the way, you will recall, resembles opium and not alcohol in its effects upon the system, was followed within two minutes by complete muscular relaxation, and examination was quickly completed.

It may be put down as a good general rule that in persons accustomed even to the moderate use ol alcoholic stimulants success

ful anesthesia with the minimum of after effects can best be accomplished with chloroform.

I might recite many and various experiences along these and other lines, but these must suffice. How then must one decide as to the best anesthetic in a given case? The first point in evidence must be our knowledge of the usual effect of these and other anesthetics upon the various organs and tissues of the body. To this must be added our knowledge of the patient's present condition based on a careful physical examination, including preferably analysis of the twenty-four hours urine. The third point to assist us in reaching our conclusion must, of course, be the existing pathological condition which necessitates the operation.

In several of the special text-books devoted to anesthesia, you will find numerous and reliable statements along these very lines. Perhaps it may be sufficient therefore to make the following brief statements:

In any existing pulmonary, renal or cerebral condition where the administration of ether must of necessity be attended by increased bronchial irritation, by vaso motor and other changes in the kidney or by an increased cerebral arterial pressure, then of necessity some other anesthetic must be used, notably, chloroform, as this meets these various needs or conditions satisfactorily.

Again, in any existing chronic endocarditis with poor or imperfect compensation of the cardiac muscle, it would certainly seem unwise to subject the patient to any operation other than of real necessity, and in such a case provided no other contraindication exist, ether is much to be preferred to chloroform, especially if supplemented by the coexisting administration of oxygen. By this is meant the administration of oxygen through a separate wash bottle into the inhaler and not through the column of ether, since oftentimes a patient needs a great deal of oxygen and very little anesthetic, and obviously if oxygen be sent through the anesthesia liquid much more anesthetic will be carried over than is needed. This argument will hold good with both ether and chloroform.

Lest there might be misunderstanding on the part of some it may be well to state that chloroform is not necessarily contraindicated. in organic heart disease where there exists perfect muscular compensation, though ether is preferable. Twice, at least, the writer has administered chloroform in a case of angina pectoris for relief of intense and excruciating pain which would not yield to any of the usual narcotics. In fact, in an intense protracted paroxysm, chloroform was administered to the patient sitting erect, and complete anesthesia was finally obtained and had to be continued for nearly ninety minutes before the evidence of pain subsided and the cardiac and vaso motor conditions resumed their proper state.

Second. The best possible administration of the anesthetic. It is not within the scope of this paper to treat the minutia of the administration of the several anesthetics, but the extended observation of many men in America and Europe compels one to conclude that in justice to the patient and to the anesthetist the anesthetic must be administered in the best possible way in order to

Some years

escape the larger part of the unfavorable after effects. since, while assisting in conducting surgical anesthesia with the etherated air inhaler devised by Dr. Packard, at the Massachusetts Homœopathic Hospital, one of the assisting nurses remarked, "Do you know how many of the patients are suffering intensely from after effects, that is, 'after headaches,' nausea, and vomiting?" The amount of anesthesia administered in the various cases was found to run very closely to 3 or 4 ounces of ether per hour of anesthesia. Careful observations of subsequent cases anesthetized, taken indiscriminately, showed conclusively that they were not having more trouble from after headache, nausea and vomiting, but on the contrary showed a much smaller percent of these discomforts than where ether was administered with the ordinary cone inhaler.

Those nurses who have been trained in hospitals where no other method of etherizing than the ordinary cone or cup sponge is employed, deem it almost incredible when they see patients undergoing an hour's anesthesia from ether by any one of the latest improved methods whereby the minimum of ether and the maximum of air is employed and the customary after effects are practically all absent or greatly decreased.

During the past year, by special request, in one of the private hospitals in Boston, anesthesia was conducted by the writer in the case of a young man suffering from recurrent appendicitis where ether only was used with the consumption of hardly 34 fluid ounces. The patient quickly recovered without headache, nausea, or vomiting. Nearly two months later I was asked to conduct similar anesthesia in the case of the young man's mother, where a somewhat extensive operation was necessary. A limited amount of ether was required, and the patient made an equally rapid recovery with no after effects from the anesthetic.

These I mention, not as rare cases, but as instances showing what is really of somewhat frequent occurrence. We have always to reckon with an unknown element in our patients. Some are much more susceptible to the profound effects of any drug or an anesthetic than are others, and surely in those who give a history of gastric disturbances or sick headache, nausea and vomiting, from any cause, one must expect more or less nausea and vomiting following anesthesia. Again in conditions of fulminating appendicitis with probable peritonitis where the patient had been vomiting for one or two days, or an intestinal obstruction or any pathological condition where there has been extensive nausea, vomiting, etc., subsequent trouble will be more or less continued after anesthesia despite our care. We may occasionally meet people who are as prone to exhibit nausea, vomiting, and headache after ether, chloroform, or other agents, as cases prone to show hemorrhage following operation

(hæmophilia).

A few recent experiences in nitrous oxide anesthesia show conclusively that it not only is possible but judicious to perform severe or even capital operations under it successfully and without the use of other anesthetics. In a few cases where suprapubic prostatectomy was about to be undertaken by my honored superior, Prof. Horace

Packard of Boston University, the final preparation of the patient and irrigation of the bladder having been done without anesthesia, nitrous oxide anesthesia was induced in perhaps sixty to ninety seconds. The various steps of the operation, including the removal of the prostate, were speedily and successfully carried out and the anesthesia maintained by the judicious admixture by a variable amount of air so that the patients remained relaxed and unconscious until the close of the operation, when, on stopping the anesthesia, they quickly awakened and were practically free from all of the after effects attributed to ether and chloroform, the total time for anesthesia being from ten to twenty minutes according to the special case in hand.

We have in nitrous oxide an anesthetic whose effects are more rapidly produced than are those of ether, and also more rapidly pass away. The very fact of the short time duration favors better and quicker recovery. In selected cases the supplementary use of oxygen during the greater part of the anesthesia will do much toward obviating some of the immediate and remote after effects from both ether and chloroform. During the administration of the oxygen the improved appearance of the patient, the greater warmth of the forehead and extremities, the easier respiration and more favorable cystole of the heart, do much to mimimize the amount of anesthetic required and will accelerate the recovery therefrom. While of the opinion that where one employs in any case either ether or chloroform giving the minimum amount of anesthetic, and the maximum of air, and the patient be fully anesthetized, then necessity for the use of oxygen will be greatly diminished.

The use of oxygen, therefore, in the majority of cases will be a matter of choice, but in that smaller group where the pathological process present necessitates severe and extensive operative interference, the anesthetist will find oxygen one of the strongest allies in maintaining a good condition of the patient during and after operation, and often to an astounding degree obviating all necessity for the hypodermic administration of any drug or stimulant. In such menacing conditions as, for example, intra-abdominal hemorrhage from a ruptured tubal pregnancy, the employment of oxygen as just mentioned on the one hand and the intra-abdominal or intra-venous administration of the normal saline solution will far outweigh in their benefits the effects of drugs.

For many years readers of medical books and literature have from time to time seen mention of various measures adopted either before or after the administration of anesthetics toward obviating the common after effects. What has already been mentioned in this paper would seem to bear out the truth of the old proverb, "An ounce of prevention is better than a pound of cure," and so the question comes, What are the merits of supplementary procedures which we can adopt to forestall some of these discomforts? The hypodermic administration of one or other drugs has been attempted with varying degrees of success. Apomorphia has been given per mouth one or more days before the administration of the ether, or hypodermically during the same with variable or indifferent success. Again, some

have advised drinking very freely of water before the anesthesia, with the hope that this would so wash out the stomach that it would obviate after effects. Others have suggested absolute abstinence, and in some instances this and other methods have given good results and in other cases have failed. Again the inhalation of non-anesthetic vapors has been taken up, this latter with more success than some of the previous ones. In some instances the immediate and continued inhalation of either vinegar or acetic acid vapor has wholly obviated the effects under consideration. A method totally different from these was first undertaken in the writer's observation upon a patient who had previously suffered torture for thirty-six or more hours after anesthesia from nausea, vomiting, fainting, etc. remark that she was advised by an expert chemist and pharmacologist to drink freely of water just before taking the anesthetic started a train of thought which led to the modification of that procedure, namely, the use of water by means of a stomach tube after the anesthesia was ended. Normal saline is preferable to ordinary water, and in this instance washing out the stomach wholly obviated the retching, nausea, collapse, etc., which she had invariably suffered before.

Her

Just a word of caution: It is a simple matter to carry the end of the tube down the aesophagus into the stomach so that a definite portion of the tube is in the stomach cavity, but it is not always quite so easy to determine the degree of distention of the stomach by the fluid poured in; for in one instance the distention of the stomach was attended by slightly blood-tinged appearance of the returning fluid.

We have previously noticed under choosing the proper anesthetic that much depends upon our knowledge of these upon the various body tissues and organs. It may not be amiss at this time to mention the fact that in the administration of a full dose of ether by inhalation, for example, there will be as definite symptoms or effects produced, both primary and secondary as when, for example, we are in a modified way undertaking a study of the effect of belladonna upon the human body. We are well aware that the effects of many drugs are largely governed by the size and repetition of the dose and the same general principle must of necessity hold good here. Those whose experiences are confined almost wholly to surgical anesthesia do not of necessity have the opportunity of studying the effects of the smaller doses of the anesthetic as do those who from time to time administer ether at a dentists, while he performs extraction of teeth and roots, or where one resorts to brief temporary anesthesia for the reduction of dislocations, or in obstetrical cases where the administration of ether or chlorform is resorted to at the latter part of the stage of labor for its brief but beneficial effects.

As an illustration of this a case from a dentist of my acquaintance in our city may be of interest. Apparently by mere accident he became acquainted with a method of ether administration other than the use of the pouring bottle and cone. One of my patients employed him as a dentist and wished to have some teeth extracted. By appointment I met her at his office. Complete anesthesia was quicklv