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place where strain is greatest, more decidedly in tortuosities, at the bifurcation of vessels, at the sphincter-like entrance to vessels, offering here a nidus for the formation of thrombi, or becoming detached as emboli.

I beg to exhibit specimens from autopsies on persons who suffered from nervous and mental disorders; while illustrating extreme degrees of atheroma and contributing largely to cause

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death in the subjects from which taken, they are suggestive of the grave injuries to organs which must have been going on for years before death. It is impossible to say whether this state was initiated by an acute arteritis not recognized or lost sight of as time went on, or whether it was a subchronic and slowly progressing state; certainly it was the leading pathological state and explained the nervous and mental phenomena present, as well as the cause of death in these cases.

It is a long time and a long way from the alteration of the lumen of a vessel which disorders the more sensitive and vulnerable cerebrospinal centers to the obstruction which causes. gangrene, and for years before altered elasticity or slightly altered lumen may have seriously affected those numerous subtle osmotic processes which we call collectively metabolism.

I am convinced from the findings of many autopsies that chronic Bright's disease, melancholy, hypochondria, premature physical and psychical decay, are most frequently the direct result of changes in the nephritic and cerebral nutrition caused by this degeneration, even in its early stages of impaired elasticity. The condition when established is likely to cause such nervous symptoms as vertigo, insomnia, neurasthenia, irritability, some degree of amnesia or dementia, sudden, short, partial or complete losses of consciousness, slight aphasia, arrhythmia and dyslexia or hemianopsia, and intermittence of the pulse, pseudo or true apoplexy, angina pectoris, and sudden death from plugging of a coronary or bursting of a cerebral artery. In the presenile, in melancholia with hypochondria after thirty-five, it is rare to do an autopsy and not find atheromatous change in some degree, particularly at the base of the brain. Many of the nervous disorders we have called functional, trophic, and vasomotor may come in time to be regarded as due to this condition and reverse our views as to cause and effect, stamping the disease as organic. It is to be borne in mind that central atheroma of the larger vessels may be the cause of vasomotor spasms of smaller peripheral

ones.

Opinion is shifting from the view that sclerosed kidneys cause atheroma, to the view that the fibrosed artery oftener causes the sclerosed kidney. The effect on the brain of renal inadequacy is attracting just attention as a cause of hysterical attacks, mania and melancholia. Arterial degeneration, renal cirrhosis, mental failure, and the post-mortem findings of opaque or adherent dura are frequent associations, and more and more. is it noted how often bulbar and other basal cerebral troubles depend on atheroma.

There is a recognizable symptom-complex, indicative of atheroma of the basilar and other cerebral vessels, and prodromal of apoplexy; cerebral shocks from change in the lumen of a vessel, the formation of a chalky nodule or a minute dilatation at a weak spot, slight hemiplegic attacks with short or no loss of consciousness, a unilateral numbness or weakness, vertigo, etc. To cite an illustrative case: The middle of April last Mrs. F. W. B- presented herself at the clinic for nervous diseases,

University of Denver, and gave the following history: "I am fifty-five, widow, retired nurse; passed change of life six years ago; my father and mother lived to good age. The only disease. I have suffered from was rheumatism. For the last two years I seem to have failed in strength; two months ago I had numbness in my left thumb and first finger; a few days later I awoke one morning weak; felt like falling to the left; there was a tingling in my tongue and face on the left. For three days I could not talk well; for a while my son had to assist me at things. I had a little swelling of my feet; the left worse, and it felt pricky and cold to touch. I am nervous; any little thing will make me cry. I have a weak feeling about the heart, and dizziness when I stoop. My sleep and appetite are rather poor; when alone I feel uneasy and depressed." Examinations of the urine were negative; some accentuation of the aortic second sound, no edema, no arcus senilis, but radials and temporals a trifle hard; her symptoms were attributed to atheroma of cerebral vessels, with liability to a cerebral hemorrhage; she attends the clinic occasionally, and is on diet of milk, cereals, and vegetables; she has taken. small doses of iodide of sodium and nitroglycerin.

How often are we told after a fatal or disabling cerebral hemorrhage that there had been for long dizziness when stooping, slight amnesia, flushing of face, etc., which failed to impress patient or family.

The

Many cases of dementia and of epilepsy in persons in advanced life depend on circumscribed softenings or cicatrices after thrombic or embolic injuries, slight enough to escape notice, or long enough ago to have been lost sight of as a possible cause. condition described by Erb and Charcot and called intermittent claudication or angina cruris, consisting of cramps, rheumatoid pains, tingling and weakness of the leg, and limping following slight exertion, and relieved by rest, elevation, and gentle friction, is now admitted to be not spinal, but failure of adequate blood-supply from atheroma of the abdominal aorta or the iliacs. In the latter case the symptoms may be unilateral.

The related conditions of Mitchell's red-neuralgia, erythromelalgia, Raynaud's superficial gangrene, and the attacks of sudden failure of the muscles of the legs and back called astasiaabasia, are often dependent upon similar causes. The early diagnosis of atheroma is important; not only does it make clear obscure nervous symptoms, but anticipates by prognosis or delays by management and treatment the disabling or fatal hemorrhage. Important medicolegal questions may arise as to the responsibility for moral and intellectual lapses, testamentary capacity,

etc., of persons in whom this condition of the cerebral vessels existed.

Apart from the nervous and mental symptoms enumerated, high tension, which can be felt by the finger or shown by the sphygmograph, and a lowering of the point of the greatest intensity of the aortic second sound posteriorly, from the curve of the spine of the scapula to a line from the lower angle of the scapula to the second dorsal vertebra, are the admitted points in diagnosis.

CHLOROFORM ANESTHESIA.*

BY E. T. DUKE, M.D., CUMBERLAND, MD.,

At the risk of repeating an old story I have selected for my subject chloroform anesthesia, with the hope of provoking a full and free discussion of anesthetics. Since beginning the study of medicine I have spent much of my time administering anesthetics, and am convinced chloroform has been made to suffer unjustly as an anesthetic for want of care in its administration, and for lack of appreciation of its power for good. If the element of time in operating is not to be considered, and patients are to be kept under the influence of the anesthetic for hours, chloroform is of course inadmissible. But the best surgeons of to-day, with possibly a few exceptions, are operating quickly, hence the question of time will not be as important a factor as formerly. In those cases requiring prolonged anesthesia, ether or a combination of chloroform and ether is to be preferred. In all other cases chloroform is best. As we come to realize that chloroform when it does kill does so rapidly, and endeavor by watchfulness to prevent this result, we have learned the first and most important lesson. Death may occur unexpectedly as a result of the anesthetic. In most instances it may be averted by care in the administration.

The substitution of ether for chloroform has been due in a measure at least to the fact that patients do not die so suddenly under its influence, but after being removed from the operating room; and to the further fact that inexperienced persons can administer it with less danger. Whilst admitting these facts I submit that chloroform when carefully given will not result in any more fatalities than ether. Dr. Chisholm, of Baltimore, had no death in ten thousand, and Dr. Carnochen, of New York, none in twelve thousand cases, showing positively it may be given *Read at a meeting of the Tri-State Medical Association of Western Maryland, Pennsylvania, and West Virginia.

without fatal results when two rules are observed-care in administration, and rapidity in operation.

Chloroform anesthesia should be commenced very slowly, and the patient watched with the greatest care. I have sometimes found it necessary to discontinue in the early stage, and thereby saved the patient by the gradual method. It is the practice of some physicians to give chloroform rapidly and induce anesthesia in a short time. Whilst this method is easier it is certainly attended with greater danger. The amount of chloroform required to induce anesthesia differs greatly with individuals, hence the need of going slowly. A very little of the anesthetic may be necessary to maintain the desired state of anesthesia if the patient be watched carefully. A great surgeon once said: "I don't want the patient to kick, but better kick than die." It is very difficult to determine in every fatal case whether death was due to the anesthetic or some other cause. The innocent vapor may be the scapegoat for carelessness. Shock kills so

often and so quickly that death due to this cause may be credited to chloroform. I have in mind a patient to whom I gave chloroform for the operation of version with satisfactory result and prompt recovery. Two months afterward she died in a dental chair when the same anesthetic was given for the extraction of a tooth, death being due no doubt to shock.

Many considerations enter into the choice of an anesthetic. To give exclusively one or the other is certainly not wise. Because ether has been adopted by some of the largest hospitals and used exclusively does not appeal to the broad-minded physician or surgeon. The same exclusiveness in other departments of medicine would reflect greatly upon the profession. A study of the heart, lungs, and kidneys of the patient should precede a choice of an anesthetic.

One precaution
When respira-

Infants and children take chloroform well. is necessary: see that the air-passages are free. tion is impeded too much of the vapor may be retained in the lungs and serious results follow. One such case has warned me to be more careful in this regard. Valvular murmurs of the heart are no contraindication to the use of chloroform. Weak heart action necessitates a combination of ether.

The force necessary in giving ether with the dread of its choking sensation may be avoided in using chloroform. Especially is this the case in children.

Nausea, vomiting, oversecretion of mucus, so marked in the use of ether, are absent in the vast majority of chloroform administrations. Particularly is this true when morphine hypo

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