only five to ten minutes, over the paralyzed limb, as early as the seventh to tenth day, with very beneficial results. Pfister, in Pfaundler and Schlossmann's "Pediatrics," states that "it is probable improvement in muscles that are completely paralyzed is hastened by electrical treatment."

The object of electrical treatment is to keep up the nutrition of the muscles until the spinal cord has recovered, which it is almost certain to do to a certain degree. But no amount of electrization can preserve muscles whose ganglion-cells have been completely destroyed. Faradism may be used for such muscles as respond to it; otherwise, galvanism should be employed. Where galvanism is used, there should be some device for "making" and "breaking" the circuit, in order to stimulate muscular contraction. In any case, great care must be used not to overdo the good thing by using too strong a current or for too long at one seance. The beneficial results from electricity are to be obtained during the first year after the onset of the acute stage, and chiefly during the first six months.

Strychinne may be given after all symptoms of central irritation have disappeared; but it should be used with great care, and not in the haphazard manner of the lazy doctor who gives this powerful remedial agent whenever he knows of nothing else to do. Certainly it is absolutely contraindicated in the early, irritable stage of the disease.

Friction and massage, over the affected muscles, at least twice daily, over a long period of time, undoubtedly are beneficial. A mechanical vibrator is a useful adjunct in the administration of massage.

In this stage of the disease, the medical attendant must be on the lookout for the development of deformities, and provide and fit suitable appliances for their correction, in order to avert permanent bony deformities.

there no

Treatment of the Third Stage When, at the end of a year, longer is any improvement in response to electricity, massage, warm baths, exercises, strychnine, and so on, then treatment becomes surgical. A great deal is being done, with excellent end-results, in the way of transplantation of the tendons of living muscles into those of paralyzed muscles.

In conclusion, I wish to make the plea that we should ever be on the watch for such diseases as the one I have just discussed, the symptoms of which are often so vague at the onset and the effects of which are so disastrous if strenuous measures are not instituted early, before permanent damage has been done. I believe most thoroughly that much can be done, when these cases are seen and recognized early, by at once instituting a vigorous line of treatment. Do not wait for the complete development of the disease before beginning treatment; treat what you can see, at least, until the picture becomes clear.

Fefore the Missouri Valley Medical

IVE years ago I presented an article

Society on the subject of anesthesia by the combined method of chloroform, and hyoscine and morphine, reporting seventy-five cases wherein this method had been employed. Since that time more than three thousand patients have been anesthetized

in my clinic at the Sisters Hospital, and additional information has accumulated that has a bearing of more or less general benefit.

In the earlier period of the use of hyoscine, morphine and cactin we were admonished concerning its administration, in the very young as well as the very old, that

from five to fifteen minutes was the correct time for its administration prior to operation. We were also cautioned to watch it closely, and told that a large number of patients would be unable to bear this drug combination. Endeavoring to make a thorough investigation concerning these points and to find out who could and who could not safely take it, as well as the reason for this, I exercised every caution and had the anesthetist keep elaborate notes, in the hope of coming to a definite scientific explanation, and to follow this with a safeguard.

Best Time For Giving the Obtundent

The result of this study on our first thousand cases proved that our observation did not show any ill effect except in two patients, and in only one of these was any alarm expressed. The tablet in each instance was given as directed, about fifteen minutes before the operation. Our next patient after that was given the injection one hour before operation, and this period was observed in a goodly number of patients with absolutely good results in every instance. At about this time we allowed fifteen minutes more, making the time of injecting seventy-five minutes prior to having the patient brought to the table. From that time until now, we have followed this period of administration faithfully and have never observed a tendency toward anything bordering on danger.

It seemed that the problem was solved, in view of the fact that about fifteen minutes after giving the injection is generally the time when the danger-point is reached; for, while the patient may be alseep, he is not in the right mental state, and sensation is obtunded; there is at this moment as much danger of stirring up an antagonistic influence when getting him on the table as there is in waking up a drunken man at the wrong time. Added to this period of heightened danger, there are the drugs, themselves, and these two combined influences operating upon a hypersaturated system constitute, to my mind, the dangerous stage.

The first year in which this method was followed we gave chloroform almost exclu

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sively, after that, however, turning to ether, and we have adhered to the latter ever since. The same splendid results followed the hyoscine-morphine-cactin that were obtained with chloroform. Our present method of administering the anesthetic has not changed, and because of the perfect satisfaction experienced both by patients and the surgeon we know of no reason for modifying it.

Another matter which formerly gave us considerable trouble was a certain class of heart lesions, by virtue of which a large proportion of patients with leakage or other defect were unable to undergo an operation requiring the use of a general anesthetic. And it was not so much because the anesthetic in itself was feared, but rather the high nervous tension, the excitation of every sense while taking the ether, and the universal horror of being "put to sleep." Such individuals invariably would have a bounding pulse of such rapidity that a sudden collapse would not be unexpected, and neither surgeon nor patient were inclined to take the risk. This same objection would still hold good if the hyoscine-morphine-cactin were given fifteen or twenty minutes before the operation, but no fear whatever of this nature need be entertained when proceeding as here outlined. We have paid no attention to the condition of the kidneys, except when the phenolsulphonephthalein test contraindicated operation.

10. Very little variation in the pulserate; this not exceeding ten beats in the majority of patients, even in prolonged operations.

11. Great reduction of time spent in the operating room.

12. An anesthetic sleep as near the normal slumber of the child as can be obtained.

13. A method safe, conservative, and eminently satisfactory.

The average patient-especially of the class who know nothing about hospitals, surgeons, and anesthetics-is prone to regard the ether or the chloroform inhaled as the real danger. It used to be hard to gain the confidence of patients under the old system, as the surgeon could not deliberately lie to them, for only too often the whole period of anesthesia was one long-drawn-out struggle.

Now we see the frightened patient become calm, hopeful, trustful, and willing to undergo the operation, because the oldtime horror of the anesthetic is a thing of the past. Patients who have been operated upon under the old system, still in vogue in so many hospitals, have taken the anesthetic under the system here described, and have told me many a time that they would never fear undergoing another anesthesia. Our own patients, when coming again to submit to another operation, never entertain any fear whatever of the second anesthesia.

Our Routine of Preparation and Inducing Anesthesia

Our present complete method of preparation, etc., for operations and anesthesia is as follows:

1. The patient is in the hospital from twelve to twenty-four hours before the

alcohol massage. This is done late in the afternoon, and then the patient is put to bed and kept there. A very light lunch is served at half past five, with no particular attention as to character of the food.

3. Castor oil is given in sufficient dose to move the bowels. We do not insist on the oil, however; a saline laxative or any other non-irritant cathartic will do just as well. All that is needed is one good bowel movement. Whether the bowels have moved or not during the night or early morning, a soap and water enema is administered between 6 and 7 in the morning. The rectal tube is not inserted for more than 4 or 5 inches.

4. A small piece of toast and a cup of hot tea or coffee is now permitted. We do not believe that an empty stomach during an operation, which always is a tax on the system, is desirable, just as we should not refuse a little breakfast for our morning's work.

5. Seventy-five minutes before the hour set for operation, the nurse injects the amount of hyoscine, morphine and cactin specified by the surgeon (this point will be referred to later), the curtains are drawn, and after this no one is allowed to be in the room.

Inducing the Anesthesia

When the time comes for removal to the operating room, the patient usually is asleep, but can easily be awakened, and without any protest or any fear on his part he is brought to the table in an ideal state.

The volatile anesthetic is administered in the form of a very fine spray, without hurry or excitement. The mask is gradually brought closer to the face, without increasing the amount sprayed. The patient soon is fast asleep and the operation may be proceeded

with. We pay no attention to the eyes in inducing anesthesia, but those who do will find that the hyoscine, morphine and cactin compound has limited nothing. This is not true of any morphine combination when given only a few minutes before beginning to operate. Under the method described there is complete relaxation, unless an insufficient amount of the compound was administered.

Upon completion of the skin incision, the anesthetic is withdrawn, and then given again only as needed. The total amount of ether required in conjunction with this hyoscine-morphine-cactin anesthesia is exceedingly small. Instead of ounces, as under the old system, under the new plan it is a matter of a few drams only.

The After-Management

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ten to twenty will be from 1-16 to 3-8 of a grain. From twenty to sixty the dose is from 14 to 3-4 grain. The weight of patients is always considered, and heavy patients receive two doses-usually one full-strength tablet and half of a tablet one-half hour later. The hysterical woman receives the full tablet in two doses, one administered two hours, the second one hour before the volatile anesthetic. The dark-complexioned patients should, as a rule, receive 1-8 grain of morphine more than the blondes.

Almost all rectal, prostate, and bladder operations will be more easily accomplished by a single injection of 3-8 grain. Hernia and other operations made under local anesthesia are preceded by the full tablet one hour before operation and a second in

the subject is brought to the table. In all operations of the nose and throat 1-8 grain generally is administered. In all nerve diseases, such as neuralgia and sciatica, the amount injected is one or two full-strength tablets of hyoscine, morphine and cactin

In all cases of stomach operations, the contents are removed by means of the tube while the patient is on the table. In the event of vomiting setting on after operation-which occurs in about two percent-the stomach-tube is resorted to if the patient vomits oftener than four or five times. That we have used the tube for this purpose in only 26 cases out of a total of more than 3000 operations, is conclusive evidence that severe vomiting seldom occurs. Some patients will feel like wanting to vomit, others will vomit once or twice, but, with the escape of gas, nausea and vomiting disappears.

As to the Dosage of Hyoscine-Morphine-
Cactin

6. The amount of hyoscine-morphinecactin required necessarily will vary with the patient, in very much the same manner as the quantity of ether used differs, which in one patient will be small, in another, large.

As to age, and using morphine as the basis, the dose for the young patient of

Following all operations, the patients are propped up in bed and allowed to recover from the anesthetic in this position, except rarely for particular reasons.

Beginning six hours after being placed in bed, a hypodermic injection of 1-50 of a grain of physostigmine is given every four to six hours for from two to ten times. No cathartics are given if rectal enemas sufficiently move the bowels. The customary cathartics are prescribed when required, but no routine is followed in their choice;

the hypodermic injections of physostigmine and the rectal enemas in the great majority of patients being sufficient.

The Choice of Foods, and Convalescence The urine is examined daily after operation and, if acetone is found, the patient is given baked potatoes, toast, and buttermilk. If acetone is present and the patient is vomiting, a small piece of baked potato will relieve the nausea almost immediately.

Food is administered beginning from twelve to twenty-four hours after the operation, the time of giving, most often, being