No. 4945

June 8, 1918.

An AddressON

KINEPLASTIC AMPUTATIONS.Delivered on May 30th before the Royal Society of Medicine

BY PROFESSOR V. PUTTI,DIRECTOR OF THE RIZZOLI INSTITUTE AT BOLOGNA.

MR. PRESIDENT AND GENTLEMEN,-It has afforded megreat pleasure to be able to accept the invitation of theRoyal Society of Medicine, and I appreciate the honour ofspeaking before this society on the subject of kineplasticamputations. I am convinoed of the great advance whichthe conception of kinematisation will accomplish in the cureof the disabled men, and I am of opinion that all that refersto this new current of ideas, as well as to the store of factsrelated to them, ought to be placed at the disposal of theworld at large.

In briefly reviewing the fundamental theories of plastic-motors 1 (motor flaps), and pointing out the vast field that isthrown open to the ingenuity of orthopaedic surgeons andmechanical engineers through the practical application ofthese theories, we venture to hope that our efforts may provewelcome to all those who, up to the present, have had noopportunity of studying this important scientific innovation.And doubtless these constitute the majority of my present

audience, for, whilst in Italy the tireless work of propagandaundertaken by Professor Giuliano Vanghetti, the originalexponent of these principles, has caused them to be amplydiscussed, closely studied, and experimented on-whilst bothGerman and Austrian scientists have been actively workingto obtain the most practical application of these theories-the medical literature of France, England, and Americacontains very few, if any, allusions to the subject.

In order not to try your patience further, I shall contentmyself with outlining the fundamental principles upon whichthe theory is based, with pointing out, as briefly as possible,the various ways in which it can be put into actual practice,and I will close with a short statement regarding the

technique and its attendant results.The possibility of being able to utilise the functional

resources of the stump so as to convey movement to theartificial limb was an idea that first came to Dr. Vanghetti in1896, at the time of Italy’s second expedition into Abyssinia,when those of our soldiers who had been taken prisoners bythe native forces under the Negus were cruelly tortured andmutilated.Dating from that period Dr. Vanghetti wrote and pub-

lished innumerable articles, wherein he developed his theoryof what he had now named °° kinematic amputation," amplydescribing the origin of his idea and the various methodsby which it could be practically applied. Unfortunatelyas a practising physician Dr. Vanghetti was unable to puthis theory into practice. He was therefore forced to resignhimself to endless delays before he succeeded in convincingthe surgeons of the great value and practical possibilities ofhis theory and obtaining their coöperation. This was- the

principal reason why, prior to the war, the number of casesof kineplastic amputations did not exceed twenty.

KINEMATISATION.

Before going any further, I should like to describe, as

briefly as possible, the fundamental principles of the theoryof kinematisation and the so-called plastic-motors (motoiflaps).

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Dr. Vanghetti has given the name of kinematic plast’ics, or Mmeplastics, to any kind of bloodless or operative plastics that tends t(economise, restore, or substitute muscular masses which can bEemployed towards imparting direct and voluntary movement to atartificial limb.The word kinematisation was formerly used to indicate thekineplasti(

operation : it was subsequently applied to every kind of kinemati(artificial limb, and, finally, to the active and precocious mobilisa.tion o:such muscles as are involved in kineplastic operation.Every moving entity obtained kineplastically. whether bloodlessl3

or operatively, is called plastic-motor (motor flap).These motor flaps are based on the fol1owiug general principle : Iran actual, or antecedent, amputation or disarticulation, the tenderand muscle, provided they have the necessary physiological protectior(skin, vessels, nerves, &c.) can generally be used for the kinemati<

1 Professor Putti uses the term "plastic-motor" to denote the livingpart of the apparatus that moves the artificial limb. We suggest theterm " motor flap" as possibly less open to misconstruction.

No. 4945.

prosthesis, provided that they admit of the formation of an artificialpoint of attachment, to be protected in a similar manner. Kinematiss-tion can be effected, or prepared for, at the time that the primaryamputation is made ; it can also be done on stumps that have alreadyhealed.

Motor flaps may vary as to their number, position, shape.and function.Without entering into too detailed a description of the numerous

varieties, I will limit myself to stating that, up to the present, asregards their shape, the most elementary, and the most commonlyused, are the clava and ansa motors, and also those obtained by meansof the canalising, or tunnelising, of the muscular masses.As regards the number, the motor can be single, double, or

multiple; in function it can be either zsnimotor or plitrimotor. Whenthe motor is made to execute two opposite movements in successionone to the other it is called alternative. According to the positionthey occupy motors are either terminal, when placed at the extremityof the stump, or extra-terminal should they be placed in the continuityof the stump.Up to the present the upper limb has been the part that has been

the most frequently kinematised, but the number of successful cases.of kinematisation of the lower limbs is daily increasing.

TECHNIQUE.The foregoing description of the general principles of

kinematisation and the explanation of the nomenclaturenecessitated by the novelty of the argument will contributetowards a better comprehension of what I am about to sayon the subject of the practical and technical application ofthe theory.

It is evident that the application of kinematisation mustentail a radical upheaval of all preconceived notions regardingthe ordinary methods of amputation.

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Those principles that have been observed in the performance ofamputations according to prosthetic criterions, which had alreadycaused a revolution in modern surgery, must again be subjected tamodifications in order to ensure the preservation of the greatestpossible amount of the original bone and also of the residual motormasses and integuments, as these must necessarily be used for thepreparation of the motor flap.In cases where it is practically impossible to perform primary kine-

plastic operations, as, for instance, at the first-aid dressing stations inthe full stress of battle, the surgeon can, at any rate, always so operateas to prepare the ground for a future kimematisation of the stump.Skin flaps, muscular insertions, various bone and tendinous frag-

ments and segments of limbs, which would seem utterly superfluousunder ordinary circumstances for the preparation of ordinary stumps,are to be considered of the greatest value in view of the futurekineplastics.In order to prevent the possible loss of these elements and of these’

materials whilst the stump is undergoing the process of healing it isbest to take certain special technical precautions to avoid the retrac-tion of the softer tissues; this ought to be done, however, in such away as not to hinder the ordinarv dressing of the wound.When the inflammation has decreased, and further complications are

no longer to be feared, the time has come when the actual kinematisa-tion-may be proceeded with-that is to say, the preparation of themotor flap.

The Motor 7<!p.A motor flap, in order to correspond with the object for

which it is made, must conform to the following require-ments :&mdash;

1. It must possess every requisite for withstanding a firm, resisting,and painless grip, also a traction that, in not a few instances, mayattain a high degree.

2. It must be provided with a sufficient amount of functional mus-cular tissue to guarantee the accomplishment of the task that will bedemanded of it.

Now the primary conditions for obtaining the firstrequisites are :-

1. That the motors be covered with skin in perfect condition, wellnourished, and provided with a normal degree of sensibility.

2. That, with regard to its shape and dimensions, the motor be of asize suitable for the fastening of the hooks, winga. and rods that are-destined to transmit the functional movement to the artificial limb.

The muscular masses must be sought for and obtainedfrom amongst those of which the stump still disposes, andthat, on account of their anatomical structure and physio-logical disposition for the production of broad, strong, andindependent contractions, are best adapted to the task.

In the choice and distribution of these the fundamental

principles of the physiology of movement must be thoroughlyobserved and respected.As the tendon is the element best adapted for the transmission of

muscular contractions, it must be largely employed for the formationof motor flaps.Should the tendon be missing the muscles must be utilised elther by

including muscular bundles within the terminal motors or by tunnelisingthe muscular masses in order to obtain extra-terminal motors.The antagonistic powers, indispansable to all active movement, must

be provided either from the stump itself, by the formation of motorswith elements belonging to muscular groups of opposite action, or fromthe artificial limb by means of elastic resistance in the opposite directionto the resistance offered by the motor flap.With a view to gaining both space and integuments it may be advan

tageous, at times, to shorten slightly the bony stump and to performexcision of superfluous muscular masses ; this, however, depends uponthe Lone being sufficiently long to allow it.

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In order to provlde such materials as may be missing in loco recours4may be had to the numerous methods that modern plastic surgeryplaces at our disposal, as, for instance, skin, muscular, aponeurotic, 0]osseous transplantations, &c. Arthroplastics, with the interposition oaponeurotic flap, may be utilised so as to render mobile those stumlsegments which, through stiffness and ankylosis, have become unusableBy these same means neo-arthrosis can be created in the continuityof the stump, thus giving the motor flap the power to develop a

leverage action.7?KjP?’M’ Reszclts.

The kinematisation of the thigh stump enables us to solve one of themost difficult prosthetic problems-that of gaining active power overthe knee-joint. With the ordinary artificial limbs the knee extension

, is obtained either by means of springs or of elastics, absolutely inde-pendently of the will of the patient, or else through tensors which hedirects by means of auxiliary movements of the trunk and shoulder.In some cases we have carried out successful experiments with the

quadriceps kinematisation; in this the stump itself can controlvoluntary extension of- the knee, and Is enabled to restrain flexion.(This is illustrated by the two patients shown in Fig. 1 and Fig. 2.)As a result of kineplasties we are now able to utilise those stumps

which, up to the present, had always been held as incapable of func-tional movement, as, tor instance. the carpal stumps, the very shortforearm stump3, and the disarticulation stumps.The surgeon who. in the case of shoulder disarticulation, succeeds in

sparing the - deltoid and pectoralis major, in covering these muscleswith skin, and in finding means for creating a point of attachment maybe congratulated on having preserved for the benefit of the mutilatedman a preciousfunctional capital.With regard to the difficult problem of utilising short forearm or

short leg stumps, the solution will be enormously facilitated throughthe preparation of points of attachment that correspond to the inser-tion of the biceps and patella tendons.

ILLUSTRATIVE CASES.

[The speaker here showed some plaster casts which repro-duced various types of amputation stumps wherein he hadprepared different kinds of motor flaps.]The first model represents the stump of a forearm in which there are

two terminal motors, one formed with the tendons of the flexormuscles, the other with the tendons of the extensor muscles; it was acase of disarticulated wrist-stump already completely healed. Afterhaving excised about an inch and a half of radius and of ulna, Iprepared two cutaneous flaps, each of which served to cover the twoprincipal groups of tendons in the forearm-that is to say, the flexorand extensor tendons. I obtained thus two sets of fingers, of whichone is controlled by the flexor muscles, the other by the extensor imuscles. I

Transmission of their contractions to the artificial limb I obtainedby means of metal rings covered with vulcanised rubber; thesewere placed -at the base of the fingers, and gradually tightened,and to them I joined the artificial motors of the hand. The stump wasthus enabled to give independent flexor and extensor movements tothe artificial hand.This second model is that of a forearm stump with the same charac-

teristics as the one just described-that is to say, it has two plastic flapscontrolling the flexor and extensor movements.

In cases where it is not possible to dispose of sufficientmaterial for the construction of two motors, we must limitourselves to the preparation of a single one. In thisinstance the antagonistic movement in the artificial limb isobtained by means of a spring or of an elastic. But theseare not the only types that now exist of plastic motor flaps.Amongst the models that are here before us. I have prepared a so-

called ansa motor. After having shortened sufficiently the radius andthe ulna I prepared the tendons of the flexor and extensor muscles,gathering them together in such a way as to form a ring or loop, whichI afterwards covered with skin. Wherrever the disabled man contractseither of the two muscular groups, this ring or loop displaces itselfalternately either in a flexor or in an extensor sense. In view of whatI have said already, it is needless to demonstrate the manner in whichthe motor flap is able to transmit the c rntractiona to the artificial limb.

Provision of Osseous <S’&laquo;oM’.The motor flaps that I have described up to now include

the soft tissues only of the stump. In order to give greaterconsistency an osseous support can be provided. Examplesof this type are shown on the models I am now demon-strating.The first is the reproduction of a wrist stump, in which I formed a

pseudo-arthrosis. excising from a third to a fourth of an inch of bonefrom the continuity of the radius and ulna, and then interposing adouble flap of fascia and muscle betveen the superficial parts of thesection. I was thus able to obtain an artificial wrist having all themovements with which, normally, the wrist is provided, for themuscles and tendons that cause tiiese movements had been, for thegreater part. preserved. -

I performed a similar operation on the stump of an arm. Havingdetached a fragment of bone from the extremity of the humerus at theheight of about one inch, I inte p -sed a muscular flap between thesevered sections of the bone. Thanks to the neoarthrosis, the stumpcan make flexor and extensor movements, for to the piece of severedbone the muscular bodies of the biceps and of the triceps are stillattached.

.3method of T1lnnelling lf?tscular Bodaes.I believe that these examples sufficiently show the

principal types of terminal motors.As regards their preparation it tt nearly always necessary, as I have

said, to sacrifice a certain quantity of the bone. But it can be donewithout compromising the length of the bone. [Models were shown

I demonstrating how the speaker obtained a few of these motors bydirectty tunnetising the muscular masses.]In a forearm stump I prepared the group of the flexor superficialis,

preserving its normal cutaneous envelope. By means of a skin plasticI next covered with skin the space comprised between the superficialflexor and the deep flexor, thus forming a canal completely lined withskin. During the period that the wound was healing I maintained thiscanal open constantly by means of a rubber tube. <nee the cutaneouswounds had healed I substituted for the rubber tube a metal rod

covered with vulcanised rubber. This little rod serves as point ofattachment for the cords that are used to convey movement to theartificial hand. Following each contraction of the flexor muscles thissmall rod displaces itself in a proximal sense, thus serving to givemovement to the fingers of the hand.

The arm and thigh stumps are better adapted to this styleof kinematisation than the forearm.

In the two models I now show you we find reproduced two stumpsof the lower third of the thigh, in which I have prepared a canalwhich is placed horizontally and to the full depth of the quadriceps alittle above its insertion into the patella. Within the canal I introduceda fkin flap folded back over itself in such a way that the cutaneoussurface is turned towards the lumen of the canal. The tunnel thusformed is entirely lined with skin and can withstand, free from anydanger of being damaged or causing pain, the presence of the metal rodthat serves for the transmission of the extensor movement to theartificial leg. - (See again Figs. 1 and 2 )

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Toleranoe of Neohanical Attaahments.At a first glance it may appear strange that these mechanical

attachments can be tolerated so easily.Experience has proved, however, that if the motor flap is well placed,

if the skin that covers it is healthy, and if the wounds are absolutelyhealed, neither the rings nor the rods cause the slightest harm. Whenthe cl’tva motor is sufficiently long, and its head is large enough, thering surrounding the neck of the clava need not be tightened to theextent of interfering with the blood-supply of the flap Besides, each

ring is provided with a screw by means of which the disabled man mayhimself regulate the pressure.In canalisation motors if the tunnel is well lined with skin, the

metal rod causes neither harm nor pain. The disabled men get soaccustomed to it that they leave it in place even during the night.It is necessary that the rod should be removed once every 24 hours, inorder to clean it with alcohol, and lubricate it with vaseline. I haveobserved that the skin within the canals gradually acquires theproperty of throwing off sebaceous matter in greater quantities thanis normal, thus itselt lubricating the canal.

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Another point deserving of discussion refers to the sensi-bility of the motor flaps.ProfessorAmar has shown, by means of most iiteresting physiological

researches that the superficial and deep sensibility and the muscularsense of the stump are, at first, shortly after the amputation, greatlyaltered, but with the passing of time not only recover, but finallyattain a degree of sensibility even more than normal, provided thestump un ergoes the proper functional training.

I have noted that the same thing happens w,th kinematised stumps.One of my patients on whom I operated over a year ago, is now able toappreciate, with considerable exactitude, the difference in the size andweight of the articles which he seizes with his artificial hand.

The functional results to be obtained from a motor flapdepend on numerous factors, but most especially on thekinetic powers of the muscular masses of the stump, on themanner in which the surgeon was able to utilise them, andon the functional use which the motor has to undergo. To

give a clear conception of the amount of work done I maystate that amongst the operations performed by me, thepower of the motors ranges from 10 kilogramme-centimetresat the lowest, to 100 kilo.-cms. at the highest. Foramotortobe of practical use, it must be able to shorten not less thanone inch. In the case of a thigh stump I have obtainedone motor that contracted to the extent of two and one-fifthinches, lifting a weight of 44 pounds.My time is too limited to permit me to dwell at length on

the surgical technique of kinematisation. ,

SUITABILITY OF CASES.I have only described the principal types of motor flaps.The genius and the ability of the surgeons will find here a vast field

of action. Naturally, it is not possible to treat all amputated stumpsin this manner. The ones best adapted to it are those that dispose ofhealthy muscular masses, that are provided with the normal inner-vation, and that possess an ample contractility. The stumps that haverigid or ankylosed joints, that are covered by aki’t that does not glideeasily, being adherent or crossed by scars, cannot supply satisfactorymotor flps.The age as well as the moral and intellectual condition of the patient

are also important. The best age is one ranging from 20 to 30 years.The disabled men that suffer from deficient mental development, ordo not appear to be ready to follow with patience and assiduity theperiod of time during which the stump must undergo the necessaryfunctional training, ought not to be operated upon.As matter of facu, it is not assumed that kinematisation invariably

demands a cutting operation. There are stumps whi’h are alreadyformed, and are endowed spontaneously with kinematic resources,and which, wisely employed, could be utilised for transmitting move-ment to the artificial limb.

I will content myself with mentioning the wrist and forearm stumpsin which rotary movements are preserved, amd the arm and forearmstumps that possess a terminal hood having a development and con-tractility suffident to ensure a good grip.

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Kinematisation as applied by P1’ojess01’ Pntti to an Amputation Stump of the Lozvei- Third of the Thigh.FiG. 1. Fic4. 2.

Two patients are shown whom quadriceps kinematisation has enabled to control voluntary extension of the knee. Theparticular method here employed is a terminal tunnelised plastic-motor or motor flap. z

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ARTIFICIAL LIMBS.

Whatever type of motor flaps may be chosen, it is anessential condition that the artificial limb be adapted ina manner suitable to their power, number, and shape.The question of kinematic prosthesis is so vast, and still so new, that

it deserves a special study all to itself.This study is now following a grafiual development, and will bring

with it a substantial reform in ordinary constructive methods. Thesurgeon, the physiologist, and the mechanic must all collaborateintimately in this work, av only by means ot the perfect combination ofthpse three can we obtain new methods of a scientific chlracteranswering to modern requirements, in the place of tne emoirioatsystems that have been followed up to now in the manufacture ofartificial limbs.

I will now, if you will allow me, demonstrate a few

specimens of artificial limbs that were specially constructedfor kinematised stumps.

fattd’.&mdash;Of these three hands, the first and the second serve forstumps that are supplied with a single motor flap. In one of thesethe contraction of the motor is used for opening the hand, which iskept closed by means of a spring ; in the other the motor is called

upon to close the hand. The third hand is prepared for a, stumpthat possesses a do ible motor. The movement of closing and openingthe fingers is exclusively controlled by the two motors. , .Forearm.-The appliances which I now show you represent varioust

types of artificial limbs for forearm stumps. I beg ’you to considerto what an exrent the construntion of the artificial limb is simplifiedby the possibility that now exists of being able to utilise the intnnsicpowers of the stump. The mechanical contrivances that serve formoving the fingers are most elementary. The cords, the levers, andthe springs which have, up to i1 w; been used for’conveving movement =

to the hand by utilising the movements of the elbow and of the;shoulder are completely done away with. The disabled man can openor close the fingars in whatever position the limb may find itself.Even the workman’s tools can be used in a practical way by the

kinematised stump. The clamps which I am showing you, and thatyou will presently see in actual use by one of the disabled men thatwill be shown in the kinematagraph, were specially manufactured formechanical work. (These clamps are shown in Fig. 3.) ,

RESULTS.I would like to say one word more with regard to the value

of kineplastic results. I must premise, however, that nofinal judgment is yet possible on the subject. ,Although the actual idea was conceived over 20 years ago, kinema-

tisation has been applied on a large scale only since the beginning of the

FiG. 3.-Kinematisation as applied by P1’o.!CSS01’ Plttti to a Forearm Aznpzctcttion Stump.

A terminal plastic-motor or motor flap has been formed from the forearm muscles ; this flap has been tunnelled to containa rod to which are attached the cords actuating the clamps on the tools. This is the form of kir ematisation which hasbeen found best adapted to mechanical work. Comparing the clamp with a crab’s claw, the fixed prong is part of theprosthesis rigidly attached to the forearm, while the movable prong is activated by the motor flap.

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war. The very few cases ot these types of oper .tions that were per-formed prior to the war-almost exclusively by Italian surgeons-hadgiven sufficient proof as to the feasability of the methods, but they hadnot provided enough elements to enable us to judge with regard to theirpractical usefulness.Only since the beginning of the war, when the necessity of giving

practical aid to the tragically large army of disabled men came to thefore, were our surgeons convince j of the expediency of testing theprinciples and methods of kineplastic surgery. We are yet at thevery beginning of this new scientific movement, and the majority of thesurgeons of the Allied nations have not, as yet, contributed to it.The German surgeons have followed Sauerbruch’s example, and

although thoy have created an admirable scientific organisation theyhave limited themselves to the repetition of a single type of motor flap.Consequently, in analysing the results obtained by them, we can formbut a partial judgment of the practical value of ilinematisation. Thenumber of operations performed by Italian surgeons is probably lessthan those done in Germany, but the variety of the motors experi-mented upon by us is certainly greater.

It is easily understood that, for the moment, it would be impossibleto make a synthesis of such a variety of facts.I therefore believe that it will prove of greater benefit, in

discussing the results that have been obtained, to considerthe question solely and exclusively from the point of view ofmy own cases.These consist of about 50 cases of kinematisation of the, upper and

lower limbs, either primary or secondary; they were obtained bymeans of the preparation of motor nips of various types, and in eachcase there followed the application of an artificial Ilimb. The funetioual.value of the motors was studied according to dvnamographic and dyna-mometric methods, whilst their practical capacity was verified in the,actual use of the artificial limb. ’ ,

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At the Istituto Rizzoli I have at my disposal a large workshop for theconstruction of arttfioial limbs, so that I have been enabled to studykineplastic prosthesis as well; this. as I have said already, constitutesone of the most important sides of this complex question. ,

The researches that have been made in our Institute havebrought me to the following conclusions :&mdash;

1. The practical results that have been obtained throughkinematisation have assured me that the hopes placed in theprinciples and methods of the modern theory of motor flapsare thoroughly justified. Kineplastics are entitled to beplaced amongst the most brilliant of the discoveries oforthopaedic surgery, deserve to be accepted with perfectconfidence, and to be tested on a large scale by all thosewhose aim it is to restore to the disabled man his functionalactivity.

2. The preparation of motor flaps is a well-definedsurgical act that must be performed in accordance withits own special technique, the methods of which have

already stood the test of experience.3. From a physiological point of view motor flaps are

actually capable of giving both the quality and quantity ofaction determined by the muscular masses that actuatethem. Yet, practically considered, motor flaps will be ableto yield the full measure of their value only if the artificiallimb is perfectly adapted to their shape and their strength.

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4. As the principal aim is to attain the vitalisation of the artificial limb, it is essential that the surgeon and themechanic should work in harmony in order to solve satisfac-torily this most interesting, if difficult, problem.

METHODS OF GENERAL AN&AElig;STHESIA INFACIAL SURGERY.

BY R. WADE, M.R.O.S., L.R.C.P. LOND.,LIEUTENANT, R.A.M.C.; AN&AElig;STHETIST TO QUEEN’S HOSPITAL, SIDCUP.

THERE are two main difficulties in anaesthesia for opera-tions on the face and lower jaw : (1) Maintenance of goodairway ; (2) difficulty of avoiding interference with aseptictechnique and field of view of surgeon. In September, 1916,Colonel J. F. W. Silk suggested that cases in which bloodwas likely to find its way into the mouth during operationshould be aneesthetised in the sitting-up position. This wasat once found very satisfactory. I have anaesthetised in thisway nearly 300 patients, and there have been no bad after-effects or complications. Daring the last five months we haveendeavoured to form an opinion as to which of the followingmethods of administering chloroform or ether to the varioustypes of cases give the most satisfactory results.Mode of preparation and induction. -This, for all methods

except oil ether, is as follows :-Patients prepared in usual way, but without preliminary hypo-

dermic injection of morphia. Atropine, gr. 1/100. half hour beforeinduction. I first tried a series of caies with morphia gr. &frac14; in additionto atropine ; an i then another series with atropine al.me. The patientsin latter,series were certainly in better condition after operation; andI could not persuade myself that induction was much quieter, withmorphia injection. I always induce anaesthesia with chloroform, using

ordinary mask and drop-bonte. very often changing to mixture ofchloroform and ether before patient is under.

The following is the technique employed in the seven

methods:-In the Lying-down Position.

1. Chloroform, C.E., or ether, by Shipway’s warm etherapparatus.When patient is under, a small-size Hewitt’s airway is introduced into

mouth, then a small, bent metal tube is connected to rubber tube fromShipway apparatus. End of metal tube is placed just inside mouth ofHewitt’s airway. By this means it is possible, in majority of cases, touse a mixture of chloroform and ether and to keep patient under withone compression of bulb in every three or four inspirations. The an&aelig;s-thetist sits at one or other side of operating table, and, if necessary,can hold up patient’s chin with one hand beneath towels, whilst havingother hand free to work bulb of apparatus.This method is useful for short operations when airway is good, and

not likely to be interfered with by blood and mucus. It can be usedin such operations as eye plastics, cheek plastics (not involving oralcavity), epithelial inlays.

Contra-indications.-Plastics involving oral or nasal cavities. Opera-tions on jaw (owing to possibility of interference with aseptictechnique)..

2. Sterile anaesthetic.This method was especially devised for such operations as wiring and

bone-grafts in lower jaw. When patient is under the anaeathetistwashes up in exactly same way as surgeon, while someone else carrieson with anaesthetic. When necessary preparation of site of operationhas been completed the anaesthetist, in sterile face-mask, gown, andgloves, continues ansesthetto with sterillsed drop-bottle and mask.The mask is held in position beneath towels in one hand, and chloro-form or C.E. dropped on to upper surface of towel with other. Thehands may not be changed during operation. :

In these cases the jaws are firmly splinted together in closed biteposition. I have never experienced any trouble from tongue fallingback; laryngotomy instruments are always ready, but it has neverbeen necessary to use them. Lately our dental surgeons have fittedsplints which are joined together with screws, so that in cases ofemergency the jaws can easily be separated.

3. Intratracheal administration of warmed ether vapour.Owing to necessity for economy in ether it is not justifiable to use

the open-ether method of induction in these cases, although I believe itto be the best. I think the catheter is more easily passed by the directmethod with patient’s head and shoulders en same level-i.e., withouthaving the shoulders raised, as is sometimes done.This method is particularly useful for plastics involving the nasal

and buc .al cavities.Contra-indications.-1. Contracted mandibular arch through loss of

bone. 2. Trismus from various causes. 3. Jaws splinted together.4. Contracted mouths from gunshot wounds or burns. 5. Extensivelip plastics on account of interference with surgeon’s manipulations.Disadvantages: -1. Blood frothing up during expiration, especially

in intra-oral and palate operations. 2. Occasional sp-lsms of larynx onintroduction of catheter (probably owing to faulty technique).

4. Kahn’s tube.This is useful for the same sort of cases as the intratracheal, with the

exception of any lip plastics where its bulk precludes its use. In casescomplicated by loss of bone in lower jaw where it is impossible to passintratraoheal catheter, this instrument is avallab’e either as a means ofgiving the anaesthetic. or merely to act as an airway when oil ether isadministered per rectum.Disadvantages of teeliniq2ie.-I. The larynx maybe small. 2. Possi-

bility of injury to larynx. Great care should be exercised duringintroduction. I have seen one or two cases of slight laryngitis afterits use.

5. Oil ether per rectum.Preliminary preparation.-These patients should have saline aperient

on morning of day previous to operation, also dose of castor oil sameevening. The following morning a simple enema is given, and rectumwell washed out. A hypodermic injection of hyoscine gr. 1/100,morphine gr. :1:. atropine gr. 1/150. should be given half hour beforepatient is brought to theatre, when the oil ether is immediatelyinjected in a quiet and darkened an&aelig;sthetic-room as nearly as possibleone hour before operation is timed to start.

I have tried two mixtures : (1) Ether 6 oz., olive oil 2 oz.*; (2) ether5 oz., olive oil 2 oz., paraldehyde 2 dr., and have come to the conclusionthat the second gives the better results. The mixture is run in slowlythrough a funnel and tube attached to a soft rubber catheter. Cathetermust not be passed more than four or five inches into rectum. Patientscomplain of less discomfort, if mixture be slightly warmed beforeintroduction. I have only had one case in which injection was notretained.

If necessary it Is better to give chloroform or C.E. rather than etheras additional in these cases. If ether alone is given p atient Is morelikely to have some bronchitis as after-complication; this appliesespecially to operations lasting for two hours or longer.

I nmediately on patient’s arrival back to ward rectum is verythoroughly washed out with warm water until no smell of ether canbe detected, and no drops of oil seen in wash-out. I have noticed thatafter long operations (over two hours) there has been some intestinalparalysis, which causes difficulty in washing out rectum, and subse-quent abdominal distension and constipation. These effects are besttreated by a hypodermic injection of picuitrin &frac12;-1 c.cm.There is no doubt that this is a very valuable method of

an&aelig;sthesia for many operations in plastic surgery.This is owing to its adaptability to surgeon’s convenience during

operation and on account of compiratively mild after-effect co patient,Another point in its favour is that airway is very rarely obstructed bytongue.With regard to after-effects, the great drawback is length of time that

patients take in coming round from anaesthetic. This may be anythingfrom two to four hours. But, on the other hand, vomiting is eitherabsent, or only occurs once or twice; and patients themselves feelbetter than after an ordinary anaesthetic. As to local complications in