and asphyxia.

In order that the anesthetist may successfully meet and combat these conditions when they arise he must be able, first, to recognize the condition and the cause producing same, and by a thorough knowledge of the proper treatment in each case be able to successfully cope with these emergencies or accidents as they arise.

For the purpose of rendering certain parts of the body insensible to pain for the performance of certain minor surgical operations, various agents have been suggested and used with different degrees of success. These are known as local anesthetics, and are used by either applying directly to the skin or mucous membrane of the part to be rendered insensible to pain, as in the use of the refrigerant agents, or by the injection method into the skin, cellular tissue or deeper structues of the body. Among the agents in general use at the present time may be mentioned, Hydrochlorate of Cocaine, Eucain B., Rhigolene, Ethyl Chloride, Ice, Ice and Salt Mixture, Sulphuric Ether, Infiltration Method, and the injection of Schleich's Solution, consisting of Mur. Cocain Gr. 12; Mur. Morphia Gr. 13; Sod. Chloride Gr. 3; aq. Dest. 31⁄2 oz. Rapidly repeated deep inspirations kept up for a few minutes will also produce insensibility to pain, but sensibility to contact is not obliterated. Many of these local anæsthetic agents are of little value to the sugeon except in the performance of very minor operations. Cocaine standing perhaps at the head of the list as a local anæsthetic agent, although Eucain has many admirers, especially among the dental branch of medicine, and is said to be entirely devoid of dangerous properties. Cocaine on the contrary, is said to have produced fatal results and is generally used with some degree of caution. However, I have never witnessed any bad results from the use of this drug as a local anesthetic, and I do not believe if it is used with judgment and skill in solutions of proper strength that any such results will follow its use.

To Dr. J. Leonard Corning, of New York, the medical profession is indebted for the discovery of the intraspinal method of inducing anæsthesia. This method has since.

the first discovery and successful use by Dr. Corning in 1885, been practiced very extensively by other able men, to whom due credit should be given for improvements made in methods of applications, technique, etc. This method of producing anæsthesia which consists in the injection of various local anesthetic agents not into the spinal cord, but into the canal around the cord, has been a much discussed one during the past year, and while the various writers all aim at the same object, yet, we find that the subject has been written of at various times under such high sounding headings as, Medullary Narcosis, Subdural anesthesia, Subarachnoid anæsthesia, Rachidian anesthesia, Intra-spinal Cocainization, Lumbar puncture and Lumbar anæsthesia; but to my mind the term Spinal Anæsthesia is the most appropriate, covering as it does the use of any local anesthetic agent at any point along the spinal canal, having for its object the production of a sufficient anæsthetic effect for the painless performance of surgical operations below a given point; that point generally speaking the diaphragm, although anæsthesia has often been produced as high as the axillary region, yet we have no record of operations done above the abdomen. The agents used in this method prior to the present time with more or less success are Cocaine Mur., Eucain B., Antipyrin, Ergot and Quinine. The general concensus of opinion, however, is, that of this entire list only two will stand the test-Cocaine and Eucain. The majority of operators using cocaine, while some prefer eucain on account of the ease with which a perfectly sterile solution may be made, it also being less toxic than cocaine, while it is practically impossible to sterilize cocaine without the process having some destructive effects upon the drug.

The technic of lumbar puncture is a very simple one. The point of election being usually just below the fourth lumbar vertebra, although it may be made at any point below the termination of the cord. The injection should be made with a long slender and somewhat flexible needle, with a sufficiently large opening to permit the escape of the cerebro spinal fluid which serves as a guide

for the successful performance of the operation. The needle having a very short bevel at the point. About 15 to 20 M. of a 2% solution of cocaine or eucain properly injected into the subarachnoid space will usually produce an anæsthetic effect lasting from one to five hours, and admit of the painless performance of all operations below the costal margin, with perhaps the exception of intraabdominal lesions of an inflammatory character. At the present stage of spinal anesthesia it is impossible to predict a future for it. That it has come to stay there seems to be no doubt, and yet we do not believe that it will ever take the place of Ether or Chloroform as a routine anæsthetic. It is not without its dangers, having already been productive of fatal results, and we find that its use is almost invariably followed by a train of very distressing symptoms, which sometimes become alarming to the operator, such as acceleration of pulse rate, increased respiration, elevation of temperature, severe headache, involuntary action of the bladder and bowels, and nausea and vomiting. Some of these distressing symptoms lasting as long as twenty-four to forty-eight hours after operation. The chief danger in this method of anææsthesia, however, is the danger of an imperfect asepsis; hence, it is a method not to be used by everybody, but only by careful, competent and skilled surgeons.

All experienced surgeons recognize the great importance of a careful administration of anæsthetics, and all physicians at some time during their professional career are liable to be called upon to administer them. Notwithstanding this fact, very little attention is paid to the teaching of anæsthesia in any of our medical colleges at the present. Even in England, the home of professional anææsthetists too little attention is paid to the teaching of anæsthesia at present, although they are far in advance of their brethren this side of the waters. Students should be taught the subject of anæsthesia by being required to examine their patients before, during, and after anæsthesia, studying any noteworthy difference from the normal; and also be taught to make the choice of an anæsthetic. I trust the time is not far distant, when medical facul

ties will recognize the tremendous responsibility of the anæsthetist, and that all graduates may be called upon to administer them. The facilities for teaching this important subject should be increased and made compulsory. In this way the students of the future will graduate and go out in the vast field of practice, much better equipped in a very important requisite than their predecessors have been.

Assistant to Chair of Medicine, Medical Department University of Tennessee; late Interne Nashville City Hospital.

Mutilating surgery should only be invoked for irreparable injuries, hopeless pathological sequences, or in the exchange of limb for life. While the exact study of morbid conditions is of chief scientific interest, yet it is dispiriting unless potential remedies are at hand.

The war with tubercular processes is simplified only when the area of infection can be radically removed, but it has not been possible to accomplish this end with comparative safety, where the entire lower extremity was involved, until the last few decades of the century just closed. The technique of complete hematosis, allowing rapid and safe operating, has been achieved by the method of Dr. John A. Wyeth, of New York. The following report illustrates its very satisfactory application:

"D. M., col., age 34, coal miner, was seen by me at Pineville, Ky., May 1, 1900, when the following history was obtained:

"Family history negative; 15 years ago he was kicked on the knee by a horse. It did not give him much trouble

until 5 or six months later, when he noticed a gradual enlargement and stiffness of knee; two or three months later the knee was greatly enlarged and painful. A physycian was consulted, who made a diagnosis of Rheumatism, and treated him for same.

"After 2 or 3 weeks treatment, with no results, the knee was punctured with a trocar and canula, and about 8 ounces of fluid evacuated. Following this there was a violent inflammatory action of knee, terminating in suppuration, pointing and rupturing at the original point of entrance of trocar and canula. After that the acute symptoms subsided, leaving fistula that continued to discharge pus.

"About a year later the ankle became involved, which resulted in fistulous openings, and was followed by suppuration of articulations of foot. Since that time numerous fistulæ have developed over tibia and lower third of femur.

666

Upon examination I found the patient fairly well nourished; entire limb greatly enlarged; complete ankylosis of knee and ankle joints. The great and two adjoining toes had sloughed off and the metatarsal bones were exposed. Foot, leg and lower third of thigh were pepperboxed with fistulæ, discharging pus. The entire limb was indurated, but did not pit on pressure. There was slight motion in hip-joint which produced a sound not unlike that produced by new leather. He was able to go about on crutches by supporting leg from the shoulders by leather straps.

"Diagnosis: Tubercular Osteo-Myelitis.""

Hip-joint amputation was advised. He was given a week's preparatory treatment, which consisted of tonics, purgatives, baths and nutritious diet. May 8 he was prepared for operation. The buttock, pubis and thigh were shaved and scrubbed with soap and water, followed by ether, alcohol and bi-chloride. A green soap poultice was applied and left on until patient was brought to the table for operation.

May 9, under chloroform anesthesia, the soap poultice