H. E. G. Boyle
1918 BMJ (Clinical Research Edition)  
DEc. 2r, xg8x oP diagnosis only, thle routine estimations of the agglutinin couteut of the blood have here been found of such value as to justify a recommendation for their continuance. The question of blood agglutinins opens up the whole quiestioni of tlje dependence which slhould be placed upon tihe agglutinability of meningococci with regard to the p)atlhogellic properties. Vines draws attention to the fact tiL-,t agglutinability varies in primary and subcultures and wonders wletlher it is
more » ... ssible to define a border line be;ween pathogenicity and apathogellicity by using the -hliitination test as a criterion.-5 In the present changing colidition of our knowle.ige of the problem I am firmly COtivinced that no single one of tlle criteria in vogue solw-ices to determine wlvether Gramxi-negative cocci are Ipthogenic or not. The whole evidence obtaiped from ti: Imorpliological, cultural, and serological observations demands review in every instance. Society of London on "The use of -nitrous oxide and oxvgen with regulated rebreathing in military surgery," (I in tlhat parer X wept into detail with regard to the ztwhal administration, aud gave my results up to that .-t.e. Since tlhen I hal'le lhad further opportunities of ( 1 arging my experience of tlhis metlhod in civilian surgery, d.t(l hlave developed a technique for tle admi-nistration of 1 trous oxide and oxygen in combination witli etliet or E.III ixture for nose and tlhroat operations. iln working out thje details of tllis metlhod I lhave had tie cordial co-operation of Captain Douglaa Harmer, the senior surgeon to tlle Tlhroat Department of St. Bartlholo. oiiew's Hospital, and we have now arrived at a stage at which ve are both confident that the results we obtain are infinitely better than we ever got before vitli the older o etlhods. 'lThere are tlhree points that stand out as a result of our work: 1. The exceedingly small amount of C.E. miixture tllat is required. 2. The enormnous difference in tlle patient's wellbeing after tlle oopeation, as compared witlh the older methiods. 3. The excellence of the anaesthesia. The techlnique, briefly, is as follows: A hypodermnic injection of morphine and atropine is giveni half an hour before the time of operation. I vary the amount of the dose' with the nature of the operation and the conditiou of the patienit, and in some cases I add scopolamine to the inject.ion. The largest dose that I use (and this is the routine (lose for the military cases) is morphine J gr., atropine igr., aid(l scopolamine TAP gr.; whilst for some women,.and children of about 15 years of age, the dose is usually morphine B gr. anid atrop)ine TAo gr., and for small children I omit the hypodermic altogether, or at most give atropine 2> gr. The patient is then anaesthetized with nitrous oxide and oxygen with rebreathing in the metbod that I have described in 1nr paper before the Medical Society, and as so8on as anaesthesia is obtained, or, to be precise, just before that state is obtained, tie nlitrous oxide and oxygen is allowedto run through the etlher or C.E. mixture until the requisite depthl of anaesthesia is obtained; the face-piece is then removed, and tlhe anaesthesia is: maintained by runuing the combination either through the. Iose or into the month. The patient's conditioln will determine wbhether the piiituie is g1vn throughout the operation; usually it is unn'ecessary, the CI.E. being eony vrequited from time to time for few seconds-Given in this way, and piovided always that the airway is kept open and the breathing is not unduly obstructed by sponges, the anaesthesia will meet the requirements of most operators. Throughout the wlhole anaesthesia the patient should be pink in colour, there should be no cyanosis whatever, nor should there be any pallor; both of these conditions are signs of overdosage and of a bad administration of the anaesthetic. Tlhe former is easily remedied by additional oxygen but the latter is more serious. It is a remarkable fact that in several of the anaesthetics I-lhave given for the enucleation of tonsils only 1 drachm of C.E. mixture has been used, and witlh this in combination with the nitrous oxide and oxygen the anaesthesia has been all that was required. This method as I lhave described it sounds easy, but I do not advise any one to try it until he has made himself tlhorouglhly acquainted with the various points of nitrous oxide and oxygen anaesthesia with rebreathling for long cases. That I consider necessary as a preliminary training. Apart from the ordinary throat operations, such as enucleation of tonsils, submucous resection of septumu, and the like, I have used this method for bronchoscopies and oesophagoscopies, and have been particularly struck by the ease and quietness of the anaestlhesia, and the rapid return to a condition of well-being and comfort after tlhe operation. The more I see of the anaestlhesia produced by iitrous oxide and oxygenv witli rebreatlhing i colbination with etlher or G.E. mixture when necessarv, the more am I convinced tllat whilst the anaestlhesia is whlolly adequate for the surgeon's needs, and can be prolonged as long as is necessary, so that there is no need for hurry on the part of the operator, the condition of tlle patient, botlh during and after the operation, is infinitely better than with etlher, chloroform, or mixtures thlereof. To give but one instance. Even if the patient is ".sick' after the anaesthetic, lie does not hiave that lhorrible sickly smell of ether or chloroform hanging about himself and the room for hours and it may be days, but he is rid of his anaestlietic mixture in a few minutes, and is hiis normal self again. During the administration of this combination of anaesthetics for nose and throat operations I have observed that-1. Complete relaxation of the jaW is obtained, eveni in musculat subjects, and .with this goes also therelaxation of the soft palatp as vell. 2. The swallowing and cougb reflexes are easily abolished, aind yet are restored almost immediately ou wvitlidrawivig the anaesthetic. 3. The amount of bleeding appears to be less, both during aii&d after the anaesthetic, than with other methods. 4. The rapid recovery to conisciouisness after the operation is a point of extreme importance, for oiie never sees patients lying, after the operation, in that deep unconscious state that so frequently follows the admiinistration of chloroform, but on the contrary they are conscious itn a few minlutes, have a good colour, an4 are well. Tlle numiber of cases tllat I can n1OW report as lhaving been anaesthetized with nitrous oxide and oxygeni witlh rebreathliiln, and witlh etller or-G.E. miiiixture wheii necessary is-
doi:10.1136/bmj.2.3025.684 fatcat:pn6l2mqquvggjmfw5unvqm4ejq