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Anesthesia Supplement

To each 30 mils of this solution 1 mil of adrenalin solution (1 to 1000) is added. This provides a somewhat longer duration for the obtunding effect.

The main features of the routine procedure for handling penetrating brain wounds developed by Cushing from his extended experience and those. of other operators, are as follows: (1) The removal en bloc, rather than piecemeal, of the area of cranial penetration. (2) The detection of the in-driven bony fragments by catheter palpation of the track, rather than by the exploring finger. (3) The suction method of removal of the disorganized brain, thereby cleansing the track of the so-called pulped or devitalized tissue, the retention of which, as is the case with dead tissue anywhere, favors infection. (4) The use of dichloramine-T in oils as an antiseptic particularly suitable for infections in the central nervous tissues.

In addition to these more essential features of the operative procedure, the routine preoperative neurological study of the case; stereoscopic x-ray negatives; the shaving of the entire scalp; the invariable use of local anesthesia supplemented with alkaloidal amnesia; preferential tripod rather than flap incisions; foreign body extraction with the magnet when possible; closure of the wounds with buried sutures in the galea; the dressing of all serious cases in the operating room rather than in the wards -all these steps, though less novel, were found to be contributory to the successful outcome of the

more severe cases.

By utilizing two or three tables for each operating team, series of cases may be handled without delay, the neurological examination, x-ray exposure, shaving of the scalp, hypodermic and local anesthesia injection, all of which are time-consuming, being carried out during the operating period of the previous case.

It is to be noted especially that Cushing's entire technic has been an elaboration of the velvet-touch method of operating, which is an essential for all procedures done under local anesthesia. In this connection it should also be emphasized that the use of alkaloidal amnesia, puts the patient in a sufficiently drowsy condition not to mind the use of trephine, drill, or ronguer, the effects of which are somewhat distressing when local anesthesia is used alone.

The summary of the results of examinations of blood presure in head wounds, in the report of the British Medical Research Committee, December 25, 1917, is of interest in connection with the subject under discussion. Fraser and Cowell conclude

that:

The blood pressure subsequent to wounds of the head is apt to be unstable. If operation is performed under general anesthesia before the blood pressure has become stable, disaster is liable to ensue. The possibility of such an ill result can be diminished by delaying operation until the blood pressure has become stable or by performing it under local anesthesia, supplemented with scopolamin-morphin.

THE AUSCULTATORY CONTROL OF VAPOR ANESTHESIA.*

ARTHUR E. GUEDEL, M.D.

Captain U. S. Army Medical Corps, Base Hospital 23, American Expeditionary Force, France. INDIANAPOLIS, IND.

In an effort to meet a shortage of proper anesthesia apparatus for head surgery in the American Expeditionary Force, and at the same time provide a suitable device for the administration of the accepted high-volume, low-tension ether vapor for operations about the head and face, by the intrapharyngeal method, the illustrated apparatus was assembled from material that every base hospital has in stock. With a photo or drawing of this device at hand its assembling should not take more than an hour's time.

The apparatus supplants the high-priced and complicated (but good) devices now on the market for anesthesia in head surgery and produces results equally good in a simpler manner. The anesthetic novice will learn to operate it much more readily than the more intricate devices. Also the auscultatory tube, which is a feature in intrapharyngeal anesthesia that, I believe, has never before been used in this way, is a great help in the maintenance of an even and light anesthesia. It is of particular value in the dark-room for the removal of foreign bodies about the head, under fluoroscopic control. In fact it was the need of some method of control in dark-room anesthesia that prompted the conception of the auscultatory tube for this purpose. It has worked out so well that it has been used in anesthesia for general surgery as well as to facilitate the maintenance of even anesthesia.

There is less ether wasted with this apparatus than with those devices which employ a hot place for the vaporization of the ether.

The apparatus consists of: (1) A dental footbellows; (2) a rubber tube, through which air is carried into the other container. By manipulating the Dakin clamp on this tube the percentage strength of the ether vapor is controlled by regulating the amount of air passing through the ether; (3) A rubber tube through which a stream of air passes to the patient without passing through the ether container. By manipulating the Dakin clamp on this tube, in a direction contrary to that of the inlet tube, the strength of ether vapor delivered to the patient may be further controlled; (4) a

Read by proxy during the Fourth Annual Meeting of the InterState Association of Anesthetists, in conjunction with the Indiana State Medical Association, Claypool Hotel, Indianapolis, Ind., Sept. 25-27, 1918.

Anesthesia Supplement

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Fig. 1. Showing the position of the Anesthetist to the field of operation in Auscultatory Control of Vapor Anesthesia.

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Anesthesia Supplement

rubber tube which carries the mixture of ether and air to the patient. This tube is 4 feet in length, thus enabling the anesthetist to sit well out of the way of the operators; (5) Dakin U glass distributing tube for the purpose of dividing the air current between the ether bottle and the patient; (5) Dakin 3Way distributing tube for the purpose of combining the streams of pure air and etherized air, and for the connection of the auscultatory tube; (7) The Auscultatory Tube, which conveys all the information that the anesthetist may need regarding the condition of the patient.

Through this auscultatory tube the anesthetist may determine the following: (a) the patient's respiration; (b) whether or not the patient is swallowing, or (c) the patient's larynx is being flooded with mucous. This complication is rare with the high-volume, low-tension ether vapor method of anesthesia, because the end openings of the nasal tubes, when in position, are just above the larynx and the volume of etherized air is sufficient in most cases to blow all excess mucous into the mouth, from which it is either allowed to drain or is milked-out by pressure of the cheek; (e) the slightest effort of the patient to cough or vomit, indicating too light anesthesia, a matter that may be immediately remedied by deepening the narcosis; (f) the amount of air bubbling through the ether, thus helping to ascertain the strength of the ether vapor. This strength may also be determined by removing the auscultatory tube from the ear and smelling the ether vapor flowing through the tube, as it is always the same percentage strength as that being delivered to the patient. This auscultatory tube is particularly valuable in dark-room work, such as the removal of shrapnel under the fluoroscope. Here the anesthetist need not see the patient at all. He conducts the anesthesia entirely in accordance with the signs obtained through the auscultatory tube; (8) Dakin U tube connected with two catheters which are passed through the nostrils into the pharynx, and (9) the ether container.

The accompanying photograph shows the position of the anesthetist and apparatus with relation to the patient and the field of operation, with the auscultatory tube in place.

In conclusion, it may be remarked that the auscul tatory tube furnishes more definite information as to what is going on in the patient's throat and chest than can be had in any other way, not excluding the use of the stethescope continuously over the chest. In cases where it is necessary to watch the pulse of the patient, this is easily accomplished at the wrist on the radial artery.

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AN APPARATUS FOR DOSIMETRIC ANESTHESIA FOR FIELD AMBULANCE, EMERGENCY SURGERY AND

OBSTETRICAL USE.*

M. L. TOWNSEND, M.D.

Captain, U. S. Medical Corps, Field Ambulance Service, American Expeditionary Force, France.

CHARLOTTE, N. C.

In Field Ambulance service, emergency surgery and obstetrics the physician or medical officer is repeatedly confronted with the problem of giving an anesthetic and operating or delivering without an assistant, either skilled or otherwise. This necessity prompted the designing of an anesthetic inhaler as automatic and dosimetric as could be made. The inhaler, herewith presented, is simple, compact and always ready for use. It is an inhaler and container combined and packs into so small a space that it may be carried in the pocket or emergency grip, filled and ready for instant use.

It furnishes a steady, uniform, dosimetric vaporization of the anesthetic without requiring any dropping of the agent; and can be automatically set to deliver certain percentage strengths of the anesthetic used.

As the accompanying illustrations show, the inhaler is composed of a mask and container. When closed the container screws into the mask, sealing itself so that the ether or chloroform within neither evaporates nor deteriorates. To prepare the inhaler for use the container is unscrewed from the cap inside the mask and engaged in the outer socket and screwed into place so that the O of the dosimetric scale is opposite the nasal end of the mask. The mask is so modeled that it will fit any sized face and nose without the need of a rubber air cushion or gauze sponges. The inhaler is indestructible and can be washed or sterilized in any desired manner without fear of damage.

The inside of the container is fitted with sheet metal, concentric rings, covered with absorbent material. These concentric rings are so arranged that when engaged, with the mask in use, the vaporization of the anesthetic may be controlled dosimetrically by turning the container on the mask, either to right or left, as a stronger or weaker concentration is desired. The contents will not spill out irrespective of the position of the inhaler.

This device is not only simple, sensible and practicable, but comparatively reasonable in cost. It

*Read by proxy during the Fourth Annual Meeting of the Interstate Association of Anesthetists, in conjunction with the Ind iana State Medical Association, Claypool Hotel, Indianapolis, Ind., Sept. 25-27, 1918.

requires no renewal of its absorbent material and as there are no complicated parts to get out of order, its upkeep is negligible. Also it will induce and maintain anesthesia with about one-half the amount of any anesthetic required by open methods of anes thesia and this advantage makes for economy.

Its greatest advantage, however, is the increased safety to the patient. Because of the uniform, dosimetric anesthetic vapor provided, there is no coming out one minute and drowning the next. The operation of the inhaler is so simple that any anesthetist, even a novice, may expect satisfactory results.

Anesthesia Supplement

tions with their stomach full of slumgullion, and in spite of this lack of preparation for an anesthetic, the use of this inhaler, providing a minimal dosage and absorption of the anesthetic, has been followed by a very low percentage of after-nausea. While the percentage strength of anesthetic vapor must be rather rapidly raised during induction, the patient's more or less fixed dosimetric requirement during the stage of maintenance is readily determined and can be kept at that level to the end of the operation.

In obstetrics the inhaler may be used by the par

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Figs. 1 and 2. The Townsend Inhaler in use in Field Ambulance Service and in Obstetrics. The container will hold approximately 100 cc. of ether, chloroform or anesthol and if the anesthesia is of sufficient length to exhaust this amount, the container may be immediately refilled by using the mask as a funnel.

In Field Ambulance service, or emergency surgery, whether of a military or civilian sort, this inhaler, in the originator's personal experience, has satisfactorily met all demands made upon it. Soldiers in service almost routinely present for opera

turient woman herself, after the dosimetric requirement to obtund the pains of labor has been determined. There is no danger of overdosage, for with waning consciousness and the onset of relaxation the inhaler drops away from the patient's face, to be reapplied by the woman at the next pain. The dosimetric requirement for continuous, light anesthesia during delivery may be determined by the obstetrician and maintained by an attendant holding the inhaler in place.

Anesthesia Supplement

GENERAL ANESTHESIA IN WAR
SURGERY.
P. PICARD.

Interne des Hôpitaux de Paris, Médecin Aide-Major.

This procedure, inspired by that of our preceptor, M. Savariaud, (La Presse Medicale, No. 55, 1917), has rendered us the greatest service during the most intense activity of our Unit. Since January, 1917, we have employed it exclusively for all our general anesthesias.

Simplicity and rapidity of anesthesia, without complicated apparatus so difficult to procure, are of great importance from the standpoint of surgical service. It is on this account that we recommend this simple, convenient and easily-constructed apparatus.

and ethyl chlorid 10 grams), which is easily made. For a long time J. Louis Faure has drawn attention to this mixture. Upon the anesthetic table is a graduated glass and flask of Schleich Mixture, prepared in advance. When everything is in readiness for the operation, and the wounded patient has been placed on the table, the apparatus is charged. Two medium-sized, fluffed compresses of gauze (which are renewed for each operation), are placed in the reservoir, and saturated with 20 cc. of the mixture, poured from the graduate through the top aperture.

The cover is closed, the inhaler is gently placed over the face with the air-vent wide open. After two or at most three expirations, the air-vent is closed and the inhaler closely adapted. The rebreathing bag is fully distended. The period of

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Apparatus-It is similar to but larger than that of our comrade Dr. Noiré, employed for prolonged, general anesthesia with ethyl chlorid. The mask is a truncated cone of galvanized metal 12cm. high. The bottom is modeled to accurately fit the nose, cheeks and chin. To accomplish this it is reinforced with a thickened border. The top is closed by a cover which can easily be removed. The inside o fthe mask is divided, by a metal-mesh partition, into compartments of about equal size. The upper compartment is the resorvoir for the anesthetic. Near the top and to the left it is connected with a rebreathing bag (as in the Ombrédanne and Camus inhalers), so that the respiration may be partially or entirely confined. Symmetrically and to the right is an air-vent, easily regulated, formed by two sleeved tubes, with overlapping openings 2 cm. by 0.007 mm.

Anesthesia. The choice of the anesthetic is not indifferent. We employ exclusively Schleich's Mixture (ether 60 grams, chloroform 20 grams

Fig. 2.

excitation is either absent or negligible, even in alcoholics. In two minutes the time necessary for the preparation of the field of operation, muscular relaxation is complete, and the narcosis remarkably calm.

After the operation is begun nothing remains but to maintain anesthesia and watch the condition of the patient.

The initial dose of 20 cc. assures a period of at least from 8 to 10 minutes of anesthesia, after which, to maintain anesthesia, it is necessary to add 5 cc. of the mixture every 7 minutes. This dosimetric administration of the mixture is accomplished through the upper aperture of the inhaler without displacing it.

Ordinarily the the air-vent remains completely closed, and is only opened when necessary.

The return to consciousness is rapid and complete. Nausea is rare and vomiting not more frequent than with chloroform. quent than with chloroform. We have administered 500 anesthesias without untoward incident.

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