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six months, that other attempts to administer ether by this method have been made, but have failed; and it has been stated by an eminent surgeon connected with one of the large hospitals of Boston that the method is impracticable, his experiments convincing him that intoxication without anæsthesia results.

In the simplest terms, the method consists in forcing air through a volume of ether, and then conducting it to the patient's respiratory tract. It has always been accepted that the anæsthetic mixture resulting from the less potent ether, in this way must be totally inadequate to produce surgical anesthesia.

My first experiments in this direction impressed me with the falsity of this theory, for I found that the vapor which reached my nostrils was of such strength that my respiratory tract could not at once tolerate it without still further dilution. My first practical attempts to etherize patients by this method were with the crudest possible apparatus. The final development of the apparatus in its present simple and efficient form I attribute solely to the good fortune that the first two cases were very susceptible to ether anæsthesia, for my later experience showed me that, in very many cases, it was impossible with the same apparatus to carry patients beyond a state of intoxication.

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In brief, the results of this method with the apparatus now used are:

First. The induction of surgical anesthesia with from two to six drams of ether.

Second. The minimum of discomfort to the patient while taking it.

Third. The consumption of about three ounces of ether per hour.

Fourth. The very rare occurrence of cyanosis.

Fifth. Recovery with frequently no vomiting, and, when it does occur, but very little.

It will at once be seen that, by this method, there is an enor mous economy in the use of ether, and that a great many of the unpleasant features of ether anæsthesia are obviated. I cannot better illustrate the importance of this last-mentioned desirable feature than by relating an experience with a boy of six years, upon whom I wired a compound fracture of the lower jaw. He objected strenuously to taking the ether, but after a few mo ments conversation he decided to take it voluntarily. When he found there was nothing unpleasant about it, he took it without the slightest resistance, and in a few moments was completely etherized, with the consumption of two drams. On making examination I found it desirable to defer the operation until the following morning, and the ether was at once removed. In a few moments he awakened and began to talk, and the following conversation ensued between the patient and his aunt, who was close at hand:

Auntie "Nice boy, good boy, took it well."
Georgie-"'Twasn't wet,

'twasn't hot,

Auntie-"How was it, dear?"

Georgie-"Just middlin'."

'twas kind of dusty, 'twasn't cold."

The next morning, at the hour appointed for operation, on entering the room I said: "Well, Georgie, will you take ether for me this morning?" He answered without the slightest hesitancy: "Yes, sir"; and allowed himself to be placed upon the operating-table and etherized, without the slightest resistance. Two or three days later, on proceeding to make some change in the dressings, he asked me if I would please give him some ether.

Such an experience as this, with a child, was all so new to me that I thought it worthy of record, as being the best possible testimony of the desirable qualities of this method of anesthesia.

I herewith append a table showing the exact amount of ether used and time consumed in all the cases so anesthetized, with the apparatus in its present perfected state:

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amount of ether required for same, 5 drams.
total duration of anesthesia, 48 minutes.

"amount of ether consumed, 2 ounces.

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The 26 patients have been etherized on a total of about 3 lbs. of ether. In only 7 of the 26 cases has there been vomiting which would at all compare with that usually experienced.

The apparatus consists of an ether reservoir of a capacity of four ounces, a hand bulb, and face piece, with the necessary rubber tubing for connections. The face piece is so constructed that it fits, air tight, over the mouth and nose, and is provided with an air valve and a vapor reservoir.

One of the greatest conveniences accruing from this method. of using ether is the facility with which patients can be kept anææsthetized while operations are in progress about the face, nasal and oral cavities. E. g. In operations about the lower part of the face or within the mouth, a bifurcated curved tube, terminating in bulbs which just fit the anterior nares, through which the etherized air is forced, enables the anesthetizer to continue the anesthesia without interruption. During operations involving the nasal cavities or upper part of the face, the same result is attained with the aid of a tube, curved not unlike a male catheter, held in the angle of the mouth, and reaching to the pharynx. One who is familiar with the interruptions incident to cleft-palate operations, resection of the jaw, removal

of post-nasal adenoid vegetations, or in fact any prolonged opertion about the face, will be more than delighted with this method of anesthesia.

It has been my experience that the most satisfactory way of employing ether by this method is to purchase the four-ounce cans of Squibb's preparation. This always insures perfectly fresh ether for every case, and I have never yet had an operation so prolonged that this quantity proved insufficient. A recent operation which occupied an hour and forty minutes required a total of three and one-third ounces of ether. The quarter-pound cans prepared by Squibb actually contain 100 grams.

DIRECTIONS FOR INDUCING ANESTHESIA WITH ETHERATED AIR

Before beginning the administration of the anesthetic, it is well to address the following reassuring words to the patient: "Do not fear; you will have plenty of fresh air; you will feel no sense of suffocation."

Having placed the face piece in position, with the air valve wide open, command the patient to "breathe rapidly." (Let the breathing go on in this way a few seconds before introducducing any ethor vapor to the reservoir.)

Begin very gentle compression of the hand bulb. (This last direction is extremely important, for the strength of the vapor is such that, if in the beginning it is carried to the patient's face to the full capacity of the inhaler, it will overwhelm and frighten him.)

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After the lapse of a very few seconds, 15 or 20 - half-close the air valve. (Continue all the while the very gentle compression of the bulb.)

After the lapse of 15 or 20 seconds more, close the valve to three-quarters. (Continue the same gentle pressure of the bulb.)

At the end of one minute, completely close the air valve. (Slightly increase the pressure of the bulb. The patient is now breathing in and out of the bag, the contents of which is replenished with the etherated air oxygen and ether vapor- to the exact amount of each bulb pressure. The respirations of the patient are readily followed by observing the expansion and collapse of the bag.)

From this point on one forcible half compression of the hand bulb at every other expiration will result in complete surgical anesthesia in from six to eight minutes. (Repeated full compressions of the bulb during this stage of anesthesia usually result disastrously, in overwhelming the patient and interrupting the progress of the anesthesia.)

As soon as the patient fails to respond to questions, three or

four short, rapid compressions of the bulb during each expiration will hasten the anesthesia.

In a few moments the conjunctival reflex is lost, and entire muscular relaxation ensues, with full and deeper respiration.

The air valve should now be half opened; very gentle compression of the bulb at every third or fourth expiration is quite sufficient.

. Coughing during anæsthesia, or labored respirations tending to stertor, indicate that more air is required, and the valve should be opened wider.

Throughout the whole course of anesthesia, careful watch should be kept for any indication of cyanosis.

Some cases, when once in a state of surgical anesthesia, require but an extremely small amount of etherized air to keep them anesthetized; not infrequently the air valve can be kept wide open during the whole period.

In brief, keep the patient just within the bounds of surgical anæsthesia, and no farther.

It quite suffices for all surgical purposes to have the patient so superficially narcotized that at all times there is slight reflex on touching the conjunctiva.

I.

Summary.

Compress bulb very gently at first.

2. Close air valve by the end of the first minute.

3.

4.

Watch carefully for signs of cyanosis.

At first indication of stertor open the air valve wide. 5. At the end of six to eight minutes the patient should be in a state of surgical anesthesia, with the consumption of two to six drams of ether.

6.

Two and one-half ounces of ether should suffice for each hour of anesthesia.

FURTHER OBSERVATIONS OF TUBERCLE BACILLI.— THE LESSON OF ONE HUNDRED CASES.

BY J. P. RAND, M. D., WORCESTER, MASS.

[Read before the Worcester County Homœopathic Medical Society, August 10, 1892.] Gentlemen: A year and one-half ago, as some of you will remember, I read a paper before this society, giving my personal observations of Koch's Bacilli and results as taught by a summary of fifty cases. My object to-day is to supplement the lessons of that paper by the subsequent history of cases then. reported, and to substantiate or weaken the evidence it contained by additional facts.

I make no claim for the results of these examinations. They

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