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SURGICAL PAPERS.

REPORT ON THE PROGRESS OF SURGERY.

THOMAS H. RUSSELL, M.D.,

NEW HAVEN,

One of the foremost surgeons in America stated at the organization of the American Medical Association in 1882 that "In my opinion surgery has nearly reached its limit." If that surgeon had been asked a year ago to prepare a report on the progress of surgery requiring a perusal of the last year's surgical literature, one could hadly imagine his surprise at the remarkable advances which have been made.

ANESTHESIA.

We have been heretofore accustomed to rely upon Ethyl Chloride as a local anesthetic only. It is important to know that it is coming into very extensive use for general anesthesia by inhalation for short operations, and it is claimed to have some advantages over ether and chloroform. Out of twelve hundred and forty-three administrations--of which one thousand were by Ware of New York-there was only one death proven to have resulted, and two others that may have been caused by it.

Ware, in his thousand cases, noted dangerous symptoms six times. It is stated that absolutely satisfactory anesthesia is obtained in ninety-five per cent: of operations, commencing promptly at intervals of a few seconds in infants, two or three minutes in adults, and the period of awakening is equally brief.

Ethyl Chloride is prompt and evanescent in its effect to a degree to render it somewhat comparable to laughing gas, and is useful in effecting preliminary narcosis previous to administering ether or chloroform.

Nausea is more frequently produced by it than by nitrous oxide, but less so than after ether. It is usually inhaled very quietly, and is best adapted for operations lasting only about ten minutes, although Ware of New York, has used it for fifty minutes in operations for strangulated hernia in infants and in other cases from forty to seventy-five minutes. He considers it a safe anesthetic, and that its danger point is not as readily or as suddenly reached as in chloroform, nor does it carry with it the remoter danger of ether. It is believed to be best used in the form known as "Kelene," although as put up under the names of Antidolorin and Anodynone, it has been said to act as a general anesthetic. It is certainly convenient to know that these agents which we regarded only as local anesthetics, are well adapted for general anesthesia also.

McCardie "thinks Ethyl Chloride an ideal anesthetic in short operations in country practice, on account of its portability and the satisfactory narcosis obtained by it."

We must all be interested in the fact that Dwight H. Murray in New York Medical Journal, June 27, 1903, reports that while performing a tedious operation in a hospital the ether vapor ignited from the closed electric light burning the face of the patient.

Starling described an important method for resuscitating patients from ether narcosis. His patient had been anesthetized, and the vermiform appendix removed, when both respiration and circulation ceased. He introduced his hand through the wound into the abdomen and up against the diaphragm, and feeling that the heart was not beating, he then with his hand gave the heart a squeeze or two, which immediately put it into action. Artificial respiration was at the same time continued for a few minutes. The patient completely recovered. Suc cessful massage of the heart after the failure of artificial respiration in chloroform narcosis for abdominal operation was described by H. M. Cohen in the Journal American Medical Association, Nov. 7, 1902.

These are methods which we all should remember in abdominal operations.

Heretofore Spinal Anesthesia (Analgesia) has been considered not beyond its experimental stage, and somewhat dangerous, but Bier announces this month in an article which may be referred to in the Journal American Medical Association, May 7th, 1904, that the introduction of the suprarenal preparations has now placed it on a safer basis, for by their use it is possible to insure the strict localization of the cocain at the point where it is desired to act. This method was employed on one hundred and twenty-one patients, aged sixteen to eighty years, all but twenty-two being men, all being in various conditions contraindicating the use of general anesthesia, and not a single mishap occurred in any instance. It was evident that the adrenalin prevented the action of the cocain from extending up as high as when used alone, and is a great improvement upon all previous methods.

The present procedure requires that the patient lie on the table, the upper part of the body raised, the spine curved, humping outward. A line drawn to connect the two crests of the ilium crosses the fourth vertebra. The forefinger is then carried from its spinous process to the process above and beyond it until it is in the interspace above, between the second and third lumbar vertebrae. The needle is then introduced into this interspace on the convex side of the spine, the side toward the table, and about one c. m. to one side of the finger. The needle is readily pushed up and in. The injection is not made until the cerebrospinal fluid appears. If it spurts in a jet it is advisable to allow a few c. c. to escape. The syringe is then attached to the needle and the adrenalin or suprarenin injected. The syringe left attached to the needle closes the opening. After waiting for five minutes to allow the suprarenin or adrenalin to get in its work, the cocain is injected from a second syringe. In ten minutes the patient is ready for the operation. The

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