Part 1

PRACTICAL POINTS IN ANESTHESIA

BY

FREDERICK-EMIL NEEF B. S., B. L., M. L., M. D. NEW YORK CITY

NEW YORK, U. S. A. Surgery Publishing Company 92 WILLIAM STREET 1908

COPYRIGHT, OCTOBER, 1908 BY SURGERY PUBLISHING CO. NEW YORK

PREFACE

I have tried to present some of my impressions on the correct use of chloroform and ether and of a very useful combination of these—anaesthol. No doubt, my observations and conclusions will have to be modified in many details by the experiences of others. I have merely voiced a simple and coherent working theory, which has gradually forced itself upon me as my views on the practice of anesthesia have become a little broader and more comprehensive.

FREDERICK-EMIL NEEF

941 Madison Avenue New York

CONTENTS

Preface, 5

The Induction of Anesthesia—The German Hospital System, 9

Cardiac Collapse, 12

Respiratory Collapse, 13

When Shall the Patient be Declared Ready for Operation, 15

Maintenance of the Surgical Plane of Anesthesia, 16

Some Important Reflexes, 22

Vomiting During Anesthesia, 23

Obstructed Breathing, 24

The Use of the Breathing Tube, 26

Indications for Stimulation during Anesthesia, 28

The Influence of Morphine on Narcosis, 30

General Course of the Anesthesia, 31

Awakening, 31

Recession of the Tongue after Narcosis, 33

Post-Operative Distress, 34

Morphine-Anaesthol-Ether Sequence, 36

Minor Anesthesia with Ethyl Chloride, 38

Intubation Anesthesia, 38

Cases Requiring Superficial Anesthesia, 43

Cases Requiring Anesthesia Of Moderate Depth, 44

Cases Requiring Profound Anesthesia, 44

Conclusion, 45

PRACTICAL POINTS IN ANESTHESIA

THE INDUCTION OF ANESTHESIA.

I can spare the reader the ordeal of many words by beginning in a concrete way with the outline of a system of anesthesia that is now largely followed at the German Hospital, New York City.

[Sidenote: The Mask]

The Schimmelbusch mask is used; this fits the face and is large enough to include the bridge of the nose and prominence of the chin. It is covered with a piece of thin flannel, and, over this, impermeable cloth in the center of which a lozenge-shaped fenestra (1½”×1”) has been cut. In the upper half of this little window with the flannel pane, on the inside of the mask, a small wad of gauze is fastened. The mask is then complete and _can be used for administering any anesthetic by the drop method—chloroform, anaesthol or ether._ In giving ether one makes use of the upper half of the fenestra with its separate ether pad; while chloroform and anaesthol are given to advantage through the lower portion. The chin, cheek and bridge of the nose are anointed with a little white vaseline at the line of contact with the mask, and then the latter is allowed to rest lightly on the face of the patient for a few moments, until he can reconcile himself to the strange procedure, and resumes his normal breathing. There must be absolute quiet. The anesthetist alone may speak when he deems fit.

[Sidenote: The Induction]

[Sidenote: Primary Anesthesia]

The beginning is made with anaesthol or chloroform drop by drop. The slightest objection on the part of the patient that the vapors are too strong must be considered; irritation of the throat, slight coughing, all merely emphasize that the introduction must be very gradual. If the patient is solicitous about the efficacy of the anesthetic he should be assured that there is no hurry, and he should be enjoined to take deeper breaths, if he breathes too lightly. As long as the patient is conscious he will respond to the injunction to take a deep breath; if he does not respond to this request he has reached the _stage of unconsciousness—the state of primary anesthesia_.

Sometimes a remarkable calm, a period of relative apnea, _precedes_ the stage of excitement. At other times, this stage ushers the patient _directly_ into the state of complete anesthesia. There need be no stage of excitement at all. This is especially true if morphine has been administered hypodermatically before narcosis, and if the induction of the anesthetic is cautious and gradual.

[Sidenote: Surgical Degree]

_The surgical degree, the state of complete anesthesia_, is announced by the respiration when it assumes the more or less well marked snoring character of one who is fast asleep.

In the German Hospital system the patient, male or female, is given a quarter of a grain of morphine sulphate hypodermatically half an hour before narcosis. The anesthesia is always induced with anaesthol or chloroform. _Where much blood is lost or the operation is of very long duration one may at any time make the transition to ether by the drop method without changing the mask._ As a rule, a morphine-anaesthol narcosis is given with a few drops of ether now and then (ether feeding), when a little stimulation is indicated. In a small number of cases, among them choledochotomies and other operations on the gall-bladder, particularly where there is jaundice, the morphine-anaesthol introduction is followed by the ether drop method.

CARDIAC COLLAPSE.

Cardiac collapse is fortunately uncommon. It usually occurs during the induction of anesthesia. Suddenly there is a marked pallor of the face and the pulse becomes weak. It happens in chloroform, and occasionally in anaesthol narcosis. When such a tendency is discovered _ether_ should be given by the drop method.

_Gradual induction_ of anesthesia until the patient’s tolerance to chloroform is ascertained, is of cardinal importance.

RESPIRATORY COLLAPSE.

Obstructed breathing developing during the induction of narcosis is apt to be due to _crowding_. If obstructed breathing becomes manifest later, that is, during the course of the operation, it may be due to _inhibitory reflex elicited by the surgeon_. Traction on the gall bladder or mesentery will sometimes evoke a peculiar noisy breathing which does _not_ mean that the patient is insufficiently under the influence of the anesthetic. The breathing becomes normal and unrestrained as soon as the surgeon desists from these vigorous manipulations.

[Sidenote: Crowding]

[Sidenote: Respiratory Collapse]

_Probably the most common of mistakes is crowding the anesthetic._ The anesthetist becomes aware of faint, high pitched notes in the breathing—the beginning of obstructed respiration. He examines the lid and corneal reflex and these convince him that the patient is in the state of _superficial_ anesthesia. Naturally, he gives more of the anesthetic. To his great chagrin the breathing becomes progressively more stertorous. The cyanosis which was at first slight, deepens. The noisy breathing attracts the surgeon’s attention. The perspiring anesthetist is enjoined to push the jaw forward; but the spasm of the muscles is too great. The teeth are pried apart, barbarous instruments are brought into play to pull the tongue forward. The patient has not received sufficient air all this time—his face is slate-colored. The nasal or pharyngeal tube, tongue traction, oxygen, artificial respiration with rhythmic chest compression, stretching of the sphincter ani, all follow in an illogical onslaught, until finally a long deep breath is induced and the victim is resuscitated. The condition was one of _respiratory-collapse_. The cause was crowding of the anesthetic.

WHEN SHALL THE PATIENT BE DECLARED READY FOR OPERATION?

As soon as the first, unimpeded, snoring respirations are heard, the cleansing of the field of operation may begin. If the cleansing manipulations do not disturb the rhythm of the snoring respiration, the rate of the pulse does not increase and the patient makes no defensive movements, he is very likely already in the proper plane of anesthesia. Note is at once made of the state of the pupil and lid corresponding to this plane.

[Sidenote: Initial Incision]

When the surgeon makes the initial incision observation is again made as to whether the rhythm of the respiration and the rate of the pulse remain undisturbed and whether the patient continues to be passive; if this is the case, the patient is considered to be in the correct plane of anesthesia—the plane in which he must be kept throughout the operation.

[Sidenote: Awakening Stimuli]

Of course, it is clear that the depth of the narcosis must, in a measure, be proportionate to the magnitude of the awakening impulses set up by the surgeon’s manipulations. In abdominal work these impulses are more intense near the solar plexus of nerves, that is, in the upper part of the abdomen. Traction on the mesentery or the introduction of long gauze tampons into the abdominal cavity for “walling off” sets up powerful awakening stimuli.

MAINTENANCE OF THE SURGICAL PLANE OF ANESTHESIA.

In order to conduct a narcosis scientifically one must know the signs of sufficient anesthesia and the signs of awakening.

[Sidenote: Respiration]

The respiration is studied by watching the movements of the chest or abdomen, by placing the hand in the vicinity of the nostril to feel the respiratory current of air, or, best of all, for the respiration is rarely noiseless, by listening to the breathing. The quality of the breathing is noted. The faintest indication of a snoring respiration means that the surgical degree has been reached. Any change in the quality of the breathing compels the questions “Has the patient escaped from the proper surgical plane?” “Is the anesthesia too deep or too superficial?” or “Is the change simply a _respiratory reflex_ induced by the surgeon’s manipulations?”

[Sidenote: Color]

The color of the _ear_ is a most useful guide. This does not hold good of the color of the forehead. The forehead in some individuals becomes cyanotic with slight changes of posture. The ear is not so subject to postural influences and is therefore a less misleading indicator of the venous condition of the blood. Even a slightly bluish tinge of the ear demands attention. Usually, crowding is the cause, and a little more air allows the normal red flush to return. Slight pallor developing during the course of the narcosis should always be regarded as a danger sign. It means that the patient is in profound anesthesia, and that the heart is threatening collapse. The mask should be removed promptly and the patient allowed to breathe pure air. As long as the pulse is not weak or irregular one need not worry about the outcome.

[Sidenote: Pulse]

There are some advantages in choosing the temporal pulse as the guide, instead of the radial pulse, which is ordinarily followed; occasionally the temporal can still be felt when the radial has become impalpable. The pulsation of the temporal artery is best felt by placing the index finger flat over the tragus into the depression at the root of the ear. The pulse is important because it tells how the heart reacts towards the anesthetic and the surgeon’s manipulations. The _frequency_ is not very important. Exceptionally, it may be 120 or 130 during the greater part of an anesthesia without vital significance, if the _quality_ is good. A diffuse and weakening pulse is a signal that the narcosis is too profound and that the heart is in danger of collapse. A somewhat irregular pulse may immediately precede or accompany the act of vomiting, and it is not a cause for alarm.

Accessory to the respiration, color and pulse, but of lesser significance, are the pupil, the cornea and eyelid, and the secretions.

[Sidenote: Pupil]

In patients _who have not received morphine before narcosis_ the pupil is, as a rule, a guide of some importance. If the pupil is narrow, examination of its reaction to light is generally superfluous. A wide pupil, however, often means one or the other extreme of narcosis. A wide pupil which reacts promptly to light indicates superficial anesthesia; the patient may need more of the anesthetic. A wide pupil which reacts to light sluggishly or not at all means that the danger line has been overstepped; the anesthesia is too deep; the patient must have air. Without knowledge of the reaction, every markedly dilated pupil should be looked upon as prognostic of danger.

[Sidenote: Cornea]

To touch the cornea repeatedly with the finger for the purpose of obtaining the corneal reflex, is a bad habit. The reflex can be tested just as satisfactorily by shifting the eyelid gently across its surface.

A point worth remembering is that in the morphine-anaesthol (or morphine-chloroform) anesthesia the corneal reflex may remain quite active, while with ether it soon becomes feeble or extinct.

[Sidenote: Eyelid]

A useful indicator of the degree of muscular relaxation is, I believe, the tonicity of the eyelid. The usual arm test is very misleading. Flexing the elbow once or twice may give the impression that the muscles are thoroughly relaxed, and yet, on repeating the manipulation five or six times one may be surprised to obtain a sudden, powerful contraction of the biceps, showing that the patient is still not fully under the influence of the narcotic.

Normally the upper lid has a certain tonicity. If it is lifted gently by means of the superimposed ball of the finger it springs back to its natural position promptly. When the patient is fully under the influence of the anesthetic, this tonicity is partly or completely lost and the lid returns sluggishly to its natural position, or not at all. The patient can sometimes be kept in a proper surgical plane by giving a few drops of the anesthetic each time as the tonicity returns, and ceasing when relaxation of the eyelid is obtained.

[Sidenote: Secretions]

[Sidenote: Individual Idiosyncrasy]

When the patient is under anesthesia to the surgical degree the activity of the salivary, sweat and tear glands ceases. The accumulation of mucus in the mouth, the appearance of a tear in the eye, beads of perspiration on the brow all mean that the anesthesia is becoming superficial, that more anesthetic is required. It is worth bearing in mind that these indicators of the depth of narcosis do not, in all individuals, react in exactly the same way. While initiating the narcosis the anesthetist can get his bearings in regard to this point, and watch for any individual idiosyncrasy which may exist.

It is unsafe to concentrate the attention on one sign, lest the general aspect of the patient be overlooked.

The anesthetist watches _constantly_ the rhythm and quality of the breathing, the color of the ear and the character of the pulse. From time to time, only as occasion demands, he refers to the accessory signs for confirmation. Should he, at any time, be in doubt about the depth of the narcosis, the first step is always to desist from giving more of the anesthetic until he has regained his bearings or the signs of awakening are recognized.

SOME IMPORTANT REFLEXES.

[Sidenote: Pharyngeal Reflex]

(1) _Pharyngeal reflex._ Coughing does not necessarily indicate awakening. It usually means that the vapor of the anesthetic is too concentrated and irritates the air passages. “Holding the breath” occurs even in fairly deep narcosis and has the same significance. The treatment is to dilute the anesthetic by admitting air.

[Sidenote: Ano-respiratory Reflex]

(2) _Ano-respiratory reflex._ The crowing inspiration heard during operation on the perineum or rectum, _does not indicate that the patient should have more anesthetic_.

[Sidenote: Splanchnic Reflex]

(3) The reflex produced by traction on the gall bladder or mesentery is similar in its significance to that of the ano-respiratory reflex.

VOMITING DURING ANESTHESIA.

[Sidenote: Vomiting]

It may happen to the conscientious anesthetist, who desists from giving more of the anesthetic until he has regained his bearings, that the patient suddenly shows signs of awakening, and vomiting begins. This is a disagreeable, but generally not a serious interruption. The anesthetist is absolute master of the situation. Although the patient’s face turns somewhat blue during the vomiting efforts, the anesthetist _should not attempt to push the jaw forward or exert traction on the tongue_. The face is merely turned to the side and kept in position by placing the hand on the cheek. The mouth and pharynx are cleansed gently with a piece of gauze and the anesthetic is continued, drop by drop. It is often surprising in such cases how rapidly the patient can be brought back into the proper plane of anesthesia. There need be no fear that the patient will fully awake.

OBSTRUCTED BREATHING.

Many anesthesias are unsatisfactory because the breathing is obstructed. To my mind the prime cause of obstructed breathing is too great a concentration of the anesthetic. The importance of avoiding the _crowding of the anesthetic_ is the secret of a good narcosis.

[Sidenote: Concentrated Anesthetic]

The irritability of the air passages varies greatly in different individuals. Concentrated vapor may cause reflex spasm of the larynx and, consequently, obstructed breathing. This is the condition that leads to what is ordinarily called _respiratory collapse_. It is due to crowding—undue concentration—rather than excessive quantity of the anesthetic. If there were no superior laryngeal and trifacial nerves to warn the inexperienced or inattentive by closing the larynx to more of the anesthetic, real _respiratory paralysis_, which is apt to be fatal, and is due to direct toxic action of the anesthetic on the respiratory centre, might be more common.

“Have I crowded the anesthetic?” is the first question that should be considered when there are signs of obstructed breathing. The jaw is rigid, the patient is almost awake, and yet the mask is lifted to admit more air. Paradoxical as it may seem, the jaw begins to relax, the breathing becomes free and the anesthesia at once more profound. The reason is simple. As long as the spasm of the larynx persists the anesthetic cannot readily pass the barrier to exert its physiological action. As soon as the spasm is overcome by admitting air the anesthetic can be freely inhaled. By observing the precaution to dilute the anesthetic generously with air pharyngeal irritation and laryngeal spasm can be avoided and an undisturbed narcosis secured.

[Sidenote: Valve-action of the Lips]

Sometimes, however, the obstruction is purely mechanical. It may be due to compression of the trachea by a shoulder brace. In aged individuals, after removing the tooth plate, progressively increasing cyanosis may be due to _valve-action of the lips_. Expiration is unhindered, but inspiration becomes impossible on account of collapse of the lips and cheeks. The difficulty is overcome by turning the head to one side and placing a spindle of gauze in the dependent angle of the mouth to keep the lips apart.

[Sidenote: Recession of the Tongue]

There are other cases in which the base of the tongue drops back into the oropharynx, and hinders breathing. There is a peculiar, noisy, “fluttering” respiration which indicates this condition. The jaw-grip, that is, pushing the jaw forward, is often insufficient. Most of us have been taught to use the wedge, mouth-gag and tongue forceps at once in such an emergency, but it is certainly desirable to escape this maneuver whenever possible. A naso-pharyngeal catheter, or breathing tube of soft rubber, passed through the nostril into the pharynx sometimes instantly relieves the obstruction.

THE USE OF THE BREATHING TUBE.

[Sidenote: Breathing Tube]

The breathing tube is a soft rubber tube 5/16” in calibre and 7¼” in length. The end is smooth and beveled and has an opening, there being a second opening on the side, about a quarter of an inch distant. To introduce it, the tip of the nose is lifted and the rounded end of the catheter directed into the larger nostril perpendicularly to the face. The use of a little white vaseline obviates friction and unnecessary traumatism. The tube is pushed gently back into the pharynx behind the receded base of the tongue until the respiratory air streams freely through it. Very rarely, it is necessary to pull the tongue forward until the tube is in position. At times it is of advantage to support the angle of the jaw lightly, in order to get the full benefit of the tube breathing. Oxygen, it is true, improves the color when the tongue has receded and there is partial asphyxia, but no one will argue that it _eliminates the cause of the obstruction_, viz., that the base of the tongue has dropped back into the pharynx and occludes the way to the air passages.

Sometimes, when the recession of the tongue is slight, supporting the angle of the jaw helps, because the base of the tongue is carried forward with it. Frequently, this is insufficient. The tongue may be drawn forward by means of forceps or suture, but this method is crude and necessitates also the use of a wedge and mouth gag. The same accessories are imperative, when an attempt is made to introduce a breathing tube _through the mouth_ into the pharynx. It is for these reasons that the nasal route is preferred. The method outlined is uncomplicated—its efficacy is often striking. It seems to be the simplest solution of the problem to re-establish the respiratory air channel, which has been occluded by the recession of the tongue.

INDICATIONS FOR STIMULATION DURING NARCOSIS.

[Sidenote: Volume of the Pulse]

[Sidenote: Camphor-Ether]

[Sidenote: Strychnine]

[Sidenote: Venous Infusion]

The volume of the pulse diminishes during protracted narcosis. The volume may be expected to decrease about one-third in the course of an hour, and as much as one-half in a two hours’ anesthesia. If, in _a chloroform or anaesthol anesthesia_, the pulse gives the impression, to the palpating finger, of having lost more than one-half of its original volume, stimulation is indicated. If ether feeding through the Schimmelbusch mask, and one drachm of 25% camphor-ether hypodermatically do not improve the volume notably, an intravenous infusion of physiological saline at 98°-105° F. should be given without delay. _If the anesthesia has been conducted with ether instead_ of anaesthol or chloroform, camphor-ether stimulation is not in place; the resort is to strychnine stimulation instead—one twentieth of a grain of strychnine sulphate hypodermatically, which may be repeated in half an hour. If there is no prompt improvement in the condition of the pulse, the intravenous infusion should not be postponed. It must also be borne in mind that, not drugs, but infusion of fluid alone can make good any _great_ loss of blood.

THE INFLUENCE OF MORPHINE ON NARCOSIS.

[Sidenote: Morphine]