tion being far preferable to the risk of injecting a larger amount. Particular stress is also to be laid upon the great importance of allowing the blood to enter only at a very slow rate, not exceeding a half fluidounce a minute. It is a question worthy of careful study whether in such cases some of the grave dangers of the operation may not be avoided by injecting into one of the smaller arteries instead of a vein. In a most valuable case reported by Mosler (Berl. Klin. Wochenschrift, May 17, 1875), this arterial mode of transfusion was successfully performed on a woman who was pulseless and unconscious from profuse intestinal hemorrhage in typhoid fever.

3d. The apparatus to be used will, of course, depend upon the mode of transfusion adopted. If the direct method is to be pursued, Aveling's apparatus is to be recommended; while for the injection of defibrinated blood, the apparatus here exhibited, as elaborated by Dr. C. T. Hunter, of Philadelphia, leaves nothing to be desired. Whatever be the apparatus employed, the points of importance to be observed, are the avoidance of the introduction of bubbles of air or minute coagula, and the use of great deliberation in the introduction of the blood. The recommendation given by a late writer (Dr. Moore, before the American Medical Association), in favor of his own modification of Aveling's apparatus, that it enables the operation to be completed in, at the most, fifty seconds, would seem to be the most serious disadvantage and danger that could possibly attach to any method of transfusion.

4th. The question, however, which, beyond all others connected with this subject, demands an answer, is in regard to the real clinical value of the operation, and the conditions in which it is indicated. There can be no doubt that in cases of intense acute anæmia caused by profuse hemorrhage, whether traumatic, post-partum, or resulting from disease, or from the hemorrhagic diathesis, the injection. of even f3 vi of healthy blood and the stimulus thereby given to the heart may be, and has been shown to be, capable of saving life. But such cases are of comparatively rare occurrence, and unfortunately it often happens that it is almost impracticable to perform the operation at the very crises which most urgently demand it.

It is the earnest hope of many, however, that the field of transfusion will be found to be much wider, and that it will constitute a new and most valuable mode of treatment for constitutional diseases, such as tuberculosis, scrofula, pyæmia, leucocythæmia, pernicious anæmia, and many others. And, indeed, it is upon the determination of the value or uselessness of transfusion in such cases as these that much of the interest connected with the opera

tion hinges. I do not think that the data yet exist for the positive settlement of this question; and I could not venture, at this time, to sum up the evidence in our possession. It is certainly safe, however, to say that there are several of these diseases in which it is very desirable that the operation should be carefully employed, with suitable precautions. There are, however, some important considerations which must render it doubtful whether transfusion will establish a permanent position in the treatment of such conditions.

a. Thus it is evident that its curative effects must depend on the fact that the morbid changes are limited to the blood, or that if any changes in the solids exist, they are secondary to the blood alteration, and are not in themselves fatal. But it is well known, that, in most of the conditions referred to, there are primary lesions of the solids.

b. I believe it will also be found that in most of these cases there are special conditions, such as fatty heart, internal serous effusions, etc., which will render it necessary to transfuse only very small quantities of blood at one time; so that, while the only way in which the operation can produce benefit is by changing the character of the mass of the blood, it will be possible to introduce but two or three or four fluidounces at one time. Still, although skeptical as to the results, I feel compelled to say that, in view of the tremendous importance of the subject, and the absence of suitable and sufficient evidence, I am strongly in favor of a full trial being given to the cautious and repeated use of very small transfusions of healthy blood, either into one of the smaller arteries or directly into a vein, in the early stage of leukæmia, and in pernicious anæmia, as well as in the intense anæmia of constitutional syphilis, scrofula, and malaria, when they have proved rebellious to other modes of treatment.

I would gladly have touched upon the even more interesting revival of the old discussion concerning venesection, which, after long and ill-deserved neglect, is once more assuming prominence. It is sufficient to say that the attention of the profession has been again called to this subject, within a short time, by men of such commanding position and influence as Paget in England, and Hiram Corson and Gross among ourselves, to assure ourselves that it will receive the close study and consideration it demands. But the weary length to which I find I have already protracted my remarks warns me that I must not venture upon this fertile topic. I am convinced, however, that, in a very few years, he who fills my present place before you will have much to report on the restoration of venesection to its legitimate position, circumscribed and restrained, however,

by the limits of a far more scientific method of employment than has hitherto been possible.

I have thus endeavored to sketch, though with but superficial touches, some of the topics on which medical interest has of late concentrated itself; and I shall have succeeded if I have been so fortunate in the selection of my themes as to indicate with sufficient clearness a few of the directions in which it seems to me that clinical study promises the most marked and most valuable progress during the next few years.

A FEW SUGGESTIONS UPON THE USE OF ETHER.

BY O. H. ALLIS, M.D.,

PHILADELPHIA.

THERE are but two anæsthetics available to the physician and surgeon, and these are ether and chloroform. The latter possesses every charm that could be desired in an agent for producing prompt insensibility to pain; and were it not that its use has been attended with frequent and fatal disasters, it is not likely that the profession would seek a substitute for it.

Ether, as it is commonly employed, presents a very striking contrast to it, and holds a place of rivalry by its side, simply from the fact that it is a safer, though less effective agent. But the safety of an anæsthetic is no mean recommendation, and it is with the hope that I may offer a few hints that may assist in overcoming the apparent defects of ether, that I ask a few moments of your time.

The most striking defects of ether are (a). Its proneness to irritate the air-passages. (b). Its comparative feebleness as an anæsthetic agent. (c). Its long and vexatious stage of excitement.

These and other points are seen in the use of ether, and it cannot be denied that, ordinarily, they contrast strongly with chloroform. But are these the defects of ether, or of its mode of administration? I think the latter.

That ether often irritates the larynx is true, but only in the early stages of the anæsthetic procedure; and that, too, when it is used in too strong and concentrated a form. If a faint odor of ether is given at first, and this gradually increased, it will be found the exception, and the rare exception, that it is in the slightest degree irritating.

The other objections to ether may be embraced under the head of its feebleness as an anesthetic. This I think needs no argument, and all that is left us is to add to its strength by an effective mode of administration. It requires a concentrated vapor of ether to accomplish any prompt results, and those who use it most have

learned that it should be used with great profusion, and that the respired air should be thoroughly impregnated with the ether. Such a course has been found to be prompt and to be unattended with danger. I shall offer no criticism upon it, but simply state that I think the effect can be gained quite as promptly and without the waste of ether, or the offence to the patient. What ether requires is an opportunity to evaporate, and, under favorable circumstances, when there is a thin stratum of it, its disappearance is almost instantaneous. Any apparatus or vehicle for the administration of ether, that holds it in any quantity and retains it in the fluid state, is not well adapted for its use, while any contrivance that will favor the rapid deliverance of the vapor of ether must, cæteris paribus, be more effective.

To reach this point, I have contrived a wire frame-work for keeping many folds of a bandage at a slight distance from each other, and yet having the whole in a compact form that will readily adjust itself to the face. The sides are inclosed, but the ends are left open -the one for the patient's face, the other for the entrance of air and the ready supply of ether.

It might at first appear unscientific, and to favor a waste of ether, but it is in every way an advantage; not only as it permits the ether to be added in small and constant quantities, but as the vapor of ether falls, by its density, there can be no need of closing it at the top.

The folds of bandage, being separate from each other, cannot hold the ether, and must almost instantly liberate it, and the extent of free exposed surface of bandage, in a space less than four inches square is over one thousand square inches. When one thinks that the air has ready access to both sides of so great a surface, and that upon this surface the ether falls, it must seem rational that such a mode of administration must be effective; and when, too, it is seen that the supply of ether may be constant, one need never add more than a half drachm at a time, if he will permit but a few seconds to elapse between the successive supplies.

I have found it very effective. I usually produce complete anæsthesia in females in seven minutes, and with about two ounces of ether. Persons seldom object to taking it, and the stage of excitement is no more excessive, prolonged, or frequent, than with chloroform.

I adhere strictly to the following plan. The patient, being freed from all restraint as to clothing, I place the apparatus over the face and add a few drops of ether, hardly enough to give a strong