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UNIVERSITY OF PENNSYLVANIA PRESL 
PHILADELPHIA. PA. 
Great Britain: Caasell and Company. London: 
*••>« r«tW. Tw SMlIlnr* 
DECEMBER, 1894 
ETHER ANESTHESIA; CLINICAL NOTES ON THREE 
HUNDRED CASES. 
By G. GORDON CAMPBELL, M.D., 
OF MONTREAL, 
Assistant Demonstrator in Medicine, McGill College; Assistant Physician, Montreal 
General Hospital. ETHER ANAESTHESIA; CLINICAL NOTES ON THREE 
HUNDRED CASES., 
G. GORDON CAMPBELL, M.D., 
OF MONTREAL, 
ASSISTANT DEMONSTRATOR IN MEDICINE, MCGILL COLLEGE ; ASSISTANT PHYSICIAN, 
MONTREAL GENERAL HOSPITAL. 
THE additions of late to the literature of anaesthesia have 
been so largely through experimentation on the lower ani- 
mals that, in treating the subject from another stand-point,— 
that is, from observations made by the anaesthetist at the bedside 
and at the operation table,—I have ventured to think we may obtain 
some valuable information. As a great part of my work depends, 
both in the results achieved and in the possibility of recording 
them correctly, upon the form of inhaler used, a description of 
it will be in order first. 
The instrument used throughout was Clover’s ether 
well known and popular in England, but not so widely known 
on this continent as it deserves. The principle on which it is 
constructed will be easily understood from the following descrip- 
tion taken from Joseph Mill’s article on anaesthesia in Treves’s 
“ Manual of Surgery” and from the accompanying cut. 
“ The inhaler consists of a face-piece with an indicator, which, 
by rotation, may be made to point to o, i, 2, 3, or F, on the circum- 
ference of a metallic vessel containing fluid ether; and of a bag, into 
which and from which the patient breathes. It is so constructed that 
when the indicator is at o, the expired and inspired air passes to and 
from the bag, without in any way communicating with the ether- 
chamber. If the indicator stands at F, the whole of the expired air 
must pass through the ether-vessel to the bag, and at inspiration 
return from the bag through the ether-vessel. When the indicator is 
at 2, half the respired air passes to and from the bag direct; the 
other half passes through the ether-vessel ; and so on for the other G. GORDON CAMPBELL. 
numbers. The air does not pass through the ether, but simply 
through the vessel containing it, and this is sufficient to carry off a 
large amount of its vapor.” A slight addition has been made to the 
instrument lately in the form of an elbow, which allows the face- 
piece to be coupled to the ether-reservoir at right angles, if necessary, 
so that the ether-reservoir can still be kept horizontal with the patient 
lying on the side. 
The Method of Administration used.—Before beginning, I 
always explain to the patient the possible disagreeable effects of 
inhaling ether, its pungent, irritating vapor, and its tendency at 
the outset to cause coughing and choking sensations ; I take care, 
at the same time, to let it be understood that I shall endeavor to 
prevent these undesirable effects, as far as possible, by allowing 
Clover’s Inhaler. 
frequent breaths of pure air, if necessary. The pillows are so 
arranged that the patient’s head is low and in a line with the 
body,—that is, as it would be held in standing, and not at an 
angle with the thorax, as it usually is while lying in bed. An 
ounce and a half, fluid measure, is put into the reservoir, and it is 
rotated so that the indicator points to o. The patient’s eyes 
being closed, the inhaler (with the tap attached to air-cushion 
of the face-piece open is placed on the face and tilted away 
from the chin so that the mouth is left free; the patient is then 
directed to take several deep breaths, and the face-piece lowered 
in time to catch each expiration, and raised again at inspiration ; 
and thus the bag is filled with expired air. The tap of the air- 
cushion is closed while the inhaler is pressed against the face ETHER ANAESTHESIA. 
3 
during expiration. The patient is now directed to breathe 
quietly; and the ether-reservoir is turned so that the indicator 
points to about one-fourth of the distance of i from o; which 
means that the patient is getting about 5 per cent, of ether vapor 
in the air breathed, reckoning as 100 the proportion of ether 
vapor which will be mixed with the air, when the indicator 
points to F. 
As usually happens, after several deep breaths, the succeed- 
ing ones are shallow as compared to the normal; and thus a 
very small amount of ether vapor is inhaled at the outset, and 
its irritating effects are reduced to a minimum. After a few 
breaths, and before there can possibly have been any sensation 
due to the deprivation of pure air, one end of the inhaler is 
raised and the patient allowed an inspiration from without; and 
then the reservoir is slowly turned, so as gradually and imper- 
ceptibly to increase the strength of ether vapor in the air breathed ; 
a breath of pure air from without being given every now and 
then, as the want of it is seen to be causing distress. At the 
first sign of intolerance, such as swallowing, raising the hand, or 
ceasing to breathe, the inhaler is raised and the patient directed 
to take a deep breath; and if this fails to produce the desired 
result, the reservoir is turned back so as to diminish the strength 
of the ether vapor. On again increasing its strength care is 
taken not to exceed the limits of tolerance. Very soon a stage 
is reached at which the patient seems to fall asleep, and regular 
deep breathing ensues ; there being either an extremely slight 
stage of excitement, or more frequently none at all. I call this 
the sleeping stage, because the patient is, to all intents and pur- 
poses, in the condition of deep sleep, and not of surgical anaes- 
thesia. Once this stage has been reached, however, the strength 
of ether vapor can be quickly increased; and full anaesthesia, 
with loss of the corneal reflex and general muscular relaxation, 
rapidly ensues. By following strictly this method, I have had 
but two cases of struggling or screaming in 300 administrations, 
—that is, less than one in a hundred of my patients has required 
to have even the hands held, for purposes of restraint, while 
taking the anaesthetic. This is undoubtedly a very low propor- 4 
G. GORDON CAMPBELL. 
tion, even under the most favorable circumstances; and I think 
no stronger argument can be adduced in favor of the induction 
of anaesthesia by gradually increasing the dose of ether as com- 
pared with the method of giving it by keeping a saturated sponge 
or gauze a few inches from the patient’s nose, and, as is too often 
the case, causing all the symptoms of strangulation. 
The circumstances and surroundings in which most of my 
cases were placed are, I think, the most favorable in some re- 
spects that can be attained. With a few exceptions, twenty in all, 
my patients were adult females of the upper classes, prepared for 
operation in a private hospital, and the ether was given in the 
patient’s own bed. 
In my own experience, the better educated and the more 
intellectual people are, the more confidence they have in the 
anaesthetist, and confidence goes a long way in keeping up one’s 
courage when one feels one’s self gradually passing into the realms 
of unconsciousness. This favorable element, however, was offset 
to a great extent by the large proportion of extremely nervous 
people met with among those requiring gynaecological operations, 
people who easily lose control of their actions and emotions. It 
must not be understood that all cases are as easily managed and 
go under ether as readily as described; a great many nervous 
people, who have “ screwed their courage to the sticking point,” 
lose all control of themselves after the administration has once 
actually begun and commence to either struggle or scream or 
more often to do both before they have had more than a few 
whiffs of ether. With these the proper plan is to at once remove 
the inhaler altogether and state plainly that you cannot proceed 
until quiet is restored, at the same time assuring the patient 
that if your instructions with regard to taking the ether are 
adhered to there will be no necessity for any screaming or strug- 
gling, but that she will drop off to sleep quietly ; and then on 
recommencing the administration there is no further trouble. 
This plan answered ten times in the last ioo of my cases and 
failed but once, and I believe a possible explanation of the change 
in the patient’s behavior is this: that the fear, or whatever emo- 
tion caused the excitement, is replaced by indignation at the ETHER ANAESTHESIA. 
5 
anaesthetist’s supposed want of sympathy with one who, in all 
probability, has been doing her best to control herself. The fact 
that the most of these patients on recovering from the anaesthetic 
expressed themselves as indignant at the manner in which they 
were treated bears this out. In other cases, again, control is lost 
just before the stage is reached at which it is possible to push 
the ether more rapidly, and two or three breaths then serve to 
quiet all struggling. 
Of the two cases in which I failed to produce anaesthesia 
without struggling, I endeavored three times in one, by abruptly 
ceasing the administration and waiting until I could get rational 
answers to my questions before going on, to do without restraint, 
but failed. In the other, the patient informed me that she had 
taken ether several times, and always “ screamed herself off,” so 
I made no attempt to combat her resolution. 
It occasionally happens that a state of tonic contraction or 
spasm of the whole body comes on along with full anaesthesia 
instead of the usual relaxation. This occurred thirty-four times, 
or in ii per cent, of the cases. 
An explanation of this I am not prepared to give, but it may 
be noted that when the anaesthesia ordinarily is not yet quite fully 
established, and also when it is commencing to pass off, there is 
almost always found to be exaggeration of the patellar reflex and 
ankle and rectus clonus. And, moreover, clonic contractions of 
an individual muscle or limb tend to become general in character; 
thus elevating the leg by placing a finger under the heel often 
sets up a fine tremor of the whole limb, and tapping the triceps 
tendon in the arm brings out the same phenomenon in that 
member. In the same way spasm of the glottis, due to the direct 
irritation from ether vapor, may, during a late stage in the pro- 
duction of anaesthesia, spread from this as a centre over the 
whole body and cause general rigidity. Quite apart from this 
theory as to its cause, the fact has been noted that this condition 
of spasm is more apt to occur in those subjects exhibiting greater 
irritability of the mucous membranes to ether vapor. Added to 
this is the fact that pushing the ether does not overcome but pro- 
longs the rigidity, whereas withdrawing it altogether soon brings 6 
G. GORDON CAMPBELL. 
about relaxation of the muscles without return to consciousness. 
This point was determined experimentally in half a dozen cases 
by pushing the ether, or at least not decreasing the proportion of 
vapor breathed, for from twenty to twenty-five minutes, and in all. 
cases the rigidity persisted until the ether vapor was either wholly 
withdrawn or greatly diminished in strength. Hence the proper 
procedure on the occurrence of spasm is to discontinue the 
administration until it passes off, and begin again with a lessened 
percentage of vapor. It very rarely ever recurs. 
Very much less ether is required to keep up anaesthesia than to 
induce it, hence, as soon as the patient becomes fully anaesthetized, 
the indicator is allowed to point midway between i and 2, and 
one inspiration of pure air given to every two from the bag; and, 
as time goes on, the proportion of ether is decreased and of pure 
air increased. In the majority of cases full anaesthesia is reached 
when the patient is breathing from 50 to 75 per cent, of ether 
vapor in the air,—that is, with the indicator between 2 and 3. 
The percentage reached is higher in winter than summer, owing 
to the slower rate of evaporation at lower temperatures. 
In most forms of the inhaler there is a closed water-chamber 
below the ether reservoir, and by standing the cylinder for a few 
minutes in hot water this can be heated sufficiently to warm the 
ether vapor in cold weather. 
The Length of Time Required to produce Full Ancesthesia.— 
In considering this point the time is calculated from the moment 
the inhaler is applied to the patient’s face until full anaesthesia is 
produced. The average time for the whole 300 cases is 4.8 
minutes, the longest being twelve minutes and the shortest two 
minutes. 
Thus in 62 per cent, of the whole number the time required 
was under five minutes, and in 80 per cent, under six minutes. 
These figures do not represent the actual time elapsing in pro- 
ducing anaesthesia while the patient is breathing the ether, but 
include all those cases in which, as before described, the adminis- 
tration was temporarily ceased. Undoubtedly if screaming and 
struggling were ignored and the anaesthetic pushed, as in dealing 
with children, the average time would be shortened considerably. ETHER ANAESTHESIA. 
7 
I have been unable to obtain any exact statistics of the time 
required in other forms of inhalers, but from my own experience 
I judge it is considerably shorter on the average with the Clover 
than with the others. Of the causes tending to prolong the time 
beyond the average the chief one was loss of control on the 
patient’s part, as already referred to; another, difficulty in getting 
the patients to breathe properly, owing to their timidity ; and 
lastly, a badly-fitting face-piece, which allowed air to enter 
between it and the face, so that very little of the respired air 
passed through the ether-vessel. This can be guarded against 
by having several different sizes of face-pieces, and by allowing 
sufficient air to escape from the air-cushion so that it adjusts 
accurately to the face when pressed down. 
The following table (No. I) shows the details : 
Table I. 
Two minutes and under three . . . 
per cent 
Three “ 
<< 
four .... 
... 60 = 20 
ii 
Four “ 
“ 
five . . . 
. . . 118 — 40 
it 
Five “ 
U 
six .... 
it 
Six “ 
« 
seven . . . 
H 
Seven “ 
u 
eight . . . 
. . . 16= 5 
ti 
Eight “ 
Nine “ 
Ten “ 
Eleven and 
“ nine . . . 
“ ten .... 
twelve minutes .... 
. . . 10= 3 
. . . 4 
a 
The Amount of Ether consumed.—This is obtained by com- 
paring the average time under anaesthesia with the average 
amount of ether used. The time is reckoned from the moment 
the inhaler is first applied to the face until the administration is 
stopped, although the anaesthesia lasts for a variable length of 
time after this. The average length of administration was eighty- 
seven and a half minutes, and the average of ether forty fluid 
drachms for the 280 cases of which I have notes ; or, in round 
numbers, five fluid ounces of ether, or about the amount in an 
ordinary 100-gramme tin, sufficed for an administration lasting 
an hour and a half. The amount varies relatively in inverse pro- 
portion to the length of administration thus, for those operations 
lasting three hours or over, ten in all, the average amount of 8 
G. GORDON CAMPBELL. 
ether used in an hour and a half was only twenty-eight fluid 
drachms as compared with forty. About four fluid ounces, as a 
rule, should be allowed for the first hour, two and a half for the 
second, and so on in proportion. There is, too, roughly speak- 
ing, a direct proportion between the body weight and the amount 
of ether used, but this is often disturbed by other causes of 
which, perhaps, individual idiosyncrasy is the prominent one. An- 
aemia appears to be a factor tending to diminish, and plethora one 
tending to increase the amount necessary to keep up anaesthesia. 
Vomiting During the Operation.—This occurred seventeen 
times, or in 5.6 per cent, of the cases. Its occurrence, though 
of little moment in the majority of surgical operations, often 
greatly increases the danger of spreading infection where there is 
a localized collection of pus within the abdomen. The determin- 
ing cause in many of these cases could not be satisfactorily fixed ; 
in one or two it was partial recovery from anaesthesia through 
faulty administration, in others I fancied that swallowing air 
before almost every breath, while going under, accounted for it. 
After Vomiting.—This is the point on which I have obtained 
the least satisfactory results. Nausea or vomiting occurred in 
90 per cent, of all cases. Several of the methods recommended 
for modifying this untoward effect of ether were tried, but with- 
out success. Atropine, either alone or with morphia, was tried 
both hypodermically and by the mouth, but without satisfactory 
results; and, besides, it disguised the real condition of the patient 
by its influence on pulse, pupils, and respiration. For this reason, 
as will be shown in speaking of pulse and respiration, I consider 
it is contraindicated. Possibly the relatively long duration of the 
series of cases under discussion in this paper as compared with 
operations in general may account for the large amount of after- 
sickness noted. 
Pulse and Respiration.—Plastic operations certainly give one 
the best opportunity of investigating clinically the effect of ether 
upon the pulse and respiration. In a case, for example, of repair 
of the perineum, where there has been normal temperature, pulse, 
and respiration, and where the operation itself does not produce 
any shock from haemorrhage or other cause, all changes in these ETHER ANAESTHESIA. 
9 
must be due entirely to the ether inhaled. In order to determine 
as far as possible the usual effect and to detect any causes tending 
to alter this, the pulse and respirations were taken every fifteen 
minutes throughout the anaesthesia in ioo cases; and in a large 
number of these, for the hour following also. From the data 
thus obtained are prepared pulse-respiration charts, the ratio 
being the usual one of four to one. As the pulse is usually 
extremely rapid at the outset, from the excited condition of the 
patient, the first time recorded is at the end of fifteen minutes, 
marked on the chart as i ; 2, 3, and 4, thus representing the 
half hour, three-quarters, and hour, and so on for the other 
hours. 
The general course of the pulse shows an initial rise above 
the normal of from thirty to seventy beats a minute, caused by 
the excitement and the stimulating action of the drug; then a 
gradual fall amounting to twenty or thirty beats by the first 
quarter and continuing, so that at the half or three-quarters it 
has reached the rate normal to the individual, at which it remains. 
The respirations are also at the outset greatly increased, but 
they do not fall with the pulse and do not come down to the 
normal rate, while the ether continues to be inhaled ; thus the 
pulse-respiration ratio is altered from four to one, to three or two 
to one. The rate of respiration is usually between twenty-four 
and thirty-six, but it is liable to rapid alterations. 
Now the question arises, whether we can. lay down any fixed 
rule for the pulse and respiration rate, and the ratio between the 
two, of practical value, so that variations from this may be accepted 
as evidence of some cause, acting either in the way of faulty 
administration or in the operation itself, which is affecting the 
patient’s condition. I think we can, but before discussing the 
subject it is necessary to refer again to the inhaler, with which, 
as previously stated, the strength of ether vapor inhaled can be 
regulated at will by the anaesthetist. It is claimed by some 
writers, however, that a definite proportion of the effect produced 
in this method of administering ether is due to the production of 
a certain .degree of asphyxia by breathing over again already 
respired air along with the ether vapor, and it is this point I will G. GORDON CAMPBELL. 
now consider. I admit that the production of anaesthesia by this 
method is due to ether plus a certain amount of asphyxia ; I hold, 
nowever, that the method of giving the ether followed after 
anaesthesia has been set up, practically eliminates entirely any ele- 
ment of asphyxia then. It was in this order : one inspiration and 
expiration of air, inspiration of air, expiration into the bag, inspi- 
ration from and expiration into the bag, and so on over again. 
Thus, in every three respirations, two inspirations were of air and 
one from the bag, and in other cases, in every four breaths, two 
195 
Cervix Round Liyamen/o 
2# - /SO - 3n 
199 
Cirri A & Rd L/gamen/j 
5 - /So — 3 'nr 
290 
Ccrv/x & Ova.no/-omy. 
a - 120 — 3-vt 
were of air ; moreover, the air in the bag is replenished each time 
by an expiration containing the amount of pure air in the respi- 
ratory passages at the end of inspiration, as this must first be 
driven out before the foul air from the lungs can follow it. The 
air in the bag is thus diluted with a certain amount of good 
air before it is drawn into the lungs, and as at least half of 
all breaths are pure air and the breathing is double the normal 
rate, the degree of asphyxia must be practically nil. I have, too, 
in a measure, tested the matter practically by comparing two 
series of ten administrations each, of which the aggregate time in ETHER ANAESTHESIA. 
11 
both was the same, in one series the ether was given in the ordi- 
nary manner, in the other with much less pure air, and there was 
only the difference of a couple of drachms between the amounts 
of ether used in each series. 
Purposely taking a class of cases in which we may reasonably 
expect the nature of the operation to have little effect upon the 
condition of the patient, and selecting from among these the 
ones in which the anaesthesia was kept up for the longest period, 
2-44 
Abdominal Hysterectomy 
7 " *85 - 3 ss. 
24-1 
Cervix & Round Ligaments 
* - /4o — 3 cri 
we find, in cases 195 and 199, lasting three hours and two hours 
and a half respectively, that the pulse does not become faster as 
the time progresses, but remains at about the normal. The 
respirations vary between twenty-eight and thirty-six, but evi- 
dently the variations do not correspond with those of the pulse. 
Chart 199 shows, moreover, the gradual fall, as described, at the 
beginning of the administration ; and both show the alteration in 12 
G. GORDON CAMPBELL. 
pulse-respiration ratio. In Case 250, where the abdominal cavity 
was opened, and hence the operation was of a more serious nature, 
the pulse chart shows the same general course and the respira- 
tions are also increased, and the pulse-respiration ratio altered. 
As soon as the ether is stopped, however, the normal ratio is 
re-established. I have, besides the ones shown, twenty-five 
245 
Cervix 
4• — 65 — 3 t» 
2*3 
Cervix & fid tiyaments 
4- - /50 — 3 vt« 
213 
Cenex Haemorrhoids etc. 
5-180 — 3 snr a*. 
similar charts, all showing the fall in the rate of the pulse at the 
outset, and then no further tendency to rise above normal limits. 
Case 244, although a very serious operation,—viz., total 
extirpation of the uterus, in which the anaesthesia was kept up 
three hours and the abdominal cavity was open for over two,— 
show's no rise of the pulse above 92, and at the end of the three ETHER ANAESTHESIA. 
hours it was 76, and full and strong in character. Case 241, 
again, appears to be due to an individual peculiarity of which I 
will have something to say later. 
Another series of charts shows changes due to various 
causes. These are,— 
(1) Changes, both in pulse and respiration, from an over- 
dose of ether,—i.e., more than is required to keep up surgical 
anaesthesia. 
2/7 
Exp/ora/-ton Mcf/rey 
fJ vf 
200 231 
Ccrvrx Perineum Ampul- - 
3- /30- 3 fdrss J- 60-3 TjpSr 
228 
Abdominal EpjlerecP. 
4--/6S- 3 tz 
(2) Changes in the pulse from loss of blood. 
(3) Reflex quickening of the respirations from various 
manipulations on the part of the operator. 
The effect produced by an overdose of ether was obtained 
experimentally as follows : With the breathing and pulse at what 
was the best obtainable for each individual case, the strength of 
ether vapor was doubled, but given with exactly the same pro- 
portion of pure air, in ten cases, and the results noted. These 14 
G. GORDON CAMPBELL. 
were: a sudden rise in the rate of respiration of from io to 14 
per minute with stridor and labored breathing; a less marked 
rise in the pulse-rate of from 12 to 20 beats; and dilatation of 
the pupils. On allowing the patient to breathe pure air for a short 
period almost as sudden a return to the former rates was noted. 
See Cases 245,247, and 248, which explain themselves. Experi- 
186 
Ovariotomy 
5- 135- 3 yrjs 
2 35 
Ovariotomy 
7-/2S — 3 vm 
225 252 
Curettcngs. 
5SO-3vss 7-55 3*&s 
ments of this nature can, of course, only be carried on within 
very narrow limits, but enough has been shown to prove that an 
overdose of ether can cause an alarming change in the condition 
of the patient, and so lessen the resisting powers. Acting on the 
knowledge gained through this experiment, I have several times 
been able to detect an overdose in my own cases, and, by ETHER ANAESTHESIA. 
decreasing the strength of ether vapor, to better the condition of 
the patient. Case 243 is one of those alluded to. 
The effect of haemorrhage is shown in Case 217, where an 
unusually slow pulse rises from 72 to 96 from free bleeding from 
an incised kidney; and in Case 200, where there was smart 
haemorrhage from the perineum. In both of these cases, and in 
others to be referred to, the possibility of the effects noted being 
due to an overdose of ether was first considered and tested. 
Case 231 shows an extremely rapid pulse-rate, the relative posi- 
tion of pulse and respirations having changed. The case was one 
of amputation of the thigh in an old woman weakened by sup- 
puration of a joint. The pulse-rate before operation was for days 
over 120, and there was considerable pyrexia. There was no loss 
of blood, and the case did well. I introduce it here to show that> 
any observations forming a basis for generalizations must be made 
on subjects who are in normal health at the time of operation. 
Another series of cases shows the effects produced upon the 
respiration by various manipulations on the part of the operator. 
In almost all articles upon anaesthesia one sees the statement 
made that a much deeper degree of anaesthesia is required for 
operations upon the perineum and rectum than in other cases. 
The reason for this opinion is evident. Reflexes persist from 
these parts when all others are abolished. These reflexes, how- 
ever, I can show, affect only the breathing, and not the general 
condition of the patient. The manipulations which affect the 
breathing are, stretching of the sphincter ani and working with 
the mucosa of the rectum, rough handling of the peritoneum, 
and especially breaking down peritoneal adhesions, compression 
or rough handling of the ovaries and testes, and stretching of the 
perineum. The latter is not so invariable as the others. Take, 
for example, Case 213. Here, with respiration 38, pulse 66, 
dilating the sphincter ani caused a sudden rise to 40 of the 
respirations, with marked stridor, and no change at all could be 
detected in the pulse or pupils. This observation has been made 
over twenty times. The same thing is seen in Case 248. Case 
186 shows the effect of breaking down peritoneal adhesions. 
Although the respirations shot up at once when tearing away the 16 
G. GORDON CAMPBELL. 
ovaries from firm adhesions was commenced, the pulse continued 
to fall gradually, and at one time, when the respirations rose to 54 
from 35, there was no change noticed in the pulse or pupils. 
Case 235 shows a similar case, and also the accidental occurrence 
of an overdose of ether at the half hour. After the anaesthesia 
was stopped the respirations fell to normal, and the pulse went 
up a little. Although these reflexes were present in all cases 
tested, the intensity of them varied very much. 
Some individuals show a special susceptibility to the action 
of ether in the form of an extremely sensitive respiratory mucous 
membrane, which is intensely irritated by even a very low per- 
centage of vapor. The respirations are very rapid in these cases, 
and the slightest increase in the strength of vapor causes cough- 
ing even under deep anaesthesia. Case 228, total extirpation of 
the uterus, is one in which this was present to a moderate degree. 
The pulse rise shown towards the end of operation appeared due 
to the high rate of respiration, as there was nothing else to 
account for it. This case was very similar to No. 244, already 
referred to, where we have a very different tracing both of pulse 
and respiration. In Cases 225 and 252 this idiosyncrasy, if such 
we may call it, was present to a marked degree. They show two 
administrations, at an interval of two months, to the same patient; 
and here there was the condition described, and although every 
means was tried in the way of regulating the amount of ether 
vapor exhibited, it was found impossible to keep up the anaesthesia 
without causing the high respiration and pulse-rate shown. Al- 
most immediately after ceasing the administration, however, the 
pulse and respirations are seen to have come down to normal. 
The Character of the Pulse.—On placing the fingers on the 
radial artery during ether anaesthesia, one notices that there is 
something peculiar in the character of the pulse-wave, the tension 
seems to be rather high and sustained, and yet there is not the 
sensation of a forcible rise and slow and gradual fall given by the 
ordinary high-tension pulse. The cause of this peculiarity is 
shown in the following sphygmograms, which were taken at 
intervals during the anaesthesia by Dr. Kenneth Cameron and 
myself. The tracings were made by the Marey sphygmograph ETHER ANAESTHESIA. 
17 
placed upon the radial artery; and all those from the same case 
were taken without any readjustment of the instrument, so as to 
secure uniform pressure; and at the quarter hours to correspond 
with the pulse-respiration charts which I append. Each sphyg- 
mogram is lettered to correspond with the lettering on the chart, 
247 
Cervix Perineum> 
4 - /5Z? - 3 ~177~3s 
248 
Cervix T Haemorrhoids 
3A.-8S-3tp 
249 
Cervtx A Vag/'na, 
4- ~ tOO— 3 V77 
and has marked on it the time at which it was taken and the 
respiration and pulse-rate. 
Case 247.. Operations on the Cervix and for the Repair of 
the Perineum.—The only unusual feature in the case was a copious 
secretion of viscid mucus, which collected in the air-passages, and 
so seriously interfered with respiration that at one and a half 
hours the anaesthesia was allowed to pass off sufficiently to induce 18 
G. GORDON CAMPBELL. 
vomiting, in the hope of getting rid of some of the mucus by 
that means. 
Sphygmogram A was taken at the half-hour. A few minutes 
later the ether vapor was doubled in strength, and given thus for 
two minutes when B was taken. The pulse is seen to have risen 
247 A. 
247 B. 
18, the respirations 8 to the minute, and the pupils became widely 
dilated. The apparent irregularity of the pulse is probably due 
entirely to movements of the patient’s arm caused by the deep 
respirations. The character of the pulse-wave is not changed. 
247 C. 
C, D, and £ were taken at three-quarters, one, and one and 
a quarter hours. C shows that the effect of the overdose of 
ether given at B has passed off. 
247 D. 
247 £■ 
F was immediately after retching had been induced by stop- 
ping the ether. As no breathing occurred during the attempts at 
vomiting, there was considerable blueness of the face and increase 
in the pulse-rate. Besides the irregularity due to labored breath- 
247 F. 
ing, note that the upward stroke of the lever is almost straight, 
as compared with the oblique or curved rise shown in the others. 
In G and H, taken one and a half and one and three-quarters 
hours, the breathing was choked and labored from the mucus in ETHER ANAESTHESIA. 
the throat. The patient was being drowned in her own secretions. 
As the mucus was out of reach of a sponge passed into the 
247 G. 
247 H. 
throat, vomiting was again induced, and this time a considerable 
amount expelled. 
K is taken from the same patient ten days after operation, 
and shows a moderately high-tension pulse. 
247 K. 
Case 248. Operations upon the Cervix and for Hemor- 
rhoids.—The pulse-respiration chart shows an average case with 
the usual reflex quickening of the breathing. There was no 
mucus. 
248 A. 
248 C. 
A and C, the half and three-quarters hour, show the same 
general character found in all the tracings taken under ether. 
The ascent is curved, the lever at first rises rapidly, then more 
slowly, and does not reach its highest point until one-quarter of 
the whole time occupied by the beat has passed. The descent is 
just as gradual, with a barely perceptible pause in the fall repre- 
senting the dicrotic wave. 
248 D. 
D, taken after two minutes of double the usual dose of 
ether, shows the alternate beats large and small. Here exactly 20 
G. GORDON CAMPBELL, 
the same effect was observed as in 247 B. The rise in pulse-rate 
is 14, and in respirations 13 to the minute. 
248 E. 
248 F. 
E and F show the pulse-wave at one and one and a quarter 
hours to be exactly similar to those taken earlier in the operation. 
248 G. 
G was taken the day following the operation, and the straight, 
almost vertical ascent with immediate fall and dicrotic and pre- 
dicrotic waves are in sharp contrast with the same pulse under 
ether. 
Case 249, Plastic operations on the cervix and of vagina, 
shows five tracings taken at quarter-hour intervals, beginning at 
the three-quarter hour. 
249 A. 
249 B. 
249 C. 
249 D. 
There was the same difficulty with stiff mucus in the throat 
in this case as in No. 247. The curve in the first three tracings 
is simply a gradual rise and somewhat more gradual fall. The 
other two resemble the other cases, but there is no trace of the 
dicrotic wave in any of them. 
249 E. ETHER ANAESTHESIA. 
21 
Case 250. Cervix and Ovariotomy.—The first tracing was 
taken fifteen minutes after the ether was stopped and the second 
twenty-four hours later. In the first, the curved ascent as seen 
under ether has already begun to pass off, but the highest press- 
ure is maintained for nearly half the beat, and there is no dicrotic 
wave. The second is a normal tracing. 
249 F. 
250 A. 
Case 251. An Operation for Hcemorrhoids in a very 
Ancemic Girl.—The three-quarter-hour tracings, A, B, and C, 
resemble No. 248. 
250 B. 
251 A. 
D, taken three days later, shows a moderate tension pulse 
met with during fever, which is here seen to be 99.4° F- The 
absence of any dicrotic wave is remarkable. 
251 B. 
251 C. 
251 D. 
The series of sphygmogra’ms shown are not selected, but are 
taken from five consecutive cases. They all show the same gen- 
eral character, and are, as far as I know, totally unlike those 
obtained during health or in disease. The chief points of dif- G. GORDON CAMPBELL. 
ference are the entire absence of straight lines and sharp angles, 
and the more or less complete obliteration of the dicrotic wave. 
In the present state of our knowledge the exact conditions of the 
circulation, which this form of sphygmogram denotes, cannot be 
positively stated. I am inclined to attribute it to high arterial 
tension with a slowly-acting heart. The absence of the dicrotic 
wave points to high tension and to that increased blood-pressure 
which has been shown to be present during the inhalation of 
ether. The curved ascent of the wave, I think, is best explained 
by a slowly-acting ventricle, which, on purely theoretical grounds, 
one would be inclined to expect under deep anaesthesia. What 
ever the explanation, the state of the circulation under ether 
anaesthesia is shown to be profoundly modified. 
The practical points suggested by the consideration of this 
part of the subject are these : 
(1) That there are certain reflexes, present during full surgi- 
cal anaesthesia, which manifest themselves by increasing the rate 
and the depth of the respirations. 
(2) That the production of these reflexes does not affect the 
pulse, pupils, or general condition of the patient. 
(3) That during their occurrence the amount of ether being 
inhaled should be temporarily diminished; as the increased fre- 
quency and depth of respiration would otherwise lead to an over- 
dose being exhibited. 
(4) That the pulse and respiration, if watched from the out- 
set, are a valuable indication of the degree of anaesthesia present; 
and that quickening, especially of the respirations, denotes an 
overdose of ether unless it is accounted for by the reflexes men- 
tioned or by interference with the breathing from the presence of 
mucus in air-passages. 
(5) That quickening of the pulse alone denotes haemorrhage. 
The Condition of the Pupils.—The pupils are usually mod- 
erately contracted and react actively to light, there are, however, 
noticeable variations in size from time to time which cannot be 
easily accounted for. An overdose of ether causes wide dilata- 
tion and partial loss of the light reflex; a partial degree of 
asphyxia, from the admission of too little pure air, causes fine con- ETHER ANAESTHESIA. 
23 
traction. It is not uncommon to find the pupil which has been 
frequently examined smaller than the other; the repeated expos- 
ure here causes a certain amount of permanent contraction. I 
strongly deprecate the practice of repeatedly testing for the pres- 
ence of the corneal reflex; it is rarely necessary to do so more 
than once, and often I omit it altogether. The rate and especially 
the character of the breathing are a reliable index to the occur- 
rence of full anaesthesia, even at the outset of the administration ; 
and after that, as has been already shown, they are the best 
evidence to go by. 
The Reflexes.—I have not as yet collected sufficient data on 
which to base any general statement. There appears, however, 
to be a period, during the production of anaesthesia, in which the 
knee-jerk is increased and ankle clonus is present. As I insist 
on absolute quiet and non-interference with the patient during the 
production of the anaesthesia, the reflexes were not examined 
until the breathing denoted insensibility. Similarly there is a 
period during recovery in which there is increased knee-jerk and 
ankle clonus. 
Reflexes during deep anaesthesia, as before described, are 
obtained from the anus, rectum, ovaries, testes, perineum, and 
peritoneum. 
Secretion of Mucus in the Respiratory Tract.—The collec- 
tion of a large amount of sticky mucus in the larynx and pharynx 
during anaesthesia very often seriously interferes with the 
breathing, especially where the nature of the operation neces- 
sitates the supine position. In 7.5 per cent, of the cases 
I noted the presence of mucus in sufficient quantity to cause 
some difficulty. Its removal is usually readily effected by a 
small sponge fixed on a holder thrust into the pharynx; where 
this fails, it is well to have the patient recover sufficiently to 
allow of vomiting being induced by tickling the pharynx with 
the sponge. The act of vomiting forces the mucus out of the 
upper part of the trachea and larynx, and it can be induced 
before the patient has regained consciousness. 
Before leaving this part of the subject, let us contrast this, 
which I will call the rational method of ether administration, with 24 
G. GORDON CAMPBELL. 
that in general use. I contend that ether, like all other powerful 
drugs, should be given in doses just sufficient to bring about the 
required result, and no more. How do we attain this in other 
cases? The maximum and minimum dose has been determined, 
and in giving a drug we use our judgment with regard to the 
first dose, and alter this to more or less according to the result 
obtained. It is hardly necessary to point out that no data on 
which to base the strength of subsequent doses can be obtained 
unless the amount actually taken into the body is known. When 
one, wishing to produce a definite physiological action by a cer- 
tain drug, orders an ounce of it to be taken in a wineglass of 
water, and returns the following day to find that an unknown 
proportion was spilt in the act of administering it, one has abso- 
lutely no data on which to base one’s further procedure in the 
case; unless the desired action is already present, and then the 
only knowledge gained is that something less than the ounce was 
sufficient to produce it, but whether just enough or more than 
was necessary has been taken, it is impossible to tell. Now this 
represents fairly well what occurs when ether is administered by 
those forms of inhaler which consist essentially of a sponge 
gauze pad, or other means of holding the ether with a more 
or less accurately-fitting mask ; the commonly-used “ cone” is the 
best known type. No attempt is made or can be made to meas- 
ure the actual amount of ether inhaled, and it is wellnigh impos- 
sible to regulate the strength of vapor, owing to the extremely 
volatile nature of the drug. The amount “ spilt” on expiration 
must be very large, but is always an unknown quantity, conse- 
quently, although the administrator acquires by long experience 
a certain degree of exactness in determining the amount of ether 
to keep pouring into the inhaler, he is never able to tell what 
proportion of this the patient has actually inhaled, and the most 
he can do is either to continuously exceed the necessary amount 
or to run the risk of frequently having the anaesthesia partially 
pass off. But, as I have shown, by using Clover’s inhaler the 
anaesthetist can measure the amount inhaled, and can regulate 
the further administration in exact proportion to the effects pro- 
duced. . ETHER ANAESTHESIA. 
25 
There are three principal points to be considered in discuss- 
ing the advantages of any inhaler; its safety, the patient’s com- 
fort, and the administrator’s comfort. With regard to the first 
of these, we are here able to give the minimum dose necessary to 
produce the required effect, and the pulse-respiration charts are 
evidence of the patient’s condition. The extremely slight liability 
to vomiting on the operating table is also important, as a large per- 
centage of the fatal results recorded have been due to this cause. 
That the patient’s comfort is considered is seen in the absence 
of struggling during the administration, and in the preference 
expressed for this inhaler by those who have tried others. It is 
a most significant fact, too, that where there had been no pre- 
vious experience of other inhalers, I rarely had any trouble in 
giving the ether, and never in repeating the administration after 
once using this one. In considering the administrator’s comfort, 
it must be remembered that in profound anaesthesia, a state but 
little removed from death, constant watchfulness is essential to 
detect any dangerous symptoms. The state of the respiration 
has been shown to be the most reliable evidence of the patient’s 
condition, and with this inhaler we have the means of accurately 
observing this. The filling and collapsing of the bag show the 
actual amount of air entering the lungs, and the noise produced 
by the breath in passing through the ether reservoir enables the 
ear to detect the slightest obstruction to the breathing or altera- 
tion in its character. This, too, is an additional element in re- 
gard to its safety. Other advantages are, rapidity in the produc- 
tion of anaesthesia, the small amount of ether used, and the rela- 
tively slight escape of ether vapor into the room. I do not claim 
that, with statistics of only 300 cases to draw from, the dose can 
at present be positively stated, but I do think that by careful 
observation, and the collection of a large number of cases, we 
will yet be able to fix the dose for the required time, and admin- 
ister it in a rational manner. May it not be that failure to recog- 
nize the existence of those respiration reflexes, before described, 
has been in a considerable measure accountable for the increased 
risk attending anaesthesia in operations on the rectum and anus ? 
The administrator, considering the quickening o£ the breathing 26 
G. GORDON CAMPBELL. 
to show partial recovery of the patient, increases the amount of 
the anaesthetic given, and this is taken up quickly, owing to the 
increased depth and rate of respiration, and leads to an overdose, 
which, in chloroform especially, is so often followed by fatal conse- 
quences. 
The Urine.—The effect produced by ether anesthesia upon 
the secretion and composition of the urine was arrived at by the 
following method of investigation. Examinations were made of— 
(1) A specimen of urine obtained just before commencing 
the administration, designated “ ante" in my notes. 
(2) The urine secreted during the anaesthesia, drawn off by 
catheter immediately after ceasing the administration, and before 
the patient had been removed from the operating table, desig- 
nated “ post." 
(3) One or more specimens obtained from twelve hours to 
five days after the operation, and designated by the number of 
hours after. 
The ante specimen was examined as a control for those 
cases in which abnormal constituents were found post. 
For the post the points recorded are : amount, odor, specific 
gravity, presence of albumen, acetone, sugar, and the total amount 
of urea in grains. The other specimens were treated more espe- 
cially for albumen, sugar, and acetone. 
The following tests were made use of: 
Albumen.—Overlaying cold nitric acid with the urine. Boiling 
of the upper portion of urine in a small calibre test-tube with the 
subsequent addition of nitric acid. Where present, the quantity 
was estimated by Esbach’s albumenometer. 
Sugar.—By freshly-prepared Fehling’s solution. 
Acetone.—By testing the distillate with Lieben’s iodoform 
test. A practical difficulty experienced at first in making this 
test is worth noting. I found that in distilling one specimen 
containing acetone, a considerable quantity of it had lodged in 
the tube (worm) of the condenser, and was carried over with 
the next distillate. This was overcome by drawing off the cold 
water from the condenser, and passing steam through the tube 
after each distjUation. ETHER ANAESTHESIA. 
27 
Urea was estimated with the ureometer of Doremus, by 
the decomposition of sodium hypobromide. 
Deposits.—By the microscope and chemical tests. 
The amount of urine secreted while in a state of anaesthesia 
was 256.85 fluid ounces in 100 cases, lasting 9130 minutes,— 
that is, 2.5 ounces in an hour and a half, or at the rate of 40.5 
ounces in twenty-four hours. This is within the average normal 
amount. It is found, too, that the amount varies with the length 
of the anaesthesia, becoming relatively less as the time is length- 
ened thus. 
Table II. 
29 cases lasting one hour or under, averaged . .2.6 ounces per hour. 
50 “ between one and Wo hours “ . . 1.9 . “ “ “ 
30 “ “ two and three hours “ . . 1.42 “ “ “ 
The amount secreted depended largely too upon the char- 
acter of the ante specimen; thus, in extremely nervous patients 
and where there was a large amount of ante of low specific 
gravity, the post was of similar character. There was no 
instance of entire suppression, but in two or three cases, where 
the anaesthesia lasted between one and two hours, only a couple 
of drachms was obtained, in these, however, it is probable that 
the bladder was not properly emptied at the time. Later expe- 
rience showed that, unless pressure is made over the bladder 
above the pubes, a portion of the urine may remain in the organ 
even after catheterization. 
The total amount of urea in the same 100 cases was 1122.8 
grains,—that is, at the rate of 177.08 grains per diem,—about 
three-eighths of the normal amount. As one would expect, there 
is a gradual diminution in the amount secreted as the time passes; 
thus long anaesthesias show a smaller amount per hour than short 
ones. This fact is well shown by the table given (III), and also 
by the following case: No. 241, duration 135 minutes. At the 
end of 60 minutes 1 ounces of urine were drawn off, and found 
to contain 9 grains of urea ; 75 minutes later, 2 ounces more were 
obtained ; but, although the interval was longer, and the quantity 
proportionately increased, there was only 7.2 grains of urea 
present. 28 
G. GORDON CAMPBELL. 
Table III. 
29 cases, one hour and under, averaged . . 10.75 grains per hour. 
50 “ between 1 and 2 hours, “ . . 7.34 -j- “ 44 “ 
20 “ “ 2 44 3 “ “ . . 5.68-4-“ 44 44 
Albumen was detected post in 7 of 100 cases, in which it 
had been absent ante; and it disappeared again within 48 hours 
in every case. The cases are given in detail. 
No. 122. Anaemic woman, blood-count showing 3,800,000 
red and 37,600 white per centimetre. Duration of anaesthesia 120 
minutes. Operation on cervix and ligaments. Urine, post, three 
fluid ounces, acid, clear, uric acid sediment; contains 16.5 grains 
urea and albumen, one-eighth bulk on boiling with nitric acid; 
24 hours later only a slight trace of albumen was present, and 
48 hours, no albumen. 
No. 127. Same patient, twelve days later, duration ninety 
minutes. Operation on perineum. Urine, post, 3.5 ounces ; 
again containing albumen, one-tenth bulk, which disappeared by 
the second day. 
No. 134. Total extirpation of the uterus. One hundred 
and sixty minutes. Urine, four ounces, contained a trace of 
albumen ; not present the following day. 
No. 143. Operation on perineum, 130 minutes. Urine, 5.5 
ounces, contains albumen less than 1 in 1000. 
No. 185. Total extirpation of the uterus, 225 minutes. 
Urine, 2.25 ounces, contains a trace of albumen. 
No. 190. Operation on the perineum, 160 minutes. Urine, 
three ounces, contains albumen less than 1 in 1000. Esbach : 
Twenty-four hours later, no albumen present. 
No. 228. Total extirpation of the uterus, 165 minutes. 
Urine, one ounce, contains albumen 2 in 1000. Esbach: This 
had disappeared in a couple of days. 
In all the above cases microscopical examinations were made 
of the sediment, but no casts or other evidences of renal disease 
were discovered. It is to be noted that three of the above cases 
were total extirpation of the uterus in which a sound was intro- 
duced into the bladder during the operation. In a large number 
of cases a trace of albumen was found the second or third day after ETHER ANAESTHESIA. 
29 
operation, due to the vaginal discharge. The small amount and 
transient nature of the albuminuria present in these cases, together 
with the absence of any signs of renal disease, plainly show it to 
have been due to changes in the circulation at the time. 
The presence of acetone was not suspected at first, and con- 
sequently not looked for until discovered accidentally. Then 
seventy-five consecutive cases were examined, and it was found 
in all within twenty-four hours after the anaesthesia. Table IV 
shows the percentage of cases giving acetone at various intervals 
after anaesthesia. 
Table IV. 
Post. 58 tested. Acetone present in 37 = 64 per cent. 
24 hours. 54 “ “ “ “ all = 100 “ “ 
48 “ 17 “ “ “ “ all = 100 “ « 
72 “ 20 “ “ “ “ 17 = 85 “ “ 
96 “ 9 “ “ “ “ 6 = 66 “ “ 
120 “ 5 “ Slight trace in 3 = 60 “ “ 
Acetone is thus seen to be a constant product of ether anaes- 
thesia, but I think of little or no clinical significance. 
A decided odor of ether was noticed in all the post specimens, 
whether acetone was present or not. It was not, however, dis- 
tinguishable in specimens obtained afterwards, although it re- 
mained for weeks in the post if tightly corked up. It was prob- 
ably due to ether excreted in the urine while the body tissues 
were saturated with the drug. By slowly distilling a number of 
post specimens at a very low temperature, and passing the vapor 
through alcohol, the alcohol became strongly impregnated with 
the odor of ether. 
Squibb’s ether was used in every administration.