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diff --git a/.gitattributes b/.gitattributes new file mode 100644 index 0000000..d7b82bc --- /dev/null +++ b/.gitattributes @@ -0,0 +1,4 @@ +*.txt text eol=lf +*.htm text eol=lf +*.html text eol=lf +*.md text eol=lf diff --git a/LICENSE.txt b/LICENSE.txt new file mode 100644 index 0000000..6312041 --- /dev/null +++ b/LICENSE.txt @@ -0,0 +1,11 @@ +This eBook, including all associated images, markup, improvements, +metadata, and any other content or labor, has been confirmed to be +in the PUBLIC DOMAIN IN THE UNITED STATES. + +Procedures for determining public domain status are described in +the "Copyright How-To" at https://www.gutenberg.org. + +No investigation has been made concerning possible copyrights in +jurisdictions other than the United States. Anyone seeking to utilize +this eBook outside of the United States should confirm copyright +status under the laws that apply to them. diff --git a/README.md b/README.md new file mode 100644 index 0000000..cd2777f --- /dev/null +++ b/README.md @@ -0,0 +1,2 @@ +Project Gutenberg (https://www.gutenberg.org) public repository for +eBook #53199 (https://www.gutenberg.org/ebooks/53199) diff --git a/old/53199-0.txt b/old/53199-0.txt deleted file mode 100644 index a6ff915..0000000 --- a/old/53199-0.txt +++ /dev/null @@ -1,1599 +0,0 @@ -Project Gutenberg's Practical Points in Anesthesia, by Frederick-Emil Neef - -This eBook is for the use of anyone anywhere in the United States and most -other parts of the world at no cost and with almost no restrictions -whatsoever. You may copy it, give it away or re-use it under the terms of -the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you'll have -to check the laws of the country where you are located before using this ebook. - -Title: Practical Points in Anesthesia - -Author: Frederick-Emil Neef - -Release Date: October 3, 2016 [EBook #53199] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK PRACTICAL POINTS IN ANESTHESIA *** - - - - -Produced by The Online Distributed Proofreading Team at -http://www.pgdp.net (This file was produced from images -generously made available by The Internet Archive) - - - - - - - - - - PRACTICAL POINTS - IN - ANESTHESIA - - - BY - - FREDERICK-EMIL NEEF - B. S., B. L., M. L., M. D. - NEW YORK CITY - - [Illustration: colophon] - - 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] - -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=. - - - - - -End of the Project Gutenberg EBook of Practical Points in Anesthesia, by -Frederick-Emil Neef - -*** END OF THIS PROJECT GUTENBERG EBOOK PRACTICAL POINTS IN ANESTHESIA *** - -***** This file should be named 53199-0.txt or 53199-0.zip ***** -This and all associated files of various formats will be found in: - http://www.gutenberg.org/5/3/1/9/53199/ - -Produced by The Online Distributed Proofreading Team at -http://www.pgdp.net (This file was produced from images -generously made available by The Internet Archive) - -Updated editions will replace the previous one--the old editions will -be renamed. - -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the United -States without permission and without paying copyright -royalties. 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You may copy it, give it away or re-use it under the terms of -the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you'll have -to check the laws of the country where you are located before using this ebook. - -Title: Practical Points in Anesthesia - -Author: Frederick-Emil Neef - -Release Date: October 3, 2016 [EBook #53199] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK PRACTICAL POINTS IN ANESTHESIA *** - - - - -Produced by The Online Distributed Proofreading Team at -http://www.pgdp.net (This file was produced from images -generously made available by The Internet Archive) - - - - - - -</pre> - - -<div> - <h1 class='c000'><span class='xxlarge'>PRACTICAL POINTS</span> <br /> <span class='xxlarge'>IN</span> <br /> <span class='xxlarge'>ANESTHESIA</span></h1> -</div> - -<div class='nf-center-c1'> -<div class='nf-center c001'> - <div><span class='small'><span class='sc'>By</span></span></div> - <div class='c002'><span class='large'>FREDERICK-EMIL NEEF</span></div> - <div><span class='small'>B. S., B. L., M. L., M. D.</span></div> - <div><span class='small'><span class='sc'>New York City</span></span></div> - </div> -</div> - -<div class='figcenter id001'> -<img src='images/i003.jpg' alt='colophon' class='ig001' /> -</div> - -<div class='nf-center-c1'> - <div class='nf-center'> - <div><span class='small'><span class='sc'>New York, U. S. A.</span></span></div> - <div>Surgery Publishing Company</div> - <div><span class='xsmall'>92 WILLIAM STREET</span></div> - <div><span class='small'>1908</span></div> - </div> -</div> - -<div class='pbb'> - <hr class='pb c002' /> -</div> - -<div class='nf-center-c1'> -<div class='nf-center c003'> - <div><span class='xsmall'>COPYRIGHT, OCTOBER, 1908</span></div> - <div><span class='xsmall'>BY</span></div> - <div><span class='xsmall'>SURGERY PUBLISHING CO.</span></div> - <div><span class='xsmall'>NEW YORK</span></div> - </div> -</div> - -<div class='pbb'> - <hr class='pb c003' /> -</div> - -<div class='chapter'> - <h2 id='preface' class='c004'><span class='large'>PREFACE</span></h2> -</div> - -<p class='c005'>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.</p> - -<div class='c006'>FREDERICK-EMIL NEEF</div> - -<div class='lg-container-l c001'> - <div class='linegroup'> - <div class='group'> - <div class='line'>941 Madison Avenue</div> - <div class='line'>New York</div> - </div> - </div> -</div> - -<div class='pbb'> - <hr class='pb c002' /> -</div> - -<div class='chapter'> - <h2 class='c004'>CONTENTS</h2> -</div> - -<ul class='index c001'> - <li class='c007'>Preface, <a href='#preface'>5</a></li> - <li class='c007'>The Induction of Anesthesia—The German Hospital System, <a href='#anesthesia'>9</a></li> - <li class='c007'>Cardiac Collapse, <a href='#cardiaccollapse'>12</a></li> - <li class='c007'>Respiratory Collapse, <a href='#respiratorycollapse'>13</a></li> - <li class='c007'>When Shall the Patient be Declared Ready for Operation, <a href='#operation'>15</a></li> - <li class='c007'>Maintenance of the Surgical Plane of Anesthesia, <a href='#surgicalplane'>16</a></li> - <li class='c007'>Some Important Reflexes, <a href='#reflexes'>22</a></li> - <li class='c007'>Vomiting During Anesthesia, <a href='#vomiting'>23</a></li> - <li class='c007'>Obstructed Breathing, <a href='#obstructedbreathing'>24</a></li> - <li class='c007'>The Use of the Breathing Tube, <a href='#breathingtube'>26</a></li> - <li class='c007'>Indications for Stimulation during Anesthesia, <a href='#stimulation'>28</a></li> - <li class='c007'>The Influence of Morphine on Narcosis, <a href='#morphine'>30</a></li> - <li class='c007'>General Course of the Anesthesia, <a href='#course'>31</a></li> - <li class='c007'>Awakening, <a href='#awakening'>31</a></li> - <li class='c007'>Recession of the Tongue after Narcosis, <a href='#tongue'>33</a></li> - <li class='c007'>Post-Operative Distress, <a href='#distress'>34</a></li> - <li class='c007'>Morphine-Anaesthol-Ether Sequence, <a href='#sequence'>36</a></li> - <li class='c007'>Minor Anesthesia with Ethyl Chloride, <a href='#ethylchloride'>38</a></li> - <li class='c007'>Intubation Anesthesia, <a href='#intubation'>38</a></li> - <li class='c007'>Cases Requiring Superficial Anesthesia, <a href='#superficial'>43</a></li> - <li class='c007'>Cases Requiring Anesthesia Of Moderate Depth, <a href='#moderatedepth'>44</a></li> - <li class='c007'>Cases Requiring Profound Anesthesia, <a href='#profound'>44</a></li> - <li class='c007'>Conclusion, <a href='#conclusion'>45</a></li> -</ul> -<div class='pbb'> - <hr class='pb c002' /> -</div> - -<div class='nf-center-c1'> -<div class='nf-center c003'> - <div><span class='pageno' id='Page_9'>9</span><span class='xlarge'>PRACTICAL POINTS IN</span></div> - <div><span class='xlarge'>ANESTHESIA</span></div> - </div> -</div> - -<div class='chapter'> - <h2 id='anesthesia' class='c004'><span class='large'><span class='sc'>The Induction of Anesthesia.</span></span></h2> -</div> - -<p class='c005'>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.</p> - -<div class='sidenote'>The Mask</div> - -<p class='c008'>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 -<i>can be used for administering any anesthetic -by the drop method—chloroform, anaesthol -<span class='pageno' id='Page_10'>10</span>or ether.</i> 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.</p> - -<div class='sidenote'>The Induction</div> - -<p class='c008'>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 -<span class='pageno' id='Page_11'>11</span><span class='sni'><span class='hidev'>|</span>Primary Anesthesia<span class='hidev'>|</span></span> 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 <i>stage -of unconsciousness—the state of primary anesthesia</i>.</p> - -<p class='c008'>Sometimes a remarkable calm, a period of -relative apnea, <i>precedes</i> the stage of excitement. -At other times, this stage ushers the -patient <i>directly</i> 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.</p> - -<div class='sidenote'>Surgical Degree</div> - -<p class='c008'><i>The surgical degree, the state of complete -anesthesia</i>, is announced by the respiration -when it assumes the more or less well marked -snoring character of one who is fast asleep.</p> - -<p class='c008'>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. -<i>Where much blood is lost or the operation is -<span class='pageno' id='Page_12'>12</span>of very long duration one may at any time -make the transition to ether by the drop -method without changing the mask.</i> 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.</p> - -<div class='chapter'> - <h2 id='cardiaccollapse' class='c004'><span class='large'><span class='sc'>Cardiac Collapse.</span></span></h2> -</div> - -<p class='c005'>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 <i>ether</i> should be given by the -drop method.</p> - -<p class='c008'><span class='pageno' id='Page_13'>13</span><i>Gradual induction</i> of anesthesia until the -patient’s tolerance to chloroform is ascertained, -is of cardinal importance.</p> - -<div class='chapter'> - <h2 id='respiratorycollapse' class='c004'><span class='large'><span class='sc'>Respiratory Collapse.</span></span></h2> -</div> - -<p class='c005'>Obstructed breathing developing during -the induction of narcosis is apt to be due -to <i>crowding</i>. If obstructed breathing becomes -manifest later, that is, during the course -of the operation, it may be due to <i>inhibitory -reflex elicited by the surgeon</i>. Traction on -the gall bladder or mesentery will sometimes -evoke a peculiar noisy breathing which does -<i>not</i> 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.</p> - -<div class='sidenote'>Crowding</div> - -<p class='c008'><i>Probably the most common of mistakes is -crowding the anesthetic.</i> The anesthetist becomes -aware of faint, high pitched notes in -the breathing—the beginning of obstructed -<span class='pageno' id='Page_14'>14</span>respiration. He examines the lid and corneal -reflex and these convince him that the patient -is in the state of <i>superficial</i> 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 <span class='sni'><span class='hidev'>|</span>Respiratory Collapse<span class='hidev'>|</span></span> -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 -<i>respiratory-collapse</i>. The cause was crowding -of the anesthetic.</p> - -<div class='chapter'> - <span class='pageno' id='Page_15'>15</span> - <h2 id='operation' class='c004'><span class='large'><span class='sc'>When Shall the Patient be</span></span> <br /> <span class='large'><span class='sc'>Declared Ready for Operation?</span></span></h2> -</div> - -<p class='c005'>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.</p> - -<div class='sidenote'>Initial Incision</div> - -<p class='c008'>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.</p> - -<div class='sidenote'>Awakening Stimuli</div> - -<p class='c008'>Of course, it is clear that the depth of the -narcosis must, in a measure, be proportionate -<span class='pageno' id='Page_16'>16</span>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.</p> - -<div class='chapter'> - <h2 id='surgicalplane' class='c004'><span class='large'><span class='sc'>Maintenance of the Surgical Plane</span></span> <br /> <span class='large'><span class='sc'>of Anesthesia.</span></span></h2> -</div> - -<p class='c005'>In order to conduct a narcosis scientifically -one must know the signs of sufficient anesthesia -and the signs of awakening.</p> - -<div class='sidenote'>Respiration</div> - -<p class='c008'>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 -<span class='pageno' id='Page_17'>17</span>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 <i>respiratory reflex</i> induced -by the surgeon’s manipulations?”</p> - -<div class='sidenote'>Color</div> - -<p class='c008'>The color of the <i>ear</i> 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 -<span class='pageno' id='Page_18'>18</span>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.</p> - -<div class='sidenote'>Pulse</div> - -<p class='c008'>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 <i>frequency</i> is -not very important. Exceptionally, it may be -120 or 130 during the greater part of an -anesthesia without vital significance, if the -<i>quality</i> 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.</p> - -<p class='c008'><span class='pageno' id='Page_19'>19</span>Accessory to the respiration, color and -pulse, but of lesser significance, are the pupil, -the cornea and eyelid, and the secretions.</p> - -<div class='sidenote'>Pupil</div> - -<p class='c008'>In patients <i>who have not received morphine -before narcosis</i> 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.</p> - -<div class='sidenote'>Cornea</div> - -<p class='c008'>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.</p> - -<p class='c008'><span class='pageno' id='Page_20'>20</span>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.</p> - -<div class='sidenote'>Eyelid</div> - -<p class='c008'>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.</p> - -<p class='c008'>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 -<span class='pageno' id='Page_21'>21</span>plane by giving a few drops of the anesthetic -each time as the tonicity returns, and ceasing -when relaxation of the eyelid is obtained.</p> - -<div class='sidenote'>Secretions</div> - -<p class='c008'>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 <span class='sni'><span class='hidev'>|</span>Individual Idiosyncrasy<span class='hidev'>|</span></span> -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.</p> - -<p class='c008'>It is unsafe to concentrate the attention on -one sign, lest the general aspect of the patient -be overlooked.</p> - -<p class='c008'>The anesthetist watches <i>constantly</i> 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, -<span class='pageno' id='Page_22'>22</span>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.</p> - -<div class='chapter'> - <h2 id='reflexes' class='c004'><span class='large'><span class='sc'>Some Important Reflexes.</span></span></h2> -</div> - -<div class='c001'></div> -<div class='sidenote'>Pharyngeal Reflex</div> - -<p class='c008'>(1) <i>Pharyngeal reflex.</i> 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.</p> - -<div class='sidenote'>Ano-respiratory Reflex</div> - -<p class='c008'>(2) <i>Ano-respiratory reflex.</i> The crowing -inspiration heard during operation on the -perineum or rectum, <i>does not indicate that the -patient should have more anesthetic</i>.</p> - -<div class='sidenote'>Splanchnic Reflex</div> - -<p class='c008'>(3) The reflex produced by traction on -the gall bladder or mesentery is similar in its -<span class='pageno' id='Page_23'>23</span>significance to that of the ano-respiratory -reflex.</p> - -<div class='chapter'> - <h2 id='vomiting' class='c004'><span class='large'><span class='sc'>Vomiting During Anesthesia.</span></span></h2> -</div> - -<div class='c001'></div> -<div class='sidenote'>Vomiting</div> - -<p class='c008'>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 <i>should not attempt to push -the jaw forward or exert traction on the -tongue</i>. 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.</p> - -<div class='chapter'> - <span class='pageno' id='Page_24'>24</span> - <h2 id='obstructedbreathing' class='c004'><span class='large'><span class='sc'>Obstructed Breathing.</span></span></h2> -</div> - -<p class='c005'>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 <i>crowding of -the anesthetic</i> is the secret of a good narcosis.</p> - -<div class='sidenote'>Concentrated Anesthetic</div> - -<p class='c008'>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 <i>respiratory collapse</i>. 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 <i>respiratory paralysis</i>, -which is apt to be fatal, and is due to direct -toxic action of the anesthetic on the respiratory -centre, might be more common.</p> - -<p class='c008'><span class='pageno' id='Page_25'>25</span>“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.</p> - -<div class='sidenote'>Valve-action of the Lips</div> - -<p class='c008'>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 <i>valve-action of the lips</i>. Expiration -is unhindered, but inspiration becomes -<span class='pageno' id='Page_26'>26</span>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.</p> - -<div class='sidenote'>Recession of the Tongue</div> - -<p class='c008'>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.</p> - -<div class='chapter'> - <h2 id='breathingtube' class='c004'><span class='large'><span class='sc'>The Use of the Breathing Tube.</span></span></h2> -</div> - -<div class='c001'></div> -<div class='sidenote'>Breathing Tube</div> - -<p class='c008'>The breathing tube is a soft rubber tube -5/16” in calibre and 7¼” in length. The -<span class='pageno' id='Page_27'>27</span>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 <i>eliminates the cause of the obstruction</i>, -viz., that the base of the tongue has -dropped back into the pharynx and occludes -the way to the air passages.</p> - -<p class='c008'>Sometimes, when the recession of the -tongue is slight, supporting the angle of the -<span class='pageno' id='Page_28'>28</span>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 <i>through -the mouth</i> 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.</p> - -<div class='chapter'> - <h2 id='stimulation' class='c004'><span class='large'><span class='sc'>Indications for Stimulation During</span></span> <br /> <span class='large'><span class='sc'>Narcosis.</span></span></h2> -</div> - -<div class='c001'></div> -<div class='sidenote'>Volume of the Pulse</div> - -<p class='c008'>The volume of the pulse diminishes during -protracted narcosis. The volume may be expected -to decrease about one-third in the -<span class='pageno' id='Page_29'>29</span>course of an hour, and as much as one-half -in a two hours’ anesthesia. If, in <i>a chloroform -or anaesthol anesthesia</i>, 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 <span class='sni'><span class='hidev'>|</span>Camphor-Ether<span class='hidev'>|</span></span> -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. -<i>If the anesthesia has been conducted -with ether instead</i> of anaesthol or chloroform, <span class='sni'><span class='hidev'>|</span>Strychnine<span class='hidev'>|</span></span> -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 <span class='sni'><span class='hidev'>|</span>Venous Infusion<span class='hidev'>|</span></span> -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 -<i>great</i> loss of blood.</p> - -<div class='chapter'> - <span class='pageno' id='Page_30'>30</span> - <h2 id='morphine' class='c004'><span class='large'><span class='sc'>The Influence of Morphine on</span></span> <br /> <span class='large'><span class='sc'>Narcosis.</span></span></h2> -</div> - -<div class='c001'></div> -<div class='sidenote'>Morphine</div> - -<p class='c008'>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.</p> - -<div class='chapter'> - <span class='pageno' id='Page_31'>31</span> - <h2 id='course' class='c004'><span class='large'><span class='sc'>General Course of the Anesthesia.</span></span></h2> -</div> - -<div class='c001'></div> -<div class='sidenote'>Tranquil Narcosis</div> - -<p class='c008'>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.</p> - -<div class='chapter'> - <h2 id='awakening' class='c004'><span class='large'><span class='sc'>Awakening.</span></span></h2> -</div> - -<p class='c005'>If the narcosis has been conducted correctly -the patient should become conscious -promptly after operation. The premonitors -of awakening are readily recognized, the -<span class='pageno' id='Page_32'>32</span>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.</p> - -<div class='sidenote'>Termination of Narcosis</div> - -<p class='c008'>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.</p> - -<p class='c008'>If the morphine-anaesthol narcosis has been -continued with <i>ether</i> 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 -<span class='pageno' id='Page_33'>33</span>laparotomy the anesthetist desists at once from -giving ether when the surgeon has applied the -<i>peritoneal suture</i> for the closure of the abdominal -wound.</p> - -<div class='chapter'> - <h2 id='tongue' class='c004'><span class='large'><span class='sc'>Recession of the Tongue After</span></span> <br /> <span class='large'><span class='sc'>Narcosis.</span></span></h2> -</div> - -<div class='c001'></div> -<div class='sidenote'>Post-operative Asphyxia</div> - -<p class='c008'>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.</p> - -<div class='chapter'> - <span class='pageno' id='Page_34'>34</span> - <h2 id='distress' class='c004'><span class='large'><span class='sc'>Post-Operative Distress.</span></span></h2> -</div> - -<div class='c001'></div> -<div class='sidenote'>Gas-Pain</div> - -<p class='c008'>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.</p> - -<div class='sidenote'>Vomiting</div> - -<p class='c008'>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 -<span class='pageno' id='Page_35'>35</span>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.</p> - -<p class='c008'>I have gathered the impression that <i>crowding</i> -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.</p> - -<div class='sidenote'>Nausea</div> - -<p class='c008'>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 <span class='sni'><span class='hidev'>|</span>Thirst<span class='hidev'>|</span></span> -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 -<span class='pageno' id='Page_36'>36</span>iced water may be laid over the lips and -nostrils.</p> - -<div class='sidenote'>Pain</div> - -<p class='c008'>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.</p> - -<div class='chapter'> - <h2 id='sequence' class='c004'><span class='large'><span class='sc'>Morphine-Anaesthol Sequence.</span></span></h2> -</div> - -<p class='c005'>For general use in every day practice the -morphine-anaesthol sequence already described -is most satisfactory.</p> - -<p class='c008'>As indicated, the adult receives a quarter -grain of morphine sulphate hypodermatically -one-half hour before anesthesia.</p> - -<div class='sidenote'>Anaesthol</div> - -<p class='c008'>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 -<span class='pageno' id='Page_37'>37</span>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.</p> - -<div class='sidenote'>Morphine Breathing</div> - -<p class='c008'>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 <i>ether</i> 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.</p> - -<div class='sidenote'>After-effects</div> - -<p class='c008'>Post-anesthetic distress is, on the whole, -less marked than with pure ether. Not infrequently -there is neither nausea nor vomiting.</p> - -<div class='chapter'> - <span class='pageno' id='Page_38'>38</span> - <h2 id='ethylchloride' class='c004'><span class='large'><span class='sc'>Minor Anesthesia with Ethyl</span></span> <br /> <span class='large'><span class='sc'>Chloride.</span></span></h2> -</div> - -<div class='c001'></div> -<div class='sidenote'>Office Anesthesia</div> - -<p class='c008'>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.</p> - -<div class='chapter'> - <h2 id='intubation' class='c004'><span class='large'><span class='sc'>Intubation Anesthesia.</span></span></h2> -</div> - -<p class='c005'>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 -<span class='pageno' id='Page_39'>39</span>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.</p> - -<p class='c008'>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.</p> - -<div class='sidenote'>Intubation Narcosis</div> - -<p class='c008'>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 -<span class='pageno' id='Page_40'>40</span>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 <i>conducting -tube</i>, 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.</p> - -<p class='c008'>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.</p> - -<div class='sidenote'>Cocainization of the Pharynx</div> - -<p class='c008'><i>Cocainization of the pharynx is an unnecessary -procedure.</i></p> - -<p class='c008'>For operations on the mastoid or brain the -pharynx need not be tamponed about the -tubes. This is done only when blood is apt -<span class='pageno' id='Page_41'>41</span>to flow down into the air passages, as in resecting -the upper jaw, in Kocher’s excision -of the tongue and various <i>intrabuccal</i> operations.</p> - -<p class='c008'>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 <i>both</i> nostrils are involved it becomes -necessary to introduce the tubes through the -mouth—oro-pharyngeal intubation.</p> - -<div class='sidenote'>The Surgical Plane</div> - -<p class='c008'>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 <i>pupil</i> is no longer a very useful guide -because the patient has received morphine. -There is access to the pulse at the wrist or the -<span class='pageno' id='Page_42'>42</span>dorsal artery of the foot and its regularity and <span class='sni'><span class='hidev'>|</span>Pulse<span class='hidev'>|</span></span> -quality can be noted. A <i>diffuse</i> and <i>weakening</i> -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.</p> - -<div class='sidenote'>Color and Breathing</div> - -<p class='c008'>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.</p> - -<div class='sidenote'>Clogging of the Tube</div> - -<p class='c008'>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.</p> - -<p class='c008'><span class='pageno' id='Page_43'>43</span>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.</p> - -<div class='chapter'> - <h2 id='superficial' class='c004'><span class='large'><span class='sc'>Cases Requiring Superficial</span></span> <br /> <span class='large'><span class='sc'>Anesthesia.</span></span></h2> -</div> - -<p class='c005'>(1) Suprapubic prostatectomy and cystotomy -after the skin incision is made.</p> - -<p class='c008'>(2) Nephrectomy in general, but especially -in tuberculous and enfeebled women.</p> - -<p class='c008'>(3) Mastoid and brain operations.</p> - -<p class='c008'>(4) Osteotomy and operations on the extremities.</p> - -<p class='c008'>(5) Curettage and obstetrical manipulations.</p> - -<div class='chapter'> - <span class='pageno' id='Page_44'>44</span> - <h2 id='moderatedepth' class='c004'><span class='large'><span class='sc'>Cases Requiring Anesthesia Of</span></span> <br /> <span class='large'><span class='sc'>Moderate Depth.</span></span></h2> -</div> - -<p class='c005'>(1) Trachelorrhaphy, Colporrhaphy and -perineorrhaphy.</p> - -<p class='c008'>(2) Stretching of the sphincter and -hemorrhoid operations.</p> - -<p class='c008'>(3) Resection of the rectum by the perineal -or sacral route.</p> - -<p class='c008'>(4) Perineal prostatectomy.</p> - -<p class='c008'>(5) Inguinal and femoral herniotomy.</p> - -<div class='chapter'> - <h2 id='profound' class='c004'><span class='large'><span class='sc'>Cases Requiring Profound</span></span> <br /> <span class='large'><span class='sc'>Anesthesia.</span></span></h2> -</div> - -<p class='c005'>(1) Gynecological laparotomies: salpingo-oophorectomy -and hysterectomy.</p> - -<p class='c008'>(2) Operations on the stomach or gall-bladder: -gastro-enterostomy, cholecystectomy.</p> - -<p class='c008'>(3) Orthopedic manipulations necessitating -complete muscular relaxation: reduction -of congenital dislocation of the hip.</p> - -<div class='chapter'> - <span class='pageno' id='Page_45'>45</span> - <h2 id='conclusion' class='c004'><span class='large'><span class='sc'>Conclusion.</span></span></h2> -</div> - -<p class='c005'>Anesthesia is a science which deserves -more attention.</p> - -<p class='c008'>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.</p> - -<p class='c008'>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 -<span class='pageno' id='Page_46'>46</span>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.</p> - -<p class='c008'>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.</p> - -<p class='c008'>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 <i>that there are -some who are anxiously awaiting the outcome, -and have a deep interest in the life that is in -his hands</i>.</p> - -<div class='chapter'> - <span class='pageno' id='Page_47'>47</span> - <h2 class='c004'><span class='large'>INDEX</span></h2> -</div> - -<ul class='index c001'> - <li class='c007'>Anaesthol, <a href='#Page_36'>36</a></li> - <li class='c007'>Anesthesia, Complete, <a href='#Page_11'>11</a> - <ul> - <li>Depth Required by Various Cases, <a href='#Page_43'>43</a></li> - <li>General Course of, <a href='#Page_31'>31</a></li> - <li>Induction of, <a href='#Page_10'>10</a></li> - <li>Intubation, <a href='#Page_39'>39</a></li> - <li>Minor, with Ethyl-Chloride, <a href='#Page_38'>38</a></li> - <li>Primary, <a href='#Page_11'>11</a></li> - </ul> - </li> - <li class='c007'>Anesthetic, Concentrated, <a href='#Page_24'>24</a></li> - <li class='c007'>Ano-respiratory Reflex, <a href='#Page_22'>22</a></li> - <li class='c007'>Asphyxia, Post-operative, <a href='#Page_33'>33</a></li> - <li class='c007'>Awakening, Signs of, <a href='#Page_16'>16</a>, <a href='#Page_31'>31</a> - <ul> - <li>Stimuli, <a href='#Page_16'>16</a></li> - </ul> - </li> - <li class='c001'>Breath, Holding the, <a href='#Page_22'>22</a></li> - <li class='c007'>Breathing, Influence of Morphine on, <a href='#Page_37'>37</a> - <ul> - <li>Mechanical Obstruction to, <a href='#Page_25'>25</a></li> - <li>Obstructed, <a href='#Page_24'>24</a></li> - </ul> - </li> - <li class='c007'>Breathing-tube, <a href='#Page_26'>26</a></li> - <li class='c001'>Camphor-Ether Stimulation, <a href='#Page_29'>29</a></li> - <li class='c007'>Cardiac Collapse, <a href='#Page_12'>12</a></li> - <li class='c007'>Cases Requiring Superficial Anesthesia, <a href='#Page_43'>43</a> - <ul> - <li>Deep Anesthesia, <a href='#Page_44'>44</a></li> - </ul> - </li> - <li class='c007'><span class='pageno' id='Page_48'>48</span>Clogging of the Anesthesia Tubes, <a href='#Page_42'>42</a></li> - <li class='c007'>Cocainization of the Pharynx, <a href='#Page_40'>40</a></li> - <li class='c007'>Collapse, Cardiac, <a href='#Page_12'>12</a> - <ul> - <li>Respiratory, <a href='#Page_14'>14</a></li> - </ul> - </li> - <li class='c007'>Color, <a href='#Page_17'>17</a> - <ul> - <li>In Intubation Anesthesia, <a href='#Page_42'>42</a></li> - </ul> - </li> - <li class='c007'>Complete Anesthesia, <a href='#Page_11'>11</a></li> - <li class='c007'>Cornea, <a href='#Page_19'>19</a></li> - <li class='c007'>Coughing During Narcosis, <a href='#Page_22'>22</a></li> - <li class='c007'>Crowding, <a href='#Page_13'>13</a>, <a href='#Page_24'>24</a></li> - <li class='c001'>Degree, Surgical, <a href='#Page_11'>11</a> - <ul> - <li>In Intubation Anesthesia, <a href='#Page_41'>41</a></li> - </ul> - </li> - <li class='c007'>Distress, Post Operative, <a href='#Page_34'>34</a></li> - <li class='c001'>Ethyl-Chloride, Minor Anesthesia with, <a href='#Page_38'>38</a></li> - <li class='c007'>Eyelid Test, <a href='#Page_20'>20</a></li> - <li class='c001'>Gas Pain, <a href='#Page_34'>34</a></li> - <li class='c001'>Holding the Breath, <a href='#Page_22'>22</a></li> - <li class='c001'>Idiosyncrasy, Individual, <a href='#Page_21'>21</a></li> - <li class='c007'>Incision, Initial, <a href='#Page_15'>15</a></li> - <li class='c007'>Individual Idiosyncrasy, <a href='#Page_21'>21</a></li> - <li class='c007'><span class='pageno' id='Page_49'>49</span>Induction of Anesthesia, <a href='#Page_10'>10</a></li> - <li class='c007'>Infusion, Venous, <a href='#Page_29'>29</a></li> - <li class='c007'>Initial Incision, <a href='#Page_15'>15</a></li> - <li class='c007'>Intubation Anesthesia, <a href='#Page_39'>39</a> - <ul> - <li>Color in, <a href='#Page_42'>42</a></li> - <li>Clogging of the Tubes in, <a href='#Page_42'>42</a></li> - <li>Pulse in, <a href='#Page_42'>42</a></li> - <li>Respiration in, <a href='#Page_42'>42</a></li> - <li>Surgical Degree, <a href='#Page_41'>41</a></li> - </ul> - </li> - <li class='c001'>Lips, Valve Action of, <a href='#Page_25'>25</a></li> - <li class='c001'>Maintenance of the Surgical Plane, <a href='#Page_16'>16</a></li> - <li class='c007'>Mask, Schimmelbusch, <a href='#Page_9'>9</a></li> - <li class='c007'>Mechanical Obstruction to Breathing, <a href='#Page_25'>25</a></li> - <li class='c007'>Minor Anesthesia with Ethyl-Chloride, <a href='#Page_38'>38</a></li> - <li class='c007'>Morphine Breathing, <a href='#Page_37'>37</a></li> - <li class='c007'>Morphine, Influence of, <a href='#Page_30'>30</a></li> - <li class='c001'>Nausea, <a href='#Page_35'>35</a></li> - <li class='c001'>Obstructed Breathing, <a href='#Page_24'>24</a></li> - <li class='c007'>Obstruction, Mechanical, Breathing, <a href='#Page_25'>25</a></li> - <li class='c007'>Office Anesthesia, <a href='#Page_38'>38</a></li> - <li class='c001'>Pain, Post-operative, <a href='#Page_36'>36</a></li> - <li class='c007'><span class='pageno' id='Page_50'>50</span>Paralysis, Respiratory, <a href='#Page_24'>24</a></li> - <li class='c007'>Pharyngeal Reflex, <a href='#Page_22'>22</a></li> - <li class='c007'>Pharynx, Cocainization of, <a href='#Page_40'>40</a></li> - <li class='c007'>Post-operative Asphyxia, <a href='#Page_33'>33</a></li> - <li class='c007'>Post operative Distress, <a href='#Page_34'>34</a></li> - <li class='c007'>Primary Anesthesia, <a href='#Page_11'>11</a></li> - <li class='c007'>Pulse, <a href='#Page_18'>18</a> - <ul> - <li>Volume of, During Narcosis, <a href='#Page_29'>29</a></li> - </ul> - </li> - <li class='c007'>Pupil, <a href='#Page_19'>19</a></li> - <li class='c001'>Recession of the Tongue During Narcosis, <a href='#Page_26'>26</a> - <ul> - <li>After Narcosis, <a href='#Page_33'>33</a></li> - </ul> - </li> - <li class='c007'>Reflex, Pharyngeal, <a href='#Page_22'>22</a> - <ul> - <li>Ano-respiratory, <a href='#Page_22'>22</a></li> - <li>Splanchnic, <a href='#Page_22'>22</a></li> - </ul> - </li> - <li class='c007'>Respiration, <a href='#Page_16'>16</a> - <ul> - <li>In Intubation Anesthesia, <a href='#Page_42'>42</a></li> - </ul> - </li> - <li class='c007'>Respiratory Collapse, <a href='#Page_14'>14</a></li> - <li class='c007'>Respiratory Paralysis, <a href='#Page_24'>24</a></li> - <li class='c001'>Schimmelbusch Mask, <a href='#Page_9'>9</a></li> - <li class='c007'>Secretions, <a href='#Page_20'>20</a></li> - <li class='c007'>Signs of Awakening, <a href='#Page_16'>16</a>, <a href='#Page_31'>31</a> - <ul> - <li>Of Sufficient Anesthesia, <a href='#Page_16'>16</a></li> - </ul> - </li> - <li class='c007'><span class='pageno' id='Page_51'>51</span>Splanchnic Reflex, <a href='#Page_22'>22</a></li> - <li class='c007'>Stimulation During Narcosis, <a href='#Page_28'>28</a> - <ul> - <li>With Camphor-Ether, <a href='#Page_29'>29</a></li> - <li>With Strychnine, <a href='#Page_29'>29</a></li> - </ul> - </li> - <li class='c007'>Stimuli, Awakening, <a href='#Page_16'>16</a></li> - <li class='c007'>Strychnine Stimulation, <a href='#Page_29'>29</a></li> - <li class='c007'>Sufficient Anesthesia, Signs of, <a href='#Page_16'>16</a></li> - <li class='c007'>Surgical Degree, <a href='#Page_11'>11</a> - <ul> - <li>In Intubation Anesthesia, <a href='#Page_41'>41</a></li> - </ul> - </li> - <li class='c007'>Surgical Plane, Maintenance of the, <a href='#Page_16'>16</a></li> - <li class='c001'>Termination of Narcosis, <a href='#Page_32'>32</a></li> - <li class='c007'>Thirst after Narcosis, <a href='#Page_35'>35</a></li> - <li class='c007'>Tongue, Recession of, During Narcosis, <a href='#Page_26'>26</a> - <ul> - <li>After Narcosis, <a href='#Page_33'>33</a></li> - </ul> - </li> - <li class='c007'>Tranquil Narcosis, <a href='#Page_31'>31</a></li> - <li class='c001'>Valve Action of the Lips, <a href='#Page_25'>25</a></li> - <li class='c007'>Venous Infusion, <a href='#Page_29'>29</a></li> - <li class='c007'>Volume of the Pulse During Narcosis, <a href='#Page_29'>29</a></li> - <li class='c007'>Vomiting During Anesthesia, <a href='#Page_23'>23</a> - <ul> - <li>After Anesthesia, <a href='#Page_34'>34</a></li> - </ul> - </li> -</ul> -<div class='pbb'> - <hr class='pb c002' /> -</div> - -<div class='chapter'> - <h2 class='c004'><span class='large'>TRANSCRIBER’S NOTE</span></h2> -</div> - -<p class='c005'>Punctuation has been normalized. -Variations in hyphenation have been maintained. -Assumed printer’s errors have been corrected.</p> - -<p class='c008'>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:</p> - -<div class='lg-container-b'> - <div class='linegroup'> - <div class='group'> - <div class='line'>Cases Requiring Anesthesia Of Moderate Depth, 44</div> - </div> - <div class='group'> - <div class='line'>Cases Requiring Profound Anesthesia, 44</div> - </div> - </div> -</div> - - - - - - - - -<pre> - - - - - -End of the Project Gutenberg EBook of Practical Points in Anesthesia, by -Frederick-Emil Neef - -*** END OF THIS PROJECT GUTENBERG EBOOK PRACTICAL POINTS IN ANESTHESIA *** - -***** This file should be named 53199-h.htm or 53199-h.zip ***** -This and all associated files of various formats will be found in: - 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