continued malarial fever, the debility from the former hemorrhage of course complicating matters. From beginning to end there were no uterine symptoms of any kind. During the last week there was profuse sweating at times, and in the morning complete defervescence, but with recurrence of high temperature in the evening. Delirium appeared and was nearly constant for the last two or three days. Died from asthenia on the twelfth day.

Treatment seemed to have very little effect in controlling fever. Quinine was given in full antipyretic doses. Nourishment and stimulants exhibited carefully and pushed as required. Heart failure was apprehended and cardiac tonics and stimulants given in anticipation. This case is regarded as malarial from the absence of all inflammatory symptoms, and the periodicity in the febrile phenomena, noticed both before and after the confinement. The only symptom that looked towards sepsis was the profuse sweating present during the last days of the disease. This, however, is often seen in malarial continued fevers of adynamic type.

Case 9.-Mrs. M. S., æt. 38. III-para. Youngest child ten years old. Of melancholy temperament; general health fair. During pregnancy had been very sedentary, taking little out-door exercise. Was often morbidly depressed; declared she could not live through her confinement. Surroundings very pleasant, and the coming of a baby very welcome.

Labor normal, very rapid, placenta speedily followed child without assistance. Uterus did not contract very promptly, but there was no serious hemorrhage, and the after-contraction was satisfactory. There was considerable tenderness over the uterus for a few days, but less than there had been for weeks before, and it steadily declined until it disappeared. Lochia normal and not offensive at any time. Milk appeared on the third day in fair quantity and continued through the second week.

Chill followed by high fever on the third day. Lochia rather abundant than scanty; on the fourth day two clots were passed, afterwards lochia normal to the end.

The fever was markedly periodical during the three weeks of the case, and the diurnal variations in temperature were very considerable. One day the morning temperature might be 102° and the afternoon 103°, the next day the morning temperature 100° and the afternoon 105°. The type of fever was obscurely tertian. At the close of the second week nearly complete defervescence was established, the morning temperature being normal and the evening below 100°, and the symptoms were all favorable.

On the beginning of the third week there was a return of fever, and the temperature again ran high, 105° at night, though in the morning there was a very considerable fall. Towards the close of the third week the febrile symptoms again yielded and convalescence seemed at hand, when signs of heart failure became manifest,

and the patient died suddenly on the 23d day, the symptoms pointing unmistakably to heart clot.

General nutrition was well kept up, milk and cocoa were freely taken and the stomach and bowels were not irritated. Careful watch of the circulation was maintained, and quinine in full doses kept the temperature well in hand. The case ordinarily would not have been regarded as alarming up to the 20th day, and I regard it as an almost typical one of continued malarial fever in a puerperal woman. If any septic poisoning existed, the signs were so masked as to be unrecognized.

The late Prof. Armor saw the case in consultation with me on the evening of death, and coincided in the diagnosis.

Case 10.-Mrs. M. Primipara, æt. 29, of nervous temperament, general health fair. Had been treated for some unknown uterine disease before marriage. Married. less than two years.

Pregnancy was not marked by any peculiarity, except that during the last few weeks there were symptoms of malarial poisoning; periodical fever, coated tongue, Saw her first about one week before confinement, and during that week the temperature was frequently above normal, but there were no special symptoms referable to the uterus.

etc.

Labor was not difficult nor prolonged, for a primipara. Presentation, breech; feet brought down and head delivered as rapidly as possible. A little delay in bringing head through the outlet of pelvis caused use of the left blade of forceps as a vectis. No laceration of perineum; cervix not noted, as it was before the days when the cervix began to be so closely watched. Patient was left very comfortable and in a very satisfactory condition. The second night, about twelve o'clock, I was called to relieve a very intense pain, felt in the left iliac region. Digital examination revealed the uterus tilted to that side in a curious position. The organ was not unnaturally large or sensitive except in the region of the broad ligament. The organ was easily placed in normal. position, when the pain was relieved, though an opiate. was administered.

The second day there was slight fever, with tenderness in hypogastrium and some pain. Third day temperature 104°, local symptoms the same; slight tympanites, lochia scanty and not offensive. Milk appeared moderately on fourth day, pain and tenderness severe for many days. At the close of first week tympanites extreme. Condition remained critical until about the fourteenth day, temperature ranging from 103° to 105°, after which the local symptoms began to be mitigated and an extensive exudation could be made out in the left iliac fossa and which also fixed the uterus. After the fourth day a distinct tertian movement to the fever was noticeable and unless antiperiodic doses were kept up in full doses, the febrile symptoms were much aggravated. More or less elevation of temperature continued for two

months, and the exudation did not wholly disappear for at least five months.

Local

The treatment was chiefly by quinine or cinchonidine in doses of from 25 to 38 grains daily, and any reduction in the quantity was followed by rise in temperature. This course was continued for four or six weeks. symptoms were met by hot fomentations, counter irritation, and opiates as required. The result was good and five years later the patient went through a second labor, but with an unfavorable puerperium; but the history of it I do not know.

Case 11.-Mrs B. H., æt. 38, IV-para; youngest child eight years old. General health good, except a tendency to insomnia, and occasional violent attacks of sick headache lasting for one or two days occurring two or three times a year, but always following some unusual strain, physical or mental. Insomnia had been very distressing for several months before the termination of pregnancy; often the patient sat up unable to sleep until four o'clock in the morning and then slept for two or three hours. She was also morbidly sensitive with regard to her appearance and size. The birth of the child was looked forward to with happy anticipation. Labor, occurring in the forenoon, was easy and brief, not more than two hours from beginning of pains. Membranes ruptured while she was undressing for bed, into which she was lifted, barely in time for me to receive the child in my hands. No laceration of any kind discovered; afterpains not severe; condition excellent that day and up to noon the next, when headache was complained of, followed by a chill, and fever in the afternoon. In the evening temperature was 103°, with intense frontal headache and photophobia. Full doses of quinine with sedatives relieved symptoms, though headache in less degree persisted. The morning temperature of the third day was 100°, afternoon, 101°. Fourth day, 992°, in the afternoon, 102°; no chill. Fifth day, pretty well in the morning, but a chill occurred late in the afternoon and all the symptoms were aggravated; evening temperature, 104°. Sixth day, better again, but headache rather severe. Seventh day, Monday, headache very severe; slight chill at noon; temperature 104°; photophobia, pupils somewhat contracted, hebetude. Complained for the first time of pain in left iliac region, lochia normal, bowels somewhat tympanitic, but relieved by catharsis. Eighth day, cerebral symptoms more grave, fever less, headache intense; stupid, with difficulty aroused to answer; not comatose, but dull. During second week local symptoms moderated; milk in small quantity, but soon disappeared with the progress of the local inflammatory symptoms. The fever range averaged higher with less fluctuation, and the tertian movement was less distinct.

By the close of the second week the local symptoms had all disappeared, there was no induration or thickening of tissues about the uterus, and from that

time on, the course of the case was that of a continued malarial fever. Final defervescence was established during the fourth week.

In this instance the cerebral symptoms were very striking after the eighth day, and were a source of the greatest anxiety. Unconsciousness supervened upon that date, and for three weeks only very slight signs of even the lowest grade of intelligence were manifested. Only liquid food could be administered, and a portion of the time rectal alimentation was necessary. The rectum and bladder were emptied involuntarily, and while the patient was restless and tossing about, the motions seemed purposeless. When the stupor began to pass away the condition was one of dementia, with ever varying delusions, and it was two months later before the mind regained its balance.

The only disturbing element shown in this case was a mental one. A communication was made on the morning before the first chill, which irritated the patient exceedingly, and seemed to produce a profound effect upon her. The slight headache was quickly aggravated,. and in a few hours the chill occurred. This, at least, was

This case showed a distinct malarial character throughout the pyrexial period, but upon the eighth day there was developed a mild local inflammation, which ran its course and disappeared during the second week, while the pre-existing disease pursued its way for two weeks longer.

Case 11. Mrs. S., æt. 25, blonde, primipara, nervous temperament, previous health good; during pregnancy had suffered very little from any disturbance of any function. Labor every way normal, except that pains were lacking in force, and the head resting for some time within the lower outlet of pelvis, without making advances, I applied forceps, but delivery through the external orifice was unaided. Laceration of fourchette very slight if any. Labor, after waters were discharged, about one hour. Condition after labor, excellent in every way. Patient peculiarly happy and sanguine. Labor completed about 9:30 p. m.

The next morning everything normal; also the morning of the second day. About 4:00 p. m. had chill. Saw her shortly after. Saw her shortly after. Temperature 101°, skin moist, pulse 115, slight headache, lochia normal, no odor, not the slightest tenderness over abdomen, mammæ beginning to enlarge. Ten p. m., temperature 104,°, perspiring freely.

Third day, morning temperature 100°, relieved in every way; signs of milk; pulse 100. No tenderness of abdomen, no tympanites. In fact, from beginning to

end there were absolutely no abnormal symptoms connected with the uterus or its appendages. Afternoon of third day: chill and headache, about as on the first day of fever, continued more or less through night. Temperature on morning of fourth day, 102°. This afternoon passed without chill, but fever rose in the evening. Some headache, nervous and excitable.

Every morning would show marked diminution in all the bad symptoms. The fifth and sixth days were similar, fever less marked. Temperature in the afternoon and evening 102° or 103°. During height of fever some delirium, but when spoken to would talk rationally. The seventh day all the symptoms were better, mind clear, temperature in forenoon 99°, took food-I saw her at 4:00 o'clock p. m.-and she was still very well. Temperature, I think, 991⁄2°. An hour later a severe chill. and when I saw her, about 5:30 p. m., temperature 103°; at 10:00 p. m., 1051⁄2°, at 1:00 a. m. 102°, at 9:00 a. m. below 100°, and continued down until the usual time, when it began to ascend, so that by 10:00 o'clock p. m. it was 106°, at 1:00 o'clock 105°, at 4:00 o'clock 1081⁄2°, and she died about 5:00 o'clock a. m., on the eighth day. Half an hour after death the temperature in the axilla was 108°.

With fever the cerebral distress became very intense and the mind wandered continually. From 9:00 o'clock she became somnolent and this deepened into coma for the last three hours. At no time during her illness was the tongue or skin dry or parched.

During most of the time there was free, but not excessive perspiration, and the tongue was fairly clean. Nourishment was taken very well most of the time, and the seventh and eighth days in the forenoon she partook of light food with relish.

Treatment. I began quinine on the second day as a prophylactic. After the first chill it was pushed in full antipyretic doses until cinchonism was marked, when it was substituted by salicin. Other antipyretics were not well borne. The vaginal douche, carbolized, was used daily as a detergent, but not for any appearance of an abnormal character.

The pulse, when necessary, was controlled by digitalis or aconite. Sedatives were necessary during the last four days. Bromide of sodium and codeine proved the most satisfactory, and were relied upon.

Drs. McGraw and McLean were in consultation, and approved entirely of the treatment. Indeed, the indications to be fulfilled were very plain, and the final fatal result seemed to depend upon the morbid influence expending its force upon the cerebral centres evidently involving the heat as well as the cardiac and respiratory centres. The respiration during the last six hours was jerky and rather slow-12 per minute. Pupils were contracted during fore part of the night, but for an hour or two before death, widely dilated. There was undoubtedly serous effusion within the cranium, and from this death resulted.

83 Lafayette Ave.

IT

ANESTHETICS.*

BY R. HARVEY REED, M. D.

T MAY be considered as taking up an old “thread bare" subject to present to this association a paper on a topic that has almost become a household word throughout the entire civilized world.

Yet this very fact is sufficient guarantee to warrant a few words on a class of drugs whose mission is the relieving of pain, and suppressing sensibility; yet in doing so they carry the patient within sight of eternity, and then allow him to return from the very verge of a gulf, the slightest mistake, or one step too far, would plunge him into forever beyond recovery in its unfathonable depths.

Among the thousands of great discoveries made during the last half century, I feel certain I am safe in asserting there is not a single one the world would part with more reluctantly than with anæsthetics.

Yet, when so potent a therapeutic agent becomes so familiar to the laity that school-children scarcely out of their A B C's will fearlessly beg for it in the most trivial operations, and when men skilled and unskilled, professional and non-professional, literate or illiterate, will presume to give it indiscriminately to all classes and under all circumstances, with or without a knowledge of its physiological action, or the pathological condition of their subject at the time of their administering the anaesthetic, saying nothing of the drug used, much less the particular drug given, we feel that we are justifiable in reviewing an old subject, and, from the past and present experience of ourselves and others, try to crystallize a few practical facts, and at the same time throw out a word of warning against the careless use of these potent therapeutic agents.

Besides the more common anæsthetics (ether and chloroform) that are in daily use by surgeons, we have bromide of ethyl, nitrous oxide, bichloride of methylene, ethidene, cocaine, and the various mixtures of some of these, the most common of which is ether, chloroform and alcohol; ether, bromide of ethyl and alcohol; ether and nitrous oxide, and chloroform and nitrous oxide (the last mixture is popularly known as "vitalized air"); and a host of less valuable anæsthetics that are as but little more than scientific relics or chemical curiosities.

To the busy practical surgeon, the most important question is, which one of all this array of drugs is the safest, and which one is the best, under all circumstances everything considered? Heretofore among all the anaesthetics ether and chloroform have taken the lead, notwithstanding the demands made upon them for a share of their honor, especially by the bromide of ethyl; but more recently ether has been pitted against all other drugs of its class and from present appearances seems to

*A paper read before the Association of the Surgeons to the Pennsylvania Co., held at Fort Wayne, Ind., Oct. 20, 1885.

A marked difference in the temperature was observed in these experiments, especially between those in which chloroform had been used and those in which ether had been inhaled.

In the former it required two or three days for the animal to regain its normal temperature, while in those where we had used ether it only required as many hours.

The series of experiments conducted by Prof. Wood, shows that chloroform and bromide of ethyl are both powerful depressants of the heart, while ether was found to be a cardiac stimulant, the former reducing the blood pressure to an alarming extent, while in the same subjects the use of ether would not only restore the blood-pressure to the normal, but even increases it.

The simple experiment of cutting out a frog's heart, and suspending it in the vapor, or making a direct application to the exposed heart of the living frog, of bromide of ethyl or chloroform, will immediately arrest the heart's action, while ether does not, which shows that the former have direct action on the heart while the latter has not.

[After the reading of the paper, vivisection of three frogs was made, so as to completely expose the heart of each, and ether dropped on the one, bromide of ethyl on

the other, and chloroform on the third, resulting in death in 14 minutes from the chloroform, and in 27 minutes from the bromide of ethyl, and not at all from the effects of the ether, although used longer and in much greater quantities than either of the others.

Although I have repeatedly performed these experiments, and frequently tried to resuscitate the heart's action by the use of the battery from the effects of the chloroform and ethyl, yet I have failed to do so in every instance.]

When death is induced by ether, it is caused by asphyxia, and the heart is found to beat after the respiration has ceased, but when death is induced by either chloroform or the bromide of ethyl, the heart ceases first, while feeble respirations are continued for a short time after the heart ceases to beat.

The comparative influence of these drugs on the heart is readily observed by the use of the sphygmograph, which shows a marked decrease of the arterial tension from the normal, by the use of ether.

In addition to these, a comparison of the mortality statistics will leave scarcely a doubt as to the relative safety of these anæsthetics.

Prof. Agnew states in his surgery that up to 1869 there has been reported 210 deaths from chloroform, and from 1860 to 1872, 195 deaths from chloroform, while during the same period there were not more than 6 deaths from ether, and in three of these there was a mixture of chloroform and ether, leaving really but three traceable to ether direct, against 405 from chloroform. Notwithstanding, each of these drugs have their advocates, and have proved a success in the hands of those using them, and each one has some peculiar advantage over the other, yet, when a preponderance of testimony is poured in upon us from all directions in favor of ether, and against chloroform, we are in duty bound to respect it.*

For my part, I have used them all, more or less, especially chloroform, ether, and the various mixtures of these with alcohol, and even the bromide of ethyl, and must say that they have all acted satisfactorily in my hands so far, and I am free to confess that I suspended the use of chloroform with a great deal of reluctancy, for (excepting the danger) there is no anæsthetic familiar to me to-day that acts more promptly, and acts more satisfactorily than pure chloroform; yet, notwithstanding all this, I feel that every time that I use chloroform as an anæsthetic, I am trifling with a dangerous element, and that it will only require time and perseverance in its use until I will share the fate of many others, whose misfor

* Since preparing this paper Dr. Laurence Turnbull, in an article on Hydrobromic Ether or Bromide of Ethyl as an Anæsthetic," reports that "chloroform kills in round numbers about one in every 3,000," and in referring to ether he says: "Only 17 cases of death, and many of these doubtful,”—Journal of the American Medical Association, Vol. 1, Nov. 21, 1885.

tune ought to be a timely warning to us against its dangerous effects; and, if not heeded, an accident will be all the more inexcusable.

Although one of the oldest of anesthetics, and much used in dentistry, we cannot recommend nitrous oxide for surgical purposes for various reasons.

I. It is too transient in its effects for anything excepting short operations.

2. It is bulky and unmanageable, not readily portable, and hence, is only fit for office practice; and even there it is an unwieldly quantity, and hard to manage, except it is used with a gasometer and a lot of paraphernalia of a stationary character for inhaling it.

All these different arrangements for the inhaling of this gas are very objectionable as every person who uses it is compelled to use the same inhaler, and thus is obliged to run the gauntlet, and take his chances of contracting some disease from his predecessor, which is not limited to skin diseases alone, but syphilis and phthisis pulmonalis, besides any of the more contagious diseases.

The very idea of having a rubber funnel placed over your face that has served for a cover for all classes and conditions of individuals for years, or even months, who may have preceded you, or taking into your mouth at tube that has been in the mouths of every Tom, Dick and Harry, is alone too disgusting to need further comment, saying nothing of the dangers of contagion.

The so-called "vitalized air," which is a mixture of nitrous oxide and chloroform, which the former is made to take up as it passes from the gas-generator or cylinder into the gasometer, has only been vaunted by dentists, who either do not know of its. dangers, or care less if they do, only so that they can hood-wink their unsuspecting victims, and thus secure the remuneration it may aid them for a time to procure.

Although pure nitrous oxide is perhaps the safest of all anesthetics when properly used, yet it is not entirely free from danger, but when mixed with chloroform or bromide of ethyl, it becomes a dangerous and unreliable compound.

Dr. Clark, assistant surgeon of the Middlesex Hospital, reports a death from the use of nitrous oxide, in the British Journal of Dental Surgery for October, 1883, the patient being a robust sailor, who was given the pure gas for the extraction of some teeth, and died suddenly, while in the act of taking the gas, from syncope.

Any person who is acquainted with the nitro-oxygen compounds, and their unstable character, of which nitrous oxide is the most stable, and perhaps the most harmless, while its twin sister is a deadly poison, would certainly hesitate in giving a mixture of this gas with anything else that might, under favorable circumstances, in any way change its chemical relations, and thus

render its influence on the economy, toxic, instead of mild and harmless.

This is undoubtedly the principal reason the socalled "vitalized air" is so uncertain in its effects. A dozen patients may take it, and with the most pleasant results, while the very next patient will not get over its effects for weeks, or even months.

Within the last four or five years I have had at least a score of patients who have consulted me in regard to nervous prostration and heart trouble, directly traceable to the use of "vitalized air."

Other physicians have made the same observations, and have frequently spoken to me of its deleterious effects, and this reason alone, saying nothing of the objections raised against the uses of pure nitrous oxide, should be reason enough to deter any conscientious physician from using it, or even recommending it.

There are a number of etherial compounds that have anæsthetic properties of more or less virtue and stability; yet, excepting bichloride of methylene and ethidene, there are none of those known at present that have any virtues even approximating ether. The former of these compounds has been used considerable in England, in hospital practice, and for a time was highly recommended by such authorities as Drs. Richardson and Wells, who used it mostly in ophthalmic practice, but was soon found to be treacherous and unreliable, and after the occurrence of several deaths from its use from syncope, it was almost entirely suspended, excepting for experimentation.

The compound introduced by Dr. Snow, made from aldehyde, known as ethidene, has thus far proved to be

safe and efficient.

Should subsequent experience of investigators substantiate the claims made for ethidene, now advocated for it by its friends, the day is not far distant when it will be in general use. The most objectionable points we find against ether seem to be covered by this compound, in giving us a more pleasant preparation than ether, with a more rapid action, from which there is more speedy recovery.

Among all the discoveries of local anesthetics yet presented to the public, the hydrochlorate of cocaine is certainly the only one deserving of general recognition.

Notwithstanding erythroxylon coca and some of its compounds were known to the profession for years, its alkaloids and salts having been isolated as early as 1855, when it was known as erythroxylin, under which name it was known until 1860, when Dr. Neumann, of Germany, made some investigations of the leaves and gave the alkaloid found the name of cocaine, yet its most valuable property which caused its fame to spread like wild fire all over the civilized world was not discovered until September, 1884, when Dr. D. C. Koller, of the Vienna Hospital, applied some of the hydrochlorate of cocaine to his own eye, and found to his surprise, as well as that of the world, that it produced complete local anesthesia.