IN

N connection with the forthcoming Centennial, the University will have an opportunity to show honor to a number of her alumni who have attained distinction in various walks of life. As the Institution has been devoted so largely to professional training, it is especially in the professions we find them prominent. There is hardly a city of the country in which there are not a number of eminent doctors, lawyers, ministers, pharmacists, dentists, teachers, etc., who claim and cherish warmly their association as graduates with this University. In honoring them the University will honor herself and cement still more closely those ties which policy, no less than sentiment, demand should be drawn ever closer and closer. We are glad to learn that this sentiment is being fully recognized by our authorities, and that the occasion will partake in so large degree of family felicitations and filial appreciation.-Old Maryland.

BALTIMORE CITY AS IT APPEARED AT THE FOUNDING OF THE COLLEGE OF MEDICINE OF MARYLAND IN THE

ON reviewing the current medical literature I find an enormous amount of material on the subject of anesthesia and on the verious methods of administration. None of the methods suggested, however, can approach the drop method if it be properly applied. The vapor method as described by Gwathmey in the Journal of the American Medical Association, October 27, 1906, with a few improvements in his apparatus and by preceding the ether vapor with either nitrous oxide or kelene, will in all probability be the only method that can in any way approach the drop method.

About a year and a half ago I first saw the drop method, during a visit to St. Mary's Hospital in Rochester, Minn., where it was so skillfully administered by Miss Alice Magaw and her assistant. Later I again was impressed with its merits by seeing it used at the Mercy Hospital in Chicago, where it was equally well administered by a Sister of Charity. I have seen it administered in various other institutions, but, unfortunately, in many instances new interns were given the very responsible duty-a duty only secondary to that of the operator. In these cases the anesthesia was poorly given and the true merit of the method inadequately demonstrated. Too much importance cannot be given to the anesthetic.

We often fail to appreciate the responsibilities of our positions when we have the patient's life absolutely in our hands, frequently hovering between life and death. That the patient should be in a certain state of anesthesia is of great importance to the operator, and in many instances the success of the operation depends quite as much upon the anesthetist as upon the operator. We can readily see that if the surgeon is working in the pelvis or abdomen and the patient is not kept thoroughly anesthetized the contraction of

the abdominal muscles antero-laterally and the diaphragm above causes the intestines to force through or around the packing and to obstruct the view of the field of operation, and even serious complications may develop. If there is an infected area the healthy intestine will become infected and the patient may be lost from general peritonitis, due solely to the lack of skill of the anesthetist. In a case of simple appendectomy if the patient is not relaxed there is great danger of gas and of particles of fecal matter being forced into the cecum, and the stump of the appendix may open after it has been sealed with the clamp and cautery before the surgeon has had time to apply the sutures. Here again there will be great danger of peritonitis, and the loss of the patient will be due not so much to the operator, but to the anesthetist. If the surgeon is working in the cranial cavity it is most important to keep the patient quiet and free from cyanosis. Suppose the patient should choke, cough, become black in the face, the small veins that did not bleed and would not ordinarily give any trouble now bleed freely, and consequently the surgeon would almost have to abandon the operation or the patient might die without warning. So it is with operations on the eye, such as iridectomy; a slight motion of the patient may cause the loss of an eye.

It has been my custom during my nine years of work at the Church Home and Infirmary to ascertain the condition of the patient before the administration of the anesthetic. Always make yourself familiar with the thoracic and abdominal examination. Always learn fully about any pathological condition of the blood or urine. Examine the air passages for obstruction, such as false teeth, gums, tobacco, etc. New growths in the nasal cavity or malformations may cause serious obstruction to the free entrance of air. Frequently the malformation of alae of the nose act as a valve to shut off the free entrance of air.

One of the most important procedures is to gain the confidence of the patient. Make him or her feel that they are absolutely safe in your hands and tell them how to breathe and what is expected of them.

For several years it has been my custom to put a piece of rubber protective over the patient's eyes to shield them from the ether vapor. Since adopting this method I have not had a single case of ether conjunctivitis. The face is protected with a moist towel or gauze, which extends over the rubber tissue and around the chin. The apparatus usually employed for the adimnistration of ether is a wire frame, patterned very much after the Esmarch chloroform inhaler, made larger in order to give more space under the inhaler for the mixture of air and ether. The outline of the mask curves to fit the face closely. The wire frame may be covered with one or two layers of stockinette or several layers of gauze. I have found by experience that the air space under the frame should contain about 25 cubic inches-that is, about three times larger than the ordinary Esmarch's chloroform inhaler. The best covering is about six layers of ordinary gauze, which can be quickly

applied and thrown away after being used. The wire frame. should be boiled immediately after use. The mask is applied over the patient's face and the ether dropped on drop by drop, very slowly at first, then gradually increasing as the patient is able to take the stronger vapor. Finally, about the time he will not respond to questions, a moist towel or gauze is wrapped snugly around the mask, leaving a small area in the center for the free passage of air through the gauze. By this method the air is prevented from escaping around the edges of the mask and is made to pass through the ether-laden gauze. The ether should not be dropped on faster than the patient can comfortably breathe it in. Patients should, preferably, be anesthetized on the operating table. Such cases as are too nervous to be taken to the operatingroom can be put on the table in the anesthetizing-room and rolled into the operating-room after the anesthetic has taken effect. The anesthetizing-room should be kept absolutely quiet, no unnecessary talking, slamming of doors or heavy walking, as all sounds. are very much magnified to a patient who is about to pass into the second stage of anesthesia. Never be in a hurry to put the patient to sleep. Do not let an impatient operator worry or hurry you on, but remember that the welfare of the patient, yourself and frequently that of the operator depends upon the slow and gradual ratio of the increasing concentration of the ether vapor. The patient will become unconscious in two or three minutes, and should be ready for the operator in about 10 minutes. When a patient has become completely anesthetized, very little ether, dropped slowly, but continuously, will suffice to maintain the proper condition.

The further efforts of the anesthetist should be devoted to observing the respiration, pulse, pupils and the patient's general condition, and to prevent him from passing into that dread stage of respiratory paralysis. The respiration should be quiet, with perhaps a very slight snore. Panting and rapid breathing, irregular stertorous breathing indicates that the patient needs more air. The pulse should be regular, full and bounding. The pupils should be normal in size, quickly responding to the light. A pupil that is rapidly dilated indicates danger, and an immobile dilated pupil indicates extreme danger.

Of the 2000 recent ether anesthesias in the Church Home and Infirmary 1500 were given by the old-fashioned crural cone method, 500 by the drop method: 100 of these were kelene-ether sequence; about 200 of those given by the cone were chloroformether sequence. Since adopting the open method I have discarded the chloroform-ether sequence, as I was not able to detect any advantage in it over straight ether. A patient can be put to sleep. as quickly, and perhaps with less inconvenience, with the ether dropped on rather cautiously as with chloroform. Of the 100 kelene-ether sequence the patients have gone to sleep promptly, without any unpleasant sensations, in from 30 seconds to one minute and a half. Those who have taken nitrous oxide say the

kelene is more pleasant, as they did not feel as if they were breathing "nothing," and surely they did not look as if they needed oxygen; on the contrary, they maintained a good color, with the face slightly flushed. Anesthesia by the kelene-ether sequence can be produced by one of two methods-the patient is fully anesthetized with the kelene administered with any good closed inhaler, such as the Hollenberger, Green or Wore-Stork, or for children the semi-open inhaler devised by Wore. Dr. A. E. Osmond of Cincinnati, uses an ordinary glass funnel with great success. During an expiration the ether work is substituted and ether continued by the drop method. The period of kelene anesthesia is of such short duration that the patient begins to loose the effects of the kelene before the ether anesthesia can be produced; consequently there is a slight disturbance and time lost. In order to overcome this difficulty I had Gwathmey's gas-ether apparatus so modified that the kelene can be gradually discontinued and the ether slowly substituted by the closed method. In two or three minutes the patient is fully etherized. Then the ether is continued by the drop method. As a rule, just enough ether is given to keep the patient quiet and relaxed. A majority of the cases begin to wake up before leaving the operating-room. Many of the anesthetics were given for Dr. Thomas S. Cullen, who in all abdominal cases orders a one-quarter grain of morphia before the patient. leaves the operating table. These patients usually sleep for several hours, awakening with comparatively little nausea. I find there is a great deal less vomiting after the drop method. After an abdominal operation the patient is given plenty of water, so that if vomiting does occur the water brings up the mucous; if no vomiting, then any mucous in the stomach is at once carried by the water into the intestines.

THE DISPENSARY TREATMENT OF

NEURASTHENIA.

By William Rush Dunton, Jr.,

Assistant Physician, the Sheppard and Enoch Pratt Hospital, Towson, Md.

THE treatment of neurasthenia has always been a long, tedious task, taxing the patience of both physician and the subject, and it is only in recent years that the treatment of these cases seems to be getting shorter in duration and less taxing to those concerned. As most of my medical work has been in a hospital for the insane, where the patients, in addition to neurasthenic symptoms, usually have some mental trouble, the treatment of these cases did not follow the exact technique as laid down by Weir Mitchell, but was subjected to certain modification on account of the necessity of paying primary attention to the treatment of their mental symp