The art of anaesthesia

Front matter

Oass.

Book

COPYRIGHT DEPOSIT

Preface To The Third Edition

With a view of bringing the present edition up to date, the entire text has been carefully re-read with the result that deletions, corrections and additions have been freely made. Since the appearance of the first edition in 1916, the author has been much interested in the question of the color sign. The need of a clinical measure of cyanosis is obvious to those familiar with operating-room work. To speak of cyanosis without being in a position to refer to its degree is to make ourselves unintelligible. To speak of a definite percentage of cyanosis, or oxygen unsaturation, is an entirely different thing. As all tissue color depends upon the color of the circulating blood (pigmentation alone excepted ) the blood has formed the criterion for our investigation. The absence of cyanosis, or complete oxygen saturation has formed one end of our scale ; complete cyanosis or complete oxygen unsaturation has formed the other. The blood escaping from the fresh wound of incision supplies the basis for our readings. At the present writing an investigation is being made into the opacity presented by the skin and mucous membranes. An instrument has been devised called the "h,emoxometer," or, oxyh^moglobinometer," which affords a simple clinical means of reading the oxygen content of the blood. While this instrument has just appeared, and has not yet been in extensive use, nevertheless, the author does not hesitate to recommend it, because of the fundamental truths which underly its construction. All of the oxygen quantitative determinations were made at the Rockefeller Institute through the courtesy of Doctor D. Van Slyke.

vi PREFACE TO THE THIRD EDITION

While the present form of this device will, doubtless, change, the facts upon which it is based are permanent.

It is the author's opinion, that the wide spread use of gas and oxygen has passed its peak, at least, in the Eastern portion of the United States. There is a distinct reversion to the oldest, and most trustworthy of anaesthetic agents, ether. With this situation in mind, a section has been included, entitled, " General observations based upon ten years' experience with Nitrous Oxide Oxygen as an Anaesthetic." One of the most disturbing facts associated with Gas Oxygen Anaesthesia are the deaths which have occurred through its use. Some of these have been reported, must of them have not.

In the author's experience, chloroform has completely given way to ether administered by intrapharyngeal methods. This condition holds, with the single exception of oral cases in which the actual cautery is used.

In attempting to convert the rather old-fashion terms, acapnia, hypercapnia, etc., into the more modern views of low alkaline reserve, buffer salts, etc., the author finds himself nonplussed. He confesses a rather hazy understanding of acidosis and alkalosis, but, is entirely unable to offer these in the tabloid form which the available space demands. Inasmuch, however, as our original theories in regard to carbon dioxide in its role as a respiratory stimulant have not been refuted, and inasmuch as our practical experience daily tends to confirm these views, we may be pardoned for omitting a detailed consideration of the last analysis of the phenomena which we observe.

Paravertebral, conductive or regional anaesthesia has been much in vogue. It has been pointed out that the

PREFACE TO THE THIRD EDITION vii

enthusiam with which this form of local anaesthesia has been received in some clinics is an indication of the inability of such a clinic to secure all that general anaesthesiahas to offer.

Synergistic anaesthesia has been briefly referred to and status lymphaticus has been noted. The chapter on " the patient's viewpoint " was so well received, that the author was constrained to prepare a small volume on this subject.

The author wishes to take this opportunity to thank his many friends for their interest and forbearance and to express his appreciation for the unfailing courtesy of his publisher.

P. J. F.

410 East 57th Street

Preface To The Second Edition

The original purpose of this little volume "as a groundwork upon which the student, interne, and general practitioner may acquire a more comprehensive knowledge of the Art of Anaesthesia," has been strictly adhered to in this, the second edition. A long chapter dealing with anaesthesia on the western battle front was carefully prepared and discarded as too comprehensive and transient for inclusion in a book reserved for fundamentals.

Repeated lectures to army officers and other medical men since the appearance of the first edition has served to crystallize the ideas of inhalation and insufflation anaesthesia. The former method has been developed with a view to the needs of the medical man who must improvise his apparatus, the worker in the field hospital, casualty clearing station and autochir, the latter is recommended for the officer at work in the fully equipped base hospital.

A chapter on the choice of the anaesthetic and the method of administration has been added as a resume of the preceding chapters.

It would appear that there is little difference whether the patient to be anaesthetized receives his injuries in a street car accident or in a spad ten thousand feet in the air. Military anaesthesia resembles anaesthesia in civil practice with the following exceptions — the patient is not prepared for operation; induction must be rapid and recovery must follow quickly; a large number of cases require treatment at one time, and, finally, the anaesthetic

ix x PREFACE TO THE SECOND EDITION

is often administered under trying conditions with improvised apparatus. If these difficulties are recognized and met, the well-trained anaesthetist in civil life will not fail to render his country a great service when called to the battle line.

Many anaesthetics are now being administered by nurses, noncommissioned officers, and other lay persons. In employing such an administrator the surgeon automatically assumes the duties of the anaesthetist. He must make the preliminary examination, order suitable medication as well as ante- and postoperative treatment. The lay administrator of anaesthetics is a technician — an anaesthetic technician, pure and simple. She is a technician in the same sense as is the lay worker in the pathological laboratory who examines urine, blood, or sputum. And she holds the same position as does the X-ray technician who can take pictures but who is never expected to make a diagnosis or suggest treatment. When we become familiar witK the term anaesthetic technician and realize the legitimate limitations of such a worker we will accept these services under the proper supervision and control and the discussion of the relative merits of the medical and nonmedical anaesthetists will cease.

The author wishes to take this opportunity to express

his warmest appreciation for the kindly reception which greeted the appearance of the first edition.

P. J. F.

400 West 160th Street New York City

Preface To The First Edition

The proper administration of an anaesthetic is more than a mere mechanical performance, it is an art.

The Art of Ancesthesia is acquired by becoming familiar with the laws which govern its administration and by developing the ability to properly correlate and apply these laws.

It will be perceived that while a knowledge of laws is essential, yet this knowledge is superseded by the ability to properly apply them. This controlling element is what constitutes the essence of the art. Experience begets dexterity, tact and skill. These qualities, while somewhat intangible, are nevertheless indispensable. They imply a correct and spontaneous response to the demands of the patient.

The Art of Ancesthesia is not contained within any particular mode of administration. So-called empirical, percentage and shock-absorbing methods have their place, but should not be permitted to dominate over the art in its broader sense. They are its tools and must be observed from a point of view which considers the surgeon, the patient, the time, the place and many other factors.

Since familiarity breeds contempt, the anaesthetist must never forget to approach each case with a certain degree of courtesy and respect, for the possibilities of success as well as of failure in each are almost unlimited.

A thousand anaesthesias, instead of leading to crudeness, should make one a thousand times more careful. As one proceeds, one should try to formulate laws, and these one should strive to prove by the next case.

xi xii PREFACE TO THE FIRST EDITION

The Art of Anaesthesia implies an intimate knowledge of general medicine, pathology, surgery, therapeutics, psychology and special branches. Those who are not familiar with these subjects cannot understand the language of anaesthesia.

For example, how can a lay person intelligently form an opinion upon such vital matters as acidosis, toxaemia, carbon dioxide, stimulation, and depression? How can he unravel and relieve the untoward symptoms which might arise in a case complicated by respiratory obstruction, morphine depression, and reflex inhibition?

Death, due to anaesthesia, is not an unheard-of thing in lay conversation. As a consequence some timidity exists towards the taking of an anaesthetic. Intelligent people

often ask : " How does Dr. know that I can safely

take an anaesthetic? " This fairly common query implies not only the necessity of a preliminary examination, but of an examination by a physician. Aside from this consideration, a surgeon can ill afford to let the public know that he is willing to risk the patient's life at the hands of an anaesthetist who is not a medical man. Does not this very evident lack of concern imply to the mind of the thoughtful patient a greater lack of care which may include the operative procedure?

A layman who administers an anaesthetic is like a blind guide who is led by the patient, instead of leading him. Unable to properly anticipate the stages of an operation he cannot judge the indications for artificial stimulation.

Those who relegate anaesthesia to the layman, place the responsibility of the outcome on their own shoulders.

To give an anaesthetic is one thing, to practice the Art of Ancethesia is another.

PREFACE TO THE FIRST EDITION xiii

This book, therefore, is intended as a groundwork, upon which the student, interne, and general practitioner may acquire a more comprehensive knowledge of the Art of Ancesthesia. Without an understanding of the broad truths which underlie present day anesthetization, clinical experiences and reference reading will lose much of their value.

It is proposed to describe anesthesia as the student will actually find it.

The history of ancesthesia has been briefly considered. A resume of the entire field of anesthesia is then attempted by defining and describing general, local and mixed anesthesia. General ancesthesia is then taken up in detail. A classification of the stages of anesthesia based upon circumstances present in all methods and by all anesthetics is much to be desired. It has been found in practice that a classification made up of the stages of induction, maintenance and recovery meets these requirements admirably. Such a classification is easily demonstrated and grasped. At the conclusion of an elaboration of these stages we have appended a summary, which will be found valuable for reviewing and quizzing purposes.

The classification of the stages of anaesthesia forms a basis upon which we may intelligently attack the problem of the signs of anesthesia. Ether being the most widely used anesthetic, we have thought it wise to use this type of anesthesia as a basis.

The classification of the stages of anaesthesia forms a basis upon which to consider the administration of ether ancesthesia. The various methods employed, oral insufflation, intrapharyngeal insufflation, intratracheal insufflation, rectal and intravenous methods are fully discussed.

xiv PREFACE TO THE FIRST EDITION

General ancesthesia by ethyl chloride, chloroform, nitrous oxide, nitrous oxide and oxygen, and nitrous oxide oxygen ether are then taken up, the stages of ancesthesia in each case forming a common basis for the administration and the signs described.

In accordance with the resume suggested above, local anaesthesia is then discussed. A chapter on mixed or spinal anaesthesia follows. '

Medication preliminary to ancesthesia is next taken up. This is followed by a chapter on carbon dioxide and rebreathing. Bearing in mind the needs of the general practitioner, a chapter on emergency ancesthesia has been prepared. Last, but not least, we recommend the patient's point of view to the earnest anaesthetist.

The collection of table positions which are presented in connection with the classification of the stages of anaesthesia is, it is believed, quite complete.

Chapters I, II, III, IV, XIII, XIV, XVIII and XX have been written with the needs of the trained nurse in mind.

In conclusion the author wishes to take this opportunity to thank Dr. G. W. Crile for the hospitality extended him while in Cleveland, during which visit he was enabled to study the method of anoci association, so earnestly and constantly advocated by his charming host. He is also indebted to Dr. John B. Murphy for courtesies extended while visiting his clinic in Chicago, and is under deep obligations to Dr. Charles Mayo for a delightful visit to his remarkable clinic; to the gentlemen of the American Surgical Society indebtedness is expressed for many privileges extended while visiting in the West.

To Dr. C. N. Dowd the author is indebted, hot only

PREFACE TO THE FIRST EDITION xv

for innumerable courtesies, but for the help which he has offered in curtailing crudeness in this book ; to Dr. Lucius Hotchkiss for having made much of this book possible ; to Dr. Karl Connell for having explained the use of the Ansesthetometer, and for the loan of original illustrations ; to Dr. L. Booth for illustrations on intratracheal insufflation. To the Attending Staff of Fordham Hospital and to the Faculty of Fordham University Medical School indebtedness is acknowledged for much encouragement and support, as well as to the Attending Staff of the Woman's Hospital, with whom many pleasant hours have been passed.

Acknowledgment is made to Dr. K. Dwight for assistance in the classification of the stages of anaesthesia. To Berchman Bittl, O. M. Cap., and an old friend Robert Getty for reading the proofs. To Dr. A. Bruno for assistance in preparing many of the illustrations. To Dr. L. De Yoe for preparing the index. To the daughters of the late Dr. C. W. Long, the discoverer of ether anaesthesia, grateful acknowledgment is made for photographs and pamphlets relating to the discovery of ether anaesthesia.

For the loan of illustrations credit is due Appleton & Co.. The Modern Hospital Magazine, The Journal of the American Medical Association and Old Penn.

Finally to J. B. Lippincott Co. gratitude is expressed for the patience and courtesy which they have shown in the preparation of this book.

P. J. F. 120 Central Park South, New York City.

Contents

PAGE

Introduction (History) 1

Part I

Bearing Upon the Classification of Anaesthesia, Its Characteristic Signs and Its Administration by the Various Methods Ordinarily Employed

Types of Anaesthesia

A. GENERAL ANAESTHESIA. B. LOCAL ANAESTHESIA. C. SPINAL ANaESTHESIA.

A. GENERAL ANaESTHESIA CHAPTER

I. General Anaesthesia 11

1. Complete. 2. Incomplete.

II. General Anaesthesia. A Detailed Consideration 15

1. Induction. 2. Maintenance. 3. Recovery.

III. Signs of Anaesthesia 82

1. Respiration. 2. Color. 3. Muscle. 4. Eye. 5. Pulse.

IV. Ether Anaesthesia. General Considerations 120

1. Oral Insufflation. 2. Intrapharyngeal. 3. Intratracheal. 4. Oil Ether Rectal. 5. Intravenous.

V. Ethyl Chloride 181

General Consideration. Technic of Administration.

VI. Chloroform 185

General Consideration. Technic of Administration.

VII. Nitrous Oxide 201

General Consideration. Technic of Administration.

VIII. Nitrous Oxide Oxygen Anaesthesia 214

General Consideration. Technic of Administration.

IX. Nitrous Oxide Oxygen Ether Anaesthesia 223

General Consideration. Technic of Administration. Anoci Association.

B. LOCAL ANaESTHESIA

X. Unusual Methods 249

1. By Freezing. 2. By Pressure. 3. By Regional Intravenous Injections of Novocaine.

XI. Usual Methods 255

1. By Surface Amplication. 2. By Infiltration Anaesthesia. 3. By Conductive Anaesthesia.

C. SPINAL ANaESTHESIA

XII. General Consideration 261

XIII. Method of Administration 265 xvu xviii CONTENTS

PART II Bearing Upon Factors Incidental to the Actual Administration of the

Anesthetic chapter page

XIV. Preliminary Medication in Anesthesia 277

XV. Post-Operative Treatment of the Patient; Duties of the Nurse

Before, During and After Anesthesia 285

XVI. Carbon Dioxide and Rebreathing 296

XVII. Emergency Anesthesia 308

XVIII. The Anesthetist's Records 318

XIX. Aspirators 321

XX. The Point of View of the Patient 328

XXI. Selection of Anesthetic and Method of Administration 334

Appendix 361

Bibliography , 365

Index 367

ILLUSTRATIONS

FIG. PAGE

The Actual Effect of Oxygen upon the Color of Human Blood, Forming the Basis for the Author's Haemoxometer Frontispiece

1. Homer 3

2. Du Bartas , 3

3. Shakespeare . . 3

4. Dr. C. W. Long 3

5. A Documentary Reference to the Existence of Ether Frolics 4

6. The First Suggestion of the Use of Ether as an Anaesthetic 4

7. An Account of the First Anaesthesia 4

8. Long's Discovery no Secret 5

9. Curve of Complete Anaesthesia 12

10. Curve of an Incomplete Anaesthesia 13

11. Correct Control of the Head, the Patient Across the Bed 24

12. Incorrect Control of the Head, the Patient Parallel with the Bed 24

13. The Boxwood Mouth Wedge 34

14. The Author's Modification of the Connell Throat Tube 34

15. Throat Tube in Place 35

16. Table in Trendelenburg Position 38

17. Patient Ready for Trendelenburg Position 38

18. Patient in Trendelenburg Position 39

19. Table in Position for Trendelenburg Position — Feet Straight 39

20. Patient in Trendelenburg Position — Feet Straight 41

21. The Simms Position 41

22. Position Favoring Brachial Paralysis 13

23. Position Favoring Musculospiral Paralysis 43

24. Position for Exploration of Knee-joint 44

25. Prone Position 44

26. Prone Position for Sacral Operation 45

27. Position for Operation on Sacrum 45

28. Table with Gall-bladder Kidney Rack in Position 46

29. Patient in Kidney Position Over Rack 46

30. Patient in Gail-Bladder Position Over Rack 49

31. Table Broken Instead of Raising Rack 49

32. Kidney Position on Broken Table 50

33. Gall-bladder Position on Broken Table 50

34. Ordinary Neck Position for Goitre Operation 51

35. Ordinary Neck Position for Glands of Neck 51

36. The Rose Position 52

37. The Elevated Neck Position 52

38. The Table Set for Elevated Neck Position 53

xix xx ILLUSTRATIONS

39. Patient in Elevated Neck Position 53

40. Table Set for Lithotomy 55

41. Patient in Lithotomy • • • 55

42. Table Set for Closure of Upper Abdominal Wounds 56

43. Patient in Position for Closure of Upper Abdominal Wounds 56

44. The Walcher Position • • 57

45. Diagram to Explain the Walcher Position 58

46. Curve Showing Variable and Constant Maintenance 61

47. Diagram Showing Vapor Tension of Ether in Alveolar Air During the Three

Stages of a Complete Anaesthesia 65

48. Vapor Pressure of Ether in Tidal Air for Induction and Maintenance of

Full Anaesthesia 6H

49. Plot of Ether Vapor Pressure in Pulmonary Tidal Air 69

50. Plot of Ether Tension in Body 70

51. Zones of Ether Anaesthesia 73

52. Recovery by Crisis 76

53. Recovery by Lysis 77

54. Gauze on Upper Lip Moistened with Essence of Orange 80

55. 56. Sylvester Method— Artificial Respiration 93, 91

57. Simple Form of Mercury Manometer ,, 95

58. The Hsemoxometer 96

59. Normal Movements of Diaphragm 104

60. Movement of Diaphragm Before a Fatal Issue 104

61. Diagram Showing Enervation of the Dilator and Sphincter Pupilse 109

62. 63. Intravenous Administration of Saline 115, 116

64. Hypodermoclysis 118

65. Yankauer Gwathmey Drop and Vapor Mask 123

66. Making the Ether Drop Bottle 124

67-71. Ether by the Semi-open Drop Method 128

72. The Author's Apparatus for the Administration of Ether by the Closed Drop

Method and for Gas Oxygen Ether Anaesthesia 132

73, 74. Bennett Apparatus 137

75. Apparatus for the Vapor Method of Oral Inhalation 144

76. Showing Pharyngeal Tube and Nasal Tube Employed for Intrapharyngeal

Inhalation. The Stylet is for Intratracheal Use 147

77. The Author's "Tin Can" Method 148

78. Intrapharyngeal Inhalation with Rebreathing, Nasal Method 154

79. Intrapharyngeal Inhalation with Rebreathing, Oral Method 154

80. Jackson Laryngoscope with Tieman Pocket Flashlight Adapter 154

81. Showing Oral Tube, Special Mouth Gag, and Simplified Chloroform Apparatus 155

82. Ansesthetometer (Connell) 154

83. Nasal Tubes 155

84. Nasal Tube in Place 155

ILLUSTRATIONS xxi

85, 86. Intrapharyngeal Anaesthesia 155

87. Electric Motor Blower and Suction Apparatus with Ether Attachment 161

88. Intratracheal Catheter 162

89. Jackson Laryngoscope and Rheostat 163

90. 91. Intratracheal Anaesthesia 165-166

92. Intravenous Apparatus 177

93. Chloroform Containers 182

94. Ethyl Chloride Container, Spray Type 182

95. Various Sizes of Gas and Oxygen Tanks 202

96. Reducing Valve 203

97. Label on N2O Cylinder 204

98. Plan of Apparatus Installed in Lakeside Hospital for the Manufacture

of Nitrous Oxide 205

99. The Author's Cylinder Holder 209

100. The Author's Cylinder Holder Clamped to the Edge of a Table 210

101. Cylinders Lying on a Chair Supported by the Author's Holder 211

102. Cylinder Clamp Fastened to a Window-sill 212

103. A Simple Wooden Stand for Three Cylinders, Suitable for Hospital Use. ... 215

104. Miller Apparatus 230

105. McKesson Apparatus 231

106. The Gwathmey Gas Oxygen Apparatus 231

107. Connell Gas Oxygen Apparatus 232

108. Zones of Nitrous Oxide Oxygen Anaesthesia in Normal Man without Sup-

plemental Narcosis 234

109. Connell Nitrous Oxide, Oxygen, Ether Flow Control 235

110. Esmarch Bandage 251

111. 112. Bandage for Regional Intravenous 253

113. Dunn Automatic Outfit for Local Anaesthesia 257

114. Relative Sensitiveness of Tissues 259

115. The Relations of the Lumbar and Dorsal Interspaces to the Crests of the

Ilia and Lower Ribs 266

116. Localization of the Spinal Interspaces 267

117. The Point of Skin Puncture is Anaesthetized by Freezing 269

118. The Needle is Introduced in the Middle Line Forward and Inward 270

119. As the Dura is Pierced, the Cerebrospinal Fluid Escapes and May be Col-

lected in Test-tube for Further Study 271

120. The Syringe Containing the Proper Dose of Stovaine is Attached to the

Needle and Slowly Injected 272

121. Nurse Grasping Patient's Wrists 286

122. The Fowler Position 292

123. The Shock Position 293

124. Tracing of Experiment in Respiration 306

125. Making the Cone 313

126. Tin-can Method for Nirta Pharyngeal Anaesthesia 315

127. Funnel with Tube for Intratracheal Anaesthesia 316 xxii ILLUSTRATIONS

128. Front of Anaesthesia Record Card . . .-, 318

129. Reverse of Anaesthesia Record Card 319

130. Foot Aspirator .322

131. Water Aspirator 323

132. Electrical Aspirator . 324

133. Ejector for Steam Aspirator 324

134. The Steam Pump Aspirator Complete with Aspirating Tongue Depressor. . . 325

135. Aspirating Tongue Depressor 326

THE ART OF ANAESTHESIA

Introduction

THE HISTORY OF ANESTHESIA

The history of anaesthesia may be broadly divided into two periods : the pre-ancesthetic period and the ancesthetic period. The pre-ancesthetic period ends and the ancesthetic period begins with the discovery of ether in 1842 and its general introduction in 1846.

THE PRE-ANCESTHETIC PERIOD (Before 1842)

The beginning of the use of anaesthesia is not known ; it dates from the earliest antiquity. The following commonly accepted references prove that narcotics were used in pre-ancesthetic times.

Homer (Fig. 1), in "The Odyssey," says: "Helen dropped into the wine of which (the soldiers) drank a drug, an antidote of grief and pain inducing oblivion to all ills. He who drinks of this mingled cup sheds not a tear the livelong day were death to seize his venerated sire or her who gave him birth, or were the sword buried in the bosom of his brother or greatly loved sister, no tear would even then bedew his cheeks."

In 484 B.C., Herodotus refers to the inhalation of the vapors of hemp (Cannabis Indica) to produce intoxication.

In 23 a.d., Pliny, the Roman author, speaks of the juice of certain leaves taken before cuttings and burning to produce sleep.

St ANAESTHESIA

In 134 a.d., Galen, the physician, speaks of the power of mandr agora to paralyze sensation and motion.

In 250 a.d., Lucian, the Greek historian, refers to the narcotic effects of mandragora.

In 1250, Hugo de Luca, physician, refers to a certain oil with which he put patients to sleep before operations.

In 1544 Du Bartas implies a custom by writing:

Even as a Surgeon, minding off to cut Some cureless limb, before in use he put His violent engines on the viscious member Bringeth his patient in a senseless slumber.

In 1613, Shakespeare (Fig. 3) in " Cymbeline," Act I, Scene VI, implies the use of a narcotic. (Cornelius plans to give a secret drug which)

Will stupify and dull the sense awhile,

No danger in what show of death it makes.

In 1772, Priestly discovers nitrous oxide.

In 1804, Sir Humphrey Davy suggests the use of nitrous oxide as an anaesthetic.

In 1818, Faraday notes resemblance between nitrous oxide and ether.

The narcotic effects secured in ancient, mediaeval and modern times, during the period which we have designated as pre-ancesthetic (previous to 1842), were brought about chiefly by the use of:

Cannabis indica, a certain kind of hemp, smoked as haschisch.

Secret Chinese mixtures.

Pressure on blood-vessels and nerve trunks.

Hypnotism.

The ancesthetic period was foreshadowed by the sporadic use of nitrous oxide both in England and America. At about this time it became a common practice for persons to

INTRODUCTION

Fig. 1. — Homer.

Fig. 2.— DuBartas.

Fig. 3. —Shakespeare.

Fig. 4.— Dr. C. W. Long, from a crayon

drawing made in 1842.

(Courtesy of Florence Long Bartow.)

Homer, Du Bartas and Shakespeare, Poets of the pre-anaesthetic period who wrote of the use of narcotics

for the control of pain. Dr. C. W. Long, of Georgia, who opened the anaesthetic period by employing

ether, to secure unconsciousness during an operation which he performed in the spring of 1842.

inhale the fumes of ether for the exhilarating effects. This practice sometimes formed the chief entertainment at country parties. These ether frolics probably suggested the use of this agent as an anaesthetic, for during these frolics, the stage of excitement occasionally led to unconsciousness and loss of sensation. A portion of a document, sworn to by one R. H. Goodman of Georgia, shown in Fig. 5, " refers to these ether frolics."

THE ANESTHETIC PERIOD (From 1842 to the present time)

The proper discovery of anaesthesia involves the names of four investigators: Crawford W. Long of Georgia; William T. Morton of Hartford; Horace Wells of Hartford and Charles T. Jackson of Boston.

Dr. Crawford Long (Fig. 4) of Georgia, having observed the loss of sensation incidental to injuries received during ether frolics, concluded that sulphuric ether might well be used to allay the pain of surgical operations. This idea occurred to Dr. Long late in the year 1841, as may be seen in Fig. 6. In the spring of 1842 Dr. Long put his theory into practice. After having rendered his patient, one James Venable, unconscious with inhalations of ether, he successfully removed two small tumors from the man's neck. The documents reproduced in Figs. 6 and 7 give brief accounts of the first operation ever done under ether.

H. Wells of Hartford had a tooth extracted under the influence of nitrous oxide. He subsequently used it upon his patients with such good results that he attempted a demonstration at the Harvard University Medical School. His exhibition was a failure and so disheartened him that he later committed suicide. ,

W. T. Morton was a student under Wells and conse-

Courtesy Dr. Allen J. Smith, Old Penn.

Fig. 5. — Ether frolic. A documentary reference to the existence of Ether Frolics.

~x v<s>

A--' tTptM^icJkff iCourtesy Dr. Allen T. Smith, Old Penn. ,. t;/1

Fig. 6 — The first suggestion of the use of ether as an anaesthetic.

Courtesy Dr. Allen J. Smith. Old Penn.

Fig. 7.— An account of the first anaesthesia.

INTRODUCTION 5

quently was familiar with the use of nitrous oxide. While serving as a medical student under the preceptorship of C. T. Jackson, the latter suggested that he use ether in place of nitrous oxide. Morton did so and after several experimental successes gave a demonstration at the Massachusetts General Hospital, October 16, 1846.

As the operator, Dr. Warren, remarked at the conclusion of the operation, " Gentlemen, this is no humbug," so subsequent events proved this public demonstration to be the birth of a new era. The crudeness of pre-ansesthetic methods is vividly depicted by Hayden, who describes an operation performed on a woman: " With a meek, imploring look and the air of a startled fawn, as her modest gaze meets the bold eyes fixed upon her, she is brought into the amphitheatre crowded with men, anxious to see the shedding of her blood, and laid upon the table. With a knowledge and merciful regard as to the intensity of the agony which she is to suffer, opiates and stimulants have been freely given her which, perhaps at this last stage, are again repeated. She is cheered by kind words and the information that it will soon be over and she freed forever from what now afflicts her ; she is enj oined to be calm and to keep quiet and still; and with assistance at hand to hold her struggling form, the operation is commenced.

"But of what avail are all her attempts at fortitude! At the first clear, crisp cut of the scalpel, agonizing screams burst from her, and with convulsive efforts she endeavors to leap from the table; but force is nigh. Strong men throw themselves upon her and pinion her limbs. Shrieks upon shrieks make their horrible way into the stillness of the room, until the heart of the boldest sinks into his bosom like a lump of lead.

" At length it is finished and, prostrate with pain, weak from her exertions and bruised by the violence used, she is borne from the amphitheatre to her bed in the wards, to recover from the shock by slow degrees."

A short time after this demonstration at the Massachusetts General Hospital, Morton and Jackson patented ether and called it letheon. The secret soon leaked out, however, because of the characteristic odor of the new preparation. Petition was later made before Congress for recognition. The honorarium consisted of one hundred thousand dollars. Morton, Jackson and a friend of Wells, who had since died, became claimants. As the controversy was about to close, Jackson recognized the claims of Long, which had just been received. The bill was thereupon dropped and never again presented.