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with the five-day treatment. It is difficult to obtain exact figur,es on the incidence of these complications, but Moore7 agrees with both Cole and Phelps that treatment deaths from routine standard treatment approximate 0.3 per cent. It is entirely probable, therefore, that in so far as the occurrence of all reactions is concerned, the five-day treatment method is as safe as the present standard procedure.

We wish to thank Dr. J. F. Burgess, Head of the Department of Dermatology, the Montreal General Hospital, for permission to report this work.
REFERENCES

1. 2. 3. 4.

RIcE: Arch. Dernm. d Syph., 1940, 42: 283. MARIN, A.: P*ersonal correspondence. C{HARGIN, L.: J. Am. M. Ass., 1941, 117: 278. United States Public Health Service: ibid., 1941, 117: 283. 5. MOORE, J. E.: Arch. Derm. 6- Syph., 1940, 42: 279. 6. CORMIA, F. E.: Camad. M. Ass. J., 1940, 43: 278. 7. MOORE, J. E.: Modern Treatment of Syphilis, Thomas. Springfield, 1933, P. 2237.

PREOPERATIVE SEDATION IN CHILDREN*

BY K. BORTHWICK-LESLIE, M.D.

Winnipeg

WANT briefly to review a few basic points in the physiology of anaesthesia, which as you know is produced by the reduction of the reflex activity of the nervous system. Reflex activity itself is directly proportional to the metabolic rate, which in turn is variable depending on the age, sex, temperature, glandular activity and emotional state of the individual. Du Bois and Benedict have demonstrated that the caloric output or metabolic rate is normally highest at 6 years, falls slightly to 10 years, rises during puberty, and slowly declines to old age. Since reflex activity and metabolic rate are parallel, such a chart gives us a starting point for estimating the basal requirements for anaesthesia. It is readily seen that even without outside stimulation, such as fear and emotion, the child between 6 and 14 years will tolerate larger amounts of anesthetic and drug therapy per pound of body weight than at any other period of its life. Factors that increase the metabolic rate and coincidently the reflex activity, increase the amount and potency of ancesthetic necessary in the individual case, and, conversely, factors that reduce the one reduce the other. Fear, excitement, sleeplessness, elevated temperature and abnormal endocrine activity are important items, so that preoperative recognition and judicious control of those factors are definitely indicated for the welfare of the patient. For example, take the patient, admitted in the morning for tonsillectomy. In spite of years of effort our profession cannot convince parents or be convinced themselves, of the
* Read at the Seventy-second Annual Meeting of the Canadian Medical Association, Winnipeg, June 25, 1941.

advantages of admitting the child the night before. Consequently there is a restless night, early rising, hasty dressing, no breakfast (much water), rushed to hospital, through the admitting examination, needles for clotting time, and hypodermic. Rushed upstairs, undressed by strangers, nervous parents watching, rolled on a stretcher; kissed "good-bye" by a tearful mother, and wheeled screaming upstairs to my tender care. A short - we hope - road to oblivion, but to the child, a horrible smell, a horrible sensation, a terrifying experience. Waking up, sick, vomiting, sore throat, more strangers. What is that child's never-to-beforgotten impression of hospitals? From a scientific point of view, what is its metabolic rate at the beginning of ancesthesia? Adults, you who know what is going to happen to you, you have a sedative, you go into the hospital the night before, waken up, have a hypodermic of morphine and hyoscine, come up to the operating room with a "jag" on, but probably scared stiff. Primarily, it is probable my maternal instinct that rebels at screaming inductions, but my professional conscience and pride come a close second. The preoperative medications available today are legion, but mainly are: (1) The opiates, with which you are familiar. (2) Drugs, including the barbiturates, which produce a state of basal anwsthesia. Basal anwsthesias aim at the comfortable production, preferably in bed, of a sufficient depth of narcosis that surgical anaesthesia may be obtained and maintained by minimum amounts of inhalation or regional agents. None of the basal types, except evipal or sodium

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THE

THE CA-NADIAN MEDICAL ASSOCIATION JOURNAL

CANADIAN
MEDICAL
ASSOCIATION
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[April 1942

pentothal intravenously, should ever be pushed to surgical anaesthesia. The barbiturates comprise an important and valuable group of central nervous system depressants. New ones are constantly being produced under confusing trade names, but the fundamental action does not differ much from the first ones, - barbital and phenobarbital. Barbital was first introduced in 1903 as veronal, and phenobarbital next as luminal. Latterly more than a score have been synthesized and marketed; for instance, amytal, dial, evipal, sodium ortal, pentobarbital sodium (nembutal), phanodorm, noctinal, delvinal sodium. The most recent advance is the substitution of sulphur for oxygen in the chemical formule, producing the thiobarbiturates. In passing I would like to draw your attention to the fact that sodium pentothal is a sulphur compound and thus is definitely contraindicated as an intravenous anaesthetic in conjunction with sulfanilamide therapy. The fate of the barbiturates in the body depends on their chemical structure, barbital and phenobarbital being excreted in the urine, nembutal, evipal, thiobarbiturates destroyed in the body tissues, delvinal in the liver. All are depressants of the central nervous system, affecting the cerebral cortex and diencephalon. They all depress the motor cortex, inhibiting convulsions, but phenobarbital has a selective action on the motor cortex not shared by the others, hence its value in epilepsy. They all act on the internuncial neurones, rather than on the afferent or motor fibres, causing a blocking of the cortex, first liberating conscious control, then in descending, affecting the vegetative centres in the mid brain controlling sleep, and as the stages of saturation proceed the subcortical centres controlling vasomotor and respiratory reactions, finally to brain stem paralysis. Death is due to respiratory failure. In ordinary hypnotic and preoperative doses only the first stages of loss of memory and conscious control are produced, with varying degrees of narcosis. There is little effect on respiration and in those showing a slight depression, it is, I think, due to the cutting off of some of the numerous respiratory centres scattered through the cortex and midbrain. Modern physiologists apparently do not agree that we are equipped with just one respiratory centre in the medulla, but have numerous scattered ones, with the co-

ordinating control centre in the medulla. There is no cardiovascular effect except through sedation. Death from therapeutic doses is unknown, there being no case on record of serious complications from either a single or repeated doses. Severe poisoning has occurred in doses 5 to 10 times the full hypnotic dose, which of course should never occur in sane medication. The barbiturates differ from morphine in that they are not analgesics, and are useless in controlling pain, but in severely disturbed patients, as in cerebral irritation, toxic delirium, psychoses, the soluble sodium luminal is extremely useful. They are powerful anticonvulsants, so are direct antidotes for strychnine, cocaine or novocaine poisoning and should routinely be used preoperatively in local anawsthesia. Conversely, the convulsants strychnine, metrazol, picrotoxin, are antidotes for both the barbiturates and avertin. They may be given orally, rectally or intravenously (special preparations). Rectal suppositories must be used 1 to 2 hours preoperatively. Nembutal capsules may be punctured and used rectally at least 1 hour before operation. Orally, for general surgery and eye cases I give small doses at bedtime and the usual dose 45 minutes preoperatively. For tonsils and adenoid operations with nembutal, one dose 45 minutes preoperatively with atropine is given. For children coming in the morning, if possible the mother gives nembutal at bedtime and a smaller dose of codeine is given preoperatively. Delvinal sodium is more soluble, so can be given in a small enema or ex aqua by mouth. It is a lighter barbiturate, eliminated faster, and has less "hangover", so may safely be given at bedtime and preoperatively as well. Supposedly it is associated with less restlessness than the others, but the nurses report little difference. I find it more useful for home therapy. Doses quoted are:
Nembu&tal
2
to 31/2 years, gr. 1/2 to Y4 '' 'g 4 g 11/4 31/2it 5 4 5 " 7 " " 1 "g 1Y2 7 "9 11 it it 1 it 2

Delvinal

gr. Y2 to 1 " 1 " g1/2

" 1 it"

2'4

Sodium luminal (hypodermically) 2 to 4 years ....... gr. %ato 14 410 6 i .......... g 1 V4 "1% 6t"10 It "t%t "1 t " 10 ..... 1% 1 it
........

..........

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Series of cases public tonsils and adenoids Females ...................................... 360 Males ........................................ 370 Codeine postoperatively ......... 45 ............... Hamorrhage postoperatively (none concealed) 16 Co-operative ................... ............... 690 Non-co-operative .............. ................ 60 Pale or dusky (one seriously depressed after induction) .............. ................. 28 Chest complications (all recovered with little trouble) ................................ 3
....

3. May be difficult for anaesthetist to estimate stages of anaesthetic due to eye changes and reflexes. Tendency to have too light an anesthesia.
AVERTIN

Must be mixed carefully and in fresh solution. Rectal only. Quiet natural sleep, lasting ADVANTAGES 1. Psychic. Difficult to overestimate the value 1 to 1/2 hours. Asleep on reaching operating room. Pale, shallow respirations, blood pressure of loss of fear. falls 10 to 30 points; retums to normal with 2. Reduction in amount of anwesthetic used, ether. Restless postoperatively. Coramine is 1/4 to 1/3. Less vomiting. 3. Postoperative amnesia and rest. antidote. Expensive, the average dose costing 80 4. Economy. Time and cost. Saving of cents in comparison with 5 to 8 cents (includopiates for war use. ing postoperative period) of the barbiturates. DISADVANTAGES I want to thank the nursing and intern staff of the 1. Individual investigation of patients. Children 's Hospital for their co-operation and assistance 2. Postoperative nursing care. Watch for and the surgeons for their tolerance in my estimation of dosages. relaxed jaw and restlessness.

POST-ANAESTHETIC COMPLICATIONS IN A MILITARY HOSPITAL BY S. M. CAMPBELL, M.B., D.A., MAJOR, R.C.A.M.C. AND R. A. GORDON, B.Sc., M.D., D.A., CAPTAIN, R.C.A.M.C. THIS report is based on an analysis of 2,094 reported by the surgical or nursing staffs to
anasthetic records. These cases include all those patients anawsthetized during one year on all the services of a military hospital. We feel that they may be of special interest because all the patients fall within a well defined agegroup, and were in almost all cases entirely well except for their present surgical disability. The majority of the operations were procedures which are not of themselves associated with high mortality or morbidity rates. We believe that such a group of patients should provide an excellent opportunity for the study and comparison of anesthetic agents and techniques with relation to post-anawsthetic complications. It is for that reason that we present this report. Each of the patients included in this series was seen before operation by one of us when practicable, and in the other cases was examined by another member of the staff of the hospital. An attempt has been made to record all pre-anesthetic complicating factors, especially those relating to the respiratory tract. After operation each patient was seen at least once by us when the pressure of work permitted, and we have seen all patients who were
have any evidence of a complication following anaesthesia. VVe have had excellent co-operation in this respect, and are satisfied that the post-anwsthetic records relating to the factors included in this report are fully adequate. While we have endeavoured to record all complications which could reasonably be related to the anawsthetic procedure, particular attention has been paid to post-anaesthetic pulmonary complications, which will be discussed at rather greater length than others. In this general survey of the whole group of cases we do not attempt to relate one set of factors to another, and attention should be drawn to the fact that the general figures presented in Table I may give rise to false impressions unless they are related to the more particular analyses in subsequent sections of this report. With the exception of the total number of cases in each group, percentages alone are given without particular figures, since we feel that it is only as they are related to a standard in this way that the figures given have any practical value. Not included in this Table is one case of mediastinal emphysema which followed tearing