a probe. I performed a circumcision and the child improved wonderfully.

I do not think there is much danger in giving an anesthetic for operation in these cases. It seems to me that it is indispensable.

Dr. Visanska (in closing): I am glad this paper has brought out some discussion, and in regard to the doctor's remarks on Case 1, will state that bromides and other treatment had been used, and it was a case of life and death. I operated, and the result was almost instantaneous and very gratifying. As long as you see these results you will operate. I do not believe in operating on every case just because the child is brought to you and there is a fee in sight, but we should be prepared to tell just what cases are operable.

ANESTHESIA AND ANESTHETISTS.

BY RALPH M. THOMSON, M.D., SAVANNAH.

In the nomenclature of modern medicine the significance of anesthesia is as apparent to a master as it should be awe-inspiring to a tyro. Any agent that artificially produces insensibility and prevents feeling, or that exhibits such effect by being received into the lungs in vaporous or gaseous form, and which passes with the blood to the nerve-centres on which its action is exerted, deserves greater consideration than we, as exemplars of a profession founded on precision, are prone to extend. Without presuming, however, on the intelligence of this distinguished audience; without maliciously incurring the displeasure of any who may be at variance with the views presented; or attempting dogmatically to sustain the opinion of, perhaps, a bigoted egotism, I would endeavor, in a measure, and as consistently as the propriety of the occasion will allow, to divest anesthesia of some of its clinging dangers and clothe the anesthetist with becoming modesty and yet essential confidence.

The relative merits of chloroform and ether as anesthetizing agents are without the province of this paper. The advocates of one shall not be arrayed in internecine strife against the other. A happy medium shall be sought, and anesthesia considered in a general sense, not as specifically applying to any one narcotizing drug.

Whatever may be the indications for its use, a certain element of risk and danger must of necessity accompany the administration of a general anesthetic. No power

ful agent capable, through inhalation, of benumbing the sensibilities; of producing a state of intoxication with loss of co-ordination of muscular movements; of subsequently or simultaneously affecting the functionating power of the sensory and motor ganglia and creating artificial sleep; of suspending respiration and ultimately destroying the action of the respiratory centre; of changing the rhythm of an otherwise healthy heart and exerting a depressing influence on the circulation, can be regarded save with gravity or conjured except through fear. Highly toxic in character, such substances should be employed cautiously; and then the mortality that follows in their wake-the mortality largely of carelessness and incompetency-will be greatly reduced and death denied the company of the hapless victims.

To employ one anesthetic exclusively is, in the light of present knowledge, as unjustifiable as it is heretical. While ether and chloroform are the most serviceable and widely used agents for the induction of general surgical narcosis, it would be illogical to assume that either the one or the other can, with safety and impunity, be administered in every condition requiring operative intervention. Nature alters cases to conform to her requirements, and no fixed law can be framed nor esteemed as axiomatic. Fatal results follow the administration of both; and while, perhaps, less frequently than formerly, the fact remains indisputable that any agent sufficiently potent to "hold life captive with a breath" must be viewed with apprehension and regarded with distrust. The essentially ideal anesthetic has not as yet been discovered; not one completely fulfils the demands required by the exponents of an art who, in the interest of common humanity, laudably "claim and seek ascendency." The safest anesthesia, therefore, depends on : (1) the selection of that anesthetic most admirably adapted to each individual

case; (2) "the best technic of preparation, administration and general management "; (3) the capability and aptitude of the anesthetizer.

Both "ether and chloroform have their individual contraindications." The fatalities connected with the administration of either are proportionately commensurate with the wisdom displayed in selection; and the danger lies not more in the inherent property of the agent used than in the manner in which it may be given. The dose of any anesthetic, therefore, is not the quantity indiscriminately employed in the effort to produce narcosis, but the amount inhaled and finally absorbed by the economy. Clinical experience not only demonstrates this fact but unalterably proves that choice is an important adjunct to a successful termination; and this is made possible, aside from climatic conditions, by giving due consideration to the age, physical condition, posture, environments, and idiosyncrasies of the patient, together with the skill of the anesthetizer, in conjunction with his willingness or ability to concentrate every thought on the prostrate and] helpless form before him. No physician, even in this enlightened age, can safely and consistently discharge the obligation of surgeon and anesthetist-or, perhaps, and charitably, of pedantic critic-at one and the same time without seriously jeopardizing the life of an innocent and unsuspecting victim. "No age, no sex, no climate confers immunity" from the risks attending narcosis; and while the indications. for its induction may be absolute, the only scientific method of procedure lies in the selection of that agent best adapted to the case in hand. Therefore, as has been aptly said, "The contraindications to the use of chloroform furnish the indications for the use of ether." Whenever possible all subjects for anesthesia should be kept under observation for two or three days prior

to contemplated surgical intervention. The value of preparatory treatment can not be discounted, and especially should marked attention be accorded the eliminative organs. The intestinal canal, the skin and kidneys form a trinity whose inportance can not be overestimated, and should be considered as carefully and conscientiously as the cardio-vascular system and lungs. The patient about to undergo the ordeal of narcosis deserves to approach the table in as constitutionally clean and sound state as is consistent with the demands required of enlightened and ambitious medicine. For several days prior to the operation the most nutritious, assimilative and palatable food should be recommended; and, in delicate persons particularly, should an effort be made to obtain the maximum of vitality in order that the possibility of shock eventuating either from the procedure itself, the narcotizing agent, or both, may be minimized. Until the day preceding the operation the same method should prevail, when the diet should become either liquid or semiliquid, and light, stimulating and sustaining. A full stomach and satisfactory anesthesia are incompatible; ard the administration of the latter, aside from the element of danger involved, is almost invariably impeded by the nausea and vomiting so frequently associated with an overfed viscus. No food nor milk should be allowed within several hours of anesthesia, and, except perhaps, coffee or beef-tea, which are stimulating in character, should be interdicted altogether. Water, however, may be given advantageously to within two or three hours of narcosis, because, as has been rightly asserted, "all the functions of the body are carried on in a fluid medium," and success thereby is facilitated.

The reputation of the anesthetizer, from the standpoint of the patient especially, is not infrequently com