Part 2

During the course of any operation, the surgeon is responsible for a long chain of ingoing impulses, which travel along the sensory paths from the site of operation to the spinal cord and brain. Morphine diminishes the awakening effect of these impulses by benumbing the perceptive centers in the brain. The correct plane of anesthesia for a patient who has had morphine, for example, one quarter of a grain of morphine sulphate hypodermatically half an hour before narcosis, must appear very superficial as compared with a case to which morphine has not been administered. Not only is considerably less of the anesthetic required, but the lid, for instance, may be quite tonic without indicating that more of the anesthetic is necessary. These observations apply cardinally to anesthesias with chloroform, or chloroform combinations, such as anaesthol.

GENERAL COURSE OF THE ANESTHESIA.

[Sidenote: Tranquil Narcosis]

The ideal narcosis is tranquil. It resembles a natural sleep. The breathing is unimpeded and easy. Any change in the character of the breathing sound, or the rhythm, demands attention. If, for the moment, the anesthetic has been given too hurriedly, a few breaths of air will restore the calm. If, on the other hand, signs of awakening are discovered—the lid becomes more tonic, the corneal reflex more active, a tear appears in the eye, the patient begins to sweat, saliva collects in the throat, the pulse becomes more rapid—a few drops of the anesthetic should be administered until the desired free and unembarrassed respiration returns.

AWAKENING.

If the narcosis has been conducted correctly the patient should become conscious promptly after operation. The premonitors of awakening are readily recognized, the corneal reflex becomes more active, the tonicity of the eyelid approaches the normal, a tear may appear in the eye, beads of perspiration are seen on the forehead, the patient may begin to mutter incoherently, the pulse becomes faster, the breathing loses its snoring character, and the patient begins to move his head.

[Sidenote: Termination of Narcosis]

If the operation is a laparotomy and the patient is under the influence of morphine-anaesthol, the narcosis is terminated by giving a drop occasionally when the surgeon puts his first sutures into the abdominal wall; after the fascial repair, the anesthetic is stopped entirely. The narcosis may be so timed that the patient becomes conscious and responds to questions promptly after the last stitch has been placed.

If the morphine-anaesthol narcosis has been continued with _ether_ by the drop method, as is frequently indicated, and if considerable ether has been used, the patient will be a little tardier in arousing, and the administration of the narcotic should be stopped at an earlier period. To be less abstract, in the case of a laparotomy the anesthetist desists at once from giving ether when the surgeon has applied the _peritoneal suture_ for the closure of the abdominal wound.

RECESSION OF THE TONGUE AFTER NARCOSIS.

[Sidenote: Post-operative Asphyxia]

Sometimes, especially in individuals who show this tendency during narcosis, a marked obstruction in breathing is met with, attended by increasing cyanosis, a condition due to dropping back or recession of the base of the tongue into the laryngo-pharyngeal space. Changing the position of the head does not improve the breathing, the jaw cannot be pushed forward because the masseter is rigidly contracted and the teeth are clenched tightly. To draw forward the tongue would require a rough procedure, with wedge, gag, and forceps. If a soft rubber catheter or the breathing tube be passed through the nostril into the pharynx the respiratory air streams freely through the tube.

POST-OPERATIVE DISTRESS.

[Sidenote: Gas-Pain]

Post-operative gas pain is often the source of great distress to patients who have undergone the ordeal of laparotomy. It is due to a temporary paresis of the gut and consequent distension with gas. When the trouble is in the lower bowel considerable relief may follow the insertion of the rectal tube. Irrigation of the colon, when permissible, may stimulate peristalsis in the higher segments of the bowel. A routine intended to militate against intestinal paresis in celiotomies, and worth a fair trial, is to administer with the morphine sulphate a small dose of eserine sulphate hypodermatically. For the ordinary adult the dose should be about one-fourth of a grain of morphine sulphate and one fiftieth of a grain of eserine sulphate given subcutaneously one-half hour before narcosis.

[Sidenote: Vomiting]

When it is important to avoid post-operative vomiting, gastric lavage with plain water, made faintly alkaline with lime water or milk of magnesia, may be done as soon as the narcosis is ended and while the patient is still on the operating table. During the procedure the head end of the table is lowered a few degrees.

I have gathered the impression that _crowding_ is one of the prime causes of excessive vomiting after anesthesia. It has been my experience that cases in which I could truly say that I had not crowded the anesthetic and where it was not swallowed to any extent during the induction, have suffered little or not at all from this disagreeable after-effect of the narcosis.

[Sidenote: Nausea]

[Sidenote: Thirst]

The attentive nurse will find that there are numerous little things, seemingly insignificant, that help greatly toward the patient’s comfort. She may support the wound during a coughing spell or if the patient vomits. If her charge is tormented with nausea a piece of cotton saturated with a mixture of alcohol and acetic acid can be dropped into a tumbler and the patient allowed to inhale the vapor. If the lips and throat are dry and parched, moisture is grateful and small pieces of gauze wet with iced water may be laid over the lips and nostrils.

[Sidenote: Pain]

If the patient is suffering after operation, one should be generous with morphine. It should always be given hypodermatically. To the adult less than one quarter grain as a dose is of little avail. In such post-operative use there need be no fear of inculcating the morphine habit.

MORPHINE-ANAESTHOL SEQUENCE.

For general use in every day practice the morphine-anaesthol sequence already described is most satisfactory.

As indicated, the adult receives a quarter grain of morphine sulphate hypodermatically one-half hour before anesthesia.

[Sidenote: Anaesthol]

Anaesthol, a fairly stable combination of chloroform, ether and ethyl chloride in molecular proportions, is given by the drop method, but in slightly greater quantity than pure chloroform. For the average “interval” case of appendicitis, for example, about 15 to 20 cc. should be used for the induction, and 40-60 cc. for the entire narcosis.

[Sidenote: Morphine Breathing]

The morphine, in susceptible individuals, sometimes causes very shallow respirations so that the conduct of the anesthesia to the stage of unconsciousness becomes prolonged because the patient does not inhale sufficient of the anesthetic at each breath. Crowding would be incorrect. The solution is patience, and a little _ether_ to excite deeper respirations. The patient has but a slight stage of excitement, often none at all. The narcosis is continued until the first unimpeded, snoring respiration is heard, and then the surgeon may begin. Much of the narcotic is not required and the anesthesia can be so conducted that the patient promptly becomes conscious after the placing of the last suture.

[Sidenote: After-effects]

Post-anesthetic distress is, on the whole, less marked than with pure ether. Not infrequently there is neither nausea nor vomiting.

MINOR ANESTHESIA WITH ETHYL CHLORIDE.

[Sidenote: Office Anesthesia]

In surgical office work, there is occasionally the need of a rapid and fleeting anesthesia which does not necessitate the use of a cumbersome apparatus for its induction. In these cases, in place of chloroform, anaesthol or ether, the ethyl chloride spray can be used on the Schimmelbusch mask already described. It produces a prompt anesthesia during which an abscess can be opened, washed and dressed without causing the patient the slightest pain.

INTUBATION ANESTHESIA.

In intubation anesthesia, or tube anesthesia, as it might be called, the patient does not receive the anesthetic directly from a cone or mask. It is inhaled through a soft rubber tube which is introduced into the pharynx through the nostril or mouth. It is most successful in cases that do not require a very profound narcosis. It is indicated in operations on the head, enabling the anesthetist to be at a distance from the field of operation and out of the surgeon’s province.

An important preliminary is to give the patient morphine sulphate, gr. ¼, hypodermatically one half hour before anesthesia is begun, as much less of the anesthetic is then required.

[Sidenote: Intubation Narcosis]

The method is simple. The anesthesia is carried to the surgical degree in the ordinary way with anaesthol or chloroform. A soft rubber catheter with an opening at the end and side, and varying in diameter between ¼ and ⅜ inch, is made smooth with sterile vaseline and then passed through the nostril down into the naso-pharynx for a distance of about 7¼ inches in the adult, to the vicinity of the larynx. If the respiratory air streams freely through the tube it is assumed to be at the proper level and the tube is anchored and held in place by making a single turn of zinc oxide adhesive plaster about it, near the nostril, and fastening the ends to the cheek. It is important that these straps adhere firmly and the skin should therefore be cleaned with a little ether or chloroform before they are attached. This naso-pharyngeal tube must now be connected with a second tube, the _conducting tube_, to which a perforated funnel covered with gauze is attached, or which is dipped into a tumbler containing loosely packed gauze; the conducting tube should lie by the side of the patient, beneath the sterile sheets and it should be so long that the anesthetist can sit at the foot of the operating table to administer the anesthetic.

Catheters, a piece of rubber tubing, some zinc oxide plaster, and a tumbler containing some gauze, are, therefore, all that one needs in order to improvise, in a few minutes, an adequate intubation apparatus. In practice, simplicity is frequently important.

[Sidenote: Cocainization of the Pharynx]

_Cocainization of the pharynx is an unnecessary procedure._

For operations on the mastoid or brain the pharynx need not be tamponed about the tubes. This is done only when blood is apt to flow down into the air passages, as in resecting the upper jaw, in Kocher’s excision of the tongue and various _intrabuccal_ operations.

In such cases, the Roser mouth gag is inserted and the tongue drawn gently forward out of the way, while, aided by the index finger of the right or left hand, a piece of gauze tampon is placed snugly about the naso-pharyngeal tube or tubes. If a stream of expiratory air issues from the tube it is certain that the pharyngeal openings in the tube have not been plugged by the tampon or tenacious secretions. In certain operations on the nose where _both_ nostrils are involved it becomes necessary to introduce the tubes through the mouth—oro-pharyngeal intubation.

[Sidenote: The Surgical Plane]

[Sidenote: Pulse]

The anesthetist need not be at sea, although he is at a considerable distance from the face and eyes, which he is accustomed to watch with such care during narcosis. In any case, the _pupil_ is no longer a very useful guide because the patient has received morphine. There is access to the pulse at the wrist or the dorsal artery of the foot and its regularity and quality can be noted. A _diffuse_ and _weakening_ pulse wave is at once appreciated as a danger sign—too much chloroform—and the tube should be disconnected from the funnel to admit pure air, until the pulse has recovered its quality.

[Sidenote: Color and Breathing]

The color of the face can be observed; also the breathing movement of the chest and abdomen, and the respirations are readily heard through the tube. Any change in the character of the breathing or any hindrance in inspiration or expiration is readily detected. From time to time the funnel is disconnected and fluid which may have accumulated in the tube, as for instance condensed anesthetic, is allowed to flow out.

[Sidenote: Clogging of the Tube]

Secretions clogging the pharyngeal end of the tube are expelled by “milking” the tube, that is, forcing an occluded column of air through it by stroking it between the finger and thumb in a direction towards the patient, or allowing a gentle stream of oxygen to flow into its lumen.

As long as the breathing remains unembarrassed and regular, the pulse is of good quality and a general, passive condition maintained, the patient is in the normal plane of surgical anesthesia and any interference would be meddling.

CASES REQUIRING SUPERFICIAL ANESTHESIA.

(1) Suprapubic prostatectomy and cystotomy after the skin incision is made.

(2) Nephrectomy in general, but especially in tuberculous and enfeebled women.

(3) Mastoid and brain operations.

(4) Osteotomy and operations on the extremities.

(5) Curettage and obstetrical manipulations.

CASES REQUIRING ANESTHESIA OF MODERATE DEPTH.

(1) Trachelorrhaphy, Colporrhaphy and perineorrhaphy.

(2) Stretching of the sphincter and hemorrhoid operations.

(3) Resection of the rectum by the perineal or sacral route.

(4) Perineal prostatectomy.

(5) Inguinal and femoral herniotomy.

CASES REQUIRING PROFOUND ANESTHESIA.

(1) Gynecological laparotomies: salpingo-oophorectomy and hysterectomy.

(2) Operations on the stomach or gall-bladder: gastro-enterostomy, cholecystectomy.

(3) Orthopedic manipulations necessitating complete muscular relaxation: reduction of congenital dislocation of the hip.

CONCLUSION.

Anesthesia is a science which deserves more attention.

The extensive use of ether and the experience that its incautious administration is fraught with but little immediate danger, has gotten the hospital interne into reckless habits which cling to him in practice. There the anesthetist finds himself frequently compelled to use chloroform, a narcotic many times more powerful than ether. In the hands of the inexperienced, and above all, the inattentive, chloroform is certainly a dangerous drug. But this does not detract from its great value as an anesthetic and it would be illogical to condemn its use.

In the aged, we know that it is not so much the operation itself as the broncho-pneumonia that often follows the anesthesia which deserves grave consideration. Chloroform, or a chloroform-ether combination, such as anaesthol, is undoubtedly, in such cases, preferable to pure ether, because it causes less bronchial irritation. In the morphine-anaesthol-ether sequence which I have tried to outline, chloroform and ether are blended in a way most adequate for anesthesia, and the system is so flexible that it readily adapts itself to an anomalous case.

The difficulties in respiration so frequently encountered, even by the experienced anesthetist, find a natural solution; if he has been studying the case he will be able to judge whether the trouble is due to crowding or to a mechanical cause.

I have no hopeful word for the anesthetist who is inattentive. Whether the case is an apparently simple or a critical one, it should be remembered that the good anesthetist, like the good surgeon, is he who, besides being competent, has a conscience, and feels his responsibility, who appreciates _that there are some who are anxiously awaiting the outcome, and have a deep interest in the life that is in his hands_.

INDEX

Anaesthol, 36

Anesthesia, Complete, 11 Depth Required by Various Cases, 43 General Course of, 31 Induction of, 10 Intubation, 39 Minor, with Ethyl-Chloride, 38 Primary, 11

Anesthetic, Concentrated, 24

Ano-respiratory Reflex, 22

Asphyxia, Post-operative, 33

Awakening, Signs of, 16, 31 Stimuli, 16

Breath, Holding the, 22

Breathing, Influence of Morphine on, 37 Mechanical Obstruction to, 25 Obstructed, 24

Breathing-tube, 26

Camphor-Ether Stimulation, 29

Cardiac Collapse, 12

Cases Requiring Superficial Anesthesia, 43 Deep Anesthesia, 44

Clogging of the Anesthesia Tubes, 42

Cocainization of the Pharynx, 40

Collapse, Cardiac, 12 Respiratory, 14

Color, 17 In Intubation Anesthesia, 42

Complete Anesthesia, 11

Cornea, 19

Coughing During Narcosis, 22

Crowding, 13, 24

Degree, Surgical, 11 In Intubation Anesthesia, 41

Distress, Post Operative, 34

Ethyl-Chloride, Minor Anesthesia with, 38

Eyelid Test, 20

Gas Pain, 34

Holding the Breath, 22

Idiosyncrasy, Individual, 21

Incision, Initial, 15

Individual Idiosyncrasy, 21

Induction of Anesthesia, 10

Infusion, Venous, 29

Initial Incision, 15

Intubation Anesthesia, 39 Color in, 42 Clogging of the Tubes in, 42 Pulse in, 42 Respiration in, 42 Surgical Degree, 41

Lips, Valve Action of, 25

Maintenance of the Surgical Plane, 16

Mask, Schimmelbusch, 9

Mechanical Obstruction to Breathing, 25

Minor Anesthesia with Ethyl-Chloride, 38

Morphine Breathing, 37

Morphine, Influence of, 30

Nausea, 35

Obstructed Breathing, 24

Obstruction, Mechanical, Breathing, 25

Office Anesthesia, 38

Pain, Post-operative, 36

Paralysis, Respiratory, 24

Pharyngeal Reflex, 22

Pharynx, Cocainization of, 40

Post-operative Asphyxia, 33

Post operative Distress, 34

Primary Anesthesia, 11

Pulse, 18 Volume of, During Narcosis, 29

Pupil, 19

Recession of the Tongue During Narcosis, 26 After Narcosis, 33

Reflex, Pharyngeal, 22 Ano-respiratory, 22 Splanchnic, 22

Respiration, 16 In Intubation Anesthesia, 42

Respiratory Collapse, 14

Respiratory Paralysis, 24

Schimmelbusch Mask, 9

Secretions, 20

Signs of Awakening, 16, 31 Of Sufficient Anesthesia, 16

Splanchnic Reflex, 22

Stimulation During Narcosis, 28 With Camphor-Ether, 29 With Strychnine, 29

Stimuli, Awakening, 16

Strychnine Stimulation, 29

Sufficient Anesthesia, Signs of, 16

Surgical Degree, 11 In Intubation Anesthesia, 41

Surgical Plane, Maintenance of the, 16

Termination of Narcosis, 32

Thirst after Narcosis, 35

Tongue, Recession of, During Narcosis, 26 After Narcosis, 33

Tranquil Narcosis, 31

Valve Action of the Lips, 25

Venous Infusion, 29

Volume of the Pulse During Narcosis, 29

Vomiting During Anesthesia, 23 After Anesthesia, 34

TRANSCRIBER’S NOTE

Punctuation has been normalized. Variations in hyphenation have been maintained. Assumed printer’s errors have been corrected.

The following chapter headings appeared in the book but not in the original table of contents, and have therefore been added to the contents section of this e-text:

Cases Requiring Anesthesia Of Moderate Depth, 44

Cases Requiring Profound Anesthesia, 44

Italicized words and phrases are presented by surrounding the text with _underscores_; boldfaced words and phrases are surrounded with =equal signs=.