COCAINE AS AN AID TO INTUBATION IN INFANTS

291 The first case developed local battery action is probably responsible. Such ulceration has been noticed with brass screws, and was ulceration of the soft tissues more severe when these were nickel-plated and subat the site of insertion of the pins, 16 days after operation. sequently drilled to facilitate introduction, thus exposing a metallic junction. The bacteriological report When a plated steel screw was appeared to be sufficient ex- similarly treated, a small ulcer persisted for 3 weeks, planation. Before the pins were while the head of the screw almost disintegrated. Since removed from case 1, case 2 stainless steel screws have been substituted, no ulcers was operated on, and case 3 from this cause have been observed. Ulceration is also was grafted before the ulcer seen opposite soldered junctions on the appliances. developed in case 2. Within This is more noticeable with a new cadmium solder than 8 days case 2 also developed with hard silver solder, although this difference does not an ulcer of a similar type, and outweigh certain other advantages. Minor degrees of ulceration from these causes tend to cultures taken from this ulcer proved negative under both heal after 4-8 days. At the same time the metal assumes a dull appearance. aerobic and anaerobic conditions. The change may be due to loss of The similarity in appearance of the more electro-positive metal from the surface layers, the ulcers in 2 cases in which and possibly also to a protective coating of mouth the same type of apparatus debris, tobacco stain, &c. Investigations are being had been used, and the sterile ,:continued in an effort to avoid this action, partly by the cultures from the second case, employment of a suitable protective film and partly by after removal, Fig.3-Sequestrum that the ulceration suggested eliminating the causative metals. showing pin -holes might in fact be due to electrical SUMMARY action. The fact that the pins on removal from case 1 cases of fractured In three mandible treated by A corroded also were grossly supported this view., recording galvanometer was therefore employed to see if bone-grafting and extra-oral fixation, electrolytic action developed between the copper-silver dental splint and any difference in potential could b detected between the the chromium plated steel pins, causing ulceration, bone two ends of the apparatus. In vitro, with a piece of splint necrosis and very delayed healing. The graft survived metal and a Kirschner pin as electrodes, suspended in Ringer’s solution as the electrolyte, a reading of between in each case but a sequestrum formed t-1 in. around the pin-holes. Electrolytic action may also account for 400 and 500 millivolts was obtained. In case 2, by ulceration around screws, projecting points and soldered one lead from the and the other from the taking pins splint while in position on the patient, a reading of 40-50 junctions on intra-oral splints. Preventive measures include the use of non-conductive plastic materials in millivolts with surges up to 200 millivolts was recorded. In case 3, at a stage when there was some inflammation connecting bars and stainless steel pins and screws. but no ulceration, readings were 5-10 millivolts. As the We wish to thank Mr. Rainsford Mowlem, who performed ulceration was no longer increasing it was considered the bone-grafting- operations, for his cooperation in these unjustifiable’to jeopardise the bone-graft by dismantling investigations; Miss D. E. Orpen for the drawings; and the the splints, and the apparatus was therefore left in place. other members of the unit who have assisted in many ways. The lesion was similar in each case-a deep punchedREFERENCES out ulcer symmetrically placed around the pins, with E. S. and Caughron, G. S. (1936) J. Amer. dent. Ass. 23, 1641. yellow, sloughy margin, purulent discharge and sur- Lain, R., MacGregor, A. B., Buxton, J. L. D. B. and Barron, rounding swelling and hyperaemia. More pain was Mowlem, J. N. (1941) Lancet ii, 391. experienced than is usual in pin fixation. The ulcer, like Venables, C. S. (1938) Arch. phys. Therapy, 19, 285. and Stuck, W. G. (1938) J. Amer. med. Ass. 111, 1349. all lesions due to electrical action, proved very indolent. Subsequent radiogramsshowed complete survival of the COCAINE AS AN AID TO INTUBATION graft, but localised necrosis around the pin site. Sequestra were removed comprising the whole thickness IN INFANTS of the ramus including both pin-holes (fig. 3) and in one case a portion of pin, which was so corroded as to fracture MARGARET HAWKSLEY, M B LOND in situ. The total healing time was 10 months in one ANÆSTHETIST (WAR-TIME) TO THE HOSPITAL FOR SICK CHILDREN, GREAT ORMOND STREET; ANÆSTHETIST, EMS, HEMEL On account case, and over a year in the other two. HEMPSTEAD BASE HOSPITAL of the site of the fracture the pins were inserted high up on the ramus of the mandible and radical surgery was Ir 1940’ Macintoshsuggested the application of a therefore contra-indicated. minute quantity of 10% cocaine directly to the larynx The Kirschner wire used was of chromium-plated steel. before intubation for endotracheal anaesthesia in infants. In the method of pin fixation previously referred to, using He reported its use in 8 cases under one year of age, in two sets of pins (fig. 1), the series of metals are symall of which intubation was made easier ; there were no metrically placed and the contact voltages are neutra- untoward effects.At this base hospital the procedure lised. In this development of the method a silver splint has been tried on 51 consecutive cases of hare-lip and and copper oxide cement within the mouth form one cleft-palate, all between the ages of six weeks and three pole, the other being an external pin fixation, the circuit years using 5% instead of 10% cocaine.being completed with brass, german silver and aluminium Anaesthesia is induced with either vinyl ether or ethyl1 alloy (fig. 2). The EMF developed between the copper- chloride, followed by’ Vinef3thene" mixture (vinyl ether 25%, silver alloy forming the dental splint and the chromiumether 75%) on, an mask. When the first plane third plated steel pins, with the tissue fluid forming the electro- stage of anaesthesiaopen is reached and the jaw is’ slack, the lyte, was probably sufficient to liberate iron and chro- mouth is opened by the thumb and fingers of the left hand, mium ions from the pins into the tissues. Both iron which at the same’time hold down the tongue. The tip of and chromium ions are known to be cell poisons, and the the index finger of the right hand; moistened with 5 % cocaine, sequestra when tested for iron by the ferricyanide method is now applied directly to the larynx, the anaesthetist remaingave a strongly positive reaction, particularly round the at the head of the table in the usual way. The cocaine ing pin-holes, whereas controls did not. is- thus confined tò the’vital part, the glottic entrance and the Two changes have been made to obviate further posterior surface of the epiglottis supplied by the superior ulceration. A non-conducting junction made of acrylic laryngeal nerve,2 or at least there is no extensive application resin has replaced a metallic junction in the connecting such ss would occur if a was used. The mask is now while ’ bar, Staybritestainless steel pins have replaced reapplied and anaesthesiaspray is maintained for two or thref the plated pins. With these modifications 7 further minutes to allow the cocaine to act before laryngoscopy and cases have been treated without ulceration or necrosis. intubation are undertaken the mouth. —

’

through

INTRA -ORAL FIXATION

Some

degree

of injury is often noticed opposite proand soldered junctions on dental splints. In some cases the ulceration is well-marked, there is yellow discoloration and slow healing. In these cases

jecting points

No ill effects of any kind have been encountered. Unless anaesthesia is deep, infants are notoriously liable to spasm when the larynx is exposed, and in my experi1. 2.

Macintosh, R. R. Practitioner, 1940, 145, 280. Macintosh, R. R. Lancet, 1943, i, 205.

292 the younger the infant the more obstinate the spasm a magnification of 11,000 (undreamt of by Donne who if it is allowed to develop. By using-a minute amount almost a hundred years ago was the first to describe these " of cocaine intubation can be undertaken at a lighter globulins " of the blood) even the bulb-like endings anaesthesia without of this the pseudopodia appear to possess a structure. Those of stage encountering difficulty. In one case a slight technical hitch had resulted in the who mean to study thrombocytic choreography will find anaesthesia lightening to such an extent that the child’s full technical details in the early section of this fascinating limbs were actually moving, yet the larynx was seen to little book.’ be wide open and the tube was passed without any difficulty. Without the cocaine the larynx would have Psychoiogy of Fascism been in spasm (and remained so) at the first touch of PETER NATHAN, MB LOND, MRCP. (Faber. Pip. 158. 8so.) the tube, and its passage would have been impossible. THIS intelligent little book exhibits a confident asserWithout cocainisation spasm is often engendered by tiveness which would lead one to,suppose the author the removal of the tube at the close of the operation. quite young if it were not that some of it may be explained Hare-lip and cleft-plate operations take on an average by his belief in psycho-analysis. Sweeping phrases like : 20-40 minutes ; the cocaine remains effective for this 4 4 as the religious account of life has had the bottom period. knocked out of it, ,.’ ." " Wagner is one of the biggest In fat children and those with big tongues it may be factors the causation of this war," " Fascism is the difficult to avoid losing some of the cocaine on the in both sexes of the wish ’Iwant to be a expression back of - the tongue as the larynx is approached ; a man’," are instances of this weakness. In the main, curved tongue-depressor has been found helpful in such however, his argument is well sustained and plausible, cases. provided that the common psycho-analytical tenets are To sum up, this small manoeuvre facilitates the passage accepted, and are considered applicable to the behaviour of an endotracheal tube by direct vision at a lighter of nations or large groups. Even if unwilling to accept level of anaesthesia than would otherwise be possible, these provisos, the reader will find Dr. Nathan a stimuand thus makes deep general anaesthesia unnecessary for casuist. lating and the procedure. It obviates spasm both on passing on removing the tube, and in 51 cases has proved Vertebrate Photoreceptors harmless. SAMUEL R. DETWILER, professor of anatomy, College of Physicians and Surgeons, Columbia University. (Mac-

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Bibliography

FIELDING H; GABRiso, revised with additions and annotations by LESLIE T. MoRTOrr, librarian, St. Thomas’s Hospital Medical School. (Grafton. Pp. 412. 12 10s.) WEILE that inspired scribe FieldingGarrison was

assistant at the Army Medical Library in Washington, he dropped into the Index Catalogue a list of Texts illustrating the History of Medicine which, with characteristic modesty, he called a " historical exhibit " -but was- soon recognised as a classic. He used the list himself as scaffolding to his Introduction to the History of 11‘edicine and. later revised it, again as part of a serial publication. But discerning readers came to use it as a vade mecum to their study of medical thought throughout the ages. An English librarian has had the happy idea of bringing Garrison’s " exhibit " up to date and making it accessible in a handy volume of its own. Mr. Morton has discarded 360 entries, mostly not concerned with medicine, and added 1680 of his own making a total of 5506, indexed by number under authors and subjects. Under each subject the selected works are arranged in chronological order, revealing the growth and trend of medical thought, and Mr. Morton has added a line or two (sometimes only a few chosen words) to help the reader where the title is foreign or not informative. He-suggests that the compilation may serve as a starting-point for something better, and while this may be true its present form will certainly be the startingpoint for many readers in an intelligent study of medical history., Others will find the immediate clue to that name that had so tiresomely dropped out of mind. Die Thrombozyten des menschlichen Blutes A. FoNio, professor of surgery in the University of

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of the series. It is a book of wide scope in its range and with a wealth of accurate detail, described so clearly that all essentials are included in the compass of 163 pages. Its breadth of view reveals the parallelisms in the structural details of the eyes of the different verte. brate classes ; and it sounds a warning note about the assumptions of Woollard and the generalisations of Elliot Smith on,the correlatyed evolution of the eye and - brain among the mammals. - The bibliography is useful but omits the work of Kelvin O’Day, a study of which would have ruled out the statements that: " double cones " and " oil occur in all retinas except in mammals shown are in has mammals." O’Day droplets lacking conclusively that both are present in monotremes and marsupials, as others had done before him. But these little things which can readily be put right in subsequent editions do not detract from the value of a book that is wholly admirable in scope and presentation. ...

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