ON ANASSTHETICS. 301 
of the time only a quarter. In a series of hospital cases the average 
amount of the mixture consumed was an ounce in fourteen minutes :— 
The least used was 4 oz. in twenty-two minutes (feeble infant). 
The most used was 3} oz. in thirty minutes (fat aleoholic woman). 
6. The Condition of the Patient during Operation and the Occurrence of 
Shock or other Reflex Effects. 
A condition which is highly satisfactory with regard to the state of 
the circulation, the respiration, the relaxation of muscles, and the 
immobility of the patient can almost invariably be obtained and main- 
tained. Respiration is usually rather deeper, the pulse quicker, and the 
colour better than in average chloroform cases. The pupil is usually of 
moderate size. In one case only was a change of anesthetic demanded. 
In this case, during the removal of a gall-stone a condition of persistent 
rigidity of the rectus led to a change from the mixture to ether (F. H.). 
In cases with marked respiratory defect the mixture can be given with 
oxygen. The type of anesthesia obtained is more like that secured by 
low percentages of chloroform vapour than like that seen with ether. It 
is generally possible to secure a condition in which the corneal reflex is 
just present without the occurrence of inconvenient contraction of 
muscles or of coughing or retching. Reflex effects due to the operative 
procedure have been noted in several cases. Serious disturbance of pulse 
or of breathing arising in this way appears to be less liable to occur with 
this mixture than with pure chloroform, though more likely than when 
ether alone is given. Thus reflex effects during anesthesia, chiefly bear- 
ing upon respiration, were evident in fifteen of seventy-five carefully 
recorded cases. In most cases these effects were in the nature of stridor, 
or of grunting expirations. They occurred during stretching of anal 
sphincter, forcible pulling up of uterus, internal urethrotomy, &c. The 
most marked instance of respiratory effect was produced by dragging upon 
the sac of a hernia, and this case afforded an excellent example of the 
degree to which such an effect can go, respiration becoming absolutely 
obstructed and the chest having to be compressed three times before 
breathing started again. At-the same time the pulse scarcely showed any 
change. Reflex movements of limbs or reflex rigidities of muscle were 
very rarely met with, and this absence was particularly noticeable in 
rectal operations which, under ether, are frequently attended by such 
reflexes. Slowing of pulse as a reflex effect was occasionally observed. 
Tn a few cases well-marked pallor occurred during surgical manipulations. 
Severe surgical shock, resulting in disappearance of pulse, dilatation 
of pupils, opening of eyes, pallor, and stopping of respiration, was 
seen in one case in which laparotomy was being performed upon a 
thin anemic young woman, the subject of extreme chronic constipation. 
The corneal reflex was faintly present at the moment when symptoms of 
shock suddenly showed themselves. 
7. After-effects. 
Speaking generally, recovery takes place rapidly and without any 
disagreeable after-effects, provided, of course, that the patient has been 
properly prepared. In no cases of our series were there severe after- 
effects. The worst instance was that of a case of removal of glands from 
