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around this opening, and the director being introduced, Mr. Adams carried his bistoury nearly an inch deep and one inch in the line of the director. I then narcotised the deep-seated parts, and enabled him to cut for another inch and a half in the same direction. The director was then placed in the upper line of the abscess, the process was repeated, and the incision was carried two and a half inches in that direction. The patient was entirely unconscious of pain, and after narcotising the whole of the deep surfare, Mr. Adams inserted his fingers and cleared out the wound without creating the slightest evidence of pain.
Afterwards in the case of a lacerated wound, six inches long, in the arm of a boy, who had been injured with machinery, I narcotised while six sutures were introduced by Mr. Adams. The first needle was carried through without the anæsthetic, and caused expression of acute pain; the remaining eleven needles, after a few seconds' administration of the ether spray, were passed through painlessly. The twisting of the wire sutures gave no pain.
These results are so interesting that I make no apology for bringing them at once before my Medical brethren. I wish it to be distinctly understood that at the present moment I only introduce the method here described for the production of superficial local anæsthesia. It is, I believe, applicable to a large number of minor operations, for which the more dangerous agent chloroform is now commonly employed -I mean such operations as tooth extraction, tying nævus, tying piles, incising carbuncles, opening abscesses, putting in sutures, removing small tumours, removing the toe-pail, dividing tendons, operating for fistula, removing cancer of the lip, and other similar minor operations which I need not mention. The process may also be applied to reduce local inflammation.
In course of time, and guided by experience and the advancement of science, we may, however, expect more. If an anæsthetic fluid of negative qualities, as regards irritation of nerve, and which has a boiling point of 75° or 80°, can be obtained from the hydro-carbon series, the deepest anæsthesia may be produced, and even a limb may be amputated by this method. It may also turn out that certain anæsthetics may be added to the etherial solution with advantage, such as small quantities of chloroform, or some of the narcotic alkaloids, if they could be made soluble in ether. A solution of morphia and atropia combined, if they could be diffused through ether, which at present seems impossible, could thus be brought into action so as to cause deep insensibility. In operating on the extremities it would be good practice to stop the current of warm blood by making pressure above on the main artery.
Reaction from the anesthesia is in no degree painful, and hæmorrhage is almost entirely controlled during the anæsthesia.
One or two precautions are necessary. It is essential, in the first place, to use pure rectified ether; methylated ether causes irritation, and chloroform, unless largely diluted with ether say one part in eight-does the same.
The modus operandi of this process is exceedingly simple. It acts at first merely by extracting force, and afterwards, when the nevous filaments are exposed, by preventing the conveyance of force through them. To be plain, sensation means the conveyance of force or motion from the extreme parts to the brain. The motion is communicated by the blood in the form of heat: it is communicated to the nervous filaments, and by them is conveyed to the sensorium. This is passive sensibility. When we irritate a nervous fibre, as by a cut, we communicate more motion rapidly along that fibre and cause pain. This is active or exalted sensibility. To remove sensibility, therefore, we must adopt one of three processes : we must remove or render inert the sensorium ; we must stop the evolution of force generally by arresting oxidation of blood; or we must rob the body locally of its force beyond that with which it is constantly being renewed. We see the first of these processes in action in cases of pressure on the brain, as from injury or effusion of blood; we see the second whenever we produce general anæsthesia by charging the blood with chloroform or other analagous anæsthetic; and we see the third when, by means of extreme cold, we rob the local part of the force that has been brought to it by the blood.
The problem of local anesthesia will consequently be quite solved when by a rapid process we can exhaust the natural force of a part as fast as such force is evolved in the local structure ; and especially when with this we can combine the action of a substance which for the moment controls, as by compression, the conducting power of nerve matter. These two latter objects are to a large extent carried out by the method I have described above.
THE PRINCIPLE OF THE PROCESS.
The principle of the new anæsthetic process consists in directing on a part of the body a volatile liquid having a boiling point at or below blood heat, in a state of fine subdivision or spray, such subdivision being pro duced by the action of air or other gaseous substance on the volatile liquid to be dispersed.
When the volatile fluid, dispersed in the form of spray, falls on the human body, it comes with force into the most minute contact with the surface upon which it strikes. As a result there is rapid evaporation of the volatile fluid, and so great an evolution of heat force from the surface of the body struck, that the blood cannot supply the equivalent loss. The part consequently dies for the moment, and is insensible as in death ; but as the vis a tergo of the body is unaffected, the blood, so soon as the external reducing agency is withdrawn, quickly makes its way again through the dead parts, and restoration is immediate. The extreme rapidity of the action of this deadening process is the cause of its safety. The process can suspend life without causing disorganisation ; if I may use the expression, it produces syncope of the part-temporary death-but not necessarily destruction. When we produce general anæsthesia we virtually extend this mere local action to the body altogether-i. e., we check the evolution of force at the centre, and produce an approach to temporary death of the whole of the organism.
THE INSTRUMENT.- IMPROVEMENTS.
In my original paper, I described simply the single dispersion-tube. Since then, I have made a large number of tubes to answer various powers and purposes. I have a tube in which there is a bulb enlargement at the end with perforated side, or side and central jets. This tube is exceedingly useful for the cavities of the body, such as the vagina or rectum. It distributes the fluid in the same manner as a syringe with several perforations at its point. In practice, I find that the dispersion of the fluid delivered from one fine tube by a series of jets is not so efficient, proportionately, as when it is delivered by one jet; the fluid, that is to say, requires a certain degree of concentration to ensure success.
In order to multiply the anæsthetic producing power, I have other instruments constructed which may be called compound. In these cases the bottle holding the volatile fuid either receives a common central tube of large size communicating with a number of terminal jets, or each terminal jet has a separate jet running into the fluid. By this means I have a brush of jets, which may be circular, or long, or flat, as required. For this compound tube a six ounce containing bottle for the fluid is necessary, and additional bellows power. . The present small hand bellows will only work a compound jet of two elements with efficiency. I have tried various plans to do away with the hand bellows.
I have used carbonic acid compressed into an iron bottle, and have applied the gas in its escape so as to act in the same manner as the air from the bellows. The apparatus complicates, and the pressure of gas cannot be so nicely regulated. I have modified this plan also by trying to get force by generating carbonic acid gas at the time; also by generating hydrogen from
zinc and dilute sulphuric acid, and using the pressure of the gas as the distributing agency,
Again, I have tried water pressure, as in the common gas holder; and I think in the dentist's room this plan would succeed well, if the preliminary expense were no obstacle. But taking all in all the hand bal} bellows are as yet the most practical and most ready; they carry in the pocket, and one can go with them to the patient and commence anæsthesia at once--a great consideration. In many small operations, requiring only one or two strokes of the knife, the whole may be done painlessly, while the patient thinks the preparations are merely being mademuch, of course, to his gratification.
Several suggestions for the improvement of the jets offer themselves for consideration ; the fish-tail gas-burner, the Argand burner, the conservatory water engine, and many other mechanical contrivances similar in kind will occur to every one as worthy of imitation, and as quickly as they can be made they will be produced and tested.
TAE FLUID TO BE USED. I still continue to use absolute ether for operations, and now, as Mr. Robbins has produced an ether of specific gravity 0.720 of negative effect on the tissues, and having a boiling point of 92° Fahr., a better fluid can hardly be demanded. Many other fluids have been suggested by various readers of my original paper--viz., methylic ether, amylene, monochloretted chloride of ether, pure chloric ether, nitrite of ethyle, a volatile hydrocarbon derived from the manufacture of portable gas, chloroform, rectified turpentine, and numerous compounds and mixtures. As regards these I may state that they have all been under my careful consideration, but that as yet none of them, taking their quallties all in all, are equal to absolute ether. Some are open to rejection at once from their boiling point being too high ; others are unpleasant, and would not admit of being used in operations on the mouth or teeth ; others cause irritation of skin; others in their pure state are so extremely volatile that they could not be kept in the surgery for any length of time—this is specially the case with methylic ether and nitrate of ethyle, both promising substitutes for ether; lastly, a body too volatile would somewhat affect the operator during the operation if it were diffused in the pure state. — Nitrite of ethyl is open to this objection not so much as the nitrite of amy! would be, but to some extent.
In time we may, perhaps, by experiment, get a compound volatile misture which, being as negative as absolute ether in its effects on the body, shall boil a few degrees lower.
Before leaving this topic, let me state that the mere alteration or change of the volatile fluid used is no change of the principle of the present anæssthetic process. Ether itself is only a local anesthetic on being employed according to this principle. This is important to be borne in mind, otherwise a principle may become confounded with a detail, and every fluid with a low boiling point and the other physical qualities, as I have described them, for producing insensibility will be dubbed a local anæsthetic. By a slip of the pen, indeed, this error was committed in the Medical Times and Gazette of last week, a short leading article having been headed “Kerosolene a Local Anæsthetic.” Kerosolene-a body very impure, unpleasant, and of unsteady but low boiling-point—when applied by my method acts like ether, because it resembles ether physically. But kerosolene is no anæsthetic per se, although it would serve as a substitution agent for one part of the anæsthetic process, in the same manner, and in none other, as an earthenware bottle would take the place of the graduated glass bottle in which the volatile liquid is commonly retained.
Dr. F. D. Fletcher, of Southport, has suggested to me the employment of liquid carbonic gas, and, as will be seen by last week's Medical Times and Gazette, Sir James Simpson has had carbonic acid in view for some years. I believe the first physiologist who actually tried to apply the reducing agency of carbonic acid for the production of anæsthesia was the late Dr. Snow. He went to great trouble and expense to experiment on the gas in the solid state, and he applied it in that state to his own skin. Singularly enough, the insensibility produced was slow and imperfect, but the worst feature was that slough was always produced on the part where the acid had been applied. Snow, therefore, gave up the effort, convinced that carbonic acid in the solid form could never be made applicable in actual practice, and that if it could it would not be a safe agent.
I myself moved for a time in a similar direction by using carbonic acid in the liquid form. Mr. Robbins supplied me with the gas reduced in a three-pint iron bottle under pressure. When the stop-cock was opened and the carbonic was liberated through a fine jet, an intense cold was produced; but I utterly failed in attaching a conveying tube that would be applicable for operations. The pressure, in a word, was unmanageable, and for ordinary practice, dangerous. In one experiment, while the jet was being directed on the back of my band, the nozzle of the tube became set free, and, being projected with violence, injured me severely. I, therefore, like Snow, gave up carbonic acid as a body that would not submit to guidance, and as impossible to use in surgical practice.
We need not, fortunately, trouble ourselves on this subject. I have shown that by the dispersion of fluids of low boiling points we can get a