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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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