309 



ANESTHETICS. 



ANAKIM. 



slo 



suppose that the air which a patient breathes is saturated at 60, 

 the ordinary temperature of a dwelling room, with one or other of 

 the vapours, and see how much air he would hare to breathe in 

 either case in order to be narcotised to the third degree, the extent 

 of insensibility usually required in a surgical operation. Thirty-six 

 minims is about the average quantity of chloroform required to pro- 

 duce this degree of narcotism in the adult, and this would saturate 

 257 cubic inches of air at 60, making it expand to nearly 300 cubic 

 inches, which would be breathed in 12 ordinary respirations of 25 

 cnbic inches each. The quantity of ether usually required to produce 

 the same amount of insensibility in the adult, is about 7J fluid 

 drachms ; this would saturate 440 cubic inches of air at 60", and in- 

 crease its volume to rather more than 800 cubic inches, which would 

 require 32 ordinary respirations to breathe it. We see, therefore, that 

 12 inspirations of air charged with vapour of chloroform are equal to 

 32 similar inspirations of air charged with vapour of ether, at the same 

 temperature ; and that, consequently, choloroform is nearly three times 

 as strong as ether. In actual practice the difference in strength is gene- 

 rally greater than this, for ether abstracts much more caloric than chloro- 

 form during its evaporation, thereby reducing the temperature of the 

 air passing over it, and the sponge or whatever contains it, and limiting 

 its own evaporation, in a greater degree." ' Edinburgh Medical and 

 Surgical Journal," No. 180. 



It is on account of its greater strength that a larger number of 

 accidents have occurred with chloroform than with ether. At the 

 same time, where great care is taken in its administration, there seems 

 to be no reason why chloroform should not be employed for the pro- 

 duction of amosthesia. The usual method of administering this agent 

 ->prinlde a few drops upon a handkerchief and apply it to the 

 mouth and nostrils of the patient, in such a way that the ]tient may 

 take air into the lungs which is saturated with the vapour of chloro- 

 form. During this operation care should be taken that a larger quan- 

 tity of the vapour is not inhaled than will produce the fourth stage of 

 anwsthesia. By removing the handkerchief from time to time the 

 patient may be kept in the third or fourth stage, according as it seems 

 desirable. Although the administering of chloroform in the hand- 

 kerchief is undoubtedly the most simple and convenient plan, it ap- 

 to be much safer to nsc an instrument called an inhaler, by 

 which the quantity administered can be regulated and controlled with 

 certainty. Such an instrument was early introduced and employed by 

 Dr. Snow, and the accidents which have occurred have certainly been 

 fewer when this instrument has been employed than with the hand- 

 kerchief. In the inhaler employed by Dr. Snow, the compartment 

 containing the chloroform is surrounded with cold water, to limit the 

 quantity taken up by the air, and the expiration valve of the face-piece 

 is so adapted as to admit additional air to any extent to dilute the 

 vapour still further. From an investigation of the fatal cases, and 

 experiments upon animals, Dr. Snow has arrived at the following con- 

 clusions : 



1. Chloroform vapour, if it be inhaled in large proportion with 

 atmospheric air, destroys life by paralysing the heart. 



2. In smaller proportions, but long continued, it produces death 

 apparently by the brain, and by interfering with the respiratory func- 

 ti' in. In such cases the heart ia found to beat after the respiration has 

 r- and. 



3. Chloroform vapour, if it be blown upon the heart, paralyses it 

 immediately. 



4. Atmospheric air loaded with from 4 to 5, or even 6 per cent, of 

 chloroform vapour may be safely administered, inasmuch as that mix- 

 ture will not act directly upon the heart, but will give timely notice of 

 its increasing effects in modifying the normal discharge of the functions 

 of life. The average time occupied in producing insensibility is from 

 three to four minutes. 



5. The proportion of as much as from 8 to 10 per cent, of vapour oi 

 chloroform to atmospheric air is a dangerous mixture, as it suddenly 

 charges the blood going into the heart with a poison capable of acting 

 directly on that organ. 



In cases where an over-dose of chloroform has been administered, 

 the only remedy which appears to offer a chance of relief is artificial 

 respiration. Where the muscles of the tongue become relaxed, and 

 this organ falls back over the glottis, it should be pulled forward till 

 the jiatient revives. It might be desirable to open the jugular vein in 

 order to relieve the distension of the right cavities of the heart. 



The cases in which ether was first employed, and in which chloro- 

 f'lrm is to be recommended as an anaesthetic, are those in which 

 'ions producing pain are perfgrmed. There are no operations, 

 from the extraction of a tooth to the capital operations of surgery, in 

 which it may not be employed. At the same time it may always 

 become a question whether it is worth while running the slight hazard 

 of fatal effects for the sake of relieving a small amount of pain. Where 

 chloroform is skilfully administered, there appears to be little or no 

 hazard, but unfortunately it is not every one who is prepared to 

 administer chloroform successfully. As a rule it may be stated, that 

 it is not advisable for the surgeon who o]rates to administer the 

 chloroform, and a competent assistant should always be employed to 

 do this. Whatever may l, e the doubt in the minor operations of 

 surgery, the beneficial effect of relieving pain upon the subsequent 

 welfare of the patient in the capital operations of surgery, have led 



surgeons very generally to insist on its administration in these cases. 

 [t has now been shown, both by Dr. Simpson and Dr. Snow, that the 

 'atal cases, after capital operations, more especially amputations, are 

 'ewer when chloroform has been administered, than when this or some 

 other anaesthetic has not been employed. Looking to these results, it 

 would appear that the life saved by the use of chloroform has been 

 nmch greater than that sacrificed by its careless administration. When 

 n addition to this it is recollected how great an amount of suffering is 

 prevented, there can be little doubt about the propriety of its admi- 

 nistration. 



It has been supposed that certain states of the system are less favour- 

 able to the administration of chloroform than others, but Dr. Snow has 

 pointed out that in these states of the system the pain of an operation 

 would be as likely to act as injuriously as the chloroform. At the same 

 time, it would appear that a certain number of the fatal eases have 

 occurred in persons with diseased heart, and perhaps in these caution 

 should be employed. 



Besides in operations with the knife, chloroform has been employed 

 to facilitate the reduction of dislocations and of hernia. It has also 

 been recommended in asthma, and as a means of procuring sleep in 

 excessive watchfulness. It was first introduced by Dr. Simpson, of Edin- 

 burgh, as a means of alleviating the pain attendant upon child-birth, 

 and although it has been much opposed in these cases, it is at the 

 present day very largely administered by the obstetric practitioners of 

 Great Britain. In some of the more difficult cases it becomes an im- 

 portant aid to the accoucheur, and in all cases it diminishes the suffering 

 without in any way interfering with the natural actions attendant upon 

 this condition. The injurious effects attributed to chloroform are at 

 most problematical, and the benefits so decided as to lead to its use 

 wherever circumstances will permit. At the same time here, as in 

 other cases, it is not desirable that the operator should administer the 

 chloroform, and as the services of an assistant, or person competent to 

 administer cannot always be procured, it is not likely to come into 

 general use throughout the country. But when assistants can be found, 

 there is no doubt that it is an alleviation of suffering that ought not to 

 be discountenanced. 



From having experimented with various agents, Dr. Snow was 

 induced to try the action of Amylenc as an aniesthetic on the human 

 system. This substance is a colourless mobile fluid, having a specific 

 gravity of 0'659. It is very volatile, and boils at 102. Its composition 

 is C 10 H'. It is soluble in ten or eleven pints of water, and its odour 

 is not disagreeable. The quantity of amylene required to produce 

 anaesthesia is intermediate between that of chloroform and ether. The 

 quantity of amylene consumed in Dr. Snow's inhaler was at the rate of 

 rather more than a fluid drachm in a minute, and in this way insensi- 

 bility was produced in about three minutes. Although Dr. Snow 

 successfully administered this remedy in several cases, he met with two 

 fatal cases, and afterwards abandoned its use. 



Other substances are capable of producing anesthesia in the form of 

 vapour, but none of these have been generally employed. 



(Snow, On the Inhalation of lite Vapour of Ethtr, 1847 ; On Narcotism 

 by the Inhalation of Vapoun, Medical Gazette, 1848 to 1851 ; On l)eath 

 from Chloroform, Lancet, 1856. Pereira, The Elements nf Matcrw, 

 Medica and Therapeutics, 1853. On Chloroform and other Anrrxt/ictict, 

 by Dr. Snow : this work was published in 1858, after the author's death.) 

 A'NAGRAM signifies a new word formed out of the letters of any 

 given word by the process of writing them over again, as the term 

 literally signifies, or placing them in a new order. Sometimes the 

 anagram is formed out of two or more words, and it may be itself 

 always either one word or several. Some traces of this species of 

 trifling have been detected in the writings of the ancients ; but the 

 taste for it does not seem to have spread much among the Greeks or 

 Romans. The artifice appears to have first become fashionable in 

 modern literature in the early part of the sixteenth century. Many 

 authors, instead of putting their names on the title-pages of their 

 works, have, with an affectation of modesty, used the anagrams of 

 their names. At one time also the anagram was made much use of by 

 mathematicians in announcing discoveries, the credit or property of 

 which they wished to secure to themselves without revealing the 

 secret in which they consisted. Huyghens, Galileo, and Newton inti- 

 mated several of their discoveries in this way. 



ANAKIM, or Benei-Anak, the sons of Anak, were a race descended 

 from Ahiman, Sheshai, and Talmai, the three sous of Anak men- 

 tioned in Numbers xiii. 22. They inhabited the mountainous parts 

 of southern Canaan, which afterwards formed part of the territory of 

 the tribe of Judah. At the time of the invasion of that country by 

 the Israelites, the Anakim possessed the towns of Anab, Hebron, 

 Debir, and others. They were apparently above the common size of 

 men. The spies sent by Joshua represented them as giants, to whom 

 they were but as grasshoppers; and their mere appearance alarmed 

 them when sent to examine their land. They were, however, eventually 

 conquered by the Israelites under Caleb, and expelled, but a remnant 

 took refuge with the Philistines. The total number could not 

 have been large, as, though described as consisting of three tribes 

 under separate kings, it would appear that all three of the sons were 

 alive at the time of the conquest, and that Ahiman dwelt in Hebron. 

 Sons of Anak, may, however, mean descendants ; and in Numbers xiii. 23, 

 the three chiefs are called children of Anak, which may imply a more 



