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Average time required for anæsthesia, 84 minutes.

amount of ether required for same, 5å dranis.

total duration of anæsthesia, 48 minutes. " " amount of ether consumed, 24 ounces. 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 anæsthetized 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 anæsthetizer to continue the anaesthesia 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 anæsthesia.

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.


Before beginning the administration of the anæsthetic, 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.)

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 anæsthesia in from six to eight minutes. (Repeated full compressions of the bulb during this stage of anæsthesia usually result disastrously, in overwhelming the patient and interrupting the progress of the anæsthesia.)

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 anæsthesia.

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 anæsthesia, careful watch should be kept for any indication of cyanosis.

Some cases, when once in a state of surgical anæsthesia, require but an extremely small amount of etherized air to keep them anæsthetized; 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 anästhesia, 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.

Summary 1. Compress bulb very gently at first. 2. Close air valve by the end of the first minute. 3. Watch carefully for signs of cyanosis. 4. 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 anaesthesia, with the consumption of two to six drams of ether.

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



BY J. P. RAND, M. D., WORCESTER, MASS. [Read before the Worcester County Homeopathic 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

must speak for themselves. If I have failed to find bacilli in a real case of tuberculosis, it proves nothing positively regarding my skill as an observer or the bacilli as an ætiological factor. As Prof. Clapp has very truly pointed out, bacilli may be present in the lungs and not continuously so in the sputa; and as the particle used in a single examination is very small, not a thousandth part of the expectorations of a single day, would it be strange if, in that small part, bacilli in a genuine case were sometimes absent? Then, too, the process of staining and searching for such minute objects is delicate; so that the fault may be in the observer through haste, poor luck, or lack of skill.

However, I am not here as an advocate. The evidence I bring for your consideration comes from the two score of physicians for whom I have done work of this kind. They have no interest in me, or in any theory that is not founded upon facts. Some of them have very kindly expressed their opinions regarding the value of this kind of work. You can have them for what they are worth ; but I call you to witness if the evidence they bring is not entitled to more consideration than the opinions of a like number of physicians who never had a patient's sputa examined, and know nothing about it.

Of the fifty cases reported in my last paper, you may recall that thirty-seven of them contained bacilli, of whom not one had fully recovered; eight had improved, four were then living, and twenty-five had died. Of the other thirteen cases, in which no bacilli had been found, eight had recovered, four improved, and one had died from gangrene of the lungs. Not one, at that time, had developed consumption; which is more than I can boast of to-day. Thus, you see, of the twenty-four patients alive at my last report, twelve of them had bacilli in their sputa, and in twelve I had been unable to find them. These cases are of much more interest than my recent ones, and, naturally, come first.

Let me begin by reporting the death of my own wife, whose lungs began to fail her four years ago, whose sputa I examined in the fall of 1888, and whose case I reported in my last paper. At that time she was in the best health she had known since her lungs became affected. In July, 1891, she had an abscess gather in her right lung, and again I examined the sputa. No bacilli were present, and again she recovered so as to be free from cough. In August of the same year, she had another attack, which confined her to her bed for about three weeks; and she coughed and raised continually after. In March, 1892, I found her sputa full of bacilli ; and on the 6th of May she died. Her history confirms a belief which I have long entertained, that many cases of pulmonary consumption are not tuberculous

at the start. The lung may become impaired from a variety of causes, and a lower vitality resulting therefrom renders it a prepared soil for the germs of tuberculosis, as a saccharine substance readily undergoes fermentive processes through the absorption of yeast.

Of the other eleven patients whose sputa I had examined without finding bacilli, two have left town, but were well when they left; eight are as well as when I gave the report; and one has not been heard from.

These cases have no such general interest as the remaining twelve, in whose sputa bacilli were found. In a slipshod way they may represent the character of the specimen examined and the ability of the man who did it, but they prove nothing either way. Even should they all die of consumption, as did my wife, it would not prove them to have had it at the time of the examination. Strong people have been known to take the disease, and the weak are surely much more liable to do so. I even believe that we may have a destruction of lung tissue to a great and perhaps to a fatal extent without its becoming tubercular, or even showing the characteristic bacilli. If such is the case, we must learn not to give too much weight to the value of a microscopic examination that does not reveal them. Even though repeated examinations have been made, with negative results, we are only presumptively better off. We are still agnostics so far as a possible tubercular condition is concerned. It may develop if it has not already done so, and it is simply foolishness to try and build up hopes on a foundation of ignorance, however permanent that foundation may be. On the other hand, we have no right to despair of our patients, even though we know them to be subjects of tubercular disease. If the reports of hospitals are true, one-half of all who die therein have had it, three-fifths of whom having recovered, afterward died from something else.

I shall show you at least seven out of the thirty-seven reported in my last paper who are alive, and three of them in better condition than they were then. But thirty deaths out of thirtyseven patients is a pretty big mortality, and I would rather take the chances of a condemned murderer for life than those.

I think the cases which showed bacilli at my last report are of sufficient interest to merit individual notice, and, if you will bear with me, I will hastily review them.

CASE I. Maiden lady of 40. Is a maiden yet, and exceedingly vexed with me for placing her age so high, and not reporting her as perfectly well in my last paper. I should not dare to ask her how she was ; but her neighbors have no fear of her dying for a good while yet.

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