Two cases in which, through extensive injuries of cranium, large areas of brain proper were exposed. Linder prolonged amesthesia, chloroform reduced cerebral circulation. In onc ease in which the local lnernorrhage was severe tile latter subsided as soon as patient was fully under amesthet ie. Bedford Brown (Titer. Caz., Dec. 15, '94).
The -use of chloroform and ether is always dangerous in ordinary dental sur gery, and is unjustifiable. Nitrous-oxide gas Is, by far, the best dental ansthetic. H. Sewill (Archives of Otology, Dec. 8, '94).
For operations about the mouth or throat full extension of the head upon the trunk, while the patient is' lying down, answers admirably, but, as shown by Buxton, it produces some congestion of the head and neck- vessels, which in certain subjects induces a very undesir able amount of bleeding. If the exten sion is not exaggerated, however, and if the head is supported beyond the edge of the table so that the traction upon the anterior portion of the neck through an excessive extension is not too great, the abnormal bleeding can be avoided. For the removal of adenoid vegetations this position is of value. In the illustration shown herewith, while the general posi tion of the patient is, on the whole, the proper one, the head is unduly forced downward. A small pillow or three or four towels adjusted to the edge of the table to support the head somewhat higher would place the patient within easy reach of the surgeon and at the same time avoid the danger of excessive bleeding.
For operations in the vault of the pharynx., as in the case of adenoid growths, the blood is thereby prevented from flowing in the direction of the larynx: an element of danger, in many cases, when the position of the body is on a line to that of the region operated upon.
Dudley Buxton calls attention to the fact that the lateral position, recom mended by many, is by no means pos sible in stout persons, while short-necked subjects also bear this position badly. He prefers to place a pillow well under the shoulders, giving just sufficient ex tension of the head upon the trunk for practical purposes. This position I have found a most advantageous one in opera tions about the posterior nasal space.
A certain amount of care must be taken when the bead is not fully ex tended, however, that the tongue, dur ing the deep stage, be not allowed to fall back against the pharynx and thus tend to occlude the respiratory area.
the surrounding air as a cause of danger. When the air is surcharged with moist ure the chloroform condensation in the pulmonary air-cells and its subsequent entrance into the blood arc impeded; the stages of narcotism will, by this, be prolonged. Recovery is also slower. Syncopal attacks in a moist atmosphere are more likely to terminate fatally. Again, the moisture which should escape from the air-passages cannot do so when Howard, in 18S8, showed that the most effectual way of opening the air-passages was by forced extension of the bead upon the trunk, thereby raising the epiglottis ancl tongue; but this does not prove true unless excessive extension be resorted to; and, as this is inadvisable, the benefit of Howard's method is not obtained.
Influence of Atmospheric Conditions. : —Benjamin Ward Richardson attached much importance to the condition of the atmosphere is too saturated, and the tendency to waterlogging of the lungs under chloroform is increased.
The temperature also bears a marked influence when it is high, the volatiliza tion is more rapid, its diffusion and con densation are increased, and both the onset and the recovery are more rapid. The safest temperature is GO° to 70° F.; a higher rather than a low range is best.
Chloroform aincsthetization under varying atmospheric pressures: The ac tion of chloroform is more rapid but less lasting if the atmospheric pressure is re duced. The elimination of chloroform by the lungs is much more rapidly ef fected in animals subjected to very low pressures. Benedicenti (Archives Ital. de Biol., vol. xxiv. No. 3, '98).
In India the mortality from chloro form does not exceed I in S000 eases, and in some of the largest institutions it is less than 1 in 20,000 cases. Safety does not appear to be related to any special constitutional condition of Indian races and but little to their habits. It is prob ably due entirely to the warm atmos phere. which favors the rapid action of the drug and its rapid elimination. To obtain similar safety in England, it would be advisable to operate in well-ventilated rooms, with a temperature not below 70° 17. Ainesthesia should be produced gradually, with the chloroform diluted with plenty of air. Arthur Neve (Brit. Med. Jour., Nov. 5, '93).