Anesthesia Supplement American Journal of Surgery QUARTERLY SUPPLEMENT of Surgery Publishing Co. J. MacDONALD, Jr., M.D., President and Treasurer 15 EAST 26TH STREET NEW YORK, U. S. A. Original Articles, Clinical Reports and Experimental Subscribers Changing Address should immediately notify F. HOEFFER McMECHAN, A.M., M.D., Editor a little alcohol as a rectal injection in shock and intravenously, without the alcohol, in severe hemorrhage. Now, who will check-up on this matter and present a series of clinical observations on the value of sugar therapy in relation to operation and anesthesia?-McM. THE NURSE ANESTHETIST IN OHIO. The present General Assembly of Ohio has seen fit to legalize the "administration of anesthetics by registered nurses, properly trained in recognized hospitals, under the direction and supervision of a licensed and qualified physician.” Thus supervised anesthesia by anesthetist technicians now has the endorsement of law, although this pernicious legislation was opposed by all those having the interests of anesthesia as a specialty at heart. Those behind the passage of this legislation are the surgeons and hospitals who are exploiting nurses as cheap, scab labor. They also represent a clique within the profession and hospital associa1919 tions, who are precipitating the practice of medicine into socialized medicine under hospital domination. SUGAR IN RELATION TO OPERATION P. J. Flagg has drawn attention to the value of candy in the pre- and postoperative dietary of patients coming to operation under anesthesia. Litchfield, speaking before the A. M. A., at its last session, claimed that the intravenous injection. of dextrose overcomes dehydration, intoxication and nitrogen starvation. Dehydration occurs in vomiting, diarrhea, hemorrhage, acidosis, inflammatory exudation, dysentary and cholera and in these conditions in which the symptoms are most striking the injection of dextrose changes the whole clinical picture. Patients who are desparately ill, frequently recover promptly after a single injection of from 400 to 500 cc. of a solution of dextrose. Litchfield uses a 25 per cent. isotonic solution of dextrose where he previously used normal saline, especially in pneumonia, purulent pericarditis, meningitis, alcoholic intoxication, in surgical cases, pre- and postoperatively, in vomiting and in acidosis. The technic is that of salvarsan injection. As much as 1,700 cc. has been given in 11 hours, but one hour's time should be consumed in injecting 200 cc., or sharp reactions may occur. Other conditions demanding the use of dextrose are acetonuria, the toxemias of pregnancy and the puerperium as well as delayed chloroform poisoning. Piper commends the use of glucose solution with Presently the profession-at-large will realize the fact that it has been sold-out by supposedly altruistic leaders and when the revulsion against them comes it is to be hoped that they will be relegated to the oblivion they so richly deserve for betraying the long fight for betterment in the practice of medicine and especially in the development of the newer specialties. When these same altruists come to operation it is to be hoped they will receive a dose of the same sort of anesthesia they are now legalizing.—McM. Society Proceedings Membership in a society devoted to your specialty is an essential to success. INTERSTATE ASSOCIATION OF ANESTHETISTS -FIFTH ANNUAL MEETING. The Interstate Association of Anesthetists has been accorded the distinction of a Joint Meeting with the American Association of Gynecologists and Obstetricians. This Fifth Annual Meeting will be held at Cincinnati, Ohio, September 15-17, at the Hotel Gibson, where the Interstate was organized in 1915. A Joint Session will be devoted to papers of mutual interest, among them the following: Safety Factors in the Team-Work of Operator and Anesthetist, John J. Buettner, M.D., Syracuse, N. Y. (Chairman's Address.) The Value of Blood Pressure as a Guide Before, During and After Operation, E. I. McKesson, M.D. and Chas. Moots, M.D., Toledo, O. Some Practical Points in Gas-Oxygen Obstetrical Analgesia and Anesthesia, A. E. Guedel, M.D., Indianapolis, Ind. Discussion and film demonstration, C. E. Turner, M.D., Columbus, O. Some Adjuncts for Facilitating Local and Regional Anesthesia for Major Surgery, R. E. Farr, M.D., Minneapolis, Minn. (Film demonstration.) Which Solution for Intravenous Injection in Shock?, Jos. Erlanger, M.D., St. Louis, Mo. A special effort is also being made to hold an outstanding Section on Anesthesia for Oral Surgery and Dentistry and the following papers have so far been scheduled: Somnoform, a Neglected Anesthetic for Oral Surgery, Oel E. Lanphear, D.D.S., Kalamazoo, Mich. Nitrous Oxid-Oxygen Anesthesia in Dentistry and Oral Surgery, J. P. Henahan, D.D.S., Cleveland, O. Some Observations on General Anesthesia for Oral Surgery, C. H. Burmeister, D.D.S., Cincinnati, O. demonstration.) (Lantern Interested surgeons, dentists and anesthetists are cordially invited to attend and find out how the Interstate meets their needs for progress. The following nominations have been made for 1920: Chairman, W. I. Jones, D.D.S., Columbus, O.; Vice-Chairman, Samuel Johnston, M.D., Toronto, Canada; SecretaryTreasurer, F. H. McMechan, M.D., Avon Lake, O.; Executive Committee, Alex S. McCormick, M.D., Akron, O.; John H Evans, M.D., Buffalo, N. Y.; Marie Kast, M.D., Indianapolis, Ind.: A. E. Smith, D.D.S., M.D., Chicago, Ill. Ralph M. Waters, M.D., Sioux City, Iowa, and Roy S. Hopkinson, D.D.S., Milwaukee, Wis. Members are requested to submit further nominations. The Annual Dinner will be served at the Hotel Gibson at 6:30 o'clock on the evening of September 15. A large attendance is expected so make your reservations early. As usual the visiting ladies will be delightfully entertained, so bring along your women folks. Bring in at least one new member and don't overlook sending in your check for dues so that your Membership Card can be sent you in advance of the meeting. If you have a paper to present get in touch with the Secretary at once so that it can be scheduled. Don't hesitate to give the Interstate the benefit of your experiences and researches. For further particulars address F. H. McMechan, M.D., Secretary, Avon Lake, O. AMERICAN ASSOCIATION OF ANESTHETISTS SEVENTH ANNUAL MEETING. The American Association of Anesthetists held its Seventh Annual Meeting at The Breakers, Atlantic City, June 9-10, 1919. Dr. Jos. E. Lumbard, vice-president, called the meeting to order and presided during the executive session. The minutes of the 1918 meeting at Chicago and the secretary-treasurer's report were accepted as read. Anesthesia Supplement The following officers were elected for the ensuing year: President, Albert H. Miller, Providence, R. I.; vice-presidents, W. T. Shannon, Detroit, Mich., and Frances Haines, Chicago, Ill.; secretary-treasurer, F. H. McMechan, Avon Lake, O.; members of executive committee, Robert L. Charles, Denver, Col., and Wm. H. Long, Louisville, Ky. The following were elected to membership: W. T. Bailey, Boston; Anna L. Bartholomew, Chicago; Edward W. Beach, Philadelphia; Philip E. Brundage, Grantwood, N. J.; Emmett J. Craig, Kansas City; W. F. Curran, Waco, Texas; W. T. Doran, New York City: James M. Gates, New York City; Wm. G. Hepburn, Westmount, Canada; F. Elmore Hubbard, Montclair, N. J.; H. W. Kearney, Washington, D. C.; Bella Lewinson, Erie, Pa.; Arnold J. Mackay, New York City; J. R. McCurdy, Pittsburgh; George Piness, Los Angeles; John W. Rayhill, Utica, N. Y.; Boris Rapoport, Dorchester, Mass.; Claude E. Richmond, Colorado Springs; C. La Rocque, Montreal, Canada; Arthur E. Smith, Chicago, Ill.; Wm. S. Sykes, Cleveland, O.; Harold G. Walker, Wyckoff, N. Y.; Thos. A. Young, Toledo, O. The Constitution was amended so as to admit prominent dentists, specializing in anesthesia to membership. The secretary-treasurer was voted an appropriation of $125.00. Dr. Jos. E. Lumbard presided during the first Scientific Session and papers were presented by Drs. S. P. Reimann, Philadelphia; Wm. deB. MacNider, Chapel Hill, N. C.; Frank C. Mann, Rochester, Minn.; Fenton B. Turck, New York City; F. L. Richardson, Boston, Mass. Dr. Wm. B. Howell, President, presided at the remaining Scientific Sessions during which the following presented papers: Drs. Jos. E. Lumbard, New York City; Albert H. Miller, Providence, R. I.; A. W. Adson, Rochester, Minn., H. Clifton Luke, New York City; Frank Dyer Sanger, Baltimore, Md.; W. G. Hepburn, Montreal, Canada; Wm. B. Howell, Montreal, Canada; Howard Lilienthal, New York City; Walter B. Cannon, Boston; Frances Haines, Chicago; W. T. Shannon, Detroit, and W. S. Sykes, Cleveland, O. The papers devoted to anesthesia for war surgery were especially enjoyed, as were the films and slides of Lt. Com. Seaman Bainbridge, who was the after-dinner speaker. The annual dinner was served by The Breakers, and was well attended and enjoyed by ali. As is customary the American Association of Anesthetists will meet the first two days of A. M. A. week in New Orleans, La., June, 1920. This will be the first meeting of anesthetists in the south and it is hoped that southern anesthetists will take especial interest in making it a success. Those interested in becoming members or in presenting papers are requested to get in touch with F. H. McMechan, M. D., secretary, Avon Lake, Ohio. NEW YORK SOCIETY OF ANESTHETISTS. The following excerpt from the New York Times, Sunday, May 25, 1919, is of pertinent interest to all specialists in anesthesia: The restriction of the administration of anesthesia to licensed physicians and the exclusion of nurses from doing such work during surgical operations was urged yesterday by James Taylor Lewis, counsel for the New York State Medical Society. On the ground that the law prohibits any one without a doctor's license from giving ether or chloroform or other poisonous gas to a patient, except when directly and continuously supervised by a physician, Mr. Lewis held that criminal action should be brought to prevent the continuation of this practice in certain hospitals, as not only was the law being violated, but lives were continually being placed in danger. If it could be shown that nurses, after special training, were competent to administer anesthetics, then, he contended, the law would have to be changed so as to give the nurse the right to do the work under the proper restrictions. Mr. Lewis recently read a paper on this subject before the New York Society of Anesthetists. After paying tribute to the importance of the nurse in the treatment of disease, Mr. Lewis showed that nevertheless there were elements concerned in the giving of anesthetics that made it a phase of the practice of medicine as defined by the law. He then quoted the section of the public health law (Article 8, Sec. 160, subdiv. 7:) "A person who practices medicine within the meaning of this article, except as hereinafter stated, who holds himself out as being able to diagnose, treat, operate, or prescribe for any human disease, pain, injury, deformity or physical condition, and who shall either offer or undertake, by any means or method, to diagnose, treat, operate or prescribe for any human disease, pain, injury, deformity or physical condition. Mr. Lewis then pointed out how, in his opinion, the nurse in administering an anesthetic, did something more than place the cone over the patient's mouth, and that she had other duties which came within the definition of practicing medicine. "The nurse who gives the anesthetic and sits with the cone over the face and the unconscious patient is required to go much further. It is her duty to keep the tongue up, to watch the pulse, to pass upon the strength of the pulse, its quality, the color of the lips, the color of the skin, the condition of the skin; indeed, many other symptoms which indicate the then present physical condition of the patient to whom she is administering the anesthetic. If that is not even diagnosing the presence or absence of a disease, perhaps, then, the definition as described in our own statute means nothing. "The operating surgeon can give no attention to the effects of the anesthetic, and if the nurse notices symptoms which seem to indicate that the patient is 'going bad' the responsibility of taking action is hers, and she must prescribe. Because some great surgeon has a woman nurse who has given an anesthetic to an enormous number of patients. and is now qualified, has no relationship to the question. Because a few nurses, through large experience, have acquired skill furnishes a poor reason for saying that all nurses, however qualified, may calmly walk into a hospital, even as a nurse on probation, or a pupil nurse, and proceed with administering an anesthetic, putting in danger the life of the patient. I am convinced that any hospital sued under such circumstances might be mulcted in damages for negligence in not furnishing qualified employees and agents in the administration of their affairs." Mr. Lewis cited the statutes and court decisions in a number of other States, and especially that of Judge Kirby in Kentucky, in which the court said: "Dr. Frank and other physicians employing trained nurses say that in so doing they assume the responsibility. Where the trained nurse is known to them to be competent they may take the responsibility, but rt is a responsibility the extent of which they probably have not duly considered. In a suit growing out of the death of a patient where the surgeon had voluntarily employed an anesthetist who was not licensed, he would in the event of his brother physicians testifying in this case certainly be held responsible." "If a doctor," continued Mr. Lewis, "operating in a hospital in the City of New York or elsewhere, allows a nurse to administer an anesthetic, of whose knowledge he knows nothing, and of whose ability as an anesthetist he is uninformed, he must expect to be held responsible for any untoward result which ensues by reason of the giving of the anesthetic. The hospital, in turn, must be held responsible if it permits unsupervised and inexperienced women to give anesthetics, whether they be graduate or pupil nurses, because the employment of such inexperienced persons cannot be pleaded by them as a bar to an action against such institution where damage or death ensues." Quarterly Index ANALGESIA FOR INOPERABLE CANCER. J. Blanc Fortacin. Revista de Medicine y Cirurgia Practicas, Madrid, January 21, 1919; Vol. 122, No. 1539. ANESTHESIA, DEPARTMENT OF, AT ROYAL VICTORIA Hos- PUT. CHLOROFORM ANESTHESIA, ON TUBERCULOSIS, EFFECTS OF. E. Olivares. Revista Medica, December 15, 1918. ETHER AS AN ANESTHETIC. J. B. Holyrod. Indian Medical Gazette, February, 1919. ETHER HYPERGLYCEMIA, EFFECTS OF ATROPIN ON. E. L. Ross, Chicago. Journal of Pharmacology and Experimental Therapeutics, February, 1919. ETHER HYPERGLYCEMIA, MECHANISM OF. R. W. Keeton, Urbana and E. L. Ross, Chicago. American Journal of Physiology, March 1, 1919. ETHER-OIL COLONIC ANESTHESIA FOR OPERATIONS ON THE HEART MASSAGE, NEW TECHNIC FOR, UNDER CHLOROFORM LOCAL ANESTHESIA, REGIONAL FOR AMPUTATION OF THE LOCAL ANESTHESIA FOR RESECTION OF THE NASAL SEPTUM. LOCAL ANESTHESIA, RECTAL SURGERY UNDER. R. E. Farr LOCAL AND REGIONAL ANESTHESIA. J. de Mendonca. LOCAL ANESTHETIC, NEW; PHARMACOLOGICAL ACTION OF MAGNESIUM SALTS, GENERAL REVIEW OF THEIR NARCOTIC B. Van Hoosen, Chicago. A PLEA FOR CHLOROFORM EXPERIENCES OF AN ANESTHETIST AT THE FRONT HEART LESIONS IN ANESTHESIA THE INFLUENCE OF AGE IN SURGICAL PROGNOSIS OBSERVATIONS ON INTRATRACHEAL ANESTHESIA IN NEUROLOGICAL SURGERY POSTOPERATIVE ANALGESIA APPARATUS FOR PHARYNGEAL NITROUS OXID-OXY- 126 NEWER APPARATUS 125 QUARTERLY INDEX 128 Journal A PLEA FOR CHLOROFORM.* WM. B. HOWELL, M.D. The pendulum of medical opinion generally swings from one extreme to another before coming to rest in the position which experience ultimately justifies. This is particularly true regarding chloroform. From being used too much it has, in many clinics, especially in this country, been completely abandoned. In others, it is used so rarely, that those who are called upon to administer it, however proficient with other anesthetics, have not the experience necessary to use it to the fullest advantage. It is an easy step from using it only occasionally to forgetting its existence altogether. No doubt ether or nitrous oxid and oxygen can be used for every type of case requiring general anesthesia, but this does not prove that in certain conditions chloroform will not be found more useful than either. We must not be content with good enough but only with the best, and if we are to attain this we must define exactly the sphere of its usefulness. CHLOROFORM IN WAR SURGERY. The war will have put chloroform in a new light to many of those who gave anesthetics in the Military Hospitals abroad. Whether from climatic conditions or a difference in the quality of the ether supplied, or possibly owing to the special type of patient, most of them being given to smoking cigarettes to excess, ether alone was not as satisfactory as it is in this country and many anesthetists were glad to turn to the free use of chloroform. It is not intended to suggest that there is any serious tendency to establish chloroform as the routine anesthetic in these northern latitudes, but a certain familiarity with it having been obtained, it will be realized by many of us that we have allowed it to fall into somewhat unmerited neglect. It is undoubtedly more dangerous than ether, and therefore the less it is used by those who only occasionally give anesthetics, the better. It is for those who are qualified by experience with other anesthetics and whose ambition it is to reduce to the utmost that part of the suffering of the patient which may be referred to the anesthetic, to make judicious use of an agent which in its proper sphere is in the highest degree useful. The majority of soldiers who came to operation were only slightly wounded and were, apart from the wound, in excellent physical condition. They *Read during the Seventh Annual Meeting of the American Association of Anesthetists, at The Breakers, Atlantic City, N. J., June 9-10, 1919. were highly resistant to ether employed alone and very frequently shouted and struggled. Even after his return to this side of the Atlantic the soldier requires more ether than the average civilian. Where the necessary equipment and supplies can be obtained in Military hospitals, the difficulties in inducing anesthesia with ether can be overcome by the preliminary use of nitrous oxid or ethyl chlorid. But where there is a large number of soldiers to be anesthetized, nitrous oxid and ethyl chlorid may not be obtainable, and then the value of chloroform becomes most apparent. It is, of course, better that ether should be used when the anesthetist is inexperienced and perhaps not particularly interested in this work, but with care and skill the dangers of chloroform can be reduced to a minimum, with a great saving of time and discomfort. THE VALUE OF DOSIMETRIC ADMINISTRATION. One difficulty in appreciating the significance of a death under chloroform is the lack of particulars given in reports as to the experience of the anesthetist and the amount of care taken by him. If he is carelessly pouring unknown amounts, at irregular intervals, on a cotton mask, and part of his attention is directed to watching the operation, he can do an astonishing amount to give choloroform a bad name where it may really not be merited. It seems reasonable to require that with so potent an agent as chloroform, we should be able to control exactly the amount the patient is getting and that we should be able to evenly increase the dosage during the period of induction and continue it uniformly during the period of maintenance. These requirements can be attained by the use of a dosimetric inhaler such as that devised by Vernon Harcourt. When giving chloroform on an open mask, one is often made uneasy by symptoms of apparent danger and is at times puzzled to know just how deeply the patient is anesthetized. When using the Vernon Harcourt inhaler in France I was greatly struck by the absence of these symptoms and I was very rarely, if ever, in any doubt as to the depth of anesthesia. It is not enough, however, to use a dosimetric inhaler to ensure absolute safety. There have been deaths with it even in skilful hands, but it is undoubtedly a means to eliminate part of the danger. Levy's investigations of ventricular fibrillation as the usual cause of death under chloroform are worth the most careful study. The evidence he adduces to prove that the most dangerous time is that of light anesthesia is too strong to be ignored. It should teach us to hasten, as far as possible, the stage of induction, to insist that there is no hurry in commencing the operation, and to resist the |