of her case, yet she has decided dimness of vision. I saw her this afternoon, and she is getting gradually worse, and yet Dr. Ray has never been able to demonstrate any change about the retina.

Dr. J. M. Ray: In the case I have exhibited the examination can be so easily made that I thought the members, outside of the specialists, would be interested, is my reason for bringing the man here. Interstitial Bright's disease is the form in which the fundus is most likely to show the characteristic changes. Dr. Blitz, under whose care this patient has been, has taken considerable interest in the case, and has examined the urine a number of times. I expected to have his analysis, but it was overlooked. The prognosis in this case is unfavorable; I believe the man will live but a short while.

Dr. William Cheatham: I think I have mentioned before this Society on several occasions a most remarkable case of this kind, the patient being under the care of Dr. Cottell, in which the ophthalmoscope showed changes in the retina at least six months before there were any urinary symptoms. Dr. Cottell examined the urine time and again without finding any thing to indicate Bright's disease. The patient lived but a short time after development of symptoms referable to the kidney. It is in the interstitial or contracted form of kidney that the retinal changes are most often observed. The prognosis is always bad, as retinal changes do not often occur until late in the disease. Patients do not, however, always die promptly. I have seen one case where the patient lived eight or ten years after the appearance of changes in the retina. It is also remarkable, in some cases, that extensive changes in the retina may exist, and still the patient have almost perfect vision.

The essay of the evening, "Some Observations on Administration of Anesthetics," was read by Dr. B. C. Frazier. [See page 12.]

Discussion. Dr. A. M. Vance: I know very little about the practical administration of the anesthetic; I have performed this function but few times, and this has usually been when I was alone in emergency cases. I have always been a chloroform man, probably because I have always had a gentleman as anesthetist who understood the administration of chloroform better than he did ether, and I have never lost a patient on the table when chloroform was administered as the anesthetic. I have seen but two deaths on the table in my own work, and in both of them ether was the anesthetic, and both patients died

from shock. I do not believe the anesthetic had any thing to do with it.

I agree with Dr. Frazier that his method must be good, because probably in the vast majority of his six hundred cases the anesthetic has been given for me, and I feel perfectly at ease when I have him at the other end. And it is the greatest factor in the world for the surgeon to feel that he has some one at the other end upon whom he can depend; that he can go ahead with his part of the work without worrying about the anesthetic. I know of no more distressing position in which the surgeon can be placed than to have somebody in whom he has no confidence as the anesthetist. I believe chloroform is the safer

anesthetic in proper hands.

Dr. T. H. Baker: I will briefly relate two cases in my own experience, one in which Dr. Dabney was to enucleate the eye of a phlegmatic, beer-drinking German who was never gotten beyond the stage of excitement. Whenever I attempted to bring him beyond that point he would stop breathing. After we inverted him four or five times and then resumed the anesthetic with the same result, the doctor finally enucleated the eye without going any further.

The other case was a man in the second stage of consumption, and a competent surgeon was going to perform a hemorrhoidal operation. The surgeon in this case became more frightened about the actions of the patient than anybody else, and absolutely refused to proceed with the operation that day. The following day the patient took the anesthetic as nicely as any one I ever saw, and the operation was completed without trouble.

I have never seen ether administered except in the East, where it seems to be used exclusively, and where they apparently give it without the least thought about any danger, and, it seems to me, in a very careless and haphazard way, a student being frequently brought down to administer the anesthetic. I do not like ether, either in immediate or after-effects, as well as chloroform.

Dr. L. S. McMurtry: Dr. Frazier has given us a very interesting paper, and it is especially valuable because he has selected the most important points after a very large experience in the administration of chloroform, and certainly the subject is one which can never cease to possess interest, and its repeated discussion is bound to be profitable to us all.

One of the great difficulties encountered about the administration

of anesthetics, both chloroform and ether, is that this subject is greatly neglected in our system of medical education. Students, as a rule, are not practically instructed in the administration of anesthetics, and unless a man has the advantages of service as interne in some hospital, or happens to have the good fortune which Dr. Frazier has had early in his professional experience, the association with an active, careful surgeon as anesthetist, he has no practical knowledge when he begins in the profession of the use of anesthetics. I believe it ought to be the case in every medical college which has connected with it a hospital, as all medical colleges now have, that there ought to be a practical system of instruction on anesthetics, where an experienced anesthetizer like Dr. Frazier might take fourth-year students with him, stand over them and show them how to administer the anesthetic. That ought to be part of the fixed curriculum of study in every medical college.

Dr. Frazier has limited his paper to chloroform, which is the most popular method of anesthesia; but I have seen ether given a great deal, and have given it myself for several years. Here in Louisville, and in the South generally, under the influence particularly of the teaching of the elder Gross, who molded professional opinion on these subjects very much in the earlier years of the present generation of surgeons and others of his pupils, ether is not as favorably regarded as it deserves to be. We have ideas about it that I am satisfied in many instances are incorrect. Take, as an example, the idea that ether is so dangerous to the kidneys. This is incorrect. But, as stated by Dr. Vance, if a man knows how to give chloroform and knows nothing. about the administration of ether, of course chloroform in his hands will be the safer anesthetic. If a man is accustomed to giving ether and knows nothing about the administration of chloroform, then, of course, ether will be the safer. There is almost no similarity between the methods of giving these two anesthetics.

In the first place, we will find there is a great difference in the subjects to which anesthetics are given. Women take anesthetics much better than men, as a class; children usually take anesthetics well. I do not know exactly why it is that women take anesthetics better than men, unless it is that men are accustomed to habitual drinking, which is far more common with men than with women; such men do not take anesthetics well. Take a man who is given to his daily dram, and you will find him an exceeding bad subject for anesthesia, and the stage of

excitement will be prolonged. Another reason is that women trust themselves more completely to the surgeon after they make up their minds to have an operation performed than do men. They lay aside all idea of helping themselves, all idea of watching the progress of the operation; they give themselves up more than men do, and consequently the element of fright is more eliminated, and this of itself is a great element of danger.

Dr. Frazier has spoken thoroughly of the preparation of the patient, which is so frequently disregarded. I especially wish to emphasize his remarks on that subject, particularly the three days' preparation spoken of where this is possible, in order to have the patient prepared to take the anesthetic. In the preparation of the patient the instructions he gives are of the greatest importance. The patient should have a brisk cathartic; the alimentary tract should be thoroughly emptied; the patient should have an abundance of water, so as to place all the emunctories and eliminative organs, skin, and kidneys in good condition; the patient should have warm baths so as to empty the skin and deplete all congested blood vessels of every part of the system. We know how common it is to send a patient to the hospital one day and operate upon him the next. Such a patient will usually be found very troublesome. The diet should be carefully looked after; all vegetables should be interdicted, and every thing depleted by elimination.

It is important that there should be perfect quiet about the patient when the anesthetic is administered. I believe the psychological condition is a large feature in the danger from the anesthetic. If it is possible, the patient should not be anesthetized in the immediate vicinity of the operating-room; the patient should not be allowed to see the assistants in gowns, nor any of the paraphernalia of surgery which we as surgeons see every day and are accustomed to handling, but to those unaccustomed to them they are frightful. The greatest danger to a patient who is going to take an anesthetic is fright. We should, therefore, have the patient under conditions that are peaceful, where there is nothing about to suggest danger. The anesthetist should cleanse himself thoroughly; put on a washable coat, and be in a condition to protect the patient from infection in every way; and then he should go into the room quietly and always examine the patient before commencing the anesthetic; even if he is satisfied about the patient's condition he should examine the heart, etc., in order to eliminate the question of fright. Every surgeon here knows that, no matter how serious the

surgical operation to be undertaken, the patient will invariably tell him "I do not have any fear of the operation, it is the chloroform that I am afraid of." They are in a state of alarm about that all the time. They know there is danger in it; they have all heard about it. This element is always present, and can be dissipated by a little tact and patience on the part of anesthetist. Frequently in hospitals no preparation of the patient is made; he is wheeled into the operating-room before narcosis has been completed, while he is still conscious of things about him, all of which is entirely wrong. The anesthetist should not talk to the patient while the anesthetic is being administered; perfect quietude should obtain in order that the patient may feel as if he is going to sleep; it is not necessary to tell the patient to breathe deeply.

I have never seen the necessity of seizing the patient's tongue with forceps. Three years ago I witnessed a series of operations by Richelot in the hospital of Paris, and I have never seen a more barbarous method of administering the anesthetic than they practice there. As soon as consciousness was abolished they passed a double tenaculum forceps on the tongue locked, and held it there one and a quarter hours during the operation. The patient suffers severely from this, and it is entirely unnecessary.

As Dr. Frazier has stated, it is not proper to continue to touch the conjunctivæ during the operation. I think Dr. Ray will tell us that it may be productive of much harm. All danger of burning the patient with the anesthetic should be eliminated. The anesthetist does not know it, but the surgeon often knows it afterward, that the patient is frequently burned about the face with chloroform, and considerable suffering is thus entailed; it gives the patient a bad impression about the whole procedure. Women with delicate skin are often burned about the neck and face from falling of the chloroform, which makes them exceedingly uncomfortable after the operation.

In regard to resuscitation of a patient apparently dead from the anesthetic, I have never had the unfortunate experience to lose a patient from the anesthetic, and I think this is an evidence of the safety of anesthetics. I have operated a great many times in the country, where the doctor who gave chloroform for abdominal section had not performed this function three times in five years. I have operated in all kinds of conditions and surroundings, and have never lost a patient from the anesthetic. When we take into consideration how many people are giving anesthetics every day, how little preparation is