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With a diet as has been recommended by these men, a patient can be kept in nitrogen equilibrium throughout the course of the disease, and the patient will get from his bed at the end of the disease as did one of Dr. Coleman's patients, weighing two pounds more than when he went to bed three or four weeks before.

Ewing believes that many of the clinical and pathological phenomena in severe cases are due directly to autointoxication from the destroyed tissues of the body.

The more serious objections to a more liberal diet are: (a) Tympanites; this in itself is not an indication of typhoid fever, and it is doubtless found much more frequently and more severely in milk fed patients. (b) Indigestion; digestive troubles, many writers assert, are only occasionally improved by rest of the organ, but generally the opposite is true; relief coming only when the proper diet is given. (c) Absorption; the best authorities say absorption is only from 5 to 10 per cent. below normal in the typhoid patients. (d) Perforation, hemorrhage, and diarrhoea.

Let us look for a moment at three different patients, with three distinct diseased conditions, all of which are somewhat similar in their gross, morbid anatomy, and yet the treatment is so different.

To the typhoid fever patient you give milk, and guard carefully against solids for fear of causing hemorrhage, perforation or diarrhoea. While Lenhartz and many others even forced the feeding of a gastric ulcer patient or a patient with tubercular ulcers of any part of the bowel. And better results are reported from forced feeding than with the partial starvation diet.

In typhoid, according to reports, probably relapses are about as frequent in one method of feeding as another.

In one report of eighty patients on a liberal diet, compared with 74 patients on a milk diet, the death rate was 2 per cent. less in the liberal diet.

In another record of 246 cases on liberal diet and 233 on milk diet, the death rate was 22 per cent. lower in liberal diet.

In a very large collection of cases on liberal diet compared with another large collection on a milk diet, there were two hemorrhages in milk diet patients to one on liberal diet; in the same collections there were just 1 per cent. more perforations in milk fed patients, and the death rate was more than I per cent. greater in milk diet patients.

Dr. Barr, of England, believes that not only are perforations less frequent, but that the ulcers heal more readily with a liberal diet.

Dr. Houghton, of Long Island, sums up his experience thus: "Patients on a liberal diet are more comfortable and content, and not emaciated and weak, temperature lower, pulse rate less frequent, less meteorism, less toxemia, less delerium, fewer complications and fewer deaths.

In suming up then, I believe that:

1. The profession has been and is responsible for considerable unnecessary suffering.

2. The practice of partial starvation, as at present followed in the treatment of typhoid fever, is highly detrimental to the patient's welfare.

3. It is not only desirable but also necessary that the typhoid patient be given sufficient food to cover his energy expenditure.

4. Milk alone is not the best diet.

5. Liberal diet is perfectly safe.

6. The patient has fewer bad symptoms and complications when given a liberal diet.

7. Convalescence earlier, restoration easier.

8. Last, but by no means least, a lower percentage of deaths.

ETHYL CHLORIDE AS A GENERAL ANESTHETIC.

BY DR. CHARLES L. SHAFER, KINGSTON, PA.

READ NOVEMBER 22, 1911.

Ethyl chloride as a general anesthetic has been known to the medical profession for over a half century, but only in recent years has it gained for itself an established place in the aramentarium of the anesthetist. Heyfelder, in 1848, first employed the drug to induce general anesthesia in the human subject, but failed to attract any attention to it. In 1867 Richardson experimented with it and called it a good and safe anesthetic, but again the drug fell into disuse. It was not until 1895 that Carlson, of Gothenburg, showed that in certain cases in which ethyl chloride was used locally on the gums that the patient became quite unconscious. He rightly concluded that this was due to inhalations of the vaporized ethyl chloride. Then Thiesing and Billeter purposely employed it as a general anesthetic, with good results. Many others followed in the next few years and to-day it is being used in all parts of the world as a general anesthetic alone, in combination or as a preliminary to ether and chloroform.

Ethyl chloride is a colorless, very volatile, inflammable liquid of agreeable odor and burning taste, boiling at 12-50 C. and having a chemical formula of Ca Hs Cl. It is necessary, therefore, to keep it in sealed tubes. The ends of these larger tubes are drawn out to fine capillary tubes which are then sealed, or the capillary opening is closed by a metal cap which may be replaced when a part of the contents of the tube has been used. When required for use, the glass tip is broken off or the metal cap unscrewed, whereupon the heat of the hand causes the ethyl chloride to volatilize, forcing out a fine stream which may be directed against the surface that is to be frozen for the local anesthesia or the stream may supply the vapor for inhalation to produce general anesthesia.

Many methods have been tried for the administration of ethyl chloride as a general anesthetic, but the closed method with a rubber bag inhaler and the Ware inhaler, are the most satisfactory in use to-day. The Ware inhaler consists of a

soft rubber mask into which fits a brass tube, over the end of which tube is stretched a layer of gauze. The gauze may be renewed at will. In using the inhaler a fine stream of ethyl chloride is directed through the brass tube on to the gauze. The vapor of the ethyl chloride is retained by the soft rubber mask from which it is inhaled by the patient.

(The rubber bag type of inhaler which I have with me tonight will explain itself better than any description.)

When administering ethyl chloride or its compounds, such as Sommoforme, Kelene, or Brugg's mixed anesthesia, the mask must fit the face snugly. A graduate container must also be employed or else the dose is uncertain. The other rules every anesthetist knows to watch the eyes, respiration, pulse, to insist upon quiet in the room and avoid the flame.

From three to five cc of the drug is the usual amount used in the beginning. The capillary tube is placed in the hole in the angle junction tube or else sprayed into the inhaler. The patient is instructed to breathe normally. After about five to ten full breaths the patient will commence to take deeper inspirations, which are closely followed by a condition characterized by tonic contractions, accelerated respirations, and usually a little contraction of the pupils. This is quickly followed, in fifteen to sixty seconds, by that of profound anesthesia. The mucles are now relaxed, the breathing deep and rhythmical, perhaps snoring, when the pupil usually becomes dilated and the conjunctival reflex is abolished.

Drs. Malherbe and Laval, of Paris, have described three distinct stages in the anesthesia.

(1) An analgesic stage, which commences after two or three breaths and lasts from twenty to thirty seconds.

(2) An anesthetic stage, which lasts from two to three minutes; and

(3) A second analgesic stage, during which time the patient may move and talk but feels no pain.

In my personal experience I have seen a patient remain in the last stage five minutes after the mask had been removed, 5 cc of Brugg's mixed anaesthetic having been used. In many

instances the patient passes at once into the last stage while occasionally it may take five minutes to produce the third stage. If ethyl chloride is to be continued, small doses, viz.: I cc are given about one minute apart, or if mixed anesthetic is to be used, such as ether and chloroform, the change can readily be made without the patient coming out between the two anesthetics.

After a short anesthesia the patient is seldom nauseated and rarely complains of headache. They are often bewildered but quickly recover and go about their duties. Luke says in cases in which the anesthesia was kept up for half an hour or upwards by means of this anesthetic alone, violent and painful retching has often resulted, and for this reason it is best not to maintain anesthesia with ethyl chloride for longer than ten minutes.

With regard to the type of patient, children, as a rule, take ethyl chloride very well. Webster, of Winnipeg, has given it at all ages, the youngest being twenty-four hours and the oldest eighty years.

The use of ethyl chloride as an anesthetic has many decided advantages; it induces anesthesia more rapidly than ether or chloroform, and when it is withdrawn the patient recovers more quickly. Its use as a preliminary anesthetic to ether and chloroform anesthesia is probably one of its greatest advantages. In a major operation, where long time is necessary for results, it is best to induce anesthesia with ethyl chloride or with one or more of its compounds and then pass on immediately to ether or chloroform. In this way the struggling period is avoided, and, as Hewitt has said, is the time when a large majority of chloroform fatalities occur.

Thomas D. Luke, instructor in anesthetics at the University of Edinburg, says: "It is somewhat astonishing that at the present day in the United States as long as fifteen minutes are required to anesthetize a patient, the reason being that ether is employed." He further says: "Apart from the waste of time the patient is semi-conscious during a large portion of this time and striving to endure a most unpleasant, almost suffocating vapor? Hence, it seems almost barbarous to sub

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