1297ROYAL SOCIETY OF MEDICINE.—MEDICAL SOCIETY OF LONDON.

Medical Societies.ROYAL SOCIETY OF MEDICINE.

SECTION OF ANÆSTHETICS.

Death after Hedonal Anæsthesia,-.Exhibition of ApparatusA MEETING of this section was held on Nov. lst, Dr. J

BLUMFELD, the President, being in the chair.Dr. G. A. H. BARTON read the notes of a case of Deatl

after Hedonal Anaesthesia. He said that the virtues of ! anew anæsthetic were apt to be over-estimated ; one heard ofthe successes, but little of the deaths. He had only founcthree, including the present case, reported in the journal:up to date ; these were excessive considering the smal.number of administrations. Rumours of unreported fata:cases, however, were rife, and it was in the hopes oj

eliciting some definite information on the safety of hedonal,and in the class of case in which it was contra-

indicated, that he reported this fatality. The patient wasan ill-nourished tailor, who had lately been on strike. Therewas no complaint of cough, and his respirations andtemperature were normal; nothing was noted amiss withhis lungs. The pulse was, of course, rather poor. Operationwas opening and draining both frontal sinuses, the posteriornares being first plugged with a sponge. The induction wasvery quiet in three and a half minutes, and after the infusionof 400 c.c. he appeared to be under. The rate of flow wasslowed down, and at the end of five minutes he had nearly500 c.c., and operation was commenced. The rate was cutdown to slowest possible and remained at that. It was appar-ently one of the quietest and best anaesthesias. The only adversepoint about it was that the patient’s colour was dusky through-out. Dr. Barton attributed this at the time to the post-nasalplug and a towel over the mouth causing some obstruction.The operation lasted 1½ hours ; 1000 c-c. were infused in all.A quarter of an hour before the termination of the operationhe ceased the infusion and administered oxygen, which

speedily improved the patient’s colour. No blood got intohis air passages during the operation ; the post-nasal plugwas removed at its termination. He left him still un-

conscious, but apparently in good condition. The patientdied two hours after without regaining consciousness.-Dr.R. S. TREVOR read an account of the post-mortem findings,and said he attributed death to heart failure while the

patient was suffering from the toxæmia of tuberculosis, suchdeath having been hastened by the administration of hedonaland by interference with his respiration owing to bleedinginto the trachea. The man was anything but a fit subjectfor an anæsthetic, and his privations owing to the strikehad reduced him very much. The blood in the trachea wasnot frothy, and probably some of it was of post-mortemorigin. There was a mottled or "tigroid " condition of lung.- Dr. Z. MENNELL said he had given hedonal in 56 cases ofcerebral surgery, and not one death occurred within 12 hoursof the operation. He had given it 196 times altogether, andat St. Thomas’s Hospital some 500 administrations of thedrug had been given. The contra-indications against its usewere : (1) for operations which would cause bleeding into thelarynx or trachea ; (2) cases in which the blood pressure washigh; and (3) cases in which the anaesthesia could beobtained as safely and satisfactorily by other means. Forcerebral surgery he considered the drug almost ideal. The

prolonged sleep after the operation was often most useful,and obviated the necessity of giving a narcotic. The rate atwhich he now gave the drug was 100 c. c. every two or threeminutes. Rapid administration produced cyanosis, which heregarded as the greatest danger signal in connexion withthe drug. The corneal reflex he regarded as valueless ; theskin reflex on the sole-causing toe movement and draw-ing up of the leg-was much more useful. One of his

early cases died within eight hours of operation, whichwas enucleation of a cancerous tongue in an old man ;and post mortem a clot 4 inches long was removed fromthe larynx. By giving gr. of morphia at intervals onepatient was able to take as little as 240 c.c.-Dr. J. F. W.SILK considered that the doses of hedonal recommendedand used were too large. There seemed to be a

difficulty in giving just sufficient to get the patient under,while not giving too much. No doubt hedonal could be

usefully employed as an adjunct to other anaesthetics. Hecommented on the fact that the advocates of hedonal nowabandoned their recommendation of it as an universalanaesthetic and acknowledged its limitations.--Mr. J. D. E.MORTIMER reminded those present that Dr. Barton

published a short note on the case now detailed imme-

diately after its occurrence, and he thought this shouldbe done far more frequently when difficulties and disastersappeared during the trial of new methods. He knew, indeed,of two fatalities not mentioned that evening, and so far ashe knew unreported, although they happened some monthsago.-Dr. BARTON replied. He thought that if the reflexeswere abolished hedonal became dangerous, and if the skinreflex was allowed to persist that the anaesthesia would beunsatisfactory.

Dr. SILK explained the working of Dr. Elsberg’s apparatusfor the Intratracheal Insufflation of Ether. He had had

difficulty in introducing the catheter, but when once in

position the anesthesia was good.Mr. G. E. GASK and Mr. H. E. G. BoYLE showed their

apparatus. Mr. Gask said that the apparatus was mainlyintended for intrathoracic operations, and the anaesthesiawas quite satisfactory.—Mr. BoYLE explained the working ofthe apparatus, but as he had only done 20 cases he was notprepared to discuss the merits or otherwise of the method.

Dr. F. E. SHIPWAY showed and explained the workingof an apparatus made after the pattern of Kelly’s.

MEDICAL SOCIETY OF LONDON.

Hedonal Anæsthesia,A MEETING of this society was held on Oct. 28th, Sir

W. WATSON CHEYNE, the President, being in the chair.Mr. C. M. PAGE communicated a paper on Further

Experiences of Hedonal Anæsthesia, in which he said thathedonal anaesthesia had been employed at St. Thomas’s Hos-pital for about a year. The saphenous vein had been com-monly chosen ; it was exposed by incision, where it lies onthe internal malleolus, and the cannula tied into it. He

thought that for most cases this was convenient, as the legrequired no special fixation, and the tube could be steadiedin the cleft of the toes. The fluid in the tank was

formerly kept at a temperature of about 120° F., butthis was too hot, 110° or 105° being quite sufficient.He attributed several cases of local thrombosis of the vein tothe use of too hot a solution. No death could be attributedto the anaesthetic at St. Thomas’s Hospital. The fatal cases

reported were due to over-dosage. Safe anaesthesia was usuallyassociated with the persistence of a skin reflex, and thepatient should react in a moderate degree to the first skinincision. The cases which were unsuitable for the methodwere : (1) Aged subjects, and especially those in whom therewas marked arterio-sclerosis ; (2) cases which were the subjectof active pulmonary disease ; and (3) cases in which theheart was not sound. The following were the forms of casesin which the drug had been exceptionally successful : (1)Cases of goitre, including five of Graves’s disease ; (2) casesof shock associated with haemorrhage; (3) cerebral and spinalcases ; and (4) any case in which there was considerable post-operative pain, the prolonged narcosis in such being entirelyadvantageous. He had found the quiet type of lightanæsthesia which a small dose produced very useful incases of cellulitis of the neck. In conclusion, he said thatthe method had, for properly chosen cases, a definite value.The procedure had distinct dangers, due chiefly to theease with which an overdose could be given.

Dr. Z. MENNELL read a paper on Hedonal InfusionAnæsthesia, with special reference to its uses in intra-cranial surgery. This form of anaesthesia had been induced310 times at St. Thomas’s Hospital since Mr. Page publishedits original 200 cases ; no death had occurred withinL2 hours. His technique was that of Mr. Page with slightlifferences in manipulation and apparatus. The standardsolution used was 0’75 per cent. of hedonal in normalsaline. If possible the blood pressure was taken first. Thevhole foot was painted with iodine and the internal saphenousvein opened under novocaine. An ordinary silver cannula washen tied into the vein and the solution, at a temperature

1298 MEDICAL SOCIETY OF LONDON.

between 100° and 110° F., was run in slowly at the rate ofabout 100 c.c. every two or three minutes. The temperatureshould not exceed this, as several cases of thrombosis occurredwhen a hotter solution was used. To run in 100 c.c. a

minute, as was originally described, was too fast, and cyanosiswas liable to occur, which was a dangerous symptom. Theamount necessary to induce anæsthesia varied greatly, andthe higher the blood pressure the more anaesthestic wasrequired. Far too big doses had been given in the past, andthe more the method was used the smaller was the dose given.Usually, after 300 or 400 c.c. had been given, the patientcould be prepared for operation, and the incision could bemade when 500 c.c. had been given. It was essential thatthere should be a brisk skin reflex, so brisk, in fact, that thepatient had to be held down, in consequence of which it wasnecessary for the surgeon to make one quick cut throughthe skin and afterwards avoid touching the skin edges.The internal saphenous vein was used by choice : 1. Becauseit was out of the way. 2. As a convenience to the anaes-thetist, enabling him to take the blood pressure in the arm.3. The vein had large calibre and was easily exposed. 4.There was no need for such special apparatus, as suggested bySir Berkeley Moynihan. Directly the incision had been madethe abdominal muscles remained absolutely lax throughout along abdominal operation without movement on the part ofthe patient. The flaccidity of the abdomen was marked, andwas only comparable to that obtained during a satisfactoryspinal anaesthesia. The type of anaesthesia obtained wasalmost perfect. There was complete relaxation, an excellentcolour and pulse combined, with quiet, regular respira-tion ; in fac, the picture of natural quiet sleep. Thisstate could be maintained for prolonged periods and withthe use of very small quantities of the drug. The bestrate of flow was about 30 to 60 drops a minute and shouldnot fall below 10 drops a minute, as otherwise bloodwould block the cannula. It was important to note the

following points during the progress of anaesthesia: 1. Re-

spiration : This should be quiet and free from stertor. Anystertorous breathing meant that the tongue had fallen back.With the lighter anaesthesia as now used this but very rarelyoccurred. Any irregularity indicated too much anaesthetic.2. Skin reflex : This should never be abolished. It oughtalways to be possible to elicit a movement of the leg bystroking the sole of the foot sharply or by pinching the lobeof the ear to get a lateral movement of the head. 3. Blood

pressure : Especially in cerebral work the blood pressureshould not be allowed to fall too low. It was his custom totake the blood pressure every four or five minutes duringoperation. 4. The pulse : Always increases in rapidity.A pulse-rate of 140 or 160 was not uncommon. This per-sisted sometimes after the operation for some hours, andif not expected might cause unnecessary alarm Heconsidered the following to be contra-indications to theuse of hedonal: 1. Any operation about the air-passageswhich caused haemorrhage into them, without preliminarylaryngotomy. The laryngeal reflex was not recovered quicklyenough to prevent the blood trickling into the larynx.2. Cases of high blood pressure. 3. Cases in which anæs-thesia could be obtained as safely and as satisfactorily byother means. Hedonal was indicated in : 1. Operations in theneck; goitre, including Graves’s disease. 2. Ventral hernia, onaccount of the absence of vomiting after operation. 3. Intra-cranial operations. In 56 consecutive intracranial opera-tions since February last hedonal was the only anaestheticused. The advantages over the method of giving chloro-form and oxygen with the Vernon Harcourt inhaler were wellmarked. 1. The anaesthetist was out of the way. 2. Any postureof the patient was possible, as long as there was a free air-way.3. There was no initial fall of blood pressure, as was so commonwith chloroform ; the blood pressure was well maintained atfirst, and only fell gradually after prolonged operation ormechanical interference with the brain. 4. It was frequentlypossible to proceed further with the operation, thus avoidinga second stage. 5. There was no vomiting after operation, avery great gain in these cases, when the head had to remainin sandbags in one position. The nursing was easier for thesame reason. 6. The prolonged sleep after returning to bedwas invaluable from a nursing point of view as well as from thepatient’s. No narcotics were necessary, and there was seldomany pain or malaise after operation. 7. If necessary,ordinary saline infusion could be given at once, without

any further incision. These advantages in cerebral

surgery were important and far outweighed the generaldisadvantages which lie had already put forward. Whenthe dura was incisecl it was good to see a slow movementeither of an arm or leg and to see a brisk skin reflex whichcould be elicited by stroking the soles of the feet. At such atime anaesthesia must be as light as possible. A suddenincrease of the depth of anesthesia was often most striking,and might be due to the increased facility with which the drughad access to the nerve cells when the intracranial pressurehad been diminished. From a somewhat large personalexperience of cerebral operations he had no hesitation inexpressing his preference for hedonal as compared with anyother general anæsthetic, more especially chloroform.

Mr. PERCY SARGENT said that hedonal had been used to

promote anesthesia in 43 intracranial operations he had

performed, 33 for cerebral tumours, 4 for removal of theGasserian ganglion, and 6 for hydrocephalus, meningitis, andJacksonian epilepsy other than that produced by tumours.No deaths had occurred directly from the anesthetic. The

operative fatality within the first 48 hours, possibly partlydue to the anæsthetic, was as follows : In 60 chloroform hadbeen given, mortality 20 per cent. ; in 29 ether, mortality13 per cent. ; in 31 hedonal, mortality 3 per cent.

Mr. BARRINGTON WARD read a paper on Hedonal Anoes-thesia-its Use in Children. He had employed it in 70 cases.The first 50 cases were for all kinds of conditions, but in thelast 20 only those cases were selected for which hedonal wasthought to be particularly suitable. It was by far the mostconvenient anesthetic in children. It was constant in posi-tion, out of the way of the operator, and obtruded itselfless on the patient. The insertion of the cannula was not

always an easy matter, and it was one of the disadvantages ofthe method that practically an operation had to be performedto find the vein before the main interference. In only onecase were the veins found to be too small for the purpose.Induction took on an average 7 minutes, and the amount ofsolution varied from 30 c. c. in a child of 9 days, to 680 c. c.in a boy of 7 years. It varied within fairly wide limits, thevariation being due to the size of the cannula and of the vein.A small quantity run in quickly induced anæsthesia soonerthan a much larger quantity run in slowly. The only satis-factory way of estimating the depth of anesthesia was byslight cutaneous stimuli, such as a pin prick. It was not at all

infrequent for the patient to make slight movements inreaction to the stimulus of the skin incision. During the sub-sequent manipulations even the peritoneum could be freelyhandled without calling forth any reaction, but if the skinwas at any time stimulated slight movements occurred. This

uncertainty of when the patient was under was one of thegreat disadvantages. In children there was a very small

margin between the complete abolition of the skin reflexand the danger sign of respiratory depression. Evenif the skin reflex was present, muscular relaxation was

very complete. The colour of the patient was remarkablygood. When once anaesthesia had been established verylittle hedonal, if any, was required to be given to maintain it.In 9 cases no further anæsthesia at all was necessary for

operations lasting for from 18 to 50 minutes. The colour hadnot been useful as a warning of danger. Gradual slowing ofthe respiration and deep sighing with apnœic pauses weresigns that the drug had been pushed too far. There hadbeen one fatality. The patient was a girl, aged 8, withtuberculous glands of the neck. 300 c. c. of solution hadbeen used to induce anæsthesia, and 200 had been givenduring the progress of the operation, which had lasted 30minutes. A post-mortem examination revealed the conditionof status lymphaticus. In only one other case had therebeen any anxiety, and that was in a similar type of child.He did not think hedonal could be extolled as a safeanæsthetic. Federoff, the originator of the method, had’reported temporary cessation of respiration in 8 out of530 cases. The advantages were : for the patient hedonalwas one of the most pleasant anesthetics, and its adminis-tration was practically free from discomfort. It was notice-able that the preliminaries to an operation under hedonalwere always quieter than under any other anaesthetic.One patient after an experience of spinal, inhalation, andintravenous anæsthesia begged when an anæsthetic was

required on a fourth occasion that intravenous anoesthesiashould be given. For the operator the conditions wereall that could be desired. Excellent muscular relaxationwas obtained. In operations about the head it was of

1299MEDICAL SOCIETY OF LONDON.—HARVEIAN SOCIETY.

advantage not to be hampered by the armamentarium of theanaesthetist. In the acute empyemas of children with hedonalthe respiration was quiet and regular throughout, andno explosive coughing occurred even when the chest was

opened. The after results of the anaesthetic were excellent.The drug was excreted very slowly, and a quiet sleepfor from five to seven hours was usually obtained. On

recovery the child was perfectly fit and ready to take food,but inclined to sleep for the next 24 hours. The absence ofvomiting was a noticeable feature. The urines were examinedbefore and after operation. The figures were too small to beof much value, but less than half showed any increase inacetone, and in 9 per cent. of the cases acetone was presentbefore operation and absent afterwards. None of the cases

gave any clinical signs of the presence of acetone. The

disadvantages of the method were by no means few. In itsimmediate effects it was probably as dangerous as chloro-form, and much more dangerous than open ether. Itslate effects, however, compared very favourably with any’other anaesthetic. The estimation of the depth of anæs-

thesia was difficult to determine exactly. The slow-ness with which hedonal was excreted demanded verycareful administration. If by any unhappy accident anoverdose were to be given resuscitation was almost a forlornhope because of the amount of the drug in the circulationand the slowness of its excretion. As a routine anaestheticthe preliminaries of finding the vein and inserting the’cannula might be rather tedious and certainly took longerthan induction with the open methods. There was also some

uncertainty as regards the size of the vein. The use ofhedonal was contra-indicated in short operations because ofthe slow recovery from the effects of the anaesthetic. It wascontra-indicated in the ordinary hospital list of operationsbecause of the extra time consumed and the excellentresults that attended anæsthesia by open ether with the pre-liminary injection of morphine. For the acute abdomens ofchildren spinal anaesthesia with Tyrrell Gray’s solution ofstovaine-dextrin gave by far the best results. The indica-tions for hedonal were therefore narrowed down to verv few.It was the best anaesthetic for brain operations. Withhedonal the administration was convenient and the prolongedsleep afterwards greatly reduced the shock of the operation.Moreover, a surprisingly small amount of anaesthetic was

required. In empyemata the results were excellent. Hewould not advocate its routine use in empyemata, however,because except in infants a rib could be resected easily andwithout distress and with complete safety to the patientwith local infiltration anaesthesia. Finally, hedonal shouldbe considered if a patient had already had experience of ageneral anaesthetic and dreaded another operation on thataccount, a condition by no means infrequent in olderchildren.

Mr. J. F. DOBSON quoted statistics obtained from therecords of the Leeds General Infirmary. Between Feb. 20thand Oct. 8th 436 cases had been operated upon underhedonal anaesthesia; in this series there were 44 deaths,being at the rate of 10 per cent. During the same periodthe number of general surgical and gynaecological operationstotalled 2302 with 164 deaths, a rate of 7-1 per cent.1866 operations were performed with the older methods ofanaesthesia with 120 deaths, a rate of 6-4 per cent. Thehedonal cases therefore showed a death-rate of 10 per cent.,;as compared with 6.4 percent. for other methods. Hedonalhad not been given frequently for the very trivial operations,though, on the other hand, it had only occasionally beenemployed for emergency operations, such as those for acuteabdominal disease. An analysis of the 44 cases whichsuccumbed after operation performed under hedonal anæs-

thesia gave the following figures. Five cases dyingshortly after operation had marked oedema of the lungs.With the exception of one case, in which 900 c.c.

were injected, all received more than 1200 c. c. In4 cases dying from three to six days after operationthe lungs were very eedematous. These cases had1650 c.c., 1450 c.c., 1000 c.c., and 970 c.c. respectively.Of these 9 cases it could safely be said that death was

directly due to the anaesthetic in 2, and in 5 cases oedemaof the lungs was a factor in causing death. Pneumonia wasfound on post-mortem examination in 8 cases. In 2 it wasassociated with peritonitis, and these might be dismissed.Of the remaining 6 cases, 2 had simple broncho-pneumonia ;in 3 cases broncho-pneumonia was associated with the

presence ot multiple abscesses m tne lung. There was i

case of pneumonia with cavitation and gangrene of thelung. Infarction of the lung was found on post-mortemexamination in 4 cases. In 3 cases there were numerousinfarcts in both lungs; in the remaining case one lungcontained two large areas of infarction, the other lungshowing diffuse broncho-pneumonia. There were twodeaths attributed to shock. In one as much as 1750 c.c.was administered. In the series there were 1 deathfrom pulmonary thrombosis, 2 deaths from pyaemia,and 1 from symptoms suggestive of cerebral thrombosis.The figures showed the frequency of pulmonary complica-tions after hedonal. It was not suggested that in all thecases quoted the death of the patient was due to the an2es-thetic ; in all, however, it was a factor, and in many thechief. Pulmonary oedema could be largely avoided by takingcare not to give more than 1200 c.c. ; it followed thathedonal was unsuitable for prolonged operations. The twodeaths from shock were perhaps due to the direct toxic actionof the drug. The most serious complication was pulmonaryinfarction and thrombosis. Dr. R. A. Veale had shownthat thrombosis at the seat of the venesection was frequent ;emboli would readily become detached. This complicationmight perhaps be avoided by elevating the arm to empty theveins immediately on the cessation of the infusion and thenapplying a firm bandage. Infarction was probably not in-frequent ; it was not always fatal, but might occur after thesimplest operations. A method of producing general anæs-

thesia without incurring the risk of inducing pulmonarycomplications was an urgent necessity. The mortality ofcertain abdominal operations was due largely to bronchitisand pneumonia, particularly in such operations as partialgastrectomy, colectomy, gastro-enterostomy, and gastrostomy.In many cases this was due to inhalation anaesthesia. Itseemed that these complications would be even more

frequently met with were hedonal in common use.Dr. J. F. W. SILK considered intravenous anaesthesia one

of the most notable advances in anæsthetisation. In thefew cases in which he had used hedonal he had been alarmedby the fact that sleep had persisted for a long time. Nodoubt in the fatal cases recorded the patients had been toodeeply anæsthetised-namely, as deeply as in inhalationanaesthesia. Another reason might be that the solutionused was too strong. He had added hedonal to ether givenintravenously, and thought this was an improvement both asregards ether and hedonal anaesthesia.

Mr. HUGH M. RIGBY had had experience of hedonal anoes-thesia in 20 cases in which he had operated. He had been

impressed by the ease with which anaesthesia was producedand the freedom of manipulation permitted in abdominal

operations. One case was fatal.Mr. E. M. CORNER considered affections of the jaw, tongue,

and respiratory passages unsuitable for hedonal anaesthesia.The method was valuable from the patients’ point of viewand was preferred by them to the ordinary methods.

HARVEIAN SOCIETY.

Preparation, Choice of Anæsthetic, and its Management inDifficult Types of Patients during Abdominal andPelvic Operations.

A MEETING of this society was held on Oct. 31st.Dr. DUDLEY W. BUXTON, in opening a discussion upon

the above subject, said that the underlying physical andpathological states which produced types of patientswere the essential matters for the anaesthetist to study.Adopting as his guide that the patient’s safety, the

suitability of the anaesthetic to the particular opera-tion, and the predilection of the operator for any anæs-

thetic or method should be placed in this order of im-

portance, the anaesthetist had yet to remember that thesuccess of the operation might depend upon whether thesurgeon’s desiderata were granted him, and upon this successultimately must depend the patient’s safety or chance ofspeedy recovery. The environing conditions of the patientwere (1) those outside the region of operation, the age andsex, his physique, his habits as regards drugs and alcohol, andso on, and such blood states as anaemia or toxæmia-e.g.,sepsis, glycosuria, albuminuria, cholaemia, and the presenceof intercurrent organic disease affecting the respiratory, the