Ethyl Chloride as a General Anæsthetic, By M. FITZMAURICE-KELLY, M.R.C.S., L.R.C.P. (Late Resident Anesthetist St. Mary's Hospital.) It is only recently that Ethyl Chloride has been in use to any large extent as a general anæsthetic. Its action has, indeed, been known to the physiologist for a much longer time, but the clinician is ever distrustful of suggestions from the laboratory, and its employment as a surgical narcotic only dates from some five years ago. Since then it has rapidly advanced in favour on the Continent, and has even found its way into these islands. Quite recently it has been tried in the hospital theatre, and, as it seems to have some points to recommend it, I venture to think that a few notes about it may be of interest to readers of the GAZETTE. For some months stories have been circulating about the marvellous properties of Ethyl Chloride; one heard them, and one formed an opinion of the veracity of one's informants. But the surgeons showed a persistent interest in a device that promised to save their time, and at last it got a trial one evening. I was so pleased with the result that I have used it almost as a routine anæsthetic since; and further use and practice has only confirmed my early impression. In the first place, a word as to its physical properties. The liquid has a density of 0'92 at o°C.; the density of its vapour, taking air as unity, is 23. It is very volatile, its boiling point being 125°C., and it is important to remember that, like ether, it is inflammable. As an anesthetic, it may be employed in several distinct ways. It may be given alone, or it may be used to initiate chloroform or ether anesthesia. No special apparatus is necessary; perhaps the best results are obtained with an ordinary Ormsby's ether inhaler. The method I have employed is very simple, and it may perhaps be of use to give a short account of it. The apparatus required is an Ormsby's inhaler, a tube of Ethyl Chloride, and a gag-if the operation is within the mouth. The dose required is sprayed on to the sponge of the Ormsby, and the face-piece is immediately applied closely to the face. No air is allowed until anesthesia has supervened; this is, I think, an important factor in success. After a few seconds, if the patient is breathing freely, the pupils dilate widely; then there is a perceptible deepening of the breathing, which is slightly accelerated, and some rigidity of the muscles. This is quickly followed by muscular relaxation, not always complete at once, and anææsthesia is established. The conjunctival reflex, as a rule, remains present. The rapidity of the process is often startling; 20 seconds is about the average for children, while adults rarely take longer than 45 to 60 seconds. For short operations within the mouth, the inhaler is kept on a few breaths longer, and then removed. I have given it thus in 7 cases, the ages of the patients varying from 7 to 32 years. The average dose has been 4 c.c., varying from 3 c.c. to 7 c.c. The shortest anæsthesia was 1 minutes, the longest 4 minutes-quite an exceptional case-the average cases is small, and the average is, I think, too high; but 1 to 1 minutes is about what one expects. This is time enough for a moderately competent operator to remove tonsils and adenoids thoroughly, and to allow the extraction of many teeth. In the only two dental cases in which I have given it, 8 and 15 teeth were removed. But its use is by no means limited to these short minor operations. It may be given almost indefinitely, and cases are reported in which the anesthesia has been prolonged for more than an hour. I have given it for several long operations, the longest being an amputation through the thigh. This was a particularly interesting case. The patient, a girl of eighteen, had twice recently been anæsthetized-once for an excision of the knee for tuberculous disease, and a second time to make a further attempt to save the limb. On both occasions she took the anaesthetic so badly as to be in actu 1 danger, with a pulse, imperceptible at the wrist, counted 180 at the heart-and each time an intravenous injection of saline was given on the table, and she was in a grave condition for many hours. After a month of pain and hectic fever, amputation was decided upon. For the amputation, she was anesthetized with Ethyl Chloride, narcosis occurring in 30 seconds. The splints were removed at once, and the operation proceeded with. The patient kept a good colour; the pulse slowed from 156 to 140, and became distinctly fuller. Fresh quantities of the anesthetic, 2 or 3 c.c., were given about every 2 minutes, plenty of air being given in between; in fact, the drug was administered just like ether, but of course less freely. When the dressings were applied, the anesthetic was stopped, having been given for 32 minutes. Recovery took place in one minute, without vomiting, or any aftereffects except a feeling of faintness. Altogether, 38 c.c. were used from the tube, and no doubt some of it was wasted. If Ethyl Chloride is to be used in mixed anæsthesia the same method is followed. When anæsthesia is induced, the chloroform cone is substituted for the Ormsby, and the dose pushed slightly at first. It most cases the transition to chloroform anæsthesia is smooth and uninterrupted, though occasionally there may be some slight reflex movement in the first minute. For operations that do not entail absolute muscular relaxation, as in some operations on the extremities, the surgeon may start at once; in many of my cases the first cut has been made before the change to chloroform. But in abdominal operations it is safer, perhaps, to wait a minute or so longer. If ether is to be used after it, one may go straight on with the same inhaler. It needs a little practice to give this combination with success; if the patient shows any signs of coming round in the transition, the best plan is to spray 2 c.c. more of the Ethyl Chloride into the mask, and to push the Ether at the same time. Given in this way, the results are much more certain than the old " gas and ether" combination, even when given with Hewitt's apparatus; and at least 3 or 4 minutes are saved. I have in the last fortnight used Ethyl Chloride in thing over 50 cases. The patients have not been selected; the anesthetic has been used as a routine, on the assumption that it had no contra-indications, for every case that I was called upon to anæsthetize. The ages of the patients varied from 18 months to 67 years, and included a case of acute bronchitis, of mitral regurgitation, five or six of phthisis, and the usual percentage of alcoholic subjects. Among all these there was no failure to induce anesthesia, the most stubborn falling in 65 seconds. In a few cases there was some rigidity, and one or two reflex movements, but these were mostly among the earlier cases, and were due to mistaken ideas about dosage. In the great majority the transition was perfect, and the operation was begun immediately. With regard to the course of the anesthesia, there are a few points which need notice. One is, the difficulty of judging, by the conventional signs, whether the patient is ready for the operation to begin. The pupils dilate widely, and often remain so for 10 or 15 minutes. The colour is perfect, the breathing is a little deeper than usual, but easy and regular, and the conjunctival reflex is present and well-marked. My advice is to let the operation begin at once, and push on with the anaesthetic just as one would in a patient in whom chloroform anesthesia had been induced in the usual way; in fact, I think it is an advantage to get the skin incision over before the Ethyl Chloride anæsthesia wears off. With the conjunctival reflex present one is always safe, and it is extraordinary how sparingly chloroform need be given after the smooth, rapid induction by Ethyl Chloride. This is a matter in which each must feel his way for himself, and find out the best method by practice, but my own impression is that the succeeding chloroform anæsthesia may be lighter, and that less of the drug is required to maintain it. In the matter of dosage, one has much to learn. The average dose is about 5 c.c., but it varies within rather wide limits. For young children, 2 or 3 c.c. is amply sufficient, while for strong, alcoholic men 7 or 8 c.c. are needed, even 10 c.c. in some cases. have found it a good plan in the latter to induce anesthesia with 5 c.c., and then spray 3 c.c. more into the bag, and re-apply it. I It would be idle to claim that Ethyl Chloride is absolutely free from danger. The suspension of consciousness necessary for surgical purposes, however induced, is bound to be fraught with some risk to life. In the case of Ethyl Chloride, I can only say that my short experience has not enabled me to find out what the dangers are. There is no sign of vascular depression; the pulse, though usually slowed a few beats, is full and regular; indeed, an hyperæmic rash, exactly resembling the ether rash, is the rule. Respiration is also stimulated, and these effects persist even when the anæsthetic is pushed to abolition of the corneal reflex. So that it is difficult to see from what quarter danger comes, and statistics-for what they are worth-bear this out, there being only two deaths recorded in association with it, and these in cases so unfavourable as to suggest that the anaesthetic was not the cause of death. The question of cost is one that has to be seriously used-one sufficiently advertised in the journalscosts four shillings for a 60 c.c. tube to the retail buyer. So that, calling the average dose 5 c.c., which is a fair estimate, each case costs fourpence. This is about the same as nitrous oxide, and as the resulting anææsthesia is about three times as long, one can hardly grumble. The same dose is sufficient to initiate a chloroform anæsthesia, and, reckoning the chloroform that is spared, the extravagance can scarcely amount to more than twopence. If given throughout for a long operation, the cost becomes more considerable. In the longest case I have given, 32 minutes, half-a-crown's worth of the stuff was used; and though that would not be serious for private work, it is almost too great an expense for the hospital authorities to sanction. What, then, is to be the place of Ethyl Chloride in the anesthesia of the future? For short throat operations, especially in children, I think it is the best anæsthetic we have, and its use as a routine should diminish the terrible death-roll of Chloroform when given for the removal of tonsils and adenoids. In dental work, I am inclined to think that it will not replace nitrous oxide. This gives a long enough anææsthesia for a good operator to do all he wants in most cases, and the complete immunity from aftereffects is an immense advantage that Ethyl Chloride does not always possess. The latter should be of use in great clearances, as in the case already mentioned, in which 15 teeth were removed, and in cases where gas is contra-indicated. For Ethyl Chloride has no special contra-indications that I have been able to discover. But it is in general surgical work that it is likely to be of most service. Setting aside the saving of time, the rapid and safe induction of anesthesia is a gain that would outweigh many disadvantages. For it is just that dangerous period of chloroform narcosis, when the semiconscious patient, with the fear of death upon him, may succumb to syncope, that is avoided, and the anesthesia sets out with both cardiac and respiratory stimulation. In fact, it seems to me that the dangers of chloroform are greatly reduced by using Ethyl Chloride to induce anææsthesia; and from the patient's point of view, it is far pleasanter to take than ether used for the sa ne purpose, as well as much more rapid. Another great advantage, especially for private work, is the ease with which it is carried. The weight of the cylinders has always been a great drawback to the use of nitrous oxide; but the Ethyl Chloride tube can be carried in the coat pocket, and the Ormsby is always with us. It should certainly recommend itself to men in practice who give anæsthetics but seldom, as being both easy to use and safe, while in hospital practice it will soon prove indispensable both to surgeon and anæsthetist. In conclusion, it must be remarked that there are other methods and other inhalers recommended. They may be excellent, but I have no experience of them. No doubt readers of the GAZETTE will find many valuable suggestions in the literature that is springing up round the subject; meanwhile, the method described gives quite good results, and is at Notes. Sir William Broadbent will present the Testimonials to Sir Anderson Critchett and Mr. Malcoln Morris on Friday the 20th of this month, in the Board Room of the Hospital. It is hoped that there will be a large attendance of the friends of these two distinguished members of the consulting staff, who served the Hospital so well through a long term of years. We are asked to make it known that Ladies are invited to attend. Any Gentlemen who have not yet subscribed and wish to do so, should send their subscriptions at once to Mr. Geo. P. Field. The subject of the Harveian Lectures which Dr. Lees gives this year is "The Treatment of some acute Visceral Inflammations." The first lecture was given in the rooms of the Harveian Society, Titchborne Street, Edgware Road, on Nov. 5th. Mr. Silcock has delivered some capital lectures in the Operating Theatre, and the large attendances showed how teaching of this sort, with the cases in attendance, is appreciated. The first of the series was especially interesting, as Dr. Wright also spoke, two cases shown having been materially benefited since treatment by his tuberculin. Might we not venture to hope that some day there will be a revival of the "Front Row"; the tradition is too good a one to die out. The careful and scholarly paper by Mr. Morris on the History of Paddington has been standing in type for some time, and we apologise to the author for unavoidable delay in printing it. It is always surprising to learn how recently country was where London is. Nightingales in Lisson Grove! though we certainly have heard of a fauna of about that size in the neighbourhood. Ask the externes. We print in this number a letter from Dr. Oswald Browne, written on behalf of the Uni chance that it may appeal to some adventurous spirit who wishes to see a little of the world before settling down to the humdrum of General Practice. The chance of gaining experience, not only of surgery but of men and of life away from the tall hat and frockcoat which oppress us at home, is not one to be lightly missed in early life. As years pass the ties which bind us down to one place become increasingly strong, and the opportunities" for to admire and for to see " become fewer. An Examination of Candidates for not less than 30 Commissions in the Royal Army Medical Corps will be held on 28th January next and following days. Applications to compete should be made to the Director-General, Army Medical Service, 68, Victoria Street, London, S.W., not later than the 18th January, on which date the list will be closed. The presence of Candidates will be required in London from 26th idem. Candidates who are over the regulated. limit of age at the date of the examination will be permitted to deduct from their actual age any period of service in the field after 1st October, 1899, that they could reckon towards retired pay and gratuity, if such deduction will bring them within the age limit. The Medical Society have every reason to be satisfied with the result of their innovation. The debate on the subject of Medical Education was most successful. Possibly as the Secretary suggests it would be better if the subject were one on which a division could be taken. But it should be easy so to word many of the propositions put forward for debate as to allow of members taking sides in discussing them. Possibly there might be some way found of so wording the subject of the next debate, though general Peritonitis lends itself less to division of opinion than Medical Education. The last two meetings of the Medical Society have been addressed by Dr. Graham to publish both papers in course of time, we need make no further comment on them meantime. Dr. C. F. Coombs will read the next paper "On the results of Rheumatic Infection." To add to the interest of that meeting a further series of microscopical specimens illustrating Rheumatic Infection will be shown by Drs. Poynton and Payne. We are glad to know that Dr. Poynton has been persuaded to retain the Presidency of the Society which he has served so well for many years. We do not quite know what to say about the football teams this season. Of course it is early in the season yet, and possibly an early recognition of the fact that the teams are not brilliant will lead to the development of soundness and hard work which in the long run will score better than brilliancy. The Association Club commenced the season well with a victory over the City of London School, but since then up to the time of writing, they have had to put up with defeat. The Rugby Club have had a succession of defeats. We do not think that either club need be discouraged by these early reverses. The Cup Ties do not come on for some time yet, and in a couple of months very much can be done to make a team. It is hardly necessary for us to insist on the necessity for each individual member of the team doing his best to play up to the top of his form, but what we would like to lay stress on is the responsibility each man has to support the respective captains and secretaries by turning up regularly, not only to matches, but to practice games. Many a time has a good team been made out of material by no means so good as we have at present, when the men had learned to play together, and to play hard. There are strong teams to be met, but they are not too strong for the teams that could be produced in St. Mary's if only We congratulate Louwrens on being the only man to score on the side of the United Hospitals against Cambridge University. The process of installing the Electric Light in the Wards of the Hospital proceeds apace. We must congratulate the authorities on the way in which they are managing this important transformation with so little dislocation in the normal working of the Hospital. The improvement is a most marked one, and the conveniences are great. The post which has been recently created on the Surgical side of the Hospital will, we think, be found to be one of the most important and useful posts which can be held The name which has been by a junior inan. chosen of Casualty House Surgeon is possibly not altogether fortunate, as it is apt to give the idea of a somewhat glorified in-dresser. There will be a lot of responsibility thrown on his shoulders, and that will be one of the most important advantages from the point of view of future practice. Too frequently a doctor passes straight from the wards of a Hospital, where he can, in any doubt or difficulty throw all the responsibility on to his Surgeon or Physician, to the full charge of a private practice where he has to stand all by himself, and where for every mistake he makes he has to pay the penalty, and if the mistake be serious, a very heavy penalty. This new post will be a half-way house, where the responsibility will be great, but where support will be available if necessary. We understand that the regulations relating to this new office are still under discussion, but we are sure that when they are settled, it will prove to be one of the most valuable posts that a junior man can hold in the Hospital, and it has the additional advantage of being a paid post. Rehearsals for the Dramatic Entertainment to be given at Christmas time are already in progress. We understand that the Board-room Dramatists are showing Wild horses would not draw the name of their production from us, but the laurels of the only Arthur will be endangered, and the fair forms that flit o'er the Gaiety boards will find themselves rivalled by the stars that are destined to shine in the Out-Patient Hall at the end of the year. The Committee of the South African Memorial have adjourned the final decision as to the form the Memorial should take until the New Wing is somewhat nearer completion. The choice lies between a stained glass window and a piece of sculpture in the form of a mural tablet. The rumour runs that a well known sculptor has promised to help if the decision should be in favour of the latter proposal. The total sum collected amounts to one hundred and six pounds, and for this response, more generous than was anticipated at the outset, we have specially to thank the efforts of Dr. Poynton and Messrs. Whitworth Jones and Wood. We hope sometime to publish a short paper on "the Motor Car, considered (1) as a means of Progression," and (2) “as a means of obtaining exercise." The author of the paper holds very pronounced views on the subject, but we hope to be able to modify the language sufficiently to enable it to appear in our columns. It is again rumoured that the Hospital Pharmacopoeia will shortly appear. Some months back we published one or two epitaphs of professional interest. Lately we received from an old St. Mary's man, well known in his day and generation, the following one on Civiale, the great protagonist of the operation of crushing stone in the bladder :- "Here where the dead are laid In this cemetery lone, No monument on his grave displayed, The remark came from a distinguished surgeon who had just seen a succession of fifteen cases of specific disease in different soon have the County Council erecting fountains for supplying the British public with Liquor Hydrarg. Perchlor. one drachm, Potass Iodid. grains ten, and distilled water to the ounce." It was quite another surgeon who was set down at the doors of St. Mary's one day by a hansom. He had driven from some remote part of London, and the cabby demanded. seven and six as his fare. "Look here,” said the surgeon, "it isn't the horse I want to buy." again in another form lately, when the small It's a chesnut possibly, but it turned up girl meekly asked the cabby, "But must we take the poor old horse away?" We must congratulate the Rugby Football Club on the excellent form in which they have issued their Fixture Card for the present season. If their results only conie up to their card, we may expect to see the glint of silver from the walls of the Library again. We noticed the other day that the Rugger team were to start for a certain town from "St. Pancreas" Station. Since the production of "Little Mary" it would seem that splanchnology is becoming quite comme-ilfaut as a topic of general conversation, but we were not aware that railway directors had been driven to the viscera for the names of their stations. This is true, as many will testify. An OutPatient Surgeon was in a hurry, and a mother brought in a child whose distorted limbs cried aloud of a tinned food dietary. "What did you bring it up on? Hurry up now," exclaimed the surgeon. "On a tram sir, and then a 'bus," came the glib answer. Of the humours of the Examination Hall there is no end, but we venture to think the following gem, which hails from the Dental side, and for whose authenticity we vouch, will take a lot of beating. The question ran thus: "In what different ways may |