W. C. ABBOTT, M. D., CHICAGO, ILL.
(When you read this glowing praise, remember: W. C. Abbott was rather involved in Abbott's Alkaloidal Company, who manufactured H-M-C. -Henriette)
Since the introduction of cocain no such general interest has been aroused by any newly suggested anesthetic as at present is being displayed in the hyoscine, morphine and cactin method. Although it is still in the preliminary trials, it is being virulently attacked and warmly defended.
In favor of the new method it is claimed that it is safe, effective, as a rule free from nausea, shock, and post-operative disease of the pulmonary and renal structures, while it enables the operator to do without a special anesthetizer, to operate in emergencies and in the patients' homes without assistants; to do operations requiring long time without the continuous administration of the anesthetic, and in cases of multiple accidents, as at a railway wreck, many injured persons may be promptly put at ease while waiting their turn for attention.
The safety of hyoscine has been called in question, since this agent sometimes occasions relaxation of vascular pressure and slowing of respiration. In the treatment of the morphine habit, where there are evidences of depression after that drug has been withdrawn, even to syncope, hyoscine has been largely employed. Hare has reported favorably on the treatment, giving up to the one-fourth of a grain each twenty-four hours, for several days in succession, with impunity. It does not seem likely that less than one-eighth this dose—three injections of gr. 1/100 each, two hours apart-for surgical anesthesia, could be so very perilous. Still, it would be the first exception to a universal rule if a new anesthetic, whose technic has not yet been definitely fixed, placed in the hands of all sorts and conditions of physicians, and administered to all sorts and conditions of subjects, should not prove perilous to some.
Up to the present time there have come in reports from thousands of cases without a solitary fatality except possibly one, which is disputed. A few instances have been reported where "alarming symptoms" developed, but he who has employed hyoscine much is accustomed to these, and does not get alarmed. This drug is peculiar in causing conditions that would in other cases be alarming, but the patients always recover. In one case the patient had received three injections of the tablets, one each, and her respiration descended to six per minute. The surgeon, who had had much experience with this method, prohibited the strychnine injection, proposed by a frightened assistant, finished his dinner, went about the operation—for appendicitis in the most leisurely manner, and all went well.
In discussing the action of a drug it is sometimes overlooked that the physiologic action as laid down by the text-books relates to toxic doses, and not to those ordinarily used. Still, the reader will do well to recall the history of the introduction of ethyl bromide. Levis announced that it could safely be employed even in cases of heart disease in which ether and chloroform were impossible; and for a time all went well. Then a patient of that description died under the anesthetic, and it was dropped altogether by most surgeons, in consequence. That the same case would have or might .have died under any anesthetic was ignored.
The sedative action of morphine is a question that might be discussed with advantage. Theoretically this alkaloid is ranked as a depressant, and is administered as such in certain conditions. But, take the depression following the withdrawal of morphine for a habitué, or that attending .great physical suffering, and administer morphine and note the powerful stimulation ensuing; would you call it a sedative there, in the sense of a depressant? Is it not a fact that the sedation of pain and the prevention of suffering and shock, directly enhance the vitality and prevent the danger that would follow from any true depression?
Whatever depression may be possible from the morphine and the hyoscine it is claimed is obviated by the addition of cactin. Cactus is a valuable cardiant, regulating heart action by stimulating the vasomotor centers. It has been found that its addition does not in the least interfere with the anesthetic action of the other ingredients but rather increases it. That the reasons for its use are well founded appears to be verified by the fact that when the cactin was omitted by reason of shortage in the supply, the tablets were promptly pronounced unsatisfactory by those using them.
The mortality attributed to "scopolamine" anesthesia in Wood's tables shows remarkable discrepancies; for while 7 operators report 1072 cases with 9 deaths attributed to the anesthetic, 18 others report 890 cases with no deaths. It would be as unfair to judge the method by the experience of one man who used it in a single case, with fatal results, as from that of another who employed it in 200 cases with no death. But when such marked discrepancies exist as to the effects of a new method, whose technic is as yet not definitely determined, it seems reasonable that we should judge it by the results secured by the most successful. How else?
As to the questions on the value of the method in inducing anesthesia, and the absence of the deplorable effects following ether and chloroform sometimes, we must hear from the field. It is up to the surgeon to decide these. There seems to be a consensus of testimony in this respect, but it can scarcely be expected that any method should prove so universally applicable that there are no exceptions, and we expect to hear of some in time. If the reports on the use of these tablets in obstetrics, and in the treatment of such agonizing maladies as gallstone colic and tetanus, should be confirmed generally, our therapeutic armamentarium will have been enriched by an addition of untold value.
Can we afford to have such a method fall from our hands without first giving it a thorough, intelligent, unbiased trial?
Apparently the medical profession has decided this question in the negative, since at the time of writing they have taken more than two millions of these anesthetic tablets and the demand increases steadily. If we allow two tablets for each anesthesia there should be, according to Wood, over 5000 deaths from this anesthetic. Where are they? Reported to date—one and that evidently not due to the anesthetic.
Ellingwood's Therapeutist, Vol. 2, 1908, was edited by Finley Ellingwood M.D.