A NEW CHLOROFORM INHALER.

THE Vernon Harcourt Chloroform Regulator was first introduced to a special chloroform committee appointed by the British Medical Association to investigate the subject of anesthesia in certain directions. One of the committee, Dr. Dudley Buxton, at the instance of the other members of the committee, tested the Inhaler clinically and reported in favorable terms of it. (Supplement to the British Medical Journal, July 18, 1903.) Mr. Walter Tyrrell also employed the Inhaler, and his cases, which further demonstrated its value, appeared as an appendix to the committee's report. Since this pronouncement the Regulator has been in con

CRIFFIN

LONDON

stant use at University College Hospital, and in the hands of several anesthetists, and has earned for itself the warmest approval.

From a clinical standpoint it is not too much to say that Mr. Vernon Harcourt's patient and truly scientific endeavor to produce an exact apparatus has been successful. It was somewhat doubtful, until extended use proved such to be the fact, whether a 2 per cent. vapor of chloroform was adequate for all cases. The common objection urged is that such a low tension vapor could only be applicable to subjects who were easily anesthetised; but when the apparatus is intelligently used it is found to be capable of the widest employment.

The features most noticeable about the narcosis are that as the

patient at first inspires a 2 per cent. vapor he is soothed and not excited; if the increase in vapor strength be graduated with precision, the onset of narcosis is gradual, and what is more impor tant, is even. There is no sudden variation. The onset travels as it were along an inclined plane; there are no irregular elevations and depressions, and as a result struggling, whether voluntary or the result of overstrong vapor, seldom occurs. The nerve storms and convulsive respiratory phenomena, at times met with among the alcoholic or muscular during the inhalation of chloroform, seldom if ever occur when the low tension vapor is used, and hence the risks of the period of induction are lessened, if not wholly removed.

After effects are certainly less when the Regulator is used, and most patients express themselves as having found the method less.

painful than former experiences, in which other methods of giving chloroform had been adopted.

There can, we think, be no doubt that Mr. Vernon Harcourt's Inhaler is the best apparatus we possess, and marks an enormous advance in our available methods. It would be premature to say more, but we confidently await the criticism of the next few years; we believe it will more than justify what has been said, and will show that a low percentage vapor of chloroform from an accurate scientific apparatus such as Mr. Vernon Harcourt's, administered by an experienced anesthetist, will give most satisfactory results.

When this method is universally adopted chloroform will once again take the premier place as the anesthetic among anesthetics, and its accidents will, if they arise at all, result from an unwise departure from known physiological principles.

DESCRIPTION OF THE APPARATUS.

Mr. Harcourt's Inhaler provides, in sufficient quantity for full and free respiration, a mixture of air and chloroform, which is automatically limited to a maximum strength of 2 per cent., and can be diluted at will with additional air down to any smaller proportion.

The two-necked bottle is filled with chloroform to near the top of the conical part, and two colored glass beads are dropped into the liquid to indicate when the temperature is within the range, 13 to 15 deg. C. If the temperature of the chloroform is below 13 deg. both the colored beads will float; if it is above 15 deg., both will sink; in the former case the proportion of chloroform inhaled will be less than the pointer of the stopcock indicates; in the latter case it will be greater. During inhalation the chloroform is cooled by evaporation; its temperature may be kept between 13 and 15 deg. by now and then holding the bottle in the hand till the red bead has floated up and the blue bead is beginning to rise. The stopcock is so made that when the pointer is at the end of the are nearest the bottle of chloroform the maximum quantity is being administered-namely, 2 per cent. When the pointer is at the opposite end only air will be inhaled; and when it is midway dilution of the 2 per cent. mixture with an equal volume of air will make the proportion 1 per cent. The shorter lines on either side indicate intermediate quantities-namely, 0.8, 0.6, 0.4, 0.2; and towards the chloroform bottle, 1.2, 1.4, 1.6, 1.8. The valves on the two branches prevent the entrance into the apparatus of expired air, and also serve to show whether the stopcock is working rightly. Only one valve opens when the pointer is at either end of the scale, both equally when the pointer is midway, and for all other positions one valve opens more and the other less, in the degree indicated by the position of the pointer on the scale. The movement of these valves shows also how full and regular the breathing is, and the slight click which they make conveys this information to the ears when the eyes are otherwise occupied.

It is generally found that beginning with the pointer at 0.2 and moving it on towards the chloroform bottle at the rate of one division about every half-minute up to 1.6 or 1.8 produces narcosis as quickly as is desirable.

For the maintenance of narcosis it is believed that 1 per cent. or even less will be found sufficient. The stopcock can be moved by a touch of the finger so as at once to increase or diminish the dose.

The face-piece, which is provided with an expiratory valve and can be fixed in any position, is either attached directly to the inhaler, which in this case is held in the hand, and should be kept

as nearly vertical and as steady as possible, or can be connected by about 20 inches of half-inch rubber tubing; the inhaler in this case being supported on a stand or hung on to the back of the bed.

The mask is made of solid toughened rubber, fitted with a rubber air-cushion. It can be washed, or boiled, and as it becomes plastic in hot water the shape can easily be modified, if required, so as better to fit the patient's face.

No chloroform evaporates excepting that which is inhaled by the patient; and only that which is exhaled passes into the air of the room. A great economy of chloroform is thus effected, which should in a short time repay the cost of the apparatus to institutions or medical men in large practice by whom it may be used.

ON THE USE OF THE VERNON HARCOURT INHALER.

The apparatus must be carefully examined to see the parts are adjusted, and the administrator should inhale to see that the valves are working properly. About 11-2 oz. of chloroform should be poured into the conical bottle and the beads seen to be floating. The face mask should then be carefully applied. This is best done when the head is turned to one side. Breathing taking place freely and the air inlet valve and expiry valve flapping properly, the inhaler should be grasped at the horizontal cross-piece with the right-hand, while the lower jaw is pressed forward by the left hand placed behind the angle of the mandible. Firm pressure is necessary, as absolute co-adaptation of the mask to the patient's face is essential. If the pressure used is equal over the whole area of the face the patient will not complain. It is a common fault to allow air to enter by the sides of the bridge of the nose. Absolute fitting of the face-piece having been secured, the strength of the vapor may be gradually increased by turning the pointer. This is done slowly, but unless the patient is restless and struggles, not too slowly. Struggling is an indication for the lessening of the strength of the vapor but not for removal of the face-piece unless duskiness supervenes. When narcosis is attained, the usual signs being relied upon, in most cases the maintaining of anesthesia can be effected with 1.5 or even .5 per cent, according to the physique of the patient and the requirements of the operation. After prolonged administration. slight duskiness may appear, and in this case the apparatus may be lifted for a few breaths and then replaced.

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TORONTO, JULY, 1904.

Editorials.

OUR REPORT OF THE ONTARIO MEDICAL ASSOCIATION.

WE have decided, rather than hold our July issue too late, to publish our special report of the proceedings of the Ontari Medical Association, which closed the other day, in the August number, and feel that, in doing so, we have acted wisely, our readers preferring, we think, to receive the JoURNAL promptly on the first of each month.