The other case was in a woman who had lost a large amount of blood, and an operation was performed with the patient lying on a bed. Suddenly she became pale and respiration ceased. After a few minutes' artificial respiration, without the injection of any heart stimulant, she was revived, and the operation was proceeded with. There was no further trouble. I afterward found that she had formerly been under chloroform on two occasions for surgical operations, and the surgeon had to discontinue because she could not take chloroform. I did not know this before I began to give her chloroform.

The question has not been fully settled in my mind as to the mode of death from anesthesia, and I am very much inclined to think the cause of death is not always the same. I have never seen a death from chloroform anesthesia except in dogs, and all of these ceased breathing before the heart quit beating. I have killed several dogs with chloroform, and it has always required several minutes, though I had one to die in another's hands, while I was preparing for operation, inside of two minutes. The conclusions of Hyderabad Chloroform Commissions. on this point are thus clearly expressed:

"The inhalation of chloroform vapor, no matter in what doses or in what manner carried out, can not kill a dog by acting directly upon its heart. We must invariably affect the nervous mechanism of respiration before involving the cardiac centers of the medulla oblongata or affecting the contractions of the ventricles and auricles to any extent. The commission further consider that chloroform vapor administered to dogs never kills by acting on the intracardiac ganglia, either primarily or secondarily. It is impossible to produce syncope from chloroform in dogs. The commission are of the opinion that in the dog the danger of life from chloroform inhalation arises only when the cells of the respiratory centers (both respiratory and expiratory) of the medulla oblongata have their functions interfered with."

These positive assertions of the first Hyderabad Chloroform Commission were the outcome of carefully and ably conducted experiments on one hundred and forty-one dogs in the year 1888. They were so opposed to clinical evidence, and the results of the experiments of the Glasgow Committee and others, that their deductions were not generally accepted as applicable to man. A second Hyderabad Chloroform Commission was held in the following year. The experiments numbered five hundred and eighty-eight. They were conducted chiefly upon dogs and monkeys on thoroughly scientific principles, and "were

designed to show the effect upon the blood-pressure, heart, and respiration of the inhalation of chloroform, ether, and the A. C. E. mixture, administered in various ways and under varying conditions." The results of this commission were the same as those of the first.

In quoting from Bartholow on the same subject, we have as follows: 1. By the first mode, the death is sudden and occurs very soon after the inhalation has begun, and is ascribed to "irritation of the peripheral nervous system, accumulation of carbonic acid in the blood, and arrest of the action of the heart." This explanation, the author submits with diffidence, seems very unsatisfactory, for phenomena of this kind, up to the point of cardiac paralysis, must ensue in all cases of chloroform narcosis. The sudden death at the beginning of inhalation seems to be more properly explicable on the theory that the first chloroform vapor which reaches them paralyzes the cardiac ganglia, already in an abnormal state of susceptibility from causes not now understood, for this accident sometimes occurs in persons who have previously taken the anesthetic without unfavorable symptoms of any kind.

2. By the second mode, called by Richardson epileptiform syncope, death ensues in the stage of rigidity preceding complete muscular relaxation, and is due to tetanic fixation of the respiratory muscles, and consequent interference with the pulmonary circulation, accumulation of the blood on the venous side, and arrest of the heart's action. In these cases respiration ceases before the pulsations of the heart cease.

3. By paralysis of the respiratory muscles. Death ensues during the stage of complete muscular relaxation, and the action of the heart continues for some seconds, or even minutes, after respiration has ceased.

4. By paralysis of the heart. This also occurs in the course of complete insensibility; the motor ganglia are paralyzed, and the heart suddenly ceases to act, the respiration continuing for a short time. longer.

5. This mode of dying is made up of two factors: Depression of the functions by chloroform narcosis and the shock of the accident or the surgical operation. Death may ensue during the inhalation, or may occur afterward.

An anesthetic should never be begun unless there has been made. every preparation for resuscitation. For shock attending the operation hot applications over the chest are first in importance. Heart stimu

lants, such as whisky, strychnia, nitro-glycerine, and atropine, are valuable, and each has its place in suitable cases. Nitro-glycerine is the most rapid of the above named drugs, to be used hypodermatically. Nitrite amyl is safe if used carefully, and is the most rapid of all heart stimulants.

I do not consider chloroform a heart depressant if given in proper amounts and administered slowly. Organic heart disease is no barrier to the use of chloroform unless there is dilatation of the heart without hypertrophy. There should not be given any thing into the stomach immediately before beginning the anesthetic. It is sure to cause vomiting. When vomiting does occur, don't withdraw your anesthesia if you are sure there is no food in the stomach. It only prolongs the time, and there is no danger if there is no food to be regurgitated into the air passages. Push the anesthetic and the vomiting will cease. It is an admirable plan to keep the hand under the jaw to keep the tongue up in the mouth. I have never had a case where the tongue was swallowed.

In conclusion, chloroform is more pleasant to inhale than ether, and more rapid even when given slowly enough to make it pleasant; old people bear it better than the middle aged, as do also children. It is less likely to cause nausea; is less irritating to the kidneys. It can be given where it would be dangerous to give ether (I refer to where there is an open flame). It is in my opinion not more dangerous when given by a man who is wide awake, careful, and has good judgment, and one that does not care more for what the operator is doing than what he is doing himself.

A drug that is regarded by most authorities as the best heart stimulant and equalizer of blood pressure is atropine. There is one great objection to this, viz., in abdominal cases, where you do not want to give the patient any thing to drink for some time after the operation, it makes the mouth and throat so dry that it is almost unbearable. Otherwise it is one of the best drugs that we have for use in depression of the heart or the circulation when chloroform is being administered.

LOUISVILLE.

Reports of Societies.

THE LOUISVILLE MEDICO-CHIRURGICAL SOCIETY.*

Stated Meeting, May 31, 1901, the President, T. L. Butler, M. D., in the Chair.

Bright's Retina. Dr. J. M. Ray: The patient I wish to present is a man aged thirty-one years. He came first to the University Dispensary with the history of dimness of sight and headache. He said these headaches had been persistent for several months, and that recently his sight began to become dim. He first presented himself during the month of April of this year, and Dr. Lederman, who had charge of the clinic, asked me to look at him. I examined him, and we then turned him over to the medical clinic for treatment. Since then he has been under the care of Dr. Blitz.

The man was in good health up to the time he began to suffer with headaches, but since that time he has gone down rapidly. He presents a most typical picture of Bright's retina. I have his pupils partially dilated with atropine, and as we have several times had the subject up for discussion before this Society, I thought it might be interesting to have the patient come before you. His vision is about, but he says

it has gotten a little better recently.

The diagnosis of Bright's disease was not made until the eyes were examined with the ophthalmoscope. I brought for your examination an atlas of ophthalmology, which contains several pictures illustrating this condition, and two of them, which I show you, resemble very much the picture of this man's eyes as seen by the ophthalmoscope.

Discussion. Dr. T. C. Evans: The case presents a beautiful illustration of Bright's retina. It is a little strange that the so-called typical cases, as laid down in our text-books and atlases of this disease, are really the rare ones. I have seen very few that conformed to the pictures given in our text-books. This case shows the spots plainly, but does not show the stellated appearance around the macula given. in all text-books on the subject.

Dr. William Cheatham: This is a typical case of Bright's retina, and it is especially interesting, inasmuch as the diagnosis was made by the ophthalmoscope before the condition was recognized by the family practitioner. This is rather a common occurrence.

*Stenographically reported for this journal by C. C. Mapes, Louisville, Ky.

I have seen a good many of these cases; one was the case of a prominent judge whose wife is now living in this city. He had been under the care of Dr. Hammond, one of the most noted neurologists in the country, for some trouble, and when he returned here he complained of loss of vision, etc. I examined his eyes, and found he had typical neuro-retinitis. He lived but a few months.

Another similar case was a prominent manufacturer of this city. Such cases are always interesting, because of our ability to make the diagnosis with the ophthalmoscope. In these typical cases we can make the diagnosis beyond any doubt with the ophthalmoscope; some of them, however, may simulate other conditions; for instance, the anemias and the other condition that we sometimes see in diabetes, but we often have associated with diabetes involvement of the kidney. In a typical case like the one presented a mistake could hardly be made with the ophthalmoscope. I do not believe, however, that the changes in the retina indicate the amount of change in the kidney, or the approaching termination of the disease. There may be a small hemorrhage or a small spot of fatty degeneration, yet it may indicate an early death. The prognosis can not be made by the amount of change in the retina, but by watching the progress carefully the prognosis can be made as to termination with a fair degree of certainty.

Dr. J. G. Cecil: This subject has been emphasized so often that it is hardly necessary to discuss it further before this Society; yet Dr. Ray and myself now have under observation a widow who has the general appearance-the urinary symptoms and gross appearances of Bright's disease-with dimness of vision, yet I do not believe he has ever demonstrated any change about the retina as far as the ophthalmoscope is able to reveal it. It is a very interesting line of observation to me, and I have always taken occasion to have my own opinions verified by the oculist in this class of cases.

I would like to ask Dr. Ray, or some of the other oculists present, if there is any especial tendency to ocular change in any particular kind of Bright's disease; that is, whether it varies much between the parenchymatous or interstitial varieties.

The case to which I have referred has been of unusual interest to me, because the lady in question has for a long time, many years, suffered from edema of one leg and not the other; but only recently has she shown any urinary symptoms, unmistakable evidences of Bright's disease. She improves under treatment directed to that special feature